Association between health systems performance and treatment outcomes in patients co-infected with MDR-TB and HIV in KwaZulu-Natal, South Africa: implications for TB programmes

The association between HIV infection, disability and lifestyle activity among middle-aged and older adults: an analytical cross-sectional study in Ivory Coast (the VIRAGE study)

INTRODUCTION

People living with HIV (PLWH) live longer and face new health challenges resulting from the confluence of chronic HIV infection and the natural effect of aging and comorbidities. However, there is a dearth of information on the long-term impact of HIV infection on the health and wellbeing of PLWH in sub-Saharan Africa. This research aimed to fill this gap by reporting on physical, functional and social outcomes among PLWH treated at a referral center in Abidjan, Ivory Coast, and comparing them with those of a control group.

METHODS

Body composition, functional capacity, sarcopenia, limitations in daily activities and social participation were assessed among 300 PLWH (aged ≥ 30 years) and 200 uninfected adults of similar age and sex. The associations between these outcomes and participants' socioeconomic characteristics, HIV history and physical activity level were assessed using generalized additive models adjusted for age and sex.

RESULTS

The median age was 51 years, and the median antiretroviral therapy duration was 15 years. Compared to controls, PLWH reported higher levels of physical activity (p < 0.0001). They had a lower muscle index (adjusted p < 0.0001) and grip strength (adjusted p < 0.0001) but achieved similar performance on the 6-min walk test (6MWT, p = 0.2). Among PLWH, physical activity level was positively associated with better performance in the 6MWT (p = 0.006) and greater hand grip strength (p = 0.04). The difference in physical performance according to the level of physical activity appeared mainly after the age of 60. PLWH reported similar rates of activity limitations (p = 0.8), lower depression levels and greater scores for social functioning (p = 0.02).

CONCLUSION

In this study, PLWH achieved high levels of physical activity, which may explain why they maintained good physical performance and social functioning despite having a higher risk of sarcopenia. These results have important implications for resource-limited health systems and show avenues for chronic care models.

TRIAL REGISTRATION

This study was registered on the ClinicalTrials.gov website (NCT05199831, first registration the 20/01/2022).

Identifying longitudinal patterns of HIV treatment (dis)engagement and re-engagement from oral histories of virologically unsuppressed persons in Uganda: A thematic trajectory analysis

BACKGROUND

There is limited study of persons deemed "harder to reach" by HIV treatment services, including those discontinuing or never initiating antiretroviral therapy (ART). We conducted narrative research in southern Uganda with virologically unsuppressed persons identified through population-based sampling to discern longitudinal patterns in HIV service engagement and identify factors shaping treatment persistence.

METHODS

In mid-2022, we sampled adult participants with high-level HIV viremia (≥1000 RNA copies/mL) from the prospective, population-based Rakai Community Cohort Study. Using life history calendars, we conducted initial and follow-up in-depth interviews to elicit oral histories of participants' journeys in HIV care, from diagnosis to the present. We then used thematic trajectory analysis to identify discrete archetypes of HIV treatment engagement by "re-storying" participant narratives and visualizing HIV treatment timelines derived from interviews and abstracted clinical data.

RESULTS

Thirty-eight participants (median age: 34 years, 68% men) completed 75 interviews. We identified six HIV care engagement archetypes from narrative timelines: (1) delayed ART initiation, (2) early treatment discontinuation, (3) treatment cycling, (4) prolonged treatment interruption, (5) transfer-related care disruption, and (6) episodic viremia. Patterns of service (dis)engagement were highly gendered, occurred in the presence and absence of optimal ART adherence, and were shaped by various factors emerging at different time points, including: denial of HIV serostatus and disclosure concerns; worsening HIV-related symptoms; psychological distress and depression; social support; intimate partner violence; ART side effects; accessibility constraints during periods of mobility; incarceration; and inflexible ART dispensing regulations.

CONCLUSIONS

Identified trajectories uncovered heterogeneities in both the timing and drivers of ART (re-)initiation and (dis)continuity, demonstrating the distinct characteristics and needs of people with different patterns of HIV treatment engagement throughout the life course. Enhanced mental health service provision, expanded eligibility for differentiated service delivery models, and streamlined facility switching processes may facilitate timely (re-)engagement in HIV services.

