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SummaryIn the developing world, little is known about the risk and precipitating factors for abortion, due to a dearth of community-based surveys. Most analyses of determinants of induced abortion consider only a small set of household and individual socio-demographic factors and treat abortion as an isolated outcome, which ignores its relationship with prior reproductive health behaviours and experiences. In this paper, data from a cross-sectional survey of abortion knowledge, attitudes and practices among 2571 currently married women of reproductive age in Rajasthan, India, were used to examine contextual-, household- and individual-level determinants of abortion. Bivariate probit models, which jointly determine the probability of pregnancy and the conditional probability of abortion, were used to reflect the probability of abortion as a result of interrelated and sequential events. Increased socioeconomic status and life-cycle factors were associated with both the probability of pregnancy and with the conditional likelihood of abortion. Women who reported personal networks were also more likely to terminate pregnancies, particularly if their network members purportedly had abortion experience. Community knowledge of sex-selective abortion also exerted a significant positive effect on the propensity to terminate a pregnancy. For rural women only, community beliefs regarding spousal consent requirements pre-abortion were also significantly associated with abortion.

Objective: To increase access to safe abortion, the feasibility, efficacy and acceptability of a medical abortion regimen entailing a reduced dose of mifepristone and the option of home administration of sublingual misoprostol was assessed at a government hospital providing legal abortion services on a regular basis. Methods: Consenting women (n=99) with amenorrhea of =56 days received mifepristone 200mg orally at the hospital. Two days later, women either returned to the hospital for 400µg sublingual misoprostol or took it at home. All women returned after two weeks for abortion confirmation. Results: The vast majority of women (88%) chose home use of misoprostol and did so mainly to decrease the number of clinic visits (65%) and to take care of their household responsibilities (16%). Adherence to the drug protocol was comparable among home and clinic users, with only a single woman in each group not taking misoprostol at the scheduled time. Efficacy was similarly high in both groups (home users 95% vs. clinic users 96%). No serious side effects were noted in either home or clinic users. Conclusion: The safety, efficacy and acceptability of home use of misoprostol observed in our study suggest this option should be available to women in India.

Introduction: To increase access to safe abortion in rural India, the feasibility and acceptability of mifepristone-misoprostol abortion was assessed in a typical government run primary health center (PHC) in Nagpur district, Maharashtra State, that does not offer surgical abortion services and must refer off-site for emergency and backup services. Materials and Methods: Consenting pregnant women (n=149) with ≤56 days amenorrhea seeking terminations received 200 mg mifepristone, and returned 48 h later for 400-μg sublingual misoprostol and 12 days later for abortion confirmation. Surgical backup was conducted at a nearby community health center (CHC). Results: Nearly all women (98.6%) with known outcomes had successful medical abortions, and those who did not (1.4%) were successfully referred to the CHC for surgical backup. Women reported the method's ease and simplicity as the best features. Conclusion: Medical abortion provision is feasible and acceptable in an Indian rural PHC that does not offer surgical abortion services. This study suggests that introduction of medical abortion at lower levels of the health-care system could increase access to safe abortion in rural India.

