Task shifting and integration of HIV care into primary care in South Africa: The development and content of the streamlining tasks and roles to expand treatment and care for HIV (STRETCH) intervention

Background: Task shifting and the integration of human immunodeficiency virus (HIV) care into primary care services have been identified as possible strategies for improving access to antiretroviral treatment (ART). This paper describes the development and content of an intervention involving these two strategies, as part of the Streamlining Tasks and Roles to Expand Treatment and Care for HIV (STRETCH) pragmatic randomised controlled trial. Methods: Developing the intervention: The intervention was developed following discussions with senior management, clinicians, and clinic staff. These discussions revealed that the establishment of separate antiretroviral treatment services for HIV had resulted in problems in accessing care due to the large number of patients at ART clinics. The intervention developed therefore combined the shifting from doctors to nurses of prescriptions of antiretrovirals (ARVs) for uncomplicated patients and the stepwise integration of HIV care into primary care services. Results: Components of the intervention: The intervention consisted of regulatory changes, training, and guidelines to support nurse ART prescription, local management teams, an implementation toolkit, and a flexible, phased introduction. Nurse supervisors were equipped to train intervention clinic nurses in ART prescription using outreach education and an integrated primary care guideline. Management teams were set up and a STRETCH coordinator was appointed to oversee the implementation process. Discussion: Three important processes were used in developing and implementing this intervention: active participation of clinic staff and local and provincial management, educational outreach to train nurses in intervention sites, and an external facilitator to support all stages of the intervention rollout

Bringing HIV Prevention to Scale: An Urgent Global Priority

Illustrates the need for a scaled-up HIV prevention response in order to stem the epidemic, describes impediments to HIV prevention efforts and examples of successful initiatives, and includes recommendations for governments, health agencies, and donors

Review of Universal Salt Iodation in East Central and Southern Africa (ACSA)

\ud This paper presents a regional position on Universal Salt Iodation (USI) intervention in 14 countries ill the East, Central and Southern Africa( ECSA) region,namely;Botswana,Kenya,Malawi,Mauritius,Mozambique,Namibia,bells,South Africa, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe The is a follow-up to a resolution on the need to develop a regional position on USI intervention which was made at the Commonwealth Regional Health Community 25th Health Ministers Conference in Port Louis, Mauritius from November;29,1996. The overall objective was to get views on the implementation of USI intervention in order to identify areas requiring facilitation, harmonization , coordination and collaboration at nation and regional levels in the ECSA. The preparation of paper involved reviewing of USI legislation regulations plans of action, survey reports and workshop papers. To substantiate the literature review, individual interviews were held with USI stakeholders in Malawi, Namibia, Tanzania, Zambia, and Zimbabwe from July 10-21, 1997 In respect of the findings, all the CRHC mainland member states are implementing USI intervention as a long term strategy for virtual elimination of the year 2000. The evaluation results of some of the national programmes have shown improvement of indicators of adequacy of iodine in the body. For example there is crease in levels of urinary iodine and reduction of goiter in countries where the intervention has been implemented actively over the past few years. In order to enforce the marketing of iodated salt, more than half of the CRHC member states have legislated USI where those who have not passed legislation yet are promoting USI through extensive advocacy and marketing strategy. These national USI programmes are being augmented by technical, financial and material support from United Nations and multilateral agencies, and the cooperation and compliance of the salt industry in iodating and packaging salt in line with USI legislation of country in the ECSA region. There are obstacles and constraints that impinge on the progress of USI in the entire ECSA region: The national USI legislation and regulations are not harmonized. The role of other sub-sector such