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PubMed | U.S. Army, World Health Organization, University of Maryland, Baltimore, Partners in Health Inshuti Mu Buzima and 3 more.
Type: Journal Article | Journal: Tropical medicine & international health : TM & IH | Year: 2016

To evaluate HIV drug resistance (HIVDR) and determinants of virological failure in a large cohort of patients receiving first-line tenofovir-based antiretroviral therapy (ART) regimens.A nationwide retrospective cohort from 42 health facilities was assessed for virological failure and development of HIVDR mutations. Data were collected at ART initiation and at 12 months of ART on patients with available HIV-1 viral load (VL) and ART adherence measurements. HIV resistance genotyping was performed on patients with VL 1000 copies/ml. Multiple logistic regression was used to determine factors associated with treatment failure.Of 828 patients, 66% were women, and the median age was 37 years. Of the 597 patients from whom blood samples were collected, 86.9% were virologically suppressed, while 11.9% were not. Virological failure was strongly associated with age <25 years (adjusted odds ratio [aOR]: 6.4; 95% confidence interval [CI]: 3.2-12.9), low adherence (aOR: 2.87; 95% CI: 1.5-5.0) and baseline CD4 counts <200 cells/l (aOR 3.4; 95% CI: 1.9-6.2). Overall, 9.1% of all patients on ART had drug resistance mutations after 1 year of ART; 27% of the patients who failed treatment had no evidence of HIVDR mutations. HIVDR mutations were not observed in patients on the recommended second-line ART regimen in Rwanda.The last step of the UNAIDS 90-90-90 target appears within grasp, with some viral failures still due to non-adherence. Nonetheless, youth and late initiators are at higher risk of virological failure. Youth-focused programmes could help prevent further drug HIVDR development.


PubMed | Partners In Health Inshuti Mu Buzima, Harvard University and Ministry of Health
Type: Journal Article | Journal: World journal of surgery | Year: 2016

Most mortality attributable to surgical emergencies occurs in low- and middle-income countries. District hospitals, which serve as the first-level surgical facility in rural sub-Saharan Africa, are often challenged with limited surgical capacity. This study describes the presentation, management, and outcomes of non-obstetric surgical patients at district hospitals in Rwanda.This study included patients seeking non-obstetric surgical care at three district hospitals in rural Rwanda in 2013. Demographics, surgical conditions, patient care, and outcomes are described; operative and non-operative management were stratified by hospitals and differences assessed using Fishers exact test.Of the 2660 patients who sought surgical care at the three hospitals, most were males (60.7%). Many (42.6%) were injured and 34.7% of injuries were through road traffic crashes. Of presenting patients, 25.3% had an operation, with patients presenting to Butaro District Hospital significantly more likely to receive surgery (57.0%, p<0.001). General practitioners performed nearly all operations at Kirehe and Rwinkwavu District Hospitals (98.0 and 100.0%, respectively), but surgeons performed 90.6% of the operations at Butaro District Hospital. For outcomes, 39.5% of all patients were discharged without an operation, 21.1% received surgery and were discharged, and 21.1% were referred to tertiary facilities for surgical care.Significantly more patients in Butaro, the only site with a surgeon on staff and stronger surgical infrastructure, received surgery. Availing more surgeons who can address the most common surgical needs and improving supplies and equipment may improve outcomes at other districts. Surgical task sharing is recommended as a temporary solution.


PubMed | Ministry of Health, Partners In Health Inshuti Mu Buzima, Harvard University, College of Medicine and Health Sciences, University of Rwanda and 2 more.
Type: Journal Article | Journal: Surgery | Year: 2016

In developing countries, 9 out of 10 patients lack access to timely operative care. Most patients seek care at district hospitals that often lack operative capacity, creating a need for referral. Delays in referrals contribute to substantial disability and death. This study assessed the predictors of delayed referrals for injured patients.This retrospective cohort study included injured patients, recommended for referral between January 1, 2013, and December 31, 2013, from 3 rural district hospitals in Rwanda. We defined delay as nonexecution of referral 2days after referral recommendation. We performed a multivariate logistic regression using stepwise backward selection to identify the predictors of delayed referral.Of the 1,227 injured patients, 23.0% (n=282) were recommended for referral. Of these, 36.5% (n=103) had road traffic injuries and 53.6% (n=151) were diagnosed with closed fractures/dislocation. Among 231 patients, 108 (46.8%) had a delay in referral execution. The predictors of delay included age >35years (odds ratio=2.45, 95% confidence interval: 1.09-5.50), closed fractures/dislocation (odds ratio=16.37, 95% confidence interval: 3.13-85.78), admission to surgical wards (odds ratio=10.25, 95% confidence interval: 2.70-38.82), and a duration 7days from admission to referral recommendation (odds ratio=4.80, 95% confidence interval: 1.38-16.63).Over 50% of referrals were completed in a timely fashion due to a strong referral system and a patient support program. Empowering district hospitals with trained staff and appropriate equipment could reduce the need for referral, and increasing surgeons at referral hospitals could reduce referral delays.


