Journal Article > CommentaryFull Text
PLOS Med. 2020 February 14; Volume 17 (Issue 2); e1003028.; DOI:10.1371/journal.pmed.1003028.
Ford NP, Geng EH, Ellman T, Orrell C, Ehrenkranz PD, et al.
PLOS Med. 2020 February 14; Volume 17 (Issue 2); e1003028.; DOI:10.1371/journal.pmed.1003028.
Journal Article > ResearchFull Text
AIDS. 2018 November 16; Volume 33 (Issue 2); DOI:10.1097/QAD.0000000000002070
Loarec A, Carnimeo V, Molfino L, Kizito W, Muyindike WR, et al.
AIDS. 2018 November 16; Volume 33 (Issue 2); DOI:10.1097/QAD.0000000000002070
: A multicentric, retrospective case-series analysis (facility-based) in five sites across Kenya, Malawi, Mozambique, and Uganda screened HIV-positive adults for hepatitis C virus (HCV) antibodies using Oraquick rapid testing and viral confirmation (in three sites). Results found substantially lower prevalence than previously reported for these countries compared with previous reports, suggesting that targeted integration of HCV screening in African HIV programs may be more impactful than routine screening.This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0.
Journal Article > CommentaryFull Text
PLOS Med. 2019 May 29; Volume 16 (Issue 5); e1002820.; DOI:10.1371/journal.pmed.1002820
Ehrenkranz PD, Baptiste SL, Bygrave H, Ellman T, Doi N, et al.
PLOS Med. 2019 May 29; Volume 16 (Issue 5); e1002820.; DOI:10.1371/journal.pmed.1002820
Conference Material > Abstract
Oza S, Harris P, Ansbro E, Perel P, Frieden M, et al.
MSF Scientific Days International 2020: Research. 2020 May 20
INTRODUCTION
Globally, hypertension is responsible for approximately half of all heart disease and stroke deaths. Over 75% of these deaths occur in low- and middle-income countries. However globally, hypertension awareness, treatment, and control remain low (39%, 29%, and 10%, respectively). Reasons for poor control are multifactorial, and include patient-specific factors such as poor adherence, often associated with high pill-burden regimens. Health system factors are also important and may include the use of complex algorithms, leading to clinical inertia amongst healthcare workers. Fixed-dose combination (FDC) medications may be one way of reducing pill burden and simplifying clinical algorithms. To understand the use of multiple drug classes in the management of hypertension we analysed antihypertensive prescribing patterns and blood pressure (BP) control in cohorts from MSF treatment programmes in Jordan and Zimbabwe to determine the proportion of patients who may benefit from a FDC (those currently treated with more than two drug classes) and the potential extent of clinical inertia.
METHODS
We used routine, retrospective data from two cohorts of adult patients with hypertension; one from Jordan, a semi-urban clinic managed by doctors (using data from October 2016 to December 2018) and one from Zimbabwe, a rural setting managed by nurses (data from May 2016 to July 2019). We carried out descriptive analyses of prescribing patterns and their relationship with BP control.
Ethics
This study was approved by the ethics committees of Jordan and Zimbabwe and the MSF Ethics Review Board.
RESULTS
We analysed data from 3305 and 3957 hypertensive patients from Jordan and Zimbabwe respectively; with median ages in Jordan 61 (interquartile range, IQR, 53-69) and in Zimbabwe 63 (IQR 53-70); the majority were female (62.7% and 80.4% respectively). Retention and BP control at 12 months were 95% and 77% (Jordan) and 59% and 42.3% (Zimbabwe). The proportion of patients on two, three, or four-five antihypertensive drug classes at baseline were 42%, 19%, 4% in Jordan and 46%, 7%, <1% in Zimbabwe. At 12 months follow-up, proportions were 40%, 28%, 11% in Jordan and 46%, 17%, 1% in Zimbabwe. Proportions with controlled BP at 12 months on two, three, or four-five drug classes were 71%, 64% and 55% in Jordan, and 40%, 27%, 25% in Zimbabwe. No medication change for uncontrolled BP was made at the next visit for 1,843 (79.3%) of 2,325 visits in Jordan, and 4,763 (63.5%) of 7,497 visits in Zimbabwe. This included 545 (28.6%) and 2,549 (53.5%) visits with uncontrolled stage two or three hypertension respectively.
