Risk Factors for Delayed Viral Suppression on First-Line Antiretroviral Therapy among Persons Living with HIV in Haiti, 2013-2017

Studies of viral suppression on first-line antiretroviral therapy (ART) in persons living with human immunodeficiency virus (PLHIV) in Haiti are limited, particularly among PLHIV outside of the Ouest department, where the capital Port-au-Prince is located. This study described the prevalence and risk factors for delayed viral suppression among PLHIV in all geographic departments of Haiti between 2013 and 2017. Individuals who received viral load testing 3 to 12 months after ART initiation were included. Data on demographics and clinical care were obtained from the Haitian Active Longitudinal Tracking of HIV database. Multivariable logistic regression was performed to predict delayed viral suppression, defined as a viral load ≥1000 HIV-1 RNA copies/mL after at least 3 months on ART. Viral load test results were available for 3,368 PLHIV newly-initiated on ART. Prevalence of delayed viral suppression was 40%, which is slightly higher than previous estimates in Haiti. In the multivariable analysis, delayed viral suppression was significantly associated with younger age, receiving of care in the Ouest department, treatment with lamivudine (3TC), zidovudine (AZT), and nevirapine (NVP) combined ART regimen, and CD4 counts below 200 cells/mm3. In conclusion, this study was the first to describe and compare differences in delayed viral suppression among PLHIV by geographic department in Haiti. We identified populations to whom public health interventions, such as more frequent viral load testing, drug resistance testing, and ART adherence counseling should be targeted

Development of novel composite data quality scores to evaluate facility-level data quality in electronic data in Kenya: A nationwide retrospective cohort study

BACKGROUND: In this evaluation, we aim to strengthen Routine Health Information Systems (RHIS) through the digitization of data quality assessment (DQA) processes. We leverage electronic data from the Kenya Health Information System (KHIS) which is based on the District Health Information System version 2 (DHIS2) to perform DQAs at scale. We provide a systematic guide to developing composite data quality scores and use these scores to assess data quality in Kenya. METHODS: We evaluated 187 HIV care facilities with electronic medical records across Kenya. Using quarterly, longitudinal KHIS data from January 2011 to June 2018 (total N = 30 quarters), we extracted indicators encompassing general HIV services including services to prevent mother-to-child transmission (PMTCT). We assessed the accuracy (the extent to which data were correct and free of error) of these data using three data-driven composite scores: 1) completeness score; 2) consistency score; and 3) discrepancy score. Completeness refers to the presence of the appropriate amount of data. Consistency refers to uniformity of data across multiple indicators. Discrepancy (measured on a Z-scale) refers to the degree of alignment (or lack thereof) of data with rules that defined the possible valid values for the data. RESULTS: A total of 5,610 unique facility-quarters were extracted from KHIS. The mean completeness score was 61.1% [standard deviation (SD) = 27%]. The mean consistency score was 80% (SD = 16.4%). The mean discrepancy score was 0.07 (SD = 0.22). A strong and positive correlation was identified between the consistency score and discrepancy score (correlation coefficient = 0.77), whereas the correlation of either score with the completeness score was low with a correlation coefficient of -0.12 (with consistency score) and -0.36 (with discrepancy score). General HIV indicators were more complete, but less consistent, and less plausible than PMTCT indicators. CONCLUSION: We observed a lack of correlation between the completeness score and the other two scores. As such, for a holistic DQA, completeness assessment should be paired with the measurement of either consistency or discrepancy to reflect distinct dimensions of data quality. Given the complexity of the discrepancy score, we recommend the simpler consistency score, since they were highly correlated. Routine use of composite scores on KHIS data could enhance efficiencies in DQA at scale as digitization of health information expands and could be applied to other health sectors beyondHIV clinics

Developing a competency-based curriculum in HIV for nursing schools in Haiti

<p>Abstract</p> <p>Background</p> <p>Preparing health workers to confront the HIV/AIDS epidemic is an urgent challenge in Haiti, where the HIV prevalence rate is 2.2% and approximately 10 100 people are taking antiretroviral treatment. There is a critical shortage of doctors in Haiti, leaving nurses as the primary care providers for much of the population. Haiti's approximately 1000 nurses play a leading role in HIV/AIDS prevention, care and treatment. However, nurses do not receive sufficient training at the pre-service level to carry out this important work.</p> <p>Methods</p> <p>To address this issue, the Ministry of Health and Population collaborated with the International Training and Education Center on HIV over a period of 12 months to create a competency-based HIV/AIDS curriculum to be integrated into the 4-year baccalaureate programme of the four national schools of nursing.</p> <p>Results</p> <p>Using a review of the international health and education literature on HIV/AIDS competencies and various models of curriculum development, a Haiti-based curriculum committee developed expected HIV/AIDS competencies for graduating nurses and then drafted related learning objectives. The committee then mapped these learning objectives to current courses in the nursing curriculum and created an 'HIV/AIDS Teaching Guide' for faculty on how to integrate and achieve these objectives within their current courses. The curriculum committee also created an 'HIV/AIDS Reference Manual' that detailed the relevant HIV/AIDS content that should be taught for each course.</p> <p>Conclusion</p> <p>All nursing students will now need to demonstrate competency in HIV/AIDS-related knowledge, skills and attitudes during periodic assessment with direct observation of the student performing authentic tasks. Faculty will have the responsibility of developing exercises to address the required objectives and creating assessment tools to demonstrate that their graduates have met the objectives. This activity brought different administrators, nurse leaders and faculty from four geographically dispersed nursing schools to collaborate on a shared goal using a process that could be easily replicated to integrate any new topic in a resource-constrained pre-service institution. It is hoped that this experience provided stakeholders with the experience, skills and motivation to strengthen other domains of the pre-service nursing curriculum, improve the synchronization of didactic and practical training and develop standardized, competency-based examinations for nursing licensure in Haiti.</p

