Workplace programmes for HIV and tuberculosis: a systematic review to support development of international guidelines for the health workforce

Interventions to improve linkage along the HIV-tuberculosis care cascades in low- and middle-income countries: A systematic review and meta-analysis

INTRODUCTION

In support of global targets to end HIV/AIDS and tuberculosis (TB) by 2030, we reviewed interventions aiming to improve TB case-detection and anti-TB treatment among people living with HIV (PLHIV) and HIV testing and antiretroviral treatment initiation among people with TB disease in low- and middle-income countries (LMICs).

METHODS

We conducted a systematic review of comparative (quasi-)experimental interventional studies published in Medline or EMBASE between January 2003-July 2021. We performed random-effects effect meta-analyses (DerSimonian and Laird method) for interventions that were homogenous (based on intervention descriptions); for others we narratively synthesized the intervention effect. Studies were assessed using ROBINS-I, Cochrane Risk-of-Bias, and GRADE. (PROSPERO #CRD42018109629).

RESULTS

Of 21,516 retrieved studies, 23 were included, contributing 53 arms and 84,884 participants from 4 continents. Five interventions were analyzed: co-location of test and/or treatment services; patient education and counselling; dedicated personnel; peer support; and financial support. A majority were implemented in primary health facilities (n = 22) and reported on HIV outcomes in people with TB (n = 18). Service co-location had the most consistent positive effect on HIV testing and treatment initiation among people with TB, and TB case-detection among PLHIV. Other interventions were heterogenous, implemented concurrent with standard-of-care strategies and/or diverse facility-level improvements, and produced mixed effects. Operational system, human resource, and/or laboratory strengthening were common within successful interventions. Most studies had a moderate to serious risk of bias.

CONCLUSIONS

This review provides operational clarity on intervention models that can support early linkages between the TB and HIV care cascades. The findings have supported the World Health Organization 2020 HIV Service Delivery Guidelines update. Further research is needed to evaluate the distinct effect of education and counselling, financial support, and dedicated personnel interventions, and to explore the role of community-based, virtual, and differentiated service delivery models in addressing TB-HIV co-morbidity.

Reaching 90-90-90: outcomes of a 15-year multi-country HIV workplace programme in sub-Saharan Africa

BACKGROUND

In 2001, an international beverage company implemented an HIV workplace programme providing free antiretroviral treatment (ART) for employees and dependents in sub-Saharan Africa, at a time when ART, cost assessments of ART programmes and related public funding was hardly available. This study describes the outcomes of this programme with respect to achieving the UNAIDS 90-90-90 targets in five African countries and analyses trends over the past 15 years.

METHODS

Anonymous human resource data were analysed in three cohorts of participants (those enrolling in 2001-2005, 2006-2010 and 2011-2015).

RESULTS

Over 15 years, 42,490 unique individuals in five African countries were tested for HIV in this programme and 746 (1.8%) were found to be HIV-infected. Between 2002 and 2015, the proportion of HIV-positive participants on ART increased from 42% to 94% and the proportion of participants on ART who achieved virological suppression increased from 38% to 87%.

CONCLUSIONS

This study shows that in one of the earliest HIV treatment programmes in Africa long-term success has been achieved, approaching the current UNAIDS 90-90-90 targets, demonstrating that the treatment of HIV in developing countries is possible with superior results at low costs (45 US dollars/employee). Reasons for this success include continuous access to on-site quality care and ART and the assistance of an independent NGO with experience in HIV treatment. This provides an argument to continue private sector involvement in international efforts to combat HIV/AIDS, particularly in light of increased ART targets, under-capacity in the public sector and stagnating international funding.

Effectiveness of interventions for reducing TB incidence in countries with low TB incidence: a systematic review of reviews

AIMS

What is the evidence base for the effectiveness of interventions to reduce tuberculosis (TB) incidence in countries which have low TB incidence?

