Household socio-economic status as a determinant of under five mortality at Rufiji DSS Tanzania

Background Disparities in health outcomes between the poor and the rich are increasingly attracting attention from researchers and policy-makers. However, policies aimed at reducing inequities need to be based on a sound assessment of the nature, magnitude and determinants of the problem, as policy decisions based on intuition are likely to be misguided. Objective The work investigates the relationship between household socio-economic status and under-five mortality at Rufiji DSS in year 2005. The specific objectives were; 1.To construct wealth and concentration indices for households with children under age five. 2. To measure health inequality by poorest / least poor mortality rate ratio and the use of concentration index 3. To determine significance in gradient of mortality rates across wealth index quintiles by a trend test (chi-square) 4. To assess the magnitude of association between socio-economic status of households and under-five mortality. Methods Data from Rufiji DSS, Tanzania was used for the analysis. Out of 11,189 children under five years of age from 7298 households, 251 died in the year 2005. These yielded a total of 9341.6 PYO in 2005 which was used in the analysis. Household wealth index was constructed by use of Principal Component Analysis (PCA), as a proxy measure of each household SES. From this index households were categorized into five quintiles (i.e., poorest, poorer, poor, less poor and least poor). Kaplan-Meier (K-M) survival estimates of incidence rates were used to estimate mortality rates per 1000 PYO for infants (0-1), children (1-4) and under-fives. Health inequality was measured by poorest to least poor mortality rate ratio and by computing mortality concentration indices. Trend test chi-square was used to determine significance in gradient of mortality rates across wealth index quintiles. Risk factors of child mortality were assessed by the use of Poisson regression taking into account potential confounders. Results The result indicates that the mortality rate was higher for infants (123.4 per 1000 PYO, 95% CI (104.3, 146.1)) than for children aged 1-4 years (17.3 per 1000 PYO, 95% CI (14.3, 20.9)). Under-five mortality was 26.9 per 1000 PYO (95% CI (23.7, 30.4)). The poorest to least poor ratio were 1.5, 3.8 and 2.4 for infants, children, and under-five year olds, respectively indicating that children in the poorest quintile were more likely to die as compared to those in the least poor household. Computed values for concentration indices were negative (infant C= -0.07, children C= -0.24 and under-five C= -0.16) indicating a disproportionate concentration of under-five mortality among the poor. The mortality rates trend test chi-square across wealth index quintiles were significant for both children (P<0.001) and under-five year old children (P<0.001) but not for infants (P=0.10). In univariate Poisson regression, children in the least poor households were shown to have a 58% significantly reduced risk of dying as compared to the poorest households [crude RR=0.42, P < 0.001, 95% CI (0.27 - 0.62)]. The effect of household socio-economic status attenuated after adjusting for maternal education, maternal age and occupation. Children in vi the least poor households had a 52% significantly reduced risk of dying as compared to the poorest households [adjusted RR=0.48, P = 0.002, 95% CI (0.30 - 0.80)]. Conclusion The study shows that household socio-economic inequality is associated with under-five mortality in Rufiji DSS in 2005 and that the survival advantage of under-five year old children is associated with maternal education. Reducing poverty and making essential health services more available to the poor are critical to improving overall childhood mortality in rural Tanzania

Relationship Between Household Socio-Economic Status and under-five Mortality in Rufiji DSS, Tanzania.

