BACKGROUND

Access to safe abortion care (SAC) should be improved in fragile and humanitarian settings, and the implementation of interventions in that regard are currently limited. This is especially true for self-managed abortion (SMA), although it holds the potential of revolutionizing the prevention of maternal death and suffering.

CASE PRESENTATION

The medical humanitarian organization Doctors Without Borders/Médecins Sans Frontières (MSF) piloted a self-managed abortion model of care in the Middle East. 22 women were remotely supported in managing their safe abortions with a counsellor over the phone, using misoprostol doses that they took at home after having taken mifepristone in our health facility. We share our experience by describing the model of care and discussing the lessons learned through its implementation.

CONCLUSIONS

The program delivered abortion services successfully and required few resources. This paper also reflects on the importance of facilitating SMA in humanitarian contexts. It increases access to care by providing increased confidentiality, close support, ample information, autonomy, and flexibility. It is simple to implement, effective, often preferred by women, and can be linked to information about contraception. The implementation of self-managed models should be expanded, notably in projects that do not have a sexual and reproductive health focus and in restrictive and challenging contexts. It represents a true revolution for access to safe abortion care.

BACKGROUND

Traditionally in the Democratic Republic of the Congo (DRC), centralised Ebola treatment centres (ETCs) have been set exclusively for Ebola virus disease (EVD) case management during outbreaks. During the 2020 EVD outbreak in DRC’s Equateur Province, existing health centres were equipped as decentralised treatment centres (DTC) to improve access for patients with suspected EVD. Between ETCs and DTCs, we compared the time from symptom onset to admission and diagnosis among patients with suspected EVD.

METHODS

This was a cohort study based on analysis of a line-list containing demographic and clinical information of patients with suspected EVD admitted to any EVD health facility during the outbreak.

RESULTS

Of 2359 patients with suspected EVD, 363 (15%) were first admitted to a DTC. Of 1996 EVD-suspected patients initially admitted to an ETC, 72 (4%) were confirmed as EVD-positive. Of 363 EVD-suspected patients initially admitted to a DTC, 6 (2%) were confirmed and managed as EVD-positive in the DTC. Among all EVD-suspected patients, the median (interquartile range) duration between symptom onset and admission was 2 (1-4) days in a DTC compared to 4 (2-7) days in an ETC (p<0.001). Similarly, time from symptom onset to admission was significantly shorter among EVD-suspected patients ultimately diagnosed as EVD-negative.

CONCLUSIONS

Since <5% of the EVD-suspected patients admitted were eventually diagnosed with EVD, there is a need for better screening to optimise resource utilization and outbreak control. Only one in seven EVD-suspected patients were admitted to a DTC first, as the DTCs were piloted in a limited and phased manner. However, there is a case to be made for considering decentralized care especially in remote and hard-to-reach areas in places like the DRC to facilitate early access to care, contain viral shedding by patients with EVD and ensure no disrupted provision of non-EVD services.

BACKGROUND

Improving treatment success rates among multi drug-resistant tuberculosis (MDR-TB) patients is critical to reducing its incidence and mortality, but adherence poses an important challenge. Video-based direct observed therapy (vDOT) may provide adherence benefits, while addressing the time and cost burden associated with community treatment supporter (CTS)-DOT. This study explored experiences of patients, family members and healthcare workers with different DOT modalities for adherence support in Eswatini.

METHODS

Between April 2021 and May 2022, thirteen men and five women with MDR-TB, ten healthcare workers, and nine caregivers were purposively sampled to include a range of characteristics and experiences with DOT modalities. Data were generated through individual in-depth interviews and a smartphone messaging application (WhatsApp). Data coding was undertaken iteratively, and thematic analysis undertaken, supported by Nvivo.

RESULTS

Four themes emerged that reflected participants’ experiences with different DOT modalities, including stigma, efficiency, perceived risks of TB acquisition, and patient autonomy. vDOT was appreciated by patients for providing them with privacy and shielding them from stigmatisation associated with being seen in TB clinics or with community treatment supporters. vDOT was also seen as more efficient than CTS-DOT. Health workers acknowledged that it saved time, allowing them to attend to more patients, while many patients found vDOT more convenient and less expensive by removing the need to travel for in-person consultations. Health workers also appreciated vDOT because it reduced risks of TB acquisition by minimising exposure through virtual patient monitoring. Although many patients appreciated greater autonomy in managing their illness through vDOT, others preferred human contact or struggled with making video recordings. Most family members appreciated vDOT, although some resented feeling removed from the process of supporting loved ones.