METHODS

We conducted a systematic review of interventions for TB control and prevention relevant to low TB incidence settings (<10 cases per 100 000 population). Our analysis was stratified according to "direct" or "indirect" effects on TB incidence. Review quality was assessed using AMSTAR2 criteria. We summarised the strength of review level evidence for interventions as "sufficient", "tentative", "insufficient" or "no" using a framework based on the consistency of evidence within and between reviews.

RESULTS

We found sufficient review level evidence for direct effects on TB incidence/case prevention of vaccination and treatment of latent TB infection. We also found sufficient evidence of beneficial indirect effects attributable to drug susceptibility testing and adverse indirect effects (measured as sub-optimal treatment outcomes) in relation to use of standardised first-line drug regimens for isoniazid-resistant TB and intermittent dosing regimens. We found insufficient review level evidence for direct or indirect effects of interventions in other areas, including screening, adherence, multidrug-resistant TB, and healthcare-associated infection.

DISCUSSION

Our review has shown a need for stronger evidence to support expert opinion and country experience when formulating TB control policy.

Implementation of a National Workplace Wellness Program for Health Workers in Botswana

The Botswana workplace wellness program (WWP) for health care workers (HCWs) was initiated in 2007. WWP implementation was assessed using a sequential, explanatory, mixed methods design including a national implementation assessment (27 health districts) and in-depth interviews (n = 38). Level of implementation varied across districts with health screening, therapeutic recreation, and health promotion implemented more frequently than occupational health activities and psychosocial services. Facilitators to WWP implementation included establishment of a dedicated, diverse WWP committee; provision of administrative support, and integration of activities into organizational culture. Barriers included competing priorities related to delivery of health services to clients, limited technical ability to deliver occupation health activities and psychosocial support, receipt of health services from colleagues, and limited appreciation for personal wellness by some HCWs. Ensuring the well-being of HCWs is critical in reaching international health goals.

Associations between healthcare worker participation in workplace wellness activities and job satisfaction, occupational stress and burnout: a cross-sectional study in Botswana

OBJECTIVES

Healthcare workers (HWs) are prone to high levels of stress and burnout, particularly when caring for people with HIV/AIDS. This study assessed whether participation in Botswana's Workplace Wellness Programme (WWP) for HWs was associated with job satisfaction, occupational stress, well-being and burnout.

METHODS

Using multistage sampling, a paper-based questionnaire was distributed to 1856 randomly selected HWs at 135 public facilities across Botswana. Well-validated scales assessed key outcomes. Analysis of covariance models were built for psychosocial factors associated with WWP participation, controlling for associated demographics.

RESULTS

Response rate was 73% (n=1348). The majority of respondents were female (62%), not married (65%) and had children (84%). Mean age was 40.0 years (SD±9.9). Respondents were roughly split between participation in no WWP activities (29.4%), 1-6 WWP activities (38.9%) and seven or more WWP activities (31.7%) in the past year. High participation was associated with older age, being a doctor or other professional, working at hospitals or District Health Management Teams, working longer in health services or working longer at a facility. In unadjusted analyses, high participation was significantly associated (P<0.05) with higher satisfaction with overall job, work, supervision, promotion, pay and professional efficacy and lower stress, exhaustion and cynicism. All associations remained significant in controlled analyses except cynicism.

CONCLUSIONS

Results from this study suggest that participation in workplace wellness activities is associated with higher satisfaction with multiple job facets and lower stress, exhaustion and cynicism. Introduction of these activities may help ameliorate high occupational stress levels among HWs.

African and Caribbean Nurses' Decisions about HIV Testing: A Mixed Methods Study

Nurses in Jamaica, Kenya, South Africa, and Uganda are at risk for occupational exposure to HIV. Little is known about the experiences and policy supports related to nurses having themselves tested for the virus. This article reports a mixed-methods study about contextual influences on nurses' decision-making about HIV testing. Individual and focus group interviews, as well as a questionnaire on workplace polices and quality assurance and a human resource management assessment tool provided data. Fear of a positive diagnosis and stigma and lack of confidentiality along with gaps in the policy environment contributed to indecision about testing. There were significant differences in policy supports among countries. Institutional support must be addressed if improvements in HIV testing for health care workers are going to be effectively implemented. Future work is required to better understand how HRM policies intersect to create conditions of perceived vulnerability for HIV positive staff.

