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1.
PLoS Med ; 16(7): e1002874, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31335865

RESUMO

BACKGROUND: Differentiated antiretroviral therapy (ART) delivery models, in which patients are provided with care relevant to their current status (e.g., newly initiating, stable on treatment, or unstable on treatment) has become an essential part of patient-centered health systems. In 2015, the South African government implemented Chronic Disease Adherence Guidelines (AGLs), which involved five interventions: Fast Track Initiation Counseling for newly initiating patients, Enhanced Adherence Counseling for patients with an unsuppressed viral load, Early Tracing of patients who miss visits, and Adherence Clubs (ACs) and Decentralized Medication Delivery (DMD) for stable patients. We evaluated two of these interventions in 24 South African facilities: ACs, in which patients meet in groups outside usual clinic procedures and receive medication; and DMD, in which patients pick up their medication outside usual pharmacy queues. METHODS AND FINDINGS: We compared those participating in ACs or receiving DMD at intervention sites to those eligible for ACs or DMD at control sites. Outcomes were retention and sustained viral suppression (<400 copies/mL) 12 months after AC or DMD enrollment (or comparable time for controls). 12 facilities were randomly allocated to intervention and 12 to control arms in four provinces (Gauteng, North West, Limpopo, and KwaZulu Natal). We calculated adjusted risk differences (aRDs) with cluster adjustment using generalized estimating equations (GEEs) using difference in differences (DiD) with patients eligible for ACs/DMD prior to implementation (Jan 1, 2015) for comparison. For DMD, randomization was not preserved, and the analysis was treated as observational. For ACs, 275 intervention and 294 control patients were enrolled; 72% of patients were female, 61% were aged 30-49 years, and median CD4 count at ART initiation was 268 cells/µL. AC patients had higher 1-year retention (89.5% versus 81.6%, aRD: 8.3%; 95% CI: 1.1% to 15.6%) and comparable sustained 1-year viral suppression (<400 copies/mL any time ≤ 18 months) (80.0% versus 79.6%, aRD: 3.8%; 95% CI: -6.9% to 14.4%). Retention associations were apparently stronger for men than women (men RD: 13.1%, 95% CI: 0.3% to 23.5%; women RD: 6.0%, 95% CI: -0.9% to 12.9%). For DMD, 232 intervention and 346 control patients were enrolled; 71% of patients were female, 65% were aged 30-49 years, and median CD4 count at ART initiation was 270 cells/µL. DMD patients had apparently lower retention (81.5% versus 87.2%, aRD: -5.9%; 95% CI: -12.5% to 0.8%) and comparable viral suppression versus standard of care (77.2% versus 74.3%, aRD: -1.0%; 95% CI: -12.2% to 10.1%), though in both cases, our findings were imprecise. We also noted apparently increased viral suppression among men (RD: 11.1%; 95% CI: -3.4% to 25.5%). The main study limitations were missing data and lack of randomization in the DMD analysis. CONCLUSIONS: In this study, we found comparable DMD outcomes versus standard of care at facilities, a benefit for retention of patients in care with ACs, and apparent benefits in terms of retention (for AC patients) and sustained viral suppression (for DMD patients) among men. This suggests the importance of alternative service delivery models for men and of community-based strategies to decongest primary healthcare facilities. Because these strategies also reduce patient inconvenience and decongest clinics, comparable outcomes are a potential success. The cost of all five AGL interventions and possible effects on reducing clinic congestion should be investigated. CLINICAL TRIAL REGISTRATION: NCT02536768.


Assuntos
Fármacos Anti-HIV/uso terapêutico , Infecções por HIV/tratamento farmacológico , Acesso aos Serviços de Saúde , Adesão à Medicação , Infuência dos Pares , Resposta Viral Sustentada , Adolescente , Adulto , Fármacos Anti-HIV/efeitos adversos , Fármacos Anti-HIV/provisão & distribução , Feminino , Infecções por HIV/diagnóstico , Infecções por HIV/psicologia , Infecções por HIV/virologia , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Pacientes Desistentes do Tratamento , Retenção nos Cuidados , África do Sul , Fatores de Tempo , Resultado do Tratamento , Carga Viral , Adulto Jovem
2.
Glob Health Sci Pract ; 7(2): 300-316, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31249025

