"She is my teacher and if it was not for her I would be dead" : exploration of rural South African Community Health Worker's informational and mediating roles in the home

This thesis seeks to fill the gap in the literature by exploring CHW IEC roles through: a protocol for the Health Information in the Home (HIH) study of the quality of IEC services by Community Care Workers; a structured literature review of the current state of the evidence and a journal manuscript based on the HIH study findings

EXPERIENCES OF FEMALE SEX WORKERS ALONG THE HIV CARE CONTINUUM IN SANTO DOMINGO, DOMINICAN REPUBLIC

Introduction Approximately 12% of all female sex workers (FSWs) around the world are living with HIV. FSWs confront heightened vulnerability not only to HIV infection, but also to social, economic and systemic barriers throughout the HIV care continuum and have sub-optimal engagement in HIV care. Despite this large burden of disease, there is very limited evidence on the HIV care experiences of FSWs living with HIV. Methods This study utilized a mixed methods approach to investigate FSWs’ experiences along the HIV care continuum. The first manuscript explored the experiences of 44 FSWs living with HIV throughout the HIV care continuum through in-depth interviews and focus group discussions in Santo Domingo, Dominican Republic. Informed by the findings from this thematic and narrative analysis, the second manuscript analyzed a quantitative, cross-sectional survey to describe the baseline HIV care continuum among 268 FSWs living with HIV in Santo Domingo. The manuscript then specifically examined factors associated with experience of antiretroviral therapy (ART) interruption using multiple logistic regression. The final manuscript determined the factors associated with retention in HIV care in the same study population using multiple measure of retention. Results FSWs living with HIV disengaged at each step of the HIV care continuum. Engagement in HIV care was not a static construct as participants continually negotiated engagement within a broader context of structural constraints and social conditions. FSWs described critical influences across multiple levels that either facilitated (re)engagement in HIV care or led to disengagement. Key individual-level factors identified in the qualitative analysis were physical and mental health as post-diagnosis depression was often followed by disengagement in HIV care until declines in physical health were noted. Interpersonal factors centered on disclosure of HIV or FSW status and existent support. At the environmental level, participants frequently described systemic delays and the high costs of care, but good relationships with HIV care providers. Some experiences of discrimination within the clinic environment were, however, described. Lack of economic resources and pervasive HIV stigma and discrimination also complicated adherence to clinical appointments and ART. Within the quantitative sample, most participants linked to HIV care (92%), attended HIV services in the past six months (85%) and were initiated onto ART (78%), but discontinuation of treatment and irregular adherence to clinical appointments were frequent. A total of 36% of the participants ever initiated onto ART reported lifetime experience with an interruption of ART. The odds of ART interruption were 3.24 times higher among women who experienced sex work (SW)-related discrimination (95% confidence interval [CI]: 1.28, 8.20), 2.41 times higher among women who reported ever using any drug (95% CI: 1.09, 5.34) and 2.35 times higher among women who worked in a SW establishment (95% CI: 1.20, 4.60). Self-stigmatizing beliefs related to SW were associated with higher odds of interruption as each additional point on the SW self-stigma scale was associated with a 9% increase in the odds of ART interruption (95% CI: 1.02, 1.16). Positive perceptions of HIV providers were protective with each additional point on the perception of HIV provider scale associated with a 9% reduction in the odds of treatment interruption (95% CI: 0.85, 0.98). The final manuscript determined that a retention measure which included both attended and missed visits was the most appropriate measure of retention in this study population. A total of 37% of the women who attended HIV services in the past six months had missed at least one clinical appointment. The odds of being retained in HIV care were higher among participants with more positive perceptions of HIV service providers (adjusted relative odds [ARO]: 1.17; 95% confidence interval [CI]: 01.09, 1.25). The odds of retention were lower among women who reported recent alcohol consumption (ARO: 0.50; 95% CI: 0.28, 0.92) and among women with self-stigmatizing beliefs related to SW (ARO: 0.93; 95% CI: 0.88, 0.98). Conclusions Individual, interpersonal, environmental and structural factors were important influences on engagement in HIV care among FSWs throughout the HIV care continuum. In addition to challenges faced by the general population living with HIV, FSWs confronted additional economic instability and the compounded stigma of being both HIV-infected and a FSW. Given the clear importance of improving engagement in HIV care to maximize individual and public health, there is an urgent need for multi-level interventions to help support FSWs throughout the HIV care continuum

