HIV vulnerability of men and women who inject drugs in Kumasi, Ghana

This study was implemented by Boston University in collaboration with the Kwame Nkrumah University of Science and Technology with support from the President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for International Development under Project SEARCH Task Order No. GHH‐I‐00‐07‐00023‐00, beginning August 27, 2010. The content and views expressed here are the authors’ and do not necessarily reflect the opinion or policy of USAID or the U.S. Government.Reducing vulnerability to HIV infection among key populations in Ghana is a major goal for the National AIDS Control Program (NACP) and the GAC. While a number of studies have explored HIV risk behaviours among several key vulnerable populations in Ghana including female sex workers, men who have sex with men, and prisoners, little is known about the drug use and sexual vulnerability of people who inject drugs (PWID). In addition, no programs have been implemented to reduce the vulnerability among this population. This report provides the findings from a qualitative study that aimed to understand the social, economic and behavioral vulnerability to HIV of PWID in Kumasi and to inform the development and implementation of HIV prevention programs for this population. The research was conducted by a collaborative team comprised of researchers from Boston University’s Center for Global and Health and Development (CGHD) and the Kwame Nkrumah University of Science and Technology (KNUST) School of Medical Sciences. It is one of nine studies under the Operations Research on Key Populations project funded by the United States Agency for International Development (USAID). The study was designed and carried out in collaboration with the Ghana AIDS Commission (GAC).Support from the President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for International Development under Project SEARCH Task Order No. GHH‐I‐00‐07‐00023‐00, beginning August 27, 201

Using Electronic Drug Monitor Feedback to Improve Adherence to Antiretroviral Therapy Among HIV-Positive Patients in China

Effective antiretroviral therapy (ART) requires excellent adherence. Little is known about how to improve ART adherence in many HIV/AIDS-affected countries, including China. We therefore assessed an adherence intervention among HIV-positive patients in southwestern China. Eighty subjects were enrolled and monitored for 6 months. Sixty-eight remaining subjects were randomized to intervention/control arms. In months 7–12, intervention subjects were counseled using EDM feedback; controls continued with standard of care. Among randomized subjects, mean adherence and CD4 count were 86.8 vs. 83.8% and 297 vs. 357 cells/μl in intervention vs. control subjects, respectively. At month 12, among 64 subjects who completed the trial, mean adherence had risen significantly among intervention subjects to 96.5% but remained unchanged in controls. Mean CD4 count rose by 90 cells/μl and declined by 9 cells/μl among intervention and control subjects, respectively. EDM feedback as a counseling tool appears promising for management of HIV and other chronic diseases.Boston University and the Office of Health and Nutrition of the United States Agency for International Development (GHS-A-00-03-00030-00); World Health Organization; United States Centers for Disease Control; National Institutes of Health, National Institute of Allergy and Infectious Diseases (K23 AI 62208); Mid-Career Mentoring Award (K24 RR020300

The Ghana retention on ART study (ROARS): keeping HIV-positive patients on antiretroviral therapy

