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Chibi M, Wasswa W, Ngongoni CN, Lule F. Scaling up delivery of HIV services in Africa through harnessing trends across global emerging innovations. Front Health Serv 2023; 3:1198008. [PMID: 38028944 PMCID: PMC10644308 DOI: 10.3389/frhs.2023.1198008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 09/22/2023] [Indexed: 12/01/2023]
Abstract
Globally, innovations for HIV response present exciting opportunities to enhance the impact and cost-effectiveness of any HIV program. However, countries especially in the African region are not on equal footing to effectively harness some of the existing innovations to accelerate impact on HIV services delivery. This paper aims to add to the discourse on innovative solutions to support countries to make informed decisions related to technologies that can be adapted in different contexts to strengthen HIV programs. A scoping review which involved a search of innovations that can be used in response to the HIV epidemic was carried out between June 2021 and December 2022. The results showed that a high level of technological advancement occurred in the area of digital technologies and devices. Out of the 202 innovations, 90% were digital technologies, of which 34% were data collection and analytics, 45% were mobile based applications, and 12% were social media interventions. Only 10% fell into the category of devices, of which 67% were rapid diagnostic tools (RDTs) and 19% were drone-based technologies among other innovative tools. The study noted that most of the innovations that scaled relied on a strong ICT infrastructure backbone. The scoping review presents an opportunity to assess trends, offer evidence, and outline gaps to drive the adoption and adaptation of such technologies in Africa.
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Affiliation(s)
- Moredreck Chibi
- Science and Innovation, Assistant Regional Director, World Health Organization Africa Region, Brazzaville, Congo
| | - William Wasswa
- HIV, Tuberculosis and Hepatitis, Universal Health Coverage/Communicable and Non Communicable Disease Cluster, World Health Organization Africa Region, Brazzaville, Congo
| | - Chipo Nancy Ngongoni
- Science and Innovation, Assistant Regional Director, World Health Organization Africa Region, Brazzaville, Congo
| | - Frank Lule
- HIV, Tuberculosis and Hepatitis, Universal Health Coverage/Communicable and Non Communicable Disease Cluster, World Health Organization Africa Region, Brazzaville, Congo
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Schaefer R, Schmidt HMA, Ravasi G, Mozalevskis A, Rewari BB, Lule F, Yeboue K, Brink A, Mangadan Konath N, Sharma M, Seguy N, Hermez J, Alaama AS, Ishikawa N, Dongmo Nguimfack B, Low-Beer D, Baggaley R, Dalal S. Adoption of guidelines on and use of oral pre-exposure prophylaxis: a global summary and forecasting study. Lancet HIV 2021; 8:e502-e510. [PMID: 34265283 PMCID: PMC8332196 DOI: 10.1016/s2352-3018(21)00127-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 05/24/2021] [Accepted: 05/25/2021] [Indexed: 04/12/2023]
Abstract
BACKGROUND In 2016, the UN General Assembly set a global target of 3 million oral pre-exposure prophylaxis (PrEP) users by 2020. With this target at an end, we aimed to assess global trends in the adoption of WHO PrEP recommendations into national guidelines and numbers of PrEP users, defined as people who received oral PrEP at least once in a given year, and to estimate future trajectories of PrEP use. METHODS In this global summary and forecasting study, data on adoption of WHO PrEP recommendations and numbers of PrEP users were obtained through the Global AIDS Monitoring system and WHO regional offices. Trends in these indicators for 2016-19 by region and for 2019 by country were described, including by gender and priority populations where data were available. PrEP user numbers were forecasted until 2023 by selecting countries with at least 3 years of PrEP user data as example countries in each region to represent possible future PrEP user trajectories. PrEP user growth rates observed in example countries were applied to countries in corresponding regions under different scenarios, including a COVID-19 disruption scenario with static global PrEP use in 2020. FINDINGS By the end of 2019, 120 (67%) of 180 countries with data had adopted the WHO PrEP recommendations into national guidelines (23 in 2019 and 30 in 2018). In 2019, there were about 626 000 PrEP users across 77 countries, including 260 000 (41·6%) in the region of the Americas and 213 000 (34·0%) in the African region; this is a 69% increase from about 370 000 PrEP users across 66 countries in 2018. Without COVID-19 disruptions, 0·9-1·1 million global PrEP users were projected by the end of 2020 and 2·4-5·3 million are projected by the end of 2023. If COVID-19 disruptions resulted in no PrEP user growth in 2020, the projected number of PrEP users in 2023 is 2·1-3·0 million. INTERPRETATION Widespread adoption of WHO PrEP recommendations coincided with a global increase in PrEP use. Although the 2020 global PrEP target will be missed, strong future growth in PrEP use is possible. New PrEP products could expand the PrEP user base, and, with greater expansion of oral PrEP, further adoption of WHO PrEP recommendations, and simplified delivery, PrEP could contribute to ending AIDS by 2030. FUNDING Unitaid, Bill & Melinda Gates Foundation, and WHO.
