Community support is associated with better antiretroviral treatment outcomes in a resource-limited rural district in Malawi.
ABSTRACT A study was carried in a rural district in Malawi among HIV-positive individuals placed on antiretroviral treatment (ART) in order to verify if community support influences ART outcomes. Standardized ART outcomes in areas of the district with and without community support were compared. Between April 2003 (when ART was started) and December 2004 a total of 1634 individuals had been placed on ART. Eight hundred and ninety-five (55%) individuals were offered community support, while 739 received no such support. For all patients placed on ART with and without community support, those who were alive and continuing ART were 96 and 76%, respectively (P<0.001); death was 3.5 and 15.5% (P<0.001); loss to follow-up was 0.1 and 5.2% (P<0.001); and stopped ART was 0.8 and 3.3% (P<0.001). The relative risks (with 95% CI) for alive and on ART [1.26 (1.21-1.32)], death [0.22 (0.15-0.33)], loss to follow-up [0.02 (0-0.12)] and stopped ART [0.23 (0.08-0.54)] were all significantly better in those offered community support (P<0.001). Community support is associated with a considerably lower death rate and better overall ART outcomes. The community might be an unrecognized and largely 'unexploited resource' that could play an important contributory role in countries desperately trying to scale up ART with limited resources.
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ABSTRACT: Background: We examine attrition and loss to follow-up (LTFU) and their baseline predictors among HIV-infected children and adolescents in a Community Home-Based Care (CHBC) model in Kampala (Uganda). Methods: We conducted a retrospective cohort analysis of attrition and LTFU and their predictors among children and adolescents aged 0-20 years in the Tukula Fenna project. The project operates at the Home Care Department of Nsambya Hospital and four outreach clinics, located in Kampala and three surrounding districts in Uganda. The project uses community home-based care to provide free Antiretroviral Therapy (ART), other medical treatment as necessary, nutritional support, psychosocial support, and home visits. Kaplan-Meier curves were used to assess attrition and LTFU, and multivariate Cox proportional hazard regression models were used to identify their predictors. Results: 1162 children and adolescents with confirmed positive HIV status were enrolled in the Tukula Fenna project between October 2003 and August 2012. Over this period, 5.34% (62) of patients died 37.61% were LTFU (437), and overall attrition was 42.94% (499). This resulted in overall incidence of death of 18 per 1000 person-years, of LTFU of 126 per 1000 person-years, and of attrition of 144 per 1000 person-years. The single factor significantly associated with overall attrition among the 1162 patients was absence of ART (HR: 0.11, 95% CI: 0.09,0.14). Both baseline BMI z-score (HR: 0.96, 95% CI: 0.91, 1.00) and receipt of ART (HR: 0.12, 95% CI: 0.10, 0.15) were significantly negatively associated with LTFU among all 1162 patients in this cohort. Conclusion: Not receiving ART was the single factor significantly associated with overall attrition. Both baseline BMI z-scores and receipt of ART were protective against LTFU among HIV positive children and adolescents enrolled in the Tukula Fenna project. Orphans need more nutritional support and improved access to early ART initiation.
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ABSTRACT: In Thailand people living with HIV (PLHIV) have played a major role in shaping policy and practice. They have acted as volunteer co-providers, although their potential in terms of paediatric service provision has seldom been explored from a health systems perspective. We describe the Thai paediatric HIV care system and use both demand- and supply-side perspectives to explore the impact, opportunities and challenges of PLHIV acting as volunteer co-providers. We employed qualitative methods to assess experiences and perceptions and triangulate stakeholder perspectives. Data were collected in Khon Kaen province, in the poorest Northeastern region of Thailand: three focus group discussions and two workshops (total participants n=31) with co-providers and hospital staff; interviews with ART service-users (n=35). Nationally, key informant interviews were conducted with policy actors (n=20). Volunteer co-providers were found to be ideally placed to broker the link between clinic and communities for HIV infected children and played an important part in the vital psychosocial support component of HIV care. As co-providers they were recognized as having multiple roles linking and delivering services in clinics and communities. Clear emerging needs include strengthened coordination and training as well as strategies to support funding. Using motivated volunteers with a shared HIV status as co-providers for specific clinical services can contribute to strengthening health systems in Asia; they are critical players in delivering care (supply side) and being responsive to service-users needs (demand side). Co-providers blur the boundaries between these two spheres. Sustaining and optimising co-providers’ contribution to health systems strengthening requires a health systems approach. Our findings help to guide policy makers and service providers on how to balance clinical priorities with psycho-social responsiveness and on how best to integrate the views and experience of volunteers into a holistic model of care.Social Science & Medicine 09/2014; DOI:10.1016/j.socscimed.2014.09.017 · 2.56 Impact Factor
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ABSTRACT: Background In 2008, the WHO facilitated the primary health care (PHC) revitalisation agenda. The purpose was to strengthen African health systems in order to address communicable and non-communicable diseases. Our aim was to assess the position of civil society-led community home based care programmes (CHBC), which serve the needs of patients with HIV, within this agenda. We examined how their roles and place in health systems evolved, and the prospects for these programmes in national policies and strategies to revitalise PHC, as new health care demands arise.Methods The study was conducted in Ethiopia, Malawi, South Africa and Zambia and used an historical, comparative research design. We used purposive sampling in the selection of countries and case studies of CHBC programmes. Qualitative methods included semi-structured interviews, focus group discussions, service observation and community mapping exercises. Quantitative methods included questionnaire surveys.ResultsThe capacity of PHC services increased rapidly in the mid-to-late 2000s via CHBC programme facilitation of community mobilisation and participation in primary care services and the exceptional investments for HIV/AIDS. CHBC programmes diversified their services in response to the changing health and social care needs of patients on lifelong anti-retroviral therapy and there is a general trend to extend service delivery beyond HIV-infected patients. We observed similarities in the way the governments of South Africa, Malawi and Zambia are integrating CHBC programmes into PHC by making PHC facilities the focal point for management and state-paid community health workers responsible for the supervision of community-based activities. Contextual differences were found between Ethiopia, South Africa, Malawi and Zambia, whereby the policy direction of the latter two countries is to have in place structures and mechanisms that actively connect health and social welfare interventions from governmental and non-governmental actors.Conclusions Countries may differ in the means to integrate and co-ordinate government and civil society agencies but the net result is expanded PHC capacity. In a context of changing health care demands, CHBC programmes are a vital mechanism for the delivery of primary health and social welfare services.Globalization and Health 12/2014; 10(1):85. DOI:10.1186/s12992-014-0085-5 · 1.83 Impact Factor