Incidence rate, predictors and outcomes of interruption of HIV care: nationwide results from the Belgian HIV cohort.

OBJECTIVES: We aimed to study the incidence rate, predictors and outcomes of HIV care interruption (HCI) in Belgium. METHODS: We analysed data for adult patients with at least two HIV care records in the Belgian HIV cohort between 1 January 2007 and 31 December 2016. An HCI episode was defined as 1 year without an HIV care record. The HCI incidence rate was analysed using Poisson regression, return to HIV care using a cumulative incidence function with death as a competing risk, and viral load (VL) status upon return to HIV care using logistic regression. RESULTS: We included 16 066 patients accounting for 78 625 person-years of follow-up. The incidence rate of HCI was 5.3/100 person-years [95% confidence interval (CI) 5.1-5.4/100 person-years]. The incidence of return to HIV care after HCI was estimated at 77.5% (95% CI 75.7-79.2%). Of those who returned to care, 43.7% had a VL ≤ 200 HIV-1 RNA copies/mL, suggesting care abroad or suboptimal care (without an HIV-related care record) in Belgium during the HCI, and 56.3% returned without controlled VL and were therefore considered as having experienced a real gap in HIV care; they represented 2.3/100 person-years of follow-up. Factors individually associated with HCI were no antiretroviral therapy (ART) uptake, lower age, injecting drug use, non-Belgian nationality, male gender, not being a man who has sex with men, a shorter time since HIV diagnosis, no high blood pressure and CD4 count < 350 cells/µL. CONCLUSIONS: This study highlights the need to investigate return to care and viral status at return, to better understand HCI. Identified predictors can help health care workers to target patients at higher risk of HCI for awareness and support.

The place of learning in a universal health coverage health policy process: the case of the RAMED policy in Morocco.

BACKGROUND: To progress towards universal health coverage (UHC), each country will have to develop its systemic learning capacity. This study aims at documenting how, across time, learning can feed into a UHC policy process, and how the latter can itself strengthen (or not) the learning capacity of the health system. It specifically focuses on the development of a major health financing policy aligned with the UHC goal in Morocco, the RAMED, a health financing scheme covering hospital costs for the poorest segment of the population. METHODS: We conducted a retrospective analysis of the RAMED policy for the period between 1997 and 2018, along with a case study design. For the data collection and analysis, we developed a framework combining Garvin's learning organisation framework and the heuristic health policy analysis framework. We gathered data from key informants and document reviews. RESULTS: The study confirmed the importance of learning during the different stages of the RAMED policy process. There is evidence of a leadership encouraging learning, the introduction and adoption of knowledge management processes, and the start of a transformation of the administrative culture. Yet, our study also showed some major shortcomings, especially the lack of structure of the learning, and insufficient effort to systemise and sustain a transformation of practices within the health administration. Our study also confirms that the learning changes in nature across the different stages of the policy process. CONCLUSION: The policy decisions and the implementation strategy create a learning dynamic, though not structured in all cases. Despite the positive interaction between learning and the RAMED policy, the opportunity to push forward a more structural transformation towards a learning system has not been fully seized. Hierarchical logics still largely prevail in the Moroccan health administration. The impact of future health policies for both the target beneficiaries and the health system will be bigger if their design integrates purposeful and structured actions in favour of organisational learning. This recommendation probably applies beyond Morocco.

Scoping literature review on the Learning Organisation concept as applied to the health system.

ᅟ: There is growing interest in the use of the management concept of a 'learning organisation'. The objective of this review is to explore work undertaken towards the application of this concept to the health sector in general and to reach the goal of universal health coverage in particular. Of interest are the exploration of evaluation frameworks and their application in health. METHOD: We used a scoping literature review based on the York methodology. We conducted an online search using selected keywords on some of the main databases on health science, selected websites and main reference books on learning organisations. We restricted the focus of our search on sources in the English language only. Inclusive and exclusive criteria were applied to arrive at a final list of articles, from which information was extracted and then selected and inserted in a chart. RESULTS: We identified 263 articles and other documents from our search. From these, 50 articles were selected for a full analysis and 27 articles were used for the summary. The majority of the articles concerned hospital settings (15 articles, 55%). Seven articles (25%) were related to the application of the concept to the health centre setting. Four articles discussed the application of the concept to the health system (14%). Most of the applications involved high-income countries (21 articles, 78%), with only one article being related to a low-income country. We found 13 different frameworks that were applied to different health organisations. CONCLUSIONS: The scoping review allowed us to assess applications of the learning organisation concept to the health sector to date. Such applications are still rare, but are increasingly being used. There is no uniform framework thus far, but convergence as for the dimensions that matter is increasing. Many methodological questions remain unanswered. We also identified a gap in terms of the use of this concept in low- and middle-income countries and to the health system as a whole.

