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Abstract

Background: Swaziland has the highest national incidence of tuberculosis (TB) in the world, with treatment success rates well below the 85 % international target. Treatment support as part of comprehensive TB services is a core component of the Stop TB Strategy. This study investigated the effects of financial incentives for treatment supporters on TB treatment outcomes in Swaziland.

Methods: This was a controlled study that compared treatment outcomes for patients with a treatment supporter who received or did not receive a financial incentive.

Results: The intervention group had a higher chance of treatment success as compared with the control group: 73 % (95 % confidence intervals [CIs] 66–80 %) versus 60 % (95 % CIs 57–64 %), respectively, p = 0.003. This improvement remained significant when treatment success rates were adjusted for differences in baseline characteristics, with the effect of incentivised treatment supporters on treatment outcomes having an odds ratio (OR) of 1.8. There was also a significant improvement in the death rate in the intervention group, as compared with the control group (10.6 versus 23.5 %, p = <0.001).

Conclusion: Incentives provided to TB treatment supporters appear to significantly improve TB treatment outcomes. Incentivising treatment support may be appropriate as an effective addition to support and supervision measures (199 words).

Find more: Kliner-et-al-2015-Effects-of-financial-incentives-for-treatment-supporters-on-tuberculosis-treatment-outcomes-in-Swaziland-a-pragmatic-interventional-study


Abstract

Background: Mobile technology has great potential to improve adherence and treatment outcomes in healthcare settings. However, text messaging and phone calls are unaffordable in many resource-limited areas. This study investigates the use of a no-cost alternative mobile phone technology using missed calls (‘buzzing’) to act as a patient reminder. The use of missed calls as a patient reminder was evaluated for feasibility and effectiveness as an appointment reminder in the follow-up of newly-diagnosed human immunodeficiency virus (HIV) positive patients in an HIV testing and counselling department in rural Swaziland.

Methods: This pilot study uses a before-and-after operational research study design, with all patients with mobile phones being offered the intervention. The primary outcome was the rate of attendance at the HIV testing and counselling department for collection of results in those with mobile phones before and after the introduction of the intervention.

Results: Over two-thirds, 71.8% (459/639), of patients had a mobile phone. All patients with a mobile phone consented to being buzzed. There was no difference in attendance for follow-up at the clinic before and after the intervention was implemented (80.1% versus 83.3%, p = 0.401), or after adjusting for confounding factors (OR 1.13, p = 0.662).

Conclusion: This pilot study illustrates that mobile technology may be feasible in rural, resource-poor settings as there are high rates of mobile phone ownership and the intervention had a 100% uptake rate, with positive feedback from staff and patients. In this particular setting, the intervention did not improve attendance rates. However, further research is planned to investigate the impact on adherence to appointments and medications in other settings, such as HIV chronic care follow-up and as part of an enhanced package to improve adherence.

Find more: Kliner-et-al.-2013-Using-no-cost-mobile-phone-reminders-to-improve-attendance-for-HIV-test-results-a-pilot-study-in-rural-Swaziland_


  1. Introduction prevailing paradigm explaining the immunologic mechanism underlying this epidemiologic phenomenon is that HIV

Compared to HIV-uninfected individuals living with                               eliminates CD4 T cells, including those presumed to be

Mycobacterium tuberculosis infection (MTBI), people living essential for Mtb control. Interferon-gamma (IFN-) production by T cells in response to an Mtb stimulus is the standard immunologic test for MTBI; however, this measurement does not differentiate MTBI from TB disease. Since progression along the TB disease spectrum is a major predictor of mortality for PLHIV, there is a critical need for clinical immune biomarkers that reliably predict a patient’s precise TB condition.

