Social Support is Key to Retention in Care during Covid-19 Pandemic among Older People with HIV and Substance Use Disorders in Ukraine

Older people with human immunodeficiency virus - HIV (OPWH) defined as ≥50 years old account for a growing proportion of newly diagnosed infections in Ukraine (16% in 2018), but the prevalence of substance use disorder among OPWH in Ukraine remains unknown. Ukraine responded to the Covid-19 pandemic with a comprehensive lockdown in late March 2020. Objectives: We conducted a phone survey among 123 OPWH with substance use disorders (SUD) in Kyiv in May 2020 to learn if these older adults may continue HIV and SUD therapy while coping with the Covid-19 pandemic. Results: Data from the survey demonstrated that while OPWH with SUD maintained HIV and SUD therapy throughout Covid-19 lockdown, social support is critical to avoiding treatment interruption for OPWH with SUD. Conclusions/Importance: During reopening, reduction of support may lead to OPWH feeling even more isolated. Post-Covid-19 pharmacological approaches to SUD treatment without social support are like vehicles without gas. The research agenda for OPWH patients with SUD going forward must include determining the type of telehealth support that will be optimally effective to retain OPWH including people who inject drugs (PWID), provision of support by lay health workers, and cost-effectiveness of such interventions. The lessons learned may be relevant to other countries as well.

Experience of implementing new mental health indicators within information systems in six low- and middle-income countries

BACKGROUND

Successful scale-up of integrated primary mental healthcare requires routine monitoring of key programme performance indicators. A consensus set of mental health indicators has been proposed but evidence on their use in routine settings is lacking.

AIMS

To assess the acceptability, feasibility, perceived costs and sustainability of implementing indicators relating to integrated mental health service coverage in six South Asian (India, Nepal) and sub-Saharan African countries (Ethiopia, Nigeria, South Africa, Uganda).

METHOD

A qualitative study using semi-structured key informant interviews (n = 128) was conducted. The 'Performance of Routine Information Systems' framework served as the basis for a coding framework covering three main categories related to the performance of new tools introduced to collect data on mental health indicators: (1) technical; (2) organisation; and (3) behavioural determinants.

RESULTS

Most mental health indicators were deemed relevant and potentially useful for improving care, and therefore acceptable to end users. Exceptions were indicators on functionality, cost and severity. The simplicity of the data-capturing formats contributed to the feasibility of using forms to generate data on mental health indicators. Health workers reported increasing confidence in their capacity to record the mental health data and minimal additional cost to initiate mental health reporting. However, overstretched primary care staff and the time-consuming reporting process affected perceived sustainability.

CONCLUSIONS

Use of the newly developed, contextually appropriate mental health indicators in health facilities providing primary care services was seen largely to be feasible in the six Emerald countries, mainly because of the simplicity of the forms and continued support in the design and implementation stage. However, approaches to implementation of new forms generating data on mental health indicators need to be customised to the specific health system context of different countries. Further work is needed to identify ways to utilise mental health data to monitor and improve the quality of mental health services.

DECLARATION OF INTEREST

None.

Evaluation of performance and perceived utility of mental healthcare indicators in routine health information systems in five low- and middle-income countries

BACKGROUND

In most low- and middle-income countries (LMIC), routine mental health information is unavailable or unreliable, making monitoring of mental healthcare coverage difficult. This study aims to evaluate a new set of mental health indicators introduced in primary healthcare settings in five LMIC.

METHOD

A survey was conducted among primary healthcare workers (n = 272) to assess the acceptability and feasibility of eight new indicators monitoring mental healthcare needs, utilisation, quality and payments. Also, primary health facility case records (n = 583) were reviewed by trained research assistants to assess the level of completion (yes/no) for each of the indicators and subsequently the level of correctness of completion (correct/incorrect - with incorrect defined as illogical, missing or illegible information) of the indicators used by health workers. Assessments were conducted within 1 month of the introduction of the indicators, as well as 6-9 months afterwards.

