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Leno NN, Guilavogui F, Camara A, Kadio KJJO, Guilavogui T, Diallo TS, Diallo MA, Leno DWA, Ricarte B, Koita Y, Kaba L, Ahiatsi A, Touré N, Traoré P, Chaloub S, Kamano A, Vicente CA, Delamou A, Cissé M. Retention and Predictors of Attrition Among People Living With HIV on Antiretroviral Therapy in Guinea: A 13-Year Historical Cohort Study in Nine Large-Volume Sites. Int J Public Health 2023; 68:1605929. [PMID: 37519433 PMCID: PMC10372218 DOI: 10.3389/ijph.2023.1605929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 05/22/2023] [Indexed: 08/01/2023] Open
Abstract
Objectives: The objective of this study was to estimate the retention rate of patients in an ART program and identify the predictors of attrition. Methods: This was a historical cohort study of HIV patients who started ART between September 2007 and April 2020, and were followed up on for at least 6 months in nine large-volume sites. Kaplan Meier techniques were used to estimate cumulative retention and attrition probabilities. Cox proportional hazards models were used to identify predictors of attrition. Results: The cumulative probability of retention at 12 and 24 months was 76.2% and 70.2%, respectively. The attrition rate after a median follow-up time of 3.1 years was 35.2%, or an incidence of 11.4 per 100 person-years. Having initiated ART between 2012 and 2015; unmarried status; having initiated ART with CD4 count <100 cells/μL; and having initiated ART at an advanced clinical stage were factors significantly associated with attrition. Conclusion: The retention rate in our study is much lower than the proposed national target (90%). Studies to understand the reasons for loss to follow-up are needed.
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Affiliation(s)
- Niouma Nestor Leno
- African Center of Excellence for Prevention and Control of Communicable Diseases (CEA-PCMT), Faculty of Health Sciences and Techniques, Gamal Abdel Nasser University, Conakry, Guinea
- Department of Public Health, Faculty of Health Sciences and Techniques, Gamal Abdel Nasser University Conakry, Conakry, Guinea
- Ministry of Health, Conakry, Guinea
| | - Foromo Guilavogui
- Department of Public Health, Faculty of Health Sciences and Techniques, Gamal Abdel Nasser University Conakry, Conakry, Guinea
- Ministry of Health, Conakry, Guinea
- National AIDS and Hepatitis Control Program, Conakry, Guinea
| | - Alioune Camara
- African Center of Excellence for Prevention and Control of Communicable Diseases (CEA-PCMT), Faculty of Health Sciences and Techniques, Gamal Abdel Nasser University, Conakry, Guinea
- Department of Public Health, Faculty of Health Sciences and Techniques, Gamal Abdel Nasser University Conakry, Conakry, Guinea
- National Malaria Control Program, Conakry, Guinea
| | | | - Timothé Guilavogui
- Department of Public Health, Faculty of Health Sciences and Techniques, Gamal Abdel Nasser University Conakry, Conakry, Guinea
- Ministry of Health, Conakry, Guinea
| | | | | | | | | | - Youssouf Koita
- National AIDS and Hepatitis Control Program, Conakry, Guinea
| | - Laye Kaba
- National AIDS and Hepatitis Control Program, Conakry, Guinea
| | - Arnold Ahiatsi
- National AIDS and Hepatitis Control Program, Conakry, Guinea
| | - Nagnouman Touré
- National AIDS and Hepatitis Control Program, Conakry, Guinea
| | - Pascal Traoré
- Department of Public Health, Faculty of Health Sciences and Techniques, Gamal Abdel Nasser University Conakry, Conakry, Guinea
| | | | - André Kamano
- NGO “Doctors Without Borders Belgium”, Conakry, Guinea
| | | | - Alexandre Delamou
- African Center of Excellence for Prevention and Control of Communicable Diseases (CEA-PCMT), Faculty of Health Sciences and Techniques, Gamal Abdel Nasser University, Conakry, Guinea
- Department of Public Health, Faculty of Health Sciences and Techniques, Gamal Abdel Nasser University Conakry, Conakry, Guinea
- National Center for Education and Research in Rural Health Maférinyah, Forécariah, Guinea
| | - Mohamed Cissé
- Department of Dermatology and Sexually Transmitted Infections, Gamal Abdel Nasser University of Conakry Faculty of Health Sciences and Techniques, Conakry, Guinea
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Li L, Lin C, Pham LQ, Nguyen DB, Le TA. Networking community health workers for service integration: role of social media. AIDS Care 2023; 35:1030-1036. [PMID: 35014579 PMCID: PMC9271530 DOI: 10.1080/09540121.2021.2019668] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 12/08/2021] [Indexed: 10/19/2022]
Abstract
Community health workers (CHW) can play an active role in providing integrated HIV and harm reduction services. We used social media to create a virtual network among Vietnamese CHW. This paper reports CHW's social media engagement and the relationships with other work-related indicators. Sixty CHW participated in an intervention for integrated HIV/drug use service delivery. Following two in-person sessions, Facebook groups were established for CHW to share information, seek consultation, and refer patients. CHW's levels of online engagements were tracked for six months and linked to their service provision confidence, interaction with patients and other providers, and job satisfaction. The CHW made 181 posts, which received 557 comments and 1,607 reactions during the six months. Among the 60 CHW, 22 (36.6%) had three or more posts, 19 (31.7%) had one or two posts, and 19 (31.7%) had no post. Comparing the baseline and 6-month follow-up data, we observed that those who posted three or more times showed better service provision confidence (p = 0.0081), more interaction with providers in other settings (p = 0.0071), and higher job satisfaction (p = 0.0268). Our study suggests using social media to engage CHW in virtual communications to improve service provision in communities.
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Affiliation(s)
- Li Li
- Semel Institute for Neuroscience and Human Behavior – Center for Community Health, University of California, Los Angeles, CA, U.S.A
| | - Chunqing Lin
- Semel Institute for Neuroscience and Human Behavior – Center for Community Health, University of California, Los Angeles, CA, U.S.A
| | - Loc Quang Pham
- Semel Institute for Neuroscience and Human Behavior – Center for Community Health, University of California, Los Angeles, CA, U.S.A
| | - Diep Bich Nguyen
- Semel Institute for Neuroscience and Human Behavior – Center for Community Health, University of California, Los Angeles, CA, U.S.A
| | - Tuan Anh Le
- National Institute of Hygiene and Epidemiology, Hanoi, Vietnam
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Golub SA, Fikslin RA. Recognizing and disrupting stigma in implementation of HIV prevention and care: a call to research and action. J Int AIDS Soc 2022; 25 Suppl 1:e25930. [PMID: 35818865 PMCID: PMC9274207 DOI: 10.1002/jia2.25930] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 05/04/2022] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION There is robust evidence that stigma negatively impacts both people living with HIV and those who might benefit from HIV prevention interventions. Within healthcare settings, research on HIV stigma has focused on intra-personal processes (i.e. knowledge or internalization of community-level stigma that might limit clients' engagement in care) or inter-personal processes (i.e. stigmatized interactions with service providers). Intersectional approaches to stigma call us to examine the ways that intersecting systems of power and oppression produce stigma not only at the individual and interpersonal levels, but also within healthcare service delivery systems. This commentary argues for the importance of analysing and disrupting the way in which stigma may be (intentionally or unintentionally) enacted and sustained within HIV service implementation, that is the policies, protocols and strategies used to deliver HIV prevention and care. We contend that as HIV researchers and practitioners, we have failed to fully specify or examine the mechanisms through which HIV service implementation itself may reinforce stigma and perpetuate inequity. DISCUSSION We apply Link and Phelan's five stigma components (labelling, stereotyping, separation, status loss and discrimination) as a framework for analysing the way in which stigma manifests in existing service implementation and for evaluating new HIV implementation strategies. We present three examples of common HIV service implementation strategies and consider their potential to activate stigma components, with particular attention to how our understanding of these dynamics can be enhanced and expanded by the application of intersectional perspectives. We then provide a set of sample questions that can be used to develop and test novel implementation strategies designed to mitigate against HIV-specific and intersectional stigma. CONCLUSIONS This commentary is a theory-informed call to action for the assessment of existing HIV service implementation, for the development of new stigma-reducing implementation strategies and for the explicit inclusion of stigma reduction as a core outcome in implementation research and evaluation. We argue that these strategies have the potential to make critical contributions to our ability to address many system-level form stigmas that undermine health and wellbeing for people living with HIV and those in need of HIV prevention services.
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Affiliation(s)
- Sarit A Golub
- Department of Psychology, Hunter College, New York, New York, USA.,Basic and Applied Social Psychology, The Graduate Center of the City University of New York, New York, New York, USA.,Hunter Alliance for Research and Translation, Hunter College, New York, New York, USA.,Einstein-Rockefeller-CUNY Center for AIDS Research (ERC-CFAR), New York, New York, USA
| | - Rachel A Fikslin
- Department of Psychology, Hunter College, New York, New York, USA.,Basic and Applied Social Psychology, The Graduate Center of the City University of New York, New York, New York, USA.,Hunter Alliance for Research and Translation, Hunter College, New York, New York, USA
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Bulstra CA, Hontelez JAC, Otto M, Stepanova A, Lamontagne E, Yakusik A, El-Sadr WM, Apollo T, Rabkin M, Atun R, Bärnighausen T. Integrating HIV services and other health services: A systematic review and meta-analysis. PLoS Med 2021; 18:e1003836. [PMID: 34752477 PMCID: PMC8577772 DOI: 10.1371/journal.pmed.1003836] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 10/05/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Integration of HIV services with other health services has been proposed as an important strategy to boost the sustainability of the global HIV response. We conducted a systematic and comprehensive synthesis of the existing scientific evidence on the impact of service integration on the HIV care cascade, health outcomes, and cost-effectiveness. METHODS AND FINDINGS We reviewed the global quantitative empirical evidence on integration published between 1 January 2010 and 10 September 2021. We included experimental and observational studies that featured both an integration intervention and a comparator in our review. Of the 7,118 unique peer-reviewed English-language studies that our search algorithm identified, 114 met all of our selection criteria for data extraction. Most of the studies (90) were conducted in sub-Saharan Africa, primarily in East Africa (55) and Southern Africa (24). The most common forms of integration were (i) HIV testing and counselling added to non-HIV services and (ii) non-HIV services added to antiretroviral therapy (ART). The most commonly integrated non-HIV services were maternal and child healthcare, tuberculosis testing and treatment, primary healthcare, family planning, and sexual and reproductive health services. Values for HIV care cascade outcomes tended to be better in integrated services: uptake of HIV testing and counselling (pooled risk ratio [RR] across 37 studies: 1.67 [95% CI 1.41-1.99], p < 0.001), ART initiation coverage (pooled RR across 19 studies: 1.42 [95% CI 1.16-1.75], p = 0.002), time until ART initiation (pooled RR across 5 studies: 0.45 [95% CI 0.20-1.00], p = 0.050), retention in HIV care (pooled RR across 19 studies: 1.68 [95% CI 1.05-2.69], p = 0.031), and viral suppression (pooled RR across 9 studies: 1.19 [95% CI 1.03-1.37], p = 0.025). Also, treatment success for non-HIV-related diseases and conditions and the uptake of non-HIV services were commonly higher in integrated services. We did not find any significant differences for the following outcomes in our meta-analyses: HIV testing yield, ART adherence, HIV-free survival among infants, and HIV and non-HIV mortality. We could not conduct meta-analyses for several outcomes (HIV infections averted, costs, and cost-effectiveness), because our systematic review did not identify sufficient poolable studies. Study limitations included possible publication bias of studies with significant or favourable findings and comparatively weak evidence from some world regions and on integration of services for key populations in the HIV response. CONCLUSIONS Integration of HIV services and other health services tends to improve health and health systems outcomes. Despite some scientific limitations, the global evidence shows that service integration can be a valuable strategy to boost the sustainability of the HIV response and contribute to the goal of 'ending AIDS by 2030', while simultaneously supporting progress towards universal health coverage.
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Affiliation(s)
- Caroline A. Bulstra
- Heidelberg Institute of Global Health, Heidelberg University Medical Center, Heidelberg, Germany
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
- * E-mail:
| | - Jan A. C. Hontelez
- Heidelberg Institute of Global Health, Heidelberg University Medical Center, Heidelberg, Germany
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Moritz Otto
- Heidelberg Institute of Global Health, Heidelberg University Medical Center, Heidelberg, Germany
| | - Anna Stepanova
- Heidelberg Institute of Global Health, Heidelberg University Medical Center, Heidelberg, Germany
| | - Erik Lamontagne
- Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland
- Aix-Marseille School of Economics, CNRS, EHESS, Centrale Marseille, Aix-Marseille University, Les Milles, France
| | - Anna Yakusik
- Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland
| | - Wafaa M. El-Sadr
- ICAP, Columbia University, New York, New York, United States of America
| | | | - Miriam Rabkin
- ICAP, Columbia University, New York, New York, United States of America
| | | | - Rifat Atun
- Harvard Center for Population and Development Studies, Harvard University, Cambridge, Massachusetts, United States of America
| | - Till Bärnighausen
- Heidelberg Institute of Global Health, Heidelberg University Medical Center, Heidelberg, Germany
- Harvard Center for Population and Development Studies, Harvard University, Cambridge, Massachusetts, United States of America
- Africa Health Research Institute, KwaZulu-Natal, South Africa
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Kiwuwa-Muyingo S, Abongomera G, Mambule I, Senjovu D, Katabira E, Kityo C, Gibb DM, Ford D, Seeley J. Lessons for test and treat in an antiretroviral programme after decentralisation in Uganda: a retrospective analysis of outcomes in public healthcare facilities within the Lablite project. Int Health 2020; 12:429-443. [PMID: 31730168 DOI: 10.1093/inthealth/ihz090] [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] [Received: 05/11/2019] [Revised: 07/20/2019] [Accepted: 08/27/2019] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND We describe the decentralisation of antiretroviral therapy (ART) alongside Option B+ roll-out in public healthcare facilities in the Lablite project in Uganda. Lessons learned will inform programmes now implementing universal test and treat (UTT). METHODS Routine data were retrospectively extracted from ART registers between October 2012 and March 2015 for all adults and children initiating ART at two primary care facilities (spokes) and their corresponding district hospitals (hubs) in northern and central Uganda. We describe ART initiation over time and retention and use of Cox models to explore risk factors for attrition due to mortality and loss to follow-up. Results from tracing of patients lost to follow-up were used to correct retention estimates. RESULTS Of 2100 ART initiations, 1125 were in the north, including 944 (84%) at the hub and 181 (16%) at the spokes; children comprised 95 (10%) initiations at the hubs and 14 (8%) at the spokes. Corresponding numbers were 642 (66%) at the hub and 333 (34%) at the spokes in the central region (77 [12%] and 22 [7%], respectively, in children). Children <3 y of age comprised the minority of initiations in children at all sites. Twenty-three percent of adult ART initiations at the north hub were Option B+ compared with 45% at the spokes (25% and 65%, respectively, in the central region). Proportions retained in care in the north hub at 6 and 12 mo were 92% (95% CI 90 to 93) and 89% (895% CI 7 to 91), respectively. Corresponding corrected estimates in the north spokes were 87% (95% CI 78 to 93) and 82% (95% CI 72 to 89), respectively. In the central hub, corrected estimates were 84% (95% CI 80 to 87) and 78% (95% CI 74 to 82), and were 89% (95% CI 77.9 to 95.1) and 83% (95% CI 64.1 to 92.9) at the spokes, respectively. Among adults newly initiating ART, being older was independently associated with a lower risk of attrition (adjusted hazard ratio [aHR] 0.93 per 5 y [95% CI 0.88 to 0.97]). Other independent risk factors included initiating with a tenofovir-based regimen vs zidovudine (aHR 0.60 [95% CI 0.46 to 0.77]), year of ART initiation (2013 aHR 1.55 [95% CI 1.21 to 1.97], ≥2014 aHR 1.41 [95% CI 1.06 to 1.87]) vs 2012, hub vs spoke (aHR 0.35 [95% CI 0.29 to 0.43]) and central vs north (aHR 2.28 [95% CI 1.86 to 2.81]). Independently, patient type was associated with retention. CONCLUSIONS After ART decentralisation, people living with human immunodeficiency virus (HIV) were willing to initiate ART in rural primary care facilities. Retention on ART was variable across facilities and attrition was higher among some groups, including younger adults and women initiating ART during pregnancy/breastfeeding. Interventions to support these groups are required to optimise benefits of expanded access to HIV services under UTT.
