Poor ventilation, overcrowding and HIV co-infection make prison an ideal breeding-ground for tuberculosis (TB), but a new study will be among the first in South Africa to quantify TB among inmates and personnel. ‘Herisa Rifuba’, or ‘Stop TB’ in Setswana, will include about 3,500 prisoners and staff at the Johannesburg Central Prison, with around 12,000 existing inmates and about 500 new prisoners arriving daily. So far this year, the prison has recorded more than 100 cases of TB (an infection rate of about 10%). In 2006, Johannesburg Central became one of the first prisons accredited to offer antiretroviral (ARV) treatment on site. About 530 of were receiving treatment from the prison clinic, said Joyce Lethoba, a project manager at The Aurum Institute, which helped the prison obtain accreditation. If a prison does not have its own clinic, inmates on ARVs have to be transported to nearby state hospitals to fetch their medication, which carries a greater risk of escapes.
Equitable health services
The World Health Organization (WHO) has launched an eight-point plan to respond to extensively drug-resistant tuberculosis (XDR-TB): strengthen the quality of basic TB and HIV/AIDS control; scale up programmatic management of multi-drug-resistant TB (MDR-TB) and XDR-TB; strengthen laboratory services; expand MDR-TB and XDR-TB surveillance; develop and implement infection control measures; strengthen advocacy, communication and social mobilization; pursue resource mobilisation at all levels; and promote research and development of new tools. Additional considerations included: conducting adherence research; building the evidence-base for infection control practices; supporting communities affected by TB; enhancing public health response, while addressing the social determinants of health; embracing palliative care; and advocacy for research.
The researchers in this paper identify a gap between what most international health organisations say they are doing to strengthen health systems, and the reality on the ground. Although global health actors claim to be strengthening health systems, the authors argue that they engage almost exclusively with activities that match their own specific aims; tend to concentrate on single diseases, and focus on strengthening elements of health systems essential to their own programmes. Part of the problem, say the researchers, is that the term 'health system strengthening' is being used for any capacity building. They call for a definition that is both shared and consistently applied.
Scale-up of vertical HIV transmission prevention has been too slow in sub-Saharan Africa. We describe approaches, challenges, and results obtained in Kinshasa. Staff members of 21 clinics managed by public servants or non-governmental organizations were trained in improved basic antenatal care (ANC) including nevirapine (NVP)-based HIV transmission prevention. Program initiation was supported on-site logistically and technically. Aggregate implementation data were collected and used for program monitoring. Contextual information was obtained through a survey. Among 45,262 women seeking ANC from June 2003 through July 2005, 90% accepted testing; 792 (1.9%) had HIV of whom 599 (76%) returned for their result. Among 414 HIV+ women who delivered in participating maternities, NVP coverage was 79%; 92% of newborns received NVP. Differences were noted by clinic management in program implementation and HIV prevalence (1.2 to 3.0%). Initiating vertical HIV transmission prevention embedded in improved antenatal services in a fragile, fragmented, severely resource-deprived health care system was possible and improved over time. Scope and quality of service coverage should further increase; strategies to decrease loss to follow-up of HIV+ women should be identified to improve program effectiveness. The observed differences in HIV prevalence highlight the importance of selecting representative sentinel surveillance centers.
