How countries cope with competing demands and expectations: perspectives of different stakeholders on priority setting and resource allocation for health in the era of HIV and AIDS

Background: Health systems have experienced unprecedented stress in recent years, and as yet no consensus has emerged as to how to deal with the multiple burden of disease in the context of HIV and AIDS and other competing health priorities. Priority setting is essential, yet this is a complex, multifaceted process. Drawing on a study conducted in five African countries, this paper explores different stakeholders′ perceptions of health priorities, how priorities are defined in practice, the process of resource allocation for HIV and Health and how different stakeholders perceive this. Methods: A sub-analysis was conducted of selected data from a wider qualitative study that explored the interactions between health systems and HIV and AIDS responses in five sub-Saharan countries (Burkina Faso, the Democratic Republic of Congo, Ghana, Madagascar and Malawi). Key background documents were analysed and semi-structured interviews (n = 258) and focus group discussions (n = 45) were held with representatives of communities, health personnel, decision makers, civil society representatives and development partners at both national and district level. Results: Health priorities were expressed either in terms of specific health problems and diseases or gaps in service delivery requiring a strengthening of the overall health system. In all five countries study respondents (with the exception of community members in Ghana) identified malaria and HIV as the two top health priorities. Community representatives were more likely to report concerns about accessibility of services and quality of care. National level respondents often referred to wider systemic challenges in relation to achieving the Millennium Development Goals (MDGs). Indeed, actual priority setting was heavily influenced by international agendas (e.g. MDGs) and by the ways in which development partners were supporting national strategic planning processes. At the same time, multi-stakeholder processes were increasingly used to identify priorities and inform sector-wide planning, whereby health service statistics were used to rank the burden of disease. However, many respondents remarked that health system challenges are not captured by such statistics. In all countries funding for health was reported to fall short of requirements and a need for further priority setting to match actual resource availability was identified. Pooled health sector funds have been established to some extent, but development partners′ lack of flexibility in the allocation of funds according to country-generated priorities was identified as a major constraint. Conclusions Although we found consensus on health priorities across all levels in the study countries, current funding falls short of addressing these identified areas. The nature of external funding, as well as programme-specific investment, was found to distort priority setting. There are signs that existing interventions have had limited effects beyond meeting the needs of disease-specific programmes. A need for more comprehensive health system strengthening (HSS) was identified, which requires a strong vision as to what the term means, coupled with a clear strategy and commitment from national and international decision makers in order to achieve stated goals. Prospective studies and action research, accompanied by pilot programmes, are recommended as deliberate strategies for HSS

Medicinal Plants used in the Treatment of Hepatitis in BoboDioulasso: Studying the Availability and Analyzing the Phytochemical Properties of Combretum micranthum G. Don and Entada africana Guill. et Perr.

This paper focuses on studying the inventory of the medicinal plants used in hepatitis care in Bobo-Dioulasso and evaluating their availability in local vegetation and their phytochemical properties. To achieve this objective, several approaches were developed which include: (1) an ethnobotanical survey among 111 traditional health practitioners (THP); (2) a dendrometric study to evaluate the abundance and spatial distribution of these species in Dindérésso Classified Forest; and (3) an evaluation of polyphenolic compounds and antioxidant activity of the two most quoted species roots using three methods such as anti-DPPH*, anti-FRAP, and antiABTS. The results show that Entada africana and Combretum micranthum were the most quoted species among 40 species used in the treatment of liver disease. The availability study revealed that juvenile and adult individuals of E. africana are frequent in woody savannah, shrubby savannah, and grassy savannah. As for juvenile and adult C. micranthum individuals, they are only frequent in wooded savannah (RI<60%). These populations are therefore declining due to anthropogenic pressure. Phytochemical analysis reveal polyphenols contents of 37.91 and 20.71 mg EAG/100 mg respectively for C. micranthum and E. africana and flavonoids contents of 0.85 ± 0.09 and 0.66 ± 0.05 mg EQ/100 mg respectively for C. micranthum and E. africana. Finally, the results show that there is an anti-oxidant activity for the two species. There were about 198 and 13 μmol EAA/g for the two species i.e., ABTS and DPPH, respectively. The results show that the antioxidant activity could partially justify the traditional use of this plant

High blood viscosity is associated with high pulse wave velocity in African sickle cell trait carriers

Background: Sickle cell trait (SCT) is the benign condition of sickle cell disease. Often asymptomatic, the SCT carriers have hemorheological disturbances such as blood hyper-viscosity compared to healthy subjects. These disturbances could lead to structural and functional changes in large vessels. The aim of the study was to evaluate the association between blood viscosity (ηb) and pulse wave velocity (PWV) in SCT carriers.Methods: Thirteen SCT with high blood viscosity (SCT_hηb) aged 34±12 years (4 men) were compared to 13 SCT with low blood viscosity (SCT_lηb) aged 32±9 years (5 men) recruited from the National Blood Transfusion Center (CNTS) in Dakar (Senegal). Pulse wave velocity finger-toe (PWVft) was assessed using pOpmètre® (Axelife SAS-France). Cardiovascular risk (CVR) was assessed according to the Framingham Laurier score.Results: SCT_hηb had higher PWVft (m/s) than SCT_lηb respectively 8.98±1.98 and 7.11±1.18 (p = 0.004). CVR score (%) was higher in SCT_hηb than SCT_lηb, but this difference was not statistically significant (5.96±7.45 vs 2.09±2.15; p=0.31). Multivariate linear regression showed a positive correlation between PWVft and ηb and CVR score (r2=0.74, F=21.19, p˂0.001).Conclusions: Present results indicate that the SCT_hηb carriers have arteries stiffer than SCT_lηb and ηb and CVR could remain independent determinants of arterial stiffness in SCT carriers