Using Data from the iSanté National Electronic Medical Record System to Strengthen Haiti's HIV Antiretroviral Therapy Program

Thesis (Ph.D.)--University of Washington, 2014The scale-up of electronic medical records (EMR) in low resource settings offers opportunities to improve patient care and health outcomes through improved information to guide decision-making at individual patient, facility, and national levels. In this dissertation, we explored use of data relevant for quality improvement in Haiti's national HIV care and treatment program, at each of these three levels of decision-making. Our first analysis was relevant to improved clinical decision making for individual patients. We developed a simple prediction model for risk of therapeutic failure among patients on HIV antiretroviral therapy (ART), using pharmacy-based adherence data and other patient characteristics. This model strongly differentiated patients at high, medium and low risk and could be help providers identify which patients to target with intensive adherence support services. We concluded that targeting patients according to their predicted risk could help providers to reach the greatest number of patients with high need in the context of constrained resources. Our second analysis examined attrition from the ART program in two large departmental hospitals in Haiti and identified patient demographic, clinical, temporal, and health service-related factors associated with ART attrition. This analysis was relevant to improved management of services at the facility level. We found that at 12 months after ART initiation 26.6% of ART patients were no longer retained in care (95% CI: 24.6-28.7%). Location of patient residence in communes distant from the health care facility was strongly associated with attrition, as was briefer duration of enrollment within HIV care and treatment prior to ART initiation, having a non-standard ART regimen, and having no counseling sessions prior to ART initiation. We concluded that quality improvement interventions which address these risk factors merit further testing within the two facilities. Our third analysis examined the performance of 95 facilities using the iSanté EMR system with respect to a series of 14 priority data quality indicators. In this analysis, we examined consistency of performance across the indicators, as well as site and system use characteristics associated with strong vs. weak data quality. This analysis offers insight on where and how efforts to strengthen data quality should focus, and on which system "ingredients" may be necessary to produce strong data quality. Together our analyses demonstrate the value of using data from the iSanté EMR system to identify improvements in individual patient follow-up, organization of services, quality of information, and allocation of system-wide resources. There are tremendous on-going pressures to expand access to HIV care and treatment, to assure quality of services, and to optimize efficiency in Haiti and other low-resource settings. Our analyses of iSanté EMR data represent three examples of data use which address these pressures. Building upon the momentum of the present analyses by translating the findings into on-ground program improvements, and by exploring other data uses which answer timely health services research questions is of great importanc

Evaluating the long-term impact of large-scale trainings: an exposure based cross-sectional study on female genital mutilation-related knowledge, attitudes and practices among Sudanese midwives in Khartoum State

Objectives To examine the long-term impact of large-scale training targeting midwives in a setting where they are the main female genital mutilation (FGM) practitioners. We hypothesised that trained midwives would have significantly higher knowledge, greater opposition to midwives’ involvement in this practice, and improved clinical practice in FGM prevention and care compared with non-trained midwives.Design We conducted an exposure based cross-sectional study, using closed-ended and open-ended questions during phone interviews.Setting Khartoum State in Sudan has a high prevalence of FGM (88%) mainly performed by midwives.Participants Midwives who received (n=127) and did not receive FGM training (n=55).Primary and secondary outcome measures We developed primary outcomes aligned to the three levels (reaction, learning and behaviour) of Kirkpatrick’s training evaluation model for descriptive and multivariable analyses in Stata.Results All the midwives interviewed were female, mostly village midwives (92%) and worked in health centres (89%). The mean age and midwifery experience was 51 years (SD=10) and 23 years (SD=12), respectively. Overall, most midwives (&gt;90%) reported being supportive of FGM discontinuation. Midwives who had FGM training were more aware that performing FGM violates code of conduct (p=0.001) and reported to always counsel patients to abandon FGM (p&lt;0.001) compared with midwives who did not report training. However, these associations were not statistically significant in multivariable logistic regression model adjusting for age. Exploratory analysis of training curricula showed higher knowledge, correct attitude and practices among those who reported in-service training before 2016.Conclusion Though past trainings were associated with higher knowledge and greater opposition to midwives’ involvement in FGM, this was not translated into appropriate corrective clinical procedures among affected women during labour. The Sudan Ministry of Health invested heavily in training midwives and it would be important to investigate why trained midwives do not implement recommended FGM-related clinical management

Strengthening health information systems to support post-disaster healthcare in Haiti

The project aimed to mitigate the impact of the January 2010 earthquake and strengthen the healthcare system in Haiti through application of broad informatics methods to improve, integrate, and build interoperability among information systems through action research, collaboration, and learning. Overall progress was hampered by the cholera outbreak in October 2010. While IDRC-supported work in the area ended in 2012, the momentum for deployment of the new iSanté modules continued. As of 2013, 88 facilities use iSanté for capturing data on HIV patient care, 53 sites use it for women’s health and 43 sites for primary care