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Basera TJ, Schmitz K, Price J, Willcox M, Bosire EN, Ajuwon A, Mbule M, Ronan A, Burtt F, Scheepers E, Igumbor J. Community surveillance and response to maternal and child deaths in low- and middle-income countries: A scoping review. PLoS One 2021; 16:e0248143. [PMID: 33725013 PMCID: PMC7963102 DOI: 10.1371/journal.pone.0248143] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 02/22/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Civil registration and vital statistics (CRVS) systems do not produce comprehensive data on maternal and child deaths in most low- and middle-income countries (LMICs), with most births and deaths which occur outside the formal health system going unreported. Community-based death reporting, investigation and review processes are being used in these settings to augment official registration of maternal and child deaths and to identify death-specific factors and associated barriers to maternal and childcare. This study aims to review how community-based maternal and child death reporting, investigation and review processes are carried out in LMICs. METHODS We conducted a scoping review of the literature published in English from January 2013 to November 2020, searching PubMed, EMBASE, PsycINFO, Joanna Briggs, The Cochrane Library, EBM reviews, Scopus, and Web of Science databases. We used descriptive analysis to outline the scope, design, and distribution of literature included in the study and to present the content extracted from each article. The scoping review is reported following the PRISMA reporting guideline for systematic reviews. RESULTS Of 3162 screened articles, 43 articles that described community-based maternal and child death review processes across ten countries in Africa and Asia were included. A variety of approaches were used to report and investigate deaths in the community, including identification of deaths by community health workers (CHWs) and other community informants, reproductive age mortality surveys, verbal autopsy, and social autopsy. Community notification of deaths by CHWs complements registration of maternal and child deaths missed by routinely collected sources of information, including the CRVS systems which mostly capture deaths occurring in health facilities. However, the accuracy and completeness of data reported by CHWs are sub-optimal. CONCLUSIONS Community-based death reporting complements formal registration of maternal and child deaths in LMICs. While research shows that community-based maternal and child death reporting was feasible, the accuracy and completeness of data reported by CHWs are sub-optimal but amenable to targeted support and supervision. Studies to further improve the process of engaging communities in the review, as well as collection and investigation of deaths in LMICs, could empower communities to respond more effectively and have a greater impact on reducing maternal and child mortality.
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Affiliation(s)
- Tariro J. Basera
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- * E-mail:
| | | | - Jessica Price
- MRC-Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Merlin Willcox
- School of Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, United Kingdom
| | - Edna N. Bosire
- South African Medical Research Council Developmental Pathways for Health Research Unit (DPHRU), School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ademola Ajuwon
- Department of Health Promotion and Education, Faculty of Public Health, University of Ibadan, Ibadan, Nigeria
| | | | | | | | | | - Jude Igumbor
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Magadi MA. HIV and Unintended Fertility in Sub-Saharan Africa: Multilevel Predictors of Mistimed and Unwanted Fertility Among HIV-Positive Women. POPULATION RESEARCH AND POLICY REVIEW 2020. [DOI: 10.1007/s11113-020-09620-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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3
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Were LP, Hogan JW, Galárraga O, Wamai R. Predictors of Health Insurance Enrollment among HIV Positive Pregnant Women in Kenya: Potential for Adverse Selection and Implications for HIV Treatment and Prevention. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E2892. [PMID: 32331351 PMCID: PMC7216063 DOI: 10.3390/ijerph17082892] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 04/14/2020] [Accepted: 04/15/2020] [Indexed: 11/17/2022]
Abstract
Background: The global push to achieve the 90-90-90 targets designed to end the HIV epidemic has called for the removing of policy barriers to prevention and treatment, and ensuring financial sustainability of HIV programs. Universal health insurance is one tool that can be used to this end. In sub-Saharan Africa, where HIV prevalence and incidence remain high, the use of health insurance to provide comprehensive HIV care is limited. This study looked at the factors that best predict social health insurance enrollment among HIV positive pregnant women using data from the Academic Model Providing Access to Healthcare (AMPATH) in western Kenya. Methods: Cross-sectional clinical encounter data were extracted from the electronic medical records (EMR) at AMPATH. We used univariate and multivariate logistic regressions to estimate the predictors of health insurance enrollment among HIV positive pregnant women. The analysis was further stratified by HIV disease severity (based on CD4 cell count <350 and 350>) to test the possibility of differential enrollment given HIV disease state. Results: Approximately 7% of HIV infected women delivering at a healthcare facility had health insurance. HIV positive pregnant women who deliver at a health facility had twice the odds of enrolling in insurance [2.46 Adjusted Odds Ratio (AOR), Confidence Interval (CI) 1.24-4.87]. They were 10 times more likely to have insurance if they were lost to follow-up to HIV care during pregnancy [9.90 AOR; CI 3.42-28.67], and three times more likely to enroll if they sought care at an urban clinic [2.50 AOR; 95% CI 1.53-4.12]. Being on HIV treatment was negatively associated with health insurance enrollment [0.22 AOR; CI 0.10-0.49]. Stratifying the analysis by HIV disease severity while statistically significant did not change these results. Conclusions: The findings indicated that health insurance enrollment among HIV positive pregnant women was low mirroring national levels. Additionally, structural factors, such as access to institutional delivery and location of healthcare facilities, increased the likelihood of health insurance enrollment within this population. However, behavioral aspects, such as being lost to follow-up to HIV care during pregnancy and being on HIV treatment, had an ambiguous effect on insurance enrollment. This may potentially be because of adverse selection and information asymmetries. Further understanding of the relationship between insurance and HIV is needed if health insurance is to be utilized for HIV treatment and prevention in limited resource settings.