The determinants of informal caregivers' burden in the care of frail older persons: a dynamic and role-related perspective.

Research into informal caregivers' burden does not distinguish between different stages of impairment. This study explored the determinants of burden from an in-depth perspective in order to identify which determinants apply to which phases of impairment. METHODS: This was a cross-sectional study including frail older persons aged 65 and above. Instruments used were the interRAI Home Care, the Zarit-12 interview and an ad hoc economic questionnaire. A combination of variables from the Stress Process Model and Role Theory and a sub-group analysis enabled refined multivariate logistic analyses. RESULTS: The study population consisted of 4175 older persons (average age: 81.4 ± 6.8, 67.8% female) and their informal caregivers. About 57% of them perceived burden. Depressive symptoms, behavioral problems, IADL impairment, previous admissions to nursing homes and risk of falls yielded significant odds ratios in relation to informal caregivers' burden for the whole sample. These determinants were taken from the Stress Process Model. When the population was stratified according to impairment, some factors were only significant for the population with severe impairment (behavioral problems OR:2.50; previous admissions to nursing homes OR:2.02) and not for the population with mild or moderate impairment. The informal caregiver being an adult child, which is a determinant from Role Theory, and cohabitation showed significant associations with burden in all strata. CONCLUSION: Determinants of informal caregivers' burden varied according to stages of impairment. The results of this study can help professional caregivers gain a greater insight into which informal caregivers are most susceptible to perceive burden. ABBREVIATIONS: NIHDI: National Institute for Health and Disability Insurance; ZBI12: Zarit Burden Interview - 12 items; InterRAI HC: interRAI Home Care instrument; ADL: Activities of Daily Living; ADLH: interRAI Activities of Daily Living Hierarchy scale; IADL: Instrumental Activities of Daily Living; IADLP: InterRAI Instrumental Activities of Daily Living Performance scale; CPS2: InterRAI Cognitive Performance scale 2; DRS: InterRAI Depression Rating scale.

[Point of view of older adults on the potentially inappropriate medications prescribing in primary care facilities in Bobo-Dioulasso, Burkina Faso]. / Regard des personnes âgées sur la prescription des médicaments potentiellement inappropriés dans le premier niveau de soins à Bobo-Dioulasso, Burkina Faso.

BACKGROUND: Little is known about the organization of primary care facilities in sub-Saharan Africa that might lead to potentially inappropriate prescribing. The aim of this study was to analyze the factors that could lead to potentially inappropriate prescribing in primary care facilities in Bobo-Dioulasso (Burkina Faso), taking into consideration the patient's perspective. METHODS: A cross-sectional qualitative study was conducted in primary care facilities from November 2013 to February 2014. People aged 60 years or more with at least one chronic disease were included. Individual interviews were conducted. An analysis of the thematic content of the interviews was conducted. RESULTS: Our results showed that the patient referral system was insufficient. We also found many different prescribers for older people seeking care and poor communication between prescribers and patients. This caused some consequences such as the absence of review of drugs consumed before a new prescription, a lack of exchange on medication changes and repeated treatment change during hospitalization. Most of the persons who prescribed potentially inappropriate medications were nurses. CONCLUSION: The poor communication between prescribers and patients is a challenge for the prevention of prescribing potentially inappropriate medications. Teamwork is an important feature of the organizational care system, strengthening it could be a way to improve rational prescription.

[Clinical course of post-stroke depression in Kinshasa]. / Évolution clinique de la dépression post-accident vasculaire cérébral à Kinshasa.

