Articles tagged as "Civil society and community responses / Resilience"

Intimate partner violence common among microbicide trial participants

Hidden harms: women's narratives of intimate partner violence in a microbicide trial, South Africa.

Stadler J, Delany-Moretlwe S, Palanee T, Rees H. Soc Sci Med. 2014 Jun;110:49-55. doi: 10.1016/j.socscimed.2014.03.021. Epub 2014 Mar 22.

In a context of high rates of intimate partner violence (IPV), trials of female-controlled technologies for HIV prevention such as microbicides may increase the possibility of social harms. Seeking to explore the relationship between IPV and microbicide use further, this paper documents women’s narratives of participating in the Microbicide Development Program (MDP) trial in Johannesburg, South Africa, and experiences of partner violence and conflict. A social science sub-study, nested within the trial, was conducted between September 2005 and August 2009, and 401 serial in-depth-interviews were undertaken with 150 women. Using coded interview transcripts, we describe the distribution of IPV and the possible association thereof with microbicide gel use and trial participation. More than a third of these 150 women reported IPV, of which half the cases were related to involvement in the trial. In their narratives, those women reporting IPV cast their partners as authoritarian, controlling and suspicious and reported verbal abuse, abandonment, and in some cases, beatings. Shared experiences of everyday violence shaped women’s feelings of unease about revealing their participation in the trial to intimate partners and attempted concealment further contributed to strains and conflict within relationships. Our findings point to the role of social scientific enquiry in identifying the less obvious, hidden negative impacts of participation in a clinical trial therefore exposing limitations in the biomedical construction of ‘social harms’, as well as the implications thereof for potential future use outside the clinical trial setting.

Abstract access 

Editor’s notes: Violence within intimate partnerships is common globally. Longitudinal research from South Africa and Uganda has shown that women in violent relationships are at increased risk of acquiring HIV infection. This study presents qualitative data, collected as part of a nested study of 150 women in Orange Farm, South Africa who participated in the Microbicide Development Programme (MDP) trial. Although experiences of violence were not framed as a social harm in the trial, or actively explored in the research, violence did emerge as an important issue. More than a third of respondents were living with men who were physically or psychologically violent and/or controlling. The violent events resulting from trial participation were primarily psychological, along with some incidents of physical violence.

Women described using a range of strategies to try to minimise the risk of violence that could result from being part of the trial. Some women were very adept at negotiating gel use with a controlling, violent or potentially violent partner.  The pervasiveness of violence and its links with HIV vulnerability illustrates the challenges of reducing women's risk of HIV acquisition. The findings suggests that female initiated technologies, such as microbicides, are urgently needed, but that broader programmes, to address violence within relationships, will also be important. The findings also raise issues of how to conceptualise and respond to such forms of social harms within clinical trials. The findings suggest that trialists need to be better equipped to deal with IPV, for example by providing counselling and social and legal referral, as well as possibly supporting the sharing of successful strategies between women. It also highlights the potential synergies that could be obtained by more effectively bringing together biomedical developments, such as microbicides, along with broader development initiatives, that seek to prevent violence within relationships. 

Africa
South Africa
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Addressing cognitive delay in children living with and affected by HIV

A systematic review examining whether interventions are effective in reducing cognitive delay in children infected and affected with HIV.

Sherr L, Croome N, Bradshaw K, Parra Castaneda K. AIDS Care. 2014 Apr 10. [Epub ahead of print]

