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Keywords:

  • human immunodeficiency virus;
  • preventive care;
  • primary care;
  • Botswana;
  • package of care services;
  • local adaptation

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. The Botswana setting and family model clinic (FMC) context
  5. Methods
  6. Results
  7. Discussion
  8. Conclusion
  9. References
  10. Supporting Information

Background

As life expectancy of HIV-infected patients improves due to antiretroviral treatment (ART) and the importance of associated co-morbidities and chronic diseases increases, preventive care will become increasingly important. Adaptation of existing preventive guidelines to local environments will become a priority for HIV treatment programmes.

Methods

Guidance from the World Health Organization, a focused evidenced-based literature review, Botswana national guidelines, Botswana-specific morbidity and mortality data and centre-specific data were used to adapt a published general primary care package for limited-resource areas to our centre's specific setting.

Results

The preventive care package contains recommendations on tuberculosis prevention, malnutrition, depression, cervical and breast cancer, hepatitis B coinfection, cardiovascular risk factors, external injury prevention, domestic violence screening, tobacco and substance-abuse counselling, contraception and screening and treatment of sexually transmitted infections.

Conclusion

This preventive care package addresses the comprehensive health needs of HIV-infected adults in the FMC in an evidence-based manner. The process of combining clinic-specific prevalence data, national guidelines, regional literature and assessment of public-sector resources to adapt an existing general package could be utilised to develop similar guidelines in other resource-limited locales.

Contexte

Alors que l'espérance de vie des patients infectés par le VIH s'améliore grâce au traitement antirétroviral (ART) et l'importance des co-morbidités et maladies chroniques associées augmente, les soins préventifs deviendront de plus en plus importants. L'adaptation des directives de prévention existantes à l'environnement local deviendra une priorité pour les programmes de traitement du VIH.

Méthodes

Les directives de l'Organisation Mondiale de la Santé, une revue de la littérature centrée sur l’évidence, les directives nationales du Botswana, les données sur la morbidité et la mortalité spécifiques au Botswana et les données centrales spécifiques ont été utilisées pour adapter un ensemble de soins primaires généraux publiés sur des zones à ressources limitées, à notre contexte central spécifique.

Résultats

L'ensemble des soins préventifs contient des recommandations sur la prévention contre la tuberculose, la malnutrition, la dépression, le cancer du sein et de l'utérus, la coïnfection avec l'hépatite B, les facteurs de risque cardiovasculaire, la prévention des blessures externes, le dépistage de la violence domestique, le conseil sur le tabagisme et la toxicomanie, la contraception et le dépistage et le traitement des infections sexuellement transmissibles.

Conclusion

Cet ensemble de soins préventifs répond aux besoins complets de santé des adultes infectés par le VIH, sur base d’évidence. Le processus de combinaison des données de prévalence spécifiques à la cliniques, les directives nationales, la littérature régionale et l’évaluation des ressources du secteur public afin d'adapter un ensemble général existant pourrait être utilisé pour élaborer des directives similaires dans d'autres contextes locaux à ressources limitées.

Antecedentes

A medida que la expectativa de vida de los pacientes infectados con VIH mejora debido al tratamiento antirretroviral (TAR) y la importancia de las comorbilidades asociadas y las enfermedades crónicas aumentan, los cuidados preventivos serán cada vez más importantes. La adaptación de las guías preventivas existentes a ambientes locales se convertirá en una prioridad para los programas de tratamiento del VIH.

Métodos

Se utilizaron las guías de la Organización Mundial de la Salud, una revisión centrada en literatura basada en evidencia, las guías nacionales de Botswana, datos de morbilidad y mortalidad específicos para Botswana y datos específicos del centro, para adaptar un paquete ya publicado de cuidados primarios generales para áreas con recursos limitados a las especificidades de nuestro emplazamiento.

Resultados

El paquete contiene recomendaciones para la prevención de la tuberculosis, la desnutrición, depresión, el cáncer cervical y de mama, la coinfección por hepatitis B, factores de riesgo cardiovascular, prevención de daños externos, rastreo de violencia doméstica, aconsejamiento sobre el tabaco y abuso de sustancias, métodos anticonceptivos, y análisis y tratamiento de enfermedades de transmisión sexual.

Conclusión

Este paquete preventivo aborda de forma integral las necesidades sanitarias de adultos infectados con VIH con una estrategia basada en la evidencia. El proceso de combinar datos clínicos específicos de prevalencia, guías nacionales, literatura regional y evaluación de los recursos del sector público para adaptarse al paquete general existente podrían utilizarse para desarrollar unas guías similares en otras localidades con recursos limitados.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. The Botswana setting and family model clinic (FMC) context
  5. Methods
  6. Results
  7. Discussion
  8. Conclusion
  9. References
  10. Supporting Information

National approaches to HIV in resource-limited settings have historically focused on the scale-up of antiretroviral treatment (ART) programmes. For good reason, as fewer than half of HIV-infected individuals in need of antiretroviral treatment worldwide receive it (UNAIDS 2009). While more developed settings have seen HIV transformed by ART into a chronic disease whose management includes non-communicable aspects such as long-term HIV- and ART-related complications, diabetes, cardiovascular disease, renal disease and hyperlipidaemia (IDSA 2009; European AIDS Society 2011a,b), care in the developing world has remained focused primarily on HIV-specific aspects, such as diagnosis, treatment of opportunistic infections and ART delivery.

