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Tegbe M, Moon K, Nawaz S. Re-envisioning contributory health schemes to achieve equity in the design of financial protection mechanisms in low- and middle-income countries. HEALTH AFFAIRS SCHOLAR 2024; 2:qxae044. [PMID: 38756182 PMCID: PMC11057020 DOI: 10.1093/haschl/qxae044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 04/04/2024] [Accepted: 04/15/2024] [Indexed: 05/18/2024]
Abstract
Universal health coverage has emerged as a global health priority, requiring that financing strategies that ensure low-income and medically and financially at-risk individuals can access health services without the threat of financial catastrophe. Contributory financing schemes and social health insurance (SHI) schemes, in particular, predominate in low- and middle-income countries (LMICs), despite evidence that suggests the most vulnerable remain excluded from such schemes. In this commentary, we discuss the need to re-envision schemes to prioritize equity, offering 3 concrete recommendations: adopt participatory designs for the co-design of schemes with beneficiaries, establish linkages between contributory financial protection schemes with economic empowerment initiatives, and prioritize the needs and preferences of beneficiaries over political expediency. Co-design alone does not necessarily translate into more equitable schemes, underscoring the need for greater monitoring and evaluation of these schemes that consider differential impacts across contexts and subgroups. In doing so, SHI schemes can be both attractive and accessible to populations that have long been excluded from financial protections in LMICs, acting as 1 channel in a broader financing strategy to achieve universal health coverage.
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Affiliation(s)
- Muyiwa Tegbe
- Primary Health Care Program, PATH, Seattle, WA 98121, United States
| | - Kyle Moon
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, United States
| | - Saira Nawaz
- Primary Health Care Program, PATH, Seattle, WA 98121, United States
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2
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Olakunde BO, Itanyi IU, Olawepo JO, Liu L, Bembir C, Idemili-Aronu N, Lasebikan NN, Onyeka TC, Dim CC, Chigbu CO, Ezeanolue EE, Aarons GA. Comparative effectiveness of implementation strategies for Accelerating Cervical Cancer Elimination through the integration of Screen-and-treat Services (ACCESS study): protocol for a cluster randomized hybrid type III trial in Nigeria. Implement Sci 2024; 19:25. [PMID: 38468266 PMCID: PMC10926605 DOI: 10.1186/s13012-024-01349-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 02/03/2024] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND Despite the increased risk of cervical cancer (CC) among women living with HIV (WLHIV), CC screening and treatment (CCST) rates remain low in Africa. The integration of CCST services into established HIV programs in Africa can improve CC prevention and control. However, the paucity of evidence on effective implementation strategies (IS) has limited the success of integration in many countries. In this study, we seek to identify effective IS to enhance the integration of CCST services into existing HIV programs in Nigeria. METHODS Our proposed study has formative and experimental activities across the four phases of the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework. Through an implementation mapping conducted with stakeholders in the exploration phase, we identified a core package of IS (Core) and an enhanced package of IS (Core+) mostly selected from the Expert Recommendations for Implementing Change. In the preparation phase, we refined and tailored the Core and Core+ IS with the implementation resource teams for local appropriateness. In the implementation phase, we will conduct a cluster-randomized hybrid type III trial to assess the comparative effectiveness of Core versus Core+. HIV comprehensive treatment sites (k = 12) will be matched by region and randomized to Core or Core+ in the ratio of 1:1 stratified by region. In the sustainment phase, we will assess the sustainment of CCST at each site. The study outcomes will be assessed using RE-AIM: reach (screening rate), adoption (uptake of IS by study sites), IS fidelity (degree to which the IS occurred according to protocol), clinical intervention fidelity (delivery of CC screening, onsite treatment, and referral according to protocol), clinical effectiveness (posttreatment screen negative), and sustainment (continued integrated CCST service delivery). Additionally, we will descriptively explore potential mechanisms, including organizational readiness, implementation climate, CCST self-efficacy, and implementation intentions. DISCUSSION The assessment of IS to increase CCST rates is consistent with the global plan of eliminating CC as a public health threat by 2030. Our study will identify a set of evidence-based IS for low-income settings to integrate evidence-based CCST interventions into routine HIV care in order to improve the health and life expectancy of WLHIV. TRIAL REGISTRATION Prospectively registered on November 7, 2023, at ClinicalTrials.gov no. NCT06128304. https://classic. CLINICALTRIALS gov/ct2/show/study/NCT06128304.
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Affiliation(s)
- Babayemi O Olakunde
- Department of Community Prevention and Care Services, National Agency for the Control of AIDS, Abuja, Nigeria
- Center for Translation and Implementation Research, University of Nigeria Nsukka, Enugu, Nigeria
| | - Ijeoma U Itanyi
- Center for Translation and Implementation Research, University of Nigeria Nsukka, Enugu, Nigeria
- Department of Community Medicine, College of Medicine, University of Nigeria Nsukka, Enugu, Nigeria
| | - John O Olawepo
- Center for Translation and Implementation Research, University of Nigeria Nsukka, Enugu, Nigeria
- Department of Health Sciences, Northeastern University, Boston, MA, USA
| | - Lin Liu
- Herbert Wertheim School of Public Health & Human Longevity Science, University of California San Diego, La Jolla, CA, USA
| | - Chinenye Bembir
- Center for Translation and Implementation Research, University of Nigeria Nsukka, Enugu, Nigeria
| | - Ngozi Idemili-Aronu
- Center for Translation and Implementation Research, University of Nigeria Nsukka, Enugu, Nigeria
- Department of Sociology and Anthropology, University of Nigeria Nsukka, Enugu, Nigeria
| | - Nwamaka N Lasebikan
- Center for Translation and Implementation Research, University of Nigeria Nsukka, Enugu, Nigeria
- Oncology Center, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Tonia C Onyeka
- Center for Translation and Implementation Research, University of Nigeria Nsukka, Enugu, Nigeria
- Department of Anaesthesia/Pain & Palliative Care Unit, College of Medicine, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria
| | - Cyril C Dim
- Center for Translation and Implementation Research, University of Nigeria Nsukka, Enugu, Nigeria
- Department of Obstetrics and Gynecology, College of Medicine, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria
| | - Chibuike O Chigbu
- Center for Translation and Implementation Research, University of Nigeria Nsukka, Enugu, Nigeria
- Department of Obstetrics and Gynecology, College of Medicine, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria
| | - Echezona E Ezeanolue
- Center for Translation and Implementation Research, University of Nigeria Nsukka, Enugu, Nigeria
- HealthySunrise Foundation, Las Vegas, NV, USA
| | - Gregory A Aarons
- Department of Psychiatry, University of California San Diego, La Jolla, CA, 92093-0812, USA.
- UC San Diego ACTRI Dissemination and Implementation Science Center, La Jolla, CA, USA.
- Moores Cancer Center, University of California San Diego, La Jolla, CA, 92093, USA.
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Zakumumpa H, Paina L, Ssegujja E, Shroff ZC, Namakula J, Ssengooba F. The impact of shifts in PEPFAR funding policy on HIV services in Eastern Uganda (2015-21). Health Policy Plan 2024; 39:i21-i32. [PMID: 38253438 PMCID: PMC10803197 DOI: 10.1093/heapol/czad096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 09/19/2023] [Accepted: 10/20/2023] [Indexed: 01/24/2024] Open
Abstract
Although donor transitions from HIV programmes are increasingly common in low-and middle-income countries, there are limited analyses of long-term impacts on HIV services. We examined the impact of changes in President's Emergency Plan for AIDS Relief (PEPFAR) funding policy on HIV services in Eastern Uganda between 2015 and 2021.We conducted a qualitative case study of two districts in Eastern Uganda (Luuka and Bulambuli), which were affected by shifts in PEPFAR funding policy. In-depth interviews were conducted with PEPFAR officials at national and sub-national levels (n = 46) as well as with district health officers (n = 8). Data were collected between May and November 2017 (Round 1) and February and June 2022 (Round 2). We identified four significant donor policy transition milestones: (1) between 2015 and 2017, site-level support was withdrawn from 241 facilities following the categorization of case study districts as having a 'low HIV burden'. Following the implementation of this policy, participants perceived a decline in the quality of HIV services and more frequent commodity stock-outs. (2) From 2018 to 2020, HIV clinic managers in transitioned districts reported drastic drops in investments in HIV programming, resulting in increased patient attrition, declining viral load suppression rates and increased reports of patient deaths. (3) District officials reported a resumption of site-level PEPFAR support in October 2020 with stringent targets to reverse declines in HIV indicators. However, PEPFAR declared less HIV-specific funding. (4) In December 2021, district health officers reported shifts by PEPFAR of routing aid away from international to local implementing partner organizations. We found that, unlike districts that retained PEPFAR support, the transitioned districts (Luuka and Bulambuli) fell behind the rest of the country in implementing changes to the national HIV treatment guidelines adopted between 2017 and 2020. Our study highlights the heavy dependence on PEPFAR and the need for increasing domestic financial responsibility for the national HIV response.
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Affiliation(s)
- Henry Zakumumpa
- Department of Health Policy, Planning and Management, School of Public Health, Makerere University, P O Box 7061, Kampala, Uganda
| | - Ligia Paina
- Bloomberg School of Public Health, Johns Hopkins University, P O Box 7062, Kampala, Uganda
| | - Eric Ssegujja
- Department of Health Policy, Planning and Management, School of Public Health, Makerere University, P O Box 7061, Kampala, Uganda
| | - Zubin Cyrus Shroff
- Alliance for Health Policy and Systems, World Health Organization, 20 Avenue Appia, Geneva 1211, Switzerland
| | - Justin Namakula
- Department of Health Policy, Planning and Management, School of Public Health, Makerere University, P O Box 7061, Kampala, Uganda
| | - Freddie Ssengooba
- Department of Health Policy, Planning and Management, School of Public Health, Makerere University, P O Box 7061, Kampala, Uganda
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Parker W. Beyond the discourses of policy and power: HIV, AIDS, and community perspectives on the lived pandemic. AFRICAN JOURNAL OF AIDS RESEARCH : AJAR 2023; 22:261-268. [PMID: 38117745 DOI: 10.2989/16085906.2023.2289392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 11/01/2023] [Indexed: 12/22/2023]
Abstract
As HIV unfolded in the 1980s, HIV and AIDS were heard and seen through the lives of those whom it touched directly. Personal histories were foregrounded, centred by the inevitable mortality attached to HIV infection, the courage of circumstance in the face of illness, and the activism necessary to make a difference. In the later part of the decade, the impacts of HIV were most apparent in East Africa, where community responses and political leadership coalesced to reduce new HIV infections. The 1990s marked a turn towards centralised policy, funding, and the reification of biomedically oriented approaches and systems that are intrinsically top-down. This biomedical turn centred on foregrounding the widespread availability of low-cost antiretroviral therapy and was articulated in the 90-90-90 and subsequent targets. Biomedicalisation reinforces individualised approaches to health primarily focused on biomedical technologies and health service provision that do not rely on community or social organisation formats. Emphasis on HIV treatment, along with the promise of reduced HIV transmission through viral load suppression, contributed to limiting socio-behavioural approaches to HIV prevention. While the importance of community-led response was highlighted in the 2016 United Nations Political Declaration on Ending AIDS, community-led response has devolved towards concepts such as community-led monitoring and community-led response that frame responses in direct relation to the dominant biomedical paradigm. There are lessons in the history of the AIDS response that demonstrate that communities formulate responses to AIDS differently when there have been opportunities for community members to determine the pathways for action to address HIV independently. Older research studies offer retrospective insights into moments in the history of HIV when communities were foregrounded and highlighted the need to reconsider the current trajectory of the HIV response. Not only for history's sake but to acknowledge that community leadership remains overwhelmed by elites. While lofty targets and goals drive the contemporary HIV response, the way forward is mired by uncertainty. HIV prevention efforts remain uneven, and millions of people living with HIV depend on access to treatment for decades to come in the context of budgetary uncertainties. Changing the course of AIDS will not be achieved if we fail to ensure that communities occupy a genuine and unambiguous place in shaping HIV response.
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Affiliation(s)
- Warren Parker
- Centre for Communication Media and Society, University of KwaZulu-Natal, South Africa, Durban
- Public Health & Communication Specialist, United States, California, San Diego, USA
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Ahmed CV, Doyle R, Gallagher D, Imoohi O, Ofoegbu U, Wright R, Yore MA, Brooks MJ, Flores DD, Lowenthal ED, Rice BM, Buttenheim AM. A Systematic Review of Peer Support Interventions for Adolescents Living with HIV in Sub-Saharan Africa. AIDS Patient Care STDS 2023; 37:535-559. [PMID: 37956242 DOI: 10.1089/apc.2023.0094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023] Open
Abstract
Despite widespread availability of life-saving antiretroviral therapy (ART) in sub-Saharan Africa, AIDS remains one of the leading causes of death among adolescents living with HIV (ALHIV) in sub-Saharan Africa. The purpose of this article was to review the state of the science regarding interventions to improve ART adherence and/or HIV care retention among ALHIV throughout sub-Saharan Africa. The primary aim of this review was to describe the impact of peer support interventions in improving treatment outcomes (i.e., ART adherence and retention in HIV care) among ALHIV in sub-Saharan Africa. The secondary aim of this review was to determine whether these interventions may be efficacious at improving mental health outcomes. We identified 27 articles that met the eligibility criteria for our review, and categorized each article based on the type of peer support provided to ALHIV-individualized peer support, group-based support, and individualized plus group-based support. Results regarding the efficacy of these interventions are mixed and most of the studies included were deemed moderate in methodological quality. Although studies evaluating group-based peer support interventions were the most common, most of these studies were not associated with retention, adherence, or mental health outcomes. More robust, fully powered studies are needed to strengthen our knowledge base regarding peer support for ALHIV.