Multiple imputation using chained equations for missing data in survival models: applied to multidrug-resistant tuberculosis and HIV data

BACKGROUND

Missing data are a prevalent problem in almost all types of data analyses, such as survival data analysis.

OBJECTIVE

To evaluate the performance of multivariable imputation via chained equations in determining the factors that affect the survival of multidrug-resistant-tuberculosis (MDR-TB) and HIV-coinfected patients in KwaZulu-Natal.

MATERIALS AND METHODS

Secondary data from 1542 multidrug-resistant tuberculosis patients were used in this study. First, data from patients with some missing observations were deleted from the original data set to obtain the complete case (CC) data set. Second, missing observations in the original data set were imputed 15 times to obtain complete data sets using a multivariable imputation case (MIC). The Cox regression model was fitted to both the CC and MIC data, and the results were compared using the model goodness of fit criteria [likelihood ratio tests, Akaike information criterion (AIC), and Bayesian Information Criterion (BIC)].

RESULTS

The Cox regression model fitted the MIC data set better (likelihood ratio test statistic =76.88 on 10 df with P<0.01, AIC =1040.90, and BIC =1099.65) than the CC data set (likelihood ratio test statistic =42.68 on 10 df with P<0.01, AIC =1186.05 and BIC =1228.47). Variables that were insignificant when the model was fitted to the CC data set became significant when the model was fitted to the MIC data set.

CONCLUSION

Correcting missing data using multiple imputation techniques for the MDR-TB problem is recommended. This approach led to better estimates and more power in the model.

Models of integration of TB and HIV services and factors associated with perceived quality of TB-HIV integrated service delivery in O. R Tambo District, South Africa

BACKGROUND

Tuberculosis is the leading infectious cause of death among people living with HIV. Reducing morbidity and mortality from HIV-associated TB requires strong collaboration between TB and HIV services at all levels with fully integrated, people-centered models of care.

METHODS

This is a qualitative study design using principles of ethnography and the application of aggregate complexity theory. A total of 54 individual interviews with healthcare workers and patients took place in five primary healthcare facilities in the O.R. Tambo district. The participants were purposively selected until the data reached saturation point, and all interviews were tape-recorded. Quantitative analysis of qualitative data was used after coding ethnographic data, looking for emerging patterns, and counting the number of times a qualitative code occurred. A Likert scale was used to assess the perceived quality of TB/HIV integration. Regression models and canonical discriminant analyses were used to explore the associations between the perceived quality of TB and HIV integrated service delivery and independent predictors of interest using SPSS® version 23.0 (Chicago, IL) considering a type I error of 0.05.

RESULTS

Of the 54 participants, 39 (72.2%) reported that TB and HIV services were partially integrated while 15 (27.8%) participants reported that TB/HIV services were fully integrated. Using the Likert scale gradient, 23 (42.6%) participants perceived the quality of integrated TB/HIV services as poor while 13 (24.1%) and 18 (33.3%) perceived the quality of TB/HIV integrated services as moderate and excellent, respectively. Multiple linear regression analysis showed that access to healthcare services was significantly and independently associated with the perceived quality of integrated TB/HIV services following the equation: Y = 3.72-0.06X (adjusted R2 = 23%, p-value = 0.001). Canonical discriminant analysis (CDA) showed that in all 5 municipal facilities, long distances to healthcare facilities leading to reduced access to services were significantly more likely to be the most impeding factor, which is negatively influencing the perceived quality of integrated TB/HIV services, with functions' coefficients ranging from 9.175 in Mhlontlo to 16.514 in KSD (Wilk's Lambda = 0.750, p = 0.043).

CONCLUSION

HIV and TB integration is inadequate with limited access to healthcare services. Full integration (one-stop-shop services) is recommended.

