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How HIV/AIDS scale-up has impacted on non- HIV priority services in Zambia

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      Abstract

      BackgroundMuch of the debate as to whether or not the scaling up of HIV service delivery in Africa benefits non-HIV priority services has focused on the use of nationally aggregated data. This paper analyses and presents routine health facility record data to show trend correlations across priority services.MethodsReview of district office and health facility client records for 39 health facilities in three districts of Zambia, covering four consecutive years (2004-07). Intra-facility analyses were conducted, service and coverage trends assessed and rank correlations between services measured to compare service trends within facilities.ResultsVCT, ART and PMTCT client numbers and coverage levels increased rapidly. There were some strong positive correlations in trends within facilities between reproductive health services (family planning and antenatal care) and ART and PMTCT, with Spearman rank correlations ranging from 0.33 to 0.83. Childhood immunisation coverage also increased. Stock-outs of important drugs for non-HIV priority services were significantly more frequent than were stock-outs of antiretroviral drugs.ConclusionsThe analysis shows scale-up in reproductive health service numbers in the same facilities where HIV services were scaling up. While district childhood immunisations increased overall, this did not necessarily occur in facility catchment areas where HIV service scale-up occurred. The paper demonstrates an approach for comparing correlation trends across different services, using routine health facility information. Larger samples and explanatory studies are needed to understand the client, facility and health systems factors that contribute to positive and negative synergies between priority services.

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      Rapid scale-up of antiretroviral therapy at primary care sites in Zambia: feasibility and early outcomes.

      The Zambian Ministry of Health has scaled-up human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) care and treatment services at primary care clinics in Lusaka, using predominately nonphysician clinicians. To report on the feasibility and early outcomes of the program. Open cohort evaluation of antiretroviral-naive adults treated at 18 primary care facilities between April 26, 2004, and November 5, 2005. Data were entered in real time into an electronic patient tracking system. Those meeting criteria for antiretroviral therapy (ART) received drugs according to Zambian national guidelines. Survival, regimen failure rates, and CD4 cell response. We enrolled 21,755 adults into HIV care, and 16,198 (75%) started ART. Among those starting ART, 9864 (61%) were women. Of 15,866 patients with documented World Health Organization (WHO) staging, 11,573 (73%) were stage III or IV, and the mean (SD) entry CD4 cell count among the 15,336 patients with a baseline result was 143/microL (123/microL). Of 1142 patients receiving ART who died, 1120 had a reliable date of death. Of these patients, 792 (71%) died within 90 days of starting therapy (early mortality rate: 26 per 100 patient-years), and 328 (29%) died after 90 days (post-90-day mortality rate: 5.0 per 100 patient-years). In multivariable analysis, mortality was strongly associated with CD4 cell count between 50/microL and 199/microL (adjusted hazard ratio [AHR], 1.4; 95% confidence interval [CI], 1.0-2.0), CD4 cell count less than 50/microL (AHR, 2.2; 95% CI, 1.5-3.1), WHO stage III disease (AHR, 1.8; 95% CI, 1.3-2.4), WHO stage IV disease (AHR, 2.9; 95% CI, 2.0-4.3), low body mass index (<16; AHR,2.4; 95% CI, 1.8-3.2), severe anemia (<8.0 g/dL; AHR, 3.1; 95% CI, 2.3-4.0), and poor adherence to therapy (AHR, 2.9; 95% CI, 2.2-3.9). Of 11,714 patients at risk, 861 failed therapy by clinical criteria (rate, 13 per 100 patient-years). The mean (SD) CD4 cell count increase was 175/microL (174/microL) in 1361 of 1519 patients (90%) receiving treatment long enough to have a 12-month repeat. Massive scale-up of HIV and AIDS treatment services with good clinical outcomes is feasible in primary care settings in sub-Saharan Africa. Most mortality occurs early, suggesting that earlier diagnosis and treatment may improve outcomes.
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        Financing of global health: tracking development assistance for health from 1990 to 2007.