IntroductionMost HIV‐positive persons in sub‐Saharan Africa initiate antiretroviral therapy (ART) with advanced infection (late ART initiation). Intervening on the drivers of late ART initiation is a critical step towards achieving the full potential of HIV treatment scale‐up. This study aimed to identify modifiable factors associated with late ART initiation in Ethiopia.MethodsFrom 2012 to 2013, Ethiopian adults (n=1180) were interviewed within two weeks of ART initiation. Interview data were merged with HIV care histories to assess correlates of late ART initiation (CD4+ count <150 cells/µL or World Health Organization Stage IV).ResultsThe median CD4 count at enrolment in HIV care was 263 cells/µL (interquartile range (IQR): 140 to 390) and 212 cells/µL (IQR: 119 to 288) at ART initiation. Overall, 31.2% of participants initiated ART late, of whom 85.1% already had advanced HIV disease at enrolment. Factors associated with higher odds of late ART initiation included male sex (vs. non‐pregnant females; adjusted odds ratio (aOR): 2.02; 95% CI: 1.50 to 2.73), high levels of psychological distress (vs. low/none, aOR: 1.96; 95% CI: 1.34 to 2.87), perceived communication barriers with providers (aOR: 2.42, 95% CI: 1.24 to 4.75), diagnosis via provider initiated testing (vs. voluntary counselling and testing, aOR: 1.47, 95% CI: 1.07 to 2.04), tuberculosis (TB) treatment prior to ART initiation (aOR: 2.16, 95% CI: 1.43 to 3.25) and a gap in care of six months or more prior to ART initiation (aOR: 2.02, 95% CI: 1.10 to 3.72). Testing because of partner illness/death (aOR: 0.64, 95% CI: 0.42 to 0.95) was associated with lower odds of late ART initiation.ConclusionsProgrammatic initiatives promoting earlier diagnosis, engagement in pre‐ART care, and integration of TB and HIV treatments may facilitate earlier ART initiation. Men and those experiencing psychological distress may also benefit from targeted support prior to ART initiation.

IntroductionRetention in HIV care prior to ART initiation is generally felt to be suboptimal, but has not been well‐characterized.MethodsWe examined data on 37,352 adult pre‐ART patients (ART ineligible or unknown eligibility) who enrolled in care during 2005–2008 with >1 clinical visit at 23 clinics in Mozambique. We defined loss to clinic (LTC) as >12 months since the last visit among those not known to have died/transferred. Cox proportional‐hazards models were used to examine factors associated with LTC, accounting for clustering within sites.ResultsOf 37,352 pre‐ART patients, 61% had a CD4 count within three months of enrolment (median CD4: 452, IQR: 345–611). 17,598 (47.1%) were ART ineligible and 19,754 (52.9%) were of unknown eligibility status at enrolment because of missing information on CD4 count and/or WHO stage. Kaplan‐Meier estimates for LTC at 12 months were 41% (95% CI: 40.2–41.8) and 48% (95% CI: 47.2–48.8), respectively. Factors associated with LTC among ART ineligible patients included male sex (AHRmen_vs_non‐pregnant women: 1.5; 95% CI: 1.4–1.6) and being pregnant at enrolment (AHRpregnant_vs_non‐pregnant women: 1.3; 95% CI: 1.1–1.5). Older age, more education, higher weight and more advanced WHO stage at enrolment were independently associated with lower risks of LTC. Similar findings were observed among patients whose ART eligibility status was unknown at enrolment.ConclusionsSubstantial LTC occurred prior to ART initiation among patients not yet known to be eligible for ART, including nearly half of patients without documented ART eligibility assessment. Interventions are needed to target pre‐ART patients who may be at higher risk for LTC, including pregnant women and patients with less advanced HIV disease.

AbstractIntroductionThere are approximately 1.7 million adolescents living with HIV (ALHIV, ages 10 to 19) globally, including 110,000 in Kenya. While ALHIV experience poor retention in care, limited data exist on factors underlying disengagement. We investigated the burden of trauma among disengaged ALHIV in western Kenya, and its potential role in HIV care disengagement.MethodsWe performed in‐depth qualitative interviews with ALHIV who had disengaged from care at two sites, their caregivers and healthcare workers (HCW) at 10 sites, from 2018 to 2020. Disengagement was defined as not attending clinic ≥60 days past a missed scheduled visit. ALHIV and their caregivers were traced through phone calls and home visits. Interviews ascertained barriers and facilitators to adolescent retention in HIV care. Dedicated questions elicited narratives surrounding traumatic experiences, and the ways in which these did or did not impact retention in care. Through thematic analysis, a conceptual model emerged for a cascade from adolescent experience of trauma to disengagement from HIV care.ResultsInterviews were conducted with 42 disengaged ALHIV, 34 caregivers and 28 HCW. ALHIV experienced a high burden of trauma from a range of stressors, including experiences at HIV disclosure or diagnosis, the loss of parents, enacted stigma and physical or sexual violence. A confluence of factors – trauma, stigma and isolation, and lack of social support – led to hopelessness and depression. These factors compounded each other, and resulted in complex mental health burdens, poor antiretroviral adherence and care disengagement. HCW approaches aligned with the factors in this model, suggesting that these areas represent targets for intervention and provision of trauma‐informed care.ConclusionsTrauma is a major factor underlying disengagement from HIV care among Kenyan adolescents. We describe a cascade of factors representing areas for intervention to support mental health and retention in HIV care. These include not only the provision of mental healthcare, but also preventing or addressing violence, trauma and stigma, and reinforcing social and familial support surrounding vulnerable adolescents. In this conceptualization, supporting retention in HIV care requires a trauma‐informed approach, both in the individualized care of ALHIV and in the development of strategies and policies to support adolescent health outcomes.

