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Krankowska D, Flanczewski S, Gajek-Flanczewska W, Sapuła M, Cybula A, Wiercińska-Drapało A. Comparison between patients who interrupted ART and those with late HIV diagnosis. AIDS Care 2024; 36:374-381. [PMID: 37584430 DOI: 10.1080/09540121.2023.2237711] [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] [Received: 10/19/2022] [Accepted: 07/12/2023] [Indexed: 08/17/2023]
Abstract
Early diagnosis of human immunodeficiency virus (HIV) and retention in care are cornerstones of better prognosis of people living with HIV (PLWH). The purpose of this study was to compare patients who discontinued antiretroviral treatment (ART) with those who were diagnosed late with HIV. In this retrospective analysis of PLWH under the care of one of the Infectious Diseases Clinics in Poland between 2020 and 2021, two sub-analyses were carried out. One comparing patients who relinked to care after treatment interruption ("Group A") with those who had late HIV diagnosis ("Group B"), another comparing group A to those who were adherent to ART ("Group C"). 215 patients were included in this study (Group A = 47, Group B = 53, Group C = 115). Those who discontinued ART more often used actively drugs (p = 0.001) in comparison to those with late HIV diagnosis. In both bivariate and multivariable analysis migrants were more often diagnosed late with HIV than interrupted ART (p = 0.004 and 0.015, respectively). In the second analysis, in the multivariable analysis female sex was not associated with treatment interruption, whereas active drug usage was. People using drugs have a higher risk of ART interruption. Migrants are more at risk of late HIV diagnosis. Adequate interventions should be made towards both groups.
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Affiliation(s)
- Dagny Krankowska
- Department of Infectious and Tropical Diseases and Hepatology, Medical University of Warsaw, Warsaw, Poland
- Hospital for Infectious Diseases, Warsaw, Poland
| | - Sebastian Flanczewski
- Student's Scientific Society, Department of Infectious and Tropical Diseases and Hepatology, Medical University of Warsaw, Poland
| | - Wiktoria Gajek-Flanczewska
- Student's Scientific Society, Department of Infectious and Tropical Diseases and Hepatology, Medical University of Warsaw, Poland
| | - Mariusz Sapuła
- Department of Infectious and Tropical Diseases and Hepatology, Medical University of Warsaw, Warsaw, Poland
- Hospital for Infectious Diseases, Warsaw, Poland
| | - Aneta Cybula
- Department of Infectious and Tropical Diseases and Hepatology, Medical University of Warsaw, Warsaw, Poland
- Hospital for Infectious Diseases, Warsaw, Poland
| | - Alicja Wiercińska-Drapało
- Department of Infectious and Tropical Diseases and Hepatology, Medical University of Warsaw, Warsaw, Poland
- Hospital for Infectious Diseases, Warsaw, Poland
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Maphosa T, Denoeud-Ndam L, Kapanda L, Khatib S, Chilikutali L, Matiya E, Munthali B, Dambe R, Chiwandira B, Wilson B, Nyirenda R, Nyirenda L, Chikwapulo B, Musopole OM, Tiam A, Katirayi L. Understanding health systems challenges in providing Advanced HIV Disease (AHD) care in a hub and spoke model: a qualitative analysis to improve AHD care program in Malawi. BMC Health Serv Res 2024; 24:244. [PMID: 38408975 PMCID: PMC10897989 DOI: 10.1186/s12913-024-10700-1] [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] [Received: 06/05/2023] [Accepted: 02/08/2024] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND Despite tremendous progress in antiretroviral therapy (ART) and access to ART, many patients have advanced human immunodeficiency virus (HIV) disease (AHD). Patients on AHD, whether initiating ART or providing care after disengagement, have an increased risk of morbidity and mortality. The Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) launched an enhanced care package using a hub-and-spoke model to optimize AHD care in Malawi. This model improves supply availability and appropriate linkage to care. We utilized a hub-and-spoke model to share health facility challenges and recommendations on the AHD package for screening and diagnosis, prophylaxis, treatment, and adherence support. METHODS This qualitative study assessed the facility-level experiences of healthcare workers (HCWs) and lay cadres (LCs) providing AHD services to patients through an intervention package. The study population included HCWs and LCs supporting HIV care at four intervention sites. Eligible study participants were recruited by trained Research Assistants with support from the health facility nurse to identify those most involved in supporting patients with AHD. A total of 32 in-depth interviews were conducted. Thematic content analysis identified recurrent themes and patterns across participants' responses. RESULTS While HCWs and LCs stated that most medications are often available at both hub and spoke sites, they reported that there are sometimes limited supplies and equipment to run samples and tests necessary to provide AHD care. More than half of the HCWs stated that AHD training sufficiently prepared them to handle AHD patients at both the hub and spoke levels. HCWs and LCs reported weaknesses in the patient referral system within the hub-and-spoke model in providing a linkage of care to facilities, specifically improper referral documentation, incorrect labeling of samples, and inconsistent availability of transportation. While HCWs felt that AHD registers were time-consuming, they remained motivated as they thought they provided better patient services. CONCLUSIONS These findings highlight the importance of offering comprehensive AHD services. The enhanced AHD program addressed weaknesses in service delivery through decentralization and provided services through a hub-and-spoke model, improved supply availability, and strengthened linkage to care. Additionally, addressing the recommendations of service providers and patients is essential to improve the health and survival of patients with AHD.
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Affiliation(s)
- Thulani Maphosa
- Elizabeth Glaser Pediatric AIDS Foundation, Lilongwe, Malawi.
| | | | - Lester Kapanda
- Elizabeth Glaser Pediatric AIDS Foundation, Lilongwe, Malawi
| | - Sarah Khatib
- George Washington University, Washington, DC, USA
| | | | | | | | - Rosalia Dambe
- Elizabeth Glaser Pediatric AIDS Foundation, Lilongwe, Malawi
| | - Brown Chiwandira
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi
| | - Bilaal Wilson
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi
| | - Rose Nyirenda
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi
| | | | | | | | | | - Leila Katirayi
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, USA
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Meng X, Yin H, Ma W, Gu J, Lu Z, Fitzpatrick T, Zou H. Peer-Led Community-Based Support Services and HIV Treatment Outcomes Among People Living With HIV in Wuxi, China: Propensity Score-Matched Analysis of Surveillance Data From 2006 to 2021. JMIR Public Health Surveill 2023; 9:e43635. [PMID: 36961492 PMCID: PMC10131765 DOI: 10.2196/43635] [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: 10/19/2022] [Revised: 01/02/2023] [Accepted: 01/11/2023] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Community-based organizations deliver peer-led support services to people living with HIV. Systematic reviews have found that peer-led community-based support services can improve HIV treatment outcomes; however, few studies have been implemented to evaluate its impact on mortality using long-term follow-up data. OBJECTIVE We aimed to evaluate the associations between the receipt of peer-led community-based support services and HIV treatment outcomes and survival among people living with HIV in Wuxi, China. METHODS We performed a propensity score-matched retrospective cohort study using data collected from the Chinese National HIV/AIDS Comprehensive Information Management System for people living with HIV in Wuxi, China, between 2006 and 2021. People living with HIV who received adjunctive peer-led community-based support for at least 6 months from a local community-based organization (exposure group) were matched to people living with HIV who only received routine clinic-based HIV care (control group). We compared the differences in HIV treatment outcomes and survival between these 2 groups using Kaplan-Meier curves. We used competing risk and Cox proportional hazards models to assess correlates of AIDS-related mortality (ARM) and all-cause mortality. We reported adjusted subdistribution hazard ratio and adjusted hazard ratio with 95% CIs. RESULTS A total of 860 people living with HIV were included (430 in the exposure group and 430 in the control group). The exposure group was more likely to adhere to antiretroviral therapy (ART; 396/430, 92.1% vs 360/430, 83.7%; P<.001), remain retained in care 12 months after ART initiation (402/430, 93.5% vs 327/430, 76.1%; P<.001), and achieve viral suppression 9 to 24 months after ART initiation (357/381, 93.7% vs 217/243, 89.3%; P=.048) than the control group. The exposure group had significantly lower ARM (1.8 vs 7.0 per 1000 person-years; P=.01) and all-cause mortality (2.3 vs 9.3 per 1000 person-years; P=.002) and significantly higher cumulative survival rates (P=.003). The exposure group had a 72% reduction in ARM (adjusted subdistribution hazard ratio 0.28, 95% CI 0.09-0.95) and a 70% reduction in all-cause mortality (adjusted hazard ratio 0.30, 95% CI 0.11-0.82). The nonrandomized retrospective nature of our analysis prevents us from determining whether peer-led community-based support caused the observed differences in HIV treatment outcomes and survival between the exposure and control groups. CONCLUSIONS The receipt of peer-led community-based support services correlated with significantly improved HIV treatment outcomes and survival among people living with HIV in a middle-income country in Asia. The 15-year follow-up period in this study allowed us to identify associations with survival not previously reported in the literature. Future interventional trials are needed to confirm these findings.
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Affiliation(s)
- Xiaojun Meng
- Wuxi Municipal Center for Disease Control and Prevention, Wuxi, China
| | - Hanlu Yin
- Wuxi Municipal Center for Disease Control and Prevention, Wuxi, China
| | - Wenjuan Ma
- Wuxi Municipal Center for Disease Control and Prevention, Wuxi, China
| | - Jing Gu
- Wuxi Municipal Center for Disease Control and Prevention, Wuxi, China
| | - Zhen Lu
- School of Public Health (Shenzhen), Sun Yat-sen University, Shenzhen, China
| | - Thomas Fitzpatrick
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, United States
| | - Huachun Zou
- School of Public Health (Shenzhen), Sun Yat-sen University, Shenzhen, China
- Kirby Institute, University of New South Wales, Sydney, Australia
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Bose DL, Hundal A, Singh S, Singh S, Seth K, Hadi SU, Saran A, Joseph J, Goyal K, Salve S. Evidence and gap map report: Social and Behavior Change Communication (SBCC) interventions for strengthening HIV prevention and research among adolescent girls and young women (AGYW) in low- and middle-income countries (LMICs). CAMPBELL SYSTEMATIC REVIEWS 2023; 19:e1297. [PMID: 36911864 PMCID: PMC9831290 DOI: 10.1002/cl2.1297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
BACKGROUND Adolescent girls and young women (AGYW), aged 15-24 years, are disproportionately affected by HIV and other sexual and reproductive health (SRH) risks due to varying social, cultural, and economic factors that affect their choices and shape their knowledge, understanding, and practices with regard to their health. Socio-Behavioral Change Communication (SBCC) interventions targeted at strengthening the capabilities of individuals and their networks have supported the demand and uptake of prevention services and participation in biomedical research. However, despite growing global recognition of the domain, high-quality evidence on the effectiveness of SBCC remains scattered. This evidence and gap map (EGM) report characterizes the evidence base on SBCC interventions for strengthening HIV Prevention and Research among AGYW in low- and middle-income countries (LMICs), identifying evidence gaps and outlining the scope of future research and program design. OBJECTIVES The objectives of the proposed EGM are to: (a) identify and map existing EGMs in the use of diverse SBCC strategies to strengthen the adoption of HIV prevention measures and participation in research among AGYW in LMICs and (b) identify areas where more interventions and evidence are needed to inform the design of future SBCC strategies and programs for AGYW engagement in HIV prevention and research. METHODS This EGM is based on a comprehensive search of systematic reviews and impact evaluations corresponding to a range of interventions and outcomes-aimed at engaging AGYW in HIV prevention and research - that were published in LMICs from January 2000 to April 2021. Based on guidance for producing a Campbell Collaboration EGM, the intervention and outcome framework was designed in consultation with a group of experts. These interventions were categorized across four broad intervention themes: mass-media, community-based, interpersonal, and Information Communication and Technology (ICT)/Digital Media-based interventions. They were further sub-categorized into 15 intervention categories. Included studies looked at 23 unique behavioral and health outcomes such as knowledge attitude and skills, relationship dynamics, household dynamics, health care services, and health outcomes and research engagement. The EGM is presented as a matrix in which the rows are intervention categories/sub-categories, and the columns are outcome domains/subdomains. Each cell is mapped to an intervention targeted at outcomes. Additional filters like region, country, study design, age group, funding agency, influencers, population group, publication status, study confidence, setting, and year of publication have been added. SELECTION CRITERIA To be eligible, studies must have tested the effectiveness of SBCC interventions at engaging AGYW in LMICs in HIV prevention and research. The study sample must have consisted of AGYW between the ages of 15-24, as defined by UNAIDS. Both experimental (random assignment) and quasi-experimental studies that included a comparison group were eligible. Relevant outcomes included those at the individual, influencer, and institutional levels, along with those targeting research engagement and prevention-related outcomes. RESULTS This EGM comprises 415 impact evaluations and 43 systematic reviews. Interventions like peer-led interactions, counseling, and community dialogues were the most dominant intervention sub-types. Despite increased digital penetration use of media and technology-driven interventions are relatively less studied. Most of the interventions were delivered by peers, health care providers, and educators, largely in school-based settings, and in many cases are part of sex-education curricula. Evidence across geographies was mostly concentrated in Sub-Saharan Africa (70%). Most measured outcomes focused on disease-related knowledge dissemination and enhancing awareness of available prevention options/strategies. These included messaging around consistent condom use, limiting sexual partners, routine testing, and awareness. Very few studies were able to include psychographic, social, and contextual factors influencing AGYW health behaviors and decisions, especially those measuring the impact of social and gender norms, relationship dynamics, and household dynamics-related outcomes. Outcomes related to engagement in the research were least studied. CONCLUSION This EGM highlights that evidence is heavily concentrated within the awareness-intent spectrum of behavior change and gets lean for outcomes situated within the intent-action and the action-habit formation spectrum of the behavior change continuum. Most of the evidence was concentrated on increasing awareness, knowledge, and building risk perception around SRH domains, however, fewer studies focused on strengthening the agency and self-efficacy of individuals. Similarly, evidence on extrinsic factors-such as strengthening social and community norms, relationships, and household dynamics-that determine individual thought and action such as negotiation and life skills were also found to be less populated. Few studies explore the effectiveness of these interventions across diverse AGYW identities, like pregnant women and new mothers, sex workers, and people living with HIV, leading to limited understanding of the use of these interventions across multiple user segments including key influencers such as young men, partners, families, religious leaders, and community elders was relatively low. There is a need for better quality evidence that accounts for the diversity of experiences within these populations to understand what interventions work, for whom, and toward what outcome. Further, the evidence for use of digital and mass-media tools remains poorly populated. Given the increasing penetration of these tools and growing media literacy on one end, with widening gender-based gaps on the other, it is imperative to gather more high-quality evidence on their effectiveness. Timely evidence generation can help leverage these platforms appropriately and enable intervention designs that are responsive to changing communication ecologies of AGYW. SBCC can play a critical role in helping researchers meaningfully engage and collaborate with communities as equal stakeholders, however, this remains poorly evidenced and calls for investigation and investment. A full list of abbreviations and acronyms are available in Supporting Information: Appendix F.
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Impact of Community Support Workers in Rural Ethiopia on Emotional and Psychosocial Health of Persons Living with HIV: Results of a Three-Year Randomized Community Trial. AIDS Behav 2023:10.1007/s10461-023-04007-1. [PMID: 36788166 DOI: 10.1007/s10461-023-04007-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2023] [Indexed: 02/16/2023]
Abstract
People living with HIV face multiple psychosocial challenges. In a large, predominantly rural Ethiopian region, 1799 HIV patients new to care were enrolled from 32 sites in a cluster randomized trial using trained community support workers with HIV to provide individual health education, counseling and social support. Participants received annual surveys through 36 months using items drawn from the Centre for Epidemiologic Studies Depression Scale-10, Medical Outcome Study Social Support Survey, and HIV/AIDS Stigma Instrument-PLWA. At 12 months (using linear mixed effects regression models controlling for enrollment site clustering), intervention participants had greater emotional/informational and tangible assistance social support scores, and lower scores assessing depression symptoms and negative self-perception due to HIV status. A significant treatment effect at 36 months was also seen on scores assessing emotional/informational social support, depression symptoms, and internalized stigma. An intervention using peer community support workers with HIV to provide individualized informational and psychological support had a positive impact on the emotional health of people living with HIV who were new to care.(ClinicalTrials.gov protocol ID: 1410S54203, May 19, 2015).
