Does the public antiretroviral treatment programme meet patients' needs? A study at four hospitals in eThekwini, KwaZulu-Natal, South Africa

Background: Patients play a major role in the success of any antiretroviral treatment (ART) programme. Hence, their needs should be articulated on a regular basis for interventional processes to promote adherence, retention and quality care.Aim: This study investigated whether patients' needs were being met, described which needs were met, which were not and how such needs could be met.Setting: The study took place at four ART clinics in eThekwini district public hospitals.Methods: This study formed part of a larger study that utilised a sequential mixed-methods design. However, only the qualitative component is documented herein. Twelve HIV-infected patients engaged in in-depth interviews (three patients from each of the four hospitals). A socio-ecological framework divided responses into four categories, namely, the individual, interpersonal, institutional and policy. Each category presented (1) patients' needs that are being met, (2) needs that are not being met, (3) recommendations on how they can be met and (4) researchers' observations.Results: All 12 patients reported that all their needs were not being met. They further shared their met needs, unmet needs and made recommendations for meeting their unmet needs. These needs varied per antiretroviral clinic because of unique processes at each institution.Conclusion: To adequately address the needs of HIV-infected patients, it is imperative for all stakeholders involved in the public ART programme to gain an understanding of what constitutes 'patients' needs'. The results reflect patients' willingness to be involved in their care, treatment and interventional strategies to adequately meet their needs

How accurately do routinely reported HIV viral load suppression proportions reflect progress towards the 90-90-90 target in the population on antiretroviral treatment in Khayelitsha, South Africa?

Background. The Joint United Nations Programme on HIV/AIDS (UNAIDS) third 90-90-90 target requires 90% of patients on antiretroviral treatment (ART) to be virally suppressed (<1 000 copies/mL). In Khayelitsha, Cape Town, South Africa viral load (VL) suppression of <400 copies/mL was reported as 89% in 2016, but only 56% of patients had a result recorded in routine data. We conceived a VL 'cascade' to represent the steps required for an expected VL to be reported as complete in routine data and thus contribute to reported VL suppression: among those for whom a VL is 'expected', a sample must be collected and tested ('done'), a result must be 'filed' in the patient folder, 'noted' by a clinician and electronically 'captured'. The low reported completion suggested gaps along the VL cascade and cast doubt on the validity of reported suppression.Objectives. To assess the validity of routinely reported VL suppression and identify barriers to VL completion. Methods. A retrospective cohort study between 1 July 2015 and 30 June 2016, which included all Khayelitsha patients receiving ART, with a routine VL expected, was conducted. We obtained data routinely captured on site and VL data from the laboratory system. A sample of 1 035 patient folders was reviewed. VL suppression was calculated using laboratory data, including all tests done, and compared with reported suppression based on on-site captured electronic data. Successful progression through each step on the VL cascade was estimated. We used logistic regression to identify factors associated with laboratory data and reported VL testing.Results. Of 22 991 patients for whom a routine VL test was due, 84% were done, 79% filed, 76% noted and 55% captured. Using all laboratory data, VL suppression was estimated as 82%, 87%, 89% and 91% at the 50, 200, 400 and 1 000 copies/mL thresholds, respectively, but reported suppression using captured results was 80%, 86%, 88% and 89% at those thresholds. Routine VL testing is more likely to be done in children <15 years old (adjusted odds ratio (aOR) 1.89, 95% confidence interval (CI) 1.45 - 2.48) and pregnant women (aOR 1.90, 95% CI 1.28 - 2.81) than in men, adjusted for facility. Conclusions. Despite a low reported completion, VL testing completion was high. Reported suppression using captured data was similar to suppression calculated using all laboratory data, which provided an accurate measure of progress towards the 90-90-90 target. More work is needed to reach the 16% of patients missed by routine testing

At this [adherence] club, we are a family now': A realist theory-testing case study of the antiretroviral treatment adherence club, South Africa

