Early infant diagnosis of HIV: review of current and innovative practices.

PURPOSE OF REVIEW: Only 51% of HIV-exposed infants receive an HIV test between 4 and 6 weeks of age, with even lower repeat testing rates at older ages, and only 49% of infants tested are initiated on antiretroviral therapy. The purpose of this article is to discuss potential solutions for increasing coverage of early infant diagnosis (EID), decreasing turnaround time for result return, improving linkages to care and treatment and fulfilling the objective of improving outcomes for HIV-infected children. RECENT FINDINGS: Differences in HIV testing guidelines have emerged in different countries, with some recommending HIV testing at birth. Although EID programs are not yet optimal, some solutions have proven successful including the use of short message service printers, community-based interventions and support and education of mothers. Birth and EID point-of-care testing have emerged as potential game changers for improving EID programs. SUMMARY: For EID programs to impact on child health outcomes, by preventing HIV-associated morbidity and mortality, and provide more value than a mere surveillance tool, efforts need to be aligned toward the implementation of a comprehensive set of interventions that take cognizance of different contexts, epidemiology and health systems, and that are backed by political and community support.

Attitudes of medical school deans toward interprofessional education in Western Pacific Region countries.

To examine the attitudes of medical school deans toward interprofessional education (IPE) and collaborative practice (CP), we conducted survey research in the Western Pacific Region. This regional survey was conducted as a collaborative research project with the World Health Organization. A survey was distributed to the medical school deans in Malaysia, the Philippines, Republic of Korea and Japan. Thirty-five surveys were returned from four countries. The survey demonstrated that many medical school deans have positive attitudes toward IPE and CP. However, respondents also reported that it is not easy to introduce interprofessional learning in their academic settings. It is suggested that collaboration between education systems and health systems is needed to introduce IPE in the academic setting. The possible role of international organizations is mentioned. This information helps to identify local efforts on which global health organizations and national governments can build.

Educating a new generation of doctors to improve the health of populations in low- and middle-income countries.

Francesca Celletti and colleagues from WHO argue that a transformation in the scale-up of medical education in low- and middle-income countries is needed, and detail what this might look like.

Task-shifting in HIV care: a case study of nurse-centered community-based care in Rural Haiti.

INTRODUCTION: At least 36 countries are suffering from severe shortages of healthcare workers and this crisis of human resources in developing countries is a major obstacle to scale-up of HIV care. We performed a case study to evaluate a health service delivery model where a task-shifting approach to HIV care had been undertaken with tasks shifted from doctors to nurses and community health workers in rural Haiti. METHODS: Data were collected using mixed quantitative and qualitative methods at three clinics in rural Haiti. Distribution of tasks for HIV services delivery; types of tasks performed by different cadres of healthcare workers; HIV program outcomes; access to HIV care and acceptability of the model to staff were measured. RESULTS: A shift of tasks occurred from doctors to nurses and to community health workers compared to a traditional doctor-based model of care. Nurses performed most HIV-related tasks except initiation of TB therapy for smear-negative suspects with HIV. Community health workers were involved in over half of HIV-related tasks. HIV services were rapidly scaled-up in the areas served; loss to follow-up of patients living with HIV was less than 5% at 24 months and staff were satisfied with the model of care. CONCLUSION: Task-shifting using a community-based, nurse-centered model of HIV care in rural Haiti is an effective model for scale-up of HIV services with good clinical and program outcomes. Community health workers can provide essential health services that are otherwise unavailable particularly in rural, poor areas.

Prevention and management of chronic disease: a litmus test for health-systems strengthening in low-income and middle-income countries.

