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BackgroundImplementation outcome assessment such as fidelity is essential in implementing health intervention. Limited studies that have been conducted have assessed fidelity separately at the healthcare provider level or facility level with managers. However, there might be variations in facility resources and their utilization, skewing such comparisons. We, therefore, would like to investigate whether a combined provider-facility level fidelity is a more effective assessment. We aim to describe the weighted fidelity of implementing the guidelines for TB screening among PLHIV and examine its effect on TB screening coverage at selected HIV clinics in Ghana.MethodsWe used cross-sectional study and collected data from 226 HIV care providers and 27 managers of district hospitals implementing the TB screening intervention at the HIV clinics. We also extracted information from TB registers monthly for 2018. Weighted fidelity was measured based on the extent to which the intervention was implemented, considering both the facility and the provider level assessments. Response scores and extracted data on fidelity were analyzed and summarized using the median and inter-quartile range for non-normal data such as fidelity scores and coverage and frequencies and percentages for categorical data such as resources availability. Linear regressions models were fitted for TB screening coverage using the fidelities separately.ResultsThe study revealed that the weighted fidelity median score was 67% (IQR: 59.9 – 74.9%), and the TB screening coverage was 71.3% (IQR: 56.9 – 96.7). Weighted fidelity of delivery was statistically associated with TB screening coverage (p0.05) except for IE&C. Facilities with TB IE&C materials available had a significantly (p=0.025) higher median fidelity score 75.4% (74.9 – 88.5) than their counterparts 65.7% (59.4 – 72.6).ConclusionsThe combined provider-facility level assessment of fidelity demonstrated that weighted fidelity of delivery is positively associated with TB screening coverage and provided a better platform for assessing implementation fidelity. It also showed that the availability of IE&C materials significantly moderates the weighted fidelity of delivery. Weighted fidelity is an efficient way of holistically assessing fidelity within health facilities.

Background Decreasing the burden of Tuberculosis (TB) among PLHIV through TB screening is an effective intervention recommended by the World Health Organization (WHO). However, after over a decade of implementation in Ghana, the intervention does not realize the expected outcomes. It is also not well understood whether this lack of success is due to implementation barriers. Our study, therefore, sought to examine the factors influencing the implementation of the intervention among people living with HIV (PLHIV) attending HIV clinics at district hospitals in Ghana. Methods This was a qualitative study conducted from 6th to 31 May 2019 in three regions of Ghana. We conducted 17 in-depth interviews (IDIs – comprising two regional, six districts and nine facility TB/HIV coordinators) and eight focus group discussions (FGD – consisting of a total of 65 participants) with HIV care providers. The Consolidated Framework for Implementation Research (CFIR) guided the design of interview guides, data collection and analysis. All responses were digitally audio-recorded and transcribed verbatim for coding and analysis using the Framework Approach. Participants consented to the interview and recording. Results The main barriers to TB screening relate to the low commitment of the implementers to screen for TB and limited facility infrastructure for the screening activities. Facilitators of TB screening include (1) ease in TB screening, (2) good communication and referral channels, (3) effective goals and feedback mechanisms, (4) health workers recognizing the need for the intervention and (5) the role of chemical sellers. Conclusions Key barriers and facilitators to the intervention are revealed. The study has shown that there is a need to increase HIV care providers and institutional commitment towards TB screening interventions. In addition, cost issues need to be assessed as they are drivers of sustainability. Our study also advances the field of implementation science through CFIR to better understand the factors influencing the implementation.

Background: Antiretroviral therapy (ART) impact has prolonged survival of people living with HIV. We evaluated HIV disease progression among ART patients using routinely collected patient-level data between 2004 and 2017 in Zimbabwe.Methods: We partitioned HIV disease progression into four transient CD4 cell counts states: state 1 (CD4 ≥ 500 cells/μl), state 2 (350 cells/μl ≤ CD4 < 500 cells/μl), state 3 (200 cells/μl ≤ CD4 < 350 cells/μl), state 4 (CD4 < 200 cells/μl), and the absorbing state death (state 5). We proposed a semiparametric time-homogenous multistate Markov model to estimate bidirectional transition rates. Covariate effects (age, gender, ART initiation period, and health facility level) on the transition rates were assessed.Results: We analyzed 204,289 clinic visits by 63,422 patients. There were 24,325 (38.4%) patients in state 4 (CD4 < 200) at ART initiation, and 7,995 (12.6%) deaths occurred by December 2017. The overall mortality rate was 3.9 per 100 person-years. The highest mortality rate of 5.7 per 100 person-years (4,541 deaths) was from state 4 (CD4 < 200) compared to other states. Mortality rates decreased with increase in time since ART initiation. Health facility type was the strongest predictor for immune recovery. Provincial or central hospital patients showed a diminishing dose–response effect on immune recovery by state from a hazard ratio (HR) of 8.30 [95% confidence interval (95% CI), 6.64–10.36] (state 4 to 3) to HR of 3.12 (95% CI, 2.54–4.36) (state 2 to 1) compared to primary healthcare facilities. Immune system for male patients was more likely to deteriorate, and they had a 32% increased mortality risk (HR, 1.32; 95% CI, 1.23–1.42) compared to female patients. Elderly patients (45+ years) were more likely to immune deteriorate compared to 25–34 years age group: HR, 1.35; 95% CI, 1.18–1.54; HR, 1.56; 95% CI, 1.34–1.81 and HR, 1.53; 95% CI, 1.32–1.79 for states 1 to 2, state 2 to 3, and states 3 to 4, respectively.Conclusion: Immune recovery was pronounced among provincial or central hospitals. Male patients with lower CD4 cell counts were at a higher risk of immune deterioration and mortality, while elderly patients were more likely to immune deteriorate. Early therapeutic interventions when the immune system is relatively stable across gender and age may contain mortality and increase survival outcomes. Interventions which strengthen ART services in primary healthcare facilities are essential.