TB/HIV Co-Infection Care in Conflict-Affected Settings: A Mapping of Health Facilities in the Goma Area, Democratic Republic of Congo

Background : HIV/AIDS and Tuberculosis (TB) are major contributors to the burden of disease in sub- Saharan Africa. The two diseases have been described as a harmful synergy as they are biologically and epidemiologically linked. Control of TB/HIV co-infection is an integral and most challenging part of both national TB and national HIV control programmes, especially in contexts of instability where health systems are suffering from political and social strife. This study aimed at assessing the provision of HIV/ TB co-infection services in health facilities in the conflict-ridden region of Goma in Democratic Republic of Congo. Methods: A cross-sectional survey of health facilities that provide either HIV or TB services or both was carried out. A semi-structured questionnaire was used to collect the data which was analysed using descriptive statistics. Results: Eighty facilities were identified, of which 64 facilities were publicly owned. TB care was more available than HIV care (in 61% vs. 9% of facilities). Twenty-three facilities (29%) offered services to co-infected patients. TB/HIV co-infection rates among patients were unknown in 82% of the facilities. Only 19 facilities (24%) reported some coordination with and support from concerned diseases’ control programmes. HIV and TB services are largely fragmented, indicating imbalances and poor coordination by disease control programmes. Conclusion: HIV and TB control appear not to be the focus of health interventions in this crisis affected region, despite the high risks of TB and HIV infection in the setting. Comprehensive public health response to this setting calls for reforms that promote joint TB/HIV co-infection control, including improved leadership by the HIV programmes that accuse weaknesses in this conflict-ridden region

Can biomedical and traditional health care providers work together? Zambian practitioners' experiences and attitudes towards collaboration in relation to STIs and HIV/AIDS care: a cross-sectional study

BACKGROUND: The World Health Organization's World health report 2006: Working together for health underscores the importance of human resources for health. The shortage of trained health professionals is among the main obstacles to strengthening low-income countries' health systems and to scaling up HIV/AIDS control efforts. Traditional health practitioners are increasingly depicted as key resources to HIV/AIDS prevention and care. An appropriate and effective response to the HIV/AIDS crisis requires reconsideration of the collaboration between traditional and biomedical health providers (THPs and BHPs). The aim of this paper is to explore biomedical and traditional health practitioners' experiences of and attitudes towards collaboration and to identify obstacles and potential opportunities for them to collaborate regarding care for patients with sexually transmitted infections (STIs) and HIV/AIDS. METHODS: We conducted a cross-sectional study in two Zambian urban sites, using structured questionnaires. We interviewed 152 biomedical health practitioners (BHPs) and 144 traditional health practitioners (THPs) who reported attending to patients with STIs and HIV/AIDS. RESULTS: The study showed a very low level of experience of collaboration, predominated by BHPs training THPs (mostly traditional birth attendants) on issues of safe delivery. Intersectoral contacts addressing STIs and HIV/AIDS care issues were less common. However, both groups of providers overwhelmingly acknowledged the potential role of THPs in the fight against HIV/AIDS. Obstacles to collaboration were identified at the policy level in terms of legislation and logistics. Lack of trust in THPs by individual BHPs was also found to inhibit collaboration. Nevertheless, as many as 40% of BHPs expressed an interest in working more closely with THPs. CONCLUSION: There is indication that practitioners from both sectors seem willing to strengthen collaboration with each other. However, there are missed opportunities. The lack of collaborative framework integrating maternal health with STIs and HIV/AIDS care is at odds with the needed comprehensive approach to HIV/AIDS control. Also, considering the current human resources crisis in Zambia, substantial policy commitment is called for to address the legislative obstacles and the stigma reported by THPs and to provide an adequate distribution of roles between all partners, including traditional health practitioners, in the struggle against HIV/AIDS

The interface between biomedical and traditional health practitioners in STI and HIV/ADIS care : A study on intersectoral collaboration in Zambia

