Dick Chamla

Geographical information system and access to HIV testing, treatment and prevention of mother-to-child transmission in conflict affected Northern Uganda

ObjectivesUsing Geographical Information System (GIS) as a tool to determine access to and gaps in providing HIV counselling and testing (VCT), treatment (ART) and mother-to-child transmission (PMTCT) services in conflict affected northern Uganda.MethodsCross-sectional data on availability and utilization, and geo-coordinates of health facilities providing VCT, PMTCT, and ART were collected in order to determine access. ArcView software produced maps showing locations of facilities and Internally Displaced Population(IDP) camps.FindingsThere were 167 health facilities located inside and outside 132 IDP camps with VCT, PMTCT and ART services provided in 32 (19.2%), 15 (9%) and 10 (6%) facilities respectively. There was uneven availability and utilization of services and resources among districts, camps and health facilities. Inadequate staff and stock-out of essential commodities were found in lower health facility levels. Provision of VCT was 100% of the HSSP II target at health centres IV and hospitals but 28% at HC III. For PMTCT and ART, only 42.9% and 20% of the respective targets were reached at the health centres IV.ConclusionAccess to VCT, PMTCT and ART services was geographically limited due to inadequacy and heterogeneous dispersion of these services among districts and camps. GIS mapping can be effective in identifying service delivery gaps and presenting complex data into simplistic results hence can be recommended in need assessments in conflict settings.

Lessons learnt from coordinating emergency health response during humanitarian crises: a case study of implementation of the health cluster in northern Uganda.

BackgroundBetween the late 1980s and 2000s, Northern Uganda experienced over twenty years of armed conflict between the Government of Uganda and Lord’s Resistance Army. The resulting humanitarian crisis led to displacement of a large percentage of the population and disruption of the health care system of the area. To better coordinate the emergency health response to the crisis, the humanitarian cluster approach was rolled out in Uganda in October 2005. The health, nutrition and HIV/AIDS cluster became fully operational at the national level and in all the conflict affected districts of Acholi and Lango in April 2006. It was phased out in 2011 following the return of the internally displaced persons to their original homelands.ConclusionsThe implementation of the health cluster approach in the northern Uganda and other humanitarian crises in Africa highlights a few issues which are important for strengthening health coordination in similar settings. While health clusters are often welcome during humanitarian crises because they have the possibility to improve health coordination, their potential to create an additional layer of bureaucracy into already complex and bureaucratic humanitarian response architecture is a real concern. Although anecdotal evidence has showed that implementation of the humanitarian reforms and the roll out of the cluster approach did improve humanitarian response in northern Uganda; it is critical to establish a mechanism for measuring the direct impact of health clusters on improving health outcomes, and in reducing morbidity and mortality during humanitarian crisis. Successful implementation of health clusters requires availability of other components of the humanitarian reforms such as predictable funding, strong humanitarian coordination system and strong partnerships. Importantly, successful health clusters require political commitment of national humanitarian and government stakeholders.RecommendationsAlthough leaving health coordination entirely to governments (in crises where they exist) may result in political interference and ineffectiveness of the aid response efforts, the role of government in health coordination cannot be overemphasized. Health clusters must respond to the rapidly changing humanitarian environment and the changing needs of populations affected by humanitarian crises as they evolve from emergency towards transition, early recovery and development.

Integration of HIV in child survival platforms: a novel programmatic pathway towards the 90-90-90 targets

Integration of HIV into child survival platforms is an evolving territory with multiple connotations. Most literature on integration of HIV into other health services focuses on adults; however promising practices for children are emerging. These include the Double Dividend (DD) framework, a new programming approach with dual goal of improving paediatric HIV care and child survival. In this commentary, the authors discuss why integrating HIV testing, treatment and care into child survival platforms is important, as well as its potential to advance progress towards global targets that call for, by 2020, 90% of children living with HIV to know their status, 90% of those diagnosed to be on treatment and 90% of those on treatment to be virally suppressed (90–90–90).

Integration of HIV infant testing into immunization programmes: a systematic review

Background: Integration of HIV infant testing into immunization sessions is one of the strategies designed to increase coverage of early infant diagnosis. Objective: To determine the evidence on the outcomes of such integration. Methods: A systematic review of peer-reviewed and grey literature was undertaken from electronic sources such as MEDLINE, Google Scholar, websites of international agencies, past conferences and ministries of health reports published between year 2002 and 2013. Randomized controlled trials, observational and qualitative studies were searched and those meeting selection criteria were selected and relevant information extracted using structured tool. Statistical pooling was not possible owing to the heterogeneity of the study designs and outcome measures. Results: Of the nine articles which met the selection criteria, none used a randomized controlled design. Of these, five articles measured mother’s acceptability of their infants being tested for HIV during its first pentavalent or DPT vaccination visit, and 89·5–100% accepted. Four articles reported the proportion of mothers who returned for HIV test results, ranging from 56·8% to 86·0%. Increased uptake of HIV testing following integration was confirmed by two articles. Only one study in Tanzania determined the uptake of vaccinations following integration, with urban facilities showing stable or slight increase of monthly vaccine uptake while decreases were observed across the rural sites. In two articles, stigma was perceived by service-providers and mothers as the potential risk following integration, particularly in rural settings. Discussion: Despite the limited number of articles, the findings in this systematic review suggest that HIV testing during immunization clinic visits is acceptable and feasible as a possible model for service delivery. However, the impact on vaccination uptake needs further study.

