Nsambya Community Home-Based Care Complements National HIV and TB Management Efforts and Contributes to Health Systems Strengthening in Uganda: An Observational Study
Community Home-Based Care (CHBC) has evolved in resource-limited settings to fill the unmet needs of people living with HIV/AIDS (PLHA). We compare HIV and tuberculosis (TB) outcomes from the Nsambya CHBC with national averages in Kampala, Uganda. This retrospective observational study compared HIV and TB outcomes from adults and children in the Nsambya CHBC to national averages from 2007 to 2011. Outcomes included numbers of HIV and TB patients enrolled into care, retention, loss to follow-up (LTFU), and mortality among patients on antiretroviral therapy (ART) at 12 months from initiation; new smear-positive TB cure and defaulter rates; and proportion of TB patients tested for HIV. Chi-square test and trends analyses were used to compare outcomes from Nsambya CHBC with national averages. By 2011, approximately 14,000 PLHA had been enrolled in the Nsambya CHBC, and about 4,000 new cases of TB were detected and managed over the study period. Overall, retention and LTFU of ART patients 12 months after initiation, proportion of TB patients tested for HIV, and cure rates for new smear-positive TB scored higher in the Nsambya CHBC compared to national averages. The findings show that Nsambya CHBC complements national HIV and TB management and results in more positive outcomes. 1. Background In the wake of the human immunodeficiency virus (HIV) epidemic in Sub-Saharan Africa (SSA), alternative service delivery models like the Community Home-Based Care (CHBC) [1–6] have evolved to fill the gap left by overstretched and underresourced health systems. CHBC includes any form of care (physical, psychosocial, palliative, and spiritual) given to the sick and the affected in their own homes and care extended from the hospital or health facility to their homes through family participation and community involvement [7, 8]. CHBC provides for the unmet needs of the large and growing population of PLHA in many resource-limited settings [7, 9, 10]. However, the effects of CHBC on national HIV and TB outcomes have not been examined in detail. In Uganda, the first CHBC programmes were established in 1987 in response to increasing numbers of acutely ill HIV/AIDS patients leading to congestion of hospital wards, increased staff workload, and excessive pressure on infrastructure. Three different organisations pioneered this approach: Kitovu Mobile HIV Programme, The AIDS Support Organization (TASO), and Nsambya Hospital Home Care Department, popularly known as Nsambya Home Care (NHC). TASO was started by local people, whereas, Kitovu Mobile and Nsambya Home Care were pioneered
References
[1]
UNAIDS, “UNAIDS report on the global AIDS epidemic,” Global Report, 2010, http://www.who.int/hiv/pub/global_report2010/en/.
[2]
WHO, “Taking stock: health worker shortages and the response to AIDS,” 2006, http://www.who.int/hiv/toronto2006/takingstockttr.pdf.
[3]
WHO, “Working together for health,” World Health Report, 2006, http://www.who.int/whr/2006/whr06_en.pdf.
[4]
E. Friedman, I. Katz, E. Kiley, E. Williams, and A. Lion, “Global Fund's Support for Health Systems Strengthening Interventions: a reference guide,” Health Systems 20/20 Project, Physicians for Human Rights, Bethesda, Md, USA, 2011, http://www.healthsystems2020.org/.
[5]
A. Buvé, S. Kalibala, and J. McIntyre, “Stronger health systems for more effective HIV/AIDS prevention and care,” International Journal of Health Planning and Management, vol. 18, no. 1, pp. S41–S51, 2003.
[6]
D. Maher, L. Smeeth, and J. Sekajugo, “Health transition in Africa: practical policy proposals for primary care,” Bulletin of the World Health Organization, vol. 88, no. 12, pp. 943–948, 2010.
[7]
WHO, “Community home-based care in resource-limited settings: a framework for action,” 2002, http://www.who.int/chp/knowledge/publications/comm_home_based_care/en/index.html.
[8]
N. Mohammad and J. Gikonyo, “Operational Challenges Community Home Based Care (CHBC) for PLWHA in Multi-Country Aids Programs (MAP) in Africa,” Africa Region Working Paper Series 88, 2005.
[9]
UNAIDS, “Keeping the promise: summary of the declaration of commitment on HIV/AIDS,” United Nations General Assembly Special Session on HIV/AIDS, New York, NY, USA, 2001, http://whqlibdoc.who.int/unaids/2002/9291731900_eng.pdf.
[10]
B. P. Ncama, “Models of community/home-based care for people living with HIV/AIDS in Southern Africa,” Journal of the Association of Nurses in AIDS Care, vol. 16, no. 3, pp. 33–40, 2005.
[11]
Ministry of Health Uganda, “Annual health sector performance report,” Tech. Rep., 2011-2012, http://health.go.ug/docs/AHSPR_11_12.pdf.
[12]
WHO, “The Global Plan to StopTB, 2011–2015,” 2011, http://www.who.int/tb/publications/global_plan_to_stop_tb/en/.
