Abstract Background Reaching the 90–90-90 targets requires efficient resource use to deliver HIV testing and treatment services. We investigated the costs and efficiency of HIV services in relation to HIV testing yield in rural Karonga District, Malawi. Methods Costs of HIV services were measured over 12 months to September 2017 in five health facilities, drawing on recognised health costing principles. Financial and economic costs were collected in Malawi Kwacha and United States Dollars (US$). Costs were calculated using a provider perspective to estimate average annual costs (2017 US$) per HIV testing episode, per HIV-positive case diagnosed, and per patient-year on antiretroviral therapy (ART), by facility. Costs were assessed in relation to scale of operation and facility-level annual HIV positivity rate. A one-way sensitivity analysis was undertaken to understand how staffing levels and the HIV positivity rate affected HIV testing costs. Results HIV testing episodes per day and per full-time equivalent HIV health worker averaged 3.3 (range 2.0 to 5.7). The HIV positivity rate averaged 2.4% (range 1.9 to 3.7%). The average cost per testing episode was US$2.85 (range US$1.95 to US$8.55), and the average cost per HIV diagnosis was US$116.35 (range US$77.42 to US$234.11), with the highest costs found in facilities with the lowest daily number of tests and lowest HIV yield respectively. The mean facility-level cost per patient-year on ART was approximately US$100 (range US$90.67 to US$115.42). ART drugs were the largest cost component averaging 71% (range 55 to 76%). The cost per patient-year of viral load tests averaged US$4.50 (range US$0.52 to US$7.00) with cost variation reflecting differences in the tests to ART patient ratio across facilities. Conclusion Greater efficiencies in HIV service delivery are possible in Karonga through increasing daily testing episodes among existing health workers or allocating health workers to tasks in addition to testing. Costs per diagnosis will increase as yields decline, and therefore, encouraging targeted testing strategies that increase yield will be more efficient. Given the contribution of drug costs to per patient-year treatment costs, it is critical to preserve the life-span of first-line ART regimens, underlining the need for continuing adherence support and regular viral load monitoring.
We estimated the costs of Option B+ for HIV-infected pregnant women in 12 facilities in Morogoro Region, Tanzania, from a provider perspective. Costs of prevention of mother-to-child (PMTCT) HIV services were measured over 12 months to September 2017 to estimate the average costs per HIV testing episode, per HIV-positive case diagnosed, per patient-year on antiretroviral therapy (ART), and per neonatal HIV care. A one-way sensitivity analysis was undertaken to understand how staffing levels and other core resource inputs affected costs. The total number of HIV testing episodes was 25,593 with 279 HIV cases identified yielding a 1.1% positivity rate. The average cost per testing episode was US$5.49 (range US$2.13 to US$13.93), and the average cost per HIV case detected was US$503.29 (range US$230.61 to US$3330.38). The number of pregnant women initiated on ART was 278. The mean cost per patient-year on ART was US$159.89 (range US$100.91 to US$812.23). The average cost of neonatal HIV care was US$90.09 (range US$41.53 to US$180.26). PMTCT service costs varied widely across facilities due to variations in resource use, number of women testing, and HIV prevalence. The study provides further evidence against generalising cost estimates, and that budgeting and planning requires context specific cost information.