Discharge Outcomes of Severely Sick Patients Hospitalized with Multidrug-Resistant Tuberculosis, Comorbidities, and Serious Adverse Events in Kyrgyz Republic, 2020-2022

Patients with multidrug-resistant tuberculosis (MDR-TB) who have comorbidities, complications, and experience serious adverse events (SAEs) are at substantial risk of having unfavorable hospital outcomes. We assessed characteristics and discharge outcomes of 138 MDR-TB patients hospitalized in the National Referral Center of Bishkek, Kyrgyz Republic, from January 2020 to August 2022. The main clinical characteristics included pulmonary complications (23%), malnutrition (33%), severe anemia (17%), diabetes mellitus (13%), viral hepatitis B and C (5%), and HIV infection (3%). Of those patients, 95% were successfully managed and discharged from hospital. Seven patients had unfavorable discharge outcomes (three patients died and four had a worsened clinical condition). Comorbidities (diabetes, and/or HIV), severe anemia, pulmonary complications, cardiovascular disorders, alcohol abuse, and SAEs were associated with unfavorable discharge outcomes. Sixty-five percent of the patients had SAEs, with electrolyte imbalance (25%), gastrointestinal disease (18%), hepatotoxicity (16%), and anemia (14%) being the most frequent. Successful resolution occurred in 91% of patients with SAEs. In summary, our study documented that sick patients who were hospitalized with MDR-TB were well managed and had good hospital discharge outcomes, despite the fact that they had comorbidities, complications, and SAEs. This information should assist in the referral and management of such patients in the future.

Developing a Model for Integrating of Tuberculosis, Human Immunodeficiency Virus and Primary Healthcare Services in Oliver Reginald (O.R) Tambo District, Eastern Cape, South Africa

Despite the policy, frameworks for integration exist; integration of TB and HIV services is far from ideal in many resource-limited countries, including South Africa. Few studies have examined the advantages and disadvantages of integrated TB and HIV care in public health facilities, and even fewer have proposed conceptual models for proven integration. This study aims to fill this vacuum by describing the development of a paradigm for integrating TB, HIV, and patient services in a single facility and highlights the importance of TB-HIV services for greater accessibility under one roof. Development of the proposed model occurred in several phases that included assessment of the existing integration model for TB-HIV and synthesis of quantitative and qualitative data from the study sites, which were selected public health facilities in rural and peri-urban areas in the Oliver Reginald (O.R.) Tambo District Municipality in the Eastern Cape, South Africa. Secondary data on clinical outcomes from 2009-2013 TB-HIV were obtained from various sources for the quantitative analysis of Part 1. Qualitative data included focus group discussions with patients and healthcare workers, which were analyzed thematically in Parts 2 and 3. The development of a potentially better model and the validation of this model shows that the district health system was strengthened by the guiding principles of the model, which placed a strong emphasis on inputs, processes, outcomes, and integration effects. The model is adaptable to different healthcare delivery systems but requires the support of patients, providers (professionals and institutions), payers, and policymakers to be successful.

Decentralized Care for Rifampin-Resistant Tuberculosis, Western Cape, South Africa

In 2011, South Africa implemented a policy to decentralize treatment for rifampin-resistant tuberculosis (TB) to reduce durations of hospitalization and enable local treatment. We assessed policy implementation in Western Cape Province, where services expanded from 6 specialized TB hospitals to 406 facilities, by analyzing National Health Laboratory Service data on TB during 2012-2015. We calculated the percentage of patients who visited a TB hospital <1 year after rifampin-resistant TB diagnosis, the median duration of their hospitalizations, and the total distance between facilities visited. We assessed temporal changes with linear regression and stratified results by location. Of 2,878 patients, 65% were from Cape Town. In Cape Town, 29% visited a TB hospital; elsewhere, 68% visited a TB hospital. We found that hospitalizations and travel distances were shorter in Cape Town than in the surrounding areas.

Provider perspectives of the introduction and implementation of care for drug-resistant tuberculosis patients in district-level facilities in South Africa: a qualitative study

OBJECTIVES

Drug-resistant tuberculosis (DR-TB) is a growing concern in many low-income and middle-income countries. Facing rising numbers of DR-TB patients, South Africa (SA) introduced a decentralised model of care for DR-TB in 2011. We aimed to document the introduction and implementation of the new models of care for patients with DR-TB in four provinces (Northern Cape, KwaZulu-Natal, Eastern Cape and Gauteng) in 2015 using mixed methods, including interviews, register reviews and clinical audits. This paper reports on the qualitative component of the study.

DESIGN

This is a qualitative interview study.

SETTING

Data were collected in 22 decentralised DR-TB sites, primary healthcare facilities and district hospitals and one provincial central DR-TB hospital.

PARTICIPANTS

58 healthcare workers (HCWs), facility staff and provincial and district TB coordinators were included in qualitative interviews.

