Journal Article > CommentaryFull Text
PLOS Med. 2016 September 6; Volume 13 (Issue 9); e1002111.; DOI:10.1371/journal.pmed.1002111
Sheather J, Jobanputra K, Schopper D, Pringle J, Venis S, et al.
PLOS Med. 2016 September 6; Volume 13 (Issue 9); e1002111.; DOI:10.1371/journal.pmed.1002111
SUMMARY POINTS
• Humanitarian organisations often have to innovate to deliver health care and aid to populations in complex and volatile contexts.
• Innovation projects can involve ethical risks and have consequences for populations even if human participants are not directly involved. While high-level principles have been developed for humanitarian innovation, there is a lack of guidance for how these should be applied in practice.
• Médecins sans Frontières (MSF) has well-established research ethics frameworks, but application of such frameworks to innovation projects could stifle innovation by introducing regulation disproportionate to the risks involved. In addition, the dynamic processes of innovation do not fit within conventional ethics frameworks.
• MSF developed and is piloting an ethics framework for humanitarian innovation that is intended for self-guided use by innovators or project owners to enable them to identify and weigh the harms and benefits of such work and be attentive towards a plurality of ethical considerations.
• Humanitarian organisations often have to innovate to deliver health care and aid to populations in complex and volatile contexts.
• Innovation projects can involve ethical risks and have consequences for populations even if human participants are not directly involved. While high-level principles have been developed for humanitarian innovation, there is a lack of guidance for how these should be applied in practice.
• Médecins sans Frontières (MSF) has well-established research ethics frameworks, but application of such frameworks to innovation projects could stifle innovation by introducing regulation disproportionate to the risks involved. In addition, the dynamic processes of innovation do not fit within conventional ethics frameworks.
• MSF developed and is piloting an ethics framework for humanitarian innovation that is intended for self-guided use by innovators or project owners to enable them to identify and weigh the harms and benefits of such work and be attentive towards a plurality of ethical considerations.
Journal Article > ResearchFull Text
BMC Public Health. 2018 March 20; Volume 18 (Issue 1); DOI:10.1186/s12889-018-5258-3
Etoori D, Kerschberger B, Staderini N, Ndlangamandla M, Nhlabatsi B, et al.
BMC Public Health. 2018 March 20; Volume 18 (Issue 1); DOI:10.1186/s12889-018-5258-3
Background
Universal antiretroviral therapy (ART) for all pregnant/ breastfeeding women living with Human Immunodeficiency Virus (HIV), known as Prevention of mother-to child transmission of HIV (PMTCT) Option B+ (PMTCTB+), is being scaled up in most countries in Sub-Saharan Africa. In the transition to PMTCTB+, many countries face challenges with proper implementation of the HIV care cascade. We aimed to describe the feasibility of a PMTCTB+ approach in the public health sector in Swaziland.
Methods
Lifelong ART was offered to a cohort of HIV+ pregnant women aged ≥16 years at the first antenatal care (ANC1) visit in 9 public sector facilities, between 01/2013 and 06/2014. The study enrolment period was divided into 3 phases (early: 01–06/2013, mid: 07–12/2013 and late: 01–06/2014) to account for temporal trends. Kaplan-Meier estimates and Cox proportional-hazards regression models were applied for ART initiation and attrition analyses.
Results
Of 665 HIV+ pregnant women, 496 (74.6%) initiated ART. ART initiation increased in later study enrolment phases (mid: aHR: 1.41; later: aHR: 2.36), and decreased at CD4 ≥ 500 (aHR: 0.69). 52.9% were retained in care at 24 months. Attrition was associated with ANC1 in the third trimester (aHR: 2.37), attending a secondary care facility (aHR: 1.98) and ART initiation during later enrolment phases (mid aHR: 1.48; late aHR: 1.67). Of 373 women eligible, 67.3% received a first VL. 223/251 (88.8%) were virologically suppressed (< 1000 copies/mL). Of 670 infants, 53.6% received an EID test, 320/359 had a test result recorded and of whom 7 (2.2%) were HIV+.
Conclusions
PMTCTB+ was found to be feasible in this setting, with high rates of maternal viral suppression and low transmission to the infant. High treatment attrition, poor follow-up of mother-baby pairs and under-utilisation of VL and EID testing are important programmatic challenges.
Universal antiretroviral therapy (ART) for all pregnant/ breastfeeding women living with Human Immunodeficiency Virus (HIV), known as Prevention of mother-to child transmission of HIV (PMTCT) Option B+ (PMTCTB+), is being scaled up in most countries in Sub-Saharan Africa. In the transition to PMTCTB+, many countries face challenges with proper implementation of the HIV care cascade. We aimed to describe the feasibility of a PMTCTB+ approach in the public health sector in Swaziland.
