Odile Ferroussier-Davis, Deus Lukoye, Susan Alwedo, Mary N. Mudiope, Joanitah Nalunjogi, James Bruce Kirenga, Joseph N. Kabanda, Julius N. Kalamya, Benson Nasasira, Estella Birabwa, Seyoum Dejene, Miriam Murungi, Immaculate Ddumba, Brittany Moore, Aldomoro Burua, Henry Luzze, Ebony Quinto, Moorine Sekadde, Raymond Byaruhanga, Patrick Ajuna, Ivan Arinaitwe, Cordelia Katureebe, Proscovia Namuwenge, Michelle R. Adler, Stavia Turyahabwe
<div> <section> <h3> Introduction</h3> <p>Differentiated service delivery (DSD) models aim to tailor health services delivery to clients’ preferences and clinical characteristics while reducing the burden on health systems. In Uganda, DSD models developed for HIV care were adapted to the tuberculosis (TB) services context to mitigate disruptions from the COVID-19 pandemic and inform national efforts to improve TB care.</p> </section> <section> <h3> Methods</h3> <p>Beginning in April 2021, four facility-based and five community-based DSD models were implemented in 28 TB clinics in Kampala and Soroti Regions. All clients in the intensive (months 1–2) and continuation (months 3–6) phases of treatment were eligible. Client preference and clinician concurrence determined model choice. All models allowed TB medication dispensing intervals ranging from biweekly to multi-month dispensing (MMD; ≥ 2 months). Data abstracted in December 2022 from TB registers and DSD enrolment tracking tools at 21 of 28 implementing facilities were used to evaluate the intervention. The TB treatment success rate (i.e. proportion cured or who completed treatment, vs. those who died, failed, were lost-to-follow-up or had no recorded outcome) in the DSD cohort was compared to facilities’ 2018–2019 results using Fischer's exact test.</p> </section> <section> <h3> Results</h3> <p>Most facilities offered one (Kampala) or two (Soroti) facility-based models and one community-based model. Among 1864 TB clients enrolled between April 2021 and March 2022, 1822 (97.7%) used ≥ 1 DSD models; 210/1822 (11.5%) ever switched models. Overall, 70.5% (1284/1822) of clients enrolled in ≥ 1 facility-based model and 40.5% (737/1822) in ≥ 1 community-based model. The use of community-based models increased during the continuation phase. Facility-Based Individual Management and Home Delivery were the most-used models. In the intensive phase, the longest medication dispensation interval was biweekly for 50.0% of patients, monthly for 41.3% and MMD for 8.8%. During the continuation phase, the longest interval was biweekly for 0.6%, monthly for 71.7% and MMD for 27.6%. Overall, 1582/1864 (84.9%) clients were successfully treated, compared to 858/1177 (72.9%) in 2018–2019 (<i>p</i> < 0.001). Seven (0.4%) patients failed treatment, 32 (1.7%) were lost to follow-up, 101 (5.4%) died and 142 (7.6%) were not evaluated.</p> </section> <section> <h3> Conclusions</h3> <p>TB DSD models were successfully implemented. TB treatment outcomes under DSD compared favourably to historical outcomes. Investigating facto
{"title":"Introducing differentiated service delivery models for tuberculosis treatment: a pilot project to inform national policy in Uganda","authors":"Odile Ferroussier-Davis, Deus Lukoye, Susan Alwedo, Mary N. Mudiope, Joanitah Nalunjogi, James Bruce Kirenga, Joseph N. Kabanda, Julius N. Kalamya, Benson Nasasira, Estella Birabwa, Seyoum Dejene, Miriam Murungi, Immaculate Ddumba, Brittany Moore, Aldomoro Burua, Henry Luzze, Ebony Quinto, Moorine Sekadde, Raymond Byaruhanga, Patrick Ajuna, Ivan Arinaitwe, Cordelia Katureebe, Proscovia Namuwenge, Michelle R. Adler, Stavia Turyahabwe","doi":"10.1002/jia2.26483","DOIUrl":"https://doi.org/10.1002/jia2.26483","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Introduction</h3>\u0000 \u0000 <p>Differentiated service delivery (DSD) models aim to tailor health services delivery to clients’ preferences and clinical characteristics while reducing the burden on health systems. In Uganda, DSD models developed for HIV care were adapted to the tuberculosis (TB) services context to mitigate disruptions from the COVID-19 pandemic and inform national efforts to improve TB care.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>Beginning in April 2021, four facility-based and five community-based DSD models were implemented in 28 TB clinics in Kampala and Soroti Regions. All clients in the intensive (months 1–2) and continuation (months 3–6) phases of treatment were eligible. Client preference and clinician concurrence determined model choice. All models allowed TB medication dispensing intervals ranging from biweekly to multi-month dispensing (MMD; ≥ 2 months). Data abstracted in December 2022 from TB registers and DSD enrolment tracking tools at 21 of 28 implementing facilities were used to evaluate the intervention. The TB treatment success rate (i.e. proportion cured or who completed treatment, vs. those who died, failed, were lost-to-follow-up or had no recorded outcome) in the DSD cohort was compared to facilities’ 2018–2019 results using Fischer's exact test.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Most facilities offered one (Kampala) or two (Soroti) facility-based models and one community-based model. Among 1864 TB clients enrolled between April 2021 and March 2022, 1822 (97.7%) used ≥ 1 DSD models; 210/1822 (11.5%) ever switched models. Overall, 70.5% (1284/1822) of clients enrolled in ≥ 1 facility-based model and 40.5% (737/1822) in ≥ 1 community-based model. The use of community-based models increased during the continuation phase. Facility-Based Individual Management and Home Delivery were the most-used models. In the intensive phase, the longest medication dispensation interval was biweekly for 50.0% of patients, monthly for 41.3% and MMD for 8.8%. During the continuation phase, the longest interval was biweekly for 0.6%, monthly for 71.7% and MMD for 27.6%. Overall, 1582/1864 (84.9%) clients were successfully treated, compared to 858/1177 (72.9%) in 2018–2019 (<i>p</i> < 0.001). Seven (0.4%) patients failed treatment, 32 (1.7%) were lost to follow-up, 101 (5.4%) died and 142 (7.6%) were not evaluated.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>TB DSD models were successfully implemented. TB treatment outcomes under DSD compared favourably to historical outcomes. Investigating facto","PeriodicalId":201,"journal":{"name":"Journal of the International AIDS Society","volume":"28 S3","pages":""},"PeriodicalIF":4.6,"publicationDate":"2025-07-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/jia2.26483","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144573988","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Oratile Mokgethi, Amy Huber, Idah Mokhele, Khumbo Shumba, Vinolia Ntjikelane, Sydney Rosen, Sophie Pascoe
