Jason Beste

Excellent clinical outcomes and retention in care for adults with HIV-associated Kaposi sarcoma treated with systemic chemotherapy and integrated antiretroviral therapy in rural Malawi

HIV‐associated Kaposi sarcoma (HIV‐KS) is the most common cancer in Malawi. In 2008, the non‐governmental organization, Partners In Health, and the Ministry of Health established the Neno Kaposi Sarcoma Clinic (NKSC) to treat HIV‐KS in rural Neno district. We aimed to evaluate 12‐month clinical outcomes and retention in care for HIV‐KS patients in the NKSC, and to describe our implementation model, which featured protocol‐guided chemotherapy, integrated antiretroviral therapy (ART) and psychosocial support delivered by community health workers.

Assessing and Responding to Palliative Care Needs in Rural Sub-Saharan Africa: Results from a Model Intervention and Situation Analysis in Malawi

Introduction Palliative care is rarely accessible in rural sub-Saharan Africa. Partners In Health and the Malawi government established the Neno Palliative Care Program (NPCP) to provide palliative care in rural Neno district. We conducted a situation analysis to evaluate early NPCP outcomes and better understand palliative care needs, knowledge, and preferences. Methods Employing rapid evaluation methodology, we collected data from 3 sources: 1) chart review of all adult patients from the NPCP’s first 9 months; 2) structured interviews with patients and caregivers; 3) semi-structured interviews with key stakeholders. Results The NPCP enrolled 63 patients in its first 9 months. Frequent diagnoses were cancer (n = 50, 79%) and HIV/AIDS (n = 37 of 61, 61%). Nearly all (n = 31, 84%) patients with HIV/AIDS were on antiretroviral therapy. Providers registered 112 patient encounters, including 22 (20%) home visits. Most (n = 43, 68%) patients had documented pain at baseline, of whom 23 (53%) were treated with morphine. A majority (n = 35, 56%) had ≥1 follow-up encounter. Mean African Palliative Outcome Scale pain score decreased non-significantly between baseline and follow-up (3.0 vs. 2.7, p = 0.5) for patients with baseline pain and complete pain assessment documentation. Providers referred 48 (76%) patients for psychosocial services, including community health worker support, socioeconomic assistance, or both. We interviewed 36 patients referred to the NPCP after the chart review period. Most had cancer (n = 19, 53%) or HIV/AIDS (n = 10, 28%). Patients frequently reported needing income (n = 24, 67%) or food (n = 22, 61%). Stakeholders cited a need to make integrated palliative care widely available. Conclusions We identified a high prevalence of pain and psychosocial needs among patients with serious chronic illnesses in rural Malawi. Early NPCP results suggest that comprehensive palliative care can be provided in rural Africa by integrating disease-modifying treatment and palliative care, linking hospital, clinic, and home-based services, and providing psychosocial support that includes socioeconomic assistance.

Mozambique’s Debt and the International Monetary Fund’s Influence on Poverty, Education, and Health:

For nearly 30 years, Mozambique has been facing austerity measures regulated by the IMF. These austerity measures, grounded in macroeconomic policies, were supposed to lift Mozambique out of poverty, and improve its healthcare and education systems. By taking an in-depth look at the major etiologies of Mozambique’s debt and the conditions which forced the country to accept austerity measures-despite their protests-prior to receiving IMF funding, this paper examines how IMF policies over the past 30 years have affected poverty, health, and the education system. The results of these policies have contributed to Mozambique’s enduring classification as one of the poorest countries in the world. Aside from economic outcomes, Mozambique also has abysmal health and education systems, with one of the lowest life expectancies in Sub-Saharan Africa. It is time to re-evaluate how the current IMF macroeconomic policies negatively affect, health, education and the socioeconomic status of those who live in abject poverty. As short term macroeconomic policies of PARPA have been ineffective at reducing poverty, promoting education and improving health, the IMF should consider using longer term macroeconomic policies which invest in—rather than limit—public services such as health and education.

