A formative and outcome evaluation of a community based antiretroviral therapy adherence programme : the case of Sizophila, Cape Town, South Africa

This dissertation is informed by a formative and outcome evaluation of the Sizophila programme, a community based antiretroviral therapy (ART) programme. The programme is administered by the Desmond Tutu HIV Foundation, a non-profit organization. The aim of the programme is to enhance ART health outcomes and promote individual wellbeing among people accessing human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) related services in the Hannan-Crusaid Centre. The goal of the evaluation was to assess the Sizophila programme implementation and to determine the impact of the home visit intervention on the medium-term outcomes of HIV viral load suppression and loss to follow-up. The evaluation was primarily for the programme staff. An implicit Sizophila programme theory was explicated from the programme staff and the evaluator reviewed relevant programme documentation to formulate an explicit programme theory. To assess the plausibility of this theory, social science perspectives based on reviews of empirical evidence of previous research were solicited. The initial Sizophila programme theory was simplistic in assuming a simple cause-effect relationship. The final programme theory recognised that programme interventions function through certain moderators and mediators that can either strengthen or weaken the intervention-outcome effect

Workplace stress and coping strategies among nurses in HIV/AIDS care: Geita District Hospital, Tanzania

Magister Public Health - MPHThe unprecedented increase in HIV and AIDS cases has trickled down to the already impoverished health sector, thus impacting health workers in various ways. In a shrinking health workforce, HIV/AIDS has created an extra demand and workload, emotional burden and stress among health workers. The study aimed to explore and describe nurses’ workplace stressors and coping strategies with regards to HIV/AIDS environment. The exploratory- descriptive study was qualitative in nature. Geita District Hospital was selected as it is the only health facility in the district that provides in-patient care services related to HIV/AIDS. The study population consisted of all nurses who work with HIV and AIDS patients and the managers providing support to nurses. The researcher interviewed twelve nurses and two key informants. Face to face interviews were conducted and a semi-structured interview guide was utilised to collect data. Thematic content analysis was utilised and themes were derived from the concepts that emerged during the process. Validity and trustworthiness of the study was established through triangulation and member checking. The findings of the study revealed that nurses in HIV/AIDS experience stress from the workplace. Nurses struggled with issues of death and dying, feared occupational exposure and found it difficult to cope with nursing shortage, increased workload and inadequate training. The nurses were generally disturbed by lack of organisational support and the unavailability of resources such as; basic medical supplies and protective equipment. Nurses seemed to be resorting more to positive reappraisal, planful problem solving and seeking social support strategies

Assessment of a screening tool to aid home-based identification of adolescents (aged 10-14) living with HIV in Zambia and South Africa: HPTN 071 (PopART) study.

INTRODUCTION: The HPTN071 (PopART) for Youth (P-ART-Y) study evaluated the acceptability and uptake of a community-level combination HIV prevention package including universal testing and treatment (UTT) among young people in Zambia and South Africa. We determined whether a four-question primary care level screening tool, validated for use in clinical settings, could enhance community (door-to-door) identification of undiagnosed HIV-positive younger adolescents (aged 10-14) who are frequently left out of HIV interventions. METHOD: Community HIV-care Providers (CHiPs) contacted and consented adolescents in their homes and offered them participation in the PopART intervention. CHiPs used a four question-screening tool, which included: history of hospital admission; recurring skin problems; poor health in last 3 months; and death of at least one parent. A "yes" response to one or more questions was classified as being "at risk" of being HIV-positive. Rapid HIV tests were offered to all children. Data were captured through an electronic data capture device from August 2016 to December 2017. The sensitivity, specificity, positive predictive value and negative predictive value were estimated for the screening tool, using the rapid HIV test result as the gold standard. RESULTS: In our 14 study sites, 33,710 adolescents aged 10-14 in Zambia and 8,610 in South Africa participated in the study. About 1.3% (427/33,710) and 1.2% (106/8,610) self-reported to be HIV positive. Excluding the self-reported HIV-positive, we classified 11.3% (3,746/33,283) of adolescents in Zambia and 17.5% (1,491/8,504) in South Africa as "at risk". In Zambia the estimated sensitivity was 35.3% (95% CI 27.3%-44.2%) and estimated specificity was 88.9% (88.5%-89.2%). In South Africa the sensitivity was 72.3% (26.8%-94.9%) and specificity was 82.5% (81.6-83.4%). CONCLUSION: The sensitivity of the screening tool in a community setting in Zambia was low, so this tool should not be considered a substitute for universal testing where that is possible. In South Africa the sensitivity was higher, but with a wide confidence interval. Where universal testing is not possible the tool may help direct resources to adolescents more likely to be living with undiagnosed HIV. TRIAL REGISTRATION: Clinical Trial Number: NCT01900977

