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Fauk NK, Gesesew HA, Seran AL, Ward PR. Barriers to access to antiretroviral therapy by people living with HIV in an indonesian remote district during the COVID-19 pandemic: a qualitative study. BMC Infect Dis 2023; 23:296. [PMID: 37147599 PMCID: PMC10161978 DOI: 10.1186/s12879-023-08221-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 04/04/2023] [Indexed: 05/07/2023] Open
Abstract
BACKGROUND Coronavirus disease (COVID-19) pandemic has a significant influence on the access to healthcare services. This study aimed to understand the views and experiences of people living with HIV (PLHIV) about barriers to their access to antiretroviral therapy (ART) service in Belu district, Indonesia, during the COVID-19 pandemic. METHODS This qualitative inquiry employed in-depth interviews to collect data from 21 participants who were recruited using a snowball sampling technique. Data analysis was guided by a thematic framework analysis. RESULTS The findings showed that fear of contracting COVID-19 was a barrier that impeded participants' access to ART service. Such fear was influenced by their awareness of their vulnerability to the infection, the possibility of unavoidable physical contact in public transport during a travelling to HIV clinic and the widespread COVID-19 infection in healthcare facilities. Lockdowns, COVID-19 restrictions and lack of information about the provision of ART service during the pandemic were also barriers that impeded their access to the service. Other barriers included the mandatory regulation for travellers to provide their COVID-19 vaccine certificate, financial difficulty, and long-distance travel to the HIV clinic. CONCLUSIONS The findings indicate the need for dissemination of information about the provision of ART service during the pandemic and the benefits of COVID-19 vaccination for the health of PLHIV. The findings also indicate the need for new strategies to bring ART service closer to PLHIV during the pandemic such as a community-based delivery system. Future large-scale studies exploring views and experiences of PLHIV about barriers to their access to ART service during the COVID-19 pandemic and new intervention strategies are recommended.
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Affiliation(s)
- Nelsensius Klau Fauk
- Research Centre on Public Health, Equity and Human Flourishing (PHEHF), Torrens University, 88 Wakefield Street, 5000, Adelaide, South Australia, Australia
- Institute of Resource Governance and Social Change, 85227, Kupang, Indonesia
| | - Hailay Abrha Gesesew
- Research Centre on Public Health, Equity and Human Flourishing (PHEHF), Torrens University, 88 Wakefield Street, 5000, Adelaide, South Australia, Australia.
- College of Health Sciences, Mekelle University, P.O. Box 231, Mekelle, Tigray, Ethiopia.
| | - Alfonsa Liquory Seran
- Health Department of Belu District, Atapupu Public Health Centre, 85752, Atambua, Belu, Indonesia
| | - Paul Russell Ward
- Research Centre on Public Health, Equity and Human Flourishing (PHEHF), Torrens University, 88 Wakefield Street, 5000, Adelaide, South Australia, Australia
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Global Health Facility-Based Interventions to Achieve UNAIDS 90-90-90: A Systematic Review and Narrative Analysis. AIDS Behav 2022; 26:1489-1503. [PMID: 34694526 DOI: 10.1007/s10461-021-03503-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2021] [Indexed: 10/20/2022]
Abstract
To evaluate whether health facility-based HIV interventions align with UNAIDS 90-90-90 targets, we performed a systematic review through the lens of UNAIDS targets. We searched 11 databases, retrieving 5201 citations with 26 eligible studies classified by country income and UNAIDS target. We analyzed whether reporting of study outcome metrics was in line with UNAIDS targets using a standardized extraction form and results were summarized in a narrative synthesis given data heterogeneity. We also assessed the quality of randomized trials with the Cochrane Risk of Bias Tool and observational studies with the Newcastle-Ottawa Scale. Stratification of interventions by country income level revealed themes in successful interventions that provide insight for scale-up in similar resource contexts. Few studies reported outcomes using metrics according to UNAIDS targets. Standardization of reporting according to the UNAIDS framework could facilitate comparability of interventions and inform country-level progress on an international scale.
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Fosu M, Teye-Kwadjo E, Salifu Yendork J. Patient-Reported Experiences of Medication Adherence at a Community-Based HIV Clinic, Ghana. J Patient Exp 2022; 9:23743735221107263. [PMID: 35719416 PMCID: PMC9203957 DOI: 10.1177/23743735221107263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
There is little information on patients’ medication adherence experiences at community-based clinics in Ghana. This study investigated adherence to antiretroviral medication among people living with HIV (PLHIV) attending a community-based HIV clinic. PLHIV (N = 349) completed a questionnaire battery on medication adherence, doctor–patient communication, HIV stigma, patient general self-efficacy, perceived social support, and on patient spirituality. Linear Regression was used to analyze the data. Results showed that doctor–patient communication (β = .38, 95% CI [0.09, 0.18], P <.001) and social support from significant others (β = .46, 95% CI [0.18, 0.67], P <.001) were positively associated with medication adherence in this sample. In contrast, HIV stigma (β = –.16, 95% CI [–0.58, −0.09], P <.01), patient spirituality (β = –.22, 95% CI [–0.44, −0.00], P <.05), and patient general self-efficacy (β = –.14, 95% CI [–0.17, −0.02], P <.01) were negatively associated with medication adherence. There is a need for educational interventions targeted at enhancing doctor–patient communication and social support while reducing stigma among PLHIV in Ghana.
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Affiliation(s)
- Morrison Fosu
- Department of Psychology, University of Ghana, Legon, Accra, Ghana
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Shuper PA. The Role of Alcohol-Related Behavioral Research in the Design of HIV Secondary Prevention Interventions in the Era of Antiretroviral Therapy: Targeted Research Priorities Moving Forward. AIDS Behav 2021; 25:365-380. [PMID: 33987783 DOI: 10.1007/s10461-021-03302-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2021] [Indexed: 12/17/2022]
Abstract
HIV secondary prevention focuses on averting onward HIV transmission, which can be realized when people living with HIV enact requisite HIV care continuum-related behaviors to achieve viral suppression, and engage in condom-protected sex when virally unsuppressed. Alcohol has been detrimentally linked to all aspects of HIV secondary prevention, and although a growing number of behavioral interventions account for and address alcohol use within this realm, further efforts are needed to fully realize the potential of such initiatives. The present article proposes a series of targeted priorities to inform the future design, implementation, and evaluation of alcohol-related behavioral intervention research within the scope of HIV secondary prevention. These priorities and corresponding approaches account for the challenges of resource-constrained clinic environments; capitalize on technology; and address key comorbidities. This framework provides the foundation for a range of alcohol-related behavioral interventions that could potentially enhance global HIV secondary prevention efforts in the years ahead.
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Affiliation(s)
- Paul A Shuper
- Institute for Mental Health Policy Research and Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health (CAMH), 33 Russell Street, Toronto, ON, M5S 2S1, Canada.
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
- Institute for Collaboration On Health, Intervention, and Policy (InCHIP), University of Connecticut, Storrs, CT, USA.
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Pretoria, South Africa.
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Kriel Y, Milford C, Cordero JP, Suleman F, Steyn PS, Smit JA. Quality of care in public sector family planning services in KwaZulu-Natal, South Africa: a qualitative evaluation from community and health care provider perspectives. BMC Health Serv Res 2021; 21:1246. [PMID: 34789232 PMCID: PMC8600736 DOI: 10.1186/s12913-021-07247-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 10/19/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Quality of care is a multidimensional concept that forms an integral part of the uptake and use of modern contraceptive methods. Satisfaction with services is a significant factor in the continued use of services. While much is known about quality of care in the general public health care service, little is known about family planning specific quality of care in South Africa. This paper aims to fill the gap in the research by using the Bruce-Jain family planning quality of care framework. METHODS This formative qualitative study was conducted in South Africa, Zambia, and Kenya to explore the uptake of family planning and contraception. The results presented in this paper are from the South African data. Fourteen focus group discussions, twelve with community members and two with health care providers, were conducted along with eight in-depth interviews with key informants. Thematic content analysis using the Bruce-Jain Quality of Care framework was conducted to analyse this data using NVIVO 10. RESULTS Family planning quality of care was defined by participants as the quality of contraceptive methods, attitudes of health care providers, and outcomes of contraceptive use. The data showed that women have limited autonomy in their choice to either use contraception or the method that they might prefer. Important elements that relate to quality of care were identified and described by participants and grouped according to the structural or process components of the framework. Structure-related sub-themes identified included the lack of technically trained providers; integration of services that contributed to long waiting times and mixing of a variety of clients; and poor infrastructure. Sub-themes raised under the process category included poor interpersonal relations; lack of counselling/information exchange, fear; and time constraints. Neither providers nor users discussed follow up mechanisms which is a key aspect to ensure continuity of contraceptive use. CONCLUSION Using a qualitative methodology and applying the Bruce-Jain Quality of Care framework provided key insights into perceptions and challenges about family planning quality of care. Identifying which components are specific to family planning is important for improving contraceptive outcomes. In particular, autonomy in user choice of contraceptive method, integration of services, and the acceptability of overall family planning care was raised as areas of concern.