Background: An estimated 7.9 million people were living with HIV in South Africa in 2017, with 63.3% of them remaining in antiretroviral therapy (ART) care and 62.9% accessing ART. Poor retention in care and suboptimal adherence to ART undermine the successful efforts of initiating people living with HIV on ART. To address these challenges, the antiretroviral adherence club intervention was designed to streamline ART services to 'stable' patients. Nevertheless, it is poorly understood exactly how and why and under what health system conditions the adherence club intervention works.Objectives: The aim of this study was to test a theory on how and why the adherence club intervention works and in what health system context(s) in a primary healthcare facility in the Western Cape Province.Method: Within the realist evaluation framework, we applied a confirmatory theory-testing case study approach. Kaplan­Meier descriptions were used to estimate the rates of dropout from the adherence club intervention and virological failure as the principal outcomes of the adherence club intervention. Qualitative interviews and non-participant observations were used to explore the context and identify the mechanisms that perpetuate the observed outcomes or behaviours of the actors. Following the retroduction logic of making inferences, we configured information obtained from quantitative and qualitative approaches using the intervention­context­actor­mechanism­outcome heuristic tool to formulate generative theories.Results: We confirmed that patients on ART in adherence clubs will continue to adhere to their medication and remain in care because their self-efficacy is improved; they are motivated or are being nudged.Conclusion: A theory-based understanding provides valuable lessons towards the adaptive implementation of the adherence club intervention

Alerte précoce de la pharmacorésistance du VIH au Togo

Introduction. Dans le cadre de l'ambition globale de mettre fin à l'épidémie du VIH, le Togo a débuté en 2016 la stratégie « Tester et traiter » proposée par l'ONUSIDA pour les cibles telles que les femmes enceintes, couples sérodiscordants, enfants, patients coinfectés TB/VIH, populations clés. Ainsi la stratégie nationale prévoit d'atteindre 90% de couverture de traitement antirétroviral (TARV) à l'horizon 2020. Le passage à grande échelle du TARV peut occasionner une augmentation du risque d'émergence des résistances du VIH aux ARV (RDVIH). La résistance pouvant mettre en échec l'impact de l'accélération en cours du Traitement ARV, nous avons évalué au Togo les indicateurs d'alerte précoce de la pharmacorésistance du VIH (IAP). C'est une stratégie reconnue efficiente dans les pays à ressources limitées pour assurer l'efficacité des protocoles antirétroviraux de première ligne moins dispendieux. Méthodologie. Nous avons en juin 2017 suivant les normes de l'OMS mené une étude rétrospective dans 80 sites de TARV représentatifs des 06 régions sanitaires du pays. Les cinq IAP suivants ont été étudiés : IAP1 : Retrait des médicaments ARV dans les délais ; avec comme seuils : Rouge <80% ; Orange 80­90% ; Vert >90%. IAP2 : Rétention sous TARV après 12 mois d'initiation du traitement avec pour seuils : Rouge <75%; Orange 75­85%; Vert >85%. IAP3 : Ruptures de stocks de médicaments avec comme seuils : Rouge <100%; Vert =100% sans rupture de stock en 2016, IAP4: Pratiques de prescription à l'initiation du traitement ARV avec comme seuils: Rouge <100%; Vert =100% de prescription conformes aux directives nationales. IAP5a : Couverture de réalisation des charges virales avec rendu des résultats avec comme seuils : Rouge < 70%, Vert > 70% des patients ayant une charge virale disponible à 12 mois de TARV. IAP5b: suppression de la charge virale à 12 mois avec pour seuils: Rouge <75%, Orange 75-90%, Vert >90% de suppression de charge virale à 12 mois de TARV, Résultats. Seuls 5468 patients (67%) ont retiré leurs médicaments dans les délais. Cependant 91% (3429/3767) des personnes initiées au TARV sont restées sous traitement douze mois après (IAP 2) mais seulement 5,2% (178/3429) des PVVIH dans le besoin ont eu accès à l'examen de la charge virale, (5a). Seuls 13 sites parmi les 36 ayant un score vert à l'IAP2 avaient atteint l'objectif de suppression de la charge virale (IAP 5b.). Seuls 63 sites sur les 80 ont atteint le seuil de l'IAP et 36/80 enquêtés ont pu atteindre l'objectif de l'IAP2. Conclusion. Nos résultats font craindre un risque d'émergence de la pharmaco-résistance du VIH sur le plan national. Les pratiques de dispensation sont conformes aux directives nationales, la rétention sous TARV à 12 mois est excellente, mais le respect des délais de retrait des médicaments ARV et les ruptures de stocks dans l'approvisionnement des ARV, constituent des facteurs majeurs dans plusieurs sites, pouvant permettre l'émergence de la pharmaco-résistance du VIH au Togo. La couverture de l'examen de la charge virale est très faible et nécessite en urgence d'être étendue

