Articles tagged as "Health care delivery"

Cash incentivises short-term retention in PMTCT services in Kinshasa

Conditional cash transfers and uptake of and retention in prevention of mother-to-child HIV transmission care: a randomised controlled trial.

Yotebieng M, Thirumurthy H, Moracco KE, Kawende B, Chalachala JL, Wenzi LK, Ravelomanana NL, Edmonds A, Thompson D, Okitolonda EW, Behets F. Lancet HIV. 2016 Feb;3(2):e85-93. doi: 10.1016/S2352-3018(15)00247-7.

Background: Novel strategies are needed to increase retention in and uptake of prevention of mother-to-child HIV transmission (PMTCT) services in sub-Saharan Africa. We aimed to determine whether small, increasing cash payments, which were conditional on attendance at scheduled clinic visits and receipt of proposed services can increase the proportions of HIV-infected pregnant women who accept available PMTCT services and remain in care.

Methods: In this randomised controlled trial, we recruited newly diagnosed HIV-infected women, who were 32 or less weeks pregnant, from 89 antenatal care clinics in Kinshasa, Democratic Republic of Congo, and randomly assigned (1:1) them to either the intervention group or the control group using computer-based randomisation with varying block sizes of four, six, and eight. The intervention group received compensation on the condition that they attended scheduled clinic visits and accepted offered PMTCT services (US$5, plus US$1 increment at every subsequent visit), whereas the control group received usual care. Outcomes assessed included retention in care at 6 weeks' post partum and uptake of PMTCT services, measured by attendance of all scheduled clinic visits and acceptance of proposed services up to 6 weeks' post partum. Analyses were by intention to treat. This trial is registered with ClinicalTrials.org, number NCT01838005.

Findings: Between April 18, 2013, and Aug 30, 2014, 612 potential participants were identified, 545 were screened, and 433 were enrolled and randomly assigned; 217 to the control group and 216 to the intervention group. At 6 weeks' post partum, 174 participants in the intervention group (81%) and 157 in the control group (72%) were retained in care (risk ratio [RR] 1.11; 95% CI 1.00-1.24). 146 participants in the intervention group (68%) and 116 in the control group (54%) attended all clinic visits and accepted proposed services (RR 1.26; 95% CI 1.08-1.48). Results were similar after adjustment for marital status, age, and education.

Interpretation: Among women with newly diagnosed HIV, small, incremental cash incentives resulted in increased retention along the PMTCT cascade and uptake of available services. The cost-effectiveness of these incentives and their effect on HIV-free survival warrant further investigation.

Abstract access

Editor’s notes: Eliminating new HIV infections in children and keeping their mothers alive is a crucial component in ending the AIDS epidemic. However, engaging and retaining women in prevention of mother-to-child transmission services can be problematic, with high rates of loss to follow up being documented in many sub-Saharan countries. Noting the success of financial incentives to promote positive health behaviours, this study applies this approach in antenatal care clinics in Kinshasa, Democratic Republic of Congo.   

Newly-diagnosed HIV-positive pregnant women were randomised to receive usual care versus small escalating cash payments. This payment started at $5, increasing by $1 each visit, on the proviso they attended scheduled appointments and adhered to medical advice until six weeks post-partum. This cash offer resulted in both increased attendance to all visits and increased retention at six weeks post-partum. As might be expected, the effect was strongest among the most vulnerable women, including women who walked to the clinic. This is in line with the rationale that addressing non-medical, structural barriers enables engagement with care.

It is worth noting that follow-up stopped at six weeks post-partum so the impact of the programme over a longer period needs further exploration. However, the study is reported to be the first of its kind in prevention of mother-to-child transmission of HIV and certainly supports the need for continued research into the use of financial incentives for prevention of mother-to-child transmission.

Africa
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Sex and drugs: cost-effectiveness of risk reduction programmes for female sex workers who inject drugs in Mexico

Cost-effectiveness of combined sexual and injection risk reduction interventions among female sex workers who inject drugs in two very distinct Mexican border cities.

Burgos JL, Patterson TL, Graff-Zivin JS, Kahn JG, Rangel MG, Lozada MR, Staines H, Strathdee SA. PLoS One. 2016 Feb 18;11(2):e0147719. doi: 10.1371/journal.pone.0147719. eCollection 2016.

Background: We evaluated the cost-effectiveness of combined single session brief behavioral intervention, either didactic or interactive (Mujer Mas Segura, MMS) to promote safer-sex and safer-injection practices among female sex workers who inject drugs (FSW-IDUs) in Tijuana (TJ) and Ciudad-Juarez (CJ) Mexico. Data for this analysis was obtained from a factorial RCT in 2008-2010 coinciding with expansion of needle exchange programs (NEP) in TJ, but not in CJ.

