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Abstract Background Although Zambia has integrated HIV-self-testing (HIVST) into its Human Immunodeficiency Virus (HIV) regulatory frameworks, few best practices to optimize the use of HIV self-testing to increase testing coverage have been documented. We conducted a prospective case study to understand contextual factors guiding implementation of four HIVST distribution models to inform scale-up in Zambia. Methods We used the qualitative case study method to explore user and provider experiences with four HIVST distribution models (two secondary distribution models in Antenatal Care (ANC) and Antiretroviral Therapy (ART) clinics, community-led, and workplace) to understand factors influencing HIVST distribution. Participants were purposefully selected based on their participation in HIVST and on their ability to provide rich contextual experience of the distribution models. Data were collected using observations (n = 31), group discussions (n = 10), and in-depth interviews (n = 77). Data were analyzed using the thematic approach and aligned to the four Consolidated Framework for Implementation Research (CFIR) domains. Results Implementation of the four distribution models was influenced by an interplay of outer and inner setting factors. Inadequate compensation and incentives for distributors may have contributed to distributor attrition in the community-led and workplace HIVST models. Stockouts, experienced at the start of implementation in the secondary-distribution and community-led distribution models often disrupted distribution. The existence of policy and practices aided integration of HIVST in the workplace. External factors complimented internal factors for successful implementation. For instance, despite distributor attrition leading to excessive workload, distributors often multi-tasked to keep up with demand for kits, even though distribution points were geographically widespread in the workplace, and to a less extent in the community-led models. Use of existing communication platforms such as lunchtime and safety meetings to promote and distribute kits, peers to support distributors, reduction in trips by distributors to replenish stocks, increase in monetary incentives and reorganisation of stakeholder roles proved to be good adaptations. Conclusion HIVST distribution was influenced by a combination of contextual factors in variable ways. Understanding how the factors interacted in real world settings informed adaptations to implementation devised to minimize disruptions to distribution.

Abstract Background In Malawi, female sex workers (FSW) have high HIV incidence and regular testing is suggested. HIV self-testing (HIVST) is a safe and acceptable alternative to standard testing services. This study assessed; whether social harms were more likely to be reported after HIVST distribution to FSW by peer distributors than after facility-based HIV testing and whether FSW regretted HIVST use or experienced associated relationship problems. Methods Peer HIVST distributors, who were FSW, were recruited in Blantyre district, Malawi between February and July 2017. Among HIVST recipients a prospective cohort was recruited. Interviews were conducted at baseline and at end-line, 3 months later. Participants completed daily sexual activity diaries. End-line data were analysed using logistic regression to assess whether regret or relationship problems were associated with HIVST use. Sexual activity data were analysed using Generalised Estimating Equations to assess whether HIVST use was temporally associated with an increase in social harms. Results Of 265 FSW recruited and offered HIVST, 131 completed both interviews. Of these, 31/131(23.7%) reported initial regret after HIVST use, this reduced to 23/131(17.6%) at the 3-month follow-up. Relationship problems were reported by 12/131(9.2%). Regret about HIVST use was less commonly reported in those aged 26–35 years compared to those aged 16–25 years (OR immediate regret—0.40 95% CI 0.16–1.01) (OR current regret—0.22 95% CI 0.07 – 0.71) and was not associated with the HIVST result. There was limited evidence that reports of verbal abuse perpetrated by clients in the week following HIVST use were greater than when there was no testing in the preceding week. There was no evidence for increases in any other social harms. There was some evidence of coercion to test, most commonly initiated by the peer distributor. Conclusions Little evidence was found that the peer distribution model was associated with increased levels of social harms, however programmes aimed at reaching FSW need to carefully consider possible unintended consequences of their service delivery approaches, including the potential for peer distributors to coerce individuals to test or disclose their test results and alternative distribution models may need to be considered.

Abstract Introduction Fishing populations constitute a suitable key population amongst which to conduct HIV prevention trials due to very high HIV prevalence and incidence, however, these are highly mobile populations. We determined the feasibility and acceptability of using fingerprinting and geographical positioning systems to describe mobility patterns and retention among fisherfolks on the shoreline of Lake Victoria in South-western Uganda. Methods Between August 2015 and January 2017, two serial cross-sectional surveys were conducted during which fingerprinting of all residents aged 18–30 years on the shoreline of Lake Victoria was done. A mapper moving ahead of the survey team, produced village maps and took coordinates of every household. These were accessed by the survey team that assigned household and individual unique identifiers (ID) and collected demographic data. Using the assigned IDs, individuals were enrolled and their fingerprints scanned. The fingerprinting was repeated 6 months later in order to determine the participant’s current household. If it was different from that at baseline, a new household ID was assigned which was used to map migrations both within and between villages. Results At both rounds, over 99% accepted to be fingerprinted. No fingerprinting faults were recorded at baseline and the level was under 1% at round two. Over 80% of the participants were seen at round two and of these, 16.3%, had moved to a new location whilst the majority, 85%, stayed within the same village. Movements between villages were mainly observed for those resident in large villages. Those who did not consider a fishing village to be their permanent home were less likely to be migrants than permanent residents (adjusted odds ratio = 0.37, 95%CI:0.15–0.94). Conclusion Use of fingerprinting in fishing populations is feasible and acceptable. It is possible to track this mobile population for clinical trials or health services using this technology since most movements could be traced within and between villages.