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Affiliation(s)
- Charisse V Ahmed
- National Clinician Scholars Program, Division of General Internal Medicine & Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- Charles R. Drew University of Medicine and Science, Los Angeles, California, USA
| | - Rebecca Doyle
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Darby Gallagher
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Olore Imoohi
- Charles R. Drew University of Medicine and Science, Los Angeles, California, USA
| | - Ugochi Ofoegbu
- Charles R. Drew University of Medicine and Science, Los Angeles, California, USA
| | - Robyn Wright
- Charles R. Drew University of Medicine and Science, Los Angeles, California, USA
| | - Mackensie A Yore
- VA Los Angeles and UCLA National Clinician Scholars Program, VA Greater Los Angeles Healthcare System HSR&D Center of Innovation, Los Angeles, California, USA
| | - Merrian J Brooks
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Botswana UPENN Partnership, Gaborone, Botswana
| | | | - Elizabeth D Lowenthal
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Bridgette M Rice
- M. Louise Fitzpatrick College of Nursing, Villanova University, Villanova, Pennsylvania, USA
| | - Alison M Buttenheim
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Toska E, Zhou S, Chen-Charles J, Gittings L, Operario D, Cluver L. Factors Associated with Preferences for Long-Acting Injectable Antiretroviral Therapy Among Adolescents and Young People Living with HIV in South Africa. AIDS Behav 2023; 27:2163-2175. [PMID: 36622486 PMCID: PMC9827015 DOI: 10.1007/s10461-022-03949-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2022] [Indexed: 01/10/2023]
Abstract
Long-acting injectable anti-retroviral therapy (LAART) may overcome barriers to long-term adherence and improve the survival of adolescents and young people living with HIV (AYLHIV). Research on the acceptability of LAART for this age-group is limited. We asked 953 AYLHIV about their preferred (theoretical) ART mode of delivery (pill, injectable, or other) in 2017-2018, before LAART was available or known to AYLHIV in South Africa. One in eight (12%) AYLHIV preferred LAART over single or multiple pill regimens. In multivariate analyses, six factors were associated with LAART preference: medication stock-outs (aOR = 2.56, 95% CI 1.40-4.68, p = 0.002), experiencing side-effects (aOR = 1.84, 95% CI 1.15-2.97, p = 0.012), pill-burden (aOR = 1.88, 95% CI 1.20-2.94, p = 0.006), past-year treatment changes (aOR = 1.63, 95% CI 1.06-2.51, p = 0.025), any HIV stigma (aOR = 2.22, 95% CI 1.39-3.53, p ≤ 0.001) and recent ART initiation (aOR = 2.02, 95% CI 1.09-3.74, p = 0.025). In marginal effects modelling, 66% of adolescents who experienced all factors were likely to prefer LAART, highlighting the potential high acceptability of LAART among adolescents and young people living with HIV struggling to adhere and have good HIV treatment outcomes. Adolescent boys who reported high ART pill burden were more likely to prefer LAART than their female peers in moderation analyses, suggesting that LAART may be particularly important to improve treatment outcomes among male AYLHIV as they become older. Adding LAART to existing treatment options for AYLHIV, particularly higher risk groups, would support AYLHIV to attain and sustain viral suppression-the third 95, and reduce their risk of AIDS-related mortality.
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Affiliation(s)
- Elona Toska
- Centre for Social Science Research, University of Cape Town, Cape Town, South Africa.
- Department of Sociology, University of Cape Town, Cape Town, South Africa.
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK.
- Centre for Social Science Research, Leslie Social Sciences Building, University of Cape Town, 4.89, Rondebosch, Cape Town, 7700, South Africa.
| | - Siyanai Zhou
- Centre for Social Science Research, University of Cape Town, Cape Town, South Africa
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Jenny Chen-Charles
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK
| | - Lesley Gittings
- Centre for Social Science Research, University of Cape Town, Cape Town, South Africa
- School of Health Studies, Faculty of Health Sciences, Western University, London, Canada
| | - Don Operario
- Rollins School of Public Health, Emory University, Atlanta, USA
| | - Lucie Cluver
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK
- Department of Child and Adolescent Psychiatry, University of Cape Town, Cape Town, UK
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Zakumumpa H, Rujumba J, Kyomuhendo M, Stempler L, Amde W. Drivers of retention of the HIV workforce transitioned from PEPFAR support to the Uganda government payroll. HUMAN RESOURCES FOR HEALTH 2023; 21:38. [PMID: 37161486 PMCID: PMC10170838 DOI: 10.1186/s12960-023-00824-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 05/02/2023] [Indexed: 05/11/2023]
Abstract
BACKGROUND Health worker (HW) retention in the public health sector in Uganda is an enduring health system constraint. Although previous studies have examined the retention of in-service HWs, there is little research focusing on donor-recruited HWs. The objective of this study was to explore drivers of retention of the HIV workforce transitioned from PEPFAR support to the Uganda government payroll between 2015 and 2017. METHODS We conducted ten focus group discussions with HWs (n = 87) transitioned from PEPFAR support to the public sector payroll in 10 purposively selected districts across Uganda. In-depth interviews were conducted with national-level stakeholders (n = 17), district health and personnel officers (n = 15) and facility in-charges (n = 22). Data were analyzed by a hybrid approach of inductive and deductive thematic development based on the analytical framework by Schaefer and Moos regarding individual-level and organizational-context drivers. RESULTS At the individual level, job security in the public sector was the most compelling driver of health worker retention. Community embeddedness of HWs in the study districts, opportunities for professional development and career growth and the ability to secure salary loans due to 'permanent and pensionable' terms of employment and the opportunity to work in 'home districts', where they could serve their 'kinsmen' were identified as enablers. HWs with prior private sector backgrounds perceived public facilities as offering more desirable challenging professional work. Organizational context enablers identified include perceptions that public facilities had relaxed supervision regimes and more flexible work environments. Work environment barriers to long-term retention include frequent stock-out of essential commodities, heavy workloads, low pay and scarcity of rental accommodation, particularly in rural Northern Uganda. Compared to mid-cadres (such as nurses and midwives), higher calibre cadres, such as physicians, pharmacists and laboratory technologists, expressed a higher affinity for seeking alternative employment in the private sector in the immediate future. CONCLUSIONS Overall, job security was the most compelling driver of retention in public service for the health workforce transitioned from PEPFAR support to the Uganda government payroll. Monetary and non-monetary policy strategies are needed to enhance the retention of upper cadre HWs, particularly physicians, pharmacists and laboratory technologists in rural districts of Uganda.
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Affiliation(s)
- Henry Zakumumpa
- School of Public Health, Makerere University, Kampala, Uganda.
| | - Joseph Rujumba
- College of Health Sciences, Makerere University, Kampala, Uganda
| | - Marjorie Kyomuhendo
- College of Humanities and Social Sciences, Makerere University, Kampala, Uganda
| | - Llyse Stempler
- Open Development LLC, Washington, DC, United States of America
| | - Woldekidan Amde
- School of Public Health, University of the Western Cape, Cape Town, South Africa
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Self-Management Frameworks for Youth Living with Human Immunodeficiency Virus. Pediatr Clin North Am 2022; 69:759-777. [PMID: 35934498 DOI: 10.1016/j.pcl.2022.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
HIV is now a chronic condition that can be managed. Adolescents and emerging adults represent a large proportion of new diagnoses, but struggle with many aspects of HIV-related self-management. Self-management of HIV is critical to maintaining health and involves retention in HIV care, medication adherence to achieve viral suppression, managing substance use, and sexual and general health-related behaviors. This article describes theoretic frameworks for HIV self-management as adapted for youth and reviews self-management interventions developed to improve health outcomes in youth living with HIV identified from a recent systematic review.
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Akanbi MO, Bilaver LA, Achenbach C, Hirschhorn LR, Rivera AS, Silas OA, Agaba PA, Agbaji O, Shehu NY, Sagay SA, Hou L, Murphy RL. Analyses of Kaposi Sarcoma trends among adults establishing initial outpatient HIV care in Nigeria: 2006-2017. Infect Agent Cancer 2022; 17:10. [PMID: 35313941 PMCID: PMC8935748 DOI: 10.1186/s13027-022-00424-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 03/11/2022] [Indexed: 12/24/2022] Open
Abstract
Background The incidence of Human Immunodeficiency Virus (HIV)-associated Kaposi Sarcoma (KS) in the pre-antiretroviral therapy (ART) population remains high in several countries in sub-Saharan Africa. We examined trends of KS prevalence in adults, establishing initial outpatient HIV care from 2006 to 2017 in Nigeria. Methods We analyzed data of 16,431 adults (age ≥ 18 years) enrolled for HIV care from January 1, 2006, to December 31, 2017, in a large clinic in Jos, Nigeria. KS at enrollment was defined as KS recorded in the electronic health record within 30 days of clinic enrollment. Time trends were compared among four periods: 2006–2008, 2009–2011, 2012–2014, and 2015–2017 using logistic regression models. Annual trends were analyzed using join point regression and restricted splines. Results The study population had a mean age 35.1 (standard deviation, SD 9.5) years, and were 65.7% female (n = 10,788). The mean CD4 cell count was 220 (95% CI 117–223). The overall KS prevalence at entry was 0.59% (95% CI 0.48–0.72). Compared to 2006–2008, KS prevalence was significantly higher in 2009–2011 (adjusted odds ratio 5.07 (95% CI 3.12–8.24), p < 0.001), but remained unchanged in subsequent periods. Male sex and low CD4 T-cell count independently increased odds for KS. Conclusions Despite ART expansion, KS at enrollment showed no significant decline. The low CD4 cell count, across all periods, indicates delay in enrollment for HIV care, which increases KS risk. Interventions aimed at early HIV diagnosis and linkage to ART is critical to KS risk reduction in this population. Supplementary Information The online version contains supplementary material available at 10.1186/s13027-022-00424-4.
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Affiliation(s)
- Maxwell O Akanbi
- Department of Internal Medicine, McLaren Hospital, 401 S Ballenger Hwy, Flint, MI, 48532, USA. .,Health Sciences Integrated Ph.D. Program, Center for Education in Health Sciences, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, USA. .,Robert J Havey Institute for Global Health, Center for Global Communicable Diseases, Feinberg School of Medicine, Northwestern University, Chicago, USA. .,Department of Medicine, College of Health Sciences, University of Jos, Jos, Nigeria.
| | - Lucy A Bilaver
- Health Sciences Integrated Ph.D. Program, Center for Education in Health Sciences, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, USA
| | - Chad Achenbach
- Robert J Havey Institute for Global Health, Center for Global Communicable Diseases, Feinberg School of Medicine, Northwestern University, Chicago, USA.,Department of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Lisa R Hirschhorn
- Robert J Havey Institute for Global Health, Center for Global Communicable Diseases, Feinberg School of Medicine, Northwestern University, Chicago, USA.,Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Adovich S Rivera
- Health Sciences Integrated Ph.D. Program, Center for Education in Health Sciences, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, USA
| | - Olugbenga A Silas
- Department of Pathology, College of Human Sciences, University of Jos, Jos, Nigeria
| | - Patricia A Agaba
- Department of Family Medicine, College of Human Sciences, University of Jos, Jos, Nigeria
| | - Oche Agbaji
- Department of Medicine, College of Health Sciences, University of Jos, Jos, Nigeria
| | - Nathan Y Shehu
- Department of Medicine, College of Health Sciences, University of Jos, Jos, Nigeria
| | - Solomon A Sagay
- Department of Obstetrics and Gynecology, College of Human Sciences, University of Jos, Jos, Nigeria
| | - Lifang Hou
- Health Sciences Integrated Ph.D. Program, Center for Education in Health Sciences, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, USA.,Department of Prevention Diseases (Cancer Epidemiology and Prevention), Northwestern University Feinberg School of Medicine, Chicago, USA.,Institute for Global Health, Center for Global Oncology, Feinberg School of Medicine, Northwestern University, Chicago, USA
| | - Robert L Murphy
- Robert J Havey Institute for Global Health, Center for Global Communicable Diseases, Feinberg School of Medicine, Northwestern University, Chicago, USA.,Department of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, USA
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Woldu M, Minzi O, Shibeshi W, Shewaamare A, Engidawork E. Biomarkers and Prevalence of Cardiometabolic Syndrome Among People Living With HIV/AIDS, Addis Ababa, Ethiopia: A Hospital-Based Study. Clin Med Insights Endocrinol Diabetes 2022; 15:11795514221078029. [PMID: 35237088 PMCID: PMC8883384 DOI: 10.1177/11795514221078029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 01/14/2022] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND While the fast extension of combination antiretroviral therapy (cART) has resulted in significant increases in life expectancy, disorders such as cardiometabolic syndrome (CMetS), which have received less attention, are becoming a major concern in HIV/AIDS patients (PLWHA). OBJECTIVES The purpose of this research was to identify biomarkers and determine the prevalence of CMetS in PLWHA using the National Cholesterol Education Program (NCEP) and the International Diabetes Federation (IDF) tools. METHODS Between January 2019 and February 2021, a hospital-based study of HIV-infected patients (n = 288) was conducted. The data were analyzed using binary logistic regression. To control the effect of confounders, independent variables with a P-value of <.20 in the bivariate logistic regression were incorporated into multivariate logistic regression. Statistical significance was defined as a 95% confidence interval and a P-value of less than .05. RESULTS The risk of CMetS increased twofold as age increased each year (P = .009), 1.2 times as the age at which cART began increased (P = .015), and 6 times with 1 or more co-morbidities (P = .028), according to the NCEP tool. Furthermore, significant NCEP-CMetS correlations were produced by a rise in diastolic blood pressure (P < .001) and cART duration (P = .006). Male gender was 99.9% less likely to be related to CMetS using the IDF tool, and the risk of CMetS increased fourfold with each unit increase in waist circumference (P < .001). Triglycerides and blood type "A" have been found to have substantial relationships with CMetS using both techniques. CONCLUSION According to the study, CMetS was found to be common in PLWHA. Age, time on cART, age when cART started, gender, co-morbidities, waist circumference, and diastolic blood pressure were all revealed to be significant predictors of CMetS. Triglycerides and blood type "A" were the only biomarkers found to be significant with CMetS using both the NCEP and IDF tools.
