HIV This Week

Why reinvent the wheel? Leveraging the lessons of HIV scale-up to confront non-communicable diseases

Rabkin M, El-Sadr WM. Global Public Health, 2011 Apr;6(3):247-56.

The dramatic scale-up of HIV services in lower-income countries has led to the development of service delivery models reflecting the specific characteristics of HIV and its treatment as well as local contexts and cultures. Given the shared barriers and challenges faced by health programmes in lower-income countries, many of the implementation approaches developed for HIV programmes have the potential to contribute to the continuity care framework needed to address non-communicable diseases in resource-limited settings. HIV programmes are, in fact, the first large-scale chronic disease programmes in many countries, offering local and effective tools, models, and approaches that can be replicated, adapted, and expanded. As such, they might be used to 'jumpstart' the development of initiatives to provide prevention, care, and treatment services for non-communicable diseases and other chronic conditions.

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Editors’ note: With chronic non-communicable diseases (NCD) such as diabetes, cardiovascular disease, cancers, and chronic respiratory disease now the leading causes of death globally, attention is turning to the successes of scale-up of services for HIV infection, itself a chronic condition. Millennium Development Goal (MDG) 6 is focused on HIV, tuberculosis, and malaria, but it also refers to ‘other major diseases’. The United Nations NCD high-level meeting that will take place in September 2011 will push to see integration of chronic disease indicators in the MDGs and outline strategies to reach these goals. The five priority interventions are tobacco control, salt reduction, improved diets and physical activity, reduction of hazardous alcohol intake, and essential drugs and technologies. This article on not reinventing the wheel is essential reading for all of us. Episodic care and relief of acute symptoms characterise most health service delivery in low- and middle-income countries, the exception being antiretroviral therapy programmes. As the NCD field looks to HIV chronic care for inspiration, the unique features of HIV service delivery are drawing attention. These include innovative service delivery models (including task shifting/sharing, data monitoring for improved care, procurement strengthening, etc.), civil society involvement, engagement of people living with HIV, local leadership and ownership, domestic and international funding, and multi-sectoral engagement. The hallmark of HIV service delivery is continuity of care with a focus on commitment to lifelong antiretroviral therapy by individuals, by programme planners, and by funders. This commitment is built on a base of activism, leadership, community engagement, and health worker empowerment, with donors stepping forward in response. The growing NCD movement can take a leaf from the HIV book but change will come more quickly if we work together to raise awareness, mobilise effective responses, and integrate services to provide continuity of care for chronic conditions worldwide—while prioritising primary prevention of hypertension, tobacco and alcohol addiction, diabetes, obesity, and HIV risk, based on clear understandings of their underlying determinants.

Health workforce skill mix and task shifting in low income countries: a review of recent evidence

Fulton BD, Scheffler RM, Sparkes SP, Auh EY, Vujicic M, Soucat A. Hum Resour Health. 2011 Jan 11;9(1):1

Health workforce needs-based shortages and skill mix imbalances are significant health workforce challenges. Task shifting, defined as delegating tasks to existing or new cadres with either less training or narrowly tailored training, is a potential strategy to address these challenges. This study uses an economics perspective to review the skill mix literature to determine its strength of the evidence, identify gaps in the evidence, and to propose a research agenda. Studies primarily from low-income countries published between 2006 and September 2010 were found using Google Scholar and PubMed. Keywords included terms such as skill mix, task shifting, assistant medical officer, assistant clinical officer, assistant nurse, assistant pharmacist, and community health worker. Thirty-one studies were selected to analyze, based on the strength of evidence. First, the studies provide substantial evidence that task shifting is an important policy option to help alleviate workforce shortages and skill mix imbalances. For example, in Mozambique, surgically trained assistant medical officers, who were the key providers in district hospitals, produced similar patient outcomes at a significantly lower cost as compared to physician obstetricians and gynaecologists. Second, although task shifting is promising, it can present its own challenges. For example, a study analyzing task shifting in HIV in sub-Saharan Africa noted quality and safety concerns, professional and institutional resistance, and the need to sustain motivation and performance. Third, most task shifting studies compare the results of the new cadre with the traditional cadre. Studies also need to compare the new cadre's results to the results from the care that would have been provided--if any care at all--had task shifting not occurred. Task shifting is a promising policy option to increase the productive efficiency of the delivery of health care services, increasing the number of services provided at a given quality and cost. Future studies should examine the development of new professional cadres that evolve with technology and country-specific labour markets. To strengthen the evidence, skill mix changes need to be evaluated with a rigorous research design to estimate the effect on patient health outcomes, quality of care, and costs.

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Editors’ note: Economic analysis defines the ‘optimal skill mix’ for health care workers as ‘productively efficient’, i.e. the combination of health workers that will produce a given level of health care services of a particular quality for the lowest cost. Factors that influence the productively efficient mix of workers include other health inputs (facilities, equipment, information systems, supplies, pharmaceuticals) and non-health inputs (transportation infrastructure and patient education levels), the production processes that use the inputs to create health care services, and the type (e.g. primary care, HIV treatment, birth deliveries, chronic care) and quality of services that are produced. This review of health workforce studies published since 2006 presents the evidence that task shifting can increase productive efficiency and reduce the time needed to scale-up health services, highlighting examples of studies comparing patient outcomes and presenting cost-effectiveness analyses. In addition to setting out a research agenda based on evidence gaps, it points to the role of new technologies, including e-health and telemedicine. Examples include the Kenya trial of community-based care provided by people living with HIV equipped with pre-programmed personal digital assistants (HIV This Week Issue 85) and the internet mentoring of health workers in Zambia by HIV clinicians in South Africa, Canada, and the USA. Although the concept of ‘task sharing’, piloted at the Orange Farm male circumcision service, is not mentioned here, it is an excellent example of improved efficiency with quality outcomes for patients.