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Affiliation(s)
- Lawrence P.O. Were
- Department of Health Sciences, Boston University’s College of Health and Rehabilitation Sciences: Sargent College & Department of Global Health, Boston University School of Public Health, Boston, MA 02215, USA
| | - Joseph W Hogan
- School of Public Health, Brown University, Providence, RI 02912, USA; (J.W.H.); (O.G.)
| | - Omar Galárraga
- School of Public Health, Brown University, Providence, RI 02912, USA; (J.W.H.); (O.G.)
| | - Richard Wamai
- Department of Cultures, Societies and Global Studies, Northeastern University, Boston, MA 02115, USA;
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Were LPO, Were E, Wamai R, Hogan J, Galarraga O. Effects of social health insurance on access and utilization of obstetric health services: results from HIV+ pregnant women in Kenya. BMC Public Health 2020; 20:87. [PMID: 31959153 PMCID: PMC6971983 DOI: 10.1186/s12889-020-8186-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 01/09/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Reducing maternal morbidity and mortality remains a top global health agenda especially in high HIV/AIDS endemic locations where there is increased likelihood of mother to child transmission (MTCT) of HIV. Social health insurance (SHI) has emerged as a viable option to improve population access to health services, while improving outcomes for disenfranchised populations, particularly HIV+ women. However, the effect of SHI on healthcare access for HIV+ persons in limited resource settings is yet to undergo rigorous empirical evaluation. This study analyzes the effect of health insurance on obstetric healthcare access including institutional delivery and skilled birth attendants for HIV+ pregnant women in Kenya. METHODS We analyzed cross-sectional data from HIV+ pregnant women (ages 15-49 years) who had a delivery (full term, preterm, miscarriage) between 2008 and 2013 with their insurance enrollment status available in the electronic medical records database of a HIV healthcare system in Kenya. We estimated linear and logistic regression models and implemented matching and inverse probability weighting (IPW) to improve balance on observable individual characteristics. Additionally, we estimated heterogeneous effects stratified by HIV disease severity (CD4 < 350 as "Severe HIV disease", and CD4 > 350 otherwise). FINDINGS Health Insurance enrollment is associated with improved obstetric health services utilization among HIV+ pregnant women in Kenya. Specifically, HIV+ pregnant women covered by NHIF have greater access to institutional delivery (12.5-percentage points difference) and skilled birth attendants (19-percentage points difference) compared to uninsured. Notably, the effect of NHIF on obstetric health service use is much greater for those who are sicker (CD4 < 350) - 20 percentage points difference. CONCLUSION This study confirms conceptual and practical considerations around health insurance and healthcare access for HIV+ persons. Further, it helps to inform relevant policy development for health insurance and HIV financing and delivery in Kenya and in similar countries in sub-Saharan Africa in the universal health coverage (UHC) era.
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Affiliation(s)
- Lawrence P O Were
- Department of Health Sciences, Boston University's College of Health and Rehabilitation Sciences: Sargent College, Boston, USA.
- School of Public Health, Brown University, Providence, RI, USA.
| | - Edwin Were
- Department of Reproductive Health, Moi University & AMPATH-Kenya, Eldoret, Kenya
| | - Richard Wamai
- Department of Cultures, Societies and Global Studies, Northeastern University, Boston, MA, USA
| | - Joseph Hogan
- School of Public Health, Brown University, Providence, RI, USA
| | - Omar Galarraga
- School of Public Health, Brown University, Providence, RI, USA
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Muzyamba C, Groot W, Pavlova M, Tomini SM. Factors associated with choice of antenatal, delivery and postnatal services between HIV positive and HIV negative women in Zambia. BMC Pregnancy Childbirth 2019; 19:127. [PMID: 30987608 PMCID: PMC6466675 DOI: 10.1186/s12884-019-2272-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 03/31/2019] [Indexed: 11/25/2022] Open
Abstract
Background Previous research has shown that developing countries account for the majority of maternal deaths around the world. Relatively high maternal mortality in developing countries has been linked to high HIV prevalence rates in these countries. Several studies have shown that women living with HIV are more vulnerable and are thus more likely to die during maternity than those who are not. Although there has been increased focus on this subject in contemporary research, the relationship between HIV status and maternal-care-utilization is not very well understood. It is not clear whether factors associated with professional maternal care utilization during antenatal, delivery and postnatal periods are similar for HIV positive and HIV negative women. It is also not known whether being HIV positive has an impact on the choice of care (professional care or traditional birth attendants). Thus the aim of this study is to investigate the differences in factors affecting choice of care during antenatal, delivery and postnatal periods between HIV positive and HIV negative women. We also investigate the effect of HIV positive status on choice of care. Methods By using the 2013–2014 Zambia Demographic Health Survey Data (ZDHS), we performed two different quantitative analyses. a) Regression analysis: to identify and compare factors associated with the likelihood of utilizing professional care during antenatal, at birth and postnatal periods between HIV positive and HIV negative women. b) Propensity score matching: to investigate the effect of being HIV positive on the choice of care (Professional care or TBAs). Results Our results show that reasons for choosing professional care during antenatal, at birth, and postnatal periods are the same for both HIV positive and HIV negative women. Further, we also showed that although the probability of utilizing professional care is slightly higher for HIV positive women, the difference is negligible. Conclusion We demonstrated that in Zambia, utilization of professional care among HIV positive women is not particularly high. We also demonstrate that although institutional care is desirable and an ideal solution for HIV positive women, insisting on institutional care when the health facilities lack adequate trained personnel, drugs, and equipment is counterproductive.
