HIV This Week

Ladenheim D, Horn O, Werneke U, Phillpot M, Murungi A, Theobald N, Orkin C. Potential health risks of complementary alternative medicines in HIV patients. HIV Med. Volume 9, Issue 8, Pages: 653-659

The objective of this study was to determine the prevalence and purpose of complementary alternative medicines use in people receiving treatment for HIV infection. To identify and quantify potential health risks of complementary alternative medicines use in this population and to explore options for improved pharmacovigilance. A cross-sectional questionnaire survey of 293 patients receiving antiretroviral (ARV) therapy at three specialist HIV out-patient clinics in central London, UK was conducted. The use of herbal medicines and supplements was explored, and potentially adverse side effects or significant drug interactions with conventional therapies were identified. Of the 293 patients included, 61% (n=179) were taking herbal remedies or supplements and 35% (n=103) were using physical treatments. Twenty-seven per cent (n=80) used a combination of both. Twenty per cent (n=59) potentially compromised their HIV management through using complementary alternative medicines therapy. Ten per cent (n=29) were advised to stop their complementary alternative medicines and 15% (n=43) were made aware of potential drug interactions and adverse effects and were advised to monitor their care. There are potentially significant health risks posed by the concomitant use of complementary alternative medicines in patients taking ARV therapy. Medical practitioners need to be able to identify complementary alternative medicine use in HIV-positive patients and recognize potential health risks. Patients should be encouraged to disclose CAM use to their clinicians and other healthcare professionals.

Editors’ note: Many patients living with chronic illnesses and their associated physical and psychological problems use alternative medicines. This study found potentially serious health risks in patients living with HIV, of whom 20% received warnings and 10% were advised to stop their alternative medicines. Some people were at risk of adverse reactions to them while others risked antiretroviral drug side effects or sub-therapeutic drug levels due to possible interference with the cytochrome P metabolism system used by protease inhibitors and non-nucleoside reverse transcriptase inhibitors.

Peltzer K, Preez NF, Ramlagan S, Fomundam H. Use of traditional complementary and alternative medicine for HIV patients in KwaZulu-Natal, South Africa. BMC Public Health. 2008;8:255.

Traditional medicine use has been reported is common among individuals with moderate and advanced HIV disease. The aim of this cross-sectional study was to assess the use of traditional complementary and alternative medicine for HIV patients prior to initiating antiretroviral therapy in three public hospitals in KwaZulu-Natal, South Africa. Using systematic sampling, 618 HIV-positive patients were selected from outpatient departments from three hospitals and interviewed with a questionnaire. Traditional complementary and alternative medicine was commonly used for HIV in the past six months by study participants (317, 51.3%) and herbal therapies alone (183, 29.6%). The use of micronutrients (42.9%) was excluded from traditional complementary and alternative medicine since mostly vitamins were provided by the health facility. Herbal therapies were the most expensive, costing on average 128 Rand (US$16) per patient per month. Most participants (90%) indicated that their health care provider was not aware that they were taking herbal therapies for HIV (90%). Herbal therapies were mainly used for pain relief (87.1%) and spiritual practices or prayer for stress relief (77.6%). Multivariate logistic regression with use of herbs for HIV as the dependent variable identified being on a disability grant and fewer clinic visits to be associated with use of herbs, and traditional complementary and alternative medicine use for HIV identified being on a disability grant, number of HIV symptoms and family members not contributing to main source of household income to be associated with traditional complementary and alternative medicine use. Traditional herbal therapies and traditional complementary and alternative medicine are commonly used by HIV treatment naïve outpatients of public health facilities in South Africa. Health care providers should routinely screen patients on traditional complementary and alternative medicine use when initiating ART and also during follow-up and monitoring keeping in mind that these patients may not fully disclose other therapies.

Editors’ note: This study revealed that treatment naive HIV patients in South Africa use a variety of traditional herbal therapies and other complementary/alternative medicines that they may be reticent to discuss fully with their care providers and that may negatively affect household income. Creating trust and involving patients more in treatment decision-making processes may help determine which aspects of their alternative treatment can be safely incorporated into their medical regimen.

Remien RH, Berkman A, Myer L, Bastos FI, Kagee A, El-Sadr WM. Integrating HIV care and HIV prevention: legal, policy and programmatic recommendations. AIDS. 2008; Suppl 2:S57-65.

Since the start of the HIV epidemic we have witnessed significant advances in our understanding of the impact of HIV disease worldwide. Furthermore, breakthroughs in treatment and the rapid expansion of HIV care and treatment programmes in heavily affected countries over the past 5 years are potentially critical assets in a comprehensive approach to controlling the continued spread of HIV globally. A strategic approach to controlling the epidemic requires continued and comparable expansion and integration of care, treatment and prevention programmes. As every new infection involves transmission, whether vertically or horizontally, from a person living with HIV, the integration of HIV prevention into HIV care settings has the potential to prevent thousands of new infections, as well as to improve the lives of people living with HIV. In this paper, Remien and colleagues highlight how to better utilize opportunities created by the antiretroviral roll-out to achieve more effective prevention, particularly in sub-Saharan Africa. The authors offer specific recommendations for action in the domains of healthcare policy and practice in order better to utilize the advances in HIV treatment to advance HIV prevention.

