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Topp SM, Chipukuma JM. How did rapid scale-up of HIV services impact on workplace and interpersonal trust in Zambian primary health centres: a case-based health systems analysis. BMJ Glob Health 2016; 1:e000179. [PMID: 28588985 PMCID: PMC5321392 DOI: 10.1136/bmjgh-2016-000179] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 11/07/2016] [Accepted: 11/24/2016] [Indexed: 11/09/2022] Open
Abstract
Background In sub-Saharan Africa, large amounts of funding continue to be directed towards HIV-specific care and treatment, often with claims of ‘health system strengthening’ effect. Such claims rarely account for the impact on human relationships and decisions that are core to functional health systems. This research examined how establishment of externally funded HIV services influenced trusting relationships in Zambian health centres. Methods An in-depth, multicase study included four health centres selected for urban, peri-urban and rural characteristics. Case data included healthcare worker (HCW) interviews (60); patient interviews (180); direct observation of facility operations (2 weeks/centre) and key informant interviews (14) which were recorded and transcribed verbatim. Thematic analysis adopted inductive and deductive coding guided by a framework incorporating concepts of workplace trust, patient–provider trust, intrinsic and extrinsic motivation. Results HIV service scale-up impacted trust in positive and negative ways. Investment in HIV-specific infrastructure, supplies and quality assurance mechanisms strengthened workplace trust, HCW motivation and patient–provider trust in HIV departments in the short-term. In the health centres more broadly and over time, however, non-governmental organisation-led investment and support of HIV departments reinforced HCW's perceptions of the government as uninterested or unable to provide a quality work environment. Exacerbating existing perceptions of systemic workplace inequity and nepotism, uneven distribution of personal and professional opportunities related to HIV service establishment contributed to interdepartmental antagonism and reinforced workplace practices designed to protect individual HCW's interests. Conclusions Findings illustrate long-term negative effects of the vertical HIV resourcing and support structures which failed to address and sometimes exacerbated HCW (dis)trust with their own government and supervisors. The short-term and long-term effects of weakened workplace trust on HCWs' motivation and performance signal the importance of understanding how such relationships play a role in generating virtuous or perverse cycles of actor interactions, with implications for service outcomes.
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Affiliation(s)
- Stephanie M Topp
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia.,Nossal Institute for Global Health, University of Melbourne, Melbourne, Victoria, Australia
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Topp SM, Black J, Morrow M, Chipukuma JM, Van Damme W. The impact of human immunodeficiency virus (HIV) service scale-up on mechanisms of accountability in Zambian primary health centres: a case-based health systems analysis. BMC Health Serv Res 2015; 15:67. [PMID: 25889803 PMCID: PMC4347932 DOI: 10.1186/s12913-015-0703-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 01/13/2015] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Questions about the impact of large donor-funded HIV interventions on low- and middle-income countries' health systems have been the subject of a number of expert commentaries, but comparatively few empirical research studies. Aimed at addressing a particular evidence gap vis-à-vis the influence of HIV service scale-up on micro-level health systems, this article examines the impact of HIV scale-up on mechanisms of accountability in Zambian primary health facilities. METHODS Guided by the Mechanisms of Effect framework and Brinkerhoff's work on accountability, we conducted an in-depth multi-case study to examine how HIV services influenced mechanisms of administrative and social accountability in four Zambian primary health centres. Sites were selected for established (over 3 yrs) antiretroviral therapy (ART) services and urban, peri-urban and rural characteristics. Case data included provider interviews (60); patient interviews (180); direct observation of facility operations (2 wks/centre) and key informant interviews (14). RESULTS Resource-intensive investment in HIV services contributed to some early gains in administrative answerability within the four ART departments, helping to establish the material capabilities necessary to deliver and monitor service delivery. Simultaneous investment in external supervision and professional development helped to promote transparency around individual and team performance and also strengthened positive work norms in the ART departments. In the wider health centres, however, mechanisms of administrative accountability remained weak, hindered by poor data collection and under capacitated leadership. Substantive gains in social accountability were also elusive as HIV scale-up did little to address deeply rooted information and power asymmetries in the wider facilities. CONCLUSIONS Short terms gains in primary-level service accountability may arise from investment in health system hardware. However, sustained improvements in service quality and responsiveness arising from genuine improvements in social and administrative accountability require greater understanding of, and investment in changing, the power relations, work norms, leadership and disciplinary mechanisms that shape these micro-level health systems.
