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Corcorran MA, Scott JD, Naveira M, Easterbrook P. Training the healthcare workforce to support task-shifting and viral hepatitis elimination: a global review of English language online trainings and in-person workshops for management of hepatitis B and C infection. BMC Health Serv Res 2023; 23:849. [PMID: 37568106 PMCID: PMC10422775 DOI: 10.1186/s12913-023-09777-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 07/03/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND Achieving World Health Organization (WHO) targets for viral hepatitis elimination will require simplification and decentralisation of care, supported through task-shifting and training of non-specialist frontline healthcare workers. To inform development of national health worker trainings in viral hepatitis, we review and summarise available online and workshop trainings for management of hepatitis B virus (HBV) and hepatitis C virus (HCV). METHODS We performed a systematic search of PubMed, Embase, Web of Science, conference abstracts, and grey literature using Google to identify online and in-person workshop trainings for health workers focused on HBV and/or HCV. Additional trainings were identified through a WHO regional network. We included online trainings written in English and in-person workshops developed for low-and-middle-income countries (LMICs). Available curricula are summarised together with key operational features (e.g. training length, year developed/updated, developing institution) and programmatic features (e.g. content, mechanism for self-assessment, use of clinical case studies). RESULTS A total of 30 trainings met our inclusion criteria (10 online trainings; 20 in-person workshops). 50% covered both HBV and HCV, 13% HBV alone and 37% HCV alone. Among online trainings, only 2 (20%) were specifically developed or adapted for LMICs; 70% covered all aspects of hepatitis care, including prevention, assessment, and treatment; 9 (90%) included guidance on when to refer to specialists, and 6 (60%) included modules on management in specific populations (e.g., people who inject drugs [PWID], prisoners, and children). Online trainings used different formats including text-based modules, narrated slide-sets, and interactive web-based modules. Most workshops (95%) were targeted towards non-specialty providers, and 50% were an integral part of a national strategy for viral hepatitis elimination. Workshop length ranged from several hours to multiple sessions over the course of months, and many were part of a blended educational model, which included other opportunities for ongoing learning (e.g., telementorship). CONCLUSION This compendium of online and in-person workshop trainings for HBV and HCV is a useful resource for national hepatitis programmes developing training curricula for non-specialists. Additional online training curricula are needed for use in LMICs, and additional materials are needed to address management challenges in key populations, such as PWID.
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Affiliation(s)
- Maria A Corcorran
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington School of Medicine, 325 9Th Ave, Box 359782, Seattle, WA, 98104, USA.
| | - John D Scott
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington School of Medicine, 325 9Th Ave, Box 359782, Seattle, WA, 98104, USA
| | - Marcelo Naveira
- World Health Organization Regional Office for Europe, Copenhagen, Denmark
| | - Philippa Easterbrook
- Department of Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
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Corcorran MA, Thornton K, Struminger B, Easterbrook P, Scott JD. Training the healthcare workforce: the global experience with telementorship for hepatitis B and hepatitis C. BMC Health Serv Res 2023; 23:824. [PMID: 37533025 PMCID: PMC10394928 DOI: 10.1186/s12913-023-09849-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 07/26/2023] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND Telementorship has emerged as an innovative strategy to decentralise medical knowledge and increase healthcare capacity across a wide range of disease processes. We report the global experience with telementorship to support healthcare workers delivering hepatitis B virus (HBV) and hepatitis C virus (HCV) care and treatment. METHODS In early 2020, we conducted a survey of HBV and HCV telementorship programmes, followed by an in-depth interview with programme leads. Programmes were eligible to participate if they were located outside of the United States (U.S.), focused on support to healthcare workers in management of HBV and/or HCV, and were affiliated with or maintained adherence to the Project ECHO model, a telementorship programme pioneered at the University of New Mexico. One programme in the U.S., focused on HCV treatment in the Native American community, was purposively sampled and invited to participate. Surveys were administered online, and all qualitative interviews were performed remotely. Descriptive statistics were calculated for survey responses, and qualitative interviews were assessed for major themes. RESULTS Eleven of 18 eligible programmes completed the survey and follow up interview. Sixty-four percent of programmes were located at regional academic medical centers. The majority of programmes (64%) were led by hepatologists. Most programmes (82%) addressed both HBV and HCV, and the remainder focused on HCV only. The median number of participating clinical spoke sites per programme was 22, and most spoke site participants were primary care providers. Most ECHO sessions were held monthly (36%) or bimonthly (27%), with sessions ranging from 45 min to 2 h in length. Programme leaders identified collective learning, empowerment and collaboration to be key strengths of their telementorship programme, while insufficient funding and a lack of protected time for telementorship leaders and participants were identified as major barriers to success. CONCLUSION The Project ECHO model for telementorship can be successfully implemented across high and low-and-middle-income countries to improve provider knowledge and experience in management of viral hepatitis. There is a tremendous opportunity to further expand upon the existing experience with telementorship to support non-specialist healthcare workers and promote elimination of viral hepatitis.
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Affiliation(s)
- Maria A Corcorran
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA, USA.
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington School of Medicine, Harborview Medical Center, 325 9th Ave, Box 359782, Seattle, WA, 98104, USA.
| | - Karla Thornton
- Division of Infectious Diseases, Department of Internal Medicine, University of New Mexico, Albuquerque, NM, USA
- Project ECHO, University of New Mexico, Albuquerque, NM, USA
| | - Bruce Struminger
- Division of Infectious Diseases, Department of Internal Medicine, University of New Mexico, Albuquerque, NM, USA
- Project ECHO, University of New Mexico, Albuquerque, NM, USA
| | - Philippa Easterbrook
- Department of Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | - John D Scott
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA, USA
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Okoroafor SC, Christmals CD. Task Shifting and Task Sharing Implementation in Africa: A Scoping Review on Rationale and Scope. Healthcare (Basel) 2023; 11:1200. [PMID: 37108033 PMCID: PMC10138489 DOI: 10.3390/healthcare11081200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 04/14/2023] [Accepted: 04/20/2023] [Indexed: 04/29/2023] Open
Abstract
Numerous studies have reported task shifting and task sharing due to various reasons and with varied scopes of health services, either task-shifted or -shared. However, very few studies have mapped the evidence on task shifting and task sharing. We conducted a scoping review to synthesize evidence on the rationale and scope of task shifting and task sharing in Africa. We identified peer-reviewed papers from PubMed, Scopus, and CINAHL bibliographic databases. Studies that met the eligibility criteria were charted to document data on the rationale for task shifting and task sharing, and the scope of tasks shifted or shared in Africa. The charted data were thematically analyzed. Sixty-one studies met the eligibility criteria, with fifty-three providing insights on the rationale and scope of task shifting and task sharing, and seven on the scope and one on rationale, respectively. The rationales for task shifting and task sharing were health worker shortages, to optimally utilize existing health workers, and to expand access to health services. The scope of health services shifted or shared in 23 countries were HIV/AIDS, tuberculosis, hypertension, diabetes, mental health, eyecare, maternal and child health, sexual and reproductive health, surgical care, medicines' management, and emergency care. Task shifting and task sharing are widely implemented in Africa across various health services contexts towards ensuring access to health services.
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Affiliation(s)
- Sunny C. Okoroafor
- Universal Health Coverage—Life Course Cluster, World Health Organization Country Office for Uganda, Kampala, Uganda
- Centre for Health Professions Education, Faculty of Health Sciences, North-West University, Potchefstroom Campus, Building PC-G16, Office 101, 11 Hoffman Street, Potchefstroom 2520, South Africa
| | - Christmal Dela Christmals
- Centre for Health Professions Education, Faculty of Health Sciences, North-West University, Potchefstroom Campus, Building PC-G16, Office 101, 11 Hoffman Street, Potchefstroom 2520, South Africa
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Zhou J, Yun J, Ye X, Liu W, Xiao W, Song P, Wang H. Interventions to improve antiretroviral adherence in HIV-infected pregnant women: A systematic review and meta-analysis. Front Public Health 2022; 10:1056915. [PMID: 36568785 PMCID: PMC9773995 DOI: 10.3389/fpubh.2022.1056915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 11/22/2022] [Indexed: 12/13/2022] Open
Abstract
Background Medication adherence in HIV-infected pregnant women remains suboptimal. This systematic review and meta-analysis aimed to evaluate the effectiveness of interventions on improving antiretroviral adherence targeting among HIV-infected pregnant women. Methods Five databases were screened to identify quasi-experimental studies and randomized controlled trials. The risk ratios (RR) and confidential intervals (CI) were extracted to estimate the improvement in antiretroviral adherence after interventions compared with control conditions. This study was registered with PROSPERO, number CRD42021256317. Results Nine studies were included in the review, totaling 2,900 participants. Three interventions had significance: enhanced standard of care (eSOC, RR 1.14, 95%CI 1.07-1.22, Z = 3.79, P < 0.01), eSOC with supporter (RR 1.12, 95%CI 1.04-1.20, Z = 2.97, P < 0.01) and device reminder (RR 1.33, 95%CI 1.04-1.72, Z = 2.23, P = 0.03). Discussion The study supported the eSOC and the device reminder as effective intervention strategies for improving HIV medication adherence. Based on the current findings, the study called for more efforts to improve antiretroviral care for pregnant women through involving multicenter, large-sample, and high-quality research and combining the device reminder with other intervention methods. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021256317, identifier CRD42021256317.
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Affiliation(s)
- Jie Zhou
- Department of Social Medicine of School of Public Health and Department of Pharmacy of the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jingyi Yun
- Department of Social Medicine of School of Public Health and Department of Pharmacy of the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xinxin Ye
- Department of Social Medicine of School of Public Health and Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wen Liu
- Department of Social Medicine of School of Public Health and Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wenhan Xiao
- Department of Social Medicine of School of Public Health and Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Peige Song
- Department of Social Medicine of School of Public Health and Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China,Peige Song
| | - Hongmei Wang
- Department of Social Medicine of School of Public Health and Department of Pharmacy of the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China,*Correspondence: Hongmei Wang
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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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Toegel F, Rodewald AM, Novak MD, Pollock S, Arellano M, Leoutsakos JM, Holtyn AF, Silverman K. Psychosocial Interventions to Promote Undetectable HIV Viral Loads: A Systematic Review of Randomized Clinical Trials. AIDS Behav 2022; 26:1853-1862. [PMID: 34783938 PMCID: PMC9050821 DOI: 10.1007/s10461-021-03534-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2021] [Indexed: 10/19/2022]
Abstract
Suppressing HIV viral loads to undetectable levels is essential for ending the HIV/AIDS epidemic. We evaluated randomized controlled trials aimed to increase antiretroviral medication adherence and promote undetectable viral loads among people living with HIV through November 22, 2019. We extracted data from 51 eligible interventions and analyzed the results using random effects models to compare intervention effects between groups within each intervention and across interventions. We also evaluated the relation between publication date and treatment effects. Only five interventions increased undetectable viral loads significantly. As a whole, the analyzed interventions were superior to Standard of Care in promoting undetectable viral loads. Interventions published more recently were not more effective in promoting undetectable viral loads. No treatment category consistently produced significant increases in undetectable viral loads. To end the HIV/AIDS epidemic, we should use interventions that can suppress HIV viral loads to undetectable levels.
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Affiliation(s)
- Forrest Toegel
- Department of Psychiatry and Behavioral Sciences, Center for Learning and Health, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Psychological Science, Northern Michigan University, Marquette, MI, USA
| | - Andrew M Rodewald
- Department of Psychiatry and Behavioral Sciences, Center for Learning and Health, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Matthew D Novak
- Department of Psychiatry and Behavioral Sciences, Center for Learning and Health, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sarah Pollock
- Department of Psychiatry and Behavioral Sciences, Center for Learning and Health, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Meghan Arellano
- Department of Psychiatry and Behavioral Sciences, Center for Learning and Health, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jeannie-Marie Leoutsakos
- Department of Psychiatry and Behavioral Sciences, Center for Learning and Health, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - August F Holtyn
- Department of Psychiatry and Behavioral Sciences, Center for Learning and Health, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kenneth Silverman
- Department of Psychiatry and Behavioral Sciences, Center for Learning and Health, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Department of Psychiatry and Behavioral Sciences, Center for Learning and Health, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Suite 350 East, Baltimore, MD, 21224, USA.
