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Wang R, Rouleau G, Booth GL, Brazeau AS, El-Dassouki N, Taylor M, Cafazzo JA, Greenberg M, Nakhla M, Shulman R, Desveaux L. Understanding Whether and How a Digital Health Intervention Improves Transition Care for Emerging Adults Living With Type 1 Diabetes: Protocol for a Mixed Methods Realist Evaluation. JMIR Res Protoc 2023; 12:e46115. [PMID: 37703070 PMCID: PMC10534286 DOI: 10.2196/46115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 06/27/2023] [Accepted: 07/24/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND Emerging adults living with type 1 diabetes (T1D) face a series of challenges with self-management and decreased health system engagement, leading to an increased risk of acute complications and hospital admissions. Effective and scalable strategies are needed to support this population to transfer seamlessly from pediatric to adult care with sufficient self-management capability. While digital health interventions for T1D self-management are a promising strategy, it remains unclear which elements work, how, and for which groups of individuals. OBJECTIVE This study aims to evaluate the design and implementation of a multicomponent SMS text message-based digital health intervention to support emerging adults living with T1D in real-world settings. The objectives are to identify the intervention components and associated mechanisms that support user engagement and T1D health care transition experiences and determine the individual characteristics that influence the implementation process. METHODS We used a realist evaluation embedded alongside a randomized controlled trial, which uses a sequential mixed methods design to analyze data from multiple sources, including intervention usage data, patient-reported outcomes, and realist interviews. In step 1, we conducted a document analysis to develop a program theory that outlines the hypothesized relationships among "individual-level contextual factors, intervention components and features, mechanisms, and outcomes," with special attention paid to user engagement. Among them, intervention components and features depict 10 core characteristics such as transition support information, problem-solving information, and real-time interactivity. The proximal outcomes of interest include user engagement, self-efficacy, and negative emotions, whereas the distal outcomes of interest include transition readiness, self-blood glucose monitoring behaviors, and blood glucose. In step 2, we plan to conduct semistructured realist interviews with the randomized controlled trial's intervention-arm participants to test the hypothesized "context-intervention-mechanism-outcome" configurations. In step 3, we plan to triangulate all sources of data using a coincidence analysis to identify the necessary combinations of factors that determine whether and how the desired outcomes are achieved and use these insights to consolidate the program theory. RESULTS For step 1 analysis, we have developed the initial program theory and the corresponding data collection plan. For step 2 analysis, participant enrollment for the randomized controlled trial started in January 2023. Participant enrollment for this realist evaluation was anticipated to start in July 2023 and continue until we reached thematic saturation or achieved informational power. CONCLUSIONS Beyond contributing to knowledge on the multiple pathways that lead to successful engagement with a digital health intervention as well as target outcomes in T1D care transitions, embedding the realist evaluation alongside the trial may inform real-time intervention refinement to improve user engagement and transition experiences. The knowledge gained from this study may inform the design, implementation, and evaluation of future digital health interventions that aim to improve transition experiences. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/46115.
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Affiliation(s)
- Ruoxi Wang
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
| | - Geneviève Rouleau
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
- Département des Sciences Infirmières, Université du Québec en Outaouais, St-Jérôme, QC, Canada
- Faculté des sciences infirmières, l'Université de Montréal, Montreal, QC, Canada
| | - Gillian Lynn Booth
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | | | - Noor El-Dassouki
- Centre for Digital Therapeutics, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Madison Taylor
- Centre for Digital Therapeutics, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Joseph A Cafazzo
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Centre for Digital Therapeutics, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada
- Department of Computer Science, University of Toronto, Toronto, ON, Canada
| | - Marley Greenberg
- Department of Philosophy, Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada
- Diabetes Action Canada, Toronto, ON, Canada
| | - Meranda Nakhla
- Division of Endocrinology, Montreal Children's Hospital, McGill University, Montréal, QC, Canada
- Research Institute of the McGill University Health Centre, Montréal, QC, Canada
| | - Rayzel Shulman
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada
- Division of Endocrinology, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Laura Desveaux
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
