Time to change the single-centre approach to management of patients with tuberculosis: a novel network platform with automatic data import and data sharing

Time to change the single-centre approach to TB http://ow.ly/lCeM30hBcbB

Impact of a mobile phone-based interactive voice response software on tuberculosis treatment outcomes in Uganda (CFL-TB): a protocol for a randomized controlled trial.

BACKGROUND: Throughout the last decade, tuberculosis (TB) treatment success has not surpassed 90%, the global target. The impact of mobile health interventions (MHIs) on TB treatment outcomes is unknown, especially in low- and middle-income countries (LMICs). MHIs, including interactive voice response technology (IVRT), may enhance adherence and retention in the care of patients with tuberculosis and improve TB treatment outcomes. This study seeks to determine the impact of IVRT-based MHI on TB treatment success (treatment completion and cure rates) in patients with TB receiving care at five public health facilities in Uganda. METHODS: We used a theory-based and human-centered design (HCD) to adapt an already piloted software to design "Call for life-TB" (CFL-TB), an MHI that utilizes IVRT to deliver adherence and appointment reminders and allows remote symptom reporting. This open-label, multicenter, randomized controlled trial (RCT), with nested qualitative and economic evaluation studies, will determine the impact of CFL-TB on TB treatment success in patients with drug-susceptible TB in Uganda. Participants (n = 274) at the five study sites will be randomized (1:1 ratio) to either control (standard of care) or intervention (adherence and appointment reminders, and health tips) arms. Multivariable regression models will be used to compare treatment success, adherence to treatment and clinic appointments, and treatment completion at 6 months post-enrolment. Additionally, we will determine the cost-effectiveness, acceptability, and perceptions of stakeholders. The study received national ethical approval and was conducted in accordance with the international ethical guidelines. DISCUSSION: This randomized controlled trial aims to evaluate interactive voice response technology in the context of resource-limited settings with a high burden of TB and high illiteracy rates. The software to be evaluated was developed using HCD and the intervention was based on the IMB model. The software is tailored to the local context and is interoperable with the MHI ecosystem. The HCD approach ensures higher usability of the MHI by integrating human factors in the prototype development. This research will contribute towards the understanding of the implementation and impact of the MHI on TB treatment outcomes and the health system, especially in LMICs. TRIAL REGISTRATION: ClinicalTrials.gov NCT04709159 . Registered on January 14, 2021

TB STIGMA – MEASUREMENT GUIDANCE

TB is the most deadly infectious disease in the world, and stigma continues to play a significant role in worsening the epidemic. Stigma and discrimination not only stop people from seeking care but also make it more difficult for those on treatment to continue, both of which make the disease more difficult to treat in the long-term and mean those infected are more likely to transmit the disease to those around them. TB Stigma – Measurement Guidance is a manual to help generate enough information about stigma issues to design and monitor and evaluate efforts to reduce TB stigma. It can help in planning TB stigma baseline measurements and monitoring trends to capture the outcomes of TB stigma reduction efforts. This manual is designed for health workers, professional or management staff, people who advocate for those with TB, and all who need to understand and respond to TB stigma

The association of organizational contextual factors and HIV-Tuberculosis service integration following exposure to quality improvement interventions in primary healthcare clinics in rural KwaZulu-Natal.

