Peter Memiah

Prevalence and Risk Factors Associated with Precancerous Cervical Cancer Lesions among HIV-Infected Women in Resource-Limited Settings.

Objective. To assess the prevalence and identified associated risk factors for precancerous cervical cancer lesions among HIV-infected women in resource-limited settings in Kenya. Methods. HIV-infected women attending the ART clinic at the Nazareth Hospital ART clinic between June 2009 and September 2010. Multivariate logistic regression model with odds ratios and 95% confidence intervals (CI) were estimated after controlling for important covariates. Result. A total of 715 women were screened for cervical cancer. The median age of the participants was 40 years (range 18–69 years). The prevalence of precancerous lesions (CINI, CINII, CIN III, ICC) was 191 (26.7%). After controlling for other variables in logistic regression analysis, cervical precancerous lesions were associated with not being on ART therapy; whereby non-ART were 2.21 times more likely to have precancerous lesions than ART patients [(aOR) = 2.21, 95% CI (1.28–3.83)]. Conclusion. The prevalence of precancerous cervical lesions was lower than other similar settings. It is recommended that cancer screening of HIV-infected women should be an established practice. Availability and accessibility of these services can be done through their integration into HIV. Prompt initiation of HAART through an early enrollment into care has an impact on reducing the prevalence and progression of cervical precancerous lesions.

Magnitude and Correlates of Intimate Partner Violence against Women and Its Outcome in Southwest Ethiopia

Background Intimate Partner Violence (IPV) is a major public health problem with serious consequences. This study was conducted to assess the magnitude of IPV in Southwest Ethiopia in predominantly rural community. Methods This community based cross-sectional study was conducted in May, 2009 in Southwest Ethiopia using the World Health Organization core questionnaire to measure violence against women. Trained data collectors interviewed 851 ever-married women. Stata version 10.1 software and SPSS version 12.0.1 for windows were used for data analysis. Result In this study the life time prevalence of sexual or physical partner violence, or both was 64.7% (95%CI: 61.4%–67.9%). The lifetime sexual violence [50.1% (95% CI: 46.7%–53.4%)] was considerably more prevalent than physical violence [41.1% (95%:37.8–44.5)]. A sizable proportion [41.5%(95%CI: 38.2%–44.8%)] of women reported physical or sexual violence, or both, in the past year. Men who were controlling were more likely to be violent against their partner. Conclusion Physical and sexual violence is common among ever-married women in Southwest Ethiopia. Interventions targeting controlling men might help in reducing IPV. Further prospective longitudinal studies among ever-married women are important to identify predictors and to study the dynamics of violence over time.

Can palliative care integrated within HIV outpatient settings improve pain and symptom control in a low-income country? A prospective, longitudinal, controlled intervention evaluation

A high burden of pain, symptoms and other multidimensional problems persist alongside HIV treatment. WHO policy indicates palliative care as essential throughout the disease course. This study aimed to determine whether palliative care delivered from within an existing HIV outpatient setting improves control of pain and symptoms compared to standard care. A prospective, longitudinal controlled design compared patient outcomes at an outpatient facility that introduced palliative care training to clinicians and stocked essential palliative care drugs, to outcomes of a cohort of patients at a similar HIV care facility with no palliative care, in Tanzania. Inclusion criteria were clinically significant pain or symptoms. Patients were followed from baseline fortnightly until week 10 using validated self-report outcome measures. For the primary pain outcome, the required sample size of 120 patients was recruited. Odds of reporting pain reduced significantly more at intervention site (OR=0.60, 95% CI 0.50–0.72) than at control (OR=0.85, 95% CI 0.80–0.90), p=0.001. For secondary outcomes, longitudinal analysis revealed significant difference in slope between intervention and control, respectively: Medical Outcomes Study-HIV (MOS-HIV) physical score 1.46 vs. 0.54, p=0.002; MOS-HIV mental health 1.13 vs. 0.26, p=0.006; and POS total score 0.84 vs. 0.18, p=0.001. Neither baseline CD4 nor antiretroviral therapy (ART) use was associated with outcome scores. These data are the first to report outcomes evaluating integrated HIV outpatient palliative care in the presence of ART. The data offer substantive evidence to underpin the existing WHO clinical guidance that states an essential role for palliative care alongside HIV treatment, regardless of prognosis.

