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Beginning in 2003, Uganda used Lot Quality Assurance Sampling (LQAS) to assist district managers collect and use data to improve their human immunodeficiency virus (HIV)/AIDS program. Uganda's LQAS-database (2003–2012) covers up to 73 of 112 districts. Our multidistrict analysis of the LQAS data-set at 2003–2004 and 2012 examined gender variation among adults who ever tested for HIV over time, and attributes associated with testing. Conditional logistic regression matched men and women by community with seven model effect variables. HIV testing prevalence rose from 14% (men) and 12% (women) in 2003–2004 to 62% (men) and 80% (women) in 2012. In 2003–2004, knowing the benefits of testing, knowing where to get tested, and secondary education were significantly associated with HIV testing. By 2012, knowing the benefits of testing, where to get tested, primary education, being female, and being married were significantly associated with HIV testing. HIV testing prevalence in Uganda has increased dramatically, more for women than men. Our results concurred with other authors that education, knowledge of HIV, and marriage (women only) are associated with testing for HIV and suggest that couples testing is more prevalent than other authors found.

SETTING: Amhara and Oromia Regions, Ethiopia.OBJECTIVE: To determine trends in case notification rates (CNRs) among new tuberculosis (TB) cases and treatment outcomes of sputum smear-positive (SS+) patients based on geographic setting, sex and age categories.METHODS: We undertook a trend analysis over a 4-year period among new TB cases reported in 10 zones using a trend test, a mean comparison t-test and one-way analysis of variance.RESULTS: The average CNR per 100 000 population was 128.9: 126.4 in Amhara and 131.4 in Oromia. The CNR in the project-supported zones declined annually by 6.5%, compared with a 14.5% decline in Tigray, the comparator region. TB notification in the intervention zones contributed 26.1% of the national TB case notification, compared to 13.3% before project intervention. The overall male-to-female ratio was 1.2, compared to 0.8 among SS+ children, with a female preponderance. Over 4 years, the cure rate increased from 75% to 88.4%, and treatment success from 89% to 93%. Default, transfer out and mortality rates declined significantly.CONCLUSION: Project-supported zones had lower rates of decline in TB case notification than the comparator region; their contribution to national case finding increased, and treatment outcomes improved significantly. High SS+ rates among girls deserve attention.

Universal health coverage (UHC) has gained prominence as a global health priority. The UHC movement aims to increase access to quality, needed health services while reducing financial hardship from health spending, particularly in low- and middle-income countries. As a policy agenda, UHC has been identified primarily with prepayment and risk-pooling programs. While financing policies provide important benefits, increasing access to health services will require broader reforms. For lessons, the UHC movement should look to the global HIV response, which has confronted many of the same barriers to access in weak health systems. Considerable success on HIV has resulted from innovative approaches that UHC efforts can build upon, in areas including governance, financing, service delivery, political mobilization, accountability, and human rights. UHC and HIV efforts must capitalize on potential synergies, especially in settings with a high HIV burden and major resource limitations.

The objective of this study was to compare the diagnostic yield of GeneXpert MTB/RIF with Ziehl-Neelson (ZN) sputum smear microscopy among index TB cases and their household contacts. A cross sectional study was conducted among sputum smear positive index TB cases and their household contacts in Northern Ethiopia. Results: Of 353 contacts screened, 41 (11%) were found to have presumptive TB. GeneXpert test done among 39 presumptive TB cases diagnosed 14 (35.9%) cases of TB (one being rifampicin resistant), whereas the number of TB cases diagnosed by microscopy was only 5 (12.8%): a 64.3% increased positivity rate by GeneXpert versus ZN microscopy. The number needed to screen and number needed to test to diagnose a single case of TB was significantly lower with the use of GeneXpert than ZN microscopy. Of 119 index TB cases, GeneXpert test revealed that 106 (89.1%) and 5 (4.2%) were positive for rifampicin sensitive and rifampicin resistant TB, respectively. GeneXpert test led to increased TB case detection among household contacts in addition to its advantage in the diagnosis of Rifampicin resistance among contacts and index TB cases. There should be a consideration in using GeneXpert MTB/RIF as a point of care TB testing tool among high risk groups.

Abstract Background: To ascertain equity in financing for essential medicines and health supplies (EMHS) in Uganda, this paper explores the relationships among government funding allocations for EMHS, patient load, and medicines availability across facilities at different levels of care.

Abstract The scale-up of antiretroviral therapy (ART) in Malawi was based on a public health approach adapted to its resource-poor setting, with principles and practices borrowed from the successful tuberculosis control framework. From 2004 to 2015, the number of new patients started on ART increased from about 3,000 to over 820,000.

Abstract Purpose: Active surveillance pharmacovigilance systems better estimate the burden of adverse events (AEs) and can generate useful information on risk factors of AEs for more effective medicine use, especially in conjunction with introduction of new medicines and/or changes in treatment guidelines.

