Understanding HIV care delays in the US South and the role of the social-level in HIV care engagement/retention: a qualitative study

Introduction: In a significant geographical shift in the distribution of HIV infection, the US South - comprising 17 states - now has the greatest number of adults and adolescents with HIV (PLHIV) in the nation. More than 60% of PLHIV are not in HIV care in Alabama and Mississippi, contrasted with a national figure of 25%. Poorer HIV outcomes raise concerns about HIV-related inequities for southern PLHIV, which warrant further study. This qualitative study sought to understand experiences of low-income PLHIV on the AIDS Drug Assistance Program in engagement and retention in continuous HIV care in two sites in Alabama. Methods: The study was designed using grounded theory. Semi-structured interviews with 25 PLHIV explored experiences with care linkage, reported factors and behaviors affecting engagement/retention in continuous HIV care, including socio-economic factors. To triangulate sources, 25 additional interviews were conducted with health and social service providers from the same clinics and AIDS Service Organizations where clients obtained services. Across the narratives, we used the HIV care continuum to map where care delays and drop out occurred. Using open coding, constant comparison and iterative data collection and analysis, we constructed a conceptual model illustrating how participants described their path to HIV care engagement and retention. Results: Most respondents reported delayed HIV care, describing concentric factors: psychological distress, fear, lack of information, substance use, incarceration, lack of food, transport and housing. Stark health system drop out occurred immediately after receipt of HIV test results, with ART initiation generally occurring when individuals became ill. Findings highlight these enablers to care: Alabama\u27s \u27social infrastructure\u27; \u27twinning\u27 medical with social services, \u27social enablers\u27 who actively link PLHIV to care; and \u27enabling spaces\u27 that break down PLHIV isolation, facilitating HIV care linkage/retention. Conclusions: Ryan White-funded programs, together with housing, food and psychological support were pre-conditions for participants\u27 entry and retention in HIV care. The path to achieving continuous HIV care for individuals at risk of lack of entry or delayed HIV care requires robust social-level responses, like in Alabama, that address physical and mental health of clients and directly engage the particular social and economic contexts and vulnerabilities of southern PLHIV

Social Actors Fight the Rising Tide of HIV in U.S. Southern Poor

The greatest number of persons living with HIV in the United States are now living in the South, and they face poorer health outcomes and increased AIDS-related deaths as compared to the rest of the country. The southern United States has a disproportionate share of low-income individuals, with many lacking access to health care and health insurance. Health facilities are also comparatively fewer and more difficult to reach than in other areas of the United States. The impacts of this already poor health infrastructure on low-income people living with HIV in the South can be life-threatening. This policy brief summarizes key findings and recommendations based on qualitative research carried out in 2012 by HIV researchers at the University of Massachusetts Boston

Cui bono?: a capabilities approach to understanding HIV prevention and treatment for pregnant women and children in South Africa