Magge H.,Boston Childrens Hospital | Magge H.,Partners in Health Inshuti Mu Buzima | Magge H.,Brigham and Women's Hospital | Magge H.,Childrens Hospital Boston | And 3 more authors.
Journal of General Internal Medicine | Year: 2013

BACKGROUND: Millions of adults will gain Medicaid or private insurance in 2014 under the Affordable Care Act, and prior research shows that underinsurance is common among middle-income adults. Less is known about underinsurance among low-income adults, particularly those with public insurance. OBJECTIVE: To compare rates of underinsurance among low-income adults with private versus public insurance, and to identify predictors of being underinsured. DESIGN: Descriptive and multivariate analysis of data from the 2005-2008 Medical Expenditure Panel Survey. PARTICIPANTS: Adults 19-64 years of age with family income less than 125 % of the Federal Poverty Level (FPL) and full-year continuous coverage in one of four mutually exclusive insurance categories (N = 5,739): private insurance, Medicaid, Medicare, and combined Medicaid/Medicare coverage. MAIN MEASURES: Prevalence of underinsurance among low-income adults, defined as out-of-pocket expenditures greater than 5 % of household income, delays/failure to obtain necessary medical care due to cost, or delays/failure to obtain necessary prescription medications due to cost. KEY RESULTS: Criteria for underinsurance were met by 34.5 % of low-income adults. Unadjusted rates of underinsurance were 37.7 % in private coverage, 26.0 % in Medicaid, 65.1 % in Medicare, and 45.1 % among Medicaid/Medicare dual enrollees. Among underinsured adults, household income averaged $6,181 and out-of-pocket spending averaged $1,115. Due to cost, 8.1 % and 12.8 % deferred or delayed obtaining medical care or prescription medications, respectively. Predictors of underinsurance included being White, unemployed, and in poor health. After multivariate adjustment, Medicaid recipients were significantly less likely to be underinsured than privately insured adults (OR 0.22, 95 % CI 0.17-0.28). CONCLUSIONS: Greater than one-third of low-income adults nationally were underinsured. Medicaid recipients were less likely to be underinsured than privately insured adults, indicating potential benefits of expanded Medicaid under health care reform. Nonetheless, more than one-quarter of Medicaid recipients were underinsured, highlighting the importance of addressing cost-related barriers to care even among those with public coverage. © 2013 Society of General Internal Medicine.


Betancourt T.S.,Harvard University | Ng L.C.,Harvard University | Kirk C.M.,Harvard University | Munyanah M.,Partners in Health Inshuti Mu Buzima | And 9 more authors.
AIDS | Year: 2014

OBJECTIVE:: The objective of this study is to assess the feasibility and acceptability of an intervention to reduce mental health problems and bolster resilience among children living in households affected by caregiver HIV in Rwanda. DESIGN:: Pre-post design, including 6-month follow-up. METHODS:: The Family Strengthening Intervention (FSI) aims to reduce mental health problems among HIV-Affected children through improved child-caregiver relationships, family communication and parenting skills, HIV psychoeducation and connections to resources. Twenty families (N = 39 children) with at least one HIV-positive caregiver and one child 7-17 years old were enrolled in the FSI. Children and caregivers were administered locally adapted and validated measures of child mental health problems, as well as measures of protective processes and parenting. Assessments were administered at pre and postintervention, and 6-month follow-up. Multilevel models accounting for clustering by family tested changes in outcomes of interest. Qualitative interviews were completed to understand acceptability, feasibility and satisfaction with the FSI. RESULTS:: Families reported high satisfaction with the FSI. Caregiver-reported improvements in family connectedness, good parenting, social support and children's pro-social behaviour (P < 0.05) were sustained and strengthened from postintervention to 6-month follow-up. Additional improvements in caregiver-reported child perseverance/self-esteem, depression, anxiety and irritability were seen at follow-up (P < .05). Significant decreases in child-reported harsh punishment were observed at postintervention and follow-up, and decreases in caregiver reported harsh punishment were also recorded on follow-up (P < 0.05). CONCLUSION:: The FSI is a feasible and acceptable intervention that shows promise for improving mental health symptoms and strengthening protective factors among children and families affected by HIV in low-resource settings. © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins.


