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Carnero Canales CS, Marquez Cazorla JI, Marquez Cazorla RM, Roque-Borda CA, Polinário G, Figueroa Banda RA, Sábio RM, Chorilli M, Santos HA, Pavan FR. Breaking barriers: The potential of nanosystems in antituberculosis therapy. Bioact Mater 2024; 39:106-134. [PMID: 38783925 PMCID: PMC11112550 DOI: 10.1016/j.bioactmat.2024.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 04/17/2024] [Accepted: 05/05/2024] [Indexed: 05/25/2024] Open
Abstract
Tuberculosis (TB), caused by Mycobacterium tuberculosis, continues to pose a significant threat to global health. The resilience of TB is amplified by a myriad of physical, biological, and biopharmaceutical barriers that challenge conventional therapeutic approaches. This review navigates the intricate landscape of TB treatment, from the stealth of latent infections and the strength of granuloma formations to the daunting specters of drug resistance and altered gene expression. Amidst these challenges, traditional therapies often fail, contending with inconsistent bioavailability, prolonged treatment regimens, and socioeconomic burdens. Nanoscale Drug Delivery Systems (NDDSs) emerge as a promising beacon, ready to overcome these barriers, offering better drug targeting and improved patient adherence. Through a critical approach, we evaluate a spectrum of nanosystems and their efficacy against MTB both in vitro and in vivo. This review advocates for the intensification of research in NDDSs, heralding their potential to reshape the contours of global TB treatment strategies.
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Affiliation(s)
| | | | | | - Cesar Augusto Roque-Borda
- Tuberculosis Research Laboratory, School of Pharmaceutical Science, Sao Paulo State University (UNESP), Araraquara, 14800-903, Brazil
| | - Giulia Polinário
- Tuberculosis Research Laboratory, School of Pharmaceutical Science, Sao Paulo State University (UNESP), Araraquara, 14800-903, Brazil
| | | | - Rafael Miguel Sábio
- School of Pharmaceutical Science, Sao Paulo State University (UNESP), Araraquara, 14800-903, Brazil
- Department of Biomaterials and Biomedical Technology, University Medical Center Groningen (UMCG), University of Groningen, Groningen, 9713 AV, the Netherlands
| | - Marlus Chorilli
- School of Pharmaceutical Science, Sao Paulo State University (UNESP), Araraquara, 14800-903, Brazil
| | - Hélder A. Santos
- Department of Biomaterials and Biomedical Technology, University Medical Center Groningen (UMCG), University of Groningen, Groningen, 9713 AV, the Netherlands
- Drug Research Program, Division of Pharmaceutical Chemistry and Technology, Faculty of Pharmacy, University of Helsinki, Helsinki, FI-00014, Finland
| | - Fernando Rogério Pavan
- Tuberculosis Research Laboratory, School of Pharmaceutical Science, Sao Paulo State University (UNESP), Araraquara, 14800-903, Brazil
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Dlangalala T, Musekiwa A, Mashamba-Thompson T. Quality of TB diagnostic services at primary healthcare clinics in eThekwini district, South Africa. PLoS One 2024; 19:e0307149. [PMID: 39024321 PMCID: PMC11257344 DOI: 10.1371/journal.pone.0307149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 07/02/2024] [Indexed: 07/20/2024] Open
Abstract
Overcoming the TB epidemic requires moving past expanding the coverage of healthcare services and looking to improve the quality of TB services. During COVID-19, the suboptimal state of TB services has further deteriorated, and little is known about how these services have fared after the pandemic. The study aims to assess the quality TB diagnostic services in primary health care (PHC) clinics in the eThekwini district, South Africa. Twenty-one clinics with the lowest and highest headcounts from each region of eThekwini were purposively selected. An audit tool adapted from the United States Agency for International Development (USAID) and the national TB guidelines was used to collect data on six different audit components. To assess quality, a 3-point scale was used where clinics could get a rating of either excellent, moderate, or poor performance. Descriptive statistics were employed to summarize and analyze clinic scores in Stata v15.1. Additionally, associations between clinic scores and clinic characteristics were investigated using Pearson's pairwise correlation coefficient and a linear regression model, where p < 0.05 was the measure of statistical significance. The audit found that the quality of diagnostic services in eThekwini was moderate. The gaps that required addressing were the lack of TB training among staff, adherence to infection prevention and control practices, and contact screening. Without feasible solutions, these will hinder current TB management strategies and slow progress toward ending the TB epidemic.
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Affiliation(s)
- Thobeka Dlangalala
- School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria, Gauteng, South Africa
| | - Alfred Musekiwa
- School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria, Gauteng, South Africa
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Salomon A, Law S, Johnson C, Baddeley A, Rangaraj A, Singh S, Daftary A. Interventions to improve linkage along the HIV-tuberculosis care cascades in low- and middle-income countries: A systematic review and meta-analysis. PLoS One 2022; 17:e0267511. [PMID: 35552547 PMCID: PMC9098064 DOI: 10.1371/journal.pone.0267511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 04/09/2022] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION In support of global targets to end HIV/AIDS and tuberculosis (TB) by 2030, we reviewed interventions aiming to improve TB case-detection and anti-TB treatment among people living with HIV (PLHIV) and HIV testing and antiretroviral treatment initiation among people with TB disease in low- and middle-income countries (LMICs). METHODS We conducted a systematic review of comparative (quasi-)experimental interventional studies published in Medline or EMBASE between January 2003-July 2021. We performed random-effects effect meta-analyses (DerSimonian and Laird method) for interventions that were homogenous (based on intervention descriptions); for others we narratively synthesized the intervention effect. Studies were assessed using ROBINS-I, Cochrane Risk-of-Bias, and GRADE. (PROSPERO #CRD42018109629). RESULTS Of 21,516 retrieved studies, 23 were included, contributing 53 arms and 84,884 participants from 4 continents. Five interventions were analyzed: co-location of test and/or treatment services; patient education and counselling; dedicated personnel; peer support; and financial support. A majority were implemented in primary health facilities (n = 22) and reported on HIV outcomes in people with TB (n = 18). Service co-location had the most consistent positive effect on HIV testing and treatment initiation among people with TB, and TB case-detection among PLHIV. Other interventions were heterogenous, implemented concurrent with standard-of-care strategies and/or diverse facility-level improvements, and produced mixed effects. Operational system, human resource, and/or laboratory strengthening were common within successful interventions. Most studies had a moderate to serious risk of bias. CONCLUSIONS This review provides operational clarity on intervention models that can support early linkages between the TB and HIV care cascades. The findings have supported the World Health Organization 2020 HIV Service Delivery Guidelines update. Further research is needed to evaluate the distinct effect of education and counselling, financial support, and dedicated personnel interventions, and to explore the role of community-based, virtual, and differentiated service delivery models in addressing TB-HIV co-morbidity.