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Affiliation(s)
- Stephanie M Topp
- Schools of Public Health and Medicine, University of Alabama, Birmingham, USA.
- Centre for Infectious Disease Research in Zambia, PO Box 30338, Lusaka, Zambia.
- Nossal Institute for Global Health, University of Melbourne, Level 4, 161 Barry Street, Alan Gilbert Building, Carlton, 3010, VIC, Australia.
| | - Jim Black
- Nossal Institute for Global Health, University of Melbourne, Level 4, 161 Barry Street, Alan Gilbert Building, Carlton, 3010, VIC, Australia.
| | - Martha Morrow
- Nossal Institute for Global Health, University of Melbourne, Level 4, 161 Barry Street, Alan Gilbert Building, Carlton, 3010, VIC, Australia.
| | - Julien M Chipukuma
- University of Lusaka, Plot No 37413, Mass Media, Lusaka, 101010, Zambia.
| | - Wim Van Damme
- Public Health and Health Policy Unit, ITM-Antwerp, Sint-Rochusstraat 2, 2000, Antwerpen, Belgium.
- School of Public Health, University of the Western Cape, Robert Sobukwe Road, Bellville, 7535, Republic of South Africa.
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Hegazi A, Forsyth S, Prime K. Testing the children of HIV-infected parents: 6 years on from 'Don't forget the children'. Sex Transm Infect 2014; 91:76-7. [PMID: 25316913 DOI: 10.1136/sextrans-2014-051817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Aseel Hegazi
- Department of Genitourinary Medicine, St George's University Hospital, London, UK
| | - Sophie Forsyth
- Department of Genitourinary Medicine, Great Western Hospital, Swindon, UK
| | - Katia Prime
- Department of Genitourinary Medicine, St George's University Hospital, London, UK
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Remembering the Children: Implementation and Success of a Robust Method for Identifying and Testing Children of HIV Patients. JOURNAL OF SEXUALLY TRANSMITTED DISEASES 2013; 2013:828024. [PMID: 26316965 PMCID: PMC4437414 DOI: 10.1155/2013/828024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Accepted: 09/23/2013] [Indexed: 11/17/2022]
Abstract
Background. Children of HIV patients are a historically neglected demographic by HIV services. It has been recommended by CHIVA that HIV services have a robust method of detecting and testing untested children. We note that no such method is either in widespread use or in the literature. Method. In December 2011, a one-page proforma to identify HIV untested children and a clear multidisciplinary pathway to test them were implemented. Twelve months later the uptake of the proforma and pathway, the numbers of patients and children identified for testing, and their outcomes were audited. Results. The proforma was completed in 192/203 (94.6%) eligible patients. Twenty-five (21.5%) of 118 identified offspring had not been tested. Ten (8.5%) of these were <18 years old. All were reported to be clinically well. Ten children were referred for testing, seven were tested immediately, and three were tested within 18 months of identification. All children were tested HIV negative. Discussion. We have identified a method of identification that is easy and robust and provides a user-friendly safety net to empower healthcare providers to identify and test children at risk. We recommend the implementation of such strategies nationwide to prevent death due to undiagnosed HIV in children.
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Alvarez-del Arco D, Monge S, Azcoaga A, Rio I, Hernando V, Gonzalez C, Alejos B, Caro AM, Perez-Cachafeiro S, Ramirez-Rubio O, Bolumar F, Noori T, Del Amo J. HIV testing and counselling for migrant populations living in high-income countries: a systematic review. Eur J Public Health 2012; 23:1039-45. [PMID: 23002238 PMCID: PMC4051291 DOI: 10.1093/eurpub/cks130] [Citation(s) in RCA: 139] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND The barriers to HIV testing and counselling that migrants encounter can jeopardize proactive HIV testing that relies on the fact that HIV testing must be linked to care. We analyse available evidence on HIV testing and counselling strategies targeting migrants and ethnic minorities in high-income countries. METHODS Systematic literature review of the five main databases of articles in English from Europe, North America and Australia between 2005 and 2009. RESULTS Of 1034 abstracts, 37 articles were selected. Migrants, mainly from HIV-endemic countries, are at risk of HIV infection and its consequences. The HIV prevalence among migrants is higher than the general population's, and migrants have higher frequency of delayed HIV diagnosis. For migrants from countries with low HIV prevalence and for ethnic minorities, socio-economic vulnerability puts them at risk of acquiring HIV. Migrants have specific legal and administrative impediments to accessing HIV testing-in some countries, undocumented migrants are not entitled to health care-as well as cultural and linguistic barriers, racism and xenophobia. Migrants and ethnic minorities fear stigma from their communities, yet community acceptance is key for well-being. CONCLUSIONS Migrants and ethnic minorities should be offered HIV testing, but the barriers highlighted in this review may deter programs from achieving the final goal, which is linking migrants and ethnic minorities to HIV clinical care under the public health perspective.
