SP R I NG20 1 7
GLOBALHEAL T H MA T E R NA LHE A L T H V OL UMEV I I I SSUEI I
Letter from the Editors Editors-in-Chief Zhenrui Liao, Diana Ruan Managing Editor (ERB) Jeremy Sherman Executive Editor (ERB) Emily Sun Managing Editor (JGH Europe) Anne Boyer Managing Editor (Online) Ricardo de Luca e Tuma
Faculty Advisors Norman J. Kleiman, Ph.D., Mailman School of Public Health, Columbia University Vincent Racaniello, Ph.D., College of Physicians and Surgeons, Columbia University Bhaven Sampat, Ph.D., Mailman School of Public Health, Columbia University
Editorial Review Board Senior Editors Smriti Kanangat, Sidney Perkins, Rahi Punjabi Associate Editors Waleed Ali, Azraf Anwar, Emily Brown, Anthony Chesebro, Joshua Choe, Hyunsoo Chung, Aimee Cicciello, Ailis Dooner, Hans Gao, Chandana Golla, Francesca Jarrett, Linnie Jiang, Rebekah, Kim, Brooke Levy, Nathan Lian, Rachel Mintz, Chidemma Nzerem, Cherry Pu, Asim Rana, Sairaj Sajjath, Ankita Saxena, Katie Tsui
JGH Online & Web Development Team Executive Web Editor Kenneth Li Web Developers Hyunsoo Chung, Carolyn Ho, Cathy Sun Associate Editors Maylis Basturk, Yanyang (Gracie) Chen, Betty Hu, Aunoy Poddar, Yameng Zhang
Design & Layout Team Executive Design Editor Julie Joohyun Lee
Business & Communications Board
The year 2016 has without a doubt been a turbulent year in the world, politically, socially, and economically, with lasting reverberations for the state of global health. A devastating Zika epidemic spread in the Americas, just as the world had begun to rebuild from the Ebola outbreak in West Africa. The global refugee crisis intensified, with the Syrian Civil War raging into its sixth year, and Da’esh consolidating power in the Middle East. Meanwhile, voters in the US and UK ushered nationalist movements back into mainstream politics. It is easy to become consumed by pessimism, but we must remember the profound link between science and hope: new innovations in smartphone technology may eliminate resource barriers in medical testing. Meanwhile, sustainable and culturally sensitive approaches are being developed to address global health issues, such as fatty liver disease. As of 2016, the number of people living in absolute poverty has halved since the 1980s, and continues to fall, while literacy, nutrition, medicine, and education are making gains. Even when the problems facing the world seem dire, it is incredibly inspiring to watch immensely talented physicians, scientists, policymakers, and others step up to fill the need. Global health is an inherently and unavoidably politicized field, but we as a journal do not take political positions. Nevertheless, we also firmly believe that questions of fundamental human rights must not become partisan, and we condemn racism, sexism, and xenophobia in all their manifestations. In the coming years, the preservation of independent dialogue about global policies and needs will become more important than ever. No matter the political circumstances, The Journal of Global Health is firmly committed to publishing original global health research, as well as to advocating for human rights, including for immigrants and refugees. This issue marks The Journal of Global Health’s sixth year of leading impactful global health discussions around the world. We are proud to present the product of months of hard work by our authors and JGH. There remains much more research to be done and many more stories to be told. The JGH team continues our mission to promote global health dialogue and impactful research in the form of our physical journal, global health podcasts, and regularly updated content on our website, www. ghjournal.org.
Zhenrui Liao Diana Ruan Editors-in-Chief
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Cover design by Julie Joohyun Lee All articles published, including research articles, perspectives and field notes, represent the opinions of the author(s) and do not reflect the official policy of JGH or of the institution(s) with which the author is affiliated, unless this is clearly indicated. Manuscripts should be submitted online via our online manuscript submission system at www. ghjournal.org. All inquiries regarding submissions, advertisments, subscriptions and permissions to republish or adapt material should be addressed to: firstname.lastname@example.org.
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Contents Academic Research Papers 3
Jiving and driving: Taxi drivers, HIV and edutainment in rural KwaZulu-Natal, South Africa Astrid Jane Treffry-Goatley
HIV Medication Adherence in Rural Mufindi District of Southern Tanzania Ryan C. Eid, Emily M. Knittle, Benjamin Belknap MD, Mary B. Carter MD PhD
Are Cash Transfer Programs Effective in Improving Maternal and Child Health in Sub-Saharan Africa? A Systematic Review of Randomized Controlled Trials Christiana Chinyere Ekezie, Kathleen Lamont, Sohinee Bhattacharya
The Impact of Material Services on the Prevention of Mother-to-Child HIV transmission (PMTCT): A Literature Review Cynthia Mouafo PiapliĂŠ
Pe r s p e c t i ve s 30
Enhancing Cancer Control in Kenya Through Knowledge Translation: A Perspective Review Joshua Munywoki, Helen Dimaras
Academic Research Jiving and driving: Taxi drivers, HIV and edutainment in rural KwaZulu-Natal, South Africa Astrid Jane Treffry-Goatley1
Postdoctoral student, Centre for Visual Methodologies for Social Change (CVMSC), School of Education, University of KwaZulu-Natal, South Africa South Africa has one of the largest HIV epidemics in the world, with close to seven million people living with HIV.1 HIV has had a major impact on the national workforce, particularly on unskilled workers such as minibus taxi drivers, who play a key role in the public transportation system. A myriad of contextual factors, including long working hours, risky sexual behaviour, inaccessible health care services and an unregulated taxi industry, place drivers at an elevated risk of HIV infection, and there is a dire need for health interventions to target this population group. Here, I describe an innovative, low-budget public engagement project that uses entertainment education, popular music and small media to engage minibus taxi drivers and their patrons in a rural South African community with a high prevalence of HIV. A series of three edutainment CDs were produced over two years, and over 1000 copies of them were freely distributed to local taxi drivers. A small-scale quantitative survey tested the reach of the intervention and its influence on HIV-related knowledge and behaviour. Results indicated that approximately half of taxi driver respondents and one-third of taxi user respondents reported exposure. While there was no significant association between exposure and knowledge or reported behaviour (p=0.335), there was a strong association between exposure and dialogue about HIV in taxis (p < 0.001). Since dialogue may represent a key step in social change, I suggest that this study be followed by a sequential explanatory study with a mixedmethods design to further explore the nature of this dialogue and its potential impact on the health-seeking behaviour of taxi drivers. 1
Introduction The HIV epidemic has had a significant impact on the national workforce in South Africa, particularly on semi-skilled and unskilled workers, who are the key drivers of the national economy.2 Minibus taxi drivers (hereafter referred to as taxi drivers) play a vital role in the national public transportation system, and yet they remain at an elevated risk of contracting HIV due to their long working hours, risky sexual behaviour, inaccessible health care services and the unregulated nature of the taxi industry.3, 4 For example, two studies of urban drivers in South Africa confirmed through qualitative and quantitative methods that while taxi drivers have some understanding of HIV
infection, HIV treatment and prevention strategies and the effects of HIV on the taxi industry, they frequently engage in risky sexual behaviour, such as having multiple and concurrent sexual relations.5,3 Additionally, drivers are known to use traditional herbal medicines to protect themselves from HIV and have difficulty accessing HIV testing and antiretroviral treatment (ART) services due to their long and irregular working hours. Moreover, even though minibus taxis are the chief form of public transport in the country, the safety and well-being of the taxi drivers is not prioritised, as the industry is not regulated by the state. On the contrary, it is a privatised and profitdriven sector that is largely controlled by individual taxi owners.3
â€œEdutainment is a potentially powerful HIV communication tool because individuals tend to identify with the stories shared in print, television or radio drama.â€?
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ACADEMIC RESEARCH Consequently, there is a great shortage of targeted Table One: Summary of CD Content health interventions, and taxi drivers remain a difficult population group for the state to reach.3 Title Aim of Product Target The large majority of drivers in South Africa are men, and it seems that prevalent gender norms may Audience pose an additional risk to the health of this population group, as it is well-documented internationally that far Uhlelo lukaMambiyela 1) Inform the public about local research fewer men visit healthcare facilities than do women.5,6 Local adults These global healthcare-seeking trends may be linked 2) Remind adults that HIV affects us all to a wide variety of context-specific factors such as Mam’Biyela’s story conceptions of masculinity, cultural stigmatization 3) Provide health information relevant to: and gendered working conditions, and have a detrimental impact on male health. For example, ● Prevention of Mother to Child while the number of men and women infected with HIV in Africa are almost the same, more men die Transmission from HIV-related causes due to their poor adherence 7,8 to ART treatment. Men in Africa also initiate ART ● Breastfeeding at a more advanced stage of HIV disease,9,10 and are 11 also more likely to interrupt treatment. Therefore, ● Tuberculosis it is apparent that these gender norms can have a detrimental impact on male health and make men ● Local HIV testing facilities more vulnerable to chronic illnesses, particularly HIV. Nonetheless, there is still a lack of attention to ● Local antiretroviral treatment (ART) men’s health in current HIV research, and funding is often angled towards other population groups, such as pregnant women and children.7 1) Inform the public about local research Local youth Entertainment education (edutainment) is defined Indaba kaDJ Tira as the ‘intentional placement of educational content in 2) Remind the youth about the high rates of entertainment messages.12 Soul City is an example of DJ Tira’s Story youth infection in the community a popular audio-visual, audio and print edutainment campaign in South Africa that focuses on combating 3) Encourage the delay of sexual debut HIV and other key social challenges.13 Edutainment is a potentially powerful HIV communication tool because individuals tend to identify with the stories 4) Promote the use of condoms shared in print, television or radio drama. This engagement can help to catalyze dialogue and debate 5) Provide information about local HIV testing around issues that are difficult to talk about, such and antiretroviral treatment (ART) services as HIV.14 In this paper, I provide a critical analysis of an independent, researcher-led communication 1) Inform the public about local research intervention called Jiving with Science, where we used Mixed small media, edutainment and popular music to target Uhlelo lukaMroza audience 2) Encourage regular and repeated HIV testing taxi drivers in rural KwaZulu-Natal and to stimulate dialogue about health and HIV. It is important to note Mroza’s Show that while I use the first person in the critical discussion 3) Remind public about the local expansion of presented in this paper, the project involved a team of HIV treatment researchers and community engagement specialists, who are listed in the acknowledgements section of the 4) Provide information about local HIV testing paper. Therefore, when describing the project design and orchestration, I use the third person to reflect this and antiretroviral treatment (ART) services team effort. South African households have relatively high levels of access to mass media channels, such as television (83.4%), cellphones (93.8%) and radio (67.9). 15 Consequently, there has been a proliferation of mass media-based HIV edutainment campaigns, such as Soul City.16 Nevertheless, while these mass media communication Jiving with Science is that these instruments can potentially spark campaigns may be effective at sharing general information with large debate about relevant issues among the audiences, and that these audiences, there is a need for more targeted media products to meet can lead to collective social change.18 Taxis have long functioned the specific health requirements of high risk population groups.4 In in South Africa as sites of community discussion, dialogue and this climate, small media, such as stickers, posters, audio CDs, videos informal education,19 and in this project, we aimed to harness this and photographs, have become popular tools in targeted health culture of ‘Taxi Talk’ by encouraging discussions about HIV in interventions.16 taxis. In the following paper, I explore how popular music, small Since we were operating in a rural community with relatively low media and edutainment were harnessed in Jiving with Science to (1) literacy levels, we designed an audio product that featured a selection reach local taxi drivers, (2) improve community knowledge of HIV of songs and stories instead of creating printed pamphlets, stickers or testing, (3) encourage uptake of local HIV testing and care services billboards.17 As storytelling is a part of everyday life in rural communities, and (4) promote interpersonal dialogue about HIV. I use the results we adopted a narrative-based approach to convey the developmental of a small-scale quantitative survey to guide this discussion and to messages at hand (Table One). We also decided to create a popular highlight the potential use of the Jiving with Science concept in future music-orientated product as taxi drivers were our key target audience interventions. and were likely to use it in their taxis, providing edutainment not only for themselves but also for their patrons. Methods The key assumption behind edutainment interventions such as Setting spring 2017 | VOL viI ISSUE iI | JGH 4
ACADEMIC RESEARCH Figure One: Survey One Music Preferences The research facility is located in the Hlabisa health sub district, which is located in the rural district of uMkhanyakude in KwaZulu-Natal. The centre is situated about two hundred kilometres north of Durban, the third largest city in South Africa. The population in the sub district consists of approximately 200,000 Zulu-speaking people, of whom 3% live in a formal urban township called KwaMsane, 20% live in peri-urban areas and the remaining 77% live in rural areas.4 Rates of unemployment are high in this area: 52.6% among adults and 61.9% among youth at the time of the 2011 national Census. HIV prevalence rates are also high: 29% in the adult population aged 15-49 years in 2011.20 Since 2004, HIV treatment and care have been delivered to the general public free of charge at healthcare clinics located in the town centre and local townships.21 By 2010, 40% of the population lived in a household with at least one member in HIV care and 25% in a household with at least one member on ART.22 The scale-up of ART has had a profound impact on population-level mortality, with a rise in adult life expectancy of 11 years between 2003 and 2011.23 interspersed with popular music tracks, targeted health/HIV Target Audiences messages and calls to action. The CDs were developed primarily Our target audience in this project consisted of local taxi drivers by the project team, but key health issues and behaviour change and their patrons. Through informal discussions with representatives goals were identified by conducting research on local health from the local taxi industry of Mtubatuba, we learned that there concerns, interviewing scientific and community engagement are approximately 400 taxi drivers and an estimated 50,000-60,000 staff and consulting community stakeholders, including local taxi weekly users of local taxis that pass through the Hlabisa health sub authorities. The data collected was used to design scripts in which district, where the research facility operates. health information was embedded in dialogue-rich, entertaining narratives. Partners in the music industry showed their support for this charitable initiative by wavering production rights on specific Table Two: Breakdown of CD Distribution popular music tracks. This allowed the product to be made on a low budget with each CD costing approximately R20 (2 US dollars) to CD 1 and produce, exclusive of salaries and other project running costs (for Recipient 2 CD 3 more production details please see.24 Taxi drivers, owners and association executives 354 415 Distribution Strategy Research Centre staff and vehicles 39 10 Six hundred copies of each CD were produced and freely Project team and selected research centre staff 51 28 distributed to research partners and project stakeholders, including Musicians and participating record labels 22 24 community authorities, shop owners and hair dressing salons. Since General public at research centre edutainment taxi drivers and users were our target audience, we gave the majority roadshows 75 60 of the CDs to the Mtubatuba Taxi Owners Association, who assisted us with their distribution. The Association is responsible for 300 taxis Local AIDS Councils, Community Advisory and the five-formal taxi ranks of the local area, and hosted the project Board and Municipalities 33 30 launch at the main taxi rank in February 2011. We used the launch as Hairdressers at local salons 9 9 an opportunity to engage drivers, informing them about the project Schools 8 0 and telling them about the content of the CDs. We also distributed Hlabisa Hospital Board 5 5 CDs One and Two directly to all of the drivers in attendance. Drivers Shops 4 19 participated in this project on a voluntary basis and were not coerced 600 600 TOTAL to receive CDs or to play them at any point. The third CD was produced at a later stage after obtaining feedback on the first two CDs, and was distributed directly by the local Taxi Association on Product Description our behalf. It is important to note that while the Association was our Jiving with Science consisted of a series of three audio CDs. key distribution partner in this project, we also engaged with drivers Each CD contained an informational narrative presented in Zulu, from the Mtubatuba â€˜Up Rank,â€™ an informal rank that is located on the other side of town. In this case, we gave the CDs directly to the drivers themselves. Table Two below provides Table Three: Quantitative Survey Details a detailed breakdown of CD Distribution. Product Evaluation No: Date Sample Purpose The CDs were evaluated using two quantitative surveys (Table Three). Gain feedback about CDs 1 and 2 Survey One Details 207 (81 taxi drivers and The aim of Survey One was to assess the feasibility Survey 1 Apr-11 and inform the development of CD and acceptability of this targeted intervention and to 126 public) obtain feedback that could inform the development of the 3. third CD. The participants comprised 81 taxi drivers and 126 members of the general public. Using a convenience 421 (127 drivers, 4 sampling methodology, five research assistants (RAs) (three men and two women) were posted at four local taxi ranks Survey 2 Oct-11 hairdressers and 290 Evaluate the impact of CD 3. for three days. These RAs were working for another project at the research site and had been appropriately trained public) to conduct this quantitative survey. They approached all of the taxi drivers and as many members of the public as possible on a given day. At no point in Surveys One or Two were respondents asked to reveal their identities, and 5
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ACADEMIC RESEARCH Table Four: Results of Survey Two QUESTION
Driver NO exposure
Driver with exposure
n= 57 (%)
Public NO exposure
Public with exposure
1. Stable Partner (SP) should test for HIV 0.619
2. SP should discuss their HIV test results. 0.241
3. SP should test for HIV regularly. 0.024
4. HIV testing is beneficial. 0.428
5. Knowledge of HIV status. 0.491
6. Had an HIV test & received results. 0.335
Yes, tested once
Yes, more than once
7. Plan to test in the future. 0.198
8. Have stable partner 0.076
all of the information provided has been kept confidential. Relevant International Review Board approval was granted through the Research Centre. Survey Two Details Once we had analysed Survey One data and determined that the intervention was feasible and had been accepted by local drivers and their patrons, we proceeded to tailor the final CD to meet the musical preferences and health needs of the target group at hand. The second
summative survey, ‘Survey Two,’ was conducted in October 2011 and specifically evaluated the influence of Uhlelo lukaMroza, which had been released three months previously. We thought that three months would be a good time period to use, since it was short enough for participants to remember information from the CDs but also allowed us to test the durability of the product over a few months. Survey Two was a convenience survey and was designed to assess the reach, coverage and frequency of the intervention, the impact on information recall and whether the product had inspired dialogue about HIV in the taxi. In total, we interviewed 421 people over five days. The participants comprised 127 taxi drivers and 290 members of the general public. The RAs were the same five who had assisted for Survey One. In this paper, while I briefly clarify the results of Survey One, I have chosen to focus on the results of Survey Two, since these results are directly relevant to my aim of exploring the influence of CD three on the HIV testing and treatment knowledge and relevant behaviour of local taxi drivers and their patrons. Survey Two Data Analysis Once the quantitative data had been collected, we used STATA statistical software programme (version 11) to conduct descriptive analysis.25 Chi-square Fishers Exact Tests were used to examine associations between exposure to the CD and information recall, reported behaviour and taxi dialogue about HIV. These models were used since they seemed best suited to answer our questions concerning the association between exposure to this edutainment product and driver and patron HIV-related knowledge and behaviour. Results EIn Survey One, we found that most participants (78 drivers and 126 passengers) were able to identify antiretroviral drugs (ARVs) as medicines to fight HIV, and almost all of them knew that condoms can protect against HIV. However, testing levels in this community still appear to be low, with less than half of the participants reporting to have tested for HIV. As it is important for both HIV treatment and prevention that people know their status, we decided to use CD Three to encourage regular and repeated HIV testing. We also referred to the results of Survey One to guide our music selection for the third CD. Responses Rate The response rates for Survey One were 81/101 (80%) and 126/160 (78%) for drivers and public respondents, respectively. The response rates for Survey Two were 290/346 (84%) and 127/173 (73%) for public and driver respondents, respectively. The mean age of driver participants was 32 years old (21 to 62 years), which was slightly older than the public respondents’ mean age of 28 years (18 to 63 years). Moreover, while public respondents consisted of 128 males and 162 females, there were only four female drivers. The small number of female drivers is unsurprising since we knew there were very few female taxi drivers in the area, although exact statistics are unavailable Survey One Summary In Survey One, we found that while most participants (78 drivers and 126 passengers) were able to identify antiretroviral drugs (ARVs) as medicines to fight HIV and almost all of them knew that condoms protect one from HIV, testing levels in this community still appeared to be low, with less than half of the participants reporting to have tested for HIV. It is important for HIV treatment and prevention that people know their status, therefore, we decided to use CD Three to encourage regular and repeated HIV testing. We also referred to the results of Survey One to guide our music selection for the third CD. Below, we have included a diagram to illustrate the results (Figure One), where it is clear that taxi drivers had a strong preference for maskanda, followed by kwaito and gospel. Exposure and Frequency of Use In terms of our objective to reach taxi drivers, we found that 70 of the 127 (coverage=55%) drivers to whom the CDs had been given reported to Survey Two. Regarding frequency of use, 35 (50%) of these 70 drivers reported that they had played CD 3 between 0-10 times, 26 (37%) that they had played it more than 10 times and 9 (13%) reported that they had never played the CD. About a quarter of the drivers (18/70) indicated that they were still using the CDs at the time, and the remaining 52 respondents (74%) indicated spring 2017 | VOL viI ISSUE iI | JGH 6
Table Five: Relationship between CD Use and Discussion about HIV in Taxis HIV Taxi Talk CD in use Discussed HIV with patron n=127
dialogue about HIV in the taxi when the CD was playing. Upon further exploration, we discovered that there was a significant association between frequency of CD usage and driver engagement with passengers about HIV and reported discussion about HIV amongst passengers (Table Five).