The role of support groups in linking and retaining newly diagnosed clients in HIV care in a peri-urban location in South Africa

Although South Africa has the largest number of people on antiretroviral therapy (ART) in the world, many HIV clients drop out of care immediately after HIV diagnosis. This qualitative study explored the perceptions and experiences of newly diagnosed clients on the role support groups play in linking and retaining newly diagnosed clients in HIV care in Mbandazayo peri-urban location. The data were analysed using the thematic content analysis approach. Data revealed four mechanisms through which support groups appeared to link and retain newly diagnosed clients in the HIV care continuum. First, support groups were a formal link between newly diagnosed clients and health facilities. Second, support groups mitigated the effects of both felt and enacted stigma, thereby facilitating acceptance of HIV diagnosis among newly diagnosed clients. Third, support groups were an advocacy and networking tool for newly diagnosed clients to make their health related needs, challenges, and concerns known to local health clinics, thereby forging and maintaining a close relationship with their local health facilities. Last, support groups were spaces within the community where practical needs of newly diagnosed clients are met, which in turn help in retaining them within support groups, and facilitate their linkage and retention in the HIV continuum of care in Mbandazayo. Our findings suggest that HIV support groups are critical in enhancing linkages and retention of newly diagnosed clients in HIV care. With the introduction of universal test and treat (UTT) in South Africa, our findings suggest that support groups can play a significant role in retaining HIV care clients who are diagnosed and immediately enrolled on ART

HIV prevalence and related behaviours of older people in Botswana ­ secondary analysis of the Botswana AIDS Impact Survey (BAIS) IV

The focus of HIV interventions in Botswana, a country with the second highest prevalence of HIV in the world, remains targeted at those aged 15­49 years despite a growing cohort of older people living with the disease ­ driven largely by the successful roll-out of antiretroviral therapy (ART). Primarily utilising the Botswana AIDS Impact Survey IV, we set out to examine HIV related characteristics and behaviours of this often ignored older cohort (50­64 years) relative to younger (25­49 years) adults. Analysis revealed that more than 80% of older people living with HIV were on ART. HIV prevalence among this older cohort was 24.6% in 2013 compared to 35.1% among the younger cohort, p < 0.0001. Prevalence in older adults was higher among older males (27.8%) than females (21.9%), p = 0.02. Furthermore, 58.9% of older adults acknowledged being sexually active, with 59.0% of these admitting to inconsistent condom use during sexual intercourse. In addition to this low condom usage, older men (6.0%) were significantly more likely to be unaware of their HIV-positive status than older women (3.0%), p = 0.002. While HIV prevalence showed a dramatic increase among older men over time (17.2% in 2004, to 23.4% in 2008, to 27.8% in 2013), the trend was flatter among older women (16.3% in 2004, to 22.4% in 2008, to 21.9% in 2013). These trends are likely attributable to a large increase in ART coverage and uptake. Going forward, more targeted interventions acknowledging the ageing epidemic are important to consider

'Treating a patient should be approached in a holistic manner': collaboration of doctors and physiotherapists in the rehabilitation of people living with HIV

People living with HIV facing impairments and subsequent disabilities related to the virus and its treatment require involvement of a collaborative team of healthcare professionals to ensure reintegration into daily life and community living. Healthcare teams responsible for this care include doctors and physiotherapists. This paper explores the collaboration of doctors and physiotherapists in the rehabilitation of people living with HIV in a semi-rural healthcare setting in KwaZulu-Natal, South Africa. Six doctors and two physiotherapists were interviewed using a semi-structured interview guide. The qualitative approach led to the emergence of five themes, namely a biomedical versus biopsychosocial approach; scope of practice challenge; multidisciplinary team enigma; institutional structure limitations; and recommendations from healthcare professionals. Both groups of professionals believed that a lack of understanding of the scope of practice and role of the associate profession in the multidisciplinary team led to poor referrals and lack of communication. Furthermore, shortage of personnel and resource limitations posed barriers to effective team interaction. Timely referrals, good communication and understanding of roles were suggested as endorsements to improved collaboration

