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1.
AIDS Patient Care STDS ; 31(4): 153-166, 2017 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-28358624

RESUMO

As lifelong antiretroviral therapy (ART) for pregnant women is implemented, it is important to understand the attitudes and norms affecting women's postpartum ART adherence. This is a qualitative cross-sectional study of HIV-positive postpartum women (n = 112) enrolled in a 2-year observational prospective cohort in Rwanda. Informed by the Theory of Reasoned Action (TRA), we conducted in-depth interviews with women whose children were 0-6, 7-12, 13-18, or 21-24 months of age to describe factors contributing to adherence and changes over time. Positive ART attitudes reported by women included mothers' health promotion, prevention of infant HIV infection, higher CD4 count, and improved physical appearance. Negative attitudes were few, but included side effects and the lifelong nature of treatment. Learning from people living with HIV (PLHIV) was identified as a norm facilitating adherence; ART adherence was inhibited by fear of disclosure or stigmatization in communities and clinics. Poor adherence behaviors were common immediately after HIV diagnosis, not necessarily during prevention of mother-to-child transmission (PMTCT). Women with older children, most of whom stopped breastfeeding by 13-18 months, reported more barriers and missed doses than women with younger children. The TRA was useful in identifying the collective influence of attitudes, norms, and intentions on behavior. Findings suggest that HIV-positive women are vulnerable to poor adherence following HIV diagnosis and around the time of breastfeeding cessation. Lifelong treatment adherence can be supported through PLHIV exemplifying long-term ART use, fewer and less stigmatizing clinic visits, and counseling messages highlighting the benefits of drugs on appearance and illness prevention and incorporating biological feedback.


Assuntos
Infecções por HIV/tratamento farmacológico , Transmissão Vertical de Doença Infecciosa/prevenção & controle , Adesão à Medicação , Complicações Infecciosas na Gravidez/tratamento farmacológico , Gestantes/psicologia , Estigma Social , Adulto , Aleitamento Materno , Contagem de Linfócito CD4 , Estudos Transversais , Medo , Feminino , Infecções por HIV/diagnóstico , Infecções por HIV/etnologia , Infecções por HIV/psicologia , Humanos , Lactente , Entrevistas como Assunto , Período Pós-Parto , Gravidez , Complicações Infecciosas na Gravidez/etnologia , Complicações Infecciosas na Gravidez/psicologia , Estudos Prospectivos , Pesquisa Qualitativa , Ruanda/epidemiologia
2.
AIDS Care ; 29(3): 326-334, 2017 03.
Artigo em Inglês | MEDLINE | ID: mdl-27539782

RESUMO

HIV testing and counselling forms the gateway to the HIV care and treatment continuum. Therefore, the World Health Organization recommends provider-initiated testing and counselling (PITC) in countries with a generalized HIV epidemic. Few studies have investigated linkage-to-HIV-care among out-patients after PITC. Our objective was to study timely linkage-to-HIV-care in six Rwandan health facilities (HFs) before and after the introduction of PITC in the out-patient departments (OPDs). Information from patients diagnosed with HIV was abstracted from voluntary counselling and testing, OPD and laboratory registers of six Rwandan HFs during three-month periods before (March-May 2009) and after (December 2009-February 2010) the introduction of PITC in the OPDs of these facilities. Information on patients' subsequent linkage-to-pre-antiretroviral therapy (ART) care and ART was abstracted from ART clinic registers of each HF. To triangulate the findings from HF routine, a survey was held among patients to assess reasons for non-enrolment. Of 635 patients with an HIV diagnosis, 232 (36.5%) enrolled at the ART clinic within 90 days of diagnosis. Enrolment among out-patients decreased after the introduction of PITC (adjusted odds ratio, 2.0; 95% confidence interval, 1.0-4.2; p = .051). Survey findings showed that retesting for HIV among patients already diagnosed and enrolled into care was not uncommon. Patients reported non-acceptance of disease status, stigma and problems with healthcare services as main barriers for enrolment. Timely linkage-to-HIV-care was suboptimal in this Rwandan study before and after the introduction of PITC; the introduction of PITC in the OPD may have had a negative impact on linkage-to-HIV-care. Healthier patients tested through PITC might be less ready to engage in HIV care. Fear of HIV stigma and mistrust of test results appear to be at the root of these problems.