Methods: A Markov model was developed to estimate the incremental cost per quality adjusted life year gained (QALY) over a lifetime time frame among a hypothetical cohort of 1000 FSW-IDUs comparing a less intensive didactic vs. a more intensive interactive format of the MMS, separately for safer sex and safer injection combined behavioral interventions. The cost for antiretroviral therapy was not included in the model. We applied a societal perspective, a discount rate of 3% per year and currency adjusted to US$2014. A multivariate sensitivity analysis was performed. The combined and individual components of the MMS interactive behavioral intervention were compared with the didactic formats by calculating the incremental cost-effectiveness ratios (ICER), defined as incremental unit of cost per additional health benefit (e.g., HIV/STI cases averted, QALYs) compared to the next least costly strategy. Following guidelines from the World Health Organization, a combined strategy was considered highly cost-effective if the incremental cost per QALY gained fell below the gross domestic product per capita (GDP) in Mexico (equivalent to US$ 10 300).

Findings: For CJ, the mixed intervention approach of interactive safer sex/didactic safer injection had an incremental cost-effectiveness ratio (ICER) of US$4360 ($310-$7200) per QALY gained compared with a dually didactic strategy. Using the dually interactive strategy had an ICER of US$5874 ($310-$7200) compared with the mixed approach. For TJ, the combination of interactive safer sex/didactic safer injection had an ICER of US$5921 ($104-$9500) per QALY compared with dually didactic. Strategies using the interactive safe injection intervention were dominated due to lack of efficacy advantage. The multivariate sensitivity analysis showed a 95% certainty that in both CJ and TJ the ICER for the mixed approach (interactive safer sex didactic safer injection intervention) was less than the GDP per capita for Mexico. The dual interactive approach met this threshold consistently in CJ, but not in TJ.

Interpretation: In the absence of an expanded NEP in CJ, the combined-interactive formats of the MMS behavioral intervention is highly cost-effective. In contrast, in TJ where NEP expansion suggests that improved access to sterile syringes significantly reduced injection-related risks, the interactive safer-sex combined didactic safer-injection was highly cost-effective compared with the combined didactic versions of the safer-sex and safer-injection formats of the MMS, with no added benefit from the interactive safer-injection component.

Abstract  Full-text [free] access 

Editor’s notes: Female sex workers who inject drugs are a particularly vulnerable group with potential risks of HIV infection stemming from both condomless sex and use of contaminated injecting equipment. In the northern border towns of Mexico, which are on major drug trafficking routes into the United States, the prevalence of HIV among female sex workers who inject drugs is 12%. This is in comparison with 6% among female sex workers who do not inject drugs and 0.3% among the general population. In this context, the authors conducted a cost-effectiveness analysis of a combined single-session brief behavioural programme. It was either didactic or interactive, to promote safer sexual and injection practices among female sex workers who inject drugs in two Mexican cities: Ciudad Juarez and Tijuana.

The authors found that the programme can be highly cost-effective in reducing HIV risky behaviours, although with varying results. Sensitivity analyses suggested that in both cities, the mixed approach (interactive safer sex/didactic safer injection intervention) was highly cost-effective. The dual interactive approach was highly cost-effective in Ciudad Juarez but not in Tijuana.

This article illustrates the importance of targeting programmes that take into consideration city-level contexts. Although the cities are similar in many ways, the double interactive approach was not highly cost-effective in the Tijuana setting. This is likely to be due to the fact that needle syringe distribution at the community level expanded at the same time, making the interactive safer injection practice component redundant. This supports previous research that community-level programmes, such as needle-exchange programmes, could be potentially more cost-effective than individual-level activities. Individual-level activities may then be best suited for settings where needle-syringe programmes are not available, such as in prisons. 

Latin America
Mexico
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HIV and injecting ‘krokodile’

Krokodile Injectors in Ukraine: fueling the HIV Epidemic?

Booth RE, Davis JM, Brewster JT, Lisovska O, Dvoryak S. AIDS Behav. 2016 Feb;20(2):369-76. doi: 10.1007/s10461-015-1008-z.