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Andrews S, Handyside R, Carpenter L, Price A, Majewska W, Prime K. Testing children of mothers with HIV infection: experience in three south-west London HIV clinics. HIV Med 2011; 13:138-40. [PMID: 22093151 DOI: 10.1111/j.1468-1293.2011.00948.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE There are several reported cases of vertically infected children presenting with advanced HIV infection in the UK. The children of women with HIV infection are at increased risk of being infected. There are few data available on the number of such children that are yet to be tested for HIV. This study looked at the HIV testing status of children whose mothers attend HIV services at three south-west London clinics. METHODS Case notes of women attending the clinics from 1 January to 30 June 2009 were reviewed. When data were incomplete, women were prospectively interviewed. RESULTS Case notes of 605 women were reviewed; 478 women had 1107 children. The majority of women (386; 81%) were of Black African ethnicity. Sixty-one per cent (675 of 1107) of the children were known to have been tested for HIV. The children resident abroad were more likely to be untested compared with those resident in the UK; 186 of 255 (73%) vs. 246 of 852 (29%). A quarter (106 of 432) of the untested children were ≤ 18 years old; 49 (46%) of these were resident in the UK. The most common reason given by the mothers for not testing was a perceived 'unlikely risk'. CONCLUSIONS A significant number of children at risk of vertically transmitted HIV infection, including 49 children ≤ 18 years and resident in the UK, were identified through this study. The mothers are being encouraged to have these children tested and a multidisciplinary team involving adult and paediatric HIV healthcare professionals has been set up to negotiate and facilitate testing.
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Affiliation(s)
- S Andrews
- Department of Genitourinary Medicine, St George's Hospital, London, UK.
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Abstract
We aimed to establish current practice regarding the testing of children of HIV-positive women in two centres in the South Yorkshire HIV Network, UK. Notes were reviewed from 59 women who attended clinic over a three-month period from 01 September 2009 to 30 November 2009. In our sample, only 29 of 52 (56%) children living in the UK who required testing had been HIV tested. Testing rates were high in preschool children (15/15) and fell with age to 2/11 (18%) in the 16-20 years age group. Uptake of testing for children of HIV-positive parents could potentially be improved if testing was incorporated into routine clinic practice as part of the package of care offered to a newly diagnosed individual.
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Affiliation(s)
- A Briggs
- Department of Genitourinary Medicine, Royal Hallamshire Hospital, Glossop Road, Sheffield, UK.
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Whitfield CA, Kingston M, Fothergill H, Thng C. Are we forgetting the children? Testing the children of HIV-positive parents. Int J STD AIDS 2011; 22:177-8. [PMID: 21464458 DOI: 10.1258/ijsa.2010.010351] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Undiagnosed HIV infection in children carries significant risks and national guidelines recommend that children of HIV-positive parents be tested. We reviewed the testing of HIV-positive patients' children in those new to our service from April 2008 to December 2009. Of the 86 women, 95% were asked about children. Of the 243 men, 53 were heterosexual or bisexual, and 190 identified themselves as men who have sex with men (MSM). Parental status was determined in 37 (70%) of heterosexual and bisexual men and in 14 (17%) of 84 MSM with a history of previous female partners. All untested children apart from one lived in their country of origin. In MSM, recording of parental status was uncommon. Following this audit, clinic proformas were changed to document the parental status of men of all sexual orientations, and the HIV status of all children.
