Interventions To Reduce Hiv/aids Stigma: What Have We Learned?

J Acquir Immune Defic Syndr. Author manuscript; available in PMC 2016 Jan 12.

Published in final edited form as:

PMCID: PMC4709521

NIHMSID: NIHMS748096

The Impact of Back up Groups for People Living with HIV on Clinical Outcomes: a systematic review of the literature

Moses Bateganya, MBChB, MMed, MPH,^one, ^§ Ugo Amanyeiwe, BDS, FWACS, MS,ⁱⁱ Uchechi Roxo, MSc,² and Maxia Dong, MD, PhD^one

Moses Bateganya

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

Ugo Amanyeiwe

^twoOffice of HIV and AIDS, United States Agency for International Development

Uchechi Roxo

ⁱⁱRole of HIV and AIDS, United States Agency for International Evolution

Maxia Dong

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

Abstract

Background

Support groups for people living with HIV (PLHIV) are integrated into Human Immunodeficiency Virus (HIV) care and handling programs equally a modality for increasing patient literacy and every bit an intervention to address the psychosocial needs of patients. However, the impact of back up groups on key wellness 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, every bit well equally their cost effectiveness.

Results

Of 1809 citations identified, twenty met inclusion criteria. One reported on mortality, 7 on morbidity, five on memory in intendance, vii on quality of life, and 7 on ongoing HIV transmission. Xviii (xc%) of the manufactures reported largely positive results on the impact of back up group interventions on key outcomes. Support groups were associated with reduced mortality and morbidity, increased retention in intendance and improved quality of life. Due to study limitations, the overall quality of evidence was rated as fair for bloodshed, morbidity, retention in intendance, and quality of life, and poor for HIV transmission.

Conclusions

Implementing back up groups as an intervention is expected to have a loftier impact on morbidity and retention in care and a moderate impact on bloodshed 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 price-effective given the paucity of studies in this area.

Keywords: Support groups, clinical, outcomes, developing countries, PLHIV

Introduction

HIV programs employ support groups every bit an opportunity for health care workers to provide information to people living with HIV (PLHIV). HIV mail service-exam clubs were among the first support groups to be utilized to provide support to clients who tested positive for HIV. ¹ The Globe Health Organization (WHO) proposes support groups equally an intervention to address retentiveness and adherence among PLHIV receiving ART. ²

Both WHO and the President's Emergency Plan for AIDS Relief (PEPFAR) promote peer support groups facilitated past trained PLHIV to address the special needs of boyfriend PLHIV and their partners.^{3, iv} Such groups serve the purpose of sharing experiences, encouraging disclosure, reducing stigma and discrimination, improving self-esteem, enhancing patients' coping skills and psychosocial functioning and supporting medication adherence and improved memory in HIV intendance. ^{five, 6, 7} These benefits tin be maximized further if the support groups are formed around specific populations such every bit men who have sex with men, significant women, adolescents, or couples in discordant relationships. Support groups are also considered an intervention in the management of mental wellness bug, including alcohol and other substance abuse disorders.²

Support groups are generally initiated and supported by non-governmental organizations (NGOs), civil society or community-based organizations and may convene in a health facility or in the community.

Disclosure of HIV positive condition, one of the potential benefits of support groups, has wide prevention implications and is emphasized past both the WHO and the Centers for Disease Control and Prevention (CDC) in all HIV testing protocols. ^{viii, 9} The Mentor Mother support grouping model — utilizing mothers living with HIV—is a key strategy in the United Nations Global Program for elimination paediatric AIDS by 2015 and for keeping mothers alive. ¹⁰ The Mentor Mothers is considered an effective intervention to amend maternal and infant well-being among women living with HIV. They work alongside wellness care workers in the clinic and at customs meetings to provide health educational activity, to promote adherence to antiretroviral therapy (ART), and to promote disclosure of HIV status amidst other services. ¹¹

Although the WHO and PEPFAR promote the office of support groups ^{ii, 4}, evidence of their impact on key wellness outcomes has not been assessed. This article presents the results of a systematic review of studies examining the evidence of affect of support groups on mortality, morbidity, retention in intendance, quality of life, and HIV transmission, and determining whether they are cost-effective.

Methods

This review was conducted as function of an assessment of 13 care and support interventions funded past PEPFAR. ¹² Details most the interventions and methods for the review including the full general search strategy are described fully in the introductory article to this supplement. ^xiii

The review squad conducted a systematic search of the literature using: Medline (via PubMed), EMBASE, Global Health, CINAHL (Cumulative Index to Nursing and Allied Wellness Literature), SOCA (Sociological Abstracts) and AIM (African Index Medicus) from Jan 1995 through May 2014 using the post-obit Medical Subject Headings (MeSH) terms: HIV, community back up, social support grouping, breezy group, PLHIV network, PLHIV group, volunteer group, support group, cocky-help grouping, cocky-help, peer back up and peer back up group. These were used in addition to the general search terms described in the introductory commodity. ¹³

The authors reviewed the citations and abstracts independently and identified studies that appeared to address support group interventions and at to the lowest degree one of the outcomes of interest. For these "eligible" studies, full-text articles were obtained and evaluated independently by two authors. Studies that met the following criteria were "included" in the review: (1) evaluated the impact of HIV support groups; two) were conducted in resource-limited settings; and three) addressed ane or more of the outcomes of interest -- mortality, morbidity, memory in HIV care, quality of life, or prevention of ongoing HIV transmission. Costing and price-effectiveness outcomes where available were also considered.

