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Bridging the Gap: implementing tuberculosis and HIV/AIDS collaborative activities in the Northwest Region of Cameroon
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
2011 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Introduction

The human immunodeficiency virus (HIV) epidemic has led to the upsurge of tuberculosis (TB) infection globally, but most especially in areas with high HIV prevalence. In the past, there was lack of a coordinated global and national response between TB and HIV programmes to curb the devastating impacts of both infections. However, the ProTEST Initiative piloted in sub-Saharan Africa in 1997 demonstrated that TB and HIV programmes could collaborate successfully in delivering joint services. This prompted the development of the WHO interim policy on collaborative TB/HIV activities in 2004, aimed at reducing the burden of TB and HIV in populations affected by both infections. This thesis explores how collaborative activities between TB and HIV programmes have been established in Cameroon and implemented in the Northwest Region. It also highlights the achievements and constraints in delivering joint services to TB patients co-infected with HIV.

Methods

The study was conducted in the Northwest Region, one of the 10 regions of Cameroon with the highest HIV prevalence. The study uses health system research combining qualitative and quantitative methods to explore the research objectives. Qualitative methods were used to capture the perspectives of: i) the service providers; key informants from the central, regional and district levels concerned with the collaboration process and in delivering HIV services to TB patients, and ii) TB patients regarding HIV testing as an entry point to HIV services. Quantitative methods were used to ascertain TB patients’ access to HIV services provided for by the collaboration.

Results

The study demonstrated that although there were varying levels of collaboration between TB and HIV programmes from the central to operational level in the health system, delivering joint services was feasible. Furthermore, despite the challenges TB patients faced in testing for HIV, overall implementing TB/HIV collaborative activities increased TB patients’ acceptability and accessibility to HIV services. These were facilitated by the improved collaboration at the operational level, and enhanced service provider-patient alliance which was instrumental in building patients’ trust in the health system. Collaboration also led to cross-training and teamwork between staffs from both programmes, and improved networking between service providers and other actors involved in TB and HIV care. Nevertheless, there were health system constraints including inadequate leadership and management, shortage of human and infrastructural resources, frequent interruptions in the supply of essential drugs and laboratory materials

Conclusion

TB/HIV collaborative activities have improved service delivery and TB patients’ access to HIV services. Nonetheless, appropriate stewardship which guarantees joint planning, monitoring and evaluation of essential activities, and accountability at all levels in the health system is invaluable. Besides, the identified health system constraints which could adversely influence effective joint service delivery and a sustainable collaboration deserve due appraisal.

 

 

Abstract [fr]

Introduction

L’épidémie du virus de l’immunodéficience humaine (VIH) a conduit à une augmentation globale  de la tuberculose(TB), particulièrement dans les régions à forte prévalence du VIH. Il y’avait par le passé un manque de coordination tant sur le plan mondial que national, des programmes de lutte contre la TB et le VIH pour freiner les effets dévastateurs liés à la co-infection des deux pathogènes. Cependant, l’initiative pilote “ProTEST”  conduite en 1997 en Afrique sub-saharienne  a démontré que les programmes de lutte contre le VIH et la TB pouvaient collaborer avec succès en combinant leurs services. Cette étude pilote a inévitablement incité a un changement de politique du bureau intérimaire a l’Organisation Mondiale de la Santé (OMS), de lutte contre le VIH/TB  à mettre sur pieds en 2004 des objectifs pour la réduction de l’impact du VIH/TB parmi les populations atteintes des deux infections. Cette thèse explore comment la collaboration entre les activités des programmes  de lutte VIH/TB a été établie au Cameroun, et comment son application se fait  dans la région du nord ouest. Il est également mis en exergue et les réalisations les difficultés que rencontrent les services combinés lors de la dispensation des soins aux malades de TB avec une coïnfection au VIH.

Méthodes

L’étude a été faite dans la région du nord ouest, une des 10 régions du Cameroun, avec le taux de prévalence au VIH le plus élevé. L’étude utilise le système de recherche en santé combinant des méthodes qualitatives et quantitatives pour explorer les objectifs de la recherche. Les méthodes qualitatives ont été utilisées pour enregistrer les données suivantes: i) centre offrant les services combinés; les personnes en charge au niveau central, régional, et des districts, qui sont responsables de l’intégration au processus et qui d’autre part veillent a ce que les malades de TB bénéficient des services du VIH ; et ii) les malades de TB qui considèrent le dépistage du VIH  comme porte d’entrée dans les services VIH. Des méthodes quantitatives ont été utilisées  pour confirmer  l’accès des malades de TB aux soins de services VIH offerts par la collaboration.

