AIDSTAR-One developed and piloted provider and patient educational tools to increase appropriate prescription and use of co-trimoxazole for eligible people living with HIV. Before and after the pilot, AIDSTAR-One conducted a mixed-methods assessment to analyze the effectiveness and acceptability of the co-trimoxazole tools. This report recommends adoption and scale-up of the tools in Uganda and other countries.
Assessing the Vulnerability of Watersheds to Climate Changeculvertboy
Furniss, Michael J.; Roby, Ken B.; Cenderelli, Dan; Chatel, John; Clifton, Caty F.;
Clingenpeel, Alan; Hays, Polly E.; Higgins, Dale; Hodges, Ken; Howe, Carol;
Jungst, Laura; Louie, Joan; Mai, Christine; Martinez, Ralph; Overton, Kerry;
Staab, Brian P.; Steinke, Rory; Weinhold, Mark. 2013. Assessing the vulnerability
of watersheds to climate change: results of national forest watershed vulnerability
pilot assessments. Gen. Tech. Rep. PNW-GTR-884. Portland, OR: U.S. Department of
Agriculture, Forest Service, Pacific Northwest Research Station. 32 p. plus appendix.
Existing models and predictions project serious changes to worldwide hydrologic processes as a result of global climate change. Projections indicate that significant change may threaten National Forest System watersheds that are an important source of water used to support people, economies, and ecosystems.
Wildland managers are expected to anticipate and respond to these threats, adjusting
management priorities and actions. Because watersheds differ greatly in: (1) the values they support, (2) their exposure to climatic changes, and (3) their sensitivity to climatic changes, understanding these differences will help inform the setting of priorities and selection of management approaches. Drawing distinctions in climate change vulnerability among watersheds on a national forest or grassland allows more efficient and effective allocation of resources and better land and watershed stewardship.
Eleven national forests from throughout the United States, representing each of the
nine Forest Service regions, conducted assessments of potential hydrologic change resulting from ongoing and expected climate warming. A pilot assessment approach was developedand implemented. Each national forest identified water resources important in that area, assessed climate change exposure and watershed sensitivity, and evaluated the relative vulnerabilities of watersheds to climate change. The assessments provided management recommendations to anticipate and respond to projected climate-hydrologic changes. Completed assessments differed in level of detail, but all assessments identified priority areas and management actions to maintain or improve watershed resilience in response to a changing climate. The pilot efforts also identified key principles important to conducting future vulnerability assessments.
AIDSTAR-One Assessment of Infection Prevention and Patient Safety Commodities...AIDSTAROne
In Ethiopia, ensuring a sufficient and sustainable supply of infection prevention and patient safety (IPPS) commodities is an important strategy to combat the high risk of transmission of health care–associated infections. However, there is a lack of awareness on the proper utilization of IPPS commodities by health care workers, and a lack of accurate data on the quantity of essential IPPS commodities needed by the health care system to adequately protect workers, patients, and the community from health care-associated infections. This assessment used a consultative approach to develop a national standardized and prioritized list of IPPS commodities for all levels of health care facilities, and quantified the annual need of IPPS commodities for the four levels of health care facilities in Ethiopia. This report summarizes the findings of the assessment.
www.aidstar-one.com/focus_areas/prevention/resources/reports/ethiopia_ipps
Benchmarking Costs for Non-Clinical Services in Botswana’s Public HospitalsHFG Project
Authors: Peter Stegman, Elizabeth Ohadi, Heather Cogswell, Carlos Avila and Mompati Buzwani
Published: April 30, 2015
Botswana’s health sector has embarked on a broad program of reforms and, to this end, the Ministry of Health (MOH) has developed the Health Services Outsourcing Strategy and Programme 2011-2016. This planning document emerges from major strategic thrusts outlined in the National Development Plan 10 and the revised National Health Policy. Decision makers at the MOH, as well as hospital managers and others involved in implementing the outsourcing strategy at the facility level, need to know, among other things, how much the provision of non-clinical services is already costing the government under the existing arrangements. The study described here intended to support the implementation of the outsourcing plan by generating actual costs for the delivery of four non-clinical services that are, or will be, the focus of future outsourcing efforts: cleaning, laundry, catering, and grounds maintenance. The study looked at costs in five public sector hospitals: Athlone District Hospital, Deborah Retief Memorial Hospital, Gumare Primary Hospital, Goodhope Primary Hospital, and Mahalapye District Hospital.
An analysis of the costs and cost drivers of delivering non-clinical services in hospitals that are not currently outsourcing service delivery provides a cost benchmark. This will enable MOH decision makers and implementers to better understand the costs and cost drivers of non-clinical services and to compare current costs with estimated private sector costs, effectively negotiate contracts, and move toward greater efficiency and cost-savings. Further, cost benchmarks will provide hospitals with the critical data needed to understand not only the cost foundation of outsourced services but also more about what they can expect to receive for that cost, such as the type, quantity, and quality of service or product they are purchasing.
Evidence for Maori Under-utlisation of ACC Services: Report 1 (Wren , 2015)John Wren
This report presents a public health orientated argument that at the population level there is substantive evidence for large inequity in Maori utilisation of ACC funded injury treatment services given that Maori have approximately double the injury rates of non-Maori. However, Maori were only utilising ACC services at the same level as non-Maori. One would expect that given that Maori injury rates are double non-Maori, then Maori rates of utilisation should be of the same magnitude - but they are not. From a population public health perspective this represents a clear inequity, however from a insurance/banking perspective there is no inequity as everybody has the same access to services and it is the individual choice whether the services are used or not. The first report has a table in it that compares the two perspectives side by side. It is enlightening.
Assessing the Vulnerability of Watersheds to Climate Changeculvertboy
Furniss, Michael J.; Roby, Ken B.; Cenderelli, Dan; Chatel, John; Clifton, Caty F.;
Clingenpeel, Alan; Hays, Polly E.; Higgins, Dale; Hodges, Ken; Howe, Carol;
Jungst, Laura; Louie, Joan; Mai, Christine; Martinez, Ralph; Overton, Kerry;
Staab, Brian P.; Steinke, Rory; Weinhold, Mark. 2013. Assessing the vulnerability
of watersheds to climate change: results of national forest watershed vulnerability
pilot assessments. Gen. Tech. Rep. PNW-GTR-884. Portland, OR: U.S. Department of
Agriculture, Forest Service, Pacific Northwest Research Station. 32 p. plus appendix.
Existing models and predictions project serious changes to worldwide hydrologic processes as a result of global climate change. Projections indicate that significant change may threaten National Forest System watersheds that are an important source of water used to support people, economies, and ecosystems.
Wildland managers are expected to anticipate and respond to these threats, adjusting
management priorities and actions. Because watersheds differ greatly in: (1) the values they support, (2) their exposure to climatic changes, and (3) their sensitivity to climatic changes, understanding these differences will help inform the setting of priorities and selection of management approaches. Drawing distinctions in climate change vulnerability among watersheds on a national forest or grassland allows more efficient and effective allocation of resources and better land and watershed stewardship.
Eleven national forests from throughout the United States, representing each of the
nine Forest Service regions, conducted assessments of potential hydrologic change resulting from ongoing and expected climate warming. A pilot assessment approach was developedand implemented. Each national forest identified water resources important in that area, assessed climate change exposure and watershed sensitivity, and evaluated the relative vulnerabilities of watersheds to climate change. The assessments provided management recommendations to anticipate and respond to projected climate-hydrologic changes. Completed assessments differed in level of detail, but all assessments identified priority areas and management actions to maintain or improve watershed resilience in response to a changing climate. The pilot efforts also identified key principles important to conducting future vulnerability assessments.
AIDSTAR-One Assessment of Infection Prevention and Patient Safety Commodities...AIDSTAROne
In Ethiopia, ensuring a sufficient and sustainable supply of infection prevention and patient safety (IPPS) commodities is an important strategy to combat the high risk of transmission of health care–associated infections. However, there is a lack of awareness on the proper utilization of IPPS commodities by health care workers, and a lack of accurate data on the quantity of essential IPPS commodities needed by the health care system to adequately protect workers, patients, and the community from health care-associated infections. This assessment used a consultative approach to develop a national standardized and prioritized list of IPPS commodities for all levels of health care facilities, and quantified the annual need of IPPS commodities for the four levels of health care facilities in Ethiopia. This report summarizes the findings of the assessment.
www.aidstar-one.com/focus_areas/prevention/resources/reports/ethiopia_ipps
Benchmarking Costs for Non-Clinical Services in Botswana’s Public HospitalsHFG Project
Authors: Peter Stegman, Elizabeth Ohadi, Heather Cogswell, Carlos Avila and Mompati Buzwani
Published: April 30, 2015
Botswana’s health sector has embarked on a broad program of reforms and, to this end, the Ministry of Health (MOH) has developed the Health Services Outsourcing Strategy and Programme 2011-2016. This planning document emerges from major strategic thrusts outlined in the National Development Plan 10 and the revised National Health Policy. Decision makers at the MOH, as well as hospital managers and others involved in implementing the outsourcing strategy at the facility level, need to know, among other things, how much the provision of non-clinical services is already costing the government under the existing arrangements. The study described here intended to support the implementation of the outsourcing plan by generating actual costs for the delivery of four non-clinical services that are, or will be, the focus of future outsourcing efforts: cleaning, laundry, catering, and grounds maintenance. The study looked at costs in five public sector hospitals: Athlone District Hospital, Deborah Retief Memorial Hospital, Gumare Primary Hospital, Goodhope Primary Hospital, and Mahalapye District Hospital.
An analysis of the costs and cost drivers of delivering non-clinical services in hospitals that are not currently outsourcing service delivery provides a cost benchmark. This will enable MOH decision makers and implementers to better understand the costs and cost drivers of non-clinical services and to compare current costs with estimated private sector costs, effectively negotiate contracts, and move toward greater efficiency and cost-savings. Further, cost benchmarks will provide hospitals with the critical data needed to understand not only the cost foundation of outsourced services but also more about what they can expect to receive for that cost, such as the type, quantity, and quality of service or product they are purchasing.
Evidence for Maori Under-utlisation of ACC Services: Report 1 (Wren , 2015)John Wren
This report presents a public health orientated argument that at the population level there is substantive evidence for large inequity in Maori utilisation of ACC funded injury treatment services given that Maori have approximately double the injury rates of non-Maori. However, Maori were only utilising ACC services at the same level as non-Maori. One would expect that given that Maori injury rates are double non-Maori, then Maori rates of utilisation should be of the same magnitude - but they are not. From a population public health perspective this represents a clear inequity, however from a insurance/banking perspective there is no inequity as everybody has the same access to services and it is the individual choice whether the services are used or not. The first report has a table in it that compares the two perspectives side by side. It is enlightening.