Assuntos
Continuidade da Assistência ao Paciente , Aconselhamento , Infecções por HIV/diagnóstico , Encaminhamento e Consulta , Adulto , Instituições de Assistência Ambulatorial , Feminino , Humanos , Masculino , Razão de Chances , Ruanda , Inquéritos e Questionários
3.
Medicine (Baltimore) ; 96(51): e9445, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29390577

RESUMO

Lifelong antiretroviral therapy (ART) provision to all pregnant HIV-positive women ("Option B+") has been recommended by the World Health Organization since 2013, but there remain limited data on the effects of Option B+ on long-term HIV-free survival in breastfeeding HIV-exposed infants. The Kigali Antiretroviral and Breastfeeding Assessment for the Elimination of HIV (Kabeho) study enrolled HIV-positive women from the third trimester of pregnancy to 2 weeks postpartum in 14 heath facilities implementing Option B+ in Kigali, Rwanda. Mother-child pairs in the longitudinal observational cohort were followed until 24 months postpartum, with HIV diagnostic testing at 6 weeks, and 9, 18 and 24 months. The Kaplan-Meier method was used to estimate HIV transmission, survival, and HIV-free survival through 24 months. We enrolled 608 HIV-positive women in 2013-2014; birth outcome data were available for 600 women and 597 live-born infants. By 6 weeks, 11 infants had died and 3 infants had confirmed HIV infection (0.5% transmission; 95% confidence interval [CI] 0.2-1.6). At 9 months, there were 9 additional deaths and 2 new infections (cumulative transmission 0.9%, 95% CI 0.4-2.2). At 18 months, there were 6 additional deaths and no new infant infections. At 24 months, there were no additional child deaths and 1 new infection (cumulative 2.2%, 95% CI 0.7-7.0), for an overall 24-month HIV-free survival of 93.2% (95% CI 89.5-95.6). Low transmission rates and high HIV-free survival at 24 months were achieved in breastfeeding infants of HIV-positive mothers receiving universal ART in urban health facilities in Rwanda, though vigilance on maintaining viral suppression for ART-experienced women is needed.


Assuntos
Fármacos Anti-HIV/uso terapêutico , Infecções por HIV/prevenção & controle , Transmissão Vertical de Doença Infecciosa/prevenção & controle , Adulto , Pré-Escolar , Feminino , Infecções por HIV/epidemiologia , Humanos , Lactente , Mortalidade Infantil , Recém-Nascido , Transmissão Vertical de Doença Infecciosa/estatística & dados numéricos , Masculino , Gravidez , Complicações Infecciosas na Gravidez/virologia , Resultado da Gravidez , Ruanda
4.
PLoS One ; 11(12): e0168671, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-28006001

RESUMO

There are limited viral load (VL) data available from programs implementing "Option B+," lifelong antiretroviral treatment (ART) to all HIV-positive pregnant and postpartum women, in resource-limited settings. Extent of viral suppression from a prevention of mother-to-child transmission of HIV program in Rwanda was assessed among women enrolled in the Kigali Antiretroviral and Breastfeeding Assessment for the Elimination of HIV (Kabeho) Study. ARV drug resistance testing was conducted on women with VL>2000 copies/ml. In April 2013-January 2014, 608 pregnant or early postpartum HIV-positive women were enrolled in 14 facilities. Factors associated with detectable enrollment VL (>20 copies/ml) were examined using generalized estimating equations. The most common antiretroviral regimen (56.7%, 344/607) was tenofovir/lamivudine/efavirenz. Median ART duration was 13.5 months (IQR 3.0-48.8); 76.1% of women were on ART at first antenatal visit. Half of women (315/603) had undetectable RNA-PCR VL and 84.6% (510) had <1,000 copies/ml. Detectable VL increased among those on ART > 36 months compared to those on ART 4-36 months (72/191, 37.7% versus 56/187, 29.9%), though the difference was not significant. The odds of having detectable enrollment VL decreased significantly as duration on ART at enrollment increased (AOR = 0.99, 95% CI: 0.9857, 0.9998, p = 0.043). There was a higher likelihood of detectable VL for women with lower gravidity (AOR = 0.90, 95% CI: 0.84, 0.97, p = 0.0039), no education (AOR = 2.25, (95% CI: 1.37, 3.70, p = 0.0004), nondisclosure to partner (AOR = 1.97, 95% CI: 1.21, 3.21, p = 0.0063) and side effects (AOR = 2.63, 95% CI: 1.72, 4.03, p<0.0001). ARV drug resistance mutations were detected in all of the eleven women on ART > 36 months with genotyping available. Most women were receiving ART at first antenatal visit, with relatively high viral suppression rates. Shorter ART duration was associated with higher VL, with a concerning increasing trend for higher viremia and drug resistance among women on ART for >3 years.