Cognitive delay has been recorded in children infected and affected by HIV. This finding is well established, yet few countries report provision of special educational interventions for this group of children. The general rehabilitation literature describes an array of effective interventions for children with learning difficulties. These have rarely been adapted for children affected by HIV, despite their growing numbers. A systematic review was conducted to examine effective interventions for cognitive delay in children (under 18 years) infected with HIV and/or exposed to HIV (HIV-negative child born to an HIV-positive mother). A keyword search of electronic databases with reference follow-up generated 1 745 hits. These abstracts were screened for relevance, resulting in 17 papers available for shortlisting. Studies were then included if they were randomised control trials, were longitudinal, pre/post or cohort studies and presented empirical data on an intervention for children infected by HIV or exposed to HIV and had at least one cognitive measure. Carer interventions were included if they had at least one child cognitive measure. Of the 17 papers, 4 met the inclusion criteria based on design and quality. Interventions included cognitive rehearsal, home-based stimulation and parental support. All four interventions showed at least one significant child improvement at follow-up. Despite such improvements, many children still scored within the disability range at follow-up. These results show that the effective interventions are available and should be scaled up to meet the needs of children. Complex interventions are not sufficiently studied. This review suggests an ongoing need to build evidence-based interventions, but calls on evidence-based programmes to be initiated for HIV-positive and HIV-affected children.

 Abstract access 

Editor’s notes: Delay in cognitive development is well recognised in HIV-positive and HIV-affected children, and can affect long-term achievement. Cognitive development can be affected by HIV itself or its treatment, as well as social and economic deprivation which may result from a child’s parents living with HIV.

This review summarises the effect of four different types of activities for children aged below 18 years, with cognitive delay. The children were HIV-positive and/or exposed to HIV (HIV-negative child born to an HIV-positive mother). These included provision of i) family-based coping skills to parents living with HIV and their children, ii) home-based stimulation for children, iii) sessions of computerised cognitive rehearsal and iv) training caregivers on strategies to enhance their children’s cognitive and emotional development through daily interactions. While all these activities showed improvement in at least one cognitive measure, many of the scores remained in the disability range. There are, hence, promising activities that can help improve cognitive performance.  The activities can be directed at the child or at the family or caregiver. Direct comparison of different types of activities to address cognitive delay is not possible as they utilise different measures and approaches.

Unlike in adults, the range of neurocognitive disabilities in children is far less well defined, and the causes are multifactorial. It is unlikely that one single activity will address the different domains of cognitive disability. There are no data on combined approaches, and the activities required are intensive and complex. There is no doubt that special programmes to address cognitive delay are urgently needed to enable children to attain their full potential. The main challenge is to adapt the activities that are effective, so that they can be delivered at low cost and by people with relatively little training, enabling scale-up. 

Africa, Northern America
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Lessons learned from a multi-disease community health campaign, to increase testing and knowledge of HIV status

Uptake of community-based HIV testing during a multi-disease health campaign in rural Uganda.

Chamie G, Kwarisiima D, Clark TD, Kabami J, Jain V, Geng E, Balzer LB, Petersen ML, Thirumurthy H, Charlebois ED, Kamya MR, Havlir DV. PLoS One 2014 Jan 2;9(1):e84317. doi: 10.1371/journal.pone.0084317.

Background: The high burden of undiagnosed HIV in sub-Saharan Africa is a major obstacle for HIV prevention and treatment. Multi-disease, community health campaigns (CHCs) offering HIV testing are a successful approach to rapidly increase HIV testing rates and identify undiagnosed HIV. However, a greater understanding of population-level uptake is needed to maximize effectiveness of this approach.

Methods: After community sensitization and a census, a five-day campaign was performed in May 2012 in a rural Ugandan community. The census enumerated all residents, capturing demographics, household location, and fingerprint biometrics. The CHC included point-of-care screening for HIV, malaria, TB, hypertension and diabetes. Residents who attended vs. did not attend the CHC were compared to determine predictors of participation.

Results: Over 12 days, 18 census workers enumerated 6 343 residents. 501 additional residents were identified at the campaign, for a total community population of 6 844. 4 323 (63%) residents and 556 non-residents attended the campaign. HIV tests were performed in 4 795/4 879 (98.3%) participants; 1 836 (38%) reported no prior HIV testing. Of 2 674 adults tested, 257 (10%) were HIV-infected; 125/257 (49%) reported newly diagnosed HIV. In unadjusted analyses, adult resident campaign non-participation was associated with male sex (62% male vs. 67% female participation, p = 0.003), younger median age (27 years in non-participants vs. 32 in participants; p<0.001), and marital status (48% single vs. 71% married/widowed/divorced participation; p<0.001). In multivariate analysis, single adults were significantly less likely to attend the campaign than non-single adults (relative risk [RR]: 0.63 [95% CI: 0.53-0.74]; p<0.001), and adults at home vs. not home during census activities were significantly more likely to attend the campaign (RR: 1.20 [95% CI: 1.13-1.28]; p<0.001).

