HIV This Week

The effects of global health initiatives on country health systems: a review of the evidence from HIV/AIDS control.

Biesma RG, Brugha R, Harmer A, Walsh A, Spicer N, Walt G. Health Policy Plan. 2009; 24:239-52.

This paper reviews country-level evidence about the impact of global health initiatives, which have had profound effects on recipient country health systems in middle- and low- income countries. Biesma and colleagues have selected three initiatives that account for an estimated two-thirds of external funding earmarked for HIV control in resource-poor countries: the Global Fund to Fight AIDS, TB and Malaria, the World Bank Multi-country AIDS Program (MAP) and the US President’s Emergency Plan for AIDS Relief (PEPFAR). This paper draws on 31 original country-specific and cross-country articles and reports, based on country-level fieldwork conducted between 2002 and 2007. Positive effects have included a rapid scale-up in HIV service delivery, greater stakeholder participation, and channelling of funds to non-governmental stakeholders, mainly NGOs and faith-based bodies. Negative effects include distortion of recipient countries’ national policies, notably through distracting governments from coordinated efforts to strengthen health systems and re-verticalization of planning, management and monitoringand evaluation systems. Sub-national and district studies are needed to assess the degree to which global health initiatives are learning to align with and build the capacities of countries to respond to HIV; whether marginalized populations access and benefit from global health initiatives-funded programmes; and about the cost-effectiveness and long-term sustainability of the HIV programmes funded by the global health initiatives. Three multi-country sets of evaluations, which will be reporting in 2009, will answer some of these questions.

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Editor’s note: Global health initiatives are defined as ‘ a blueprint for financing, resourcing, coordinating and/or implementing disease control across at least several countries in more than one region of the world’. They may be bilateral (e.g. US PEPFAR), multilateral (e.g. World Bank MAP), or public-private partnerships (Global Fund) aid mechanisms. This first systematic review of published and unpublished reports from 2002 to 2007 examines the effects of these three initiatives on national policy; coordination and planning; stakeholder involvement; disbursement, absorptive capacity, and management; monitoring and evaluation; and human resources. It suggests that these initiatives, each with different effects, initially often had negative effects, revealing country system weaknesses. As lessons were learned, the effects on health systems were more positive. The principal recommendations of this review are first, that global health initiatives, recipient donor countries, civil society organisations, and technical agencies alike should engage more fully with the Paris Principles for AIDS Effectiveness. Secondly, country and global policy makers and donors should demand and fund the acquisition of better evidence, including more analytical health policy and health systems evaluation. This article should be very high on your reading list!

Sanjana P, Torpey K, Schwarzwalder A, Simumba C, Kasonde P, Nyirenda L, Kapanda P, Kakungu-Simpungwe M, Kabaso M, Thompson C. Hum Resour Health. 2009 ;7:44.

The human resource shortage in Zambia is placing a heavy burden on the few health care workers available at health facilities. The Zambia Prevention, Care and Treatment Partnership began training and placing community volunteers as lay counsellors in order to complement the efforts of the health care workers in providing HIV counselling and testing services. These volunteers are trained using the standard national counselling and testing curriculum. This study was conducted to review the effectiveness of lay counsellors in addressing staff shortages and the provision of HIV counselling and testing services. Quantitative and qualitative data were collected by means of semistructured interviews from all active lay counsellors in each of the facilities and a facility manager or counselling supervisor overseeing counselling and testing services and clients. At each of the 10 selected facilities, all counselling and testing record books for the month of May 2007 were examined and any recordkeeping errors were tallied by cadre. Qualitative data were collected through focus group discussions with health care workers at each facility. Lay counsellors provide counselling and testing services of quality and relieve the workload of overstretched health care workers. Facility managers recognize and appreciate the services provided by lay counsellors. Lay counsellors provide up to 70% of counselling and testing services at health facilities. The data review revealed lower error rates for lay counsellors, compared to health care workers, in completing the counselling and testing registers. Community volunteers, with approved training and ongoing supervision, can play a major role at health facilities to provide counselling and testing services of quality, and relieve the burden on already overstretched health care workers.

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Editors’ note: Zambia is more than an order-of-magnitude (10 times) below the recommended staff-to-population ratios for nurses (1:700 versus 1:8064) and pharmacists (1:8000 versus 1:473,000), spurring it on to find solutions to this health care bottleneck. A two-week classroom component followed by a four-week supervised practicum and training in finger-prick HIV testing has created a cadre of lay counsellors providing quality services to satisfied clients. Some lay counsellors view reducing stigma and representing community role models as additional responsibilities. The fact that this is a voluntary programme (lay counsellors receive 25USD per month to defray travel costs but no other compensation) may jeopardise its sustainability. Continued supervision of the work of these lay counsellors, along with formalisation of their relationship with health facilities, could enhance both performance and retention. 