This study was implemented by Boston University in collaboration with the Kwame Nkrumah University of Science and Technology with support from the President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for International Development under Project SEARCH Task Order No. GHH‐I‐00‐07‐00023‐00, beginning August 27, 2010. The content and views expressed here are the authors’ and do not necessarily reflect the opinion or policy of USAID or the U.S. Government.This report presents the findings of a study that employed qualitative research methods to explore the beliefs, attitudes, and behaviors of people living with HIV (PLHIV) in Ghana who are either in care and on antiretroviral therapy (ART), or are no longer in care and have been lost to follow-up. The study was designed to deepen our understanding of the challenges ART patients face in continuing on ART in Ghana and to contribute information with the potential to improve retention in care and outcomes for PLHIV in Ghana.This study was carried out by a collaborative team of researchers based at Boston University’s Center for Global and Health and Development (CGHD) and the Kwame Nkrumah University of Science and Technology’s (KNUST) School of Medical Sciences. The team conducted this research in Kumasi, Ghana’s second largest urban center. It is a component of the ‘Operations Research among Key Populations in Ghana’ project funded by the United States Agency for International Development (USAID). We designed and conducted the research in collaboration with the Ghana AIDS Commission (GAC).Expanding access to ART among HIV-positive individuals has been a major goal of the Ghana AIDS Commission and Ghana Health Service. Since 2005, Ghana has scaled up ART rapidly; by 2011, 150 health facilities were providing ART to over 60,000 people, an increase from fewer than 5,000 just six years earlier. At the same time, like in most countries in sub-Saharan Africa, ensuring that those who begin ART remain on treatment has proven a major challenge. Previous studies suggest that retention in care for 12 months or longer is approximately 70-80% in Ghana, similar to the rate in many other low-resource settings. While research elsewhere in sub-Saharan Africa indicates that a number of barriers affect retention in care, little research on this topic has been conducted in Ghana. Given that ART is currently the only known way to prolong life for PLHIV, it is critical to identify barriers that affect different groups of patients and to find ways to support them in remaining on treatment.This study was motivated by a desire to increase understanding of the challenges of and facilitators to retention in care among individuals on ART in Kumasi, Ghana. We conducted it in collaboration with the Suntreso Government Hospital, one of Kumasi’s largest medical facilities, and specifically with the hospital’s STI (sexually transmitted infection)/HIV clinic, which has experienced high levels of patient dropout from care and treatment. Together with staff at the clinic, we designed this research with the aim of contributing to understanding of the range of barriers PLHIV in Ghana experience trying to stay on treatment, the reasons they default, and the types of supports they believe would help themselves and other patients remain on or return to treatment if they do default. Our hope is that the study’s findings will add in a meaningful way to the evidence base on strategies and approaches for improving retention in treatment, thereby maximizing the potential benefits of ART, for PLHIV in Ghana.Support from the President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for International Development under Project SEARCH Task Order No. GHH‐I‐00‐07‐00023‐00, beginning August 27, 201

A tailored mHealth intervention for improving treatment adherence for people living with HIV in Iran (HamRaah):Protocol for a feasibility study and randomised pilot trial with a nested realist evaluation

Introduction Middle East and North Africa (MENA) has a rising rate of new HIV infections and AIDS-related mortality. Consistent adherence to antiretroviral therapy (ART) leads to viral suppression, preventing HIV transmission and treatment failure. mHealth interventions can improve ART adherence by providing tailored support and directing patients to existing healthcare services. HamRaah (Persian for ‘together-in-path’) is the first mHealth-based intervention in a MENA country and is designed to improve adherence through two-way mobile messaging for people recently diagnosed with HIV in Tehran, Iran. The objectives of this pilot randomised controlled trial (RCT) are to examine the feasibility, acceptability and preliminary effectiveness of HamRaah, and to develop an explanatory theory for any observed effects through a nested realist evaluation.Methods A feasibility study and two-arm RCT of HamRaah, with an embedded realist evaluation will be conducted. Participants will be randomised 1:1 to HamRaah or routine care for a 6-month intervention. The initial effectiveness of HamRaah will be assessed through the primary outcome of self-reported ART adherence and several secondary outcomes: retention in care, CD4 count and viral suppression. A theory-driven realist evaluation framework will be used to develop an explanatory theory regarding what works, for whom, how and in what context.Ethics and dissemination The study received ethical clearance from Tehran University of Medical Sciences Ethics Committee and Oxford Tropical Research Ethics Committee People living with HIV in Tehran and key country stakeholders in HIV policy and programming have been involved in the development of HamRaah and this pilot trial. Participants will provide informed consent prior to study enrolment. The results will be disseminated to all stakeholders and presented in peer-reviewed journal publications and conferences.Trial registration number IRCT20100601004076N23; Pre-results

Research report: Exploring the beliefs, attitudes, and behaviors of MSM engaged in substance use and transactional sex in Ghana