RESUMO

BACKGROUND: While measuring, monitoring, and improving supply chain management (SCM) for antiretrovirals (ARVs) is understood at many levels of health systems, a gap remains in the identification and measurement of facility-level practices and behaviors that affect SCM. This study identifies practices and behaviors that are associated with SCM of ARVs at the hospital level and proposes new indicators for measurement. METHODS: We performed an in-depth literature review to identify facility-level practices and behaviors and existing indicators that are associated with SCM. We used the United States Agency for International Development's 2013 National Supply Chain Assessment Toolkit to define 7 supply chain function areas to frame the study. Qualitative, semistructured key informant and focus group interviews were conducted in hospitals with health professionals from Cameroon, Namibia, and Swaziland to understand facility-level practices and behaviors. RESULTS: Using the results from 54 key informant and focus group interviews from 12 hospitals, we identified 30 practices and behaviors that may affect ARV SCM at the facility level. The following practice areas were particularly associated with SCM: order verification, actions taken when ARV stock is received, changes in prescription and dispensing due to ARV stock-out, actions to ensure patient adherence, and communication with other affiliated facilities and higher-level SCM. We subsequently developed measurable indicators for future research. CONCLUSION: This study characterizes facility-level practices and behaviors that can affect ARV SCM. It also identifies gaps in their measurement. While this study uses ARVs as a tracer medicine to understand gaps in practices at the facility level, many of the findings are more broadly applicable to other medicines in an integrated setting. This study provides real-world evidence and the groundwork for further research to characterize the link between 30 facility-level practices and behaviors and ARV SCM at the facility and central levels.


Assuntos
Fármacos Anti-HIV/provisão & distribução , Assistência à Saúde , Infecções por HIV/tratamento farmacológico , Hospitais , Administração de Materiais no Hospital , Fármacos Anti-HIV/uso terapêutico , Antirretrovirais/provisão & distribução , Antirretrovirais/uso terapêutico , Camarões , Grupos Focais , Instalações de Saúde , Humanos , Namíbia
3.
Ghana Med J ; 53(1): 59-62, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31138945

RESUMO

Background: The aim of this review was to summarize the data on HIV/AIDS epidemiology and affected populations in Ghana and to describe the United States President's Emergency Plan for Emergency Relief's (PEPFAR) response to the epidemic. Design: We conducted a literature review focusing on PEPFAR's contribution to the HIV response in Ghana. Additionally, we summarized the epidemiology of HIV. We searched both peer-reviewed and grey literature. Setting: Ghana. Results: Overall, HIV prevalence in Ghana is 1.6% with regional variation. Key populations (KPs) are disproportionately affected by HIV in the country. FSW and their clients, and MSM, account for 28% of all new infections. PEPFAR provides technical assistance (TA) to Ghana to maximize the quality, coverage and impact of the national HIV/AIDS response. To ensure adequate supply of antiretrovirals (ARVs), in 2016-2017, PEPFAR invested $23.7 million as a onetime supplemental funding to support Ghana's ARV treatment program. In addition, the National AIDS Control Programme in collaboration with PEPFAR is implementing a scale up of viral load testing. PEPFAR is also implementing a comprehensive package of prevention services in five regions to help reach MSM and FSW and to expand HIV testing services for KPs. Conclusions: Ghana is making changes at both policy and program level in the fight against HIV/AIDS and is working towards achieving the UNAIDS' 90-90-90 targets. PEPFAR is providing TA to ensure these goals can be achieved. Funding: This manuscript has been supported by the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) through the Centers for Disease Control and Prevention (CDC).


Assuntos
Fármacos Anti-HIV/economia , Fármacos Anti-HIV/provisão & distribução , Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologia , Cooperação Internacional , Fármacos Anti-HIV/uso terapêutico , Países em Desenvolvimento , Gana/epidemiologia , Homossexualidade , Humanos , Prevalência , Avaliação de Programas e Projetos de Saúde , Carga Viral
6.
Clin Pharmacol Ther ; 104(6): 1042-1046, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30412658

RESUMO

Worldwide, over 77 million people have been infected by human immunodeficiency virus (HIV) but its cure remains elusive. Once considered a fatal disease, advances in antiretroviral therapy (ART) have dramatically increased the life expectancy of infected persons. Much progress has been made in the development and utilization of combination ART and preventative pre-exposure prophylaxis products, however, numerous obstacles prevent eradication. Clinical pharmacologists along with world health organizations continue to play a key role in identifying and implementing strategies to combat this disease.