Background Early infant diagnosis (EID) for HIV-exposed infants is essential due to high mortality during the first months of their lives. In Conakry (Guinea), timely EID is difficult as traffic congestion prevents the rapid transport of blood samples to the central laboratory. We investigated the cost-effectiveness of transporting EID blood samples by unmanned aerial vehicles (UAV), also known as drones.Methods and findings Using Monte Carlo simulations, we conducted a cost-effectiveness comparative analysis between EID blood samples transportation by on-demand UAV transportation versus the baseline scenario (ie, van with irregular collection schedules) and compared with a hypothetic on-demand motorcycle transportation system. Incremental cost-effectiveness ratio (ICER) per life-year gained was computed. Simulation models included parameters such as consultation timing (eg, time of arrival), motorcycle and UAV characteristics, weather and traffic conditions. Over the 5-year period programme, the UAV and motorcycle strategies were able to save a cumulative additional 834.8 life-years (585.1–1084.5) and 794.7 life-years (550.3–1039.0), respectively, compared with the baseline scenario. The ICER per life-year gained found were US$535 for the UAV strategy versus baseline scenario, US$504 for the motorcycle strategy versus baseline scenario and US$1137 per additional life-year gained for the UAV versus motorcycle strategy. Respectively, those ICERs represented 44.8%, 42.2% and 95.2% of the national gross domestic product (GDP) per capita in Guinea—that is, US$1194.Conclusion Compared with the baseline strategy, both transportation of EID blood samples by UAVs or motorcycles had a cost per additional life-year gained below half of the national GDP per capita and could be seen as cost-effective in Conakry. A UAV strategy can save more lives than a motorcycle one although the cost needed per additional life-year gained might need to consider alongside budget impact and feasibility considerations.

Abstract Background Accurate birthweight is critical to inform clinical care at the individual level and tracking progress towards national/global targets at the population level. Low birthweight (LBW) 98% for four hospitals) and legible > 99.9%. Weighing of stillbirths varied by hospital, ranging from 12.5–89.0%. Observed LBW rate was 15.6%; survey-reported rate 14.3% (8.9–20.9%), sensitivity 82.9% (75.1–89.4%), specificity 96.1% (93.5–98.5%); register-recorded rate 14.9%, sensitivity 90.8% (85.9–94.8%), specificity 98.5% (98–99.0%). In surveys, “don’t know” responses for birthweight measured were 4.7%, and 2.9% for knowing the actual weight. 95.9% of observed babies were weighed within 1 h of birth, only 14.7% with a digital scale. Weight heaping indices were around two-fold lower using digital scales compared to analogue. Observed heaping was almost 5% higher for births during the night than day. Survey-report further increased observed birthweight heaping, especially for LBW babies. Enablers to register birthweight measurement in qualitative interviews included digital scale availability and adequate staffing. Conclusions Hospital registers captured birthweight and LBW prevalence more accurately than women’s survey report. Even in large hospitals, digital scales were not always available and stillborn babies not always weighed. Birthweight data are being captured in hospitals and investment is required to further improve data quality, researching of data flow in routine systems and use of data at every level.

Abstract Background About 13 years since the introduction of antiretroviral therapy (ART) for children living with HIV (CLHIV) in Zambia, HIV/AIDS testing and treatment guidelines for children have evolved over the years with limited documentation of long-term trends in the numbers testing HIV positive and initiating ART. We examined trends in HIV testing and ART initiation in Zambia. Methods We conducted a retrospective cohort study using routinely collected patient level data from 496 health facilities across Zambia. We used Poisson regression to derive incident rate ratios and 95% confidence intervals (95% CI) for background characteristics and used a Cuzick non-parametric test for trends to test the 13-year trends. Median time from testing to ART initiation in days and incidence rates were derived using life tables in survival analysis. We used multi-level random effects Poisson regression model to determine variations in time from HIV testing to ART initiation by facility. Results Overall, the cumulative proportion of the children who tested positive and initiated antiretroviral therapy (ART for HIV) from 2004 to 2017 was 69% (n = 99 592). During the period under review proportions of ART initiation increased from 52% in 2004–2006 to 97% in 2016–2017 (P

Summary: Background: Brazil is one of the countries worst affected by the COVID-19 pandemic with over 20 million cases and 557,000 deaths reported by August 2021. Comparison of real-time local COVID-19 data between areas is essential for understanding transmission, measuring the effects of interventions, and predicting the course of the epidemic, but are often challenging due to different population sizes and structures. Methods: We describe the development of a new app for the real-time visualisation of COVID-19 data in Brazil at the municipality level. In the CLIC-Brazil app, daily updates of case and death data are downloaded, age standardised and used to estimate the effective reproduction number (Rt). We show how such platforms can perform real-time regression analyses to identify factors associated with the rate of initial spread and early reproduction number. We also use survival methods to predict the likelihood of occurrence of a new peak of COVID-19 incidence. Findings: After an initial introduction in São Paulo and Rio de Janeiro states in early March 2020, the epidemic spread to northern states and then to highly populated coastal regions and the Central-West. Municipalities with higher metrics of social development experienced earlier arrival of COVID-19 (decrease of 11·1 days [95% CI:8.9,13.2] in the time to arrival for each 10% increase in the social development index). Differences in the initial epidemic intensity (mean Rt) were largely driven by geographic location and the date of local onset. Interpretation: This study demonstrates that platforms that monitor, standardise and analyse the epidemiological data at a local level can give useful real-time insights into outbreak dynamics that can be used to better adapt responses to the current and future pandemics. Funding: This project was supported by a Medical Research Council UK (MRC-UK) -São Paulo Research Foundation (FAPESP) CADDE partnership award (MR/S0195/1 and FAPESP 18/14389-0)