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Affiliation(s)
- S Kiwuwa-Muyingo
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine, Uganda Research Unit, PO Box 49, Entebbe, Uganda
- African Population and Health Research Center, P.O. Box 10787-00100, Kitisuru, Nairobi, Kenya
| | - G Abongomera
- Joint Clinical Research Centre, PO Box 10005, Kampala, Uganda
- University of Zurich, Epidemiology, Biostatistics and Prevention Institute, CH 8001, Zurich, Switzerland
| | - I Mambule
- Infectious Diseases Institute, Makerere University, PO Box 22418, Kampala, Uganda
| | - D Senjovu
- Infectious Diseases Institute, Makerere University, PO Box 22418, Kampala, Uganda
| | - E Katabira
- Infectious Diseases Institute, Makerere University, PO Box 22418, Kampala, Uganda
| | - C Kityo
- Joint Clinical Research Centre, PO Box 10005, Kampala, Uganda
| | - D M Gibb
- Medical Research Council, Clinical Trials Unit at University College London, London WC1V 6LH, UK
| | - D Ford
- Medical Research Council, Clinical Trials Unit at University College London, London WC1V 6LH, UK
| | - J Seeley
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine, Uganda Research Unit, PO Box 49, Entebbe, Uganda
- Global Health and Development Department, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
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Sande O, Burtscher D, Kathumba D, Tweya H, Phiri S, Gugsa S. Patient and nurse perspectives of a nurse-led community-based model of HIV care delivery in Malawi: a qualitative study. BMC Public Health 2020; 20:685. [PMID: 32410597 PMCID: PMC7227037 DOI: 10.1186/s12889-020-08721-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 04/16/2020] [Indexed: 11/10/2022] Open
Abstract
Background Differentiated models of care (DMOC) are used to make antiretroviral therapy (ART) accessible to people living with HIV (PLHIV). In Malawi, Lighthouse Trust has piloted various DMOCs aimed at providing quality care while reducing personal and logistical barriers when accessing clinic-based healthcare. One of the approaches was community-based provision of ART by nurses to stable patients. Methods To explore how the nurse-led community ART programme (NCAP) is perceived, we interviewed eighteen purposively selected patients receiving ART through NCAP and the four nurses providing the community-based health care. Information obtained from them was complemented with observations by the study team. Interviews were recorded and transcribed. Data was analysed using manual coding and thematic analysis. Results Through the NCAP, patients were able to save money on transportation and the time it took them to travel to a health facility. Caseloads and waiting times were also reduced, which made patients more comfortable and gave nurses the time to conduct thorough consultations. Closer relationships were built between patients and care providers, creating a space for more open conversations (although this required care providers to set clear boundaries and stick to schedule). Patients’ nutritional needs and concerns related to stigma remain a concern, while operational issues affect the quality of the services provided in the community. Considerations for community-led healthcare programmes include the provision of transportation for care providers; the physical structure of community sites (in regard to private spaces); the timely consolidation of data collected in the field to a central database; and the need for care providers to cover multiple facility-based staff roles. Conclusions The patients interviewed in this study preferred the NCAP approach to the facility-based model of care because it saved them money on transport, reduced waiting-times, and allowed for a more thorough consultation, while continuing to provide quality HIV care. However, when considering a community-level DMOC approach, certain factors – including staff transportation and workload – must be taken into consideration and purposefully planned.
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Affiliation(s)
| | - Doris Burtscher
- Médecins Sans Frontières, Vienna Evaluation Unit, Vienna, Austria
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Teasdale CA, Abrams EJ, Yuengling KA, Lamb MR, Wang C, Vitale M, Hawken M, Melaku Z, Nuwagaba-Biribonwoha H, El-Sadr WM. Expansion and scale-up of HIV care and treatment services in four countries over ten years. PLoS One 2020; 15:e0231667. [PMID: 32298331 PMCID: PMC7162457 DOI: 10.1371/journal.pone.0231667] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 03/27/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Scale-up and expansion of antiretroviral therapy (ART) for people living with HIV (PLHIV) have been a global priority for more than 15 years. METHODS We describe PLHIV at enrollment in care and ART initiation in Ethiopia, Kenya, Mozambique and Tanzania from 2005-2014 and report on enrollment location, CD4 count and loss to follow-up (LTF), death, and combined attrition (LTF and death) pre- and post-ART initiation over time. Pre-ART outcomes were estimated using competing risk and post-ART using Kaplan-Meier estimators; LTF defined as no visit within six months pre-ART and 12 months after ART start. RESULTS From 2005-2014, 884,328 PLHIV enrolled in care at 350 health facilities, median age was 32.0 years (interquartile range [IQR] 26.0-42.0), and majority were female (66.5%). The proportion of PLHIV enrolled at primary and rural facilities increased from 12.9% and 15.3% in 2005-2006 to 43.5% and 41.7% in 2013-2014 (p<0.0001). Median CD4+ cell count at enrollment increased from 171 cell/mm3 in 2005-2006 (IQR 71-339) to 289 cell/mm3 in 2013-2014 (IQR 133-485) (p<0.0001). A total of 460,758 (57.4%) PLHIV initiated treatment. Cumulative risk of LTF for PLHIV prior to ART initiation 12 months after enrollment was 33.5% (95%CI 33.36-33.58) and 21.98% (95%CI 21.9-22.1) after ART initiation. Pregnant women and the youngest PLHIV group had the highest attrition after ART initiation, at 24 months 40.8% (95%CI 40.1-41.6) of pregnant women and 47.4% (95%CI 46.4-48.4) of PLHIV 15-19 years were not retained. Attrition at 12 months after enrollment among PLHIV regardless of ART status was 38.5% (95%CI 38.4-38.6). CONCLUSION Over 10 years of HIV scale-up in four sub-Saharan African countries, close to a million PLHIV were enrolled in care increasingly at rural and primary facilities with increasing CD4 count. Loss to follow-up from HIV care remains alarmingly high, particularly among pregnant women and younger PLHIV.
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Affiliation(s)
- Chloe A Teasdale
- Department of Epidemiology & Biostatistics, CUNY Graduate School of Public Health and Health Policy, New York, NY, United States of America
- ICAP-Columbia University, Mailman School of Public Health, Columbia University, New York, NY, United States of America
- Department of Epidemiology, Mailman School of Public Health Columbia University, New York, NY, United States of America
| | - Elaine J Abrams
- ICAP-Columbia University, Mailman School of Public Health, Columbia University, New York, NY, United States of America
- Department of Epidemiology, Mailman School of Public Health Columbia University, New York, NY, United States of America
- Department of Pediatrics, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY, United States of America
| | - Katharine A Yuengling
- ICAP-Columbia University, Mailman School of Public Health, Columbia University, New York, NY, United States of America
| | - Matthew R Lamb
- ICAP-Columbia University, Mailman School of Public Health, Columbia University, New York, NY, United States of America
- Department of Epidemiology, Mailman School of Public Health Columbia University, New York, NY, United States of America
| | - Chunhui Wang
- ICAP-Columbia University, Mailman School of Public Health, Columbia University, New York, NY, United States of America
| | | | | | | | - Harriet Nuwagaba-Biribonwoha
- Department of Epidemiology, Mailman School of Public Health Columbia University, New York, NY, United States of America
- ICAP-Columbia University, Mbabane, Eswatini
| | - Wafaa M El-Sadr
- ICAP-Columbia University, Mailman School of Public Health, Columbia University, New York, NY, United States of America
- Department of Epidemiology, Mailman School of Public Health Columbia University, New York, NY, United States of America
- Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY, United States of America
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Bulstra CA, Hontelez JA, Ogbuoji O, Bärnighausen T. Which delivery model innovations can support sustainable HIV treatment? AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2020; 18:315-323. [PMID: 31779572 DOI: 10.2989/16085906.2019.1686033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The rapid scale-up of antiretroviral treatment (ART) for HIV since the mid-2000s, mostly through disease-specific or "vertical" programmes, has been a highly successful undertaking, which averted millions of deaths and prevented many new infections. However, the dynamics of the HIV epidemic and changing political and financial commitment to fight the disease will likely require new models for the delivery of ART over the coming decades if the promises of universal treatment are to be met. Delivery model innovations for ART are intended to improve both the effectiveness and efficiency of the HIV treatment cascade, reaching new people who require ART and providing ART to more people without an increase in resources. We describe twelve models for ART delivery, which could be achieved through five categories of delivery innovations: integrating ART ("vertical ART plus", "partially-integrated ART" and "fully-integrated ART"); modifying steps in the ART value chain ("professional task-shifted ART", "people task-shifted ART" and "technology-supported ART"); eliminating steps in the ART value chain ("immediate ART" and "less frequent ART pick-up"); changing ART locations ("private-sector ART", "traditional-sector ART" and "ART outside the health sector"); and keeping the status quo ("vertical ART"). The different delivery model innovations are not mutually exclusive and several could be combined, such as "vertical ART plus" with "task-shifted ART". Suitability of the models will highly depend on local and national contexts, including existing health systems resources, available funding, and type of HIV epidemic. Future implementation research needs to identify which models are the best fit for different contexts.
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Affiliation(s)
- Caroline A Bulstra
- Erasmus Medical Centre, Department of Public Health, Rotterdam, The Netherlands.,Institute of Global Health, University of Heidelberg, Germany
| | - Jan Ac Hontelez
- Erasmus Medical Centre, Department of Public Health, Rotterdam, The Netherlands.,Institute of Global Health, University of Heidelberg, Germany
| | - Osondu Ogbuoji
- Center for Policy Impact in Global Health, Duke University, Durham, USA
| | - Till Bärnighausen
- Institute of Global Health, University of Heidelberg, Germany.,Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, USA.,Africa Health Research Institute, Durban, South Africa
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9
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Haghighat R, Steinert J, Cluver L. The effects of decentralising antiretroviral therapy care delivery on health outcomes for adolescents and young adults in low- and middle-income countries: a systematic review. Glob Health Action 2020; 12:1668596. [PMID: 31558145 PMCID: PMC6781195 DOI: 10.1080/16549716.2019.1668596] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background: Decentralisation of antiretroviral therapy has been implemented to scale up HIV care provision for patients in resource-limited countries. Youth living with HIV demonstrate the poorest care outcomes, compared to other age groups. Objectives: To systematically evaluate evidence on the effects of decentralising facility-based HIV care on care outcomes for youth living with HIV in low- and middle-income countries. Methods: A systematic review was conducted through 12 electronic databases of peer-reviewed articles, conference abstracts, and grey literature; contacting relevant experts; and hand-searching references. Records were included if they were published after 1 January 1996 (advent of triple-drug ART) and reported health outcomes for decentralised and centralised care, separately, or evaluated the effect of decentralised care on care outcomes. Two authors independently screened search results. When age-disaggregated data (10-24 years old) were required for inclusion, we contacted study authors for data abstraction. Implementation fidelity of decentralisation, study quality, and risk of bias was assessed using the TIDieR checklist, CASP checklists, and ROBINS-I tool, respectively. Results: Of 11 potentially eligible studies, two studies from sub-Saharan Africa met inclusion criteria after data disaggregation by age. The studies and abstracted data were insufficiently homogenous in implementation and study design to justify meta-analysis. However, evidence suggests the potential for decentralised care to result in at least equivalent attrition-related outcomes (retention in care and mortality) for youth within decentralised HIV care. Limited sample size and significant selection and allocation bias confound clear, generalisable conclusions for youth living with HIV in resource-limited settings. Conclusions: There is a paucity of evidence for the effects of decentralising HIV care for youth living in resource-limited settings, particularly recent evidence reflective of the current HIV care landscape. Further work is required to rigorously analyse the effects of decentralising HIV care to inform policymakers and care providers, particularly as demand for HIV care in this population grows.
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Affiliation(s)
- Roxanna Haghighat
- Department of Social Policy & Intervention, University of Oxford , Oxford , UK
| | - Janina Steinert
- Department of Social Policy & Intervention, University of Oxford , Oxford , UK
| | - Lucie Cluver
- Department of Social Policy & Intervention, University of Oxford , Oxford , UK.,Department of Psychiatry and Mental Health, University of Cape Town , Rondebosch , South Africa
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10
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Onyegbutulem H, Pillatar B, Afiomah E, Sagay F, Amadi O, Dankyau M. Impacts of a pilot of community antiretroviral group initiative on HIV-positive patients in a tertiary health facility in Abuja, North Central Nigeria. NIGERIAN JOURNAL OF MEDICINE 2020. [DOI: 10.4103/njm.njm_69_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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11
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Amstutz A, Lejone TI, Khesa L, Muhairwe J, Nsakala BL, Tlali K, Bresser M, Tediosi F, Kopo M, Kao M, Klimkait T, Battegay M, Glass TR, Labhardt ND. VIBRA trial - Effect of village-based refill of ART following home-based same-day ART initiation vs clinic-based ART refill on viral suppression among individuals living with HIV: protocol of a cluster-randomized clinical trial in rural Lesotho. Trials 2019; 20:522. [PMID: 31439004 PMCID: PMC6704675 DOI: 10.1186/s13063-019-3510-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Accepted: 06/10/2019] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND There is a need for evaluating community-based antiretroviral therapy (ART) delivery models to improve overall performance of HIV programs, specifically in populations that may have difficulties to access continuous care. This cluster-randomized clinical trial aims to evaluate the effectiveness of a multicomponent differentiated ART delivery model (VIBRA model) after home-based same-day ART initiation in remote villages in Lesotho, southern Africa. METHODS/DESIGN The VIBRA trial (VIllage-Based Refill of ART) is a cluster-randomized parallel-group superiority clinical trial conducted in two districts in Lesotho, southern Africa. Clusters (i.e., villages) are randomly assigned to either the VIBRA model or standard care. The clusters are stratified by district, village size, and village access to the nearest health facility. Eligible individuals (HIV-positive, aged 10 years or older, and not taking ART) identified during community-based HIV testing campaigns are offered same-day home-based ART initiation. The intervention clusters offer a differentiated ART delivery package with two features: (1) drug refills and follow-ups by trained and supervised village health workers (VHWs) and (2) the option of receiving individually tailored adherence reminders and notifications of viral load results via SMS. The control clusters will continue to receive standard care, i.e., collecting ART refills from a clinic and no SMS notifications. The primary endpoint is viral suppression 12 months after enrolment. Secondary endpoints include linkage to and engagement in care. Furthermore, safety and cost-effectiveness analyses plus qualitative research are planned. The minimum target sample size is 262 participants. The statistical analyses will follow the CONSORT guidelines. The VIBRA trial is linked to another trial, the HOSENG (HOme-based SElf-testiNG) trial, both of which are within the GET ON (GETing tOwards Ninety) research project. DISCUSSION The VIBRA trial is among the first to evaluate the delivery of ART by VHWs immediately after ART initiation. It assesses the entire HIV care cascade from testing to viral suppression. As most countries in sub-Saharan Africa have cadres like the VHW program in Lesotho, this model-if shown to be effective-has the potential to be scaled up. The system impact evaluation will provide valuable cost estimations, and the qualitative research will suggest how the model could be further modified to optimize its impact. TRIAL REGISTRATION Clinicaltrials.gov, NCT03630549 . Registered on 15 August 2018.