Background: Survival patterns after HIV infection in African populations in the era before antiretroviral therapy (ART) form an important baseline for measuring future successes of treatment programmes. Few studies have followed seroconverters for 10 or more years to describe such patterns. Methods: The Kisesa open cohort study conducted four rounds of village-based HIV testing and 20 rounds of household-based demographic surveillance between 1994 and 2006. Approximate infection dates were established for individual seroconverters by allocating a date between the last negative and first positive test. Person-years lived post-infection were computed, allowing for left truncation and right censoring, and Kaplan–Meier survival functions were constructed, truncating the analysis at the start of 2005 when ART first became available in the community. Weibull models were fitted to estimate median survival time, and parametric regression methods were used to investigate the influence of sex and age at infection. Results: A total of 369 seroconverters were identified, providing 890 person-years of follow-up during which 44 deaths were observed. The Kaplan–Meier function showed 67% surviving 9 years post-infection, and the overall predicted median survival was 11.5 years. Survival was strongly related to age at infection (hazard ratio 1.06 for each additional year of age, and weakly to sex. A strong effect of age was evident even after allowing for mortality from non-HIV-related causes using cause deletion methods to estimate net mortality. Conclusion: The survival of HIV-infected individuals was comparable to that reported in developed country studies before the introduction of HAART. Survival patterns in Kisesa are marginally more favourable than those reported in cohort studies in Uganda.
To compare national human immunodeficiency virus (HIV) policies influencing access to HIV testing and treatment services in six sub-Saharan African countries.We reviewed HIV policies as part of a multi-country study on adult mortality in sub-Saharan Africa. A policy extraction tool was developed and used to review national HIV policy documents and guidelines published in Kenya, Malawi, South Africa, Uganda, the United Republic of Tanzania and Zimbabwe between 2003 and 2013. Key informant interviews helped to fill gaps in findings. National policies were categorized according to whether they explicitly or implicitly adhered to 54 policy indicators, identified through literature and expert reviews. We also compared the national policies with World Health Organization (WHO) guidance.There was wide variation in policies between countries; each country was progressive in some areas and not in others. Malawi was particularly advanced in promoting rapid initiation of antiretroviral therapy. However, no country had a consistently enabling policy context expected to increase access to care and prevent attrition. Countries went beyond WHO guidance in certain areas and key informants reported that practice often surpassed policy.Evaluating the impact of policy differences on access to care and health outcomes among people living with HIV is challenging. Certain policies will exert more influence than others and official policies are not always implemented. Future research should assess the extent of policy implementation and link these findings with HIV outcomes.Comparer les politiques nationales de lutte contre le virus de l'immunodéficience humaine (VIH) qui influencent l'accès aux services de dépistage et de traitement du VIH dans six pays d'Afrique subsaharienne.Nous avons examiné les politiques de lutte contre le VIH dans le cadre d'une étude multi-pays sur la mortalité des adultes en Afrique subsaharienne. Un outil d'extraction de données a été mis au point et utilisé afin d'examiner les documents et les directives des politiques nationales de lutte contre le