Adherence to antiretroviral therapy (ART) is important to optimise treatment outcomes and prevent the development of drug resistance. It is however compromised under a number of situations in the countries most heavily affected by HIV and AIDS. The question this paper is concerned with is: ‘How do we keep people on treatment?’ It proposes that the answer to this question is an improved understanding of why adherence is important; what levels of adherence are needed to ensure that treatment remains effective; how different types of crisis affect access to treatment; and how patients and service providers respond to difficulties. The paper considers the longer-term impact of unplanned ART treatment interruptions and offers suggestions as to how they might be avoided and managed in future. It considers three case studies, by looking at the problems with health system functioning and ART delivery during the 2007 public sector strike in South Africa, the ongoing political and economic crisis in Zimbabwe and the 2008 floods in Mozambique. It is based on a literature review and a relatively small number of interviews with health managers and clinicians in each country.
Equitable health services
Cervical cancer is a leading killer among women living with HIV, but a low-cost screening programme developed in Zambia is proving that simple techniques can go a long way in saving lives. New research presented at the 17th Conference on Retroviruses and Opportunistic Infections (CROI) in San Francisco has shown that cervical cancer screening among HIV-positive women prevented one death for every 32 women screened. The research originated from a pilot study of about 6,600 HIV-positive women examined as part of the Cervical Cancer Prevention Programme in Zambia (CCPPZ), an ongoing low-cost screening project. More than half the women had abnormal results, and about 20% were diagnosed as having lesions at varying stages from pre-cancerous to advanced cancer. Screening by the programme's service costs about US$1 as compared to pap smears that cost about $15 and remain prohibitively expensive even in richer countries like South Africa. To keep costs this low, the programme enables health workers and nurses to carry out screening and treatment, allowing doctors - already in short supply - to perform other tasks. The screening programme has also drawn interest from other countries, including Botswana, Tanzania and Cameroon, which have sent delegations for training.
This study took the form of a randomised, placebo-controlled, multicenter trial in South Africa and Malawi to evaluate the efficacy of a live, oral rotavirus vaccine in preventing severe rotavirus gastroenteritis. A total of 4,939 infants were enrolled and randomly assigned to one of the three groups: 1,647 infants received two doses of the vaccine, 1,651 infants received three doses of the vaccine, and 1,641 received placebo. Of the 4,417 infants included in the per-protocol efficacy analysis, severe rotavirus gastroenteritis occurred in 4.9% of the infants in the placebo group and in 1.9% of those in the pooled vaccine group. Vaccine efficacy was lower in Malawi than in South Africa (49.4% vs. 76.9%); however, the number of episodes of severe rotavirus gastroenteritis that were prevented was greater in Malawi than in South Africa (6.7 vs. 4.2 cases prevented per 100 infants vaccinated per year). Efficacy against all-cause severe gastroenteritis was 30.2%. In conclusion, human rotavirus vaccine significantly reduced the incidence of severe rotavirus gastroenteritis among African infants during the first year of life.
The expiry of medicines in the supply chain is a serious threat to the already constrained access to medicines in developing countries. This study investigated the extent of, and the main contributing factors to, expiry of medicines in medicine supply outlets in Kampala and Entebbe, Uganda. A cross-sectional survey of six public and 32 private medicine outlets was done using semi-structured questionnaires. The study area has 19 public medicine outlets (three non-profit wholesalers, 16 hospital stores/pharmacies), 123 private wholesale pharmacies and 173 retail pharmacies, equivalent to about 70% of the country’s pharmaceutical businesses. The findings indicate that medicines prone to expiry include those used for vertical programmes, donated medicines and those with a slow turnover. Sound coordination is needed between public medicine wholesalers and their clients to harmonise procurement and consumption as well as with vertical programmes to prevent duplicate procurement. Additionally, national medicine regulatory authorities should enforce existing international guidelines to prevent dumping of donated medicine. Medicine selection and quantification should be matched with consumer tastes and prescribing habits. Lean supply and stock rotation should be considered.
This report is a short update to the WHO report on global tuberculosis (TB) control that was published in March 2009, based on data collected from July to September 2009. It is designed to fill an 18-month gap between the full reports of 2009 (in March) and 2010 (in October), following changes to the production cycle of the report in 2009 that have been made to ensure that future reports in the series contain more up-to-date data. In 2008, there were an estimated 8.9–9.9 million incident cases of TB, 9.6–13.3 million prevalent cases of TB, 1.1–1.7 million deaths from TB among HIV-negative people and an additional 0.45–0.62 million TB deaths among HIV-positive people (classified as HIV deaths in the International Statistical Classification of Diseases), with best estimates of 9.4 million, 11.1 million, 1.3 million and 0.52 million, respectively. The number of notified cases of TB in 2008 was 5.7 million, equivalent to 55–67% of all incident cases, with a best estimate of 61% (10% less than the Global Plan milestone of a case detection rate of 71% in 2008). Among patients in the 2007 cohort, 87% were successfully treated; this is the first time that the target of 85% (first set in 1991) has been exceeded at global level. Funding for TB control has increased since 2002, and is expected to reach US$ 4.1 billion in 2010. Funding gaps remain, however; compared with the Global Plan, funding gaps amount to at least US$ 2.1 billion in 2010.
