Articles tagged as "National responses"

Taking services to the community: the effective provision of TB, HIV and vertical HIV prevention services by community care workers

Community-based intervention to enhance provision of integrated TB-HIV and PMTCT services in South Africa.

Uwimana J, Zarowsky C, Hausler H, Swanevelder S, Tabana H, Jackson D. . Int J Tuberc Lung Dis. 2013 Oct;17(10 Suppl 1):48-55.doi: 10.5588/ijtld.13.0173.

Objective: To conduct an impact assessment of an intervention to enhance the provision of community-based integrated services for tuberculosis (TB), human immunodeficiency virus (HIV) and prevention of mother-to-child transmission (PMTCT).

Methods: The intervention consisted of a combination of training of community care workers (CCWs), structural adjustments, harmonisation of scope of practice and stipend of CCWs and enhanced supervision of CCWs to provide comprehensive TB-HIV/PMTCT services in a rural South African district. A before and after study design was used with a household survey to assess the operational effectiveness of the intervention. Six clusters were randomised into intervention and control arms. Quantitative data were analysed using logistic regression, adjusting for cluster design.

Results: Logistic regression analyses of the survey data show that CCWs from the intervention arm performed better in the provision of TB-HIV/PMTCT services, such as screening for TB and sexually transmitted infections, adherence to anti-tuberculosis treatment and antiretroviral therapy and counselling on infant feeding compared to the control CCWs (P < 0.05). However, intervention CCWs performed worse in the integrated management of childhood illnesses education and social welfare referrals (P < 0.05). The uptake of HIV testing increased significantly in the intervention arm, from 55% to 78% (P < 0.001).

Conclusion: The intervention was effective in enhancing the provision of community-based TB-HIV and PMTCT services. However, attention to other primary health care services is required to ensure that all key services are provided.

Abstract  Full-text [free] access 

Editor’s notes: Community care workers (CCWs) have the potential to expand primary health care beyond health facilities. However, in many settings where integrated TB-HIV services have mainly been promoted at facility level, there is little engagement of communities and community care workers. This is inefficient, and can lead to fragmented services. This clustered, before after study, assessed the impact of an intervention that trained/upskilled CCWs to provide comprehensive TB-HIV/vertical HIV prevention services. The intervention integrated CCWs into one cadre, established a facility-community linkage, harmonized the scope of practice of CCWs and improved CCW supervision. The findings are very positive, suggesting that the intervention increased the coverage of TB-HIV/STI case finding, infant feeding counselling and antiretroviral treatment adherence support, and improved anti-tuberculosis treatment adherence and outcomes. However, other outcomes were more mixed: with less education on the integrated management of childhood illnesses, referral for vital documents and referral for social grants, performance was worse; but there was improved referral for weighing and immunization. The findings highlight the feasibility and effectiveness of community-based integrated TB-HIV/PMTCT services provision, and the need to ensure that other outcomes are not adversely affected.  

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South Africa
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Community health workers are an effective and potentially low cost support to clinical staff in the provision of a range of technical and non-technical roles in HIV care

Role and outcomes of community health workers in HIV care in sub-Saharan Africa: a systematic review.

Mwai GW, Mburu G, Torpey K, Frost P, Ford N, Seeley J.  J Int AIDS Soc. 2013 Sep 10;16(1):18586. doi: 10.7448/IAS.16.1.18586.

Introduction: The provision of HIV treatment and care in sub-Saharan Africa faces multiple challenges, including weak health systems and attrition of trained health workers. One potential response to overcome these challenges has been to engage community health workers (CHWs).

Methodology: A systematic literature search for quantitative and qualitative studies describing the role and outcomes of CHWs in HIV care between inception and December 2012 in sub-Saharan Africa was performed in the following databases: PubMed, PsychINFO, Embase, Web of Science, JSTOR, WHOLIS, Google Scholar and SAGE journals online. Bibliographies of included articles were also searched. A narrative synthesis approach was used to analyze common emerging themes on the role and outcomes of CHWs in HIV care in sub-Saharan Africa.