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Affiliation(s)
- Minyahil Woldu
- Department of Clinical Pharmacy and Pharmacology, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania.,Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Omary Minzi
- Department of Clinical Pharmacy and Pharmacology, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Workineh Shibeshi
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | | | - Ephrem Engidawork
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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11
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Bershteyn A, Kim HY, Scott Braithwaite R. Real-Time Infectious Disease Modeling to Inform Emergency Public Health Decision Making. Annu Rev Public Health 2022; 43:397-418. [DOI: 10.1146/annurev-publhealth-052220-093319] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Infectious disease transmission is a nonlinear process with complex, sometimes unintuitive dynamics. Modeling can transform information about a disease process and its parameters into quantitative projections that help decision makers compare public health response options. However, modelers face methodologic challenges, data challenges, and communication challenges, which are exacerbated under the time constraints of a public health emergency. We review methods, applications, challenges and opportunities for real-time infectious disease modeling during public health emergencies, with examples drawn from the two deadliest pandemics in recent history: HIV/AIDS and coronavirus disease 2019 (COVID-19). Expected final online publication date for the Annual Review of Public Health, Volume 43 is April 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
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Affiliation(s)
- Anna Bershteyn
- New York University Grossman School of Medicine, New York, NY, USA
| | - Hae-Young Kim
- New York University Grossman School of Medicine, New York, NY, USA
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12
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Gilbert RF, Cichowitz C, Bibangambah P, Kim JH, Hemphill LC, Yang IT, Sentongo RN, Kakuhikire B, Christiani DC, Tsai AC, Okello S, Siedner MJ, North CM. Lung function and atherosclerosis: a cross-sectional study of multimorbidity in rural Uganda. BMC Pulm Med 2022; 22:12. [PMID: 34983492 PMCID: PMC8728924 DOI: 10.1186/s12890-021-01792-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 12/09/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is a leading cause of global mortality. In high-income settings, the presence of cardiovascular disease among people with COPD increases mortality and complicates longitudinal disease management. An estimated 26 million people are living with COPD in sub-Saharan Africa, where risk factors for co-occurring pulmonary and cardiovascular disease may differ from high-income settings but remain uncharacterized. As non-communicable diseases have become the leading cause of death in sub-Saharan Africa, defining multimorbidity in this setting is critical to inform the required scale-up of existing healthcare infrastructure. METHODS We measured lung function and carotid intima media thickness (cIMT) among participants in the UGANDAC Study. Study participants were over 40 years old and equally divided into people living with HIV (PLWH) and an age- and sex-similar, HIV-uninfected control population. We fit multivariable linear regression models to characterize the relationship between lung function (forced expiratory volume in one second, FEV1) and pre-clinical atherosclerosis (cIMT), and evaluated for effect modification by age, sex, smoking history, HIV, and socioeconomic status. RESULTS Of 265 participants, median age was 52 years, 125 (47%) were women, and 140 (53%) were PLWH. Most participants who met criteria for COPD were PLWH (13/17, 76%). Median cIMT was 0.67 mm (IQR: 0.60 to 0.74), which did not differ by HIV serostatus. In models adjusted for age, sex, socioeconomic status, smoking, and HIV, lower FEV1 was associated with increased cIMT (β = 0.006 per 200 mL FEV1 decrease; 95% CI 0.002 to 0.011, p = 0.01). There was no evidence that age, sex, HIV serostatus, smoking, or socioeconomic status modified the relationship between FEV1 and cIMT. CONCLUSIONS Impaired lung function was associated with increased cIMT, a measure of pre-clinical atherosclerosis, among adults with and without HIV in rural Uganda. Future work should explore how co-occurring lung and cardiovascular disease might share risk factors and contribute to health outcomes in sub-Saharan Africa.
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Affiliation(s)
- Rebecca F Gilbert
- Massachusetts General Hospital, 55 Fruit Street, BUL-148, Boston, MA, 02114, USA
| | - Cody Cichowitz
- Massachusetts General Hospital, 55 Fruit Street, BUL-148, Boston, MA, 02114, USA
| | | | - June-Ho Kim
- Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Linda C Hemphill
- Massachusetts General Hospital, 55 Fruit Street, BUL-148, Boston, MA, 02114, USA.,Harvard Medical School, Boston, MA, USA
| | | | - Ruth N Sentongo
- Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - David C Christiani
- Massachusetts General Hospital, 55 Fruit Street, BUL-148, Boston, MA, 02114, USA.,Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Alexander C Tsai
- Massachusetts General Hospital, 55 Fruit Street, BUL-148, Boston, MA, 02114, USA.,Mbarara University of Science and Technology, Mbarara, Uganda.,Harvard Medical School, Boston, MA, USA
| | - Samson Okello
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Mark J Siedner
- Massachusetts General Hospital, 55 Fruit Street, BUL-148, Boston, MA, 02114, USA.,Mbarara University of Science and Technology, Mbarara, Uganda.,Harvard Medical School, Boston, MA, USA
| | - Crystal M North
- Massachusetts General Hospital, 55 Fruit Street, BUL-148, Boston, MA, 02114, USA. .,Harvard Medical School, Boston, MA, USA.
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13
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Weichseldorfer M, Reitz M, Latinovic OS. Past HIV-1 Medications and the Current Status of Combined Antiretroviral Therapy Options for HIV-1 Patients. Pharmaceutics 2021; 13:pharmaceutics13111798. [PMID: 34834213 PMCID: PMC8621549 DOI: 10.3390/pharmaceutics13111798] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 09/27/2021] [Accepted: 10/13/2021] [Indexed: 11/17/2022] Open
Abstract
Combined antiretroviral therapy (cART) is treatment with a combination of several antiretroviral drugs that block multiple stages in the virus replication cycle. An estimated 60% of the 38 million HIV-1 patients globally receive some form of cART. The benefits of cART for controlling HIV-1 replication, transmission, and infection rates have led to its universal recommendation. Implementation has caused a substantial reduction in morbidity and mortality of persons living with HIV-1/AIDS (PLWHA). More specifically, standard cART has provided controlled, undetectable levels of viremia, high treatment efficacy, reduction in pill burden, and an improved lifestyle in HIV-1 patients overall. However, HIV-1 patients living with AIDS (HPLA) generally show high viral loads upon cART interruption. Latently infected resting CD4+ T cells remain a major barrier to curing infected patients on long-term cART. There is a critical need for more effective compounds and therapies that not only potently reactivate latently infected cells, but also lead to the death of these reactivated cells. Efforts are ongoing to better control ongoing viral propagation, including the identification of appropriate animal models that best mimic HIV-1 pathogenesis, before proceeding with clinical trials. Limited toxicity profiles, improved drug penetration to certain tissues, and extended-release formulations are needed to cover gaps in existing HIV-1 treatment options. This review will cover past, current, and new cART strategies recently approved or in ongoing development.
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Affiliation(s)
- Matthew Weichseldorfer
- Institute of Human Virology, School of Medicine, University of Maryland, Baltimore, MD 21201, USA;
| | - Marvin Reitz
- Department of Medicine, School of Medicine, University of Maryland, Baltimore, MD 21201, USA;
| | - Olga S. Latinovic
- Institute of Human Virology, School of Medicine, University of Maryland, Baltimore, MD 21201, USA;
- Department of Microbiology and Immunology, School of Medicine, University of Maryland, Baltimore, MD 21201, USA
- Correspondence:
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14
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Implementing Cancer Care in Rwanda: Capacity Building for Treatment and Scale-Up. SUSTAINABILITY 2021. [DOI: 10.3390/su13137216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: The majority of countries in sub-Saharan Africa are ill-prepared to address the rising burden of cancer. While some have been able to establish a single cancer referral center, few have been able to scale-up services nationally towards universal health coverage. The literature lacks a step-wise implementation approach for resource-limited countries to move beyond a single-facility implementation strategy and implement a national cancer strategy to expand effective coverage. Methods: We applied an implementation science framework, which describes a four-phase approach: Exploration, Preparation, Implementation, and Sustainment (EPIS). Through this framework, we describe Rwanda’s approach to establish not just a single cancer center, but a national cancer program. Results: By applying EPIS to Rwanda’s implementation approach, we analyzed and identified the implementation strategies and factors, which informed processes of each phase to establish foundational cancer delivery components, including trained staff, diagnostic technology, essential medicines, and medical informatics. These cancer delivery components allowed for the implementation of Rwanda’s first cancer center, while simultaneously serving as the nidus for capacity building of foundational components for future cancer centers. Conclusion: This “progressive scaling” approach ensured that initial investments in the country’s first cancer center was a step toward establishing future cancer centers in the country.
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15
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El-Sadr WM. Beyond the Magic Bullet: What Will It Take to End the AIDS Epidemic? Am J Public Health 2021; 111:1234-1236. [PMID: 34110928 DOI: 10.2105/ajph.2021.306290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Wafaa M El-Sadr
- Wafaa M. El-Sadr is Global Director of ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY
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16
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What has comprehensive HIV/AIDS knowledge got to do with HIV testing among men in Kenya and Mozambique? Evidence from Demographic and Health Surveys. J Biosoc Sci 2021; 54:558-571. [PMID: 34099074 DOI: 10.1017/s0021932021000237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
People living with undiagnosed HIV are big contributors to the transmission of the virus. Although measures have been made to scale up HIV prevention and voluntary counselling and testing in sub-Saharan Africa, testing coverage remains low in many sub-Saharan African countries, including Mozambique and Kenya, where most people live with HIV/AIDS. Studies have shown that, in most countries in sub-Saharan Africa, men are less likely to test for HIV compared with women. This study examined the relationship between comprehensive HIV/AIDS knowledge and HIV testing among men in Kenya and Mozambique. Data were from the men's re-code file of the Demographic and Health Surveys of Mozambique and Kenya. Binary logistic regression models were generated and the results presented as crude odds ratios (cOR) and adjusted odds ratios (aOR). The prevalences of HIV testing in Kenya and Mozambique were 80.1% and 46.7%, respectively. Men in Mozambique who had comprehensive HIV/AIDS knowledge (aOR=1.26, CI: 1.07-1.47) were more likely to test for HIV compared with their counterparts who had no comprehensive HIV/AIDS knowledge. In Kenya, men who had comprehensive HIV/AIDS knowledge (aOR=1.23, CI: 1.09-1.39) were more likely to test for HIV compared with their counterparts who had no comprehensive HIV/AIDS knowledge. This study found a statistically strong significant association between comprehensive HIV/AIDS knowledge and HIV testing among men in Kenya and Mozambique. To improve HIV testing rate among men, it is important that interventions are geared towards improving men's comprehensive HIV/AIDS knowledge, perhaps by expanding HIV/AIDS education programmes and campaigns. This could improve HIV testing rates and ensure the realization of the global HIV/AIDS target of 95-95-95 by the year 2030.
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17
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Zakumumpa H, Paina L, Wilhelm J, Ssengooba F, Ssegujja E, Mukuru M, Bennett S. The impact of loss of PEPFAR support on HIV services at health facilities in low-burden districts in Uganda. BMC Health Serv Res 2021; 21:302. [PMID: 33794880 PMCID: PMC8017884 DOI: 10.1186/s12913-021-06316-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 03/25/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Although donor transitions from HIV programs are more frequent, little research exists seeking to understand the perceptions of patients and providers on this process. Between 2015 and 2017, PEPFAR implemented the ´geographic prioritization´ (GP) policy in Uganda whereby it shifted support from 734 'low-volume' facilities and 10 districts with low HIV burden and intensified support in select facilities in high-burden districts. Our analysis intends to explore patient and provider perspectives on the impact of loss of PEPFAR support on HIV services in transitioned health facilities in Uganda. METHODS We report qualitative findings from a larger mixed-methods evaluation. Six facilities were purposefully selected as case studies seeking to ensure diversity in facility ownership, size, and geographic location. Five out of the six selected facilities had experienced transition. A total of 62 in-depth interviews were conducted in June 2017 (round 1) and November 2017 (round 2) with facility in-charges (n = 13), ART clinic managers (n = 12), representatives of PEPFAR implementing organizations (n = 14), district health managers (n = 23) and 12 patient focus group discussions (n = 72) to elicit perceived effects of transition on HIV service delivery. Data were analyzed using thematic analysis. RESULTS While core HIV services, such as testing and treatment, offered by case-study facilities prior to transition were sustained, patients and providers reported changes in the range of HIV services offered and a decline in the quality of HIV services offered post-transition. Specifically, in some facilities we found that specialized pediatric HIV services ceased, free HIV testing services stopped, nutrition support to HIV clients ended and the 'mentor mother' ART adherence support mechanism was discontinued. Patients at three ART-providing facilities reported that HIV service provision had become less patient-centred compared to the pre-transition period. Patients at some facilities perceived waiting times at clinics to have become longer, stock-outs of anti-retroviral medicines to have been more frequent and out-of-pocket expenditure to have increased post-transition. CONCLUSIONS Participants perceived transition to have had the effect of narrowing the scope and quality of HIV services offered by case-study facilities due to a reduction in HIV funding as well as the loss of the additional personnel previously hired by the PEPFAR implementing organizations for HIV programming. Replacing the HIV programming gap left by PEPFAR in transition districts with Uganda government services is critical to the attainment of 90-90-90 targets in Uganda.
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Affiliation(s)
- Henry Zakumumpa
- School of Public Health, Makerere University, Kampala, Uganda.
| | - Ligia Paina
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | - Jess Wilhelm
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | | | - Eric Ssegujja
- School of Public Health, Makerere University, Kampala, Uganda
| | - Moses Mukuru
- School of Public Health, Makerere University, Kampala, Uganda
| | - Sara Bennett
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
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18
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Varriano B, Crouzat F, Sandler I, Smith G, Kovacs C, Gupta M, Brunetta J, Fletcher D, Knox D, Merkley B, Chang B, Tilley D, Acsai M, Loutfy M. Cardiovascular Events in an Inner-City HIV Clinic and Relationship to Abacavir Versus Tenofovir Disoproxil Fumarate-Containing Antiretroviral Regimens. AIDS Res Hum Retroviruses 2021; 37:44-53. [PMID: 33019803 DOI: 10.1089/aid.2020.0053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Following cardiovascular events (CVE) among people living with HIV (PLWH) is essential. Abacavir (ABC)'s impact on CVE challenges clinicians. We characterized CVE at our HIV clinic associated with ABC versus tenofovir disoproxil fumarate (TDF). This was a retrospective study of PLWH who started combination antiretroviral therapy with no prior CVE. Patients were evaluated as antiretroviral naive or antiretroviral experienced. Regimens included the following: always-ABC, always-TDF, first-ABC-switched-to-TDF, and first-TDF-switched-to-ABC regimens. Frequencies, rates, and Poisson regression were used to analyze CVE (cardiovascular/cerebrovascular) and were stratified with an a priori cutoff of before or after January 1, 2009. 1,440/2,852 patients were antiretroviral naive; 658 on always-ABC regimens, 1,186 on always-TDF regimens, 737 first-ABC-switched-to-TDF regimens, and 271 first-TDF-switched-to-ABC regimens. Seventy seven CVE occurred overall [16 naive vs. 61 experienced (p < .0001)]. Sixty events were cardiovascular and 17 cerebrovascular (p < .0001). Sixty-nine CVE occurred before 2009 and eight after (p < .0001). There were 5.65 CVE-per-1,000-years [95% confidence interval (CI) 3.23-9.87] in the always-ABC, 1.95 CVE-per-1,000-years (95% CI 1.08-3.51) in the always-TDF, 2.01 CVE-per-1,000-years (95% CI 1.14-3.56) in the ABC-switched-to-TDF, and 1.82 CVE-per-1,000-years (95% CI 0.77-4.30) in TDF-switched-to-ABC (p <.01). Multivariable Poisson regression incidence rate ratios (IRRs) revealed that being on ABC-only (IRR 2.89; 95% CI 2.13-3.94), age (IRR 1.06 per year; 95% CI 1.04-1.07), and smoking (IRR for current 2.81; 95% CI 1.97-3.99; IRR for former 2.49; 95% CI 1.72-3.61) increased risk of CVE. Thus, in our clinic, CVE rates were increased in those on ABC and adds to the body of literature suggesting concern.
