Factors Determining Survival and Retention among HIV-Infected Children and Adolescents in a Community Home-Based Care and a Facility-Based Family-Centred Approach in Kampala, Uganda: A Cohort Study.

We describe factors determining retention and survival among HIV-infected children and adolescents engaged in two health care delivery models in Kampala, Uganda: one is a community home-based care (CHBC) and the other is a facility-based family-centred approach (FBFCA). This retrospective cohort study reviewed records from children aged from 0 to 18 years engaged in the two models from 2003 to 2010 focussing on retention/loss to follow-up, mortality, use of antiretroviral therapy (ART), and clinical characteristics. Kaplan Meier survival curves with log rank tests were used to describe and compare retention and survival. Overall, 1,623 children were included, 90.0% (1460/1623) from the CHBC. Children completed an average of 4.2 years of follow-up (maximum 7.7 years). Median age was 53 (IQR: 11-109) months at enrolment. In the CHBC, retention differed significantly between patients on ART and those not (log-rank test, adjusted, P < 0.001). Comparing ART patients in both models, there was no significant difference in long-term survival (log-rank test, P = 0.308, adjusted, P = 0.489), while retention was higher in the CHBC: 94.8% versus 84.7% in the FBFCA (log-rank test, P < 0.001, adjusted P = 0.006). Irrespective of model of care, children receiving ART had better retention in care and survival.

Indigenous NGO involvement in TB treatment programmes in high-burden settings: experiences from the Northern Cape province, South Africa.

Effective tuberculosis (TB) treatment delivery in high-burden countries increasingly requires a multisectoral approach. This paper examines the role two local non-governmental organisations (NGOs) play in TB care delivery in a high-burden setting, the Northern Cape province, South Africa. NGOs played a complementary role to the formal health sector in effecting TB treatment delivery by training facilitators and recruiting and training lay volunteers for directly observed treatment. One key challenge was the paucity of systematised information to enable rigorous evaluation of the effectiveness of NGO contribution, which led to inadequate funding, as potential donors were sceptical about supporting activities whose value they could not assess. In high disease burden settings, where auxiliary actors can play useful roles in effective service delivery, it is important for NGOs to document and self-evaluate their role. One way of building this capacity is through technical support by government and development partners.

Combating tuberculosis: barriers to widespread non-governmental organisation involvement in community-based tuberculosis treatment in South Africa.

OBJECTIVES: To explore barriers to indigenous non-governmental organisation (NGO) involvement in community-based tuberculosis treatment delivery in high incidence areas. DESIGN: Qualitative study comprising in-depth interviews with key informants in non-government organisations and the formal health sector. Participant observation and documentary review methods were also employed. SETTING: Six non-governmental organisations involved in community-based tuberculosis care delivery in South Africa. SUBJECTS: Directors and Programme Managers of organisations and formal health sector personnel involved in tuberculosis control. RESULTS: Four major barriers were identified. Lack of adequate funding was the central issue linked to most of the other barriers identified, which included lack of adequate collaboration, competition, and a paucity of human resources. CONCLUSIONS: While indigenous non-governmental organisations face significant barriers to involvement in TB care delivery, on their part there is a need for closer collaboration of efforts as well as a more rigorous approach towards monitoring and evaluation of their contribution in order to fully realise their potential. Government and other external funders also need to increase their commitment to ensuring greater participation of these organisations in high TB incidence areas.

Tuberculosis treatment delivery in high burden settings: does patient choice of supervision matter?

SETTING: The Northern Cape Province, Republic of South Africa. OBJECTIVES: To determine the effect of patient choice of treatment delivery option on the treatment outcomes of tuberculosis (TB) patients in a high burden setting under actual programme conditions. DESIGN: Cohort study involving 769 new and retreatment TB patients recruited from 45 randomly selected clinics. Patients were interviewed and subsequent follow-up was done through regular visits to the clinics to check progress through formal health records. RESULTS: There was a statistically significant difference (P < 0.001) between the treatment outcome of new patients (70% successful) and re-treatment patients (54% successful). Direct observation of treatment (DOT) was found to have no effect on the treatment outcome of new patients (P = 0.875), but re-treatment patients were found to fare better with than without DOT (OR 14.2, 95% CI 4.18-53.14, P < 0.001). CONCLUSION: The results obtained for new patients are similar to those of two recent randomised controlled trials on DOT. This study revealed that for new patients, undue emphasis on universal DOT might be unnecessary. It would perhaps be more beneficial to target supervision at those patients who are most likely to benefit from it (i.e., re-treatment patients). This is of particular relevance in high burden, resource-limited settings where universal DOT for all TB patients is generally unfeasible.

What motivates lay volunteers in high burden but resource-limited tuberculosis control programmes? Perceptions from the Northern Cape province, South Africa.

SETTING: The Northern Cape province, Republic of South Africa. OBJECTIVES: To explore factors that motivate lay volunteers to join tuberculosis (TB) control programmes in high burden but resource-limited settings. DESIGN: A qualitative study consisting of three focus group discussions and a documentary review of the records of 347 lay volunteers involved in the tuberculosis programme in the Northern Cape province of South Africa. Additional data were also collected in a cross-sectional study that involved questionnaire interviews with 135 lay volunteers. SUBJECTS: Lay volunteers in the TB programme. One focus group discussion was also carried out with youth not involved in the TB programme. RESULTS: Volunteers do not receive any monetary incentives in the TB programme in the Northern Cape province, but due to the high level of unemployment in this setting, hope for eventual remuneration was found to be the strongest factor motivating youth to join the programme. The study found attrition rates among volunteers to be high (22% had dropped out of the programme within one year of joining); 75% of the dropouts gave loss of interest and a desire for paid work as the reasons for leaving the TB programme. Other motivating factors identified included altruism, a need to find something to do with one's spare time, gaining work experience, and the novelty of the community-based TB programme. CONCLUSION: In the absence of monetary incentives, attrition rates of lay volunteers may be high and this can threaten the effectiveness of community-based TB programmes. In resource-limited settings, it is important to identify and implement appropriate alternative incentives that could motivate lay persons in order to sustain community participation in high TB burden areas.