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Bosongo S, Belrhiti Z, Chenge F, Criel B, Marchal B. Capacity building of district health management teams in the era of provincial health administration reform in the Democratic Republic of Congo: a realist evaluation protocol. BMJ Open 2023; 13:e073508. [PMID: 37463816 PMCID: PMC10357782 DOI: 10.1136/bmjopen-2023-073508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2023] Open
Abstract
INTRODUCTION In 2006, the Congolese Ministry of Health developed a health system strengthening strategy focusing on health district development. This strategy called for reforming the provincial health administration in order to better support the health district development through leadership and management capacity building of district health management teams. The implementation is currently underway, yet, more evidence on how, for whom and under what conditions this capacity building works is needed. The proposed research aims to address this gap using a realist evaluation approach. METHODS AND ANALYSIS We will follow the cycle of the realist evaluation. First, we will elicit the initial programme theory through a scoping review (completed in December 2022, using MEDLINE, Health Systems Evidence, Wiley Online Library, Cochrane Library, Google Scholar and grey literature), a review of health policy documents (completed in March 2023), and interviews with key stakeholders (by June 2023). Second, we will empirically test the initial programme theory using a multiple-embedded case study design in two provincial health administrations and four health districts (by March 2024). Data will be collected through document reviews, in-depth interviews, non-participant observations, a questionnaire, routine data from the health information management system and a context mapping tool. We will analyse data using the Intervention-Context-Actor-Mechanism-Outcome configuration heuristic. Last, we will refine the initial programme theory based on the results of the empirical studies and develop recommendations for policymakers (by June 2024). ETHICS AND DISSEMINATION The Institutional Review Board of the Institute of Tropical Medicine and the Medical Ethics Committee of the University of Lubumbashi approved this study. We will also seek approvals from provincial-level and district-level health authorities before data collection in their jurisdictions. We will disseminate the study findings through the publication of articles in peer-reviewed academic journals, policy briefs for national policymakers and presentations at national and international conferences.
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Affiliation(s)
- Samuel Bosongo
- Faculté de Médecine et Pharmacie, Département de Santé Publique, Université de Kisangani, Kisangani, Congo (the Democratic Republic of the)
- Ecole de Santé Publique, Université Libre de Bruxelles, Bruxelles, Belgium
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- Centre de Connaissances en Santé en République Démocratique du Congo, Kinshasa, Congo (the Democratic Republic of the)
| | - Zakaria Belrhiti
- Ecole Internationale de Santé Publique, Université Mohammed VI des sciences de la santé (UM6SS), Casablanca, Morocco
- Centre Mohammed VI de la recherche et innovation (CM6), Rabat, Morocco
| | - Faustin Chenge
- Faculté de Médecine et Pharmacie, Département de Santé Publique, Université de Kisangani, Kisangani, Congo (the Democratic Republic of the)
- Centre de Connaissances en Santé en République Démocratique du Congo, Kinshasa, Congo (the Democratic Republic of the)
- Ecole de Santé Publique, Université de Lubumbashi, Lubumbashi, Congo (the Democratic Republic of the)
| | - Bart Criel
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Bruno Marchal
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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Pressiat C, Dainguy E, Tréluyer JM, Yonaba C, Urien S, Eboua F, Foissac F, Dahourou DL, Bouazza N, Malateste K, Desmonde S, Pruvost A, Leroy V, Hirt D, Study Group TMONODANRS. Comparison of three galenic forms of lamivudine in young West African children living with Human Immunodeficiency Virus. Antivir Ther 2021; 26:134-140. [DOI: 10.1177/13596535211058267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Few pharmacokinetic data were reported on dispersible tablets despite their increasing use. One hundred fifty HIV-infected children receiving lamivudine were enrolled in the MONOD ANRS 12,206 trial. Three galenic forms were administered: liquid formulation, tablet form and dispersible scored tablet. Method HIV-infected children <4 years old were enrolled in the MONOD ANRS 12,206 trial designed to assess the simplification of a successful 12-months lopinavir-based antiretroviral treatment with efavirenz. Lamivudine plasma concentrations were analysed using nonlinear mixed effects modelling approach. Results One hundred and fifty children (age: 2.5 years (1.9–3.2), weight 11.1 (9.5–12.5) kg (median (IQR)) were included in this study. Over the study period, 79 received only the syrup form, 29 children switched from syrup form to tablet 3TC/AZT form, 36 from syrup to the orodispersible ABC/3TC form and two from the 3TC/AZT form to the orodispersible ABC/3TC form. The 630 lamivudine concentrations were best described by a two-compartment model allometrically scaled. Galenic form had no significant effect on 3TC pharmacokinetic. Conclusion This trial provided an opportunity to compare three galenic forms (liquid formulation, tablet form and dispersible scored tablet) of lamivudine in the target population of young HIV–1-infected children. Galenic form had no significant effect on lamivudine pharmacokinetics.
