Jackie Ndirangu, Wendee Wechsberg, William Zule,
description
Transcript of Jackie Ndirangu, Wendee Wechsberg, William Zule,
Jackie Ndirangu, Wendee Wechsberg, William Zule,Tracy Kline, Irene Doherty & Charlie van der Horst
International AIDS Conference
Melbourne, July 20, 2014
Methods for Increasing Access and ARV Retention among Sex Workers and
Drug-using Women in Pretoria, South Africa: Structural and Individual
Determinants
Thank you to all the women in the study and for the dedicated women’s Health CoOp Plus (WHC+)
staff who have made this happen
Funded by RODA032061
Forerunner: Women’s Health CoOp (WHC) -Pretoria*
R01AA014488
*Listed in USAID’s “Multiple Gender Strategies to Improve HIV and AIDS Interventions: A compendium of Programs in Africa”
Research Aim/Outcomes
Seek, test, treat and retain for Vulnerable womenR01 DA032061
To test whether adding WHC to standard Treat, Test, and Retain (TTR) practices results in more HIV-positive AOD-using women getting medical evaluations (e.g., CD4, viral load), starting treatment, staying in treatment and in greater reductions in risk behaviors (e.g., AOD use, condom use, victimization) among all women—positive or negative
.
Randomized Zones & Distance
Outreach targeted High-Risk Target Areas (HRTA) and other hotspots in Pretoria
The whole of Pretoria was divided into 14 Zones that were later paired and randomized into 7 (zones) clusters
WHC+ Team:Mapping each day’s work to be efficient with time and petrol
Vulnerable women have basic needs
Shower, donated clothes, toiletries and donated food available
Sample Characteristics by Intervention (N=561) preliminary
Standard
n=274
Women’s
n=287
Age 29.4 (7.2) 30.0 (8.1)
Main sex partner* 99% 98%
Unemployed 83% 87%
Education
None to Primary 9% 9%
Secondary 22% 15%
Tertiary 64% 71%
Diploma + 5% 5%
Ever given birth 76% 76%
* Also have multiple partners
Biologicals at Intake by Intervention (preliminary)
Standard
n=274
Women’s
n=287
HIV confirmed (p=0.006) 61% 49%
Confirmed Pregnancy 4% 5%
Alcohol 16% 14%
Benzodiazepines 3% 2%
Cocaine (p<0.0001) 10% 23%
Methamphetamine 1% 1%
Opiates (p<0.0001) 11% 29%
Marijuana (p=0.0007) 28% 42%
**Not testing for glue/inhalants.
Biologicals at Intake by Sex Worker (preliminary)
Ever Sex Work
n=236
No Sex Work
n=325
HIV confirmed (p<0.0001) 68% 46%
Confirmed Pregnancy (p=0.003)
2% 7%
Alcohol 11% 17%
Benzodiazepines 3% 2%
Cocaine (p=0.0003) 23% 12%
Methamphetamine 2% 1%
Opiates (p=0.008) 26% 17%
Marijuana (p=0.0006) 44% 30%
Lack of Knowledge of HIV Status
Although 89% of the total sample had been previously tested for HIV at least once, 35% of those testing HIV positive were new diagnoses
Among sex workers, HIV prevalence was very high, however, 73% of those infected reported being previously informed of status
Among the non-sex workers infected with HIV, 55% reported being previously informed of their status
Referrals for ARV
Those aware of HIV+ status, 43% (n=86) reported ever taken ARV treatment
We have referred 197 women for further HIV evaluation and care
At 6 months follow-up, 68 women are currently taking ARVs, and of those 24 have reported to have recently started taking or re-initiated ARV treatment
Referrals for Substance Abuse Treatment
We have actively referred 52 women in the intervention group for drug rehabilitation services
19% (10/52) have followed through with the referral. However, only 4 have completed rehab; the others having defaulted on their rehab treatment
What are the challenges to this strategy Seek, Test, Treat, Retain (STTR) In Pretoria?
Reaching high risk women and sex workers through outreach across Pretoria takes time and is costly
Recent cleaning up of the city from drug-users and sex workers
Transient cohort
Health system is not fully in sync
Stigmatization of vulnerable populations
Barriers reported to obtaining and adhering to ARVs
Structural Barriers
Poor clinic linkages
Nearest clinic does not provide ARV/Inconsistent access to medication
Transportation costs to clinic
No identification card or locator information
Food Insecurity
Homelessness and poverty
No safe place to store ARVs
Missed staging/ initiation appointment
Low levels of social support
Barriers reported to obtaining and adhering to ARVs
Individual barriers
Took when pregnant but stopped after pregnancy
Missed staging appointment/did not attend ARV initiation classes
Did not see the need/ not ready to start
Fear of ARV side effects especially when concurrently taking TB medication
Fear of commitment to ARV daily dose/ missing doses
Non disclosure of HIV status to family and partners
Denial/disbelief/unclear results
Preference of traditional medicine
AOD Use/Arrests
Case Management Barriers
Tracking challenges; lack of cell phones or charged cell phones and distance from the field site
Lack of rehab centers with pro bono slots
Lack of adherence to substance abuse treatment once allocated slots
Poor treatment in clinics
Lack of a proper medical referral system
Trying to change behavior in resistant environment
Solutions: Problem Solving
Reducing stigmatization and facilitating ART initiation by creating relationships with local clinics
Educating participants and denouncing myths about HIV/AIDS and ARVs
Monthly case management to remind women of personal health goals including checking on ART initiation and adherence.
Staff support and debriefing
Actively working with the Community Advisory Board
Solutions: Lessons Learned
Accompanying the women for clinical staging and initiation
Acquiring a point-of-care CD4 testing machine
Keeping ARVs at the clinic site for self-medication
Seeking more food donations
Striving to find substance abuse rehabilitation centres willing to admit the participants, pro bono
Conducting intakes in the rural and brothel areas
Current FU rate 84% at 6 MFU; 88% at 12 MFU
Next Steps..
Open a Halfway House in Pretoria (waiting on submitted proposal)
Accelerate access to Point-of Care (POC) HIV diagnostics in HCT programs
Engage groups that are responsible for reaching at-risk vulnerable women in strategic planning activities
Identify gaps in service delivery and develop plans for reducing social and structural barriers to treatment
Implement above processes in combination with behavioral interventions in order to achieve maximum impact