Disparities in health outcomes between the poor and the better off are increasingly attracting attention from researchers and policy makers. However, policies aimed at reducing inequity need to be based on evidence of their nature, magnitude, and determinants. The study aims to investigate the relationship between household socio-economic status (SES) and under-five mortality, and to measure health inequality by comparing poorest/least poor quintile mortality rate ratio and the use of a mortality concentration index. It also aims to describe the risk factors associated with under-five mortality at Rufiji Demographic Surveillance Site (RDSS), Tanzania. This analytical cross sectional study included 11,189 children under-five residing in 7,298 households in RDSS in 2005. Principal component analysis was used to construct household SES. Kaplan-Meier survival incidence estimates were used for mortality rates. Health inequality was measured by calculating and comparing mortality rates between the poorest and least poor wealth quintile. We also computed a mortality concentration index. Risk factors of child mortality were assessed using Poisson regression taking into account potential confounders. Under-five mortality was 26.9 per 1,000 person-years [95% confidence interval (CI) (23.7-30.4)]. The poorest were 2.4 times more likely to die compared to the least poor. Our mortality concentration index [-0.16; 95% CI (-0.24, -0.08)] indicated considerable health inequality. Least poor households had a 52% reduced mortality risk [incidence rate ratio (IRR) = 0.48; 95% CI 0.30-0.80]. Furthermore, children with mothers who had attained secondary education had a 70% reduced risk of dying compared to mothers with no education [IRR = 0.30; 95% CI (0.22-0.88)]. Household socio-economic inequality and maternal education were associated with under-five mortality in the RDSS. Targeted interventions to address these factors may contribute towards accelerating the reduction of child mortality in rural Tanzania

Determinants of loss to follow-up in patients on antiretroviral treatment, South Africa, 2004–2012 : a cohort study

BACKGROUND : The number of Human Immunodeficiency Virus (HIV) infected people eligible for initiation on antiretroviral Therapy (ART) is increasing. ART programmatic success requires that patients who are taking ART remain on treatment and are followed up regularly. This study investigated factors associated with being lost to follow-up, in a cohort of patients enrolled in a pharmacovigilance study in South Africa. METHODS : This was a retrospective observational cohort study performed at one of the Medunsa National Pharmacovigilance Centre’s (MNPC) ART sentinel surveillance sites. Loss to Follow-up (LTFU) was defined as “a patient who had been followed up at the sentinel site, who had not had contact with the health facility for 180 days or more since their last recorded expected date of return or if there were 180 days or more between the expected date of return and the next clinic visit”. RESULTS : Out of 595 patients, 65.5 % (n = 390) were female and 23.4 % (n = 139) were LTFU. The median time on ART before LTFU was 21.5 months (interquartile range: 12.9 – 34.7 months). The incidence rate of LTFU was 103 per 1000 person-years in the first year on ART and increased to 405 per 1000 person-years in the eighth year of taking ART. Factors associated with becoming LTFU included not having a committed partner (Adjusted Hazard Ratio (aHR): 2.9, 95 % Confidence Interval (CI):1.19-6.97, p = 0.019), being self-employed (aHR: 13.9, 95 % CI:2.81 - 69.06, p = 0.001), baseline CD4 count > 200 cells/ml (aHR: 3.8, 95 % CI: 1.85-7.85, p < 0.001), detectable last known Viral Load (VL) (aHR: 3.6, 95 % CI:1.98 - 6.52, p < 0.001) and a last known World Health Organisation clinical stage three or four (aHR: 2.0, 95 % CI:1.22-3.27, p = 0.006). Patients that previously had an ART adverse event had a lower risk (aHR: 0.6, 95 % CI: 0.38 - 0.99, p = 0.044) of becoming LTFU than those that had not. CONCLUSION : The incidence rate of LTFU increases with additional years on ART. Intensified measures to improve patient retention on ART must be prioritised with increasing patient time on ART and in patients that are at increased risk of becoming lost to follow-up.The University of Pretoria School of Health systems and Public Health and the South African Field Epidemiology and Laboratory training program.http://www.biomedcentral.com/bmchealthservresam201

Time of HIV diagnosis, CD4 count and viral load at antenatal care start and delivery in South Africa.

