Browsing by Author "Atuhaire, Lydia"

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    Effect of community-based interventions targeting female sex workers along the HIV care cascade in sub-Saharan Africa : a systematic review and meta-analysis
    (BMC (part of Springer Nature), 2021-05-06) Atuhaire, Lydia; Adetokunboh, Olatunji; Shumba, Constance; Nyasulu, Peter S.
    Background: Female sex workers are extremely vulnerable and highly susceptible to being infected with human immunodeficiency virus. As a result, community-based targeted interventions have been recommended as one of the models of care to improve access to HIV services and continued engagement in care. We conducted a systematic review to (1) assess the effect of FSW-targeted community interventions on the improvement of HIV services access along the treatment cascade and (2) describe community-based interventions that positively affect continuation in HIV care across the HIV treatment cascade for FSWs in sub-Saharan Africa. Methods: We defined the 5 steps that make up the HIV care cascade and categorized them as outcomes, namely, HIV testing and diagnosis, linkage to care, receipt of ART, and achievement of viral suppression. We conducted a systematic search of randomized controlled trials, cohort, and cross-sectional studies done in sub-Saharan African countries and published from 2004 to 2020. The period was selected based on the time span within which ART was scaled up through widespread roll-out of comprehensive HIV programs in sub-Saharan Africa. We reviewed studies with data on the implementation of community interventions for any of the HIV care cascade stage. The data were analyzed using random effects meta-analysis where possible, and for the rest of the studies, data were synthesized using summary statistics. Results: The significant impact of the community interventions was observed on HIV testing, HIV diagnosis, and ART use. However, for HIV testing and ART use, the improvement was not sustained for the entire period of implementation. There were minimal interventions that had impact on HIV diagnosis, with only one community service delivery model showing significance. Generally, the interventions that had reasonable impact are those that implemented targeted and comprehensive package of HIV services provided at one location, and with unique strategies specific to each cascade stage. Conclusions: The evidence brought forward from this review shows that the effect of community-based interventions varies across the different stages of HIV care cascade. A broad package of interventions including a combination of behavioral, biomedical, and structural, designed with specific strategies, unique to each cascade stage appears to be more effective, although information on long-term treatment outcomes and the extent to which FSWs remain engaged in care is sparse. There is need to conduct a further research to deepen the assessment of the effectiveness of community-based interventions on HIV care cascade for FSWs. This will enhance identification of evidence-based optimal interventions that will guide effective allocation of scarce resources for strategies that would have a significant impact on HIV service delivery.
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    Effect of female sex work-targeted community-based interventions along the HIV treatment cascade in sub-Saharan Africa : a systematic review protocol
    (BMJ Publishing Group, 2020) Atuhaire, Lydia; Adetokunboh, Olatunji; Shumba, Constance; Nyasulu, Peter S.
    Introduction: Female sex workers (FSWs) are a known high-risk group that are at increased risk of HIV transmission due to exposure to multiple sexual partners and inability to negotiate safe sex attributed to challenging economic circumstances. Previous systematic reviews have examined the effectiveness of HIV interventions prioritising FSWs and have shown that targeted interventions improve access to HIV prevention and treatment services. Interventions that increase FSWs’ uptake of services are well documented; however, evidence on specific interventions aimed at improving FSWs’ continuity in HIV care along the treatment cascade is lacking. This systematic review aims to document the performance of community-based interventions along the HIV treatment cascade. Methods and analysis: We will use a sensitive search strategy for electronic bibliographic databases, bibliographies of included articles and grey literature sources. In addition, the Joint United Nations Programme on HIV/AIDS and the WHO websites, peer-reviewed conference papers and grey literature sources will be searched for additional reports of sex work programmes. We will include randomised controlled trials, cross-sectional surveys and cohort interventions where community-based HIV services were provided to FSWs and measure the performance of the HIV intervention on one or more cascade stages. We will conduct a systematic review of studies published from 2004 to present within the sub-Saharan Africa region. We will report quantitative study outcomes of HIV testing and diagnosis, linkage to care, initiation on antiretroviral therapy and viral suppression. We will analyse the data using the random-effects meta-analysis method, and funnel plots will be used to assess the publication bias. Ethics and dissemination: This systematic review will not require ethical approval; we will publish data from manuscripts. The results of this study will be disseminated in peer-reviewed journals and conference presentations.
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    HIV continuum of care outcomes among female sex workers in Kampala Uganda
    (Stellenbosch : Stellenbosch University, 2022-12) Atuhaire, Lydia; Nyasulu, Peter; Shumba, Constance; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Epidemiology and Biostatistics.
