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Leeper SC, Montague BT, Friedman JF, Flanigan TP. Lessons learned from family-centred models of treatment for children living with HIV: current approaches and future directions. J Int AIDS Soc 2010; 13 Suppl 2:S3. [PMID: 20573285 PMCID: PMC2890972 DOI: 10.1186/1758-2652-13-s2-s3] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Despite strong global interest in family-centred HIV care models, no reviews exist that detail the current approaches to family-centred care and their impact on the health of children with HIV. A systematic review of family-centred HIV care programmes was conducted in order to describe both programme components and paediatric cohort characteristics. METHODS We searched online databases, including PubMed and the International AIDS Society abstract database, using systematic criteria. Data were extracted regarding programme setting, staffing, services available and enrolment methods, as well as cohort demographics and paediatric outcomes. RESULTS The search yielded 25 publications and abstracts describing 22 separate cohorts. These contained between 43 and 657 children, and varied widely in terms of staffing, services provided, enrolment methods and cohort demographics. Data on clinical outcomes was limited, but generally positive. Excellent adherence, retention in care, and low mortality and/or loss to follow up were documented. CONCLUSIONS The family-centred model of care addresses many needs of infected patients and other household members. Major reported obstacles involved recruiting one or more types of family members into care, early diagnosis and treatment of infected children, preventing mortality during children's first six months of highly active antiretroviral therapy, and staffing and infrastructural limitations. Recommendations include: developing interventions to enrol hard-to-reach populations; identifying high-risk patients at treatment initiation and providing specialized care; and designing and implementing evidence-based care packages. Increased research on family-centred care, and better documentation of interventions and outcomes is also critical.
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Affiliation(s)
- Sarah C Leeper
- Brown University Medical School, Providence, Rhode Island, USA.
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Sauvageot D, Schaefer M, Olson D, Pujades-Rodriguez M, O'Brien DP. Antiretroviral therapy outcomes in resource-limited settings for HIV-infected children <5 years of age. Pediatrics 2010; 125:e1039-47. [PMID: 20385636 DOI: 10.1542/peds.2009-1062] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE We describe medium-term outcomes for young children receiving antiretroviral therapy (ART) in resource-limited countries. METHODS Analyses were conducted on surveillance data for children <5 years of age receiving ART (initiated April 2002 to January 2008) in 48 HIV/AIDS treatment programs in Africa and Asia. Primary outcome measures were probability of remaining in care, probability of developing World Health Organization stage 4 clinical events, rate of switching to second-line ART, and drug toxicity, compared at 6, 12, 24, and 36 months of ART. RESULTS Of 3936 children (90% in Africa) initiating ART, 9% were <12 months, 50% were 12 to 35 months, and 41% were 36 to 59 months of age. The median time of ART was 10.5 months. Probabilities of remaining in care after 12, 24, and 36 months of ART were 0.85, 0.80, and 0.75, respectively. Compared with children 36 to 59 months of age at ART initiation, probabilities of remaining in care were significantly lower for children <12 months of age. Overall, 55% and 69% of deaths and losses to follow-up occurred in the first 3 and 6 months of ART, respectively. Probabilities of developing stage 4 clinical events after 12, 24, and 36 months of ART were 0.03, 0.06, and 0.09, respectively. Only 33 subjects (0.8%) switched to second-line regimens, and 151 (3.8%) experienced severe drug toxicities. CONCLUSIONS Large-scale ART for children <5 years of age in resource-limited settings is feasible, with encouraging clinical outcomes, but efforts should be increased to improve early HIV diagnosis and treatment.