This study was implemented by Boston University in collaboration with the Kwame Nkrumah University of Science and Technology with support from the President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for International Development under Project SEARCH Task Order No. GHH‐I‐00‐07‐00023‐00, beginning August 27, 2010. The content and views expressed here are the authors’ and do not necessarily reflect the opinion or policy of USAID or the U.S. Government.This report presents findings from a qualitative study examining the vulnerability to HIV of young men who have sex with men (MSM) in Kumasi, Ghana, and their prevention needs. The study was jointly conducted in Kumasi, Ghana’s second largest urban center, by Boston University’s Center for Global and Health and Development (CGHD) and the Kwame Nkrumah University of Science and Technology (KNUST). It was carried out as a component of Project SEARCH funded by the United States Agency for International Development. The study was designed and conducted in collaboration with FHI 360 (formerly Family Health International (FHI)), an international non‐governmental organization based in the capital city of Accra which operates programs targeting MSM and other key populations in Kumasi, and the Ghana AIDS Commission (GAC). Preventing HIV among key populations in Ghana is a major goal for the National AIDS Control Program (NACP) and the GAC.1 MSM are a particularly stigmatized population in Ghana, in part because male‐to‐male sex has traditionally been viewed as illegal, making them a difficult yet critical to reach population with HIV/AIDS‐related services. This qualitative study was conducted in order to enhance understanding of the beliefs, attitudes, and behaviors of adolescent and young MSM (aged 15‐29). In this population, we particularly sought to focus on two sub‐groups: MSM who engage in transactional sex and those who use alcohol or illicit substances (hereinafter “substances”). The specific objectives were to explore: 1) the types and extent of substance use by MSM; 2) the overlap between substance use and transactional sex among MSM; 3) the beliefs and attitudes related to substance use and transactional sex; 4) knowledge and risk behaviors of both subgroups. The study’s broader goal was to collect and analyze in‐depth data that can be used to improve the outreach and effectiveness of local programs that aim to reach these groups with important HIV prevention and treatment information and with services appropriate to their needs.Support from the President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for International Development under Project SEARCH Task Order No. GHH‐I‐00‐07‐00023‐00, beginning August 27, 201

Health facility and skilled birth deliveries among poor women with Jamkesmas health insurance in Indonesia: a mixed-methods study

BACKGROUND: The growing momentum for quality and affordable health care for all has given rise to the recent global universal health coverage (UHC) movement. As part of Indonesia’s strategy to achieve the goal of UHC, large investments have been made to increase health access for the poor, resulting in the implementation of various health insurance schemes targeted towards the poor and near-poor, including the Jamkesmas program. In the backdrop of Indonesia’s aspiration to reach UHC is the high rate of maternal mortality that disproportionally affects poor women. The objective of this study was to evaluate the association of health facility and skilled birth deliveries among poor women with and without Jamkesmas and explore perceived barriers to health insurance membership and maternal health service utilization. METHODS: We used a mixed-methods design. Utilizing data from the 2012 Indonesian Demographic and Health Survey (n = 45,607), secondary analysis using propensity score matching was performed on key outcomes of interest: health facility delivery (HFD) and skilled birth delivery (SBD). In-depth interviews (n = 51) were conducted in the provinces of Jakarta and Banten among poor women, midwives, and government representatives. Thematic framework analysis was performed on qualitative data to explore perceived barriers. RESULTS: In 2012, 63.0% of women did not have health insurance; 19.1% had Jamkesmas. Poor women with Jamkesmas were 19% (OR = 1.19 [1.03–1.37]) more likely to have HFD and 17% (OR = 1.17 [1.01–1.35]) more likely to have SBD compared to poor women without insurance. Qualitative interviews highlighted key issues, including: lack of proper documentation for health insurance registration; the preference of pregnant women to deliver in their parents’ village; the use of traditional birth attendants; distance to health facilities; shortage of qualified health providers; overcrowded health facilities; and lack of health facility accreditation. CONCLUSION: Poor women with Jamkesmas membership had a modest increase in HFD and SBD. These findings are consistent with economic theory that health insurance coverage can reduce financial barriers to care and increase service uptake. However, factors such as socio-cultural beliefs, accessibility, and quality of care are important elements that need to be addressed as part of the national UHC agenda to improve maternal health services in Indonesia