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Affiliation(s)
- Brenda Varriano
- Department of Family Medicine, Maple Leaf Medical Clinic, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Frederic Crouzat
- Department of Family Medicine, Maple Leaf Medical Clinic, Toronto, Ontario, Canada
| | - Ina Sandler
- Department of Family Medicine, Maple Leaf Medical Clinic, Toronto, Ontario, Canada
| | - Graham Smith
- Department of Family Medicine, Maple Leaf Medical Clinic, Toronto, Ontario, Canada
| | - Colin Kovacs
- Department of Family Medicine, Maple Leaf Medical Clinic, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Meenakshi Gupta
- Department of Family Medicine, Maple Leaf Medical Clinic, Toronto, Ontario, Canada
| | - Jason Brunetta
- Department of Family Medicine, Maple Leaf Medical Clinic, Toronto, Ontario, Canada
| | - David Fletcher
- Department of Family Medicine, Maple Leaf Medical Clinic, Toronto, Ontario, Canada
| | - David Knox
- Department of Family Medicine, Maple Leaf Medical Clinic, Toronto, Ontario, Canada
| | - Barry Merkley
- Department of Family Medicine, Maple Leaf Medical Clinic, Toronto, Ontario, Canada
| | - Benny Chang
- Department of Family Medicine, Maple Leaf Medical Clinic, Toronto, Ontario, Canada
| | - David Tilley
- Department of Family Medicine, Maple Leaf Medical Clinic, Toronto, Ontario, Canada
| | - Megan Acsai
- Department of Family Medicine, Maple Leaf Medical Clinic, Toronto, Ontario, Canada
| | - Mona Loutfy
- Department of Family Medicine, Maple Leaf Medical Clinic, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
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19
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Kanters S, Vitoria M, Zoratti M, Doherty M, Penazzato M, Rangaraj A, Ford N, Thorlund K, Anis PAH, Karim ME, Mofenson L, Zash R, Calmy A, Kredo T, Bansback N. Comparative efficacy, tolerability and safety of dolutegravir and efavirenz 400mg among antiretroviral therapies for first-line HIV treatment: A systematic literature review and network meta-analysis. EClinicalMedicine 2020; 28:100573. [PMID: 33294805 PMCID: PMC7700905 DOI: 10.1016/j.eclinm.2020.100573] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 09/17/2020] [Accepted: 09/18/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND To inform World Health Organization (WHO) global guidelines, we updated and expanded the evidence base to assess the comparative efficacy, tolerability, and safety of first-line antiretroviral therapy (ART) regimens. METHODS We searched Embase, Medline and CENTRAL on 28 February 2020 to update the systematic literature review of clinical trials comparing recommended first-line ART that informed previous WHO guidelines. Outcomes included viral suppression, change in CD4 cell counts, mortality, serious and overall adverse events (AEs), discontinuation, discontinuations due to AEs (DAEs); and new outcomes: drug-resistance, neuropsychiatric AEs, early viral suppression, weight gain and birth outcomes. Comparative effects were assessed through network meta-analyses and certainty in the evidence was assessed using the GRADE framework. FINDINGS We identified 156 publications pertaining to 68 trials for the primary population. Relative to efavirenz, dolutegravir had improved odds of viral suppression across all time points (odds ratio [OR]: 1·94; 95% credible interval [CrI]: 1·48-2·56 at 96 weeks); was protective of drug-resistance (OR: 0·13; 95%CrI: 0·04-0·48); and led to fewer discontinuations (OR: 0·58; 95%CrI: 0·48-0·70). Evidence supported dolutegravir use among TB-HIV co-infected persons and pregnant women. Adverse birth outcomes were observed in 33.2% of dolutegravir-managed pregnancies and 35.0% of efavirenz-managed pregnancies. Low-dose efavirenz had comparable efficacy and safety to standard-dose efavirenz, but led to fewer DAEs (OR: 0·70; 95%CrI: 0·50-0·92). INTERPRETATION The evidence supports choosing dolutegravir in combination with lamivudine/emtricitabine and tenofovir disoproxil fumarate as the preferred first-line regimen and low-dose efavirenz-based regimens as an alternative. Dolutegravir can be considered to be effective, safe and tolerable. FUNDING WHO.
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Affiliation(s)
- Steve Kanters
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Michael Zoratti
- Departments of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Meg Doherty
- Department of HIV/AIDS, WHO, Geneva, Switzerland
| | | | | | - Nathan Ford
- Department of HIV/AIDS, WHO, Geneva, Switzerland
| | - Kristian Thorlund
- Departments of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Prof. Aslam H. Anis
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Health Evaluation and Outcome Science, University of British Columbia, Vancouver, Canada
| | - Mohammad Ehsanul Karim
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Health Evaluation and Outcome Science, University of British Columbia, Vancouver, Canada
| | - Lynne Mofenson
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, USA
| | - Rebecca Zash
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, USA
- Botswana–Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Alexandra Calmy
- HIV/AIDS Unit, Division of Infectious Diseases, Geneva University Hospital, Geneva, Switzerland
| | - Tamara Kredo
- South African Medical Research Council, Cape Town, South Africa
| | - Nick Bansback
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Health Evaluation and Outcome Science, University of British Columbia, Vancouver, Canada
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20
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Melku M, Abebe G, Teketel A, Asrie F, Yalew A, Biadgo B, Kassa E, Damtie D, Anlay DZ. Immunological status and virological suppression among HIV-infected adults on highly active antiretroviral therapy. Environ Health Prev Med 2020; 25:43. [PMID: 32838734 PMCID: PMC7444678 DOI: 10.1186/s12199-020-00881-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 08/11/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND World Health Organization (WHO) recommends that viral load ([VL) is a primary tool that clinicians and researchers have used to monitor patients on antiretroviral therapy (ART), an antiviral drug against retroviruses. Whereas, CD4 cell counts can only be used to monitor clinical response to ART in the absence of VL testing service. Therefore, this study is aimed to assess the level of immunological status and virological suppression, and identify associated factors among human immunodeficiency virus ([HIV)-infected adults who were taking antiretroviral drugs of combination regimen know as highly active antiretroviral therapy (HAART). METHODS A hospital-based cross-sectional study was conducted at the University of Gondar comprehensive specialized referral hospital from February to April 2018. A total of 323 adult participants on HAART were selected using a systematic random sampling technique and enrolled into the study. Blood samples for viral load determination and CD4 cell count were collected. Binary logistic regression analysis was used to determine factors associated with immunologic status and virological suppression in HIV patients on HAART. Odds ratio with 95% CI was used to measure the strength of association. RESULTS Virological suppression (VL level < 1000 copies/ml) was found in 82% (95% CI 77.7, 86.1) of study participants, and it has been associated with CD4 cell count between 350 and 499 cells/mm3 (adjusted odds ratio (AOR) = 2.56; 95% CI 1.14, 5.75) and > 499 cells/mm3 (AOR = 7.71; 95% CI 3.48, 17.09) at VL testing and current age > 45 years old (AOR = 5.99; 95% CI 2.12, 16.91). Similarly, favorable immunological status (≥ 400 cells/mm3 for male and ≥ 466 cells/mm3 for female) was observed in 52.9% (95% CI 47.4, 58.8) of the study participants. Baseline CD4 cell count of > 200 cells/mm3, age at enrollment of 26 through 40 years old, and urban residence were significantly associated with favorable immunological status. CONCLUSION Though the majority of HIV-infected adults who were on HAART had shown viral suppression, the rate of suppression was sub-optimal according to the UNAIDS 90-90-90 target to help end the AIDS pandemic by 2020. Nonetheless, the rate of immunological recovery in the study cohort was low. Hence, early initiation of HAART should be strengthened to achieve good virological suppression and immunological recovery.
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Affiliation(s)
- Mulugeta Melku
- Department of Hematology and Immunohematology, School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
| | - Gizachew Abebe
- School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Amanuel Teketel
- School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Fikir Asrie
- Department of Hematology and Immunohematology, School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Aregawi Yalew
- Department of Hematology and Immunohematology, School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Belete Biadgo
- Department of Clinical Chemistry, School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Eyuel Kassa
- University of Gondar comprehensive specialize referral Hospital, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Debasu Damtie
- Department of Immunology and Molecular Biology, School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.,Food Animal Health Research Program, CFAES, Ohio Agricultural Research and Development Center, Department of Veterinary Preventive Medicine, The Ohio State University, Wooster, OH, 44691, USA.,Global One Health Initiative, Eastern African Regional Office, The Ohio State University, Addis Ababa, Ethiopia
| | - Degefaye Zelalem Anlay
- Department of Community Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Monitoring the transition to new antiretroviral treatment regimens through an enhanced data system in Kenya. PLoS One 2020; 15:e0232104. [PMID: 32324800 PMCID: PMC7179904 DOI: 10.1371/journal.pone.0232104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 04/07/2020] [Indexed: 12/03/2022] Open
Abstract
Background While the scale-up of HIV services has improved national health management information systems (HMIS), there remain challenges in using routine data to guide the introduction of optimized antiretroviral (ARV) drugs. Methods Building on the recent enhancements to the HMIS in Kenya and coinciding with the introduction of a new ARV regimen, tenofovir+lamivudine+dolutegravir (TLD), we developed and implemented an enhanced data system (EDS) to improve availability of safety and efficacy data among people living with HIV (PLHIV) in Kenya. Using data from one health facility, we showcase how the EDS can be used to monitor ARV transition and identify missed opportunities to transition eligible patients to optimized regimes. Results The EDS was designed to create a comprehensive PLHIV database by triangulating patient-level data from the EMR, the pharmacy ARV dispensing tool (ADT) and HIV viral load (VL) databases. On a monthly basis, the database is de-identified and uploaded into a national data warehouse, with interactive dashboards. Using the EDS, we determined that of the 5,500 PLHIV ≥15 years on first-line ART at one facility, 4,233 (77%) had transitioned to optimized ARVs. Of the 1,267 still on legacy regimens, 459 (36%) were determined to be eligible and prioritized to switch. Conclusions This project illustrates how enhancements to the national HMIS can facilitate the use of routine patient-level data to monitor the transition to new ARVs and inform the national HIV response.
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Teasdale CA, Abrams EJ, Yuengling KA, Lamb MR, Wang C, Vitale M, Hawken M, Melaku Z, Nuwagaba-Biribonwoha H, El-Sadr WM. Expansion and scale-up of HIV care and treatment services in four countries over ten years. PLoS One 2020; 15:e0231667. [PMID: 32298331 PMCID: PMC7162457 DOI: 10.1371/journal.pone.0231667] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 03/27/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Scale-up and expansion of antiretroviral therapy (ART) for people living with HIV (PLHIV) have been a global priority for more than 15 years. METHODS We describe PLHIV at enrollment in care and ART initiation in Ethiopia, Kenya, Mozambique and Tanzania from 2005-2014 and report on enrollment location, CD4 count and loss to follow-up (LTF), death, and combined attrition (LTF and death) pre- and post-ART initiation over time. Pre-ART outcomes were estimated using competing risk and post-ART using Kaplan-Meier estimators; LTF defined as no visit within six months pre-ART and 12 months after ART start. RESULTS From 2005-2014, 884,328 PLHIV enrolled in care at 350 health facilities, median age was 32.0 years (interquartile range [IQR] 26.0-42.0), and majority were female (66.5%). The proportion of PLHIV enrolled at primary and rural facilities increased from 12.9% and 15.3% in 2005-2006 to 43.5% and 41.7% in 2013-2014 (p<0.0001). Median CD4+ cell count at enrollment increased from 171 cell/mm3 in 2005-2006 (IQR 71-339) to 289 cell/mm3 in 2013-2014 (IQR 133-485) (p<0.0001). A total of 460,758 (57.4%) PLHIV initiated treatment. Cumulative risk of LTF for PLHIV prior to ART initiation 12 months after enrollment was 33.5% (95%CI 33.36-33.58) and 21.98% (95%CI 21.9-22.1) after ART initiation. Pregnant women and the youngest PLHIV group had the highest attrition after ART initiation, at 24 months 40.8% (95%CI 40.1-41.6) of pregnant women and 47.4% (95%CI 46.4-48.4) of PLHIV 15-19 years were not retained. Attrition at 12 months after enrollment among PLHIV regardless of ART status was 38.5% (95%CI 38.4-38.6). CONCLUSION Over 10 years of HIV scale-up in four sub-Saharan African countries, close to a million PLHIV were enrolled in care increasingly at rural and primary facilities with increasing CD4 count. Loss to follow-up from HIV care remains alarmingly high, particularly among pregnant women and younger PLHIV.
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Affiliation(s)
- Chloe A Teasdale
- Department of Epidemiology & Biostatistics, CUNY Graduate School of Public Health and Health Policy, New York, NY, United States of America
- ICAP-Columbia University, Mailman School of Public Health, Columbia University, New York, NY, United States of America
- Department of Epidemiology, Mailman School of Public Health Columbia University, New York, NY, United States of America
| | - Elaine J Abrams
- ICAP-Columbia University, Mailman School of Public Health, Columbia University, New York, NY, United States of America
- Department of Epidemiology, Mailman School of Public Health Columbia University, New York, NY, United States of America
- Department of Pediatrics, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY, United States of America
| | - Katharine A Yuengling
- ICAP-Columbia University, Mailman School of Public Health, Columbia University, New York, NY, United States of America
| | - Matthew R Lamb
- ICAP-Columbia University, Mailman School of Public Health, Columbia University, New York, NY, United States of America
- Department of Epidemiology, Mailman School of Public Health Columbia University, New York, NY, United States of America
| | - Chunhui Wang
- ICAP-Columbia University, Mailman School of Public Health, Columbia University, New York, NY, United States of America
| | | | | | | | - Harriet Nuwagaba-Biribonwoha
- Department of Epidemiology, Mailman School of Public Health Columbia University, New York, NY, United States of America
- ICAP-Columbia University, Mbabane, Eswatini
| | - Wafaa M El-Sadr
- ICAP-Columbia University, Mailman School of Public Health, Columbia University, New York, NY, United States of America
- Department of Epidemiology, Mailman School of Public Health Columbia University, New York, NY, United States of America
- Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY, United States of America
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Lince-Deroche N, Leuner R, Meyer-Rath G, Pillay Y, Long L. When donor funding leaves: an interrupted time-series analysis of the impact of integrating direct HIV care and treatment into public health services in a region of Johannesburg. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2019; 17:24. [PMID: 31673249 PMCID: PMC6814986 DOI: 10.1186/s12962-019-0192-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Accepted: 10/15/2019] [Indexed: 11/20/2022] Open
Abstract
Background Early in South Africa’s HIV response, donor-funded organizations directly provided HIV treatment through Comprehensive HIV Care, Management and Treatment sites (CCMTs), using their own and government staff. From 2012 to 2014 the donor-funded CCMT model was phased out, leaving nurses in South Africa’s public clinics responsible for delivery of antiretroviral treatment (ART) services. We aimed to examine the impact on resources, staff workloads, and service delivery throughout this period of integration of HIV treatment into primary health clinics. Methods We conducted an Interrupted Time-Series Analysis (ITSA) using data from three public clinics, including one former CCMT site, in one administrative region of Johannesburg. The ITSA was complemented by visual inspection of the data in Excel. We compared trends in expenditure, clinical staffing levels, patient headcounts, and services rendered at the clinics during four periods: pre-CCMT (2004–2007), CCMT operational (2007–2012), CCMT closure (2012–2014), and post-CCMT (2014–2016). Data were drawn from the country’s District Health Information System, a national HIV treatment database, local budget and expenditure reports, National Health Laboratory Service charge records, and staff records. Results Closure of the CCMT differentially impacted the study clinics. As expected, ART services decreased at Clinic 1, where the CCMT was co-located, and increased at Clinics 2 and 3 possibly reflecting redistribution of patients. Despite a reduction in patient headcounts post-CCMT, Clinic 1 experienced a decrease in staff and a large increase in patients seen per clinical staff member per month. In contrast, Clinics 2 and 3 increased or maintained stable workforces, and staff workloads post closure were similar to pre-closure levels. Other primary care services—contraception and immunisations—seemed largely unaffected at Clinics 1 and 2. At Clinic 3, service delivery reduced, but this was accompanied by lowered patient headcounts generally, likely due to clinic renovations. Conclusions In this study, integration of HIV treatment into primary healthcare services did not result in large-scale reductions in overall service delivery. One facility did experience increased staff workloads, but we were unable to assess service quality. To mitigate potential problems, monitoring systems should be introduced in advance and acknowledge the disparate and decentralised management of various data sources.
