Health care costs associated with clinic visits for prevention of mother-to-child transmission of HIV in Dar es Salaam, Tanzania.

ABSTRACT: Early and appropriate antenatal care (ANC) is key for the effectiveness of prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV). We evaluated the importance of ANC visits and related service costs for women receiving option B+ to prevent mother-to-child transmission (MTCT) of HIV in Tanzania.A cost analysis from a health care sector perspective was conducted using routine data of 2224 pregnant women newly diagnosed with HIV who gave birth between August 2014 and May 2016 in Dar es Salaam, Tanzania. We evaluated risk of infant HIV infection at 12 weeks postnatally in relation to ANC visits (<4 vs ≥4 visits). Costs for service utilisation were estimated through empirical observations and the World Health Organisation Global Price Reporting Mechanism.Mean gestational age at first ANC visit was 22 (±7) weeks. The average number of ANC/prevention of MTCT visits among the 2224 pregnant women in our sample was 3.6 (95% confidence interval [CI] 3.6-3.7), and 57.3% made ≥4 visits. At 12 weeks postnatally, 2.7% (95% CI 2.2-3.6) of HIV exposed infants had been infected. The risk of MTCT decreased with the number of ANC visits: 4.8% (95% CI 3.6-6.4) if the mother had <4 visits, and 1.0% (95% CI 0.5-1.7) at ≥4. The adjusted MTCT rates decreased by 51% (odds ratio 0.49, 95% CI 0.31-0.77) for each additional ANC visit made. The potential cost-saving was 2.2 US$ per woman at ≥4 visits (84.8 US$) compared to <4 visits (87.0 US$), mainly due to less defaulter tracing.Most pregnant women living with HIV in Dar es Salaam initiated ANC late and >40% failed to adhere to the recommended minimum of 4 visits. Improved ANC attendance would likely lead to fewer HIV-infected infants and reduce both short and long-term health care costs due to less spending on defaulter tracing and future treatment costs for the children.

Qualitative Assessment of Barriers and Facilitators of PrEP Use Before and After Rollout of a PrEP Program for Priority Populations in South-central Uganda.

Uganda piloted HIV pre-exposure prophylaxis (PrEP) for priority populations (sex workers, fishermen, truck drivers, discordant couples) in 2017. To assess facilitators and barriers to PrEP uptake and adherence, we explored perceptions of PrEP before and experiences after rollout among community members and providers in south-central Uganda. We conducted 75 in-depth interviews and 12 focus group discussions. We analyzed transcripts using a team-based thematic framework approach. Partners, family, peers, and experienced PrEP users provided adherence support. Occupational factors hindered adherence for sex workers and fishermen, particularly related to mobility. Pre-rollout concerns about unskilled/untrained volunteers distributing PrEP and price-gouging were mitigated. After rollout, awareness of high community HIV risk and trust in PrEP effectiveness facilitated uptake. PrEP stigma and unexpected migration persisted as barriers. Community-initiated, tailored communication with successful PrEP users may optimize future engagement by addressing fears and rumors, while flexible delivery and refill models may facilitate PrEP continuation and adherence.

RESUMEN: En 2017, Uganda introdujo profilaxis pre-exposición (PrEP), dirigida a las populaciones con alto riesgo de contraer al VIH (trabajadoras sexuales, pescadores, camioneros, parejas sero-discordantes). Para investigar facilitadores y barreras para la adopción y la adherencia a la PrEP, exploramos percepciones de PrEP antes y después de su introducción en Uganda. Realizamos 75 entrevistas y 12 grupos focales con miembros de la comunidad y trabajadores de salud. Analizamos las transcripciones temáticamente usando un marco de referencia. Parejas, familias, compañeros, y clientes usando PrEP apoyaron a los demás mantener adherencia. Movilidad fue una barrera para la adherencia a la PrEP para trabajadoras sexuales y pescadores. Preocupaciones sobre el entrenamiento de los distribuidores de PrEP y la especulación de precios no fueron realizadas. Percepciones del riesgo del VIH y confianza en la eficacia de PrEP facilitaron su adopción. Estigma y migración inesperada persistieron como barreras para la adopción de PrEP. Comunicaciones manejadas por clientes usando PrEP pueden motivar interés en PrEP y abordar rumores. Sistemas flexibles del entrego y la recarga de medicinas pueden permitir continuación de, y adherencia a, la PrEP.

