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Xie W, Paul RR, Goon IY, Anan A, Rahim A, Hossain MM, Hersch F, Oldenburg B, Chambers J, Mridha MK. Enhancing care quality and accessibility through digital technology-supported decentralisation of hypertension and diabetes management: a proof-of-concept study in rural Bangladesh. BMJ Open 2023; 13:e073743. [PMID: 37984955 PMCID: PMC10660961 DOI: 10.1136/bmjopen-2023-073743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 10/04/2023] [Indexed: 11/22/2023] Open
Abstract
OBJECTIVE The critical shortage of healthcare workers, particularly in rural areas, is a major barrier to quality care for non-communicable diseases (NCD) in low-income and middle-income countries. In this proof-of-concept study, we aimed to test a decentralised model for integrated diabetes and hypertension management in rural Bangladesh to improve accessibility and quality of care. DESIGN AND SETTING The study is a single-cohort proof-of-concept study. The key interventions comprised shifting screening, routine monitoring and dispensing of medication refills from a doctor-managed subdistrict NCD clinic to non-physician health worker-managed village-level community clinics; a digital care coordination platform was developed for electronic health records, point-of-care support, referral and routine patient follow-up. The study was conducted in the Parbatipur subdistrict, Rangpur Division, Bangladesh. PARTICIPANTS A total of 624 participants were enrolled in the study (mean (SD) age, 59.5 (12.0); 65.1% female). OUTCOMES Changes in blood pressure and blood glucose control, patient retention and patient-visit volume at the NCD clinic and community clinics. RESULTS The proportion of patients with uncontrolled blood pressure reduced from 60% at baseline to 26% at the third month of follow-up, a 56% (incidence rate ratio 0.44; 95% CI 0.33 to 0.57) reduction after adjustment for covariates. The proportion of patients with uncontrolled blood glucose decreased from 74% to 43% at the third month of follow-up. Attrition rates immediately after baseline and during the entire study period were 29.1% and 36.2%, respectively. CONCLUSION The proof-of-concept study highlights the potential for involving lower-level primary care facilities and non-physician health workers to rapidly expand much-needed services to patients with hypertension and diabetes in Bangladesh and in similar global settings. Further investigations are needed to evaluate the effectiveness of decentralised hypertension and diabetes care.
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Affiliation(s)
- Wubin Xie
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Rina Rani Paul
- Centre for Non-communicable Diseases and Nutrition, BRAC University James P Grant School of Public Health, Dhaka, Bangladesh
| | - Ian Y Goon
- Tyree Foundation Institute of Health Engineering, UNSW, Sydney, New South Wales, Australia
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- Sprightly Pte Ltd, Singapore
| | - Aysha Anan
- Centre for Non-communicable Diseases and Nutrition, BRAC University James P Grant School of Public Health, Dhaka, Bangladesh
| | | | - Md Mokbul Hossain
- Centre for Non-communicable Diseases and Nutrition, BRAC University James P Grant School of Public Health, Dhaka, Bangladesh
| | | | - Brian Oldenburg
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- School of Psychology and Public Health, La Trobe University, Melbourne, Victoria, Australia
| | - John Chambers
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
- Department of Epidemiology and Biostatistics, Imperial College London, London, UK
| | - Malay Kanti Mridha
- Centre for Non-communicable Diseases and Nutrition, BRAC University James P Grant School of Public Health, Dhaka, Bangladesh
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Sandie AB, Molinari N, Wanjoya A, Kouanfack C, Laurent C, Tchatchueng-Mbougua JB. Non-inferiority test for a continuous variable with a flexible margin in an active controlled trial: an application to the “Stratall ANRS 12110 / ESTHER” trial. Trials 2022; 23:202. [PMID: 35248123 PMCID: PMC8898539 DOI: 10.1186/s13063-022-06118-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 02/15/2022] [Indexed: 11/10/2022] Open
Abstract
Background Non-inferiority trials are becoming increasingly popular in public health and clinical research. The choice of the non-inferiority margin is the cornerstone of such trials. Most of the time, the non-inferiority margin is fixed and constant, determined from historical trials as a fraction of the effect of the reference intervention. But in some circumstances, there may some uncertainty around the reference treatment that one would like to account for when performing the hypothesis testing. In this case, the non-inferiority margin is not fixed in advance and depends on the reference intervention estimate. Hence, the uncertainty surrounding the non-inferiority margin should be accounted for in statistical tests. In this work, we explore how to perform the non-inferiority test for a continuous variable with a flexible margin. Methods We have proposed in this study, two procedures for the non-inferiority test with a flexible margin for continuous endpoints. The proposed test procedures are based on a test statistic and confidence interval approaches respectively. Simulations have been used to assess the performances and properties of the proposed test procedures. An application was done on a real-world clinical data, to assess the efficacy of clinical monitoring alone versus laboratory and clinical monitoring in HIV-infected adult patients. Results Basically, for both proposed methods, the type I error estimate was not dependent on the values of the reference treatment. In the test statistic approach, the type 1 error rate estimate was approximatively equal to the nominal value. It has been found that the confidence interval level determined approximatively the level of significance. For a given nominal type I error α, the appropriate one- and two-sided confidence intervals should be with levels 1−α and 1−2α, respectively. Conclusions Based on the type I error rate and power estimates, the proposed non-inferiority hypothesis test procedures had good performances and were applicable in practice. Trial registration ClinicalTrials.gov NCT00301561. Registered on March 13, 2006, url: https://clinicaltrials.gov/ct2/show/NCT00301561.
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Cerf ME. Quintile distribution of health resourcing in Africa. COGENT MEDICINE 2021. [DOI: 10.1080/2331205x.2021.1997161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- Marlon E. Cerf
- Grants, Innovation and Product Development, South African Medical Research Council, Cape Town, South Africa
- Biomedical Research and Innovation Platform, South African Medical Research Council, Cape Town, South Africa
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The effectiveness of the role of advanced nurse practitioners compared to physician-led or usual care: A systematic review. INTERNATIONAL JOURNAL OF NURSING STUDIES ADVANCES 2021. [DOI: 10.1016/j.ijnsa.2021.100034] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Tsui S, Kennedy CE, Moulton LH, Chang LW, Farley JE, Torpey K, van Praag E, Koole O, Ford N, Wabwire-Mangen F, Denison JA. HIV care and treatment models and their association with medication possession ratio among treatment-experienced adults in three African countries. Trop Med Int Health 2021; 26:1481-1493. [PMID: 34265155 PMCID: PMC8563398 DOI: 10.1111/tmi.13654] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE How clinics structure the delivery of antiretroviral therapy (ART) services may influence patient adherence. We assessed the relationship between models of HIV care delivery and adherence as measured by medication possession ratio (MPR) among treatment-experienced adults in Tanzania, Uganda and Zambia. METHODS Eighteen clinics were grouped into three models of HIV care. Model 1-Traditional and Model 2-Mixed represented task-sharing of clinical services between physicians and clinical officers, distinguished by whether nurses played a role in clinical care; in Model 3-Task-Shifted, clinical officers and nurses shared clinical responsibilities without physicians. We assessed MPR among 3,419 patients and calculated clinic-level MPR summaries. We then calculated the mean differences of percentages and adjusted residual ratio (aRR) of the association between models of care and incomplete adherence, defined as a MPR <90%, adjusting for individual-level characteristics. RESULTS In the adjusted analysis, patients in Model 1-Traditional were more likely than patients in Model 2-Mixed to have MPR <90% (aRR = 1.60, 95% CI 1-2.48). Patients in Model 1-Traditional were no more likely than patients in Model 3-Task-Shifted to have a MPR <90% (aRR = 1.58, 95% 0.88-2.85). There was no evidence of differences in MPR <90% between Model 2-Mixed and Model 3-Task-Shifted (aRR = 0.99, 95% CI 0.59-1.66). CONCLUSION Non-physician-led ART programmes were associated with adherence levels as good as or better than physician-led ART programmes. Additional research is needed to optimise models of care to support patients on lifelong treatment.
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Affiliation(s)
- Sharon Tsui
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Caitlin E. Kennedy
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Lawrence H. Moulton
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Larry W. Chang
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
- Department of Medicine – Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Jason E. Farley
- Department of Medicine – Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, USA
- The REACH Initiative of The Johns Hopkins School of Nursing, Baltimore, USA
- University of KwaZulu Natal, Durban, South Africa
- Association of Nurses in AIDS Care, Akron, USA
| | - Kwasi Torpey
- School of Public Health, University of Ghana College of Health Sciences, Accra, Ghana
| | | | - Olivier Koole
- Clinical Sciences Department, Institute of Tropical Medicine, Antwerp, Belgium
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, UK
| | - Nathan Ford
- Dept HIV, World Health Organization, Geneva, Switzerland
| | - Fred Wabwire-Mangen
- Department of Epidemiology and Biostatistics, Makerere University School of Public Health, Kampala, Uganda
| | - Julie A. Denison
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
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Sekiziyivu BA, Bancroft E, Rodriguez EM, Sendagala S, Nasirumbi MP, Najjengo MS, Kiragga AN, Musaazi J, Musinguzi J, Sande E, Brad B, Dalal S, Byakika-Jayne T, Kambugu A. Task Shifting for Initiation and Monitoring of Antiretroviral Therapy for HIV-Infected Adults in Uganda: The SHARE Trial. J Acquir Immune Defic Syndr 2021; 86:e71-e79. [PMID: 33230029 PMCID: PMC7879828 DOI: 10.1097/qai.0000000000002567] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 10/09/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND With countries moving toward the World Health Organization's "Treat All" recommendation, there is a need to initiate more HIV-infected persons into antiretroviral therapy (ART). In resource-limited settings, task shifting is 1 approach that can address clinician shortages. SETTING Uganda. METHODS We conducted a randomized controlled trial to test if nurse-initiated and monitored ART (NIMART) is noninferior to clinician-initiated and monitored ART in HIV-infected adults in Uganda. Study participants were HIV-infected, ART-naive, and clinically stable adults. The primary outcome was a composite end point of any of the following: all-cause mortality, virological failure, toxicity, and loss to follow-up at 12 months post-ART initiation. RESULTS Over half of the study cohort (1,760) was women (54.9%). The mean age was 35.1 years (SD 9.51). Five hundred thirty-three (31.6%) participants experienced the composite end point. At 12 months post-ART initiation, nurse-initiated and monitored ART was noninferior to clinician-initiated and monitored ART. The intention-to-treat site-adjusted risk differences for the composite end point were -4.1 [97.5% confidence interval (CI): = -9.8 to 0.2] with complete case analysis and -3.4 (97.5% CI: = -9.1 to 2.5) with multiple imputation analysis. Per-protocol site-adjusted risk differences were -3.6 (97.5% CI: = -10.5 to 0.6) for complete case analysis and -3.1 (-8.8 to 2.8) for multiple imputation analysis. This difference was within hypothesized margins (6%) for noninferiority. CONCLUSIONS Nurses were noninferior to clinicians for initiation and monitoring of ART. Task shifting to trained nurses is a viable means to increase access to ART. Future studies should evaluate NIMART for other groups (e.g., children, adolescents, and unstable patients).
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Affiliation(s)
- Brian Arthur Sekiziyivu
- Research Department, Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Elizabeth Bancroft
- Division of Global HIV and TB, Centers for Disease Control and Prevention, Entebbe, Uganda
| | - Evelyn M Rodriguez
- Division of Global HIV and TB, Centers for Disease Control and Prevention, Atlanta, GA
| | - Samuel Sendagala
- Division of Global HIV and TB, Centers for Disease Control and Prevention, Entebbe, Uganda
| | | | - Marjorie Sserunga Najjengo
- Research Department, Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Agnes N Kiragga
- Research Department, Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Joseph Musaazi
- Research Department, Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Joshua Musinguzi
- AIDS Control Programme, AIDS Control Program, Ministry of Health, Kampala, Uganda
| | - Enos Sande
- Division of Global HIV and TB, Centers for Disease Control and Prevention, Entebbe, Uganda
| | - Bartholow Brad
- Division of Global HIV and TB, Centers for Disease Control and Prevention, Atlanta, GA
| | - Shona Dalal
- World Health Organization, Geneva, Switzerland ; and
| | - Tusiime Byakika-Jayne
- Department of Public Health, School of Health Sciences, Soroti University, Soroti, Uganda
| | - Andrew Kambugu
- Research Department, Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
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Point-of-care and Near Real-time Testing for Antiretroviral Adherence Monitoring to HIV Treatment and Prevention. Curr HIV/AIDS Rep 2021; 17:487-498. [PMID: 32627120 DOI: 10.1007/s11904-020-00512-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE OF REVIEW In this report, we review the need for point-of-care (POC) or near real-time testing for antiretrovirals, progress in the field, evidence for guiding implementation of these tests globally, and future directions in objective antiretroviral therapy (ART) or pre-exposure prophylaxis (PrEP) adherence monitoring. RECENT FINDINGS Two cornerstones to end the HIV/AIDS pandemic are ART, which provides individual clinical benefits and eliminates forward transmission, and PrEP, which prevents HIV acquisition with high effectiveness. Maximizing the individual and public health benefits of these powerful biomedical tools requires high and sustained antiretroviral adherence. Routine monitoring of medication adherence in individuals receiving ART and PrEP may be an important component in interpreting outcomes and supporting optimal adherence. Existing practices and subjective metrics for adherence monitoring are often inaccurate or unreliable and, therefore, are generally ineffective for improving adherence. Laboratory measures of antiretroviral concentrations using liquid chromatography tandem mass spectrometry have been utilized in research settings to assess medication adherence, although these are too costly and resource-intensive for routine use. Newer, less costly technologies such as antibody-based methods can provide objective drug-level measurement and may allow for POC or near-patient adherence monitoring in clinical settings. When coupled with timely and targeted counseling, POC drug-level measures can support adherence clinic-based interventions to ART or PrEP in near real time.
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Farley JE, Ndjeka N, Mlandu K, Lowensen K, Geiger K, Nguyen Y, Budhathoki C, Stamper PD. Preparing the healthcare workforce in South Africa for short-course rifampicin-resistant TB treatment: inter-professional training and task-sharing considerations. HUMAN RESOURCES FOR HEALTH 2021; 19:6. [PMID: 33407541 PMCID: PMC7788975 DOI: 10.1186/s12960-020-00552-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 12/22/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND Treatment for rifampicin-resistant Mycobacterium tuberculosis (RR-TB) is complex, however, shorter treatment, with newer antimicrobials are improving treatment outcomes. The South African National Department of Health (NDoH) recently accelerated the rollout of 9-month, all-oral, RR-TB short-course regimens. We sought to evaluate an inter-professional training program using pre-test and post-test performance of Professional Nurses (PNs), Advanced Practice Professional Nurses (APPNs) and Medical Officers (MOs) to inform: (a) training needs across cadres; (b) knowledge performance, by cadres; and (c) training differences in knowledge by nurse type. METHODS A 4-day didactic and case-based clinical decision support course for RR-TB regimens in South Africa (SA) was developed, reviewed and nationally accredited. Between February 2017 and July 2018, 12 training events were held. Clinicians who may initiate RR-TB treatment, specifically MOs and PN/APPNs with matched pre-post tests and demographic surveys were analyzed. Descriptive statistics are provided. Pre-post test evaluations included 25 evidence-based clinically related questions about RR-TB diagnosis, treatment, and care. RESULTS Participants (N = 842) participated in testing, and matched evaluations were received for 800 (95.0%) training participants. Demographic data were available for 793 (99.13%) participants, of whom 762 (96.1%) were MOs, or nurses, either PN or APPNs. Average correct response pre-test and post-test scores were 61.7% (range 7-24 correct responses) and 85.9% (range 12-25), respectively. Overall, 95.8% (730/762) of participants demonstrated improved knowledge. PNs improved on average 25% (6.22 points), whereas MOs improved 10% (2.89 points) with better mean test scores on both pre- and post-test (p < 0.000). APPNs performed the same as the MOs on post-test scores (p = NS). CONCLUSIONS The inter-professional training program in short-course RR-TB treatment improved knowledge for participants. MOs had significantly greater pre-test scores. Of the nurses, APPNs outperformed other PNs, and performed equally to MOs on post-test scores, suggesting this advanced cadre of nurses might be the most appropriate to initiate and monitor treatment in close collaboration with MOs. All cadres of nurse reported the need for additional clinical training and mentoring prior to managing such patients.