Assuntos
Infecções por HIV/diagnóstico , Infecções por HIV/virologia , Transmissão Vertical de Doença Infecciosa/estatística & dados numéricos , Carga Viral , Viremia/epidemiologia , Adulto , Fármacos Anti-HIV/uso terapêutico , Feminino , Infecções por HIV/tratamento farmacológico , HIV-1/efeitos dos fármacos , HIV-1/fisiologia , Humanos , Gravidez , Prevalência , Estudos Prospectivos , Ruanda , Viremia/diagnóstico , Viremia/virologia , Adulto Jovem
6.
BMC Infect Dis ; 16: 26, 2016 Jan 25.
Artigo em Inglês | MEDLINE | ID: mdl-26809448

RESUMO

BACKGROUND: Provider-initiated HIV testing and counselling (PITC) is promoted as a means to increase HIV case finding. We assessed the effectiveness of PITC to increase HIV testing rate and HIV case finding among outpatients in Rwandan health facilities (HF). METHODS: PITC was introduced in six HFs in 2009-2010. HIV testing rate and case finding were compared between phase 1 (pre-PITC) and phase 3 (PITC period) for outpatient-department (OPD) attendees only, and for OPD and voluntary counseling & testing (VCT) departments combined. RESULTS: Out of 26,367 adult OPD attendees in phase 1, 4.7% were tested and out of 29,864 attendees in phase 3, 17.0% were tested (p < 0.001). The proportion of HIV cases diagnosed was 0.25% (67/26,367) in phase 1 and 0.46% (136/29864) in phase 3 (p < 0.001). In multivariable analysis, both testing rate and case finding were significantly higher in phase 3 for OPD attendees. In phase 1 most of the HIV testing was done in VCT departments rather than at the OPD (78.6% vs 21.4% respectively); in phase 3 this was reversed (40.0% vs 60.0%; p < 0.001). In a combined analysis of VCT and OPD attendees, testing rate increased from 18.7% in phase 1 to 25.4% in phase 3, but case finding did not increase. In multivariable analysis, testing rate was significantly higher in phase 3 (OR 1.67; 95% CI 1.60-1.73), but case finding remained stable (OR 1.09; 95% CI 0.93-1.27). CONCLUSION: PITC led to a shift of HIV testing from VCT department to the OPD, a higher testing rate, but no additional HIV case finding.


Assuntos
Sorodiagnóstico da AIDS/estatística & dados numéricos , Assistência Ambulatorial , Infecções por HIV/diagnóstico , Adulto , Aconselhamento , Feminino , Serviços de Saúde , Humanos , Masculino , Programas de Rastreamento , Ruanda , Programas Voluntários
7.
AIDS Res Treat ; 2015: 740212, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-26257954

RESUMO

Adult women (n = 113) and men (n = 100) initiating combination antiretroviral therapy (cART) and women not yet eligible for cART (n = 199) in Kigali, Rwanda, were followed for 6-24 months between 2007 and 2010. In the cART groups, 21% of patients required a drug change due to side effects and 11% of patients had virological failure (defined as >1,000 HIV RNA copies/mL) after 12 months of cART. About a third of the pregnancies since HIV diagnosis were unintended. The proportion of women in the pre-cART group using modern contraception other than condoms (50%) was similar to women in the general population, but this proportion was only 25% in women initiating cART. Of the women who carried at least one pregnancy to term since having been diagnosed HIV-positive, a third reported to have participated in a prevention-of-mother-to-child-transmission (PMTCT, option A) intervention. Many patients were coinfected with herpes simplex virus type 2 (79-92%), human papillomavirus (38-53%), and bacterial sexually transmitted infections (STIs) with no differences between groups. We applaud the Rwandan government for having strengthened family planning and PMTCT services and for having introduced HPV vaccination in recent years, but additional work is needed to strengthen STI and HPV-related cancer screening and management in the HIV-positive population.

