Articles tagged as "Cameroon"

Task shifting from doctors to nurses results in comparable outcomes

Task shifting HIV care in rural district hospitals in Cameroon: evidence of comparable antiretroviral treatment related outcomes between nurses and physicians in the Stratall ANRS/ESTHER trial.

Boullé C, Kouanfack C, Laborde-Balen G, Carrieri MP, Dontsop M, Boyer S, Aghokeng AF, Spire B, Koulla-Shiro S, Delaporte E, Laurent C; for the Stratall ANRS/ESTHER Study Group. J Acquir Immune Defic Syndr. 2013 Jan 18. [Epub ahead of print]

Task shifting to nurses for antiretroviral therapy (ART) is promoted by WHO to compensate for the severe shortage of physicians in Africa. The effectiveness of task shifting from physicians to nurses in rural district hospitals in Cameroon was assessed through a cohort study using data from the Stratall trial, designed to assess monitoring strategies in 2006-2010. ART-naive patients were followed-up for 24 months after treatment initiation. Clinical visits were performed by nurses or physicians. The associations between the consultant ratio (i.e. the ratio of the number of nurse-led visits to the number of physician-led visits) and HIV virological success, CD4 recovery, mortality, and disease progression to death or to WHO clinical stage 4 in multivariate analyses were assessed. Of the 4,141 clinical visits performed in 459 patients (70.6% female, median age 37 years), a quarter was task shifted to nurses. The consultant ratio was not significantly associated with virological success (odds ratio 1.00, 95%CI 0.59-1.72, p=0.990), CD4 recovery (coefficient -3.6, 95%CI -35.6; 28.5, p=0.827), mortality (time ratio 1.39, 95%CI 0.27-7.06, p=0.693) or disease progression (time ratio 1.60, 95%CI 0.35-7.37, p=0.543). This study brings important evidence about the comparability of ART-related outcomes between HIV models of care based on physicians or nurses in resource-limited settings. Investing in nursing resources for the management of non-complex patients should help reduce costs and patient waiting lists while freeing up physician time for the management of complex cases, for mentoring and supervision activities, as well as for other health interventions.

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Editor’s notes: Most health services in primary health facilities are provided by nurses or clinical officers, with few PHC having physician cadre staffing. The evidence is strong that nurses can ably prescribe and refill ART for adults and children living with HIV, further supporting universal access to HIV treatment. The strategies described in the accompanying articles for decentralization to primary health clinics for adults and children require task shifting in many settings – decentralization and integration of HIV services into primary care will inevitably benefit from an increased reliance on nurses as providers of primary care.

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Integration of HIV and TB services: a model to shift from "vertical to horizontal"

Integrating tuberculosis and HIV services in low- and middle-income countries: a systematic review.

Legido-Quigley H, Montgomery CM, Khan P, Atun R, Fakoya A, Getahun H, Grant AD. Trop Med Int Health. 2012 Dec 10. [Epub ahead of print]

Objectives: Given the imperative to scale up integrated tuberculosis (TB) and HIV services in settings where both are of major public health importance, we aimed to synthesise knowledge concerning implementation of TB/HIV service integration.

Methods: Systematic review of studies describing a strategy to facilitate TB and HIV service integration, searching 15 bibliographic databases including Medline, Embase and the Cochrane library; and relevant conference abstracts.

Results: Sixty-three of 1936 peer-reviewed articles and 70 of 170 abstracts met our inclusion criteria. We identified five models: entry via TB service, with referral for HIV testing and care; entry via TB service, on-site HIV testing, and referral for HIV care; entry via HIV service with referral for TB screening and treatment; entry via HIV service, on-site TB screening, and referral for TB diagnosis and treatment; and TB and HIV services provided at a single facility. Referral-based models are most easily implemented, but referral failure is a key risk. Closer integration requires more staff training and additional infrastructure (e.g. private space for HIV counselling; integrated records). Infection control is a major concern. More integrated models hold potential efficiencies from both provider and user perspective. Most papers report 'outcomes' (e.g. proportion of TB patients tested for HIV); few report downstream 'impacts' such as outcomes of TB treatment or antiretroviral therapy. Very few studies address the perspectives of service users or staff, or costs or cost-effectiveness.

Conclusions: While scaling up integrated services, robust comparisons of the impacts of different models are needed using standardised outcome measures.