RESULTS

Across both time points and across all indicators, 78% of the measurements of indicators were complete. Among the best performing indicators (diagnosis, severity and treatment), this was significantly higher. With regards to correctness, 87% of all completed indicators were correctly completed. There was a trend towards improvement over time. Health workers' perceptions on feasibility and utility, across sites and over time, indicated a positive attitude in 81% of all measurements.

CONCLUSION

This study demonstrates high levels of performance and perceived utility for a set of indicators that could ultimately be used to monitor coverage of mental healthcare in primary healthcare settings in LMIC. We recommend that these indicators are incorporated into existing health information systems and adopted within the World Health Organization Mental Health Gap Action Programme implementation strategy.

DECLARATION OF INTEREST

None.

Effectiveness of psychological treatments for depression and alcohol use disorder delivered by community-based counsellors: two pragmatic randomised controlled trials within primary healthcare in Nepal

BACKGROUND

Evidence shows benefits of psychological treatments in low-resource countries, yet few government health systems include psychological services.AimEvaluating the clinical value of adding psychological treatments, delivered by community-based counsellors, to primary care-based mental health services for depression and alcohol use disorder (AUD), as recommended by the Mental Health Gap Action Programme (mhGAP).

METHOD

Two randomised controlled trials, separately for depression and AUD, were carried out. Participants were randomly allocated (1:1) to mental healthcare delivered by mhGAP-trained primary care workers (psychoeducation and psychotropic medicines when indicated), or the same services plus individual psychological treatments (Healthy Activity Program for depression and Counselling for Alcohol Problems). Primary outcomes were symptom severity, measured using the Patient Health Questionnaire - 9 item (PHQ-9) for depression and the Alcohol Use Disorder Identification Test for AUD, and functional impairment, measured using the World Health Organization Disability Assessment Schedule (WHODAS), at 12 months post-enrolment.

RESULTS

Participants with depression in the intervention arm (n = 60) had greater reduction in PHQ-9 and WHODAS scores compared with participants in the control (n = 60) (PHQ-9: M = -5.90, 95% CI -7.55 to -4.25, β = -3.68, 95% CI -5.68 to -1.67, P < 0.001, Cohen's d = 0.66; WHODAS: M = -12.21, 95% CI -19.58 to -4.84, β = -10.74, 95% CI -19.96 to -1.53, P= 0.022, Cohen's d = 0.42). For the AUD trial, no significant effect was found when comparing control (n = 80) and intervention participants (n = 82).

CONCLUSION

Adding a psychological treatment delivered by community-based counsellors increases treatment effects for depression compared with only mhGAP-based services by primary health workers 12 months post-treatment.Declaration of interestNone.

Early childhood development: impact of national human development, family poverty, parenting practices and access to early childhood education

BACKGROUND

This study was to describe and quantify the relationships among family poverty, parents' caregiving practices, access to education and the development of children living in low- and middle-income countries (LAMIC).

METHODS

We conducted a secondary analysis of data collected in UNICEF's Multiple Indicator Cluster Surveys (MICS). Early childhood development was assessed in four domains: language-cognitive, physical, socio-emotional and approaches to learning. Countries were classified into three groups on the basis of the Human Development Index (HDI).

RESULTS

Overall, data from 97 731 children aged 36 to 59 months from 35 LAMIC were included in the after analyses. The mean child development scale score was 4.93 out of a maximum score of 10 (95%CI 4.90 to 4.97) in low-HDI countries and 7.08 (95%CI 7.05 to 7.12) in high-HDI countries. Family poverty was associated with lower child development scores in all countries. The total indirect effect of family poverty on child development score via attending early childhood education, care for the child at home and use of harsh punishments at home was -0.13 SD (77.8% of the total effect) in low-HDI countries, -0.09 SD (23.8% of the total effect) in medium-HDI countries and -0.02 SD (6.9% of the total effect) in high-HDI countries.

CONCLUSIONS

Children in the most disadvantaged position in their societies and children living in low-HDI countries are at the greatest risk of failing to reach their developmental potential. Optimizing care for child development at home is essential to reduce the adverse effects of poverty on children's early development and subsequent life.