Conclusions: CHCs provide a rapid approach to testing a majority of residents for HIV in rural African settings. However, complementary strategies are still needed to engage young, single adults and achieve universal testing.

Abstract Full-text [free] access

Editor’s notes: There are several subtle but important lessons to be learned from this paper by Chamie et al. It describes the uptake of HIV testing as part of a multi-disease community health campaign which included prior community sensitisation, a baseline community census followed by testing days at well-known public places, two schools, a government building and a market place. Regional and village political leaders were engaged in advance, announcements were made and promotional material was prepared to adequately sensitise the community. T-shirts were provided for males to increase participation. Women, older people and individuals who were or had previously been married (non-singles) were more frequently encountered at home during the census. The campaign held at the market-place on a weekend day was more effective than those held at other venues, presumably on weekdays, at engaging the individuals who were more difficult to reach at home during the census - males, singles and younger individuals. It is noteworthy that males were not less likely to participate, after adjusting for marital status and presence at home during the census. An important consideration in interpreting the results on HIV test uptake in this campaign is that it was a multi-disease effort and participation might be different in a number of complex ways, from community engagement with HIV focused ventures.

Africa
Uganda
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HIV positive women transitioning from jail experience greater comorbidity and worse HIV treatment outcomes than men

Gender disparities in HIV treatment outcomes following release from jail: results from a multicenter study.

Meyer JP, Zelenev A, Wickersham JA, Williams CT, Teixeira PA, Altice FL. Am J Public Health 2014 Mar;104(3):434-41. doi: 10.2105/AJPH.2013.301553. Epub 2014 Jan 16.

Objectives: We assessed gender differences in longitudinal HIV treatment outcomes among HIV-infected jail detainees transitioning to the community.

Methods. Data were from the largest multisite prospective cohort study of HIV-infected released jail detainees (n = 1 270) the Enhancing Linkages to HIV Primary Care and Services in Jail Setting Initiative, January 2008 and March 2011, which had 10 sites in 9 states. We assessed baseline and 6-month HIV treatment outcomes, stratifying by gender.

Results: Of 867 evaluable participants, 277 (31.9%) were women. Compared with men, women were more likely to be younger, non-Hispanic White, married, homeless, and depressed, but were similar in recent alcohol and heroin use. By 6 months postrelease, women were significantly less likely than men to experience optimal HIV treatment outcomes, including (1) retention in care (50% vs 63%), (2) antiretroviral therapy prescription (39% vs 58%) or optimal antiretroviral therapy adherence (28% vs 44%), and (3) viral suppression (18% vs 30%). In multiple logistic regression models, women were half as likely as men to achieve viral suppression.

Conclusions: HIV-infected women transitioning from jail experience greater comorbidity and worse HIV treatment outcomes than men. Future interventions that transition people from jail to community-based HIV clinical care should be gender-specific.

Abstract  Full-text [free] access

Editor’s notes: In the United States of America, the HIV epidemic is highly concentrated among populations who interact with the criminal justice system. Similarly, attrition from HIV care is markedly higher among people living with HIV who interact with the criminal justice system. This attrition is for complex reasons, with this population being disproportionately comprised of those with socio-economic instability, psychiatric disorders, and substance use disorders. This study assessed whether there are gender differences in the longitudinal HIV treatment outcomes among HIV-positive jail detainees transitioning to the community. The study found that among 867 people living with HIV released from jail, women were less likely than men to engage in every point along an HIV treatment cascade. It was also found that women were half as likely as men to achieve viral load suppression (VLS) at six months, even after controlling for substance use, psychiatric disorders, and utilization of linkage support services. The findings are in contrast to evidence from community settings, where if anything, women tend to fare better than men in engagement along the HIV treatment cascade. The authors highlight the need for a more gender sensitive service provision that recognizes the increased prevalence of comorbid conditions, including depression, substance use, housing instability and homelessness among women.

