The Impact of Support Groups for People Living with HIV on Clinical Outcomes: A Systematic Review of the Literature

Background

Support groups for people living with HIV (PLHIV) are integrated into Human Immunodeficiency Virus (HIV) care and treatment programs as a modality for increasing patient literacy and as an intervention to address the psychosocial needs of patients. However, the impact of support groups on key health outcomes has not been fully determined.

Methods

We searched electronic databases from January 1995 through May 2014 and reviewed relevant literature on the impact of support groups on mortality, morbidity, retention in HIV care, quality of life, and ongoing HIV transmission, as well as their cost effectiveness.

Results

Of 1809 citations identified, 20 met inclusion criteria. One reported on mortality, seven on morbidity, five on retention in care, seven on quality of life, and seven on ongoing HIV transmission. Eighteen (90%) of the articles reported largely positive results on the impact of support group interventions on key outcomes. Support groups were associated with reduced mortality and morbidity, increased retention in care and improved quality of life. Due to study limitations, the overall quality of evidence was rated as fair for mortality, morbidity, retention in care, and quality of life, and poor for HIV transmission.

Conclusions

Implementing support groups as an intervention is expected to have a high impact on morbidity and retention in care and a moderate impact on mortality and quality of life of PLHIV. Support groups improve disclosure with potential prevention benefits but the impact on ongoing transmission is uncertain. It is unclear if this intervention is cost-effective given the paucity of studies in this area.

...The review found largely positive results. Although limited by the quality of the included studies, the data suggest potential benefit of support groups on key health outcomes. We rated the expected impact of support groups as an intervention in PLHIV as high in terms of reducing morbidity and improving retention in care. Support groups also have the potential to influence mortality, quality of life and prevention of ongoing HIV transmission. Specific positive benefits associated with support group membership include enhancing treatment success and improving the quality of life through equipping PLHIV with coping skills.

With development of community-based care models in some settings, support groups could provide an opportunity for PLHIV to share experiences and become more engaged in their care. Given the severe human resource challenges in sub-Saharan Africa, specifically the shortage of trained health care providers³⁸, support groups can play an increasingly larger role in care models, particularly with regard to retaining HIV-infected persons in care. Based on success of the pilot program developed by Médecins Sans Frontières (MSF) and provincial health officials in Mozambique reported in this review ^16, 17, the Mozambique Ministry of Health is scaling up CAGs nationally.

We did not specifically search for adherence as an outcome in this review. However five studies reported increased adherence to ART ^{15, 23, 24, 32} associated with support group participation. In Wouters et al., 89.9% of support group members reported that support group meetings helped create a forum for sharing knowledge and experiences, some of which related to taking medications. In Mozambique PLHIV enrolled in support groups reported increased adherence. ¹⁶

Two studies described negative outcomes. In a South Africa study, male participants in support groups felt under pressure to conform to a lifestyle that was not consistent with established gender roles ³², while a large mixed methods study with participants from Burkina Faso, Kenya, Malawi and Uganda showed that membership in a support group was associated with non-disclosure to partners. ¹⁹ These issues will need to be addressed to maximize the potential of support groups as an intervention...

  

Full article at:   http://goo.gl/HNJv2T

By:  Moses Bateganya, MBChB, MMed, MPH,1,§ Ugo Amanyeiwe, BDS, FWACS, MS,2 Uchechi Roxo, MSc,2 and Maxia Dong, MD, PhD1

¹Division of Global AIDS, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia

²Office of HIV and AIDS, United States Agency for International Development

^§Corresponding author: Moses H Bateganya, MBChB, MMed, MPH, Centers for Disease Control and Prevention (CDC), 1600 Clifton Rd NE, MS E-04, Atlanta, GA 30333, USA ; Email: vog.cdc@aynagetaBM ; phone: 404-639-3220, fax: 404-639-8114

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New Infections among Women (15–49 years old) in Mozambique, 2014

