Trends in pharmacotherapy selection for the treatment of alcohol withdrawal in the Free State Province, South Africa

Background.The selection of pharmacotherapy for the treatment of alcohol withdrawal remains a clinical challenge. Research continues into the underlying pathophysiology of dependence and withdrawal. A spectrum of clinical presentations of alcohol dependence is emerging, yet recommendations and guidelines have remained unchanged for some time.  Objectives. To engage with the problem of translating research into practice, as reflected by the selection of pharmacotherapy for alcohol withdrawal by medical practitioners in the Free State Province, South Africa. Methods. A questionnaire-based survey and interviews were conducted among 121 professionals in both the private and public sectors across the province. A subgroup was formed comprising the 58 doctors who indicated that they prescribe for alcohol withdrawal. Participants worked in private general practice, specialist psychiatry practice, in a state hospital or in a treatment centre. Results. Prescribing practices varied based on practitioners’ geographical distribution and professional capacity. Deviation from standard recommendations included the routine use of clothiapine and antidepressants in withdrawal regimens. Prescribing clothiapine appears to be a local custom. While prescription of antidepressants may indicate unrealistic expectations of therapeutic benefit, there are clear indications that this is maintained to mask the diagnosis of an alcohol-related condition. Prescribing for alcohol withdrawal is therefore not necessarily determined by pathophysiology or efficacy of medication. Conclusion. Withdrawal regimens need to be reassessed by researchers, policy makers and funders, balancing new developments with the real-life experiences and challenges of prescribers and their patients

Towards universal ARV access: Achievements and challenges in Free State Province, South Africa

Objective. To study the progress and challenges with regard to universal antiretroviral (ARV) access in Free State Province, South Africa. Methods. Data from the first 4 years of the public sector ARV roll-out and selected health system indicators were used. Data were collected from the public sector ARV database in Free State Province for new patients on ARVs, average waiting times and median CD4 counts at the start of treatment. Information on staff training, vacancy rates and funding allocations for the ARV roll-out was obtained from official government reports. Projections were made of expected new ARV enrolments for 2008 and 2009 and compared with goals set by the National Strategic Plan (NSP) to achieve universal access to ARVs by 2011. Results. New ARV enrolments increased annually to 25% of the estimated need by the end of 2007. Average waiting times to enrolment decreased from 5.82 months to 3.24 months. Median CD4 counts at enrolment increased from 89 to 124 cells/mm3. There is a staff vacancy rate of 38% in the ARV programme and an inadequate increase in budget allocations. Conclusion. The current vertical model of ARV therapy delivery is unlikely to raise the number of new enrolments sufficiently to achieve the goals of universal access by 2011 as envisaged by the NSP. The Free State is implementing a project (STRETCH trial) to broaden the ARV roll-out in an attempt to increase access to ARVs

Task shifting and integration of HIV care into primary care in South Africa: The development and content of the streamlining tasks and roles to expand treatment and care for HIV (STRETCH) intervention

Background: Task shifting and the integration of human immunodeficiency virus (HIV) care into primary care services have been identified as possible strategies for improving access to antiretroviral treatment (ART). This paper describes the development and content of an intervention involving these two strategies, as part of the Streamlining Tasks and Roles to Expand Treatment and Care for HIV (STRETCH) pragmatic randomised controlled trial. Methods: Developing the intervention: The intervention was developed following discussions with senior management, clinicians, and clinic staff. These discussions revealed that the establishment of separate antiretroviral treatment services for HIV had resulted in problems in accessing care due to the large number of patients at ART clinics. The intervention developed therefore combined the shifting from doctors to nurses of prescriptions of antiretrovirals (ARVs) for uncomplicated patients and the stepwise integration of HIV care into primary care services. Results: Components of the intervention: The intervention consisted of regulatory changes, training, and guidelines to support nurse ART prescription, local management teams, an implementation toolkit, and a flexible, phased introduction. Nurse supervisors were equipped to train intervention clinic nurses in ART prescription using outreach education and an integrated primary care guideline. Management teams were set up and a STRETCH coordinator was appointed to oversee the implementation process. Discussion: Three important processes were used in developing and implementing this intervention: active participation of clinic staff and local and provincial management, educational outreach to train nurses in intervention sites, and an external facilitator to support all stages of the intervention rollout