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Affiliation(s)
- Jason E Farley
- The REACH Initiative, Johns Hopkins University School of Nursing, 855 N. Wolfe Street | Rangos Building Suite # 601, Mailbox #30, Baltimore, MD, 21205, United States of America.
| | - Norbert Ndjeka
- National Department of Health, CBD, Civitas Building, 222 Thabo Sehume St, Pretoria, 0001, South Africa
| | - Khaya Mlandu
- The REACH Initiative, Johns Hopkins University School of Nursing, 855 N. Wolfe Street | Rangos Building Suite # 601, Mailbox #30, Baltimore, MD, 21205, United States of America
| | - Kelly Lowensen
- The REACH Initiative, Johns Hopkins University School of Nursing, 855 N. Wolfe Street | Rangos Building Suite # 601, Mailbox #30, Baltimore, MD, 21205, United States of America
| | - Keri Geiger
- The REACH Initiative, Johns Hopkins University School of Nursing, 855 N. Wolfe Street | Rangos Building Suite # 601, Mailbox #30, Baltimore, MD, 21205, United States of America
| | - Yen Nguyen
- The REACH Initiative, Johns Hopkins University School of Nursing, 855 N. Wolfe Street | Rangos Building Suite # 601, Mailbox #30, Baltimore, MD, 21205, United States of America
| | - Chakra Budhathoki
- The REACH Initiative, Johns Hopkins University School of Nursing, 855 N. Wolfe Street | Rangos Building Suite # 601, Mailbox #30, Baltimore, MD, 21205, United States of America
| | - Paul D Stamper
- The REACH Initiative, Johns Hopkins University School of Nursing, 855 N. Wolfe Street | Rangos Building Suite # 601, Mailbox #30, Baltimore, MD, 21205, United States of America
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9
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Nursing Contributions to Ending the Global Adolescent and Young Adult HIV Pandemic. J Assoc Nurses AIDS Care 2020; 32:264-282. [DOI: 10.1097/jnc.0000000000000227] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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10
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Porter JD, Porter MNM, Du Plessis M. Not yet 90-90-90: A quality improvement approach to human immunodeficiency virus viral suppression in paediatric patients in the rural Eastern Cape, South Africa. S Afr Fam Pract (2004) 2020; 62:e1-e6. [PMID: 33179951 PMCID: PMC7674377 DOI: 10.4102/safp.v62i1.5169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 07/31/2020] [Accepted: 08/08/2020] [Indexed: 11/12/2022] Open
Abstract
Background A strategy implemented by the South African Department of Health to manage the high burden of human immunodeficiency virus (HIV) has been to task-shift services to primary health care clinics. Outcomes of paediatric patients with HIV are poorer than those of adults, particularly in rural areas. Viral suppression in paediatric patients at the feeder clinics of a rural South African hospital was anecdotally far below the aim of the Joint United Nations Programme on HIV/AIDS (UNAIDS) of 90%. Methods A quality improvement approach was used to conduct a baseline assessment of HIV viral suppression in paediatric patients and other process measures, implement a clinical mentorship intervention and evaluate its effectiveness. Results An initial audit of 235 clinical folders of paediatric patients with HIV revealed a viral suppression of 55.3%. Other poor measures included prescription accuracy, viral loads performed within schedule and response to successive high viral loads. A clinical mentorship intervention using dedicated doctor outreach was implemented and the audit repeated after 12 months (263 folders). Viral suppression improved to 67.4%, as did most other process measures. Conclusion The quality improvement approach regarding the aim to significantly improve viral suppression in paediatric patients through the implementation of clinical mentorship was successful.
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Affiliation(s)
- James D Porter
- Department of Family Medicine and Rural Health, Walter Sisulu University, Mthatha, South Africa; and, Madwaleni Hospital, Elliotdale.
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Iterative Development of an mHealth Intervention to Support Antiretroviral Therapy Initiation and Adherence Among Female Sex Workers in Mombasa, Kenya. J Assoc Nurses AIDS Care 2020; 31:145-156. [PMID: 31868829 DOI: 10.1097/jnc.0000000000000157] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Nurses have an integral role to play in achieving the 95-95-95 goals to stem the HIV epidemic. We used the Information-Motivation-Behavioral Skills (IMB) theoretical model to develop a nurse-delivered, mHealth intervention to support antiretroviral therapy adherence among female sex workers living with HIV in Mombasa, Kenya. Twenty-three purposively sampled female sex workers living with HIV participated in 5 focus group discussions to iteratively develop the message content as well as the format and structure of the nurse-delivered, text-based intervention. Focus group discussion interview guides were developed in accordance with the IMB model. Transcripts were analyzed according to IMB themes, and findings were used to develop the intervention. Information-oriented texts addressed concerns and misconceptions; motivation-oriented texts reinforced women's desires to feel healthy enough to engage in activities; and behavioral skills-oriented texts included strategies to remember medication doses. The nurse-delivered, theory-based, culturally tailored intervention to support medication adherence was evaluated.
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Bobbins AC, Burton S, Fogarty TL. Different models of pharmaceutical services and care in primary healthcare clinics in the Eastern Cape, South Africa: Challenges and opportunities for pharmacy practice. Afr J Prim Health Care Fam Med 2020; 12:e1-e11. [PMID: 32787403 PMCID: PMC7433309 DOI: 10.4102/phcfm.v12i1.2323] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 04/01/2020] [Accepted: 04/22/2020] [Indexed: 11/19/2022] Open
Abstract
Background Primary health care (PHC) re-engineering forms a crucial part of South Africa’s National Health Insurance (NHI), with pharmaceutical services and care being crucial to treatment outcomes. However, owing to a shortage of pharmacists within PHC clinics, task-shifting of the dispensing process to pharmacist’s assistants and nurses is common practice. The implications of this task-shifting process on the provision of pharmaceutical services and care remains largely unstudied. Aim The study aimed to explore the pharmacist-based, pharmacist’s assistant-based and nurse-based dispensing models within the PHC setting. Setting The Nelson Mandela Bay Health District, South Africa. Methods A mixed methods approach was utilised comprising of Phase 1: a pharmaceutical services audit to analyse pharmaceutical service provision and Phase 2: semi-structured interviews to describe the pharmaceutical care provision within each dispensing model thematically. Results Pharmaceutical services partially fulfilled minimum standards within all models, however, challenges exist that limit the quality of these services. Phase 2 showed that the provision of pharmaceutical care within all models was restricted by context-related constraints, thus patient-centred activities to underpin pharmaceutical services were limited. Conclusion Although pharmaceutical services may have been available for all models, compromised quality of these services impacted overall quality of care. Limited pharmaceutical care provision was evident within each dispensing model. The results raised concerns about the current utilisation of pharmacy personnel, including the pharmacist, within the PHC setting. Further opportunities exist, if constraints allow, for the pharmacist to contribute to better patient-centred care.
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Affiliation(s)
- Amy C Bobbins
- Department of Pharmacy, Faculty of Health Sciences, Nelson Mandela University, Port Elizabeth.
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13
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Mutabazi JC, Gray C, Muhwava L, Trottier H, Ware LJ, Norris S, Murphy K, Levitt N, Zarowsky C. Integrating the prevention of mother-to-child transmission of HIV into primary healthcare services after AIDS denialism in South Africa: perspectives of experts and health care workers - a qualitative study. BMC Health Serv Res 2020; 20:582. [PMID: 32586318 PMCID: PMC7318762 DOI: 10.1186/s12913-020-05381-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 05/31/2020] [Indexed: 11/23/2022] Open
Abstract
Background Integrating Prevention of Mother-to-Child Transmission (PMTCT) programmes into routine health services under complex socio-political and health system conditions is a priority and a challenge. The successful rollout of PMTCT in sub-Saharan Africa has decreased Human Immunodeficiency Virus (HIV), reduced child mortality and improved maternal health. In South Africa, PMTCT is now integrated into existing primary health care (PHC) services and this experience could serve as a relevant example for integrating other programmes into comprehensive primary care. This study explored the perspectives of both experts or key informants and frontline health workers (FHCWs) in South Africa on PMTCT integration into PHC in the context of post-AIDS denialism using a Complex Adaptive Systems framework. Methods A total of 20 in-depth semi-structured interviews were conducted; 10 with experts including national and international health systems and HIV/PMTCT policy makers and researchers, and 10 FHCWs including clinic managers, nurses and midwives. All interviews were conducted in person, audio-recorded and transcribed. Three investigators collaborated in coding transcripts and used an iterative approach for thematic analysis. Results Experts and FHCWs agreed on the importance of integrated PMTCT services. Experts reported a slow and partial integration of PMTCT programmes into PHC following its initial rollout as a stand-alone programme in the aftermath of the AIDS denialism period. Experts and FHCWs diverged on the challenges associated with integration of PMTCT. Experts highlighted bureaucracy, HIV stigma and discrimination and a shortage of training for staff as major barriers to PMTCT integration. In comparison, FHCWs emphasized high workloads, staff turnover and infrastructural issues (e.g., lack of rooms, small spaces) as their main challenges to integration. Both experts and FHCWs suggested that working with community health workers, particularly in the post-partum period, helped to address cases of loss to follow-up of women and their babies and to improve linkages to polymerase-chain reaction (PCR) testing and immunisation. Conclusions Despite organised efforts in South Africa, experts and FHCWs reported multiple barriers for the full integration of PMTCT in PHC, especially postpartum. The results suggest opportunities to address operational challenges towards more integrated PMTCT and other health services in order to improve maternal and child health.
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Affiliation(s)
- Jean Claude Mutabazi
- Département de médecine sociale et préventive, École de Santé Publique, Université de Montréal, Pavillon 7101, Avenue du Parc, Montréal, QC, H3N 1X7, Canada. .,Centre de recherche en santé publique (CReSP), Université de Montréal et CIUSSS du Centre-Sud-de-l'Île-de-Montréal, Montréal, QC, H3L 1M3, Canada. .,Centre de Recherche du Centre Hospitalier Universitaire Sainte Justine, Montréal, QC, H3T 1C5,, Canada.
| | - Corie Gray
- Collaboration for Evidence, Research and Impact in Public Health, School of Public Health, Curtin University, Kent Street, Bentley, Perth, Western Australia 6102, Australia
| | - Lorrein Muhwava
- Division of Endocrinology, Department of Medicine, Faculty of Health Science, University of Cape Town, Chronic Disease Initiative for Africa, J Floor, Old Main Building, Groote Schuur Hospital, Observatory 7925, Cape Town, Western Cape, South Africa
| | - Helen Trottier
- Département de médecine sociale et préventive, École de Santé Publique, Université de Montréal, Pavillon 7101, Avenue du Parc, Montréal, QC, H3N 1X7, Canada.,Centre de Recherche du Centre Hospitalier Universitaire Sainte Justine, Montréal, QC, H3T 1C5,, Canada
| | - Lisa Jayne Ware
- Developmental Pathways for Health Research Unit, Department of Paediatrics, School of Clinical Medicine, University of the Witwatersrand, 26 Chris Hani Road, Chris Hani Baragwanath Academic Hospital, Soweto, Johannesburg, South Africa
| | - Shane Norris
- Developmental Pathways for Health Research Unit, Department of Paediatrics, School of Clinical Medicine, University of the Witwatersrand, 26 Chris Hani Road, Chris Hani Baragwanath Academic Hospital, Soweto, Johannesburg, South Africa
| | - Katherine Murphy
- Collaboration for Evidence, Research and Impact in Public Health, School of Public Health, Curtin University, Kent Street, Bentley, Perth, Western Australia 6102, Australia
| | - Naomi Levitt
- Collaboration for Evidence, Research and Impact in Public Health, School of Public Health, Curtin University, Kent Street, Bentley, Perth, Western Australia 6102, Australia
| | - Christina Zarowsky
- Département de médecine sociale et préventive, École de Santé Publique, Université de Montréal, Pavillon 7101, Avenue du Parc, Montréal, QC, H3N 1X7, Canada.,Centre de recherche en santé publique (CReSP), Université de Montréal et CIUSSS du Centre-Sud-de-l'Île-de-Montréal, Montréal, QC, H3L 1M3, Canada.,School of Public Health, University of the Western Cape, Robert Sobukwe Rd, Bellville 7535, Cape Town, Western Cape, South Africa
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14
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Zakumumpa H. Reimagining the role of the nursing workforce in Uganda after more than a decade of ART scale-up. HUMAN RESOURCES FOR HEALTH 2020; 18:39. [PMID: 32471426 PMCID: PMC7257122 DOI: 10.1186/s12960-020-00479-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 05/11/2020] [Indexed: 05/25/2023]
Abstract
BACKGROUND The expanding roles and increasing importance of the nursing workforce in health services delivery in resource-limited settings is not adequately documented and sufficiently recognized in the current literature. Drawing upon the theme of 2020 as the International Year of the Nurse and the Midwife, we set out to describe how the role of nurses expanded tremendously in health facilities in Uganda during the era of anti-retroviral therapy (ART) scale-up that commenced in June 2004. METHODS We employed a mixed-methods sequential explanatory research design. Phase I entailed a cross-sectional health facility survey (n = 195) to assess the extent to which human resource management strategies (such as task shifting) were common. Phase II entailed a qualitative multiple case study of 16 (of the 195) health facilities for an in-depth understanding of the strategies adopted (e.g. nurse-centred HIV care). Descriptive analyses were performed in STATA (v 13) while qualitative data were analysed by thematic approach. RESULTS We found that nurses were the most represented cadre of health workers involved in the overall leadership of HIV clinics across Uganda. Most nurse-led HIV clinics were based in rural settings; however, this trend was fairly even across setting (rural/urban/peri-urban). While 181 (93%) health facilities allowed non-physician cadre to prescribe ART, a number of health facilities (n = 36) or 18% deliberately adopted nurse-led HIV care models. Nurses were empowered to be multi-skilled with a wide range of competencies across the HIV care continuum right from HIV testing to mainstream clinical HIV disease management. In several facilities, nursing cadre were the backbone of ART service delivery. A select number of facilities devised differentiated models of task shifting from physicians to nurses in which the latter handled patients who were stable on ART. CONCLUSION Overall, our study reveals a wide expansion in the scope-of-practice of nurses during ART scale-up in Uganda. Nurses were thrust in roles of HIV disease management that were traditionally the preserve of physicians. Our study underscores the importance of reforming regulatory frameworks governing nursing workforce scope of practice such as the need for developing a policy on task shifting which is currently lacking in Uganda.
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Affiliation(s)
- Henry Zakumumpa
- Makerere University, School of Public Health, P O Box 7072, Kampala, Uganda.
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15
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Abstract
PURPOSE OF REVIEW Differentiated service delivery (DSD) has emerged as an approach for HIV programs seeking to better serve the needs of people living with HIV, reduce unnecessary burdens on the health system, and improve client outcomes. We reviewed recent evidence that addresses the challenge of DSD scale-up. RECENT FINDINGS Most current evidence focuses on treatment of clinically stable adult clients in high HIV prevalence settings. Nonetheless, a growing body of research is emerging on how the concept of differentiation is being applied to HIV testing, linkage, and initiation; service delivery to specific demographic groups including key populations - MSM, people who inject drugs, people in prisons, sex workers, and transgender people; service delivery to adolescents and pregnant women; and impact on related medical conditions like advanced HIV. There is also an increasing emphasis on measuring client experience. Key barriers to scale-up include the capacity of monitoring and evaluation systems, access to viral load monitoring and funding for community-led demand generation efforts. Another barrier is the lack of sufficient data to evaluate the various manifestations of the DSD model. SUMMARY Emerging evidence is providing welcome nuance to the discourse on the concept of DSD for HIV. The challenge will be taking evolving DSD concepts from pilot to scale. Countries must review their particular context, define the expected needs of their clients in different settings, introduce appropriate models - and be willing to adjust programming based on quantitative and qualitative outcomes.