HIV/AIDS: Knowledge, attitudes and practices among adolescents in Nimule, South Sudan

Background: HIV is an infectious virus commonly transmitted through body fluids mostly semen and blood. It causes a serious and non-curable disease with grave consequences especially in sub-Saharan Africa. In South Sudan the prevalence rate of HIV was estimated at 2.6% in 2016. The treatment options are scarce and educational programs limited. This is of great concern since limited knowledge and awareness of HIV is a major risk factor particularly, among young people.Method: A cross-sectional survey using self-administered questionnaires among adolescents was carried out in November 2016.Results: Sixty-five students participated in the study. In general they had good knowledge about HIV/AIDS with the majority having heard of HIV. Majority stated that HIV spreads through sex (82%), blood transfusion (95%), and from mother to child during pregnancy and delivery (66%). Several misconceptions were present with 43% responding that HIV can be transmitted through mosquito bites and 18% stating that the virus can be spread through shaking hands, hugging and living in the same house.Conclusion: Though the respondents showed fair knowledge about HIV/AIDS, there are still some areas in which they lack knowledge especially regarding spread of the disease and practice. More information about HIV/AIDS and sexual education should be made available

Sex after ART: sexual partnerships established by HIV-infected persons taking anti-retroviral therapy in Eastern Uganda

This paper explores the social contexts that influence the formation and nature of sexual partnerships among people on anti-retroviral therapy (ART). We draw on the findings of a qualitative, longitudinal study of 70 people (36 women and 34 men) who have been participating in a home-based ART programme for over three years in Eastern Uganda. Since initiating ART, 32 (18 men and 14 women) participants reported having had a new partner. Five participants (4 men and 1 woman) renewed relationships with spouses with whom they had been prior to starting ART. Overall, 37 of the 70 participants had had a sexual partner after starting ART. Companionship, material support, social and cultural norms, as well as a desire for sex and children, are drivers of new relationships. The opportunity that ART brings for people to get on with their lives brings with it a reinstatement into a social world that places a value on marriage and child-bearing. The sexual rights of those living with HIV and on ART need to be taken seriously and safer sex facilitated

Perceived risk factors of HIV infection and ART adherence at Zewditu Memorial hospital, Addis Ababa, Ethiopia: A survey of people living with HIV/ AIDS experiences

Introduction: Despite several interventions, HIV/AIDS continued global leading cause of morbidity and mortality, particularly in developing countries including Ethiopia. Aim: This study was aimed at assessing the risks of HIV infection and conditions after ART initiation among people living with HIV/AIDS at Zewditu Hospital, Addis Ababa, Ethiopia. Methods: An ethnographic study was conducted using an in-depth interview through semi structured questionnaire and tape recorder. Using tape recorder, careful probing, verbatim transcription, interviewing up to saturation point and considering disparity are activities to keep data trustworthiness. Data were read carefully and grouped in to themes; risky behaviors, diagnosis and reactions, conditions after ART initiation, and future plan for thematic analysis. Results: Seven people living with HIV/AIDS (three male and four female) were participated. The mean age of respondents was 39.29 ± 6.34 SD. There were three orthodox followers, three divorced, two in marriage and two college graduated. All had serious risky behaviors to HIV infection: four had multiple sexual partners, three were very poor, two with substance abuse, two had blood contact history, and one had unprotected sex with different men. All accepted their diagnosis result, but only four started ART soon. All participants stopped having children or pregnancy since knowing their status and only four disclosed status. All respondents showed health improvement, and four respondents have desire to have marriage and children. Conclusions: Interviewed people were with different serious risky behaviors that will lead them HIV infection. ART service helped them improve their health, weight gain and have future plan on marriage, having children and education. Coordinated community level education, strong counseling, accessing uninterrupted HIV testing and ART services, open partner/family discussion, early HIV diagnosis and treatment, avoiding substance abuse, improving income of people with HIV/AIDS and safe sex practice are crucial to prevent HIV infection and improve ART adherence

Reticence in disclosure of HIV infection and reasons for bereavement: impact on perinatally infected adolescents' mental health and understanding of HIV treatment and prevention in Johannesburg, South Africa