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Affiliation(s)
- Alain Amstutz
- Clinical Research Unit, Department of Medicine, Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051 Basel, Switzerland
- University of Basel, 4051 Basel, Switzerland
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, 4051 Basel, Switzerland
| | | | - Lefu Khesa
- SolidarMed, Swiss Organization for Health in Africa, Butha-Buthe, Lesotho
| | - Josephine Muhairwe
- SolidarMed, Swiss Organization for Health in Africa, Butha-Buthe, Lesotho
| | | | - Katleho Tlali
- SolidarMed, Swiss Organization for Health in Africa, Butha-Buthe, Lesotho
- Butha-Buthe Government Hospital, Butha-Buthe, Lesotho
| | - Moniek Bresser
- Clinical Research Unit, Department of Medicine, Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051 Basel, Switzerland
- University of Basel, 4051 Basel, Switzerland
| | - Fabrizio Tediosi
- Clinical Research Unit, Department of Medicine, Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051 Basel, Switzerland
- University of Basel, 4051 Basel, Switzerland
| | - Mathebe Kopo
- SolidarMed, Swiss Organization for Health in Africa, Butha-Buthe, Lesotho
| | - Mpho Kao
- SolidarMed, Swiss Organization for Health in Africa, Butha-Buthe, Lesotho
| | - Thomas Klimkait
- University of Basel, 4051 Basel, Switzerland
- Molecular Virology, Department of Biomedicine, University of Basel, 4051 Basel, Switzerland
| | - Manuel Battegay
- University of Basel, 4051 Basel, Switzerland
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, 4051 Basel, Switzerland
| | - Tracy Renée Glass
- Clinical Research Unit, Department of Medicine, Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051 Basel, Switzerland
- University of Basel, 4051 Basel, Switzerland
| | - Niklaus Daniel Labhardt
- Clinical Research Unit, Department of Medicine, Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051 Basel, Switzerland
- University of Basel, 4051 Basel, Switzerland
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, 4051 Basel, Switzerland
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12
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Balogun M, Meloni ST, Igwilo UU, Roberts A, Okafor I, Sekoni A, Ogunsola F, Kanki PJ, Akanmu S. Status of HIV-infected patients classified as lost to follow up from a large antiretroviral program in southwest Nigeria. PLoS One 2019; 14:e0219903. [PMID: 31344057 PMCID: PMC6657856 DOI: 10.1371/journal.pone.0219903] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 07/04/2019] [Indexed: 11/19/2022] Open
Abstract
Background Loss to follow-up (LTFU) is a term used to classify patients no longer being seen in a clinical care program, including HIV treatment programs. It is unclear if these patients have transferred their care services elsewhere, died, or if there are other reasons for their LTFU. To better understand the status of patients meeting the criteria of LTFU, we traced a sample of HIV-infected patients that were LTFU from the Lagos University Teaching Hospital (LUTH) antiretroviral program. Methods We conducted a cross-sectional study of HIV-infected adult patients who enrolled for care between 2010 and 2014 at LUTH and were considered LTFU. Patients with locator information were traced using phone calls. Face-to-face interviews were used to collect data from successfully traced and consenting participants. Predictors of LTFU from LUTH, disengagement from care and willingness to re-engage in care in LUTH were assessed. Results Of 6108 registered patients, 3397 (56%) were LTFU and being unmarried was a predictor of being LTFU from LUTH. Of 425 patients that were traced, 355 (84%) were alive and 70 (16%) were dead. Two hundred and sixty-eight patients consented to interviews; 96 (35.8%) of these had transferred to another clinic for care while 172 (64.2%) were disengaged from care. More than half (149/268; 55.6%) were not on antiretroviral therapy (ART). Some of the primary reasons for LTFU were; long distance to clinic (56%) and feeling healthy (6.7%). Predictor of disengagement from care within the interviewed cohort was not having started ART. The predictors of willingness to re-engage in care included, not having started ART, male sex and longer duration in HIV care prior to LTFU. Conclusion Most of the interviewed cohort that was LTFU were truly disengaged from care and not on ART. Interventions are required to address processes of re-engagement of patients that are LTFU.
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Affiliation(s)
- Mobolanle Balogun
- Department of Community Health and Primary Care, College of Medicine of the University of Lagos, Lagos, Nigeria
- * E-mail:
| | - Seema Thakore Meloni
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States
| | | | - Alero Roberts
- Department of Community Health and Primary Care, College of Medicine of the University of Lagos, Lagos, Nigeria
| | - Ifeoma Okafor
- Department of Community Health and Primary Care, College of Medicine of the University of Lagos, Lagos, Nigeria
| | - Adekemi Sekoni
- Department of Community Health and Primary Care, College of Medicine of the University of Lagos, Lagos, Nigeria
| | - Folasade Ogunsola
- Department of Medical Microbiology and Parasitology, College of Medicine of the University of Lagos, Lagos, Nigeria
| | - Phyllis J. Kanki
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States
| | - Sulaimon Akanmu
- Department of Haematology and Blood Transfusion, College of Medicine of the University of Lagos, Lagos, Nigeria
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13
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Pfaff C, Singano V, Akello H, Amberbir A, Berman J, Kwekwesa A, Banda V, Speight C, Allain T, van Oosterhout JJ. Early experiences integrating hypertension and diabetes screening and treatment in a human immunodeficiency virus clinic in Malawi. Int Health 2019; 10:495-501. [PMID: 30052987 DOI: 10.1093/inthealth/ihy049] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 06/07/2018] [Indexed: 12/13/2022] Open
Abstract
Background Human immunodeficiency virus (HIV) programmes can be leveraged to manage the growing burden of non-communicable diseases (NCDs). Methods In October 2015, a model of integrated HIV-NCD care was developed at a large HIV clinic in southeast Malawi. Blood pressure was measured in adults at every visit and random blood glucose was determined every 2 y. Uncomplicated antiretroviral therapy (ART)-only care was provided by nurses, integrated HIV-NCD management was provided by clinical officers. Waiting times were assessed using the electronic medical record system. The team met monthly to identify bottlenecks. Results All (n=6036) adult HIV patients were screened and 765 were diagnosed with hypertension (prevalence 12.7% [95% confidence interval {CI} 11.9-13.5). A total of 2979 adult HIV patients were screened and 25 were diagnosed with diabetes mellitus (prevalence 0.8% [95% CI 0.6-1.2]). The mean duration of ART visits by clinical officers increased from 80.5 to 90 min during the first quarter following HIV-NCD integration but returned to 75 min the following quarter. The mean number of patients seen per day by clinical officers increased from 6 to 11 and for nurses decreased from 92 to 82 in that time period. The robust vertical HIV system made the design of integrated tools demanding. Challenges of integrated HIV-NCD care were related to patient flow, waiting times, NCD drug availability, data collection, clinic workload and the timing of diabetes and hypertension screening. Conclusions Integrated HIV-NCD services provision was feasible in our clinic.
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Affiliation(s)
- Colin Pfaff
- Dignitas International, Zomba, Malawi.,College of Medicine, University of Malawi, Private Bag 360, Chichiri, Blantyre 3, Malawi
| | | | | | | | | | | | | | - Colin Speight
- Lighthouse Trust, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Theresa Allain
- College of Medicine, University of Malawi, Private Bag 360, Chichiri, Blantyre 3, Malawi
| | - Joep J van Oosterhout
- Dignitas International, Zomba, Malawi.,College of Medicine, University of Malawi, Private Bag 360, Chichiri, Blantyre 3, Malawi
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14
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Webb S, Hartland J. A retrospective notes-based review of patients lost to follow-up from anti-retroviral therapy at Mulanje Mission Hospital, Malawi. Malawi Med J 2019; 30:73-78. [PMID: 30627332 PMCID: PMC6307064 DOI: 10.4314/mmj.v30i2.4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aim To analyse patients with HIV who were lost to follow-up from anti-retroviral therapy (ART) at Mulanje Mission Hospital (MMH), Malawi. Methods All patients on adult antiretroviral combinations at MMH, who were classified as lost to follow-up (LTFU) according to the national guidelines (patients missing a scheduled follow-up visit by more than two months) over a 12-month period, were included in the study and compared against a control group who had never been lost. Variables compared were gender, age, months on ART, time of year, WHO clinical stage, ART regimen, reported side effects, number of doses missed in the previous 12 months, whether the patient has been followed up in the community and if so, the length of time elapsed before follow-up. Results In all, 136 patients had been LTFU over the previous 12 months at MMH. Of these, 43 had incomplete or missing ART cards, resulting in 93 LTFU patient's data that could be analysed. Patients were more likely to get LTFU if they were men (p=0.03), who had been on anti-retroviral therapy for a short duration (p=0.06) and the proportion of patients who missed more than 4 doses in the previous 12 months was higher among LTFU patients (p=0.05). Only 34.4% of those LTFU had been traced in the community at the time of analysis. Of those traced, 27% had moved to another area, 5.5% had died, 5.5% had the wrong documentation and 62% gave no reason as to why they had missed appointments. Conclusion This study in MMH has highlighted the importance and feasibility of comprehensive facility-level data-collection, both to identify local patient populations at risk of becoming lost to follow-up and to assess the follow-up measures in place to bring these lost to follow-up patients back into the programme. Even in the short time and with the small sample that was collected, there was evidence that patients most likely to get LTFU in MMH were young men, who had been on anti-retroviral therapy for a short duration and had missed over 4 doses in the last 12 months.
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Affiliation(s)
- Silas Webb
- Croydon University Hospital and University of Bristol
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15
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Abongomera G, Chiwaula L, Revill P, Mabugu T, Tumwesige E, Nkhata M, Cataldo F, van Oosterhout J, Colebunders R, Chan AK, Kityo C, Gilks C, Hakim J, Seeley J, Gibb DM, Ford D. Patient-level benefits associated with decentralization of antiretroviral therapy services to primary health facilities in Malawi and Uganda. Int Health 2018; 10:8-19. [PMID: 29329396 DOI: 10.1093/inthealth/ihx061] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 11/28/2017] [Indexed: 11/14/2022] Open
Abstract
Background The Lablite project captured information on access to antiretroviral therapy (ART) at larger health facilities ('hubs') and lower-level health facilities ('spokes') in Phalombe district, Malawi and in Kalungu district, Uganda. Methods We conducted a cross-sectional survey among patients who had transferred to a spoke after treatment initiation (Malawi, n=54; Uganda, n=33), patients who initiated treatment at a spoke (Malawi, n=50; Uganda, n=44) and patients receiving treatment at a hub (Malawi, n=44; Uganda, n=46). Results In Malawi, 47% of patients mapped to the two lowest wealth quintiles (Q1-Q2); patients at spokes were poorer than at a hub (57% vs 23% in Q1-Q2; p<0.001). In Uganda, 7% of patients mapped to Q1-Q2; patients at the rural spoke were poorer than at the two peri-urban facilities (15% vs 4% in Q1-Q2; p<0.001). The median travel time one way to a current ART facility was 60 min (IQR 30-120) in Malawi and 30 min (IQR 20-60) in Uganda. Patients who had transferred to the spokes reported a median reduction in travel time of 90 min in Malawi and 30 min in Uganda, with reductions in distance and food costs. Conclusions Decentralizing ART improves access to treatment. Community-level access to treatment should be considered to further minimize costs and time.
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Affiliation(s)
- George Abongomera
- Department of Research, Joint Clinical Research Centre, Kampala, Uganda.,Faculty of Medicine, University of Antwerp, Antwerp, Belgium
| | - Levison Chiwaula
- Medical and Research Department, Dignitas International, Zomba, Malawi.,Department of Economics, University of Malawi, Zomba, Malawi
| | - Paul Revill
- Centre for Health Economics, University of York, York, UK
| | - Travor Mabugu
- Clinical Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | - Edward Tumwesige
- Department of Social Sciences, Medical Research Council/Uganda Virus Research Institute, Entebbe, Uganda
| | - Misheck Nkhata
- Medical and Research Department, Dignitas International, Zomba, Malawi
| | - Fabian Cataldo
- Medical and Research Department, Dignitas International, Zomba, Malawi
| | - J van Oosterhout
- Medical and Research Department, Dignitas International, Zomba, Malawi.,Department of Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | | | - Adrienne K Chan
- Medical and Research Department, Dignitas International, Zomba, Malawi.,Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Cissy Kityo
- Department of Research, Joint Clinical Research Centre, Kampala, Uganda
| | - Charles Gilks
- Faculty of Medicine, Imperial College London, London, UK.,School of Population Health, University of Queensland, Brisbane, Queensland, Australia
| | - James Hakim
- Clinical Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | - Janet Seeley
- Department of Social Sciences, Medical Research Council/Uganda Virus Research Institute, Entebbe, Uganda.,Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Diana M Gibb
- Medical Research CouncilClinical Trials Unit at University College London, London, UK
| | - Deborah Ford
- Medical Research CouncilClinical Trials Unit at University College London, London, UK
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Topp SM, Abimbola S, Joshi R, Negin J. How to assess and prepare health systems in low- and middle-income countries for integration of services-a systematic review. Health Policy Plan 2018; 33:298-312. [PMID: 29272396 PMCID: PMC5886169 DOI: 10.1093/heapol/czx169] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2017] [Indexed: 12/26/2022] Open
Abstract
Despite growing support for integration of frontline services, a lack of information about the pre-conditions necessary to integrate such services hampers the ability of policy makers and implementers to assess how feasible or worthwhile integration may be, especially in low- and middle-income countries (LMICs). We adopted a modified systematic review with aspects of realist review, including quantitative and qualitative studies that incorporated assessment of health system preparedness for and capacity to implement integrated services. We searched Medline via Ovid, Web of Science and the Cochrane library using terms adapted from Dudley and Garner’s systematic review on integration in LMICs. From an initial list of 10 550 articles, 206 were selected for full-text review by two reviewers who independently reviewed articles and inductively extracted and synthesized themes related to health system preparedness. We identified five ‘context’ related categories and four health system ‘capability’ themes. The contextual enabling and constraining factors for frontline service integration were: (1) the organizational framework of frontline services, (2) health care worker preparedness, (3) community and client preparedness, (4) upstream logistics and (5) policy and governance issues. The intersecting health system capabilities identified were the need for: (1) sufficiently functional frontline health services, (2) sufficiently trained and motivated health care workers, (3) availability of technical tools and equipment suitable to facilitate integrated frontline services and (4) appropriately devolved authority and decision-making processes to enable frontline managers and staff to adapt integration to local circumstances. Moving beyond claims that integration is defined differently by different programs and thus unsuitable for comparison, this review demonstrates that synthesis is possible. It presents a common set of contextual factors and health system capabilities necessary for successful service integration which may be considered indicators of preparedness and could form the basis for an ‘integration preparedness tool’.
