Understanding patients' adherence to antiretroviral therapy: a mixed-methods study in Arusha, Tanzania

Background: Over one million HIV-positive people in Africa are taking antiretroviral therapy (ART), and this number is increasing. Essential to the expansion of ART is ensuring patients' optimal adherence to therapy. This study combined qualitative and quantitative methods to understand ART adherence at one site in Tanzania where patients received free medication. The study measured ART adherence, identified factors associated with poor adherence, and explored how the social environment of patients' lives supported adherence. A theoretical framework using the Social Cognitive Theory (SCT) and social support guided the study. Methods: Semi-structured interviews were conducted in Kiswahili with 36 adult ART patients and 6 health care providers. Patients described their experiences taking ART and managing adherence and providers described their experiences caring for patients. A structured survey was conducted with 340 patients. Adherence was measured by self report, and patients were identified as having poor adherence if they took less than 95% of their pills during either the previous four days or one month. The survey measured correlates of adherence informed by the SCT, along with demographic and treatment variables. Factors associated with adherence were considered in a logistic regression model. Results: Only 5.9% (20/340) of patients reported poor adherence. Poor adherence was associated with: being young (19-30 years, vs. 31-40 years; OR=4.26, 95% CI 1.33-13.60); being old (over 50 years, vs. 31-40 years; OR=7.59, 95% CI 2.10-27.43); having lower perceived quality of patient-provider interaction (for each one-point decrease, OR=3.18, 95%CI 1.29-7.83); and ever missing a clinic appointment (OR=3.75, 95% CI 1.29-10.89). Semi-structured interviews identified five factors to explain optimal adherence. First, respondents experienced improved health on ART, which motivated adherence. Second, they linked pill-taking with routine activities. Third, they were motivated to stay healthy to meet family responsibilities. Fourth, material and emotional support from others facilitated adherence. Finally, respondents trusted health care providers' instructions to adhere. Conclusions: Adherence was high in this sample. Interventions to improve and sustain adherence should focus within the clinic to improve interactions between patients and providers and outside the clinic to bolster patients' social support. Different strategies may be necessary according to patients' ages

Missed Opportunities for Religious Organizations to Support People Living with HIV/AIDS: Findings from Tanzania

Religious beliefs play an important role in the lives of Tanzanians, but little is known about the influence of religion for people living with HIV/AIDS (PLWHA). This study shares perspectives of PLWHA and identifies opportunities for religious organizations to support the psychological well-being of this group. Data were collected in 2006 and 2007 through semistructured interviews with 36 clients (8 Muslims and 28 Christians) receiving free antiretrovirals (ARVs) in Arusha, Tanzania. Swahili-speaking interviewers asked about participation in religion, change in religious engagement since HIV diagnosis, and what role faith plays in living with HIV and taking ARVs. Interviews were audiotaped, transcribed, translated, and analyzed using Atlas t.i. The findings revealed that patients' personal faith positively influenced their experiences living with HIV, but that religious organizations had neutral or negative influences. On the positive side, prayer gave hope to live with HIV, and religious faith increased after diagnosis. Some respondents said that prayer supported their adherence to medications. On the other hand, few disclosed their HIV status in their religious communities, expressing fear of stigma. Most had heard that prayer can cure HIV, and two expected to be cured. While it was common to hear messages about HIV prevention from churches or mosques, few had heard messages about living with HIV. The findings point to missed opportunities by religious organizations to support PLWHA, particularly the need to ensure that messages about HIV are not stigmatizing; share information about HIV treatment; introduce role models of PLWHA; and emphasize that prayers and medical care go hand-in-hand

The mental health experiences and needs of methamphetamine users in Cape Town: A mixed-methods study