Survival rates of perinatally infected HIV-positive adolescents (PIA) are increasing in sub-Saharan Africa. There is a gap in understanding how disclosure and bereavement have an impact on PIA beliefs and understanding of their HIV infection and its management. In-depth interviews were conducted with 25 purposively selected adolescents aged 13­19 years from 5 public health clinics in Johannesburg, South Africa. Data were analysed using NVivo 10 using a thematic approach. PIA experience incomplete disclosure both of their HIV status and reasons for their bereavements, which limits their understanding of how they became infected, vertical transmission and prevention options like prevention of mother-to-child transmission (PMTCT). Most participants were orphaned and were experiencing complicated grieving (i.e., engaged in unresolved tasks of grieving) which had a negative impact on their mental health, and ability to accept their HIV status and adhere to treatment. PIA need improved communication regarding vertical transmission and how they became HIV-positive, as well as reasons for death of their loved ones to properly understand their HIV status and engage effectively in management. Honest communication about how relatives died and truthful engagement in the process of disclosure of HIV status is necessary to reduce stigma and complicated grieving, and improve mental health in this population

"I will take ARVs once my body deteriorates": an analysis of Swazi men's perceptions and acceptability of Test and Start

Swaziland has the highest HIV prevalence in the world. To mitigate the spread and devastation caused by HIV and to improve the wellbeing of people living with HIV, the country has adopted the latest available HIV prevention campaigns, including "Test and Start". Because evidence from randomised controlled trials has demonstrated a significant risk reduction in HIV transmission when HIV-positive people start antiretroviral therapy (ART) early, Swaziland aims to find these people and link them to treatment. This study presents findings regarding the perceptions of this promising HIV-prevention intervention among men aged 17­69 years. A combination of qualitative methods including focus group discussions (12), in-depth interviews (17), informal conversations and participant observation (21) were used to collect data in two peri-urban communities in 2013­2014. Findings illustrate that men still fear taking an HIV test because of a relatively high probability of a positive test which some still interpret as a death sentence. Other potential barriers to the effectiveness of Test and Start programmes include lack of hospitality in hospitals, fear of starting treatment early related to side effects of ART, poverty, and lack of trust in the financial stability of the Swazi government. We argue that several social factors need to be considered for the Test and Start programme to be more effective

Compliance to HIV Treatment Monitoring Guidelines can Reduce Laboratory Costs

Background: Panel tests are a predetermined group of tests commonly requested together to provide a comprehensive and conclusive diagnosis; for example; liver function test (LFT). South African HIV antiretroviral treatment (ART) guidelines recommend individual tests for toxicity monitoring over panel tests. In 2008; the National Health Laboratory Services (NHLS) request form was redesigned to list individual tests instead of panel tests and removed the 'other tests' box option to facilitate efficient ART laboratory monitoring.Objectives: This study aimed to demonstrate changes in laboratory expenditure; for individual and panel tests; for ART toxicity monitoring.Method: NHLS Corporate Data Warehouse (CDW) data were extracted for HIV conditional grant accounts to assess ART toxicity monitoring laboratory expenditure between 2010/2011 and 2014/2015. Data were classified based on the tests requested; as either panel (LFT or urea and electrolytes) or individual (alanine transaminase or creatinine) tests.Results: Expenditure on panel tests reduced from R340 million in 2010/2011 to R140m by 2014/2015 (reduction of R204m) and individual test expenditure increased from R34m to R76m (twofold increase). A significant reduction in LFT panel expenditure was noted; reducing from R322m in 2010/2011 to R130m in 2014/2015 (60% reduction).Conclusion: Changes in toxicity monitoring guidelines and the re-engineering of the NHLS request form successfully reduced expenditure on panel tests relative to individual tests. The introduction of order entry systems could further reduce unnecessary laboratory expenditure

PIMAPotassium Iodide Point-of-Care Testing for CD4 Counts in Predicting Antiretroviral Initiation in HIV-Infected Individuals in KwaZulu-Natal; Durban; South Africa