8.
PLoS One ; 9(11): e111948, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-25365302

RESUMO

BACKGROUND: With increased availability of paediatric combination antiretroviral therapy (cART) in resource limited settings, cART outcomes and factors associated with outcomes should be assessed. METHODS: HIV-infected children <15 years of age, initiating cART in Kigali, Rwanda, were followed for 18 months. Prospective clinical and laboratory assessments included weight-for-age (WAZ) and height-for-age (HAZ) z-scores, complete blood cell count, liver transaminases, creatinine and lipid profiles, CD4 T-cell count/percent, and plasma HIV-1 RNA concentration. Clinical success was defined as WAZ and WAZ >-2, immunological success as CD4 cells ≥500/mm3 and ≥25% for respectively children over 5 years and under 5 years, and virological success as a plasma HIV-1 RNA concentration <40 copies/mL. RESULTS: Between March 2008 and December 2009, 123 HIV-infected children were included. The median (interquartile (IQR) age at cART initiation was 7.4 (3.2, 11.5) years; 40% were <5 years and 54% were female. Mean (95% confidence interval (95%CI)) HAZ and WAZ at baseline were -2.01 (-2.23, -1.80) and -1.73 (-1.95, -1.50) respectively and rose to -1.75 (-1.98, -1.51) and -1.17 (-1.38, -0.96) after 12 months of cART. The median (IQR) CD4 T-cell values for children <5 and ≥5 years of age were 20% (13, 28) and 337 (236, 484) cells/mm3 respectively, and increased to 36% (28, 41) and 620 (375, 880) cells/mm3. After 12 months of cART, 24% of children had a detectable viral load, including 16% with virological failure (HIV-RNA>1000 c/mL). Older age at cART initiation, poor adherence, and exposure to antiretrovirals around birth were associated with virological failure. A third (33%) of children had side effects (by self-report or clinical assessment), but only 9% experienced a severe side effect requiring a cART regimen change. CONCLUSIONS: cART in Rwandan HIV-infected children was successful but success might be improved further by initiating cART as early as possible, optimizing adherence and optimizing management of side effects.


Assuntos
Antirretrovirais/administração & dosagem , Infecções por HIV , HIV-1 , Adesão à Medicação , Antirretrovirais/efeitos adversos , Contagem de Linfócito CD4 , Criança , Quimioterapia Combinada , Feminino , Seguimentos , Infecções por HIV/sangue , Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologia , Infecções por HIV/patologia , Humanos , Masculino , Estudos Prospectivos , RNA Viral/sangue , Ruanda/epidemiologia
9.
BMC Public Health ; 14: 889, 2014 Aug 29.
Artigo em Inglês | MEDLINE | ID: mdl-25168699

RESUMO

BACKGROUND: We report levels and determinants of attrition in Rwanda, one of the few African countries with universal ART access. METHODS: We analyzed data abstracted from health facility records of a nationally representative sample of adults [≥ 18 years] who initiated ART 6, 12, and 18 months prior to data collection; and collected facility characteristics with a health facility assessment questionnaire. Weighted proportions and rates of attrition [loss to follow-up or death] were calculated, and patient- and health facility-level factors associated with attrition examined using Cox proportional hazard models. RESULTS: 1678 adults initiated ART 6, 12 and 18 months prior to data collection, with 1508 person-years [PY] on ART. Attrition was 6.8% [95% confidence interval [CI] 6.0-7.8]: 2.9% [2.4-3.5] recorded deaths and 3.9% [3.4-4.5] lost to follow-up. Population attrition rate was 7.5/100 PY [6.1-9.3]. Adjusted hazard ratio [aHR] for attrition was 4.2 [3.0-5.7] among adults enrolled from in-patient wards [vs 2.2 [1.6-3.0] from PMTCT, ref: VCT]. Compared to adults who initiated ART 18 months earlier, aHR for adults who initiated ART 12 and 6 months earlier was 1.8 [1.3-2.5] and 1.3 [0.9-1.9] respectively. Male aHR was 1.4 [1.0-1.8]. AHR of adults enrolled at urban health facilities was 1.4 [1.1-1.8, ref: rural health facilities]. AHR for adults with CD4+ ≥ 200 cells/µL vs <200 cells/µL was 0.8 [0.6-1.0]; and adults attending facilities with performance-based financing since 2004-2006 [vs. 2007-2008] had aHR 0.8 [0.6-0.9]. CONCLUSIONS: Attrition was low in the Rwandan national program. The above patient and facility correlates of attrition can be the focus of interventions to sustain high retention.