Yet the demographic transformation of HIV into a chronic disease is clearly underway in the developing world (Hontelez et al. 2012; Mills et al. 2012). 2008 rates of ART access in the developing world, although still insufficient, show a tenfold increase from 5 years earlier (UNAIDS 2009). In southern Africa (Jahn et al. 2008; Herbst et al. 2009) and elsewhere (Kilsztajn et al. 2007), HIV-associated mortality has declined with the availability of ART. In our setting in Botswana, more than 80% of early enrollees remain alive 5 years after initiation (Bussmann et al. 2008). A recent meta-analysis has found survival rates after an individual's first year of ART ranging from 83% in sub-Saharan Africa (SSA) to 93% in the Americas (Gupta et al. 2011). And although mortality causes in HIV-infected persons in the developing world remain dominated by infectious diseases (Tillekeratne et al. 2009; Cooper et al. 2010; Garcia-Jardon et al. 2010), this, too, is changing. In Brazil, where ART scale-up occurred early, mortality causes in HIV-infected persons (Pacheco et al. 2009) are now dominated by chronic non-communicable diseases (NCDs) similar to those in North America and Europe (Antiretroviral Therapy Cohort Collaboration 2010), and a similar phenomenon has been projected to occur in South Africa over the next few years (Mayosi et al. 2009). This shift is accentuated by the fact that chronic non-communicable diseases are common in HIV-infected persons, especially those on ART, due to several factors, including both side effects of and prolonged survival due to ART, and HIV itself. Not only cardiovascular disease but neoplasms, dyslipidaemias, diabetes, chronic renal disease, osteoporosis and others occur more commonly in HIV-infected persons than in the general population (Rockstroh et al. 2010). To this will be added the demographic shift in the HIV-positive population: it is projected that by 2040 in sub-Saharan Africa, more than one HIV-infected person in four will be aged 50 or older (Hontelez et al. 2012).

Thus, many developing world settings, especially where HIV is prevalent, now suffer from a ‘double burden’ of disease with high mortality from both infectious and non-infectious causes (Mayosi et al. 2009). In fact, in 2010, NCDs combined were the leading cause of death worldwide, with the majority of deaths occurring in the developing world (World Health Organization 2011). The effects of both uncontrolled HIV replication and antiretroviral therapy have been implicated in the development of NCDs in patients with HIV.

The growing roles of the associations between HIV, ART and NCDs underscore the importance of tackling NCDs in resource-constrained regions where gains made in mortality and morbidity with ART may be lost if NCDs are not adequately addressed. However, existing national or international approaches to primary care may not be optimal for HIV-infected persons, and guidelines effective in developed world settings may not be appropriate in some or all developing world settings.

Recognition of the importance of filling this gap has driven the development of several preventive care packages for PLWH in developing settings. Three of these packages are described in Table 1. Mermin et al. (2005) proposed a package based on efficacy in PLWH in Africa of reduced morbidity/mortality, benefit to household members, accessibility and affordability in developing settings, and potential for implementation using existing health infrastructure; strong acceptance and utilisation of this package in Uganda was demonstrated by Colindres et al. (2008). Tolle (2009) adapted and expanded Mermin's package to include additional items and the screening and management of chronic non-HIV conditions with intervention both known to reduce morbidity and mortality of PLWH in resource-constrained settings, and available in an economical, feasible form implementable through family-centred care settings, especially in Africa. WHO has also developed a similar package for PLWH, based on a review of evidence in 13 areas of intervention considered low cost and of particular importance to reducing illness associated with HIV infection and preventing HIV transmission (O'Reilly 2008). While possessing some commonalities, the packages differ in specific elements, the Mermin and WHO packages being developed as broad, essential guidance for health practitioners, Ministries of Health and non-governmental organisations, while the Tolle package was developed for comprehensive, family-centred HIV care and treatment programmes in resource-constrained areas.

