Comprehensive health care for people infected with HIV in developing countries

Health workers' knowledge and practice of Isoniazid preventive treatment guidelines in health facilities in Ebonyi State, Nigeria

Background

Isoniazid preventive therapy is recommended as part of a comprehensive HIV and AIDS care strategy. IPT is used as prophylaxis to reduce the incidence of TB in HIV-infected persons. However, its implementation has been very slow and has been influenced by several factors. This study assessed health workers' knowledge and adherence to Isoniazid Preventive Therapy guidelines.

Methods

This was a cross-sectional study in six health facilities providing HIV care in Ebonyi State using a semi-structured, self-administered questionnaire. Data were collected from 85 health workers working in the HIV clinics. Data were also extracted from 200 patient treatment cards. Data analysis was carried out using SPSS version 20 software. Chi-square statistics and logistic regression were carried out to determine the association between socio-demographic characteristics and knowledge as well as self-reported practice of the guideline.

Result

Slightly over half of the respondents (58.8%) had good knowledge of the guideline, and the majority (75.3%) self-reported that they practiced the guideline. Only 17% of the treatment cards had isoniazid prescribed and only 11% of these had patient adherence assessed. The most common challenges to implementation of the guideline cited by health workers were unavailability of isoniazid, poor awareness, patient non-adherence, poor resources, high pill burden, and lack of training. Being a doctor and more than 3 years duration of work in the clinic were predictors of good knowledge. There was no predictor of practice.

Conclusion

There was good knowledge and practice of the guideline from health worker self-reports, however, review of treatment card showed prescription was low. Further studies to explore and understand why there is such low prescription of INH/IPT to HIV patients despite good knowledge of healthcare professionals are recommended.

Site-Level Comprehensiveness of Care Is Associated with Individual Clinical Retention Among Adults Living with HIV in International Epidemiology Databases to Evaluate AIDS, a Global HIV Cohort Collaboration, 2000-2016

Retention in care (RIC) reduces HIV transmission and associated morbidity and mortality. We examined whether delivery of comprehensive services influenced individual RIC within the International epidemiology Databases to Evaluate AIDS (IeDEA) network. We collected site data through IeDEA assessments 1.0 (2000-2009) and 2.0 (2010-2016). Each site received a comprehensiveness score for service availability (1 = present, 0 = absent), with tallies ranging from 0 to 7. We obtained individual-level cohort data for adults with at least one visit from 2000 to 2016 at sites responding to either assessment. Person-time was recorded annually, with RIC defined as completing two visits at least 90 days apart in each calendar year. Multivariable modified Poisson regression clustered by site yielded risk ratios and predicted probabilities for individual RIC by comprehensiveness. Among 347,060 individuals in care at 122 sites with 1,619,558 person-years of follow-up, 69.8% of person-time was retained in care, varying by region from 53.8% (Asia-Pacific) to 82.7% (East Africa); RIC improved by about 2% per year from 2000 to 2016 (p = 0.012). Every site provided CD4+ count testing, and >90% of individuals received care at sites that provided combination antiretroviral therapy adherence measures, prevention of mother-to-child transmission, tuberculosis screening, HIV-related prevention, and community tracing services. In adjusted models, individuals at sites with more comprehensive services had higher probabilities of RIC (0.71, 0.74, and 0.83 for scores 5, 6, and 7, respectively; p = 0.019). Within IeDEA, greater site-level comprehensiveness of services was associated with improved individual RIC. Much work remains in exploring this relationship, which may inform HIV clinical practice and health systems planning.

Effect of mobile-phone messaging on patient and health-worker knowledge and adherence to the isoniazid preventive therapy guideline in HIV clinics in Southeast, Nigeria

BACKGROUND

HIV-infected persons are at increased risk of developing tuberculosis and Isoniazid preventive therapy has been shown to reduce the occurrence of tuberculosis among this group of persons. M-health technology has been reported to increase both knowledge and implementation of various health services including Isoniazid preventive therapy implementation. This study aimed to determine the effect of m-health on health worker knowledge and adherence to isoniazid preventive therapy (IPT) guidelines and on patient knowledge and adherence to isoniazid treatment.

METHODS

This was a quasi-experimental study that was carried out in six health facilities in Ebonyi State, southeast Nigeria. Three health facilities were assigned to each arm (intervention and control arms) and all eligible health workers (total population of 45 and 41 in intervention and control arms respectively) were recruited. Data were also collected from 200 patients (100 per arm). The intervention consisted of mobile phone messages and reminders for health workers on the IPT guideline. Chi-square test was carried out at p < 0.05 and 95% confidence interval.

RESULTS

At baseline, 54.5% and 63.4% of health workers in intervention and control arms respectively had good knowledge which improved significantly to 90.2% in the intervention arm after the intervention (χ² = 14.22, p < 0.0001). At baseline, 61.4% and 90.2% of health workers had good adherence to the guideline in intervention and control arms respectively which also improved in the intervention arm by 28.8% after intervention although not significant(χ² = 0.37, p = 0.54). More than 50% of the patients in both study arms had poor knowledge, with the intervention arm having a significantly higher proportion of respondents (68.0%) with poor knowledge at baseline (χ² = 4.71, p = 0.03). The proportion of patients with good knowledge however increased significantly (88.8%) in the intervention arm after intervention (χ² = 25.65, p < 0.001). Patients had good adherence to IPT in intervention and control arms before (100% and 84.2% respectively) and after (96.6% and 100% respectively) the study. There was no significant difference in adherence among patients in both arms.

CONCLUSIONS

Health worker knowledge and practice of guidelines as well as patient knowledge improved in the intervention arm in this study. These findings suggest the consideration for the inclusion of mobile phone reminders in the guideline for tuberculosis prevention among HIV patients.

Measuring the uptake of continuous care among people living with HIV receiving antiretroviral therapy and social determinants of the uptake of continuous care in the southwest of China: a cross-sectional study

Background

Continuous care is essential for people living with HIV. This study aimed to measure continuous care uptake and investigate the association between higher uptake of continuous care and behavioral and social factors, including HIV-acquisition risk and socioeconomic characteristics.

Methods

A hospital-based cross-sectional study was conducted from April to November 2019 in an HIV treatment center of a specialized hospital in Kunming city, China. Fourteen service indicators were used to calculate composite care scores, which were classified into three levels (low, middle, and high), using principal component analysis. The Behavioral Model for Vulnerable Populations was employed to examine predisposing, enabling, and need factors associated with composite care scores among people living with HIV.

Results

A total of 702 participants living with HIV aged ≥ 18 years (median age: 41.0 years, 69.4% male) who had been on ART for 1–5 years were recruited. Based on ordinal logistic regression modeling, predisposing factors: being employed (adjusted odds ratio (AOR): 1.54, 95% confidence interval (CI): 1.13–2.11), heterosexuals (AOR: 1.58, 95% CI: 1.11–2.25) and men who have sex with men (AOR: 2.05, 95% CI: 1.39–3.02) and enabling factors: Urban Employee Basic Medical Insurance (AOR: 1.90, 95% CI: 1.03–3.54), middle socioeconomic status (SES) (AOR: 1.42, 95% CI: 1.01–2.01), were positively associated with the higher level of continuous care uptake, compared to the unemployed, people who inject drugs, those with no medical insurance and low SES, respectively.

Conclusion

There were large differences in continuous care uptake among people living with HIV. HIV-acquisition risk categories and socioeconomic factors were significant determinants of uptake of continuous care. Our findings could inform the development of evidence-based strategies that promote equitable healthcare for all people living with HIV.