Linkage to HIV care and antiretroviral therapy in Cape Town, South Africa

Kranzer K, Zeinecker J, Ginsberg P, Orrell C, Kalawe NN, Lawn SD, Bekker LG, WoodR. PLoS One. 2010 Nov 2;5(11):e13801.

Antiretroviral therapy has been scaled-up rapidly in Africa. Programme reports typically focus on loss to follow-up and mortality among patients receiving antiretroviral therapy. However, little is known about linkage and retention in care of individuals prior to starting antiretroviral therapy. Data on adult residents from a periurban community in Cape Town were collected at a primary care clinic and hospital. HIV testing registers, CD4 count results provided by the National Health Laboratory System and antiretroviral therapy registers were linked. A random sample (n = 885) was drawn from adults testing HIV positive through antenatal care, sexual transmitted disease and voluntary testing and counselling services between January 2004 and March 2009. All adults (n = 103) testing HIV positive through TB services during the same time period were also included in the study. Linkage to HIV care was defined as attending for a CD4 count measurement within 6 months of HIV diagnosis. Linkage to antiretroviral therapy care was defined as initiating ART within 6 months of HIV diagnosis in individuals with a CD4 count ≤200 cells/µl taken within 6 months of HIV diagnosis. Only 62.6% of individuals attended for a CD4 count measurement within 6 months of testing HIV positive. Individuals testing through sexually transmitted infection services had the best (84.1%) and individuals testing on their own initiative (53.5%) the worst linkage to HIV care. One third of individuals with timely CD4 counts were eligible for antiretroviral therapy and 66.7% of those were successfully linked to antiretroviral therapy care. Linkage to antiretroviral therapy care was highest among antenatal care clients. Among individuals not yet eligible for antiretroviral therapy only 46.3% had a repeat CD4 count. Linkage to HIV care improved in patients tested in more recent calendar period. Linkage to HIV and antiretroviral therapy care was low in this poor periurban community despite free services available within close proximity. More efforts are needed to link VCT scale-up to subsequent care.

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Editors’ note: As a chronic, lifelong infection, comprehensive treatment for HIV infection requires a continuum of care. Scaling up access to voluntary HIV testing, as South Africa has done with its ambitious campaign to test 15 million people by June 2011, will not reap its intended benefits if attention is lacking to what happens next. How many people who find out they have HIV infection then have a timely CD4 count done? If they are not yet eligible for antiretroviral treatment, they can benefit from cotrimoxasole, screening for TB and cervical cancer, isoniazid preventive therapy, contraceptive advice, and counselling and social support. In this study, there were fall-offs all along the cascade: less than two-thirds attended for a free CD4 count test within 6 months of their HIV diagnosis. Of those who did have a CD4 count test and were found not to be eligible for antiretroviral treatment, only 46% returned for a repeat CD4 count after a median of 8 months. Of those who were eligible for antiretroviral treatment, with a CD4 count less than 200 cells/µl, fully one-third did not start on free antiretroviral treatment. Qualitative studies to understand these findings should be complemented with programme reporting to routinely identify what the authors term ‘pre-antiretroviral therapy defaulting’ and address the causes of loss at each stage of the cascade.

How HIV/AIDS scale-up has impacted on non-HIV priority services in Zambia.

Brugha R, Simbaya J, Walsh A, Dicker P, Ndubani P. BMC Public Health. 2010 10(1):540.

Much of the debate as to whether or not the scaling up of HIV service delivery in Africa benefits non-HIV priority services has focused on the use of nationally aggregated data. This paper analyses and presents routine health facility record data to show trend correlations across priority services. The authors conducted a review of district office and health facility client records for 39 health facilities in three districts of Zambia, covering four consecutive years (2004-07). Intra-facility analyses were conducted, service and coverage trends assessed and rank correlations between services measured to compare service trends within facilities. Voluntary counselling and testing, antiretroviral therapy and prevention of mother-to-child transmission client numbers and coverage levels increased rapidly. There were some strong positive correlations in trends within facilities between reproductive health services (family planning and antenatal care) and antiretroviral therapy and prevention of mother-to-child transmission, with Spearman rank correlations ranging from 0.33 to 0.83. Childhood immunisation coverage also increased. Stock-outs of important drugs for non-HIV priority services were significantly more frequent than were stock-outs of antiretroviral drugs. The analysis shows scale-up in reproductive health service numbers in the same facilities where HIV services were scaling up. While district childhood immunisations increased overall, this did not necessarily occur in facility catchment areas where HIV service scale-up occurred. The paper demonstrates an approach for comparing correlation trends across different services, using routine health facility information. Larger samples and explanatory studies are needed to understand the client, facility and health systems factors that contribute to positive and negative synergies between priority services.

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Editors’ note: Whether the scale-up of HIV services is strengthening or depleting health systems continues to be hotly debated, usually with little evidence. This analysis of three districts in Zambia based on facility level data contributes interesting evidence to the dialogue. In these three districts where rapid scaling up of the delivery and coverage of HIV services was underway the impacts on non-HIV service delivery were mixed. The most positive impacts were seen on antenatal services (the intake for prevention of mother-to-child transmission) and increased client numbers in family planning services (which can help prevent unplanned pregnancy in women living with HIV). The fact that there were fewer antiretroviral drug stockouts than stockouts of other essential medicines (e.g. malaria drugs, oxytocin to accelerate labour, ergometrine for post-partum haemorrhage) suggests spill over positive effects in supply chains were not happening. Clearly more studies are needed to tease out the interactions but already this study is showing the way, highlighting the potential to derive useful evidence from routinely collected health facility data so that national planners and district programme managers can identify and address missed opportunities for synergies.