Barriers and facilitators to reporting deaths following Ebola surveillance in Sierra Leone: implications for sustainable mortality surveillance based on an exploratory qualitative assessment.

OBJECTIVES: To understand the barriers contributing to the more than threefold decline in the number of deaths (of all causes) reported to a national toll free telephone line (1-1-7) after the 2014-2016 Ebola outbreak ended in Sierra Leone and explore opportunities for improving routine death reporting as part of a nationwide mortality surveillance system. DESIGN: An exploratory qualitative assessment comprising 32 in-depth interviews (16 in Kenema district and 16 in Western Area). All interviews were audio-recorded, transcribed and analysed using qualitative content analysis to identify themes. SETTING: Participants were selected from urban and rural communities in two districts that experienced varying levels of Ebola cases during the outbreak. All interviews were conducted in August 2017 in the post-Ebola-outbreak context in Sierra Leone when the Sierra Leone Ministry of Health and Sanitation was continuing to mandate reporting of all deaths. PARTICIPANTS: Family members of deceased persons whose deaths were not reported to the 1-1-7 system. RESULTS: Death reporting barriers were driven by the lack of awareness to report all deaths, lack of services linked to reporting, negative experiences from the Ebola outbreak including prohibition of traditional burial rituals, perception that inevitable deaths do not need to be reported and situations where prompt burials may be needed. Facilitators of future willingness to report deaths were largely influenced by the perceived communicability and severity of the disease, unexplained circumstances of the death that need investigation and the potential to leverage existing death notification practices through local leaders. CONCLUSIONS: Social mobilisation and risk communication efforts are needed to help the public understand the importance and benefits of sustained and ongoing death reporting after an Ebola outbreak. Localised practices for informal death notification through community leaders could be integrated into the formal reporting system to capture community-based deaths that may otherwise be missed.

Barriers and facilitators for the sexual and reproductive health and rights of young people in refugee contexts globally: A scoping review.

BACKGROUND: The need to address sexual and reproductive health and rights (SRHR) in humanitarian settings is more urgent than ever, especially among young refugees. We conducted a scoping review to identify and synthesise the literature on perceived barriers and facilitators to SRHR among young refugees and interventions created to address their needs. METHODS: We searched three databases (PubMed, Global Health and POPLINE) for peer-reviewed and grey literature published in English between January 2008 and June 2018 that reported on SRHR barriers, facilitators and interventions for young refugees aged 10 to 24 years. We extracted data using standardised templates and assessed the quality of studies according to study design. Data were charted using qualitative content analysis and organised in line with a socio-ecological framework (individual, social and community, institutional and health system, and structural). FINDINGS: We screened 1,169 records and included 30 publications (qualitative, quantitative, and mixed methods) across 22 countries; 15 were peer-reviewed articles and 15 were from the grey literature. Twenty-two publications reported on young people in refugee camps or alternatives to camps (e.g. sustainable settlements), and eight referred to young refugees who had been resettled to a third country. We identified 19 sub-categories for barriers and 14 for facilitators at the individual, social and community, institutional and health system, and structural levels. No publications discussed the SRHR challenges faced by young homosexual, bisexual, transgender or queer refugees, or those living with HIV. Nine publications described interventions, which tended to focus on the provision of SRHR services and information, and the training of peers, parents, religious leaders and/or service providers. CONCLUSIONS: Findings highlight that while young refugees experience similar barriers to SRHR as other young people, many of these barriers are exacerbated by the refugee context. The limited number of publications and evidence on interventions underlines the immediate need to invest in and evaluate SRHR interventions in refugee contexts.