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Affiliation(s)
- Choolwe Muzyamba
- Maastricht Graduate School of Governance, UNU-Merit, Maastricht University, Maastricht, Netherlands. .,, A9 Marshlands Village Box 32379, Lusaka, Zambia.
| | - Wim Groot
- Department of Health Services Research, CAPHRI; Maastricht University Medical Center; Faculty of Health, Medicine and Life Sciences; Maastricht University, Maastricht, Netherlands.,Top Institute for Evidence-Based Education Research (TIER), Maastricht University, Maastricht, Netherlands
| | - Milena Pavlova
- Department of Health Services Research, CAPHRI; Maastricht University Medical Center; Faculty of Health, Medicine and Life Sciences; Maastricht University, Maastricht, Netherlands
| | - Sonila M Tomini
- Maastricht Graduate School of Governance, UNU-Merit, Maastricht University, Maastricht, Netherlands.,Department of Economics, University of Liege, Liege, Belgium
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6
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Muzyamba C, Groot W, Pavlova M, Rud I, Tomini SM. Professional care delivery or traditional birth attendants? The impact of the type of care utilized by mothers on under-five mortality of their children. Trop Med Health 2018. [DOI: 10.1186/s41182-018-0090-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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7
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Childbirth experiences of women living with HIV: a neglected event in the prevention of mother-to-child transmission care continuum. AIDS 2018; 32:1537-1539. [PMID: 29762160 DOI: 10.1097/qad.0000000000001860] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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8
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Mnyani CN, Buchmann EJ, Chersich MF, Frank KA, McIntyre JA. Trends in maternal deaths in HIV-infected women, on a background of changing HIV management guidelines in South Africa: 1997 to 2015. J Int AIDS Soc 2018; 20. [PMID: 29178578 PMCID: PMC5810347 DOI: 10.1002/jia2.25022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 10/05/2017] [Indexed: 12/03/2022] Open
Abstract
Introduction As work begins towards the Sustainable Development Goal target of reducing the global maternal mortality ratio (MMR) to less than 70 deaths per 100,000 live births by 2030, much needs to be done in ending preventable maternal deaths. After 1990, South Africa experienced a reversal of gains in decreasing maternal mortality, with an increase in HIV‐related maternal deaths. In this study, we assessed trends in maternal mortality in HIV‐infected women, on a background of an evolving HIV care programme. Methods This was a cross‐sectional, retrospective record review of maternal deaths in the obstetrics unit at Chris Hani Baragwanath Academic Hospital, in Johannesburg, South Africa, a referral hospital in a high HIV prevalence setting where the prevalence among pregnant women has plateaued around 29.0% for the past decade. Trends in HIV diagnosis and management in pregnancy, and causes of maternal deaths in HIV‐infected women were analysed over different time periods (1997 to 2003, 2004 to 2009, 2010 to 2012, and 2013 to 2015) reflecting major guideline changes. Results From January 1997 to December 2015, there were 692 maternal deaths in the obstetrics unit. Of the 490 (70.8%) maternal deaths with a documented HIV status, 335 (68.4%) were HIV‐infected. A Chi‐squared test for trends showed that the institutional MMR (iMMR) in women known to be HIV‐infected peaked in the period 2004 to 2009 at 380 (95% CI 319 to 446) per 100,000 live births, with a decline to 267 (95% CI 198 to 353) in 2013 to 2015, p = 0.049. This decrease coincided with changes in the South African HIV management guidelines, mainly increased availability of antiretroviral therapy (ART). Non‐pregnancy related infections were the leading cause of death throughout the review period, accounting for 61.5% (206/335) of deaths. Only 23.3% (78/335) of the women who died were on ART at the time of death, this in the context of advanced immune suppression and an overall median CD4 count of 136 cells/μl (interquartile ranges (IQR) 45 to 301). Conclusion In this 19‐year review of maternal deaths in Johannesburg, South Africa, there was evidence of a decrease in the iMMR among HIV‐infected women, but it remains unacceptably high. Efforts to address drivers of mortality and barriers to accessing ART need to be accelerated if we are to see substantial decreases in maternal mortality.