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Tsui S, Kennedy CE, Moulton LH, Chang LW, Farley JE, Torpey K, van Praag E, Koole O, Ford N, Wabwire-Mangen F, Denison JA. HIV care and treatment models and their association with medication possession ratio among treatment-experienced adults in three African countries. Trop Med Int Health 2021; 26:1481-1493. [PMID: 34265155 PMCID: PMC8563398 DOI: 10.1111/tmi.13654] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE How clinics structure the delivery of antiretroviral therapy (ART) services may influence patient adherence. We assessed the relationship between models of HIV care delivery and adherence as measured by medication possession ratio (MPR) among treatment-experienced adults in Tanzania, Uganda and Zambia. METHODS Eighteen clinics were grouped into three models of HIV care. Model 1-Traditional and Model 2-Mixed represented task-sharing of clinical services between physicians and clinical officers, distinguished by whether nurses played a role in clinical care; in Model 3-Task-Shifted, clinical officers and nurses shared clinical responsibilities without physicians. We assessed MPR among 3,419 patients and calculated clinic-level MPR summaries. We then calculated the mean differences of percentages and adjusted residual ratio (aRR) of the association between models of care and incomplete adherence, defined as a MPR <90%, adjusting for individual-level characteristics. RESULTS In the adjusted analysis, patients in Model 1-Traditional were more likely than patients in Model 2-Mixed to have MPR <90% (aRR = 1.60, 95% CI 1-2.48). Patients in Model 1-Traditional were no more likely than patients in Model 3-Task-Shifted to have a MPR <90% (aRR = 1.58, 95% 0.88-2.85). There was no evidence of differences in MPR <90% between Model 2-Mixed and Model 3-Task-Shifted (aRR = 0.99, 95% CI 0.59-1.66). CONCLUSION Non-physician-led ART programmes were associated with adherence levels as good as or better than physician-led ART programmes. Additional research is needed to optimise models of care to support patients on lifelong treatment.
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Affiliation(s)
- Sharon Tsui
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Caitlin E. Kennedy
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Lawrence H. Moulton
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Larry W. Chang
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
- Department of Medicine – Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Jason E. Farley
- Department of Medicine – Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, USA
- The REACH Initiative of The Johns Hopkins School of Nursing, Baltimore, USA
- University of KwaZulu Natal, Durban, South Africa
- Association of Nurses in AIDS Care, Akron, USA
| | - Kwasi Torpey
- School of Public Health, University of Ghana College of Health Sciences, Accra, Ghana
| | | | - Olivier Koole
- Clinical Sciences Department, Institute of Tropical Medicine, Antwerp, Belgium
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, UK
| | - Nathan Ford
- Dept HIV, World Health Organization, Geneva, Switzerland
| | - Fred Wabwire-Mangen
- Department of Epidemiology and Biostatistics, Makerere University School of Public Health, Kampala, Uganda
| | - Julie A. Denison
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
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Interventions to Improve Adherence to Antiretroviral Therapy (ART) in Sub-Saharan Africa: An Updated Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18052477. [PMID: 33802322 PMCID: PMC7967610 DOI: 10.3390/ijerph18052477] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 02/25/2021] [Accepted: 02/26/2021] [Indexed: 11/17/2022]
Abstract
Optimal adherence to antiretroviral therapy (ART) remains the bedrock of effective therapy and management of human immunodeficiency virus (HIV). This systematic review examines the effect of interventions in improving ART adherence in sub-Saharan Africa (SSA), which bears the largest global burden of HIV infection. In accordance with PRISMA guidelines, and based on our inclusion and exclusion criteria, PUBMED, MEDLINE, and Google Scholar databases were searched for published studies on ART adherence interventions from 2010 to 2019. Thirty-one eligible studies published between 2010 to 2019 were identified, the categories of interventions were structural, behavioral, biological, cognitive, and combination. Study characteristics varied across design, intervention type, intervention setting, country, and outcome measurements. Many of the studies were behavioral interventions conducted in hospitals with more studies being randomized controlled trial (RCT) interventions. Despite the study variations, twenty-four studies recorded improvements. Notwithstanding, more quality studies such as RCTs should be conducted, especially among key affected populations (KAPs) to control transmission of resistant strains of the virus. Reliable objective measures of adherence should replace the conventional subjective self-report. Furthermore, long-term interventions with longer duration should be considered when evaluating the effectiveness of interventions.
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Sekiziyivu BA, Bancroft E, Rodriguez EM, Sendagala S, Nasirumbi MP, Najjengo MS, Kiragga AN, Musaazi J, Musinguzi J, Sande E, Brad B, Dalal S, Byakika-Jayne T, Kambugu A. Task Shifting for Initiation and Monitoring of Antiretroviral Therapy for HIV-Infected Adults in Uganda: The SHARE Trial. J Acquir Immune Defic Syndr 2021; 86:e71-e79. [PMID: 33230029 PMCID: PMC7879828 DOI: 10.1097/qai.0000000000002567] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 10/09/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND With countries moving toward the World Health Organization's "Treat All" recommendation, there is a need to initiate more HIV-infected persons into antiretroviral therapy (ART). In resource-limited settings, task shifting is 1 approach that can address clinician shortages. SETTING Uganda. METHODS We conducted a randomized controlled trial to test if nurse-initiated and monitored ART (NIMART) is noninferior to clinician-initiated and monitored ART in HIV-infected adults in Uganda. Study participants were HIV-infected, ART-naive, and clinically stable adults. The primary outcome was a composite end point of any of the following: all-cause mortality, virological failure, toxicity, and loss to follow-up at 12 months post-ART initiation. RESULTS Over half of the study cohort (1,760) was women (54.9%). The mean age was 35.1 years (SD 9.51). Five hundred thirty-three (31.6%) participants experienced the composite end point. At 12 months post-ART initiation, nurse-initiated and monitored ART was noninferior to clinician-initiated and monitored ART. The intention-to-treat site-adjusted risk differences for the composite end point were -4.1 [97.5% confidence interval (CI): = -9.8 to 0.2] with complete case analysis and -3.4 (97.5% CI: = -9.1 to 2.5) with multiple imputation analysis. Per-protocol site-adjusted risk differences were -3.6 (97.5% CI: = -10.5 to 0.6) for complete case analysis and -3.1 (-8.8 to 2.8) for multiple imputation analysis. This difference was within hypothesized margins (6%) for noninferiority. CONCLUSIONS Nurses were noninferior to clinicians for initiation and monitoring of ART. Task shifting to trained nurses is a viable means to increase access to ART. Future studies should evaluate NIMART for other groups (e.g., children, adolescents, and unstable patients).
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Affiliation(s)
- Brian Arthur Sekiziyivu
- Research Department, Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Elizabeth Bancroft
- Division of Global HIV and TB, Centers for Disease Control and Prevention, Entebbe, Uganda
| | - Evelyn M Rodriguez
- Division of Global HIV and TB, Centers for Disease Control and Prevention, Atlanta, GA
| | - Samuel Sendagala
- Division of Global HIV and TB, Centers for Disease Control and Prevention, Entebbe, Uganda
| | | | - Marjorie Sserunga Najjengo
- Research Department, Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Agnes N Kiragga
- Research Department, Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Joseph Musaazi
- Research Department, Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Joshua Musinguzi
- AIDS Control Programme, AIDS Control Program, Ministry of Health, Kampala, Uganda
| | - Enos Sande
- Division of Global HIV and TB, Centers for Disease Control and Prevention, Entebbe, Uganda
| | - Bartholow Brad
- Division of Global HIV and TB, Centers for Disease Control and Prevention, Atlanta, GA
| | - Shona Dalal
- World Health Organization, Geneva, Switzerland ; and
| | - Tusiime Byakika-Jayne
- Department of Public Health, School of Health Sciences, Soroti University, Soroti, Uganda
| | - Andrew Kambugu
- Research Department, Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
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Phillips TK, Orrell C, Brittain K, Zerbe A, Abrams EJ, Myer L. Measuring retention in HIV care: the impact of data sources and definitions using routine data. AIDS 2020; 34:749-759. [PMID: 32004202 PMCID: PMC7109335 DOI: 10.1097/qad.0000000000002478] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Measuring retention is critical for antiretroviral therapy (ART) management and program monitoring; however, many definitions and data sources, usually from single health facilities, are used. We used routine electronic data, linked across facilities, to examine the impact of definitions and data sources on retention estimates among women in Cape Town, South Africa. DESIGN Retrospective cohort study. METHODS We compiled routine electronic laboratory, pharmacy and clinic visit data for 617 women who started ART during pregnancy (2013-2014) and estimated 24-month retention using different definitions and data sources. We used logistic regression to assess consistency of associations between risk factors and retention, and receiver operating characteristics analyses to describe how different retention estimates predict viremia at 12 months on ART. RESULTS Using all available data sources, retention ranged from 41% (no gap >180 days) to 72% (100% 12-month visit constancy). Laboratory data (expected infrequently) underestimated retention compared with clinic visit data that identified more than 80% of women considered retained in all definitions. In all estimates, associations with known risk factors for nonretention remained consistent and retention declined over time: 77, 65 and 58% retained using all data sources in months 6-12, 12-18 and 18-24, respectively (P < 0.001). The 180-day gap definition was most strongly associated with viremia (odds ratio 24.3 95% confidence interval 12.0-48.9, all data sources). CONCLUSION Researchers must carefully consider the most appropriate retention definition and data source depending on available data. Presenting more than one approach may be warranted to obtain estimates that are context-appropriate and comparable across settings.
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Affiliation(s)
- Tamsin K Phillips
- Division of Epidemiology & Biostatistics
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town
| | - Catherine Orrell
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Kirsty Brittain
- Division of Epidemiology & Biostatistics
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town
| | - Allison Zerbe
- ICAP at Columbia University, Mailman School of Public Health
| | - Elaine J Abrams
- ICAP at Columbia University, Mailman School of Public Health
- Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
| | - Landon Myer
- Division of Epidemiology & Biostatistics
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town
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11
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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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12
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Kim MH, Tembo TA, Mazenga A, Yu X, Myer L, Sabelli R, Flick R, Hartig M, Wetzel E, Simon K, Ahmed S, Nyirenda R, Kazembe PN, Mphande M, Mkandawire A, Chitani MJ, Markham C, Ciaranello A, Abrams EJ. The Video intervention to Inspire Treatment Adherence for Life (VITAL Start): protocol for a multisite randomized controlled trial of a brief video-based intervention to improve antiretroviral adherence and retention among HIV-infected pregnant women in Malawi. Trials 2020; 21:207. [PMID: 32075677 PMCID: PMC7031891 DOI: 10.1186/s13063-020-4131-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 02/01/2020] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Improving maternal antiretroviral therapy (ART) retention and adherence is a critical challenge facing prevention of mother-to-child transmission (PMTCT) of HIV programs. There is an urgent need for evidence-based, cost-effective, and scalable interventions to improve maternal adherence and retention that can be feasibly implemented in overburdened health systems. Brief video-based interventions are a promising but underutilized approach to this crisis. We describe a trial protocol to evaluate the effectiveness and implementation of a standardized educational video-based intervention targeting HIV-infected pregnant women that seeks to optimize their ART retention and adherence by providing a VITAL Start (Video intervention to Inspire Treatment Adherence for Life) before committing to lifelong ART. METHODS This study is a multisite parallel group, randomized controlled trial assessing the effectiveness of a brief facility-based video intervention to optimize retention and adherence to ART among pregnant women living with HIV in Malawi. A total of 892 pregnant women living with HIV and not yet on ART will be randomized to standard-of-care pre-ART counseling or VITAL Start. The primary outcome is a composite of retention and adherence (viral load < 1000 copies/ml) 12 months after starting ART. Secondary outcomes include assessments of behavioral adherence (self-reported adherence, pharmacy refill, and tenofovir diphosphate concentration), psychosocial impact, and resource utilization. We will also examine the implementation of VITAL Start via surveys and qualitative interviews with patients, partners, and health care workers and conduct cost-effectiveness analyses. DISCUSSION This is a robust evaluation of an innovative facility-based video intervention for pregnant women living with HIV, with the potential to improve maternal and infant outcomes. TRIAL REGISTRATION ClinicalTrials.gov, NCT03654898. Registered on 31 August 2018.
