Suchergebnisse

IntroductionHIV programme data from routine health information systems (RHIS) and personal health information (PHI) provide ample opportunities for secondary data analysis. However, these data pose unique opportunities and challenges for use in health system monitoring, along with process and impact evaluations.MethodsAnalyses focused on retrospective case reviews of four of the HIV‐related studies published in this JIAS supplement. We identify specific opportunities and challenges with respect to the secondary analysis of RHIS and PHI data.ResultsChallenges working with both HIV‐related RHIS and PHI included missing, inconsistent and implausible data; rapidly changing indicators; systematic differences in the utilization of services; and patient linkages over time and different data sources. Specific challenges among RHIS data included numerous registries and indicators, inconsistent data entry, gaps in data transmission, duplicate registry of information, numerator‐denominator incompatibility and infrequent use of data for decision‐making. Challenges specific to PHI included the time burden for busy providers, the culture of lax charting, overflowing archives for paper charts and infrequent chart review.ConclusionsMany of the challenges that undermine effective use of RHIS and PHI data for analyses are related to the processes and context of collecting the data, excessive data requirements, lack of knowledge of the purpose of data and the limited use of data among those generating the data. Recommendations include simplifying data sources, analysis and reporting; conducting systematic data quality audits; enhancing the use of data for decision‐making; promoting routine chart review linked with simple patient tracking systems; and encouraging open access to RHIS and PHI data for increased use.

BackgroundThis cross‐sectional study assessed factors affecting access to antiretroviral therapy (ART) among HIV‐positive women from the prevention of mother to child transmission HIV programme in Chitungwiza, Zimbabwe.MethodsData were collected between June and August 2008. HIV‐positive women attending antenatal clinics who had been referred to the national ART programme from January 2006 until December 2007 were surveyed. The questionnaire collected socio‐demographic data, treatment‐seeking behaviours, and positive or negative factors that affect access to HIV care and treatment.ResultsOf the 147 HIV‐positive women interviewed, 95 (65%) had registered with the ART programme. However, documentation of the referral was noted in only 23 (16%) of cases. Of the 95 registered women, 35 (37%) were receiving ART; 17 (18%) had not undergone CD4 testing. Multivariate analysis revealed that participants who understood the referral process were three times more likely to access HIV care and treatment (OR = 3.21, 95% CI 1.89‐11.65) and participants enrolled in an HIV support group were twice as likely to access care and treatment (OR = 2.34, 95% CI 1.13‐4.88). Those living with a male partner were 60% less likely to access care and treatment (OR = 0.40, 95% CI 0.16‐0.99). Participants who accessed HIV care and treatment faced several challenges, including long waiting times (46%), unreliable access to laboratory testing (35%) and high transport costs (12%). Of the 147 clients surveyed, 52 (35%) women did not access HIV care and treatment. Barriers included perceived long queues (50%), competing life priorities, such as seeking food or shelter (33%) and inadequate referral information (15%).ConclusionsDespite many challenges, the majority of participants accessed HIV care. Development of referral tools and decentralization of CD4 testing to clinics will improve access to ART. Psychosocial support can be a successful entry point to encourage client referral to care and treatment programmes.

INTRODUCTION: Indoor residual spraying (IRS) and insecticide-treated nets (ITNs), two principal malaria control strategies, are similar in cost and efficacy. We aimed to describe recent policy development regarding their use in Mozambique, South Africa and Zimbabwe. METHODS: Using a qualitative case study methodology, we undertook semi-structured interviews of key informants from May 2004 to March 2005, carried out document reviews and developed timelines of key events. We used an analytical framework that distinguished three broad categories: interests, ideas and events. RESULTS: A disparate mix of interests and ideas slowed the uptake of ITNs in Mozambique and Zimbabwe and prevented uptake in South Africa. Most respondents strongly favoured one strategy over the other. In all three countries, national policy makers favoured IRS, and only in Mozambique did national researchers support ITNs. Outside interests in favour of IRS included manufacturers who supplied the insecticides and groups opposing environmental regulation. International research networks, multilateral organizations, bilateral donors and international NGOs supported ITNs. Research evidence, local conditions, logistic feasibility, past experience, reaction to outside ideas, community acceptability, the role of government and NGOs, and harm from insecticides used in spraying influenced the choice of strategy. The end of apartheid permitted a strongly pro-IRS South Africa to influence the region, and in Mozambique and Zimbabwe, floods provided conditions conducive to ITN distribution. CONCLUSIONS: Both IRS and ITNs have a place in integrated malaria vector management, but pro-IRS interests and ideas slowed or prevented the uptake of ITNs. Policy makers needed more than evidence from trials to change from the time-honoured IRS strategy that they perceived was working. Those intending to promote new policies such as ITNs should examine the interests and ideas motivating key stakeholders and their own institutions, and identify where shifts in thinking or coalitions among the like-minded may be possible.