OBJECTIVES: To describe the evolution of the clinical profile of post-stroke depression over a period of one year and to determine factors associated with changes in post-stroke depression. METHODS: Prospective cohort study with a follow-up of 1year including 30 consecutive eligible patients. The severity of depression was assessed with the patient health questionnaire (PHQ9). RESULTS: The mean age was 55.87±12.67years. Seventy percent of patients were men. The two assessments for neurological status, perceived health status and test results of attention were not statistically different. The rate of depressive symptoms was 26.67% in 2011 and 20% in 2012. Disability and apathy were significantly improved. The average for disability increased from 2.77±1.19 to 2.46±2.19 (P=0.002). From 66.7% in 2011, the proportion of patients able to walk without assistance rose to 93.3% in 2012 (P=0.03). In addition, the proportion of patients apathetic decreased from 43.3% to 13.3% (P=0.01). Greater age, female sex, sleep disorders and post-stroke apathy remained associated with DPAVC between the two assessments, with an increase in the strength of the association for apathy. CONCLUSIONS: The frequency of post-stroke depression is high and remains stable over time. Disability is the clinical feature that evolved more favorably. The association with apathy, present at the beginning, of the study was strengthened one year later.

[Thirty years of tuberculosis control in Cameroon: alternating "vertical" and "horizontal" health care delivery systems]. / Trente ans de lutte antituberculeuse au Cameroun: une alternance entre systèmes d'offre de soins de santé "vertical" et "horizontal".

BACKGROUND: In sub-Saharan Africa, tuberculosis remains endemic despite reforms of health systems and the tuberculosis control organization carried out in the last decades. METHODS: We conducted a retrospective study of tuberculosis control in Cameroon from the period 2009 back to 1980. Data were collected from documents and activity reports of tuberculosis control, and interviews with managers of the National tuberculosis control program. FINDINGS: The history of tuberculosis control in Cameroon from 2009 back to 1980 can be divided into three main periods. The first period, from 1980 to 1994, corresponded to the implementation of the 'primary health care' policy. At that time, tuberculosis case management was delivered free of charge, but centralized in specialized services with a gradual and mild increase in new cases detected. The second period, from 1995 to 2000, was characterized by the implementation of the 'primary health care reorientation' policy that decentralized tuberculosis care to all health facilities, but introduced cost recovery --which came along with a dramatic drop in the number of tuberculosis cases detected. The National tuberculosis control program, established in 1996, entrusted health facilities--especially hospitals--with the responsibility of tuberculosis diagnosis and treatment, and referred to them as tuberculosis diagnosis and treatment centers. During the third period, from 2001 to 2009, owing to major support from global health initiatives, the number of tuberculosis diagnosis and treatment centers was increased (reaching 216 centers in 2009), with a significant increase of new cases detected that peaked in 2006, from where the situation started declining till 2009. CONCLUSION: Tuberculosis control indicators have never been optimal in Cameroon, despite the generally positive trend from 1980 to 2009. The strategy of tuberculosis diagnosis and treatment centers, which are essentially nested within hospitals, seems to have reached its intrinsic limitations. Better performance in tuberculosis control will henceforth require greater decentralization of tuberculosis detection and treatment to health centers. This careful decentralization will improve access for tuberculosis patients and lead to a comprehensive use of hospital technical expertise for tuberculosis care.

[The unmet needs of the elderly living with functional disabilities in Bobo-Dioulasso (Burkina Faso)]. / Les besoins non couverts des personnes âgées en incapacités fonctionnelles à Bobo-Dioulasso (Burkina Faso).

BACKGROUND: In sub-Sahara Africa, the strong involvement of the family in multidimensional cares/supports of elderly is often presented like the family ensures almost everything to these people. Thus, few studies have focused on unmet needs of the elderly in their family or above. This study was conducted in Bobo-Dioulasso to identify those needs. METHODS: This is a longitudinal study including 58 people or 15 elderly and 43 caregivers from 15 families in Bobo-Dioulasso. In addition to regular observations of these families during 1 year, we conducted in-depth individual interview with each participant at the beginning and at the end of the study. The data were analyzed using QSR NVivo 8 software. RESULTS: A priori, respondents let believe that there is no unmet functional needs of the elderly in their family. However, the food, the first and main functional need of the elderly is not qualitatively satisfied by their family as well as other equipments or health needs. The quality of social cares/supports, biomedical cares and community supports are insufficient when these cares/supports are provided. The family demands many free or subsidized services to public or community structures then they are not currently available. DISCUSSION: In a context of widespread poverty, it is difficult for each actor of the social system of maintaining elderly in functional autonomy to provide services/supports of optimal quality. A synergy of action will reduce the unmet needs of the elderly in Bobo-Dioulasso.

