Articles tagged as "Namibia"

Better integration of programmes against alcohol use necessary at every step of the HIV treatment cascade

The impact of alcohol use and related disorders on the HIV continuum of care: a systematic review: alcohol and the HIV continuum of care.

Vagenas P, Azar MM, Copenhaver MM, Springer SA, Molina PE, Altice FL. Curr HIV/AIDS Rep. 2015 Sep 28. [Epub ahead of print]

Alcohol use is highly prevalent globally with numerous negative consequences to human health, including HIV progression, in people living with HIV (PLH). The HIV continuum of care, or treatment cascade, represents a sequence of targets for intervention that can result in viral suppression, which ultimately benefits individuals and society. The extent to which alcohol impacts each step in the cascade, however, has not been systematically examined. International targets for HIV treatment as prevention aim for 90% of PLH to be diagnosed, 90% of them to be prescribed with antiretroviral therapy (ART), and 90% to achieve viral suppression; currently, only 20% of PLH are virally suppressed. This systematic review, from 2010 through May 2015, found 53 clinical research papers examining the impact of alcohol use on each step of the HIV treatment cascade. These studies were mostly cross-sectional or cohort studies and from all income settings. Most (77 %) found a negative association between alcohol consumption on one or more stages of the treatment cascade. Lack of consistency in measurement, however, reduced the ability to draw consistent conclusions. Nonetheless, the strong negative correlations suggest that problematic alcohol consumption should be targeted, preferably using evidence-based behavioral and pharmacological interventions, to indirectly increase the proportion of PLH achieving viral suppression, to achieve treatment as prevention mandates, and to reduce HIV transmission.

Abstract access 

Editor’s notes: This systematic review examined the impact of alcohol consumption on each step of the HIV treatment cascade. This covered HIV diagnosis, linkage to care, retention in care, ART initiation and adherence, and sustained virologic suppression. Overall, there was an association between alcohol consumption and negative consequences on various steps of the treatment cascade. The majority of studies focused on the effect of alcohol use disorders and ART adherence, and on viral suppression. There was fairly consistent evidence of reduced adherence among people with alcohol use disorders. Key findings of this review include the lack of consistency in studies of alcohol consumption. Many studies are not using standardised, validated, measures such as the AUDIT, and there is the lack of studies on the association of alcohol use with earlier stages of the cascade, including testing uptake and linkage to care. Further studies in this area would be useful, to identify whether programmes focused on problematic alcohol use are necessary at HIV testing centres.

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Using storybooks to tell children about their HIV in Namibia: what works

Growing-up just like everyone else: key components of a successful pediatric HIV disclosure intervention in Namibia.

Brandt L, Beima-Sofie K, Hamunime N, Shepard M, Ferris L, Ingo P, John-Stewart G, O'Malley G. AIDS. 2015 Jun;29 Suppl 1:S81-9. doi: 10.1097/QAD.0000000000000667.

Objectives: To facilitate replication and adaptation of pediatric HIV disclosure interventions, we identified key components of a child-friendly cartoon book used to guide Namibian caregivers and healthcare workers (HCWs) through a gradual, structured disclosure process.

Design: Qualitative interviews were conducted with caregivers and HCWs from four high-volume pediatric HIV clinics in Namibia.

Methods: Semi-structured in-depth interviews with 35 HCWs and 64 caregivers of HIV+ children aged 7-15 were analyzed using constant comparative and modified grounded theory analysis. Major barriers to disclosure were compared to accounts of intervention success, and themes related to key components were identified.

Results: The disclosure book overcomes barriers to disclosure by reducing caregiver resistance, increasing HIV and disclosure knowledge, and providing a gradual, structured framework for disclosure. The delayed mention of HIV-specific terminology overcomes caregiver fears associated with HIV stigma, thus encouraging earlier uptake of disclosure initiation. Caregivers value the book's focus on staying healthy, keeping the body strong, and having a future 'like other kids', thus capitalizing on evidence of the positive benefits of resilience and hopefulness rather than the negative consequences of HIV. The book's concepts and images resonate with children who readily adopt the language of 'body soldiers' and 'bad guys' in describing how important it is for them to take their medicine. Discussion cues ease communication between HCWs, caregivers, and pediatric patients.

Conclusion: Given the urgent need for available pediatric HIV disclosure interventions, easily implementable tools like the Namibian disclosure book should be evaluated for utility in similar settings.