Kiggundu V, Watya S, Kigozi G, Serwadda D, Nalugoda F, Buwembo D, Settuba A, Anyokorit M, Nkale J, Kighoma N, Ssempijja V, Wawer M, Gray RH. The number of procedures required to achieve optimal competency with male circumcision: findings from a randomized trial in Rakai, Uganda. BJU Int. 2009 Apr 17. [Epub ahead of print]

Kiggundu and colleagues set out to assess the number of procedures required to achieve optimal competency (time required for surgery with minimal adverse events) in Rakai, Uganda, and thus facilitate the development of guidelines for training providers, as male circumcision reduces the acquisition of human immunodeficiency virus (HIV) in men and is recommended for HIV prevention. In a randomized trial, 3011 men were circumcised, using the sleeve method, by six physicians who had completed training, which included 15-20 supervised procedures. The duration of surgery from local anaesthesia to wound closure, moderate or severe surgery-related adverse events, and wound healing were assessed in relation to the number of procedures done by each physician. The median age of the patients was 24 years. The number of procedures per surgeon was 20-981. The mean time required to complete surgery was approximately 40 min for the first 100 procedures and declined to 25 min for the subsequent 100 circumcisions. After controlling for the number of procedures there was no significant difference in duration of the surgery by patient HIV status or age. The rate of moderate and severe adverse events was 8.8% (10/114) for the first 19 unsupervised procedures after training, 4.0% for the next 20-99 (13/328) and 2.0% for the last 100 (P for trend, 0.003). All adverse events resolved with management. The completion of more than 100 circumcisions was required before newly trained physicians achieved the optimum duration of surgery. Adverse events were higher immediately after training and additional supervision is needed for at least the first 20 procedures after completing training.

Editors’ note: This is the kind of operational research that will improve service outcomes if its results are now taken on board. They strongly suggest that time pressure should not be placed on newly trained surgeons, who will become more efficient with time in any case, and that they should be supervised for the first 20 circumcisions they perform after training, in addition to periodic supervision for the next 80. This surgical procedure, described in male circumcision circles as ‘minor surgery on a major organ’, warrants the strong emphasis being placed on safety and quality assurance.

Kline MW, Ferris MG, Jones DC, Calles NR, Mizwa MB, Schwarzwald HL, Wanless RS, Schutze GE. The Paeditric AIDS Corps: responding to the African HIV/AIDS health professional resource crisis. Paediatrics. 2009 Jan;123(1):134-6.

Health professional capacity for delivery of HIV care and treatment is severely constrained across sub-Saharan Africa. African health professional expertise in paediatrics is in particularly short supply. Here Kline et al describe a Paediatric AIDS Corps program that was designed to place paediatricians and other physicians in Africa on a long-term basis to expand existing health professional capacity for paediatric and family HIV care and treatment. In the first 2 years of this program, 76 physicians were placed in 5 African countries that have been hit hard by AIDS. Enrolment of HIV-infected children in care more than quadrupled over a 24-month period, to 26 590. The authors believe that this pilot program can serve as a model for larger-scale efforts to immediately expand access for African children and families to life-saving HIV care and treatment.

Editors’ notes: With health professional capacity for delivering HIV treatment and care severely constrained across sub-Saharan Africa, attention has turned to task-shifting to other health cadres, task-sharing which involves parts of procedures or tasks being taken on by different health care providers, recruiting and retaining new health caregivers, and hosting short-term volunteer projects. This programme, responding to the fact that children are underrepresented among patients on antiretroviral treatment in virtually every setting in sub-Saharan Africa, mobilised US graduates of residency training programmes in paediatrics, family medicine, and internal medicine for assignments of a year or longer in Botswana, Lesotho, Swaziland, Malawi, and Burkina Faso. They receive a living stipend, full benefits, a housing allowance, and student loan debt relief. The programme plans its own obsolescence by training local health professionals. Its success in improving paediatric treatment coverage while being locally acceptable will be of interest to many worldwide who would like to contribute in some way to improve the dire situation of the vast majority of the 2 million children living with HIV in Africa.

Kim JC, Askew I, Muvhango L, Dwane N, Abramsky T, Jan S, Ntlemo E, Chege J, Watts C. RADAR, School of Public Health, University of the Witwatersrand, Acornhoek, South Africa. Comprehensive care and HIV prophylaxis after sexual assault in rural South Africa: the Refentse intervention study. BMJ. 2009 Mar 13;338:b515.