Background: Research conducted before the introduction of anti-retroviral therapy (ART), showed that the majority of children living with HIV (CLHIV) would die before their second birthday. In Zambia, ART was rolled out to the public health system in 2004 with subsequent improved survival in CLHIV. However, the survival rates of CLHIV on ART in Zambia since 2004 have not been extensively documented. We assessed survival experiences and the factors associated with survival in CLHIV on ART in Zambia.Methods: We conducted a retrospective cohort analysis of CLHIV (aged up to 15 years) using routinely collected data from health facilities across Zambia, over 13 years to ascertain mortality rates. We explored survival factors using Cox regression giving adjusted hazard ratios (AHR) and 95% confidence intervals (95% CI). Nelson Aalen estimates were used to show the cumulative hazards of mortality for different levels of explanatory factors.Results: A total of 65,448 eligible children, were initiated on ART between 2005 and 2018, of which 33,483 (51%) where female. They contributed a total survival time of 275,715-person years at risk during which 3,265 children died which translated into an incidence rate of 1.1 deaths per 100 person-years during the review period. Mortality rates were highest in children in the first year of life (Mortality rate 2.24; 95% CI = 2.08–2.42) and during the first year on ART (Mortality rate 3.82 95% CI = 3.67–3.98). Over 50% of the children had been on ART for 5–10 years by 2018, and they had the lowest risk of mortality compared to children who had been on ART for

Abstract Background Mother to child transmission of HIV (MTCT) still remains a challenge affecting many countries. Globally, an estimated 150,000 children were newly infected with HIV in 2015, over 90% of them in Sub-Saharan Africa through MTCT. In Zambia approximately 500,000 babies are born and 40,000 acquire the infection vertically if there is no intervention annually. This study estimated the HIV testing coverage and associated factors among Zambian women of reproductive age 15–49 years. Methods A cross-sectional study based on data extracted from the Zambia Demographics and Health Survey [Zambia Demographic and Health Survey. Central Statistical Office (CSO), Ministry of Health (MOH), Tropical Diseases Research Centre (TDRC), University of Zambia, and Macro International Inc. 2009. 2014]. Women aged 15–49 years, 15,388 who reported having ever tested for HIV or not comprised the de facto eligible sample. Extracted data comprised women’s demographic characteristics; their full birth history and records of antenatal care for the most recent birth within a 5 year period preceding the survey. A weighted multiple logistic regression model was done to determine factors associated with the odds of HIV testing coverage among women of reproductive age. Results Out of 15,388 women in the study, 12,413 (81%) reported ever tested for HIV. Of the 6461 women who attended antenatal care (ANC) 6139 (95%) reported ever tested for HIV. Additionally, 6139 (95%) out of 6461 of the women were given information on PMTCT during ANC sessions. Testing coverage was higher among women aged 20–24 years compared to women aged 15–19 years [AOR 2.1, 95% CI 1.14–3.84; p = 0.017]. Women with higher socio-economic status had 6.6 times the odds of having ever tested compared to women with lower status [AOR 6.6, 95% CI 3.04–14.14; p

Abstract Background Understanding the implementation of 2013 World Health Organization (WHO) consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection at the facility level provides important lessons for the roll-out of future HIV policies. Methods A national policy review was conducted in six sub-Saharan African countries to map the inclusion of the 2013 WHO HIV treatment recommendations. Twenty indicators of policy adoption were selected to measure ART access (n = 12) and retention (n = 8). Two sequential cross-sectional surveys were conducted in facilities between 2013/2015 (round 1) and 2015/2016 (round 2) from ten health and demographic surveillance sites in Kenya, Malawi, South Africa, Tanzania, Uganda and Zimbabwe. Using standardised questionnaires, facility managers were interviewed. Descriptive analyses were used to assess the change in the proportion of facilities that implemented these policy indicators between rounds. Results Although, expansion of ART access was explicitly stated in all countries’ policies, most lacked policies that enhanced retention. Overall, 145 facilities were included in both rounds. The proportion of facilities that initiated ART at CD4 counts of 500 or less cells/μL increased between round 1 and 2 from 12 to 68%, and facilities initiating patients on 2013 WHO recommended ART regimen increased from 42 to 87%. There were no changes in the proportion of facilities reporting stock-outs of first-line ART in the past year (18 to 11%) nor in the provision of three-month supply of ART (43 to 38%). None of the facilities provided community-based ART delivery. Conclusion The increase in ART initiation CD4 threshold in most countries, and substantial improvements made in the provision of WHO recommended first-line ART regimens demonstrates that rapid adoption of WHO recommendations is possible. However, improved logistics and resources and/or changes in policy are required to further minimise ART stock-outs and allow lay cadres to dispense ART in the community. Increased efforts are needed to offer longer durations between clinic visits, a strategy purported to improve retention. These changes will be important as countries move to implement the revised 2015 WHO guidelines to initiate all HIV positive people onto ART regardless of their immune status.

