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Brame JL, Quinonez RB, Ciszek BP, Weintraub JA. Implementing a Prenatal Oral Health Program for Dental Students: Lessons Learned. Health Promot Pract 2023:15248399231207070. [PMID: 37904487 DOI: 10.1177/15248399231207070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2023]
Abstract
The Prenatal Oral Health Program (pOHP) was developed to educate dental students on prenatal oral health and promote access to dental care for pregnant women. Program advancement has occurred in support of quality improvement. This mixed-methods design combined quantitative data from fourth-year dental students who participated the pOHP (N = 81) and qualitative data from a student-faculty-staff focus group discussion (N = 7). Different clinical structures, appropriate leveling in the curriculum, management with a patient care coordinator, and inclusion of interprofessional learning experiences (IPE) were compared. The survey response rate was 96.4% (N = 81). Trends were noted between students who provided clinical care for a pregnant patient (31%) versus those who did not. Results indicated that an integrated clinic was preferred, though students who had treated a pOHP patient showed greater support for a standalone clinic model. Survey and focus group data agreed that pOHP should occur during the third-year dental school training; however, students with patient experience favored second-year placement. Survey and focus group data emphasize the importance of a patient care coordinator for clinical management and IPE as an essential learning element. Innovating new clinical models requires a period of evolution to determine preferred and sustainable infrastructure. Results reveal the advantages and disadvantages of various program implementation models and demonstrate that student perceptions were influenced by their clinical experiences. Study findings will inform implementation and guide other programs as they create and modify existing curricula to enhance prenatal oral health.
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Affiliation(s)
- Jennifer L Brame
- The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Rocio B Quinonez
- The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Brittney P Ciszek
- The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- The University of Utah, Salt Lake City, UT, USA
| | - Jane A Weintraub
- The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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2
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Hassan F, Renju J, Songo J, Chimukuche RS, Kalua T, McLean E, Luwanda L, Geubbels E, Seeley J, Moshabela M, Kajoka D, Wringe A. Implementation and experiences of integrated prevention of mother-to-child transmission services in Tanzania, Malawi and South Africa: A mixed methods study. Glob Public Health 2020; 16:201-215. [PMID: 33119433 PMCID: PMC7612851 DOI: 10.1080/17441692.2020.1839927] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Although integration of HIV and maternal health services is recommended by the World Health Organization, evidence to guide implementation is limited. We describe facility-level implementation of policies for integrating HIV care within maternal health services and explore experiences of service users and providers in rural Tanzania (Ifakara), South Africa (uMkhanyakude) and Malawi (Karonga). Policy in all countries included HIV testing during antenatal care (ANC), same-day antiretroviral therapy (ART) initiation for HIV-positive pregnant women, and postpartum referral to ART clinics, between six weeks (Malawi, South Africa) and two years after delivery (Tanzania). All facilities offered HIV testing within ANC, most commonly during the first visit. Although most women were comfortable with HIV testing, some felt that opting out would lead to sub-standard services. Some facilities conducted group post-test counselling for HIV-negative women, raising concerns of unintended HIV status disclosure. ART initiation was offered on the same day, the same room as an HIV diagnosis in >90% of facilities. Women’s worries around postpartum referral included having unknown providers, insufficient privacy and queues. Adoption and implementation of policies on integrated HIV and maternal health services varied across settings. Patients’ experiences of these policies may influence uptake and retention in care.
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Affiliation(s)
- Farida Hassan
- Health System, Impact Evaluation and Policy, Ifakara Health Institute, United Republic of Tanzania
| | - Jenny Renju
- Department of population studies, London School of Hygiene and Tropical Medicine, London, UK.,Department of Epidemiology and Biostatistics, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - John Songo
- Malawi Epidemiology and Intervention Research Unit, Karonga, Malawi
| | | | | | - Estelle McLean
- Department of population studies, London School of Hygiene and Tropical Medicine, London, UK.,Malawi Epidemiology and Intervention Research Unit, Karonga, Malawi
| | - Lameck Luwanda
- Health System, Impact Evaluation and Policy, Ifakara Health Institute, United Republic of Tanzania
| | - Eveline Geubbels
- Health System, Impact Evaluation and Policy, Ifakara Health Institute, United Republic of Tanzania
| | - Janet Seeley
- Department of population studies, London School of Hygiene and Tropical Medicine, London, UK.,Africa Health Research Institute, Durban, South Africa
| | - Mosa Moshabela
- Malawi Epidemiology and Intervention Research Unit, Karonga, Malawi.,School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Deborah Kajoka
- Ministry of Health, Community Development, Gender, Elderly and Children, Dodoma, Tanzania
| | - Alison Wringe
- Department of population studies, London School of Hygiene and Tropical Medicine, London, UK
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3
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Mayhew SH, Warren CE, Ndwiga C, Narasimhan M, Wilcher R, Mutemwa R, Abuya T, Colombini M. Health systems software factors and their effect on the integration of sexual and reproductive health and HIV services. Lancet HIV 2020; 7:e711-e720. [PMID: 33010243 DOI: 10.1016/s2352-3018(20)30201-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 05/14/2020] [Accepted: 05/22/2020] [Indexed: 11/19/2022]
Abstract
Despite a large and growing body of literature on sexual and reproductive health (SRH) and HIV integration, the drivers of integration of SRH and HIV services, from a health systems perspective, are not well understood. These drivers include complex so-called hardware (structural and resource) and software (values and norms, and human relations and interactions) factors. Two groups of software factors emerge as essential enablers of effective integration of SRH and HIV services that often interact with systems hardware: (1) leadership, management, and governance processes and (2) provider motivation, agency, and relationships. Evidence suggests the potential for software elements that are essential enablers to overcome some of the obstacles posed by the non-integration of health system hardware elements (eg, financing, guidelines, and commodity supplies). These enabling factors include flexible decision making, inclusive management, and support in motivating frontline staff who can work with agency as a team. Improved software, even within constrained hardware (especially in low-income and middle-income countries), can directly contribute to improved SRH and HIV service delivery.
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Affiliation(s)
- Susannah H Mayhew
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK.
| | | | | | - Manjulaa Narasimhan
- Department of Sexual and Reproductive Health and Research, WHO, Geneva, Switzerland
| | - Rose Wilcher
- Knowledge Management and Structural Interventions, HIV Unit, FHI 360, Durham, NC, USA
| | - Richard Mutemwa
- School of Medicine and Health Sciences, University of Lusaka, Lusaka, Zambia
| | | | - Manuela Colombini
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
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4
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Abuhammad S, Alzoubi KH, Al-Azzam SI, Karasneh RA. Knowledge and Practice of Patients' Data Sharing and Confidentiality Among Nurses in Jordan. J Multidiscip Healthc 2020; 13:935-942. [PMID: 32982270 PMCID: PMC7502382 DOI: 10.2147/jmdh.s269511] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 08/17/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The key patient rights entail respecting human decency, receiving healthcare services of high-quality, the right to information, the initial agreement of the patient to medical intervention, respecting privacy and personal life, and sustaining care and treatment. This study aims to survey the knowledge and practice of nurses in various healthcare industries toward sharing and confidentiality of patients' data. METHODS A descriptive cross-sectional design was employed through an online survey from May to June 2020. The authors sent a developed tool containing 19 statements reflecting the understanding of nurses' knowledge and practice of privacy and sharing of data required to safeguard patient privacy. A total of 800 nurses agreed to participate in the study out of 1000 nurses. RESULTS Roughly, all participants agreed that junior nurses should participate in a data sharing and confidentiality course before engaging in practice. Regarding institution policies for data sharing and protection, many nurses agreed that there are special recommendations and instructions from the institution in which they work to exchange patient information among nurses and the medical staff. The predictors of sharing practices and confidentiality among nurses include age, gender, marriage status, and attending a security course before practice. Young age, female, not attending a data sharing course, and single nurses are less engaging with data sharing and confidentiality of the patients for unauthorized patients. CONCLUSION A significant proportion of the staff had appropriate practices that ensured data security. However, practices that ensure patient confidentiality in the aspects of access, sharing, and transferring of patient data need improvement. Training is essential since it will have a beneficial relationship with knowledge, opinions, views, and actions. Thus, planning continuous training on policies and regulations about data safety and privacy may assist in improving healthcare setting practices.