Editors’ note: Control of the global HIV epidemic remains elusive with poor coordination, underutilisation of effective interventions to slow the epidemic, and suboptimal expansion of prevention, treatment, care, and support programmes. This paper reviews some basic biological, epidemiological, and behavioural concepts that underpin potential synergies between care/treatment programmes and effective prevention. Failure to retain patients in care and failure to support high levels of adherence in those on antiretroviral therapy have negative consequences for both individuals and for public health. Integration of HIV prevention into HIV care and treatment programmes for people living with HIV is a key strategy advocated here.

Kidorf M, King VL. Expanding the public health benefits of syringe exchange programs. Can J Psychiatry. 2008 Aug;53(8):487-95.

The objective of this study is to provide a brief history of community syringe exchange programmes, describe the clinical profile of those who attend them, identify factors interfering with the transition of syringe exchange programmes participants to more comprehensive substance abuse treatment services, review studies designed to improve rates of treatment seeking, and offer practical suggestions to facilitate links between syringe exchange programmes and substance abuse treatment. Relevant articles were identified using a PubMed literature search of English-language journals from 1997 to 2007. Studies were included that evaluated the effectiveness of syringe exchange programmes or methods for increasing treatment enrolment in syringe exchange programme participants or other out-of-treatment intravenous drug users. Relevant articles prior to 1997 were identified using reference lists of identified articles. Syringe exchange programmes have little impact on rates of drug use or injections. Substance abuse treatment reduces human immunodeficiency virus transmission through drug use reduction and psychosocial functioning improvement, yet syringe exchange programme participants only infrequently engage in treatment. Psychological and pharmacological interventions delivered at the syringe exchange programme setting can improve treatment seeking in syringe exchange programme participants. Use of syringe exchange programmes by substance abuse treatment programs can improve harm-reduction efforts at these settings. Kidorf and colleagues concluded that efforts to improve the link between syringe exchange programmes and substance abuse treatment should include interventions to enhance cooperation across programs, motivate treatment enrolment and syringe exchange programme use, and expand access to treatment. A more fluent and bidirectional continuum of services can enhance the public health benefits of both of these health care delivery settings.

Editors’ note: Community-based syringe exchange programmes and substance use treatment programmes share a common goal – reducing the harm associated with substance use disorder - but they function as independent silos. Conceptualising them as part of a continuum of therapeutic harm reduction services can strengthen the connections between them. Syringe exchange programmes tend to draw in hard-to-reach drug users, who have a more severe spectrum of drug use and may become motivated for treatment. Drug users that are responding poorly to substance use treatment need to be encouraged to participate in community syringe exchange programmes.

The ART-LINC Collaboration of the International Databases to Evaluate AIDS (IeDEA). Antiretroviral therapy in resource-limited settings 1996 to 2006: patient characteristics, treatment regimens and monitoring in sub-Saharan Africa, Asia and Latin America. Trop Med Int Health. 2008;13(7):870-9

The collaboration set out to describe temporal trends in baseline clinical characteristics, initial treatment regimens, and monitoring of patients starting antiretroviral therapy in resource-limited settings. The collaborators analysed data from 17 antiretroviral therapy programmes in 12 countries in sub-Saharan Africa, South America and Asia.  Patients aged 16 years or older with documented date of start of highly active antiretroviral therapy were included. Data were analysed by calculating medians, interquartile ranges and percentages by regions and time periods. Not all centres provided data for 2006 and therefore 2005 and 2006 were combined. A total of 36 715 patients who started antiretroviral therapy 1996-2006 were included in the analysis. Patient numbers increased substantially in sub-Saharan Africa and Asia, and the number of initial regimens declined, to four and five, respectively, in 2005-2006. In South America 20 regimes were used in 2005-2006. A combination of 3TC/D4T/NVP was used for 56% of African patients and 42% of Asian patients; AZT/3TC/EFV was used in 33% of patients in South America. The median baseline CD4 count increased in recent years, to 122 cells/mul (interquartile range 53-194) in 2005-2006 in Africa, 134 cells/mul (interquartile range 72-191) in Asia, and 197 cells/mul (interquartile range 61-277) in South America, but 77%, 78% and 51%, respectively, started with <200 cells/mul in 2005-2006. In all regions baseline CD4 cell counts were higher in women than men: differences were 22cells/mul in Africa, 65 cells/mul in Asia and 10 cells/mul in South America. In 2005-2006 a viral load at 6 months was available in 21% of patients Africa, 8% of Asian patients and 73% of patients in South America.  Corresponding figures for 6-month CD4 cell counts were 74%, 77% and 81%.  The public health approach to providing ART proposed by the World Health Organization has been implemented in sub-Saharan Africa and Asia. Although CD4 cell counts at the start of ART have increased in recent years, most patients continue to start with counts well below the recommended threshold. Particular attention should be paid to more timely initiation of ART in HIV-infected men.