Impact of HIV programmes on health systems strengthening in five African countries: methodological challenges in studying complex systems

Health is a complicated issue, and health service delivery depends on highly complex systems which are constantly evolving. Moreover, health systems everywhere have a reputation for having insatiable appetites for both money and human resources. The demands on the system are numerous and often only partially met. Because of the complexity of health systems and the budgetary implications of potential innovations, researching health systems is a key development priority. However, researching complex systems poses many challenges – for both developing and wealthy nations – and the multifaceted nature of these systems has important implications for the methods used to understand them. This chapter explores the experience of recent research designed to study the impact of HIV programmes on health systems in five African countries: Burkina Faso, Democratic Republic of Congo, Ghana, Madagascar and Malawi. This chapter is primarily concerned with documenting the methods used to conduct the research, the practical lessons we learned while collaborating with research institutes in the five countries on implementing this study, and the research innovations that we discovered in doing so

Parental HIV disclosure in Burkina Faso: Experiences and challenges in the era of HAART

International audienceIncreasingly parents living with HIV will have to confront the dilemmas of concealing their lifelong treatment or disclosing to their children exposed to their daily treatment practices. However, limited data are available regarding parental HIV disclosure to children in Burkina Faso. Do parents on antiretroviral therapy disclose their HIV status to their children? What drives them? How do they proceed and how do children respond? We conducted in-depth interviews with 63 parents of children aged seven and above where the parents had been in treatment for more than 3 years in two major cities of Burkina Faso. Interviews addressed parental disclosure and the children's role in their parents' treatment. The rate of parental HIV status disclosure is as high as that of non-disclosure. Factors associated with parental disclosure include female sex, parent's older age, parent's marital history and number of children. After adjustment, it appears that the only factor remaining associated with parental disclosure was the female gender of the parent. In most of the cases, children suspected, and among non-disclosers many believed their children already knew without formal disclosure. Age of the children and history of divorce or widowhood were associated with parental disclosure. Most parents believed children do not have the necessary emotional skills to understand or that they cannot keep a secret. However, parents who disclosed to their children did not experience blame nor was their secret revealed. Rather, children became treatment supporters. Challenges to parental HIV disclosure to children are neither essential nor specific since disclosure to adults is already difficult because of perceived risk of public disclosure and subsequent stigma. However, whether aware or not of their parents' HIV-positive status, children contribute positively to the care of parents living with HIV. Perceptions about children's vulnerability and will to protect them against stigma lead parents to delay disclosure and not to overwhelm them with their experience of living with HIV. Finally, without institutional counselling support, disclosure to children remains a challenge for both parents and children, which suggests a need for rethinking of current counselling practices

High blood viscosity is associated with high pulse wave velocity in African sickle cell trait carriers

Background: Sickle cell trait (SCT) is the benign condition of sickle cell disease. Often asymptomatic, the SCT carriers have hemorheological disturbances such as blood hyper-viscosity compared to healthy subjects. These disturbances could lead to structural and functional changes in large vessels. The aim of the study was to evaluate the association between blood viscosity (ηb) and pulse wave velocity (PWV) in SCT carriers.Methods: Thirteen SCT with high blood viscosity (SCT_hηb) aged 34±12 years (4 men) were compared to 13 SCT with low blood viscosity (SCT_lηb) aged 32±9 years (5 men) recruited from the National Blood Transfusion Center (CNTS) in Dakar (Senegal). Pulse wave velocity finger-toe (PWVft) was assessed using pOpmètre® (Axelife SAS-France). Cardiovascular risk (CVR) was assessed according to the Framingham Laurier score.Results: SCT_hηb had higher PWVft (m/s) than SCT_lηb respectively 8.98±1.98 and 7.11±1.18 (p = 0.004). CVR score (%) was higher in SCT_hηb than SCT_lηb, but this difference was not statistically significant (5.96±7.45 vs 2.09±2.15; p=0.31). Multivariate linear regression showed a positive correlation between PWVft and ηb and CVR score (r2=0.74, F=21.19, p˂0.001).Conclusions: Present results indicate that the SCT_hηb carriers have arteries stiffer than SCT_lηb and ηb and CVR could remain independent determinants of arterial stiffness in SCT carriers

Making sense of fidelity: Young Africans’ cross-national and longitudinal representations of fidelity and infidelity in their HIV-related creative narratives, 1997–2014