Patching the gaps towards the 90-90-90 targets: outcomes of Nigerian children receiving antiretroviral treatment who are co-infected with tuberculosis.

Nigeria has a high burden of children living with HIV and tuberculosis (TB). This article examines the magnitude of TB among children receiving antiretroviral treatment (ART), compares their ART outcomes with their non‐TB counterparts and argues that addressing TB among children on ART is critical for achieving the 90–90–90 targets.

Children, HIV, emergencies and Sustainable Development Goals: roadblocks ahead and possible solutions

Climate change, violent conflicts, and HIV/AIDS are linked to multiple Sustainable Development Goals (SDGs) through complex pathways (Figure 1) that include food insecurity, population displacements and migration, disruptions of health and HIV services, and increased incidences of sexual based violence. This interlinkage has the potential to result in high newborn and under five mortality rates and increased burden of HIV, directly affecting SDG 3.2 and 3.3 with children and adolescents being primarily affected. In the past two years, five severe (classified by the UN as L3) emergencies were declared with over 50 million children caught up in major conflicts and other humanitarian crises [1]. Nine of 21 countries deemed “high priority” for HIV by UNAIDS are fragile, conflict-affected, or affected by climaterelated hazards. Today, more than 59 million people are displaced – 22 million more than a decade ago [2], while more than 70 million people in 45 countries are food insecure – 40% more than in 2015. There are more than 1.8 million people living with HIV in emergency settings, with children under the age of 15 years accounting for around 10% [3]. Emergencies have increasingly become protracted (long term) with an average stay in refugee camps reaching 20 years [4] – implying that children could face more HIV risks throughout their adolescence in a refugee camp. The road towards the SDGs is further constrained by rapid population growth with an estimated one billion children likely to live in Africa by mid-century, of which 217 million will be under-five and over one third living in conflict-affected zones [5]. Yet, most humanitarian plans and appeals have not been included in national development strategies, HIV interventions are largely underfunded despite high HIV vulnerability in emergency contexts [6], and most funding opportunities have been short term and focussed on immediate life-saving interventions. Similarly, the opportunities provided by investments in SDGs are not optimal in humanitarian settings. These include medium-long term funding by global financial instruments such as the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) and novel service delivery models, including enabled community systems that have had remarkable impact on improving HIV service delivery and access in countries such as South Africa [7]. These roadblocks, and a divide between humanitarian and development fields have tremendous implications for children and adolescents living with HIV in emergency contexts such that a clear way forward, building on the current global discourse on humanitarian-development nexus, remains critical.

Caregiver satisfaction with paediatric HIV treatment and care in Nigeria and equity implications for children living with HIV

ABSTRACT Caregiver satisfaction has the potential to promote equity for children living with HIV, by influencing health-seeking behaviour. We measured dimensions of caregiver satisfaction with paediatric HIV treatment in Nigeria, and discuss its implications for equity by conducting facility-based exit interviews for caregivers of children receiving antiretroviral therapy in 20 purposively selected facilities within 5 geopolitical zones. Descriptive analysis and factor analysis were performed. Due to the hierarchical nature of the data, multilevel regression modelling was performed to investigate relationships between satisfaction factors and socio-demographic variables. Of 1550 caregivers interviewed, 63% (95% CI: 60.6–65.4) reported being very satisfied overall; however, satisfaction varied in some dimensions: only 55.6% (53.1–58.1) of caregivers could talk privately with health workers, 56.9% (54.4–59.3) reported that queues to see health workers were too long, and 89.9% (88.4–91.4) said that some health workers did not treat patients living with HIV with sufficient respect. Based on factor analysis, two underlying factors, labelled Availability and Attitude, were identified. In multilevel regression, the satisfaction with availability of services correlated with formal employment status (p < .01), whereas caregivers receiving care in private facilities were less likely satisfied with both availability (p < .01) and attitude of health workers (p < .05). State and facility levels influenced attitudes of the health workers (p < .01), but not availability of services. We conclude that high levels of overall satisfaction among caregivers masked dissatisfaction with some aspects of services. The two underlying satisfaction factors are part of access typology critical for closing equity gaps in access to HIV treatment between adults and children, and across socio-economic groups.