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Affiliation(s)
- Angela Salomon
- School of Medicine, Queen’s University, Kingston, Canada
- McGill International TB Centre, Research Institute of the McGill University Health Centre, Montréal, Canada
| | - Stephanie Law
- McGill International TB Centre, Research Institute of the McGill University Health Centre, Montréal, Canada
| | - Cheryl Johnson
- Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | - Annabel Baddeley
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Ajay Rangaraj
- Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | - Satvinder Singh
- The Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland
| | - Amrita Daftary
- School of Global Health and Dahdaleh Institute of Global Health Research, York University, Toronto, Canada
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
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Gengiah S, Naidoo K, Mlobeli R, Tshabalala MF, Nunn AJ, Padayatchi N, Yende-Zuma N, Taylor M, Barker PM, Loveday M. A Quality Improvement Intervention to Inform Scale-Up of Integrated HIV-TB Services: Lessons Learned From KwaZulu-Natal, South Africa. GLOBAL HEALTH, SCIENCE AND PRACTICE 2021; 9:444-458. [PMID: 34593572 PMCID: PMC8514040 DOI: 10.9745/ghsp-d-21-00157] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 07/22/2021] [Indexed: 11/15/2022]
Abstract
INTRODUCTION In South Africa, mortality rates among HIV-TB coinfected patients are among the highest in the world. The key to reducing mortality is integrating HIV-TB services, however, a generalizable implementation method and package of tested change ideas to guide the scale-up of integrated HIV-TB services are unavailable. We describe the implementation of a quality improvement (QI) intervention, health systems' weaknesses, change ideas, and lessons learned in improving integrated HIV-TB services. METHODS Between December 1, 2016, and December 31, 2018, 8 nurse supervisors overseeing 20 primary health care (PHC) clinics formed a learning collaborative to improve a set of HIV-TB process indicators. HIV-TB process indicators comprised: HIV testing services (HTS), TB screening among PHC clinic attendees, isoniazid preventive therapy (IPT) for eligible HIV patients, antiretroviral therapy (ART) for HIV-TB coinfected patients, and viral load (VL) testing at month 12. Routine HIV-TB process data were collected and analyzed. RESULTS Key change interventions, generated by health care workers, included: patient-flow redesign, daily data quality checks; prior identification of patients eligible for IPT and VL testing. Between baseline and post-QI intervention, IPT initiation rates increased from 15.9% to 76.4% (P=.019), HTS increased from 84.8% to 94.5% (P=.110), TB screening increased from 76.2% to 85.2% (P=.040), and VL testing increased from 61.4% to 74.0% (P=.045). ART initiation decreased from 95.8% to 94.1% (P=.481). DISCUSSION Although integrating HIV-TB services is standard guidance, existing process gaps to achieve integration can be closed using QI methods. QI interventions can rapidly improve the performance of processes, particularly if baseline performance is low. Improving data quality enhances the success of QI initiatives.
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Affiliation(s)
| | - Kogieleum Naidoo
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
- Medical Research Council-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa
| | - Regina Mlobeli
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
| | | | - Andrew J Nunn
- Medical Research Council, Clinical Trials Unit at University College London, London, United Kingdom
| | - Nesri Padayatchi
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
- Medical Research Council-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa
| | - Nonhlanhla Yende-Zuma
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
- Medical Research Council-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa
| | - Myra Taylor
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Pierre M Barker
- Institute for Healthcare Improvement, Cambridge, MA, USA
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Marian Loveday
- Medical Research Council-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa
- HIV Prevention Research Unit, South African Medical Research Council, South Africa
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Abstract
Tuberculosis (TB) remains a leading cause of morbidity and mortality among people living with HIV. HIV-associated TB disproportionally affects African countries, particularly vulnerable groups at risk for both TB and HIV. Currently available TB diagnostics perform poorly in people living with HIV; however, new diagnostics such as Xpert Ultra and lateral flow urine lipoarabinomannan assays can greatly facilitate diagnosis of TB in people living with HIV. TB preventive treatment has been underutilized despite its proven benefits independent of antiretroviral therapy (ART). Shorter regimens using rifapentine can support increased availability and scale-up. Mortality is high in people with HIV-associated TB, and timely initiation of ART is critical. Programs should provide decentralized and integrated TB and HIV care in settings with high burden of both diseases to improve access to services that diagnose TB and HIV as early as possible. The new prevention and diagnosis tools recently recommended by WHO offer an immense opportunity to advance our fight against HIV-associated TB. They should be made widely available and scaled up rapidly supported by adequate funding with robust monitoring of the uptake to advance global TB elimination.