Assuntos
Fármacos Anti-HIV/uso terapêutico , Desenvolvimento de Medicamentos/tendências , Epidemias , Saúde Global , Infecções por HIV/tratamento farmacológico , Acesso aos Serviços de Saúde/tendências , Fármacos Anti-HIV/efeitos adversos , Fármacos Anti-HIV/provisão & distribução , Infecções por HIV/epidemiologia , Infecções por HIV/imunologia , Infecções por HIV/virologia , Humanos , Prevalência , Prognóstico
7.
Epidemiol Serv Saude ; 27(3): e2017406, 2018 10 22.
Artigo em Inglês, Português | MEDLINE | ID: mdl-30365700

RESUMO

OBJECTIVE: to evaluate the availability of Brazilian National Health System (SUS) outpatient services for people living with HIV in Mato Grosso state, Brazil. METHODS: this is an evaluative study with descriptive cross-sectional design carried out in 2016; data were collected via the HIV Services Quality Assessment System in all 15 outpatient services; data were analyzed by frequency of answers. RESULTS: five of the 15 services had a sufficient number of physicians; antirretroviral drugs were out of stock for more than seven days in half of the services; other medications for sexually transmitted infections, opportunistic infections, Hepatitis B and C, and metabolic disorders were available in less than 1/3 of the services within the recommended timeframe. CONCLUSION: resources were found to be deficient in services for people living with HIV in Mato Grosso, mainly regarding the availability of professionals and drugs.


Assuntos
Assistência Ambulatorial/organização & administração , Infecções por HIV/terapia , Recursos em Saúde/provisão & distribução , Programas Nacionais de Saúde/organização & administração , Fármacos Anti-HIV/provisão & distribução , Brasil , Estudos Transversais , Infecções por HIV/complicações , Acesso aos Serviços de Saúde , Humanos , Fatores de Tempo
9.
BMC Res Notes ; 11(1): 723, 2018 Oct 12.
Artigo em Inglês | MEDLINE | ID: mdl-30309385

RESUMO

OBJECTIVES: Disruption in HIV care provision may enhance the development and spread of drug resistance due to inadequate antiretroviral therapy. This study thus determined the prevalence of HIV-1 transmitted drug resistance (TDR) in settings of decentralized therapy and care in Senegal and, the Ebola outbreak in Guinea. Antiretroviral-naïve patients were enrolled following a modified WHO TDR Threshold Survey method, implemented in Senegal (January-March 2015) and Guinea (August-September 2015). Plasma and dried blood spots specimens, respectively from Senegalese (n = 69) and Guinean (n = 50) patients, were collected for direct sequencing of HIV-1 pol genes. The Stanford Calibrated Population Resistance program v6.0 was used for Surveillance Drug Resistance Mutations (SDRMs). RESULTS: Genotyping was successful from 54/69 (78.2%) and 31/50 (62.0%) isolates. In Senegal, TDR prevalence was 0% (mean duration since HIV diagnosis 4.08 ± 3.53 years). In Guinea, two patients exhibited SDRMs M184V (NRTI), T215F (TAM) and, G190A (NNRTI), respectively. TDR prevalence at this second site, however, could not be ascertained because of low sample size. Phylogenetic inference confirmed CRF02_AG predominance in Senegal (62.96%) and Guinea (77.42%). TDR prevalence in Senegal remains extremely low suggesting improved control measures. Continuous surveillance in both settings is mandatory and, should be done closest to diagnosis/transmission time and with larger sample size.


Assuntos
Fármacos Anti-HIV/provisão & distribução , Surtos de Doenças , Farmacorresistência Viral/genética , Infecções por HIV/epidemiologia , HIV-1/genética , Doença pelo Vírus Ebola/epidemiologia , Adulto , Ebolavirus/patogenicidade , Feminino , Técnicas de Genotipagem , Guiné/epidemiologia , Infecções por HIV/transmissão , HIV-1/classificação , HIV-1/isolamento & purificação , Humanos , Masculino , Pessoa de Meia-Idade , Mutação , Filogenia , Vigilância em Saúde Pública/métodos , Senegal/epidemiologia
10.
Clin Pharmacol Ther ; 104(6): 1054-1056, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30076604

RESUMO

We discuss how corruption affects access to antiretroviral therapies (ARVs) globally. Recent cases of theft of ARVs, collusion, and manipulation in procurement found in countries such as Central African Republic, Bangladesh, Malawi, and Guinea, show there is still much work to be done to reduce the risk of corruption. This includes addressing the structural weaknesses in procurement mechanisms and supply chain management systems of health commodities and medicines.