This study was designed to assess the characteristics of krokodile injectors, a recent phenomenon in Ukraine, and HIV-related risk factors among people who inject drugs (PWID). In three Ukraine cities, Odessa, Donetsk and Nikolayev, 550 PWID were recruited between December 2012 and October 2013 using modified targeted sampling methods. The sample averaged 31 years of age and they had been injecting for over 12 years. Overall, 39% tested positive for HIV, including 45% of krokodile injectors. In the past 30 days, 25% reported injecting krokodile. Those who injected krokodile injected more frequently (p < 0.001) and they injected more often with others (p = 0.005). Despite knowing their HIV status to be positive, krokodile users did not reduce their injection frequency, indeed, they injected as much as 85% (p = 0.016) more frequently than those who did not know their HIV status or thought they were negative. This behavior was not seen in non-krokodile using PWID. Although only a small sample of knowledgeable HIV positive krokodile users was available (N = 12), this suggests that krokodile users may disregard their HIV status more so than non-krokodile users. In spite of widespread knowledge of its harmful physical consequences, a growing number of PWID are turning to injecting krokodile in Ukraine. Given the recency of krokodile use in the country, the associated higher frequency of injecting, a propensity to inject more often with others, and what could be a unique level of disregard of HIV among krokodile users, HIV incidence could increase in future years.

Abstract access

Editor’s notes: This is an important study among a highly vulnerable population of people who inject drugs where HIV prevalence has been consistently high over the last decade. This is one of the first empirical studies to examine the role of krokodile use on HIV risk acquisition. Krokodile is a home produced drug that has become more popular among people who inject drugs in Ukraine and the Russian Federation over the last five years. There is a long history of injection with home-produced opioids and amphetamines in these countries. The key component of krokodile is codeine, an opioid, but severe side effects have been associated with its injection including tissue damage, gangrene and organ failure. This study highlights some of the characteristics and HIV risk behaviours associated with krokodile injection to inform appropriate HIV prevention programming. Findings note that people who inject krokodile are more likely to inject with others. This reflects the home-produced nature of the drug that facilitates more group injecting as people congregate at places where it is produced to buy and inject. Programmes need to focus on strategies to avoid injecting with other people’s used injecting equipment, such as marking equipment, as can happen in group injecting scenarios. This programme would ensure there are sufficient numbers of clean needles/syringes in circulation. Worryingly, a higher prevalence of HIV was observed among people who inject krokodile, most likely associated with their older age and more frequent injecting. Targeted harm reduction information is urgently needed for krokodile users to prevent further HIV transmission and prevent soft tissue damage. There is already a large network of needle-syringe programmes and opioid substitution therapy available for people who inject drugs in Ukraine. However, access is often reduced since people who inject drugs are concerned about being arrested. Registration as a person who injects drugs causes problems with employment, families and police. Collaboration with the police is necessary to increase access to opioid substitution and needle and syringe programmes. Programmes are also required to reduce the stigma associated with injection in order to address the health needs of this population. 

Europe
Ukraine
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Novel specimens feasible and sensitive for Xpert® MTB/RIF diagnosis in children

Performance of Xpert® MTB/RIF and alternative specimen collection methods for the diagnosis of tuberculosis in HIV-infected children.

Marcy O, Ung V, Goyet S, Borand L, Msellati P, Tejiokem M, Nguyen Thi NL, Nacro B, Cheng S, Eyangoh S, Pham TH, Ouedraogo AS, Tarantola A, Godreuil S, Blanche S, Delacourt C, PAANTHER study group. Clin Infect Dis. 2016 Feb 7. pii: ciw036. [Epub ahead of print]

Methods: HIV-infected children aged 13 years with suspected intrathoracic tuberculosis were enrolled in 8 hospitals in Burkina Faso, Cambodia, Cameroon, and Vietnam. Gastric aspirates were taken for children aged <10 years and expectorated sputum samples were taken for children aged 10 years (standard samples); nasopharyngeal aspirate and stool were taken for all children, and a string test was performed if the child was aged 4 years (alternative samples). All samples were tested with Xpert®. The diagnostic accuracy of Xpert® for culture-confirmed tuberculosis was analyzed in intention-to-diagnose and per-protocol approaches.

Results: Of 281 children enrolled, 272 (96.8%) had ≥1 specimen tested with Xpert® (intention-to-diagnose population), and 179 (63.5%) had all samples tested with Xpert® (per-protocol population). Tuberculosis was culture-confirmed in 29/272 (10.7%) children. Intention-to-diagnose sensitivities of Xpert® performed on all, standard, and alternative samples were 79.3% (95% confidence interval [CI], 60.3-92.0), 72.4% (95% CI, 52.8-87.3), and 75.9% (95% CI, 56.5-89.7), respectively. Specificities were 97.5%. Xpert® combined on nasopharyngeal aspirate and stool had intention-to-diagnose and per-protocol sensitivities of 75.9% (95% CI, 56.5-89.7) and 75.0% (95% CI, 47.6-92.7), respectively.