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Affiliation(s)
- Maria H Kim
- Baylor College of Medicine International Pediatric AIDS Initiative, Texas Children's Hospital, Houston, TX, USA. .,Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi.
| | - Tapiwa A Tembo
- Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Alick Mazenga
- Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Xiaoying Yu
- University of Texas Medical Branch at Galveston, Galveston, TX, USA
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Rachael Sabelli
- Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Robert Flick
- Baylor College of Medicine International Pediatric AIDS Initiative, Texas Children's Hospital, Houston, TX, USA.,Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Miriam Hartig
- Baylor College of Medicine International Pediatric AIDS Initiative, Texas Children's Hospital, Houston, TX, USA.,Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Elizabeth Wetzel
- Baylor College of Medicine International Pediatric AIDS Initiative, Texas Children's Hospital, Houston, TX, USA.,Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Katie Simon
- Baylor College of Medicine International Pediatric AIDS Initiative, Texas Children's Hospital, Houston, TX, USA.,Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Saeed Ahmed
- Baylor College of Medicine International Pediatric AIDS Initiative, Texas Children's Hospital, Houston, TX, USA.,Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Rose Nyirenda
- HIV Unit, Malawi Ministry of Health, Lilongwe, Malawi
| | - Peter N Kazembe
- Baylor College of Medicine International Pediatric AIDS Initiative, Texas Children's Hospital, Houston, TX, USA.,Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Mtisunge Mphande
- Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Angella Mkandawire
- Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Mike J Chitani
- Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Christine Markham
- Health Promotion & Behavioral Sciences, The University of Texas School of Public Health, Houston, TX, USA
| | - Andrea Ciaranello
- Division of Infectious Diseases, Department of Medicine; Medical Practice Evaluation Center; both at Massachusetts General Hospital, Boston, MA, USA
| | - Elaine J Abrams
- ICAP at Columbia, Mailman School of Public Health and Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
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13
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Yanes-Lane M, Dussault C, Linthwaite B, Cox J, Klein MB, Sebastiani G, Lebouché B, Kronfli N. Using the barriers and facilitators to linkage to HIV care to inform hepatitis C virus (HCV) linkage to care strategies for people released from prison: Findings from a systematic review. J Viral Hepat 2020; 27:205-220. [PMID: 31638294 DOI: 10.1111/jvh.13220] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 09/09/2019] [Accepted: 10/06/2019] [Indexed: 01/05/2023]
Abstract
Elimination of hepatitis C virus (HCV) among short-term sentenced prison populations will require improved access to HCV care and specific strategies dedicated to linkage upon release. Prison-based HCV care has lagged behind HIV care, but much can be learned from HIV studies. We performed a systematic review to identify individual-, provider- and system-level barriers and facilitators to linkage to HCV and HIV care among released inmates. We searched MEDLINE, Scopus, the Cochrane Central Register of Controlled Trials and Embase, and performed a grey literature search for English articles published up to November 2018. Two searches were conducted, one each for HCV and HIV; 323 and 684 unique articles were identified of which two and 27 studies were included, respectively. Facilitators to linkage to HCV care included social support, having an existing primary care provider, and receipt of methadone, whereas barriers included a perceived lack of healthcare information and a lack of specialized linkage to care programs. The principal facilitators to linkage to HIV care included social support, treatment for substance use and mental illness, the provision of education, case management, discharge planning and transportation assistance. Important barriers were unstable housing, age <30 years, HIV-related stigma, poor providers' attitudes and the lack of post-release reintegration assistance. While HCV care-specific studies are needed, much can be learned from linkage to HIV care studies. Ultimately, a multi-pronged approach, addressing several individual-level social determinants of health, and key provider- and system-level barriers may be an appropriate starting point for the development of HCV linkage to care strategies.
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Affiliation(s)
- Mercedes Yanes-Lane
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Camille Dussault
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Blake Linthwaite
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Joseph Cox
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Marina B Klein
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.,CIHR Canadian HIV trials Network, Vancouver, British Columbia, Canada.,Department of Medicine, Division of Infectious Diseases and Chronic Viral Illness Service, McGill University, Montreal, Quebec, Canada
| | - Giada Sebastiani
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.,Department of Medicine, Division of Infectious Diseases and Chronic Viral Illness Service, McGill University, Montreal, Quebec, Canada
| | - Bertrand Lebouché
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.,Department of Medicine, Division of Infectious Diseases and Chronic Viral Illness Service, McGill University, Montreal, Quebec, Canada.,Department of Family Medicine, McGill University, Montreal, Quebec, Canada
| | - Nadine Kronfli
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.,Department of Medicine, Division of Infectious Diseases and Chronic Viral Illness Service, McGill University, Montreal, Quebec, Canada
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14
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A Systematic Review and Meta-analysis of Antiretroviral Therapy (ART) Adherence Interventions for Women Living with HIV. AIDS Behav 2019; 23:1998-2013. [PMID: 30443806 DOI: 10.1007/s10461-018-2341-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
A systematic review and meta-analysis was conducted to determine the efficacy of women-focused ART adherence interventions. Included studies (a) reported on a behavioral ART adherence intervention for cis-women living with HIV, (b) measured ART adherence as an outcome, and (c) employed a randomized controlled trial design. Thirteen studies were included in the meta-analysis. Overall, interventions significantly improved ART adherence compared to control conditions (random-effects d = 0.82, 95% CI [0.18, 1.45], p = 0.01), however, this was largely driven by two studies that had effect sizes greater than 3 standard errors above the mean effect size. Key moderators were location, recruitment method, group-based intervention, and alteration of the healthcare system. Innovative behavioral interventions that focus on young women and adolescents, target the critical periods of pregnancy and postpartum and test the integration of multiple levels of intervention to create lasting effects on ART adherence are needed.
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15
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Brandt T, Wubneh SB, Handebo S, Debalkie G, Ayanaw Y, Alemu K, Jede F, von Knebel Doeberitz M, Bussmann H. Genital self-sampling for HPV-based cervical cancer screening: a qualitative study of preferences and barriers in rural Ethiopia. BMC Public Health 2019; 19:1026. [PMID: 31366402 PMCID: PMC6669971 DOI: 10.1186/s12889-019-7354-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 07/22/2019] [Indexed: 12/17/2022] Open
Abstract
Background In the context of WHO’s “task shifting” project and growing global consensus on primary HPV-based cervical cancer screening, self-sampling is a promising new tool to expand screening access, uptake and coverage for women worldwide. We aimed to explore perceptions and acceptability of HPV self-sampling-based cervical cancer screening among community members and health professionals in rural northwest Ethiopia and to identify preferences and socio-cultural barriers regarding self-sampling in order to design a suitable high-coverage screening intervention for a rural African setting. Methods Four community-based focus group discussions (FGD) were conducted in the rural district of Dabat, Northwest Ethiopia, each comprising 8 to 14 female participants, counting a total of 41 participants. The groups were homogenously composed in terms of their socio-economic status in the community. They included health centre attendees, community members, nurses and health development army leaders (HDAL). Two qualitative data collection experts conducted the interviews in the local language, using a FGD guide with several thematic areas. All participants granted written informed consent prior to the conduct of the interviews. As a concrete example of an existing self-sampling approach for cervical cancer screening we used the Evalyn® Brush. Results Emerging themes included (i) misconceptions and low awareness about cervical cancer among community residents and primary health care providers in rural northwest Ethiopia, (ii) stigmatization and social exclusion of affected women, (iii) delay in seeking of health care due to poor access and availability of services, and lacking of a concept of early cancer prevention, (iv) need of spousal permission, (v) fear of financial burden and (vi) fear of social marginalization. The self-sampling device was regarded to be acceptable and was judged to be easy to use for most women. The existing Ethiopian health care structure could facilitate a community approach. Conclusion Home-based self-sampling for cervical cancer screening is a socially acceptable and feasible “task shifting” method that will increase cervical cancer screening access and coverage in the Ethiopian study community. Education, awareness creation, community mobilization and family inclusion are identified as key activities to promote, implement and facilitate “task shifting” approaches like self-sampling. Electronic supplementary material The online version of this article (10.1186/s12889-019-7354-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Theresa Brandt
- Department of Applied Tumor Biology, Institute of Pathology, Heidelberg University Hospital, Im Neuenheimer Feld 224, 69120, Heidelberg, Germany.
| | - Solomon Berhe Wubneh
- Department of Gynaecology, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Simegnew Handebo
- Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Getu Debalkie
- Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Yohanes Ayanaw
- Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Kassahun Alemu
- Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.,Dabat Research Centre Health and Demographic Surveillance System, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Felix Jede
- Department of Applied Tumor Biology, Institute of Pathology, Heidelberg University Hospital, Im Neuenheimer Feld 224, 69120, Heidelberg, Germany
| | - Magnus von Knebel Doeberitz
- Department of Applied Tumor Biology, Institute of Pathology, Heidelberg University Hospital, Im Neuenheimer Feld 224, 69120, Heidelberg, Germany
| | - Hermann Bussmann
- Department of Applied Tumor Biology, Institute of Pathology, Heidelberg University Hospital, Im Neuenheimer Feld 224, 69120, Heidelberg, Germany
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16
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Fayorsey RN, Wang C, Chege D, Reidy W, Syengo M, Owino SO, Koech E, Sirengo M, Hawken MP, Abrams EJ. Effectiveness of a Lay Counselor-Led Combination Intervention for Retention of Mothers and Infants in HIV Care: A Randomized Trial in Kenya. J Acquir Immune Defic Syndr 2019; 80:56-63. [PMID: 30399035 PMCID: PMC6319592 DOI: 10.1097/qai.0000000000001882] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 09/27/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Retention of mothers and infants across the prevention of mother-to-child HIV transmission (PMTCT) continuum remains challenging. We assessed the effectiveness of a lay worker administered combination intervention compared with the standard of care (SOC) on mother-infant attrition. METHODS HIV-positive pregnant women starting antenatal care at 10 facilities in western Kenya were randomized using simple randomization to receive individualized health education, retention/adherence support, appointment reminders, and missed visit tracking vs. routine care per guidelines. The primary endpoint was attrition of mother-infant pairs at 6 months postpartum. Attrition was defined as the proportion of mother-infant pairs not retained in the clinic at 6 months postpartum because of mother or infant death or lost to follow-up. Intent-to-treat analysis was used to assess the difference in attrition. This trial is registered with ClinicalTrials.gov; NCT01962220. RESULTS From September 2013 to June 2014, 361 HIV-positive pregnant women were screened, and 340 were randomized to the intervention (n = 170) or SOC (n = 170). Median age at enrollment was 26 years (interquartile range 22-30); median gestational age was 24 weeks (interquartile range 17-28). Overall attrition of mother-infant pairs was 23.5% at 6 months postpartum. Attrition was significantly lower in the intervention arm compared with SOC (18.8% vs. 28.2%, relative risk (RR) = 0.67, 95% confidence interval: 0.45 to 0.99, P = 0.04). Overall, the proportion of mothers who were retained and virally suppressed (<1000 copies/mL) at 6 months postpartum was 54.4%, with no difference between study arms. CONCLUSIONS Provision of a combination intervention by lay counselors can decrease attrition along the PMTCT cascade in low-resource settings.
