GPS-measured distance to clinic, but not self-reported transportation factors, are associated with missed HIV clinic visits in rural Uganda

aMassachusetts General Hospital Center for Global Health bChester M. Pierce MD Division of Global Psychiatry, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA cMbarara University of Science and Technology dUniversitiy of California, San Francisco eMassahusetts General Hospital Center for Global Health, Ragon Institute of Massachusetts General Hospital MIT and Harvard, and Harvard Medical School.
AIDS (London, England) (Impact Factor: 6.56). 02/2013; 27(9). DOI: 10.1097/QAD.0b013e32835fd873
Source: PubMed

ABSTRACT OBJECTIVE:: Studies of the association between transportation barriers and HIV-related health outcomes have shown both positive and negative effects, possibly because a reliable, validated measure of transportation barriers has not been identified. DESIGN:: Prospective cohort study of HIV-infected patients in rural Uganda. METHODS:: Participants were enrolled from the HIV clinic at the regional referral hospital in Mbarara, Uganda as part of the Uganda AIDS Rural Treatment Outcomes (UARTO) Study. We collected the following measures of transportation barriers to HIV clinic: a) global positioning systems (GPS)-tracked distance measured by driving participants to their homes along their typical route, b) straight-line GPS distance from clinic to home, calculated with the Great Circle Formula, c) self-reported travel time, and d) self-reported travel cost. We assessed inter-measure agreement using linear regression, correlation coefficients and kappa statistics (by measure quartile) and validated measures by fitting linear regression models to estimate associations with days late for clinic visits. RESULTS:: 188 participants were tracked with GPS. 76% were female, with a median age of 40 years and median CD4 count of 193 cells/mm. We found a high correlation between GPS-based distance measures (β = 0.74, p < 0.001, R = 0.92, κ = 0.73), but little correlation between GPS-based and self-reported measures (all R≤0.4). GPS-based measures were associated with days late to clinic (p < 0.001); but neither self-reported measure was associated (p > 0.85). CONCLUSIONS:: GPS-measured distance to clinic is associated with HIV clinic absenteeism and should be prioritized over self-reported measures to optimally risk-stratify patients accessing care in rural, resource limited settings.

  • [Show abstract] [Hide abstract]
    ABSTRACT: We sought to examine which socioeconomic indicators are risk factors for virologic failure among HIV-1 infected patients receiving antiretroviral therapy (ART) in KwaZulu-Natal, South Africa. A case-control study of virologic failure was conducted among patients recruited from the outpatient clinic at McCord Hospital in Durban, South Africa between October 1, 2010 and June 30, 2012. Cases were those failing first-line ART, defined as viral load >1,000 copies/mL. Univariate logistic regression was performed on sociodemographic data for the outcome of virologic failure. Variables found significant (p < 0.05) were used in multivariate models and all models were stratified by gender. Of 158 cases and 300 controls, 35 % were male and median age was 40 years. Gender stratification of models revealed automobile ownership was a risk factor among males, while variables of financial insecurity (unemployment, non-spouse family paying for care, staying with family) were risk factors for women. In this cohort, financial insecurity among women and automobile ownership among men were risk factors for virologic failure. Risk factor differences between genders demonstrate limitations of generalized risk factor analysis.
    AIDS and Behavior 07/2014; 18(11). DOI:10.1007/s10461-014-0849-1 · 3.49 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Abstract Migration and geographic mobility increase risk for HIV infection and may influence engagement in HIV care and adherence to antiretroviral therapy. Our goal is to use the migration-linked communities of Santo Domingo, Dominican Republic, and New York City, New York, to determine the impact of geographic mobility on HIV care engagement and adherence to treatment. In-depth interviews were conducted with HIV+Dominicans receiving antiretroviral therapy, reporting travel or migration in the past 6 months and key informants (n=45). Mobility maps, visual representations of individual migration histories, including lifetime residence(s) and all trips over the past 2 years, were generated for all HIV+ Dominicans. Data from interviews and field observation were iteratively reviewed for themes. Mobility mapping revealed five distinct mobility patterns: travel for care, work-related travel, transnational travel (nuclear family at both sites), frequent long-stay travel, and vacation. Mobility patterns, including distance, duration, and complexity, varied by motivation for travel. There were two dominant barriers to care. First, a fear of HIV-related stigma at the destination led to delays seeking care and poor adherence. Second, longer trips led to treatment interruptions due to limited medication supply (30-day maximum dictated by programs or insurers). There was a notable discordance between what patients and providers perceived as mobility-induced barriers to care and the most common barriers found in the analysis. Interventions to improve HIV care for mobile populations should consider motivation for travel and address structural barriers to engagement in care and adherence.
    AIDS PATIENT CARE and STDs 05/2014; DOI:10.1089/apc.2014.0028 · 3.58 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: A case-control study was conducted to describe the frequency with which structural- and individual-level barriers to adherence are experienced by people receiving antiretroviral (ARV) treatment and to determine predictors of non-adherence. Three hundred adherent and 300 non-adherent patients from 6 clinics in Cape Town completed the LifeWindows Information-Motivation-Behavioral Skills ART Adherence Questionnaire, the Substance Abuse and Mental Illness Symptoms Screener and the Structural Barriers to Clinic Attendance (SBCA) and Medication-taking (SBMT) scales. Overall, information-related barriers were reported most frequently followed by motivation and behaviour skill defects. Structural barriers were reported least frequently. Logistic regression analyses revealed that gender, behaviour skill deficit scores, SBCA scores and SBMT scores predicted non-adherence. Despite the experience of structural barriers being reported least frequently, structural barriers to medication-taking had the greatest impact on adherence (OR: 2.32, 95% CI: 1.73 to 3.12), followed by structural barriers to clinic attendance (OR: 2.06, 95% CI: 1.58 to 2.69) and behaviour skill deficits (OR: 1.34, 95% CI: 1.05 to 1.71). Our data indicate the need for policy directed at the creation of a health-enabling environment that would enhance the likelihood of adherence among antiretroviral therapy users. Specifically, patient empowerment strategies aimed at increasing treatment literacy and management skills should be strengthened. Attempts to reduce structural barriers to antiretroviral treatment adherence should be expanded to include increased access to mental health care services and nutrition support.
    AIDS Care 01/2015; 27(3):1-8. DOI:10.1080/09540121.2014.994471 · 1.60 Impact Factor


Available from
Aug 24, 2014
Available from

Alexander J Lankowski