Via:   http://ht.ly/V7ouT  By:  https://twitter.com/unaids

Full slide deck:  http://goo.gl/uS2HNO

Number of People Living with HIV Who Know Their Status and Are Not Receiving Antiretroviral Therapy in Mozambique

Via:   http://ht.ly/V7ouT  By:  https://twitter.com/unaids

Full slide deck:  http://goo.gl/VMVnWm

Lower Levels of Antiretroviral Therapy Enrollment among Men with HIV Compared with Women — 12 Countries, 2002–2013

Equitable access to antiretroviral therapy (ART) for men and women with human immunodeficiency virus (HIV) infection is a principle endorsed by most countries and funding bodies, including the U.S. President's Emergency Plan for AIDS (acquired immunodeficiency syndrome) Relief (PEPFAR) (1). To evaluate gender equity in ART access among adults (defined for this report as persons aged ≥15 years), 765,087 adult ART patient medical records from 12 countries in five geographicregions* were analyzed to estimate the ratio of women to men among new ART enrollees for each calendar year during 2002–2013. 

This annual ratio was compared with estimates from the Joint United Nations Programme on HIV/AIDS (UNAIDS)^† of the ratio of HIV-infected adult women to men in the general population. In all 10 African countries and Haiti, the most recent estimates of the ratio of adult women to men among new ART enrollees significantly exceeded the UNAIDS estimates for the female-to-male ratio among HIV-infected adults by 23%–83%. In six African countries and Haiti, the ratio of women to men among new adult ART enrollees increased more sharply over time than the estimated UNAIDS female-to-male ratio among adults with HIV in the general population. Increased ART coverage among men is needed to decrease their morbidity and mortality and to reduce HIV incidence among their sexual partners. 

Reaching more men with HIV testing and linkage-to-care services and adoption of test-and-treat ART eligibility guidelines (i.e., regular testing of adults, and offering treatment to all infected persons with ART, regardless of CD4 cell test results) could reduce gender inequity in ART coverage.

Full article at:  http://goo.gl/ppLdvz  

By:  https://twitter.com/cdcmmwr

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Children Living with HIV-Infected Adults: Estimates for 23 Countries in Sub-Saharan Africa

Background

In sub-Saharan Africa many children live in extreme poverty and experience a burden of illness and disease that is disproportionately high. The emergence of HIV and AIDS has only exacerbated long-standing challenges to improving children’s health in the region, with recent cohorts experiencing pediatric AIDS and high levels of orphan status, situations which are monitored globally and receive much policy and research attention. Children’s health, however, can be affected also by living with HIV-infected adults, through associated exposure to infectious diseases and the diversion of household resources away from them. While long recognized, far less research has focused on characterizing this distinct and vulnerable population of HIV-affected children.

Methods

Using Demographic and Health Survey data from 23 countries collected between 2003 and 2011, we estimate the percentage of children living in a household with at least one HIV-infected adult. We assess overlaps with orphan status and investigate the relationship between children and the adults who are infected in their households.

Results

The population of children living in a household with at least one HIV-infected adult is substantial where HIV prevalence is high; in Southern Africa, the percentage exceeded 10% in all countries and reached as high as 36%. This population is largely distinct from the orphan population. Among children living in households with tested, HIV-infected adults, most live with parents, often mothers, who are infected; nonetheless, in most countries over 20% live in households with at least one infected adult who is not a parent.

Conclusion

Until new infections contract significantly, improvements in HIV/AIDS treatment suggest that the population of children living with HIV-infected adults will remain substantial. It is vital to on-going efforts to reduce childhood morbidity and mortality to consider whether current care and outreach sufficiently address the distinct vulnerabilities of these children.

