Dignitas International

Toronto, Canada

Dignitas International

Toronto, Canada
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Cataldo F.,Dignitas International | Sam-Agudu N.A.,Institute of Human Virology Nigeria | Sam-Agudu N.A.,University of Maryland Baltimore County | Phiri S.,Lighthouse Trust | And 6 more authors.
Journal of Acquired Immune Deficiency Syndromes | Year: 2017

Introduction: Several initiatives aiming to improve retention and adherence in Prevention of Mother-to-Child Transmission of HIV (PMTCT) programs include "expert mothers" (EMs) as a central tenet of their interventions. This article compares the role of EMs in 3 implementation research studies examining approaches for improving retention in care among mothers living with HIV. Methods: We compared and synthesized qualitative data and lessons learned from 3 studies (MoMent in Nigeria, PURE in Malawi, and EPAZ in Zimbabwe) with respect to the involvement of EMs in supporting PMTCT clients. The frame of reference for the comparison is the role that EMs play in PMTCT service delivery for individuals, at the health facility, within the health system, and in the community. Results: EMs' role was positively perceived by PMTCT clients and health care workers, as EMs provided an expanded range of services directly benefiting clients and enabling health care workers to share their workload. Common challenges included difficulties in reaching male partners and fear of stigma. The lack of structure and standardization in EM interventions in relation to eligibility criteria, training, certification, and remuneration were identified as important barriers to EMs' role development within existing health systems. Conclusions: The role of EMs within PMTCT programs continues to expand rapidly. There is a need for coordinated action to develop shared standards and principles commensurate with the new roles and additional demands placed on EMs to support PMTCT services, including EM certification, mentoring and supervision standards, standardized PMTCT-specific training curricula, and, where appropriate, agreed remuneration rates. © Copyright 2017 Wolters Kluwer Health, Inc.

Kalua T.,Malawi Ministry of Health HIV | Barr B.A.T.,Centers for Disease Control and Prevention | Van Oosterhout J.J.,Dignitas International | Van Oosterhout J.J.,University of Malawi | And 13 more authors.
Journal of Acquired Immune Deficiency Syndromes | Year: 2017

The acceleration of prevention of mother-to-child transmission (PMTCT) activities, coupled with the rollout of 2010 World Health Organization (WHO) guidelines, led to important discussions and innovations at global and country levels. One paradigm-shifting innovation was Option B+ in Malawi. It was later included in WHO guidelines and eventually adopted by all 22 Global Plan priority countries. This article presents Malawi's experience with designing and implementing Option B+ and provides complementary narratives from Cameroon and Tanzania. Malawi's HIV program started in 2002, but by 2009, the PMTCT program was lagging far behind the antiretroviral therapy (ART) program because of numerous health system challenges. When WHO recommended Option A and Option B for PMTCT in 2010, it was clear that Malawi's HIV program would not be able to successfully implement either option without increasing existing barriers to PMTCT services and potentially decreasing women's access to care. Subsequent stakeholder discussions led to the development of Option B+. Operationalizing Option B+ required several critical considerations, including the complete integration of ART and PMTCT programs, systematic reduction of barriers to facilitate doubling the number of ART sites in less than a year, building consensus with stakeholders, and securing additional resources for the new program. During the planning and implementation process, several lessons were learned which are considerations for countries transitioning to "treat-all": Comprehensive change requires effective government leadership and coordination; national clinical guidelines must accommodate health system limitations; ART services and commodities should be decentralized within facilities; the general public should be well informed about major changes in the national HIV program; and patients should be educated on clinic processes to improve program monitoring. © 2017 Wolters Kluwer Health, Inc. All rights reserved.

Negin J.,University of Sydney | van Lettow M.,Dignitas International | van Lettow M.,University of Toronto | Semba M.,Ministry of Health | And 5 more authors.
PLoS ONE | Year: 2011

