How can expensive antiretroviral therapy be best prioritised in under-resourced health systems? In Malawi, targeting laboratory-based tests that measure the progress of the disease may offer one solution to help target those most in need.
Equity and HIV/AIDS
Passing the test: Allocating antiretroviral therapy in Malawi
ID21 Health News, 30 May 2006
Patient and nurse perspectives of a nurse-led community-based model of HIV care delivery in Malawi: a qualitative study
Sande O; Burtscher D; Kathumba D; Tweya H; et al: BMC Public Health 20(685), 1-8, 2020
The authors explored how the nurse-led community-based ART programme in Malawi was perceived, through interview of patients and nurses providing the care. Patients reported saving money on transportation and the time it took them to travel to a health facility. Caseloads and waiting times were also reduced, which made patients more comfortable and gave nurses the time to conduct thorough consultations. Closer relationships were built between patients and care providers, creating a space for more open conversations. Patients’ nutritional needs and concerns related to stigma remain a concern, while operational issues affect the quality of the services provided in the community. The patients interviewed in this study preferred the nurse-led community ART programme approach to the facility-based model of care because of the features above. The authors note that community-led healthcare programmes need to plan for the provision of transportation for care providers; the physical structure of community sites; the timely consolidation of data collected in the field to a central database; and the need for care providers to cover multiple facility-based staff roles.
Patient satisfaction with antiretroviral services at primary health-care facilities in the Free State, South Africa: A two-year study using four waves of cross-sectional data
Wouters E, Heunis C, van Rensburg D and Meulemans H: BMC Health Services Research 8(21) 9 October 2008
The study's first objective was to determine the levels of patient satisfaction with services at antiretroviral treatment (ART) assessment sites. Four cross-sectional waves of data were collected from a random sample of 975 patients enrolled in the Free State's public-sector ART programme. With respect to both general services and the services provided by nurses, results indicated high overall satisfaction among Free State patients receiving public-sector ART. However, the data presents a less positive picture of patient satisfaction with waiting times. Significant geographical and temporal differences were observed in these three aspects of patient satisfaction, according to the district surveyed. Patients attending facilities with high professional nurse vacancy rates reported significantly less satisfaction with nurses' services than did those attending facilities with fewer vacant nursing posts.
Patient satisfaction with health care services provided at HIV clinics at Amana and Muhimbili hospitals in Dar es Salaam
Kagashe GAB and Rwebangila F: African Health Sciences 11(Special Issue 1): 560-566, August 2011
Since the establishment of free HIV and AIDS care and treatment services in Tanzania a lot of research has been done to assess how health care providers discharge their duties in these clinics. Little research however has been done regarding satisfaction of HIV patients with free health care services provided. The authors of this study aimed to determine satisfaction of HIV patients with health care services provided at the HIV clinics and specifically, to determine patients’ satisfaction with the general physical environment of the clinic and with services offered by doctors, nurses, laboratory, and pharmacy. A cross-sectional study was conducted at Muhimbili National Hospital (MNH) and Amana hospital. A total of 375 patients attending outpatient HIV clinics were selected randomly and interviewed using a questionnaire, after obtaining a verbal consent. Results showed that patients at Amana Hospital clinic were either very satisfied (44.3%) or satisfied (55.7%) and none were dissatisfied, while at MNH clinic 1.1% patients were very satisfied while (94.7%) were satisfied and (4.2%) were dissatisfied with health care services provided. Lack of privacy when consulting with doctors and the dispenser contributed to patients’ dissatisfaction with the services.
Policy and programme responses for addressing the structural determinants of HIV
Pronyk Paul and Lutz Brian: Aidstarone, June 2013
According to this report, one reason that HIV prevention efforts have not kept pace has been insufficient attention to HIV’s “structural factors”, namely those areas beyond individual knowledge or awareness that shape risk and vulnerability to infection. Examples are often context-specific but can include economic inequality and livelihood insecurity, as well as hunger, gender inequality, and lack of education. These factors, many of which are rooted in various formal and informal types of marginalisation, underpin the diversity of HIV epidemics, helping to explain why some countries have a higher HIV burden than others. Structural factors have been demonstrated to influence treatment access and retention. The authors argue that action on structural factors can have multiple beneficial impacts not only on HIV-related goals but also on other health, development and human rights objectives. Implementing structural approaches requires a range of disciplinary perspectives that extend beyond the health sector, as well as cross-sector governance and financing.
Poor drug supply causing treatment problems in South Africa, Nigeria
Problems with drug supply of antiretrovirals have come to the surface in both Nigeria and South Africa in the past few weeks as the realities of implementing large-scale treatment access begin to hit home. In South Africa the Treatment Action Campaign (TAC) has issued a warning that supplies of the paediatric formulation of efavirenz (Stocrin) are running out, with no stock guaranteed to be brought into the country by the drug’s manufacturer, Merck Sharp and Dohme (MSD), before January 28. TAC claims that one patient has already had to interrupt treatment as a result of the drug `stock out`, and highlights the risk of resistance that may arise if efavirenz treatment is interrupted without planning.