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Affiliation(s)
- Yolandie Kriel
- MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa.
- School of Public Health and Nursing, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa.
| | - Cecilia Milford
- MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Joanna Paula Cordero
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Fatima Suleman
- Discipline of Pharmaceutical Science, College of Health Sciences, University of KwaZulu-Natal, Westville, Durban, South Africa
| | - Petrus S Steyn
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Jennifer Ann Smit
- MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
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Khumalo GE, Lutge EE, Naidoo P, Mashamba-Thompson TP. Barriers and facilitators of rendering HIV services by community health workers in sub-Saharan Africa: a meta-synthesis. Fam Med Community Health 2021; 9:fmch-2021-000958. [PMID: 34561220 PMCID: PMC8475151 DOI: 10.1136/fmch-2021-000958] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Objectives To synthesise qualitative studies that address the barriers to and facilitators of providing HIV services by community health workers (CHWs) in sub-Saharan Africa (SSA). Design This meta-synthesis was guided by Preferred Reporting Items for Systematic Reviews and Meta-Analyses. We included studies that were published between 2009 and 2019. The Ritchie and Spencer framework and the Supporting the Use of Research Evidence framework were used for thematic analysis and framework analysis, respectively. The Qualitative Assessment and Review Instrument was used to assess the quality of selected studies. Eligibility criteria Qualitative studies published between 2009 and 2019, that included CHWs linked directly or indirectly to the Ministry of Health and providing HIV services in the communities. Information sources An extensive search was conducted on the following databases: EBSCOhost- (ERIC; Health Source-Nursing/Academic Edition; MEDLINE Full Text), Google Scholar and PubMed. Results Barriers to rendering of HIV services by CHWs were community HIV stigma; lack of CHW respect, CHWs’ poor education and training; poor stakeholders’ involvement; poor access to the communities; shortage of CHWs; unsatisfactory incentives; lack of CHW support and supervision, lack of equipment and supplies and social barriers due to culture, language and political structures. The altruistic behaviour of CHWs and the availability of job facilitated the provision of HIV services. Conclusion The delivery of HIV services by CHWs in SSA is faced by more lingering barriers than facilitators. Planners and policymakers can minimise the barriers by investing in both CHW and community training regarding HIV services. Furthermore, sufficient funding should be allocated to the programme to ensure its efficiency. PROSPERO registration number CRD42020160012.
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Affiliation(s)
- Gugulethu Eve Khumalo
- Nursing and Public Health, University of KwaZulu-Natal College of Health Sciences, Durban, KwaZulu-Natal, South Africa .,Health Research and Knowledge Management Unit, KwaZulu-Natal Department of Health, Pietermaritzburg, KwaZulu-Natal, South Africa
| | - Elizabeth E Lutge
- Nursing and Public Health, University of KwaZulu-Natal College of Health Sciences, Durban, KwaZulu-Natal, South Africa.,Health Research and Knowledge Management Unit, KwaZulu-Natal Department of Health, Pietermaritzburg, KwaZulu-Natal, South Africa
| | - Praba Naidoo
- Library, University of KwaZulu-Natal Nelson R Mandela School of Medicine, Durban, KwaZulu-Natal, South Africa
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7
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Masa R, Baca-Atlas S, Hangoma P. Walking and perceived lack of safety: Correlates and association with health outcomes for people living with HIV in rural Zambia. JOURNAL OF TRANSPORT & HEALTH 2021; 22:101140. [PMID: 35495575 PMCID: PMC9053861 DOI: 10.1016/j.jth.2021.101140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Geographic inaccessibility disproportionately affects health outcomes of rural populations due to lack of suitable transport, prolonged travel time, and poverty. Rural patients are left with few transport options to travel to a health facility. One common option is to travel by foot, which may present additional challenges, such as perceived lack of safety while transiting. We examined the correlates of perceived lack of safety when walking to a health facility and its association with treatment and psychosocial outcomes among adults living with HIV. METHODS Data were collected from 101 adults living with HIV in Eastern Province, Zambia. All participants were receiving antiretroviral therapy at one of two health clinics. Perceived lack of safety was measured by asking respondents whether they felt unsafe traveling to and from the health facility in which they were receiving their HIV care. Outcomes included medication adherence, perceived stress, hope for the future, and barriers to pill taking. Linear and logistic regression methods were used to examine the correlates of perceived safety and its association with health outcomes. RESULTS Being older, a woman, having a primary education, living farther from a health facility, traveling longer to reach a health facility, and owing money were associated with higher likelihood of feeling unsafe when traveling by foot to health facility. Perceived lack of safety was associated with medication nonadherence, higher level of stress, lower level of agency, and more barriers to pill taking. CONCLUSIONS Perceived lack of safety when traveling by foot to a health facility may be a barrier to better treatment and psychosocial outcomes, especially among rural patients. Practitioners and policymakers should consider implementation of differentiated HIV service delivery models to reduce frequent travel to health facilities and to alleviate ART patients' worry about lack of safety when traveling by foot to a health facility.
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Affiliation(s)
- Rainier Masa
- School of Social Work, University of North Carolina at Chapel Hill, USA
- Global Social Development Innovations, University of North Carolina at Chapel Hill, USA
| | | | - Peter Hangoma
- School of Public Health, University of Zambia, Lusaka, Zambia
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8
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Geldsetzer P, Sauer A, Francis JM, Mboggo E, Lwezaula S, Sando D, Fawzi W, Ulenga N, Bärnighausen T. Willingness to pay for community delivery of antiretroviral treatment in urban Tanzania: a cross-sectional survey. Health Policy Plan 2021; 35:1300-1308. [PMID: 33083837 PMCID: PMC7886440 DOI: 10.1093/heapol/czaa088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2020] [Indexed: 11/23/2022] Open
Abstract
Community health worker (CHW)-led community delivery of HIV antiretroviral therapy (ART) could increase ART coverage and decongest healthcare facilities. It is unknown how much patients would be willing to pay to receive ART at home and, thus, whether ART community delivery could be self-financing. Set in Dar es Salaam, this study aimed to determine patients’ willingness to pay (WTP) for CHW-led ART community delivery. We sampled ART patients living in the neighbourhoods surrounding each of 48 public-sector healthcare facilities in Dar es Salaam. We asked participants (N = 1799) whether they (1) preferred ART community delivery over standard facility-based care, (2) would be willing to pay for ART community delivery and (3) would be willing to pay each of an incrementally increasing range of prices for the service. 45.0% (810/1799; 95% CI: 42.7—47.3) of participants preferred ART community delivery over standard facility-based care and 51.5% (417/810; 95% CI: 48.1—55.0) of these respondents were willing to pay for ART community delivery. Among those willing to pay, the mean and median amount that participants were willing to pay for one ART community delivery that provides a 2-months’ supply of antiretroviral drugs was 3.61 purchasing-power-parity-adjusted dollars (PPP$) (95% CI: 2.96–4.26) and 1.27 PPP$ (IQR: 1.27–2.12), respectively. An important limitation of this study is that participants all resided in neighbourhoods within the catchment area of the healthcare facility at which they were interviewed and, thus, may incur less costs to attend standard facility-based ART care than other ART patients in Dar es Salaam. While there appears to be a substantial WTP, patient payments would only constitute a minority of the costs of implementing ART community delivery. Thus, major co-financing from governments or donors would likely be required.
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Affiliation(s)
- Pascal Geldsetzer
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, 1265 Welch Road, Stanford, CA 94305, USA.,Heidelberg Institute of Global Health (HIGH), Heidelberg University, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - Alexander Sauer
- Department of Statistics, University of Oxford, 24-29 St Giles', Oxford OX1 3LB, UK
| | - Joel M Francis
- Department of Family Medicine and Primary Care, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Eric Mboggo
- Management and Development for Health, Plot #802, Mwai Kibaki Road, Mikocheni, Dar es Salaam, Tanzania
| | - Sharon Lwezaula
- National AIDS Control Program, Lithuli Street, Dar es Salaam, P.O. Box 11857, Tanzania
| | - David Sando
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Wafaie Fawzi
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA.,Department of Nutrition, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA
| | - Nzovu Ulenga
- Management and Development for Health, Plot #802, Mwai Kibaki Road, Mikocheni, Dar es Salaam, Tanzania
| | - Till Bärnighausen
- Heidelberg Institute of Global Health (HIGH), Heidelberg University, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany.,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Africa Health Research Institute (AHRI), Africa Centre Building, Via R618 to Hlabisa, Somkhele, P.O. Box 198, Mtubatuba 3935, South Africa
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9
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Woznica DM, Ntombela N, Hoffmann CJ, Mabuto T, Kaufman MR, Murray SM, Owczarzak J. Intersectional Stigma Among People Transitioning From Incarceration to Community-Based HIV Care in Gauteng Province, South Africa. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2021; 33:202-215. [PMID: 34014112 PMCID: PMC8479561 DOI: 10.1521/aeap.2021.33.3.202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
People transitioning from incarceration to community-based HIV care experience HIV stigma, incarceration stigma, and the convergence of these stigmas with social inequities. The objective of this study is to understand intersectional stigma among people returning from incarceration with HIV in Gauteng Province, South Africa. Qualitative interviews were conducted with 42 study participants. We analyzed transcript segments and memos from these interviews. Our results showed that anticipated HIV stigma increased participants' difficulty with disclosure and treatment collection. Incarceration stigma, particularly the mark of a criminal record, decreased socioeconomic stability in ways that negatively affected medication adherence. These stigmas converged with stereotypes that individuals were inherently criminal "bandits." Male participants expressed concerns that disclosing their HIV status would lead others to assume they had engaged in sexual activity with men while incarcerated. AIDS education and prevention efforts will require multilevel stigma interventions to improve HIV care outcomes.
