Assisted reproductive technologies and equity of access issues

In Australia and other countries, certain groups of women have traditionally been denied access to assisted reproductive technologies (ARTs). These typically are single heterosexual women, lesbians, poor women, and those whose ability to rear children is questioned, particularly women with certain disabilities or who are older. The arguments used to justify selection of women for ARTs are most often based on issues such as scarcity of resources, and absence of infertility (in lesbians and single women), or on social concerns: that it "goes against nature"; particular women might not make good mothers; unconventional families are not socially acceptable; or that children of older mothers might be orphaned at an early age. The social, medical, legal, and ethical reasoning that has traditionally promoted this lack of equity in access to ARTs, and whether the criteria used for client deselection are ethically appropriate in any particular case, are explored by this review. In addition, the issues of distribution and just "gatekeeping" practices associated with these sensitive medical services are examined.     

Adherence to antiretroviral therapy in sub-Saharan Africa and North America: a meta-analysis

Context  Adherence to antiretroviral therapy is a powerful predictor of survival for individuals living with human immunodeficiency virus (HIV) and AIDS. Concerns about incomplete adherence among patients living in poverty have been an important consideration in expanding the access to antiretroviral therapy in sub-Saharan Africa. Objective  To evaluate estimates of antiretroviral therapy adherence in sub-Saharan Africa and North America. Data Sources  Eleven electronic databases were searched along with major conference abstract databases (inclusion dates: inception of database up until April 18, 2006) for all English-language articles and abstracts; and researchers and treatment advocacy groups were contacted. Study Selection and Data Abstraction  To best reflect the general population, studies of mixed populations in both North America and Africa were selected. Studies evaluating specific populations such as men only, homeless individuals, or drug users, were excluded. The data were abstracted in duplicate on study adherence outcomes, thresholds used to determine adherence, and characteristics of the populations. A random-effects meta-analysis was performed in which heterogeneity was examined using multivariable random-effects logistic regression. A sensitivity analysis was performed using Bayesian methods. Data Synthesis  Thirty-one studies from North America (28 full-text articles and 3 abstracts) and 27 studies (9 full-text articles and 18 abstracts) from sub-Saharan Africa were included. African studies represented 12 sub-Saharan countries. Of the North American studies, 71% used patient self-report to assess adherence; this was true of 66% of the African assessments. Studies reported similar thresholds for adherence monitoring (eg, 100%, >95%, >90%, >80%). A pooled analysis of the North American studies (17 573 patients total) indicated a pooled estimate of 55% (95% confidence interval, 49%-62%; I², 98.6%) of the populations achieving adequate levels of adherence. Our pooled analysis of African studies (12 116 patients total) indicated a pooled estimate of 77% (95% confidence interval, 68%-85%; I², 98.4%). Study continent, adherence thresholds, and study quality were significant predictors of heterogeneity. Bayesian analysis was used as an alternative statistical method for combining adherence rates and provided similar findings. Conclusion  Our findings indicate that favorable levels of adherence, much of which was assessed via patient self-report, can be achieved in sub-Saharan African settings and that adherence remains a concern in North America.      

Adolescent girls' use of the Internet for health information: issues beyond access

Whilst the digital divide in access to Internet technology has rightly concerned commentators on health inequalities, there are issues beyond physical access that must be tackled if adolescents and adults are to optimize the benefits of this developing medium. Emerging themes from an exploratory qualitative study of adolescents' use of the Internet for information about health and medicines describe four major challenges. Access issues persist if there are insufficient school computers that are unable to cope with increasing Web site sophistication. Software on school-based machines preventing exposure to material that is deemed to be unsuitable may also prohibit access to educational sites about sexual health and drug misuse. Strategies to manage the volume of available information are needed. The interplay of active and passive information seeking challenges whether the Internet can be truly useful during acute illnessepisodes. This exploration with future health service users highlights important questions for further study.     

Oral health service systems in Gauteng Province, South Africa

OBJECTIVES: To describe the provision of restorative care and dental operators' opinion about their conditions of service in a South African provincial oral health service system. DESIGN: Assessment of oral health service over a four-month period. SETTING: Gauteng Province, South Africa. SUBJECTS: Dental operators in public oral health service. INTERVENTIONS: Operator interview, collection of treatment statistics, calculation of the mean score of restoration-extraction ratio per operator. MAIN OUTCOME MEASURES: Number and type of restorations and tooth extractions rendered, daily patient load, perceived occupational stress level and opinion about main reasons for operator stress. RESULTS: A total of 88,705 patients had been treated. The mean number of patients treated daily was 26 (SD = 8.4). Operators extracted 39,242 teeth and placed 2992 restorations. The main type of dental treatment was extraction. The mean score of the restoration-extraction ratio per operator was 0.09 in the primary, and 0.07 in the permanent dentition. The mean level of stress was 4.9 (SD = 1.9). The majority of operators regarded patients' high dental anxiety as the main reason for stress, followed by high patient load. The mean level of stress increased with the increase in number of patients treated per day (r = 0.44, p = 0.004) and also with the increase in the number of tooth extractions performed per day (r = 0.41, p = 0.008). CONCLUSIONS: Restorative dental care in this public oral health service is limited, tooth extraction being the predominant treatment provided. High patient load and high patient levels of dental anxiety determine this situation, according to the operators. The health authority should introduce appropriate solutions in order to address the prevailing situation adequately.     