National health systems need strengthening if they are to meet the growing challenge of chronic diseases in low-income and middle-income countries. By application of an accepted health-systems framework to the evidence, we report that the factors that limit countries' capacity to implement proven strategies for chronic diseases relate to the way in which health systems are designed and function. Substantial constraints are apparent across each of the six key health-systems components of health financing, governance, health workforce, health information, medical products and technologies, and health-service delivery. These constraints have become more evident as development partners have accelerated efforts to respond to HIV, tuberculosis, malaria, and vaccine-preventable diseases. A new global agenda for health-systems strengthening is arising from the urgent need to scale up and sustain these priority interventions. Most chronic diseases are neglected in this dialogue about health systems, despite the fact that non-communicable diseases (most of which are chronic) will account for 69% of all global deaths by 2030 with 80% of these deaths in low-income and middle-income countries. At the same time, advocates for action against chronic diseases are not paying enough attention to health systems as part of an effective response. Efforts to scale up interventions for management of common chronic diseases in these countries tend to focus on one disease and its causes, and are often fragmented and vertical. Evidence is emerging that chronic disease interventions could contribute to strengthening the capacity of health systems to deliver a comprehensive range of services-provided that such investments are planned to include these broad objectives. Because effective chronic disease programmes are highly dependent on well-functioning national health systems, chronic diseases should be a litmus test for health-systems strengthening.

Can the deployment of community health workers for the delivery of HIV services represent an effective and sustainable response to health workforce shortages? Results of a multicountry study.

In countries severely affected by HIV/AIDS, shortages of health workers present a major obstacle to scaling up HIV services. Adopting a task shifting approach for the deployment of community health workers (CHWs) represents one strategy for rapid expansion of the health workforce. This study aimed to evaluate the contribution of CHWs with a focus on identifying the critical elements of an enabling environment that can ensure they provide quality services in a manner that is sustainable. The method of work included a collection of primary data in five countries: Brazil, Ethiopia, Malawi, Namibia, and Uganda. The findings show that delegation of specific tasks to cadres of CHWs with limited training can increase access to HIV services, particularly in rural areas and among underserved communities, and can improve the quality of care for HIV. There is also evidence that CHWs can make a significant contribution to the delivery of a wide range of other health services. The findings also show that certain conditions must be observed if CHWs are to contribute to well-functioning and sustainable service delivery. These conditions involve adequate systems integration with significant attention to: political will and commitment; collaborative planning; definition of scope of practice; selection and educational requirements; registration, licensure and certification; recruitment and deployment; adequate and sustainable remuneration; mentoring and supervision including referral system; career path and continuous education; performance evaluation; supply of equipment and commodities. The study concludes that, where there is the necessary support, the potential contribution of CHWs can be optimized and represents a valuable addition to the urgent expansion of human resources for health, and to universal coverage of HIV services.

An assessment of interactions between global health initiatives and country health systems.

Since 2000, the emergence of several large disease-specific global health initiatives (GHIs) has changed the way in which international donors provide assistance for public health. Some critics have claimed that these initiatives burden health systems that are already fragile in countries with few resources, whereas others have asserted that weak health systems prevent progress in meeting disease-specific targets. So far, most of the evidence for this debate has been provided by speculation and anecdotes. We use a review and analysis of existing data, and 15 new studies that were submitted to WHO for the purpose of writing this Report to describe the complex nature of the interplay between country health systems and GHIs. We suggest that this Report provides the most detailed compilation of published and emerging evidence so far, and provides a basis for identification of the ways in which GHIs and health systems can interact to mutually reinforce their effects. On the basis of the findings, we make some general recommendations and identify a series of action points for international partners, governments, and other stakeholders that will help ensure that investments in GHIs and country health systems can fulfil their potential to produce comprehensive and lasting results in disease-specific work, and advance the general public health agenda. The target date for achievement of the health-related Millennium Development Goals is drawing close, and the economic downturn threatens to undermine the improvements in health outcomes that have been achieved in the past few years. If adjustments to the interactions between GHIs and country health systems will improve efficiency, equity, value for money, and outcomes in global public health, then these opportunities should not be missed.

Can non-physician health-care workers assess and manage cardiovascular risk in primary care?