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Affiliation(s)
- Coceka N Mnyani
- School of Clinical Medicine, Department of Obstetrics and Gynaecology, University of the Witwatersrand, Johannesburg, South Africa.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.,SACEMA (DST/NRF Centre of Excellence in Epidemiological Modelling and Analysis), Stellenbosch University, Stellenbosch, South Africa
| | - Eckhart J Buchmann
- School of Clinical Medicine, Department of Obstetrics and Gynaecology, University of the Witwatersrand, Johannesburg, South Africa
| | - Matthew F Chersich
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,International Centre for Reproductive Health, Department of Obstetrics and Gynaecology, University of Ghent, Ghent, Belgium
| | - Karlyn A Frank
- School of Clinical Medicine, Department of Obstetrics and Gynaecology, University of the Witwatersrand, Johannesburg, South Africa
| | - James A McIntyre
- Anova Health Institute, Johannesburg, South Africa.,School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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9
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Muzyamba C, Groot W, Tomini S, Pavlova M. Community mobilization and maternal Care of Women Living with HIV in poor settings: the case of Mfuwe, Zambia. BMC Health Serv Res 2018; 18:155. [PMID: 29499703 PMCID: PMC5834889 DOI: 10.1186/s12913-018-2959-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 02/21/2018] [Indexed: 11/10/2022] Open
Abstract
Background Research has shown that community mobilization is a useful strategy in promoting maternal care of HIV negative women in resource poor settings; however, similar evidence for women living with HIV is missing. Therefore, in this study we provide this evidence by exploring the relevance of community mobilization in the promotion of maternal health care among women living with HIV in resource-poor settings by using Mfuwe, a rural district in Zambia as a case study. Methods By relying on Focus Group Discussions (FGDs), qualitative data were collected from Mfuwe, Zambia. The data were digitally recorded, transcribed and later translated from CheChewa (local language) to English. We relied on Thematic analysis to analyze the data. Results By focusing on community mobilization, our results showed that within their social fabrics, resource-poor communities often contain unrecognized and sometimes ignored strategies which are contextually-feasible and have been used for generations to promote maternal care for HIV positive women. Further, it was evident that although the three forms of community mobilization were largely and uniquely useful in promoting maternal health care of women living with HIV, they also presented unique and various shortcomings. Conclusion We demonstrated that community mobilization was largely and often characterized as a force for good (e.g. providing support, improving access to maternal care etc.) and sometimes for bad (e.g. reinforced harmful misconceptions, superstition and stigma). Thus we recommend that community mobilization needs to be factored into maternal health care policies for HIV positive women in resource poor settings either to optimize their potential benefits or to minimize their potential harm.
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Affiliation(s)
- Choolwe Muzyamba
- Maastricht Graduate School of Governance/UNU-Merit, Maastricht University, Maastricht, The Netherlands.
| | - Wim Groot
- Department of Health Services Research, CAPHRI, Maastricht University Medical Center, Faculty of Health, Medicine and Life Sciences, Maastricht University, PO Box 616, 6200, MD, Maastricht, The Netherlands
| | - Sonila Tomini
- UNU MERIT, Boschstraat, 246211, AX, Maastricht, The Netherlands
| | - Milena Pavlova
- Department of Health Services Research, CAPHRI, Maastricht University Medical Center, Faculty of Health, Medicine and Life Sciences, Maastricht University, PO Box 616, 6200, MD, Maastricht, The Netherlands
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Caplan MR, Phiri K, Parent J, Phoya A, Schooley A, Hoffman RM. Provider perspectives on barriers to reproductive health services for HIV-infected clients in Central Malawi. ACTA ACUST UNITED AC 2018; 4. [PMID: 30828465 DOI: 10.15761/cogrm.1000208] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Despite widespread availability of Depo-Provera in HIV clinics in Malawi, coverage of family planning (FP) remains low. We sought to understand provider perspectives about the challenges of providing reproductive health services to HIV-infected clients in antiretroviral therapy (ART) clinics in Central Malawi by conducting surveys and semi structured in-depth interviews with 31 ART providers across 16 clinical sites. Additionally, site surveys were performed to assess contraceptive resources. Major barriers to the provision of FP in ART clinics were inadequate staff in the facility, shortage of trained providers, limited time to counsel on FP, and lack of private space for the provision of FP services. These barriers limit the direct delivery of FP in ART clinics. Strategies to integrate FP with HIV/ART services and task shifting FP service provision to non-ART providers should be explored in Malawi as a means to improve coverage of services to HIV-infected clients.
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Affiliation(s)
- Margaret R Caplan
- Division of HIV Medicine, Los Angeles Biomedical Institute at Harbor-UCLA Medical Center, Torrance, California, USA
| | | | | | - Ann Phoya
- UNC Maternal and Safe Motherhood Program, Lilongwe, Malawi
| | - Alan Schooley
- Partners in Hope, Lilongwe, Malawi.,Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Risa M Hoffman
- Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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Rodriguez MI, Gaffield ME, Han L, Caughey AB. Re-Evaluating the Possible Increased Risk of HIV Acquisition With Progestin-Only Injectables Versus Maternal Mortality and Life Expectancy in Africa: A Decision Analysis. GLOBAL HEALTH: SCIENCE AND PRACTICE 2017; 5:581-591. [PMID: 29284696 PMCID: PMC5752605 DOI: 10.9745/ghsp-d-17-00243] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 11/11/2017] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The association between increased risk of HIV acquisition and use of progestin-only injectables (POIs) is controversial. We sought to compare the competing risks of maternal mortality and HIV acquisition with use of POIs using updated data on this association and considering an expanded number of African countries. METHODS We designed a decision-analytic model to compare the benefits and risks of POIs on the competing risks of maternal mortality and HIV acquisition on life expectancy for women in 9 African countries. For the purposes of this analysis, we assumed that POIs were associated with an increased risk of HIV acquisition (hazards ratio of 1.4). Our primary outcome was life-years and the population was women of reproductive age (15-49 years) in these countries, who did not have HIV infection and were not currently planning a pregnancy. Probabilities for each variable included in the model, such as HIV incidence, access to antiretroviral therapy, and contraceptive prevalence, were obtained from the literature. Univariate and multivariate sensitivity analyses were performed to check model assumptions and explore how uncertainty in estimates would affect the model results. RESULTS In all countries, discontinuation of POIs without replacement with an equally effective contraceptive method would result in decreased life expectancy due to a significant increase in maternal deaths. While the removal of POIs from the market would result in the prevention of some new cases of HIV, the life-years gained from this are mitigated due to the marked increase in neonatal HIV cases and maternal mortality with associated life-years lost. In all countries, except South Africa, typical-use contraceptive failure rates with POIs would need to exceed 39%, and more than half of women currently using POIs would have to switch to another effective method, for the removal of POIs to demonstrate an increase in total life-years. CONCLUSION Women living in sub-Saharan Africa cope with both high rates of HIV infection and high rates of pregnancy-related maternal death relative to the rest of the world. Based on the most current estimates, our model suggests that removal of POI contraception from the market without effective and acceptable contraception replacement would have a net negative effect on maternal health, life expectancy, and mortality under a variety of scenarios.
