John Rule

Structural Barriers to Timely Initiation of Antiretroviral Treatment in Vietnam: Findings from Six Outpatient Clinics

In Vietnam, premature mortality due to AIDS-related conditions is commonly associated with late initiation to antiretroviral therapy (ART). This study explores reasons for late ART initiation among people living with HIV (PLHIV) from the perspectives of health care providers and PLHIV. The study was undertaken in six clinics from five provinces in Vietnam. Baseline CD4 counts were collected from patient records and grouped into three categories: very late initiators (≤100 cells/mm3 CD4), late initiators (100–200 cells/mm3) and timely initiators (200–350 cells/mm3). Thirty in-depth interviews with patients who started ART and 15 focus group discussions with HIV service providers were conducted and thematic analysis of the content performed. Of 934 patients, 62% started ART very late and 11% initiated timely treatment. The proportion of patients for whom a CD4 count was obtained within six months of their HIV diagnosis ranged from 22% to 72%. The proportion of patients referred to ART clinics by voluntary testing and counselling centres ranged from 1% to 35%. Structural barriers to timely ART initiation were poor linkage between HIV testing and HIV care and treatment services, lack of patient confidentiality and a shortage of HIV/AIDS specialists. If Vietnam’s treatment practice is to align with WHO recommendations then the connection between voluntary counselling and testing service and ART clinics must be improved. Expansion and decentralization of HIV/AIDS services to allow implementation at the community level increased task sharing between doctors and nurses to overcome limited human resources, and improved patient confidentiality are likely to increase timely access to HIV treatment services for more patients.

Strengthening Primary Health Care in Low- and Middle-Income Countries Generating Evidence Through Evaluation

Since the publication of the World Health Report 2008, there has been renewed interest in the potential of primary health care (PHC) to deliver global health policy agendas. The WHO Western Pacific Regional Strategy 2010 states that health systems in low- and middle-income countries (LMICs) can be strengthened using PHC values as core principles. This review article explores the development of an evidence-based approach for assessing the effectiveness of PHC programs and interventions in LMICs. A realist review method was used to investigate whether there is any internationally consistent approach to evaluating PHC. Studies from LMICs using an explicit methodology or framework for measuring PHC effectiveness were collated. Databases of published articles were searched, and a review of gray literature was undertaken to identify relevant reports. The review found no consistent approach for assessing the effectiveness of PHC interventions in LMICs. An innovative approach used in China, which developed a set of core community health facility indicators based on stakeholder input, does show some potential for use in other LMIC contexts.

Peer-based Education and the Integration of HIV and Sexual and Reproductive Health Services for Young People in Vietnam: Evidence from a Project Evaluation

Introduction This paper reports changes in behavioral outcomes related to the use of HIV testing service of a project that employed peer-based education strategies and integration of HIV voluntary counseling and testing (VCT) and Sexual and Reproductive Health (SRH) services targeting young people aged 15–24 across 5 provinces in Vietnam. Methods A pre-test/post-test, non-experimental evaluation design was used. Data were collected from cross-sectional surveys of youth and client exit interviews at project supported SRH clinics conducted at baseline and again at 24 months following implementation. The baseline samples consisted of 813 youth and 399 exit clients. The end line samples included 501 youths and 399 exit clients. Z test was used to assess changes in behavioral outcomes. Results Results show that there was a significant increase (p<0.05) in the percentage of youth who wanted to obtain a HIV test (from 33% to 51%), who had ever had a test (from 7.5% to 15%), and who had a repeat test in the last 12 months (from 54.5% to 67.5%). Exit client interviews found a nearly five-fold increase in the percentage of clients seeking HIV VCT in their current visit (5.0% vs. 24.5%) and almost two-fold increase in the percentage of those having their last test at a project supported clinic (9.3% vs. 17.8%). There were also positive changes in some aspects of youth HIV/AIDS knowledge, attitudes, and risk perceptions. Conclusions This study provides preliminary evidence regarding the benefits of the integration of HIV VCT-SRH services in terms of increased access to HIV services and testing in Vietnam. Benefits of peer-based education regarding increased HIV knowledge were also identified. Further investigations, including experimental studies with assessment of health outcomes and the uptake of HIV testing services, are required to better elucidate the effectiveness and challenges of this intervention model in Vietnam.

The Politics of Space and the Spatialisation of Politics: New Directions for Examining the Connections between Immigration and Contagion

Politics is thoroughly spatialised and space is thoroughly politicised. Whilst there has been a renewed interest in this contention, marked by the so-called “spatial turn” in political science and related sub-disciplinary fields, much of the literature continues to treat “space” as a mere empirical referent, rather than a product of prior political conflict(s) and competing political discourse(s). This article draws upon an emerging body of literature in political science that treats borders as sites where the inextricable links between space and politics crystallise most clearly, bringing their imbrications sharply into focus. It argues that this body of work underscores the constitutive role of the political in the construction of space and consequential notions of who is “inside” and “outside,” and suggests this is codified in the enactment and administration of immigration law(s). Drawing on examples from migration politics in the Australian context, pertaining to the ways in which HIV and tuberculosis are figured, it illustrates how the proximity of the supposedly “infectious” outsider, their perceived literal and moral “contagiousness” and the supposed “threat” they pose to the “wider community,” is constructed. This always involves the invocation of notions of space through the construction of frontiers delineating who is “inside” and “outside.” The article argues that this approach opens up promising avenues of inquiry that seek to explore the connections between immigration and contagion; two enduring tropes in the public and political imagination.