Sexual Violence–Related Pregnancy Among Internally Displaced Women in an Internally Displaced Persons Camp in Northeast Nigeria:

Sexual violence is quite common in conflict situations and puts women at risk of unintended pregnancies. In the northeast region of Nigeria with the ongoing insurgency, a substantial number of women are kidnapped and subjected to forced marriages and repeated sexual assaults. This study set out to report on the disclosure and outcomes of sexual violence-related pregnancies (SVRPs) among women liberated from insurgents and relocated to one of largest Internally Displaced Persons (IDP) camps located in Borno State, northeast Nigeria. The clinic records of women with SVRP were reviewed. Forty-seven women with SVRP were identified by the health care providers using a snowball technique to reach as many of the women with SVRP as possible. The mean age of the participants was 15.3 years ( SD = 3.4 years), and all the participants had spent 2 years or more in captivity. Most of the women first disclosed the pregnancy to their peers before disclosure to health care providers or family members. All the women initially requested to have the pregnancy terminated; however, abortion services are not offered in the clinic in line with the countrys restrictive abortion laws. Following counseling and psychosocial support offered in the clinic, 19 (40%) of the women continued with the pregnancy and were delivered in the camp clinic while the remaining 26 women left the camp shortly after disclosure and pregnancy outcomes are not known. SVRP is not uncommon in humanitarian settings with its associated stigma and unwillingness among the survivors to keep the pregnancy. There is a need for further studies to provide more insight into the extent of this problem and help-seeking for SVRPs especially for women in such difficult circumstances to provide needed empirical information to drive advocacy efforts for more comprehensive services.

LESSONS FROM INTEGRATION OF MASS NUTRITION SCREENING DURING COMBINED BOPV/IPV CAMPAIGN IN ARMED CONFLICT SETTINGS, BORNO STATE, NIGERIA

Background: The Boko Haram insurgency has led to severe humanitarian crisis with high levels of malnutrition and polio outbreak in Borno state, Nigeria. In response, outbreak campaigns were conducted that provided an opportunity to integrate nutrition screening during the combined bivalent oral and inactivated polio vaccination (bOPV/IPV) campaign. Methods : This was a cross-sectional study that measured nutrition status of children using a mid-upper arm circumference (MUAC) measurement tape during bOPV/IPV campaign in 4 of the 24 local government areas (LGAs). Data were collected using tally sheets and mobile ODK Collector and bivariate analysis using logistic regression done. Results : Over 1.66 million and 1.47 million children received bOPV and IPV vaccines respectively in 24 LGAs. The coverage of bOPV and IPV in integrated and non-integrated LGAs were above 90% with no statistical difference (OR:0.85; 95%CI: 0.55-1.29; p=0.42). Only 48.5% (351795/725509) of targeted children were screened for malnutrition, of those 3.7% (13050/351795) had severe acute malnutrition (SAM). Less than 47.5% of children with SAM were successfully referred and enrolled in the treatment facilities. Conclusion : Coverage of bOPV and IPV were similar in both integrated and non-integrated LGAs indicating that integrating nutrition screening in polio campaigns is feasible with minimal negative effects. As children with SAM have lower serological protection against polio, provides a strong rationale for inclusion of nutrition interventions in global polio eradication efforts. There are critical lessons that were identified including joint planning, well-defined optimal partnership including military collaborations, and a need for joint monitoring.

Understanding the Influence of Socioeconomic Environment on Paediatric Antiretroviral Treatment Coverage: Towards Closing Treatment Gaps in Sub-Saharan Africa

OBJECTIVE Many sub-Saharan African countries have massively scaled-up their antiretroviral treatment (ART) programmes, but many national programmes still show large gaps in paediatric ART coverage making it challenging to reduce AIDS-related deaths among HIV-infected children. We sought to identify enablers of paediatric ART coverage in Africa by examining the relationship between paediatric ART coverage and socioeconomic parameters measured at the population level so as to accelerate reaching the 90-90-90 targets. METHODS Ecological analyses of paediatric ART coverage and socioeconomic indicators were performed. The data were obtained from the United Nations agencies and Forum for a new World Governance reports for the 21 Global Plan priority countries in Africa with highest burden of mother-to-child HIV transmission. Spearmans correlation and median regression were utilized to explore possible enablers of paediatric ART coverage. RESULTS Factors associated with paediatric ART coverage included adult literacy (r=0.6, p=0.004), effective governance (r=0.6, p=0.003), virology testing by 2 months of age (r=0.9, p=0.001), density of healthcare workers per 10,000 population (r=0.6, p=0.007), and government expenditure on health (r=0.5, p=0.046). The paediatric ART coverage had a significant inverse relationship with the national mother-to-child transmission (MTCT) rate (r=-0.9, p<0.001) and gender inequality index (r=-0.6, p=0.006). Paediatric ART coverage had no relationship with poverty and HIV stigma indices. CONCLUSIONS Low paediatric ART coverage continues to hamper progress towards eliminating AIDS-related deaths in HIV-infected children. Achieving this requires full commitment to a broad range of socioeconomic development goals.