Abstract access 

Editor’s notes: There is clear guidance from global and national policy that school-aged children should be fully disclosed to about their positive HIV status. However in reality disclosure to children continues to be done at a much later stage and in an incomplete way. Simple activities are necessary to support carers to disclose, equipping them with appropriate ways to tell children what they need to know about their HIV status and the nature of their condition. This paper presents the findings from a qualitative study evaluating a child-friendly storybook activity in Namibia designed to facilitate and ease the challenges carers face in timely and full disclosure to children. 

Both the caregivers and the healthcare workers reported that the book helped them overcome many of the barriers to disclosure. This finding suggests that the activity has considerable potential. The empirical literature focuses heavily on the reasons behind delayed disclosure including guilt, fear, and inadequate knowledge about how to approach and explain the topic. The particular value of this study is the contribution the authors are able to make to our understanding of what works to overcome these barriers to disclosure and why. They focus in particular on the use of metaphor within a narrative and the positive impact of a particular health behaviour (treatment adherence) in helping children to ameliorate the significance of the condition itself in their physical and social lives. What contributes to the success and applicability of the programme is that these books are designed to address common challenges faced by paediatric HIV clinics in resource-stretched settings with relative ease. For example the challenges posed by inconsistent caregivers accompanying the child to the clinic or the pressing demands on a healthcare worker’s time in a busy clinic.

The evidence presented in this paper is based on self-report from the healthcare workers and carers. The study suggests that there would be considerable value in evaluating this programme through larger studies to assess its efficacy. However, in addition to that, asking children themselves, who have been exposed to the book, about their experiences in any future research would further strengthen our understanding of the impact of the programme in this setting.  Involving the children in the research would inform how the programme can be refined and adapted for other settings. 

Africa
Namibia
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Men who have sex with men in sub-Saharan Africa: a review of the evidence

Emerging themes for sensitivity training modules of African healthcare workers attending to men who have sex with men: a systematic review.

Dijkstra M, van der Elst EM, Micheni M, Gichuru E, Musyoki H, Duby Z, Lange JM, Graham SM, Sanders EJ. Int Health. 2015 May;7(3):151-162. Epub 2015 Jan 16.

Sensitivity training of front-line African health care workers (HCWs) attending to men who have sex with men (MSM) is actively promoted through national HIV prevention programming in Kenya. Over 970 Kenyan-based HCWs have completed an eight-modular online training free of charge (http://www.marps-africa.org) since its creation in 2011. Before updating these modules, we performed a systematic review of published literature of MSM studies conducted in sub-Saharan Africa (sSA) in the period 2011-2014, to investigate if recent studies provided: important new knowledge currently not addressed in existing online modules; contested information of existing module topics; or added depth to topics covered already. We used learning objectives of the eight existing modules to categorise data from the literature. If data could not be categorised, new modules were suggested. Our review identified 142 MSM studies with data from sSA, including 34 studies requiring module updates, one study contesting current content, and 107 studies reinforcing existing module content. ART adherence and community engagement were identified as new modules. Recent MSM studies conducted in sSA provided new knowledge, contested existing information, and identified new areas of MSM service needs currently unaddressed in the online training.

Abstract  Full-text [free] access

Editor’s notes: Same sex practices remain criminalised in sub-Saharan Africa. Gay men and other men who have sex with men face stigma, discrimination, harassment and arrest. Health care workers frequently have no training on issues affecting gay men and other men who have sex with men and are ill-prepared to work sensitively with them. Together these can deter these men from accessing health care and HIV/STI services, increasing their risk of HIV and other poor health outcomes.

This study conducted a systematic review of gay men and other men who have sex with men in sub-Saharan Africa. The findings were used to update an on-line training programme for health care workers in Kenya. This previously comprised modules on i) men who have sex with men and HIV in Africa ii) homophobia: stigma and its effects; iii) sexual identity, coming out and disclosure; iv) anal sex and common sexual practices; v) HIV and STIs; vi) condom and lubricant use; vii) mental health: anxiety, depression and substance use; and viii) risk-reduction counselling. The review updated the training programme with new evidence and two new modules were introduced: ix) ART adherence; and x) community engagement.

Health care workers play a crucial role in reducing stigma and discrimination facing gay men and other men who have sex with men. This systematic review provided a valuable step in updating an important, accessible training programme. Reducing homoprejudice and ensuring health care workers have accurate and up-to-date knowledge are key to improving service uptake by gay men and other men who have sex with men.