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Early clinical outcomes in children enrolled in human immunodeficiency virus infection care and treatment in lesotho. Pediatr Infect Dis J 2010; 29:340-5. [PMID: 20019645 DOI: 10.1097/inf.0b013e3181bf8ecb] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Children are largely underrepresented among those accessing treatment of HIV infection in Africa. Reported outcomes of children enrolled in national care and treatment programs are needed to inform the widespread scale-up of pediatric HIV care in resource-limited settings. METHODS The objective of this article is to report on the early outcomes of a pediatric HIV infection care and treatment program in Lesotho during its first 14 months of operation. Clinical protocols are described, and characteristics and outcomes of the first cohort of children enrolled in care are reported, derived from a retrospective review of medical records. RESULTS In the program's first 14 months, 1566 children and adolescents aged between 0 and 16 years were evaluated for HIV, with 567 (36%) confirmed to be infected. Of infected patients, 61% presented with advanced or severe symptoms of HIV disease and 65% presented with CD4 profiles consistent with advanced or severe immunodeficiency, based on World Health Organization 2006 guidelines. Two hundred and eighty four children received highly active antiretroviral therapy. The mortality rate was 18.6 deaths per 100 patient years of follow-up. Ninety-nine percent of deaths occurred within 90 days of enrollment. Deceased patients were significantly younger, had higher rates of stunting and wasting, and were more likely to present with low CD4 cell counts. CONCLUSION Highly active antiretroviral therapy was well tolerated, but the early mortality rate was high despite concurrent management of HIV and comorbidities. Given that hundreds of thousands of children remain without access to HIV care, renewed efforts are needed to reach this underserved population.
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Callaghan M, Ford N, Schneider H. A systematic review of task- shifting for HIV treatment and care in Africa. HUMAN RESOURCES FOR HEALTH 2010; 8:8. [PMID: 20356363 PMCID: PMC2873343 DOI: 10.1186/1478-4491-8-8] [Citation(s) in RCA: 434] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2009] [Accepted: 03/31/2010] [Indexed: 05/04/2023]
Abstract
BACKGROUND Shortages of human resources for health (HRH) have severely hampered the rollout of antiretroviral therapy (ART) in sub-Saharan Africa. Current rollout models are hospital- and physician-intensive. Task shifting, or delegating tasks performed by physicians to staff with lower-level qualifications, is considered a means of expanding rollout in resource-poor or HRH-limited settings. METHODS We conducted a systematic literature review. Medline, the Cochrane library, the Social Science Citation Index, and the South African National Health Research Database were searched with the following terms: task shift*, balance of care, non-physician clinicians, substitute health care worker, community care givers, primary healthcare teams, cadres, and nurs* HIV. We mined bibliographies and corresponded with authors for further results. Grey literature was searched online, and conference proceedings searched for abstracts. RESULTS We found 2960 articles, of which 84 were included in the core review. 51 reported outcomes, including research from 10 countries in sub-Saharan Africa. The most common intervention studied was the delegation of tasks (especially initiating and monitoring HAART) from doctors to nurses and other non-physician clinicians. Five studies showed increased access to HAART through expanded clinical capacity; two concluded task shifting is cost effective; 9 showed staff equal or better quality of care; studies on non-physician clinician agreement with physician decisions was mixed, with the majority showing good agreement. CONCLUSIONS Task shifting is an effective strategy for addressing shortages of HRH in HIV treatment and care. Task shifting offers high-quality, cost-effective care to more patients than a physician-centered model. The main challenges to implementation include adequate and sustainable training, support and pay for staff in new roles, the integration of new members into healthcare teams, and the compliance of regulatory bodies. Task shifting should be considered for careful implementation where HRH shortages threaten rollout programmes.
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Affiliation(s)
- Mike Callaghan
- Department of Anthropology, University of Toronto, Canada
| | - Nathan Ford
- Médecins Sans Frontières, Cape Town, South Africa
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa
| | - Helen Schneider
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa
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Early versus deferred antiretroviral therapy in children in low-income and middle-income countries. Curr Opin HIV AIDS 2010; 5:12-7. [PMID: 20046143 DOI: 10.1097/coh.0b013e3283339b27] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW We reviewed current literatures on early and deferred initiation of antiretroviral therapy in HIV-infected infants and children in low-income and middle-income countries. RECENT FINDINGS Data from children with HIV antiretroviral (Children with HIV Early Antiretroviral Therapy) study showed a significant reduction of 76% in mortality among infants who received antiretroviral therapy within 3 months of their life as opposed to those on deferred therapy. These data led World Health Organization to promptly revise the guideline to recommend initiation of antiretroviral therapy in all HIV-infected infants regardless of clinical or immunological status. The recommendation for older children is differed between guidelines of developed and developing countries. In general, higher CD4 cell count threshold is used for younger children and similar criteria to those used for adults are used once children are above 5 years of age. The randomized study of when to start antiretroviral therapy in children older than 1 year is ongoing. SUMMARY The current trend is to move toward early treatment to reduce morbidity and mortality, achieve immune recovery, normal growth, and development. Even though the antiretroviral rollout program has been successful in Asia and Africa, the challenges lie in diagnosing infants in a timely manner and maintaining infrastructure and resources to support life-long treatment.
