Adherence to standards of quality HIV/AIDS care and antiretroviral therapy in the West Nile Region of Uganda

BACKGROUND: Over one million people in Uganda are estimated to be infected with HIV and about 20% of these were already accessing antiretroviral therapy (ART), by 2010. There is a dearth of data on adherence to antiretroviral therapy and yet high client load on a weak and resource constrained health system impacts on provision of quality HIV/AIDS care. We assessed adherence to standards of HIV care among health workers in the West Nile Region of Uganda. METHODS: We conducted a cross sectional study in nine health facilities. Records of a cohort of 270 HIV clients that enrolled on ART 12 months prior were assessed. The performance of each health facility on the different indicators of standards of HIV/AIDS care was determined and compared with the recommended national guidelines. RESULTS: We found that 94% of HIV clients at all the facilities were assessed for ART eligibility using WHO clinical staging while only two thirds (64.8%) were assessed using CD4. Only 42% and 37% of HIV clients at district hospitals and health centers respectively, received basic laboratory work up prior to ART initiation and about a half (46.7%) of HIV clients at these facilities received the alternative standard 1st line antiretroviral (ARV) regimen. Standards of ART adherence and tuberculosis assessment declined from over 70% to less than 50% and from over 90% to less than 70% respectively, during follow up visits with performance being poorer at the higher level regional referral facility compared to the lower level facilities. CONCLUSIONS: Adherence to standards of HIV/AIDS care at facilities was inadequate. Performance was better at the start of ART but declined during the follow up period. Higher level facilities were more likely to adhere to standards like CD4 monitoring and maintaining HIV clients on standard ARV regimen. Efforts geared towards strengthening the health system, including support supervision and provision of care guidelines and job aides are needed, especially for lower level facilities

Effect of integrated capacity-building interventions on malaria case management by health professionals in Uganda: a mixed design study with pre/post and cluster randomized trial components.

BACKGROUND: The Integrated Infectious Diseases Capacity Building Evaluation (IDCAP) designed two interventions: Integrated Management of Infectious Disease (IMID) training program and On-Site Support (OSS). We evaluated their effects on 23 facility performance indicators, including malaria case management. METHODOLOGY: IMID, a three-week training with two follow-up booster courses, was for two mid- level practitioners, primarily clinical officers and registered nurses, from 36 primary care facilities. OSS was two days of training and continuous quality improvement activities for nine months at 18 facilities, to which all health workers were invited to participate. Facilities were randomized as clusters 1∶1 to parallel OSS "arm A" or control "arm B". Outpatient data on four malaria case management indicators were collected for 14 months. Analysis compared changes before and during the interventions within arms (relative risk = RR). The effect of OSS was measured with the difference in changes across arms (ratio of RR = RRR). FINDINGS: The proportion of patients with suspected malaria for whom a diagnostic test result for malaria was recorded decreased in arm B (adjusted RR (aRR) = 0.97; 99%CI: 0.82,1.14) during IMID, but increased 25% in arm A (aRR = 1.25; 99%CI:0.94, 1.65) during IMID and OSS relative to baseline; (aRRR = 1.28; 99%CI:0.93, 1.78). The estimated proportion of patients that received an appropriate antimalarial among those prescribed any antimalarial increased in arm B (aRR = 1.09; 99%CI: 0.87, 1.36) and arm A (aRR = 1.50; 99%CI: 1.04, 2.17); (aRRR = 1.38; 99%CI: 0.89, 2.13). The proportion of patients with a negative diagnostic test result for malaria prescribed an antimalarial decreased in arm B (aRR = 0.96; 99%CI: 0.84, 1.10) and arm A (aRR = 0.67; 99%CI: 0.46, 0.97); (aRRR = 0.70; 99%CI: 0.48, 1.00). The proportion of patients with a positive diagnostic test result for malaria prescribed an antibiotic did not change significantly in either arm. INTERPRETATION: The combination of IMID and OSS was associated with statistically significant improvements in malaria case management

Percentage of patients with a negative diagnostic test result for malaria who were prescribed an antimalarial, dispersion by facility and arm.

<p>Percentage of patients with a negative diagnostic test result for malaria who were prescribed an antimalarial, dispersion by facility and arm.</p

Exploratory analysis.

<p>p<0.01.</p

Estimated percentage of patients who received an appropriate antimalarial, dispersion by facility and arm.

<p>Estimated percentage of patients who received an appropriate antimalarial, dispersion by facility and arm.</p

Adjusted relative risk across time periods and arms of prescribing based on diagnostic malaria test result.

<p>p<0.01.</p

Indicators for malaria case management.

<p>Indicators for malaria case management.</p

Percentage of patients with a positive diagnostic test result for malaria who were prescribed an antibiotic, dispersion by facility and arm.

<p>Percentage of patients with a positive diagnostic test result for malaria who were prescribed an antibiotic, dispersion by facility and arm.</p