The aim of this thesis is to explore potential opportunities for and obstacles to collaboration between biomedical and traditional health practitioners (BHPs and THPs) and to test a dialogue nurturing intervention in order to improve attitudes and increase collaborative activities pertinent for STIs and HIV/AIDS care in Zambia. The specific objectives were: to explore the local communities views on prerequisites (or preconditions) to collaboration between biomedical and traditional health providers with regards to STIs and HIV/AIDS care (I); to explore BHPs and THPs' experiences of and attitudes toward collaboration and to identify obstacles and potential opportunities for them to collaborate with regard to care for patients with STIs and HIV/AIDS (II); to explore biomedical and traditional health practitioners perceptions of good STIs and HIV/AIDS care and their opinions on weaknesses in the services they provide to patients with STIs and HIV/AIDS (III); to assess the changes in attitudes to and practices of collaboration among a set of BHPs and THPs following a participatory intervention in the Zambian city of Ndola, focusing on STIs and HIV/AIDS care (IV). The studies were conducted in Ndola and Kabwe, in Zambia. Both qualitative and quantitative methods were used. The study population consisted of community members, BHPs (nurses, midwives, physicians and laboratory and environmental health technicians) and THPs (herbalists, spiritualists, diviners and traditional birth attendants (TBAs)). Twenty one focus group discussions (I), semi-structured interviews with BHPs (n=152) and THPs (n=144) (II, III) and pre- and post-intervention KAP questionnaires with BHPs (n=19) and THPs (n=28) (IV) were used to collect the data. The community members underscored both the potential advantages of collaboration and the risks associated with failed collaboration. The prerequisites for collaboration included protection of traditional medicine and compensation of THPs, education of both groups of providers, preservation of some degree of secrecy in traditional medicine and adequate community involvement (I). Thirty seven BHPs (24%) and 19 THPs (13%) reported past collaboration with the other group. Most BHPs reported that they trained TBAs in conducting safer deliveries, whereas THPs mainly reported having been trained by BHPs on HIV/AIDS matters. Both groups believed that THPs had a role to play in the control of HIV/AIDS, including 126 BHPs (83%) and 136 THPs (97%). The suggested roles were mainly health education (including HIV prevention) and treatment of opportunistic infections and/or sexually transmitted infections. Sixty-one BHPs (40%) and 139 THPs (97%) expressed an interest in working together with the other sector (II). Substantial proportions of providers from both sectors perceived drugs availability (63% of BHPs and 70% of THPs) and welcoming attitude (73% of BHPs and 64% of THPs) as important aspects of good quality care. A majority of BHPs (87%) and THPs (80%) acknowledged deficiencies in their STIs and HIV/AIDS-related services. Both groups regarded training of providers, nutritional support and health education to patients as lacking. None of the THPs alluded to voluntary counselling and testing (VCT) or supportive/home-based care as aspects needing improvement (III). At pre intervention, BHPs expressed generally positive attitudes about collaboration. But additional improvements were observed afterwards, such as willingness to refer to THPs (68% before and 100% after); more BHPs agreed that THPs could provide counselling to patients with HIV (36% before, 71% after) and that collaboration was easy (36% before, 71% after). THPs were also positive to collaboration even before the intervention. After intervention, fewer said they would never visit a clinic (14% before, 3% after); fewer agreed with the statement that they would be annoyed if a patient visited a clinic before coming to them (21% before, 8% after). THPs self confidence in their role in HIV prevention increased after the intervention (39% before, 100% after). Cross-referrals and visits increased fairly after the intervention (IV). Lack of collaboration between BHPs and THPs may result in missed opportunities. Both groups seem willing to collaborate. Interventions enhancing dialogue between the two groups are feasible. A more participatory approach allowing for both groups learning together and from each other seems appropriate. More involvement by other community actors and leadership by district health authorities might be influential. Further research is called for to enhance evidence based collaboration before scaling up can be recommended

Intensive TB Case Finding in Unsafe Settings : Testing an Outreach Peer Education Intervention for Increased TB Case Detection among Displaced Populations and Host Communities in South-Kivu Province, Democratic Republic of Congo