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Affiliation(s)
- Claire Pressiat
- Pharmacology Department, AP-HP, Hôpitaux Universitaires Henri Mondor, Paris Est-Créteil University, Créteil, France
| | - Evelyne Dainguy
- Pediatric Department, Centre Hospitalier Universitaire of Cocody, Abidjan, Côte d’Ivoire
| | - Jean-Marc Tréluyer
- Paris Descartes University, Paris, France
- Clinical Pharmacology Department, AP-HP, Paris Centre Hospital Group, Paris, France
| | - Caroline Yonaba
- Pediatric Department, Centre Hospitalier Universitaire Yalgado Ouédraogo, Ouagadougou, Burkina Faso
| | - Saik Urien
- Paris Descartes University, Paris, France
| | - François Eboua
- Pediatric Department, Centre Hospitalier Universitaire de Yopougon, Abidjan, Côte d’Ivoire
| | | | - Désiré Lucien Dahourou
- MONOD Project, Centre de Recherche Internationale pour la Santé, Ouagadougou, Burkina Faso
- Centre Muraz, Bobo-Dioulasso, Burkina Faso
- Institut de Recherche en Sciences de la Santé (IRSS), Ouagadougou, Burkina Faso
| | | | - Karen Malateste
- Inserm, Institut de Recherche pour le Développement (IRD), University of Bordeaux, Bordeaux, France
| | - Sophie Desmonde
- Inserm, Unité U1027, CERPOP, Université Paul Sabatier of Toulouse3, Toulouse, France
| | - Alain Pruvost
- CEA, INRAE, SPI, Université Paris Saclay, Gif-sur-Yvette, France
| | - Valériane Leroy
- Inserm, Unité U1027, CERPOP, Université Paul Sabatier of Toulouse3, Toulouse, France
| | - Déborah Hirt
- Paris Descartes University, Paris, France
- Clinical Pharmacology Department, AP-HP, Paris Centre Hospital Group, Paris, France
- Inserm CESP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
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Twimukye A, Laker M, Odongpiny EAL, Ajok F, Onen H, Kalule I, Kajubi P, Seden K, Owarwo N, Kiragga A, Armstrong-Hough M, Katahoire A, Mujugira A, Lamorde M, Castelnuovo B. Patient experiences of switching from Efavirenz- to Dolutegravir-based antiretroviral therapy: a qualitative study in Uganda. BMC Infect Dis 2021; 21:1154. [PMID: 34774018 PMCID: PMC8590364 DOI: 10.1186/s12879-021-06851-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 11/09/2021] [Indexed: 11/10/2022] Open
Abstract
Background In 2019, the World Health Organisation (WHO) recommended Dolutegravir (DTG) as the preferred first-line antiretroviral treatment (ART) for all persons with HIV. ART regimen switches may affect HIV treatment adherence. We sought to describe patient experiences switching from EFV to DTG-based ART in Kampala, Uganda. Methods Between July and September 2019, we purposively sampled adults living with HIV who had switched to DTG at the Infectious Diseases Institute HIV clinic. We conducted in-depth interviews with adults who switched to DTG, to explore their preparation to switch and experiences on DTG. Interviews were audio-recorded, transcribed and analysed thematically using Atlas ti version 8 software. Results We interviewed 25 adults: 18 (72%) were women, and the median age was 35 years (interquartile range [IQR] 30–40). Median length on ART before switching to DTG was 67 months (IQR 51–125). Duration on DTG after switching was 16 months (IQR 10–18). Participants reported accepting provider recommendations to switch to DTG mainly because they anticipated that swallowing a smaller pill once a day would be more convenient. While most participants initially felt uncertain about drug switching, their providers offer of frequent appointments and a toll-free number to call in the event of side effects allayed their anxiety. At the same time, participants said they felt rushed to switch to the new ART regimen considering that they had been on their previous regimen(s) for several years and the switch to DTG happened during a routine visit when they had expected their regular prescription. Some participants felt unprepared for new adverse events associated with DTG and for the abrupt change in treatment schedule. Most participants said they needed additional support from their health providers before and after switching to DTG. Conclusion and recommendations Adults living with HIV stable on an EFV-based regimen but were switched to DTG in a program-wide policy change found the duration between counselling and drug switching inadequate. DTG was nonetheless largely preferred because of the small pill size, once daily dosing, and absence of EFV-like side effects. Community-engaged research is needed to devise acceptable ways to prepare participants for switching ART at scale. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-06851-9.
