Mary Bachman DeSilva

Prevalence of HIV infection and median CD4 counts among health care workers in South Africa

OBJECTIVE To determine the prevalence of HIV infection and the extent of disease progression based on CD4 count in a public health system workforce in southern Africa. DESIGN Cross-sectional voluntary, anonymous, unlinked survey including an oral fluid or blood sample and a brief demographic questionnaire. SETTING Two public hospitals in Gauteng, South Africa. SUBJECTS All 2 032 professional and support staff employed by the two hospitals. OUTCOME MEASURES HIV prevalence and CD4 cell count distribution. RESULTS Overall prevalence of HIV was 11.5%. By occupation, prevalence was highest among student nurses (13.8%) and nurses (13.7%). The highest prevalence by age was in the 25 - 34-year group (15.9%). Nineteen per cent of HIV-positive participants who provided blood samples had CD4 counts less than or equal to 200 cells/ microl 28% had counts 201 - 350 cells/ microl, 18% had counts 351 - 500 cells/ microl, and 35% had counts above 500 cells/ microl. CONCLUSIONS One out of 7 nurses and nursing students in this public sector workforce was HIV-positive. A high proportion of health care workers had CD4 counts below 350 cells/ microl, and many were already eligible for antiretroviral therapy under South African treatment guidelines. Given the short supply of nurses in South Africa, knowledge of prevalence in this workforce and provision of effective AIDS treatment are crucial for meeting future staffing needs.

BARRIERS TO ADHERENCE TO ANTIRETROVIRAL MEDICATIONS AMONG PATIENTS LIVING WITH HIV IN SOUTHERN CHINA: A QUALITATIVE STUDY

Abstract Although Chinas government is rapidly expanding access to antiretroviral therapy, little is known about barriers to adherence among Chinese HIV-infected patients, particularly among injection drug users. To better understand barriers to antiretroviral treatment adherence, we conducted a qualitative research study, using both focus group and key informant methods, among 36 HIV-positive men and women in Dali, in southwestern China. All interviews utilized semi-structured question guides and were conducted in Mandarin, audio-recorded and translated into English for analysis. The most commonly cited adherence challenges were stigma, including secondary stigma experienced by family members; mental health issues; and economic concerns, particularly related to finding and maintaining employment. Distinctive gender differences emerged, partly due to previous heroin use among male respondents. Optimizing adherence may require that antiretroviral therapy programs be linked to other services, including drug addiction treatment, mental health services and vocational treatment and support. HIV care and service providers and policy makers in China responsible for HIV treatment should be aware of these important barriers to adherence.

Exploring the Cinderella myth: intrahousehold differences in child wellbeing between orphans and non-orphans in Amajuba District, South Africa.

Objective:To determine whether differences in wellbeing (defined by a variety of education and health outcomes) exist between recent school-aged orphans and non-orphans who live in the same household in a context of high HIV/AIDS mortality in KwaZulu Natal, South Africa. Design:The data come from the first 2 years (2004–2006) of an ongoing 3-year longitudinal cohort study in a district in KwaZulu-Natal, the Amajuba Child Health and Well-being Research Project. Using stratified cluster sampling based on school and age, we constructed a cohort of 197 recent orphans and 528 non-orphans aged 9–16 years and their households and caregivers. Household heads, caregivers, and children were interviewed regarding five domains of child wellbeing: demographic, economic, educational, health/nutrition/lifestyle, and psychosocial status. Methods:The analytical sample consists of 174 children (87 orphans and 87 comparable non-orphans who live together) at baseline and 124 children in round 2. We estimated a linear regression model using household fixed effects for continuous outcomes (grade adjusted for age, annual expenditure on schooling and body mass index) and a logit model using household fixed effects for categorical variables (malnutrition) to compare co-resident orphans and non-orphans. Results:We found no statistically significant differences in most education, health and labour outcomes between orphans and the non-orphans with whom they live. Paternal orphans are more likely to be behind in school, and recent mobility has a positive effect on schooling outcomes.

Feasibility and Acceptability of a Real-Time Adherence Device among HIV-Positive IDU Patients in China

We collected data on feasibility and acceptability of a real-time web-linked adherence monitoring container among HIV-positive injection drug users (IDU) in China. “Wisepill” uses wireless technology to track on-time medication dosing. Ten patients on antiretroviral therapy (ART) at the Guangxi CDC HIV clinic in Nanning, China, used Wisepill for one ART medication for one month. We monitored device use and adherence and explored acceptability of the device among patients. Mean adherence was 89.2% (SD 10.6%). Half of the subjects reported a positive overall experience with Wisepill. Seven said that it was inconvenient, supported by comments that it was large and conspicuous. Five worried about disclosure of HIV status due to the device; no disclosures were reported. Twelve signal lapses occurred (5.4% of prescribed doses), of which one was due to technical reasons, nine to behavioral reasons (both intentional and unintentional), and two to unclear reasons. Although the technical components must be monitored carefully, and acceptability to patients presents challenges which warrant further exploration, the Wisepill device has potential for adherence interventions that deliver rapid adherence-support behavioral feedback directly to patients, including IDU. The use of wireless technology appears uniquely promising for providing time-sensitive communication on patient behavior that can be harnessed to maximize the benefits of HIV treatment.

