Moses Bateganya

Impact of support groups for people living with HIV on clinical outcomes: a systematic review of the literature.

Background:Support groups for people living with HIV are integrated into HIV care and treatment programs as a modality for increasing patient literacy and as an intervention to address the psychosocial needs of patients. However, the impact of support groups on key health outcomes has not been fully determined. Methods:We searched electronic databases from January 1995 through May 2014 and reviewed relevant literature on the impact of support groups on mortality, morbidity, retention in HIV care, quality of life (QOL), and ongoing HIV transmission, as well as their cost-effectiveness. Results:Of 1809 citations identified, 20 met the inclusion criteria. One reported on mortality, 7 on morbidity, 5 on retention in care, 7 on QOL, and 7 on ongoing HIV transmission. Eighteen (90%) of the articles reported largely positive results on the impact of support group interventions on key outcomes. Support groups were associated with reduced mortality and morbidity, increased retention in care, and improved QOL. Because of study limitations, the overall quality of evidence was rated as fair for mortality, morbidity, retention in care, and QOL, and poor for HIV transmission. Conclusions:Implementing support groups as an intervention is expected to have a high impact on morbidity and retention in care and a moderate impact on mortality and QOL of people living with HIV. Support groups improve disclosure with potential prevention benefits but the impact on ongoing transmission is uncertain. It is unclear whether this intervention is cost-effective given the paucity of studies in this area.

Predictors of survival after a diagnosis of non-Hodgkin lymphoma in a resource-limited setting: a retrospective study on the impact of HIV infection and its treatment.

Objective:We examined factors associated with survival among patients with newly diagnosed non-Hodgkin lymphoma (NHL) in Uganda. Methods:Information was abstracted from medical records for all NHL patients >13 years of age at the Uganda Cancer Institute between January 2004 and August 2008. Cox proportional hazard models were used to identify predictors of NHL survival. Results:One hundred sixty patients with NHL were identified; 51 (31.9%) were known to be HIV positive. Overall, 154 patients had records sufficient for further analysis. The median person-time observed was 104 days (interquartile range 26-222). Median survival after presentation among those whose mortality status was confirmed was 61 days (interquartile range 25-203). HIV-positive patients receiving antiretroviral therapy had survival rates approximating those of HIV-negative persons, but the adjusted hazard of death was significantly elevated among HIV-positive patients not receiving antiretroviral therapy [adjusted hazard ratio (HR) 8.99, P < 0.001] compared with HIV-negative patients. Both B-symptoms (HR 2.08, P = 0.05) and female gender (HR 1.72, P = 0.05) were associated with higher mortality. Conclusions:In Uganda, overall survival of NHL patients is poor, and predictors of survival differed from those described in resource-rich regions. HIV is a common comorbidity to NHL, and its lack of treatment was among the strongest predictors of mortality. Strategies are needed for optimal management of HIV-infected individuals with cancer in resource-limited settings.

Incentives and barriers to implementing national hospital standards in Uganda

OBJECTIVE The objective of this study was to elicit hospital staffs knowledge, attitudes, and current practices regarding hospital standards and to assess the level of motivation for staff and hospitals to meet new standards. DESIGN This was a qualitative study using in-depth interviews and focus group discussions with staff in four hospitals. There was no intervention. SETTING Four rural public and private not-for-profit hospitals in central Uganda. PARTICIPANTS Medical superintendents and other staff of four hospitals in Uganda who were familiar with the use of standards and had participated in a previous Uganda national accreditation program (Yellow Star). RESULTS All staff expressed strong support for the development and implementation of hospital standards, but also said they would need more recognition and ongoing motivation. They cited the need for technical assistance, funding, and training as the main obstacles. Key areas requiring standards were: infection control, cleanliness and hygiene, infrastructure and medical records. CONCLUSIONS There was strong support for the development and implementation of hospital standards. The main perceived obstacles to the implementation of hospital standards are resource limitations and technical capability. There is a need to develop and implement preliminary standards for hospitals in Uganda.