BACKGROUND:Despite the success of prevention of mother to child transmission (PMTCT) program in South Africa, the 30% HIV prevalence among women of childbearing age requires the PMTCT program to be maximally efficient to sustain gains in the prevention of vertical HIV transmission. We aimed to determine the immunologic and virologic status at entry into antenatal care (ANC) and at childbirth among HIV positive women who conceived under the CD418 years) postpartum women who gave birth between September 2016 and December 2017. Demographic, viral load (VL) and CD4 data at ANC start (3-9 months before delivery) and delivery (3 months before/after) were obtained from medical records of consenting women. We compared CD4≥500 cell/μl and viral load (VL) suppression (<400 copes/ml) rates at ANC start and delivery among women with a pre-pregnancy ART, women known HIV positive but with in-pregnancy ART and newly diagnosed women with in-pregnancy ART. Predictors of having a high CD4 and suppressed VL were assessed by log-binomial regression. RESULTS:Of the 692 participants, 394 (57.0%) had CD4 data and 326 (47.1%) had VL data. Overall women with a pre-pregnancy ART were more likely to start ANC with CD4 count≥500 cell/μl (46.3% vs 24.8%, adjusted risk ratio (aRR) = 1.9; 95% confidence interval (95% CI): 1.4-2.5), compared to newly diagnosed women. This difference was no longer apparent at the time of delivery (aRR 1.2 95% CI: 0.4-3.7). Similarly, viral suppression at delivery was higher among women with pre-pregnancy ART (87.2% vs 69.3%, aRR 1.3, 95% CI: 1.1-1.6) as compared to the newly diagnosed women. Viral suppression rate among newly diagnosed women increased substantially by the time of delivery from 43.5% to 69.3% (p = 0.001). CONCLUSION:These results show that pre-pregnancy ART improves immunologic and virologic control during pregnancy and call for renewed efforts in HIV testing, linkage to ART and viral monitoring

Prevalence and predictors of postpartum depression by HIV status and timing of HIV diagnosis in Gauteng, South Africa.

BackgroundPostpartum depression (PPD) is a common mental health condition that can compromise the quality of life and functional capacity of mothers and cause health and developmental problems in children born to affected mothers.ObjectivesWe set out to measure the prevalence of PPD comparing postpartum HIV-1 infected women with pre-pregnancy HIV care experience, newly diagnosed (in latest pregnancy) HIV-1 infected women and HIV negative women, and to identify predictors of major PPD among these women in a peri-urban clinic in South Africa.MethodsWe conducted a cross-sectional survey of 1151 adult (≥18 years) postpartum HIV-1 infected (690) and HIV negative (461) women who delivered up to 30 days before study enrolment, interviewed after their first post-natal visit (3-6 days post- delivery) at Midwife Obstetric Units in Gauteng, South Africa. PPD was categorised into no depression (CES-D 10 total score ResultsOverall 288 (25.0%) women screened positive for postpartum depression, a total of 168 (14.6%) women had low to medium PPD and 120 (10.4%) had major PPD. A higher proportion of HIV negative women experienced PPD, 129/461 (28.0%) among HIV negative vs. 159/690 (23.0%) among HIV-1 infected. Among HIV positive women, there was no meaningful difference in PPD between newly HIV diagnosed and those diagnosed before the most recent pregnancy (aOR 1.3, 95% confidence interval (CI): 0.9-1.8). Predictors of PPD among HIV positive women were living with friends/in a house-share (aOR 0.5 for house-share vs. own home, 95% CI: 0.3-0.9), and attending antenatal care (ANC) for the most recent pregnancy (aOR 0.2 for ANC attendance vs. no ANC attendance, 95% CI: 0.0-0.5). Living with friends/in a house-share was also a predictor of PPD among HIV negative women (aOR 0.4 for house-share vs. own home, 95% CI: 0.2-0.8).Conclusions and recommendationsTargeted symptom screening based on identified risk factors should be considered for postpartum women to increase PPD case-finding and referral to specialised social support services

Perceived barriers to the uptake of health services among first-year university students in Johannesburg, South Africa.