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Affiliation(s)
- Stephanie M Topp
- College of Public Health Medical and Veterinary Sciences, James Cook University, Townsville, QLD 4812, Australia.,Nossal Institute for Global Health, University of Melbourne, Melbourne, Australia
| | - Seye Abimbola
- Sydney School of Public Health, University of Sydney, Sydney, NSW 2006, Australia
| | - Rohina Joshi
- The George Institute, University of New South Wales, NSW 2042, Australia.,Sydney Medical School, University of Sydney, Sydney, Australia
| | - Joel Negin
- Sydney School of Public Health, University of Sydney, Sydney, NSW 2006, Australia
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Dyslipidemia among rural and urban HIV patients in south-east Malawi. PLoS One 2018; 13:e0197728. [PMID: 29782548 PMCID: PMC5962094 DOI: 10.1371/journal.pone.0197728] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Accepted: 05/08/2018] [Indexed: 12/17/2022] Open
Abstract
Background While dyslipidemia importantly contributes to increased cardiovascular disease risk among patients on antiretroviral therapy (ART), data on lipid patterns among African adults on ART are limited. We describe the prevalence of lipid abnormalities and associated factors in two HIV clinics in Malawi. Methods We conducted a cross-sectional study in 2014 and enrolled adult patients at a rural and an urban HIV clinic in Zomba district, Malawi. We recorded patient characteristics, CVD risk factors and anthropometric measurements, using the WHO STEPS validated instrument. Non-fasting samples were taken for determination of total cholesterol (TC), triglyceride (TG) and HDL-cholesterol (HDL-c) levels. Logistic regression analysis was used to determine factors associated with elevated TC and elevated TC/HDL-c ratio. Results 554 patients were enrolled, 50% at the rural HIV clinic, 72.7% were female, the median (IQR) age was 42 years (36–50); 97.3% were on ART, 84.4% on tenofovir/lamivudine/efavirenz, 17.5% were overweight/obese and 27.8%% had elevated waist/hip ratio. 15.5% had elevated TC, 15.9% reduced HDL-c, 28.7% had elevated TG and 3.8% had elevated TC/HDL-c ratio. Lipid abnormalities were similar in rural and urban patients. Women had significantly higher burden of elevated TC and TG whereas men had higher prevalence of reduced HDL-c. Waist-to-hip ratio was independently associated with elevated TC (aOR = 1.90; 95% CI: 1.17–3.10, p = 0.01) and elevated TC/HDL-c ratio (aOR = 3.50; 95% CI: 1.38–8.85, p = 0.008). Increasing age was independently associated with elevated TC level (aOR = 1.54, 95% CI 0.51–4.59 for age 31–45; aOR = 3.69, 95% CI 1.24–10.95 for age >45 years vs. ≤30 years; p-trend <0.01). Conclusions We found a moderate burden of dyslipidemia among Malawian adults on ART, which was similar in rural and urban patients but differed significantly between men and women. High waist-hip ratio predicted elevated TC and elevated TC/HDL-c ratio and may be a practical tool for CVD risk indication in resource limited settings.
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Semitala FC, Camlin CS, Wallenta J, Kampiire L, Katuramu R, Amanyire G, Namusobya J, Chang W, Kahn JG, Charlebois ED, Havlir DV, Kamya MR, Geng EH. Understanding uptake of an intervention to accelerate antiretroviral therapy initiation in Uganda via qualitative inquiry. J Int AIDS Soc 2018; 20. [PMID: 29206357 PMCID: PMC5810312 DOI: 10.1002/jia2.25033] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 11/10/2017] [Indexed: 11/13/2022] Open
Abstract
Introduction The Streamlined Antiretroviral Therapy Initiation Strategy (START‐ART) study found that a theory‐based intervention using opinion leaders to inform and coach health care providers about the risks of treatment delay, provision of point of care (POC) CD4 testing machines (PIMA) and reputational incentives, led to rapid rise in ART initiation. We used qualitative research methods to explore mechanisms of provider behaviour change. Methods We conducted in‐depth interviews (IDIs) with 24 health care providers and nine study staff to understand perceptions, attitudes and the context of changes in ART initiation practices. Analyses were informed by the Theoretical Domains Framework. Results Rapid dissemination of new practices was enabled in the environmental context of an existing relationship based on communication, implementation and accountability between Makerere University Joint AIDS Program (MJAP), a Ugandan University‐affiliated organization that provided technical oversight for HIV service delivery at the health facilities where the intervention was implemented, and a network of health facilities operated by the Uganda Ministry of Health. Coaching carried out by field coordinators from MJAP strengthened influence and informal accountability for carrying out the intervention. Frontline health workers held a pre‐existing strong sense of professional identity. They were proud of attainment of new knowledge and skills and gratified by providing what they perceived to be higher quality care. Peer counsellors, who were not explicitly targeted in the intervention design, effectively substituted some functions of health care providers; as role models for successful ART uptake, they played a crucial role in creating demand for rapid ART initiation through interactions with patients. Point of care (POC) CD4 testing enabled immediate action and relieved providers from frustrations of lost or delayed laboratory results, and led to higher patient satisfaction (due to reduced costs because of ability to initiate ART right away, requiring fewer return trips to clinic). Conclusions Qualitative data revealed that a multicomponent intervention to change provider behaviour succeeded in the context of strong institutional and individual relationships between a University‐affiliated organization, government facilities, and peer health workers (who acted as a crucial link between stakeholders) and the community. Fostering stable institutional relationships between institutional actors (non‐governmental organization (NGOs) and ministry‐operated facilities) as well as between facilities and the community (through peer health workers) can enhance uptake of innovations targeting the HIV cascade in similar clinical settings.
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Affiliation(s)
- Fred C Semitala
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda.,Makerere University Joint AIDS Program (MJAP), Kampala, Uganda.,Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Carol S Camlin
- Division of HIV, ID and Global Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, Department of Medicine, University of California, San Francisco, CA, USA
| | - Jeanna Wallenta
- Philip R. Lee Institute for Health Policy Studies, Department of Epidemiology and Biostatistics, and Global Health Sciences, University of California, San Francisco, CA, USA
| | | | | | - Gideon Amanyire
- Makerere University Joint AIDS Program (MJAP), Kampala, Uganda.,Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Wei Chang
- Philip R. Lee Institute for Health Policy Studies, Department of Epidemiology and Biostatistics, and Global Health Sciences, University of California, San Francisco, CA, USA
| | - James G Kahn
- Philip R. Lee Institute for Health Policy Studies, Department of Epidemiology and Biostatistics, and Global Health Sciences, University of California, San Francisco, CA, USA
| | - Edwin D Charlebois
- Division of HIV, ID and Global Medicine, Department of Medicine, University of California, San Francisco, CA, USA
| | - Diane V Havlir
- Division of HIV, ID and Global Medicine, Department of Medicine, University of California, San Francisco, CA, USA
| | - Moses R Kamya
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda.,Makerere University Joint AIDS Program (MJAP), Kampala, Uganda.,Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Elvin H Geng
- Division of HIV, ID and Global Medicine, Department of Medicine, University of California, San Francisco, CA, USA
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Davis N, Kanagat N, Sharer M, Eagan S, Pearson J, Amanyeiwe UU. Review of differentiated approaches to antiretroviral therapy distribution. AIDS Care 2018; 30:1010-1016. [PMID: 29471667 DOI: 10.1080/09540121.2018.1441970] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
In response to global trends of maximizing the number of patients receiving antiretroviral therapy (ART), this review summarizes literature describing differentiated models of ART distribution at facility and community levels in order to highlight promising strategies and identify evidence gaps. Databases and gray literature were searched, yielding thirteen final articles on differentiated ART distribution models supporting stable adult patients. Of these, seven articles focused on distribution at facility level and six at community level. Findings suggest that differentiated models of ART distribution contribute to higher retention, lower attrition, and less loss to follow-up (LTFU). These models also reduced patient wait time, travel costs, and time lost from work for drug pick-up. Facility- and community-level ART distribution models have the potential to extend treatment availability, enable improved access and adherence among people living with HIV (PLHIV), and facilitate retention in treatment and care. Gaps remain in understanding the desirability of these models for PLHIV, and the need for more information the negative and positive impacts of stigma, and identifying models to reach traditionally marginalized groups such as key populations and youth. Replicating differentiated care so efforts can reach more PLHIV will be critical to scaling these approaches across varying contexts.
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Affiliation(s)
- Nicole Davis
- a JSI Research & Training Institute, Inc , Boston , MA , Washington, DC
| | - Natasha Kanagat
- a JSI Research & Training Institute, Inc , Boston , MA , Washington, DC
| | - Melissa Sharer
- a JSI Research & Training Institute, Inc , Boston , MA , Washington, DC.,b Department of Public Health , St. Ambrose University , Iowa , USA
| | - Sabrina Eagan
- a JSI Research & Training Institute, Inc , Boston , MA , Washington, DC
| | - Jennifer Pearson
- a JSI Research & Training Institute, Inc , Boston , MA , Washington, DC
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Agaba PA, Genberg BL, Sagay AS, Agbaji OO, Meloni ST, Dadem NY, Kolawole GO, Okonkwo P, Kanki PJ, Ware NC. Retention in Differentiated Care: Multiple Measures Analysis for a Decentralized HIV Care and Treatment Program in North Central Nigeria. ACTA ACUST UNITED AC 2018; 9. [PMID: 29682399 PMCID: PMC5909978 DOI: 10.4172/2155-6113.1000756] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Objective Differentiated care refers collectively to flexible service models designed to meet the differing needs of HIV-infected persons in resource-scarce settings. Decentralization is one such service model. Retention is a key indicator for monitoring the success of HIV treatment and care programs. We used multiple measures to compare retention in a cohort of patients receiving HIV care at “hub” (central) and “spoke” (decentralized) sites in a large public HIV treatment program in north central Nigeria. Methods This retrospective cohort study utilized longitudinal program data representing central and decentralized levels of care in the Plateau State Decentralization Initiative, north central Nigeria. We examined retention with patient- level (retention at fixed times, loss-to-follow-up [LTFU]) and visit-level (gaps-in-care, visit constancy) measures. Regression models with generalized estimating equations (GEE) were used to estimate the effect of decentralization on visit-level measures. Patient-level measures were examined using survival methods with Cox regression models, controlling for baseline variables. Results Of 15,650 patients, 43% were enrolled at the hub. Median time in care was 3.1 years. Hub patients were less likely to be LTFU (adjusted hazard ratio (AHR)=0.91, 95% CI: 0.85-0.97), compared to spoke patients. Visit constancy was lower at the hub (−4.5%, 95% CI: −3.5, −5.5), where gaps in care were also more likely to occur (adjusted odds ratio=1.95, 95% CI: 1.83-2.08). Conclusion Decentralized sites demonstrated better retention outcomes using visit-level measures, while the hub achieved better retention outcomes using patient-level measures. Retention estimates produced by incorporating multiple measures showed substantial variation, confirming the influence of measurement strategies on the results of retention research. Future studies of retention in HIV care in sub-Saharan Africa will be well-served by including multiple measures.
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Affiliation(s)
| | - Becky L Genberg
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Oche O Agbaji
- Faculty of Medical Sciences, University of Jos, Nigeria
| | | | - Nancin Y Dadem
- APIN Centre, Jos University Teaching Hospital, Jos, Nigeria
| | | | | | | | - Norma C Ware
- Harvard Medical School, Boston MA, USA.,Brigham & Women's Hospital, Boston, MA, USA
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21
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Abstract
One of the four national HIV prevention goals is to incorporate combinations of effective, evidence-based approaches to prevent HIV infection. In fields of public health, techniques that alter environment and affect choice options are effective. Structural approaches may be effective in preventing HIV infection. Existing frameworks for structural interventions were lacking in breadth and/or depth. We conducted a systematic review and searched CDC's HIV/AIDS Prevention Research Synthesis Project's database for relevant interventions during 1988-2013. We used an iterative process to develop the taxonomy. We identified 213 structural interventions: Access (65%), Policy/Procedure (32%), Mass Media (29%), Physical Structure (27%), Capacity Building (24%), Community Mobilization (9%), and Social Determinants of Health (8%). Forty percent targeted high-risk populations (e.g., people who inject drugs [12%]). This paper describes a comprehensive, well-defined taxonomy of structural interventions with 7 categories and 20 subcategories. The taxonomy accommodated all interventions identified.
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Bilinski A, Birru E, Peckarsky M, Herce M, Kalanga N, Neumann C, Bronson G, Po-Chedley S, Kachimanga C, McBain R, Keck J. Distance to care, enrollment and loss to follow-up of HIV patients during decentralization of antiretroviral therapy in Neno District, Malawi: A retrospective cohort study. PLoS One 2017; 12:e0185699. [PMID: 28973035 PMCID: PMC5626468 DOI: 10.1371/journal.pone.0185699] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 09/18/2017] [Indexed: 12/03/2022] Open
Abstract
HIV/AIDS remains the second most common cause of death in low and middle-income countries (LMICs), and only 34% of eligible patients in Africa received antiretroviral therapy (ART) in 2013. This study investigated the impact of ART decentralization on patient enrollment and retention in rural Malawi. We reviewed electronic medical records of patients registered in the Neno District ART program from August 1, 2006, when ART first became available, through December 31, 2013. We used GPS data to calculate patient-level distance to care, and examined number of annual ART visits and one-year lost to follow-up (LTFU) in HIV care. The number of ART patients in Neno increased from 48 to 3,949 over the decentralization period. Mean travel distance decreased from 7.3 km when ART was only available at the district hospital to 4.7 km when ART was decentralized to 12 primary health facilities. For patients who transferred from centralized care to nearer health facilities, mean travel distance decreased from 9.5 km to 4.7 km. Following a transfer, the proportion of patients achieving the clinic’s recommended ≥4 annual visits increased from 89% to 99%. In Cox proportional hazards regression, patients living ≥8 km from a health facility had a greater hazard of being LTFU compared to patients <8 km from a facility (adjusted HR: 1.7; 95% CI: 1.5–1.9). ART decentralization in Neno District was associated with increased ART enrollment, decreased travel distance, and increased retention in care. Increasing access to ART by reducing travel distance is one strategy to achieve the ART coverage and viral suppression objectives of the 90-90-90 UNAIDS targets in rural impoverished areas.