n = 127
Discussion Study Limitations This project is an example of how small media Frequency of CD No Yes p No Yes p value can be used by health researchers to create targeted edutainment products. We viewed this intervention as Usage value an opportunity to engage with drivers, who value music and rarely visit health services.3 Nevertheless, the lack of n% n% 0.000 n% n% 0.000 an effective distribution structure remained a challenge for this small media enterprise, with just over half of 0 times 63 1 2.3 48 16 30.2 the drivers (n=70) and 81 passengers (28%) reporting exposure, despite our attempt to work closely with the 74.1 64.4 local Taxi Association. It is possible that experimentation with newer media formats, such as MP3 tracks shared on mobile phones, or collaboration with local radio stations 0-5 times 10 11 26.2 6 8.1 15 28.3 would allow us to extend the reach of this intervention. It is also important to note that the information presented 11.7 here is drawn from a single study in a single rural area. Therefore, generalizability may be a limitation to consider 6-10 times 67 921.4 9 6 22.6 in the interpretation of the results. Nevertheless, although further testing would be required to conform this 12.1 argument, I believe that these results may be relevant in other rural and urban settings in South Africa as music More than 10 67 21 50 11 16 30.2 is enjoyed in taxis throughout this region and dialogue about HIV remains a challenge due to high levels of HIV 14.8 stigma.26 However, in urban regions, one may wish to include a text-based product such as stickers as literacy levels are generally higher in these areas. Total 85 42 74 53 Sample Size Limitations We found that attempting to administer a research survey about HIV in taxi ranks was very challenging. For Survey Two, although our five RAs spent seven full days at that they had stopped using them. In terms of reach amongst the the local ranks and approached all drivers and patrons, we struggled general public, we found that 81 of the 290 (28%) individuals that to meet our target sample size. The RAs also found that many taxi we interviewed could recall hearing the CD. drivers were simply unwilling to engage while others appeared to Impact on HIV Testing Knowledge be out on the road on short and long-distance journeys. Therefore, Concerning our objective to improve community knowledge of even though a relatively high percentage of those who allowed us to HIV testing, we found no significant association between exposure approach them agreed to participate in the survey, we came far short to CD and information recall, although there was a negative link of reaching the 400 drivers that operate in this region. When it came between exposure to CD and drivers’ belief that stable partners to public recipients, the RAs found that busy commuters simply were should test regularly for HIV (Table Four). In terms of our objective not interested in participating in the survey during their daily schedule to promote uptake of local testing treatment and care services, we did and were unwilling to be approached. Perhaps the inclusion of an not find any association between participant exposure and reported incentive of some sort in the study design, such as a competition, may behaviour change. have encouraged Inspiring greater participation Interpersonal and interest in the Dialogue initiative. However, With regard this might be to our objective to considered as a form inspire dialogue of coercion and about HIV in taxis, would need relevant we established that ethical approval. The there was a significant fact that the research association between Centre is closely exposure to the associated with CD and reported HIV research in the discussion with a region is likely to passenger about have been a further HIV (p=0.000, see deterrent for drivers Table Five below). and commuters Furthermore, 42 of alike, since high 70 (60%) drivers levels of HIV with exposure to stigma still prevail the CD reported in South Africa,26 hearing passenger and it is quite likely
“...there was a significant association between frequency of CD usage and driver engagement with passengers about HIV and reported discussion about HIV amongst passengers.”
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ACADEMIC RESEARCH that people were unwilling to engage in a discussion about this sensitive subject in a busy public environment. It is important to consider that our results may be subject to nonresponse bias since it is possible that the drivers who felt comfortable participating in the survey might have been more open to talking about HIV with their patrons than the ones who refused to participate. WTherefore, while our response rate was rather high, we did not reach the thousands of commuters that we had hoped to reach and, as a result, our sample size was radically diminished. These challenges are illustrative of the difficulty of attempting to conduct health research with mobile population groups who are often busy and literally on the move. Perhaps, in the future, we can boost participant numbers through creatively employing more qualitative evaluation methods, such as interviewing drivers and passengers on route or conducting interviews or surveys at a popular music concert arranged at the taxi rank over the weekend. Greater focus on the music and the drama in the survey may encourage participants to feel at ease and to engage with us around this stigmatized topic. Unfortunately, the small sample size is a limitation of this study as it reduced the statistical power to robustly test the hypotheses underpinning the intervention. In the future, it would be helpful to test these findings with a larger sample size. Nevertheless, our results suggest that exposure to the CD did not have a significant impact on driver or public knowledge of HIV testing and that drivers with exposure seemed less supportive of stable partners testing on a regular basis. Further research is needed to explore these results.
Conclusions and Future Study Overall, both drivers and their patrons, and drivers in particular, seem to have a good knowledge of HIV. This is in line with previous research that revealed that taxi drivers understand the dangers of HIV.3, 27 Nevertheless, as other studies have also found, this knowledge does not seem to be translated into practice. For example, even though a relatively high percentage of drivers and the public have stable partners and believe that stable partners should test regularly for HIV, less than half of all respondents had ever tested for HIV. A similar theme arose in another study, where taxi drivers reported a great fear of testing, and many preferred to use traditional medicines for prevention instead of getting tested.3 Perhaps a greater degree of participatory methodologies in the CD design, creation and implementation may have inspired greater identification with the product.28 This identification is important since it may inspire drivers and patron to apply their knowledge and understanding of HIV and to take relevant action. Indeed, as Moletsane and colleagues have noted, it is only when ‘the most marginalized themselves are engaged in identifying the issues that affect them and the possible solutions for addressing them, that interventions are more likely to
work.28 Therefore, I highly recommend that future initiatives include a much greater degree of participatory methods at all levels. Nevertheless, even though there is no clear linkage between exposure to the product and relevant behaviour change, our results suggest an association between exposure to the CD and interpersonal communication about HIV. This might be important since ‘dialogue represents a primary resource for transforming how we understand ourselves and others and the organizational worlds we inhabit’ and can be a key step in bringing about social change.18 While this is not the first time that the taxi industry has been targeted to raise HIV awareness, to our knowledge, our concept of partnering with the music industry to create an appealing and affordable HIV communication product to target rural taxi drivers is novel. Moreover, this is the first time that the performance of this type of intervention has been evaluated and shown to be a potential solution for sharing health information and stimulating dialogue about HIV in rural taxis. In terms of future research, we suggest that this study be followed by a sequential explanatory qualitative study to further explore the link between the CDs and dialogue stimulation in taxis and to better understand the nature and meaning of this dialogue. As mentioned above, I also propose that future initiatives should be more participatory in nature and actively work with local taxi authorities and the state to better understand and alter the structures that are making HIV testing so challenging for this subgroup.
Acknowledgements I would like to thank the Mtubatuba Taxi Owners Association and the local drivers and commuters for their support and participation in the project. I would also like to acknowledge the assistance of my colleagues, Mduduzi Mahlinza, John Imrie, Natsayi Chimbindi, Steven Oliver and Till Bärnighausen for their assistance with previous versions of this manuscript and for their help with quantitative data analysis. This work was supported by the Wellcome Trust [WT091342Z10Z]. References
1. UNAIDS. (2015). South Africa (2015). http:// www.unaids.org/en/regionscountries/countries/ southafrica. [retrieved Oct 22, 2017]. 2. Evian, C., Fox, M., MacLeod, W., Slotow, S. J., & Rosen, S. (2004). Prevalence of HIV in workforces in Southern Africa, 2000-2001. South African Medical Journal, 94 (2), 125-30. 3. Mchunu, G., Ncama, B., Naidoo, J., Majeke, S., Myeza, T., Ndebele, T., & Pillay, P. (2012). Kwazulu-Natal minibus taxi drivers’ perceptions on HIV and AIDS: Transmission, prevention, support and effects of the industry. Journal of Social Aspects of HIV/AIDS, 9, 210-217. 4. Tanser, F., Bärnighausen, T., Cooke, G., & Newell, M. (2009). Localized spatial clustering of HIV infections in a widely disseminated rural South African epidemic. International Journal of Epidemiology, 38, 1008–1017. 5. Ncama, B., Mchunu, G., Naidoo, J., Majeke, S., Pillay, P., Myeza T., & Ndebele T. (2013). Minibus taxi drivers’ sexual beliefs and practices associated with HIV infection and AIDS in KwaZulu-Natal, South Africa. Curationis, 36(1). http://dx.doi.org/10.4102/ curationis. v36i1.59.
6. Peacock, J., Weston M., Evans K., Daub, A., & Grieg, A. (2008). Literature Review on Men, Gender, Health and HIV and AIDS in South Africa. Johannesbureg and Cape Town: Sonke Gender Justice Network. 7. Cornell M., McIntyre J., & Myer, L. (2011). Men and antiretroviral therapy in Africa: our blindspot. Tropical Medicine International Health, 16, 828–829. 8. Taylor-Smith, K., Tweya, H., Harries, A., Schoutene, E., & Jahn, A. (2010). Gender differences in retention and survival on antiretroviral therapy of HIV-infected adults in Malawi. Malawi Medical Journal, 22, 49–56. 9. Cornell, M., Technau, K., Fairall, L., Wood, R., Moultrie, H., van Cutsem, G., … Boulle, A. (2009). Monitoring the South African national antiretroviral treatment programme 2003–2007: The IeDEA Southern Africa collaboration. South African Medical Journal, 99, 653– 660. 10. Stringer, J., Zulu, I., Levy J., Stringer, E., Mwango, A., Chi, B., … Sinkala, M. (2006). Rapid scale-up of antiretroviral therapy at primary care sites in Zambia: feasibility and early outcomes. Jama, 296,782–93. 11. Kranzer K., Lewis, J., Ford, N., Zeinecker, J., Orrell, C., Lawn, S., Bekker, L., … Wood, R. (2010). Treatment interruption in a primary care antiretroviral therapy program in South Africa: cohort analysis of trends and risk factors. Journal of Acquired Immune Deficiency Syndromes, 55, e17–23. 12. Singhal, A., & Rogers, E. M. (2002). A theoretical agenda for entertainment education, Communication Theory, 122, 117-135. 13. Tufte, T. (2008). Edutainment in HIV prevention. Building on the Soul City experience in South Africa. In Jan Servaes (Ed.). Communication for Development and Social Change (327-344). New Delhi: Sage Publications, Incorporated. 14. Tufte, T. (2005). Entertainment-education in development communication: Between marketing behaviours and empowering people. In Thomas Tufte and Oscar Hemer (Eds.). Media and Glocal Change: Rethinking Communication for Development (159174). Goteborg and Buenes Aires: Nordicom. 15. Statistics South Africa (Stats S. A). (2016). Community survey: Statistical release P0301. Pretoria: Stats SA. http://cs2016.statssa.gov.za/?portfolio_page=census2011-fact-sheet. [retrieved Oct 22, 2017]. 16. Parker, W., Dalrymple, L., & Durden, E. (2000). Communicating beyond Aids awareness: A manual for South Africa. The Department of Health, South Africa. 17. Leach, A. (1999). The provision of information to adults in rural Kwazulu-Natal, South Africa. Libri, 49, 71-89. 18. Papa, M., & Singhal, A. (2009). How entertainmenteducation programmes promote dialogue in support of social change. Journal of Creative Communications, 4, 185–208. 19. Hansen, T.B. (2006). Sounds of freedom: music, taxis, and racial imagination in urban South Africa. Public Culture, 18, 185-208. 20. Zaidi, J., Grapsa E., Tanser F., Newell M., & Bärnighausen, T. (2013). Dramatic increase in HIV prevalence after scale-up of antiretroviral treatment. AIDS, 2714. 21. Houlihan C., Bland R., Mutevedzi P., Lessells R., Ndirangu J., Thulare, H., & Newell, M. (2011). Cohort profile: Hlabisa HIV Treatment and Care Programme’, International Journal Epidemiology, 40 (2), 318-326. 22. Bor, J., Herbst, A., Newell, M., & Bärnighausen, T. (2013). Increase in adult life expectancy in rural South Africa: valuing the scale-up of HIV treatment. Science, 339, 961-965. 23. Bor, J., Bärnighausen, T., Newell, C., Tanser F., Newell, M. (2011). Social exposure to an antiretroviral treatment programme in rural KwaZulu-Natal. Tropical Medicine International Health, 16(8), 988-994. 24. Treffry-Goatley, A., Mahlinza M., & Imrie J. (2013). Public engagement with HIV in a rural, South African context: An analysis of a small media, taxi-based, edutainment model applied in Jiving with Science. Critical Arts: South-North Cultural and Media Studies, 27,112-126. 25. StataCorp. 2013. Stata Statistical Software: Release 13.1. College Station, TX: StataCorp LLC. 26. Simbayi, R., Zuma, K., Cloete, A., Jooste, S., Zimela, S., Blose, S., Wabiri, N., … Mafoko, G. (2015). The people: living with HIV stigma index: South Africa 2014: summary report. http://www.stigmaindex.org/sites/ default/files/reports/Summary-Booklet-on-StigmaIndex-Survey%20South%20Africa.pdf [retrieved Oct 22 2017]. 27. Orisatoki, R., & Oguntibeju, O. (2010). HIV-related knowledge and condom use by taxi drivers in southern St Lucia West Indies. Scientific Research and Essays, 5, 304-308. 28. Moletsane, et al. (2009) Giving a face to HIV and AIDS: on the uses of photo-voice by teachers and community health care workers working with youth in rural South Africa. Qualitative Research in Psychology, 2, 257-270.