<div> <section> <h3> Introduction</h3> <p>Global and national guidelines recommend the integration of care for HIV and other chronic conditions to improve individual and public health outcomes. South Africa's differentiated service delivery (DSD) models extend beyond HIV care, relying on pickup points that also distribute hypertension (HTN) medications. We assessed the alignment between antiretroviral treatment (ART) and HTN medication collection visits and dispensing intervals as an indicator of integration progress.</p> </section> <section> <h3> Methods</h3> <p>The AMBIT project conducted a SENTINEL survey across 18 public clinics in three South African districts between September 2022 and April 2023, enrolling adult clients ≥ 6 months on ART. We recruited up to 180 clients across each model of care: conventional care-not DSD eligible (conventional-not-eligible); conventional care-DSD eligible but not enrolled (conventional-eligible); facility- (FAC-PuP) and external (EX-PuP) pickup points. Healthcare interaction data were extracted from paper and electronic sources for clients with a 12-month observation period. We analysed both self-reported alignment and actual visit data. We estimated the number and proportion of HTN visits aligned with ART dispensing. Log-binomial regression estimated adjusted risk ratios (ARR) to assess the association with a higher visit burden (> 5 interactions).</p> </section> <section> <h3> Results</h3> <p>Of 724 enrolled, 644 (90%) client records were successfully linked (76% female; median age 42; 15% Conventional-not-eligible; 17% Conventional-eligible; 18% FAC-PuP; 28% EX-PuP). Among these, 85 (13%) with HTN (81 self-reported, 4 from medical records), self-reported 94% and 95% aligned facility visits and medication pickups, respectively. Visit data was retrieved for self-reported HTN diagnoses. Of 477 visits for HIV/HTN comorbid clients, 83% (395) dispensed both ART and HTN medication, and 97% had aligned dispensing durations (Conventional-not-eligible 97%, Conventional-eligible 95%, FAC-PuP 98%, EX-PuP 100%). Comorbid clients had a similar visit burden to ART-only clients (ARR 1.05, 95% CI: 0.80−1.39). FAC-PuP (ARR 0.55, 95% CI: 0.40−0.78) and EX-PuP (ARR 0.75, 95% CI: 0.57−0.98) clients were less likely than Conventional-E clients to have high annual visit burden.</p> </section> <section> <h3> Conclusions</h3> <p>Aligning medication visits and dispensing for HIV and other chronic diseases marks an initial step towards integrated service delivery. Our results demonstrate achievable medication visit alignment wit
{"title":"Aligning HIV treatment and hypertension clinic visits and dispensing as a first step towards service delivery integration in South Africa","authors":"Oratile Mokgethi, Amy Huber, Idah Mokhele, Khumbo Shumba, Vinolia Ntjikelane, Sydney Rosen, Sophie Pascoe","doi":"10.1002/jia2.26444","DOIUrl":"https://doi.org/10.1002/jia2.26444","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Introduction</h3>\u0000 \u0000 <p>Global and national guidelines recommend the integration of care for HIV and other chronic conditions to improve individual and public health outcomes. South Africa's differentiated service delivery (DSD) models extend beyond HIV care, relying on pickup points that also distribute hypertension (HTN) medications. We assessed the alignment between antiretroviral treatment (ART) and HTN medication collection visits and dispensing intervals as an indicator of integration progress.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>The AMBIT project conducted a SENTINEL survey across 18 public clinics in three South African districts between September 2022 and April 2023, enrolling adult clients ≥ 6 months on ART. We recruited up to 180 clients across each model of care: conventional care-not DSD eligible (conventional-not-eligible); conventional care-DSD eligible but not enrolled (conventional-eligible); facility- (FAC-PuP) and external (EX-PuP) pickup points. Healthcare interaction data were extracted from paper and electronic sources for clients with a 12-month observation period. We analysed both self-reported alignment and actual visit data. We estimated the number and proportion of HTN visits aligned with ART dispensing. Log-binomial regression estimated adjusted risk ratios (ARR) to assess the association with a higher visit burden (> 5 interactions).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Of 724 enrolled, 644 (90%) client records were successfully linked (76% female; median age 42; 15% Conventional-not-eligible; 17% Conventional-eligible; 18% FAC-PuP; 28% EX-PuP). Among these, 85 (13%) with HTN (81 self-reported, 4 from medical records), self-reported 94% and 95% aligned facility visits and medication pickups, respectively. Visit data was retrieved for self-reported HTN diagnoses. Of 477 visits for HIV/HTN comorbid clients, 83% (395) dispensed both ART and HTN medication, and 97% had aligned dispensing durations (Conventional-not-eligible 97%, Conventional-eligible 95%, FAC-PuP 98%, EX-PuP 100%). Comorbid clients had a similar visit burden to ART-only clients (ARR 1.05, 95% CI: 0.80−1.39). FAC-PuP (ARR 0.55, 95% CI: 0.40−0.78) and EX-PuP (ARR 0.75, 95% CI: 0.57−0.98) clients were less likely than Conventional-E clients to have high annual visit burden.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Aligning medication visits and dispensing for HIV and other chronic diseases marks an initial step towards integrated service delivery. Our results demonstrate achievable medication visit alignment wit","PeriodicalId":201,"journal":{"name":"Journal of the International AIDS Society","volume":"28 S3","pages":""},"PeriodicalIF":4.6,"publicationDate":"2025-07-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/jia2.26444","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144574070","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Maitreyi Sahu, Adam A. Szpiro, Heidi van Rooyen, Stephen Asiimwe, Maryam Shahmanesh, D. Allen Roberts, Meighan L. Krows, Kombi Sausi, Nsika Sithole, Torin Schaafsma, Jared M. Baeten, Adrienne E. Shapiro, Alastair van Heerden, Ruanne V. Barnabas
<div> <section> <h3> Introduction</h3> <p>As differentiated HIV services provided outside of clinics are scaled up, clients may have fewer interactions with ancillary services for non-communicable disease (NCD) prevention and management traditionally offered within facilities. This study was embedded in the DO ART randomised trial (2016−2019), which demonstrated that community-based differentiated service delivery (DSD) improved HIV viral suppression compared with facility-based care. We assessed NCD risk among men and women living with HIV accessing community-based DSD versus facility-based care in KwaZulu-Natal, South Africa.</p> </section> <section> <h3> Methods</h3> <p>First, we described lifestyle and clinical NCD risk among DO ART participants in rural and semi-rural KwaZulu-Natal. Next, we compared clinical NCD risk at 12 months by randomisation arm (community-based DSD vs. facility-based care). Finally, we explored the relationship between 12-month viral suppression and clinical NCD risk, overall and stratified by randomisation arm (i.e. service delivery type).</p> </section> <section> <h3> Results</h3> <p>Among 1010 participants, the median age was 32 years, 245 (24%) smoked, 229 (23%) had hypertension and 502 (50%) were overweight or obese (body mass index [BMI] ≥ 25). Smoking was more common among men than women (43% vs. 6%, <i>p</i> ≤ 0.001), while overweight/obesity was more common among women than men (65% vs. 34%, <i>p</i> ≤ 0.001). We found no statistically significant association between service delivery type and clinical NCD risk factors at 1 year. We also found no significant associations between viral suppression at 12 months and blood pressure, haemoglobin A1c or smoking. However, virally suppressed clients had higher mean BMI (+0.93 kg/m<sup>2</sup>, <i>p</i> = 0.004) and higher mean cholesterol (+5.79 mg/dl, <i>p</i> = 0.001). These associations were greater in effect size and statistically significant among clients receiving community-based DSD (BMI: <i>p</i> = 0.003; cholesterol: <i>p</i> = 0.001), but smaller and not significant for facility-based care (BMI: <i>p</i> = 0.299; cholesterol: <i>p</i> = 0.448).</p> </section> <section> <h3> Conclusions</h3> <p>Relatively younger adults accessing HIV treatment in South Africa had substantial NCD risk, which differed by gender and may increase with age. Among clients receiving community-based DSD, viral suppression was associated with modestly higher BMI and cholesterol levels. Community-based DSD programmes should consider integrating NCD risk screening and management that addr
