Improving rates of cotrimoxazole prophylaxis in resource-limited settings: implementation of a quality improvement approach.

OBJECTIVE: To demonstrate the effectiveness of quality improvement methods to monitor and improve administration of cotrimoxazole (CTX) prophylaxis to improve health outcomes among adults living with HIV/AIDS in low resource countries. DESIGN: Program evaluation. SETTING: HIV/AIDS health care facilities in Uganda, Mozambique, Namibia and Haiti. INTERVENTION: Performance measures based on national guidelines are developed in each country. These may include CD4 monitoring, ART adherence and uptake of CTX prophylaxis. CTX prophylaxis is routinely selected, because it has been shown to reduce HIV-related morbidity and mortality. Patient records are sampled using a standard statistical table to achieve a minimum confidence interval of 90% with a spread of ±8% in participating clinics. If an electronic medical record is available, all patients are reviewed. Routine review of performance measures, usually every 6 months, is conducted to identify gaps in care. Improvement interventions are developed and implemented at health facilities, informed by performance results, and local/national public health priorities. MAIN OUTCOME MEASURE: Median clinic rates of CTX prophylaxis. RESULTS: Median performance rates of CTX prophylaxis generally improved for adult HIV+ patients between 2006 and 2013 across countries, with median clinic rates higher than baseline at follow-up in 16 of 18 groups of clinics implementing CTX -focused improvement projects. CONCLUSIONS: Quality management offers a data-driven method to improve the quality of HIV care in low resource countries. Application of improvement principles has been shown to be effective to increase the rates of CTX prophylaxis in national HIV programs in multiple countries.

HIV-related knowledge and adherence to HAART.

Near perfect adherence is considered essential for patients on HAART, yet adherence to medical recommendations is rarely so high. Supportive services and reminder tools may help individuals to become adherent, yet it is difficult to determine who may need such interventions. In this study, based on data from the NYSDOH/AIDS Institute Treatment Adherence Demonstration Program, we look at the association between HIV-related knowledge and adherence, hypothesizing that a better understanding of HIV and its treatment is associated with better adherence. In analyses based on 997 participants, knowledge, as measured by five true/false questions, was significantly associated with self-reported adherence. In multivariate analysis, compared to persons with four or five items answered correctly, persons with fewer correct answers were more likely to report missed doses (OR = 1.72 for 2-3 correct, p < 0.01; OR = 2.92 for 0-1 correct, p < 0.05). Our data suggest that providers should include questions focused on knowledge of HIV in their assessments of medication readiness and need for adherence support. Similarly, providers should be diligent with respect to patient education, ensuring that each patient has the information needed to support reasoned decision making and adequate adherence.

A new paradigm for HIV care: ethical and clinical considerations.

Although dramatic advances in clinical treatment have greatly improved the lives of many people with HIV/AIDS, many other patients do not have information about or access to these treatments because of health care providers' presumptive judgments about patients' ability to adhere to medical regimens. The authors contend that with sufficient support and education most patients, even those with difficult social and medical problems, can be helped to initiate and maintain HIV treatment in accordance with current clinical standards. This commentary delineates a new paradigm for HIV care in which patients and providers collaborate on individualized plans to establish patients' readiness for treatment, ensure maintenance of treatment, and make use of the social services necessary to accomplish these goals. Providers have an ethical responsibility to do everything possible to see that patients who might benefit from new HIV treatments have a fair opportunity to do so, and health systems have a responsibility to facilitate this process. Substantial progress toward meeting these responsibilities can be made within the current health care environment.

Hospitalization of patients infected with active TB in New York State, 1987-1992: the effect of the HIV epidemic.

Hospital discharge records were used to study the relationship between human immunodeficiency virus (HIV) epidemic and hospitalized patients with tuberculosis in New York State from 1987 through 1992. The discharges of patients coinfected with HIV and tuberculosis increased by 270%, rising from 1,573 in 1987 to 5,825 in 1992. This constitutes an increase from 19.8 to 49.1% of all discharges of patients with tuberculosis. Discharges of tuberculosis patients who were not infected with HIV decreased slightly during this time, going from 6,359 to 6,039. Postdischarge treatment plans, HIV prevention, HIV testing, and HIV educational programs for the tuberculosis population require special consideration, given the significant rise of HIV in the tuberculosis-infected population.

Managing early HIV infection. Agency for Health Care Policy and Research.

This Quick Reference Guide for Clinicians contains highlights from the Clinical Practice Guideline on Evaluation and Management of Early HIV Infection, which was developed by a private-sector panel of health care providers and consumers. Selected aspects of evaluating and managing patients, both adults and children, who are in the early stages of human immunodeficiency virus infection are presented. Topics covered include disclosure of HIV status, monitoring of CD4 lymphocyte counts, prevention of Pneumocystis carinii pneumonia and infection with Mycobacterium tuberculosis, initiation of antiretroviral therapy, treatment of syphilis, eye and oral care, performance of Papanicolaou smears, diagnosis of HIV infection in infants and children, preventive therapy for PCP and assessment of neurologic problems in HIV-infected children, pregnancy counseling, and development of a comprehensive case management system. Algorithms are included that show the sequence of events related to evaluating and managing early HIV infection in adults and children, as well as drug dosing tables for antiretroviral, PCP, and M. tuberculosis therapies.