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Affiliation(s)
- Maria Isabel Rodriguez
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR, USA.
| | - Mary E Gaffield
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Leo Han
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR, USA
| | - Aaron B Caughey
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR, USA
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Vieira N, Rasmussen DN, Oliveira I, Gomes A, Aaby P, Wejse C, Sodemann M, Reynolds L, Unger HW. Awareness, attitudes and perceptions regarding HIV and PMTCT amongst pregnant women in Guinea-Bissau- a qualitative study. BMC WOMENS HEALTH 2017; 17:71. [PMID: 28870180 PMCID: PMC5584044 DOI: 10.1186/s12905-017-0427-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 08/18/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND The human immunodeficiency virus (HIV) continues to be a major cause of maternal and infant mortality and morbidity in sub-Saharan Africa. Prevention of mother-to-child transmission of HIV (PMTCT) strategies have proven effective in decreasing the number of children infected in utero, intrapartum and during the breastfeeding period. This qualitative study explores knowledge and perceptions of HIV amongst pregnant women, healthcare workers' experiences of the national PMTCT services, and barriers to PMTCT, during a period of programme scale-up in urban Guinea-Bissau (2010-11). METHODS In-depth interviews were undertaken amongst 27 women and 19 key informants at local antenatal clinics and the national maternity ward in Bissau, Guinea-Bissau. RESULTS Amongst women who had been tested for HIV, awareness and knowledge of HIV and PMTCT remained low. Testing without informed consent was reported in some cases, in particular when the test was performed around the time of delivery. Possible drivers of inadequate counselling included lack of confidentiality, suboptimal healthcare worker training, lack of time, and perceived occupational risk. Demand-side barriers to PMTCT included lack of HIV and PMTCT knowledge, customary and cultural beliefs associated with HIV and ill-health, HIV stigma and discrimination, and fear of partnership dissolution. CONCLUSIONS Socio-cultural and operational challenges, including HIV testing without informed consent, present significant barriers to the scale-up of PMTCT services in Bissau. Strengthening local capacity for effective counselling and testing in the antenatal setting is paramount. Further research into local customary beliefs relating to HIV is warranted.
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Affiliation(s)
- Noel Vieira
- Association Ceu e Terras, Avenida do Brasil n. 7, Apartado 1257, 1031, Bissau Codex, Guinea-Bissau.
| | - Dlama Nggida Rasmussen
- Bandim Health Project, INDEPTH Network, Apartado 861, 1004, Bissau Codex, Guinea-Bissau.,Department of Infectious Diseases, Odense University Hospital, Sdr. Boulevard 29, DK-5000, Odense, Denmark
| | - Inês Oliveira
- Bandim Health Project, INDEPTH Network, Apartado 861, 1004, Bissau Codex, Guinea-Bissau
| | - Aureliano Gomes
- Bandim Health Project, INDEPTH Network, Apartado 861, 1004, Bissau Codex, Guinea-Bissau
| | - Peter Aaby
- Bandim Health Project, INDEPTH Network, Apartado 861, 1004, Bissau Codex, Guinea-Bissau.,Statens Serum Institut, Artillerivej 5, DK-2300, Copenhagen, Denmark
| | - Christian Wejse
- Bandim Health Project, INDEPTH Network, Apartado 861, 1004, Bissau Codex, Guinea-Bissau.,Department of Infectious Diseases, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK-8200, Aarhus, Denmark
| | - Morten Sodemann
- Bandim Health Project, INDEPTH Network, Apartado 861, 1004, Bissau Codex, Guinea-Bissau.,Department of Infectious Diseases, Odense University Hospital, Sdr. Boulevard 29, DK-5000, Odense, Denmark
| | - Lucy Reynolds
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Holger W Unger
- Bandim Health Project, INDEPTH Network, Apartado 861, 1004, Bissau Codex, Guinea-Bissau.,Department of Obstetrics and Gynaecology, The Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, UK.,Department of Medicine at the Doherty Institute, The University of Melbourne, Post Office Royal Melbourne Hospital, Parkville, Melbourne, VIC, 3050, Australia
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Muzyamba C, Groot W, Tomini SM, Pavlova M. The role of Community Mobilization in maternal care provision for women in sub-Saharan Africa- A systematic review of studies using an experimental design. BMC Pregnancy Childbirth 2017; 17:274. [PMID: 28851299 PMCID: PMC5576335 DOI: 10.1186/s12884-017-1458-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 08/21/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND While the role of community mobilization in improving maternal health outcomes of HIV positive women in sub-Saharan Africa is continuously emphasized, little is known about how legitimate these claims are. The aim of this study is to systematically review the empirical evidence on this issue. METHODS A systematic search was conducted in PuBMed, Scopus, Web of Science, MEDLINE, COCHRANE, Allied Health Literature, and Cumulative Index to Nursing. RESULTS Our search identified 14 publications on the role of community mobilization in maternal care provision in sub-Saharan Africa, including both HIV negative women and women with HIV, that have used experimental research designs. Regarding HIV negative women, literature has demonstrated that community mobilization is a useful strategy for promoting both positive maternal process results and maternal health outcomes. Most of the literature on women with HIV has focused only on demonstrating the causal link between community mobilization and process results. There has been very little focus on demonstrating the causal link between community mobilization and maternal outcomes for women living with HIV. Overall, the results show that while there is some empirical evidence on a causal link between community mobilization and maternal health outcomes for HIV negative women, this kind of evidence is still missing for HIV positive women. Moreover, as shown by the studies, community mobilization as a maternal health strategy is still in its infancy. CONCLUSION Given the gaps identified in our review, we recommend further research with the aim of providing sound evidence on the role of community mobilization in improving maternal health outcomes of women with HIV in sub-Saharan Africa.