Doctoral Degree. University of KwaZulu-Natal, Durban.A key strategy to reduce Tuberculosis (TB)-related mortality among people living with HIV is integrating HIV and TB diagnostic and treatment services. In South Africa, integrated HIV-TB service provision is standard of care, however, there is evidence that patients accessing primary healthcare clinics (PHC) are missed for HIV and TB testing and screening, diagnosis, linkage to treatment, and preventive services. Gaps in the HIV-TB care cascade are indicative of weaknesses in healthcare systems at the frontline. Quality Improvement (QI) collaboratives are a widely adopted approach to facilitating improvement among multiple clinics and scaling up best practices to improve on a given health topic. Little is known of the effectiveness of QI collaboratives and less is known of the role of organizational contextual factors (OCFs) in influencing the success of QI collaboratives to improve integrated HIV-TB services. Scaling up TB/HIV Integration (SUTHI) was a cluster-randomised trial designed to test the effectiveness of a QI intervention to enhance integrated HIV-TB services on mortality in HIV, TB, and HIV-TB patients. The study was from 01 December 2016-31 December 2018. Sixteen nurse supervisors (clusters) overseeing 40 PHC clinics were randomized (1:1) to receive either a structured QI intervention (QI group), which comprised, clinical training, three QI workshops timed at 6-month intervals, and in-person mentorship visits; or standard of care (SOC group) supervision and support for HIV-TB service delivery. This PhD project was a nested sub-study embedded in the SUTHI trial which aimed to describe and assess the influence of OCFs on the QI intervention to improve process indicators of HIV-TB services. A description of the QI intervention, including change ideas generated and lessons learned from practical application of the intervention in 20 QI clinics are presented in Paper I. Baseline performance of indicators was highlighted as important in influencing the size of improvements. OCFs that undermined the QI process were poor data quality, data capturing backlogs, lack of data analytic skills among clinic staff, poor transfer of training knowledge to peers, low clinic staff motivation to consistently track performance and limited involvement of the clinic management team in QI activities due to heavy workloads. A comparison between the QI and SOC group clinics showed that the QI intervention was only effective in improving two of five HIV-TB indicators, HIV testing services (HTS) andIsoniazid Preventive Therapy (IPT) initiation rates in new antiretroviral therapy patients. HTS was 19% higher (94.5% versus (vs) 79.6%; Relative Risk (RR)=1.19; 95% CI:1.02% - 1.38%; p=0.029) and IPT initiation was 66% higher (61.2% vs 36.8%; RR=1.66; 95% CI:1.02% -2.72%; p=0.044), in the QI group compared to the SOC group. Small clusters showed larger improvements in IPT initiation rates compared to big clusters, likely due to better coordination of efforts (Paper II). Several OCFs were quantitatively assessed and inserted into a linear mixed model to determine which factors likely influenced the improvement observed in the IPT initiation rates (Paper III). The practice of monitoring data for improvement was significantly associated with higher IPT initiation rates (Beta coefficient (β)=0.004; p=0.004). The main recommendations made from the PhD project are to encourage the practice of monitoring data for improvement among clinic teams; provision of widespread QI training for all levels of staff, different staff categories and leadership; to ensure good quality of routine data, and provision of regular performance feedback from upper management to the clinics

Adult HIV care resources, management practices and patient characteristics in the Phase 1 IeDEA Central Africa cohort

Introduction: Despite recent advances in the management of HIV infection and increased access to treatment, prevention, care and support, the HIV/AIDS epidemic continues to be a major global health problem, with sub-Saharan Africa suffering by far the greatest humanitarian, demographic and socio-economic burden of the epidemic. Information on HIV/AIDS clinical care and established cohorts’ characteristics in the Central Africa region are sparse. Methods: A survey of clinical care resources, management practices and patient characteristics was undertaken among 12 adult HIV care sites in four countries of the International Epidemiologic Databases to Evaluate AIDS Central Africa (IeDEA-CA) Phase 1 regional network in October 2009. These facilities served predominantly urban populations and offered primary care in the Democratic Republic of Congo (DRC; six sites), secondary care in Rwanda (two sites) and tertiary care in Cameroon (three sites) and Burundi (one site). Results: Despite some variation in facility characteristics, sites reported high levels of monitoring resources, including electronic databases, as well as linkages to prevention of mother-to-child HIV transmission programs. At the time of the survey, there were 21,599 HIV-positive adults (median age=37 years) enrolled in the clinical cohort. Though two-thirds were women, few adults (6.5%) entered HIV care through prevention of mother-to-child transmission services, whereas 55% of the cohort entered care through voluntary counselling and testing. Two-thirds of patients at sites in Cameroon and DRC were in WHO Stage III and IV at baseline, whereas nearly all patients in the Rwanda facilities with clinical stage information available were in Stage I and II. WHO criteria were used for antiretroviral therapy initiation. The most common treatment regimen was stavudine/lamivudine/nevirapine (64%), followed by zidovudine/lamivudine/nevirapine (19%). Conclusions: Our findings demonstrate the feasibility of establishing large clinical cohorts of HIV-positive individuals in a relatively short amount of time in spite of challenges experienced by clinics in resource-limited settings such as those in this region. Country differences in the cohort's site and patient characteristics were noted. This information sets the stage for the development of research initiatives and additional programs to enhance adult HIV care and treatment in Central Africa

Task Shifting for Scale-up of HIV Care: Evaluation of Nurse-Centered Antiretroviral Treatment at Rural Health Centers in Rwanda

Fabienne Shumbusho and colleagues evaluate a task-shifting model of nurse-centered antiretroviral treatment prescribing in rural primary health centers in Rwanda and find that nurses can effectively and safely prescribe ART when given adequate training, mentoring, and support