A systematic review of adherence to oral pre-exposure prophylaxis for HIV - how can we improve uptake and adherence?

INTRODUCTION: Oral pre-exposure prophylaxis (PrEP) is an effective strategy to reduce the risk of HIV transmission in high risk individuals. However, the effectiveness of oral pre-exposure prophylaxis is highly dependent on user adherence, which some previous trials have struggled to optimise particularly in low and middle income settings. This systematic review aims to ascertain the reasons for non-adherence to pre-exposure prophylaxis to guide future implementation. METHODS: We performed structured literature searches of online databases and conference archives between August 8, 2016 and September 16, 2017. In total, 18 prospective randomized control trials and implementation studies investigating oral pre-exposure prophylaxis were reviewed. A structured form was used for data extraction and findings summarized regarding efficacy, effectiveness, adherence and possible reasons for non-adherence. RESULTS: Adherence varied between differing populations both geographically and socioeconomically. Common reasons for non-adherence reported over multiple studies were; social factors such as stigma, low risk perception, low decision making power, an unacceptable dosing regimen, side effects, and the logistics of daily life. Oral pre-exposure prophylaxis with included antiviral regimens was not associated with a high risk of antiviral resistance development in the reviewed studies. CONCLUSION: Our findings indicate that oral pre-exposure prophylaxis should be delivered within a holistic intervention, acknowledging the other needs of the targeted demographic in order to maximise acceptability. Socioeconomic factors and poor governmental policy remain major barriers to widespread implementation of pre-exposure prophylaxis.

Gender differences in health-related quality of life at the time of a positive HIV test - a cross-sectional study in a resource-poor, high prevalence setting in Nairobi, Kenya.

Few studies have examined gender differences in sub-Saharan Africa, where HIV disproportionately affects women. Objectives of this cross-sectional study were to determine gender differences in HRQoL at the time of a positive HIV test, and whether factors associated with HRQoL differed between men and women. Adults testing HIV-positive were recruited from two clinics located in informal settlements. HRQoL was measured with the SF-12. Multiple linear regression was used to test whether there were gender differences in physical (PCS) and mental composite summary (MCS) scores. Separate models were built for men and women to examine factors associated with HRQoL. Between April 2013 and June 2015, 775 individuals from were recruited. The mean PCS score was higher in women (adjusted mean difference 2.49, 95% CI 0.54 to 4.44, p = 0.012). There was no significant gender difference in MCS scores. Similar factors were associated with better physical HRQoL in men and women: secondary education, younger age, higher CD4, and employment. Employment was the only factor associated with MCS in men, while less social support and low CD4 were associated with poorer MCS scores in women. Gender differences in factors related to HRQoL should be considered in broader policy and interventions to improve the HRQoL in those diagnosed with HIV.

The potential of task-shifting in scaling up services for prevention of mother-to-child transmission of HIV: a time and motion study in Dar es Salaam, Tanzania.

BACKGROUND: In many African countries, prevention of mother-to-child transmission of HIV (PMTCT) services are predominantly delivered by nurses. Although task-shifting is not yet well established, community health workers (CHWs) are often informally used as part of PMTCT delivery. According to the 2008 World Health Organization (WHO) Task-shifting Guidelines, many PMTCT tasks can be shifted from nurses to CHWs. METHODS: The aim of this time and motion study in Dar es Salaam, Tanzania, was to estimate the potential of task-shifting in PMTCT service delivery to reduce nurses' workload and health system costs. The time used by nurses to accomplish PMTCT activities during antenatal care (ANC) and postnatal care (PNC) visits was measured. These data were then used to estimate the costs that could be saved by shifting tasks from nurses to CHWs in the Tanzanian public-sector health system. RESULTS: A total of 1121 PMTCT-related tasks carried out by nurses involving 179 patients at ANC and PNC visits were observed at 26 health facilities. The average time of the first ANC visit was the longest, 54 (95% confidence interval (CI) 42-65) min, followed by the first PNC visit which took 29 (95% CI 26-32) minutes on average. ANC and PNC follow-up visits were substantially shorter, 15 (95% CI 14-17) and 13 (95% CI 11-16) minutes, respectively. During both the first and the follow-up ANC visits, 94% of nurses' time could be shifted to CHWs, while 84% spent on the first PNC visit and 100% of the time spent on the follow-up PNC visit could be task-shifted. Depending on CHW salary estimates, the cost savings due to task-shifting in PMTCT ranged from US$ 1.3 to 2.0 (first ANC visit), US$ 0.4 to 0.6 (ANC follow-up visit), US$ 0.7 to 1.0 (first PNC visit), and US$ 0.4 to 0.5 (PNC follow-up visit). CONCLUSIONS: Nurses working in PMTCT spend large proportions of their time on tasks that could be shifted to CHWs. Such task-shifting could allow nurses to spend more time on specialized PMTCT tasks and can substantially reduce the average cost per PMTCT patient.