Ethics and geographical equity in health care

Important variations in access to health care and health outcomes are associated with geography, giving rise to profound ethical concerns. This paper discusses the consequences of such concerns for the allocation of health care finance to geographical regions. Specifically, it examines the ethical drivers underlying capitation systems, which have become the principal method of allocating health care finance to regions in most countries. Although most capitation systems are based on empirical models of health care expenditure, there is much debate about which needs factors to include in (or exclude from) such models. This concern with legitimate and illegitimate drivers of health care expenditure reflects the ethical concerns underlying the geographical distribution of health care finance.     

新医改与我国医疗卫生体制的公平性

医疗体制的公平是每个人基本权利的保证条件之一,我国经济快速平稳增长,医疗体制的公平性却不断受到质疑。在宏观形势与医疗体制自身需要的契机下,2009年中国开始了被称为"新医改"的医疗卫生体制改革。从医疗体制公平性角度,分析了改革方案中对医疗筹资、医疗支付和医疗服务机构3个方面的公平性考虑,提出加强累进性最强的税收筹资的力度,以及将财政资金更多地用于医疗需求方,即社会医疗保险的支持,以提高医疗筹资和支付的公平程度。坚持公立医院为主导,充分体现医院服务机构的公益性,也是改革方案中对公平性地体现,反映了新医改对公平性问题的高度关注。最后提出有待进一步明确的关于政府主导与市场调节的兼顾问题,农村医疗保障的完善、医疗筹资中公共资金的适度比例以及中医药的重新定位和重点发展。     

Electronic medical record systems are associated with appropriate placement of HIV patients on antiretroviral therapy in rural health facilities in Kenya: a retrospective pre-post study

Background and objective

There is little evidence that electronic medical record (EMR) use is associated with better compliance with clinical guidelines on initiation of antiretroviral therapy (ART) among ART-eligible HIV patients. We assessed the effect of transitioning from paper-based to an EMR-based system on appropriate placement on ART among eligible patients.

Methods

We conducted a retrospective, pre-post EMR study among patients enrolled in HIV care and eligible for ART at 17 rural Kenyan clinics and compared the: (1) proportion of patients eligible for ART based on CD4 count or WHO staging who initiate therapy; (2) time from eligibility for ART to ART initiation; (3) time from ART initiation to first CD4 test.

Results

7298 patients were eligible for ART; 54.8% (n=3998) were enrolled in HIV care using a paper-based system while 45.2% (n=3300) were enrolled after the implementation of the EMR. EMR was independently associated with a 22% increase in the odds of initiating ART among eligible patients (adjusted OR (aOR) 1.22, 95% CI 1.12 to 1.33). The proportion of ART-eligible patients not receiving ART was 20.3% and 15.1% for paper and EMR, respectively (χ²=33.5, p<0.01). Median time from ART eligibility to ART initiation was 29.1 days (IQR: 14.1–62.1) for paper compared to 27 days (IQR: 12.9–50.1) for EMR.

Conclusions

EMRs can improve quality of HIV care through appropriate placement of ART-eligible patients on treatment in resource limited settings. However, other non-EMR factors influence timely initiation of ART.     

Clinical outcomes and CD4 cell response in children receiving antiretroviral therapy at primary health care facilities in Zambia