Conclusions: The combination of nasopharyngeal aspirate and stool sample is a promising alternative to methods usually recommended by national programs. Xpert® performed on respiratory and stools samples enables rapid confirmation of tuberculosis diagnosis in HIV-infected children.

Abstract access  

Editor’s notes: This article reports on a prospective cohort study of HIV-positive children (≤ 13 years) with suspected intrathoracic tuberculosis in eight hospitals in Burkina Faso, Cambodia, Cameroon, and Viet Nam. Diagnosis of tuberculosis among children is challenging because it is more difficult to obtain sputum, and their sputum often has fewer bacilli, requiring more sensitive tests. In 2014, WHO recommended scaling-up the use of Xpert® MTB/RIF among children. However, any test which is dependent on obtaining a sputum specimen will be suboptimal for diagnosis of tuberculosis in children.

In this study the investigators examined the feasibility of using alternative specimens with Xpert® MTB/ RIF for the diagnosis of tuberculosis in HIV-positive children. Using an intention-to-diagnose and a per-protocol analysis, they also assessed the diagnostic accuracy of Xpert® on nasopharyngeal aspirate and stool samples, using culture-confirmed tuberculosis as the reference standard.

The authors found that the performance of Xpert® in alternative samples was comparable to that of standard samples. They found excellent feasibility of obtaining samples of nasopharyngeal aspirates and stool, and a good sensitivity of Xpert® (~76%) when using that combination of samples. The authors suggested more research to simplify the processing of the stool samples for Xpert®, which would make the combination of both samples an attractive collection method for children unable to produce sputum.

Although Xpert® produces results relatively rapidly, some testing was done retrospectively, and only half of the Xpert® results were immediately available. As many children in this study had features of severe disease, it is not surprising that clinicians often started TB treatment immediately without waiting for results. Thus in practice the Xpert® result often provided bacteriological confirmation of a clinical diagnosis for children who had already started TB treatment, although it did also lead to some TB treatment initiations.

Despite conducting this study over more than two years in eight hospitals, the final number of enrolled children with culture-confirmed tuberculosis was only 29. It would be interesting to know whether using Xpert® on alternative specimens from children had an impact on patient-important outcomes, particularly mortality, though this would have required a much larger study. Studies of Xpert® implementation among adults have found increased yield in terms of bacteriological diagnoses. However, most have not found an impact on patient-important outcomes. Several children died before all the protocol-required specimens could be obtained, emphasizing the importance of rapid and more sensitive TB diagnostic tests for severely-ill children.

Africa, Asia
Burkina Faso, Cambodia, Cameroon, Viet Nam
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CrAg screening needs strengthened implementation in South Africa

Evaluation of a public-sector, provider-initiated cryptococcal antigen screening and treatment program, western Cape, South Africa.

Vallabhaneni S, Longley N, Smith M, Smith R, Osler M, Kelly N, Cross A, Boulle A, Meintjes G, Govender NP. J Acquir Immune Defic Syndr. 2016 Feb 29. [Epub ahead of print]

Background: Screening for serum cryptococcal antigen (CrAg) may identify those at risk for disseminated cryptococcal disease (DCD), and pre-emptive fluconazole treatment may prevent progression to DCD. In August 2012, the Western Cape Province (WC), South Africa, adopted provider-initiated CrAg screening. We evaluated the implementation and effectiveness of this large-scale public-sector program during its first year, September 1, 2012-August 31, 2013.

Methods: We used data from the South African National Health Laboratory Service, WC provincial HIV program, and nationwide surveillance data for DCD. We assessed the proportion of eligible patients screened for CrAg (CrAg test done within 30 days of CD4 date) and the prevalence of CrAg positivity. Incidence of DCD among those screened was compared with those not screened.

Results: Of 4395 eligible patients, 26.6% (n=1170) were screened. The proportion of patients screened increased from 15.9% in September 2012 to 36.6% in August 2013. The prevalence of positive serum CrAg was 2.1%. Treatment data were available for 13 of 24 CrAg-positive patients; nine of 13 were treated with fluconazole. Nine (0.8%) incident cases of DCD occurred among the 1170 patients who were screened for CrAg vs. 49 (1.5%) incident cases among the 3225 patients not screened (p=0.07).

Conclusions: Relatively few eligible patients were screened under the WC provider-initiated CrAg screening program. Unscreened patients were nearly twice as likely to develop DCD. CrAg screening can reduce the burden of DCD, but needs to be implemented well. To improve screening rates, countries should consider laboratory-based reflexive screening when possible.

