Task-shifting HIV counselling and testing services in Zambia: the role of lay counsellors

BACKGROUND: The human resource shortage in Zambia is placing a heavy burden on the few health care workers available at health facilities. The Zambia Prevention, Care and Treatment Partnership began training and placing community volunteers as lay counsellors in order to complement the efforts of the health care workers in providing HIV counselling and testing services. These volunteers are trained using the standard national counselling and testing curriculum. This study was conducted to review the effectiveness of lay counsellors in addressing staff shortages and the provision of HIV counselling and testing services.METHODS: Quantitative and qualitative data were collected by means of semistructured interviews from all active lay counsellors in each of the facilities and a facility manager or counselling supervisor overseeing counseling and testing services and clients. At each of the 10 selected facilities, all counselling and testing record books for the month of May 2007 were examined and any recordkeeping errors were tallied by cadre. Qualitative data were collected through focus group discussions with health care workers at each facility.RESULTS: Lay counsellors provide counselling and testing services of quality and relieve the workload of overstretched health care workers. Facility managers recognize and appreciate the services provided by lay counsellors. Lay counsellors provide up to 70% of counselling and testing services at health facilities. The data review revealed lower error rates for lay counsellors, compared to health care workers, in completing the counselling and testing registers.CONCLUSION: Community volunteers, with approved training and ongoing supervision, can play a major role at health facilities to provide counselling and testing services of quality, and relieve the burden on already overstretched health care workers

Increasing the uptake of prevention of mother-to-child transmission of HIV services in a resource-limited setting

<p>Abstract</p> <p>Background</p> <p>As in other resource limited settings, the Ministry of Health in Zambia is challenged to make affordable and acceptable PMTCT interventions accessible and available. With a 14.3% HIV prevalence, the MOH estimates over one million people are HIV positive in Zambia. Approximately 500,000 children are born annually in Zambia and 40,000 acquire the infection vertically each year if no intervention is offered. This study sought to review uptake of prevention of mother-to-child (PMTCT) services in a resource-limited setting following the introduction of context-specific interventions.</p> <p>Methods</p> <p>Interventions to improve PMTCT uptake were introduced into 38 sites providing PMTCT services in Zambia in July 2005. Baseline and follow up service data were collected on a monthly basis through September 2008. Data was checked for internal and external consistency using logic built into databases used for data management. Data audits were conducted to determine accuracy and reliability. Trends were analyzed pre- and post- intervention.</p> <p>Results</p> <p>Uptake among pregnant women increased across the 13 quarters (39 months) of observation, particularly in the case of acceptance of counseling and HIV testing from 45% to 90% (p value = 0.00) in the first year and 99% by year 3 (p value = 0.00). Receipt of complete course of antiretroviral (ARV) prophylaxis increased from 29% to 66% (p = 0.00) in the first year and 97% by year 3 (p value = 0.00). There was also significant improvement in the percentage of HIV positive pregnant women referred for clinical care.</p> <p>Conclusions</p> <p>Uptake of PMTCT services in resource-limited settings can be improved by utilizing innovative alternatives to mitigate the effects of human resource shortage such as by providing technical assistance and mentorship beyond regular training courses, integrating PMTCT services into existing maternal and child health structures, addressing information gaps, mobilizing traditional and opinion leaders and building strong relationships with the government. These health system based approaches provide a sustainable improvement in the capacity and uptake of services.</p

Excluding pregnancy among women initiating antiretroviral therapy: efficacy of a family planning job aid