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Affiliation(s)
- Sawsan Abuhammad
- Department of Maternal and Child Health, Jordan University of Science and Technology, Irbid22110, Jordan
| | - Karem H Alzoubi
- Department of Clinical Pharmacy, Jordan University of Science and Technology, Irbid22110, Jordan
| | - Sayer I Al-Azzam
- Department of Clinical Pharmacy, Jordan University of Science and Technology, Irbid22110, Jordan
| | - Reema A Karasneh
- Department of Basic Medical Sciences, Faculty of Medicine, Yarmouk University, Irbid, Jordan
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Factors Associated with Improved HIV/AIDS Treatment Outcomes: Comparing two Major ART Service Delivery Models in Vietnam. AIDS Behav 2019; 23:2840-2848. [PMID: 31236748 DOI: 10.1007/s10461-019-02571-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
A mixed design approach was performed to assess the CD4 count levels over time and their associated factors among 362 HIV patients on ART from clinics with HIV testing and counseling (ART-HTC) services and those with general healthcare (ART-GH) services. Longitudinal CD4 count data were retrospectively collected from medical records. Sociodemographic, clinical, alcohol use and smoking characteristics were obtained via face-to-face interviews. Multivariate mixed effect linear regression was utilized to determine the association. We found that HIV patients at ART-GH clinics were more likely to achieve higher CD4 counts over time compared to patients at ART-HTC clinics. Additionally, having an increase in CD4 counts was found to be associated with having longer duration of ART and higher baseline CD4 levels. Cigarette smoking and hazardous alcohol use, however, were not associated with CD4 count improvement. Our findings suggest that combining HTC and GH services might provide a synergistic benefit in ART treatment outcomes through an improved access to comprehensive HIV healthcare services for HIV patients on therapy.
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Feyissa GT, Lockwood C, Woldie M, Munn Z. Reducing HIV-related stigma and discrimination in healthcare settings: A systematic review of quantitative evidence. PLoS One 2019; 14:e0211298. [PMID: 30682131 PMCID: PMC6347272 DOI: 10.1371/journal.pone.0211298] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 01/10/2019] [Indexed: 12/20/2022] Open
Abstract
Introduction Stigma and discrimination (SAD) related to HIV compromise access and adherence to treatment and support programs among people living with HIV (PLHIV). The ambitious goal of ending the epidemic of HIV by 2030 set by the United Nations Joint Program of HIV/AIDS (UNAIDS) will thus only be achieved if HIV-related stigma and discrimination are reduced. The objective of this review was to locate, appraise and describe international literature reporting on interventions that addressed HIV-related SAD in healthcare settings. Methods The databases searched were: Cumulative Index to Nursing and Allied Health (CINAHL), Excerpta Medica Database from Elsevier (EMBASE), PubMed and Psychological Information (PsycINFO) database. Two individuals independently appraised the quality of the papers using appraisal instruments from the Joanna Briggs Institute (JBI). Data were extracted from papers included in the review using the standardized data extraction tool from JBI. Quality of evidence for major outcomes was assessed using Grading of Recommendations, Assessment, Development and Evaluation (GRADE). Results We retained 14 records reporting on eight studies. Five categories of SAD reduction (information-based, skills building, structural, contact-based and biomedical interventions) were identified. Training popular opinion leaders (POLs) resulted in significantly lower mean avoidance intent scores (MD = -1.87 [95% CI -2.05 to -1.69]), mean prejudicial attitude scores (MD = -3.77 [95% CI -5.4 to -2.09]) and significantly higher scores in mean compliance to universal precaution (MD = 1.65 [95% CI 1.41 to 1.89]) when compared to usual care (moderate quality evidence). The Summary of Findings table (SOF) is shown in Table 1. Conclusions Evidence of moderate quality indicates that training popular opinion leaders is effective in reducing avoidance intent and prejudicial attitude and improving compliance to universal precaution. Very low quality evidence indicates that professionally-assisted peer group interventions, modular interactive training, participatory self-guided assessment and intervention, contact strategy combined with information giving and empowerment are effective in reducing HIV-related stigma.Further Randomized Controlled Trials (RCTs) are needed. Future trials need to use up-to-date and validated instruments to measure stigma and discrimination.
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Affiliation(s)
- Garumma Tolu Feyissa
- Jimma University, Department of Health, Behavior and Society, Jimma, Ethiopia
- Ethiopian Evidence Based Health Care Centre: JBI Center of Excellence, Jimma University, Jimma, Ethiopia
- The Joanna Briggs Institute, the University of Adelaide, Adelaide, Australia
- * E-mail:
| | - Craig Lockwood
- The Joanna Briggs Institute, the University of Adelaide, Adelaide, Australia
| | - Mirkuzie Woldie
- Ethiopian Evidence Based Health Care Centre: JBI Center of Excellence, Jimma University, Jimma, Ethiopia
- Department of Health Policy and Management, Jimma University, Jimma, Ethiopia
- Department of Global Health and Population, T.H. Chan Harvard School of Public Health, Addis Ababa, Ethiopia
| | - Zachary Munn
- The Joanna Briggs Institute, the University of Adelaide, Adelaide, Australia
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Shukla S, Muchomba FM, McCoyd JLM. 'Drug adherence levels are falling down again': health worker perceptions of women's service utilization before and after integration of HIV/AIDS services into general care in India. Health Policy Plan 2018; 33:623-632. [PMID: 29590366 DOI: 10.1093/heapol/czy024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2018] [Indexed: 11/13/2022] Open
Abstract
Integrated models of HIV/AIDS service delivery are believed to have advantages over stand-alone models of care from health planners' and providers' perspectives. Integration models differ, yet there is little information about the influence of differing models on workers' beliefs about models' efficacy. Here, we examine the effect of integration of HIV care into the general health system in India. In 2014, India replaced its stand-alone model of HIV service delivery-Community Care Centers (CCCs)-with a purported integrated model that delivers HIV medical services at general hospitals and HIV psychosocial services at nearby Care and Support Centers (CSCs). We examine 15 health workers' perceptions of how change from the earlier stand-alone model to the current model impacted women's care in a district in Uttar Pradesh, India. Results indicate that (1) Women's antiretroviral (ART) adherence and utilization of psychosocial support service for HIV/AIDS suffered when services were not provided at one site; (2) Provision of inpatient care in the CCC model offered women living in poverty personal safety in accessing HIV health services and promoted chances of competent ART usage and repeat service utilization; and (3) Although integration of HIV services with the general health system was perceived to improve patient anonymity and decrease chances of HIV-related stigma and discrimination, resource shortages continued to plague the integrated system while shifting costs of time and money to the patients. Findings suggest that integration efforts need to consider the context of service provision and the gendered nature of access to HIV care.