[Results of tuberculosis control programs in Madagascar from 1996 to 2004]. / Etat des lieux de la lutte contre la tuberculose à Madagascar de 1996 à 2004.

OBJECTIVE: Madagascar's national tuberculosis control program has been operational since 1991. The purpose of this article is to provide up-to-date information about the results of this program. METHOD: Data from reports sent to the Tuberculosis Control Department between 1996 and 2004 by diagnosis and treatment centers were retrospectively studied. Special focus was placed on new cases of tuberculosis identified by positive smear. RESULTS: During the study period the annual incidence of new cases of tuberculosis confirmed by positive smear increased from 65 to 82 per 100,000 inhabitants. The highest incidence of new cases was observed in the active population. The treatment success rate rose from 64.4% to 70.8% in patients with positive smear tests. The dropout rate decreased from 21% to 16.5%. However discrepancies were observed between the number of cases diagnosed and number of cases treated. CONCLUSIONS: These findings indicate that tuberculosis control improved slowly over the study period. However these data do not allow identification of strategies to improve program performance. This will require detailed review of data taking into account the context in which they were obtained.

[A patient-centered approach to tuberculosis control in Burkina Faso]. / L'approche centrée sur le patient pour la lutte contre la tuberculose au Burkina Faso.

BACKGROUND: The Burkina Faso health system is divided into 55 health districts (DS), each with more than 10 primary care health centers (CSPS) that comprise the first level of the health care system. For this study, we chose two intervention districts (one rural, one urban) and two control districts. OBJECTIVE: To evaluate the impact of the patient-centered approach to tuberculosis control on the detection and treatment of tuberculosis. METHOD: This intervention, defined in a consensus process by various participants in tuberculosis management, was implemented in two districts (one rural and one urban). Study outcomes were measured before and after the intervention in two intervention districts and two control districts. RESULTS: The proportion of patients suspected of tuberculosis who chose sputum sampling in the CSPS was higher in the rural district (Gorom-Gorom) than in the urban one (Pissy): 46% versus 18.7% (p < 0.001). Detection improved more in the intervention than control districts (59% versus 20%). The increase in diagnosis was better in the intervention districts than in their matched control districts (46% versus 5% in the rural district; 75% versus 32% in the urban district). The treatment success rate was better in the rural district's decentralized CSPSs than in its CDTs (Gorom-Gorom) (61.8% vs 52.8%), while the reverse was true in the urban district (Pissy) (75% vs 83.1%). CONCLUSION: Detection of new tuberculosis cases increased throughout this study. Improvement in treatment regularity was limited. A longer intervention is needed to evaluate the effects of this approach on treatment results.

Conversion rate at two-month follow-up of smear-positive tuberculosis patients in Burkina Faso.

SETTING: Burkina Faso, West Africa. OBJECTIVE: 1) To determine the trend of sputum smear conversion rates at the 2-month follow-up of new smear-positive tuberculosis (TB) patients; and 2) to compare conversion rates in cured TB patients and treatment failures. DESIGN: Retrospective cohort study based on TB registers from all 80 diagnostic and treatment centres from 1995 to 2003. The conversion rate was defined as the number of negative results divided by the number of smear-positive patients for whom the 2-month follow-up examination was completed. RESULTS: The 2-month follow-up completion rate was 92.1%; it increased from 86.3% in 1996 to 94.3% in 2003. The conversion rate was 82.9%, increasing from 76.3% in 1995 to 87.9% in 1997 and falling to 80.3% in 2003. The cure rate was higher among patients who were smear-negative at the 2-month follow-up (77.3%) CONCLUSION: The conversion rate was satisfying, but had declined since 1997, which may be a matter of concern. This could be due to patient characteristics such as associated conditions (human immunodeficiency virus, malnutrition) or to drug management (ineffective administration of drugs even under directly observed treatment, insufficient dosages, resistance). Thorough research is needed to elucidate this negative trend.

