A counseling intervention to address HIV stigma at entry into antenatal care in Tanzania (Maisha): study protocol for a pilot randomized controlled trial.

BACKGROUND: HIV-related stigma significantly impacts HIV care engagement, including in prevention of mother-to-child transmission of HIV (PMTCT) programs. Maisha is a stigma-based counseling intervention delivered during the first antenatal care (ANC) visit, complementing routine HIV counseling and testing. The goal of Maisha is to promote readiness to initiate and sustain treatment among those who are HIV-positive, and to reduce HIV stigmatizing attitudes among those who test negative. METHODS: A pilot randomized control trial will assess the feasibility and acceptability of delivering Maisha in a clinical setting, and the potential efficacy of the intervention on HIV care engagement outcomes (for HIV-positive participants) and HIV stigma constructs (for all participants). A total of 1000 women and approximately 700 male partners will be recruited from two study clinics in the Moshi municipality of Tanzania. Participants will be enrolled at their first ANC visit, prior to HIV testing. It is estimated that 50 women (5%) will be identified as HIV-positive. Following consent and a baseline survey, participants will be randomly assigned to either the control (standard of care) or the Maisha intervention. The Maisha intervention includes a video and counseling session prior to HIV testing, and two additional counseling sessions if the participant tests positive for HIV or has an established HIV diagnosis. A subset of approximately 500 enrolled participants (all HIV-positive participants, and a random selection of HIV-negative participants who have elevated stigma attitude scores) will complete a follow-up assessment at 3 months. Measures will include health outcomes (care engagement, antiretroviral adherence, depression) and HIV stigma outcomes. Quality assurance data will be collected and the feasibility and acceptability of the intervention will be described. Statistical analysis will examine potential differences between conditions in health outcomes and stigma measures, stratified by HIV status. DISCUSSION: ANC provides a unique and important entry point to address HIV stigma. Interventions are needed to improve retention in PMTCT care and to improve community attitudes toward people living with HIV. Results of the Maisha pilot trial will be used to generate parameter estimates and potential ranges of values to estimate power for a full cluster-randomized trial in PMTCT settings, with extended follow-up and enhanced adherence measurement using a biomarker.

Unlocking the health system barriers to maximise the uptake and utilisation of molecular diagnostics in low- and middle- income country setting

The study was funded by the European and Developing Countries Clinical Trials Partnership (EDCTP), grant TWENDE-EDCTP-CSA-2014-283.Background : Early access to diagnosis is crucial for effective management of any disease including tuberculosis (TB). We investigated the barriers and opportunities to maximise uptake and utilisation of molecular diagnostics in routine healthcare settings. Methods : Using the implementation of World Health Organisation approved TB diagnostics, Xpert MTB/RIF and Line Probe Assay (LPA) as a benchmark we evaluated the barriers and how they could be unlocked to maximise uptake and utilisation of molecular diagnostics. Results : Health officers representing 190 districts/counties participated in the survey across Kenya, Tanzania and Uganda. The survey findings were corroborated by 145 healthcare facility (HCF) audits and 11 policymaker engagement workshops. Xpert MTB/RIF coverage was 66%, falling behind microscopy and clinical diagnosis by 33% and 1% respectively. Stratified by HCF type, Xpert MTB/RIF implementation was 56%, 96% and 95% at district-, regional- and national referral- hospital levels. LPA coverage was 4%, 3% below culture across the three countries. Out of 111 HCFs with Xpert MTB/RIF, 37 (33%) utilised it to full capacity, performing ≥8 tests per day of which 51% of these were level five (zonal consultant and national referral) HCFs. Likewise, 75% of LPA was available at level five HCFs. Underutilisation of Xpert MTB/RIF and LPA was mainly attributed to inadequate- utilities, 26% and human resource, 22%. Underfinancing was the main reason underlying failure to acquire molecular diagnostics. Second to underfinancing was lack of awareness with 33% healthcare administrators and 49% practitioners were unaware of LPA as TB diagnostic. Creation of a health tax and decentralising its management was proposed by policymakers as a booster of domestic financing needed to increase access to diagnostics. Conclusion : Our findings suggest higher uptake and utilisation of molecular diagnostics at tertiary level HCFs contrary to the WHO recommendation. Country-led solutions are crucial for unlocking barriers to increase access to diagnostics.Publisher PDFPeer reviewe

"Mä oon aina kunnolla" : uhmakkuus- ja käytöshäiriödiagnoosin saaneen lapsen oman käytöksen käsittely perheterapiassa ja aikuisten rooli lapsen siihen ohjaamisessa