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Affiliation(s)
- Robin Schaefer
- Global HIV, Hepatitis and STIs Programmes, World Health Organization, Geneva, Switzerland.
| | - Heather-Marie A Schmidt
- Global HIV, Hepatitis and STIs Programmes, World Health Organization, Geneva, Switzerland; UNAIDS Regional Office for Asia and the Pacific, Bangkok, Thailand
| | | | - Antons Mozalevskis
- World Health Organization Regional Office for Europe, Copenhagen, Denmark
| | - Bharat B Rewari
- World Health Organization Regional Office for South-East Asia, New Delhi, India
| | - Frank Lule
- World Health Organization Regional Office for Africa, Brazzaville, Republic of the Congo
| | - Kouadio Yeboue
- World Health Organization Regional Office for Africa, Inter-Country Support Team, Ouagadougou, Burkina Faso
| | - Anne Brink
- World Health Organization Regional Office for the Western Pacific, Manila, Philippines
| | | | - Mukta Sharma
- World Health Organization Regional Office for South-East Asia, New Delhi, India
| | - Nicole Seguy
- World Health Organization Regional Office for Europe, Copenhagen, Denmark
| | - Joumana Hermez
- World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt
| | - Ahmed S Alaama
- World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt
| | - Naoko Ishikawa
- World Health Organization Regional Office for the Western Pacific, Manila, Philippines
| | | | - Daniel Low-Beer
- Global HIV, Hepatitis and STIs Programmes, World Health Organization, Geneva, Switzerland
| | - Rachel Baggaley
- Global HIV, Hepatitis and STIs Programmes, World Health Organization, Geneva, Switzerland
| | - Shona Dalal
- Global HIV, Hepatitis and STIs Programmes, World Health Organization, Geneva, Switzerland
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Affiliation(s)
| | - Frank Lule
- African Regional Office, WHO, Brazzaville, Republic of Congo
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Luyirika E, Towle MS, Achan J, Muhangi J, Senyimba C, Lule F, Muhe L. Scaling up paediatric HIV care with an integrated, family-centred approach: an observational case study from Uganda. PLoS One 2013; 8:e69548. [PMID: 23936337 PMCID: PMC3735564 DOI: 10.1371/journal.pone.0069548] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Accepted: 06/10/2013] [Indexed: 11/19/2022] Open
Abstract
Family-centred HIV care models have emerged as an approach to better target children and their caregivers for HIV testing and care, and further provide integrated health services for the family unit's range of care needs. While there is significant international interest in family-centred approaches, there is a dearth of research on operational experiences in implementation and scale-up. Our retrospective case study examined best practices and enabling factors during scale-up of family-centred care in ten health facilities and ten community clinics supported by a non-governmental organization, Mildmay, in Central Uganda. Methods included key informant interviews with programme management and families, and a desk review of hospital management information systems (HMIS) uptake data. In the 84 months following the scale-up of the family-centred approach in HIV care, Mildmay experienced a 50-fold increase of family units registered in HIV care, a 40-fold increase of children enrolled in HIV care, and nearly universal coverage of paediatric cotrimoxazole prophylaxis. The Mildmay experience emphasizes the importance of streamlining care to maximize paediatric capture. This includes integrated service provision, incentivizing care-seeking as a family, creating child-friendly service environments, and minimizing missed paediatric testing opportunities by institutionalizing early infant diagnosis and provider-initiated testing and counselling. Task-shifting towards nurse-led clinics with community outreach support enabled rapid scale-up, as did an active management structure that allowed for real-time review and corrective action. The Mildmay experience suggests that family-centred approaches are operationally feasible, produce strong coverage outcomes, and can be well-managed during rapid scale-up.