Background. South Africa (SA) has a burgeoning problem of methamphetamine use, particularly in the Western Cape Province. Although methamphetamine has been associated with elevated psychological distress, there has been little examination of the mental health needs of out-of-treatment methamphetamine users in SA.Objective. To describe the mental health experiences and needs of out-of-treatment methamphetamine users in Cape Town. Methods. Active methamphetamine users were recruited using respondent-driven sampling techniques. Eligible participants (N=360) completed a computer-assisted assessment and clinical interview, where they provided data on mental health symptoms and treatment- seeking behaviour. A subset of 30 participants completed qualitative in-depth interviews in which they provided narrative accounts of their mental health experiences and needs. Analysis of the mixed-methods data was conducted using a concurrent triangulation strategy whereby both methods contributed equally to the analysis and were used for cross-validation. Results. About half of the participants met screening criteria for depression and traumatic stress, and there were some indications of paranoia. Using substances to cope with psychological distress was common, with participants talking about using methamphetamine to numb their feelings or forget stressful memories. One-third of women and 13% of men had previously tried to commit suicide. Despite the huge mental health burden in this population, very few had ever received mental health treatment. Conclusion. The data indicate a need for integrated care that addresses both substance use and psychiatric needs in this population. Mental health and drug treatment services targeting methamphetamine users should include a concerted focus on suicide prevention.

Vitamin D Status of Anabaptist Children in Southwestern Ontario, Canada

The objective was to determine vitamin D status of Old Order Anabaptist children in rural Southwestern, Ontario, Canada, given concerns of community healthcare professionals. Fifty-two children (2.5 months - 6.5 years) (56% female) were recruited. Finger prick blood spot (BSp) samples were analyzed for 25-hydroxy (OH) vitamins D2 & D3 (BSp25(OH)D). Three-day food records were evaluated using Dietary Reference Intakes and Canada’s Food Guide (CFG) (Bush, et al. 2007). Compared to national Canadian data: mean BSp25(OH)D concentrations (78±31 nmol/L) were similar; a slightly smaller proportion (0% vs 2%) were at risk of deficiency (\u3c30 nmol/L) or had inadequate status (4% vs 7%) (\u3c40 nmol/L); and 10% vs 1% had BSp25(OH)D higher than 125 nmol/L. BSp25(OH)D was significantly associated (r2=0.358; p=0.001) with total vitamin D intake. From food alone, vitamin D intake was 68±39 IU/day, lower than the Recommended Dietary Allowance (RDA) of 600 IU/day, and intakes were all below the Estimated Average Requirement (EAR) of 400 IU. Even including supplemental vitamin D, 87% were below the EAR (total intake=213±194 IU/day). No children had vitamin D intakes greater than the Upper Limit. Servings of milk and alternates were 1.6±0.8/day (CFG=2/day). Unfortified farm milk was consumed by 88% of children and 89% received a vitamin D supplement. Results were comparable to recent Canadian data suggesting that most children have adequate vitamin D status. Nevertheless, these findings support the need to encourage appropriate vitamin D intake (from food and supplements) to achieve the RDA for Old Order Anabaptist children in these communities. [Abstract by authors.

Religion and HIV in Tanzania: influence of religious beliefs on HIV stigma, disclosure, and treatment attitudes

Abstract Background Religion shapes everyday beliefs and activities, but few studies have examined its associations with attitudes about HIV. This exploratory study in Tanzania probed associations between religious beliefs and HIV stigma, disclosure, and attitudes toward antiretroviral (ARV) treatment. Methods A self-administered survey was distributed to a convenience sample of parishioners (n = 438) attending Catholic, Lutheran, and Pentecostal churches in both urban and rural areas. The survey included questions about religious beliefs, opinions about HIV, and knowledge and attitudes about ARVs. Multivariate logistic regression analysis was performed to assess how religion was associated with perceptions about HIV, HIV treatment, and people living with HIV/AIDS. Results Results indicate that shame-related HIV stigma is strongly associated with religious beliefs such as the belief that HIV is a punishment from God (p < 0.01) or that people living with HIV/AIDS (PLWHA) have not followed the Word of God (p < 0.001). Most participants (84.2%) said that they would disclose their HIV status to their pastor or congregation if they became infected. Although the majority of respondents (80.8%) believed that prayer could cure HIV, almost all (93.7%) said that they would begin ARV treatment if they became HIV-infected. The multivariate analysis found that respondents' hypothetical willingness to begin ARV treatme was not significantly associated with the belief that prayer could cure HIV or with other religious factors. Refusal of ARV treatment was instead correlated with lack of secondary schooling and lack of knowledge about ARVs. Conclusion The decision to start ARVs hinged primarily on education-level and knowledge about ARVs rather than on religious factors. Research results highlight the influence of religious beliefs on HIV-related stigma and willingness to disclose, and should help to inform HIV-education outreach for religious groups