Multiparametric analyses of the immune system have illuminated our insight of the mechanisms of disease pathogenesis and protection [4–10]. It is clear now that the immune response to any given pathogen is complex and multifaceted [11]. Thus, relying on a single immunologic measure to yield an accurate diagnosis is suboptimal and perhaps even misleading. Understanding the dynamics of an immune equilibrium between competing responses may improve our predictive capacity for clinical outcome (see Supplemental Figure 1 in Supplementary Material available online at http://dx.doi.org/10.1155/2016/1478340). For example, during TB infection, anti-inflammatory agents (such as IL-4, IL10, and immune checkpoint inhibitors) prevent host tissue destruction due to excessive cellmediated immunity [11–14]. In contrast, excessive IL-4 or IL-10 production may result in a decreased containment of intracellular Mtb and therefore theoretically increased risk of TB disease progression [15, 16].

To evaluate if the balance between pro- and antiinflammatory CD4 T cell responses from PLHIV subjects with TB correlates with TB progression, we quantified the production of mycobacteria-specific IFN-, IL-4, and IL-10 simultaneously. We hypothesized a direct relationship between HIV disease severity and a skewing of the immune equilibrium away from cell-mediated and towards an anti-inflammatory profile. In addition, we profiled the cytokine responses from CD8, CD56+CD3NK cells, and CD3+CD4CD8CD56(Double Negative T Lymphocytes). As the CD4 T cell compartment wanes with advancing HIV disease status, these immune cell types gain prominence. For PLHIV at risk for TB disease development, our objective is to elucidate the effect of HIV progression on the balance of the antimycobacterial immune response.

Find more: HIV-Progression-Perturbs-the-Balance-of-the-Cell-Mediated-and-Anti-Inflammatory-Adaptive-and-Innate-Mycobacterial-Immune-Response-1


Find more: Ford-et-al.-1994-Bacterial-meningitis-in-Swaziland-an-18-month-prospective-study-of-its-impact


Abstract

This study explored the experience of people involved in a new community-based tuberculosis (TB) programme in rural Swaziland. Patients have their treatment observed in the community after choosing a treatment supporter (either community health worker or family member) in dialogue with the TB nurse. Interviews were conducted with TB patients, treatment supporters, clinic nurses, nurses working in the hospital-based TB team and medical staff. The study generated two main themes: (1) issues relating to the TB programme and (2) wider societal issues. Both are important, however this paper reports only the issues directly related to the TB programme.

The study found that community-based care is preferred to hospital care, which should be retained only for the very ill patients. The importance of selecting suitable patients and ensuring individualised and flexible arrangements was highlighted. Although treatment outcomes are known to have improved since introducing the new TB programme a number of issues require further attention. Communication between different levels of the health service needs to be improved and consultation communication skills, taught prior to introducing the programme, need to be refreshed. All relevant staff must be trained on the TB programme and patient education (on TB, HIV and treatment adherence) needs to be reinforced throughout TB treatment. Health education of the wider community is also needed. Ongoing support of treatment supporters must recognise that their role is not simply treatment observation. In this context, where the large majority of TB patients are HIV positive, better co-ordination with the HIV/AIDS services is required, including treatment of other HIV-related infections and home-based care for TB patients who deteriorate. Although the findings and recommendations of this study are context specific they are likely to be of relevance to other programmes. r 2005 Elsevier Ltd. All rights reserved.

Find more: Escott-et-al.-2005-Listening-to-those-on-the-frontline


Abstract

Background: Antiretroviral treatment services delivered in hospital settings in Africa increasingly lack capacity to meet demand and are difficult to access by patients. We evaluate the effectiveness of nurse led primary care based antiretroviral treatment by comparison with usual hospital care in a typical rural sub Saharan African setting.

Methods: We undertook a prospective, controlled evaluation of planned service change in Lubombo, Swaziland. Clinically stable adults with a CD4 count > 100 and on antiretroviral treatment for at least four weeks at the district hospital were assigned to either nurse led primary care based antiretroviral treatment care or usual hospital care. Assignment depended on the location of the nearest primary care clinic. The main outcome measures were clinic attendance and patient experience.

