Analysis of Recurrent Events with Associated Informative Censoring: Application to HIV Data

In this study, we adapt a Cox-based model for recurrent events; the Prentice, Williams and Peterson Total -Time (PWP-TT) that has largely, been used under the assumption of non-informative censoring and evaluate it under an informative censoring setting. Empirical evaluation was undertaken with the aid of the semi-parametric framework for recurrent events suggested by Huang [1] and implemented in R Studio software. For validation we used data from a typical HIV care setting in Kenya. Of the three models under consideration; the standard Cox Model had gender hazard ratio (HR) of 0.66 (p-value=0.165), Andersen-Gill had HR 0.46 (with borderline p-value=0.054) and extended PWP TT had HR 0.22 (p-value=0.006). The PWP-TT model performed better as compared to other models under informative setting. In terms of risk factors under informative setting, LTFU due to stigma; gender [base=Male] had HR 0.544 (p-value =0.002), age [base is < 37] had HR 0.772 (p-value=0.008), ART regimen [base= First line] had HR 0.518 (p-value= 0.233) and differentiated care model (Base=not on DCM) had HR 0.77(p-value=0.036). In conclusion, in spite of the multiple interventions designed to address incidences of LTFU among HIV patients, within-person cases of LTFU are usually common and recurrent in nature, with the present likelihood of a person getting LTFU influenced by previous occurrences and therefore informative censoring should be checked.

Evaluation of implementation and effectiveness of digital adherence technology with differentiated care to support tuberculosis treatment adherence and improve treatment outcomes in Ethiopia: a study protocol for a cluster randomised trial

Background Digital adherence technologies (DATs) are recommended to support patient-centred, differentiated care to improve tuberculosis (TB) treatment outcomes, but evidence that such technologies improve adherence is limited. We aim to implement and evaluate the effectiveness of smart pillboxes and medication labels linked to an adherence data platform, to create a differentiated care response to patient adherence and improve TB care among adult pulmonary TB participants. Our study is part of the Adherence Support Coalition to End TB (ASCENT) project in Ethiopia. Methods/Design We will conduct a pragmatic three-arm cluster-randomised trial with 78 health facilities in two regions in Ethiopia. Facilities are randomised (1:1:1) to either of the two intervention arms or standard of care. Adults aged ≥ 18 years with drug-sensitive (DS) pulmonary TB are enrolled over 12 months and followed-up for 12 months after treatment initiation. Participants in facilities randomised to either of the two intervention arms are offered a DAT linked to the web-based ASCENT adherence platform for daily adherence monitoring and differentiated response to patient adherence for those who have missed doses. Participants at standard of care facilities receive routine care. For those that had bacteriologically confirmed TB at treatment initiation and can produce sputum without induction, sputum culture will be performed approximately 6 months after the end of treatment to measure disease recurrence. The primary endpoint is a composite unfavourable outcome measured over 12 months from TB treatment initiation defined as either poor end of treatment outcome (lost to follow-up, death, or treatment failure) or treatment recurrence measured 6 months after the scheduled end of treatment. This study will also evaluate the effectiveness, feasibility, and cost-effectiveness of DAT systems for DS-TB patients. Discussion This trial will evaluate the impact and contextual factors of medication label and smart pillbox with a differentiated response to patient care, among adult pulmonary DS-TB participants in Ethiopia. If successful, this evaluation will generate valuable evidence via a shared evaluation framework for optimal use and scale-up. Trial registration: Pan African Clinical Trials Registry PACTR202008776694999, https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=12241, registered on August 11, 2020.

A Atuação do Pedagogo dentro do Ambiente Hospitalar: O Papel do Pedagogo além da Sala de Aula / The Performance of the Pedagogue within the Hospital Environment: The Role of the Pedagogue beyond the Classroom

