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Shrivastava R, Stevens T, Westerman L, Bressler D, van Schalkwyk E, Bressler C, Ugwu K, Mwangi C, Opio JP, Nkodyo J, Mwangi JW, Martin MD, Nesby-O'Dell S. Measuring training effectiveness of laboratory biosafety program offered at African Center for Integrated Laboratory Training in 22 President's Emergency Plan for AIDS Relief supported countries (2008-2014). Trop Med Health 2023; 51:65. [PMID: 37990251 PMCID: PMC10662895 DOI: 10.1186/s41182-023-00557-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 10/31/2023] [Indexed: 11/23/2023] Open
Abstract
INTRODUCTION The African Center for Integrated Laboratory Training (ACILT) in Johannesburg, South Africa offered a laboratory biosafety program to improve laboratory biosafety practices in 22 President's Emergency Plan for AIDS Relief (PEPFAR) supported countries. This manuscript evaluates the transference of newly gained knowledge and skills to the participants' place of employment for HIV and TB diagnostic laboratory programs. It also serves as a follow-on to a previously published manuscript that measured training effectiveness for all courses offered at ACILT. METHODS ACILT offered 20 Laboratory Biosafety and Infrastructure courses (2008-2014), also referred as biosafety course/course comprising of 14 core laboratory safety elements to 402 participants from 22 countries. In 2015, participants received 22 e-questions divided into four categories: (1) Safety Policies, (2) Management's Engagement, (3) Safety Programs and (4) Assessments of Safety Practices to determine retrospectively the training effectiveness of biosafety practices in their place of employment 6 months before and after attending their course. We used Kirkpatrick model to assess the transference of knowledge, skills and obstructive factors. RESULTS 20% (81/402) of the participants completed the e-questionnaire. The overall percentage of positive responses indicating implementation of new safety practices increased from 50% to 84%. Improvement occurred in all four categories after attending the course, with the greatest increases in Safety Policies (67-94%) and Safety Programs (43-91%). Creating a safety committee, allocating resources, and establishing a facility safety policy were important drivers for implementing and maintaining laboratory safety practices. In addition, accredited laboratories and countries with national safety regulations or policies had a higher percentage of improvements. The most reported challenges were inadequate funding and lack of management enforcement. CONCLUSIONS PEPFAR and other partners' investments in training institutions, such as ACILT, were effective in building sustainable country ownership to strengthen biosafety practices and were leveraged to combat zoonotic diseases and COVID-19. Although support continues at the national/regional level, a standardized, coordinated and continent-wide sustainable approach to offer a biosafety program-like ACILT is missing. Continuous offerings of biosafety programs similar to ACILT could contribute to sustainable strengthening of laboratory biosafety, QMS and pandemic preparedness.
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Affiliation(s)
| | - Thomas Stevens
- Centers for Disease Control and Prevention, Lusaka, Zambia
| | | | - David Bressler
- Centers for Disease Control and Prevention, Atlanta, USA
| | - Elsie van Schalkwyk
- African Center for Integrated Laboratory Training, Johannesburg, South Africa
| | | | - Ken Ugwu
- Government of Canada, Ottawa, Canada
| | | | | | | | - Jane W Mwangi
- Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Monte D Martin
- Centers for Disease Control and Prevention, Atlanta, USA
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Touré F, Etheredge GD, Brennan C, Parris K, Diallo MO, Ouffoue AF, Ekra A, Prao H, Assamoua NV, Gnongoue C, Kone F, Koffi C, Kamagaté F, Rivadeneira E, Carpenter D. Retention and Predictors of Attrition Among HIV-infected Children on Antiretroviral Therapy in Côte d'Ivoire Between 2012 and 2016. Pediatr Infect Dis J 2023; 42:299-304. [PMID: 36689665 DOI: 10.1097/inf.0000000000003839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND An estimated 21,000 children 0-14 years of age were living with HIV in Côte d'Ivoire in 2020, of whom only 49% have been diagnosed and are receiving antiretroviral therapy (ART). Retention in HIV care and treatment is key to optimize clinical outcomes. We evaluated pediatric retention in select care and treatment centers (CTCs) in Côte d'Ivoire. METHODS We retrospectively reviewed medical records using 2-stage cluster sampling for children under 15 years initiated on ART between 2012 and 2016. Kaplan-Meier time-to-event analysis was done to estimate cumulative attrition rates per total person-years of observation. Cox proportional hazard regression was performed to identify factors associated with attrition. RESULTS A total of 1198 patient records from 33 CTCs were reviewed. Retention at 12, 24, 36, 48 and 60 months after ART initiation was 91%, 84%, 74%, 72% and 70%, respectively. A total of 309 attrition events occurred over 3169 person-years of follow-up [266 children were lost to follow-up (LTFU), 29 transferred to another facility and 14 died]. LTFU determinants included attending a "public-private" CTC [adjusted hazard ratio (aHR) 6.05; 95% confidence interval (CI): 4.23-8.65], receiving care at a CTC without an on-site laboratory (aHR: 4.01; 95% CI: 1.70-9.46) or attending a CTC without an electronic medical record (EMR) system (aHR: 2.22; 95% CI: 1.59-3.12). CONCLUSIONS In Cote d'Ivoire, patients attending a CTC that is public-private, does not have on-site laboratory or EMR system were likely to be LTFU. Decentralization of laboratory services and scaling use of EMR systems could help to improve pediatric retention.
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Affiliation(s)
- Fatoumata Touré
- From the Global Health and Population Business Unit, FHI 360, Abidjan, Côte d'Ivoire
| | - Gina D Etheredge
- Global Health and Population Business Unit, FHI 360, Washington, DC
| | - Claire Brennan
- US Centers for Disease Control and Prevention, Division of Global HIV and TB, Atlanta, Georgia
| | - KaeAnne Parris
- Food Security and Agriculture Division, RTI, Durham, North Carolina
| | - Mamadou Otto Diallo
- US President's Malaria Initiative (PMI), US Centers for Disease Control and Prevention, USAID, Liberia
| | | | - Alexandre Ekra
- Division of Global HIV and TB, US Centers for Disease Control and Prevention, Abidjan, Côte d'Ivoire
| | - Herve Prao
- Division of Global HIV and TB, US Centers for Disease Control and Prevention, Abidjan, Côte d'Ivoire
| | - N'Da Viviane Assamoua
- Service Recherche, Programme National de Lutte contre le Sida (PNLS), Abidjan, Côte d'Ivoire
| | | | - Foungnigue Kone
- Service Recherche, Programme National de Lutte contre le Sida (PNLS), Abidjan, Côte d'Ivoire
| | - Christian Koffi
- Service Recherche, Programme National de Lutte contre le Sida (PNLS), Abidjan, Côte d'Ivoire
| | - Fathim Kamagaté
- Division of Global HIV and TB, US Centers for Disease Control and Prevention, Abidjan, Côte d'Ivoire
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Akoku DA, Tickell KD, Niamien KR, Kemper KE, Yacouba D, Kouyate S, Kouassi DA, Balachandra S, Swor M, Luxenberg AK, Gloyd S, Kone A. The association between health workforce availability and HIV-program outcomes in Côte d'Ivoire. HUMAN RESOURCES FOR HEALTH 2022; 20:18. [PMID: 35183202 PMCID: PMC8858454 DOI: 10.1186/s12960-022-00715-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 02/02/2022] [Indexed: 05/26/2023]
Abstract
OBJECTIVE The purpose of this study was to assess the distribution of HIV-program staff and the extent to which their availability influences HIV programmatic and patient outcomes. METHODS The study was a facility level cross-sectional survey. Data from October 2018 to September 2019 were abstracted from HIV program reports conducted in 18 districts of Côte d'Ivoire. The distribution of staff in clinical, laboratory, pharmacy, management, lay, and support cadres were described across high and low antiretroviral therapy (ART) volume facilities. Non-parametric regression was used to estimate the effects of cadre categories on the number of new HIV cases identified, the number of cases initiated on ART, and the proportion of patients achieving viral load suppression. RESULTS Data from 49,871 patients treated at 216 health facilities were included. Low ART volume facilities had a median of 8.1 staff-per-100 ART patients, significantly higher than the 4.4 staff-per-100 ART patients at high-ART volume facilities. One additional laboratory staff member was associated with 4.30 (IQR: 2.00-7.48, p < 0.001) more HIV cases identified and 3.81 (interquartile range [IQR]: 1.44-6.94, p < 0.001) additional cases initiated on ART. Similarly, one additional lay worker was associated with 2.33 (IQR: 1.00-3.43, p < 0.001) new cases identified and 2.24 (IQR: 1.00-3.31, p < 0.001) new cases initiated on ART. No cadres were associated with viral suppression. CONCLUSIONS HCWs in the laboratory and lay cadre categories were associated with an increase in HIV-positive case identification and initiation on ART. Our findings suggest that allocation of HCWs across health facilities should take into consideration the ART patient volume. Overall, increasing investment in health workforce is critical to achieve national HIV goals and reaching HIV epidemic control.
