Cost-effectiveness of intervention combinations towards the elimination of vertical transmission of HIV in limited-resource settings: a mathematical modelling study.

BACKGROUND: Since 2000, there has been a substantial global reduction in the vertical transmission of HIV. Despite effective interventions, gaps still remain in progress towards elimination in many low-income and middle-income countries. We developed a mathematical model to determine the most cost-effective combinations of interventions to prevent vertical transmission. METHODS: We developed a 12-month Markov model to follow a cohort of women of childbearing age (aged 15-49 years) in Zambia (n=1 107 255) who were either pregnant, in delivery, or breastfeeding; the population included in the model reflects the estimated number of pregnant women in Zambia from the 2018 Zambia Demographic and Health Survey. The model incorporated nine interventions: infant prophylaxis; three different HIV retesting schedule options; oral pre-exposure prophylaxis; maternal peer-support groups; regimen shift; tracing of loss to follow-up; and point-of-care viral load testing. We analysed incident HIV infections among mothers and infants, intervention costs, and evaluated 190 scenarios of different combinations of inventions to calculate the incremental cost-effectiveness ratios (ICERs) over 1 year. FINDINGS: Three interventions with the greatest reduction in vertical transmission, individually, were support groups for 80% of those in need (35% reduction in infant infections), HIV retesting schedules (6·5% reduction), and infant prophylaxis (4·5% reduction). Of all 190 scenarios evaluated, eight were on the cost-effectiveness frontier (ie, were considered to be cost-effective); all eight included increasing infant prophylaxis, regimen shift, and use of support groups. Excluding the highest-cost scenarios, for a 1-22% increase in total budget, 23-43% of infant infections could be prevented, producing ICERs between US$244 and $16 242. INTERPRETATION: Using the interventions modelled, it is possible to reduce vertical transmission and to cost-effectively prevent up to 1734 infant HIV infections (43% reduction) in Zambia over a period of 1 year. To optimise their effect, these interventions must be scaled with fidelity. Future work is needed to incorporate evidence on additional innovative interventions and HIV risk factors, and to apply the model to other country contexts to support targeted implementation and resource use. FUNDING: The ELMA Foundation.

Predicting Lost to Follow-Up Status Using an Adolescent HIV Psychosocial Attrition Risk Assessment Tool: Results From a Mixed Methods Prospective Cohort Study in Uganda.

BACKGROUND: Low retention in care for adolescents living with HIV (ALHIV) has been a key driver of suboptimal viral load suppression rates in Uganda. The objective of this study was to develop a psychosocial risk assessment tool and evaluate its ability to predict the risk of attrition of ALHIV between the ages 15 and 19 years. SETTING: The study was conducted in 20 facilities in Central and Western Uganda from August 2021 through July 2022. METHODS: A mixed methods prospective cohort study was conducted in two phases. In the first phase, the Adolescent Psychosocial Attrition Risk Assessment tool was developed and revised using feedback from focus group discussions and interviews. In the second phase, the ability of the Adolescent Psychosocial Attrition Risk Assessment tool to predict attrition among ALHIV was evaluated using diagnostic accuracy tests. RESULTS: A total of 597 adolescents between the ages 15 and 19 years were enrolled, of which 6% were lost to follow-up at the end of the study period. A 20-question tool was developed, with 12 questions being responded to affirmatively by >50% of all participants. Using a cut-off score of 6 or more affirmative answers translated to an area under the curve of 0.58 (95% CI: 0.49 to 0.66), sensitivity of 55% (95% CI: 36% to 72%), and specificity of 61% (95% CI: 56% to 65%). CONCLUSION: Although the Adolescent Psychosocial Attrition Risk Assessment tool was not effective at predicting lost to follow-up status among ALHIV, the tool was useful for identifying psychosocial issues experienced by ALHIV and may be appropriate to administer during routine care visits to guide action.