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Affiliation(s)
- Alyssa Bilinski
- Abwenzi Pa Za Umoyo, Neno, Malawi and Partners In Health, Boston, Massachusetts, United States of America
- Interfaculty Initiative in Health Policy, Harvard Graduate School of Arts and Sciences, Cambridge, Massachusetts, United States of America
- * E-mail:
| | - Ermyas Birru
- Abwenzi Pa Za Umoyo, Neno, Malawi and Partners In Health, Boston, Massachusetts, United States of America
| | - Matthew Peckarsky
- Abwenzi Pa Za Umoyo, Neno, Malawi and Partners In Health, Boston, Massachusetts, United States of America
| | - Michael Herce
- Abwenzi Pa Za Umoyo, Neno, Malawi and Partners In Health, Boston, Massachusetts, United States of America
- Division of Infectious Diseases, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, United States of America
| | - Noel Kalanga
- Abwenzi Pa Za Umoyo, Neno, Malawi and Partners In Health, Boston, Massachusetts, United States of America
| | - Christian Neumann
- Abwenzi Pa Za Umoyo, Neno, Malawi and Partners In Health, Boston, Massachusetts, United States of America
| | - Gay Bronson
- Abwenzi Pa Za Umoyo, Neno, Malawi and Partners In Health, Boston, Massachusetts, United States of America
| | - Stephen Po-Chedley
- Abwenzi Pa Za Umoyo, Neno, Malawi and Partners In Health, Boston, Massachusetts, United States of America
| | - Chembe Kachimanga
- Abwenzi Pa Za Umoyo, Neno, Malawi and Partners In Health, Boston, Massachusetts, United States of America
| | - Ryan McBain
- Abwenzi Pa Za Umoyo, Neno, Malawi and Partners In Health, Boston, Massachusetts, United States of America
| | - James Keck
- Abwenzi Pa Za Umoyo, Neno, Malawi and Partners In Health, Boston, Massachusetts, United States of America
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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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Mortality in the First 3 Months on Antiretroviral Therapy Among HIV-Positive Adults in Low- and Middle-income Countries: A Meta-analysis. J Acquir Immune Defic Syndr 2017; 73:1-10. [PMID: 27513571 DOI: 10.1097/qai.0000000000001112] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Previous meta-analyses reported mortality estimates of 12-month post-antiretroviral therapy (ART) initiation; however, 40%-60% of deaths occur in the first 3 months on ART, a more sensitive measure of averted deaths through early ART initiation. To determine whether early mortality is dropping as treatment thresholds have increased, we reviewed studies of 3 months on ART initiation in low- to middle-income countries. Studies of 3-month mortality from January 2003 to April 2016 were searched in 5 databases. Articles were included that reported 3-month mortality from a low- to middle-income country; nontrial setting and participants were ≥15. We assessed overall mortality and stratified by year using random effects models. Among 58 included studies, although not significant, pooled estimates show a decline in mortality when comparing studies whose enrollment of patients ended before 2010 (7.0%; 95% CI: 6.0 to 8.0) with the studies during or after 2010 (4.0%; 95% CI: 3.0 to 5.0). To continue to reduce early HIV-related mortality at the population level, intensified efforts to increase demand for ART through active testing and facilitated referral should be a priority. Continued financial investments by multinational partners and the implementation of creative interventions to mitigate multidimensional complex barriers of accessing care and treatment for HIV are needed.
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25
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Abongomera G, Kiwuwa-Muyingo S, Revill P, Chiwaula L, Mabugu T, Phillips AN, Katabira E, Chan AK, Gilks C, Musiime V, Hakim J, Kityo C, Colebunders R, Gibb DM, Seeley J, Ford D. Impact of decentralisation of antiretroviral therapy services on HIV testing and care at a population level in Agago District in rural Northern Uganda: results from the Lablite population surveys. Int Health 2017; 9:91-99. [PMID: 28338914 DOI: 10.1093/inthealth/ihx006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 02/22/2017] [Indexed: 11/13/2022] Open
Abstract
Background We conducted unlinked cross-sectional population-based surveys in Northern Uganda before and after antiretroviral therapy (ART) provision (including Option B+ [lifelong ART for pregnant/breast-feeding women]) at a local primary care facility (Lira Kato Health Centre [HC]). Prior to decentralisation, people travelled 56-76 km round-trip for ART; we aimed to evaluate changes in uptake of HIV-testing, ART coverage and access to ART following decentralisation. Methods A total of 2124 adults in 1351 households in two parishes closest to Lira Kato HC were interviewed using questionnaires between March and April 2013 and 2123 adults in 1229 households between January and March 2015. Results Adults reporting HIV-testing in the last year increased from 1077/2124 (50.7%) to 1298/2123 (61.1%) between surveys (p<0.001). ART coverage increased from 74/136 (54.4%) self-reported HIV-positive adults in 2013 to 108/133 (81.2%) in 2015 (p<0.001). Post-decentralisation, 47/108 (43.5%) of those on ART were in care at Lira Kato HC (including 37 new initiations). Most of the remainder (47/61, 77%) started ART prior to any ART provision at Lira Kato HC; the most common reason given for not accessing ART locally was concern about drug-stock-outs (30/59, 51%). Conclusions HIV-testing and ART coverage increased after decentralisation combined with Option B+ roll-out. However, patients on ART before decentralisation were reluctant to transfer to their local facility.
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Affiliation(s)
- George Abongomera
- Department of Research, Joint Clinical Research Centre, P.O. Box 10005, Kampala, Uganda.,Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Wilrijk, Antwerp, Belgium
| | - Sylvia Kiwuwa-Muyingo
- Department of Statistics, Medical Research Council/Uganda Virus Research Institute, P.O. Box 49, Entebbe, Uganda
| | - Paul Revill
- Centre for Health Economics, University of York, York, YO10 5DD, UK
| | - Levison Chiwaula
- Department of Research, Dignitas International, P.O. Box 1071, Zomba, Malawi
| | - Travor Mabugu
- Clinical Research Centre, University of Zimbabwe, P.O. Box MP 167 Harare, Zimbabwe
| | - Andrew N Phillips
- Department of Infection & Population Health, University College London, London, WC1E 6JB, UK
| | - Elly Katabira
- Department of Research, Infectious Diseases Institute, Makerere University, P.O. Box 22418, Kampala, Uganda
| | - Adrienne K Chan
- Department of Research, Dignitas International, P.O. Box 1071, Zomba, Malawi.,Department of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Charles Gilks
- Faculty of Medicine, Imperial College London, London, SW7 2AZ, UK.,School of Population Health, University of Queensland, Brisbane, QLD 4072, Australia
| | - Victor Musiime
- Department of Research, Joint Clinical Research Centre, P.O. Box 10005, Kampala, Uganda.,Faculty of Paediatrics, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
| | - James Hakim
- Clinical Research Centre, University of Zimbabwe, P.O. Box MP 167 Harare, Zimbabwe
| | - Cissy Kityo
- Department of Research, Joint Clinical Research Centre, P.O. Box 10005, Kampala, Uganda
| | - Robert Colebunders
- Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Wilrijk, Antwerp, Belgium
| | - Diana M Gibb
- Medical Research Council, Clinical Trials Unit at University College London, London, WC2B 6NH, UK
| | - Janet Seeley
- Department of Statistics, Medical Research Council/Uganda Virus Research Institute, P.O. Box 49, Entebbe, Uganda.,Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Deborah Ford
- Medical Research Council, Clinical Trials Unit at University College London, London, WC2B 6NH, UK
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Landes M, Thompson C, Mwinjiwa E, Thaulo E, Gondwe C, Akello H, Chan AK. Task shifting of triage to peer expert informal care providers at a tertiary referral HIV clinic in Malawi: a cross-sectional operational evaluation. BMC Health Serv Res 2017; 17:341. [PMID: 28486980 PMCID: PMC5423418 DOI: 10.1186/s12913-017-2291-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 05/04/2017] [Indexed: 11/21/2022] Open
Abstract
Background HIV treatment models in Africa are labour intensive and require a high number of skilled staff. In this context, task-shifting is considered a feasible alternative for ART service delivery. In 2006, a lay health cadre of expert patients (EPs) at a tertiary referral HIV clinic in Zomba, Malawi was capacitated. There are few evaluations of EP program efficacy in this setting. Triage is the process of prioritizing patients in terms of the severity of their condition and ensures that no harmful delays occur to treatment and care. This study evaluates the safety of task-shifting triage, in an ambulatory low resource setting, to EPs. Methods As a quality improvement exercise in April 2010, formal triage training was conducted by adapting the World Health Organization Emergency Triage Assessment and Treatment Triage Module Guidelines. A cross sectional observation study was conducted 2 years after the intervention. Triage assessments performed by EPs were repeated by a clinical officer (gold standard) to assess sensitivities, specificities, positive and negative predictive values for EP triage scores. Proportions were calculated for categories of disposition by stratifying by EP and clinician triage scores. Results A total of 467 patients were triaged by 7 EPs and re-triaged by clinical officers. With combined triage scores for emergency and priority patients we report a sensitivity of 85% and specificity of 74% for the EP scoring, with a low positive predictive value (41%) and a high negative predictive value (96%). We calculate a serious miss rate of EP scoring (i.e. missed priority or emergency patients) as 2.2%. Admission rates to hospital were highest among those patients triaged as emergency cases either by the EP’s (21%) or the clinicians (83%). Fewer patients triaged as priority by either EPs (5%) or clinicians (15%) were admitted to hospital, however these patients had the highest prevalence of same day lab testing and/or specialty referral. Conclusions Our study provides reassurance that in the context of adequate training and ongoing supervision, task-shifting triage to lay health care workers does not necessarily lead to less accurate triaging. EPs have a tendency to be more conservative in over-triaging patients. Electronic supplementary material The online version of this article (doi:10.1186/s12913-017-2291-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Megan Landes
- Dignitas International-Malawi Country Program, Zomba, Malawi.,Department of Emergency Medicine, University Health Network, Toronto, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, Canada
| | - Courtney Thompson
- Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Canada.,London School of Tropical Medicine and Hygiene, London, UK
| | - Edson Mwinjiwa
- Dignitas International-Malawi Country Program, Zomba, Malawi.,Tisungane Clinic, Zomba Central Hospital, Malawi Ministry of Health, Zomba, Malawi
| | - Edith Thaulo
- Tisungane Clinic, Zomba Central Hospital, Malawi Ministry of Health, Zomba, Malawi
| | - Chrissie Gondwe
- Dignitas International-Malawi Country Program, Zomba, Malawi.,Tisungane Clinic, Zomba Central Hospital, Malawi Ministry of Health, Zomba, Malawi
| | - Harriet Akello
- Dignitas International-Malawi Country Program, Zomba, Malawi.,Tisungane Clinic, Zomba Central Hospital, Malawi Ministry of Health, Zomba, Malawi
| | - Adrienne K Chan
- Dignitas International-Malawi Country Program, Zomba, Malawi. .,Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Canada. .,Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, Canada. .,Institute for Health Policy, Management and Evaluation and Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
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Miyano S, Syakantu G, Komada K, Endo H, Sugishita T. Cost-effectiveness analysis of the national decentralization policy of antiretroviral treatment programme in Zambia. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2017; 15:4. [PMID: 28413361 PMCID: PMC5388995 DOI: 10.1186/s12962-017-0065-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 03/24/2017] [Indexed: 11/23/2022] Open
Abstract
Background In resource-limited settings with a high prevalence of human immunodeficiency virus (HIV) infection such as Zambia, decentralization of HIV/acquired immunodeficiency syndrome (HIV/AIDS) treatment and care with effective use of resources is a cornerstone of universal treatment and care. Objectives This research aims to analyse the cost effectiveness of the National Mobile Antiretroviral Therapy (ART) Services Programme in Zambia as a means of decentralizing ART services. Methods Cost-effectiveness analyses were performed using a decision analytic model and Markov model to compare the original ART programme, ‘Hospital-based ART’, with the intervention programme, Hospital-based plus ‘Mobile ART’, from the perspective of the district government health office in Zambia. The total cost of ART services, quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs) were examined. Results The mean annual per-patient costs were 1259.16 USD for the original programme and 2601.02 USD for the intervention programme, while the mean number of QALYs was 6.81 for the original and 7.27 for the intervention programme. The ICER of the intervention programme relative to the original programme was 2965.17 USD/QALY, which was much below the willingness-to-pay (WTP), or three times the GDP per capita (4224 USD), but still over the GDP per capita (1408 USD). In the sensitivity analysis, the ICER of the intervention programme did not substantially change. Conclusion The National Mobile ART Services Programme in Zambia could be a cost-effective approach to decentralizing ART services into rural areas in Zambia. This programme could be expanded to more districts where it has not yet been introduced to improve access to ART services and the health of people living with HIV (PLHIV) in rural areas. Electronic supplementary material The online version of this article (doi:10.1186/s12962-017-0065-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Shinsuke Miyano
- Bureau of International Health Cooperation, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655 Japan
| | - Gardner Syakantu
- Department of Clinical Care and Diagnostic Services, Ministry of Health Zambia, Lusaka, Zambia
| | - Kenichi Komada
- Bureau of International Health Cooperation, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655 Japan
| | - Hiroyoshi Endo
- Graduate School of Public Health, St. Luke's International University, Tokyo, Japan
| | - Tomohiko Sugishita
- Department of International Affairs and Tropical Medicine, Tokyo Women's University, Tokyo, Japan
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Patient Experiences of Decentralized HIV Treatment and Care in Plateau State, North Central Nigeria: A Qualitative Study. AIDS Res Treat 2017; 2017:2838059. [PMID: 28331636 PMCID: PMC5346378 DOI: 10.1155/2017/2838059] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 12/01/2016] [Accepted: 12/07/2016] [Indexed: 11/23/2022] Open
Abstract
Background. Decentralization of care and treatment for HIV infection in Africa makes services available in local health facilities. Decentralization has been associated with improved retention and comparable or superior treatment outcomes, but patient experiences are not well understood. Methods. We conducted a qualitative study of patient experiences in decentralized HIV care in Plateau State, north central Nigeria. Five decentralized care sites in the Plateau State Decentralization Initiative were purposefully selected. Ninety-three patients and 16 providers at these sites participated in individual interviews and focus groups. Data collection activities were audio-recorded and transcribed. Transcripts were inductively content analyzed to derive descriptive categories representing patient experiences of decentralized care. Results. Patient participants in this study experienced the transition to decentralized care as a series of “trade-offs.” Advantages cited included saving time and money on travel to clinic visits, avoiding dangers on the road, and the “family-like atmosphere” found in some decentralized clinics. Disadvantages were loss of access to ancillary services, reduced opportunities for interaction with providers, and increased risk of disclosure. Participants preferred decentralized services overall. Conclusion. Difficulty and cost of travel remain a fundamental barrier to accessing HIV care outside urban centers, suggesting increased availability of community-based services will be enthusiastically received.
