Philip Owiti

Integrating tuberculosis and HIV services in rural Kenya: uptake and outcomes.

SETTING Seventeen rural public health facilities in Western Kenya that introduced three models of integrated care for tuberculosis (TB) and human immunodeficiency virus (HIV) patients. OBJECTIVE To assess the uptake and timing of cotrimoxazole preventive therapy (CPT) and antiretroviral treatment (ART) as well as anti-tuberculosis treatment outcomes among HIV-infected TB patients before (March-October 2010) and after (March-October 2012) the introduction of integrated TB-HIV care. DESIGN A before-and-after cohort study using programme data. RESULTS Of 501 HIV-infected TB patients, 357 (71%) were initiated on CPT and 178 (39%) on ART in the period before the introduction of integrated TB-HIV care. Following the integration of services, respectively 316 (98%) and 196 (61%) of 323 HIV-infected individuals were initiated on CPT and on ART (P < 0.001). The median time to CPT and ART initiation dropped from 7 to 2 days and from 42 to 34 days during the pre- and post-integration phases, respectively. Overall TB success rates did not vary with integration or with type of model instituted. CONCLUSION Integration of TB and HIV services enhanced uptake and reduced delay in instituting CPT and ART in rural health facilities. There is a need to increase impetus in these efforts.

A Clinical Decision Support System for Integrating Tuberculosis and HIV Care in Kenya: A Human-Centered Design Approach

With the aim of integrating HIV and tuberculosis care in rural Kenya, a team of researchers, clinicians, and technologists used the human-centered design approach to facilitate design, development, and deployment processes of new patient-specific TB clinical decision support system for medical providers. In Kenya, approximately 1.6 million people are living with HIV and have a 20-times higher risk of dying of tuberculosis. Although tuberculosis prevention and treatment medication is widely available, proven to save lives, and prioritized by the World Health Organization, ensuring that it reaches the most vulnerable communities remains challenging. Human-centered design, used in the fields of industrial design and information technology for decades, is an approach to improving the effectiveness and impact of innovations that has been scarcely used in the health field. Using this approach, our team followed a 3-step process, involving mixed methods assessment to (1) understand the situation through the collection and analysis of site observation sessions and key informant interviews; (2) develop a new clinical decision support system through iterative prototyping, end-user engagement, and usability testing; and, (3) implement and evaluate the system across 24 clinics in rural West Kenya. Through the application of this approach, we found that human-centered design facilitated the process of digital innovation in a complex and resource-constrained context.

Community Health Volunteers in Primary Healthcare in Rural Uganda: Factors Influencing Performance

Introduction Community health volunteers (CHVs) play an integral role in primary healthcare. Several countries rely on CHV programs as a major element in improving access to care and attaining universal health coverage. However, their performance has been heterogeneous and at times context-specific, and influenced by multiple factors. We describe the socio-demographic and workplace characteristics affecting CHVs’ performance in a public health program in rural western Uganda. Methods This was a cross-sectional study based on routine program data of CHVs serving the catchment of Bwindi Community Hospital, Kanungu District, South Western Uganda, in 2014 and 2015. Information was collected on individual socio-demographic and workplace characteristics of the CHVs. To assess their work output, we defined study-specific targets in terms of attendance at monthly CHVs’ meetings with community health nurses, households followed-up and reported, children screened for malnutrition, immunization coverage, and health facility deliveries. Frequencies and proportions are reported for characteristics and outputs and odds ratios for study-specific factors associated with overall performance. Results Of the 508 CHVs, 65% were women, 48% were aged 35 years and below, and 37% took care of more than the recommended 20–30 households. Seventy-eight percent of the CHVs had ≥80% of pregnant women under their care delivering in health units, 71% had ≥95% of the children on schedule for routine immunization, while 27% screened ≥75% of the children under 5 years for malnutrition. More refresher trainings was associated with better overall performance [adjusted odds ratio (aOR): 12.2, 95% confidence interval (CI): 1.6–93.6, P = 0.02] while overseeing more than the recommended 20–30 households reduced overall performance (aOR: 0.6, 95% CI: 0.4–0.9, P = 0.02). Conclusion Being in-charge of more than the recommended households was associated with reduced performance of CHVs, while more refresher trainings were associated with improved performance. If the CHVs are to remain a strategic pillar in universal health coverage, it is imperative to address those factors known to impact on their performance.

Follow-up and programmatic outcomes of HIV-exposed infants registered in a large HIV centre in Lilongwe, Malawi: 2012 - 2014.