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Ware NC, Wyatt MA, Pisarski EE, Kamusiime B, Kasiita V, Nalukwago G, Nalumansi A, Twesigye C, Boyer J, Nakyanzi A, Naddunga F, Mujugira A, Celum CL. How pregnant women living with HIV and their male partners manage men's HIV self-testing: qualitative analysis of an HIVST secondary distribution process in Kampala, Uganda. J Int AIDS Soc 2023; 26:e26050. [PMID: 36659835 PMCID: PMC9852794 DOI: 10.1002/jia2.26050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 11/30/2022] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Increased HIV testing by men in sub-Saharan Africa is key to meeting UNAIDS 2025 testing targets. Secondary distribution of HIV self-testing (HIVST) kits by pregnant women attending antenatal care to male partners has been shown to increase testing among African men. A detailed understanding of how women and male partners manage the distribution and use of HIVST and subsequent linkage to clinic-based follow-up can inform implementation and scale-up efforts. METHODS We use qualitative data from the Obumu Study, a randomized trial of secondary distribution of HIVST by pregnant women living with HIV to male partners in Kampala, Uganda, to unpack the HIVST delivery process. The protocol included a clinic visit by male partners to confirm HIVST results. Individual interviews eliciting data on experiences of delivering and using HIVST and of subsequent linkage to clinic-based testing were conducted with a purposefully selected sample of 45 women and 45 male partner Obumu Study participants from November 2018 to March 2021. Interview data from 59 participants (29 women and 30 men) in the HIVST arm were analysed through coding and category construction. RESULTS Women living with HIV were apprehensive about delivering HIVST to their partners, especially if they had not disclosed their HIV status. They invested effort in developing strategies for introducing HIVST. Male partners described a range of responses to receiving the self-testing kit, especially fear of a positive test result. Women reported leading the self-testing process, often conducting the test themselves. Most women confidently interpreted HIVST results. However, they tended to defer to healthcare workers rather than report positive results directly to partners. Women told their partners the testing process required a clinic follow-up visit, often without explaining the visit's purpose. Many partners delayed the visit as a result. Women again responded by strategizing to persuade their partners to link to follow-up care. CONCLUSIONS Secondary distribution of HIVST by pregnant women living with HIV to male partners can be challenging, especially when women have not disclosed their HIV status. Additional support may alleviate the burden; outreach to male partners may facilitate linkage to confirmatory testing and HIV care or prevention.
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Affiliation(s)
- Norma C. Ware
- Department of MedicineBrigham and Women's HospitalBostonMassachusettsUSA
- Department of Global Health and Social MedicineHarvard Medical SchoolBostonMassachusettsUSA
| | - Monique A. Wyatt
- Department of Global Health and Social MedicineHarvard Medical SchoolBostonMassachusettsUSA
- Harvard GlobalCambridgeMassachusettsUSA
| | - Emily E. Pisarski
- Department of Global Health and Social MedicineHarvard Medical SchoolBostonMassachusettsUSA
| | | | - Vicent Kasiita
- Infectious Diseases InstituteMakerere UniversityKampalaUganda
| | - Grace Nalukwago
- Infectious Diseases InstituteMakerere UniversityKampalaUganda
| | | | | | - Jade Boyer
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
| | - Agnes Nakyanzi
- Infectious Diseases InstituteMakerere UniversityKampalaUganda
| | - Faith Naddunga
- Infectious Diseases InstituteMakerere UniversityKampalaUganda
| | - Andrew Mujugira
- Infectious Diseases InstituteMakerere UniversityKampalaUganda
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
| | - Connie L. Celum
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
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Lofgren SM, Tsui S, Natala N, Nakasujja N, Sebuliba R, Ndyetukira JF, Arinda A, Akinyange V, Hullsiek KH, Nalintya E, Sadiq A, Pastick KA, Stadleman A, Meya D, Boulware DR. Differences in Reasons for Late Presentation to HIV Care in Uganda Among Men and Women. AIDS Behav 2023; 27:303-313. [PMID: 35916948 PMCID: PMC9343575 DOI: 10.1007/s10461-022-03764-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2022] [Indexed: 01/24/2023]
Abstract
Late presentation to HIV care, i.e., presenting with < 200 CD4 cells/mL, is associated with higher mortality and worse outcomes. Despite that, a quarter of people living with HIV in Uganda still present late to care. We surveyed Ugandans living with HIV who enrolled in clinic ≤ 90 days prior. We compared groups who presented 'late' with CD4 < 200 and 'early' with CD4 > 350, stratifying by sex. We found men who presented late had higher externalized stigma than early presenters. Thirty-six percent of the entire cohort were depressed. Social support was stronger in late presenters versus early, although weak overall. Social support was inversely correlated with depression, with social support dropping as depression increased. Interventions to improve clinic privacy, reduce stigma, improve social support, and help women disclose their HIV status to male partners are needed to reduce late presentation to HIV care.
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Affiliation(s)
- Sarah M Lofgren
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, 689 23rd Avenue S.E., Minneapolis, MN, 55455, USA.
- Infectious Diseases Institute, Makerere University, Kampala, Uganda.
| | - Sharon Tsui
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Nakita Natala
- Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN, USA
| | | | - Raymond Sebuliba
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Anita Arinda
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Department of Psychiatry, Makerere University, Kampala, Uganda
| | | | - Kathy H Hullsiek
- Division of Biostatistics, University of Minnesota, School of Public Health, Minneapolis, MN, USA
| | | | - Alisat Sadiq
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Katelyn A Pastick
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, 689 23rd Avenue S.E., Minneapolis, MN, 55455, USA
| | - Anna Stadleman
- Division of Biostatistics, University of Minnesota, School of Public Health, Minneapolis, MN, USA
| | - David Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, 689 23rd Avenue S.E., Minneapolis, MN, 55455, USA
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Uwimana A, Dessalegn S, Vianney Dusengimana JM, Stauber C, Fata A, Hagenimana M, Uwinkindi F, Balinda JP, Shulman LN, Revette A, Rwamuza E, Pace LE. Integrating Breast Cancer Early Detection Into a Resource-Constrained Primary Health Care System: Health Care Workers' Experiences in Rwanda. JCO Glob Oncol 2022; 8:e2200181. [PMID: 36508703 PMCID: PMC10166372 DOI: 10.1200/go.22.00181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
PURPOSE There is limited evidence to guide incorporation of breast cancer early detection into resource-constrained health systems where mammography screening is not yet available. To inform such strategies, we sought to understand health care workers' perspectives on a breast cancer early detection initiative integrated into community, primary, and secondary levels of care in Rwanda. METHODS We conducted a qualitative study using semistructured interviews with 33 community health workers, clinicians, and administrators at health facilities participating in the Women's Cancer Early Detection Program (WCEDP), through which women received clinical breast examination if they were receiving cervical cancer screening, or had breast concerns. Through thematic analysis, we identified dynamics and patterns associated with successes and challenges of the program's breast health services. RESULTS Successes and challenges identified by participants corresponded with the community- and primary care-based steps of cancer early diagnosis identified by the WHO. Regarding step 1 (community awareness/access), participants noted increases in awareness and care-seeking. Challenges included difficulty overcoming stigma and engaging older women. Regarding step 2 (clinical evaluation), all participants described increased breast health knowledge, skills, and confidence. Integrating the WCEDP with other services was challenging because of inadequate staffing; offering WCEDP services on a designated day/week had advantages and disadvantages. Although participants appreciated WCEDP referral mechanisms, they desired more communication from referral facilities. Patients' poverty was the most consistently identified impediment to referral completion. CONCLUSION Rwandan health care workers identified real-world successes and challenges of implementing principles of early cancer diagnosis for breast cancer early detection. Future interventions should focus on engagement of older women, community awareness, patient socioeconomic support, and optimizing integration into primary care.
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Lifson AR, Hailemichael A, Workneh S, MacLehose RF, Horvath KJ, Hilk R, Sites A, Slater L, Shenie T. A three-year randomized community trial of community support workers in rural Ethiopia to promote retention in HIV care. AIDS Care 2022; 34:1506-1512. [PMID: 35195481 PMCID: PMC9395549 DOI: 10.1080/09540121.2022.2029819] [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: 08/03/2021] [Accepted: 01/12/2022] [Indexed: 01/26/2023]
Abstract
Retention in care is a major challenge for global AIDS control, including sub-Saharan Africa. In a large Ethiopian region, we evaluated an intervention where HIV positive community support workers (CSWs) provided HIV health education, personal counseling and social support for HIV patients new to care. We enrolled 1,799 patients recently entering care from 32 hospitals and health centers, randomized to intervention or control sites. Dates of all clinic visits, plus deaths or transfers were abstracted from HIV medical records. Primary outcomes were gap in clinical care (>90 days from a missed clinical or drug pickup appointment) and death. For 36 months of follow-up, and for the first 12 months after enrollment, weighted risk differences [RD] between treatment arms were modest and non-significant for gap in clinical care, death or either outcome. Through 36 months, 624 of 980 controls and 469 of 819 intervention participants had gaps in clinical care (RD = -5.5%, 95% confidence interval [CI] = -17.9%, 7.0%); 79 controls and 82 intervention participants died (RD = 2.5% 95% CI = -1.7%, 6.8%). Factors including HIV stigma and a volatile political climate may have attenuated the advantages we anticipated, demonstrating how benefits of CSW interventions may depend upon psychosocial, clinical and structural factors particular to specific community settings.
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Affiliation(s)
- Alan R Lifson
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Abera Hailemichael
- Ethiopian Office, National Alliance of State and Territorial AIDS Directors, Addis Ababa, Ethiopia
| | - Sale Workneh
- Ethiopian Office, National Alliance of State and Territorial AIDS Directors, Addis Ababa, Ethiopia
| | - Richard F MacLehose
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Keith J Horvath
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN, USA
- Department of Psychology, San Diego State University, San Diego, CA, USA
| | - Rose Hilk
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Anne Sites
- Global Program, National Alliance of State and Territorial AIDS Directors, Washington, DC, USA
| | - Lucy Slater
- Global Program, National Alliance of State and Territorial AIDS Directors, Washington, DC, USA
| | - Tibebe Shenie
- Ethiopian Office, National Alliance of State and Territorial AIDS Directors, Addis Ababa, Ethiopia
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Galea JT, Wong M, Ninesling B, Ramos A, Senador L, Sanchez H, Kolevic L, Matos E, Sanchez E, Errea RA, Lindeborg A, Benites C, Lecca L, Shin S, Franke MF. Patient and provider perceptions of a community-based accompaniment intervention for adolescents transitioning to adult HIV care in urban Peru: a qualitative analysis. J Int AIDS Soc 2022; 25:e26019. [PMID: 36251163 PMCID: PMC9575940 DOI: 10.1002/jia2.26019] [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: 03/30/2022] [Accepted: 09/15/2022] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Adolescents living with HIV (ALWH) experience higher mortality rates compared to other age groups, exacerbated by the suboptimal transition from paediatric to adult HIV care, during which decreased adherence to antiretroviral therapy (ART) and unsuppressed viremia are frequent. Care transition-a process lasting months or years-ideally prepares ALWH for adult care and can be improved by interventions that are youth-friendly and address psychosocial issues affecting ART adherence; however, such interventions are infrequently operationalized. Community-based accompaniment (CBA), in which laypeople provide individualized support and health system navigation, can improve health outcomes among adults with HIV. Here, we describe patient and provider perceptions of a novel HIV CBA intervention called "PASEO" for ALWH in Lima, Peru. METHODS PASEO consisted of six core elements designed to support ALWH during and after the transition to adult HIV care. During 2019-2021, community-based health workers provided tailored accompaniment for ALWH aged 15-21 years over 9 months, after which adolescent participants were invited to provide feedback in a focus group or in-depth interview. HIV care personnel were also interviewed to understand their perspectives on PASEO. A semi-structured interview guide probing known acceptability constructs was used. Qualitative data were analysed using a framework analysis approach and emergent themes were summarized with illustrative quotes. RESULTS We conducted five focus groups and 11 in-depth interviews among N = 26 ALWH and nine key-informant interviews with HIV care personnel. ALWH participants included males, females and one transgender female, and those with both early childhood and recent HIV infection. ALWH praised PASEO, attributing increased ART adherence to the project. Improved mental health, independence, self-acceptance and knowledge on how to manage their HIV were frequently cited. HIV professionals similarly voiced strong support for PASEO. Both ALWH and HIV professionals expressed hope that PASEO would be scaled. HIV professionals voiced concerns regarding financing PASEO in the future. CONCLUSIONS A multicomponent CBA intervention to increase ART adherence among ALWH in Peru was highly acceptable by ALWH and HIV programme personnel. Future research should determine the efficacy and economic impact of the intervention.
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Affiliation(s)
- Jerome T Galea
- School of Social Work, College of Behavioral and Community Sciences, University of South Florida, Tampa, Florida, USA.,College of Public Health, University of South Florida, Tampa, Florida, USA.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Brennan Ninesling
- Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | | | | | | | - Lenka Kolevic
- Servicio de Infectologia, Instituto Nacional del Salud del Niño, Lima, Peru.,Programa de ITS, VIH/SIDA y hepatitis, Ministerio de Salud, Lima, Peru
| | - Eduardo Matos
- Programa de ITS, VIH/SIDA y hepatitis, Ministerio de Salud, Lima, Peru.,Servicio de Infectología, Hospital Nacional Arzobispo Loayza, Lima, Peru
| | - Eduardo Sanchez
- Servicio de Infectologia, Instituto Nacional del Salud del Niño, Lima, Peru.,Programa de ITS, VIH/SIDA y hepatitis, Ministerio de Salud, Lima, Peru.,Servicio de Enfermedades Infecciosas y Tropicales, Hospital Nacional Hipólito Unanue, Lima, Peru
| | - Renato A Errea
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Socios En Salud Sucursal Peru, Lima, Peru
| | - Andrew Lindeborg
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Carlos Benites
- Programa de ITS, VIH/SIDA y hepatitis, Ministerio de Salud, Lima, Peru
| | - Leonid Lecca
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Socios En Salud Sucursal Peru, Lima, Peru
| | - Sonya Shin
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Molly F Franke
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
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11
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Pugh LE, Roberts JS, Viswasam N, Hahn E, Ryan S, Turpin G, Lyons CE, Baral S, Hansoti B. Systematic review of interventions aimed at improving HIV adherence to care in low- and middle-income countries in Sub-Saharan Africa. J Infect Public Health 2022; 15:1053-1060. [PMID: 36063721 PMCID: PMC10117278 DOI: 10.1016/j.jiph.2022.08.012] [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: 10/22/2021] [Revised: 08/12/2022] [Accepted: 08/23/2022] [Indexed: 11/15/2022] Open
Abstract
Long-term adherence to antiretroviral medication continues to present as a challenge along the continuum of the HIV care cascade. HIV interventions and support programs are significantly threatened in resource-limited settings by challenges in maintaining long-term follow-up for ART adherence. We sought to complete a systematic review to comprehensively examine ART adherence and retention in care interventions in Sub-Saharan Africa and to report on the implementation of interventions in real-world settings to inform future health investments in HIV care. Interventions were grouped according to their impact on individual, community, and health-systems levels. While a vast majority of studies evaluated a combination of interventions, those studies that incorporated the community as a resource were most successful. In addition, providing education and behavior reminders proved effective and should be accompanied by community and peer efforts for best results. Multi-level interventions, such as combining individual and community-level interventions showed promising results for long term ART adherence.
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Affiliation(s)
- Laura E Pugh
- School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jacob S Roberts
- School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Nikita Viswasam
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Elizabeth Hahn
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sophia Ryan
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ghilane Turpin
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Carrie E Lyons
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Stefan Baral
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Bhakti Hansoti
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of International Health, Bloomberg School of Public Health, Baltimore, Maryland, USA.