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Affiliation(s)
- Choolwe Muzyamba
- UNU MERIT, Boschstraat, 246211 AX Maastricht, The Netherlands
- A9 Marshlands Village Box 32379, Lusaka, Zambia
| | - Wim Groot
- Department of Health Services Research. Room 0.073, Maastricht University, Duboisdomein 30, 6229 GT Maastricht, The Netherlands
| | | | - Milena Pavlova
- Department of Health Services Research. Room 0.073, Maastricht University, Duboisdomein 30, 6229 GT Maastricht, The Netherlands
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Realizing the Promise of the Global Plan: Engaging Communities and Promoting the Health and Human Rights of Women Living With HIV. J Acquir Immune Defic Syndr 2017; 75 Suppl 1:S86-S93. [PMID: 28399001 DOI: 10.1097/qai.0000000000001330] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The Global Plan Towards the Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive highlighted the need to put the health and well-being of women and mothers at the center of efforts to prevent vertical transmission. This article will examine a selection of community engagement practices in 3 key areas: (1) as an accountability tool, (2) in service delivery, and (3) as a facilitator of human rights. The lived experiences of women living with HIV as recipients of and participants in services for the prevention of vertical transmission provide both the framework for an exploration of best community engagement practices and suggestions for the way forward.
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González R, Rupérez M, Sevene E, Vala A, Maculuve S, Bulo H, Nhacolo A, Mayor A, Aponte JJ, Macete E, Menendez C. Effects of HIV infection on maternal and neonatal health in southern Mozambique: A prospective cohort study after a decade of antiretroviral drugs roll out. PLoS One 2017; 12:e0178134. [PMID: 28575010 PMCID: PMC5456062 DOI: 10.1371/journal.pone.0178134] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 05/08/2017] [Indexed: 12/20/2022] Open
Abstract
Introduction The HIV epidemic is concentrated in sub-Saharan Africa. However, limited information exists on its impact on women and infant’s health since the introduction of antiretroviral drugs in this region, where health resources are often scarce. Methods The effect of HIV infection on maternal health, birth outcomes and infant health was analysed in two contemporary cohorts of HIV-uninfected and HIV-infected pregnant women from southern Mozambique. Pregnant women attending the first antenatal care visit were followed until one month after delivery. Antiretroviral therapy was administered based on CD4+T cell count and clinical stage. Maternal and neonatal morbidity and mortality, as well as pregnancy outcomes were assessed by mother’s HIV status. Results A total of 1183 HIV-uninfected and 561 HIV-infected pregnant women were enrolled. HIV-infected women were more likely to have anaemia both at the first antenatal care visit and at delivery than HIV-uninfected women (71.5% versus 54.8% and 49.4% versus 40.6%, respectively, p<0.001). Incidence of hospital admissions during pregnancy was increased among HIV-infected women (RR, 2.04, [95%CI, 1.45; 2.86]; p<0.001). At delivery, 21% of HIV-infected women reported being on antiretroviral therapy, and 70% having received antiretroviral drugs for prevention of mother to child transmission of HIV. The risk of stillbirths was doubled in HIV-infected women (RR, 2.16 [95%CI 1.17; 3.96], p = 0.013). Foetal anaemia was also increased among infants born to HIV-infected women (10.6% versus 7.3%, p = 0.022). No differences were found in mean birth weight, malaria, prematurity and maternal and neonatal deaths between groups. Conclusions HIV infection continues to be associated with significant maternal morbidity and poor neonatal health outcomes. Efforts should urgently be made to identify the barriers that impede improvements on the devastating effects of HIV in African women and their infants. Trial registration ClinicalTrials.gov NCT 00811421.
