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Sub-Saharan Africa has the highest burden of HIV globally, with 54% of the world’s people living with HIV (PLHIV) living in this region. By 2018 in East and Southern Africa there were 20.6 million ...

Little is known about how CD4 and viral load testing have evolved following implementation of universal test and treat (UTT) in African settings. We reviewed World Health Organization (WHO) guidance from 2013 to 2018, and compared it against national HIV policies in Malawi, Tanzania and South Africa. Three surveys rounds were conducted in 2013, 2016 and 2017-2018 in 33 health facilities across the three settings to assess implementation of national policies on the use of biological markers. Qualitative interviews were conducted with 26 HIV policymakers or programme managers, 21 providers and 66 people living with HIV to explore understandings and experiences of these tests. Various factors influenced adoption and implementation of WHO guidance, including historical policies on CD4 counts, governance issues, supply chain challenges and funding mechanisms. Facility-level practices relating to the use of these tests often diverged from national policies. Patients and providers valued both tests, but did not always understand their roles. In addition to continued support for scaling-up viral load testing, renewed focus should be placed on the ongoing value of point-of-care CD4 tests in the UTT era, including its role in assessing disease progression and informing clinical management of cases to reduce HIV-related mortality.

Universal antiretroviral therapy (ART) for pregnant and postpartum women in sub-Saharan Africa has required adaptations to service delivery. We compared national policies on differentiated HIV service delivery with facility-level implementation, and explored provider and user experiences in rural Malawi, Tanzania and South Africa. Four national policies and two World Health Organization guidelines on HIV treatment for pregnant and postpartum women published between 2013 and 2017 were reviewed and summarised. Results were compared with implementation data from surveys undertaken in 34 health facilities. Eighty-seven in-depth interviews were conducted with pregnant and post-partum women living with HIV, their partners and providers. In 2018, differentiated service policies varied across countries. None specifically accounted for pregnant or postpartum women. Malawian policies endorsed facility-based multi-month scripting for clinically-stable adult ART patients, excluding pregnant or breastfeeding women. In Tanzania and South Africa, national policies proposed community-based and facility-based approaches, for which pregnant women were not eligible. Interview data suggested some implementation of differentiated services for pregnant and postpartum women beyond stipulated policies in all settings. Although these adaptations were appreciated by pregnant and postpartum women, they could lead to frustrations among other users when criteria for fast-track services or multi-month prescriptions were not clear.

Few studies have explored the relationship between early infant diagnosis (EID) of HIV and mothers' engagement in care under Option B+. We conducted in-depth interviews with 20 women who initiated antiretroviral therapy (ART) under Option B+ in rural South Africa to explore the interactions between EID and maternal care engagement. Drawing on practice theory, we identified themes relating to Option B+ care engagement and EID. Women's practice of engagement with HIV care shaped their decision-making around EID. Mothers who disengaged from care during pregnancy were less inclined to utilise EID as they lacked information about its availability and benefits. For some mothers, tensions between wanting to breastfeed and perceptions that it could facilitate transmission led to repeated utilisation of EID as reassurance that the child remained negative. Some mothers used their child's negative result as a proxy for their status, subsequently disengaging from care. For some participants, an HIV diagnosis of their infant and the subsequent double burden of treatment visits for themselves and their infant, contributed to their disengagement. Women's care-seeking practices for themselves and their infants work in a symbiotic ecosystem and should be viewed interdependently to tailor interventions to improve EID uptake and Option B+ care engagement.

Effective implementation of policies for expanding antiretroviral therapy (ART) requires a well-trained and adequately staffed workforce. Changes in national HIV workforce policies, health facility practices, and provider experiences were examined in rural Malawi and Tanzania between 2013 and 2017. In both countries, task-shifting and task-sharing policies were explicit by 2013. In facilities, the cadre mix of providers varied by site and changed over time, with a higher and growing proportion of lower cadre staff in the Malawi site. In Malawi, the introduction of lay counsellors was perceived to have eased the workload of other providers, but lay counsellors reported inadequate support. Both countries had guidance on the minimum numbers of personnel required to deliver HIV services. However, patient loads per provider increased in both settings for HIV tests and visits by ART patients and were not met with corresponding increases in provider capacity in either setting. Providers reported this as a challenge. Although increasing patient numbers bodes well for achieving universal antiretroviral therapy coverage, the quality of care may be undermined by increased workloads and insufficient provider training. Task-shifting strategies may help address workload concerns, but require careful monitoring, supervision and mentoring to ensure effective implementation.