Results: In total, 21 studies met the inclusion criteria, documenting a range of tasks performed by CHWs. These included patient support (counselling, home-based care, education, adherence support and livelihood support) and health service support (screening, referral and health service organization and surveillance). CHWs were reported to enhance the reach, uptake and quality of HIV services, as well as the dignity, quality of life and retention in care of people living with HIV. The presence of CHWs in clinics was reported to reduce waiting times, streamline patient flow and reduce the workload of health workers. Clinical outcomes appeared not to be compromised, with no differences in virologic failure and mortality comparing patients under community-based and those under facility-based care. Despite these benefits, CHWs faced challenges related to lack of recognition, remuneration and involvement in decision making.

Conclusions: CHWs can clearly contribute to HIV services delivery and strengthen human resource capacity in sub-Saharan Africa. For their contribution to be sustained, CHWs need to be recognized, remunerated and integrated in wider health systems. Further research focusing on comparative costs of CHW interventions and successful models for mainstreaming CHWs into wider health systems is needed.

Keywords: HIV, care, community health workers, sub-Saharan Africa, systematic review

Abstract Full-text [free] access

Editor’s notes: This paper is an exceedingly useful reference – it is a systematic review examining the roles of community health care workers in HIV care.  African health care systems are looking to task-shifting as a means to reduce costs and fill the human resource gap.  Task-shifting means different things to different countries and the review confirms this.  Community health workers (CHW) in this review included peer health workers, community volunteers, community health workers and lay workers. Methods and levels of payment were not reported on but their tasks varied in the different settings.  Tasks covered administrative support; providing health education; patient triage and registration; home visits; adherence and HIV counselling; and support to directly observed therapy.  CHWs are therefore working in a range of increasingly technical roles.  Importantly the review found no instance where CHWs performed less well than their health service counterparts in terms of health outcomes.  Only one study provided evidence on the costs of using CHWs and this found a lower cost than the traditional model.  This is a huge success and identifies great potential for future human resource planning.  However, the concerns identified associated with the recognition and remuneration of the CHW, are critical. Addressing these issues around the CHWs payment and status within the health system will be vital to ensure the continued success of these programmes.

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‘Public’ and ‘hidden’ transcripts of the Global Fund in India

Transforming governance or reinforcing hierarchies and competition: examining the public and hidden transcripts of the Global Fund and HIV in India.

Kapilashrami A, McPake B. Health Policy Plan. 2013 Sep;28(6):626-35. doi: 10.1093/heapol/czs102. Epub 2012 Nov 11.

Global health initiatives (GHIs) have gained prominence as innovative and effective policy mechanisms to tackle global health priorities. More recent literature reveals governance-related challenges and their unintended health system effects. Much less attention is received by the relationship between these mechanisms, the ideas that underpin them and the country-level practices they generate. The Global Fund has leveraged significant funding and taken a lead in harmonizing disparate efforts to control HIV/AIDS. Its growing influence in recipient countries makes it a useful case to examine this relationship and evaluate the extent to which the dominant public discourse on Global Fund departs from the hidden resistances and conflicts in its operation. Drawing on insights from ethnographic fieldwork and 70 interviews with multiple stakeholders, this article aims to better understand and reveal the public and the hidden transcript of the Global Fund and its activities in India. We argue that while its public transcript abdicates its role in country-level operations, a critical ethnographic examination of the organization and governance of the Fund in India reveals a contrasting scenario. Its organizing principles prompt diverse actors with conflicting agendas to come together in response to the availability of funds. Multiple and discrete projects emerge, each leveraging control and resources and acting as conduits of power. We examine how management of HIV is punctuated with conflicts of power and interests in a competitive environment set off by the Fund protocol and discuss its system-wide effects. The findings also underscore the need for similar ethnographic research on the financing and policy-making architecture of GHIs.

Abstract access 

Editor’s notes: The paper presents results of a study on the implementation of the Global Fund fourth round HIV/AIDS grant in five states of India. It draws on Scott’s (1992) distinction between ‘dominant public transcripts’ –  official and documented statements describing principles, structures and activities - and ‘hidden transcripts’ meaning the unofficial practices and realities that are rarely acknowledged in official documents. While such a distinction is not new in the social sciences, for instance public and private accounts of experiences of health and illness are often contrasted, this framing provides a useful way to distinguish official rhetoric from interviewees’ discourses and observation of day-to-day practices of decision making and implementation. The study took an ethnographic approach between 2007 and 2009 to articulate these ‘hidden transcripts’ consisting of observations of meetings, document review and 70 ‘in-depth’ stakeholder interviews.