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Dovel K, Yeatman S, van Oosterhout JJ, Chan A, Mantengeni A, Landes M, Bedell R, Kawalazira G, Sodhi S. Trends in ART Initiation among Men and Non-Pregnant/Non-Breastfeeding Women before and after Option B+ in Southern Malawi. PLoS One 2016; 11:e0165025. [PMID: 28002413 PMCID: PMC5176160 DOI: 10.1371/journal.pone.0165025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 10/05/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Option B+ is promoted as a key component to eliminating vertical transmission of HIV; however, little is known about the policy's impact on non-targeted populations, such as men and non-pregnant/non-breastfeeding women. We compare ART uptake among non-targeted populations during pre/post Option B+ periods in Zomba District, Malawi. METHODS Individual-level ART registry data from 27 health facilities were digitized and new ART initiates were disaggregated by sex and type of initiate (Option B+ or not). Data were analyzed over the pre- (January 2009-June 2011) and post- (July 2011- December 2013) Option B+ periods. RESULTS After the implementation of Option B+, the total number of new female initiates increased significantly (quarterly median: 547 vs. 816; P = 0.001) and their median age decreased from 34 to 31 years (P = <0.001). Both changes were the result of the rapid and sustained uptake of ART among Option B+ clients. Post-policy, Option B+ clients represented 48% of all new female initiates while the number of females who initiated through CD4 or WHO staging criteria significantly decreased (quarterly median: 547 vs. 419; P = 0.005). The number and age of male initiates remained stable; however, the proportion of men among new initiates decreased (36% vs. 31%; P = <0.001). CONCLUSIONS Option B+ shifted the profile of first-time initiates towards younger and fertile women. Declines among non-Option B+ women most likely reflect earlier initiation during pregnancies before deteriorations in health. The decreased proportion of men among first-time initiates represents a growing gender disparity in HIV services that deserves immediate attention.
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Affiliation(s)
- Kathryn Dovel
- Center for World Health, Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, United States of America
- * E-mail:
| | - Sara Yeatman
- Department of Health and Behavioral Sciences, University of Colorado Denver, Denver, United States of America
| | - Joep J. van Oosterhout
- Department of Medicine, University of Malawi College of Medicine, Blantyre, Malawi
- Dignitas International, Zomba, Malawi
| | - Adrienne Chan
- Dignitas International, Zomba, Malawi
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | | | - Megan Landes
- Dignitas International, Zomba, Malawi
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
| | | | | | - Sumeet Sodhi
- Dignitas International, Zomba, Malawi
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- Department of Family and Community Medicine, University Health Network, Toronto Western Hospital, Toronto, Canada
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Mutenda N, Bukowski A, Nitschke AM, Nakanyala T, Hamunime N, Mekonen T, Tjituka F, Mazibuko G, Mwinga S, Mabirizi D, Sagwa E, Indongo R, Dean N, Jordan MR, Hong SY. Assessment of the World Health Organization's HIV Drug Resistance Early Warning Indicators in Main and Decentralized Outreach Antiretroviral Therapy Sites in Namibia. PLoS One 2016; 11:e0166649. [PMID: 27906995 PMCID: PMC5132260 DOI: 10.1371/journal.pone.0166649] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 11/01/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The World Health Organization (WHO) early warning indicators (EWIs) of HIV drug resistance (HIVDR) assess factors at individual ART sites that are known to create situations favourable to the emergence of HIVDR. METHODS In 2014, the Namibia HIV care and treatment program abstracted the following adult and pediatric EWIs from all public ART sites (50 main sites and 143 outreach sites): On-time pill pick-up, Retention in care, Pharmacy stock-outs, Dispensing practices, and Viral load suppression. Comparisons were made between main and outreach sites and between 2014 and 2012 using the Wilcoxon signed-rank test in a matched analysis. RESULTS The national estimates were: On-time pill pick-up 81.9% (95% CI 81.1-82.8) for adults and 82.4% (81.3-83.4) for pediatrics, Retention in care 79% retained on ART after 12 months for adults and 82% for pediatrics, Pharmacy stock-outs 94% of months without a stock-out for adults and 88% for pediatrics, and Dispensing practices 0.01% (0.001-0.056) dispensed mono- or dual-therapy for adults and 0.01% (0.001-0.069) for pediatrics. Viral load suppression was significantly affected by low rates of Viral load completion. Main sites had higher On-time pill pick-up than outreach sites for adults (p<0.001) and pediatrics (p<0.001), and no difference between main and outreach sites for Retention in care for adults (p = 0.761) or pediatrics (p = 0.214). From 2012 to 2014 in adult sites, On-time pill pick-up (p = 0.001), Retention in care (p<0.001), and Pharmacy stock-outs (p = 0.002) worsened. In pediatric sites, On-time pill pick-up (p<0.001) and Pharmacy stock-outs (p = 0.012) worsened. CONCLUSIONS Results of EWIs monitoring in Namibia provide evidence about ART programmatic functioning and contextualize results from national surveys of HIVDR. These results are worrisome as they show a decline in program performance over time. The national ART program is taking steps to minimize the emergence of HIVDR by strengthening adherence and retention of patients on ART, reducing stock-outs, and strengthening ART data quality.
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Affiliation(s)
- Nicholus Mutenda
- Directorate of Special Programmes, Republic of Namibia Ministry of Health and Social Services, Windhoek, Namibia
| | - Alexandra Bukowski
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts, United States of America
| | - Anne-Marie Nitschke
- Directorate of Special Programmes, Republic of Namibia Ministry of Health and Social Services, Windhoek, Namibia
| | - Tuli Nakanyala
- Directorate of Special Programmes, Republic of Namibia Ministry of Health and Social Services, Windhoek, Namibia
| | - Ndapewa Hamunime
- Directorate of Special Programmes, Republic of Namibia Ministry of Health and Social Services, Windhoek, Namibia
| | - Tadesse Mekonen
- Directorate of Special Programmes, Republic of Namibia Ministry of Health and Social Services, Windhoek, Namibia
| | - Francina Tjituka
- Directorate of Special Programmes, Republic of Namibia Ministry of Health and Social Services, Windhoek, Namibia
| | - Greatjoy Mazibuko
- Systems for Improved Access to Pharmaceuticals and Services (SIAPS), Management Sciences for Health, Windhoek, Namibia
| | - Samson Mwinga
- Systems for Improved Access to Pharmaceuticals and Services (SIAPS), Management Sciences for Health, Windhoek, Namibia
| | - David Mabirizi
- Systems for Improved Access to Pharmaceuticals and Services (SIAPS), Management Sciences for Health, Windhoek, Namibia
| | - Evans Sagwa
- Systems for Improved Access to Pharmaceuticals and Services (SIAPS), Management Sciences for Health, Windhoek, Namibia
| | - Rosalia Indongo
- United States Agency for International Development, Windhoek, Namibia
| | - Natalie Dean
- Department of Biostatistics, University of Florida, Gainesville, Florida, United States of America
| | - Michael R. Jordan
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts, United States of America
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts, United States of America
| | - Steven Y. Hong
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts, United States of America
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts, United States of America
- * E-mail:
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Brophy JC, Hawkes MT, Mwinjiwa E, Mateyu G, Sodhi SK, Chan AK. Survival Outcomes in a Pediatric Antiretroviral Treatment Cohort in Southern Malawi. PLoS One 2016; 11:e0165772. [PMID: 27812166 PMCID: PMC5094712 DOI: 10.1371/journal.pone.0165772] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Accepted: 10/18/2016] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Pediatric uptake and outcomes in antiretroviral treatment (ART) programmes have lagged behind adult programmes. We describe outcomes from a population-based pediatric ART cohort in rural southern Malawi. METHODS Data were analyzed on children who initiated ART from October/2003 -September/2011. Demographics and diagnoses were described and survival analyses conducted to assess the impact of age, presenting features at enrolment, and drug selection. RESULTS The cohort consisted of 2203 children <15 years of age. Age at entry was <1 year for 219 (10%), 1-1.9 years for 343 (16%), 2-4.9 years for 584 (27%), and 5-15 years for 1057 (48%) patients. Initial clinical diagnoses of tuberculosis and wasting were documented for 409 (19%) and 523 (24%) patients, respectively. Median follow-up time was 1.5 years (range 0-8 years), with 3900 patient-years of follow-up. Over the period of observation, 134 patients (6%) died, 1324 (60%) remained in the cohort, 345 (16%) transferred out, and 387 (18%) defaulted. Infants <1 year of age accounted for 19% of deaths, with a 2.7-fold adjusted mortality hazard ratio relative to 5-15 year olds; median time to death was also shorter for infants (60 days) than older children (108 days). Survival analysis demonstrated younger age at ART initiation, more advanced HIV stage, and presence of tuberculosis to each be associated with shorter survival time. Among children <5 years, severe wasting (weight-for-height z-score </ = -3.0) was also associated with reduced survival. CONCLUSIONS Cumulative incidence of mortality was 5.2%, 7.1% and 7.7% after 1, 3, and 5 years, respectively, with disproportionate mortality in infants <1 year of age and those presenting with tuberculosis. These findings reinforce the urgent need for early diagnosis and treatment in this population, but also demonstrate that provision of pediatric care in a rural setting can yield outcomes comparable to more resourced urban settings of poor countries.
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Affiliation(s)
- Jason C. Brophy
- Dignitas International, Zomba, Malawi
- Department of Pediatrics, University of Ottawa, Children’s Hospital of Eastern Ontario, Ottawa, Canada
- * E-mail:
| | - Michael T. Hawkes
- Department of Pediatrics, University of Alberta, Stollery Children’s Hospital, Edmonton, Canada
| | - Edson Mwinjiwa
- Zomba Central Hospital, Ministry of Health, Zomba, Malawi
| | | | - Sumeet K. Sodhi
- Dignitas International, Zomba, Malawi
- Department of Family and Community Medicine, University of Toronto, University Health Network, Toronto, Canada
| | - Adrienne K. Chan
- Dignitas International, Zomba, Malawi
- Department of Medicine, University of Toronto, Sunnybrook Hospital, Toronto, Canada
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Dziuban EJ, Rivadeneira ED. Universal Antiretroviral Treatment Eligibility for Children and Adolescents Living With HIV: A New Era. Pediatr Infect Dis J 2016; 35:1225-1228. [PMID: 27294308 PMCID: PMC6403488 DOI: 10.1097/inf.0000000000001276] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Antiretroviral treatment coverage for children living with HIV is low, and new efforts are underway to expand eligibility so that all children and adolescents qualify for the treatment regardless of immune suppression or clinical stage. Although recent trials provide direct evidence of the benefit of this approach in adults, no such studies have been performed in children. This report examines the available body of evidence regarding universal HIV treatment for children and adolescents and assesses the benefits and challenges both at individual patient health, as well as at programmatic level. Universal treatment eligibility for children with HIV has great potential for improved growth and neurodevelopment and fewer morbidities for children, and treatment coverage would be expected to increase through guideline simplification. However, concerns regarding toxicities, drug resistance and costs require careful planning. Successful implementation will depend on effective strategies for case-finding, treatment adherence support and program monitoring that will contribute to the growing evidence base for this pivotal pediatric HIV policy shift.
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Insights into Adherence among a Cohort of Adolescents Aged 12-20 Years in South Africa: Reported Barriers to Antiretroviral Treatment. AIDS Res Treat 2016; 2016:4161738. [PMID: 27867661 PMCID: PMC5102702 DOI: 10.1155/2016/4161738] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 10/05/2016] [Indexed: 12/27/2022] Open
Abstract
Adolescents experience disproportionately high rates of poor ART outcomes compared to adults despite prolonged use of antiretroviral therapy in Southern African treatment programs, presenting a significant challenge to national attempts to meet the UNAIDS 90-90-90 targets for 2020. This cohort study among adolescents aged 12-20 years accessing ART care at two urban public-sector clinics in Johannesburg between September and November 2013 aimed to identify factors potentially associated with poor attendance at clinic visits. Patients were followed up through routine medical records to identify missed visits (failing to attend clinic within 30 days of scheduled visit date) up to 2 years after enrolment. We enrolled 126 adolescents on ART for a median of 6.3 years (IQR: 2.7-8.4). A total of 47 (38%) adolescents missed a scheduled visit within 24 months of enrolment. Older adolescents (18-20 years) were more likely to miss a visit compared to adolescents aged 12-14 years (risk ratio (RR) = 1.72; 95% CI: 1.00-2.95). Those who were identified to have difficulty in taking medication (RR = 1.57; 95% CI: 1.13-2.18) as a barrier to care were more likely to miss a visit compared to adolescents who did not. Awareness of treatment fatigue, challenges to taking ART, and caregiver difficulties is important when considering interventions to improve treatment outcomes among adolescents.
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Decentralization of health systems in low and middle income countries: a systematic review. Int J Public Health 2016; 62:219-229. [DOI: 10.1007/s00038-016-0872-2] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 07/22/2016] [Accepted: 07/26/2016] [Indexed: 11/26/2022] Open
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Rachlis B, Bakoyannis G, Easterbrook P, Genberg B, Braithwaite RS, Cohen CR, Bukusi EA, Kambugu A, Bwana MB, Somi GR, Geng EH, Musick B, Yiannoutsos CT, Wools-Kaloustian K, Braitstein P. Facility-Level Factors Influencing Retention of Patients in HIV Care in East Africa. PLoS One 2016; 11:e0159994. [PMID: 27509182 PMCID: PMC4980048 DOI: 10.1371/journal.pone.0159994] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 07/12/2016] [Indexed: 12/25/2022] Open
Abstract
Losses to follow-up (LTFU) remain an important programmatic challenge. While numerous patient-level factors have been associated with LTFU, less is known about facility-level factors. Data from the East African International epidemiologic Databases to Evaluate AIDS (EA-IeDEA) Consortium was used to identify facility-level factors associated with LTFU in Kenya, Tanzania and Uganda. Patients were defined as LTFU if they had no visit within 12 months of the study endpoint for pre-ART patients or 6 months for patients on ART. Adjusting for patient factors, shared frailty proportional hazard models were used to identify the facility-level factors associated with LTFU for the pre- and post-ART periods. Data from 77,362 patients and 29 facilities were analyzed. Median age at enrolment was 36.0 years (Interquartile Range: 30.1, 43.1), 63.9% were women and 58.3% initiated ART. Rates (95% Confidence Interval) of LTFU were 25.1 (24.7–25.6) and 16.7 (16.3–17.2) per 100 person-years in the pre-ART and post-ART periods, respectively. Facility-level factors associated with increased LTFU included secondary-level care, HIV RNA PCR turnaround time >14 days, and no onsite availability of CD4 testing. Increased LTFU was also observed when no nutritional supplements were provided (pre-ART only), when TB patients were treated within the HIV program (pre-ART only), and when the facility was open ≤4 mornings per week (ART only). Our findings suggest that facility-based strategies such as point of care laboratory testing and separate clinic spaces for TB patients may improve retention.