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Prasitsuebsai W, Bowen AC, Pang J, Hesp C, Kariminia A, Sohn AH. Pediatric HIV clinical care resources and management practices in Asia: a regional survey of the TREAT Asia pediatric network. AIDS Patient Care STDS 2010; 24:127-31. [PMID: 20059355 DOI: 10.1089/apc.2009.0224] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Characterizing intraregional differences in current pediatric HIV care and treatment in Asia can guide the development of clinical practice guidelines and improve the understanding of local resource availability. The Therapeutics Research, Education, and AIDS Training in Asia (TREAT Asia) Pediatric Program is a collaboration of clinics and referral hospitals studying pediatric HIV outcomes in the region. A Web-based survey to characterize clinical management practices and monitoring resources was developed and distributed to 20 sites in January 2008. Seventeen (85%) sites from 6 countries responded through April 2008; 14 (82%) were hospital-based and 16 (94%) were public facilities. Of 4050 HIV-infected children under care, 3606 (89%) were on antiretroviral treatment; 80% were on their first mono-, dual-, or triple-drug regimen and 74% were on nevirapine- or efavirenz-based regimens. Fifteen (88%) sites had consistent access to polymerase chain reaction (PCR) testing for infant diagnosis. All sites had access to CD4 testing, with 13 (76%) routinely monitoring patients every 3-6 months; 7 (41%) sites monitored viral load at 6- to 12-month intervals. Although there is some variation in clinical practices, high levels of treatment and monitoring resources were available at these sites. The availability of PCR for early infant diagnosis positions them to implement recent WHO recommendations to treat HIV-infected children younger than 1 year of age. This information will be used to develop future research and programs to support children with HIV in Asia.
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Affiliation(s)
| | - Asha C. Bowen
- Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Joselyn Pang
- TREAT Asia, amfAR–The Foundation for AIDS Research, Bangkok, Thailand
| | - Cees Hesp
- PharmAccess, Amsterdam, The Netherlands
| | - Azar Kariminia
- National Centre in HIV Epidemiology and Clinical Research, Sydney, New South Wales, Australia
| | - Annette H. Sohn
- TREAT Asia, amfAR–The Foundation for AIDS Research, Bangkok, Thailand
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Anaky MF, Duvignac J, Wemin L, Kouakoussui A, Karcher S, Touré S, Seyler C, Fassinou P, Dabis F, N'Dri-Yoman T, Anglaret X, Leroy V. Scaling up antiretroviral therapy for HIV-infected children in Côte d'Ivoire: determinants of survival and loss to programme. Bull World Health Organ 2009; 88:490-9. [PMID: 20616968 DOI: 10.2471/blt.09.068015] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2009] [Revised: 08/19/2009] [Accepted: 11/02/2009] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To investigate deaths and losses to follow-up in a programme designed to scale up antiretroviral therapy (ART) for HIV-infected children in Côte d'Ivoire. METHODS Between 2004 and 2007, HIV-exposed children at 19 centres were offered free HIV serum tests (polymerase chain reaction tests in those aged < 18 months) and ART. Computerized monitoring was used to determine: (i) the number of confirmed HIV infections, (ii) losses to the programme (i.e. death or loss to follow-up) before ART, (iii) mortality and loss-to-programme rates during 12 months of ART, and (iv) determinants of mortality and losses to the programme. FINDINGS The analysis included 3876 ART-naïve children. Of the 1766 with HIV-1 infections (17% aged < 18 months), 124 (7.0%) died, 52 (2.9%) left the programme, 354 (20%) were lost to follow-up before ART, 259 (15%) remained in care without ART, and 977 (55%) started ART (median age: 63 months). The overall mortality rate during ART was significantly higher in the first 3 months than in months 4-12: 32.8 and 6.9 per 100 child-years of follow-up, respectively. Loss-to-programme rates were roughly double mortality rates and followed the same trend with duration of ART. Independent predictors of 12-month mortality on ART were pre-ART weight-for-age z-score < -2, percentage of CD4+ T lymphocytes < 10, World Health Organization HIV/AIDS clinical stage 3 or 4, and blood haemoglobin < 8 g/dl. CONCLUSION The large-scale programme to scale up paediatric ART in Côte d'Ivoire was effective. However, ART was often given too late, and early mortality and losses to programme before and just after ART initiation were major problems.