The paper reports on several aspects of the Indian experience that reinforce findings from previous studies of the effects of Global Fund HIV/AIDS programmes in other countries. These include limited involvement of local civil society organisations in grant application processes. Instead the application process was dominated by government, bilateral and multilateral agencies and large national/international civil society organisations. Country Coordination Mechanism (CCM) activities were confined to applying for grants rather than overseeing programme implementation. Demanding reporting requirements strained an already weak health system, created competition between implementers and impacted negatively on the continuity of interventions. The paper concludes that while the Global Fund claims to be a financial mechanism for country-driven programmes, its structures, rules and conditions create a highly regulating environment for programme implementation. 

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India
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Patient expenditures for TB care are impoverishing and may prevent access to care

Household catastrophic payments for tuberculosis care in Nigeria: incidence, determinants, and policy implications for universal health coverage.

Ukwaja KN, Alobu I, Abimbola S, Hopewell PC. Infect Dis Poverty. 2013 Sep17;2(1):21. [Epub ahead of print]

Background: Studies on costs incurred by patients for tuberculosis (TB) care are limited as these costs are reported as averages, and the economic impact of the costs is estimated based on average patient/household incomes. Average expenditures do not represent the poor because they spend less on treatment compared to other economic groups. Thus, the extent to which TB expenditures risk sending households into, or further into, poverty and its determinants, is unknown. We assessed the incidence and determinants of household catastrophic payments for TB care in rural Nigeria.

Methods: Data used were obtained from a survey of 452 pulmonary TB patients sampled from three rural health facilities in Ebonyi State, Nigeria. Using household direct costs and income data, we analyzed the incidence of household catastrophic payments using, as thresholds, the traditional >10% of household income and the >=40% of non-food income, as recommended by the World Health Organization. We used logistic regression analysis to identify the determinants of catastrophic payments.

Results: Average direct household costs for TB were US$157 or 14% of average annual incomes. The incidence of catastrophic payment was 44%; with 69% and 15% of the poorest and richest household income-quartiles experiencing catastrophic activity, respectively. Independent determinants of catastrophic payments were: age >40 years (adjusted odds ratio [aOR] 3.9; 95% confidence interval [CI], 2.0, 7.8), male gender (aOR 3.0; CI 1.8, 5.2), urban residence (aOR 3.8; CI 1.9, 7.7), formal education (aOR 4.7; CI 2.5, 8.9), care at a private facility (aOR 2.9; 1.5, 5.9), poor household (aOR 6.7; CI 3.7, 12), household where the patient is the primary earner (aOR 3.8; CI 2.2, 6.6]), and HIV co-infection (aOR 3.1; CI 1.7, 5.6).

Conclusions: Current cost-lowering strategies are not enough to prevent households from incurring catastrophic out-of-pocket payments for TB care. Financial and social protection interventions are needed for identified at-risk groups, and community-level interventions may reduce inefficiencies in the care-seeking pathway. These observations should inform post-2015 TB strategies and influence policy-making on health services that are meant to be free of charge.

Abstract access 

Editor’s notes: Household health care expenditures can often push households into poverty. These payments, known as catastrophic payments, mean that households are giving up the consumption of basic goods and services to pay for health care.  This study uses individual level data on health care expenditures for TB services and income levels, to examine the extent to which TB involves catastrophic payments in Nigeria.  Although TB services are subsidized and supposed to be free, this survey confirms this is not the case with patients paying most frequently for drugs, laboratory tests and transport.   Of particular concern is the high level of pre-diagnostic costs; that the poor are more vulnerable and the situation is exacerbated for those with HIV co-infection. The findings are important for policy makers trying to improve access to TB care, HIV care and access to health care in general. They emphasize the importance of prepayment schemes to facilitate access to health care when individuals are at their most in need.  

Africa
Nigeria
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Scope for improvements to the UNAIDS model of Modes of Transmission

Can the UNAIDS modes of transmission model be improved?: a comparison of the original and revised model projections using data from a setting in West Africa.