The post-obit data were abstracted from each study that fulfilled the inclusion criteria; report characteristics (commendation, design, report year and twelvemonth of publication); key findings (the magnitude of result of the intervention, presented as hazard ratios, odds ratios, or relative hazard and 95% confidence intervals); and the quality of evidence. For the latter, we assessed the internal and external validity and other factors and rated the quality of evidence of each study as potent, medium or weak. Qualitative studies were rated on a scale of I-IV based on methods adjusted from Daly et al. ¹⁴ The methods for rating study quality are described in detail in the introductory paper in this supplement. ¹³

Variability in the intervention, report blueprint, and report population precluded combining report results or meta-analysis. Instead the review team summarised results from all studies that reported on each event. Nosotros rated the overall quality of evidence for each upshot every bit good, fair or poor based on criteria developed a priori. We then rated the expected impact — based on the magnitude of effect reported in individual studies, the quality of the trunk of testify (all studies addressing each outcome), and consistency of results beyond the studies —of the intervention on each outcome as loftier, moderate, low or uncertain (further details regarding rating of quality of bear witness for individual studies, and quality of bear witness and expected impact for each outcome can be found in the introductory newspaper in this supplement). ^thirteen

Results

We screened 1,809 abstracts and deemed 137 of the studies to be "eligible" (Fig. 1). Total-text articles of these 137 studies were reviewed; 20 met "inclusion" criteria. Studies that were not "included" either did not accost back up groups as an intervention or did non report on any of the outcomes of interest. Characteristics of the 20 included studies are presented in Tabular array 1. Six articles reported on multiple outcomes while xiv addressed one outcome of interest (Table 1). The majority of studies were conducted in sub-Saharan Africa: South Africa, n=7 ^{15, xviii, 22, 26, 32, 35, 36} ; Republic of kenya, n=ii ^{23, 30}; Mozambique, n=2 ^{17, 17}; and 1 each from Nigeria ²⁵, Rwanda ²⁴, Tanzania ²¹, Uganda ³¹ and Republic of zimbabwe. ²⁷ Two studies were conducted in Vietnam ^{33, 34}; the remaining two reported multi-country results. ^{19, 20}

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Study menses diagram

Total number of studies identified; screened; eligible and included in the systematic review of support groups for People Living with HIV January 1990- May 2014.

* Duplicate citations removed.

^ Numbers below in effect section add upward to more than twenty as some studies addressed more than one outcome.

