PharmAccess Foundation

Amsterdam, Netherlands

PharmAccess Foundation

Amsterdam, Netherlands

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Hassan A.S.,Wellcome Trust Research Programme | Nabwera H.M.,Wellcome Trust Research Programme | Mwaringa S.M.,Wellcome Trust Research Programme | Obonyo C.A.,Kilifi District Hospital | And 7 more authors.
AIDS Research and Therapy | Year: 2014

Background: An increasing number of people on antiretroviral therapy (ART) in sub-Saharan Africa has led to declines in HIV related morbidity and mortality. However, virologic failure (VF) and acquired drug resistance (ADR) may negatively affect these gains. This study describes the prevalence and correlates of HIV-1 VF and ADR among first-line ART experienced adults at a rural HIV clinic in Coastal Kenya.Methods: HIV-infected adults on first-line ART for ≥6 months were cross-sectionally recruited between November 2008 and March 2011. The primary outcome was VF, defined as a one-off plasma viral load of ≥400 copies/ml. The secondary outcome was ADR, defined as the presence of resistance associated mutations. Logistic regression and Fishers exact test were used to describe correlates of VF and ADR respectively.Results: Of the 232 eligible participants on ART over a median duration of 13.9 months, 57 (24.6% [95% CI: 19.2 - 30.6]) had VF. Fifty-five viraemic samples were successfully amplified and sequenced. Of these, 29 (52.7% [95% CI: 38.8 - 66.3]) had at least one ADR, with 25 samples having dual-class resistance mutations. The most prevalent ADR mutations were the M184V (n = 24), K103N/S (n = 14) and Y181C/Y/I/V (n = 8). Twenty-six of the 55 successfully amplified viraemic samples (47.3%) did not have any detectable resistance mutation. Younger age (15-34 vs. ≥35 years: adjusted odd ratios [95% CI], p-value: 0.3 [0.1-0.6], p = 0.002) and unsatisfactory adherence (<95% vs. ≥95%: 3.0 [1.5-6.5], p = 0.003) were strong correlates of VF. Younger age, unsatisfactory adherence and high viral load were also strong correlates of ADR.Conclusions: High levels of VF and ADR were observed in younger patients and those with unsatisfactory adherence. Youth-friendly ART initiatives and strengthened adherence support should be prioritized in this Coastal Kenyan setting. To prevent unnecessary/premature switches, targeted HIV drug resistance testing for patients with confirmed VF should be considered. © 2014 Hassan et al.; licensee BioMed Central Ltd.


Sigaloff K.C.E.,PharmAccess Foundation | Sigaloff K.C.E.,University of Amsterdam | Ramatsebe T.,University of Witwatersrand | Viana R.,University of Witwatersrand | And 4 more authors.
AIDS Research and Human Retroviruses | Year: 2012

Patients failing antiretroviral treatment for extended periods of time are at risk of accumulating HIV drug resistance mutations (DRMs), which negatively influences second-line treatment. This retrospective study assessed the rate of DRM accumulation among South African patients with continued virological failure. Serial genotypic resistance testing was performed and DRMs were scored according to the 2009 IAS-USA list. Among 43 patients, 38 (88.4%) harbored ≥1 DRM. The median time between two sequential resistance tests was 5 months (IQR: 3-10). Thymidine analogue mutations accumulated at a rate of 0.07 mutation per month of drug exposure, which is faster than previously reported. Routine virological monitoring should be implemented in resource-limited settings to preserve susceptibility to second-line regimens. © Copyright 2012, Mary Ann Liebert, Inc.