A telemedicine service for HIV/AIDS physicians working in developing countries

In 2003, the Institute of Tropical Medicine (ITM) in Antwerp set up an Internet-based decision support service to assist health-care workers in the management of difficult HIV/AIDS cases. This service is available to physicians working in resource-limited settings. Between April 2003 and December 2009, the telemedicine service received 1058 queries, from more than 40 countries, mostly resource-constrained. In the first six years there were 952 queries, of which 459 (49%) were posted on the web-based telemedicine discussion forum and the rest sent by email. All queries were handled by a co-ordinator who forwarded them to a network of specialists, based at the ITM and at other institutions. The average time to provide a first reply was 24 hours. Almost half of the queries received in the first six years (n = 466) were related to the use of antiretroviral medications. The response rate to a user questionnaire was 19% (73 questionnaires returned out of 387 delivered): half of those (n = 37) came from active users and the remainder (n = 36) from clinicians who had never used the system. The user survey showed that telemedicine advice was valuable in the management of specific cases, and significantly influenced the way that clinicians managed other similar cases subsequently. Nonetheless, there was a declining trend in the rate of use of the service.

The Impact of HIV Care and Support Interventions on Key Outcomes in Low and Middle-Income Countries: A Literature Review. Introduction

BACKGROUND As of December 2013, an estimated 35 million persons were living with HIV; approximately two thirds of these people were living in sub-Saharan Africa. The response to the HIV pandemic in Africa and in other lowand middleincome regions of the world has consisted of a variety of bilateral and multilateral support from donor agencies, and local support from countries. A majority of the support has been directed toward HIV care and treatment. Accordingly, the past 10 years have witnessed a remarkable increase in the number of HIV-infected persons receiving antiretroviral therapy in lowand middle-income countries (LMIC)—from 300,000 in 2003 to 11.7 million in 2013. Expanded access to ART in these countries has led to significant increases in the proportion of eligible persons enrolled on ART, reaching coverage rates as high as 61% globally based on the World Health Organization (WHO) treatment guidelines’ eligibility criteria of CD4 ,350 cells per microliter in 2012. In 2013, WHO revised its guidelines to indicate eligibility at CD4 ,500 cells per microliter; under these criteria, only 34% of eligible persons were on ART in 2013. Nevertheless, these changes in access to ART were estimated to have averted 4.2 million deaths through 2012. HIV prevention, care, and treatment programs in LMIC have been supported by a variety of sources, including over US

Barriers to and acceptability of provider-initiated HIV testing and counselling and adopting HIV-prevention behaviours in rural Uganda: A qualitative study:

41 billion through the US President’s Emergency Plan for AIDS Relief (PEPFAR) from 2004 to 2013, in addition to nearly US

The impact of social services interventions in developing countries: a review of the evidence of impact on clinical outcomes in people living with HIV.

9 billion in PEPFAR funds to support HIV, tuberculosis (TB), and malaria programs through the Global Fund to Fight AIDS, Tuberculosis and Malaria during this period. PEPFAR programs are coordinated by the US Department of State’s Office of the US Global AIDS Coordinator and Health Diplomacy (OGAC) in Washington, DC and concentrated in 36 countries and regions in sub-Saharan Africa, South and Central Asia, Eastern Europe, Central America, and the Caribbean. Oversight, accountability, and support of incountry PEPFAR programs are accomplished through the US government (USG) interagency teams. PEPFAR “country operating plans” and budgets are submitted annually for review at OGAC with ultimate approval by the US Congress. In HIV care and treatment, PEPFAR supports a range of care and support services besides ART including clinical (eg, monitoring to determine eligibility for ART and prevention and treatment of opportunistic infections) and nonclinical (eg, psychological, social, and preventive) services. Programming implemented with PEPFAR support in each country is determined through a dialog between the USG and host governments. In 2013, the US Institute of Medicine (IOM), in its evaluation of PEPFAR, called attention to the wide range of non-ART care and support services supported by PEPFAR, and challenged PEPFAR to assess the impact of these services on key outcomes. The IOM recommended prioritizing care and support services that should be funded in PEPFAR country portfolios based on their impact—a recommendation consistent with the current focus of PEPFAR on “accountability, transparency, and impact.” In response, the From the *Division of Global HIV/AIDS, Center for Global Health, Centers for Disease Control and Prevention (CDC), Atlanta, GA; †US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD; ‡Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD; §Division of Epidemiology, Analysis, and Library Services, Center for Surveillance, Epidemiology, and Laboratory Services, CDC, Atlanta, GA; kDepartment of State, Office of the US Global AIDS Coordinator and Health Diplomacy, Washington, DC; and ¶United States Agency for International Development, Washington, DC. Supported by the US President’s Emergency Plan for AIDS Relief (PEPFAR) through the US Department of State, Office of the US Global AIDS Coordinator and Health Diplomacy, the US Centers for Disease Control and Prevention, and the US Agency for International Development, and also supported through a cooperative agreement (W81XWH-07-2-0067) between The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. and the US Department of Defense. The authors have no conflicts of interest to disclose. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jaids.com). The findings and conclusions in this article are those of the authors and should not be construed to represent the positions of the US Department of State’s Office of the US Global AIDS Coordinator and Health Diplomacy, the US Centers for Disease Control and Prevention, the US Agency for International Development, the US Department of Defense, or the US Federal Government. Correspondence to: Jonathan E. Kaplan, MD, Division of Global HIV/AIDS, Mailstop E-04, Centers for Disease Control and Prevention, 1600 Clifton Road NE, Atlanta, GA 30333 (e-mail: jxk2@cdc.gov). Copyright