AbstractIntroductionAdolescents living with HIV (ALHIV, ages 10–19) have developmentally specific needs in care, and have lower retention compared to other age groups. Family‐level contexts may be critical to adolescent HIV outcomes, but have often been overlooked. We investigated family‐level factors underlying disengagement and supporting re‐engagement among adolescents disengaged from HIV care.MethodsSemi‐structured interviews were performed with 42 disengaged ALHIV, 32 of their caregivers and 28 healthcare workers (HCW) in the Academic Model Providing Access to Healthcare (AMPATH) program in western Kenya, from 2018 to 2020. Disengaged ALHIV had ≥1 visit within the 18 months prior to data collection at one of two sites and nonattendance ≥60 days following their last scheduled appointment. HCW were recruited from 10 clinics. Transcripts were analysed through thematic analysis. A conceptual model for family‐level domains influencing adolescent HIV care engagement was developed from these themes.ResultsFamily‐level factors emerged as central to disengagement. ALHIV‐particularly those orphaned by the loss of one or both parents‐experienced challenges when new caregivers or unstable living situations limited support for HIV care. These challenges were compounded by anticipated stigma; resultant non‐disclosure of HIV status to household members; enacted stigma in the household, with overwhelming effects on adolescents; or experiences of multiple forms of trauma, which undermined HIV care engagement. Some caregivers lacked finances or social support to facilitate care. Others did not feel equipped to support adolescent engagement or adherence. Regarding facilitators to re‐engagement, participants described roles for household disclosure; and solidarity from caregivers, especially those also living with HIV. Family‐level domains influencing HIV care engagement were conceptualized as follows: (1) adolescent living situation and contexts; (2) household material resources or poverty; (3) caregiver capacities and skills to support adolescent HIV care; and (4) HIV stigma or solidarity at the household level.ConclusionsFamily‐level factors are integral to retention in care for ALHIV. The conceptual model developed in this study for family‐level influences on care engagement may inform holistic approaches to promote healthy outcomes for ALHIV. Developmentally appropriate interventions targeting household relationships, disclosure, HIV stigma reduction, HIV care skills and resources, and economic empowerment may promote adolescent engagement in HIV care.