VIH publiés en Afrique du Sud, au Kenya, au Malawi, en Ouganda, en République-Unie de Tanzanie et au Zimbabwe entre 2003 et 2013. Des entretiens avec des informateurs clés ont permis de combler les carences de ces résultats. Les politiques nationales ont été classées suivant leur degré de correspondance, explicite ou implicite, avec 54 indicateurs relatifs aux politiques, déterminés d'après des analyses documentaires et des examens d'experts. Nous avons également comparé les politiques nationales avec les recommandations de l'Organisation mondiale de la Santé (OMS).Nous avons observé de grandes différences entre les politiques de ces pays ; chaque pays était avancé dans certains domaines et pas dans d'autres. Le Malawi l'était particulièrement en matière de promotion du démarrage rapide du traitement antirétroviral. Cependant, aucun pays n'avait un contexte politique pouvant systématiquement permettre d'augmenter l'accès aux soins et d'éviter l'arrêt du traitement. Dans certains domaines, les pays allaient plus loin que les recommandations de l'OMS et les informateurs ont indiqué que la pratique dépassait souvent le cadre des politiques.Évaluer l'impact des différentes politiques sur l'accès aux soins et les résultats en termes de santé des personnes qui vivent avec le VIH n'est pas chose simple. Certaines politiques exercent une influence plus forte que d'autres et les politiques officielles ne sont pas toujours mises en œuvre. Des recherches ultérieures devraient évaluer le degré de mise en œuvre des politiques et mettre en lien leurs conclusions avec les résultats de la lutte contre le VIH.Comparar las políticas nacionales relativas al virus de la inmunodeficiencia humana (VIH) que influencian el acceso a las pruebas del VIH y a los tratamientos en seis países sub-saharianos.Se revisaron las políticas relativas al VIH como parte de un estudio multinacional sobre la mortalidad de adultos en África Subsahariana. Se desarrolló una herramienta de extracción de políticas y se utilizó para revisar los documentos y guías de las políticas nacionales relativas al VIH publicadas en Kenia, Malawi, República Unida de Tanzania, Sudáfrica, Uganda y Zimbabue entre 2003 y 2013. Se hicieron entrevistas a informantes claves que ayudaron a llenar los vacíos en los resultados. Las políticas nacionales se clasificaron según si se adhirieron explícita o implícitamente a 54 indicadores de políticas, identificados mediante bibliografía y opiniones de expertos. Asimismo, se compararon las políticas nacionales con las directrices de la Organización Mundial de la Salud (OMS).Se descubrió que había una amplia variedad entre las políticas de los países. Cada país estaba más avanzado en algunas áreas que en otras. Malawi estaba especialmente avanzado en la promoción de empezar rápidamente la terapia antirretroviral. Sin embargo, ningún país tenía un contexto de introducción de políticas consistente que incrementara el acceso a la atención primaria y evitara la deserción. Algunos países iban más allá de las orientaciones de la OMS en algunas áreas e informantes clave informaron de que la práctica a menudo superaba la política.Evaluar el impacto de las diferencias en las políticas relativas en el acceso a la atención primaria y los resultados en la salud entre aquellas personas con VIH es un reto. Algunas políticas ejercerán más influencia que otras y las políticas oficiales no siempre se aplican. Las investigaciones futuras deberían evaluar el grado de aplicación de las políticas y vincular estos resultados con los resultados del VIH.