[An action research network to improve the quality of tuberculosis care in West Africa]. / Améliorer la qualité des soins aux patients tuberculeux par la recherche-action en réseau. Une expérience en Afrique de l'Ouest.

BACKGROUND: Improvement in management systems for tuberculosis (TB) care is urgently needed in West Africa. In 2003, an experimental action research network began there, involving care providers, health system managers, and TB programme managers. Each project in all 6 countries used a "patient-centered" approach to improve tuberculosis case management. METHODS: The research teams included care providers, district medical officers, anthropologists and TB programme managers. Each research team conducted its project for a one-year period and then assessed its results. The specific problems identified were low TB detection rates (Burkina Faso, Côte d'Ivoire and Niger) and poor compliance among patients receiving treatment, including their ensuing loss to follow-up (Benin, Mali and Senegal). Investigators concluded that these weaknesses were due to the lack of access to care (geographical, financial and cultural), the complexity of the care system and the low quality of care. Solutions for all 6 countries aimed at improving access to high-quality care. RESULTS: One year after the experiment began, results varied from one country to another. In general, all participants understood the need to collaborate beyond national health systems because the problems from all 6 countries were quite similar. The research process led to better sharing of work between care providers and sometimes between care providers and TB patients. It provided participants with new concepts and a constant opportunity to implement them. These repeated meetings, however, keep care providers away from their offices. CONCLUSION: The research would have improved case management and care more effectively had the teams taken into account the psychological and sociological need of TB patients. A new regional dynamic has begun and must be pursued to help improve health care systems.

Advantages and disadvantages of using the PRISMA7 to determine the elderly subjects for whom the SMAF is useful for assessing functional status in Bobo-Dioulasso (Burkina Faso).

One of the difficulties faced by African actors working with the elderly is the lack of appropriate tools for the identification and/or diagnosis of functional disabilities among older people in this limited-resource (material, human, and financial) setting. This study sought to assess the advantages and disadvantages of the combined use of two tools, PRISMA7 (for identifying older individuals at risk of functional disabilities and loss of autonomy) and SMAF (to evaluate the functional status of the elderly) in Bobo-Dioulasso (Burkina Faso). PRISMA7 and SMAF were administered to a representative sample of elderly people who lived at home. Data analysis was performed with Stata. The results show that the combination of PRISMA7 and SMAF made it possible to avoid unncessary administration of the SMAF to all subjects, reducing the number of questionnaires to photocopy by 48 % and the working time by 45 %. The prevalence of moderate to severe functional disabilities was 32 % according to the SMAF alone and 25 % when PRISMA7 was administered first and determined whether the SMAF would be used. The 7 % rate of loss to follow-up shows a need for monitoring or help, generally in instrumental activities. In a limited-resource setting, this combination is a good strategy for identifying and evaluating functional disabilities in the elderly. This strategy allows the development of work plans tailored to individual functional needs.

Are patients who present spontaneously with PTB symptoms to the health services in Burkina Faso well managed?

SETTING: Six health districts selected from a total of 53 in Burkina Faso. OBJECTIVE: To evaluate the performance of the health services in identifying infectious pulmonary tuberculosis (PTB) cases in Burkina Faso. DESIGN: Retrospective review of initial consultation registers in the first level health centres and the laboratory and treatment registers kept at the Centres for TB Diagnosis and Treatment (CDTs) in 2001. RESULTS: The rate of detection of sputum-positive cases of PTB was 11.7 cases per 100000 population. Cough was the reason for consulting for 10.6% of 248,730 adults; 1.1% had chronic cough. Among patients with chronic cough, 66% had been referred for smear microscopy, 69.7% of whom were registered at the CDT to which they were referred. A positive diagnosis was made in 22.5% of the suspects referred and traced to the CDT. Among those with a positive diagnosis, 87.1% were put on treatment in the same CDT. CONCLUSIONS: The PTB case detection rate in Burkina Faso is low, due to the loss of cases at each of the stages leading to the diagnosis of TB. Case detection depends on the operational effectiveness of the staff working in the health services, as well as the referral of suspect patients to the CDT.

Decentralising tuberculosis case management in two districts of Burkina Faso.