Table 1. Components of general packages of HIV primary care services for resource-limited settings
Rationale for componentPackage component
MerminTolleWHO
Reduction in waterborne illnessWater purificationWater purificationWater purification
Malaria preventionInsecticide-treated bednetsInsecticide-treated bednetsInsecticide-treated bednets or indoor residual spraying
Tuberculosis preventionIsoniazid prophylaxis for tuberculosisIsoniazid prophylaxis for tuberculosisIsoniazid prophylaxis for tuberculosis
Prevention of opportunistic infectionCotrim prophylaxis for opportunistic infections(not included universally due to the availability of ART)Cotrim prophylaxis based on CD4 count/clinical stage
Addressing mental health comorbidity Depression screeningPsychosocial counselling and support
Cervical cancer screening Cervical cancer screening including visualisation with acetic acidCervical cancer screening including visualisation with acetic acid
Management of vascular and metabolic disease Management of cardiovascular disease, diabetes and hyperlipidaemia 
Prevention of new HIV infections  Disclosure and partner notification
   Needle exchange and opioid therapy where applicable
   Family planning services and PMTCT
Prevention of opportunistic fungal infection  Antifungal prophylaxis with azoles based on CD4/clinical stage
Prevention of infections sharing mode of transmission  Screening and treatment of sexually transmitted infections
Prevention of infections exacerbated in immunocompromised hosts  Vaccination for vaccine-preventable diseases
Prevention of HIV-associated malnutrition  Routine nutritional assessment and support

These packages are broadly applicable but not directed to any specific clinical setting or geographical location. Adaptation of such general HIV packages to local conditions and evidence is a separate and important process, as explicitly recognised by the WHO package above. Variations among developing countries in disease prevalence, screening sensitivity and specificity, specific therapeutic options and health system and provider capabilities may be considerable.

Given its emphasis on family-centred care and treatment settings as well as on the screening and management of chronic non-HIV conditions in the context of comprehensive, longitudinal care, we aimed to adapt the Tolle package to our local Family Model Clinic setting, considering the availability and quality of healthcare resources, provider/patient ratio, disease burden and local morbidity/mortality profiles. We used a systematic process that could be applicable to adapting general preventive care packages to other specific settings.

The Botswana setting and family model clinic (FMC) context

  1. Top of page
  2. Abstract
  3. Introduction
  4. The Botswana setting and family model clinic (FMC) context
  5. Methods
  6. Results
  7. Discussion
  8. Conclusion
  9. References
  10. Supporting Information

As the first African nation to begin universal ART rollout in 2001 (Bussman et al. 2008) and with almost 90% of Botswana citizens in need of ART receiving it (Botswana Country Report 2010), Botswana occupies a unique position between the developed world, where HIV is managed as a chronic disease, and some settings struggling to scale up ART to those in need.

The Botswana-Baylor Children's Clinical Centre of Excellence (COE) is a national HIV/AIDS care and treatment facility that provides services in Gaborone, Botswana, for HIV-infected children from around the country. The FMC operates within the COE and serves the primary care needs of many of the HIV-infected adult caregivers of these children (Davis et al. 2010).

The COE is located on the campus of a tertiary care referral hospital and has access to its facilities, including subspecialists in some clinical service areas. There is a comprehensive national formulary, although stock is occasionally limited. During development and implementation of this package, the FMC was staffed by an internist and medical officers on a rotational basis with a typical case load of 5–15 adult patients daily. The physician/patient ratio is higher than is generally available elsewhere in the country and allows for greater continuity of care and an optimal opportunity to implement preventive care services.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. The Botswana setting and family model clinic (FMC) context
  5. Methods
  6. Results
  7. Discussion
  8. Conclusion
  9. References
  10. Supporting Information

Overview

The process of adapting preventive care packages to the local setting involved several stages of information gathering. WHO data on regional mortality and morbidity as well as available Botswana-specific and FMC-specific epidemiologic data were used to tailor guidelines from the Tolle package. Existing international and Botswana-specific national HIV treatment guidelines and general preventive care recommendations were incorporated. Discussions with patients in the FMC complemented the process. In pursuit of political acceptability and ultimately feasible implementation beyond the FMC, the entire adaptation proceeded in consultation with review and approval from a representative of the Botswana Ministry of Health and Social Welfare. Six steps were taken.

Examination of the country-level burden of disease data: The 2009 WHO Mortality and Burden of Disease Estimate for WHO Member States documents the most common causes of morbidity and mortality in Botswana in persons aged 15–59 years and >60 years (Table 2). Although WHO considers these data to be of low quality and although they reflect the general, not the HIV-positive population, they remain the only available country-specific data for Botswana. It is noteworthy that chronic diseases account for the majority of the burden in the group older than 60 years (Table 3).

Table 2. WHO mortality and burden of disease estimate of deaths in 15–59-year-olds in Botswana
HIV/AIDS
Tuberculosis
Violence
Cancers (no breakdown data available)
Cerebrovascular accident (CVA)
Road traffic accidents
Other unintentional injuries
Non-infectious respiratory diseases (COPD, asthma)
Ischaemic heart disease
Drowning
Table 3. WHO mortality and burden of disease estimate of deaths in over 60-year-olds in Botswana
CVA
Cancer
Ischaemic heart disease
Lower respiratory infections
HIV
Diabetes mellitus
Tuberculosis
COPD
Diarrhoeal diseases
Hypertensive heart disease

Causes from Tables 2 and 3 perceived as being amenable to screening were retained or added to the package: tuberculosis, cancer, road traffic accidents, violence (domestic component), ischaemic and hypertensive heart disease and cerebrovascular accident (CVA), diarrhoeal diseases, diabetes and smoking cessation. Entities lacking evidence-based screening guidelines, such as asthma, pneumonia, drowning and other unintentional injuries, were pared from the list.