الغرض : مقارنة السياسات الوطنية لمكافحة فيروس العوز المناعي البشري(HIV) والتي تؤثر على القدرة على الاستفادة من خدمات الاختبار والعلاج من فيروس العوز المناعي البشري في ستة بلدان أفريقية واقعة جنوبي الصحراء. الطريقة : لقد راجعنا سياسات مكافحة فيروس العوز المناعي البشري كجزء من دراسة شملت العديد من البلدان حول معدلات وفيات البالغين في البلدان الأفريقية الواقعة جنوبي الصحراء. تم إعداد واستخدام أداة استخلاص السياسة لمراجعة الوثائق والمبادئ التوجيهية لسياسة مكافحة فيروس العوز المناعي البشري الوطنية التي نشرت في كينيا وملاوي وجنوب أفريقيا وأوغندا وجمهورية تنزانيا المتحدة وزمبابوي في الفترة ما بين عام 2003 و2013. ولقد ساعدت مقابلات المبلّغين الرئيسين على سد الثغرات في النتائج. صُنِّفت السياسات الوطنية وفقًا لما إذا كانت التزمت صراحةً أو ضمنيًا بـ 54 من مؤشرات السياسة، التي تم تحديدها من خلال المؤلفات الطبية ومراجعات الخبراء. وقمنا أيضًا بمقارنة السياسات الوطنية مع توجيهات منظمة الصحة العالمية (WHO). النتائج : كان هناك تفاوت كبير في السياسات بين البلدان؛ حيث تميز كل بلد بالتقدم في بعض الجوانب دون غيرها. كانت ملاوي متقدمة على وجه الخصوص في تعزيز فكرة الإسراع في بدء العلاج باستخدام مضادات الفيروسات القهقرية. ومع ذلك، لم يكن لدى أي بلد سياق لتطبيق سياسة تتيح تطوير القدرات بصورة ثابتة، بحيث يُنتظر منه تيسير سبل الاستفادة من الرعاية والحد من الاستنزاف. قامت البلدان بتجاوز توجيهات منظمة الصحة العالمية في مناطق معينة وذكر المبلّغون الرئيسون أن الممارسة غالبًا ما كانت تتجاوز السياسة. الاستنتاج : من العسير تقييم تأثير اختلافات السياسة في فرص الحصول على الرعاية والنتائج الصحية بين الأشخاص المصابين بفيروس العوز المناعي البشري. فسوف تحقق بعض السياسات المعينة المزيد من التأثير دون سواها، كما لا يتم دائمًا تنفيذ السياسات الرسمية. ينبغي على الأبحاث المستقبلية تقييم مدى تنفيذ السياسات وربط هذه النتائج بحصائل الإصابة بفيروس العوز المناعي البشري.旨在对比在撒哈拉沙漠以南的六个非洲国家中能够影响艾滋病病毒测试和治疗服务的国家艾滋病病毒 (HIV) 政策。.在撒哈拉沙漠以南的非洲国家中进行有关成人死亡率的多国研究期间,我们评审了艾滋病病毒政策。 当时开发了一种政策提取工具并将其用于评审津巴布韦、肯尼亚、马拉维、南非、坦桑尼亚联合共和国以及乌干达在 2003 年和 2013 年期间出版的国家艾滋病病毒政策文件和指南。关键知情人访谈帮助我们弥补了调查结果中的不足之处。 我们依据国家政策是否以明确或隐含的方式遵循 54 项政策指标来对其进行分类,并且通过文献和专家评审加以确认。 同时,我们还对比了国家政策和世界卫生组织 (WHO) 指南。.各国的政策差异很大;每个国家都在一些方面达到先进水平,而在另一些方面却没有达到先进水平。 马拉维在推动抗逆转录病毒疗法的快速启动方面尤为先进。 然而,没有一个国家能够终保持一贯有利的政策环境,难以按预期提高护理普及率和预防消耗。 各国在某些方面超出了世界卫生组织指南的范围,并且据关键知情人报告,实际情况往往超越政策范围。.评估政策差异对艾滋病病毒患者的护理普及率和医疗效果的影响具有挑战性。 某些政策会比其他政策产生更大的影响,并且官方政策并不总是能够得到落实。 今后的研究应评估政策实施的程度,并将这些调查结果与艾滋病病毒的医疗效果联系起来。.Сравнить политику в отношении вируса иммунодефицита человека (ВИЧ) в шести странах Африки к югу от Сахары. Оценивается доступность анализа на ВИЧ и услуг по лечению.Политики в отношении ВИЧ были рассмотрены в рамках многонационального исследования смертности взрослого населения в странах Африки к югу от Сахары. Для анализа политик был разработан специальный инструмент, который использовался для проверки официальных документов и рекомендаций, связанных с государственной политикой в отношении ВИЧ, опубликованных в Кении, Малави, Южной Африке, Уганде, Объединенной Республике Танзания и Зимбабве в период между 2003 и 2013 гг. Неясные моменты уточнялись благодаря ключевым информаторам. Национальные политики распределялись по категориям в зависимости от того, придерживались ли они явным или косвенным образом 54 показателей, выявленных в ходе оценки публикаций и отчетов специалистов. Было также проведено сравнение национальных политик с рекомендациями Всемирной организации здравоохранения (ВОЗ).Политики в разных странах отличались друг от друга; в каждой из стран отмечался прогресс в одних областях и отставание в других. В частности, Малави значительно выделялась продвижением раннего начала антиретровирусной терапии. Тем не менее ни в одной стране не была реализована эффективная политика, которая облегчала бы доступ к медицинской помощи и препятствовала бы оттоку персонала. В некоторых областях страны пошли дальше рекомендаций ВОЗ и основные информаторы сообщили, что практика часто опережала политику.Оценить, насколько отличия в государственной политике влияют на доступ к лечению и результаты мероприятий по охране здоровья для лиц, живущих с ВИЧ, довольно сложно. Некоторые из политик имеют сравнительно больший эффект, и официальная политика не всегда выполняется. В будущих исследованиях необходимо оценить степень выполнения политик и связать полученные данные с результатами лечения ВИЧ.
