Tuberculosis care cascade in Zambia - identifying the gaps in order to improve outcomes: a population-based analysis

ObjectiveTuberculosis (TB) remains a leading cause of morbidity and mortality in Zambia, especially for people living with HIV (PLHIV). We undertook a care cascade analysis to quantify gaps in care and align programme improvement measures with areas of need.DesignRetrospective, population-based analysis.SettingWe derived national-level estimates for each step of the TB care cascade in Zambia. Estimates were informed by WHO incidence estimates, nationally aggregated laboratory and notification registers, and individual-level programme data from four provinces.ParticipantsParticipants included all individuals with active TB disease in Zambia in 2018. We characterised the overall TB cascade and disaggregated by drug susceptibility results and HIV status.ResultsIn 2018, the total burden of TB in Zambia was estimated to be 72 495 (range, 40 495–111 495) cases. Of these, 43 387 (59.8%) accessed TB testing, 40 176 (55.4%) were diagnosed with TB, 36 431 (50.3%) were started on treatment and 32 700 (45.1%) completed treatment. Among all persons with TB lost at any step along the care cascade (n=39 795), 29 108 (73.1%) were lost prior to accessing diagnostic services, 3211 (8.1%) prior to diagnosis, 3745 (9.4%) prior to initiating treatment and 3731 (9.4%) prior to treatment completion. PLHIV were less likely than HIV-negative individuals to successfully complete the care cascade (42.8% vs 50.2%, p<0.001). Among those with rifampicin-resistant TB, there was substantial attrition at each step of the cascade and only 22.8% were estimated to have successfully completed treatment.ConclusionsLosses throughout the care cascade resulted in a large proportion of individuals with TB not completing treatment. Ongoing health systems strengthening and patient-centred engagement strategies are needed at every step of the care cascade; however, scale-up of active case finding strategies is particularly critical to ensure individuals with TB in the population reach initial stages of care. Additionally, a renewed focus on PLHIV and individuals with drug-resistant TB is urgently needed to improve TB-related outcomes in Zambia.

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Trends in HIV care cascade engagement among diagnosed people living with HIV in Ontario, Canada: A retrospective, population-based cohort study

PLoS ONE ◽

10.1371/journal.pone.0210096 ◽

2019 ◽

Vol 14 (1) ◽

pp. e0210096 ◽

Cited By ~ 5

Author(s):

James Wilton ◽

Juan Liu ◽

Ashleigh Sullivan ◽

Beth Rachlis ◽

Alex Marchand-Austin ◽

...

Keyword(s):

Cohort Study ◽

Population Based ◽

Hiv Care ◽

People Living With Hiv ◽

Hiv Care Cascade ◽

Care Cascade ◽

Living With Hiv

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Understanding implementation barriers in the national scale-up of Differentiated ART delivery in Uganda

10.21203/rs.2.18363/v3 ◽

2020 ◽

Author(s):

HENRY ZAKUMUMPA ◽

Joseph Rujumba ◽

Japheth Kwiringira ◽

Cordelia Katureebe ◽

Neil Spicer

Keyword(s):