Below: Co-residence of Children 0–17 with HIV-infected Adults and Adult HIV Prevalence (15–49), by Country

Below:  Among Children 0–17 Living with at Least One HIV-infected Adult, Percent Living with HIV-infected Mothers, Fathers, and Others, by Country

Full article at:  http://goo.gl/IAtHln

By:  

Susan E. Short

Department of Sociology and Population Studies and Training Center, Brown University, Providence, RI, United States of America

Rachel E. Goldberg

Department of Sociology, University of California Irvine, Irvine, CA, United States of America

 

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Impact and Cost of the HIV/AIDS National Strategic Plan for Mozambique, 2015-2019—Projections with the Spectrum/Goals Model

Mozambique continues to face a severe HIV epidemic and high cost for its control, largely born by international donors. We assessed feasible targets, likely impact and costs for the 2015–2019 national strategic HIV/AIDS plan (NSP).

The HIV epidemic and response was modelled in the Spectrum/Goals/Resource Needs dynamical simulation model, separately for North/Center/South regions, fitted to antenatal clinic surveillance data, household and key risk group surveys, program statistics, and financial records. Intervention targets were defined in collaboration with the National AIDS Council, Ministry of Health, technical partners and implementing NGOs, considering existing commitments.

Implementing the NSP to meet existing coverage targets would reduce annual new infections among all ages from 105,000 in 2014 to 78,000 in 2019, and reduce annual HIV/AIDS-related deaths from 80,000 to 56,000. Additional scale-up of prevention interventions targeting high-risk groups, with improved patient retention on ART, could further reduce burden to 65,000 new infections and 51,000 HIV-related deaths in 2019. Program cost would increase from US$ 273 million in 2014, to US$ 433 million in 2019 for ‘Current targets’, or US$ 495 million in 2019 for ‘Accelerated scale-up’. The ‘Accelerated scale-up’ would lower cost per infection averted, due to an enhanced focus on behavioural prevention for high-risk groups. Cost and mortality impact are driven by ART, which accounts for 53% of resource needs in 2019. Infections averted are driven by scale-up of interventions targeting sex work (North, rising epidemic) and voluntary male circumcision (Center & South, generalized epidemics).

The NSP could aim to reduce annual new HIV infections and deaths by 2019 by 30% and 40%, respectively, from 2014 levels. Achieving incidence and mortality reductions corresponding to UNAIDS’ ‘Fast track’ targets will require increased ART coverage and additional behavioural prevention targeting key risk groups.

Below:  Goals model fit to historical HIV prevalence trends, 3 regions of Mozambique. Surveillance/AIM represents the statistical estimates of epidemic trends as of 2014 using the Spectrum/AIM version 5.1, beta 34.

Below:  (a) New HIV infections among 15–49 years old adults by risk group, scenario and region, compared to 2014 baseline; (b) HIV infections averted thanks to incremental intervention scale-up over 2015–2019, compared to a scenario with coverage constant at 2014 levels, by region in the ‘Accelerated scale-up’ (C) scenario, adults 15-49-years.

Below:  Infections averted (among all ages) from coverage scale-up over 2015–2019, relative to resource needs over 2015–2019, by intervention, in the ‘Accelerated scale-up’ scenario.  Both costs and infections averted are discounted, at 3% per year. Abbreviations in Fig 5: ART = Antiretroviral therapy; Sex work = behavioural prevention for Female Sex Workers and their clients; HTC = HIV Testing and Counselling; MSM = Men having sex with men; IDU = Intravenous drug users; PMTCT = Prevention of Mother-to-Child Transmission; VMMC = voluntary medical male circumcision; Youth = behavioural prevention for youth in and out of schools.

Below:  Costs and cost drivers of the Mozambique NSP 2015–2019: a) Resource needs, by scenario and intervention; b) PLWH on first-line and second-line ART, ‘Accelerated scale-up’ scenario; c) ART cost break-down, ‘Accelerated scale-up’ scenario. In (a), the dashed line represents resources available and committed from within the national government, other Mozambican implementers, the Global Fund, PEPFAR and other donors–as of January 2015.