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Affiliation(s)
| | | | | | | | | | - Frank Lule
- World Health Organization Regional Office for Africa, Brazzaville, Republic of Congo
| | - Lulu Muhe
- World Health Organization Headquarters, Geneva, Switzerland
- * E-mail:
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Baggaley R, Hensen B, Ajose O, Grabbe KL, Wong VJ, Schilsky A, Lo YR, Lule F, Granich R, Hargreaves J. From caution to urgency: the evolution of HIV testing and counselling in Africa. Bull World Health Organ 2012; 90:652-658B. [PMID: 22984309 DOI: 10.2471/blt.11.100818] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Revised: 05/09/2012] [Accepted: 05/11/2012] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To describe recent changes in policy on provider-initiated testing and counselling (PITC) for human immunodeficiency virus (HIV) infection in African countries and to investigate patients' experiences of and views about PITC. METHODS A review of the published literature and of national HIV testing policies, strategic frameworks, plans and other relevant documents was carried out. FINDINGS Of the African countries reviewed, 42 (79.2%) had adopted a PITC policy. Of the 42, all recommended PITC for the prevention of mother-to-child HIV transmission, 66.7% recommended it for tuberculosis clinics and patients, and 45.2% for sexually transmitted infection clinics. Moreover, 43.6% adopted PITC in 2005 or 2006. The literature search identified 11 studies on patients' experiences of and views about PITC in clinical settings in Africa. The clear majority regarded PITC as acceptable. However, women in antenatal clinics were not always aware that they had the right to decline an HIV test. CONCLUSION Policy and practice on HIV testing and counselling in Africa has shifted from a cautious approach that emphasizes confidentiality to greater acceptance of the routine offer of HIV testing. The introduction of PITC in clinical settings has contributed to increased HIV testing in several of these settings. Most patients regard PITC as acceptable. However, other approaches are needed to reach people who do not consult health-care services.
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Affiliation(s)
- R Baggaley
- HIV/AIDS Department, World Health Organization, Geneva, Switzerland
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Scorgie F, Chersich MF, Ntaganira I, Gerbase A, Lule F, Lo YR. Socio-demographic characteristics and behavioral risk factors of female sex workers in sub-saharan Africa: a systematic review. AIDS Behav 2012; 16:920-33. [PMID: 21750918 DOI: 10.1007/s10461-011-9985-z] [Citation(s) in RCA: 177] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Sex work remains an important contributor to HIV transmission within early, advanced and regressing epidemics in sub-Saharan Africa, but its social and behavioral underpinnings remain poorly understood, limiting the impact of HIV prevention initiatives. This article systematically reviews the socio-demographics of female sex workers (FSW) in this region, their occupational contexts and key behavioral risk factors for HIV. In total 128 relevant articles were reviewed following a search of Medline, Web of Science and Anthropological Index. FSW commonly have limited economic options, many dependents, marital disruption, and low education. Their vulnerability to HIV, heightened among young women, is inextricably linked to the occupational contexts of their work, characterized most commonly by poverty, endemic violence, criminalization, high mobility and hazardous alcohol use. These, in turn, predict behaviors such as low condom use, anal sex and co-infection with other sexually transmitted infections. Sex work in Africa cannot be viewed in isolation from other HIV-risk behaviors such as multiple concurrent partnerships-there is often much overlap between sexual networks. High turn-over of FSW, with sex work duration typically around 3 years, further heightens risk of HIV acquisition and transmission. Targeted services at sufficiently high coverage, taking into account the behavioral and social vulnerabilities described here, are urgently required to address the disproportionate burden of HIV carried by FSW on the continent.
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Affiliation(s)
- Fiona Scorgie
- Maternal, Adolescent and Child Health, Department of Obstetrics and Gynaecology, University of the Witwatersrand, Johannesburg, Durban, South Africa.