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Affiliation(s)
- Yohhei Hamada
- Centre for International Cooperation and Global TB Information, 46635Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association, Tokyo, Japan.,Institute for Global Health, 4919University College London, London, UK
| | - Haileyesus Getahun
- Department of Global Coordination and Partnership on Antimicrobial Resistance, 3489WHO, Geneva, Switzerland
| | - Birkneh Tilahun Tadesse
- Department of Global Coordination and Partnership on Antimicrobial Resistance, 3489WHO, Geneva, Switzerland
| | - Nathan Ford
- Department of Paediatrics, College of Medicine and Health Sciences, 128167Hawassa University, Hawassa, Ethiopia
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Vanleeuw L, Atkins S, Zembe-Mkabile W, Loveday M. Provider perspectives of the introduction and implementation of care for drug-resistant tuberculosis patients in district-level facilities in South Africa: a qualitative study. BMJ Open 2020; 10:e032591. [PMID: 32019816 PMCID: PMC7044892 DOI: 10.1136/bmjopen-2019-032591] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES Drug-resistant tuberculosis (DR-TB) is a growing concern in many low-income and middle-income countries. Facing rising numbers of DR-TB patients, South Africa (SA) introduced a decentralised model of care for DR-TB in 2011. We aimed to document the introduction and implementation of the new models of care for patients with DR-TB in four provinces (Northern Cape, KwaZulu-Natal, Eastern Cape and Gauteng) in 2015 using mixed methods, including interviews, register reviews and clinical audits. This paper reports on the qualitative component of the study. DESIGN This is a qualitative interview study. SETTING Data were collected in 22 decentralised DR-TB sites, primary healthcare facilities and district hospitals and one provincial central DR-TB hospital. PARTICIPANTS 58 healthcare workers (HCWs), facility staff and provincial and district TB coordinators were included in qualitative interviews. RESULTS HCWs felt that the introduction of DR-TB care in their facility came with little warning or engagement, creating fear and anxiety. They expressed a need for support from the district and province to guide them through the changes but this support was often lacking. In addition, many respondents expressed feeling isolated and not supported by other healthcare providers which they feel impacts on the quality of the care they provide. CONCLUSION Introduction of a new service such as DR-TB care can be difficult and does not always result in the intended outcomes. Improved engagement with front-line providers and addressing the fear and anxiety that may be raised by changes in daily practices should be addressed to ensure successful implementation and prevent negative consequences that can hamper quality of care for patients. Attention should be paid to how the decentralised DR-TB unit can be supported by district management and other healthcare providers.
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Affiliation(s)
- Lieve Vanleeuw
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Salla Atkins
- Faculty of Social Sciences, Tampere University, Tampere, Finland
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Wanga Zembe-Mkabile
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Marian Loveday
- Health Systems Research Unit, South African Medical Research Council, Durban, South Africa
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal Nelson R Mandela School of Medicine, Durban, South Africa
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Effect of TB/HIV Integration on TB and HIV Indicators in Rural Ugandan Health Facilities. J Acquir Immune Defic Syndr 2019; 79:605-611. [PMID: 30383587 DOI: 10.1097/qai.0000000000001862] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The World Health Organization recommends integrating services for patients coinfected with tuberculosis (TB) and HIV. We assessed the effect of TB/HIV integration on antiretroviral therapy (ART) initiation and TB treatment outcomes among TB/HIV-coinfected patients using data collected from 14 rural health facilities during 2 previous TB and HIV quality of care studies. METHODS A facility was considered to have integrated TB/HIV services if patients with TB/HIV had combined treatment for both illnesses by 1 provider or care team at 1 treatment location. We analyzed the effect of integration by conducting a cross-sectional analysis of integrated and nonintegrated facility periods comparing performance on ART initiation and TB treatment outcomes. We conducted logistic regression, with the patient as the unit of analysis, controlling for other intervention effects, adjusting for age and sex, and clustering by health facility. RESULTS From January 2012 to June 2014, 996 patients with TB were registered, 97% were tested for HIV, and 404 (42%) were HIV-positive. Excluding transfers, 296 patients were eligible for analysis with 117 and 179 from nonintegrated and integrated periods, respectively. Being treated in a facility with TB/HIV integration was associated with lower mortality [adjusted odds ratio (aOR) = 0.38, 95% confidence interval (CI): 0.18 to 0.77], but there was no difference in the proportion initiating ART (aOR = 1.34, 95% CI: 0.40 to 4.47), with TB treatment success (aOR = 1.43, 95% CI: 0.73 to 2.82), lost to follow-up (aOR = 1.64, 95% CI: 0.53 to 5.04), or failure (aOR = 1.21, 95% CI: 0.34 to 4.32). CONCLUSIONS TB/HIV service integration was associated with lower mortality during TB treatment even in settings with suboptimal proportions of patients completing TB treatment and starting on ART.
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Naidoo K, Gengiah S, Singh S, Stillo J, Padayatchi N. Quality of TB care among people living with HIV: Gaps and solutions. J Clin Tuberc Other Mycobact Dis 2019; 17:100122. [PMID: 31788564 PMCID: PMC6880007 DOI: 10.1016/j.jctube.2019.100122] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Tuberculosis (TB) is the leading infectious cause of death among people living with HIV, causing one third of AIDS-related deaths globally. The concerning number of missing TB cases, ongoing high TB mortality, slow reduction in TB incidence, and limited uptake of TB preventive treatment among people living with HIV, all indicate the urgent need to improve quality of TB services within HIV programs. In this mini-review we discuss major gaps in quality of TB care that impede achieving prevention and treatment targets within the TB-HIV care cascades, show approaches of assessing gaps in TB service provision, and describe outcomes from innovative quality improvement projects among HIV and TB programs. We also offer recommendations for measuring quality of TB care.
