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      Population level usage of health services, and HIV testing and care, prior to decentralization of antiretroviral therapy in Agago District in rural Northern Uganda

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          Abstract

          Background Decentralization of ART services scaled up significantly with the country wide roll out of option B plus in Uganda. Little work has been undertaken to examine population level access to HIV care particularly in hard to reach areas in rural Africa. Most work on ART scale up has been done at health facility level which omits people not accessing healthcare in the community. This study describes health service usage, particularly HIV testing and care in 2/6 parishes of Lapono sub-county of northern Uganda, prior to introduction of ART services in Lira Kato Health Centre (a local lower-level health centre III), as part of ART decentralization. Methods Household and individual questionnaires were administered to household members (aged 15–59 years). Logit random effects models were used to test for differences in proportions (allowing for clustering within villages). Results 2124 adults from 1351 households were interviewed (755 [36 %] males, 1369 [64 %] females). 2051 (97 %) participants reported seeking care locally for fever, most on foot and over half at Lira Kato Health Centre. 574 (76 %) men and 1156 (84 %) women reported ever-testing for HIV (P < 0.001 for difference); 34/574 (6 %) men and 102/1156 (9 %) women reported testing positive (P = 0.04). 818/850 (96 %) women who had given birth in the last 5 years had attended antenatal care in their last pregnancy: 7 women were already diagnosed with HIV (3 on ART) and 790 (97 %) reported being tested for HIV (34 tested newly positive). 124/136 (91 %) HIV-positive adults were in HIV-care, 123/136 (90 %) were taking cotrimoxazole and 74/136 (54 %) were on ART. Of adults in HIV-care, most were seen at Kalongo hospital (n = 87), Patongo Health Centre (n = 7) or Lira Kato Health Centre (n = 23; no ART services). 58/87, 5/7 and 20/23 individuals walked to Kalongo hospital (56 km round-trip, District Health Office information), Patongo Health Centre (76 km round-trip, District Health Office information) and Lira Kato Health Centre (local) respectively. 8 HIV-infected children were reported; only 2 were diagnosed aged <24 months: 7/8 were in HIV-care including 3 on ART. Conclusions Higher proportions of women compared to men reported ever-testing for HIV and testing HIV-positive, similar to other surveys. HIV-infected men and women travelled considerable distances for ART services. Children appeared to be under-accessing testing and referral for treatment. Decentralization of ART services to a local health facility would decrease travel time and transport costs, making care and treatment more easily accessible. Electronic supplementary material The online version of this article (doi:10.1186/s12913-015-1194-4) contains supplementary material, which is available to authorized users.

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          Most cited references11

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          Implementing antiretroviral therapy in rural communities: the Lusikisiki model of decentralized HIV/AIDS care.

          Health worker shortages are a major bottleneck to scaling up antiretroviral therapy (ART), particularly in rural areas. In Lusikisiki, a rural area of South Africa with a population of 150,000 serviced by 1 hospital and 12 clinics, Médecins Sans Frontières has been supporting a program to deliver human immunodeficiency virus (HIV) services through decentralization to primary health care clinics, task shifting (including nurse-initiated as opposed to physician-initiated treatment), and community support. This approach has allowed for a rapid scale-up of treatment with satisfactory outcomes. Although the general approach in South Africa is to provide ART through hospitals-which seriously limits access for many people, if not the majority of people-1-year outcomes in Lusikisiki are comparable in the clinics and hospital. The greater proximity and acceptability of services at the clinic level has led to a faster enrollment of people into treatment and better retention of patients in treatment (2% vs. 19% lost to follow-up). In all, 2200 people were receiving ART in Lusikisiki in 2006, which represents 95% coverage. Maintaining quality and coverage will require increased resource input from the public sector and full acceptance of creative approaches to implementation, including task shifting and community involvement.
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            Impact of geographic and transportation-related barriers on HIV outcomes in sub-Saharan Africa: a systematic review.

            Difficulty obtaining reliable transportation to clinic is frequently cited as a barrier to HIV care in sub-Saharan Africa (SSA). Numerous studies have sought to characterize the impact of geographic and transportation-related barriers on HIV outcomes in SSA, but to date there has been no systematic attempt to summarize these findings. In this systematic review, we summarized this body of literature. We searched for studies conducted in SSA examining the following outcomes in the HIV care continuum: (1) voluntary counseling and testing, (2) pre-antiretroviral therapy (ART) linkage to care, (3) loss to follow-up and mortality, and (4) ART adherence and/or viral suppression. We identified 34 studies containing 52 unique estimates of association between a geographic or transportation-related barrier and an HIV outcome. There was an inverse effect in 23 estimates (44 %), a null association in 26 (50 %), and a paradoxical beneficial impact in 3 (6 %). We conclude that geographic and transportation-related barriers are associated with poor outcomes across the continuum of HIV care.
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              Adult mortality and antiretroviral treatment roll-out in rural KwaZulu-Natal, South Africa

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                Author and article information

                Journal
                BMC Health Services Research
                BMC Health Serv Res
                Springer Science and Business Media LLC
                1472-6963
                June 2015
                November 28 2015
                June 2015
                : 15
                : 1
                Article
                10.1186/s12913-015-1194-4
                e81acdcb-f15c-40fa-acfc-c8feda1ed3ea
                © 2015

                http://www.springer.com/tdm

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