Introduction: Limited information is available on the usefulness of the PIMATM analyser in predicting antiretroviral treatment eligibility and outcome in a primary healthcare clinic setting in disadvantaged communities in KwaZulu-Natal; South Africa.Materials and methods: The study was conducted under the eThekwini Health Unit; Durban; KwaZulu-Natal. Comparison of the enumeration of CD4+ T-cells in 268 patients using the PIMATM analyser and the predicate National Health Laboratory Services (NHLS) was undertaken during January to July 2013. Bland-Altman analysis to calculate bias and limits of agreement; precision and levels of clinical misclassification at various CD4+ T-cell count thresholds was performed.Results: There was high precision of the PIMATM control bead cartridges with low and normal CD4+ T-cell counts using three different PIMATM analysers (%CV 5). Under World Health Organization (WHO) guidelines (

Computational Models as Predictors of HIV Treatment Outcomes for the Phidisa Cohort in South Africa

Background: Selecting the optimal combination of HIV drugs for an individual in resourcelimited settings is challenging because of the limited availability of drugs and genotyping.Objective: The evaluation as a potential treatment support tool of computational models that predict response to therapy without a genotype; using cases from the Phidisa cohort in South Africa.Methods: Cases from Phidisa of treatment change following failure were identified that had the following data available: baseline CD4 count and viral load; details of failing and previous antiretroviral drugs; drugs in new regimen and time to follow-up. The HIV Resistance Response Database Initiative's (RDI's) models used these data to predict the probability of a viral load 50 copies/mL at follow-up. The models were also used to identify effective alternative combinations of three locally available drugs.Results: The models achieved accuracy (area under the receiver-operator characteristic curve) of 0.72 when predicting response to therapy; which is less accurate than for an independent global test set (0.80) but at least comparable to that of genotyping with rules-based interpretation. The models were able to identify alternative locally available three-drug regimens that were predicted to be effective in 69% of all cases and 62% of those whose new treatment failed in the clinic.Conclusion: The predictive accuracy of the models for these South African patients together with the results of previous studies suggest that the RDI's models have the potential to optimise treatment selection and reduce virological failure in different patient populations; without the use of a genotype

Trends in task shifting in HIV treatment in Africa: effectiveness, challenges and acceptability to the health professions

Background: Task shifting has been suggested to meet the demand for initiating and managing more patients on antiretroviral therapy. Although the idea of task shifting is not new; it acquires new relevance in the context of current healthcare delivery.Aim: To appraise current trends in task shifting related to HIV treatment programmes in order to evaluate evidence related to the effectiveness of this strategy in addressing human resource constraints and improving patient outcomes; challenges identified in practice and the acceptability of this strategy to the health professions. Method: Electronic databases were searched for studies published in eng between January 2009 and December 2014. Keywords such as 'task shifting'; 'HIV treatment'; 'human resources' and 'health professions' were used.Results: Evidence suggests that task shifting is an effective strategy for addressing human resource constraints in healthcare systems in many countries and provides a cost-effective approach without compromising patient outcomes. Challenges include inadequate supervision support and mentoring; absent regulatory frameworks; a lack of general health system strengthening and the need for monitoring and evaluation. The strategy generally seems to be accepted by the health professions although several arguments against task shifting as a long-term approach have been raised.Conclusion: Task shifting occurs in many settings other than HIV treatment programmes and is viewed as a key strategy for governing human resources for healthcare. It may be an opportune time to review current task shifting recommendations to include a wider range of programmes and incorporate initiatives to address current challenges

The Economics; Financing and Implementation of HIV Treatment as Prevention: What will it Take to Get there?

