Showing papers by "Nicola Desmond published in 2014"

Effect of optional home initiation of HIV care following HIV self-testing on antiretroviral therapy initiation among adults in Malawi: a randomized clinical trial.

Abstract: RESULTS A significantly greater proportion of adults in the home group initiated ART (181/8194, 2.2%) compared with the facility group (63/8466, 0.7%; risk ratio [RR], 2.94, 95% CI, 2.10-4.12; P < .001). Uptake of HIV self-testing was high in both the home (5287/8194, 64.9%) and facility groups (4433/8466, 52.7%; RR, 1.23; 95% CI, 0.96-1.58; P = .10). Significantly more adults reported positive HIV self-test results in the home group (490/8194 [6.0%] vs the facility group, 278/8466 [3.3%]; RR, 1.86; 95% CI, 1.16-2.97; P = .006). After 6 months, 52 of 181 ART initiators (28.7%) and 15 of 63 ART initiators (23.8%) in the home and facility groups, respectively, were lost from ART (adjusted incidence rate ratio, 1.18; 95% CI, 0.62-2.25, P =. 57).

Factors Shaping Initial Decision-Making to Self-test Amongst Cohabiting Couples in Urban Blantyre, Malawi

Abstract: In sub-Saharan Africa, most new HIV infections occur in stable relationships, making couples testing an important intervention for HIV prevention. We explored factors shaping the decision-making of cohabiting couples who opted to self-test in Blantyre, Malawi. Thirty-four self-tested participants (17 couples) were interviewed. Motivators for HIV self-testing (HIVST) emerged at three main levels. Individual motivations included perceived benefits of access to treatment, and self-checking of serostatus in the hope of having been cured by prolonged treatment or faith-healing. HIVST was considered convenient, confidential, reassuring and an enabling new way to test with one’s partner. Partnership motivations included both positive (mutual encouragement) and negative (suspected infidelity) aspects. For women, long-term health and togetherness were important goals that reinforced motivations for couples testing, whereas men often needed persuasion despite finding HIVST more flexible and less onerous than facility-based testing. Internal conflict prompted some partners to use HIVST as a way of disclosing their previously concealed HIV positive serostatus. Thus, the implementation of community-based HIVST should acknowledge and appropriately respond to decision-making processes within couples, which are shaped by gender roles and relationship dynamics.

Control, struggle, and emergent masculinities: a qualitative study of men's care-seeking determinants for chronic cough and tuberculosis symptoms in Blantyre, Malawi.

Abstract: Background: Men’s healthcare-seeking delay results in higher mortality while on HIV or tuberculosis (TB) treatment, and implies contribution to ongoing community-level TB transmission before initiating treatment. We investigated masculinity’s role in healthcare-seeking delay for men with TB-suggestive symptoms, with a view to developing potential interventions for men. Methods: Data were collected during March 2011- March 2012 in three high-density suburbs in urban Blantyre. Ten focus group discussions were carried out of which eight (mixed sex = two; female only = three; male only = three) were with 74 ordinary community members, and two (both mixed sex) were with 20 health workers. Individual interviews were done with 20 TB patients (female =14) and 20 un-investigated chronic coughers (female = eight), and a three-day workshop was held with 27 health stakeholder representatives. Results: An expectation to provide for and lead their families, and to control various aspects of their lives while facing limited employment opportunities and small incomes leaves men feeling inadequate, devoid of control, and anxious about being marginalised as men. Men were fearful about being looked at as less than men, and about their wives engaging in extramarital sex without ability to detect or monitor them. Control was a key defining feature of adequate manhood, and efforts to achieve it also led men into side-lining their health. Articulate and consistent concepts of men’s bodily strength or appropriate illness responses were absent from the accounts. Conclusions: Facilitating men to seek care early is an urgent public health imperative, given the contexts of high HIV/AIDS prevalence but increasingly available treatment, and the role of care-seeking delay in TB transmission. Men’s struggles trying to achieve ideal images seem to influence their engagement with their health. Ambiguous views regarding some key masculinity representations and the embrace of less harmful masculinities raise questions about some common assumptions that guide work with men. Apparent ‘emergent masculinities’ might be a useful platform from which to support the transformation of harmful masculinity. Finally, the complex manifestations of masculinity indicate the need for interventions targeting men in health and TB control to assume supportive, multidimensional and long-term outlooks.