Editors´note: This database of HIV-infected patients followed clinically in resource-limited settings permits valuable analyses of trends over time in the scale-up of the public health approach to antiretroviral treatment. Standardised first-line and second-line regimens, simplified decision making, and standardised clinical and laboratory monitoring are key features of this approach. Although patients in South America are starting on treatment with less severe immunodeficiency, the majority of African and Asian patients are starting late, which has important implications both for early mortality and for more rapid disease progression.

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Hallett TB, Gregson S, Dube S, Garnett GP. The Impact of Monitoring HIV Patients Prior to Treatment in Resource-Poor Settings: Insights from Mathematical Modelling. PLoS Med. 2008;5(3):e53

The roll-out of antiretroviral treatment in developing countries concentrates on finding patients currently in need, but over time many HIV-infected individuals will be identified who will require treatment in the future. Hallett and colleagues investigated the potential influence of alternative patient management and antiretroviral treatment initiation strategies on the impact of antiretroviral treatment programmes in sub-Saharan Africa. They developed a stochastic mathematical model representing disease progression, diagnosis, clinical monitoring, and survival in a cohort of 1,000 hypothetical HIV-infected individuals in Africa. If individuals primarily enter antiretroviral treatment programmes when symptomatic, the model predicts that only 25% will start treatment and, on average, 6 life-years will be saved per person treated. If individuals are recruited to programmes while still healthy and are frequently monitored, and CD4(+) cell counts are used to help decide when to initiate antiretroviral treatment, three times as many are expected to be treated, and average life-years saved among those treated increases to 15. The impact of programmes can be improved further by performing a second CD4(+) cell count when the initial value is close to the threshold for starting treatment, maintaining high patient follow-up rates, and prioritising monitoring the oldest (>/= 35 y) and most immune-suppressed patients (CD4(+) cell count </= 350). Initiating antiretroviral treatment at higher CD4(+) cell counts than the World Health Organization recommends leads to more life-years saved, but disproportionately more years spent on antiretroviral treatment. The authors conclude that the overall impact of antiretroviral treatment programmes will be limited if rates of diagnosis are low and individuals enter care too late. Frequently monitoring individuals at all stages of HIV infection and using CD4 cell count information to determine when to start treatment can maximise the impact of ART.

Editors´note: This modelling work demonstrates that measuring CD4 cells frequently will save more life-years because it can trigger the start of antiretroviral treatment before the immune system is irreversibly damaged. In resource-limited settings, more life years can be saved per year on antiretroviral treatment by frequent CD4 cell count measurements. Therefore, there are strong arguments in favour of improved patient monitoring even before treatment initiation.

Nilmanat K, Street AF. Karmic quest: Thai family caregivers promoting a peaceful death for people with AIDS. Contemp Nurse. 2007;27(2):94-103.

Nilmanat and colleagues report the constructions of karma by four Thai family caregivers living with a dying person with AIDS in southern Thailand. These four families form a subset of a larger ethnographic case study exploring the experiences of families living with a relative with AIDS. Serial interviews, observations, and field journals were used as data collection methods with the four families. The findings indicated that the karmic quest is a dominant theme in the narratives of these families caring for their loved ones dying with AIDS.  The ‘calm and peaceful’ death that is described in the palliative care literature equated with their desire for the Buddhist philosophy of a harmonious death. The families used the law of karma and reincarnation as their main frame of reference and mobilised their religious resources to create meaning and purpose. Karmic healing activities were aimed at ending suffering, promoting a peaceful and calm death and ensuring a better life in the next one. The findings are important for the development of palliative nursing practice in Thailand by acknowledging religious and cultural values to promote peaceful death.

Editors´note: Palliative care aims to provide the best quality of life and relieve the suffering of people living with an incurable illness while offering comfort and support to their families and carers. It is a holistic approach which takes account of emotional, psychological, and spiritual needs as well as physical ones. In southern Thailand, Buddhist philosophy and karmic healing activities provide just such a holistic approach.

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Ridge D, Williams I, Anderson J, Elford J. Like a prayer: the role of spirituality and religion for people living with HIV in the UK. Sociol Health Illn. 2008;30(3):413-28.

Over 40,000 people are now living with diagnosed HIV in the United Kingdom (UK). There is, however, uncertainty about how people with HIV use religion or spirituality to cope with their infection. Adopting a modified grounded theory approach, Ridge and colleagues analysed individual and group interviews with the people most affected by HIV in the UK: black African heterosexual men and women and gay men (mostly white). For the majority of black African heterosexual men and women in our study, religion was extremely important. The authors found that gay men in the study were less religious than black Africans, although many were spiritual in some way. Black African individuals constructed their spiritual narratives as largely Christian or collective, while gay men described more individualistic or ‘New Age’ approaches.  The authors developed a six-level heuristic device to examine the ways in which prayer and meditation were deployed in narratives to modulate subjective wellbeing. These were: (i) creating a dialogue with an absent counsellor; (ii) constructing a compassionate ‘life scheme’; (iii) interrupting rumination; (iv) establishing mindfulness; (v) promoting positive thinking, and (vi) getting results. That people with HIV report specific subjective benefits from prayer or meditation presents a challenge to secular healthcare professionals and sociologists.