IntroductionAccording to UNAIDS, the world currently has an adequate collection of proven HIV prevention, treatment and diagnostic tools, which, if scaled up, can lay the foundation for ending the AIDS epidemic. HIV operations research (OR) tests and promotes the use of interventions that can increase the demand for and supply of these tools. However, current publications of OR mainly focus on outcomes, leaving gaps in reporting of intervention characteristics, which are essential to address for the utilization of OR findings. This has prompted WHO and other international public health agencies to issue reporting requirements for OR studies. The objective of this commentary is to review experiences in HIV OR intervention design, implementation, process data collection and publication in order to identify gaps, contribute to the body of knowledge and propose a way forward to improve the focus on "implementation" in implementation research.DiscussionInterventions in OR, like ordinary service delivery programmes, are subject to the programme cycle, which continually uses insights from implementation and the local context to modify service delivery modalities. Given that some of these modifications in the intervention may influence study outcomes, the documentation of process data becomes vital in OR. However, a key challenge is that study resources tend to be skewed towards documentation and the reporting of study outcomes to the detriment of process data, even though process data is vital for understanding factors influencing the outcomes.ConclusionsInterventions in OR should be viewed using the lens of programme evaluation, which includes formative assessment (to determine concept and design), followed by process evaluation (to monitor inputs and outputs) and effectiveness evaluation (to assess outcomes and effectiveness). Study resources should be equitably used between process evaluation and outcome measurement to facilitate inclusion of data about fidelity and dose in publications in order to enable explanation of the relationship between dosing and study outcomes for purposes of scaling up and further refinement through research.

ObjectivesInvestigate levels of retention at specified time periods along the prevention of mother‐to‐child transmission (PMTCT) cascade among mother‐infant pairs as well as individual‐ and facility‐level factors associated with retention.MethodsA retrospective cohort of HIV‐positive pregnant women and their infants attending five health centres from November 2010 to February 2012 in the Option B programme in Rwanda was established. Data were collected from several health registers and patient follow‐up files. Additionally, informant interviews were conducted to ascertain health facility characteristics. Generalized estimating equation methods and modelling were utilized to estimate the number of mothers attending each antenatal care visit and assess factors associated with retention.ResultsData from 457 pregnant women and 462 infants were collected at five different health centres (three urban and two rural facilities). Retention at 30 days after registration and retention at 6 weeks, 3, 6, 9 and 12 months post‐delivery were analyzed. Based on an analytical sample of 348, we found that 58% of women and 81% of infants were retained in care within the same health facility at 12 months post‐delivery, respectively. However, for mother‐infant paired mothers, retention at 12 months was 74% and 79% for their infants. Loss to facility occurred early, with 26% to 33% being lost within 30 days post‐registration. In a multivariable model retention was associated with being married, adjusted relative risk (ARR): 1.26, (95% confidence intervals: 1.11, 1.43); antiretroviral therapy eligible, ARR: 1.39, (1.12, 1.73) and CD4 count per 50 mm3, ARR: 1.02, (1.01, 1.03).ConclusionsThese findings demonstrate varying retention levels among mother‐infant pairs along the PMTCT cascade in addition to potential determinants of retention to such programmes. Unmarried, apparently healthy, HIV‐positive pregnant women need additional support for programme retention. With the significantly increased workload resulting from lifelong antiretroviral treatment for all HIV‐positive pregnant women, strategies need to be developed to identify, provide support and trace these women at risk of loss to follow‐up. This study provides further evidence for the need for such a targeted supportive approach.

IntroductionDespite recent advances in the management of HIV infection and increased access to treatment, prevention, care and support, the HIV/AIDS epidemic continues to be a major global health problem, with sub‐Saharan Africa suffering by far the greatest humanitarian, demographic and socio‐economic burden of the epidemic. Information on HIV/AIDS clinical care and established cohorts' characteristics in the Central Africa region are sparse.MethodsA survey of clinical care resources, management practices and patient characteristics was undertaken among 12 adult HIV care sites in four countries of the International Epidemiologic Databases to Evaluate AIDS Central Africa (IeDEA‐CA) Phase 1 regional network in October 2009. These facilities served predominantly urban populations and offered primary care in the Democratic Republic of Congo (DRC; six sites), secondary care in Rwanda (two sites) and tertiary care in Cameroon (three sites) and Burundi (one site).ResultsDespite some variation in facility characteristics, sites reported high levels of monitoring resources, including electronic databases, as well as linkages to prevention of mother‐to‐child HIV transmission programs. At the time of the survey, there were 21,599 HIV‐positive adults (median age=37 years) enrolled in the clinical cohort. Though two‐thirds were women, few adults (6.5%) entered HIV care through prevention of mother‐to‐child transmission services, whereas 55% of the cohort entered care through voluntary counselling and testing. Two‐thirds of patients at sites in Cameroon and DRC were in WHO Stage III and IV at baseline, whereas nearly all patients in the Rwanda facilities with clinical stage information available were in Stage I and II. WHO criteria were used for antiretroviral therapy initiation. The most common treatment regimen was stavudine/lamivudine/nevirapine (64%), followed by zidovudine/lamivudine/nevirapine (19%).ConclusionsOur findings demonstrate the feasibility of establishing large clinical cohorts of HIV‐positive individuals in a relatively short amount of time in spite of challenges experienced by clinics in resource‐limited settings such as those in this region. Country differences in the cohort's site and patient characteristics were noted. This information sets the stage for the development of research initiatives and additional programs to enhance adult HIV care and treatment in Central Africa.