"Riesgo cancerígeno" esta expresión de la serie Monografías de la IARC se entiende que un agente que es capaz de causar cáncer. EstasMonografías evaluan los riesgos de cáncer, a pesar de la presencia histórica de los «riesgos» que figuran en el título.
La inclusión de un agente en las monografías no implica que se trata de un carcinógeno, sólo que los datos publicados han sido examinados. Igualmente, el hecho de que un agente aún no ha sido evaluado en una
Monografía no significa que no es cancerígeno. Del mismo modo, la identificación de los tipos de cáncer con pruebas suficientes o evidencia limitada en humanos no debe considerarse como excluyente de la posibilidad de que un agente puede causar cáncer en otros sitios.
Las evaluaciones de riesgo de cáncer son realizados por grupos de trabajo internacionales de científicos independientes y no son de naturaleza cualitativa. Ninguna recomendación se da para la regulación o legislación.
Cualquier persona que es consciente de los datos publicados que pueden alterar la evaluación del riesgo cancerígeno de un agente para el ser humano se le anima a hacer esta información disponible a la Sección de Monografías del IARC, Agencia Internacional para la Investigación del Cáncer, 150 cours Albert Thomas, 69372 Lyon Cedex 08 de Francia, con el fin de que el agente puede ser considerado para la re-evaluación de un futuro grupo de trabajo.
Aunque no se escatiman esfuerzos para preparar las monografías con la mayor precisión posible, los errores pueden ocurrir. Los lectores deben comunicar los errores a la Sección de Monografías del IARC, por lo que las correcciones pueden ser reportados en los volúmenes futuros.
We are an unconventional mobile marketing company, specializing in guerrilla activation's for clients looking to expand their brand awareness. We help you reach customers in a more effective and creative way. We have launched daily, weekly, monthly and multi-month / national campaigns for clients including Google, Kraft Foods, Arizona Ice Tea, Uber, MetroPCS, T-Mobile, Discovery Channel and many more. All of our trucks are fully customization. Our clients activate them to hand out promotional goods, sample new items, or educate customers on new products hitting the stores / available online.
"An evaluation of the Corporate Governance Arrangements of Australian Irrigation Water Providers." Nov 2007
Cooperative Research Centre for Irrigation Futures,
WHO reports recommend lifestyle changes to prevent millions of cancer deathsΔρ. Γιώργος K. Κασάπης
a new WHO report outline steps to avert a rise in cancer deaths in low- and middle-income countries. If current trends continue, these countries could see an 80% increase in the number of cancer cases over 20 years, the agency says. The majority of cancer deaths are now due to lifestyle factors such as tobacco use - which is responsible for about a quarter of all cancer deaths. As such, the WHO’s recommendations focus on scaling up programs for tobacco cessation, alcohol prevention, wider access to healthy foods, and physical activity.
"Riesgo cancerígeno" esta expresión de la serie Monografías de la IARC se entiende que un agente que es capaz de causar cáncer. EstasMonografías evaluan los riesgos de cáncer, a pesar de la presencia histórica de los «riesgos» que figuran en el título.
La inclusión de un agente en las monografías no implica que se trata de un carcinógeno, sólo que los datos publicados han sido examinados. Igualmente, el hecho de que un agente aún no ha sido evaluado en una
Monografía no significa que no es cancerígeno. Del mismo modo, la identificación de los tipos de cáncer con pruebas suficientes o evidencia limitada en humanos no debe considerarse como excluyente de la posibilidad de que un agente puede causar cáncer en otros sitios.
Las evaluaciones de riesgo de cáncer son realizados por grupos de trabajo internacionales de científicos independientes y no son de naturaleza cualitativa. Ninguna recomendación se da para la regulación o legislación.
Cualquier persona que es consciente de los datos publicados que pueden alterar la evaluación del riesgo cancerígeno de un agente para el ser humano se le anima a hacer esta información disponible a la Sección de Monografías del IARC, Agencia Internacional para la Investigación del Cáncer, 150 cours Albert Thomas, 69372 Lyon Cedex 08 de Francia, con el fin de que el agente puede ser considerado para la re-evaluación de un futuro grupo de trabajo.
Aunque no se escatiman esfuerzos para preparar las monografías con la mayor precisión posible, los errores pueden ocurrir. Los lectores deben comunicar los errores a la Sección de Monografías del IARC, por lo que las correcciones pueden ser reportados en los volúmenes futuros.
We are an unconventional mobile marketing company, specializing in guerrilla activation's for clients looking to expand their brand awareness. We help you reach customers in a more effective and creative way. We have launched daily, weekly, monthly and multi-month / national campaigns for clients including Google, Kraft Foods, Arizona Ice Tea, Uber, MetroPCS, T-Mobile, Discovery Channel and many more. All of our trucks are fully customization. Our clients activate them to hand out promotional goods, sample new items, or educate customers on new products hitting the stores / available online.
"An evaluation of the Corporate Governance Arrangements of Australian Irrigation Water Providers." Nov 2007
Cooperative Research Centre for Irrigation Futures,
WHO reports recommend lifestyle changes to prevent millions of cancer deathsΔρ. Γιώργος K. Κασάπης
a new WHO report outline steps to avert a rise in cancer deaths in low- and middle-income countries. If current trends continue, these countries could see an 80% increase in the number of cancer cases over 20 years, the agency says. The majority of cancer deaths are now due to lifestyle factors such as tobacco use - which is responsible for about a quarter of all cancer deaths. As such, the WHO’s recommendations focus on scaling up programs for tobacco cessation, alcohol prevention, wider access to healthy foods, and physical activity.
Upaya Meningkatkan Minat Baca Mahasiswa IndonesiaIqwal Akmar
2. Apa tujuan meningkatkan minat baca mahasiswa pada program studi fisika ?
3. Apa saja faktor yang mempengaruhi menurunnya minat baca mahasiswa pada program studi fisika ?
4. Bagaimana cara meningkatkan minat baca mahasiswa pada program studi fisika ?
This presentation is regarding the basic knowledge about the japanese 5S system. The management skill by this presentation we can improve. By this topic we can easily understand the concept of management and how it's gonna work in companies further to improve skill as well as production.
AIDSTAR-One Caring for Children Living with HIV in AfricaAIDSTAROne
This report, Equipping Parents and Health Providers to Address the Psychological and Social Challenges of Caring for Children Living with HIV in Africa, provides information to better understand the psychological and social challenges faced in Africa by perinatally-infected children (aged 0-12 years), their parents/caregivers, and their health providers. It explores factors that contribute to the ability of children living with HIV to cope and thrive, and identifies the tools and approaches being used to help parents/caregivers and health providers provide psychosocial support (PSS) to these children. The report elaborates on the themes discussed in the Meeting the Psychosocial Needs of Children Living with HIV in Africa technical brief.
www.aidstar-one.com/focus_areas/care_and_support/resources/report/clhiv_pss_needs_africa
CAH has worked with front-line organizations in Estonia, Mozambique and South Africa to prepare analytic case studies of three outstanding initiatives that have scaled up the provision of health services to adolescents. The South African case study is of the Evolution of the National Adolescent Friendly Clinic Initiative which was an integral part of the high profile loveLife programme. The Mozambican case study was of the progress made by the multisectoral Geraçao Biz programme, a key component of which was youth-friendly health services, in moving from inception to large scale. The Estonian case study was that of the nationwide spread of the Amor youth clinic network, led by the Sexual Health Association in that country.
Programs that help farmers manage risk are a major component of the Federal Government’s
support to rural America. Changes to this risk—and thus to the Government’s fiscal exposure—
are expected as weather averages and extremes change over the coming decades. This study
uses a combination of statistical and economic modeling techniques to explore the mechanisms
by which climate change could affect the cost of the Federal Crop Insurance Program (FCIP) to
the Federal Government, which accounts for approximately half of Government expenditures
on agricultural risk management. Our approach is to compare scenarios of the future that differ
only in terms of climate. Using weather scenarios for 2060-99 from general circulation models,
we project decreases in corn and soybean yields and mixed changes to winter wheat yields,
compared to a baseline scenario in which climate is identical to that of the past three decades.
We use an economic model of the U.S. agricultural sector to estimate how projected yield
changes may induce farmers to change what and where they plant, and the resulting impacts on
production and output prices. These ingredients allow us to explore drivers of change in the cost
of the FCIP’s Revenue Protection program, which is used as a heuristic for potential farm safety
net programs that could exist in the future. Differences between the scenarios are driven by
increasing prices for the three crops studied, caused by relatively lower production in the presence
of inelastic demand, as well as by changing volatility in both yields and prices.
Keywords: climate change, risk management, machine learning, agriculture, Regional
Environment and Agriculture Programming, REAP, model, crop insurance, semiparametric
neural networks, general circulation model
AIDSTAR-One conducted a 3-year demonstration project in Namibia to reduce heavy drinking and risky sexual behavior among bar patrons in a low-income neighborhood on the outskirts of Namibia's capital, Windhoek. This report describes how the intervention was implemented, monitored, and evaluated, and reports the final assessment results. It also offers key recommendations for future research and programming. http://aidstarone.com/focus_areas/prevention/resources/reports/alcohol_namibia_intervention_report
Final Report on the Cost-Effectiveness of Providing HIV Testing and Counselin...HFG Project
Resource Type: Report
Authors: Olena Doroshenko, Lisa Tarantino, Peter Cowley, and Ben Johns
Published: 4/30/2015
Resource Description:
HIV service delivery in Ukraine is a vertically structured system, targeting key populations, but compromising efficiency and access to care. HIV testing and counseling (HTC) service is especially meaningful in Ukraine, where of the total estimated number of 238,000 people living with HIV (PLHIV), only 138,000 were registered for HIV care in January 2015. Currently, HTC is available mainly at polyclinics, located in rayon (district) centers and cities, in specialized offices for HTC provision. HIV is mainly diagnosed using ELISA tests. High HIV prevalence in key populations, high levels of loss to follow up after diagnosis, and undiagnosed HIV cases underpin the need to improve access and the existing continuum of HIV care in Ukraine.
Information on the effectiveness and cost-effectiveness of HIV testing and counseling strategies is scarce globally and absent for Ukraine. In Ukraine, HFG worked with the Chernigiv Oblast Administration, the Ukraine Ministry of Health, the Clinton Health Access Initiative, and other partners to design and implement a pilot model of HTC using rapid HIV tests as a service offered at primary care facilities by non-specialized primary care physicians. The program was implemented in 2014 at 30 primary health care (PHC) facilities in the Chernigiv Region of Ukraine.