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Affiliation(s)
- Derick Akompab Akoku
- Health Alliance International, Abidjan, Côte d'Ivoire.
- Department of Global Health, University of Washington, Seattle, USA.
| | - Kirkby D Tickell
- Department of Global Health, University of Washington, Seattle, USA
| | | | | | | | - Seydou Kouyate
- Health Alliance International, Abidjan, Côte d'Ivoire
- Health Alliance International, Seattle, WA, USA
| | - Daniel A Kouassi
- Ministère de la Santé et de l'Hygiène Publique, Abidjan, Côte d'Ivoire
| | - Shirish Balachandra
- Center for Global Health/Division of Global HIV and TB (DGHT), Centers for Disease Control and Prevention, Abidjan, Côte d'Ivoire
| | - Meghan Swor
- Affiliation of Center for Global Health/Division of Global HIV and TB (DGHT), Centers for Disease Control and Prevention, Abidjan, Côte d'Ivoire
| | - Audrey Knutson Luxenberg
- Center for Global Health/Division of Global HIV and TB (DGHT), Centers for Disease Control and Prevention, Abidjan, Côte d'Ivoire
| | - Steve Gloyd
- Department of Global Health, University of Washington, Seattle, USA
- Health Alliance International, Seattle, WA, USA
| | - Ahoua Kone
- Department of Global Health, University of Washington, Seattle, USA
- Health Alliance International, Seattle, WA, USA
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Okere NE, Sambu V, Ndungile Y, van Praag E, Hermans S, Naniche D, de Wit TFR, Maokola W, Gomez GB. The Shinyanga Patient: A Patient's Journey through HIV Treatment Cascade in Rural Tanzania. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:8418. [PMID: 34444166 PMCID: PMC8393654 DOI: 10.3390/ijerph18168418] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 07/23/2021] [Accepted: 08/04/2021] [Indexed: 12/30/2022]
Abstract
The 2016-2017 Tanzania HIV Impact Survey (THIS) reported the accomplishments towards the 90-90-90 global HIV targets at 61-94-87, affirming the need to focus on the first 90 (i.e., getting 90% of people living with HIV (PLHIV) tested). We conducted a patient-pathway analysis to understand the gap observed, by assessing the alignment between where PLHIV seek healthcare and where HIV services are available in the Shinyanga region, Tanzania. We used existing and publicly available data from the National AIDS Control program, national surveys, registries, and relevant national reports. Region-wide, the majority (n = 458/722, 64%) of THIS respondents accessed their last HIV test at public sector facilities. There were 65.9%, 45.1%, and 74.1% who could also access antiretroviral therapy (ART), CD4 testing, and HIV viral load testing at the location of their last HIV test, respectively. In 2019, the viral suppression rate estimated among PLHIV on ART in the Shinyanga region was 91.5%. PLHIV access HIV testing mostly in public health facilities; our research shows that synergies can be achieved to improve access to services further down the cascade in this sector. Furthermore, effective engagement with the private sector (not-for-profit and for-profit) will help to achieve the last mile toward ending the HIV epidemic.
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Affiliation(s)
- Nwanneka E Okere
- Department of Global Health, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (S.H.); (T.F.R.d.W.)
- Amsterdam Institute for Global Health and Development, 1105 BP Amsterdam, The Netherlands;
| | - Veryeh Sambu
- National AIDS Control Programme, Dodoma 41110, Tanzania; (V.S.); (W.M.)
| | - Yudas Ndungile
- Regional Health Management Team, Shinyanga 37103, Tanzania;
| | - Eric van Praag
- Amsterdam Institute for Global Health and Development, 1105 BP Amsterdam, The Netherlands;
| | - Sabine Hermans
- Department of Global Health, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (S.H.); (T.F.R.d.W.)
- Amsterdam Institute for Global Health and Development, 1105 BP Amsterdam, The Netherlands;
| | - Denise Naniche
- ISGlobal-Barcelona Institute for Global Health, Hospital Clinic, University of Barcelona, 08036 Barcelona, Spain;
| | - Tobias F Rinke de Wit
- Department of Global Health, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (S.H.); (T.F.R.d.W.)
- Amsterdam Institute for Global Health and Development, 1105 BP Amsterdam, The Netherlands;
| | - Werner Maokola
- National AIDS Control Programme, Dodoma 41110, Tanzania; (V.S.); (W.M.)
| | - Gabriela B Gomez
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK;
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Mnyaka OR, Mabunda SA, Chitha WW, Nomatshila SC, Ntlongweni X. Barriers to the Implementation of the HIV Universal Test and Treat Strategy in Selected Primary Care Facilities in South Africa's Eastern Cape Province. J Prim Care Community Health 2021; 12:21501327211028706. [PMID: 34189991 PMCID: PMC8252362 DOI: 10.1177/21501327211028706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: The South African government implemented the Universal Test and Treat (UTT) approach to treating HIV in the second half of 2016. As part of a contribution to the successful implementation of UTT, this study looked at barriers to implementation of UTT emanating from weaknesses of the health system in 2 Community Health Centers in South Africa’s Eastern Cape Province. Methods: This was a quantitative cross-sectional design which had both descriptive and analytical components. Convenience sampling was used to select and recruit 2 primary care facilities and 30 nurses. Self-administered questionnaires were used to solicit data from facility managers and nurses. In addition, a record review was used to access 6 months’ data for the period 1 October 2017 to 31 March 2018. Data were analyzed using Stata 14.1. Categorical data were presented using frequency and contingency tables. The 95% confidence interval (95% CI) is used for the precision of estimates and the P-value of statistical significance is P < .05. Results: Facilities were found to have poor leadership and governance; human resource challenges that include shortages, lack of skills and lack of developmental support; poorly resourced service delivery platforms and poor information management. Of the three 90-90-90 targets, health facilities only satisfactorily achieved the second 90 of initiating all who test positive for HIV within a week (93.1% or n = 288/307). Conclusions: This study has been able to identify potential barriers to the implementation of the UTT strategy at the selected facilities including the lack of structured programs in place to monitor performance of healthcare staff, knowledge gaps, and a lack of good clinical governance practices as evidenced by the lack of customized protocols and Standard Operating Procedures.