Abstract Background The extent to which routinely collected HIV data from Zambia has been used in peer-reviewed published articles remains unexplored. This paper is an analysis of peer-reviewed articles that utilised routinely collected HIV data from Zambia within six programme areas from 2004 to 2014. Methods Articles on HIV, published in English, listed in the Directory of open access journals, African Journals Online, Google scholar, and PubMed were reviewed. Only articles from peer-reviewed journals, that utilised routinely collected data and included quantitative data analysis methods were included. Multi-country studies involving Zambia and another country, where the specific results for Zambia were not reported, as well as clinical trials and intervention studies that did not take place under routine care conditions were excluded, although community trials which referred patients to the routine clinics were included. Independent extraction was conducted using a predesigned data collection form. Pooled analysis was not possible due to diversity in topics reviewed. Results A total of 69 articles were extracted for review. Of these, 7 were excluded. From the 62 articles reviewed, 39 focused on HIV treatment and retention in care, 15 addressed prevention of mother-to-child transmission, 4 assessed social behavioural change, and 4 reported on voluntary counselling and testing. In our search, no articles were found on condom programming or voluntary male medical circumcision. The most common outcome measures reported were CD4+ count, clinical failure or mortality. The population analysed was children in 13 articles, women in 16 articles, and both adult men and women in 33 articles. Conclusion During the 10 year period of review, only 62 articles were published analysing routinely collected HIV data in Zambia. Serious consideration needs to be made to maximise the utility of routinely collected data, and to benefit from the funds and efforts to collect these data. This could be achieved with government support of operational research and publication of findings based on routinely collected Zambian HIV data.

Background: Mother to child transmission of HIV (MTCT) is a global challenge affecting many countries especially in sub-Saharan Africa. In 2009 about 370,000 infants were infected with HIV mainly through MTCT and most of them in sub-Saharan Africa. We aimed to determine the effectiveness of Option B+ compared to other options in reducing rates of early MTCT of HIV infections in Zambia.Methods: This was a retrospective cohort study based on routinely collected data using SmartCare in Zambia. Survival analysis with Cox Proportional Hazard regression was used to determine association between MTCT and regimen type of mothers. Kaplan-Meier (K-M) curves were used to compare MTCT for infants born to mothers option B+ to those on other options, and Wilcoxon (Breslow) test was used to establish statistical significance.Results: Overall (n = 1,444), mother-baby pairs with complete data were included in the analysis, with the median age of mothers being 33 (28–38) years; and 57% of these women were on Option B+. MTCT rate was estimated at 5% (73/1,444) [P = 0.025]. A Kaplan-Meier estimate showed that HIV Exposed Infants (HEI) of mothers on Option B+ had lower MTCT rate than those who were on other MTCT prevention interventions [Wilcoxon test; chi2 = 4.97; P = 0.025]. Furthermore, The Nelson Aalen cumulative hazard estimates indicated similar evidence of option B+ being more effective than other options with some statistical significance [HR = 0.63, P = 0.068]. HEI of option B+ mothers had 50% reduced risk of having HIV infection compared to option A/B [adjusted HR = 0.4; 95% CI = 0.28–0.84; P = 0.010]. HEI to women who were married had an increased risk 50% of getting infected compared to those not married [adjusted HR = 1.5; 95% CI = 3.43–6.30; P < 0.001]. Exposed infants whose mothers had assisted delivery had 3 times increased risk of getting infected compared to those born through normal vaginal delivery [Adjusted HR = 3.2; 95% CI = 0.98–10.21; P = 0.050].Conclusions: The use of Option B+ as PMTCT intervention was found to be more effective in reducing MTCT of HIV compared to other options. Scaling up access to life-long ART and improving retention for women on treatment can potentially reduce further vertical transmission.

Introduction A cluster randomised controlled trial (cRCT) to determine whether HIV self-testing (HIVST) delivered by peers either directly or through incentivised peer-networks, could increase the uptake of antiretroviral therapy and pre-exposure prophylaxis (PrEP) among young women (18 to 24 years) is being undertaken in an HIV hyperendemic area in KwaZulu-Natal, South Africa.Methods and analysis A three-arm cRCT started mid-March 2019, in 24 areas in rural KwaZulu-Natal. Twenty-four pairs of peer navigators working with ~12 000 young people aged 18 to 30 years over a period of 6 months were randomised to: (1) incentivised-peer-networks: peer-navigators recruited participants ‘seeds’ to distribute up to five HIVST packs and HIV prevention information to peers within their social networks. Seeds receive an incentive (20 Rand = US$1.5) for each respondent who contacts a peer-navigator for additional HIVST packs to distribute; (2) peer-navigator-distribution: peer-navigators distribute HIVST packs and information directly to young people; (3) standard of care: peer-navigators distribute referral slips and information. All arms promote sexual health information and provide barcoded clinic referral slips to facilitate linkage to HIV testing, prevention and care services. The primary outcome is the difference in linkage rate between arms, defined as the number of women (18 to 24 years) per peer-navigators month of outreach work (/pnm) who linked to clinic-based PrEP eligibility screening or started antiretroviral, based on HIV-status, within 90 days of receiving the clinic referral slip.Ethics and dissemination This study was approved by the Institutional Review Boards at the WHO, Switzerland (Protocol ID: STAR CRT, South Africa), London School of Hygiene and Tropical Medicine, UK (Reference: 15 990–1), University of KwaZulu-Natal (BFC311/18) and the KwaZulu-Natal Department of Health (Reference: KZ_201901_012), South Africa. The findings of this trial will be disseminated at local, regional and international meetings and through peer-reviewed publications.Trial registration number NCT03751826; Pre-results.