All product and company names mentioned herein are for identification and educational purposes only and are the property of, and may be trademarks of, their respective owners.
Income, expenditures, health facility utilization, and health insurance statu...HFG Project
The primary objective of this study is to estimate the average income and general expenditures of people living with HIV/AIDS (PLWHA). The null hypothesis is that income among PLWHA is the same as that of the general population.
Additionally, this study will help to inform estimates of the potential liability faced by Vietnam’s Social Health Insurance scheme if it assumes responsibility for paying for HIV/AIDS treatment. VAAC is also seeking answers to questions about why patients are not enrolling in the insurance scheme and how to increase the enrollment rate.
www.sprivailorg
The Steadman Philippon Research Institute 2007 Annual Report
Patients with hip pain may suffer from femoro- acetabular impingement, or FAI, in which bony abnormalities of both the femur and acetabulum irregularly and repetitively contact each other, creating damage to articular cartilage and labrum. This may lead to a more rapid onset of osteoar- thritis, which is the leading cause of disability in the United States. In the past, the treatment for FAI was an open surgical dislocation procedure to repair this pathology. It has shown good mid-term results, but it is a highly invasive procedure.
The recovery from this open surgical dislocation procedure may limit activities for nine months. This length of postoperative inactivity is not feasible for the recreational or professional athlete. Dr. Marc J. Philippon has developed an arthroscopic technique to repair this hip joint disease that allows individu- als to return to activities, including athletics, as early as three months.
Patients with osteoarthritis of the shoulder have pain and loss of function that significantly affect their quality of life. When the disease becomes more advanced and the symptoms do not respond to conservative methods, total shoulder arthroplasty (TSA) is the preferred surgical treatment. The number of TSAs performed annually in the U.S. has increased from about 5,000 in the early 1990s to more than 20,000 in 2005. This is largely because an aging population wants to stay active, but
it may also be due to better prosthesis designs, better surgical techniques, and better training of surgeons.
While the overall outcomes after shoulder replacements are excellent, the motions of the bones or implants inside the shoulder joint during motion in living subjects are not well known because we haven’t been able to “see” inside the joint.
Contents:
The Year in Review
2 Governing Boards
4 Scientific Advisory Committee
Femoroacetabular Impingement
5 Imaging Research Set to Become Newest Area of Science
6 Lee Schmidt: A Lesson in the Art of Giving
8 John Kelly: An Elite Photographer
20 Research and Education (Shoulder Joint Research)
22 Basic Science Research (knee micro fracture)
Osteoarthritis Knee Treatment
Patient Outcomes
AIDSTAR-One Case Study: Targeted Outreach Program BurmaAIDSTAROne
The Targeted Outreach Project (TOP) provides HIV prevention services, as well as social, civic, and educational programs, for sex workers and men who have sex with men in Burma. TOP's community-driven and evidence-based strategies have contributed to its success and scale up across the country. Furthermore, epidemiological data suggest that TOP has contributed to declining HIV incidence in Burma. http://www.aidstar-one.com/focus_areas/prevention/resources/case_study_series/top_burma
AIDSTAR-One Issue Paper: The Debilitating Cycle of HIV, Food Insecurity, and ...AIDSTAROne
This document aims to facilitate an understanding of the bi-directional relationship between HIV and food and nutrition security. It illuminates the causes of HIV-related food and nutrition insecurity, and points to a list of programmatic interventions and resources to consider for addressing each cause in detail. http://j.mp/U1L0iV
AIDSTAR-One Faith-Based Organizations and HIV Prevention with MARPs in MexicoAIDSTAROne
The influence of religious groups in parts of Latin America positions them to target most-at-risk populations (MARPs) who may have been overlooked by traditional HIV prevention outreach. In Mexico, La Iglesia de la Reconciliación, VIHas de Vida, and El Mesón de la Misericordia are challenging assumptions about faith-based organizations (FBOs) and the role they can play in HIV prevention. These three FBOs integrate spirituality and a holistic vision of health into their activities, sharing information on HIV and providing other HIV-related services in Mexico City and Guadalajara.
www.aidstar-one.com/focus_areas/prevention/resources/case_study_series/fbos_and_hiv_prevention_with_marps_in_mexico
AIDSTAR-One HIV Treatment Guidelines in Guyana - The Fast Track to Diagnosis ...AIDSTAROne
This case study details Guyana's process for revision of their national HIV treatment guidelines, based on WHO's 2010 revised recommendations . While many countries are still working to revise their national guidelines in response to WHO's latest guidance, the National AIDS Programme in Guyana has been implementing elements of WHO's 2010 recommendations since 2006.
www.aidstar-one.com/focus_areas/treatment/resources/case_study/guyana_treatment_guidelines
AIDSTAR-One Implementation of WHO's 2008 Pediatric HIV Treatment GuidelinesAIDSTAROne
In April 2008, the WHO Technical Reference Group for Pediatric HIV/ART and Care released a series of nine updated recommendations for diagnostic testing, initiation of treatment, and appropriate treatment regimens for HIV-exposed and infected infants. This technical brief outlines practical implementation considerations for program planners and policymakers working to incorporate these recommendations into their local efforts.
http://www.aidstar-one.com/implementation_whos_2008_pediatric_hiv_treatment_guidelines
AIDSTAR-One Protecting Children Affected by HIV Against Abuse, Exploitation, ...AIDSTAROne
This document is intended to explore strategies to protect children orphaned or made vulnerable by HIV (OVC) from abuse, exploitation, violence, and neglect. The report draws from lessons learned by OVC program managers, designers, and policy developers—particularly those associated with the President’s Emergency Plan for AIDS Relief (PEPFAR).
http://www.aidstar-one.com/focus_areas/OVC/reports/protecting_children_affected_by_HIV
AIDSTAR-One Increasing Access to Prevention of Mother-to-Child Transmission S...AIDSTAROne
This technical report discusses the many services needed throughout the prevention of mother-to-child transmission (PMTCT) and infant care services continuum and identifies potential barriers to service coverage, access, and utilization. AIDSTAR-One provides examples of evidence-based and emerging practices to mitigate these barriers.
www.aidstar-one.com/focus_areas/pmtct/resources/report/increasing_access_to_pmtct_services
AIDSTAR-One Prevention of Alcohol-Related HIV Risk BehaviorsAIDSTAROne
A growing body of research suggests that alcohol consumption is associated with the sexual behaviors that put people at risk for HIV. In developing countries battling severe HIV epidemics, addressing harmful drinking in conjunction with interventions to reduce sexual risk behavior may reduce HIV transmission more quickly than conventional HIV prevention interventions alone. Developed for program planners and implementers, this technical brief reviews the evidence on new and innovative programs in this emerging area. The brief catalogs what is known about the relationship between harmful alcohol use and HIV sexual risk behavior and offers a critical analysis of interventions to address the issue.
www.aidstar-one.com/focus_areas/prevention/resources/technical_briefs/prevention_alcohol_related_risk_behavior
AIDSTAR-One Meeting the Psychosocial Needs of Children Living with HIV in AfricaAIDSTAROne
An abbreviated version of the Equipping Parents and Health Providers to Address the Psychological and Social Challenges of Caring for Children Living with HIV in Africa report, this technical brief documents promising practices in critical services related to the psychological and social wellbeing of perinatally-infected children in Africa. These promising practices include the identification, testing, and counseling of children so that they are linked to appropriate care as early as possible, as well as on-going support to help children and their families manage disclosure, stigma, grief and bereavement processes.
www.aidstar-one.com/focus_areas/care_and_support/resources/technical_briefs/foundation_future
AIDSTAR-One NuLife—Food and Nutrition Interventions for UgandaAIDSTAROne
This technical report examines a nutritional assessment, counseling, and support (NACS) program in Uganda that uses a quality improvement approach to services.
www.aidstar-one.com/focus_areas/care_and_support/resources/report/nulife_food_and_nutrition_interventions_uganda
AIDSTAR-One PRASIT: Using Strategic Behavioral Communication to Change Gender...AIDSTAROne
Programs focused on promoting gender equity and combating detrimental gender norms play a key role in HIV prevention. This case study (one of nine in a series) documents how the PRASIT program in Cambodia targets entertainment workers, their mainly middle class and male clients, and males who have sex with males using strategic behavior communication. Although the programs vary in their approaches, strategies employed by PRASIT have focused on community outreach, mass media campaigns, and peer education.
www.aidstar-one.com/focus_areas/gender/resources/case_study_series/prasit_cambodia
AIDSTAR-One Outreach to Most-at-Risk Populations through SIDC in LebanonAIDSTAROne
Successful outreach to most-at-risk populations (MARPs) recognizes the sociocultural context and particularly the gendered norms in which MARPs live. This case study (one of nine in a series) documents how outreach workers in Lebanon raise awareness about how gender norms can increase HIV risk; deliver basic information on HIV, hepatitis, and other STIs; offer counseling to support positive behavior change, and distribute free condoms, syringes, and lubricants.
www.aidstar-one.com/focus_areas/gender/resources/case_study_series/sidc_lebanon
AIDSTAR-One STIGMA Foundation in IndonesiaAIDSTAROne
Integrating strategies to address gender inequity and change harmful gender norms is an increasingly important component of HIV programs. However, gender integration among programs targeting most-at-risk populations (MARPs) is much less prevalent. In Indonesia, the STIGMA Foundation uses a peer outreach model to help men and women who inject drugs live safer, healthier, more productive lives through community organizing, advocacy, and networking.
www.aidstar-one.com/focus_areas/gender/resources/case_study_series/STIGMA_foundation
Prompted by a growing knowledge of the complexity of HIV transmission, many countries are reassessing the nature of their HIV epidemics. "Mixed" epidemics, or concurrent epidemics experienced by both the general population and members of most-at-risk populations (MARPs), are of growing importance in HIV programming. Nigeria, a country with a range of regional and local epidemics, is now attempting to incorporate programming for MARPs into the national HIV response. This case study documents the country's analysis of its epidemics and the efforts of the Nigerian government to adjust their national strategic plan according to the results of the analysis.