To assess follow‐up and programmatic outcomes of HIV‐exposed infants at Martin Preuss Centre, Lilongwe, from 2012 to 2014.

Knockdown and recovery of malaria diagnosis and treatment in Liberia during and after the 2014 Ebola outbreak

Setting: The malaria-endemic country of Liberia, before, during and after the 2014 Ebola outbreak. Objective: To describe the consequences of the Ebola outbreak on Liberias National Malaria Programme and its post-Ebola recovery. Design: A retrospective cross-sectional study using routine countrywide programme data. Results: Malaria caseloads decreased by 47% during the Ebola outbreak and by 11% after, compared to the pre-Ebola period. In those counties most affected by Ebola, a caseload reduction of >20% was sustained for 12 consecutive months, while this lasted for only 4 consecutive months in the counties least affected by Ebola. Linear regression of monthly proportions of confirmed malaria cases-as a proxy indicator of programme performance-over the pre- and post-Ebola periods indicated that the malaria programme could require 26 months after the end of the acute phase of the Ebola outbreak to recover to pre-Ebola levels. Conclusions: The differential persistence of reduced caseloads in the least- and most-affected counties, all of which experienced similar emergency measures, suggest that factors other than Ebola-related security measures played a key role in the programmes reduced performance. Clear guidance on when to abandon the emergency measures after an outbreak may be needed to ensure faster recovery of malaria programme performance.

Did the Ebola Outbreak Disrupt Immunisation Services? A Case Study from Liberia

Setting: All health facilities providing routine immunisation services in Liberia. Objective: To compare the number of routine facility-based and outreach immunisations and measles cases before, during and after the Ebola outbreak. Design: A descriptive cross-sectional study. Results: Immunisation coverage for fully immunised children before the Ebola outbreak was 73%. Immunisation coverage for all antigens declined by half compared to baseline during the outbreak. These findings were similar in facility-based and outreach immunisations. During the outbreak, the proportion of fully immunised children dropped by respectively 58%, 33% and 39% in the most, moderately and least Ebola-affected counties. Immunisation rate of recovery in the post-Ebola period was respectively 82%, 21% and 9% in the most, moderately and least affected counties compared to the Ebola-outbreak period. Outreach immunisation recovered slowly compared to facility-based immunisation. The mean number of measles cases reported per month was 12 pre-Ebola, 16 Ebola and 60 post-Ebola. Conclusion: This study provides insights into the possible impact of an Ebola outbreak on countrywide immunisation. The outbreak weakened a struggling national immunisation programme, and post-outbreak recovery took significant time, which likely contributed to the measles epidemic. Recommendations for the improvement of immunisation services that could limit further preventable epidemics in Liberia and similar contexts at risk for Ebola are provided.

Diagnosis and treatment of TB patients with rifampicin resistance detected using Xpert® MTB/RIF in Zimbabwe

SETTING In Zimbabwe, there are concerns about the management of tuberculosis (TB) patients with rifampicin (RMP) resistance diagnosed using Xpert(®) MTB/RIF. OBJECTIVE To assess linkages between diagnosis and treatment for these patients in Harare and Manicaland provinces in 2014. DESIGN A retrospective cohort study. RESULTS Of 20 329 Xpert assays conducted, 90% were successful, 11% detected Mycobacterium tuberculosis and 4.5% showed RMP resistance. Of 77 patients with RMP-resistant TB diagnosed by Xpert, 70% had samples sent to the reference laboratory for culture and drug susceptibility testing (CDST); 53% of the samples arrived. In 21% the samples showed M. tuberculosis growth, and in 17% the DST results were recorded, all of which confirmed RMP resistance. Of the 77 patients, 34 (44%) never started treatment for multidrug-resistant (MDR) TB, with documented reasons being death, loss to follow-up and incorrect treatment. Of the 43 patients who started MDR-TB treatment, 12 (71%) in Harare and 17 (65%) in Manicaland started within 2 weeks of diagnosis. CONCLUSION Xpert has been rolled out successfully in two Zimbabwe provinces. However, the process of confirming CDST for Xpert-diagnosed RMP-resistant TB works poorly, and many patients are either delayed or never initiate MDR-TB treatment. These shortfalls must be addressed at the programmatic level.