Editors´note: Open-ended in-depth interviews and focus groups revealed that most black Africans in this study were deeply spiritual in their approach to living with HIV and despite high stigma levels in their place of worship they relied heavily on their religion for support. Although some gay men had deep misgivings about religion and its wounding hostility to gay sexuality, they sought meaning in life, were striving to live in harmony and balance, and saw earth as a stepping-stone to another existence. In both groups, whether it was secular, spiritual, or religious in nature, prayer helped interrupt negative rumination and promoted mindfulness.

Unge C, Johansson A, Zachariah R, Some D, Van Engelgem I, Ekstrom AM. Reasons for unsatisfactory acceptance of antiretroviral treatment in the urban Kibera slum, Kenya. AIDS Care. 2008;20(2):146-9.

The aim of this study was to explore why patients in the urban Kibera slum, Nairobi, Kenya, offered free antiretroviral treatment at the Médecins Sans  Frontièrs (MSF) clinic, choose not to be treated despite signs of AIDS. Qualitative semi-structured interviews were conducted with 26 patients, 9 men and 17 women. Six main reasons emerged for not accepting antiretroviral treatment: a) fear of taking medication on an empty stomach due to lack of food; b) fear that side-effects associated with antiretroviral treatment would make one more ill; c) fear of disclosure and its possible negative repercussions; d) concern for continuity of treatment and care; e) conflicting information from religious leaders and community, and seeking alternative care (e.g. traditional medicine); f) illiteracy making patients unable to understand the information given by health workers.

Editors´note: The findings of this study guided the following urgent policy changes in the treatment programme: nutritional supplementation with ready-to-use food, adaptation of information pamphlets to local realities, alternative communication methods (peer groups, church, and traditional leaders), voluntary as opposed to mandatory disclosure to a `treatment buddy´, and enhanced links to other community partners in Kibera. Action-oriented research such as this explores problems and their underpinnings to create a platform for reality-based solutions.

Samb B, Celletti F, Holloway J, Van Damme W, De Cock KM, Dybul M. Rapid expansion of the health workforce in response to the HIV epidemic. N Engl J Med. 2007; 357(24):2510-4.

The World Health Organization (WHO) estimates that there is now a global deficit of more than 4 million trained health workers. The shortages in health workers are critical in 57 countries, mostly in sub-Saharan Africa and parts of Asia. The situation is further exacerbated by the direct effect of the human immunodeficiency virus (HIV) on health workers in resource-constrained countries in which the disease is epidemic. Poor working conditions and low pay conspire with the risks of occupational transmission and the stress of working in communities devastated by the HIV epidemic to drive up rates of attrition. In countries with the highest rate of HIV, leading causes of attrition are the morbidity and mortality caused by HIV itself. In Botswana, 17% of the health workers died from diseases related to AIDS from 1999 to 2005. The “Treat, Train, Retrain” global effort aims to prevent HIV among health workers and to treat those who are infected, to expand the workforce by training new people and by making more efficient use of the current pool of human resources for health, and to retain skilled staff. Possibly the most challenging imperative to expand the health workforce is the need for “task shifting”, the process of delegation in which tasks are moved, where appropriate, from more to less specialized health workers. Reorganizing the force in this way allows more efficient use of available human resources and quickly expands the overall human resource pool. Although such programs are in their early days, there is evidence of success. In South Africa, care models that shift many medical tasks to nurses were found to be feasible, acceptable to patients, and potentially more affordable. After 6 months of follow-up, outcomes such as virologic suppression, adherence, and retention of patients at sites with doctors were similar to those at sites without doctors where there was adequate supervision. The process of delegation can further extended from health professionals to community members. Adopting new models for the delivery of health services requires political and financial commitment. Governments, as well as international and bilateral agencies, will need to recognize and allow systems that train and deploy nonphysicians, including community-level workers and patients living with HIV in health care delivery. Although research is needed in these areas, sufficient data are already available to support a prompt scale-up of HIV prevention, care, and treatment through task shifting to save as many lives as quickly as possible.

Editors’ note: Although the term “task shifting” is new, the experience of task substitution has been documented since the 1970s in a variety of settings, often as a measure to enhance quality and reduce cost rather than as an emerging response to scarcity. Task shifting works best when standardized protocols, appropriate training, ongoing supervisory support, and a meaningful career pathway support it.

