The impact of HIV on tuberculosis control--towards concerted action.

The well-established international control strategy for tuberculosis is based upon passive case-finding of the most infectious cases followed by effective chemotherapy with sufficient support to ensure and record a successful outcome. However, no country with a severe HIV epidemic is successfully controlling tuberculosis. HIV exerts a double blow. Not only must the health service manage a greatly increased number of patients (as many as fourfold higher in many African settings) but each individual patient needs to be managed more effectively if the control programme is to have a similar impact on transmission as it did in the pre-HIV era. In this paper, we discuss some of the effects of increased burden and stigmatization. We consider the potential of preventive therapy to reduce the impact of HIV on tuberculosis control and describe a more integrated approach to both infections that is being piloted in several sites in Southern Africa

ZAMSTAR, The Zambia South Africa TB and HIV Reduction study: Design of a 2 × 2 factorial community randomized trial

BACKGROUND: TB and HIV form a deadly synergy in much of the developing world, especially Africa. Interventions to reduce the impact of these diseases at community level are urgently needed. This paper presents the design of a community randomised trial to evaluate the impact of two complex interventions on the prevalence of tuberculosis (TB) in high HIV prevalence settings in Zambia and South Africa. METHODS: The interaction between TB and HIV is reviewed and possible interventions that could reduce the prevalence of TB in HIV-endemic populations are discussed. Two of these interventions are described in detail and the design of a 2 x 2 factorial community randomised trial to test these interventions is presented. The limitations and challenges of the design are identified and discussed. CONCLUSION: There is an urgent need to reduce the prevalence of TB in communities highly affected by HIV. Potential interventions are complex and require innovative trial designs to provide the rigorous evidence needed to inform health policy makers and to ensure that resources are used optimally. TRIAL REGISTRATION: Number: ISRCTN36729271

The Beaufort Sea Conference 2000 on the Renewable Marine Resources of the Canadian Beaufort Sea

The Beaufort Sea Conference 2000, held in Inuvik, Northwest Territories, in September 1999, had three objectives: to review our current understanding of the renewable aquatic resources of the Beaufort Sea; to review the factors that affect those resources; and to develop a vision that will guide management of those resources for the benefit of present and future generations. To achieve these objectives, the conference brought together representatives of the full range of groups interested in the renewable resources of the Beaufort Sea. These included hunters and fishers, other resource users, scientists, government managers, educators, students, and the public. The conference was structured to encourage interaction between participants so that they could jointly discuss opportunities for the future. ... This special issue of the journal "Arctic" presents the formal scientific papers on each resource species or group and the presentation by Inuvialuit elder Billy Day. The paragraphs below summarize the conference discussions under the four themes, as well as the discussions of the youth delegation. The Canadian Beaufort Sea region pioneered and put into practice the theory of co-management in the Canadian Arctic, beginning with the signing of the Inuvialuit Final Agreement in 1984 and the Gwich'in Final Agreement eight years later. Workshop discussions considering the role of co-management of renewable resources in this region focused on the following challenges for the future: Community engagement .... Youth and elders .... Communication .... Good governance .... Research .... Traditional ecological knowledge .... Chaos and innovation ...

Validation of brief screening tools for depressive and alcohol use disorders among TB and HIV patients in primary care in Zambia

BACKGROUND: This study was conducted to evaluate the diagnostic accuracy and determine the optimum cut-off scores for clinical use of the Center for Epidemiological Studies Depression scale (CES-D) and Alcohol Use Disorders Identification Test (AUDIT) against a reference psychiatric diagnostic interview, in TB and anti-retroviral therapy (ART) patients in primary care in Zambia. METHODS: This was a cross-sectional study in 16 primary level care clinics. Consecutive sampling was used to select 649 participants who started TB treatment or ART in the preceding month. Participants were first interviewed using the CES-D and AUDIT, and subsequently with a psychiatric diagnostic interview for current major depressive disorder (MDD) and alcohol use disorders (AUDs) using the Mini-International Neuropsychiatric Interview (MINI). The diagnostic accuracy was calculated using the Area Under the Receiver Operating Characteristic curve (AUROC). The optimum cut-off scores for clinical use were calculated using sensitivity and positive predictive value (PPV). RESULTS: The CES-D and AUDIT had high internal consistency (Cronbach's alpha = 0.84; 0.98 respectively). Confirmatory factor analysis showed that the four-factor CES-D model was not a good fit for the data (Tucker-Lewis Fit Index (TLI) = 0.86; standardized root-mean square residual (SRMR) = 0.06) while the two-factor AUDIT model fitted the data well (TFI = 0.99; SRMR = 0.04). Both the CES-D and AUDIT demonstrated good discriminatory ability in detecting MINI-defined current MDDs and AUDs (AUROC for CES-D = 0.78; AUDIT = 0.98 for women and 0.75 for men). The optimum CES-D cut-off score in screening for current MDD was 22 (sensitivity 73%, PPV 76%) while that of the AUDIT in screening for AUD was 24 for women (sensitivity 60%, PPV 60%), and 20 for men (sensitivity 55%, PPV 50%). CONCLUSIONS: The CES-D and AUDIT showed high discriminatory ability in measuring MINI-defined current MDD and AUD respectively. They are suitable mental health screening tools for use among TB and ART patients in primary care in Zambia

Application of system thinking concepts in health system strengthening in low-income settings: a proposed conceptual framework for the evaluation of a complex health system intervention: the case of the BHOMA intervention in Zambia.