CONCLUSION
Most patients with hypertension required more than two antihypertensive medications, but a significant proportion persisted with uncontrolled BP. No additional class of antihypertensive was given in the majority of visits by patients with uncontrolled BP, suggesting possible clinical inertia by healthcare workers. Despite recent inclusion of FDC’s in MSF guidelines and WHO’s Essential Medicines List, their lack of inclusion in national guidelines, and procurement challenges, have hindered MSF’s implementation of FDC’s. Demonstrating feasibility of FDC use in MSF pilot projects could play an important role in furthering uptake.
Conflicts of Interest
None declared.
Globally, hypertension is responsible for approximately half of all heart disease and stroke deaths. Over 75% of these deaths occur in low- and middle-income countries. However globally, hypertension awareness, treatment, and control remain low (39%, 29%, and 10%, respectively). Reasons for poor control are multifactorial, and include patient-specific factors such as poor adherence, often associated with high pill-burden regimens. Health system factors are also important and may include the use of complex algorithms, leading to clinical inertia amongst healthcare workers. Fixed-dose combination (FDC) medications may be one way of reducing pill burden and simplifying clinical algorithms. To understand the use of multiple drug classes in the management of hypertension we analysed antihypertensive prescribing patterns and blood pressure (BP) control in cohorts from MSF treatment programmes in Jordan and Zimbabwe to determine the proportion of patients who may benefit from a FDC (those currently treated with more than two drug classes) and the potential extent of clinical inertia.
METHODS
We used routine, retrospective data from two cohorts of adult patients with hypertension; one from Jordan, a semi-urban clinic managed by doctors (using data from October 2016 to December 2018) and one from Zimbabwe, a rural setting managed by nurses (data from May 2016 to July 2019). We carried out descriptive analyses of prescribing patterns and their relationship with BP control.
Ethics
This study was approved by the ethics committees of Jordan and Zimbabwe and the MSF Ethics Review Board.
RESULTS
We analysed data from 3305 and 3957 hypertensive patients from Jordan and Zimbabwe respectively; with median ages in Jordan 61 (interquartile range, IQR, 53-69) and in Zimbabwe 63 (IQR 53-70); the majority were female (62.7% and 80.4% respectively). Retention and BP control at 12 months were 95% and 77% (Jordan) and 59% and 42.3% (Zimbabwe). The proportion of patients on two, three, or four-five antihypertensive drug classes at baseline were 42%, 19%, 4% in Jordan and 46%, 7%, <1% in Zimbabwe. At 12 months follow-up, proportions were 40%, 28%, 11% in Jordan and 46%, 17%, 1% in Zimbabwe. Proportions with controlled BP at 12 months on two, three, or four-five drug classes were 71%, 64% and 55% in Jordan, and 40%, 27%, 25% in Zimbabwe. No medication change for uncontrolled BP was made at the next visit for 1,843 (79.3%) of 2,325 visits in Jordan, and 4,763 (63.5%) of 7,497 visits in Zimbabwe. This included 545 (28.6%) and 2,549 (53.5%) visits with uncontrolled stage two or three hypertension respectively.
CONCLUSION
Most patients with hypertension required more than two antihypertensive medications, but a significant proportion persisted with uncontrolled BP. No additional class of antihypertensive was given in the majority of visits by patients with uncontrolled BP, suggesting possible clinical inertia by healthcare workers. Despite recent inclusion of FDC’s in MSF guidelines and WHO’s Essential Medicines List, their lack of inclusion in national guidelines, and procurement challenges, have hindered MSF’s implementation of FDC’s. Demonstrating feasibility of FDC use in MSF pilot projects could play an important role in furthering uptake.
Conflicts of Interest
None declared.
Journal Article > ResearchFull Text
PLOS One. 2016 October 20; Volume 11 (Issue 10); e0164634.; DOI:10.1371/journal.pone.0164634
Venables E, Edwards JK, Baert S, Etienne W, Khabala K, et al.
PLOS One. 2016 October 20; Volume 11 (Issue 10); e0164634.; DOI:10.1371/journal.pone.0164634
INTRODUCTION
The number of people on antiretroviral therapy (ART) for the long-term management of HIV in low- and middle-income countries (LMICs) is continuing to increase, along with the prevalence of Non-Communicable Diseases (NCDs). The need to provide large volumes of HIV patients with ART has led to significant adaptations in how medication is delivered, but access to NCD care remains limited in many contexts. Medication Adherence Clubs (MACs) were established in Kibera, Kenya to address the large numbers of patients requiring chronic HIV and/or NCD care. Stable NCD and HIV patients can now collect their chronic medication every three months through a club, rather than through individual clinic appointments.