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Academic Research HIV Medication Adherence in Rural Mufindi District of Southern Tanzania Ryan C. Eid1, Emily M. Knittle1, Benjamin Belknap MD2, Mary B. Carter MD PhD1
University of Louisville, School of Medicine State University of New York Health Science Center This study explored adherence to HIV antiretroviral therapy (ART) in an open care clinic in the Mufindi District of Tanzania. We analyzed survey data from a convenience sample of 30 HIV-positive adults who received ART at no cost from the Mdabulo Care and Treatment Center. Respondents self-reported their ART adherence on a visual analogue scale from one to ten, with ten being “always taking the medication on time as directed.” Mean adherence was 8.9 ± 1.0, with seven respondents self-reporting perfect adherence. Respondents who did not perceive adequate social support or who used alcohol had a tendency towards decreased adherence, but this did not reach statistical significance (perceived social support: Cohen’s d = 1.41, p = 0.061; alcohol use: Cohen’s d = 0.66, p = 0.123). Participants with a more recent diagnosis of HIV started ART sooner than those diagnosed a decade ago (p < 0.001). These results highlight the success of the local open care clinic model in improving both access and adherence to ART. Open care clinics provide care for free or at a nominal cost to any person seeking care. Future studies involving larger populations in the Mufindi District of Tanzania are needed to validate how social support and alcohol use influence ART adherence. Introduction 200; WHO stage 4 clinical criteria (severe disease, with AIDS 1 2
It is estimated that there are 36.9 million people living with HIV (PLWH) in the world, with approximately twothirds residing in sub-Saharan Africa (SSA). In Tanzania, the adult HIV prevalence rate is approximately 5%, but prevalence rates vary widely by region, from 2% in Manyara and Tanga in Northern Tanzania to nearly 15% in Njombe in South Central Tanzania.1 Young women are almost three times more likely to be seropositive for HIV-1 than their male counterparts.1 Historically, the southern Iringa Region of Tanzania has had the second highest prevalence rate of HIV in Tanzania, estimated to be 9.1% in 2014 by the United States Agency for International Development and the Tanzania Commission on AIDS.1 Data on the incidence of new HIV infections are not available for the Iringa Region, but in neighboring Mbeya, the incidence is 1.35 per 100 person-years.2 The high prevalence and incidence of HIV in this area of Tanzania has led to a large burden of disease that has only now begun to be curbed by the availability of HIV treatment. Anti-retroviral therapy (ART) treats HIV infection by using combinations of drugs. As the only treatment known to suppress viral replication and preserve patient immune function, it is the gold standard for HIV treatment. The use of ART to treat HIV has resulted in a notable reduction of HIV-related morbidity and mortality.3 Antiretroviral therapy has been shown to reduce viral load, increase CD4+ T-cell count, and increase the clinical wellbeing of the patient.4-6 CD4+ T cells are essential for instigating an adaptive immune response; without them, the immune system is crippled. Without ART, HIV infection will kill CD4+ cells and progress to AIDS (Acquired Immune Deficiency Syndrome), which may ultimately result in death due to other infections.7 Strict adherence to ART is imperative not only to maintain therapeutic serum levels and thus ensure the efficacy of the medication, but also to prevent drug-resistance.8 Early intervention with ART has been associated with prolonged disease-free survival, decreased risk of treatment failure and reduced risk of viral transmission. Early intervention is also thought to be more cost effective than delayed treatment, as it may reduce illness and hospitalizations. Although there has been an increase in ART access in much of SSA, many developing countries, including Tanzania, do not have the resources to start all newly diagnosed HIV positive patients on ART therapy. Current criteria for initiation of ART in Tanzania include: CD4 count < 9
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defining illness); or CD4 count < 350 and WHO stage 3 clinical criteria (symptomatic, with potentially serious disease).9 These criteria are extremely late-stage compared to those established in developed countries, where all newly diagnosed HIV patients are started on ART regardless of CD4 count. It is important to begin ART before the CD4 count is significantly reduced to prevent the patient from becoming immunocompromised. Despite the recent success in promoting ART use globally, ART initiation, adherence and patient retention rates in HIV care programs remain low in some countries, even when ART treatment is available at no cost. In 2006, it was estimated that 80% of PLWH in SSA were adherent to their ART medication.10 Unfortunately, adherence tends to decrease over time, with only 70% of PLWH in SSA adherent to ART medication by the third year of therapy.10, 11 ART adherence is essential for viral suppression and important in reducing viral resistance. This highlights the need to better understand factors that determine ART adherence in SSA so that patient services and support programs can be improved. To our knowledge, this is the first study to explore ART adherence in the Mufindi District of the southern Iringa Region of Tanzania. This study is an analysis of survey data collected from patients who received care at the Mdabulo Care and Treatment Center (CTC), an open care clinic established and operated by the non-government organization Foxes Community and Wildlife Conservation Trust (FCWCT).12 Open care clinics provide care either for free or at a nominal cost. The survey data collected in this study were gathered exclusively from patients who received care from the Mdabulo Care and Treatment Center and revealed the efficacy of the open care clinic model in this community. The Mufindi District was chosen for this study because FCWCT only serves this part of Tanzania.
Materials and Method We analyzed survey data initially collected in 2014. Foxes Community and Wildlife Conservation Trust’s HIV program, based out of a CTC located in the village of Mdabulo (CTC Mdabulo), has been operational since 2010 and is the sole provider of HIV care to all PLWH in 16 surrounding villages. Employees of the Foxes Community and Wildlife Conservation Trust collected survey data in order to evaluate their effectiveness in addressing ART medication adherence of their HIV program in Tanzania.
ACADEMIC RESEARCH I. Demographic Questions (Maswali ya Demografia) Questionnaire items were created by FCWTC administrators and edited to ensure cultural sensitivity 1. Patient Age (Umri wake Mgonjwa) and relevance (Figure 1). Survey data were collected in June 2014 as a quality evaluation using a stratified 2. Patient Gender (Jinsi yake Mgonjwa) random convenience sample of known HIV positive adults from two of the 16 villages (Ibwanzi and Ilasa) 3. Patient’s Level of Education (Kiwango cha Elimu Alichofika Mgonjwa): surrounding the CTC Mdabulo. Ilasa and Ibwanzi 4. Patient’s Occupation (Kazi yake Mgonjwa) (the closest village and farthest village served by CTC Mdabulo, respectively) were chosen since transportation 5. Marital Status (Hali ya Ndoa): has traditionally always been a principal barrier to access to medical care in this region. A list of patients’ II. Psychosocial Questions: (Maswali kuhusu nafsi na ujamii) names from these two villages (92 from Ilasa and 67 from Ibwanzi) was generated in random order, and 6. Do you feel like you have social support both emotionally and physically by family every third patient was chosen until 30% (48 of 159) of and/or community members? (Je, unajisikia kama unayo mategemeo ya ujamii the total patients were attained. FCWTC administrators hoped that selecting 48 patients at random from these ya marafiki na familia zako?) two villages would provide a representative cross section. 7. How many Alcoholic drinks to you consume per day? One drink being 12 ounces Selected patients were invited to complete the survey during regular home visits by home-based care workers beer, 8 ounces of wine, or drink consisting of 1.5 ounces of liquor. (Je, employed by the CTC Mdabulo. Home-based care unakunywa vinywaji vya pombe vingapi kwa siku? Kinywaji kimoja ni 12 aunsi ya workers are members from the community who make monthly home visits to PLWH to address issues patients bia au 8 aunsi ya mvinyo au 1.5 aunsi ya pombe kali) may encounter between their monthly visits to CTC Mdabulo. Verbal consent was obtained before beginning III. Treatment-Specific Questions (Maswali Kuhusu Matibabu) each survey. Home-based care workers told participants that their responses would be kept confidential and that 8. When were you diagnosed with HIV? (Lini umekutwa na daktari kuhusu hali ya surveys would not include their names or birthdates. To UKIMWI?) control for illiteracy, home-based care workers verbally administered surveys in Swahili while documenting 9. How long have you been taking ART? (Umetibiwa na dawa za UKIMWI kwa participants’ responses on paper. Completed surveys were placed into folders separate from patients’ medical muda gani?) records and stored in offices separate from the medical records department. 10. On a scale from 1 to 10, 1 being never and 10 being always, in the past week, Demographic and HIV data collected and used in this how many doses of your medication were you able to take correctly? Ask patient analysis included age, gender, marital status, education (highest year of school completed), occupation, alcohol to point to the number line to indicate their answer. (Kutumia kipimo cha 1 mpaka use, date of HIV diagnosis and years on ART therapy. To measure perception of adequate social support, 1. 10, 1 ina maana kamwe na 10 ina maana kila mara, kutoka wiki 1 iliyopita participants were asked if they felt both emotionally and physically supported by family and/or community umeweza kutumia dawa zako kwa sahihi mara ngapi? Mgonjwa aonyeshe members. Their responses were recorded as either “yes” kwenye kipimo) or “no.” Monthly ART adherence was measured by asking participants to estimate their level of medication adherence over the past month by pointing to a number on a visual analogue scale from one to ten with one being “never taking the medication on time as directed” and ten being “always taking the medication on time as directed.” After we visited the CTC Mdabulo in 2014 Figure 1: Questionnaire in English with Swahili translation and obtained University of Louisville Institutional Review Board approval, completed questionnaires were translated into English and numerically coded. Data were of 63%. Analysis of respondent demographics reveal that the uploaded into SPSS (IBM, version 22) for statistical analysis. The mean age of the sample population is 39.0 ± 9.9 years, and the variable “years since diagnosis” was calculated by tallying total population had a mean of 5.7 [± 2.6 years] of education, with 93% time elapsed between date of HIV diagnosis and June 2014. The reporting their occupation as farmer. In addition, the population variable “LAG” (units: years) was calculated as the numerical is 70% female and 77% married. On average, respondents were difference between “years since diagnosis” and “years on ART.” diagnosed with HIV 3.9 ± 2.8 years prior to the survey and had We characterized sample data using frequencies, means and been taking ART for 3.0 ± 1.8 years. standard deviations. All variables were found by graphical testing The average monthly ART adherence as reported on a visual to be non-normally distributed. Fisher’s exact test was used to analogue scale from one to ten was 8.9 ± 1.0. There were no discern associations between categorical variables while the Mann significant relationships between monthly ART adherence and Whitney U exact statistic was used to compare variables between age, gender, marital status, education, occupation, years since groups. Spearman’s correlation coefficient (rs) was computed to diagnosis, or years on ART therapy (Figures 2 and 3). To measure assess the relationship between LAG and year diagnosed. Cohen’s perception of adequate social support, participants were asked d as a measure of effect size for ART Adherence was calculated if they felt both emotionally and physically supported by family when comparing the effects of perceived social support and alcohol and/or community members. Their responses were recorded as use.13 The null hypothesis was rejected for p < 0.05. either “yes” or “no.” There was a tendency among respondents who did not perceive adequate social support (n = 3) to report a Results decreased monthly ART adherence (7.3 ± 1.5) compared to those Although the sample size is small, of the 48 adults invited to who did (9.0 ± 0.8, n = 27, Cohen’s d = 1.41, p = 0.061, Figure participate, 30 completed the survey for an overall response rate 4). This did not reach statistical significance. There was also a spring 2017 | VOL viI ISSUE iI | JGH 10
Figure 2: Monthly ART Adherence versus demographic variables of 30 survey respondents. Data represented as mean ± SD. Abbreviations: ART, antiretroviral therapy; SD, standard deviation. Monthly ART adherence was measured on a visual analogue scale from one to ten with one being “never taking the medication on time as directed” and ten being “always taking the medication on time as directed.” Education level is measured by the highest year of school completed. There were no significant relationships between monthly ART adherence and age, gender, marital status, education and occupation.
Figure 3: Monthly ART Adherence versus Years Since Diagnosis and Years on AR. N = 30 survey respondents. Data represented as mean ± SD. Abbreviations: ART, antiretroviral therapy; SD, standard deviation. Monthly ART adherence was measured on a visual analogue scale from one to ten with one being “never taking the medication on time as directed” and ten being “always taking the medication on time as directed.” Years since diagnosis was calculated by tallying total elapsed time between date of HIV diagnosis and June 2014. There were no significant relationships between monthly ART adherence and years since diagnosis or years on ART therapy. 11
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tendency among respondents who used alcohol to report a decreased monthly ART adherence (8.5 ± 1.1, n = 11) compared to those who did not use alcohol (9.1 ± 0.8, n = 19) but again this did not reach statistical significance (Cohen’s d = 0.66, p = 0.123, Figure 4). Respondents who reported using alcohol (n = 11) were significantly less likely to report that they perceived adequate social support (8 of 11 (73%) adequate social support) than those who did not use alcohol (n = 19, 19 of 19 (100%) adequate social support, p = 0.041.). The variable “LAG” (units: years) was calculated as the difference between “years since diagnosis” and “years on ART.” By Spearman’s rank correlation, between 2000 and 2014 there was a significant negative correlation between LAG and year diagnosed (rs = - 0.66, n = 28, p < 0.001, Figure 5), indicating that participants diagnosed with HIV in recent years initiated ART earlier after diagnosis than those diagnosed a decade ago.
Discussion In the present study of 30 respondents, the average self-reported monthly ART adherence as described on a visual analogue scale from one to ten was 8.9 ± 1.0, with only seven of 30 respondents reporting perfect adherence within the past month. The greater proportion of females than males surveyed reflects the population of PLWH in Tanzania, where there is a significantly higher burden of HIV disease among females. Young women in particular aged 23-24 are almost three times more likely to be seropositive for HIV-1 than their male counterparts.1 There were no significant relationships between monthly ART adherence and age, gender, marital status, education, occupation, years since diagnosis, or years on ART therapy. While a nearly 90% medication adherence might be considered excellent for a patient with diabetes or hypertension, HIV patients with less than 95% adherence are less likely to experience adequate viral suppression compared to those with 95% or higher adherence.14 Not only is ART medication adherence essential for viral suppression, it is also important in reducing the development of viral resistance to treatment. In order for ART to sufficiently suppress viral replication and to stabilize CD4 counts, Satten et al. have recommend that patients must attain >95% medication adherence.14 For patients on twice daily ART regimens, this translates to missing no more than three doses of HIV medication per month.14 Strict medication compliance can be especially difficult since ART is a lifelong therapy for HIV patients. In our study only seven out of 30 participants reported taking over 95% of their ART. Between 2005 and 2013, AIDS related illness decreased by 44% in Tanzania, coinciding with the increased availability of ART medication in the country.15 ART adherence is of the utmost importance to prevent drug resistance. In remote places like the southern Iringa Region of Tanzania, where medical services and pharmaceuticals are scarce, ART adherence becomes even more important because patients who fail or do not respond to available ART regimens may not have access to further antiretroviral options. A 2011 study of HIV drug resistance via phenotype
ACADEMIC RESEARCH testing in northern Tanzania found that nearly 15% of naïve patients (never started on ART) had been infected with a drug resistant virus.16 This poses a significant public health threat, as newly infected patients may have limited treatment options at the time of initial diagnosis due to inherited drug resistance. One finding in this study that speaks to the success of the local open care clinic model is that CTC Mdabulo patients have been started on ART therapy earlier in their disease process than they had been prior to the CTC’s establishment in 2010. This suggests that humanitarian efforts in providing open care clinics locally, and thus offering patients greater access to ART treatment, are worthwhile. We expect this early access to ART will likely have a positive longterm effect on morbidity and mortality in these patients. Another notable finding of our study is that participants with perceived lack of social support tended to be less likely to tightly adhere to their ART regimen. With a strong Figure 4: Monthly ART Adherence versus Perceived Adequate Social Support and effect size of 1.41, this may represent a key result because it highlights the importance Alcohol Use among 30 survey respondents. Data represented as mean ± SD. of social support for ART adherence in small rural communities.13 Although the barriers to Abbreviations: ART, antiretroviral therapy; SD, standard deviation. Monthly ART ART adherence are multifactorial, multiple studies have demonstrated that patients with adherence was measured on a visual analogue scale from one to ten with one perceived lack of social support have lower ART adherence.17 This finding was supported being “never taking the medication on time as directed” and ten being “always by a 2015 study of 44,204 HIV-infected adults on ART in Dar es Salaam, Tanzania, in which taking the medication on time as directed.” inadequate social support was found to be an independent predictor of poor ART adherence.18 Although numerous studies have examined the strong correlation between inadequate social support and ART difficulty maintaining confidentiality) are much different than that adherence, very few have focused on this correlation in small rural of large metropolitan cities.19-21 Alcohol use has also been previously described as having a negative effect on ART adherence.17 Although respondents in the current study who used alcohol had a tendency to report decreased medication adherence, this tendency did not reach statistical significance despite a moderate effect size of 0.66. This is likely due to the limited power of a study with a sample size of only 30.13 However, our findings did demonstrate that patients who used alcohol (n = 11) were proportionately less likely to perceive adequate social support (73% adequate social support compared to 100% adequate social support among non-users of alcohol, p = 0.041). This relationship has rarely been described in other studies and raises an important question as to whether alcohol use, as an independent variable, further reduces ART medication adherence in patients with inadequate social support. One limitation of this finding is the possibility Figure 5: LAG (years) vs Year Diagnosed. The variable “LAG” (units: years) was of a confounding variable problem, in that inadequate social support may have calculated as the difference between “years since diagnosis” and “years on ART.” a causal relationship with both alcohol consumption and low ART adherence. Between 2000 and 2014, there was a significant negative correlation between LAG and This exploratory study is by no means comprehensive and is not without year diagnosed (rs = -0.66, n = 28, p < 0.001), meaning that patients diagnosed with HIV limitations. The principal limitation to this study includes the limited sample in more recent years were started on ART sooner than those diagnosed a decade ago. size and thus reduced statistical power. Furthermore, as the data were not settings where the community dynamics (e.g. lack of anonymity, normally distributed, the limitation of using all non-parametric spring 2017 | VOL viI ISSUE iI | JGH 12
tests increases the possibility of Type I error. Future investigations should look at a larger number of participants to increase power and reduce the chance of Type I error, and should compare subjective self-reported adherence data with more objective data, such as CD4 count and viral load data. In addition, although many studies have validated the use of questionnaires to assess ART adherence in PLWH, adherence is often overestimated in questionnairebased research due to respondents’ desire to deny undesirable traits (such as alcohol use) and ascribe to traits that are socially desirable (such as abstinence from alcohol).22 This is especially true when researchers and respondents know each other, as in the present study. Therefore, our respondents may have underestimated alcohol consumption, overestimated social support and overestimated ART adherence most likely in order to please the home-based care workers. Despite these limitations, however, findings within this study warrant further research. An additional limitation of the present study concerns the use of data present at patient presentation to the Hospital of Mbour. Due to the limited access to hospital care for patients in rural regions of Senegal, it is difficult to confirm the exact point in disease progression in which the patients initiated care at the Hospital of Mbour. It is not known whether patients sought care immediately after the onset of concerning symptoms, or if disease had been present for months or years before the initial visit to the hospital. Further research might focus on identifying barriers to obtaining laboratory testing in the initial stages of HIV diagnosis in order to facilitate earlier diagnosis and better diagnostic outcomes. In addition, outreach programs focusing on educating members of the community about the common symptoms of HIV/AIDS may be implemented as a means of increasing the number of patients who are recognized and treated at early stages of disease. A study by Lewden et al. that aimed to describe the causes of mortality in HIV-positive adults hospitalized in West Africa found that the most frequent fatal diseases were tuberculosis (36%), cerebral toxoplasmosis (10%) and cryptococcus (9%).19 The study concluded that sustained efforts are needed to optimize earlier diagnosis of HIV infection and initiation of treatment. A goal of the present study is to expand the understanding of clinical presentations to enhance early diagnosis of HIV. The results of this study reveal that the most common condition in patients with HIV/AIDS at presentation in Mbour is chronic diarrhea (30.7% of patients), followed by dermatitis (29.5%) and oral candidiasis (25.4%). Patients presenting with candida infection, dermatitis and diarrheal illness have significantly lower CD4 counts than those presenting without 13
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these conditions and patients with CD4 counts below 200 cells/µL present with a greater number of comorbidities than patients with higher CD4 values. With very little existing data on the clinical presentation of HIV/AIDS patients in Mbour and Senegal as a whole, it is our hope that this study will increase the pool of available knowledge on this subject. In addition, the clinical comorbidities discussed in this study may be used as an indicator of disease to prompt patients to seek diagnostic workup for earlier detection of disease.