RESULTS

HCWs felt that the introduction of DR-TB care in their facility came with little warning or engagement, creating fear and anxiety. They expressed a need for support from the district and province to guide them through the changes but this support was often lacking. In addition, many respondents expressed feeling isolated and not supported by other healthcare providers which they feel impacts on the quality of the care they provide.

CONCLUSION

Introduction of a new service such as DR-TB care can be difficult and does not always result in the intended outcomes. Improved engagement with front-line providers and addressing the fear and anxiety that may be raised by changes in daily practices should be addressed to ensure successful implementation and prevent negative consequences that can hamper quality of care for patients. Attention should be paid to how the decentralised DR-TB unit can be supported by district management and other healthcare providers.

Quality of TB care among people living with HIV: Gaps and solutions

Tuberculosis (TB) is the leading infectious cause of death among people living with HIV, causing one third of AIDS-related deaths globally. The concerning number of missing TB cases, ongoing high TB mortality, slow reduction in TB incidence, and limited uptake of TB preventive treatment among people living with HIV, all indicate the urgent need to improve quality of TB services within HIV programs. In this mini-review we discuss major gaps in quality of TB care that impede achieving prevention and treatment targets within the TB-HIV care cascades, show approaches of assessing gaps in TB service provision, and describe outcomes from innovative quality improvement projects among HIV and TB programs. We also offer recommendations for measuring quality of TB care.

MDR-TB patients in KwaZulu-Natal, South Africa: Cost-effectiveness of 5 models of care

BACKGROUND

South Africa has a high burden of MDR-TB, and to provide accessible treatment the government has introduced different models of care. We report the most cost-effective model after comparing cost per patient successfully treated across 5 models of care: centralized hospital, district hospitals (2), and community-based care through clinics or mobile injection teams.

METHODS

In an observational study five cohorts were followed prospectively. The cost analysis adopted a provider perspective and economic cost per patient successfully treated was calculated based on country protocols and length of treatment per patient per model of care. Logistic regression was used to calculate propensity score weights, to compare pairs of treatment groups, whilst adjusting for baseline imbalances between groups. Propensity score weighted costs and treatment success rates were used in the ICER analysis. Sensitivity analysis focused on varying treatment success and length of hospitalization within each model.

RESULTS

In 1,038 MDR-TB patients 75% were HIV-infected and 56% were successfully treated. The cost per successfully treated patient was 3 to 4.5 times lower in the community-based models with no hospitalization. Overall, the Mobile model was the most cost-effective.

CONCLUSION

Reducing the length of hospitalization and following community-based models of care improves the affordability of MDR-TB treatment without compromising its effectiveness.

Empiric tuberculosis treatment in South African primary health care facilities - for whom, where, when and why: Implications for the development of tuberculosis diagnostic tests

Background

The extent and circumstances under which empiric tuberculosis (TB) treatment (treatment without microbiological confirmation at treatment initiation) is administered in primary health care settings in South Africa are not well described.

Methods

We used data from a pragmatic evaluation of Xpert MTB/RIF in which persons undergoing TB investigations by PHC nurses were followed for six months. Following Xpert or smear-microscopy at enrolment, investigations for tuberculosis were undertaken at the discretion of health care workers. We identified persons whose TB treatment was initiated empirically (no microbiological confirmation at time of treatment initiation at a primary health care facility) and describe pathways to treatment initiation.

Results

Of 4665 evaluable participants, 541 persons were initiated on treatment of whom 167 (31%) had negative sputum tests at enrolment. Amongst these 167, the median number of participant visits to health care providers prior to treatment initiation was 3 (interquartile range [IQR] 2–4). Chest radiography, sputum culture or hospital referral was done in 106/167 (63%). Reasons for TB treatment start were: 1) empiric (n = 82, 49%); 2) a positive laboratory test (n = 49, 29%); 3) referral and treatment start at a higher level of care (n = 28, 17%); and 4) indeterminable (n = 8, 5%). Empiric treatment accounted for 15% (82/541) of all TB treatment initiations and 1.7% (82/4665) of all persons undergoing TB investigations. Chest radiography findings compatible with TB (63/82 [77%]) were the basis for treatment initiation amongst the majority of empirically treated participants. Microbiological confirmation of TB was subsequently obtained for 11/82 (13%) empirically-treated participants. Median time to empiric treatment start was 3.9 weeks (IQR 1.4–11 weeks) after enrolment.