Corrigendum to: community-based health workers implementing universal access to HIV testing and treatment: lessons from South Africa and Zambia-HPTN 071 (PopART).

In the originally published version of this manuscript, the spelling of the co-author’s name was incorrect. The name should be “Mubekapi-Musadaidzwa” but is listed as “Mubekapi-Muzadaidzwa”. This error has now been corrected online

Community-based health workers implementing universal access to HIV testing and treatment: lessons from South Africa and Zambia-HPTN 071 (PopART).

The global expansion of HIV testing, prevention and treatment services is necessary to achieve HIV epidemic control and promote individual and population health benefits for people living with HIV (PLHIV) in sub-Saharan Africa. Community-based health workers (CHWs) could play a key role in supporting implementation at scale. In the HPTN 071 (PopART) trial in Zambia and South Africa, a cadre of 737 study-specific CHWs, working closely with government-employed CHW, were deployed to deliver a 'universal' door-to-door HIV prevention package, including an annual offer of HIV testing and referral services for all households in 14 study communities. We conducted a process evaluation using qualitative and quantitative data collected during the trial (2013-2018) to document the implementation of the CHW intervention in practice. We focused on the recruitment, retention, training and support of CHWs, as they delivered study-specific services. We then used these descriptions to: (i) analyse the fidelity to design of the delivery of the intervention package, and (ii) suggest key insights for the transferability of the intervention to other settings. The data included baseline quantitative data collected with the study-specific CHWs (2014-2018); and qualitative data from key informant interviews with study management (n = 91), observations of CHW training events (n = 12) and annual observations of and group discussions (GD) with intervention staff (n = 68). We show that it was feasible for newly recruited CHWs to implement the PopART intervention with good fidelity, supporting the interpretation of the trial outcome findings. This was despite some challenges in managing service quality and CHW retention in the early years of the programme. We suggest that by prioritizing the adoption of key elements of the in-home HIV services delivery intervention model-including training, emotional support to workers, monitoring and appropriate remuneration for CHWs-these services could be successfully transferred to new settings

Knowledge, attitudes and practices of male circumcision as an HIV prevention method among males in a Mine, Geita, Tanzania