Assuntos
Fármacos Anti-HIV/provisão & distribução , Comércio , Medicamentos Falsificados/provisão & distribução , Países em Desenvolvimento , Saúde Global , Infecções por HIV/tratamento farmacológico , Acesso aos Serviços de Saúde , Roubo , Fármacos Anti-HIV/efeitos adversos , Fármacos Anti-HIV/economia , Comércio/economia , Medicamentos Falsificados/efeitos adversos , Medicamentos Falsificados/economia , Países em Desenvolvimento/economia , Custos de Medicamentos , Saúde Global/economia , Infecções por HIV/economia , Infecções por HIV/epidemiologia , Acesso aos Serviços de Saúde/economia , Humanos , Métodos de Controle de Pagamentos , Roubo/economia
11.
BMC Public Health ; 18(1): 1069, 2018 Aug 29.
Artigo em Inglês | MEDLINE | ID: mdl-30157896

RESUMO

BACKGROUND: Current World Health Organization (WHO) guidelines recommend early initiation of HIV positive patients on antiretroviral therapy (ART) irrespective of their clinical or immunological status known as the test and start approach. Lesotho, like many other countries introduced this approach in 2016 as a strategy to reach epidemic control. There will be rapidly growing number of HIV-infected individuals initiating treatment leading to practical challenges on health systems such as congestion, long waiting time for patients and limited time to provide quality services to patients. Differentiated models of ART delivery is an innovative solution that helps to increase access to care, while reducing the burden on existing health systems. Ultimately this model will help to achieve retention and viral suppression. We describe a demonstration study designed to evaluate a community-based differentiated model of multi-month dispensing (MMD) approaches of ART among stable HIV patients in Lesotho. METHODS: This study will be a three-arm cluster randomised trial, which will enrol approximately 5760 HIV-infected individuals who are stable on ART in 30 selected clusters. The clusters, which are health facilities, will be randomly assigned into the following differentiated model of care arms: (i) 3 monthly ART supply at facilities (Control), (ii) 3 monthly ART supply through community ART groups (CAGs) and (iii) 6 monthly ART supply through community ART distribution points (CAD). Primary outcomes are retention in care and virologic suppression, and secondary outcomes include feasibility and cost effectiveness. DISCUSSION: Important lessons will be learnt to allow for improved implementation of such demonstration projects, including various needs for reliable supply of medication, access to quality clinical data including access to viral loads (VLs) results, frameworks to support lay worker cadre, involvement of community stakeholders, and reliable data systems including records of key indicators. MMD will have positive implications including improved retention, virologic suppression, convenience and access to medication. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03438370 . Accepted on 16 February 2018.


Assuntos
Fármacos Anti-HIV/provisão & distribução , Fármacos Anti-HIV/uso terapêutico , Serviços de Saúde Comunitária/organização & administração , Infecções por HIV/tratamento farmacológico , Protocolos Clínicos , Análise por Conglomerados , Humanos , Lesoto , Modelos Organizacionais , Fatores de Tempo , Resultado do Tratamento
12.
Int J Health Plann Manage ; 33(4): e1160-e1178, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30109898

RESUMO

This article studies the epidemiological and economic impacts of a universal testing and treatment policy of Human Immunodeficiency Virus (HIV) in South Africa. A model of disease transmission is built to simulate several implementation scenarios of the policy. Different behavioral responses in the general population are considered. The results show that the success of a large-scale HIV testing and treatment program in South Africa depends on its implementation conditions. The policy can lead to a reduction of the HIV epidemic, even in the case of a large relapse in preventive behaviors in the general population, if implementation conditions are favorable. This is the case if the number of infected individuals who are infectious is greatly reduced. From an economic point of view, taking into account the positive externality of antiretroviral (ARV) treatments changes the traditional framework of cost-benefit analyses. A large-scale testing and treatment program would be cost-saving in the case of favorable implementation conditions, even following a large increase in risk behaviors after the scaling up of ARV treatments. By contrast, the analysis stresses out the potential perverse effects of scaling up ARV treatments in South Africa if the intervention is set up without ensuring enough resources for patients' monitoring and the availability of effective ARV drugs. Indeed, if the number of treated patients rises while adherence of patients to treatments decreases and the rate of loss to follow-up increases, the policy could extend the pool of infectious patients and lead to a long-term amplification of the epidemic.