Prudden HJ, Watts CH, Vickerman P, Bobrova N, Heise L, Ogungbemi MK, Momah A,  Blanchard JF, Foss AM. AIDS. 2013 Aug 6. [Epub ahead of print]

Objective:  The UNAIDS Modes of Transmission Model (MoT) is a user-friendly model, developed to predict the distribution of new HIV infections among different subgroups. The model has been used in 29 countries to guide interventions. However, there is the risk that the simplification inherent in the MoT produces misleading findings. Using input data from Nigeria, we compare projections from the MoT with those from a revised model that incorporates additional heterogeneity.

Methods:  We revised the MoT to explicitly incorporate brothel and street-based sex-work, transactional sex, and HIV-discordant couples. Both models were parameterized using behavioural and epidemiological data from Cross River State, Nigeria. Model projections were compared, and the robustness of the revised model projections to different model assumptions, was investigated.

Results:  The original MoT predicts 21% of new infections occur in most-at-risk-populations (MARPs), compared with 45% (40-75%, 95% Crl) once additional heterogeneity and updated parameterization is incorporated. Discordant couples, a subgroup previously not explicitly modelled, are predicted to contribute a third of new HIV infections. In addition, the new findings suggest that women engaging in transactional sex may be an important but previously less recognised risk group, with 16% of infections occurring in this subgroup.

Conclusion:  The MoT is an accessible model that can inform intervention priorities. However, the current model may be potentially misleading, with our comparisons in Nigeria suggesting that the model lacks resolution, making it challenging for the user to correctly interpret the nature of the epidemic. Our findings highlight the need for a formal review of the MoT.

Abstract access

Editor’s notes: This innovative study modifies the UNAIDS Modes of Transmission (MoT) model, which is used to estimate the distribution of new HIV infections in different population subgroups, with the findings being used to prioritize interventions. The revised model incorporates subgroups to the original population groupings – for example, the category of “female sex workers” is further divided into “brothel based” and “non-brothel based” sex workers; and inclusion of “transactional sex” and discordant couples.  The addition of new categories means that this revised model requires more data. The revised model changed the authors’ conclusions about the epidemic in the example setting of Cross River State, Nigeria, suggesting that the original MoT model may underestimate the importance of different vulnerable groups, including girls involved in transactional sex.  Overall, the paper suggests a need to review the MoT model to assess whether further refinement would improve the reliability of the model projections. The HIV Modelling Consortium is currently working on a revision of the MoT model.

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Nigeria
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Accelerating initiation of antiretroviral therapy in India in the era of free roll-out

Impact of generic antiretroviral therapy (ART) and free ART programs on time to initiation of ART at a tertiary HIV care center in Chennai, India.

Solomon SS, Lucas GM, Kumarasamy N, Yepthomi T, Balakrishnan P, Ganesh AK, Anand S, Moore RD, Solomon S, Mehta SH. AIDS Care. 2013 Aug;25(8):931-6. doi:10.1080/09540121.2012.748160. Epub 2012 Dec 7.

Antiretroviral therapy (ART) access in the developing world has improved, but whether increased access has translated to more rapid treatment initiation among those who need it is unknown. We characterize time to ART initiation across three eras of ART availability in Chennai, India (1996-1999: pregeneric; 2000-2003: generic; 2004-2007: free rollout). Between 1996 and 2007, 11 171 patients registered for care at the YR Gaitonde Centre for AIDS Research and Education (YRGCARE), a tertiary HIV referral center in southern India. Of these, 5 726 patients became eligible for ART during this period as per Indian guidelines for initiation of ART. Generalized gamma survival models were used to estimate relative times (RT) to ART initiation by calendar periods of eligibility. Time to initiation of ART among patients in Chennai, India was also compared to an HIV clinical cohort in Baltimore, USA. Median age of the YRGCARE patients was 34 years; 77% were male. The median CD4 at presentation was 140 cells/µl. After adjustment for demographics, CD4 and WHO stage, persons in the pregeneric era took 3.25 times longer (95% confidence interval [CI]: 2.53-4.17) to initiate ART versus the generic era and persons in the free rollout era initiated ART more rapidly than the generic era (RT: 0.73; 95% CI: 0.63-0.83). Adjusting for differences across centers, patients at YRGCARE took longer than patients in the Johns Hopkins Clinical Cohort (JHCC) to initiate ART in the pregeneric era (RT: 4.90; 95% CI: 3.37-7.13) but in the free rollout era, YRGCARE patients took only about a quarter of the time (RT: 0.31; 95% CI: 0.22-0.44). These data demonstrate the benefits of generic ART and government rollouts on time to initiation of ART in one developing country setting and suggests that access to ART may be comparable to developed country settings.