Abstract access  

Editor’s notes: Cryptococcus, a ubiquitous soil fungus, can cause cryptococcal meningitis (CM) or disseminated cryptococcal disease (DCD), which is often fatal among people with advanced HIV disease.  Despite antiretroviral therapy availability, CM is now the leading cause of adult meningitis in sub-Saharan Africa with a mortality of up to 70% at 12 weeks in low-income settings. Asymptomatic individuals with a positive serum cryptococcal antigen (CrAg) and low CD4 counts are at a high risk of progression to disease. Identifying these individuals and initiating pre-emptive treatment to reduce morbidity and mortality forms the rationale for the inclusion of CrAg screening in the South African national guidelines.

This evaluation of the public sector provider-initiated CrAg screening and treatment programme in the western Cape revealed disappointing coverage during the first year of implementation. A laboratory-based reflex testing strategy, where the CrAg test is performed in the laboratory on any blood sample with CD4<100 may improve screening coverage. But, this requires adequate laboratory infrastructure and needs to be paired with optimal uptake of pre-emptive fluconazole among people with a positive CrAg result. In this study, uptake of fluconazole was lower than desired with about a third of eligible patients, for whom records were available, lacking any evidence of receiving fluconazole. In addition, a significantly higher proportion of people screened started ART compared with people who were not screened. This might partly explain the reduced incidence of cryptococcal disease in the screened group. 

A stepped-wedge randomised trial evaluating CrAg screening in Uganda, presented at CROI 2016, found that one-third of persons with baseline CrAg titre of ≥1:160 died, despite receiving recommended pre-emptive fluconazole therapy. This suggests that semi-quantitative CrAg screening may be required to identify people at risk of death in whom more potent antifungal therapy may be necessary. The very high mortality in CrAg-positive patients despite antifungal therapy suggests that, for people at highest risk, CrAg screening should be implemented as part of a combined opportunistic infection screening and intervention package, including more intensive follow-up.

Africa
South Africa
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Exploring community perceptions of community health workers roles in chronic disease management in western Kenya.

Community perceptions of community health workers (CHWs) and their roles in management for HIV, tuberculosis and hypertension in western Kenya.

Rachlis B, Naanyu V, Wachira J, Genberg B, Koech B, Kamene R, Akinyi J, Braitstein P. PLoS One. 2016 Feb 22;11(2):e0149412. doi: 10.1371/journal.pone.0149412. eCollection 2016.

Given shortages of health care providers and a rise in the number of people living with both communicable and non-communicable diseases, Community Health Workers (CHWs) are increasingly incorporated into health care programs. We sought to explore community perceptions of CHWs including perceptions of their roles in chronic disease management as part of the Academic Model Providing Access to Healthcare Program (AMPATH) in western Kenya. In depth interviews and focus group discussions were conducted between July 2012 and August 2013. Study participants were purposively sampled from three AMPATH sites: Chulaimbo, Teso and Turbo, and included patients within the AMPATH program receiving HIV, tuberculosis (TB), and hypertension (HTN) care, as well as caregivers of children with HIV, community leaders, and health care workers. Participants were asked to describe their perceptions of AMPATH CHWs, including identifying the various roles they play in engagement in care for chronic diseases including HIV, TB and HTN. Data was coded and various themes were identified. We organized the concepts and themes generated using the Andersen-Newman Framework of Health Services Utilization and considering CHWs as a potential enabling resource. A total of 207 participants including 110 individuals living with HIV (n = 50), TB (n = 39), or HTN (n = 21); 24 caregivers; 10 community leaders; and 34 healthcare providers participated. Participants identified several roles for CHWs including promoting primary care, encouraging testing, providing education and facilitating engagement in care. While various facilitating aspects of CHWs were uncovered, several barriers of CHW care were raised, including issues with training and confidentiality. Suggested resources to help CHWs improve their services were also described. Our findings suggest that CHWs can act as catalysts and role models by empowering members of their communities with increased knowledge and support.

Abstract  Full-text [free] access 

Editor’s notes: As community-health workers are becoming an integrated part of the health care systems in Kenya, more information is required on how they are perceived by the communities they serve. This qualitative study explores perceptions on the role of community-health workers in chronic disease management.

Generally, community health workers are well received by the communities. They are perceived as an enabling resource in generating awareness on specific health issues and promoting positive health seeking behaviours. However, some negative perceptions were raised by several study participants, including their inability to maintain confidentiality and their sometimes limited or inaccurate knowledge on specific health issues, due to limited training.

Suggested resources to strengthen the role of community health workers in engaging communities in chronic disease management include additional training. Also information tools e.g. brochures, posters and charts and participation in larger communities’ awareness events e.g. through community gatherings. These findings are particularly useful for other community-health worker programmes to promote positive health seeking behaviours including successful linkage and retention in care.