SETTING: In West Africa, national tuberculosis programmes (NTPs) face many problems due to the low performance of health care delivery systems and patients' social and cultural environment. OBJECTIVE: To improve the case management of TB in Burkina Faso. DESIGN: Using the operational research process as a tool, TB case management was decentralised from the district hospital to eight primary health care centres in 2003. RESULTS: Twelve months after decentralisation, the quality of case detection remained satisfactory. The delay between the identification of TB suspects with chronic cough and the confirmation of TB was reduced from 13 to 6 days. The detection rate of TB suspects during the study (30%) was twice as high as for 2001 and 2002 (15%). However, the detection rate for smear-positive TB cases decreased from 32.3% in 2001 and 2002 to 6.5% during the year of the study. CONCLUSION: Sufficient time and commitment are essential to obtain a case management system that is decentralised and effective. Efforts therefore need to continue to obtain more information and better results.

[Contextual factors regarding the effectiveness of tuberculosis control in Madagascar: a nationwide validity study]. / Facteurs contextuels de l'efficacité du contrôle de la tuberculose à Madagascar : étude de validité au niveau national.

INTRODUCTION: This study assesses the nationwide applicability of results from a study in the tuberculosis (TB) diagnostic and treatment centers (DTCs) in a sample of six districts in Madagascar, which identified adaptations of national guidelines and local initiatives that might explain the effectiveness of individual DTCs in improving adherence to TB treatment and thus reducing treatment default. OBJECTIVE: To assess, at a national level, the importance of these adaptations/initiatives for TB treatment adherence. METHODS: This analytical cross-sectional study assessed the responses to a questionnaire based on the previously identified adaptations/initiatives, which was sent to the heads of all 205 DTCs in Madagascar. RESULTS: Decentralization of TB care decreased the rate of patient default. The private DTCs report better results than public DTCs. Adaptations/initiatives in relation to local contexts often lead to good results. The relation between some adaptations/initiatives and continued adherence sometimes varies with the local context of the DTC; the same initiatives can result in better adherence or in higher of treatment default rates, depending on the setting. CONCLUSION: These initiatives should be applied after adaptation to the context.

Access and adhering to tuberculosis treatment: barriers faced by patients and communities in Burkina Faso.

SETTING: Three selected districts in Burkina Faso. OBJECTIVES: 1) To explore patients' and community members' perceptions and problems associated with accessing formal tuberculosis (TB) treatment; and 2) to identify patients' and community members' perceptions and problems associated with adhering to formal TB treatment. METHODS: Twenty-eight focus group discussions and 68 in-depth interviews with TB patients, community representatives, members of the health centre management committee, traditional healers and health professionals. RESULTS: Attending the health centre was the last resort for patients with symptoms indicative of TB. When on treatment, patients faced a number of barriers in adhering to care. These related to the centralised nature of direct observation and the problems faced whilst at the treatment unit. CONCLUSION: Patients experience three sets of inextricably linked barriers to successfully treating TB: attending the health centre initially, attending the health centre repeatedly and experiences whilst at the health centre. These barriers are further complicated by geography, poverty and gender. The challenge ahead lies in moving beyond documenting barriers from patients' perspectives to addressing them in resource-poor contexts.

The cost of medical care and people's health-seeking behaviour before being suspected of tuberculosis in three local health systems, Nicaragua.

OBJECTIVE: To assess the medical costs incurred by users and delay between first contact with a care provider and sputum test for acid-fast bacilli (AFB) in three areas of Nicaragua. METHODS: Directed interviews of consecutive series of tuberculosis (TB) suspects whose sputum had been examined for AFB. RESULTS: Of 252 TB suspects interviewed, 52% used more than one type of care giver and 35% used private practitioners. As a consequence, 18%, 21% and 29% of the interviewees in Carazo, El Viejo and Matagalpa, respectively, spent more than 1 month of the country's median income per inhabitant on medical care between the first visit to a care provider and the first sputum examination. Furthermore, more than 3 months elapsed on that part of the care pathway for 30%, 17% and 3% of interviewees in Matagalpa, El Viejo and Carazo, respectively. CONCLUSION: This study sheds light on the costs and delays incurred by TB suspects before reaching a laboratory for sputum smear examination. Both costs are lower for those suspects who exclusively use first-line governmental health services (FLGHS). This has been relatively little documented in Latin America to date and could be used as an argument to develop strategies to strengthen the credibility of FLGHS.