The size, characteristics and partnership networks of the health-related non-profit sector in three regions of South Africa: implications of changing primary health care policy for community-based care

Web of Scienc

HIV care and treatment experiences among female sex workers living with HIV in sub-Saharan Africa: A systematic review

Female sex workers (FSW) living with HIV in sub-Saharan Africa have poor engagement to HIV care and treatment. Understanding the HIV care and treatment engagement experiences of FSW has important implications for interventions to enhance care and treatment outcomes. We conducted a systematic review to examine the HIV care experiences and determinants of linkage and retention in care, antiretroviral therapy (ART) initiation, and ART adherence and viral suppression among FSW living with HIV in sub-Saharan Africa. The databases PubMed, Embase, Web of Science, SCOPUS, CINAHL, Global Health, Psycinfo, Sociological Abstracts, and Popline were searched for variations of search terms related to sex work and HIV care and treatment among sub-Saharan African populations. Ten peer-reviewed articles published between January 2000 and August 2015 met inclusion criteria and were included in this review. Despite expanded ART access, FSW in sub-Saharan Africa have sub-optimal HIV care and treatment engagement outcomes. Stigma, discrimination, poor nutrition, food insecurity, and substance use were commonly reported and associated with poor linkage to care, retention in care, and ART initiation. Included studies suggest that interventions with FSW should focus on multilevel barriers to engagement in HIV care and treatment and explore the involvement of social support from intimate male partners. Our results emphasise several critical points of intervention for FSW living with HIV, which are urgently needed to enhance linkage to HIV care, retention in care, and treatment initiation, particularly where the HIV prevalence among FSW is greatest

"She is my teacher and if it was not for her I would be dead": Exploration of rural South African community health workers' information, education and communication activities

Community health workers (CHWs) are important resources in health systems affected by the HIV/AIDS pandemic. International guidelines on task-shifting recommend that CHWs can provide diverse HIV services, ranging from HIV prevention to counselling patients for lifelong antiretroviral therapy. There is, however, little evidence on the experiences with CHW delivery of these services in Africa. This qualitative study included 102 interviews that explored experiences with information, education and communication (IEC) activities provided by CHWs within rural South Africa. Semi- structured interviews were conducted with CHWs (n = 17), their clients (n = 33) and the primary caregivers of these clients (n = 30), allowing for data source triangulation. Twenty-two follow-up interviews explored emergent themes from preliminary interviews. Despite limited formal education and training, CHWs in this study were significant providers of IEC, including provision of generic health talks and HIV-specific information and facilitation to support clients’ entry and maintenance in the formal health system. They often incorporated local knowledge and understanding of illness in their communication. CHWs in this study were able to bridge the lifeworlds of the community and the formal services to expedite access and adherence to local clinics and other services. As mediators between the two worlds, CHWs reinterpreted health information to make it comprehensible in their communities. With growing formalisation of CHW programmes in South Africa and elsewhere, CHWs’ important role in health service access, health promotion and health maintenance must be recognised and supported in order to maximise impact.Web of Scienc

Malaria prevention knowledge, attitudes, and practices in Zambezia Province, Mozambique

Funding Information: This study was funded by the Principal Investigator as part of her Ph.D. thesis. The findings and conclusions in this report are those of the authors. Publisher Copyright: © 2021, The Author(s). Copyright: Copyright 2021 Elsevier B.V., All rights reserved.Background: In Mozambique, socio-economic and cultural factors influence the wide adoption of disease preventive measures that are relevant for malaria control strategies to promote early recognition of disease, prompt seeking of medical care, sleeping under insecticide-treated nets (ITNs), and taking intermittent preventive treatment for pregnant women. However, there is a critical information gap regarding previous and ongoing malaria social and behavioural change (SBC) interventions. The aim of this study is to assess the knowledge, attitudes, practices of beneficiaries of SBC interventions. Methods: A descriptive cross-sectional survey was undertaken in 2018 in two rural districts of Zambezia Province, Mozambique. A structured questionnaire was administered to 773 randomly selected households. Respondents were the adult heads of the households. Descriptive statistics were done. Results: The main results show that 96.4% of respondents recalled hearing about malaria in the previous 6 months, 90.0% had knowledge of malaria prevention, and 70.0% of preventive measures. Of the 97.7% respondents that had received ITNs through a mass ITN distribution campaign, 81.7% had slept under an ITN the night before the survey. In terms of source of health information, 70.5% mentioned the role of community volunteers in dissemination of malaria prevention messages, 76.1% of respondents considered worship places (churches and mosques) to be the main places where they heard key malaria prevention messages, and 79.1% asserted that community dialogue sessions helped them better understand how to prevent malaria. Conclusions: Results show that volunteers/activists/teachers played an important role in dissemination of key malaria prevention messages, which brought the following successes: community actors are recognized and people have knowledge of malaria transmission, signs and symptoms, preventive measures, and where to get treatment. There is, however, room for improvement on SBC messaging regarding some malaria symptoms (anaemia and convulsions) and operational research is needed to ascertain the drivers of malaria prevalence and inform the SBC approach.publishersversionpublishe