Mutual fidelity and partner reduction have been identified as key behavioural strategies to prevent HIV transmission in sub-Saharan Africa, particularly following recognition of the role that multiple concurrent sexual partnerships play in driving generalised HIV epidemics. We analysed social representations of fidelity and infidelity in a sample of 1,343 narratives about HIV written by young Africans between 1997 and 2014. The narratives were written at four different time points (1997, 2005, 2008, 2014) by authors aged 10–24 in urban and rural areas of Senegal, Burkina Faso, South-east Nigeria, Kenya and Eswatini. We combined three analytical approaches: descriptive statistics of quantifiable characteristics of the narratives, thematic data analysis and a narrative-based approach. In the sample, fidelity is often promoted as the ideal by narrators, peers and romantic partners, in line with broader discourses around HIV prevention, romantic relationships, familial obligations, and religious and moral imperatives. However, mutual fidelity is rarely modelled in the narratives and representations of combining methods to prevent HIV from entering relationships via infidelity are uncommon. Representations of fidelity reflect loss-framed fear arousal techniques that perpetuate HIV-related stigma. Narrative-based approaches that facilitate skills-building, critical reflection and address stigma can better address fidelity and partner reduction

Effectiveness of a community-based approach for the investigation and management of children with household tuberculosis contact in Cameroon and Uganda: a cluster-randomised trial.

BACKGROUND: Globally, the uptake of tuberculosis-preventive treatment (TPT) among children with household tuberculosis contact remains low, partly due to the necessity of bringing children to health facilities for investigations. This study aimed to evaluate the effect on TPT initiation and completion of community-based approaches to tuberculosis contact investigations in Cameroon and Uganda. METHODS: We did a parallel, cluster-randomised, controlled trial across 20 clusters (consisting of 25 district hospitals and primary health centres) in Cameroon and Uganda, which were randomised (1:1) to receive a community-based approach (intervention group) or standard-of-care facility-based approach to contact screening and management (control group). The community-based approach consisted of symptom-based tuberculosis screening of all household contacts by community health workers at the household, with referral of symptomatic contacts to local facilities for investigations. Initiation of TPT (3-month course of rifampicin-isoniazid) was done by a nurse in the household, and home visits for TPT follow-up were done by community health workers. Index patients were people aged 15 years or older with bacteriologically confirmed, drug-susceptible, pulmonary tuberculosis diagnosed less than 1 month before inclusion and who declared at least one child or young adolescent (aged 0-14 years) household contact. The primary endpoint was the proportion of declared child contacts in the TPT target group (those aged 2 months) and ten in the control group. Between Oct 14, 2019 and Jan 13, 2022, 2894 child contacts were declared by 899 index patients with bacteriologically confirmed tuberculosis. Among all child contacts declared, 1548 (81·9%) of 1889 in the intervention group and 475 (47·3%) of 1005 in the control group were screened for tuberculosis. 1400 (48·4%) child contacts were considered to be in the TPT target group: 941 (49·8%) of 1889 in the intervention group and 459 (45·7%) of 1005 in the control group. In the TPT target group, TPT was commenced and completed in 752 (79·9%) of 941 child contacts in the intervention group and 283 (61·7%) of 459 in the control group (odds ratio 3·06 [95% CI 1·24-7·53]). INTERPRETATION: A community-based approach using community health workers can significantly increase contact investigation coverage and TPT completion among eligible child contacts in a tuberculosis-endemic setting. FUNDING: Unitaid. TRANSLATION: For the French translation of the abstract see Supplementary Materials section

Feasibility of a randomized clinical trial evaluating a community intervention for household tuberculosis child contact management in Cameroon and Uganda

Background: One of the main barriers of the management of household tuberculosis child contacts is the necessity for parents to bring healthy children to the facility. We assessed the feasibility of a community intervention for tuberculosis (TB) household child contact management and the conditions for its evaluation in a cluster randomized controlled trial in Cameroon and Uganda.Methods: We assessed three dimensions of feasibility using a mixed method approach: (1) recruitment capability using retrospective aggregated data from facility registers; (2) acceptability of the intervention using focus group discussions with TB patients and in-depth interviews with healthcare providers and community leaders; and (3) adaptation, integration, and resources of the intervention in existing TB services using a survey and discussions with stakeholders.Results: Reaching the sample size is feasible in all clusters in 15 months with the condition of regrouping 2 facilities in the same cluster in Uganda due to decentralization of TB services. Community health worker (CHW) selection and training and simplified tools for contact screening, tolerability, and adherence of preventive therapy were key elements for the implementation of the community intervention. Healthcare providers and patients found the intervention of child contact investigations and TB preventive treatment management in the household acceptable in both countries due to its benefits (competing priorities, transport cost) as compared to facility-based management. TB stigma was present, but not a barrier for the community intervention. Visit schedule and team conduct were identified as key facilitators for the intervention.Conclusions: This study shows that evaluating a community intervention for TB child contact management in a cluster randomized trial is feasible in Cameroon and Uganda.Trial registration: Clini calTr ials. gov NCT03832023 . Registered on February 6th 2019