Unravelling how and why the Antiretroviral Adherence Club Intervention works (or not) in a public health facility: A realist explanatory theory-building case study.

BACKGROUND: Although empirical evidence suggests that the adherence club model is more effective in retaining people living with HIV in antiretroviral treatment care and sustaining medication adherence compared to standard clinic care, it is poorly understood exactly how and why this works. In this paper, we examined and made explicit how, why and for whom the adherence club model works at a public health facility in South Africa. METHODS: We applied an explanatory theory-building case study approach to examine the validity of an initial programme theory developed a priori. We collected data using a retrospective cohort quantitative design to describe the suppressive adherence and retention in care behaviours of patients on ART using Kaplan-Meier methods. In conjunction, we employed an explanatory qualitative study design using non-participant observations and realist interviews to gain insights into the important mechanisms activated by the adherence club intervention and the relevant contextual conditions that trigger the different mechanisms to cause the observed behaviours. We applied the retroduction logic to configure the intervention-context-actor-mechanism-outcome map to formulate generative theories. RESULTS: A modified programme theory involving targeted care for clinically stable adult patients (18 years+) receiving antiretroviral therapy was obtained. Targeted care involved receiving quick, uninterrupted supply of antiretroviral medication (with reduced clinic visit frequencies), health talks and counselling, immediate access to a clinician when required and guided by club rules and regulations within the context of adequate resources, and convenient (size and position) space and proper preparation by the club team. When grouped for targeted care, patients feel nudged, their self-efficacy is improved and they become motivated to adhere to their medication and remain in continuous care. CONCLUSION: This finding has implications for understanding how, why and under what health system conditions the adherence club intervention works to improve its rollout in other contexts.

Problems with prioritization: exploring ethical solutions to inequalities in HIV care.

Enormous gaps between HIV burden and health care availability in low-income countries raise severe ethical problems. This article analyzes four HIV-priority dilemmas with interest across contexts and health systems. We explore principled distributive conflicts and use the Atkinson index to make explicit trade-offs between health maximization and equality in health. We find that societies need a relatively low aversion to inequality to favor treatment for children, even with large weights assigned to extending the lives of adults: higher inequality aversion is needed to share resources equally between high-cost and low-cost treatment; higher inequality aversion is needed to favor treatment rather than prevention, and the highest inequality aversion is needed to favor sharing treatment between urban and rural regions rather than urban provision of treatment. This type of ethical sensitivity analysis may clarify the ethics of health policy choice.

Science and ethics of human immunodeficiency virus/acquired immunodeficiency syndrome controversies in Africa.

The human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) epidemic in Africa has raised important ethical issues for both researchers and clinicians. The most notorious controversy has been related to the zidovudine (AZT) trials in Africa in the late 1990s, in which the control groups were given a placebo rather than an effective drug to prevent vertical transmission. This raised concerns in the sponsoring country about exploitation of subjects, injustice and an ethical double standard between donor countries and resource-poor settings. However, the real double standard is between clinical practice standards in Western versus African countries, which must be addressed as part of the increasing global inequity of wealth both between countries and also within countries. There are important limitations to ethical declarations, principles and guidelines on their own without contextual ethical reasoning. The focus on research ethics with the HIV epidemic has led to a relative neglect of ethical issues in clinical practice. Although the scientific advances in HIV/AIDS have changed the ethical issues since the 1990s, there has also been progress in the bioethics of HIV/AIDS in terms of ethical review capability by local committees as well as in exposure to ethical issues by clinicians and researchers in Africa. However, serious concerns remain about the overregulation of research by bureaucratic agencies which could discourage African research on specifically African health issues. There is also a need for African academic institutions and researchers to progressively improve their research capacity with the assistance of research funders and donor agencies.

Reflexiones en torno a los problemas éticos y bioéticos en el tratamiento del paciente con VIH/SIDA / Reflections around the ethical and bioethical problems related to treatment of HIV-AIDS patient

Se realizó una revisión bibliográfica sobre aspectos éticos y bioéticos en el tratamiento del paciente con VIH/SIDA. Se destacó que hace poco más de 30 años surgieron en el mundo con gran fuerza los problemas de la ética médica, con tal pasión e intensidad, que desbordaron los límites clásicos e interdisciplinarios, lo que consecuentemente dio lugar al surgimiento de la Bioética. Las infecciones de transmisión sexual azotan el mundo con su alta incidencia, y se han convertido en un importante problema de salud, reto para científicos, médicos e investigadores; al comienzo de los 80, el descubrimiento del SIDA, multiplicó el poder devastador de estas enfermedades. Cada año se producen millones de casos de infecciones víricas, incluida la infección por VIH. La aparición de la Bioética como nuevo paradigma del pensamiento médico, con sus principios de beneficencia, no maleficencia, autonomía y justicia, ha conmocionado al mundo de las ciencias médicas. Este trabajo realiza algunas reflexiones que debe tener en cuenta el Equipo Básico de Salud y el resto de los trabajadores de la Atención Primaria de Salud, en el tratamiento en la comunidad del paciente con VIH/SIDA...