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Affiliation(s)
- Onke R Mnyaka
- University of the Witwatersrand, Johannesburg, South Africa
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Building and Sustaining Optimized Diagnostic Networks to Scale-up HIV Viral Load and Early Infant Diagnosis. J Acquir Immune Defic Syndr 2021; 84 Suppl 1:S56-S62. [PMID: 32520916 DOI: 10.1097/qai.0000000000002367] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Progress toward meeting the UNAIDS 2014 HIV treatment (90-90-90) targets has been slow in some countries because of gaps in access to HIV diagnostic tests. Emerging point-of-care (POC) molecular diagnostic technologies for HIV viral load (VL) and early infant diagnosis (EID) may help reduce diagnostic gaps. However, these technologies need to be implemented in a complementary and strategic manner with laboratory-based instruments to ensure optimization. METHOD Between May 2019 and February 2020, a systemic literature search was conducted in PubMed, the Cochrane Library, MEDLINE, conference abstracts, and other sources such as Unitaid, UNAIDS, WHO, and UNICEF websites to determine factors that would affect VL and EID scale-up. Data relevant to the search themes were reviewed for accuracy and were included. RESULTS Collaborations among countries, implementing partners, and donors have identified a set of framework for the effective use of both POC-based and laboratory-based technologies in large-scale VL and EID testing programs. These frameworks include (1) updated testing policies on the operational utility of POC and laboratory-based technologies, (2) expanded integrated testing using multidisease diagnostic platforms, (3) laboratory network mapping, (4) use of more efficient procurement and supply chain approaches such as all-inclusive pricing and reagent rental, and (5) addressing systemic issues such as test turnaround time, sample referral, data management, and quality systems. CONCLUSIONS Achieving and sustaining optimal VL and EID scale-up within tiered diagnostic networks would require better coordination among the ministries of health of countries, donors, implementing partners, diagnostic manufacturers, and strong national laboratory and clinical technical working groups.
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Shrivastava R, Poxon R, Rottinghaus E, Essop L, Sanon V, Chipeta Z, van-Schalkwyk E, Sekwadi P, Murangandi P, Nguyen S, Devos J, Nesby-Odell S, Stevens T, Umaru F, Cox A, Kim A, Yang C, Parsons LM, Malope-Kgokong B, Nkengasong JN. Leveraging gains from African Center for Integrated Laboratory Training to combat HIV epidemic in sub-Saharan Africa. BMC Health Serv Res 2021; 21:22. [PMID: 33407442 PMCID: PMC7787229 DOI: 10.1186/s12913-020-06005-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 12/08/2020] [Indexed: 11/24/2022] Open
Abstract
Background In sub-Saharan Africa, there is dearth of trained laboratorians and strengthened laboratory systems to provide adequate and quality laboratory services for enhanced HIV control. In response to this challenge, in 2007, the African Centre for Integrated Laboratory Training (ACILT) was established in South Africa with a mission to train staffs from countries with high burdens of diseases in skills needed to strengthen sustainable laboratory systems. This study was undertaken to assess the transference of newly gained knowledge and skills to other laboratory staff, and to identify enabling and obstructive factors to their implementation. Methods We used Kirkpatrick model to determine training effectiveness by assessing the transference of newly gained knowledge and skills to participant’s work environment, along with measuring enabling and obstructive factors. In addition to regular course evaluations at ACILT (pre and post training), in 2015 we sent e-questionnaires to 867 participants in 43 countries for course participation between 2008 and 2014. Diagnostics courses included Viral Load, and systems strengthening included strategic planning and Biosafety and Biosecurity. SAS v9.44 and Excel were used to analyze retrospective de-identified data collected at six months pre and post-training. Results Of the 867 participants, 203 (23.4%) responded and reported average improvements in accuracy and timeliness in Viral Load programs and to systems strengthening. For Viral Load testing, frequency of corrective action for unsatisfactory proficiency scores improved from 57 to 91%, testing error rates reduced from 12.9% to 4.9%; 88% responders contributed to the first national strategic plan development and 91% developed strategies to mitigate biosafety risks in their institutions. Key enabling factors were team and management support, and key obstructive factors included insufficient resources and staff’s resistance to change. Conclusions Training at ACILT had a documented positive impact on strengthening the laboratory capacity and laboratory workforce and substantial cost savings. ACILT’s investment produced a multiplier effect whereby national laboratory systems, personnel and leadership reaped training benefits. This laboratory training centre with a global clientele contributed to improve existing laboratory services, systems and networks for the HIV epidemic and is now being leveraged for COVID-19 testing that has infected 41,332,899 people globally. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-020-06005-8.
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Affiliation(s)
- Ritu Shrivastava
- International Laboratory Branch (ILB), Division of Global HIV and TB (DGHT), Centres for Disease Control and Prevention (CDC), 1600 Clifton Road NE, Atlanta, GA, 30333, USA.