Factors associated with prognostic or treatment outcomes in HIV/AIDS patients with and without hypertension in Eswatini

Non-communicable diseases are increasing faster in HIV/AIDS patients than in the general population. We studied the association between hypertension and other possible confounding factors on viral load and CD4-cell counts in hypertensive and non-hypertensive HIV/AIDS patients receiving antiretroviral therapy (ART) at a large hospital in Eswatini over a 4-year period. We performed a retrospective longitudinal review of the medical records of 560 ART patients divided into non-hypertension and hypertension groups (n = 325 and n = 235) from July 27 to September 8, 2018. Generalized Estimated Equation was used to analyze the longitudinal data. Hypertensive patients were more likely to have improved CD4-cell counts than non-hypertensive patients (OR = 1.83, [1.37–2.44]). ART patients with hypertension were more likely to have detectable viral loads, though not significant (OR = 1.37 [0.77–2.43]). In non-hypertensive patients, second line ART was significantly associated with viral load (OR = 8.61 [2.93–25.34]) and adverse side effects (OR = 3.50 [1.06–11.54]), while isoniazid preventive therapy was significantly associated with CD4-cell counts (OR = 1.68 [1.16–2.45]). In hypertensive patients, factors associated with viral load were WHO HIV stage (OR = 2.84 [1.03–7.85]) and adherence (OR = 8.08 [1.33–49.04]). In both groups, CD4-cell counts significantly and steadily increased over time (p-value < 0.001). Results show a significant association between hypertension and CD4 cell counts but not viral load. In ART patients with and without hypertension, the factors associated with prognostic markers were different. More attention may need to be paid to ART patients with well controlled HIV status to monitoring and controlling of hypertension status.

Evaluation of an integrated HIV and hypertension management model in rural south africa: a mixed methods approach

Background: A summary of Soter Ameh's PhD thesis titled, 'An integrated HIV and hypertension management model in rural South Africa: A mixed methods approach' is presented here. In responding to the dual high burden of non-communicable diseases (NCDs) and HIV in South Africa, the national government initiated an integrated chronic disease management (ICDM) model in health facilities as a pilot programme. The aim of the ICDM model is to leverage the successes of the innovative HIV treatment programme for NCDs to improve the quality of care and health outcomes of adult patients.Objectives: The specific objectives of this study were to: (1) determine the quality of care provided in the integrated model in 2013, (2) describe patients' and operational managers' perceptions of quality of care in the integrated model in 2013, and (3) assess effectiveness of the integrated model in controlling CD4 counts (>350 cells/mm3) and blood pressure (<140/90 mmHg) of patients from 2011 to 2013.Methods: A combination of quantitative and qualitative methods was used to assess and describe the quality of care in the model. Effectiveness of the model in controlling patients' blood pressure (BP) and CD4 counts was assessed in selected PHC facilities in the Bushbuckridge municipality in Mpumalanga province, South Africa.Results: The findings showed the suboptimal quality of care in five of the eight priority dimensions of care used as leverage for the NCD programme. The ICDM model had a small but significant effect on BP control for hypertension patients receiving treatment.Conclusions: The HIV programme needs to be more extensively leveraged for hypertension treatment to achieve an optimal BP control in the study area. These findings could have policy relevance for low- and middle-income countries currently undertaking proof of concept studies to demonstrate the feasibility of implementing an integrated chronic disease care model.

Multilevel predictors of controlled CD4 count and blood pressure in an integrated chronic disease management model in rural South Africa: a panel study

OBJECTIVE

In 2011, The National Department of Health introduced the Integrated Chronic Disease Management (ICDM) model as a pilot programme in selected primary healthcare facilities in South Africa. The objective of this study was to determine individual-level and facility-level predictors of controlled CD4 count and blood pressure (BP) in patients receiving treatment for HIV and hypertension, respectively.

DESIGN

A panel study.

SETTING AND PARTICIPANTS

This study was conducted in the Bushbuckridge Municipality, South Africa from 2011 to 2013. Facility records of patients aged ≥18 years were retrieved from the integrated chronic disease management (ICDM) pilot (n=435) and comparison facilities (n=443) using a three-step probability sampling process. CD4 count and BP control are defined as CD4 count >350 cells/mm³ and BP <140/90 mm Hg. A multilevel Least Absolute Shrinkage and Selection Operator binary logistic regression analysis was done at a 5% significance level using STATA V.16.

PRIMARY OUTCOME MEASURES

CD4 (cells/mm³) count and BP (mm Hg).

RESULTS

Compared with the comparison facilities, patients receiving treatment in the pilot facilities had increased odds of controlling their CD4 count (OR=5.84, 95% CI 3.21-8.22) and BP (OR=1.22, 95% CI 1.04-2.14). Patients aged 50-59 (OR=6.12, 95% CI 2.14-7.21) and ≥60 (OR=7.59, 95% CI 4.75-11.82) years had increased odds of controlling their CD4 counts compared with those aged 18-29 years. Likewise, patients aged 40-49 (OR=5.73, 95% CI 1.98-8.43), 50-59 (OR=7.28, 95% CI 4.33-9.27) and ≥60 (OR=9.31, 95% CI 5.12-13.68) years had increased odds of controlling their BP. In contrast, men had decreased odds of controlling their CD4 count (OR=0.12, 95% CI 0.10-0.46) and BP (OR=0.21, 95% CI 0.19-0.47) than women.

CONCLUSION

The ICDM model had a small but significant effect on BP control, hence, the need to more effectively leverage the HIV programme for optimal BP control in the setting.

Knowledge and adherence to isoniazid preventive therapy among people living with HIV in multilevel health facilities in South-East, Nigeria: baseline findings from a quasi-experimental study

Introduction

isoniazid preventive therapy is a crucial component of TB/HIV collaborative program and patient good knowledge and adherence to this preventive treatment are essential in improving implementation. The aim of this study was to determine the knowledge and adherence to isoniazid preventive therapy among patients receiving HIV care.

Methods

this is a baseline result of a quasi-experimental study which was carried out among 200 patients receiving HIV care in six high patient load health facilities providing comprehensive HIV care in Ebonyi State. This included a tertiary health facility and five secondary level health facilities. We used structured interviewer-administered questionnaire to collect information from the participants. Adherence was assessed by self-reports. Descriptive, bivariate and multivariate logistic regression analyses were conducted using SPSS version 20 at 5% level of significance.

Results

majority (65%) of the respondents were between 30 and 49 years and most (73.5%) were females. Majority (85%) had been on antiretroviral therapy (ART) for more than one year. More than half of the respondents had ever received and had been counselled on IPT (55%, 62% respectively) while only 17.5% were on IPT during the study. More than half (60.5%) of the respondents had low level of knowledge. Marital status was the only predictor of knowledge. Unmarried respondents were 2 times more likely to have knowledge of IPT compared with the married (AOR = 2.11, CI = 1.10-4.06). Among the 35 patients who were on IPT, 32 (91%) reported good adherence in the 30 days preceding the survey. Conclusion: there was poor knowledge of IPT among the respondents however self-reported adherence was high. We recommend intensification of general and personalized education of PLHIV on IPT by health workers.

Performance and trend for quality of service in a large HIV/AIDS treatment program in Nigeria

Background

As antiretroviral therapy (ART) programs expand access, there is an increase in burden to a healthcare system. These results are reduced provider-patient contact time and poor programmatic and patient outcomes. Quality management offers providers a standardized approach for addressing the appropriateness of care to be applied in resource-limited settings. This study aimed to determine the trend of performance on HIV/AIDS quality management indicators of health facilities providing ART over a period of 5 years.

Methods

The annual performance scores of quality of care (QoC) indicators of 31 health facilities providing ART was extracted from a database covering a period of 5 years (from October 2008 to September 2012). The data are percentages that indicate scores of each health facility assessed based on compliance to National ART guidelines categorized into several indicator domains. A Chi square statistic for the trend, as well as test for departure from the trend line was determined. The p value associated with each indicator provides the significant level for testing an alternative hypothesis that the rate of change over the period considered for that indicator does not equal to zero. The slope of the regression line also gives the magnitude of the rate of change for each indicator by healthcare level across the review period.