The 2014–2015 Ebola virus disease outbreak and primary healthcare delivery in Liberia: Time-series analyses for 2010–2016

Background The aim of this study is to estimate the immediate and lasting effects of the 2014–2015 Ebola virus disease (EVD) outbreak on public-sector primary healthcare delivery in Liberia using 7 years of comprehensive routine health information system data. Methods and findings We analyzed 10 key primary healthcare indicators before, during, and after the EVD outbreak using 31,836 facility-month service outputs from 1 January 2010 to 31 December 2016 across a census of 379 public-sector health facilities in Liberia (excluding Montserrado County). All indicators had statistically significant decreases during the first 4 months of the EVD outbreak, with all indicators having their lowest raw mean outputs in August 2014. Decreases in outputs comparing the end of the initial EVD period (September 2014) to May 2014 (pre-EVD) ranged in magnitude from a 67.3% decrease in measles vaccinations (95% CI: −77.9%, −56.8%, p < 0.001) and a 61.4% decrease in artemisinin-based combination therapy (ACT) treatments for malaria (95% CI: −69.0%, −53.8%, p < 0.001) to a 35.2% decrease in first antenatal care (ANC) visits (95% CI: −45.8%, −24.7%, p < 0.001) and a 38.5% decrease in medroxyprogesterone acetate doses (95% CI: −47.6%, −29.5%, p < 0.001). Following the nadir of system outputs in August 2014, all indicators showed statistically significant increases from October 2014 to December 2014. All indicators had significant positive trends during the post-EVD period, with every system output exceeding pre-Ebola forecasted trends for 3 consecutive months by November 2016. Health system outputs lost during and after the EVD outbreak were large and sustained for most indicators. Prior to exceeding pre-EVD forecasted trends for 3 months, we estimate statistically significant cumulative losses of −776,110 clinic visits (95% CI: −1,480,896, −101,357, p = 0.030); −24,449 bacille Calmette–Guérin vaccinations (95% CI: −45,947, −2,020, p = 0.032); −9,129 measles vaccinations (95% CI: −12,312, −5,659, p < 0.001); −17,191 postnatal care (PNC) visits within 6 weeks of birth (95% CI: −28,344, −5,775, p = 0.002); and −101,857 ACT malaria treatments (95% CI: −205,839, −2,139, p = 0.044) due to the EVD outbreak. Other outputs showed statistically significant cumulative losses only through December 2014, including losses of −12,941 first pentavalent vaccinations (95% CI: −20,309, −5,527, p = 0.002); −5,122 institutional births (95% CI: −8,767, −1,234, p = 0.003); and −45,024 acute respiratory infections treated (95% CI: −66,185, −24,019, p < 0.001). Compared to pre-EVD forecasted trends, medroxyprogesterone acetate doses and first ANC visits did not show statistically significant net losses. ACT treatment for malaria was the only indicator with an estimated net increase in system outputs through December 2016, showing an excess of +78,583 outputs (95% CI: −309,417, +450,661, p = 0.634) compared to pre-EVD forecasted trends, although this increase was not statistically significant. However, comparing December 2013 to December 2017, ACT malaria cases have increased 49.2% (95% CI: 33.9%, 64.5%, p < 0.001). Compared to pre-EVD forecasted trends, there remains a statistically significant loss of −15,144 PNC visits within 6 weeks (95% CI: −29,453, −787, p = 0.040) through December 2016. Conclusions The Liberian public-sector primary healthcare system has made strides towards recovery from the 2014–2015 EVD outbreak. All primary healthcare indicators tracked have recovered to pre-EVD levels as of November 2016. Yet, for most indicators, it took more than 1 year to recover to pre-EVD levels. During this time, large losses of essential primary healthcare services occurred compared to what would have been expected had the EVD outbreak not occurred. The disruption of malaria case management during the EVD outbreak may have resulted in increased malaria cases. Large and sustained investments in public-sector primary care health system strengthening are urgently needed for EVD-affected countries.

Treatment outcomes of TB-infected individuals attending public sector primary care clinics in rural Liberia from 2015 to 2017: a retrospective cohort study

In June 2015, Partners in Health (PIH) and the Liberian Ministry of Health began a community health worker (CHW) programme containing food support, reimbursement of transport and social assistance to address gaps in tuberculosis (TB) treatment exacerbated by the 2014‐2015 Ebola virus disease (EVD) epidemic. The purpose of this article was to analyse the performance of routine clinical TB care and the effects of this CHW programme.

Impact of community-based adherence support on treatment outcomes for tuberculosis, leprosy and HIV/AIDS-infected individuals in post-Ebola Liberia