Ministry of Health Uganda, “National policy guidelines for Tb/Hiv collaborative activities in Uganda,” 2006, http://www.who.int/hiv/pub/guidelines/uganda.pdf.
[15]
Ministry of Health Uganda, “National antiretroviral treatment and care guidelines for adults, adolescents, and children,” 2008, http://www.who.int/hiv/amds/uganda_moh_treatment_guidelines.pdf.
[16]
UAC, 2007, Moving Toward Universal Access: National HIV & AIDS Strategic Plan 2007/8, 2011/12, Uganda AIDS Commission, Republic of Uganda http://siteresources.worldbank.org/INTHIVAIDS/Resources/375798.
[17]
S. Miti, V. Mfungwe, P. Reijer, and D. Maher, “Integration of tuberculosis treatment in a community-based home care programme for persons living with HIV/AIDS in Ndola, Zambia,” International Journal of Tuberculosis and Lung Disease, vol. 7, no. 9, supplement 1, pp. S92–S98, 2003.
[18]
F. Terris-Prestholt, L. Kumaranayake, R. Ginwalla et al., “Integrating tuberculosis and HIV services for people living with HIV: costs of the Zambian ProTEST Initiative,” Cost Effectiveness and Resource Allocation, vol. 6, article 2, 2008.
[19]
J. Uwimana, C. Zarowsky, H. Hausler, and D. Jackson, “Training community care workers to provide comprehensive TB/HIV/PMTCT integrated care in KwaZulu-Natal: lessons learnt,” Tropical Medicine and International Health, vol. 17, no. 4, pp. 488–496, 2012.
[20]
J. C. Brust, N. S. Shah, M. Scott et al., “Integrated, home-based treatment for MDR-TB and HIV in rural South Africa: an alternate model of care,” The International Journal of Tuberculosis and Lung Disease, vol. 16, no. 8, pp. 998–1004, 2012.
[21]
Uganda Bureau of Statistics, “Statistical abstract,” 2012, http://www.ubos.org/onlinefiles/uploads/ubos/pdf%20documents/2012StatisticalAbstract.pdf.
[22]
W. Massavon, R. Lundin, P. Costenaro, M. Penazzato, P. C. Namisi, et al., “Attrition and loss to follow-up among children and adolescents in a community home-based care HIV programme in uganda,” Pediat Therapeut, vol. 3, p. 183, 2013.
[23]
B. Criel, G. Kegels, and P. Van Der Stuyft, “Editorial: a framework for analysing the relationship between disease control programmes and basic health care,” Tropical Medicine and International Health, vol. 9, no. 6, pp. A1–A4, 2004.
[24]
B. Keugoung, J. Macq, A. Buvé, J. Meli, and B. Criel, “The interface between health systems and vertical programmes in Francophone Africa: the managers' perceptions,” Tropical Medicine and International Health, vol. 16, no. 4, pp. 478–485, 2011.
[25]
W. Van Damme, M. Pirard, Y. Assefa, and J. Van Olmen :, “Which health systems for disease control? How can disease control programmes contribute to health systems strengthening in Sub-Saharan Africa?” Studies in Health Services Organisation & Policy 1, Institue of Tropical Medicine, Antwerp, Belgium, 2010, www.itg.be/WPshsop.
[26]
Y. Souteyrand, M. A. Banda, J. Kaufman, J. H. Perri？ns, and D. Yu, “Investment in HIV/AIDS programs: does it help strengthen health systems in developing countries?” Globalization and Health, vol. 4, article 8, 2008.
[27]
E. Wouters, W. Van Damme, D. van Rensburg, C. Masquillier, and H. Meulemans, “Impact of community-based support services on antiretroviral treatment programme delivery and outcomes in resource-limited countries: a synthetic review,” BMC Health Services Research, vol. 12, article 194, 2012.
[28]
M. W. G. Brinkhof, M. Pujades-Rodriguez, and M. Egger, “Mortality of patients lost to follow-up in antiretroviral treatment programmes in resource-limited settings: systematic review and meta-analysis,” PLoS ONE, vol. 4, no. 6, Article ID e5790, 2009.
[29]
M. Egger, B. D. Spycher, J. Sidle et al., “Correcting mortality for loss to follow-up: a nomogram applied to antiretroviral treatment programmes in sub-Saharan Africa,” PLoS Medicine, vol. 8, no. 1, Article ID e1000390, 2011.
[30]
J. K. Yu, S. C. Chen, K. Y. Wang et al., “True outcomes for patients on antiretroviral therapy who are “lost to follow-up” in Malawi,” Bull World Health Organ, vol. 85, no. 7, pp. 550–554, 2007.
[31]
A. D. Harries, R. Zachariah, S. D. Lawn, and S. Rosen, “Strategies to improve patient retention on antiretroviral therapy in sub-Saharan Africa,” Tropical Medicine and International Health, vol. 15, no. 1, pp. 70–75, 2010.