Conclusion

Uncommon prescription of empiric TB treatment with reliance on chest radiography in a nurse-managed programme underscores the need for highly sensitive TB diagnostics suitable for point-of-care, and strong health systems to support TB diagnosis in this setting.

The South African Tuberculosis Care Cascade: Estimated Losses and Methodological Challenges

Background

While tuberculosis incidence and mortality are declining in South Africa, meeting the goals of the End TB Strategy requires an invigorated programmatic response informed by accurate data. Enumerating the losses at each step in the care cascade enables appropriate targeting of interventions and resources.

Methods

We estimated the tuberculosis burden; the number and proportion of individuals with tuberculosis who accessed tests, had tuberculosis diagnosed, initiated treatment, and successfully completed treatment for all tuberculosis cases, for those with drug-susceptible tuberculosis (including human immunodeficiency virus (HIV)–coinfected cases) and rifampicin-resistant tuberculosis. Estimates were derived from national electronic tuberculosis register data, laboratory data, and published studies.

Results

The overall tuberculosis burden was estimated to be 532005 cases (range, 333760–764480 cases), with successful completion of treatment in 53% of cases. Losses occurred at multiple steps: 5% at test access, 13% at diagnosis, 12% at treatment initiation, and 17% at successful treatment completion. Overall losses were similar among all drug-susceptible cases and those with HIV coinfection (54% and 52%, respectively, successfully completed treatment). Losses were substantially higher among rifampicin- resistant cases, with only 22% successfully completing treatment.

Conclusion

Although the vast majority of individuals with tuberculosis engaged the public health system, just over half were successfully treated. Urgent efforts are required to improve implementation of existing policies and protocols to close gaps in tuberculosis diagnosis, treatment initiation, and successful treatment completion.

Collaborative public-private initiatives targeting multidrug-resistant tuberculosis (MDR-TB) supported by the Lilly MDR-TB Partnership: experiences in 2012-2016

Since 2003, the Lilly Foundation has supported the noncommercial Lilly MDR-TB Partnership, which involves more than 45 local, national, global, and nongovernmental organizations and governments. The aim of the Lilly MDR-TB Partnership is to achieve significant global impact on multidrug-resistant tuberculosis (MDR-TB) by addressing a series of important local health care needs in highly affected countries: China, India, Russia, and South Africa. The main focus of activities during 2012–2016 was on community needs in primary care. Supported projects seek to make meaningful and measurable progress toward global and national TB objectives. The partnership programs share an overall conceptual approach known as “research, report, advocate”, based on the piloting of novel approaches on a small scale, with outcomes assessed at early stages. The results are analyzed and communicated to governments, health-policy experts, and local and national stakeholders, including those in other countries facing similar MDR-TB challenges. For successful, cost-effective initiatives, the analysis is used as support when advocating for the scaling up of initiatives to regional or national levels. This article discusses representative examples of projects supported by the Lilly MDR-TB Partnership in the time period 2012–2016. The examples illustrate the potential for globally informed, locally designed primary-care collaborations to strengthen health care systems and support TB policies and offer observations to inform future health care public–private partnerships.

Implementation and Operational Research: Clinical Impact of the Xpert MTB/RIF Assay in Patients With Multidrug-Resistant Tuberculosis

BACKGROUND

The Xpert MTB/RIF assay has been widely implemented in South Africa for rapid tuberculosis (TB) screening. However, its usefulness in management and improving treatment outcomes in patients with multidrug-resistant TB (MDR-TB) remains undefined. The aim of this study was to evaluate the clinical impact of introduction of the Xpert MTB/RIF assay in patients with MDR-TB.

METHODS

We enrolled 921 patients with MDR-TB, who presented to a specialist drug-resistant TB facility in KwaZulu-Natal, South Africa, pre- and post-rollout and implementation of the Xpert MTB/RIF assay. Clinical, laboratory, chest radiograph, and follow-up data from 108 patients with MDR-TB, post-introduction of the Xpert MTB/RIF assay (Xpert group) in November 2010, were analyzed and compared with data from 813 MDR-TB patients from the pre-MTB/RIF assay period (Conventional group), July 2008-2010. Primary impact measure was "treatment success" (World Health Organization definition) at 24 months. Secondary outcomes were time to treatment initiation and disease morbidity.