Tässä pro gradu -tutkielmassa tarkastelemme uhmakkuus- ja käytöshäiriödiagnoosin saaneen lapsen tapoja käsitellä omaa käytöstään perheterapiassa. Olemme myös kiinnostuneita terapeuttien ja vanhempien tavoista ohjata lasta käsittelemään käytöstään. Havainnoimme oman käytöksen käsittelyä kattavasta näkökulmasta, joka pitää sisällään sanallisen itsereflektion lisäksi myös muita terapeuttiseen keskusteluun reagoimisen tapoja. Tutkimme terapiassa tapahtunutta vuorovaikutusta multimodaalisella keskustelunanalyysilla, joka mahdollistaa myös nonverbaalisen viestinnän monipuolisen analysoinnin. Aineistomme koostuu yhden perheen kotona toteutetuista perheterapiatapaamisista, joista tarkastelemme tässä tutkielmassa kolmessa eri tapaamisessa tapahtunutta kuutta vuorovaikutustilannetta. Kolme aineisto-otetta käsittelee lasta oman käytöksen käsittelijänä ja kaksi terapeuttien ja vanhempien tapoja ohjata lasta. Analyysin monipuolistamiseksi valitsimme tarkasteluun myös yhden otteen, jossa havainnoimme terapeutin tapaa ohjata samanaikaisesti vanhempaa ja lasta. Aineisto on kerätty Jyväskylän yliopiston Psykoterapian opetus- ja tutkimusklinikan ja Kuopion yliopistollisen sairaalan lastenpsykiatrian poliklinikan kanssa yhteistyössä toteutetun tutkimusprojektin yhteydessä. Tulokset osoittivat, että uhmakkuus- ja käytöshäiriödiagnoosin saaneen lapsen tavoissa käsitellä omaa käytöstään oli paljon vaihtelua. Lapsi osoitti oman käytöksen käsittelyä tilasta poistumalla, jäämällä tilanteeseen haastavasti käyttäytyen ja prososiaalisesti reflektoiden omaa käytöstään. Myös terapeuttien ja vanhempien tavoissa ohjata lasta oli eroja. Terapeutit ohjasivat lasta useammin kannustaen ja motivoiden, kun taas vanhempien ohjaus piti sisällään uhkauksia, kiristämistä ja negatiivista vahvistusta. Terapeutin tapa ohjata samanaikaisesti vanhempaa ja lasta keskittyi yhteistyön tärkeyden korostamiseen. Tuloksemme tarjoavat tärkeää tietoa lapsen monipuolisista tavoista osallistua ja käsitellä omaa käytöstään perheterapiassa. Aikuisten on tärkeä nähdä nämä kaikki tavat merkityksellisinä ja ottaa ne huomioon lapsen osallistamisessa. Lisäksi tuloksemme painottavat erityisesti lapsen ja vanhemman samanaikaista ohjaamista, jonka avulla terapeutit voivat tukea perheen vuorovaikutussuhteita

Depression and anxiety among pregnant women living with HIV in Kilimanjaro region, Tanzania.

IntroductionMental health disorders in pregnant women living with HIV are associated with poor maternal and child outcomes, and undermine the global goals of prevention of mother-to-child transmission of HIV (PMTCT). This study aimed to determine prevalence of depression and anxiety and identify factors associated with these common mental health disorders among HIV-infeced pregnant women in Tanzania.MethodsWe enrolled 200 pregnant women living with HIV from antenatal care clinics in the Kilimanjaro region. Women were eligible if they were in the second or third trimester of pregnancy and had been in PMTCT care for a minimum of one month. Data were collected via interviewer administered surveys. Participants self reported depression symptoms (Edinburgh Postnatal Depression Scale, EPDS) and anxiety symptoms (Brief Symptom Index, BSI). Multivariate logistic regression models examined factors associated with depression, anxiety, and comorbid depression and anxiety.Results25.0% of women met screening criteria for depression (EPDS ≥10). Depression was significantly associated with being single (aOR = 4.2, 95% CI = 1.1-15.5), food insecurity (aOR = 2.4, 95% CI = 1.0-6.4), and HIV shame (aOR = 1.2, 95% CI = 1.1-1.3). 23.5% of participants met screening criteria for anxiety (BSI ≥1.01). Anxiety was associated with being single (aOR = 3.6, 95%CI = 1.1-11.1), HIV shame (aOR = 1.1, 95% CI = 1.1-1.2) and lifetime experience of violence (aOR = 2.3, 95% CI = 1.0-5.1). 17.8% of the sample met screening criteria for both depression and anxiety. Comorbid depression and anxiety was associated with being single (aOR = 4.5, 95%CI = 1.0-19.1), HIV shame (aOR = 1.2, 95%CI = 1.1-1.3) and lifetime experience of violence (aOR = 3.4, 95% CI = 1.2-9.6).ConclusionDepression and anxiety symptomatology was common in this sample of pregnant women living with HIV, with a sizable number screening positive for comorbid depression and anxiety. In order to successfully engage women in PMTCT care and support their well-being, strategies to screen for mental health disorders and support women with mental illnesses are needed

Viral-bacterial (co-)occurrence in the upper airways and the risk of childhood pneumonia in resource-limited settings

Contains fulltext : 221601.pdf (Publisher’s version ) (Open Access

Implementation and effectiveness of evriMED with short messages service (SMS) reminders and tailored feedback compared to standard care on adherence to treatment among tuberculosis patients in Kilimanjaro, Tanzania: Proposal for a cluster randomized controlled trial

Background: Adherence to tuberculosis (TB) treatment is challenging because of many factors. The World Health Organization has recommended the use of digital adherence monitoring technologies in its End TB Strategy. However, evidence on improving adherence is limited. EvriMED is a real-time medication-monitoring device which was found to be feasible and acceptable in a few studies in Asia. In Tanzania, however, there may be challenges in implementing evriMED due to stigmatization, network and power access, accuracy, and cost effectiveness, which may have implications for treatment outcome. We propose a pragmatic cluster randomized trial to investigate the effectiveness of evriMED with reminder cues and tailored feedback on adherence to TB treatment in Kilimanjaro, Tanzania. Methods/design: We will create clusters in Kilimanjaro based on level of health care facility. Clusters will be randomized in an intervention arm, where evriMED will be implemented, or a control arm, where standard practice directly observed treatment will be followed. TB patients in intervention clusters will take their medication from the evriMED pillbox and receive tailored feedback. We will use the 'Stages of Change' model, which assumes that a person has to go through the stages of pre-contemplation, contemplation, preparation, action, and evaluation to change behavior for tailored feedback on adherence reports from the device. Discussion: If the intervention shows a significant effect on adherence and the devices are accepted, accurate, and sustainable, the intervention can be scaled up within the National Tuberculosis Programmes. Trial registration: Pan African Clinical Trials Registry, PACTR201811755733759. Registered on 8 November 2018