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16
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Abstract
Purpose of Review Clinical trials have found that PrEP is highly effective in reducing risk of HIV acquisition across types of exposure, gender, PrEP regimens, and dosing schemes. Evidence is urgently needed to inform scale-up of PrEP to meet the ambitious WHO/UNAIDS prevention target of 3,000,000 individuals on PrEP by 2020. Recent Findings Successful models of delivering HIV services at scale evolved from years of formal research and programmatic evidence. These efforts produced lessons-learned relevant for scaling-up PrEP delivery, including the importance of streamlining laboratory tests, expanding prescription and management authority, differentiating medication access points, and reducing stigma and barriers of parental consent for PrEP uptake. Further research is especially needed in areas differentiating PrEP from ART delivery, including repeat HIV testing to ensure HIV negative status and defining and measuring prevention-effective adherence. Summary Evidence from 15 years of ART scale-up could immediately inform a public health approach to PrEP delivery.
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17
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Barrera-Cancedda AE, Riman KA, Shinnick JE, Buttenheim AM. Implementation strategies for infection prevention and control promotion for nurses in Sub-Saharan Africa: a systematic review. Implement Sci 2019; 14:111. [PMID: 31888673 PMCID: PMC6937686 DOI: 10.1186/s13012-019-0958-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 12/02/2019] [Indexed: 12/13/2022] Open
Abstract
Background Despite impressive reductions in infectious disease burden within Sub-Saharan Africa (SSA), half of the top ten causes of poor health or death in SSA are communicable illnesses. With emerging and re-emerging infections affecting the region, the possibility of healthcare-acquired infections (HAIs) being transmitted to patients and healthcare workers, especially nurses, is a critical concern. Despite infection prevention and control (IPC) evidence-based practices (EBP) to minimize the transmission of HAIs, many healthcare systems in SSA are challenged to implement them. The purpose of this review is to synthesize and critique what is known about implementation strategies to promote IPC for nurses in SSA. Methods The databases, PubMed, Ovid/Medline, Embase, Cochrane, and CINHAL, were searched for articles with the following criteria: English language, peer-reviewed, published between 1998 and 2018, implemented in SSA, targeted nurses, and promoted IPC EBPs. Further, 6241 search results were produced and screened for eligibility to identify implementation strategies used to promote IPC for nurses in SSA. A total of 61 articles met the inclusion criteria for the final review. The articles were evaluated using the Joanna Briggs Institute’s (JBI) quality appraisal tools. Results were reported using PRISMA guidelines. Results Most studies were conducted in South Africa (n = 18, 30%), within the last 18 years (n = 41, 67%), and utilized a quasi-experimental design (n = 22, 36%). Few studies (n = 14, 23%) had sample populations comprising nurses only. The majority of studies focused on administrative precautions (n = 36, 59%). The most frequent implementation strategies reported were education (n = 59, 97%), quality management (n = 39, 64%), planning (n = 33, 54%), and restructure (n = 32, 53%). Penetration and feasibility were the most common outcomes measured for both EBPs and implementation strategies used to implement the EBPs. The most common MAStARI and MMAT scores were 5 (n = 19, 31%) and 50% (n = 3, 4.9%) respectively. Conclusions As infectious diseases, especially emerging and re-emerging infectious diseases, continue to challenge healthcare systems in SSA, nurses, the keystones to IPC practice, need to have a better understanding of which, in what combination, and in what context implementation strategies should be best utilized to ensure their safety and that of their patients. Based on the results of this review, it is clear that implementation of IPC EBPs in SSA requires additional research from an implementation science-specific perspective to promote IPC protocols for nurses in SSA.
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Affiliation(s)
| | - Kathryn A Riman
- School of Nursing, University of Pennsylvania, Philadelphia, PA, 19104, USA
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18
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Ngoga G, Park PH, Borg R, Bukhman G, Ali E, Munyaneza F, Tapela N, Rusingiza E, Edwards JK, Hedt-Gauthier B. Outcomes of decentralizing hypertension care from district hospitals to health centers in Rwanda, 2013-2014. Public Health Action 2019; 9:142-147. [PMID: 32042605 DOI: 10.5588/pha.19.0007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 07/26/2019] [Indexed: 02/08/2023] Open
Abstract
Setting Three district hospitals (DHs) and seven health centers (HCs) in rural Rwanda. Objective To describe follow-up and treatment outcomes in stage 1 and 2 hypertension patients receiving care at HCs closer to home in comparison to patients receiving care at DHs further from home. Design A retrospective descriptive cohort study using routinely collected data involving adult patients aged ⩾18 years in care at chronic non-communicable disease clinics and receiving treatment for hypertension at DH and HC between 1 January 2013 and 30 June 2014. Results Of 162 patients included in the analysis, 36.4% were from HCs. Patients at DHs travelled significantly further to receive care (10.4 km vs. 2.9 km for HCs, P < 0.01). Odds of being retained were significantly lower among DH patients when not adjusting for distance (OR 0.11, P = 0.01). The retention effect was consistent but no longer significant when adjusting for distance (OR 0.18, P = 0.10). For those retained, there was no significant difference in achieving blood pressure targets between the DHs and HCs. Conclusion By removing the distance barrier, decentralizing hypertension management to HCs may improve long-term patient retention and could provide similar hypertension outcomes as DHs.
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Affiliation(s)
- G Ngoga
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | - P H Park
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda.,Department of Medicine, Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - R Borg
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | - G Bukhman
- Department of Medicine, Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.,Partners In Health, Boston, MA, USA
| | - E Ali
- Médecins Sans Frontières, Operational Centre Brussels, Operational Research Unit (LuxOR), Luxembourg, Luxembourg
| | - F Munyaneza
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | - N Tapela
- Department of Medicine, Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA.,Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - E Rusingiza
- Ministry of Health, Kigali, Rwanda.,School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - J K Edwards
- Médecins Sans Frontières, Operational Centre Brussels, Operational Research Unit (LuxOR), Luxembourg, Luxembourg.,Department of Global Health, University of Washington, Seattle, WA, USA
| | - B Hedt-Gauthier
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
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A Successful Model of Expedited Antiretroviral Therapy for Clinically Stable Patients Living With HIV in Haiti. J Acquir Immune Defic Syndr 2019; 79:70-76. [PMID: 29771791 DOI: 10.1097/qai.0000000000001725] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Recommendations for universal antiretroviral therapy have greatly increased the number of HIV-infected patients who qualify for treatment, particularly with early clinical disease. Less intensive models of care are needed for clinically stable patients. SETTING A rapid pathway (RP) model of expedited outpatient care for clinically stable patients was implemented at the Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO) Center, Port-au-Prince, Haiti. Expedited visits included nurse-led assessments and point-of-service antiretroviral therapy dispensing. METHODS We conducted a retrospective analysis including patients who initiated RP care between June 1, 2014, and September 30, 2015, comparing outcomes of patients with timely visit attendance (never >3 days late) with patients with ≥1 nontimely visit within 6 months before RP enrollment. We calculated retention in care and adherence at 12 months, and assessed predictors of both outcomes. RESULTS Of the 2361 patients who initiated RP care during the study period, 1429 (61%) had timely visit attendance and 932 (39%) had ≥1 nontimely visit before RP enrollment. Among RP-enrolled patients, 94% were retained at 12 months and 75% had ≥90% adherence, with higher proportions in those with timely pre-RP visits (95% vs. 92%; 87% vs. 55%). In multivariable analysis, pre-RP visit timeliness was associated with both retention (adjusted odds ratio: 1.67; 95% confidence interval: 1.08 to 2.59) and adherence (adjusted odds ratio: 4.53; 95% confidence interval: 3.58 to 5.72). CONCLUSIONS RP care was associated with high levels of retention and adherence for clinically stable patients. Timeliness of pre-RP visits was predictive of outcomes after RP initiation.
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Kurth AE, Sidle JE, Chhun N, Lizcano JA, Macharia SM, Garcia MM, Mwangi A, Keter A, Siika AM. Computer-Based Counseling Program (CARE+ Kenya) to Promote Prevention and HIV Health for People Living With HIV/AIDS: A Randomized Controlled Trial. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2019; 31:395-406. [PMID: 31550197 PMCID: PMC6764770 DOI: 10.1521/aeap.2019.31.5.395] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
In countries experiencing the dual burden of HIV disease and health care worker shortages, information and communication technology tools offer the potential to help support HIV treatment adherence and secondary HIV transmission risk reduction for people living with HIV/AIDS. We conducted a randomized controlled trial (September 1, 2011-July 12, 2012) with follow-up through April 2013. Participants were recruited from two clinics affiliated with the Academic Model Providing Access to Healthcare program in western Kenya. A total of 236 participants were enrolled, randomly assigned to intervention (n = 118) or risk-assessment only control (n = 118) and followed up for 9 months. Both arms had > 0.5 log10 reduction in viral load over time (p = .0007), a clinically relevant finding. A computer-based counseling tool is feasible and acceptable in a high-volume East African HIV setting and provides evidence-based ART adherence and risk reduction support that may extend health workforce deficits.
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Affiliation(s)
- Ann E. Kurth
- Yale University School of Nursing, Orange, CT, USA
| | - John E. Sidle
- Indiana University, School of Medicine, Department of General Internal Medicine, Indianapolis, IN, USA
| | - Nok Chhun
- Yale University School of Nursing, Orange, CT, USA
| | | | - Stephen M. Macharia
- Moi Teaching and Referral Hospital, Eldoret, Kenya
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | | | - Ann Mwangi
- Moi University, College of Health Sciences, School of Medicine, Department of Behavioral Sciences, Eldoret, Kenya
| | - Alfred Keter
- Moi University, College of Health Sciences, School of Medicine, Department of Behavioral Sciences, Eldoret, Kenya
| | - Abraham M. Siika
- Moi University, College of Health Sciences, School of Medicine, Department of Medicine, Eldoret, Kenya
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
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21
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Point-of-Care HIV Viral Load Testing: an Essential Tool for a Sustainable Global HIV/AIDS Response. Clin Microbiol Rev 2019; 32:32/3/e00097-18. [PMID: 31092508 DOI: 10.1128/cmr.00097-18] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The global public health community has set ambitious treatment targets to end the HIV/AIDS pandemic. With the notable absence of a cure, the goal of HIV treatment is to achieve sustained suppression of an HIV viral load, which allows for immunological recovery and reduces the risk of onward HIV transmission. Monitoring HIV viral load in people living with HIV is therefore central to maintaining effective individual antiretroviral therapy as well as monitoring progress toward achieving population targets for viral suppression. The capacity for laboratory-based HIV viral load testing has increased rapidly in low- and middle-income countries, but implementation of universal viral load monitoring is still hindered by several barriers and delays. New devices for point-of-care HIV viral load testing may be used near patients to improve HIV management by reducing the turnaround time for clinical test results. The implementation of near-patient testing using these new and emerging technologies may be an essential tool for ensuring a sustainable response that will ultimately enable an end to the HIV/AIDS pandemic. In this report, we review the current and emerging technology, the evidence for decentralized viral load monitoring by non-laboratory health care workers, and the additional considerations for expanding point-of-care HIV viral load testing.
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Karimi‐Shahanjarini A, Shakibazadeh E, Rashidian A, Hajimiri K, Glenton C, Noyes J, Lewin S, Laurant M, Colvin CJ. Barriers and facilitators to the implementation of doctor-nurse substitution strategies in primary care: a qualitative evidence synthesis. Cochrane Database Syst Rev 2019; 4:CD010412. [PMID: 30982950 PMCID: PMC6462850 DOI: 10.1002/14651858.cd010412.pub2] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Having nurses take on tasks that are typically conducted by doctors (doctor-nurse substitution, a form of 'task-shifting') may help to address doctor shortages and reduce doctors' workload and human resource costs. A Cochrane Review of effectiveness studies suggested that nurse-led care probably leads to similar healthcare outcomes as care delivered by doctors. This finding highlights the need to explore the factors that affect the implementation of strategies to substitute doctors with nurses in primary care. In our qualitative evidence synthesis (QES), we focused on studies of nurses taking on tasks that are typically conducted by doctors working in primary care, including substituting doctors with nurses or expanding nurses' roles. OBJECTIVES (1) To identify factors influencing implementation of interventions to substitute doctors with nurses in primary care. (2) To explore how our synthesis findings related to, and helped to explain, the findings of the Cochrane intervention review of the effectiveness of substituting doctors with nurses. (3) To identify hypotheses for subgroup analyses for future updates of the Cochrane intervention review. SEARCH METHODS We searched CINAHL and PubMed, contacted experts in the field, scanned the reference lists of relevant studies and conducted forward citation searches for key articles in the Social Science Citation Index and Science Citation Index databases, and 'related article' searches in PubMed. SELECTION CRITERIA We constructed a maximum variation sample (exploring variables such as country level of development, aspects of care covered and the types of participants) from studies that had collected and analysed qualitative data related to the factors influencing implementation of doctor-nurse substitution and the expansion of nurses' tasks in community or primary care worldwide. We included perspectives of doctors, nurses, patients and their families/carers, policymakers, programme managers, other health workers and any others directly involved in or affected by the substitution. We excluded studies that collected data using qualitative methods but did not analyse the data qualitatively. DATA COLLECTION AND ANALYSIS We identified factors influencing implementation of doctor-nurse substitution strategies using a framework thematic synthesis approach. Two review authors independently assessed the methodological strengths and limitations of included studies using a modified Critical Appraisal Skills Programme (CASP) tool. We assessed confidence in the evidence for the QES findings using the GRADE-CERQual approach. We integrated our findings with the evidence from the effectiveness review of doctor-nurse substitution using a matrix model. Finally, we identified hypotheses for subgroup analyses for updates of the review of effectiveness. MAIN RESULTS We included 66 studies (69 papers), 11 from low- or middle-income countries and 55 from high-income countries. These studies found several factors that appeared to influence the implementation of doctor-nurse substitution strategies. The following factors were based on findings that we assessed as moderate or high confidence.Patients in many studies knew little about nurses' roles and the difference between nurse-led and doctor-led care. They also had mixed views about the type of tasks that nurses should deliver. They preferred doctors when the tasks were more 'medical' but accepted nurses for preventive care and follow-ups. Doctors in most studies also preferred that nurses performed only 'non-medical' tasks. Nurses were comfortable with, and believed they were competent to deliver a wide range of tasks, but particularly emphasised tasks that were more health promotive/preventive in nature.Patients in most studies thought that nurses were more easily accessible than doctors. Doctors and nurses also saw nurse-doctor substitution and collaboration as a way of increasing people's access to care, and improving the quality and continuity of care.Nurses thought that close doctor-nurse relationships and doctor's trust in and acceptance of nurses was important for shaping their roles. But nurses working alone sometimes found it difficult to communicate with doctors.Nurses felt they had gained new skills when taking on new tasks. But nurses wanted more and better training. They thought this would increase their skills, job satisfaction and motivation, and would make them more independent.Nurses taking on doctors' tasks saw this as an opportunity to develop personally, to gain more respect and to improve the quality of care they could offer to patients. Better working conditions and financial incentives also motivated nurses to take on new tasks. Doctors valued collaborating with nurses when this reduced their own workload.Doctors and nurses pointed to the importance of having access to resources, such as enough staff, equipment and supplies; good referral systems; experienced leaders; clear roles; and adequate training and supervision. But they often had problems with these issues. They also pointed to the huge number of documents they needed to complete when tasks were moved from doctors to nurses. AUTHORS' CONCLUSIONS Patients, doctors and nurses may accept the use of nurses to deliver services that are usually delivered by doctors. But this is likely to depend on the type of services. Nurses taking on extra tasks want respect and collaboration from doctors; as well as proper resources; good referral systems; experienced leaders; clear roles; and adequate incentives, training and supervision. However, these needs are not always met.