Review on Ascites in Pets

Ascites is one of the major complications seen in various disease conditions in pets. Ascites is characterised by distension of the abdomen with accumulation of fluid of various colours and consistencies depending on the cause. The most common causes of ascites in pets include but not limited to the following health conditions: hypoproteinaemia, left-sided heart failure, congestive heart failure, cirrhosis, hepatic diseases, renal diseases, ancylostomosis and bacterial infection such as tuberculosis. Pathogenesis of ascites often emanate from portal hypertension, cirrhosis, hepatorenal syndrome, etc. Oftentimes the diagnosis of ascites could be cumbersome considering the myriad of diseases implicated in the condition. Standard diagnostic procedures include the following: physical examination, clinical examination, ultrasonography, computed tomography, serum ascites albumin gradient (SAAG), biochemical analysis such as triglyceride, urea and creatinine concentration, total protein, etc. Novel diagnostic procedures with possible clinical relevance include the following: leucocyte esterase reagent strip, platelet indices, tumour markers, etc. Diagnosis is made through standard diagnostic procedure, while special cases of idiopathic origin are detected through diagnostic laparotomy. Novel diagnostic procedures such as platelet indices, leucocyte esterase reagent strip and tumour markers would aid in easy diagnosis of ascites. Treatment of ascites is dependent on identification of the cause of ascites

IMPACT OF TECHNOLOGY ON IMPROVING HIV AND TUBERCULOSIS HEALTH OUTCOMES AMONG AFRICAN COUNTRIES

This study used health analytics approach to evaluate the association between population health outcomes and Information and Communication Technology (ICT) infrastructures at a country level. This study used aggregate data obtained from the World Bank database, and the International Telecommunication Union (ITU) database for 53 African countries for the periods 2000 to 2016, and quantitatively explored the impact of ICT infrastructures’ diffusion on population health outcomes. ICT data was obtained from the ITU database. Similarly, population health attributes were retrieved from the World Bank database. ICT infrastructure variables used in this study include: internet access, mobile phone use, and fixed telephone subscriptions. However, population health outcome variables for this study include: HIV prevalence, access to antiretroviral therapy, Tuberculosis incidence, and mortality rates. Econometric study methodology involved a Dynamic Panel Model (DPM). Study findings showed that promoting ICT use among the public has opportunities for improving Tuberculosis (TB) and HIV health outcomes. However, the impact of each ICT infrastructures on improving TB and HIV health outcomes differed, which this study inferred to be as a result of different functionalities of the ICT infrastructures, as well as the peculiar features of the health outcomes studied. This study also did an Exploratory Spatial Data Analysis (ESDA) of TB treatment completion rates among health systems in Africa to help visualize trends and identify patterns, clusters and outliers. It evaluated spatial relationships between mobile phone use and TB treatment completion rates using differential local Moran’s I and bivariate Moran’s I techniques. Study result identified statistically significant positive autocorrelation values for the periods evaluated, as well as varying cluster patterns in TB treatment completion rates. The cluster patterns increased across the three-time periods among geographically referenced data evaluated in this study. This study also identified a direct relationship between mobile phone use and TB treatment completion rates among relevant African countries studied. Thereby, necessitating the need to strengthen national policies that promote TB and HIV medication adherence and completion using eHealth strategies among African health systems. Another important policy implication of this study for African governments is that investing in eHealth, including educating the masses on ICT use, could be an alternative policy to improve population health

Electronic recording and reporting for tuberculosis care and control

"This guide on electronic recording and reporting is the result of a major collaborative effort involving 9 agencies and institutions and 21 individuals. This document was funded by the United States Agency for International Development under the USAID Tuberculosis CARE I, Cooperative Agreement No. AID-OAA-A-10-000020. Development of the guide was led by the World Health Organization (WHO) in close cooperation with the KNCV Tuberculosis Foundation (KNCV) and Management Sciences for Health (MSH). Hazim Timimi in the WHO Stop TB Department\ue2\u20ac\u2122s TB monitoring and evaluation team coordinated the production of the document, under the guidance of Katherine Floyd and Philippe Glaziou." --p. v"Adopting electronic recording and reporting is not simply about choosing a piece of software: it is also about changing how people work. This is not a simple undertaking. This document introduces the key questions to be considered and illustrates what the questions, options and recommendations mean in practice by drawing on examples of recent experience from a variety of countries. It is an essential resource for all those planning to introduce electronic recording and reporting systems for TB care and control, or to enhance existing systems."--p. [4] of cover.1. Identifying general requirements -- 2. Identifying detailed requirements -- 3. Selecting a solution -- 4. Implementing an electronic recording and reporting system -- Annex 1. Development of this document.Also available online.Includes bibliographical references

Point-of-care testing, new antiretroviral regimens and community-based treatment to enhance primary care HIV services in South Africa