Janssens B, Van Damme W, Raleigh B, Gupta J, Khem S, Soy Ty K, Vun M, Ford N, Zachariah R. Offering integrated care for HIV/AIDS, diabetes and hypertension within chronic disease clinics in Cambodia. Bull World Health Organ. 2007; 85(11):880-5.

In Cambodia, care for people living with HIV (prevalence 1.9%) is expanding, but care for people with type II diabetes (prevalence 5-10%), arterial hypertension, and other treatable chronic diseases remains very limited. Janssens and colleagues describe the experience and outcomes of offering integrated care for HIV, diabetes, and hypertension within the setting of chronic disease clinics. Chronic disease clinics were set up in the provincial referral hospitals of Siem Reap and Takeo, 2 provincial capitals in Cambodia. At 24 months of care, 87.7% of all HIV patients were alive and in active follow-up. For diabetes patients, this proportion was 71%. Of the HIV patients, 9.3% had died and 3% were lost to follow-up, while for diabetes this included 3 (0.1%) deaths and 28.9% lost to follow-up. Of all diabetes patients who stayed more than 3 months in the cohort, 90% were still in follow-up at 24 months. Over the first three years, the chronic disease clinics have demonstrated the feasibility of integrating care for HIV with non-communicable chronic diseases in Cambodia. Adherence support strategies proved to be complementary, resulting in good outcomes. Services were well accepted by patients, and this has had a positive effect on HIV -related stigma. This experience shows how care for HIV patients can act as an impetus to tackle other common chronic diseases.

Editors’ note: With antiretroviral therapy becoming more accessible in resource-constrained settings, HIV care is increasingly becoming chronic disease management. Integrating care for HIV, diabetes, and hypertension can have efficiency gains, improved patient outcomes, and reduction in HIV-related stigma. In many settings, HIV care has introduced adherence support functions into the health care system. These can be applied to other chronic diseases, often neglected despite their disease burden, that also require sustained adherence to medication and lifestyle changes.

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Bärnighausen T, Welz T, Hosegood V, Bätzing-Feigenbaum J, Tanser F, Herbst K, Hill C, Newell ML. Hiding in the shadows of the HIV epidemic: obesity and hypertension in a rural population with very high HIV prevalence in South Africa. J Hum Hypertens. 2008; 22(3):236-9..

Bärnighausen and colleagues conducted a large population-based survey of body mass and blood pressure nested within an HIV survey in rural KwaZulu-Natal, South Africa, to measure the prevalence of obesity and hypertension in a community with very high HIV prevalence and to investigate the effect of HIV on body mass and blood pressure in a general population in rural Africa before antiretroviral treatment was widely available. Crude prevalence of overweight, obesity, stage-I and stage-II hypertension was 58% (95% confidence interval (CI) 56–60%), 32% (95% CI 30–33%), 24% (95% CI 22–26%) and 9% (95% CI 8–10%), respectively. Controlling for age, sex, education, household wealth, marital status and rural vs urban residence in multiple regression (after multiple imputation of missing values), HIV infection reduced body mass index by 1.9 units (Po0.001) and––when additionally controlling for body mass––systolic blood pressure by 3.0mmHg (P¼0.005).

Editors’ note: Despite an HIV prevalence of 35% in this 2003-2004 population-based survey, more than half of people were overweight, a third were obese and a third had high blood pressure. HIV had an effect on body mass index equivalent to a 5 kg. weight reduction and was a significant predictor of lower systolic blood pressure – findings that will likely be reversed as antiretroviral treatment is scaled up. This highlights the relevance of integrated chronic disease management to increase antihypertensive treatment coverage and promote lifestyle modification for HIV patients starting on antiretroviral treatment, as well as for the general population.

El-Sadr WM, Abrams EJ. Scale-up of HIV care and treatment: can it transform healthcare services in resource-limited settings? AIDS. 2007 ;21 Suppl 5:S65-70.

The rapid expansion of HIV care and treatment in resource-limited settings will undoubtedly ameliorate conditions in communities ravaged by this epidemic around the world and enable persons living with HIV to live longer, more productive lives. Concerns have been raised, however, regarding the possible deleterious effects on other health services. This paper argues that efforts to scale up HIV care and treatment in resource-limited countries, if designed and implemented with the additional goal of achieving broad health benefits, may serve as a catalyst for the establishment of more effective and responsive health systems. In order to determine these broader effects, mechanisms need to be established that enable relevant research and evaluation questions to be answered.

Editors’ note: HIV treatment programmes have the potential to decongest medical clinics, emergency services, and hospital wards as well as to increase laboratory support, health care personnel job satisfaction, and health care infrastructure. Programmatic monitoring and evaluation frameworks need to be modified to detect both improvement in outcomes for people living with HIV and effects on the broader healthcare system.

Bassey EB, Elemuwa CO, Anukam KC. Knowledge of, and attitudes to, acquired immune deficiency syndrome (AIDS) among traditional birth attendants (TBAs) in rural communities in Cross River State, Nigeria. Int Nurs Rev 2007;54:354-8.