Results

Generally, performance trends showed improvement across most indicator domains. The highest improvement occurred for “3 month loss to follow-up” and “1 year no-visit”, with scores declining from 37 to 3%, and 42% to 12% respectively. However, there was a sharp decline in performance between 2010 and 2012 in weight monitoring of patients (p < 0.01), adherence assessment to ARVs (p < 0.01) and hematocrit measurements (p = 0.01). The aggregate rate of change β, as obtained from the slope of the trend line is highly significant (p < 0.01) for all the quality of care indicators considered, whether improving or declining.

Conclusion

Periodic assessment to determine HIV/AIDS quality of care can guide rapid scale-up of services to achieve universal coverage in resource-limited settings. Determining trends to understand patterns is very useful for improving programmatic and patient outcomes.

Healthcare and economic impact

This chapter reviews the current model of HIV patient care and its economic impact. There are clinical and geographical differences in the care HIV patients receive and a need to develop new models of comprehen-sive HIV care has been identified. HIV infection in Spain is an important and expensive public health problem. The main costs are due to an-tiretroviral therapy, indirect costs and the cost of admission, consultation and diagnostic testing. A strong correlation between severity and cost has been identified. Patients diagnosed late have a poorer clinical course, increased mortality and require more medical and therapeutic resources. Early detection of the disease significantly improves the clinical outcomes of patients. The increased number of patients receiving treatment and their progressive ageing will increase costs of HIV healthcare in the coming years.

Clinical care of patients with HIV

There has been a significant change in the clinical characteristics of people living with HIV, with new needs arising that must be tackled. The life expectancy of a subject diagnosed early with HIV infection and recei-ving suppressive antiretroviral therapy is currently on a par with the life expectancy of the general popula-tion. HIV is now a chronic treatable disease and requires a multidisciplinary approach that includes both the hospital medicine specialties and primary care physicians. The fragmented model to provide social and medical healthcare hinders the proper management of patients with HIV infection. There is significant clinical and geographical variability in the healthcare provided for HIV infection in Spain and the need to define and implement new models of healthcare delivery for this disease has been identified.

HIV-related posts from a Chinese internet discussion forum: An exploratory study

Background

In China, the introduction of antiretroviral treatment has increased the number of people living with HIV/AIDS (PLWHA). New technologies, such as social media, might be useful for enhancing HIV surveillance, especially given the lack of Chinese research, which is related to stigma and discrimination. Thus, the relative anonymity of social media may make it useful for evaluating “hard to reach” PLWHA.

Setting

This study used social media data to assess whether it reflected the prevalence of HIV and to explore PLWHA’ needs and online habits.

Methods

In 2017, the Baidu Tieba platform was searched to obtain 2,500 HIV-related postings and 2,500 tuberculosis-related postings as a comparative sample. Word clouds and coding schemes were used to analyze the contents and review the users’ needs and online habits. Negative binomial regression was used to evaluate the relationships between word cloud geolocations and provincial numbers of men who have sex with men (MSM) PLWHA cases, after controlling for socioeconomic status.

Results

Word cloud geolocations were associated with reported MSM-PLWHA cases (p<0.001). Over one-third of the HIV-related posts were seeking advice, with 40.12% being related to medical topics, although these posts received the fewest replies. The number of HIV-related social support requests was approximately 3-fold higher than the number of posts providing social support, although relatively similar proportions of support requests and support provision were observed in the tuberculosis-related postings.

Conclusion

Social media may help enhance HIV surveillance. Our findings also indicate that the Chinese government, non-government organizations, and healthcare professionals should offer more online support to PLWHA.

Effectiveness of an Integrated Approach to HIV and Hypertension Care in Rural South Africa: Controlled Interrupted Time-Series Analysis

Supplemental Digital Content is Available in the Text.

Background:

South Africa faces a dual burden of HIV/AIDS and noncommunicable diseases. In 2011, a pilot integrated chronic disease management (ICDM) model was introduced by the National Health Department into selected primary health care (PHC) facilities. The objective of this study was to assess the effectiveness of the ICDM model in controlling patients' CD4 counts (>350 cells/mm³) and blood pressure [BP (<140/90 mm Hg)] in PHC facilities in the Bushbuckridge municipality, South Africa.

Methods:

A controlled interrupted time-series study was conducted using the data from patients' clinical records collected multiple times before and after the ICDM model was initiated in PHC facilities in Bushbuckridge. Patients ≥18 years were recruited by proportionate sampling from the pilot (n = 435) and comparing (n = 443) PHC facilities from 2011 to 2013. Health outcomes for patients were retrieved from facility records for 30 months. We performed controlled segmented regression to model the monthly averages of individuals' propensity scores using autoregressive moving average model at 5% significance level.

Results:

The pilot facilities had 6% greater likelihood of controlling patients' CD4 counts than the comparison facilities (coefficient = 0.057; 95% confidence interval: 0.056 to 0.058; P < 0.001). Compared with the comparison facilities, the pilot facilities had 1.0% greater likelihood of controlling patients' BP (coefficient = 0.010; 95% confidence interval: 0.003 to 0.016; P = 0.002).

Conclusions:

Application of the model had a small effect in controlling patients' CD4 counts and BP, but showed no overall clinical benefit for the patients; hence, the need to more extensively leverage the HIV program for hypertension treatment.

Disclosure Pattern of Self-Labeled People Living with HIV/AIDS on Chinese Social Networking Site: An Exploratory Study

HIV/AIDS is an important public health issue in China. The number of people living with HIV/AIDS (PLWHA) has been increasing since the introduction of highly active antiretroviral therapy. PLWHA's life quality is becoming an important issue, with lack of research in China. In this study, a group of PLWHA (n = 663) was identified using HIV/AIDS relevant usernames on a Chinese social networking site (Weibo) to study their daily living situations. We found that more than 99.10% of PLWHA were male, among whom 90.80% turned out to be homosexual. They had significantly more fans and followees, but fewer postings compared to the general population. The mean age of the PLWHA was 28.96 (SD = 5.05) years old, and southwest and northwest China had a high prevalence of HIV/AIDS. In addition, PLWHA's postings were coded and we found that more than half of the postings (n = 769, 51.03%) contained strong emotions. Less than one-fifth of the postings were directly related to HIV/AIDS topics (n = 269, 17.85%), while seeking emotional support, such as looking for stable partnership, was ranked as the first priority of support seeking. In summary, we found that the majority of the self-labeled PLWHA were likely to be men who have sex with men. They used Weibo to share their daily life events and seek emotional support. Implications for promoting HIV/AIDS education and prevention through Chinese social networking sites were also discussed.

Delivery of health care for cardiovascular and metabolic diseases among people living with HIV/AIDS in African countries: a systematic review protocol

BACKGROUND

People living with HIV (PLHIV) in African countries are living longer due to the rollout of antiretroviral drug therapy programs, but they are at increasing risk of non-communicable diseases (NCDs). However, there remain many gaps in detecting and treating NCDs in African health systems, and little is known about how NCDs are being managed among PLHIV. Developing integrated chronic care models that effectively prevent and treat NCDs among PLHIV requires an understanding of the current patterns of care delivery and the major barriers and facilitators to health care. We present a systematic review protocol to synthesize studies of healthcare delivery for an important subset of NCDs, cardiovascular and metabolic diseases (CMDs), among African PLHIV.

METHODS/DESIGN

We plan to search electronic databases and reference lists of relevant studies published in African settings from January 2003 to the present. Studies will be considered if they address one or both of our major objectives and focus on health care for one or more of six interrelated CMDs (ischemic heart disease, stroke, heart failure, hypertension, diabetes, and hyperlipidemia) in PLHIV. Our first objective will be to estimate proportions of CMD patients along the "cascade of care"-i.e., screened, diagnosed, aware of the diagnosis, initiated on treatment, adherent to treatment, and with controlled disease. Our second objective will be to identify unique barriers and facilitators to health care faced by PLHIV in African countries. For studies deemed eligible for inclusion, we will assess study quality and risk of bias using previously published criteria. We will extract study data using standardized instruments. We will meta-analyze quantitative data at each level of the cascade of care for each CMD (first objective). We will use meta-synthesis techniques to understand and integrate qualitative data on health-related behaviors (second objective).