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Affiliation(s)
- Shrivridhi Shukla
- Rutgers, The State University of New Jersey, School of Social Work, New Brunswick, NJ, USA
| | - Felix M Muchomba
- Rutgers, The State University of New Jersey, School of Social Work, New Brunswick, NJ, USA
| | - Judith L M McCoyd
- Rutgers, The State University of New Jersey, School of Social Work, New Brunswick, NJ, USA
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8
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Hopkins J, Collins L. How linked are national HIV and SRHR strategies? A review of SRHR and HIV strategies in 60 countries. Health Policy Plan 2018; 32:iv57-iv66. [PMID: 29194540 PMCID: PMC5886072 DOI: 10.1093/heapol/czw119] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2016] [Indexed: 11/13/2022] Open
Abstract
The connection between HIV and sexual and reproductive health and rights (SRHR) is widely recognised along with the benefits of linking them at the legal/policy, health systems, and service delivery levels. However, despite increased rhetoric about the need for this three-tiered approach, integrated service delivery has not been fully addressed at the legal/policy level through national strategies. Thus a review of HIV and SRHR strategies was conducted for 60 countries, determining the extent to which they reflected the intersections between HIV and SRHR. Each HIV strategy was scored on whether five key SRHR components were incorporated and had an associated measurable target. SRHR strategies were similarly assessed for incorporation of five HIV components and associated targets. HIV strategies had a higher level of inclusion of SRHR components with a global average of 6.6/10 compared to 3.7/10 for SRHR strategies. The highest scoring component was the elimination of mother-to-child transmission of HIV (EMTCT) and the lowest was SRHR of people living with HIV. Countries with higher scores in one strategy tended to have higher scores in the other but there was no difference over time. Whilst there has been increased global commitment since 2004 to link SRHR and HIV, insufficient headway has been made in linking related national strategies. Although EMTCT is included with targets in the majority of HIV and SRHR strategies, the broader SRHR needs of women living with HIV are not. Also, condoms are not being considered an effective triple protection tool. HIV and SRHR strategies provide direction and targets which ultimately may influence funding and vice versa. Therefore, it is essential that these strategies are right-based and incorporate the key connections between SRHR and HIV with measurable targets to realise the full benefits of a joint response.
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9
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Khac Hai N, Lawpoolsri S, Jittamala P, Thi Thu Huong P, Kaewkungwal J. Practices in security and confidentiality of HIV/AIDS patients' information: A national survey among staff at HIV outpatient clinics in Vietnam. PLoS One 2017; 12:e0188160. [PMID: 29136017 PMCID: PMC5685590 DOI: 10.1371/journal.pone.0188160] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 11/01/2017] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Breach of confidentiality or invasion of privacy from the collection and use of medical records, particularly those of patients with HIV/AIDS or other diseases sensitive to stigmatization, should be prevented by all related stakeholders in healthcare settings. The main focus of this study was to assess practices regarding security and confidentiality of HIV-related information among staff at HIV outpatient clinics (HIV-OPCs) in Vietnam. METHODS A descriptive cross-sectional study was conducted at all 312 HIV-OPCs across the country using an online survey technique. RESULTS In general, the staff practices for securing and protecting patient information were at acceptable levels. Most staff had proper measures and practices for maintaining data security; however, the protection of patient confidentiality, particularly for data access, sharing, and transfer still required improvement. Most HIV-OPC staff had good or moderate knowledge and positive perceptions towards security and confidentiality issues. Staff who were not trained in the practice of security measures differed significantly from those who were trained (OR: 3.74; 95%CI: 1.44-9.67); staff needing improved knowledge levels differed significantly from those with good (OR: 5.20; 95%CI: 2.39-11.32) and moderate knowledge levels (OR: 5.10; 95%CI: 2.36-11.00); and staff needing improved perception levels differed significantly from those with good (i.e., with 100% proper practices) and moderate perception levels (OR: 5.67; 95%CI: 2.93-10.95). Staff who were not trained in the protection of data confidentiality differed significantly from those who were trained (OR: 2.18; 95%CI: 1.29-3.65). CONCLUSIONS Training is an important factor to help raise the levels of proper practices regarding confidentiality and security, to improve knowledge and raise awareness about change among staff. The operation and management of HIV treatment and care in Vietnam are currently transitioning from separate healthcare clinics (HIV-OPC) into units integrated into general hospitals/healthcare facilities. The findings of this study highlight topics that could be used for improving management and operation of information system and revising guidelines and regulations on protection measures/strategies for data security and confidentiality of HIV/AIDS patients by Vietnam health authorities or other countries facing similar situations. Secure infrastructure and secure measures for data access and use are very important, worthwhile investments. The provision of continuous training and active enforcement and monitoring of the practices of healthcare personnel might lead to an improved understanding and acknowledegement of the importance of national policies/guidelines regarding HIV-related patient information.
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Affiliation(s)
| | | | | | - Phan Thi Thu Huong
- Vietnam Authority of HIV/AIDS Control, Ministry of Health, Hanoi, Vietnam
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10
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Watt N, Sigfrid L, Legido-Quigley H, Hogarth S, Maimaris W, Otero-García L, Perel P, Buse K, McKee M, Piot P, Balabanova D. Health systems facilitators and barriers to the integration of HIV and chronic disease services: a systematic review. Health Policy Plan 2017; 32:iv13-iv26. [PMID: 28666336 PMCID: PMC5886067 DOI: 10.1093/heapol/czw149] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2016] [Indexed: 01/15/2023] Open
Abstract
Integration of services for patients with more than one diagnosed condition has intuitive appeal but it has been argued that the empirical evidence to support it is limited. We report the findings of a systematic review that sought to identify health system factors, extrinsic to the integration process, which either facilitated or hindered the integration of services for two common disorders, HIV and chronic non-communicable diseases. Findings were initially extracted and organized around a health system framework, followed by a thematic cross-cutting analysis and validation steps. Of the 150 articles included, 67% (n = 102) were from high-income countries. The articles explored integration with services for one or several chronic disorders, the most studied being alcohol or substance use disorders (47.7%), and mental health issues (29.5%). Four cross-cutting themes related to the health system were identified. The first and most common theme was the requirement for effective collaboration and coordination: formal and informal productive relationships throughout the system between providers and within teams, and between staff and patients. The second was the need for adequate and appropriately skilled and incentivized health workers-with the right expertise, training and operational support for the programme. The third was the need for supportive institutional structures and dedicated resources. The fourth was leadership in terms of political will, effective managerial oversight and organizational culture, indicating that actual implementation is as important as programme design. A fifth theme, outside the health system, but underpinning all aspects of the system operation, was that placing the patient at the centre of service delivery and responding holistically to their diverse needs. This was an important facilitator of integration. These findings confirm that integration processes in service delivery depend substantially for their success on characteristics of the health systems in which they are embedded.