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Household food insecurity is associated with poor adherence to antiretroviral therapy

Household food insecurity associated with antiretroviral therapy adherence among HIV-infected patients in Windhoek, Namibia.

Hong SY, Fanelli TJ, Jonas A, Gweshe J, Tjituka F, Sheehan HM, Wanke C, Terrin N, Jordan MR, Tang AM. J Acquir Immune Defic Syndr. 2014 Dec 1;67(4):e115-22. doi: 10.1097/QAI.0000000000000308.

Objective: Food insecurity is emerging as an important barrier to antiretroviral therapy (ART) adherence. The objective of this study was to determine if food insecurity is associated with poor ART adherence among HIV-positive adults in a resource-limited setting that uses the public health model of delivery.

Design: A cross-sectional study using a 1-time questionnaire and routinely collected pharmacy data.

Methods: Participants were HIV-infected adults on ART at the public ART clinics in Windhoek, Namibia: Katutura State Hospital, Katutura Health Centre, and Windhoek Central Hospital. Food insecurity was measured by the Household Food Insecurity Access Scale (HFIAS). Adherence was assessed by the pharmacy adherence measure medication possession ratio (MPR). Multivariate regression was used to assess whether food insecurity was associated with ART adherence.

Results: Among 390 participants, 7% were food secure, 25% were mildly or moderately food insecure and 67% were severely food insecure. In adjusted analyses, severe household food insecurity was associated with MPR <80% [odds ratio (OR), 3.84; 95% confidence interval (CI): 1.65 to 8.95]. Higher household health care spending (OR, 1.92; 95% CI, 1.02 to 3.57) and longer duration of ART (OR, 0.82; 95% CI: 0.70 to 0.97) were also associated with <80% MPR.

Conclusions: Severe household food insecurity is present in more than half of the HIV-positive adults attending a public ART clinic in Windhoek, Namibia and is associated with poor ART adherence as measured by MPR. Ensuring reliable access to food should be an important component of ART delivery in resource-limited settings using the public health model of care.

Abstract access

Editor’s notes:  United Nations Subcommittee on Nutrition defines food insecurity as “the limited or uncertain availability of nutritionally adequate, safe foods, or the inability to acquire personally acceptable foods in socially acceptable ways.” Qualitative studies in resource-limited settings have identified food insecurity as a potential risk for antiretroviral (ART) non-adherence. This is one of the first quantitative studies to analyse this issue. The findings from this cross-sectional survey of people living with HIV on ART in Namibia, are striking.  Four of the ten top reasons given for missing a medication dose, were related to food insecurity, e.g. “Did not take ARVs because they make me hungry and I did not have enough food” or, “Did not take ARVs because I cannot afford good food while taking medicine”. After adjusting for potential confounders, severe household food insecurity was significantly and positively associated with poor ART adherence. Depression and travel to the clinic via walking, biking or hitchhiking were also significantly associated with poor adherence. Research into the potential causal pathway between food insecurity and ART adherence is required, including evaluation of programmes to assess the relative effectiveness of nutritional versus livelihood programmes. 

Africa
Namibia
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Counting and classifying global deaths

Global, regional, and national incidence and mortality for HIV, tuberculosis, and malaria during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.

Murray CJ, Ortblad KF, Guinovart C, et al. Lancet. 2014 Sep 13;384(9947):1005-70. doi: 10.1016/S0140-6736(14)60844-8. Epub 2014 Jul 22.

Background: The Millennium Declaration in 2000 brought special global attention to HIV, tuberculosis, and malaria through the formulation of Millennium Development Goal (MDG) 6. The Global Burden of Disease 2013 study provides a consistent and comprehensive approach to disease estimation for between 1990 and 2013, and an opportunity to assess whether accelerated progress has occurred since the Millennium Declaration.