Objective This study aimed to investigate the challenges in implementing a Zambian electronic health records (EHR) system labelled ‘SmartCare’ from diverse stakeholder perspectives in order to improve prevention of mother-to-child transmission (PMTCT) data collection so that SmartCare can be used for clinic performance strengthening and programme monitoring.Design This is a qualitative retrospective study.Setting and participants SmartCare is a Zambian Ministry of Health (MoH)-led project funded by the US Centre for Disease Control and Prevention. Data were collected using in-depth interviews, observations and focus group discussions (FGDs) between September and November 2016. Seventeen in-depth interviews were held with a range of key informants from the MoH and local and international organisations implementing SmartCare. Four data entry observations and three FGDs with 22 pregnant and lactating women seeking PMTCT services were conducted. Data were analysed using a thematic content approach.Results The SmartCare system has evolved from various patient tracking systems into a multifunctional system. There is a burden of information required so that sometimes not all is collected and entered into the database, resulting in poor data quality. Funding challenges impede data collection due to manpower constraints and shortages of supplies. Challenges associated with data collection depend on whether a paper-based or computer-based system is used. There is no uniformity in the data quality verification and submission strategies employed by various IPs. There is little feedback from the EHR system at health facility level, which has led to disengagement as stakeholders do not see the importance of the system.Conclusion SmartCare has structural challenges which can be traced from its development. Funding gaps have resulted in staffing and data collection disparities within IPs. The lack of feedback from the system has also led to complacency at the operational level, which has resulted in poor data quality in later years.

Introduction: Accurate estimates of coverage of prevention of mother-to-child (PMTCT) services among HIV-infected pregnant women are vital for monitoring progress toward HIV elimination targets. The achievement of high coverage and uptake of services along the PMTCT cascade is crucial for national and international mother-to child transmission (MTCT) elimination goals. In eastern and southern Africa, MTCT rate fell from 18% of infants born to mothers living with HIV in 2010 to 6% in 2015. This paper describes the degree to which World Health Organization (WHO) guidelines for PMTCT services were implemented in Zambia between 2010 and 2015.Method: The study used routinely collected data from all pregnant women attending antenatal clinics (ANC) in SmartCare health facilities from January 2010 to December 2015. Categorical variables were summarized using proportions while continuous variables were summarized using medians and interquartile ranges.Results: There were 104,155 pregnant women who attended ANC services in SmartCare facilities during the study period. Of these, 9% tested HIV-positive during ANC visits whilst 43% had missing HIV test result records. Almost half (47%) of pregnant women who tested HIV-positive in their ANC visit were recorded in 2010. Among HIV-positive women, there was an increase in those already on ART at first ANC visit from 9% in 2011 to 74% in 2015. The overall mean time lag between starting ANC care and ART initiation was 7 months, over the 6 year period, but there were notable variations between provinces and years.Conclusion: The implementation of the WHO post 2010 PMTCT guidelines has resulted in an increase in the proportion of HIV-infected pregnant women attending ANC who are already on ART. However, the variability in HIV infection rates, missing data, and time to initiation of ART suggests there are some underlying health service or database issues which require attention.

Background: The WHO recommendation for lifelong antiretroviral therapy (ART) for all pregnant and lactating women (Option B+) has been adopted by nearly all countries with the highest HIV burdens. In January, 2013, Zambia announced that it would revise its guidelines on prevention of mother-to-child transmission (PMTCT) and adopt Option B+. Accurate estimates of coverage of PMTCT services in pregnant women with HIV are vital for monitoring progress towards HIV elimination targets. We aimed to show trends in the coverage of PMTCT services in Zambia from 2010 to 2015. We describe the proportion of women attending antenatal care who are HIV positive, the proportion of HIV-positive pregnant women who started ART, the proportion of HIV-infected women already on ART, and time to treatment initiation. Methods: This was a retrospective cohort study using routinely collected data from SmartCare, an electronic health record system. We included data from all pregnant women who attended antenatal care in the 889 health facilities using the SmartCare database in Zambia. Findings: We included data for 104 155 pregnant women who attended antenatal services in SmartCare facilities between Jan 1, 2010, and Dec 31, 2015. Of these women, 9% (9262) tested HIV-positive during antenatal visits and 43% (44 387) had missing HIV test results. Almost half (47%, [4375]) the pregnant women who tested HIV-positive in their antenatal visit were recorded in 2010. Among HIV-positive women, there was an increase in those already on ART at first antenatal visit from 9% (40) in 2011 to 74% (1 155) in 2015. In our study, 65% (983/1501) of the women who started ART after testing HIV-positive during antenatal care were documented after the adoption of Option B+ (2013–15). Mean time lag between starting antenatal care and ART initiation was 7 months over the 6 year study period, but there were notable variations between provinces and years. Interpretation: The implementation of WHO PMTCT guidelines introduced after 2010 in Zambia has resulted in an increase in the proportion of HIV-infected pregnant women attending antenatal care who are already on ART. The SmartCare database could enable Zambian health policy makers to act on urgent PMTCT interventions and improve health-care quality and outcomes for mothers and their infants. However, there is a need first to improve procedures for data collection and entry. The number of missing data observations indicate the need for further qualitative research on why so many records were missing from the database. Funding: SEARCH (Sustainable Evaluation through Analysis of Routinely Collected HIV data) and the Bill & Melinda Gates Foundation (grant number OPP1084472).