Results: Those receiving primary care based treatment were less likely to miss an appointment compared with those continuing to receive hospital care (RR 0·37, p < 0·0001). Average travel cost was half that of those receiving hospital care (p = 0·001). Those receiving primary care based, nurse led care were more likely to be satisfied in the ability of staff to manage their condition (RR 1·23, p = 0·003). There was no significant difference in loss to followup or other health related outcomes in modified intention to treat analysis. Multilevel, multivariable regression identified little inter-cluster variation.

Conclusions: Clinic attendance and patient experience are better with nurse led primary care based antiretroviral treatment care than with hospital care; health related outcomes appear equally good. This evidence supports efforts of the WHO to scale-up universal access to antiretroviral treatment in sub Saharan Africa.

Find more: Humphreys-et-al.-2010-Nurse-led-primary-care-based-antiretroviral-treatment-versus-hospital-care-a-controlled-prospective-study-in-Swaziland 


Abstract

Background: In Swaziland, as in many high HIV/TB burden settings, there is not information available regarding the household location of TB cases for identifying areas of increased TB incidence, limiting the development of targeted interventions. Data from “Butimba”, a TB REACH active case finding project, was re-analyzed to provide insight into the location of TB cases surrounding Mbabane, Swaziland.

Objective: The project aimed to identify geographical areas with high TB burdens to inform active case finding efforts.

Methods: Butimba implemented household contact tracing; obtaining landmark based, informal directions, to index case homes, defined here as relative locations. The relative locations were matched to census enumeration areas (known location reference areas) using the Microsoft Excel Fuzzy Lookup function. Of 403 relative locations, an enumeration area reference was detected in 388 (96%). TB cases in each census enumeration area and the active case finders in each Tinkhundla, a local governmental region, were mapped using the geographic information system, QGIS 2.16.

Results: Urban Tinkhundla predictably accounted for most cases; however, after adjusting for population, the highest density of cases was found in rural Tinkhundla. There was no correlation between the number of active case finders currently assigned to the 7 Tinkhundla surrounding Mbabane and the total number of TB cases (Spearman rho = −0.57 , p = 0.17) or the population adjusted TB cases (Spearman rho = 0.14, p = 0.75) per Tinkhundla.

Discussion: Reducing TB incidence in high-burden settings demands novel analytic approaches to study TB case locations. We demonstrated the feasibility of linking relative locations to more precise geographical areas, enabling data-driven guidance for National Tuberculosis Programs’ resource allocation. In collaboration with the Swazi National Tuberculosis Control Program, this analysis highlighted opportunities to better align the active case finding national strategy with the TB disease burden.

Find more: Leveraging-tuberculosis-case-relative-locations-to-enhance-case-detection-and-linkage-to-care-in-Swaziland


ABSTRACT

Objective: To implement and evaluate a formal pre-antiretroviral therapy (ART) care service at a district hospital in Swaziland.

Design: Operational research.

Setting: District hospital in Southern Africa. Participants: 1171 patients with a previous diagnosis of HIV. A baseline patient group consisted of the first 200 patients using the service. Two follow-up groups were defined: group 1 was all patients recruited from April to June 2009 and group 2 was 200 patients recruited in February 2010.

Intervention: Introduction of pre-ART careda package of interventions, including counselling; regular review; clinical staging; timely initiation of ART; social and psychological support; and prevention and management of opportunistic infections, such as tuberculosis.

Primary and secondary outcome measures: Proportion of patients assessed for ART eligibility, proportion of eligible patients who were started on ART and proportion receiving defined evidence-based interventions (including prophylactic co-trimoxazole and tuberculosis screening). Results: Following the implementation of the pre-ART service, the proportion of patients receiving defined interventions increased; the proportion of patient being

assessed for ART eligibility significantly increased (baseline: 59%, group 1: 64%, group 2: 76%; p¼0.001); the proportion of ART-eligible patients starting treatment increased (baseline: 53%, group 1:81%, group: 2, 81%; p<0.001) and the median time year of antiretroviral therapy (ART).