Conclusion The present study describes ART adherence among PLWH in the Mufindi region of Tanzania. Studies have shown that stigma against PLWH negatively impacts family and community support.23 Interventions targeted around increasing awareness of HIV and in educating people about modes of transmission may increase family and community support of PLWH.23 Future studies should also address other more practical reasons for missing doses of medication, such as how far patients have to travel for monthly care visits. This study and future studies of factors that influence ART adherence in rural Tanzania are of vital importance for planning interventions for communities and for PLWH, as strong adherence can directly reduce HIV related morbidity and mortality. Acknowledgments We wish to thank the Managers of the Foxes Community and Wildlife Trust, Jenny Peck and Geoff Knight, for their invitation to analyze these data, and in doing so, for granting us the opportunity to contribute to their tireless service to the people of Tanzania through their work at the Mdabulo Care and Treatment Center. References
1. UNAIDS and Tanzanian Commission on AIDS (2014) UNGASS Country Progress Report TM. http://www.unaids.org/sites/default/ files/countr y/documents/TZA_narrative_ report_2014.pdf. Published 2014. Accessed March 22, 2016. 2. Geis S, Maboko L, Saathoff E, Hoffmann O, Geldmacher C, Mmbando D, et al. Risk factors for HIV-1 infection in a longitudinal, prospective cohort of adults from the Mbeya Region, Tanzania. Journal of Acquired Immune Deficiency Syndromes (1999). 2011;56(5):453459. 3. Nachega JB, Hislop M, Dowdy DW, Lo M, Omer SB, Regensberg L, et al. Adherence to highly active antiretroviral therapy assessed by pharmacy claims predicts survival in HIV-infected South African adults. Journal of Acquired Immune Deficiency Syndromes (1999). 2006;43(1):78-84. 4. Paintsil E. Monitoring Antiretroviral Therapy in HIV-Infected Children in Resource-Limited Countries: A Tale of Two Epidemics. AIDS Research and Treatment. 2011;2011:280901. 5. Bangsberg DR. Preventing HIV antiretroviral resistance through better monitoring of treatment adherence. The Journal of Infectious Diseases. 2008;197 Suppl 3:S272-278. 6.. Kiwuwa-Muyingo S, Walker AS, Oja H, Levin J, Miiro G, Katabira E, et al. The impact of first year adherence to antiretroviral therapy on longterm clinical and immunological outcomes
in the DART trial in Uganda and Zimbabwe. Tropical Medicine & International health : TM & IH. 2012;17(5):584-594. 7. Fauci AS, Marston HD. Ending the HIV–AIDS Pandemic — Follow the Science. New England Journal of Medicine. 2015;373(23):2197-2199. 8. Rawizza HE, Chaplin B, Meloni ST, Eisen G, Rao T, Sankale JL, et al. Immunologic criteria are poor predictors of virologic outcome: implications for HIV treatment monitoring in resource-limited settings. Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America. 2011;53(12):1283-1290. 9. (NACP) NACP. National Guidelines For the Management of HIV and AIDS. http://www. who.int/hiv/pub/guidelines/tanzania_art.pdf. Published 2009. Accessed March 3, 2016. 10. Mills EJ, Nachega JB, Buchan I, Orbinski J, Attaran A, Singh S, et al. Adherence to antiretroviral therapy in sub-Saharan Africa and North America: a meta-analysis. JAMA. 2006;296(6):679-690. 11. Fox MP, Rosen S. Patient retention in antiretroviral therapy programs up to three years on treatment in sub-Saharan Africa, 2007-2009: systematic review. Tropical Medicine & International Health : TM & IH. 2010;15 Suppl 1:1-15. 12. Trust FCaW. The Care and Treatment Center for HIV/AIDS. http://www.mufindiorphans.org/ !care-and-treatment-center-for-hivaids/cwg7. Published 2015. Accessed May 20, 2016. 13. Cohen J. Statistical Power Analysis for the Behavioral Sciences. Hillsdale, N.J.: L. Erlbaum Associates; 1988. 14. Palella FJ, Jr., Delaney KM, Moorman AC, Loveless MO, Fuhrer J, Satten GA, et al. Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. HIV Outpatient Study Investigators. The New England Journal of Medicine. 1998;338(13):853860. 15. Statistics TNBo. 2011-12 Tanzania HIV/AIDS and Malaria Indicator Survey. http://www. dhsprogram.com/pubs/pdf/SR196/SR196.pdf. Published 2011. Accessed April10, 2016. 16. Kasang C, Kalluvya S, Majinge C, Stich A, Bodem J, Kongola G, et al. HIV drug resistance (HIVDR) in antiretroviral therapy-naive patients in Tanzania not eligible for WHO threshold HIVDR survey is dramatically high. PLOS ONE. 2011;6(8):e23091. 17. Medley A, Seth P, Pathak S, Howard AA, DeLuca N, Matiko E, et al. Alcohol use and its association with HIV risk behaviors among a cohort of patients attending HIV clinical care in Tanzania, Kenya, and Namibia. AIDS Care. 2014;26(10):1288-1297. 18. Muya AN, Geldsetzer P, Hertzmark E, Ezeamama AE, Kawawa H, Hawkins C, et al. Predictors of Nonadherence to Antiretroviral Therapy among HIV-Infected Adults in Dar es Salaam, Tanzania. Journal of the International Association of Providers of AIDS Care. 2015;14(2):163-171. 19. Cluver LD, Hodes RJ, Toska E, Kidia KK, Orkin FM, Sherr L, et al. ‘HIV is like a tsotsi. ARVs are your guns’: associations between HIV-disclosure and adherence to antiretroviral treatment among adolescents in South Africa. AIDS (London, England). 2015;29 Suppl 1:S57-65. 20. Kim MH, Mazenga AC, Yu X, Ahmed S, Paul ME, Kazembe PN, et al. High self-reported non-adherence to antiretroviral therapy amongst adolescents living with HIV in Malawi: barriers and associated factors. Journal of the International AIDS Society. 2017;20(1):1-12. 21. Mutumba M, Musiime V, Lepkwoski JM, Harper GW, Snow RC, Resnicow K, et al. Examining the relationship between psychological distress and adherence to anti-retroviral therapy among Ugandan adolescents living with HIV. AIDS Care. 2016;28(7):807-815. 22. Buscher A, Hartman C, Kallen MA, Giordano TP. Validity of self-report measures in assessing antiretroviral adherence of newly diagnosed, HAART-naive, HIV patients. HIV Clinical Trials. 2011;12(5):244-254. 23. Takada S, Weiser SD, Kumbakumba E, Muzoora C, Martin JN, Hunt PW, et al. The dynamic relationship between social support and HIVrelated stigma in rural Uganda. Annals of Behavioral Medicine : a Publication of the Society of Behavioral Medicine. 2014;48(1):26-37.
Academic Research Are Cash Transfer Programs Effective in Improving Maternal and Child Health in Sub-Saharan Africa? A Systematic Review of Randomized Controlled Trials Christiana Chinyere Ekezie, Kathleen Lamont, Sohinee Bhattacharya
Objective: Conduct a systematic review to assess the impact of poverty elimination on maternal and child health through cash transfer programs in sub-Saharan Africa. Methods: We searched Medline, Embase, Cochrane library, CINAHL, PsychInfo, Pubmed, Scopus and African Journals for randomized controlled trials (RCTs) assessing cash transfer interventions for improving maternal and/ or child health in Sub-Saharan Africa We also searched organizational websites, reference lists of included studies, relevant reviews and Google Scholar for grey literature using search terms such as “conditional/ unconditional cash transfer program”, “maternal health”, “child health”, “Sub-Saharan Africa” as MeSH headings or synonym search combining with AND or OR Boolean operators as appropriate. Searches were not limited to a particular language or time period. Two reviewers independently screened all potentially relevant records against inclusion criteria, extracted data and assessed methodological quality of included studies using critical appraisal skills programme scoring. Findings: Seven studies were found to meet the inclusion criteria agreed a priori and were included in the review. Findings from one study showed increased probability of delaying pregnancy in adolescents and reduced risky sexual behaviour, with another study reporting increased utilization of antenatal care and increased skilled attendance at delivery. In terms of child health benefits, there was reduced probability of chronic illnesses in children from households who benefited from cash transfers, however, there was no effect seen on the proportion of children vaccinated when compared to the controls. Other positive effects seen include increased acceptance of Prevention of Mother to Child Transmission (PMTCT) services, and increased birth registrations and school attendance for school age children. Conclusion: This review suggests that cash transfers have a positive impact on maternal and child health in subSaharan Africa, however, the evidence is limited and this topic will benefit from more in-depth trials conducted in the region. Keywords: Poverty, cash transfer, social protection, maternal and child health, pregnant women, antenatal care, sub-Saharan Africa. Introductionn child health indices such as maternal and infant mortality and Poverty is a phenomenon that affects all regions of the world. accessibility of maternal healthcare, which includes antenatal It manifests in different forms, some of which include lack of visits and skilled attendance at delivery. According to the income and productive resources, hunger and malnutrition, ill- World Health Organization, a delivery should be attended by health, limited or lack of access to education and other basic a skilled birth attendant (SBA) who is trained to proficiency in services, increased morbidity and mortality from illness.1 It the skills needed to manage normal pregnancies, childbirth and has far-reaching effects not only at the individual level but also the immediate postnatal period, as well as in the identification, on the development of nations, prompting world leaders to management and referral of complications in women and include eradication of poverty as a Millennium Development newborns.4 The proportion of deliveries assisted by SBAs has Goal. However, statistics show that about 896 million people been used as an indicator for maternal mortality reduction. still live at or below 1.90 USD per week, with 42.6% of these This indicator shows a wide gap between the rich and the poor, people living in sub-Saharan Africa.2 both when comparing between countries and when comparing Impoverished societies tend to have worse health outcomes. between different populations within the same country.4n This often leads to a vicious cycle where one perpetuates Many countries and international organizations have tried the other.3 One possible link between the two conditions to create poverty alleviation programs and interventions for the is through nutrition and employment, since malnutrition improvement of health outcomes for poor populations.5,6,7 Such associated with poverty leads to ill health, which in turn leads programs include cash transfer programs, which began in Latin to unemployment and loss of earnings, sustaining the cycle America and the Caribbean (LAC) and have since been extended of poverty. Other factors such as living conditions, access to to other low- and middle-income countries (LMICs). The cash water and sanitation, education, access to healthcare and social transfer programs are demand-driven, anti-poverty measures exclusion, also contribute to the perpetuation of this cycle. that transfer monetary resources to targeted households. A good measure of the health of a nation are maternal and Transfers are usually sized to close the gap between average spring 2017 | VOL viI ISSUE iI | JGH 14
Fig.1. Flow Diagram of study selection
Records identified through database searching (n = 1, 796 )
Additional records identified through other sources (n = 182 )
Records after duplicates removed (n = 1,678 )
Records screened (n = 1,678 )
Records excluded (n = 1,664 )
14 Full-text articles assessed for eligibility (n = 14 )
Full-text articles excluded, with reasons: (n = 7) 3 duplicate study population 1 qualitative study 1 cross-sectopnal study 1 interrupted time series study 1 longitudinal propensity matched design
Studies included in qualitative synthesis (n = 7 )
Due to herterogeneity in interventions and outcomes quantitative synthesis not conducted
From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and MetaAnalyses: The PRISMA Statement. PLoS Med 6(7): e1000097. doi:10.1371/journal.pmed1000097
For more information, visit www.prisma-statement.org.
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Table 1 Quality assessment of included studies using the Critical Appraisal Skills Programme (CASP) Randomised Controlled Trials Checklist CASP question Trial validity1. Focussed issue 2. Assignment to intervention randomised 3. Blinding of participants, health workers/study team 4. Were groups similar at start of trial
Crea et al 2015
Handa et al 2015
Handa et al 2016
5. Apart from intervention were groups treated equally 6. Were all participants accounted for at conclusion of trial
No – elderly-headed households prioritised in intervention areas but not control areas Yes
Results 7. How large was intervention effect 8. How precise was estimate of intervention effect 9. Can results be applied to local population 10. Were all important outcomes considered 11. Are benefits worth harms and costs CASP quality score
Yes, but some children lost/new/ left household. Some data missing for some covariates. CTs- Direct effects on OVC well-being and school attendance. Weak but positive effect on children’s chronic illness.