Characteristics of Patients Accessing Care and Treatment for HIV/AIDS at Public and Nongovernmental Sites in South Africa

Little is known about the characteristics of patients accessing antiretroviral therapy (ART) in South Africa. In a random sample of 1069 pre-ART and ART patients attending an urban public hospital, a periurban nongovernmental organization (NGO) clinic, and a rural NGO clinic, 79% were female; average age was 34 for women and 37 for men. Two thirds reported having 1 long-term partner, but most did not live with their partner. Three fourths had completed some secondary school or higher; 47% were employed formally (26%) or informally (21%), and 40% lived in informal housing or shacks. Patients at the rural site were less likely to be employed and more likely to receive government grant support. Relative to the HIV-positive population as a whole, ART patients are older, more likely to be female and have 1 long-term partner, live in informal housing, have reached secondary school, and earn an income from formal or informal employment.

Longitudinal evaluation of the psychosocial well-being of recent orphans compared with non-orphans in a school-attending cohort in KwaZulu-Natal, South Africa

To assess differences in psychosocial well-being between recent orphans and non-orphans, we followed a cohort of 157 school-going orphans and 480 non-orphans ages 9–15 in a context of high HIV/AIDS mortality in South Africa from 2004 to 2007. Several findings were contrary to the published evidence to date, as we found no difference between orphans and non-orphans in anxiety/depression symptoms, oppositional behavior, self-esteem, or resilience. Female gender, self-reported poor health, and food insecurity were the most important predictors of childrens psychosocial well-being. Notably, girls had greater odds of reporting anxiety/depression symptoms than boys, and scored lower on self-esteem and resilience scales. Food insecurity predicted greater anxiety/depression symptoms and lower resilience. Perceived social support was a protective factor, as it was associated with lower odds of anxiety/depression symptoms, lower oppositional scores, and greater self-esteem and resilience. Our findings suggest a need to identify and strengthen psychosocial supports for girls, and for all children in contexts of AIDS-affected and economic adversity.

Early impacts of orphaning: Health, nutrition, and food insecurity in a cohort of school-going adolescents in South Africa

We recruited a cohort of 157 recent orphans and 480 non-orphans aged 9–15 in a region of high HIV/AIDS mortality in South Africa using stratified cluster sampling to determine the impact of recent parental death on health and food insecurity of school-going orphans compared to non-orphans over time. Between September 2004 and June 2007, household heads, caregivers, and children were interviewed at three annual intervals. Bivariate associations and multivariate models were assessed using generalized estimating equations (GEE). In the health domain, compared to non-orphans, double orphans were more likely to report worse health status and being very ill in the previous 12 months. For those who reported being very ill, maternal or paternal orphans were more than twice as likely not to seek care than non-orphans; no differences were found for double orphans. For nutrition and food insecurity, maternal or paternal orphans were more likely not to have eaten dinner and to have gone to bed hungry the previous night compared to non-orphans; no differences were found for double orphans. Overall, recent school-aged orphans were disadvantaged in health and food insecurity within two years after the death of a parent, compared to their non-orphaned counterparts, but the disparities were smaller than expected. No changes in health, nutritional status, or food insecurity were apparent over the three study rounds. Longer term effects into adulthood may well be more pronounced and warrant careful longitudinal investigation.

Increasing compliance with alcohol service laws in a developing country: intervention trial in the Kingdom of Bhutan.