<p>Abstract</p> <p>Background</p> <p>Guidelines for initiating ART recommend pregnancy testing, typically a urine test, as part of the basic laboratory package. The principal reason for this recommendation is that Efavirenz, a first-line antiretroviral medication, has the potential of causing birth defects when used in the first trimester of pregnancy and is therefore contraindicated for use by pregnant women. Unfortunately, in many African countries pregnancy tests are not routinely provided or available in ART clinics, and, when available outside clinics, are often not affordable for clients.</p> <p>Recently, the World Health Organization added a family planning job aid called the 'pregnancy checklist,' developed by researchers at Family Health International, as a recommended tool for screening new ART clients to exclude pregnancy. Although the checklist has been validated for excluding pregnancy among family planning clients, there are no data on its efficacy among ART clients.</p> <p>This study was conducted to assess the clinical performance of a job aid to exclude pregnancy among HIV positive women initiating ART.</p> <p>Methods</p> <p>Non-menstruating women eligible for ART were enrolled from 20 sites in four provinces in Zambia. The pregnancy checklist was administered followed by a urine pregnancy test as a reference standard. Sensitivity, specificity, and positive and negative predictive values were estimated.</p> <p>Results</p> <p>Of the 200 women for whom the checklist ruled out pregnancy, 198 were not pregnant, for an estimated negative predictive value of 99%. The sensitivity of the checklist was 90.0%, and specificity was 38.7%. Among the women, 416 out of 534 (77.9%) did not abstain from sex since their last menses. Only 72 out of the 534 women (13.4%) reported using reliable contraception. Among the 416 women who did not abstain, 376 (90.4%) did not use reliable contraception.</p> <p>Conclusion</p> <p>The pregnancy checklist is effective for excluding pregnancy in many women initiating ART, but its moderate sensitivity and specificity precludes its use to completely replace pregnancy testing. Its use should be encouraged in low resource settings where pregnancy tests are unavailable or must be rationed. Family planning methods should be available and integrated into ART clinics.</p

Adherence Support Workers: A Way to Address Human Resource Constraints in Antiretroviral Treatment Programs in the Public Health Setting in Zambia

BACKGROUND: In order to address staff shortages and improve adherence counseling for people on antiretroviral therapy (ART), the Zambia Prevention, Care and Treatment Partnership (ZPCT) developed an innovative strategy of training community volunteers to provide adherence support at the health facility and community levels. The objective of this study was to assess the effectiveness of these 'adherence support workers' (ASWs) in adherence counseling, treatment retention and addressing inadequate human resources at health facilities.METHODOLOGY/PRINCIPAL FINDINGS: The study used quantitative and qualitative research techniques at five selected ART sites in four provinces in Zambia. Five hundred patients on ART were interviewed using a structured questionnaire to compare the quality of adherence counseling before and after the ASW scheme was introduced at the selected sites and between ASWs and HCWs after the introduction of ASWs. In addition, 3,903 and 4,972 electronic records of all new patients accessing antiretroviral therapy for the time period of 12 months before and 12 months after the introduction of ASWs respectively, were analyzed to assess loss to follow-up rates. Two focus group discussions with ASWs and health care workers (HCWs) were conducted in each clinic. Key informant interviews in the ART clinics were also conducted. There was a marked shift of workload from HCWs to ASWs without any compromise in the quality of counseling. Quality of adherence counseling by ASWs was comparable to HCWs after their introduction. The findings suggest that the deployment of ASWs helped reduce waiting times for adherence counseling. Loss to follow-up rates of new clients declined from 15% to 0% after the deployment of ASWs.CONCLUSION: Adherence counseling tasks can be shifted to lay cadres like ASWs without compromising the quality of counseling. Follow-up of clients by ASWs within the community is necessary to improve retention of clients on ART

Prevention of mother-to-child transmission of HIV in Zambia: implementing efficacious ARV regimens in primary health centers

<p>Abstract</p> <p>Background</p> <p>Safety and effectiveness of efficacious antiretroviral (ARV) regimens beyond single-dose nevirapine (sdNVP) for prevention of mother-to-child transmission (PMTCT) have been demonstrated in well-controlled clinical studies or in secondary- and tertiary-level facilities in developing countries. This paper reports on implementation of and factors associated with efficacious ARV regimens among HIV-positive pregnant women attending antenatal clinics in primary health centers (PHCs) in Zambia.</p> <p>Methods</p> <p>Blood sample taken for CD4 cell count, availability of CD4 count results, type of ARV prophylaxis for mothers, and additional PMTCT service data were collected for HIV-positive pregnant women and newborns who attended 60 PHCs between April 2007 and March 2008.</p> <p>Results</p> <p>Of 14,815 HIV-positive pregnant women registered in the 60 PHCs, 2,528 (17.1%) had their CD4 cells counted; of those, 1,680 (66.5%) had CD4 count results available at PHCs; of those, 796 (47.4%) had CD4 count ≤ 350 cells/mm³and thus were eligible for combination antiretroviral treatment (cART); and of those, 581 (73.0%) were initiated on cART. The proportion of HIV-positive pregnant women whose blood sample was collected for CD4 cell count was positively associated with (1) blood-draw for CD4 count occurring on the same day as determination of HIV-positive status; (2) CD4 results sent back to the health facilities within seven days; (3) facilities <it>without </it>providers trained to offer ART; and (4) urban location of PHC. Initiation of cART among HIV-positive pregnant women was associated with the PHC's capacity to provide care and antiretroviral treatment services. Overall, of the 14,815 HIV-positive pregnant women registered, 10,015 were initiated on any type of ARV regimen: 581 on cART, 3,041 on short course double ARV regimen, and 6,393 on sdNVP.</p> <p>Conclusion</p> <p>Efficacious ARV regimens beyond sdNVP can be implemented in resource-constrained PHCs. The majority (73.0%) of women identified eligible for ART were initiated on cART; however, a minority (11.3%) of HIV-positive pregnant women were assessed for CD4 count and had their test results available. Factors associated with implementation of more efficacious ARV regimens include timing of blood-draw for CD4 count and capacity to initiate cART onsite where PMTCT services were being offered.</p