No, high attrition at follow up (!8%) but little evidence of differential attrition
No, attrition was ~9%, but no differential attrition between treatment/controls
Schooling current enrolment grade attainment strongly protective of early pregnancy based on self-report (subject to social desirability bias
Slight effect. Outcomes and control indicators based on self-report thus may be subject to recall bias
Consideration of orphanhood indicators could be explored
Could include CT programmes that support strengthening health services in programme areas Yes
consumption in the lowest income quintile and the extreme poverty line. Some cash transfers are given conditional upon household investment in their children’s health, education and nutrition—in these cases, spending is monitored and transfers are withheld until conditions are satisfied—while some transfers are unconditional and the beneficiaries are not expected to fulfill any preset conditions.8 The type of cash transfer employed— conditional or unconditional—is determined by the program organizers and whether they aim to assess the effects of poverty alleviation on particular aspects of social service utilization. An example is the Janani Suraksha Yojana in India, which specifically assesses maternal and newborn health.9 Although the program has been successful in other regions of the world, and some African countries have even implemented the same strategies, little has been studied about its impact in sub-Saharan Africa, especially in the area of maternal and child health outcomes. Reviews of financial incentives have found the strategies to be effective in improving utilization of healthcare in the broader context of LMICs but the quality of the evidence utilized was poor with minimal inclusion of randomized controlled trials.10, 11 This systematic review therefore aims to assess the impact of cash transfer programs on maternal and child health in sub-Saharan Africa using evidence from randomized controlled trials. Methods We followed the PRISMA guidelines for conducting systematic reviews ,which include a checklist for evaluating and reporting RCTs.12 Data Sources and Searches We systematically searched the bibliographic databases: Medline, Embase and PsycINFO through Ovid (1946 to May 28th 2016), the Cochrane library through Wiley Interscience, Cumulative Index to Nursing and Allied Health Literature (CINAHL) through EBSCO host, PubMed through the National Center for Biotechnology Information), Scopus through Elsevier and African Journals online. The search used Boolean operators to combine MeSH terms and text words and synonyms for “cash transfer”, “maternal health”, “child health” and “sub-Saharan Africa.” The search strategy developed was first used to conduct a search in Medline between March and May
2016, and was then adapted for searching the other databases (Appendix 1). Other sources such as World Bank reports, WHO reports, Institute for Fiscal studies, United Nations reports, United Nations International Children’s Fund (UNICEF), Department for International Development (DfID) UK, United Nations Development Programme (UNDP) and the United States Agency for International Development (USAID) were also searched. In addition, we screened the reference lists of all of the included studies and also relevant reviews. Google Scholar was used to identify grey literature and unpublished studies. No restrictions were placed on language or date of publication. Study Selection
The scope of the study was limited to countries in subSaharan Africa. Other inclusion criteria include RCTs that evaluate both the impact of increased income/cash to households through cash transfers (conditional or unconditional) as well as report their effects on maternal or child health. Studies with outcomes such as increased access to hospital services, improved nutrition, family planning, school enrollment, vaccination programs and anthropometric measurements were included. RCTs assessing the effects of cash transfer on men the elderly, or those reporting sexual or mental health outcomes were excluded, as well as those conducted in other low-and-middle income countries outside the subSaharan Africa region. Two reviewers independently assessed study titles and abstracts and those that satisfied the inclusion criteria were obtained for full-text appraisal for eligibility for inclusion in the review. Disagreements between reviewers were resolved through discussion or referred to a third reviewer for arbitration. Data Extraction and Quality Assessment
Two independent reviewers extracted the following information from each eligible study: name of first author, the year that the study was conducted, study location, description of the participants, type of cash transfer and conditional requirements where applicable and the results and effect size when reported. Quality of the included studies was assessed using the Critical Appraisal Skills Programme (CASP) tool designed for evaluating RCTs. This tool uses a set of 11 questions to assess the study validity, the randomization procedure, the spring 2017 | VOL viI ISSUE iI | JGH 16
ACADEMIC RESEARCH of vulnerable girls into adulthood, with Luseno et al 2014 Robertson et al 2013 reduced incidence of risky sexual behaviour Yes Yes Yes (at village group level) Yes in the intervention group compared to Unclear No the control group.13 A different study reported increased Yes Yes antenatal clinic Yes Yes attendance in households receiving Yes, but large number of children Yes, but data missing for 19 excluded- not observed at base-line, households in CCT group. 0.40 USD per visit no longer in household at follow-up, 31% households in UCT group compared to controls not verified, missing baseline reported receiving cash and having to covariates meet conditions suggesting although the study contamination between groups. noted no difference in Large effect- children in beneficiary CCT but not UCT had a significant the odds of delivering households-37% lower odds of child effect on birth registration. Neither illness, 42% lower odds of illness that programme significantly increased in a health facility stopped normal activities and proportion of complete vaccination between the women substantially higher odds of utilising record. Large effect of CCT on school health services for a serious illness attendance. in the intervention ? ? group and the control Yes Yes group.17 However, results from a national, randomized Yes but verification of illness from Yes social cash transfer medical records could be considered. program in Zambia Yes Yes show increased skilled 8.5 8.5 attendance at birth, meaning that more The included studies evaluated women in the intervention group utilized interventions that raised household hospital services during delivery.15 income through regular payments to Effects of Cash Transfer on Child Health the identified households. The income Two studies reported improved came in the form of cash transfers: Some child health outcomes such as decreased experiments evaluated an unconditional likelihood of chronic or childhood cash transfer while others evaluated a illnesses.13, 18 One of the studies also conditional cash transfer program.15, 19 reported higher odds of children Only two other cash transfer programs utilizing health services and decreased consisted of mixed conditional and odds of illnesses that prevented normal unconditional transfers, with one arm activities.18 Non-health benefits of cash each of conditional and unconditional transfer programs included increased transfers.13, 14 The remaining three birth registration and increased school studies evaluated social cash transfers, in attendance for children of school age, which unconditional cash transfers were although these benefits may further made to vulnerable households or groups translate into health benefits in the of individuals.16, 17, 18,20 The conditional longer term (with the children being transfers were based on fulfilling certain better educated on how to live healthy conditions such as food provision in the lives, and the government using the home, regular health check-ups for the statistics from the birth registrations to household and school enrollment for the plan for health services).13, 14 This study children. In contrast, the unconditional did not, however, note any difference transfers had no conditions which had in the proportion of children who were to be met, but the recipients had to be vaccinated in both the intervention and identified by the community and check the control groups.14 The one study in regularly with the distributors. One of conducted in the Democratic Republic the transfers was targeted specifically at of the Congo reported increased households with orphaned or vulnerable attendance at clinics and increased children, where the children had lost one acceptance of PMTCT in intervention or both parents or were separated from groups compared to controls.19 them.14 The value of cash transfer varied Discussion between 18 and 21 USD monthly Principal Findings and were dependent on the number We conducted a systematic review of of children or eligible women in the randomized controlled trials evaluating household. the effect of cash transfer programs on Effects of Cash Transfer on Maternal Health maternal and child health in sub-Saharan Three of the seven included studies Africa. The primary studies reported a assessed maternal health outcomes. One variety of health and non-health related study found that an unconditional cash outcomes. There was an increase in the transfer program in Kenya resulted in probability of delaying pregnancy noted in a 5% reduction in early pregnancy and adolescents, which reduced the likelihood an increase in the healthy transition of early pregnancy, as well as an increase
Table 2 Quality assessment of included studies using the Critical Appraisal Skills Programme (CASP) Randomised Controlled Trials Checklist CASP question Trial validity1. Focussed issue 2. Assignment to intervention randomised
Kahn et al 2015
3. Were participants, health workers and study personnel blinded 4. Were groups similar at start of trial 5. Apart from intervention were groups treated equally 6. Were all participants accounted for at conclusion of trial
Results 7. How large was intervention effect
Large effect- women who received 0.4USD/ visit almost twice as likely to attend 3 or more ante-natal visits than control group
8. How precise was estimate of intervention effect 9. Can results be applied to local population
10. Were all important outcomes considered 11. Are benefits worth harms and costs CASP quality score
Yes Yes Yes, minimal loss at follow up
Debatable- women enrolled when presenting for antenatal care (perhaps more likely to attend antenatal care) Could have measured effect on pregnancy outcomes Yes 9.5
reporting of results and the relevance of the findings and a study with a score of â‰Ľ 8 is considered a good quality study (maximum score of 11). Results Our searches yielded a total of 1,978 citations. After removing duplicates, screening titles, and abstracts, 14 citations (11 studies, two theses and one conference presentation) were considered potentially eligible for inclusion and selected for further appraisal. Of these, seven did not meet the inclusion criteria and were therefore excluded - three of these were duplicate papers of the same study and four were not RCTs. Seven RCTs met the inclusion criteria and were included in the review. Figure 1 presents the flow diagram of study selection process. All studies scored â‰Ľ8 on the CASP scoring system. Study Setting All studies were conducted in subSaharan Africa, with an emphasis in the southern regions, as per inclusion criteria. Two trials were conducted in Zimbabwe.13, 14 One experiment each took place in Zambia, Kenya, Uganda, Malawi and the Democratic Republic of Congo, respectively.15, 16, 17, 18, 19 Study Design All of the studies used a cluster randomized control design where eligible villages or lowest units of administration were the unit of randomization. Two studies conducted three-arm randomized controlled trials â€“ unconditional cash transfer, conditional cash transfer and control.13, 14 In one study, the control arm consisted of delayed entry into the cash transfer programs.16 Types of Cash Transfer 17
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ACADEMIC RESEARCH in the utilization of antenatal care, with an associated increase in skilled birth attendance following delivery. This is in keeping with the findings of a review that assessed different countries from Asia and Latin America and reported an increase in antenatal visits, skilled birth attendance at delivery, delivery at health facilities and tetanus vaccination for the mothers.9 A different article, not specifically targeted toward vulnerable populations, reviewed the effects of conditional cash transfers for improving uptake of health interventions in LMIC, and concluded that overall cash transfers are effective in increasing usage of preventive health services such as vaccination and sometimes effective in improving general health, although the effect was small or unclear.21 These findings suggest that increasing income through cash transfers to poor households subsequently increases health-care seeking behaviour and reduces home deliveries and the attendant risks associated with unskilled birth attendance.22 Increased income may also have served as an aid to overcome the barrier effects created by user fees charged by health facilities which the poor cannot afford; hence, with more resources for the household, women have more incentive to seek health care.3 In terms of child health benefits, the review reported lower odds of illnesses that prevented normal activities and an overall reduction in childhood and chronic illnesses. Other positive effects include increased acceptance of the PMTCT services, increased birth registrations for newborns and for children less than 18 years who had not been previously registered and increased school attendance for children of school age. Although we did not find any review that assessed the impact of cash transfer on these particular aspects of child health, the review by Bassani et al (2013) assessed the impact of financial incentives on child health including breastfeeding practices, use of healthcare facilities (when ill and for regular medical check-ups) and vaccination. They found that there was low quality evidence of the impact of cash transfers on health care use by children especially for children under five years. They also found no effect of financial incentive on age-appropriate immunization coverage which supports our finding in this review that the cash transfers had no impact on vaccination.11 Leroy et al (2009) in their own study assessed impact of cash transfer on child nutrition and its impact on child health and they found an increase in their anthropometric measurements following cash transfers to their households.23 These findings show that cash transfers may have a positive impact on child health but the documented evidence is not enough to prove it. Strengths and Limitations
Strengths of this review include a focused question with strict inclusion and exclusion criteria agreed a priori, a comprehensive
Table 2 Quality assessment of included studies using the Critical Appraisal Skills Programme (CASP) Randomised Controlled Trials Checklist CASP question Trial validity1. Focussed issue 2. Assignment to intervention randomised 3. Were participants, health workers and study personnel blinded 4. Were groups similar at start of trial 5. Apart from intervention were groups treated equally 6. Were all participants accounted for at conclusion of trial Results 7. How large was intervention effect
Yotebieng et al 2016
Yes Yes Unclear Yes Yes Yes, but an appreciable number of women lost at follow up. Substantial effect on uptake of available services.
8. How precise was estimate of intervention effect 9. Can results be applied to local population 10. Were all important outcomes considered 11. Are benefits worth harms and costs CASP quality score
Yes Unclear as to cost-effectiveness
Setting and participants
Type of transfer/size
Crea et al 2015
Setting- 3 districts- Nyanga, Makoni and Mutasa, Manicaland Province Zimbabwe 2009 and 2010 Participants- Vulnerable households that included children <18 years old and were not in the wealthiest 20% of households and had one of the following criteria: 1.In the poorest quintile of households 2.Had one or more orphans 3.The household head was <18 4. Had at least one member chronically ill 5. At least one member disabled.
UCT and CCTevery 2 months USD$18 plus $4/child up to a maximum of 3 children
CCT 1. Apply for a birth certificate for all children <18 (including newborn babies whose births had not been registered) within 3 months 2. School attendance for at least 90% per month for children 6-17 3. Representative from every household to attend two-thirds of local parenting classes
Table 1: Description of included studies
search strategy with no language or date restrictions applied to multiple bibliographic databases and a systematic approach. We deliberately included only randomized controlled trials, as this type of study design provides the highest quality of evidence. We also intended to focus on maternal and child health outcomes, but there was a dearth of primary studies assessing measurable outcomes in this area. Both clinical and statistical heterogeneity were evident in all the included studies, especially in terms of the outcomes assessed. This precluded pooling of studies in a meta-analysis. Furthermore, we cannot rule out publication bias,
Community randomised controlled trial
Result/Effect size 95% CI *99%CI Birth registration and school attendance increased in all groups Children in the CCT/UCT more likely to obtain birth certificates than controls CCT x time significantly predicted birth registration OR* 4.34 (2.88-6.55) UCT x time OR 1.5 (1.03-2.20) Orphans less likely to have obtained birth certificates and children with unknown status of one or both parents less likely to be registered. Children from high asset households (child age, number of children in household) less likely to suffer chronic illness.
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ACADEMIC RESEARCH although this is less likely in a systematic review of randomized controlled trials. Although there were recorded successes of the cash transfer program as a way of increasing the income in the households receiving the payments, most of the studies were conducted in the eastern and southern regions of Africa and not from other regions of subSaharan Africa. Also, because most were large-scale programs, the evaluation and proper analysis of the outcomes were not all recorded, making the assessment and generalizability of the results to other parts of the sub-Saharan African region difficult. Implications for Policy and Practice This review found a positive impact of cash transfer programs on sexual health behavior with a reduction in risky sexual activities. As a result of the raised income, women have more financial control and are able to make better decisions. This has great implication for the fight against HIV/ AIDS, which also has a high incidence rate in the sub-Saharan African region and strongly affects the morbidity and mortality rates of maternal and child health in the region. In this way, cash transfer programs may address the causal pathways linking poverty to HIV/AIDS and also reduce the number of the vulnerable children mostly orphaned by the death of their parents due to HIV/AIDS.24 The review also showed an increase in birth registration of the children, which implies an increase in health facility utilization at delivery by mothers since birth registrations were far more likely if the birth took place in a health facility. This will contribute to vital statistics that are not very well-recorded in most parts of sub-Saharan Africa—such accurate data will assist in planning and policymaking. There was also no evidence of increased uptake of vaccination as reported by Robertson et al.,14 which is of great concern especially in such a region where vaccines are available for childhood preventable diseases. However, reduced childhood and chronic illnesses were noted from these households,18 which will lead to the improved well-being of the children, fewer absences due to illness and a reduction in child mortality. The enrollment of children in school was a requirement for the conditional cash transfer programs.13,14 The implication is that more school-age children will have access to education. This especially has a great impact on female children, as this reduces the rate of early marriages (through increased knowledge and exposure which helps with making better decisions), age of first sexual experience and early pregnancies with the attendant increase in morbidity and mortality for under-aged pregnant women.16 It should also be noted that there are no reports on the supply-side of the health provision to assess the quality of services delivered at the health facilities. 19
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This highlights the importance of a focus on the supply-side of adequate and effective health services for demand-side programs to have a more reliable effect on health outcome.18 There are also limited reports on the cost-effectiveness of the cash transfer programs and their sustainability in sub-Saharan Africa, as most of them are currently international donor-driven with little inputs from the benefiting governments. Therefore, more research in this area is crucial to produce more evidence which can influence policy makers to invest more funds in such programs. As most of the cash transfer programs are not designed primarily for the objective of affecting maternal health, (most are targeted at the household with vulnerable children), there is no measurable program impact on a range of maternal health indicators.13 This therefore calls for more research to assess more maternal health care indicators. It is also important to study the impact of the cash transfer programs in different settings and countries of the sub-Saharan region to assess the influence of culture and geographical location on the success of these programs. Emphasis should be put on the need for carefully designed evaluation of programs to ensure correct interpretation of effects starting with baseline collection of data prior to cash payments to help with progress monitoring. Conclusion
This review has shown visible but limited evidence that cash transfer programs have an effect on maternal and child health by increasing the income and resources available in the household and subsequently increasing health-seeking behaviour and improving the standard of living for beneficiaries. Nevertheless, more evidence is still emerging and will further in-depth research in this area, especially in the sub-Saharan African region, will help to provide more quantifiable information that can be used to influence policy making in the region. Acknowledgments The authors would like to thank Mrs Melanie Bickerton of the Medical School Library, University of Aberdeen for her help with developing the search strategies.
1. United Nations. Department of Economic and Social Affairs. Population Division. World Summit for Social Development Programme of Action Chapter 2: Eradication of Poverty. 1995. 2. Beegle, K., Christiaensen, L., Dabalen, A., & Gaddis, I. (2016). Poverty in a rising Africa. World Bank Publications. 3. Wagstaff, A. (2002). Poverty and health sector inequalities. Bulletin of the World Health Organization, 80(2), 97-105. 4. WHO. The Global Strategy for Women’s, Children’s and Adolescent’s Health (2016-2030). 2015.
5. World Development Report 2000/1 Attacking Poverty. World Bank. September 2, 1999 6. Better Health for poor people: Strategies for Achieving the International Development Targets. Department for International Development. 2000. 7. Claeson M, Griffin C, Johnston T, McLachlan M, Soucat AL, Wagstaff A ea. Poverty reduction and the health sector. Washington (DC): World Bank, Health, Nutrition and Population. 2001. 8. Attanasio, O., Pellerano, L., & Reyes, S. P. (2009). Building trust? Conditional cash transfer programmes and social capital. Fiscal Studies, 30(2), 139-177. 9. Glassman, A., Duran, D., Fleisher, L., Singer, D., Sturke, R., Angeles, G., ... & Saldana, K. (2013). Impact of conditional cash transfers on maternal and newborn health. Journal of health, population, and nutrition, 31(4 Suppl 2), S48 10. Lagarde, M., Haines, A., & Palmer, N. (2009). The impact of conditional cash transfers on health outcomes and use of health services in low and middle income countries. The Cochrane Library. 11. Bassani, D. G., Arora, P., Wazny, K., Gaffey, M. F., Lenters, L., & Bhutta, Z. A. (2013). Financial incentives and coverage of child health interventions: a systematic review and meta-analysis. BMC Public Health, 13(3), 1. 12. Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., & Prisma Group. (2009). Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS med, 6(7), e1000097. 13. Crea, T. M., Reynolds, A. D., Sinha, A., Eaton, J. W., Robertson, L. A., Mushati, P., ... & Nyamukapa, C. A. (2015). Effects of cash transfers on Children’s health and social protection in Sub-Saharan Africa: differences in outcomes based on orphan status and household assets. BMC public health, 15(1), 1. 14. Robertson, L., Mushati, P., Eaton, J. W., Dumba, L., Mavise, G., Makoni, J., ... & Garnett, G. P. (2013). Effects of unconditional and conditional cash transfers on child health and development in Zimbabwe: a cluster-randomised trial. The Lancet, 381(9874), 1283-1292. 15. Handa, S., Peterman, A., Seidenfeld, D., & Tembo, G. (2016). Income Transfers and Maternal Health: Evidence from a National Randomized Social Cash Transfer Program in Zambia. Health economics, 25(2), 225-236. 16. Handa, S., Peterman, A., Huang, C., Halpern, C., Pettifor, A., & Thirumurthy, H. (2015). Impact of the kenya cash transfer for orphans and vulnerable children on early pregnancy and marriage of adolescent girls. Social Science & Medicine, 141, 36-45. 17. Kahn, C., Iragua, M., Baganizi, M., Kolenic, G. E., Paccione, G. A., & Tejani, N. (2015). Cash Transfers to Increase Antenatal Care Utilization in Kisoro, Uganda: A Pilot Study. African journal of reproductive health, 19(3), 144-150. 18. Luseno, W. K., Singh, K., Handa, S., & Suchindran, C. (2013). A multilevel analysis of the effect of Malawi’s social cash transfer pilot scheme on school-age children’s health. Health policy and planning, czt028. 19. Yotebieng, M., Thirumurthy, H., Moracco, K. E., Kawende, B., Chalachala, J. L., Wenzi, L. K., ... & Behets, F. (2016). Conditional cash transfers and uptake of and retention in prevention of motherto-child HIV transmission care: a randomised controlled trial. The Lancet HIV, 3(2), e85-e93. 20. Javad, S. (2011). Social cash transfers: a useful instrument in development cooperation?. Potential and Pitfalls. Perspective, Dialogue on Globalisation. 21. Lagarde, M., Haines, A., & Palmer, N. (2007). Conditional cash transfers for improving uptake of health interventions in low-and middle-income countries: a systematic review. Jama, 298(16), 19001910. 22. Powell-Jackson, T. (2011). Financial Incentives in Health: New Evidence from India’s Janani Suraksha Yojana. Available at SSRN 1935442. 23. Leroy, J. L., Ruel, M., & Verhofstadt, E. (2009). The impact of conditional cash transfer programmes on child nutrition: a review of evidence using a programme theory framework. Journal of Development Effectiveness, 1(2), 103-129. 24. Bhargava, P. K., & Satihal, D. G. (2005). Poverty linked HIV/AIDS as determinants of mortality: evidence from a community based study in Karnataka, India. CICRED Seminar on Mortality as Both a Determinant and a Consequence of Poverty and Hunger, Thiruvananthapuram, India.