Thesis (MPhil)--Stellenbosch University, 2013.ENGLISH ABSTRACT: HIV and AIDS remains the most important public health problem in Tanzania. Male Circumcision (MC) has been hailed as an effective intervention for the prevention of HIV-1 among heterosexual transmission. There is convincing evidence that MC has a positive effect on the control of HIV infection. As a result, this procedure has been widely promoted as a preventive effort that might have a significant decrease in the rate of HIV transmission. This study aimed to establish the knowledge, attitudes and practices of MC as an HIV prevention strategy among males in Geita Gold Mine (GGM), Geita, Tanzania. Random sampling was used to select participants (n=164) who worked at GGM. Respondents were asked to complete a standardised self-reported questionnaire. In total, 95 participants (57.9%) were circumcised while 69 (42.1%) were not circumcised. The acceptability of MC among uncircumcised males was high (95.6%). Reasons for this desire included prevention of STIs/HIV, promoting hygiene and for religious and cultural grounds. Overall, the majority of the respondents were knowledgeable about the health benefits of MC. Nearly all respondents (89.6%) expressed willingness to circumcise a male child. This study provided baseline information with regards to male circumcision among GGM employees. Though data reveals that respondents were aware of the health benefits of MC, results indicated that there is need to further impact this knowledge and promote the adoption of the practice among uncircumcised individuals/communities on a larger scale. It was recommended that the mine, through its HIV/AIDS programme, should promote MC awareness and recommend appropriate channels for access to MC for its employees.AFRIKAANSE OPSOMMING: MIV en VIGS is steeds die belangrikste gesondheidsprobleem in Tanzanië. Manlike besnyding (MC) is lof toegeswaai as ‘n doeltreffende intervensie vir die voorkoming van MIV-1 veral wat betref heteroseksuele oordraging. Daar is oortuigende bewys dat MC ‘n positiewe invloed op die beheer van MIV-infeksie het. Die gevolg is dat dié prosedure wyd en ver lof toegeswaai is as ‘n voorkomende poging wat ‘n beduidende afname in die tempo van MIV-oordraging kan teweeg bring. Die doel van hierdie studie was om die kennis, ingesteldhede en praktyke van MC as ‘n MIV-voorkomingstrategie onder mans by die Geita-goudmyn (GGM) in Geita in Tanzanië te bepaal. Ewekansige steekproewe is van gebruik gemaak om deelnemers (n=164) te selekteer wat in diens van GGM is. Respondente is versoek om ‘n gestandardiseerde selfverslagdoeningsvraelys te voltooi. In totaal was 95 deelnemers (57,9%) besny en 69 (42,1%) was nie besny nie. Die aanvaarbaarheid van MC onder onbesnyde mans was hoog, naamlik 95,6%. Redes vir die koestering van hierdie begeerte het onder meer die voorkoming van seksueel oordragbare infeksies/MIV en die bevordering van hygiene ingesluit – verskeie godsdienstige en kulturele redes is ook in hierdie verband gemeld. In die geheel was die meerderheid van die respondent ingelig oor die gesondheidsvoordele van MC en bykans almal van hulle (89,6%) het te kenne gegee dat hulle ‘n seun sou wou laat besny. Hierdie studie het basiese inligting opgelewer met betrekking tot manlike besnyding onder GGM-werknemers. Hoewel data daarop dui dat respondente heel bewus is van die gesondheidsvoordele wat MC inhou, dui die bevindinge daarop dat daar die behoefte bestaan om hierdie kennis verder uit te brei en die aanvaarding van dié gebruik onder onbesnyde individue/gemeenskappe op groter skaal te bevorder. Daar is aanbeveel dat die myn deur middel van sy MIV/VIGS-programme die bewusmaking van MC behoort te bevorder en toepaslike wyses daar moet stel sodat MC vir sy werknemers ‘n uitvoerbare opsie word

Predictors of timely linkage-to-ART within universal test and treat in the HPTN 071 (PopART) trial in Zambia and South Africa: findings from a nested case-control study

INTRODUCTION: HPTN 071 (PopART) is a three-arm community randomized trial in Zambia and South Africa evaluating the impact of a combination HIV prevention package, including universal test and treat (UTT), on HIV incidence. This nested study examined factors associated with timely linkage-to-care and ART initiation (TLA) (i.e. within six-months of referral) in the context of UTT within the intervention communities of the HPTN 071 (PopART) trial. METHODS: Of the 7572 individuals identified as persons living with HIV (PLWH) (and not on antiretroviral treatment (ART)) during the first year of the PopART intervention provided by Community HIV-care Providers (CHiPs) through door-to-door household visits, individuals who achieved TLA (controls) and those who did not (cases), stratified by gender and community, were randomly selected to be re-contacted for interview. Standardized questionnaires were administered to explore factors potentially associated with TLA, including demographic and behavioural characteristics, and participants' opinions on HIV and related services. Odds ratios comparing cases and controls were estimated using a multi-variable logistic regression. RESULTS: Data from 705 participants (333 cases/372 controls) were analysed. There were negligible differences between cases and controls by demographic characteristics including age, marital or socio-economic position. Prior familiarity with the CHiPs encouraged TLA (aOR of being a case: 0.58, 95% CI: 0.39 to 0.86, p = 0.006). Participants who found clinics overcrowded (aOR: 1.51, 95% CI: 1.08 to 2.12, p = 0.006) or opening hours inconvenient (aOR: 1.63, 95% CI: 1.06 to 2.51, p = 0.02) were less likely to achieve TLA, as were those expressing stronger feelings of shame about having HIV (ptrend  = 0.007). Expressing "not feeling ready" (aOR: 2.75, 95% CI: 1.89 to 4.01, p < 0.001) and preferring to wait until they felt sick (aOR: 2.00, 95% CI: 1.27 to 3.14, p = 0.02) were similarly indicative of being a case. Worrying about being seen in the clinic or about how staff treated patients was not associated with TLA. While the association was not strong, we found that the greater the number of self-reported lifetime sexual partners the more likely participants were to achieve TLA (ptrend  = 0.06). There was some evidence that participants with HIV-positive partners on ART were less likely to be cases (aOR: 0.75, 95% CI: 0.53 to 1.06, p = 0.07). DISCUSSION: The lack of socio-demographic differences between cases and controls is encouraging for a "universal" intervention that seeks to ensure high coverage across whole communities. Making clinics more "patient-friendly" could enhance treatment uptake further. The finding that those with higher risk behaviour are more actively engaging with UTT holds promise for treatment-as-prevention