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Affiliation(s)
- Akram Karimi‐Shahanjarini
- Hamadan University of Medical SciencesDepartment of Public HealthMahdeieh Ave. Hamadan, IranHamadanHamadanIran
- Hamadan University of Medical SciencesSocial Determinants of Health Research CenterHamadanIran
| | - Elham Shakibazadeh
- Tehran University of Medical SciencesDepartment of Health Education and Health PromotionTehranTehranIran
| | - Arash Rashidian
- Tehran University of Medical SciencesDepartment of Health Management and Economics, School of Public HealthPoursina AveTehranIran1417613191
| | - Khadijeh Hajimiri
- School of Public Health, Zanjan University of Medical SciencesDepartment of Health Education and Health PromotionZanjanIran
| | - Claire Glenton
- Norwegian Institute of Public HealthPO Box 7004 St Olavs plassOsloNorwayN‐0130
| | - Jane Noyes
- Bangor UniversityCentre for Health‐Related Research, Fron HeulogBangorWalesUKLL57 2EF
| | - Simon Lewin
- Norwegian Institute of Public HealthPO Box 7004 St Olavs plassOsloNorwayN‐0130
- South African Medical Research CouncilHealth Systems Research UnitPO Box 19070TygerbergSouth Africa7505
| | - Miranda Laurant
- Radboud Institute for Health Sciences, IQ healthcareRadboud University Medical CenterPO Box 9101NijmegenNetherlands6500 HB
- Institute of Nursing StudiesHAN University of Applied SciencesNijmegenNetherlands
| | - Christopher J Colvin
- School of Public Health and Family Medicine, University of Cape TownDivision of Social and Behavioural SciencesCape TownSouth Africa
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Harper BD, Nganga W, Armstrong R, Forsyth KD, Ham HP, Keenan WJ, Russ CM. Where are the paediatricians? An international survey to understand the global paediatric workforce. BMJ Paediatr Open 2019; 3:bmjpo-2018-000397. [PMID: 30815583 PMCID: PMC6361365 DOI: 10.1136/bmjpo-2018-000397] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 12/23/2018] [Accepted: 12/26/2018] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE Our primary objective was to examine the global paediatric workforce and to better understand geographic differences in the number of paediatricians globally. Secondary objectives were to describe paediatric workforce expectations, who provides children with preventative care and when children transition out of paediatric care. DESIGN Survey of identified paediatric leaders in each country. SETTING Paediatric association leaders worldwide. MAIN OUTCOME MEASURES Paediatrician numbers, provision of primary care for children, age of transition to adult care. RESULTS Responses were obtained from 121 countries (73% of countries approached). The number of paediatricians per 100 000 children ranged from a median of 0.5 (IQR 0.3-1.4) in low-income countries to 72 (IQR 4-118) in high-income countries. Africa and South-East Asia reported the lowest paediatrician density (median of 0.8 paediatricians per 100 000 children, IQR 0.4-2.6 and median of 4, IQR 3-9, respectively) and fewest paediatricians entering the workforce. 82% of countries reported transition to adult care by age 18% and 39% by age 15. Most countries (91%) but only 64% of low-income countries reported provision of paediatric preventative care (p<0.001, Cochran-Armitage trend test). Systems of primary care provision varied widely. A majority of countries (63%) anticipated increases in their paediatric workforce in the next decade. CONCLUSIONS Paediatrician density mirrors known inequities in health provider distribution. Fewer paediatricians are entering the workforce in areas with already low paediatrician density, which may exacerbate disparities in child health outcomes. In some regions, children transition to adult care during adolescence, with implications for healthcare training and delivery. Paediatrician roles are heterogeneous worldwide, and country-specific strategies should be used to address inequity in child health provision.
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Affiliation(s)
- Beth D Harper
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Waceke Nganga
- Department of Paediatrics and Child Health, Aga Khan University, Nairobi, Kenya
| | | | - Kevin D Forsyth
- Flinders University Faculty of Medicine Nursing and Health Sciences, Adelaide, South Australia, Australia
| | - Hazen P Ham
- Global Pediatric Education Consortium, Chapel Hill, North Carolina, USA
| | - William J Keenan
- Department of Pediatrics, Saint Louis University, St Louis, Missouri, USA
| | - Christiana M Russ
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
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Desalegn H, Aberra H, Berhe N, Mekasha B, Stene-Johansen K, Krarup H, Pereira AP, Gundersen SG, Johannessen A. Treatment of chronic hepatitis B in sub-Saharan Africa: 1-year results of a pilot program in Ethiopia. BMC Med 2018; 16:234. [PMID: 30554571 PMCID: PMC6296040 DOI: 10.1186/s12916-018-1229-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 11/30/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The World Health Organization has set an ambitious goal of eliminating viral hepatitis as a major public health threat by 2030. However, in sub-Saharan Africa, antiviral treatment of chronic hepatitis B (CHB) is virtually unavailable. Herein, we present the 1-year results of a pilot CHB treatment program in Ethiopia. METHODS At a public hospital in Addis Ababa, CHB patients were treated with tenofovir disoproxil fumarate based on simplified eligibility criteria. Baseline assessment included liver function tests, viral markers, and transient elastography (Fibroscan). Changes in laboratory markers were analyzed using Wilcoxon signed-rank tests. Adherence to therapy was measured by pharmacy refill data. RESULTS Out of 1303 patients, 328 (25.2%) fulfilled the treatment criteria and 254 (19.5%) had started tenofovir disoproxil fumarate therapy prior to September 1, 2016. Of the patients who started therapy, 30 (11.8%) died within the first year of follow-up (28 of whom had decompensated cirrhosis), 9 (3.5%) self-stopped treatment, 7 (2.8%) were lost to follow-up, and 4 (1.6%) were transferred out. In patients who completed 12 months of treatment, the median Fibroscan value declined from 12.8 to 10.4 kPa (p < 0.001), 172 of 202 (85.1%) patients with available pharmacy refill data had taken ≥ 95% of their tablets, and 161 of 189 (85.2%) patients with viral load results had suppressed viremia. Virologic failure (≥ 69 IU/mL) at 12 months was associated with high baseline HBV viral load (> 1,000,000 IU/mL; adjusted OR 2.41; 95% CI 1.04-5.55) and suboptimal adherence (< 95%; adjusted OR 3.43, 95% CI 1.33-8.88). CONCLUSIONS This pilot program demonstrated that antiviral therapy of CHB can be realized in Ethiopia with good clinical and virologic response. Early mortality was high in patients with decompensated cirrhosis, underscoring the need for earlier detection of hepatitis B virus infection and timely initiation of treatment, prior to the development of irreversible complications, in sub-Saharan Africa. TRIAL REGISTRATION NCT02344498 (ClinicalTrials.gov identifier). Registered 16 January 2015.
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Affiliation(s)
- Hailemichael Desalegn
- Medical Department, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Hanna Aberra
- Medical Department, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Nega Berhe
- Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia.,Centre for Imported and Tropical Diseases, Oslo University Hospital, Ullevål, PO Box 4956 Nydalen, 0424, Oslo, Norway
| | - Bitsatab Mekasha
- Medical Department, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | | | - Henrik Krarup
- Section of Molecular Diagnostics, Aalborg University Hospital, Aalborg, Denmark
| | | | - Svein Gunnar Gundersen
- Research Unit, Sørlandet Hospital HF, Kristiansand, Norway.,Department of Global Development and Planning, University of Agder, Kristiansand, Norway
| | - Asgeir Johannessen
- Centre for Imported and Tropical Diseases, Oslo University Hospital, Ullevål, PO Box 4956 Nydalen, 0424, Oslo, Norway. .,Department of Infectious Diseases, Vestfold Hospital Trust, Tønsberg, Norway.
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Laurant M, van der Biezen M, Wijers N, Watananirun K, Kontopantelis E, van Vught AJAH. Nurses as substitutes for doctors in primary care. Cochrane Database Syst Rev 2018; 7:CD001271. [PMID: 30011347 PMCID: PMC6367893 DOI: 10.1002/14651858.cd001271.pub3] [Citation(s) in RCA: 175] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Current and expected problems such as ageing, increased prevalence of chronic conditions and multi-morbidity, increased emphasis on healthy lifestyle and prevention, and substitution for care from hospitals by care provided in the community encourage countries worldwide to develop new models of primary care delivery. Owing to the fact that many tasks do not necessarily require the knowledge and skills of a doctor, interest in using nurses to expand the capacity of the primary care workforce is increasing. Substitution of nurses for doctors is one strategy used to improve access, efficiency, and quality of care. This is the first update of the Cochrane review published in 2005. OBJECTIVES Our aim was to investigate the impact of nurses working as substitutes for primary care doctors on:• patient outcomes;• processes of care; and• utilisation, including volume and cost. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), part of the Cochrane Library (www.cochranelibrary.com), as well as MEDLINE, Ovid, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and EbscoHost (searched 20.01.2015). We searched for grey literature in the Grey Literature Report and OpenGrey (21.02.2017), and we searched the International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov trial registries (21.02.2017). We did a cited reference search for relevant studies (searched 27.01 2015) and checked reference lists of all included studies. We reran slightly revised strategies, limited to publication years between 2015 and 2017, for CENTRAL, MEDLINE, and CINAHL, in March 2017, and we have added one trial to 'Studies awaiting classification'. SELECTION CRITERIA Randomised trials evaluating the outcomes of nurses working as substitutes for doctors. The review is limited to primary healthcare services that provide first contact and ongoing care for patients with all types of health problems, excluding mental health problems. Studies which evaluated nurses supplementing the work of primary care doctors were excluded. DATA COLLECTION AND ANALYSIS Two review authors independently carried out data extraction and assessment of risk of bias of included studies. When feasible, we combined study results and determined an overall estimate of the effect. We evaluated other outcomes by completing a structured synthesis. MAIN RESULTS For this review, we identified 18 randomised trials evaluating the impact of nurses working as substitutes for doctors. One study was conducted in a middle-income country, and all other studies in high-income countries. The nursing level was often unclear or varied between and even within studies. The studies looked at nurses involved in first contact care (including urgent care), ongoing care for physical complaints, and follow-up of patients with a particular chronic conditions such as diabetes. In many of the studies, nurses could get additional support or advice from a doctor. Nurse-doctor substitution for preventive services and health education in primary care has been less well studied.Study findings suggest that care delivered by nurses, compared to care delivered by doctors, probably generates similar or better health outcomes for a broad range of patient conditions (low- or moderate-certainty evidence):• Nurse-led primary care may lead to slightly fewer deaths among certain groups of patients, compared to doctor-led care. However, the results vary and it is possible that nurse-led primary care makes little or no difference to the number of deaths (low-certainty evidence).• Blood pressure outcomes are probably slightly improved in nurse-led primary care. Other clinical or health status outcomes are probably similar (moderate-certainty evidence).• Patient satisfaction is probably slightly higher in nurse-led primary care (moderate-certainty evidence). Quality of life may be slightly higher (low-certainty evidence).We are uncertain of the effects of nurse-led care on process of care because the certainty of this evidence was assessed as very low.The effect of nurse-led care on utilisation of care is mixed and depends on the type of outcome. Consultations are probably longer in nurse-led primary care (moderate-certainty evidence), and numbers of attended return visits are slightly higher for nurses than for doctors (high-certainty evidence). We found little or no difference between nurses and doctors in the number of prescriptions and attendance at accident and emergency units (high-certainty evidence). There may be little or no difference in the number of tests and investigations, hospital referrals and hospital admissions between nurses and doctors (low-certainty evidence).We are uncertain of the effects of nurse-led care on the costs of care because the certainty of this evidence was assessed as very low. AUTHORS' CONCLUSIONS This review shows that for some ongoing and urgent physical complaints and for chronic conditions, trained nurses, such as nurse practitioners, practice nurses, and registered nurses, probably provide equal or possibly even better quality of care compared to primary care doctors, and probably achieve equal or better health outcomes for patients. Nurses probably achieve higher levels of patient satisfaction, compared to primary care doctors. Furthermore, consultation length is probably longer when nurses deliver care and the frequency of attended return visits is probably slightly higher for nurses, compared to doctors. Other utilisation outcomes are probably the same. The effects of nurse-led care on process of care and the costs of care are uncertain, and we also cannot ascertain what level of nursing education leads to the best outcomes when nurses are substituted for doctors.
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Affiliation(s)
- Miranda Laurant
- Radboud Institute for Health Sciences, IQ healthcareRadboud University Medical CenterPO Box 9101NijmegenNetherlands6500 HB
- HAN University of Applied SciencesFaculty of Health and Social StudiesNijmegenNetherlands
| | - Mieke van der Biezen
- Radboud Institute for Health Sciences, IQ healthcareRadboud University Medical CenterPO Box 9101NijmegenNetherlands6500 HB
| | | | - Kanokwaroon Watananirun
- Faculty of Medicine, Siriraj Hospital, Mahidol UniversityDepartment of Obstetrics and GynaecologyMahidolThailand
| | - Evangelos Kontopantelis
- The University of ManchesterCentre for Health Informatics, Institute of Population HealthWilliamson Building, 5th FloorOxford RoadManchesterGreater ManchesterUKM13 9PL
| | - Anneke JAH van Vught
- HAN University of Applied SciencesFaculty of Health and Social StudiesNijmegenNetherlands
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Strengthening the health workforce to support integration of HIV and noncommunicable disease services in sub-Saharan Africa. AIDS 2018; 32 Suppl 1:S47-S54. [PMID: 29952790 DOI: 10.1097/qad.0000000000001895] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The successful expansion of HIV services in sub-Saharan Africa has been a signature achievement of global public health. This article explores health workforce-related lessons from HIV scale-up, their implications for integrating noncommunicable disease (NCD) services into HIV programs, ways to ensure that healthcare workers have the knowledge, skills, resources, and enabling environment they need to provide comprehensive integrated HIV/NCD services, and discussion of a priority research agenda. DESIGN AND METHODS We conducted a scoping review of the published and 'gray' literature and drew upon our cumulative experience designing, implementing and evaluating HIV and NCD programs in low-resource settings. RESULTS AND CONCLUSION Lessons learned from HIV programs include the role of task shifting and the optimal use of multidisciplinary teams. A responsible and adaptable policy environment is also imperative; norms and regulations must keep pace with the growing evidence base for task sharing, and early engagement of regulatory authorities will be needed for successful HIV/NCD integration. Ex-ante consideration of work culture will also be vital, given its impact on the quality of service delivery. Finally, capacity building of a robust interdisciplinary workforce is essential to foster integrated patient-centered care. To succeed, close collaboration between the health and higher education sectors is needed and comprehensive competency-based capacity building plans for various health worker cadres along the education and training continuum are required. We also outline research priorities for HIV/NCD integration in three key domains: governance and policy; education, training, and management; and service delivery.
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Visser CA, Wolvaardt JE, Cameron D, Marincowitz GJO. Clinical mentoring to improve quality of care provided at three NIM-ART facilities: A mixed methods study. Afr J Prim Health Care Fam Med 2018; 10:e1-e7. [PMID: 29943605 PMCID: PMC6018522 DOI: 10.4102/phcfm.v10i1.1579] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 04/05/2018] [Accepted: 04/12/2018] [Indexed: 11/20/2022] Open
Abstract
Background The South African Department of Health implemented the nurse-initiated management of antiretroviral treatment (NIM-ART) programme as a policy to decentralise services. Increasing access to ART through nurse initiation results in significant consequences. Aim This study evaluated the quality of care provided, the barriers to the effective rollout of antiretroviral services and the role of a clinical mentor. Setting The study was conducted at three NIM-ART facilities in South Africa. One clinic provided a high standard of care, one had a high defaulter rate, and at the third clinic, treatment failures were missed, and routine bloods were not collected. Methods A mixed methods study design was used. Data were collected using patient satisfaction surveys, review of clinical records, facility audits, focus group interviews, field notes and a reflection diary. Results NIM-ART nurses prescribed rationally and followed antiretroviral guidelines. Mortality rates and loss to follow-up rates were lower than those at the surrounding hospitals, and 91.1% of nurse-monitored patients had an undetectable viral load after a year. The quality of care provided was comparable to doctor-monitored care. The facility audits found recurrent shortages of essential drugs. Patients indicated a high level of satisfaction. Salary challenges, excessive workload, a lack of trained nurses and infrastructural barriers were identified as barriers. On-going mentoring and support by a clinical mentor strengthened each of the facilities, facilitated quality improvement and stimulated health workers to address constraints. Conclusion Clinical mentors are the key to addressing institutional treatment barriers and ensuring quality of patient care.
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Affiliation(s)
- Chris A Visser
- School of Health Systems and Public Health, University of Pretoria.