DISCUSSION

CMDs and other NCDs are becoming major health concerns for African PLHIV. The results of our review will inform the development of research into chronic care models that integrate care for HIV/AIDS and CMDs among PLHIV. Our findings will be highly relevant to health policymakers, administrators, and practitioners in African settings.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015029375.

HIV stigma intervention in a low-HIV prevalence setting: a pilot study in an Egyptian healthcare facility

This pilot study is the first to evaluate stigma-reduction intervention in a healthcare setting in Egypt and in the Middle East and North Africa region. It also contributes to knowledge on how to address stigma in low-HIV prevalence settings. A quasi-experimental study design was used to evaluate the effect of anti-HIV stigma intervention in one hospital in Egypt. A control hospital was selected and matched to the intervention hospital by type, size and location. The intervention focused on HIV-related stigma, infection control and medical ethics. Stigma was measured at baseline and at three months post-intervention. A standardized, 10-point scale was developed to measure stigmatizing attitudes and fear-based stigma among participants. Comparisons of overall and job-stratified stigma scores were made across the intervention and control hospitals, before and after the intervention, using two-sample t-test and multivariate regression analysis. Mean stigma scores did not reveal significant differences between the intervention and control hospitals at baseline. After intervention, the overall value-based and fear-based stigma scores were significantly lower in the intervention hospital compared to the control hospital (2.1 and 1.1 compared to 3.8 and 3.2, respectively; p < .001). Context-specific and culturally appropriate HIV stigma-reduction interventions in low-HIV prevalence settings can reduce fear-based and value-based stigma among physicians and nurses.

Characteristics and comprehensiveness of adult HIV care and treatment programmes in Asia-Pacific, sub-Saharan Africa and the Americas: results of a site assessment conducted by the International epidemiologic Databases to Evaluate AIDS (IeDEA) Collaboration

INTRODUCTION

HIV care and treatment programmes worldwide are transforming as they push to deliver universal access to essential prevention, care and treatment services to persons living with HIV and their communities. The characteristics and capacity of these HIV programmes affect patient outcomes and quality of care. Despite the importance of ensuring optimal outcomes, few studies have addressed the capacity of HIV programmes to deliver comprehensive care. We sought to describe such capacity in HIV programmes in seven regions worldwide.

METHODS

Staff from 128 sites in 41 countries participating in the International epidemiologic Databases to Evaluate AIDS completed a site survey from 2009 to 2010, including sites in the Asia-Pacific region (n=20), Latin America and the Caribbean (n=7), North America (n=7), Central Africa (n=12), East Africa (n=51), Southern Africa (n=16) and West Africa (n=15). We computed a measure of the comprehensiveness of care based on seven World Health Organization-recommended essential HIV services.

RESULTS

Most sites reported serving urban (61%; region range (rr): 33-100%) and both adult and paediatric populations (77%; rr: 29-96%). Only 45% of HIV clinics that reported treating children had paediatricians on staff. As for the seven essential services, survey respondents reported that CD4+ cell count testing was available to all but one site, while tuberculosis (TB) screening and community outreach services were available in 80 and 72%, respectively. The remaining four essential services - nutritional support (82%), combination antiretroviral therapy adherence support (88%), prevention of mother-to-child transmission (PMTCT) (94%) and other prevention and clinical management services (97%) - were uniformly available. Approximately half (46%) of sites reported offering all seven services. Newer sites and sites in settings with low rankings on the UN Human Development Index (HDI), especially those in the President's Emergency Plan for AIDS Relief focus countries, tended to offer a more comprehensive array of essential services. HIV care programme characteristics and comprehensiveness varied according to the number of years the site had been in operation and the HDI of the site setting, with more recently established clinics in low-HDI settings reporting a more comprehensive array of available services. Survey respondents frequently identified contact tracing of patients, patient outreach, nutritional counselling, onsite viral load testing, universal TB screening and the provision of isoniazid preventive therapy as unavailable services.

CONCLUSIONS

This study serves as a baseline for on-going monitoring of the evolution of care delivery over time and lays the groundwork for evaluating HIV treatment outcomes in relation to site capacity for comprehensive care.

Health-related quality of life as a predictor of tuberculosis treatment outcomes in Iraq

OBJECTIVES

To determine how tuberculosis (TB) treatment affects the health-related quality of life (HRQL) of patients with pulmonary TB and to identify the predictors of favourable TB treatment outcomes in Baghdad, Iraq.

METHODS

The Functional Assessment of Chronic Illness Therapy-Tuberculosis (FACIT-TB), a new TB-specific quality of life instrument derived from the internationally recognized FACIT measurement system for the assessment of HRQL, was administered. The mean total and subscale scores of the FACIT-TB at baseline, end of the intensive phase, and end of TB treatment were compared.

RESULTS

After the 2-month intensive phase, physical well-being, functional well-being, and the overall total scores were significantly increased (p<0.01). Furthermore, at completion of TB treatment, there were significant improvements in the overall HRQL as indicated by the FACIT-TB total score and all subscales, except social and economic well-being and spiritual well-being. In a direct logistic regression model, only the FACIT-TB total score made a statistically significant contribution towards predicting the likelihood that a patient would have a favourable TB treatment outcome.

CONCLUSIONS

Therapeutic intervention had a positive impact on patient HRQL. We conclude that FACIT-TB is a reliable tool to monitor HRQL during the course of TB treatment.

The use of modern quality improvement approaches to strengthen African health systems: a 5-year agenda

There is a growing international consensus that African health systems need to improve, but no agreement on how to accomplish this. From the perspective of modern quality improvement (QI), a central issue for low performance in these health systems is the relative neglect of health-care processes. Both health system leaders and international donors have focused their efforts elsewhere, producing noteworthy health gains. But these gains are at risk if health systems do not develop the capacity to study and improve care processes. Substantial experience with QI in Africa shows impressive potential for broad-based process improvement. But this experience also highlights the need for modifying these growing programs to incorporate a more rigorous learning component to address challenges that have emerged recently. The addition of a region-wide knowledge management program could increase the efficiency of each country's QI program by learning from the experiences of other programs. With a coordinated donor initiative, it is reasonable to project that within 5 years, evidence-based improvement will become a norm in health services, and African health systems will approach the model of a learning organization.

Challenging the paradigm: anthropological perspectives on HIV as a chronic disease

Recently HIV has been framed as a 'manageable' chronic disease in contexts in which access to effective care is reliable. The chronic disease paradigm emphasizes self-care, biomedical disease management, social normalization, and uncertainty. Data from a longitudinal study of patients (N = 949) in HIV care at two sites in Uganda, collected through semistructured interviews and ethnographic data, permit examination of the salience of this model in a high burden, low resource context struggling to achieve the promise of a manageable HIV epidemic. Our data highlight the complexity of the emerging social reality of long-term survival with HIV. Participants struggle to manage stigma as well as to meet the costs involved in care seeking. In these settings, economic vulnerability leads to daily struggles for food and basic services. Reconceptualizing the chronic disease model to accommodate a 'social space,' recognizing this new social reality will better capture the experience of long-term survival with HIV.

HIV and disability: a pilot study exploring the use of the Assessment of Motor and Process Skills to measure daily life performance

Introduction

Limitations in performing activities of daily living (ADL) are important indicators of health and overall wellness, yet relatively few studies specifically identify the ADL abilities of people living with HIV/AIDS (PHAs). Given the wide range of abilities and ages of PHAs, there is an urgent need to utilize an assessment of ADL ability that can validly evaluate those who are very able, as well as those who are very disabled, without the presence of ceiling or floor effects, to provide sensitive measures to detect change.

Purpose

The purpose of this study was to gather preliminary evidence of the validity of using the Assessment of Motor and Process Skills (AMPS) with PHAs.

Methods

By utilizing existing data records of PHAs from the international AMPS database, we explored (a) demographic factors; (b) person response validity by examining person and individual item goodness-of-fit to the AMPS measurement model; and (c) trends in ADL abilities of PHAs.