National HIV testing policies aim to increase the proportion of people living with HIV who know their status. National HIV testing policies were reviewed for each country from 2013 to 2018, and compared with WHO guidance. Three rounds of health facility surveys were conducted to assess facility level policy implementation in Karonga (Malawi), uMkhanyakude (South Africa), and Ifakara (Tanzania). A policy 'implementation' score was developed and applied to each facility by site for each round. Most HIV testing policies were explicit and aligned with WHO recommendations. Policies about service coverage, access, and quality of care were implemented in >80% of facilities per site and per round. However, linkage to care and the provision of outreach HIV testing for key populations were poorly implemented. The proportion of facilities reporting HIV test kit stock-outs in the past year reduced over the study period in all sites, but still occurred in ≥17% of facilities per site by 2017. The implementation score improved over time in Karonga and Ifakara and declined slightly in uMkhanyakude. Efforts are needed to address HIV test kit stock-outs and to improve linkage to care among people testing positive in order to reach the 90-90-90 targets.

Art-based research methods can enable young people to generate data that provide insights into their lives. We assessed the feasibility, value, and limitations of collages as a participatory research method to understand the experiences of young women living with HIV. Individual collages were created in participatory workshops, firstly in 2015 and secondly in 2017, by a cohort of young women living with HIV in Lusaka, Zambia. Collages were analyzed visually and thematically and compared to other qualitative methods. Participants engaged readily with making collages and expressed how the collages represented themselves. The collages conveyed aspirations, resilience, optimism, and identities beyond HIV. Other data generation methods focused more on challenges associated with HIV. The second collages demonstrated more complex portrayals of participants’ life and developmental transitions. Collages provided a feasible, effective, and therapeutic method of empowering young women living with HIV to tell their own stories and express their full selves.

Treat-all recommends prompt treatment initiation for those diagnosed HIV positive, requiring adaptations to individuals' behavior and practice. Drawing on data from a longitudinal qualitative study in Eswatini, we examine the choice to initiate treatment when asymptomatic, the dissonance between the biomedical logic surrounding Treat-all and individuals' conceptions of treatment necessity, and the navigation over time of ongoing engagement with care. We reflect on the perspectives of healthcare workers, responsible for implementing Treat-all and holding a duty of care for their patients. We explore how the potentially differing needs and priorities of individuals and the public health agenda are navigated and reconciled. Rationalities regarding treatment-taking extend beyond the biomedical realm, requiring adjustments to sense of self and identity, and decision-making that is situated and socially embedded. Sense of choice and ownership for this process is important for individuals' engagement with treatment and care.

Young perinatally-infected women living with HIV in Zambia grew up alongside antiretroviral therapy (ART) roll-out and expanding prevention programmes. We used Bonnington's temporal framework to understand how HIV impacted the experiences of these women over time. Data were drawn from two sequential studies with a cohort of young women living with HIV: a qualitative study in 2014-16 and an ethnographic study in 2017-18. Data from workshops, in-depth interviews, participant observation and diaries were analysed thematically, guided by three temporalities within the framework: everyday, biographical and epochal time. In everyday time, repetitive daily treatment-taking reminded young women of their HIV status, affecting relationships and leading to secrecy with ART. In biographical time, past events including HIV disclosure, experiences of illness, and loss shaped present experiences and future aspirations. Lastly, in epochal time, the women's HIV infection and their survival were intimately interlinked with the history of ART availability. The epochal temporal understanding leads us to extend Reynolds Whyte's notion of "biogeneration" to conceptualise these women, whose experiences of living with HIV are enmeshed with their biosocial environment. Support groups for young women living with HIV should help them to process biographical events, as well as supporting their everyday needs.