www.aidstar-one.com/focus_areas/prevention/resources/case_study_series/nigeria_mixed_epidemics
AIDSTAR-One Sex Work and Life with Dignity: Sex Work, HIV, and Human Rights P...AIDSTAROne
In Peru, where cultural norms emphasize women's subordination and the importance of masculinity, programs with a focus on gender—particularly those involving sex workers—are often underfunded and underrepresented. This case study (one of nine in a series) describes how three organizations focused on sex workers and transgendered and transsexual people have joined together to advance the rights of sex workers. The Sex Work, HIV, and Human Rights Program uses a democratic and participatory approach in order to raise awareness of human rights and advocate for sex workers' rights on both national and local levels.
www.aidstar-one.com/focus_areas/gender/resources/case_study_series/life_with_dignity_peru
AIDSTAR-One Different Needs But Equal Rights: Giving Voice to Transgender Com...AIDSTAROne
Although transgender individuals are a highly vulnerable segment of El Salvador's population, the national political climate has only recently begun to support HIV programming that is tailored to their needs. Additionally, limited access to medical services and legal protection and considerable societal stigma and discrimination means that organizations working with transgender individuals must meet a variety of complex and varied needs. This case study, one of 9 in a series, describes the challenges and successes of the Solidarity Association to Promote Human Development (ASPIDH), an NGO that promotes transgender rights via sensitization, education, and advocacy activities.
www.aidstar-one.com/focus_areas/gender/resources/case_study_series/aspidh_salvador
AIDSTAR-One Breaking New Ground in VietnamAIDSTAROne
Gender norms affect the behavior and life choices of both men and women. In Vietnam, these norms sometimes drive people into situations where they are at increased risk of violence, STI acquisition, and/or incarceration. This case study (one of nine in a series) examines CARE International's STEP program, which seeks to ensure that both men and women have equal access to services to prevent STIs, safeguard their health, avoid gender-based violence, and participate in income-generating activities.
http://www.aidstar-one.com/focus_areas/gender/resources/case_study_series/step_vietnam
AIDSTAR-One Emergency Planning for ART During Post-Election Violence in KenyaAIDSTAROne
In 2007, Kenya experienced a wave of violence following its presidential elections. This case study documents the emergency plans that had been in place to ensure continuity of HIV treatment programs prior to the outbreak of violence, and the events that occurred during the period of violence. It also highlights the changes to contingency planning for HIV that have taken place since the violence ended.
www.aidstar-one.com/focus_areas/treatment/resources/case_study_series/emergency_planning_for_art_kenya
The Gram stain is a fundamental technique in microbiology used to classify bacteria based on their cell wall structure. It provides a quick and simple method to distinguish between Gram-positive and Gram-negative bacteria, which have different susceptibilities to antibiotics
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Thyroid Gland- Gross Anatomy by Dr. Rabia Inam Gandapore.pptx
AIDSTAR-One Co-trimoxazole Pilot Assessment Report
1. |
PILOT CO-TRIMOXAZOLE TOOLS
ASSESSMENT
GULU, UGANDA
______________________________________________________________________________________
DECEMBER 2012
This publication was made possible through the support of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR)
through the U.S. Agency for International Development under contract number GHH-I-00-07-00059-00, AIDS Support and
Technical Assistance Resources (AIDSTAR-One) Project, Sector I, Task Order 1.
2.
3. PILOT CO-TRIMOXAZOLE
TOOLS ASSESSMENT
GULU, UGANDA
The authors' views expressed in this publication do not necessarily reflect the views of the U.S. Agency for
International Development or the United States Government.
4. AIDS Support and Technical Assistance Resources Project
AIDS Support and Technical Assistance Resources, Sector I, Task Order 1 (AIDSTAR-One) is funded by the
U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for International
Development (USAID) under contract no. GHH-I-00–07–00059–00, funded January 31, 2008. AIDSTAR-
One is implemented by John Snow, Inc., in collaboration with Broad Reach Healthcare, Encompass, LLC,
International Center for Research on Women, MAP International, Mothers 2 Mothers, Social and Scientific
Systems, Inc., University of Alabama at Birmingham, the White Ribbon Alliance for Safe Motherhood, and
World Education. The project provides technical assistance services to the Office of HIV/AIDS and USG
country teams in knowledge management, technical leadership, program sustainability, strategic planning, and
program implementation support.
Recommended Citation
Pearson, Jennifer, Daniel Cothran, Helen Cornman, and Malia H. Duffy. 2012. Pilot Co-trimoxazole Tools
Assessment, Gulu, Uganda. Arlington, VA: USAID’s AIDS Support and Technical Assistance Resources,
AIDSTAR-One, Task Order 1.
Acknowledgments
With the high level of participation, support, and leadership from the Uganda Ministry of Health, AIDSTAR-
One was able to ensure country ownership throughout all phases of this effort. Thank you especially to Dr.
Alex Riolexus Ario, AIDS Control Program, and Dr. Christopher Oleke, Health Promotion Specialist, for
their support and leadership. Thank you also to Sam Enginyu, Sr. Health Educationist, MOH, and to the
Gulu District Health team, especially Dr. Onek Awil, District Health Officer, Celetino Ojok, District Health
Education Officer, and John Opwonya. Thank you to the Gulu data collection team: Michael Ochora,
Bernard Odong, Francis Opoka, Esther Atto, and Fred Owara. Thank you to the NUMAT team especially
Christine Oryema Lalobo, Andrew Ocero, Luigi Ciccio, and Med Makumbi. Thank you to USAID/Uganda
especially Jackie Calnan, Julius Kalamya, Gerald Mwima, Grace Namayanja, Seyoum Dejene, and Fred
Magala, for their input and support. Thank you to Ilana Lapidos-Salaiz, USAID, and to Melissa Sharer, Peace
Corps.
AIDSTAR-One
John Snow, Inc.
1616 Fort Myer Drive, 16th Floor
Arlington, VA 22209 USA
Phone: 703-528-7474
Fax: 703-528-7480
E-mail: info@aidstar-one.com
Internet: aidstar-one.com
5. CONTENTS
CONTENTS ................................................................................................................................. iii
Acronyms ....................................................................................................................................... v
Executive Summary .................................................................................................................... vii
INTRODUCTION ......................................................................................................................... 1
Background..................................................................................................................................................................... 1
AIDSTAR-One Pilot Tools ......................................................................................................................................... 2
Pilot Country Selection ............................................................................................................................................... 2
Assessment Objectives................................................................................................................................................ 3
METHODOLOGY ......................................................................................................................... 5
Methods .......................................................................................................................................................................... 5
Pilot Facilities ................................................................................................................................................................. 6
FINDINGS...................................................................................................................................... 9
Prescription/Recommendation of Co-trimoxazole ............................................................................................. 9
Provider Knowledge .................................................................................................................................................... 9
Client Knowledge of Potential Side Effects .........................................................................................................11
Self-Reported Client Non-adherence ....................................................................................................................11
Baseline Client Feedback ..........................................................................................................................................12
Follow-up Assessment ...............................................................................................................................................14
Pharmacy Record Review .........................................................................................................................................18
COUNTRY OWNERSHIP ......................................................................................................... 19
LIMITATIONS ............................................................................................................................. 21
RECOMMENDATIONS.............................................................................................................. 23
CONCLUSION............................................................................................................................ 25
Effectiveness of Tools ................................................................................................................................................25
Feasibility of Integration ............................................................................................................................................25
References .................................................................................................................................... 27
ANNEX A .................................................................................................................................... 29
Revisions to the Pilot Co-trimoxazole Tools .....................................................................................................29
ANNEX B..................................................................................................................................... 31
Revised Co-trimoxazole Clinical and Community Poster ................................................................................31
iii
6. Figures
Figure 1. Assessment Methodology ..................................................................................................................... 5
Figure 2. Prescription/Recommendation of Co-trimoxazole, Provider Self-Report ............................... 9
Figure 3. Provider Self-Report of Knowledge of Co-trimoxazole Benefits .............................................10
Figure 4. Provider Correct Identification of Potential Side Effects of Co-trimoxazole ........................10
Figure 5. Client Correct Identification of Potential Side Effects of Co-trimoxazole .............................11
Figure 6. Client Co-trimoxazole Adherence – Previous Week .................................................................12
Figure 7. Provider Satisfaction with Co-trimoxazole Tools Post-Pilot .....................................................14
Figure 8. Frequency of Client Understanding of Co-trimoxazole Tools, Provider Report .................16
Figure 9. Recommendation of Pilot Co-trimoxazole Tools ........................................................................16
Figure 10. Percent of Clients Reporting Having Seen Pilot Tools at Follow-up .....................................17
iv
7. ACRONYMS
ACP Uganda AIDS Control Program
ART antiretroviral therapy
CDC U.S. Centers for Disease Control and Prevention
CME continuing medical education
CTXp co-trimoxazole prophylaxis
HMIS health information management systems
IRC internal review committee
LTFU lost to follow-up
MOH ministry of health
NMS Uganda National Medical Stores
PLHIV people living with HIV
WHO World Health Organization
v
9. EXECUTIVE SUMMARY
Co-trimoxazole is a well-tolerated, inexpensive, and cost-effective antimicrobial that has been shown
to reduce the risk of pneumonia, diarrhea, malaria, and other opportunistic infections among people
living with HIV (PLHIV). However, limited awareness of the benefits of co-trimoxazole use among
health care providers and service recipients continues to be a key barrier to its use (Anand et al.
2010). AIDSTAR-One developed provider and patient educational tools to increase appropriate
prescription and use of co-trimoxazole for PLHIV eligible for its use and piloted these tools in
Northern Uganda between May and August 2012. AIDSTAR-One conducted a mixed-methods
assessment pre- and post-pilot to analyze the effectiveness and acceptability of the co-trimoxazole
tools.
The pilot began with introduction of the tools as well as baseline data collection. At baseline both
providers and clients were able to easily identify the messages in the co-trimoxazole tools. They
indicated the text and the images were simple, clear, and concise. Feedback provided by health
providers, clients, and stakeholders was taken into account and small revisions were made to further
increase the cultural relevance of the tools in Uganda.
Prior to introduction of the tools, providers reported heavy client loads prevented them from
providing adequate counseling related to co-trimoxazole to all patients. Clients indicated that,
although they utilize co-trimoxazole, most had not received counseling beyond being instructed to
take co-trimoxazole daily. At baseline, 31 percent of adults reported missing doses, and 37 percent
of caregivers reported failing to administer doses of co-trimoxazole to children/infants in their care
in the previous week, emphasizing the need for tools to improve adherence. At follow-up, adult
clients reported higher levels of adherence to their co-trimoxazole prescriptions (only 20 percent
reported missing doses in the previous week). Almost all clients (97 percent) who reported viewing
the co-trimoxazole pilot tools reported they would be more likely to remember to take co-
trimoxazole each day because of the tools.