Full article at: http://goo.gl/84WlFr

By:

Eline L. Korenromp, Lori Bollinger, John Stover

Avenir Health, Geneva, Switzerland/Glastonbury, United States of America

Benjamin Gobet, Erika Fazito

UNAIDS, Mozambique country office, Maputo, Mozambique

Joseph Lara

Mozambique Ministry of Health, Maputo, Mozambique

 

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The Triple Threat of Pregnancy, HIV Infection & Malaria: Reported Causes of Maternal Mortality in Two Nationwide Health Facility Assessments in Mozambique, 2007 & 2012

The paper’s primary purpose is to determine changes in magnitude and causes of institutional maternal mortality in Mozambique. We also describe shifts in the location of institutional deaths and changes in availability of prevention and treatment measures for malaria and HIV infection.

Two national cross-sectional assessments of health facilities with childbirth services were conducted in 2007 and 2012. Each collected retrospective data on deliveries and maternal deaths and their causes. In 2007, 2,199 cases of maternal deaths were documented over a 12 month period; in 2012, 459 cases were identified over a three month period. In 2007, data collection also included reviews of maternal deaths when records were available (n = 712).

Institutional maternal mortality declined from 541 to 284/100,000 births from 2007 to 2012. The rate of decline among women dying of direct causes was 66 % compared to 26 % among women dying of indirect causes. Cause-specific mortality ratios fell for all direct causes. Patterns among indirect causes were less conclusive given differences in cause-of-death recording. In absolute numbers, the combination of antepartum and postpartum hemorrhage was the leading direct cause of death each year and HIV and malaria the main non-obstetric causes. Based on maternal death reviews, evidence of HIV infection, malaria or anemia was found in more than 40 % of maternal deaths due to abortion, ectopic pregnancy and sepsis. Almost half (49 %) of all institutional maternal deaths took place in the largest hospitals in 2007 while in 2012, only 24 % occurred in these hospitals. The availability of antiretrovirals and antimalarials increased in all types of facilities, but increases were most dramatic in health centers.

The rate at which women died of direct causes in Mozambique’s health facilities appears to have declined significantly. Despite a clear improvement in access to antiretrovirals and antimalarials, especially at lower levels of health care, malaria, HIV, and anemia continue to exact a heavy toll on child-bearing women. Going forward, efforts to end preventable maternal and newborn deaths must maximize the use of antenatal care that includes integrated preventive/treatment options for HIV infection, malaria and anemia.

Below:  Map of maternal death reviews, with HIV implicated, 2007

Below:  Map of maternal death reviews, with malaria implicated, 2007

Full article at: http://goo.gl/RDaJx9

By: Patricia E. Bailey^12*, Emily Keyes¹², Allisyn C. Moran³, Kavita Singh⁴⁵, Leonardo Chavane⁶ and Baltazar Chilundo⁷

¹RMNCH Unit, Global Health Programs, FHI 360 359 Blackwell Street, Durham 27701, NC, USA

²Averting Maternal Death & Disability, Mailman School of Public Health, Columbia University, New York, NY, USA

³Global Health Fellows Program II, United States Agency for International Development (USAID), Washington, DC, USA

⁴MEASURE Evaluation/Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

⁵Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

⁶MCSP/Jhpiego, Maputo, Mozambique

⁷Departamento de Saúde da Comunidade, Faculdade de Medicina, Universidade Eduardo Mondlane, Maputo, Mozambique

 

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Bridging User & Provider Perspectives: Family Planning Access & Utilization in Rural Mozambique

To examine how the contraceptive behavior of women in rural southern Mozambique is shaped by their individual and household characteristics; community characteristics; access to family planning services; and characteristics of health facilities.