Context  The Zambian Ministry of Health provides pediatric antiretroviral therapy (ART) at primary care clinics in Lusaka, where, despite scale-up of perinatal prevention efforts, many children are already infected with the human immunodeficiency virus (HIV). Objective  To report early clinical and immunologic outcomes of children enrolled in the pediatric treatment program. Design, Setting, and Patients  Open cohort assessment using routinely collected clinical and outcome data from an electronic medical record system in use at 18 government primary health facilities in Lusaka, Zambia. Care was provided primarily by nurses and clinical officers ("physician extenders" akin to physician assistants in the United States). Patients were children (<16 years of age) presenting for HIV care between May 1, 2004, and June 29, 2007. Intervention  Three-drug ART (zidovudine or stavudine plus lamivudine plus nevirapine or efavirenz) for children who met national treatment criteria. Main Outcome Measures  Survival, weight gain, CD4 cell count, and hemoglobin response. Results  After enrollment of 4975 children into HIV care, 2938 (59.1%) started ART. Of those initiating ART, the median age was 81 months (interquartile range, 36-125), 1531 (52.1%) were female, and 2087 (72.4%) with World Health Organization stage information were in stage III or IV. At the time of analysis, 158 children (5.4%) had withdrawn from care and 382 (13.0%) were at least 30 days late for follow-up. Of the remaining 2398 children receiving ART, 198 (8.3%) died over 3018 child-years of follow-up (mortality rate, 6.6 deaths per 100 child-years; 95% confidence interval [CI], 5.7-7.5); of these deaths, 112 (56.6%) occurred within 90 days of therapy initiation (early mortality rate, 17.4/100 child-years; post–90-day mortality rate, 2.9/100 child-years). Mortality was associated with CD4 cell depletion, lower weight-for-age, younger age, and anemia in multivariate analysis. The mean CD4 cell percentage at ART initiation among the 1561 children who had at least 1 repeat measurement was 12.9% (95% CI, 12.5%-13.3%) and increased to 23.7% (95% CI, 23.1%-24.3%) at 6 months, 27.0% (95% CI, 26.3%-27.6%) at 12 months, 28.0% (95% CI, 27.2%-28.8%) at 18 months, and 28.4% (95% CI, 27.4%-29.4%) at 24 months. Conclusions  Care provided by clinicians such as nurses and clinical officers can result in good outcomes for HIV-infected children in primary health care settings in sub-Saharan Africa. Mortality during the first 90 days of therapy is high, pointing to a need for earlier intervention.      

昆明市HIV感染者未接受抗病毒治疗原因及对策分析

目的 对昆明市未治疗的HIV感染者进行调查,分析未接受抗病毒治疗的原因,为制定针对性的干预措施、提高HIV感染者治疗率及治疗依从性提供参考依据.方法 采用方便抽样的方法,抽取昆明市截至2018年8月31日尚存活但未治疗的HIV感染者进行问卷调查,调查内容包括一般人口学信息和和未治疗原因(包括对ART的认知、躯体因素、社...     

Integration of nutrition in the antiretroviral therapy scale up plan for Malawi

Malawi is one of the countries experiencing an unprecedented HIV/AIDS epidemic in an environment where malnutrition is rampant. In 2001 Malawi started providing ARVs to HIV patients. This ARV programme is now being scaled up to cover the whole country. Since underlying malnutrition is associated with adverse ART outcomes, the Malawi government commissioned a study to design a programme for integrating nutrition in the ARV scale up plan. This study used a Participatory qualitative research methodology. The study recommends that nutritional support should include therapeutic feeding, food supplements and take home ration and proposes a clear enrolment and discharge criteria.     

Hepatotoxicity in HIV-infected children and adolescents on antiretroviral therapy.

CONTEXT AND OBJECTIVE: Adverse drug reactions are a significant problem in patients on antiretroviral therapy (ART). We determined liver enzyme elevation frequencies in HIV-infected children and adolescents receiving ART, and their association with risk factors. DESIGN AND SETTING: Cross-sectional study, at the Pediatrics Immunodeficiency Division, University Hospital, Universidade Estadual de Campinas. METHODS: Medical records of 152 children and adolescents (54.6% male; median age 7.48 years) were analyzed, with a mean of 2.6 liver enzyme determinations per patient. Clinically, patients were classified in categories N (6), A (29), B (78) and C (39). Serum levels of aspartate aminotransferase and alanine aminotransferase were evaluated. Hepatotoxicity was scored as grade 1 (1.1-4.9 times upper limit of normality, ULN), grade 2 (5.0-9.9 times ULN), grade 3 (10.0-15.0 times ULN) and grade 4 (> 15.0 times ULN). To assess hepatotoxicity risk factors, odds ratios (OR) and adjusted odds ratios (aOR) for age, gender, TCD4+ cell count, viral load and medication usage were calculated. RESULTS: We observed grade 1 hepatotoxicity in 19.7 % (30/152) patients. No cases of grade 2, 3 or 4 were detected. There was a significant association between hepatotoxicity and use of sulfonamides (OR, 3.61; 95% confidence interval (CI), 1.50-8.70; aOR, 3.58; 95% CI, 1.44-8.85) and antituberculous agents (OR, 9.23; 95% CI, 1.60-53.08; aOR, 9.05; 95% CI, 1.48-55.25). No toxicity was associated with ART. CONCLUSIONS: One fifth of patients experienced mild hepatotoxicity, attributed to antituberculous agents and sulfonamides. Our results suggest that ART was well tolerated.