A screening tool enhances home-based identification of adolescents (aged 10-14) living with HIV in Zambia and South Africa: HPTN 071 (PopART) Study

ABSTRACTIntroductionThe HPTN071 (PopART) for Youth (P-ART-Y) study evaluated the acceptability and uptake of a community-level combination HIV prevention package including universal testing and treatment (UTT) among young people in Zambia and South Africa (SA). We determined whether a four-question primary care level screening tool, validated for use in clinical settings, could enhance community (door-to-door) identification of undiagnosed HIV-positive younger adolescents (aged 10-14) who are frequently left out of HIV interventions.MethodCommunity HIV-care Providers (CHiPs) contacted and consented adolescents in their homes and offered them participation in the PopART intervention. CHiPs used a four question-screening tool, which included: history of hospital admission; recurring skin problems; poor health in last 3 months; and death of at least one parent. A “yes” response to one or more questions was classified as being “at risk” of being HIV-positive. The data were captured through an electronic data capturing device from August 2016 to December 2017. Proportions of adolescents who were deemed “at risk” were calculated and the association of screening “at risk” with age, sex and community was tested using a chi-squared test. The adjusted odds ratio (OR) comparing the odds of testing HIV-positive if “at risk” with the odds of testing positive if “not at risk” was estimated using logistic regression.ResultsIn our 14 study sites, 33,283 adolescents aged 10-14 in Zambia and 8,610 in SA participated in the study. About 1.3% (427/33,710) and 1.2% (106/8,610) self-reported to be HIV positive. Excluding the self-reported HIV-positive, we classified 11.3% (3,746/33,283) of adolescents in Zambia and 17.5% (1,491/8,504) in SA as “at risk”. In Zambia and SA, the “at risk” adolescents were 4.6 and nearly 16.7 times more likely to test HIV-positive compared to the “not at risk”, respectively (both p&lt;0.001). Using the screening tool, one-third of HIV-positive adolescents could be diagnosed using just a tenth of the number of HIV tests compared to universal testing.ConclusionThe screening tool may be of some value where UTT is not possible and limited resources must be prioritised toward adolescents who are more likely to be living with HIV. Further, the tool is of greater value in settings where there are more adolescents living with HIV who are undiagnosed. However, given our goal is to identify and treat all ALHIV, as well as link all HIV uninfected young people to prevention services, this screening tool should not be a substitute for UTT in community settings.Clinical Trial NumberNCT01900977</jats:sec

Assessment of a screening tool to aid home-based identification of adolescents (aged 10–14) living with HIV in Zambia and South Africa: HPTN 071 (PopART) study. S1 Data

Supporting data for the manuscript, "Assessment of a screening tool to aid home-based identification of adolescents (aged 10–14) living with HIV in Zambia and South Africa: HPTN 071 (PopART) study". Dataset is made available by PLOS and hosted on Figshare