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Editor’s notes: This study documents changes in the time from HIV diagnosis until initiation of ART over three defined calendar periods, for ART eligible patients attending a single treatment centre in Chennai, India. Over three periods of time between1996 and 2007 which were characterized by (i) treatment with pre-generics (ii) treatment with generics (iii) free roll-out of ART, there were sequential very substantial reductions in time to treatment, to the extent that in the latter period, the time to treatment was shorter than treatment in a clinical cohort in Baltimore, USA, in adjusted analyses.

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India
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Combination HIV prevention for MSM needed urgently

The global HIV epidemics in MSM: time to act.

Beyrer C, Sullivan P, Sanchez J, Baral SD, Collins C, Wirtz AL, Altman D, Trapence G, Mayer K. AIDS. 2013 Aug6. [Epub ahead of print]

Epidemics of HIV in MSM continue to expand in most low, middle, and upper income countries in 2013 and rates of new infection have been consistently high among young MSM. Current prevention and treatment strategies are insufficient for this next wave of HIV spread. We conducted a series of comprehensive reviews of HIV prevalence and incidence, risks for HIV, prevention and care, stigma and discrimination, and policy and advocacy options. The high per act transmission probability of receptive anal intercourse, sex role versatility among MSM, network level effects, and social and structural determinants play central roles in disproportionate disease burdens. HIV can be transmitted through large MSM networks at great speed. Molecular epidemiologic data show marked clustering of HIV in MSM networks and high proportions of infections due to transmission from recent infections. Prevention strategies that lower biological risks, including those using antiretrovirals, offer promise for epidemic control, but are limited by structural factors including, discrimination, criminalization, and barriers to healthcare. Sub-epidemics, including among racial and ethnic minority MSM in the United States and UK, are particularly severe and will require culturally tailored efforts. For the promise of new and combined bio-behavioral interventions to be realized, clinically competent healthcare is necessary and community leadership, engagement, and empowerment are likely to be key. Addressing the expanding epidemics of HIV in MSM will require continued research, increased resources, political will, policy change, structural reform, community engagement, and strategic planning and programming, but it can and must be done.

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Editor’s notes: This paper provides a useful summary of HIV epidemics among men who have sex with men, highlighting that infection levels continue to rise in most countries – both industrialized and developing, and including countries where HIV treatment is widely available. Drawing upon the findings from a range of comprehensive reviews, the paper presents important summary data on the prevalence of HIV among MSM.  It paints a global picture of the very high prevalence burdens found in the United States, the Caribbean, Peru, multiple African countries, Thailand, Myanmar, and parts of China, with the highest rates among the youngest age groups. The paper discusses options for prevention and treatment, arguing that much more needs to be done. The authors suggest that antiretrovirals – including both early treatment and PrEP, could be important additions for prevention.  However, these interventions will only be effective if strategies address structural barriers, including violence, stigmatization and criminalization. The authors argue that interventions and services need to be better equipped to respond to sub-epidemics in particularly marginalized MSM populations; and that an effective response will only be achieved through political will, community engagement and structural change.

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Strengthening the provision of PITC in STI clinics: operational insights

Implementing a provider-initiated testing and counselling (PITC) intervention in Cape town, South Africa: a process evaluation using the normalisation process model.

Leon N, Lewin S, Mathews C Implement Sci. 2013 Aug 26;8(1):97. [Epub ahead of print] 

Background:  Provider-initiated HIV testing and counselling (PITC) increases HIV testing rates in most settings, but its effect on testing rates varies considerably. This paper reports the findings of a process evaluation of a controlled trial of PITC for people with sexually transmitted infections (STI) attending publicly funded clinics in a low-resource setting in South Africa, where the trial results were lower than anticipated compared to the standard Voluntary Counselling and Testing (VCT) approach.