Both provider self-assessment of knowledge level and correct identification of side effects of co-
trimoxazole increased after introduction of the tools. At follow-up, identification of vomiting as a
side effect increased 36 percent and identification of jaundice (yellow eye) more than doubled. In
comparison, only 83 percent of control site providers could identify skin rash as a potential side
effect and even lower numbers could identify vomiting (50 percent) and yellow eye (27 percent).
Among clients, correct identification of skin rash, the most common side effect reported, increased
from 45 to 64 percent (a 42 percent increase). The percentage of clients who correctly identified
vomiting and yellow eye as potential side effects of co-trimoxazole more than doubled (106 percent
increase).
Providers expressed satisfaction with the time-saving that the pilot tools provide. Providers reported
that formulation changes are challenging for clients who have difficulty understanding changes in
tablet size, shape, and color. By providing a job aid with clear counseling points, providers rely less
on their memories for information, and the images provide clients with visual cues that supplement
the verbal counseling received. Although many clients are illiterate, the images removed the necessity
of reading, and providers counseled using the photos as a guide. Less time per client lead to more
vii
10. clients counseled. Providers also reported that clients were better able to understand the messages
improving the quality of counseling provided. Because of this, 100 percent of the providers reported
they would recommend the pilot co-trimoxazole tools to other providers.
However, even with access to the co-trimoxazole tools, provider counseling efforts were frustrated
by stock-outs in some health facilities. These stock-outs require examination to determine the cause.
Increased focus on adequate and timely record keeping is recommended. The inconsistent
availability and quality of pharmacy records did not permit the use of pharmacy records as a method
of measuring the number of clients receiving/refilling co-trimoxazole prescriptions before and after
introduction of the co-trimoxazole tools.
This pilot, although small in sample size, demonstrated that the co-trimoxazole job aids and client
educational tools were both effective and feasible to integrate. The tools were well-received among
providers, clients, as well as Ugandan Ministry of Health representatives who recommended scale-up
of the tools throughout the country. Ministry of Health representatives agreed that inclusion of the
client trifold brochures with distribution of co-trimoxazole tablets to the health facilities could be an
effective method of stocking health facilities throughout Uganda with the AIDSTAR-One tools.
In a recent study in Uganda, co-trimoxazole, when taken daily by persons with HIV, reduced death
by 46 percent, malaria by 72 percent, diarrhea by 35 percent, and hospitalizations by 31 percent. It
also slowed the rate of CD4 decline and the rate of viral load increase (Mermin et al. 2004).
Adoption and scale up of the tools by the Ugandan Ministry of Health is recommended, and as the
tools were designed for a general audience, they can be scaled up outside of Uganda as well.
viii
11. INTRODUCTION
BACKGROUND
Co-trimoxazole (trimethoprim plus sulfamethoxazole) is a well-tolerated, inexpensive, and cost-
effective antimicrobial that is commonly used to reduce the risk of Pneumocystis jiroveci pneumonia
(PCP) and toxoplasmosis among people living with HIV (PLHIV) (Abimbola and Marston 2012;
World Health Organization [WHO] 2006). Within developed countries, this drug had long been a
standard part of HIV care; however, until 2006, there were no WHO or Joint United Nations
Programme on HIV/AIDS (UNAIDS) guidelines for HIV-related co-trimoxazole prophylaxis
(CTXp) in resource-limited settings (Mermin et al. 2004).
In 2006, WHO published guidelines on co-trimoxazole prophylaxis for HIV-related infections
among children, adolescents, and adults living in low-resource settings. These guidelines
recommended that HIV-exposed infants and all clinically eligible children and adults living with HIV
should take co-trimoxazole prophylaxis unless contraindicated (WHO 2006). Soon afterward,
Uganda incorporated these guidelines in its own policy, stating: “Co-trimoxazole prophylaxis should
be given to all HIV-infected adults and children in Uganda regardless of whether they are on
antiretroviral therapy (ART) or not” (Ministry of Health [MOH] 2006). In a recent study in Uganda,
co-trimoxazole, when taken daily by persons with HIV, reduced death by 46 percent, malaria by 72
percent, diarrhea by 35 percent, and hospitalizations by 31 percent. It also slowed the rate of CD4
decline and the rate of viral load increase (Mermin et al. 2004).
One study evaluated the effect of co-trimoxazole on ART initiation within the first year (following
CD4 count and staging) at primary health care sites in Johannesburg. Of 491 patients who initiated
co-trimoxazole, approximately 96 percent later enrolled in ART; however, 91 percent of patients
who did not initiate co-trimoxazole (138 of 151) did not later initiate ART (three-quarters were lost
to follow-up [LTFU] and 17 percent died). Co-trimoxazole may improve patient retention and
probability of initiated ART, and may be a cost-effective intervention to improve retention among
HIV-positive patients (Clouse et al. 2012).
With the global scale-up of HIV treatment and care programs, substantial funding has been
committed to guarantee an uninterrupted supply of co-trimoxazole prophylaxis for people living
with HIV (PLHIV) but access to this important intervention remains inconsistent in developing
countries (Anand et al. 2010). A 2007 study of 41 countries (representing 82 percent of the global
burden of HIV infection) found supply chain challenges to be the major barrier to co-trimoxazole
access/administration, along with limited awareness of the benefits of co-trimoxazole use among
health care providers and service recipients, as well as perceived low priority of CTXp because of
the lack of integration of TB/HIV services and fear that co-trimoxazole prescription would identify
patients as infected with HIV, being other important barriers (MOH 2006). In 2011, AIDSTAR-
One conducted a 15-country study examining the availability and management of co-trimoxazole
supplies (Nersesian, Fullem, and Sharer 2011). From the findings revealed through the country desk
reviews, it is apparent that there are many supply chain challenges posing obstacles to ensure co-
trimoxazole availability for all uses. And, conversely, there are many innovative approaches being
developed and implemented to help ensure its availability. The AIDSTAR-One co-trimoxazole tools
1
12. were developed to address the issue of limited awareness and to increase use of and adherence to
this life-saving medicine.
AIDSTAR-ONE PILOT TOOLS
Based on the WHO recommendations, AIDSTAR-One
worked with the Ugandan MOH, USAID, U.S. Centers
for Disease Control and Prevention (CDC), and behavior
change specialists to develop provider and patient
educational tools to increase appropriate prescription and
use of co-trimoxazole for PLHIV eligible for its use.
Tools for providers—including a wall poster and hand-
held counseling tool—emphasize the benefits of co-
trimoxazole and include information about how and
when it should be administered, the details of eligibility,
and potential reactions related to use. It can serve as a
tool for educating, reminding, and stimulating demand at
the facility level. A set of complementary educational
brochures was developed for clients to take home. The
brochures focus on increasing the demand for, use of,
and adherence to co-trimoxazole among PLHIV. The
tools include depictions of male, female, child, and infant
clients.
Designed to be used in low-literacy settings, the tools rely
heavily on illustrations that were designed by Kwikpoint
and extensively pilot-tested in six countries across three
continents. Kwikpoint is a designer of innovative and
simple visual communication tools that solve language
and training challenges. The tools, although developed
with input from the Ugandan MOH, were intended to
remain general enough to be adapted for use across sub-
Saharan Africa.
The tools were translated into Acholi and Kiswahili for the pilot; however, at the request of the
MOH, when revisions were made to the tools, they were converted back to English. The tools can
be found on the AIDSTAR-One website at http://www.aidstar-
one.com/focus_areas/care_and_support/resources/tools_and_curricula/cotrim_tools
PILOT COUNTRY SELECTION
To determine the feasibility of integrating the co-trimoxazole tools into clinical settings and
practices, and to evaluate the effect of the tools on provider and client behaviors, AIDSTAR-One
designed a pilot assessment. The team selected Uganda based on expressed need and the availability
of structures through which to conduct the assessment—namely, the presence of the Northern
Uganda Malaria, AIDS, and Tuberculosis (NUMAT) program, a USAID-funded program
implemented by John Snow Inc. (JSI), that worked to expand access to and utilization of HIV,
tuberculosis, and malaria prevention, treatment, and care and support activities in northern Uganda.
2
13. AIDSTAR-One received internal review committee (IRC) approval from the Uganda National
Council for Science and Technology (UNCST) on January 11, 2012; the Ugandan Ministry of Health
Department of Health Education and Promotion on March 15, 2012; and the Ugandan President’s
Office on March 19, 2012, to conduct a pilot assessment of these tools in Gulu District, Uganda,
with active support from NUMAT.
ASSESSMENT OBJECTIVES
1. Pilot the integration of provider and patient educational tools on co-trimoxazole into health care
facilities in northern Uganda.
2. Assess the feasibility of fully integrating the co-trimoxazole tools through provider acceptability,
satisfaction, and adaptation of the tools into national policy.
3. Assess the effectiveness of the co-trimoxazole tools on increasing demand for, use of, and
adherence to co-trimoxazole prophylaxis among people living with HIV in northern Uganda.
3
15. METHODOLOGY
METHODS
AIDSTAR-One conducted a mixed-methods assessment with the support of the Gulu District
Health Office to analyze the effectiveness and acceptability of the co-trimoxazole tools. The
assessment team included two AIDSTAR-One researchers, two consultants, and three enumerators
(data collectors). The co-trimoxazole tools were piloted in May 2012 in 10 health facilities in Gulu
and 10 control sites were also selected.
Figure 1. Assessment Methodology
Pilot and Baseline – May 2012
Provider pre- Facility introduction Provider post-
test knowledge of pilot co- test and Client focus
assessment trimoxazole tools qualitative Stakeholder
groups and
interviews pre-test interviews
Tools piloted in 10 facilities
May to August 2012
Follow-up – August 2012
Provider post-post-
test and qualitative Client Pharmacy / Control sites: pharmacy
interviews post-test enrollment record review and provider
record review knowledge assessment
The assessment utilized a pre–post–post design. A pre-test of health providers captured co-
trimoxazole knowledge before introduction of the tools at the intervention facilities. The pre-test
was followed by a brief orientation to the co-trimoxazole tools for the health providers. A post-test
5
16. of health providers was administered to reassess co-trimoxazole knowledge immediately after
introduction of the tools; the post-test also included questions related to satisfaction with the draft
(pilot) tools.
