Stephen Bertel Squire

Effect of Optional Home Initiation of HIV Care Following HIV Self-testing on Antiretroviral Therapy Initiation Among Adults in Malawi: A Randomized Clinical Trial

IMPORTANCE Self-testing for HIV infection may contribute to early diagnosis of HIV, but without necessarily increasing antiretroviral therapy (ART) initiation. OBJECTIVE To investigate whether offering optional home initiation of HIV care after HIV self-testing might increase demand for ART initiation, compared with HIV self-testing accompanied by facility-based services only. DESIGN, SETTING, AND PARTICIPANTS Cluster randomized trial conducted in Blantyre, Malawi, between January 30 and November 5, 2012, using restricted 1:1 randomization of 14 community health worker catchment areas. Participants were all adult (≥16 years) residents (n = 16,660) who received access to home HIV self-testing through resident volunteers. This was a second-stage randomization of clusters allocated to the HIV self-testing group of a parent trial. INTERVENTIONS Clusters were randomly allocated to facility-based care or optional home initiation of HIV care (including 2 weeks of ART if eligible) for participants reporting positive HIV self-test results. MAIN OUTCOMES AND MEASURES The preplanned primary outcome compared between groups the proportion of all adult residents who initiated ART within the first 6 months of HIV self-testing availability. Secondary outcomes were uptake of HIV self-testing, reporting of positive HIV self-test results, and rates of loss from ART at 6 months. RESULTS A significantly greater proportion of adults in the home group initiated ART (181/8194, 2.2%) compared with the facility group (63/8466, 0.7%; risk ratio [RR], 2.94, 95% CI, 2.10-4.12; P < .001). Uptake of HIV self-testing was high in both the home (5287/8194, 64.9%) and facility groups (4433/8466, 52.7%; RR, 1.23; 95% CI, 0.96-1.58; P = .10). Significantly more adults reported positive HIV self-test results in the home group (490/8194 [6.0%] vs the facility group, 278/8466 [3.3%]; RR, 1.86; 95% CI, 1.16-2.97; P = .006). After 6 months, 52 of 181 ART initiators (28.7%) and 15 of 63 ART initiators (23.8%) in the home and facility groups, respectively, were lost from ART (adjusted incidence rate ratio, 1.18; 95% CI, 0.62-2.25, P = .57). CONCLUSIONS AND RELEVANCE Among Malawian adults offered HIV self-testing, optional home initiation of care compared with standard HIV care resulted in a significant increase in the proportion of adults initiating ART. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01414413.

A Multi-Country Non-Inferiority Cluster Randomized Trial of Frontloaded Smear Microscopy for the Diagnosis of Pulmonary Tuberculosis

Luis Cuevas and colleagues report findings from a multicenter diagnostic clinical trial in tuberculosis, showing that the sensitivity and specificity of a “front-loaded” diagnostic scheme is not inferior to that of a standard diagnostic scheme.

LED Fluorescence Microscopy for the Diagnosis of Pulmonary Tuberculosis: A Multi-Country Cross-Sectional Evaluation

This study, nested within a clinical trial, by Luis Cuevas and colleagues finds that LED-FM microscopy has higher sensitivity but lower specificity than Zn microscopy for detecting tuberculosis in sputum samples.

Suboptimal patterns of provider initiated HIV testing and counselling, antiretroviral therapy eligibility assessment and referral in primary health clinic attendees in Blantyre, Malawi*

Objective:  To understand reasons for suboptimal and delayed uptake of antiretroviral therapy (ART) by describing the patterns of HIV testing and counselling (HTC) and outcomes of ART eligibility assessments in primary clinic attendees.

Barriers and facilitators to linkage to ART in primary care: a qualitative study of patients and providers in Blantyre, Malawi

Linkage from HIV testing and counselling (HTC) to initiation of antiretroviral therapy (ART) is suboptimal in many national programmes in sub‐Saharan Africa, leading to delayed initiation of ART and increased risk of death. Reasons for failure of linkage are poorly understood.