Intimate Partner Violence, Relationship Power Inequity and the Role of Sexual and Social Risk Factors in the Production of Violence among Young Women Who Have Multiple Sexual Partners in a Peri-Urban Setting in South Africa.

INTRODUCTION: This paper aims to assess the extent and correlates of intimate partner violence (IPV), explore relationship power inequity and the role of sexual and social risk factors in the production of violence among young women aged 16-24 reporting more than one partner in the past three months in a peri-urban setting in the Western Cape, South Africa. Recent estimates suggest that every six hours a woman is killed by an intimate partner in South Africa, making IPV a leading public health problem in the country. While there is mounting evidence that levels of IPV are high in peri-urban settings in South Africa, not much is known about how it manifests among women who engage in concomitantly high HIV risk behaviours such as multiple sexual partnering, transactional sex and age mixing. We know even less about how such women negotiate power and control if exposed to violence in such sexual networks. METHODS: Two hundred and fifty nine women with multiple sexual partners, residing in a predominantly Black peri-urban community in the Western Cape, South Africa, were recruited into a bio-behavioural survey using Respondent Driven Sampling (RDS). After the survey, focus group discussions and individual interviews were conducted among young women and men to understand the underlying factors informing their risk behaviours and experiences of violence. FINDINGS: 86% of the young women experienced IPV in the past 12 months. Sexual IPV was significantly correlated with sex with a man who was 5 years or older than the index female partner (OR 1.7, 95% CI 1.0-3.2) and transactional sex with most recent casual partner (OR 2.1, 95% CI 1.1-3.8). Predictably, women experienced high levels of relationship power inequity. However, they also identified areas in their controlling relationships where they shared decision making power. DISCUSSION: Levels of IPV among young women with multiple sexual partners were much higher than what is reported among women in the general population and shown to be associated with sexual risk taking. Interventions targeting IPV need to address sexual risk taking as it heightens vulnerability to violence.

A Cost-Effectiveness Analysis of a Home-Based HIV Counselling and Testing Intervention versus the Standard (Facility Based) HIV Testing Strategy in Rural South Africa.

INTRODUCTION: There is growing evidence concerning the acceptability and feasibility of home-based HIV testing. However, less is known about the cost-effectiveness of the approach yet it is a critical component to guide decisions about scaling up access to HIV testing. This study examined the cost-effectiveness of a home-based HIV testing intervention in rural South Africa. METHODS: Two alternatives: clinic and home-based HIV counselling and testing were compared. Costs were analysed from a provider's perspective for the period of January to December 2010. The outcome, HIV counselling and testing (HCT) uptake was obtained from the Good Start home-based HIV counselling and testing (HBHCT) cluster randomised control trial undertaken in KwaZulu-Natal province. Cost-effectiveness was estimated for a target population of 22,099 versus 23,864 people for intervention and control communities respectively. Average costs were calculated as the cost per client tested, while cost-effectiveness was calculated as the cost per additional client tested through HBHCT. RESULTS: Based on effectiveness of 37% in the intervention (HBHCT) arm compared to 16% in control arm, home based testing costs US$29 compared to US$38 per person for clinic HCT. The incremental cost effectiveness per client tested using HBHCT was $19. CONCLUSIONS: HBHCT was less costly and more effective. Home-based HCT could present a cost-effective alternative for rural 'hard to reach' populations depending on affordability by the health system, and should be considered as part of community outreach programs.