Academic Research The Impact of Material Services on the Prevention of Mother-to-Child HIV transmission (PMTCT): A Literature Review Cynthia Mouafo Piaplié1
M.A Candidate, International Affairs,The Norman Paterson School of International Affairs, Carleton University, Ottawa, Ontario, Canada This paper provides a review of the available literature regarding prevention of mother-to-child HIV transmission (PMTCT) in sub-Saharan Africa. To narrow the focus of this broad subject, the review concentrates on antenatal care (ANC) and its effects on PMTCT. how do inadequate maternal services (antenatal clinics) affect the rate of mother-to-child HIV transmission in sub-Saharan Africa? The paper attempts to answer the question by focusing on peer-reviewed literature, as well as policy literature published from 2005 until now. The aim is to compare existing evidence on PMTCT with actual policy programs in order to evaluate any gaps between theory and practice. This was done through the examination of three recurrent themes identified while conducting research: 1) access and quality of ANC, 2) stigma and discrimination surrounding HIV/AIDS, and 3) knowledge and education available on HIV/AIDS. Keywords: prevention of mother-to-child transmission (PMTCT), HIV, antenatal care, sub-Saharan Africa, review Introduction regarding PMTCT in sub-Saharan Africa. Specifically, the Mother-to-child human immunodeficiency virus (HIV) review concentrates on care during pregnancy (antenatal care transmission is defined as “the spread of HIV from an HIV- or ANC) and its effects on PMTCT. The following question infected woman to her child during pregnancy, childbirth, is addressed: how do inadequate maternal services (antenatal or breastfeeding.”1 While mother-to-child transmission is the clinics) affect the rate of mother-to-child HIV transmission in most common method by which children become infected sub-Saharan Africa? The paper attempts to answer the question with the virus, with the transmission rate ranging from 15% by focusing on peer-reviewed literature, as well as policy to 45% without intervention this rate can be reduced to literature published from 2005 to 2015. 2005 was chosen below 5% with effective interventions during the periods as a cutoff point due to the various initiatives undertaken of pregnancy, labor, delivery and breastfeeding,1 Globally, goals have been set by the international health community in attempts to prevent transmission to children, particularly INTERNATIONAL INITIATIVE in the most affected regions such as Sub-Saharan Africa. For ACTOR(S) instance, the joint United Nations Programme on HIV/ AIDS (UNAIDS), in partnership with the United States’ G8 Implementation of a health initiative, President’s Emergency Plan for AIDS Relief package of HIV (PEPFAR) outlined objectives towards prevention of motherto-child transmission (PMTCT) including reducing the prevention, number of new HIV infections among children to fewer than treatment and care 40,000 by 2018 and to fewer than 20,000 by 2020.2 UNAIDS and PEPFAR have also jointly committed to ensure that 95% Governments, Call to Action for of pregnant women living with HIV are receiving lifelong HIV donors and the Elimination of treatment by 2018. As a result of these objectives, MTCT has been nearly eliminated in high income countries with effective implementing HIV infection in voluntary testing and counseling, access to antiretroviral partners Infants and Children therapy, safe delivery practices, and the widespread availability and safe use of breast-milk substitutes.3 However, despite United Nations Campaign to support the availability of such interventions and measures to ensure International universal access to PMTCT, the pandemic still lingers in sub-Saharan Africa. In fact, approximately 50% of HIV-positive pregnant women in Children’s treatment and the region do not have access to the medications necessary to Emergency Fund address the impact prevent mother-to-child transmission.4 This shortcoming is alarming because transmission can be avoided through a more (UNICEF) and of HIV and AIDS on comprehensive application of the aforementioned measures. UNAIDS children This paper provides a review of the available literature 1
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ACADEMIC RESEARCH throughout the year, some of them listed as followed: 5 Searching from 2005 to 2015 allows long-term analysis, as well as for adequate analysis of potential changes following these implementations. HIV prevalence varies greatly among regions within sub-Saharan Africa, going as low as 00.5% (Senegal) in West Africa to as high as 27.4% (Swaziland) in East Africa.6 Yet, many countries in the region face the same barriers to HIV prevention. Such barriers include (1) dependence upon external funds and resources in order to tackle the epidemics; (2) stigma and discrimination surrounding the issue; (3) and elevation in HIVspecific criminal legislation in parts of sub-Saharan Africa which does not acknowledge the role of antiretroviral therapy (ART). ART, defined as a “treatment of people infected with HIV using anti-HIV drugs,”7 can be crucial in reducing transmission risk and improving quality of life for those living with HIV.8 Given the similar obstacles faced by many sub-Saharan countries, it is assumed that the conclusions drawn in the present paper can be applicable to most of the countries in the region. Research was conducted to find any particular barriers that affect only certain regions/countries, in which none could be found hence a general regional pattern can thus be established.9 Methods Literature on HIV/AIDS in sub-Saharan Africa with particular reference to maternal services remains limited. By consequence, a broad search strategy for the literature review was necessary. The policy literature was collected from four databases: Scopus, BioMed Central, ScienceDirect, and Google Scholar. The input terms chosen included “maternal services”, “HIV”, “mother-to-child transmission”, “sub-Saharan Africa”, “antenatal clinics”, and “PMTCT”. Additional search parameters included the exclusion of web page data and opinion pieces, as well as any articles written prior to 2005. The policy literature collected was found on the databases of the official websites of the international organizations known to be the most involved in HIV/AIDS issues. These organizations are: PEPFAR, The Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund), UNAIDS, International Drug Purchase Facility (UNITAID), and the World Health Organization (WHO). While conducting research, seven articles from the peerreviewed literature and six articles from policy literature were retained. The aim was to compare existing evidence on PMTCT with actual policy programs in order to evaluate any gaps between theory and practice. The results generated across the various databases were summarized into three different types of obstacles identified during the research: 1) normative (knowledge and education available on HIV/AIDS); 2) sociocultural and environmental (stigma and discrimination surrounding HIV/AIDS); and 3) economic and structural (access and quality of ANC). Additional evidence from various sources was also integrated to the paper to support its claims. After offering a brief overview of each theme from the perspectives of both peer-reviewed and policy literature, a discussion outlining all the elements is presented. 1. Knowledge and Education of HIV/AIDS One of the main issues raised in the peer-reviewed literature 21 JGH | VOL ISSUEsubject Ii | Spring 2017the overall knowledge and education available onVIIthe was displayed regarding HIV/AIDS-related issues. The peer-reviewed literature considers this to be the least impactful of the three, suggesting that access and quality of ANC, and the stigma surrounding HIV tend to have more implications. Nonetheless, knowledge and education are important for PMTCT because populations, particularly women, need to know about HIV, but also about methods of transmission, in order to understand and reject misconceptions regarding the disease, and to know how to protect themselves from infection.10 The literature suggests that mass information campaigns should be launched given the lack of universal belief that PMTCT is beneficial. The loveLife campaign initiated in South Africa is a good example of such outreach and support programmes as it specifically targets the most vulnerable 21
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populations.11 The information should also be accessible to all, and especially illiterate women, since studies show that illiterate women are more likely to believe that HIV cannot be prevented.12 A study conducted by Keating et al. in Nigeria shows that people were twice as likely to know that HIV risk is reduced by condoms and a half times as likely to discuss HIV with their partner if they have been highly exposed to mass-media campaigns via television and radio.13 Moreover, lack of information and the presence of misinformation perpetuate stigma and discrimination, and foster mistrust of, and reluctance to engage in PMTCT testing and medication. In a survey of 1200 women of reproductive age in Bida Emirate of Niger State, Nigeria, only 15% were able to describe HIV/AIDS as a deadly disease.12 As such, the literature notes the need for real health education, as well as HIV/AIDS sensitization on all levels and among both women and men.17 The literature further argues the need to provide more general information on HIV and PMTCT, both inside and outside of health structures. Also recognized by Torpey et al. is the importance of opinion leaders’ engagement in community sensitization and mobilization with regard to HIV/AIDS issues. In Luapula Province, Zambia, for instance, the involvement of traditional leaders within the community is encouraged. PMTCT providers from local hospitals first lead a series of informational campaigns targeting opinion leaders. Subsequent community meetings are then led by the leaders, where all men are encouraged to accompany their spouses to ANC appointments and to be actively involved in their care.18 The role of informal sources such as radio shows and peer-to-peer conversations in transmitting information is also raised in most of the literature, and warnings of possible medical and superstitious fallacies contained in such discourse given. For instance, in a survey of adolescents attending high schools in Addis Ababa, Ethiopia, one-third thought there was a vaccine for AIDS.19 Moreover, a study of secondary students in Nigeria shows that 72% believed AIDS could be cured.20 The myth that having sex with a virgin can cure AIDS is also widespread through the region.21 Overall, the peer-reviewed literature acknowledges the importance of governmental and local support in health literacy, especially with respect to HIV/ AIDS, ANC and PMTCT. The policy literature barely outlines the importance of education and mobilization in convincing pregnant women to seek ANC and adhere to PMTCT programs. Moreover, it attributes sole responsibility of implementation, reforms and campaigns to national leaders and the international community, stating that leadership and good governance are central in any sort of advocacy. The approach of the policy literature is mostly macroscopic and state-centered in comparison to the more microscopic and grassroot stance of the peer-reviewed literature. 2. Stigma and Discrimination The peer-reviewed literature unanimously highlights the role that stigma plays in preventing pregnant women from seeking ANC in sub-Saharan Africa. Several studies have found that HIV/ AIDS-related stigma tends to be associated with contentious behavior such as sexual promiscuity, resulting in HIV/AIDS victims being seen as people with a ‘spoilt’ identity.22 A multi-site mixed methods study conducted in Burkina Faso, Kenya, Malawi, and Uganda found that only 37% of HIV-positive pregnant women disclose their HIV status to their husband.23 More often than not, pregnant women avoid going to antenatal clinics out of fear of exposure to their community. Studies conducted in subSaharan Africa on the subject found that “pregnant women [do] not disclose their HIV status to relatives for fear of stigma and discrimination,”24 with discrimination potentially taking the form of family exclusion. For example, according to the Demographic and Health Survey in 2003, only 40% of Nigerians were willing to care for an HIV-infected family member.25 In Nigeria, “when one member of the family becomes HIV-positive, the whole family will be called an “AIDS family” by other villagers, and will experience shame for being treated discriminatory by their entourage.26 Women are also reluctant to disclose their HIV
ACADEMIC RESEARCH diagnosis to their husbands out of fear of potential repercussions, especially intimate partner violence.27 A study conducted by Karamagi et al. established a strong correlation between intimate partner violence and HIV due to similar underlying factors such as poverty, gender inequality, alcoholism, and multiple partners, and outlined the need to address these underlying factors to prevent said violence.28 The stigma surrounding HIV/ AIDS is so prominent that many pregnant women identified as HIV-positive prefer to change to another antenatal clinic where their status is not known. This makes proper follow-up and monitoring more difficult and greatly affects PMTCT. Stigma and discrimination from health personnel further discourages consultation. HIV also remains a major obstacle to individuals in the workplace who may be unable to find or continue working as a result of discrimination. For instance, the People Living with HIV (PLHIV) Stigma Index indicates that in 2012, 50% of the respondents in Kenya claimed discrimination was involved in the loss of their employment/source of income.29 In addition to the stigma and discrimination surrounding HIV/AIDS, the literature notes a lack of involvement from male partners of pregnant women in antenatal clinics. It is estimated that in West Africa, the involvement has rarely been over 10%, and has sometimes been even lower.30
Compared to the peer-reviewed literature, the policy literature overlooks the effect of stigma and discrimination on PMTCT. UNAIDS is the only organization to formally recognize the need to address stigma and discrimination, as well as the necessity of increased male involvement. This stance may very well be the result of UNAIDS’ collaboration with civil society when elaborating its policy report. UNICEF briefly mentions stigma and outlines the important role that women peer support groups can play in helping to fight it. In addition to the issue of stigma being considered a minor barrier to the effective responses to the HIV epidemic in policy literature, “there is little consensus among policy-makers and program implementers about how best to define, measure, and diminish the phenomenon.”35 For instance, a study conducted in Botswana by Weiser et al. indicates that some people may avoid going to the doctor out of fear of reprisals, suggesting that prevailing stigma in the general population leads to unintended but significant consequences.36 As such, policy recommendations should encourage community preparedness and social mobilization, as well as relevant legal and public service organizations to minimize these unintended consequences. In 2002 for instance, local leaders were being trained to address issues of discrimination and stigma and to be
“Women are also reluctant to disclose their HIV diagnosis to their husbands out of fear of potential repercussions, especially intimate partner violence.”
Another reason for the lack of male involvement in antenatal clinics is that most men feel that their wives’ HIV-test results will mirror their own.31 This rationale is closely related to the lack of mass information and awareness campaigns. The literature also provides a semantic explanation that is illustrated by the terminology employed when referring to PMTCT and ANC. The use of terms such as ‘mother-to-child transmission’ is itself troublesome as it appears to place the burden associated with HIV/AIDS solely on the mother and reinforces male disengagement.32 Lastly, stigmatization and discrimination are closely related to a lack of female empowerment that seems to be prevalent in most sub-Saharan African communities. As such, the literature argues for interventions that empower women, and more specifically mothers, living with HIV/AIDS. Take for example Mothers2Mothers, a PMTCT intervention that began in South Africa in 2001 which seeks to “empower mothers living with HIV/AIDS by enabling them to fight stigma in their communities and to live positive and productive lives.33” The nonprofit organization currently works in over 400 sites in 7 countries in sub-Saharan Africa and employs over a 1000 women living with HIV.34 Hence, by citing examples like this one, the peer-reviewed literature appears to advocate for grassroots initiatives to challenge popular beliefs and fight stigmatization surrounding HIV.
knowledgeable advocates on HIV/AIDS in their communities. The program was supported by the African Capacity-Building Foundation, which was funded by the African Development Bank, the United Nations Programme for Development (UNDP), African governments, and bilateral donors.37 While the involvement of the UNDP in this initiative shows that stigma and discrimination are being considered as potential obstacles to reduction of mother-to-child transmission, the fact that few other initiatives of the kind have been launched since indicates that this consideration remains minimal. 3. Access and Quality of ANC The third and last theme identified in the research is access to, and quality of, maternal services. According to all the peer-reviewed articles assessed, the lack of integration of PMTCT programs into maternal services is one of the major contributors of ineffective PMTCT. All peer review literature agree that integrated services may result in increased workload, increased training needs, and a lack of space and equipment. This ultimately leads to a lack of motivation to provide more and better quality services.38 Nonetheless, there is a consensus that “in sub-Saharan Africa [...] integrating ANC and HIV services may result in a variety of benefits for HIV-positive women and their families; including better uptake of services, more women receiving counseling, reduction of the time to spring 2017 | VOL viI ISSUE iI | JGH 22
ACADEMIC RESEARCH treatment initiation, improved quality of care, and reduction of stigma.”39 Service integration would remove the requirement of multiple visits, which can be particularly hard for pregnant women and can increase the risk of breaches in confidentiality. To avoid compromising confidentiality, the literature encourages the implementation of same-day test results coupled with onsite post-result counselling, better follow-up from health personnel and increased availability of ART in antenatal clinics.40 In addition to lacking HIV testing, antenatal clinics in sub-Saharan Africa are typically characterized by insufficiently trained health personnel, limited equipment, a shortage of tests, long wait times and a lack of appropriate places to conduct counseling.41 In sub-Saharan Africa, the number of women visiting antenatal clinics four or more times has remained static, at about 44%.42 As shown in the literature review conducted by Msellati, implementation, childcare research and treatment programs in West Africa shows an inability of health providers to establish friendly and trusting relationships with their patients due to not being equipped to deal with the great psychological distress experienced by HIV-infected pregnant women.43 The review states that “from a more general point of view, patients have not yet identified health workers as being as friendly as they should be”.44 The perceived lack of sensitivity in health care workers makes it hard for pregnant women to continue with consultation, because they often do not confide and open up in an environment in which they feel uncomfortable. As a result, many pregnant women tend to avoid antenatal clinics. This is highly problematic since antenatal clinics constitute the primary way for pregnant women to access PMTCT
the cost of treatment and the remoteness of the clinics. For instance, prior to 2003, people living in rural Kenya areas might have to travel hundreds of miles to test for HIV.45 In fact, antenatal clinics in sub-Saharan Africa are, for the most part, designed without consideration of men and most health workers are not trained and/or at ease to deal with men. As a result, ANC tends to be specifically and exclusively addressed to women when, in reality, it needs to be targeted at both parentsto-be to allow for positive impact in PMTCT. Hence, the peerreviewed literature emphasizes the limitations in access to, and quality of, maternal services by looking at specific case studies in various sub-Saharan African countries. Policy literature treats the question of access and quality of ANC from a more medical perspective. Having been strongly influenced by western ideas and approaches in dealing with HIV, the policy literature46 promotes the idea of HIV as a special disease demanding confidentiality47. As a result, policy literature argues that the solution to improving access and quality of ANC lies with a greater initiation of ART irrespective of gestational age in antenatal clinics. While ART drugs used for PMTCT of HIV can virtually eliminate the risk of childhood HIV infection, failure to couple such actions with regular HIV testing, as well as adequate counseling and proper health education may result in cumulative losses of pregnant mothers from PMTCT services, with increased risk of HIV transmission to their infants. These claims seem to be supported by a study conducted by Sweat and Denison which looked at strategies to reduce HIV incidence in developing countries.48 As concluded by the authors, HIV is not just a health problem, since the spread of the virus is highly correlated with social, cultural, political and economic factors. Such factors require the development of culturally-appropriated and communitysponsored prevention programs on multiple levels.49 In contrast, according to the overall policy literature analyzed for the purpose of this paper, the solution rather lies in national implementation of HIV/ AIDS treatment and effective monitoring in order to prevent motherto-child transmission. This approach to the issue was officially adopted by the World Health Organization in its 2010 version of Recommendations for a Public Health, and has subsequently been supported by many international health organizations, such as the Global Fund, UNICEF and UNITAID. Some of the literature does mention the importance of taking into consideration the specificity of health systems, although, surprisingly, none of them actually elaborate on the nature of this specificity. This is because the strategies put forth are essentially a means to rapidly deliver targeted interventions instead of being directed towards the root causes of health system shortcomings. In addition, PEPFAR is the only actor advocating a better integration of PMTCT into maternal services in order “to strengthen national ownership
“The stigma surrounding HIV/AIDS is so prominent that many pregnant women identified as HIVpositive prefer to change to another antenatal clinic where their status is not known.”