Stockouts of HIV commodities in public health facilities in Kinshasa: Barriers to end HIV

Stockouts of HIV commodities increase the risk of treatment interruption, antiretroviral resistance, treatment failure, morbidity and mortality. The study objective was to assess the magnitude and duration of stockouts of HIV medicines and diagnostic tests in public facilities in Kinshasa, Democratic Republic of the Congo. This was a cross-sectional survey involving visits to facilities and warehouses in April and May 2015. All zonal warehouses, all public facilities with more than 200 patients on antiretroviral treatment (ART) (high-burden facilities) and a purposive sample of facilities with 200 or fewer patients (low-burden facilities) in Kinshasa were selected. We focused on three adult ART formulations, cotrimoxazole tablets, and HIV diagnostic tests. Availability of items was determined by physical check, while stockout duration until the day of the survey visit was verified with stock cards. In case of ART stockouts, we asked the pharmacist in charge what the facility coping strategy was for patients needing those medicines. The study included 28 high-burden facilities and 64 low-burden facilities, together serving around 22000 ART patients. During the study period, a national shortage of the newly introduced first-line regimen Tenofovir-Lamivudine-Efavirenz resulted in stockouts of this regimen in 56% of high-burden and 43% of low-burden facilities, lasting a median of 36 (interquartile range 29–90) and 44 days (interquartile range 24–90) until the day of the survey visit, respectively. Each of the other investigated commodities were found out of stock in at least two low-burden and two high-burden facilities. In 30/41 (73%) of stockout cases, the commodity was absent at the facility but present at the upstream warehouse. In 30/57 (54%) of ART stockout cases, patients did not receive any medicines. In some cases, patients were switched to different ART formulations or regimens. Stockouts of HIV commodities were common in the visited facilities. Introduction of new ART regimens needs additional planning.

Did the 2014 Ebola Outbreak in Liberia Affect HIV Testing, Linkage to Care and ART Initiation?

Setting: Health facilities providing human immunodeficiency virus (HIV) testing, care and treatment in Liberia. Objective: To evaluate individuals aged ⩾15 years who were tested, diagnosed and enrolled into HIV care before (2013), during (2014) and after the Ebola outbreak (2015). Design: A cross-sectional descriptive study. Results: A median of 6930 individuals aged ⩾15 years per county were tested for HIV before the Ebola outbreak; this number declined by 35% (2444/6930) during the outbreak. HIV positivity remained similar before (7028/207 314, 3.4%) and during the outbreak (4146/121 592, 3.5%). During Ebola, HIV testing declined more in highly affected counties (68 035/127 468, 47%) than in counties that were less affected (16 444/23 955, 31%, P < 0.001). Compared to the pre-Ebola period, HIV testing in less-affected counties recovered more quickly during the post-outbreak period, with a 19% increase in testing, while medium and highly affected counties remained at respectively 38% and 48% below pre-outbreak levels. Enrolment for HIV care increased during and after the outbreak compared to the pre-Ebola period. Conclusion: HIV testing and diagnosis were significantly limited during the Ebola outbreak, with the most severe effects occurring in highly affected counties. However, enrolment for HIV care and treatment were resilient throughout the outbreak. Pro-active measures are needed to sustain HIV testing rates in future epidemics.

The Ebola outbreak: effects on HIV reporting, testing and care in Bonthe district, rural Sierra Leone.

Setting: All public health facilities in Bonthe District, rural Sierra Leone. Objective: To compare, in the periods before and during the Ebola virus disease outbreak, 1) the submission and completeness of monthly human immunodeficiency virus (HIV) reports, and 2) the uptake of HIV testing and care for pregnant women and the general population. Design: A cross-sectional study using routine programme data. Results: Of the 627 HIV reports expected in each period, 406 (65%) were submitted in the pre-Ebola period and 376 (60%) during the Ebola outbreak (P = 0.08), of which respectively 318 (78%) and 335 (89%) had complete information (P < 0.001). In the pre-Ebola period, 5012 pregnant women underwent testing for HIV, of whom 25 were HIV-positive, compared to 4254 during the Ebola period, of whom 21 were HIV-positive (P < 0.001). Of those who were HIV-positive, respectively 14 (56%) and 21 (100%) received antiretroviral prophylaxis or antiretroviral therapy (ART) (P < 0.001). In the general population, 5770 persons underwent HIV testing pre-Ebola vs. 3095 in the Ebola period (P < 0.001); of those who tested positive for HIV, respectively 62% (33/53) and 81% (33/41) were started on ART (P = 0.06). Conclusion: There was suboptimal reporting on HIV/acquired immune-deficiency disease syndrome activities before and during the Ebola virus disease outbreak. HIV testing decreased during the Ebola outbreak, while the uptake of prevention of mother-to-child transmission and ART increased. Pre-emptive actions are needed to maintain the levels of HIV testing in any future outbreak.