In Cameroon, in 2019, tuberculosis (TB) treatment coverage was estimated at 53%, indicating that almost half of all people sick with TB were not diagnosed or linked to care. To inform strategies to improve access to TB services, we conducted an evaluation of the alignment between patient-initiated care-seeking behavior and spatial and institutional allocation of TB services. Data sources included the Cameroon Demographic and Health Survey (2018), the Health Facility List (2017), and routinely collected TB surveillance data. Data visualization was performed in Tableau and QGIS. The pathway analysis showed that only an estimated 9% of people attended a health facility providing TB services at initial care-seeking, with access varying from

Background Eliminating mother-to-child transmission of HIV (MTCT) in sub-Saharan Africa is hindered by limited understanding of HIV-testing and HIV-care engagement among pregnant and breastfeeding women. Methods We investigated HIV-testing and HIV-care engagement during pregnancy and breastfeeding from 2014 to 2018 in the Agincourt Health and Demographic Surveillance System (HDSS). We linked HIV patient clinic records to HDSS pregnancy data. We modelled time to a first recorded HIV-diagnosis following conception, and time to antiretroviral therapy (ART) initiation following diagnosis using Kaplan-Meier methods. We performed sequence and cluster analyses for all pregnancies linked to HIV-related clinic data to categorise MTCT risk period engagement patterns and identified factors associated with different engagement patterns using logistic regression. We determined factors associated with ART resumption for women who were lost to follow-up (LTFU) using Cox regression. Results Since 2014, 15% of 10,735 pregnancies were recorded as occurring to previously (51%) or newly (49%) HIV-diagnosed women. New diagnoses increased until 2016 and then declined. We identified four MTCT risk period engagement patterns (i) early ART/stable care (51.9%), (ii) early ART/unstable care (34.1%), (iii) late ART initiators (7.6%), and (iv) postnatal seroconversion/early, stable ART (6.4%). Year of delivery, mother’s age, marital status, and baseline CD4 were associated with these patterns. A new pregnancy increased the likelihood of treatment resumption following LTFU. Conclusion Almost half of all pregnant women did not have optimal ART coverage during the MTCT risk period. Programmes need to focus on improving retention, and leveraging new pregnancies to re-engage HIV-positive women on ART.

BackgroundPre-exposure-prophylaxis (PrEP) has been heralded for its potential to put women in control of preventing HIV infection, but uptake and continuation rates have been disappointing in high-incidence settings in sub-Saharan Africa. We explored structural and social factors that influenced PrEP use among young women and pregnant or breastfeeding women in rural Eswatini.MethodsWe conducted two in-depth interviews with ten women on PrEP, and one-time in-depth interviews with fourteen women who declined or discontinued PrEP. Interviews covered decision-making processes around PrEP initiation and experiences with pill-taking. In-depth interviews were conducted with nine health workers, covering experiences in delivering PrEP services, and two focus group discussions were held with men to elicit their perceptions of PrEP. Interviews and discussions were audio-recorded, translated, transcribed and analysed thematically, using an inductive approach.ResultsPrEP initiation and use were experienced by many women as empowering them to take control of their health and well-being, and stay HIV free, facilitating them to realise their aspirations relating to motherhood and educational attainment. However, the social norms that defined relationship dynamics with partners or family members either undermined or promoted this empowerment potential. In particular, young women were rarely supported by family members to take PrEP unless it was perceived to be for protecting an unborn child. Stigmatisation of pill-taking through its associations with HIV and the burden of daily pill-taking also contributed to PrEP discontinuation.ConclusionsUnlike many prevention tools, PrEP enabled women to achieve a sense of control over their lives. Nevertheless, women’s agency to continue and adhere to PrEP was influenced by social and structural factors including gender norms, family expectations of young women, relationship dynamics and stigma related to HIV. Future interventions should address these barriers to promote PrEP use among sexually-active women.