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Affiliation(s)
- M-F Anaky
- Aconda-VS-CI, Abidjan, Côte d'Ivoire
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Zachariah R, Harries AD, Ishikawa N, Rieder HL, Bissell K, Laserson K, Massaquoi M, Van Herp M, Reid T. Operational research in low-income countries: what, why, and how? THE LANCET INFECTIOUS DISEASES 2009; 9:711-7. [DOI: 10.1016/s1473-3099(09)70229-4] [Citation(s) in RCA: 140] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Cohen R, Lynch S, Bygrave H, Eggers E, Vlahakis N, Hilderbrand K, Knight L, Pillay P, Saranchuk P, Goemaere E, Makakole L, Ford N. Antiretroviral treatment outcomes from a nurse-driven, community-supported HIV/AIDS treatment programme in rural Lesotho: observational cohort assessment at two years. J Int AIDS Soc 2009; 12:23. [PMID: 19814814 PMCID: PMC2768674 DOI: 10.1186/1758-2652-12-23] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2009] [Accepted: 10/08/2009] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Lesotho has the third highest HIV prevalence in the world (an adult prevalence of 23.2%). Despite a lack of resources for health, the country has implemented state-of-the-art antiretroviral treatment guidelines, including early initiation of treatment (<350 cells/mm3), tenofovir in first line, and nurse-initiated and managed HIV care, including antiretroviral therapy (ART), at primary health care level. PROGRAMME APPROACH: We describe two-year outcomes of a decentralized HIV/AIDS care programme run by Doctors Without Borders/Médecins Sans Frontières, the Ministry of Health and Social Welfare, and the Christian Health Association of Lesotho in Scott catchment area, a rural health zone covering 14 clinics and one district hospital. Outcome data are described through a retrospective cohort analysis of adults and children initiated on ART between 2006 and 2008. DISCUSSION AND EVALUATION Overall, 13,243 people have been enrolled in HIV care (5% children), and 5376 initiated on ART (6.5% children), 80% at primary care level. Between 2006 and 2008, annual enrolment more than doubled for adults and children, with no major external increase in human resources. The proportion of adults arriving sick (CD4 <50 cells/mm3) decreased from 22.2% in 2006 to 11.9% in 2008. Twelve-month outcomes are satisfactory in terms of mortality (11% for adults; 9% for children) and loss to follow up (8.8%). At 12 months, 80% of adults and 89% of children were alive and in care, meaning they were still taking their treatment; at 24 months, 77% of adults remained in care. CONCLUSION Despite major resource constraints, Lesotho is comparing favourably with its better resourced neighbour, using the latest international ART recommendations. The successful two-year outcomes are further evidence that HIV/AIDS care and treatment can be provided effectively at the primary care level. The programme highlights how improving HIV care strengthened the primary health care system, and validates several critical areas for task shifting that are being considered by other countries in the region, including nurse-driven ART for adults and children, and lay counsellor-supported testing and counselling, adherence and case management.