The Development and Piloting of Parallel Scales Measuring External and Internal HIV and Tuberculosis Stigma Among Healthcare Workers in the Free State Province, South Africa

BACKGROUND

The dual burden of tuberculosis and human immunodeficiency virus (HIV) is severely impacting the South African healthcare workforce. However, the use of on-site occupational health services is hampered by stigma among the healthcare workforce. The success of stigma-reduction interventions is difficult to evaluate because of a dearth of appropriate scientific tools to measure stigma in this specific professional setting.

METHODS

The current pilot study aimed to develop and test a range of scales measuring different aspects of stigma-internal and external stigma toward tuberculosis as well as HIV-in a South African healthcare setting. The study employed data of a sample of 200 staff members of a large hospital in Bloemfontein, South Africa.

RESULTS

Confirmatory factor analysis produced 7 scales, displaying internal construct validity: (1) colleagues' external HIV stigma, (2) colleagues' actions against external HIV stigma, (3) respondent's external HIV stigma, (4) respondent's internal HIV stigma, (5) colleagues' external tuberculosis stigma, (6) respondent's external tuberculosis stigma, and (7) respondent's internal tuberculosis stigma. Subsequent analyses (reliability analysis, structural equation modeling) demonstrated that the scales displayed good psychometric properties in terms of reliability and external construct validity.

CONCLUSIONS

The study outcomes support the use of the developed scales as a valid and reliable means to measure levels of tuberculosis- and HIV-related stigma among the healthcare workforce in a resource-limited context. Future studies should build on these findings to fine-tune the instruments and apply them to larger study populations across a range of different resource-limited healthcare settings with high HIV and tuberculosis prevalence.

Delivery arrangements for health systems in low-income countries: an overview of systematic reviews

BACKGROUND

Delivery arrangements include changes in who receives care and when, who provides care, the working conditions of those who provide care, coordination of care amongst different providers, where care is provided, the use of information and communication technology to deliver care, and quality and safety systems. How services are delivered can have impacts on the effectiveness, efficiency and equity of health systems. This broad overview of the findings of systematic reviews can help policymakers and other stakeholders identify strategies for addressing problems and improve the delivery of services.

OBJECTIVES

To provide an overview of the available evidence from up-to-date systematic reviews about the effects of delivery arrangements for health systems in low-income countries. Secondary objectives include identifying needs and priorities for future evaluations and systematic reviews on delivery arrangements and informing refinements of the framework for delivery arrangements outlined in the review.

METHODS

We searched Health Systems Evidence in November 2010 and PDQ-Evidence up to 17 December 2016 for systematic reviews. We did not apply any date, language or publication status limitations in the searches. We included well-conducted systematic reviews of studies that assessed the effects of delivery arrangements on patient outcomes (health and health behaviours), the quality or utilisation of healthcare services, resource use, healthcare provider outcomes (such as sick leave), or social outcomes (such as poverty or employment) and that were published after April 2005. We excluded reviews with limitations important enough to compromise the reliability of the findings. Two overview authors independently screened reviews, extracted data, and assessed the certainty of evidence using GRADE. We prepared SUPPORT Summaries for eligible reviews, including key messages, 'Summary of findings' tables (using GRADE to assess the certainty of the evidence), and assessments of the relevance of findings to low-income countries.