Method:  This longitudinal study used a variety of qualitative methods, including participant observation of project implementation processes, staff focus groups, patient interviews, and observation of clinical practice. Data were content analysed by identifying the main influences shaping the implementation process. The Normalisation Process Model (NPM) was used as a theoretical framework to analyse implementation processes and explain the trial outcomes.

Results:  The new PITC intervention became embedded in practice (normalised) during a two-year period (2006 to 2007). Factors that promoted the normalising include strong senior leadership, implementation support, appropriate accountability mechanisms, an intervention design that was responsive to service needs and congruent with professional practice, positive staff and patient perceptions, and a responsive organisational context. Nevertheless, nurses struggled to deploy the intervention efficiently, mainly because of poor sequencing and integration of HIV and STI tasks, a focus on HIV education, tension with a patient-centred communication style, and inadequate training on dealing with the operational challenges. This resulted in longer consultation times, which may account for the low test coverage outcome.

Conclusion:  Leadership and implementation support, congruent intervention design, and a responsive organisational context strengthened implementation. Poor compatibility with nurse skills on the level of the clinical consultation may have contributed to limiting the size of the trial outcomes. A close fit between the PITC intervention design and clinical practices, as well as appropriate training, are needed to ensure sustainability of the programme. The use of a theory-driven analysis promotes transferability of the results, and the findings are therefore relevant to the implementation of HIV testing and to the design and evaluation of complex interventions in other settings. Trial registration: Current controlled trials ISRCTN93692532.

Abstract Full-text [free] access

Editor’s notes: HIV testing is the main entry point for HIV prevention and treatment, and it is important that provider initiated HIV testing is integrated into a range of health care services. This paper uses a combination of qualitative methods to describe what factors influenced the coverage of HIV testing in STI clinics in South Africa. They identify a range of factors that help to support and normalize HIV testing, and the challenges that some nurses faced in trying to deploy the intervention effectively.  These challenges include issues related to the levels of institutional support and commitment, how to sequence STI and HIV tasks, the content of training, and tensions with a patient centred communication model. The research not only provides practical insights into the operational issues that need to be considered when integrating PITC care into services, but also illustrates the value of process evaluation methods, as a complement to trial research.

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South Africa
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Integrating HIV treatment with primary care services

Integrating HIV treatment with primary care outpatient services: opportunities and challenges from a scaled-up model in Zambia.

Topp SM, Chipukuma JM, Chiko MM, Matongo E, Bolton-Moore C, Reid SE., Health Policy Plan. 2013; 4:347-57. doi: 10.1093/heapol/czs065

Background: Integration of HIV treatment with other primary care services has been argued to potentially improve effectiveness, efficiency and equity. However, outside the field of reproductive health, there is limited empirical evidence regarding the scope or depth of integrated HIV programmes or their relative benefits. Moreover, the body of work describing operational models of integrated service-delivery in context remains thin. Between 2008 and 2011, the Lusaka District Health Management Team piloted and scaled-up a model of integrated HIV and general outpatient department (OPD) services in 12 primary health care clinics. This paper examines the effect of the integrated model on the organization of clinic services, and explores service providers' perceptions of the integrated model.

Methods: We used a mixed methods approach incorporating facility surveys and key informant interviews with clinic managers and district officials. On-site facility surveys were carried out in 12 integrated facilities to collect data on the scope of integrated services, and 15 semi-structured interviews were carried out with 12 clinic managers and three district officials to explore strengths and weaknesses of the model. Quantitative and qualitative data were triangulated to inform overall analysis.

Findings: Implementation of the integrated model substantially changed the organization of service delivery across a range of clinic systems. Organizational and managerial advantages were identified, including more efficient use of staff time and clinic space, improved teamwork and accountability, and more equitable delivery of care to HIV and non-HIV patients. However, integration did not solve ongoing human resource shortages or inadequate infrastructure, which limited the efficacy of the model and were perceived to undermine service delivery.

Conclusion: While resource and allocative efficiencies are associated with this model of integration, a more important finding was the model's demonstrated potential for strengthening organizational culture and staff relationships, in turn facilitating more collaborative and motivated service delivery in chronically under-resourced primary healthcare clinics.