BACKGROUND: The current drive to strengthen health systems provides an opportunity to develop new strategies that will enable countries to achieve targets for millennium development goals. In this paper, we present a proposed framework for evaluating a new health system strengthening intervention in Zambia known as Better Health Outcomes through Mentoring and Assessment. APPROACH: We briefly describe the intervention design and focus on the proposed evaluation approach through the lens of systems thinking. DISCUSSION: In this paper, we present a proposed framework to evaluate a complex health system intervention applying systems thinking concepts. We hope that lessons learnt from this process will help to adapt the intervention and limit unintended negative consequences while promoting positive effects. Emphasis will be paid to interaction and interdependence between health system building blocks, context and the community

Patient Diagnostic Rate as Indicator of Tuberculosis Case Detection, South Africa.

To address the uncertainty of the indirectly measured tuberculosis case detection rate, we used survey data stratified by HIV status to calculate the patient diagnostic rate, a directly measurable indicator, in 8 communities in South Africa. Rates were lower among HIV-negative than HIV-positive persons. Tuberculosis programs should focus on HIV-negative persons

Systems thinking in practice: the current status of the six WHO building blocks for health system strengthening in three BHOMA intervention districts of Zambia: a baseline qualitative study.

BACKGROUND: The primary bottleneck to achieving the MDGs in low-income countries is health systems that are too fragile to deliver the volume and quality of services to those in need. Strong and effective health systems are increasingly considered a prerequisite to reducing the disease burden and to achieving the health MDGs. Zambia is one of the countries that are lagging behind in achieving millennium development targets. Several barriers have been identified as hindering the progress towards health related millennium development goals. Designing an intervention that addresses these barriers was crucial and so the Better Health Outcomes through Mentorship (BHOMA) project was designed to address the challenges in the Zambia's MOH using a system wide approach. We applied systems thinking approach to describe the baseline status of the Six WHO building blocks for health system strengthening. METHODS: A qualitative study was conducted looking at the status of the Six WHO building blocks for health systems strengthening in three BHOMA districts. We conducted Focus group discussions with community members and In-depth Interviews with key informants. Data was analyzed using Nvivo version 9. RESULTS: The study showed that building block specific weaknesses had cross cutting effect in other health system building blocks which is an essential element of systems thinking. Challenges noted in service delivery were linked to human resources, medical supplies, information flow, governance and finance building blocks either directly or indirectly. Several barriers were identified as hindering access to health services by the local communities. These included supply side barriers: Shortage of qualified health workers, bad staff attitude, poor relationships between community and health staff, long waiting time, confidentiality and the gender of health workers. Demand side barriers: Long distance to health facility, cost of transport and cultural practices. Participating communities seemed to lack the capacity to hold health workers accountable for the drugs and services. CONCLUSION: The study has shown that building block specific weaknesses had cross cutting effect in other health system building blocks. These linkages emphasised the need to use system wide approaches in assessing the performance of health system strengthening interventions

Effect of home-based interventions on virologic outcomes in adults receiving antiretroviral therapy in Africa: a meta-analysis.

BACKGROUND: The success of adherence to combination antiretroviral therapy (ART) in sub-Saharan Africa is hampered by factors that are unique to this setting. Home based interventions have been identified as possible strategies for decentralizing ART care and improving access and adherence to ART. There is need for evidence at individual- or community-level of the benefits of home-based interventions in improving HIV suppression in African patients receiving ART. METHODS: We conducted a systematic review and meta-analysis of the literature to assess the effect of home-based interventions on virologic outcomes in adults receiving ART in Africa. RESULTS: A total of 260 publications were identified by the search strategy, 249 were excluded on initial screening and 11 on full review, leaving 5 publications for analysis. The overall OR of virologic suppression at 12 months after starting ART of home-based interventions to standard of care was 1.13 (95% CI: 0.51-2.52). CONCLUSIONS: There was insufficient data to know whether there is a difference in HIV suppression at 12 months in the home-based arm compared with the standard of care arm in adults receiving ART in Africa. Given the few trials conducted from Africa, there is need for further research that measures the effects of home-based models on HIV suppression in African populations