Major WHO, North American and European guidelines were reviewed, with an informal literature review performed for topics which lacked guidelines from a major authoritative body.

Botswana National HIV Guidelines and National Treatment Guidelines were reviewed and our guidelines harmonised where possible.

Informal analysis of public-sector healthcare resources was performed to establish the availability of laboratory testing, medications and other imaging and diagnostic modalities.1

Systematic review of the locally relevant literature on the included topics to assess regional burden of diseases and evidence on regional benefit of screening and/or management: Pubmed and the African Index Medicus were chosen because both are open-access databases available to any provider with Internet access. For Pubmed, a simple systematic search strategy (see Appendix S1) was developed using predefined composite terms to restrict results to Southern African countries, to HIV and, for topics where only screening (not management) lay within the primary care domain, to screening and prevention. This was expanded to include articles from all of Southern Africa where insufficient Botswana-specific data were available, and data from non-HIV patients where the yield remained insufficient. For the smaller African Index Medicus, searches were performed using only the topic terms identified in the Pubmed search.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. The Botswana setting and family model clinic (FMC) context
  5. Methods
  6. Results
  7. Discussion
  8. Conclusion
  9. References
  10. Supporting Information

Table 4 lists the final adapted package components, along with the supporting evidence and rationale for each item's inclusion, resources available and known local challenges to implementation. The systematic review process discussed above resulted in minimal change to the package.

Table 4. Components and evidence basis of a comprehensive preventive care package for HIV-infected adults in the FMC at the Botswana-Baylor COE in Gaborone, Botswana
FMC guidelinesNational (Ministry of Health 2008)/international or preventive care package recommendationsKey Data/rationale for inclusionLocally available resourcesChallenges
Clean water provisions and water storageCDC Safe Water System Handbook (Department of Health & Human Services 2000)

2010 Botswana study showed OR of 3.9 for diarrhoea for those in homes storing drinking water (Arvelo et al. 2010)

Malawian study of storage of water clean at source showed 31% diarrhoea reduction with the use of a covered water container with spout (Roberts et al. 2001) and others (WRC 1997; Quick et al. 2002), although the results are mixed (Teklu & Kebede 1998).

Treated water available in most homes or villages.

Plastic and covered containers readily available.

Safe water storage and in some settings safe water collection from public sources.
Isoniazid Prophylaxis

National Tuberculosis Programme Manual of Botswana

Botswana National HIV Guidelines

WHO Antiretroviral Therapy for HIV-infected adults and Adolescents 2010

Preventive Care Packages: Tolle 2009; Mermin et al. 2005

TB is the most common cause of death among PLWH in Botswana (Tedla et al. 2010). The efficacy of IPT in HIV-infected patients appears to range from 60 to 90% (Padmapryiadarsini & Swaminathan 2005). A review of FMC HIV-infected patients found that 83.7% of eligible patients were referred for IPT with 79% of patients completing therapy (Sheikh et al. 2011).National IPT referral system. Physician-led screening for signs or symptoms of active TBOptimal duration of IPT is unknown (Padma pryiadarsini & Swaminathan 2005). Appropriate screening for active TB by symptoms of baseline PPD and/or CXR for resource-limited settings is under active investigation (Bassett et al. 2010).
Depression Screening and Treatment

WHO essential Prevention and Care Interventions for Adults and Adolescents Living with HIV in resource-limited settings 2008

Preventive Care packages: Tolle 2009

Depression prevalence among HIV-infected patients in Botswana was found to be 24–38% with 9–12% with suicidal ideations (Lawler et al. 2009). Mental illness may be higher in HIV-infected individuals (Rabkin 2008), and effective antidepressants have been associated with improved adherence to ARVs (Dalessandro et al. 2007).Antidepressants (SSRIs, TCAs). Referral to COE psychologist, outpatient psychiatry clinic, inpatient psychiatry admissionSignificant stigma associated with mental illnesses (Sorsdahl et al. 2010).
Cervical Cancer Screening

Botswana National HIV Guidelines

WHO Essential Prevention and Care Interventions for Adults and Adolescents Living with HIV in resource-limited settings 2008 (WHO 2008)

Preventive Care Packages: Tolle 2009

Primary Care Guidelines for the Management of Persons Infected with Human Immunodeficiency Virus: 2009 Update by the HIV Medicine Association of the Infectious Diseases Society of America (Aberg et al. 2009)

Cervical cancer is the most common cancer amongst women of all ages in Botswana (WHO/ICO 2010).

FMC clinic data showed abnormal cytology in 21.8% of patients (Marukutira et al. 2009).

Specialised clinics capable of performing pap smears.

Referral for colposcopy and advanced gynaecologic care

Lack of reliable ordering system to ensure continued supply of equipment.