Africa
Kenya
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We need to listen to people living with HIV who refuse or delay starting ART: lessons from Australia

On the margins of pharmaceutical citizenship: not taking HIV medication in the "treatment revolution" era.

Persson A, Newman CE, Mao L, de Wit J. Med Anthropol Q. 2016 Jan 12. doi: 10.1111/maq.12274. [Epub ahead of print]

With the expanding pharmaceuticalization of public health, anthropologists have begun to examine how biomedicine's promissory discourses of normalization and demarginalization give rise to new practices of and criteria for citizenship. Much of this work focuses on the biomedicine-citizenship nexus in less-developed, resource-poor contexts. But how do we understand this relationship in resource-rich settings where medicines are readily available, often affordable, and a highly commonplace response to illness? In particular, what does it mean to not use pharmaceuticals for a treatable infectious disease in this context? We are interested in these questions in relation to the recent push for early and universal treatment for HIV infection in Australia for the twin purposes of individual and community health. Drawing on Ecks's concept of pharmaceutical citizenship, we examine the implications for citizenship among people with HIV who refuse or delay recommended medication. We find that moral and normative expectations emerging in the new HIV "treatment revolution" have the capacity to both demarginalize and marginalize people with HIV.

Abstract 

Editor’s notes: Following the release of WHO ‘Guidelines on when to start antiretroviral therapy and on pre-exposure prophylaxis for HIV’ at the end of September 2015, there has been growing momentum to roll out treatment to all people living with HIV. This important paper highlights an important issue affecting the provision of antiretroviral therapy (ART) to all people living with HIV, regardless of CD4 cell count. Not everyone wants to start treatment promptly. The authors interviewed 27 people in Australia who had declined to start ART. Ten of these people had never used ART, while the remaining 17 had started and then stopped therapy. There were many reasons why these people chose not to start or continue with ART. These reasons included fears over side-effects and the commitment to life-long therapy. Some doubted that they needed ‘treatment’ because they were well. A few were sceptical about the efficacy of the drugs.  These reasons for delaying treatment are being echoed in research from other parts of the world. The authors of this paper note that if treatment is promoted as ‘normal’, then people who decline ART risk marginalisation for ‘not doing the right thing’. This, they suggest, is particularly the case in places where ART are readily and freely available, like Australia. The authors conclude by highlighting the importance of listening to people who do not want to start ART, and understanding their reservations, while ensuring they do not become marginalised.

Oceania
Australia
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The power of PEPFAR programmes: estimates of infections averted and life years gained in Africa

Estimating the impact of the US President's Emergency Plan for AIDS Relief on HIV treatment and prevention programmes in Africa.

Heaton LM, Bouey PD, Fu J, Stover J, Fowler TB, Lyerla R, Mahy M. Sex Transm Infect. 2015 Dec;91(8):615-20. doi: 10.1136/sextrans-2014-051991. Epub 2015 Jun 8.

Background: Since 2004, the US President's Emergency Plan for AIDS Relief (PEPFAR) has supported the tremendous scale-up of HIV prevention, care and treatment services, primarily in sub-Saharan Africa. We evaluate the impact of antiretroviral treatment (ART), prevention of mother-to-child transmission (PMTCT) and voluntary medical male circumcision (VMMC) programmes on survival, mortality, new infections and the number of orphans from 2004 to 2013 in 16 PEPFAR countries in Africa.

Methods: PEPFAR indicators tracking the number of persons receiving ART for their own health, ART regimens for PMTCT and biomedical prevention of HIV through VMMC were collected across 16 PEPFAR countries. To estimate the impact of PEPFAR programmes for ART, PMTCT and VMMC, we compared the current scenario of PEPFAR-supported interventions to a counterfactual scenario without PEPFAR, and assessed the number of life years gained (LYG), number of orphans averted and HIV infections averted. Mathematical modelling was conducted using the SPECTRUM modelling suite V.5.03.

Results: From 2004 to 2013, PEPFAR programmes provided support for a cumulative number of     24 565 127 adults and children on ART, 4 154 878 medical male circumcisions, and ART for PMTCT among 4 154 478 pregnant women in 16 PEPFAR countries. Based on findings from the model, these efforts have helped avert 2.9 million HIV infections in the same period. During 2004-2013, PEPFAR ART programmes alone helped avert almost 9 million orphans in 16 PEPFAR countries and resulted in 11.6 million LYG.

