Factors predictive of successful retention in care among HIV-infected men in a universal test-and-treat setting in Uganda and Kenya: A mixed methods analysis

Lillian B Brown, Monica Getahun, James Ayieko, Dalsone Kwarisiima, Asiphas Owaraganise, Mucunguzi Atukunda, Winter Olilo, Tamara Clark, Elizabeth A Bukusi, Craig R Cohen, Moses R Kamya, Maya L Petersen, Edwin D Charlebois, Diane V Havlir, Carol S Camlin, Lillian B Brown, Monica Getahun, James Ayieko, Dalsone Kwarisiima, Asiphas Owaraganise, Mucunguzi Atukunda, Winter Olilo, Tamara Clark, Elizabeth A Bukusi, Craig R Cohen, Moses R Kamya, Maya L Petersen, Edwin D Charlebois, Diane V Havlir, Carol S Camlin

Abstract

Background: Previous research indicates clinical outcomes among HIV-infected men in sub-Saharan Africa are sub-optimal. The SEARCH test and treat trial (NCT01864603) intervention included antiretroviral care delivery designed to address known barriers to HIV-care among men by decreasing clinic visit frequency and providing flexible, patient-centered care with retention support. We sought to understand facilitators and barriers to retention in care in this universal treatment setting through quantitative and qualitative data analysis.

Methods: We used a convergent mixed methods study design to evaluate retention in HIV care among adults (age > = 15) during the first year of the SEARCH (NCT01864603) test and treat trial. Cox proportional hazards regression was used to evaluate predictors of retention in care. Longitudinal qualitative data from n = 190 in-depth interviews with HIV-positive individuals and health care providers were analyzed to identify facilitators and barriers to HIV care engagement.

Results: There were 1,863 men and 3,820 women who linked to care following baseline testing. Retention in care was 89.7% (95% CI 87.0-91.8%) among men and 89.0% (86.8-90.9%) among women at one year. In both men and women older age was associated with higher rates of retention in care at one year. Additionally, among men higher CD4+ at ART initiation and decreased time between testing and ART initiation was associated with higher rates of retention. Maintaining physical health, a patient-centered treatment environment, supportive partnerships, few negative consequences to disclosure, and the ability to seek care in facilities outside of their community of residence were found to promote retention in care.

Conclusions: Features of the ART delivery system in the SEARCH intervention and social and structural advantages emerged as facilitators to retention in HIV care among men. Messaging around the health benefits of early ART start, decreasing logistical barriers to HIV care, support of flexible treatment environments, and accelerated linkage to care, are important to men's success in ART treatment programs. Men already benefit from increased social support following disclosure of their HIV-status. Future efforts to shift gender norms towards greater equity are a potential strategy to support high levels of engagement in care for both men and women.

Conflict of interest statement

I have read the journal's policy and the authors of this manuscript have the following competing interests: LBB, CRC, EDC, MLP, MRK, DVH, and CSC have received grants from the National Institutes of Health. DVH has received non-financial support (donation of study drug Truvada) from Gilead Sciences. All other authors declare that no competing interests exist.

Figures

Fig 1. Retention in HIV care over…
Fig 1. Retention in HIV care over one year by sex.