A Model for Accelerating Access to Care and Treatment for Children and Adolescents Living with HIV in Nigeria, Tanzania, Uganda, and Zambia: The Faith-Based Action for Scaling-Up Testing and Treatment for the Epidemic Response (FASTER) Initiative.

The number of children newly infected with HIV dropped by 50%, from 320 000 in 2010 to 160 000 in 2021. Despite progress, ongoing gaps persist in diagnosis, continuity of care, and treatment optimization. In response, the United States President's Emergency Plan for AIDS Relief created the Faith-based Action for Scaling-Up Testing and Treatment for Epidemic Response (FASTER). Faith-based Action for Scaling-Up Testing and Treatment for Epidemic Response addressed gaps in countries with the highest unmet need by working with government to operationalize innovative interventions and ensure alignment with national priorities and with communities living with HIV to ensure the change was community-led. Between 2019 and 2021, FASTER's interventions were incorporated into national policies, absorbed by Ministries of Health, and taken up in subsequent awards and country operating plans. Continued effort is needed to sustain gains made during the FASTER initiative and to continue scaling evidence-based interventions to ensure that children and adolescents are not left behind in the global HIV response.

Optimizing and validating a pediatric screening tool to more efficiently test and identify children living with HIV.

OBJECTIVE: To develop and validate a screening tool to improve testing efficiency and increase case finding of children living with HIV. DESIGN: Cross-sectional study. METHODS: Between November 2020 and September 2021, children 18 months to 14 years presenting at outpatient departments in 30 health facilities in Zambia were administered a 14-question pediatric HIV screening tool and then tested for HIV. Data were analyzed using a randomly extracted 'validation' dataset and multivariable logistic regression to determine the highest performing and optimal number of screening questions. The final tool was then evaluated in the 'test' dataset. Sensitivity and specificity were calculated for both datasets. The final tool was then also implemented in 12 additional facilities to determine operational feasibility and uptake. RESULTS: A total of 9902 children were included in the final analysis. HIV prevalence was 1.3%. Six questions were significantly associated with HIV-positivity. The optimal screening cutoff score was to answer 'yes' to one or more of the six questions; using this cutoff sensitivity was 92.5% [95% confidence interval (CI) 85.7-96.7%] and specificity was 62.9% (95% CI 61.9-64%). In the test dataset, the same tool had a sensitivity of 84.6% (95% CI 65.1-95.6%) and specificity of 64.6% (95% CI 62.4-66.7%). Uptake was 89%. CONCLUSION: The results of this study show sensitivity and acceptable specificity in a six-question validated HIV screening tool. Implementing this screening tool in settings where universal testing is not feasible should more efficiently accelerate identification of children living with HIV (CLHIV) and their timely initiation onto life-saving drugs.

A national Delphi study: experiences of general practitioner (GP) trainees in the Republic of Ireland undertaking online small group learning as part of the GP Training Programme during COVID-19.

INTRODUCTION: During the COVID-19 pandemic, GP training day release was redirected from face-to-face to an online setting. With this study, our aim was to assess trainee experiences of online small group learning and to make recommendations with regards to future GP training. METHODS: A qualitative study using the Delphi survey technique, approved by the Irish College of General Practitioners (ICGP) Ethics Committee. A series of three sequential online questionnaires were sent to our trainee cohort in all 14 training schemes in Ireland. The first questionnaire explored GP trainee experiences and key themes were generated. Subsequent questionnaires were developed using these themes, with second and third round questionnaires establishing consensus on these experiences. RESULTS: In total, 64 GP trainees responded. Each training scheme was represented. Response rates for round 1 and 2 were 76% and 56% respectively, with round 3 currently underway. Trainees felt that online teaching was convenient, reduced commuting costs, and provided peer support. They also reported loss in unstructured discussion, practical teaching sessions and relationship building. Seven key themes were generated: future format of GP training; accessibility and flexibility; teaching experience; provision of GP training; support and collegiality; educational experience; and technical problems. There is a consensus that some online teaching should be retained for the future. DISCUSSION: Online teaching provided a continuation in training that was more convenient and accessible but affected social interactions and relationship building amongst trainees. Future online sessions could be utilised in a hybrid model of teaching going forward.