Résultats

L’étude a démontré que bien qu’il y ait  plusieurs niveaux de collaborations entre les programmes de VIH et TB depuis le sommet jusqu’ à la base du  système de santé, la provision de services combinés  est faisable. Malgré les difficultés rencontrées par les malades de TB pour avoir accès au dépistage du VIH, l’application en somme de la collaboration des activités entre les programmes de VIH et de TB a augmenté l’acceptation et l’accessibilité des malades de TB aux services de VIH. Ceci fut facilité par l’amélioration de la coopération au niveau des opérations des deux programmes permettant ainsi  la facilitation de l’établissement d’une alliance entre le personnel de soin et le patient, alliance qui fut primordiale dans l’élaboration du rapport de confiance que le malade doit avoir à l’endroit du system de santé. La collaboration a également conduit  à un travail d’équipe et une formation croisée entre les équipes des deux programmes, il a été également établi une amélioration du réseau d’échange entre les personnels de soins et toutes personnes actives dans le secteur du VIH et TB.    Néanmoins, il a été relevé des défis dans le système de santé telle une insuffisance dans le leadership et la gestion de fréquente interruption dans la chaine de distribution des médicaments essentiels et du matériel de laboratoire.

Conclusion

La collaboration des activités des programmes VIH/TB a amélioré la qualité des soins et services  avec pour résultante une meilleure accessibilité des malades de TB aux services de VIH. Néanmoins, une conduite appropriée qui garantie une planification mixte, une évaluation et un suivi des activités essentielles, ainsi qu’une gestion fiable a tous les niveaux du système de santé est indispensable. Outre, les difficultés liées au système de santé identifiées par cette étude et qui méritent une évaluation, du fait  qu’elles pourraient affecter négativement l’application effective du but recherché et la collaboration durable entre les deux services.

 

 

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2011. , 63 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1431
Keyword [en]
Tuberculosis, HIV/AIDS, collaborative activities, Northwest Region, Cameroon.
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public health
Identifiers
URN: urn:nbn:se:umu:diva-43847ISBN: 978-91-7459-228-3OAI: oai:DiVA.org:umu-43847DiVA: diva2:416793
Public defence
2011-06-10, Room 135, Building 9A, Family Medicine, Norrlands Universitetssjukhus, Umeå, 10:00 (English)
Opponent
Supervisors
Available from: 2011-05-13 Created: 2011-05-12 Last updated: 2015-04-29Bibliographically approved
List of papers
1. Voices from the frontline: counsellors’ perspectives on TB/HIV collaborative activities in the Northwest Region, Cameroon
Open this publication in new window or tab >>Voices from the frontline: counsellors’ perspectives on TB/HIV collaborative activities in the Northwest Region, Cameroon
2011 (English)In: BMC Health Services Research, ISSN 1472-6963, Vol. 11, 328- p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: The overlapping epidemiology of tuberculosis (TB) and human immunodeficiency virus (HIV) infections prompted the World Health Organisation in 2004 to recommend collaboration between national TB and HIV programmes. The goal of this collaboration is to decrease the burden of both infections in the population. This policy was subsequently adopted by the national TB and HIV programmes in Cameroon with TB and HIV nurses/counsellors acting as frontline implementers of the collaborative activities in the 10 regions of the country.

METHODS: Qualitative research interviews were conducted with 30 nurses/counsellors in four approved treatment centres providing comprehensive TB and HIV/AIDS services in the Northwest region of Cameroon. The aim was to explore their experiences in counselling, in delivering joint TB and HIV services, and the constraints to effective collaboration between TB and HIV services. To complement the findings from the counsellors' interviews, as part of an emergent design, further interviews with 2 traditional healers and non-participant observations in two HIV support group meetings were conducted.

RESULTS: According to the respondents, counselling was regarded as a call to serve humanity irrespective of the reasons for choosing the profession. In addition, the counselling training and supervision received, and the skills acquired, have altogether contributed to build patients' trust in the healthcare system. Teamwork among healthcare workers and other key stakeholders in the community involved in TB/HIV prevention and control was used as a strategy to improve joint service delivery and patients' uptake of services. Several constraints to effective collaboration between TB and HIV services were identified, including shortage of human resources, infrastructure and drug supplies, poor patients' adherence to treatment and the influence of traditional healers who relentlessly dissuade patients from seeking mainstream medical care.

CONCLUSIONS: In order to achieve a sustainable collaboration between TB and HIV services, adequate planning, investment and strengthening of the health system including human resources, infrastructure and ensuring uninterrupted supplies of medicines are essential. A multidisciplinary approach to service delivery particularly focusing on harnessing the enormous potentials of traditional healers in TB/HIV prevention and control would also be indispensible.