随着诊所外提供的差异化艾滋病毒服务的扩大，客户与传统上在设施内提供的非传染性疾病预防和管理辅助服务的互动可能会减少。该研究嵌入在DO ART随机试验（2016 - 2019）中，该试验表明，与基于设施的护理相比，基于社区的差异化服务提供（DSD）改善了HIV病毒抑制。我们评估了南非夸祖鲁-纳塔尔省艾滋病毒感染者接受社区DSD与设施护理的非传染性疾病风险。首先，我们描述了夸祖鲁-纳塔尔省农村和半农村DO ART参与者的生活方式和临床非传染性疾病风险。接下来，我们通过随机分组（基于社区的DSD与基于设施的护理）比较了12个月的临床非传染性疾病风险。最后，我们探讨了12个月病毒抑制与临床非传染性疾病风险之间的关系，并按随机分组（即服务提供类型）进行了总体和分层。结果1010名参与者中，年龄中位数为32岁，吸烟245人（24%），高血压229人（23%），超重或肥胖502人（50%）（体重指数[BMI]≥25）。吸烟在男性中比女性更常见（43%比6%，p≤0.001），而超重/肥胖在女性中比男性更常见（65%比34%，p≤0.001）。我们发现服务提供类型和临床非传染性疾病风险因素在1年内没有统计学上的显著关联。我们还发现，12个月时的病毒抑制与血压、血红蛋白A1c或吸烟之间没有显著关联。然而，病毒抑制的患者有较高的平均BMI （+0.93 kg/m2, p = 0.004）和较高的平均胆固醇（+5.79 mg/dl, p = 0.001）。这些关联在效应大小上更大，在接受社区DSD的客户中具有统计学意义(BMI: p = 0.003；胆固醇：p = 0.001)，但在基于设施的护理中较小且不显著(BMI: p = 0.299；胆固醇：p = 0.448)。结论：在南非，接受HIV治疗的相对年轻的成年人有很大的NCD风险，这种风险因性别而异，并可能随着年龄的增长而增加。在接受社区DSD治疗的患者中，病毒抑制与中等较高的BMI和胆固醇水平相关。以社区为基础的疾病和发展规划应考虑整合非传染性疾病风险筛查和管理，以解决针对性别的需求，防止艾滋病毒感染者过早死亡。临床试验编号NCT0292999
{"title":"Non-communicable disease (NCD) risk among people living with HIV in KwaZulu-Natal, South Africa: evidence from a randomised trial of community-based differentiated service delivery","authors":"Maitreyi Sahu, Adam A. Szpiro, Heidi van Rooyen, Stephen Asiimwe, Maryam Shahmanesh, D. Allen Roberts, Meighan L. Krows, Kombi Sausi, Nsika Sithole, Torin Schaafsma, Jared M. Baeten, Adrienne E. Shapiro, Alastair van Heerden, Ruanne V. Barnabas","doi":"10.1002/jia2.26513","DOIUrl":"https://doi.org/10.1002/jia2.26513","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Introduction</h3>\u0000 \u0000 <p>As differentiated HIV services provided outside of clinics are scaled up, clients may have fewer interactions with ancillary services for non-communicable disease (NCD) prevention and management traditionally offered within facilities. This study was embedded in the DO ART randomised trial (2016−2019), which demonstrated that community-based differentiated service delivery (DSD) improved HIV viral suppression compared with facility-based care. We assessed NCD risk among men and women living with HIV accessing community-based DSD versus facility-based care in KwaZulu-Natal, South Africa.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>First, we described lifestyle and clinical NCD risk among DO ART participants in rural and semi-rural KwaZulu-Natal. Next, we compared clinical NCD risk at 12 months by randomisation arm (community-based DSD vs. facility-based care). Finally, we explored the relationship between 12-month viral suppression and clinical NCD risk, overall and stratified by randomisation arm (i.e. service delivery type).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Among 1010 participants, the median age was 32 years, 245 (24%) smoked, 229 (23%) had hypertension and 502 (50%) were overweight or obese (body mass index [BMI] ≥ 25). Smoking was more common among men than women (43% vs. 6%, <i>p</i> ≤ 0.001), while overweight/obesity was more common among women than men (65% vs. 34%, <i>p</i> ≤ 0.001). We found no statistically significant association between service delivery type and clinical NCD risk factors at 1 year. We also found no significant associations between viral suppression at 12 months and blood pressure, haemoglobin A1c or smoking. However, virally suppressed clients had higher mean BMI (+0.93 kg/m<sup>2</sup>, <i>p</i> = 0.004) and higher mean cholesterol (+5.79 mg/dl, <i>p</i> = 0.001). These associations were greater in effect size and statistically significant among clients receiving community-based DSD (BMI: <i>p</i> = 0.003; cholesterol: <i>p</i> = 0.001), but smaller and not significant for facility-based care (BMI: <i>p</i> = 0.299; cholesterol: <i>p</i> = 0.448).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Relatively younger adults accessing HIV treatment in South Africa had substantial NCD risk, which differed by gender and may increase with age. Among clients receiving community-based DSD, viral suppression was associated with modestly higher BMI and cholesterol levels. Community-based DSD programmes should consider integrating NCD risk screening and management that addr","PeriodicalId":201,"journal":{"name":"Journal of the International AIDS Society","volume":"28 S3","pages":""},"PeriodicalIF":4.6,"publicationDate":"2025-07-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/jia2.26513","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144573989","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Matthew D. Hickey, Asiphas Owaraganise, Sabina Ogachi, Helen Sunday, Colette Aoko, Norton Sang, George Agengo, Jane Kabami, Elijah Kakande, Erick Wafula Mugoma, Josh Schwab, Nicole Sutter, Douglas Black, Anthony Muiru, Gabriel Chamie, Maya L. Petersen, Laura B. Balzer, Elizabeth A. Bukusi, Diane V. Havlir, Moses R. Kamya, James Ayieko
<div> <section> <h3> Introduction</h3> <p>Clinic-based hypertension screening and treatment for people with and without HIV depends on consistent clinic engagement. Retention is challenging in rural areas, especially for people with severe hypertension, which typically requires more frequent visits than clinically stable HIV. We hypothesised that Ministry of Health (MoH) community health workers (CHWs) could improve severe hypertension detection and treatment through an integrated hypertension/HIV intervention.</p> </section> <section> <h3> Methods</h3> <p>In rural Uganda and Kenya, we added HIV testing and a status-neutral hypertension intervention to CHW workflow in an ongoing cluster-randomised population-level study (SEARCH:NCT05768763). Data spans March 2023–August 2024. Trained CHWs screened all adults aged ≥ 40 years in intervention communities for hypertension, referring those with blood pressure (BP) ≥ 140/90 mmHg to MoH HIV/primary care clinics. After initial in-clinic evaluation, adults with BP ≥ 160/100 mmHg were offered choice of clinic-based or telehealth (CHW home visit, clinician telehealth evaluation, medication delivery) follow-up care. Telehealth used a MoH-compatible CHW smartphone app that syncs with electronic clinic records, prompts CHW follow-up visits and facilitates clinician telehealth assessment/medication prescribing. We report hypertension control achieved through the implementation of CHW-supported screening and telehealth and used targeted minimum loss-based estimation to estimate the change in population prevalence of uncontrolled hypertension from baseline to 1 year.</p> </section> <section> <h3> Results</h3> <p>Across eight communities, 198 CHWs measured BP in 14,378/15,879 adults aged ≥ 40 years at baseline (91%) and 13,334/15,879 after 1 year (84%); 55% were female and 19% living with HIV. Estimated population prevalence of BP ≥ 140/90 mmHg decreased from 16.0% at baseline to 6.4% at year 1 (9.6% absolute decrease, 95% CI 8.6%, 10.6%). Among people with HIV aged ≥ 40 years (<i>n</i> = 3036), the prevalence of BP ≥ 140/90 mmHg decreased from 10.5% to 4.7% (5.9% absolute decrease, 95% CI 3.0%, 8.8%). In the subset with BP ≥ 160/100 who enrolled in the intervention (<i>n</i> = 919), 96% received antihypertensive medication, 81% were retained in care at 1 year and 79% achieved BP control; people with HIV (<i>n</i> = 120) had similar retention (80%) and BP control (80%).</p> </section> <section> <h3> Conclusions</h3> <p>Within the context of a pragmatic trial, leveraging existing CHWs in an integrated HIV/hypertensio