Background: Globally, an estimated 150,000 children were newly infected with HIV in 2015, over 90% of them in Sub-Saharan Africa. In Zambia, ~500,000 babies are born to HIV positive mothers every year, and without intervention 40,000 of them would acquire the infection. Studies have shown a strong association between education and HIV prevalence, but in Zambia, this association has not been demonstrated. There is little published information on the association between educational attainment and HIV testing uptake among pregnant women, which is fundamental in understanding the mother to child transmission of HIV. This study investigated whether educational attainment was associated with uptake of HIV testing among women of reproductive age in Zambia.Methods: Data were taken from Zambia Demographic and Health Survey in 2014 (ZDHS14). The analysis consisted of all women aged 15–49 years, who responded to the question on HIV testing in the ZDHS. Multivariable logistic regression was used to determine whether educational attainment was associated with uptake of HIV testing among women of reproductive age in Zambia.Results: Educational attainment was strongly associated with HIV testing among 15,388 women of child bearing age [AOR 3.8, 95% CI 1.7–8.2; p = 0.001]. HIV testing differed greatly by socioeconomic social status with an increased uptake among women with higher wealth index [AOR 4.4, 95% CI 1.9–9.9; p = 0.001]. Additionally, HIV testing was observed to be higher among the older women 25–34 years compared to the young women 15–19 years [AOR 2.3, 95% CI 1.3–4.3; p = 0.007].Conclusions: This study revealed educational attainment to be a strong predictor of HIV testing among women of child bearing age in this population. High HIV testing uptake among educated pregnant women indicated that low-educated women may not fully realize the benefits of testing for HIV. Therefore, strengthening HIV testing in rural health facilities and providing initiatives to overcome barriers to testing among women with no formal education may help reduce vertical transmission of HIV.

INTRODUCTION:Interventions to keep adolescent girls and young women in school, or support their return to school, are hypothesised to also reduce HIV risk. Such interventions are included in the DREAMS combination package of evidence-based interventions. Although there is evidence of reduced risky sexual behaviours, the impact on HIV incidence is unclear. We used nationally representative surveys to investigate the association between being in school and HIV prevalence. METHODS:We analysed Demographic and Health Survey data from nine DREAMS countries in sub-Saharan Africa restricted to young women aged 15-19 (n = 20,429 in total). We used logistic regression to assess cross-sectional associations between being in school and HIV status and present odds ratios adjusted for age, socio-economic status, residence, marital status, educational attainment and birth history (aOR). We investigated whether associations seen differed across countries and by age. RESULTS:HIV prevalence (1.0%-9.8%), being currently in school (50.0%-72.6%) and the strength of association between the two, varied between countries. We found strong evidence that being currently in school was associated with a reduced odds of being HIV positive in Lesotho (aOR: 0.37; 95%CI: 0.17-0.79), Swaziland (aOR: 0.32; 95%CI: 0.17-0.59), and Uganda (aOR: 0.48: 95%CI: 0.29-0.80) and no statistically significant evidence for this in Kenya, Malawi, Mozambique, Tanzania, Zambia or Zimbabwe. CONCLUSIONS:Although the relationship is not uniform across countries or over time, these data are supportive of the hypothesis that young women in school are at lower risk of being HIV positive than those who leave school in some sub-Saharan African settings. There is a possibility of reverse causality, with pre-existing HIV infection leading to school drop-out. Further investigation of the contextual factors behind this variation will be important in interpreting the results of HIV prevention interventions promoting retention in school.

Introduction. Health and demographic surveillance systems (HDSS) have been an invaluable resource for monitoring the health status of populations, but often contain self-reported health service utilisation, which are subject to reporting bias. Objectives. To implement point-of-contact interactive record linkage (PIRL) between demographic and health facility systems data, characterise attributes associated with (un)successful record linkage, and compare findings with a fully automated retrospective linkage approach. Methods. Individuals visiting the Kisesa Health Centre were matched to their HDSS records during a short uptake interview in the waiting area of the health facility. The search algorithm was used to rank potential matches, from which the true match(es) were selected after consultation with the patient. Multivariable logistic regression models were used to identify characteristics associated with being matched to an HDSS record. Records matched based on respondent’s clarifications were subsequently used as the gold-standard to evaluate fully automated retrospective record linkage by calculating sensitivity and positive predictive value (PPV). Results. Among 2,624 individuals who reportedly lived in the HDSS coverage area, we matched 2,206 (84.1%) to their HDSS records. Characteristics associated with a higher odds of being matched were increased age (OR 1.07, 95% CI 1.02, 1.12; per 5-year increment), a later consent into the study (OR 2.07, 95% CI 1.37, 3.12; in the most recent six-month period), and fieldworker level of experience. The main drivers of the linkage algorithm were name, sex, year of birth, village, sub-village, and household member name. At the lowest match score threshold, automated retrospective linkage would have only correctly identified and linked 55% (1440/2612) of the records with a PPV of 55% (1440/2612). Conclusion. Where resources are available, PIRL is a viable approach to link HDSS and other administrative data sources that outperforms purely retrospective approaches.