Findings

There were 137 data records in the international AMPS database (0.08% of the database). Goodness-of-fit analyses revealed that >90% of the individuals in the sample fit AMPS measurement model and >99% of the individual item ratings fit the model. More than 80% of the data record had ADL motor abilities that were significantly lower than age expectations, and 67% had ADL process ability measures that were significantly lower than age expectations.

Conclusions

The findings indicate that the AMPS is a valid measure of ADL ability for PHAs. Coupled with the lower than expected number of AMPS data records for PHAs and the significant ADL ability challenges that were encountered by this sample, this pilot study may indicate that PHAs encounter barriers to accessing rehabilitation services and/or may not receive referrals until significant ADL challenges are encountered.

Reducing HIV-related stigma in health care settings: a randomized controlled trial in China

OBJECTIVES

The objective of the intervention was to reduce service providers' stigmatizing attitudes and behaviors toward people living with HIV.

METHODS

The randomized controlled trial was conducted in 40 county-level hospitals in 2 provinces of China between October 2008 and February 2010. Forty-four service providers were randomly selected from each hospital, yielding a total of 1760 study participants. We randomized the hospitals to either an intervention condition or a control condition. In the intervention hospitals, about 15% of the popular opinion leaders were identified and trained to disseminate stigma reduction messages.

RESULTS

We observed significant improvements for the intervention group in reducing prejudicial attitudes (P < .001), reducing avoidance intent towards people living with HIV (P < .001), and increasing institutional support in the hospitals (P = .003) at 6 months after controlling for service providers' background factors and clinic-level characteristics. The intervention effects were sustained and strengthened at 12 months.

CONCLUSIONS

The intervention reduced stigmatizing attitudes and behaviors among service providers. It has the potential to be integrated into the health care systems in China and other countries.

Nurses' engagement in AIDS policy development

BACKGROUND

A multidisciplinary team of 20 researchers and research users from six countries - Canada, Jamaica, Barbados, Kenya, Uganda and South Africa - are collaborating on a 5-year (2007-12) program of research and capacity building project. This program of research situates nurses as leaders in building capacity and promotes collaborative action with other health professionals and decision-makers to improve health systems for human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) nursing care. One of the projects within this program of research focused on the influence of workplace policies on nursing care for individuals and families living with HIV. Nurses are at the forefront of HIV prevention and AIDS care in these countries but have limited involvement in related policy decisions and development. In this paper, we present findings related to the barriers and facilitators for nurses' engagement in policymaking.

METHODS

A participatory action research design guided the program of research. Purposive sampling was used to recruit 51 nurses (unit managers, clinic and healthcare managers, and senior nurse officers) for interviews.

FINDINGS

Participants expressed the urgent need to develop policies related to AIDS care. The need to raise awareness and to 'protect' not only the workers but also the patients were critical reason to develop policies. Nurses in all of the participating countries commented on their lack of involvement in policy development. Lack of communication from the top down and lack of information sharing were mentioned as barriers to participation in policy development. Resources were often not available to implement the policy requirement. Strong support from the management team is necessary to facilitate nurses involvement in policy development.

CONCLUSIONS

The findings of this study clearly express the need for nurses and all other stakeholders to mobilize nurses' involvement in policy development. Long-term and sustained actions are needed to address gaps on the education, research and practice level.

Health related quality of life among patients with tuberculosis and HIV in Thailand

Introduction

Health utilities of tuberculosis (TB) patients may be diminished by side effects from medication, prolonged treatment duration, physical effects of the disease itself, and social stigma attached to the disease.

Methods

We collected health utility data from Thai patients who were on TB treatment or had been successfully treated for TB for the purpose of economic modeling. Structured questionnaire and EuroQol (EQ-5D) and EuroQol visual analog scale (EQ-VAS) instruments were used as data collection tools. We compared utility of patients with two co-morbidities calculated using multiplicative model (U_CAL) with the direct measures and fitted Tobit regression models to examine factors predictive of health utility and to assess difference in health utilities of patients in various medical conditions.

Results

Of 222 patients analyzed, 138 (62%) were male; median age at enrollment was 40 years (interquartile range [IQR], 35–47). Median monthly household income was 6,000 Baht (187 US$; IQR, 4,000–15,000 Baht [125–469 US$]). Concordance correlation coefficient between utilities measured using EQ-5D and EQ-VAS (U_EQ-5D and U_VAS, respectively) was 0.6. U_CAL for HIV-infected TB patients was statistically different from the measured U_EQ-5D (p-value<0.01) and U_VAS (p-value<0.01). In tobit regression analysis, factors independently predictive of U_EQ-5D included age and monthly household income. Patients aged ≥40 years old rated U_EQ-5D significantly lower than younger persons. Higher U_EQ-5D was significantly associated with higher monthly household income in a dose response fashion. The median U_EQ-5D was highest among patients who had been successfully treated for TB and lowest among multi-drug resistant TB (MDR-TB) patients who were on treatment.

Conclusions

U_CAL of patients with two co-morbidities overestimated the measured utilities, warranting further research of how best to estimate utilities of patients with such conditions. TB and MDR-TB treatments impacted on patients' self perceived health status. This effect diminished after successful treatment.

Energy expenditure in HIV infection

Energy intake recommendations for adults should be based preferably on direct measurements of total daily energy expenditure (TDEE) in corresponding populations who are maintaining healthy body weight and satisfactory physical activity levels. During adolescence, pregnancy, and lactation, energy requirements should be based on TDEE plus the additional energy required to advance these physiologic states. With illness, energy expenditure and energy intake change, but nutritional intervention is not necessarily beneficial. This article reviews data on energy expenditure in HIV infection with a focus on adults, adolescents aged ≥14 y, and pregnant and lactating women. Resting energy expenditure (REE) in adults with untreated asymptomatic HIV is ~ 10% higher than in healthy control subjects. In asymptomatic adults receiving antiretroviral therapy, REE may be similarly increased. HIV wasting and secondary infections are also associated with increased REE. In contrast, TDEE is typically normal in asymptomatic HIV and decreased in HIV wasting and secondary infection. No direct measurements of REE or TDEE are available in adolescents or in pregnant or lactating women with HIV. On the basis of current data, energy intake may need to increase by ~ 10% in adults with asymptomatic HIV to maintain body weight. In adolescents and in pregnant and lactating women with asymptomatic HIV, energy requirements should approximate recommendations for their uninfected counterparts until further data are available. In the resource-rich world, the energy expenditure changes associated with HIV are unlikely to contribute to significant weight loss. More data are needed on energy expenditure in HIV-infected populations from developing nations, where concurrent malnutrition and coinfections are common.

Knowledge, stigma, and behavioral outcomes among antiretroviral therapy patients exposed to Nalamdana's radio and theater program in Tamil Nadu, India

Arts-based programs have improved HIV-related knowledge, attitudes, and behavior in general and at-risk populations. With HIV transformed into a chronic condition, this study compares patients at consecutive stages of receiving antiretroviral treatment, coinciding with exposure to a radio-and-theater-based educational program (unexposed [N = 120], just exposed [N = 77], Exposed a month ago [N = 60]). Exposure was associated with significantly higher HIV-related knowledge (15-20%, all p < .01), lower levels of stigma (2-7% lower, all p < .10), and over four times the adjusted odds of asking doctors questions about HIV (p = .07). Higher dose of exposure was associated with lower felt stigma (28% reduction per message recalled), greater odds of consistent condom use (adjusted odds ratio [AOR]: 1.12, p = .01), doctor-patient communication (AOR: 1.20, p = .003), peer advice-giving (AOR: 1.18, p = .03) and HIV-related advocacy (AOR: 2.35, p = .07). Similar partnerships between arts-based nongovernmental organizations and government hospitals may improve patient outcomes in HIV treatment settings.