Assuntos
Fármacos Anti-HIV/provisão & distribução , Infecções por HIV/tratamento farmacológico , Acesso aos Serviços de Saúde/economia , Algoritmos , Custos e Análise de Custo/métodos , Humanos , Formulação de Políticas
13.
Ann Epidemiol ; 28(12): 841-849, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-29983236

RESUMO

PURPOSE: The number of individuals who have started a regimen for HIV pre-exposure prophylaxis (PrEP) in the United States is not well characterized but has been on the rise since 2012. This analysis assesses the distribution of PrEP use nationally and among subgroups. METHODS: A validated algorithm quantifying tenofovir disoproxil fumarate/emtricitabine for PrEP in the United States was applied to a national prescription database to determine the quarterly prevalence of PrEP use. HIV diagnoses from 2016 were used as an epidemiological proxy for PrEP need. The PrEP-to-need ratio (PnR) was defined as the number of PrEP users divided by new HIV diagnoses. RESULTS: A total of 70,395 individuals used PrEP in the fourth quarter of 2017: 67,166 males and 3229 females. Nationally, prevalence of PrEP use was 26/100,000 (range across states per 100,000 [RAS/100k]: 4-73) and the PnR was 1.8 (RAS: 0.5-6.6). Prevalence of PrEP use among males and females, respectively, was 50/100,000 and 2/100,000 (RAS/100k: 7-143 and 0.3-7) and PnR was 2.1 and 0.4 (RAS: 0.6-7.1 and 0.1-4.0). Prevalence of PrEP use was lowest among individuals aged less than or equal to 24 and more than or equal to 55 years (15/100,000 and 6/100,000, RAS/100k: 1-45 and 0.4-14), with PnR 0.9 and 1.5 (RAS: 0.2-5.6 and 0.3-7.0). The Northeast had the highest PnR (3.3); the South had the lowest (1.0). States with Medicaid expansion had more than double the PnR than states without expansion. CONCLUSIONS: Available data suggest that females, individuals aged less than or equal to 24 years and residents of the South had lower levels of PrEP use relative to epidemic need. These results are ecological, and misclassification may attenuate results. PnR is useful for future assessments of HIV prevention strategy uptake.


Assuntos
Fármacos Anti-HIV/administração & dosagem , Combinação Emtricitabina e Fumarato de Tenofovir Desoproxila/administração & dosagem , Infecções por HIV/prevenção & controle , Profilaxia Pré-Exposição/métodos , Profilaxia Pré-Exposição/estatística & dados numéricos , Prescrições/estatística & dados numéricos , Adolescente , Adulto , Distribuição por Idade , Fármacos Anti-HIV/provisão & distribução , Estudos Transversais , Feminino , Infecções por HIV/diagnóstico , Infecções por HIV/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Estados Unidos/epidemiologia , Adulto Jovem
14.
AIDS Care ; 30(12): 1477-1487, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30037312

RESUMO

Many gaps in care exist for provision of antiretroviral therapy (ART) in sub-Saharan Africa. Differentiated HIV care tailors provision of ART for patients based on their level of acuity, providing alternatives for where, by whom, and how often care occurs. We conducted a scoping review to assess novel differentiated care models for ART provision for stable HIV-infected adults in sub-Saharan Africa, and how these models can be used to guide differentiated care implementation in Kenya. A systematic search was conducted using PubMed, Embase, Web of Science, Popline, Cochrane Library, and African Index Medicus between January 2006 and January 2017. Grey literature searches and handsearching were also used. We included articles that quantitatively assessed the health, acceptability, and cost-effectiveness of differentiated HIV care. Two reviewers independently performed article screening, data extraction and determination of inclusion for analysis. We included 40 publications involving over 240,000 participants spanning nine countries in sub-Saharan Africa - 54.4% evaluated clinical outcomes, 23.5% evaluated acceptability outcomes, and 22.1% evaluated cost outcomes. Differentiated care models included: facility fast-track drug refills and appointment spacing, facility or community-based ART groups, community ART distribution points or home-based care, and task-shifting or decentralization of care. Studies suggest that these approaches had similar outcomes in viral load suppression and retention in care and were acceptable alternatives to standard HIV care. No clear results could be inferred for studies investigating task shifting and those reporting cost-effectiveness outcomes. Kenya has started to scale up differentiated care models, but further evaluation, quality improvement and research studies should be performed as different models are rolled out.


Assuntos
Fármacos Anti-HIV/economia , Terapia Antirretroviral de Alta Atividade , Assistência à Saúde/métodos , Infecções por HIV/tratamento farmacológico , Aceitação pelo Paciente de Cuidados de Saúde , Carga Viral/efeitos dos fármacos , Adulto , Fármacos Anti-HIV/provisão & distribução , Fármacos Anti-HIV/uso terapêutico , Terapia Antirretroviral de Alta Atividade/economia , Análise Custo-Benefício , Assistência à Saúde/economia , Feminino , Custos de Cuidados de Saúde , Humanos , Quênia , Resultado do Tratamento
15.
PLoS One ; 13(7): e0196498, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30024874