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Affiliation(s)
- Naomi Lince-Deroche
- 1Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, 39 Empire Rd, Parktown, Johannesburg, 2194 South Africa
| | - Rahma Leuner
- 1Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, 39 Empire Rd, Parktown, Johannesburg, 2194 South Africa
| | - Gesine Meyer-Rath
- 1Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, 39 Empire Rd, Parktown, Johannesburg, 2194 South Africa.,2Department of Global Health, School of Public Health, Boston University, Boston, USA
| | - Yogan Pillay
- 3South African National Department of Health, Pretoria, South Africa
| | - Lawrence Long
- 1Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, 39 Empire Rd, Parktown, Johannesburg, 2194 South Africa.,2Department of Global Health, School of Public Health, Boston University, Boston, USA
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Kilmarx PH, Katz F, Razak MH, Palen J, Cheever LW, Glass RI. The Medical Education Partnership Initiative: Strengthening Human Resources to End AIDS and Improve Health in Africa. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2019; 94:1704-1713. [PMID: 30334836 PMCID: PMC6467693 DOI: 10.1097/acm.0000000000002489] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Faced with a critical shortage of physicians in Africa, which hampered the efforts of the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), the Medical Education Partnership Initiative (MEPI) was established in 2010 to increase the number of medical graduates, the quality of their education, and their retention in Africa. To summarize the accomplishments of the initiative, lessons learned, and remaining challenges, the authors conducted a narrative review of MEPI-from the perspectives of the U.S. government funding agencies and implementing agencies-by reviewing reports from grantee institutions and conducting a search of scientific publications about MEPI. African institutions received 11 programmatic grants, totaling $100 million in PEPFAR funds, to implement MEPI from 2010 to 2015. The National Institutes of Health (NIH) provided an additional 8 linked and pilot grants, totaling $30 million, to strengthen medical research capacity. The 13 grant recipients (in 12 countries) partnered with dozens of additional government and academic institutions, including many in the United States, forming a robust community of practice in medical education and research. Interventions included increasing the number of medical school enrollees, revising curricula, recruiting new faculty, enhancing faculty development, expanding the use of clinical skills laboratories and community and rural training sites, strengthening computer and telecommunications capacity, and increasing e-learning. Research capacity and productivity increased through training and support. Additional support from NIH for faculty development, and from PEPFAR for health professions education and research, is sustaining and extending MEPI's transformative effect on medical education in select African sites.
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Affiliation(s)
- Peter H. Kilmarx
- P.H. Kilmarx is deputy director, Fogarty International Center, National Institutes of Health, Bethesda, Maryland, and infectious diseases medical epidemiologist; ORCID: http://orcid.org/0000-0001-6464-3345
| | - Flora Katz
- F. Katz is director, Division of International Training and Research, Fogarty International Center, National Institutes of Health, Bethesda, Maryland
| | - Myat Htoo Razak
- M.H. Razak was program officer, Medical Education Partnership Initiative, Fogarty International Center, National Institutes of Health, Bethesda, Maryland, and is currently director, Division of Global HIV/AIDS Programs, HIV/AIDS Bureau, Health Resources and Services Administration, Rockville, Maryland
| | - John Palen
- J. Palen is deputy coordinator for program quality, Office of the U.S. Global AIDS Coordinator, Department of State, Washington, DC
| | - Laura W. Cheever
- L.W. Cheever is associate administrator, HIV/AIDS Bureau, Health Resources and Services Administration, Rockville, Maryland
| | - Roger I. Glass
- R.I. Glass is director, Fogarty International Center, National Institutes of Health, Bethesda, Maryland; ORCID: https://orcid.org/0000-0001-7968-9530
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Zakumumpa H, Bennett S, Ssengooba F. Leveraging the lessons learned from financing HIV programs to advance the universal health coverage (UHC) agenda in the East African Community. Glob Health Res Policy 2019; 4:27. [PMID: 31535036 PMCID: PMC6743123 DOI: 10.1186/s41256-019-0118-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 08/26/2019] [Indexed: 02/02/2023] Open
Abstract
Background Although there is broad consensus around the need to accelerate progress towards universal health coverage (UHC) in Sub-Saharan Africa, the financing strategies for achieving it are still unclear. We sought to leverage the lessons learned in financing HIV programs over the past two decades to inform efforts to advance the universal health coverage agenda in the East African Community. Methods We conducted a literature review of studies reporting financing mechanisms for HIV programs between 2004 and 2014. This review is further underpinned by evidence from a mixed-methods study entailing a survey of 195 health facilities across Uganda supplemented with 18 semi-structured interviews with HIV service managers. Results Our data shows that there are six broad HIV financing strategies with potential for application to the universal health coverage agenda in the East African Community (EAC); i) Bi-lateral and multi-lateral funding vehicles: The establishment of HIV-specific global financing vehicles such as PEPFAR and The Global Fund heralded an era of unprecedented levels of international funding of up to $ 500 billion over the past two decades ii) Eliciting private sector contribution to HIV funding: The private sector's financial contribution to HIV services was leveraged through innovative engagement and collaborative interventions iii) Private sector-led alternative HIV financing mechanisms: The introduction of 'VIP' HIV clinics, special 'HIV insurance' schemes and the rise of private philanthropic aid were important alternatives to the traditional sources of funding iv) Commodity social marketing: Commodity social marketing campaigns led to an increase in condom use among low-income earners v) The use of vouchers: Issuing of HIV-test vouchers to the poor was an important demand-side financing approach vi) Earmark HIV taxes: Several countries in Africa have introduced 'special HIV' taxes to boost domestic HIV funding. Conclusions The lessons learned from financing HIV programs suggest that a hybrid of funding strategies are advisable in the quest to achieve UHC in EAC partner states. The contribution of the private sector is indispensable and can be enhanced through targeted interventions towards UHC goals.
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Affiliation(s)
- Henry Zakumumpa
- 1Makerere University, School of Public Health, Kampala, Uganda
| | - Sara Bennett
- 2Johns Hopkins University, Bloomberg School of Public Health, Baltimore, USA
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Affiliation(s)
- Satish Gopal
- Department of Medicine, University of North Carolina at Chapel Hill
- Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
| | - Patrick J Loehrer
- Department of Medicine, Indiana University, Indianapolis
- Melvin and Bren Simon Cancer Center, Indianapolis, Indiana
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Close MA, Barden-O'Fallon J, Mejia C. Quality of family planning services in HIV integrated and non-integrated health facilities in Malawi and Tanzania. Reprod Health 2019; 16:58. [PMID: 31138248 PMCID: PMC6538555 DOI: 10.1186/s12978-019-0712-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background The integration of family planning (FP) and HIV-related services is common in sub-Saharan Africa. Little research has examined how FP quality of care differs between integrated and non-integrated facilities. Using nationally representative data from Malawi and Tanzania, we examined how HIV integration was associated with FP quality of care. Methods Data were drawn from Service Provision Assessments (SPAs) from Malawi (2013–2014) and Tanzania (2014–2015). The analytic sample was restricted to lower-level facilities in Malawi (n = 305) and Tanzania (n = 750) that offered FP services. We matched SPA measures to FP quality of care indicators in the Quick Investigation of Quality (QIQ). We conducted bivariate and multivariate analyses of 22 QIQ indicators to examine how integration status was related to individual QIQ indicators and overall FP quality of care at the facility- and client-level. Results The prevalence of HIV integration in Malawi (39%) and Tanzania (38%) was similar. Integration of HIV services was significantly associated (p < 0.05) with QIQ indicators in Malawi (n = 3) and Tanzania (n = 4). Except for one negative association in Tanzania, all other associations were positive. At the facility-level, HIV integration was associated with increased odds of being at or above the median in FP quality of care in Malawi (adjusted odd ratio (OR) = 2.24; 95% confidence interval (CI) = 1.32, 3.79) and Tanzania (adjusted OR = 2.10; 95% CI = 1.37, 3.22). At the client-level, HIV integration was not associated with FP quality of care in either country. Conclusion Based on samples in Malawi and Tanzania, HIV integration appears to be beneficially associated with FP quality of care. Using a spectrum of FP quality of care indicators, we found little evidence to support concerns that HIV integration may strain facilities and providers, and adversely impact quality outcomes. Rather, it appears to strengthen FP service delivery by increasing the likelihood of stocked FP commodities and achievement of other facility-level quality indicators, potentially through HIV-related supply chains. Further research is needed to assess FP quality of care outcomes across the various platforms of FP integration found in sub-Saharan Africa. Electronic supplementary material The online version of this article (10.1186/s12978-019-0712-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Michael A Close
- Carolina Population Center, Health Behavior Department, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Janine Barden-O'Fallon
- Carolina Population Center, Maternal & Child Health Department, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Carolina Mejia
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Zakumumpa H, Kwiringira J, Rujumba J, Ssengooba F. Assessing the level of institutionalization of donor-funded anti-retroviral therapy (ART) programs in health facilities in Uganda: implications for program sustainability. Glob Health Action 2019; 11:1523302. [PMID: 30295159 PMCID: PMC6179085 DOI: 10.1080/16549716.2018.1523302] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: In the context of declining international assistance for ART scale-up in Sub-Saharan Africa, the institutionalization of ART programs through integrating them in the organizational routines of health facilities is gaining importance as a program sustainability strategy. Objective: The aims of this study were; (i) to compare the level of institutionalization of ART programs in health facilities in Uganda and (ii) to explore reasons for variations in the degree of program institutionalization. Methods: In Phase One, we utilized Level of Institutionalization Scales developed by Goodman (1993) to measure the degree of institutionalization of ART interventions in 195 health facilities across Uganda. The 45-item questionnaire measured institutionalization based on four sub-systems (production, maintenance, supportive, managerial) theorized to make up an organization assessed against two levels of institutionalization; routines (lowest) niche saturation (highest). In Phase Two, four health facilities were purposively selected (2 with the highest and 2 with the lowest institutionalization scores) for a multiple case-study involving semi-structured interviews with ART clinic managers(n = 32), on-site observations and document review. Results: The two highest scoring health facilities had a longer HIV intervention implementation history of between 8 and 11 years. The highest scoring cases associated intervention institutionalization with sustained workforce trainings in ART management, the retention of ART-trained personnel and generating in-house ART manuals. The turnover of ART-proficient staff was identified as a barrier to intervention institutionalization in the lowest-ranked cases. Significant differences in organizational contexts were identified. The two highest-ranked health facilities were well-established, higher-tier hospitals while the lowest scoring health facilities were lower-level health facilities. Conclusions: The level of institutionalization of ART interventions appeared to be differentiated by level of care in the Ugandan health system. Interventions aimed at strengthening program institutionalization in lower-level health centers at the level of human resources for health could enhance ART scale-up sustainability.
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Affiliation(s)
- Henry Zakumumpa
- a School of Public Health , Makerere University , Kampala , Uganda
| | | | - Joseph Rujumba
- c School of Medicine , Makerere University , Kampala , Uganda
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Varriano B, Sandler I, Loutfy M, Steinberg S, Smith G, Kovacs C, Brunetta J, Fletcher D, Knox D, Merkley B, Chang B, Tilley D, Acsai M, Crouzat F. Assessment of antiretroviral third agent virologic durability after initiation of first antiretroviral regimen. Int J STD AIDS 2019; 30:680-688. [PMID: 31042101 DOI: 10.1177/0956462418815292] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Information on the virologic durability of modern antiretroviral regimens is important to clinicians. We aimed to describe virologic durability of first-line integrase strand transfer inhibitor (INSTI)-, nonnucleoside reverse transcriptase inhibitor (NNRTI)-, or protease inhibitor (PI)-based antiretroviral regimens. This was a retrospective study of antiretroviral-naïve patients that initiated first-line antiretroviral regimens with two nucleoside reverse transcriptase inhibitors and an INSTI, NNRTI, or PI between January 2006 and June 2016. The outcome was time to virologic failure, which was assessed by Kaplan-Meier survival analysis and Cox regression models. There were 780 patients (median age = 37 years [interquartile range (IQR) = 30-45], 93.3% male, 56.2% Caucasian, median HIV duration = 1.8 years [IQR = 0.4-5.4], baseline log10 viral load [VL]=4.6 [IQR = 4.1-5.1], and baseline CD4+ cell count = 320 cells/µl [IQR = 217-440]). In total, 189/780 were on a third agent INSTI, 339/780 on a third agent NNRTI, and 252/780 on a third agent PI. Kaplan-Meier survival probability revealed longer time to virologic failure for INSTI, followed by NNRTI then PI (p < 0.001). Multivariable Cox regression revealed that being on an INSTI regimen (aHR = 0.27; 95%CI = 0.18-0.41) or NNRTI regimen (aHR = 0.64; 95%CI = 0.47-0.87) versus PI regimen, frequent VL testing (per year), (aHR = 0.64; 95%CI = 0.47-0.87), and duration of ART (aHR = 0.22; 95%CI = 0.17-0.30) (years) were inversely associated with time to virologic failure, and log10 of baseline VL (aHR = 1.94; 95%CI = 1.58-2.39 per log10) increased risk. Virologic failure was delayed and virologic durability prolonged for INSTI- compared to NNRTI- and PI-based regimens, supporting current antiretroviral therapy guidelines.