Benefits and limitations of the transfer online of Irish College of General Practitioners (ICGP) continuing medical education (CME) small group learning (SGL) during COVID-19: a national Delphi study.

INTRODUCTION: In Ireland, continuing medical education (CME) small group learning (SGL) has been shown to be an effective way of delivering CME, particularly for rural general practitioners (GPs). This study sought to determine the benefits and limitations of the relocation of this education from face to face to online learning during COVID-19. METHODS: A Delphi survey method was used to obtain a consensus opinion from a group of GPs recruited via email through their respective CME tutors, and who had consented to participate. The first round gathered demographic details and asked doctors to report the benefits and/or limitations of learning online in their established Irish College of General Practitioners (ICGP) small groups. RESULTS: A total of 88 GPs from 10 different geographical areas participated. Response rates in rounds one, two and three were 72%, 62.5% and 64%, respectively. The study group was 40% male; 70% were in practice ≥15 years, 20% practiced rurally, and 20% were single-handed. Attending established CME-SGL groups allowed GPs to discuss the practical application of rapidly changing guidelines both in COVID-19 and non-COVID-19 care. They could discuss new local services and compare their practice with others during a time of change; this helped them feel less isolated. They reported that online meetings were less social; moreover, the informal learning that occurs before and after meetings did not take place. CONCLUSION: GPs in established CME-SGL groups benefited from online learning as they could discuss how to adapt to rapidly changing guidelines while feeling supported and less isolated. They report that face to face meetings offer more opportunities for informal learning.

How does small group continuing medical education (CME) impact on practice for rural GPs and their patients, a mixed-methods study.

Studies which report outcomes of continuing medical education (CME) interventions for rural general practitioners (GPs) are limited. This mixed methods study recruited GPs from four CME small group learning (SGL) tutor groups based in different rural locations in the Republic of Ireland. A two-hour teaching module on deprescribing in older patients was devised and implemented. Assessment of educational outcomes was via questionnaires, prescribing audits and qualitative focus groups. All GPs (n = 43) in these CME-SGL groups agreed to participate, 27 of whom (63%) self-identified as being in rural practice. Rural GPs were more likely to be male (56%), in practice for longer (19 years), and attending CME for longer (13 years). The questionnaires indicated learning outcomes were achieved knowledge increased immediately after the education, and was maintained 6 months later. Twenty-four GPs completed audits involving 191 patients. Of these, 152 (79.6%) were de-prescribed medication. In the qualitative focus groups, GPs reported sharing experiences with their peers during CME-SGL helped them to improve patient care and ensured that clinical practice is more consistent across the group. For rural GPs, CME-SGL involving discussion of cases and the practical implementation of guidelines, associated with audit, can lead to changes in patient care.

What are the current 'top five' perceived educational needs of Irish general practitioners?

INTRODUCTION: Doctors' continuing medical educational and professional development (CME and CPD) needs are known to be strongly influenced by national and local contextual characteristics. A crucial step in the development of effective education and training programmes is the assessment of learner needs. METHODS: A national needs assessment was conducted among general practitioners (GPs) in the Republic of Ireland who attended continuing medical education small group learning meetings (CME-SGL) in late 2017. Doctors completed a self-administered anonymous three-page questionnaire which gathered demographic data and asked them to choose their 'top five' perceived educational needs from separate lists of topics for CME and CPD. RESULTS: There were 1669 responses (98% of monthly attendance). The topics most commonly identified as a priority for further CME were prescribing (updates/therapeutics), elderly medicine, management of common chronic conditions, dermatology, and patient safety/medical error. The most commonly selected CPD topics were applying evidence-based guidelines to practice, appraising performance/conducting practice audits, coping with change, and managing risk and legal medicine. There was no difference between urban and rural practice settings regarding the most commonly chosen topics in each category; however, more rural GPs selected pre-hospital/emergency care as one of their 'top five'. CONCLUSION: Our findings identified priority areas where CME and CPD for GPs in Ireland should focus. The topics selected may reflect the changing nature of general practice, which increasingly requires delivery of care to an ageing population with more multi-morbidity and chronic disease management, while trying to apply evidence-based medicine and consider patient safety issues. CME/CPD programmes need to adapt accordingly.