"Money talks, bullshit walks" interrogating notions of consumption and survival sex among young women engaging in transactional sex in post-apartheid South Africa: a qualitative enquiry.

BACKGROUND: Transactional sex is believed to be a significant driver of the HIV epidemic among young women in South Africa. This sexual risk behaviour is commonly associated with age mixing, concurrency and unsafe sex. It is often described as a survival- or consumption-driven behaviour. South Africa's history of political oppression as well as the globalization-related economic policies adopted post-apartheid, are suggested as the underlying contexts within which high risk behaviours occur among Black populations. What remains unclear is how these factors combine to affect the particular ways in which transactional sex is used to negotiate life among young Black women in the country.In this paper we explore the drivers of transactional sex among young women aged 16-24, who reside in a peri-urban community in South Africa. We also interrogate prevailing constructions of the risk behaviour in the context of modernity, widespread availability of commodities, and wealth inequalities in the country. METHODS: Data were collected through 5 focus group discussions and 6 individual interviews amongst young women, men, and community members of various age groups in a township in the Western Cape, South Africa. FINDINGS: Young women engaged in transactional sex to meet various needs: some related to survival and others to consumption. In this poverty-stricken community, factors that created a high demand for transactional sex among young women included the pursuit of fashionable images, popular culture, the increased availability of commodities, widespread use of global technologies, poverty and wealth inequalities. Transactional sex encounters were characterized by sexual risk, a casual attitude towards HIV, and male dominance. However, the risk behaviour also allowed women opportunities to adopt new social roles as benefactors in sexual relationships with younger men. CONCLUSION: Transactional sex allows poor, young women to access what young people in many parts of the world also prioritize: fashionable clothing and opportunities for inclusion in popular youth culture. In the context of high HIV prevalence in South Africa, strategies are needed that present young women with safer economic gateways to create and consume alternative symbols of modernity and social inclusion.

The effect of weekly short message service communication on patient retention in care in the first year after HIV diagnosis: study protocol for a randomised controlled trial (WelTel Retain).

INTRODUCTION: Interventions to improve retention in care after HIV diagnosis are necessary to optimise the timely initiation of antiretroviral therapy (ART) and HIV/AIDS control outcomes. Widespread mobile phone use presents new opportunities to engage patients in care. A randomised controlled trial (RCT), WelTel Kenya1, demonstrated that weekly text messages led to improved ART adherence and viral load suppression among those initiating ART. The aim of this study was to determine whether the WelTel intervention is an effective and cost-effective method of improving retention in care in the first year of care following HIV diagnosis. METHODS AND ANALYSIS: WelTel Retain is an open, parallel group RCT that will be conducted at the Kibera Community Health Centre in Nairobi, Kenya. Over a 1-year period, we aim to recruit 686 individuals newly diagnosed with HIV who will be randomly allocated to an intervention or control arm (standard care) at a 1:1 ratio. Intervention arm participants will receive the weekly WelTel SMS 'check-in' to which they will be instructed to respond within 48 h. An HIV clinician will follow-up and triage any problems that are identified. Participants will be followed for 1 year, with a primary endpoint of retention in care at 12 months. Secondary outcomes include retention in stage 1 HIV care (patients return to the clinic to receive their first CD4 results) and timely ART initiation. Cost-effectiveness will be analysed through decision-analytic modelling. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the University of British Columbia and the African Medical and Research Foundation. This trial will test the effectiveness and cost-effectiveness of the WelTel intervention to engage patients during the first year of HIV care. Trial results and economic evaluation will help inform policy and practice on the use of WelTel in the early stages of HIV care. TRIAL REGISTRATION: ClinicalTrials.gov NCT01630304.