Table 1

Assessment of individual studies on support groups (SGs) by outcome

Report Characteristics				Central Findings (Magnitude of effect (HR, OR, RR, RD & 95% CI) or other description)	Quality of prove for individual studies			Evidence from Economic Evaluation (Yep or No;	Comments
Report Characteristics					Validity (Practiced, Fair, or Poor)		Quality of Evidence (Strong, Medium, Weak)
Commendation	Study Design	Written report Period, Country	Participants and outcomes		Internal	External	Quality of Evidence (Strong, Medium, Weak)
Mortality
Decroo J, et al. ¹⁷	Cohort	ii/2008–12/2012 Mozambique	5729 community adherence group (CAG) members	Mortality rates amidst 5729 CAG members was, two.1 per 100 person-years (PYs). Of the 5729 developed CAG members, only 208 (3.6%) died later on a median follow-upward time of 19 months (IQR ten–29). Factors associated with LTFU and bloodshed were presented together.	Off-white	Good	Medium	No information	At that place was no comparison group; instead the authors in their discussion quoted mortality from a accomplice in Mozambique, 17.iv% (14.9–20.0) were known to have died (Wandeler et al).
Morbidity
Wouters Due east, et al. ¹⁵	Prospective cohort	2004–2007, S. Africa	268, Assessed community support (CHWs, SGs, Handling buddies on VL, CD4)	At 12 months, SG participants were significantly more than likely (β 0.12, P <0.001) to have an undetectable viral load and a CD4 prison cell count above 200 cells/mL than those who did not participate in a SG. Similar outcomes were maintained 24 months after enrolment (β 0.xiii, P < 0.01)	Fair	Adept	Medium	No data	SG meetings were at the dispensary-67.3%, church-6.0%, dwelling house of a SG member-9.7%, hospice-3.9% Most met once a week-59.vi%, 21.2% met 2–iii times/month 19.2% only one time a month. VL
AchiengL, et al. ²³	Prospective observational cohort	xi/2009–four/2010, Republic of kenya	301 assigned to various adherence interventions incl. SGs. End points: time to treatment failure, stoppage of ART; death; or loss to follow-up	Fourth dimension to treatment failure was longer in patients participating in SGs (448 days vs. 337 days, P, 0.001). SGs were associated with better adherence (89% vs. 82%, P = 0.05) and adventure of handling failure was significantly reduced by SGs (HR = 0.43, P = 0.003), the impact being college with the number of SG sessions attended (three vs. 2, p=0.01p=0.01). Women were more likely than men to be retained (74% vs. 6%, p=0.027)	Fair	Off-white	Medium	No data
Dageid, Westward, et al. ^eighteen	Mixed methods- Qualitative & Quantitative, program evaluation	2003–2005, South Africa	44 Kudu SG Members were compared to 23 non-members	SG membership was associated with statistically significant reduction in; somatic symptoms [10.54 to 7.08 (p=0.05)], anxiety and insomnia [x.35 to seven.96 (p= 0.05)]; and social dysfunction [6.38 to 2.46 (p=0.01)], only a not-significant decrease in depression scores [4.85 to 3.38, (P>0.05); while non-SG members showed but non-significant reductions on somatic scores on the somatic scale and social dysfunction scale just an increment in scores for anxiety, insomnia and for depression respectively	Poor	N/A	Weak	No data	Results from the quantitative component are limited by the small sample size
Elul, B, et al. ²⁴	Cross sectional survey	9/2008–4/2009, Rwanda	1472 participants at 20 sites. 53% were enrolled in SGs. Outcomes; adherence and viral load	Participating in an association of PLHIV was associated with decreased risk of non-adherence and of having detectable viral load (AOR = 0.60, 95% CI [0.42–0.87]). Afterwards adjusting for elapsing on Art, age and CD4 count at Fine art initiation, participating in an association for PLHIV showed an inverted association with having a viral load of more than than 40 copies/mL (AOR= 0.39, 95% CI [0.24–0.65]).	Fair,	Proficient	Medium	No data	The article did not directly report on morbidity or mortality but adherence and VL
Kaaya, S, et al. ²¹	Unblinded RCT	x/2001 – ii/2004, Tanzania	331, randomized to SG (n= 168) and command (n =163)	A SG intervention was associated with a marginal reduction in depressive symptoms. Fewer women in the intervention (60%) were depressed compared to command (73%), RR=0.82, 95% CI, 0.67–1.01 (p= 0.066). There was a 20% increase in disclosure among women in the intervention arm compared with those in the control arm (56% vs. 46%), RR=i.2, 95% CI: 0.91–one.half dozen, (p= 0.nineteen). 88% of SG participants were satisfied with results of disclosure versus 62% in the command arm (RR 1.four, 95% CI: one.i–1.viii, p0.004).	Fair	Fair	Strong	No data	Over 30% randomized to intervention did not initiate intervention or SOC. Intervention lasted only six weeks.
Ndu, A, et al. ²⁵	Cross Sectional	half dozen/2007 Nigeria	122 ART clinic attendees	Participants who belonged to a SG (simply 46.2%) were less likely to exist depressed than those who did not (66.7% vs. 54.3% P=0.236) (not statistically meaning)	Poor	Poor	Medium	No data	Causality between symptoms of anxiety and depression and their correlates could non be firmly established.
Pappin M, et al. ²⁶	Cross Sectional	2007–08, S. Africa	716 starting ART at 12 public health facilities	Participating in a SG was associated with decreased symptoms of depression (OR = 0.21, CI 0.05–0.99)	Poor	Fair	Medium
Retention in care
Decroo, J, et al. ¹⁶	Observational Accomplice Written report	2/2008–5/2010, Mozambique	1384 CAG members, program data	During follow up 1301 patients nevertheless remained in community groups, 1269 (97.v%) were remaining in care, thirty (2%) had died, and 2 (0.ii%) were LTFU. Proportion of patients LTFU was lower (0.1%, range 0–0.5%) than the Mozambique national average (15%) and that reported in the literature (1.2–26%). Mortality was depression. At that place was no comparison group. Just 3.5% decided to transfer back to conventional care.	Poor	Fair	Medium	No data
Decroo J, et al. ¹⁷	Same equally above. Longer follow up	ii/2008–12/2012, Mozambique	5729 CAG members, programme data (No comparing)	Long term retentiveness was very high (91.viii%) at 4 years of follow-up. Retention at 1 twelvemonth on ART was 97.7% (95% CI 97.4–98.2); at 2 years, 96.0% (95% CI 95.3–96.6); at 3 years, 93.4% (95% CI 92.iii–94.3); and at iv years, 91.eight% (95% CI 90.one–93.2). Overall attrition was 2.two/100 PYs (3.ix%); bloodshed and LTFU rates were 2.i and 0.1/100 PYs respectively compared to; 5/100 PYs among patients more than ii years on ART in Sub-Saharan Africa (Play a joke on & Rosen 2010); 19.8 per 100 PYs in Mozambique [27]; and 48.6% at 3 years [38]	Poor	Fair	Medium	No data
Wouters E, et al. ³⁷	Prospective cohort/program data	2004–2007, S. Africa	268 patients enrolled in the public sector Art. No statistical measures reported	Having a treatment buddy, CHW, or participation in SG at 6 months positively influenced patient retention at time 12 months. Having a TrB, CHW, or participation in a SG at 12 months positively influenced patient retention at 24 months after starting ART.	Fair	Practiced	Medium	No data	Findings may reverberate the inherent differences between the patients lost and those retained.
Lamb MR, et al. ¹⁹	Cohort written report	Jan one, 2005–Sept 30, 2011	312,335 patients (x–24 yrs) at 160 HIV clinics: Republic of kenya-41, Mozambique-31, Rwanda-41, Tanz-47	Pre-Fine art: In that location was no clan between Pre-compunction and attending clinics that offered adolescent SGs (Data not reported). Fine art: Youth attending clinics that offered boyish SGs experienced lower attrition after Fine art initiation than youth attending clinics not offering these services (AHR=0.73, 95% CI: 0.52–1.0)	Good	Adept	Medium	No data
