Implementation determinants and strategies in integration of PrEP into maternal and child health and family planning services: experiences of frontline healthcare workers in Kenya

BackgroundDelivery of PrEP to adolescent girls and young women (AGYW) and to pregnant women through maternal and child health (MCH) and family planning (FP) clinics is scaling up in Kenya. Evaluation of implementation challenges and strategies is critical to optimize delivery.MethodsWe conducted focus group discussions (FGDs) with healthcare workers (HCWs) in MCH and FP clinics offering PrEP in a large implementation project in Kisumu, Kenya. Discussion guides were based on the Consolidated Framework for Implementation Research (CFIR). FGDs were audio recorded and transcribed. Directed content analysis was used to identify implementation challenges and strategies to overcome them.ResultsFifty HCWs from 26 facilities participated in 8 FGDs. HCWs believed PrEP integration was appropriate because it met the needs of AGYW and pregnant women by providing a female-controlled prevention strategy and aligned with policy priorities of elimination of vertical HIV transmission. They were universally accepting of PrEP provision, especially through MCH clinics, noting the relative advantage of this approach because it: (1) enabled high coverage, (2) harmonized PrEP and MCH visits, and (3) minimized stigma compared to PrEP offered through HIV care clinics. However, HCWs noted implementation challenges affecting feasibility and adoption including: (1) increased workload and documentation burden amid workforce shortages, (2) insufficient health care worker knowledge (3) multiple implementing partners with competing priorities (4) drug and documentation form stockouts. HCWs employed various implementation strategies to overcome challenges, including task shifting from nurses to HIV testing providers, patient flow modifications (e.g., fast-tracking PrEP clients to reduce wait times), PrEP demand generation and myth clarification during health talks, provider education, dedicated PrEP delivery rooms, and coordination with adolescent-friendly services. Additional suggested strategies to improve PrEP integration included community education to increase broader PrEP awareness and enable shorter counseling sessions, and task-shifting data entry and client risk assessments.ConclusionsHCWs were enthusiastic about the appropriateness and acceptability of integrating PrEP services into MCH and FP clinics but noted challenges to adoption and feasibility. Strategies to address challenges focused on improving provider time and space constraints, and increasing provider and client knowledge

Healthcare workers' perspectives and practices regarding the disclosure of HIV status to children in Malawi: A cross-sectional study

Background: In 2011 the World Health Organisation recommended that children with a diagnosis of HIV be gradually informed about their HIV status between the ages of 6 and 12 years. However, to date, literature has focused mainly on primary caregiver and child experiences with HIV disclosure, little is known about healthcare workers' perspectives and practices of HIV status disclosure to children. The aim of this study was to assess healthcare workers' perspectives and practices regarding the disclosure of HIV status to children aged between 6 and 12 years in Malawi. Methods: A cross-sectional survey was used to collect data from 168 healthcare providers working in antiretroviral clinics in all government District and Tertiary Hospitals in Malawi. Participants were asked questions regarding their knowledge, practice, and barriers to HIV disclosure. Data were analysed using binary logistic regression. Results: Almost all healthcare workers (98%) reported that it was important to disclose HIV status to children. A significant proportion (37%) reported that they had never disclosed HIV status to a child and about half estimated that the rate of HIV disclosure at their facility was 25% or less. The main barriers to disclosure were lack of training on disclosure (85%) and lack of a standard tool for disclosure (84%). Female healthcare workers (aOR) 2.4; 95% CI: 1.1-5.5) and lack of training on disclosure (aOR 7.7; 95% CI: 3.4-10.7) were independently associated with never having disclosed HIV status to a child. Conclusions: This study highlights the need for providing appropriate training in HIV disclosure for healthcare workers and the provision of standardised disclosure materials

Track A Basic Science

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/138319/1/jia218438.pd

From Bench to Bedside: Understanding Multiple Dimensions of Pediatric HIV in Kenya

