INTEGRATED COMMUNITY CASE MANAGEMENT OF CHILDHOOD ILLNESSES IN THE CONTEXT OF FREE PRIMARY HEALTH CARE IN RURAL SIERRA LEONE: EFFECTS ON CARE SEEKING, TREATMENT AND EQUITY

Problem statement: Integrated community case management (ICCM) of childhood illnesses by community health workers (CHWs) is an endorsed strategy to reduce child mortality in developing countries. The evidence on the effectiveness of ICCM programs in Sub-Saharan Africa is growing; however, evidence on ICCM in the context of free health care is limited. Methods: The study examined: (1) CHW influences on pre-post changes in care seeking and treatment, analyzed using a difference-in-differences (DID) analysis; (2) factors associated with CHW utilization, analyzed using weighted logistic regression; and (3) ICCM effect on equitable coverage of care seeking and treatment by ethnicity and socioeconomic status, analyzed using comparative and DID analysis. Study districts were purposively selected; 2 intervention districts had ICCM by CHWs plus free facility care and 2 comparison districts with free facility care only. A household cluster survey was conducted among caregivers of 5,643 and 5,259 children U5 at baseline (2010) and endline (2012), respectively. Results: ICCM was associated with increased odds in appropriate treatment for pneumonia (OR=2.00, 95%CI: 1.20-3.35) and decreased odds in traditional treatment for diarrhea (OR=0.44, 95%CI: 0.21-0.95) and facility treatments for malaria (OR=0.21, 95%CI: 0.07-0.62). Though no effect on inequalities by wealth, ICCM was associated with increased odds in care seeking (OR=2.98, 95%CI: 1.60-5.54) and appropriate treatment (OR=2.15, 95%CI: 1.12-4.41) and decreased odds in traditional treatments (OR=0.34, 95%CI: 0.14-0.87) among children from ethnic groups other than Mende. ICCM was also associated with increased odds in care seeking (OR=2.17, 95%CI: 1.03-4.57) and appropriate treatment (OR=2.55, 95%CI: 1.24-5.27) among children whose caregivers reported some education and decreased odds in traditional treatment (OR=0.48, 95%CI: 0.23-0.99) among children whose caregivers reported no education. Conclusions: ICCM by CHWs was associated with some increases in appropriate treatment, reduced treatment burden at the facility level, and reduced reliance on traditional treatments. Children from disadvantaged groups also appeared to benefit most from ICCM. The availability of trained and supervised CHWs can be an asset to provision of free healthcare in Sierra Leone

Factors associated with long‐term antiretroviral therapy attrition among adolescents in rural Uganda: a retrospective study

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/138247/1/jia20841.pd

Cost-effectiveness of voluntary medical male circumcision for HIV prevention across sub-Saharan Africa : results from five independent models

BACKGROUND: Voluntary medical male circumcision (VMMC) has been a recommended HIV prevention strategy in sub-Saharan Africa since 2007, particularly in countries with high HIV prevalence. However, given the scale-up of antiretroviral therapy programmes, it is not clear whether VMMC still represents a cost-effective use of scarce HIV programme resources. METHODS: Using five existing well described HIV mathematical models, we compared continuation of VMMC for 5 years in men aged 15 years and older to no further VMMC in South Africa, Malawi, and Zimbabwe and across a range of setting scenarios in sub-Saharan Africa. Outputs were based on a 50-year time horizon, VMMC cost was assumed to be US$90, and a cost-effectiveness threshold of US$500 was used. FINDINGS: In South Africa and Malawi, the continuation of VMMC for 5 years resulted in cost savings and health benefits (infections and disability-adjusted life-years averted) according to all models. Of the two models modelling Zimbabwe, the continuation of VMMC for 5 years resulted in cost savings and health benefits by one model but was not as cost-effective according to the other model. Continuation of VMMC was cost-effective in 68% of setting scenarios across sub-Saharan Africa. VMMC was more likely to be cost-effective in modelled settings with higher HIV incidence; VMMC was cost-effective in 62% of settings with HIV incidence of less than 0·1 per 100 person-years in men aged 15-49 years, increasing to 95% with HIV incidence greater than 1·0 per 100 person-years. INTERPRETATION: VMMC remains a cost-effective, often cost-saving, prevention intervention in sub-Saharan Africa for at least the next 5 years. FUNDING: Bill & Melinda Gates Foundation for the HIV Modelling Consortium