Muchedzi A et al. ²⁷	Cross-exclusive	6–8,2008 Republic of zimbabwe	147 PMTCT clients were interviewed and included in the survey.	Women enrolled in a SG were twice as likely to access care and treatment (OR = ii.34, 95% CI one.13–4.88). On multivariate analysis, access to HIV care and handling were associated with participants enrolled in a SG (OR = 2.34, CI 1.13–4.88).	Poor	Poor	Medium	No information	Assessed factors associated with enrolment in care and not morbidity straight
Quality of life
Dageid W, et al. ^eighteen	Mixed methods Programme evaluation	See in a higher place	44 Kudu SG Members and 23 non-members	From FGDs: SG members reported that they had lived positively 35/44, felt stronger (50%) compared to non-members. Negative findings included gossip and stigmatization from other SG members and from the community and inadvertent disclosure. From Surveys: (forty/44)90% of SG members reported that the SG had a positive touch, all SG participants felt stronger. Statistically significant improvement in scales from baseline for somatic symptoms, anxiety and insomnia and social dysfunction, come across above.	Poor	N/A	Weak,	No data
Gillet HJ, et al. ^xxx	Qualitative	five–six/2009, Republic of kenya	21 HIV-positive women	Women believed they had gained emotional back up at their SG.	N/A	N/A	Weak	No data
Kim YM, et al. ³¹	Qualitative	2007–2008, Uganda	113 key informants, 16 FGDs (11 with SG members & 5 with not-SG customs members).	SGs helped to reduce the stigma and discrimination that previously deterred PLHIV from seeking care. The project helped transform the part and self-image of PLHIV. PLHIV trained as network back up agents (NSAs) compensated for staffing shortages at health facilities, reducing client await time and increasing attending to each customer.	N/A	Due north/A	Weak	No information	More than people in the community accessed intendance with potential mortality & prevention benefits. NSAs also conducted abode visits to encourage adherence and retention
Mfecane S, et al. ³²	Qualitative	2/2006–5/2007, Due south. Africa	25 men attending a rural S. African wellness facility	SGs enabled almost participants to take their HIV diagnosis, resist HIV stigmatization, and gain confidence that they would live longer despite having HIV. Helped participants to dispense of feelings of helplessness and suicidal tendencies. Enabled adherence to ARVs. Negative effects: Men felt pressure was imposed on them in the SGs to exist disciplined and responsible patients.	N/A	North/A	Weak	No information	Some negative comments: SGs help in the transformation of PLHIV into docile and passive bodies in order to facilitate their adherence to handling
Mundell JP, et al. ²²	Quasi-experimental	4/2005 – 9/2006, South. Africa	361 pregnant women, (144 participated in the 10-session weekly psychosocial SG [intervention] and 217 who declined (control)	At 2- and 8-month follow-ups, the rates of disclosure in the intervention group was significantly higher than in the comparing grouping (p <0.001). At follow up, the intervention group displayed higher levels of agile coping (t-score, t = 2.68, p < 0.05) and lower levels of avoidant coping (t =2.02, p < 0.05) compared to control, and those who attended at least half of the intervention sessions exhibited improved self-esteem (t = ii.xi, p < 0.05).	Poor	Poor	Medium	No data
Nguyen TA, et al. ³³	Qualitative	2004–2007 Vietnam	30 women access HIV-related postnatal care	Involvement in cocky-assistance groups improved the women's self-esteem, increased knowledge about HIV, and had a positive effect on both felt and enacted stigma from family, community, and health services. Many mothers in the group actively sought care and started to help others to access services.	Due north/A	North/A	Weak	No data
Oosterhoff P, et al. ³⁴	Qualitative methods applied to a Instance Study	4/2004 –6/2007, Vietnam	153 (84 HIV+ women 47 HIV+ men, and 22 household members)	Past participating in SGs, PLHIV gained access vital social, medical and economical support and services for themselves, their children and partners. They gained self-confidence, and learned to communicate with their peers and vocalism their needs to service providers. More members were able to access ARVs including for PMTCT.	N/A	N/A	Weak		Most outcomes were programmatic and not private.
HIV Transmission
Gaede B, et al. ³⁵	Descriptive cross sectional	Year not specified, S. Africa	262 HIV positive pregnant and non-pregnant women (165 urban and 97 rural)	The findings supported positive benefits of counseling and SGs amongst women. Membership in a SG also showed a positive clan with condom use (Spearman'due south correlation Coeff=0.394; p<0.001). The overall SG membership was but 12% (seven% in urban and 21% in rural (p =0.001)	Poor	Fair	Medium
Hardon A, et al. ²⁰	Descriptive cross sectional	2008–09, Burkina Faso, Kenya, Malawi, Uganda	3659 for the quantitative component and 157 for the qualitative component	Membership to a SG was strongly associated with not disclosing to partners (uRR 0.53 [95% CI 0.39–0.72], p < 0.001) even after aligning (aRR 0.67 [95% CI 0.51–0.88], p = 0.004). In the qualitative component, interviews and focus group discussions suggested that SGs advocated caution when disclosing to partners.	N/A	Due north/A	Medium		Few HIV positive members answered open up ended questions
Skogma S, et al. ³⁶	Mixed (qualitative &quantitative)	9–12, 2003, Due south Africa	144 (118 women and 26 men) two HIV clinics in central Johannesburg	The disclosure rate was generally high (92%). No meaning differences in disclosure betwixt the patients with simply pre- and mail service-exam counseling vs. those attending professional counseling or SGs, and to those not attending any form of counseling.	Poor	Fair	Medium		In the setting, disclosure was high (92%). Sample size used in the written report may have been too modest
Wouters E, et al. ³⁷	Prospective cohort/routine data	2004–2007, Southward. Africa	268 patients enrolled in the public sector ART.	Public disclosure at six-month follow-up was significantly associated with bonding social capital measures including back up groups Participating in an HIV/AIDS SG grouping at 12 months and 24 months were associated with public disclosure. (β= 0.22 and β= 0.22 respectively).	Encounter above	Come across above	Encounter above		Potential confounders such as psychosocial and socio-behavioral factors were non bachelor in the dataset and were not controlled for. Nosotros assumed for purposes of this review that disclosure and VL are associated with less manual
Gillet HJ, et al. ^thirty	Qualitative	five–6/2009, Kenya	21 HIV-positive women	Women gained conviction to disclose to relatives and partners after meeting other PLHIV in their SG. No information on affect of SG on disclosure to non-SG members	Northward/A	N/A	Weak	No data	Did not investigate the bear on of support groups on disclosure to people outside the SG
Kim YM, et al. ³¹	Qualitative	2007–2008, Uganda	113 key informants, 16 FGDs (11 with SG members & 5 with non-SG community members).	NSAs trained from the SGs contributed to an increase in the disclosure of HIV-positive status to spouses, family unit members, PLHIV group members, service providers, and customs members.	Due north/A	Due north/A	Weak	No data	Disclosure to family unit members has prevention benefits within discordant couples
Kaaya, S, et al. ²¹	Unblinded RCT	10/2001 – 2/2004, Tanzania	331, randomized to SG (north= 168) and control (n =163)	There was a twenty% increase in disclosure among women in the intervention arm compared with those in the command arm (56% vs. 46%), RR=1.2, 95% CI: 0.91–1.6, (p= 0.19). 88% of SG participants were satisfied with results of disclosure versus 62% in the control arm (RR i.4, 95% CI: 1.1–1.8, p=0.004).	Off-white	Fair	Stiff	No data	Intervention lasted only six weeks.