    ENGLISH SUMMARY: Background: Female sex workers (FSWs) account for 11% of all HIV infections globally and are twenty-six times at a greater risk of acquiring HIV than their female counterparts in the general population. In Uganda, HIV prevalence among FSWs is estimated at 31% - 37%, six times higher than the HIV prevalence of 5.4% in the general population. FSWs, not only are confronted by heightened risk to HIV infection, but they are also more vulnerable to social and economic inequalities that hinder access to HIV services throughout the HIV care continuum. Moreover, the few HIV positive FSWs who eventually access HIV care, experience unique barriers that hinder their continuity on life-long Antiretroviral therapy (ART) and thus drop out of care along the various stages of HIV continuum of care. Consequently, FSWs continue to widen the gap to attaining the global HIV treatment targets of 95-95-95 by 2025 and ending the AIDS epidemic by 2030. Notably, there has been an increased focuson improving HIV care continuum. However, data are sparse regarding the service uptake across the HIV care cascade for FSWs. Absence of recent data for FSWs impedes monitoring of HIV service provision and identifying missed opportunities important in guiding program strategies, optimal for improved and equal access to HIV services among FSWs. The aim of this research project was to understand service delivery approaches along the HIV continuum of care for FSWs in a routine care setting in Kampala, Uganda. Methods: The research project used multiple approaches to respond to the objectives as described as follows: In objective one, we conducted a systematic review on the implementation of community interventions for any of the HIV care cascade stage. We conducted a systematic search of randomized controlled trials, cohort and cross-sectional studies done in sub-Saharan African countries and published from 2004 to 2020. The study outcomes were HIV testing and diagnosis, linkage to care, receipt of ART and achievement of viral suppression. The data were analysed using random effects meta-analysis, where possible and for the rest of the studies, data were synthesized using summary statistics. For objective two, we conducted a cross-sectional survey and used simple random sampling method to select 200 participants from 12 sex work hotspots in Kampala. Participants were allocated proportionally in each hotspot. Frequencies were used to describe categorical characteristics of FSWs, and a multivariable logistic regression model was used to determine the factors associated with adherence to the HIV testing guidelines. In the third objective, we performed a retrospective cross-sectional study of routine patient management data for FSWs diagnosed with HIV and enrolled in care from January 2018 to December 2020 at the government primary health care facilities in Kampala. Two outcome variables were assessed and these which included i) Lost-to-follow-up from HIV care; and ii) Virological non-suppression. We used cluster sampling methods to select initial clusters and purposively selected a cluster of six health facilities and data was collected from 275 medical records. Both univariable and multivariable logistic regression models were performed on study outcomes. Data were analysed using Stata 15.1 software (Stata Statistical Software: Release 14. College Station, TX: Stata Corp LP). Finally, the fourth objective applied a qualitative descriptive design through use of in-depth interviews among FSWs, who were accessing HIV services through differentiated service delivery models in primary health facilities and drop-in centres in Kampala. We purposively sampled 2 health facilities and 2 drop-in centres and following the principle of data saturation, 24 FSWs were interviewed. Data analysis was conducted manually using framework analysis, and we applied an inductive approach which involved systematically reviewing the code framework, reduction, and interpretation of the data. Results: From the systematic review, the results showed variations in the effectiveness of community-based interventions along the various stages of HIV care cascade. The level of effectiveness was more pronounced in HIV testing and ART use; with average effectiveness observed in HIV diagnosis, than it is for linkage to care and viral load suppression. In addition, the interventions tended to be more impactful if they were provided in a combination of various strategies unique for each HIV care cascade stage. Among the sample of two hundred study participants from the adherence to HIV testing guidelines study, 88% of the study participants reported their HIV testing status; of these, 56% adhered to the HIV testing guidelines, having tested three or more times in the 12 months preceding the survey. Attaining a secondary education was associated with adherence to HIV testing guidelines [odds ratio (OR) 1.86, 95% confidence interval (CI) 1.01 – 3.44; P = 0.047]. Testing for sexually transmitted infection in the preceding 3 months (OR: 2.13, 95% CI: 0.95 – 4.74, P = 0.065) and accessing HIV testing at a drop-in centre (OR: 5.90, 95% CI: 0.71 – 49.1; P = 0.101) were associated with higher odds of adherence to the HIV testing guidelines, although the association was not significant. Results from the study on retention and non-viral suppression showed retention of 85.1% (n = 234) at six months, corresponding to LTFU of 14.9% (n = 41) within the same period. Retention decreased with duration of being in care to 73.5% (n = 202) at 24 months, translating to LTFU of 26.5% (n = 73). Viral load testing coverage was 62% (n = 132) and of these, 90.9% (n = 120) were virally suppressed. Factors associated with LTFU at <0.2 significance level in univariable logistic regression model were age, marital status, education level, having treatment supporter, having a telephone contact, WHO stage at baseline, and having been diagnosed with TB during the study period. In multivariable logistic regression model, age (OR: 0.56, 95% CI: 0.031 - 1.00, p = 0.049), marital status (OR: 0.46, 95% CI: 0.23 - 0.89, p = 0.021), having telephone contact (OR: 0.22, 95% CI: 0.07 - 0.70, p = 0.010) and WHO stage at baseline (OR: 0.11, 95% CI: 0.01 - 0.97, p = 0.046), were significantly associated with LTFU at 0.05 significance level after adjusting for other factors. Factors associated with viral load suppression in univariable logistic regression models included age, having telephone contact, lost to follow up, and reason for lost-to-follow-up at <0.2 level of significancy. Age at enrolment remained statistically significant in multivariable logistic regression model (OR: 0.09, 95% CI: 0.01 – 0.82 P = 0.033) at 0.05 level of significance. Findings from the qualitative phase of the research study showed that HIV services provided through community based Differentiated Service Delivery (DSD) models were perceived to be of low quality, with a non-comprehensive package of HIV services for FSWs which did not match FSWs’ needs, preferences, and health risks. In addition, services were provided irregularly with compromised privacy and being provided by health workers who were perceived to have less than adequate specialised skills. Further, the process of deciding on how and what services should be provided through community DSD models targeting FSWs, the latter were not part of the process. Consequently, FSWs preferred facility-based models even though community DSD models were considered to be as a more convenient and a less costly option for access to HIV services and were thought to be a good complementary option if the quality of services provided in the community would be improved. Conclusion: Evidence brought forward in this research project shows that the effect of community-based interventions varies across the various stages of HIV care cascade. Therefore, it is critical to consistently monitor, review, and evaluate strategies under implementation to identify and realign those that have long term impact in improving HIV services access along the care continuum for FSWs. In addition, the suboptimal retention and viral load testing coverage underscores the need to improve the quality of services provided under differentiated care models, by ensuring that services are tailored to FSWs individual preferences, needs, and contexts.