BackgroundMobile technology has great potential to improve adherence and treatment outcomes in healthcare settings. However, text messaging and phone calls are unaffordable in many resource-limited areas. This study investigates the use of a no-cost alternative mobile phone technology using missed calls (‘buzzing’) to act as a patient reminder. The use of missed calls as a patient reminder was evaluated for feasibility and effectiveness as an appointment reminder in the follow-up of newly-diagnosed human immunodeficiency virus (HIV) positive patients in an HIV testing and counselling department in rural Swaziland.MethodsThis pilot study uses a before-and-after operational research study design, with all patients with mobile phones being offered the intervention. The primary outcome was the rate of attendance at the HIV testing and counselling department for collection of results in those with mobile phones before and after the introduction of the intervention.ResultsOver two-thirds, 71.8% (459/639), of patients had a mobile phone. All patients with a mobile phone consented to being buzzed. There was no difference in attendance for follow-up at the clinic before and after the intervention was implemented (80.1% versus 83.3%, p = 0.401), or after adjusting for confounding factors (OR 1.13, p = 0.662).ConclusionThis pilot study illustrates that mobile technology may be feasible in rural, resource-poor settings as there are high rates of mobile phone ownership and the intervention had a 100% uptake rate, with positive feedback from staff and patients. In this particular setting, the intervention did not improve attendance rates. However, further research is planned to investigate the impact on adherence to appointments and medications in other settings, such as HIV chronic care follow-up and as part of an enhanced package to improve adherence.

BackgroundAntiretroviral treatment services delivered in hospital settings in Africa increasingly lack capacity to meet demand and are difficult to access by patients. We evaluate the effectiveness of nurse led primary care based antiretroviral treatment by comparison with usual hospital care in a typical rural sub Saharan African setting.MethodsWe undertook a prospective, controlled evaluation of planned service change in Lubombo, Swaziland. Clinically stable adults with a CD4 count > 100 and on antiretroviral treatment for at least four weeks at the district hospital were assigned to either nurse led primary care based antiretroviral treatment care or usual hospital care. Assignment depended on the location of the nearest primary care clinic. The main outcome measures were clinic attendance and patient experience.ResultsThose receiving primary care based treatment were less likely to miss an appointment compared with those continuing to receive hospital care (RR 0·37, p < 0·0001). Average travel cost was half that of those receiving hospital care (p = 0·001). Those receiving primary care based, nurse led care were more likely to be satisfied in the ability of staff to manage their condition (RR 1·23, p = 0·003). There was no significant difference in loss to follow-up or other health related outcomes in modified intention to treat analysis. Multilevel, multivariable regression identified little inter-cluster variation.ConclusionsClinic attendance and patient experience are better with nurse led primary care based antiretroviral treatment care than with hospital care; health related outcomes appear equally good. This evidence supports efforts of the WHO to scale-up universal access to antiretroviral treatment in sub Saharan Africa.

a 53% TB case detection rate (World Health Organization target 70%); there is currently no systematic programme for tracing contacts of TB cases for screening. The Swaziland Ministry of Health has identifi ed inadequate investigation of household contacts as one reason why the national TB response is insuffi cient, and it has committed to conducting systematic investigation of contacts.The aim of the present study is to evaluate hospitalbased contact screening and test approaches to improve effectiveness, through community follow-up. METHODS Study settingThe present study was conducted in the TB department of Good Shepherd Hospital (GSH), a regional rural hospital serving a population of 200 000. The hospital provides support to community clinics and outreach services such as trained fi eld offi cers, known as motorcycle adherence offi cers. Study designThis is an evaluation of hospital-based universal TB household contact screening, conducted from November 2011 to October 2012. It includes a quality improvement project evaluating three enhanced models to investigate the effectiveness of community follow-up. Study populationAll household contacts of index patients were included in the study. An index patient was defi ned as any patient aged >5 years with pulmonary TB or <5 years with any form of TB. A household contact was defi ned as someone living under the same roof as an index case at the time of, or within 3 months of, diagnosis. InterventionNewly diagnosed index patients providing consent for contact tracing were asked to list their household contacts. The standard (hospital-based) model for TB contact tracing was as follows: 1) all contacts attending the TB clinic with the index patient at any appointment were offered TB screening, and 2) a letter was given to the index patient to invite household contacts for screening at the hospital.Adult contacts were screened by clinical assessment using the Swaziland TB screening tool (Table 1). 9 In high HIV prevalence settings, symptom-based screening tools are sensitive in adults (84%), although not very specifi c (60%). 12 Contacts aged <5 years were screened by the paediatrician, and investigated using chest X-ray Interna onal Union Against Tuberculosis and Lung DiseaseHealth solu ons for the poor VOL 3 NO 4 PUBLISHED 21 DECEMBER 2013http://dx.doi.org/10.5588/pha.13.0070Setting: A regional hospital in rural Swaziland. Objectives: To evaluate a hospital-based contact screening programme and test approaches to improve its effectiveness. Design: An evaluation and quality improvement study of tuberculosis (TB) contact tracing services. Results: Hospital-based TB contact tracing led to screening of 157 (24%) of 658 contacts; of these, 4 (2.5%) were diagnosed with TB. Of 68 contacts eligible for human immunodeficiency virus (HIV) testing and counselling, 45 (66%) were tested and 7/45 (16%) were identified as HIV-positive. Twelve (50%) of 24 screened contacts aged <5 years were provided isoniazid prophylaxis. Three enhanced models of TB contact tracing were piloted to...

ObjectiveTo implement and evaluate a formal pre-antiretroviral therapy (ART) care service at a district hospital in Swaziland.DesignOperational research.SettingDistrict hospital in Southern Africa.Participants1171 patients with a previous diagnosis of HIV. A baseline patient group consisted of the first 200 patients using the service. Two follow-up groups were defined: group 1 was all patients recruited from April to June 2009 and group 2 was 200 patients recruited in February 2010.InterventionIntroduction of pre-ART care—a package of interventions, including counselling; regular review; clinical staging; timely initiation of ART; social and psychological support; and prevention and management of opportunistic infections, such as tuberculosis.Primary and secondary outcome measuresProportion of patients assessed for ART eligibility, proportion of eligible patients who were started on ART and proportion receiving defined evidence-based interventions (including prophylactic co-trimoxazole and tuberculosis screening).ResultsFollowing the implementation of the pre-ART service, the proportion of patients receiving defined interventions increased; the proportion of patient being assessed for ART eligibility significantly increased (baseline: 59%, group 1: 64%, group 2: 76%; p=0.001); the proportion of ART-eligible patients starting treatment increased (baseline: 53%, group 1: 81%, group: 2, 81%; p<0.001) and the median time between patients being declared eligible for ART and initiation of treatment significantly decreased (baseline: 61 days, group 1: 39 days, group 2: 14 days; p<0.001).ConclusionsThis intervention was part of a shift in the model of care from a fragmented acute care model to a more comprehensive service. The introduction of structured pre-ART was associated with significant improvements in the assessment, management and timeliness of initiation of treatment for patients with HIV.