ABSTRACT Background: Partners In Health (PIH) committed to improving health care delivery in Maryland County, Liberia following the Ebola epidemic by employing 71 community health workers (CHWs) to provide treatment support to tuberculosis (TB), HIV and leprosy patients. PIH simultaneously deployed a socioeconomic assistance program with three core components: transportation reimbursement to clinics; food support; and additional social assistance in select cases. Objective: This study aimed to evaluate how a CHW program for community treatment support and addressing socioeconomic barriers to care can impact patient outcomes in a post-conflict and post-epidemic context. Methods: Retrospective observational study utilizing registry data from 513 TB, 447 HIV and 75 leprosy patients at three health facilities in Maryland County, Liberia. Treatment coverage and clinical outcomes for patient cohorts enrolled in the pre-intervention period (January 2015 to June 2015) and the post-intervention period (July 2015 to July 2017) are compared using logistic regression analyses. Results: TB treatment coverage increased from 7.7% pre-intervention to 43.2% (p < 0.001) post-intervention and lost to follow-up (LTFU) rates decreased from 9.5% to 2.1% (p = 0.003). ART treatment coverage increased 3.8 percentage points (p = 0.03), with patient retention improving 63.9% to 86.1% (p < 0.001); a 6.0 percentage point decrease in HIV LTFU was also observed (p = 0.21). Despite an 84.3% treatment success rate observed for leprosy patients, pre-intervention data was largely unavailable and statistical significance could not be reached for any treatment outcomes pre-post intervention. Conclusions: The PIH approach to CHW community treatment support in Liberia demonstrates how, with the right inputs, excellent clinical outcomes are possible even in post-conflict and post-epidemic contexts. Care should be taken to position and support CHWs so that they have the opportunity to succeed, including full integration and recognition within the system, and the addition of clinical system improvements and social supports that are too often dismissed as unsustainable.

“My Heart Die in Me”: Idioms of Distress and the Development of a Screening Tool for Mental Suffering in Southeast Liberia

The integration of culturally salient idioms of distress into mental healthcare delivery is essential for effective screening, diagnosis, and treatment. This study systematically explored idioms, explanatory models, and conceptualizations in Maryland County, Liberia to develop a culturally-resonant screening tool for mental distress. We employed a sequential mixed-methods process of: (1) free-lists and semi-structured interviews (n = 20); patient chart reviews (n = 315); (2) pile-sort exercises, (n = 31); and (3) confirmatory focus group discussions (FGDs); (n = 3) from June to December 2017. Free-lists identified 64 idioms of distress, 36 of which were eliminated because they were poorly understood, stigmatizing, irrelevant, or redundant. The remaining 28 terms were used in pile-sort exercises to visualize the interrelatedness of idioms. Confirmatory FDGs occurred before and after the pile-sort exercise to explain findings. Four categories of idioms resulted, the most substantial of which included terms related to the heart and to the brain/mind. The final screening tool took into account 11 idioms and 6 physical symptoms extracted from patient chart reviews. This study provides the framework for culturally resonant mental healthcare by cataloguing language around mental distress and designing an emic screening tool for validation in a clinical setting.

Delivering comprehensive HIV services across the HIV care continuum: a comparative analysis of survival and progress towards 90-90-90 in rural Malawi

Introduction Partners In Health and the Malawi Ministry of Health collaborate on comprehensive HIV services in Neno, Malawi, featuring community health workers, interventions addressing social determinants of health and health systems strengthening. We conducted an observational study to describe the HIV care continuum in Neno and to compare facility-level HIV outcomes against health facilities nationally. Methods We compared facility-level outcomes in Neno (n=13) with all other districts (n=682) from 2013 to 2015 using mixed-effects linear regression modelling. We selected four outcomes that are practically useful and roughly mapped on to the 90-90-90 targets: facility-based HIV screenings relative to population, new antiretroviral therapy (ART)enrolments relative to population, 1-year survival rates and per cent retained in care at 1 year. Results In 2013, the average number of HIV tests performed, as a per cent of the adult population, was 11.75%, while the average newly enrolled patients was 10.03%. Percent receiving testing increased by 4.23% over 3 years (P<0.001, 95% CI 2.98% to 5.49%), while percent enrolled did not change (P=0.28). These results did not differ between Neno and other districts (P=0.52), despite Neno having a higher proportion of expected patients enrolled. In 2013, the average ART 1-year survival was 80.41% nationally and 91.51% in Neno, which is 11.10% higher (P=0.002, 95% CI 4.13% to 18.07%). One-year survival declined by 1.75% from 2013 to 2015 (P<0.001, 95% CI −2.61% to −0.89%); this was similar in Neno (P=0.83). Facility-level 1-year retention was 85.43% nationally in 2013 (P<0.001, 95% CI 84.2% to 86.62%) and 12.07% higher at 97.50% in Neno (P=0.001, 95% CI 5.08% to19.05%). Retention declined by 2.92% (P<0.001, 95% CI −3.69% to −2.14%) between 2013 and 2015, both nationally and in Neno. Conclusion The Neno HIV programme demonstrated significantly higher survival and retention rates compared with all other districts in Malawi. Incorporating community health workers, strengthening health systems and addressing social determinants of health within the HIV programme may help Malawi and other countries accelerate progress towards 90-90-90.