| | - Richard Poxon
- African Center for Integrated Laboratory Training at National Health Laboratory Service, Johannesburg, South Africa
| | - Erin Rottinghaus
- International Laboratory Branch (ILB), Division of Global HIV and TB (DGHT), Centres for Disease Control and Prevention (CDC), 1600 Clifton Road NE, Atlanta, GA, 30333, USA
| | - Leyya Essop
- African Center for Integrated Laboratory Training at National Health Laboratory Service, Johannesburg, South Africa
| | - Victoria Sanon
- Georgia State University, intern at ILB, DGHT, CDC, Atlanta, USA
| | | | - Elsie van-Schalkwyk
- African Center for Integrated Laboratory Training at National Health Laboratory Service, Johannesburg, South Africa
| | - Phuti Sekwadi
- African Center for Integrated Laboratory Training at National Health Laboratory Service, Johannesburg, South Africa
| | - Pelagia Murangandi
- African Center for Integrated Laboratory Training at National Health Laboratory Service, Johannesburg, South Africa
| | - Shon Nguyen
- International Laboratory Branch (ILB), Division of Global HIV and TB (DGHT), Centres for Disease Control and Prevention (CDC), 1600 Clifton Road NE, Atlanta, GA, 30333, USA
| | - Josh Devos
- International Laboratory Branch (ILB), Division of Global HIV and TB (DGHT), Centres for Disease Control and Prevention (CDC), 1600 Clifton Road NE, Atlanta, GA, 30333, USA
| | - Shanna Nesby-Odell
- International Laboratory Branch (ILB), Division of Global HIV and TB (DGHT), Centres for Disease Control and Prevention (CDC), 1600 Clifton Road NE, Atlanta, GA, 30333, USA
| | - Thomas Stevens
- International Laboratory Branch (ILB), Division of Global HIV and TB (DGHT), Centres for Disease Control and Prevention (CDC), 1600 Clifton Road NE, Atlanta, GA, 30333, USA
| | - Farouk Umaru
- Supply Chain Management System, United States Agency for Internationl Development, Atlanta, USA
| | | | | | - Chunfu Yang
- International Laboratory Branch (ILB), Division of Global HIV and TB (DGHT), Centres for Disease Control and Prevention (CDC), 1600 Clifton Road NE, Atlanta, GA, 30333, USA
| | - Linda M Parsons
- International Laboratory Branch (ILB), Division of Global HIV and TB (DGHT), Centres for Disease Control and Prevention (CDC), 1600 Clifton Road NE, Atlanta, GA, 30333, USA
| | - Babatyi Malope-Kgokong
- African Center for Integrated Laboratory Training at National Health Laboratory Service, Johannesburg, South Africa
| | - John N Nkengasong
- International Laboratory Branch (ILB), Division of Global HIV and TB (DGHT), Centres for Disease Control and Prevention (CDC), 1600 Clifton Road NE, Atlanta, GA, 30333, USA
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Lakoh S, Jiba DF, Vandy AO, Poveda E, Adekanmbi O, Murray MJS, Deen GF, Sahr F, Hoffmann CJ, Jacobson JM, Salata RA, Yendewa GA. Assessing eligibility for differentiated service delivery, HIV services utilization and virologic outcomes of adult HIV-infected patients in Sierra Leone: a pre-implementation analysis. Glob Health Action 2021; 14:1947566. [PMID: 34404330 PMCID: PMC8381912 DOI: 10.1080/16549716.2021.1947566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background There are limited data to help guide implementation of differentiated HIV service delivery (DSD) in resource-limited settings in sub-Saharan Africa. Objectives This pre-implementation study sought to assess the proportion of patients eligible for DSD and HIV services utilization, as well as risk factor analysis of virologic failure in Sierra Leone. Methods We conducted a retrospective study of adult HIV-infected patients aged 18 years and older receiving care at the largest HIV treatment center in Sierra Leone 2019–2020. Multiple logistic regression was used to identify predictors of virologic failure. Results Of 586 unique patients reviewed, 210 (35.8%) qualified as ‘stable’ for antiretroviral therapy (ART) delivery. There was high utilization of certain HIV service programs (e.g. HIV status disclosure to partners (83%) and treatment ‘buddy’ program participation (62.8%)), while other service programs (e.g. partner testing and community HIV support group participation) had low utilization (<50%). Of 429 patients with available viral load, 277 (64.6%) were virologically suppressed. In the multivariate logistic regression analysis of risk factors of virologic failure, CD4 < 350 cells/mm3 (p = 0.009), atazanavir-based ART (p = 0.032), once monthly versus once two- or three-monthly ART dispensing (p = 0.028), history of ART switching (p = 0.02), poor adherence (p = 0.001) and not having received adherence support (p < 0.001) were independent predictors of virologic failure. Conclusion Approximately one in three HIV-infected patients on ART were eligible for DSD. We identified gaps in HIV care (i.e. low partner testing, treatment ‘buddy’, program participation and a substantially high rate of virologic failure) that need to be addressed in preparation for full implementation of DSD in Sierra Leone.
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Affiliation(s)
- Sulaiman Lakoh
- Department of Medicine, College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone.,Ministry of Health and Sanitation, Freetown, Sierra Leone
| | | | - Alren O Vandy
- Ministry of Health and Sanitation, Freetown, Sierra Leone
| | - Eva Poveda
- Group of Virology and Pathogenesis, Galicia Sur Health Research Institute (IIS Galicia Sur)-Complexo Hospitalario Universitario De Vigo, SERGAS-UVigo, Spain
| | - Olukemi Adekanmbi
- Department of Medicine, College of Medicine, University of Ibadan, Ibadan, Nigeria.,Department of Medicine, University College Hospital, Ibadan, Nigeria
| | | | - Gibrilla F Deen
- Department of Medicine, College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone.,Ministry of Health and Sanitation, Freetown, Sierra Leone
| | - Foday Sahr
- Department of Medicine, College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone.,Ministry of Health and Sanitation, Freetown, Sierra Leone
| | - Christopher J Hoffmann
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.,Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Jeffrey M Jacobson
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Division of Infectious Diseases and HIV Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Robert A Salata
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Division of Infectious Diseases and HIV Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - George A Yendewa
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Division of Infectious Diseases and HIV Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA.,Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Alemnji G, Pati R, Chun H, Zeh C, Mosha F, Siberry G, Ondoa P. Clinical/Laboratory Interface Interventions to Improve Impact of Viral Load and Early Infant Diagnosis Testing Scale-Up. AIDS Res Hum Retroviruses 2020; 36:550-555. [PMID: 32070109 DOI: 10.1089/aid.2019.0266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Despite tremendous improvements in viral load (VL) monitoring and early infant diagnosis (EID) in many countries, low VL and EID testing rates and low VL suppression rates persist in specific regions and among certain subpopulations. The VL/EID cascade includes patient and provider demand creation, sample collection and transportation, laboratory testing, results transmission back to the clinic, and patient management. Gaps in communication and coordination between clinical and laboratory counterparts can lead to suboptimal outcomes, such as delay or inability to collect and transport samples to the laboratory for testing and failure of test results to reach providers and patients in an efficient, timely, and effective manner. To bridge these gaps and optimize the impact of VL/EID scale-up, we reviewed the components of the cascade and their interrelationships to identify barriers and facilitators. As part of this process, people living with HIV must be engaged in creating demand for VL/EID testing. In addition, there should be strong communication and collaboration between the clinical and laboratory teams throughout the cascade, along with joint performance review, site visits, and continuous quality improvement activities. Strengthening the clinical/laboratory interface requires innovative solutions and implementation of best practices, including the use of point-of-care diagnostics, simplified data systems, and an efficient supply chain system to minimize interface gaps.
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Affiliation(s)
- George Alemnji
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- Office of the U.S. Global AIDS Coordinator and Health Diplomacy, Washington, District of Columbia, USA
| | - Rituparna Pati
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Helen Chun
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Clement Zeh
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Fausta Mosha
- HTH/Communicable Diseases Cluster, AFRO Inter-Country Support Team, World Health Organization, Harare, Zimbabwe
| | - George Siberry
- Division of Prevention, Care and Treatment, United States Agency for International Development, Arlington, Virginia, USA
| | - Pascale Ondoa
- African Society for Laboratory Medicine, Addis Ababa, Ethiopia
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Kumar M, Mostafa J. Electronic health records for better health in the lower- and middle-income countries. LIBRARY HI TECH 2020. [DOI: 10.1108/lht-09-2019-0179] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PurposeElectronic health records (EHR) can enable collection and use of data for achieving better health both at the patient and population health levels. The World Health Organization's (WHO) draft 2019 four-year global digital health strategy aims to “improve health for everyone, everywhere by accelerating the adoption of appropriate digital health” and EHRs are key to achieving better health goals. Despite the fact that EHRs can help to achieve better health, there is lack of evidence explaining national and sub-national EHR development in the limited resource settings.Design/methodology/approachWe conducted a landscape study to describe the EHR development and use in the low- and middle-income countries for achieving better health. We reviewed literature from four scientific databases and analyzed gray literature identified in consultation with 17 international experts.FindingsThe findings of this literature review are presented in three subsections. The first two subsections describe key stakeholders for development of national and sub-national EHR and health information architecture which includes status of ehealth foundations, EHR, and sub-systems in the country. The third subsection presents and discusses key challenges related to sustainability of national and sub-national EHRs. The findings in these three subsections are further explored through examples of health information flow in Uganda, and electronic medical record/EHR implementation in Sierra Leone and Malawi. These examples briefly describe stakeholders, information architecture, and sustainability challenges.Originality/valueThis paper fills an important research gap and clearly explains the urgent research need to build context-specific EHR development models to enable use of data for better health.