At baseline, 33 health providers (including doctors, clinical officers, nurses, and midwives)
participated in the introduction of the AIDSTAR-One tools at all intervention facilities (10) in May
2012. Focus group discussions were conducted with providers that covered topics such as how they
currently prescribe co-trimoxazole, how they perceive clients reacting to the tools, how they could
use the tools, and how (or if) they would change them to make them better. Facility management
was notified prior to the site visit and asked to invite approximately 10 HIV-positive clients, or
caregivers of HIV-positive children, to participate in data collection. In several of the sites, more
clients participated in the focus groups, demonstrating strong interest in the topic. In total 116
clients provided baseline data, with 73 clients participating in the focus group discussions at five
facilities that covered issues such as client experiences with co-trimoxazole and asked participants to
critique the pilot tools. In addition, 43 clients participated in the client knowledge and use
assessment (24 adult clients and 19 caregivers on behalf of their child/infant) at five facilities. The
knowledge and use assessment included questions related to adherence, self-assessment of co-
trimoxazole knowledge level, and side effects.
At follow-up (August 2012), qualitative interviews were conducted with providers and facility heads
to assess usability and satisfaction with the tools. In total, 24 health providers at 9 of the 10
intervention facilities participated in a post-post-test of co-trimoxazole knowledge, behavior, and
satisfaction with the pilot tools. Due to low staff turnover, many of the providers interviewed and
tested at baseline participated in the follow-up assessment. Client knowledge and use assessments
were also administered. A total of 49 clients participated in a post-test of co-trimoxazole knowledge
and behavior (45 adult clients and 4 caregivers on behalf of their child/infant) at the 9 follow-up
facilities. At follow-up, participating clients were present at the health facility HIV clinic when the
assessment team arrived and had not been notified or invited in advance. The provider knowledge
assessment was also administered at the 10 control facilities. Where available, the assessment team
examined pharmacy records in an effort to ascertain the number of clients utilizing co-trimoxazole
at both the intervention and control sites.
PILOT FACILITIES
All 17 health facilities in Gulu District (both rural and urban) that operated at, or above, level III,
were randomly assigned to intervention or control. Three level II facilities were also included.
Intervention Sites:
1. Lalogi Health Center – Level IV Facility
2. Bobi Health Center – Level III Facility
3. Gulu Referral Hospital – Level V Facility
4. 4th Div Military Hospital – Level V Facility
5. Patiko Health Center – Level III Facility
6. Odek Health Center – Level II Facility
6
17. 7. Ongako Health Center – Level III Facility
8. Pabwor Health Center – Level II Facility
9. Bardege Health Center – Level III Facility
10. Layibi Health Center – Level III Facility
Control Sites:
1. Gulu Independent Hospital – Level V Facility
2. The AIDS Support Organization (TASO) Hospital – Level V Facility
3. Awach Health Center – Level IV Facility
4. Lapainat Health Center – Level III Facility
5. Lanenober Health Center – Level III Facility
6. Cwero Health Center – Level III Facility
7. Labworomor Health Center Level II
8. Laroo Health Center – Level III Facility
9. Aywe Health Center – Level III Facility
10. Gulu Prison Health Center – Level III Facility
7
19. FINDINGS
PRESCRIPTION/RECOMMENDATION OF
CO-TRIMOXAZOLE
More providers reported prescribing/recommending co-trimoxazole to eligible clients at follow-up
compared to before introduction of the pilot tools. At baseline, 79 percent of providers reported
always recommending co-trimoxazole to eligible HIV-positive clients compared to 87 percent at
follow-up, a 10 percent increase in providers reporting always recommending co-trimoxazole to
their eligible clients. In comparison, 76 percent of control site providers reported always
recommending co-trimoxazole to eligible HIV-positive clients. See Figure 2.
Figure 2. Prescription/Recommendation of Co-trimoxazole, Provider Self-Report
Frequency of Prescription/Recommendation of Co-
trimoxazole to Eligible Clients
100%
87%
79% 76%
80%
60%
40%
20%
0%
Baseline (Intervention) Follow-up Control Sites
(Intervention)
Always
PROVIDER KNOWLEDGE
Although most providers did report always prescribing co-trimoxazole to eligible clients, provider
self-assessment of their knowledge of co-trimoxazole varied. Nearly a quarter of providers (21
percent) rated their knowledge of co-trimoxazole benefits as “medium” at baseline. After
introduction and use of the tools, provider reports of “very high” knowledge of co-trimoxazole
benefits increased from 36 percent to 50 percent (a 39 percent increase). In order to gather
additional information, specific knowledge questions were also included in the pre- and post-test.
At baseline, over half of providers rated their knowledge of co-trimoxazole side effects as less than
high (24 percent medium, 30 percent low). After use of the co-trimoxazole tools, nearly three-
quarters of providers (71 percent) rated their knowledge of the side effects of co-trimoxazole as high
to very high (a 58 percent increase). Providers at control sites rated their knowledge of co-
9
20. trimoxazole side effects as lower than providers who were introduced to the tools: only 37 percent
of control providers rated their knowledge as high to very high. This increase in confidence in
knowledge was reflected in their improved identification of potential side effects.
Figure 3. Provider Self-Report of Knowledge of Co-trimoxazole Benefits
Knowledge Level - Co-trimoxazole Side Effects
Provider Self-Report
100%
80% 37%
45%
71%
60%
High to Very High
33%
40% 24% Medium
Low
20% 17%
30% 30%
13%
0%
Baseline Follow-up Control Sites
(Intervention) (Intervention)
Before introduction of the tools, providers were aware of skin rash as a possible side effect of co-
trimoxazole use; however, knowledge of other potential side effects was lower. Over 60 percent of
providers could not identify vomiting and yellow eye as potential side effects.
At follow-up, three months after introduction of the tools, providers were more likely to correctly
identify the potential side effects of co-trimoxazole. Identification of vomiting increased 36 percent
and identification of yellow eye more than doubled (106 percent increase). In comparison, only 83
percent of control site providers could identify skin rash as a potential side effect and even lower
numbers could identify vomiting (50 percent) and yellow eye (27 percent).
Figure 4. Provider Correct Identification of Potential Side Effects of Co-trimoxazole
Provider Correct Identification of
Co-trimoxazole Side Effects
100% 100%
100%
87%
83%
80% 74%
64%
60% 50%
36%
40%
27%
20%
0%
Skin Rash Vomiting Yellow Eye
Control Sites Baseline (Pilot) Follow-up (Pilot)
10
21. Although providers reported that they do observe side effects in clients related to co-trimoxazole
use, they reported observation of side effects was rare. Approximately 20 percent of the providers
reported seeing a client during the previous three months with a side effect due to co-trimoxazole
use. Skin reactions were most commonly observed and ranged from minor (and controllable with
medication) to severe (requiring discontinuation of co-trimoxazole). Some providers reported
prescribing Dapsone, the second-line therapy when severe skin reactions occur, but they noted
Dapsone can be more difficult to obtain than co-trimoxazole.
CLIENT KNOWLEDGE OF POTENTIAL
SIDE EFFECTS
After the tools were introduced at the pilot facilities, clients’ knowledge of the potential side effects
of co-trimoxazole increased. Correct identification of skin rash, the most common side effect
reported, increased from 45 to 64 percent (a 42 percent increase). The percentage of clients who
correctly identified vomiting and yellow eye as potential side effects of co-trimoxazole more than
doubled.
Figure 5. Client Correct Identification of Potential Side Effects of Co-trimoxazole
Client Correct Identification of
Co-trimoxazole Side Effects
100%
80% 64%
60% 45% 46%
40%
40% 22% 18%
20%
0%
Skin Rash Vomiting Yellow Eye
Baseline Follow-up
SELF-REPORTED CLIENT NON-ADHERENCE
Results of the client focus groups at baseline indicated a need for the co-trimoxazole educational
tools, which emphasize that co-trimoxazole is to be taken daily and highlight the consequences of
non-adherence. Clients who participated in the knowledge and use assessment reported
missing/forgetting co-trimoxazole doses.
• Forty-six percent of adult clients reported forgetting to take co-trimoxazole (ever).
• Thirty-one percent of adults reported missing doses of co-trimoxazole in the previous week.
11
22. • Thirty-seven percent of caregivers reported failing to administer doses of co-trimoxazole to
children/infants in their care in the previous week.
• Twenty-one percent of caregivers reported stopping administration of co-trimoxazole to
children/infants in their care if the child appeared to feel worse.
This reported non-adherence reinforced the need for tools that emphasize both dosage and
consequences of non-adherence.
CLIENT ADHERENCE AT FOLLOW-UP
Almost all clients (97 percent) who reported viewing the co-trimoxazole pilot tools reported they
would be more likely to remember to take co-trimoxazole each day because of the tools.
At follow-up, clients reported higher levels of adherence to their co-trimoxazole (80 percent
reported not missing any doses in the previous week) compared to baseline (65 percent) before
introduction of the co-trimoxazole tools. This represents a 23 percent increase in self-reported
adherence.
Figure 6. Client Co-trimoxazole Adherence – Previous Week
Client Co-trimoxazole Adherence
Previous Week - Self Report
100%
80%
80%
65%
60%
40%
20%
0%
Baseline Follow-up
Have not skipped any doses (previous week)
BASELINE CLIENT FEEDBACK
Clients interviewed were able to interpret the images correctly and reported strong understanding of
the purpose and messages of the tools: to encourage appropriate use of, and adherence to, co-
trimoxazole (commonly referred to by clients as “Septrin”). As strong endorsement and further
demonstration of this understanding, clients in many of the focus group discussions expressed
interest in taking the client brochures home, where they said they would use them to encourage
friends and/or family to either take their prescription or to visit the health facility for a prescription.
Women repeatedly remarked that they would like to share the brochure with their male partner to
encourage him to avoid becoming sick and recognize the importance of co-trimoxazole. Many
female clients reported that their male partners are unwilling to visit the health center and some
12
23. reported their male partners “steal” co-trimoxazole from them even if the males have not been
tested for HIV. One female client reported she hides her co-trimoxazole from her male partner by
carrying the tablets with her at all times.
Clients (and providers) were often observed interpreting the tools based on the images rather than
reading the text which further demonstrates the necessity of clear messaging through the images.
Clients could clearly identify the behaviors/action steps in the tools. The client consensus was that
the messages are simple to understand even when utilizing the photos and not relying on the text.
Before the pilot, most clients reported previously being given information on co-trimoxazole orally
but were never given reference or reading tools to view or to take home. Some clients reported
receiving little to no information about co-trimoxazole beyond being told they needed to take co-
trimoxazole daily.