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Affiliation(s)
- Nicola Watt
- The Centre for Health and Social Change (ECOHOST), London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place London, London WC1H 9SH, UK
| | - Louise Sigfrid
- Centre for Tropical Medicine and Global Health, Nuffield Dept. of Medicine, University of Oxford, Oxford, UK
| | - Helena Legido-Quigley
- Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2, #10-01, Tahir Foundation Building, 117549 Singapore
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
| | - Sue Hogarth
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
- Public Health Consultant at Tower Hamlets Together
| | - Will Maimaris
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
- Public Health Consultant, Haringey Council, London
| | - Laura Otero-García
- Nursing Section, Faculty of Medicine, Universidad Autonoma de Madrid, Arzobispo Morcillo Av., 4, Madrid and CIBER of Epidemiology and Public 15 Health (CIBERESP), Madrid, Spain
| | - Pablo Perel
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
| | - Kent Buse
- Chief, Strategic Policy Directions, UNAIDS, Geneva, Switzerland
| | - Martin McKee
- The Centre for Health and Social Change (ECOHOST), London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place London, London WC1H 9SH, UK
| | - Peter Piot
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
| | - Dina Balabanova
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
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11
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Bonnington O, Wamoyi J, Ddaaki W, Bukenya D, Ondenge K, Skovdal M, Renju J, Moshabela M, Wringe A. Changing forms of HIV-related stigma along the HIV care and treatment continuum in sub-Saharan Africa: a temporal analysis. Sex Transm Infect 2017; 93:sextrans-2016-052975. [PMID: 28736394 PMCID: PMC5739847 DOI: 10.1136/sextrans-2016-052975] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 03/23/2017] [Accepted: 04/01/2017] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Stigma remains pervasive for people living with HIV (PLHIV) in sub-Saharan Africa, undermining care engagement. Using everyday, biographical and epochal temporalities, we explored the manifestation of stigma at different stages of the HIV care continuum in seven health and demographic surveillance sites in Eastern and Southern Africa. METHODS Between 2015 and 2016, we conducted qualitative in-depth interviews with 264 PLHIV, 54 health providers and 48 family members of people who had died from HIV. Topic guides explored experiences of HIV testing, care and treatment services. Data were analysed thematically, aided by NVivo 10. RESULTS In everyday time across these communities, stigma was evident in the presence of gossiping and the relative absence of supportive interpersonal discourse, which fuelled judicious disclosure. This was especially disruptive at testing, counselling and early antiretroviral therapy adherence stages of care. Biographical time framed everyday stigma events, highlighting the dilemma of disclosure in relation to sexual relationship norms, as well as the interfacing of age and healthcare continuum points. Epochal patriarchal relations gave a structural context to everyday and biographical stigma dynamics. Historical shifts to social acceptance of PLHIV within these communities, while positive, were complicated by stigma in everyday life and in respect of biographical goals like having a family. Moreover, low community-level resistance to HIV-related stigma jeopardised stigma reduction strategies. CONCLUSIONS Despite improvements to HIV care services, stigma remains pervasive across the HIV care continuum in these sites. Context-specific interventions are needed to address stigma and discrimination of PLHIV within the community and in health services, and greater reflection is required to ensure policies aiming to expand HIV treatment do not exacerbate stigma and result in negative HIV outcomes.
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Affiliation(s)
- O Bonnington
- Department of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - J Wamoyi
- National Institute for Medical Research, Mwanza, Tanzania, United Republic of
| | - W Ddaaki
- Rakai Health Sciences Program, Rakai, Uganda
| | - D Bukenya
- Medical Research Council/Uganda Virus Research Institute Research Unit on AIDS, Entebbe, Uganda
| | - K Ondenge
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - M Skovdal
- University of Copenhagen, Copenhagen, Denmark.,Biomedical Research and Training Institute, Harare, Zimbabwe
| | - J Renju
- Department of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK.,Malawi Epidemiology and Intervention Research Unit, Karonga, Malawi
| | - M Moshabela
- Africa Health Research Institute, KwaZulu Natal, South Africa.,University of KwaZulu Natal, South Africa
| | - A Wringe
- Department of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
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12
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Warren CE, Mayhew SH, Hopkins J. The Current Status of Research on the Integration of Sexual and Reproductive Health and HIV Services. Stud Fam Plann 2017; 48:91-105. [PMID: 28493283 PMCID: PMC5518217 DOI: 10.1111/sifp.12024] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Integration of services for sexual and reproductive health (SRH) and HIV has been widely promoted globally in the belief that both clients and health providers benefit through improvements in quality, efficient use of resources, and lower costs, helping to maximize limited health resources and provide comprehensive client-centered care. This article builds on the growing body of research on integrated sexual SRH and HIV services. It brings together critical reviews on issues within the wider SRH and rights agenda and synthesizes recent research on integrated services, drawing on the Integra Initiative and other major research. Unintended pregnancy and HIV are intrinsically interrelated SRH issues, however broadening the constellation of services, scaling up, and mainstreaming integration continue to be challenging. Overcoming stigma, reducing gender-based violence, and meeting key populations' SRH needs are critical. Health systems research using SRH as the entry point for integrated services and interaction with communities and clients is needed to realize universal health coverage.
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Colombini M, Mayhew SH, Mutemwa R, Kivunaga J, Ndwiga C. Perceptions and Experiences of Integrated Service Delivery Among Women Living with HIV Attending Reproductive Health Services in Kenya: A Mixed Methods Study. AIDS Behav 2016; 20:2130-40. [PMID: 27071390 PMCID: PMC4995223 DOI: 10.1007/s10461-016-1373-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This is one of the few studies that explores preferences of and experiences with integrated sexual and reproductive health (SRH)-HIV care among users of mainstream family planning and postnatal care services who are women living with HIV (WLWH). This paper reports on the quantitative data from 179 clients attending public sector clinics and from 30 qualitative in-depth interviews with WLHIV in Kenya. Quantitative data show that integration is happening for the vast majority of these clients at their last HIV visit. However, qualitative data show that very often the care received by WLWH is fragmented as providers do not offer multiple same-day appointments for FP and ARV refills. Our study has shown factors that could either prevent or enable receipt of integrated SRH and HIV care for WLWH. To address these factors, management systems need to be able to support providers to make flexible decisions and facilitate better coordination and communication across clinics within facilities.
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Affiliation(s)
- M Colombini
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
| | - S H Mayhew
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - R Mutemwa
- Health Systems Strengthening & Primary Health Care, Centre for Infectious Disease Research Zambia (CIDRZ), Lusaka, Zambia
| | | | - C Ndwiga
- Reproductive Health Program, Population Council, Nairobi, Kenya
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Narasimhan M, Loutfy M, Khosla R, Bras M. Sexual and reproductive health and human rights of women living with HIV. J Int AIDS Soc 2015; 18:20834. [PMID: 28326129 PMCID: PMC4813610 DOI: 10.7448/ias.18.6.20834] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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Huchko MJ, Maloba M, Nakalembe M, Cohen CR. The time has come to make cervical cancer prevention an essential part of comprehensive sexual and reproductive health services for HIV-positive women in low-income countries. J Int AIDS Soc 2015; 18:20282. [PMID: 26643456 PMCID: PMC4672400 DOI: 10.7448/ias.18.6.20282] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 08/29/2015] [Accepted: 09/22/2015] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION HIV and cervical cancer are intersecting epidemics that disproportionately affect one of the most vulnerable populations in the world: women in low- and middle-income countries (LMICs). Historically, the disparity in cervical cancer risk for women in LMICs has been due to the lack of organized screening and prevention programmes. In recent years, this risk has been augmented by the severity of the HIV epidemic in LMICs. HIV-positive women are at increased risk for developing cervical precancer and cancer, and while the introduction of antiretroviral therapy has dramatically improved life expectancies among HIV-positive women it has not been shown to improve cancer-related outcomes. Therefore, an increasing number of HIV-positive women are living in LMICs with limited or no access to cervical cancer screening programmes. In this commentary, we describe the gaps in cervical cancer prevention, the state of evidence for integrating cervical cancer prevention into HIV programmes and future directions for programme implementation and research. DISCUSSION Despite the biologic, behavioural and demographic overlap between HIV and cervical cancer, cervical cancer prevention has for the most part been left out of sexual and reproductive health (SRH) services for HIV-positive women. Lower cost primary and secondary prevention strategies for cervical cancer are becoming more widely available in LMICs, with increasing evidence for their efficacy and cost-effectiveness. Going forward, cervical cancer prevention must be considered a part of the essential package of SRH services for HIV-positive women. Effective cervical cancer prevention programmes will require a coordinated response from international policymakers and funders, national governments and community leaders. Leveraging the improvements in healthcare infrastructure created by the response to the global HIV epidemic through integration of services may be an effective way to make an impact to prevent cervical cancer among HIV-positive women, but more work remains to determine optimal approaches. CONCLUSIONS Cervical cancer prevention is an essential part of comprehensive HIV care. In order to ensure maximal impact and cost-effectiveness, implementation strategies for screening programmes must be adapted and rigorously evaluated through a framework that includes equal participation with policymakers, programme planners and key stakeholders in the target communities.
