Factors that influence risk behavior in HIV infected women receiving antiretroviral therapy in Kampala and Masaka, Uganda

Women living in sub-Saharan Africa are more affected by HIV/AIDS than any other population in the world. Two-thirds of all new HIV infections worldwide occur in sub-Saharan Africa and over 60% of these infections are in women. Indeed, 70% of all women globally who are infected with HIV reside in this region (UNAIDS, 2006). If women are already infected with HIV, unprotected sex puts them at risk of transmitting the virus to a partner or to an unborn child. It also puts them at risk of becoming superinfected with different HIV strains, including HIV strains that are already resistant to HIV drugs (Little et al., 1999; Hecht et al., 1998; Flaks, Burman, Gourley, Rietmeijer, Cohn, 2003; Kozal et al., 2006). HIV infected women also need to be concerned with adherence to their antiretroviral therapy (ART) regimen. Lack of adherence to drug regimens puts women at risk of poor HIV treatment outcomes such as drug resistance (Chesney, 2003). When used consistently and correctly, male condoms are the most effective method of protection against HIV for sexually active persons (Stone, Timyan, Thomas,1999). Women, however, may be unable to negotiate the use of a male condom because strong gender-based power differentials and conservative social and cultural norms often make this decision completely up to a man (Gupta, 2002; Cohen, 2004). The constraints on a woman’s ability to reduce her risk have led to concerns about the use of individual based models for HIV/AIDS behavior in women. These models often fail to acknowledge the relationship factors and the social, cultural and economic contexts that influence women’s behavior. These concerns with inadequate models of HIV risk reduction for women have resulted in the publication of numerous articles proposing social-structural, also referred to as structural and environmental, models of HIV/AIDS risk reduction for women (Parker et al., 2002; O’Leary & Martins, 2000; Parker et al., 2000; Sumartojo,2000; Sweat & Denison, 1995; Decosas, 1996; Farmer, 2003; Turshen, 1998; Tawil et al., 1995; Lurie et al., 2004). This study, therefore, sought to use social-structural variables in exploring women’s HIV-related risk behaviors in a sub-Saharan Africa setting, Uganda, in East Africa. Although much is known about structural and environmental approaches to HIV prevention among HIV negative women, little is known about the potential application of this approach to studying sexual risk behaviors and adherence to ART among HIV infected women. The overall aim of the study was to examine associations between social-structural variables (e.g., poverty, gender power dynamics) and two outcome variables: history of unprotected sex and self-reported adherence to ART among HIV infected women enrolled in drug therapy programs. Data were collected using structured interviews with 377 HIV infected women in four different HIV/AIDS treatment programs in Kampala and Masaka, Uganda. A major finding of the study was that few women in the sample were sexually active(34%), partly due to the high proportion of non-sexually active widows (49%). The majority of sexually active women reported condom use at last sex act (75%) and disclosure of their HIV status to a main partner (78%). In multivariate analysis condom use at last sex act was strongly predicted by the need to borrow food to survive (OR=5.440, 95% CI 1.237, 23.923, p<.05), possibly indicating that women engaging in sexual exchange for food are more likely to use condoms. Forced, coercive or survival sex was significantly associated with the number of meals missed per week due to lack of food (OR=1.130, 95% CI 1.125, 1.526, p<.005). In addition, married women compared to unmarried women were three times more likely to have experienced forced, coercive or survival sex (OR=2.911, 95% CI 1.234, 6.87, p<.05). Because married women are considered to be relatively more economically stable, the findings that missing meals due to lack of food and married marital status are both associated with forced, coercive or survival sex, when adjusted for other factors, support the conclusion that both impoverished women and women with access to more resources can be at risk. Alternately, married women may not have as ready access to resources as is usually assumed and could also be engaging in sexual exchange behavior and borrowing food to get by. In either case, married women are probably more likely than their unmarried counterparts to experience large gender power differentials, despite their economic resources, that limit their ability to use condoms. Indeed, for all women in the study, the structural equation modeling (SEM) model fitting analyses indicated that genderbased power may be a more important predictor than economic security of women’s sexual risk behaviors. Neither factor was, however, predictive of ART adherence in this study sample. In summary, findings suggested that sexual exchange for food and other assistance is probably common and likely driven by economic deprivation. On the contrary, results indicated that sexual exchange is not necessarily linked with risky behaviors such as lack of condom use. There is evidence of increased risk for married women in the study, especially the risk of forced, coercive or survival sex. The complex interactions between poverty, hunger, marital status, gender-based power and different HIV/AIDS risk behaviors should be further examined in order to inform the implementation of HIV/AIDS programs designed for women