Clients agreed that the tools were appropriate for them, and that the tools increased their knowledge
about co-trimoxazole. There appeared to be hope that the tools would influence community opinion
about the value of co-trimoxazole, to the point where people would risk the potential for stigma in
order to access this important drug. It was also verbalized that the tools eventually may increase the
overall community understanding of the benefits of co-trimoxazole to overcome the barrier of
stigma that remains. By increasing awareness of the drug’s importance and increasing conversations
at the community level and between providers and clients, fear of stigma may decrease leading to
increased uptake and use of co-trimoxazole. Clients reported that, in general, co-trimoxazole use is
currently associated with HIV status, although co-trimoxazole is prescribed by health providers to
HIV-negative clients as well. Direct client feedback included:
• “We should take these tools to our friends and spouse at home so that they stop living in denial
and come out to take Septrin because of the benefits shown in the material.”
• “What I like from this material is the message that if you take your Septrin consistently for your
HIV care, you will remain healthy and be a living testimony to others.”
• “I see that people who are taking Septrin for their HIV care are healthy and looking happy and
this gives us morale to take our Septrin.”
REVISIONS TO PILOT CO-TRIMOXAZOLE TOOLS
At baseline, almost all providers (97 percent) reported high satisfaction with the pilot co-trimoxazole
tools, of which 27 percent reported very high satisfaction. At baseline, all providers reported the
tools would be easy (43 percent) to very easy (57 percent) to integrate into their daily routine. All
providers also reported at baseline they would recommend the tools to colleagues/other health
providers, most (87 percent) would highly recommend the tools.
Overall clients and providers expressed very strong satisfaction with, and understanding of, the pilot
tools; however, suggestions were offered for minor revisions to increase relevance in the Ugandan
context. These included changing the references to the drug from “co-trimoxazole” to “Septrin”—
the term clients are most familiar with; changing the representation of the pill bottle; and changing
the color of the clothing of the nurse from white to pink, and the female client’s clothing from pink
to blue to reduce confusion. The full list of revisions is listed in Annex I.
13
24. FOLLOW-UP ASSESSMENT
PROVIDER FEEDBACK
Providers reported that the co-trimoxazole tools had been utilized during individual counseling
sessions, mother support groups, group health education sessions, HIV-positive support groups,
and provider continuing medical education (CME) sessions.
At follow-up, providers reported distributing take-home brochures to clients; however, sufficient
copies were not available for all clients, and take-home brochures were exhausted before the pilot
period ended. At facilities with larger client loads, providers reported that client take-home copies
were exhausted in approximately the first six to eight weeks. Providers reported that clients
appreciated the take-home copies, and repeatedly stressed the need for a continuous supply of tools.
However, providers stressed that a take-home tool is not enough, recognizing the importance of
their own role in counseling and walking clients through the tools prior to distribution.
Providers reported high satisfaction with use of the tools, commenting that they were “very
systematic” and improved the quality of counseling. The tools were described by providers as an
important job aid, serving as both visual and written cues to remember each point that must be
conveyed to clients. Overall, at post-pilot, provider satisfaction with the co-trimoxazole tools was
high (96 percent)—31 percent of providers reported very high satisfaction with the tools.
Figure 7. Provider Satisfaction with Co-trimoxazole Tools Post-Pilot
Provider Satisfaction with Co-trimoxazole Tools
August 2012
4%
Very high
31% High
Medium
Low
65%
14
25. Some providers commented that often in the past they viewed co-trimoxazole as a simple
intervention that did not require counseling beyond instructing clients to take their co-trimoxazole
daily. Limited counseling time instead often focused on ART regimens and adherence messaging
when applicable, or for PLHIV not on ART, or other important health messages. However, stock-
outs highlighted the importance of continuous counseling on co-trimoxazole for all HIV-positive
clients, regardless of ART usage, not just counseling for new clients. In order to fill co-trimoxazole
prescriptions in the case of a stock-out at the health facility, clients could resort to other public
facilities (assuming they were close enough), or private facilities/pharmacies; however, the incentive
to take this extra effort is diminished if the client does not understand the importance of adherence
to their prescription.
Providers reported that formulation changes continued to provide a challenge for clients and that
clients struggle to understand how many tablets to take when switched back and forth between 960-
mg and 480-mg tablets. Providers also reported difficulties clients have with changes in tablet size,
shape, and color. Clients often doubt the authenticity of tablets that are different than those they
have taken in the past and report non-adherence, asking for the co-trimoxazole they “used to take.”
Providers repeatedly noted that the tools made counseling faster and easier. One provider reported,
“Before, I had to explain. The client would not understand, so I would start again. Sometimes I had
to explain some things three times.” The co-trimoxazole tools focus on images, and providers
reported their appreciation with being able to explain as clients follow along with the visuals. Many
job aids currently available to providers are text-based, often algorithms that do not inform clients,
confuse clients, or require reading aloud to clients. Providers emphasized that clients learn best
when they can both look at the photos and have someone explain to them. These findings are
supported by research that demonstrates that pictures accompanied by written or spoken text can
increase attention to and recall of health education information compared to text alone (Houts et al.
2006). One provider reported that he was able to observe that clients appeared to pay more
attention during counseling when the co-trimoxazole pilot tools were utilized, “Visuals create more
interest; they really are better than just talking.”
Providers reported that clients increasingly recognized the importance of co-trimoxazole with
increased counseling that utilized the co-trimoxazole tools. In particular, the image of the sick
person in bed (due to non-adherence to co-trimoxazole) was very clear to clients. Not wanting to be
sick in bed, the clients understood that they should adhere to their co-trimoxazole.
Providers agreed that clients understood the tools (96 percent reported “always” or “almost
always”). Although many clients are illiterate, the images removed the necessity of reading, and
providers counseled using the photos as a guide. Providers also reported that the pilot tools were
comprehensive and provided all of the information that clients need related to co-trimoxazole use.
15
26. Figure 8. Frequency of Client Understanding of Co-trimoxazole Tools, Provider Report
Clients Understand Co-trimoxazole Tools
(Provider Report)
4%
Always
22%
Almost always
Sometimes
74% Never
Heavy client loads are a reality for providers. Providers admitted that counseling each client that
visits the health center on co-trimoxazole use as well as other health messages is often impossible.
Providers expressed satisfaction with the time saving the pilot tools provide. Less time per client
leads to more clients counseled. Because of this, all providers reported they would recommend the
pilot co-trimoxazole tools to other providers. Most providers (78 percent) indicated they would
strongly recommend the tools. Providers reported that the pilot tools made their work easier, but,
more importantly, they can “feel satisfied that my clients really do understand what I am counseling
about.”
Figure 9. Recommendation of Pilot Co-trimoxazole Tools
Recommendation of Co-trimoxazole Tools to
Colleagues or Other Health Providers
22%
Strongly recommend
Recommend
78%
16
27. Even with access to the co-trimoxazole tools, however, provider counseling efforts were frustrated
by stock-outs in some health facilities. One provider remarked, “We tell our clients co-trimoxazole is
so important, and these are the consequences of non-adherence so take it every day, but then we
have none to give them. We have failed our clients.”
INTEGRATION
Usability of the co-trimoxazole pilot tools was also measured by proxy through assessment of how
many of the clients reported viewing or receiving counseling with the tools at follow-up. Nearly
three-quarters of the clients (72 percent) interviewed at the pilot health facilities reported viewing the
tools. Most clients who recognized the tools reported a health provider utilized the tools during
counseling, some of which reported receipt of a take home copy in addition to counseling. Only 11
percent of clients reporting recognition of the tools indicated that they viewed the tools without also
receiving counseling from a provider.
Figure 10. Percent of Clients Reporting Having Seen Pilot Tools at Follow-up
Clients Reporting Recognition of the
Co-trimoxazole Materials
28%
Yes
No
72%
17
28. PHARMACY RECORD REVIEW
The inconsistent availability and quality of pharmacy records did not permit the use of pharmacy
records as a method of measuring the number of clients receiving/refilling co-trimoxazole
prescriptions.
The pilot facilities included both ART and pre-ART care sites. ART sites are responsible for
ordering co-trimoxazole, whereas pre-ART sites receive a set amount of co-trimoxazole as a part of
a basic services package and are not responsible for submitting order forms. Overall, most facilities
struggled with record keeping. Common problems observed included days or even weeks with no
data available, as well as records that were not updated regularly. Stock cards were also observed to
be of questionable accuracy. At most of the facilities, co-trimoxazole consumption was recorded in
multiples of 1000 each month (i.e., exactly 1000, 2000, or 3000 tablets consumed every month)
which is likely a data quality issue.
Because of stock-outs, a facility might have reported no co-trimoxazole consumed the month before
the pilot and a large consumption in the month post pilot; however, this is not necessarily an
accurate increase, simply a reflection of a stock-out. Changes in formulation also create false
increases and decreases. A large increase in 480-mg tablet consumption was seen to reflect a stock-
out of 960-mg tablets (requiring a double dosage per client) rather than a true increase in clients or
client adherence.
Stock-outs were not the only cause of quality issues. A staff member in at least one facility expressed
challenges translating the lessons learned during off-site training to his work within the facility
without follow-up supervision.
18
29. COUNTRY OWNERSHIP
The piloted co-trimoxazole tools received a very positive response from the Uganda MOH at the
district and national levels. The MOH emphasized the importance of integrated messaging, as
providers need to counsel clients on a variety of health behaviors and was satisfied by the inclusion
of secondary messages related to male partner involvement, healthy eating, and the use of
insecticide-treated bed nets within the AIDSTAR-One tools.
A representative of the Uganda AIDS Control Program (ACP) commented that the tools are
“clear,” “straight-forward,” “give the message right away,” and “don't require interpretation.”
The tools were received as useful for adoption by the MOH through integration into the
current Positive Living Profiling Tool for Health Care Workers (available at
http://archive.k4health.org/toolkits/uganda-positivelivingcommunication/health-care-workers-
positive-living-profiling-tool) in order to ensure sustainability and impact.
The Uganda National Medical Store (NMS) is responsible for ensuring continuous distribution of
pharmaceutical products in a financially viable and sustainable manner. NMS distributes essential
drug kits, family planning commodities, and MOH-direct distributions to the districts. MOH
representatives agreed that inclusion of the client trifold brochures with distribution of co-
trimoxazole tablets to the health facilities could be an effective method of stocking health facilities
throughout Uganda with the AIDSTAR-One tools.
19
31. LIMITATIONS
After a short pilot period (approximately three months), the assessment sought to measure the
effects of the co-trimoxazole tools through the use of pharmacy and/or enrollment records to
determine how many clients refilled their tablets, or how many tablets were consumed before and
after the tools were introduced. However, due to data quality issues, the pharmacy and enrollment
data could not be effectively utilized to associate use of tools with increased use of co-trimoxazole at
the facility level.
