Suchergebnisse

Implementation of cotrimoxazole prophylaxis (CTX‐p) among HIV‐exposed children is poor in southern Africa. We conducted a multi‐methods study to investigate the barriers to delivery of CTX‐p to HIV exposed infants in Zimbabwe at each step of the care cascade. Here we report findings of the qualitative component designed to investigate issues related to adherence conducted among women identified as HIV positive whose babies were started on CTX‐p postnatally. Between Feb–Dec 2011, the first 19 HIV infected mothers identified were invited for in‐depth interview 4–5 months postnatally. Interviews were recorded, transcribed, translated and analysed thematically. Of note, Zimbabwe also provides nevirapine prophylaxis for HIV‐exposed babies, so the majority were giving nevirapine and CTX‐p to their babies. All women desired their baby's health above all else, and were determined to do all they could to ensure their wellbeing. They did not report problems remembering to give drugs. The baby's apparent good health was a huge motivator for continued adherence. Testimonies from women whose babies had tested HIV negative strengthened the resolve to adhere. However, most women reported that their husbands were less engaged in HIV care, refusing to be HIV tested and in some cases stealing drugs prescribed for their wives for themselves. In two instances the man stopped the woman from giving CTX‐p to the baby either because of fear of side effects or not appreciating its importance: "he said if I kept giving CTX‐p he would take the baby away from me and give him to his mother." Stigma continues to be an important issue. Mothers reported being reluctant to disclose their HIV status to other people so found it difficult to collect prescription refills from the HIV clinic for fear of being seen by friends/relatives. Some women reported that it was hard to administer the drugs if there were people around at home. Other challenges faced were stock‐outs of CTX‐p at the clinic, which occurred four times during the study. The baby would then go without CTX‐p if the woman could not afford buying at a private pharmacy. The study highlights that adherence knowledge and desire alone is insufficient to overcome the familial and structural barriers to maintaining CTX‐p. Improving adherence to CTX‐p among HIV exposed infants will require interventions to improve male involvement, reduce HIV stigma at facilities and ensure adequate supply of drugs.

There is a wide time gap between the publication of evidence and the application of new knowledge into routine clinical practice. The consequence is sub-optimal outcomes, particularly concerning for long-term relapsing/remitting conditions such as allergic diseases. In response, there has been a proliferation of published guidelines which systematically review evidence for the gold-standard management of most allergic disorders. However, this has not necessarily been followed by improved outcomes, partly due to a lack of coordination across the patient pathway. This has become known as the "second translational gap". A proposed solution is the development and implementation of integrated care pathways (ICPs) to optimize patient outcomes, with the notion that evidence-based medicine requires evidence-based implementation. ICP implementation is shown to improve short-term outcomes for acute conditions and routine surgery, including reduced length of hospital stay, improved documentation and improved patient safety. However, this improvement is not reflected in patient experience or patient-centered functional outcomes. The implementation of life-long, cost-effective interventions within comprehensive pathways requires a deep appreciation for complexity within allergy care. We promote an evidence-based methodology for the implementation of ICPs for allergic disorders in which all stakeholders in allergy care are positioned equally and encouraged to contribute, particularly patients and their caregivers. This evidence-based process commences with scoping the unmet needs, followed by stakeholder mapping. All stakeholders are invited to meetings to develop a common vision and mission through the generation of action/effect diagrams which helps build concordance across the agencies. Dividing the interventions into achievable steps and reviewing with plan/do/study/act cycles will gradually modify the pathway to achieve the best outcomes. While the management guidelines provide the core knowledge, the key component of implementation involves education, training, and support of all healthcare professionals (HCPs), patients and their caregivers. The pathways should define the level of competence required for each clinical task. It may be useful to leave the setting of care delivery or the specific HCP involved undefined to account for variable patterns of health service delivery as well as local socioeconomic, ethnic, environmental, and political imperatives. In all cases, where competence is exceeded, it is necessary to refer to the next stage in the pathway. The success and sustainability of ICPs would ideally be judged by patient experience, health outcomes, and health economics. We provide examples of successful programs, most notably from Finland, but recommend that further research is required in diverse settings to optimize outcomes worldwide.