RESUMO

INTRODUCTION: Several models of differentiated care for stable HIV patients on antiretroviral therapy (ART) in Malawi have been introduced to ensure that care is efficient and patient-centered. Three models have been prioritized by the government for a deeper and broader understanding: adjusted appointment spacing through multi-month scripting (MMS); fast-track drug refills (FTRs) on alternating visits; and community ART groups (CAGs) where rotating group members collect medications at the facility for all members. This qualitative study aimed to understand the challenges and successes of implementing these models of care and of the process of patient differentiation. METHODS: A qualitative study was conducted as a part of a broader process evaluation in 30 purposefully selected ART facilities between February and May 2016. Semi-structured, in-depth interviews with 32 health workers that managed and coordinated ART clinics and 30 focus groups were held with 216 ART patients. Interviews and focus groups were audio recorded, transcribed, and coded thematically. RESULTS: Participants reported that the models of differentiated care have yielded key benefits, including: reduced patients' travel and visit time, decongestion of facilities, and enhanced social support. Participants suggested that these benefits could lead to improved HIV treatment outcomes for patients. At the same time, some challenges were reported, such as inconsistent stocks of drugs, which can inhibit implementation of MMS. For CAGs, the group-based nature of the model presented some unique problems, such as conflicts within groups or concerns about privacy. Health workers also described some of the reasons why eligible patients may not receive the models or conversely why ineligible patients sometimes get the models. CONCLUSIONS: Documenting patient and health worker perspectives on models of differentiated care is critical to understanding and improving these models. While these models can offer important benefits, the models may not be appropriate for all sites or patients, and patient status and needs may change over time. Key challenges should be recognized and addressed for optimal utilization of the models.


Assuntos
Fármacos Anti-HIV/provisão & distribução , Assistência à Saúde/métodos , Infecções por HIV/psicologia , Pessoal de Saúde/psicologia , Modelos Organizacionais , Pacientes Ambulatoriais/psicologia , Programas de Monitoramento de Prescrição de Medicamentos/estatística & dados numéricos , Adulto , Fármacos Anti-HIV/uso terapêutico , Terapia Antirretroviral de Alta Atividade , Feminino , Grupos Focais , Infecções por HIV/tratamento farmacológico , Humanos , Malaui , Masculino , Pessoa de Meia-Idade , Satisfação do Paciente/estatística & dados numéricos , Pesquisa Qualitativa , Apoio Social , Inquéritos e Questionários
16.
Cien Saude Colet ; 23(7): 2277-2290, 2018 Jul.
Artigo em Português, Inglês | MEDLINE | ID: mdl-30020381

RESUMO

This article examines the activities of national and international actors in Pharmaceutical Services (PS) in Mozambique from 2007 to 2012, focusing on the public provision of HIV/Aids, malaria and tuberculosis medicines. It describes how PS functions in the country, what actors are involved in this area and the relations among them, pursuing salient issues in the modus operandi of partners in cooperation. The methodology combines literature review, document survey and analysis and interviews. The theoretical and analytical framework was given by the policy analysis approach, focusing on the role of the State and its interrelations with other actors in foreign aid in PS, and also by the networks approach. It was concluded that the interactions among the actors involved is complex and characterised by operational fragmentation and overlapping of activities between entities, centralised medicine procurement in the hands of few agents, bypassing of national structures and disregard for the strengthening needed to bolster national health system autonomy. Despite some advances in the provision and availability of medicines for these diseases, external dependence is strong, which undermines the sustainability of PS in Mozambique.


Assuntos
Cooperação Internacional , Assistência Farmacêutica/organização & administração , Fármacos Anti-HIV/administração & dosagem , Fármacos Anti-HIV/provisão & distribução , Antimaláricos/administração & dosagem , Antimaláricos/provisão & distribução , Antituberculosos/administração & dosagem , Antituberculosos/provisão & distribução , Infecções por HIV/tratamento farmacológico , Política de Saúde , Humanos , Malária/tratamento farmacológico , Moçambique , Tuberculose/tratamento farmacológico
17.
PLoS One ; 13(5): e0194305, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29718906

RESUMO

OBJECTIVE: We estimated the average annual cost per patient of ART per facility (unit cost) in Nigeria, described the variation in costs across facilities, and identified factors associated with this variation. METHODS: We used facility-level data of 80 facilities in Nigeria, collected between December 2014 and May 2015. We estimated unit costs at each facility as the ratio of total costs (the sum of costs of staff, recurrent inputs and services, capital, training, laboratory tests, and antiretroviral and TB treatment drugs) divided by the annual number of patients. We applied linear regressions to estimate factors associated with ART cost per patient. RESULTS: The unit ART cost in Nigeria was $157 USD nationally and the facility-level mean was $231 USD. The study found a wide variability in unit costs across facilities. Variations in costs were explained by number of patients, level of care, task shifting (shifting tasks from doctors to less specialized staff, mainly nurses, to provide ART) and provider´s competence. The study illuminated the potentially important role that management practices can play in improving the efficiency of ART services. CONCLUSIONS: Our study identifies characteristics of services associated with the most efficient implementation of ART services in Nigeria. These results will help design efficient program scale-up to deliver comprehensive HIV services in Nigeria by distinguishing features linked to lower unit costs.


