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Treatment 2.0 is an initiative launched by UNAIDS and WHO in 2011 to catalyze the next phase of treatment scale-up for HIV. The initiative defines strategic activities in 5 key areas--drugs, diagnostics, commodity costs, service delivery and community engagement--in an effort to simplify treatment, expand access and maximize program efficiency. For adults, many of these activities have already been turned into treatment policies. The recent WHO recommendation to use a universal first line regimen regardless of gender, pregnancy and TB status is a treatment simplification very much in line with Treatment 2.0. But despite that fact that Treatment 2.0 encompasses all people living with HIV, we have not seen the same evolution in policy development for children. In this paper we discuss how Treatment 2.0 principles can be adapted for the pediatric population.

A new and more expansive agenda must be articulated to ensure that those infants and children who will never feel the impact of the current elimination agenda are reached and linked to appropriate care and treatment. This agenda must addresses challenges around both reducing vertical transmission through PMTCT and ensuring access to appropriate HIV testing, care, and treatment for all affected children who were never able to access PMTCT programming. Option B+, or universal test and treat for HIV-infected pregnant women, is an excellent start, but it may be time to rethink our current approaches to delivering PMTCT services. New strategies will reduce vertical transmission to less than 1% for those mother-infant pairs who can access them allowing for the contemplation of not just PMTCT, but actual elimination of MTCT. But expanded thinking is needed to ensure elimination of pediatric HIV.

The current elimination strategy has focused primarily on the expansion of HIV testing and counseling of pregnant women and the provision of antiretroviral therapy (ART) to those living with HIV to protect their health and prevent HIV transmission to their infants. Something is missing: despite WHO guidelines calling for 100% treatment coverage for all infected children younger than 5 years, early infant diagnosis and pediatric treatment have thus far been neglected. The primary focus on prevention of maternal-to-child transmission (PMTCT) has inadvertently perpetuated poor access to treatment for those children who still are inevitably acquire HIV. New ideas are needed that can propel programming to diagnose, link, and retain infected children in care, particularly those missed by current PMTCT programming, and provide optimal care for those children who do get diagnosed and linked to care and treatment services.

Although antiretroviral treatment (ART) has reduced the incidence of HIV-related opportunistic infections among children living with HIV, access to ART remains limited for children, especially in resource-limited settings. This paper reviews current knowledge on the contribution of opportunistic infections and common childhood illnesses to morbidity and mortality in children living with HIV, highlights interventions known to improve the health of children, and identifies research gaps for further exploration.

In 2012, there were an estimated 2 million children in need of antiretroviral therapy (ART) in the world, but ART is still reaching fewer than 3 in 10 children in need of treatment. As more HIV-infected children are identified early and universal treatment is initiated in children under 5 regardless of CD4, the success of pediatric HIV programs will depend on our ability to link children into care and treatment programs, and retain them in those services over time. In this review, we summarize key individual, institutional, and systems barriers to diagnosing children with HIV, linking them to care and treatment, and reducing loss to follow-up. We also explore how linkage and retention can be optimally measured so as to maximize the impact of available pediatric HIV care and treatment services.

Each year over a million infants are born to HIV-infected mothers. With scale up of prevention of mother-to-child transmission (PMTCT) interventions, only 210 000 of the 1.3 million infants born to mothers with HIV/AIDS in 2012 became infected. Current programmatic efforts directed at infants born to HIV-infected mothers are primarily focused on decreasing their risk of infection, but an emphasis on maternal interventions has meant follow-up of exposed infants has been poor. Programs are struggling to retain this population in care until the end of exposure, typically at the cessation of breastfeeding, between 12 and 24 months of age. But HIV exposure is a life-long condition that continues to impact the health and well being of a child long after exposure has ended. A better understanding of the impact of HIV on exposed infants is needed and new programs and interventions must take into consideration the long-term health needs of this growing population. The introduction of lifelong treatment for all HIV-infected pregnant women is an opportunity to rethink how we provide services adapted for the long-term retention of mother–infant pairs.

If children are to be protected from HIV, the expansion of PMTCT programs must be complemented by increased provision of paediatric treatment. This is expensive, yet there are humanitarian, equity and children's rights arguments to justify the prioritization of treating HIV-infected children. In the context of limited budgets, inefficiencies cost lives, either through lower coverage or less effective services. With the goal of informing the design and expansion of efficient paediatric treatment programs able to utilize to greatest effect the available resources allocated to the treatment of HIV-infected children, this article reviews what is known about cost drivers in paediatric HIV interventions, and makes suggestions for improving efficiency in paediatric HIV programming. High-impact interventions known to deliver disproportional returns on investment are highlighted and targeted for immediate scale-up. Progress will carry a cost - increased funding, as well as additional data on intervention costs and outcomes, will be required if universal access of HIV-infected children to treatment is to be achieved and sustained.