Find more: Burtle-2012-Introduction-and-evaluation-of-a-pre-ART-care-service-in-Swaziland-an-operational-research-study


SUMMARY

Increasingly, international health links are evolvingbetween UK health-careinstitutions and thosein developing countries, the core aims of which are to seek the transfer of ideas, knowledge, skills and training.This studyaimed to evaluate established health links, what constitutes them and how they are supported. Benefits andchallengesassociatedwiththelinks,asperceivedboth by link coordinators in the UK and their overseas partners, were explored. Fourteenlinks between health-care organizations in the UK and those in developing countries were identified and interviews were successfully conducted with 22 link coordinators:13 in the UK and nine in developing countries.

The interviews indicated that health links offer mutual benefits to both partners in terms of shared skills and the promotionofglobalawareness. Linkscanactasimportant catalysts; stimulatingincreasesininstitutionalcapacity for research and training.

They provide opportunities for personal and professionaldevelopmentofstaffandpromotethedevelopment of friendships and supportive networks between diverse communities. Many of the health links showed signs of evolving from uniprofessional links between individual institutions into broader, multidisciplinary community partnerships.

The main challenges facing health links arise from cultural differences, funding problems, communication difficulties and bureaucracy.There was broad agreement that greaterrecognition of thevalue andimportance of health links by the NHS and closer collaboration between government departments to provide support and resources couldpromotewiderandmoreeffectivelinkpartnerships.

Find more: bmj-2011-343-d4163_huber_how-define-healthSHIMS_Incidence_Justman_et_al_Lancet_HIV_Nov_15_2016


Introduction

The tuberculin skin test (TST) can be used to identify HIV-infected people who would benefit the most from longterm isoniazid preventive therapy (IPT). However, in resourceconstrained settings, implementation of the TST can be challenging. The objectives of this study were to assess the feasibility of implementing the TST for IPT initiation and to estimate the proportion of TST-positive incidence among HIV-positive patients in 2 high tuberculosis and HIV burden settings. Methods: Two prospective observational cohort studies were conducted under programmatic conditions in Mathare, an urban slum of Nairobi, Kenya, and in rural Shiselweni, Swaziland. HIV-positive adults with negative tuberculosis symptomatic screening underwent the TST. Those testing positive were started on 36-month IPT. Results: Of 897 and 1021 patients screened in Mathare and

Shiselweni, 550 and 696, respectively, were included. Median age was 38 years, 67.7% were female, and 86.8% were on antiretroviral therapy. Among TST-eligible participants, 88.0% (491/558) and 81.8% (694/848) accepted TST and 74.2% (414/558) and 77.1% (654/858) returned for test reading in Mathare and Shiselweni, respectively. The TST was positive in 49.8% (95% confidence interval: 44.9 to 54.6) in Mathare and 33.2% (95% confidence interval: 29.6 to 36.8) in Shiselweni. The 36-month IPT was accepted by 96.1% (198/206) patients in Mathare and 99.5% (216/ 217) in Shiselweni. IPT implementation at the clinics was managed with no additional staff or extra space.

Conclusion: Implementing the TST for IPT initiation was feasible and acceptable in both urban and rural resource-constrained settings.

Find more: Implementation_and_Operational_Research__.11-1-1


Background

Limited data exists to inform contact tracing guidelines in children and HIV-affected populations. We evaluated the yield and additionality of household contact and source case investigations in Swaziland, a TB/HIV high-burden setting, while prioritizing identification of childhood TB.

Find more: BUTIMBA-Intensifying-the-Hunt-for-Child-TB-in-Swaziland-through-Household-Contact-Tracing


ABSTRACT

Objective: To implement and evaluate a formal pre-antiretroviral therapy (ART) care service at a district hospital in Swaziland.

Design: Operational research.

Setting: District hospital in Southern Africa. Participants: 1171 patients with a previous diagnosis of HIV. A baseline patient group consisted of the first 200 patients using the service. Two follow-up groups were defined: group 1 was all patients recruited from April to June 2009 and group 2 was 200 patients recruited in February 2010.

Intervention: Introduction of pre-ART careda package of interventions, including counselling; regular review; clinical staging; timely initiation of ART; social and psychological support; and prevention and management of opportunistic infections, such as tuberculosis.