The Effect of Depressive Symptoms and CD4 Count on Adherence to Highly Active Antiretroviral Therapy in Sub-Saharan Africa:

Background: Studies have identified several programmatic and nonprogrammatic indicators that affect adherence to highly active antiretroviral therapy (HAART). Depression has been shown to impact adherence to HAART. This cross-sectional analysis of data collected from Nigeria, Uganda, Zambia, and Tanzania in 2008 examined the relationship between levels of depressive symptoms, clinical progression, and adherence to HAART. Methods: A multinational, multicenter, observational, retrospective cross-sectional evaluation of a population of focus comprised randomly selected patients on HAART. The dependent variable was adherence to HAART. The primary variable of interest to be assessed was patients’ level of depressive symptom score. A multivariable logistic regression model was used to examine the relationship between explanatory variables and adherence to HAART. Results: A total of 2344 patients were recruited for adherence survey. About 70% of the study sample reported having some level of depression. Logistic regression results show that patients who reported, respectively, low, moderate, and high levels of depressive symptoms are 35% (P < .001), 56% (P < .001), and 64% (P < .001) less likely to adhere to HAART than those who reported having no depressive symptoms. At multivariate analysis, adherence to HAART was independently associated with the levels of depressive symptoms, older age, CD4 count >200 cells/mm3, Truvada (tenofovir [TDF]/emtricitabine [FTC])-based regimens, good knowledge about HAART, and longer period on therapy. Conclusions: These results indicate that mental health and clinical parameters are significant factors in determining patients’ adherence to their HAART, which need to be more aggressively addressed as a critical component of care and treatment support.

Palliative care and support for persons with HIV/AIDS in 7 African countries: implementation experience and future priorities.

To combat morbidity and mortality from the worldwide epidemic of the human immunodeficiency virus (HIV), the United States Congress implemented a Presidents Emergency Plan for AIDS Relief (PEPFAR) in 30 resource-limited countries to integrate combination antiretroviral therapy (ART) for both prevention and cure. Over 35% of eligible persons have been successfully treated. Initial legislation cited palliative care as an essential aspect of this plan but overall health strengthening became critical to sustainability of programing and funding priorities shifted to assure staffing for care delivery sites; laboratory and pharmaceutical infrastructure; data collection and reporting; and financial management as individual countries are being encouraged to assume control of in-country funding. Given infrastructure requisites, individual care delivery beyond ART management alone has received minimal funding yet care remains necessary for durable viral suppression and overall quality of life for individuals. Technical assistance staff of one implementing partner representing seven African countries met to clarify domains of palliative care compared with the substituted term “care and support” to understand potential gaps in on-going HIV care. They prioritized care needs as: 1) mental health (depression and other mood disorders); 2) communication skills (age-appropriate disclosure of HIV status); 3) support of care-providers (stress management for sustainability of a skilled HIV workforce); 4) Tied Priorities: symptom management in opportunistic infections; end-of-life care; spiritual history-taking; and 5) Tied Priorities: attention to grief-related needs of patients, their families and staff; and management of HIV co-morbidities. This process can inform health policy as funding transitions to new priorities.

Treatment outcomes for multidrug-resistant tuberculosis under DOTS-Plus: a systematic review and meta-analysis of published studies.