Bassey and colleagues aimed to survey knowledge of, and attitudes towards HIV held by traditional birth attendants (TBAs) in rural communities in Cross River State, Nigeria. As the HIV epidemic continues to spread, undermining development, reversing health gains and exacerbating poverty, TBAs in rural communities in Cross River State, Nigeria are still less informed about this dreadful disease. A survey consisting of structured questionnaires was used with 140 randomly selected TBAs to assess their knowledge of HIV, source of information on HIV, and protective practices. Sixty-two (44.3%) of the TBAs had no formal education. Forty-four (31.4%) had primary education, while 19 (13.6%) had secondary education. On knowledge of HIV and sources of information, 49 (35.0%) of respondents reported knowing what HIV means. While 26.4% indicated that they received information about HIV from the government health centres, 23.6% had no information about the disease. There was a great disparity between male (73.7%) and female (28.9%) respondents on knowledge about HIV. On the use of protective safety procedures during delivery, 61 (43.6%) used sterilized blades, while 10.7% admitted wearing protective clothes and gloves. Only three (2.1%) of the respondents said that they were aware of the HIV status of their clients prior to delivery. The authors conclude that this survey has demonstrated that few TBAs in the communities studied in Cross River State are informed about HIV, and that this has revealed the urgency of starting a programme specifically designed for TBAs in rural communities towards a massive educational campaign on HIV.

Editors’ note: These are extraordinary (we hope) and highly discouraging findings in this day and age – 35% of traditional birth attendants in this Nigerian study knew about HIV and less than half were using sterilised blades – a problem for HIV, hepatitis B and C and other blood borne infections including tetanus. Education and training in universal precautions for all traditional birth attendants should be a priority on public health grounds.

Madon T, Hofman JK, Kupfer L, Glass RI. Implementation Science. Science. 2007 Dec 14;318(5857):1728-9.

Nearly 14,000 people in sub-Saharan Africa and South Africa die daily from HIV, malaria, and diarrhoeal disease, even though scientific advances have enabled prevention, treatment, and, in some cases, elimination of these diseases in developed countries. Many evidence-based innovations fail to produce results when transferred to communities in the global south, largely because their implementation is untested, unsuitable, or incomplete. Why is effective implementation, particularly in resource-poor countries, such as an intractable problem? The reasons are complex. First, scientists have been slow to view implementation as a dynamic, adaptive, multiscale phenomenon that can be addressed through a research agenda. Second, people living in poverty face a bewildering constellation of social constraints and health threats that make prevention and treatment more difficult. Realizing the need for a quantitative, scientific framework to guide health-care scale up in developing countries, researchers in health, engineering, and business are building interest in implementation science. Unlike routine applied (or operations) research, which may identify and address barriers related to the performance of specific objects, implementation sciences creates generalizable knowledge that can be applied across settings and contexts to answer central questions. Why do established programs lose effectiveness over days, weeks, or months? Why do tested programs sometimes exhibit unintended effects when transferred to a new setting? How can multiple interventions be effectively packaged to capture cost efficiencies and to reduce the splintering of health systems into disease-specific programs? Many implementation experiments- particularly cluster-randomized trials and agent-based models that compare the population level health impacts of different delivery strategies-can be coupled with the planning and roll-out of new programs by health ministries, making the cost of research marginal. They can also be used to model the potential gains of health-system designs, policies, and multisector interventions that cannot be tested experimentally. These approaches all require the involvement of scientists in early planning to ensure that research questions are incorporated into program design. There are three additional imperatives facing the research community. First, we must advance theoretical models and new analytic methods that apply to resource-poor settings. Second, we need to train a generation of researchers who can effectively bridge the implementation gap. A final imperative is for researchers to collaborate with developing country governments, nongovernmental organizations (NGOs), and communities. Although implementation experiments and computational modelling may be more complex- in terms of study design and data analysis- than the monitoring and observational studies currently funded by donors, any inconvenience is outweighed by the profound ability of scientifically rigorous findings to focus limited health resources and to save more lives.

Editors’ note: Donors and governments are increasingly aware of the importance of monitoring and evaluation and of operational research to improve the quality, efficiency, and effectiveness of programmes. This article draws attention to the exciting new ‘implementation science’ which can provide answers to central questions about how to maximise impact across different settings.

Dreesch N, Nyoni J, Mokopakgosi O, Seipone K, Kalilani JA, Kaluwa O, Musowe V. Public-private options for expanding access to human resources for HIV/AIDS in Botswana. Hum Resour Health 2007;5:25.

In responding to the goal of rapidly increasing access to antiretroviral treatment (ART), the government of Botswana undertook a major review of its health systems options to increase access to human resources, one of the major bottlenecks preventing people from receiving treatment. In mid-2004, a team of government and World Health Organization (WHO) staff reviewed the situation and identified a number of public sector scale up options. The team also reviewed the capacity of private practitioners to participate in the provision of antiretroviral treatment. Subsequently, the government created a mechanism to include private practitioners in rolling out antiretroviral treatment. At the end of 2006, more than 4500 patients had been transferred to the private sector for routine follow up. It was estimated that the cooperation reduced the immediate need for recruiting up to 40 medically qualified staff into the public sector over the coming years, depending on the development of the national standard for the number and duration of patient visits to a doctor per year. Thus welcome relief was brought, while at the same time not exercising a pull factor on human resources for health in the sub-Saharan region.