RESULTS

There were no significant differences in treatment success rates between the pre-Xpert MTB/RIF and post-Xpert MTB/RIF groups (54% versus 56.5%, P = 0.681). Median time to treatment initiation was 20 days (interquartile range, 13-31) in the Xpert group versus 92 days (interquartile range, 69-120) in the Conventional group (P < 0.001).

CONCLUSIONS

Although use of Xpert MTB/RIF assay significantly reduces the time to initiation of MDR-TB treatment, it had no significant impact on treatment outcomes of patients with MDR-TB. Studies on the impact of the Xpert MTB/RIF assay usage on transmission of MDR-TB are required.

[Access barriers to comprehensive care for people affected by tuberculosis and human immunodeficiency virus coinfection in Peru, 2010-2015]

OBJECTIVE

Identify the programmatic barriers that hinder access to comprehensive care of patients with tuberculosis and human immunodeficiency virus (TB/HIV) coinfection.

METHODS

This is a mixed-method study. Qualitative research was conducted via in-depth interviews with key actors and the quantitative component involved cross-sectional descriptive analysis of programmatic data from 2010-2015 on tuberculosis and HIV programs at health facilities in the cities of Lima and Iquitos.

RESULTS

Twenty-two key actors in seven establishments were interviewed. The identified barriers were: little or no coordination between tuberculosis and HIV teams, separate management of tuberculosis and HIV cases at different levels of care, insufficient financing, limited or poorly trained human resources, and lack of an integrated information system. It was found that HIV screening in TB patients increased (from 18.8% in 2011 to 95.2% in 2015), isoniazid coverage of HIV patients declined (from 62% to 9%), and the proportion of deaths among TB/HIV coinfection cases averaged 20%.

CONCLUSIONS

There is poor coordination between HIV and TB health strategies. Management of TB/HIV coinfection is fragmented into different levels of care, which has an impact on comprehensive patient care. As a result of this research, a technical document was prepared to establish joint procedures that should be implemented to improve comprehensive care of TB/HIV coinfection.

Sharing the spotlight in Durban: A report from IAS TB2016 at AIDS2016

Tuberculosis (TB) is now recognized as the number one cause of death worldwide due to a single infectious pathogen and is the cause of death in one-third of people living with HIV worldwide. An inaugural pre-conference focused on TB (TB2016) was held at the International AIDS Society Conference AIDS2016. This report focuses on key messages from the TB2016 conference that are important for the medical, public health, activist, and scientific communities.

Early Outcomes Of Decentralized Care for Rifampicin-Resistant Tuberculosis in Johannesburg, South Africa: An Observational Cohort Study

OBJECTIVE

We describe baseline characteristics, time to treatment initiation and interim patient outcomes at a decentralized, outpatient treatment site for rifampicin-resistant TB (RR-TB).

METHODS

Prospective observational cohort study of RR-TB patients from March 2013 until December 2014. Study subjects were followed until completion of the intensive phase of treatment (6 months), transfer out, or a final outcome (loss from treatment (LFT) or death).

RESULTS

214 patients with RR-TB were enrolled in the study. Xpert MTB/RIF was the diagnostic test of rifampicin resistance for 87% (n = 186), followed by direct PCR on AFB positive specimen in 14 (7%) and indirect PCR on cultured isolate in 5 (2%). Median time between sputum testing and treatment initiation was 10 days (IQR 6-21). Interim outcomes were available in 148 patients of whom 78% (n = 115) were still on treatment, 9% (n = 13) had died, and 14% (n = 20) were LFT. Amongst 131 patients with culture positive pulmonary TB, 85 (64.9%) were culture negative at 6 months, 12 were still sputum culture positive (9.2%) and 34 had no culture documented or contaminated culture (26%). Patients who initiated as outpatients within 1 week of sputum collection for diagnosis of RR-TB had a significantly lower incidence of LFT (IRR 0.30, 95% CI: 0.09-0.98). HIV co-infection occurred in 178 patients (83%) with a median CD4 count 88 cells/ml3 (IQR 27-218).

CONCLUSIONS

Access to decentralized treatment coupled with the rapid diagnosis of RR-TB has resulted in short time to treatment initiation. Despite the lack of treatment delays, early treatment outcomes remain poor with high rates of death and loss from care.