Almost studies (xviii) were observational—using either a cross-sectional or accomplice design (eleven), a qualitative (5), or a mixed methods study design (two); and two were experimental studies-- an unblinded randomised controlled study (RCT) ²¹ and a study using a quasi-experimental design. ²² Sample sizes ranged from 21 in a qualitative written report to over 300,000 in a multi-land observational cohort. Three studies targeted only women; 1 recruited just men; the remaining studies (n=16) included both men and women. In add-on to being enrolled in back up groups, PLHIV often received other interventions, such as being seen by community health workers or being assigned treatment buddies. Tabular array 1 presents farther details on the characteristics and findings from the 20 individual studies.

Outcomes, Quality of the Bear witness and Expected Impact

Mortality

I report examined the result of back up groups on mortality. Decroo et al., reporting on a Mozambique cohort, found a mortality charge per unit amid 5729 individuals enrolled in Customs Adherence Groups (CAGs) of just 2.1 per 100 person-years (PYs) and a loss to follow-upwards (LTFU) rate of 0.ane per 100 PYs. But 208 (3.vi%) were reported equally dead subsequently a median follow-upwards fourth dimension of 19 months (IQR 10–29). ¹⁷ The authors too reported an overall attrition of 3.nine% mostly from bloodshed (3.7%) and the rest from LTFU (0.ii%). Factors associated with attrition (both mortality and LTFU) were presented at individual and group level. At the individual level, attrition in CAGs was associated with a low CD4 count at the time of enrolment in CAG (aHR 2.28, 95% CI 1.60–three.24) and being male (aHR i.93, 95% CI 1.48–two.51). At the group (CAG) level, lack of rotational representation by each of the different grouping members at the dispensary (aHR one.72, 95% CI ane.27–2.33), lack of regular CD4 count ascertainment amid members of the same group (aHR 1.88 95% CI i.18–3.00), and attending a rural (aHR ii.59, 95% CI one.81–3.70) or district dispensary (aHR one.57, 95% CI 1.14–two.16) were associated with higher compunction. In that location was no comparison group.