Northern America
United States of America
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An integrated investment approach for women’s and children’s health

Advancing social and economic development by investing in women's and children's health: a new Global Investment Framework.

Stenberg K, Axelson H, Sheehan P, Anderson I, Gülmezoglu AM, Temmerman M, Mason E, Friedman HS, Bhutta ZA, Lawn JE, Sweeny K, Tulloch J, Hansen P, Chopra M, Gupta A, Vogel JP, Ostergren M, Rasmussen B, Levin C, Boyle C, Kuruvilla S, Koblinsky M, Walker N, de Francisco A, Novcic N, Presern C, Jamison D, Bustreo F; on behalf of the Study Group for the Global Investment Framework for Women's Children's Health. Lancet. 2013 Nov 18. doi: S0140-6736(13)62231-X. pii: 10.1016/S0140-6736(13)62231-X. [Epub ahead of print]

A new Global Investment Framework for Women's and Children's Health demonstrates how investment in women's and children's health will secure high health, social, and economic returns. We costed health systems strengthening and six investment packages for: maternal and newborn health, child health, immunisation, family planning, HIV/AIDS, and malaria. Nutrition is a cross-cutting theme. We then used simulation modelling to estimate the health and socioeconomic returns of these investments. Increasing health expenditure by just $5 per person per year up to 2035 in 74 high-burden countries could yield up to nine times that value in economic and social benefits. These returns include greater gross domestic product (GDP) growth through improved productivity, and prevention of the needless deaths of 147 million children, 32 million stillbirths, and 5 million women by 2035. These gains could be achieved by an additional investment of $30 billion per year, equivalent to a 2% increase above current spending.

Abstract access 

Editor’s notes: Over the past 20 years there have been substantial gains in maternal and child health (MCH). However, much still needs to be done – assuming a continuation of current rates of progress, there would nevertheless be shortfalls in the achievement of MDG 4 and 5 targets. Especially in sub-Saharan Africa, HIV is an important underlying cause of maternal and child ill health. This paper models the costs and benefits of an accelerated action on MCH, including for HIV, the prevention of mother to child HIV transmission; first line treatment for pregnant women; cotrimoxazole for children, and the provision of paediatric antiretroviral therapy (ART). These HIV services are complemented by health systems strengthening; increased family planning provision; and packages for malaria, immunisation, and child health. The paper is interesting for many reasons, including both the breadth of its intervention focus, and the detailed modelling of the likely health, social and economic benefits of such investments.

Although the direct HIV related benefits are not described in detail in the main paper, it is likely that these result both from increased contraceptive use (prong 2 for preventing vertical HIV transmission), as well as ART and cotrimoxazole provision. It also illustrates the potential value of developing a cross-disease investment approach, as a means to ensure that services effectively respond to the breadth of women’s and children’s health needs. This more ‘joined up’, integrated perspective on strategies for health investment can support core investments in health systems strengthening. It can also potentially achieve important cross-disease synergies, e.g., ensuring that a child who has not acquired HIV at birth does not then die from malaria. 

Africa, Asia, Latin America, Oceania
Afghanistan, Angola, Azerbaijan, Bangladesh, Benin, Bolivia, Botswana, Brazil, Burkina Faso, Burundi, Cambodia, Cameroon, Central African Republic, Chad, China, Comoros, Congo, Côte d'Ivoire, Democratic People's Republic of Korea, Democratic Republic of the Congo, Djibouti, Egypt, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Guatemala, Guinea, Guinea-Bissau, Haiti, India, Indonesia, Iraq, Kenya, Kyrgyzstan, Lao People's Democratic Republic, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Mexico, Morocco, Mozambique, Myanmar, Nepal, Niger, Nigeria, Pakistan, Papua New Guinea, Peru, Philippines, Rwanda, Sao Tome and Principe, Senegal, Sierra Leone, Solomon Islands, Somalia, South Africa, Sudan, Swaziland, Tajikistan, Togo, Turkmenistan, Uganda, United Republic of Tanzania, Uzbekistan, Viet Nam, Yemen, Zambia, Zimbabwe
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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.  