Supply Chain ◽

Health System ◽

National Level ◽

Scale Up ◽

World Health ◽

Community Factors ◽

Individual Level ◽

Multi Level ◽

Art Delivery ◽

Selection Of

Abstract Background Although Differentiated Service Delivery (DSD) for anti-retroviral therapy (ART) has been rolled-out nationally in several countries since World Health Organization (WHO)’s landmark 2016 guidelines, there is little research evaluating post-implementation outcomes. The objective of this study was to explore patients’ and HIV service managers’ perspectives on barriers to implementation of Differentiated ART delivery in Uganda. Methods We employed a qualitative descriptive design involving 124 participants. Between April and June 2019 we conducted 76 qualitative interviews with national-level HIV program managers (n=18), District Health Team leaders (n=24), representatives of PEPFAR implementing organizations (11), ART clinic in-charges (23) in six purposively selected Uganda districts with a high HIV burden (Kampala, Luwero, Wakiso, Mbale, Budadiri, Bulambuli). Six focus group discussions (48 participants) were held with patients enrolled in DSD models in case-study districts. Data were analyzed by thematic approach as guided by a multi-level analytical framework: Individual-level factors; Health-system factors; Community factors; and Context. Results Our data shows that multiple barriers have been encountered in DSD implementation. Individual-level: Individualized stigma and a fear of detachment from health facilities by stable patients enrolled in community-based models were reported as bottlenecks. Socio-economic status was reported to have an influence on patient selection of DSD models. Health-system: Insufficient training of health workers in DSD delivery and supply chain barriers to multi-month ART dispensing were identified as constraints. Patients perceived current selection of DSD models to be provider-intensive and not sufficiently patient-centred. Community: Community-level stigma and insufficient funding to providers to fully operationalize community drug pick-up points were identified as limitations. Context: Frequent changes in physical addresses among urban clients were reported to impede the running of patient groups of rotating ART refill pick-ups. Conclusion This is one of the first multi-stakeholder evaluations of national DSD implementation in Uganda since initial roll-out in 2017. Multi-level interventions are needed to accelerate further DSD implementation in Uganda from demand-side (addressing HIV-related stigma, community engagement) and supply-side dimensions (strengthening ART supply chain capacities, increasing funding for community models and further DSD program design to improve patient-centeredness).

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Understanding implementation barriers in the national scale-up of Differentiated ART delivery in Uganda

10.21203/rs.2.18363/v4 ◽

2020 ◽

Author(s):

HENRY ZAKUMUMPA ◽

Joseph Rujumba ◽

Japheth Kwiringira ◽

Cordelia Katureebe ◽

Neil Spicer

Keyword(s):

Supply Chain ◽

Health System ◽

National Level ◽

Scale Up ◽

World Health ◽

Community Factors ◽

Individual Level ◽

Multi Level ◽

Art Delivery ◽

Selection Of

Abstract Background Although Differentiated Service Delivery (DSD) for anti-retroviral therapy (ART) has been rolled-out nationally in several countries since World Health Organization (WHO)’s landmark 2016 guidelines, there is little research evaluating post-implementation outcomes. The objective of this study was to explore patients’ and HIV service managers’ perspectives on barriers to implementation of Differentiated ART delivery in Uganda. Methods We employed a qualitative descriptive design involving 124 participants. Between April and June 2019 we conducted 76 qualitative interviews with national-level HIV program managers (n=18), District Health Team leaders (n=24), representatives of PEPFAR implementing organizations (11), ART clinic in-charges (23) in six purposively selected Uganda districts with a high HIV burden (Kampala, Luwero, Wakiso, Mbale, Budadiri, Bulambuli). Six focus group discussions (48 participants) were held with patients enrolled in DSD models in case-study districts. Data were analyzed by thematic approach as guided by a multi-level analytical framework: Individual-level factors; Health-system factors; Community factors; and Context. Results Our data shows that multiple barriers have been encountered in DSD implementation. Individual-level: Individualized stigma and a fear of detachment from health facilities by stable patients enrolled in community-based models were reported as bottlenecks. Socio-economic status was reported to have an influence on patient selection of DSD models. Health-system: Insufficient training of health workers in DSD delivery and supply chain barriers to multi-month ART dispensing were identified as constraints. Patients perceived current selection of DSD models to be provider-intensive and not sufficiently patient-centred. Community: Community-level stigma and insufficient funding to providers to fully operationalize community drug pick-up points were identified as limitations. Context: Frequent changes in physical addresses among urban clients were reported as an impediment to the running of patient groups of rotating ART refill pick-ups. Conclusion This is one of the first multi-stakeholder evaluations of national DSD implementation in Uganda since initial roll-out in 2017. Multi-level interventions are needed to accelerate further DSD implementation in Uganda from demand-side (addressing HIV-related stigma, community engagement) and supply-side dimensions (strengthening ART supply chain capacities, increasing funding for community models and further DSD program design to improve patient-centeredness).