Integrating HIV Care into Primary Care Services: Quantifying Progress of an Intervention in South Africa

<div><h3>Background</h3><p>Integration of human immunodeficiency virus (HIV) care into primary care services is one strategy proposed to achieve universal access to antiretroviral treatment (ART) for HIV-positive patients in high burden countries. There is a need for controlled studies of programmes to integrate HIV care with details of the services being integrated.</p> <h3>Methods</h3><p>A semi-quantitative questionnaire was developed in consultation with clinic staff, tested for internal consistency using Cronbach's alpha coefficients and checked for inter-observer reliability. It was used to conduct four assessments of the integration of HIV care into referring primary care clinics (mainstreaming HIV) and into the work of all nurses within ART clinics (internal integration) and the integration of pre-ART and ART care during the Streamlining Tasks and Roles to Expand Treatment and Care for HIV (STRETCH) trial in South Africa. Mean total integration and four component integration scores at intervention and control clinics were compared using one way analysis of variance (ANOVA). Repeated measures ANOVA was used to analyse changes in scores during the trial.</p> <h3>Results</h3><p>Cronbach's alpha coefficients for total integration, pre-ART and ART integration and mainstreaming HIV and internal integration scores showed good internal consistency. Mean total integration, mainstreaming HIV and ART integration scores increased significantly at intervention clinics by the third assessment. Mean pre-ART integration scores were almost maximal at the first assessment and showed no further change. There was no change in mean internal integration score.</p> <h3>Conclusion</h3><p>The questionnaire developed in this study is a valid tool with potential for monitoring integration of HIV care in other settings. The STRETCH trial interventions resulted in increased integration of HIV care, particularly ART care, by providing HIV care at referring primary care clinics, but had no effect on integrating HIV care into the work of all nurses with the ART clinic.</p> </div

Integration of HIV care into primary care in South Africa: effect on survival of patients needing antiretroviral treatment

INTRODUCTION: Integration of human immunodeficiency virus (HIV) care into primary care is a potential strategy to improve access to antiretroviral therapy (ART) in high-burden countries. This study was conducted to determine the effect of integration of HIV care on survival of patients needing ART. METHODS: A questionnaire was used to measure integration of HIV care into primary care during a randomized controlled trial of task shifting and decentralization of HIV care in South Africa.. Cox proportional hazard ratios were estimated for the effect of 5 different integration scores (total, pre-ART, ART, mainstreaming HIV and internal integration) on survival of patients with CD4=350 cells/µl and not yet on ART. RESULTS: A total of 9,252 patients were followed up for 12-18 months. Cox proportional hazards ratios adjusted for patient and clinic characteristics, showed decreased risk of mortality in clinics with high scores for total integration (HR 0.97; 95% CI 0.95-0.98;

Progress of mean total integration scores during the STRETCH trial.

<p>Line graph of mean total integration scores at intervention and control clinics plotted against mean date of assessment, for four assessments during the STRETCH trail. Error bars depict standard error on the mean at each assessment.</p

Intervention and control clinic characteristics during STRETCH trial.

<p>Elements of STRETCH trial intervention including nurse training, patient care guidelines, toolkit and support teams at intervention clinics and their referring primary care clinics compared to standard care at control clinics and their referring primary care clinics.</p

Progress of mean pre-ART and ART integration scores during the STRETCH trial.

<p>Two line graphs of mean pre-ART and ART integration scores at intervention and control clinics plotted against mean date of assessment, for four assessments during the STRETCH trial. Error bars depict standard error on the mean at each assessment.</p

Component questions of the five different integration scores.

<p>A summary describing which questions from the integration questionnaire contributed to each integration score during the four assessments of the trial. An example of the questions contributing to each integration score is also included. The full questionnaire is included in Additional File 1.</p