MAIN RESULTS

We identified 7272 systematic reviews and included 51 of them in this overview. We judged 6 of the 51 reviews to have important methodological limitations and the other 45 to have only minor limitations. We grouped delivery arrangements into eight categories. Some reviews provided more than one comparison and were in more than one category. Across these categories, the following intervention were effective; that is, they have desirable effects on at least one outcome with moderate- or high-certainty evidence and no moderate- or high-certainty evidence of undesirable effects. Who receives care and when: queuing strategies and antenatal care to groups of mothers. Who provides care: lay health workers for caring for people with hypertension, lay health workers to deliver care for mothers and children or infectious diseases, lay health workers to deliver community-based neonatal care packages, midlevel health professionals for abortion care, social support to pregnant women at risk, midwife-led care for childbearing women, non-specialist providers in mental health and neurology, and physician-nurse substitution. Coordination of care: hospital clinical pathways, case management for people living with HIV and AIDS, interactive communication between primary care doctors and specialists, hospital discharge planning, adding a service to an existing service and integrating delivery models, referral from primary to secondary care, physician-led versus nurse-led triage in emergency departments, and team midwifery. Where care is provided: high-volume institutions, home-based care (with or without multidisciplinary team) for people living with HIV and AIDS, home-based management of malaria, home care for children with acute physical conditions, community-based interventions for childhood diarrhoea and pneumonia, out-of-facility HIV and reproductive health services for youth, and decentralised HIV care. Information and communication technology: mobile phone messaging for patients with long-term illnesses, mobile phone messaging reminders for attendance at healthcare appointments, mobile phone messaging to promote adherence to antiretroviral therapy, women carrying their own case notes in pregnancy, interventions to improve childhood vaccination. Quality and safety systems: decision support with clinical information systems for people living with HIV/AIDS. Complex interventions (cutting across delivery categories and other health system arrangements): emergency obstetric referral interventions.

AUTHORS' CONCLUSIONS

A wide range of strategies have been evaluated for improving delivery arrangements in low-income countries, using sound systematic review methods in both Cochrane and non-Cochrane reviews. These reviews have assessed a range of outcomes. Most of the available evidence focuses on who provides care, where care is provided and coordination of care. For all the main categories of delivery arrangements, we identified gaps in primary research related to uncertainty about the applicability of the evidence to low-income countries, low- or very low-certainty evidence or a lack of studies.

Feasibility of district wide screening of health care workers for tuberculosis in Zambia

Background

Many health care workers (HCWs) are at increased risk for tuberculosis (TB). The World Health Organization (WHO) recommends screening HCWs for TB in high burden settings but this is often not implemented in countries with a high TB incidence. We assessed the feasibility of TB screening among HCWs, including participation rate and yield, as part of a project introducing facility specific TB interventions.

Methods

This study had a cross-sectional design. HCWs (including paid staff and community volunteers) from 13 clinics and two hospitals in the Ndola district of Zambia participated. HCWs were screened by a designated person in their own facility. The agreed screening algorithm for HCWs included annual symptom screening, with sputum smear, culture (or Xpert) and chest x-ray offered to HCWs with at least one TB symptom, i.e. those with presumptive TB.

Results

A total of 1011 out of 1619 (62%) staff and 71 out of 138 (51%) community volunteers were screened within one year, total 1082/1757 (62%). Five percent (52/1082) of those screened were presumptive TB patients. Seventy-three percent (38/52) of presumptive TB patients received all diagnostic tests according to the agreed algorithm. Eighteen out of 1757 staff and volunteers combined were diagnosed with TB within a calendar year, showing a notified TB incidence of 1%. At least five of them were diagnosed during the screening appointment (0.5% of those screened). One of the 18 HCWs died of TB. Seventy-six percent (822/1082) of screened HCWs indicated that they already knew their HIV status. Screening was considered feasible if confidentiality can be guaranteed although challenges such as the time required for screening and sample transport were reported.

Conclusions

It is feasible to conduct and implement screening programs for TB among HCWs in hospitals and clinics, and the notified incidence and yield is high. Advocacy is needed to educate managers and HCWs on the importance of screening and the implementation of locally relevant screening algorithms. It is essential to ensure access to TB infection control, diagnostics, treatment and confidential registration for HCW.