{"title":"A prospective cohort study of the SEARCH integrated HIV/hypertension community health worker-led intervention in rural Kenya and Uganda","authors":"Matthew D. Hickey, Asiphas Owaraganise, Sabina Ogachi, Helen Sunday, Colette Aoko, Norton Sang, George Agengo, Jane Kabami, Elijah Kakande, Erick Wafula Mugoma, Josh Schwab, Nicole Sutter, Douglas Black, Anthony Muiru, Gabriel Chamie, Maya L. Petersen, Laura B. Balzer, Elizabeth A. Bukusi, Diane V. Havlir, Moses R. Kamya, James Ayieko","doi":"10.1002/jia2.26500","DOIUrl":"https://doi.org/10.1002/jia2.26500","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Introduction</h3>\u0000 \u0000 <p>Clinic-based hypertension screening and treatment for people with and without HIV depends on consistent clinic engagement. Retention is challenging in rural areas, especially for people with severe hypertension, which typically requires more frequent visits than clinically stable HIV. We hypothesised that Ministry of Health (MoH) community health workers (CHWs) could improve severe hypertension detection and treatment through an integrated hypertension/HIV intervention.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>In rural Uganda and Kenya, we added HIV testing and a status-neutral hypertension intervention to CHW workflow in an ongoing cluster-randomised population-level study (SEARCH:NCT05768763). Data spans March 2023–August 2024. Trained CHWs screened all adults aged ≥ 40 years in intervention communities for hypertension, referring those with blood pressure (BP) ≥ 140/90 mmHg to MoH HIV/primary care clinics. After initial in-clinic evaluation, adults with BP ≥ 160/100 mmHg were offered choice of clinic-based or telehealth (CHW home visit, clinician telehealth evaluation, medication delivery) follow-up care. Telehealth used a MoH-compatible CHW smartphone app that syncs with electronic clinic records, prompts CHW follow-up visits and facilitates clinician telehealth assessment/medication prescribing. We report hypertension control achieved through the implementation of CHW-supported screening and telehealth and used targeted minimum loss-based estimation to estimate the change in population prevalence of uncontrolled hypertension from baseline to 1 year.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Across eight communities, 198 CHWs measured BP in 14,378/15,879 adults aged ≥ 40 years at baseline (91%) and 13,334/15,879 after 1 year (84%); 55% were female and 19% living with HIV. Estimated population prevalence of BP ≥ 140/90 mmHg decreased from 16.0% at baseline to 6.4% at year 1 (9.6% absolute decrease, 95% CI 8.6%, 10.6%). Among people with HIV aged ≥ 40 years (<i>n</i> = 3036), the prevalence of BP ≥ 140/90 mmHg decreased from 10.5% to 4.7% (5.9% absolute decrease, 95% CI 3.0%, 8.8%). In the subset with BP ≥ 160/100 who enrolled in the intervention (<i>n</i> = 919), 96% received antihypertensive medication, 81% were retained in care at 1 year and 79% achieved BP control; people with HIV (<i>n</i> = 120) had similar retention (80%) and BP control (80%).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Within the context of a pragmatic trial, leveraging existing CHWs in an integrated HIV/hypertensio","PeriodicalId":201,"journal":{"name":"Journal of the International AIDS Society","volume":"28 S3","pages":""},"PeriodicalIF":4.6,"publicationDate":"2025-07-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/jia2.26500","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144574080","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Jason J. Ong, Doug Fraser, Christopher Bourne, Andrew Grulich, Benjamin R. Bavinton
<div> <section> <h3> Introduction</h3> <p>Gay, bisexual and other men who have sex with men are disproportionately affected by HIV and other sexually transmitted infections (STIs). This study explores preferences for different models of sexual health services among gay, bisexual and other men who have sex with men in Australia, using discrete choice experiments (DCEs).</p> </section> <section> <h3> Methods</h3> <p>A cross-sectional online survey was conducted from November 2022 to February 2023, targeting three groups: (1) gay, bisexual and other men who have sex with men living with HIV; (2) pre-exposure prophylaxis (PrEP) users; and (3) non-PrEP users. Participants were recruited through paid advertisements, sexual health clinics and community networks. The survey included demographic questions, sexual behaviour inquiries and three tailored DCEs to quantify preferences for service delivery attributes such as cost, type of clinic, appointment type, appointment frequency, extra services and where samples are taken for HIV/STI testing. We used latent class analyses to identify subgroups of people with similar preferences.</p> </section> <section> <h3> Results</h3> <p>We recruited 1422 participants. The median age was 41 (interquartile range [IQR]: 32–54) for gay, bisexual and other men who have sex with men living with HIV (<i>N</i> = 396), 35 (IQR: 29–45) for PrEP users (<i>N</i> = 436) and 33 (IQR: 26–44) for non-PrEP users (<i>N</i> = 590). In our latent class analyses, gay, bisexual and other men who have sex with men living with HIV preferred sexual health services to be delivered via sexual health clinics (46.2%), general practitioners (GP) with expertise in lesbian, gay, bisexual, trans, queer and others (LGBTQ+) health (33.0%) or were happy to go anywhere and to pay (20.7%). PrEP users preferred either PrEP-only clinics or GP with expertise in LGBTQ+ health (75.2%) and GP with expertise in LGBTQ+ health only (24.8%). Non-PrEP users preferred GP with expertise in LGBTQ+ health (44.7%) or any free service (22.8%); some did not want to test (22.2%) or were unsure of their preferences (10.2%).</p> </section> <section> <h3> Conclusions</h3> <p>To align service models with client needs, investment in specialist sexual health clinics and LGBTQ+ competent GPs is important, though this may depend on local resources and infrastructure. Future research should focus on addressing financial barriers, evaluating telehealth and digital health interventions, and understanding testing reluctance among non-PrEP users.</p> </section>
{"title":"Preferences for models of sexual health service delivery among gay, bisexual and other men who have sex with men in Australia: a discrete choice experiment","authors":"Jason J. Ong, Doug Fraser, Christopher Bourne, Andrew Grulich, Benjamin R. Bavinton","doi":"10.1002/jia2.26482","DOIUrl":"https://doi.org/10.1002/jia2.26482","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Introduction</h3>\u0000 \u0000 <p>Gay, bisexual and other men who have sex with men are disproportionately affected by HIV and other sexually transmitted infections (STIs). This study explores preferences for different models of sexual health services among gay, bisexual and other men who have sex with men in Australia, using discrete choice experiments (DCEs).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>A cross-sectional online survey was conducted from November 2022 to February 2023, targeting three groups: (1) gay, bisexual and other men who have sex with men living with HIV; (2) pre-exposure prophylaxis (PrEP) users; and (3) non-PrEP users. Participants were recruited through paid advertisements, sexual health clinics and community networks. The survey included demographic questions, sexual behaviour inquiries and three tailored DCEs to quantify preferences for service delivery attributes such as cost, type of clinic, appointment type, appointment frequency, extra services and where samples are taken for HIV/STI testing. We used latent class analyses to identify subgroups of people with similar preferences.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>We recruited 1422 participants. The median age was 41 (interquartile range [IQR]: 32–54) for gay, bisexual and other men who have sex with men living with HIV (<i>N</i> = 396), 35 (IQR: 29–45) for PrEP users (<i>N</i> = 436) and 33 (IQR: 26–44) for non-PrEP users (<i>N</i> = 590). In our latent class analyses, gay, bisexual and other men who have sex with men living with HIV preferred sexual health services to be delivered via sexual health clinics (46.2%), general practitioners (GP) with expertise in lesbian, gay, bisexual, trans, queer and others (LGBTQ+) health (33.0%) or were happy to go anywhere and to pay (20.7%). PrEP users preferred either PrEP-only clinics or GP with expertise in LGBTQ+ health (75.2%) and GP with expertise in LGBTQ+ health only (24.8%). Non-PrEP users preferred GP with expertise in LGBTQ+ health (44.7%) or any free service (22.8%); some did not want to test (22.2%) or were unsure of their preferences (10.2%).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>To align service models with client needs, investment in specialist sexual health clinics and LGBTQ+ competent GPs is important, though this may depend on local resources and infrastructure. Future research should focus on addressing financial barriers, evaluating telehealth and digital health interventions, and understanding testing reluctance among non-PrEP users.</p>\u0000 </section>\u0000 ","PeriodicalId":201,"journal":{"name":"Journal of the International AIDS Society","volume":"28 S3","pages":""},"PeriodicalIF":4.6,"publicationDate":"2025-07-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/jia2.26482","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144573993","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Emmah Owidi, Kenneth Ngure, Vallery Ogello, Njeri Wairimu, Lydia Etyang’, Winnie Waituika, Margaret Mwangi, Dominic Mwangi, Simon Maina, Elizabeth Irungu, Catherine Kiptinness, Nelly Mugo, Kenneth Mugwanya, for the Efficiency Study Team