PhD, Faculty of Law, Commerce and Management, University of the Witwatersrand, 2009.The global health revolution of the last 50 years has generated significant health gains in terms of increased life expectancy and reduced maternal mortality. South Africa, an upper middle income country, has performed poorly along the same development indicators. Development gains for women and children won over two decades are now being reversed, largely due to HIV/AIDS. This is in spite of the evidence that lifesaving antiretroviral medication can prolong life and enhance quality of life. Using a joint capabilities and health equity lens, this thesis seeks to understand a critical development problem in South Africa – premature mortality in pregnant women and children attributed to HIV – an infectious disease that is both preventable and treatable. The research identifies key barriers faced by pregnant and postnatal women with HIV who seek (freely available) access to PMTCT (prevention of mother to child HIV transmission) and ART (antiretroviral therapy) programmes in the public health sector. The study considers whether disparities in, and missed opportunities for, preventing and treating HIV in these population groups comprise avoidable, systematic and unfair health inequities. The implications for the capabilities of women and children with HIV in this country are also explored. Qualitative research methods are employed to investigate the research concern. Semi-structured interviews with 83 women comprise the mainstay of the field research. Interviews with 37 caregivers of children with HIV, together with patient files and interviews with key informants, supplement the data collection. Research was undertaken in two sites in two provinces: Eastern Cape and Gauteng. Each site constitutes a bounded case study. A rural-urban perspective is put forward – with attention to equity considerations in access to maternal-child HIV services. The study evinces a host of avoidable factors in the operational delivery of ART/PMTCT, along a range of intervention points in the continuum of care: including the antenatal, labour, postnatal and pediatric wards. While some of these factors are influenced by individual behaviour, the vast majority are directly linked to the health system – illuminating the ways in which the health system serves as a social determinant of health (SDH), and often restricting, constraining, and ironically, preventing people from obtaining the interventions and information they need to improve their health. iii By connecting the empirical findings related to ART/PMTCT within the health system to the capabilities and health equity literatures, an understanding of disparities in access to, and delivery of, such services – and their importance in shaping health, development and health outcomes of these population groups – becomes clearer. As a consequence, strengthening the public health system is a necessary first step to ensuring at least some of the minimum conditions that allow people to be healthy. As an entry point, there is great scope for systems’ interventions that would address the shortfall in health for black South Africans and deprivations in their health capability. At the same time, the research reveals that – owing to the contribution of social determinants of health (e.g., factors that impact on health such as living and working conditions, but lie outside the realm of healthcare) to health status: good health is not achieved solely by access to and provision of good healthcare. This reality underscores the importance of health as a central capability; and good health as a normative social goal. In the capability view, the moral concern for state and society is the reduced capability of individuals due to health inequities that are socially-constructed, and in turn, changeable. Recommendations to address modifiable factors related to effective ART/PMTCT provision in these facilities are put forward, with a set of suggestions for future research in maternal, child and women’s health in South Africa

Health system weaknesses constrain access to PMTCT and maternal HIV services in South Africa: a qualitative enquiry

Background: HIV remains responsible for an estimated 40% of mortality in South African pregnant women and their children. To address these avoidable deaths, eligibility criteria for antiretroviral therapy (ART) in pregnant women were revised in 2010 to enhance ART coverage. With greater availability of HIV services in public health settings and increasing government attention to poor maternal-child health outcomes, this study used the patient’s journey through the continuum of maternal and child care as a framework to track and document women’s experiences of accessing ART and prevention of mother-to-child HIV transmission (PMTCT) programmes in the Eastern Cape (three peri-urban facilities) and Gauteng provinces (one academic hospital). Results: In-depth interviews identified considerable weaknesses within operational HIV service delivery. These manifested as missed opportunities for HIV testing in antenatal care due to shortages of test kits; insufficient staff assigned to HIV services; late payment of lay counsellors, with consequent absenteeism; and delayed transcription of CD4 cell count results into patient files (required for ART initiation). By contrast, individual factors undermining access encompassed psychosocial concerns, such as fear of a positive test result or a partner’s reaction; and stigma. Data and information systems for monitoring in the three peri-urban facilities were markedly inadequate. Conclusions: A single system- or individual-level delay reduced the likelihood of women accessing ART or PMTCT interventions. These delays, when concurrent, often signalled wholesale denial of prevention and treatment. There is great scope for health systems’ reforms to address constraints and weaknesses within PMTCT and ART services in South Africa. Recommendations from this study include: ensuring autonomy over resources at lower levels; linking performance management to facility-wide human resources interventions; developing accountability systems; improving HIV services in labour wards; ensuring quality HIV and infant feeding counselling; and improved monitoring for performance management using robust systems for data collection and utilisation

Interruptions in payments for lay counsellors affects HIV testing at antenatal clinics in Johannesburg

HIV testing uptake at 3 antenatal clinics in Johannesburg was 53% (1 333/2 502) during 4 months when lay counsellors were unpaid, which was lower than the 7 months when payment was provided (79%; 3 705/4 722; p<0.001), and a subsequent 12-month period (86.3%, 11 877/13 767; p<0.001) when counsellors were paid. Consistent remuneration of lay counsellors could markedly improve services for preventing mother-to-child HIV transmission

Health care providers' perceptions of barriers to perinatal mental healthcare in South Africa

