Risk factors barriers and facilitators for linkage and retention in pre art care
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Risk factors, barriers and facilitators for linkage and retention in pre-ART care. Darshini Govindasamy Health Economics and Epidemiology Research Office, SA Katharina Kranzer London School of Hygiene and Tropical Medicine, UK. HIV continuum of care. Not in care. Not in care. HIV

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Risk factors, barriers and facilitators for linkage and retention in pre-ART care

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Risk factors barriers and facilitators for linkage and retention in pre art care

Risk factors, barriers and facilitators for linkage and retention in pre-ART care

Darshini Govindasamy

Health Economics and Epidemiology Research Office, SA

Katharina Kranzer

London School of Hygiene and Tropical Medicine, UK


Hiv continuum of care

HIV continuum of care

Not in care

Not in care

HIV

testing

Pre-ART care

ART care

HIV infection

eligible

ART initiation

Continuous lifelong ART

  • Assessment for ART eligibility:

  • Clinical staging

  • CD4 count

HIV test

Retention in pre-ART care until eligible

not yet eligible

Kranzer et al 2012


Hiv continuum of care1

HIV continuum of care

Not in care

Not in care

HIV

testing

Pre-ART care

ART care

HIV infection

eligible

ART initiation

Continuous lifelong ART

  • Assessment for ART eligibility:

  • Clinical staging

  • CD4 count

HIV test

Retention in pre-ART care until eligible

not yet eligible

Kranzer et al 2012


Systematic review

Systematic review

  • Search limited to sub-Saharan Africa studies published before May 2011

  • Total number of studies: 42

    • Semi-qualitative studies:19

    • Quantitative 17

    • Qualitative 6


Barriers to retention in pre art care

Barriers to retention in pre-ART care

  • Medical

  • TB treatment

  • Health systems

  • Long waiting times

  • Shortage of HCWs

  • Economic

  • Transport cost

  • Distance

  • Food shortage

  • Unable to take time of work

  • Psychosocial

  • Stigma

  • Fear of disclosure

  • Fear of drug toxicities

  • Perceived good health

Govindasamy, Ford, Kranzer 2012


Predictors of attrition

Predictors of attrition

  • Economic

  • Transport cost

  • Distance

  • Health systems

  • Shortage of HCWs

  • Medical

  • TB treatment

  • Pregnancy

  • Advanced immunodeficiency

  • Severe malnutrition

  • Other

  • Male sex

  • Younger age

  • Lower levels of education

Govindasamy, Ford, Kranzer 2012


Predictors of attrition1

Predictors of attrition

  • Economic

  • Transport cost

  • Distance

  • Health systems

  • Shortage of HCWs

  • Medical

  • TB treatment

  • Pregnancy

  • Advanced immunodeficiency

  • Severe malnutrition

  • Other

  • Male sex

  • Younger age

  • Lower levels of education

Govindasamy, Ford, Kranzer 2012


Risk factors barriers and facilitators for linkage and retention in pre art care

Men

  • Lower test uptake

  • Lower ART coverage

  • More advanced immunodeficiency at diagnosis and ART initiation

  • Higher mortality

  • Lower adherence

  • Higher risk of loss to follow-up

on ART

Johnson 2013, Cornell 2012, Druyts 2013, Peltzer 2009, Kranzer 2013, Johnson 2012, Muula 2009, Remien 2009


How to address gender inequality

How to address gender inequality

  • Men do not become pregnant

  • Men are less health seeking

  • Health care staff are predominantly women

  • Health care services are targeted at women and children

Health care services AIMED at men

or "men friendly" health care services


Areas for interventions

Areas for interventions

Govindasamy, Ford, Kranzer 2012


Systematic review of interventions to improve linkage to and retention in pre art care

Systematic review of interventions to improve linkage to and retention in pre-ART care

N=11129 potentially eligible citations identified through:

Search strategy on electronic databases (n=11 048)

Keyword search on electronic conference abstract databases (n=45)

References obtained from experts (n=36)

N=67 of full text articles assessed for eligibility

(54 published articles + 1 unpublished article from experts + 10 conference abstracts + 2 conference abstracts from experts)

24 studies retained for analysis

(19 published articles + 1 unpublished article from experts + 2 conference abstracts + 2 conference abstracts from experts)

Govindasamy, Kranzer 2013


Intervention studies design and populations

Intervention studies - design and populations

  • Before after studies: n=11

    • Observational studies with control group(s): n=6

    • Individuals randomized controlled trials: n=4

    • Cluster randomized controlled trials: n=3

  • Adults: n=11

  • Children: n=1

  • Adolescents: n=1

  • Pregnant women: n=8

  • Inpatients: n=1

  • TB patients: n=1

  • IVDU: n=1

Govindasamy, Kranzer 2013


Intervention studies design and populations1

Intervention studies - design and populations

  • Before after studies: N=11

    • Observational studies with control group(s): n=6

    • Individuals randomized controlled trials: n=4

    • Cluster randomized controlled trials: n=3

  • Adults: n=11

  • Children: n=1

  • Adolescents: n=1

  • Pregnant women: n=8

  • Inpatients: n=1

  • TB patients: n=1

  • IVDU: n=1

Few studies with rigorous design

Govindasamy, Kranzer 2013


Intervention studies design and populations2

Intervention studies - design and populations

  • Before after studies: N=11

    • Observational studies with control group(s): n=6

    • Individuals randomized controlled trials: n=4

    • Cluster randomized controlled trials: n=3

  • Adults: n=11

  • Children: n=1

  • Adolescents: n=1

  • Pregnant women: n=8

  • Inpatients: n=1

  • TB patients: n=1

  • IVDU: n=1

Few studies with rigorous design

Few studies in special risk groups

Govindasamy, Kranzer 2013


Pregnant women

Pregnant women


Interventions and outcomes in special groups

Interventions and outcomes in special groups


Interventions and outcomes in adults

Interventions and outcomes in adults


Interventions addressing the barriers

Interventions addressing the barriers

  • Psychosocial

  • Stigma

  • Fear of disclosure

  • Fear of drug toxicities

  • Perceived good health

  • Health systems

  • Long waiting times

  • Shortage of HCWs

  • Economic

  • Transport cost

  • Distance

  • Food shortage

  • Unable to take time of work

  • Medical

  • TB treatment


Interventions addressing the barriers1

Interventions addressing the barriers

  • Psychosocial

  • Stigma

  • Fear of disclosure

  • Fear of drug toxicities

  • Perceived good health

  • Health systems

  • Long waiting times

  • Shortage of HCWs

  • Economic

  • Transport cost

  • Distance

  • Food shortage

  • Unable to take time of work

  • Medical

  • TB treatment


Thank you

Thank you!


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