Post-traumatic stress disorder: A biopsychosocial case-control study investigating peripheral blood protein biomarkers

Experiencing traumatic events is unfortunately commonplace and, in some cases, may lead to the onset of debilitating mental health disorders, such as post-traumatic stress disorder (PTSD). Current diagnostic criteria for PTSD results in high depression and anxiety comorbidity. Better understanding of biological mechanisms and pathways underlying PTSD could aid in more accurate case identification and stratification of treatments. Recent meta-analysis has identified chronic PTSD to be associated with increased expression of pro-inflammatory cytokines and alterations in neuronal structures which contribute to an overall reduction in brain volume. Despite this, there are currently no biological markers in clinical use to identify PTSD or monitor treatment. This case-control study (n = 40) aimed to identify differences in peripheral blood biomarkers, and biomarker combinations, able to distinguish PTSD participants from controls, and examine in a biopsychosocial framework. The levels of 5/37 biomarkers investigated were significantly altered in the serum of PTSD participants: HDL and LDL cholesterol, tPA, IL-8 and EGF. Biomarkers could be used in combination with psychological criteria, in a biopsychosocial model, to support clinical management decisions and ensure appropriate individual treatment pathways

Unpacking Loss to Follow-Up Among HIV-Infected Women Initiated on Option B+ In Northern Tanzania: A Retrospective Chart Review

Background:&nbsp;In 2014, Tanzania adopted the Option B+ policy for the prevention of mother-to-child transmission of HIV (PMTCT), which stipulates lifelong antiretroviral therapy (ART) for HIV-infected pregnant, postpartum and breastfeeding women, irrespective of CD4 count or WHO clinical staging. Loss to follow-up (LTFU) during pregnancy and the postpartum period may undermine the effectiveness of Option B+. Factors associated with no follow-up (NFU)&nbsp; care, may differ from those associated with LTFU at later time points. This study aimed to identify factors associated with NFU and LTFU among women who initiate ART under Option B+ in Moshi, Tanzania. &nbsp; Methods:&nbsp;We conducted a retrospective chart review of patients initiating ART on Option B+ between February 2014 and December 2015 in Moshi Municipality, Tanzania. Multivariable log-binomial regression was used to analyse factors associated with NFU. Kaplan-Meier survival functions were used to estimate time to LTFU. Multivariable Cox proportion hazards regression models were used to evaluate variables associated with time to LTFU. &nbsp; Results:&nbsp;Among 468 women initiating ART under the option B+ programme, 109 (23.3%) had NFU after the initial appointment. Factors associated with increased risk of NFU were: age &lt; 25 years (adjusted hazard ratio [aRR] 1.7; 95% CI, 1.2 to 2.3), initiating ART at a hospital compared to a lower level health facilities (aRR 2.9; 95% CI, 2.1 to 3.9), and having no treatment supporter (aRR 1.5; 95% CI, 1.1 to 2.1). LTFU was higher in women aged &lt; 25 years (aHR 1.4; 95% CI, 1.1 to 1.9), and in women with no treatment supporter (aHR 1.8; 95% CI, 1.4 to 2.3). In women who returned to the clinic after ART initiation, no factor was significantly associated with LTFU. &nbsp; Conclusion:&nbsp;The factors associated with NFU (being young, not having a treatment supporter, and being diagnosed at hospitals) reflect a vulnerable and potentially highly mobile population. Additional interventions are needed to support and retain this group at ART initiation on Option B+

Missed opportunities for timely diagnosis of pediatric lupus in South Africa: a qualitative study