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Editor’s notes:This study emphasizes the need to implement the most effective integrated services for the prevention and cure of HIV and TB.  TB remains one of the most deadly infectious diseases that dramatically impacts on people in sub-Saharan Africa and represent the major cause of death in those living with HIV in the region. In fact, the progressive weakening of the immune system in HIV-positive people increases the likelihood of contracting/reactivating tuberculosis. Already in 2004, the WHO published "A Interim Policy on TBV/HIV Collaborative Activities" with the purpose of providing a guide to establish integration of TB and HIV services, and to reduce the TB load in people living with HIV. An updated document "WHO policy on collaborative TB/HIV activities: guidelines for national programmes and other stakeholders" is now available. The document provides guidance for integrating care activities between TB and HIV health services. However, to put this paper into perspective, a consensus can be reached by saying that integration shall not just be about HIV and TB. Indeed, the old debate between "vertical approaches (e.g. disease focused)" and horizontal approaches (e.g. health systems focused) shall now be concluded and integration of services shall expand to care of other diseases, particularly when, at the horizon, an epidemic of chronic non-communicable diseases is slowly but surely rising in Africa. In summary, HIV is a chronic infection impacting the lifecycle; with periods of illness and wellness, with multiple clinical and psychosocial needs, requiring lifelong care and treatment with a secure supply of medicines and laboratory tests.

It is evident that HIV care may inform appropriate responses to other health threats which share the same demand for services, training of health care workers, support for adherence, infrastructure and equipment, programme management, drug and laboratory supplies, linkage to care and community involvement. In other words, there is a wide recognition of the spillover effect of HIV interventions towards health systems strengthening, not only to the benefit of other communicable diseases, but also of child and maternal health and of chronic non-communicable diseases (like diabetes, hypertension and cancer).

Africa, Asia, Europe, Latin America
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Preventing new paediatric infections

Health facility characteristics and their relationship to coverage of PMTCT of HIV services across four African countries: The PEARL Study

Ekouevi DK, Stringer E, Coetzee D, Tih P, Creek T, Stinson K, Westfall AO, Welty T, Chintu N, Chi BH, Wilfert C, Shaffer N, Stringer J, Dabis F. PLoS One. 2012;7(1):e29823. Epub 2012 Jan 20

Health facility characteristics associated with effective prevention of mother-to-child transmission of HIV (PMTCT) coverage in sub-Saharan are poorly understood. Ekouevi and colleagues conducted surveys in health facilities with active PMTCT services in Cameroon, Cote d'Ivoire, South Africa, and Zambia. Data was compiled via direct observation and exit interviews. The authors constructed composite scores to describe provision of PMTCT services across seven topical areas: antenatal quality, PMTCT quality, supplies available, patient satisfaction, patient understanding of medication, and infrastructure quality. Pearson correlations and Generalized Estimating Equations (GEE) to account for clustering of facilities within countries were used to evaluate the relationship between the composite scores, total time of visit and select individual variables with PMTCT coverage among women delivering. Between July 2008 and May 2009, they collected data from 32 facilities; 78% were managed by the government health system. An opt-out approach for HIV testing was used in 100% of facilities in Zambia, 63% in Cameroon, and none in Côte d'Ivoire or South Africa. Using Pearson correlations, PMTCT coverage (median of 55%, (IQR: 33-68) was correlated with PMTCT quality score (rho = 0.51; p = 0.003); infrastructure quality score (rho = 0.43; p = 0.017); time spent at clinic (rho = 0.47; p = 0.013); patient understanding of medications score (rho = 0.51; p = 0.006); and patient satisfaction quality score (rho = 0.38; p = 0.031). PMTCT coverage was marginally correlated with the antenatal quality score (rho = 0.304; p = 0.091). Using GEE adjustment for clustering, the, antenatal quality score became more strongly associated with PMTCT coverage (p<0.001) and the PMTCT quality score and patient understanding of medications remained marginally significant. The authors observed a positive relationship between an antenatal quality score and PMTCT coverage but did not identify a consistent set of variables that predicted PMTCT coverage.

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Editor’s note: The PEARL Study (PMTCT Effectiveness in Africa: Research and Linkages to Care) was conducted from 2007-2009 in 32 health facilities with PMTCT services in four countries: Cameroon (8), Cote d’Ivoire (9), South Africa (6), and Zambia (9). It found that coverage of single-dose nevirapine of both mother and baby was variable and reached only 55% overall. In this first study to do so systematically, the researchers assessed antenatal clinic and service characteristics to see if they would predict coverage. One factor stood out as distinguishing the worst-performing sites from the others and that was the lack of registers with PMTCT information. Although some other obvious variables were associated with coverage, variables related to general antenatal care were more predictive of PMTCT coverage. This supports the importance of strengthening health care in general in order to improve PMCTC coverage. But it does not in anyway decrease the need for quality assessments and creative improvements in PMTCT programmes themselves.

Cameroon, Côte d'Ivoire, South Africa, Zambia
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