Closing the gap in implementation of HIV clinical guidelines in a low resource setting using electronic medical records

Addressing the Need for a Preexposure Prophylaxis Monitoring and Evaluation Implementation Guide: Experience From Zambia

BACKGROUND

The HIV care continuum comprises well-defined steps and indicators. In contrast, indicators along the preexposure prophylaxis (PrEP) cascade are still in the early stages of implementation. Monitoring and evaluation (M&E) of PrEP services is critical to optimizing PrEP uptake and adherence during periods of HIV risk. We provide an overview of global indicators for PrEP, describe the development process and outcomes of Zambia's 2022 National Pre-Exposure Prophylaxis (PrEP) Program Monitoring & Evaluation Implementation Guide, and discuss the guide's implications for other countries in sub-Saharan Africa.

NATIONAL M&E GUIDE DEVELOPMENT PROCESS

During the scale-up of PrEP, the Zambia Ministry of Health (MOH) and the National HIV/AIDS/STI/TB Council recognized the need for a national unified monitoring system to guide the effective implementation of PrEP services. Stakeholders from the MOH, civil society, professional organizations, funding agencies, and implementing partners developed the National Pre-Exposure Prophylaxis (PrEP) Program Monitoring & Evaluation Implementation Guide. This guide is aligned with the existing global indicators from the World Health Organization and the U.S. President's Emergency Plan for AIDS Relief and adapted to the country's needs, context, and health information systems. Zambia's experience in developing the guide has highlighted the importance of strengthening client-level monitoring systems for HIV prevention, ensuring flexibility of the PrEP monitoring system to accommodate PrEP delivery modalities and differentiated service delivery models, and training health workers to enhance PrEP services and deliver care PrEP services along the continuum to prevent HIV acquisition effectively.

CONCLUSIONS

Using a collaborative and consensus-based approach, Zambia developed its first national PrEP M&E implementation guide to provide standardized guidelines for optimizing the delivery, monitoring, and evaluation of PrEP service delivery. Zambia's experience can inform other countries in sub-Saharan Africa as they develop national M&E implementation approaches for PrEP.

Patient and health worker perspectives on quality of HIV care and treatment services in Haiti

BACKGROUND

Poor quality of care is a barrier to engagement in HIV care and treatment in low- and middle-income country settings. This study involved focus group discussions (FGD) with patients and health workers in two large urban hospitals to describe quality of patient education and psychosocial support services within Haiti's national HIV antiretroviral therapy (ART) program. The purpose of this qualitative study was to illuminate key gaps and salient "ingredients" for improving quality of care.

METHODS

The study included 8 FGDs with a total of 26 male patients and 32 female patients and 15 smaller FGDs with 57 health workers. The analysis used a directed content analysis method, with the goal of extending existing conceptual frameworks on quality of care through rich description.

RESULTS

Dimension of safety, patient-centeredness, accessibility, and equity were most salient. Patients noted risks to privacy with both clinic and community-based services as well as concerns with ART side effects, while health workers described risks to their own safety in providing community-based services. While patients cited examples of positive interactions with health workers that centered their needs and perspectives, they also noted concerns that inhibited trust and satisfaction with services. Health workers described difficult working conditions that challenged their ability to provide patient-centered services. Patients sought favored relationships with health workers to help them navigate the health care system, but this undermined the sense of fairness. Both patients and health workers described frustration with lack of resources to assist patients in dire poverty, and health workers described great pressure to help patients from their "own pockets."

CONCLUSIONS

These concerns reflected the embeddedness of patient - provider interactions within a health system marked by scarcity, power dynamics between patients and health workers, and social stigma related to HIV. Reinforcing a respectful and welcoming atmosphere, timely service, privacy protection, and building patient perception of fairness in access to support could help to build patient satisfaction and care engagement in Haiti. Improving working conditions for health workers is also critical to achieving quality.

EMR adoption in Dhaka, Bangladesh: a template to index pediatric central nervous system tumor care and a review of preliminary neuro-oncologic observations

PURPOSE

To describe the design, implementation, and adoption of a simplified electronic medical record (EMR) and its use in documenting pediatric central nervous system (CNS) tumors at a tertiary care referral hospital in South-East Asia.

METHODS

A novel EMR, cataloguing pediatric CNS tumors was used to collect data from August 2017 to March 2020 at National Institute of Neurosciences and Hospital (NINS&H) in Dhaka, Bangladesh.

RESULTS

Two hundred forty-nine pediatric patients with a CNS tumor were admitted to NINS&H. Fifty-eight percent of patients were male, and the median age was 8 years. A total of 188/249 patients (76%) underwent surgery during their index admission. Radiographic locations were known for 212/249 (85%) of cases; the most common radiographic locations were infratentorial (81/212; 38%), suprasellar (45/212; 21%), and supratentorial (29/212; 14%). A histopathological classification was reported on 156/249 (63%) of patients' cytology. The most common infratentorial pathologies were medulloblastoma (22/47; 47%) and pilocytic astrocytoma (14/47; 30%). The median time between admission and surgery was 36 days, while the median post-operation stay was 19.5 days.

CONCLUSIONS

The feasibility of a basic EMR platform for a busy pediatric neurosurgery department in a lower-middle income country is demonstrated, and preliminary clinical data is reviewed. A wide variety of pediatric CNS tumors were observed, spanning the spectrum of anatomic locations and histopathologic subtypes. Surgical intervention was performed for the majority of patients. Barriers to care include limited molecular diagnostics and unavailable data on adjuvant therapy. Future targets include improvement of clinical documentation in the pre-operative and post-operative period.