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Affiliation(s)
- Kogieleum Naidoo
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa.,MRC-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, South Africa
| | | | - Satvinder Singh
- TBHIV and Quality of Care, HIV Department, World Health Organization, Geneva, Switzerland
| | - Jonathan Stillo
- Wayne State University, College of Liberal Arts and Sciences, Detroit, MI, United States
| | - Nesri Padayatchi
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa.,MRC-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, South Africa
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Kalonji D, Mahomed OH. Health system challenges affecting HIV and tuberculosis integration at primary healthcare clinics in Durban, South Africa. Afr J Prim Health Care Fam Med 2019; 11:e1-e7. [PMID: 31170790 PMCID: PMC6556920 DOI: 10.4102/phcfm.v11i1.1831] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 11/12/2018] [Accepted: 11/15/2018] [Indexed: 11/23/2022] Open
Abstract
Background Tuberculosis (TB) is the most common presenting illness among people living with human immunodeficiency virus (HIV), with co-infection occurring in up to 60% of cases in South Africa. In line with international guidelines, South Africa has adopted an integrated model at primary healthcare level to provide HIV and TB services by the same healthcare provider at the same visit. Aim The aim of the study was to conduct a rapid appraisal of integration of HIV and TB services at primary healthcare level in eThekwini District in 2015. Setting The study was conducted in 10 provincial primary healthcare clinics in the eThekwini Metropolitan Health District in KwaZulu-Natal Province. Methods An observational, cross-sectional study was conducted. Key informant interviews with operational managers and community health workers were conducted, as well as a review of registers and electronic databases for the period of January to March 2015. Results Two clinics complied with the mandated integrated model. Three clinics were partially integrated; while five clinics maintained the stand-alone model. Possible constraints included reorganisation of on-site location of services, drug provision, TB infection control and inadequate capacity building, while potential enablers comprised structural infrastructure, staffing ratios and stakeholder engagement. Conclusion HIV and TB integration is suboptimal and will need to be improved by addressing the systemic challenges affecting health service delivery, including strengthening supervision, training and the implementation of a change management programme.
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Affiliation(s)
- Dishiki Kalonji
- Discipline of Public Health Medicine, University of KwaZulu-Natal, Durban.
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Tesfaye B, Alebel A, Gebrie A, Zegeye A, Tesema C, Kassie B. The twin epidemics: Prevalence of TB/HIV co-infection and its associated factors in Ethiopia; A systematic review and meta-analysis. PLoS One 2018; 13:e0203986. [PMID: 30281631 PMCID: PMC6169899 DOI: 10.1371/journal.pone.0203986] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Accepted: 09/02/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Tuberculosis and HIV/AIDS are the major public health problems in many parts of the world particularly in resource limited countries like Ethiopia. Although studies have been conducted on the prevalence and associated factors of TB / HIV co-infection in Ethiopia, there is no comprehensive data on the magnitude and risk factors at a national and regional levels. Therefore, this review is aimed to summarize the prevalence of TB /HIV co-infection in Ethiopia using meta-analysis based on a systematic review of published articles & grey literatures. METHODS To conduct this systematic review and meta-analysis, major databases such as Pub Med, Google scholar, CINAHL, Africa Journals Online and Google were systematically searched using search terms. PRISMA guideline was followed in the study. Two authors extracted all necessary data using a standardized data extraction format, and analysis was done using STATA version 11. A Statistical heterogeneity across the studies was evaluated by using Cochran's Q test and I2 statistic. The pooled effect size was conducted in the form of prevalence and associations were measured using odds ratio. Moreover, the univariate meta regression was performed by considering the sample size to determine potential sources of heterogeneity. The Egger's weighted regression and Begg's rank correlation tests were used to assess potential publication biases. RESULTS This meta-analysis included 21 studies with a total of 12,980 participants. The pooled prevalence of TB / HIV Co-infection was 25.59% (95% CI (20.89%-30.29%). A significant association was found between low CD4 counts (OR: 3.53; 95% CI: 1.55, 8.06), advanced WHO stage (OR: 6.81; 95% CI: 3.91, 11.88) and TB/ HIV/AIDS Co-infection. CONCLUSION This finding revealed that the magnitude of TB /HIV co-infection in Ethiopia is increasing and deserves special attention. Low CD4 count and advanced WHO stage are contributing factors for dual infection. Establishing mechanisms such as Conducting surveillance to determine HIV burden among TB patients and TB burden among HIV patients, and intensifying the three I's (Intensive case finding, INH Preventive Therapy and Infection control) should be routine work of clinicians. Moreover, early screening & treatment should be provided to those patients with low CD4 count and advanced WHO stage.