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Affiliation(s)
- Megan J Huchko
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA, USA;
| | - May Maloba
- Family AIDS Care and Education Services, Kenya Medical Research Institute, Kisumu, Kenya
| | - Miriam Nakalembe
- Department of Obstetrics and Gynaecology and Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Craig R Cohen
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA, USA
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Human rights and the sexual and reproductive health of women living with HIV--a literature review. J Int AIDS Soc 2015; 18:20290. [PMID: 26643461 PMCID: PMC4672398 DOI: 10.7448/ias.18.6.20290] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 09/23/2015] [Accepted: 10/05/2015] [Indexed: 12/04/2022] Open
Abstract
Introduction Even as the number of women living with HIV around the globe continues to grow, realization of their sexual and reproductive health and human rights remains compromised. The objective of this study was to review the current state of knowledge on the sexual and reproductive health and human rights of women living with HIV to assess evidence and gaps. Methods Relevant databases were searched for peer-reviewed and grey literature. Search terms included a combination of MeSH terms and keywords representing women, HIV/AIDS, ART, human rights, sexual and reproductive health. We included both qualitative and quantitative literature published in English, French, or Spanish between July 2011 and December 2014. Results and discussion The search yielded 2228 peer-reviewed articles, of which 40 met the inclusion criteria in the final review. The grey literature search yielded 2186 documents of which seven met the inclusion criteria in the final review. Of the articles and documents reviewed, not a single peer-reviewed article described the explicit implementation of rights in programming, and only two documents from the grey literature did so. With one possible exception, no articles or documents were found which addressed rights comprehensively, or addressed the majority of relevant rights (i.e. equality; non-discrimination; participation; privacy and confidentiality; informed decision making; availability, accessibility, acceptability and quality (3AQ) of services individually or in their totality; and accountability). Additional findings indicate that the language of rights is used most often to describe the apparent neglect or violation of human rights and what does exist only addresses a few rights in the context of a few areas within sexual and reproductive health. Conclusions Findings from this review suggest the need to better integrate rights into interventions, particularly with attention to provider training, service delivery, raising awareness and capacity building among the community of women living with HIV. Further research is urgently needed to support the sexual and reproductive health and rights of women living with HIV, to identify what works and to inform future programming and policies to improve care, treatment and support for women living with HIV.
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Implementation and Operational Research: Effects of Antenatal Care and HIV Treatment Integration on Elements of the PMTCT Cascade: Results From the SHAIP Cluster-Randomized Controlled Trial in Kenya. J Acquir Immune Defic Syndr 2015; 69:e172-81. [PMID: 25967269 DOI: 10.1097/qai.0000000000000678] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Integrating antenatal care (ANC) and HIV care may improve uptake and retention in services along the prevention of mother-to-child transmission (PMTCT) cascade. This study aimed to determine whether integration of HIV services into ANC settings improves PMTCT service utilization outcomes. METHODS ANC clinics in rural Kenya were randomized to integrated (6 clinics, 569 women) or nonintegrated (6 clinics, 603 women) services. Intervention clinics provided all HIV services, including highly active antiretroviral therapy (HAART), whereas control clinics provided PMTCT services but referred women to HIV care clinics within the same facility. PMTCT utilization outcomes among HIV-infected women (maternal HIV care enrollment, HAART initiation, and 3-month infant HIV testing uptake) were compared using generalized estimating equations and Cox regression. RESULTS HIV care enrollment was higher in intervention compared with control clinics [69% versus 36%; odds ratio = 3.94, 95% confidence interval (CI): 1.14 to 13.63]. Median time to enrollment was significantly shorter among intervention arm women (0 versus 8 days, hazard ratio = 2.20, 95% CI: 1.62 to 3.01). Eligible women in the intervention arm were more likely to initiate HAART (40% versus 17%; odds ratio = 3.22, 95% CI: 1.81 to 5.72). Infant testing was more common in the intervention arm (25% versus 18%), however, not statistically different. No significant differences were detected in postnatal service uptake or maternal retention. CONCLUSIONS Service integration increased maternal HIV care enrollment and HAART uptake. However, PMTCT utilization outcomes were still suboptimal, and postnatal service utilization remained poor in both study arms. Further improvements in the PMTCT cascade will require additional research and interventions.
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Tran BX, Nguyen LH, Phan HTT, Nguyen LK, Latkin CA. Preference of methadone maintenance patients for the integrative and decentralized service delivery models in Vietnam. Harm Reduct J 2015; 12:29. [PMID: 26377824 PMCID: PMC4574353 DOI: 10.1186/s12954-015-0063-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2015] [Accepted: 08/23/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Integrating and decentralizing services are essential to increase the accessibility and provide comprehensive care for methadone patients. Moreover, they assure the sustainability of a HIV/AIDS prevention program by reducing the implementation cost. This study aimed to measure the preference of patients enrolling in a MMT program for integrated and decentralized MMT clinics and then further examine related factors. METHODS A cross-sectional study was conducted among 510 patients receiving methadone at 3 clinics in Hanoi. Structured questionnaires were used to collect data about the preference for integrated and decentralized MMT services. Covariates including socio-economic status; health-related quality of life (using EQ-5D-5 L instrument) and HIV status; history of drug use along with MMT treatment; and exposure to the discrimination within family and community were also investigated. Multivariate logistic regression with polynomial fractions was used to identify the determinants of preference for integrative and decentralized models. RESULTS Of 510 patients enrolled, 66.7 and 60.8 % preferred integrated and decentralized models, respectively. The main reason for preferring the integrative model was the convenience of use of various services (53.2 %), while more privacy (43.5 %) was the primary reason to select stand-alone model. People preferred the decentralized model primarily because of travel cost reduction (95.0 %), while the main reason for not selecting the model was increased privacy (7.7 %). After adjusting for covariates, factors influencing the preference for integrative model were poor socioeconomic status, anxiety/depression, history of drug rehabilitation, and ever disclosed health status; while exposure to community discrimination inversely associated with this preference. In addition, people who were self-employed, had a longer duration of MMT, and use current MMT with comprehensive HIV services were less likely to select decentralized model. CONCLUSION In conclusion, the study confirmed the high preference of MMT patients for the integrative and decentralized MMT service delivery models. The convenience of healthcare services utilization and reduction of geographical barriers were the main reasons to use those models within drug use populations in Vietnam. Countering community stigma and encouraging communication between patients and their societies needed to be considered when implementing those models.
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Affiliation(s)
- Bach Xuan Tran
- Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam. .,Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Long Hoang Nguyen
- Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam.,School of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
| | | | | | - Carl A Latkin
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Meehan SA, Leon N, Naidoo P, Jennings K, Burger R, Beyers N. Availability and acceptability of HIV counselling and testing services. A qualitative study comparing clients' experiences of accessing HIV testing at public sector primary health care facilities or non-governmental mobile services in Cape Town, South Africa. BMC Public Health 2015; 15:845. [PMID: 26329262 PMCID: PMC4557635 DOI: 10.1186/s12889-015-2173-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 08/21/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The South African government is striving for universal access to HIV counselling and testing (HCT), a fundamental component of HIV care and prevention. In the Cape Town district, Western Cape Province of South Africa, HCT is provided free of charge at publically funded primary health care (PHC) facilities and through non-governmental organizations (NGOs). This study investigated the availability and accessibility of HCT services; comparing health seeking behaviour and client experiences of HCT across public PHC facilities (fixed sites) and NGO mobile services. METHODS This qualitative study used semi-structured interviews. Systematic sampling was used to select 16 participants who accessed HCT in either a PHC facility (8) or a NGO mobile service (8). Interviews, conducted between March and June 2011, were digitally recorded, transcribed and where required, translated into English. Constant comparative and thematic analysis was used to identify common and divergent responses and themes in relation to the key questions (reasons for testing, choice of service provider and experience of HCT). RESULTS The sample consisted of 12 females and 4 males with an age range of 19-60 years (median age 28 years). Motivations for accessing health facilities and NGO services were similar; opportunity to test, being affected by HIV and a perceived personal risk for contracting HIV. Participants chose a particular service provider based on accessibility, familiarity with and acceptability of that service. Experiences of both services were largely positive, though instances of poor staff attitude and long waiting times were reported at PHC facilities. Those attending NGO services reported shorter waiting times and overall positive testing experiences. Concerns about lack of adequate privacy and associated stigma were expressed about both services. CONCLUSIONS Realised access to HCT is dependent on availability and acceptability of HCT services. Those who utilised either a NGO mobile service or a public PHC facility perceived both service types as available and acceptable. Mobile NGO services provided an accessible opportunity for those who would otherwise not have tested at that time. Policy makers should consider the perceptions and experiences of those accessing HCT services when increasing access to HCT.