Assuntos
Fármacos Anti-HIV/uso terapêutico , Infecções por HIV/tratamento farmacológico , Acesso aos Serviços de Saúde , Adolescente , Adulto , África , Contagem de Linfócito CD4 , Feminino , Infecções por HIV/mortalidade , Instalações de Saúde , Humanos , Perda de Seguimento , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Estudos Retrospectivos , População Rural , Ruanda/epidemiologia , População Urbana , Adulto Jovem
10.
PLoS One ; 9(4): e95459, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-24743295

RESUMO

INTRODUCTION: Routine provider-initiated HIV testing and counselling (PITC) may increase HIV testing rates, but whether PITC is acceptable to health facility (HF) attendees is unclear. In the course of a PITC intervention study in Rwanda, we assessed the acceptability of PITC, reasons for being or not being tested and factors associated with HIV testing. METHODS: Attendees were systematically interviewed in March 2009 as they left the HF, regarding knowledge and acceptability of PITC, history of testing and reasons for being tested or not. Subsequently, PITC was introduced in 6 of the 8 HFs and a second round of interviews was conducted. Independent factors associated with testing were analysed using logistic regression. Randomly selected health care workers (HCWs) were also interviewed. RESULTS: 1772 attendees were interviewed. Over 95% agreed with the PITC policy, both prior to and after implementation of PITC policy. The most common reasons for testing were the desire to know one's HIV status and having been offered an HIV test by an HCW. The most frequent reasons for not being tested were known HIV status and test not being offered. In multivariable analysis, PITC, age ≥15 years, and not having been previously tested were factors significantly associated with testing. Although workload was increased by PITC, HIV testing rates increased and HCWs overwhelmingly supported the policy. CONCLUSION: Among attendees and HCWs in Rwandan clinics, the acceptability of PITC was very high. PITC appeared to increase testing rates and may be helpful in prevention and early access to treatment.


Assuntos
Infecções por HIV/diagnóstico , Adulto , Aconselhamento/estatística & dados numéricos , Feminino , Pessoal de Saúde , Humanos , Masculino , Programas de Rastreamento/estatística & dados numéricos , Ruanda , Adulto Jovem
12.
Global Health ; 9: 37, 2013 Aug 30.
Artigo em Inglês | MEDLINE | ID: mdl-24119388

RESUMO

The notion of "reverse innovation"--that some insights from low-income countries might offer transferable lessons for wealthier contexts--is increasingly common in the global health and business strategy literature. Yet the perspectives of researchers and policymakers in settings where these innovations are developed have been largely absent from the discussion to date. In this Commentary, we present examples of programmatic, technological, and research-based innovations from Rwanda, and offer reflections on how the global health community might leverage innovative partnerships for shared learning and improved health outcomes in all countries.


Assuntos
Comportamento Cooperativo , Assistência à Saúde , Países Desenvolvidos , Países em Desenvolvimento , Difusão de Inovações , Saúde Global , Disseminação de Informação , Humanos , Ruanda
13.
Lancet Oncol ; 14(4): e189-95, 2013 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-23561751

RESUMO

The creation and implementation of national cancer control plans is becoming increasingly necessary for countries in Africa, with the number of new cancer cases per year in the continent expected to reach up to 1·5 million by 2020. Examples from South Africa, Egypt, Nigeria, Ghana, and Rwanda describe the state of national cancer control plans and their implementation. Whereas in Rwanda the emphasis is on development of basic facilities needed for cancer care, in those countries with more developed economies, such as South Africa and Nigeria, the political will to fund national cancer control plans is limited, even though the plans exist and are otherwise well conceived. Improved awareness of the increasing burden of cancer and increased advocacy are needed to put pressure on governments to develop, fund, and implement national cancer control plans across the continent.


Assuntos
Assistência à Saúde , Neoplasias , Egito , Gana , Humanos , Neoplasias/economia , Neoplasias/epidemiologia , Nigéria , Ruanda , África do Sul
14.
PLoS One ; 8(1): e53586, 2013.
Artigo em Inglês | MEDLINE | ID: mdl-23326462

RESUMO

BACKGROUND: Generalizable data are needed on the magnitude and determinants of adherence and virological suppression among patients on antiretroviral therapy (ART) in Africa. METHODS: We conducted a cross-sectional survey with chart abstraction, patient interviews and site assessments in a nationally representative sample of adults on ART for 6, 12 and 18 months at 20 sites in Rwanda. Adherence was assessed using 3- and 30-day patient recall. A systematically selected sub-sample had viral load (VL) measurements. Multivariable logistic regression examined predictors of non-perfect (<100%) 30-day adherence and detectable VL (>40 copies/ml). RESULTS: Overall, 1,417 adults were interviewed and 837 had VL measures. Ninety-four percent and 78% reported perfect adherence for the last 3 and 30 days, respectively. Eighty-three percent had undetectable VL. In adjusted models, characteristics independently associated with higher odds of non-perfect 30-day adherence were: being on ART for 18 months (vs. 6 months); younger age; reporting severe (vs. no or few) side effects in the prior 30 days; having no documentation of CD4 cell count at ART initiation (vs. having a CD4 cell count of <200 cells/µL); alcohol use; and attending sites which initiated ART services in 2003-2004 and 2005 (vs. 2006-2007); sites with ≥600 (vs. <600 patients) on ART; or sites with peer educators. Participation in an association for people living with HIV/AIDS; and receiving care at sites which regularly conduct home-visits were independently associated with lower odds of non-adherence. Higher odds of having a detectable VL were observed among patients at sites with peer educators. Being female; participating in an association for PLWHA; and using a reminder tool were independently associated with lower odds of having detectable VL. CONCLUSIONS: High levels of adherence and viral suppression were observed in the Rwandan national ART program, and associated with potentially modifiable factors.