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Affiliation(s)
- Raquel González
- ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain
- Manhiça Health Research Center (CISM), Manhiça, Mozambique
- * E-mail:
| | - María Rupérez
- ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain
- Manhiça Health Research Center (CISM), Manhiça, Mozambique
| | - Esperança Sevene
- Manhiça Health Research Center (CISM), Manhiça, Mozambique
- Eduardo Mondlane University, Faculty of medicine, Maputo, Mozambique
| | - Anifa Vala
- Manhiça Health Research Center (CISM), Manhiça, Mozambique
| | - Sónia Maculuve
- Manhiça Health Research Center (CISM), Manhiça, Mozambique
| | - Helder Bulo
- Manhiça Health Research Center (CISM), Manhiça, Mozambique
| | | | - Alfredo Mayor
- ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain
- Manhiça Health Research Center (CISM), Manhiça, Mozambique
| | - John J. Aponte
- ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain
- Manhiça Health Research Center (CISM), Manhiça, Mozambique
| | - Eusébio Macete
- Manhiça Health Research Center (CISM), Manhiça, Mozambique
| | - Clara Menendez
- ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain
- Manhiça Health Research Center (CISM), Manhiça, Mozambique
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16
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Chevalier MS, King CC, Ellington S, Wiener J, Kayira D, Chasela CS, Jamieson DJ, Kourtis AP. Maternal and neonatal outcomes among women with HIV infection and their infants in Malawi. Int J Gynaecol Obstet 2017; 137:282-289. [PMID: 28258582 PMCID: PMC5419872 DOI: 10.1002/ijgo.12136] [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: 08/25/2016] [Revised: 01/11/2017] [Accepted: 02/28/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To describe maternal and neonatal morbidity and mortality among women with HIV infection and their infants. METHODS A secondary analysis was undertaken of data obtained in the BAN Study, a trial of postnatal antiretrovirals among pregnant women with HIV infection enrolled in 2004-2010. Mothers and infants had 13 scheduled visits through 48 weeks of follow-up. Serious maternal morbidity and mortality were examined at delivery (n=2791), from delivery to 6 weeks later (n=2369) and from 7 to 48 weeks (n=1980). Neonatal morbidity and mortality were examined (n=2685). RESULTS Of 2791 deliveries, 169 (6.1%) were by cesarean (153 emergency). Compared with women with vaginal delivery, those with cesarean delivery had lower prenatal HIV viral loads (P=0.016) and increased odds of pre-eclampsia/eclampsia (odds ratio [OR] 10.8, 95% CI 4.4-26.8). Women with cesarean delivery also had increased odds of serious infection with 14 days of delivery (OR 3.0, 95% CI 1.3-7.4) and severe anemia (grade 3 or 4) by 6 weeks (OR 6.7, 95% CI 2.3-19.1). Infants born by cesarean had increased odds of a low 5-minute Apgar score (OR 8.1, 95% CI 3.5-18.6) and admission to an intensive care unit (OR 5.4, 95% CI 3.7-7.8). CONCLUSION Odds of serious maternal and neonatal morbidity were higher after cesarean than vaginal delivery, despite lower maternal viral loads.
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Affiliation(s)
- Michelle S. Chevalier
- Division of Global HIV and Tuberculosis, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Caroline C. King
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Sascha Ellington
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jeffrey Wiener
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Dumbani Kayira
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | - Charles S. Chasela
- Epidemiology and Strategic Information, Human Sciences Research Council, Pretoria, South Africa
| | - Denise J. Jamieson
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Athena P. Kourtis
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Cooper D, Mantell JE, Moodley J, Mall S. The HIV epidemic and sexual and reproductive health policy integration: views of South African policymakers. BMC Public Health 2015; 15:217. [PMID: 25879464 PMCID: PMC4389705 DOI: 10.1186/s12889-015-1577-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 02/19/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Integration of sexual and reproductive health (SRH) and HIV policies and services delivered by the same provider is prioritised worldwide, especially in sub-Saharan Africa where HIV prevalence is highest. South Africa has the largest antiretroviral treatment (ART) programme in the world, with an estimated 2.7 million people on ART, elevating South Africa's prominence as a global leader in HIV treatment. In 2011, the Southern African HIV Clinicians Society published safer conception guidelines for people living with HIV (PLWH) and in 2013, the South African government published contraceptive guidelines highlighting the importance of SRH and fertility planning services for people living with HIV. Addressing unintended pregnancies, safer conception and maternal health issues is crucial for improving PLWH's SRH and combatting the global HIV epidemic. This paper explores South African policymakers' perspectives on public sector SRH-HIV policy integration, with a special focus on the need for national and regional policies on safer conception for PLWH and contraceptive guidelines implementation. METHODS It draws on 42 in-depth interviews with national, provincial and civil society policymakers conducted between 2008-2009 and 2011-2012, as the number of people on ART escalated. Interviews focused on three key domains: opinions on PLWH's childbearing; the status of SRH-HIV integration policies and services; and thoughts and suggestions on SRH-HIV integration within the restructuring of South African primary care services. Data were coded and analysed according to themes. RESULTS Participants supported SRH-HIV integrated policy and services. However, integration challenges identified included a lack of policy and guidelines, inadequately trained providers, vertical programming, provider work overload, and a weak health system. Participants acknowledged that SRH-HIV integration policies, particularly for safer conception, contraception and cervical cancer, had been neglected. Policymakers supported public sector adoption of safer conception policy and services. Participants interviewed after expanded ART were more positive about safer conception policies for PLWH than participants interviewed earlier. CONCLUSION The past decade's HIV policy changes have increased opportunities for SRH-HIV integration. The findings provide important insights for international, regional and national SRH-HIV policy and service integration initiatives.
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Affiliation(s)
- Diane Cooper
- Women's Health Research Unit, School of Public Health and Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa.
- School of Public Health, University of Western Cape, Private Bag X17, Bellville, 7535, South Africa.
| | - Joanne E Mantell
- HIV Center for Clinical and Behavioral Studies, Division of Gender, Sexuality, and Health, New York State Psychiatric Institute and Columbia University, New York, NY, USA.
| | - Jennifer Moodley
- Women's Health Research Unit, School of Public Health and Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa.
- Cancer Research Initiative, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
| | - Sumaya Mall
- Women's Health Research Unit, School of Public Health and Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa.