Assuntos
Síndrome de Imunodeficiência Adquirida/tratamento farmacológico , Síndrome de Imunodeficiência Adquirida/economia , Fármacos Anti-HIV/economia , Fármacos Anti-HIV/provisão & distribução , Assistência à Saúde/economia , Custos de Cuidados de Saúde/estatística & dados numéricos , Fármacos Anti-HIV/uso terapêutico , Humanos , Nigéria
18.
PLoS Med ; 15(5): e1002565, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29727458

RESUMO

INTRODUCTION: Access to antiretroviral therapy (ART) is a global priority. However, the attrition across the continuum of care for HIV-infected children between their HIV diagnosis and ART initiation is not well known. We analyzed the time from enrollment into HIV care to ART initiation in HIV-infected children within the International Epidemiology Databases to Evaluate AIDS (IeDEA) Global Cohort Consortium. METHODS AND FINDINGS: We included 135,479 HIV-1-infected children, aged 0-19 years and ART-naïve at enrollment, between 1 January 2004 and 31 December 2015, in IeDEA cohorts from Central Africa (3 countries; n = 4,948), East Africa (3 countries; n = 22,827), West Africa (7 countries; n = 7,372), Southern Africa (6 countries; n = 93,799), Asia-Pacific (6 countries; n = 4,045), and Latin America (7 countries; n = 2,488). Follow-up in these cohorts is typically every 3-6 months. We described time to ART initiation and missed opportunities (death or loss to follow-up [LTFU]: last clinical visit >6 months) since baseline (the date of HIV diagnosis or, if unavailable, date of enrollment). Cumulative incidence functions (CIFs) for and determinants of ART initiation were computed, with death and LTFU as competing risks. Among the 135,479 children included, 99,404 (73.4%) initiated ART, 1.9% died, 1.4% were transferred out, and 20.4% were lost to follow-up before ART initiation. The 24-month CIF for ART initiation was 68.2% (95% CI: 67.9%-68.4%); it was lower in sub-Saharan Africa-ranging from 49.8% (95% CI: 48.4%-51.2%) in Central Africa to 72.5% (95% CI: 71.5%-73.5%) in West Africa-compared to Latin America (71.0%, 95% CI: 69.1%-72.7%) and the Asia-Pacific (78.3%, 95% CI: 76.9%-79.6%). Adolescents aged 15-19 years and infants <1 year had the lowest cumulative incidence of ART initiation compared to other ages: 62.2% (95% CI: 61.6%-62.8%) and 66.4% (95% CI: 65.7%-67.0%), respectively. Overall, 49.1% were ART-eligible per local guidelines at baseline, of whom 80.6% initiated ART. The following children had lower cumulative incidence of ART initiation: female children (p < 0.01); those aged <1 year, 2-4 years, 5-9 years, and 15-19 years (versus those aged 10-14 years, p < 0.01); those who became eligible during follow-up (versus eligible at enrollment, p < 0.01); and those receiving care in low-income or lower-middle-income countries (p < 0.01). The main limitations of our study include left truncation and survivor bias, caused by deaths of children prior to enrollment, and use of enrollment date as a proxy for missing data on date of HIV diagnosis, which could have led to underestimation of the time between HIV diagnosis and ART initiation. CONCLUSIONS: In this study, 68% of HIV-infected children initiated ART by 24 months. However, there was a substantial risk of LTFU before ART initiation, which may also represent undocumented mortality. In 2015, many obstacles to ART initiation remained, with substantial inequities. More effective and targeted interventions to improve access are needed to reach the target of treating 90% of HIV-infected children with ART.