Lost samples/results. Long waiting time for results.

Delayed referral for colposcopy

Breast Cancer ScreeningBreast Health Global Initiative Consensus Statement for Middle-Income Settings (Yip et al. 2011)

Breast cancer is reportedly the third-most common solid tumour in Botswana (following Kaposi's Sarcoma and cervical cancer) (Piniel 2010).

Although breast cancers in younger women represent a larger proportion of diagnoses in middle-income than in high-income countries, this appears to reflect underlying population age structures rather than unique African differences in age-specific risk, so age cut-offs remain the same(Yip et al. 2011).

Data on mortality benefits of screening come from industrialised world.

Mammogram (when functioning); general surgery, oncology and chemotherapyBottleneck issues with obtaining mammography; consider recommend biennial screening?
Cardio-vascular Disease (CVD) Risk Assessment

Preventive Care Package: Tolle 2009

WHO Guidelines for assessment and management of cardiovascular risk 2007

Of deaths in Africa, CVD responsible for 9.2% (Kadiri 2005).

In South Africa, it has been noted that treatment-naïve HIV patients with acute coronary syndrome are younger and have fewer traditional risk factors than HIV-negative patients (Becker et al. 2010).

HIV-infected patients suffer from myocardial infarctions at earlier ages than non-infected patients (Perelló et al. 2011).

Echocardiography; EKG; cardiology referral

Specialist cardiology clinic operates once a week.

Challenges of risk factor modification (e.g. smoking, diet, exercise)

Hypertension ScreeningPreventive Care packages: Tolle 2009

Prevalence of HTN across Africa ranges from 14.1 to 34.1% of adults (Kearney et al. 2004) with up to 47% among South African females in one study (Addo et al. 2007). A study of our FMC HIV-infected populationrevealed a prevalence of HTN of 16% in patients >30yo and 25.5% in patients >40yo (Patel et al. 2011b).

Data on benefits of treatment are largely from the developed world.

Antihypertensives in various classes (thiazides, ace inhibitors, beta blockers, nitrates) readily available.

Ambulatory blood pressure monitoring at local clinics. Laboratory monitoring for renal function.

Steady supply of particular antihypertensives.
Hypercholesterolaemia Screening

Preventive Care Packages: Tolle 2009

Primary Care Guidelines for the Management of Persons Infected with Human Immunodeficiency Virus: 2009 Update by the HIV Medicine Association of the Infectious Diseases Society of America (Aberg et al. 2009)

About 59% of ischaemic heart disease and 29% of ischaemic stroke burden in adult males and females were attributable to high cholesterol with marked variation by population group in South Africa in 2000 (Norman et al. 2007).

Antiretroviral therapy itself can be implicated in the development of hyperlipidaemia (Reust 2011).

Laboratory monitoring of lipid panels

Statins available in public formulary

Consistent availability of lipid-lowering medicines, especially fibrates
Diabetes Screening

Screening for Type 2 DM Report of a WHO and International Diabetes Federation meeting 2003 stated that DM2 screening was important and encouraged health authorities to formulate appropriate screening policies (WHO Dept of Noncommunicable Disease Management 2003)

Preventive Package: Tolle 2009

Data on DM2 prevalence in sub-Saharan Africa are sparse but noted to be 4.2-8% in South Africa (Motala 2002). Rates are expected to increase in SSA by 18% with 185% more people with the disease (Motala 2002).

Antiretroviral therapy has been implicated in the development of hyperglycaemia (Catza et al. 2004).

Diabetic education and counselling by a diabetic nurse. Referral to endocrine clinic. Available metformin, sulfonylureas and insulin. A1C monitoring.Glucometers sometimes out of stock
Hepatitis Screening and management

European AIDS Clinical Society Guidelines 2010

IDSA Guidelines: Primary Care Guidelines for the Management of Persons Infected with Human Immunodeficiency Virus: 2009 Update (Aberg et al. 2009)

World Health Organization Essential Prevention and Care Interventions for Adults and Adolescents Living with HIV in Resource-limited Settings (2008)

Botswana HBsAg seroprevalence in PLWH: 10.6% (clinic population of a major urban healthcare facility) 17, 6% in 127 patients without transaminitis in 8 clinics (Tedla et al. 2010).

HIV coinfection may increase the progression of HBV liver disease and risk of hepatocellular carcinoma.

Ultrasound screening has some evidence for mortality reduction in the developed world (Bruix & Sherman 2011).

ARVs with anti-HBC activity: lamivudine, emtricitabine,

tenofovir

Serum AFP testing and ultrasound hepatocellular carcinoma screening (limited access in rural areas)

Universal birth dose HBV; HBIG available at tertiary care centres

No national screening policy in place

Interferon not available

Exogenous Risk Factors:Domestic violence (DV) 

Thirty-two per cent of urban and rural Botswanawomen report having had > = 1 abusive relationship (Modie-Moroka 2009).