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12
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Musengimana G, Umugisha JP, Habinshuti P, Anderson T, Mukesharurema G, Remera E, Ndahimana JD, Barnhart DA. Characteristics and clinical outcomes of patients presenting with advanced HIV disease in the "treat all" era: a retrospective cohort study from rural Rwanda. BMC Infect Dis 2022; 22:706. [PMID: 36008786 PMCID: PMC9404671 DOI: 10.1186/s12879-022-07692-w] [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: 03/03/2022] [Accepted: 08/16/2022] [Indexed: 11/21/2022] Open
Abstract
Background In 2016 Rwanda adopted “treat all” where all patients with HIV are immediately eligible for ART regardless of disease progression. Despite widespread availability of treatment, it is unknown whether presentation with advanced HIV persists. Methods We conducted a retrospective cohort among patients aged ≥ 15 who enrolled in care between July 2016 and July 2018 in three rural Rwandan districts. We estimated the prevalence of advanced HIV, defined as presenting with CD4 count < 200 cells/mm3 or WHO stage 3 or 4, and compared baseline characteristics of patients with and without advanced HIV. We compared cumulative incidences and time to events using Chi squared tests and Cox proportional hazards models, respectively, for (a) viral load tests; (b) viral suppression; (c) death; and (d) treatment failure (a composite of death, lost to follow up, or virologic failure). Results Among 957 patients, 105 (11.0%) presented with advanced HIV. These patients were significantly more likely to have low body mass index, come from Burera district, be older, and be identified through inpatient settings rather than through voluntary or prenatal testing. Patients with advanced HIV had significantly higher risks of death at 12-months (9.5% vs 1.5%, p < 0.001) and 18-months (10.5% vs 1.9%, p < 0.001) and significantly higher risk of treatment failure at 12-months (21.9% vs. 14.2%, p = 0.037). After adjusting for confounders, patients with advanced HIV had still higher rates of death (adjusted Hazard ratio [aHR] = 4.4, 95% CI: 1.9, 10.2, p < 0.001) and treatment failure (aHR = 1.7, 95% CI: 1.1, 2.5, p = 0.017), but no difference in viral load testing (aHR = 1.1, 95% CI: 0.8, 1.5, p = 0.442) or viral suppression (aHR = 1.0, 95% CI: 0.8, 1.4, p = 0.949). When allowing for the hazard ratio to vary over time, patients with advanced HIV experienced elevated rates of treatment failure in the first six of enrollment, but not after nine months. Conclusion Presenting with advanced HIV remains common and is still associated with poor patient outcomes. Sensitization of the community to the benefits of early ART initiation, identification of patients with advanced HIV, and holistic support programs for the first 6 months of treatment may be needed to improve outcomes.
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Affiliation(s)
- Gentille Musengimana
- Division of HIV/AIDs, Rwanda Biomedical Center, STIs and Viral Hepatitis, City of Kigali, Rwanda.
| | - Jean Paul Umugisha
- Partners in Heath, Inshuti Mu Buzima, Infectious Disease Program, City of Kigali, Rwanda
| | - Placide Habinshuti
- Partners in Heath, Inshuti Mu Buzima, Infectious Disease Program, City of Kigali, Rwanda
| | - Todd Anderson
- Partners in Heath, Inshuti Mu Buzima, Infectious Disease Program, City of Kigali, Rwanda
| | | | - Eric Remera
- Division of HIV/AIDs, Rwanda Biomedical Center, STIs and Viral Hepatitis, City of Kigali, Rwanda
| | - Jean D'Amour Ndahimana
- Partners in Heath, Inshuti Mu Buzima, Infectious Disease Program, City of Kigali, Rwanda
| | - Dale A Barnhart
- Partners in Heath, Inshuti Mu Buzima, Infectious Disease Program, City of Kigali, Rwanda.,Department of Global Health and Social Medicine Boston, Harvard Medical School, Boston, MA, USA
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13
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Gabster A, Socha E, Pascale JM, Cabezas Talavero G, Castrellón A, Quiel Y, Gantes C, Mayaud P. Barriers and facilitators to antiretroviral adherence and retention in HIV care among people living with HIV in the Comarca Ngäbe-Buglé, Panama. PLoS One 2022; 17:e0270044. [PMID: 35709223 PMCID: PMC9202867 DOI: 10.1371/journal.pone.0270044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 06/03/2022] [Indexed: 11/19/2022] Open
Abstract
Introduction Panama’s HIV epidemic is far from under control. One of the populations with the fastest-growing epidemic among the Indigenous peoples of the Comarca Ngäbe-Buglé (CNB). The CNB is an administratively autonomous Indigenous region in Western Panama that is home to over 200,000 individuals of Ngäbe and Buglé ethnicities. This population is unique and, in several ways, represents the early stages of the AIDS epidemics in high-income countries. The CNB is the most impoverished region in Panama and is relatively isolated from outside influences, with limited roads, electricity, and an internet connection, including medical assistance. Around 1.5% of all rapid HIV tests are positive, compared to a national prevalence of 0.9%; in CNB, diagnosis tends to be late. In CNB, 56.3% of individuals had an initial CD4 count of <350 cells/mm3. Antiretroviral treatment (ART) dropout in this region is five times higher than the national average; there is high early mortality due to opportunistic infections. Using the Social-Ecological Theory for Health as a framework, this study aims to describe the facilitators and barriers associated with ART adherence and retention in HIV care among people living with HIV (PLHIV) in the CNB. A better understanding of factors that obstruct adherence could lead to more effective HIV care and prevention in CNB. Methods We conducted 21 semi-structured interviews with PLHIV who reside across all three regions of the CNB and have attended an antiretroviral (ART) clinic at least once. Deductive thematic analysis was used to uncover themes related ART adherence and retention in HIV care at the individual, social and structural levels. Discussion This unique, isolated population of rural Indigenous peoples has high infection rates, late diagnosis, poor ART adherence, and high AIDS-related death rates. The CNB is an important region to examen ART adherence and retention in care. We determined that psychological health, social support, and discrimination acted as individual-level facilitators and barriers to adherence and retention. Notably, structural barriers included difficult access to ART care due to travel costs, ART shortages, and uncooperative Western/Traditional medical systems. Recommended interventions used in other Low- and Middle-Income settings include increasing peer and family-level support and community knowledge and understanding of HIV infection. Additionally, our study suggests structural interventions, including decreasing the cost and distance of traveling to the ART clinic, by decentralizing services, decreasing food scarcity, and increasing collaboration between Western and Traditional providers.
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Affiliation(s)
- Amanda Gabster
- Instituto Conmemorativo Gorgas de Estudios de la Salud, Panamá, Panamá
- London School of Hygiene and Tropical Medicine, London, United Kingdom
- Sistema Nacional de Investigación, Secretaría Nacional de Ciencia, Tecnología e Innovación, Panamá, Panamá
- * E-mail: ,
| | - Eliana Socha
- Community Development Network of the Americas, Panamá, Panamá
| | - Juan Miguel Pascale
- Instituto Conmemorativo Gorgas de Estudios de la Salud, Panamá, Panamá
- Facultad de Medicina, Universidad de Panamá, Panamá, Panamá
| | | | | | - Yaremis Quiel
- Ministerio de Salud, Comarca Ngäbe-Buglé, Panamá, Panamá
| | - César Gantes
- Ministerio de Salud, Comarca Ngäbe-Buglé, Panamá, Panamá
| | - Philippe Mayaud
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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14
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Sisson N, Starke J. Promotores de Salud in Montana: An Analysis of a Rural Health Care Intervention Rooted in Catholic Social Teaching and its Place in Medical Curricula. Linacre Q 2022; 89:21-35. [PMID: 35321492 PMCID: PMC8935425 DOI: 10.1177/00243639211059346] [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: 02/03/2023] Open
Abstract
The Latino population in the United States faces significant health disparities compared to their White counterparts. Community-based processes in Gallatin County, Montana, through academic-community partnerships have identified strategies to overcome these barriers. One such strategy includes the utilization of community health workers (CHWs) in the Latino population-in Spanish, "Promotores de Salud." CHWs are often selected to target community health problems because they share the cultural, social, and demographic features of the population they serve. This paper explores the inherent ties between Catholic Social Teaching and the CHW health care model while focusing on a community-academic partnership in Montana that is implementing a CHW program. Catholic health care providers are called to apply CST principles to their health care systems and communities in order to achieve health equity for their patients. This paper proposes that community organizing and advocacy should be taught in medical school curricula across the country in order to promote physician involvement in solving public health disparities. Additionally, the authors suggest that practicing Catholic health care providers immediately incorporate community organizing through the use of CHWs to attain health equity for their patient panels.
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Affiliation(s)
- Nathaniel Sisson
- School of Medicine, University of Washington, Seattle, WA, USA,Nathaniel Sisson, School of Medicine, University of Washington, 1959 NE Pacific St, A-300 Health Sciences Center, Box 356340, Seattle, WA 98195-0005, USA.
| | - Jenna Starke
- School of Medicine, University of Washington, Seattle, WA, USA
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15
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Ndayizigiye M, Allan-Blitz LT, Dally E, Abebe S, Andom A, Tlali R, Gingras E, Mokoena M, Msuya M, Nkundanyirazo P, Mohlouoa T, Mosebo F, Motsamai S, Mabathoana J, Chetane P, Ntlamelle L, Curtain J, Whelley C, Birru E, McBain R, Andrea DM, Schwarz D, Mukherjee JS. Improving access to health services through health reform in Lesotho: Progress made towards achieving Universal Health Coverage. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000985. [PMID: 36962564 PMCID: PMC10021396 DOI: 10.1371/journal.pgph.0000985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 10/06/2022] [Indexed: 11/17/2022]
Abstract
In 2014 the Kingdom of Lesotho, in conjunction with Partners In Health, launched a National Health Reform with three components: 1) improved supply-side inputs based on disease burden in the catchment area of each of 70 public primary care clinics, 2) decentralization of health managerial capacity to the district level, and 3) demand-side interventions including paid village health workers. We assessed changes in the quarterly average of quality metrics from pre-National Health Reform in 2013 to 2017, which included number of women attending their first antenatal care visit, number of post-natal care visits attended, number of children fully immunized at one year of age, number of HIV tests performed, number of HIV infection cases diagnosed, and the availability of essential health commodities. The number of health centers adequately equipped to provide a facility-based delivery increased from 3% to 95% with an associated increase in facility-based deliveries from 2% to 33%. The number of women attending their first antenatal and postnatal care visits rose from 1,877 to 2,729, and 1,908 to 2,241, respectively. The number of children fully immunized at one year of life increased from 191 to 294. The number of HIV tests performed increased from 5,163 to 12,210, with the proportion of patients living with HIV lost to follow-up falling from 27% to 22%. By the end of the observation period, the availability of essential health commodities increased to 90% or above. Four years after implementation of the National Health Reform, we observed increases in antenatal and post-natal care, and facility-based deliveries, as well as child immunization, and HIV testing and retention in care. Improved access to and utilization of primary care services are important steps toward improving health outcomes, but additional longitudinal follow-up of the reform districts will be needed.
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Affiliation(s)
| | - Lao-Tzu Allan-Blitz
- Division of Global Health Equity: Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, United States of America
| | - Emily Dally
- Partners In Health, Boston, Massachusetts, United States of America
| | | | - Afom Andom
- Partners In Health, Boston, Massachusetts, United States of America
| | | | | | | | - Meba Msuya
- Partners In Health, Boston, Massachusetts, United States of America
| | | | | | | | | | | | | | | | - Joel Curtain
- Partners In Health, Boston, Massachusetts, United States of America
| | - Collin Whelley
- Homebase Center for Common Concerns, San Francisco, California, United States of America
| | - Ermyas Birru
- University of Washington, Seattle, Washington, United States of America
| | - Ryan McBain
- RAND Corporation, Boston, Massachusetts, United States of America
| | - Di Miceli Andrea
- Analysis Group Inc., Boston, Massachusetts, United States of America
| | - Dan Schwarz
- Division of Global Health Equity: Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
- Ariadne Labs, Boston, Massachusetts, United States of America
| | - Joia S Mukherjee
- Division of Global Health Equity: Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
- Partners In Health, Boston, Massachusetts, United States of America
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16
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Bercu C, Moseson H, McReynolds-Pérez J, Wilkinson Salamea E, Grosso B, Trpin M, Zurbriggen R, Cisternas C, Meza M, Díaz V, Kimport K. In-person later abortion accompaniment: a feminist collective-facilitated self-care practice in Latin America. Sex Reprod Health Matters 2021; 29:2009103. [PMID: 34928196 PMCID: PMC8725943 DOI: 10.1080/26410397.2021.2009103] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
In Argentina, Chile and Ecuador, abortion at later durations of pregnancy is legally restricted. Feminist collectives in these contexts support people through self-managed medical abortion outside the healthcare system. The model of in-person abortion accompaniment represents an opportunity to examine a self-care practice that challenges and reimagines abortion provision. We formed a collaborative partnership built on a commitment to shared power and decision-making between researchers and partners. We conducted 28 key informant interviews with accompaniers in Argentina, Chile and Ecuador in 2019 about their model of in-person abortion accompaniment at later durations of pregnancy. We iteratively coded transcripts using a thematic analysis approach. Accompaniers premised their work in a feminist activist framework that understands accompaniment as addressing inequalities and expanding rights, especially for the historically marginalised. Through a detailed description of the process of in-person accompaniment, we show that the model, including the logistical considerations and security mechanisms put in place to ensure favourable abortion outcomes, emphasises peer-to-peer provision of supportive physical and emotional care of the accompanied person. In this way, it represents supported self-care through which individuals are centred as the protagonists of their own abortion, while being accompanied by feminist peers. This model of supported self-care challenges the idea that “self-care” necessarily means “solo care”, or care that happens alone. The model’s focus on peer-to-peer transfer of knowledge, providing emotional support, and centring the accompanied person not only expands access to abortion, but represents person-centred practices that could be scaled and replicated across contexts.
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Affiliation(s)
- Chiara Bercu
- Senior Project Manager, Ibis Reproductive Health, Oakland, CA, USA. Correspondence:
| | - Heidi Moseson
- Senior Research Scientist, Ibis Reproductive Health, Oakland, CA, USA
| | | | | | - Belén Grosso
- Activist and Researcher, La Colectiva Feminista La Revuelta, Neuquén, Argentina
| | - María Trpin
- Activist and Researcher, La Colectiva Feminista La Revuelta, Neuquén, Argentina
| | - Ruth Zurbriggen
- Activist and Researcher, La Colectiva Feminista La Revuelta, Neuquén, Argentina
| | | | - Milena Meza
- Activist and Researcher, Con las Amigas y en la Casa, Santiago, Chile
| | - Viviana Díaz
- Activist and Researcher, Con las Amigas y en la Casa, Santiago, Chile
| | - Katrina Kimport
- Associate Professor, Advancing New Standards in Reproductive Health (ANSIRH), University of California, San Francisco, CA, USA
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17
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Kadia BM, Dimala CA, Fongwen NT, Smith AD. Barriers to and enablers of uptake of antiretroviral therapy in integrated HIV and tuberculosis treatment programmes in sub-Saharan Africa: a systematic review and meta-analysis. AIDS Res Ther 2021; 18:85. [PMID: 34784918 PMCID: PMC8594459 DOI: 10.1186/s12981-021-00395-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 09/23/2021] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION Programmes that merge management of Human Immunodeficiency Virus (HIV) and tuberculosis (TB) aim to improve HIV/TB co-infected patients' access to comprehensive treatment. However, several reports from sub-Saharan Africa (SSA) indicate suboptimal uptake of antiretroviral therapy (ART) even after integration of HIV and TB treatment. This study assessed ART uptake, its barriers and enablers in programmes integrating TB and HIV treatment in SSA. METHOD A systematic review was performed. Seven databases were searched for eligible quantitative, qualitative and mixed-methods studies published from March 2004 through July 2019. Random-effects meta-analysis was used to obtain pooled estimates of ART uptake. A thematic approach was used to analyse and synthesise data on barriers and enablers. RESULTS Of 5139 references identified, 27 were included in the review: 23/27 estimated ART uptake and 10/27 assessed barriers to and/or enablers of ART uptake. The pooled ART uptake was 53% (95% CI: 42, 63%) and between-study heterogeneity was high (I2 = 99.71%, p < 0.001). WHO guideline on collaborative TB/HIV activities and sample size were associated with heterogeneity. There were statistically significant subgroup effects with high heterogeneity after subgroup analyses by region, guideline on collaborative TB/HIV activities, study design, and sample size. The most frequently described socioeconomic and individual level barriers to ART uptake were stigma, low income, and younger age group. The most frequently reported health system-related barriers were limited staff capacity, shortages in medical supplies, lack of infrastructure, and poor adherence to or lack of treatment guidelines. Clinical barriers included intolerance to anti-TB drugs, fear of drug toxicity, and contraindications to antiretrovirals. Health system enablers included good management of the procurement, supply, and dispensation chain; convenience and accessibility of treatment services; and strong staff capacity. Availability of psychosocial support was the most frequently reported enabler of uptake at the community level. CONCLUSIONS In SSA, programmes integrating treatment of TB and HIV do not, in general, achieve high ART uptake but we observe a net improvement in uptake after WHO issued the 2012 guidelines on collaborative TB/HIV activities. The recurrence of specific modifiable system-level and patient-level factors in the literature reveals key intervention points to improve ART uptake in these programmes. Systematic review registration: CRD42019131933.