BackgroundAnti-tuberculosis drug resistance is a major public health problem that threatens the progress made in tuberculosis care and control worldwide. Treatment success rates of multidrug-resistant tuberculosis (MDR-TB) is a key issue that cannot be ignored. There is a paucity of evidence that assessed studies on the treatment of MDR-TB, which focus on the effectiveness of the directly observed treatment, short-course (DOTS)-Plus program. Therefore, it is crucial to assess and summarize the overall treatment outcomes for MDR-TB patients enrolled in the DOTS-Plus program in recent years. The purpose of this study was to thus assess and summarize the available evidence for MDR-TB treatment outcomes under DOTS-Plus.MethodsA systematic review and meta-analysis of published literature was conducted. Original studies were identified using the databases MEDLINE®/PubMed®, Hinari, and Google Scholar. Heterogeneity across studies was assessed using the Cochran’s Q test and I2 statistic. Pooled estimates of treatment outcomes were computed using the random effect model.ResultsBased on the 14 observational studies included in the meta-analysis, it was determined that 5 047 patients reported treatment outcomes. Of these, the pooled prevalence, 63.5% (95% CI: 58.4–68.5%) successfully completed full treatment (cured or treatment completed) with a pooled cure rate of 55.6%, whereas 12.6% (95% CI: 9.0–16.2%) of the patients died, 14.2% (95% CI: 11.6–16.8%) defaulted from therapy, and 7.6% (95% CI: 5.6–9.7%) failed therapy. Overall 35.4% (95% CI: 30–40.8%) of patients had unsuccessful treatment outcomes. An unsatisfactorily high percentage 43% (95% CI: 32–54%) of unsuccessful treatment outcomes was observed among patients who were enrolled in standardized treatment regimens.ConclusionThis study revealed that patients with MDR-TB exhibited a very low treatment success rate compared to the World Health Organization 2015 target of at least 75 to 90%. The high default rate observed by conducting this literature review could possibly explain the spread of the MDR-TB strain in various populations. A better treatment success rate was observed among patients in individualized treatment regimens than in standardized ones. Conducting further individual-based meta-analysis is recommended to identify potential factors for defaulting treatment using large-scale and multi-center studies.

Are Female College Students Who are Diagnosed with Depression at Greater Risk of Experiencing Sexual Violence on College Campus

We examined the association between depression and sexual violence among 18–24 year-old female college students using National College Health Assessment survey. Data were collected from a nationally representative sample of 10,541 female students on 33 college campuses. Results showed that female students who were reportedly ever diagnosed with depression were 1.56 times more likely than those who had never been diagnosed with depression to have experienced sexual violence. Female students who had one or more sexual partners currently were found 3.17 times more likely than those who had no sexual partner to have experienced sexual violence; similarly, female students who engaged in binge drinking in the previous two weeks were found about two times more likely than their counterparts to have experienced sexual violence. Depression is a public health issue and must be addressed sooner rather than later in order to reduce and prevent sexual violence on college campuses.

Perceived barriers to the implementation of Isoniazid preventive therapy for people living with HIV in resource constrained settings: a qualitative study.

Introduction Isoniazid preventive therapy (IPT) reduces the risk of active TB. IPT is a key public health intervention for the prevention of TB among people living with HIV and has been recommended as part of a comprehensive HIV and AIDS care strategy. However, its implementation has been very slow and has been impeded by several barriers. Objective: The Objective of the study is to assess the perceived barriers to the implementation of Isoniazid preventive therapy for people living with HIV in resource constrained settings in Addis Ababa, Ethiopia in 2010. Methods A qualitative study using a semi-structured interviewed guide was used for the in-depth interview. A total of 12 key informants including ART Nurse, counselors and coordinators found in four hospitals were included in the interview. Each session of the in-depth interview was recorded via audio tape and detailed notes. The interview was transcribed verbatim. The data was analyzed manually. Results The findings revealed that poor patient adherence was a major factor; with the following issues cited as the reasons for poor adherence; forgetfulness; lack of understanding of condition and patient non- disclosure of HIV sero-status leading to insubstantial social support; underlying mental health issues resulting in missed or irregular patient appointments; weak patient/healthcare provider relationship due to limited quality interaction; lack of patient information, patient empowerment and proper counseling on IPT; and the deficient reinforcement by health officials and other stakeholders on the significance of IPT medication adherence as a critical for positive health outcomes. Conclusion Uptake of the implementation of IPT is facing a challenge in resource limited settings. This recalled provision of training/capacity building and awareness creation mechanism for the health workers, facilitating disclosure and social support for the patients is recommended.