Decentralization and health system performance - a focused review of dimensions, difficulties, and derivatives in India

Introduction

One of the principal goals of any health care system is to improve health through the provision of clinical and public health services. Decentralization as a reform measure aims to improve inputs, management processes and health outcomes, and has political, administrative and financial connotations. It is argued that the robustness of a health system in achieving desirable outcomes is contingent upon the width and depth of ‘decision space’ at the local level. Studies have used different approaches to examine one or more facets of decentralization and its effect on health system functioning; however, lack of consensus on an acceptable framework is a critical gap in determining its quantum and quality. Theorists have resorted to concepts of ‘trust’, ‘convenience’ and ‘mutual benefits’ to explain, define and measure components of governance in health. In the emerging ‘continuum of health services’ model, the challenge lies in identifying variables of performance (fiscal allocation, autonomy at local level, perception of key stakeholders, service delivery outputs, etc.) through the prism of decentralization in the first place, and in establishing directed relationships among them.

Methods

This focused review paper conducted extensive web-based literature search, using PubMed and Google Scholar search engines. After screening of key words and study objectives, we retrieved 180 articles for next round of screening. One hundred and four full articles (three working papers and 101 published papers) were reviewed in totality. We attempted to summarize existing literature on decentralization and health systems performance, explain key concepts and essential variables, and develop a framework for further scientific scrutiny. Themes are presented in three separate segments of dimensions, difficulties and derivatives.

Results

Evaluation of local decision making and its effect on health system performance has been studied in a compartmentalized manner. There is sparse evidence about innovations attributable to decentralization. We observed that in India, there is very scant evaluative study on the subject. We didn’t come across a single study examining the perception and experiences of local decision makers about the opportunities and challenges they faced. The existing body of evidences may be inadequate to feed into sound policy making. The principles of management hinge on measurement of inputs, processes and outputs. In the conceptual framework we propose three levels of functions (health systems functions, management functions and measurement functions) being intricately related to inputs, processes and outputs. Each level of function encompasses essential elements derived from the synthesis of information gathered through literature review and non-participant observation. We observed that it is difficult to quantify characteristics of governance at institutional, system and individual levels except through proxy means.

Conclusion

There is an urgent need to sensitize governments and academia about how best more objective evaluation of ‘shared governance’ can be undertaken to benefit policy making. The future direction of enquiry should focus on context-specific evidence of its effect on the entire spectrum of health system, with special emphasis on efficiency, community participation, human resource management and quality of services.

Identifying Perceived Barriers along the HIV Care Continuum: Findings from Providers, Peer Educators, and Observations of Provider-Patient Interactions in Ethiopia

Increasing the proportion of HIV-positive individuals who link promptly to and are retained in care remains challenging in sub-Saharan Africa, but little evidence is available from the provider perspective. In 4 Ethiopian health facilities, we (1) interviewed providers and peer educators about their perceptions of service delivery- and patient-level barriers and (2) observed provider-patient interactions to characterize content and interpersonal aspects of counseling. In interviews, providers and peer educators demonstrated empathy and identified nonacceptance of HIV status, anticipated stigma from unintended disclosure, and fear of antiretroviral therapy as patient barriers, and brusque counseling and insufficient counseling at provider-initiated testing sites as service delivery-related. However, observations from the same clinics showed that providers often failed to elicit patients' barriers to retention, making it unlikely these would be addressed during counseling. Training is needed to improve interpersonal aspects of counseling and ensure providers elicit and address barriers to HIV care experienced by patients.

Achieving high treatment success for multidrug-resistant TB in Africa: initiation and scale-up of MDR TB care in Ethiopia--an observational cohort study

Background

In Africa, fewer than half of patients receiving therapy for multidrug-resistant TB (MDR TB) are successfully treated, with poor outcomes reported for HIV-coinfected patients.

Methods

A standardised second-line drug (SLD) regimen was used in a non-governmental organisation–Ministry of Health (NGO-MOH) collaborative community and hospital-based programme in Ethiopia that included intensive side effect monitoring, adherence strategies and nutritional supplementation. Clinical outcomes for patients with at least 24 months of follow-up were reviewed and predictors of treatment failure or death were evaluated by Cox proportional hazards models.

