May, 2017 - SUPPORT Summary of a systematic review | print this article |

Do workplace programmes for the diagnosis and treatment of HIV improve workers’ health outcomes and attitudes?

The HIV epidemic may threaten the health workforce by imposing heavier workloads and increasing complexity of care; by exposing health workers and other workers living with HIV and AIDS to tuberculosis (TB) and other infectious diseases; and through the psychological stress placed on health workers who have to administer care. HIV and AIDS may also have substantial impacts on the workforce in sectors other than health. Workplace programmes aim to improve access for health workers and other workers to HIV prevention, treatment and support.

 

 

Key messages

  • Workplace programmes for health workers may increase the uptake of HIV testing.
  • Workplace programmes for health workers may increase awareness of post-
  • exposure prophylaxis to prevent HIV infection.
  • Onsite, compared with offsite, rapid HIV testing may increase the uptake of
  • voluntary counselling and testing among workers in sectors other than health.
  • Workplace programmes offering free antiretroviral therapy may improve markers of effective antiretroviral therapy among workers living with HIV and AIDS in sectors other than health.
  • All studies included in this review were conducted in low- and middle-income countries.

 

 

 

Background

Programmes to improve the diagnosis and treatment of HIV and AIDS can be located in healthcare or other workplaces. Workplace programmes can include treatment and care, fol-low-up, provision of voluntary counselling and testing, and prevention or education for staff and their families.

 

Workplace interventions that include only education and prevention resources and do not offer priority access to diagnosis and/or treatment were not included in this review. These excluded interventions include promotion of condom use and sharp injury prevention.

 



About the systematic review underlying this summary

Review objectives: To determine the effectiveness of workplace programmes for the diagnosis or treatment of HIV or tuberculosis (TB)
Type of What the review authors searched for What the review authors found
Study designs & interventions Randomised trials, quasi-experimental or comparative observational studies assessing workplace programmes to diagnose and/or manage HIV and/or TB, and analytical studies if none of the previous designs were found. Three studies among healthcare workers (1 controlled before-after study, 1 uncontrolled before-after study, and 1 descriptive study) and seven among employees in other sectors (1 cluster-randomised trial, 2 interrupted time series, 4 qualitative/quantitative descriptive studies)
Participants Health workers and employees in any sector (including private and public workplaces) Health workers at hospitals and medical centres. Small- and medium-sized businesses
Settings Workplaces (all countries) South Africa (7), Botswana (jointly with South Africa), Rwanda, Zambia and Zimbabwe (1 each)
Outcomes Incidence of infection, absenteeism, worker retention, uptake of voluntary counselling and testing, uptake of treatment, morbidity, mortality, working conditions, cost (or cost–benefit), discrimination or stigma, job loss, services to the community Mortality, active TB cases, adverse drug effects, uptake of HIV testing and appropriate treatment, adoption of HIV-preventative behaviours, knowledge and attitudes about HIV, stigma and morale       
Date of most recent search: 2009
Limitations: This is a well-conducted systematic review with only minor limitations.

Yassi A, O'Hara LM, Lockhart K, Spiegel JM. Workplace programmes for HIV and tuberculosis: a systematic review to support development of international guidelines for the health workforce. AIDS Care 2013; 25:525-43.

Yassi A, O'Hara LM, Lockhart K, Spiegel JM. Workplace programmes for HIV and tuberculosis: a systematic review to support development of international guidelines for the health workforce. AIDS Care 2013; 25:525-43.

Summary of findings

Three studies with the lowest risk of bias are summarised here: one targeted at health workers and two at employees in other (non-health) sectors. The additional descriptive and qualitative studies included in the review consistently showed acceptance of counselling, testing and treatment for HIV and AIDS in the workplace.

 

1) Workplace programmes for health workers

A controlled before-after study in Zambia assessed the effects of a peer-led HIV risk reduction programme for hospital-based health workers and their families.

 

  • Workplace programmes for health workers may increase the uptake of HIV testing. The certainty of this evidence is low.
  • Workplace programmes for health workers may increase awareness of post exposure prophylaxis to prevent HIV infection. The certainty of this evidence is low.

 

 

Workplace programme for health workers focusing on HIV risk reduction compared to no programme

People:  Health workers
Settings
:  Five hospitals in Zambia
Intervention
: Peer-led workplace programme focusing on HIV risk reduction
Comparison
: No programme
Outcomes Impact Certainty of the evidence
(GRADE)
Been tested for HIV
Attending peer-led education sessions may increase the rate of testing (AOR 1.7 (95% CI 1.1 to 2.6)), compared to those health workers who were not aware of the programme 

Low

Aware of post-exposure prophylaxis to prevent HIV infection
Attending peer-led education sessions may increase awareness of post-exposure prophylaxis (AOR 5.5 (95% CI 2.9 to 10.2), compared to those health workers who were not aware of the programme

Low

GRADE: GRADE Working Group grades of evidence (see above and last page)

CI: Confidence interval   AOR: Adjusted odds ratio

2) Workplace programmes for workers in sectors other than health

Two studies are summarized here: the first is a cluster-randomised trial of two strategies of voluntary counselling and testing for HIV (onsite rapid HIV testing versus vouchers for offsite testing) offered to 24 small- and medium-sized businesses in Zimbabwe. The second is an interrupted time series study of a workplace HIV care programme in South Africa, which described treatment outcomes in sequential groups of individuals starting antiretroviral therapy.