METHODOLOGY
We conducted a qualitative research study to assess patient and health-care worker perceptions and experiences of MACs in the urban informal settlement of Kibera, Kenya. A total of 106 patients (with HIV and/or other NCDs) and health-care workers were purposively sampled and included in the study. Ten focus groups and 19 in-depth interviews were conducted and 15 sessions of participant observation were carried out at the clinic where the MACs took place. Thematic data analysis was conducted using NVivo software, and coding focussed on people’s experiences of MACs, the challenges they faced and their perceptions about models of care for chronic conditions.
RESULTS
MACs were considered acceptable to patients and health-care workers because they saved time, prevented unnecessary queues in the clinic and provided people with health education and group support whilst they collected their medication. Some patients and health-care workers felt that MACs reduced stigma for HIV positive patients by treating HIV as any other chronic condition. Staff and patients reported challenges recruiting patients into MACs, including patients not fully understanding the eligibility criteria for the clubs. There were also some practical challenges during the implementation of the clubs, but MACs have shown that it is possible to learn from ART provision and enable stable HIV and NCD patients to collect chronic medication together in a group.
CONCLUSIONS
Extending models of care previously only offered to HIV-positive cohorts to NCD patients can help to de-stigmatise HIV, allow for the efficient clinical management of co-morbidities and enable patients to benefit from peer support. Through MACs, we have demonstrated that an integrated approach to providing medication for chronic diseases including HIV can be implemented in resource-poor settings and could thus be rolled out in other similar contexts.
The number of people on antiretroviral therapy (ART) for the long-term management of HIV in low- and middle-income countries (LMICs) is continuing to increase, along with the prevalence of Non-Communicable Diseases (NCDs). The need to provide large volumes of HIV patients with ART has led to significant adaptations in how medication is delivered, but access to NCD care remains limited in many contexts. Medication Adherence Clubs (MACs) were established in Kibera, Kenya to address the large numbers of patients requiring chronic HIV and/or NCD care. Stable NCD and HIV patients can now collect their chronic medication every three months through a club, rather than through individual clinic appointments.
METHODOLOGY
We conducted a qualitative research study to assess patient and health-care worker perceptions and experiences of MACs in the urban informal settlement of Kibera, Kenya. A total of 106 patients (with HIV and/or other NCDs) and health-care workers were purposively sampled and included in the study. Ten focus groups and 19 in-depth interviews were conducted and 15 sessions of participant observation were carried out at the clinic where the MACs took place. Thematic data analysis was conducted using NVivo software, and coding focussed on people’s experiences of MACs, the challenges they faced and their perceptions about models of care for chronic conditions.
RESULTS
MACs were considered acceptable to patients and health-care workers because they saved time, prevented unnecessary queues in the clinic and provided people with health education and group support whilst they collected their medication. Some patients and health-care workers felt that MACs reduced stigma for HIV positive patients by treating HIV as any other chronic condition. Staff and patients reported challenges recruiting patients into MACs, including patients not fully understanding the eligibility criteria for the clubs. There were also some practical challenges during the implementation of the clubs, but MACs have shown that it is possible to learn from ART provision and enable stable HIV and NCD patients to collect chronic medication together in a group.
CONCLUSIONS
Extending models of care previously only offered to HIV-positive cohorts to NCD patients can help to de-stigmatise HIV, allow for the efficient clinical management of co-morbidities and enable patients to benefit from peer support. Through MACs, we have demonstrated that an integrated approach to providing medication for chronic diseases including HIV can be implemented in resource-poor settings and could thus be rolled out in other similar contexts.
Journal Article > ReviewFull Text
J Int AIDS Soc. 2016 May 13; Volume 19 (Issue 1); DOI:10.7448/IAS.19.1.20751
Bemelmans M, Baert S, Negussie E, Bygrave H, Biot M, et al.