Revell A.D.,The HIV Resistance Response Database Initiative RDI | Wang D.,The HIV Resistance Response Database Initiative RDI | Harrigan R.,The Center for Excellence in AIDS | Hamers R.L.,PharmAccess Foundation | And 5 more authors.
Journal of Antimicrobial Chemotherapy | Year: 2010

In the absence of widespread access to individualized laboratory monitoring, which forms an integral part of HIV patient management in resource-rich settings, the roll-out of highly active antiretroviral therapy (HAART) in resource-limited settings has adopted a public health approach based on standard HAART protocols and clinical/immunological definitions of therapy failure. The cost-effectiveness of HIV-1 viral load monitoring at the individual level in such settings has been debated, and questions remain over the long-term and population-level impact of managing HAART without it. Computational models that accurately predict virological response to HAART using baseline data including CD4 count, viral load and genotypic resistance profile, as developed by the Resistance Database Initiative, have significant potential as an aid to treatment selection and optimization. Recently developed models have shown good predictive performance without the need for genotypic data, with viral load emerging as by far the most important variable. This finding provides further, indirect support for the use of viral load monitoring for the long-term optimization of HAART in resource-limited settings. © The Author 2010. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved.


Alhassan R.K.,University of Ghana | Alhassan R.K.,University of Amsterdam | Nketiah-Amponsah E.,University of Ghana | Spieker N.,PharmAccess Foundation | And 3 more authors.
BMC Health Services Research | Year: 2016

Background: Barely a decade after introduction of Ghana's National Health Insurance Scheme (NHIS), significant successes have been recorded in universal access to basic healthcare services. However, sustainability of the scheme is increasingly threatened by concerns on quality of health service delivery in NHIS-accredited health facilities coupled with stakeholders' discontentment with the operational and administrative challenges confronting the NHIS. The study sought to ascertain whether or not Systematic Community Engagement (SCE) interventions have a significant effect on frontline health workers' perspectives on the NHIS and its impact on quality health service delivery. Methods: The study is a randomized cluster trial involving clinical and non-clinical frontline health workers (n = 234) interviewed at baseline and follow-up in the Greater Accra and Western regions of Ghana. Individual respondents were chosen from within each intervention and control groupings. Difference-in-difference estimations and propensity score matching were performed to determine impact of SCE on staff perceptions of the NHIS. The main outcome measure of interest was staff perception of the NHIS based on eight (8) factor-analyzed quality service parameters. Results: Staff interviewed in intervention facilities appeared to perceive the NHIS more positively in terms of its impact on "availability and quality of drugs (p < 0.05)" and "workload on health staff/infrastructure" than those interviewed in control facilities (p < 0.1). Delayed reimbursement of service providers remained a key concern to over 70 % of respondents in control and intervention health facilities. Conclusion: Community engagement in quality service assessment is a potential useful strategy towards empowering communities while promoting frontline health workers' interest, goodwill and active participation in Ghana's NHIS. © 2016 Alhassan et al.


Alhassan R.K.,University of Ghana | Alhassan R.K.,University of Amsterdam | Spieker N.,PharmAccess Foundation | van Ostenberg P.,Joint Commission International JCI | And 4 more authors.
Human Resources for Health | Year: 2013

Background: Ghana is one of the sub-Saharan African countries making significant progress towards universal access to quality healthcare. However, it remains a challenge to attain the 2015 targets for the health related Millennium Development Goals (MDGs) partly due to health sector human resource challenges including low staff motivation.Purpose: This paper addresses indicators of health worker motivation and assesses associations with quality care and patient safety in Ghana. The aim is to identify interventions at the health worker level that contribute to quality improvement in healthcare facilities.Methods: The study is a baseline survey of health workers (n = 324) in 64 primary healthcare facilities in two regions in Ghana. Data collection involved quality care assessment using the SafeCare Essentials tool, the National Health Insurance Authority (NHIA) accreditation data and structured staff interviews on workplace motivating factors. The Spearman correlation test was conducted to test the hypothesis that the level of health worker motivation is associated with level of effort by primary healthcare facilities to improve quality care and patient safety.Results: The quality care situation in health facilities was generally low, as determined by the SafeCare Essentials tool and NHIA data. The majority of facilities assessed did not have documented evidence of processes for continuous quality improvement and patient safety. Overall, staff motivation appeared low although workers in private facilities perceived better working conditions than workers in public facilities (P <0.05). Significant positive associations were found between staff satisfaction levels with working conditions and the clinic's effort towards quality improvement and patient safety (P <0.05).Conclusion: As part of efforts towards attainment of the health related MDGs in Ghana, more comprehensive staff motivation interventions should be integrated into quality improvement strategies especially in government-owned healthcare facilities where working conditions are perceived to be the worst. © 2013 Alhassan et al.; licensee BioMed Central Ltd.