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Affiliation(s)
- Sue-Ann Meehan
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Ave, Parow, Cape Town, South Africa.
| | - Natalie Leon
- Health Research Unit, South African Medical Research Council, Francie van Zijl Ave, Parow, Cape Town, South Africa.
| | - Pren Naidoo
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Ave, Parow, Cape Town, South Africa.
| | - Karen Jennings
- City of Cape Town Health Directorate, Cape Town, South Africa.
| | - Ronelle Burger
- Department of Economics, Stellenbosch University, Stellenbosch, Cape Town, South Africa.
| | - Nulda Beyers
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Ave, Parow, Cape Town, South Africa.
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Church K, Wringe A, Lewin S, Ploubidis GB, Fakudze P, Mayhew SH. Exploring the Feasibility of Service Integration in a Low-Income Setting: A Mixed Methods Investigation into Different Models of Reproductive Health and HIV Care in Swaziland. PLoS One 2015; 10:e0126144. [PMID: 25978632 PMCID: PMC4433110 DOI: 10.1371/journal.pone.0126144] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 03/30/2015] [Indexed: 11/23/2022] Open
Abstract
Integrating reproductive health (RH) with HIV care is a policy priority in high HIV prevalence settings, despite doubts surrounding its feasibility and varying evidence of effects on health outcomes. The process and outcomes of integrated RH-HIV care were investigated in Swaziland, through a comparative case study of four service models, ranging from fully integrated to fully stand-alone HIV services, selected purposively within one town. A client exit survey (n=602) measured integrated care received and unmet family planning (FP) needs. Descriptive statistics were used to assess the degree of integration per clinic and client demand for services. Logistic regression modelling was used to test the hypothesis that clients at more integrated sites had lower unmet FP needs than clients in a stand-alone site. Qualitative methods included in-depth interviews with clients and providers to explore contextual factors influencing the feasibility of integrated RH-HIV care delivery; data were analysed thematically, combining deductive and inductive approaches. Results demonstrated that clinic models were not as integrated in practice as had been claimed. Fragmentation of HIV care was common. Services accessed per provider were no higher at the more integrated clinics compared to stand-alone models (p>0.05), despite reported demand. While women at more integrated sites received more FP and pregnancy counselling than stand-alone models, they received condoms (a method of choice) less often, and there was no statistical evidence of difference in unmet FP needs by model of care. Multiple contextual factors influenced integration practices, including provider de-skilling within sub-specialist roles; norms of task-oriented routinised HIV care; perceptions of heavy client loads; imbalanced client-provider interactions hindering articulation of RH needs; and provider motivation challenges. Thus, despite institutional support, factors related to the social context of care inhibited provision of fully integrated RH-HIV services in these clinics. Programmes should move beyond simplistic training and equipment provision if integrated care interventions are to be sustained.
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Affiliation(s)
- Kathryn Church
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
- * E-mail:
| | - Alison Wringe
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Simon Lewin
- Global Health Unit, Norwegian Knowledge Centre for the Health Services, Oslo, Norway
- Health Systems Research Unit, Medical Research Council of South Africa, Cape Town, South Africa
| | - George B. Ploubidis
- Centre for Longitudinal Studies, Department of Quantitative Social Science, Institute of Education, University of London, London, United Kingdom
| | | | | | - Susannah H. Mayhew
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Michaels-Igbokwe C, Lagarde M, Cairns J, Terris-Prestholt F. Designing a package of sexual and reproductive health and HIV outreach services to meet the heterogeneous preferences of young people in Malawi: results from a discrete choice experiment. HEALTH ECONOMICS REVIEW 2015; 5:9. [PMID: 25984434 PMCID: PMC4424232 DOI: 10.1186/s13561-015-0046-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 03/06/2015] [Indexed: 05/05/2023]
Abstract
BACKGROUND This article examines young people's preferences for integrated family planning (FP) and HIV services in rural Malawi. Different hypothetical configurations for outreach services are presented using a Discrete Choice Experiment (DCE). Responses are analysed using Random Parameters Logit and Generalised Mixed Logit (GMXL) models in preference space and a GMXL model parameterised in willingness-to-pay space. Simulations are used to estimate the proportion of respondents expected to choose different service packages as elements are varied individually and in combination. RESULTS Responses were collected from 537 young people aged 15-24. Results show that when considering attending an outreach service to access family planning young people value confidentiality and the availability of HIV services including HIV counselling and testing (HCT) and HIV treatment, though significant observable and unobservable heterogeneity is present. Female respondents and those aged 20-24 were less concerned with service confidentiality compared to male respondents and those aged 15-19; respondents who were in a relationship at the time of the survey valued confidentiality more than those who reported being single. The addition of sports and recreation for young people may also be an attractive feature of a youth-friendly service; however, preferences for this attribute vary according to respondent gender. Results of the simulation modelling indicate that the most preferred service package is one that offers confidential services, both HCT and HIV treatment and sports for youth, with up to 32% of respondents expected to choose this service over a service where clients may have concerns over confidentiality, only HCT is available and there are no additional activities for young people. Estimates of willingness-to-pay for service attributes indicate that respondents were willing to pay up to USD$1.76 for confidentiality, USD$0.65 for a service offering both HCT and HIV treatment and USD$0.26 for a service including sports for youth. CONCLUSIONS Young people were able to complete a complex DCE and appeared to trade between the different characteristics used to describe the outreach services. These findings may offer important insight to policy makers designing youth friendly SRH outreach services and providers aiming to improve the acceptability and uptake of FP services.