<div> <section> <h3> Introduction</h3> <p>High client opportunity costs and a burdened healthcare system limit oral pre-exposure prophylaxis (PrEP) delivery in Kenyan public HIV clinics. We conducted a qualitative study among PrEP clients and providers to understand the acceptability, feasibility and willingness to implement a client-centred, differentiated direct-to-pharmacy (DTP) PrEP refill visits intervention aimed at improving the efficiency of PrEP implementation in real-world clinics.</p> </section> <section> <h3> Methods</h3> <p>From March 2021 to March 2022, we conducted in-depth interviews with clients and healthcare providers participating in an individual facility pharmacy-based PrEP delivery model for PrEP refills among clients in the continuation phase at two public HIV clinics in central Kenya. The core components of the DTP model included directed-to-PrEP pharmacy refill visits conducted by facility pharmacy staff and client HIV self-testing (HIVST) while waiting for services at the pharmacy. We used semi-structured interview guides informed by the Consolidated Framework for Implementation Research (CFIR). We analysed data using thematic content analysis and organised findings by CFIR constructs.</p> </section> <section> <h3> Results</h3> <p>We interviewed 20 PrEP clients and 20 healthcare providers. PrEP clients included 15 females and had a median age of 39 years (interquartile range [IQR]: 33–48). Providers included 13 females, had a median age of 32 years (IQR: 30–41), and included 10 HIV counsellors, 5 pharmacy and 3 clinical providers. Both providers and clients reported high satisfaction with DTP PrEP refill visits derived from improved clinic flow and quality of service. Among clients, shorter waiting times and less movement between multiple clinic rooms reduced delays, improved privacy and reduced stigma associated with visiting HIV clinics. Furthermore, shorter waiting times and infrequent clinic visits reduced loss of working hours and income among clients, motivating PrEP continuation. Providers reported improved clinic flow, reduced work burden among non-pharmacy providers, improved knowledge and ease of implementing DTP refill visits. However, providers expressed concerns about the potential loss of roles among HIV counsellors and the shifting of workload burden to pharmacy providers.</p> </section> <section> <h3> Conclusions</h3> <p>Differentiated DTP refill visits with HIVST were highly acceptable and feasible among PrEP clients and providers. Context-specific modifications and scale-up of the intervention could impr
{"title":"High acceptability, feasibility and sustainability of a direct-to-pharmacy differentiated PrEP delivery model in public health HIV clinics in Kenya: perspectives of PrEP clients and healthcare providers","authors":"Emmah Owidi, Kenneth Ngure, Vallery Ogello, Njeri Wairimu, Lydia Etyang’, Winnie Waituika, Margaret Mwangi, Dominic Mwangi, Simon Maina, Elizabeth Irungu, Catherine Kiptinness, Nelly Mugo, Kenneth Mugwanya, for the Efficiency Study Team","doi":"10.1002/jia2.26442","DOIUrl":"https://doi.org/10.1002/jia2.26442","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Introduction</h3>\u0000 \u0000 <p>High client opportunity costs and a burdened healthcare system limit oral pre-exposure prophylaxis (PrEP) delivery in Kenyan public HIV clinics. We conducted a qualitative study among PrEP clients and providers to understand the acceptability, feasibility and willingness to implement a client-centred, differentiated direct-to-pharmacy (DTP) PrEP refill visits intervention aimed at improving the efficiency of PrEP implementation in real-world clinics.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>From March 2021 to March 2022, we conducted in-depth interviews with clients and healthcare providers participating in an individual facility pharmacy-based PrEP delivery model for PrEP refills among clients in the continuation phase at two public HIV clinics in central Kenya. The core components of the DTP model included directed-to-PrEP pharmacy refill visits conducted by facility pharmacy staff and client HIV self-testing (HIVST) while waiting for services at the pharmacy. We used semi-structured interview guides informed by the Consolidated Framework for Implementation Research (CFIR). We analysed data using thematic content analysis and organised findings by CFIR constructs.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>We interviewed 20 PrEP clients and 20 healthcare providers. PrEP clients included 15 females and had a median age of 39 years (interquartile range [IQR]: 33–48). Providers included 13 females, had a median age of 32 years (IQR: 30–41), and included 10 HIV counsellors, 5 pharmacy and 3 clinical providers. Both providers and clients reported high satisfaction with DTP PrEP refill visits derived from improved clinic flow and quality of service. Among clients, shorter waiting times and less movement between multiple clinic rooms reduced delays, improved privacy and reduced stigma associated with visiting HIV clinics. Furthermore, shorter waiting times and infrequent clinic visits reduced loss of working hours and income among clients, motivating PrEP continuation. Providers reported improved clinic flow, reduced work burden among non-pharmacy providers, improved knowledge and ease of implementing DTP refill visits. However, providers expressed concerns about the potential loss of roles among HIV counsellors and the shifting of workload burden to pharmacy providers.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Differentiated DTP refill visits with HIVST were highly acceptable and feasible among PrEP clients and providers. Context-specific modifications and scale-up of the intervention could impr","PeriodicalId":201,"journal":{"name":"Journal of the International AIDS Society","volume":"28 S3","pages":""},"PeriodicalIF":4.6,"publicationDate":"2025-07-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/jia2.26442","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144574071","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Maurice Musheke, Jake M. Pry, Izukanji Sikazwe, Walusiku J. Muyunda, Kanema Chiyenu, Charity M. Siame, Winfred K. Khondowe, Bwalya Mushiki, Martha M. Mwaba, Pelile Zulu, Flavia Mwape, Bridget Siamasuku, Davies Shula, Mable B. Mweemba, Cuthbert Kanene, Arlene Phiri, Michael E. Herce
Introduction
Despite being at high risk of HIV acquisition, access to pre-exposure prophylaxis (PrEP) among adolescent girls and young women (AGYW) is low in Zambia because PrEP is traditionally delivered in clinical settings. We describe the effects of community centres supported by the Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe (DREAMS) initiative on PrEP outcomes in Zambia and examine factors associated with PrEP continuation.