Conclusions: Modelling results suggest that the rapid scale-up of PEPFAR-funded ART, PMTCT and VMMC programmes in Africa during 2004-2013 led to substantially fewer new HIV infections and orphaned children during that time and longer lives among people living with HIV. Our estimates do not account for the impact of the PEPFAR-funded non-biomedical interventions such as behavioural and structural interventions included in the comprehensive HIV prevention, care and treatment strategy used by PEPFAR countries. Therefore, the number of HIV infections and orphans averted and LYG may be underestimated by these models.

Abstract access

Editor’s notes: The President’s Emergency Plan for AIDS Relief (PEPFAR) was initiated in 2004 with $42 billion spent up until the end of 2013. Despite limitations in monitoring the overall contribution of PEPFAR to individual programmes, this article attempts to provide an overview of PEPFAR support for ART, prevention of mother to child transmission and voluntary medical male circumcision (VMMC) programmes using the 2014 version of Spectrum Software model. The Spectrum modules used included DemProj, AIDS Impact Model (AIM) and Goals, which interact to model the impact and future course of the HIV epidemic at the population level.  An estimate of PEPFAR’s contribution was obtained by subtracting it from the total for the national programme statistics reported by UNAIDS on ART, PMTCT and VMMC.

The baseline scenario of PEPFAR-supported programmes in 2013 was compared to a counterfactual scenario, which subtracts the direct contribution of PEPFAR. The results estimate that the combined programmes have averted 2.7 million infections in Africa, with over 11.5 million life years gained and the aversion of almost nine million orphans. Other key population programmes that the funding supported including gender equity and health strengthening were not evaluated and therefore, the estimate for impact may be conservative. A limitation of the analysis is that it is unable to predict the national response without PEPFAR and the impact of ART calculated by the model is sensitive to the distribution of new ART patients by CD4 count at the initiation of treatment. In addition, few countries have sufficient death registration systems to validate mortality estimates, which may result in the accomplishments of PEPFAR’s impact being overestimated. However, with the operation of PEPFAR in a larger context of partnership consortiums, an improvement in evaluation methods will be necessary. 

Africa
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Evidence for large regional disparities in the quality of PMTCT provision across Ghana (2011-2013)

Towards elimination of mother-to-child transmission of HIV in Ghana: an analysis of national programme data.

Dako-Gyeke P, Dornoo B, Ayisi Addo S, Atuahene M, Addo NA, Yawson AE. Int J Equity Health. 2016 Jan 13;15(1):5. doi: 10.1186/s12939-016-0300-5.

Background: Despite global scale up of interventions for Preventing Mother-to-Child HIV Transmissions (PMTCT), there still remain high pediatric HIV infections, which result from unequal access in resource-constrained settings. Sub-Saharan Africa alone contributes more than 90% of global Mother-to-Child Transmission (MTCT) burden. As part of efforts to address this, African countries (including Ghana) disproportionately contributing to MTCT burden were earmarked in 2009 for rapid PMTCT interventions scale-up within their primary care system for maternal and child health. In this study, we reviewed records in Ghana, on ANC registrants eligible for PMTCT services to describe regional disparities and national trends in key PMTCT indicators. We also assessed distribution of missed opportunities for testing pregnant women and treating those who are HIV positive across the country. Implications for scaling up HIV-related maternal and child health services to ensure equitable access and eliminate mother-to-child transmissions by 2015 are also discussed.

Methods: Data for this review is from the National AIDS/STI Control Programme (NACP) regional disaggregated records on registered antenatal clinic (ANC) attendees across the country, who are also eligible to receive PMTCT services. These records cover a period of 3 years (2011-2013). Number of ANC registrants, utilization of HIV Testing and Counseling among ANC registrants, number of HIV positive pregnant women, and number of HIV positive pregnant women initiated on ARVs were extracted. Trends were examined by comparing these indicators over time (2011-2013) and across the ten administrative regions. Descriptive statistics were conducted on the dataset and presented in simple frequencies, proportions and percentages. These are used to determine gaps in utilization of PMTCT services. All analyses were conducted using Microsoft Excel 2010 version.

Results: Although there was a decline in HIV prevalence among pregnant women, untested ANC registrants increased from 17 % in 2011 to 25 % in 2013. There were varying levels of missed opportunities for testing across the ten regions, which led to a total of 487 725 untested ANC clients during the period under review. In 2013, Greater Accra (31 %), Northern (27 %) and Volta (48 %) regions recorded high percentages of untested ANC clients. Overall, HIV positive pregnant women initiated onto ARVs remarkably increased from 57% (2011) to 82 % (2013), yet about a third (33 %) of them in the Volta and Northern regions did not receive ARVs in 2013.