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Affiliation(s)
- Bekele Tesfaye
- Department of Nursing, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Animut Alebel
- Department of Nursing, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Alemu Gebrie
- Department of Biomedical Science, College of medicine, Debre Markos University, Debre Markos, Ethiopia
| | - Abriham Zegeye
- Department of Biomedical Science, College of medicine, Debre Markos University, Debre Markos, Ethiopia
| | - Cheru Tesema
- Department of Public Health, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Bekalu Kassie
- Department of midwifery, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
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Naidoo K, Grobler AC, Deghaye N, Reddy T, Gengiah S, Gray A, Karim SA. Cost-Effectiveness of Initiating Antiretroviral Therapy at Different Points in TB Treatment in HIV-TB Coinfected Ambulatory Patients in South Africa. J Acquir Immune Defic Syndr 2015; 69:576-84. [PMID: 26167618 PMCID: PMC4503368 DOI: 10.1097/qai.0000000000000673] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Initiation of antiretroviral therapy (ART) during tuberculosis (TB) treatment improves survival in TB-HIV coinfected patients. In patients with CD4 counts <50 cells per cubic millimeter, there is a substantial clinical and survival benefit of early ART initiation. The purpose of this study was to assess the costs and cost-effectiveness of starting ART at various time points during TB treatment in patients with CD4 counts ≥50 cells per cubic millimeter. METHODS In the SAPiT trial, 642 HIV-TB coinfected patients were randomized to 3 arms: receiving ART within 4 weeks of starting TB treatment (early treatment arm; Arm-1), after the intensive phase of TB treatment (late treatment arm; Arm-2), or after completing TB treatment (sequential arm; Arm-3). Direct health care costs were measured from a provider perspective using a micro-costing approach. The incremental cost per death averted was calculated using the trial outcomes. RESULTS For patients with CD4 count ≥50 cells per cubic millimeter, median monthly variable costs per patient were US $116, US $113, and US $102 in Arm-1, Arm-2 and Arm-3, respectively. There were 12 deaths in 177 patients in Arm-1, 8 deaths in 180 patients in the Arm-2, and 19 deaths in 172 patients in Arm-3. Although the costs were lower in Arm-3, it had a substantially higher mortality rate. The incremental cost per death averted associated with moving from Arm-3 to Arm-2 was US $4199. There was no difference in mortality between Arm-1 and Arm-2, but Arm-1 was slightly more expensive. CONCLUSIONS Initiation of ART after the completion of the intensive phase of TB treatment is cost-effective for patients with CD4 counts ≥50 cells per cubic millimeter.
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Affiliation(s)
- Kogieleum Naidoo
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, South Africa
| | - Anneke C Grobler
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, South Africa
| | - Nicola Deghaye
- Health Economics and HIV & AIDS Research Division (HEARD), University of KwaZulu-Natal, South Africa
| | - Tarylee Reddy
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, South Africa
- Biostatistics Unit, Medical Research Council, South Africa
| | - Santhanalakshmi Gengiah
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, South Africa
| | - Andrew Gray
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, South Africa
- Discipline of Pharmaceutical Sciences, University of KwaZulu-Natal, South Africa
| | - Salim Abdool Karim
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, South Africa
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, USA
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Maponga BA, Chirundu D, Gombe NT, Tshimanga M, Bangure D, Takundwa L. Delayed initiation of anti-retroviral therapy in TB/HIV co-infected patients, Sanyati District, Zimbabwe, 2011-2012. Pan Afr Med J 2015; 21:28. [PMID: 26401222 PMCID: PMC4561155 DOI: 10.11604/pamj.2015.21.28.5195] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 04/22/2015] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Tuberculosis (TB) remains a public health problem and is driven by HIV. Recent studies indicate that anti-retroviral therapy (ART) initiated during the first two months of anti-TB treatment (ATT) reduces risk of HIV morbidity and mortality. In Sanyati district, 14% of TB/HIV co-infected patients were initiated on ART during TB treatment, in 2010. The study was conducted to determine the magnitude and determinants of delay in ART initiation, in TB/HIV co-infected patients. METHODS An analytic cross sectional study was conducted at three study sites in Sanyati district. The outcome was delayed ART initiation, being failure to be initiated on ART during the first two months of ATT. Respondents were interviewed using pre-tested questionnaires. Epi-Info was used to generate frequencies, means, odds ratios and 95% confidence intervals. Stratified and logistic regression analysis was done. RESULTS Of the 186 respondents, 63% had delayed ART initiation. Median delay from initiation of ATT to ART was 48 days (Q1=20; Q3=82). Risk factors for delayed ART initiation were: being treated for TB first time, AOR=2.23 (p=0.03); initially registered for HIV care outside Sanyati, AOR=3.08 (p<0.01); staying more than 5km from a clinic, AOR=3.29 (p<0.01). Enabling factors for early ART initiation was having a family member on ART, AOR=0.23 (p<0.01). CONCLUSION Significant delay and barriers to ART initiation were identified. Decentralization of ART initiation should be expedited. ART initiation should be expedited in patients with identified risk factors for delaying ART initiation. Peer support should be strengthened in families and community. Periodic evaluation of magnitude of delay and impact of early ART initiation in TB/HIV patients is recommended.
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Affiliation(s)
| | | | | | - Mufuta Tshimanga
- Department of Community Medicine, University of Zimbabwe, Zimbabwe
| | - Donewell Bangure
- Department of Community Medicine, University of Zimbabwe, Zimbabwe
| | - Lucia Takundwa
- Department of Community Medicine, University of Zimbabwe, Zimbabwe
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Amo-Adjei J, Kumi-Kyereme A, Fosuah Amo H, Awusabo-Asare K. The politics of tuberculosis and HIV service integration in Ghana. Soc Sci Med 2014; 117:42-9. [PMID: 25042543 DOI: 10.1016/j.socscimed.2014.07.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Revised: 06/14/2014] [Accepted: 07/04/2014] [Indexed: 11/29/2022]
Abstract
The need to integrate TB/HIV control programmes has become critical due to the comorbidity regarding these diseases and the need to optimise the use of resources. In developing countries such as Ghana, where public health interventions depend on donor funds, the integration of the two programmes has become more urgent. This paper explores stakeholders' views on the integration of TB/HIV control programmes in Ghana within the remits of contingency theory. With 31 purposively selected informants from four regions, semi-structured interviews and observations were conducted between March and May 2012, and the data collected were analysed using the inductive approach. The results showed both support for and opposition to integration, as well as some of the avoidable challenges inherent in combining TB/HIV control. While those who supported integration based their arguments on clinical synergies and the need to promote the efficient use of resources, those who opposed integration cited the potential increase in workload, the clinical complications associated with joint management, the potential for a leadership crisis, and the "smaller the better" propositions to support their stance. Although a policy on TB/HIV integration exists, inadequate 'political will' from the top management of both programmes has trickled down to lower levels, which has stifled progress towards the comprehensive management of TB/HIV and particularly leading to weak data collection and management structures and unsatisfactory administration of co-trimoxazole for co-infected patients. It is our view that the leadership of both programmes show an increased commitment to protocols involving the integration of TB/HIV, followed by a commitment to addressing the 'fears' of frontline service providers to encourage confidence in the process of service integration.