Methods
Lifelong ART was offered to a cohort of HIV+ pregnant women aged ≥16 years at the first antenatal care (ANC1) visit in 9 public sector facilities, between 01/2013 and 06/2014. The study enrolment period was divided into 3 phases (early: 01–06/2013, mid: 07–12/2013 and late: 01–06/2014) to account for temporal trends. Kaplan-Meier estimates and Cox proportional-hazards regression models were applied for ART initiation and attrition analyses.
Results
Of 665 HIV+ pregnant women, 496 (74.6%) initiated ART. ART initiation increased in later study enrolment phases (mid: aHR: 1.41; later: aHR: 2.36), and decreased at CD4 ≥ 500 (aHR: 0.69). 52.9% were retained in care at 24 months. Attrition was associated with ANC1 in the third trimester (aHR: 2.37), attending a secondary care facility (aHR: 1.98) and ART initiation during later enrolment phases (mid aHR: 1.48; late aHR: 1.67). Of 373 women eligible, 67.3% received a first VL. 223/251 (88.8%) were virologically suppressed (< 1000 copies/mL). Of 670 infants, 53.6% received an EID test, 320/359 had a test result recorded and of whom 7 (2.2%) were HIV+.
Conclusions
PMTCTB+ was found to be feasible in this setting, with high rates of maternal viral suppression and low transmission to the infant. High treatment attrition, poor follow-up of mother-baby pairs and under-utilisation of VL and EID testing are important programmatic challenges.
Journal Article > ResearchFull Text
J Int AIDS Soc. 2018 October 21; Volume 21 (Issue 10); DOI:10.1002/jia2.25194
Etoori D, Ciglenecki I, Ndlangamandla M, Edwards CG, Jobanputra K, et al.
J Int AIDS Soc. 2018 October 21; Volume 21 (Issue 10); DOI:10.1002/jia2.25194
As antiretroviral therapy (ART) is scaled up, more patients become eligible for routine viral load (VL) monitoring, the most important tool for monitoring ART efficacy. For HIV programmes to become effective, leakages along the VL cascade need to be minimized and treatment switching needs to be optimized. However, many HIV programmes in resource-constrained settings report significant shortfalls.
Journal Article > ResearchFull Text
BMJ Open. 2019 November 24; Volume 9 (Issue 11); DOI:10.1136/bmjopen-2019-030176
Ansbro É, Biringanine M, Caleo GNC, Prieto-Merino D, Sadique Z, et al.
BMJ Open. 2019 November 24; Volume 9 (Issue 11); DOI:10.1136/bmjopen-2019-030176
Journal Article > ReviewFull Text
J Migr Health. 2021 October 29; Volume 4; 100071.; DOI:10.1016/j.jmh.2021.100071
Cantor D, Swartz J, Roberts B, Abbara A, Ager A, et al.
J Migr Health. 2021 October 29; Volume 4; 100071.; DOI:10.1016/j.jmh.2021.100071
We seek to strengthen understanding of the health needs of internally displaced persons (IDPs) in contexts of conflict or violence. Based upon a scoping review, our paper identified limited evidence on IDP health, but nevertheless indicates that IDPs tend to experience worse health outcomes than other conflict-affected populations across a range of health issues; and this is due to the particularly vulnerable situation of IDPs relative to these other populations, including reduced access to health services. Further research is required to better understand these needs and the interventions that can most effectively address these needs.
Journal Article > ResearchFull Text
J Int AIDS Soc. 2020 March 3; Volume 23 (Issue 3); DOI:10.1002/jia2.25458
Kerschberger B, Schomaker M, Jobanputra K, Kabore SM, Teck R, et al.
J Int AIDS Soc. 2020 March 3; Volume 23 (Issue 3); DOI:10.1002/jia2.25458
INTRODUCTION:
The Treat-All policy - antiretroviral therapy (ART) initiation irrespective of CD4 cell criteria - increases access to treatment. Many ART programmes, however, reported increasing attrition and viral failure during treatment expansion, questioning the programmatic feasibility of Treat-All in resource-limited settings. We aimed to describe and compare programmatic outcomes between Treat-All and standard of care (SOC) in the public sectors of Eswatini.
METHODS:
This is a prospective cohort study of ≥16-year-old HIV-positive patients initiated on first-line ART under Treat-All and SOC in 18 health facilities of the Shiselweni region, from October 2014 to March 2016. SOC followed the CD4 350 and 500 cells/mm3 treatment eligibility thresholds. Kaplan-Meier estimates were used to describe crude programmatic outcomes. Multivariate flexible parametric survival models were built to assess associations of time from ART initiation with the composite unfavourable outcome of all-cause attrition and viral failure.