A single-blind randomized controlled trial to evaluate the effect of extended counseling on uptake of pre-antiretroviral care in Eastern Uganda

Background

Many newly screened people living with HIV (PLHIV) in Sub-Saharan Africa do not understand the importance of regular pre-antiretroviral (ARV) care because most of them have been counseled by staff who lack basic counseling skills. This results in low uptake of pre-ARV care and late treatment initiation in resource-poor settings. The effect of providing post-test counseling by staff equipped with basic counseling skills, combined with home visits by community support agents on uptake of pre-ARV care for newly diagnosed PLHIV was evaluated through a randomized intervention trial in Uganda.

Methods

An intervention trial was performed consisting of post-test counseling by trained counselors, combined with monthly home visits by community support agents for continued counseling to newly screened PLHIV in Iganga district, Uganda between July 2009 and June 2010, Participants (N = 400) from three public recruitment centres were randomized to receive either the intervention, or the standard care (the existing post-test counseling by ARV clinic staff who lack basic training in counseling skills), the control arm. The outcome measure was the proportion of newly screened and counseled PLHIV in either arm who had been to their nearest health center for clinical check-up in the subsequent three months +2 months. Treatment was randomly assigned using computer-generated random numbers. The statistical significance of differences between the two study arms was assessed using chi-square and t-tests for categorical and quantitative data respectively. Risk ratios and 95% confidence intervals were used to assess the effect of the intervention.

Results

Participants in the intervention arm were 80% more likely to accept (take up) pre-ARV care compared to those in the control arm (RR 1.8, 95% CI 1.4-2.1). No adverse events were reported.

Conclusions

Provision of post-test counseling by staff trained in basic counseling skills, combined with home visits by community support agents had a significant effect on uptake of pre-ARV care and appears to be a cost-effective way to increase the prerequisites for timely ARV initiation.

Trial registration

The trial was registered by Current Controlled Trials Ltd C/OBioMed Central Ltd as ISRCTN94133652 and received financial support from Sida and logistical support from the European Commission.

Linkage to HIV care and antiretroviral therapy in Cape Town, South Africa

Background

Antiretroviral therapy (ART) has been scaled-up rapidly in Africa. Programme reports typically focus on loss to follow-up and mortality among patients receiving ART. However, little is known about linkage and retention in care of individuals prior to starting ART.

Methodology

Data on adult residents from a periurban community in Cape Town were collected at a primary care clinic and hospital. HIV testing registers, CD4 count results provided by the National Health Laboratory System and ART registers were linked. A random sample (n = 885) was drawn from adults testing HIV positive through antenatal care, sexual transmitted disease and voluntary testing and counseling services between January 2004 and March 2009. All adults (n = 103) testing HIV positive through TB services during the same time period were also included in the study. Linkage to HIV care was defined as attending for a CD4 count measurement within 6 months of HIV diagnosis. Linkage to ART care was defined as initiating ART within 6 months of HIV diagnosis in individuals with a CD4 count ≤200 cells/µl taken within 6 months of HIV diagnosis.

Findings

Only 62.6% of individuals attended for a CD4 count measurement within 6 months of testing HIV positive. Individuals testing through sexually transmitted infection services had the best (84.1%) and individuals testing on their own initiative (53.5%) the worst linkage to HIV care. One third of individuals with timely CD4 counts were eligible for ART and 66.7% of those were successfully linked to ART care. Linkage to ART care was highest among antenatal care clients. Among individuals not yet eligible for ART only 46.3% had a repeat CD4 count. Linkage to HIV care improved in patients tested in more recent calendar period.

Conclusion

Linkage to HIV and ART care was low in this poor peri-urban community despite free services available within close proximity. More efforts are needed to link VCT scale-up to subsequent care.

Barriers to use of antiretroviral drugs in Rakai district of Uganda

BACKGROUND

About 75% of people living with HIV/AIDS (PHAs) who need antiretroviral therapy have no access to these drugs in low-income countries.

OBJECTIVE

To investigate the barriers to use of ART in Rakai district of Uganda.

METHODS

We interviewed 38 key informants and 384 PHAs. Data was collected on: education/mobilization for ART, sources of information for ART, beliefs regarding ART, social support, use of alternative medicine, stigma/discrimination towards PHAs, distance to ART centres, transport costs to ART centres, waiting time, and on suggestions as how to improve the use of ART.

RESULTS

The major barriers mentioned regarding use of ART included: inadequate mobilization, long waiting time at ART treatment centres, high cost of transport to reach ART centres, stigma/discrimination towards PHAs and inadequate number of health workers to attend to PHAs.

CONCLUSIONS

Access to antiretroviral therapy could be ameliorated by: improving community education using innovative approaches such as through music, dance and videos, increasing the number of providers who are able to provide ART as through engagement of non health professionals in ART care, bringing ART nearer to where people live and instituting measures aimed at reducing stigma/discrimination such as through involvement of PHAs in demystisfying HIV/AIDS.

Surveying health professionals' satisfaction with the Integrated Management of Adult and Adolescent Illness Chronic HIV Care training programme: the Papua New Guinea experience

This study reports findings from a survey of Papua New Guinean registered nurse who completed the Integrated Management of Adult and Adolescent Illness (IMAI) Chronic HIV Care training conducted between November 2005 and December 2006. The survey conducted is one component of a mixed method evaluation of the IMAI program in Papua New Guinea. Data from the questionnaires were entered into version 16 of the Statistical Package for the Social Sciences (SPSS) software program. The responses on the effect of the IMAI training program had on various aspects of how care is provided, learning needs and other program outcomes were analysed with a chi-square test being applied to detect any difference in the response given by the different demographic subgroups in terms of gender, age, care status, current employer and past educational attainment. The survey revealed that all thirty-five respondents have a positive impression of the IMAI program and expressed the view that the IMAI program had a positive effect on various aspects of patient care and their learning and experience. Overall, the survey identified that registered nurses who participated in the IMAI Chronic HIV Care training program perceive the program to be beneficial for improving the way HIV care is provided.

Socioeconomic Differentials Between HIV Caregivers and Noncaregivers: Is There a Selection Effect? A Case of Older People Living in Nairobi City Slums

This article seeks to investigate the association between caregiving to someone with an HIV-related illness and the socioeconomic status of the caregiver using a population-based survey of 1,587 older people living in Nairobi slums. Findings indicate significant differences in living arrangements, wealth, income, and expenditure between HIV caregivers and noncaregivers. HIV caregivers lived in larger households and were also more likely to live in households with a large number of children younger than the age of 15 years. Whereas a high proportion of HIV caregivers were ranked highly in terms of wealth status, differences in per capita income and expenditure were not significant when household size and other confounders were accounted for. The financial costs associated with caring for someone with a chronic illness and the reliance on family members with financial ability for material support, a common feature of African extended family systems, may account for the relative economic advantage of HIV caregivers.

The burden of non-communicable diseases in South Africa

15 years after its first democratic election, South Africa is in the midst of a profound health transition that is characterised by a quadruple burden of communicable, non-communicable, perinatal and maternal, and injury-related disorders. Non-communicable diseases are emerging in both rural and urban areas, most prominently in poor people living in urban settings, and are resulting in increasing pressure on acute and chronic health-care services. Major factors include demographic change leading to a rise in the proportion of people older than 60 years, despite the negative effect of HIV/AIDS on life expectancy. The burden of these diseases will probably increase as the roll-out of antiretroviral therapy takes effect and reduces mortality from HIV/AIDS. The scale of the challenge posed by the combined and growing burden of HIV/AIDS and non-communicable diseases demands an extraordinary response that South Africa is well able to provide. Concerted action is needed to strengthen the district-based primary health-care system, to integrate the care of chronic diseases and management of risk factors, to develop a national surveillance system, and to apply interventions of proven cost-effectiveness in the primary and secondary prevention of such diseases within populations and health services. We urge the launching of a national initiative to establish sites of service excellence in urban and rural settings throughout South Africa to trial, assess, and implement integrated care interventions for chronic infectious and non-communicable diseases.