Methods: To estimate incidence and mortality for HIV, we used the UNAIDS Spectrum model appropriately modified based on a systematic review of available studies of mortality with and without antiretroviral therapy (ART). For concentrated epidemics, we calibrated Spectrum models to fit vital registration data corrected for misclassification of HIV deaths. In generalised epidemics, we minimised a loss function to select epidemic curves most consistent with prevalence data and demographic data for all-cause mortality. We analysed counterfactual scenarios for HIV to assess years of life saved through prevention of mother-to-child transmission (PMTCT) and ART. For tuberculosis, we analysed vital registration and verbal autopsy data to estimate mortality using cause of death ensemble modelling. We analysed data for corrected case-notifications, expert opinions on the case-detection rate, prevalence surveys, and estimated cause-specific mortality using Bayesian meta-regression to generate consistent trends in all parameters. We analysed malaria mortality and incidence using an updated cause of death database, a systematic analysis of verbal autopsy validation studies for malaria, and recent studies (2010-13) of incidence, drug resistance, and coverage of insecticide-treated bednets.

Findings: Globally in 2013, there were 1.8 million new HIV infections (95% uncertainty interval 1.7 million to 2.1 million), 29.2 million prevalent HIV cases (28.1 to 31.7), and 1.3 million HIV deaths (1.3 to 1.5). At the peak of the epidemic in 2005, HIV caused 1.7 million deaths (1.6 million to 1.9 million). Concentrated epidemics in Latin America and eastern Europe are substantially smaller than previously estimated. Through interventions including PMTCT and ART, 19.1 million life-years (16.6 million to 21.5 million) have been saved, 70.3% (65.4 to 76.1) in developing countries. From 2000 to 2011, the ratio of development assistance for health for HIV to years of life saved through intervention was US$ 4498 in developing countries. Including in HIV-positive individuals, all-form tuberculosis incidence was 7.5 million (7.4 million to 7.7 million), prevalence was 11.9 million (11.6 million to 12.2 million), and number of deaths was 1.4 million (1.3 million to 1.5 million) in 2013. In the same year and in only individuals who were HIV-negative, all-form tuberculosis incidence was 7.1 million (6.9 million to 7.3 million), prevalence was 11.2 million (10.8 million to 11.6 million), and number of deaths was 1.3 million (1.2 million to 1.4 million). Annualised rates of change (ARC) for incidence, prevalence, and death became negative after 2000. Tuberculosis in HIV-negative individuals disproportionately occurs in men and boys (versus women and girls); 64.0% of cases (63.6 to 64.3) and 64.7% of deaths (60.8 to 70.3). Globally, malaria cases and deaths grew rapidly from 1990 reaching a peak of 232 million cases (143 million to 387 million) in 2003 and 1.2 million deaths (1.1 million to 1.4 million) in 2004. Since 2004, child deaths from malaria in sub-Saharan Africa have decreased by 31.5% (15.7 to 44.1). Outside of Africa, malaria mortality has been steadily decreasing since 1990.

Interpretation: Our estimates of the number of people living with HIV are 18.7% smaller than UNAIDS's estimates in 2012. The number of people living with malaria is larger than estimated by WHO. The number of people living with HIV, tuberculosis, or malaria have all decreased since 2000. At the global level, upward trends for malaria and HIV deaths have been reversed and declines in tuberculosis deaths have accelerated. 101 countries (74 of which are developing) still have increasing HIV incidence. Substantial progress since the Millennium Declaration is an encouraging sign of the effect of global action.

Abstract  Full-text [free] access

Editor’s notes: The Global Burden of Disease (GBD) study uses standard methods to compare and track over time national distributions of deaths by cause, and the prevalence of disease and disability.  This detailed report focuses on HIV, TB and Malaria. It presents regional summaries of incidence, prevalence and mortality rates, and national estimates of the number of male and female deaths and new infections. Point estimates are shown for 2013, and annualised rates of change for 1990-2000 and 2000-2013. These highlight the contrasting trends in disease impact before and after the formulation of the Millennium Development Goal to combat these diseases.  The global peak of HIV mortality occurred in 2005, but regional annualised rates of change for 2000-2013 indicate that HIV deaths are still increasing significantly in east Asia, southern Africa, and most rapidly in eastern Europe.

The GBD 2013 global estimates of new infections and deaths agree closely with the corresponding estimates made by UNAIDS. But there are significant differences in the respective estimates of the number of people currently living with HIV (UNAIDS estimates are some 18% higher), and historical trends in AIDS deaths, with UNAIDS judging that the recent fall has been steeper. These differences are attributed primarily to methods used in the GBD study to ensure that the sum of deaths from specific causes fits the estimated all cause total, and to varying assumptions about historical survival patterns following HIV infection. 

It may be worthwhile to look at a comment by Michel Sidibé, Mark Dybul, and Deborah Birx in the Lancet on MDG 6 and beyond: from halting and reversing AIDS to ending the epidemic which refers to this study.