Developing hospital accreditation standards in Uganda

In Uganda, a nationwide scale-up of provider-initiated HIV testing and counselling presents an opportunity to deliver HIV-prevention services to large numbers of people. In a rural Ugandan hospital, focus group discussions and key informant interviews were conducted with outpatients receiving provider-initiated HIV testing and counselling and staff to explore the HIV-prevention information, motivation and behavioural skills strengths and weaknesses, and community-level and structural barriers to provider-initiated HIV testing and counselling acceptability and HIV prevention among this population. Strengths and weakness occurred at all levels, and results suggest brief client-centred interventions during provider-initiated HIV testing and counselling may be an effective approach to increase prevention behaviours in outpatient settings.

Prioritizing HIV care and support interventions-moving from evidence to policy.

Background:Social service interventions have been implemented in many countries to help people living with HIV (PLHIV) and household members cope with economic burden as a result of reduced earning or increased spending on health care. However, the evidence for specific interventions—economic strengthening and legal services—on key health outcomes has not been appraised. Methods:We searched electronic databases from January 1995 to May 2014 and reviewed relevant literature from resource-limited settings on the impact of social service interventions on mortality, morbidity, retention in HIV care, quality of life, and ongoing HIV transmission and their cost-effectiveness. Results:Of 1685 citations, 8 articles reported the health impact of economic strengthening interventions among PLHIV in resource-limited settings. None reported on legal services. Six of the 8 studies were conducted in sub-Saharan Africa: 1 reported on all 5 outcomes and 2 reported on 4 and 2 outcomes, respectively. The remaining 5 reported on 1 outcome each. Seven studies reported on quality of life. Although all studies reported some association between economic strengthening interventions and HIV care outcomes, the quality of evidence was rated fair or poor because studies were of low research rigor (observational or qualitative), had small sample size, or had other limitations. The expected impact of economic strengthening interventions was rated as high for quality of life but uncertain for all the other outcomes. Conclusions:Implementation of economic strengthening interventions is expected to have a high impact on the quality of life for PLHIV but uncertain impact on mortality, morbidity, retention in care, and HIV transmission. More rigorous research is needed to explore the impact of more targeted intervention components on health outcomes.

Strategies for delivery of HIV test results in population-based HIV seroprevalence surveys: a review of the evidence

BACKGROUND Whereas accreditation is widely used as a tool to improve quality of healthcare in the developed world, it is a concept not well adapted in most developing countries for a host of reasons, including insufficient incentives, insufficient training and a shortage of human and material resources. The purpose of this paper is to describe refining use and outcomes of a self-assessment hospital accreditation tool developed for a resource-limited context. METHODS We invited 60 stakeholders to review a set of standards (from which a self-assessment tool was developed), and subsequently refined them to include 485 standards in 7 domains. We then invited 60 hospitals to test them. A study team traveled to each of the 40 hospitals that agreed to participate providing training and debrief the self-assessment. The study was completed in 8 weeks. RESULTS Hospital self-assessments revealed hospitals were remarkably open to frank rating of their performance and willing to rank all 485 measures. Good performance was measured in outreach programs, availability of some types of equipment and running water, 24-h staff calls systems, clinical guidelines and waste segregation. Poor performance was measured in care for the vulnerable, staff living quarters, physician performance reviews, patient satisfaction surveys and sterilizing equipment. CONCLUSION We have demonstrated the feasibility of a self-assessment approach to hospital standards in low-income country setting. This low-cost approach may be used as a good precursor to establishing a national accreditation body, as indicated by the Ministrys efforts to take the next steps. Copyright