Abstract Introduction: Active surveillance pharmacovigilance is a systematic approach to medicine safety assessment and health systems strengthening, but has not been widely implemented in low- and middle-income countries.

Abstract Background: One of the main goals of the post-2015 global tuberculosis (TB) strategy is that no families affected by TB face catastrophic costs. We revised an existing TB patient cost measurement tool to specifically also measure multi-drug resistant (MDR) TB patients’ costs and applied it in Ethiopia, Indonesia and Kazakhstan.

This editorial introduces the Lancet series on maternal health.

The purpose of this study was to investigate the quality of a select group of medicines sold in accredited drug dispensing outlets (ADDOs) and pharmacies in different regions of Tanzania as part of an in-depth cross-sectional assessment of community access to medicines and community use of medicines. We collected 242 samples of amoxicillin trihydrate, artemether-lumefantrine (ALu), co-trimoxazole, ergometrine maleate, paracetamol, and quinine from selected ADDOs and pharmacies in Mbeya, Morogoro, Singida, and Tanga regions. The analysis included physical examination and testing with validated analytical techniques. The physical examination of samples revealed no defects in the solid and oral liquid dosage forms, but unusual discoloration in an injectable solution, ergometrine maleate. Over 90% of the medicines sold in ADDOs and pharmacies met quality standards. Policy makers need to reconsider ergometrine maleate’s place on the list of medicines that ADDOs are allowed to dispense, by either substituting a more temperature-stable therapeutically equivalent product or requiring those sites to have refrigerators, which is not a feasible option for rural Tanzania.

In 2003, the government  of Tanzania introduced the accredited drug dispensing outlet (ADDO) program to improve access to good-quality medicines in rural and peri-urban areas that have frequent drug shortages in public health facilities and few or no registered pharmacies. However, increasing access may also contribute to antimicrobial resistance (AMR) due to the potential overuse and misuse of drugs. We conducted a cross-sectional household survey in four regions in mainland Tanzania to characterize consumer care-seeking habits and medicines use and to determine the extent to which members of the community are knowledgeable about antimicrobials and AMR. We revealed that communities in the four regions have low levels of knowledge of the concepts of antimicrobials and their use and AMR. Level of public understanding rose with wealth status and education. Only one-third of 1,200 respondents (33.6%) had ever heard of a medicine called an antimicrobial, and 5–15% could name at least one antimicrobial spontaneously. Some thought other medicines, such as paracetamol, were antimicrobial (7.5%). People were equally likely to agree that pneumonia should be treated with an antimicrobial (21.4%) as well as common cold (28.4%). Understanding of AMR risks was better, particularly related to HIV and AIDS (32.2%) and malaria (38.6%)—most likely due to information campaigns focused on those two diseases. The level of knowledge decreased the further away respondents lived from an ADDO and where ADDO density was lower, which supports the use of ADDO dispensers as sources of community information and change agents for more appropriate medicine use. Lack of knowledge about antimicrobials and AMR in Tanzanian communities needs to be addressed through multi-pronged strategies that focus on prescribers and the public— especially those who are poorer and less educated.

In Tanzania, a public-private partnership launched in 2003 used an accreditation approach to improve access to quality medicines and pharmaceutical services in underserved areas. The government scaled up the accredited drug dispensing outlet (ADDO) program nationally, with over 9,000 shops now accredited. This study assessed the relationships between community members and their sources of health care and medicines, particularly antimicrobials, with a specific focus on the role ADDOs play in the health care system. We surveyed 1,185 households and audited 96 ADDOs and 84 public/nongovernmental health facilities using a list of 17 tracer drugs. To determine practices in health facilities, we interviewed 1,365 exiting patients. To assess dispensing practices, mystery shoppers visited 306 ADDOs presenting one of three scenarios (102 each) about a child’s respiratory symptoms. Of 614 household members with a recent acute illness, 73% sought outside care-30% at a public facility and 31% at an ADDO. However, people bought medicines more often at ADDOs no matter who recommended the treatment; of the 581 medicines that people had received, 49% came from an ADDO. ADDO dispensers are trained to refer complicated cases to a health facility, and notably, 99% of mystery shoppers presenting a pneumonia scenario received an antimicrobial (54%), a referral (90%), or both (45%), which are recommended practices for managing pediatric pneumonia. However, one-third of the dispensers needlessly sold antibiotics for cold symptoms, and 85% sold an antibiotic on request. In addition, the pneumonia scenario elicited more advice on handling the illness than the cold symptoms scenario (61% vs. 15%; p<0.0001), but overall, only 44% of the dispensers asked any of the shoppers about danger signs potentially associated with pneumonia in a child. Poor prescribing in health facilities, poor dispensing at ADDOs, and inappropriate patient demand continue to contribute to inappropriate medicines use. Therefore, while accreditation has attempted to address the quality of pharmaceutical services in private sector drug outlets, efforts to improve access to and use of medicines in Tanzania need to target ADDOs, public/nongovernmental health facilities, and the public to be effective.