Background: The global rollout of antiretroviral therapy has significantly reduced HIV/AIDS related morbidity and mortality. However, there are new challenges in a) providing HIV viral load testing to monitor the effectiveness of ART, b) combating HIV drug resistance, and c) efficiently providing treatment to the 39 million people living with HIV globally. In low- and middle-income countries such as South Africa, most ART is provided in primary care, where there is limited laboratory capacity and where available, viral load testing typically takes several days to turn around, resulting in additional clinic visits for review of results and treatment adjustment. New point-of-care assays have been developed which could be used in primary care clinics to provide same-day viral load results. Patients with viraemia and uncontrolled HIV infection could receive immediate adherence counselling, and ART optimization for those likely to have HIV drug resistance. However, we do not know the clinical effectiveness of these point-of-care assays HIV in primary care settings. Furthermore, the new antiretroviral dolutegravir, which has a higher genetic barrier to HIV drug resistance, has been introduced and will require new monitoring strategies. Lastly, the impacts of dolutegravir, and new models of efficient community ART provision, are not known. Aims: To determine whether point-of-care viral load testing is a promising strategy to improve management of viraemia in primary care in South Africa, and whether its clinical effectiveness can be tested in a large, randomised trial. To assess changes in the ART programme, including the introduction of dolutegravir and community ART delivery programmes, which may necessitate new monitoring strategies. Methods: First, I evaluated the diagnostic accuracy of three point-of-care viral load assays, and conducted the Point-Of-care HIV viral load testing to Enhance Re-suppression (POwER) trial, a randomised pilot/feasibility study. I assessed trial feasibility outcomes (enrolment and retention), 12-week point-of care viral load process outcomes, and the future trial primary outcome of viral suppression at <50 copies/mL after 24 weeks, in the point-of-care and laboratory viral load arms. Second, to explore the impact of a new, likely more effective antiretroviral, dolutegravir, I conducted a post-hoc analysis within POwER, evaluating viral load outcomes and HIV drug resistance by baseline ART regimen. I then evaluated the analytic performance of a novel point-of-care test that measures urine concentrations of tenofovir, a key component of most ART regimens. Third, I evaluated the healthcare context in which these assays may be implemented. I assessed the rollout of dolutegravir, and its impact on viral load outcomes, in a retrospective cohort study using data from 59 South African primary care clinics. Then, using interviews and focus group discussions with patients and healthcare workers, I explored the impact of a community ART programme, that includes over 1 million patients, on the ‘social practice’ of engagement in HIV care. Lastly, I used interrupted time series analysis of routine data from 60 clinics to quantify the impact of COVID-19 on primary care HIV services in South Africa. Results: First, in 189 paired samples, sensitivity and specificity of three different point-of-care viral load assays to detect viraemia was >90%. Enrolment into POwER was disrupted by the COVID-19 pandemic, with 80 eligible participants enrolled between August 2020 to March 2022, versus an initial target of 100 in six months. The 12-week point-of-care viral load result was delivered to participants a median of 3.1 hours (IQR 2.6-3.8) after blood draw, versus 7 days (IQR 6-8, p<0.001) for standard laboratory viral load results. Point-of-care participants had median 3 (IQR 3-4) clinic visits versus 4 (IQR 4-5) in the standard-of-care arm (p<0.001). Retention was high at 95.0% at 24 weeks, and the exploratory primary outcome of 24-week viral suppression was achieved by 27/39 (69.2% [95%CI 53.4-81.4]) point-of-care participants versus 29/40 (72.5% [57.0-83.9]) standard-of-care participants (p=0.808). Second, at enrolment into POwER, 43 participants were receiving dolutegravir, and 37 were receiving the older drug efavirenz as part of their ART regimen. People receiving dolutegravir had no major HIV drug resistance, and therefore achieved rapid viral resuppression after enhanced adherence counselling, meaning there was little opportunity for the point-of-care viral load to exert an effect. The point-of-care urine test had good analytic performance, with >90% sensitivity and specificity to detect tenofovir. Third, in over 220,000 people in 59 South African primary care clinics, over 75% of people were receiving dolutegravir by February 2022. Viral suppression was slightly higher in people receiving dolutegravir compared to those receiving efavirenz (adjusted risk ratio 1·04 [1·01,1·06], adjusted risk difference 3·1% [1·2,5·1]). In a qualitative study, the South African community-based ART programme was found to be acceptable to both patients and healthcare workers and was perceived to overcome several barriers to clinic-based ART collection, resulting in quicker and more convenient care for people living with HIV. Lastly, the COVID-19 lockdown led to a 47.6% drop in HIV testing (incidence rate ratio [IRR] 0.52, 95% CI 0.45-0.62) and a 46.2% decrease in ART initiations (IRR 0.54, 95% CI 0.46-0.63), while there was no marked change in ART collection visits (IRR 0.93, 95% CI 0.79-1.09). Conclusion: Point-of-care viral load assays have acceptable clinical performance in primary care, and it would be feasible to assess their clinical effectiveness in a larger randomised trial. However, the widespread rollout of dolutegravir means that there may be less HIV drug resistance and a potential smaller role for point-of-care viral load tests to improve HIV viraemia. Instead, combination interventions including novel point-of-care adherence assays should be investigated to manage viraemia. Whether point-of-care viral load tests may have more of a role in improving efficiency of community ART delivery programmes should also be evaluated