Lack of pre-antiretroviral care and competition from traditional healers, crucial risk factors for very late initiation of antiretroviral therapy for HIV--a case-control study from eastern Uganda.

BACKGROUND: Although WHO recommends starting antiretroviral treatment at a CD4 count of 350 cells/[µ]L, many Ugandan districts still struggle with large proportions of clients initiating ART very late at CD4<50 cells/[µ]L. This study seeks to establish crucial risk factors for very late ART initiation in eastern Uganda. METHODS: All adult HIV-infected clients on ART in Iganga who enrolled between 2005 and 2009 were eligible for this case-control study. Clients who started ART at CD4 cell count of <50 cells/[µ]L (very late initiators) were classified as cases and 50-200 cells/[µ]L (late initiators) as control subjects. A total of 152 cases and 202 controls were interviewed. Multivariate analyses were performed to calculate adjusted odds ratios and 95% confidence intervals. RESULTS: Reported health system-related factors associated with very late ART initiation were stock-outs of antiretroviral drugs stock-outs (affecting 70% of the cases and none of the controls), competition from traditional/spiritual healers (AOR 7.8, 95 CI% 3.7-16.4), and lack of pre-ARV care (AOR 4.6, 95% CI: 2.3-9.3). Men were 60% more likely and subsistence farmers six times more likely (AOR 6.3, 95% CI: 3.1-13.0) to initiate ART very late. Lack of family support tripled the risk of initiating ART very late (AOR 3.3, 95% CI: 1.6-6.6). CONCLUSION: Policy makers should prevent ARV stock-outs though effective ARV procurement and supply chain management. New HIV clients should seek pre-ARV care for routine monitoring and determination of ART eligibility. ART services should be more affordable, accessible and user-friendly to make them more attractive than traditional healers.

"Not a boy, not a child": A qualitative study on young people's views on childbearing in Uganda.

To understand reasons for persistent high fertility rate, we explored perceptions and influences of fertility motivation among young people from Uganda. Qualitative inquiry was used, data were organised using NVivo 2 package and latent content analysis performed. Major themes that emerged on factors that entrench high fertility included "Sustenance of 'men's blood' through the male child"; "poverty, joblessness and child bearing", and "other socio-cultural issues: religion, kin, elders and child bearing". Factors that reduce fertility included "perception on women emancipation, job security and couple fertility communication". Young peoples' views on motivation for childbearing in Uganda are embedded in cultural norms and linked strongly to patriarchy, social respectability and women's sustenance. Innovative cultural practices and programs that increase women's social respectability such as emphasis that a girl can be heir and inherit her father's property are needed to reduce son-preference and fertility rates in the younger generation.

Policy and practice, lost in transition: Reasons for high drop-out from pre-antiretroviral care in a resource-poor setting of eastern Uganda.

OBJECTIVE: This study explores reasons for drop-out from pre-ARV care in a resource-poor setting where premature death is a common consequence of delayed ARV initiation. METHODS: In Iganga, Uganda, we conducted key informant interviews with staff at the pre-ARV clinic, focus group discussions with persons who looked after people living with HIV (PLWH) and in-depth interviews with PLWH half of whom had dropped out of pre-ARV care. Content data analysis was done to identify recurrent themes. RESULTS: Reasons cited for dropping out of pre-ARV care include: inadequate post-test counseling due to staff work overload, competition from the holistic and less stigmatizing traditional/spiritual healers. Others were transportation costs, long waiting time lack of incentives to seek pre-ARV care by healthy looking PLWH and gender inequalities. CONCLUSIONS: Pre-ARV adherence counseling should be improved through recruitment of counselors or multi-skilling in counseling skills for the available staff to reduce on the work load. Traditional/ spiritual healers should be integrated and supervised to offer pre-ARV care. Door step supply of cotrimoxazole using agents could reduce transport costs, waiting time and increase access to pre-ARV. Women should be sensitized on comprehensive HIV care through the local media and local leaders to address gender inequalities.