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Affiliation(s)
- Benjamin Momo Kadia
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.
| | - Christian Akem Dimala
- Department of Medicine, Reading Hospital, Tower Health System, West Reading, PA, USA
- Health and Human Development (2HD) Research Network, Douala, Cameroon
| | - Noah T Fongwen
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
- Africa Centres for Disease Control and Prevention (CDC) Innovation Hub, Africa CDC, Addis Ababa, Ethiopia
| | - Adrian D Smith
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
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18
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Stockton MA, Minnick CE, Kulisewa K, Mphonda SM, Hosseinipour MC, Gaynes BN, Maselko J, Pettifor AE, Go V, Udedi M, Pence BW. A Mixed-Methods Process Evaluation: Integrating Depression Treatment Into HIV Care in Malawi. GLOBAL HEALTH, SCIENCE AND PRACTICE 2021; 9:611-625. [PMID: 34593585 PMCID: PMC8514021 DOI: 10.9745/ghsp-d-20-00607] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 06/08/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Depression is highly prevalent among people living with HIV in Malawi. Depression can undermine engagement in HIV care and worsen HIV morbidity and mortality. The Ministry of Health integrated a pilot depression management program into HIV care at 2 clinics. This program included a measurement-based care protocol for prescribing antidepressants and an adapted Friendship Bench psychotherapy protocol for providing problem solving. Early evaluations indicated successful integration of the initial stages of training and depression screening, diagnosis, and treatment initiation. This follow-up mixed-method investigation contextualizes our previous findings and shares insights from the implementation experience. METHODS We conducted a mixed-methods process evaluation drawing on both patient clinical data and qualitative interviews with patients and clinic staff. We focus on the following implementation outcomes: fidelity, acceptability, and sustainability. RESULTS Although fidelity to depression screening and treatment initiation was high, fidelity to the follow-up treatment protocol was poor. Antidepressants and problem-solving therapy were acceptable to patients, but clinic staff found delivering treatment challenging given constrained human resources and infrastructure. The program was not sustained after the project. Key identified needs included substantial support to supervise the implementation of the program, continue to build and maintain the capacity of providers, integrate the program into the electronic medical records system, and ensure the availability of Friendship Bench counselors. CONCLUSIONS Although initial steps were successful, sustained integration of this depression treatment program into HIV care in this setting met greater challenges. Implementation science studies that support both implementation and evaluation should recognize the potential for clinical implementers to rely on evaluation staff for clinical support and consider distancing evaluation staff from the actual program implementation. Further research is needed to test enhanced implementation strategies for integrating evidence-based mental health interventions into existing health care systems in a sustainable fashion, particularly in low-resource settings.
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Affiliation(s)
- Melissa A Stockton
- Epidemiology Department, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Caroline E Minnick
- University of North Carolina Project-Malawi, Tidziwe Centre, Lilongwe, Malawi
| | - Kazione Kulisewa
- Department of Mental Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Steven M Mphonda
- University of North Carolina Project-Malawi, Tidziwe Centre, Lilongwe, Malawi
| | - Mina C Hosseinipour
- University of North Carolina Project-Malawi, Tidziwe Centre, Lilongwe, Malawi
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Bradley N Gaynes
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Joanna Maselko
- Epidemiology Department, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Audrey E Pettifor
- Epidemiology Department, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Vivian Go
- Epidemiology Department, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Michael Udedi
- University of North Carolina Project-Malawi, Tidziwe Centre, Lilongwe, Malawi
- Noncommunicable Diseases and Mental Health Unit, Ministry of Health, Lilongwe, Malawi
| | - Brian W Pence
- Epidemiology Department, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Louart S, Bonnet E, Ridde V. Is patient navigation a solution to the problem of "leaving no one behind"? A scoping review of evidence from low-income countries. Health Policy Plan 2021; 36:101-116. [PMID: 33212491 PMCID: PMC7938515 DOI: 10.1093/heapol/czaa093] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2020] [Indexed: 12/25/2022] Open
Abstract
Patient navigation interventions, which are designed to enable patients excluded from health systems to overcome the barriers they face in accessing care, have multiplied in high-income countries since the 1990s. However, in low-income countries (LICs), indigents are generally excluded from health policies despite the international paradigm of universal health coverage (UHC). Fee exemption interventions have demonstrated their limits and it is now necessary to act on other dimensions of access to healthcare. However, there is a lack of knowledge about the interventions implemented in LICs to support the indigents throughout their care pathway. The aim of this paper is to synthesize what is known about patient navigation interventions to facilitate access to modern health systems for vulnerable populations in LICs. We therefore conducted a scoping review to identify all patient navigation interventions in LICs. We found 60 articles employing a total of 48 interventions. Most of these interventions targeted traditional beneficiaries such as people living with HIV, pregnant women and children. We utilized the framework developed by Levesque et al. (Patient-centred access to health care: conceptualising access at the interface of health systems and populations. Int J Equity Health 2013;12:18) to analyse the interventions. All acted on the ability to perceive, 34 interventions on the ability to reach, 30 on the ability to engage, 8 on the ability to pay and 6 on the ability to seek. Evaluations of these interventions were encouraging, as they often appeared to lead to improved health indicators and service utilization rates and reduced attrition in care. However, no intervention specifically targeted indigents and very few evaluations differentiated the impact of the intervention on the poorest populations. It is therefore necessary to test navigation interventions to enable those who are worst off to overcome the barriers they face. It is a major ethical issue that health policies leave no one behind and that UHC does not benefit everyone except the poorest.
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Affiliation(s)
- Sarah Louart
- Univ. Lille, CNRS, UMR 8019 - CLERSE - Centre Lillois d’Études et de Recherches sociologiques et Économiques, F-59000 Lille, France
| | - Emmanuel Bonnet
- Institute for Research on Sustainable Development, UMI Résiliences 236, Bondy, France
| | - Valéry Ridde
- Institute for Research on Sustainable Development, CEPED (IRD-Université de Paris), Université de Paris, ERL INSERM SAGESUD, 45 Rue des Saints-Pères, Paris 75006, France
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20
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Stockton MA, Gaynes BN, Hosseinipour MC, Pettifor AE, Maselko J, Mphonda SM, Kulisewa K, Udedi M, Pence BW. Association Between Depression and HIV Care Engagement Outcomes Among Patients Newly Initiating ART in Lilongwe, Malawi. AIDS Behav 2021; 25:826-835. [PMID: 32970274 PMCID: PMC7886828 DOI: 10.1007/s10461-020-03041-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2020] [Indexed: 12/13/2022]
Abstract
As in other sub-Saharan countries, the burden of depression is high among people living with HIV in Malawi. However, the association between depression at ART initiation and two critical outcomes-retention in HIV care and viral suppression-is not well understood. Prior to the launch of an integrated depression treatment program, adult patients were screened for depression at ART initiation at two clinics in Lilongwe, Malawi. We compared retention in HIV care and viral suppression at 6 months between patients with and without depression at ART initiation using tabular comparison and regression models. The prevalence of depression among this population of adults newly initiating ART was 27%. Those with depression had similar HIV care outcomes at 6 months to those without depression. Retention metrics were generally poor for those with and without depression. However, among those completing viral load testing, nearly all achieved viral suppression. Depression at ART initiation was not associated with either retention or viral suppression. Further investigation of the relationship between depression and HIV is needed to understand the ways depression impacts the different aspects of HIV care engagement.
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Affiliation(s)
- Melissa A Stockton
- Epidemiology Department, University of North Carolina at Chapel Hill Gillings School of Global Public Health, 135 Dauer Dr, Chapel Hill, NC, 27599, USA.
| | - Bradley N Gaynes
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, 333 S Columbia St, Chapel Hill, NC, 27516, USA
| | - Mina C Hosseinipour
- University of North Carolina Project-Malawi, Tidziwe Centre, Private Bag A-104, Lilongwe, Malawi
- Division of Infectious Disease, University of North Carolina at Chapel Hill School of Medicine, 333 S Columbia St, Chapel Hill, NC, 27516, USA
| | - Audrey E Pettifor
- Epidemiology Department, University of North Carolina at Chapel Hill Gillings School of Global Public Health, 135 Dauer Dr, Chapel Hill, NC, 27599, USA
| | - Joanna Maselko
- Epidemiology Department, University of North Carolina at Chapel Hill Gillings School of Global Public Health, 135 Dauer Dr, Chapel Hill, NC, 27599, USA
| | - Steven M Mphonda
- University of North Carolina Project-Malawi, Tidziwe Centre, Private Bag A-104, Lilongwe, Malawi
| | - Kazione Kulisewa
- College of Medicine, Department of Mental Health, University of Malawi, P/Bag 360, Chichiri, Blantyre 3, Malawi
| | - Michael Udedi
- NCDs & Mental Health Unit, Ministry of Health, P. O. Box 30377, Capital City, Lilongwe 3, Malawi
- College of Medicine, Department of Mental Health, University of Malawi, P/Bag 360, Chichiri, Blantyre 3, Malawi
| | - Brian W Pence
- Epidemiology Department, University of North Carolina at Chapel Hill Gillings School of Global Public Health, 135 Dauer Dr, Chapel Hill, NC, 27599, USA
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Matsena Zingoni Z, Chirwa T, Todd J, Musenge E. Competing risk of mortality on loss to follow-up outcome among patients with HIV on ART: a retrospective cohort study from the Zimbabwe national ART programme. BMJ Open 2020; 10:e036136. [PMID: 33028546 PMCID: PMC7539573 DOI: 10.1136/bmjopen-2019-036136] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 08/24/2020] [Accepted: 09/01/2020] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To determine the loss to follow-up (LTFU) rates at different healthcare levels after antiretroviral therapy (ART) services decentralisation among ART patients who initiated ART between 2004 and 2017 using the competing risk model in addition to the Kaplan-Meier and Cox regressions analysis. DESIGN A retrospective cohort study. SETTING The study was done in Zimbabwe using a nationwide routinely collected HIV patient-level data from various health levels of care facilities compiled through the electronic patient management system (ePMS). PARTICIPANTS We analysed 390 771 participants aged 15 years and above from 538 health facilities. OUTCOMES The primary endpoint was LTFU defined as a failure of a patient to report for drug refill for at least 90 days from last appointment date or if the patient missed the next scheduled visit date and never showed up again. Mortality was considered a secondary outcome if a patient was reported to have died. RESULTS The total exposure time contributed was 1 544 468 person-years. LTFU rate was 5.75 (95% CI 5.71 to 5.78) per 100 person-years. Adjustment for the competing event independently increased LTFU rate ratio in provincial and referral (adjusted sub-HRs (AsHR) 1.22; 95% CI 1.18 to 1.26) and district and mission (AsHR 1.47; 95% CI 1.45 to 1.50) hospitals (reference: primary healthcare); in urban sites (AsHR 1.61; 95% CI 1.59 to 1.63) (reference: rural); and among adolescence and young adults (15-24 years) group (AsHR 1.19; 95% CI 1.16 to 1.21) (reference: 35-44 years). We also detected overwhelming association between LTFU and tuberculosis-infected patients (AsHR 1.53; 95% CI 1.45 to 1.62) (reference: no tuberculosis). CONCLUSIONS We have observed considerable findings that 'leakages' (LTFU) within the ART treatment cascade persist even after the decentralisation of health services. Risk factors for LTFU reflect those found in sub-Saharan African studies. Interventions that retain patients in care by minimising any 'leakages' along the treatment cascade are essential in attaining the 90-90-90 UNAIDS fast-track targets.
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Affiliation(s)
- Zvifadzo Matsena Zingoni
- Division of Epidemiology and Biostatistics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- National Institute of Health Research, Ministry of Health and Child Care, Harare, Zimbabwe
| | - Tobias Chirwa
- Division of Epidemiology and Biostatistics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jim Todd
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Eustasius Musenge
- Division of Epidemiology and Biostatistics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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22
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Bukhman G, Mocumbi AO, Atun R, Becker AE, Bhutta Z, Binagwaho A, Clinton C, Coates MM, Dain K, Ezzati M, Gottlieb G, Gupta I, Gupta N, Hyder AA, Jain Y, Kruk ME, Makani J, Marx A, Miranda JJ, Norheim OF, Nugent R, Roy N, Stefan C, Wallis L, Mayosi B. The Lancet NCDI Poverty Commission: bridging a gap in universal health coverage for the poorest billion. Lancet 2020; 396:991-1044. [PMID: 32941823 PMCID: PMC7489932 DOI: 10.1016/s0140-6736(20)31907-3] [Citation(s) in RCA: 155] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 05/29/2020] [Accepted: 08/25/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Gene Bukhman
- Department of Global Health and Social Medicine, Harvard University, Boston, MA, USA; Program in Global NCDs and Social Change, Harvard University, Boston, MA, USA; Partners In Health, Boston, MA, USA; Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA; Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.
| | - Ana O Mocumbi
- Universidade Eduardo Mondlane, Maputo, Mozambique; Instituto Nacional de Saúde, Maputo, Mozambique
| | - Rifat Atun
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Anne E Becker
- Department of Global Health and Social Medicine, Harvard University, Boston, MA, USA
| | - Zulfiqar Bhutta
- Center for Global Child Health, Hospital for Sick Kids, Toronto, ON, Canada; Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan; Institute for Global Health & Development, Aga Khan University, South-Central Asia, East Africa, and UK
| | | | - Chelsea Clinton
- Clinton Foundation, New York, NY, USA; Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Matthew M Coates
- Department of Global Health and Social Medicine, Harvard University, Boston, MA, USA; Program in Global NCDs and Social Change, Harvard University, Boston, MA, USA; Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Majid Ezzati
- MRC Centre for Environment and Health, School of Public Health, Imperial College London, London, UK
| | - Gary Gottlieb
- Department of Psychiatry, Harvard Medical School, Harvard University, Boston, MA, USA
| | - Indrani Gupta
- Health Policy Research Unit, Institute of Economic Growth, Delhi, India
| | - Neil Gupta
- Department of Global Health and Social Medicine, Harvard University, Boston, MA, USA; Program in Global NCDs and Social Change, Harvard University, Boston, MA, USA; Partners In Health, Boston, MA, USA; Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Adnan A Hyder
- Milken Institute School of Public Health, George Washington University, Washington, DC, USA
| | - Yogesh Jain
- Jan Swasthya Sahyog, Bilaspur, Chhattisgarh, India
| | - Margaret E Kruk
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Julie Makani
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Andrew Marx
- Department of Global Health and Social Medicine, Harvard University, Boston, MA, USA; Program in Global NCDs and Social Change, Harvard University, Boston, MA, USA
| | - J Jaime Miranda
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Ole F Norheim
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA; Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Rachel Nugent
- Research Triangle Institute International, Seattle, WA, USA
| | - Nobhojit Roy
- WHO Collaborating Centre for Research on Surgical Care Delivery in LMICs, Department of Surgery, BARC Hospital, HBNI University, Government of India, Mumbai, India; Field Health Systems Laboratory, Bihar Technical Support Programme, CARE India, Madhubani, Bihar, India
| | - Cristina Stefan
- SingHealth Duke-NUS Global Health Institute (SDGHI), Duke-NUS Medical School, Singapore; African Medical Research and Innovation Institute, Cape Town, South Africa
| | - Lee Wallis
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Bongani Mayosi
- Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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23
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Kamal S, Glass TR, Doco-Lecompte T, Locher S, Bugnon O, Parienti JJ, Cavassini M, Schneider MP. An Adherence-Enhancing Program Increases Retention in Care in the Swiss HIV Cohort. Open Forum Infect Dis 2020; 7:ofaa323. [PMID: 32913876 PMCID: PMC7473741 DOI: 10.1093/ofid/ofaa323] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 08/10/2020] [Indexed: 11/28/2022] Open
Abstract
Background This study tested a theory-based adherence-enhancing intervention: the “Interprofessional Medication Adherence Program” (IMAP) to increase human immunodeficiency virus (HIV) retention in care. Methods We retrospectively compared our intervention center (intervention group [IG]) with a standard of care center (control group [CG]) both participating in the Swiss HIV Cohort Study between 2004 and 2012. Endpoints were defined as >6-month and >12-month gaps in care for intervals of care longer than 6 and 12 months without any blood draw. Inverse probability of treatment weights was used to adjust for differences between patients at the 2 centers. Viral failure was defined as ribonucleic acid ≥50 copies/mL after 24+ weeks on antiretrovirals. Results The IG included 451 patients, CG 311. In the IG, 179 (40%) patients took part in the IMAP for a median of 27 months (interquartile range, 12–45). Gaps in care of ≥6 months were significantly more likely to happen in the CG versus IG (74.6% vs 57%, P < .001). The median time until the first treatment gap was longer in the IG vs CG (120 vs 84 weeks, P < .001). Gaps in care of ≥12 months evaluated in 709 (93%) patients were significantly more likely to occur in the CG compared with the IG (22.6% vs 12.5%, P < .001). The rate of viral failure was significantly lower in the IG (8.3% vs 15.1%, P = .003). Conclusions This study, in a real-world setting, shows the effectiveness of the IMAP to reduce 6- and 12-month gaps in follow up among people with HIV. These results should be confirmed by studies in other settings.