Editors’ note: In shifting thousands of patients into the private sector for treatment, the Botswana government is using the whole health system (both public and private) to optimize available resources and outsource part of its response to demand for HIV care. This avoids both longer term public sector staffing commitments and hiring staff from neighbouring countries which would have contributed to regional shortages. Equitable access and fairness in service delivery are respected with access to antiretroviral drugs free for all patients.

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Hagopian A, Micek MA, Vio F, Gimbel-Sherr K, Montoyo P.What if we decided to take care of everyone who needed treatment? Workforce planning in Mozambique using simulation of demand for HIV/AIDS care. Hum Resour Health. 2008;6(1):3. Epub ahead of print.

The growing HIV epidemic in southern Africa is placing an increased strain on health systems, which are experiencing steadily rising patient loads. Health care systems are tackling the barriers to serving large populations in scaled-up operations. One of the most significant challenges in this effort is securing the health care workforce to deliver care in settings where the manpower is already in short supply. Hagopian and colleagues have produced a demand-driven staffing model using simple spreadsheet technology, based on treatment protocols for HIV-positive patients that adhere to Mozambican guidelines. The model can be adjusted for the volumes of patients at differing stages of their disease, varying provider productivity, proportion who are pregnant, attrition rates, and other variables. The model projects the need for health workers using three different kinds of goals: 1) the number of patients to be placed on antiretroviral therapy, 2) the number of HIV-positive patients to be enrolled for treatment, and 3) the number of patients to be enrolled in a treatment facility per month. The authors propose three scenarios, depending on numbers of patients enrolled. The first scenario starts with 8000 patients on antiretroviral therapy and increases that number to 58 000 at the end of three years (those were the goals for the country of Mozambique). This would require thirteen clinicians and just over ten nurses by the end of the first year, and 67 clinicians and 47 nurses at the end of the third year. A second scenario starts with 34 000 patients enrolled for care (not all of them on antiretroviral therapy), and increases to 94 000 by the end of the third year, requiring a growth in clinician staff from 18 to 28. A third scenario starts a new clinic and enrols 200 new patients per month for three years, requiring 1.2 clinicians in year 1 and 2.2 by the end of year 3. Other clinician types in the model include nurses, social workers, pharmacists, phlebotomists, and peer counsellors. This planning tool could lead to more realistic and appropriate estimates of workforce levels required to provide high-quality HIV care in low-resource settings.

Editors’ note: This modelling work calculates incremental workforce needs for scaling up HIV care but excludes HIV testing, prevention of mother-to-child transmission, tuberculosis treatment, home care, blood banks, mental health, antenatal care, sexually transmitted infection care and inpatient care. It is helpful nonetheless as a planning tool for down-to-earth estimates of workforce requirements and may stimulate a closer look at strategies such as cross-training and task-shifting to meet workforce needs.

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Bärnighausen T, Bloom DE, Humair S. Human Resources for Treating HIV/AIDS: Needs, Capacities, and Gaps. AIDS Patient Care STDS 2007;21:799-812.

Despite recent international efforts to scale-up antiretroviral treatment (ART), more than 5 million people needing ART in low- and middle-income countries (LMIC) do not receive it. Limited human resources to treat HIV are one of the main constraints to achieving universal ART coverage. Bärnighausen and colleagues model the gap between needed and available human resources to treat HIV in order to quantify the challenge of achieving and sustaining universal ART coverage by 2017. The authors estimate the human resources gap in low- and middle-income countries using recently published estimates of ART coverage, HIV incidence, health-worker emigration rates, mortality rates of people needing antiretroviral treatment, and numbers of human resources needed to treat 1000 ART patients (based on review studies, 2006). The authors project the gap in human resources to treat HIV in 10 years (2017) using a simple discrete-time model with a health worker pool replenished through education and depleted through emigration/death; a population needing antiretroviral treatment replenished with a given HIV incidence rate; and higher survival rates for treated populations. The authors analyzed the effects of varying assumptions about inflows and outflows of human resources to treat HIV and the evolution of the HIV pandemic in three different regional base cases (sub-Saharan Africa, non-sub-Saharan African low- and middle-income countries, and South Africa). Current ART coverage for low- and middle-income countries is around 28%-32% and, if all things equal, it will drop to 16%-19% by 2017 with constant current production rates of human resources to treat HIV. A naive model, ignoring the increased survival probability resulting from ART, suggests that approximately the current number of human resources in ART services needs to be added every year for the next ten years to achieve universal coverage by 2017. In a model accounting for increased survival of treated patients, outcomes vary by region; sub-Saharan Africa requires two times, non-sub-Saharan African low-and-middle-income countries require 1.5 times and South Africa requires more than three times their respective current populations of human resources for HIV care to be added every year for the next 10 years to achieve universal coverage by 2017. Even if achieved by 2017, sustaining universal coverage requires further increases in human resources for HIV care until the system reaches steady state. ART coverage is sensitive to human resources inflow and emigration. The authors’ model quantifies the challenge of closing the human resources for HIV care gap in low- and middle-income countries.  It shows that strategies to achieve universal ART coverage must account for feedback due to higher survival probabilities of people receiving antiretroviral treatment. It suggests that universal ART coverage is unlikely to be achieved and sustained with increased inflows in human resources for HIV care alone, but will require decreased human resources outflows, substantially reduced HIV incidence, or changes in the nature or organization of care. Means to decrease emigration outflows in human resources for HIV care include scholarships for health-care education that are conditional on the recipient delivering ART in a country with high ART need for a number of years, training health workers who are not internationally mobile, or changing recruitment policies in countries receiving health workers from the developing world. Effective organizational changes include those that reduce the number of human resources required to treat a fixed number of patients on ART. Given the large number of health workers that even optimistic assumptions suggest will be needed in ART services in the coming decades, policymakers must ensure that the flow of workers into ART programs does not jeopardize the provision of other important health services.