Reviewers rated the "overall" quality of show for the outcome of mortality equally off-white . However, the expected impact on mortality was rated as moderate based on the low mortality rate amid those who participated in the support groups in this study (Table 2).

Tabular array 2

Summary of evidence from all studies by outcome

Outcomes	Overall Quality of Evidence		Impact of the intervention	Evidence from Economic Evaluation		Comments
	Number of Studies	Overall Quality of the Body of Evidence (Good, Fair, Poor)	ⁱ Expected Touch (Loftier, Moderate, Low)	Number of studies	Quality of evidence from economical evaluation	Comments
Mortality	one [17]	Fair	Moderate	None	N/A	Some back up group characteristics described in the S. Africa settings do provide some of import lessons.
Morbidity	7 [fifteen, 18, 21, 23–26]	Fair	High	None	N/A	Almost all studies were cantankerous exclusive or qualitative and only demonstrate associations. Different outcomes for morbidity were used in the different studies
Retention in Care	5 [15–17, nineteen, 27]	Off-white	High	None	N/A	Results from several large cohorts demonstrate sustained retention especially in ART patients
Quality of Life	7 [18, 22, 30–34, ]	Poor	Moderate	None	N/A	As reported, the studies all used different measures of quality of life. All reported outcomes would have an impact on quality of life for PLHIV direct or indirectly
HIV Manual	vii [xx, 21, 30, 31, 35, 36, 37]	Poor	Uncertain	None	N/A	Iii of the 4 studies were conducted in S. Africa, with mixed results. One study conducted elsewhere had mixed results and involved non-representative sample of participants from each country.

Morbidity

Seven studies ^{fifteen, eighteen, 21, 23–26} reported on the touch on of support grouping interventions on a range of morbidity outcomes (Table 1).

Support groups were associated with reduced frequency of HIV-related symptoms— somatic symptoms, anxiety and indisposition ^eighteen and depression ^{21, 25, 26}. Other benefits included improved access to Fine art, adherence to Art and treatment success ^{fifteen, 23, 24, 27}, measured equally time to handling failure and reduced risk of detectable viremia or change in CD4 cell count. For case, Achieng et al. reported that time to treatment failure was longer in patients participating in support groups (448 days vs. 337 days, P=0.001). ²³ Results from a South African accomplice of 268 PLHIV enrolled in the public sector HIV handling program reported participation in a back up group as a predictor of treatment success (i.e. viral load < 400 copies/mL, CD4 > 200 cells/mL), during the first six, 12 and 24 months of antiretroviral therapy. ¹⁵ Support grouping participants were significantly more likely to have an undetectable viral load (P <0.001) and a CD4 cell count > 200 cells/mL at 12 months (P<0.01) than those who did not participate in a back up group. Viral load suppression was maintained beyond 24 months after enrolment in a support group (P < 0.01). In the Muchedzi study, women tested for HIV in a prevention of mother to child manual (PMTCT) program and enrolled in a back up grouping were twice as likely to access care and treatment (OR = 2.34, 95% CI one.13–4.88) although their treatment outcomes were not reported. ²⁷ Outcomes from the remaining 5 studies are presented in Table 1.

Although findings from the seven studies consistently reported morbidity benefits, reviewers rated the overall quality of evidence as fair based on limitations of the included studies. Almost all were cantankerous sectional, qualitative or had small sample sizes. In addition, different morbidity-related outcomes were reported. Nevertheless, the expected impact of support groups on reducing morbidity in PLHIV was rated every bit high based on meaning associations betwixt support group participation and decrease in morbidity from studies from six different countries.

Retention in Care

Five studies ^{15–17, xix, 27} -- 2 from the same Mozambique accomplice [xvi, 16] -- reported low LTFU for patients on ART participating in support groups. Decroo et al. reported high retention with approximately 97.5% patients remaining in care for a median follow-up period of 12.9 months (range 8.5–fourteen months) ¹⁶ and 91.8% at 4 years. ¹⁷ Overall, the authors reported that compunction in the accomplice was lower than the national 12 calendar month average for Mozambique (15%) ²⁸ and lower however than rates reported in the literature for sub-Saharan Africa (1.ii–26%). ²⁹ A big study with more than 300,000 participants aged 10–24 years from four sub-Saharan countries showed that youth participating in support groups provided by clinics experienced slightly lower attrition after Fine art initiation (AHR=0.73, 95% CI: 0.52–1.0); in the pre-ART period, the authors reported no meaning associations between attrition and participation in back up groups or other boyish friendly services—availability of adolescent peer educators, or teaching on high-risk substance abusing behaviour. ¹⁹ Higher retention amidst support group participants was also reported among patients on Fine art in South Africa ¹⁵ and among women enrolled in the PMTCT programme in Republic of zimbabwe ²⁷ (Tabular array 1).