An exploration of the concept of directly observed treatment (DOT) for tuberculosis patients: from a uniform to a customised approach.

Tuberculosis (TB) management has moved from chaotic systems and low patient adherence with treatment regimens to the directly observed therapy, short course (DOTS) strategy, which has been described as a new paradigm of TB control. Directly observed treatment (DOT) is only one component of the full DOTS strategy. DOT versus self-administered treatment (SAT) has been the subject of extensive debate, particularly about what approach improves treatment adherence. This debate has been complicated by different case-holding rates and cure outcomes in different contexts where DOT is in place. The increasing range of DOT applications in different settings, including the choice of provider, place, target population, and the extent to which DOT is part of a wider approach, has not been sufficiently taken into account. However, the concrete reality of DOT is an important determinant of the overall success or failure of the programme, and has implications in terms of equity and accessibility of care during treatment. This article aims to go beyond the frequently polarised debate of DOT versus SAT and document the diversity of ways in which DOT has been implemented internationally. We also aim to raise key issues for further discussion, including 1) viewing DOT as part of a complex and lengthy set of interventions that are context-specific, 2) incorporating an equity approach that discusses individual patients' needs and the relationship between the patient and provider, and 3) the role of incentives and enablers. It is anticipated that this exchange of opinion and experiences from different parts of the world will be useful for those involved in the policy formulation and practice of TB management.

Syphilis in Murewa District, Zimbabwe: an old problem that rages on.

OBJECTIVE: To determine the prevalence of syphilis among pregnant women and women giving birth in health centres in a rural district and to identify problems associate with syphilis control in the same district. DESIGN: Cross sectional descriptive study. SETTING: Murewa District health facilities. SUBJECTS: Women attending health facilities in this district for antenatal care or delivery between February and May 1993. MAIN OUTCOME MEASURES: Syphilis sero-prevalence rate. Factors associated with poor syphilis control. RESULTS: Even though it is recommended that all women attending clinics for antenatal care (ANC) should be screened for syphilis at first visit only 308 (20%) out of 1,556 first visit attenders were screened during the study period. Three hundred and sixty six (33%) out of 1,096 women giving birth in health institutions were screened. The RPR/TPHA sero positivity rate for antenatal women was 9.2% while that for women delivering was 9.8%. A positive RPR was not significantly associated with the women's age, parity, infant's birth weight, sex or pregnancy outcome. Factors associated with poor syphilis control in this district included: lack of motivation and appreciation of the seriousness of syphilis in pregnancy; lack of transport to send specimens and receive results from Murewa District Hospital; poor record keeping; loss to follow up of women being tested or after starting treatment; lack of contact tracing and treatment of contacts and difficulties in implementing the 10 day neonatal regime and follow up of these infants. CONCLUSION: Syphilis remains poorly controlled in Murewa district and may be contributing significantly to high perinatal mortality rates. There is need to strengthen the syphilis control programme through motivation and training of health workers, decentralisation of testing and treatment of the condition and improved contact tracing. A repeat RPR test at delivery may not be cost effective.

PIP: A cross-sectional descriptive study was conducted at Murewa District health facilities to determine the prevalence of syphilis among antenatal women and women giving birth and to identify problems associated with syphilis control. The data were collected from the health center nursing staff who took care of the women during antenatal period or delivery at Murewa District health facilities. The results showed that only 308 (20%) out of 1556 first visit attendees were screened during the study period while only 366 (33%) women giving birth were screened out of 1096 subjects. The RPR/TPHA seropositivity rate for antenatal women was 9.2%, while that for women delivering was 9.8%. There was no significant association between positive RPR result and the women's age, parity, the infant's birth weight or sex or pregnancy outcome. Poor syphilis control in Murewa District Health facilities was due to lack of motivation and appreciation of the seriousness of syphilis in pregnancy, lack of transport to send specimens and receive results from Murewa District Hospital, poor record keeping, loss during follow-up of women during testing or after treatment, lack of contact tracing and treatment of contacts and difficulties in implementing the 10 day neonatal regimen and follow up for these infants. Owing to these factors, syphilis remains poorly controlled in Murewa district and may be considered a significant contributing factor to high perinatal mortality rates. Action is needed to strengthen the syphilis control program through motivation and training of health workers, improved contact tracing, and decentralization of testing and treatment.