Methods
We collected individual-level PrEP data for AGYW aged 15–24 years at risk of HIV acquisition and enrolled in DREAMS in seven districts of Zambia between August 2022 and August 2024. We used Pearson's Chi-squared test to examine differences in beneficiary characteristics between clients with a PrEP initiation visit and ≥ 2 PrEP visits (i.e. an initiation plus ≥ 1 return visit), and mixed effects Poisson regression modelling to estimate the association between DREAMS enrolment criteria and PrEP continuation (defined as ≥ 1 PrEP visit within 180 days of initiation). We also estimated the marginal probability of PrEP continuation by number of DREAMS enrolment criteria and used Kaplan-Meier methods to estimate the time to the first PrEP return visit by client age band.
Results
Between 11 August 2022 and 23 August 2024, 15,502 AGYW aged 15–24 years were screened for PrEP eligibility, of whom 15,072 (97.2%) initiated PrEP per national guidelines. Of those initiating PrEP, 9807 (65.1%) had sufficient follow-up time to allow for observation of a PrEP return visit. The proportion of AGYW who had ≥ 1 PrEP return visit within 180 days of initiation was 59.0% (n/N = 5706/9675). Across age bands, the percent probability of having a PrEP return visit within 180 days of initiation was highest among clients who reported ≥ 4 DREAMS enrolment criteria at 91.7% (95% CI: 70.7, 112.7%) for clients aged 15–19 years and 83.6% (95% CI: 61.1, 106.2%) for clients aged 20–24 years. Overall, 41.5% of clients had a first PrEP return visit between 21 and 42 days of PrEP initiation.
Conclusions
The high number and proportion of AGYW initiated on PrEP suggests that decentralising PrEP services to DREAMS community centres has the potential to improve PrEP access among AGYW. Increasing HIV risk perception among AGYW may improve PrEP continuation.
{"title":"Improving PrEP access for adolescent girls and young women: a descriptive analysis of community-based PrEP delivery in the DREAMS programme in Zambia","authors":"Maurice Musheke, Jake M. Pry, Izukanji Sikazwe, Walusiku J. Muyunda, Kanema Chiyenu, Charity M. Siame, Winfred K. Khondowe, Bwalya Mushiki, Martha M. Mwaba, Pelile Zulu, Flavia Mwape, Bridget Siamasuku, Davies Shula, Mable B. Mweemba, Cuthbert Kanene, Arlene Phiri, Michael E. Herce","doi":"10.1002/jia2.26484","DOIUrl":"https://doi.org/10.1002/jia2.26484","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Introduction</h3>\u0000 \u0000 <p>Despite being at high risk of HIV acquisition, access to pre-exposure prophylaxis (PrEP) among adolescent girls and young women (AGYW) is low in Zambia because PrEP is traditionally delivered in clinical settings. We describe the effects of community centres supported by the Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe (DREAMS) initiative on PrEP outcomes in Zambia and examine factors associated with PrEP continuation.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>We collected individual-level PrEP data for AGYW aged 15–24 years at risk of HIV acquisition and enrolled in DREAMS in seven districts of Zambia between August 2022 and August 2024. We used Pearson's Chi-squared test to examine differences in beneficiary characteristics between clients with a PrEP initiation visit and ≥ 2 PrEP visits (i.e. an initiation plus ≥ 1 return visit), and mixed effects Poisson regression modelling to estimate the association between DREAMS enrolment criteria and PrEP continuation (defined as ≥ 1 PrEP visit within 180 days of initiation). We also estimated the marginal probability of PrEP continuation by number of DREAMS enrolment criteria and used Kaplan-Meier methods to estimate the time to the first PrEP return visit by client age band.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Between 11 August 2022 and 23 August 2024, 15,502 AGYW aged 15–24 years were screened for PrEP eligibility, of whom 15,072 (97.2%) initiated PrEP per national guidelines. Of those initiating PrEP, 9807 (65.1%) had sufficient follow-up time to allow for observation of a PrEP return visit. The proportion of AGYW who had ≥ 1 PrEP return visit within 180 days of initiation was 59.0% (<i>n</i>/<i>N</i> = 5706/9675). Across age bands, the percent probability of having a PrEP return visit within 180 days of initiation was highest among clients who reported ≥ 4 DREAMS enrolment criteria at 91.7% (95% CI: 70.7, 112.7%) for clients aged 15–19 years and 83.6% (95% CI: 61.1, 106.2%) for clients aged 20–24 years. Overall, 41.5% of clients had a first PrEP return visit between 21 and 42 days of PrEP initiation.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>The high number and proportion of AGYW initiated on PrEP suggests that decentralising PrEP services to DREAMS community centres has the potential to improve PrEP access among AGYW. Increasing HIV risk perception among AGYW may improve PrEP continuation.</p>\u0000 </section>\u0000 </div>","PeriodicalId":201,"journal":{"name":"Journal of the International AIDS Society","volume":"28 S3","pages":""},"PeriodicalIF":4.6,"publicationDate":"2025-07-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/jia2.26484","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144574072","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
John Baptist Kiggundu, Fred C. Semitala, Chelsea Faith Lipoto, Lilian Giibwa, Robert Twine, Savio Mwaka, Florence Ayebare, Christine Kiwala, Evelyn N. Magambo, Gerald Mutungi, Isaac Ssinabulya, Donna Spiegelman, James Kayima, Martin Muddu, Jeremy I. Schwartz, Anne R. Katahoire, Chris T. Longenecker
<div> <section> <h3> Introduction</h3> <p>Uganda's national guidelines recommend integrated HIV and hypertension care; however, integration of hypertension care into HIV differentiated service delivery (DSD) models has not been extensively described. We aimed to describe trends in DSD models for people living with HIV (PLHIV) with hypertension and to qualitatively describe the experiences of healthcare providers (HCPs) and PLHIV with hypertension after implementing integrated care.</p> </section> <section> <h3> Methods</h3> <p>We conducted a parallel convergent mixed methods study nested in an ongoing stepped wedge cluster randomised trial in Kampala and Wakiso districts. Quantitative data (age, sex, blood pressure, DSD model, medication prescriptions) were collected from routine medical records at eight clinics implementing the enhanced care package between March 2023 and July 2024. Additionally, structured interviews were conducted at two clinics with HCPs (<i>n</i> = 6, 3 per clinic) and PLHIV with hypertension (<i>n</i> = 8, 4 per clinic). Our quantitative outcome variable was enrolment in intensive DSD models (facility-based individual and group models) versus other DSDs. A generalised estimation equation was used to account for within clinic correlation and repeated measures within participants over time. Inductive thematic analysis was applied to the qualitative data using the Consolidated Framework for Implementation Research.</p> </section> <section> <h3> Results</h3> <p>Overall, 3164 PLHIV with hypertension accessed care at the eight clinics. Median age was 46 years (IQR 38–56); more than two-thirds were female. There was considerable heterogeneity across clinics in the use of DSD models during the study period. Overall, use of intensive models increased over time (OR 1.127 [1.059−1.199] per month). However, two clinics showed significant time interaction effects (Wald test χ<sup>2</sup> (7) = 69.94, <i>p</i> < 0.001), with a decrease in the intensive models over time. HCPs and PLHIV observed that integrating hypertension care was easily adaptable in some models, while more challenging in others. The availability of resources and synchronisation of HIV and hypertension visits facilitated the integration of hypertension care within the HIV DSD models.</p> </section> <section> <h3> Conclusions</h3> <p>The integration of hypertension management into HIV DSD models is both feasible and adaptable; however, it requires transitioning PLHIV between various models based on clinical needs. To facilitate this process, comprehensive client educati