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Marotta C, Giaquinto C, Di Gennaro F, Chhaganlal KD, Saracino A, Moiane J, Maringhini G, Pizzol D, Putoto G, Monno L, Casuccio A, Vitale F, Mazzucco W. Pathways of care for HIV infected children in Beira, Mozambique: pre-post intervention study to assess impact of task shifting. BMC Public Health 2018; 18:703. [PMID: 29879951 PMCID: PMC5992883 DOI: 10.1186/s12889-018-5646-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 05/31/2018] [Indexed: 11/25/2022] Open
Abstract
Background In 2013, Mozambique implemented task-shifting (TS) from clinical officers to maternal and child nurses to improve care for HIV positive children < 5 years old. A retrospective, pre-post intervention study was designed to evaluate effectiveness of a new pathway of care in a sample of Beira District Local Health Facilities (LHFs), the primary, local, community healthcare services. Methods The study was conducted by accessing registries of At Risk Children Clinics (ARCCs) and HIV Health Services. Two time periods, pre- and post-intervention, were compared using a set of endpoints. Variables distribution was explored using descriptive statistics. T-student, Mann Whitney and Chi-square tests were used for comparisons. Results Overall, 588 HIV infected children (F = 51.4%) were recruited, 330 belonging to the post intervention period. The mean time from referral to ARCC until initiation of ART decreased from 2.3 (± 4.4) to 1.1 (± 5.0) months after the intervention implementation (p-value: 0.000). A significant increase of Isoniazid prophylaxis (O.R.: 2.69; 95%CI: 1.7–4.15) and a decrease of both regular nutritional assessment (O.R. = 0.45; 95%CI: 0.31–0.64) and CD4 count at the beginning of ART (O.R. = 0.46; 95%CI: 0.32–0.65) were documented after the intervention. Conclusions Despite several limitations and controversial results on nutrition assessment and CD4 count at the initiation of ART reported after the intervention, it could be assumed that TS alone may play a role in the improvement of the global effectiveness of care for HIV infected children only if integrated into a wider range of public health measures.
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Affiliation(s)
- Claudia Marotta
- Department of Science for Health Promotion and Mother to Child Care "G. D'Alessandro", University of Palermo, via del vespro, 133, 90127, Palermo, Italy.
| | - Carlo Giaquinto
- Department of Women's and Children's Health, University of Padova, Padova, Italy
| | | | - Kajal D Chhaganlal
- Center for Research in Infectious Diseases, Faculty of Health Sciences, Catholic University of Mozambique, Beira, Mozambique
| | | | - Jorge Moiane
- Center for Research in Infectious Diseases, Faculty of Health Sciences, Catholic University of Mozambique, Beira, Mozambique
| | | | - Damiano Pizzol
- Operational Research Unit, Doctors with Africa, Beira, Mozambique
| | - Giovanni Putoto
- Operational Research Unit, Doctors with Africa, Padova, Italy
| | - Laura Monno
- Clinic of Infectious Diseases, University of Bari, Bari, Italy
| | - Alessandra Casuccio
- Department of Science for Health Promotion and Mother to Child Care "G. D'Alessandro", University of Palermo, via del vespro, 133, 90127, Palermo, Italy
| | - Francesco Vitale
- Department of Science for Health Promotion and Mother to Child Care "G. D'Alessandro", University of Palermo, via del vespro, 133, 90127, Palermo, Italy
| | - Walter Mazzucco
- Department of Science for Health Promotion and Mother to Child Care "G. D'Alessandro", University of Palermo, via del vespro, 133, 90127, Palermo, Italy
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Das J, Woskie L, Rajbhandari R, Abbasi K, Jha A. Rethinking assumptions about delivery of healthcare: implications for universal health coverage. BMJ 2018; 361:k1716. [PMID: 29784870 PMCID: PMC5961312 DOI: 10.1136/bmj.k1716] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Simply providing more resources for universal coverage is not enough to improve health, argue Jishnu Das and colleagues. We also need to ensure good quality of care
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Affiliation(s)
| | - Liana Woskie
- Harvard Initiative on Global Health Quality, Cambridge, MA 02138, USA
| | | | | | - Ashish Jha
- Department of Health Policy and Management, Harvard T H Chan School of Public Health, Harvard Global Health Institute, Boston
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Tsui S, Denison JA, Kennedy CE, Chang LW, Koole O, Torpey K, Van Praag E, Farley J, Ford N, Stuart L, Wabwire-Mangen F. Identifying models of HIV care and treatment service delivery in Tanzania, Uganda, and Zambia using cluster analysis and Delphi survey. BMC Health Serv Res 2017; 17:811. [PMID: 29207973 PMCID: PMC5717830 DOI: 10.1186/s12913-017-2772-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 11/28/2017] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Organization of HIV care and treatment services, including clinic staffing and services, may shape clinical and financial outcomes, yet there has been little attempt to describe different models of HIV care in sub-Saharan Africa (SSA). Information about the relative benefits and drawbacks of different models could inform the scale-up of antiretroviral therapy (ART) and associated services in resource-limited settings (RLS), especially in light of expanded client populations with country adoption of WHO's test and treat recommendation. METHODS We characterized task-shifting/task-sharing practices in 19 diverse ART clinics in Tanzania, Uganda, and Zambia and used cluster analysis to identify unique models of service provision. We ran descriptive statistics to explore how the clusters varied by environmental factors and programmatic characteristics. Finally, we employed the Delphi Method to make systematic use of expert opinions to ensure that the cluster variables were meaningful in the context of actual task-shifting of ART services in SSA. RESULTS The cluster analysis identified three task-shifting/task-sharing models. The main differences across models were the availability of medical doctors, the scope of clinical responsibility assigned to nurses, and the use of lay health care workers. Patterns of healthcare staffing in HIV service delivery were associated with different environmental factors (e.g., health facility levels, urban vs. rural settings) and programme characteristics (e.g., community ART distribution or integrated tuberculosis treatment on-site). CONCLUSIONS Understanding the relative advantages and disadvantages of different models of care can help national programmes adapt to increased client load, select optimal adherence strategies within decentralized models of care, and identify differentiated models of care for clients to meet the growing needs of long-term ART patients who require more complicated treatment management.
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Affiliation(s)
- Sharon Tsui
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD USA
| | - Julie A. Denison
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD USA
| | - Caitlin E. Kennedy
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD USA
| | - Larry W. Chang
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD USA
- Department of Medicine – Infectious Diseases, Johns Hopkins University School of Medicine, 733 N. Broadway, Baltimore, MD USA
| | - Olivier Koole
- Clinical Sciences Department, Institute of Tropical Medicine, Nationalestraat 155, 2000 Antwerp, Belgium
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, Keppel St, London, UK
| | - Kwasi Torpey
- School of Public Health, University of Ghana College of Health Sciences, Legon Boundary, Accra, Ghana
| | - Eric Van Praag
- Technical Support Division, Global Health Population and Nutrition, FHI 360, Karibu St., Haile Selassie Rd., Oysterbay, Dar es Salaam, Tanzania
| | - Jason Farley
- Department of Medicine – Infectious Diseases, Johns Hopkins University School of Medicine, 733 N. Broadway, Baltimore, MD USA
- Department of Community – Public Health, Johns Hopkins University School of Nursing, 525 N. Wolfe St, Baltimore, MD USA
- University of KwaZulu Natal, King George V Ave, Durban, 4041 South Africa
- Association of Nurses in AIDS Care, 3538 Ridgewood Rd, Akron, OH USA
| | - Nathan Ford
- Dept HIV, World Health Organization, Ave. Appia 20, 1211, 27 Genève, Switzerland
| | - Leine Stuart
- FHI 360 (retired), 1825 Connecticut Ave NW, Washington, DC USA
| | - Fred Wabwire-Mangen
- Department of Epidemiology and Biostatistics, Makerere University School of Public Health, New Mulago Hill Rd, Kampala, Uganda
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High rates of viral suppression in adults and children with high CD4+ counts using a streamlined ART delivery model in the SEARCH trial in rural Uganda and Kenya. J Int AIDS Soc 2017; 20:21673. [PMID: 28770596 PMCID: PMC5577724 DOI: 10.7448/ias.20.5.21673] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Introduction: The 2015 WHO recommendation of antiretroviral therapy (ART) for all HIV-positive persons calls for treatment initiation in millions of persons newly eligible with high CD4+ counts. Efficient and effective care models are urgently needed for this population. We evaluated clinical outcomes of asymptomatic HIV-positive adults and children starting ART with high CD4+ counts using a novel streamlined care model in rural Uganda and Kenya. Methods: In the 16 intervention communities of the HIV test-and-treat Sustainable East Africa Research for Community Health Study (NCT01864603), all HIV-positive individuals irrespective of CD4 were offered ART (efavirenz [EFV]/tenofovir disoproxil fumarate + emtricitabine (FTC) or lamivudine (3TC). We studied adults (≥fifteen years) with CD4 ≥ 350/μL and children (two to fourteen years) with CD4 > 500/μL otherwise ineligible for ART by country guidelines. Clinics implemented a patient-centred streamlined care model designed to reduce patient-level barriers and maximize health system efficiency. It included (1) nurse-conducted visits with physician referral of complex cases, (2) multi-disease chronic care (including for hypertension/diabetes), (3) patient-centred, friendly staff, (4) viral load (VL) testing and counselling, (5) three-month return visits and ART refills, (6) appointment reminders, (7) tiered tracking for missed appointments, (8) flexible clinic hours (outside routine schedule) and (9) telephone access to clinicians. Primary outcomes were 48-week retention in care, viral suppression (% with measured week 48 VL ≤ 500 copies/mL) and adverse events. Results: Overall, 972 HIV-positive adults with CD4+ ≥ 350/μL initiated ART with streamlined care. Patients were 66% female and had median age thirty-four years (IQR, 28–42), CD4+ 608/μL (IQR, 487–788/μL) and VL 6775 copies/mL (IQR, <500–37,003 c/mL). At week 48, retention was 92% (897/972; 2 died/40 moved/8 withdrew/4 transferred care/21/964 [2%] were lost to follow-up). Viral suppression occurred in 778/838 (93%) and 800/972 (82%) in intention-to-treat analysis. Grade III/IV clinical/laboratory adverse events were rare: 95 occurred in 74/972 patients (7.6%). Only 8/972 adults (0.8%) switched ART from EFV to lopinavir (LPV) (n = 2 for dizziness, n = 2 for gynaecomastia, n = 4 for other reasons). Among 83 children, week 48 retention was 89% (74/83), viral suppression was 92% (65/71) and grade III/IV adverse events occurred in 4/83 (4.8%). Conclusions: Using a streamlined care model, viral suppression, retention and ART safety were high among asymptomatic East African adults and children with high CD4+ counts initiating treatment. Clinical Trial Number: NCT01864603
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Ford N, Ball A, Baggaley R, Vitoria M, Low-Beer D, Penazzato M, Vojnov L, Bertagnolio S, Habiyambere V, Doherty M, Hirnschall G. The WHO public health approach to HIV treatment and care: looking back and looking ahead. THE LANCET. INFECTIOUS DISEASES 2017; 18:e76-e86. [PMID: 29066132 DOI: 10.1016/s1473-3099(17)30482-6] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 07/20/2017] [Accepted: 07/25/2017] [Indexed: 11/18/2022]
Abstract
In 2006, WHO set forth its vision for a public health approach to delivering antiretroviral therapy. This approach has been broadly adopted in resource-poor settings and has provided the foundation for scaling up treatment to over 19·5 million people. There is a global commitment to end the AIDS epidemic as a public health threat by 2030 and, to support this goal, there are opportunities to adapt the public health approach to meet the ensuing challenges. These challenges include the need to improve identification of people with HIV infection through expanded approaches to testing; further simplify and improve treatment and laboratory monitoring; adapt the public health approach to concentrated epidemics; and link HIV testing, treatment, and care to HIV prevention. Implementation of these key public health principles will bring countries closer to the goals of controlling the HIV epidemic and providing universal health coverage.
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Affiliation(s)
- Nathan Ford
- Department of HIV and Global Hepatitis Programme, World Health Organization, Geneva, Switzerland.
| | - Andrew Ball
- Department of HIV and Global Hepatitis Programme, World Health Organization, Geneva, Switzerland
| | - Rachel Baggaley
- Department of HIV and Global Hepatitis Programme, World Health Organization, Geneva, Switzerland
| | - Marco Vitoria
- Department of HIV and Global Hepatitis Programme, World Health Organization, Geneva, Switzerland
| | - Daniel Low-Beer
- Department of HIV and Global Hepatitis Programme, World Health Organization, Geneva, Switzerland
| | - Martina Penazzato
- Department of HIV and Global Hepatitis Programme, World Health Organization, Geneva, Switzerland
| | - Lara Vojnov
- Department of HIV and Global Hepatitis Programme, World Health Organization, Geneva, Switzerland
| | - Silvia Bertagnolio
- Department of HIV and Global Hepatitis Programme, World Health Organization, Geneva, Switzerland
| | - Vincent Habiyambere
- Department of HIV and Global Hepatitis Programme, World Health Organization, Geneva, Switzerland
| | - Meg Doherty
- Department of HIV and Global Hepatitis Programme, World Health Organization, Geneva, Switzerland
| | - Gottfried Hirnschall
- Department of HIV and Global Hepatitis Programme, World Health Organization, Geneva, Switzerland
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Mulu A, Maier M, Liebert UG. Upward trends of acquired drug resistances in Ethiopian HIV-1C isolates: A decade longitudinal study. PLoS One 2017; 12:e0186619. [PMID: 29049402 PMCID: PMC5648217 DOI: 10.1371/journal.pone.0186619] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Accepted: 10/04/2017] [Indexed: 01/29/2023] Open
Abstract
Background The emergence, accumulation and spread of HIV-1 drug resistance strains in Africa could compromise the effectiveness of HIV treatment programs. This study was aimed at determining the incidence of virological failure and acquired drug resistance mutations overtime and identifying the most common mutational pathways of resistance in a well characterized HIV-1C infected Ethiopian cohort. Methods A total of 320 patients (220 ART naïve and 100 on first lines ART) were included and followed. ART initiation and patients’ monitoring was based on the WHO clinical and immunological parameters. HIV viral load measurement and genotypic drug resistance testing were done at baseline (T0-2008) and after on average at a median time of 30 months on ART at three time points (T1-2011, T2-2013, T3-2015). Findings The incidence of virological failure has increased overtime from 11 at T1 to 17 at T2 and then to 30% at T3. At all time point’s almost all of the patients with virological failure and accumulated drug resistance mutations had not met the WHO clinical and immunologic failure criteria and continued the failing regimen. A steep increase in the incidence and accumulation of major acquired NRTI and NNRTI drug resistance mutations have been observed (from 40% at T1 to 64% at T2 and then to 66% at T3). The most frequent NRTIs drug resistance associated mutations are mainly the lamivudine-induced mutation M184V which was detected in 4 patients at T1 and showed a 2 fold increase in the following time points (T2: n = 8) and at (T3: n = 12) and the thymidine analogue mutations (such as D67N, K70R and K219E) which were not-detected at baseline T0 and T1 but were increased progressively to 10 at T2 and to 17 at T3. The most frequent NNRTIs associated mutations were K103N, V106M and Y188C. Conclusions An upward trend in the incidence of virological failure and accumulation of NRTI and NNRTI associated acquired antiretroviral drug resistance mutations are observed. The data suggest the need for virological monitoring, resistance testing for early detection of failure and access for TDF and PI containing drugs. Population-level and patient targeted interventions to prevent the spread of mutant variants is warranted.
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Affiliation(s)
- Andargachew Mulu
- Armauer Hanssen Research Institute (AHRI), Addis Ababa, Ethiopia
- * E-mail:
| | - Melanie Maier
- Institute of Virology, Medical Faculty, Leipzig University, Leipzig, Germany
| | - Uwe Gerd Liebert
- Institute of Virology, Medical Faculty, Leipzig University, Leipzig, Germany
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Seth D, Cheldize K, Brown D, Freeman EF. Global Burden of Skin Disease: Inequities and Innovations. CURRENT DERMATOLOGY REPORTS 2017; 6:204-210. [PMID: 29226027 PMCID: PMC5718374 DOI: 10.1007/s13671-017-0192-7] [Citation(s) in RCA: 132] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW We review the current understanding of the burden of dermatological disease through the lens of the Global Burden of Disease project, evaluate the impact of skin disease on quality of life in a global context, explore socioeconomic implications, and finally summarize interventions towards improving quality of dermatologic care in resource-poor settings. RECENT FINDINGS The Global Burden of Disease project has shown that skin diseases continue to be the 4th leading cause of nonfatal disease burden world-wide. However, research efforts and funding do not match with the relative disability of skin diseases. International and national efforts, such as the WHO List of Essential Medicines, are critical towards reducing the socioeconomic burden of skin diseases and increasing access to care. Recent innovations such as teledermatology, point-of-care diagnostic tools, and task-shifting help to provide dermatological care to underserved regions in a cost-effective manner. SUMMARY Skin diseases cause significant non-fatal disability worldwide, especially in resource-poor regions. Greater impetus to study the burden of skin disease in low resource settings and policy efforts towards delivering high quality care are essential in improving the burden of skin diseases.