Epidemiology
Afghanistan, Albania, Algeria, Andorra, Angola, Antigua and Barbuda, Argentina, Australia, Austria, Bahamas, Bahrain, Bangladesh, Barbados, Belarus, Belgium, Belize, Benin, Bhutan, Bolivia, Bosnia and Herzegovina, Botswana, Brazil, Bulgaria, Burkina Faso, Burundi, Cambodia, Cameroon, Canada, Cape Verde, Central African Republic, Chad, Chile, China, Colombia, Comoros, Congo, Costa Rica, Côte d'Ivoire, Croatia, Cuba, Cyprus, Czech Republic, Democratic People's Republic of Korea, Democratic Republic of the Congo, Democratic Republic of Timor-Leste, Denmark, Djibouti, Dominica, Dominican Republic, Ecuador, Egypt, El Salvador, Equatorial Guinea, Eritrea, Estonia, Ethiopia, Fiji, Finland, France, Gabon, Gambia, Germany, Ghana, Greece, Grenada, Guatemala, Guinea, Guinea-Bissau, Guyana, Haiti, Honduras, Hungary, Iceland, India, Indonesia, Iran (Islamic Republic of), Iraq, Ireland, Israel, Italy, Jamaica, Jordan, Kazakhstan, Kenya, Kiribati, Kuwait, Kyrgyzstan, Lao People's Democratic Republic, Latvia, Lebanon, Lesotho, Liberia, Libyan Arab Jamahiriya, Lithuania, Luxembourg, Madagascar, Malawi, Malaysia, Maldives, Mali, Malta, Marshall Islands, Mauritania, Mauritius, Mexico, Micronesia (Federated States of), Monaco, Mongolia, Morocco, Mozambique, Myanmar, Namibia, Nepal, Netherlands, New Zealand, Nicaragua, Niger, Nigeria, Norway, Oman, Pakistan, Palestinian Territory, Occupied, Panama, Papua New Guinea, Paraguay, Peru, Philippines, Poland, Portugal, Qatar, Romania, Russian Federation, Rwanda, Saint Lucia, Saint Vincent and the Grenadines, Samoa, Sao Tome and Principe, Saudi Arabia, Senegal, Serbia and Montenegro, Seychelles, Sierra Leone, Slovakia, Slovenia, Solomon Islands, Somalia, South Africa, Spain, Sri Lanka, Sudan, Suriname, Swaziland, Sweden, Switzerland, Syrian Arab Republic, Taiwan, Tajikistan, Thailand, Togo, Tonga, Trinidad and Tobago, Tunisia, Turkey, Turkmenistan, Uganda, Ukraine, United States of America, Uruguay, Uzbekistan, Vanuatu, Venezuela, Viet Nam, Yemen, Zimbabwe
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Integrating HIV, malaria and diarrhoea prevention is far more efficient than vertical programmes

Scaling up integrated prevention campaigns for global health: costs and cost-effectiveness in 70 countries. 

Marseille E, Jiwani A, Raut A, Verguet S, Walson J, Kahn JG. BMJ Open. 2014 Jun 26;4(6):e003987. doi: 10.1136/bmjopen-2013-003987.

Objective: This study estimated the health impact, cost and cost-effectiveness of an integrated prevention campaign (IPC) focused on diarrhoea, malaria and HIV in 70 countries ranked by per capita disability-adjusted life-year (DALY) burden for the three diseases.

Methods: We constructed a deterministic cost-effectiveness model portraying an IPC combining counselling and testing, cotrimoxazole prophylaxis, referral to treatment and condom distribution for HIV prevention; bed nets for malaria prevention; and provision of household water filters for diarrhoea prevention. We developed a mix of empirical and modelled cost and health impact estimates applied to all 70 countries. One-way, multiway and scenario sensitivity analyses were conducted to document the strength of our findings. We used a healthcare payer's perspective, discounted costs and DALYs at 3% per year and denominated cost in 2012 US dollars.

Primary and secondary outcomes: The primary outcome was cost-effectiveness expressed as net cost per DALY averted. Other outcomes included cost of the IPC; net IPC costs adjusted for averted and additional medical costs and DALYs averted.