Thesis (Ph.D.)--University of Washington, 2013Introduction: Globally, over 3.3 million children are infected with HIV. Despite significant progress, there is a need to better understand mechanisms for transmission and progression of HIV in children. In addition, among children receiving HIV care, it is important to determine the best ways to inform them about their diagnosis. Methods: Consistent with the University of Washington Public Health Genetics PhD requirement of including both genetic epidemiology and social/cultural domains, this PhD dissertation addresses two projects of relevance to children with HIV. The aim of the first project is to determine the role of selected genetic mechanisms influencing pediatric HIV acquisition and progression. The aim of the second project is to determine how, when and what healthcare providers decide to tell HIV-infected children about their diagnosis. For project 1, we used genetic epidemiology methods to evaluate the role of variations in innate immune system genes on infant HIV acquisition and progression in a Kenyan mother-to-child transmission (MTCT) cohort. Specifically, we genotyped infants from this cohort for 6 candidate and 118 haplotype-tagging polymorphisms in TLRs 2, 3, 4, 7, 8, and 9, MyD88 and TIRAP, and 144 ancestral informative markers. Cox proportional hazards and linear regression were performed to assess TLR polymorphism associations with HIV acquisition, peak HIV RNA levels, and infant mortality. Sex-stratified analyses of TLR7 and TLR8 were conducted due to their X-chromosome location and Bonferroni methods were used to account for multiple comparisons. For project 2, we used qualitative methods to analyze transcripts from semi-structured interviews conducted with 21 healthcare providers caring for HIV-infected children from 5 clinics in Kenya. Interview transcripts were systematically coded and conceptually analyzed using modified grounded theory and directed content analysis approaches. Resulting themes were identified related to the disclosure processes, ethical and practical rationale for different approaches, and challenges or barriers to disclosure. Results: For project 1, we found that TLR variants influenced HIV acquisition and progression. Infants with the TLR9 1635A (rs352140) variant were more likely to acquire HIV by 1 month of age (HR=1.81, 95% CI: 1.05, 3.14; p=0.033) and 12 months of age (HR=1.62, 95% CI: 1.01, 2.60; p=0.044). We also found that among 56 infants infected by 1 month of age, the TLR9 1635A allele was associated with a decrease in peak viral load (-0.58 log10 c/ml, 95% CI: -0.95, -0.22; p=0.002) whereas female infants with the TLR8 1G (rs3764880) variant had increased peak viral load (0.78 log10 c/ml, 95% CI: 0.35, 1.21; p<0.001). We also found that among female infants infected at less than 1 year of age, infants with the TLR7 rs1634319 C allele had higher peak viral load (0.80 log10 c/ml, 95% CI: 0.40, 1.20; corrected p=0.027). For project 2, we found that all health care providers interviewed believed early, supported disclosure to children is important and cited concerns for the child's health and well-being as the central rationale. Providers viewed disclosure as a longitudinal process and advocated tailoring the approach to the individual child. Providers observed that preparation, support after disclosure, and a child's personality are more relevant predictors of the impact of disclosure on the child and family than the age when diagnosis is revealed. All stressed the need to incorporate caregiver preparation and empowerment and recognized that significant barriers to disclosure included caregiver fears about child reactions, including judgment of the parent. Conclusions: We found that variations in TLRs influence HIV acquisition and progression in infants. These associations may inform novel vaccine and therapeutic strategies for pediatric HIV. Our observations among health care providers revealed a wealth of clinical approaches that can be used in guidelines to improve pediatric HIV disclosure. Better understanding the mechanisms influencing infection and how to care for HIV-infected children can help reduce the global burden of this disease

J Int AIDS Soc

INTRODUCTION: Disclosure of HIV status to HIV-infected children and adolescents is a major care challenge. We describe current site characteristics related to disclosure of HIV status in resource-limited paediatric HIV care settings within the International Epidemiology Databases to Evaluate AIDS (IeDEA) consortium. METHODS: An online site assessment survey was conducted across the paediatric HIV care sites within six global regions of IeDEA. A standardized questionnaire was administered to the sites through the REDCap platform. RESULTS: From June 2014 to March 2015, all 180 sites of the IeDEA consortium in 31 countries completed the online survey: 57% were urban, 43% were health centres and 86% were integrated clinics (serving both adults and children). Almost all the sites (98%) reported offering disclosure counselling services. Disclosure counselling was most often provided by counsellors (87% of sites), but also by nurses (77%), physicians (74%), social workers (68%), or other clinicians (65%). It was offered to both caregivers and children in 92% of 177 sites with disclosure counselling. Disclosure resources and procedures varied across geographical regions. Most sites in each region reported performing staff members' training on disclosure (72% to 96% of sites per region), routinely collecting HIV disclosure status (50% to 91%) and involving caregivers in the disclosure process (71% to 100%). A disclosure protocol was available in 14% to 71% of sites. Among the 143 sites (79%) routinely collecting disclosure status process, the main collection method was by asking the caregiver or child (85%) about the child's knowledge of his/her HIV status. Frequency of disclosure status assessment was every three months in 63% of the sites, and 71% stored disclosure status data electronically. CONCLUSION: The majority of the sites reported offering disclosure counselling services, but educational and social support resources and capacities for data collection varied across regions. Paediatric HIV care sites worldwide still need specific staff members' training on disclosure, development and implementation of guidelines for HIV disclosure, and standardized data collection on this key issue to ensure the long-term health and wellbeing of HIV-infected youth