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Affiliation(s)
- Susan Kamal
- School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Geneva, Switzerland Geneva, Switzerland.,Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Tracy R Glass
- Clinical Statistics and Data Management Group, Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Thanh Doco-Lecompte
- HIV Unit, Department of Internal Medicine, Geneva University Hospital, Geneva, Switzerland
| | - Sophie Locher
- School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Geneva, Switzerland Geneva, Switzerland
| | - Olivier Bugnon
- School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Geneva, Switzerland Geneva, Switzerland.,Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland.,Center for Research and Innovation in Clinical Pharmaceutical Sciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | | | - Matthias Cavassini
- Infectious Disease Service, Lausanne University Hospital, University of Lausanne, Lausanne Switzerland
| | - Marie P Schneider
- School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Geneva, Switzerland Geneva, Switzerland.,Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
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Applying the Exploration Preparation Implementation Sustainment (EPIS) Framework to the Kigali Imbereheza Project for Rwandan Adolescents Living With HIV. J Acquir Immune Defic Syndr 2020; 82 Suppl 3:S289-S298. [PMID: 31764266 DOI: 10.1097/qai.0000000000002204] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Sub-Saharan African adolescents living with HIV face challenges to antiretroviral therapy (ART) adherence. Poor mental health drives nonadherence but can be improved with cognitive behavioral therapy (CBT). CBT delivered by peers may strengthen effects while building capacity for sustainment in low-income countries. This case study retrospectively applied the Exploration Preparation Implementation Sustainment framework to characterize the execution of the Kigali Imbereheza Project, a 2-arm individually randomized group controlled trial of Trauma-Informed Adherence-Enhanced CBT (TI-CBTe) delivered by Rwandan youth leaders (YLs) to adolescents living with HIV. METHODS YL (n = 14, 43% female, M = 22.71 years) had confirmed HIV and self-reported ART adherence >95%. Participants (n = 356, 51% female, M = 16.78 years) living with HIV were randomized to TI-CBTe or usual care. Two YLs co-led TI-CBTe sessions over 2 months for a total of 12 hours, while other YL observed and rated fidelity. Participants reported on YL competence. Additional data evaluated feasibility, acceptability, uptake, and fidelity. RESULTS In the Exploration phase, focus groups, stakeholder meetings, and individual interviews revealed strong consensus for delivering TI-CBT to reduce adolescent depression and trauma and improve ART adherence. In the Preparation phase, curriculum revisions were made, YLs were successfully trained, and a cascading supervision model was established. In the Implementation phase, YL delivered TI-CBTe with close monitoring and supervision. Findings revealed strong feasibility, acceptability, uptake, and fidelity, increasing the likelihood of Sustainment. CONCLUSIONS Exploration Preparation Implementation Sustainment can guide implementation planning and delivery and evaluate implementation outcomes.
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25
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Stockton MA, Udedi M, Kulisewa K, Hosseinipour MC, Gaynes BN, Mphonda SM, Maselko J, Pettifor AE, Verhey R, Chibanda D, Lapidos-Salaiz I, Pence BW. The impact of an integrated depression and HIV treatment program on mental health and HIV care outcomes among people newly initiating antiretroviral therapy in Malawi. PLoS One 2020; 15:e0231872. [PMID: 32374724 PMCID: PMC7202614 DOI: 10.1371/journal.pone.0231872] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 04/01/2020] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Depression is highly prevalent among patients newly starting antiretroviral treatment (ART) in Malawi and many other countries. Untreated depression at ART initiation can disrupt the HIV care continuum. Effective approaches for depression screening and treatment exist for low-resource settings, but they are rarely applied. Identifying effective implementation strategies are critical. METHODS A pilot program integrated depression screening and treatment into routine HIV care using existing staff at two public health clinics in Malawi in two phases; a screening-only "control" phase and an active "intervention" phase. During the intervention phase, providers prescribed antidepressants or referred patients for Friendship Bench problem-solving therapy. We evaluated the program's impact on retention in HIV care, viral suppression, and depression remission at 6 months using tabular comparisons and log-binomial models to estimate adjusted risk ratios and mean differences among the intervention group relative to the control group. RESULTS Nearly all consenting participants were screened for depression appropriately and 25% had mild to severe depressive symptoms. During the intervention phase, 86% of participants with mild depressive symptoms started Friendship Bench therapy and 96% of participants with moderate to severe depressive symptoms started antidepressants. Few participants in the intervention group received consistent depression treatment over their first 6 months in care. In the adjusted main analysis, program exposure did not demonstrably affect most HIV or mental health outcomes, though the probability of currently being on ART at 6 months was significantly lower among the intervention group than the control group [RR 0.6(95%CI: 0.4-0.9)]. CONCLUSIONS While it is feasible to integrate depression screening and treatment initiation into ART initiation, providing ongoing depression treatment over time is challenging. Similar implementation science studies focused on maintaining depression management will be increasingly important as we strive to understand and test the best ways to implement evidence-based depression treatment within HIV care.
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Affiliation(s)
- Melissa A. Stockton
- Epidemiology Department, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC, United States of America
| | - Michael Udedi
- NCDs & Mental Health Unit, Ministry of Health, Lilongwe, Malawi
- Department of Mental Health, University of Malawi, College of Medicine, Blantyre, Malawi
| | - Kazione Kulisewa
- Department of Mental Health, University of Malawi, College of Medicine, Blantyre, Malawi
| | - Mina C. Hosseinipour
- University of North Carolina Project-Malawi, Tidziwe Centre, Lilongwe, Malawi
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, United States of America
| | - Bradley N. Gaynes
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, United States of America
| | - Steven M. Mphonda
- University of North Carolina Project-Malawi, Tidziwe Centre, Lilongwe, Malawi
| | - Joanna Maselko
- Epidemiology Department, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC, United States of America
| | - Audrey E. Pettifor
- Epidemiology Department, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC, United States of America
| | - Ruth Verhey
- Friendship Bench Zimbabwe, Milton Park, Harare, Zimbabwe
| | - Dixon Chibanda
- Friendship Bench Zimbabwe, Milton Park, Harare, Zimbabwe
| | - Ilana Lapidos-Salaiz
- United States Agency for International Development (USAID), Arlington, VA, United States of America
| | - Brian W. Pence
- Epidemiology Department, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC, United States of America
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Can Changes in Service Delivery Models Improve Program Quality and Efficiency? A Closer Look at HIV Programs in Kenya and Uganda. J Acquir Immune Defic Syndr 2020; 81:533-539. [PMID: 31021985 PMCID: PMC6738623 DOI: 10.1097/qai.0000000000002064] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Supplemental Digital Content is Available in the Text. With the scale-up of antiretroviral treatment, many health facilities in low- and middle-income countries have implemented innovative practices targeted at overcoming operational challenges and delivering efficient quality HIV services. However, many of these practices remain largely unexplored as a means to better reach the global 90-90-90 targets.
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Nyoni T, Sallah YH, Okumu M, Byansi W, Lipsey K, Small E. The effectiveness of treatment supporter interventions in antiretroviral treatment adherence in sub-Saharan Africa: a systematic review and meta-Analysis. AIDS Care 2020; 32:214-227. [PMID: 32196385 DOI: 10.1080/09540121.2020.1742870] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
This systematic review and meta-analysis evaluated the effectiveness of treatment supporter interventions (TSI) in improving ART adherence and viral suppression among adults living with HIV (PLWH) in sub-Saharan Africa. This review included ten randomized controlled trials (RCT) and six cohort studies comparing treatment support interventions to the standard of care (SOC). Primary outcomes include pill count ART adherence and viral load suppression (VLS). Pooled relative risk ratios (PRR) with 95% confidence intervals were generated using random-effects models. Stratified analyses and meta-regressions were conducted to determine the effect of study type, follow-upperiod, and patient treatment supporters on ART adherence. Treatment supporters included partners, friends, family members, trained community health workers, and HIV positive peers. TSIs were associated with a 7.6% higher ART adherence compared to the SOC group (PRR = 1.076, [95% CI = 1.005, 1.151]). VLS was 5% higher in the treatment group compared to the SOC group (PRR = 1.05, [95% CI = 1.061, 1.207]). There was a significant, positive association between TSIs and VLS in community-based delivery settings but not in facility-based settings. TSIs were statistically significant for VLS in cohort study designs (RR = 1.073, [95% CI = 1.028, 1.121]) but not in RCTs. Findings suggest that TSIs critical in facilitating optimal ART adherence and VLS among PLWHs.
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Affiliation(s)
- Thabani Nyoni
- Washington University in St. Louis, St. Louis, MO, USA
| | | | - Moses Okumu
- University of North Carolina, Chapel Hill, NC, USA
| | | | - Kim Lipsey
- Washington University in St. Louis, St. Louis, MO, USA
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Carrasco H, Napier H, Giber D, Kang S, Aguerreberre M, Hing M, Silva VSTM, Montaño M, Perry H, Palazuelos D. Accompanimeter 1.0: creation and initial field testing of a tool to assess the extent to which the principles and building blocks of accompaniment are present in community health worker programs. Glob Health Action 2020; 12:1699348. [PMID: 31829114 PMCID: PMC6913655 DOI: 10.1080/16549716.2019.1699348] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background: The strategic incorporation of community health workers (CHWs) into health system strengthening efforts is recognized as a critical and high-value approach for meeting the Sustainable Development Goals established by the United Nations in 2015. How to best build CHW programs, however, is prone to a wide variety of opinions and philosophies, many of which are often externally imposed. Partners in Health (PIH) is a non-governmental organization that pioneered an approach to healthcare system strengthening, called accompaniment, in which CHWs play a key role. Learning from PIH is a critical first step in replicating the organization’s achievements beyond PIH. As such, PIH has developed a tool, referred to as the ‘Accompanimeter 1.0,’ that serves to evaluate existing CHW programs and guide adjustments in programming. Objective: To provide a standardized approach for defining, assessing, and implementing accompaniment in CHW programs using a tool called the Accompanimeter 1.0. Methods: Development of this tool included three stages: (1) desk review of literature relevant to the work of CHWs globally, (2) discussions among colleagues and initial field testing, (3) feedback from colleagues who are experts in community health and in the principles of accompaniment. Results: Three core principles of accompaniment in a CHW program were identified: professionalization, CHWs as bridges to institutional strength, and community proximity. These core principles direct five thematic areas that are found in successful CHW programs: Partnering (co-creating engagement with a continuous and intersectoral dialogue to improve the program); Choosing (identifying the right people for the right job); Educating (building CHWs´ capacity); Incentivizing (enabling CHWs to perform their work without financial sacrifice); Supervising (mentoring CHWs for personal growth). Conclusions: The Accompanimeter 1.0 can serve as a helpful tool for CHW program implementation and policy decisions that maximize system-side inputs, community engagement, and support for individuals with medical issues.
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Affiliation(s)
- Hector Carrasco
- Doctor of Public Health Program, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Ciencias Básicas, Escuela de Medicina y Ciencias de la Salud del Tecnológico de Monterrey, México City, México
| | - Harriet Napier
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - David Giber
- Community Health Systems, Partners In Health, Boston, MA, USA
| | - Stephanie Kang
- Doctor of Public Health Program, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Mercedes Aguerreberre
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.,Department of Maternal Health, Partners In Health (Compañeros En Salud), Ángel Albino Corzo, Chis, México
| | - Matthew Hing
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | | | - Mariana Montaño
- Department of Maternal Health, Partners In Health (Compañeros En Salud), Ángel Albino Corzo, Chis, México
| | - Henry Perry
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Daniel Palazuelos
- Community Health Systems, Partners In Health, Boston, MA, USA.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
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Worster DT, Franke MF, Bazúa R, Flores H, García Z, Krupp J, Maza J, Palazuelos L, Rodríguez K, Newman PM, Palazuelos D. Observational stepped-wedge analysis of a community health worker-led intervention for diabetes and hypertension in rural Mexico. BMJ Open 2020; 10:e034749. [PMID: 32152172 PMCID: PMC7064075 DOI: 10.1136/bmjopen-2019-034749] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES There is emerging interest and data supporting the effectiveness of community health workers (CHWs) in non-communicable diseases (NCDs) in low/middle-income countries (LMICs). This study aimed to determine whether a CHW-led intervention targeting diabetes and hypertension could improve markers of clinical disease control in rural Mexico. DESIGN AND SETTING A prospective observational stepped-wedge study was conducted across seven communities in rural Chiapas, Mexico from March 2014 to April 2018. PARTICIPANTS 149 adults with hypertension and/or diabetes. INTERVENTION This study was conducted in the context of the programmatic roll-out of an accompaniment-based CHW-led intervention designed to complement comprehensive primary care for adults with diabetes and/or hypertension. Implementation occurred sequentially at 3-month intervals with point-of-care data collected at baseline and every 3 months thereafter for 12 months following roll-out in all communities. OUTCOME MEASURES Primary outcomes were glycated haemoglobin (HbA1c) and systolic blood pressure (SBP), overall and stratified by baseline disease control. We conducted an individual-level analysis using mixed effects regression, adjusting for time, cohort and clustering at the individual and community levels. RESULTS Among patients with diabetes, the CHW-led intervention was associated with a decrease in HbA1c of 0.35%; however, CIs were wide (95% CI -0.90% to 0.20%). In patients with hypertension, there was a 4.7 mm Hg decrease in SBP (95% CI -8.9 to -0.6). In diabetic patients with HbA1c ≥9%, HbA1c decreased by 0.96% (95% CI -1.69% to -0.23%), and in patients with uncontrolled hypertension, SBP decreased by 10.2 mm Hg (95% CI -17.7 to -2.8). CONCLUSIONS We found that a CHW-led intervention resulted in clinically meaningful improvement in disease markers for patients with diabetes and hypertension, most apparent among patients with hypertension and patients with uncontrolled disease at baseline. These findings suggest that CHWs can play a valuable role in supporting NCD management in LMICs. TRIAL REGISTRATION NUMBER NCT02549495.
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Affiliation(s)
- Devin T Worster
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Compañeros en Salud, Ángel Albino Corzo, Mexico
| | - Molly F Franke
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Hugo Flores
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Compañeros en Salud, Ángel Albino Corzo, Mexico
| | | | | | - Jimena Maza
- Compañeros en Salud, Ángel Albino Corzo, Mexico
| | | | | | - Patrick M Newman
- Compañeros en Salud, Ángel Albino Corzo, Mexico
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Daniel Palazuelos
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Compañeros en Salud, Ángel Albino Corzo, Mexico
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Partners In Health, Boston, Massachusetts, USA
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30
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Udedi M, Stockton MA, Kulisewa K, Hosseinipour MC, Gaynes BN, Mphonda SM, Pence BW. The effectiveness of depression management for improving HIV care outcomes in Malawi: protocol for a quasi-experimental study. BMC Public Health 2019; 19:827. [PMID: 31242877 PMCID: PMC6595692 DOI: 10.1186/s12889-019-7132-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 06/09/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Depression, prevalent among people living with HIV (PLWH) in Malawi, is associated with negative HIV patient outcomes and likely affects HIV medical management. Despite the high prevalence of depression, its management has not been integrated into HIV care in Malawi or most low-income countries. METHODS This study employs a pre-post design in two HIV clinics in Lilongwe, Malawi, to evaluate the effect of integrating depression management into routine HIV care on both mental health and HIV outcomes. Using a multiple baseline design, this study is examining mental health and HIV outcome data of adult (≥18 years) patients newly initiating ART who also have depression, comparing those entering care before and after the integration of depression screening and treatment into HIV care. The study is also collecting cost information to estimate the cost-effectiveness of the program in improving rates of depression remission and HIV treatment engagement and success. DISCUSSION We anticipate that the study will generate evidence on the effect of depression management on HIV outcomes and the feasibility of integrating depression management into existing HIV care clinics. The results of the study will inform practice and policy decisions on integration of depression management in HIV care clinics in Malawi and related settings, and will help design a next-step strategy to scale-up integration to a larger scale. TRIAL REGISTRATION ClinicalTrials.gov ID [ NCT03555669 ]. Retrospectively registered on 13 June 2018.