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Kuupiel D, Bawontuo V, Drain PK, Gwala N, Mashamba-Thompson TP. Supply chain management and accessibility to point-of-care testing in resource-limited settings: a systematic scoping review. BMC Health Serv Res 2019; 19:519. [PMID: 31340833 PMCID: PMC6657084 DOI: 10.1186/s12913-019-4351-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 07/16/2019] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND World Health Organization (WHO) has created an essential list of in-vitro diagnostics. Supply chain management (SCM) is said to be the vehicle that ensures that developed point-of-care (POC) tests reach their targeted settings for use. We therefore, mapped evidence on SCM of and accessibility to POC testing (availability and use of POC tests) in low- and middle-income countries (LMICs). METHODS We conducted a systematic scoping review using Arksey and O'Malley's framework as a guide. We searched PubMed; CINAHL; MEDLINE; WEB of Science; Science Direct; and Google Scholar databases for studies that focused on POC diagnostic tests and SCM. The review included studies that were undertaken in 140 countries defined by the World Bank as LMICs published up to August 2017. Two reviewers independently screened the abstracts and full articles against the eligibility criteria. The study used the mixed methods appraisal tool version 2011 to assess the risk of bias for the included studies. NVivo version 11 was employed to extract themes from all included studies and results presented using a narrative approach. RESULTS Of 292 studies identified in this review, only 15 published between 2009 and 2017 included evidence on POC diagnostics and SCM. Of the 15 studies, three were conducted in Zambia, one each in Mozambique, Uganda, Guatemala; South Africa, one in Burkina Faso, Zimbabwe, and one multi-country study (Tanzania, Uganda, China, Peru and Zambia and Brazil). Six studies were not country specific since they were not primary studies. Majority of the studies reported stock-outs of HIV, syphilis, and malaria POC tests. There was a moderate to substantial level of agreement between the reviewers' responses at full article screening stage (Kappa statistic = 0.80, p < 0.01). Nine studies underwent methodological quality appraisal and all, scored between 90 and 100%. CONCLUSIONS The results demonstrated limited published research on SCM of and accessibility to POC testing in LMICs. Further studies aimed at investigating SCM of POC tests in resource-limited settings to identify the barriers/challenges and provide a context-specific evidence-based solutions for policy/decision makers, implementers, and POC developers, funders, and development partners would be essential. PROSPERO REGISTRATION NUMBER CRD42016043711.
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Affiliation(s)
- Desmond Kuupiel
- Department of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Vitalis Bawontuo
- Faculty of Health and Allied Sciences, Catholic University College of Ghana, Fiapre, Sunyani, Ghana
| | - Paul K. Drain
- International Clinical Research Center, Department of Global Health, University of Washington, Seattle, USA
- Division of Infectious Diseases, Department of Medicine, University of Washington, Seattle, USA
- Department of Epidemiology, University of Washington, Seattle, USA
| | - Nonjabulo Gwala
- Department of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Tivani P. Mashamba-Thompson
- Department of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
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Accessibility of pregnancy-related point-of-care diagnostic tests for maternal healthcare in rural primary healthcare facilities in Northern Ghana: A cross-sectional survey. Heliyon 2019; 5:e01236. [PMID: 30828664 PMCID: PMC6383048 DOI: 10.1016/j.heliyon.2019.e01236] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 12/25/2018] [Accepted: 02/11/2019] [Indexed: 01/07/2023] Open
Abstract
Background Improving access to maternal healthcare in resource-limited settings plays a critical role in improving maternal health outcomes and reducing maternal deaths. However, barriers and challenges may exist in rural clinics and could affect successful implementation. This study assessed the current accessibility of pregnancy-related point-of-care (POC) diagnostic tests for maternal healthcare in rural primary healthcare (PHC) clinics in northern Ghana. Method We randomly selected 100 PHC clinics providing maternal healthcare from a total list of 356 PHC clinicss obtained from the Regional Health Directorate. Selected clinics were surveyed from February to March 2018, using an adopted survey tool. We obtained data for clinic-level staffing, availability, usage, and desired POC diagnostic tests. Stata 14 was used for data analysis. Findings Majority (64%) of the respondents were midwives. The mean ± standard deviation (SD) years of work experience and working hours per week were estimated at 5.6 years ± 0.4 and 122 hours ± 5.2 respectively. Average antenatal clinic attendance (clinic census) per month was 65 ± 67 pregnant women (Range: 3–360). The mean ± SD POC tests available and use was 4.9 tests ± 2.2. POC tests for malaria, HIV, urine pregnancy, and blood pressure monitoring devices were available in most clinics. POC tests requested by the clinics to assist them care for pregnant women included: Glucose-6-phosphate dehydrogenase (95%); hepatitis C (94%); sickling (91%); tuberculosis, blood glucose and blood type (89%) each; urinary tract infection (87%); urine protein (81%); hepatitis B (78%); haemoglobin (76%); and syphilis (76%). Interpretation There is poor accessibility to pregnancy-related POC diagnostic tests for maternal healthcare due to low availability (≤5 tests per PHC clinic) of POC tests in rural PHC clinics in northern Ghana.
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Rice B, Boulle A, Baral S, Egger M, Mee P, Fearon E, Reniers G, Todd J, Schwarcz S, Weir S, Rutherford G, Hargreaves J. Strengthening Routine Data Systems to Track the HIV Epidemic and Guide the Response in Sub-Saharan Africa. JMIR Public Health Surveill 2018; 4:e36. [PMID: 29615387 PMCID: PMC5904448 DOI: 10.2196/publichealth.9344] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 02/08/2018] [Accepted: 02/14/2018] [Indexed: 01/09/2023] Open
Abstract
The global HIV response has entered a new phase with the recommendation of treating all persons living with HIV with antiretroviral therapy, and with the goals of reducing new infections and AIDS-related deaths to fewer than 500,000 by 2020. This new phase has intensive data requirements that will need to utilize routine data collected through service delivery platforms to monitor progress toward these goals. With a focus on sub-Saharan African, we present the following priorities to improve the demand, supply, and use of routine HIV data: (1) strengthening patient-level HIV data systems that support continuity of clinical care and document sentinel events; (2) leveraging data from HIV testing programs; (3) using targeting data collection in communities and among clients; and (4) building capacity and promoting a culture of HIV data quality assessment and use. When fully leveraged, routine data can efficiently provide timely information at a local level to inform action, as well as provide information at scale with wide geographic coverage to strengthen estimation efforts.