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Affiliation(s)
- Ruby N. Fayorsey
- Department of Epidemiology, ICAP at Columbia University, Mailman School of Public Health, New York, NY
| | - Chunhui Wang
- Department of Epidemiology, ICAP at Columbia University, Mailman School of Public Health, New York, NY
| | - Duncan Chege
- ICAP Kenya, Columbia University, Mailman School of Public Health, New York, NY
| | - William Reidy
- Department of Epidemiology, ICAP at Columbia University, Mailman School of Public Health, New York, NY
| | - Masila Syengo
- ICAP Kenya, Columbia University, Mailman School of Public Health, New York, NY
| | | | - Emily Koech
- ICAP Kenya, Columbia University, Mailman School of Public Health, New York, NY
- Currently, PACT Endeleza, University of Maryland, Maryland, Baltimore
- Kenya Program, Nairobi, Kenya
| | - Martin Sirengo
- National AIDS and STI Control Program, Nairobi, Kenya; and
| | - Mark P. Hawken
- ICAP Kenya, Columbia University, Mailman School of Public Health, New York, NY
| | - Elaine J. Abrams
- Department of Epidemiology, ICAP at Columbia University, Mailman School of Public Health, New York, NY
- College of Physicians and Surgeons, Columbia University, New York, NY
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17
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Ladd E, Schober M. Nurse Prescribing From the Global Vantage Point: The Intersection Between Role and Policy. Policy Polit Nurs Pract 2018; 19:40-49. [PMID: 30231768 DOI: 10.1177/1527154418797726] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Nurses around the world are increasingly prescribing and managing pharmaceutical agents. Prescribing by nurses is currently based on varying nursing roles, depending on national and regional norms and practices. Prescribing occurs within the advance practice, advanced level, and task-sharing roles, depending on the country. It is evolving both within and outside of traditional regulatory frameworks. Therefore, the purpose of this article is to describe the nurse prescribing globally among various nursing roles that support and facilitate the practice. We gathered practice, statutory, and regulatory information from gray and peer-reviewed literature, Google search and Google scholar, government websites, PubMed, and CINAHL electronic databases. In contrast to previous global policy reviews that focus primarily on high-income nations, our findings suggest that nurse prescribing occurs extensively in all six continents. Nurse prescribing within the context of advanced practice nursing occurs mostly in high-income countries. However, the predominant model of nurse prescribing from the global context occurs within the advanced level role by postbasic or postprofessional nurses. Additional nurse prescribing occurs through less formal task-sharing arrangements, primarily in low- to middle-income countries. In general, nurse prescribing is evolving rapidly around the world but within highly variable roles and regulatory frameworks. Codifying these roles by strengthening of educational and regulatory standards may serve to enhance the health system capacity, especially in low- to middle-income countries.
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Affiliation(s)
- Elissa Ladd
- 1 School of Nursing, MGH Institute of Health Professions, Boston, MA, USA
| | - Madrean Schober
- 2 Schober Global Healthcare Consulting, International Healthcare Consultants, Indianapolis, IN, USA
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18
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Marotta C, Giaquinto C, Di Gennaro F, Chhaganlal KD, Saracino A, Moiane J, Maringhini G, Pizzol D, Putoto G, Monno L, Casuccio A, Vitale F, Mazzucco W. Pathways of care for HIV infected children in Beira, Mozambique: pre-post intervention study to assess impact of task shifting. BMC Public Health 2018; 18:703. [PMID: 29879951 PMCID: PMC5992883 DOI: 10.1186/s12889-018-5646-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 05/31/2018] [Indexed: 11/25/2022] Open
Abstract
Background In 2013, Mozambique implemented task-shifting (TS) from clinical officers to maternal and child nurses to improve care for HIV positive children < 5 years old. A retrospective, pre-post intervention study was designed to evaluate effectiveness of a new pathway of care in a sample of Beira District Local Health Facilities (LHFs), the primary, local, community healthcare services. Methods The study was conducted by accessing registries of At Risk Children Clinics (ARCCs) and HIV Health Services. Two time periods, pre- and post-intervention, were compared using a set of endpoints. Variables distribution was explored using descriptive statistics. T-student, Mann Whitney and Chi-square tests were used for comparisons. Results Overall, 588 HIV infected children (F = 51.4%) were recruited, 330 belonging to the post intervention period. The mean time from referral to ARCC until initiation of ART decreased from 2.3 (± 4.4) to 1.1 (± 5.0) months after the intervention implementation (p-value: 0.000). A significant increase of Isoniazid prophylaxis (O.R.: 2.69; 95%CI: 1.7–4.15) and a decrease of both regular nutritional assessment (O.R. = 0.45; 95%CI: 0.31–0.64) and CD4 count at the beginning of ART (O.R. = 0.46; 95%CI: 0.32–0.65) were documented after the intervention. Conclusions Despite several limitations and controversial results on nutrition assessment and CD4 count at the initiation of ART reported after the intervention, it could be assumed that TS alone may play a role in the improvement of the global effectiveness of care for HIV infected children only if integrated into a wider range of public health measures.
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Affiliation(s)
- Claudia Marotta
- Department of Science for Health Promotion and Mother to Child Care "G. D'Alessandro", University of Palermo, via del vespro, 133, 90127, Palermo, Italy.
| | - Carlo Giaquinto
- Department of Women's and Children's Health, University of Padova, Padova, Italy
| | | | - Kajal D Chhaganlal
- Center for Research in Infectious Diseases, Faculty of Health Sciences, Catholic University of Mozambique, Beira, Mozambique
| | | | - Jorge Moiane
- Center for Research in Infectious Diseases, Faculty of Health Sciences, Catholic University of Mozambique, Beira, Mozambique
| | | | - Damiano Pizzol
- Operational Research Unit, Doctors with Africa, Beira, Mozambique
| | - Giovanni Putoto
- Operational Research Unit, Doctors with Africa, Padova, Italy
| | - Laura Monno
- Clinic of Infectious Diseases, University of Bari, Bari, Italy
| | - Alessandra Casuccio
- Department of Science for Health Promotion and Mother to Child Care "G. D'Alessandro", University of Palermo, via del vespro, 133, 90127, Palermo, Italy
| | - Francesco Vitale
- Department of Science for Health Promotion and Mother to Child Care "G. D'Alessandro", University of Palermo, via del vespro, 133, 90127, Palermo, Italy
| | - Walter Mazzucco
- Department of Science for Health Promotion and Mother to Child Care "G. D'Alessandro", University of Palermo, via del vespro, 133, 90127, Palermo, Italy
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19
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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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Tsui S, Denison JA, Kennedy CE, Chang LW, Koole O, Torpey K, Van Praag E, Farley J, Ford N, Stuart L, Wabwire-Mangen F. Identifying models of HIV care and treatment service delivery in Tanzania, Uganda, and Zambia using cluster analysis and Delphi survey. BMC Health Serv Res 2017; 17:811. [PMID: 29207973 PMCID: PMC5717830 DOI: 10.1186/s12913-017-2772-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 11/28/2017] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Organization of HIV care and treatment services, including clinic staffing and services, may shape clinical and financial outcomes, yet there has been little attempt to describe different models of HIV care in sub-Saharan Africa (SSA). Information about the relative benefits and drawbacks of different models could inform the scale-up of antiretroviral therapy (ART) and associated services in resource-limited settings (RLS), especially in light of expanded client populations with country adoption of WHO's test and treat recommendation. METHODS We characterized task-shifting/task-sharing practices in 19 diverse ART clinics in Tanzania, Uganda, and Zambia and used cluster analysis to identify unique models of service provision. We ran descriptive statistics to explore how the clusters varied by environmental factors and programmatic characteristics. Finally, we employed the Delphi Method to make systematic use of expert opinions to ensure that the cluster variables were meaningful in the context of actual task-shifting of ART services in SSA. RESULTS The cluster analysis identified three task-shifting/task-sharing models. The main differences across models were the availability of medical doctors, the scope of clinical responsibility assigned to nurses, and the use of lay health care workers. Patterns of healthcare staffing in HIV service delivery were associated with different environmental factors (e.g., health facility levels, urban vs. rural settings) and programme characteristics (e.g., community ART distribution or integrated tuberculosis treatment on-site). CONCLUSIONS Understanding the relative advantages and disadvantages of different models of care can help national programmes adapt to increased client load, select optimal adherence strategies within decentralized models of care, and identify differentiated models of care for clients to meet the growing needs of long-term ART patients who require more complicated treatment management.
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Affiliation(s)
- Sharon Tsui
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD USA
| | - Julie A. Denison
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD USA
| | - Caitlin E. Kennedy
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD USA
| | - Larry W. Chang
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD USA
- Department of Medicine – Infectious Diseases, Johns Hopkins University School of Medicine, 733 N. Broadway, Baltimore, MD USA
| | - Olivier Koole
- Clinical Sciences Department, Institute of Tropical Medicine, Nationalestraat 155, 2000 Antwerp, Belgium
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, Keppel St, London, UK
| | - Kwasi Torpey
- School of Public Health, University of Ghana College of Health Sciences, Legon Boundary, Accra, Ghana
| | - Eric Van Praag
- Technical Support Division, Global Health Population and Nutrition, FHI 360, Karibu St., Haile Selassie Rd., Oysterbay, Dar es Salaam, Tanzania
| | - Jason Farley
- Department of Medicine – Infectious Diseases, Johns Hopkins University School of Medicine, 733 N. Broadway, Baltimore, MD USA
- Department of Community – Public Health, Johns Hopkins University School of Nursing, 525 N. Wolfe St, Baltimore, MD USA
- University of KwaZulu Natal, King George V Ave, Durban, 4041 South Africa
- Association of Nurses in AIDS Care, 3538 Ridgewood Rd, Akron, OH USA
| | - Nathan Ford
- Dept HIV, World Health Organization, Ave. Appia 20, 1211, 27 Genève, Switzerland
| | - Leine Stuart
- FHI 360 (retired), 1825 Connecticut Ave NW, Washington, DC USA
| | - Fred Wabwire-Mangen
- Department of Epidemiology and Biostatistics, Makerere University School of Public Health, New Mulago Hill Rd, Kampala, Uganda
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Mbeye NM, Adetokunboh O, Negussie E, Kredo T, Wiysonge CS. Shifting tasks from pharmacy to non-pharmacy personnel for providing antiretroviral therapy to people living with HIV: a systematic review and meta-analysis. BMJ Open 2017; 7:e015072. [PMID: 28851770 PMCID: PMC5724105 DOI: 10.1136/bmjopen-2016-015072] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Lay people or non-pharmacy health workers with training could dispense antiretroviral therapy (ART) in resource-constrained countries, freeing up time for pharmacists to focus on more technical tasks. We assessed the effectiveness of such task-shifting in low-income and middle-income countries. METHOD We conducted comprehensive searches of peer-reviewed and grey literature. Two authors independently screened search outputs, selected controlled trials, extracted data and resolved discrepancies by consensus. We performed random-effects meta-analysis and assessed certainty of evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. RESULTS Three studies with 1993 participants met the inclusion criteria, including two cluster trials conducted in Kenya and Uganda and an individually randomised trial conducted in Brazil. We found very low certainty evidence regarding mortality due to the low number of events. Therefore, we are uncertain whether there is a true increase in mortality as the effect size suggests, or a reduction in mortality between pharmacy and non-pharmacy models of dispensing ART (risk ratio (RR) 1.86, 95% CI 0.44 to 7.95, n=1993, three trials, very low certainty evidence). There may be no differences between pharmacy and non-pharmacy models of dispensing ART on virological failure (risk ratio (RR) 0.92, 95% CI 0.73 to 1.15, n=1993, three trials, low certainty evidence) and loss to follow-up (RR 1.13, 95% CI 0.68 to 1.91, n=1993. three trials, low certainty evidence). We found some evidence that costs may be reduced for the patient and health system when task-shifting is undertaken. CONCLUSIONS The low certainty regarding the evidence implies a high likelihood that further research may find the effects of the intervention to be substantially different from our findings. If resource-constrained countries decide to shift ART dispensing and distribution from pharmacy to non-pharmacy personnel, this should be accompanied by robust monitoring and impact evaluation.