In Malawi, health-system constraints meant that only a fraction of people infected with human immunodeficiency virus (HIV) and in immediate need of antiretroviral treatment (ART) received treatment. In 2004, the Malawian Ministry of Health launched plans to scale-up ART nationwide, adhering to the principle of equity to ensure fair geographical access to therapy. A public health approach was used with standardized training and treatment and regular supervision and monitoring of the programme. Before the scale-up, an estimated 930 000 people in Malawi were HIV-infected, with 170 000 in immediate need of ART. About 3000 patients were on ART in nine clinics. By December 2015, cumulatively 872 567 patients had been started on ART from 716 clinics, following national treatment protocols and using the standard monitoring system. Strong national leadership allowed the ministry of health to implement a uniform system for scaling-up ART and provided benchmarks for implementation on the ground. New systems of training staff and accrediting health facilities enabled task-sharing and decentralization to peripheral health centres and a standardized approach to starting and monitoring ART. A system of quarterly supervision and monitoring, into which operational research was embedded, ensured stocks of drug supplies at facilities and adherence to national treatment guidelines.

Priority digital health products will be profiled and developed to support the scale-up of WHO's End TB Strategy.

To determine the yield and determinants of retrospective TB contact investigation in selected zones in Ethiopia, we conducted a community-based cross-sectional study during June-October 2014.Trained lay providers performed symptom screening for close contacts of index cases with all types of TB registered for anti-TB treatment within the last three years. Of 272,441 close contacts of 47, 021 index cases screened, 13,886 and 2, 091 had presumptive and active TB respectively. The yield of active TB was thus 768/100, 000, contributing 25.4% of the 7,954 TB cases reported from the study zones over the study period. The yield of retrospective contact investigation was about six times the case notification in the study zones, contributing a fourth of all TB cases notified over the same period. The yield was highest among workplace contacts and in those with recent past history of contact. Retrospective contact screening can serve as additional strategy to identify high risk groups not addressed through currently recommended screening approaches.

Abstract HIV testing services (HTS) are an essential component of a national response to the HIV epidemic, and in lower and middle income countries, at least 150 million persons are tested annually. HIV testing is necessary to identify persons in need of antiretroviral treatment, which has been documented to be highly effective not only for treatment but also for prevention of HIV transmission to both adults and children. An assessment of the recent literature on sustainability of health and HIV services suggests that organizational performance, flexibility, and integration with other health interventions contribute to sustainability of HIV services and programs. This article describes the experiences of two HIV testing service providers in Uganda and Zambia as well as the track record of services to prevent mother-to-child HIV transmission to illustrate the factors of performance, flexibility, adaptability, and integration which are key to the sustainability of HIV testing services.

LQAS is intended for use by local health teams to collect data at the district and sub-district levels. Our question is whether local health staff produce biased results as they are responsible for implementing the programs they also assess. This test-retest study replicates on a larger scale an earlier LQAS reliability assessment in Uganda. We conducted in two districts an LQAS survey using 15 local health staff as data collectors. A week later, the data collectors swapped districts, where they acted as disinterested non-local data collectors, repeating the LQAS survey with the same respondents. We analysed the resulting two data sets for agreement using Cohen’s Kappa. The findings of this study are remarkably similar to those produced in the first reliability study. There is no evidence that using local healthcare staff to collect LQAS data biases data collection in an LQAS study. The bias observed in the knowledge indicators was most likely due to a ‘practice effect’, whereby respondents increased their knowledge as a result of completing the first survey; no corresponding effect was seen in the practice indicators.

Opioid agonist therapies (OAT) to treat opioid addiction in people who inject drugs (PWID) began in Ukraine in 2004. Scale-up of OAT, however, has been hampered by both low enrollment and high attrition. To better understand the factors influencing OAT retention among PWID in Ukraine, qualitative data from 199 PWIDs were collected during 25 focus groups conducted in five Ukrainian cities from February to April 2013. The experiences of PWID who were currently or previously on OAT or currently trying to access OAT were analyzed to identify entry and retention barriers encountered. Transcribed data were analyzed using a grounded theory approach. Individual beliefs about OAT, particularly misaligned treatment goals between clients and providers, influenced PWID's treatment seeking behaviors. Multiple programmatic and structural issues, including inconvenient hours and treatment site locations, complicated dosing regimens, inflexible medication dispensing guidelines, and mistreatment by clinic and medical staff also strongly influenced OAT retention. Findings suggest the need for both programmatic and policy-level structural changes such as revising legal regulations covering OAT dispensing, formalizing prescription dosing policies and making OAT more available through other sites, including primary care settings as a way to improve treatment retention. Quality improvement interventions that target treatment settings could also be deployed to overcome healthcare delivery barriers. Additional patient education and medical professional development around establishing realistic treatment goals as well as community awareness campaigns that address the myths and fears associated with OAT can be leveraged to overcome individual, family and community-level barriers.