Rede social no sistema de saúde: um estudo das relações interorganizacionais em unidades de serviços de HIV/AIDS

A coordenação dos serviços de saúde, obtida pela integração e a cooperação entre as unidades de um sistema local, passa pela compreensão das relações interorganizacionais, a identificação de unidades centrais e da dinâmica de trocas, tanto de pacientes, como de informações e conhecimento. O objetivo deste artigo é demonstrar as contribuições da análise de rede social para o sistema de saúde, identificando padrões e estruturas na rede de serviços, por meio de um estudo de caso na prestação de serviços de HIV/AIDS na cidade de Porto Alegre - Brasil. Por meio de entrevistas com os responsáveis pelo atendimento e dados do município, foram pesquisados cinco tipos de relacionamento: envio e recebimento de pacientes, coordenação de caso, programas conjuntos e consultorias. Os resultados indicam uma fraca dinâmica na rede, principalmente nos relacionamentos que não envolvem troca de pacientes, sugerindo que, se há instrumentos estabelecidos, como a marcação de consultas, há maior dinâmica na rede; do contrário apenas observam-se iniciativas locais ou pessoais, que redundam em pouca ou nenhuma ação de coordenação dos serviços. As medidas da rede social também identificam o papel das unidades, a formação de subgrupos e estas informações podem apoiar o gestor local na formulação de políticas e programas para o aprimoramento da governança local.

The variability and predictors of quality of AIDS care services in Brazil

BACKGROUND

Since establishing universal free access to antiretroviral therapy in 1996, the Brazilian Health System has increased the number of centers providing HIV/AIDS outpatient care from 33 to 540. There had been no formal monitoring of the quality of these services until a survey of 336 AIDS health centers across 7 Brazilian states was undertaken in 2002. Managers of the services were asked to assess their clinics according to parameters of service inputs and service delivery processes. This report analyzes the survey results and identifies predictors of the overall quality of service delivery.

METHODS

The survey involved completion of a multiple-choice questionnaire comprising 107 parameters of service inputs and processes of delivering care, with responses assessed according to their likely impact on service quality using a 3-point scale. K-means clustering was used to group these services according to their scored responses. Logistic regression analysis was performed to identify predictors of high service quality.

RESULTS

The questionnaire was completed by 95.8% (322) of the managers of the sites surveyed. Most sites scored about 50% of the benchmark expectation. K-means clustering analysis identified four quality levels within which services could be grouped: 76 services (24%) were classed as level 1 (best), 53 (16%) as level 2 (medium), 113 (35%) as level 3 (poor), and 80 (25%) as level 4 (very poor). Parameters of service delivery processes were more important than those relating to service inputs for determining the quality classification. Predictors of quality services included larger care sites, specialization for HIV/AIDS, and location within large municipalities.

CONCLUSION

The survey demonstrated highly variable levels of HIV/AIDS service quality across the sites. Many sites were found to have deficiencies in the processes of service delivery processes that could benefit from quality improvement initiatives. These findings could have implications for how HIV/AIDS services are planned in Brazil to achieve quality standards, such as for where service sites should be located, their size and staffing requirements. A set of service delivery indicators has been identified that could be used for routine monitoring of HIV/AIDS service delivery for HIV/AIDS in Brazil (and potentially in other similar settings).

Quality of STIs and HIV/AIDS care as perceived by biomedical and traditional health care providers in Zambia: are there common grounds for collaboration?

OBJECTIVE

To explore biomedical and traditional health care providers' (BHPs and THPs, respectively) perceptions of good quality of care and opinions on weaknesses in the services they provide to patients with STIs and HIV/AIDS.

METHODS

Using data from a cross-sectional survey, we post-coded two open-ended questions related to THPs' and BHPs' perceptions on good quality of care and on provided care. The post-coding was done following Donabedian's framework of assessment of quality of care, and allowed transformation of qualitative data into quantitative. The analysis is based on comparison of frequencies, proportions and subsequent chi-square tests and odds ratios.

SETTING

Ndola and Kabwe, Zambia Main measures: Proportions of responses from 152 BHPs and 144 THPs.

RESULTS

Substantial proportions of providers from both sectors perceived drugs availability (63% of BHPs and 70% of THPs) and welcoming attitude (73% of BHPs and 64% of THPs) as important components of good quality care. BHPs were more likely than THPs to mention proper examination, medical management (provider's technical ability) and explanation of causes and prognosis of the disease as important. More THPs than BHPs cited short waiting time and cost of care. A majority of BHPs (87%) and of THPs (80%) reported deficiencies in their STIs and HIV/AIDS-related services. Both groups regarded training of providers and nutritional support and health education to patients as lacking. None of the THPs alluded to voluntary counselling and testing (VCT) or supportive/home-based care as aspects needing improvement.

CONCLUSION

Drugs availability and welcoming attitude were two aspects of quality highly valued by THPs and BHPs. Future collaborative interventions need to respond to aspects of joint concern including training of providers, nutritional support and health education to patients. Further, there is an imperative of expanding and adapting VCT, home-based care and palliative care to THPs for better care of STIs and HIV/AIDS.

Offering integrated care for HIV/AIDS, diabetes and hypertension within chronic disease clinics in Cambodia

PROBLEM

In Cambodia, care for people with HIV/AIDS (prevalence 1.9%) is expanding, but care for people with type II diabetes (prevalence 5-10%), arterial hypertension and other treatable chronic diseases remains very limited.

APPROACH

We describe the experience and outcomes of offering integrated care for HIV/AIDS, diabetes and hypertension within the setting of chronic disease clinics.

LOCAL SETTING

Chronic disease clinics were set up in the provincial referral hospitals of Siem Reap and Takeo, 2 provincial capitals in Cambodia.

RELEVANT CHANGES

At 24 months of care, 87.7% of all HIV/AIDS patients were alive and in active follow-up. For diabetes patients, this proportion was 71%. Of the HIV/AIDS patients, 9.3% had died and 3% were lost to follow-up, while for diabetes this included 3 (0.1%) deaths and 28.9% lost to follow-up. Of all diabetes patients who stayed more than 3 months in the cohort, 90% were still in follow-up at 24 months.

LESSONS LEARNED

Over the first three years, the chronic disease clinics have demonstrated the feasibility of integrating care for HIV/AIDS with non-communicable chronic diseases in Cambodia. Adherence support strategies proved to be complementary, resulting in good outcomes. Services were well accepted by patients, and this has had a positive effect on HIV/AIDS-related stigma. This experience shows how care for HIV/AIDS patients can act as an impetus to tackle other common chronic diseases.

Funding for palliative care programs in developing countries

There are many palliative care developments in resource-poor regions of the world. Most of them are supported by third-party donors and grant makers. The funding necessary to cover essential palliative care services usually exceeds the financial means of many developing countries. Health care services may have to be complemented by nongovernmental organizations that are dependent on fund raising and voluntary donations from a variety of external sources. Coordinated action by international funding agencies is needed to ensure that the world's poorest people have access to essential medications and appropriate palliative care. To this end, international networking in the palliative care field is vital. There are now a number of collaborative networks that make a significant contribution to the development and sustainability of hospice and palliative care across many resource-poor regions of the world.

Resource allocation within the National AIDS Control Program of Pakistan: a qualitative assessment of decision maker's opinions

BACKGROUND

Limited resources, whether public or private, demand prioritisation among competing needs to maximise productivity. With a substantial increase in the number of reported HIV cases, little work has been done to understand how resources have been distributed and what factors may have influenced allocation within the newly introduced Enhanced National AIDS Control Program of Pakistan. The objective of this study was to identify perceptions of decision makers about the process of resource allocation within Pakistan's Enhanced National AIDS Control Program.

METHODS

A qualitative study was undertaken and in-depth interviews of decision makers at provincial and federal levels responsible to allocate resources within the program were conducted.

RESULTS

HIV was not considered a priority issue by all study participants and external funding for the program was thought to have been accepted because of poor foreign currency reserves and donor agency influence rather than local need. Political influences from the federal government and donor agencies were thought to manipulate distribution of funds within the program. These influences were thought to occur despite the existence of a well-laid out procedure to determine allocation of public resources. Lack of collaboration among departments involved in decision making, a pervasive lack of technical expertise, paucity of information and an atmosphere of ad hoc decision making were thought to reduce resistance to external pressures.