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Affiliation(s)
- Nyanyiwe Masingi Mbeye
- Cochrane South Africa, South African Medical Research Council, Cape Town, Western Cape, South Africa
- Centre for Evidence-based Health Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Olatunji Adetokunboh
- Cochrane South Africa, South African Medical Research Council, Cape Town, Western Cape, South Africa
- Centre for Evidence-based Health Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | | | - Tamara Kredo
- Cochrane South Africa, South African Medical Research Council, Cape Town, Western Cape, South Africa
- Division of Clinical Pharmacology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Charles Shey Wiysonge
- Cochrane South Africa, South African Medical Research Council, Cape Town, Western Cape, South Africa
- Centre for Evidence-based Health Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Hickey MD, Odeny TA, Petersen M, Neilands TB, Padian N, Ford N, Matthay Z, Hoos D, Doherty M, Beryer C, Baral S, Geng EH. Specification of implementation interventions to address the cascade of HIV care and treatment in resource-limited settings: a systematic review. Implement Sci 2017; 12:102. [PMID: 28784155 PMCID: PMC5547499 DOI: 10.1186/s13012-017-0630-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 07/17/2017] [Indexed: 01/23/2023] Open
Abstract
Background The global response to HIV has started over 18 million persons on life-saving antiretroviral therapy (ART)—the vast majority in low- and middle-income countries (LMIC)—yet substantial gaps remain: up to 40% of persons living with HIV (PLHIV) know their status, while another 30% of those who enter care are inadequately retained after starting treatment. Identifying strategies to enhance use of treatment is urgently needed, but the conceptualization and specification of implementation interventions is not always complete. We sought to assess the completeness of intervention reporting in research to advance uptake of treatment for HIV globally. Methods We carried out a systematic review to identify interventions targeting the adult HIV care cascade in LMIC dating from 1990 to 2017. We identified components of each intervention as “intervention types” to decompose interventions into common components. We grouped “intervention types” into a smaller number of more general “implementation approaches” to aid summarization. We assessed the reporting of six intervention characteristics adapted from the implementation science literature: the actor, action, action dose, action temporality, action target, and behavioral target in each study. Findings In 157 unique studies, we identified 34 intervention “types,” which were empirically grouped into six generally understandable “approaches.” Overall, 42% of interventions defined the actor, 64% reported the action, 41% specified the intervention “dose,” 43% reported action temporality, 61% defined the action target, and 69% reported a target behavior. Average completeness of reporting varied across approaches from a low of 50% to a high of 72%. Dimensions that involved conceptualization of the practices themselves (e.g., actor, dose, temporality) were in general less well specified than consequences (e.g., action target and behavioral target). Implications The conceptualization and Reporting of implementation interventions to advance treatment for HIV in LMIC is not always complete. Dissemination of standards for reporting intervention characteristics can potentially promote transparency, reproducibility, and scientific accumulation in the area of implementation science to address HIV in low- and middle-income countries. Electronic supplementary material The online version of this article (doi:10.1186/s13012-017-0630-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Matthew D Hickey
- Division of General Internal Medicine, San Francisco General Hospital, Department of Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA
| | | | - Maya Petersen
- Department of Biostatistics and Epidemiology, School of Public Health, University of California, Berkeley, CA, USA
| | - Torsten B Neilands
- Center for AIDS Prevention Studies, Department of Medicine, UCSF, San Francisco, CA, USA
| | - Nancy Padian
- Department of Biostatistics and Epidemiology, School of Public Health, University of California, Berkeley, CA, USA
| | - Nathan Ford
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | | | - David Hoos
- Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Meg Doherty
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | - Chris Beryer
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Stefan Baral
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Elvin H Geng
- Division of ID HIV and Global Medicine, San Francisco General Hospital, Department of Medicine, UCSF, Building 80, 6th Floor, 1001 Potrero Avenue, San Francisco, CA, 94110, USA.
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Naburi H, Ekström AM, Mujinja P, Kilewo C, Manji K, Biberfeld G, Sando D, Chalamila G, Bärnighausen T. The potential of task-shifting in scaling up services for prevention of mother-to-child transmission of HIV: a time and motion study in Dar es Salaam, Tanzania. HUMAN RESOURCES FOR HEALTH 2017; 15:35. [PMID: 28549434 PMCID: PMC5446714 DOI: 10.1186/s12960-017-0207-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Accepted: 05/03/2017] [Indexed: 05/13/2023]
Abstract
BACKGROUND In many African countries, prevention of mother-to-child transmission of HIV (PMTCT) services are predominantly delivered by nurses. Although task-shifting is not yet well established, community health workers (CHWs) are often informally used as part of PMTCT delivery. According to the 2008 World Health Organization (WHO) Task-shifting Guidelines, many PMTCT tasks can be shifted from nurses to CHWs. METHODS The aim of this time and motion study in Dar es Salaam, Tanzania, was to estimate the potential of task-shifting in PMTCT service delivery to reduce nurses' workload and health system costs. The time used by nurses to accomplish PMTCT activities during antenatal care (ANC) and postnatal care (PNC) visits was measured. These data were then used to estimate the costs that could be saved by shifting tasks from nurses to CHWs in the Tanzanian public-sector health system. RESULTS A total of 1121 PMTCT-related tasks carried out by nurses involving 179 patients at ANC and PNC visits were observed at 26 health facilities. The average time of the first ANC visit was the longest, 54 (95% confidence interval (CI) 42-65) min, followed by the first PNC visit which took 29 (95% CI 26-32) minutes on average. ANC and PNC follow-up visits were substantially shorter, 15 (95% CI 14-17) and 13 (95% CI 11-16) minutes, respectively. During both the first and the follow-up ANC visits, 94% of nurses' time could be shifted to CHWs, while 84% spent on the first PNC visit and 100% of the time spent on the follow-up PNC visit could be task-shifted. Depending on CHW salary estimates, the cost savings due to task-shifting in PMTCT ranged from US$ 1.3 to 2.0 (first ANC visit), US$ 0.4 to 0.6 (ANC follow-up visit), US$ 0.7 to 1.0 (first PNC visit), and US$ 0.4 to 0.5 (PNC follow-up visit). CONCLUSIONS Nurses working in PMTCT spend large proportions of their time on tasks that could be shifted to CHWs. Such task-shifting could allow nurses to spend more time on specialized PMTCT tasks and can substantially reduce the average cost per PMTCT patient.
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Affiliation(s)
- Helga Naburi
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
- Department of Public Health Sciences, Global Health (IHCAR), Karolinska Institutet, Stockholm, Sweden
| | - Anna Mia Ekström
- Department of Public Health Sciences, Global Health (IHCAR), Karolinska Institutet, Stockholm, Sweden
- Department of Infectious Diseases, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Phares Mujinja
- School of Public Health, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Charles Kilewo
- Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Karim Manji
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Gunnel Biberfeld
- Department of Public Health Sciences, Global Health (IHCAR), Karolinska Institutet, Stockholm, Sweden
| | - David Sando
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA United States of America
- Management and Development for Health (MDH), Dar es Salaam, Tanzania
| | - Guerino Chalamila
- Management and Development for Health (MDH), Dar es Salaam, Tanzania
| | - Till Bärnighausen
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA United States of America
- Africa Health Research Institute (AHRI), Somkhele, South Africa
- Institute for Public Health, University of Heidelberg, Heidelberg, Germany
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Haberer JE, Sabin L, Amico KR, Orrell C, Galárraga O, Tsai AC, Vreeman RC, Wilson I, Sam‐Agudu NA, Blaschke TF, Vrijens B, Mellins CA, Remien RH, Weiser SD, Lowenthal E, Stirratt MJ, Sow PS, Thomas B, Ford N, Mills E, Lester R, Nachega JB, Bwana BM, Ssewamala F, Mbuagbaw L, Munderi P, Geng E, Bangsberg DR. Improving antiretroviral therapy adherence in resource-limited settings at scale: a discussion of interventions and recommendations. J Int AIDS Soc 2017; 20:21371. [PMID: 28630651 PMCID: PMC5467606 DOI: 10.7448/ias.20.1.21371] [Citation(s) in RCA: 117] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Accepted: 02/24/2017] [Indexed: 01/01/2023] Open
Abstract
Introduction: Successful population-level antiretroviral therapy (ART) adherence will be necessary to realize both the clinical and prevention benefits of antiretroviral scale-up and, ultimately, the end of AIDS. Although many people living with HIV are adhering well, others struggle and most are likely to experience challenges in adherence that may threaten virologic suppression at some point during lifelong therapy. Despite the importance of ART adherence, supportive interventions have generally not been implemented at scale. The objective of this review is to summarize the recommendations of clinical, research, and public health experts for scalable ART adherence interventions in resource-limited settings. Methods: In July 2015, the Bill and Melinda Gates Foundation convened a meeting to discuss the most promising ART adherence interventions for use at scale in resource-limited settings. This article summarizes that discussion with recent updates. It is not a systematic review, but rather provides practical considerations for programme implementation based on evidence from individual studies, systematic reviews, meta-analyses, and the World Health Organization Consolidated Guidelines for HIV, which include evidence from randomized controlled trials in low- and middle-income countries. Interventions are categorized broadly as education and counselling; information and communication technology-enhanced solutions; healthcare delivery restructuring; and economic incentives and social protection interventions. Each category is discussed, including descriptions of interventions, current evidence for effectiveness, and what appears promising for the near future. Approaches to intervention implementation and impact assessment are then described. Results and discussion: The evidence base is promising for currently available, effective, and scalable ART adherence interventions for resource-limited settings. Numerous interventions build on existing health care infrastructure and leverage available resources. Those most widely studied and implemented to date involve peer counselling, adherence clubs, and short message service (SMS). Many additional interventions could have an important impact on ART adherence with further development, including standardized counselling through multi-media technology, electronic dose monitoring, decentralized and differentiated models of care, and livelihood interventions. Optimal targeting and tailoring of interventions will require improved adherence measurement. Conclusions: The opportunity exists today to address and resolve many of the challenges to effective ART adherence, so that they do not limit the potential of ART to help bring about the end of AIDS.
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Affiliation(s)
- Jessica E. Haberer
- Massachusetts General Hospital Global Health, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Lora Sabin
- Department of Global Health, Center for Global Health and Department, Boston University School of Public Health, Boston, MA, USA
| | - K. Rivet Amico
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Catherine Orrell
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Omar Galárraga
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Alexander C. Tsai
- Chester M. Pierce, MD Division of Global Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Rachel C. Vreeman
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Ira Wilson
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Nadia A. Sam‐Agudu
- Clinical Department, Institute of Human Virology Nigeria, Abuja, Nigeria
- Institute of Human Virology and Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Terrence F. Blaschke
- Department of Medicine and Clinical Pharmacology, Stanford University School of Medicine, Stanford, CA, USA
| | - Bernard Vrijens
- Department of Biostatistics, University of Liège, Liège, Wallonia, Belgium
- WestRock Healthcare, Sion, Switzerland
| | - Claude A. Mellins
- HIV Center for Clinical and Behavioral Studies, NYSPI and Department of Psychiatry, Columbia; University, New York, NY, USA
| | - Robert H. Remien
- HIV Center for Clinical and Behavioral Studies, NYSPI and Department of Psychiatry, Columbia; University, New York, NY, USA
| | - Sheri D. Weiser
- Division of HIV, ID and Global Medicine, Department of Medicine, University of California, San Francisco, CA, USA
| | - Elizabeth Lowenthal
- Departments of Pediatrics and Epidemiology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Michael J. Stirratt
- Division of AIDS Research, National Institute of Mental Health, Bethesda, MD, USA
| | - Papa Salif Sow
- Bill and Melinda Gates Foundation, Seattle, WA, USA
- Department of Infectious diseases, University of Dakar, Dakar, Sénégal
| | | | - Nathan Ford
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | - Edward Mills
- Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Richard Lester
- Division of Infectious Diseases, Department of Medicine, University of British Columbia
| | - Jean B. Nachega
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Bosco Mwebesa Bwana
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Fred Ssewamala
- Columbia University School of Social Work & School of International and Public Affairs, New York, NY, USA
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Paula Munderi
- HIV Care Research Program, Medical Research Council, Uganda Virus Research Institute, Entebbe, Uganda
| | - Elvin Geng
- Division of HIV, Infectious Disease and Global Medicine, San Francisco General Hospital, Department of Medicine, University of California, San Francisco, CA, USA
| | - David R. Bangsberg
- Oregon Health & Sciences University‐Portland State University School of Public Health, Portland, OR, USA
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Use of peers to improve adherence to antiretroviral therapy: a global network meta-analysis. J Int AIDS Soc 2016; 19:21141. [PMID: 27914185 PMCID: PMC5134746 DOI: 10.7448/ias.19.1.21141] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Revised: 10/06/2016] [Accepted: 10/24/2016] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION It is unclear whether using peers can improve adherence to antiretroviral therapy (ART). To construct the World Health Organization's global guidance on adherence interventions, we conducted a systematic review and network meta-analysis to determine the effectiveness of using peers for achieving adequate adherence and viral suppression. METHODS We searched for randomized clinical trials of peer-based interventions to promote adherence to ART in HIV populations. We searched six electronic databases from inception to July 2015 and major conference abstracts within the last three years. We examined the outcomes of adherence and viral suppression among trials done worldwide and those specific to low- and middle-income countries (LMIC) using pairwise and network meta-analyses. RESULTS AND DISCUSSION Twenty-two trials met the inclusion criteria. We found similar results between pairwise and network meta-analyses, and between the global and LMIC settings. Peer supporter+Telephone was superior in improving adherence than standard-of-care in both the global network (odds-ratio [OR]=4.79, 95% credible intervals [CrI]: 1.02, 23.57) and the LMIC settings (OR=4.83, 95% CrI: 1.88, 13.55). Peer support alone, however, did not lead to improvement in ART adherence in both settings. For viral suppression, we found no difference of effects among interventions due to limited trials. CONCLUSIONS Our analysis showed that peer support leads to modest improvement in adherence. These modest effects may be due to the fact that in many settings, particularly in LMICs, programmes already include peer supporters, adherence clubs and family disclosures for treatment support. Rather than introducing new interventions, a focus on improving the quality in the delivery of existing services may be a more practical and effective way to improve adherence to ART.