Quantitative and qualitative data were collected mostly between January 20 and December 15, 2011, in rural areas of four districts in Gaza Province, Mozambique. The data included: a retrospective household-based survey of women of reproductive age (the analytical sample consisted of 1554 non-pregnant women in marital union); qualitative interviews with a subsample of surveyed women; a survey of communities where the women resided (n = 56); and a survey of all health facilities in the study area (n = 56). Binomial and multinomial logistic models were fitted to predict current use of modern contraceptive methods. Statistical analyses were complemented by insights from qualitative data.

Positive associations were detected between contraceptive use and education, household wealth, and perceived HIV infection status. Distance to the clinic was negatively associated with contraceptive use. These effects were additive, with some varying by type of contraceptive method. Examination of qualitative data highlighted frequent cognitive dissonance between service providers and users.

A simultaneous consideration of user-level and provider-level perspectives on contraceptive use improves our understanding of contraceptive dynamics and can usefully inform policy.

Table 1

Characteristics of 1554 non-pregnant women in marital union resident in rural areas of four districts of Gaza Province, Mozambique, 2011.a

Characteristic	No.	Distribution	Range
Current contraceptive use (percent)
Currently uses any modern method	357	23.0	0.0–100
Currently uses oral contraception	195	12.5	0.0–100
Currently uses long-term contraception	134	8.6	0.0–100
Age, y (mean)	1554	32.5	21–49
No. of living children (mean)	1554	3.5	0–10
Education level (percent)
No education	397	25.5	0.0–100
1–4 y	703	45.2	0.0–100
≥5 y	455	29.3	0.0–100
Works outside of agriculture (percent)	528	34.0	0.0–100
Does not want children within next 2 years (percent)	980	63.1	0.0–100
Perceived HIV infection status (percent confirmed or suspected HIV+)	640	41.2	0.0–100
Polygamous union (percent)	413	26.6	0.0–100
Husband is a migrant (percent)	547	35.2	0.0–100
Household material conditions, scale of 1 – 4, (mean)	1554	2.1	1–4
Public transportation cost to nearest town, MZN b	1554	50	10–300
Difficulty of getting to the nearest town in the rainy season, scale of 1 – 3, (mean)	1554	1.7	1–3
Distance to nearest clinic, km (mean)	1554	4.9	0.13–17.27
Service index of nearest clinic, scale of 1 – 4 (mean)	1554	2.0	1–4
Cumulative duration that any contraceptives were out of stock in a 12-month period in nearest clinic, wk (mean)	1554	14.0	0–120
Cumulative duration that oral contraceptives were out of stock in a 12-month period in nearest clinic, wk (mean)	1554	8.1	0–120
Cumulative duration that long-term contraceptives were out of stock in a 12-month period in nearest clinic, wk (mean)	1554	2.8	0–30

Abbreviation: MZN, Mozambican metical.

aData were collected mostly between January 20 and December 15, 2011.

bThe exchange rate for 1.00 MZN is approximately US $0.04 at the time of data collection.

Full article at: http://goo.gl/MzFVYb

By: Victor Agadjanian,a,* Sarah R. Hayford,b Luciana Luz,c and Jing Yaod

^aT. Denny Sanford School of Social and Family Dynamics, Center for Population Dynamics, Arizona State University, Tempe, USA

^bDepartment of Sociology and Institute for Population Research, Ohio State University, Columbus, USA

^cCedeplar, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil

^dUrban Big Data Centre, School of Social and Political Sciences, University of Glasgow, Glasgow, UK

^*Corresponding author at: T. Denny Sanford School of Social and Family Dynamics, Center for Population Dynamics, Arizona State University, 951 S. Cady Mall, Tempe, AZ, 85287-3701, USA. Tel.: +1 480 965 3804; fax: +1 480 965 6779. Email: ude.usa@gav (V. Agadjanian)

   

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A Geographical Perspective on Access to Sexual & Reproductive Health Care for Women in Rural Africa

Utilization of sexual and reproductive health (SRH) services can significantly impact health outcomes, such as pregnancy and birth, prenatal and neonatal mortality, maternal morbidity and mortality, and vertical transmission of infectious diseases like HIV/AIDS. 