Background: There are approximately 3 million people aged 50 and older in sub-Saharan Africa who are HIV-positive. Despite this, little is known about the characteristics of older adults who are on treatment and their treatment outcomes. Methods: A retrospective cohort analysis was performed using routinely collected data with Malawi Ministry of Health monitoring tools from facilities providing antiretroviral therapy services in Zomba district. Patients aged 25 years and older initiated on treatment from July 2005 to June 2010 were included. Differences in survival, by age group, were determined using Kaplan-Meier survival plots and Cox proportional hazards regression models. Results: There were 10,888 patients aged 25 and older. Patients aged 50 and older (N = 1419) were more likely to be male (P<0.0001) and located in rural areas (P = 0.003) than those aged 25-49. Crude survival estimates among those aged 50-59 were not statistically different from those aged 25-49 (P = 0.925). However, survival among those aged 60 and older (N = 345) was worse (P = 0.019) than among those 25-59. In the proportional hazards model, after controlling for sex and stage at initiation, survival in those aged 50-59 did not differ significantly from those aged 25-49 (hazard ratio 1.00 (95% CI: 0.79 to 1.27; P = 0.998) but the hazard ratio was 1.46 (95% CI: 1.03 to 2.06; P = 0.032) for those aged 60 and older compared to those aged 25-49. Conclusions: Treatment outcomes of those aged 50-59 are similar to those aged 25-49. A better understanding of how older adults present for and respond to treatment is critical to improving HIV services. © 2011 Negin et al.

Tenthani L.,Ministry of Health | Tenthani L.,University of Bern | Tenthani L.,University of Washington | Haas A.D.,University of Bern | And 16 more authors.
AIDS | Year: 2014

OBJECTIVE:: To explore the levels and determinants of loss to follow-up (LTF) under universal lifelong antiretroviral therapy (ART) for pregnant and breastfeeding women ('Option B+') in Malawi. DESIGN, SETTING, AND PARTICIPANTS:: We examined retention in care, from the date of ART initiation up to 6 months, for women in the Option B+ program. We analysed nationwide facility-level data on women who started ART at 540 facilities (nS=S21S939), as well as individual-level data on patients who started ART at 19 large facilities (nS=S11S534). RESULTS:: Of the women who started ART under Option B+ (nS=S21S939), 17% appeared to be lost to follow-up 6 months after ART initiation. Most losses occurred in the first 3 months of therapy. Option B+ patients who started therapy during pregnancy were five times more likely than women who started ART in WHO stage 3/4 or with a CD4 cell count 350Scells/μl or less, to never return after their initial clinic visit [odds ratio (OR) 5.0, 95% confidence interval (CI) 4.2-6.1]. Option B+ patients who started therapy while breastfeeding were twice as likely to miss their first follow-up visit (OR 2.2, 95% CI 1.8-2.8). LTF was highest in pregnant Option B+ patients who began ART at large clinics on the day they were diagnosed with HIV. LTF varied considerably between facilities, ranging from 0 to 58%. CONCLUSION:: Decreasing LTF will improve the effectiveness of the Option B+ approach. Tailored interventions, like community or family-based models of care could improve its effectiveness. © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins.

Chan A.K.,Dignitas International | Chan A.K.,University of Toronto | Mateyu G.,Dignitas International | Jahn A.,Ministry of Health | And 6 more authors.
Tropical Medicine and International Health | Year: 2010

Objective To assess the effect of decentralization (DC) of antiretroviral therapy (ART) provision in a rural district of Malawi using an integrated primary care model. Methods Between October 2004 and December 2008, 8093 patients (63% women) were registered for ART. Of these, 3440 (43%) were decentralized to health centres for follow-up ART care. We applied multivariate regression analysis that adjusted for sex, age, clinical stage at initiation, type of regimen, presence of side effects because of ART, and duration of treatment and follow-up at site of analysis. Results Patients managed at health centres had lower mortality [adjusted OR 0.19 (95% C.I. 0.15-0.25)] and lower loss to follow-up (defaulted from treatment) [adjusted OR 0.48 (95% C.I. 0.40-0.58)]. During the first 10 months of follow-up, those decentralized to health centres were approximately 60% less likely to default than those not decentralized; and after 10 months of follow-up, 40% less likely to default. DC was significantly associated with a reduced risk of death from 0 to 25 months of follow-up. The lower mortality may be explained by the selection of stable patients for DC, and the mentorship and supportive supervision of lower cadre health workers to identify and refer complicated cases. Conclusion Decentralization of follow-up ART care to rural health facilities, using an integrated primary care model, appears a safe and effective way to rapidly scale-up ART and improves both geographical equity in access to HIV-related services and adherence to ART. © 2010 Blackwell Publishing Ltd.