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Affiliation(s)
- Michael Udedi
- NCDs and Mental Health Unit, Ministry of Health, P. O. Box 30377, Capital City, Lilongwe 3, Malawi
- Department of Mental Health, University of Malawi, College of Medicine, P/Bag 360, Chichiri, Blantyre 3, Malawi
| | - Melissa A. Stockton
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, 135 Dauer Dr, Chapel Hill, NC 27599 USA
| | - Kazione Kulisewa
- Department of Mental Health, University of Malawi, College of Medicine, P/Bag 360, Chichiri, Blantyre 3, Malawi
| | - Mina C. Hosseinipour
- Tidziwe Centre, University of North Carolina Project-Malawi, Private Bag A-104, Lilongwe, Malawi
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, 333 S Columbia St, Chapel Hill, NC 27516 USA
| | - Bradley N. Gaynes
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, 333 S Columbia St, Chapel Hill, NC 27516 USA
| | - Steven M. Mphonda
- Tidziwe Centre, University of North Carolina Project-Malawi, Private Bag A-104, Lilongwe, Malawi
| | - Brian W. Pence
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, 135 Dauer Dr, Chapel Hill, NC 27599 USA
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Fiori KP, Belli HM, Lauria ME, Hirschhorn LR, Schechter J, Hansman E, Rajshekhar N, Katin V, Gbeleou S, Grunitsky-Bekele M, Pitche VP. Implementing an integrated community based health systems strengthening approach to improve HIV survival in Northern Togo. AIDS Care 2019; 32:705-713. [PMID: 31170827 DOI: 10.1080/09540121.2019.1626342] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
To disseminate lessons learned from the implementation experience of a public-private sector partnership, we describe a comprehensive HIV/AIDS program including 5-year survival outcomes for individuals who initiated antiretroviral therapy (ART) treatment in Togo from 2010 to 2015. A retrospective case study analysis was conducted from a cohort of patients receiving ART at an HIV/AIDS care clinic in Kara Region, Togo. Kaplan-Meier curves with Log rank tests were used to compare estimated survival curves by demographic and clinical characteristics. Associations were described between survival probability and age, gender, World Health Organization (WHO) disease stage, and timing of ART initiation. Cox proportional hazard model was used to determine predictors of mortality. After approximately five-years since ART initiation (1780 days), there were 114 deaths, with a survival probability of 75.3% (95% CI: 70.3-80.6%). Participants with advanced WHO disease stage were more likely at risk of death relative to patients categorized as WHO Stage 1, with Stage 4 approximately 9 times more likely (aHR 9.22, 95% CI 4.29-19.84). Our study suggests that delivering comprehensive HIV care through a private-public partnership may serve as a model to expand and improve HIV/AIDS care as well as high quality primary care.
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Affiliation(s)
- Kevin P Fiori
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, NY, USA.,Community Health Systems Lab, Integrate Health/Santé Intégrée, Kara, Togo and New York, NY, USA
| | - Hayley M Belli
- New York University School of Medicine, New York, NY, USA
| | - Molly E Lauria
- Community Health Systems Lab, Integrate Health/Santé Intégrée, Kara, Togo and New York, NY, USA
| | - Lisa R Hirschhorn
- Community Health Systems Lab, Integrate Health/Santé Intégrée, Kara, Togo and New York, NY, USA.,Northwestern University Feinberg School of Medicine, Chicago, USA
| | | | - Emily Hansman
- Integrate Health/Santé Intégrée, Kara, Togo and New York, NY, USA
| | | | - Venance Katin
- Integrate Health/Santé Intégrée, Kara, Togo and New York, NY, USA.,Service de dermatologie et IST, Centre Hospitalier Universitaire (CHU) Kara, Kara, Togo
| | - Sesso Gbeleou
- Integrate Health/Santé Intégrée, Kara, Togo and New York, NY, USA
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Abstract
Background In low- and middle-income countries (LMIC), women have limited access to and uptake of cervical cancer screening. Delayed diagnosis leads to poorer outcomes and early mortality, and continues to impede cancer control disproportionately in LMIC. Integrating self-collected, community-based screening for High Risk-Human Papilloma Virus (HR-HPV) into existent HIV programs is a potential screening method to identify women at high risk for developing high-risk cervical lesions. Methods We implemented community-based cross-sectional study on self-collection HR-HPV screening in conjunction with existing community outreach models for the distribution of antiretroviral therapy (ART) and the World Health Organization Expanded Program on Immunization (EPI) outreach in villages in rural Zimbabwe from January 2017 through May 2017. Results Overall, there was an 82% response rate: 70% of respondents participated in self-collection and 12% were ineligible for the study (inclusion criteria: age 30–65, not pregnant, with an intact uterus). Women recruited in the first 2–3 months of the study had more opportunities to participate and therefore significantly higher participation: 81% participation (additional 11% ineligible), while those with fewer opportunities also had lower participation: 63% (additional 13% ineligible) (p < 0.001). Some village outreach centers (N = 5/12) had greater than 89% participation. Conclusions Integration of HR-HPV screening into existing community outreach models for HIV and immunizations could facilitate population-based screening to scale cancer control and prevention programs in sub-Saharan Africa. Community/village health workers (CHW/VHW) and village outreach programs offer a potential option for cervical cancer screening programs to move towards improving access of sexual and reproductive health resources for women at highest risk. Electronic supplementary material The online version of this article (10.1186/s12889-019-6810-5) contains supplementary material, which is available to authorized users.
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Bigna JJ, Tounouga DN, Kenne AM, Djikeussi TK, Foka AJ, Um LN, Asangbeh SL, Sibetcheu AT, Kaze AD, Ndangang MS, Nansseu JR. Epidemiology of depressive disorders in people living with HIV in Africa: a systematic review and meta-analysis: Burden of depression in HIV in Africa. Gen Hosp Psychiatry 2019; 57:13-22. [PMID: 30654293 DOI: 10.1016/j.genhosppsych.2018.10.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Revised: 10/19/2018] [Accepted: 10/22/2018] [Indexed: 01/02/2023]
Abstract
OBJECTIVE The burden of HIV infection is higher in Africa where 70% of people living with HIV (PLHIV) resides. Since depression can negatively impact the course of HIV infection, it is therefore important to accurately estimate its burden among PLHIV in the continent. METHODS We searched multiple databases to identify articles published between January 2000 and February 2018, reporting the prevalence of (major) depressive disorders in PLHIV residing in Africa. We used a random-effects meta-analysis model to pool studies. RESULTS Overall, 118 studies (60,476 participants, 19 countries) were included. There was no publication bias. The overall prevalence estimates of depressive disorders and probable major depressive disorders were 36.5% (95% CI 32.3-41.0; 101 studies) and 14.9% (12.1-17.9; 55 studies) respectively. The heterogeneity of the overall prevalence of depressive disorders was significantly explained by screening tool used, period (higher prevalence in recent studies) and distribution in sub-regions. The study setting, site, CD4 cell counts, age, sex, proportion of people with undetectable viral load were not sources of heterogeneity. CONCLUSIONS This study shows that more than one third of PLHIV face depressive disorders and half of them having major form, with heterogeneous distribution in the continent. As such, depressive disorders deserve more attention from HIV healthcare providers for improved detection and overall proper management.
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Affiliation(s)
- Jean Joel Bigna
- Department of Epidemiology and Public Health, Centre Pasteur of Cameroon, Yaounde, Cameroon.
| | | | | | - Tatiana K Djikeussi
- Department for the Control of Disease, Epidemics and Pandemics Diseases, Ministry of Public Health, Yaounde, Cameroon
| | - Audrey Joyce Foka
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
| | - Lewis N Um
- Mfou District Hospital, Ministry of Public Health, Mfou, Cameroon
| | - Serra Lem Asangbeh
- Department of Clinical Research, National Agency on Research for HIV and Viral Hepatitis, Yaounde, Cameroon
| | - Aurelie T Sibetcheu
- Department of Pediatrics and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaounde, Cameroon
| | - Arnaud D Kaze
- Department of Medicine, University of Maryland Medical Center Midtown Campus, Baltimore, MD, USA
| | - Marie S Ndangang
- Department of Medical Information and Informatics, Rouen University Hospital, Rouen, France
| | - Jobert Richie Nansseu
- Department for the Control of Disease, Epidemics and Pandemics Diseases, Ministry of Public Health, Yaounde, Cameroon; Department of Public Health, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaounde, Cameroon
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How faithfully do HIV clinicians administer the PHQ-9 depression screening tool in high-volume, low-resource clinics? Results from a depression treatment integration project in Malawi. Glob Ment Health (Camb) 2019; 6:e21. [PMID: 31662876 PMCID: PMC6796321 DOI: 10.1017/gmh.2019.22] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 08/02/2019] [Accepted: 08/21/2019] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Integration of mental health services into nonspecialist settings is expanding in low and middle income countries (LMICs). Among many factors required for success, such programs require reliable administration of mental health screening tools. While several tools have been validated in carefully conducted research studies, few studies have assessed how reliably nonspecialist clinicians administer these tools to low-literacy LMIC populations in routine care. METHODS Ninety-seven patients accessing human immunodeficiency virus primary care in Malawi who completed Patient Health Questionnaire (PHQ)-9 depression screening with their clinician then completed a second PHQ-9 with a trained research assistant (RA) blinded to the first result. RESULTS Compared to clinicians, RAs identified more patients with any depressive symptoms (PHQ-9 score ⩾5: 38% v. 32%), moderate/severe symptoms (PHQ-9 ⩾ 10: 14% v. 6%), any suicidality (14% v. 4%), and active suicidality (3% v. 2%). Across these indicators, clinician and RA ratings had strong overall agreement (81-97%) but low corrected Kappa agreement (31-59%). Treating RA results as the reference standard of a carefully supervised research administration of the PHQ-9, clinician administration had high specificity (90-99%) but low sensitivity (23-68%) for these indicators. CONCLUSIONS In routine care in LMICs, clinicians may administer validated mental health screening tools with varying quality. To ensure quality, integration programs must incorporate appropriate and ongoing training, support, supervision, and monitoring.
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Supportive interventions to improve retention on ART in people with HIV in low- and middle-income countries: A systematic review. PLoS One 2018; 13:e0208814. [PMID: 30550574 PMCID: PMC6294385 DOI: 10.1371/journal.pone.0208814] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 11/24/2018] [Indexed: 01/01/2023] Open
Abstract
Objectives To determine whether supportive interventions can increase retention in care for patients on antiretroviral therapy (ART) in low- and middle-income countries (LMIC). Design Systematic review and meta-analysis. Methods We used Cochrane Collaboration methods. We included randomised controlled trials (RCT) and observational studies with comparators conducted in LMIC. Our principal outcomes were retention, mortality and the combined outcome of lost-to-follow-up (LTFU) or death. Results We identified seven studies (published in nine articles); six of the studies were from Sub-Saharan Africa. We found four types of interventions: 1) directly observed therapy plus extra support (“DOT-plus”), 2) community-based adherence support, 3) adherence clubs and 4) extra care for patients with low CD4 count. One RCT of a community-based intervention showed significantly improved retention at 12 months (RR 1.14, 95% CI 1.02 to 1.27), and three observational studies found significantly improved retention for paediatric patients followed for 12 to 36 months (RR 1.07, 95 CI 1.03 to 1.11), and for adult patients at 12 (RR 1.38, 95% CI 1.13 to 1.70) and 60 months (RR 1.07, 95% CI 1.07 to 1.08). One observational study of adherence clubs showed significantly reduced LTFU or mortality (RR 0.20, 95% CI 0.12 to 0.33). A cluster RCT of an extra-care intervention for high-risk patients also showed a significant increase in retention (RR 1.06, 95% CI 1.01 to 1.10), and an observational study of extra nursing care found a significant decrease in LTFU or mortality (RR 0.76, 95% CI 0.66 to 0.87). Conclusions Supportive interventions are associated with increased ART programme retention, but evidence quality is generally low to moderate. The data from this review suggest that programmes addressing psychosocial needs can significantly help retain patients in care.
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Busza J, Dauya E, Makamba M, Ferrand RA. "I will not stop visiting!" a qualitative study of community health workers' reluctance to withdraw household support following the end of a community-based intervention in Zimbabwe. BMC Health Serv Res 2018; 18:718. [PMID: 30223831 PMCID: PMC6142685 DOI: 10.1186/s12913-018-3531-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 09/10/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Community Health Worker (CHW) programmes are increasingly important in HIV service delivery. CHWs' familiarity with the local context can improve intervention acceptability and sustainability but concerns have been raised about potential exploitation and "burnout" of CHWs as they become emotionally involved in clients' lives. Little attention has been paid to what happens at the end of time-limited CHW interventions. This study aimed to examine the experience of CHWs' withdrawal from clients and their families. METHODS We conducted a qualitative study of CHWs' experiences of "exiting" from households during the ZENITH (Zimbabwe Study for Enhancing Testing and Improving Treatment of HIV in Children) intervention, which provided 12 structured home visits over 72 weeks to families with children recently diagnosed with HIV. We conducted semi-structured interviews at 12 and 18 months with all 19 CHWs delivering the intervention and 36 purposively selected caregivers who received home visits. Analysis focused on perceptions of the end of the trial, when CHWs completed the scheduled home-based visits and there was no guarantee of programme continuation beyond the study. RESULTS Termination of scheduled home visits caused significant distress to both CHWs and the households they visited. We identify 3 thematic "lessons learned" for CHW programmes. First, CHWs derived pride and self-worth from emotional labour as they became integral to families' improved ability to cope, motivating them to go beyond formal job requirements. Second, clients' growing dependence on CHWs led to "exit" being interpreted as abandonment by both CHWs and households, causing distress on both sides. Finally, in response to anxiety about "abandoning" families, CHWs maintained contact with families long after scheduled withdrawal of services. CONCLUSIONS CHWs can forge genuine bonds with households, creating expectations of long-term engagement. On the positive side, CHW derive pride from their work, attach social responsibility to their roles, and feel personal fulfilment in supporting families. If CHWs do not disengage from interventions as planned, or become demoralised by "exits", interventions will prove less sustainable. CHWs are often lauded for their ability to develop trust with peers, yet this willingness and ability to create enduring emotional bonds could threaten programme delivery.
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Affiliation(s)
- Joanna Busza
- Department of Public Health, Environment and Society and Centre for Evaluation, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Ethel Dauya
- Biomedical Research & Training Institute, No. 10 Seagrave road, Avondale, Harare, Zimbabwe
| | - Memory Makamba
- Biomedical Research & Training Institute, No. 10 Seagrave road, Avondale, Harare, Zimbabwe
| | - Rashida A. Ferrand
- Biomedical Research & Training Institute, No. 10 Seagrave road, Avondale, Harare, Zimbabwe
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK
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Busza J, Dauya E, Bandason T, Simms V, Chikwari CD, Makamba M, Mchugh G, Munyati S, Chonzi P, Ferrand RA. The role of community health workers in improving HIV treatment outcomes in children: lessons learned from the ZENITH trial in Zimbabwe. Health Policy Plan 2018; 33:328-334. [PMID: 29309578 PMCID: PMC5886269 DOI: 10.1093/heapol/czx187] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2017] [Indexed: 11/22/2022] Open
Abstract
Reliance on community health workers (CHWs) for HIV care continues to increase, particularly in resource-limited settings. CHWs can improve HIV service use and adherence to treatment, but effectiveness of these programmes relies on providing an enabling work environment for CHWs, including reasonable workload, supportive supervision and adequate training and supplies. Although criteria for effective CHW programmes have been identified, these have rarely been prospectively applied to design and evaluation of new interventions. For the Zimbabwe study for Enhancing Testing and Improving Treatment of HIV in Children (ZENITH) randomized controlled trial, we based our intervention on an existing evidence-based framework for successful CHW programmes. To assess CHWs’ experiences delivering the intervention, we conducted longitudinal, qualitative semi-structured interviews with all 19 CHWs at three times during implementation. The study aimed to explore CHWs’ perceptions of how the intervention’s structure and management affected their performance, and consider implications for the programme’s future scale-up and adoption in other settings. CHWs expressed strong motivation, commitment and job satisfaction. They considered the intervention acceptable and feasible to deliver, and levels of satisfaction rose over interview rounds. Intensive supervision and mentoring emerged as critical to ensuring CHWs’ long-term satisfaction. Provision of job aids, standardized manuals and refresher training were also important, as were formalized links between clinics and CHWs. Concerns raised by CHWs included poor remuneration, their reluctance to stop providing support to individual families following the requisite number of home visits, and disappointment at the lack of programme sustainability following completion of the trial. Furthermore, intensive supervision and integration with clinical services may be difficult to replicate outside a trial setting. This study shows that existing criteria for designing successful CHW programmes are useful for maximizing effectiveness, but challenges remain for ensuring long-term sustainability of ‘task shifting’ strategies.