Community Case Management of Fever Due to Malaria and Pneumonia in Children Under Five in Zambia: A Cluster Randomized Controlled Trial

In a cluster randomized trial, Kojo Yeboah-Antwi and colleagues find that integrated management of malaria and pneumonia in children under five by community health workers is both feasible and effective. BACKGROUND. Pneumonia and malaria, two of the leading causes of morbidity and mortality among children under five in Zambia, often have overlapping clinical manifestations. Zambia is piloting the use of artemether-lumefantrine (AL) by community health workers (CHWs) to treat uncomplicated malaria. Valid concerns about potential overuse of AL could be addressed by the use of malaria rapid diagnostics employed at the community level. Currently, CHWs in Zambia evaluate and treat children with suspected malaria in rural areas, but they refer children with suspected pneumonia to the nearest health facility. This study was designed to assess the effectiveness and feasibility of using CHWs to manage nonsevere pneumonia and uncomplicated malaria with the aid of rapid diagnostic tests (RDTs). METHODS AND FINDINGS. Community health posts staffed by CHWs were matched and randomly allocated to intervention and control arms. Children between the ages of 6 months and 5 years were managed according to the study protocol, as follows. Intervention CHWs performed RDTs, treated test-positive children with AL, and treated those with nonsevere pneumonia (increased respiratory rate) with amoxicillin. Control CHWs did not perform RDTs, treated all febrile children with AL, and referred those with signs of pneumonia to the health facility, as per Ministry of Health policy. The primary outcomes were the use of AL in children with fever and early and appropriate treatment with antibiotics for nonsevere pneumonia. A total of 3,125 children with fever and/or difficult/fast breathing were managed over a 12-month period. In the intervention arm, 27.5% (265/963) of children with fever received AL compared to 99.1% (2066/2084) of control children (risk ratio 0.23, 95% confidence interval 0.14–0.38). For children classified with nonsevere pneumonia, 68.2% (247/362) in the intervention arm and 13.3% (22/203) in the control arm received early and appropriate treatment (risk ratio 5.32, 95% confidence interval 2.19–8.94). There were two deaths in the intervention and one in the control arm. CONCLUSIONS. The potential for CHWs to use RDTs, AL, and amoxicillin to manage both malaria and pneumonia at the community level is promising and might reduce overuse of AL, as well as provide early and appropriate treatment to children with nonsevere pneumonia.United States Agency for International Development (GHSA-00-00020-00) with Boston University; President's Malaria Initiativ

Program brief: Exploring the beliefs, attitudes, and behaviors of msm engaged in substance use and transactional sex in Ghana