[32]
M. Maruza, M. F. P. Milit？o Albuquerque, I. Coimbra et al., “Risk factors for default from tuberculosis treatment in HIV-infected individuals in the state of Pernambuco, Brazil: a prospective cohort study,” BMC Infectious Diseases, vol. 11, article 351, 2011.
[33]
K. Mungrue, A. Beharry, J. Kalloo et al., “Trends in HIV/TB coinfection in Trinidad and Tobago for the period 1998–2007,” Journal of the International Association of Physicians in AIDS Care, vol. 8, no. 3, pp. 170–175, 2009.
[34]
WHO, “Antiretroviral therapy for hiv infection in infants and children: towards universal access,” Recommendations for a public health approach, 2010, http://www.who.int/hiv/pub/paediatric/infants2010/en/index.html.
[35]
WHO, “Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection,” Recommendations for a public health approach, 2013, http://apps.who.int/iris/bitstream/10665/85321/1/9789241505727_eng.pdf.
[36]
G. Tembo, H. Friesan, G. Asiimwe-Okiror et al., “Bed occupancy due to HIV/AIDS in an urban hospital medical ward in Uganda,” AIDS, vol. 8, no. 8, pp. 1169–1171, 1994.
[37]
M. Fabiani, S. Accorsi, R. Aleni et al., “Estimating HIV prevalence and the impact of HIV/AIDS on a Ugandan hospital by combining serosurvey data and hospital discharge records,” Journal of Acquired Immune Deficiency Syndromes, vol. 34, no. 1, pp. 62–66, 2003.
[38]
A. Buvé, “AIDS and hospital bed occupancy: an overview,” Tropical Medicine and International Health, vol. 2, no. 2, pp. 136–139, 1997.
[39]
G. Arthur, S. M. Bhatt, D. Muhindi, G. A. Achiya, S. M. Kariuki, and C. F. Gilks, “The changing impact of HIV/AIDS on Kenyatta National Hospital, Nairobi from 1988/89 through 1992 to 1997,” AIDS, vol. 14, no. 11, pp. 1625–1631, 2000.
[40]
T. Puthanakit, L. Aurpibul, P. Oberdorfer et al., “Hospitalization and mortality among HIV-infected children after receiving highly active antiretroviral therapy,” Clinical Infectious Diseases, vol. 44, no. 4, pp. 599–604, 2007.
[41]
R. M. Viani, M. R. G. Araneta, J. G. Deville, and S. A. Spector, “Decrease in hospitalization and mortality rates among children with perinatally acquired HIV type 1 infection receiving highly active antiretroviral therapy,” Clinical Infectious Diseases, vol. 39, no. 5, pp. 725–731, 2004.
[42]
D. M. Gibb, T. Duong, P. A. Tookey et al., “Decline in mortality, AIDS, and hospital admissions in perinatally HIV-1 infected children in the United Kingdom and Ireland,” British Medical Journal, vol. 327, no. 7422, pp. 1019–1023, 2003.
[43]
K. Kober and W. Van Damme, Expert Patients And AIDS Care: A Literature Review on Expert Patient Programmes in High-Income Countries, and an Exploration of Their Relevance for HIV/AIDS Care in Low-Income Countries with Severe Human Resource Shortages, Institute of Tropical Medicine, Antwerp, Belgium, 2006.
[44]
E. F. Nsutebu, J. D. Walley, E. Mataka, and C. F. Simon, “Scaling-up HIV/AIDS and TB home-based care: lessons from Zambia,” Health Policy and Planning, vol. 16, no. 3, pp. 240–247, 2001.
[45]
B. Tewodros, R. Freya, A. Yibeltal, B. Atakilti, and W. Van Damme, “Disease control programs contribution to Health System Strengthening: good practices and new approaches for scale up,” Working Paper Series of the Studies in Health Services Organisation and Policy 4, Federal Ministry of Health, Ethiopia and the Institute of Tropical Medicine, Antwerp, Belgium, 2011.
[46]
WHO, “WHO Global Health Sector Strategy on HIV/AIDS, 2011–2015,” 2011, http://whqlibdoc.who.int/publications/2011/9789241501651_eng.pdf.
[47]
C. Potter and R. Brough, “Systemic capacity building: A hierarchy of needs,” Health Policy and Planning, vol. 19, no. 5, pp. 336–345, 2004.
[48]
F. Rasschaert, M. Pirard, M. P. Philips et al., “Positive spill-over effects of ART scale up on wider health systems development: Evidence from Ethiopia and Malawi,” Journal of the International AIDS Society, vol. 14, supplement 1, article s3, 2011.
[49]
R. Brugha, J. Simbaya, A. Walsh, P. Dicker, and P. Ndubani, “How HIV/AIDS scale-up has impacted on non- HIV priority services in Zambia,” BMC Public Health, vol. 10, article 540, 2010.