A bibliographic review on ethical and bioethical features in treatment of HIV/AIDS patients was carried out. It was emphasized that more or less 30 years ago in world appeared with a great strength the problems of medical ethics, so intense that they exceeded the classic and interdisciplinary limits, which consequently gave rise to appearance of Bioethic. Sexually transmitted diseases devastate the world with its high incidence and have to become in a important health problem, a challenge for scientists, physician and researchers; in the early 1980s, the discovery of AIDS, multiplied the devastating power of these diseases. Each year appear millions of cases of viral infections including HIV infection. Appearance of Bioethics as a new paradigm of medical though, with its benefit principles, the non-maleficence, autonomy and justice has shocked the medical sciences world. This paper made some reflections to be taking account by Health Basic Staff and the remainder workers of Health Primary Care related to treatment in community of HIV/AIDS patient...

Respect for persons permits prioritizing treatment for HIV/AIDS.

I defend a certain claim about rationing in the context of HIV/AIDS, namely the 'priority thesis' that the state of a developing country with a high rate of HIV should provide highly active anti-retroviral treatment (HAART) to those who would die without it, even if doing so would require not treating most other life-threatening diseases. More specifically,I defend the priority thesis in a negative way by refuting two influential and important arguments against it inspired by the Kantian principle of respect for persons. The 'equality argument' more or less maintains that prioritizing treatment for HIV/AIDS would objectionably treat those who suffer from it as more important than those who do not. The 'responsibility argument' says, roughly, that to ration life-saving treatment by prioritizing those with HIV would wrongly fail to hold people responsible for their actions, since most people infected with HIV could have avoided the foreseeable harm of infection. While it appears that a Kantian must think that one of these two arguments is sound, I maintain that, in fact, respect for persons grounds neither the equality nor responsibility argument against prioritizing HAART and hence at least permits doing so. If this negative defence of the priority thesis succeeds, then conceptual space is opened up for the possibility that respect for persons requires prioritizing HAART which argument I sketch in the conclusion as something to articulate and defend in future work.

Fighting AIDS in Sub-Saharan Africa: is a public- private partnership a viable paradigm?

UNLABELLED: In their most recent study, the United Nations AIDS Program estimates that about 22 million people around the world have died from AIDS, and about 40 million more are currently infected with the HIV virus. About 83% of AIDS deaths and 71% of HIV infections have occurred in war-ravaged, poverty-stricken Sub-Saharan Africa. This pandemic is ripping apart the social and economic fabric of this part of the world. The only remedy for this crisis is both prevention and cure. Only through massive education can early and sustained prevention efforts prevent future infections. And only by giving those infected with HIV effective treatments will people be prevented from dying of AIDS in the future. Without a bold, concerted action, not only will millions die in Africa, but the entire world will suffer. To allow sub-Saharan Africa to become socially and economically devastated will have a major impact on the economies of every country of the world. The African Comprehensive HIV/AIDS Partnership (ACHAP) is one answer to the problem. ACHAP, is a joint initiative between the government of Botswana, the Bill and Melinda Gates Foundation and the Merck Company Foundation. This public-private partnership has provided a new sense of optimism for fighting this devastating pandemic. ACHAP offers all interested parties a multifaceted paradigm that addresses not only the need for ARV medications, but also the other social and medical facets of the HIV/AIDS problem facing sub-Saharan Africa. If a coordinated effort can be launched in the other sub-Saharan African nations, using ACHAP as a paradigm, then there is the possibility that the fight against AIDS could be won. CONCLUSIONS: Clinical ethics is of necessity a two-way street, one in which ethical paradigms influence practitioners and researchers whose expertise, in turn, necessarily educates the non-clinical ethicist.

Prioritising access to antiretroviral therapy in resource-poor settings.

Until quite recently, bringing antiretroviral therapy to severely resource-constrained countries was not considered to be a priority. It was widely felt that in these settings a preventive HIV vaccine is the only way to win the war. Antiretroviral therapy was perceived to be too expensive and complex, to pose impossible monitoring demands, and to drain valuable resources from more important prevention efforts. However, both from a humanitarian and an economic and developmental perspective, we cannot afford not to bring highly active antiretroviral therapy (HAART) to these settings.