Concomitant medication polypharmacy, interactions and imperfect adherence are common in Australian adults on suppressive antiretroviral therapy

Objectives: We quantified concomitant medication polypharmacy, pharmacokinetic and pharmacodynamic interactions, adverse effects and adherence in Australian adults on effective antiretroviral therapy. Design: Cross-sectional. Methods: Patients recruited into a nationwide cohort and assessed for prevalence and type of concomitant medication (including polypharmacy, defined as ≥5 concomitant medications), pharmacokinetic or pharmacodynamic interactions, potential concomitant medication adverse effects and concomitant medication adherence. Factors associated with concomitant medication polypharmacy and with imperfect adherence were identified using multivariable logistic regression. Results: Of 522 participants, 392 (75%) took a concomitant medication (mostly cardiovascular, nonprescription or antidepressant). Overall, 280 participants (54%) had polypharmacy of concomitant medications and/or a drug interaction or contraindication. Polypharmacy was present in 122 (23%) and independently associated with clinical trial participation, renal impairment, major comorbidity, hospital/general practice-based HIV care (versus sexual health clinic) and benzodiazepine use. Seventeen participants (3%) took at least one concomitant medication contraindicated with their antiretroviral therapy, and 237 (45%) had at least one pharmacokinetic/pharmacodynamic interaction. Concomitant medication use was significantly associated with sleep disturbance and myalgia, and polypharmacy of concomitant medications with diarrhoea, fatigue, myalgia and peripheral neuropathy. Sixty participants (12%) reported imperfect concomitant medication adherence, independently associated with requiring financial support, foregoing necessities for financial reasons, good/very good self-reported general health and at least 1 bed day for illness in the previous 12 months. Conclusion: In a resource-rich setting with universal healthcare access, the majority of this sample took a concomitant medication. Over half had at least one of concomitant medication polypharmacy, pharmacokinetic or pharmacodynamic interaction. Concomitant medication use was associated with several adverse clinical outcomes.

Learning and change in the redesign of a primary health care initiative

Purpose This paper aims to provide an account of learning and change in the redesign of a primary health-care initiative in a large metropolitan city in Australia. Design/methodology/approach The paper is based on research exploring the place and role of learning in the re-making of health professional practices in a major New South Wales Government health reform called HealthOne. The analysis and findings presented here make reference to data drawn from a longitudinal ethnographic study (2011-2014) conducted by an inter-disciplinary team of researchers from the University of Technology Sydney. Socio-material and practice-based approaches for understanding learning are used in working with the data. Findings There were substantial changes in professional practice, especially in the role of the General Practice Liaison Nurse. Changes, and the learning connected to the changes, were dynamically influenced by the macro-context. HealthOne was a reform initiative with a strong focus on achieving health service redesign and a consistent focus on staff developing new ways of thinking and operating. Although learning was often discussed, it was, for the most part, expressed in general terms, and there was a lack of a formal and well-developed approach to learning collectively and individually. Originality/value This research paper will inform future attempts at service redesign in community and primary health contexts and provides a site-specific examination of workplace learning in a context of rapid change.

Human resource challenges in scaling up the response to HIV in Papua New Guinea.

WPSAR Vol 3, No 3, 2012 | doi: 10.5365/wpsar.2012.3.2.006 www.wpro.who.int/wpsar 1 a Human Resources for Health Knowledge Hub, School of Public Health and Community Medicine, Faculty of Medicine, University of New South Wales, Sydney, Australia. b School of Public Health and Community Medicine, Faculty of Medicine, University of New South Wales, Sydney, Australia. Submitted: 1 May 2012; Published: 3 September 2012 doi: 10.5365/wpsar.2012.3.2.006 In Papua New Guinea, an estimated 0.9% of the adult population is infected with HIV, and the spread of the epidemic is geographically heterogeneous.1 The seriousness of the epidemic presents many issues for the government, donors and nongovernmental organizations. One of the greatest challenges of the HIV response is that of human resources. This article highlights human resource issues specific to HIV in Papua New Guinea and raises a series of questions that need to be addressed.

Seeking Seroharmony: Changing Conceptualisations of Serodifference and Serostatus

In this chapter we provide an historical review of how sexual relationships between people infected with HIV and those not infected, which have come to be called serodiscordant, have been conceptualised in the Australian gay community. Changing scientific understandings of HIV transmission and infectiousness are shifting notions of “serodiscordance”, so in this chapter we often refer to “serodifference” instead. Drawing on selected images, including an iconic representation of serodifference by artist and activist David McDiarmid, as well as the community-based health promotion campaigns Opposites Attract, FearLessLiveMore and SERO DISCO 2, we trace the development of the idea of serodifference both to underscore its historical and cultural contingency and to suggest progressive future approaches. We interpret these images as cultural signifiers and historical framers of changing understandings of sexual relationships in the context of HIV among gay men across time in Australia. Using this historical review, we argue that representing serodifference as oppositional and conflicting is outdated. New understandings of HIV transmission have opened up the possibility of new serostatus identities such as “undetectable”. In the context of the lives of gay men, managing serodifference in the future is not just about managing risk, but also about constructing and managing new HIV identities in a world of serodiversity, hopefully leading to greater seroharmony.