"The 2013 Lancet Commission Report; Global Health 2035; rightly pointed out that we are at a unique place in history where a ""grand convergence"" of health initiatives to reduce both infectious diseases; and child and maternal mortality - diseases that still plague low income countries - would yield good returns in terms of development and health outcomes. This would also be a good economic investment. Such investments would support achieving health goals of reducing under-five (U5) mortality to 16 per 1 000 live births; reducing deaths due to HIV/AIDS to 8 per 100 000 population; and reducing annual TB deaths to 4 per 100 000 population. Treatment as prevention (TasP) holds enormous potential in reducing HIV transmission; and morbidity and mortality associated with HIV/AIDS - and therefore contributing to Global Health 2035 goals. However; TasP requires large financial investments and poses significant implementation challenges. In this review; we discuss the potential effectiveness; financing and implementation of TasP. Overall; we conclude that TasP shows great promise as a cost-effective intervention to address the dual aims of reducing new HIV infections and reducing the global burden of HIV-related disease. Successful implementation will be no easy feat; though. The dramatic increases in the numbers of persons who need antiretroviral therapy (ART) under a TasP approach will pose enormous challenges at all stages of the HIV treatment cascade: HIV diagnosis; antiretroviral (ARV) initiation; ARV adherence and retention; and increased drug resistance with long-term enrolment on ART. Overcoming these implementation challenges will require targeted implementation; not focusing exclusively on TasP; most-at-risk population (MARP)-friendly services for key populations; integrating services; task shifting; more efficient programme management; balancing supply and demand; integration into universal health coverage efforts; demand creation; improved ART retention and adherence strategies; the use of incentives to improve HIV treatment outcomes and reduce unit costs; continued operational research and tapping into technological innovations."

Evaluation of a Task-Shifting Strategy Involving Peer Educators in HIV Care and Treatment Clinics in Lusaka; Zambia

Rapid expansion of antiretroviral therapy (ART) and a shortage of health care workers (HCWs) required the implementation of a peer educator (PE) model as part of a task-shifting strategy in Lusaka District clinics. The purpose of this study was to evaluate patient and staff perceptions regarding whether the PE program: a) relieved the workload on professional HCWs; and b) delivered services of acceptable quality. Qualitative and quantitative data were gathered from five primary care clinics delivering ART in Lusaka; Zambia. Closed surveys were conducted with 148 patients receiving ART; 29 PEs; and 53 HCWs. Data was imported into Microsoft Excel to calculate descriptive statistics. Six focus group discussions and eight key informant (KI) interviews were conducted; recorded; transcribed; and coded to extract relevant data. Survey results demonstrated that 50 of 53 (96.1) HCWs agreed PEs reduced the amount of counseling duties required of HCWs. HCWs felt that PEs performed as well as HCWs in counseling patients (48 of 53; 90.6) and that having PEs conduct counseling enabled clinical staff to see more patients (44 of 53; 83). A majority of patients (141 of 148; 95.2) agreed or strongly agreed that PEs were knowledgeable about ART; and 89 of 144 (61.8) expressed a high level of confidence with PEs performing counseling and related tasks. Focus group and KI interviews supported these findings. PEs helped ease the work burden of HCWs and provided effective counseling; education talks; and adherence support to patients in HIV care. Consideration should be given to formalizing their role in the public health sector

Virologic and immunologic outcome of treatment of HIV infection with a herbal concoction, A-Zam, among clients seeking herbal remedy in Nigeria

Abstract: This study was to determine the effectiveness (CD4 count and viral load) of a safe herbal concoction, α-Zam used by clients seeking herbal remedy for treatment of HIV infection in Nigeria. 51 patients taking α-Zam as complementary and alternative therapy through the herbal therapist were studied for a period of 16 months. Preliminary medical and laboratory examinations using WHO and CDC criteria were done after confirmation of HIV infection by Western blotting in the nearest teaching hospitals to the residence of the patients. Regular visits were paid to the patients after commencement of the α-Zam to assess the side-effects, drug interactions, toxicity and effectiveness of the herbal remedy. There was a statistical significance (P<0.05) between pre-treatment and post-treatment CD4 count. 4 (7.8%) of the patients had average increase in CD4 count of 262±16 cell/µL, 23 (45.1%) patients with average increase 310±16 cell/µL, 16 (31.4%) patients with average increase 456±25 cell/µL and 8 (15.7%) patients with average increase 510±36 cell/µL( %) were at WHO staging I , II, III and IV respectively within 4 months on herbal therapy. There was very marked reduction in viral (HIV-RNA) load with 41 (80.4%) and 10 (19.6%) HIV infected patients had undetectable viral load and <1000 copies/ml respectively after the therapy. All symptoms and signs associated with HIV infection in all patients fully subsided within 4 weeks of commencement of α-zam therapy and there was no evidence of negative drug interaction in those HIV patients using both the herbal and highly active anti-retroviral therapy (HAART). The study is in progress to determine periodic immunological outcomes of post therapy in all patients