21% of Batswana men and 19% of women describe a violent argument with a partner in the past year (Andersson et al. 2007); multiple partners in past year nearly doubles OR.

Intimate partner violence associated with HIV positivity in Botswana (Andersson & Cockcroft 2011)

2010 systematic review found formal screening tools and repeated screening more effective at identifying IPV than informal or no screening; very few RCTs addressing interventions for DV and no strong evidence for efficacy (O'Reilly et al. 2010)

Reporting to police

Women's shelter

Social worker referral

Permissive social and sometimes law enforcement attitude towards DV

Lack of economic and social options for female victims deciding to leave partners

Exogenous Risk Factors: Seat Belts/Road Safety 

20 000 road traffic accidents caused an official 26.8 fatalities per 100 000 people in Botswana in 2009 (Botswana Motor Vehicle Accident Fund 2010)

A 2007 survey of vehicle crashes found only 75% of involved occupants were belted, with alcohol involved in 1% of accidents. (World Health Organization: Violence and Injury Prevention)

Provider counsellingFatalism, laws do not cover all vehicle occupants
Exogenous Risk Factors: Tobacco AbuseUnited States Preventive Services Task Force recommendations 2003

39% of Batswana adults 60 or older smokers in a nationally representative 1998 survey (Clausen et al. 2006)

Systematic review of southern African smoking prevalence found 6–19% among South African women, 15–79% among males (Townsend et al. 2006)

USPSTF found good evidence that < 3-min counselling significantly increases abstinence rates (USPSTF 2003)

 Shortage of data on screening/counselling interventions in Southern Africa.
Exogenous Risk Factors: Alcohol Abuse 

2006 population-based survey in Botswana found prevalence of problem or heavy drinking in 39% of men and 25% of women (Weiser et al. 2006).

A review of sub-Saharan African studies found a consistent relationship between alcohol consumption and HIV positivity (Pithey & Parry 2009).

Alcohol use a significant predictor or ARV non-adherence in Botswana (Do et al. 2010)

A study of correlates of heavy drinking in Botswanafound a dose–response relationship with multiple high-risk sexual behaviours for both men and women, with odds ratios of up to 3–4 (Weiser et al. 2006).

CAGE questionnaire validated in a small South African study (Claassen 1999)

WHO project showed effectiveness of brief counselling interventions in low- and middle-income countries including Kenya and Zimbabwe (Patel et al. 2007)

Antabuse, benzodiazepines in public formulary (Mehta 2011).

Clinic social worker and psychologist

Individual and family counselling by substance abuse counsellors at Botswana Substance Abuse Support Network (BOSAS)

Permissive social attitude

Reproductive Health:

Syndromic Management of STIs

Contraception

Botswana National HIV Guidelines

WHO Antiretroviral Therapy for HIV-infected Adults and Adolescents 2010

Preventive Care Packages: Mermin et al. 2005

85% of the global 340 million annual cases of reproductive and sexually transmitted infections occur in developing countries (Onen 2004). HIV prevalence was 74% among patients with GUD, 62% among men with urethral discharge, 54% among female patients with STDs and 42% among women practising family planning (Paz-Bailey et al. 2005).

Readily available family planning services.

National algorithms in place in clinics for STI management.

Tracing and treating partners of patients with STIs.

Guidelines adopted in their entirety from the Botswana National HIV Treatment guidelines included isoniazid prophylaxis for tuberculosis (IPT), annual cervical cancer screening and syndromic management of STIs. Other items from the National Guidelines and the Tolle package were adapted. Malaria prevention from the Tolle package was dropped, due to the low malaria burden in the Gaborone area. Recommendations in the WHO package not substantively implemented were either already part of routine HIV care (disclosure, partner notification and family testing, cotrimoxazole prophylaxis, PMTCT), unavailable in the public sector (influenza immunisation), or believed to be regionally less applicable (needle exchange programmes; we were unable to find data on prevalence of injection drug use in Botswana).

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. The Botswana setting and family model clinic (FMC) context
  5. Methods
  6. Results
  7. Discussion
  8. Conclusion
  9. References
  10. Supporting Information

To our knowledge, this is the first description in the literature of the adaptation of a general primary care package for patients with HIV to a specific setting. To inform similar adaptations for other specific settings, our reasoning process in selecting package elements is further discussed here.

For any adaptation, the existing universe of services in national HIV and primary care guidelines will provide a starting point. We adopted several items in their entirety from the Botswana National HIV Treatment guidelines – IPT, cervical cancer screening and the syndromic management of STIs; adapted others, such as management of NCDs; and included additional items, as discussed below…

Included interventions and justifications

IPT has strong evidence for efficacy in preventing development of active TB in PLWH with positive tuberculin skin tests and has been recommended by WHO for universal provision to all PLWH after diagnosis of HIV and exclusion of active TB. While currently not being implemented in Botswana's public health system due to operational challenges, using tuberculin skin testing to determine need for IPT would increase its impact when the national IPT programme is resumed.