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Affiliation(s)
- Beth Rachlis
- The Ontario HIV Treatment Network, Toronto, Canada.,Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Giorgos Bakoyannis
- Department of Biostatistics, Richard Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana, United States of America
| | | | - Becky Genberg
- Department of Health Services, Brown University, Providence, Rhode Island, United States of America
| | - Ronald Scott Braithwaite
- Department of Population Health, School of Medicine, New York University, New York, New York, United States of America
| | - Craig R Cohen
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - Elizabeth A Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Mwebesa Bosco Bwana
- Department of Internal Medicine, Mbarara University of Science & Technology, Mbarara, Uganda
| | | | - Elvin H Geng
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Beverly Musick
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Constantin T Yiannoutsos
- Department of Biostatistics, Richard Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana, United States of America
| | - Kara Wools-Kaloustian
- Division of Infectious Diseases, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Paula Braitstein
- Academic Model Providing Access To Healthcare (AMPATH), Eldoret, Kenya.,Department of Medicine, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya.,Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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Identifying common barriers and facilitators to linkage and retention in chronic disease care in western Kenya. BMC Public Health 2016; 16:741. [PMID: 27503191 PMCID: PMC4977618 DOI: 10.1186/s12889-016-3462-6] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Accepted: 08/05/2016] [Indexed: 11/27/2022] Open
Abstract
Background Sub-Saharan Africa is increasingly being challenged in providing care and treatment for chronic diseases, both communicable and non-communicable. In order to address the challenges of linkage to and retention in chronic disease management, there is the need to understand the factors that can influence engagement in care. We conducted a qualitative study to identify barriers and facilitators to linkage and retention in chronic care for HIV, tuberculosis (TB) and Hypertension (HTN) as part of the Academic Model Providing Access to Healthcare (AMPATH) program in western Kenya. Methods In-depth interviews and focus group discussions were conducted July 2012-August 2013. Study participants were purposively sampled from three AMPATH clinics and included patients within the AMPATH program receiving HIV, TB, and HTN care, as well as caregivers of children with HIV, community leaders, and healthcare providers. A set of interview guides were developed to explore perceived barriers and facilitators to chronic disease management, particularly related to linkage to and retention in HIV, TB and HTN care. Data were coded and various themes were identified. We organized the concepts and themes generated using the Andersen-Newman Framework of Health Services Utilization. Results A total of 235 participants including 110 individuals living with HIV (n = 50), TB (n = 39), or HTN (n = 21); 24 caregivers; 10 community leaders; and 62 healthcare providers participated. Barriers and facilitators were categorized as predisposing characteristics, enabling resources and need factors. Many of the facilitators and barriers reported in this study were consistently reported across disease categories including personal drive, patient-provider relationships and the need for social and peer support. Conclusions Our findings provide insight into the individual as well as broader structural factors that can deter or encourage linkage and retention that are relevant across communicable and non-communicable chronic diseases. The findings of the present study suggest that interventions should consider the logistical aspects of accessing care in addition to predisposing and need factors that may affect an individuals’ decision to seek out and remain in appropriate care.
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Determinants of time to antiretroviral treatment initiation and subsequent mortality on treatment in a cohort in rural northern Malawi. AIDS Res Ther 2016; 13:24. [PMID: 27398087 PMCID: PMC4938927 DOI: 10.1186/s12981-016-0110-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 06/30/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To optimise care HIV patients need to be promptly initiated on antiretroviral therapy (ART) and subsequently retained on treatment. In this study we report on the interval between enrolment and treatment initiation, and investigate subsequent attrition and mortality of patients on ART at a rural clinic in Malawi. METHODS HIV-positive individuals were recruited to a cohort study between January 2008 and August 2011 at Chilumba Rural Hospital (CRH). Outcomes were ascertained, up to 7 years after enrolment, through follow-up and by linkage to ART registers and the Karonga Health and Demographic Surveillance System (KHDSS). Kaplan-Meier methods and Cox regression were used to examine ART initiation after enrolment, mortality after ART initiation, and attrition after ART initiation. RESULTS Of the 617 individuals recruited, 523 initiated ART between January 2008 and January 2015. Median time from HIV testing to commencement of ART was 59 days (IQR: 10-330). By a year after enrolment 74.2 % (95 % CI 70.6-77.7 %) had initiated ART. Baseline clinical data at ART initiation and data on attrition was only available for the 438 individuals who initiated ART during active follow-up, between January 2008 and August 2011. Of these individuals, 6 were missing Ministry of Health numbers, leaving 432 included in analyses of attrition and mortality. At 4 years after ART initiation 71.3 % (95 % CI 65.7-76.2 %) of these patients were retained on treatment at the CRH and 17.2 % (95 % CI 13.8-21.4 %) had died. Participants who had a lower CD4 count at enrolment (≤350 cells/μl), enrolled in 2008, or tested for HIV at the CRH rather than through serosurveys, initiated treatment faster. Once on treatment, mortality rates were higher in patients who were HIV tested at the CRH, male, older (≥35 years), missing a CD4 count, or underweight (BMI < 18.5) at ART initiation. CONCLUSIONS Through linkage to the KHDSS and ART registers it was possible to continue follow-up beyond the end of the initial cohort study. Annual mortality after ART initiation remained considerable over a period of 4 years. Greater access to HIV and CD4 testing alongside initiation at higher CD4 counts, as planned in the test and treat strategy, could reduce this mortality.
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Rachlis B, Cole DC, van Lettow M, Escobar M. Survival functions for defining a clinical management Lost To Follow-Up (LTFU) cut-off in Antiretroviral Therapy (ART) program in Zomba, Malawi. BMC Med Inform Decis Mak 2016; 16:52. [PMID: 27150958 PMCID: PMC4857410 DOI: 10.1186/s12911-016-0290-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 04/30/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND While, lost to follow-up (LTFU) from antiretroviral therapy (ART) can be considered a catch-all category for patients who miss scheduled visits or medication pick-ups, operational definitions and methods for defining LTFU vary making comparisons across programs challenging. Using weekly cut-offs, we sought to determine the probability that an individual would return to clinic given that they had not yet returned in order to identify the LTFU cut-off that could be used to inform clinical management and tracing procedures. METHODS Individuals who initiated ART with Dignitas International supported sites (n = 22) in Zomba, Malawi between January 1 2007-June 30 2010 and were ≥ 1 week late for a follow-up visit were included. Lateness was categorized using weekly cut-offs from ≥1 to ≥26 weeks late. At each weekly cut-off, the proportion of patients who returned for a subsequent follow-up visit were identified. Cumulative Distribution Functions (CDFs) were plotted to determine the probability of returning as a function of lateness. Hazard functions were plotted to demonstrate the proportion of patients who returned each weekly interval relative to those who had yet to return. RESULTS In total, n = 4484 patients with n = 7316 follow-up visits were included. The number of included follow-up visits per patient ranged from 1-10 (median: 1). Both the CDF and hazard function demonstrated that after being ≥9 weeks late, the proportion of new patients who returned relative to those who had yet to return decreased substantially. CONCLUSIONS We identified a LTFU definition useful for clinical management. The simple functions plotted here did not require advanced statistical expertise and were created using Microsoft Excel, making it a particularly practical method for HIV programs in resource-constrained settings.
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Affiliation(s)
- Beth Rachlis
- The Ontario HIV Treatment Network, Toronto, Canada
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Donald C Cole
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Monique van Lettow
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
- Dignitas International, Zomba, Malawi.
| | - Michael Escobar
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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Same day HIV diagnosis and antiretroviral therapy initiation affects retention in Option B+ prevention of mother-to-child transmission services at antenatal care in Zomba District, Malawi. J Int AIDS Soc 2016; 19:20672. [PMID: 26976377 PMCID: PMC4789547 DOI: 10.7448/ias.19.1.20672] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 01/13/2016] [Accepted: 01/28/2016] [Indexed: 11/29/2022] Open
Abstract
Introduction Data from the Option B+ prevention of mother-to-child transmission (PMTCT) program in Malawi show considerable variation between health facilities in retention on antiretroviral therapy (ART). In a programmatic setting, we studied whether the “model of care,” based on the degree of integration of antenatal care (ANC), HIV testing and counselling (HTC) and ART service provision–influenced uptake of and retention on ART. Methods We conducted a retrospective cohort study of pregnant women seeking ANC at rural primary health facilities in Zomba District, Malawi. Data were extracted from standardized national ANC registers, ART registers and ART master cards. The “model of care” of Option B+ service delivery was determined at each health facility, based on the degree of integration of ANC, HTC and ART. Full integration (Model 1) of HTC and ART initiation at ANC was compared with integration of HTC only into ANC services (Model 2) with subsequent referral to an existing ART clinic for treatment initiation. Results and discussion A total of 10,528 women were newly registered at ANC between October 2011 and March 2012 in 23 rural health facilities (12 were Model 1 and 11 Model 2). HIV status was ascertained in 8,572 (81%) women. Among 914/8,572 (9%) HIV-positive women enrolling at ANC, 101/914 (11%) were already on ART; of those not on treatment, 456/813 (56%) were started on ART. There was significantly higher ART uptake in Model 1 compared with Model 2 sites (63% vs. 51%; p=0.001), but significantly lower ART retention in Model 1 compared with Model 2 sites (79% vs. 87%; p=0.02). Multivariable analysis showed that initiation of ART on the same day as HIV diagnosis, but not model of care, was independently associated with reduced retention in the first six months (adjusted odds ratio 2.27; 95% CI: 1.34–3.85; p=0.002). Conclusions HIV diagnosis and treatment on the same day was associated with reduced retention on ART, independent of the level of PMTCT service integration at ANC.
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Implementation and Operational Research: Risk Factors of Loss to Follow-up Among HIV-Positive Pediatric Patients in Dar es Salaam, Tanzania. J Acquir Immune Defic Syndr 2016; 70:e73-83. [PMID: 26247894 DOI: 10.1097/qai.0000000000000782] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To identify risk factors for loss to follow-up (LTFU) in an HIV-infected pediatric population in Dar es Salaam, Tanzania, between 2004 and 2011. DESIGN Longitudinal analysis of 6236 HIV-infected children. METHODS We conducted a prospective cohort study of 6236 pediatric patients enrolled in care and treatment in Dar es Salaam from October 2004 to September 2011. LTFU was defined as missing a clinic visit for >90 days for patients on ART and for >180 days for patients in care and monitoring. The relationship of baseline and time-varying characteristics to the risk of LTFU was examined using a Cox proportional hazards model. RESULTS A total of 2130 children (34%) were LTFU over a median follow-up of 16.7 months (interquartile range, 3.4-36.9). Factors independently associated with a higher risk of LTFU were age ≤2 years (relative risk [RR] = 1.59, 95% CI: 1.40 to 1.80), diarrhea at enrollment (RR = 1.20, 95% CI: 1.03 to 1.41), a low mid-upper arm circumference for age (RR = 1.20, CI: 1.05 to 1.37), eating protein-rich foods ≤3 times a week (RR = 1.39, 95% CI: 1.05 to 1.90), taking cotrimoxazole (RR = 1.39, 95% CI: 1.06 to 1.81), initiating onto antiretrovirals (RR = 1.37, 95% CI: 1.17 to 1.61), receiving treatment at a hospital instead of a local facility (RR = 1.39, 95% CI: 1.06 to 1.41), and starting treatment in 2006 or later (RR = 1.10, 95% CI: 1.04 to 1.16). CONCLUSIONS Health workers should be aware of pediatric patients who are at a greatest risk of LTFU, such as younger and undernourished patients, so that they can proactively counsel families about the importance of visit adherence. Findings support decentralization of HIV care to local facilities as opposed to hospitals.
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Onwujekwe O, Chikezie I, Mbachu C, Chiegil R, Torpey K, Uzochukwu B. Investigating client perception and attitude to decentralization of HIV/AIDS treatment services to primary health centres in three Nigerian states. Health Expect 2015; 19:1111-20. [PMID: 26315401 PMCID: PMC5054887 DOI: 10.1111/hex.12403] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2015] [Indexed: 11/28/2022] Open
Abstract
Background The opinions of consumers in decentralization provide insights into possible levels of improvement in access and uptake of services. Objectives The study examined clients' perception and attitude towards decentralization of antiretroviral treatment services from central hospitals to primary health centres (PHCs). Methodology A cross‐sectional survey was undertaken in three states in Nigeria. A total of 1265 exit interviews were conducted with HIV/AIDS clients in nine health facilities. Findings About a third of all the respondents were not comfortable with receiving ART services in a PHC facility close to where they live. The reasons given by 385 respondents who would not want their treatment centres near were as follows: fear of disclosure, 299 (80.4%); fear of being discriminated against, 278 (74.3%); and satisfaction with care received at current facility, 278 (74.3%). However, more than 90% of respondents in all three states felt that decentralization of ART services to PHCs would be beneficial in controlling HIV/AIDS in Nigeria; the difference in respondents' perception across the three state was found to be statistically significant (P < 0.001). Conclusion The findings imply that scaling‐up of treatment services to PHCs would be widely accepted, and probably result in increased uptake. However, this must be accompanied by targeted behaviour change interventions for clients who for the fear of disclosure and stigma would still not access care from proximate facilities.
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Affiliation(s)
- Obinna Onwujekwe
- Department of Pharmacology and Therapeutics, College of Medicine, University of Nigeria, Enugu, Nigeria.
| | - Ifeanyi Chikezie
- Health Policy Research Group, University of Nigeria, Enugu, Nigeria
| | - Chinyere Mbachu
- Health Policy Research Group, University of Nigeria, Enugu, Nigeria
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Okeke NL, Ostermann J, Thielman NM. Enhancing linkage and retention in HIV care: a review of interventions for highly resourced and resource-poor settings. Curr HIV/AIDS Rep 2015; 11:376-92. [PMID: 25323298 DOI: 10.1007/s11904-014-0233-9] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Given the widespread availability of effective antiretroviral therapy, engagement of HIV-infected persons in care is a global priority. We reviewed 51 studies, published in the past decade, assessing strategies for improving linkage to and retention in HIV care. The review included studies from highly resourced settings (HRS) and resource-poor settings (RPS), specifically the USA and sub-Saharan Africa. In HRS, strength-based case management was best supported for improving linkage and retention in care; peer navigation and clinic-based health promotion were supported for improving retention. In RPS, point of care CD4 testing was best supported for improving linkage to care; decentralization, and task-shifting for improving retention. Novel interventions continue to emerge in HRS and RPS, yet many strategies have not been adequately evaluated. Further consideration should be given to analyses that identify which interventions, or combinations of interventions, are most effective, cost-effective, scalable, and aligned with patient preferences for HIV care.