Impact of participation in continuing medical education small group learning (CME-SGL) on the stress, morale, and professional isolation of rurally-based GPs: a qualitative study in Ireland.

BACKGROUND: The pressures of general practice contribute to high levels of stress, low morale, and burnout in some GPs. In addition, rurally-based doctors may experience significant professional isolation. Participation in continuing medical education (CME) appears to reduce stress, and may improve the retention of rural GPs. AIM: As part of a larger study devised to examine the effectiveness of regular participation in CME small group learning (SGL) on rurally-based Irish GPs, this study explored whether CME-SGL had any impact on GP stress, morale, and professional isolation. DESIGN & SETTING: This was a qualitative study involving four CME-SGL groups based in rural Ireland. METHOD: Semi-structured focus group interviews were conducted in established CME-SGL groups in four different rural geographical locations. Interviews were audiorecorded, transcribed verbatim, and analysed thematically. RESULTS: All members of these CME-SGL groups (n = 43) consented to interview. These GPs reported that regular meetings with an established group of trusted colleagues who are 'in the same boat' provided a 'safe space' for discussion of, and reflection on, both clinical concerns and personal worries. This interaction in a supportive, non-threatening atmosphere helped to relieve stress, lift morale, and boost self-confidence. The social aspect of CME-SGL sustained these rural GPs, and served to alleviate their sense of professional isolation. CONCLUSION: Delivery of CME through locally-based SGL provides as an important means of supporting GPs working in rural areas. The non-educational benefits of CME-SGL, as described by these Irish GPs, are of relevance for rural doctors in other countries.

Continuing education for general practitioners working in rural practice: a review of the literature.

Background Studies demonstrate that the CME/CPD (continuing medical education/continuing professional development) needs of rural general practitioners (GPs) are unique. Little research has focused specifically on the effectiveness of CME/CPD programmes for rural practice. Aims To review the literature on CME/CPD for GPs in rural areas, focussing on studies which examined impact on doctor performance or patient outcomes. Methods A search of peer-reviewed English language literature and relevant grey literature was conducted: identified literature was reviewed. Results Nineteen articles met the pre-specified inclusion criteria. Educational delivery approaches examined include regional CME/CPD small-group learning programmes, workshops and distance learning. Most articles report on participant experience or satisfaction while doctor performance and patient outcomes are seldom reported. Distance learning programmes found it difficult to recruit or engage doctors, two out of six studies found improvements in self-reported knowledge or performance, while none reported measurable changes in doctor performance/patient care.

Experiences of suicide bereavement: a qualitative study exploring the role of the GP.

BACKGROUND: Suicide is a major public health issue. GPs are often on the front line in responding to a suicide. They are called on to support individuals and families in the aftermath of suicide yet there is a dearth of research, particularly from patients' perspectives, on how to provide optimal care for those grieving a suicide in the primary care setting. AIM: To improve GP management of suicide bereavement by exploring the lived experiences of affected individuals, focusing on the GP's involvement in the grief process. DESIGN AND SETTING: A qualitative approach was adopted using focus group interviews with individuals from suicide bereavement support groups at three locations across Ireland. METHOD: Support groups were contacted by letter. Fifteen interested participants formed three focus groups. Interviews were audiorecorded and transcripts were analysed thematically using the framework method. RESULTS: Three major themes dominated: the need for acknowledgement - of the loss and of the lived life of the deceased; the role of stigma in the aftermath of the loss; and the need for proactive provision of direction and support during the grief journey. The GP was identified as ideally positioned in the community to cater for the needs of the bereaved. CONCLUSION: Suicide can result in prolonged, complex grief generating specific patient needs. Stigma may function as a barrier to help seeking. The GP should consider initiating contact with the bereaved. Recommendations have been made to support GPs in their care of the suicide bereaved.