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A quality improvement approach to the reduction of HIV-related stigma and discrimination in healthcare settings

BMJ Global Health ◽

10.1136/bmjgh-2019-001587 ◽

2019 ◽

Vol 4 (3) ◽

pp. e001587 ◽

Cited By ~ 3

Author(s):

Daniel J Ikeda ◽

Laura Nyblade ◽

Kriengkrai Srithanaviboonchai ◽

Bruce D Agins

Keyword(s):

Quality Improvement ◽

Southeast Asia ◽

National Level ◽

Scale Up ◽

Lessons Learned ◽

Routine Practice ◽

People Living With Hiv ◽

Stigma And Discrimination ◽

Healthcare Settings ◽

Related Stigma

HIV-related stigma and discrimination (S&D) in healthcare settings represents a potent barrier to achieving global aims to end the HIV epidemic, particularly in Southeast Asia (Cambodia, Lao People’s Democratic Republic, Thailand and Vietnam). Evidence-based approaches for measuring and reducing S&D in healthcare settings exist, but their incorporation into routine practice remains limited, in part due to a lack of attention to how unique organisational practices—beyond the knowledge and attitudes of individuals—may abet and reinforce S&D. Application of a quality improvement (QI) approach in which facilities leverage routine measurement of S&D among healthcare workers and people living with HIV, team-based learning, root cause analysis, and tests of change offers a novel means through which to address S&D in local contexts and develop interventions to address individual-level and organisation-level drivers of S&D. To support the adoption of a QI approach to S&D reduction, the Southeast Asia Stigma Reduction QI Learning Network was launched with Ministries of Health from Cambodia, Lao PDR, Thailand and Vietnam, to co-develop strategies for implementing QI activities in participating facilities. Since the inception of Network activities in 2017, Ministry-led QI activities to address S&D have been implemented in 83 facilities and 29 provinces across participating countries. Moreover, 27 strategies and interventions have been tested to date and are being evaluated for scale up by participating facilities, spanning multiple drivers and organisational domains. Lessons learned through Network activities offer national-level and facility-level HIV programmes best practices for implementing a QI approach to S&D reduction.

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Understanding implementation barriers in the national scale-up of Differentiated ART delivery in Uganda

10.21203/rs.2.18363/v2 ◽

2020 ◽

Author(s):

HENRY ZAKUMUMPA ◽

Joseph Rujumba ◽

Japheth Kwiringira ◽

Cordelia Katureebe ◽

Neil Spicer

Keyword(s):

Supply Chain ◽

Service Delivery ◽

Health System ◽

National Level ◽

Scale Up ◽

World Health ◽

Community Factors ◽

Individual Level ◽

Multi Level ◽

Selection Of

Abstract Background: Although Differentiated Service Delivery (DSD) for anti-retroviral therapy (ART) has been rolled-out nationally in several countries since World Health Organization (WHO)’s landmark 2016 guidelines, there is little research evaluating post-implementation outcomes. The objective of this study was to explore patients’ and HIV service managers’ perspectives on barriers to implementation of Differentiated ART service delivery in Uganda.Methods: We employed a qualitative descriptive design involving 124 participants. Between April and June 2019 we conducted 76 qualitative interviews with national-level HIV program managers (n=18), District Health Team leaders (n=24), representatives of PEPFAR implementing organizations (11), ART clinic in-charges (23) in six purposively selected Uganda districts with a high HIV burden (Kampala, Luwero, Wakiso, Mbale, Budadiri, Bulambuli). Six focus group discussions (48 participants) were held with patients enrolled in DSD models in case-study districts. Data were analyzed by thematic approach as guided by a multi-level analytical framework: Individual-level factors; Health-system factors; Community factors; and Context.Results: Our data shows that multiple barriers have been encountered in DSD implementation. Individual-level: Individualized stigma and a fear of detachment from health facilities by stable patients enrolled in community-based models were reported as bottlenecks. Socio-economic status was reported to have an influence on patient selection of DSD models. Health-system: Insufficient training of health workers in DSD delivery and supply chain barriers to multi-month ART dispensing were identified as constraints. Patients perceived current selection of DSD models to be provider-intensive and not sufficiently patient-centred. Community: Community-level stigma and insufficient funding to providers to fully operationalize community drug pick-up points were identified as limitations. Context: Frequent changes in physical addresses among urban clients were reported to impede the running of patient groups of rotating ART refill pick-ups. Conclusion: This is one of the first multi-stakeholder evaluations of national DSD implementation in Uganda since initial roll-out in 2017. Multi-level interventions are needed to accelerate further DSD implementation in Uganda from demand-side (addressing HIV-related stigma, community engagement) and supply-side dimensions (strengthening ART supply chain capacities, increasing funding for community models and further DSD program design to improve patient-centeredness).