This study was implemented by Boston University in collaboration with the Kwame Nkrumah University of Science and Technology with support from the President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for International Development under Project SEARCH Task Order No. GHH‐I‐00‐07‐00023‐00, beginning August 27, 2010. The content and views expressed here are the authors’ and do not necessarily reflect the opinion or policy of USAID or the U.S. Government.Preventing HIV among key populations is a goal of the National AIDS Control Program (NACP) and the Ghana AIDS Commission (GAC).1 Men who have sex with men (MSM) are a particularly stigmatized group in Ghana, in part because male-to-male sex is viewed as “unnatural” and therefore illegal. MSM are a critical though difficult population to reach with HIV-related services. Until recently, specific data on MSM in the country were limited. The Ghana Men’s Study (GMS), which collected data from 1,302 MSM in five regions in 2011, has detailed information on HIV and sexually transmitted infection (STI) prevalence and risk behaviors among MSM. Whereas adult HIV prevalence in Ghana has been estimated at 1.31% in 2013,2 the GMS documented a nationwide average prevalence in 2011 of 17.5% among MSM, with the rate in Accra estimated at 34.3% and 13.7% in Kumasi.3 This qualitative study was designed to complement and supplement quantitative findings about MSM from the GMS. It was conducted by Boston University’s Center for Global Health and Development and the Kwame Nkrumah University of Science and Technology (KNUST) in collaboration with FHI 360 and with funding from the United States Agency for International Development (USAID)/Ghana. It is the first of two qualitative studies focusing on MSM in Ghana. The objectives were to explore: (1) the types and extent of substance use by MSM; (2) the overlap between substance use and transactional sex among MSM; (3) the beliefs and attitudes related to substance use and transactional sex; and (4) knowledge and risk behaviors of both subgroups. In-depth interviews (IDI) and focus group discussions (FGD) were used to collect data from four participant groups: two age groups, adolescent MSM (aged 15-17 years) and young adult MSM (aged 18-29 years), with each group including men who consume high levels of alcohol and/ or use drugs and men who engage in transactional sex (TS). Transactional sex is defined here as self-reported sex with another man in exchange for money, gifts, or favors.Support from the President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for International Development under Project SEARCH Task Order No. GHH‐I‐00‐07‐00023‐00, beginning August 27, 201

Attitudes and behaviors among older MSM in Ghana

This study was implemented by Boston University in collaboration with the Kwame Nkrumah University of Science and Technology with support from the President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for International Development under Project SEARCH Task Order No. GHH‐I‐00‐07‐00023‐00, beginning August 27, 2010. The content and views expressed here are the authors’ and do not necessarily reflect the opinion or policy of USAID or the U.S. Government.This report provides the findings of a qualitative study that explored vulnerability to HIV of men who have sex with men (MSM) in Kumasi, Ghana. It is the second of two related studies focusing on MSM. The first study, “Exploring the beliefs, attitudes, and behaviors of MSM engaged in substance use and transactional sex in Ghana,”1 focused on adolescent and young adult MSM aged 15 to 29 years. This companion study focused on ‘older MSM’, encompassing individuals aged 30 years and above. This research was conducted by a collaborative team comprised of researchers from Boston University’s Center for Global and Health and Development (CGHD) and the Kwame Nkrumah University of Science and Technology (KNUST). The team conducted this research in Kumasi, Ghana’s second largest urban center. It is a component of the ‘Operations Research for Key Populations in Ghana’ Program funded by the United States Agency for International Development (USAID). We designed and carried out the study in collaboration with FHI 360, an organization based in the capital of Accra that operates programs targeting MSM and other high‐risk individuals in Ghana, as well as the Ghana AIDS Commission (GAC). Reducing vulnerability to HIV infection among high‐risk populations in Ghana is a major goal for the National AIDS Control Program (NACP) and the GAC. MSM are highly stigmatized in Ghana, in part because male‐to‐male sex is illegal. This makes it extremely challenging to understand the challenges these men face and ensure that they have access to HIV‐ and AIDS‐related services. We designed this qualitative study to add to what is known about the beliefs, attitudes, and behaviors of older MSM in Ghana. We focused on two groups among older MSM: those aged 30‐39 years and those aged 40 years and above. Given the need for more data on these groups to better reach them with effective HIV prevention and treatment information, the study aimed to explore: 1) How older MSM find their sex partners; 2) Their views of HIV risk; 3) Their risky behaviors, including those situations in which they are most likely to engage in risky sex; 4) HIV‐related services they receive; and 5) What services would be most helpful to them. The broad goal of the study was to collect and analyze in‐depth data in order to improve the outreach and effectiveness of local programs that aim to reach older MSM with important HIV prevention and treatment information and with services appropriate to their needs.Support from the President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for International Development under Project SEARCH Task Order No. GHH‐I‐00‐07‐00023‐00, beginning August 27, 201