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Affiliation(s)
- Daniel M Woznica
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | - Christopher J Hoffmann
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Aurum Institute for Health Research, Johannesburg, South Africa
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Tonderai Mabuto
- Aurum Institute for Health Research, Johannesburg, South Africa
| | - Michelle R Kaufman
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Sarah M Murray
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health
| | - Jill Owczarzak
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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10
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Angwenyi V, Bunders‐Aelen J, Criel B, Lazarus JV, Aantjes C. An evaluation of self-management outcomes among chronic care patients in community home-based care programmes in rural Malawi: A 12-month follow-up study. HEALTH & SOCIAL CARE IN THE COMMUNITY 2021; 29:353-368. [PMID: 32671938 PMCID: PMC7983972 DOI: 10.1111/hsc.13094] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 05/02/2020] [Accepted: 06/12/2020] [Indexed: 05/08/2023]
Abstract
This paper investigates the impact of community home-based care (CHBC) on self-management outcomes for chronically ill patients in rural Malawi. A pre- and post-evaluation survey was administered among 140 chronically ill patients with HIV and non-communicable diseases, newly enrolled in four CHBC programmes. We translated, adapted and administered scales from the Stanford Chronic Disease Self-Management Programme to evaluate patient's self-management outcomes (health status and self-efficacy), at four time points over a 12-month period, between April 2016 and May 2017. The patient's drop-out rate was approximately 8%. Data analysis included descriptive statistics, tests of associations, correlations and pairwise comparison of outcome variables between time points, and multivariate regression analysis to explore factors associated with changes in self-efficacy following CHBC interventions. The results indicate a reduction in patient-reported pain, fatigue and illness intrusiveness, while improvements in general health status and quality of life were not statistically significant. At baseline, the self-efficacy mean was 5.91, which dropped to 5.1 after 12 months. Factors associated with this change included marital status, education, employment and were condition-related; whereby self-efficacy for non-HIV and multimorbid patients was much lower. The odds for self-efficacy improvement were lower for patients with diagnosed conditions of longer duration. CHBC programme support, regularity of contact and proximal location to other services influenced self-efficacy. Programmes maintaining regular home visits had higher patient satisfaction levels. Our findings suggest that there were differential changes in self-management outcomes following CHBC interventions. While self-management support through CHBC programmes was evident, CHBC providers require continuous training, supervision and sustainable funding to strengthen their contribution. Furthermore, sociodemographic and condition-related factors should inform the design of future interventions to optimise outcomes. This study provides a systematic evaluation of self-management outcomes for a heterogeneous chronically ill patient population and highlights the potential and relevant contribution of CHBC programmes in improving chronic care within sub-Saharan Africa.
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Affiliation(s)
- Vibian Angwenyi
- Athena Institute for Research on Innovation and Communication in Health and Life SciencesFaculty of SciencesVrije Universiteit AmsterdamAmsterdamthe Netherlands
- Unit of Equity and HealthDepartment of Public HealthInstitute of Tropical MedicineAntwerpBelgium
- Barcelona Institute for Global Health (ISGlobal)Hospital ClínicUniversity of BarcelonaBarcelonaSpain
| | - Joske Bunders‐Aelen
- Athena Institute for Research on Innovation and Communication in Health and Life SciencesFaculty of SciencesVrije Universiteit AmsterdamAmsterdamthe Netherlands
| | - Bart Criel
- Unit of Equity and HealthDepartment of Public HealthInstitute of Tropical MedicineAntwerpBelgium
| | - Jeffrey V. Lazarus
- Barcelona Institute for Global Health (ISGlobal)Hospital ClínicUniversity of BarcelonaBarcelonaSpain
| | - Carolien Aantjes
- Health Economics and HIV/AIDS Research Division (HEARD)University of KwaZulu‐NatalDurbanSouth Africa
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11
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Card KG, Lachowsky NJ, Althoff KN, Schafer K, Hogg RS, Montaner JSG. A systematic review of the geospatial barriers to antiretroviral initiation, adherence and viral suppression among people living with HIV. Sex Health 2020; 16:1-17. [PMID: 30409243 DOI: 10.1071/sh18104] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 07/04/2018] [Indexed: 11/23/2022]
Abstract
Background With the emergence of antiretroviral therapy (ART), Treatment as Prevention (TasP) has become the cornerstone of both HIV clinical care and HIV prevention. However, despite the efficacy of treatment-based programs and policies, structural barriers to ART initiation, adherence and viral suppression have the potential to reduce TasP effectiveness. These barriers have been studied using Geographic Information Systems (GIS). While previous reviews have examined the use of GIS for HIV testing - an essential antecedent to clinical care - to date, no reviews have summarised the research with respect to other ART-related outcomes. METHODS Therefore, the present review leveraged the PubMed database to identify studies that leveraged GIS to examine the barriers to ART initiation, adherence and viral suppression, with the overall goal of understanding how GIS has been used (and might continue to be used) to better study TasP outcomes. Joanna Briggs Institute criteria were used for the critical appraisal of included studies. RESULTS In total, 33 relevant studies were identified, excluding those not utilising explicit GIS methodology or not examining TasP-related outcomes. CONCLUSIONS Findings highlight geospatial variation in ART success and inequitable distribution of HIV care in racially segregated, economically disadvantaged, and, by some accounts, increasingly rural areas - particularly in the United States. Furthermore, this review highlights the utility and current limitations of using GIS to monitor health outcomes related to ART and the need for careful planning of resources with respect to the geospatial movement and location of people living with HIV (PLWH).
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Affiliation(s)
- Kiffer G Card
- Faculty of Health Science, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Nathan J Lachowsky
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Keri N Althoff
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Katherine Schafer
- Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Robert S Hogg
- Faculty of Health Science, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Julio S G Montaner
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
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12
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Genberg B, Wachira J, Kafu C, Wilson I, Koech B, Kamene R, Akinyi J, Knight J, Braitstein P, Ware N. Health System Factors Constrain HIV Care Providers in Delivering High-Quality Care: Perceptions from a Qualitative Study of Providers in Western Kenya. J Int Assoc Provid AIDS Care 2020; 18:2325958218823285. [PMID: 30798666 PMCID: PMC6503317 DOI: 10.1177/2325958218823285] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The burden on health systems due to increased volume of patients with HIV continues to rapidly increase. The goal of this study was to examine the experiences of HIV care providers in a high patient volume HIV treatment and care program in eastern Africa. Sixty care providers within the Academic Model Providing Access to Healthcare program in western Kenya were recruited into this qualitative study. We conducted in-depth interviews focused on providers’ perspectives on health system factors that impact patient engagement in HIV care. Results from thematic analysis demonstrated that providers perceive a work environment that constrained their ability to deliver high-quality HIV care and encouraged negative patient–provider relationships. Providers described their roles as high strain, low control, and low support. Health system strengthening must include efforts to improve the working environment and easing burden of care providers tasked with delivering antiretroviral therapy to increasing numbers of patients in resource-constrained settings.