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Affiliation(s)
- Joshua Amo-Adjei
- Department of Population and Health, Faculty of Social Sciences, University of Cape Coast, Cape Coast, Ghana.
| | - Akwasi Kumi-Kyereme
- Department of Population and Health, Faculty of Social Sciences, University of Cape Coast, Cape Coast, Ghana
| | - Hannah Fosuah Amo
- Department of Business Administration, Valley View University, Oyibi, Accra, Ghana
| | - Kofi Awusabo-Asare
- Department of Population and Health, Faculty of Social Sciences, University of Cape Coast, Cape Coast, Ghana
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Missed opportunities for retention in pre-ART care in Cape Town, South Africa. PLoS One 2014; 9:e96867. [PMID: 24806474 PMCID: PMC4013078 DOI: 10.1371/journal.pone.0096867] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Accepted: 04/13/2014] [Indexed: 02/05/2023] Open
Abstract
Background Few studies have evaluated access to and retention in pre-ART care. Objectives To evaluate the proportion of People Living With HIV (PLWH) in pre-ART and ART care and factors associated with retention in pre-ART and ART care from a community cohort. Methods A cross sectional survey was conducted from February – April 2011. Self reported HIV positive, negative or participants of unknown status completed a questionnaire on their HIV testing history, access to pre-ART and retention in pre-ART and ART care. Results 872 randomly selected adults who reported being HIV positive in the ZAMSTAR 2010 prevalence survey were included and revisited. 579 (66%) reconfirmed their positive status and were included in this analysis. 380 (66%) had initiated ART with 357 of these (94%) retained in ART care. 199 (34%) had never initiated ART of whom 186 (93%) accessed pre-ART care, and 86 (43%) were retained in pre-ART care. In a univariable analysis none of the factors analysed were significantly associated with retention in care in the pre-ART group. Due to the high retention in ART care, factors associated with retention in ART care, were not analysed further. Conclusion Retention in ART care was high; however it was low in pre-ART care. The opportunity exists, if care is better integrated, to engage with clients in primary health care facilities to bring them back to, and retain them in, pre-ART care.
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Association between health systems performance and treatment outcomes in patients co-infected with MDR-TB and HIV in KwaZulu-Natal, South Africa: implications for TB programmes. PLoS One 2014; 9:e94016. [PMID: 24718306 PMCID: PMC3981751 DOI: 10.1371/journal.pone.0094016] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Accepted: 03/12/2014] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To improve the treatment of MDR-TB and HIV co-infected patients, we investigated the relationship between health system performance and patient treatment outcomes at 4 decentralised MDR-TB sites. METHODS In this mixed methods case study which included prospective comparative data, we measured health system performance using a framework of domains comprising key health service components. Using Pearson Product Moment Correlation coefficients we quantified the direction and magnitude of the association between health system performance and MDR-TB treatment outcomes. Qualitative data from participant observation and interviews analysed using systematic text condensation (STC) complemented our quantitative findings. FINDINGS We found significant differences in treatment outcomes across the sites with successful outcomes varying from 72% at Site 1 to 52% at Site 4 (p<0.01). Health systems performance scores also varied considerably across the sites. Our findings suggest there is a correlation between treatment outcomes and overall health system performance which is significant (r = 0.99, p<0.01), with Site 1 having the highest number of successful treatment outcomes and the highest health system performance. Although the 'integration' domain, which measured integration of MDR-TB services into existing services appeared to have the strongest association with successful treatment outcomes (r = 0.99, p<0.01), qualitative data indicated that the 'context' domain influenced the other domains. CONCLUSION We suggest that there is an association between treatment outcomes and health system performance. The chance of treatment success is greater if decentralised MDR-TB services are integrated into existing services. To optimise successful treatment outcomes, regular monitoring and support are needed at a district, facility and individual level to ensure the local context is supportive of new programmes and implementation is according to guidelines.
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Chaiyachati KH, Loveday M, Lorenz S, Lesh N, Larkan LM, Cinti S, Friedland GH, Haberer JE. A pilot study of an mHealth application for healthcare workers: poor uptake despite high reported acceptability at a rural South African community-based MDR-TB treatment program. PLoS One 2013; 8:e64662. [PMID: 23724075 PMCID: PMC3665589 DOI: 10.1371/journal.pone.0064662] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Accepted: 04/17/2013] [Indexed: 11/23/2022] Open
Abstract
Introduction As the South African province of KwaZulu-Natal addresses a growing multidrug-resistant tuberculosis (MDR-TB) epidemic by shifting care and treatment from trained specialty centers to community hospitals, delivering and monitoring MDR-TB therapy has presented new challenges. In particular, tracking and reporting adverse clinical events have been difficult for mobile healthcare workers (HCWs), trained health professionals who travel daily to patient homes to administer and monitor therapy. We designed and piloted a mobile phone application (Mobilize) for mobile HCWs that electronically standardized the recording and tracking of MDR-TB patients on low-cost, functional phones. Objective We assess the acceptability and feasibility of using Mobilize to record and submit adverse events forms weekly during the intensive phase of MDR-TB therapy and evaluate mobile HCW perceptions throughout the pilot period. Methods All five mobile HCWs at one site were trained and provided with phones. Utilizing a mixed-methods evaluation, mobile HCWs’ usage patterns were tracked electronically for seven months and analyzed. Qualitative focus groups and questionnaires were designed to understand the impact of mobile phone technology on the work environment. Results Mobile HCWs submitted nine of 33 (27%) expected adverse events forms, conflicting with qualitative results in which mobile HCWs stated that Mobilize improved adverse events communication, helped their daily workflow, and could be successfully expanded to other health interventions. When presented with the conflict between their expressed views and actual practice, mobile HCWs cited forgetfulness and believed patients should take more responsibility for their own care. Discussion This pilot experience demonstrated poor uptake by HCWs despite positive responses to using mHealth. Though our results should be interpreted cautiously because of the small number of mobile HCWs and MDR-TB patients in this study, we recommend carefully exploring the motivations of HCWs and technologic enhancements prior to scaling new mHealth initiatives in resource poor settings.