PubMed | University of Ghana and PharmAccess Foundation
Type: | Journal: BMC health services research | Year: 2016

Barely a decade after introduction of Ghanas National Health Insurance Scheme (NHIS), significant successes have been recorded in universal access to basic healthcare services. However, sustainability of the scheme is increasingly threatened by concerns on quality of health service delivery in NHIS-accredited health facilities coupled with stakeholders discontentment with the operational and administrative challenges confronting the NHIS. The study sought to ascertain whether or not Systematic Community Engagement (SCE) interventions have a significant effect on frontline health workers perspectives on the NHIS and its impact on quality health service delivery.The study is a randomized cluster trial involving clinical and non-clinical frontline health workers (n=234) interviewed at baseline and follow-up in the Greater Accra and Western regions of Ghana. Individual respondents were chosen from within each intervention and control groupings. Difference-in-difference estimations and propensity score matching were performed to determine impact of SCE on staff perceptions of the NHIS. The main outcome measure of interest was staff perception of the NHIS based on eight (8) factor-analyzed quality service parameters.Staff interviewed in intervention facilities appeared to perceive the NHIS more positively in terms of its impact on availability and quality of drugs (p<0.05) and workload on health staff/infrastructure than those interviewed in control facilities (p<0.1). Delayed reimbursement of service providers remained a key concern to over 70% of respondents in control and intervention health facilities.Community engagement in quality service assessment is a potential useful strategy towards empowering communities while promoting frontline health workers interest, goodwill and active participation in Ghanas NHIS.


Nichols B.E.,Erasmus Medical Center | Sigaloff K.C.E.,PharmAccess Foundation | Sigaloff K.C.E.,University of Amsterdam | Kityo C.,Joint Clinical Research Center | And 9 more authors.
AIDS | Year: 2014

Background: Earlier antiretroviral therapy initiation can reduce the incidence of HIV-1. This benefit can be offset by increased transmitted drug resistance (TDR). We compared the preventive benefits of reducing incident infections with the potential TDR increase in East Africa. Methods: A mathematical model was constructed to represent Kampala, Uganda, and Mombasa, Kenya. We predicted the effect of initiating treatment at different immunological thresholds (350, 500 CD4+ cells/ml) on infections averted and mutationspecific TDR prevalence over 10 years compared to initiating treatment at CD4+ cell count below 200 cells/ml. Results: When initiating treatment at CD4+ cell count below 350 cells/ml, we predict 18 [interquartile range (IQR) 11-31] and 46 (IQR 30-83) infections averted for each additional case of TDR in Kampala and Mombasa, respectively, and 22 (IQR 17-35) and 32 (IQR 21-57) infections averted when initiating at below 500. TDR is predicted to increase most strongly when initiating treatment at CD4+ cell count below 500 cells/ml, from 8.3% (IQR 7.7-9.0%) and 12.3% (IQR 11.7-13.1%) in 2012 to 19.0% (IQR 16.5-21.8%) and 19.2% (IQR 17.1-21.5%) in 10 years in Kampala and Mombasa, respectively. The TDR epidemic at all immunological thresholds was comprised mainly of resistance to non-nucleoside reverse transcriptase inhibitors. When 80-100% of individuals with virological failure are timely switched to second-line therapy, TDR is predicted to decline irrespective of treatment initiation threshold. Conclusion: Averted HIV infections due to the expansion of antiretroviral treatment eligibility offset the risk of transmitted drug resistance, as defined by more infections averted than TDR gained. The effectiveness of first-line non-nucleoside reverse transcriptase inhibitor-based therapy can be preserved by improving switching practices to second-line therapy. © 2013 Wolters Kluwer Health.