Africa
South Africa
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Hundreds of thousands of HIV infections averted through the Avahan initiative in South India

Assessment of the population-level effectiveness of the Avahan HIV-prevention programme in South India: a pre-planned causal pathway-based modelling analysis.

Pickles M, Boily M-C, Vickerman P, Lowndes CM, Moses S, Blanchard JF, Deering KN, Bradley J, Ramesh BM, Washington R, Adhikary R, Mainkar M, Paranjape RS, Alary M. Lancet Global Health. 2013 Sep 30;  doi:10.1016/S2214-109X(13)70083-4

Background: Avahan, the India AIDS initiative of the Bill & Melinda Gates Foundation, was a large-scale, targeted HIV prevention intervention. We aimed to assess its overall effectiveness by estimating the number and proportion of HIV infections averted across Avahan districts, following the causal pathway of the intervention.

Methods: We created a mathematical model of HIV transmission in high-risk groups and the general population using data from serial cross-sectional surveys (integrated behavioural and biological assessments, IBBAs) within a Bayesian framework, which we used to reproduce HIV prevalence trends in female sex workers and their clients, men who have sex with men, and the general population in 24 South Indian districts over the first 4 years (2004—07 or 2005—08 dependent on the district) and the full 10 years (2004—13) of the Avahan programme. We tested whether these prevalence trends were more consistent with self-reported increases in consistent condom use after the implementation of Avahan or with a counterfactual (assuming consistent condom use increased at slower, pre-Avahan rates) using a Bayes factor, which gave a measure of the strength of evidence for the effectiveness estimates. Using regression analysis, we extrapolated the prevention effect in the districts covered by IBBAs to all 69 Avahan districts.

Findings: In 13 of 24 IBBA districts, modelling suggested medium to strong evidence for the large self-reported increase in consistent condom use since Avahan implementation. In the remaining 11 IBBA districts, the evidence was weaker, with consistent condom use generally already high before Avahan began. Roughly 32 700 HIV infections (95% credibility interval 17 900—61 600) were averted over the first 4 years of the programme in the IBBA districts with moderate to strong evidence. Addition of the districts with weaker evidence increased this total to 62 800 (32 000—118 000) averted infections, and extrapolation suggested that 202 000 (98 300—407 000) infections were averted across all 69 Avahan districts in South India, increasing to 606 000 (290 000—1 193 000) over 10 years. Over the first 4 years of the programme 42% of HIV infections were averted, and over 10 years 57% were averted.

Interpretation: This is the first assessment of Avahan to account for the causal pathway of the intervention, that of changing risk behaviours in female sex workers and high-risk men who have sex with men to avert HIV infections in these groups and the general population. The findings suggest that substantial preventive effects can be achieved by targeted behavioural HIV prevention initiatives.

Abstract access 

Editor’s notes: The Avahan initiative was established in 2003, aiming to scale-up targeted HIV prevention strategies in 4 states in South India, focusing on the high-risk groups who were driving the HIV epidemic. This paper has a number of important features.  What was striking is that Avahan had a large intervention effect which increased over time and has averted hundreds of thousands of infections. The study also provides an example of how rigorous mathematical modelling can assess the effectiveness of a large-scale intervention when a cluster randomized trial is not conducted for logistical or ethical reasons. It is also notable that the intervention used behavioural interventions and STI treatment focused on core groups, rather than antiretroviral therapy. The modelling indicates that the reduction in HIV incidence was due to these behavioural interventions which resulted in increased condom use.

Asia
India
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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.

Africa
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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. 

Asia
India
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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.

Africa
South Africa
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