AbstractIntroductionAdolescence and pregnancy are potential risk factors for loss to follow‐up (LTFU) while on antiretroviral therapy (ART). We compared adolescent and adult LTFU after ART initiation to quantify the impact of age, pregnancy, and site‐level factors on LTFU.MethodsWe used routine clinical data for patients initiating ART as young adolescents (YA; 10 to 14 years), older adolescents (OA; 15 to 19 years) and adults (≥20 years) from 2000 to 2014 at 52 health facilities affiliated with the International epidemiology Databases to Evaluate AIDS (IeDEA) East Africa collaboration. We estimated cumulative incidence (95% confidence interval, CI) of LTFU (no clinic visit for ≥6 months after ART initiation) and identified patient and site‐level correlates of LTFU, using multivariable Cox proportional hazards models for all patients as well as individual age groups.ResultsA total of 138,387 patients initiated ART, including 2496 YA, 2955 OA and 132,936 adults. Of these, 55%, 78% and 66%, respectively, were female and 0.7% of YA, 22.3% of OA and 8.3% of adults were pregnant at ART initiation. Cumulative incidence of LTFU at five years was 26.6% (24.6 to 28.6) among YA, 44.1% (41.8 to 46.3) among OA and 29.3% (29.1 to 29.6) among adults. Overall, compared to adults, the adjusted hazard ratio, aHR, (95% CI) of LTFU for OA was 1.54 (1.41 to 1.68) and 0.77 (0.69 to 0.86) for YA. Compared to males, pregnant females had higher hazard of LTFU, aHR 1.20 (1.14 to 1.27), and nonpregnant women had lower hazard aHR 0.90 (0.88 to 0.93). LTFU hazard among the OA was primarily driven by both pregnant and nonpregnant females, aHR 2.42 (1.98 to 2.95) and 1.51 (1.27 to 1.80), respectively, compared to men. The LTFU hazard ratio varied by IeDEA program. Site‐level factors associated with overall lower LTFU hazard included receiving care in tertiary versus primary‐care clinics aHR 0.61 (0.56 to 0.67), integrated adult and adolescent services and food ration provision aHR 0.93 (0.89 to 0.97) versus nonintegrated clinics with food ration provision, having patient support groups aHR 0.77 (0.66 to 0.90) and group adherence counselling aHR 0.61 (0.57 to 0.67).ConclusionsOlder adolescents experienced higher risk of LTFU compared to YA and adults. Interventions to prevent LTFU among older adolescents are critically needed, particularly for female and/or pregnant adolescents.

BackgroundEast Africa has experienced a rapid expansion in access to antiretroviral therapy (ART) for HIV‐infected patients. Regionally representative socio‐demographic, laboratory and clinical characteristics of patients accessing ART over time and across sites have not been well described.MethodsWe conducted a cross‐sectional analysis of characteristics of HIV‐infected adults initiating ART between 2002 and 2009 in Kenya, Uganda and Tanzania and in the International Epidemiologic Databases to Evaluate AIDS Consortium. Characteristics associated with advanced disease (defined as either a CD4 cell count level of less than 50 cells/mm3 or a WHO Stage 4 condition) at the time of ART initiation and use of stavudine (D4T) or nevirapine (NVP) were identified using a log‐link Poisson model with robust standard errors.ResultsAmong 48, 658 patients (69% from Kenya, 22% from Uganda and 9% from Tanzania) accessing ART at 30 clinic sites, the median age at the time of ART initiation was 37 years (IQR: 31‐43) and 65% were women. Pre‐therapy CD4 counts rose from 87 cells/mm3 (IQR: 26‐161) in 2002‐03 to 154 cells/mm3 (IQR: 71‐233) in 2008‐09 (p < 0.001). Accessing ART at advanced disease peaked at 35% in 2005‐06 and fell to 27% in 2008‐09. D4T use in the initial regimen fell from a peak of 88% in 2004‐05 to 59% in 2008‐09, and a greater extent of decline was observed in Uganda than in Kenya and Tanzania. Self‐pay for ART peaked at 18% in 2003, but fell to less than 1% by 2005. In multivariable analyses, accessing ART at advanced immunosuppression was associated with male sex, women without a history of treatment for prevention of mother to child transmission (both as compared with women with such a history) and younger age after adjusting for year of ART initiation and country of residence. Receipt of D4T in the initial regimen was associated with female sex, earlier year of ART initiation, higher WHO stage, and lower CD4 levels at ART initiation and the absence of co‐prevalent tuberculosis.ConclusionsPublic health ART services in east Africa have improved over time, but the fraction of patients accessing ART with advanced immunosuppression is still high, men consistently access ART with more advanced disease, and D4T continues to be common in most settings. Strategies to facilitate access to ART, overcome barriers among men and reduce D4T use are needed.