Improving HIV pre-exposure prophylaxis persistence among adolescent girls and young women: Insights from a mixed-methods evaluation of community, hybrid, and facility service delivery models in Namibia

IntroductionDespite the potential for community-based approaches to increase access to pre-exposure prophylaxis (PrEP) for adolescent girls and young women (AGYW), there is limited evidence of whether and how they improve PrEP persistence. We compared PrEP persistence among AGYW receiving services through community and hybrid models in Namibia to facility-based services. We subsequently identify potential mechanisms to explain how and why community and hybrid models achieved (or not) improved persistence to inform further service delivery innovation.MethodsData were collected from PrEP service delivery to AGYW over two-years in Namibia's Khomas Region. We used Kaplan-Meier analysis to estimate survival curves for PrEP persistence beyond three-months after initiation and report the cumulative probability of persistence at one- and three-months. Persistence was defined as any PrEP use within three months after initiation followed by a PrEP refill or previously prescribed supply of at least 30 days at the three-month visit. Interviews were conducted with 28 AGYW and 19 providers and analyzed using a deductive-inductive thematic approach.ResultsFrom October 2017 through September 2019, 372 (18.7%) AGYW received services through a facility model, 302 (15.1%) through a community model, and 1,320 (66.2%) through a hybrid model. PrEP persistence at one- and three-months was 41.2% and 34.9% in the community model and 6.2% and 4.8% in the hybrid model compared to 36.8% and 26.7% in the facility model. Within the community and hybrid models, we identified three potential mechanisms related to PrEP persistence. Individualized service delivery offered convenience and simplicity which enabled AGYW to overcome barriers to obtaining refills but did not work as well for highly mobile AGYW. Consistent interactions and shared experiences fostered social connectedness with providers and with peers, building social networks and support systems for PrEP use. PrEP and HIV-related stigma, however, was widely experienced outside of these networks. Community-to-facility referral for PrEP refill triggered apprehension towards unfamiliar PrEP services and providers in AGYW, which discouraged persistence.ConclusionService delivery approaches that offer convenience and simplicity and foster social connectedness may reduce access barriers and increase social support enabling AGYW to self-manage their PrEP use and achieve improved PrEP persistence

HIV issues and people with disabilities: A review and agenda for research

The recent AIDS and Disability Partners Forum at the UN General Assembly High Level Meetings on AIDS in New York in June 2011 and the International AIDS Conference in Washington, DC in July 2012 underscores the growing attention to the impact of HIV and AIDS on persons with disabilities. However, research on AIDS and disability, particularly a solid evidence base upon which to build policy and programming remains thin, scattered and difficult to access. In this review paper, we summarise what is currently known about the intersection between HIV and AIDS and disability, paying particular attention to the small but emerging body of epidemiology data on the prevalence of HIV for people with disabilities, as well as the increasing understanding of HIV risk factors for people with disabilities. We find that the number of papers in the peer-reviewed literature remains distressingly small. Over the past 20 years an average of 5 articles on some aspect of disability and HIV and AIDS were published annually in the peer-reviewed literature from 1990 to 2000, increasing slightly to an average of 6 per year from 2000 to 2010. Given the vast amount of research around HIV and AIDS and the thousands of articles on the subject published in the peer-reviewed literature annually, the continuing lack of attention to HIV and AIDS among this at risk population, now estimated to make up 15% of the world’s population, is striking. However, the statistics, while too limited at this point to make definitive conclusions, increasingly suggest at least an equal HIV prevalence rate for people with disabilities as for their nondisabled peers

Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015 : a systematic analysis for the Global Burden of Disease Study 2015

Background Improving survival and extending the longevity of life for all populations requires timely, robust evidence on local mortality levels and trends. The Global Burden of Disease 2015 Study (GBD 2015) provides a comprehensive assessment of all-cause and cause-specific mortality for 249 causes in 195 countries and territories from 1980 to 2015. These results informed an in-depth investigation of observed and expected mortality patterns based on sociodemographic measures. Methods We estimated all-cause mortality by age, sex, geography, and year using an improved analytical approach originally developed for GBD 2013 and GBD 2010. Improvements included refinements to the estimation of child and adult mortality and corresponding uncertainty, parameter selection for under-5 mortality synthesis by spatiotemporal Gaussian process regression, and sibling history data processing. We also expanded the database of vital registration, survey, and census data to 14 294 geography-year datapoints. For GBD 2015, eight causes, including Ebola virus disease, were added to the previous GBD cause list for mortality. We used six modelling approaches to assess cause-specific mortality, with the Cause of Death Ensemble Model (CODEm) generating estimates for most causes. We used a series of novel analyses to systematically quantify the drivers of trends in mortality across geographies. First, we assessed observed and expected levels and trends of cause-specific mortality as they relate to the Socio-demographic Index (SDI), a summary indicator derived from measures of income per capita, educational attainment, and fertility. Second, we examined factors affecting total mortality patterns through a series of counterfactual scenarios, testing the magnitude by which population growth, population age structures, and epidemiological changes contributed to shifts in mortality. Finally, we attributed changes in life expectancy to changes in cause of death. We documented each step of the GBD 2015 estimation processes, as well as data sources, in accordance with Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER). Findings Globally, life expectancy from birth increased from 61.7 years (95% uncertainty interval 61.4-61.9) in 1980 to 71.8 years (71.5-72.2) in 2015. Several countries in sub-Saharan Africa had very large gains in life expectancy from 2005 to 2015, rebounding from an era of exceedingly high loss of life due to HIV/AIDS. At the same time, many geographies saw life expectancy stagnate or decline, particularly for men and in countries with rising mortality from war or interpersonal violence. From 2005 to 2015, male life expectancy in Syria dropped by 11.3 years (3.7-17.4), to 62.6 years (56.5-70.2). Total deaths increased by 4.1% (2.6-5.6) from 2005 to 2015, rising to 55.8 million (54.9 million to 56.6 million) in 2015, but age-standardised death rates fell by 17.0% (15.8-18.1) during this time, underscoring changes in population growth and shifts in global age structures. The result was similar for non-communicable diseases (NCDs), with total deaths from these causes increasing by 14.1% (12.6-16.0) to 39.8 million (39.2 million to 40.5 million) in 2015, whereas age-standardised rates decreased by 13.1% (11.9-14.3). Globally, this mortality pattern emerged for several NCDs, including several types of cancer, ischaemic heart disease, cirrhosis, and Alzheimer's disease and other dementias. By contrast, both total deaths and age-standardised death rates due to communicable, maternal, neonatal, and nutritional conditions significantly declined from 2005 to 2015, gains largely attributable to decreases in mortality rates due to HIV/AIDS (42.1%, 39.1-44.6), malaria (43.1%, 34.7-51.8), neonatal preterm birth complications (29.8%, 24.8-34.9), and maternal disorders (29.1%, 19.3-37.1). Progress was slower for several causes, such as lower respiratory infections and nutritional deficiencies, whereas deaths increased for others, including dengue and drug use disorders. Age-standardised death rates due to injuries significantly declined from 2005 to 2015, yet interpersonal violence and war claimed increasingly more lives in some regions, particularly in the Middle East. In 2015, rotaviral enteritis (rotavirus) was the leading cause of under-5 deaths due to diarrhoea (146 000 deaths, 118 000-183 000) and pneumococcal pneumonia was the leading cause of under-5 deaths due to lower respiratory infections (393 000 deaths, 228 000-532 000), although pathogen-specific mortality varied by region. Globally, the effects of population growth, ageing, and changes in age-standardised death rates substantially differed by cause. Our analyses on the expected associations between cause-specific mortality and SDI show the regular shifts in cause of death composition and population age structure with rising SDI. Country patterns of premature mortality (measured as years of life lost [YLLs]) and how they differ from the level expected on the basis of SDI alone revealed distinct but highly heterogeneous patterns by region and country or territory. Ischaemic heart disease, stroke, and diabetes were among the leading causes of YLLs in most regions, but in many cases, intraregional results sharply diverged for ratios of observed and expected YLLs based on SDI. Communicable, maternal, neonatal, and nutritional diseases caused the most YLLs throughout sub-Saharan Africa, with observed YLLs far exceeding expected YLLs for countries in which malaria or HIV/AIDS remained the leading causes of early death. Interpretation At the global scale, age-specific mortality has steadily improved over the past 35 years; this pattern of general progress continued in the past decade. Progress has been faster in most countries than expected on the basis of development measured by the SDI. Against this background of progress, some countries have seen falls in life expectancy, and age-standardised death rates for some causes are increasing. Despite progress in reducing age-standardised death rates, population growth and ageing mean that the number of deaths from most non-communicable causes are increasing in most countries, putting increased demands on health systems. Copyright (C) The Author(s). Published by Elsevier Ltd.Peer reviewe

Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980-2017: a systematic analysis for the Global Burden of Disease Study 2017.

BACKGROUND: Global development goals increasingly rely on country-specific estimates for benchmarking a nation's progress. To meet this need, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016 estimated global, regional, national, and, for selected locations, subnational cause-specific mortality beginning in the year 1980. Here we report an update to that study, making use of newly available data and improved methods. GBD 2017 provides a comprehensive assessment of cause-specific mortality for 282 causes in 195 countries and territories from 1980 to 2017. METHODS: The causes of death database is composed of vital registration (VR), verbal autopsy (VA), registry, survey, police, and surveillance data. GBD 2017 added ten VA studies, 127 country-years of VR data, 502 cancer-registry country-years, and an additional surveillance country-year. Expansions of the GBD cause of death hierarchy resulted in 18 additional causes estimated for GBD 2017. Newly available data led to subnational estimates for five additional countries-Ethiopia, Iran, New Zealand, Norway, and Russia. Deaths assigned International Classification of Diseases (ICD) codes for non-specific, implausible, or intermediate causes of death were reassigned to underlying causes by redistribution algorithms that were incorporated into uncertainty estimation. We used statistical modelling tools developed for GBD, including the Cause of Death Ensemble model (CODEm), to generate cause fractions and cause-specific death rates for each location, year, age, and sex. Instead of using UN estimates as in previous versions, GBD 2017 independently estimated population size and fertility rate for all locations. Years of life lost (YLLs) were then calculated as the sum of each death multiplied by the standard life expectancy at each age. All rates reported here are age-standardised

Continuation of DMPA-SC or DMPA-IM when administered by community health workers in Uganda

The aim of this study was to examine continuation of subcutaneous and intramuscular depot medroxyprogesterone acetate (DMPA-SC and DMPA-IM) when administered by Village Health Teams (VHTs) in Uganda. Participants were family planning clients of VHTs who had decided to initiate injectable use. Women selected DMPA-SC or DMPA-IM and study staff followed them for up to four injections (providing 12-months of pregnancy protection) to determine contraceptive continuation. Study staff interviewed women at their first injection (baseline), second injection, fourth injection, and if they discontinued either product. Information from all interviews are included in this dataset. The methods and results for this study are described in the linked publication