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Pro-Environmental Behavior in an Aging World: Evidence from 31 Countries

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph18041748 ◽

2021 ◽

Vol 18 (4) ◽

pp. 1748

Author(s):

Yan Wang ◽

Feng Hao ◽

Yunxia Liu

Keyword(s):

Linear Models ◽

Population Change ◽

Population Aging ◽

Environmental Behavior ◽

National Level ◽

The Elderly ◽

Human Beings ◽

Individual Level ◽

Contemporary World ◽

The Individual

Population change and environmental degradation have become two of the most pressing issues for sustainable development in the contemporary world, while the effect of population aging on pro-environmental behavior remains controversial. In this paper, we examine the effects of individual and population aging on pro-environmental behavior through multilevel analyses of cross-national data from 31 countries. Hierarchical linear models with random intercepts are employed to analyze the data. The findings reveal a positive relationship between aging and pro-environmental behavior. At the individual level, older people are more likely to participate in environmental behavior (b = 0.052, p < 0.001), and at the national level, living in a country with a greater share of older persons encourages individuals to behave sustainably (b = 0.023, p < 0.01). We also found that the elderly are more environmentally active in an aging society. The findings imply that the longevity of human beings may offer opportunities for the improvement of the natural environment.

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Quality of life among people living with HIV in England and the Netherlands: a population-based study

The Lancet Regional Health - Europe ◽

10.1016/j.lanepe.2021.100177 ◽

2021 ◽

Vol 8 ◽

pp. 100177

Author(s):

Stephanie Popping ◽

Meaghan Kall ◽

Brooke E. Nichols ◽

Evelien Stempher ◽

Lisbeth Versteegh ◽

...

Keyword(s):

Quality Of Life ◽

The Netherlands ◽

Population Based ◽

People Living With Hiv ◽

Population Based Study ◽

Living With Hiv

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Population (Antibody) Testing for COVID-19—Technical Challenges, Application and Relevance, an English Perspective

Vaccines ◽

10.3390/vaccines9060550 ◽

2021 ◽

Vol 9 (6) ◽

pp. 550

Author(s):

Peter A. C. Maple

Keyword(s):

National Level ◽

Herd Immunity ◽

Population Based ◽

Biological Properties ◽

Limited Extent ◽

Antibody Testing ◽

Serum Samples ◽

Oral Fluids ◽

Antibody Assays ◽

The Uk

In the UK, population virus or antibody testing using virus swabs, serum samples, blood spots or oral fluids has been performed to a limited extent for several diseases including measles, mumps, rubella and hepatitis and HIV. The collection of population-based infection and immunity data is key to the monitoring of disease prevalence and assessing the effectiveness of interventions such as behavioural modifications and vaccination. In particular, the biological properties of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and its interaction with the human host have presented several challenges towards the development of population-based immunity testing. Measuring SARS-CoV-2 immunity requires the development of antibody assays of acceptable sensitivity and specificity which are capable of accurately detecting seroprevalence and differentiating protection from non-protective responses. Now that anti-COVID-19 vaccines are becoming available there is a pressing need to measure vaccine efficacy and the development of herd immunity. The unprecedented impact of the SARS-CoV-2 pandemic in the UK in terms of morbidity, mortality, and economic and social disruption has mobilized a national scientific effort to learn more about this virus. In this article, the challenges of testing for SARS-CoV-2 infection, particularly in relation to population-based immunity testing, will be considered and examples given of relevant national level studies.

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Community-based model for the delivery of antiretroviral therapy in Cambodia: a quasi-experimental study protocol

BMC Infectious Diseases ◽

10.1186/s12879-021-06414-y ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Sovannary Tuot ◽

Alvin Kuo Jing Teo ◽

Kiesha Prem ◽

Pheak Chhoun ◽

Chamroen Pall ◽

...