{"title":"Early findings from the integration of hypertension care into differentiated service delivery models for HIV in Uganda: a mixed-method study","authors":"John Baptist Kiggundu, Fred C. Semitala, Chelsea Faith Lipoto, Lilian Giibwa, Robert Twine, Savio Mwaka, Florence Ayebare, Christine Kiwala, Evelyn N. Magambo, Gerald Mutungi, Isaac Ssinabulya, Donna Spiegelman, James Kayima, Martin Muddu, Jeremy I. Schwartz, Anne R. Katahoire, Chris T. Longenecker","doi":"10.1002/jia2.26499","DOIUrl":"https://doi.org/10.1002/jia2.26499","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Introduction</h3>\u0000 \u0000 <p>Uganda's national guidelines recommend integrated HIV and hypertension care; however, integration of hypertension care into HIV differentiated service delivery (DSD) models has not been extensively described. We aimed to describe trends in DSD models for people living with HIV (PLHIV) with hypertension and to qualitatively describe the experiences of healthcare providers (HCPs) and PLHIV with hypertension after implementing integrated care.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>We conducted a parallel convergent mixed methods study nested in an ongoing stepped wedge cluster randomised trial in Kampala and Wakiso districts. Quantitative data (age, sex, blood pressure, DSD model, medication prescriptions) were collected from routine medical records at eight clinics implementing the enhanced care package between March 2023 and July 2024. Additionally, structured interviews were conducted at two clinics with HCPs (<i>n</i> = 6, 3 per clinic) and PLHIV with hypertension (<i>n</i> = 8, 4 per clinic). Our quantitative outcome variable was enrolment in intensive DSD models (facility-based individual and group models) versus other DSDs. A generalised estimation equation was used to account for within clinic correlation and repeated measures within participants over time. Inductive thematic analysis was applied to the qualitative data using the Consolidated Framework for Implementation Research.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Overall, 3164 PLHIV with hypertension accessed care at the eight clinics. Median age was 46 years (IQR 38–56); more than two-thirds were female. There was considerable heterogeneity across clinics in the use of DSD models during the study period. Overall, use of intensive models increased over time (OR 1.127 [1.059−1.199] per month). However, two clinics showed significant time interaction effects (Wald test χ<sup>2</sup> (7) = 69.94, <i>p</i> < 0.001), with a decrease in the intensive models over time. HCPs and PLHIV observed that integrating hypertension care was easily adaptable in some models, while more challenging in others. The availability of resources and synchronisation of HIV and hypertension visits facilitated the integration of hypertension care within the HIV DSD models.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>The integration of hypertension management into HIV DSD models is both feasible and adaptable; however, it requires transitioning PLHIV between various models based on clinical needs. To facilitate this process, comprehensive client educati","PeriodicalId":201,"journal":{"name":"Journal of the International AIDS Society","volume":"28 S3","pages":""},"PeriodicalIF":4.6,"publicationDate":"2025-07-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/jia2.26499","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144574069","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Lo Yan Esabelle Yam, Pheak Chhoun, Ziya Tian, Michiko Nagashima-Hayashi, Marina Zahari, Sovannary Tuot, Sovannarith Samreth, Bora Ngauv, Vichea Ouk, Kiesha Prem, Siyan Yi
<div> <section> <h3> Introduction</h3> <p>In Cambodia, of all people living with HIV, 89% knew their status, 89% were receiving antiretroviral therapy (ART) and 87% had their viral load suppressed in 2023. In 2017, the national HIV programme introduced the multi-month dispensing (MMD) model to reduce visits to ART clinics, thereby reducing the burden on people living with HIV and health facilities. A quasi-experimental study introduced the community ART delivery (CAD) model, where community action workers (CAWs) delivered pre-packaged antiretrovirals to their peers in the community. This study examined the cost-effectiveness of the CAD compared to the MMD model.</p> </section> <section> <h3> Methods</h3> <p>This study was conducted between 2021 and 2023 and involved 2040 stable people living with HIV in the CAD arm and 2049 in the MMD arm. Baseline and endline surveys included self-reported ART adherence, quality of life, and medical and non-medical expenses. Intention-to-treat analyses (ITTs) were conducted based on participants’ original treatment assignment, with multiple imputations performed for participants lost to follow-up at the endline. Incremental cost-effectiveness ratios (ICERs) on ART adherence and quality of life were generated using health system and societal perspectives. Cost-effectiveness thresholds (CETs) were one-time gross domestic product (GDP) per capita and opportunity cost.</p> </section> <section> <h3> Results</h3> <p>Both arms observed a decline in ART adherence and good physical health, with a decline in CAD less than in the MMD (<i>p</i>-value < 0.001). Similarly, a reduced proportion of participants reported good mental health across both arms; however, the difference was statistically insignificant. The ICERs for good physical health at the health system and societal levels were below the one-time GDP per capita (Incremental Net Benefit = 77.49−83.03) but exceeded the opportunity cost CET. The ICERs for ART adherence at the health system and societal levels were above both CETs.</p> </section> <section> <h3> Conclusions</h3> <p>The results showed that the CAD model was cost-effective in reducing the decline in the physical health of people living with HIV during the COVID-19 pandemic in Cambodia when a less stringent threshold was used. Further investigations are required to ascertain the cost-effectiveness of the CAD model by factoring in the productivity gains within the health system.</p> </section> <section> <h3> Clinical Trial Number</h3>
{"title":"Cost-effectiveness analysis of a community-based model for delivery of antiretroviral therapy to people with clinically stable HIV in Cambodia","authors":"Lo Yan Esabelle Yam, Pheak Chhoun, Ziya Tian, Michiko Nagashima-Hayashi, Marina Zahari, Sovannary Tuot, Sovannarith Samreth, Bora Ngauv, Vichea Ouk, Kiesha Prem, Siyan Yi","doi":"10.1002/jia2.26476","DOIUrl":"https://doi.org/10.1002/jia2.26476","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Introduction</h3>\u0000 \u0000 <p>In Cambodia, of all people living with HIV, 89% knew their status, 89% were receiving antiretroviral therapy (ART) and 87% had their viral load suppressed in 2023. In 2017, the national HIV programme introduced the multi-month dispensing (MMD) model to reduce visits to ART clinics, thereby reducing the burden on people living with HIV and health facilities. A quasi-experimental study introduced the community ART delivery (CAD) model, where community action workers (CAWs) delivered pre-packaged antiretrovirals to their peers in the community. This study examined the cost-effectiveness of the CAD compared to the MMD model.