Experiences of Irish general practice trainees who participate in 4-month rotations in Malawi and Australia.

BACKGROUND: International health electives provide doctors and medical students with unique educational experiences. The HSE South East GP training programme in Waterford, Ireland has run a four-month elective to Malawi since 2006, and also ran a four-month placement in Australia between 2004 and 2011. AIM: The aim of this study was to see whether these overseas electives provide Irish GP trainees with any positive or negative experiences, and to make recommendations regarding future similar rotations abroad. METHOD: This study used the Delphi survey technique, a qualitative research method. The first round questionnaire asked about challenges faced while overseas, what the trainees learned, and how the placement influenced their clinical practice on their return to Ireland. Doctors were also asked about the benefits and/or limitations of an overseas placement during GP training. RESULTS: These Irish GP trainees reported very positive outcomes from time spent in Malawi and Australia. They reported improved knowledge and skills, and increased awareness of health issues and cultural differences in another country. Moreover, they had an opportunity to reflect and grow personally as doctors. CONCLUSION: This is the first study looking at an international health elective as part of a vocational training programme in Ireland.

Extension of general practice training from three to four years: experiences of a vocational training programme in Southern Ireland.

The aim of this study was to evaluate the experiences of trainees taking part in an extended (four-year) general practice training programme introduced in the South Eastern region of the Republic of Ireland to replace the previous traditional (three-year) programme. In a qualitative design, eight homogeneous focus groups were held to determine the value of the additional year of training. The first cohort of trainees was interviewed towards the start and at the end of their fourth year. Trainees finishing the following year were also interviewed, as were graduates from the final three-year programme. GP trainers and the four members of the programme directing team comprised two further independent focus groups. Trainees reported that the integration of hospital posts and general practice attachments over the four years was particularly beneficial. The exposure to a variety of different general practices and the opportunity to take part in specialty clinics were considered extremely useful. The fourth year of training was felt to be less pressurised than previous years. Professional and personal development was enhanced; improved readiness to practise and confidence were noted. Perceived disadvantages of extended training included a lack of acknowledgment for doctors in their fourth year and excessive emphasis placed on research during the final year of training. The addition of an extra year of vocational training improves professional and personal development and changes the learning experience for doctors. Doctors felt more confident and ready to enter independent practice at the end of the fourth year of training.

Undergraduate teaching in palliative care in Irish medical schools: a questionnaire survey.

INTRODUCTION: The Association for Palliative Medicine of Great Britain and Ireland published an official curriculum for undergraduate teaching in 1993. This study was conducted in order to establish the current status of undergraduate teaching in this important discipline in Irish medical schools. METHODS: A questionnaire survey was sent to 26 individuals identified as having responsibility for palliative care teaching in the five Irish medical schools. The questionnaire asked about aspects of the curriculum covered, the years and setting in which teaching occurs, and the teaching and assessment methods used. RESULTS: Identification of the relevant teachers proved to be difficult; most appeared to be unaware of what teaching other than their own was occurring within their medical schools in this discipline. In no school is the teaching centrally co-ordinated. All five medical schools have specific time dedicated to the teaching of palliative care; in two cases this is one day or less. All schools covered most of the topics outlined in the curriculum. The majority of the teaching is by didactic lecture; there is some use of group discussion and case studies. Other teaching methods are rarely used. All schools have some teaching in the hospice setting. Four medical schools offer elective clinical rotations in palliative care; uptake of these by students is very poor. Assessment is usually as part of a written paper in medicine. CONCLUSIONS: The teaching of palliative care in Irish medical schools appears to fulfil the suggested curriculum. Co-ordination of this teaching should be improved.