AIM Bhutan is a low-middle income country that, like many others, experiences significant alcohol-related harm and low compliance with laws restricting availability and promotion. This study assessed changes in compliance of alcohol outlets with sales restrictions following a multi-sector programme aimed at improving this. DESIGN Pre-post design with covert observation of service practices. SETTING Thimphu, Bhutan, June-November 2013. Alcohol is not permitted for sale except from 1 to 10 p.m. Wednesday-Monday. Serving minors (< 18 years old) or intoxicated patrons is illegal. PARTICIPANTS Seventy-one outlets selected randomly from all 209 on-premises outlets in downtown Thimphu. INTERVENTION Multi-sector programme involving visits to outlets, education of owners and staff, a toolkit and implementation checks. MEASUREMENTS Ten mystery-shopper visits were made to each outlet both before and after the intervention. We assessed compliance in five purchasing scenarios: (1) before 1 p.m., (2) after 10 p.m., (3) on Tuesdays and (4) shoppers who appeared to be underage or (5) intoxicated. Changes in compliance rates were assessed using multi-variable logistic regression models. FINDINGS Overall compliance increased from 20 to 34% [difference: 14%; 95% confidence interval (CI) = 7-22%]. Improvement was found in refusals of service before 1 p.m.: 10-34% (difference(adj) = 24%; 95% CI = 12-37%) and on Tuesdays: 43-58% (difference(adj) = 14%; 95% CI = 1-28%). Differences in refusal to serve alcohol: after 10 p.m. (difference(adj) = 15%; 95% CI = -8 to 37%); to underage patrons (difference(adj) = -5%; 95% CI = 14 to 4%); and to intoxicated patrons (difference(adj) = 7%; 95% CI = -7-20%) were not statistically significant. Younger servers, stand-alone bars and outlets permitting indoor smoking were each less likely to comply with the alcohol service laws. CONCLUSION A multi-sector programme to improve compliance with legal restrictions on serving alcohol in Bhutan appeared to have a modest effect but even after the programme, in two-thirds of the occasions tested, the laws were broken.

Real-Time Electronic Drug Monitoring for HIV-Positive Adolescents: Promising Acceptability and Feasibility in China

Objective: Little research to date has focused on measuring adherence among and tailoring adherence interventions to HIV-positive youth. To explore the potential of emerging mHealth technologies as adherence tools for youth, we assessed the acceptability and feasibility of a real-time web-linked electronic drug monitoring (EDM) device to support antiretroviral (ART) adherence among HIV-positive adolescents in China. Methods: Twenty patients ages 10-15 years who were on ART at the Guangxi Center for Disease Control ART clinic in Nanning, China used a wireless EDM device for medication for one month. We monitored adherence in real time, and explored the device’s acceptability among patients using a mixed-methods approach. Results: Using EDM data, median adherence was 93.9% (IQR 10.2) of prescribed doses taken and 90.2% (IQR 13.3) using the on-time measure. Only 20% (4/20) of patients met the strictest generally-accepted criterion for optimal adherence (≥ 95% using on-time measure) over the observation period. Self-reported median adherence for the month was 100% proportion taken. Although they expressed concerns about inconvenience and the device’s size and appearance in open-ended questions, all adolescent participants reported a positive overall experience with the device in closed-ended questions. Conclusion: Wireless EDM technology represents an acceptable and rigorous method of measuring ART adherence, and a potentially useful adherence support, for HIV-positive adolescents at a critical time in their lives, as well as for adolescents who take medications for other chronic health conditions. Future studies should focus on identifying ways of strengthening caregiver-adolescent relationships and developing tailored, age-appropriate intervention packages to support adherence.

Household dynamics and socioeconomic conditions in the context of incident adolescent orphaning in KwaZulu-Natal, South Africa

We compared demographics, socioeconomic status, and food insecurity between households with and without recent orphans in a region of high HIV/AIDS mortality in South Africa. We recruited a cohort of 197 recent orphans and 528 non-orphans aged 9–15 years and their households using stratified cluster sampling. Households were classified into three groups: orphan-only (N = 50), non-orphan-only (N = 377), and mixed (N = 210). Between September 2004 and May 2007, households were interviewed three times regarding demographics, income and assets, and food insecurity. Baseline bivariate associations were assessed using chi-square test and t-test. Longitudinal bivariate associations and multivariate models were tested using generalized estimating equations. At baseline, mixed households generally exhibited greater characteristics of vulnerability than orphan-only and non-orphan-only households. They were larger, had older, less-educated household heads, and reported a much smaller annual per capita income. Orphan households were more likely to report a death in the previous year and less likely to have an adult employed. These differences persisted over the study. Even non-orphan-only households exhibited characteristics of vulnerability, with 14% reporting a death one year before baseline, 45% of whom were prime-age adults. At baseline, a much smaller proportion of orphan households reported receiving the child support grant than the other household types, but notably, there were no differences among households in receipt of the grant by Round 3. Household food insecurity was highly prevalent: more than one in five orphan-only and mixed households reported being food insecure in the previous month. These findings suggest that the effects of HIV/AIDS only exacerbate existing high levels of poverty in the district, as virtually all households are vulnerable regardless of orphan status. Community-level programs must help families address a spectrum of needs, including food security, caregiving, and financial support, as well as better target social welfare grants and make them more accessible to vulnerable households.