Looking for NTDs in the skin; an entry door for offering patient centered holistic care.

INTRODUCTION: The majority of neglected tropical diseases (NTDs) have established primary skin manifestations or associated clinical feature. Skin NTDs often result in physical impairment and disfigurement, which can lead to disability. Skin diseases have been proposed as an entry point for integrated NTDs control. However, the magnitude and overlap of skin NTDs is poorly understood. METHODOLOGY: An institution-based cross-sectional study was done using medical records of dermatology patients between July 2017 and June 2018 in a dermatology service in Northeast Ethiopia. A total of 661 patient records were selected using simple random sampling. RESULTS: A total of 656 complete records were included in analysis. Skin NTDs constituted 17.2% (n = 113) of the overall of skin diseases. Of skin NTDS, cutaneous leishmaniasis (n = 40; 35.4%), leprosy (n = 38; 33.6%), and scabies (n = 31; 27.4%) were the most common. Additionally, there were four cases of mycetoma. Of the non NTDs, poverty-related infections such as superficial fungal (n = 118; 21.1%) and bacterial (n = 33; 5.2%) infections were also frequent. Tinea capitis was the most common superficial fungal infections. Impetigo and cellulitis were the predominant bacterial infections. CONCLUSIONS: Skin NTDsand other poverty related skin infections were common at the dermatology service. Dermatological services could act as a good entry point for integrated management of skin NTDs. Future studies should assess how different preventive strategies like contact tracing, early diagnosis and mass drug administration can be integrated.

Integrating family planning services into HIV care: use of a point-of-care electronic medical record system in Lilongwe, Malawi.

BACKGROUND: Integrating family planning (FP) services into human immunodeficiency virus (HIV) clinical care helps improve access to contraceptives for women living with HIV. However, high patient volumes may limit providers' ability to counsel women about pregnancy risks and contraceptive options. OBJECTIVES: To assess trends in the use of contraceptive methods after implementing an  electronic medical record (EMR) system with FP questions and determine the reasons for non-use of contraceptives among women of reproductive age (15-49 years) receiving antiretroviral therapy (ART) at the Martin Preuss Center clinic in Malawi. METHODS: In February 2012, two FP questions were incorporated into the ART EMR system (initial FP EMR module) to prompt providers to offer contraceptives to women. In July 2013, additional questions were added to the FP EMR module (enhanced FP EMR) to prompt providers to assess risks of unintended pregnancies, solicit reasons for non-use of contraceptives and offer contraceptives to non-pregnant women . We conducted a retrospective, longitudinal cohort study using the EMR routinely collected data. The primary outcome was the use of any modern contraceptive method. Descriptive statistics were used to describe the study population and report trends in contraceptive use during the initial and enhanced study periods. RESULTS: Between February 2012 and December 2016, in HIV clinics, 20,253 women of reproductive age received ART, resulting in 163,325 clinic visits observations. The proportion of women using contraceptives increased significantly from 18% to 39% between February 2012 and June 2013, and from 39% to 67% between July 2013 and December 2016 (chi-square for trend p < 0.001). Common reasons reported for the non-use of contraceptives among those at risk of unintended pregnancy were: pregnancy ambivalence (n = 234, 51%) and never thought about it (n = 133, 29%). CONCLUSION: Incorporating the FP EMR module into HIV clinical care prompted healthcare workers to encourage the use of contraceptives.

Adherence to Antiretroviral Therapy During and After Pregnancy: Cohort Study on Women Receiving Care in Malawi's Option B+ Program.

BACKGROUND: Adherence to antiretroviral therapy (ART) is crucial to preventing mother-to-child transmission of human immunodeficiency virus (HIV) and ensuring the long-term effectiveness of ART, yet data are sparse from African routine care programs on maternal adherence to triple ART. METHODS: We analyzed data from women who started ART at 13 large health facilities in Malawi between September 2011 and October 2013. We defined adherence as the percentage of days "covered" by pharmacy claims. Adherence of ≥90% was deemed adequate. We calculated inverse probability of censoring weights to adjust adherence estimates for informative censoring. We used descriptive statistics, survival analysis, and pooled logistic regression to compare adherence between pregnant and breastfeeding women eligible for ART under Option B+, and nonpregnant and nonbreastfeeding women who started ART with low CD4 cell counts or World Health Organization clinical stage 3/4 disease. RESULTS: Adherence was adequate for 73% of the women during pregnancy, for 66% in the first 3 months post partum, and for about 75% during months 4-21 post partum. About 70% of women who started ART during pregnancy and breastfeeding adhered adequately during the first 2 years of ART, but only about 30% of them had maintained adequate adherence at every visit. Risk factors for inadequate adherence included starting ART with an Option B+ indication, at a younger age, or at a district hospital or health center. CONCLUSIONS: One-third of women retained in the Option B+ program adhered inadequately during pregnancy and breastfeeding, especially soon after delivery. Effective interventions to improve adherence among women in this program should be implemented.

Developing a point-of-care electronic medical record system for TB/HIV co-infected patients: experiences from Lighthouse Trust, Lilongwe, Malawi.

BACKGROUND: Implementation of user-friendly, real-time, electronic medical records for patient management may lead to improved adherence to clinical guidelines and improved quality of patient care. We detail the systematic, iterative process that implementation partners, Lighthouse clinic and Baobab Health Trust, employed to develop and implement a point-of-care electronic medical records system in an integrated, public clinic in Malawi that serves HIV-infected and tuberculosis (TB) patients. METHODS: Baobab Health Trust, the system developers, conducted a series of technical and clinical meetings with Lighthouse and Ministry of Health to determine specifications. Multiple pre-testing sessions assessed patient flow, question clarity, information sequencing, and verified compliance to national guidelines. Final components of the TB/HIV electronic medical records system include: patient demographics; anthropometric measurements; laboratory samples and results; HIV testing; WHO clinical staging; TB diagnosis; family planning; clinical review; and drug dispensing. RESULTS: Our experience suggests that an electronic medical records system can improve patient management, enhance integration of TB/HIV services, and improve provider decision-making. However, despite sufficient funding and motivation, several challenges delayed system launch including: expansion of system components to include of HIV testing and counseling services; changes in the national antiretroviral treatment guidelines that required system revision; and low confidence to use the system among new healthcare workers. To ensure a more robust and agile system that met all stakeholder and user needs, our electronic medical records launch was delayed more than a year. Open communication with stakeholders, careful consideration of ongoing provider input, and a well-functioning, backup, paper-based TB registry helped ensure successful implementation and sustainability of the system. Additional, on-site, technical support provided reassurance and swift problem-solving during the extended launch period. CONCLUSION: Even when system users are closely involved in the design and development of an electronic medical record system, it is critical to allow sufficient time for software development, solicitation of detailed feedback from both users and stakeholders, and iterative system revisions to successfully transition from paper to point-of-care electronic medical records. For those in low-resource settings, electronic medical records for integrated care is a possible and positive innovation.