Although the Botswana-specific burden of cervical cancer is not well quantified, abnormal pap smears are common in our FMC population. Cervical cancer risk is higher (Franceschi & Jaffe 2007) and clinical progression more rapid in HIV-positive women (Chirenje 2005). Cervical screening can be accomplished in Botswana (Ramogola-Masire et al. 2012). For STIs, given the non-availability of diagnostic testing in Botswana, the syndromic management recommended in national guidelines is reasonable.

Our other inclusions represent additions to or modifications of national guidelines. Diarrhoeal disease prevention is addressed through educating about safe water storage, as at source most Batswana have access to clean water. WHO and UNICEF estimate that 90% (rural) to 100% (urban) of Botswana's population has access to improved water, which is treated and monitored with once-to-twice-weekly chemical and coliform testing (Central Statistics Office, Government of Botswana 2009). However, only 28% (rural) to 62% (urban) have in-home connections (WHO/Unicef 2006), and there is evidence from developing countries of contamination at home of water originally clean from the tap source (Genthe et al. 1995; Teklu & Kebede 1998).

Breast cancer screening is not standard in many resource-limited settings, given lack of both mammography and treatment options, but was added to our package biennially beginning at age 50 due to strong evidence of mortality benefit from the developed world (USPSTF 2009; Yip et al. 2011), prevalence data from Botswana (Botswana Cancer Association 2010), availability of mammography and support from the latest Breast Health Global Initiative Consensus Statement for Middle-Income Settings (Yip et al. 2011). In Botswana, referrals to surgery and oncology with chemotherapy are possible in the public sector, and an extensive literature on breast cancer management in low- and middle-income countries primarily derived from the work of the Breast Health Global Initiative exists for guidance.

As recommended in existing general packages (WHO 2008; Tolle 2009), screening for depression is a key element of our package, due to its burden, prevalence and the evidence with treatment for improved ART adherence and clinical outcomes (Palombi et al. 2009; Ahoua et al. 2011). Globally, depression is leading cause of disability and, indeed, of the entire global burden of disease (World Health Organization); the second leading mental illness (after substance abuse) in the HIV-infected population in the developed world (Rabkin 2008); and highly prevalent in the Botswana PLWH population (Lawler et al. 2009). Diagnosis and treatment of depression are possible in our setting, with the availability of on-campus psychology and psychiatry services; inpatient psychiatry referral in the public sector; and antidepressants on the public formulary.

Management of non-communicable diseases such as cardiovascular disease, hypertension, hyperlipidaemia and diabetes was adapted from national guidelines with minor modification. Screening is not addressed in national guidelines (except for protease inhibitor use, which triggers glucose and lipid monitoring), but was included in our package due to their current burden in Botswana; their expected increase over time due to demographic changes (urbanisation, diet, lifestyle) already notable in Botswana (Mayosi et al. 2009; Mittal & Singh 2010); increasing numbers of patients on ART; and the availability on Botswana's national formulary of options for addressing these disorders. Modifiable risk factors such as smoking and obesity can be targeted with counselling by on-site trained staff, psychologist and/or nutrition services, and hypertension, hyperlipidaemia and diabetes are able to be screened for and treated.

Although not part of national guidelines, we included hepatitis B screening and management due to a substantial national hepatitis B coinfection prevalence in PLWH (5.3–10.5%) (Tedla et al. 2010; Patel et al. 2011a), the availability of tenofovir for first-line ART and WHO guidance (WHO 2008). We included follow-up monitoring with liver ultrasound and hepatocellular cancer screening with alfa-fetoprotein levels, as both these examinations and surgical options when needed are locally available.

The exogenous risk factors of seat belt use, domestic violence, tobacco and alcohol were also included in our package, because they are to screen for and counsel. Motor vehicle-associated death and injury are important burdens in Botswana (Tables 2 and 3), making seat belts the most important preventive intervention. Despite national seatbelt and motorcycle helmet laws, there is room for significant improvement in seat belt adherence (World Health Organization: Violence & Injury Prevention). As we did not find data on efficacy of seat belt usage, we decided to include brief screening and counselling in our package. The inclusion of alcohol-abuse screening synergises with a national antialcoholism campaign. The local prevalence of alcohol-use disorders (Weiser et al. 2006), also associated with HIV-positive status (Pithey & Parry 2009), ARV non-adherence (Do et al. 2010) and high-risk sexual behaviours (Weiser et al. 2006), is alarmingly high. As an easy screening validated in our setting (Mehta 2011), we chose the four CAGE questions. Brief clinical counselling interventions are effective in decreasing alcohol abuse in African settings (Patel et al. 2007). Tobacco-abuse screening and counselling were also included based on Botswana COPD mortality and data from both Botswana and South Africa, suggesting a high prevalence of tobacco abuse in both men and women (Clausen et al. 2006), although efficacy data for brief counselling interventions are from the developed world (USPSTF 2003).