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa.
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Kendall T, Bärnighausen T, Fawzi WW, Langer A. Towards comprehensive women's healthcare in sub-Saharan Africa: addressing intersections between HIV, reproductive and maternal health. J Acquir Immune Defic Syndr 2014; 67 Suppl 4:S169-72. [PMID: 25436814 PMCID: PMC4251906 DOI: 10.1097/qai.0000000000000382] [Citation(s) in RCA: 10] [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] [Indexed: 11/26/2022]
Abstract
This themed supplement to JAIDS: Journal of Acquired Immune Deficiency Syndromes focuses on the critical intersections between HIV, reproductive, and maternal health services in the health systems of sub-Saharan Africa. The epidemiology of HIV among women of reproductive age on the sub-continent demands a holistic conceptualization and comprehensive approaches to ensure that HIV, reproductive, and maternal health are optimally addressed. Yet, in many instances, the national and global responses to these health issues remain siloed. Women's health needs and new global and national guidelines for HIV treatment raise important policy, programmatic, and operational questions regarding service integration, scale-up, and health systems functioning. In June 2013, the Maternal Health Task Force at the Harvard School of Public Health, the United States Agency for International Development, and the United States Centers for Disease Control and Prevention convened an international technical meeting of researchers, policymakers, and practitioners to discuss the existing evidence base about the interconnections between HIV, reproductive, and maternal health and identify the most important knowledge gaps and research priorities. The articles in this special issue deepen and expand on those discussions by (1) providing empirical evidence about challenges, (2) identifying how improving clinical care and models of service delivery, strengthening health systems, and addressing social dynamics can contribute to better outcomes, and (3) mapping future research directions. Together, these articles underscore that new policy frameworks and integrated approaches are necessary but not sufficient to address health system challenges. Addressing the multiple needs of women of reproductive age who are living with HIV or are at risk of acquiring HIV is a complex undertaking that requires improved access to, utilization and quality of comprehensive women's healthcare. Continued evaluation and knowledge generation are needed to ensure that potential health gains are actualized.
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Affiliation(s)
- Tamil Kendall
- Maternal Health Task Force, Women and Health Initiative, Department of Global Health and Population, Harvard School of Public Health, Boston, MA
- Department of Global Health and Population, Harvard School of Public Health, Boston, MA; and
| | - Till Bärnighausen
- Department of Global Health and Population, Harvard School of Public Health, Boston, MA; and
- Wellcome Trust Africa Centre for Health and Population Studies, Mtubatuba, South Africa
| | - Wafaie W. Fawzi
- Department of Global Health and Population, Harvard School of Public Health, Boston, MA; and
| | - Ana Langer
- Maternal Health Task Force, Women and Health Initiative, Department of Global Health and Population, Harvard School of Public Health, Boston, MA
- Department of Global Health and Population, Harvard School of Public Health, Boston, MA; and
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Hope R, Kendall T, Langer A, Bärnighausen T. Health systems integration of sexual and reproductive health and HIV services in sub-Saharan Africa: a scoping study. J Acquir Immune Defic Syndr 2014; 67 Suppl 4:S259-70. [PMID: 25436826 PMCID: PMC4251913 DOI: 10.1097/qai.0000000000000381] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Both sexual and reproductive health (SRH) services and HIV programs in sub-Saharan Africa are typically delivered vertically, operating parallel to national health systems. The objective of this study was to map the evidence on national and international strategies for integration of SRH and HIV services in sub-Saharan Africa and to develop a research agenda for future health systems integration. METHODS We examined the literature on national and international strategies to integrate SRH and HIV services using a scoping study methodology. Current policy frameworks, national HIV strategies and research, and gray literature on integration were mapped. Five countries in sub-Saharan Africa with experience of integrating SRH and HIV services were purposively sampled for detailed thematic analysis, according to the health systems functions of governance, policy and planning, financing, health workforce organization, service organization, and monitoring and evaluation. RESULTS The major international health policies and donor guidance now support integration. Most integration research has focused on linkages of SRH and HIV front-line services. Yet, the common problems with implementation are related to delayed or incomplete integration of higher level health systems functions: lack of coordinated leadership and unified national integration policies; separate financing streams for SRH and HIV services and inadequate health worker training, supervision and retention. CONCLUSIONS Rigorous health systems research on the integration of SRH and HIV services is urgently needed. Priority research areas include integration impact, performance, and economic evaluation to inform the planning, financing, and coordination of integrated service delivery.
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Affiliation(s)
- Rebecca Hope
- Women and Health Initiative, Department of Global Health and Population, Harvard School of Public Health, Harvard University, Boston, MA
- Department of Global Health and Population, Harvard School of Public Health, Harvard University, Boston, MA; and
| | - Tamil Kendall
- Women and Health Initiative, Department of Global Health and Population, Harvard School of Public Health, Harvard University, Boston, MA
- Department of Global Health and Population, Harvard School of Public Health, Harvard University, Boston, MA; and
| | - Ana Langer
- Women and Health Initiative, Department of Global Health and Population, Harvard School of Public Health, Harvard University, Boston, MA
- Department of Global Health and Population, Harvard School of Public Health, Harvard University, Boston, MA; and
| | - Till Bärnighausen
- Department of Global Health and Population, Harvard School of Public Health, Harvard University, Boston, MA; and
- Programme on Health Systems and Impact Evaluation, Wellcome Trust Africa Centre for Health and Population Studies, Mtubatuba, South Africa
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