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Affiliation(s)
- Brian Rice
- Social and Environmental Health Research, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and Research, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Stefan Baral
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, United States
| | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Paul Mee
- Social and Environmental Health Research, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Elizabeth Fearon
- Social and Environmental Health Research, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Georges Reniers
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jim Todd
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sandra Schwarcz
- Global Health Sciences, University of California San Francisco, San Francisco, CA, United States
| | - Sharon Weir
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC, United States
| | - George Rutherford
- Global Health Sciences, University of California San Francisco, San Francisco, CA, United States
| | - James Hargreaves
- Social and Environmental Health Research, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Cranmer JN, Dettinger J, Calkins K, Kibore M, Gachuno O, Walker D. Beyond signal functions in global obstetric care: Using a clinical cascade to measure emergency obstetric readiness. PLoS One 2018; 13:e0184252. [PMID: 29474397 PMCID: PMC5825011 DOI: 10.1371/journal.pone.0184252] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 08/21/2017] [Indexed: 01/17/2023] Open
Abstract
Background Globally, the rate of reduction in delivery-associated maternal and perinatal mortality has been slow compared to improvements in post-delivery mortality in children under five. Improving clinical readiness for basic obstetric emergencies is crucial for reducing facility-based maternal deaths. Emergency readiness is commonly assessed using tracers derived from the maternal signal functions model. Objective-method We compare emergency readiness using the signal functions model and a novel clinical cascade. The cascades model readiness as the proportion of facilities with resources to identify the emergency (stage 1), treat it (stage 2) and monitor-modify therapy (stage 3). Data were collected from 44 Kenyan clinics as part of an implementation trial. Findings Although most facilities (77.0%) stock maternal signal function tracer drugs, far fewer have resources to practically identify and treat emergencies. In hypertensive emergencies for example, 38.6% of facilities have resources to identify the emergency (Stage 1 readiness, including sphygmomanometer, stethoscope, urine collection device, protein test). 6.8% have the resources to treat the emergency (Stage 2, consumables (IV Kit, fluids), durable goods (IV pole) and drugs (magnesium sulfate and hydralazine). No facilities could monitor or modify therapy (Stage 3). Across five maternal emergencies, the signal functions overestimate readiness by 54.5%. A consistent, step-wise pattern of readiness loss across signal functions and care stage emerged and was profoundly consistent at 33.0%. Significance Comparing estimates from the maternal signal functions and cascades illustrates four themes. First, signal functions overestimate practical readiness by 55%. Second, the cascade’s intuitive indicators can support cross-sector health system or program planners to more precisely measure and improve emergency care. Third, adding few variables to existing readiness inventories permits step-wise modeling of readiness loss and can inform more precise interventions. Fourth, the novel aggregate readiness loss indicator provides an innovative and intuitive approach for modeling health system emergency readiness. Additional testing in diverse contexts is warranted.
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Affiliation(s)
- John N. Cranmer
- Emory University, Atlanta, Georgia, United States of America
- * E-mail:
| | - Julia Dettinger
- University of Washington, Department of Global Health, Seattle, Washington, United States of America
| | - Kimberly Calkins
- University of Washington, Department of Global Health, Seattle, Washington, United States of America
| | - Minnie Kibore
- University of Nairobi, Department of Paediatrics & Child Health Lecturer, Kenyatta National Hospital, Nairobi, Kenya
| | - Onesmus Gachuno
- University of Nairobi, Department of Obstetrics & Gyneacology, Kenyatta National Hospital, Nairobi, Kenya
| | - Dilys Walker
- University of California—San Francisco School of Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, San Francisco, California, United States of America
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Alemnji G, Chase M, Branch S, Guevara G, Nkengasong J, Albalak R. Improving Laboratory Efficiency in the Caribbean to Attain the World Health Organization HIV Treat All Recommendations. AIDS Res Hum Retroviruses 2018; 34:132-139. [PMID: 28967269 DOI: 10.1089/aid.2017.0158] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Scientific evidence showing the benefits of early initiation of antiretroviral therapy (ART) prompted World Health organization (WHO) to recommend that all persons diagnosed as HIV positive should commence ART irrespective of CD4 count and disease progression. Based on this recommendation, countries should adopt and implement the HIV "Treat All" policy to achieve the UNAIDS 90-90-90 targets and ultimately reach epidemic control. Attaining this goal along the HIV treatment cascade depends on the laboratory to monitor progress and measure impact. The laboratory plays an important role in HIV diagnosis to attain the first 90 and in viral load (VL) and HIV drug resistance testing to reinforce adherence, improve viral suppression, and measure the third 90. Countries in the Caribbean region have endorsed the WHO HIV "Treat all" recommendation; however, they are faced with diminishing financial resources to support laboratory testing, seen as a rate-limiting factor to achieving this goal. To improve laboratory coverage with fewer resources in the Caribbean there is the need to optimize laboratory operations to ensure the implementation of high quality, less expensive evidence-based approaches that will result in more efficient and effective service delivery. Suggested practical and innovative approaches to achieve this include: (1) targeted testing within HIV hotspots; (2) strengthening sample referral systems for VL; (3) better laboratory data collection systems; and (4) use of treatment cascade data for programmatic decision-making. Furthermore, strengthening quality improvement and procurement systems will minimize diagnostic errors and guarantee a continuum of uninterrupted testing which is critical for routine monitoring of patients to meet the stated goal.
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Affiliation(s)
- George Alemnji
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
- State Department Office of the Global AIDS Coordinator and Health Diplomacy (S/GAC), Washington, District of Columbia
| | - Martine Chase
- Caribbean Regional Office, Division of Global HIV/AIDS, Centers for Disease Control and Prevention (CDC), US Embassy, Bridgetown, Barbados
| | - Songee Branch
- Ladymeade Reference Unit Laboratory, Ministry of Health, Bridgetown, Barbados
| | - Giselle Guevara
- Caribbean Regional Office, Division of Global HIV/AIDS, Centers for Disease Control and Prevention (CDC), US Embassy, Bridgetown, Barbados
| | - John Nkengasong
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Rachel Albalak
- Caribbean Regional Office, Division of Global HIV/AIDS, Centers for Disease Control and Prevention (CDC), US Embassy, Bridgetown, Barbados
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Garnett GP, Hallett TB, Takaruza A, Hargreaves J, Rhead R, Warren M, Nyamukapa C, Gregson S. Providing a conceptual framework for HIV prevention cascades and assessing feasibility of empirical measurement with data from east Zimbabwe: a case study. Lancet HIV 2017; 3:e297-306. [PMID: 27365204 PMCID: PMC4935672 DOI: 10.1016/s2352-3018(16)30039-x] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 04/25/2016] [Accepted: 05/06/2016] [Indexed: 12/27/2022]
Abstract
Background The HIV treatment cascade illustrates the steps required for successful treatment and is a powerful advocacy and monitoring tool. Similar cascades for people susceptible to infection could improve HIV prevention programming. We aim to show the feasibility of using cascade models to monitor prevention programmes. Methods Conceptual prevention cascades are described taking intervention-centric and client-centric perspectives to look at supply, demand, and efficacy of interventions. Data from two rounds of a population-based study in east Zimbabwe are used to derive the values of steps for cascades for voluntary medical male circumcision (VMMC) and for partner reduction or condom use driven by HIV testing and counselling (HTC). Findings In 2009 to 2011 the availability of circumcision services was negligible, but by 2012 to 2013 about a third of the population had access. However, where it was available only 12% of eligible men sought to be circumcised leading to an increase in circumcision prevalence from 3·1% to 6·9%. Of uninfected men, 85·3% did not perceive themselves to be at risk of acquiring HIV. The proportions of men and women tested for HIV increased from 27·5% to 56·6% and from 61·1% to 79·6%, respectively, with 30·4% of men tested self-reporting reduced sexual partner numbers and 12·8% reporting increased condom use. Interpretation Prevention cascades can be populated to inform HIV prevention programmes. In eastern Zimbabwe programmes need to provide greater access to circumcision services and the design and implementation of associated demand creation activities. Whereas, HTC services need to consider how to increase reductions in partner numbers or increased condom use or should not be considered as contributing to prevention services for the HIV-negative adults. Funding Wellcome Trust and Bill & Melinda Gates Foundation.