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Affiliation(s)
- Becky Genberg
- 1 Department of Health Services, Policy & Practice, Brown University, Providence, RI, USA.,2 Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Juddy Wachira
- 3 Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,4 Department of Behavioral Science, Moi University, College of Health Sciences, School of Medicine, Eldoret, Kenya
| | - Catherine Kafu
- 3 Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Ira Wilson
- 1 Department of Health Services, Policy & Practice, Brown University, Providence, RI, USA
| | - Beatrice Koech
- 3 Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Regina Kamene
- 3 Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Jacqueline Akinyi
- 3 Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Jennifer Knight
- 1 Department of Health Services, Policy & Practice, Brown University, Providence, RI, USA
| | - Paula Braitstein
- 3 Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,4 Department of Behavioral Science, Moi University, College of Health Sciences, School of Medicine, Eldoret, Kenya.,5 Department of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,6 Fairbanks School of Public Health, Indiana University, Indianapolis, IN, USA.,7 Regenstrief Institute, Indianapolis, IN, USA
| | - Norma Ware
- 8 Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.,9 Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
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13
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Ortblad KF, Baeten JM, Cherutich P, Wamicwe JN, Wasserheit JN. The arc of HIV epidemics in sub-Saharan Africa: new challenges with concentrating epidemics in the era of 90-90-90. Curr Opin HIV AIDS 2019; 14:354-365. [PMID: 31343457 PMCID: PMC6669088 DOI: 10.1097/coh.0000000000000569] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE OF REVIEW The aim of this review is to examine the emerging results from the HIV universal test and treat (UTT) cluster-randomized trials in sub-Saharan Africa, discuss how expanding access to HIV clinical services is likely to reshape the arc of HIV epidemics, and consider implications for HIV prevention and control strategies in the coming decade. RECENT FINDINGS The effect of universal HIV testing followed by immediate antiretroviral treatment (ART) on community-level HIV incidence remains unclear upon completion of five randomized trials. Only two of the four trials that measured HIV incidence found significant reductions in community-level incidence. Even in these trials, HIV incidence remained above levels required for epidemic control (≤1 case per 1000 person-years) despite high levels of ART coverage and viral suppression. These findings may indicate that community-delivered HIV services are not reaching the high-frequency transmitters who sustain HIV epidemics and are likely members of marginalized or hard to engage core groups. SUMMARY With expanded access to HIV services in sub-Saharan Africa, HIV epidemics are transitioning from hyperendemic to declining/endemic epidemic phases, characterized increasingly by the reconcentration of HIV in marginalized or hard to engage core groups. To move toward epidemic control, novel HIV service delivery models and technologies are needed to engage those who continue to drive HIV incidence in this new epidemic phase.
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Affiliation(s)
| | - Jared M Baeten
- Department of Global Health
- Department of Medicine
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | | | | | - Judith N Wasserheit
- Department of Global Health
- Department of Medicine
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington, USA
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14
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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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15
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Oladele EA, Badejo OA, Obanubi C, Okechukwu EF, James E, Owhonda G, Omeh OI, Abass M, Negedu-Momoh OR, Ojehomon N, Oqua D, Raj-Pandey S, Khamofu H, Torpey K. Bridging the HIV treatment gap in Nigeria: examining community antiretroviral treatment models. J Int AIDS Soc 2019; 21:e25108. [PMID: 29675995 PMCID: PMC5909112 DOI: 10.1002/jia2.25108] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 03/26/2018] [Indexed: 11/08/2022] Open
Abstract
Introduction Significant gaps persist in providing HIV treatment to all who are in need. Restricting care delivery to healthcare facilities will continue to perpetuate this gap in limited resource settings. We assessed a large‐scale community‐based programme for effectiveness in identifying people living with HIV and linking them to antiretroviral treatment. Methods A retrospective secular trend study of 14 high burden local government areas of Nigeria was conducted in which two models of community antiretroviral treatment delivery were implemented: Model A (on‐site initiation) and Model B (immediate referral) clusters. Model A cluster offered services within communities, from HIV diagnosis to immediate antiretroviral therapy initiation and some follow‐up. Model B cluster offered services for HIV diagnosis up to baseline evaluation and provided referral for antiretroviral therapy initiation to nearest health facility providing HIV services. For controls, we selected and cluster‐matched 34 local government areas where community antiretroviral treatment delivery was not implemented. Outcomes of interest were: the number of people identified as HIV positive and the number of HIV‐positive individuals started on antiretroviral treatment; from June 2014 to May 2016. We used interrupted time‐series analysis to estimate outcome levels and trends across the pre‐and post‐intervention periods. Results Before community antiretrovial treatment introduction, Model A cluster identified, per 100,000 catchment population, 500 HIV‐positives (95% CI: 399.66 to 601.41) and initiated 216 HIV‐positives on antiretroviral treatment (95% CI: 152.72 to 280.10). Model B cluster identified 32 HIV‐positives (95% CI: 25.00 to 40.51) and initiated 8 HIV‐positives on antiretroviral treatment (95% CI: 5.54 to 10.33). After commART introduction, Model A cluster showed an immediate significant increase in 744 HIV‐positive persons (p = 0.00, 95% CI: 360.35 to 1127.77) and 560 HIV‐positives initiated on treatment (p = 0.00, 95% CI: 260.56 to 859.64). Model B cluster showed an immediate significant increase in 30 HIV‐positive persons identified (p = 0.01, 95% CI: 8.38 to 51.93) but not in the number of HIV‐positives initiated on treatment. Model B cluster showed increased month‐on‐month trends of both outcomes of interest (3.4, p = 0.02, 95% CI: 0.44 to 6.38). Conclusion Both community‐models had similar population‐level effectiveness for rapidly identifying people living with HIV but differed in effectively transitioning them to treatment. Comprehensiveness, integration and attention to barriers to care are important in the design of community antiretroviral treatment delivery.
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Affiliation(s)
- Edward A Oladele
- Prevention, Care and Treatment Department, FHI 360 (Family Health International), Abuja, Nigeria
| | - Okikiolu A Badejo
- Prevention, Care and Treatment Department, FHI 360 (Family Health International), Abuja, Nigeria.,Institute of Tropical Medicine (ITM), Antwerp, Belgium
| | - Christopher Obanubi
- Prevention, Care and Treatment Department, FHI 360 (Family Health International), Abuja, Nigeria
| | - Emeka F Okechukwu
- Office of HIV/AIDS and TB, U.S. Agency for International Development (USAID), Abuja, Nigeria
| | - Ezekiel James
- Office of HIV/AIDS and TB, U.S. Agency for International Development (USAID), Abuja, Nigeria
| | | | | | - Moyosola Abass
- Monitoring and Evaluation Department, FHI 360 (Family Health International), Abuja, Nigeria
| | | | | | - Dorothy Oqua
- Howard University Global Initiative, Abuja, Nigeria
| | | | | | - Kwasi Torpey
- College of Health Sciences, University of Ghana, Accra, Ghana
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16
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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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17
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Pasipamire L, Nesbitt RC, Ndlovu S, Sibanda G, Mamba S, Lukhele N, Pasipamire M, Kabore SM, Rusch B, Ciglenecki I, Kerschberger B. Retention on ART and predictors of disengagement from care in several alternative community-centred ART refill models in rural Swaziland. J Int AIDS Soc 2018; 21:e25183. [PMID: 30225946 PMCID: PMC6141897 DOI: 10.1002/jia2.25183] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 08/10/2018] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION A broad range of community-centred care models for patients stable on anti-retroviral therapy (ART) have been proposed by the World Health Organization to better respond to patient needs and alleviate pressure on health systems caused by rapidly growing patient numbers. Where available, often a single alternative care model is offered in addition to routine clinical care. We operationalized several community-centred ART delivery care models in one public sector setting. Here, we compare retention in care and on ART and identify predictors of disengagement with care. METHODS Patients on ART were enrolled into three community-centred ART delivery care models in the rural Shiselweni region (Swaziland), from 02/2015 to 09/2016: Community ART Groups (CAGs), comprehensive outreach care and treatment clubs. We used Kaplan-Meier estimates to describe crude retention in care model and retention on ART (including patients who returned to clinical care). Multivariate Cox proportional hazard models were used to determine factors associated with all-cause attrition from care model and disengagement with ART. RESULTS A total of 918 patients were enrolled. CAGs had the most participants with 531 (57.8%). Median age was 44.7 years (IQR 36.3 to 54.4), 71.8% of patients were female, and 62.6% fulfilled eligibility criteria for community ART. The 12-month retention in ART was 93.7% overall; it was similar between model types (p = 0.52). A considerable proportion of patients returned from community ART to clinical care, resulting in lower 12 months retention in care model (82.2% overall); retention in care model was lowest in CAGs at 70.4%, compared with 86.3% in outreach and 90.4% in treatment clubs (p < 0.001). In multivariate Cox regression models, patients in CAGs had a higher risk of disengaging from care model (aHR 3.15, 95% CI 2.01 to 4.95, p < 0.001) compared with treatment clubs. We found, however, no difference in attrition in ART between alternative model types. CONCLUSIONS Concurrent implementation of three alternative community-centred ART models in the same region was feasible. Although a considerable proportion of patients returned back to clinical care, overall ART retention was high and should encourage programme managers to offer community-centred care models adapted to their specific setting.
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18
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Abstract
The advent of antiretroviral therapy (ART) in 1996 brought with it an urgent need to develop models of health care delivery that could enable its effective and equitable delivery, especially to patients living in poverty. Community-based care, which stretches from patient homes and communities—where chronic infectious diseases are often best managed—to modern health centers and hospitals, offers such a model, providing access to proximate HIV care and minimizing structural barriers to retention. We first review the recent literature on community-based ART programs in low- and low-to-middle-income country settings and document two key principles that guide effective programs: decentralization of ART services and long-term retention of patients in care. We then discuss the evolution of the community-based programs of Partners In Health (PIH), a nongovernmental organization committed to providing a preferential option for the poor in health care, in Haiti and several countries in sub-Saharan Africa, Latin America, Russia and Kazakhstan. As one of the first organizations to treat patients with HIV in low-income settings and a pioneer of the community-based approach to ART delivery, PIH has achieved both decentralization and excellent retention through the application of an accompaniment model that engages community health workers in the delivery of medicines, the provision of social support and education, and the linkage between communities and clinics. We conclude by showing how PIH has leveraged its HIV care delivery platforms to simultaneously strengthen health systems and address the broader burden of disease in the places in which it works.