Background: Systemic Lupus Erythematosus (SLE) is a serious multisystem autoimmune disease, which is more aggressive in children and people of African descent. In South Africa, pediatric SLE (pSLE) patients are at high risk for severe disease. Similar to pSLE worldwide, South African children and adolescents with SLE require subspecialized medical care. The aim of this study is to describe the care-seeking experiences of families and examine factors that contribute to delays in the diagnosis of pSLE. Specifically, we sought to identify factors to inform interventions that support the timely referral and diagnosis of pediatric SLE patients in South Africa. Methods: In-depth, semi-structured interviews were conducted with 22 caregivers of pSLE patients recruited from two government hospitals in Cape Town, South Africa in 2014. Interviews were audio-recorded, transcribed, and analyzed for themes related to barriers to diagnosis. Results: Six themes were identified and classified as either caregiver or health system barriers to diagnosis. Caregiver barriers included lack of knowledge regarding SLE, financial difficulties, and the social stigma of SLE. Health system barriers were lack of trained staff, a complex medical system, and misdiagnosis. Conclusion: Caregivers reported missed opportunities for diagnosing pSLE in their children. Raising public awareness may improve caregiver awareness and reduce stigma of pSLE. Improving family education at diagnosis holds potential to increase patient-physician trust and mitigate fear. Education modules for primary care providers at initial point of contact with the health care system may improve recognition of early pSLE and facilitate expedited referral to a specialist

Acceptability of a group intervention for initiates of antiretroviral therapy in Tanzania

The success of antiretroviral therapy (ART) programmes requires high adherence and retention in care. In light of healthcare shortages, group interventions may be optimal ways to deliver information and provide support to ART patients. This study assessed the acceptability of a group intervention for patients and their supporters, which aimed to decrease stigma, harness social support and improve adherence. 28 ART patients attended a four-hour group intervention and 11 brought someone they identified as a potential supporter. The intervention was led by HIV-infected facilitators and included interactive sessions on HIV, ART, caregiving, stigma and disclosure. Participants completed intake and exit interviews and participated in focus group discussions. Participants rated the intervention favourably and in FGDs patients said they gained knowledge about adherence, felt empowered to tackle stigma and disclose, and experienced reductions in loneliness. Supporters reported they learned how to provide better care, gained knowledge, and felt closer to the person they were taking care of. Both patients and supporters saw HIV-infected facilitators as role models. Opinions were mixed about benefits of combining patients and supporters in the same intervention due to confidentiality. The group intervention showed potential to reduce stigma, increase social support, and improve adherence to therapy

A counseling intervention to address HIV stigma at entry into antenatal care in Tanzania (Maisha): study protocol for a pilot randomized controlled trial.

BACKGROUND: HIV-related stigma significantly impacts HIV care engagement, including in prevention of mother-to-child transmission of HIV (PMTCT) programs. Maisha is a stigma-based counseling intervention delivered during the first antenatal care (ANC) visit, complementing routine HIV counseling and testing. The goal of Maisha is to promote readiness to initiate and sustain treatment among those who are HIV-positive, and to reduce HIV stigmatizing attitudes among those who test negative. METHODS: A pilot randomized control trial will assess the feasibility and acceptability of delivering Maisha in a clinical setting, and the potential efficacy of the intervention on HIV care engagement outcomes (for HIV-positive participants) and HIV stigma constructs (for all participants). A total of 1000 women and approximately 700 male partners will be recruited from two study clinics in the Moshi municipality of Tanzania. Participants will be enrolled at their first ANC visit, prior to HIV testing. It is estimated that 50 women (5%) will be identified as HIV-positive. Following consent and a baseline survey, participants will be randomly assigned to either the control (standard of care) or the Maisha intervention. The Maisha intervention includes a video and counseling session prior to HIV testing, and two additional counseling sessions if the participant tests positive for HIV or has an established HIV diagnosis. A subset of approximately 500 enrolled participants (all HIV-positive participants, and a random selection of HIV-negative participants who have elevated stigma attitude scores) will complete a follow-up assessment at 3 months. Measures will include health outcomes (care engagement, antiretroviral adherence, depression) and HIV stigma outcomes. Quality assurance data will be collected and the feasibility and acceptability of the intervention will be described. Statistical analysis will examine potential differences between conditions in health outcomes and stigma measures, stratified by HIV status. DISCUSSION: ANC provides a unique and important entry point to address HIV stigma. Interventions are needed to improve retention in PMTCT care and to improve community attitudes toward people living with HIV. Results of the Maisha pilot trial will be used to generate parameter estimates and potential ranges of values to estimate power for a full cluster-randomized trial in PMTCT settings, with extended follow-up and enhanced adherence measurement using a biomarker.