National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-43854 (URN)10.1186/1472-6963-11-328 (DOI)22129222 (PubMedID)
Available from: 2011-05-12 Created: 2011-05-12 Last updated: 2015-04-29Bibliographically approved
2. "When I get better I will do the test": facilitators and barriers to HIV testing in Northwest region of Cameroon with implications for TB and HIV/AIDS control programmes
Open this publication in new window or tab >>"When I get better I will do the test": facilitators and barriers to HIV testing in Northwest region of Cameroon with implications for TB and HIV/AIDS control programmes
2010 (English)In: SAHARA-J: Journal of Social Aspects of HIV/AIDS, ISSN 1729-0376, E-ISSN 1813-4424, Vol. 7, no 4, 24-32 p.Article in journal (Refereed) Published
Abstract [en]

The World Health Organization has recommended collaborative activities between TB and HIV programmes with routine counselling and testing for HIV among TB patients in order to improve the uptake of HIV services. We carried out qualitative research interviews with 21 TB patients in four selected TB and HIV/AIDS treatment centres in the Northwest Region of Cameroon to explore the facilitators and barriers to HIV testing. The desire to be healthy and live longer from knowing one’s status inspired by the anticipated support from loved ones, faith in a supreme being, influence and trust in the medical authority, encouraged HIV testing. Men also demonstrated their masculinity by testing, thus portraying themselves as positive role models for other men. Meanwhile, the overwhelming burden of facing both TB and HIV simultaneously, influenced by the fear of disclosure of results, harmful gender norms and practices, fear of stigma and discrimination, and misconceptions surrounding HIV/AIDS deterred HIV testing. However, as a result of conflicting emotional experiences regarding to test or not to test, the decision-making process was not straightforward and this complex process needs to be acknowledged by health care providers when advocating for routine HIV testing among TB patients.

Place, publisher, year, edition, pages
Taylor & Francis, 2010
Keyword
tuberculosis, HIV, counselling and testing, Northwest Region, Cameroon.
National Category
Public Health, Global Health, Social Medicine and Epidemiology Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:umu:diva-37292 (URN)10.1080/17290376.2010.9724974 (DOI)000284964200005 ()
Note

Title in french:

‘Quand j'irai mieux, je ferai le test’: facilitateurs et obstacles au dépistage du sida dans la région du Nord-Ouest du Cameroun, avec ses implications pour les programmes de contrôle de la tuberculose et du VIH/SIDA

Available from: 2010-10-25 Created: 2010-10-25 Last updated: 2015-10-07Bibliographically approved
3. “If the patients decide not to tell what can we do?”: TB/HIV counsellors’ dilemma on partner notification for HIV
Open this publication in new window or tab >>“If the patients decide not to tell what can we do?”: TB/HIV counsellors’ dilemma on partner notification for HIV
2011 (English)In: BMC International Health and Human Rights, ISSN 1472-698X, Vol. 11, no 6Article in journal (Refereed) Published
Identifiers
urn:nbn:se:umu:diva-43853 (URN)
Available from: 2011-05-12 Created: 2011-05-12 Last updated: 2015-04-29Bibliographically approved
4. Assessing the accessibility of HIV care packages among tuberculosis patients in the Northwest Region, Cameroon
Open this publication in new window or tab >>Assessing the accessibility of HIV care packages among tuberculosis patients in the Northwest Region, Cameroon
2010 (English)In: BMC Public Health, ISSN 1471-2458, Vol. 10, Article nr 129- p.Article in journal (Refereed) Published
Abstract [en]

Background: Tuberculosis (TB) and human immunodeficiency virus (HIV) co-infection is a major source of morbidity and mortality globally. The World Health Organization (WHO) has recommended that HIV counselling and testing be offered routinely to TB patients in order to increase access to HIV care packages. We assessed the uptake of provider-initiated testing and counselling (PITC), antiretroviral (ART) and co-trimoxazole preventive therapies (CPT) among TB patients in the Northwest Region, Cameroon.

Methods: A retrospective cohort study using TB registers in 4 TB/HIV treatment centres (1 public and 3 faith-based) for patients diagnosed with TB between January 2006 and December 2007 to identify predictors of the outcomes; HIV testing/serostatus, ART and CPT enrolment and factors that influenced their enrolment between public and faith-based hospitals.

Results: A total of 2270 TB patients were registered and offered pre-HIV test counselling; 2150 (94.7%) accepted the offer of a test. The rate of acceptance was significantly higher among patients in the public hospital compared to those in the faith-based hospitals (crude OR 1.97; 95% CI 1.33 - 2.92) and (adjusted OR 1.92; 95% CI 1.24 - 2.97). HIV prevalence was 68.5% (1473/2150). Independent predictors of HIV-seropositivity emerged as: females, age groups 15-29, 30-44 and 45-59 years, rural residence, previously treated TB and smear-negative pulmonary TB. ART uptake was 50.3% (614/1220) with 17.2% (253/1473) of missing records. Independent predictors of ART uptake were: previously treated TB and extra pulmonary TB. Finally, CPT uptake was 47.0% (524/1114) with 24% (590/1114) of missing records. Independent predictors of CPT uptake were: faith-based hospitals and female sex.

Conclusion: PITC services are apparently well integrated into the TB programme as demonstrated by the high testing rate. The main challenges include improving access to ART and CPT among TB patients and proper reporting and monitoring of programme activities.

Place, publisher, year, edition, pages
BioMed Central, 2010
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-39504 (URN)10.1186/1471-2458-10-129 (DOI)000276449900003 ()20226022 (PubMedID)
Available from: 2011-01-28 Created: 2011-01-28 Last updated: 2015-04-29Bibliographically approved

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