Towards building equitable health systems in Sub-Saharan Africa: lessons from case studies on operational research

BackgroundPublished practical examples of how to bridge gaps between research, policy and practice in health systems research in Sub Saharan Africa are scarce. The aim of our study was to use a case study approach to analyse how and why different operational health research projects in Africa have contributed to health systems strengthening and promoted equity in health service provision.MethodsUsing case studies we have collated and analysed practical examples of operational research projects on health in Sub-Saharan Africa which demonstrate how the links between research, policy and action can be strengthened to build effective and pro-poor health systems. To ensure rigour, we selected the case studies using pre-defined criteria, mapped their characteristics systematically using a case study development framework, and analysed the research impact process of each case study using the RAPID framework for research-policy links. This process enabled analysis of common themes, successes and weaknesses.Results3 operational research projects met our case study criteria: HIV counselling and testing services in Kenya; provision of TB services in grocery stores in Malawi; and community diagnostics for anaemia, TB and malaria in Nigeria. Political context and external influences: in each case study context there was a need for new knowledge and approaches to meet policy requirements for equitable service delivery. Collaboration between researchers and key policy players began at the inception of operational research cycles. Links: critical in these operational research projects was the development of partnerships for capacity building to support new services or new players in service delivery. Evidence: evidence was used to promote policy dialogue around equity in different ways throughout the research cycle, such as in determining the topic area and in development of indicators.ConclusionBuilding equitable health systems means considering equity at different stages of the research cycle. Partnerships for capacity building promotes demand, delivery and uptake of research. Links with those who use and benefit from research, such as communities, service providers and policy makers, contribute to the timeliness and relevance of the research agenda and a receptive research-policy-practice interface. Our study highlights the need to advocate for a global research culture that values and funds these multiple levels of engagement.

Strengthening "DOTS" through community care for tuberculosis.

World wide, more adult deaths are attributed to Mycobacterium tuberculosis than to any other infectious agent, and without improvements in control 30 million people are expected to die from tuberculosis in 1990-2000.1 In sub-Saharan Africa alone about 1.5 million new cases arise each year. How can we care for all these patients? We have known for almost 40 years that most patients with tuberculosis can be treated in the community without increasing the risk of their infecting contacts. Indeed, the strategy of supervised outpatient therapy was developed in poor settings.2 Nevertheless, until recently, the World Health Organisation and the International Union Against Tuberculosis and Lung Disease advocated a strategy of admission to hospital for at least the first two months of treatment, primarily as a way of ensuring adherence. Indeed hospitalisation, together with the other elements of the control programme, was highly effective.3 However, the epidemic of tuberculosis associated with HIV in sub-Saharan Africa is such that hospital based care is no longer feasible. The caseload in Malawi increased from 5334 in 1985 to 19 195 in 1995 (Malawi …

Patient costs during tuberculosis treatment in Bangladesh and Tanzania: the potential of shorter regimens

OBJECTIVE To estimate the costs incurred by patients during the intensive and continuation phases of the current 6-month tuberculosis (TB) regimen in Bangladesh and Tanzania, and thus identify potential benefits to patients of a shorter, 4-month treatment regimen. DESIGN The validated Stop TB patient cost questionnaire was adapted and used in interviews with 190 patients in the continuation phase of treatment with current regimens. RESULTS In both countries, overall patient costs were lower during 2 months of the continuation phase (US

Acceptability and Effectiveness of the Storekeeper-Based TB Referral System for TB Suspects in Sub-Districts of Lilongwe in Malawi

74 in Tanzania and US

The Impact of a Line Probe Assay Based Diagnostic Algorithm on Time to Treatment Initiation and Treatment Outcomes for Multidrug Resistant TB Patients in Arkhangelsk Region, Russia

56 in Bangladesh) than during the 2 months of the intensive phase of treatment (US