Resumo: A criança e o adolescente que permanecem hospitalizados por muito tempo, necessitam do acompanhamento de um pedagogo que atue no hospital em conjunto com outros profissionais de saúde, buscando garantir que o paciente melhore clinicamente, através de atividades desenvolvidas pelo pedagogo, como também continue a desenvolver a aprendizagem. Assim, o artigo se fundamenta na importância de desmistificar a ideia de que a atuação do pedagogo se limita apenas a sala de aula, sendo perceptível que há outros campos de atuação, como por exemplo, o ambiente hospitalar, foco da pesquisa. O objetivo do trabalho é analisar como o pedagogo pode atuar no campo hospitalar. A metodologia adotada para a realização do trabalho se deu através de uma pesquisa bibliográfica. Os resultados encontrados apontaram que a Pedagogia Hospitalar corresponde ao atendimento diferenciado cujo objetivo é dar continuidade ao ensino escolar dentro dos hospitais, em que é importante levar em consideração os conhecimentos que o paciente possui, continuando assim o trabalho que precisou ser interrompido devido á internação. Nesse contexto, o atendimento hospitalar aborda aspectos psicológicos e fisiológicos de cada paciente, em que se pretende elevar a autoestima deles, permitindo-lhes a oportunidade de continuar o processo ensino e aprendizagem mesmo diante do afastamento da escola. Diante do exposto, foi possível concluir que o atendimento hospitalar precisa ser ofertado como garantia dos direitos à saúde e educação, e por isso deve haver a preocupação em oferecer os meios para que o pedagogo hospitalar possa atuar de maneira responsável e tranquila. É válido ressaltar que este profissional carece ter capacidade e autonomia para elaborar suas atividades a partir da análise da realidade de cada paciente, a fim de criar planejamentos diferenciados que contemple a aprendizagem individual deles, levando em consideração as condições clínicas de cada um, faixa etária, ano escolar e seus saberes já adquiridos, buscando desta forma o melhor para o paciente, tanto na saúde como na educação. Palavras-Chave: Pedagogia; Atendimento Hospitalar; Saúde e Educação. Abstract: Children and adolescents who remain hospitalized for a long time need to be monitored by an educator who works in the hospital together with other health professionals, seeking to ensure that the patient improves clinically, through activities developed by the educator, as well as continuing to develop the Learn. Thus, the article is based on the importance of demystifying the idea that the pedagogue's role is limited to the classroom, and it is noticeable that there are other fields of action, such as the hospital environment, which are the focus of the research. The objective of the work is to analyze how the pedagogue can act in the hospital field. The methodology adopted to carry out the work was through bibliographical research. The results showed that Hospital Pedagogy corresponds to differentiated care whose objective is to continue school education within hospitals, in which it is important to take into account the knowledge that the patient has, thus continuing the work that had to be interrupted due to hospitalization. In this context, hospital care addresses the psychological and physiological aspects of each patient, aiming to raise their self-esteem, allowing them the opportunity to continue the teaching and learning process even when they leave school. Given the above, it was possible to conclude that hospital care needs to be offered as a guarantee of the rights to health and education, and therefore there must be a concern to offer the means so that the hospital educator can act responsibly and calmly. It is worth noting that these professional lacks the capacity and autonomy to develop their activities based on the analysis of the reality of each patient, in order to create differentiated plans that include their individual learning, taking into account the clinical conditions of each one, age group, school year and their knowledge already acquired, thus seeking the best for the patient, both in health and in education.Keywords: Pedagogy; Hospital Care; Health and Education.

Moving towards Integrated and Personalized Care in Parkinson’s Disease: A Framework Proposal for Training Parkinson Nurses

Delivering healthcare to people living with Parkinson’s disease (PD) may be challenging in face of differentiated care needs during a PD journey and a growing complexity. In this regard, integrative care models may foster flexible solutions on patients’ care needs whereas Parkinson Nurses (PN) may be pivotal facilitators. However, at present hardly any training opportunities tailored to the care priorities of PD-patients are to be found for nurses. Following a conceptual approach, this article aims at setting a framework for training PN by reviewing existing literature on care priorities for PD. As a result, six prerequisites were formulated concerning a framework for training PN. The proposed training framework consist of three modules covering topics of PD: (i) comprehensive care, (ii) self-management support and (iii) health coaching. A fourth module on telemedicine may be added if applicable. The framework streamlines important theoretical concepts of professional PD management and may enable the development of novel, personalized care approaches.

Evaluation of adherence monitoring system using evriMED with a differentiated response compared to standard of care among drug-sensitive TB patients in three provinces in South Africa: a protocol for a cluster randomised control trial

Background South Africa has achieved drug-susceptible TB (DS-TB) treatment success of only 77% among people with new and previously treated TB. Alternative approaches are required to improve medication adherence and treatment completion to limit transmission, TB relapse and the development of resistance. This study aims to implement and evaluate the use of adherence medication monitors (Wisepill evriMED 1000) with a differentiated response to patient care, among DS-TB patients in three provinces of South Africa. Methods In total, 18 public health clinics across three provinces were selected. Clinics were randomised to intervention or standard of care clinics. In each clinic, approximately 145 DS-TB patients are being enrolled to reach a total of 2610. All patients have their daily adherence monitored using medication monitors. In the intervention arm, patients are receiving medication monitor reminders and differentiated care in response to adherence data. This weekly review of daily real-time monitoring will be undertaken from a central database. The differentiated care model includes automated SMS reminders with a missed dose, research staff-initiated phone call to the patient with a second or third missed dose, a home visit if four or more doses are missed, and motivational counselling if four or more doses are missed repeatedly. Fidelity of the intervention will be measured through process evaluation. Patients in control clinics will receive medication monitors for adherence tracking, standard of care TB education, and normal clinic follow-up procedures. The primary outcome is the proportion of patients by arm with >80% adherence, as measured by the medication monitor. The feasibility and acceptability of the intervention will be assessed by in-depth interviews with patients, stakeholders, and study staff. A cost effectiveness analysis of the intervention and standard of care clinics will be conducted. Significance This trial will provide evidence for the use of an intervention, including medication monitors and differentiated care package, to improve adherence to TB treatment. Improved adherence should also improve TB treatment completion rates, thus reducing loss to follow-up rates, and TB relapse among people with TB. The intervention is intended to ultimately improve overall TB control and reduce TB transmission in South Africa. Trial registration Pan African Trial Registry PACTR201902681157721. Registered on 11 February 2019.