Introduction: The Democratic Republic of Congo (DRC) is one of the high-burden TB countries in the world. The most affected provinces were North and South Kivu where displacements of the population favor transmission of infections. Delays in diagnosis are often causes for excessive mortality among TB patients. Aim of the Study: The study aimed to test an intervention designed to increase detection of TB cases in internally displaced persons and their host communities in South Kivu province. Methods: The project used a quasi-experimental method, with prospective data collection every six months. Two peri-urban districts were selected and designated as intervention and control districts respectively. Twenty peer educators were selected among prospective TB suspects who sought care in health facilities. The peer educators were trained and encouraged to actively influence, identify and refer potential TB suspects to health centers. The data on new TB suspects seen and cases diagnosed in both districts were collected and compared over two and a half years period. Results: This pilot study has demonstrated that the intervention has had some positive effects on both the number of persons suspected with TB who were diagnosed using either microscopy or clinical assessment. Even in terms of case detection, the study demonstrated that the number of cases detected in the intervention district was at least twice the number of cases detected in the control district. Conclusion:  Nonprofessional educators can influence TB case detection even in unstable settings, but their effectiveness is dependent on the security situation. National TB control programs need to adapt community mobilization strategies to local developments even in unsafe settings.MSB 2010-787

Geographical, health systems’ and sociocultural patterns of tb/hiv co-infected patients’ health seeking behavior in a conflict affected setting : the case of Eastern Democratic Republic of Congo

Background: The Democratic Republic of Congo (DRC) is one of the high burden TB countries. The country has been affected by a political conflict for more than 15 years now. HIV prevalence has been increasing in the country too. Detection and care of TB/HIV co-infected cases is a major problem in the country. Aim: This study aimed at describing patterns of health seeking behaviors among patients with TB/HIV regarding their choice of health facilities for integrated TB/HIV care in the Goma and surrounding health districts. Methods: The methods used included a cross-sectional descriptive survey with TB/HIV co-infected patients and qualitative interviews of health workers. Results: The study found that geographical residence did not play a major role in choice of facility for care by patients infected with TB and HIV. Many patients shun facilities which are close and seek care relatively far away. Instead of geographical proximity, availability of drugs and welcoming attitudes determined the choice of integrated care facilities. Also, fear for discrimination and stigmatization in the community result into patients in this area concealing their infection; rather, they claim being victim of empoisoning. Conclusion: Sustained decentralization of integrated TB/HIV services through better programs’ coordination and community involvement to address misconceptions about TB and HIV and stigmatization are essential to promote uptake of TB/HIV services and retain patients in treatment

Health Workers’ Assessment of the Frequency of and Caring for Urinary and Fecal Incontinence among Female Victims of Sexual Violence in the Eastern Congo : An Exploratory Study

Background: Throughout the long war that the Democratic Republic of Congo (DRC) has endured,women and children have been depicted as the primary victims of widespread sexual violence. Insome settings women have been raped in entire villages, with devastating physical and psychologicalconsequences, which include sexually transmitted infections such as HIV, trauma and fistulas,as well as social isolation and involuntary pregnancies. The aim of this study was to assess theprevalent perceptions of health professionals on the magnitude of urine and/or fecal incontinenceamong assaulted women, caused by sexual violence, as well as the opinions regarding the type ofcare provided to affected women. Methods: The study was part of a larger pilot study that had across-sectional design and a descriptive approach, which explored health professionals’ views regarding their own levels of competence at responding to the health needs of victims of sexual violence, in the form of a semi-structured questionnaire. Results: 104 health workers responded to the questionnaire. Nurses reported seeing raped women more frequently on a day-to-day basis (69.2%), in comparison to medical doctors and social workers (11.5%). Urinary incontinence was common according to 79% of health workers, who estimated that up to 15% of the women affected experienced huge amounts of urine leakage. Only 30% of the care seekers underwent in depth investigations, but the majority of the victims were not offered any further examination or appropriate treatments. Conclusion: Urinary and fecal incontinence due to urogenital or colorectalfistulas among women exposed to sexual violence is a common in the specified setting, but lack of systematic investigation and appropriate treatment means that the quality of life of the victims may be negatively affected. An improvement in the ability of health workers to manage these complex diagnoses is urgently needed, as well as adequately equipping health services in the affected settings