as agriculture, trade and industry, and issues related to quality assurance are not spelt out in the regulations. There is still disparity in level of awareness of USI and its importance at all levels. Except Malawi, the rest of CRHC member states have no USI legislation for all salt intended for animal consumption. This is threatening sustenance of USI as there some leakages of uniodated salt from livestock sub-sector to people. Further threat emerges from communities who produce uniodated salt on a small scale for their own consumption and sale in their localities. The export and import duty for iodated and uniodate salt are the same. This does not deter traders and consumers to market and use uniodated salt because its price is either low or similar to the price of iodated salt. The challenge is, therefore, how to place the USI high on the agenda of relevant national and ECSA regional sub-sectors which formulate, implement and coordinate policy in order to strengthen and harmonize the intervention as well as deploying regionally acceptable measures to overcome the constraints. The CRHC should facilitate the harmonization of the USI regulations in the ECSA region including the reduction of the present high iodine levels to the levels (20-40ppm iodine[30-66ppm Potassium iodate]) that are recommended by the WHO. The CRHC should ensure that quality assurance issues are made mandatory in order to promote quality of salt iodations during production and packaging. The CRHC should facilitate development of guidelines regarding the roles of all sub-sectors such as ministries of Agriculture, Health and Trade and Industry, Departments of customs (Revenue Collection Authorities) and Bureaus of Standards in the USI which should issued under the directive of the Southern Africa Development Community and Common Market for Eastern and Southern Africa trade agreement. The CRHC should facilitate and support promotion of USI through regional networking,development and production of information, education and communication(IEC) material, designation of a regional IDD/USI day establishment of IIDD newsletter. The CRHC should ensure that member states consider making uniodated salt for whatever use a controlled commodity and impose deterrent export and import duty in order to protect, support and promote use of iodated salt for human and animal consumption in the region. The CRHC should facilitate establishment of at least one regional micronutrients reference laboratory and improvement of the national laboratories. The CHRC should strengthen the Department of Food Security and Nutrition of personnel in order to enhance capacity to accomplish the suggested activities listed below along with other planned work in the Department. The CHRC should endeavor to mobilize technical, financial and resources for support of salt iodations in the region especially in countries which are lagging behind and small salt procedure. Facilitating and supporting the evaluation of selected national USI programmes in order to confirm the case for reduction of iodine levels in the ECSA region. Facilitating review and harmonization of USI legislation and relevant Standards Act in the ECSA region. Initiating and supporting the collaboration on the proposed imposition of deterrent export and import duty on uniodated salt in order to protect and promote use of iodated salt. Facilitating and supporting the guide for role vital sub-sector such as Bureaus of Standard, Chamber of Commerce, and Ministries of Trade and Industry, Agriculture, departments of Customs and Excise, in the promotion, supporting, protecting and monitoring USI in the ECSA region. Facilitating network and all aspects of IEC and designation of an IDD day in ECSA. Conducting ECSA regional conferences on USI policy direction and review with consideration of SADC and COMESA trade agreements. Establishing a regional data bank on USI and micronutrient in order to enhance and facilitate regional networking. Establishing a regional micronutrients reference laboratory for improvement of micronutrients laboratory services whilst on one hand, supporting devolution of some the services to the provinces in order to easy congestion in national laboratories. Collecting, documenting and disseminating USI current information and technology in the ECSA member states through newsletter, bulletins and regional workshops. Conducting and supporting training on: Micronutrients, food security and nutrition in order to develop and capacity for execution of intervention and Programme-driven (operational) research on micronutrient, food security and nutrition. \u