Poor health services in Swaziland hamper PMTCT progress
Plus News: 28 June 2010
According to this article, Swaziland has made remarkable progress in reducing HIV transmission from infected mothers to their babies, but health activists have raised concerns that this progress may be stalled or even reversed if lapses in basic health services are not addressed. Since prevention of mother-to-child transmission (PMTCT) services became available in 2003, HIV transmission has almost halved, from 40% of children becoming infected by their HIV-positive mothers to 21%. The number of teenage pregnancies has also fallen. As teen mothers are less likely to use antenatal care and PMTCT services, fewer teens giving birth means fewer HIV-positive babies. However, a significant proportion of pregnant women are giving birth at home, and so are not using PMTCT services. A rise in home deliveries appears to be a direct result of poor conditions at underfunded clinics and hospitals. Leaking roofs, unreliable water supplies and a lack of beds at clinics are contributing to the problem of ‘burnout’ among nurses. According to the latest World Health Organization (WHO) guidelines, a pregnant woman's HIV status should be determined in her first trimester so as to provide optimal PMTCT services, but Swazi tradition discourages women from talking about a pregnancy during the first 14 weeks and, as a result, women delay seeking treatment.
Population uptake of antiretroviral treatment through primary care in rural South Africa
Cooke GS, Tanser FC, Barnighausen TW and Newell M: BMC Public Health 10(585), 29 September 2010
This study investigated the factors associated with uptake of antiretroviral therapy (ART) through a primary healthcare system in rural South Africa. Detailed demographic, HIV surveillance and geographic information system (GIS) data was used to estimate the proportion of HIV positive adults accessing antiretroviral treatment within northern KwaZulu-Natal, South Africa in the period from initiation of antiretroviral roll-out until the end of 2008. Demographic, spatial and socioeconomic factors influencing the likelihood of individuals accessing antiretroviral treatment were explored using multivariable analysis. Mean uptake of ART among HIV positive resident adults was found to be 21.0%. Uptake among HIV positive men (19.2%) was slightly lower than women (21.8%). An individual's likelihood of accessing ART was not associated with level of education, household assets or urban/rural locale. ART uptake was strongly negatively associated with distance from the nearest primary healthcare facility. Despite concerns about the equitable nature of antiretroviral treatment rollout, the study identified very few differences in ART uptake across a range of socio-demographic variables in a rural South African population. However, even when socio-demographic factors were taken into account, individuals living further away from primary healthcare clinics were still significantly less likely to be accessing ART.
Population-level effect of HIV on adult mortality and early evidence of reversal after introduction of antiretroviral therapy in Malawi
Jahn A, Floyd S, Crampin A, et al: The Lancet 371: 1603-1611, 2008
Malawi, which has about 80000 deaths from AIDS every year, made free antiretroviral therapy available to more than 80000 patients between 2004 and 2006. The authors aimed to investigate mortality in a population before and after the introduction of free antiretroviral therapy, and therefore to assess the effects of such programmes on survival at the population level. The study used a demographic surveillance system to measure mortality in a population of 32000 in northern Malawi, from August, 2002, when free antiretroviral therapy was not available in the study district, until February, 2006, 8 months after a clinic opened. The probability of dying between the ages of 15 and 60 years was 43% (39-49) for men and 43% (38-47) for women; 229 of 352 deaths (65.1%) were attributed to AIDS. Eight months after the clinic that provided antiretroviral therapy opened, 107 adults from the study population had accessed treatment, out of an estimated 334 in need of treatment. Overall mortality in adults had decreased by 10% from 10.2 to 8.7 deaths for 1000 person-years of observation (adjusted rate ratio 0.90, 95% CI 0.70-1.14). Mortality was reduced by 35% (adjusted rate ratio 0.65, 0.46-0.92) in adults near the main road, where mortality before antiretroviral therapy was highest (from 13.2 to 8.5 deaths per 1000 person-years of observation before and after antiretroviral therapy). Mortality in adults aged 60 years or older did not change. Findings of a reduction in mortality in adults aged between 15 and 59 years, with no change in those older than 60 years, suggest that deaths from AIDS were averted by the rapid scale-up of free antiretroviral therapy in rural Malawi, which led to a decline in adult mortality that was detectable at the population level.
Porn video shows, local brew, and transactional sex: HIV risk among youth in Kisumu, Kenya
Njue C, Voeten HA and Remes P: BMC Public Health 11(635), 8 August 2011
In this study, researchers conducted a qualitative study to explore risk situations that can explain the high HIV prevalence among youth in Kisumu town, Kenya. They conducted in-depth interviews with 150 adolescents aged 15 to 20, held four focus group discussions, and made 48 observations at places where youth spend their free time. Porn video shows and local brew dens were identified as popular events where unprotected multipartner, concurrent, coerced and transactional sex occurs between adolescents. Forced sex, gang rape and multiple concurrent relationships characterised the sexual encounters of youth, frequently facilitated by the abuse of alcohol, which is available for minors at low cost in local brew dens. A substantial number of girls and young women engaged in transactional sex, often with much older, wealthier partners. The authors conclude that local brew dens and porn video halls facilitate risky sexual encounters between youth and should be regulated and monitored by the government. Young men should be targeted in prevention activities, to change their attitudes related to power and control in relationships, while girls should be empowered how to negotiate safe sex, and their poverty should be addressed through income-generating activities.