Assuntos
Terapia Antirretroviral de Alta Atividade , Infecções por HIV/tratamento farmacológico , Infecções por HIV/virologia , Cooperação do Paciente/estatística & dados numéricos , Adolescente , Adulto , Feminino , Infecções por HIV/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Seleção de Pacientes , Ruanda/epidemiologia , Autorrelato , Fatores de Tempo , Carga Viral , Adulto Jovem
15.
Med Decis Making ; 32(6): E16-34, 2012.
Artigo em Inglês | MEDLINE | ID: mdl-23204241

RESUMO

PURPOSE: To assess how different diagnostic decision aids perform in terms of sensitivity, specificity, and harm. METHODS: Four diagnostic decision aids were compared, as applied to a simulated patient population: a findings-based algorithm following a linear or branched pathway, a serial threshold-based strategy, and a parallel threshold-based strategy. Headache in immune-compromised HIV patients in a developing country was used as an example. Diagnoses included cryptococcal meningitis, cerebral toxoplasmosis, tuberculous meningitis, bacterial meningitis, and malaria. Data were derived from literature and expert opinion. Diagnostic strategies' validity was assessed in terms of sensitivity, specificity, and harm related to mortality and morbidity. Sensitivity analyses and Monte Carlo simulation were performed. RESULTS: The parallel threshold-based approach led to a sensitivity of 92% and a specificity of 65%. Sensitivities of the serial threshold-based approach and the branched and linear algorithms were 47%, 47%, and 74%, respectively, and the specificities were 85%, 95%, and 96%. The parallel threshold-based approach resulted in the least harm, with the serial threshold-based approach, the branched algorithm, and the linear algorithm being associated with 1.56-, 1.44-, and 1.17-times higher harm, respectively. Findings were corroborated by sensitivity and Monte Carlo analyses. CONCLUSION: A threshold-based diagnostic approach is designed to find the optimal trade-off that minimizes expected harm, enhancing sensitivity and lowering specificity when appropriate, as in the given example of a symptom pointing to several life-threatening diseases. Findings-based algorithms, in contrast, solely consider clinical observations. A parallel workup, as opposed to a serial workup, additionally allows for all potential diseases to be reviewed, further reducing false negatives. The parallel threshold-based approach might, however, not be as good in other disease settings.


Assuntos
Tomada de Decisões , Pacientes , Humanos
16.
J Acquir Immune Defic Syndr ; 60 Suppl 3: S96-104, 2012 Aug 15.
Artigo em Inglês | MEDLINE | ID: mdl-22797746

RESUMO

Since its inception in 2003, the US President's Emergency Plan for AIDS Relief (PEPFAR) has been an important driving force behind the global scale-up of HIV care and treatment services, particularly in expansion of access to antiretroviral therapy. Despite initial concerns about cost and feasibility, PEPFAR overcame challenges by leveraging and coordinating with other funders, by working in partnership with the most affected countries, by supporting local ownership, by using a public health approach, by supporting task-shifting strategies, and by paying attention to health systems strengthening. As of September 2011, PEPFAR directly supported initiation of antiretroviral therapy for 3.9 million people and provided care and support for nearly 13 million people. Benefits in terms of prevention of morbidity and mortality have been reaped by those receiving the services, with evidence of societal benefits beyond the anticipated clinical benefits. However, much remains to be accomplished to achieve universal access, to enhance the quality of programs, to ensure retention of patients in care, and to continue to strengthen health systems.