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Affiliation(s)
- Divya Seth
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Khatiya Cheldize
- Weill Cornell Medical College, New York, New York
- Massachusetts General Hospital Department of Dermatology, Boston, MA
| | - Danielle Brown
- Massachusetts General Hospital Department of Pediatrics, Boston, MA
| | - Esther F Freeman
- Massachusetts General Hospital Department of Dermatology, Boston, MA
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Abstract
Purpose of review More point-of-care (POC) diagnostic tests are becoming available for HIV diagnosis and treatment in resource-limited settings. These novel technologies have the potential to foster decentralized HIV care and treatment for the benefit of clinical laboratories, HIV clinics, and HIV-infected patients. There continue to be many business, technological, and operational challenges that limit product development and regulatory approval, which limits products available for the required operational and cost-effectiveness studies and delays policy adoption and implementation. Recent findings Although the rapid HIV diagnostic test has been widely successful, the pathways for POC CD4+ cell count and HIV viral load assay analyzers have been more challenging. We describe significant hurdles for product development, approval, and implementation, which include the business case, technical development, clinical impact, and integrating laboratory and clinical networks. Summary The objective of this review is to highlight the obstacles for developing and implementing appropriate strategies for POC HIV testing assays to improve the clinical services for HIV-infected patients in resource-limited settings.
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Hickey MD, Odeny TA, Petersen M, Neilands TB, Padian N, Ford N, Matthay Z, Hoos D, Doherty M, Beryer C, Baral S, Geng EH. Specification of implementation interventions to address the cascade of HIV care and treatment in resource-limited settings: a systematic review. Implement Sci 2017; 12:102. [PMID: 28784155 PMCID: PMC5547499 DOI: 10.1186/s13012-017-0630-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 07/17/2017] [Indexed: 01/23/2023] Open
Abstract
Background The global response to HIV has started over 18 million persons on life-saving antiretroviral therapy (ART)—the vast majority in low- and middle-income countries (LMIC)—yet substantial gaps remain: up to 40% of persons living with HIV (PLHIV) know their status, while another 30% of those who enter care are inadequately retained after starting treatment. Identifying strategies to enhance use of treatment is urgently needed, but the conceptualization and specification of implementation interventions is not always complete. We sought to assess the completeness of intervention reporting in research to advance uptake of treatment for HIV globally. Methods We carried out a systematic review to identify interventions targeting the adult HIV care cascade in LMIC dating from 1990 to 2017. We identified components of each intervention as “intervention types” to decompose interventions into common components. We grouped “intervention types” into a smaller number of more general “implementation approaches” to aid summarization. We assessed the reporting of six intervention characteristics adapted from the implementation science literature: the actor, action, action dose, action temporality, action target, and behavioral target in each study. Findings In 157 unique studies, we identified 34 intervention “types,” which were empirically grouped into six generally understandable “approaches.” Overall, 42% of interventions defined the actor, 64% reported the action, 41% specified the intervention “dose,” 43% reported action temporality, 61% defined the action target, and 69% reported a target behavior. Average completeness of reporting varied across approaches from a low of 50% to a high of 72%. Dimensions that involved conceptualization of the practices themselves (e.g., actor, dose, temporality) were in general less well specified than consequences (e.g., action target and behavioral target). Implications The conceptualization and Reporting of implementation interventions to advance treatment for HIV in LMIC is not always complete. Dissemination of standards for reporting intervention characteristics can potentially promote transparency, reproducibility, and scientific accumulation in the area of implementation science to address HIV in low- and middle-income countries. Electronic supplementary material The online version of this article (doi:10.1186/s13012-017-0630-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Matthew D Hickey
- Division of General Internal Medicine, San Francisco General Hospital, Department of Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA
| | | | - Maya Petersen
- Department of Biostatistics and Epidemiology, School of Public Health, University of California, Berkeley, CA, USA
| | - Torsten B Neilands
- Center for AIDS Prevention Studies, Department of Medicine, UCSF, San Francisco, CA, USA
| | - Nancy Padian
- Department of Biostatistics and Epidemiology, School of Public Health, University of California, Berkeley, CA, USA
| | - Nathan Ford
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | | | - David Hoos
- Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Meg Doherty
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | - Chris Beryer
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Stefan Baral
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Elvin H Geng
- Division of ID HIV and Global Medicine, San Francisco General Hospital, Department of Medicine, UCSF, Building 80, 6th Floor, 1001 Potrero Avenue, San Francisco, CA, 94110, USA.
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Farley JE, Ndjeka N, Kelly AM, Whitehouse E, Lachman S, Budhathoki C, Lowensen K, Bergren E, Mabuza H, Mlandu N, van der Walt M. Evaluation of a nurse practitioner-physician task-sharing model for multidrug-resistant tuberculosis in South Africa. PLoS One 2017; 12:e0182780. [PMID: 28783758 PMCID: PMC5544244 DOI: 10.1371/journal.pone.0182780] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 07/24/2017] [Indexed: 11/18/2022] Open
Abstract
Background Treatment success rates for multidrug-resistant tuberculosis (MDR-TB) in South Africa remain close to 50%. Lack of access to timely, decentralized care is a contributing factor. We evaluated MDR-TB treatment outcomes from a clinical cohort with task-sharing between a clinical nurse practitioner (CNP) and a medical officer (MO). Methods We completed a retrospective evaluation of outcomes from a prospective, programmatically-based MDR-TB cohort who were enrolled and received care between 2012 and 2015 at a peri-urban hospital in KwaZulu-Natal, South Africa. Treatment was provided by either by a CNP or MO. Findings The cohort included 197 participants with a median age of 33 years, 51% female, and 74% co-infected with HIV. The CNP initiated 123 participants on treatment. Overall MDR-TB treatment success rate in this cohort was 57.9%, significantly higher than the South African national average of 45% in 2012 (p<0·0001) and similar to the provincal average of 60% (p = NS). There were no significant differences by provider type: treatment success was 61% for patients initiated by the CNP and 52.7% for those initiated by the MO. Interpretation Clinics that adopted a task sharing approach for MDR-TB demonstrated greater treatment success rates than the national average. Task-sharing between the CNP and MO did not adversely impact treatment outcome with similar success rates noted. Task-sharing is a feasible option for South Africa to support decentralization without compromising patient outcomes. Models that allow sharing of responsibility for MDR-TB may optimize the use of human resources and improve access to care.
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Affiliation(s)
- Jason E. Farley
- School of Nursing, Johns Hopkins University, Baltimore, Maryland, United States of America
- * E-mail:
| | - Norbert Ndjeka
- Republic of South Africa Department of Health, Pretoria, South Africa
| | - Ana M. Kelly
- School of Nursing, Columbia University, New York, New York, United States of America
| | - Erin Whitehouse
- School of Nursing, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Simmi Lachman
- Murchison District Hospital, Port Shepstone, South Africa
| | - Chakra Budhathoki
- School of Nursing, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Kelly Lowensen
- School of Nursing, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Ellie Bergren
- School of Nursing, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Hloniphile Mabuza
- Center for Disease Control and Prevention, Atlanta, Georgia, United States of America
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Koenig SP, Dorvil N, Dévieux JG, Hedt-Gauthier BL, Riviere C, Faustin M, Lavoile K, Perodin C, Apollon A, Duverger L, McNairy ML, Hennessey KA, Souroutzidis A, Cremieux PY, Severe P, Pape JW. Same-day HIV testing with initiation of antiretroviral therapy versus standard care for persons living with HIV: A randomized unblinded trial. PLoS Med 2017; 14:e1002357. [PMID: 28742880 PMCID: PMC5526526 DOI: 10.1371/journal.pmed.1002357] [Citation(s) in RCA: 174] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 06/16/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Attrition during the period from HIV testing to antiretroviral therapy (ART) initiation is high worldwide. We assessed whether same-day HIV testing and ART initiation improves retention and virologic suppression. METHODS AND FINDINGS We conducted an unblinded, randomized trial of standard ART initiation versus same-day HIV testing and ART initiation among eligible adults ≥18 years old with World Health Organization Stage 1 or 2 disease and CD4 count ≤500 cells/mm3. The study was conducted among outpatients at the Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic infections (GHESKIO) Clinic in Port-au-Prince, Haiti. Participants were randomly assigned (1:1) to standard ART initiation or same-day HIV testing and ART initiation. The standard group initiated ART 3 weeks after HIV testing, and the same-day group initiated ART on the day of testing. The primary study endpoint was retention in care 12 months after HIV testing with HIV-1 RNA <50 copies/ml. We assessed the impact of treatment arm with a modified intention-to-treat analysis, using multivariable logistic regression controlling for potential confounders. Between August 2013 and October 2015, 762 participants were enrolled; 59 participants transferred to other clinics during the study period, and were excluded as per protocol, leaving 356 in the standard and 347 in the same-day ART groups. In the standard ART group, 156 (44%) participants were retained in care with 12-month HIV-1 RNA <50 copies, and 184 (52%) had <1,000 copies/ml; 20 participants (6%) died. In the same-day ART group, 184 (53%) participants were retained with HIV-1 RNA <50 copies/ml, and 212 (61%) had <1,000 copies/ml; 10 (3%) participants died. The unadjusted risk ratio (RR) of being retained at 12 months with HIV-1 RNA <50 copies/ml was 1.21 (95% CI: 1.04, 1.38; p = 0.015) for the same-day ART group compared to the standard ART group, and the unadjusted RR for being retained with HIV-1 RNA <1,000 copies was 1.18 (95% CI: 1.04, 1.31; p = 0.012). The main limitation of this study is that it was conducted at a single urban clinic, and the generalizability to other settings is uncertain. CONCLUSIONS Same-day HIV testing and ART initiation is feasible and beneficial in this setting, as it improves retention in care with virologic suppression among patients with early clinical HIV disease. TRIAL REGISTRATION This study is registered with ClinicalTrials.gov number NCT01900080.
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Affiliation(s)
- Serena P. Koenig
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- * E-mail:
| | - Nancy Dorvil
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Jessy G. Dévieux
- AIDS Prevention Program, Florida International University, Miami, Florida, United States of America
| | - Bethany L. Hedt-Gauthier
- Department of Global Health and Social Medicine, Harvard Medical School, Harvard University, Boston, Massachusetts, United States of America
| | - Cynthia Riviere
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Mikerlyne Faustin
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Kerlyne Lavoile
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Christian Perodin
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Alexandra Apollon
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Limathe Duverger
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Margaret L. McNairy
- Center for Global Health, Department of Medicine, Weill Cornell Medical College, Cornell University, New York, New York, United States of America
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medical College, Cornell University, New York, New York, United States of America
| | - Kelly A. Hennessey
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | | | | | - Patrice Severe
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Jean W. Pape
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
- Center for Global Health, Department of Medicine, Weill Cornell Medical College, Cornell University, New York, New York, United States of America
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Lopatina E, Donald F, DiCenso A, Martin-Misener R, Kilpatrick K, Bryant-Lukosius D, Carter N, Reid K, Marshall DA. Economic evaluation of nurse practitioner and clinical nurse specialist roles: A methodological review. Int J Nurs Stud 2017; 72:71-82. [PMID: 28500955 DOI: 10.1016/j.ijnurstu.2017.04.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 02/21/2017] [Accepted: 04/28/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Advanced practice nurses (e.g., nurse practitioners and clinical nurse specialists) have been introduced internationally to increase access to high quality care and to tackle increasing health care expenditures. While randomised controlled trials and systematic reviews have demonstrated the effectiveness of nurse practitioner and clinical nurse specialist roles, their cost-effectiveness has been challenged. The poor quality of economic evaluations of these roles to date raises the question of whether current economic evaluation guidelines are adequate when examining their cost-effectiveness. OBJECTIVE To examine whether current guidelines for economic evaluation are appropriate for economic evaluations of nurse practitioner and clinical nurse specialist roles. METHODS Our methodological review was informed by a qualitative synthesis of four sources of information: 1) narrative review of literature reviews and discussion papers on economic evaluation of advanced practice nursing roles; 2) quality assessment of economic evaluations of nurse practitioner and clinical nurse specialist roles alongside randomised controlled trials; 3) review of guidelines for economic evaluation; and, 4) input from an expert panel. RESULTS The narrative literature review revealed several challenges in economic evaluations of advanced practice nursing roles (e.g., complexity of the roles, variability in models and practice settings where the roles are implemented, and impact on outcomes that are difficult to measure). The quality assessment of economic evaluations of nurse practitioner and clinical nurse specialist roles alongside randomised controlled trials identified methodological limitations of these studies. When we applied the Guidelines for the Economic Evaluation of Health Technologies: Canada to the identified challenges and limitations, discussed those with experts and qualitatively synthesized all findings, we concluded that standard guidelines for economic evaluation are appropriate for economic evaluations of nurse practitioner and clinical nurse specialist roles and should be routinely followed. However, seven out of 15 current guideline sections (describing a decision problem, choosing type of economic evaluation, selecting comparators, determining the study perspective, estimating effectiveness, measuring and valuing health, and assessing resource use and costs) may require additional role-specific considerations to capture costs and effects of these roles. CONCLUSION Current guidelines for economic evaluation should form the foundation for economic evaluations of nurse practitioner and clinical nurse specialist roles. The proposed role-specific considerations, which clarify application of standard guidelines sections to economic evaluation of nurse practitioner and clinical nurse specialist roles, may strengthen the quality and comprehensiveness of future economic evaluations of these roles.
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Affiliation(s)
- Elena Lopatina
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Health Research Innovation Centre, 3C60, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.
| | - Faith Donald
- Daphne Cockwell School of Nursing, Ryerson University, 350 Victoria Street, Toronto, ON, M5B 2K3, Canada.
| | - Alba DiCenso
- School of Nursing and Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada.
| | - Ruth Martin-Misener
- School of Nursing, Dalhousie University, Box 15000, 5869 University Avenue, Halifax, NS, B3H 4R2, Canada.
| | - Kelley Kilpatrick
- Faculty of Nursing, Université de Montréal, Research Centre Hôpital Maisonneuve-Rosemont, CSA - RC - Aile bleue - Room F121, 5415 boul. l'Assomption, Montréal, QC, H1T 2M4, Canada.
| | - Denise Bryant-Lukosius
- School of Nursing, McMaster University, 1280 Main Street West, HSC-3N28G, Hamilton, ON, L8S 4L8, Canada.
| | - Nancy Carter
- School of Nursing, McMaster University, 1280 Main Street West, HSC-3N28H, Hamilton, ON, L8S 4L8, Canada.
| | - Kim Reid
- KJResearch, Rosemere, QC, Canada.
| | - Deborah A Marshall
- Department of Community Health Sciences and Faculty of Medicine, Cumming School of Medicine, University of Calgary, Health Research Innovation Centre, Room 3C58, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.
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Modi S, Callahan T, Rodrigues J, Kajoka MD, Dale HM, Langa JO, Urso M, Nchephe MI, Bongdene H, Romano S, Broyles LN. Overcoming Health System Challenges for Women and Children Living With HIV Through the Global Plan. J Acquir Immune Defic Syndr 2017; 75 Suppl 1:S76-S85. [PMID: 28399000 PMCID: PMC5615405 DOI: 10.1097/qai.0000000000001336] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
To meet the ambitious targets set by the Global Plan Towards the Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive (Global Plan), the initial 22 priority countries quickly developed innovative approaches for overcoming long-standing health systems challenges and providing HIV testing and treatment to pregnant and breastfeeding women and their infants. The Global Plan spurred programs for prevention of mother-to-child HIV transmission to integrate HIV-related care and treatment into broader maternal, newborn, and child health services; expand the effectiveness of the health workforce through task sharing; extend health services into communities; strengthen supply chain and commodity management systems; reduce diagnostic and laboratory hurdles; and strengthen strategic supervision and mentorship. The article reviews the ongoing challenges for prevention of mother-to-child HIV transmission programs as they continue to strive for elimination of vertical transmission of HIV infection in the post-Global Plan era. Although progress has been rapid, health systems still face important challenges, particularly follow-up and diagnosis of HIV-exposed infants, continuity of care, and the promotion of services that are respectful and client centered.