BACKGROUND: Perinatal mental disorders are a leading contributor to morbidity and mortality during pregnancy and postpartum, and are highly treatable when identified early. However, many women, especially in low and middle-income countries, lack access to routine identification and treatment of mental illness in public health settings. The prevalence of perinatal depression and anxiety disorders, common mental disorders, is three times higher for South African women relative to women in high-income countries. The public health system has begun to integrate mental health into maternal care, making South Africa a relevant case study of perinatal mental healthcare. Yet studies are few. We sought to investigate healthcare providers' perceptions of the barriers to early identification and screening of common perinatal mental disorders in public health facilities in South Africa. METHODS: Employing qualitative methods, we used purposive sampling to identify study participants, supplemented by snowball sampling. From September 2019-June 2020, we conducted in-depth interviews with 24 key informants in South Africa. All interviews were recorded and transcribed verbatim. We used a thematic approach to generate initial analytical themes and then conducted iterative coding to refine them. We adapted a delivery systems' framework to organise the findings, depicted in a conceptual map. RESULTS: Reported barriers to early identification and treatment of mental illness in the perinatal period encompassed four levels: (1) structural factors related to policies, systems and resources; (2) socio-cultural factors, including language and cultural barriers; (3) organisational factors, such as lack of provider preparation and training and overburdened clinics; and (4) individual patient and healthcare provider factors. CONCLUSION: Barriers act across multiple levels to reduce quality mental health promotion and care, thereby creating an environment where inequitable access to identification of mental disorders and quality mental health services was embedded into systems and everyday practice. Integrated interventions across multiple levels are essential to improve the early identification and treatment of mental illness in perinatal women in South Africa. We provide recommendations derived from our findings to overcome barriers at each of the four identified levels.Published versio

Moral luck : exploiting South Africa's policy environment to produce a sustainable national antiretroviral treatment programme

What kinds of social policy interventions will enable South Africa to offer a universal, free and sustainable antretroviral treatment programme? Some commentators assert that government's best chance at offering such a programme will require the use of compulsory licenses and that the state's failure to make use of such a weapon is a failure to discharge its constitutional duties. The authors demur. The threat of a compulsory license is only as good as the ability to make use of such a license. South Africa currently lacks the basic science community, reverse engineering capacity and fine chemicals industry necessary to make good on such a threat. The government's best hope for discharging the duties imposed by the Constitution is a systematic, structural intervention: the implementation of a socio-industrial policy that leverages existing industrial capacity and voluntary licenses in a manner that generates price reductions and offers an uninterrupted sustainable local supply. However, voluntary licenses will only create downward pressure on prices when South Africa is able to establish a robust generics pharmaceutical industry. Such an industry can be created with appropriate tax relief, investment credits, technology transfer and assured access to active pharmaceutical ingredients. South Africa's industrial, legal and financial resources can thereby be profitably exploited in a manner that progressively achieves a comprehensive and coordinated antiretroviral treatment programme

A right-to-health lens on perinatal mental health care in South Africa

South African women experience some of the highest rates of depression and anxiety globally. Despite South Africa's laudable human rights commitments to mental health in law, perinatal women are at high risk of common mental disorders due to socioeconomic factors, and they may lack access to mental health services. We used a right to mental health framework, paired with qualitative methods, to investigate barriers to accessing perinatal mental health care. Based on in-depth interviews with 14 key informants in South Africa, we found that (1) physical health was prioritized over mental health at the clinic level; (2) there were insufficient numbers of antenatal and mental health providers to ensure minimum essential levels of perinatal mental health services; (3) the implementation of human rights-based mental health policy has been inadequate; (4) the social determinants were absent from the clinic-level approach to mental health; and (5) a lack of context-specific provider training and support has undermined the quality of mental health promotion and care. We offer recommendations to address these barriers and improve approaches to perinatal mental health screening and care, guided by the following elements of the right to mental health: progressive realization; availability and accessibility; and acceptability and quality.Published versio

Interruptions in payments for lay counsellors affects HIV testing at antenatal clinics in Johannesburg

HIV testing uptake at 3 antenatal clinics in Johannesburg was 53% (1 333/2 502) during 4 months when lay counsellors were unpaid, which was lower than the 7 months when payment was provided (79%; 3 705/4 722;

Call properties and morphology of the sound-producing organ in Ophidion rochei

peer reviewe