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Mutanga JN, Raymond J, Towle MS, Mutembo S, Fubisha RC, Lule F, Muhe L. Institutionalizing provider-initiated HIV testing and counselling for children: an observational case study from Zambia. PLoS One 2012; 7:e29656. [PMID: 22536311 PMCID: PMC3335043 DOI: 10.1371/journal.pone.0029656] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2011] [Accepted: 12/01/2011] [Indexed: 01/07/2023] Open
Abstract
Background Provider-initiated testing and counselling (PITC) is a priority strategy for increasing access for HIV-exposed children to prevention measures, and infected children to treatment and care interventions. This article examines efforts to scale-up paediatric PITC at a second-level hospital located in Zambia’s Southern Province, and serving a catchment area of 1.2 million people. Methods and Principal Findings Our retrospective case study examined best practices and enabling factors for rapid institutionalization of PITC in Livingstone General Hospital. Methods included clinical observations, key informant interviews with programme management, and a desk review of hospital management information systems (HMIS) uptake data following the introduction of PITC. After PITC roll-out, the hospital experienced considerably higher testing uptake. In a 36-month period following PITC institutionalization, of total inpatient children eligible for PITC (n = 5074), 98.5% of children were counselled, and 98.2% were tested. Of children tested (n = 4983), 15.5% were determined HIV-infected; 77.6% of these results were determined by DNA polymerase chain reaction (PCR) testing in children under the age of 18 months. Of children identified as HIV-infected in the hospital’s inpatient and outpatient departments (n = 1342), 99.3% were enrolled in HIV care, including initiation on co-trimoxazole prophylaxis. A number of good operational practices and enabling factors in the Livingstone General Hospital experience can inform rapid PITC institutionalization for inpatient and outpatient children. These include the placement of full-time nurse counsellors at key areas of paediatric intake, who interface with patients immediately and conduct testing and counselling. They are reinforced through task-shifting to peer counsellors in the wards. Nurse counsellor capacity to draw specimen for DNA PCR for children under 18 months has significantly enhanced early infant diagnosis. The hospital’s bolstered antiretroviral supply chain, package of on-site HIV services, and follow-up care for children and families improved the continuum of service uptake. Conclusions and Significance The clinical impact and operational experience emphasizes that institutional PITC is a feasible strategy for increasing access to paediatric HIV care, particularly in generalized epidemic settings.
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Affiliation(s)
| | | | | | - Simon Mutembo
- Southern Provincial Medical Office, Livingstone, Zambia
| | - Robert Captain Fubisha
- Department of Paediatrics and Child Health, Livingstone Paediatric Centre of Excellence, Livingstone, Zambia
| | - Frank Lule
- World Health Organization Regional Office for Africa, Brazzaville, Congo
| | - Lulu Muhe
- World Health Organization Headquarters, Geneva, Switzerland
- * E-mail:
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Lutalo IM, Schneider G, Weaver MR, Oyugi JH, Sebuyira LM, Kaye R, Lule F, Namagala E, Scheld WM, McAdam KPWJ, Sande MA. Training needs assessment for clinicians at antiretroviral therapy clinics: evidence from a national survey in Uganda. Hum Resour Health 2009; 7:76. [PMID: 19698146 PMCID: PMC2752450 DOI: 10.1186/1478-4491-7-76] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2008] [Accepted: 08/23/2009] [Indexed: 05/28/2023]
Abstract
BACKGROUND To increase access to antiretroviral therapy in resource-limited settings, several experts recommend "task shifting" from doctors to clinical officers, nurses and midwives. This study sought to identify task shifting that has already occurred and assess the antiretroviral therapy training needs among clinicians to whom tasks have shifted. METHODS The Infectious Diseases Institute, in collaboration with the Ugandan Ministry of Health, surveyed health professionals and heads of antiretroviral therapy clinics at a stratified random sample of 44 health facilities accredited to provide this therapy. A sample of 265 doctors, clinical officers, nurses and midwives reported on tasks they performed, previous human immunodeficiency virus training, and self-assessment of knowledge of human immunodeficiency virus and antiretroviral therapy. Heads of the antiretroviral therapy clinics reported on clinic characteristics. RESULTS Thirty of 33 doctors (91%), 24 of 40 clinical officers (60%), 16 of 114 nurses (14%) and 13 of 54 midwives (24%) who worked in accredited antiretroviral therapy clinics reported that they prescribed this therapy (p<0.001). Sixty-four percent of the people who prescribed antiretroviral therapy were not doctors. Among professionals who prescribed it, 76% of doctors, 62% of clinical officers, 62% of nurses and 51% of midwives were trained in initiating patients on antiretroviral therapy (p=0.457); 73%, 46%, 50% and 23%, respectively, were trained in monitoring patients on the therapy (p=0.017). Seven percent of doctors, 42% of clinical officers, 35% of nurses and 77% of midwives assessed that their overall knowledge of antiretroviral therapy was lower than good (p=0.001). CONCLUSION Training initiatives should be an integral part of the support for task shifting and ensure that antiretroviral therapy is used correctly and that toxicity or drug resistance do not reverse accomplishments to date.