BackgroundYoung people face many barriers to accessing appropriate health care services including screening for HIV and tuberculosis (TB). The study aimed to identify perceived barriers to the uptake of health services among young adults entering the tertiary education system in South Africa.MethodsWe conducted a cross-sectional study among first-year students aged 18-25 years, registered at one of three universities in Johannesburg, South Africa, in 2017. Participants completed a self-administered paper-based questionnaire. We describe perceived barriers to accessing health services, stratified by gender and recent engagement in TB or HIV services, together with sources of information about HIV and TB.ResultsSeven hundred and ninety-two (792) students were included in the study of which 54.8% were female. Perceived barriers to accessing services included long waiting time (n = 342,43.2%), attitude of health workers (n = 263,33.2%), lack of sufficient information/poor health literacy (n = 148,18.7%), and inability to leave/stay away from studies (n = 137,17.3%). Among participants who tested for HIV in the past 6 months (n = 400, 50.5%), waiting time and attitude of health care workers were perceived as barriers to accessing services. Compared to males, females were more likely to view attitudes of health workers (40.3% vs. 25.0%; p = 0.001) and inability to leave/stay away from studies (20.5% vs.13.4%; p = 0.025) as potential barriers. While just over half of the students (50.5%; 400/792) in this study had accessed health services in the past 6 months, very few (15.0%) opted to use campus health services, and even less (5%) reported receiving information about HIV and TB from the university itself.ConclusionDespite perceived barriers to accessing HIV and TB services off campus, fewer than one in five students starting out at university opted to use campus health services. Campus health services could address many of the barriers unique to university students

Persistent High Burden of Advanced HIV Disease Among Patients Seeking Care in South Africa’s National HIV Program: Data From a Nationwide Laboratory Cohort

Background The South African national HIV program has increased antiretroviral therapy (ART) coverage over the last decade, supported by policy changes allowing for earlier ART initiation. However, many patients still enter care with advanced (<200 cells/μL) and very advanced (<100 cells/μL) HIV disease. We assessed disease progression at entry to care using nationwide laboratory data. Methods We constructed a national HIV cohort using laboratory records containing HIV RNA loads and CD4 counts from 2004 to 2016 to determine entry into care. We estimated numbers and proportions of adults with the first CD4 count <100 cells/ μL or 100–199 cells/μL. We calculated relative risks of presenting with advanced disease associated with male sex. Results 8.04 million first CD4 results were identified. From 2005 to 2011, the proportion of patients entering into care with CD4 count <200 cells/μL declined from 46.8% to 35.6%. From 2011 onward, the proportion of patients entering ART with advanced HIV disease has remained relatively unchanged. In 2016, we estimated that of 654 868 patients entering care, 32.9% had advanced HIV disease, and 16.8% had very advanced HIV disease. Men were almost twice as likely as women (23.1% vs 12.6% ) to enter care with very advanced HIV disease. Conclusions The proportion of patients presenting with advanced HIV disease in South Africa remains consistently high despite ART scale-up, representing a large and avoidable burden of morbidity. Early HIV diagnosis, rapid linkage to ART and approaches to attract men into early ART initiation should be prioritized

Data_Sheet_1_Assessment of facility-level antiretroviral treatment patient status utilizing a national-level laboratory cohort: Toward an understanding of system-level tracking and clinic switching in South Africa.DOCX

BackgroundMost estimates of HIV retention are derived at the clinic level through antiretroviral (ART) patient management systems, which capture ART clinic visit data, yet these cannot account for silent transfers across HIV treatment sites. Patient laboratory monitoring visits may also be observed in routinely collected laboratory data, which include ART monitoring tests such as CD4 count and HIV viral load, key to our work here.MethodsIn this analysis, we utilized the NHLS National HIV Cohort (a system-wide viewpoint) to investigate the accuracy of facility-level estimates of retention in care for adult patients accessing care (defined using clinic visit data on patients under ART recorded in an electronic patient management system) at Themba Lethu Clinic (TLC). Furthermore, we describe patterns of facility switching among all patients and those patients classified as lost to follow-up (LTFU) at the facility level.ResultsOf the 43,538 unique patients in the TLC dataset, we included 20,093 of 25,514 possible patient records (78.8%) in our analysis that were linked with the NHLS National Cohort, and we restricted the analytic sample to patients initiating ART between 1 January 2007 and 31 December 2017. Most (60%) patients were female, and the median age (IQR) at ART initiation was 37 (31–45) years. We found the laboratory records augmented retention estimates by a median of 860 additional active records (about 8% of all median active records across all years) from the facility viewpoint; this augmentation was more noticeable from the system-wide viewpoint, which added evidence of activity of about one-third of total active records in 2017. In 2017, we found 7.0% misclassification at the facility-level viewpoint, a gap which is potentially solvable through data integration/triangulation. We observed 1,134/20,093 (5.6%) silent transfers; these were noticeably more female and younger than the entire dataset. We also report the most common locations for clinic switching at a provincial level.DiscussionIntegration of multiple data sources has the potential to reduce the misclassification of patients as being lost to care and help understand situations where clinic switching is common. This may help in prioritizing interventions that would assist patients moving between clinics and hopefully contribute to services that normalize formal transfers and fewer silent transfers.</p