OBJECTIVE: To ascertain the reliability of applying the WHO Cardiovascular Risk Management Package by non-physician health-care workers (NPHWs) in typical primary health-care settings. METHODS: Based on an a priori 80% agreement level between the NPHWs and the "expert" physicians (gold standard), 649 paired (matched) applications of the protocol were obtained for analysis using Kappa statistic and multivariate logit regression. FINDINGS: Results indicate over 80% agreement between raters, from moderate to perfect levels of agreement in almost all of the sections in the package. The odds of obtaining a difference between raters and a benchmark are not statistically significant. CONCLUSION: Applying the WHO Cardiovascular Risk Management Package, NPHWs can be retrained to reliably and effectively assess and manage cardiovascular risks in primary health-care settings where there are no attending physicians. The package could be a useful tool for scaling up the management of cardiovascular diseases in primary health care.

Barriers to management of cardiovascular risk in a low-resource setting using hypertension as an entry point.

OBJECTIVE: Assess capacity of health-care facilities in a low-resource setting to implement the absolute risk approach for assessment of cardiovascular risk in hypertensive patients and effective management of hypertension. DESIGN AND SETTING: A descriptive cross-sectional study in Egbeda and Oluyole local government areas of Oyo State in Nigeria in 56 randomly selected primary- (n = 42) and secondary-level (n = 2) health-care and private health-care (n = 12) facilities. PARTICIPANTS: One thousand consecutive, known hypertensives attending the selected facilities for follow-up, and health-care providers working in the above randomly selected facilities, were interviewed. RESULTS: About two-thirds of hypertensives utilized primary-care centers both for diagnosis and for follow-up. Laboratory and other investigations to exclude secondary hypertension or to assess target organ damage were not available in the majority of facilities, particularly in primary care. A considerable knowledge and awareness gap related to hypertension and its complications was found, both among patients and health-care providers. Blood pressure control rates were poor (28% with systolic blood pressure (SBP) < 140 mmHg and diastolic blood pressure (DBP) < 90 mmHg] and drug prescription patterns were not evidence based and cost effective. The majority of patients (73%) in this low socio-economic group (mean monthly income 73 US dollars) had to pay fully, out of their own pocket, for consultations and medications. CONCLUSIONS: If the absolute risk approach for assessment of risk and effective management of hypertension is to be implemented in low-resource settings, appropriate policy measures need to be taken to improve the competency of health-care providers, to provide basic laboratory facilities and to develop affordable financing mechanisms.

Inhibition of vascular endothelial growth factor-mediated neointima progression with angiostatin or paclitaxel.

PURPOSE: Therapeutic angiogenesis represents a new paradigm for treatment of ischemic vascular syndromes. However, vascular endothelial growth factor (VEGF) enhances the rate and degree of plaque formation. This study evaluates the potential to block these effects nonspecifically with paclitaxel or specifically with angiostatin. MATERIALS AND METHODS: Recombinant human VEGF(165) (rhVEGF) was administrated intramuscularly (2-microg/kg single injection) in combination with adventitial delivery of paclitaxel, angiostatin, or vehicle alone at the site of femoral arterial balloon overdilation injury in New Zealand White rabbits (n = 5 per treatment). Five additional animals with no rhVEGF and no adventitial delivery served as procedural controls. All rabbits were fed according to a 0.25% cholesterol diet beginning 28 days before angioplasty. Treated arteries were harvested after 7 days and evaluated to determine intima-to-media (I/M) ratios, macrophage infiltrate, and endothelial cell density. RESULTS: On histologic analysis, the rhVEGF/gel control group exhibited a mean I/M ratio of 0.337 +/- 0.028, a 77% increase over procedural controls, which exhibited a mean I/M of 0.190 +/- 0.010. rhVEGF/paclitaxel reduced I/M ratios to 0.151 +/- 0.007. In contrast, specific antiangiogenic therapy (rhVEGF/angiostatin) reduced I/M ratios to 0.032 +/- 0.003, a 91% decrease relative to rhVEGF/gel and an 83% decrease relative to procedural controls (P =.001 for each comparison). Local macrophages and endothelial cells also decreased with treatment. CONCLUSIONS: This study shows that paclitaxel and angiostatin each afford local protection against rhVEGF-mediated increases in neointima. Angiostatin further prevents progression of underlying neointima. These local therapies may allow broader use of therapeutic angiogenesis while avoiding and treating potentially undesirable effects.