programs and testing. Furthermore, Msellati identifies other practical obstacles faced by pregnant women: lack of time in an already busy schedule, cost of transportation, the language barrier between them and the staff, and the distance between their residence and the antenatal clinics are among the top impediments that pregnant women face when trying to access ANC. Finally, pregnant women may also be restricted in their access to ANC by their economic dependence on their spouse, which can be particularly troublesome when considering 23
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ACADEMIC RESEARCH of programs, increase the coverage of quality PMTCT [...], increase program sustainability, strengthen the health system, and improve maternal, newborn and child health outcomes overall.”50 None of the literature addresses the economic, sociocultural, and legal barriers to HIV prevention in sub-Saharan Africa, and although integration is indeed touched upon, it is always implied that the initiative can only come from decisionmakers. As such, the solutions proposed by the policy literature to improve the access and quality of ANC reflect the macroscopic and medical approach of the actors who propose them. These solutions include “more active and earlier identification of pregnant women who are HIV-infected, improved screening and rapid initiation or referral of women eligible for ART, effective linkages between PMTCT and ART services, [and] longer duration of antiretroviral (ARV) prophylaxis during pregnancy”.51 The policy literature thus tackles the issue by adopting a more technical and medical stance, in comparison to the more structural outlook showcased by the peer-reviewed literature. Discussion Comparing the peer-reviewed literature and the policy literature reveals significant gaps in terms of how each analyzes the effects of maternal services on PMTCT. On one hand, the peer-reviewed literature appears to offer a more localized and sensitive perspective on the issue. It identifies structural challenges specific to the targeted populations and supports its arguments with rigorous data collected from relevant case studies from different sub-Saharan countries. The variety of sampled countries and the fact that conclusions are similar, confirm the reasonable generalizations that can be made when tackling the specific issue of ANC and PMTCT. These countries were considered to be among the worst in terms of mother-to-child transmission rate; for example, UNAIDS reports prevalence rates of 33.7 percent in Zimbabwe, 11.8 percent in Cameroon, and 21.5 percent in Zambia.52 All of the studies assessed showed significant improvement in PMTCT after peer-reviewed literature solutions were implemented, suggesting that the recommendations made by the peer-reviewed articles are more credible and convincing. Given the peer-reviewed literature, one might reasonably assume that following the proposed recommendations – namely mass information campaigns, grassroot awareness initiatives, and large-scale training and implementation programs –, could allow for positive results similar to those obtained in the case studies. Yet, looking at the policy literature, the disparity between the evidence gathered in the field and the rationale of the policies actually implemented is remarkable. Essentially, the evidence gathered from international health organizations seems to focus solely on medical supply and equipment, and to prioritize national actions over any sort of grassroots initiative which can be a source of mainstream innovation for sustainable development. At times the role that communities can play during implementation of policies is mentioned, as well as the necessity of strengthening national systems by addressing structural difficulties and eliminating stigma surrounding HIV/AIDS and women. However, the policy literature reviewed never elaborates on the nature of those challenges, or on their implications for ANC and consequently, PMTCT. In neglecting this, the policy literature reveals a failure to comprehend the structural, sociocultural and normative dimensions associated with sub-Saharan Africa in terms of HIV/AIDS issues which may partly explain why the region is still so afflicted by the epidemic despite countless interventions In evaluating the effects of inadequate ANC on PMTCT, putting emphasis on national leadership and good governance alone does not reflect the complexity of the topic, as it does not encompass all of its components and variables. Another alarming realization is that decontextualization is often hidden behind a shallow discourse that pretends to adopt a more microscopic approach. As stated by Catherine Campbell, professor at the London School of Economics and Political Science, “the discourses of HIV prevention are often
the discourses of western science and policy, regardless of the extent to which these are appropriate for local conditions. [As a result,] projects are often designed by ‘overseas experts’, with only minimal and tokenistic consultation of local people, who may have little sense of ‘ownership’ of project proposals and lack the conceptual understandings, technical skills, or trained staff to implement them properly.”53 In other words, the solutions offer little to no innovation and the objectives, as well as the rationale, are often vague and are not tailored to the targeted populations. As a result, although the policy literature appears more substantial in terms of its elaboration and length, it becomes evident after review that the peer-reviewed literature offers a more comprehensive understanding of how inadequate ANC may affect PMTCT, doing so by adopting a multilevel approach and supporting its arguments with actual case studies. The overall assessment of the literature outlined throughout this paper further illustrates the relative redundancy and limitations of the policy literature. The focus was not the result of biased preference, but rather that of an elusive policy literature that did not incorporate any of the peer-reviewed literature into its analysis and subsequent recommendations. Doing so would have undoubtedly strengthened the arguments found in the policy literature and, more concretely, might have played a significant role in improving PMTCT in sub-Saharan Africa through extensive ANC reforms. This contrast is further illustrated by the ongoing debate of the horizontal versus vertical approach to global health. The horizontal approach, as embodied by the peer-reviewed literature, focuses on all the activities whose primary purpose is to promote, restore and maintain health. In contrast, the vertical approach, reflected in the policy literature, focuses on tackling the issue of inadequate ANC through a one-dimensional action that would most likely come from decision-makers. In light of the obstacles raised by the peer-reviewed literature, it can be concluded that in order for sub-Saharan Africa to eliminate the vertical transmission of HIV, interventions need to move beyond an individual-level or state-centered approach to address the structural and social barriers preventing women from receiving ANC which would subsequently increase PMTCT. The peer-reviewed literature already supports these claims, and a next logical step would be for the policy literature to adopt a similar approach. This would allow for significant improvement in prevention of mother-tochild HIV transmission, as outlined in most of the case studies presented. Lastly, there needs to be less focus on remedial measures and more attention given to prevention to address the root causes of transmission and allow for sustainable results. This will only be possible with significant structural reforms and capacity-building initiatives, mass awareness campaigns and education programs, and comprehensive and active attacks denouncing stigma and discrimination surrounding HIV/AIDS and gender. Nonetheless, this may only be possible if more literature is devoted to this approach and if this is appropriately reflected in policy implementation. Conclusion The objective of the current literature review was to analyze and compare both theory (the peer-reviewed literature) and practice (policy literature) produced from 2005 to the present, in order to answer the following question: how do inadequate maternal services (antenatal clinics) affect the rate of mother-tochild HIV transmission in sub-Saharan Africa?54 Through the review of the different articles found, three recurrent themes were identified as potential outcomes and were examined in-depth: access to and quality of ANC, the stigma surrounding HIV/ AIDS, and the knowledge and information available on the issues. The results revealed that while peer-reviewed literature seems to attribute the inadequacy of ANC in preventing mother-to-child HIV transmission to a combination of structural, environmental and normative factors, the policy literature supports a more state-centered and technical approach in understanding the relationship between ANC and PMTCT by advocating for the spring 2017 | VOL viI ISSUE iI | JGH 24
ACADEMIC RESEARCH strengthening of national systems and for increased provisions of medication and testing. One of the main challenges when researching the topic of PMTCT and ANC, was the lack of literature currently available, as well as the lack of content in the articles that were found. This showcases the significant gap in understanding the correlation between inadequate maternal services and the prevention of motherto-child HIV transmission that remains, despite some improvement in recent years. The initial research question has been partially answered, as discussed in this paper, but additional field research is required for real improvement. There is a current lack of analysis regarding the social structures hindering HIV PMTCT; as such, in order to eliminate mother-to-child transmission of HIV, the context in which HIV-positive mothers make decisions regarding their status needs to be better understood in the literature, and adequately addressed through efficient policies. References
1. World Health Organization, Mother-to-child transmission. Page retrieved from http://www. who.int/hiv/topics/mtct/en/. 2. Ibid. 3. UNAIDS, President’s Emergency Plan for AIDS Relief (PEPFAR) and Partners (2016) ‘Start Free, Stay Free, AIDS Free: A super fast track framework for ending AIDS among children, adolescents and young women by 2020’. 4. AVERT (2015). Pregnancy, childbirth & breastfeeding and HIV. Page retrieved from http://w w w.aver t.org/hiv-transmissionprevention/pregnancy-childbirthbreastfeeding. 5. Karen Hampada, Vertical Transmission of HIV in Sub-Saharan Africa: Applying Theoretical Frameworks to Understand Social Barriers to PMTCT, ISRN Infectious Diseases, Volume 2013, p. 1. Page retrieved from https://www.hindawi. com/journals/isrn/2013/420361/. 6. Luo, C., Akwara, P., Ngongo, N., Doughty, P., Gass, R., Ekpini, R., ... & Hayashi, C. (2007). Global progress in PMTCT and paediatric HIV care and treatment in low-and middle-income countries in 2004–2005. Reproductive health matters, 15(30), 180. 7. AVERT (2013). HIV AND AIDS IN SUB-SAHARAN AFRICA REGIONAL OVERVIEW. Page retrieved from https://www.avert.org/professionals/hivaround-world/sub-saharan-africa/overview 8. World Health Organization. Antiretroviral Therapy. Retrieved from http://www.who.int/ topics/antiretroviral_therapy/en/. 9. Global Commission on HIV and the Law (2012) ‘Risks, Rights and Health’. 10. Gourlay, A., Birdthistle, I., Mburu, G., Iorpenda, K., & Wringe, A. (2013). Barriers and facilitating factors to the uptake of antiretroviral drugs for prevention of mother-to-child transmission of HIV in sub-Saharan Africa: a systematic review. Journal of the International AIDS Society, 16(1). 11. Detailed documentation of the research process is available in appendices B. C and D. 12. Burgoyne, A. D., & Drummond, P. D. (2008). Knowledge of HIV and AIDS in women in subSaharan Africa. African Journal of Reproductive Health, 12(2), 15. 13. AVERT (2015). HIV AND AIDS IN SOUTH AFRICA. Page retrieved from https://www.avert.org/ professionals/hiv-around-world/sub-saharanafrica/south-africa. 14. UNAIDS, United Nations Population Fund (UNFPA) and UNIFEM (2004). Women and HIV/AIDS: Confronting the Crisis, p. 39. Page 25
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retrieved from http://www.unfpa.org/sites/ default/files/pub-pdf/women_aids.pdf. 15. Keating, J., Meekers, D., & Adewuyi, A. (2006). Assessing effects of a media campaign on HIV/ AIDS awareness and prevention in Nigeria: results from the VISION Project. BMC Public health, 6(1), 123. 16. Burgoyne, A. D., & Drummond, P. D. Ibid, 17. 17. Kwasi Torpey et al. Increasing the uptake of prevention of mother-to-child transmission of HIV services in a resource-limited setting, BMC Health Services Research, (2010) 10, p. 29. 18. Ibid, p. 13. 19. Cherie A, Mitkie G, Ismail S, Berhane Y. Perceived sufficiency and usefulness of IEC materials and methods related to HIV/AIDS among high school youth in Addis Ababa, Ethiopia. African Journal of Reproductive Health 2005; 9(1): 6677. 20. Oyo-Ita AE, Ikpeme BM, Etokidem AJ, Offor JB, Okokon EO, Etuk SJ. Knowledge of HIV/ AIDS among secondary school adolescents in Calabar- Nigeria. Annals of African Medicine 2005; 4: 2-6. 21. Simbayi LC, Kalichman SC, Jooste S, Cherry C, Mfecane S, Cain D. Risk factors for HIVAIDS among youth in Cape Town, South Africa. AIDS and Behavior 2005; 9: 53-61. 22. Apanga, P. (2014). HIV/AIDS-Related Stigma and Discrimination in Sub-Saharan Africa: A Review. Journal of Natural Science Research, 4, 41. 23. Karen Hampada, p. 3. 24. Ibid. 25. Kautz, p. 9. 26. Li, L., Wu, S., Wu, Z., Sun, S., Cui, H., & Jia, M. (2006). Understanding family support for people living with HIV/AIDS in Yunnan, China. AIDS and Behavior, 10(5), p. 510. 27. Philippe Msellati, p. 809. 28. Karamagi, C. A., Tumwine, J. K., Tylleskar, T., & Heggenhougen, K. (2006). Intimate partner violence against women in eastern Uganda: implications for HIV prevention. BMC public health, 6(1), 284, p. 10. 29. Global Network of People Living with HIV. The People Living with HIV Stigma Index. Evidence Brief: Stigma and Discrimination at Work. 2012, p. 12. Retrieved from http://www.gnpplus.net/ assets/wbb_file_updown/4621/Stigma%20 and%20Discrimination%20at%20work.pdf. 30. Ibid. 31. Ibid. 32. Ibid, p. 810. 33. Karen Hampada, p. 3. 34. Mothers2Mothers. Where We Work. Retrieved from https://www.m2m.org/where-we-work/. 35. Mahajan, A. P., Sayles, J. N., Patel, V. A., Remien, R. H., Ortiz, D., Szekeres, G., & Coates, T. J. (2008). Stigma in the HIV/AIDS epidemic: a review of the literature and recommendations for the way forward. AIDS (London, England), 22(Suppl 2), S67. 36. Weiser SD, Heisler M, Leiter K, et al. Routine HIV testing in Botswana: A population based study on attitudes, practices, and human rights concerns. PLoS Med. 2006;3:e261. 37. Kelly, M. M. (2002). Fighting AIDS-related stigma in Africa. 38. Karen Hampada. Vertical Transmission of HIV in Sub-Saharan Africa: Applying Theoretical Frameworks to Understand Social Barriers to PMTCT, ISRN Infectious Diseases, Volume 2013, p. 1. Page retrieved from https://www. hindawi.com/journals/isrn/2013/420361/; Janet M. Turan et al. The Study of HIV and Antenatal Care Integration in Pregnancy in Kenya: Design, Methods, and Baseline Results of a Cluster-Randomized Controlled Trial. PLOS ONE, September 2012, 7(9), p. 2. Page retrieved from http://journals.plos.org/plosone/ article?id=10.1371/journal.pone.0044181; Philippe Msellati. Improving mothers’ access to PMTCT programs in West Africa: A public health perspective. Social Science & Medicine 69, 2009, p. 808. Retrieved from http://journals2. scholarsportal.info.proxy.library.carleton.ca/ pdf/02779536/v69i0006/807_imatppwaaphp. xml/ Kwasi Torpey et al. Increasing the uptake of prevention of mother-to-child transmission
of HIV services in a resource-limited setting, BMC Health Services Research, (2010) 10, p. 29. Retrieved from http://go.galegroup.com.proxy. library.carleton.ca/ps/i.do?p=AONE&u=ocul_ carleton&id=GALE|A220675846&v=2.1 &it=r&sid=summon&userGroup=ocul_ carleton&authCount=1#/; Thiloshini Govender and Hoosen Coovadia. Eliminating mother to child transmission of HIV-1 and keeping mothers alive: Recent progress. Journal of Infection (2014) 68, p. 557-562. Retrieved from http:// www.sciencedirect.com.proxy.library.carleton. ca/science/article/pii/S016344531300282X/; Putu Duff et al. Barriers to accessing highly active antiretroviral therapy by HIV-positive women attending an antenatal clinic in a regional hospital in western Uganda. Journal of the International AIDS Society, 2010, 13(27). Retrieved from http://jiasociety.biomedcentral. com/ar ticles/10.1186/1758-2652-13-37/; Ange Anitha Irakoze. Uptake of PMTCT sites for increasing accessibility of services in prevention of mother to child HIV transmission program in Rwanda, January 2005 - June 2010, Retrovirology, 2012, 9(1). Retrieved from http://retrovirology.biomedcentral.com/ articles/10.1186/1742-4690-9-S1-P100. 39. Janet M. Turan et al. The Study of HIV and Antenatal Care Integration in Pregnancy in Kenya: Design, Methods, and Baseline Results of a Cluster-Randomized Controlled Trial. PLOS ONE, September 2012, 7(9), p. 2. Page retrieved from http://journals.plos.org/plosone/ article?id=10.1371/journal.pone.0044181. 40. Philippe Msellati. Improving mothers’ access to PMTCT programs in West Africa: A public health perspective. Social Science & Medicine 69, 2009, p. 808. Retrieved from http://journals2. scholarsportal.info.proxy.library.carleton.ca/ pdf/02779536/v69i0006/807_imatppwaaphp. xml. 41. Ibid, p. 808. 42. Finlayson, Kenneth, and Soo Downe. “Why do women not use antenatal services in low-and middle-income countries? A meta-synthesis of qualitative studies.” PLoS Med 10, no. 1 (2013): e1001373. 43. Msellati, p. 809. 44. Ibid, p. 811. 45. Kautz, T. (2008). Stigma, Fear and Hope: A Model of HIV Testing in Sub-Saharan Africa, p. 24. 46. The policy literature collected comes from from the WHO, PEPFAR, UNAIDS, the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund), UNICEF and the International Drug Purchasing Facility (UNITAID). 47. Dickinson, C., & Buse, K. (2008). Understanding the politics of national HIV policies: the roles of institutions, interests and ideas. HLSP institute. 48. Sweat, M. D., & Denison, J. A. (1995). Reducing HIV incidence in developing countries with structural and environmental interventions. Aids, 9, S251-7. 49. Ibid. 50. PEPFAR. Guidance on Integrating Prevention of Mother to Child Transmission of HIV, Maternal, Neonatal, and Child Health and Pediatric HIV Services. January 2011, p. 1. Retrieved from http://www.pepfar.gov/documents/ organization/158963.pdf. 51. World Health Organization. Antiretroviral Drugs for Treating Pregnant Women and Preventing HIV Infection in Infants: Recommendations for a Public Health Approach. 2010, p. 66. Retrieved from http://apps.who.int/iris/ bitstream/10665/75236/1/9789241599818_ eng.pdf. 52. UNAIDS, Report on the Global HIV/AIDS Epidemic: July 2002. 53. Campbell, Catherine (2003) Why HIV prevention programmes fail. Student BMJ, 11, p. 479. 54. Focusing on sub-Saharan Africa does not take away from the fact that the region is diverse and heterogeneous. It is characterized by different cultures, languages, mentalities and challenges. As such, although the conclusions that were made through this review tend to be generally applicable, it is important to keep in mind that some nuances and exceptions will most likely be present.
Appendix A: Sub-Saharan Africa Sub-Saharan African consists of the following countries: Angola, Benin, Botswana, Burkina Faso, Burundi, Cameroon, Cape Verde, Central African Republic, Chad, Comoros, Congo, CĂ´te dâ€™Ivoire, Djibouti, Equatorial Guinea, Ethiopia, Gabon, The Gambia, Ghana, Guinea, GuineaBissau, Kenya, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Mauritius, Mozambique, Namibia, Niger, Nigeria, Rwanda, Sao Tome and Principe, Senega, Seychelles, Sierra Leone, Somali, South Africa, Sudan, Swaziland, Tanzania, Togo, Uganda, Zaire, Zambia, and Zimbabwe. The evidence gathered for this paper is supported by actual case studies conducted in different subSaharan countries. These countries include Cameroon, Zambia, Uganda, South Africa, Benin, Kenya, Malawi and Rwanda.