Voices on adherence to ART in Ethiopia and Uganda: a matter of choice or simply not an option?

This paper explores HIV patients' adherence to antiretroviral treatment (ART) in resource-limited contexts in Uganda and Ethiopia, where ART is provided free of charge. Qualitative semi-structured interviews were conducted with 79 patients, 17 peer counselors, and 22 providers in ART facilities in urban and rural areas of Ethiopia and Uganda. Interviewees voiced their experiences of, and views on ART adherence both from an individual and a system level perspective. Two main themes emerged from the content analysis: "Patients' competing costs and systems' resource constraints" and "Patients' trust in ART and quality of the patient-provider encounters." The first theme refers to how patients' adherence was challenged by difficulties in supporting themselves and their families, paying for transportation, for drug refill and follow-up as well as paying for registration fees, opportunistic infection treatment, and expensive referrals to other hospitals. The second theme describes factors that influenced patients' capacity to adhere: personal responsibility in treatment, trust in the effects of antiretroviral drugs, and trust in the quality of counseling. To grant patients a fair choice to successfully adhere to ART, transport costs to ART facilities need to be reduced. This implies providing patients with drugs for longer periods of time and arranging for better laboratory services, thus not necessitating frequent revisits. Services ought to be brought closer to patients and peripheral, community-based healthworkers used for drug distribution. There is a need for training providers and peer counselors, in communication skills and adherence counseling.

Relative response: ranking country responses to HIV and AIDS.

The aim of this article is to support efforts to hold governments accountable for their commitments to respond to HIV and AIDS. It describes a new approach to ranking countries' responses in order to facilitate cross-country comparisons. The method uses the United Nations General/Assembly Speecial Session on HIV/AIDS (UNGASS) Declaration of Commitment as its point of departure and was designed to rank countries in terms of their efforts to fight HIV and AIDS. Three indicators of the country response were analyzed. (1) prevention of mother-to-child transmission (PMTCT) coverage; (2) antiretroviral (ARV) coverage; and (3) the ratio of orphans to non-orphans attending school An assessment of this nature must acknowledge the unique situation of each country, depending on its infrastructure and access to resources. To account for these differences, a regression analysis with contextual control variables was carried out to identify the variation resulting from controllable factors. It is this variation which is used to examine countries' relative response to HIV as it considers what was actually achieved relative to what was expected given the context. The results highlight the efforts of not only some well-reputed, strong actors but also some unexpected front-runners. The results also point to a group of countries which are lagging behind in all regards. Comparisons between the three indicators show great variations in the focus of countries' efforts. Rating countries' relative response to HIV highlghts countries that do well in spite of diffcult circumstances. The article argues that these "relative overachievers" should be examined more closely so that lessons may be learnt from their efforts. The rating also draws attention to countries where the response is comparatively weak, and where governments, as lead actors in the AIDS partnership, bear the greatest responsibility.

Antiretroviral treatment of HIV in Uganda: a comparison of three different delivery models in a single hospital.

This exploratory study examined health worker's perspectives and the type of HIV care received in three different delivery models of antiretroviral treatment (ART) at St Francis Hospital, Kampala, Uganda. Two of the clinics were financed by external donors and the third through out-of-pocket payments. Key informant interviews with health workers investigated potential challenges with ART care, and exit interviews with patients collected data on the care received. Despite the fact that all three clinics were located in the same hospital, services offered and quality of care varied extensively. Health staff at all ART clinics identified the lack of collaboration between different HIV programmes and low patient adherence as the main challenges. More women than men accessed ART through the externally financed programmes. These programmes provided more comprehensive care because of higher staff density and more frequent laboratory monitoring compared to the private clinic. Despite these shortcomings and the fact that prescriptions were often renewed without a preceding medical check-up at the private clinic, many chose to pay a monthly average equivalent of US$60 for ART in return for privacy and access to drugs without HIV disclosure requirements. Stigma and fear of abandonment were thought to be the main barriers for access to ART.