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Affiliation(s)
- Adelline Twimukye
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P. O Box 22418, Kampala, Uganda.
| | - Miriam Laker
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P. O Box 22418, Kampala, Uganda
| | - Eva Agnes Laker Odongpiny
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P. O Box 22418, Kampala, Uganda
| | | | - Henry Onen
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P. O Box 22418, Kampala, Uganda
| | - Ivan Kalule
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P. O Box 22418, Kampala, Uganda
| | - Phoebe Kajubi
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P. O Box 22418, Kampala, Uganda
| | - Kay Seden
- University of Liverpool, Liverpool, UK
| | - Noela Owarwo
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P. O Box 22418, Kampala, Uganda
| | - Agnes Kiragga
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P. O Box 22418, Kampala, Uganda
| | - Mari Armstrong-Hough
- School of Global Public Health, New York University, New York, NY, USA.,Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda.,Center for Interdisciplinary Research on AIDS, Yale University, New Haven, CT, USA
| | - Anne Katahoire
- School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Andrew Mujugira
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P. O Box 22418, Kampala, Uganda.,School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Mohammed Lamorde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P. O Box 22418, Kampala, Uganda
| | - Barbara Castelnuovo
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P. O Box 22418, Kampala, Uganda
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Nebot Giralt A, Nöstlinger C, Lee J, Salami O, Lallemant M, Onyango-Ouma W, Nyamongo I, Marchal B. Understanding acceptance of and adherence to a new formulation of paediatric antiretroviral treatment in the form of pellets (LPV/r)-A realist evaluation. PLoS One 2019; 14:e0220408. [PMID: 31433803 PMCID: PMC6703671 DOI: 10.1371/journal.pone.0220408] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 07/14/2019] [Indexed: 11/24/2022] Open
Abstract
Background Improving access to paediatric HIV treatment requires large-scale antiretroviral treatment programmes and medication adapted to infants and children’s needs. The World Health Organisation recommends lopinavir/ritonavir plus two nucleoside reverse transcriptase inhibitors as first-line treatment for all HIV-infected children younger than three years, usually given as a syrup. A pellet formulation (i.e. tiny cylinders of compressed medication put in capsules) was developed to overcome the syrup formulation’s disadvantages such as bitterness, toxicity and cold storage. This study assessed multi-level factors influencing caregivers’ acceptance of and adherence to lopinavir/ritonavir pellets as well as their underlying mechanisms. Methods A realist evaluation (a theory-driven evaluation method considering the social context and mechanisms of change), embedded in a clinical trial was carried out in three hospital settings in Kenya. Data were collected through document review, observations (n = 34) in home and clinic settings and semi-structured interviews (n = 44) with caregivers and providers. Data analysis was based on realist principles. Results High levels of treatment initiation and adherence were observed. Taste masking, neutral packaging and easy storage made the new formulation highly acceptable. Caregivers developed individual strategies to deliver the treatment, particularly to overcome specific problems e.g. in case of just-weaned babies or food shortage. A refined program theory emerged from the triangulated findings showing that ease of administration combined with increased self-efficacy and competences of the caregivers, and effective provider support contributed to high levels of adherence. Conclusions Formulating combined antiretroviral treatment in the form of pellets is clearly a more acceptable solution for infants and children and their caregivers compared to the syrup. Further research in non-trial settings may shed light on factors related to providers, services and the health system that contribute to better adherence of such formulations.
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Affiliation(s)
| | | | - Janice Lee
- Drugs for Neglected Diseases Initiative, Geneva, Switzerland
| | | | - Marc Lallemant
- Drugs for Neglected Diseases Initiative, Geneva, Switzerland
| | - Washington Onyango-Ouma
- Institute of Anthropology, Gender and African Studies, University of Nairobi, Museum Hill, Nairobi, Kenya
| | - Isaac Nyamongo
- Institute of Anthropology, Gender and African Studies, University of Nairobi, Museum Hill, Nairobi, Kenya
| | - Bruno Marchal
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- * E-mail:
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Desmonde S, Frank SC, Coovadia A, Dahourou DL, Hou T, Abrams EJ, Amorissani-Folquet M, Walensky RP, Strehlau R, Penazzato M, Freedberg KA, Kuhn L, Leroy V, Ciaranello AL. Cost-Effectiveness of Preemptive Switching to Efavirenz-Based Antiretroviral Therapy for Children With Human Immunodeficiency Virus. Open Forum Infect Dis 2019; 6:ofz276. [PMID: 31334298 PMCID: PMC6634435 DOI: 10.1093/ofid/ofz276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 06/05/2019] [Indexed: 11/12/2022] Open
Abstract