References

    1. UNAIDS. AIDS by the numbers 2015. 2015.
    1. Staveteig SW S; Head S.K.; Bradley S; Nybo E. Demographic Patterns of HIV Testing Uptake in Sub-Saharan Africa. Calverton, Maryland, USA: ICF International, 2013.
    1. Cornell M, Schomaker M, Garone DB, Giddy J, Hoffmann CJ, Lessells R, et al. Gender differences in survival among adult patients starting antiretroviral therapy in South Africa: a multicentre cohort study. PLoS medicine. 2012;9(9):e1001304 Epub 2012/09/14. 10.1371/journal.pmed.1001304
    1. Ochieng-Ooko V, Ochieng D, Sidle JE, Holdsworth M, Wools-Kaloustian K, Siika AM, et al. Influence of gender on loss to follow-up in a large HIV treatment programme in western Kenya. Bulletin of the World Health Organization. 2010;88(9):681–8. Epub 2010/09/25. 10.2471/BLT.09.064329
    1. Kranzer K, Lewis JJ, Ford N, Zeinecker J, Orrell C, Lawn SD, et al. Treatment interruption in a primary care antiretroviral therapy program in South Africa: cohort analysis of trends and risk factors. Journal of acquired immune deficiency syndromes (1999). 2010;55(3):e17–23. Epub 2010/09/10. 10.1097/QAI.0b013e3181f275fd
    1. Hawkins C, Chalamilla G, Okuma J, Spiegelman D, Hertzmark E, Aris E, et al. Sex differences in antiretroviral treatment outcomes among HIV-infected adults in an urban Tanzanian setting. AIDS (London, England). 2011;25(9):1189–97. Epub 2011/04/21. 10.1097/QAD.0b013e3283471deb .
    1. Takarinda KC, Harries AD, Shiraishi RW, Mutasa-Apollo T, Abdul-Quader A, Mugurungi O. Gender-related differences in outcomes and attrition on antiretroviral treatment among an HIV-infected patient cohort in Zimbabwe: 2007–2010. International journal of infectious diseases: IJID: official publication of the International Society for Infectious Diseases. 2015;30:98–105. Epub 2014/12/03. 10.1016/j.ijid.2014.11.009 .
    1. Marson KG, Tapia K, Kohler P, McGrath CJ, John-Stewart GC, Richardson BA, et al. Male, mobile, and moneyed: loss to follow-up vs. transfer of care in an urban African antiretroviral treatment clinic. PloS one. 2013;8(10):e78900 Epub 2013/11/10. 10.1371/journal.pone.0078900 ; PubMed Central PMCID: PMCPmc3812001.
    1. Penot P, Hema A, Bado G, Kabore F, Sore I, Sombie D, et al. The vulnerability of men to virologic failure during antiretroviral therapy in a public routine clinic in Burkina Faso. Journal of the International AIDS Society. 2014;17:18646 Epub 2014/01/18. 10.7448/IAS.17.1.18646
    1. Mosha F, Muchunguzi V, Matee M, Sangeda RZ, Vercauteren J, Nsubuga P, et al. Gender differences in HIV disease progression and treatment outcomes among HIV patients one year after starting antiretroviral treatment (ART) in Dar es Salaam, Tanzania. BMC public health. 2013;13:38 Epub 2013/01/17. 10.1186/1471-2458-13-38
    1. Kipp W, Alibhai A, Saunders LD, Senthilselvan A, Kaler A, Konde-Lule J, et al. Gender differences in antiretroviral treatment outcomes of HIV patients in rural Uganda. AIDS care. 2010;22(3):271–8. Epub 2010/04/15. 10.1080/09540120903193625 .
    1. Boulle C, Kouanfack C, Laborde-Balen G, Boyer S, Aghokeng AF, Carrieri MP, et al. Gender Differences in Adherence and Response to Antiretroviral Treatment in the Stratall Trial in Rural District Hospitals in Cameroon. Journal of acquired immune deficiency syndromes (1999). 2015;69(3):355–64. Epub 2015/07/17. 10.1097/qai.0000000000000604 .
    1. Tsai AC, Siedner MJ. The Missing Men: HIV Treatment Scale-Up and Life Expectancy in Sub-Saharan Africa. PLoS medicine. 2015;12(11):e1001906 Epub 2015/11/26. 10.1371/journal.pmed.1001906
    1. Druyts E, Dybul M, Kanters S, Nachega J, Birungi J, Ford N, et al. Male sex and the risk of mortality among individuals enrolled in antiretroviral therapy programs in Africa: a systematic review and meta-analysis. AIDS (London, England). 2013;27(3):417–25. Epub 2012/09/06. 10.1097/QAD.0b013e328359b89b .
    1. Beckham SW, Beyrer C, Luckow P, Doherty M, Negussie EK, Baral SD. Marked sex differences in all-cause mortality on antiretroviral therapy in low- and middle-income countries: a systematic review and meta-analysis. Journal of the International AIDS Society. 2016;19(1):21106 Epub 2016/11/12. 10.7448/IAS.19.1.21106
    1. Bor J, Rosen S, Chimbindi N, Haber N, Herbst K, Mutevedzi T, et al. Mass HIV Treatment and Sex Disparities in Life Expectancy: Demographic Surveillance in Rural South Africa. PLoS medicine. 2015;12(11):e1001905; discussion e. Epub 2015/11/26. 10.1371/journal.pmed.1001905
    1. Camlin CS, Ssemmondo E, Chamie G, El Ayadi AM, Kwarisiima D, Sang N, et al. Men "missing" from population-based HIV testing: insights from qualitative research. AIDS care. 2016;28 Suppl 3:67–73. Epub 2016/07/16. 10.1080/09540121.2016.1164806 .