CONCLUSIONS

vDOT was generally appreciated by MDR-TB patients, their family members and health workers as it addressed barriers to adherence which could contribute to improved treatment completion rates and reduced workplace exposure. However, patients should be offered an alternative to vDOT such as CTS-DOT if this modality does not suit their circumstances or preferences.

INTRODUCTION

The health systems of countries in the South and the North have been directly affected by the COVID-19 pandemic. Healthcare workers have paid a high price. The aim of this study was to better describe the personnel who are on the front line when patients visit health care facilities and to analyze their risk factors for exposure, their perception of infection and the prevention practices implemented by these health care workers.

METHODS

A cross-sectional study was conducted over a 6-month period from October 2021 to March 2022 (i.e., at a distance from the index cases) among health care workers in 62 integrated health centers and five public urban hospitals in Niamey and Dosso. Information on socio-demographic characteristics, clinical symptoms, co-morbidities, knowledge and attitudes, and vaccination status was collected by means of a questionnaire. Blood samples were taken for serological analysis for each agent included.

RESULTS

A total of 733 agents were included, mostly women (628, 85.67%) with a mean age of 40.5 years. Only 5.5% (40/733) of the workers reported having been in contact with a positive case of Covid-19. The most common method of protection was the use of alcohol and soap for hand hygiene. 76% of them reported having been vaccinated against the SARS-CoV2 virus. However, only 7.7% reported having used a Covid-19 diagnostic test in the last few months. IgM and IgG COVID-19 serologies were positive in 1.2% and 92.2% of the health care workers, respectively, during the survey period.

CONCLUSION

In Niger, frontline health workers have been widely exposed to SARS CoV-2, but most of them don't think so. As a result, in their daily practice, they make poor use of means to prevent and control COVID-19 infection and rarely use diagnostic tests in case of illness. Vaccination was widely accepted by these staff, according to their statements.

BACKGROUND

Mobility of people living with HIV (PWH) among urban population in Goma and the fisherfolk community in western Uganda can serve as a barrier to retention in care. To address this challenge, MSF supported MoH in deployment of WHO recommended Differentiated Services Delivery Models (DSDM), especially Community ART groups (CAG) where clients form groups and rotate drug pick-up. In these studies, we aimed to explore retention-in-care, viral load coverage and suppression among PWH enrolled in DSDM and describe acceptability and satisfaction of these models in Goma, DRC and Kasese, Uganda.

METHODS

In both contexts, we carried out a retrospective cohort analysis complemented by a cross-sectional survey in Goma and a qualitative survey in Kasese. For the cohort analysis, we examined the characteristics of PWH enrolled in DSDM. Utilizing Kaplan-Meier survival analysis, we estimated retention in care and calculated viral coverage and suppression rates at 12 months post-model initiation. In Goma, we administered a satisfaction questionnaire to a subset of the active cohort, while in Kasese, we conducted interviews and facilitated focus group discussions to document the acceptability and relevance of DSDM.

RESULTS

In total, 1950 PWH in Goma and 1773 PWH in Kasese were included in the cohort analyses. After one year of model initiation, more than 90% of PWH enrolled in MSF-supported DSDM were retained in care (94.1% among PWH in Goma and 97.6% in Kasese). Of PWH who retained in care at 1-year, proportion of virally suppressed PWH was high in both contexts (96.4% in Goma and 97.0% in Goma). PWH and healthcare providers expressed positive sentiments towards DSMD, acknowledging their utility in enhancing convenience and reducing transport expenses for ART access. Moreover, they noted benefits such as decreased waiting times, alleviation of overcrowding and workload at healthcare facilities, as well as the role of DSDM in mitigating stigma and fostering responsibility sharing among group members.

CONCLUSION

Although great progress has been made in the fight against the HIV epidemic in recent years, a one-size-fits-all approach to caring for people living with HIV is no longer appropriate. The findings from these evaluations underscore the effectiveness of tailored, differentiated services, which maintain high retention rates in care, even within mobile communities, while also garnering strong acceptability. It is imperative to consider integrating DSDM into routine programming for chronic illnesses. By adapting clinical care to suit the lifestyles of PWH, such models can offer enhanced support to patients, ultimately improving health outcomes.