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Affiliation(s)
- Brenda Varriano
- 1 Maple Leaf Medical Clinic, Toronto, Canada.,2 Institute of Medical Science, University of Toronto, Toronto, Canada
| | - Ina Sandler
- 1 Maple Leaf Medical Clinic, Toronto, Canada
| | - Mona Loutfy
- 1 Maple Leaf Medical Clinic, Toronto, Canada.,3 Department of Medicine, University of Toronto, Toronto, Canada.,4 Women's College Research Institute, Women's College Hospital, Toronto, Canada
| | | | | | - Colin Kovacs
- 1 Maple Leaf Medical Clinic, Toronto, Canada.,3 Department of Medicine, University of Toronto, Toronto, Canada
| | | | | | - David Knox
- 1 Maple Leaf Medical Clinic, Toronto, Canada
| | | | - Benny Chang
- 1 Maple Leaf Medical Clinic, Toronto, Canada
| | | | - Megan Acsai
- 1 Maple Leaf Medical Clinic, Toronto, Canada
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Wang D, Abrams M. Health Care Providers' Profiles and Evaluations of a Statewide Online Education Program for Dissemination of Clinical Evidence on HIV, Hepatitis C Virus, and Sexually Transmitted Disease: Cross-Sectional Study. JMIR MEDICAL EDUCATION 2019; 5:e10722. [PMID: 30920374 PMCID: PMC6458535 DOI: 10.2196/10722] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 01/02/2019] [Accepted: 01/06/2019] [Indexed: 05/03/2023]
Abstract
BACKGROUND Timely and effective dissemination of the latest clinical evidence to health care providers is essential for translating biomedical research into routine patient care. Online platforms offer unique opportunities for dissemination of medical knowledge. OBJECTIVE In this study, we report the profiles of health care providers participating in the New York State HIV-HCV-STD Clinical Education Initiative online program and their evaluations of the online continuing professional development courses. METHODS We compiled professional and personal background information of the clinicians who completed at least one online course. We collected their self-reported program evaluation data with regard to the course content, format, knowledge increase, and impact on clinical practice. RESULTS We recorded a total of 4363 completions of 88 online courses by 1976 unique clinicians during a 12-month study period. The clinicians' background was diverse in terms of demographics, education levels, professional disciplines, practice years, employment settings, caseloads, and clinical services. The evaluation of online courses was very positive (usefulness/relevance, 91.08%; easy comprehension, 89.09%; knowledgeable trainer, 92.00%; appropriate format, 84.35%; knowledge increase, 48.52%; intention to use knowledge, 85.26%; and plan to change practice, 21.98%). Comparison with the reference data indicated that the online program successfully reached out to the primary care communities. Both the younger generation and the senior health care providers were attracted to the online program. High-quality multimedia resources, flexibility of access, ease of use, and provision of continuing professional development credits contributed to the initial success of this online clinical education program. CONCLUSIONS We have successfully characterized a diverse group of clinicians participating in a statewide online continuing professional development program. The evaluation has shown effective use of online resources to disseminate clinical evidence on HIV, hepatitis C virus, and sexually transmitted disease to primary care clinicians.
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Affiliation(s)
- Dongwen Wang
- Arizona State University, Scottsdale, AZ, United States
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Naar S, Parsons JT, Stanton BF. Adolescent Trials Network for HIV-AIDS Scale It Up Program: Protocol for a Rational and Overview. JMIR Res Protoc 2019; 8:e11204. [PMID: 30707102 PMCID: PMC6376339 DOI: 10.2196/11204] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 10/02/2018] [Accepted: 10/04/2018] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND The past 30 years have witnessed such significant progress in the prevention and treatment of HIV/AIDS that an AIDS-free generation and the end to the global AIDS epidemic are ambitious, but achievable, national and global goals. Despite growing optimism, globally, youth living with HIV are markedly less likely to receive antiretroviral therapy than adults (23% vs 38%). Furthermore, marked health disparities exist regarding HIV infection risk, with young men of color who have sex with men disproportionately affected. A large body of research has identified highly impactful facilitators of and barriers to behavior change. Several efficacious interventions have been created that decrease the rate of new HIV infections among youth and reduce morbidity among youth living with HIV. However, full benefits that should be possible based on the tools and interventions currently available are yet to be realized in youth, in large part, because efficacious interventions have not been implemented in real-world settings. Scale It Up (SIU) primarily aims to assemble research teams that will ultimately bring to practice evidence-based interventions that positively impact the youth HIV prevention and care cascades, and in turn, advance the fields of implementation science and self-management science. OBJECTIVE This paper aims to describe the structure of the U19-SIU and the effectiveness-implementation hybrid trials, as well as other center-wide protocols and initiatives, implemented within SIU. METHODS SIU will achieve its aims through 4 individual primary protocols, 2 center-wide protocols, and 3 cross-project initiatives. RESULTS SIU was funded by National Institute for Child Health and Human Development (U19HD089875) and began in October 2016. As of November 2018, 6 SIU protocols have launched at least the first phase of work (ATN 144 SMART: Sequential Multiple Assignment Randomized Trial; ATN 145 YMHP: Young Men's Health Project; ATN 146 TMI: Tailored Motivational Interviewing Intervention; ATN 153 EPIS: Exploration, Preparation, Implementation, Sustainment model; ATN 154 CM: Cascade Monitoring; ATN 156 We Test: Couples' Communication and HIV Testing). Further details can be found in the individual protocol papers. CONCLUSIONS To date, the youth HIV research portfolio has not adequately advanced the important care area of self-management. SIU protocols and initiatives address this broad issue by focusing on evaluating the effectiveness and implementation of self-management interventions. SIU is highly innovative for 5 primary reasons: (1) our research framework expands the application of "self-management"; (2) the 4 primary protocols utilize innovative hybrid designs; (3) our Analytic Core will conduct cost-effectiveness analyses of each intervention; (4) across all 4 primary protocols, our Implementation Science Core will apply implementation scales designed to assess inner and outer context factors; and (5) we shall advance understanding of the dynamics between provider and patient through analysis of recorded interactions. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/11204.
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Affiliation(s)
- Sylvie Naar
- College of Medicine, Florida State University, Tallahassee, FL, United States
| | - Jeffrey T Parsons
- Center for HIV Educational Studies and Training, Hunter College of the City University of New York, New York, NY, United States
- Health Psychology and Clinical Science Doctoral Program, Graduate Center of the City University of New York, New York, NY, United States
| | - Bonita F Stanton
- Hackensack Meridian School of Medicine, Seton Hall University, South Orange, NJ, United States
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Thomson DR, Amoroso C, Atwood S, Bonds MH, Rwabukwisi FC, Drobac P, Finnegan KE, Farmer DB, Farmer PE, Habinshuti A, Hirschhorn LR, Manzi A, Niyigena P, Rich ML, Stulac S, Murray MB, Binagwaho A. Impact of a health system strengthening intervention on maternal and child health outputs and outcomes in rural Rwanda 2005-2010. BMJ Glob Health 2018; 3:e000674. [PMID: 29662695 PMCID: PMC5898359 DOI: 10.1136/bmjgh-2017-000674] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 03/08/2018] [Accepted: 03/11/2018] [Indexed: 11/17/2022] Open
Abstract
Introduction Although Rwanda’s health system underwent major reforms and improvements after the 1994 Genocide, the health system and population health in the southeast lagged behind other areas. In 2005, Partners In Health and the Rwandan Ministry of Health began a health system strengthening intervention in this region. We evaluate potential impacts of the intervention on maternal and child health indicators. Methods Combining results from the 2005 and 2010 Demographic and Health Surveys with those from a supplemental 2010 survey, we compared changes in health system output indicators and population health outcomes between 2005 and 2010 as reported by women living in the intervention area with those reported by the pooled population of women from all other rural areas of the country, controlling for potential confounding by economic and demographic variables. Results Overall health system coverage improved similarly in the comparison groups between 2005 and 2010, with an indicator of composite coverage of child health interventions increasing from 57.9% to 75.0% in the intervention area and from 58.7% to 73.8% in the other rural areas. Under-five mortality declined by an annual rate of 12.8% in the intervention area, from 229.8 to 83.2 deaths per 1000 live births, and by 8.9% in other rural areas, from 157.7 to 75.8 deaths per 1000 live births. Improvements were most marked among the poorest households. Conclusion We observed dramatic improvements in population health outcomes including under-five mortality between 2005 and 2010 in rural Rwanda generally and in the intervention area specifically.
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Affiliation(s)
- Dana R Thomson
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.,College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | | | - Sidney Atwood
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Matthew H Bonds
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Woods Institute, Stanford University, Stanford, California, USA
| | | | - Peter Drobac
- Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda.,Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Global Health Delivery, University of Global Health Equity, Kigali, Rwanda
| | - Karen E Finnegan
- Department of International Health, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Paul E Farmer
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda.,Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Lisa R Hirschhorn
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Anatole Manzi
- Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda
| | | | - Michael L Rich
- Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda.,Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Sara Stulac
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda.,Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Megan B Murray
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Agnes Binagwaho
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire, USA
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Matima R, Murphy K, Levitt NS, BeLue R, Oni T. A qualitative study on the experiences and perspectives of public sector patients in Cape Town in managing the workload of demands of HIV and type 2 diabetes multimorbidity. PLoS One 2018. [PMID: 29538415 PMCID: PMC5851623 DOI: 10.1371/journal.pone.0194191] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Current South African health policy for chronic disease management proposes integration of chronic services for better outcomes for chronic conditions; that is based on the Integrated Chronic Disease Model (ICDM). However, scant data exist on how patients with chronic multimorbidities currently experience the (re)-organisation of health services and what their perceived needs are in order to enhance the management of their conditions. METHODS A qualitative study was conducted in a community health centre treating both HIV and diabetes patients in Cape Town. The study was grounded in the Shippee's Cumulative Complexity Model (CCM) and explored "patient workload" and "patient capacity" to manage chronic conditions. Individual interviews were conducted with 10 adult patient-participants with HIV and type two diabetes (T2D) multimorbidity and 6 healthcare workers who provided health services to these patient-participants. RESULTS Patient-participants in this study experienced clinic-related workload such as: two separate clinics for HIV and T2D and perceived and experienced power mismatch between patients and healthcare workers. Self-care related workloads were largely around nutritional requirements, pill burden, and stigma. Burden of these demands varied in difficulty among patient-participants due to capacity factors such as: positive attitudes, optimal health literacy, social support and availability of economic resources. Strategies mentioned by participants for improved continuity of care and self-management of multi-morbidities included integration of chronic services, consolidated guidelines for healthcare workers, educational materials for patients, improved information systems and income for patients. CONCLUSION Using the CCM to explore multimorbidity captured most of the themes around "patient workload" and "patient capacity", and was thus a suitable framework to explore multimorbidity in this high HIV/T2D burden setting. Integration of chronic services and addressing social determinants of health may be the first steps towards alleviating patient burden and improving their access and utilisation of these services. Further studies are necessary to explore multimorbidity beyond the context of HIV/T2D.
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Affiliation(s)
- Rangarirai Matima
- School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- * E-mail:
| | - Katherine Murphy
- Chronic Disease Initiative for Africa, Division of Diabetes and Endocrinology, Department of Medicine, Groote Schuur Hospital, Cape Town, South Africa
| | - Naomi S. Levitt
- Chronic Disease Initiative for Africa, Division of Diabetes and Endocrinology, Department of Medicine, Groote Schuur Hospital, Cape Town, South Africa
| | - Rhonda BeLue
- Department of Health Policy and Administration, Pennsylvania State University, University Park, Pennsylvania, United States of America
| | - Tolu Oni
- School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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McRobie E, Matovu F, Nanyiti A, Nonvignon J, Abankwah DNY, Case KK, Hallett TB, Hanefeld J, Conteh L. National responses to global health targets: exploring policy transfer in the context of the UNAIDS '90-90-90' treatment targets in Ghana and Uganda. Health Policy Plan 2018; 33:17-33. [PMID: 29040476 PMCID: PMC5886235 DOI: 10.1093/heapol/czx132] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2017] [Indexed: 12/11/2022] Open
Abstract
Global health organizations frequently set disease-specific targets with the goal of eliciting adoption at the national-level; consideration of the influence of target setting on national policies, programme and health budgets is of benefit to those setting targets and those intended to respond. In 2014, the Joint United Nations Programme on HIV/AIDS set 'ambitious' treatment targets for country adoption: 90% of HIV-positive persons should know their status; 90% of those on treatment; 90% of those achieving viral suppression. Using case studies from Ghana and Uganda, we explore how the target and its associated policy content have been adopted at the national level. That is whether adoption is in rhetoric only or supported by programme, policy or budgetary changes. We review 23 (14 from Ghana, 9 from Uganda) national policy, operational and strategic documents for the HIV response and assess commitments to '90-90-90'. In-person semi-structured interviews were conducted with purposively sampled key informants (17 in Ghana, 20 in Uganda) involved in programme-planning and resource allocation within HIV to gain insight into factors facilitating adoption of 90-90-90. Interviews were transcribed and analysed thematically, inductively and deductively, guided by pre-existing policy theories, including Dolowitz and Marsh's policy transfer framework to describe features of the transfer and the Global Health Advocacy and Policy Project framework to explain observations. Regardless of notable resource constraints, transfer of the 90-90-90 targets was evident beyond rhetoric with substantial shifts in policy and programme activities. In both countries, there was evidence of attempts to minimize resource constraints by seeking programme efficiencies, prioritization of programme activities and devising domestic financing mechanisms; however, significant resource gaps persist. An effective health network, comprised of global and local actors, mediated the adoption and adaptation, facilitating a shift in the HIV programme from 'business as usual' to approaches targeting geographies and populations.