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ACADEMIC RESEARCH Appendix B: Exclusion/Inclusion Criteria Included
· Peer-reviewed · From International Organizations with review process (primary sources only)
Qualitative studies Quantitative studies
· The Rest of the World
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Web page data Opinion pieces
Appendix C: Search Strategy for Peer-reviewed Literature Date of Search
Total # Articles
· Maternal services · HIV · Mother-to-child transmission · Sub-Saharan Africa
Same as previous, but added: · antenatal clinics
BioMed Central - Infectious diseases
· PMTCT · Antenatal clinics · HIV
· PMTCT · Antenatal clinics
1 * Three (3) articles could not be accessed for free; I had to let them go
· · · ·
Antenatal clinics PMTCT HIV Sub-Saharan
· 10,300 · 6,730 after I added sub-Saharan as a search term · 5,910 after I added time frame (after 2005) I stopped my search after 10 pages to keep relevancy
· · · ·
PMTCT Antenatal HIV Africa
426 I stopped my search after 10 pages to keep relevancy
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Appendix D: Search Strategy for Policy Literature Date of Search
Total # Articles
PEPFAR official website
· ANC · PMTCT · Sub-Saharan Africa
The website did not provide total number of results. I stopped my search after 10 pages to keep relevancy
Global Fund official website
· ANC · PMTCT · AIDS
542 1 I stopped my search after 10 pages to keep relevancy
UNAIDS official website
· ANC · PMTCT · Sub-Saharan Africa
UNITAID official website
· ANC · PMTCT · Sub-Saharan Africa
45 1 I stopped my search after 10 pages to keep relevancy
World Health · ANC Organization · PMTCT Official website · Sub-Saharan Africa
· 188 · 94 after I added sub-Saharan as a search term
UNICEF official website
· 1 · 2 after I changed ANC for antenatal clinics
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· ANC · PMTCT
Perspectives Enhancing Cancer Control in Kenya Through Knowledge Translation: A Perspective Review Joshua Munywoki1, Helen Dimaras1,2,3,4,5,6
Department of Human Pathology, University of Nairobi, Nairobi, Kenya; Department of Ophthalmology & Vision Sciences, The Hospital for Sick Children, Toronto, Canada 3 Division of Clinical Public Health, Dalla Lana School of Public Health 4 Department of Ophthalmology & Vision Sciences, Faculty of Medicine, University of Toronto, Toronto, Canada 5 Child Health Evaluative Sciences Program 6 Center for Global Child Health, SickKids Research Institute, Toronto, Canada. Background: Cancer is the third leading cause of death in Kenya. With inadequate and unevenly distributed cancer diagnoses, management facilities and equipment, Kenya’s capacity to diagnose and manage cancer remains limited. Knowledge translation, or the application of existing knowledge to drive changes in policy and practice, could lead to dramatic improvements in Kenya’s capacity to manage cancer. Methods: This perspective review explores the relevance of knowledge translation to cancer control in Kenya as described in the Kenya National Cancer Control Strategy. We explore the history of cancer control and knowledge translation in Kenya, and compare and contrast the circumstances in Kenya with knowledge translation for global health developed in Canada. Results: We uncovered a need for further development of knowledge translation in Kenya such that national cancer control goals may be achieved. Conclusion: Sustained and integrated development of knowledge translation in Kenya, championed by local leaders and supported by strong international partnerships, could dramatically reduce global health inequities related to cancer control and prevention. 1 2
The World Health Organization defines knowledge translation (KT) as “the process by which evidence produced by research is translated into policy, practice and product development.”1 Some examples of KT activities include the dissemination of research findings to decision makers via policy briefs that recommend policy change; public awareness campaigns to promote healthy behaviors in the general population; and consensus-building workshops to develop treatment protocols informed by the best available evidence, with the goal of improving clinical care. KT aims at effectively bridging the “know-do” gap, i.e., the difference between what is known and what is practiced. The volume of scientific findings produced far exceeds the volume of scientific findings that are actually applied to make improvements to the health sector, suggesting that stronger and sustained KT efforts are needed to narrow this gap. The “know-do” gap is most striking when observing health inequities in the developing world. One of the most commonly cited examples is childhood vaccinations: While the technology to save lives exists, KT is required to overcome challenges in distribution and delivery of vaccines in low-resourced nations. Canada has spearheaded the creation of methods to facilitate translation of evidence into action, informed by research aimed at uncovering factors that bolster or weaken the implementation of scientific findings. These methods include online KT platforms for knowledge exchange,2 knowledge transfer plans3 and implementation tool kits to improve uptake and utilization of research by end-users. Recognizing that KT has a role to play in reducing health inequities worldwide, the Canadian Coalition for Global Health Research also created a learning module to train Canadian scientists in the conduct of KT in low-and-middle income countries (LMICs).4 The author (JM), a student from the University of Nairobi,
gained a greater knowledge of and interest in KT during a 3-month exchange to the University of Toronto, Canada, where he met several global health researchers and KT experts at the SickKids Research Institute. With cancer being the third highest cause of morbidity in Kenya,5 it became evident that effective implementation of KT could address the growing cancer challenge. Furthermore, despite KT being touted as an essential tool for improving health by global health players outside Kenya, there was a scarcity of information and resources concerning KT within Kenya. This paper is a perspective review that explores the relevance of KT to cancer control in Kenya. First, a brief history of KT and cancer control in Kenya is presented. Canadian training modules on the application of KT in global health, as well as a critique on their relevance in Kenya, are explored next. The paper concludes with strategies for development of KT in Kenya to achieve goals of cancer control.
Cancer and Knowledge Translation in Kenya: A Brief Overview In Kenya, cancer is the leading cause of morbidity among noncommunicable diseases,5 Late diagnoses of cancer, coupled with uneven distributions of cancer management facilities throughout the nation (e.g., radiotherapy for cancer treatment is only available in Nairobi), make cancer difficult to manage.6 Late diagnoses are in part due to low awareness among the public, and sometimes even among healthcare workers, of early signs and symptoms of cancer. KT strategies to improve cancer education in the public and medical community could play a role in achieving earlier diagnosis. Similarly, health service research data could be utilized to better plan and manage cancer care delivery in Kenya such that resources spring 2017 | VOL viI ISSUE iI | JGH 30
Figure 1: A descriptive analysis of the distribution of stakeholder involvement in Kenya Cancer Control Strategy KT activities. The recommendations of the Kenya Cancer Control Strategy7 that involved KT were analyzed for type of stakeholder engaged in the activity (e.g. advocacy, development of clinical guidelines) or targeted by the activity (e.g. audience of advocacy efforts, adoption of guidelines). The majority of KT activities involved Healthcare Practitioners (83 activities) and Scientists, Educators and KT experts (76 activities). Active engagement in KT activities primarily involved Scientists, Educators and KT experts (56 activities), Policymakers (33 activities) and Healthcare Practitioners (22 activities). Targets of KT activities primarily involved Healthcare Practitioners (61 activities) and Patients, Families and Public (29 activities). Categories of stakeholders are based on Barwick’s knowledge translation planning template3.
are matched to distinct the needs of different geographic areas of the country. In response to the challenges of cancer management, the Kenyan government developed a Cancer Control Strategy to prioritize cancer prevention and control.7 The policy identifies needs and makes recommendations for cancer-related capacity improvements and the application of existing knowledge, coordination of referral systems and efforts to fill knowledge, attitudes and practice (KAP) gaps in the healthcare workforce. Many of the recommendations documented in the Kenya Cancer Control Strategy require some form of knowledge translation, exchange or dissemination, even if it is not explicitly stated as KT in the strategy document.7 For example, one recommendation aims to develop a strong culture of translation of research. Other activities, such as improvements in diagnosis and treatment, early detection, rehabilitation and palliative care, require enhanced harmonization and strengthening of the national health research system, which involves a variety of stakeholders. Effective KT for global health, and health in general, 31
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requires involvement from multiple parties, including researchers, educators and KT experts; policy and decision makers; healthcare practitioners; patients/families and the general public.3 We analyzed the recommended activities of the Kenya Cancer Control Strategy to isolate activities that required some form of KT. Our analysis revealed 127 activities requiring KT. Next, we looked at the type of KT stakeholder (i.e. Healthcare Practitioners; Scientists, Educators and KT experts; Policymakers; or Patients, Families and Public) required to engage in each activity. Stakeholder engagement was classified as ‘involved’ (i.e., actively engaged and participating in KT activities, as identified in the strategy) or ‘targeted’ (i.e., as passive end-users of the information disseminated by KT) by activity (Figure 1, Table 1). The majority of KT activities involved Healthcare Practitioners (83 activities) and Scientists, Educators and KT experts (76 activities). Active engagement in KT activities primarily included Scientists, Educators and KT experts (56 activities), Policymakers (33 activities) and Healthcare Practitioners (22
Table 1. Distribution of stakeholder involvement in Kenya Cancer Control Strategy KT activities
Scientists, Educators, KT experts
Patients, Families and Public
activities). Targets of KT activities primarily included Healthcare practitioners (61 activities) and Patients, Families and Public (29 activities). Furthermore, the Strategy’s approach is rather simplistic, where activities for implementation of the strategy were clearly established, with measurable outputs and monitoring indicators to track the implementation. The underlying assumption in the Strategy is a smooth and unidirectional transition of knowledge during implementation events e.g., from researchers to healthcare practitioners, when KT theory would indicate that a more comprehensive and multidirectional exchange of knowledge across the gamut of stakeholders is required.8 Effective knowledge mobilization and exchange among involved stakeholders requires a backing of KT, whose role in the Strategy is limited to informing
clinical practice.7 Successful implementation of the Strategy necessitates a strong grounding in KT: careful construction of KT tailors approaches to the identified target audiences and resources in order to support effective partnerships and collaboration. For example, knowledge brokers have been proposed as an effective means of supporting structured knowledge dissemination.9 A knowledge broker is a trusted intermediary that develops and provides the necessary networks, linkages and technical expertise for the effective exchange of knowledge between knowledge producers and knowledge users. This could be very beneficial in the implementation of the Kenya Cancer Control Strategy, as it could strengthen the linkages between the stakeholders necessary
“In Kenya, cancer is the leading cause of morbidity among noncommunicable diseases.4 Late diagnoses of cancer, coupled with uneven distributions of cancer management facilities throughout the nation (e.g., radiotherapy for cancer treatment is only available in Nairobi), make cancer difficult to manage.”
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PERSPECTIVES to execute the recommendations, particularly necessary given the heavy reliance on scientists and educators to provide networks, linkages, and technical expertise. However, there appear to be many challenges to successfully implementing the Strategy. As it stands, it is unclear how exactly the Strategy can meet its KT goals, especially as there is little training in and support of KT within Kenya. To the authors’ knowledge, only one private university offered KT training in Kenya, supported by a one-time grant from Canada’s International Development Research Council; this program is now closed.10 Outside of Kenya, St. Andrew’s University in the UK recently began a KT training initiative involving Tanzanian and Kenyan scientists to overcome barriers that prevent implementation of evidence-based tuberculosis diagnostics.11 The initiative focuses primarily on collecting robust data to better understand challenges of introducing molecular diagnostics in East Africa, engaging policymakers in the research to enhance uptake of science into policy and training knowledge transfer officers to sustain research translation into the community. It is interesting that participants in the TWENDE program expressed a desire that KT become embedded in East African institutions, pointing to the need of
Development of Knowledge Translation in Canada for Global Health Over the last 20 years, Canada has emerged as a global leader in implementing KT for improved healthcare, thanks to strong political will and support from national health and research agencies, such as the Canadian Institutes for Health Research and the global endorsement of KT by the World Health Organization. Canada boasts 6 National Collaborating Centers in its Public Health Agency, which aim to synthesize global scientific evidence of public health importance into national policies, programs and practice.12 On the international stage, the Canadian Coalition for Global Health Research (CCGHR) was formed to promote “better and more equitable health worldwide,” and to develop a strong community of global health researchers, with KT at the forefront of its activities. The CCGHR has created several toolkits to assist with implementation of KT in global health. These include online KT curricula13 and resources, as well as other tools such as the Partnerships Assessment Toolkits14, which can guide North-South collaborations to achieve a fair and equitable partnership and promote mutual benefit and leadership. The CCGHR has also developed guiding principles that promote an equitable approach
“Improvement of KT capacity in Kenya may be achievable by partnering with global experts in the field so as to better model successes in other countries.”
improved KT capacity beyond the current, project-based focus. Without the concomitant strengthening of KT as a new force towards evidence-based action in Kenya, the Cancer Control Strategy may be limited in its feasibility. The authors argue that there is a need to improve proficiency in the use of the research knowledge base in Kenya and efforts at improving KT capacity could help fill this void, particularly if championed by local leaders, such as researchers and policymakers. Partnerships with relevant Kenyan and international stakeholders were necessary to develop the Cancer Control Strategy in the first place, and included cancer experts from various government ministries, public hospitals, universities, research institutes and the World Health Organization. Similarly, partnership with entities that have used and developed KT tools, with ample experience and expertise in this field, could facilitate integration of KT in Kenyan institutions, through sustained education and training. In the next section, we explore how KT for global health has been developed in Canada, which has emerged as a global leader in in the field of KT, to draw insight into how KT could be similarly developed in Kenya. 33
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to global health research. These principles include: authentic partnering, inclusion, shared benefits, commitment to the future, responsiveness to causes of inequity and humility.15 The CCGHR also promotes KT as part of equitable global health research.. Together with the Canadian Institutes for Health Research, the CCGHR developed a KT learning module, available online for anyone to use, geared towards Canadian scientists engaged in research in LMICs4. The module establishes the need for effective KT in LMICs to bridge the “know-do” gap and provides case studies of KT efforts in LMICs where Canadian scientists are currently engaged with LMIC researchers and knowledge-users. It stresses that strong relationships with LMIC partners, as well as the inclusion of their knowledge and perspective, are crucial for the success of any KT work done in these countries. The learning module highlights the importance of trusted and credible LMIC leaders who champion the knowledge-to-action process, and strong local organizations that provide the support for such leaders to do their work. For example, one case study in the learning module focuses on the Zambia Forum for Health Research (ZAMFOHR), an organization created in Zambia with the support of the CCGHR to promote the translation of research
PERSPECTIVES findings into policy and practice. The ZAMFOHR created a database of publication and created multidisciplinary ‘research to action groups’, consisting of researchers, policy-makers and health practitioners, to facilitate their mandate. This resulted in the identification of ‘KT fellows’, who became local experts on specific topics as well as on KT.16 The research to action groups also facilitated policy dialogues that led to the implementation of evidence-based policies in mental and reproductive health.16 It follows, then, that for Kenya to make strides in KT science, it must move beyond the one-off KT workshops such as those described in the previous section and cultivate local leadership to move KT forward in an integrated manner. One limitation of the KT learning module design, however, is that it implies that KT is unidirectional, with information primarily flowing from Canadian to LMIC partners. In reality, there are many health and information gaps between and within countries.17 The module could be improved by emphasizing the concept of shared learning, and by promoting more ethical and mutually beneficial practices by explicitly acknowledging that all partners have something to learn from one another other. Even with this limitation, however, the module provides tangible examples of successful KT in LMICs; this could be useful in developing KT capacity for cancer control in Kenya. More generally, Canada’s history of success in forging and coordinating sturdy linkages between researchers, policymakers and implementation personnel and the entrenchment of KT in scientific research, positions Canadian organizations as suitable partners for strengthening KT in Kenya.
A Way Forward for Knowledge Translation in Kenya In summary, to be effectively implemented, the Kenya Cancer Control Strategy requires strong local capacity in KT, as its recommendations include the generation and application of scientific research to policy and practice. However, as discussed earlier in this manuscript, the capacity for KT in Kenya is underdeveloped, owing to few training opportunities in the field. Coupled with the host competing priorities for the country’s limited financial and technical resources, this could potentially hinder effective implementation of the Strategy. Kenya can better address prevailing health challenges through fostering strong partnerships and programs with experienced individuals and organizations, such as the CCGHR, to cultivate a culture of KT science and practice. Following the example of other international partnerships focused on KT, such as the ZAMFOHR initiative discussed earlier in this paper, building in-country KT capacity can uncover innovative KT methods that are tailored to
the local context. It would not be a stretch to suggest that Canada and Kenya partner in this mission, given the strong history of collaboration between the two nations. The leadership for such an initiative must come from within Kenyan institutions. Strong political will to support KT development was essential in Canada and would certainly be instrumental for the same Kenya. The identification of local KT champions could help build the field and advocate to policymakers, as shown in other LMICs. The importance of local leadership and ownership cannot be stressed enough, given that approaches at KT capacity building have focused on developing KT capacity in high-income countries like Canada for application in LMICs, as observed by the CCGHR module. The opportunity to develop local KT capacity in LMICs through the integrated and sustainable approaches that supported such robust development of KT capacity in countries like Canada could be missed. This is supported by the fact that thus far, many KT efforts in Kenya have been one-off workshops, or constrained to projects that are limited in scope. These approaches may actually interfere with strengthening of home-grown KT programs in Kenya, especially in cases where the research agenda is donor-driven and does not match local health priorities. Arguably, much of the health research conducted in LMICs in this manner has weakened the local capacity to conduct research.17,18,19 It is essential to avoid this in the KT field as well, hence the need for strong Kenyan ownership and leadership going forward. One constructive way to build local leadership in KT would be to engage local research champions in the process of testing and refining existing KT toolkits, as well as making recommendations for how such resources could be implemented and utilized in Kenya.
Limitations This manuscript represents the authors’ perspectives of the on how KT could be applied in Kenya to bolster national initiative to improve health. It is informed by an examination of the Kenya Cancer Control Strategy and the KT activities embedded within it. Conclusions and Recommendations There is an opportunity for capacity building in KT in Kenya that goes beyond traditional project-based application of KT principles, usually implemented by scientists from high-income countries working in low-income settings. The need for KT in LMICs is demonstrated by analysis of the Kenyan Cancer Control Strategy, which proposes activities that require robust application of KT to be impactful. Improvement of KT capacity in Kenya may be achievable by partnering with global experts in the field so as to better model successes in other countries. Most
importantly, securing strong political will and identifying local research champions in Kenya to help bring KT to the forefront of the science and research agenda will be key to achieving this goal. References
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