PubMed | Botswana Ministry of Health, Rwanda Ministry of Health, University of Vermont, Partners In Health Inshuti Mu Buzima and 2 more.
Type: | Journal: BMC cancer | Year: 2016

Cancer services are inaccessible in many low-income countries, and few published examples describe oncology programs within the public sector. In 2011, the Rwanda Ministry of Health (RMOH) established Butaro Cancer Center of Excellence (BCCOE) to expand cancer services nationally. In hopes of informing cancer care delivery in similar settings, we describe program-level experience implementing BCCOE, patient characteristics, and challenges encountered.Butaro Cancer Center of Excellence was founded on diverse partnerships that emphasize capacity building. Services available include pathology-based diagnosis, basic imaging, chemotherapy, surgery, referral for radiotherapy, palliative care and socioeconomic access supports. Retrospective review of electronic medical records (EMR) of patients enrolled between July 1, 2012 and June 30, 2014 was conducted, supplemented by manual review of paper charts and programmatic records.In the programs first 2 years, 2326 patients presented for cancer-related care. Of these, 70.5% were female, 4.3% children, and 74.3% on public health insurance. In the first year, 66.3% (n = 1144) were diagnosed with cancer. Leading adult diagnoses were breast, cervical, and skin cancer. Among children, nephroblastoma, acute lymphoblastic leukemia, and Hodgkin lymphoma were predominant. As of June 30, 2013, 95 cancer patients had died. Challenges encountered include documentation gaps and staff shortages.Butaro Cancer Center of Excellence demonstrates that complex cancer care can be delivered in the most resource-constrained settings, accessible to vulnerable patients. Key attributes that have made BCCOE possible are: meaningful North-south partnerships, innovative task- and infrastructure-shifting, RMOH leadership, and an equity-driven agenda. Going forward, we will apply our experiences and lessons learned to further strengthen BCCOE, and employ the developed EMR system as a valuable platform to assess long-term clinical outcomes and improve care.


Cyamatare F.R.,Partners In Health Inshuti Mu Buzima | Mezzacappa C.,Brigham and Women's Hospital | Nkikabahizi F.,Rwanda Ministry of Health | Niyonzima S.,Rwanda Ministry of Health | And 3 more authors.
Archives of disease in childhood | Year: 2015

OBJECTIVE: Integrated Management of Childhood Illness (IMCI) is the leading clinical protocol designed to decrease under-five mortality globally. However, impact is threatened by gaps in IMCI quality of care (QOC). In 2010, Partners In Health and the Rwanda Ministry of Health implemented a nurse mentorship intervention Mentoring and Enhanced Supervision at Health Centres (MESH) in two rural districts. This study measures change in QOC following the addition of MESH to didactic training.DESIGN: Prepost intervention study of change in QOC after 12 months of MESH support measured by case observation using a standardised checklist. Study sample was children age 2 months to 5 years presenting on the days of data collection (292 baseline, 413 endpoint).SETTING: 21 rural health centres in Rwanda.OUTCOMES: Primary outcome was a validated index of key IMCI assessments. Secondary outcomes included assessment, classification and treatment indicators, and QOC variability across providers. A mixed-effects regression model of the index was created.RESULTS: In multivariate analyses, the index significantly improved in southern Kayonza (β-coefficient 0.17, 95% CI 0.12 to 0.22) and Kirehe (β-coefficient 0.29, 95% CI 0.23 to 0.34) districts. Children seen by IMCI-trained nurses increased from 83.2% to 100% (p<0.001) and use of IMCI case recording forms improved from 65.9% to 97.1% (p<0.001). Correct classification improved (56.0% to 91.5%, p<0.001), as did correct treatment (78.3% to 98.2%, p<0.001). Variability in QOC decreased (intracluster correlation coefficient 0.613-0.346).CONCLUSIONS: MESH was associated with significant improvements in all domains of IMCI quality. MESH could be an innovative strategy to improve IMCI implementation in resource-limited settings working to decrease under-five mortality. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.