J Int AIDS Soc. 2016 May 13; Volume 19 (Issue 1); DOI:10.7448/IAS.19.1.20751
Introduction: Counselling services are recommended by the World Health Organization and have been partially adopted by national HIV guidelines. In settings with a high HIV burden, patient education and counselling is often performed by lay workers, mainly supported with international funding. There are few examples where ministries of health have been able to absorb lay counsellors into their health systems or otherwise sustain their work. We document the role of lay cadres involved in HIV testing and counselling and adherence support and discuss approaches to sustainability. Methods: We focused on a purposive sample of eight sub-Saharan African countries where Médecins Sans Frontières supports HIV programmes: Guinea, Lesotho, Malawi, Mozambique, South Africa, Swaziland, Zambia and Zimbabwe. We reviewed both published and grey literature, including national policies and donor proposals, and interviewed key informants, including relevant government staff, donors and non-governmental organizations. Results and discussion: Lay counsellors play a critical role in scaling up HIV services and addressing gaps in the HIV testing and treatment cascade by providing HIV testing and counselling and adherence support at both the facility and community levels. Countries have taken various steps in recognizing lay counsellors, including harmonizing training, job descriptions and support structures. However, formal integration of this cadre into national health systems is limited, as lay counsellors are usually not included in national strategies or budgeting. Conclusions: The current trend of reduced donor support for lay counsellors, combined with lack of national prioritization, threatens the sustainability of this cadre and thereby quality HIV service delivery.
Journal Article > CommentaryAbstract
Lancet Infect Dis. 2014 November 19; Volume 15 (Issue 2); DOI:10.1016/S1473-3099(14)70896-5
Ford NP, Meintjes GA, Pozniak A, Bygrave H, Hill AM, et al.
Lancet Infect Dis. 2014 November 19; Volume 15 (Issue 2); DOI:10.1016/S1473-3099(14)70896-5
For more than two decades, CD4 cell count measurements have been central to understanding HIV disease progression, making important clinical decisions, and monitoring the response to antiretroviral therapy (ART). In well resourced settings, the monitoring of patients on ART has been supported by routine virological monitoring. Viral load monitoring was recommended by WHO in 2013 guidelines as the preferred way to monitor people on ART, and efforts are underway to scale up access in resource-limited settings. Recent studies suggest that in situations where viral load is available and patients are virologically suppressed, long-term CD4 monitoring adds little value and stopping CD4 monitoring will have major cost savings. CD4 cell counts will continue to play an important part in initial decisions around ART initiation and clinical management, particularly for patients presenting late to care, and for treatment monitoring where viral load monitoring is restricted. However, in settings where both CD4 cell counts and viral load testing are routinely available, countries should consider reducing the frequency of CD4 cell counts or not doing routine CD4 monitoring for patients who are stable on ART.
Journal Article > CommentaryFull Text
Trop Med Int Health. 2015 February 16; Volume 20 (Issue 4); 430-447.; DOI:10.1111/tmi.12460
Duncombe C, Rosenblum S, Hellmann N, Holmes CB, Wilkinson LS, et al.
Trop Med Int Health. 2015 February 16; Volume 20 (Issue 4); 430-447.; DOI:10.1111/tmi.12460
The delivery of HIV care in the initial rapid scale-up of HIV care and treatment was based on existing clinic-based models, which are common in highly resourced settings and largely undifferentiated for individual needs. A new framework for treatment based on variable intensities of care tailored to the specific needs of different groups of individuals across the cascade of care is proposed here. Service intensity is characterized by four delivery components: (1) types of services delivered, (2) location of service delivery, (3) provider of health services, and (4) frequency of health services. How these components are developed into a service delivery framework will vary across countries and populations, with the intention being to improve acceptability and care outcomes. The goal of getting more people on treatment before they become ill will necessitate innovative models of delivering both testing and care. As HIV programs expand treatment eligibility, many people entering care will not be "patients" but healthy, active and productive members of society.(1) In order to take the framework to scale, it will be important to: (1) define which individuals can be served by an alternative delivery framework; (2) strengthen health systems that support decentralization, integration and task shifting; (3) make the supply chain more robust; and (4) invest in data systems for patient tracking and for program monitoring and evaluation.
Journal Article > CommentaryFull Text
Lancet Diabetes Endocrinol. 2019 August 1; DOI:10.1016/S2213-8587(19)30197-4.
Kehlenbrink S, Jaacks LM, Perone SA, Ansbro É, Ashbourne E, et al.
Lancet Diabetes Endocrinol. 2019 August 1; DOI:10.1016/S2213-8587(19)30197-4.
Journal Article > CommentaryAbstract
Int Health. 2012 July 31; Volume 4 (Issue 3); DOI:10.1016/j.inhe.2012.06.002
Bygrave H, Saranchuk P, Makakole L, Ford NP
Int Health. 2012 July 31; Volume 4 (Issue 3); DOI:10.1016/j.inhe.2012.06.002