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Affiliation(s)
- Krisda H Chaiyachati
- Yale University School of Medicine, New Haven, Connecticut, United States of America.
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Chehab JC, Vilakazi-Nhlapo AK, Vranken P, Peters A, Klausner JD. Current integration of tuberculosis (TB) and HIV services in South Africa, 2011. PLoS One 2013; 8:e57791. [PMID: 23469242 PMCID: PMC3587619 DOI: 10.1371/journal.pone.0057791] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2012] [Accepted: 01/29/2013] [Indexed: 01/19/2023] Open
Abstract
Setting Public Health Facilities in South Africa. Objective To assess the current integration of TB and HIV services in South Africa, 2011. Design Cross-sectional study of 49 randomly selected health facilities in South Africa. Trained interviewers administered a standardized questionnaire to one staff member responsible for TB and HIV in each facility on aspects of TB/HIV policy, integration and recording and reporting. We calculated and compared descriptive statistics by province and facility type. Results Of the 49 health facilities 35 (71%) provided isoniazid preventive therapy (IPT) and 35 (71%) offered antiretroviral therapy (ART). Among assessed sites in February 2011, 2,512 patients were newly diagnosed with HIV infection, of whom 1,913 (76%) were screened for TB symptoms, and 616 of 1,332 (46%) of those screened negative for TB were initiated on IPT. Of 1,072 patients newly registered with TB in February 2011, 144 (13%) were already on ART prior to Tb clinical diagnosis, and 451 (42%) were newly diagnosed with HIV infection. Of those, 84 (19%) were initiated on ART. Primary health clinics were less likely to offer ART compared to district hospitals or community health centers (p<0.001). Conclusion As of February 2011, integration of TB and HIV services is taking place in public medical facilities in South Africa. Among these services, IPT in people living with HIV and ART in TB patients are the least available.
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Affiliation(s)
- Joel C Chehab
- Centers for Disease Control and Prevention, Pretoria, South Africa.
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Choun K, Pe R, Thai S, Lorent N, Lynen L, van Griensven J. Timing of antiretroviral therapy in Cambodian hospital after diagnosis of tuberculosis: impact of revised WHO guidelines. Bull World Health Organ 2012; 91:195-206. [PMID: 23476092 DOI: 10.2471/blt.12.111153] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Revised: 11/14/2012] [Accepted: 11/16/2012] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To determine if implementation of 2010 World Health Organization (WHO) guidelines on antiretroviral therapy (ART) initiation reduced delay from tuberculosis diagnosis to initiation of ART in a Cambodian urban hospital. METHODS A retrospective cohort study was conducted in a nongovernmental hospital in Phnom Penh that followed new WHO guidelines in patients with human immunodeficiency virus (HIV) and tuberculosis. All ART-naïve, HIV-positive patients initiated on antituberculosis treatment over the 18 months before and after guideline implementation were included. A competing risk regression model was used. FINDINGS After implementation of the 2010 WHO guidelines, 190 HIV-positive patients with tuberculosis were identified: 53% males; median age, 38 years; median baseline CD4+ T-lymphocyte (CD4+ cell) count, 43 cells/µL. Before implementation, 262 patients were identified; 56% males; median age, 36 years; median baseline CD4+ cell count, 59 cells/µL. With baseline CD4+ cell counts ≤ 50 cells/µL, median delay to ART declined from 5.8 weeks (interquartile range, IQR: 3.7-9.0) before to 3.0 weeks (IQR: 2.1-4.4) after implementation (P < 0.001); with baseline CD4+ cell counts > 50 cells/µL, delay dropped from 7.0 (IQR: 5.3-11.3) to 3.6 (IQR: 2.9-5.3) weeks (P < 0.001). The probability of ART initiation within 4 and 8 weeks after tuberculosis diagnosis rose from 23% and 65%, respectively, before implementation, to 62% and 90% after implementation. A non-significant increase in 6-month retention and antiretroviral substitution was seen after implementation. CONCLUSION Implementation of 2010 WHO recommendations in a routine clinical setting shortens delay to ART. Larger studies with longer follow-up are needed to assess impact on patient outcomes.