Results: Implementation of the IPC in the 10 most cost-effective countries at 15% population coverage would cost US$583 million over 3 years (adjusted costs of US$398 million), averting 8.0 million DALYs. Extending IPC programmes to all 70 of the identified high-burden countries at 15% coverage would cost an adjusted US$51.3 billion and avert 78.7 million DALYs. Incremental cost-effectiveness ranged from US$49 per DALY averted for the 10 countries with the most favourable cost-effectiveness to US$119, US$181, US$335, US$1 692 and US$8 340 per DALY averted as each successive group of 10 countries is added ordered by decreasing cost-effectiveness.

Conclusions: IPC appears cost-effective in many settings, and has the potential to substantially reduce the burden of disease in resource-poor countries. This study increases confidence that IPC can be an important new approach for enhancing global health.

Abstract  Full-text [free] access

Editor’s notes: Increasingly governments and policy makers are seeking to identify how to invest resources most effectively, to achieve multiple health and development outcomes. This paper presents a cost-effectiveness analysis of an integrated campaign to prevent diarrhoea, malaria and HIV.  

They developed a model to estimate the cost per disability adjusted life year (DALY) averted by this intervention, across 70 countries with high disease burden, assuming 15% coverage. The authors categorise countries by income level and their opportunity index (i.e. the opportunity to avert DALYs by having a high disease burden). The findings suggest that an integrated prevention campaign (IPC) could cost as little as US$7 per DALY averted in Guinea-Bissau, a low income, high opportunity country. As would be expected, the contribution of the different IPC components varied by country, depending on their relative disease burdens. This suggests that further focusing of activities within countries may further improve efficiency.

The model was also used to consider potential roll out strategies across counties. For this, countries were grouped into blocks of 10, and ordered with increasing incremental-cost effectiveness. The authors suggest that reaching the top 40 countries with IPC, even at just 15% coverage, could achieve far greater health benefits, with a substantially lower budget, than requested under PEPFAR for antiretroviral therapy alone.

This paper provides further evidence of the need for a more integrated approach to improve population health across disease areas.

Africa, Asia, Europe, Latin America
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Refusal bias in HIV prevalence estimates from nationally-representative surveys: small overall effects may conceal substantial bias for certain subgroups

Refusal bias in the estimation of HIV prevalence.

Janssens W, van der Gaag J, Rinke de Wit TF, Tanovic Z. Janssens W, van der Gaag J, Rinke de Wit TF, Tanović Z. Demography. 2014 May 2. [Epub ahead of print]

In 2007, UNAIDS corrected estimates of global HIV prevalence downward from 40 million to 33 million based on a methodological shift from sentinel surveillance to population-based surveys. Since then, population-based surveys are considered the gold standard for estimating HIV prevalence. However, prevalence rates based on representative surveys may be biased because of nonresponse. This article investigates one potential source of nonresponse bias: refusal to participate in the HIV test. We use the identity of randomly assigned interviewers to identify the participation effect and estimate HIV prevalence rates corrected for unobservable characteristics with a Heckman selection model. The analysis is based on a survey of 1 992 individuals in urban Namibia, which included an HIV test. We find that the bias resulting from refusal is not significant for the overall sample. However, a detailed analysis using kernel density estimates shows that the bias is substantial for the younger and the poorer population. Nonparticipants in these subsamples are estimated to be three times more likely to be HIV-positive than participants. The difference is particularly pronounced for women. Prevalence rates that ignore this selection effect may be seriously biased for specific target groups, leading to misallocation of resources for prevention and treatment.

Abstract access 

Editor’s notes: Refusal bias in HIV prevalence estimates from nationally representative surveys has been a contested issue ever since UNAIDS made a downward revision of its estimates to accommodate the evidence from such surveys. Most authors nowadays agree that an adjustment of estimates based on unobserved characteristics – for example, prior knowledge of one’s HIV status – is necessary. The Heckman sample selection model with the interviewer identities as the instrumental variable is often used for that. Results from Heckman models have not always been conclusive however, and this study is no exception. The authors take the lack of significant bias as a starting point for exploring the characteristics of nonparticipants and their relative contribution to HIV prevalence estimates in greater detail. They conclude that even though the impact of refusal on national-level HIV prevalence estimates may be small, it could lead to substantial downward bias of HIV prevalence estimates for certain subgroups, in this case women, younger individuals and the poor.

Africa
Namibia
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Pervasive geographic and transportation-related barriers to HIV services use in sub-Saharan Africa

Impact of geographic and transportation-related barriers on HIV outcomes in sub-Saharan Africa: a systematic review.