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Affiliation(s)
- Surbhi Modi
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Atlanta, GA
| | - Tegan Callahan
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Atlanta, GA
| | | | - Mwikemo D. Kajoka
- Department of Preventive Services, Reproductive and Child Health Section, PMTCT Programme Ministry of Health, Community Development, Gender, Elderly, and Children, Dar es Salaam, United Republic of Tanzania
| | - Helen M. Dale
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Atlanta, GA
| | - Judite O. Langa
- Division of Global HIV and Tuberculosis Centers for Disease Control and Prevention, Maputo, Mozambique
| | - Marilena Urso
- Division of Global HIV and Tuberculosis Centers for Disease Control and Prevention, Maputo, Mozambique
| | | | | | - Sostena Romano
- HIV/AIDS Section United Nations Children’s Fund, New York, NY
| | - Laura N. Broyles
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Atlanta, GA
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Rabkin M, Lamb M, Osakwe ZT, Mwangi PR, El-Sadr WM, Michaels-Strasser S. Nurse-led HIV services and quality of care at health facilities in Kenya, 2014-2016. Bull World Health Organ 2017; 95:353-361. [PMID: 28479636 PMCID: PMC5418825 DOI: 10.2471/blt.16.180646] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 12/27/2016] [Accepted: 01/18/2017] [Indexed: 11/27/2022] Open
Abstract
Objective To develop a novel measure to characterize human immunodeficiency virus (HIV) programme quality at health facilities in Kenya and explore its associations with patient- and facility-level characteristics. Methods We developed a composite indicator to measure quality of HIV care, comprising: assessment of eligibility for antiretroviral therapy (ART); initiation of ART; and retention on ART or in care, if ineligible for ART, for 12 months. We applied the comprehensive retention indicator to routinely collected clinical data from 13 331 patients enrolled in HIV care and treatment at 63 health facilities in the Eastern and Nyanza regions of Kenya from 1 January 2014 to 31 March 2016. We explored the association between facility- and patient-level characteristics and the primary outcome: appropriate staging and management of HIV, and retention in care over 12 months. Findings Of the enrolled patients, 8404 (63%) achieved comprehensive retention 12 months after enrolment in care. In univariate analyses, patients at facilities where nurses delivered HIV treatment services (including eligibility assessment, initiation and follow up of ART) had significantly higher comprehensive retention rates at 12 months. In multivariate analyses, after adjusting for both facility- and patient-level characteristics, patients at facilities where nurses initiated ART had significantly higher comprehensive retention in care at 12 months (relative risk, RR: 1.22; 95% confidence interval, CI: 1.00–1.48). Conclusion Nurse-led HIV services were significantly associated with quality of care, confirming the central role of nurses in the achievement of global health goals, and the need for further investment in nursing education, training and mentoring.
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Affiliation(s)
- Miriam Rabkin
- International Center for AIDS Care and Treatment Programs (ICAP) at Columbia University, 722 West 168 Street, New York, NY 10032, United States of America
| | - Matthew Lamb
- International Center for AIDS Care and Treatment Programs (ICAP) at Columbia University, 722 West 168 Street, New York, NY 10032, United States of America
| | - Zainab T Osakwe
- International Center for AIDS Care and Treatment Programs (ICAP) at Columbia University, 722 West 168 Street, New York, NY 10032, United States of America
| | | | - Wafaa M El-Sadr
- International Center for AIDS Care and Treatment Programs (ICAP) at Columbia University, 722 West 168 Street, New York, NY 10032, United States of America
| | - Susan Michaels-Strasser
- International Center for AIDS Care and Treatment Programs (ICAP) at Columbia University, 722 West 168 Street, New York, NY 10032, United States of America
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Fwemba I, Musonda P. Modelling adverse treatment outcomes of HIV-infected adolescents attending public-sector HIV clinics in Lusaka. Public Health 2017; 147:8-14. [PMID: 28404502 DOI: 10.1016/j.puhe.2017.01.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 01/12/2017] [Accepted: 01/22/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND In resource-limited setting, there is scarce evidence comparing antiretroviral therapy (ART) outcomes among HIV-infected adolescents to that of other age groups. METHODS AND STUDY DESIGN We analysed data from 25 ART facilities in Lusaka District, comparing treatment-naïve ART-eligible young adolescents (10-14 years), older adolescents (15-19) and young adults (20-24 years) initiating first-line ART to those aged 24 years or older. The adjusted relative risk (RR) of failure to achieve an adequate CD4 response (defined as failure to increase CD4 count by ≥ 50 cells/mm3 at 6 months or by ≥ 100 cells/mm3) at 6 or 12 months after ART initiation was modelled using log-binomial regression. The effect of age group on mortality and loss to follow-up (LTFUP; ≥60 days since scheduled visit date) was estimated using adjusted Cox proportional hazards models, respectively. This was a routine retrospective design using program data. RESULTS Of the 94,023 patients initiating ART from May 2004 to February 2011, 1303 (1.4%) were young adolescents, 1440 (1.5%) were older adolescents and 5825 (6.2%) were young adults. 85,455 (90.9%) were 24 years or older at the time of ART initiation. Compared with adults, both young adolescents (RR: 0.88, 95% confidence interval [CI]: 0.76-1.01 at 6 months and RR: 0.80, 95% CI: 0.69-0.93 at 12 months) and older adolescents (RR: 0.82, 95% CI: 0.71-0.95 at 6 months) were less likely to achieve adequate CD4 response. No evidence of a difference in mortality risk was observed among older adolescents (hazard ratio [HR] 1.20, 95% CI: 0.93-1.56) compared with adults; however, there was a reduced risk of mortality in young adolescents compared with adults (HR: 0.61, 95% CI: 0.40-0.92). Young adolescents were less likely to be LTFUP following ART initiation (HR: 0.74, 95% CI: 0.59-0.92), while older adolescents and young adults were reported to be more likely to drop out of care (HR: 1.54 95% CI: 1.33-1.78; HR: 1.51 95% CI: 1.40-1.63 respectively). CONCLUSION Older adolescents and young adults had poorer ART treatment outcomes, including failure to achieve adequate CD4 recovery and failure to remain in long-term care, when compared with adults. Interventions are necessary to help increase outcomes and retention in care.
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Affiliation(s)
- I Fwemba
- University of Zambia, School of Public Health, P.O. Box 5010, Ridgeway Campus, Lusaka, Zambia
| | - P Musonda
- University of Zambia, School of Public Health, P.O. Box 5010, Ridgeway Campus, Lusaka, Zambia
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McNairy ML, Bashi JB, Chung H, Wemin L, Lorng MNA, Brou H, Nioble C, Lokossue A, Abo K, Achi D, Ouattara K, Sess D, Sanogo PA, Ekra A, Ettiegne-Traore V, Diabate CJ, Abrams EJ, El-Sadr WM. Task-sharing with nurses to enhance access to HIV treatment in Côte d'Ivoire. Trop Med Int Health 2017; 22:431-441. [PMID: 28101954 DOI: 10.1111/tmi.12839] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE We report the first national programme in Côte d'Ivoire to evaluate the feasibility of nurse-led HIV care as a model of task-sharing with nurses to increase coverage and decentralisation of HIV services. METHODS Twenty-six public HIV facilities implemented either a nurse-with-onsite-physician or a nurse-with-visiting-physician model of HIV task-sharing. Routinely collected patient data were reviewed to analyse patient characteristics of those enrolling in care and initiating antiretroviral therapy (ART). Retention, loss to programme and death were compared across facility-level characteristics. RESULTS A total of 1224 patients enrolled in HIV care, with 666 initiating ART, from January 2012 to May 2013 (median follow-up 13 months). The majority (94%) were adults ≥15 years. Fourteen facilities provided ART initiation for the first time during the pilot period; 20 facilities were primary level. Nurse-led care with a visiting physician was provided in 14 of the primary-level facilities. Nurse-led ART care with an onsite physician was provided in all secondary-level facilities and six of the primary-level facilities. During the pilot, 567 (85%) of patients were retained, 28 (4.2%) died, 47 (7.1%) were lost to follow-up, and 24 (3.6%) transferred. Five deaths (10.9%) were recorded among children as compared to 23 deaths (3.7%) among adults (P = 0.037). There were no differences in retention by model of nurse-led ART care. CONCLUSION Task-sharing of HIV care and ART initiation with nurses in Côte d'Ivoire is feasible. This pilot illustrates two models of nurse-led HIV care and has informed national policy on nurse-led HIV care in Côte d'Ivoire.
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Affiliation(s)
- Margaret L McNairy
- ICAP at Columbia University, New York, NY, USA.,Weill Cornell Medical College, New York, NY, USA
| | | | | | | | - Marie-Nicole Akpro Lorng
- Ministère de la Santé et de la Lutteontre le Sida, Programme National de Prise en Charge Médicale des Personnes Vivant Avec le VIH, Abidjan, Cote d'Ivoire
| | | | | | | | - Kouame Abo
- Ministère de la Santé et de la Lutteontre le Sida, Programme National de Prise en Charge Médicale des Personnes Vivant Avec le VIH, Abidjan, Cote d'Ivoire
| | | | | | - Daniel Sess
- Ministère de la Santé et de la Lutte Contre le Sida, Institut National de la Formation des Agents de Sante, Abidjan, Cote d'Ivoire
| | - Pongathie Adama Sanogo
- Ministère de la Santé et de la Lutte Contre le Sida, Direction de la Formation et de la Recherche, Abidjan, Cote d'Ivoire
| | | | - Virginie Ettiegne-Traore
- Ministère de la Santé et de la Lutteontre le Sida, Programme National de Prise en Charge Médicale des Personnes Vivant Avec le VIH, Abidjan, Cote d'Ivoire
| | - Conombo J Diabate
- Ministère de la Santé et de la Lutte Contre le Sida, Direction Générale de la Lutte Contre le Sida, Abidjan, Cote d'Ivoire
| | - Elaine J Abrams
- ICAP at Columbia University, New York, NY, USA.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Wafaa M El-Sadr
- ICAP at Columbia University, New York, NY, USA.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
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Pham MD, Romero L, Parnell B, Anderson DA, Crowe SM, Luchters S. Feasibility of antiretroviral treatment monitoring in the era of decentralized HIV care: a systematic review. AIDS Res Ther 2017; 14:3. [PMID: 28103895 PMCID: PMC5248527 DOI: 10.1186/s12981-017-0131-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 01/06/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Regular monitoring of HIV patients who are receiving antiretroviral therapy (ART) is required to ensure patient benefits and the long-term effectiveness and sustainability of ART programs. Prompted by WHO recommendations for expansion and decentralization of HIV treatment and care in low and middle income countries, we conducted a systematic review to assess the feasibility of treatment monitoring in these settings. METHODS A comprehensive search strategy was developed using a combination of MeSH and free text terms relevant to HIV treatment and care, health service delivery, health service accessibility, decentralization and other relevant terms. Five electronic databases and two conference websites were searched to identify relevant studies conducted in LMICs, published in English between Jan 2006 and Dec 2015. Outcomes of interest included the proportion of patients who received treatment monitoring and health system factors related to monitoring of patients on ART under decentralized HIV service delivery models. RESULTS From 5363 records retrieved, twenty studies were included in the review; all but one was conducted in sub-Saharan African countries. The majority of studies (15/20) had relatively short follow-up duration (≤24 months), and only two studies were specifically designed to assess treatment monitoring practices. The most frequently studied follow-up period was 12 months and a wide range of treatment monitoring coverage was observed. The reported proportions of patients on ART who received CD4 monitoring ranged from very low (6%; N = 2145) to very high (95%; N = 488). The median uptake of viral load monitoring was 86% with studies in program settings reporting coverage as low as 14%. Overall, the longer the follow-up period, the lower the proportion of patients who received regular monitoring tests; and programs in rural areas reported low coverage of laboratory monitoring. Moreover, uptake in the context of research had significantly better where monitoring was done by dedicated research staff. In the absence of point of care (POC) testing, the limited capacity for blood sample transportation between clinic and laboratory and poor quality of nursing staff were identified as a major barrier for treatment monitoring practice. CONCLUSIONS There is a paucity of data on the uptake of treatment monitoring, particularly with longer-term follow-up. Wide variation in access to both virological and immunological regular monitoring was observed, with some clinics in well-resourced settings supported by external donors achieving high coverage. The feasibility of treatment monitoring, particularly in decentralized settings of HIV treatment and care may thus be of concern and requires further study. Significant investment in POC diagnostic technologies and, improving the quality of and training for nursing staff is required to ensure effective scale up of ART programs towards the targets of 90-90-90 by the year 2020.
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Katz IT, Bangsberg DR. Cascade of Refusal-What Does It Mean for the Future of Treatment as Prevention in Sub-Saharan Africa? Curr HIV/AIDS Rep 2016; 13:125-30. [PMID: 26894487 DOI: 10.1007/s11904-016-0309-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Recent recommendations by the World Health Organization support treatment for all people living with HIV (PLWH) globally to be initiated at the point of testing. While there has been marked success in efforts to identify and expand treatment for PLWH throughout sub-Saharan Africa, the goal of universal treatment may prove challenging to achieve. The pre-ART phase of the care cascade from HIV testing to HIV treatment initiation includes several social and structural barriers. One such barrier is antiretroviral therapy (ART) treatment refusal, a phenomenon in which HIV-infected individuals choose not to start treatment upon learning their ART eligibility. Our goal is to provide further understanding of why treatment-eligible adults may choose to present for HIV testing but not initiate ART when indicated. In this article, we will discuss factors driving pre-ART loss and present a framework for understanding the impact of decision-making on early losses in the care cascade, with a focus on ART refusal.
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Affiliation(s)
- Ingrid T Katz
- Division of Women's Health, Department of Medicine, Brigham and Women's Hospital, 1620 Tremont St, Boston, MA, 02120, USA. .,Harvard Medical School, Boston, MA, USA. .,Massachusetts General Hospital Center for Global Health, Boston, MA, USA.
| | - David R Bangsberg
- Harvard Medical School, Boston, MA, USA.,Massachusetts General Hospital Center for Global Health, Boston, MA, USA
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Heestermans T, Browne JL, Aitken SC, Vervoort SC, Klipstein-Grobusch K. Determinants of adherence to antiretroviral therapy among HIV-positive adults in sub-Saharan Africa: a systematic review. BMJ Glob Health 2016; 1:e000125. [PMID: 28588979 PMCID: PMC5321378 DOI: 10.1136/bmjgh-2016-000125] [Citation(s) in RCA: 192] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 10/30/2016] [Accepted: 11/01/2016] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE The rapid scale up of antiretroviral treatment (ART) in sub-Saharan Africa (SSA) has resulted in an increased focus on patient adherence. Non-adherence can lead to drug-resistant HIV caused by failure to achieve maximal viral suppression. Optimal treatment requires the identification of patients at high risk of suboptimal adherence and targeted interventions. The aim of this review was to identify and summarise determinants of adherence to ART among HIV-positive adults. DESIGN Systematic review of adherence to ART in SSA from January 2002 to October 2014. METHODS A systematic search was performed in 6 databases (PubMed, Cochrane Library, EMBASE, Web of Science, Popline, Global Health Library) for qualitative and quantitative articles. Risk of bias was assessed. A meta-analysis was conducted for pooled estimates of effect size on adherence determinants. RESULTS Of the 4052 articles screened, 146 were included for final analysis, reporting on determinants of 161 922 HIV patients with an average adherence score of 72.9%. Main determinants of non-adherence were use of alcohol, male gender, use of traditional/herbal medicine, dissatisfaction with healthcare facility and healthcare workers, depression, discrimination and stigmatisation, and poor social support. Promoters of adherence included counselling and education interventions, memory aids, and active disclosure among people living with HIV. Determinants of health status had conflicting influence on adherence. CONCLUSIONS The sociodemographic, psychosocial, health status, treatment-related and intervention-related determinants are interlinked and contribute to optimal adherence. Clinics providing ART in SSA should therefore design targeted interventions addressing these determinants to optimise health outcomes.