Cost and cost-effectiveness of indoor residual spraying with pirimiphos-methyl in a high malaria transmission district of Mozambique with high access to standard insecticide-treated nets

Background: As malaria cases increase in some of the highest burden countries, more strategic deployment of new and proven interventions must be evaluated to meet global malaria reduction goals. Methods: The cost and cost-effectiveness of indoor residual spraying (IRS) with pirimiphos-methyl (Actellic®300 CS) were assessed in a high transmission district (Mopeia) with high access to pyrethroid insecticide-treated nets (ITNs), compared to ITNs alone. The major mosquito vectors in the area were susceptible to primiphos-methyl, but resistant to pyrethoids. A decision analysis approach was followed to conduct deterministic and probabilistic sensitivity analyses in a theoretical cohort of 10,000 children under five years of age (U5) and 10,000 individuals of all ages, separately. Model parameters and distributions were based on prospectively collected cost and epidemiological data from a cluster-randomized control trial and a literature review. The primary analysis used health facility-malaria incidence, while community cohort incidence and cross-sectional prevalence rates were used in sensitivity analyses. Lifetime costs, malaria cases, deaths and disability-adjusted life-years (DALYs) were calculated to determine the incremental costs per DALY averted through IRS. Results: The average IRS cost per person protected was US$8.26 and 51$400 (95% CI 399–402) per DALY averted. In the all-age cohort, the ICER was higher: US$1,860 (95$7.06) and IRS was highly cost-effective in children U5 (ICER = US$312) and cost-effective in individuals of all ages (ICER = US$1,431), compared to ITNs alone. Conclusion: This study provides robust evidence that IRS with pirimiphos-methyl can be cost-effective in high transmission regions with high pyrethroid ITN coverage where the major vector is susceptible to pirimiphos-methyl but resistant to pyrethroids. The finding that insecticide cost is the main driver of IRS costs highlights the need to reduce the insecticide price without jeopardizing effectiveness. Trial registration: ClinicalTrials.gov identifier NCT02910934 (Registered 22 September 2016). https://clinicaltrials.gov/ct2/show/NCT02910934?term=NCT02910934&draw=2&rank=

Correlates of Delayed Diagnosis among Human Immunodeficiency Virus-Infected Pulmonary Tuberculosis Suspects in a Rural HIV Clinic, South Africa.

Background. Delay in pulmonary tuberculosis (PTB) diagnosis is one of the major factors that affect outcome and threatens continued spread of tuberculosis. This study aimed at determining factors associated with delayed PTB diagnosis among human immunodeficiency virus (HIV) infected individuals. Methods. A retrospective observational study was done using clinic records of HIV-infected PTB suspects attending an HIV/AIDS clinic at Tintswalo rural hospital in South Africa (SA) between January 2006 and December 2007. Using routine clinic registers, 480 records were identified. Results. PTB diagnosis delay was found among 77/176 (43.8%) of the patients diagnosed with PTB. The mean delay of PTB diagnosis was 170.6 days; diagnosis delay ranged 1-30 days in 27 (35.1%) patients, 31-180 days in 24 (33.8%) patients; 24 (31.2%) patients remained undiagnosed for ≥180 days. Independent factors associated with delayed diagnosis were: older age >40 years (Odds Ratio (OR) 3.43, 95% CI 1.45-8.08) and virological failure (OR 2.72, 95% CI 1.09-6.74). Conclusion. There is a considerable delayed PTB diagnosis among HIV-infected patients in rural SA. Older patients as well as patients with high viral load are at a higher risk of PTB diagnosis delay. Therefore efforts to reduce PTB diagnosis delay need to emphasised