Nurses’ roles and experiences with enhancing adherence to tuberculosis treatment among patients in Burundi : a qualitative study

Background In TB control, poor treatment adherence is a major cause of relapse and drug resistance. Nurses have a critical role in supporting patients in TB treatment process. Yet, very little research has been done to inform policymakers and practitioners on nurses’ experiences of treatment adherence among patients with TB. Aim. To describe nurses’ experiences of supporting treatment adherence among patients with tuberculosis in Burundi. Method The study adopted qualitative approach with a descriptive design. A purposive sampling was performed. Eight nurses were selected from two TB treatment centers in Burundi. Content analysis was used to analyze the data. Result According to the nurses,most patients complete their treatment. Educating patients, providing the medication, observing and following up treatment, and communicating with the patients were the key tasks by nurses to support adherence. Causes for interruption were medication-related difficulties, poverty, and patients’ indiscipline. Treatment adherence could also be affected by patients’ and nurses’ feelings. Providing transportation and meals could enhance treatment compliance. Conclusion Nurses are critical resources to TB treatment success. In a poverty stricken setting, nurses’ work could be facilitated and adherence further could be enhanced if socioeconomic problems (transportation and nutritional support) were alleviated

Patients-related predictors of poor adherence to antihypertensive treatment in Congo-Brazzaville : a cross-sectional study

Studies suggest that poor adherence to hypertension treatment is responsible for about two-thirds of uncontrolled hypertension, leading to complications such as stroke. Yet, patients-associated factors explaining poor adherence to antihypertensive treatment in Africa remains under-researched. This study aimed at assessing the level of compliance in hypertensive patients and identifying patients-related predictors of poor compliance. The study was a prospective cross-sectional. The data was collected during a six-month period. Participants were recruited from outpatients’ departments in three urban hospitals in Congo-Brazzaville. Bivariate and multivariate analyses (using T-test and chi-2) were performed to identify predictors of poor compliance. In total, 212 hypertensive patients were included. Their mean age was 58.3 ± 10.6 years (range 34 – 81). Compliance was poor in 69 (32.5%) and good or fair in 143 cases (67.5%). Bivariate analysis indicated several patient-related factors that could predict poor adherence. However, after adjustment by logistic regression, only knowledge of the treatment and perception of the severity of complications of hypertension showed statistically significant associations with poor compliance (p =0.0170 and p=0.0373 respectively). Efforts to enhance patients’ awareness about hypertension’s treatment and severity of the complications associated with the disease are called for in this particular context

Patients-related predictors of poor adherence to antihypertensive treatment in Congo-Brazzaville : a cross-sectional study

Studies suggest that poor adherence to hypertension treatment is responsible for about two-thirds of uncontrolled hypertension, leading to complications such as stroke. Yet, patients-associated factors explaining poor adherence to antihypertensive treatment in Africa remains under-researched. This study aimed at assessing the level of compliance in hypertensive patients and identifying patients-related predictors of poor compliance. The study was a prospective cross-sectional. The data was collected during a six-month period. Participants were recruited from outpatients’ departments in three urban hospitals in Congo-Brazzaville. Bivariate and multivariate analyses (using T-test and chi-2) were performed to identify predictors of poor compliance. In total, 212 hypertensive patients were included. Their mean age was 58.3 ± 10.6 years (range 34 – 81). Compliance was poor in 69 (32.5%) and good or fair in 143 cases (67.5%). Bivariate analysis indicated several patient-related factors that could predict poor adherence. However, after adjustment by logistic regression, only knowledge of the treatment and perception of the severity of complications of hypertension showed statistically significant associations with poor compliance (p =0.0170 and p=0.0373 respectively). Efforts to enhance patients’ awareness about hypertension’s treatment and severity of the complications associated with the disease are called for in this particular context