Keyword(s):

Experimental Study ◽

Antiretroviral Therapy ◽

Scale Up ◽

Economic Evaluations ◽

People Living With Hiv ◽

Cad Model ◽

Community Based ◽

Quasi Experimental ◽

Living With Hiv ◽

Art Delivery

Abstract Background Multi-month dispensing (MMD) is the mainstay mechanism for clinically stable people living with HIV in Cambodia to refill antiretroviral therapy (ART) every 3-6 months. However, less frequent ART dispensing through the community-based ART delivery (CAD) model could further reduce the clients’ and health facilities’ burden. While community-based services have been recognized as an integral component of HIV response in Cambodia, their role and effectiveness in ART delivery have yet to be systematically assessed. This study aims to evaluate the CAD model’s effectiveness on the continuum of care and treatment outcomes for stable people living with HIV in Cambodia. Methods We will conduct this quasi-experimental study in 20 ART clinics across the capital city and nine provinces between May 2021 and April 2023. Study sites were purposively selected based on the availability of implementing partners, the number of people living with HIV each clinic serves, and the accessibility of the clinics. In the intervention arm, approximately 2000 stable people living with HIV will receive ART and services from the CAD model. Another 2000 stable people living with HIV in the control arm will receive MMD—a standard care model for stable people living with HIV. The primary outcomes will be retention in care, viral load suppression, and adherence to ART. The secondary endpoints will include health providers’ work burden, the model’s cost-effectiveness, quality of life, mental health, social support, stigma, and discrimination. We will compare the outcome indicators within each arm at baseline, midline, and endline using descriptive and inferential statistics. We will evaluate the differences between the intervention and control arms using the difference-in-differences method. We will perform economic evaluations to determine if the intervention is cost-effective. Discussion This study will build the evidence base for future implementation and scale-up of CAD model in Cambodia and other similar settings. Furthermore, it will strengthen engagements with community stakeholders and further improve community mobilization, a vital pillar of the Cambodian HIV response. Trial registration ClinicalTrials.gov, NCT04766710. Registered 23 February 2021, Version 1.

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Incidence of diabetes mellitus among people living with and without HIV in British Columbia, Canada between 2001 and 2013: a longitudinal population-based cohort study

BMJ Open ◽

10.1136/bmjopen-2021-048744 ◽

2021 ◽

Vol 11 (5) ◽

pp. e048744

Author(s):

Andreea Bratu ◽

Taylor McLinden ◽

Katherine Kooij ◽

Monica Ye ◽

Jenny Li ◽

...

Keyword(s):

Diabetes Mellitus ◽

British Columbia ◽

Cohort Study ◽

Population Based ◽

Incidence Rates ◽

Trend Test ◽

People Living With Hiv ◽

Age Related ◽

Hiv Serostatus ◽

The Impact

IntroductionPeople living with HIV (PLHIV) are increasingly at risk of age-related comorbidities such as diabetes mellitus (DM). While DM is associated with elevated mortality and morbidity, understanding of DM among PLHIV is limited. We assessed the incidence of DM among people living with and without HIV in British Columbia (BC), Canada, during 2001–2013.MethodsWe used longitudinal data from a population-based cohort study linking clinical data and administrative health data. We included PLHIV who were antiretroviral therapy (ART) naïve at baseline, and 1:5 age-sex-matched persons without HIV. All participants had ≥5 years of historic data pre-baseline and ≥1 year(s) of follow-up. DM was identified using the BC Ministry of Health’s definitions applied to hospitalisation, physician billing and drug dispensation datasets. Incident DM was identified using a 5-year run-in period. In addition to unadjusted incidence rates (IRs), we estimated adjusted incidence rate ratios (IRR) using Poisson regression and assessed annual trends in DM IRs per 1000 person years (PYs) between 2001 and 2013.ResultsA total of 129 PLHIV and 636 individuals without HIV developed DM over 17 529 PYs and 88,672 PYs, respectively. The unadjusted IRs of DM per 1000 PYs were 7.4 (95% CI 6.2 to 8.8) among PLHIV and 7.2 (95% CI 6.6 to 7.8) for individuals without HIV. After adjustment for confounding, HIV serostatus was not associated with DM incidence (adjusted IRR: 1.03, 95% CI 0.83 to 1.27). DM incidence did not increase over time among PLHIV (Kendall trend test: p=0.9369), but it increased among persons without HIV between 2001 and 2013 (p=0.0136).ConclusionsAfter adjustment, HIV serostatus was not associated with incidence of DM, between 2001 and 2013. Future studies should investigate the impact of ART on mitigating the potential risk of DM among PLHIV.

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