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Affiliation(s)
- N Lance Okeke
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, NC, USA,
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Implementation and Operational Research: Evaluation of Swaziland's Hub-and-Spoke Model for Decentralizing Access to Antiretroviral Therapy Services. J Acquir Immune Defic Syndr 2015; 69:e1-12. [PMID: 25942465 DOI: 10.1097/qai.0000000000000547] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND In 2007, Swaziland initiated a hub-and-spoke model for decentralizing antiretroviral therapy (ART) access. Decentralization was facilitated through (1) down-referral of stable ART patients from overburdened central facilities (hubs) to primary health care clinics (spokes) and (2) ART initiation at spokes (spoke initiation). METHODS We conducted a nationally representative retrospective cohort study among adult ART enrollees during 2004-2010 to assess the effect of down-referral and spoke-initiation on rates of loss to follow-up (LTFU), death, and attrition (death or LTFU). Sixteen of 31 hubs were randomly selected using probability-proportional-to-size sampling. Seven selected facilities had initiated the hub-and-spoke model by study start. At these facilities, 1149 of 24,782 hub-initiated and maintained and 878 of 7722 down-referred or spoke-initiated patient records were randomly selected and analyzed. At the 9 hub-only facilities, 483 of 6638 records were randomly selected and analyzed. Multivariable proportional hazards regression was used to assess effect of down-referral (a time-varying covariate) and spoke-initiation on outcomes. RESULTS At ART initiation, median age was 35, 65% were female, and median CD4 count was 147 cells per microliter. Controlling for known confounders, down-referral was strongly protective against LTFU [adjusted hazard ratio (AHR) 0.38; 95% confidence interval (CI): 0.29 to 0.50] and attrition (AHR = 0.50; 95% CI: 0.34 to 0.76) but not mortality. Compared with hub-initiated and maintained patients, spoke-initiated patients had lower LTFU (AHR 0.59; 95% CI: 0.45 to 0.77) and attrition rates (AHR 0.60; 95% CI: 0.47 to 0.77), but not mortality. CONCLUSIONS Down-referral and spoke-initiation within a hub-and-spoke ART decentralization model were protective against LTFU and overall attrition and could facilitate future ART program expansion.
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Jacobson KB, Moll AP, Friedland GH, Shenoi SV. Successful Tuberculosis Treatment Outcomes among HIV/TB Coinfected Patients Down-Referred from a District Hospital to Primary Health Clinics in Rural South Africa. PLoS One 2015; 10:e0127024. [PMID: 25993636 PMCID: PMC4438008 DOI: 10.1371/journal.pone.0127024] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Accepted: 04/10/2015] [Indexed: 12/12/2022] Open
Abstract
Background HIV and tuberculosis (TB) coinfection remains a major public health threat in sub-Saharan Africa. Integration and decentralization of HIV and TB treatment services are being implemented, but data on outcomes of this strategy are lacking in rural, resource-limited settings. We evaluated TB treatment outcomes in TB/HIV coinfected patients in an integrated and decentralized system in rural KwaZulu-Natal, South Africa. Methods We retrospectively studied a cohort of HIV/TB coinfected patients initiating treatment for drug-susceptible TB at a district hospital HIV clinic from January 2012-June 2013. Patients were eligible for down-referral to primary health clinics(PHCs) for TB treatment completion if they met specific clinical criteria. Records were reviewed for patients’ demographic, baseline clinical and laboratory information, past HIV and TB history, and TB treatment outcomes. Results Of 657(88.7%) patients, 322(49.0%) were female, 558(84.9%) were new TB cases, and 572(87.1%) had pulmonary TB. After TB treatment initiation, 280(42.6%) were down-referred from the district level HIV clinic to PHCs for treatment completion; 377(57.4%) remained at the district hospital. Retained patients possessed characteristics indicative of more severe disease. In total, 540(82.2%) patients experienced treatment success, 69(10.5%) died, and 46(7.0%) defaulted. Down-referred patients experienced higher treatment success, and lower mortality, but were more likely to default, primarily at the time of transfer to PHC. Conclusion Decentralization of TB treatment to the primary care level is feasible in rural South Africa. Treatment outcomes are favorable when patients are carefully chosen for down-referral. Higher mortality in retained patients reflects increased baseline disease severity while higher default among down-referred patients reflects failed linkage of care. Better linkage mechanisms are needed including improved identification of potential defaulters, increased patient education, active communication between hospitals and PHCs, and tracing of patients lost to follow up. Decentralized and integrated care is successful for carefully selected TB/HIV coinfected patients and should be expanded.
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Affiliation(s)
- Karen B. Jacobson
- Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Anthony P. Moll
- Church of Scotland Hospital, Tugela Ferry, KwaZulu-Natal, South Africa
| | - Gerald H. Friedland
- Department of Medicine, Section of Infectious Diseases, AIDS Program, Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - Sheela V. Shenoi
- Department of Medicine, Section of Infectious Diseases, AIDS Program, Yale University School of Medicine, New Haven, Connecticut, United States of America
- * E-mail:
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Decentralization of HIV care and treatment services in Central Province, Kenya. J Acquir Immune Defic Syndr 2015; 67:e34-40. [PMID: 24977728 DOI: 10.1097/qai.0000000000000264] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Since 2006, the government of Kenya began decentralizing HIV care from secondary health facilities (SHF) to an expanded network, including primary health facilities (PHF). We evaluated the impact of this strategy on enrollment, care, and outcomes among adult patients in Central Province, Kenya, from 2006 to 2010. METHODS We analyzed electronic patient-level data for 26,690 patients at 15 SHF and 22 PHF. Enrollment, patient, and facility characteristics and patterns in CD4 testing, World Health Organization staging, and antiretroviral treatment (ART) initiation were compared between SHF and PHF. Survival analysis was used to estimate cumulative death and loss to follow-up (LTF) rates in PHF and SHF. Multivariate competing risks regression and Cox proportional hazards models were constructed to identify correlates of LTF and death. RESULTS Enrollment in PHF increased mainly between 2007 and 2009, representing 5% and 25% of all new enrollments, respectively. CD4 test provision and World Health Organization staging, time to ART initiation, and CD4 count at ART initiation were for the most part similar between PHF and SHF. In multivariate analyses, pre-ART patients enrolled in PHF had a lower risk of LTF than those enrolled in SHF (SHR = 0.77, 95% confidence interval: 0.61 to 0.96). No differences in risk of death among pre-ART patients or in LTF or death among ART patients were observed. CONCLUSIONS Enrollment at PHF increased substantially during the period; death rates were comparable between PHF and SHF, whereas LTF among pre-ART patients was lower at PHF. This suggests that decentralization can be a successful strategy for expanding HIV care.
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Improved retention of patients starting antiretroviral treatment in Karonga District, northern Malawi, 2005-2012. J Acquir Immune Defic Syndr 2015; 67:e27-e33. [PMID: 24977375 DOI: 10.1097/qai.0000000000000252] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patient retention in antiretroviral therapy (ART) programs remains a major challenge in sub-Saharan Africa. We examined whether and why retention in ART care has changed with increasing access. METHODS Retrospective cohort study combining individual data from ART registers and interview data, enabling us to link patients across different ART clinics in Karonga District, Malawi. We recorded information on all adults (≥15 years) starting ART between July 2005 and August 2012, including those initiating due to pregnancy and breastfeeding (Option B+). Retention in care was defined as being alive and receiving ART at the end of study. Predictors of attrition were assessed using a multivariable Cox proportional hazards model. RESULTS The number of clinics providing ART increased from 1 in 2005 to 16 in 2012. Six-month retention increased from 73% [95% confidence interval (CI): 71 to 76] to 93% (95% CI: 92 to 94) when comparing the 2005-2006 and 2011-2012 cohorts, and 12-month retention increased from 70% (95% CI: 67 to 73) to 92% (95% CI: 90 to 93). Over the study period, the proportion of patients starting ART at World Health Organization stage 4 declined from 62% to 10%. Being a man, younger than 35 years, having a more advanced World Health Organization stage and being part of an earlier cohort were all independently associated with attrition. Women starting ART for Option B+ experienced higher attrition than women of childbearing age starting for other reasons. CONCLUSIONS In this area, retention in care has increased dramatically. Improved health in patients starting ART and decentralization of ART care to peripheral health centers seem to be the major drivers for this change.
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Zanganeh Baygi M, Seyedin H, Salehi M, Jafari Sirizi M. Structural and contextual dimensions of Iranian primary health care system at local level. IRANIAN RED CRESCENT MEDICAL JOURNAL 2014; 17:e17222. [PMID: 25763257 PMCID: PMC4341539 DOI: 10.5812/ircmj.17222] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Revised: 02/03/2014] [Accepted: 02/23/2014] [Indexed: 11/28/2022]
Abstract
Background: In recent years, family physician plan was established as the main strategy of health system in Iran, while organizational structure of the primary health care system has remained the same as thirty years ago. Objectives: This study was performed to illustrate structural and contextual dimensions of organizational structure and relationship between them in Iranian primary health care system at local level. Materials and Methods: A cross-sectional quantitative study was conducted from January to June 2013, during which 121 questionnaires were distributed among senior and junior managers of city health centers at Medical Sciences universities in Iran. Validity of the questionnaire was confirmed by experts (CVI = 0.089 and CVR more than 0.85) and Cronbach α was utilized for reliability (α = 0.904). We used multistage sampling method in this study and analysis of the data was performed by SPSS software using different tests. Results: Local level of primary health care system in Iran had mechanical structure, but in contextual dimensions the results showed different types. There was a significant relationship between structural and contextual dimensions (r = 0.642, P value < 0.001). Goals and culture dimensions had strongest effects on structural dimensions. Conclusions: Because of the changes in goals and strategies of Iranian health system in recent years, it is urgently recommended to reform the current structure to increase efficiency and effectiveness of the system.
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Affiliation(s)
| | - Hesam Seyedin
- International Campus, Iran University of Medical Sciences, Tehran, IR Iran
- Corresponding Author: Hesam Seyedin, International Campus, Iran University of Medical Sciences, Tehran, IR Iran. Tel: +98-2188772088, E-mail:
| | - Masoud Salehi
- Department of Biostatistics, Faculty of Public Health, Iran University of Medical Sciences, Tehran, IR Iran
| | - Mehdi Jafari Sirizi
- Health Management and Economics Research Centre, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, IR Iran
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Koole O, Tsui S, Wabwire-Mangen F, Kwesigabo G, Menten J, Mulenga M, Auld A, Agolory S, Mukadi YD, Colebunders R, Bangsberg DR, van Praag E, Torpey K, Williams S, Kaplan J, Zee A, Denison J. Retention and risk factors for attrition among adults in antiretroviral treatment programmes in Tanzania, Uganda and Zambia. Trop Med Int Health 2014; 19:1397-410. [PMID: 25227621 DOI: 10.1111/tmi.12386] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES We assessed retention and predictors of attrition (recorded death or loss to follow-up) in antiretroviral treatment (ART) clinics in Tanzania, Uganda and Zambia. METHODS We conducted a retrospective cohort study among adults (≥18 years) starting ART during 2003-2010. We purposefully selected six health facilities per country and randomly selected 250 patients from each facility. Patients who visited clinics at least once during the 90 days before data abstraction were defined as retained. Data on individual and programme level risk factors for attrition were obtained through chart review and clinic manager interviews. Kaplan-Meier curves for retention across sites were created. Predictors of attrition were assessed using a multivariable Cox-proportional hazards model, adjusted for site-level clustering. RESULTS From 17 facilities, 4147 patients were included. Retention ranged from 52.0% to 96.2% at 1 year to 25.8%-90.4% at 4 years. Multivariable analysis of ART initiation characteristics found the following independent risk factors for attrition: younger age [adjusted hazard ratio (aHR) and 95% confidence interval (95%CI) = 1.30 (1.14-1.47)], WHO stage 4 ([aHR (95% CI): 1.56 (1.29-1.88)], >10% bodyweight loss [aHR (95%CI) = 1.17 (1.00-1.38)], poor functional status [ambulatory aHR (95%CI) = 1.29 (1.09-1.54); bedridden aHR1.54 (1.15-2.07)], and increasing years of clinic operation prior to ART initiation in government facilities [aHR (95%CI) = 1.17 (1.10-1.23)]. Patients with higher CD4 cell count were less likely to experience attrition [aHR (95%CI) = 0.88 (0.78-1.00)] for every log (tenfold) increase. Sites offering community ART dispensing [aHR (95%CI) = 0.55 (0.30-1.01) for women; 0.40 (0.21-0.75) for men] had significantly less attrition. CONCLUSIONS Patient retention to an individual programme worsened over time especially among males, younger persons and those with poor clinical indicators. Community ART drug dispensing programmes could improve retention.
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Affiliation(s)
- Olivier Koole
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK; Clinical Sciences Department, Institute of Tropical Medicine, Antwerp, Belgium
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Chan AK, Ford D, Namata H, Muzambi M, Nkhata MJ, Abongomera G, Mambule I, South A, Revill P, Grundy C, Mabugu T, Chiwaula L, Cataldo F, Hakim J, Seeley J, Kityo C, Reid A, Katabira E, Sodhi S, Gilks CF, Gibb DM. The Lablite project: a cross-sectional mapping survey of decentralized HIV service provision in Malawi, Uganda and Zimbabwe. BMC Health Serv Res 2014; 14:352. [PMID: 25138583 PMCID: PMC4148932 DOI: 10.1186/1472-6963-14-352] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2014] [Accepted: 07/29/2014] [Indexed: 12/05/2022] Open
Abstract
Background In sub-Saharan Africa antiretroviral therapy (ART) is being decentralized from tertiary/secondary care facilities to primary care. The Lablite project supports effective decentralization in 3 countries. It began with a cross-sectional survey to describe HIV and ART services. Methods 81 purposively sampled health facilities in Malawi, Uganda and Zimbabwe were surveyed. Results The lowest level primary health centres comprised 16/20, 21/39 and 16/22 facilities included in Malawi, Uganda and Zimbabwe respectively. In Malawi and Uganda most primary health facilities had at least 1 medical assistant/clinical officer, with average 2.5 and 4 nurses/midwives for median catchment populations of 29,275 and 9,000 respectively. Primary health facilities in Zimbabwe were run by nurses/midwives, with average 6 for a median catchment population of 8,616. All primary health facilities provided HIV testing and counselling, 50/53 (94%) cotrimoxazole preventive therapy (CPT), 52/53 (98%) prevention of mother-to-child transmission of HIV (PMTCT) and 30/53 (57%) ART management (1/30 post ART-initiation follow-up only). All secondary and tertiary-level facilities provided HIV and ART services. In total, 58/81 had ART provision. Stock-outs during the 3 months prior to survey occurred across facility levels for HIV test-kits in 55%, 26% and 9% facilities in Malawi, Uganda and Zimbabwe respectively; for CPT in 58%, 32% and 9% and for PMTCT drugs in 26%, 10% and 0% of facilities (excluding facilities where patients were referred out for either drug). Across all countries, in facilities with ART stored on-site, adult ART stock-outs were reported in 3/44 (7%) facilities compared with 10/43 (23%) facility stock-outs of paediatric ART. Laboratory services at primary health facilities were limited: CD4 was used for ART initiation in 4/9, 5/6 and 13/14 in Malawi, Uganda and Zimbabwe respectively, but frequently only in selected patients. Routine viral load monitoring was not used; 6/58 (10%) facilities with ART provision accessed centralised viral loads for selected patients. Conclusions Although coverage of HIV testing, PMTCT and cotrimoxazole prophylaxis was high in all countries, decentralization of ART services was variable and incomplete. Challenges of staffing and stock management were evident. Laboratory testing for toxicity and treatment effectiveness monitoring was not available in most primary level facilities. Electronic supplementary material The online version of this article (doi:10.1186/1472-6963-14-352) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Deborah Ford
- MRC Clinical Trials Unit at University College London, London, U,K.
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