Assuntos
Fármacos Anti-HIV/administração & dosagem , Terapia Antirretroviral de Alta Atividade/métodos , Terapia Antirretroviral de Alta Atividade/tendências , Infecções por HIV/tratamento farmacológico , Controle de Doenças Transmissíveis/métodos , Controle de Doenças Transmissíveis/organização & administração , Controle de Doenças Transmissíveis/tendências , Transmissão de Doença Infecciosa/prevenção & controle , Uso de Medicamentos/estatística & dados numéricos , Saúde Global , Infecções por HIV/epidemiologia , Infecções por HIV/prevenção & controle , Infecções por HIV/transmissão , Humanos , Cooperação Internacional , Masculino , Programas Nacionais de Saúde/organização & administração , Programas Nacionais de Saúde/tendências , Parcerias Público-Privadas/organização & administração , Parcerias Público-Privadas/tendências , Estados Unidos
17.
PLoS One ; 7(5): e36792, 2012.
Artigo em Inglês | MEDLINE | ID: mdl-22606289

RESUMO

INTRODUCTION: Access to antiretroviral therapy (ART) has increased greatly in sub-Saharan Africa. However many patients do not enrol timely into HIV care and treatment after HIV diagnosis. We studied enrolment into care and treatment and determinants of non-enrolment in Rwanda. METHODS: Data were obtained from routine clinic registers from eight health facilities in Rwanda on patients who were diagnosed with HIV at the antenatal care, voluntary counselling-and-testing, outpatient or tuberculosis departments between March and May 2009. The proportion of patients enrolled into HIV care and treatment was calculated as the number of HIV infected patients registered in ART clinics for follow-up care and treatment within 90 days of HIV diagnosis divided by the total number of persons diagnosed with HIV in the study period. RESULTS: Out of 482 patients diagnosed with HIV in the study period, 339 (70%) were females, and the median age was 29 years (interquartile range [IQR] 24-37). 201 (42%) enrolled into care and treatment within 90 days of HIV diagnosis. The median time between testing and enrolment was six days (IQR 2-14). Enrolment in care and treatment was not significantly associated with age, sex, or department of testing, but was associated with study site. None of those enrolled were in WHO stage 4. The median CD4 cell count among adult patients was 387 cells/mm(3) (IQR: 242-533 cells/mm(3)); 81 of 170 adult patients (48%) were eligible to start ART (CD4 count<350 cells/mm(3) or WHO stage 4). Among those eligible, 45 (56%) started treatment within 90 days of HIV diagnosis. CONCLUSION: Less than 50% of diagnosed HIV patients from eight Rwandan health facilities had enrolled into care and treatment within 90 days of diagnosis. Improving linkage to care and treatment after HIV diagnosis is needed to harness the full potential of ART.


Assuntos
Infecções por HIV/diagnóstico , Infecções por HIV/tratamento farmacológico , Adolescente , Adulto , Assistência Ambulatorial , Fármacos Anti-HIV/uso terapêutico , Contagem de Linfócito CD4 , Criança , Pré-Escolar , Feminino , Infecções por HIV/imunologia , Instalações de Saúde , Acesso aos Serviços de Saúde , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Programas Nacionais de Saúde , Ruanda , Fatores de Tempo , Adulto Jovem
18.
BMC Public Health ; 12: 134, 2012 Feb 18.
Artigo em Inglês | MEDLINE | ID: mdl-22340083

RESUMO

BACKGROUND: Male Circumcision (MC) has been recommended as one of the preventive measures against sexual HIV transmission by the World Health Organization (WHO). Rwanda has adopted MC as recommended but the country is a non-traditionally circumcising society. The objective was to explore knowledge and perception of Rwandan men on Male Circumcision (MC) and to determine the factors associated with the willingness to be circumcised and to circumcise their sons. METHODS: This cross sectional study was conducted in 29 districts of Rwanda between January and March 2010. Data were collected using a structured questionnaire among men aged 15-59 years. The rate of MC was measured and its perception from respondents, and then the factors associated with the willingness to go for MC were analysed using multiple logistic regressions. RESULTS: A total of 1098 men were interviewed. Among respondents 17% (95% CI 14-19%) reported being circumcised. About three-quarter (72%) could define MC, but 37% of adolescent could not. Half of the participants were willing to get circumcised and 79% of men would accept circumcision for their sons. The main motivators for MC were its benefits in HIV/STI prevention (69%) and improving hygiene (49%). Being too old was the main reason (32%) reported by men reluctant to undergo MC and younger men were afraid of pain in particular those less than 19 years old (42%). The willingness to circumcise was significantly associated with younger age, living in the Eastern Province, marital status, and the knowledge of the preventive role of circumcision. CONCLUSIONS: Adolescents and young adults were more willing to be circumcised. It is critical to ensure the availability of pain free services in order to satisfy the increasing demand for the scale up of MC in Rwanda.