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Affiliation(s)
- Ellen McRobie
- Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, UK
| | - Fred Matovu
- School of Economics, Makerere University, Kampala, Uganda
- Policy Analysis & Development Research Institute, Kampala, Uganda
| | - Aisha Nanyiti
- School of Economics, Makerere University, Kampala, Uganda
| | - Justice Nonvignon
- Department of Health Policy, Planning & Management, School of Public Health, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Daniel Nana Yaw Abankwah
- Department of Social and Behavioural Sciences, School of Public Health, University of Ghana, Accra, Ghana
| | - Kelsey K Case
- Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, UK
| | - Timothy B Hallett
- Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, UK
| | - Johanna Hanefeld
- Anthropology, Politics and Policy Group, Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Lesong Conteh
- Health Economics Group, School of Public Health, Imperial College London, London, UK
- Medical Research Council Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, UK
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Mathur P, Comstock E, McSweegan E, Mercer N, Kumar NS, Kottilil S. A pilot study to expand treatment of chronic hepatitis C in resource-limited settings. Antiviral Res 2017; 146:184-190. [PMID: 28927676 DOI: 10.1016/j.antiviral.2017.09.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 07/11/2017] [Accepted: 09/13/2017] [Indexed: 01/06/2023]
Abstract
The past five years have seen a revolution in the treatment of chronic hepatitis C, as short duration oral regimens of direct-acting antiviral drugs (DAAs), with nearly 100% cure rates for all genotypes, have replaced longer courses of ribavirin and injected interferon. Although initially very expensive, these DAAs are now becoming available in generic equivalents in countries with large numbers of chronically infected people, such as India. However, a number of obstacles may hinder the delivery of these drugs in resource-limited settings, including lack of access to diagnostic testing and the restriction of treatment to a small number of medical specialists. New approaches are therefore needed to make DAAs available to the estimated 71 million infected people, many of whom disproportionately live in low- or middle-income countries. A recent pilot study (ASCEND) of hepatitis C management in a low-income population in Washington, D.C., demonstrated that trained nurse practitioners, primary care physicians and hepatologists were equally successful in diagnosing and treating patients, indicating that such an approach might be successful in resource-limited regions of the world. Members of the Global Virus Network have received funding to carry out a similar training project in a region of India with a high prevalence of hepatitis C. This paper reviews the challenges of delivering DAA therapy in low- and middle-income countries, describes plans for performing and evaluating the effectiveness of a training program in India, and discusses future needs for the eventual elimination of hepatitis C.
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Affiliation(s)
- Poonam Mathur
- Division of Clinical Care and Research at the Institute of Human Virology (IHV), University of Maryland, School of Medicine, Baltimore, MD, USA
| | - Emily Comstock
- Division of Clinical Care and Research at the Institute of Human Virology (IHV), University of Maryland, School of Medicine, Baltimore, MD, USA
| | | | | | | | - Shyamasundaran Kottilil
- Division of Clinical Care and Research at the Institute of Human Virology (IHV), University of Maryland, School of Medicine, Baltimore, MD, USA; Global Virus Network, Baltimore, MD, USA.
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Siedner MJ. Aging, Health, and Quality of Life for Older People Living With HIV in Sub-Saharan Africa: A Review and Proposed Conceptual Framework. J Aging Health 2017; 31:109-138. [PMID: 28831864 DOI: 10.1177/0898264317724549] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The number of people living with HIV (PLWH) over 50 years old in sub-Saharan Africa is predicted to triple in the coming decades, to 6-10 million. Yet, there is a paucity of data on the determinants of health and quality of life for older PLWH in the region. METHODS A review was undertaken to describe the impact of HIV infection on aging for PLWH in sub-Saharan Africa. RESULTS We (a) summarize the pathophysiology and epidemiology of aging with HIV in resource-rich settings, and (b) describe how these relationships might differ in sub-Saharan Africa, (c) propose a conceptual framework to describe determinants of quality of life for older PLWH, and (d) suggest priority research areas needed to ensure long-term gains in quality of life for PLWH in the region. CONCLUSIONS Differences in traditional, lifestyle, and envirnomental risk factors, as well as unique features of HIV epidemiology and care delivery appear to substantially alter the contribution of HIV to aging in sub-Saharan Africa. Meanwhile, unique preferences and conceptualizations of quality of life will require novel measurement and intervention tools. An expanded research and public health infrastructure is needed to ensure that gains made in HIV prevention and treamtent are translated into long-term benefits in this region.
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Affiliation(s)
- Mark J Siedner
- 1 Harvard Medical School, Boston, MA, USA.,2 Massachusetts General Hospital, Boston, MA, USA.,3 Mbarara University of Science and Technology, Mbarara, Uganda
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van Griensven F, Guadamuz TE, de Lind van Wijngaarden JW, Phanuphak N, Solomon SS, Lo YR. Challenges and emerging opportunities for the HIV prevention, treatment and care cascade in men who have sex with men in Asia Pacific. Sex Transm Infect 2017; 93:356-362. [PMID: 28729520 DOI: 10.1136/sextrans-2016-052669] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 04/19/2017] [Accepted: 06/03/2017] [Indexed: 01/23/2023] Open
Abstract
In Asia Pacific, most countries have expanded HIV treatment guidelines to include all those with HIV infection and adopted antiretroviral treatment for prevention (TFP) as a blanket strategy for HIV control. Although the overall epidemic development associated with this focus is positive, the HIV epidemic in men who have sex with men (MSM) is continuing unperturbed without any signs of decline or reversal. This raises doubt about whether TFP as a blanket HIV prevention policy is the right approach. This paper reviews currently available biomedical HIV prevention strategies, national HIV prevention policies and guidelines from selected countries and published data on the HIV cascade in MSM. No evidence for efficacy of TFP in protecting MSM from HIV infection was found. The rationale for this approach is based on assumptions about biological plausibility and external validity of latency-based efficacy found in heterosexual couples. This is different from the route and timing of HIV transmission in MSM. New HIV infections in MSM principally occur in chains of acutely HIV-infected highly sexually active young men, in whom acquisition and transmission are correlated in space and time. By the time TFP renders its effects, most new HIV infections in MSM will have already occurred. On a global level, less than 6% of all reports regarding the HIV care cascade from 1990 to 2016 included MSM, and only 2.3% concerned MSM in low/middle-income countries. Only one report originated from Asia Pacific. Generally, HIV cascade data in MSM show a sobering picture of TFP in engaging and retaining MSM along the continuum. Widening the cascade with a preventive extension, including pre-exposure prophylaxis, the first proven efficacious and only biomedical HIV prevention strategy in MSM, will be instrumental in achieving HIV epidemic control in this group.
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Affiliation(s)
- Frits van Griensven
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Thomas E Guadamuz
- Department of Society and Health, Mahidol University, Nakorn Pathom, Thailand
| | | | - Nittaya Phanuphak
- Prevention Department, Thai Red Cross AIDS Research Center, Bangkok, Thailand
| | - Sunil Suhas Solomon
- Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ying-Ru Lo
- HIV, Hepatitis and STI Unit, Regional Office for the Western Pacific, World Health Organization, Manila, Philippines
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Lessons Learned From Transitioning PEPFAR Track 1.0 Care and Treatment Programs: Case Studies in Financial Management Capacity Building in Zambia and Botswana. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2017; 21:564-72. [PMID: 25514757 DOI: 10.1097/phh.0000000000000194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In 2008, the United States government mandated transition of internationally managed HIV care and treatment programs to local country ownership. Three case studies illustrate the US Health Resources Services Administration's fiscal assessment and technical assistance (TA) processes to strengthen local organizations' capabilities to absorb and manage United States government funding. Review of initial, TA and follow-up reports reveal that the 1 Botswanan and 2 Zambian organizations closed 10 of 17 financial capacity gaps, with Health Resources Services Administration assisting on 2. Zambian organizations requested and absorbed targeted TA on the basis of the consultant's desk review, their finance staff revised fiscal policies and procedures, and accordingly trained other staff. In Botswana, delays in integrating recommendations necessitated on-site TA for knowledge building and role modeling. Organizational maturity may explain differences in responsiveness, ownership, and required TA approaches. Clarifying expectations of capacity building, funding agreement, and nonmonetary donor involvement can help new organizations determine and act on intervening actions.
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Teklu AM, Delele K, Abraha M, Belayhun B, Gudina EK, Nega A. Exploratory Analysis of Time from HIV Diagnosis to ART Start, Factors and effect on survival: A longitudinal follow up study at seven teaching hospitals in Ethiopia. Ethiop J Health Sci 2017; 27:17-28. [PMID: 28465650 PMCID: PMC5402800 DOI: 10.4314/ejhs.v27i1.3s] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 08/12/2016] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The HIV care in Ethiopia has reached 79% coverage. The timeliness of the care provided at the different levels in the course of the disease starting from knowing HIV positive status to ART initiation is not well known. This study intends to explore the timing of the care seeking, the care provision and associated factors. METHODS This is a longitudinal follow-up study at seven university hospitals. Patients enrolled in HIV care from September 2005 to December 2013 and aged ≥14 years were studied. Different times in the cascade of HIV care were examined including the duration from date HIV diagnosed to enrollment in HIV care, duration from enrollment to eligibility for ART and time from eligibility to initiation of ART. Ordinal logistic regression was used to investigate their determinants while the effect of these periods on survival of patients was determined using cox-proportional hazards regression. RESULTS 4159 clients were studied. Time to enrollment after HIV test decreased from 39 days in 2005 to 1 day after 2008. It took longer if baseline CD4 was higher, and eligibility for ART was assessed late. Young adults, lower baseline CD4, HIV diagnosis<2008, late enrollment, and early eligibility assessment were associated with early ART initiation. Male gender, advanced disease stage and lower baseline CD4 were consistent risk factors for mortality. CONCLUSION AND RECOMMENDATION Time to enrollment and duration of ART eligibility assessment as well as ART initiation time after eligibility is improving. Further study is required to identify why mortality is slightly increasing after 2010.
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Affiliation(s)
| | | | | | | | | | - Abiy Nega
- MERQ Consultancy Services, Addis Ababa, Ethiopia
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Palma AM, Rabkin M, Nuwagaba-Biribonwoha H, Bongomin P, Lukhele N, Dlamini X, Kidane A, El-Sadr WM. Can the Success of HIV Scale-Up Advance the Global Chronic NCD Agenda? Glob Heart 2016; 11:403-408. [PMID: 27938826 PMCID: PMC5157698 DOI: 10.1016/j.gheart.2016.10.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 10/04/2016] [Indexed: 11/30/2022] Open
Abstract
Noncommunicable diseases (NCD) are the leading causes of death and disability worldwide but have received suboptimal attention and funding from the global health community. Although the first United Nations General Assembly Special Session (UNGASS) for NCD in 2011 aimed to stimulate donor funding and political action, only 1.3% of official development assistance for health was allocated to NCD in 2015, even less than in 2011. In stark contrast, the UNGASS on human immunodeficiency virus and acquired immune deficiency syndrome (HIV/AIDS) in 2001 sparked billions of dollars in funding for HIV and enabled millions of HIV-infected individuals to access antiretroviral treatment. Using an existing analytic framework, we compare the global responses to the HIV and NCD epidemics and distill lessons from the HIV response that might be utilized to enhance the global NCD response. These include: 1) further educating and empowering communities and patients to increase demand for NCD services and to hold national governments accountable for establishing and achieving NCD targets; and 2) evidence to support the feasibility and effectiveness of large-scale NCD screening and treatment programs in low-resource settings. We conclude with a case study from Swaziland, a country that is making progress in confronting both HIV and NCD.
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Affiliation(s)
- Anton M Palma
- Department of Epidemiology, Columbia University, New York, NY, USA; ICAP at Columbia University, New York, NY, USA.
| | - Miriam Rabkin
- Department of Epidemiology, Columbia University, New York, NY, USA; ICAP at Columbia University, New York, NY, USA; Department of Medicine, Columbia University, New York, NY, USA
| | - Harriet Nuwagaba-Biribonwoha
- Department of Epidemiology, Columbia University, New York, NY, USA; ICAP at Columbia University, New York, NY, USA
| | - Pido Bongomin
- Department of Epidemiology, Columbia University, New York, NY, USA; ICAP at Columbia University, New York, NY, USA
| | | | | | | | - Wafaa M El-Sadr
- Department of Epidemiology, Columbia University, New York, NY, USA; ICAP at Columbia University, New York, NY, USA; Department of Medicine, Columbia University, New York, NY, USA
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Zakumumpa H, Taiwo MO, Muganzi A, Ssengooba F. Human resources for health strategies adopted by providers in resource-limited settings to sustain long-term delivery of ART: a mixed-methods study from Uganda. HUMAN RESOURCES FOR HEALTH 2016; 14:63. [PMID: 27756428 PMCID: PMC5070071 DOI: 10.1186/s12960-016-0160-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 10/01/2016] [Indexed: 05/25/2023]
Abstract
BACKGROUND Human resources for health (HRH) constraints are a major barrier to the sustainability of antiretroviral therapy (ART) scale-up programs in Sub-Saharan Africa. Many prior approaches to HRH constraints have taken a top-down trend of generalized global strategies and policy guidelines. The objective of the study was to examine the human resources for health strategies adopted by front-line providers in Uganda to sustain ART delivery beyond the initial ART scale-up phase between 2004 and 2009. METHODS A two-phase mixed-methods approach was adopted. In the first phase, a survey of a nationally representative sample of health facilities (n = 195) across Uganda was conducted. The second phase involved in-depth interviews (n = 36) with ART clinic managers and staff of 6 of the 195 health facilities purposively selected from the first study phase. Quantitative data was analysed based on descriptive statistics, and qualitative data was analysed by coding and thematic analysis. RESULTS The identified strategies were categorized into five themes: (1) providing monetary and non-monetary incentives to health workers on busy ART clinic days; (2) workload reduction through spacing ART clinic appointments; (3) adopting training workshops in ART management as a motivation strategy for health workers; (4) adopting non-physician-centred staffing models; and (5) devising ART program leadership styles that enhanced health worker commitment. CONCLUSIONS Facility-level strategies for responding to HRH constraints are feasible and can contribute to efforts to increase country ownership of HIV programs in resource-limited settings. Consideration of the human resources for health strategies identified in the study by ART program planners and managers could enhance the long-term sustainment of ART programs by providers in resource-limited settings.
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Affiliation(s)
- Henry Zakumumpa
- School of Public Health, Makerere University, Kampala, Uganda
| | | | - Alex Muganzi
- The Infectious Diseases Institute, Makerere University, Kampala, Uganda
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Zakumumpa H, Bennett S, Ssengooba F. Accounting for variations in ART program sustainability outcomes in health facilities in Uganda: a comparative case study analysis. BMC Health Serv Res 2016; 16:584. [PMID: 27756359 PMCID: PMC5070310 DOI: 10.1186/s12913-016-1833-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Accepted: 10/08/2016] [Indexed: 11/13/2022] Open
Abstract
Background Uganda implemented a national ART scale-up program at public and private health facilities between 2004 and 2009. Little is known about how and why some health facilities have sustained ART programs and why others have not sustained these interventions. The objective of the study was to identify facilitators and barriers to the long-term sustainability of ART programs at six health facilities in Uganda which received donor support to commence ART between 2004 and 2009. Methods A case-study approach was adopted. Six health facilities were purposively selected for in-depth study from a national sample of 195 health facilities across Uganda which participated in an earlier study phase. The six health facilities were placed in three categories of sustainability; High Sustainers (2), Low Sustainers (2) and Non- Sustainers (2). Semi-structured interviews with ART Clinic managers (N = 18) were conducted. Questionnaire data were analyzed (N = 12). Document review augmented respondent data. Based on the data generated, across-case comparative analyses were performed. Data were collected between February and June 2015. Results Several distinguishing features were found between High Sustainers, and Low and Non-Sustainers’ ART program characteristics. High Sustainers had larger ART programs with higher staffing and patient volumes, a broader ‘menu’ of ART services and more stable program leadership compared to the other cases. High Sustainers associated sustained ART programs with multiple funding streams, robust ART program evaluation systems and having internal and external program champions. Low and Non Sustainers reported similar barriers of shortage and attrition of ART-proficient staff, low capacity for ART program reporting, irregular and insufficient supply of ARV drugs and a lack of alignment between ART scale-up and their for-profit orientation in three of the cases. Conclusions We found that ART program sustainability was embedded in a complex system involving dynamic interactions between internal (program champion, staffing strength, M &E systems, goal clarity) and external drivers (donors, ARVs supply chain, patient demand). ART program sustainability contexts were distinguished by the size of health facility and ownership-type. The study’s implications for health systems strengthening in resource-limited countries are discussed.