Background The NEVEREST-3 (South Africa) and MONOD-ANRS-12206 (Côte d'Ivoire, Burkina Faso) randomized trials found that switching to efavirenz (EFV) in human immunodeficiency virus-infected children >3 years old who were virologically suppressed by ritonavir-boosted lopinavir (LPV/r) was noninferior to continuing o LPV/r. We evaluated the cost-effectiveness of this strategy using the Cost-Effectiveness of Preventing AIDS Complications-Pediatric model. Methods We examined 3 strategies in South African children aged ≥3 years who were virologically suppressed by LPV/r: (1) continued LPV/r, even in case of virologic failure, without second-line regimens; continued on LPV/r with second-line option after observed virologic failure; and preemptive switch to EFV-based antiretroviral therapy (ART), with return to LPV/r after observed virologic failure. We derived data on 24-week suppression (<1000 copies/mL) after a switch to EFV (98.4%) and the subsequent risk of virologic failure (LPV/r, 0.23%/mo; EFV, 0.15%/mo) from NEVEREST-3 data; we obtained ART costs (LPV/r, $6-$20/mo; EFV, $3-$6/mo) from published sources. We projected discounted life expectancy (LE) and lifetime costs per person. A secondary analysis used data from MONOD-ANRS-12206 in Côte d'Ivoire. Results Continued LPV/r led to the shortest LE (18.2 years) and the highest per-person lifetime cost ($19 470). LPV/r with second-line option increased LE (19.9 years) and decreased per-person lifetime costs($16 070). Switching led to the longest LE (20.4 years) and the lowest per-person lifetime cost ($15 240); this strategy was cost saving under plausible variations in key parameters. Using MONOD-ANRS-12206 data in Côte d'Ivoire, the Switch strategy remained cost saving only compared with continued LPV/r, but the LPV/r with second-line option strategy was cost-effective compared with switching. Conclusion For children ≥3 years old and virologically suppressed by LPV/r-based ART, preemptive switching to EFV can improve long-term clinical outcomes and be cost saving. Clinical Trials Registration NCT01127204.
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Affiliation(s)
- Sophie Desmonde
- UMR 1027 Inserm, Université Paul Sabatier, Toulouse.,Bordeaux School of Public Health, France.,Medical Practice Evaluation Center, Boston
| | - Simone C Frank
- Medical Practice Evaluation Center, Boston.,Division of General Internal Medicine, Department of Medicine, Boston
| | - Ashraf Coovadia
- Empilweni Service and Research Unit, Johannesburg, South Africa
| | - Désiré L Dahourou
- Bordeaux School of Public Health, France.,Centre Muraz, Bobo-Dioulasso, Burkina Faso
| | - Taige Hou
- Medical Practice Evaluation Center, Boston.,Division of General Internal Medicine, Department of Medicine, Boston
| | - Elaine J Abrams
- ICAP at Columbia University, Mailman School of Public Health, and Vagelos College of Physicians & Surgeons, Columbia University, New York
| | | | - Rochelle P Walensky
- Medical Practice Evaluation Center, Boston.,Division of General Internal Medicine, Department of Medicine, Boston.,Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston.,Center for AIDS Research, Harvard University, Boston
| | - Renate Strehlau
- Empilweni Service and Research Unit, Johannesburg, South Africa
| | | | - Kenneth A Freedberg
- Medical Practice Evaluation Center, Boston.,Division of General Internal Medicine, Department of Medicine, Boston.,Center for AIDS Research, Harvard University, Boston.,Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston
| | - Louise Kuhn
- Gertrude H. Sergievsky Center, College of Physicians and Surgeons and Department of Epidemiology, Mailman School of Public Health, Columbia University Medical Center, New York, New York
| | | | - Andrea L Ciaranello
- Medical Practice Evaluation Center, Boston.,Division of General Internal Medicine, Department of Medicine, Boston.,Harvard Medical School, Boston
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Marchal B, Giralt AN, Sulaberidze L, Chikovani I, Abejirinde IOO. Designing and evaluating provider results-based financing for tuberculosis care in Georgia: a realist evaluation protocol. BMJ Open 2019; 9:e030257. [PMID: 30987995 PMCID: PMC6500265 DOI: 10.1136/bmjopen-2019-030257] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 03/14/2019] [Accepted: 03/18/2019] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION In 2016, Georgian researchers and policymakers were developing a policy to improve the performance of the national tuberculosis (TB) control programme. The research programme 'Designing and Evaluating Provider Results-Based Financing for Tuberculosis Care in Georgia: Understanding Costs, Mechanisms of Effect and Impact (Results4TB)' was initiated to inform the policy formulation phase, document the policy implementation and assess the effectiveness, cost-effectiveness and the processes of change. To achieve this, the research team intends to combine an impact evaluation, a cost-effectiveness study and a realist evaluation (RE) within an overarching theory-informed design. This protocol is the RE component of the programme. METHODS A realist methodological approach will be adopted to guide the research design and evaluation. RE answers the question of 'what works in which conditions for whom?' and starts with the development of an initial programme theory (IPT). The IPT will feed into other phases of the realist research cycle (study design, data collection, data analysis and synthesis and theory refinement). Data will be collected in a multiple embedded case study design (five intervention and three control sites) through document reviews, in-depth interviews, non-participant observations and context mapping at facility and national levels. Additional data from other research components (cost-effectiveness and impact evaluation) will aid data triangulation. ETHICS AND DISSEMINATION The Institutional Review Boards of the National Centre for Disease Control and Public Health in Georgia (ref. IRB # 2018-019) and the Institute of Tropical Medicine, Antwerp (ref. IRB #- 1240/18) have granted ethical approval to the study. TRIAL REGISTRATION NUMBER ISRCTN14667607.