Editors’ note: Strategies to achieve universal access to antiretroviral therapy must take into account the effects of increased patient survival when projecting human resource needs. This modelling work demonstrates why decreasing HIV incidence through effective prevention is key to ensuring that antiretroviral treatment coverage, based on the numbers in treatment compared to the number in need, does not fall tragically from current levels over the next decade. Innovative solutions to current health worker shortages are needed now both to ensure expanded access to ART and improve general health care delivery.

Mehtar S, Shisana O, Mosala T, Dunbar R. Infection control practices in public dental care services: findings from one South African province. J Hosp Infect 2007;66:65-70.

Infection control practices which increase the risk of blood-borne virus transmission with associated dental practice in one South African province were studied. All 24 state dental clinics were observed for adequate provision to carry out good infection prevention and control (IPC) practice, 75 staff including dentists, nurses and dental assistants were interviewed to assess IPC knowledge and 23 dental procedures were observed. Significant findings were the difference between knowledge and practice, despite adequate provisions for safe infection control practice. The lack of protective eye wear during a dental procedure, not washing hands between patients, not disassembling an item prior to disinfection or sterilization, and not using a sterile drill for each patient were identified. A rapid method for detection of occult blood was used as a marker for inadequate IPC practice. Contaminated dental items of equipment just prior to patient use in 25% of equipment tested and 37% of surfaces and surrounding areas in the dental clinics and units were recorded. This study concludes that, despite provision for safe dental practice available in state dental clinics, there was a lack of knowledge application in clinical practice. The risk of blood-borne virus transmission in a population with high human immunodeficiency virus (HIV) prevalence cannot be ignored.

Editors’ note: Those who avoid the dentist’s office until it can no longer be avoided will be encouraged to stay away even more on reading this article. The need to intensify infection control practices in dental practices is not restricted to low-and-middle-income countries. At the dentist’s office, we recommend that, regardless of where you are, you observe and ask questions when your mouth isn’t full.

Nyika A. Ethical and regulatory issues surrounding African traditional medicine in the context of HIV/AIDS. Developing World Bioeth 2007;7:25-34.

It has been estimated that more than 80% of people in Africa use traditional medicine. With the HIV epidemic claiming many lives in Africa, the majority of people affected rely on traditional medicine mainly because it is relatively affordable and available to the poor populations who cannot afford orthodox medicine. Whereas orthodox medicine is practiced under stringent regulations and ethical guidelines emanating from The Nuremburg Code,(1) African traditional medicine seems to be exempt from such scrutiny. Although recently there have been calls for traditional medicine to be incorporated into the health care system, less emphasis has been placed on ethical and regulatory issues. In this paper, an overview of the use of African traditional medicine in general, and for HIV in particular, is given, followed by a look at: (i) the relative laxity in the application of ethical standards and regulatory requirements with regards to traditional medicine; (ii) the importance of research on traditional medicine in order to improve and demystify its therapeutic qualities; (iii) the need to tailor-make intellectual property laws to protect traditional knowledge and biodiversity. A framework of partnerships involving traditional healers’ associations, scientists, policy makers, patients, community leaders, members of the communities, and funding organizations is suggested as a possible method to tackle these issues. It is hoped that this paper will stimulate objective and constructive debate that could enhance the protection of patients’ welfare.

Editors’ note : The pragmatic approach suggested here fits with the perspectives of the UNAIDS’ best practice publication from November 2006: Collaborating with Traditional Healers for HIV Prevention and Care in sub-Saharan Africa: suggestions for Programme Managers and Field Workers which will shortly be available in the new 16 page Highlights version.