WASH in Schools Empowers Girls' Education: Proceedings of the Menstrual Hygiene Management in Schools Virtual Conference 2013

This publication brings together the key elements of the 16 presentations made at the Second Annual Virtual MHM in WinS Conference at UNICEF Headquarters in New York City on 21 November 2013. Building on recommendations from the MHM 2012 virtual conference, the 2013 conference focused on the research tools and instruments being used to explore MHM barriers and practices and to evaluate the interventions being trialed or implemented in various contexts

Inclusion of Persons with Disabilities in the Health Financing System in Tanzania

This report assesses the potential barriers and obstacles that people with disabilities might face when accessing health care services. It is the overall objective of this study to provide evidence on obstacles and financial barriers that people with disabilities might face when accessing health care services in Tanzania. The study presents data of a household surveys with a total amount of 1,480 participants as well as evidence from in-depth interviews and Focus Group Discussions (FGDs) which have been conducted in two selected regions in Tanzania: Tanga and Lindi. The report summarizes these findings and provides evidence on the financing gap in terms of both direct and indirect costs. In order to overcome the many barriers that this report identifies, recommendations on how the gap can be addressed. The relationship between disability and ill-health is complex and need not necessarily result in negative health outcomes for persons with disabilities. This section provides some information on how to define disability. The World Report on Disability (WRD), which was jointly published by the World Bank and the World Health Organization (WHO), notes that disability is associated with a diverse range of primary health conditions of which may result in poor health and high health care needs. Furthermore, the reciprocal relationship ill-health, poverty and vulnerability is emphasized in this chapter.The cross-sectional study at hand employs both quantitative and qualitative research methods. As for the quantitative household survey, 1,480 participants, who were divided into treatment group (households with people with disabilities) and control group (households without people with disabilities), were interviewed in two regions: Tanga and Lindi. The differentiation in these two groups allows to statistically compare whether people with disabilities experience significantly higher barriers to access health care services compared to people without disabilities (instead of just having occurred by chance). Both areas were selected in order to obtain a broader picture in both, rural and urban areas. Furthermore, ethnographic approaches such as in-depth interviews and Focus Group Discussions (FGDs) were used in triangulation, incorporating the advantages of each research approach. The findings of the report suggest that persons with disabilities experience worse socio-economic outcomes and are more prone to poverty than persons without disabilities. Since people with disabilities have lower educational achievements, participate less in the economy and have higher rates of poverty than people without disabilities, they also have a higher risk of poorer health outcomes. Furthermore, the findings of this report show that people with disabilities seldom access health care facilities for either routine or specialised health care services. Only 21 % of the respondents went for routine care within the past three months. The majority of those who went to seek medical assistance went to public health facilities at primary level. Health care seekers reported being overall satisfied with the services and the waiting time. Also, the respondents reported that health service providers tried to establish a trustworthy environment where they treated them in privacy. Those people with disabilities who accessed health services mainly paid the services out of their pocket or through their insurance scheme. Only few people paid the services with other means of informal payment. Additionally, the findings of the report with regards to costs are presented. Costs for medical care can be broken down into three broader categories: (1) Direct Medical Care Costs, (2) Direct Non-Medical Care Costs, (3) Indirect Costs. Overall, 97.4% of the respondents reported to have incurred direct medical costs in both districts. There were more respondents who incurred medical costs for specialised health care in Nachingwea 63.1% as compared to Tanga municipality 47.3%. In terms of indirect costs, 67% of respondents reported that they had to pay for transportation and almost 40 % indicated their consumable costs. In terms of indirect costs, participants reported that they encounter losses of productivity due to the necessity to access health care services (10 days on overage per three months, mean average income lost in Nachingwea and Tanga were Tshs.45,580 (29US$) and Tshs.20,178 (13US$) respectively). Notably, people with disabilities seem to have lower costs for outpatient services than others. This might be due to the fact that many people with disabilities are exempted at dispensary and health center level, though there were complains about the intransparency and malfunctioning of the exemption/waiver-policy in general. In addition, costs for inpatient services (provided at health center and hospital level) for people living with disabilities are almost double the average costs of the control group. (Tshs.77,438 vs Tshs. 41,938). In terms of access to social health protection, few people reported actually using health insurance schemes. Only 12.8 % of the respondents reported to have access to social security related to specialized health care services. Many participants reported that there is not enough information for people with disabilities on insurance schemes and that waiving policies for exempting poor and vulnerable people are inconclusive. More, lack of money seems to be the decisive factor of why people with disabilities are not able to access health care services (72 % reported missing routine health care services and 62 % for specialised health services due to constraint financial resources). Social and communal network are considered particularly important in supporting people with disabilities in accessing health care services. Last but not least, people with disabilities reported a number of unmet needs, including the lack of various services like rehabilitation, counselling services and vocational trainings to improve their productivity. The discussion part of the study contextualises the findings. It reiterates the reciprocal link of poverty and disability and tries to find answers of why people with disabilities hardly access health care services. It further outlines the importance of making health care services available to all, in order to ensure the well-being of people with disabilities. In order to promote the utilization of health care services for people with disability, it further suggests to consider the health care user‟s own perceptions [1]. Despite efforts made by the Ministry of Heath to deliver health care services to the people, most of health care services are still inaccessible to the majority of people with disability. Hence, this study provides a number of recommends with regards to Policy and Legislation, Financing and Affordability, Accessibility and Communit

A Practical Guide to Integrating Reproductive Health and HIV/AIDS into Grant Proposals to the Global Fund

Integrating RH and HIV can greatly contribute to mitigating the AIDS pandemic by reducing unintended pregnancy; preventing perinatal transmission; expanding to more target groups; reducing gender based violence; meeting the needs of people living with HIV and providing our youth with the knowledge and services they need. Whether to integrate, how to integrate and exactly what to integrate will depend on a country's epidemiological profile, policies and program structures.Experience with implementation of integration initiatives in countries around the world shows that scale up and sustainability requires attention to policy and program operations issues. This document, with links to a range of resources, will help CCMs, civil society organizations and others developing proposals for the Global Fund that contribute to preventing HIV and mitigating the effects of the AIDS pandemic through programs that link and integrate RH and HIV/AIDS

Operational research in low-income countries: what, why, and how?