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Affiliation(s)
- Bruno Marchal
- Department of Public Health, Institute of Tropical Medicine, Health Systems and Equity Unit, Antwerp, Belgium
| | - Ariadna Nebot Giralt
- Department of Public Health, Institute of Tropical Medicine, Health Systems and Equity Unit, Antwerp, Belgium
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Malati CY, Golin R, O'Brien L, Sugandhi N, Srivastava M, Larson C, Phelps BR. Pursuing use of optimal formulations for paediatric HIV epidemic control - a look at the use of LPV/r oral pellets and oral granules. J Int AIDS Soc 2019; 22:e25267. [PMID: 30983152 PMCID: PMC6462808 DOI: 10.1002/jia2.25267] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 03/05/2019] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Despite a significant reduction in mother-to-child transmission of HIV, an estimated 180,000 children were infected with HIV in 2017, and only 52% of children under 15 years of age living with HIV (CLHIV) are on life-saving antiretroviral therapy (ART). Without effective treatment, half of CLHIV die before the age of two years and only one in five survives to five years of age. DISCUSSION Over the past four years, the United States Food and Drug Administration tentatively approved new formulations of lopinavir/ritonavir (LPV/r) in the form of oral pellets and oral granules. However, the slow uptake of the aforementioned formulations in the low- and middle-income countries with the highest paediatric HIV burden is largely due to three challenges: limited manufacturing capacity; current unit cost of the pellets and granules; and slow uptake of these new formulations by policy makers and health care workers. CONCLUSIONS Solutions to overcome these barriers include ensuring availability of an adequate supply of LPV/r oral pellets and oral granules, considering all programmatic and clinical factors when selecting paediatric ART formulations, and leveraging current resources to decrease paediatric HIV morbidity and mortality.
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Affiliation(s)
| | - Rachel Golin
- United States Agency for International DevelopmentWashingtonDCUSA
| | | | | | - Meena Srivastava
- United States Agency for International DevelopmentWashingtonDCUSA
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Pasipanodya B, Kuwengwa R, Prust ML, Stewart B, Chakanyuka C, Murimwa T, Brophy J, Salami O, Mushavi A, Apollo T. Assessing the adoption of lopinavir/ritonavir oral pellets for HIV-positive children in Zimbabwe. J Int AIDS Soc 2018; 21:e25214. [PMID: 30549217 PMCID: PMC6293134 DOI: 10.1002/jia2.25214] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 11/05/2018] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Heat-stable lopinavir/ritonavir (LPV/r) oral pellets were developed to overcome challenges with administration and storage experienced with previously available tablet and syrup forms of LPV/r prescribed to paediatric HIV patients. We report on the adoption of LPV/r pellets for infants living with HIV in the public sector antiretroviral therapy (ART) programme in Zimbabwe. METHODS Infants aged three months to three years who had been prescribed a LPV/r-based regimen (including ART-naïve patients) in fourteen facilities across the country were eligible to receive the pellets. Caregivers were counselled on the new formulation and provided with administration guides. A caregiver questionnaire was administered three to four months after the child initiated on pellets. Data were also extracted from patient ART records. RESULTS AND DISCUSSION One hundred and fifty-seven children were enrolled (median age: 21 months; interquartile range 11.8 to 29.4). Survey data from 74 caregivers were included for analysis. Eighty-one per cent of the caregivers preferred pellets while 19% preferred the syrup formulation. Eighty-nine per cent assessed their child's response to taking the pellets as good or very good. Overall, 46% did not report any challenges while 54% reported one or more challenges with using the pellets. Difficulties with administration included: poor taste (36%; 26 participants); swallowing pellets (16%; 12 participants); finishing the dose (14%; 10 participants); and opening the capsule (10%; seven participants). Caregivers who were not confident to instruct others on pellet administration were 5.64 (95% confidence interval 1.45 to 21.95, p = 0.013) times as likely to experience a challenge. CONCLUSIONS A large proportion of caregivers preferred pellets to other formulations of LPV/r and reported a good response to pellets; however, they also reported challenges with administration. Counselling should focus on ensuring that caregivers can confidently administer pellets and are able to instruct others, to ensure high uptake and good adherence to treatment. LPV/r pellets may be an acceptable substitute for other available forms of LPV/r for eligible children under three years if they are currently on or in need of LPV/r-containing regimens; however, challenges with administration still highlight the need for improved drug formulations for paediatric ART patients.