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Affiliation(s)
- Joanna Busza
- Department of Population Health, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK
| | - Ethel Dauya
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Tsitsi Bandason
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Victoria Simms
- Department of Population Health, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK
| | - Chido Dziva Chikwari
- Department of Population Health, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK.,Biomedical Research and Training Institute, Harare, Zimbabwe
| | | | - Grace Mchugh
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Shungu Munyati
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | | | - Rashida A Ferrand
- Department of Population Health, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK.,Biomedical Research and Training Institute, Harare, Zimbabwe
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Udedi M, Stockton MA, Kulisewa K, Hosseinipour MC, Gaynes BN, Mphonda SM, Mwagomba BM, Mazenga AC, Pence BW. Integrating depression management into HIV primary care in central Malawi: the implementation of a pilot capacity building program. BMC Health Serv Res 2018; 18:593. [PMID: 30064418 PMCID: PMC6069990 DOI: 10.1186/s12913-018-3388-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 07/12/2018] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND In Malawi, early retention in HIV care remains challenging. Depression is strongly associated with reduced anti-retroviral therapy (ART) adherence and viral suppression. Appropriate depression care for people initiating ART is likely to be supportive of early and continued engagement in the HIV care continuum. This paper aims to provide an overview of a task-shifting program that integrates depression screening and treatment into HIV care and the strategy used to evaluate this program, describes the implementation process, and discusses key challenges and lessons learned in the first phase of program implementation. METHODS We are implementing a program integrating depression screening and treatment into HIV care initiation at two clinics in Lilongwe District, Malawi. The program's effect on patients' depression and HIV outcomes will be evaluated using a multiple baseline pre-post study. In this manuscript, we draw from our experiences as program implementers and some of the quantitative data to describe the process of implementation and key lessons learned. RESULTS We successfully implemented the screening phase of this program at both clinics; 88.3 and 93.2% of newly diagnosed patients have been screened for depression at each clinic respectively. 25% of enrolled patients reported symptoms of mild-to-severe depression and only 6% reported symptoms of moderate-to-severe depression. Key lessons learned from the process show the importance of utilizing existing processes and infrastructure and focusing on iterative and collaborative learning. We continued to face challenges around establishing a sense of program ownership among providers, developing capacity to diagnose and manage depression, and ensuring the availability of appropriate medication. Our efforts to address these challenges provide insight into the technical and managerial support needed to prepare for, roll out, and sustain integrated models of mental health and HIV care. CONCLUSIONS This activity demonstrates how a depression screening program can successfully be integrated into HIV care within the public health system in Malawi. While this program focuses on integrating depression management into HIV care, most of the lessons learned could apply to integration of mental health into any non-psychiatric specialist setting. TRIAL REGISTRATION ClinicalTrials.gov ID [ NCT03555669 ]. Retrospectively registered on 13 June 2018.
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Affiliation(s)
- Michael Udedi
- NCDs & Mental Health Unit, Ministry of Health, Ministry of Health, P. O. Box 30377 Capital City, Lilongwe 3, Malawi
| | - Melissa A. Stockton
- Epidemiology Department, University of North Carolina at Chapel Hill Gillings School of Global Public Health, 135 Dauer Dr, Chapel Hill, NC 27599 USA
| | - Kazione Kulisewa
- Ministry of Health, Kamuzu Central Hospital and Bwaila Psychiatric Hospital, Private Bag, 149 Lilongwe, Malawi
| | - Mina C. Hosseinipour
- University of North Carolina Project-Malawi, Tidziwe Centre, Private Bag, A-104 Lilongwe, Malawi
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, 333 S Columbia St, Chapel Hill, NC 27516 USA
| | - Bradley N. Gaynes
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, 333 S Columbia St, Chapel Hill, NC 27516 USA
| | - Steven M. Mphonda
- University of North Carolina Project-Malawi, Tidziwe Centre, Private Bag, A-104 Lilongwe, Malawi
| | | | - Alick C. Mazenga
- Baylor College of Medicine Abbott Fund Children’s Clinical Centre of Excellence, Kamuzu Central Hospital, Private Bag, B-397 Lilongwe, Malawi
| | - Brian W. Pence
- Epidemiology Department, University of North Carolina at Chapel Hill Gillings School of Global Public Health, 135 Dauer Dr, Chapel Hill, NC 27599 USA
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Patient Navigation by Community Health Workers Increases Access to Surgical Care in Rural Haiti. World J Surg 2018; 41:3025-3030. [PMID: 28948326 DOI: 10.1007/s00268-017-4246-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION In the Hôpital Albert Schweitzer district in rural Haiti, patients from mountain areas receive fewer operations per capita than patients from the plains. Possible additional barriers for mountain patients include lower socioeconomic status, lack of awareness of financial support, illiteracy and unfamiliarity with the hospital system. We sought to increase the rate of elective surgery for a mountain population using a patient navigation program. MATERIALS AND METHODS Patient navigators were trained to guide subjects from a mountain population through the entire hospital process for elective surgery. We compared the rate of elective operations before and after the patient navigation intervention between three groups: a control group from a mountainous area, a control group from the plains and an intervention group from a mountainous area. RESULTS The baseline elective operation rate differed significantly between the plains control group, the mountain control group and the mountain intervention group (361 vs. 57 vs. 68 operations per 100,000 population per year). The rate of elective surgery between the two mountain groups was not statistically different prior to the intervention. After the intervention, the elective operation rate in the mountain group that received patient navigation increased from 68 to 131 operations per 100,000 population per year (p = 0.017). DISCUSSION Patient navigation doubled the elective operation rate for a mountain population in rural Haiti. While additional barriers to access remain for this vulnerable population, patient navigation is an essential augmentation to financial assistance programs to ensure that the poor gain access to surgical care.
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Lifson AR, Workneh S, Hailemichael A, MacLehose RF, Horvath KJ, Hilk R, Fabian L, Sites A, Shenie T. A multi-site community randomized trial of community health workers to provide counseling and support for patients newly entering HIV care in rural Ethiopia: study design and baseline implementation. HIV CLINICAL TRIALS 2018; 19:112-119. [PMID: 29688139 DOI: 10.1080/15284336.2018.1461999] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Although HIV therapy is delivered to millions globally, treatment default (especially soon after entering care) remains a challenge. Community health workers (CHWs) can provide many services for people with HIV, including in rural and resource-limited settings. OBJECTIVES We designed and implemented a 32 site community randomized trial throughout southern Ethiopia to assess an intervention using CHWs to improve retention in HIV care. METHODS Sixteen district hospital and 16 local health center HIV clinics were randomized 1:1 to be intervention or control sites. From each site, we enrolled adults newly entering HIV care. Participants at intervention sites were assigned a CHW who provided: HIV and health education; counseling and social support; and facilitated communication with HIV clinics. All participants are followed through three years with annual health surveys, plus HIV clinic record abstraction including clinic visit dates. CHWs record operational data about their client contacts. RESULTS 1799 HIV patients meeting inclusion criteria were enrolled and randomized: 59% were female, median age = 32 years, median CD4 + count = 263 cells/mm3, and 41% were WHO Stage III or IV. A major enrollment challenge was fewer new HIV patients initiating care at participating sites due to shortage of HIV test kits. At intervention sites, 71 CHWs were hired, trained and assigned to clients. In meeting with clients, CHWs needed to accommodate to various challenges, including HIV stigma, distance, and clients lacking cell phones. CONCLUSIONS This randomized community HIV trial using CHWs in a resource-limited setting was successfully launched, but required flexibility to adapt to unforeseen challenges.
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Affiliation(s)
- Alan R Lifson
- a Division of Epidemiology and Community Health , University of Minnesota , Minneapolis , MN , USA
| | - Sale Workneh
- b Ethiopian Office , National Alliance of State and Territorial AIDS Directors , Addis Ababa , Ethiopia
| | - Abera Hailemichael
- b Ethiopian Office , National Alliance of State and Territorial AIDS Directors , Addis Ababa , Ethiopia
| | - Richard F MacLehose
- a Division of Epidemiology and Community Health , University of Minnesota , Minneapolis , MN , USA
| | - Keith J Horvath
- a Division of Epidemiology and Community Health , University of Minnesota , Minneapolis , MN , USA
| | - Rose Hilk
- a Division of Epidemiology and Community Health , University of Minnesota , Minneapolis , MN , USA
| | - Lindsey Fabian
- a Division of Epidemiology and Community Health , University of Minnesota , Minneapolis , MN , USA
| | - Anne Sites
- c Global Program , National Alliance of State and Territorial AIDS Directors , Washington , DC , USA
| | - Tibebe Shenie
- b Ethiopian Office , National Alliance of State and Territorial AIDS Directors , Addis Ababa , Ethiopia
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Knaul FM, Farmer PE, Krakauer EL, De Lima L, Bhadelia A, Jiang Kwete X, Arreola-Ornelas H, Gómez-Dantés O, Rodriguez NM, Alleyne GAO, Connor SR, Hunter DJ, Lohman D, Radbruch L, Del Rocío Sáenz Madrigal M, Atun R, Foley KM, Frenk J, Jamison DT, Rajagopal MR. Alleviating the access abyss in palliative care and pain relief-an imperative of universal health coverage: the Lancet Commission report. Lancet 2018; 391:1391-1454. [PMID: 29032993 DOI: 10.1016/s0140-6736(17)32513-8] [Citation(s) in RCA: 599] [Impact Index Per Article: 99.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 07/28/2017] [Accepted: 07/28/2017] [Indexed: 02/07/2023]
Affiliation(s)
- Felicia Marie Knaul
- Department of Public Health Sciences, Leonard M. Miller School of Medicine, University of Miami, Coral Gables, FL, USA; Institute for Advanced Study of the Americas, University of Miami, Coral Gables, FL, USA; Sylvester Comprehensive Cancer Center, University of Miami, Coral Gables, FL, USA; Tómatelo a Pecho, A.C., Mexico City, Mexico; Fundación Mexicana para la Salud, A.C., Mexico City, Mexico.
| | | | - Eric L Krakauer
- Harvard Medical School, Boston, MA, USA; Massachusetts General Hospital, Boston, MA, USA; World Health Organization, Geneva, Switzerland
| | - Liliana De Lima
- International Association for Hospice and Palliative Care, Houston, TX, USA
| | - Afsan Bhadelia
- Institute for Advanced Study of the Americas, University of Miami, Coral Gables, FL, USA; Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Xiaoxiao Jiang Kwete
- Institute for Advanced Study of the Americas, University of Miami, Coral Gables, FL, USA; Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Héctor Arreola-Ornelas
- Institute for Advanced Study of the Americas, University of Miami, Coral Gables, FL, USA; Tómatelo a Pecho, A.C., Mexico City, Mexico; Fundación Mexicana para la Salud, A.C., Mexico City, Mexico
| | | | - Natalia M Rodriguez
- Institute for Advanced Study of the Americas, University of Miami, Coral Gables, FL, USA
| | - George A O Alleyne
- Pan American Health Organization, Regional Office of WHO, Washington, DC, USA
| | | | - David J Hunter
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Diederik Lohman
- Health and Human Rights Division, Human Rights Watch, Maplewood, NJ, USA
| | - Lukas Radbruch
- International Association for Hospice and Palliative Care, Houston, TX, USA; Department of Palliative Medicine, University Hospital Bonn, Germany; The Malteser Hospital, Bonn, Germany
| | | | - Rifat Atun
- Harvard Medical School, Boston, MA, USA; Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | - Julio Frenk
- Department of Public Health Sciences, Leonard M. Miller School of Medicine, University of Miami, Coral Gables, FL, USA; School of Business Administration, University of Miami, Coral Gables, FL, USA
| | | | - M R Rajagopal
- Trivandrum Institute of Palliative Sciences, WHO Collaborating Centre for Training and Policy on Access to Pain Relief, Pallium India, Kerala, India
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Newman PM, Franke MF, Arrieta J, Carrasco H, Elliott P, Flores H, Friedman A, Graham S, Martinez L, Palazuelos L, Savage K, Tymeson H, Palazuelos D. Community health workers improve disease control and medication adherence among patients with diabetes and/or hypertension in Chiapas, Mexico: an observational stepped-wedge study. BMJ Glob Health 2018. [PMID: 29527344 PMCID: PMC5841495 DOI: 10.1136/bmjgh-2017-000566] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background Non-communicable diseases (NCDs) contribute greatly to morbidity and mortality in low-income and middle-income countries (LMICs). Community health workers (CHWs) may improve disease control and medication adherence among patients with NCDs in LMICs, but data are lacking. We assessed the impact of a CHW-led intervention on disease control and adherence among patients with diabetes and/or hypertension in Chiapas, Mexico. Methods We conducted a prospective observational study among adult patients with diabetes and/or hypertension, in the context of a stepped-wedge roll-out of a CHW-led intervention. We measured self-reported adherence to medications, blood pressure and haemoglobin A1c at baseline and every 3 months, timed just prior to expansion of the intervention to a new community. We conducted individual-level mixed effects analyses of study data, adjusting for time and clustering by patient and community. Findings We analysed 108 patients. The CHW-led intervention was associated with a twofold increase in the odds of disease control (OR 2.04, 95% CI 1.15 to 3.62). It was also associated with optimal adherence assessed by 30-day recall (OR 1.86; 95% CI 1.15 to 3.02) and a positive self-assessment of adherence behaviour (OR 2.29; 95% CI 1.26 to 4.15), but not by 5-day recall. Interpretation A CHW-led adherence intervention was associated with disease control and adherence among adults with diabetes and/or hypertension. This study supports a role of CHWs in supplementing comprehensive primary care for patients with NCDs in LMICs. Trial registration number NCT02549495.
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Affiliation(s)
- Patrick M Newman
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Molly F Franke
- Harvard Medical School, Department of Global Health and Social Medicine, Boston, Massachusetts, USA
| | - Jafet Arrieta
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Hector Carrasco
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Patrick Elliott
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Hugo Flores
- Compañeros en Salud, Angel Albino Corzo, Chiapas, Mexico
| | - Alexandra Friedman
- University of California San Francisco School of Medicine, San Francisco, California, USA
| | | | - Luis Martinez
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Kevin Savage
- Harvard Medical School, Department of Global Health and Social Medicine, Boston, Massachusetts, USA
| | - Hayley Tymeson
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
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Wroe EB, Dunbar EL, Kalanga N, Dullie L, Kachimanga C, Mganga A, Herce M, Beste J, Rigodon J, Nazimera L, McBain RK. Delivering comprehensive HIV services across the HIV care continuum: a comparative analysis of survival and progress towards 90-90-90 in rural Malawi. BMJ Glob Health 2018; 3:e000552. [PMID: 29564158 PMCID: PMC5859809 DOI: 10.1136/bmjgh-2017-000552] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 11/26/2017] [Accepted: 11/27/2017] [Indexed: 11/16/2022] Open
Abstract
Introduction Partners In Health and the Malawi Ministry of Health collaborate on comprehensive HIV services in Neno, Malawi, featuring community health workers, interventions addressing social determinants of health and health systems strengthening. We conducted an observational study to describe the HIV care continuum in Neno and to compare facility-level HIV outcomes against health facilities nationally. Methods We compared facility-level outcomes in Neno (n=13) with all other districts (n=682) from 2013 to 2015 using mixed-effects linear regression modelling. We selected four outcomes that are practically useful and roughly mapped on to the 90-90-90 targets: facility-based HIV screenings relative to population, new antiretroviral therapy (ART)enrolments relative to population, 1-year survival rates and per cent retained in care at 1 year. Results In 2013, the average number of HIV tests performed, as a per cent of the adult population, was 11.75%, while the average newly enrolled patients was 10.03%. Percent receiving testing increased by 4.23% over 3 years (P<0.001, 95% CI 2.98% to 5.49%), while percent enrolled did not change (P=0.28). These results did not differ between Neno and other districts (P=0.52), despite Neno having a higher proportion of expected patients enrolled. In 2013, the average ART 1-year survival was 80.41% nationally and 91.51% in Neno, which is 11.10% higher (P=0.002, 95% CI 4.13% to 18.07%). One-year survival declined by 1.75% from 2013 to 2015 (P<0.001, 95% CI −2.61% to −0.89%); this was similar in Neno (P=0.83). Facility-level 1-year retention was 85.43% nationally in 2013 (P<0.001, 95% CI 84.2% to 86.62%) and 12.07% higher at 97.50% in Neno (P=0.001, 95% CI 5.08% to19.05%). Retention declined by 2.92% (P<0.001, 95% CI −3.69% to −2.14%) between 2013 and 2015, both nationally and in Neno. Conclusion The Neno HIV programme demonstrated significantly higher survival and retention rates compared with all other districts in Malawi. Incorporating community health workers, strengthening health systems and addressing social determinants of health within the HIV programme may help Malawi and other countries accelerate progress towards 90-90-90.