Scorza P.,Harvard University | Stevenson A.,Harvard University | Canino G.,University of Puerto Rico at San Juan | Mushashi C.,Partners in Health Inshuti Mu Buzima | And 3 more authors.
PLoS ONE | Year: 2013

Overview: The World Health Organization Disability Assessment Schedule for children (WHODAS-Child) is a disability assessment instrument based on the WHO's International Classification of Functioning, Disability and Health for children and youth. It is modified from the original adult version specifically for use with children. The aim of this study was to assess the WHODAS-Child structure and metric properties in a community sample of children with and without reported psychosocial problems in rural Rwanda. Methods: The WHODAS-Child was first translated into Kinyarwanda through a detailed committee translation process and back-translation. Cognitive interviewing was used to assess the comprehension of the translated items. Test-retest reliability was assessed in a group of 64 children. The translated WHODAS-Child was then administered to a final sample of 367 children in southern Kayonza district in rural southeastern Rwanda within a larger psychosocial assessment battery. The latent structure was assessed through confirmatory factor analysis. Reliability was evaluated in terms of internal consistency (Cronbach's alpha) and test-retest reliability (Pearson's correlation coefficient). Construct validity was explored by examining convergence between WHODAS-Child scores and mental disorder status, and divergence of WHODAS-Child scores with protective factors and prosocial behaviors. Concordance between parent and child scores was also assessed. Results: The six-factor structure of the WHODAS-Child was confirmed in a population sample of Rwandan children. Test-retest and inter-rater reliability were high (r =. 83 and ICC =. 88). WHODAS-Child scores were moderately positively correlated with presence of depression (r =. 42, p<.001) and post-traumatic stress disorder (r =. 31, p<.001) and moderately negatively correlated with prosocial behaviors (r =. 47, p<.001). The Kinyarwanda version of the WHODAS-Child was found to be a reliable and acceptable self-report tool for assessment of functional impairment among children largely referred for psychosocial problems in the study district in rural Rwanda. Further research in low-resource settings and with more general populations is recommended. © 2013 Scorza et al.


Krumme A.A.,Harvard University | Kaigamba F.,Ruhengeri Hospital | Binagwaho A.,Ministry of Health of Rwanda | Murray M.B.,Harvard University | And 4 more authors.
Journal of Epidemiology and Community Health | Year: 2015

Background: A better understanding of the relationship between depression and HIV-related outcomes, particularly as it relates to adherence to treatment, is critical to guide effective support and treatment of individuals with HIV and depression. We examined whether depression was associated with attrition from care in a cohort of 610 HIV-infected adults in rural Rwanda and whether this relationship was mediated through suboptimal adherence to treatment. Methods: The association between depression and attrition from care was evaluated with a Cox proportional hazard model and with mediation methods that calculate the direct and indirect effects of depression on attrition and are able to account for interactions between depression and suboptimal adherence. Depression was assessed with the Hopkins Symptom Checklist-15; attrition was defined as death, treatment default, or loss to follow-up. Results: Baseline depression was significantly associated with time to attrition after adjustment for receipt of community-based accompaniment, physical functioning quality of life score, and CD4 cell count (HR=2.40, 95% CI 1.27 to 4.52, p=0.005). In multivariable mediation analysis, we found no evidence that the association between depression and attrition after 3 months was mediated by suboptimal adherence (direct effect of depression on attrition: OR=3.90 (1.26 to 12.04), p=0.02; indirect effect: OR=1.07 (0.92 to 1.25), p=0.38). Conclusions: Even in the context of high antiretroviral therapy adherence, depression may adversely influence HIV outcomes through a pathway other than suboptimal adherence. Treatment of depression is critical to achieving good mental health and retention in HIVinfected individuals with depression.


Ng L.C.,Center for Health and Human Rights | Kanyanganzi F.,Partners in Health Inshuti Mu Buzima | Munyanah M.,Partners in Health Inshuti Mu Buzima | Mushashi C.,Partners in Health Inshuti Mu Buzima | Betancourt T.S.,Harvard University
PLoS ONE | Year: 2014

This study developed and validated the Youth Conduct Problems Scale-Rwanda (YCPS-R). Qualitative free listing (n = 74) and key informant interviews (n = 47) identified local conduct problems, which were compared to existing standardized conduct problem scales and used to develop the YCPS-R. The YCPS-R was cognitive tested by 12 youth and caregiver participants, and assessed for test-retest and inter-rater reliability in a sample of 64 youth. Finally, a purposive sample of 389 youth and their caregivers were enrolled in a validity study. Validity was assessed by comparing YCPS-R scores to conduct disorder, which was diagnosed with the Mini International Neuropsychiatric Interview for Children, and functional impairment scores on the World Health Organization Disability Assessment Schedule Child Version. ROC analyses assessed the YCPS-R's ability to discriminate between youth with and without conduct disorder. Qualitative data identified a local presentation of youth conduct problems that did not match previously standardized measures. Therefore, the YCPS-R was developed solely from local conduct problems. Cognitive testing indicated that the YCPS-R was understandable and required little modification. The YCPS-R demonstrated good reliability, construct, criterion, and discriminant validity, and fair classification accuracy. The YCPS-R is a locally-derived measure of Rwandan youth conduct problems that demonstrated good psychometric properties and could be used for further research. © 2014 Ng et al.

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