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19
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Vasan A, Mabey DC, Chaudhri S, Brown Epstein HA, Lawn SD. Support and performance improvement for primary health care workers in low- and middle-income countries: a scoping review of intervention design and methods. Health Policy Plan 2017; 32:437-452. [PMID: 27993961 PMCID: PMC5400115 DOI: 10.1093/heapol/czw144] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2016] [Indexed: 11/16/2022] Open
Abstract
Primary health care workers (HCWs) in low- and middle-income settings (LMIC) often work in challenging conditions in remote, rural areas, in isolation from the rest of the health system and particularly specialist care. Much attention has been given to implementation of interventions to support quality and performance improvement for workers in such settings. However, little is known about the design of such initiatives and which approaches predominate, let alone those that are most effective. We aimed for a broad understanding of what distinguishes different approaches to primary HCW support and performance improvement and to clarify the existing evidence as well as gaps in evidence in order to inform decision-making and design of programs intended to support and improve the performance of health workers in these settings. We systematically searched the literature for articles addressing this topic, and undertook a comparative review to document the principal approaches to performance and quality improvement for primary HCWs in LMIC settings. We identified 40 eligible papers reporting on interventions that we categorized into five different approaches: (1) supervision and supportive supervision; (2) mentoring; (3) tools and aids; (4) quality improvement methods, and (5) coaching. The variety of study designs and quality/performance indicators precluded a formal quantitative data synthesis. The most extensive literature was on supervision, but there was little clarity on what defines the most effective approach to the supervision activities themselves, let alone the design and implementation of supervision programs. The mentoring literature was limited, and largely focused on clinical skills building and educational strategies. Further research on how best to incorporate mentorship into pre-service clinical training, while maintaining its function within the routine health system, is needed. There is insufficient evidence to draw conclusions about coaching in this setting, however a review of the corporate and the business school literature is warranted to identify transferrable approaches. A substantial literature exists on tools, but significant variation in approaches makes comparison challenging. We found examples of effective individual projects and designs in specific settings, but there was a lack of comparative research on tools across approaches or across settings, and no systematic analysis within specific approaches to provide evidence with clear generalizability. Future research should prioritize comparative intervention trials to establish clear global standards for performance and quality improvement initiatives. Such standards will be critical to creating and sustaining a well-functioning health workforce and for global initiatives such as universal health coverage.
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Affiliation(s)
- Ashwin Vasan
- Department of Population and Family Health & Department of Medicine, Columbia University, New York, NY, USA.,Department of Clinical Research, Faculty of Infectious & Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK.,Division of Global Health Equity, Department of Medicine, Brigham & Women's Hospital/Harvard Medical School, Boston, MA, USA
| | - David C Mabey
- Department of Clinical Research, Faculty of Infectious & Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Simran Chaudhri
- Department of Population and Family Health & Department of Medicine, Columbia University, New York, NY, USA
| | | | - Stephen D Lawn
- Department of Clinical Research, Faculty of Infectious & Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK.,Desmond Tutu HIV Centre, Institute of Infectious Diseases and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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20
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Agolory SG, Auld AF, Odafe S, Shiraishi RW, Dokubo EK, Swaminathan M, Dalhatu I, Onotu D, Abiri O, Debem H, Bashorun A, Ellerbrock TV. High rates of loss to follow-up during the first year of pre-antiretroviral therapy for HIV patients at sites providing pre-ART care in Nigeria, 2004-2012. PLoS One 2017; 12:e0183823. [PMID: 28863160 PMCID: PMC5581182 DOI: 10.1371/journal.pone.0183823] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 08/11/2017] [Indexed: 12/27/2022] Open
Abstract
Background With about 3.4 million HIV-infected persons, Nigeria has the second highest number of people living with HIV (PLHIV) in the world. However, antiretroviral treatment (ART) coverage in Nigeria remains low with only 748,846 (22%) of PLHIV on ART by the end of 2014. Retention of HIV-infected patients in pre-ART care is essential to ensure timely ART initiation. We assessed outcomes of patients enrolled in Nigeria’s pre-ART program during 2004–2012. Methods We conducted a nationally representative retrospective cohort study among adults (≥15 years old), enrolling in pre-ART programs supported by the U.S. President’s Emergency Plan for AIDS Relief in Nigeria. A total of 35 sites enrolling ≥50 patients in pre-ART were selected using probability proportional-to-size sampling; 2,415 eligible medical records at these sites were randomly selected for abstraction. Determinants of loss to follow-up (LTFU) and mortality during pre-ART care were estimated using Cox proportional hazards regression models. Results The median age at enrollment was 32 years (interquartile range (IQR) 27–40). A total of 1,216 (51.4%) initiated ART by the time of data abstraction. Among the remaining 1,199 patients, 898 (74.9%) had been LTFU, 180 (15.0%) were alive and in pre-ART care, 71 (5.9%) had died, 50 (4.2%) had transferred out or stopped care. Baseline markers of advanced disease, including weight <45 kg (adjusted hazard ration (AHR) = 4.23; 95% confidence interval (CI): 1.51–15.58) and more advanced WHO disease stage, were predictive of pre-ART mortality. Compared with patients aged 15–24, patients aged 35–44 (AHR = 0.67; 95% CI: 1.0.47–0.95) and age 45–54 (AHR = 0.66; 95% CI: 0.48–0.91) had lower LTFU rates. Compared with attending facilities in North Central geopolitical zone, attending facility locations in South East (AHR = 0.44; 95% CI: 0.24–0.83) was protective against LTFU. Conclusions About half of patients enrolling in HIV program during 2004–2012 in Nigeria had not initiated ART by 2013. Key strategies to improve early ART initiation among pre-ART enrollees include implementation of the WHO test and treat guidelines, earlier HIV testing, and better monitoring to improve ART initiation rates. Further research to understand regional variations in pre-ART outcomes is warranted.
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Affiliation(s)
- Simon G. Agolory
- Division of Global HIV & TB, U.S. Centers for Disease Control & Prevention, Atlanta, United States of America
| | - Andrew F. Auld
- Division of Global HIV & TB, U.S. Centers for Disease Control & Prevention, Atlanta, United States of America
| | - Solomon Odafe
- Division of Global HIV & TB, U.S. Centers for Disease Control & Prevention, Abuja, Nigeria
- * E-mail:
| | - Ray W. Shiraishi
- Division of Global HIV & TB, U.S. Centers for Disease Control & Prevention, Atlanta, United States of America
| | - E. Kainne Dokubo
- Division of Global HIV & TB, U.S. Centers for Disease Control & Prevention, Atlanta, United States of America
| | - Mahesh Swaminathan
- Division of Global HIV & TB, U.S. Centers for Disease Control & Prevention, Atlanta, United States of America
| | - Ibrahim Dalhatu
- Division of Global HIV & TB, U.S. Centers for Disease Control & Prevention, Abuja, Nigeria
| | - Dennis Onotu
- Division of Global HIV & TB, U.S. Centers for Disease Control & Prevention, Abuja, Nigeria
| | - Oseni Abiri
- Division of Global HIV & TB, U.S. Centers for Disease Control & Prevention, Abuja, Nigeria
- School of Biomedical Informatics, University of Texas, Houston, United States of America
| | - Henry Debem
- Division of Global HIV & TB, U.S. Centers for Disease Control & Prevention, Abuja, Nigeria
| | - Adebobola Bashorun
- National AIDS & STIs Control Program, Federal Ministry of Health, Abuja, Nigeria
| | - Tedd V. Ellerbrock
- Division of Global HIV & TB, U.S. Centers for Disease Control & Prevention, Atlanta, United States of America
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Vogt F, Kalenga L, Lukela J, Salumu F, Diallo I, Nico E, Lampart E, Van den Bergh R, Shah S, Ogundahunsi O, Zachariah R, Van Griensven J. Brief Report: Decentralizing ART Supply for Stable HIV Patients to Community-Based Distribution Centers: Program Outcomes From an Urban Context in Kinshasa, DRC. J Acquir Immune Defic Syndr 2017; 74:326-331. [PMID: 27787343 PMCID: PMC5305289 DOI: 10.1097/qai.0000000000001215] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Facility-based antiretroviral therapy (ART) provision for stable patients with HIV congests health services in resource-limited countries. We assessed outcomes and risk factors for attrition after decentralization to community-based ART refill centers among 2603 patients with HIV in Kinshasa, Democratic Republic of Congo, using a multilevel Poisson regression model. Death, loss to follow-up, and transfer out were 0.3%, 9.0%, and 0.7%, respectively, at 24 months. Overall attrition was 5.66/100 person-years. Patients with >3 years on ART, >500 cluster of differentiation type-4 count, body mass index >18.5, and receiving nevirapine but not stavudine showed reduced attrition. ART refill centers are a promising task-shifting model in low-prevalence urban settings with high levels of stigma and poor ART coverage.