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Affiliation(s)
- C A Whitfield
- Manchester Centre for Sexual Health, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
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Ferrand RA, Weiss HA, Nathoo K, Ndhlovu CE, Mungofa S, Munyati S, Bandason T, Gibb DM, Corbett EL. A primary care level algorithm for identifying HIV-infected adolescents in populations at high risk through mother-to-child transmission. Trop Med Int Health 2010; 16:349-55. [PMID: 21176006 PMCID: PMC3132444 DOI: 10.1111/j.1365-3156.2010.02708.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objective To present an algorithm for primary-care health workers for identifying HIV-infected adolescents in populations at high risk through mother-to-child transmission. Methods Five hundred and six adolescent (10–18 years) attendees to two primary care clinics in Harare, Zimbabwe, were recruited. A randomly extracted ‘training’ data set (n = 251) was used to generate an algorithm using variables identified as associated with HIV through multivariable logistic regression. Performance characteristics of the algorithm were evaluated in the remaining (‘test’) records (n = 255) at different HIV prevalence rates. Results HIV prevalence was 17%, and infection was independently associated with client-reported orphanhood, past hospitalization, skin problems, presenting with sexually transmitted infection and poor functional ability. Classifying adolescents as requiring HIV testing if they reported >1 of these five criteria had 74% sensitivity and 80% specificity for HIV, with the algorithm correctly predicting the HIV status of 79% of participants. In low-HIV-prevalence settings (<2%), the algorithm would have a high negative predictive value (≥99.5%) and result in an estimated 60% decrease in the number of people needing to test to identify one HIV-infected individual, compared with universal testing. Conclusions Our simple algorithm can identify which individuals are likely to be HIV infected with sufficient accuracy to provide a screening tool for use in settings not already implementing universal testing policies among this age-group, for example immigrants to low-HIV-prevalence countries.
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Affiliation(s)
- Rashida A Ferrand
- Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.
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Eisenhut M, Kawsar M, Connan M, Balachandran T. Why are HIV-positive mothers refusing to have their children screened for vertically transmitted HIV infection? Int J STD AIDS 2009; 20:506-7. [PMID: 19541896 DOI: 10.1258/ijsa.2008.008506] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
A previous audit showed that the HIV status of the majority (73%) of children of HIV-positive mothers attending a genitourinary clinic in the United Kingdom was unknown because mothers did not take up the offer of testing. The objectives of a re-audit were to establish the impact of the audit process on the uptake of testing and reasons for not taking up the offer of screening of offspring. One year after the previous audit, 13/92 (14%) of children not previously tested had their HIV status established. The reason for not testing was, in 43/52 (82%) mothers, the perception that a well child can not be infected with HIV. This was the only reason for not having their children tested in 16 mothers (31%). The next most common theme was fear of disclosure to others, in 29 (56%). The barriers for screening included fear of feeling guilty if the child was found to be positive.
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Affiliation(s)
- M Eisenhut
- Luton & Dunstable Hospital NHS Foundation Trust, Lewsey Road, Luton LU4 0DZ, UK.
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Judd A, Ferrand RA, Jungmann E, Foster C, Masters J, Rice B, Lyall H, Tookey PA, Prime K. Vertically acquired HIV diagnosed in adolescence and early adulthood in the United Kingdom and Ireland: findings from national surveillance. HIV Med 2009; 10:253-6. [PMID: 19187173 DOI: 10.1111/j.1468-1293.2008.00676.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The aim of the study was to describe the characteristics of young people with vertically acquired HIV diagnosed aged > or =13 years. METHODS A retrospective review of HIV diagnoses reported to well-established national paediatric and adult HIV surveillance systems in the United Kingdom/Ireland was conducted. RESULTS Forty-two young people with vertically acquired HIV diagnosed aged > or =13 years were identified; 23 (55%) were female, 40 (95%) were black African and 36 (86%) were born in sub-Saharan Africa. The median age at HIV diagnosis was 14 years (range, 13-20 years). Half of the patients presented with symptoms; the remainder were screened for HIV following diagnosis of a relative. The median CD4 count at diagnosis was 210 cells/microL (range, 0-689 cells/microL), 12 patients (29%) were diagnosed with AIDS at HIV diagnosis or subsequently, and 34 (81%) started combination antiretroviral therapy (ART), most (31 of 34) within a year of diagnosis. CONCLUSION A small number of young people with vertically acquired HIV survive childhood without ART and are diagnosed at age > or =13 years in the United Kingdom/Ireland. Half of the patients were asymptomatic, highlighting the importance of considering HIV testing for all offspring of HIV-infected women, regardless of age or symptoms. Increased awareness among clinicians and parents is required to reduce delayed presentation with advanced disease and to avoid onward transmission as these young people become sexually active.
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Affiliation(s)
- A Judd
- MRC Clinical Trials Unit, London, UK
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