Primary and secondary outcome measures: Proportion of patients assessed for ART eligibility, proportion of eligible patients who were started on ART and proportion receiving defined evidence-based interventions (including prophylactic co-trimoxazole and tuberculosis screening). Results: Following the implementation of the pre-ART service, the proportion of patients receiving defined interventions increased; the proportion of patient being

assessed for ART eligibility significantly increased (baseline: 59%, group 1: 64%, group 2: 76%; p¼0.001); the proportion of ART-eligible patients starting treatment increased (baseline: 53%, group 1:81%, group: 2, 81%; p<0.001) and the median time year of antiretroviral therapy (ART).

Find more: Burtle-2012-Introduction-and-evaluation-of-a-pre-ART-care-service-in-Swaziland-an-operational-research-study-1

 


Abstract

Background: Swaziland has the highest HIV prevalence in the world and the highest estimated tuberculosis incidence rate in the world. An estimated 80% of TB patients are also infected with HIV. TB detection through intensified case finding (ICF) has yet to become a routine aspect of integrated tuberculosis and HIV care. The purpose of this study was to evaluate implementation of ICF for TB into routine integrated tuberculosis and HIV care at 16 community clinics and one district hospital in Swaziland.

Methods: Nurses and lay counsellors conducted ICF using a TB screening tool and patient pathway at all HIV service entry points in clinics and the hospital. The patient pathway had three-stages; screening, sputum smear diagnosis and TB treatment initiation. Outcomes and losses to follow up were monitored at each stage. Patient demographics, access, and service feasibility and effectiveness were compared at hospital and clinic sites.

Results: 1467 HIV patients at clinics and the hospital were screened over a 3 month period. Large losses to follow up occurred prior to the sputum diagnosis stage; only 47% (n = 172) of TB suspects provided a specimen. 28 cases of smear positive TB were diagnosed and 24 commenced treatment. People screened at clinics were significantly more likely to be female, older, and from rural or geographically remote areas (p < 0.001). There was no significant difference between the hospital and clinics sites in the proportion of all participants screened who were smear positive (x2 = 1.909; p = 0.16). The number needed to screen to detect one sputum positive TB case was 34 at clinics and 63 at the district hospital.

Conclusions: ICF was operationally feasible and became established as a routine aspect of tuberculosis and HIV integrated care. ICF in community clinics was potentially more accessible to an underserved, rural population and was as effective as the hospital service in detecting smear positive TB.

Find more: Elden-et-al.-2011-Integrating-intensified-case-finding-of-tuberculosis-into-HIV-care-an-evaluation-from-rural-Swaziland


SUMMARY

Increasingly, international health links are evolvingbetween UK health-careinstitutions and thosein developing countries, the core aims of which are to seek the transfer of ideas, knowledge, skills and training.This studyaimed to evaluate established health links, what constitutes them and how they are supported. Benefits andchallengesassociatedwiththelinks,asperceivedboth by link coordinators in the UK and their overseas partners, were explored. Fourteenlinks between health-care organizations in the UK and those in developing countries were identified and interviews were successfully conducted with 22 link coordinators:13 in the UK and nine in developing countries.

The interviews indicated that health links offer mutual benefits to both partners in terms of shared skills and the promotionofglobalawareness. Linkscanactasimportant catalysts; stimulatingincreasesininstitutionalcapacity for research and training.

They provide opportunities for personal and professionaldevelopmentofstaffandpromotethedevelopment of friendships and supportive networks between diverse communities. Many of the health links showed signs of evolving from uniprofessional links between individual institutions into broader, multidisciplinary community partnerships.

The main challenges facing health links arise from cultural differences, funding problems, communication difficulties and bureaucracy.There was broad agreement that greaterrecognition of thevalue andimportance of health links by the NHS and closer collaboration between government departments to provide support and resources couldpromotewiderandmoreeffectivelinkpartnerships.

Find more: Baguley-2006-International-health-links-an-evaluation-of-partnerships-between-healthcare-organisations-in-the-UK-and-developing-countries-1