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Affiliation(s)
- Kimcheng Choun
- Sihanouk Hospital Centre of Hope, St. 134, Sangkat Vealvong, Khan 7 Makara, Phnom Penh, Cambodia
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Hedt-Gauthier BL, Tenthani L, Mitchell S, Chimbwandira FM, Makombe S, Chirwa Z, Schouten EJ, Pagano M, Jahn A. Improving data quality and supervision of antiretroviral therapy sites in Malawi: an application of Lot Quality Assurance Sampling. BMC Health Serv Res 2012; 12:196. [PMID: 22776745 PMCID: PMC3411464 DOI: 10.1186/1472-6963-12-196] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2012] [Accepted: 07/09/2012] [Indexed: 11/10/2022] Open
Abstract
Background High quality program data is critical for managing, monitoring, and evaluating national HIV treatment programs. By 2009, the Malawi Ministry of Health had initiated more than 270,000 patients on HIV treatment at 377 sites. Quarterly supervision of these antiretroviral therapy (ART) sites ensures high quality care, but the time currently dedicated to exhaustive record review and data cleaning detracts from other critical components. The exhaustive record review is unlikely to be sustainable long term because of the resources required and increasing number of patients on ART. This study quantifies the current levels of data quality and evaluates Lot Quality Assurance Sampling (LQAS) as a tool to prioritize sites with low data quality, thus lowering costs while maintaining sufficient quality for program monitoring and patient care. Methods In January 2010, a study team joined supervision teams at 19 sites purposely selected to reflect the variety of ART sites. During the exhaustive data review, the time allocated to data cleaning and data discrepancies were documented. The team then randomly sampled 76 records from each site, recording secondary outcomes and the time required for sampling. Results At the 19 sites, only 1.2% of records had discrepancies in patient outcomes and 0.4% in treatment regimen. However, data cleaning took 28.5 hours in total, suggesting that data cleaning for all 377 ART sites would require over 350 supervision-hours quarterly. The LQAS tool accurately identified the sites with the low data quality, reduced the time for data cleaning by 70%, and allowed for reporting on secondary outcomes. Conclusions Most sites maintained high quality records. In spite of this, data cleaning required significant amounts of time with little effect on program estimates of patient outcomes. LQAS conserves resources while maintaining sufficient data quality for program assessment and management to allow for quality patient care.
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Uwimana J, Jackson D, Hausler H, Zarowsky C. Health system barriers to implementation of collaborative TB and HIV activities including prevention of mother to child transmission in South Africa. Trop Med Int Health 2012; 17:658-65. [PMID: 22394016 DOI: 10.1111/j.1365-3156.2012.02956.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In South Africa, the control of TB and HIV co-infection remains a major challenge despite the availability of international and national guidelines for integration of TB and HIV services. This study was undertaken in KwaZulu-Natal, one of the provinces most affected by both TB and HIV, to identify and understand managers' and community care workers' (CCWs) perceptions of health systems barriers related to the implementation of collaborative TB/HIV activities, including prevention of mother to child transmission of HIV (PMTCT). We conducted 29 in-depth interviews with health managers at provincial, district and facility level and with managers of NGOs involved in TB and HIV care, as well as six focus group discussions with CCWs. Thematic analysis of transcripts revealed a convergence of perspectives on the process and the level of the implementation of policy directives on collaborative TB and HIV activities across all categories of respondents (i.e. province-, district-, facility- and community-based organizations). The majority of participants felt that the implementation of the policy was insufficiently consultative and that leadership and political will were lacking. The predominant themes related to health systems barriers include challenges related to structure and organisational culture; management, planning and power issues; unequal financing; and human resource capacity and regulatory problems notably relating to scope of practice of nurses and CCWs. Accelerated implementation of collaborative TB/HIV activities including PMTCT will require political will and leadership to address these health systems barriers.
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Affiliation(s)
- J Uwimana
- School of Public Health, University of the Western Cape, Cape Town, South Africa.
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Luetkemeyer AF, Getahun H, Chamie G, Lienhardt C, Havlir DV. Tuberculosis drug development: ensuring people living with HIV are not left behind. Am J Respir Crit Care Med 2011; 184:1107-13. [PMID: 21868507 DOI: 10.1164/rccm.201106-0995pp] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
An unprecedented number of new tuberculosis (TB) medications are currently in development, and there will be great pressure to deploy these new drugs among all populations after their efficacy is demonstrated. People living with HIV experience a large burden of TB and have a particularly pressing need for TB treatments that are shorter and less toxic. In addition, all people living with HIV now require antiretroviral therapy during TB treatment. A roadmap of the research, programmatic, and regulatory considerations includes the following: (1) inclusion of people living with HIV early in clinical trials for treatment and prevention using new TB medications, (2) prioritization of key studies of HIV-TB drug interactions and interactions between new TB agents, and (3) optimization of clinical trial infrastructure, laboratory capacity, and drug susceptibility testing.
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Affiliation(s)
- Anne F Luetkemeyer
- HIV/AIDS Division, San Francisco General Hospital, University of California, San Francisco, CA 94110, USA.
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Scott V, Zweigenthal V, Jennings K. Between HIV diagnosis and initiation of antiretroviral therapy: assessing the effectiveness of care for people living with HIV in the public primary care service in Cape Town, South Africa. Trop Med Int Health 2011; 16:1384-91. [PMID: 21771213 DOI: 10.1111/j.1365-3156.2011.02842.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To assess the quality of pre-antiretroviral therapy (ART) care in Cape Town and its continuity with HIV counselling and testing (HCT) and ART. METHODS The scale-up of the HCT, pre-ART and ART service platform and programmatic support in Cape was described. Data from the August 2010 routine annual HIV/TB/STI evaluation, which included interviews with 133 facility managers and folder reviews of 634 HCT clients who tested positive and 1115 clients receiving pre-ART HIV care, were analysed. RESULTS Historically, the implementation and management of pre-ART care has been relatively neglected compared with the scale-up of HCT and ART. CD4 counts were carried out for 77.5% of positive HCT clients, and 46.6% were clinically staged - crucial steps that determine the care path. There were gaps in quality of care (32.2% of women had a PAP smear), missed opportunities for integrated care (67% were symptomatically screened for tuberculosis) and positive prevention (48.3% had contraceptive needs assessed). Breaks in the continuity of care of pre-ART clients occurred with only 47.2% of eligible clients referred appropriately to the ARV service. CONCLUSION While a package of pre-ART care is clearly defined in Cape Town, it has not been fully implemented. There are weaknesses in the continuity and quality of service delivered that undermine the programme objectives of provision of positive prevention and timely access to ART.
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Affiliation(s)
- Vera Scott
- School of Public Health, University of the Western Cape, Western Cape, South Africa.
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