It has long been recognized that access to SRH services is essential to positive health outcomes, especially in rural areas of developing countries, where long distances as well as poor transportation conditions, can be potential barriers to health care acquisition. Improving accessibility of health services for target populations is therefore critical for specialized healthcare programs. Thus, understanding and evaluation of current access to health care is crucial. 

Combining spatial information using geographical information system (GIS) with population survey data, this study details a gravity model-based method to measure and evaluate access to SRH services in rural Mozambique, and analyzes potential geographic access to such services, using family planning as an example. Access is found to be a significant factor in reported behavior, superior to traditional distance-based indicators. Spatial disparities in geographic access among different population groups also appear to exist, likely affecting overall program success.

Below:  Study area and data

Below:  Health service quality of clinics

Below:  Potential geographic access of communities

Below:  Spatial variation of potential geographic access

Full article at: http://goo.gl/bQ4oR9

By: Jing Yao,a,* Alan T. Murray,b and Victor Agadjanianc

^a Centre for GeoInformatics, School of Geography and Geosciences, University of St Andrews, St Andrews, Fife, KY16 9AL, Scotland, UK

^b GeoDa Center for Geospatial Analysis and Computation, School of Geographical Sciences and Urban Planning, Arizona State University, Tempe, AZ 85287, USA

^c Center for Population Dynamics, T. Denny Sanford School of Social and Family Dynamics, Arizona State University, Tempe, AZ 85287, USA

^* Corresponding author. School of Geography & Geosciences, Irvine Building, University of St Andrews, North Street, St Andrews, KY16 9AL, Fife, Scotland, UK. Tel.: +44 01334 464026; fax: +44 01334 463949. Email: ku.ca.swerdna-ts@oay.gnij, Email: moc.liamg@usaoayj (J. Yao).

   

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Socio-demographic, Behavioral and Health Characteristics of Underage Female Sex Workers in Mozambique: The Need to Protect a Generation from HIV Risk

Characteristics, HIV risk, and program coverage for underage female sex workers (FSW) are rarely systematically described worldwide. We compared characteristics of underage (15-17 years old) and adult (≥18 years old) FSW in three main urban areas of Mozambique (Maputo, Beira and Nampula) using data from three respondent-driven sampling surveys implemented in 2011-2012. 

Among survey participants, 9.8 % in Maputo, 17.0 % in Beira and 25.6 % in Nampula were underage. Over half reported performing sex work to afford daily living, and 29.7-50.0 % had unprotected sex with their last client. 

The proportion of underage FSW having accessed care and prevention services was lower compared to adult FSW. While HIV prevalence among underage FSW was lower than in adults, it increased markedly with age. Our results point to the urgency of expanding prevention and care programs geared towards underage FSW.

Purchase full article at: http://goo.gl/wDAvNY

By: Inguane C1,2, Horth RZ3, Miranda AE4, Young PW5, Sathane I6, Cummings BE5, Augusto Â7, Raymond HF3, Mcfarland W3.

• 1Department of Anthropology, University of Washington, Box 353100, Seattle, WA, 98195-3100, USA. celsoi@uw.edu.
• 2International Training and Education Center for Health (I-TECH), Maputo, Mozambique. celsoi@uw.edu.
• 3Global Health Sciences Department, University of California, San Francisco (UCSF), San Francisco, CA, USA.
• 4Universidade Federal do Espírito Santo (UFES), Vitória, Espirito Santo, Brazil.
• 5Strategic Information, Centers for Disease Control and Prevention (CDC), Maputo, Mozambique.
• 6International Training and Education Center for Health (I-TECH), Maputo, Mozambique.
• 7Department of Laboratory Platforms, Instituto Nacional de Saúde (INS), Maputo, Mozambique.  

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