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Affiliation(s)
- Florian Vogt
- *Institute of Tropical Medicine Antwerp, Antwerp, Belgium; †Doctors Without Borders/Médecins Sans Frontières, Kinshasa, Democratic Republic of the Congo; ‡Réseau National des Organisations d'Assise Communautaires, Kinshasa, Democratic Republic of the Congo; §Ministry of Health, Kinshasa, Democratic Republic of the Congo; ‖Doctors Without Borders/Médecins Sans Frontières, Brussels, Belgium; and ¶World Health Organization, Geneva, Switzerland
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Abstract
The concept of lay worker health literacy is created by concurrently analyzing and synthesizing two intersecting concepts, lay workers and health literacy. Articulation of this unique intersection is the result of implementing a simplified Wilson's Concept Analysis Procedure. This process incorporates the following components: a) selecting a concept, b) determining the aims/purposes of analysis, c) identifying all uses of the concept, d) determining defining attributes, e) identifying a model case, f) identifying borderline, related, contrary, and illegitimate cases, g) identifying antecedents and consequences, and h) defining empirical referents. Furthermore, as current literature provides no operational definition for lay worker health literacy, one is created to contribute cohesion to the concept.
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Affiliation(s)
- Kathleen Paco Cadman
- Assistant Professor of Nursing, Weber State University, Ogden, UT, and PhD Student, University of Nevada, Las Vegas
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23
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Modifications to ART service delivery models by health facilities in Uganda in promotion of intervention sustainability: a mixed methods study. Implement Sci 2017; 12:45. [PMID: 28376834 PMCID: PMC5379666 DOI: 10.1186/s13012-017-0578-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Accepted: 03/28/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In November 2015, WHO released new treatment guidelines recommending that all diagnosed as HIV positive be enrolled on antiretroviral therapy (ART). Sustaining and expanding ART scale-up programs in resource-limited settings will require adaptations and modifications to traditional ART delivery models to meet the rapid increase in demand. We identify modifications to ART service delivery models by health facilities in Uganda to sustain ART interventions over a 10-year period (2004-2014). METHODS A mixed methods approach involving two study phases was adopted. In the first phase, a survey of a nationally representative sample of health facilities (n = 195) in Uganda which were accredited to provide ART between 2004 and 2009 was conducted. The second phase involved semi-structured interviews (n = 18) with ART clinic managers of 6 of the 195 health facilities purposively selected from the first study phase. We adopted a thematic framework consisting of four categories of modifications (format, setting, personnel, and population). RESULTS The majority of health facilities 185 (95%) reported making modifications to ART interventions between 2004 and 2014. Of the 195 health facilities, 157 (81%) rated the modifications made to ART as "major." Modifications to ART were reported under all the four themes. The quantitative and qualitative findings are integrated and presented under four themes. Format: Reducing the frequency of clinic appointments and pharmacy-only refill programs was identified as important strategies for decongesting ART clinics. SETTING Home-based care programs were introduced to reduce provider ART delivery costs. Personnel: Task shifting to non-physician cadre was reported in 181 (93%) of the health facilities. POPULATION Visits to the ART clinic were rationalized in favor of the sub-population deemed to have more clinical need. Two health facilities focused on patients living nearer the health facilities to align with targets set by external donors. CONCLUSIONS Over the study period, health facilities made several modifications ART interventions to improve fit with their resource-constrained settings thereby promoting long-term sustainability. Further research evaluating the effect of these modifications on patient outcomes and ART delivery costs is recommended. Our findings have implications for the sustainability of ART scale-up programs in Uganda and other resource-limited settings.
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24
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Geldsetzer P, Francis JM, Ulenga N, Sando D, Lema IA, Mboggo E, Vaikath M, Koda H, Lwezaula S, Hu J, Noor RA, Olofin I, Larson E, Fawzi W, Bärnighausen T. The impact of community health worker-led home delivery of antiretroviral therapy on virological suppression: a non-inferiority cluster-randomized health systems trial in Dar es Salaam, Tanzania. BMC Health Serv Res 2017; 17:160. [PMID: 28228134 PMCID: PMC5322683 DOI: 10.1186/s12913-017-2032-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 01/17/2017] [Indexed: 11/18/2022] Open
Abstract
Background Home delivery of antiretroviral therapy (ART) by community health workers (CHWs) may improve ART retention by reducing the time burden and out-of-pocket expenditures to regularly attend an ART clinic. In addition, ART home delivery may shorten waiting times and improve quality of care for those in facility-based care by decongesting ART clinics. This trial aims to determine whether ART home delivery for patients who are clinically stable on ART combined with facility-based care for those who are not stable on ART is non-inferior to the standard of care (facility-based care for all ART patients) in achieving and maintaining virological suppression. Methods This is a non-inferiority cluster-randomized trial set in Dar es Salaam, Tanzania. A cluster is one of 48 healthcare facilities with its surrounding catchment area. 24 clusters were randomized to ART home delivery and 24 to the standard of care. The intervention consists of home visits by CHWs to provide counseling and deliver ART to patients who are stable on ART, while the control is the standard of care (facility-based ART and CHW home visits without ART home delivery). In addition, half of the healthcare facilities in each study arm were randomized to standard counseling during home visits (covering family planning, prevention of HIV transmission, and ART adherence), and half to standard plus nutrition counseling (covering food production and dietary advice). The non-inferiority design applies to the endpoints of the ART home delivery trial; the primary endpoint is the proportion of ART patients at a healthcare facility who are virally suppressed at the end of the study period. The margin of non-inferiority for this primary endpoint was set at nine percentage points. Discussion As the number of ART patients in sub-Saharan Africa is expected to rise, this trial provides causal evidence on the effectiveness of a home-based care model that could decongest ART clinics and reduce patients’ healthcare expenditures. More broadly, this trial will inform the increasing policy interest in task-shifting of chronic disease care from facility- to community-based healthcare workers. Trial registration ClinicalTrials.gov: NCT02711293. Registration date: 16 March 2016. Electronic supplementary material The online version of this article (doi:10.1186/s12913-017-2032-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Pascal Geldsetzer
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA
| | - Joel M Francis
- Management and Development for Health, Plot #802, Mwai Kibaki Road, Mikocheni, Dar es Salaam, Tanzania. .,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA. .,National Institute for Medical Research, 3 Barack Obama Drive, 11101, Dar es Salaam, Tanzania.
| | - Nzovu Ulenga
- Management and Development for Health, Plot #802, Mwai Kibaki Road, Mikocheni, Dar es Salaam, Tanzania
| | - David Sando
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA
| | - Irene A Lema
- Management and Development for Health, Plot #802, Mwai Kibaki Road, Mikocheni, Dar es Salaam, Tanzania
| | - Eric Mboggo
- Management and Development for Health, Plot #802, Mwai Kibaki Road, Mikocheni, Dar es Salaam, Tanzania
| | - Maria Vaikath
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA
| | - Happiness Koda
- Management and Development for Health, Plot #802, Mwai Kibaki Road, Mikocheni, Dar es Salaam, Tanzania
| | - Sharon Lwezaula
- National AIDS Control Program, Lithuli Street, P.O. Box 11857, Dar es Salaam, Tanzania
| | - Janice Hu
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA.,Duke University School of Medicine, Duke University, 8 Duke University Medical Center Greenspace, Durham, NC, 27703, USA
| | - Ramadhani A Noor
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA.,Department of Nutrition, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA, 02115, USA.,Africa Academy for Public Health (AAPH), Plot #802, Mwai Kibaki Road, Dar es Salaam, Tanzania
| | - Ibironke Olofin
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA
| | - Elysia Larson
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA
| | - Wafaie Fawzi
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA.,Department of Nutrition, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA, 02115, USA.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA, 02115, USA
| | - Till Bärnighausen
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA.,Institute for Public Health, Faculty of Medicine, Heidelberg University, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany.,Africa Health Research Institute, Mtubatuba 3935, KwaZulu-Natal, South Africa
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Zakumumpa H, Taiwo MO, Muganzi A, Ssengooba F. Human resources for health strategies adopted by providers in resource-limited settings to sustain long-term delivery of ART: a mixed-methods study from Uganda. HUMAN RESOURCES FOR HEALTH 2016; 14:63. [PMID: 27756428 PMCID: PMC5070071 DOI: 10.1186/s12960-016-0160-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 10/01/2016] [Indexed: 05/25/2023]
Abstract
BACKGROUND Human resources for health (HRH) constraints are a major barrier to the sustainability of antiretroviral therapy (ART) scale-up programs in Sub-Saharan Africa. Many prior approaches to HRH constraints have taken a top-down trend of generalized global strategies and policy guidelines. The objective of the study was to examine the human resources for health strategies adopted by front-line providers in Uganda to sustain ART delivery beyond the initial ART scale-up phase between 2004 and 2009. METHODS A two-phase mixed-methods approach was adopted. In the first phase, a survey of a nationally representative sample of health facilities (n = 195) across Uganda was conducted. The second phase involved in-depth interviews (n = 36) with ART clinic managers and staff of 6 of the 195 health facilities purposively selected from the first study phase. Quantitative data was analysed based on descriptive statistics, and qualitative data was analysed by coding and thematic analysis. RESULTS The identified strategies were categorized into five themes: (1) providing monetary and non-monetary incentives to health workers on busy ART clinic days; (2) workload reduction through spacing ART clinic appointments; (3) adopting training workshops in ART management as a motivation strategy for health workers; (4) adopting non-physician-centred staffing models; and (5) devising ART program leadership styles that enhanced health worker commitment. CONCLUSIONS Facility-level strategies for responding to HRH constraints are feasible and can contribute to efforts to increase country ownership of HIV programs in resource-limited settings. Consideration of the human resources for health strategies identified in the study by ART program planners and managers could enhance the long-term sustainment of ART programs by providers in resource-limited settings.