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Affiliation(s)
| | - Timothy B Hallett
- Department of Infectious Disease Epidemiology, Imperial College London School of Public Health, London, UK
| | - Albert Takaruza
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | | | - Rebecca Rhead
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | | | - Constance Nyamukapa
- Department of Infectious Disease Epidemiology, Imperial College London School of Public Health, London, UK; Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Simon Gregson
- Department of Infectious Disease Epidemiology, Imperial College London School of Public Health, London, UK; Biomedical Research and Training Institute, Harare, Zimbabwe
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Abstract
PURPOSE OF REVIEW Although the concept of the HIV treatment cascade has reached nearly ubiquitous acceptance in international HIV policy and research, methods for estimating it vary drastically. These variations become increasingly important as the focus of the HIV response shifts from emergency response to long-term outcomes and financial and organizational sustainability. We review the history of the cascade and the current literature and develop the first comprehensive typology of cascade scope and methods. RECENT FINDINGS We define the cascade scope in terms of both breadth (range from first to final event) and depth (given breadth, number of cascade stages that analyzed). We distinguish cascade measurement according to four dimensions: denominator-denominator linkage (data used for cascade construction are linked at the individual level across stages); denominator-numerator linkage (data are linked at the individual level within each stage); single vs. multiple populations from which data sources are drawn; and longitudinal vs. cross-sectional design. SUMMARY Everything else equal, we would prefer broader and deeper cascades, denominator-denominator linkage, denominator-numerator linkage, single population, and longitudinal data over their respective alternatives. Increased investments in population-based cohorts and data linkage are required to complement clinical cohorts for 'broad' longitudinal cascade analyses.
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Abstract
In a perspective on Habiyambere and colleagues, Peter Kilmarx and Raiva Simbi discuss the disconnect between HIV testing instrument capacity and utilization.
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Affiliation(s)
- Peter H. Kilmarx
- Fogarty International Center, National Institutes of Health, Bethesda, Maryland, United States of America
- * E-mail:
| | - Raiva Simbi
- Ministry of Health and Child Care, Harare, Zimbabwe
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Geographical targeting to improve progression through the sexually transmitted infection/HIV treatment continua in different populations. Curr Opin HIV AIDS 2016; 10:477-82. [PMID: 26352392 DOI: 10.1097/coh.0000000000000195] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE OF REVIEW The purpose of this study is to review and synthesize the recent literature on the use of geographical targeting to improve progression through HIV and sexually transmitted disease (STD) prevention and treatment continua in different populations. RECENT FINDINGS Geographical targeting can help identify obstacles to progression through prevention and treatment continua for each stage and in specific geographic locations. Macro-level geographical targeting can help maximize allocative efficiency, while micro-level targeting of hot spots increases effectiveness of interventions. Migration into and out of geographical areas of interest constitutes a challenge to geographical targeting in that stage-specific monitoring strategies tend to yield inaccurate results when people leave the area. Despite these issues, it is possible to identify failures in each stage of the continuum by specific spatial location such as census tracts and focus improvement efforts accordingly. SUMMARY Vulnerabilities, risk behaviours and infections all cluster across age, race-ethnicity, socioeconomic status, key populations, risk networks and geographic space. Spatial concentration may be the most important in this context, as it allows prevention programmes to identify and reach target populations more easily. Geographical targeting can be employed at both macro and micro levels and in combination with targeting of key populations and high-risk networks.
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Dominique JK, Ortiz-Osorno AA, Fitzgibbon J, Gnanashanmugam D, Gilpin C, Tucker T, Peel S, Peter T, Kim P, Smith S. Implementation of HIV and Tuberculosis Diagnostics: The Importance of Context. Clin Infect Dis 2016; 61Suppl 3:S119-25. [PMID: 26409272 DOI: 10.1093/cid/civ552] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Novel diagnostics have been widely applied across human immunodeficiency virus (HIV) and tuberculosis prevention and treatment programs. To achieve the greatest impact, HIV and tuberculosis diagnostic programs must carefully plan and implement within the context of a specific healthcare system and the laboratory capacity. METHODS A workshop was convened in Cape Town in September 2014. Participants included experts from laboratory and clinical practices, officials from ministries of health, and representatives from industry. RESULTS The article summarizes best practices, challenges, and lessons learned from implementation experiences across sub-Saharan Africa for (1) building laboratory programs within the context of a healthcare system; (2) utilizing experience of clinicians and healthcare partners in planning and implementing the right diagnostic; and (3) evaluating the effects of new diagnostics on the healthcare system and on patient health outcomes. CONCLUSIONS The successful implementation of HIV and tuberculosis diagnostics in resource-limited settings relies on careful consideration of each specific context.
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Affiliation(s)
- Joyelle K Dominique
- Office of Global Research, Office of Science Management and Operations, Office of the Director
| | - Alberto A Ortiz-Osorno
- Clinical Research Implementation Subject Matter Expert, Henry M. Jackson Foundation, Division of AIDS Therapeutic Research Program, Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, US Department of Health and Human Services, Rockville, Maryland
| | - Joseph Fitzgibbon
- Therapeutic Research Program, Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, US Department of Health and Human Services, Rockville, Maryland
| | | | | | - Timothy Tucker
- Strategic Evaluation, Advisory and Development Consulting, Cape Town, South Africa
| | - Sheila Peel
- Diagnostics and Laboratory Monitoring, US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland
| | - Trevor Peter
- Diagnostics, Clinton Health Access Initiative, Gaborone, Botswana
| | - Peter Kim
- Adolescent and Pediatric Research Branch, Prevention Sciences Program, Division of AIDS
| | - Steven Smith
- Office of Global Affairs, Office of the Secretary, US Department of Health and Human Services, Pretoria, South Africa
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Ying R, Granich RM, Gupta S, Williams BG. CD4 Cell Count: Declining Value for Antiretroviral Therapy Eligibility. Clin Infect Dis 2016; 62:1022-8. [PMID: 26826372 DOI: 10.1093/cid/civ1224] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 12/16/2015] [Indexed: 01/09/2023] Open
Abstract
Antiretroviral therapy (ART) policy for people living with human immunodeficiency virus (HIV) has historically been based on clinical indications, such as opportunistic infections and CD4 cell counts. Studies suggest that CD4 counts early in HIV infection do not predict relevant public health outcomes such as disease progression, mortality, and HIV transmission in people living with HIV. CD4 counts also vary widely within individuals and among populations, leading to imprecise measurements and arbitrary ART initiation. To capture the clinical and preventive benefits of treatment, the global HIV response now focuses on increasing HIV diagnosis and ART coverage. CD4 counts for ART initiation were necessary when medications were expensive and had severe side effects, and when the impact of early ART initiation was unclear. However, current evidence suggests that although CD4 counts may still play a role in guiding clinical care to start prophylaxis for opportunistic infections, CD4 counts should cease to be required for ART initiation.