Lessons from PrEP: a qualitative study investigating how clinical and policy experts weigh ethics and evidence when evaluating preventive medications for use in pregnant and breastfeeding women

This study explored how multinational HIV experts weigh clinical, evidential, and ethical considerations regarding preexposure prophylaxis in pregnant/breastfeeding women. Semi-structured interviews were conducted with experts in HIV policy, research, treatment, and implementation from three global regions. A constant comparative approach identifed major themes. Experts noted that exclusion of pregnant women from research limits evidence regarding risks/benefts, emphasizing that underinclusion of pregnant women in RCTs shifts the onus of evidence-building to clinical care. Experts discussed approaches for weighing evidence to make decisions, including triangulating evidence from sources other than RCTs. Likelihood and severity of disease strongly infuenced decisions. Less efective interventions with limited fetal risk were preferred over interventions of uncertain safety, unless the disease was serious. Experts resisted the dichotomous choice between protecting maternal and fetal interests, arguing that these interests are intertwined and that more holistic approaches to maternal–fetal balance support greater inclusion of pregnant women in research

Estimating the costs of adolescent HIV care visits and an intervention to facilitate transition to adult care in Kenya.

IntroductionAdolescents with HIV in sub-Saharan Africa face challenges transitioning to adult HIV care, which can affect long-term HIV care adherence and retention. An adolescent transition package (ATP) focused on transition tools can improve post-transition clinical outcomes, but its implementation costs are unknown.MethodsWe estimated the average cost per patient of an HIV care visit and ATP provision to adolescents. Data was collected from 13 HIV clinics involved in a randomized clinical trial evaluating ATP in western Kenya. We conducted a micro-costing and activity-driven time estimation to assess costs from the provider perspective. We developed a flow-map, conducted staff interviews, and completed time and motion observation. ATP costs were estimated as the difference in average cost for an HIV care transition visit in the intervention compared to control facilities. We assessed uncertainty in costing estimates via Monte Carlo simulations.ResultsThe average cost of an adolescent HIV care visit was 29.8USD (95%CI 27.5, 33.4) in the standard of care arm and 32.9USD (95%CI 30.5, 36.8) in the ATP intervention arm, yielding an incremental cost of 3.1USD (95%CI 3.0, 3.4) for the ATP intervention. The majority of the intervention cost (2.8USD) was due ATP booklet discussion with the adolescent.ConclusionThe ATP can be feasibly implemented in HIV care clinics at a modest increase in overall clinic visit cost. Our cost estimates can be used to inform economic evaluations or budgetary planning of adolescent HIV care interventions in Kenya

Lessons from PrEP: a qualitative study investigating how clinical and policy experts weigh ethics and evidence when evaluating preventive medications for use in pregnant and breastfeeding women

This study explored how multinational HIV experts weigh clinical, evidential, and ethical considerations regarding preexposure prophylaxis in pregnant/breastfeeding women. Semi-structured interviews were conducted with experts in HIV policy, research, treatment, and implementation from three global regions. A constant comparative approach identifed major themes. Experts noted that exclusion of pregnant women from research limits evidence regarding risks/benefts, emphasizing that underinclusion of pregnant women in RCTs shifts the onus of evidence-building to clinical care. Experts discussed approaches for weighing evidence to make decisions, including triangulating evidence from sources other than RCTs. Likelihood and severity of disease strongly infuenced decisions. Less efective interventions with limited fetal risk were preferred over interventions of uncertain safety, unless the disease was serious. Experts resisted the dichotomous choice between protecting maternal and fetal interests, arguing that these interests are intertwined and that more holistic approaches to maternal–fetal balance support greater inclusion of pregnant women in research

Debrief Reports to Expedite the Impact of Qualitative Research: Do They Accurately Capture Data from In-depth Interviews?

"Debrief reports" (DRs) use structured forms to capture key concepts from in-depth interviews and focus group discussions. They are completed by interviewers and rapidly disseminated to key team members to facilitate identification of potential problems with study procedures, recruitment, or participant engagement and to inform critical adjustments, which can be especially pertinent in intervention studies. Their reliability and validity have yet to be formally evaluated. To assess the accuracy of DRs in capturing key content, raters analyzed a random sub-sample of 20 pairs of de-identified transcripts and their linked DRs from the VOICE-D trial. Analyses generally supported the accuracy of DRs; however, pertinent information from transcripts was occasionally missed or recorded with discrepancies or lack of detail. Longer transcripts and DR sections describing complex topic areas were more likely to involve discrepancies. Recommendations are offered for further research and optimizing the use of DRs