Reviewers categorized the quality of testify for this outcome every bit fair . All v studies were observational. Sample sizes were small-scale for two of the studies ^{15, 27} and the findings from the larger study ^xix are non generalizable beyond the 10–24 yr historic period group. Lack of a comparison group in 2 studies^{16, 17} and other methodological limitations affected the quality of evidence for this issue. The expected impact of support groups on retention was rated as high for patients on ART only uncertain for pre-ART patients (Tabular array two).

Quality of Life

Seven studies—five qualitative ^30–34, one quasi experimental ²² and some other using mixed methods ^xviii — reported associations between membership and/or attendance at support groups and several measures of quality of life (QOL) (Table one). Measures varied by report and included reported improvement in symptoms, improved confidence and self-esteem, better coping skills, and perceived reduction in stigma. The authors reported that support group participation enabled patients to seek care ³¹ and start ARVs. ³⁴ Other benefits reported by Kim et al. were spill-over effects to the community in which HIV-infected persons who were not in back up groups were encouraged to seek care.³¹ While the benefits were more often than not positive, Mfecane et al. reported that a accomplice of men who attended support groups felt that participation imposed pressure level to conform in a way that negatively affected their perception of masculinity. ³² Dageid et al. reported negative furnishings such every bit inadvertent disclosure of HIV-positive status and gossip and stigmatization from other support group members and/or the community. ¹⁸

Reviewers categorized the quality of evidence for this outcome as poor . Four of the studies were qualitative ^{xxx, 31, 33, 34} and most had small sample sizes. 1 reported only on men ³² and 3 only on women ^{22, thirty, 33} limiting generalizability of the findings. Despite the limitations in some of the studies the expected impact on quality of life was rated equally moderate (Table two) based on consistently positive results on quality of life across studies.

HIV transmission

Seven studies ^{20, 21, xxx, 31, 35–37} reported on outcomes which may directly or indirectly bear upon HIV transmission, such as risky sexual behaviour and disclosure of HIV-positive condition to sex partners. Three of the seven studies were conducted in South Africa ^{15, 35, 36} (Table 1). Gaede et al. reported positive associations between attendance at back up groups and health behaviours and condom use. ³⁵ Four studies ^{xx, 21, 36, 37} reported mixed results regarding the association betwixt support group participation and disclosure of HIV status: Skogmar found no pregnant difference in disclosure rates between those who attended just pre/post-examination counselling (standard of care) and those who received either professional counselling or participated in back up groups. ³⁶ Woulters reported that assistance of community health workers and back up group participation resulted in disclosure of HIV condition to non-family members but in the second twelvemonth of implementation of the plan; however, the impact of support groups alone was not reported. ³⁷ Hardon et al., in a mixed methods written report involving participants from four African countries (Burkina Faso, Kenya, Republic of malaŵi, Uganda), showed that membership in a support group was associated with not disclosing to partners for fear of stigma — the feel of prejudice and discrimination every bit the consequence of beingness HIV- positive. ²⁰ Additionally, although an unblinded randomized command report conducted in Tanzania reported a 20% increment in disclosure for support group participants compared to controls, the difference was not statistically significant (RR=i.2, 95% CI: 0.91–1.6, P=0.nineteen) and 12% of those who gave feedback almost the disclosure reported negative reactions such as anger, blame and beingness told to exit the household. ²¹ Two articles reported an association betwixt support group attendance and increased disclosure to spouses and other family members. ^{30, 31}

Reviewers categorized the quality of evidence from the seven studies every bit poor and the expected impact on HIV transmission every bit uncertain .

Discussion

Nosotros identified 20 studies from depression- and middle-income countries which evaluated the bear on of support groups on bloodshed, morbidity, retention in care, quality of life or HIV transmission. No studies reported costing or price-effectiveness data. The studies were primarily from sub-Saharan Africa and varied in study pattern, target population and sample size.

The review institute largely positive results. Although limited by the quality of the included studies, the information suggest potential benefit of support groups on key health outcomes. We rated the expected bear on of support groups as an intervention in PLHIV as high in terms of reducing morbidity and improving retentivity 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 grouping 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 providers ³⁸, support groups can play an increasingly larger role in care models, especially with regard to retaining HIV-infected persons in care. Based on success of the pilot programme adult by Médecins Sans Frontières (MSF) and provincial health officials in Mozambique reported in this review ^{xvi, 17}, the Mozambique Ministry of Health is scaling upwards CAGs nationally.

We did not specifically search for adherence equally an outcome in this review. Withal v studies reported increased adherence to ART ^{15, 23, 24, 32} associated with support group participation. In Wouters et al., 89.ix% of support group members reported that back up grouping meetings helped create a forum for sharing noesis 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 level to arrange to a lifestyle that was not consistent with established gender roles ³², while a large mixed methods report with participants from Burkina Faso, Kenya, Malawi and Republic of uganda showed that membership in a back up group was associated with non-disclosure to partners. ¹⁹ These issues will demand to be addressed to maximize the potential of support groups as an intervention.