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Kanters S, Park JJH, Chan K, Socias ME, Ford N, Forrest JI, Thorlund K, Nachega JB, Mills EJ. Interventions to improve adherence to antiretroviral therapy: a systematic review and network meta-analysis. Lancet HIV 2016; 4:e31-e40. [PMID: 27863996 DOI: 10.1016/s2352-3018(16)30206-5] [Citation(s) in RCA: 170] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 09/13/2016] [Accepted: 09/16/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND High adherence to antiretroviral therapy is crucial to the success of HIV treatment. We evaluated comparative effectiveness of adherence interventions with the aim of informing the WHO's global guidance on interventions to increase adherence. METHODS For this systematic review and network meta-analysis, we searched for randomised controlled trials of interventions that aimed to improve adherence to antiretroviral therapy regimens in populations with HIV. We searched Cochrane Central Register of Controlled Trials, Embase, and MEDLINE for reports published up to July 16, 2015, and searched major conference abstracts from Jan 1, 2013, to July 16, 2015. We extracted data from eligible studies for study characteristics, interventions, patients' characteristics at baseline, and outcomes for the study populations of interest. We used network meta-analyses to compare adherence and viral suppression for all study settings (global network) and for studies in low-income and middle-income countries only (LMIC network). FINDINGS We obtained data from 85 trials with 16 271 participants. Short message service (SMS; text message) interventions were superior to standard of care in improving adherence in both the global network (odds ratio [OR] 1·48, 95% credible interval [CrI] 1·00-2·16) and in the LMIC network (1·49, 1·04-2·09). Multiple interventions showed generally superior adherence to single interventions, indicating additive effects. For viral suppression, only cognitive behavioural therapy (1·46, 1·05-2·12) and supporter interventions (1·28, 1·01-1·71) were superior to standard of care in the global network; none of the interventions improved viral response in the LMIC network. For the global network, the time discrepancy (whether the study outcome was measured during or after intervention was withdrawn) was an effect modifier for both adherence to antiretroviral therapy (coefficient estimate -0·43, 95% CrI -0·75 to -0·11) and viral suppression (-0·48; -0·84 to -0·12), suggesting that the effects of interventions wane over time. INTERPRETATION Several interventions can improve adherence and viral suppression; generally, their estimated effects were modest and waned over time. FUNDING WHO.
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Affiliation(s)
- Steve Kanters
- Precision Global Health, Vancouver, BC, Canada; School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | | | - Keith Chan
- Precision Global Health, Vancouver, BC, Canada
| | - Maria Eugenia Socias
- Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada; BC Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, BC, Canada
| | - Nathan Ford
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | - Jamie I Forrest
- Precision Global Health, Vancouver, BC, Canada; School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | | | - Jean B Nachega
- Departments of Epidemiology and International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Departments of Epidemiology, Infectious Diseases, and Microbiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
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Nachega JB, Adetokunboh O, Uthman OA, Knowlton AW, Altice FL, Schechter M, Galárraga O, Geng E, Peltzer K, Chang LW, Van Cutsem G, Jaffar SS, Ford N, Mellins CA, Remien RH, Mills EJ. Community-Based Interventions to Improve and Sustain Antiretroviral Therapy Adherence, Retention in HIV Care and Clinical Outcomes in Low- and Middle-Income Countries for Achieving the UNAIDS 90-90-90 Targets. Curr HIV/AIDS Rep 2016; 13:241-55. [PMID: 27475643 PMCID: PMC5357578 DOI: 10.1007/s11904-016-0325-9] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Little is known about the effect of community versus health facility-based interventions to improve and sustain antiretroviral therapy (ART) adherence, virologic suppression, and retention in care among HIV-infected individuals in low- and middle-income countries (LMICs). We systematically searched four electronic databases for all available randomized controlled trials (RCTs) and comparative cohort studies in LMICs comparing community versus health facility-based interventions. Relative risks (RRs) for pre-defined adherence, treatment engagement (linkage and retention in care), and relevant clinical outcomes were pooled using random effect models. Eleven cohort studies and eleven RCTs (N = 97,657) were included. Meta-analysis of the included RCTs comparing community- versus health facility-based interventions found comparable outcomes in terms of ART adherence (RR = 1.02, 95 % CI 0.99 to 1.04), virologic suppression (RR = 1.00, 95 % CI 0.98 to 1.03), and all-cause mortality (RR = 0.93, 95 % CI 0.73 to 1.18). The result of pooled analysis from the RCTs (RR = 1.03, 95 % CI 1.01 to 1.06) and cohort studies (RR = 1.09, 95 % CI 1.03 to 1.15) found that participants assigned to community-based interventions had statistically significantly higher rates of treatment engagement. Two studies found community-based ART delivery model either cost-saving or cost-effective. Community- versus facility-based models of ART delivery resulted in at least comparable outcomes for clinically stable HIV-infected patients on treatment in LMICs and are likely to be cost-effective.
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Affiliation(s)
- Jean B Nachega
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA.
- Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, South Africa.
- Johns Hopkins University, Baltimore, MD, USA.
| | - Olatunji Adetokunboh
- Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, South Africa
| | - Olalekan A Uthman
- Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, South Africa
- Warwick Medical School, The University of Warwick, Coventry, UK
| | | | | | | | - Omar Galárraga
- Brown University School of Public Health, Providence, RI, USA
| | - Elvin Geng
- University of California, San Francisco, CA, USA
| | - Karl Peltzer
- Mahidol University, Salaya, Thailand
- University of Limpopo, Polokwane, South Africa
- Human Sciences Research Council, Pretoria, South Africa
| | | | | | | | - Nathan Ford
- World Health Organization, Geneva, Switzerland
| | - Claude A Mellins
- HIV Center for Clinical and Behavioral Studies, Columbia University, New York, NY, USA
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Genberg BL, Shangani S, Sabatino K, Rachlis B, Wachira J, Braitstein P, Operario D. Improving Engagement in the HIV Care Cascade: A Systematic Review of Interventions Involving People Living with HIV/AIDS as Peers. AIDS Behav 2016; 20:2452-2463. [PMID: 26837630 DOI: 10.1007/s10461-016-1307-z] [Citation(s) in RCA: 110] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Improving patient engagement in HIV care is critical for maximizing the impact of antiretroviral therapy (ART). We conducted a systematic review of studies that used HIV-positive peers to bolster linkage, retention, and/or adherence to ART. We searched articles published and indexed in Pubmed, PsycINFO, and CINAHL between 1996 and 2014. Peers were required to be HIV-positive. Studies were restricted to those published in English. Nine studies with n = 4658 participants met the inclusion criteria. Peer-based interventions were predominantly focused on improving adherence to ART, or evaluations of retention and adherence via viral suppression. Five (56 %) were conducted in sub-Saharan Africa. Overall findings were mixed on the impact of peers on ART adherence, viral suppression, and mortality. While positive effects of peer interventions on improving linkage and retention were found, there were limited studies assessing these outcomes. Additional research is warranted to demonstrate the impact of peers on linkage and retention in diverse populations.
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Geldsetzer P, Yapa HMN, Vaikath M, Ogbuoji O, Fox MP, Essajee SM, Negussie EK, Bärnighausen T. A systematic review of interventions to improve postpartum retention of women in PMTCT and ART care. J Int AIDS Soc 2016; 19:20679. [PMID: 27118443 PMCID: PMC4846797 DOI: 10.7448/ias.19.1.20679] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 03/21/2016] [Accepted: 03/31/2016] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION The World Health Organization recommends lifelong antiretroviral therapy (ART) for all pregnant and breastfeeding women living with HIV. Effective transitioning from maternal and child health to ART services, and long-term retention in ART care postpartum is crucial to the successful implementation of lifelong ART for pregnant women. This systematic review aims to determine which interventions improve (1) retention within prevention of mother-to-child HIV transmission (PMTCT) programmes after birth, (2) transitioning from PMTCT to general ART programmes in the postpartum period, and (3) retention of postpartum women in general ART programmes. METHODS We searched Medline, Embase, ISI Web of Knowledge, the regional World Health Organization databases and conference abstracts for data published between 2002 and 2015. The quality of all included studies was assessed using the GRADE criteria. RESULTS AND DISCUSSION After screening 8324 records, we identified ten studies for inclusion in this review, all of which were from sub-Saharan Africa except for one from the United Kingdom. Two randomized trials found that phone calls and/or text messages improved early (six to ten weeks) postpartum retention in PMTCT. One cluster-randomized trial and three cohort studies found an inconsistent impact of different levels of integration between antenatal care/PMTCT and ART care on postpartum retention. The inconsistent results of the four identified studies on care integration are likely due to low study quality, and heterogeneity in intervention design and outcome measures. Several randomized trials on postpartum retention in HIV care are currently under way. CONCLUSIONS Overall, the evidence base for interventions to improve postpartum retention in HIV care is weak. Nevertheless, there is some evidence that phone-based interventions can improve retention in PMTCT in the first one to three months postpartum.
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Affiliation(s)
- Pascal Geldsetzer
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA;
| | - H Manisha N Yapa
- Africa Centre for Population Health, University of KwaZulu Natal, Mtubatuba, South Africa
| | - Maria Vaikath
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Osondu Ogbuoji
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Matthew P Fox
- Center for Global Health & Development, Boston University, Boston, MA, USA
| | | | | | - Till Bärnighausen
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Africa Centre for Population Health, University of KwaZulu Natal, Mtubatuba, South Africa
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Dynes M, Tison L, Johnson C, Verani A, Zuber A, Riley PL. Regulatory Advances in 11 Sub-Saharan Countries in Year 3 of the African Health Profession Regulatory Collaborative for Nurses and Midwives (ARC). J Assoc Nurses AIDS Care 2015; 27:285-96. [PMID: 27086189 DOI: 10.1016/j.jana.2015.11.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 11/10/2015] [Indexed: 11/30/2022]
Abstract
Sub-Saharan Africa carries the greatest burden of the HIV pandemic. Enhancing the supply and use of human resources through policy and regulatory reform is a key action needed to improve the quality of HIV services in this region. In year 3 of the African Health Profession Regulatory Collaborative for Nurses and Midwives (ARC), a President's Emergency Plan for AIDS Relief initiative, 11 country teams of nursing and midwifery leaders ("Quads") received small grants to carry out regulatory improvement projects. Four countries advanced a full stage on the Regulatory Function Framework (RFF), a staged capability maturity model used to evaluate progress in key regulatory functions. While the remaining countries did not advance a full stage on the RFF, important gains were noted. The year-3 evaluation highlighted limitations of the ARC evaluation strategy to capture nuanced progress and provided insight into how the RFF might be adapted for future use.