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Affiliation(s)
- Henry Zakumumpa
- School of Public Health, Makerere University, Kampala, Uganda
| | | | - Alex Muganzi
- The Infectious Diseases Institute, Makerere University, Kampala, Uganda
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26
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Geldsetzer P, Ortblad K, Bärnighausen T. The efficiency of chronic disease care in sub-Saharan Africa. BMC Med 2016; 14:127. [PMID: 27566531 PMCID: PMC5002156 DOI: 10.1186/s12916-016-0675-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 08/19/2016] [Indexed: 03/16/2023] Open
Abstract
The number of people needing chronic disease care is projected to increase in sub-Saharan Africa as a result of expanding human immunodeficiency virus (HIV) treatment coverage, rising life expectancies, and lifestyle changes. Using nationally representative data of healthcare facilities, Di Giorgio et al. found that many HIV clinics in Kenya, Uganda, and Zambia appear to have considerable untapped capacity to provide care for additional patients. These findings highlight the potential for increasing the efficiency of clinical processes for chronic disease care at the facility level. Important questions for future research are how estimates of comparative technical efficiency across facilities change, when they are adjusted for quality of care and the composition of patients by care complexity. Looking ahead, substantial research investment will be needed to ensure that we do not forgo the opportunity to learn how efficiency changes, as chronic care is becoming increasingly differentiated by patient type and integrated across diseases and health systems functions.Please see related article: http://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-016-0653-z.
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Affiliation(s)
- Pascal Geldsetzer
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Building 1, Boston, MA, 02115, USA
| | - Katrina Ortblad
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Building 1, Boston, MA, 02115, USA
| | - Till Bärnighausen
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Building 1, Boston, MA, 02115, USA. .,Institute of Public Health, Heidelberg University, Im Neuenheimer Feld 324, Heidelberg, 69120, Germany. .,Africa Health Research Institute, P.O. Box 198, Mtubatuba, 3935, South Africa.
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27
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Wekesah FM, Mbada CE, Muula AS, Kabiru CW, Muthuri SK, Izugbara CO. Effective non-drug interventions for improving outcomes and quality of maternal health care in sub-Saharan Africa: a systematic review. Syst Rev 2016; 5:137. [PMID: 27526773 PMCID: PMC4986260 DOI: 10.1186/s13643-016-0305-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 06/20/2016] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Many interventions have been implemented to improve maternal health outcomes in sub-Saharan Africa (SSA). Currently, however, systematic information on the effectiveness of these interventions remains scarce. We conducted a systematic review of published evidence on non-drug interventions that reported effectiveness in improving outcomes and quality of care in maternal health in SSA. METHODS African Journals Online, Bioline, MEDLINE, Ovid, Science Direct, and Scopus databases were searched for studies published in English between 2000 and 2015 and reporting on the effectiveness of interventions to improve quality and outcomes of maternal health care in SSA. Articles focusing on interventions that involved drug treatments, medications, or therapies were excluded. We present a narrative synthesis of the reported impact of these interventions on maternal morbidity and mortality outcomes as well as on other dimensions of the quality of maternal health care (as defined by the Institute of Medicine 2001 to comprise safety, effectiveness, efficiency, timeliness, patient centeredness, and equitability). RESULTS Seventy-three studies were included in this review. Non-drug interventions that directly or indirectly improved quality of maternal health and morbidity and mortality outcomes in SSA assumed a variety of forms including mobile and electronic health, financial incentives on the demand and supply side, facility-based clinical audits and maternal death reviews, health systems strengthening interventions, community mobilization and/or peer-based programs, home-based visits, counseling and health educational and promotional programs conducted by health care providers, transportation and/or communication and referrals for emergency obstetric care, prevention of mother-to-child transmission of HIV, and task shifting interventions. There was a preponderance of single facility and community-based studies whose effectiveness was difficult to assess. CONCLUSIONS Many non-drug interventions have been implemented to improve maternal health care in SSA. These interventions have largely been health facility and/or community based. While the evidence on the effectiveness of interventions to improve maternal health is varied, study findings underscore the importance of implementing comprehensive interventions that strengthen different components of the health care systems, both in the community and at the health facilities, coupled with a supportive policy environment. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42015023750.
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Affiliation(s)
- Frederick M. Wekesah
- African Population Health Research Center, 2nd Floor, APHRC Campus, Manga Close, Off Kirawa Road, Kitisuru, P. O. Box 10787, Nairobi, 00100 Kenya
- Julius Global Health, Julius Center for Health Sciences and Primary Care, Utrecht Medical Center, Utrecht Huispost Str. 6.131, P.O. Box 85500, 3508 GA Utrecht, Netherlands
| | - Chidozie E. Mbada
- African Population Health Research Center, 2nd Floor, APHRC Campus, Manga Close, Off Kirawa Road, Kitisuru, P. O. Box 10787, Nairobi, 00100 Kenya
- Department of Medical Rehabilitation, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Adamson S. Muula
- Department of Public Health, School of Public Health and Family Health, College of Medicine, University of Malawi, Private Bag 360, Chichiri, Blantyre, Malawi
- African Center for Public Health and Herbal Medicine, University of Malawi, Blantyre, Malawi
| | - Caroline W. Kabiru
- African Population Health Research Center, 2nd Floor, APHRC Campus, Manga Close, Off Kirawa Road, Kitisuru, P. O. Box 10787, Nairobi, 00100 Kenya
| | - Stella K. Muthuri
- African Population Health Research Center, 2nd Floor, APHRC Campus, Manga Close, Off Kirawa Road, Kitisuru, P. O. Box 10787, Nairobi, 00100 Kenya
| | - Chimaraoke O. Izugbara
- African Population Health Research Center, 2nd Floor, APHRC Campus, Manga Close, Off Kirawa Road, Kitisuru, P. O. Box 10787, Nairobi, 00100 Kenya
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Impact of Health System Inputs on Health Outcome: A Multilevel Longitudinal Analysis of Botswana National Antiretroviral Program (2002-2013). PLoS One 2016; 11:e0160206. [PMID: 27490477 PMCID: PMC4974006 DOI: 10.1371/journal.pone.0160206] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 07/17/2016] [Indexed: 11/19/2022] Open
Abstract
Objective To measure the association between the number of doctors, nurses and hospital beds per 10,000 people and individual HIV-infected patient outcomes in Botswana. Design Analysis of routinely collected longitudinal data from 97,627 patients who received ART through the Botswana National HIV/AIDS Treatment Program across all 24 health districts from 2002 to 2013. Doctors, nurses, and hospital bed density data at district-level were collected from various sources. Methods A multilevel, longitudinal analysis method was used to analyze the data at both patient- and district-level simultaneously to measure the impact of the health system input at district-level on probability of death or loss-to-follow-up (LTFU) at the individual level. A marginal structural model was used to account for LTFU over time. Results Increasing doctor density from one doctor to two doctors per 10,000 population decreased the predicted probability of death for each patient by 27%. Nurse density changes from 20 nurses to 25 nurses decreased the predicted probability of death by 28%. Nine percent decrease was noted in predicted mortality of an individual in the Masa program for every five hospital bed density increase. Conclusion Considerable variation was observed in doctors, nurses, and hospital bed density across health districts. Predictive margins of mortality and LTFU were inversely correlated with doctor, nurse and hospital bed density. The doctor density had much greater impact than nurse or bed density on mortality or LTFU of individual patients. While long-term investment in training more healthcare professionals should be made, redistribution of available doctors and nurses can be a feasible solution in the short term.