Assuntos
Circuncisão Masculina , Aceitação pelo Paciente de Cuidados de Saúde/psicologia , Adolescente , Adulto , Estudos Transversais , Humanos , Entrevistas como Assunto , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Ruanda , Adulto Jovem
19.
BMC Med Inform Decis Mak ; 12: 2, 2012 Jan 19.
Artigo em Inglês | MEDLINE | ID: mdl-22260242

RESUMO

BACKGROUND: The algorithmic approach to guidelines has been introduced and promoted on a large scale since the 1970s. This study aims at comparing the performance of three algorithms for the management of chronic cough in patients with HIV infection, and at reassessing the current position of algorithmic guidelines in clinical decision making through an analysis of accuracy, harm and complexity. METHODS: Data were collected at the University Hospital of Kigali (CHUK) in a total of 201 HIV-positive hospitalised patients with chronic cough. We simulated management of each patient following the three algorithms. The first was locally tailored by clinicians from CHUK, the second and third were drawn from publications by Médecins sans Frontières (MSF) and the World Health Organisation (WHO). Semantic analysis techniques known as Clinical Algorithm Nosology were used to compare them in terms of complexity and similarity. For each of them, we assessed the sensitivity, delay to diagnosis and hypothetical harm of false positives and false negatives. RESULTS: The principal diagnoses were tuberculosis (21%) and pneumocystosis (19%). Sensitivity, representing the proportion of correct diagnoses made by each algorithm, was 95.7%, 88% and 70% for CHUK, MSF and WHO, respectively. Mean time to appropriate management was 1.86 days for CHUK and 3.46 for the MSF algorithm. The CHUK algorithm was the most complex, followed by MSF and WHO. Total harm was by far the highest for the WHO algorithm, followed by MSF and CHUK. CONCLUSIONS: This study confirms our hypothesis that sensitivity and patient safety (i.e. less expected harm) are proportional to the complexity of algorithms, though increased complexity may make them difficult to use in practice.


Assuntos
Algoritmos , Tosse , Tomada de Decisões Assistida por Computador , Infecções por HIV , Melhoria de Qualidade/normas , Adolescente , Adulto , Idoso , Doença Crônica , Tosse/etiologia , Tosse/terapia , Países em Desenvolvimento , Infecções por HIV/complicações , Infecções por HIV/diagnóstico , Humanos , Pessoa de Meia-Idade , Pneumonia por Pneumocystis/complicações , Pneumonia por Pneumocystis/diagnóstico , Ruanda , Sensibilidade e Especificidade
20.
J Acquir Immune Defic Syndr ; 58(5): e127-34, 2011 Dec 15.
Artigo em Inglês | MEDLINE | ID: mdl-21909032

RESUMO

OBJECTIVE: To assess the safety and efficacy of the PrePex device for nonsurgical circumcision in adult males as part of a comprehensive HIV prevention program in Rwanda. METHODS: Single-center 6-week noncontrolled study in which healthy men underwent circumcision using the PrePex device, which employs fitted rings to clamp the foreskin, leading to distal necrosis. In the first phase of the study, the feasibility of the procedure was tested on 5 subjects in a sterile environment; in the main phase, an additional 50 subjects were circumcised in a nonsterile setting by physicians or a nurse. Outcome measures included the rate of successful circumcision, time to complete healing, pain, and adverse events. RESULTS: In the feasibility phase, all 5 subjects achieved complete circumcision without adverse events. In the main phase, all 50 subjects achieved circumcision with 1 case of diffuse edema after device removal, which resolved with minimal intervention. Pain was minimal except briefly during device removal (day 7 after placement in most cases). The entire procedure was bloodless, requiring no anesthesia, no suturing, and no sterile settings. Subjects had no sick/absent days associated with the procedure. Median time for complete healing was 21 days after device removal. There were no instances of erroneous placement and no mechanical problems with the device. CONCLUSION: The PrePex device was safe and effective for nonsurgical adult male circumcision without anesthesia or sterile settings and may be useful in mass circumcision programs to reduce the risk of HIV infection, particularly in resource-limited settings.


Assuntos
Circuncisão Masculina , Infecções por HIV/prevenção & controle , Instrumentos Cirúrgicos , Adolescente , Adulto , Estudos de Viabilidade , Infecções por HIV/epidemiologia , Humanos , Masculino , Ruanda/epidemiologia , Adulto Jovem
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