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Walter J, Molfino L, Moreno V, Edwards CG, Chissano M, Prieto A, Bocharnikova T, Antierens A, Lujan J. Long-term outcomes of a pediatric HIV treatment program in Maputo, Mozambique: a cohort study. Glob Health Action 2015; 8:26652. [PMID: 26287397 PMCID: PMC4541076 DOI: 10.3402/gha.v8.26652] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Revised: 06/30/2015] [Accepted: 07/14/2015] [Indexed: 11/14/2022] Open
Abstract
Objective To describe long-term treatment outcomes of a pediatric HIV cohort in Mozambique. Design Retrospective analysis of routine monitoring data. Setting Secondary health care facilities in the Chamanculo Health District of Maputo. Subjects A total of 1,335 antiretroviral treatment (ART) naïve children <15 years of age enrolled in HIV care between 2002 and 2010. Intervention HIV care, ART (since 2003), task shifting to lower cadre nurses, counseling by lay counselors, active patient tracing, nutritional support, support by a psychologist, targeted viral load testing, and switch to second-line treatment. Main outcome measures Kaplan–Meier estimates for retention in care (RIC), CD4 cell percentage, body mass index for age z-score, and adjusted incidence rate ratios for attrition (death or loss to follow-up) as calculated by Poisson regression. Results The RIC at 6 years in the pre-ART cohort was 44% (95% confidence interval: 38–49), and the one at 8 years in the ART cohort was 70% (64–75). Risk factors for attrition included young age, low CD4 percentage, underweight, active tuberculosis, and enrollment/treatment initiation after 2006. The mean CD4 percentage increased strongly at 1 year on treatment and remained high thereafter. The body mass index for age z-score sharply increased at 1 year after treatment initiation before stabilizing at pre-ART levels thereafter. Conclusions Good clinical and immunological treatment outcomes up to 8 years of follow-up on ART can be achieved in a context of shortage of health workers and a high level of task-shifting approach.
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Affiliation(s)
- Jan Walter
- Médecins Sans Frontières, Maputo, Mozambique
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Katende D, Mutungi G, Baisley K, Biraro S, Ikoona E, Peck R, Smeeth L, Hayes R, Munderi P, Grosskurth H. Readiness of Ugandan health services for the management of outpatients with chronic diseases. Trop Med Int Health 2015; 20:1385-95. [PMID: 26095069 PMCID: PMC4758403 DOI: 10.1111/tmi.12560] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Traditionally, health systems in sub-Saharan Africa have focused on acute conditions. Few data exist on the readiness of African health facilities (HFs) to address the growing burden of chronic diseases (CDs), specifically chronic, non-communicable diseases (NCDs). METHODS A stratified random sample of 28 urban and rural Ugandan HFs was surveyed to document the burden of selected CDs by analysing the service statistics, service availability and service readiness using a modified WHO Service Availability and Readiness Assessment questionnaire. Knowledge, skills and practice in the management of CDs of 222 health workers were assessed through a self-completed questionnaire. RESULTS Among adult outpatient visits at hospitals, 33% were for CDs including HIV vs. 14% and 4% at medium-sized and small health centres, respectively. Many HFs lacked guidelines, diagnostic equipment and essential medicines for the primary management of CDs; training and reporting systems were weak. Lower-level facilities routinely referred patients with hypertension and diabetes. HIV services accounted for most CD visits and were stronger than NCD services. Systems were weaker in lower-level HFs. Non-doctor clinicians and nurses lacked knowledge and experience in NCD care. CONCLUSION Compared with higher level HFs, lower-level ones are less prepared and little used for CD care. Health systems in Uganda, particularly lower-level HFs, urgently need improvement in managing common NCDs to cope with the growing burden. This should include the provision of standard guidelines, essential diagnostic equipment and drugs, training of health workers, supportive supervision and improved referral systems. Substantially better HIV basic service readiness demonstrates that improved NCD care is feasible.
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Affiliation(s)
- David Katende
- Medical Research Council/Uganda Virus Research Institute Uganda Research Unit on AIDS, Entebbe, Uganda
| | | | - Kathy Baisley
- MRC Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Samuel Biraro
- Medical Research Council/Uganda Virus Research Institute Uganda Research Unit on AIDS, Entebbe, Uganda
| | | | - Robert Peck
- Mwanza Intervention Trials Unit and Weill Bugando School of Medicine, Mwanza, Tanzania
| | - Liam Smeeth
- Department of Non-communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Richard Hayes
- MRC Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Paula Munderi
- Medical Research Council/Uganda Virus Research Institute Uganda Research Unit on AIDS, Entebbe, Uganda
| | - Heiner Grosskurth
- MRC Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
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Manabe YC, Zawedde-Muyanja S, Burnett SM, Mugabe F, Naikoba S, Coutinho A. Rapid improvement in passive tuberculosis case detection and tuberculosis treatment outcomes after implementation of a bundled laboratory diagnostic and on-site training intervention targeting mid-level providers. Open Forum Infect Dis 2015; 2:ofv030. [PMID: 26034778 PMCID: PMC4438908 DOI: 10.1093/ofid/ofv030] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 03/02/2015] [Indexed: 11/25/2022] Open
Abstract
Background. Tuberculosis (TB) control is a public health priority with 3 million cases unrecognized by the public health system each year. We assessed the impact of improved TB diagnostics and on-site training on TB case detection and treatment outcomes in rural healthcare facilities. Methods. Fluorescence microscopy, Xpert MTB/RIF, and on-site training were introduced at 10 healthcare facilities. Using quasi-experimental methods, these 10 intervention healthcare facilities were compared with 2 controls and their own performance the previous year. Results. From January to October 2012, 186 357 and 32 886 outpatients were seen in the 10 intervention and 2 control facilities, respectively. The intervention facilities had a 52.04% higher proportion of presumptive TB cases with a sputum examination (odds ratio [OR] = 12.65; 95% confidence interval [CI], 5.60–28.55). After adjusting for age group and gender, the proportion of smear-positive patients initiated on treatment was 37.76% higher in the intervention than in the control facilities (adjusted OR [AOR], 7.59; 95% CI, 2.19–26.33). After adjusting for the factors above, as well as human immunodeficiency virus and TB retreatment status, the proportion of TB cases who completed treatment was 29.16% higher (AOR, 4.89; 95% CI, 2.24–10.67) and the proportion of TB cases who were lost to follow-up was 66.98% lower (AOR, 0.04; 95% CI, 0.01–0.09). When compared with baseline performance, the intervention facilities had a significantly higher proportion of presumptive TB cases with a sputum examination (64.70% vs 3.44%; OR, 23.95; 95% CI, 12.96–44.25), and these facilities started 56.25% more smear-positive TB cases on treatment during the project period (AOR, 15.36; 95% CI, 6.57–35.91). Conclusions. Optimizing the existing healthcare workforce through a bundled diagnostics and on-site training intervention for nonphysician healthcare workers will rapidly improve TB case detection and outcomes towards global targets.
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Affiliation(s)
- Yukari C Manabe
- Infectious Diseases Institute , Makerere College of Health Sciences , Kampala , Uganda ; Division of Infectious Diseases, Department of Medicine , Johns Hopkins University School of Medicine , Baltimore, Maryland
| | | | - Sarah M Burnett
- Accordia Global Health Foundation , Washington, District of Columbia
| | - Frank Mugabe
- National Tuberculosis and Leprosy Program , Uganda Ministry of Health
| | - Sarah Naikoba
- Infectious Diseases Institute , Makerere College of Health Sciences , Kampala , Uganda
| | - Alex Coutinho
- Infectious Diseases Institute , Makerere College of Health Sciences , Kampala , Uganda
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Sigaloff KCE, Lange JMA, Montaner J. Global response to HIV: treatment as prevention, or treatment for treatment? Clin Infect Dis 2015; 59 Suppl 1:S7-S11. [PMID: 24926037 DOI: 10.1093/cid/ciu267] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
The concept of "treatment as prevention" has emerged as a means to curb the global HIV epidemic. There is, however, still ongoing debate about the evidence on when to start antiretroviral therapy in resource-poor settings. Critics have brought forward multiple arguments against a "test and treat" approach, including the potential burden of such a strategy on weak health systems and a presumed lack of scientific support for individual patient benefit of early treatment initiation. In this article, we highlight the societal and individual advantages of treatment as prevention in resource-poor settings. We argue that the available evidence renders the discussion on when to start antiretroviral therapy unnecessary and that, instead, efforts should be aimed at offering treatment as soon as possible.
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Affiliation(s)
- Kim C E Sigaloff
- Department of Global Health Department of Internal Medicine, Academic Medical Center, University of Amsterdam Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
| | | | - Julio Montaner
- British Columbia Center for Excellence in HIV/AIDS, Vancouver, Canada
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Elison NK, Verani AR, McCarthy C. National nursing and midwifery legislation in countries of South-East Asia with high HIV burdens. WHO South East Asia J Public Health 2015; 4:12-19. [PMID: 26568920 DOI: 10.4103/2224-3151.206615] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
This paper analyses nursing and midwifery legislation in high HIV-burden countries of the World Health Organization (WHO) South-East Asia Region, with respect to global standards, and suggests areas that could be further examined to strengthen the nursing and midwifery professions and HIV service delivery. To provide universal access to HIV/AIDS prevention, care and treatment, sufficient numbers of competent human resources for health are required. Competence in this context means possession and use of requisite knowledge and skills to fulfil the role delineated in scopes of practice. Traditionally, the purpose of professional regulation has been to set standards that ensure the competence of practising health workers, such as nurses and midwives. One particularly powerful form of professional regulation is assessed here: national legislation in the form of nursing and midwifery acts. Five countries of the WHO South-East Asia Region account for more than 99% of the region's HIV burden: India, Indonesia, Myanmar, Nepal and Thailand. Online legislative archives were searched to obtain the most recent national nursing and midwifery legislation from these five countries. Indonesia was the only country included in this review without a national nursing and midwifery act. The national nursing and midwifery acts of India, Myanmar, Nepal and Thailand were all fairly comprehensive, containing between 15 and 20 of the 21 elements in the International Council of Nurses Model Nursing Act. Legislation in Myanmar and Thailand partially delineates nursing scopes of practice, thereby providing greater clarity concerning professional expectations. Continuing education was the only element not included in any of these four countries' legislation. Countries without a nursing and midwifery act may consider developing one, in order to facilitate professional regulation of training and practice. Countries considering reform to their existing nursing acts may benefit from comparing their legislation with that of other similarly situated countries and with global standards. Countries interested in improving the sustainability of scale-up for HIV services may benefit from a greater understanding of the manner in which nursing and midwifery is regulated, be it through continuing education, scopes of practice or other relevant requirements for training, registration and licensing.
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Affiliation(s)
- Nila K Elison
- School of Public Health, Georgia State University, Atlanta, Georgia, United States of America
| | - Andre R Verani
- Division of Global HIV/AIDS, US Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, United States of America
| | - Carey McCarthy
- Division of Global HIV/AIDS, US Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, United States of America
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Interventions to promote adherence to antiretroviral therapy in Africa: a network meta-analysis. Lancet HIV 2014; 1:e104-11. [PMID: 26424119 DOI: 10.1016/s2352-3018(14)00003-4] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Accepted: 11/04/2014] [Indexed: 12/23/2022]
Abstract
BACKGROUND Adherence to antiretroviral therapy (ART) is necessary for the improvement of the health of patients and for public health. We sought to determine the comparative effectiveness of different interventions for improving ART adherence in HIV-infected people living in Africa. METHODS We searched for randomised trials of interventions to promote antiretroviral adherence within adults in Africa. We searched AMED, CINAHL, Embase, Medline (via PubMed), and ClinicalTrials.gov from inception to Oct 31, 2014, with the terms "HIV", "ART", "adherence", and "Africa". We created a network of the interventions by pooling the published and individual patients' data for comparable treatments and comparing them across the individual interventions with Bayesian network meta-analyses. The primary outcome was adherence defined as the proportion of patients meeting trial defined criteria; the secondary endpoint was viral suppression. FINDINGS We obtained data for 14 randomised controlled trials, with 7110 patients. Interventions included daily and weekly short message service (SMS; text message) messaging, calendars, peer supporters, alarms, counselling, and basic and enhanced standard of care (SOC). Compared with SOC, we found distinguishable improvement in self-reported adherence with enhanced SOC (odds ratio [OR] 1·46, 95% credibility interval [CrI] 1·06-1·98), weekly SMS messages (1·65, 1·25-2·18), counselling and SMS combined (2·07, 1·22-3·53), and treatment supporters (1·83, 1·36-2·45). We found no compelling evidence for the remaining interventions. Results were similar when using viral suppression as an outcome, although the network contained less evidence than that for adherence. Treatment supporters with enhanced SOC (1·46, 1·09-1·97) and weekly SMS messages (1·55, 1·01-2·38) were significantly better than basic SOC. INTERPRETATION Several recommendations for improving adherence are unsupported by the available evidence. These findings can inform future intervention choices for improving ART adherence in low-income settings. FUNDING None.