Lankowski AJ, Siedner MJ, Bangsberg DR, Tsai AC. AIDS Behav. 2014 Feb 23. [Epub ahead of print]

Difficulty obtaining reliable transportation to clinic is frequently cited as a barrier to HIV care in sub-Saharan Africa (SSA). Numerous studies have sought to characterize the impact of geographic and transportation-related barriers on HIV outcomes in SSA, but to date there has been no systematic attempt to summarize these findings. In this systematic review, we summarized this body of literature. We searched for studies conducted in SSA examining the following outcomes in the HIV care continuum: (1) voluntary counseling and testing, (2) pre-antiretroviral therapy (ART) linkage to care, (3) loss to follow-up and mortality, and (4) ART adherence and/or viral suppression. We identified 34 studies containing 52 unique estimates of association between a geographic or transportation-related barrier and an HIV outcome. There was an inverse effect in 23 estimates (44 %), a null association in 26 (50 %), and a paradoxical beneficial impact in 3 (6 %). We conclude that geographic and transportation-related barriers are associated with poor outcomes across the continuum of HIV care.

Abstract

Editor’s notes: This systematic review focuses on the importance of structural barriers to uptake of HIV treatment and care. Specifically, these are the association between geographic and transportation-related barriers and poor outcomes among HIV positive persons. Most of the quantitative and qualitative evidence reviewed in this paper (from 66 studies in sub-Saharan Africa) support the authors’ hypothesis that geographic and transportation-related barriers contribute to poor outcomes in HIV-positive individuals at all points along the continuum of HIV care. These were indexed in terms of voluntary counselling and testing, pre- antiretroviral therapy linkage to care, loss to follow-up, and adherence and/or viral suppression. A lack of association between these barriers and HIV services use was more common in studies where the study had clear limitations. For example, the use of self-reported as opposed to objective measures of exposures, small sample sizes, and the lack of control for confounding variables. The study has important policy implications related to the decentralisation of HIV treatment and care services, point-of-care services delivery, the provision of transportation stipends, the simplification of management protocols, and the reduction in the frequency of follow up visits.

Africa
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The do’s and don’ts for human resource strategies as external financing makes its exit: lessons from Namibia

Confronting 'scale-down': Assessing Namibia's human resource strategies in the context of decreased HIV/AIDS funding.

Cairney LI, Kapilashrami A. Glob Public Health. 2014 Jan-Feb;9(1-2):198-209. doi: 10.1080/17441692.2014.881525. Epub 2014 Feb 6.

In Namibia, support through the Global Fund and President’s Emergency Plan for AIDS Relief has facilitated an increase in access to HIV and AIDS services over the past 10 years. In collaboration with the Namibian government, these institutions have enabled the rapid scale-up of prevention, treatment and care services. Inadequate human resources capacity in the public sector was cited as a key challenge to initial scale-up; and a substantial portion of donor funding has gone towards the recruitment of new health workers. However, a recent scale-down of donor funding to the Namibian health sector has taken place, despite the country’s high HIV and AIDS burden. With a specific focus on human resources, this paper examines the extent to which management processes that were adopted at scale-up have proven sustainable in the context of scale-down. Drawing on data from 43 semi-structured interviews, we argue that human resources planning and management decisions made at the onset of the country’s relationship with the two institutions appear to be primarily driven by the demands of rapid scale-up and counter-productive to the sustainability of interventions.

Abstract access 

Editor’s notes: Some countries graduate to higher income categories and become ineligible for funding from major donors, such as the Global Fund and PEPFAR. As this happens, it is increasingly important to draw lessons on how to manage this transition from international to domestic financing and ownership. Using the case of human resource management, this study underscores the need to establish exit strategies early on. It also emphasises the need to ensure the integration of management processes within government systems. These are deemed necessary if high service coverage rates are to be maintained. The case study documents how additional health professionals were recruited at higher salaries than government salaries through a parallel recruitment system.  This was done in order to meet the needs of service scale-up. However, that approach led to an unsustainable situation. Sudden salary cuts jeopardised service continuity and the expectation that these staff would be absorbed on to the government payroll. There appears to be a trade-off between certain structures to enable rapid scale-up and programme sustainability. These ought to be planned for at an early stage of funding partnerships.   

Africa
Namibia
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