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Affiliation(s)
- Ibrahim M Lutalo
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Gisela Schneider
- DIFAEM – German Institute of Medical Mission, Tuebingen, Germany
| | - Marcia R Weaver
- Department of Global Health and International Training and Education Centre on HIV (I-TECH), University of Washington, Seattle WA, USA
| | - Jessica H Oyugi
- Coordinating Center for Infectious Diseases, Centers for Disease Control and Prevention, Lilongwe, Malawi
| | | | - Richard Kaye
- African Palliative Care Association, Kampala, Uganda
| | - Frank Lule
- Regional Office for Africa, World Health Organization, Brazzaville, Congo
| | | | - W Michael Scheld
- Department of Internal Medicine, University of Virginia, Charlottesville VA, USA
| | - Keith PWJ McAdam
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Department of Clinical Tropical Medicine, London School of Hygiene and Tropical Medicine, London, UK
- Pratt Medical Group, Tufts-New England Medical Center, Boston MA, USA
| | - Merle A Sande
- Formerly of the Department of Medicine, University of Washington, Seattle, WA, and the Accordia Global Health Foundation, Arlington, VA, USA
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Vasan A, Kenya-Mugisha N, Seung KJ, Achieng M, Banura P, Lule F, Beems M, Todd J, Madraa E. Agreement between physicians and non-physician clinicians in starting antiretroviral therapy in rural Uganda. Hum Resour Health 2009; 7:75. [PMID: 19695083 PMCID: PMC2738652 DOI: 10.1186/1478-4491-7-75] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2009] [Accepted: 08/20/2009] [Indexed: 05/21/2023]
Abstract
BACKGROUND The scarcity of physicians in sub-Saharan Africa - particularly in rural clinics staffed only by non-physician health workers - is constraining access to HIV treatment, as only they are legally allowed to start antiretroviral therapy in the HIV-positive patient. Here we present a pilot study from Uganda assessing agreement between non-physician clinicians (nurses and clinical officers) and physicians in their decisions as to whether to start therapy. METHODS We conducted the study at 12 government antiretroviral therapy sites in three regions of Uganda, all of which had staff trained in delivery of antiretroviral therapy using the WHO Integrated Management of Adult and Adolescent Illness guidelines for chronic HIV care. We collected seven key variables to measure patient assessment and the decision as to whether to start antiretroviral therapy, the primary variable of interest being the Final Antiretroviral Therapy Recommendation. Patients saw either a clinical officer or nurse first, and then were screened identically by a blinded physician during the same clinic visit. We measured inter-rater agreement between the decisions of the non-physician health workers and physicians in the antiretroviral therapy assessment variables using simple and weighted Kappa analysis. RESULTS Two hundred fifty-four patients were seen by a nurse and physician, while 267 were seen by a clinical officer and physician. The majority (>50%) in each arm of the study were in World Health Organization Clinical Stages I and II and therefore not currently eligible for antiretroviral therapy according to national antiretroviral therapy guidelines. Nurses and clinical officers both showed moderate to almost perfect agreement with physicians in their Final Antiretroviral Therapy Recommendation (unweighted kappa=0.59 and kappa=0.91, respectively). Agreement was also substantial for nurses versus physicians for assigning World Health Organization Clinical Stage (weighted kappa=0.65), but moderate for clinical officers versus physicians (kappa=0.44). CONCLUSION Both nurses and clinical officers demonstrated strong agreement with physicians in deciding whether to initiate antiretroviral therapy in the HIV patient. This could lead to immediate benefits with respect to antiretroviral therapy scale-up and decentralization to rural areas in Uganda, as non-physician clinicians--particularly clinical officers--demonstrated the capacity to make correct clinical decisions to start antiretroviral therapy. These preliminary data warrant more detailed and multicountry investigation into decision-making of non-physician clinicians in the management of HIV disease with antiretroviral therapy, and should lead policy-makers to more carefully explore task-shifting as a shorter-term response to addressing the human resource crisis in HIV care and treatment.
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Affiliation(s)
- Ashwin Vasan
- Partners In Health, Boston, Massachusetts, USA
- University of Michigan Medical School, Ann Arbor, Michigan, USA
- Masaka Regional Referral Hospital, Ministry of Health, Masaka, Uganda
- London School of Hygiene & Tropical Medicine, London, UK
| | - Nathan Kenya-Mugisha
- Masaka Regional Referral Hospital, Ministry of Health, Masaka, Uganda
- National STI/AIDS Programme, Ministry of Health, Kampala, Uganda
| | | | - Marion Achieng
- Masaka Regional Referral Hospital, Ministry of Health, Masaka, Uganda
| | - Patrick Banura
- Masaka Regional Referral Hospital, Ministry of Health, Masaka, Uganda
| | - Frank Lule
- National STI/AIDS Programme, Ministry of Health, Kampala, Uganda
| | - Megan Beems
- University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Jim Todd
- London School of Hygiene & Tropical Medicine, London, UK
- Medical Research Council, Entebbe and Masaka, Uganda
| | - Elizabeth Madraa
- National STI/AIDS Programme, Ministry of Health, Kampala, Uganda
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