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Ford N, Swan T, Beyer P, Hirnschall G, Easterbrook P, Wiktor S. Simplification of antiviral hepatitis C virus therapy to support expanded access in resource-limited settings. J Hepatol 2014; 61:S132-8. [PMID: 25443341 DOI: 10.1016/j.jhep.2014.09.019] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 09/16/2014] [Accepted: 09/16/2014] [Indexed: 02/07/2023]
Abstract
Currently, access to treatment for HCV is limited, with treatment rates lowest in the more resource-limited countries, including those countries with the highest prevalence. The use of oral DAAs has the potential to provide treatment at scale by offering opportunities to simplify drug regimens, laboratory requirements, and service delivery models. Key desirable characteristics of future HCV treatment regimens include high efficacy, tolerability, pan-genotype activity, short treatment duration, oral therapy, affordability, and availability as fixed-dose combination. Using such a regimen, HCV treatment delivery could be greatly simplified. Treatment could be initiated following confirmation of the presence of viraemia, with an initial assessment of the stage of liver disease. A combination DAA therapy that is safe and effective across genotypes could remove the need for genotyping and intermediary viral load assessments for response-guided therapy and reduce the need for adverse event monitoring. Simpler, safer, shorter therapy will also facilitate simplified service delivery, including task shifting, decentralization, and integration of treatment and care. The opportunity to scale up HCV treatment using such delivery approaches will depend on efforts needed to guarantee that the new DAAs are affordable in low-income settings. This will require the engagement of all stakeholders, ranging from the companies developing these new treatments, WHO and other international organizations, including procurement and funding mechanisms, governments and civil society.
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Affiliation(s)
- Nathan Ford
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | | | - Peter Beyer
- Department of Essential Medicines and Health Products, World Health Organization, Geneva, Switzerland
| | | | | | - Stefan Wiktor
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland.
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Kredo T, Adeniyi FB, Bateganya M, Pienaar ED. Task shifting from doctors to non-doctors for initiation and maintenance of antiretroviral therapy. Cochrane Database Syst Rev 2014; 2014:CD007331. [PMID: 24980859 PMCID: PMC11214583 DOI: 10.1002/14651858.cd007331.pub3] [Citation(s) in RCA: 109] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND The high levels of healthcare worker shortage is recognised as a severe impediment to increasing patients' access to antiretroviral therapy. This is particularly of concern where the burden of disease is greatest and the access to trained doctors is limited.This review aims to better inform HIV care programmes that are currently underway, and those planned, by assessing if task-shifting care from doctors to non-doctors provides both high quality and safe care for all patients requiring antiretroviral treatment. OBJECTIVES To evaluate the quality of initiation and maintenance of HIV/AIDS care in models that task shift care from doctors to non-doctors. SEARCH METHODS We conducted a comprehensive search to identify all relevant studies regardless of language or publication status (published, unpublished, in press, and in progress) from 1 January 1996 to 28 March 2014, with major HIV/AIDS conferences searched 23 May 2014. We had also contacted relevant organizations and researchers. Key words included MeSH terms and free-text terms relevant to 'task shifting', 'skill mix', 'integration of tasks', 'service delivery' and 'health services accessibility'. SELECTION CRITERIA We included controlled trials (randomised or non-randomised), controlled-before and after studies, and cohort studies (prospective or retrospective) comparing doctor-led antiretroviral therapy delivery to delivery that included another cadre of health worker other than a doctor, for initiating treatment, continuing treatment, or both, in HIV infected patients. DATA COLLECTION AND ANALYSIS Two authors independently screened titles, abstracts and descriptor terms of the results of the electronic search and applied our eligibility criteria using a standardized eligibility form to full texts of potentially eligible or uncertain abstracts. Two reviewers independently extracted data on standardized data extraction forms. Where possible, data were pooled using random effects meta-analysis. We assessed evidence quality with GRADE methodology. MAIN RESULTS Ten studies met our inclusion criteria, all of which were conducted in Africa. Of these four were randomised controlled trials while the remaining six were cohort studies.From the trial data, when nurses initiated and provided follow-up HIV therapy, there was high quality evidence of no difference in death at one year, unadjusted risk ratio was 0.96 (95% CI 0.82 to 1.12), one trial, cluster adjusted n = 2770. There was moderate quality evidence of lower rates of losses to follow-up at one year, relative risk of 0.73 (95% CI 0.55 to 0.97). From the cohort data, there was low quality evidence that there may be an increased risk of death in the task shifting group, relative risk 1.23 (95% CI 1.14 to 1.33, two cohorts, n = 39 160) and very low quality data reporting no difference in patients lost to follow-up between groups, relative risk 0.30 (95% CI 0.05 to 1.94).From the trial data, when doctors initiated therapy and nurses provided follow-up, there was moderate quality evidence that there is probably no difference in death compared with doctor-led care at one year, relative risk of 0.89 (95% CI 0.59 to 1.32), two trials, cluster adjusted n = 4332. There was moderate quality evidence that there is probably no difference in the numbers of patients lost to follow-up at one year, relative risk 1.27 (95% CI 0.92 to 1.77), P = 0.15. From the cohort data, there is very low quality data that death at one year may be lower in the task shifting group, relative risk 0.19 (95% CI 0.05 to 0.78), one cohort, n = 2772, and very low quality evidence that loss to follow-up was reduced, relative risk 0.34 (95% CI 0.18 to 0.66).From the trial data, for maintenance therapy delivered in the community there was moderate quality evidence that there is probably no difference in mortality when doctors deliver care in the hospital or specially trained field workers provide home-based maintenance care and antiretroviral therapy at one year, relative risk 1.0 (95% CI 0.62 to 1.62), 1 trial, cluster adjusted n = 559. There is moderate quality evidence from this trial that losses to follow-up are probably no different at one year, relative risk 0.52 (0.12 to 2.3), P = 0.39. The cohort studies did not report on one year follow-up for these outcomes.Across the studies that reported on virological and immunological outcomes, there was no clear evidence of difference whether a doctor or nurse or clinical officer delivered therapy. Three studies report on costs to patients, indicating a reduction in travel costs to treatment facilities where task shifting was occurring closer to patients homes. There is conflicting evidence regarding the relative cost to the health system, as implementation of the strategy may increase costs. The two studies reporting the patient and staff perceptions of the quality of care, report good acceptability of the service by patients, and general acceptance by doctors of the shifting of roles. One trial reported on the time to initiation of antiretroviral therapy, finding no clear evidence of a difference between groups. The same trial reports on new diagnosis of tuberculosis which favours nurse initiation of HIV care for increasing the numbers of diagnoses of tuberculosis made. AUTHORS' CONCLUSIONS Our review found moderate quality evidence that shifting responsibility from doctors to adequately trained and supported nurses or community health workers for managing HIV patients probably does not decrease the quality of care and, in the case of nurse initiated care, may decrease the numbers of patients lost to follow-up.
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Affiliation(s)
- Tamara Kredo
- South African Medical Research CouncilSouth African Cochrane CentrePO Box 19070TygerbergCape TownWestern CapeSouth Africa7505
| | - Folasade B Adeniyi
- Stellenbosch UniversityCentre for Evidence‐based Health Care, Faculty of Medicine and Health SciencesFrancie v ZylTygerbergCape TownSouth Africa
| | - Moses Bateganya
- University of WashingtonDepartment of Global Health901 Boren Avenue, Suite 1100SeattleWAUSA98104
| | - Elizabeth D Pienaar
- South African Medical Research CouncilSouth African Cochrane CentrePO Box 19070TygerbergCape TownWestern CapeSouth Africa7505
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Green A, de Azevedo V, Patten G, Davies MA, Ibeto M, Cox V. Clinical mentorship of nurse initiated antiretroviral therapy in Khayelitsha, South Africa: a quality of care assessment. PLoS One 2014; 9:e98389. [PMID: 24887260 PMCID: PMC4041881 DOI: 10.1371/journal.pone.0098389] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Accepted: 05/01/2014] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION To combat the AIDS epidemic and increase HIV treatment access, the South African government implemented a nurse-based, doctor-supported model of care that decentralizes administration of antiretroviral treatment (ART) for HIV positive patients through nurse initiated and managed ART. Médecins Sans Frontières (MSF) implemented a mentorship programme to ensure successful task-shifting, subsequently assessing the quality of clinical care provided by nurses. METHODS A before-after cross-sectional study was conducted on nurses completing the mentorship programme in Khayelitsha, South Africa, from February 2011-September 2012. Routine clinical data from 229 patient folders and 21 self-assessment questionnaires was collected to determine the number of patients initiated on ART by nurses; quality of ART management before-after mentorship; patient characteristics for doctor and nurse ART initiations; and nurse self-assessments after mentorship. RESULTS Twenty one nurses were authorized by one nurse mentor with one part-time medical officer's support, resulting in nurses initiating 77% of ART eligible patients. Improvements in ART management were found for drawing required bloods (91% vs 99%, p = 0.03), assessing adherence (50% vs 78%, p<0.001) and WHO staging (63% vs 91%, p<0.001). Nurse ART initiation indicators were successfully completed at 95-100% for 11 of 16 indicators: clinical presentation; patient weight; baseline blood work (CD4, creatinine, haemoglobin); STI screening; WHO stage, correlating medical history; medications prescribed appropriately; ART start date; and documented return date. Doctors initiated more patients with TB/HIV co-infection and WHO Stage 3 and 4 disease than nurses. Nurse confidence improved for managing HIV-infected children and pregnant women, blood result interpretation and long-term side effects. CONCLUSIONS Implementation of a clinical mentorship programme in Khayelitsha led to nurse initiation of a majority of eligible patients, enabling medical officers to manage complex cases. As mentorship can increase clinical confidence and enhance professional development, it should be considered essential for universal ART access in resource limited settings.
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Affiliation(s)
- Ann Green
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Gabriela Patten
- Médecins Sans Frontières Khayelitsha, Khayelitsha, South Africa
| | - Mary-Ann Davies
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Mary Ibeto
- Médecins Sans Frontières Khayelitsha, Khayelitsha, South Africa
| | - Vivian Cox
- Médecins Sans Frontières Khayelitsha, Khayelitsha, South Africa
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Task shifting for the delivery of pediatric antiretroviral treatment: a systematic review. J Acquir Immune Defic Syndr 2014; 65:414-22. [PMID: 24583614 DOI: 10.1097/qai.0000000000000024] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pediatric antiretroviral treatment coverage in resource-limited settings continues to lag behind adults. Task shifting is an effective approach broadly used for adults, which some countries have also adopted for children, but implementation is limited by lack of confidence and skills among nonspecialist staff. METHODS A systematic review was conducted by combining key terms for task shifting, antiretroviral therapy (ART), and children. Five databases and two conferences were searched from inception till August 01, 2013. RESULTS Eight observational studies provided outcome data for 11,828 children who received ART from nonphysician providers across 10 countries in sub-Saharan Africa. The cumulative pooled proportion of deaths was 3.2% [95% confidence interval (CI): 2.0 to 4.5] at 6 months, 4.6% (95% CI: 2.1 to 7.1) at 12 months, 6.2% (95% CI: 3.7 to 8.8) at 24 months, and 5.9% (95% CI: 3.5 to 8.3) at 36 months. Mortality and loss to follow-up in task-shifting programs were comparable to those reported by programs providing doctor- or specialist-led care. CONCLUSIONS Our review suggests that task shifting of ART care can result in outcomes comparable to routine physician care, and this approach should be considered as part of a strategy to scale-up pediatric treatment. Specialist care will remain important for management of sick patients and complicated cases. Further qualitative research is needed to inform optimal implementation of task shifting for pediatric patients.
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