This report offers a fresh and practical approach to strengthening health systems through ‘systems thinking’. It first decodes the complexity of a health system, and then applies that understanding to design better interventions to strengthen health systems, increase coverage, and improve health. The report suggests ways to more realistically forecast how health systems might respond to strengthening interventions, while also exploring potential synergies and dangers among those interventions. Additionally, it shows how better evaluations of health system strengthening initiatives can yield valuable lessons about what works, how it works and for whom. It is hoped that this report will deepen understanding and stimulate fresh thinking among stewards of health systems, health systems researchers, and development partners.
The objective of the study was to determine the prevalence of musculoskeletal conditions (MSC) and the functional implications in a sample of people attending community health centres in Cape Town, South Africa. It was conducted in clinics in two resource poor communities. A total of 1,005 people were screened. Of these, 362 (36%) reported MSC not due to injury in the past three months. Those with MSC had higher rates of co-morbidities in every category than those without. The mean Disability Index for those with MSC was mild to moderate, and moderate to severe in those aged over 55 years. In conclusion, although the sample may not be representative of the general community, the prevalence is considerably greater than those reported elsewhere, even when the population of the catchment area is used as a denominator. The common presentation of MSC with co-morbid diabetes and hypertension requires holistic management by appropriately trained health care practitioners. Any new determination of burden of disease due to MSC should recognise that these disorders may be more prevalent in developing countries than previously estimated.
South Africa remains the country with the greatest burden of HIV-infected individuals and the second highest estimated tuberculosis (TB) incidence per capita worldwide. This study reviewed records of consecutive HIV-infected people initiated onto ART between 1 January 2005 and 31 March 2006. Patients were screened for TB at initiation and incident episodes recorded. CD4 counts, viral loads and follow-up status were recorded; data was censored on 5 August 2008. Geographic cluster analysis was performed using spatial scanning. Eight hundred and one patients were initiated. TB prevalence was 25.3%, associated with lower CD4 and prior TB. Prevalent and incident TB were significantly associated with mortality. Incident TB was associated with a non-significant trend towards viral load >25copies/ml. A low-risk cluster for incident TB was identified for patients living near the local hospital in the geospatial analysis. The study concluded that there is a large burden of TB in the population. Rate of incident TB stabilises at a rate higher than that of the overall population. This data highlights the need for greater research on strategies for active case finding in rural settings and the need to focus on strengthening primary health care.
In this study, 167 people (59 people with epilepsy [PWE], 62 relatives of PWEs and 46 villagers) were interviewed at a local hospital and in the community with a semi-structured validated questionnaire regarding the prevailing attitude towards traditional medicine for treatment of epilepsy in a rural area of northern Tanzania. Various traditional healing methods (THM) could be ascertained, namely traditional herbal medicine, spiritual healing, scarifications and spitting. In total, 44.3% the interviewed people were convinced that epilepsy could be treated successfully with THM. Interestingly, 34.1% thought that Christian prayers could cure the cause and/or treat symptoms of epilepsy. Significantly more PWE and their relatives were in favour of THM compared to villagers not knowing about or not immediately affected by epilepsy. Further factors influencing people’s attitudes towards THM were gender, tribe, religion and urbanity of people’s dwellings. This study demonstrates that not only THM but also prayers in the Christian sense seem to play an important role in people’s beliefs regarding successful treatment of epilepsy. Factors influencing this belief system have been identified and are discussed.
South Africa's Medicines Control Council (MCC) is sitting on a seven-year backlog of nearly 3,000 medicines, which could take another two years to be registered for use in the country. The medicines include treatments for life-threatening conditions such as HIV and AIDS, cancer, tuberculosis and diabetes, as well as antibiotics for bacterial infections. Pharmaceutical companies need to have their drugs registered with the MCC after being licensed to produce them. Only then can they be sold in the country. A task team, put in place by former health minister Barbara Hogan late last year, is busy clearing the backlog and transforming the MCC, and has registered about 200 medicines so far. The team, led by Nicholas Crisp of Benguela Health, includes 12 technical assistants and 24 clerks and has already audited the entire backlog and clinically evaluated nearly 800 medicines. About R13.5 million has so far been spent on the backlog project. Pharmaceutical representatives said they welcomed the task team's work. 'We have seen an increase in the numbers of medicines corresponded to the MCC,' said Shivani Patel, a regulatory affairs pharmacist at Merck's. Part of the project was the development of a new public entity, the South African Health Products Regulatory Authority, although what its role would be was unclear.