Intimate partner violence is highly prevalent among both genders in Botswana (Andersson et al. 2007; Modie-Moroka 2009) and is nationally associated with HIV-infected status (Andersson & Cockcroft 2011). Data on sensitivity of screening questioning and efficacy of counselling interventions are from the developed world and showed mixed or weak results (O'Reilly et al. 2010). Our centre offers psychology, counselling and social work services, including information regarding a woman's shelter and encouragement/assistance in notifying authorities. Conservatively, and given high prevalence, we included brief informal screening with counselling and resource referral in our package.

Challenges

Challenges to implementation include lack of medical evidence or consensus in some areas and logistical, cultural and economic obstacles in others. Most lie outside the direct control of local providers. Local approaches to these challenges include adaptation (changing mammography from annual to biennial, consistent with the Breast Health Global Initiative Consensus Statement for Middle-Income Settings (Yip et al. 2011) and raising awareness of underemphasised issues such as alcohol abuse and cardiovascular health. As mentioned, political acceptability and feasibility are important considerations; packages targeted to broad implementation may fare better when developed in concert with policy makers, as this package was.

Our search highlighted, as others have done, the many areas in which evidence for the efficacy of standard interventions is from the developed world or simply lacking. Especially for interventions whose efficacy is system- or culture-bound, there is an urgent need for efficacy data from developing countries.

Monitoring and evaluation

Monitoring and evaluation of this specific package's implementation is of interest. Whether providers find the package useful and are able to implement the package effectively in the course of routine patient care is important, as is whether the package appears to influence clinical outcomes.

The package described here has been implemented in the FMC for approximately 12 months. A retrospective review of the first 9 months of implementation showed generally good uptake of package items by providers, with depression screening the least commonly applied guideline (16% of encounters), and trends towards males and younger patients being less likely to access screening recommendations (Tshiamo et al. 2012). A checklist to support adherence to the guidelines by providers seemed useful, and actions taken in the FMC to improve package utilisation by providers include ongoing guidelines education for providers, simplifying the depression screening form and emphasising inclusion of younger and male patients in appropriate screening.

Broader implementation

Although well known to national policy makers given the MOHSW's participation in developing the package and the COE's position on policy-making bodies in Botswana, the dynamics of our clinical setting are unique, and extension of all of the package's elements to other Botswana clinics, particularly in the public sector, may be limited by several factors. Important among these are lower provider/patient ratios and high demands on provider time spent with individual patients. However, given that the diagnostic and pharmaceutical resources employed are available in the public sector nationwide, many elements of the package will remain relevant. Future uptake of the package, then, within Botswana's public-sector HIV programme will likely be as an adaptation to the programme's particularities.

This underlies our hope that the process described in this paper of adapting existing guidance to specific settings could be of wider benefit. The scope of this search, using a major international and the major regional open-access database, was intended to represent a compromise between thoroughness and accessibility that would allow providers without substantial resources to make reasonable programme decisions and identify evidence gaps.

More importantly, our package elements were chosen for demonstrated or reasonably expected relevance, with varying levels of evidence on local effectiveness available, and without any reference to cost-effectiveness – a much more massive but critical consideration, which is beyond our scope. At the point when those analyses are undertaken, local experience with feasibly developed packages like that described here may help to provide a basis for their more rigorous conclusions.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. The Botswana setting and family model clinic (FMC) context
  5. Methods
  6. Results
  7. Discussion
  8. Conclusion
  9. References
  10. Supporting Information

The maturation of both the HIV epidemic and the global response to it, along with our understanding of the benefits of preventive care in low-resource settings, increasingly demands evidence-based, systematic primary care packages for PLWH addressing both infectious and non-communicable causes of morbidity and mortality. The locally relevant preventive care package described here addresses the comprehensive health needs of HIV-infected adults in the FMC in an evidence-based manner. We believe that local adaptation of validated generic packages holds promise for allowing health systems to leverage existing HIV infrastructure and knowledge to tackle chronic non-communicable and HIV-related diseases in tandem. The process employed of combining clinic-specific prevalence data, national guidelines, regional and relevant literature review and assessment of public-sector resources in adapting an existing general package can be utilised to develop similar packages for other resource-constrained locales.

  1. 1

    The resulting package was piloted at this point after review and approval from a MOHSW representative and the COE's executive director.

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  1. Top of page
  2. Abstract
  3. Introduction
  4. The Botswana setting and family model clinic (FMC) context
  5. Methods
  6. Results
  7. Discussion
  8. Conclusion
  9. References
  10. Supporting Information
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Supporting Information

  1. Top of page
  2. Abstract
  3. Introduction
  4. The Botswana setting and family model clinic (FMC) context
  5. Methods
  6. Results
  7. Discussion
  8. Conclusion
  9. References
  10. Supporting Information
FilenameFormatSizeDescription
tmi12041-sup-0001-AppendixS1.docxWord document13KAppendix S1 Pubmed Search Strategies used in the Literature Review.

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