Continuation of DMPA-SC or DMPA-IM when administered by facility-based health workers in Burkina Faso

The aim of this study was to examine continuation of subcutaneous and intramuscular depot medroxyprogesterone acetate (DMPA-SC and DMPA-IM) when administered by facility-based health workers in Burkina Faso. Participants were family planning clients who had decided to initiate injectable use. Women selected DMPA-SC or DMPA-IM and study staff followed them for up to four injections (providing 12-months of pregnancy protection) to determine contraceptivve continuation. Study staff interviewed women at their first injection (baseline), second injection, fourth injection, and if they discontinued either product. Information from all interviews are included in this dataset. The methods and results for this study are described in the linked publication

PrEP uptake and early persistence among adolescent girls and young women receiving services via community and hybrid community-clinic models in Namibia

Introduction Adolescent girls and young women (AGYW) face barriers in accessing clinic-based HIV pre-exposure prophylaxis (PrEP) services and community-based models are a proposed alternative. Evidence from such models, however, is limited. We evaluated PrEP service coverage, uptake, and early persistence among AGYW receiving services through community and hybrid models in Namibia. Methods We analyzed routine data for AGYW aged 15–24 who initiated PrEP within HIV prevention programming. PrEP was delivered via three models: community-concierge (fully community-based services with individually-tailored refill locations), community-fixed (community-based initiation and refills delivered by community providers on a set schedule at fixed sites), and hybrid community-clinic (community-based initiation and referral to clinics for refills delivered by clinic providers). We examined proportions of AGYW engaged in services along a programmatic PrEP cascade, overall and by model, and assessed factors associated with PrEP uptake and early persistence (refill within 15–44 days after initiation) using multivariable generalized estimating equations. Results Over 10-months, 7593 AGYW participated in HIV prevention programming. Of these, 7516 (99.0%) received PrEP education, 6105 (81.2%) received HIV testing services, 6035 (98.9%) tested HIV-negative, and 2225 (36.9%) initiated PrEP. Of the 2047 AGYW expected for PrEP refill during the study period, 254 (12.4%) persisted with PrEP one-month after initiation. Structural and behavioral HIV risk factors including early school dropout, food insecurity, inconsistent condom use, and transactional sex were associated with PrEP uptake. AGYW who delayed starting PrEP were 2.89 times more likely to persist (95% confidence interval (CI): 1.52–5.46) and those receiving services via the community-concierge model were 8.7 times (95% CI: 5.44–13.9) more likely to persist (compared to the hybrid model). Conclusion Community-based models of PrEP service delivery to AGYW can achieve high PrEP education and HIV testing coverage and moderate PrEP uptake. AGYW-centered approaches to delivering PrEP refills can promote higher persistence

“We Are Now Free to Speak”: Qualitative Evaluation of an Education and Empowerment Training for HIV Patients in Namibia

<div><p>Although numerous studies provide evidence that active patient engagement with health care providers improves critical outcomes such as medication adherence, very few of these have been done in low resource settings. In Namibia, patient education and empowerment trainings were conducted in four antiretroviral (ART) clinics to increase patient engagement during patient-provider interactions. This qualitative study supplements findings from a randomized controlled trial, by analyzing data from 10 in-depth patient interviews and 94 training evaluation forms. A blended approach of deductive and inductive coding was used to understand training impact. Findings indicated the trainings increased patients’ self-efficacy through a combination of improved HIV-related knowledge, greater communication skills and enhanced ability to overcome complex psychosocial barriers, such as fear of speaking up to providers. This study suggests patient empowerment training may be a powerful method to engage HIV patients in their own care and treatment.</p></div