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Abstract
Even as pediatric rollout programs are struggling to meet global need, increasing numbers of children are failing first-line antiretroviral therapy in low- and middle-income countries. Without better access to viral load monitoring, second-line antiretrovirals and research to guide optimal regimen selection, it will be difficult to ensure that HIV-infected children will survive into adulthood. Data available on pediatric drug resistance demonstrate that failure occurs early in childhood. Studies of salvage drug options have been promising, but are primarily conducted in adults. Evidence-based approaches to regimen selection, pediatric antiretroviral formulations and expanded access to novel drugs are now required to prepare for the future.
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Affiliation(s)
- Annette H Sohn
- TREAT Asia/amfAR – The Foundation for AIDS Research, Bangkok, Thailand
| | - Jintanat Ananworanich
- The Southeast Asia Research Collaboration with Hawaii (SEARCH), Bangkok, Thailand
- The HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT), Bangkok, Thailand
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Lutalo IM, Schneider G, Weaver MR, Oyugi JH, Sebuyira LM, Kaye R, Lule F, Namagala E, Scheld WM, McAdam KPWJ, Sande MA. Training needs assessment for clinicians at antiretroviral therapy clinics: evidence from a national survey in Uganda. HUMAN RESOURCES FOR HEALTH 2009; 7:76. [PMID: 19698146 PMCID: PMC2752450 DOI: 10.1186/1478-4491-7-76] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2008] [Accepted: 08/23/2009] [Indexed: 05/28/2023]
Abstract
BACKGROUND To increase access to antiretroviral therapy in resource-limited settings, several experts recommend "task shifting" from doctors to clinical officers, nurses and midwives. This study sought to identify task shifting that has already occurred and assess the antiretroviral therapy training needs among clinicians to whom tasks have shifted. METHODS The Infectious Diseases Institute, in collaboration with the Ugandan Ministry of Health, surveyed health professionals and heads of antiretroviral therapy clinics at a stratified random sample of 44 health facilities accredited to provide this therapy. A sample of 265 doctors, clinical officers, nurses and midwives reported on tasks they performed, previous human immunodeficiency virus training, and self-assessment of knowledge of human immunodeficiency virus and antiretroviral therapy. Heads of the antiretroviral therapy clinics reported on clinic characteristics. RESULTS Thirty of 33 doctors (91%), 24 of 40 clinical officers (60%), 16 of 114 nurses (14%) and 13 of 54 midwives (24%) who worked in accredited antiretroviral therapy clinics reported that they prescribed this therapy (p<0.001). Sixty-four percent of the people who prescribed antiretroviral therapy were not doctors. Among professionals who prescribed it, 76% of doctors, 62% of clinical officers, 62% of nurses and 51% of midwives were trained in initiating patients on antiretroviral therapy (p=0.457); 73%, 46%, 50% and 23%, respectively, were trained in monitoring patients on the therapy (p=0.017). Seven percent of doctors, 42% of clinical officers, 35% of nurses and 77% of midwives assessed that their overall knowledge of antiretroviral therapy was lower than good (p=0.001). CONCLUSION Training initiatives should be an integral part of the support for task shifting and ensure that antiretroviral therapy is used correctly and that toxicity or drug resistance do not reverse accomplishments to date.
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Affiliation(s)
- Ibrahim M Lutalo
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Gisela Schneider
- DIFAEM – German Institute of Medical Mission, Tuebingen, Germany
| | - Marcia R Weaver
- Department of Global Health and International Training and Education Centre on HIV (I-TECH), University of Washington, Seattle WA, USA
| | - Jessica H Oyugi
- Coordinating Center for Infectious Diseases, Centers for Disease Control and Prevention, Lilongwe, Malawi
| | | | - Richard Kaye
- African Palliative Care Association, Kampala, Uganda
| | - Frank Lule
- Regional Office for Africa, World Health Organization, Brazzaville, Congo
| | | | - W Michael Scheld
- Department of Internal Medicine, University of Virginia, Charlottesville VA, USA
| | - Keith PWJ McAdam
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Department of Clinical Tropical Medicine, London School of Hygiene and Tropical Medicine, London, UK
- Pratt Medical Group, Tufts-New England Medical Center, Boston MA, USA
| | - Merle A Sande
- Formerly of the Department of Medicine, University of Washington, Seattle, WA, and the Accordia Global Health Foundation, Arlington, VA, USA
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