Conclusions: Missed opportunities to test pregnant women for HIV and also initiate those who are positive on ARVs across all the regions pose challenges to the quest to eliminate mother-to-child transmission of HIV in Ghana. For some regions these missed opportunities mimic previously observed gaps in continuous use of primary care for maternal and child health in those areas. Increased national and regional efforts aimed at improving maternal and child healthcare delivery, as well as HIV-related care, is paramount for ensuring equitable access across the country.

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Despite substantial improvement in antiretroviral therapy coverage in many countries over the last decade, over 200 000 infants still acquire the virus each year. Prevention of mother- to-child-transmission can, in theory, eliminate these infant infections and must be an essential component of HIV prevention strategies, particularly in countries with high HIV prevalence. In Ghana, prevention of mother-to-child-transmission activities is integrated with other maternal, neonatal and child health services, to achieve the highest possible level of coverage.

The goal of this study was to see how effectively the prevention of mother- to-child-transmission has been implemented across Ghana. Using data from antenatal care (ANC) clinics, two key metrics were assessed. They are: 1) the percentage of ANC attendees who are not tested for HIV and 2) the percentage of HIV positive ANC attendees who are not initiated on treatment. The percentage of missed opportunities for HIV testing among ANC attendees nationally increased from 17% to 25% between 2011 and 2013. This overall increase is worrying, and masks regional variations including an 84% increase in the central region. Overall the percentage of pregnant women living with HIV who are not initiated on treatment decreased substantially from 43% to 18%. However, there were still large geographical differences.

The authors suggest that the regional variation is indicative of inequities in the provision of health care. The evidence for attrition over time in the provision of HIV testing in ANC clinics is of particular concern. Perhaps this is a reflection of fatigue in HIV testing efforts among this group, even over this short period. The study highlights the importance of a timely and geographically disaggregated analysis of key metrics associated with a national HIV programme. This is vital in order to ensure effective and equitable coverage and to address deficiencies in the provision of HIV services. It also emphasises that efforts to achieve the UNAIDS 90:90:90 targets need sustained generalised programmes of health systems strengthening. 

Africa
Ghana
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SMS reminders for HIV treatment adherence had a broader, positive impact on HIV-programme trial participants

The meanings in the messages: how SMS reminders and real-time adherence monitoring improve ART adherence in rural Uganda.

Ware NC, Pisarski EE, Tam M, Wyatt MA, Atukunda E, Musiimenta A, Bangsberg DR, Haberer JE. AIDS. 2016 Jan 23. [Epub ahead of print]

Objective: To understand how a pilot intervention combining SMS reminders with real-time adherence monitoring improved adherence to HIV antiretroviral therapy (ART) for adults initiating treatment in rural Uganda.

Design: Qualitative study, conducted with a pilot randomized controlled trial.

Methods: Sixty-two pilot intervention study participants took part in qualitative interviews on: (a) preferences for content, frequency and timing of SMS adherence reminders; (b) understandings and experiences of SMS reminders; and (c) understandings and experiences of real-time adherence monitoring. Analysis of interview data was inductive and derived categories describing how participants experienced the intervention, and what it meant to them.

Results: SMS reminders prompted taking individual doses of antiretroviral therapy, and helped to develop a "habit" of adherence. Real-time adherence monitoring was experienced as "being seen"; participants interpreted "being seen" as an opportunity to demonstrate seriousness of commitment to treatment and "taking responsibility" for adherence. Both SMS reminders and real-time monitoring were interpreted as signs of "caring" by the health care system. Feeling "cared about" offset depressed mood and invigorated adherence.

Conclusions: While serving as reminders, SMS messages and real-time adherence monitoring also had larger emotional and moral meanings for participants that they felt improved their adherence. Understanding the larger "meanings in the messages," as well as their more literal content and function, will be central in delineating how SMS reminders and other adherence interventions using cellular technology work or do not work in varying contexts.  

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Editor’s notes: SMS reminders have been used in a number of trials in an effort to increase adherence to antiretroviral treatment (ART). The quantitative evidence generally suggests that SMS reminders do not have a significant impact on adherence to ART. However, little is known about why reminders may or may not work for different people in different contexts. This study uses qualitative interviews with trial participants to explore why reminders improved ART adherence in rural Uganda. Participants suggested that the SMS reminders made them “feel seen”, increasing their sense of taking responsibility for adherence. They also felt “cared for” by the health system which offset some negative emotions. This study suggests that SMS reminders may have broader, unmeasured impact on trial participants than simply encouraging adherence. Receiving messages directly from the health care system may have a positive impact on participant morale and attitudes towards trials. 

  
Africa
Uganda
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