Operational research is increasingly being discussed at institutional meetings, donor forums, and scientific conferences, but limited published information exists on its role from a disease-control and programme perspective. We suggest a definition of operational research, clarify its relevance to infectious-disease control programmes, and describe some of the enabling factors and challenges for its integration into programme settings. Particularly in areas where the disease burden is high and resources and time are limited, investment in operational research and promotion of a culture of inquiry are needed so that health care can become more efficient. Thus, research capacity needs to be developed, specific resources allocated, and different stakeholders (academic institutions, national programme managers, and non-governmental organisations) brought together in promoting operational research

Shrinking the Malaria Map: A Prospectus on Malaria Elimination

\ud Thirty-nine countries across the world are making progress toward malaria elimination. Some are committed to nationwide elimination, while others are pursuing spatially progressive elimination within their borders. Influential donor and multilateral organizations are supporting their goals of achieving malaria-free status. With elimination back on the global agenda, countries face a myriad of questions. Should they change their programs to eliminate rather than control malaria? What tools are available? What policies need to be put into place? How will they benefit from elimination? Unfortunately, answers to these questions, and resources for agencies and country program managers considering or pursuing elimination, are scarce. The 39 eliminating countries are all positioned along the endemic margins of the disease, yet they naturally experience a variety of country characteristics and epidemiologies that make their malaria situations different from one another. The Malaria Elimination Group (MEG) and this Prospectus recognize\ud that there is no single solution, strategy, or time line that will be appropriate for every country, and each is encouraged to initiate a comprehensive evaluation of its readiness and strategy for elimination. The Prospectus is designed to guide countries in conducting these assessments. The Prospectus provides detailed and informed discussion on the practical means of achieving and sustaining zero transmission. It is designed as a road map, providing direction and options from which to choose an appropriate path. As on all maps, the destination is clearly marked, but the possible routes to reach it are numerous. The Prospectus is divided into two sections: Section 1 Eliminating Malaria comprises four chapters covering the strategic components important to the periods before, during, and after an elimination program. Section 2 Tools for the Job, comprises six chapters that outline basic information about how interventions in an elimination program will be different from those in a control setting. Chapter 1, Making the Decision, evaluates the issues that a country should consider when deciding whether or not to eliminate malaria. The chapter begins with a discussion about the quantitative and qualitative benefits that a country could expect from eliminating malaria and then recommends a thorough feasibility assessment. The feasibility assessment is based on three major components: operational, technical, and financial feasibility. Cross-border and regional collaboration is a key subject in this chapter. Chapter 2, Getting to Zero, describes changes that programs must consider when moving from sustained control to an elimination goal. The key strategic issues that must be addressed are considered, including supply chains, surveillance systems, intersectoral collaboration, political will, and legislative framework. Cross-border collaboration is again a key component in Getting to Zero. Chapter 3, Holding the Line, provides recommendations on how to conduct an assessment of two key factors that will affect preventing the reemergence of malaria once transmission is interrupted: outbreak risk and importation risk. The chapter emphasizes the need for a strong surveillance system in order to prevent and, if necessary, respond to imported cases. Chapter 4, Financing Elimination, reviews the cost-effectiveness of elimination as compared with sustained control and then presents the costs of selected elimination programs as examples. It evaluates four innovative financing mechanisms that must support elimination, emphasizing the need for predictable and stable financing. Case studies from Swaziland and two provinces in China are provided. Chapter 5, Understanding Malaria, considers malaria from the point of view of elimination and provides a concise overview of the current burden of the disease, malaria transmission, and the available interventions that can be used in an elimination program. Chapter 6, Learning from History, extracts important lessons from the Global Malaria Eradication Program and analyzes some elimination efforts that were successful and some that were unsuccessful. The chapter also reviews how the malaria map has been shrinking since 1900. xiv A Prosp ectus on Mala ria Elimi natio n\ud Chapter 7, Measuring Malaria for Elimination, provides a precise language for discussing malaria and gives the elimination discussion a quantitative structure. The chapter also describes the role of epidemiological theory and mathematical modeling in defining and updating an elimination agenda for malaria. Chapter 8, Killing the Parasite, outlines the importance of case detection and management in an elimination setting. Options for diagnosis, the hidden challenge of Plasmodium vivax in an elimination setting, and the impact of immunity are all discussed. Chapter 9, Suppressing the Vector, explores vector control, a necessary element of any malaria program. It considers optimal methods available to interrupt transmission and discusses potential changes, such as insecticide resistance, that may affect elimination efforts. Chapter 10, Identifying the Gaps — What We Need to Know, reviews the gaps in our understanding of what is required for elimination. The chapter outlines a short-term research agenda with a focus on the operational needs that countries are facing today. The Prospectus reviews the operational, technical, and financial feasibility for those working on the front lines and considers whether, when, and how to eliminate malaria. A companion document, A Guide on Malaria Elimination for Policy Makers, is provided for those countries or agencies whose responsibility is primarily to make the policy decisions on whether to pursue or support a malaria elimination strategy. The Guide is available at www.malaria eliminationgroup.org