Although international guidelines specify the central role of the health sector in providing comprehensive care, including HIV post-exposure prophylaxis (PEP), after sexual assault, in both industrialised and developing countries there are many challenges to providing timely and comprehensive services. A nurse-driven model of post-rape care was integrated into existing hospital services; the before and after study design evaluated impacts on quality of care, reviewing 334 hospital charts and conducting interviews with 16 service providers and 109 patients in a 450-bed district hospital in rural South Africa. The key measures for improvement examined were quality of care after rape (forensic history and examination, provision of emergency contraception, prophylaxis for sexually transmitted infections, referrals); provision of HIV counselling and testing and provision and completion of full 28 day course of PEP; and service utilisation (number of service providers seen on first visit and number of rape cases presenting to hospital per month). After completing baseline research, Kim and colleagues introduced a five-part intervention model, consisting of a sexual violence advisory committee, hospital rape management policy, training workshop for service providers, designated examining room, and community awareness campaigns. Existing services had been fragmented and of poor quality. After the intervention, there were considerable improvements in clinical history and examination, pregnancy testing, emergency contraception, prophylaxis for sexually transmitted infections; HIV counselling and testing, PEP, trauma counselling, and referrals. Completion of the 28-day course of PEP drugs increased from 20% to 58%. The authors conclude that it is possible to improve the quality of care after sexual assault, including HIV prophylaxis, within a rural South African hospital at modest cost, using existing staff. With additional training, nurses can become the primary providers of this care.

Editors’ note: Refentse means ‘we shall overcome’ in Venda, the language of this rural South African area and that is exactly what these investigators aimed to do. Aside from immediate genital and bodily injuries, sexual violence brings risks of HIV and sexually transmitted disease, unwanted pregnancy, urinary tract infections, chronic pelvic pain, miscarriage, depression, substance abuse, post-traumatic stress disorder, and suicide. They used formative research to conduct a baseline assessment with providers and patients to define problems and design a strategy for change. The process and its positive findings are an example for managers and providers of sexual assault care, but also of other services, who are keen to embark on a transparent, participatory process to improve their programme outcomes.

Zachariah R, Ford N, Philips M, S Lynch, Massaquoi M, Janssens V, Harries AD. Task shifting in HIV/AIDS: opportunities, challenges and proposed actions for sub-Saharan Africa. Trans R Soc Trop Med Hyg. 2008 Nov 5. [Epub ahead of print]

Sub-Saharan Africa is facing a crisis in human health resources due to a critical shortage of health workers. The shortage is compounded by a high burden of infectious diseases; emigration of trained professionals; difficult working conditions, and low motivation. In particular, the burden of HIV has led to the concept of task shifting being increasingly promoted as a way of rapidly expanding human resource capacity. This refers to the delegation of medical and health service responsibilities from higher to lower cadres of health staff, in some cases non-professionals. This paper, drawing on Médecins Sans Frontières’ experience of scaling-up antiretroviral treatment in three sub-Saharan African countries (Malawi, South Africa and Lesotho) and supplemented by a review of the literature, highlights the main opportunities and challenges posed by task shifting and proposes specific actions to tackle the challenges. The opportunities include: increasing access to life-saving treatment; improving the workforce skills mix and health-system efficiency; enhancing the role of the community; cost advantages and reducing attrition; and international ‘brain drain’. The challenges include: maintaining quality and safety; addressing professional and institutional resistance; sustaining motivation and performance; and preventing deaths of health workers from HIV. Task shifting should not undermine the primary objective of improving patient benefits and public health outcomes.

Editors’ note: Given that an estimated 2.4 million doctors and nurses are needed to meet the Millennium Development Goals, it is no surprise that increasing attention has turned to task shifting, a concept dating back decades. This excellent review provides examples to highlight the opportunities and challenges of task shifting in HIV care in sub-Saharan Africa. It lays out the main operational research priorities (quality, safety, acceptability, cost, management, and impact) to obtain data for decision-making to improve task shifting outcomes iteratively.

The tenets of fuzzy trace theory are summarized with respect to their relevance to health and medical decision making. Illustrations are given for HIV prevention, cardiovascular disease, surgical risk, genetic risk, and cancer prevention and control. A core idea of fuzzy trace theory is that people rely on the gist of information, its bottom-line meaning, as opposed to verbatim details in judgment and decision making. This idea explains why precise information (e.g., about risk) is not necessarily effective in encouraging prevention behaviours or in supporting medical decision making. People can get the facts right, and still not derive the proper meaning, which is key to informed decision making. Getting the gist is not sufficient, however. Retrieval (e.g., of health-related values) and processing interference brought on by thinking about nested or overlapping classes (e.g., in ratio concepts, such as probability) are also important. Theory-based interventions that work (and why they work) are presented, ranging from specific techniques aimed at enhancing representation, retrieval, and processing to a comprehensive intervention that integrates these components.

Editors’ note: An interesting read, this paper presents fuzzy trace theory assumptions of how health information is mentally represented, retrieved, and processed in decision–making and subsequent behaviour. Verbatim facts (including graphs, numbers, pictures, literal information, etc.) are less likely to influence judgment and decision-making than are gist representations (subjective, qualitative interpretations of information based on emotion, education, culture, previous experience, worldview, and level of development). Risk reduction interventions based on fuzzy trace theory build capacity for automatic responses to contextual cues that signal risk (rather than deliberative thinking), retrieval of core values and principles relevant in risky contexts, and their application to make healthy decisions. Do you get the gist?

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.