RESULTS:
Of the 3170 patients, 1888 (59.6%) initiated ART under Treat-All at a median CD4 cell count of 329 (IQR 168 to 488) cells/mm3 compared with 292 (IQR 161 to 430) (p < 0.001) under SOC. Although crude programme retention at 36 months tended to be lower under Treat-All (71%) than SOC (75%) (p = 0.002), it was similar in covariate-adjusted analysis (adjusted hazard ratio [aHR] 1.06, 95% CI 0.91 to 1.23). The hazard of viral suppression was higher for Treat-All (aHR 1.12, 95% CI 1.01 to 1.23), while the hazard of viral failure was comparable (Treat-All: aHR 0.89, 95% CI 0.53 to 1.49). Among patients with advanced HIV disease (n = 1080), those under Treat-All (aHR 1.13, 95% CI 0.88 to 1.44) had a similar risk of an composite unfavourable outcome to SOC. Factors increasing the risk of the composite unfavourable outcome under both interventions were aged 16 to 24 years, being unmarried, anaemia, ART initiation on the same day as HIV care enrolment and CD4 ≤ 100 cells/mm3 . Under Treat-All only, the risk of the unfavourable outcome was higher for pregnant women, WHO III/IV clinical stage and elevated creatinine.
CONCLUSIONS:
Compared to SOC, Treat-All resulted in comparable retention, improved viral suppression and comparable composite outcomes of retention without viral failure.
The Treat-All policy - antiretroviral therapy (ART) initiation irrespective of CD4 cell criteria - increases access to treatment. Many ART programmes, however, reported increasing attrition and viral failure during treatment expansion, questioning the programmatic feasibility of Treat-All in resource-limited settings. We aimed to describe and compare programmatic outcomes between Treat-All and standard of care (SOC) in the public sectors of Eswatini.
METHODS:
This is a prospective cohort study of ≥16-year-old HIV-positive patients initiated on first-line ART under Treat-All and SOC in 18 health facilities of the Shiselweni region, from October 2014 to March 2016. SOC followed the CD4 350 and 500 cells/mm3 treatment eligibility thresholds. Kaplan-Meier estimates were used to describe crude programmatic outcomes. Multivariate flexible parametric survival models were built to assess associations of time from ART initiation with the composite unfavourable outcome of all-cause attrition and viral failure.
RESULTS:
Of the 3170 patients, 1888 (59.6%) initiated ART under Treat-All at a median CD4 cell count of 329 (IQR 168 to 488) cells/mm3 compared with 292 (IQR 161 to 430) (p < 0.001) under SOC. Although crude programme retention at 36 months tended to be lower under Treat-All (71%) than SOC (75%) (p = 0.002), it was similar in covariate-adjusted analysis (adjusted hazard ratio [aHR] 1.06, 95% CI 0.91 to 1.23). The hazard of viral suppression was higher for Treat-All (aHR 1.12, 95% CI 1.01 to 1.23), while the hazard of viral failure was comparable (Treat-All: aHR 0.89, 95% CI 0.53 to 1.49). Among patients with advanced HIV disease (n = 1080), those under Treat-All (aHR 1.13, 95% CI 0.88 to 1.44) had a similar risk of an composite unfavourable outcome to SOC. Factors increasing the risk of the composite unfavourable outcome under both interventions were aged 16 to 24 years, being unmarried, anaemia, ART initiation on the same day as HIV care enrolment and CD4 ≤ 100 cells/mm3 . Under Treat-All only, the risk of the unfavourable outcome was higher for pregnant women, WHO III/IV clinical stage and elevated creatinine.
CONCLUSIONS:
Compared to SOC, Treat-All resulted in comparable retention, improved viral suppression and comparable composite outcomes of retention without viral failure.
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 > ResearchFull Text
BMC Health Serv Res. 2017 June 23; Volume 17 (Issue 1); DOI:10.1186/s12913-017-2362-5
Murphy A, Biringanine M, Roberts B, Stringer B, Perel P, et al.
BMC Health Serv Res. 2017 June 23; Volume 17 (Issue 1); DOI:10.1186/s12913-017-2362-5
Evidence is urgently needed from complex emergency settings to support efforts to respond to the increasing burden of diabetes mellitus (DM). We conducted a qualitative study of a new model of DM health care (Integrated Diabetic Clinic within an Outpatient Department [IDC-OPD]) implemented by Médecins Sans Frontières (MSF) in Mweso Hospital in eastern Democratic Republic of Congo (DRC). We aimed to explore patient and provider perspectives on the model in order to identify factors that may support or impede it.
Journal Article > ResearchFull Text
J Migr Health. 2021 December 31; Volume 5 (Issue 5); 100090.; DOI:10.1016/j.jmh.2022.100090
Roberts B, Ekezie W, Jobanputra K, Smith JS, Ellithy S, et al.