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Affiliation(s)
- Christine Michaels-Igbokwe
- London School of Hygiene and Tropical Medicine, Faculty of Public Health and Policy, Department of Global Health and Development, 15-17 Tavistock Place, London, WC1H 9SH UK
| | - Mylene Lagarde
- London School of Hygiene and Tropical Medicine, Faculty of Public Health and Policy, Department of Global Health and Development, 15-17 Tavistock Place, London, WC1H 9SH UK
- London School of Hygiene and Tropical Medicine, Faculty of Public Health and Policy, Health Services Research and Policy, 15-17 Tavistock Place, London, WC1H 9SH UK
| | - John Cairns
- London School of Hygiene and Tropical Medicine, Faculty of Public Health and Policy, Health Services Research and Policy, 15-17 Tavistock Place, London, WC1H 9SH UK
| | | | - Fern Terris-Prestholt
- London School of Hygiene and Tropical Medicine, Faculty of Public Health and Policy, Department of Global Health and Development, 15-17 Tavistock Place, London, WC1H 9SH UK
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Hope R, Kendall T, Langer A, Bärnighausen T. Health systems integration of sexual and reproductive health and HIV services in sub-Saharan Africa: a scoping study. J Acquir Immune Defic Syndr 2014; 67 Suppl 4:S259-70. [PMID: 25436826 PMCID: PMC4251913 DOI: 10.1097/qai.0000000000000381] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Both sexual and reproductive health (SRH) services and HIV programs in sub-Saharan Africa are typically delivered vertically, operating parallel to national health systems. The objective of this study was to map the evidence on national and international strategies for integration of SRH and HIV services in sub-Saharan Africa and to develop a research agenda for future health systems integration. METHODS We examined the literature on national and international strategies to integrate SRH and HIV services using a scoping study methodology. Current policy frameworks, national HIV strategies and research, and gray literature on integration were mapped. Five countries in sub-Saharan Africa with experience of integrating SRH and HIV services were purposively sampled for detailed thematic analysis, according to the health systems functions of governance, policy and planning, financing, health workforce organization, service organization, and monitoring and evaluation. RESULTS The major international health policies and donor guidance now support integration. Most integration research has focused on linkages of SRH and HIV front-line services. Yet, the common problems with implementation are related to delayed or incomplete integration of higher level health systems functions: lack of coordinated leadership and unified national integration policies; separate financing streams for SRH and HIV services and inadequate health worker training, supervision and retention. CONCLUSIONS Rigorous health systems research on the integration of SRH and HIV services is urgently needed. Priority research areas include integration impact, performance, and economic evaluation to inform the planning, financing, and coordination of integrated service delivery.
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Affiliation(s)
- Rebecca Hope
- Women and Health Initiative, Department of Global Health and Population, Harvard School of Public Health, Harvard University, Boston, MA
- Department of Global Health and Population, Harvard School of Public Health, Harvard University, Boston, MA; and
| | - Tamil Kendall
- Women and Health Initiative, Department of Global Health and Population, Harvard School of Public Health, Harvard University, Boston, MA
- Department of Global Health and Population, Harvard School of Public Health, Harvard University, Boston, MA; and
| | - Ana Langer
- Women and Health Initiative, Department of Global Health and Population, Harvard School of Public Health, Harvard University, Boston, MA
- Department of Global Health and Population, Harvard School of Public Health, Harvard University, Boston, MA; and
| | - Till Bärnighausen
- Department of Global Health and Population, Harvard School of Public Health, Harvard University, Boston, MA; and
- Programme on Health Systems and Impact Evaluation, Wellcome Trust Africa Centre for Health and Population Studies, Mtubatuba, South Africa
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Kufa T, Hippner P, Charalambous S, Kielmann K, Vassall A, Churchyard GJ, Grant AD, Fielding KL. A cluster randomised trial to evaluate the effect of optimising TB/HIV integration on patient level outcomes: the "merge" trial protocol. Contemp Clin Trials 2014; 39:280-7. [PMID: 25315287 DOI: 10.1016/j.cct.2014.10.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Revised: 09/30/2014] [Accepted: 10/04/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION We describe the design of the MERGE trial, a cluster randomised trial, to evaluate the effect of an intervention to optimise TB/HIV service integration on mortality, morbidity and retention in care among newly-diagnosed HIV-positive patients and newly-diagnosed TB patients. DESIGN Eighteen primary care clinics were randomised to either intervention or standard of care arms. The intervention comprised activities designed to optimise TB and HIV service integration and supported by two new staff cadres-a TB/HIV integration officer and a TB screening officer-for 24 months. A process evaluation to understand how the intervention was perceived and implemented at the clinics was conducted as part of the trial. Newly-diagnosed HIV-positive patients and newly-diagnosed TB patients were enrolled into the study and followed up through telephonic interviews and case note abstractions at six monthly intervals for up to 18 months in order to measure outcomes. The primary outcomes were incidence of hospitalisations or death among newly diagnosed TB patients, incidence of hospitalisation or death among newly diagnosed HIV-positive patients and retention in care among HIV-positive TB patients. Secondary outcomes of the study included measures of cost-effectiveness. DISCUSSION Methodological challenges of the trial such as implementation of a complex multi-faceted health systems intervention, the measurement of integration at baseline and at the end of the study and an evolving standard of care with respect to TB and HIV are discussed. The trial will contribute to understanding whether TB/HIV service integration affects patient outcomes.
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Affiliation(s)
- T Kufa
- The Aurum Institute, Johannesburg, South Africa; The School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
| | - P Hippner
- The Aurum Institute, Johannesburg, South Africa
| | - S Charalambous
- The Aurum Institute, Johannesburg, South Africa; The School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - K Kielmann
- Institute for International Health and Development, Queen Margaret University, Edinburgh, Scotland, United Kingdom
| | - A Vassall
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom
| | - G J Churchyard
- The Aurum Institute, Johannesburg, South Africa; The School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; Department of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom
| | - A D Grant
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom
| | - K L Fielding
- Department of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom
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Colombini M, Mutemwa R, Kivunaga J, Stackpool Moore L, Mayhew SH. Experiences of stigma among women living with HIV attending sexual and reproductive health services in Kenya: a qualitative study. BMC Health Serv Res 2014; 14:412. [PMID: 25239309 PMCID: PMC4261560 DOI: 10.1186/1472-6963-14-412] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Accepted: 09/15/2014] [Indexed: 11/10/2022] Open
Abstract
Background Researchers have widely documented the pervasiveness of HIV stigma and discrimination, and its impact on people living with HIV. Only a few studies, however, have analysed the perceptions of women living with HIV accessing sexual and reproductive health (SRH) services. This study explores the experiences of stigma of HIV-positive clients attending family planning and post-natal services and implications for service use and antiretroviral therapy (ART) adherence. Our aim was to gain a better understanding of the impact of various dimensions of stigma on service use and ART adherence among HIV clients in order to inform the response of integrated SRH services. Methods In-depth interviews were conducted with 48 women living with HIV attending SRH services in two districts in Kenya. Data were coded using Nvivo 8 and analysed using a thematic analysis approach. Results Findings show that many women living with HIV report high levels of anticipated stigma, resulting in a desire to hide their status from family and friends for fear of being discriminated against. Many women feared desertion following disclosure of their positive status to partners. Consequently some women preferred to hide their status and adhere to HIV treatment in secret. However, the majority of study participants attending postnatal care (PNC) services also revealed that anticipated stigma does not adversely affect their HIV drug uptake and ART adherence, as their drive to live outweighs their fear of stigma. Our findings also seem to suggest a preference for specialist HIV services by some family planning (FP) clients because of better confidentiality and reduced opportunities for unwanted disclosure that could lead to stigma. Conclusions The findings highlight that anticipated stigma leading to low disclosure is widespread and sometimes reinforced by health providers’ actions and facility layout (contributing to enacted stigma). However, the motivation to stay healthy and look after the children appears in many cases to override fears of stigma related to ART adherence in our client-based sample.
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Hyle EP, Naidoo K, Su AE, El-Sadr WM, Freedberg KA. HIV, tuberculosis, and noncommunicable diseases: what is known about the costs, effects, and cost-effectiveness of integrated care? J Acquir Immune Defic Syndr 2014; 67 Suppl 1:S87-95. [PMID: 25117965 PMCID: PMC4147396 DOI: 10.1097/qai.0000000000000254] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Unprecedented investments in health systems in low- and middle-income countries (LMICs) have resulted in more than 8 million individuals on antiretroviral therapy. Such individuals experience dramatically increased survival but are increasingly at risk of developing common noncommunicable diseases (NCDs). Integrating clinical care for HIV, other infectious diseases, and NCDs could make health services more effective and provide greater value. Cost-effectiveness analysis is a method to evaluate the clinical benefits and costs associated with different health care interventions and offers guidance for prioritization of investments and scale-up, especially as resources are increasingly constrained. We first examine tuberculosis and HIV as 1 example of integrated care already successfully implemented in several LMICs; we then review the published literature regarding cervical cancer and depression as 2 examples of NCDs for which integrating care with HIV services could offer excellent value. Direct evidence of the benefits of integrated services generally remains scarce; however, data suggest that improved effectiveness and reduced costs may be attained by integrating additional services with existing HIV clinical care. Further investigation into clinical outcomes and costs of care for NCDs among people living with HIV in LMICs will help to prioritize specific health care services by contributing to an understanding of the affordability and implementation of an integrated approach.
