Basic packages
of preventive care (BCPs) can include a variety of interventions that target a
variety of infections, chronic illnesses and other health risks.
After several
studies in Uganda had
previously shown benefits from the delivery of a basic package care and
prevention package for people living with HIV, it became a major objective in the
Ugandan National Strategic Plan, according to Simon Sensalire, of the Program
for Accessible Health Communication and Education in Kampala, Uganda.3
Sensalire gave a
presentation on the results of a cross-sectional study, evaluating the effects
of integrating the basic care package into care and treatment services for
people living with HIV in that country.
The basic care package included two long lasting
treated mosquito bed nets (ITBN), a safe water system (WaterGuard solution),
condoms and information education and communication (IEC) materials on how to
prevent opportunistic infections (OIs) and HIV transmission.
Cotrimoxazole
(CTX) was not included in the kit, but was distributed to the same population
by the National AIDS Programme.
In addition to the BCP, trained health providers
and peer educators provided multiple channels of communication on the
prevention of opportunistic infections, family planning, palliative care,
TB/HIV and nutrition during routine HIV primary care visits, to people living
with HIV.
The cross-sectional
survey recruited a nationally representative sample of 2,567 PLHIV at 50 sites
in 2010. Findings on the use of the BCP products on the health of PLHIV and
other behaviour indicators and how this was affected by the use of
communications were compared with a baseline survey conducted in the same
target population in 2004/5 (when they would have had to buy some of these
components, like the insecticide-treated bed net, for themselves, or boil their
water for drinking).
The behavioural
indicators include the use of the kit, the consistent use of the condoms among
those who are sexually active; sleeping under a treated mosquito bed net every
night; treating water with WaterGuard solution; and daily uptake of CTX.
Compared to
2005, the survey found profound improvements in all of these indicators.
Use of the basic care package
Behavioral Indicator
|
Baseline
April 2005
|
Evaluation
Jan 2010
|
significance
|
Takes CTX (Septrin) daily
|
69.3 (n=2567)
|
91.5 (n=2567)
|
P<0.001
|
Slept under ITBN last night
|
29.9 (n=944)
|
68.6 (n=1004)
|
P<0.001
|
Used a condom at last sex
|
55.3 (n=601)
|
71.8 (n=675)
|
P<0.001
|
Current water is treated with
WaterGuard
|
0.05 (n=1007)
|
52.2 (n=1023)
|
P<0.001
|
Simple provision
of the kits improved the behavioural indications, but uptake was significantly
increased when combined with “increased
exposure of the information about the BCP kits, specifically the peer education
activities,” said Sensalire. Likewise, provision of the kit improved the
perceptions among PLHIV that they could always find CTX and condoms, to around
90%. Although perceptions also improved regarding the availability of the insecticide
treated bed-net, this was less universal (58. 7%).
“This BCP kit is
an essential component for PLHIV and should really be integrated into care and
treatment services, especially in poor resource settings [as it] is associated
with the uptake of these products for healthy living, but also positive
prevention behaviour,” said Sensalire. “The involvement of peer educators, who
are PLHIV themselves, backed up by IEC on the BCP kit was associated with
improved uptake of these products, at the same time positive prevention
behaviour. So this calls for the greater involvement of people living with HIV,
in HIV programmes. Finally, the BCP is a valuable approach for promoting public
private partnerships for HIV care and prevention programmes.”
A basic care package incorporating IPT and screening for non-communicable diseases
in Botswana
Of course, the
basic care package can also refer to interventions that are more difficult to deliver
in a kit, but which should nonetheless be provided for any person living with
HIV. Once ART has been stably delivered, many of the health risks confronting
people living on long term ART change, and according to a team from the
Botswana-Baylor Children's Clinical Centre of Excellence (COE) in Gaborone, Botswana,
there is a need to adapt and implement basic care packages in this setting as
well.4
“Public policy
on HIV in resource-limited settings has focused primarily on expanding access
to antiretroviral therapy (ART), with less emphasis on preventive care for
HIV-infected individuals. However, as life expectancy of HIV-infected patients
improves due to ART and the importance of associated co-morbidities and chronic
diseases increases, preventive care will become increasingly important,” the
poster’s authors wrote.
After a
comprehensive regional literature search, an assessment of clinic-specific
prevalence data of other chronic conditions in their patients, national
guidelines, and an assessment of public-sector resources, the team adapted the
existing general basic care package to recommend, providing the following for
adults enrolled in family model care at the facility:
Basic care package components: Botswana-Baylor
Children’s Clinical Centre of Excellence
Clean water
provision and water storage
Isoniazid
Prophylaxis (IPT)
Contraceptive provision
Screening and treatment for depression, cervical cancer, breast cancer, hypertension, hyperlipidaemia, diabetes, viral hepatitis, sexually transmitted infections
Assessment of other risks including: domestic violence, road safety, smoking and alcohol abuse.
“This preventive
care package addresses the comprehensive health needs of stable HIV-infected
adults in a particular resource-limited setting in an evidence-based,
systematic manner, while minimizing manpower and resource costs of
development,” wrote the authors, who suggested the same process be utilized to
develop similar guidelines in other resource-limited settings.
It should be
noted that another poster from the same facility reported on excellent uptake,
retention in care, and completion of treatment of IPT at their site— in
contrast to the poor retention and completion rates reported for the national
programme in Botswana — which perhaps illustrates that the Botswana-Baylor
Children's Clinical Centre of Excellence is indeed just that — and somewhat better
resourced than other public sector facilities. Other presentations on TB and
HIV integration are described in the HIV
and TB in Practice section of this edition.
Leveraging HIV
programmes to support diabetes services through integrated care, the team in Botswana
concluded that that their basic care package should include screening and
management for non-communicable diseases (NCDs), such as diabetes and
hypertension, because there was a significant risk of these chronic illnesses
in their population. Note, that this may be the mark of a more mature ART
programme. In early ART programmes, where ART is initiated in late stage
disease, other complications such as TB and opportunistic infections are
initially more common].