Background: Individuals diagnosed with HIV in developing countries are not always successfully linked to onward treatment services, resulting in missed opportunities for timely initiation of antiretroviral therapy, or prophylaxis for opportunistic infections.In collaboration with local stakeholders, we designed and assessed a referral system to link persons diagnosed at a voluntary counselling and testing (VCT) clinic in a rural district in northern Tanzania with a government-run HIV treatment clinic in a nearby city.Methods: Two-part referral forms, with unique matching numbers on each side were implemented to facilitate access to the HIV clinic, and were subsequently reconciled to monitor the proportion of diagnosed clients who registered for these services, stratified by sex and referral period.Delays between referral and registration at the HIV clinic were calculated, and lists of non-attendees were generated to facilitate tracing among those who had given prior consent for follow up.Transportation allowances and a "community escort" from a local home-based care organization were introduced for patients attending the HIV clinic, with supportive counselling services provided by the VCT counsellors and home-based care volunteers.Focus group discussions and in-depth interviews were conducted with health care workers and patients to assess the acceptability of the referral procedures.Results: Referral uptake at the HIV clinic averaged 72% among men and 66% among women during the first three years of the national antiretroviral therapy (ART) programme, and gradually increased following the introduction of the transportation allowances and community escorts, but declined following a national VCT campaign.Most patients reported that the referral system facilitated their arrival at the HIV clinic, but expressed a desire for HIV treatment services to be in closer proximity to their homes.The referral forms proved to be an efficient and accepted method for assessing the effectiveness of the VCT clinic as an entry point for ART. Conclusion:The referral system reduced delays in seeking care, and enabled the monitoring of access to HIV treatment among diagnosed persons.Similar systems to monitor referral uptake and linkages between HIV services could be readily implemented in other settings.
To investigate the interplay between antiretroviral therapy (ART) scale-up, different types of stigma and Voluntary Counselling and Testing (VCT) uptake 2 years after the introduction of free ART in a rural ward of Tanzania.
Methods:
Qualitative study using in-depth interviews and group activities with a purposive sample of 91 community leaders, 77 ART clients and 16 health providers. Data were analysed for recurrent themes using NVIVO-7 software.
Results:
The complex interplay between ART, stigma and VCT in this setting is characterised by two powerful but opposing dynamics. The availability of effective treatment has transformed HIV into a manageable condition which is contributing to a reduction in self-stigma and is stimulating VCT uptake. However, this is counterbalanced by the persistence of blaming attitudes and emergence of new sources of stigma associated with ART provision. The general perception among community leaders was that as ART users regained health, they increasingly engaged in sexual relations and "spread the disease." Fears were exacerbated because they were perceived to be very mobile and difficult to identify physically. Some leaders suggested giving ART recipients drugs "for impotence," marking them "with a sign" and putting them "in isolation camps." In this context, traditional beliefs about disease aetiology provided a less stigmatised explanation for HIV symptoms contributing to a situation of collective denial.
Conclusion:
Where anticipated stigma prevails, provision of antiretroviral drugs alone is unlikely to have sufficient impact on VCT uptake. Achieving widespread public health benefits of ART roll-out requires community-level interventions to ensure local acceptability of antiretroviral drugs.