        The need for timely and reliable information about global health resource flows to low-income and middle-income countries is widely recognised. We aimed to provide a comprehensive assessment of development assistance for health (DAH) from 1990 to 2007. We defined DAH as all flows for health from public and private institutions whose primary purpose is to provide development assistance to low-income and middle-income countries. We used several data sources to measure the yearly volume of DAH in 2007 US$, and created an integrated project database to examine the composition of this assistance by recipient country. DAH grew from $5.6 billion in 1990 to $21.8 billion in 2007. The proportion of DAH channelled via UN agencies and development banks decreased from 1990 to 2007, whereas the Global Fund to Fight AIDS, Tuberculosis and Malaria, the Global Alliance for Vaccines and Immunization (GAVI), and non-governmental organisations became the conduit for an increasing share of DAH. DAH has risen sharply since 2002 because of increases in public funding, especially from the USA, and on the private side, from increased philanthropic donations and in-kind contributions from corporate donors. Of the $13.8 [corrected] billion DAH in 2007 for which project-level information was available, $4.9 [corrected] billion was for HIV/AIDS, compared with $0.6 [corrected] billion for tuberculosis, $0.7 [corrected] billion for malaria, and $0.9 billion for health-sector support. Total DAH received by low-income and middle-income countries was positively correlated with burden of disease, whereas per head DAH was negatively correlated with per head gross domestic product. This study documents the substantial rise of resources for global health in recent years. Although the rise in DAH has resulted in increased funds for HIV/AIDS, other areas of global health have also expanded. The influx of funds has been accompanied by major changes in the institutional landscape of global health, with global health initiatives such as the Global Fund and GAVI having a central role in mobilising and channelling global health funds. Bill & Melinda Gates Foundation.
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          The effects of global health initiatives on country health systems: a review of the evidence from HIV/AIDS control.

          This paper reviews country-level evidence about the impact of global health initiatives (GHIs), which have had profound effects on recipient country health systems in middle and low income countries. We have selected three initiatives that account for an estimated two-thirds of external funding earmarked for HIV/AIDS control in resource-poor countries: the Global Fund to Fight AIDS, TB and Malaria, the World Bank Multi-country AIDS Program (MAP) and the US President's Emergency Plan for AIDS Relief (PEPFAR). This paper draws on 31 original country-specific and cross-country articles and reports, based on country-level fieldwork conducted between 2002 and 2007. Positive effects have included a rapid scale-up in HIV/AIDS service delivery, greater stakeholder participation, and channelling of funds to non-governmental stakeholders, mainly NGOs and faith-based bodies. Negative effects include distortion of recipient countries' national policies, notably through distracting governments from coordinated efforts to strengthen health systems and re-verticalization of planning, management and monitoring and evaluation systems. Sub-national and district studies are needed to assess the degree to which GHIs are learning to align with and build the capacities of countries to respond to HIV/AIDS; whether marginalized populations access and benefit from GHI-funded programmes; and about the cost-effectiveness and long-term sustainability of the HIV and AIDS programmes funded by the GHIs. Three multi-country sets of evaluations, which will be reporting in 2009, will answer some of these questions.
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            Author and article information

            Affiliations
            [1 ]Departmemt of Epidemiology and Public Health Medicine, Division of Population Health Sciences Division, Royal College of Surgeons in Ireland, Dublin, Ireland
            [2 ]Institute of Economic and Social Research, University of Zambia, Lusaka, Zambia
            [3 ]Department of Global Health Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
            Contributors
            Journal
            BMC Public Health
            BMC Public Health
            BioMed Central
            1471-2458
            2010
            8 September 2010
            : 10
            : 540
            2946297
            1471-2458-10-540
            20825666
            10.1186/1471-2458-10-540
            Copyright ©2010 Brugha et al; licensee BioMed Central Ltd.

            This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

            Categories
            Research Article

            Public health

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