Background Uptake of HIV testing and counseling (HTC) is lower among members of the poorest households in sub-Saharan countries, thereby creating significant inequalities in access to HTC and possibly ARV treatment. Objectives To measure uptake of home-based HTC and estimate HIV prevalence among members of the poorest households in a sub-Saharan population. Methods Residents of 6 villages of Likoma Island (Malawi) aged 18–35 and their spouses were offered home-based HTC services. Socioeconomic status, HIV testing history and HIV risk factors were assessed. Differences in HTC uptake and HIV infection rates between members of households in the lowest income quartile and the rest of the population were estimated using logistic regression. Results Members of households in the lowest income quartile were significantly less likely to have ever used facility-based HTC services than the rest of the population (OR = 0.60, 95% CI: 0.36–0.97). In contrast, they were significantly more likely to use home-based HTC services provided during the study (aOR = 1.70, 95% CI: 1.04–2.79). Socioeconomic differences in uptake of home-based HTC were not due to underlying differences in socioeconomic characteristics or HIV risk factors. The prevalence of HIV was significantly lower among members of the poorest households tested during home-based HTC than among the rest of the population (aOR=0.37, 95% CI: 0.14–0.96). Conclusions HTC uptake was high during a home-based HTC campaign on Likoma Island, particularly among the poorest. Home-based HTC has the potential to significantly reduce existing socioeconomic gradients in HTC uptake, and help mitigate the impact of AIDS on the most vulnerable households.

Summaryobjectives To assess whether supervision of primary health care workers improves their productivity in four districts of Northern Ghana.methods We conducted a time-use study during which the activities of health workers were repeatedly observed and classified. Classification included four categories: direct patient care; documentation and reporting; staff development and facility operations; and personal time. These data were supplemented by a survey of health workers during which patterns of supervision were assessed. We used logistic regression models with health facility fixed effects to test the hypothesis that supervision increases the amount of time spent providing direct patient care (productivity). We further investigated whether these effects depend on whether or not supervision is supportive.results Direct patient care accounted for <25% of observations. In bivariate analyses, productivity was higher among midwives and in facilities with a high volume of care. Supervisory visits were frequent in those four districts, but only a minority of health workers felt supported by their supervisors. Having been supervised within the last month was associated with a significantly higher proportion of time spent on direct patient care (OR = 1.57). The effects of supervision on productivity further depended on whether the health workers felt supported by their supervisors.conclusion Supportive supervision was associated with increased productivity. Investments in supervision could help maximize the output of scarce human resources in primary health care facilities. Time-use studies represent an objective approach in monitoring the productivity of health workers and evaluating the impact of health-system interventions on human resources.

Effective treatment for patients with opioid use problems is as critical as ever given the upsurge in heroin and prescription opioid abuse. Yet, results from prior studies show that the majority of methadone maintenance treatment (MMT) programs in the US have not provided dose levels that meet evidence-based standards. Thus, this paper examines the extent to which US MMT programs have made changes in the past 23 years to provide adequate methadone doses; we also identify factors associated with variation in program performance. Program directors and clinical supervisors of nationally-representative methadone treatment programs were surveyed in 1988 (n=172), 1990 (n=140), 1995 (n=116), 2000 (n=150), 2005 (n=146), and 2011 (n=140). Results show that the proportion of patients who received doses below 60 mg/day--the minimum recommended—declined from 79.5 to 22.8 percent in a 23-year span. Results from random effects models show that programs that serve a higher proportion of African-American or Hispanic patients were more likely to report low-dose care. Programs with Joint Commission accreditation were more likely to provide higher doses, as were program that serve a higher proportion of unemployed and older patients. Efforts to improve methadone treatment practices have made substantial progress, but 23% of patients across the nation are still receiving doses that are too low to be effective.

We found that children of less educated mothers and children in Hispanic and non-Hispanic Black families with low income-to-poverty ratios were more likely to have completed the 4:3:1:3 series. Although the reasons for these results need further exploration in other data sets, possible factors are Hispanics' positive cultural attitudes regarding the needs and importance of young children and provision of information on immunizations to low-income minority mothers who access government-subsidized health care programs.