Abstract Visual loss is a rare but potentially devastating postoperative complication of prone spinal surgery with a reported incidence of 0.017 to 0.1 percent. We present a case of post-operative bilateral visual loss in a patient who had a laminectomy in prone position under general anesthesia. A 17-year-old male patient with large syringomyelia extending from C2 - T2 level had a surgical procedure done under general anesthesia in prone position that lasted four hours. After the surgical procedure, the patient presented to the Ophthalmology Clinic of Princess Marina Hospital, with a complaint of visual loss of the right eye followed by left, of one week duration. The patient never had a visual impairment in the past. Physical examination, fundal examination and CT scan revealed no primary cause for the visual loss. In this patient the absence of any finding in the optic disc and the retina and the normal CT scan, suggests that the most likely diagnosis is posterior ischemic optic neuropathy. The patient was treated with prednisolone tablet daily and showed mild improvement in vision.

To understand the potential contribution that social support interventions (SSI) can have in mitigating the personal, social and economic costs of tuberculosis (TB) treatment on patients, and improving treatment outcomes, we conducted a literature search to identify psycho-emotional (PE) and socio-economic (SE) interventions provided to TB patients and to assess the effects of these interventions on treatment adherence and treatment outcomes. We searched PubMed and Embase from 1 January 1990-15 March 2015 and abstracts of the Union World Conference on Lung Health from 2010-2014 for studies reporting TB treatment adherence and treatment outcomes following SSI. Twenty-five studies were included in the qualitative analysis; of which eighteen were included in the meta-analysis. Our review and meta-analysis concluded that PE and SE interventions are associated with beneficial effects on TB treatment outcomes. However, the quality of evidence is very low and future well-designed evaluation studies are needed.

The coverage of prevention and treatment strategies for ischemic heart disease and stroke is very low in Ethiopia. In view of Ethiopia’s meager healthcare budget, it is important to identify the most cost-effective interventions for further scale-up. This paper’s objective is to assess cost-effectiveness of prevention and treatment of ischemic heart disease (IHD) and stroke in an Ethiopian setting. Fifteen single interventions and sixteen intervention packages were assessed from a healthcare provider perspective. Combination drug treatment for individuals having >35 % absolute risk of a CVD event in the next 10 years is the most cost-effective intervention. In Ethiopia, the escalating burden of CVD and its risk factors warrants timely action. We have demonstrated that selected CVD intervention packages could be scaled up at a modest budget increase. The level of willingness-to-pay has important implications for interventions’ probability of being cost-effective. The study provides valuable evidence for setting priorities in an essential healthcare package for CVD in Ethiopia.

The tuberculosis(TB) control program of Rwanda is currently phasing in light emitting diode-fluorescent microscopy (LED-FM) as an alternative to Ziehl-Neelsen (ZN) smear microscopy. This, alongside the newly introduced Xpert (Cepheid, Sunnyvale, CA, USA) is expected to improve diagnosis of TB and detection of rifampicin resistance in patients at health facilities. We assessed the accuracy of smear microscopy and the incremental sensitivity of Xpert at TB laboratories in Rwanda. This was a cross-sectional study involving four laboratories performing ZN and four laboratories performing LED-FM microscopy. A total of 96 presumptive pulmonary tuberculosis participants were culture positive for M. tuberculosis. The overall incremental sensitivity of Xpert over smear microscopy was 32.3 %; p 

A total of 1,221 adolescents living with HIV, in eight health facilities in Ethiopia, were screened for TB. The TB incidence rate was 16.32 per 100 PYO during pre-antiretroviral therapy (pre-ART) follow-up but declined to 2.25 per 100 PYO after initiation of ART. IPT use was associated with a significant reduction in TB incidence in the ART cohort, but not in the pre-ART group.

A change of continuation phase tuberculosis (TB) treatment regimen from ethambutol (E) and isoniazid (H) combination for 6 months (6EH) to rifampicin (R) and isoniazid (H) combination for 4 months (4RH) was recommended. However, the effect of the regimen switch in the Ethiopian setting is not known. A comparative cross-sectional study among 790 randomly selected new cases of TB (395 each treated with 4RH and 6EH during the continuation phase) was conducted in nine health centers and one hospital in three zones in southwestern Ethiopia. The switch of continuation phase TB treatment regimen from 6EH to 4RH has brought better treatment outcomes which imply applicability of the recommendation in high prevalent and resource constrained settings. Therefore, it should be maintained and augmented through further studies on its impact among the older, rural residents and HIV positives.

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