Factors Associated with HIV Drug Resistance in Dar es Salaam, Tanzania: Analysis of a Complex Adaptive System
Anneleen Kiekens,
Idda H. Mosha,
Lara Zlatić,
George M. Bwire,
Ally Mangara,
Bernadette Dierckx de Casterlé,
Catherine Decouttere,
Nico Vandaele,
Raphael Z. Sangeda,
Omary Swalehe,
Paolo Cottone,
Alessio Surian,
Japhet Killewo,
Anne-Mieke Vandamme
Affiliations
Anneleen Kiekens
Department of Microbiology, Immunology and Transplantation, Rega Institute for Medical Research, Clinical and Epidemiological Virology, Institute for the Future, KU Leuven, 3000 Leuven, Belgium
Idda H. Mosha
Department of Behavioural Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam 65015, Tanzania
Lara Zlatić
Department of Microbiology, Immunology and Transplantation, Rega Institute for Medical Research, Clinical and Epidemiological Virology, Institute for the Future, KU Leuven, 3000 Leuven, Belgium
George M. Bwire
Department of Microbiology, Immunology and Transplantation, Rega Institute for Medical Research, Clinical and Epidemiological Virology, Institute for the Future, KU Leuven, 3000 Leuven, Belgium
Ally Mangara
Dar es Salaam Urban Cohort Study, Dar es Salaam 65013, Tanzania
Bernadette Dierckx de Casterlé
Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, 3000 Leuven, Belgium
Catherine Decouttere
Faculty of Economics and Business, Access to Medicine Research Center, KU Leuven, 3000 Leuven, Belgium
Nico Vandaele
Faculty of Economics and Business, Access to Medicine Research Center, KU Leuven, 3000 Leuven, Belgium
Raphael Z. Sangeda
Department of Pharmaceutical Microbiology, Muhimbili University of Health and Allied Sciences, Dar es Salaam 65013, Tanzania
Omary Swalehe
Department of Business Studies, School of Business, Mzumbe University, Dar es Salaam 20266, Tanzania
Paolo Cottone
FISPPA Department, Università degli Studi di Padova, 35139 Padova, Italy
Alessio Surian
FISPPA Department, Università degli Studi di Padova, 35139 Padova, Italy
Japhet Killewo
Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, Dar es Salaam 65001, Tanzania
Anne-Mieke Vandamme
Department of Microbiology, Immunology and Transplantation, Rega Institute for Medical Research, Clinical and Epidemiological Virology, Institute for the Future, KU Leuven, 3000 Leuven, Belgium
HIV drug resistance (HIVDR) is a complex problem with multiple interconnected and context dependent causes. Although the factors influencing HIVDR are known and well-studied, HIVDR remains a threat to the effectiveness of antiretroviral therapy. To understand the complexity of HIVDR, a comprehensive, systems approach is needed. Therefore, a local systems map was developed integrating all reported factors influencing HIVDR in the Dar es Salaam Urban Cohort Study area in Tanzania. The map was designed based on semi-structured interviews and workshops with people living with HIV and local actors who encounter people living with HIV during their daily activities. We visualized the feedback loops driving HIVDR, compared the local map with a systems map for Sub-Saharan Africa, previously constructed from interviews with international HIVDR experts, and suggest potential interventions to prevent HIVDR. We found several interconnected balancing and reinforcing feedback loops related to poverty, stigmatization, status disclosure, self-esteem, knowledge about HIVDR and healthcare system workload, among others, and identified three potential leverage points. Insights from this local systems map were complementary to the insights from the Sub-Saharan systems map showing that both viewpoints are needed to fully understand the system. This study provides a strong baseline for quantitative modelling, and for the identification of context-dependent, complexity-informed leverage points.