Lessons learned and study results from HIVCore, an HIV implementation science initiative

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/138261/1/jia21261.pd

Voluntary medical male circumcision service delivery in South Africa: The economic costs and potential opportunity for private sector involvement.

BACKGROUND:In 2010, the South African Government initiated a voluntary medical male circumcision (VMMC) program as a part of the country's HIV prevention strategy based on compelling evidence that VMMC reduces men's risk of becoming HIV infected by approximately 60%. A previous VMMC costing study at Government and PEPFAR-supported facilities noted that the lack of sufficient data from the private sector represented a gap in knowledge concerning the overall cost of scaling up VMMC services. This study, conducted in mid-2016, focused on surgical circumcision and aims to address this limitation. METHODS:VMMC service delivery cost data were collected at 13 private facilities in three provinces in South Africa: Gauteng, KwaZulu-Natal, and Mpumalanga. Unit costs were calculated using a bottom-up approach by cost components, and then disaggregated by facility type and urbanization level. VMMC demand creation, and higher-level management and program support costs were not collected. The unit cost of VMMC service delivery at private facilities in South Africa was calculated as a weighted average of the unit costs at the 13 facilities. KEY FINDINGS:At the average annual exchange rate of R10.83 = $1, the unit cost including training and cost of continuous quality improvement (CQI) to provide VMMC at private facilities was$137. The largest cost components were consumables (40%) and direct labor (35%). Eleven out of the 13 surveyed private sector facilities were fixed sites (with a unit cost of $142), while one was a fixed site with outreach services (with a unit cost of$156), and the last one provided services at a combination of fixed, outreach and mobile sites (with a unit cost per circumcision performed of $123). The unit cost was not substantially different based on the level of urbanization:$141, $129, and$143 at urban, peri-urban, and rural facilities, respectively. CONCLUSIONS:The private sector VMMC unit cost ($137) did not differ substantially from that at government and PEPFAR-supported facilities ($132 based on results from a similar study conducted in 2014 in South Africa at 33 sites across eight of the countries nine provinces). The two largest cost drivers, consumables and direct labor, were comparable across the two studies (75% in private facilities and 67% in public/PEPFAR-supported facilities). Results from this study provide VMMC unit cost data that had been missing and makes an important contribution to a better understanding of the costs of VMMC service delivery, enabling VMMC programs to make informed decisions regarding funding levels and scale-up strategies for VMMC in South Africa

Research capacity strengthening in sub-Saharan Africa: Recognizing the importance of local partnerships in designing and disseminating HIV implementation science to reach the 90–90–90 goals

Capacity building in implementation science is integral to PEPFAR’s mission and to meeting the 90–90–90 goals. The USAID funded Project SOAR sponsored a 4 day workshop for investigators and governmental and non-governmental partners from 12 African countries. The workshop was designed to address both findings from a pre-workshop online needs assessment as well as capacity challenges across the capacity building pyramid, from individual skills to institutional systems and resources. Activities were output-oriented and skill based. An online survey evaluated sessions and changes in perceptions of needs; a majority of respondents strongly agreed that after the workshop, they better understood their personal and institutional capacity strengthening needs. Participants ‘strongly agreed’ that workshop content was relevant to their jobs (90%) and that they left the workshop with a specific plan for conducting future research (65%). Workshop results suggest that skill-building should be done in conjunction with systems capacity building within the cultural context