Mburu G.,International HIV AIDS Alliance | Mburu G.,Lancaster University | Hodgson I.,Trinity College Dublin | Kalibala S.,Population Council | And 5 more authors.
Journal of the International AIDS Society | Year: 2014

Introduction: As adolescents living with HIV gain autonomy over their self-care and begin to engage in sexual relationships, their experiences of being informed about their HIV status and of telling others about their HIV status may affect their ability to cope with having the disease. Methods: In 2010, we conducted a qualitative study among adolescents aged 10-19 living with HIV in Zambia, and with their parents and health care providers. Through interviews and focus group discussions, we explored the disclosure of HIV status to adolescents living with HIV; adolescents' disclosure of their status to others; and the impact of both forms of disclosure on adolescents. Results: Our study identified three main barriers to disclosure of HIV status: local norms that deter parents from communicating with their children about sexuality; fear of HIV stigma; and an underlying presumption that adolescents would not understand the consequences of a HIV diagnosis on their lives and relationships. With regard to adolescents' disclosure of their HIV status to their sexual partners, our study identified fear of rejection as a common barrier. In rare cases, open family conversations about HIV helped adolescents come to terms with a HIV diagnosis. Findings indicated that disclosure had various outcomes at the individual and interpersonal levels. At the individual level, some adolescents described being anxious, depressed and blaming themselves after being told they had HIV. At the interpersonal level, disclosure created opportunities for adolescents to access adherence support and other forms of psychosocial support from family members and peers. At the same time, it occasionally strained adolescents' sexual relationships, although it did not always lead to rejection. Conclusions: There is a need for public health interventions that guide adolescents living with HIV, their parents and families through the disclosure process. Such interventions should help parents to assess and understand the evolving cognitive capacity and maturity of their adolescents in order to determine the appropriate time to inform them of their HIV-positive status. Such interventions should also mitigate the risk of HIV stigma, as well as local norms that may prevent discussions of sexuality within families. Adolescents who have been informed of their HIV status should be provided with on-going support to prevent disclosure from negatively affecting their psychological and sexual wellbeing. Further research is needed to explore the potential role of trusted family members in contributing to the disclosure process. © 2014 Mburu G et al; licensee International AIDS Society.

Lees S.,London School of Hygiene and Tropical Medicine | Kielmann K.,Queen Margaret University | Cataldo F.,Dignitas International | Gitau-Mburu D.,International HIV AIDS Alliance
Global Public Health | Year: 2012

In response to the human resource challenges facing African health systems, there is increasing involvement of informal care providers in HIV care. Through social and institutional interactions that occur in the delivery of HIV care, linkages between formal and informal systems of care often emerge. Based on a review of studies documenting the relationships between formal and informal HIV care in sub-Saharan Africa, we suggest that linkages can be conceptualised as either 'actor-oriented' or 'systems-oriented'. Studies adopting an actor-oriented focus examine hierarchical working relationships and communication practices among health systems actors, while studies focusing on systems-oriented linkages document the presence, absence or impact of formal inter-institutional partnership agreements. For linkages to be effective, the institutional frameworks within which linkages are formalised, as well as the ground-level interactions of those engaged in care, ought to be considered. However, to date, both actor- and system-oriented linkages appear to be poorly utilised by policy makers to improve HIV care. We suggest that linkages between formal and informal systems of care be considered across health systems, including governance, human resources, health information and service delivery in order to improve access to HIV services, enable knowledge transfer and strengthen health systems. © 2012 Copyright Taylor and Francis Group, LLC.

Cataldo F.,Dignitas International | Kielmann K.,Queen Margaret University | Kielmann T.,Independent Consultant | Mburu G.,International HIV AIDS Alliance | And 2 more authors.
BMC Health Services Research | Year: 2015

Background: Across Sub-Saharan Africa, the roll-out of antiretroviral treatment (ART) has contributed to shifting HIV care towards the management of a chronic health condition. While the balance of professional and lay tasks in HIV caregiving has been significantly altered due to changing skills requirements and task-shifting initiatives, little attention has been given to the effects of these changes on health workers' motivation and existing care relations. Methods: This paper draws on a cross-sectional, qualitative study that explored changes in home-based care (HBC) in the light of widespread ART rollout in the Lusaka and Kabwe districts of Zambia. Methods included observation of HBC daily activities, key informant interviews with programme staff from three local HBC organisations (n = 17) and ART clinic staff (n = 8), as well as in-depth interviews with home-based caregivers (n = 48) and HBC clients (n = 31). Results: Since the roll-out of ART, home-based caregivers spend less time on hands-on physical care and support in the household, and are increasingly involved in specialised tasks supporting their clients' access and adherence to ART. Despite their pride in gaining technical care skills, caregivers lament their lack of formal recognition through training, remuneration or mobility within the health system. Care relations within homes have also been altered as caregivers' newly acquired functions of monitoring their clients while on ART are met with some ambivalence. Caregivers are under pressure to meet clients and their families' demands, although they are no longer able to provide material support formerly associated with donor funding for HBC. Conclusions: As their responsibilities and working environments are rapidly evolving, caregivers' motivations are changing. It is essential to identify and address the growing tensions between an idealized rhetoric of altruistic volunteerism in home-based care, and the realities of lay worker deployment in HIV care interventions that not only shift tasks, but transform social and professional relations in ways that may profoundly influence caregivers' motivation and quality of care. © 2015 Cataldo et al.; licensee BioMed Central.