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Affiliation(s)
| | - Rudo Kuwengwa
- AIDS and TB UnitThe Ministry of Health and Child CareHarareZimbabwe
| | | | | | | | | | - Jason Brophy
- Clinton Health Access Initiative, Inc.BostonMAUSA
| | - Olawale Salami
- Drugs for Neglected Diseases – Africa Regional OfficeNairobiKenya
| | - Angela Mushavi
- AIDS and TB UnitThe Ministry of Health and Child CareHarareZimbabwe
| | - Tsitsi Apollo
- AIDS and TB UnitThe Ministry of Health and Child CareHarareZimbabwe
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10
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Moolasart V, Chottanapund S, Ausavapipit J, Likanonsakul S, Uttayamakul S, Changsom D, Lerdsamran H, Puthavathana P. The Effect of Detectable HIV Viral Load among HIV-Infected Children during Antiretroviral Treatment: A Cross-Sectional Study. CHILDREN-BASEL 2018; 5:children5010006. [PMID: 29301267 PMCID: PMC5789288 DOI: 10.3390/children5010006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Revised: 12/20/2017] [Accepted: 12/27/2017] [Indexed: 11/24/2022]
Abstract
The RNA viral load of human immunodeficiency virus (HIV) is initially used to determine the status of the HIV infection. The goal of therapy following treatment failure is to achieve and maintain virologic suppression. A detectable viral load may relate to the progression of HIV infection. A cross-sectional survey was conducted from January 2013 to December 2014 at the Bamrasnaradura Infectious Diseases Institute, Thailand. The aim was to determine the prevalence of detectable HIV viral load (dVL) and analyze the factors associated with post-dVL conditions that occur independently of a switch to a new antiretroviral agent. The prevalence of dVL was 27% (27 of 101). The mean ages of dVL and non-dVL children were 12.0 and 12.3 years, respectively. Age, sex, body mass index for age z-scores, previous tuberculosis disease history and parental tuberculosis history of both groups were not significantly different (p > 0.05). The prevalence of poor adherence (<95%), influenza-like illness (ILI) and opportunistic infections were higher in dVL than non-dVL children (p < 0.05). The mean nadir CD4 cell count during the study was lower in dVL than non-dVL children (646 compared to 867, respectively; p < 0.05). Other factors were not significant (all p > 0.05). In multivariable analysis, dVL was significantly associated with ILI (odds ratio (OR) = 9.6, 95% confidence interval (CI) = 1.3–69.4), adherence (OR = 0.195, 95% CI = 0.047–0.811) and nadir CD4 during the study (OR = 1.102, 95% CI = 1.100–1.305). The prevalence of dVL was 27% with this dVL among HIV-infected children found to be associated with ILI, poor adherence and lower nadir CD4 during the study.
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Affiliation(s)
- Visal Moolasart
- Bamrasnaradura Infectious Diseases Institute, Ministry of Public Health, 11000 Nonthaburi, Thailand.
| | - Suthat Chottanapund
- Bamrasnaradura Infectious Diseases Institute, Ministry of Public Health, 11000 Nonthaburi, Thailand.
| | - Jarurnsook Ausavapipit
- Bamrasnaradura Infectious Diseases Institute, Ministry of Public Health, 11000 Nonthaburi, Thailand.
| | - Sirirat Likanonsakul
- Bamrasnaradura Infectious Diseases Institute, Ministry of Public Health, 11000 Nonthaburi, Thailand.
| | - Sumonmal Uttayamakul
- Bamrasnaradura Infectious Diseases Institute, Ministry of Public Health, 11000 Nonthaburi, Thailand.
| | - Don Changsom
- Department of Microbiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 10700 Bangkok, Thailand.
| | - Hatairat Lerdsamran
- Department of Microbiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 10700 Bangkok, Thailand.
| | - Pilaipan Puthavathana
- Department of Microbiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 10700 Bangkok, Thailand.