Background: Antiretroviral treatment (ART) has significantly reduced HIV mortality in South Africa. The benefits have not been experienced by all groups. Here we investigate the factors associated with these inequities. Design: This study was located in a rural South African setting and used data collected from 2007 to 2010, the period when decentralised ART became available. Approximately one-third of the population were of Mozambican origin. There was a pattern of repeated circular migration between urban areas and this community. Survival analysis models were developed to identify demographic, socioeconomic, and spatial risk factors for HIV mortality. Results: Among the study population of 105,149 individuals, there were 2,890 deaths. The HIV/TB mortality rate decreased by 27% between 2007–2008 and 2009–2010. For other causes of death, the reduction was 10%. Bivariate analysis found that the HIV/TB mortality risk was lower for: those living within 5 km of the Bhubezi Community Health Centre; women; young adults; in-migrants with a longer period of residence; permanent residents; and members of households owning motorised transport, holding higher socioeconomic positions, and with higher levels of education. Multivariate modelling showed, in addition, that those with South Africa as their country of origin had an increased risk of HIV/TB mortality compared to those with Mozambican origins. For males, those of South African origin, and recent in-migrants, the risk of death associated with HIV/TB was significantly greater than that due to other causes. Conclusions: In this community, a combination of factors was associated with an increased risk of dying of HIV/TB over the period of the roll-out of ART. There is evidence for the presence of barriers to successful treatment for particular sub-groups in the population, which must be addressed if the recent improvements in population-level mortality are to be maintained.

Background: Malaria continues to be a major cause of infectious disease mortality in tropical regions. However, deaths from malaria are most often not individually documented, and as a result overall understanding of malaria epidemiology is inadequate. INDEPTH Network members maintain population surveillance in Health and Demographic Surveillance System sites across Africa and Asia, in which individual deaths are followed up with verbal autopsies. Objective: To present patterns of malaria mortality determined by verbal autopsy from INDEPTH sites across Africa and Asia, comparing these findings with other relevant information on malaria in the same regions. Design: From a database covering 111,910 deaths over 12,204,043 person-years in 22 sites, in which verbal autopsy data were handled according to the WHO 2012 standard and processed using the InterVA-4 model, over 6,000 deaths were attributed to malaria. The overall period covered was 1992–2012, but two-thirds of the observations related to 2006–2012. These deaths were analysed by site, time period, age group and sex to investigate epidemiological differences in malaria mortality. Results: Rates of malaria mortality varied by 1:10,000 across the sites, with generally low rates in Asia (one site recording no malaria deaths over 0.5 million person-years) and some of the highest rates in West Africa (Nouna, Burkina Faso: 2.47 per 1,000 person-years). Childhood malaria mortality rates were strongly correlated with Malaria Atlas Project estimates of Plasmodium falciparum parasite rates for the same locations. Adult malaria mortality rates, while lower than corresponding childhood rates, were strongly correlated with childhood rates at the site level. Conclusions: The wide variations observed in malaria mortality, which were nevertheless consistent with various other estimates, suggest that population-based registration of deaths using verbal autopsy is a useful approach to understanding the details of malaria epidemiology.

Background: The MRC/Wits University Agincourt research centre, part of the INDEPTH Network, has documented mortality in a defined population in the rural northeast of South Africa for 20 years (1992–2011) using long-term health and socio-demographic surveillance. Detail on the unfolding, at times unpredicted, mortality pattern has been published. This experience is reviewed here and updated using more recent data. Objective: To present a review and summary of mortality patterns across all age-sex groups in the Agincourt sub-district population for the period 1992–2011 as a comprehensive basis for public health action. Design: Vital events in the Agincourt population have been updated in annual surveys undertaken since 1992. All deaths have been rigorously recorded and followed by verbal autopsy interviews. Responses to questions from these interviews have been processed retrospectively using the WHO 2012 verbal autopsy standard and the InterVA-4 model for assigning causes of death in a standardised manner. Results: Between 1992 and 2011, a total of 12,209 deaths were registered over 1,436,195 person-years of follow-up, giving a crude mortality rate of 8.5 per 1,000 person-years. During the 20-year period, the population experienced a major HIV epidemic, which resulted in more than doubling of overall mortality for an extended period. Recent years show signs of declining mortality, but levels remain above the 1992 baseline recorded using the surveillance system. Conclusions: The Agincourt population has experienced a major mortality shock over the past two decades from which it will take time to recover. The basic epidemic patterns are consistent with generalised mortality patterns observed in South Africa as a whole, but the detailed individual surveillance behind these analyses allows finer-grained analyses of specific causes, age-related risks, and trends over time. These demonstrate the complex, somewhat unpredicted course of mortality transition over the years since the dawn of South Africa's democratic era in 1994.