HIV status disclosure rates to sexual partners are low in Tanzania, despite the benefits it confers to both partners. This qualitative study drew on the Disclosure Decision Model to explore the decision by people living with HIV (PLHIV) to disclose, or not, their HIV status to their partner. Six focus group discussions and thirty in-depth interviews were conducted in Mwanza, Tanzania in 2019 with PLHIV. Topics covered decision-making around disclosure and disclosure experiences. Thematic content analysis was conducted. Most respondents reported having disclosed their status to their partners. Disclosure was reported to facilitate or hinder the attainment of social goals including having intimate relationships, raising a family, relief from distress and accessing social support. Decisions made by PLHIV about whether to disclose their status were made after weighing up the perceived benefits and risks. The sense of liberty from a guilty conscious, and not "living a lie" were perceived as benefits of disclosure, while fears of stigma, family break-up or abandonment were perceived as risks. Many participants found disclosure was beneficial in promoting their adherence to treatment and clinic appointments. Interventions to support PLHIV with disclosure should include enhanced counselling, strengthening HIV support groups and enhanced assisted partner notification services.
Background Eight outbreaks of paralytic polio attributable to circulating vaccine-derived poliovirus (cVDPV) have highlighted the risks associated with oral poliovirus vaccine (OPV) use in areas of low vaccination coverage and poor hygiene. As the Polio Eradication Initiative enters its final stages, it is important to consider the extent to which these viruses spread under different conditions, so that appropriate strategies can be devised to prevent or respond to future cVDPV outbreaks. Methods and Findings This paper examines epidemiological (temporal, geographic, age, vaccine history, social group, ascertainment), and virological (type, genetic diversity, virulence) parameters in order to infer the numbers of individuals likely to have been infected in each of these cVDPV outbreaks, and in association with single acute flaccid paralysis (AFP) cases attributable to VDPVs. Although only 114 virologically-confirmed paralytic cases were identified in the eight cVDPV outbreaks, it is likely that a minimum of hundreds of thousands, and more likely several million individuals were infected during these events, and that many thousands more have been infected by VDPV lineages within outbreaks which have escaped detection. Conclusions Our estimates of the extent of cVDPV circulation suggest widespread transmission in some countries, as might be expected from endemic wild poliovirus transmission in these same settings. These methods for inferring extent of infection will be useful in the context of identifying future surveillance needs, planning for OPV cessation and preparing outbreak response plans.
Abstract Background Improving treatment success rates among multi drug-resistant tuberculosis (MDR-TB) patients is critical to reducing its incidence and mortality, but adherence poses an important challenge. Video-based direct observed therapy (vDOT) may provide adherence benefits, while addressing the time and cost burden associated with community treatment supporter (CTS)-DOT. This study explored experiences of patients, family members and healthcare workers with different DOT modalities for adherence support in Eswatini. Methods Between April 2021 and May 2022, thirteen men and five women with MDR-TB, ten healthcare workers, and nine caregivers were purposively sampled to include a range of characteristics and experiences with DOT modalities. Data were generated through individual in-depth interviews and a smartphone messaging application (WhatsApp). Data coding was undertaken iteratively, and thematic analysis undertaken, supported by Nvivo. Results Four themes emerged that reflected participants’ experiences with different DOT modalities, including stigma, efficiency, perceived risks of TB acquisition, and patient autonomy. vDOT was appreciated by patients for providing them with privacy and shielding them from stigmatisation associated with being seen in TB clinics or with community treatment supporters. vDOT was also seen as more efficient than CTS-DOT. Health workers acknowledged that it saved time, allowing them to attend to more patients, while many patients found vDOT more convenient and less expensive by removing the need to travel for in-person consultations. Health workers also appreciated vDOT because it reduced risks of TB acquisition by minimising exposure through virtual patient monitoring. Although many patients appreciated greater autonomy in managing their illness through vDOT, others preferred human contact or struggled with making video recordings. Most family members appreciated vDOT, although some resented feeling removed from the process of supporting loved ones. Conclusions vDOT was generally appreciated by MDR-TB patients, their family members and health workers as it addressed barriers to adherence which could contribute to improved treatment completion rates and reduced workplace exposure. However, patients should be offered an alternative to vDOT such as CTS-DOT if this modality does not suit their circumstances or preferences.
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