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Affiliation(s)
- Emily P. Hyle
- Harvard Medical School, Boston, MA
- The Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA
- Division of General Medicine, Massachusetts General Hospital, Boston, MA
| | - Kogieleum Naidoo
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, South Africa
| | - Amanda E. Su
- The Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
- Division of General Medicine, Massachusetts General Hospital, Boston, MA
| | - Wafaa M. El-Sadr
- ICAP at Columbia University Department of Epidemiology, Mailman School of Public Health, New York, NY
| | - Kenneth A. Freedberg
- Harvard Medical School, Boston, MA
- The Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA
- Division of General Medicine, Massachusetts General Hospital, Boston, MA
- Center for AIDS Research (CFAR), Harvard University, Boston, MA
- Department of Epidemiology, Boston University, Boston MA
- Department of Health Policy and Management, Harvard School of Public Health, Boston, MA
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Church K, Wringe A, Fakudze P, Kikuvi J, Nhlabatsi Z, Masuku R, Mayhew SH. Reliance on condoms for contraceptive protection among HIV care and treatment clients: a mixed methods study on contraceptive choice and motivation within a generalised epidemic. Sex Transm Infect 2014; 90:394-400. [PMID: 24695990 PMCID: PMC4112496 DOI: 10.1136/sextrans-2013-051339] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Objectives To (i) describe the contraceptive practices of HIV care and treatment (HCTx) clients in Manzini, Swaziland, including their unmet needs for family planning (FP), and compare these with population-level estimates; and (ii) qualitatively explore the causal factors influencing contraceptive choice and use. Methods Mixed quantitative and qualitative methods were used. A cross-sectional survey conducted among HCTx clients (N=611) investigated FP and condom use patterns. Using descriptive statistics, findings were compared with population-level estimates derived from Swaziland Demographic and Health Survey data, weighted for clustering. In-depth interviews were conducted with HCTx providers (n=16) and clients (n=22) and analysed thematically. Results 64% of HCTx clients reported current contraceptive use; most relied on condoms alone, few practiced dual method use. Rates of condom use for FP among female HCTx clients (77%, 95% CI 71% to 82%) were higher than population-level estimates in the study region (50% HIV-positive, 95% CI 43% to 57%; 37% HIV-negative, 95% CI 31% to 43%); rates of unmet FP needs were similar when condom use consistency was accounted for (32% HCTx, 95% CI 26% to 37%; vs 35% HIV-positive, 95% CI 28% to 43%; 29% HIV-negative, 95% CI 24% to 35%). Qualitative analysis identified motivational factors influencing FP choice: fears of reinfection; a programmatic focus on condoms for people living with HIV; changing sexual behaviours before and after antiretroviral therapy (ART) initiation; failure to disclose to partners; and contraceptive side effect fears. Conclusions Fears of reinfection prevailed over consideration of pregnancy risk. Given current evidence on reinfection, HCTx services must move beyond a narrow focus on condom promotion, particularly for those in seroconcordant relationships, and consider diverse strategies to meet reproductive needs.
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Affiliation(s)
- Kathryn Church
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Alison Wringe
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Joshua Kikuvi
- London School of Hygiene & Tropical Medicine, Manzini, Swaziland
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- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK Family Life Association of Swaziland, Manzini, Swaziland London School of Hygiene & Tropical Medicine, Manzini, Swaziland Family Life Association of Swaziland, Manzini, Swaziland UNFPA, Mbabane, Swaziland Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Susannah H Mayhew
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
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Bofill LM, Lopez M, Dorigo A, Bordato A, Lucas M, Cabanillas GF, Sued O, Cahn P, Cassetti I, Weiss S, Jones D. Patient-provider perceptions on engagement in HIV care in Argentina. AIDS Care 2013; 26:602-7. [PMID: 24138788 DOI: 10.1080/09540121.2013.844767] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Approximately 30% of patients participating in the national antiretroviral therapy (ART) program in Argentina fail to achieve an undetectable viral load, and approximately 25% are not retained in care. This qualitative study was designed to explore and identify factors associated with engagement and retention in public and private health care in Buenos Aires, Argentina. Qualitative data from key informants (n = 12) and focus groups (n = 4 groups) of patients and providers from private and public HIV treatment facilities were recorded and transcribed. Predetermined and arising themes related to adherence, engagement, and retention in care were coded and analyzed using qualitative data analysis software. Reasons identified for patients' lack of adherence or engagement in care differed between patients and providers, and patients attributed limitations to low self-efficacy, fear and concerns about HIV, and lack of provider involvement in treatment. In contrast, providers viewed themselves as decision-makers in patient care and patients as responsible for their own nonadherence due to lack of commitment to their own health or due to medication side effects. Patients reported health care system limitations and HIV concerns contributed to a lack of engagement, and providers identified limited HIV literacy and stigma as additional problems. Both agreed that chronic illness and substance addiction impacted adherence and retention, and agreed on the importance of trust, honesty, and communication in the patient-provider relationship. Results support the incorporation of system-, provider-, and patient-focused components into interventions to facilitate patient engagement, adherence, and retention in public and private settings in Argentina.
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Affiliation(s)
- Lina Margarita Bofill
- a Department of Psychiatry and Behavioral Sciences , University of Miami, Miller School of Medicine , Miami , FL , USA
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An analysis of the implementation of PEPFAR's anti-prostitution pledge and its implications for successful HIV prevention among organizations working with sex workers. J Int AIDS Soc 2013; 16:17354. [PMID: 23541090 PMCID: PMC3612273 DOI: 10.7448/ias.16.1.17354] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Accepted: 02/13/2013] [Indexed: 12/02/2022] Open
Abstract
Introduction Since 2003, US government funding to address the HIV and AIDS pandemic has been subject to an anti-prostitution clause. Simultaneously, the efficacy of some HIV prevention efforts for sex work in areas receiving US government funding has diminished. This article seeks to explain why. Methods This analysis utilizes a case story approach to build a narrative of defining features of organizations in receipt of funding from the President's Emergency Plan for AIDS Relief (PEPFAR) and other US funding sources. For this analysis, multiple cases were compiled within a single narrative. This helps show restrictions imposed by the anti-prostitution clause, any lack of clarity of guidelines for implementation and ways some agencies, decision-making personnel, and staff on the ground contend with these restrictions. Results Responses to PEPFAR's anti-prostitution clause vary widely and have varied over time. Organizational responses have included ending services for sex workers, gradual phase-out of services, cessation of seeking US government HIV funds and increasing isolation of sex workers. Guidance issued in 2010 did not clarify what was permitted. Implementation and enforcement has been dependent in part on the interpretations of this policy by individuals, including US government representatives and organizational staff. Conclusions Different interpretations of the anti-prostitution clause have led to variations in programming, affecting the effectiveness of work with sex workers. The case story approach proved ideal for working with information like this that is highly sensitive and vulnerable to breach of anonymity because the method limits the potential to betray confidences and sources, and limits the potential to jeopardize funding and thereby jeopardize programming. This method enabled us to use specific examples without jeopardizing the organizations and individuals involved while demonstrating unintended consequences of PEPFAR's anti-prostitution pledge in its provision of services to sex workers and clients.
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