Table_1_Assessment of facility-level antiretroviral treatment patient status utilizing a national-level laboratory cohort: Toward an understanding of system-level tracking and clinic switching in South Africa.XLSX

BackgroundMost estimates of HIV retention are derived at the clinic level through antiretroviral (ART) patient management systems, which capture ART clinic visit data, yet these cannot account for silent transfers across HIV treatment sites. Patient laboratory monitoring visits may also be observed in routinely collected laboratory data, which include ART monitoring tests such as CD4 count and HIV viral load, key to our work here.MethodsIn this analysis, we utilized the NHLS National HIV Cohort (a system-wide viewpoint) to investigate the accuracy of facility-level estimates of retention in care for adult patients accessing care (defined using clinic visit data on patients under ART recorded in an electronic patient management system) at Themba Lethu Clinic (TLC). Furthermore, we describe patterns of facility switching among all patients and those patients classified as lost to follow-up (LTFU) at the facility level.ResultsOf the 43,538 unique patients in the TLC dataset, we included 20,093 of 25,514 possible patient records (78.8%) in our analysis that were linked with the NHLS National Cohort, and we restricted the analytic sample to patients initiating ART between 1 January 2007 and 31 December 2017. Most (60%) patients were female, and the median age (IQR) at ART initiation was 37 (31–45) years. We found the laboratory records augmented retention estimates by a median of 860 additional active records (about 8% of all median active records across all years) from the facility viewpoint; this augmentation was more noticeable from the system-wide viewpoint, which added evidence of activity of about one-third of total active records in 2017. In 2017, we found 7.0% misclassification at the facility-level viewpoint, a gap which is potentially solvable through data integration/triangulation. We observed 1,134/20,093 (5.6%) silent transfers; these were noticeably more female and younger than the entire dataset. We also report the most common locations for clinic switching at a provincial level.DiscussionIntegration of multiple data sources has the potential to reduce the misclassification of patients as being lost to care and help understand situations where clinic switching is common. This may help in prioritizing interventions that would assist patients moving between clinics and hopefully contribute to services that normalize formal transfers and fewer silent transfers.</p

Advancing African Medicines Agency through Global Health Diplomacy for an Equitable Pan-African Universal Health Coverage: A Scoping Review

The African continent is home to 15% of the world’s population and suffers from a disease burden of more than 25% globally. In this COVID-19 era, the high burden and mortality are further worsened due to inequities, inequalities such as inadequate health systems, scarce financial and human resources, as well as unavailability of inexpensive medicines of good quality, safety, and efficacy. The Universal Health Coverage ensures that people have access to high-quality essential health services, secure, reliable, and affordable essential medicines and vaccines, as well as financial security. This paper aimed at addressing the critical need for a continental African Medicines Agency (AMA) in addressing the inequities and the role of global health diplomacy in building consensus to support the ratification of the Treaty of AMA. A literature review was done in Scopus, Web of Science, MEDLINE/PubMed, and Google Scholar search engine to identify the critical literature in the context of study objectives. All the articles published after 2015 till 2021 in the context of AMA were included. African Health Strategy 2016–2030 highlighted the importance of an African regulatory mechanism for medicines and medical products. Through global health diplomacy (GHD), the African Union and its partners can negotiate and cooperate in providing infrastructural, administrative, and regulatory support for establishing the AMA. The paper emphasizes the South–South cooperation and highlights the contributions of India and China in the supply of medicines and vaccines to Africa. A strong AMA created through GHD can be a vital instrument in utilizing Trade-Related Aspects of Intellectual Property Rights (TRIPS) flexibilities extension and an ideal partner for European and other regional regulatory authorities seeking to stem the tide of counterfeit, sub-standard, or fake products