CONCLUSION

Development of a unified program vision through a consultative process and advocacy is necessary to understand goals to be achieved, to enhance program ownership and develop consensus about how money and effort should be directed. Enhancing public sector expertise in planning and budgeting is essential not just for the program, but also to reduce reliance on external agencies for technical support. Strengthening available databases for effective decision making is required to make financial allocations based on real, rather than perceived needs. With a large part of HIV program funding dedicated to public-private partnerships, it becomes imperative to develop public sector capacity to administer contracts, coordinate and monitor activities of the non-governmental sector.

Setting and organization of care for persons living with HIV/AIDS

BACKGROUND

Treating the world's 40.3 million persons currently infected with HIV/AIDS is an international responsibility that involves unprecedented organizational challenges. Key issues include whether care should be concentrated or decentralized, what type and mix of health workers are needed, and which interventions and mix of programs are best. High volume centres, case management and multi-disciplinary care have been shown to be effective for some chronic illnesses. Application of these findings to HIV/AIDS is less well understood.

OBJECTIVES

Our objective was to evaluate the association between the setting and organization of care and outcomes for people living with HIV/AIDS.

SEARCH STRATEGY

Computerized searches from January 1, 1980 to December 31, 2002 of MEDLINE, EMBASE, Dissertation Abstracts International (DAI), CINAHL, HealthStar, PsychInfo, PsychLit, Social Sciences Abstracts, and Sociological Abstracts as well as searches of meeting abstracts and relevant journals and bibliographies in articles that met inclusion criteria. Searches included articles published in English and other languages.

SELECTION CRITERIA

Articles were considered for inclusion if they were observational or experimental studies with contemporaneous comparison groups of adults and/or children currently infected with HIV/AIDS that examined the impact of the setting and/or organization of care on outcomes of mortality, opportunistic infections, use of HAART and prophylaxis, quality of life, health care utilization, and costs for patient with HIV/AIDS.

DATA COLLECTION AND ANALYSIS

Two authors independently screened abstracts to determine relevance. Full paper copies were reviewed against the inclusion criteria. The findings were extracted by both authors and compared. The 28 studies that met inclusion criteria were too disparate with respect to populations, interventions and outcomes to warrant meta-analysis.

MAIN RESULTS

Twenty-eight studies were included involving 39,776 study subjects. The studies indicated that case management strategies and higher hospital and ward volume of HIV-positive patients were associated with decreased mortality. Case management was also associated with increased receipt of ARVs. The results for multidisciplinary teams or multi-faceted treatment varied. None of the studies examined quality of life or immunological or virological outcomes. Healthcare utilization outcomes were mixed.

AUTHORS' CONCLUSIONS

Certain settings of care (i.e. high volume of HIV positive patients) and models of care (i.e. case management) may improve patient mortality and other outcomes. More detailed descriptions of care models, consistent definition of terms, and studies on innovative models suitable for developing countries are needed. There is not yet enough evidence to guide policy and clinical care in this area.

Avaliação da estrutura organizacional da assistência ambulatorial em HIV/Aids no Brasil

OBJETIVO: No contexto de acesso universal à terapia antiretroviral, os resultados do Programa de Aids dependem da qualidade do cuidado prestado. O objetivo do estudo foi avaliar a qualidade do cuidado dos serviços ambulatoriais que assistem pacientes de Aids. MÉTODOS: Estudo realizado em sete Estados brasileiros, em 2001 e 2002. Foi avaliada a qualidade do atendimento a pacientes com Aids quanto à disponibilidade de recursos e a organização do trabalho de assistência. Um questionário com 112 questões estruturadas abordando esses aspectos, foi enviado a 336 serviços. RESULTADOS: A taxa de resposta foi de 95,8% (322). Os indicadores de disponibilidade de recursos mostram uma adequação maior do que os indicadores de organização do trabalho. Não faltam antiretrovirais em 95,5% dos serviços, os exames de CD4 e Carga Viral estão disponíveis em quantidade adequada em 59 e 41% dos serviços, respectivamente. Em 90,4% dos serviços há pelo menos um profissional não médico (psicólogo, enfermeiro ou assistente social). Quanto à organização, 80% não agendavam consulta médica com hora marcada; 40,4% agendavam mais que 10 consultas médicas por período; 17% não possuíam gerentes exclusivos na assistência e 68,6% não realizavam reuniões sistemáticas de trabalho com a equipe. CONCLUSÕES: Os resultados apontam que além de garantir a distribuição mais homogênea de recursos, o programa precisa investir no treinamento e disseminação do manejo do cuidado, conforme evidenciado nos resultados da organização de trabalho.

Improving the quality of health care for chronic conditions

Chronic conditions are increasingly the primary concern of health care systems throughout the world. In response to this challenge, the World Health Organization has joined with the MacColl Institute for Healthcare Innovation to adapt the Chronic Care Model (CCM) from a global perspective. The resultant effort is the Innovative Care for Chronic Conditions (ICCC) framework which expands community and policy aspects of improving health care for chronic conditions and includes components at the micro (patient and family), meso (health care organisation and community), and macro (policy) levels. The framework provides a flexible but comprehensive base on which to build or redesign health systems in accordance with local resources and demands.

Improving the quality of health care for chronic conditions

Chronic conditions are increasingly the primary concern of health care systems throughout the world. In response to this challenge, the World Health Organization has joined with the MacColl Institute for Healthcare Innovation to adapt the Chronic Care Model (CCM) from a global perspective. The resultant effort is the Innovative Care for Chronic Conditions (ICCC) framework which expands community and policy aspects of improving health care for chronic conditions and includes components at the micro (patient and family), meso (health care organisation and community), and macro (policy) levels. The framework provides a flexible but comprehensive base on which to build or redesign health systems in accordance with local resources and demands.

The health sector gap in the southern Africa crisis in 2002/2003

The southern Africa crisis represents the first widespread emergency in a region with a mature HIV/AIDS epidemic. It provides a steep learning curve for the international humanitarian system in understanding and responding to the complex interactions between the epidemic and the causes and the effects of this crisis. It also provoked much debate about the severity and causes of this emergency, and the appropriateness of the response by the humanitarian community. The authors argue that the over-emphasis on food aid delivery occurred at the expense of other public health interventions, particularly preventative and curative health services. Health service needs were not sufficiently addressed despite the early recognition that ill-health related to HIV/AIDS was a major vulnerability factor. This neglect occurred because analytical frameworks were too narrowly focused on food security, and large-scale support to health service delivery was seen as a long-term developmental issue that could not easily be dealt with by short-term humanitarian action. Furthermore, there were insufficient countrywide data on acute malnutrition, mortality rates and performance of the public health system to make better-balanced evidence-based decisions. In this crisis, humanitarian organisations providing health services could not assume their traditional roles of short-term assistance in a limited geographical area until the governing authorities resume their responsibilities. However, relegating health service delivery as a long-term developmental issue is not acceptable. Improved multisectoral analytical frameworks that include a multidisciplinary team are needed to ensure all aspects of public health are dealt with in similar future emergencies. Humanitarian organisations must advocate for improved delivery and access to health services in this region. They can target limited geographical areas with high mortality and acute malnutrition rates to deliver their services. Finally, to address the underlying problem of the health sector gap, a long-term strategy to ensure improved and sustainable health sector performance can only be accomplished with truly adequate resources. This will require renewed efforts on part of governments, donors and the international community. Public health interventions, complementing those addressing food insecurity, were and are still needed to reduce the impact of the crisis, and to allow people to re-establish their livelihoods. These will increase the population's resilience to prevent or mitigate future disasters.

Barriers to better care for people with AIDS in developing countries

WHO's “3 by 5” initiative to increase access to antiretroviral drugs to people with AIDS in developing countries is highly ambitious. Some of the biggest obstacles relate to delivering care