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29
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Mukumbang FC, Van Belle S, Marchal B, Van Wyk B. Realist evaluation of the antiretroviral treatment adherence club programme in selected primary healthcare facilities in the metropolitan area of Western Cape Province, South Africa: a study protocol. BMJ Open 2016; 6:e009977. [PMID: 27044575 PMCID: PMC4823437 DOI: 10.1136/bmjopen-2015-009977] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Suboptimal retention in care and poor treatment adherence are key challenges to antiretroviral therapy (ART) in sub-Saharan Africa. Community-based approaches to HIV service delivery are recommended to improve patient retention in care and ART adherence. The implementation of the adherence clubs in the Western Cape province of South Africa was with variable success in terms of implementation and outcomes. The need for operational guidelines for its implementation has been identified. Therefore, understanding the contexts and mechanisms for successful implementation of the adherence clubs is crucial to inform the roll-out to the rest of South Africa. The protocol outlines an evaluation of adherence club intervention in selected primary healthcare facilities in the metropolitan area of the Western Cape Province, using the realist approach. METHODS AND ANALYSIS In the first phase, an exploratory study design will be used. Document review and key informant interviews will be used to elicit the programme theory. In phase two, a multiple case study design will be used to describe the adherence clubs in five contrastive sites. Semistructured interviews will be conducted with purposively selected programme implementers and members of the clubs to assess the context and mechanisms of the adherence clubs. For the programme's primary outcomes, a longitudinal retrospective cohort analysis will be conducted using routine patient data. Data analysis will involve classifying emerging themes using the context-mechanism-outcome (CMO) configuration, and refining the primary CMO configurations to conjectured CMO configurations. Finally, we will compare the conjectured CMO configurations from the cases with the initial programme theory. The final CMOs obtained will be translated into middle range theories. ETHICS AND DISSEMINATION The study will be conducted according to the principles of the declaration of Helsinki (1964). Ethics clearance was obtained from the University of the Western Cape. Dissemination will be done through publications and curation.
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Affiliation(s)
- Ferdinand C Mukumbang
- School of Public Health, University of the Western Cape, Cape Town, Western Cape, South Africa
| | - Sara Van Belle
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- Institute of Development and Management, University of Antwerp, Antwerp, Belgium
| | - Bruno Marchal
- School of Public Health, University of the Western Cape, Cape Town, Western Cape, South Africa
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Brian Van Wyk
- School of Public Health, University of the Western Cape, Cape Town, Western Cape, South Africa
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30
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Engelhard EAN, Smit C, Nieuwkerk PT, Reiss P, Kroon FP, Brinkman K, Geerlings SE. Structure and quality of outpatient care for people living with an HIV infection. AIDS Care 2016; 28:1062-72. [PMID: 26971587 DOI: 10.1080/09540121.2016.1153590] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Policy-makers and clinicians are faced with a gap of evidence to guide policy on standards for HIV outpatient care. Ongoing debates include which settings of care improve health outcomes, and how many HIV-infected patients a health-care provider should treat to gain and maintain expertise. In this article, we evaluate the studies that link health-care facility and care provider characteristics (i.e., structural factors) to health outcomes in HIV-infected patients. We searched the electronic databases MEDLINE, PUBMED, and EMBASE from inception until 1 January 2015. We included a total of 28 observational studies that were conducted after the introduction of combination antiretroviral therapy in 1996. Three aspects of the available research linking the structure to quality of HIV outpatient care were evaluated: (1) assessed structural characteristics (i.e., health-care facility and care provider characteristics); (2) measures of quality of HIV outpatient care; and (3) reported associations between structural characteristics and quality of care. Rather than scarcity of data, it is the diversity in methodology in the identified studies and the inconsistency of their results that led us to the conclusion that the scientific evidence is too weak to guide policy in HIV outpatient care. We provide recommendations on how to address this heterogeneity in future studies and offer specific suggestions for further reading that could be of interest for clinicians and researchers.
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Affiliation(s)
- Esther A N Engelhard
- a Department of Internal Medicine, Division of Infectious Diseases , Academic Medical Center of the University of Amsterdam , Amsterdam , The Netherlands.,b Stichting HIV Monitoring , Amsterdam , The Netherlands
| | - Colette Smit
- b Stichting HIV Monitoring , Amsterdam , The Netherlands
| | - Pythia T Nieuwkerk
- c Department of Medical Psychology , Academic Medical Center of the University of Amsterdam , Amsterdam , The Netherlands
| | - Peter Reiss
- a Department of Internal Medicine, Division of Infectious Diseases , Academic Medical Center of the University of Amsterdam , Amsterdam , The Netherlands.,b Stichting HIV Monitoring , Amsterdam , The Netherlands.,d Department of Global Health and Amsterdam Institute for Global Health and Development , Academic Medical Center of the University of Amsterdam , Amsterdam , The Netherlands
| | - Frank P Kroon
- e Department of Infectious Diseases , Leiden University Medical Center , Leiden , The Netherlands
| | - Kees Brinkman
- f Onze Lieve Vrouwe Gasthuis, Internal Medicine , Amsterdam , The Netherlands
| | - Suzanne E Geerlings
- a Department of Internal Medicine, Division of Infectious Diseases , Academic Medical Center of the University of Amsterdam , Amsterdam , The Netherlands
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People living with HIV travel farther to access healthcare: a population-based geographic analysis from rural Uganda. J Int AIDS Soc 2016; 19:20171. [PMID: 26869359 PMCID: PMC4751409 DOI: 10.7448/ias.19.1.20171] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 12/09/2015] [Accepted: 01/07/2016] [Indexed: 11/21/2022] Open
Abstract
Introduction The availability of specialized HIV services is limited in rural areas of sub-Saharan Africa where the need is the greatest. Where HIV services are available, people living with HIV (PLHIV) must overcome large geographic, economic and social barriers to access healthcare. The objective of this study was to understand the unique barriers PLHIV face when accessing healthcare compared with those not living with HIV in a rural area of sub-Saharan Africa with limited availability of healthcare infrastructure. Methods We conducted a population-based cross-sectional study of 447 heads of household on Bugala Island, Uganda. Multiple linear regression models were used to compare travel time, cost and distance to access healthcare, and log binomial models were used to test for associations between HIV status and access to nearby health services. Results PLHIV travelled an additional 1.9 km (95% CI (0.6, 3.2 km), p=0.004) to access healthcare compared with those not living with HIV, and they were 56% less likely to access healthcare at the nearest health facility to their residence, so long as that facility lacked antiretroviral therapy (ART) services (aRR=0.44, 95% CI (0.24 to 0.83), p=0.011). We found no evidence that PLHIV travelled further for care if the nearest facility supplies ART services (aRR=0.95, 95% CI (0.86 to 1.05), p=0.328). Among those who reported uptake of care at one of two facilities on the island that provides ART (81% of PLHIV and 68% of HIV-negative individuals), PLHIV tended to seek care at a higher tiered facility that provides ART, even when this facility was not their closest facility (30% of PLHIV travelled further than the closest ART facility compared with 16% of HIV-negative individuals), and travelled an additional 2.2 km (p=0.001) to access that facility, relative to HIV-negative individuals (aRR=1.91, 95% CI (1.00 to 3.65), p=0.05). Among PLHIV, residential distance was associated with access to facilities providing ART (RR=0.78, 95% CI (0.61 to 0.99), p=0.044, comparing residential distances of 3–5 km to 0–2 km; RR=0.71, 95% CI (0.58 to 0.87), p=0.001, comparing residential distances of 6–10 km to 0–2 km). Conclusions PLHIV travel longer distances for care, a phenomenon that may be driven by both the limited availability of specialized HIV services and preference for higher tiered facilities.
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Ying R, Barnabas RV, Williams BG. Modeling the implementation of universal coverage for HIV treatment as prevention and its impact on the HIV epidemic. Curr HIV/AIDS Rep 2014; 11:459-67. [PMID: 25249293 PMCID: PMC4301303 DOI: 10.1007/s11904-014-0232-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
The Joint United Nations Programme on HIV/AIDS (UNAIDS) recently updated its global targets for antiretroviral therapy (ART) coverage for HIV-positive persons under which 90 % of HIV-positive people are tested, 90 % of those are on ART, and 90 % of those achieve viral suppression. Treatment policy is moving toward treating all HIV-infected persons regardless of CD4 cell count-otherwise known as treatment as prevention-in order to realize the full therapeutic and preventive benefits of ART. Mathematical models have played an important role in guiding the development of these policies by projecting long-term health impacts and cost-effectiveness. To guide future policy, new mathematical models must consider the barriers patients face in receiving and taking ART. Here, we describe the HIV care cascade and ART delivery supply chain to examine how mathematical modeling can provide insight into cost-effective strategies for scaling-up ART coverage in sub-Saharan Africa and help achieve universal ART coverage.
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Affiliation(s)
- Roger Ying
- Department of Global Health, University of Washington, Box 359927, 325 Ninth Avenue, Seattle, WA, 98104, USA,
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