J Migr Health. 2021 December 31; Volume 5 (Issue 5); 100090.; DOI:10.1016/j.jmh.2022.100090
BACKGROUND
There are an estimated 55 million internally displaced persons (IDPs) globally. IDPs commonly have worse health outcomes than host populations and other forcibly displaced populations such as refugees. Official development assistance (ODA) is a major source of the global financial response for health in low- and middle-income countries (LMICs), including for populations affected by armed conflict and forced displacement. Analysis of ODA supports efforts to improve donor accountability, transparency and the equitable use of ODA. The aim of this study is to examine international donor support and responsiveness to IDP health needs through analysis of ODA disbursements to LMICs between 2010 and 2019.
METHODS
ODA disbursement data to LMICs from 2010 to 2019 were extracted from the Creditor Reporting System (CRS) database and analysed with Stata software using a combination of: (i) text searching for IDP and refugee related terms; and (ii) relevant health and humanitarian CRS purpose codes. Descriptive analysis was used to examine patterns of ODA disbursement, and nonlinear least squared regression analysis was used to examine responsiveness of ODA disbursement to recipient country IDP population size and health system capacity and health characteristics.
FINDINGS
The study highlighted declining per IDP capita health ODA from USD 5.34 in 2010 to USD 3.72 in 2019 (with annual average decline of -38% from the 2010 baseline). In contrast, health ODA for refugees in LMICs increased from USD 18.55 in 2010 to USD 23.31 in 2019 (with an annual average increase of +14%). Certain health topics for IDPs received very low ODA, with only 0.44% of IDP health ODA disbursed for non-communicable diseases (including mental health). There was also weak evidence of IDP health ODA being related to recipient country IDP population size, and health system capacity and health characteristics. The paper highlights the need for increased investment by donors in IDP health ODA and to ensure that it is responsive to their health needs.
There are an estimated 55 million internally displaced persons (IDPs) globally. IDPs commonly have worse health outcomes than host populations and other forcibly displaced populations such as refugees. Official development assistance (ODA) is a major source of the global financial response for health in low- and middle-income countries (LMICs), including for populations affected by armed conflict and forced displacement. Analysis of ODA supports efforts to improve donor accountability, transparency and the equitable use of ODA. The aim of this study is to examine international donor support and responsiveness to IDP health needs through analysis of ODA disbursements to LMICs between 2010 and 2019.
METHODS
ODA disbursement data to LMICs from 2010 to 2019 were extracted from the Creditor Reporting System (CRS) database and analysed with Stata software using a combination of: (i) text searching for IDP and refugee related terms; and (ii) relevant health and humanitarian CRS purpose codes. Descriptive analysis was used to examine patterns of ODA disbursement, and nonlinear least squared regression analysis was used to examine responsiveness of ODA disbursement to recipient country IDP population size and health system capacity and health characteristics.
FINDINGS
The study highlighted declining per IDP capita health ODA from USD 5.34 in 2010 to USD 3.72 in 2019 (with annual average decline of -38% from the 2010 baseline). In contrast, health ODA for refugees in LMICs increased from USD 18.55 in 2010 to USD 23.31 in 2019 (with an annual average increase of +14%). Certain health topics for IDPs received very low ODA, with only 0.44% of IDP health ODA disbursed for non-communicable diseases (including mental health). There was also weak evidence of IDP health ODA being related to recipient country IDP population size, and health system capacity and health characteristics. The paper highlights the need for increased investment by donors in IDP health ODA and to ensure that it is responsive to their health needs.
Journal Article > CommentaryAbstract Only
Endocrinology and Metabolism Clinics
ENDOCRINOL METAB CLIN NORTH AM
Endocrinol Metab Clin North Am. 2023 June 18; Volume 52 (Issue 4); 603-615.; DOI:10.1016/j.ecl.2023.05.010
Kehlenbrink S, Jobanputra K, Reddy A, Boulle P, Gomber A, et al.
Endocrinology and Metabolism Clinics
ENDOCRINOL METAB CLIN NORTH AM
Endocrinol Metab Clin North Am. 2023 June 18; Volume 52 (Issue 4); 603-615.; DOI:10.1016/j.ecl.2023.05.010
Despite the increasing prevalence of diabetes in populations experiencing humanitarian crisis, along with evidence that people living with diabetes are at higher risk for poor outcomes in a crisis, diabetes care is not routinely included in humanitarian health interventions. We here describe 4 factors that have contributed to the inequities and lack of diabetes inclusion in humanitarian programmes: (1) evolving paradigms in humanitarian health care, (2) complexities of diabetes service provision in humanitarian settings, (3) social and cultural challenges, and (4) lack of financing. We also outline opportunities and possible interventions to address these challenges and improve diabetes care among crisis-affected populations.