Limitations

Conclusions of this review should be interpreted with circumspection given the methodological limitations and relatively small-scale number of studies. The majority of the studies were observational, eight employed qualitative methods, three studies enrolled less than 70 participants each ^{17, 29, 32}, one study included only men ³² and three recruited only women. ^{22, 27, 30} Therefore, the findings may non be generalizable to the broader community and to other patient populations. Additionally, PLHIV participating in support groups often received other interventions. The impact of the other interventions or their combination may have influenced the results reported in this review. Bear witness from this review may not be adequate to inform major policy changes regarding the role of support groups.

Research Gaps

Although this review has provided useful information regarding support groups, there are information gaps. Which patients are nigh in need of support group participation? What venues are optimal, and how exercise these depend on the populations participating? Who should lead the support groups? What specific considerations should be given to newly diagnosed patients, men, women, fundamental population groups, and those starting Fine art?

Cost-effectiveness of the intervention is an outstanding outcome. None of the studies included costing information; nor were they designed to test effectiveness for the outcomes under review. The Mozambique CAG pilot was successful in part because over a quarter (28%) of the members shared the toll of send. It is unclear if other types of support groups would be viable and sustainable in their corresponding settings. Programs already underway such as the national rollout of CAGs in Mozambique should be rigorously evaluated. Data from these evaluations could be useful for national governments and donor funding decisions.

Programmatic Considerations for Implementation

It is credible from this review that back up groups have the potential to play an important role in HIV intendance and treatment programs, in terms of having impact on key wellness outcomes and in retaining HIV-infected persons in care. They may likewise provide an alternative intendance model towards attaining universal access to Art in settings where long distances to health facilities, shortage of homo resources and waiting times remain barriers to HIV intendance. Implementation issues and challenges were beyond the scope of this review; however, several merit word: membership and access; resources and sustainability; monitoring and evaluation, and models of implementation.

Regarding membership, not all patients need or desire to participate in support groups, and health care facilities may not be able to suit all patients who might do good from a back up group intervention. Therefore information technology is important to target support group resources to those who might benefit the about. For instance, back up groups targeting key populations could be useful in settings with high levels of stigma and bigotry directed towards PLHIV. In this review, most support groups were formed to support patients on Art. Programs for pre-Fine art patients should exist developed to make up one's mind whether these patients might benefit from support group participation. Implementers should identify motivators for attendance and too, peradventure, criteria to make up one's mind when participation might no longer be necessary. The needs for patients in urban vs. rural HIV intendance programs may differ significantly.

Secondly, resources are needed to offset and maintain support groups-- both human and infrastructural. Support group programs require physical meeting space abroad from crowded wellness facilities; they may require phone credit, transportation support, and refreshments during meetings, among other needs. Grooming in facilitation skills and capacity edifice are peculiarly of import to foster free expression and to encourage full participation. The actual costs associated with running support groups are difficult to estimate in part due to lack of accurate data on the number of PLHIV who currently access services. The comparative evaluation of unlike models would enrich our knowledge of which support grouping models to scale up. Programs should understand how best to make support groups self-sustaining and less dependent on donor funding. Early lessons from Mozambique suggest that the CASG support group model is self-sustaining and could potentially be replicated in other settings.

Thirdly, for donors and ministries of health that fund support groups, monitoring and evaluation metrics are of import to assess the value of support group interventions. Community level HIV indicators, including those that mensurate linkage between facilities and the community and retention in back up group programs will exist important to develop to monitor success and to ensure accountability.

Lastly, support groups are however to exist formalized as standard practice in HIV intendance and handling programs; inadequate data as evident in this literature review are 1 of the challenges. Models for such programming need to be explored. For instance, a model that links community-based support groups to an assigned health facility in a hub-and-spoke way with a formalized system for bidirectional referral would exist useful to explore.

Conclusion

Implementing support groups in PLHIV is likely to accept an bear upon on morbidity and retentiveness in intendance and has the potential to meliorate quality of life and mortality. Boosted research and operational lessons are needed to maximize the benefits of back up groups equally an integral component of HIV care and treatment.

Supplementary Material

published paper

Acknowledgments

"This research has been supported by the President'southward Emergency Program for AIDS Relief (PEPFAR) through the Centers for Affliction Control and Prevention (CDC) and the Us Agency for International Evolution (USAID)."

The authors would like to acknowledge the following individuals who participated in the bear witness review: From the CDC Library, Gail Bang and Emily Weyant who conducted the literature searches and; Ratanang Balisi from USAID (Botswana) and Peter Vranken from CDC (South Africa) who helped screen citations.

Footnotes

Disclaimer: The findings and conclusions in this article are those of the authors and should not be construed to represent the positions of the U.Southward. Department of State's Office of the U.S. Global AIDS Coordinator, the U.Due south. Centers for Disease Command and Prevention or the United states of america Agency for International Development or the U.Due south. Federal Government.

The authors have no conflicts of interest to disclose

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