Assuntos
Fármacos Anti-HIV/provisão & distribução , Bases de Dados Factuais , Infecções por HIV/tratamento farmacológico , Acesso aos Serviços de Saúde/estatística & dados numéricos , Adolescente , Fármacos Anti-HIV/uso terapêutico , Criança , Pré-Escolar , Feminino , Saúde Global/estatística & dados numéricos , Humanos , Lactente , Recém-Nascido , Masculino , Fatores de Tempo , Adulto Jovem
19.
Trials ; 19(1): 79, 2018 Jan 29.
Artigo em Inglês | MEDLINE | ID: mdl-29378662

RESUMO

BACKGROUND: Sub-Saharan Africa is the world region with the greatest number of people eligible to receive antiretroviral treatment (ART). Less frequent dispensing of ART and community-based ART-delivery models are potential strategies to reduce the load on overburdened healthcare facilities and reduce the barriers for patients to access treatment. However, no large-scale trials have been conducted investigating patient outcomes or evaluating the cost-effectiveness of extended ART-dispensing intervals within community ART-delivery models. This trial will assess the clinical effectiveness, cost-effectiveness and acceptability of providing ART refills on a 3 vs. a 6-monthly basis within community ART-refill groups (CARGs) for stable patients in Zimbabwe. METHODS: In this pragmatic, three-arm, parallel, unblinded, cluster-randomized non-inferiority trial, 30 clusters (healthcare facilities and associated CARGs) are allocated using stratified randomization in a 1:1:1 ratio to either (1) ART refills supplied 3-monthly from the health facility (control arm), (2) ART refills supplied 3-monthly within CARGs, or (3) ART refills supplied 6-monthly within CARGs. A CARG consists of 6-12 stable patients who meet in the community to receive ART refills and who provide support to one another. Stable adult ART patients with a baseline viral load < 1000 copies/ml will be invited to participate (1920 participants per arm). The primary outcome is the proportion of participants alive and retained in care 12 months after enrollment. Secondary outcomes (measured at 12 and 24 months) are the proportions achieving virological suppression, average provider cost per participant, provider cost per participant retained, cost per participant retained with virological suppression, and average patient-level costs to access treatment. Qualitative research will assess the acceptability of extended ART-dispensing intervals within CARGs to both providers and patients, and indicators of potential facility-level decongestion due to the interventions will be assessed. DISCUSSION: Cost-effective health system models that sustain high levels of patient retention are urgently needed to accommodate the large numbers of stable ART patients in sub-Saharan Africa. This will be the first trial to evaluate extended ART-dispensing intervals within a community-based ART distribution model, and results are intended to inform national and regional policy regarding their potential benefits to both the healthcare system and patients. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT03238846 . Registered on 27 July 2017.


Assuntos
Fármacos Anti-HIV/economia , Fármacos Anti-HIV/provisão & distribução , Serviços Comunitários de Farmácia/economia , Custos de Medicamentos , Infecções por HIV/tratamento farmacológico , Infecções por HIV/economia , Fármacos Anti-HIV/administração & dosagem , Pesquisa Comparativa da Efetividade , Análise Custo-Benefício , Prescrições de Medicamentos/economia , Estudos de Equivalência como Asunto , Infecções por HIV/diagnóstico , Infecções por HIV/virologia , Humanos , Ensaios Clínicos Pragmáticos como Assunto , Fatores de Tempo , Resultado do Tratamento , Carga Viral , Zimbábue
20.
Int J Health Plann Manage ; 33(1): e367-e377, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-28960552

RESUMO

BACKGROUND: Prevention of parent-to-child transmission (PPTCT) of HIV is a highly complex package of interventions, which spans services in both maternal and child health programmes. In Papua New Guinea (PNG), a commitment to ensure that all pregnant women and their partners have access to the full range of PPTCT interventions exists; however, efforts to increase access and utilisation of PPTCT remain far from optimal. The aim of this paper is to examine health care worker (HCW) perception of health system factors impacting on the performance of PPTCT programmes. METHOD: Sixteen interviews were undertaken with HCWs involved in the PPTCT programme. Application of the WHO 6 building blocks of a health system was applied, and further thematic analysis was conducted on the data with assistance from the analysis software NVivo. RESULTS: Broken equipment, problems with access to medication and supplies, and poorly supported workforce were reported as barriers for implementing a successful PPTCT programme. The absence of central coordination of this complex, multistaged programme was also recognised as a key issue. CONCLUSION: The study findings highlight an important need for investment in appropriately trained and supported HCWs and integration of services at each stage of the PPTCT programme. Lessons from the PPTCT experience in PNG may inform policy discussions and considerations in other similar contexts.


Assuntos
Assistência à Saúde/organização & administração , Infecções por HIV/prevenção & controle , Transmissão Vertical de Doença Infecciosa/prevenção & controle , Fármacos Anti-HIV/provisão & distribução , Feminino , Humanos , Entrevistas como Assunto , Masculino , Serviços de Saúde Materno-Infantil/organização & administração , Papua Nova Guiné , Gravidez
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