  • Onsite compared with offsite rapid HIV testing may increase the uptake of voluntary counselling and testing. The certainty of this evidence is moderate.
  • Workplace programmes offering free antiretroviral therapy may improve markers of effective antiretroviral therapy among workers living with HIV and AIDS. The certainty of this evidence is low.

Workplace HIV programmes for workers in sectors other than health, compared to no programme

People:  Public and private sector workers
Settings
:  Medium and small-sized companies in South Africa and Zimbabwe 
Intervention
:Workplace programmes to improve the diagnosis or treatment of HIV 
Comparison
: Vouchers for offsite testing (Zimbabwe) or usual care (South Africa)
Outcomes Impact Certainty of the evidence
(GRADE)
Uptake of  voluntary counselling and testing for HIV
Workplace programmes may increase the uptake of voluntary counselling and testing for HIV, compared with vouchers for offsite testing (RR 2.8 (95% CI 1.8 to 3.8))

Low

Effective antiretroviral therapy (ART), measured by CD4 count and viral load
Workplace programmes offering free, nurse-managed ART may increase CD4 counts (90, 113 and 164 cells/microl. at 6, 12 and 24 months on treatment) and decrease viral load (below 400 copies/ml in 75, 72 and 72% of patients at 6, 12 and 24 months on treatment)

Low

GRADE: GRADE Working Group grades of evidence (see above and last page)

RR: Relative risk CI: Confidence interval ART: Antiretroviral therapy CD4: Type of white blood cell

Relevance of the review for low-income countries

Findings Interpretation*
APPLICABILITY

All studies included in this review were conducted in low and middle-income African countries.

 

  • Workplace programmes for the diagnosis and treatment of HIV may improve uptake of HIV testing and health outcomes among workers.

 

 


The applicability of these findings to low income countries may be influenced by:

- The financial and organizational resources to provide workplace programmes. The feasibility of such programmes may be influenced by the proportion of workers employed within the formal sector

- The supplies necessary to deliver services in these settings

- The ability of the health system to respond to the demand for additional services that may be stimulated by widespread implementation of workplace programmes

- The acceptability of the interventions to workers in the health sector and in other sectors, and to other stakeholders

 


EQUITY
 The systematic review did not address equity
issues. 

Workplace programmes may improve overall access to information and care on HIV and AIDS, but could also increase inequities in ac-cess between employed and unemployed populations.

 

  • Workplace programmes may increase inequi-ties in access between those employed in the formal and informal sectors as these pro-grammes may be difficult to implement in the informal sector.

 

 

ECONOMIC CONSIDERATIONS

Few cost outcomes were reported in the included studies.

  • One study found that the cost per worker of providing nurse managed antiretroviral therapy decreased over time.

The cost of workplace programmes is likely to be highly variable and needs to be estimated based on specific local conditions. Factors affecting these costs will include the scale of implementa-tion, the range of health workers involved, the range of services offered and the logistics in-volved in ensuring a reliable supply of required commodities.

 

  • It is unclear whether the wider implementation of workplace programmes for HIV and AIDS will increase or decrease demand on other parts of the health system.
  • Before workplace programmes are scaled up, robust evidence is needed regarding the cost-effectiveness of these interventions.

 

 


MONITORING & EVALUATION

The available evidence is generally of low certainty due to risk of bias in the included studies.

 

  • There is little evidence on potential adverse effects, costs or cost-effectiveness.

 

 


If decision makers from low-income countries choose to implement workplace programmes, they should ensure that these programmes include robust evaluation including health outcomes, potential adverse effects (such as stigma, discrimination or job loss), and costs.

  • The acceptability of workplace programmes to recipients and providers may need to be evaluated before such programmes are taken to scale.
*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: http://www.support-collaboration.org/summaries/methods.htm

 

Additional information

Related literature

Kisting S, Wilburn S, Protsiv M, Hsu LN. Improving health workers' access to HIV and TB prevention, treatment, care and support services. World Hosp Health Serv 2010; 46:34-5.

 

Buregyeya E, Nuwaha F, Wanyenze RK, et al. Utilization of HIV and tuberculosis services by health care workers in Uganda: implications for occupational health policies and implementation. PloS One 2012; 7(10):e46069.

 

Legido-Quigley H, Montgomery CM, Khan P, et al. Integrating tuberculosis and HIV services in low- and middle-income countries: a systematic review. Trop Med Int Health 2013; 18:199-211.

 

Weihs M, Meyer-Weitz A. Barriers to workplace HIV testing in South Africa: a systematic review of the literature. AIDS Care. 2016;28(4):495-9.

 

This summary was prepared by

Agustín Ciapponi, Instituto de Efectividad Clínica y Sanitaria, Buenos Aires, Ar-gentina

 

Conflict of interest

None declared. For details, see: www.supportsummaries.org/coi

 

Acknowledgements

This summary has been peer reviewed by: Simon Lewin.

 

This review should be cited as

Yassi A, O'Hara LM, Lockhart K, Spiegel JM. Workplace programmes for HIV and tuberculosis: a systematic review to support development of international guide-lines for the health workforce. AIDS Care 2013; 25:525-43.

 

The summary should be cited as

Agustín Ciapponi. Do workplace programmes for the diagnosis and treatment of HIV improve workers’ health outcomes and attitudes? A SUPPORT Summary of a systematic review. May 2017. www.supportsummaries.org

 

Keywords

evidence-informed health policy, evidence-based, systematic review, health sys-tems research, health care, low and middle-income countries, developing coun-tries, primary health care, workplace, HIV, tuberculosis, health personnel, health services accessibility

 



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