Background: As the HIV/AIDS pandemic has evolved over recent decades, Africa has been the most affected region, even though a large proportion of HIV/AIDS deaths have not been documented at the individual level. Systematic application of verbal autopsy (VA) methods in defined populations provides an opportunity to assess the mortality burden of the pandemic from individual data. Objective: To present standardised comparisons of HIV/AIDS-related mortality at sites across Africa and Asia, including closely related causes of death such as pulmonary tuberculosis (PTB) and pneumonia. Design: Deaths related to HIV/AIDS were extracted from individual demographic and VA data from 22 INDEPTH sites across Africa and Asia. VA data were standardised to WHO 2012 standard causes of death assigned using the InterVA-4 model. Between-site comparisons of mortality rates were standardised using the INDEPTH 2013 standard population. Results: The dataset covered a total of 10,773 deaths attributed to HIV/AIDS, observed over 12,204,043 person-years. HIV/AIDS-related mortality fractions and mortality rates varied widely across Africa and Asia, with highest burdens in eastern and southern Africa, and lowest burdens in Asia. There was evidence of rapidly declining rates at the sites with the heaviest burdens. HIV/AIDS mortality was also strongly related to PTB mortality. On a country basis, there were strong similarities between HIV/AIDS mortality rates at INDEPTH sites and those derived from modelled estimates. Conclusions: Measuring HIV/AIDS-related mortality continues to be a challenging issue, all the more so as anti-retroviral treatment programmes alleviate mortality risks. The congruence between these results and other estimates adds plausibility to both approaches. These data, covering some of the highest mortality observed during the pandemic, will be an important baseline for understanding the future decline of HIV/AIDS.

Reflecting on under-five mortality, Peter Byass and colleagues consider how some countries may fail to meet millennium development goal targets despite making considerable advances.

Background: Coverage of civil registration and vital statistics varies globally, with most deaths in Africa and Asia remaining either unregistered or registered without cause of death. One important constraint has been a lack of fit–for–purpose tools for registering deaths and assigning causes in situations where no doctor is involved. Verbal autopsy (interviewing care–givers and witnesses to deaths and interpreting their information into causes of death) is the only available solution. Automated interpretation of verbal autopsy data into cause of death information is essential for rapid, consistent and affordable processing. Methods: Verbal autopsy archives covering 54182 deaths from five African and Asian countries were sourced on the basis of their geographical, epidemiological and methodological diversity, with existing physician–coded causes of death attributed. These data were unified into the WHO 2012 verbal autopsy standard format, and processed using the InterVA–4 model. Cause–specific mortality fractions from InterVA–4 and physician codes were calculated for each of 60 WHO 2012 cause categories, by age group, sex and source. Results from the two approaches were assessed for concordance and ratios of fractions by cause category. As an alternative metric, the Wilcoxon matched–pairs signed ranks test with two one–sided tests for stochastic equivalence was used. Findings: The overall concordance correlation coefficient between InterVA–4 and physician codes was 0.83 (95% CI 0.75 to 0.91) and this increased to 0.97 (95% CI 0.96 to 0.99) when HIV/AIDS and pulmonary TB deaths were combined into a single category. Over half (53%) of the cause category ratios between InterVA–4 and physician codes by source were not significantly different from unity at the 99% level, increasing to 62% by age group. Wilcoxon tests for stochastic equivalence also demonstrated equivalence. Conclusions: These findings show strong concordance between InterVA–4 and physician–coded findings over this large and diverse data set. Although these analyses cannot prove that either approach constitutes absolute truth, there was high public health equivalence between the findings. Given the urgent need for adequate cause of death data from settings where deaths currently pass unregistered, and since the WHO 2012 verbal autopsy standard and InterVA–4 tools represent relatively simple, cheap and available methods for determining cause of death on a large scale, they should be used as current tools of choice to fill gaps in cause of death data.

Social protection programs issuing cash grants to caregivers of young children may influence fertility. Grant-related income could foster economic independence and/or increase access to job prospects, education, and health services, resulting in lower pregnancy rates. In the other direction, these programs may motivate family expansion in order to receive larger grants. Here, we estimate the net effect of these countervailing mechanisms among rural South African women.We constructed a retrospective cohort of 4845 women who first became eligible for the Child Support Grant with the birth of their first child between 1998 and 2008, with data originally collected by the Agincourt Health and Socio-Demographic Surveillance System in Mpumalanga province, South Africa. We fit Cox regression models to estimate the hazard of second pregnancy in women who reported grant receipt after birth of first child, relative to non-recipients. As a secondary analysis to explore the potential for grant loss to incentivize second pregnancy, we exploited a natural experiment created by a 2003 expansion of the program's age eligibility criterion from age seven to nine. We compared second pregnancy rates between (i) women with children age seven or eight in 2002 (recently aged out of grant eligibility) to (ii) women with children age seven or eight in 2003 (remained grant-eligible).The adjusted hazard ratio for the association between grant exposure and second pregnancy was 0.66 (95% CI: 0.58, 0.75). Women with first children who aged out of grant eligibility in 2002 had similar second pregnancy rates to women with first children who remained grant-eligible in 2003 [IRR (95% CI): 0.9 (0.5, 1.4)].Across both primary and secondary analyses, we found no evidence that the Child Support Grant incentivizes pregnancy. In harmony with South African population policy, receipt of the Child Support Grant may result in longer spacing between pregnancies.

In this study we analysed the spatial and temporal changes in patterns of mortality over a period when antiretroviral therapy (ART) was rolled out in a rural region of north–eastern South Africa. Previous studies have identified localised concentrated HIV related sub–epidemics and recommended that micro–level analyses be carried out in order to direct focused interventions.