Know your CD4 campaign: 6-year outcomes from a quality improvement initiative to promote earlier initiation of antiretroviral therapy in Tanzania

Background: Late initiation of treatment for illness secondary to the human immunodeficiency virus (HIV) remains a major challenge in developing countries. Despite the World Health Organization (WHO) recommendation that treatment be initiated early in disease management, health providers conducting quality improvement monitoring in one region of Tanzania noted that common management practice relies upon clinical signs of advanced disease alone for initiation of combination antiretroviral therapy (ART). Although Tanzanian National Treatment Guidelines followed standard WHO recommendations, few patients initiated ART based on laboratory parameters. As a potential barrier to optimal patient outcomes, further investigation of this inconsistency led to recognition of challenges reflecting patient, healthcare staff, and laboratory levels that might inhibit the use of CD4 cell counts as the entryway to care. Materials and Methods: Using a quality improvement approach, investigations were pursued for six discrete activities of HIV care delivery with before and after measures of selected indicators. With respect to patient engagement, meetings and informal educational sessions were held to promote understanding of the meaning of and need for CD4 testing. For clinic staff: (1) Qualitative interviews were conducted with providers to understand why laboratory data was not being used and (2) on-site interviews were conducted with laboratory personnel to review beliefs, methods, and practices related to measurement of CD4 cells testing. A large scale local campaign was mounted to (1) educate and empower patients to recognize a need for CD4 information in management of their own care; (2) re-educate and encourage providers to use measured, rather than clinical observation alone to initiate ART; and (3) understand and resolve clinical and laboratory challenges. Based upon findings from the interviews: (1) Meetings with hospital administrations were effected to resolve institutional barriers to using CD4 cell testing. Specific on-site training was initiated for both providers, with regard to use of CD4 cell counts, and nurses, with advanced training to initiate routine CD4 testing. These activities were well received because all staff were able to review unlinked, site-based clinical data to appreciate gaps in a local care. Results: The number of CD4 samples obtained and recorded increased by 114% between May and October 2007 at targeted health facilities. ART enrollment increased by 62% between June and September 2007 without other significant change in care delivery. The median baseline CD4 at enrollment increased from 110 cells/mm 3 in June to 150 cells/mm 3 in September. Overall retention rate was 77% for 13,333 HIV patients enrolled in seven facilities. In September 2013, the cumulative 6-year overall retention rates are 77% for 53,040 patients enrolled in 42 health facilities in the region. Obstacles were addressed and community empowerment techniques used to stimulate change in established clinical behaviors. Conclusion: This Know your CD4 campaign initiative resulted in increased uptake of CD4 testing, treatment initiation and an unanticipated improvement in patient retention. With attention to patient, staff, and laboratory elements in resource-poor settings, decline in immune function and morbidity may be reduced and viral suppression prolonged. Empowering patients to be involved in their own care resulted in better overall adherence with HIV management. Local use of reviewed data can impact overall effectiveness of HIV care delivery. Simple quality improvement approaches impact sustainable change.

Pain Management for Persons Living With HIV Disease Experience With Interprofessional Education in Nigeria

Context: Pain management (PM) has not been routinely incorporated into HIV/AIDS care and treatment in resource-constrained settings. Objectives: We describe training for multidisciplinary teams tasked with integrating care management into HIV clinics to address pain for persons living with HIV in Nigeria. Methods: Education on PM was provided to mixed-disciplinary teams including didactic and iterative sessions following home and hospital visits. Participants identified challenges and performed group problem solving. Results: HIV trainers identified barriers to introducing PM reflecting views of the patient, providers, culture, and the health environment. Implementation strategies included (1) building upon existing relationships; (2) preliminary advocacy; (3) attention to staff needs; and (4) structured data review. Conclusion: Implementing PM in Nigerian HIV clinics requires recognition of cultural beliefs.