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Affiliation(s)
- Roger Ying
- Weill Cornell Medical College, Cornell University, New York, New York
| | - Reuben M Granich
- International Association of Providers of AIDS Care, Washington D.C
| | - Somya Gupta
- International Association of Providers of AIDS Care, Washington D.C
| | - Brian G Williams
- South African Department of Science and Technology/National Research Foundation Centre of Excellence in Epidemiological Modelling and Analysis, Stellenbosch University Wits Reproductive Health and HIV Research Institute, University of the Witwatersrand, Johannesburg, South Africa
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Jongbloed K, Parmar S, van der Kop M, Spittal PM, Lester RT. Recent Evidence for Emerging Digital Technologies to Support Global HIV Engagement in Care. Curr HIV/AIDS Rep 2015; 12:451-61. [PMID: 26454756 PMCID: PMC5585015 DOI: 10.1007/s11904-015-0291-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Antiretroviral therapy is a powerful tool to reduce morbidity and mortality for the 35 million people living with HIV globally. However, availability of treatment alone is insufficient to meet new UNAIDS 90-90-90 targets calling for rapid scale-up of engagement in HIV care to end the epidemic in 2030. Digital technology interventions (mHealth, eHealth, and telehealth) are emerging as one approach to support lifelong engagement in HIV care. This review synthesizes recent reviews and primary studies published since January 2014 on digital technology interventions for engagement in HIV care after diagnosis. Technologies for health provide emerging and proven solutions to support achievement of the United Nations targets for the generalized HIV-affected population. Much of the existing evidence addresses antiretroviral therapy (ART) adherence; however, studies have begun to investigate programs to support linkage and retention in care as well as interventions to engage key populations facing extensive barriers to care.
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Affiliation(s)
- Kate Jongbloed
- School of Population & Public Health, University of British Columbia, 2206 E Mall, Vancouver, BC, V6T 1Z9, Canada.
| | - Sunjit Parmar
- Faculty of Medicine, University of British Columbia, 2350 Health Sciences Mall, Vancouver, BC, V6T 1Z3, Canada.
| | - Mia van der Kop
- Division of Infectious Diseases, Faculty of Medicine, University of British Columbia, 566-828 West 10th Avenue, Vancouver, BC, V5Z 1L8, Canada.
- Department of Public Health Sciences, Karolinska Institutet, Tomtebodavagen 18a, Campus Solna, Stockholm, Sweden.
| | - Patricia M Spittal
- School of Population & Public Health, University of British Columbia, 2206 E Mall, Vancouver, BC, V6T 1Z9, Canada.
| | - Richard T Lester
- Division of Infectious Diseases, Faculty of Medicine, University of British Columbia, 566-828 West 10th Avenue, Vancouver, BC, V5Z 1L8, Canada.
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Lagasca AM, Kan VL. Making Longitudinal Progress in the HIV Care Continuum Within an Urban Veterans Affairs Clinic. AIDS Patient Care STDS 2015; 29:579-81. [PMID: 26348605 DOI: 10.1089/apc.2015.0141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Alicia M. Lagasca
- Veterans Affairs Medical Center and George Washington University, Washington, District of Columbia
| | - Virginia L. Kan
- Veterans Affairs Medical Center and George Washington University, Washington, District of Columbia
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Landis RC, Carmichael-Simmons K, Hambleton IR, Best A. HIV Viral Load Trends in Six Eastern Caribbean Countries Utilizing a Regional Laboratory Referral Service: Implications for Treatment as Prevention. PLoS One 2015; 10:e0125435. [PMID: 25923741 PMCID: PMC4414557 DOI: 10.1371/journal.pone.0125435] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 03/23/2015] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE Since 2009, seven countries in the Organization of Eastern Caribbean States (OECS), Antigua & Barbuda, Dominica, Grenada, Montserrat, St. Kitts & Nevis, Saint Lucia, and St. Vincent & the Grenadines, have been utilizing a laboratory referral service for HIV-1 viral load (VL) offered by The Ladymeade Reference Unit (LRU) Laboratory, Barbados. The objective of this study was to evaluate 5 year VL trends in the six larger OECS countries participating in this regional referral service. METHODS Blood samples were collected in source countries and transported to Barbados as frozen plasma according to a standardized protocol. Plasma specimens were amplified by RT PCR on a Roche TaqMan 48 analyser (Roche Diagnostics, Panama City, Panama). VL was considered optimally suppressed below a threshold level of < 200 HIV-1 copies/mL of blood. The same threshold was used as a binary indicator in an analysis of the secular change in VL suppression. Montserrat was excluded due to insufficient number of samples. RESULTS A steady rise in VL referrals from OECS countries was recorded, rising from 312 samples in 2009 to 1,060 samples in 2013. A total of 3,543 samples were tested, with a sample rejection rate (9.2%) mostly due to breaks in the cold chain. Aggregate VL data showed the odds of VL suppression in the Eastern Caribbean improved by 66% for each additional year after 2009 (Odds Ratio 1.66 [95% CI 1.46 to 1.88]; p<0.001). CONCLUSION We demonstrate the feasibility of establishing a regional laboratory referral service for HIV VL monitoring in the Eastern Caribbean. Aggregate VL trends showed a significant year-on-year improvement in VL suppression, implying public health benefits through treatment as prevention in the OECS. VL provides a powerful monitoring & evaluation tool for strengthening HIV programs at country level among the small island states participating in this regional referral network.
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Affiliation(s)
- R. Clive Landis
- Chronic Disease Research Centre, The University of the West Indies, Cave Hill, Barbados
- Ladymeade Reference Unit, Ministry of Health, St. Michael, Barbados
- * E-mail:
| | | | - Ian R. Hambleton
- Chronic Disease Research Centre, The University of the West Indies, Cave Hill, Barbados
| | - Anton Best
- Ladymeade Reference Unit, Ministry of Health, St. Michael, Barbados
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Ying R, Barnabas RV, Williams BG. Modeling the implementation of universal coverage for HIV treatment as prevention and its impact on the HIV epidemic. Curr HIV/AIDS Rep 2014; 11:459-67. [PMID: 25249293 PMCID: PMC4301303 DOI: 10.1007/s11904-014-0232-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
The Joint United Nations Programme on HIV/AIDS (UNAIDS) recently updated its global targets for antiretroviral therapy (ART) coverage for HIV-positive persons under which 90 % of HIV-positive people are tested, 90 % of those are on ART, and 90 % of those achieve viral suppression. Treatment policy is moving toward treating all HIV-infected persons regardless of CD4 cell count-otherwise known as treatment as prevention-in order to realize the full therapeutic and preventive benefits of ART. Mathematical models have played an important role in guiding the development of these policies by projecting long-term health impacts and cost-effectiveness. To guide future policy, new mathematical models must consider the barriers patients face in receiving and taking ART. Here, we describe the HIV care cascade and ART delivery supply chain to examine how mathematical modeling can provide insight into cost-effective strategies for scaling-up ART coverage in sub-Saharan Africa and help achieve universal ART coverage.
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Affiliation(s)
- Roger Ying
- Department of Global Health, University of Washington, Box 359927, 325 Ninth Avenue, Seattle, WA, 98104, USA,
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