    1. Mburu G, Ram M, Siu G, Bitira D, Skovdal M, Holland P. Intersectionality of HIV stigma and masculinity in eastern Uganda: implications for involving men in HIV programmes. BMC public health. 2014;14:1061 Epub 2014/10/12. 10.1186/1471-2458-14-1061
    1. Siu GE, Seeley J, Wight D. Dividuality, masculine respectability and reputation: how masculinity affects men's uptake of HIV treatment in rural eastern Uganda. Social science & medicine (1982). 2013;89:45–52. Epub 2013/06/04. 10.1016/j.socscimed.2013.04.025 .
    1. Connell RWM, J.W. Hegemonic Masculinity: Rethinking the Concept. Gender & Society. 2005;19(6):829–59.
    1. Nyamhanga TM, Muhondwa EP, Shayo R. Masculine attitudes of superiority deter men from accessing antiretroviral therapy in Dar es Salaam, Tanzania. Global health action. 2013;6:21812 Epub 2013/10/25. 10.3402/gha.v6i0.21812
    1. Maeri IEA A; Getahun M; Charlebois E; Akatukwasa C; Tumwebaze D; Itiakorit H; Owino L; Kwarisiima D; Ssemmondo E; Sang N; Kabami J; Clark T; Petersen M; Cohen C; Bukusi E; Kamya M; Havlir D; Camlin CS. "How can I tell?" Consequences of HIV status disclosure among couples in eastern African communities in the context of an ongoing HIV "test-and-treat" trial. AIDS care. 2016;28(Suppl 3):59–66.
    1. Siu GE, Wight D, Seeley J. How a masculine work ethic and economic circumstances affect uptake of HIV treatment: experiences of men from an artisanal gold mining community in rural eastern Uganda. Journal of the International AIDS Society. 2012;15 Suppl 1:1–9. Epub 2012/06/22. 10.7448/ias.15.3.17368
    1. Geng EH, Odeny TA, Lyamuya R, Nakiwogga-Muwanga A, Diero L, Bwana M, et al. Retention in Care and Patient-Reported Reasons for Undocumented Transfer or Stopping Care Among HIV-Infected Patients on Antiretroviral Therapy in Eastern Africa: Application of a Sampling-Based Approach. Clinical infectious diseases: an official publication of the Infectious Diseases Society of America. 2015. Epub 2015/12/19. 10.1093/cid/civ1004 .
    1. Kwarisiima D, Kamya MR, Owaraganise A, Mwangwa F, Byonanebye DM, Ayieko J, et al. High rates of viral suppression in adults and children with high CD4+ counts using a streamlined ART delivery model in the SEARCH trial in rural Uganda and Kenya. Journal of the International AIDS Society. 2017;20(Suppl 4):21673 Epub 2017/08/05. PubMed Central PMCID: PMCPMC5577724. 10.7448/IAS.20.5.21673
    1. Shade SBC, W.; Kahn, J.G.; Mwai, D.; Mwanga, F.; Kwarisiima, D.; Owaranganise, A.; Ayieko, J.; Havlir, D.V.; Kamya, M.R.; Charlebois, E.D.; Petersen, M.L.; Clark, T.D.; Bukusi, E.A.; Cohen, C.R.; Jain, V. SEARCH Streamlined HIV Care is Associated with Shorter Wait Times Before and During Patient Visits in Ugandan and Kenyan HIV Clinics. The 21st International AIDS Conference; Durban, South Africa 2016.
    1. Brown LB, Havlir DV, Ayieko J, Mwangwa F, Owaraganise A, Kwarisiima D, et al. High levels of retention in care with streamlined care and universal test and treat in East Africa. AIDS (London, England). 2016;30(18):2855–64. Epub 2016/09/08. 10.1097/qad.0000000000001250 .
    1. Creswell JW. A Concise Introduction to Mixed Methods Research. Thousand Oaks, CA: Sage; 2015.
    1. Chamie G, Clark TD, Kabami J, Kadede K, Ssemmondo E, Steinfeld R, et al. A hybrid mobile approach for population-wide HIV testing in rural east Africa: an observational study. Lancet HIV. 2016;3(3):e111–9. 10.1016/S2352-3018(15)00251-9
    1. Charmaz K. Constructing Grounded Theory. 2nd ed. Thousand Oaks, CA: Sage Publications, Inc.; 2014.
    1. Camlin CS, Neilands TB, Odeny TA, Lyamuya R, Nakiwogga-Muwanga A, Diero L, et al. Patient-reported factors associated with reengagement among HIV-infected patients disengaged from care in East Africa. AIDS. 2016;30(3):495–502. 10.1097/QAD.0000000000000931 .
    1. Wringe A, Roura M, Urassa M, Busza J, Athanas V, Zaba B. Doubts, denial and divine intervention: understanding delayed attendance and poor retention rates at a HIV treatment programme in rural Tanzania. AIDS care. 2009;21(5):632–7. Epub 2009/05/16. 10.1080/09540120802385629 .
    1. Fleming PJ, Dworkin SL. The importance of masculinity and gender norms for understanding institutional responses to HIV testing and treatment strategies. AIDS (London, England). 2016;30(1):157–8. Epub 2016/01/06. 10.1097/qad.0000000000000899
    1. Skovdal M, Campbell C, Madanhire C, Mupambireyi Z, Nyamukapa C, Gregson S. Masculinity as a barrier to men's use of HIV services in Zimbabwe. Globalization and health. 2011;7:13 Epub 2011/05/18. 10.1186/1744-8603-7-13
    1. Dovel K, Yeatman S, Watkins S, Poulin M. Men's heightened risk of AIDS-related death: the legacy of gendered HIV testing and treatment strategies. AIDS (London, England). 2015;29(10):1123–5. Epub 2015/06/04. 10.1097/qad.0000000000000655

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