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>This study was conducted between 2021 and 2023 and involved 2040 stable people living with HIV in the CAD arm and 2049 in the MMD arm. Baseline and endline surveys included self-reported ART adherence, quality of life, and medical and non-medical expenses. Intention-to-treat analyses (ITTs) were conducted based on participants’ original treatment assignment, with multiple imputations performed for participants lost to follow-up at the endline. Incremental cost-effectiveness ratios (ICERs) on ART adherence and quality of life were generated using health system and societal perspectives. Cost-effectiveness thresholds (CETs) were one-time gross domestic product (GDP) per capita and opportunity cost.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Both arms observed a decline in ART adherence and good physical health, with a decline in CAD less than in the MMD (<i>p</i>-value < 0.001). Similarly, a reduced proportion of participants reported good mental health across both arms; however, the difference was statistically insignificant. The ICERs for good physical health at the health system and societal levels were below the one-time GDP per capita (Incremental Net Benefit = 77.49−83.03) but exceeded the opportunity cost CET. The ICERs for ART adherence at the health system and societal levels were above both CETs.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>The results showed that the CAD model was cost-effective in reducing the decline in the physical health of people living with HIV during the COVID-19 pandemic in Cambodia when a less stringent threshold was used. Further investigations are required to ascertain the cost-effectiveness of the CAD model by factoring in the productivity gains within the health system.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Clinical Trial Number</h3>\u0000","PeriodicalId":201,"journal":{"name":"Journal of the International AIDS Society","volume":"28 S3","pages":""},"PeriodicalIF":4.6,"publicationDate":"2025-07-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/jia2.26476","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144573916","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
<div> <section> <h3> Introduction</h3> <p>The World Health Organization promotes a transgender-differentiated service delivery (TG-DSD) model to overcome barriers to HIV service engagement among transgender people (TGP). For TGP, an essential element of DSD includes gender-affirming care which is non-stigmatising, free from discrimination and celebrates their gender identity. The <i>Jabula Uzibone</i> Study, launched in November 2023, assesses the cost and effectiveness of TG-DSD on HIV outcomes. In this paper, we describe the baseline characteristics of TGP in our study and explore whether there are differences in healthcare experiences among those seeking care at TG-DSD clinics versus standard service delivery (SSD) clinics at baseline.</p> </section> <section> <h3> Methods</h3> <p>This observational, mixed-method, prospective implementation study compares models of care at four TG-DSD and four SSD facilities using standardised observation checklists, in-depth and key informant interviews. For this paper, we asked participants about healthcare experiences and experiences of stigma through a structured, interviewer-administered quantitative survey. We assessed the sections of the quantitative survey which ask about self-reported experiences of stigma.</p> </section> <section> <h3> Results</h3> <p>The study enrolled 422 TGP with HIV (217 TG-DSD and 205 SSD) and 248 TGP without HIV (128 TG-DSD and 120 SSD); 15% (102/670) gender non-conforming, 15% (91/670) TG men and 70% (477/670) TG women. Participants’ median age was 29 years, interquartile range: 24−35 years. SSD participants at baseline were 46% more likely to experience stigma compared to their TG-DSD counterparts (aOR = 1.46, 95% CI: 1.06, 2.01). SSD participants were more likely to encounter a healthcare provider who is unwilling to provide care for them (aOR = 1.55, 95% CI: 1.09, 2.21) and to report that healthcare workers are unable to provide the same quality care to TGP as they do other people (aOR = 1.46, 95% CI: 1.00, 1.91) compared to their TG-DSD counterparts.</p> </section> <section> <h3> Conclusions</h3> <p>TGP from TG-DSD facilities were less likely to report experiences of facility-based enacted stigma at baseline, compared to the TGP from SSD facilities. Our study highlights the importance of provider training in tailored transgender healthcare to provide gender-affirming healthcare services. Results from the <i>Jabula Uzibone</i> study will provide further evidence of the effectiveness of TG-DSD models in sub-Saharan Africa, and the role of stigma and discrimination in HIV outco
{"title":"Exploring healthcare experiences of transgender people in the Jabula Uzibone study, South Africa: a longitudinal implementation science study","authors":"Rutendo Bothma, Audrey Pettifor, Innocent Maphosa, Philisiwe Ndlovu, John Imrie, Tonia Poteat","doi":"10.1002/jia2.26503","DOIUrl":"https://doi.org/10.1002/jia2.26503","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Introduction</h3>\u0000 \u0000 <p>The World Health Organization promotes a transgender-differentiated service delivery (TG-DSD) model to overcome barriers to HIV service engagement among transgender people (TGP). For TGP, an essential element of DSD includes gender-affirming care which is non-stigmatising, free from discrimination and celebrates their gender identity. The <i>Jabula Uzibone</i> Study, launched in November 2023, assesses the cost and effectiveness of TG-DSD on HIV outcomes. In this paper, we describe the baseline characteristics of TGP in our study and explore whether there are differences in healthcare experiences among those seeking care at TG-DSD clinics versus standard service delivery (SSD) clinics at baseline.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>This observational, mixed-method, prospective implementation study compares models of care at four TG-DSD and four SSD facilities using standardised observation checklists, in-depth and key informant interviews. For this paper, we asked participants about healthcare experiences and experiences of stigma through a structured, interviewer-administered quantitative survey. We assessed the sections of the quantitative survey which ask about self-reported experiences of stigma.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>The study enrolled 422 TGP with HIV (217 TG-DSD and 205 SSD) and 248 TGP without HIV (128 TG-DSD and 120 SSD); 15% (102/670) gender non-conforming, 15% (91/670) TG men and 70% (477/670) TG women. Participants’ median age was 29 years, interquartile range: 24−35 years. SSD participants at baseline were 46% more likely to experience stigma compared to their TG-DSD counterparts (aOR = 1.46, 95% CI: 1.06, 2.01). SSD participants were more likely to encounter a healthcare provider who is unwilling to provide care for them (aOR = 1.55, 95% CI: 1.09, 2.21) and to report that healthcare workers are unable to provide the same quality care to TGP as they do other people (aOR = 1.46, 95% CI: 1.00, 1.91) compared to their TG-DSD counterparts.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>TGP from TG-DSD facilities were less likely to report experiences of facility-based enacted stigma at baseline, compared to the TGP from SSD facilities. Our study highlights the importance of provider training in tailored transgender healthcare to provide gender-affirming healthcare services. Results from the <i>Jabula Uzibone</i> study will provide further evidence of the effectiveness of TG-DSD models in sub-Saharan Africa, and the role of stigma and discrimination in HIV outco","PeriodicalId":201,"journal":{"name":"Journal of the International AIDS Society","volume":"28 S3","pages":""},"PeriodicalIF":4.6,"publicationDate":"2025-07-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/jia2.26503","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144573992","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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