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Affiliation(s)
- Henry Zakumumpa
- Makerere University, School of Public Health, Kampala, Uganda.
| | - Sara Bennett
- Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA
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Abstract
This review traces the course of the US President's Emergency Plan for AIDS Relief (PEPFAR) as a foreign aid program. It illustrates how the epidemiologic and geopolitical environments of the early 2000s influenced PEPFAR's early directions and contributed to its successes. In addition to scaling up infrastructure and care delivery platforms, PEPFAR led to large increases in the number of people receiving antiretroviral therapy and reductions in mortality. These successes, in turn, have brought its principal challenges-its outsized budget, narrow focus, and problem of entitlement-into sharp relief. PEPFAR's recent evolution, then, has been in response to these challenges. This review suggests that PEPFAR's early formulation as an emergency response relieved it from a need to articulate clear goals, and that this freedom is now leading to new challenges as it struggles to identify priorities in the face of expectations to do more with a flat budget.
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Affiliation(s)
- Eran Bendavid
- Division of General Medical Disciplines, Stanford University, Stanford, CA, 94305, USA.
- Center for Health Policy and the Center for Primary Care and Outcomes Research, Stanford University, Stanford, CA, USA.
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Automating indicator data reporting from health facility EMR to a national aggregate data system in Kenya: An Interoperability field-test using OpenMRS and DHIS2. Online J Public Health Inform 2016; 8:e188. [PMID: 28149444 PMCID: PMC5266757 DOI: 10.5210/ojphi.v8i2.6722] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Introduction:Developing countries are increasingly strengthening national health
information systems (HIS) for evidence-based decision-making. However, the
inability to report indicator data automatically from electronic medical
record systems (EMR) hinders this process. Data are often printed and
manually re-entered into aggregate reporting systems. This affects data
completeness, accuracy, reporting timeliness, and burdens staff who support
routine indicator reporting from patient-level data.
Method: After conducting a feasibility
test to exchange indicator data from Open Medical Records System (OpenMRS)
to District Health Information System version 2 (DHIS2), we conducted a
field test at a health facility in Kenya. We configured a field-test DHIS2
instance, similar to the Kenya Ministry of Health (MOH) DHIS2, to receive
HIV care and treatment indicator data and the KenyaEMR, a customized version
of OpenMRS, to generate and transmit the data from a health facility. After
training facility staff how to send data using DHIS2 reporting module, we compared
completeness, accuracy and timeliness of automated indicator reporting with
facility monthly reports manually entered into MOH DHIS2.
Results: All 45 data values in the
automated reporting process were 100% complete and accurate while in manual
entry process, data completeness ranged from 66.7% to 100% and accuracy
ranged from 33.3% to 95.6% for seven months (July 2013-January 2014). Manual
tally and entry process required at least one person to perform each of the
five reporting activities, generating data from EMR and manual entry
required at least one person to perform each of the three reporting
activities, while automated reporting process had one activity performed by
one person. Manual tally and entry observed in October 2013 took 375
minutes. Average time to generate data and manually enter into DHIS2 was
over half an hour (M=32.35 mins, SD=0.29) compared to less than a minute for
automated submission (M=0.19 mins, SD=0.15). Discussion and
Conclusion: The results indicate that indicator data
sent electronically from OpenMRS-based EMR at a health facility to DHIS2
improves data completeness, eliminates transcription errors and delays in
reporting, and reduces the reporting burden on human resources. This
increases availability of quality indicator data using available resources
to facilitate monitoring service delivery and measuring progress towards set
goals.
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Shrivastava R, Gadde R, Nkengasong JN. Importance of Public-Private Partnerships: Strengthening Laboratory Medicine Systems and Clinical Practice in Africa. J Infect Dis 2016; 213 Suppl 2:S35-40. [PMID: 27025696 DOI: 10.1093/infdis/jiv574] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
After the launch of the US President's Emergency Plan for AIDS Relief in 2003, it became evident that inadequate laboratory systems and services would severely limit the scale-up of human immunodeficiency virus infection prevention, care, and treatment programs. Thus, the Office of the US Global AIDS Coordinator, Centers for Disease Control and Prevention, and Becton, Dickinson and Company developed a public-private partnership (PPP). Between October 2007 and July 2012, the PPP combined the competencies of the public and private sectors to boost sustainable laboratory systems and develop workforce skills in 4 African countries. Key accomplishments of the initiative include measurable and scalable outcomes to strengthen national capacities to build technical skills, develop sample referral networks, map disease prevalence, support evidence-based health programming, and drive continuous quality improvement in laboratories. This report details lessons learned from our experience and a series of recommendations on how to achieve successful PPPs.
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Affiliation(s)
- Ritu Shrivastava
- International Laboratory Branch, Division of Global HIV/AIDS, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Renuka Gadde
- Becton, Dickinson, and Company, Franklin Lakes, New Jersey
| | - John N Nkengasong
- International Laboratory Branch, Division of Global HIV/AIDS, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
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Vo QT, Hoffman S, Nash D, El-Sadr WM, Tymejczyk OA, Gadisa T, Melaku Z, Kulkarni SG, Remien RH, Elul B. Gender Differences and Psychosocial Factors Associated with Quality of Life Among ART Initiators in Oromia, Ethiopia. AIDS Behav 2016; 20:1682-91. [PMID: 27091027 DOI: 10.1007/s10461-016-1396-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Health-related quality of life (HRQoL) is an important outcome to assess among persons living with HIV/AIDS, but few studies have been conducted in sub-Saharan Africa. We examined HRQoL among 1180 ART-initiating adults from six clinics in Ethiopia in 2012-2013, and compared the correlates of two subscale scores between women and men. Women scored significantly higher than men on both overall function (8.4 points higher) and life satisfaction (6.3 points higher). In multivariable models, psychological distress, low CD4+ count, unemployment, and food insecurity were associated with lower quality of life scores among women and men. Men whose last sexual encounter occurred 3 months to 1 year from the interview date had lower overall function and life satisfaction scores. Men between the ages of 30-39 had lower overall function scores. Protestant women and women in the low-middle social support category had lower life satisfaction scores. Assessment of HRQoL over time will help inform HIV care and treatment practices to ensure favorable patient outcomes.
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Affiliation(s)
- Quynh T Vo
- ICAP-Columbia University, Mailman School of Public Health, Columbia University, 722 West 168th Street, New York, NY, 10032, USA.
| | - Susie Hoffman
- HIV Center for Clinical and Behavioral Studies at the NYS Psychiatric Institute, Columbia University, New York, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, USA
| | - Denis Nash
- Epidemiology and Biostatistics Program, City University of New York School of Public Health, New York, USA
| | - Wafaa M El-Sadr
- ICAP-Columbia University, Mailman School of Public Health, Columbia University, 722 West 168th Street, New York, NY, 10032, USA
| | - Olga A Tymejczyk
- Epidemiology and Biostatistics Program, City University of New York School of Public Health, New York, USA
| | - Tsigereda Gadisa
- ICAP-Columbia University, Mailman School of Public Health, Columbia University, 722 West 168th Street, New York, NY, 10032, USA
| | - Zenebe Melaku
- ICAP-Columbia University, Mailman School of Public Health, Columbia University, 722 West 168th Street, New York, NY, 10032, USA
| | - Sarah G Kulkarni
- Epidemiology and Biostatistics Program, City University of New York School of Public Health, New York, USA
| | - Robert H Remien
- HIV Center for Clinical and Behavioral Studies at the NYS Psychiatric Institute, Columbia University, New York, USA
| | - Batya Elul
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, USA
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Green NS, Mathur S, Kiguli S, Makani J, Fashakin V, LaRussa P, Lyimo M, Abrams EJ, Mulumba L, Mupere E. Family, Community, and Health System Considerations for Reducing the Burden of Pediatric Sickle Cell Disease in Uganda Through Newborn Screening. Glob Pediatr Health 2016; 3:2333794X16637767. [PMID: 27336011 PMCID: PMC4905129 DOI: 10.1177/2333794x16637767] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Revised: 01/30/2016] [Accepted: 02/08/2016] [Indexed: 11/15/2022] Open
Abstract
Sickle cell disease (SCD) is associated with high mortality for children under 5 years of age in sub-Saharan Africa. Newborn sickle screening program and enhanced capacity for SCD treatment are under development to reduce disease burden in Uganda and elsewhere in the region. Based on an international stakeholder meeting and a family-directed conference on SCD in Kampala in 2015, and interviews with parents, multinational experts, and other key informants, we describe health care, community, and family perspectives in support of these initiatives. Key stakeholder meetings, discussions, and interviews were held to understand perspectives of public health and multinational leadership, patients and families, as well as national progress, resource needs, medical and social barriers to program success, and resources leveraged from HIV/AIDS. Partnering with program leadership, professionals, patients and families, multinational stakeholders, and leveraging resources from existing programs are needed for building successful programs in Uganda and elsewhere in sub-Saharan Africa.
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Affiliation(s)
| | | | | | - Julie Makani
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | | | - Magdalena Lyimo
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Lukia Mulumba
- Uganda-American Sickle Cell Rescue Fund, Kampala, Uganda
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Kirmse B, Yao TJ, Hofherr S, Kacanek D, Williams PL, Hobbs CV, Hazra R, Borkowsky W, Van Dyke RB, Summar M. Acylcarnitine Profiles in HIV-Exposed, Uninfected Neonates in the United States. AIDS Res Hum Retroviruses 2016; 32:339-48. [PMID: 26548585 DOI: 10.1089/aid.2015.0112] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
We sought to determine the prevalence of abnormal acylcarnitine profiles (ACP) in HIV-exposed uninfected (HEU) newborns and to explore the association of abnormal ACP with clinical laboratory outcomes and antiretroviral drug exposures. Clinically, ACP are used to assess for fatty acid oxidation (FAO) dysfunction and normal FAO is necessary for optimal fetal/neonatal growth and development. We analyzed serum ACP in 522 HEU neonates enrolled in the Surveillance Monitoring for ART Toxicities (SMARTT) study of the Pediatric HIV/AIDS Cohort Study (PHACS) and evaluated the associations of abnormal ACP with in utero exposure to combination antiretroviral therapy (cART) in logistic regression models, adjusting for maternal demographic, disease, and behavioral characteristics. We evaluated the associations of abnormal ACP with laboratory parameters and measures of neurodevelopment and growth. Of 522 neonates, 89 (17%) had abnormal ACP. In adjusted analyses, in utero exposure to a protease inhibitor (PI) was associated with higher odds of having an abnormal ACP [adjusted odds ratio (aOR) = 2.35, 95% CI: 0.96, 5.76, p = 0.06] with marginal significance while exposure to a nonnucleoside reverse transcriptase inhibitor (NNRTI) was associated with lower odds (aOR = 0.23, 95% CI: 0.07, 0.80, p = 0.02). Mean ALT levels were slightly higher in those with abnormal ACP, but no differences in lactate, glucose, or CPK were observed. ACP status was not associated with neurodevelopment at 1 year or growth at 2 and 3 years of age. Abnormal ACP in HEU neonates are associated with exposure to PI-containing as opposed to NNRTI-containing antiretroviral (ARV) regimens but are not associated with serious postnatal clinical problems. Further studies are needed to determine the long-term health implications of abnormal acylcarnitine metabolism at birth in HEU children.
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Affiliation(s)
- Brian Kirmse
- Children's National Health System, Division of Genetics & Metabolism, Washington, DC
| | - Tzy-Jyun Yao
- Harvard T.H. Chan School of Public Health, Center for Biostatistics in AIDS Research, Boston, Massachusetts
| | - Sean Hofherr
- Children's National Health System, Division of Genetics & Metabolism, Washington, DC
| | - Deborah Kacanek
- Harvard T.H. Chan School of Public Health, Center for Biostatistics in AIDS Research, Boston, Massachusetts
| | - Paige L. Williams
- Harvard T.H. Chan School of Public Health, Center for Biostatistics in AIDS Research, Boston, Massachusetts
| | - Charlotte V. Hobbs
- New York University/Langone School of Medicine, Division of Pediatric Infectious Disease and Immunology, New York, New York
| | - Rohan Hazra
- National Institutes of Health (NICHD), Maternal and Pediatric Infectious Disease Branch, Bethesda, Maryland
| | - William Borkowsky
- New York University/Langone School of Medicine, Division of Pediatric Infectious Disease and Immunology, New York, New York
| | | | - Marshall Summar
- Children's National Health System, Division of Genetics & Metabolism, Washington, DC
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50
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Marten MG. From emergency to sustainability: shifting objectives in the US Government's HIV response in Tanzania. Glob Public Health 2015; 12:988-1003. [PMID: 26609563 DOI: 10.1080/17441692.2015.1094707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The US President's Emergency Plan for AIDS Relief (PEPFAR) was originally designed as an emergency initiative, operating with considerable funds, immediate roll-out, fast scale-up, and top-down technocratic administration. In a more recent iteration, PEPFAR shifted its focus from an emergency response to more closely account for healthcare sustainability. This transition came on the heels of the 2008 financial crisis, which threatened to stall the 'marvellous momentum' of the 2000's boom in donor aid for global health overall. Now many programmes are having to do more with less as funding flattens or decreases. This paper examines how this transition took shape in Tanzania in 2011-2012, and the successes and challenges associated with it, using participant observation and interview data from 20 months of fieldwork in rural and urban healthcare settings. In particular, I discuss (1) efforts to increase sustainability and country ownership of HIV programmes in Tanzania, focusing on the shift from PEPFAR-funded American non-governmental organisations to Tanzanian partner organisations; (2) principal challenges stakeholders encountered during the transition, including fragmented systems of healthcare delivery and a weakened healthcare workforce; and (3) strategies informants identified to better integrate services in order to build a stronger, more equitable, and sustainable health system in Tanzania.
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Affiliation(s)
- Meredith G Marten
- a Department of Anthropology , University of West Florida , Pensacola , FL , USA
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