Assessing private provider perceptions and the acceptability of video observed treatment technology for tuberculosis treatment adherence in three cities across Viet Nam

Background The World Health Organization recently recommended Video Observed Therapy (VOT) as one option for monitoring tuberculosis (TB) treatment adherence. There is evidence that private sector TB treatment has substandard treatment follow-up, which could be improved using VOT. However, acceptability of VOT in the private sector has not yet been evaluated. Methods We conducted a cross-sectional survey employing a theoretical framework for healthcare intervention acceptability to measure private provider perceptions of VOT across seven constructs in three cities of Viet Nam: Ha Noi, Ho Chi Minh City, and Hai Phong. We investigated the differences in private providers’ attitudes and perceptions of VOT using mixed ordinal models to test for significant differences in responses between groups of providers stratified by their willingness to use VOT. Results A total of 79 private providers completed the survey. Sixty-two providers (75%) indicated they would use VOT if given the opportunity. Between private providers who would and would not use VOT, there were statistically significant differences (p≤0.001) in the providers’ beliefs that VOT would help identify side effects faster and in their confidence to monitor treatment and provide differentiated care with VOT. There were also significant differences in providers’ beliefs that VOT would save them time and money, address problems faced by their patients, benefit their practice and patients, and be relevant for all their patients. Conclusion Private providers who completed the survey have positive views towards using VOT and specific subpopulations acknowledge the value of integrating VOT into their practice. Future VOT implementation in the private sector should focus on emphasizing the benefits and relevance of VOT during recruitment and provide programmatic support for implementing differentiated care with the technology.

Organising care and community in the era of the ‘gay disease’: Gay community responses to HIV/AIDS and the production of differentiated care geographies in Vancouver

Scholarship on the place of the HIV/AIDS crisis in urban geographies of sexual minority activism has powerfully insisted on the importance of community organising as a response to state and societal failures and to their homophobic, AIDS phobic and morally conservative underpinnings. This paper extends this scholarship by examining the urban social geographies of exclusion produced by such community organising efforts. It draws on the perspectives of long-term survivors of HIV/AIDS (LTS) in Vancouver to highlight the differentiated care geographies of HIV/AIDS that resulted from the racialised, classed and gendered politics and urban imaginations enacted by gay and allied HIV/AIDS organising. Though LTS networks, spaces and politics of care and community were more extended than Vancouver’s gay community during the 1980s and 1990s, the centring of the West End gay village in many community-led responses to HIV/AIDS resulted in LTS geographies outside the West End being excluded from important systems of care and community. LTS narratives of the city at the time of the ‘gay disease’ thus tell an urban politics of sexual and health activisms as shaped not only by processes of heteronormativity and homophobia but also of racially, colonially and class-inflected homonormative urban imaginaries.

Acceptability of point-of-care viral load testing to facilitate differentiated care: a qualitative assessment of people living with HIV and nurses in South Africa

Background Providing viral load (VL) results to people living with HIV (PLHIV) on antiretroviral therapy (ART) remains a challenge in low and middle-income countries. Point-of-care (POC) VL testing could improve ART monitoring and the quality and efficiency of differentiated models of HIV care. We assessed the acceptability of POC VL testing within a differentiated care model that involved task-shifting from professional nurses to less highly-trained enrolled nurses, and an option of collecting treatment from a community-based ART delivery programme. Methods We undertook a qualitative sub-study amongst clients on ART and nurses within the STREAM study, a randomized controlled trial of POC VL testing and task-shifting in Durban, South Africa. Between March and August 2018, we conducted 33 semi-structured interviews with clients, professional and enrolled nurses and 4 focus group discussions with clients. Interviews and focus groups were audio recorded, transcribed, translated and thematically analysed. Results Amongst 55 clients on ART (median age 31, 56% women) and 8 nurses (median age 39, 75% women), POC VL testing and task-shifting to enrolled nurses was acceptable. Both clients and providers reported that POC VL testing yielded practical benefits for PLHIV by reducing the number of clinic visits, saving time, travel costs and days off work. Receiving same-day POC VL results encouraged adherence amongst clients, by enabling them to see immediately if they were ‘good’ or ‘bad’ adherers and enabled quick referrals to a community-based ART delivery programme for those with viral suppression. However, there was some concern regarding the impact of POC VL testing on clinic flows when implemented in busy public-sector clinics. Regarding task-shifting, nurses felt that, with extra training, enrolled nurses could help decongest healthcare facilities by quickly issuing ART to stable clients. Clients could not easily distinguish enrolled nurses from professional nurses, instead they highlighted the importance of friendliness, respect and good communication between clients and nurses. Conclusions POC VL testing combined with task-shifting was acceptable to clients and healthcare providers. Implementation of POC VL testing and task shifting within differentiated care models may help achieve international treatment targets. Trial registration NCT03066128, registered 22/02/2017.