Co-trimoxazole adherence at baseline and follow-up was measured through client self-report, which
may not be accurate, but was the best available option.
Participants in client focus groups represented a convenience sample of PLHIV eligible for co-
trimoxazole use or caretakers of children eligible for co-trimoxazole use. This convenience sample
represents a population that is already seeking health care.
The assessment included all appropriate health facilities in Gulu District. Although it gives
important information about Gulu District, the results of this study may not be representative of
other districts in Uganda.
21
33. RECOMMENDATIONS
Scale-up throughout Uganda: The pilot results indicated that the co-trimoxazole tools increase
the reported frequency and quality of provider counseling and are well understood by clients.
Because these tools were associated with improved adherence and because no other stand-alone
tools exist in Uganda, scale-up of the co-trimoxazole tools throughout Uganda is recommended.
Due to the large client load, especially at level IV and level V facilities, scale-up will require a
commitment to the provision of a large quantity of the client take home tools, as well as a
sustainability plan to guarantee continuous supply at the facility level. As suggested by MOH
representatives, inclusion of the client trifold brochures with distribution of co-trimoxazole tablets
to the health facilities could be an effective method of stocking health facilities throughout Uganda
with the tools. The tools should be made available in English and other applicable local languages.
Providers indicated a preference for English language tools for their own use, but that translations
into local languages would benefit clients and facilitate community-level use by community health
workers. Scale-up of the tools to increase and sustain use and adherence among PLHIV requires full
country ownership including stocking and distributing supplies of co-trimoxazole throughout the
country as well as continuously supplying facilities with standalone educational materials related to
co-trimoxazole use.
Scale-up beyond HIV clinic use: Use of the tools should not be limited to the facility HIV clinic,
community-based clinics that provide pre-ART and ART care could also benefit from their
availability and use. Providers recommended that the poster should be posted and copies of the
client brochures should be available in the outpatient department of facilities to increase awareness
and help clients overcome fear of stigma. The take-home copies may also help to increase new usage
of co-trimoxazole among those who are not currently enrolled in clinical care through improved
awareness and prioritization of health over stigma in the community. Preventing mother-to-child
transmission clinics could also benefit from use of these tools, and the MOH or other organizations
working in Uganda may consider adapting the tools to create a tool for use with pregnant women.
Explore supply chain challenges: Regardless of the usefulness and usability of the co-trimoxazole
job aids/client education tools, without constant drug availability use and adherence will be
negatively impacted. The MOH should explore the reasons for the stock-outs at the facility level to
determine what immediate changes could improve supply, such as possibly increasing focus on
accurate ordering where applicable.
Stress importance of record keeping: Facility-level reporting quality impeded the assessment’s
ability to associate the pilot tools with increased use of co-trimoxazole. In at least one case, a health
facility staff member did report receiving training on record keeping, but the training was off-site,
and the staff member had trouble remembering the lessons and figuring out how to operationalize
them in their facility. Stressing the importance of accurate and timely records paired with training
and follow-up supervision is essential to increase the quality of services provided to clients. The
tools may serve as a reminder to providers to order co-trimoxazole in timely manner (where
applicable) and improve record keeping as use increases.
23
34. Providers reported that some clients may be visiting multiple clinics and receiving co-trimoxazole
from each. This duplication is possible because current health information management systems
(HMIS) and record keeping are not set up to effectively track prescriptions. Although the scale of
this issue is probably small, improvements in record keeping and HMIS will be valuable in helping
the government understand retention to co-trimoxazole and to prevent fraudulent sale of tablets to
private pharmacies or other PLHIV.
Study how to improve retention in care: Many PLHIV are likely to need co-trimoxazole for the
rest of their lives. Keeping them on treatment could be a daunting challenge. The MOH could
investigate different methods for improving and maintaining high retention rates—this could
include assessing the impact of co-trimoxazole tools after they are widely disseminated and used
throughout Uganda to provide more information beyond the pilot.
Continue to work to change gender norms: Many adult men living with HIV are not visiting
health facilities, and, because of norms about strength and health, some men are taking co-
trimoxazole intended for their partners or children. This is dangerous and it will hamper government
efforts to increase the number of eligible people taking co-trimoxazole if not addressed. The
underlying norms about men should be the target of behavior change campaigns that reach both
genders.
Consider impact of formulation changes: Intermittent formulation changes at the facility level are
confusing to clients and may negatively impact adherence. The MOH should consider this challenge
to adherence when procuring and supplying co-trimoxazole to both ART and pre-ART sites. An
NMS representative indicated that the MOH is planning to phase in 120-mg dispersible tablets (in
place of the co-trimoxazole suspension syrup [for infants/children]) and may reserve 960-mg tablets
exclusively at ART sites, sending pre-ART sites only 480-mg tablets. However, clients and providers
consistently reported that breaking adult dosage tablets for infants and children is difficult, provides
a possibly imprecise dosage, and may lead to contamination. Although the syrup may be easier,
dispersible tablets are a better solution than breaking adult tablets. Clients and providers also
reported that adult clients often prefer 960-mg tablets to reduce the number of tablets they must
take daily, although some clients did express fear of choking on the larger tablets. Further studies are
recommended to explore client preferences that may affect use and adherence.
Scale-up beyond Uganda: Given the success of the pilot in northern Uganda, other countries may
benefit from the use of these tools and should consider their adoption (with adaptations where
necessary). However, scale up requires champions for co-trimoxazole education within the
government and Ministry of Health.
24
35. CONCLUSION
EFFECTIVENESS OF TOOLS
Providers stated that the co-trimoxazole tools improved the quality of their counseling, providing a
counseling cue. They reported that because of the job aids, they no longer had to rely on their
memory of what points to cover during counseling. Simple, image-reinforced messages ensure that
providers can convey the essential information quickly and easily, and in a way that clients are better
able to learn and remember. Both providers and clients reported that the images are simple, clear,
and provide the necessary information. After introduction of the tools, providers and clients were
better able to identify possible side effects of co-trimoxazole. Clients also reported improved
adherence after introduction of the tools in the pilot facilities.
Distribution of the client take home tool may serve to increase co-trimoxazole use by reducing
stigma at the community level. Clients repeatedly requested the take-home tools, citing that in
addition to serving as a reminder to themselves, they can help partners, family members, and
neighbors to understand the importance of co-trimoxazole, and therefore of HIV testing.
FEASIBILITY OF INTEGRATION
The pilot demonstrated the ease of integration of the co-trimoxazole tools in a clinical setting.
Providers reported that, rather than creating an additional task or burden for them, the clear, image-
based job aids increased counseling frequency due to decreased time required for counseling.
Providers also reported high satisfaction with the tools and indicated that they would highly
recommend them to other providers.
MOH officials who were introduced to the tools were enthusiastic about both the clarity and
usefulness of the tools, as well as the potential ease of integration within Ministry systems, such as
distribution via the NMS and inclusion within the existing Positive Living profiling tool.
25
37. REFERENCES
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Advanced HIV Infection Initiating Antiretroviral Therapy in Sub-Saharan Africa.” Journal of
Acquired Immune Deficiency Syndromes 60(1):e8–e14.
Anand, A, et al. 2010. “Implementation of Co-trimoxazole Prophylaxis and Isoniazid Preventive
Therapy for People Living With HIV.” Bulletin World Health Organization 88(4). Available at
http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S0042-
96862010000400010&lng=en&nrm=iso (accessed December 20, 2012)
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ART initiation among patients initiating cotrimoxazole prophylaxis therapy in Johannesburg,
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27
39. ANNEX A
REVISIONS TO THE PILOT
CO-TRIMOXAZOLE TOOLS
Revision Rationale
Changed language from co-trimoxazole to Clients know co-trimoxazole as Septrin
Septrin (all tools)
Changed pill bottle to representation of tin (all Recommendation for improved identification; tins
tools) are used by all health centers
Labeled tin as “Septrin” (all tools) Recommendation for clarification
Added appointment reminders to accompany Suggestion from USAID/Uganda to help
dosage reminder (client brochures) track/improve client adherence and retention
Darkened skin and hair of clients (all tools) Suggestion from Gulu District Health Education
office for better representation of Ugandans
Changed female shirt color in various pictures Pink clothing is often associated with nurses in
from pink (female and child tools) Uganda
Removed tea cups from men’s hands, added Drinking tea is not a common social activity for
soccer ball (male tool) Ugandans
Changed shovel to hoe, removed helmet and Shovels are associated with digging graves; hoes are
toolbox (male tool) more appropriate work tools
Moved text “Stop Septrin only…” to under Placement with side effects is more intuitive;
side effects (client brochure) previous placement did not match images
Added roof to health center, labeled health Previous structure with no roof “looked like a
center, changed cross to blue (all tools) latrine,” blue cross to prevent confusion with Red
Cross, labeling adds clarity
Changed nurse’s uniform to pink, added cap, More recognizable representation of nurse uniform
removed stethoscope (all tools)
Added “Take Septrin with or without food” Suggestion from DHE/Gulu stakeholders to address
text challenge of food insecurity and Septrin non-
adherence
Added representation of dispersible tablets to Many health facilities are using dispersible tablets for
infant tools in addition to Septrin syrup infant dosage rather than syrup
Removed red arrows indicating taking tablet MOH stakeholders agreed the arrows were
unnecessary and potentially confusing
Added representation of bed net over sleeping Integrated messaging is important, co-trimoxazole
client counseling using the tools is also an opportunity to
discuss other healthy behaviors
Added language encouraging use of safe water Stakeholders, including USAID/Uganda,
recommended including an emphasis on the use of
clean drinking water
40. Changed dosage information for infants from Change reflects Uganda co-trimoxazole dosage
0–6 months to 6 weeks–6 months, added guidelines
alternative titles for the different formulations
(e.g., “Suspension” became “Suspension/syrup”
and “Child tablet” became “Child dispersible
tablet”) (clinic poster dosage chart)
Changed language about consequences of non- Stakeholders felt it was important to stress
adherence from “If you don’t take Co- retention
trimoxazole, you may become sick or die.” to
“If you do not continue taking Septrin, you may
become sick or die” (all tools)
30
44. AIDSTAR-One
John Snow, Inc.
1616 Fort Myer Drive, 16th Floor
Arlington, VA 22209 USA
Phone: 703-528-7474
Fax: 703-528-7480
Email: info@aidstar-one.com
Internet: aidstar-one.com