Schellekens O.,Pharmaccess Foundation | de Groot A.,Pharmaccess Foundation
Global Policy | Year: 2014

The aid model for development is broken. It has failed to deliver meaningful progress in developing countries across a wide range of development indicators. Moreover, the model is now constrained by the fiscal realities of the major donors. Its failure is a function of ignoring the institutions, formal and informal, and incentives that often work at cross purposes to donors when the state is not functioning properly. A model that recognizes and builds on the existing, often local, institutional relationships in poor countries through public private partnerships (PPPs) offers renewed possibilities for success. PPPs can create trust through enforcing existing and newly created local institutions from the bottom up and lower investment risks by using donor money as a lever to mobilize private loans and investments. These mechanisms will support economic exchange, the source of development. This paper discusses the origins of this model, the different forms it can take, and the challenges it faces. © 2013 University of Durham and John Wiley & Sons, Ltd.


Abstract In view of the recent antiretroviral therapy (ART) scale-up in Kenya, surveillance of transmitted HIV drug resistance (TDR) is important. A cross-sectional survey was conducted among newly HIV-1 diagnosed, antiretroviral-naive adults in Mombasa, Kenya. Surveillance drug resistance mutations (SDRMs) were identified according to the 2009 WHO list. HIV-1 subtypes were determined using REGA and SCUEAL subtyping tools. Genotypic test results were obtained for 68 of 81 participants, and SDRMs were identified in 9 samples. Resistance to nonnucleoside reverse transcriptase inhibitors (K103N) occurred in five participants, yielding a TDR prevalence of 7.4% (95% confidence interval 2.4-16.3%). Frequencies of HIV-1 subtypes were A (70.6%), C (5.9%), D (2.9%), and unique recombinant forms (20.6%). The TDR prevalence found in this survey is higher than previously reported in different regions in Kenya. These findings justify increased vigilance with respect to TDR surveillance in African regions where ART programs are scaled-up in order to inform treatment guidelines.


PubMed | PharmAccess Foundation
Type: Journal Article | Journal: Joint Commission journal on quality and patient safety | Year: 2016

In low- and middle-income countries (LMICs), patients often have limited access to high-quality care because of a shortage of facilities and human resources, inefficiency of resource allocation, and limited health insurance. SafeCare was developed to provide innovative health care standards; surveyor training; a grading system for quality of care; a quality improvement process that is broken down into achievable, measurable steps to facilitate incremental improvement; and a private sector-supported health financing model.Three organizations-PharmAccess Foundation, Joint Commission International, and the Council for Health Service Accreditation of Southern Africa-launched SafeCare in 2011 as a formal partnership. Five SafeCare levels of improvement are allocated on the basis of an algorithm that incorporates both the overall score and weighted criteria, so that certain high-risk criteria need to be in place before a facility can move to the next SafeCare certification level. A customized quality improvement plan based on the SafeCare assessment results lists the specific, measurable activities that should be undertaken to address gaps in quality found during the initial assessment and to meet the nextlevel SafeCare certificate.The standards have been implemented in more than 800 primary and secondary facilities by qualified local surveyors, in partnership with various local public and private partner organizations, in six sub-Saharan African countries (Ghana, Kenya, Nigeria, Namibia, Tanzania, and Zambia).Expanding access to care and improving health care quality in LMICs will require a coordinated effort between institutions and other stakeholders. SafeCares standards and assessment methodology can help build trust between stakeholders and lay the foundation for country-led quality monitoring systems.

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