Achievement of Millennium Development Goal (MDG) 4 for child survival requires acceleration of gains in newborn survival, and current trends in improving maternal health will also fall short of reaching MDG 5 without more strategic actions. We present a Maternal Newborn and Child Health (MNCH) strategy for accelerating progress on MDGs 4 and 5, sustaining the gains beyond 2015, and further bringing down maternal and child mortality by two thirds by 2030. The strategy takes into account current trends in coverage and cause-specific mortality, builds on lessons learned about what works in large-scale implementation programs, and charts a course to reach those who do not yet access services. A central hypothesis of this strategy is that enhancing interactions between frontline workers and mothers and families is critical for increasing the effective coverage of life-saving interventions. We describe a framework for measuring and evaluating progress which enables continuous course correction and improvement in program performance and impact. Evidence for the hypothesis and impact of this strategy is being gathered and will be synthesized and disseminated in order to advance global learning and to maximise the potential to improve maternal and neonatal survival.

This supplement to the Journal of Global Public Health is devoted to the re-development of the health system in Afghanistan beginning in 2002. It discusses the processes that were adopted by the Ministry of Public Health and its partners, and the activities of the non-governmental organisations that, for the most part, were responsible for overseeing the delivery of health services to the population. It also presents an overview of the results that were obtained during the ensuing 10 years.

Ensuring that medicines which achieve important health outcomes are available, accessible to all, used appropriately, and sustainably affordable is essential for realizing universal health coverage. Stakeholder cooperation and use of information and financing system levers provide opportunities to work toward this goal.

As national antiretroviral treatment (ART) programmes scale up, it is essential that information is complete, timely and accurate for site monitoring and national planning. This study assessed the quality of quarterly aggregate summary data for April to June 2006 compiled and reported by ART facilities as compared to the "gold standard" facility summary data compiled independently by the Ministry of Health supervision team. The national summary using the site reports resulted in a 12% undercount in the national total number of persons on first-line treatment. While many sites are able to generate complete data summaries, the accuracy of facility reports is not yet adequate for national monitoring. The Ministry of Health and its partners should continue to identify and support interventions such as supportive supervision to build sites' capacity to maintain and compile quality data to ensure that accurate information is available for site monitoring and national planning.

Approximately 1 million people are infected with HIV in Malawi, where AIDS is the leading cause of death in adults. By December 31, 2007, more than 141,000 patients were initiated on antiretroviral treatment (ART) by use of a public health approach to scale up HIV services. In Malawi, a public health approach to ART increased treatment access and maintained high 6- and 12-month survival. Resource-limited countries scaling up ART programs may benefit from this approach of simplified clinical decision making, standardized ART regimens, nonphysician care, limited laboratory support, and centralized monitoring and evaluation.

The global demand for artemisinin-based combination therapy (ACT) has grown sharply since its recommendation by the World Health Organization in 2002. However, a combination of financing and programmatic uncertainties, limited suppliers of finished products, information opacity across the different tiers in the supply chain, and widespread fluctuations in raw material prices have together contributed to a market fraught with demand and supply uncertainties and price volatility. Various short-term solutions have been deployed to alleviate supply shortages caused by these challenges; however, new mechanisms are required to build resilience into the supply chain. This review concludes that a mix of strategies is required to stabilize the artemisinin and ACT market. First, better and more effective pooling of demand and supply risks and better contracting to allow risk sharing among the stakeholders are needed. Physical and financial buffer stocks will enable better matching of demand and supply in the short and medium term. Secondly, physical buffers will allow stable supplies when there are procurement and supply management challenges while financial buffer funds will address issues around funding disruptions. Finally, in the medium to long term, significant investments in country level system strengthening will be required to minimize national level demand uncertainties. In addition a voluntary standard for extractors to ensure appropriate purchasing and sales practices as well as minimum quality and ethical standards could help stabilize the artemisinin market in the long term.

