Evaluating Antiretroviral Therapy Service Delivery Models Through Lot Quality Assurance Sampling in Central Uganda

Semei Christopher Mukama,1 Jane Senyondo Nakawesi,1 Dedrix Stephenson Bindeeba,1 Simon Ezajobo,1 Andrew Mugisa,1 Catherine Senyimba,1 Eve Namitala,1 Robert Onzima DDM Anguyo,2 Simon Peter Katongole,3 Barbara Mukasa1 1Mildmay Uganda, Kampala, Uganda; 2Department of International Public Health, Liverpool School of Tropical Medicine (LSTM), Kampala, Uganda; 3Department of Public Health, Gudie University Project, Kampala, UgandaCorrespondence: Simon Peter Katongole, Email [email protected]: This study evaluated the effectiveness and responsiveness of differentiated Human Immunodeficiency Virus (HIV)/Acquired Immuno-Deficiency Syndrome (AIDS) service delivery models (DSDMs) implemented to enhance antiretroviral therapy (ART) access and outcomes for patients while addressing Tuberculosis (TB)-HIV integration, focusing on four of the five DSDMs currently implemented in Uganda.Methodology: A descriptive cross-sectional survey was conducted in eight districts of central Uganda using Lot Quality Assurance Sampling approach from 7th to 23rd March 2023. We randomly sampled 2668 patients who have been on ART for at least 1 year in a Facility-Based Individual Management (FBIM) model or in a non-FBIM DSDM for at least one year. Data were collected through patient interviews and review of records in ART and DSDM registers as well as ART cards. We analyzed the data in proportions, comparing the selected ART outcome and responsiveness indicators between Community Client Led ART Distribution (CCLAD), Community Drugs Distribution Point (CDDP) and Fast-Track Drug Refill (FTDR) DSDMs with the standard care (FBIM) model. The ART outcome variables include patients retained in the 1st line of the ART regimen, patients in World Health Organization clinical stage 1 during the last facility visit, patients who had no CD4 request during the past 12 months, viral load suppression, ART adherence, and patients who reported that they did not experience HIV/AIDS-related symptoms in the past 6 months. The variables on TB care include screening for TB using the intensified case finding form and patients tested positive for TB. Responsiveness variables include the perceived; travel time for ART refill, travel distance for ART refill, convenience and flexibility during ART refill, cost of travel for ART refill, fear of being seen at ART refill point, waiting time before service, adequacy of service time, crowding and risk of infections, social support, ability to address ART treatment challenges, HIV status disclosure and barriers to access. Non-overlap in 95% confidence interval in indicator proportion between non-FBIM DSDM and FBIM means a statistically significant difference in proportion, or otherwise non-significant.Results: Higher proportions of ART patients in the CCLAD and CDDP DSDMs adhered to ART, had suppressed viral load, and a lower TB prevalence than those in FBIM model. Additionally, more CCLAD and CDDP clients reported shorter travel time and distance to access ART than their counterparts in the FBIM model. Compared to FBIM model, higher proportions of those in CCLAD and CDDP also reported flexibility in ART refill scheduling, reduced transport costs, fewer privacy concerns, less HIV/AIDS-related stigma, shorter waiting times, more efficient services, decreased congestion at ART pickup sites, enhanced peer support, improved problem-solving assistance, and increased HIV status disclosure. The FTDR model outperformed FBIM in proportions with fewer requests for CD4 testing, viral load suppression, as well as proportions of clients who reported; shorter travel time, lower transportation cost, decreased privacy concerns, shorter waiting time, and efficient service provision. Compared to both CDDP and FTDR, the FBIM had a higher proportion of clients remain on the first-line ART regimen.Conclusion: Community-based DSDMs show responsiveness to clients’ needs without compromising the effectiveness of ART care for patients. Although FTDR also demonstrates high effectiveness and responsiveness for clients on ART, there is potential for further improvement. Planners and implementers of ART programs should consider both demand- and supply-side innovations to sustain the continuation of DSDMs.Keywords: HIV/AIDS, TB-HIV, DSDM, LQA

Knowledge of Tuberculosis Prevention Across Eight Districts in Central Uganda: An Analysis of Lot Quality Assurance Sampling Survey Data