Results

From February 2009 to December 2014, 1044 patients were initiated on SLD. 612 patients with confirmed or presumed MDR TB had ≥24 months of follow-up, 551 (90.0%) were confirmed and 61 (10.0%) were suspected MDR TB cases. 603 (98.5%) had prior TB treatment, 133 (21.7%) were HIV coinfected and median body mass index (BMI) was 16.6. Composite treatment success was 78.6% with 396 (64.7%) cured, 85 (13.9%) who completed treatment, 10 (1.6%) who failed, 85 (13.9%) who died and 36 (5.9%) who were lost to follow-up. HIV coinfection (adjusted HR (AHR): 2.60, p<0.001), BMI (AHR 0.88/kg/m², p=0.006) and cor pulmonale (AHR 3.61, p=0.003) and confirmed MDR TB (AHR 0.50, p=0.026) were predictive of treatment failure or death.

Conclusions

We report from Ethiopia the highest MDR TB treatment success outcomes so far achieved in Africa, in a setting with severe resource constraints and patients with advanced disease. Intensive treatment of adverse effects, nutritional supplementation, adherence interventions and NGO-MOH collaboration were key strategies contributing to success. We argue these approaches should be routinely incorporated into programmes.

Community-based care vs. centralised hospitalisation for MDR-TB patients, KwaZulu-Natal, South Africa

SETTING

KwaZulu-Natal, South Africa, a predominantly rural province with a high burden of tuberculosis (TB), multidrug-resistant TB (MDR-TB) and human immunodeficiency virus (HIV) infection.

OBJECTIVE

To determine the most effective care model by comparing MDR-TB treatment outcomes at community-based sites with traditional care at a central, specialised hospital.

DESIGN

A non-randomised observational prospective cohort study comparing community-based and centralised care. Patients at community-based sites were closer to home and had easier access to care, and home-based care was available from treatment initiation.

RESULTS

Four community-based sites treated 736 patients, while 813 were treated at the centralised hospital (total = 1549 patients). Overall, 75% were HIV co-infected (community: 76% vs. hospitalised: 73%, P = 0.45) and 86% received antiretroviral therapy (community: 91% vs. hospitalised: 82%, P = 0.22). On multivariate analysis, MDR-TB patients were more likely to have a successful treatment outcome if they were treated at a community-based site (adjusted OR 1.43, P = 0.01). However, outcomes at the four community-based sites were heterogeneous, with Site 1 demonstrating that home-based care was associated with an increased treatment success of 72% compared with success rates of 52-60% at the other three sites.

CONCLUSION

Community-based care for MDR-TB patients was more effective than care in a central, specialised hospital. Home-based care further increased treatment success.

Improving district facility readiness: a 12-month evaluation of a data-driven health systems strengthening intervention in rural Rwanda

Background

While health systems strengthening (HSS) interventions are recommended by global health policy experts to improve population health in resource-limited settings, few examples exist of evaluations of HSS interventions conducted at the district level. In 2009, a partnership between Partners In Health (PIH), a non-governmental organization, and the Rwandan Ministry of Health (RMOH) was provided funds to implement and evaluate a district-level HSS intervention in two rural districts of Rwanda.

Design

The partnership provided limited funds to 14 health centers for targeted systems support in 2010; six others received support prior to the intervention (reference). RMOH health systems norms were mapped across the WHO HSS framework, scored from 0 to 10 and incorporated into a rapid survey assessing 11 domains of facility readiness. Stakeholder meetings allowed partnership leaders to review results, set priorities, and allocate resources. Investments included salary support, infrastructure improvements, medical equipment, and social support for patients. We compared facility domain scores from the start of the intervention to 12 months and tested for correlation between change in score and change in funding allocation to assess equity in our approach.

Results

We found significant improvements among intervention facilities from baseline to 12 months across several domains [infrastructure (+4, p=0.0001), clinical services (+1.2, p=0.03), infection and sanitation control (+0.6, p=0.03), medical equipment (+1.0, p=0.02), information use (+2, p=0.002)]. Composite score across domains improved from 6.2 at baseline to 7.4 at 12 months (p=0.002). Across facilities, 50% had composite scores greater than the average score among reference facilities (7.4) at 12 months compared to none at baseline.

Conclusions

Rapid facility surveys, stakeholder engagement, and information feedback can be used for gap analysis and resource allocation. This approach can achieve effective use of limited resources, improve facility readiness, and ensure consistency of facility capacity to provide quality care at the district level.