This article assessed private sector accredited drug dispensing outlets in Morogoro and pharmacies in Dar es Salaam, Tanzania, to determine (1) the level of knowledge about tuberculosis (TB) among dispensers in Tanzania's retail pharmaceutical sector; (2) practices related to identification of patients with suspected TB; (3) the availability of educational materials and training; and (4) the availability of first- and second-line anti-tuberculosis treatment in retail drug outlets. Private retail drug outlets are convenient; most are open at least 12 h per day, 7 days/week. Although 95% of dispensers identified persistent cough as a symptom of TB, only 1% had received TB-related training in the previous 3 years; 8% of outlets stocked first-line anti-tuberculosis medicines, which are legally prohibited from being sold at retail outlets. The majority of respondents reported seeing clients with TB-like symptoms, and of these 95% reported frequently referring clients to nearby health facilities. Private retail pharmaceutical outlets can potentially contribute to TB case detection and treatment; however, a coordinated effort is needed to train dispensers and implement appropriate referral procedures.

Bacterial meningitis is a medical emergency associated with high mortality rates. Cerebrospinal fluid (CSF) culture is the “gold standard” for diagnosis of meningitis and it is important to establish the susceptibility of the causative microorganism to rationalize treatment. The Namibia Standard Treatment Guidelines (STGs) recommends initiation of empirical antibiotic treatment in patients with signs and symptoms of meningitis after taking a CSF sample for culture and sensitivity. The objective of this study was to assess the antimicrobial sensitivity patterns of microorganisms isolated from CSF to antibiotics commonly used in the empirical treatment of suspected bacterial meningitis in Namibia. The common organisms isolated from CSF were Streptococcus Pneumoniae, Neisseria meningitidis,Haemophilus influenzae, Staphylococcus, and E. coli. All common organisms isolated from CSF showed high sensitivity to cephalosporins used in the empirical treatment of meningitis. The resistance of the common isolates to penicillin is high. Most ESBL K. pneumoniae were isolated from CSF samples drawn from neonates and were found to be resistant to the antibiotics recommended in the Namibia STGs. Based on these findings, it is recommended to use a combination of aminoglycoside and third-generation cephalosporin to treat non–ESBL Klebsiella isolates. Carbapenems (e.g., meropenem) and piperacillin/tazobactam should be considered for treating severely ill patients with suspected ESBL Klebsiella infection. Namibia should have a national antimicrobial resistance surveillance system for early detection of antibiotics that may no longer be effective in treating meningitis and other life-threatening infections due to resistance.

A public-private partnership in Tanzania launched the accredited drug dispensing outlet (ADDO) program to improve access to quality medicines and pharmaceutical services in rural areas. ADDO dispensers play a potentially important role in promoting the rational use of antimicrobials, which helps control antimicrobial resistance (AMR). The study objectives were to 1) improve dispensing practices of antimicrobials, 2) build ADDO dispensers' awareness of the consequences of misusing antimicrobials, and 3) educate consumers on the correct use of antimicrobials through the use of printed materials and counseling.The percentage of ADDO dispensers following good dispensing practices increased from an average of 67% in the first monitoring visit to an average of 91% during the last visit. After the intervention, more dispensers could name more factors contributing to AMR and negative consequences of inappropriate antimicrobial use, and over 95% of ADDO customers knew important information about the medicines they were dispensed. Conclusions: Providing educational materials and equipping ADDO dispensers with knowledge and tools helps significantly improve community medicine use and possibly reduces AMR. The number of community members who learned about AMR from ADDO dispensers indicates that they are an important source of information on medicine use.

The vision of universal health coverage (UHC) is that everyone has access to the quality prevention and treatment services they need, without enduring financial hardship as a result of essential health expenditures. UHC programmes pursue this aim by mobilising all viable financial resources, with an emphasis on increasing public funding; by using these resources to strengthen health systems and ensure service quality; and by establishing financial protection mechanisms.

To document the prevalence of multidrug resistance among people newly diagnosed with--and those retreated for--tuberculosis in Malawi, we conducted a nationally representative survey of people with sputum-smear-positive tuberculosis between 2010 and 2011. For all consenting participants, we collected demographic and clinical data, two sputum samples and tested for human immunodeficiency virus (HIV).The samples underwent resistance testing at the Central Reference Laboratory in Lilongwe, Malawi. All Mycobacterium tuberculosis isolates found to be multidrug-resistant were retested for resistance to first-line drugs – and tested for resistance to second-line drugs--at a Supranational Tuberculosis Reference Laboratory in South Africa. Overall, M. tuberculosis was isolated from 1777 (83.8%) of the 2120 smear-positive tuberculosis patients. Multidrug resistance was identified in five (0.4%) of 1196 isolates from new cases and 28 (4.8%) of 581 isolates from people undergoing retreatment. Of the 31 isolates from retreatment cases who had previously failed treatment, nine (29.0%) showed multidrug resistance. Although resistance to second-line drugs was found, no cases of extensive drug-resistant tuberculosis were detected. HIV testing of people from whom M. tuberculosis isolates were obtained showed that 577 (48.2%) of people newly diagnosed and 386 (66.4%) of people undergoing retreatment were positive. The prevalence of multidrug resistance among people with smear-positive tuberculosis was low for sub-Saharan Africa--probably reflecting the strength of Malawi’s tuberculosis control programme. The relatively high prevalence of such resistance observed among those with previous treatment failure may highlight a need for a change in the national policy for retreating this subgroup of people with tuberculosis.