Simulating the provision of antiretroviral therapy in Zambia

Zambia has over 1.9 million HIV-infected people and is one of the countries hardest hit by the HIV pandemic. Limited information exists on the long-term survival and economic costs of antiretroviral therapy (ART) in the country. The study we describe here has two aims: 1. Provide better estimates for the long-term survival of people on ART; 2. Forecast the number of people on ART and the cost of providing ART in Zambia over the next decade. Survival analysis techniques have been used to estimate distributions for the time spent on ART using electronic records from the Zambian national database. We use Discrete Event Simulation to model the number of people on ART in Zambia and provide projections for the cost of providing ART in the future. HIV-infected patients enter the model when they commence ART and exit the system due to death, becoming lost to follow up or stopping treatment

Costs of HIV/AIDS outpatient services delivered through Zambian public health facilities

OBJECTIVE: To present evidence on unit and total costs of outpatient HIV/AIDS services in ZPCT-supported facilities in Zambia; specifically, to measure unit costs of selected outpatient HIV/AIDS services, and to estimate total annual costs of antiretroviral therapy (ART) and prevention of mother-to-child transmission (PMTCT) in Zambia.METHODS: Cost data from 2008 were collected in 12 ZPCT-supported facilities (hospitals and health centres) in four provinces. Costs of all resources used to produce ART, PMTCT and CT visits were included, using the perspective of the provider. All shared costs were distributed to clinic visits using appropriate allocation variables. Estimates of annual costs of HIV/AIDS services were made using ZPCT and Ministry of Health data on numbers of persons receiving services in 2009.RESULTS: Unit costs of visits were driven by costs of drugs, laboratory tests and clinical labour, while variability in visit costs across facilities was explained mainly by differences in utilization. First-year costs of ART per client ranged from US$278 to US$523 depending on drug regimen and facility type; costs of a complete course of antenatal care (ANC) including PMTCT were approximately US$114. Annual costs of ART provided in ZPCT-supported facilities were estimated at US$14.7-$40.1 million depending on regimen, and annual costs of antenatal care including PMTCT were estimated at US$16 million. In Zambia as a whole, the respective estimates were US$41.0-114.2 million for ART and US$57.7 million for ANC including PMTCT.CONCLUSIONS: Consistent with the literature, total costs of services were dominated by drugs, laboratory tests and clinical labour. For each visit type, variability across facilities in total costs and cost components suggests that some potential exists to reduce costs through greater harmonization of care protocols and more intensive use of fixed resources. Improving facility-level information on the costs of resources used to produce services should be emphasized as an element of health systems strengthening.Objectif:? Présenter des preuves sur les coûts unitaires et totaux des services VIH/SIDA en ambulatoire dans les établissements en Zambie soutenus par le ZPCT, plus précisément, mesurer les coûts unitaires de services VIH/SIDA ambulatoires sélectionnés et estimer les coûts totaux annuels de l’ART et de la PTME.Méthodes:? Les données sur les coûts de 2008 ont été recueillies dans 12 établissements soutenus par le ZPCT (hôpitaux et centres de santé) dans quatre provinces. Les coûts de toutes les ressources utilisées pour offrir l’ART, la PTME et les visites de CT ont été inclus, en utilisant la perspective du prestataire. Tous les coûts partagés ont été répartis sur les visites à la clinique en utilisant des variables de répartition appropriées. Les estimations des coûts annuels des services VIH/SIDA ont été faites en utilisant les données du ZPCT et du Ministère de la Santé sur le nombre de personnes recevant les services en 2009.Résultats:? Les coûts unitaires des visites ont été dominés par les coûts des médicaments, des tests