The difficulties diagnosing infants and children with HIV infection have been cited as barriers to increasing the number of children receiving antiretroviral therapy worldwide. Design: We implemented routine HIV antibody counseling and testing for pediatric patients hospitalized at the University Teaching Hospital, a national reference center, in Lusaka, Zambia. We also introduced HIV DNA polymerase chain reaction (PCR) testing for early infant diagnosis. METHODS: Caregivers/parents of children admitted to the hospital wards were routinely offered HIV counseling and testing for their children. HIV antibody positive (HIV+) children <18 months of age were tested with PCR for HIV DNA. RESULTS: From January 1, 2006, to June 30, 2007, among 15,670 children with unknown HIV status, 13,239 (84.5%) received counseling and 11,571 (87.4%) of those counseled were tested. Overall, 3373 (29.2%) of those tested were seropositive. Seropositivity was associated with younger age: 69.6% of those testing HIV antibody positive were <18 months of age. The proportion of counseled children who were tested increased each quarter from 76.0% in January to March 2006 to 88.2% in April to June 2007 (P < 0.001). From April 2006 to June 2007, 1276 PCR tests were done; 806 (63.2%) were positive. The rate of PCR positivity increased with age from 22% in children <6 weeks of age to 61% at 3-6 months and to 85% at 12-18 months (P < 0.001). CONCLUSIONS: Routine counseling and antibody testing of pediatric inpatients can identify large numbers of HIV-seropositive children in high prevalence settings. The high rate of HIV infection in hospitalized infants and young children also underscores the urgent need for early infant diagnostic capacity in high prevalence settings.
A new trial to test the efficacy of a tuberculosis (TB) booster shot for babies is about to start in South Africa. Almost 2,800 infants will participate in the two-year trial, in which researchers from the South African Tuberculosis Vaccine Initiative (SATVI) hope to prove that a new vaccine can act as a booster shot to improve the efficacy of the only existing inoculation against TB, the Bacille Calmette-Guerin (BCG) vaccine, in use for nearly 90 years. An effective TB vaccine could help save some of the two million people who die annually from the disease, a quarter of whom are co-infected with HIV. The vaccine has been tested in HIV-infected adults in South Africa, the UK and Senegal, but because this will be the first test in infants, only HIV-negative infants will be enrolled. However, ethical issues have been raised by some about whether it is acceptable to test vaccines on poor African children.
Health systems in countries emerging from conflict are often characterised by damaged infrastructure, limited human resources, weak stewardship and a proliferation of non-governmental organisations, which all undermine health services. One response is to improve health service delivery in post-conflict countries by jointly contract non-governmental organisations to provide a Basic Package of Health Services for all the country's population. The approach is novel because it is intended as the only primary care service delivery mechanism throughout the country, with the available financial health resources primarily allocated to it. The aim is to scale up health services rapidly. This paper describes the Basic Package of Health Services contracting approach and discusses some of the potential challenges this approach may have for sexual and reproductive health services, particularly the challenges of availability and quality of services, and advocacy for these services.
This paper describes and analyses the GAVI Alliance's early experience with health systems strengthening (HSS) to improve immunisation coverage and other maternal-child health outcomes. The challenges have been forging a common vision and approach, governance, balancing pressure to move money with incremental learning, managing partner roles and relationships, managing the ‘value for money’ risk, and capacity building. This mid-point stock-taking makes recommendations for moving GAVI forward in a thoughtful manner. The findings should be of interest to other global health partnerships because of their larger significance. This is a story about how a successful alliance that decided to broaden its mandate has responded to the technical, organisational, and political complexities that challenge its traditional business model.
Understanding urban black women's health care practices will enable health promoters to develop interventions that are successful. The problem investigated here was to gain an understanding of the health care practices of urban black women that could influence health promotion activities. The design was qualitative and exploratory. The sampling method was convenient and purposive, and the sample size was determined by saturation of the data. Data was gathered through semi-structured interviews using six specific themes and the analysed using open coding. The results indicated that the social environment created by the registered nurses in the primary health influenced the health care practices of the women negatively. Practices regarding the seriousness of a health problem suggest a possible reason may exist for late admission of a person with a serious health problem.
The objective of this paper was to measure the extent and causes of inequalities in the ownership and utilisation of bed nets (ITNs) across socioeconomic groups (SEGs) and age groups in Tanga District, north-eastern Tanzania. A questionnaire was administered to heads of 1,603 households from rural and urban areas and focus group discussions were used to explore community perspectives on the causes of inequalities. Use of ITNs remained appallingly low compared to the RBM target of 80% coverage. The results highlight the need for mass distribution of free ITNs, a community-wide programme to treat all untreated nets and to promote the use of long-lasting insecticidal nets (LLINs) or longer-lasting treatment of nets, targeting the rural population and under-fives.