Robert Onzima DDM Anguyo,1 Semei Christopher Mukama,2 Dedrix Stephenson Bindeeba,2 Catherine Senyimba,2 Simons Ezajobo,2 Jane Senyondo Nakawesi,2 Andrew Mugisa,2 Susan Kiwanuka Nakubulwa,2 Eve Namitala,2 Ronald Mulebeke,2 Yvonne Karamagi,2 Simon Peter Katongole3 1Department of International Public Health, Liverpool School of Tropical Medicine, Uganda (LSTM-Uganda), Kampala, Uganda; 2Mildmay Uganda, Kampala, Uganda; 3Department of Public Health, Gudie University Project, Kampala, UgandaCorrespondence: Robert Onzima DDM Anguyo, Email [email protected]: This study assessed tuberculosis (TB)-related knowledge among people of different demographic groups that is essential for effective TB program planning and implementation.Materials and Methods: We conducted a cross-sectional study using the lot quality assurance sampling (LQAS) methodology in 8 districts, stratifying each district into five supervision areas (SAs). We randomly sampled 19 villages from each SA using probability proportional to size (PPS). We interviewed 2280 respondents, including 760 each of youth 15– 24 years, women 15– 49 years and men 15+ years. The data were analyzed in proportions and SA-level classifications using the LQAS-based decision rules.Results: The findings underscore variations in TB knowledge across demographic groups. Among youths, knowledge of at least two TB symptoms stood at 48.6%, while among women and men, it was 55.3% and 57.0%, respectively. Awareness of TB curability was 75.6% among youths, 80.2% among women, and 84.6% among men. A notable proportion of youths (83.4%), women (89.5%), and men (91.4%) were aware of the potential coexistence of HIV and TB. Concerning actions to take if a family member is suspected of having TB, 89.4% of youth, 92.4% of women, and 57.5% of men were knowledgeable. Knowledge of the risks of incomplete TB treatment was noted among 30.9% of youth, 33.0% of women, and 35.0% of men.Conclusion: There is variation in the level of knowledge across different TB thematic areas between demographic groups, districts and sub-districts (SAs). Planners and implementers of TB programs should be cognizant of such variations and make deliberate efforts to develop tailored interventions in order to address the information and/or education needs of specific contexts in order to improve TB outcomes. The findings highlight the need to particularly target the youth with education programs on TB.Plain Language summary: This study assessed how much different groups of people know about tuberculosis (TB).Why was the study done?: The goal was to find out how well people from different age groups and genders understand TB. Understanding this is important for planning and improving TB health programs.What methods did we employ?: We selected 2280 people across eight districts. We divided each district into five sub-divisions and selected 19 villages from each sub-division. From each village, we interviewed one each of youth aged 15– 24, women aged 15– 49, and men aged 15 years or older.What did we find?: Young people who knew about at least two TB symptoms were 48.6%, compared to 55.3% of women and 57.0% of men.Awareness that TB can be cured was 75.6% among youths, 80.2% among women, and 84.6% among men.Most people knew that TB and HIV can occur together: 83.4% of youths, 89.5% of women, and 91.4% of men.About actions to take if someone in their family might have TB, 89.4% of youths, 92.4% of women, and 57.5% of men were aware.Knowledge about the dangers of not finishing TB treatment was lower, with only 30.9% of youths, 33.0% of women, and 35.0% of men aware.Districts have differences in the amount of people who know about the different areas concerning TB.What do these results mean?: People’s knowledge about TB varies by age, gender, and location. TB programs need to consider these differences and create targeted education to improve understanding and control of TB. Planners and implementers of TB programs need to particularly target the youth with education programs on TB.Keywords: tuberculosis knowledge, central Uganda, youth 15– 24 years, women 15– 49 years, men 15+ year

Symptoms and concerns among children and young people with life limiting and life-threatening conditions: A systematic review highlighting meaningful health outcomes

Background: The design and provision of quality pediatric palliative care should prioritize issues that matter to children and their families for optimal outcomes. Objective: This review aims to identify symptoms, concerns and outcomes that matter to children and young people (“young people”) with terminal illnesses and their families. Findings from the systematic review will inform the development of a relevant framework of health outcomes. Method: This is a systematic literature review across multiple databases for identification of eligible primary evidence. Data sources included PsycINFO, MEDLINE, Embase, CINAHL, OpenGrey, and Science Direct Journals, searched from 1 August 2016 to 30 July 2017. The study also incorporates consultations with experts in the field, citation searches via Scopus, and a hand search of reference lists of included studies. Results: Of the 13,567 articles that were evaluated, 81 studies were included. Most of these studies (n = 68) were from high-income countries and foused on young people with cancer (n = 58). A total of 3236 young people, 2103 family carers, 108 families, and 901 healthcare providers were included in the studies. Young people did not contribute to data in 30% of studies. Themes on priority concerns are presented by the following domains and health outcomes: (1) physical (n = 62 studies), e.g., physical symptoms; (2) psychological (n = 65), e.g., worry; (3) psychosocial (n = 31), e.g., relationships; (4) existential (n = 37), e.g., existential loss; and (5) “other” (n = 39), e.g., information access. Conclusion: Burdensome symptoms and concerns affect young people with malignant and nonmalignant conditions and occur across the disease trajectory; pediatric palliative care should not be limited to the end-of-life phase. A child–family-centered framework of health outcomes, spanning the patient, family, and quality of service levels is proposed to inform service development. Future research should address gaps identified across the literature (i.e., the involvement of young people in research, evidence for developing countries, and a focus on nonmalignant conditions