Bedell R.A.,Dignitas International | Van Lettow M.,Dignitas International | Van Lettow M.,University of Toronto | Landes M.,Dignitas International | Landes M.,University of Toronto
AIDS Care - Psychological and Socio-Medical Aspects of AIDS/HIV | Year: 2014

The influence of HIV-related stigma on women's choices with regard to HIV testing, disclosure and partner involvement in infant feeding and care is not well understood in rural Malawi but may influence the risk of vertical HIV transmission and infant health. In a study of HIV-infected and -uninfected women in 20 rural locations in Zomba District, Malawi, mothers were questioned at 18-20 months post-partum about these issues. Ten per cent of women claimed unknown HIV status in labour so HIV testing should be routinely offered in Labour & Delivery wards. HIV-infected women were somewhat less likely to disclose to their partners than HIV-uninfected women (89 and 97%, respectively; p = 0.007) or to be cohabiting with partners during pregnancy (74 and 86%, respectively; p = 0.03). Partners of women were less inclined to disclose their HIV testing or HIV status (49 and 66% of partners of HIV-infected and -uninfected women, respectively). Greater partner testing and disclosure may improve prevention of mother to child transmission of HIV (PMTCT) in this population. A majority of women were inclined to make feeding decisions on their own, whereas most felt that other health-related decisions should also involve the father. Most mothers believe that exclusive breast feeding (EBF) is the best infant feeding method (for the first six months) but it was actually practiced by a minority of women (20% of HIV-infected and 5% of HIV-uninfected mothers; p = 0.01). EBF needs systematic support in order to be practised. © 2013 Taylor & Francis.

Landes M.,Dignitas International | Landes M.,University of Toronto | van Lettow M.,Dignitas International | van Lettow M.,University of Toronto | And 6 more authors.
PLoS ONE | Year: 2012

Background: Mortality and morbidity among HIV-exposed children are thought to be high in Malawi. We sought to determine mortality and health outcomes of HIV-exposed and unexposed infants within a PMTCT program. Method: Data were collected as part of a retrospective cohort study in Zomba District, Malawi. HIV-infected mothers were identified via antenatal, delivery and postpartum records with a delivery date 18-20 months prior; the next registered HIV-uninfected mother was identified as a control. By interview and health record review, data on socio-demographic characteristics, service uptake, and health outcomes were collected. HIV-testing was offered to all exposed children. Results: 173 HIV-infected and 214 uninfected mothers were included. 4 stillbirths (1.0%) occurred; among the 383 livebirths, 41 (10.7%) children died by 20 months (32 (18.7%) HIV-exposed and 9 unexposed children (4.3%; p<0.0001)). Risk factors for child death included: HIV-exposure [adjOR2.9(95%CI 1.1-7.2)], low birthweight [adjOR2.5(1.0-6.3)], previous child death (adjOR25.1(6.5-97.5)] and maternal death [adjOR5.3(11.4-20.5)]. At 20 months, HIV-infected children had significantly poorer health outcomes than HIV-unexposed children and HIV-exposed but uninfected children (HIV-EU), including: hospital admissions, delayed development, undernutrition and restrictions in function (Lansky scale); no significant differences were seen between HIV-EU and HIV-unexposed children. Overall, no difference was seen at 20 months among HIV-infected, HIV-EU and HIV-unexposed groups in Z-scores (%<-2.0) for weight, height and BMI. Risk factors for poor functional health status at 20 months included: HIV-infection [adjOR8.9(2.4-32.6)], maternal illness [adjOR2.8(1.5-5.0)] and low birthweight [adjOR2.0(1.0-4.1)]. Conclusion: Child mortality remains high within this context and could be reduced through more effective PMTCT including prioritizing the treatment of maternal HIV infection to address the effect of maternal health and survival on infant health and survival. HIV-infected children demonstrated developmental delays, functional health and nutritional deficits that underscore the need for increased uptake of early infant diagnosis and institution of ART for all infected infants. © 2012 Landes et al.

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