In July 2011, Malawi introduced an ambitious public health program known as “Option B+,” which provides all HIV- infected pregnant and breastfeeding women with lifelong combination antiretroviral therapy, regardless of clinical stage or CD4 count. Option B+ is expected to have benefits for HIV-infected women, their HIV-exposed infants, and their HIV-uninfected male sex partners. However, these benefits hinge on early uptake of prevention of mother-to-child transmission, good adherence, and long-term retention in care. The Prevention of mother-to-child transmission Uptake and REtention (PURE) study is a 3-arm cluster randomized controlled trial to evaluate whether clinic- or community-based peer support will improve care-seeking and retention in care by HIV- infected pregnant and breastfeeding women, their HIV-exposed infants, and their male sex partners, and ultimately improve health outcomes in all 3 populations. We describe the PURE Malawi Consortium, the initial work conducted to inform the trial and interventions, the trial design, and the analysis plan. We then discuss concerns and expected contributions to Malawi and the region.

Integrated community case management (iCCM) can be an effective strategy for expanding the provision of diarrhea, pneumonia, and malaria services to children under 5 years old but there are concerns in some countries about the corresponding cost and impact. This paper presents and compares findings from a multi–country analysis of iCCM program costs. Data were collected on iCCM programs in seven sub–Saharan African countries: Cameroon, the Democratic Republic of the Congo, Malawi, Senegal, Sierra Leone, South Sudan and Zambia. The data were used to compare some elements of program performance as well as costs per capita and costs per service (which are key indicators of resource allocation and efficiency). A comprehensive understanding of iCCM program costs and results can help countries obtain resources and use them efficiently. To be cost–effective and affordable, iCCM programs must be well utilized, while program management and supervision should be organized to minimize costs and ensure quality of care. iCCM programs will not always be low–cost, however, particularly in small, remote villages where supervision and supply challenges are greater.

In this third special issue published by the International Journal of Drug Policy, the authors of ten research papers and commentaries seek to provide additional knowledge on a range of issues related to illicit drugs in the region, including the epidemiology of drug use and drug-related infectious diseases and other consequences, drug treatment and harm reduction pro

Given similar performance and knowledge of health workers trained in 7-day and 11-day courses, potential cost savings, the possibility of training more health workers and the relative ease with which health workers in remote settings might participate in a short course, it seems prudent to standardize the 7-day course in Afghanistan, where child mortality rates remain unacceptably high.

Although there is evidence of the effectiveness of needle and syringe programme (NSP), opioid substitution therapy (OST) and antiretroviral therapy (ART) in reducing HIV prevalence, most Central and Eastern European sub-regions still have low or no coverage of most or all of these interventions. We conducted a modelling analysis to consider the potential impact on HIV incidence and prevalence of OST, NSP, and ART in three illustrative epidemic scenarios: Russia (St. Petersburg), Estonia (Tallinn), and Tajikistan (Dushanbe). For each intervention, we consider the coverage needed of each intervention separately or in combination to: (1) achieve a 30% or 50% relative reduction in HIV incidence or prevalence over 10 years; and (2) reduce HIV incidence to below 1% or HIV prevalence below 10% after 20 years. A sensitivity analysis for St. Petersburg considered the implications of greater or no risk heterogeneity, none or more sexual HIV transmission, like-with-like mixing, different injecting cessation rates, and assuming a lower HIV acute phase cofactor. The projections suggest that high but achievable coverage levels of NSP can result in large decreases (30%) in HIV incidence in settings with high HIV prevalence among PWID. Required coverage levels are much lower when interventions are combined or in lower prevalence settings. However, even when all three interventions are combined, the targets of reducing HIV incidence to less than 1% or prevalence to less than 10% in 20 years may be hard to achieve except in lower prevalence settings.

Hypoglycemia is a major cause of morbidity and mortality among preterm infants, and its management remains a challenge in resource-limited settings.

Health data can be useful for effective service delivery, decision making, and evaluating existing programs in order to maintain high quality healthcare. Studies have shown variability in data quality from national health management information systems (HMIS) in sub-Saharan Africa, which threatens utility of these data as a tool to improve health systems.

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