Health care professionals exchange ideas and approaches for improving HIV prevention strategies, scaling up access to ARVs and increasing patient adherence and retention to treatment plans. Members discuss the plethora of related issues, describe their first-hand experience, and exchange resources and lessons learned.

Discussion Briefs

Structural, social and personal barriers to linkage and retention in HIV care

Despite well-established clinical benefits of HIV antiretroviral therapy (ART), millions of individuals do not present for care or do not stay in care for a multitude of reasons. Challenges arise at every step of the path from HIV testing to collecting test results, determining CD4 count, initiating ART when appropriate, and adhering to ART. One recent study estimates that less than one-third of adult patients in sub-Saharan Africa who tested positive for HIV, but were not eligible to receive ART when diagnosed, were retained in pre-ART care (Rosen et al 2011). In the US, those numbers are much higher, with 72% of HIV-diagnosed persons entering into care within 4 months of diagnosis. (Marks et al 2011)

Members discuss structural, social and personal barriers to HIV care, as well as high and low tech solutions currently being tested to increase linkage and retention to HIV care in low resource settings.
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Promises and Pitfalls of Putting PrEP into Practice

Pre-exposure prophylaxis (PrEP) is a novel biomedical strategy being investigated for HIV prevention among diverse high-risk populations worldwide. Two completed clinical trials have demonstrated partial efficacy of PrEP in decreasing HIV acquisition risk by 39% and 44% respectively in heterosexual women and men who have sex with men (Abdool Karim et al 2010, Grant et al 2010). If safe and efficacious in ongoing trials, PrEP will likely be targeted to high-risk subpopulations. However, several questions remain regarding the most effective dosages; length and time of use; topical versus oral; patient adherence, and whether inadvertent PrEP use by HIV-infected individuals could lead to drug resistance. Additionally, the global health community will have to figure out how PrEP can fit within the larger package of sexual health promotion and HIV prevention strategies.

This discussion emanated from a GHDonline Expert Panel Discussion organized in collaboration with the HOPE Conference at Massachusetts General Hospital. Members discussed issues related to adherence and tactics being tested to promote good adherence; risks and benefits of implementing PrEP depending on patients’ risk profiles; acceptability among clinicians and patients; and topic areas for future research, including cost effectiveness, long-term safety and efficacy, different formulations and varying delivery strategies.
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Wireless Technologies to Monitor and Improve Patient Adherence

A systematic review of patients who initiated antiretroviral therapy (ART) across sub-Saharan Africa found that approximately 25% were no longer in care one year after initiation, a figure rising to 40% after two years (Rosen et al. 2007). This challenge combined with the need for strict adherence to medications for HIV and other chronic diseases make the use of technologies to monitor and improve adherence a much needed effort.

GHDonline’s Adherence & Retention and Health IT communities organized a joint panel discussion on how implementers are using wireless technologies to improve adherence monitoring and interventions. Participants discussed limitations of the technological approach and under-explored opportunities, and expanded the discussion to address challenges and solutions in the delivery of Directly Observed Treatment Short course (DOTS) for tuberculosis.
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To count lost to-follow-up as part of adherence denominator?

Frequently used to describe patients who stop coming to appointments and cannot be located, loss-to-follow-up (LTFU) is a critical issue for HIV care. Data from a diverse range of HIV treatment programs in resource limited settings show LTFU rates ranging from 5% to 40% within 6 month of antiretroviral therapy (ART) initiation, with extensive clinical impact and associated costs (Losina 2009).

In this discussion, members debate how to define LTFU in program evaluations and analyses of adherence. Practitioners and researchers share their experiences in the field and key references on LTFU, patient retention, and adherence.
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Research on HIV Prevention with Positive Interventions

In its Living 2008: The Positive Leadership Summit Report, the Global Network of People living with HIV: GNP+ defines positive prevention (PP) as “an approach to prevention that seeks to increase the psychosocial well-being of people living with HIV (PLHIV) and encourage solidarity amongst and for PLHIV” and has been recommended by UNAIDS (the Joint United Nations Programme on HIV/AIDS) since 2005.

In this discussion, members exchange information about new and ongoing studies on PP interventions in naïve HIV positive populations for risk reduction (sexual, PMTCT, disclosure, HIV testing, and discordant partners or with unknown HIV status) in South Africa, Uganda, Rwanda, Canada and the U.S.A.
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Impact of metabolic complications on ART adherence

Following the post of the abstract “Impact of metabolic complications on antiretroviral treatment adherence: clinical and public health implications” by moderator Jean Nachega, members share their experiences addressing patient adherence challenges related to the chronic side effects of Antiretroviral therapy (ART).
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Education, Counseling & Support Materials for People Living with HIV/AIDS

Peer education is an effective strategy in support of people living with HIV/AIDS (PLWHA) and in prevention of HIV/AIDS in the community. The creation of context-relevant peer education materials and training modules is essential to provide information, tips and guidance on health talks prior to antiretroviral therapy (ART) clinic visits or psychosocial counseling for example.

Stemming from a post by moderator Peter Ehrenkranz describing how he and colleagues at the National AIDS and STI Control Program in Liberia worked with the Positive Living Association of Liberia to develop peer education training and materials, members participating in this discussion exchange resources and advice on how to adapt materials.
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Promises and Pitfalls of Putting PrEP into Practice

Pre-exposure prophylaxis (PrEP) is a novel biomedical strategy being investigated for HIV prevention among diverse high-risk populations worldwide. Two completed clinical trials have demonstrated partial efficacy of PrEP in decreasing HIV acquisition risk by 39% and 44% respectively in heterosexual women and men who have sex with men (Abdool Karim et al 2010, Grant et al 2010). If safe and efficacious in ongoing trials, PrEP will likely be targeted to high-risk subpopulations. However, several questions remain regarding the most effective dosages; length and time of use; topical versus oral; patient adherence, and whether inadvertent PrEP use by HIV-infected individuals could lead to drug resistance. Additionally, the global health community will have to figure out how PrEP can fit within the larger package of sexual health promotion and HIV prevention strategies.

This discussion emanated from a GHDonline Expert Panel Discussion organized in collaboration with the HOPE Conference at Massachusetts General Hospital. Members discussed issues related to adherence and tactics being tested to promote good adherence; risks and benefits of implementing PrEP depending on patients’ risk profiles; acceptability among clinicians and patients; and topic areas for future research, including cost effectiveness, long-term safety and efficacy, different formulations and varying delivery strategies.
Read more