de laboratoire et du personnel clinique, tandis que la variabilité des coûts des visites entre les établissements était expliquée principalement par des différences dans l’utilisation. Les coûts de la première année de l’ART par patient allaient de 278 à 523 $US selon le schéma thérapeutique et le type d’établissement. Les frais d’un schéma complet de soins prénataux, y compris la PTME étaient d’environ 114$ US. Les coûts annuels pour l’ART fourni par dans les établissements soutenus par le ZPCT ont été estimés à entre 14,7 et 40,1 millions de $US selon le régime et les coûts annuels des soins prénataux y compris la PTME ont été estimés à 16 millions de$. En Zambie, dans l’ensemble, les estimations respectives étaient de 41,0 à 114,2 millions de $US pour l’ART et 57,7 millions de$ US pour les soins prénataux y compris la PTME.Conclusions:? Conformément à la littérature, les coûts totaux des services étaient dominés par les médicaments, les tests de laboratoire et les frais du personnel clinique. Pour chaque type de visite, la variabilité dans les coûts totaux et les composantes des coûts entre les établissements suggère l’existence d’une possibilité de réduire les coûts grâce à une meilleure harmonisation des protocoles des soins et une utilisation plus intensive des ressources fixées. L’amélioration de l’information au niveau des établissements sur le coût des ressources utilisées pour offrir des services devrait être soulignée comme un élément de renforcement des systèmes de santé.Objetivo:? Presentar evidencia sobre la unidad y los costes totales de los servicios de consultas externas para el VIH/SIDA en centros sanitarios públicos de Zambia (CSPZ); específicamente medir el coste unitario de ciertos servicios de consultas externas para VIH/SIDA, y estimar los costes anuales totales del TAR y la prevención de la transmisión vertical en Zambia.Métodos:? Se recogieron datos sobre el coste durante del 2008 en 12 centros sanitarios públicos de Zambia (hospitales y centros de salud) en cuatro provincias. Se incluyeron los costes de todos los recursos utilizados para realizar las visitas de TAR y prevención de la transmisión vertical, utilizando la perspectiva del proveedor. Todos los costes compartidos fueron distribuidos en las visitas clínicas utilizando la asignación de variables apropiada. Los estimativos del coste anual de los servicios de VIH/SIDA fueron utilizados utilizando datos provenientes de los CSPZ y del Ministerio de Salud sobre el número de personas recibiendo servicios durante el 2009.Resultados:? Los costes unitarios de las visitas estaban principalmente determinados por el coste de los medicamentos, las pruebas de laboratorio y el trabajo clínico, mientras que la variabilidad en los costes de las visitas entre los diferentes centros se explicaba principalmente por las diferencias en la utilización. Los costes del primer año de TAR por cliente estaban entre US$278 y US$523 dependiendo del régimen de medicación y el tipo de centro; los costes de un tratamiento completo de cuidados prenatales, incluyendo la prevención de la transmisión vertical (CP-PTV) eran de aproximadamente US$114. Los costes anuales de TAR en centros públicos de Zambia estaban estimados en US$14.7 a $40.1 millones dependiendo del régimen, y los costes anuales de CP-PTV se estimaron en US$16 millones. En Zambia en general las estimaciones respectivas fueron de US$41.0–114.2 millones para el TAR y de US$57.7 millones para CP-PTV.Conclusiones:? De forma consistente con la literatura, los costes totales de los servicios estaban dominados por los medicamentos, las pruebas de laboratorio y el trabajo de los clínicos. Para cada tipo de visita, la variabilidad entre los diferentes centros en los costes totales y los diferentes componentes de los costes, sugiere que existe el potencial de reducir los costes mediante una mayor harmonización de los protocolos sanitarios y un uso más extensivo de recursos fijos. El mejorar la información a nivel de centro sobre el coste de los recursos utilizados para producir un servicio debería enfatizarse como un elemento para el fortalecimiento de los sistemas sanitarios