The impact of leadership hubs on the uptake of evidence-informed nursing practices and workplace policies for HIV care: a quasi-experimental study in Jamaica, Kenya, Uganda and South Africa

BACKGROUND

The enormous impact of HIV on communities and health services in Sub-Saharan Africa and the Caribbean has especially affected nurses, who comprise the largest proportion of the health workforce in low- and middle-income countries (LMICs). Strengthening action-based leadership for and by nurses is a means to improve the uptake of evidence-informed practices for HIV care.

METHODS

A prospective quasi-experimental study in Jamaica, Kenya, Uganda and South Africa examined the impact of establishing multi-stakeholder leadership hubs on evidence-informed HIV care practices. Hub members were engaged through a participatory action research (PAR) approach. Three intervention districts were purposefully selected in each country, and three control districts were chosen in Jamaica, Kenya and Uganda. WHO level 3, 4 and 5 health care institutions and their employed nurses were randomly sampled. Self-administered, validated instruments measured clinical practices (reports of self and peers), quality assurance, work place policies and stigma at baseline and follow-up. Standardised average scores ranging from 0 to 1 were computed for clinical practices, quality assurance and work place policies. Stigma scores were summarised as 0 (no reports) versus 1 (one or more reports). Pre-post differences in outcomes between intervention and control groups were compared using the Mantel Haenszel chi-square for dichotomised stigma scores, and independent t tests for other measures. For South Africa, which had no control group, pre-post differences were compared using a Pearson chi-square and independent t test. Multivariate analysis was completed for Jamaica and Kenya. Hub members in all countries self-assessed changes in their capacity at follow-up; these were examined using a paired t test.

RESULTS

Response rates among health care institutions were 90.2 and 80.4 % at baseline and follow-up, respectively. Results were mixed. There were small but statistically significant pre-post, intervention versus control district improvements in workplace policies and quality assurance in Jamaica, but these were primarily due to a decline in scores in the control group. There were modest improvements in clinical practices, workplace policies and quality assurance in South Africa (pre-post) (clinical practices of self-pre 0.67 (95 % CI, 0.62, 0.72) versus post 0.78 (95 % CI, 0.73-0.82), p = 0.002; workplace policies-pre 0.82 (95 % CI, 0.70, 0.85) versus post 0.87 (95 % CI, 0.84, 0.90), p = 0.001; quality assurance-pre 0.72 (95 % CI, 0.67, 0.77) versus post 0.84 (95 % CI, 0.80, 0.88)). There were statistically significant improvements in scores for nurses stigmatising patients (Jamaica reports of not stigmatising-pre-post intervention 33.9 versus 62.4 %, pre-post control 54.7 versus 64.4 %, p = 0.002-and Kenya pre-post intervention 35 versus 51.6 %, pre-post control 34.2 versus 47.8 %, p = 0.006) and for nurses being stigmatised (Kenya reports of no stigmatisation-pre-post intervention 23 versus 37.3 %, pre-post control 15.4 versus 27 %, p = 0.004). Multivariate results for Kenya and Jamaica were non-significant. Twelve hubs were established; 11 were active at follow-up. Hub members (n = 34) reported significant improvements in their capacity to address care gaps.

CONCLUSIONS

Leadership hubs, comprising nurses and other stakeholders committed to change and provided with capacity building can collectively identify issues and act on strategies that may improve practice and policy. Overall, hubs did not provide the necessary force to improve the uptake of evidence-informed HIV care in their districts. If hubs are to succeed, they must be integrated within district health authorities and become part of formal, legal organisations that can regularise and sustain them.