Clinical practice patterns on the use of magnesium sulphate for treatment of pre-eclampsia and eclampsia: a multi-country survey

Objective

To characterise the current clinical practice patterns regarding the use of magnesium sulphate (MgSO₄) for eclampsia prevention and treatment in a multi‐country network of health facilities and compare with international recommendations.

Design

Cross‐sectional survey.

Setting

A total of 147 health facilities in 15 countries across Africa, Latin America and Asia.

Population

Heads of obstetric departments or maternity units.

Methods

Anonymous online and paper‐based survey conducted in 2015.

Main outcome measures

Availability and use of MgSO₄; availability of a formal clinical protocol for MgSO₄ administration; and MgSO₄ dosing regimens for eclampsia prevention and treatment.

Results

Magnesium sulphate and a formal protocol for its administration were reported to be always available in 87.4% and 86.4% of all facilities, respectively. MgSO₄ was used for the treatment of mild pre‐eclampsia, severe pre‐eclampsia and eclampsia in 24.3%, 93.5% and 96.4% of all facilities, respectively. Regarding the treatment of severe pre‐eclampsia, 26.4% and 7.0% of all facilities reported using dosing regimens that were consistent with Zuspan and Pritchard regimens, respectively. Across regions, intramuscular maintenance regimens were more commonly used in the African region (45.7%) than in the Latin American (3.0%) and Asian (22.9%) regions, whereas intravenous maintenance regimens were more often used in the Latin American (94.0%) and Asian (60.0%) regions than in the African region (21.7%). Similar patterns were found for the treatment of eclampsia across regions.

Conclusions

The reported clinical use of MgSO₄ for eclampsia prevention and treatment varied widely, and was largely inconsistent with current international recommendations.

Tweetable abstract

MgSO₄ regimens for eclampsia prevention and treatment in many hospitals are inconsistent with international recommendations.

MgSO₄ regimens for eclampsia prevention and treatment in many hospitals are inconsistent with international recommendations.

Morbidity and Mortality Among Community-Based People Who Inject Drugs With a High Hepatitis C and Human Immunodeficiency Virus Burden in Chennai, India

We observed high mortality and liver disease progression associated primarily driven by untreated HIV and chronic hepatitis C as well as alcohol use in a cohort of PWID in India. Interventions to reduce HIV and HCV burden are needed.

Background. There are limited data on clinical outcomes of hepatitis C virus (HCV) infection from low- and middle-income countries. We characterize mortality and liver disease progression in a cohort of people who inject drugs (PWID) with high HCV burden.

Methods. In a cohort of PWID in Chennai, India, 851 persons were observed semiannually. Information on death was obtained through verbal autopsy and liver disease progression, which was defined as an incident liver stiffness measurement of ≥12.3 kPa if it was <12.3 at baseline. Poisson and Cox regression were used to identify factors associated with mortality and disease progression, respectively.

Results. At baseline, 36.9% of cases were infected with HCV, 16.7% were infected with human immunodeficiency virus (HIV), 71.6% had no or mild stiffness, 14.9% had moderate stiffness, and 13.5% had severe stiffness or cirrhosis. Mortality was significantly higher among those with moderate (mortality rate ratio [MRR] = 2.31) and severe stiffness (MRR = 4.86) at baseline, those with ongoing substance use, those who were HIV monoinfected and not on antiretroviral therapy (ART) (MRR = 6.59), and those who were HIV/HCV coinfected regardless of ART status (MRR for no ART = 5.34; MRR for ART = 4.51). Of those with no or mild stiffness, 25.9% and 6.4% had evidence of progression to moderate and severe stiffness or cirrhosis, respectively; 38.3% of those with moderate stiffness had evidence of progression to severe stiffness or cirrhosis. Factors associated with progression included age, alcohol use, body mass index, and chronic HCV infection.

Conclusions. We observed significant morbidity and mortality primarily driven by untreated HIV, HIV/HCV coinfection, and alcohol use. Even with improved access to HIV treatment, in the absence of HCV treatment, outcomes are unlikely to improve for HIV/HCV-coinfected persons.