One Year Outcomes Following Community-Based HIV Self-Testing: A Prospective Study in Malawi

Abstract: Background: HIV testing and counselling (HTC) is key to care and prevention, but only ~25% of adults in sub-Saharan Africa report testing for HIV in the preceding 12 months. HIV self-testing (HIVST) is a novel approach that could promote increased coverage and frequency of HTC. We investigated HIVST including subsequent linkage into care. Methodology: 16,660 adult (≥16 years) residents of 14 high-density neighbourhoods (HIV prevalence 18.5%) were included in a cluster randomised trial. Two residents were trained in each neighbourhood to provide HIVST from their homes (one test per resident per year). Clients received written and verbal information to promote linkage into HIV care coupled with home-initiation of HIV care if requested. Population-level uptake was estimated from enumeration denominators. Accuracy of HIVST was assessed through quality assurance (QA) re-testing (2 parallel rapid tests) with a 10% random sample of self-testing clients asked to retest. A strong community-based reporting system was in place for monitoring adverse events. Data were analysed using summary statistics and logistic regression adjusted for clustering. Results: Overall, 13,966 self-test kits were distributed with 89% returned as used kits with feedback forms. Uptake was 76% (12,658/16,660), including 5,840 (67%) of all men. The highest uptake was in the youngest age group (16-19 years: 2,360/2,539, 93%) falling to 41% (298/733) in men ≥50 years. Early HIVST adopters (2,658 in 1st month) were significantly more likely to be female, adjusted odds ratio (aOR) 1.20 (95% CI 1.06-1.36); younger Ptrend<0.001, and not in a couple aOR 2.22 (95% CI 1.54-3.16). In total, 851/16660 (9%) residents confided positive HIVST results with 25% already on ART and 500/638 (78%) accessing HIV care (pre-ART or ART). QA showed 99.1% agreement with self-reported HIVST results (sensitivity 93.8% [95% CI 85.0-98.3%], specificity 100% [95% CI 100-100%]). No suicides or assaults were reported, but coercion was reported by 147 (3.7%) male and 119 (2.2%) female respondents; p-value<0.001, mostly from partners. Conclusions: Uptake of HIVST, subsequent linkage into care, and accuracy were high with this strategy. Uptake of HIVST, subsequent linkage into care, and accuracy were high with this strategy. Coercive testing and retesting on ART are concerning aspects of HIVST that need to be anticipated and discouraged. Community-based HIVST offers high potential to increase knowledge of HIV status, assisting with increasing access to HIV care and prevention when combined with proactive linkage strategies. Community-based HIVST offers high potential to increase knowledge of HIV status, assisting with increasing access to HIV care and prevention when combined with proactive linkage strategies.

A Novel Community Health Worker Tool Outperforms WHO Clinical Staging for Assessment of Antiretroviral Therapy Eligibility in a Resource-Limited Setting

Abstract: The accuracy of a novel community health worker anti- retroviral therapy eligibility assessment tool was examined in community members in Blantyre, Malawi. Nurses independently performed World Health Organization (WHO) staging and CD4 counts. One hundred ten (55.6%) of 198 HIV-positive participants had a CD4 count of ,350 cells per cubic millimeter. The community health worker tool significantly outperformed WHO clinical staging in identifying CD4 count of ,350 cells per cubic millimeter in terms of sensitivity (41% vs. 19%), positive predictive value (75% vs. 68%), negative predictive values (53% vs. 47%), and area under the receiver- operator curve (0.62 vs. 0.54; P = 0.017). Reliance on WHO staging is likely to result in missed and delayed antiretroviral therapy initiation.