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11
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Mukumbang FC, Van Belle S, Marchal B, van Wyk B. An exploration of group-based HIV/AIDS treatment and care models in Sub-Saharan Africa using a realist evaluation (Intervention-Context-Actor-Mechanism-Outcome) heuristic tool: a systematic review. Implement Sci 2017; 12:107. [PMID: 28841894 PMCID: PMC5574210 DOI: 10.1186/s13012-017-0638-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 08/16/2017] [Indexed: 01/24/2023] Open
Abstract
Introduction It is increasingly acknowledged that differentiated care models hold potential to manage large volumes of patients on antiretroviral therapy (ART). Various group-based models of ART service delivery aimed at decongesting local health facilities, encouraging patient retention in care, and enhancing adherence to medication have been implemented across sub-Saharan Africa. Evidence from the literature suggests that these models of ART service delivery are more effective than corresponding facility-based care and superior to individual-based models. Nevertheless, there is little understanding of how these care models work to achieve their intended outcomes. The aim of this study was to review the theories explicating how and why group-based ART models work using a realist evaluation framework. Methods A systematic review of the literature on group-based ART support models in sub-Saharan Africa was conducted. We searched the Google Scholar and PubMed databases and supplemented these with a reference chase of the identified articles. We applied a theory-driven approach—narrative synthesis—to synthesise the data. Data were analysed using the thematic content analysis method and synthesised according to aspects of the Intervention-Context-Actor-Mechanism-Outcome heuristic-analytic tool—a realist evaluation theory building tool. Results Twelve articles reporting primary studies on group-based models of ART service delivery were included in the review. The six studies that employed a quantitative study design failed to identify aspects of the context and mechanisms that work to trigger the outcomes of group-based models. While the other four studies that applied a qualitative and the two using a mixed methods design identified some of the aspects of the context and mechanisms that could trigger the outcomes of group-based ART models, these studies did not explain the relationship(s) between the theory elements and how they interact to produce the outcome(s). Conclusion Although we could distill various components of the Intervention-Context-Actor-Mechanism-Outcome analytic tool from different studies exploring group-based programmes, we could not, however, identify a salient programme theory based on the Intervention-Context-Actor-Mechanism-Outcome heuristic analysis. The scientific community, policy makers and programme implementers would benefit more if explanatory findings of how, why, for whom and in what circumstances programmes work are presented rather than just reporting on the outcomes of the interventions. Electronic supplementary material The online version of this article (doi:10.1186/s13012-017-0638-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ferdinand C Mukumbang
- School of Public Health, University of the Western Cape, Cape Town, South Africa. .,Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.
| | - Sara Van Belle
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Bruno Marchal
- School of Public Health, University of the Western Cape, Cape Town, 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, South Africa
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12
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Canals F, Masiá M, Gutiérrez F. Developments in early diagnosis and therapy of HIV infection in newborns. Expert Opin Pharmacother 2017; 19:13-25. [PMID: 28764578 DOI: 10.1080/14656566.2017.1363180] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Infants who acquire HIV have an exceptionally high risk of morbidity and mortality if they do not receive antiretroviral therapy (ART). AREAS COVERED This review aims to summarize the currently available evidence on ART in HIV-infected neonates. Data were obtained from literature searches from PubMed, abstracts from International Conferences (2000-2017), and authors' files EXPERT OPINION Current evidence favors early diagnosis and prompt ART of HIV infection in newborns. The precise timing of initiation of ART remains undetermined. Very early (close to birth) ART appears to limit the size of the viral reservoir and may restrict replication-competent virus, but the clinical benefit remains unproven. Among the current options for initial therapy, in full term neonates from 2 weeks of life onwards, a lopinavir/ritonavir-based three-drug regimen is preferred. In term infants, younger than 2 weeks a nevirapine-based regimen is recommended, although there are no clinical trial data supporting that initiating treatment before 2 weeks improves outcome compared to starting afterwards. Existing safety information is insufficient to recommend ART in preterm infants, with pharmacokinetic data available for zidovudine only. If ART is considered in this setting, an individual case assessment of the risk/benefit ratio of treatment should be made.
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Affiliation(s)
- Francisco Canals
- a Department of Infectious Diseases, Hospital General de Elche , Universidad Miguel Hernández , Alicante , Spain.,b Department of Pediatrics , Hospital General de Elche , Alicante , Spain
| | - Mar Masiá
- a Department of Infectious Diseases, Hospital General de Elche , Universidad Miguel Hernández , Alicante , Spain
| | - Félix Gutiérrez
- a Department of Infectious Diseases, Hospital General de Elche , Universidad Miguel Hernández , Alicante , Spain
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