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Affiliation(s)
| | | | - Noel Kalanga
- Health Systems and Policy, College of Medicine, Blantyre, Malawi
| | | | | | - Andrew Mganga
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi
| | - Michael Herce
- Division of Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | | | - Jonas Rigodon
- Haiti Delegation, American Red Cross, Port-au-Prince, Haiti
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Interventions to improve antiretroviral therapy adherence among adolescents in low- and middle-income countries: A systematic review of the literature. PLoS One 2018; 13:e0189770. [PMID: 29293523 PMCID: PMC5749726 DOI: 10.1371/journal.pone.0189770] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 10/08/2017] [Indexed: 01/27/2023] Open
Abstract
Introduction Globally, an estimated 30% of new HIV infections occur among adolescents (15–24 years), most of whom reside in sub-Saharan Africa. Moreover, HIV-related mortality increased by 50% between 2005 and 2012 for adolescents 10–19 years while it decreased by 30% for all other age groups. Efforts to achieve and maintain optimal adherence to antiretroviral therapy are essential to ensuring viral suppression, good long-term health outcomes, and survival for young people. Evidence-based strategies to improve adherence among adolescents living with HIV are therefore a critical part of the response to the epidemic. Methods We conducted a systematic review of the peer-reviewed and grey literature published between 2010 and 2015 to identify interventions designed to improve antiretroviral adherence among adults and adolescents in low- and middle-income countries. We systematically searched PubMed, Web of Science, Popline, the AIDSFree Resource Library, and the USAID Development Experience Clearinghouse to identify relevant publications and used the NIH NHLBI Quality Assessment Tools to assess the quality and risk of bias of each study. Results and discussion We identified 52 peer-reviewed journal articles describing 51 distinct interventions out of a total of 13,429 potentially relevant publications. Forty-three interventions were conducted among adults, six included adults and adolescents, and two were conducted among adolescents only. All studies were conducted in low- and middle-income countries, most of these (n = 32) in sub-Saharan Africa. Individual or group adherence counseling (n = 12), mobile health (mHealth) interventions (n = 13), and community- and home-based care (n = 12) were the most common types of interventions reported. Methodological challenges plagued many studies, limiting the strength of the available evidence. However, task shifting, community-based adherence support, mHealth platforms, and group adherence counseling emerged as strategies used in adult populations that show promise for adaptation and testing among adolescents. Conclusions Despite the sizeable body of evidence for adults, few studies were high quality and no single intervention strategy stood out as definitively warranting adaptation for adolescents. Among adolescents, current evidence is both sparse and lacking in its quality. These findings highlight a pressing need to develop and test targeted intervention strategies to improve adherence among this high-priority population.
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Rothman J, Kayigamba F, Hills V, Gupta N, Machara F, Niyigena P, Franke MF. The Impact of a Community-Based Intervention Including a Monthly Food Ration on Food Insecurity Among HIV-Positive Adults During the First Year of Antiretroviral Therapy. AIDS Behav 2018; 22:154-163. [PMID: 28849289 DOI: 10.1007/s10461-017-1897-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The objective of this study was to examine how food insecurity changed among HIV-positive adults during the first 12 months of combination antiretroviral therapy (cART) and whether any change differed according to the receipt of food support, which was provided in the context of a comprehensive community-based intervention. We conducted secondary data analyses of data from a prospective cohort study of the effectiveness of a community-based cART delivery model when added to clinic-based cART delivery in Rwanda. We included patients from four health centers that implemented a clinic-based cART delivery model alone and five health centers that additionally implemented the intervention, which included 10 months of food support. We compared food insecurity at 3, 6, and 12 months, relative to baseline, and stratified by receipt of the intervention. Relative to baseline, median food insecurity score decreased after 3, 6, and 12 months (p value <0.0001 for all) for patients receiving a food ration through the community-based model for cART delivery. Among patients receiving care under the clinic-based cART model, food insecurity scores remained unchanged at 3 and 12 months and were significantly higher after 6 months. In adjusted analyses, participants enrolled in the community-based intervention with a food ration had a lower risk of severe food insecurity and a lower risk of moderate or severe food insecurity after 12 months. A comprehensive community-based HIV program including a food ration likely contributes to an alleviation of food insecurity among adults newly initiating cART.
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Affiliation(s)
| | - Felix Kayigamba
- Ruhengeri Hospital, Republic of Rwanda Ministry of Health, Kigali, Rwanda
| | | | - Neil Gupta
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
| | - Faustin Machara
- HIV, AIDS, STIs and OBBI Division, Rwanda Biomedical Center, Kigali, Rwanda
| | - Peter Niyigena
- Community Health Department, Inshuti Mu Buzima/Partners In Health, Rwinkwavu, Rwanda
| | - Molly F Franke
- Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Ave, Boston, MA, 02115, USA.
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McLaughlin MM, Franke MF, Muñoz M, Nelson AK, Saldaña O, Cruz JS, Wong M, Zhang Z, Lecca L, Ticona E, Arevalo J, Sanchez E, Sebastián JL, Shin S. Community-Based Accompaniment with Supervised Antiretrovirals for HIV-Positive Adults in Peru: A Cluster-Randomized Trial. AIDS Behav 2018; 22:287-296. [PMID: 28074421 DOI: 10.1007/s10461-017-1680-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
We conducted a cluster-randomized trial to estimate effects of directly observed combination antiretroviral therapy (DOT-cART) on retention with viral suppression among HIV-positive adults in Peru. We randomly allocated facilities to receive the 12-month intervention plus the standard of care, including adherence support provided through accompaniment. In the intervention arm, health workers supervised doses, twice daily, and accompanied patients to appointments. Among 356 patients, intention-to-treat analyses showed no statistically significant benefit of DOT, relative to no-DOT, at 12 or 24 months (adjusted probability of primary outcome: 0.81 vs. 0.73 and 0.76 vs. 0.68, respectively). A statistically significant benefit of DOT was found in per-protocol and as-treated analyses at 12 months (0.83 for DOT vs. 0.73 for no DOT, p value: 0.02 per-protocol, 0.01 as-treated), but not 24 months. Rates of retention with viral suppression were high in both arms. Among adults receiving robust adherence support, the added effect of time-limited DOT, if any, is small-to-moderate.
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Affiliation(s)
| | - Molly F Franke
- Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA, 02115, USA.
| | | | - Adrianne K Nelson
- Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA, 02115, USA
| | | | | | | | - Zibiao Zhang
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Eduardo Ticona
- Peru Ministry of Health, Lima, Peru
- Universidad Nacional Mayor de San Marcos, Lima, Peru
| | | | | | | | - Sonya Shin
- Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA, 02115, USA
- Socios En Salud, Lima, Peru
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
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Abstract
The advent of antiretroviral therapy (ART) in 1996 brought with it an urgent need to develop models of health care delivery that could enable its effective and equitable delivery, especially to patients living in poverty. Community-based care, which stretches from patient homes and communities—where chronic infectious diseases are often best managed—to modern health centers and hospitals, offers such a model, providing access to proximate HIV care and minimizing structural barriers to retention. We first review the recent literature on community-based ART programs in low- and low-to-middle-income country settings and document two key principles that guide effective programs: decentralization of ART services and long-term retention of patients in care. We then discuss the evolution of the community-based programs of Partners In Health (PIH), a nongovernmental organization committed to providing a preferential option for the poor in health care, in Haiti and several countries in sub-Saharan Africa, Latin America, Russia and Kazakhstan. As one of the first organizations to treat patients with HIV in low-income settings and a pioneer of the community-based approach to ART delivery, PIH has achieved both decentralization and excellent retention through the application of an accompaniment model that engages community health workers in the delivery of medicines, the provision of social support and education, and the linkage between communities and clinics. We conclude by showing how PIH has leveraged its HIV care delivery platforms to simultaneously strengthen health systems and address the broader burden of disease in the places in which it works.
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Austad K, Chary A, Martinez B, Juarez M, Martin YJ, Ixen EC, Rohloff P. Obstetric care navigation: a new approach to promote respectful maternity care and overcome barriers to safe motherhood. Reprod Health 2017; 14:148. [PMID: 29132431 PMCID: PMC5683321 DOI: 10.1186/s12978-017-0410-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 11/02/2017] [Indexed: 11/23/2022] Open
Abstract
Background Disrespectful and abusive maternity care is a common and pervasive problem that disproportionately impacts marginalized women. By making mothers less likely to agree to facility-based delivery, it contributes to the unacceptably high rates of maternal mortality in low- and middle-income countries. Few programmatic approaches have been proposed to address disrespectful and abusive maternity care. Obstetric care navigation Care navigation was pioneered by the field of oncology to improve health outcomes of vulnerable populations and promote patient autonomy by providing linkages across a fragmented care continuum. Here we describe the novel application of the care navigation model to emergency obstetric referrals to hospitals for complicated home births in rural Guatemala. Care navigators offer women accompaniment and labor support intended to improve the care experience—for both patients and providers—and to decrease opposition to hospital-level obstetric care. Specific roles include deflecting mistreatment from hospital staff, improving provider communication through language and cultural interpretation, advocating for patients’ right to informed consent, and protecting patients' dignity during the birthing process. Care navigators are specifically chosen and trained to gain the trust and respect of patients, traditional midwives, and biomedical providers. We describe an ongoing obstetric care navigator pilot program employing rapid-cycle quality improvement methods to quickly identify implementation successes and failures. This approach empowers frontline health workers to problem solve in real time and ensures the program is highly adaptable to local needs. Conclusion Care navigation is a promising strategy to overcome the “humanistic barrier” to hospital delivery by mitigating disrespectful and abusive care. It offers a demand-side approach to undignified obstetric care that empowers the communities most impacted by the problem to lead the response. Results from an ongoing pilot program of obstetric care navigation will provide valuable feedback from patients on the impact of this approach and implementation lessons to facilitate replication in other settings.
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Affiliation(s)
- Kirsten Austad
- Wuqu' Kawoq
- Maya Health Alliance 2 Calle 5-43, Zona 1, Santiago Sacatepéquez, Guatemala.,Division of Women's Health, Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Anita Chary
- Wuqu' Kawoq
- Maya Health Alliance 2 Calle 5-43, Zona 1, Santiago Sacatepéquez, Guatemala.,Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Boris Martinez
- Wuqu' Kawoq
- Maya Health Alliance 2 Calle 5-43, Zona 1, Santiago Sacatepéquez, Guatemala
| | - Michel Juarez
- Wuqu' Kawoq
- Maya Health Alliance 2 Calle 5-43, Zona 1, Santiago Sacatepéquez, Guatemala
| | - Yolanda Juarez Martin
- Wuqu' Kawoq
- Maya Health Alliance 2 Calle 5-43, Zona 1, Santiago Sacatepéquez, Guatemala
| | - Enma Coyote Ixen
- Wuqu' Kawoq
- Maya Health Alliance 2 Calle 5-43, Zona 1, Santiago Sacatepéquez, Guatemala
| | - Peter Rohloff
- Wuqu' Kawoq
- Maya Health Alliance 2 Calle 5-43, Zona 1, Santiago Sacatepéquez, Guatemala. .,Division of Global Health Equity, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.
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49
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Shah PA, Coj M, Rohloff P. Delays in diagnosis and treatment of extrapulmonary tuberculosis in Guatemala. BMJ Case Rep 2017; 2017:bcr-2017-220777. [PMID: 28993352 DOI: 10.1136/bcr-2017-220777] [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: 11/03/2022] Open
Abstract
A 23-year-old indigenous Guatemalan man presented in 2016 to our clinic in Sololá, Guatemala, with 10 months of recurrent neck swelling, fevers, night sweats and weight loss. Previously, he had sought care in three different medical settings, including a private physician-run clinic, a tertiary private cancer treatment centre and, finally, a rural government health post. With assistance from our institution's accompaniment staff, the patient was admitted to a public tertiary care hospital for work-up. Rifampin-susceptible tuberculosis was diagnosed, and appropriate treatment was begun. The case illustrates how low tuberculosis recognition among community health workers and health system segmentation creates obstacles to appropriate care, especially for patients with limited means. As a result, significant diagnostic and treatment delays can occur, increasing the public health burden of tuberculosis.
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Affiliation(s)
| | - Merida Coj
- Wuqu' Kawoq-Maya Health Alliance, Santiago, Sacatépequez, Guatemala
| | - Peter Rohloff
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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50
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Bilinski A, Birru E, Peckarsky M, Herce M, Kalanga N, Neumann C, Bronson G, Po-Chedley S, Kachimanga C, McBain R, Keck J. Distance to care, enrollment and loss to follow-up of HIV patients during decentralization of antiretroviral therapy in Neno District, Malawi: A retrospective cohort study. PLoS One 2017; 12:e0185699. [PMID: 28973035 PMCID: PMC5626468 DOI: 10.1371/journal.pone.0185699] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 09/18/2017] [Indexed: 12/03/2022] Open
Abstract
HIV/AIDS remains the second most common cause of death in low and middle-income countries (LMICs), and only 34% of eligible patients in Africa received antiretroviral therapy (ART) in 2013. This study investigated the impact of ART decentralization on patient enrollment and retention in rural Malawi. We reviewed electronic medical records of patients registered in the Neno District ART program from August 1, 2006, when ART first became available, through December 31, 2013. We used GPS data to calculate patient-level distance to care, and examined number of annual ART visits and one-year lost to follow-up (LTFU) in HIV care. The number of ART patients in Neno increased from 48 to 3,949 over the decentralization period. Mean travel distance decreased from 7.3 km when ART was only available at the district hospital to 4.7 km when ART was decentralized to 12 primary health facilities. For patients who transferred from centralized care to nearer health facilities, mean travel distance decreased from 9.5 km to 4.7 km. Following a transfer, the proportion of patients achieving the clinic’s recommended ≥4 annual visits increased from 89% to 99%. In Cox proportional hazards regression, patients living ≥8 km from a health facility had a greater hazard of being LTFU compared to patients <8 km from a facility (adjusted HR: 1.7; 95% CI: 1.5–1.9). ART decentralization in Neno District was associated with increased ART enrollment, decreased travel distance, and increased retention in care. Increasing access to ART by reducing travel distance is one strategy to achieve the ART coverage and viral suppression objectives of the 90-90-90 UNAIDS targets in rural impoverished areas.
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Affiliation(s)
- Alyssa Bilinski
- Abwenzi Pa Za Umoyo, Neno, Malawi and Partners In Health, Boston, Massachusetts, United States of America
- Interfaculty Initiative in Health Policy, Harvard Graduate School of Arts and Sciences, Cambridge, Massachusetts, United States of America
- * E-mail:
| | - Ermyas Birru
- Abwenzi Pa Za Umoyo, Neno, Malawi and Partners In Health, Boston, Massachusetts, United States of America
| | - Matthew Peckarsky
- Abwenzi Pa Za Umoyo, Neno, Malawi and Partners In Health, Boston, Massachusetts, United States of America
| | - Michael Herce
- Abwenzi Pa Za Umoyo, Neno, Malawi and Partners In Health, Boston, Massachusetts, United States of America
- Division of Infectious Diseases, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, United States of America
| | - Noel Kalanga
- Abwenzi Pa Za Umoyo, Neno, Malawi and Partners In Health, Boston, Massachusetts, United States of America
| | - Christian Neumann
- Abwenzi Pa Za Umoyo, Neno, Malawi and Partners In Health, Boston, Massachusetts, United States of America
| | - Gay Bronson
- Abwenzi Pa Za Umoyo, Neno, Malawi and Partners In Health, Boston, Massachusetts, United States of America
| | - Stephen Po-Chedley
- Abwenzi Pa Za Umoyo, Neno, Malawi and Partners In Health, Boston, Massachusetts, United States of America
| | - Chembe Kachimanga
- Abwenzi Pa Za Umoyo, Neno, Malawi and Partners In Health, Boston, Massachusetts, United States of America
| | - Ryan McBain
- Abwenzi Pa Za Umoyo, Neno, Malawi and Partners In Health, Boston, Massachusetts, United States of America
| | - James Keck
- Abwenzi Pa Za Umoyo, Neno, Malawi and Partners In Health, Boston, Massachusetts, United States of America
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