Abstract Full-text [free] access

Editor’s notes:  In recent years, there has been much debate about the relative benefits of disease-specific programs vs. broader strengthening of health systems, which may have the potential to improve effectiveness, cost-effectiveness and equity of health care.  

The integrated model in primary care services in this study involved 3 modifications: 1) amalgamation of physical space and patient flow; 2) standardisation of record keeping; 3) introduction of provider-initiated testing and counselling for all attendees.  Integration resulted in a single cadre of health-workers providing care jointly to HIV and OPD patients.

The equitable distribution of material and human resources improved the quality and efficiency of healthcare delivery. This approach provided an opportunity for systems of HIV care to strengthen care for other chronic diseases and healthcare providers were afforded the opportunity to learn different skills.  Shared responsibility of clinic functions improved staff relationships which facilitated more collaborative and motivated service delivery.

However, these advantages cannot offset the absolute underlying problem of limited infrastructural and human resources and weak health financing, which may ultimately make integrated care unsustainable. Hence, while this study demonstrates clear benefits of integration, these macro-level determinants need to be addressed.  The impact of integrated models of healthcare delivery on the quality of medical care merits consideration.   

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Zambia
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HIV prevention laws based on moralistic judgements of lawmakers may increase stigma

'The intention may not be cruel... but the impact may be': understanding legislators' motives and wider public attitudes to a draft HIV Bill in Malawi.

Stackpool-Moore, L. Sex Transm Infect. 2013. June 89 (4)

Objectives: The law in relation to HIV has prominence in the formation and regulation of moral norms in regard to human rights, and in regard to criminalisation, the policing of sexuality and intimate behaviours, and the production of stigma. The research focuses on the potential and impotence of the law to govern for, and enable, the human right to health in the context of HIV in Malawi.

Methods: This one-country qualitative case study (Malawi) action research involved data collection during a 6-month period (October 2010-March 2011). Datasets include interviews with law commissioners (n=10), opinion leaders (n=22), life story participants who were people living with and closely affected by HIV (n=20), reflections of the action research team (n=6), and a review of the proposed HIV and AIDS (Prevention and Management) Bill, legal and policy documents.

Results: The analysis of the perspectives of the law commissioners, who formed the Special Law Commission and drafted the Bill, revealed that stigma was consciously invoked to delineate social norms and guide governance of notions of personal responsibility. The analysis of the perspectives of the life story participants, whose lives would be most directly impacted if these provisions came into force, reveals the extent to which the stigma associating criminality and HIV is falling on fertile ground through its engagement and generation of internalised stigma; unearthing an uneasy link between stigma and the law in response to HIV in Malawi.

Discussion: The results indicated that the proposed HIV Bill in Malawi manifests a tension between intention and impact. By incorporating criminal sanctions as part of the proposed HIV Bill, the lawmakers actively seek to use stigma to shape social attitudes and attempt to guide normative behaviour.

Abstract access 

Editor’s notes: This paper presents research that examines the impact of criminal law in relation to HIV on stigma in Malawi. Through interviews with lawmakers and life story interviews with people living with and closely affected by HIV, the author examined how participants understand the proposed draft HIV and AIDS (Prevention and Management) Bill. The legal initiative for the bill, whilst based on principles of non-discrimination, includes provision to imprison a person who knows that he (sic) is HIV positive and does not refrain from an act which is likely to infect another person or who deliberately infects another person. Of great concern, the interviews revealed that whilst participants stated a support for non-discrimination of people living with HIV, many supported criminalisation of HIV transmission. The lawmakers were almost unanimously in favour of criminalising HIV transmission as a way to seek retribution and justice rather than for prevention of HIV transmission. The author noted that the lawmakers were particularly judgemental and moralistic about the issue. The people living with or affected by HIV were less certain and provided arguments for and against criminalisation, especially in relation to deliberate transmission of HIV where knowledge of status is not known. They were particularly worried that this law may dissuade people from testing. This paper provides an important understanding of the tension between political level intent to reduce stigma around HIV and the moralizing position taken by law- and policy makers. More worryingly, the author suggests that the perpetuation of stigma through such means as this law could be used to maintain or establish social control. 

Africa
Malawi
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