Impact of a workplace intervention on attitudes and practices related to gender equity in Bengaluru, India

We describe the evaluation of a participatory, garment factory-based intervention to promote gender equity. The intervention comprised four campaigns focused on gender and violence against women, alcoholism, sexual and reproductive health, and HIV/AIDS, which were implemented using information displays (standees and posters) and interactive methods (street play, one-to-one interactions, experience-sharing, and health camps). Each campaign lasted six days and the entire intervention was implemented over 10 months. We evaluated the intervention using a quasi-experimental design in which one factory served as the intervention site and a second as a delayed control. Two mobile-phone-based cross-sectional surveys were conducted at baseline and 12 months with separate systematic random samples of employees from each site. Data on socio-demographic characteristics and knowledge and attitudes related to gender equity, intimate partner violence (IPV) and alcohol use were assessed, and differences in these variables associated with the intervention were examined using difference-in-difference estimation. Analyses of data from 835 respondents revealed substantial, statistically significant improvements in attitudes related to gender equity, unacceptability of IPV, and awareness of IPV and alcohol-related support services. In conclusion, our study offers compelling evidence on the effectiveness of workplace-based interventions in advancing gender equity.

Barriers to HIV counseling and testing uptake by health workers in three public hospitals in Free State Province, South Africa

Recent WHO/ILO/UNAIDS guidelines recommend priority access to HIV services for health care workers (HCWs), in order to retain and support HCWs, especially those at risk of occupationally acquired tuberculosis (TB). The purpose of this study was to identify barriers to uptake of HIV counselling and testing (HCT) services for HCWs receiving HCT within occupational health units (OHUs). Questions were included within a larger occupational health survey of a 20% quota sample of HCWs from three public hospitals in Free State Province, South Africa. Of the 978 respondents, nearly 65% believed that their co-workers would not want to know their HIV status. Barriers to accessing HCT at the OHU included ambiguity over whether antiretroviral treatment was available at the OHU (only 51.1% knew), or whether TB treatment was available (55.5% knew). Nearly 40% of respondents perceived that stigma as a barrier. When controlling for age and race, the odds of perceiving HIV stigma in the workplace among patient-care health care workers (PCHWs) were 2.4 times that for non-PCHWs [95% confidence interval (CI): 1.80-3.15]. Of the 692 survey respondents who indicated a reason for not using HIV services at the OHU, 38.9% felt that confidentiality was the reason cited. Among PCHWs, the adjusted odds of expressing concern that confidentiality may not be maintained in the OHU were 2.4 times (95% CI: 1.8-3.2) that of non-PCHWs and were higher among Black [odds ratio (OR): 2.7, CI: 1.7-4.2] and Coloured HCWs (OR: 3.0, 95% CI: 1.6-5.6) as compared to White HCWs, suggesting that stigma and confidentiality concerns are still barriers to uptake of HCT. Campaigns to improve awareness of HCT and TB services offered in the OHUs, address stigma and ensure that the workforce is aware of the confidentiality provisions that are in place are warranted.

Semi-automated, occupationally safe immunofluorescence microtip sensor for rapid detection of Mycobacterium cells in sputum

An occupationally safe (biosafe) sputum liquefaction protocol was developed for use with a semi-automated antibody-based microtip immunofluorescence sensor. The protocol effectively liquefied sputum and inactivated microorganisms including Mycobacterium tuberculosis, while preserving the antibody-binding activity of Mycobacterium cell surface antigens. Sputum was treated with a synergistic chemical-thermal protocol that included moderate concentrations of NaOH and detergent at 60°C for 5 to 10 min. Samples spiked with M. tuberculosis complex cells showed approximately 10⁶-fold inactivation of the pathogen after treatment. Antibody binding was retained post-treatment, as determined by analysis with a microtip immunosensor. The sensor correctly distinguished between Mycobacterium species and other cell types naturally present in biosafe-treated sputum, with a detection limit of 100 CFU/mL for M. tuberculosis, in a 30-minute sample-to-result process. The microtip device was also semi-automated and shown to be compatible with low-cost, LED-powered fluorescence microscopy. The device and biosafe sputum liquefaction method opens the door to rapid detection of tuberculosis in settings with limited laboratory infrastructure.