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Affiliation(s)
- Tessa Heestermans
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Joyce L Browne
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Susan C Aitken
- Ndlovu Research Consortium, Elandsdoorn, South Africa
- Department of Medical Microbiology, University Medical Centre Utrecht, The Netherlands
| | - Sigrid C Vervoort
- University Medical Centre Utrecht Cancer Center, Utrecht, The Netherlands
| | - Kerstin Klipstein-Grobusch
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- Division of Epidemiology & Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Long LC, Rosen SB, Brennan A, Moyo F, Sauls C, Evans D, Modi SL, Sanne I, Fox MP. Treatment Outcomes and Costs of Providing Antiretroviral Therapy at a Primary Health Clinic versus a Hospital-Based HIV Clinic in South Africa. PLoS One 2016; 11:e0168118. [PMID: 27942005 PMCID: PMC5152901 DOI: 10.1371/journal.pone.0168118] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Accepted: 11/27/2016] [Indexed: 12/02/2022] Open
Abstract
Background In 2010 South Africa revised its HIV treatment guidelines to allow the initiation and management of patients on antiretroviral therapy (ART) by nurses, rather than solely doctors, under a program called NIMART (Nurse Initiated and Managed Antiretroviral Therapy). We compared the outcomes and costs of NIMART between the two major public sector HIV treatment delivery models in use in South Africa today, primary health clinics and hospital-based HIV clinics. Methods and findings The study was conducted at one hospital-based outpatient HIV clinic and one primary health clinic (PHC) in Gauteng Province. A retrospective cohort of adult patients initiated on ART at the PHC was propensity-score matched to patients initiated at the hospital outpatient clinic. Each patient was assigned a 12-month outcome of alive and in care or died/lost to follow up. Costs were estimated from the provider perspective for the 12 months after ART initiation. The proportion of patients alive and in care at 12 months did not differ between the PHC (76.5%) and the hospital-based site (74.2%). The average annual cost per patient alive and in care at 12 months after ART initiation was significantly lower at the PHC (US$238) than at the hospital outpatient clinic (US$428). Conclusions Initiating and managing ART patients at PHCs under NIMART is producing equally good outcomes as hospital-based HIV clinic care at much lower cost. Evolution of hospital-based clinics into referral facilities that serve complicated patients, while investing most program expansion resources into PHCs, may be a preferred strategy for achieving treatment coverage targets.
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Affiliation(s)
- Lawrence C. Long
- Department of Internal Medical, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Johannesburg, South Africa
- * E-mail:
| | - Sydney B. Rosen
- Department of Internal Medical, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Johannesburg, South Africa
- Center for Global Health & Development, Boston University, Boston, Massachusetts, United States of America
| | - Alana Brennan
- Department of Internal Medical, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Center for Global Health & Development, Boston University, Boston, Massachusetts, United States of America
| | - Faith Moyo
- Department of Internal Medical, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Johannesburg, South Africa
| | - Celeste Sauls
- Department of Internal Medical, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Johannesburg, South Africa
| | - Denise Evans
- Department of Internal Medical, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Johannesburg, South Africa
| | | | - Ian Sanne
- Department of Internal Medical, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Johannesburg, South Africa
- Center for Global Health & Development, Boston University, Boston, Massachusetts, United States of America
- Right to Care, Johannesburg, South Africa
| | - Matthew P. Fox
- Department of Internal Medical, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Johannesburg, South Africa
- Center for Global Health & Development, Boston University, Boston, Massachusetts, United States of America
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
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Weeks G, George J, Maclure K, Stewart D. Non-medical prescribing versus medical prescribing for acute and chronic disease management in primary and secondary care. Cochrane Database Syst Rev 2016; 11:CD011227. [PMID: 27873322 PMCID: PMC6464275 DOI: 10.1002/14651858.cd011227.pub2] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND A range of health workforce strategies are needed to address health service demands in low-, middle- and high-income countries. Non-medical prescribing involves nurses, pharmacists, allied health professionals, and physician assistants substituting for doctors in a prescribing role, and this is one approach to improve access to medicines. OBJECTIVES To assess clinical, patient-reported, and resource use outcomes of non-medical prescribing for managing acute and chronic health conditions in primary and secondary care settings compared with medical prescribing (usual care). SEARCH METHODS We searched databases including CENTRAL, MEDLINE, Embase, and five other databases on 19 July 2016. We also searched the grey literature and handsearched bibliographies of relevant papers and publications. SELECTION CRITERIA Randomised controlled trials (RCTs), cluster-RCTs, controlled before-and-after (CBA) studies (with at least two intervention and two control sites) and interrupted time series analysis (with at least three observations before and after the intervention) comparing: 1. non-medical prescribing versus medical prescribing in acute care; 2. non-medical prescribing versus medical prescribing in chronic care; 3. non-medical prescribing versus medical prescribing in secondary care; 4 non-medical prescribing versus medical prescribing in primary care; 5. comparisons between different non-medical prescriber groups; and 6. non-medical healthcare providers with formal prescribing training versus those without formal prescribing training. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Two review authors independently reviewed studies for inclusion, extracted data, and assessed study quality with discrepancies resolved by discussion. Two review authors independently assessed risk of bias for the included studies according to EPOC criteria. We undertook meta-analyses using the fixed-effect model where studies were examining the same treatment effect and to account for small sample sizes. We compared outcomes to a random-effects model where clinical or statistical heterogeneity existed. MAIN RESULTS We included 46 studies (37,337 participants); non-medical prescribing was undertaken by nurses in 26 studies and pharmacists in 20 studies. In 45 studies non-medical prescribing as a component of care was compared with usual care medical prescribing. A further study compared nurse prescribing supported by guidelines with usual nurse prescribing care. No studies were found with non-medical prescribing being undertaken by other health professionals. The education requirement for non-medical prescribing varied with country and location.A meta-analysis of surrogate markers of chronic disease (systolic blood pressure, glycated haemoglobin, and low-density lipoprotein) showed positive intervention group effects. There was a moderate-certainty of evidence for studies of blood pressure at 12 months (mean difference (MD) -5.31 mmHg, 95% confidence interval (CI) -6.46 to -4.16; 12 studies, 4229 participants) and low-density lipoprotein (MD -0.21, 95% CI -0.29 to -0.14; 7 studies, 1469 participants); we downgraded the certainty of evidence from high due to considerations of serious inconsistency (considerable heterogeneity), multifaceted interventions, and variable prescribing autonomy. A high-certainty of evidence existed for comparative studies of glycated haemoglobin management at 12 months (MD -0.62, 95% CI -0.85 to -0.38; 6 studies, 775 participants). While there appeared little difference in medication adherence across studies, a meta-analysis of continuous outcome data from four studies showed an effect favouring patient adherence in the non-medical prescribing group (MD 0.15, 95% CI 0.00 to 0.30; 4 studies, 700 participants). We downgraded the certainty of evidence for adherence to moderate due to the serious risk of performance bias. While little difference was seen in patient-related adverse events between treatment groups, we downgraded the certainty of evidence to low due to indirectness, as the range of adverse events may not be related to the intervention and selective reporting failed to adequately report adverse events in many studies.Patients were generally satisfied with non-medical prescriber care (14 studies, 7514 participants). We downgraded the certainty of evidence from high to moderate due to indirectness, in that satisfaction with the prescribing component of care was only addressed in one study, and there was variability of satisfaction measures with little use of validated tools. A meta-analysis of health-related quality of life scores (SF-12 and SF-36) found a difference favouring usual care for the physical component score (MD 1.17, 95% CI 0.16 to 2.17), but not the mental component score (MD 0.58, 95% CI -0.40 to 1.55). However, the quality of life measurement may more appropriately reflect composite care rather than the prescribing component of care, and for this reason we downgraded the certainty of evidence to moderate due to indirectness of the measure of effect. A wide variety of resource use measures were reported across studies with little difference between groups for hospitalisations, emergency department visits, and outpatient visits. In the majority of studies reporting medication use, non-medical prescribers prescribed more drugs, intensified drug doses, and used a greater variety of drugs compared to usual care medical prescribers.The risk of bias across studies was generally low for selection bias (random sequence generation), detection bias (blinding of outcome assessment), attrition bias (incomplete outcome data), and reporting bias (selective reporting). There was an unclear risk of selection bias (allocation concealment) and for other biases. A high risk of performance bias (blinding of participants and personnel) existed. AUTHORS' CONCLUSIONS The findings suggest that non-medical prescribers, practising with varying but high levels of prescribing autonomy, in a range of settings, were as effective as usual care medical prescribers. Non-medical prescribers can deliver comparable outcomes for systolic blood pressure, glycated haemoglobin, low-density lipoprotein, medication adherence, patient satisfaction, and health-related quality of life. It was difficult to determine the impact of non-medical prescribing compared to medical prescribing for adverse events and resource use outcomes due to the inconsistency and variability in reporting across studies. Future efforts should be directed towards more rigorous studies that can clearly identify the clinical, patient-reported, resource use, and economic outcomes of non-medical prescribing, in both high-income and low-income countries.
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Affiliation(s)
- Greg Weeks
- Monash UniversityCentre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical SciencesParkvilleVICAustralia3052
- Barwon HealthPharmacy DepartmentGeelongVictoriaAustralia
| | - Johnson George
- Monash UniversityCentre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical SciencesParkvilleVICAustralia3052
| | - Katie Maclure
- Robert Gordon UniversitySchool of PharmacyRiverside EastGarthdee RoadAberdeenUKAB10 7GJ
| | - Derek Stewart
- Robert Gordon UniversitySchool of PharmacyRiverside EastGarthdee RoadAberdeenUKAB10 7GJ
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Educational Outreach with an Integrated Clinical Tool for Nurse-Led Non-communicable Chronic Disease Management in Primary Care in South Africa: A Pragmatic Cluster Randomised Controlled Trial. PLoS Med 2016; 13:e1002178. [PMID: 27875542 PMCID: PMC5119726 DOI: 10.1371/journal.pmed.1002178] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 10/19/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In many low-income countries, care for patients with non-communicable diseases (NCDs) and mental health conditions is provided by nurses. The benefits of nurse substitution and supplementation in NCD care in high-income settings are well recognised, but evidence from low- and middle-income countries is limited. Primary Care 101 (PC101) is a programme designed to support and expand nurses' role in NCD care, comprising educational outreach to nurses and a clinical management tool with enhanced prescribing provisions. We evaluated the effect of the programme on primary care nurses' capacity to manage NCDs. METHODS AND FINDINGS In a cluster randomised controlled trial design, 38 public sector primary care clinics in the Western Cape Province, South Africa, were randomised. Nurses in the intervention clinics were trained to use the PC101 management tool during educational outreach sessions delivered by health department trainers and were authorised to prescribe an expanded range of drugs for several NCDs. Control clinics continued use of the Practical Approach to Lung Health and HIV/AIDS in South Africa (PALSA PLUS) management tool and usual training. Patients attending these clinics with one or more of hypertension (3,227), diabetes (1,842), chronic respiratory disease (1,157) or who screened positive for depression (2,466), totalling 4,393 patients, were enrolled between 28 March 2011 and 10 November 2011. Primary outcomes were treatment intensification in the hypertension, diabetes, and chronic respiratory disease cohorts, defined as the proportion of patients in whom treatment was escalated during follow-up over 14 mo, and case detection in the depression cohort. Primary outcome data were analysed for 2,110 (97%) intervention and 2,170 (97%) control group patients. Treatment intensification rates in intervention clinics were not superior to those in the control clinics (hypertension: 44% in the intervention group versus 40% in the control group, risk ratio [RR] 1.08 [95% CI 0.94 to 1.24; p = 0.252]; diabetes: 57% versus 50%, RR 1.10 [0.97 to 1.24; p = 0.126]; chronic respiratory disease: 14% versus 12%, RR 1.08 [0.75 to 1.55; p = 0.674]), nor was case detection of depression (18% versus 24%, RR 0.76 [0.53 to 1.10; p = 0.142]). No adverse effects of the nurses' expanded scope of practice were observed. Limitations of the study include dependence on self-reported diagnoses for inclusion in the patient cohorts, limited data on uptake of PC101 by users, reliance on process outcomes, and insufficient resources to measure important health outcomes, such as HbA1c, at follow-up. CONCLUSIONS Educational outreach to primary care nurses to train them in the use of a management tool involving an expanded role in managing NCDs was feasible and safe but was not associated with treatment intensification or improved case detection for index diseases. This notwithstanding, the intervention, with adjustments to improve its effectiveness, has been adopted for implementation in primary care clinics throughout South Africa. TRIAL REGISTRATION The trial is registered with Current Controlled Trials (ISRCTN20283604).
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50
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Akeju DO, Vidler M, Sotunsa JO, Osiberu MO, Orenuga EO, Oladapo OT, Adepoju AA, Qureshi R, Sawchuck D, Adetoro OO, von Dadelszen P, Dada OA. Human resource constraints and the prospect of task-sharing among community health workers for the detection of early signs of pre-eclampsia in Ogun State, Nigeria. Reprod Health 2016; 13:111. [PMID: 27719681 PMCID: PMC5056470 DOI: 10.1186/s12978-016-0216-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background The dearth of health personnel in low income countries has attracted global attention. Ways as to how health care services can be delivered in a more efficient and effective way using available health personnel are being explored. Task-sharing expands the responsibilities of low-cadre health workers and allows them to share these responsibilities with highly qualified health care providers in an effort to best utilize available human resources. This is appropriate in a country like Nigeria where there is a shortage of qualified health professionals and a huge burden of maternal mortality resulting from obstetric complications like pre-eclampsia. This study examines the prospect for task-sharing among Community Health Extension Workers (CHEW) for the detection of early signs of pre-eclampsia, in Ogun State, Nigeria. Methods This study is part of a larger community-based trial evaluating the acceptability of community treatment for severe pre-eclampsia in Ogun State, Nigeria. Data was collected between 2011 and 2012 using focus group discussions; seven with CHEWs (n = 71), three with male decision-makers (n = 35), six with community leaders (n = 68), and one with member of the Society of Obstetricians and Gynaecologists of Nigeria (n = 9). In addition, interviews were conducted with the heads of the local government administration (n = 4), directors of planning (n = 4), medical officers (n = 4), and Chief Nursing Officers (n = 4). Qualitative data were analysed using NVivo version 10.0 3 computer software. Results The non-availability of health personnel is a major challenge, and has resulted in a high proportion of facility-based care performed by CHEWs. As a result, CHEWs often take on roles that are designated for senior health workers. This role expansion has exposed CHEWs to the basics of obstetric care, and has resulted in informal task-sharing among the health workers. The knowledge and ability of CHEWs to perform basic clinical assessments, such as measure blood pressure is not in doubt. Nevertheless, there were divergent views by senior and junior cadres of health practitioners about CHEWs’ abilities in providing obstetric care. Similarly, there were concerns by various stakeholders, particularly the CHEWs themselves, on the regulatory restrictions placed on them by the Standing Order. Conclusion Generally, the extent to which obstetric tasks could be shifted to community health workers will be determined by the training provided and the extent to which the observed barriers are addressed. Trial registration NCT01911494 Electronic supplementary material The online version of this article (doi:10.1186/s12978-016-0216-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- David O Akeju
- Department of Sociology, University of Lagos, Lagos, Nigeria.
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, and the Child and Family Research Unit, University of British Columbia, Vancouver, V5Z 4H4, Canada
| | - J O Sotunsa
- Department of Obstetrics and Gynaecology, Babcock University Teaching Hospital, Ilishan-Remo, Nigeria
| | - M O Osiberu
- Centre for Research in Reproductive Health, Sagamu, Nigeria
| | - E O Orenuga
- Centre for Research in Reproductive Health, Sagamu, Nigeria
| | | | - A A Adepoju
- Centre for Research in Reproductive Health, Sagamu, Nigeria
| | - Rahat Qureshi
- Division of Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Diane Sawchuck
- Department of Research, Vancouver Island Health Authority, Victoria, V8R 1 J8, Canada
| | - Olalekan O Adetoro
- Department of Obstetrics and Gynaecology, OlabisiOnabanjo University, Sagamu, Nigeria
| | - Peter von Dadelszen
- Department of Obstetrics and Gynaecology, St George's University London, London, SW17 0RE, UK
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