Universal antiretroviral therapy (ART) strategies have dramatically changed HIV programming across sub-Saharan Africa. We explored factors that influenced the development, adoption and implementation of universal ART policies in Tanzania, South Africa and Malawi. We conducted 26 key informant interviews and applied Kingdon's 'streams' model to explore how problems, policies and politics converged to provide a window of opportunity for universal ART roll-out. Weak health systems and sub-optimal care retention were raised as problems during Option B+ implementation, which preceded universal ART , and persisted after its implementation. The adoption and implementation of Option B+ policy facilitated the uptake of universal ART. Politics played out through pressures from different stakeholders to accelerate or slow down implementation, from governments, civil society groups, researchers and donors. Policy processes leading to universal ART were open to pressures and influence. The extraordinary financial support which enabled the widespread and rapid implementation of universal ART skewed the power balance and sometimes left little space for locally-derived solutions to respond to specific health system abilities and epidemiological contexts. Donors may be more effective if they ensure a greater focus on strengthening the whole health system as well as accounting for local contextual factors and recent policy development histories when funding policy implementation.

Background: It is common practice for HIV programmes to routinely trace patients who are late for a scheduled clinic visit to ensure continued care engagement. In South Africa, patients who are late for a scheduled visit are identified from clinic registers, and called by telephone up to three times by designated clinic staff, with home visits conducted for those who are unreachable by phone. It is important to understand outcomes among late patients in order to have accurate mortality data, identify defaulters to attempt to re-engage them into care, and have accurate estimates of patients still in care for planning purposes. Objective: We conducted a study to assess whether tracing of HIV patients in clinics in rural north-eastern South Africa was implemented in line with national policies. Methods: Thirty-three person-day of observations took place during multiple visits to eight facilities between October 2017 and January 2018 during which clinic tracing processes were captured. The facility level implementation processes were compared to the intended tracing process and gaps and challenges were identified. Results: Challenges to implementing effective tracing procedures fell into three broad categories: i) facility-level barriers, ii) issues relating to data, documentation and record-keeping, and iii) challenges relating to the roles and responsibilities of the different actors in the tracing cascade. We recommend improving linkages between clinics, improving record-keeping systems, and regular training of community health workers involved in tracing activities. Improved links between clinics would reduce the chance of patients being lost between clinics. Record-keeping systems could be improved through motivating health workers to take ownership of their data and training them on the importance of complete data. Finally, training of community health workers may improve sustained motivation, and improve their ability to respond appropriately to their clients’ needs. Conclusions: Substantial investment in data infrastructure and healthcare staff training is needed to improve routine tracing.

Although integration of HIV and maternal health services is recommended by the World Health Organization, evidence to guide implementation is limited. We describe facility-level implementation of policies for integrating HIV care within maternal health services and explore experiences of service users and providers in rural Tanzania (Ifakara), South Africa (uMkhanyakude) and Malawi (Karonga). Policy in all countries included HIV testing during antenatal care (ANC), same-day antiretroviral therapy (ART) initiation for HIV-positive pregnant women, and postpartum referral to ART clinics, between six weeks (Malawi, South Africa) and two years after delivery (Tanzania). All facilities offered HIV testing within ANC, most commonly during the first visit. Although most women were comfortable with HIV testing, some felt that opting out would lead to sub-standard services. Some facilities conducted group post-test counselling for HIV-negative women, raising concerns of unintended HIV status disclosure. ART initiation was offered on the same day, the same room as an HIV diagnosis in >90% of facilities. Women's worries around postpartum referral included having unknown providers, insufficient privacy and queues. Adoption and implementation of policies on integrated HIV and maternal health services varied across settings. Patients' experiences of these policies may influence uptake and retention in care.

Supplemental Digital Content is Available in the Text., Background: Undetermined attrition prohibits full understanding of the coverage and effectiveness of HIV programs. Outcomes following loss to follow-up (LTFU) among antiretroviral therapy (ART) patients may differ according to their reasons for ART initiation. Setting: We compare the true outcomes of adult patients previously identified as LTFU by reason for ART initiation in 8 health facilities in north eastern South Africa. Methods: Adult HIV patient records were linked to health and demographic surveillance system (HDSS) data from 2014 to 2017. Outcomes of adults categorized as LTFU (>90 days late for the last scheduled clinic visit) were determined through clinic and routine tracing record reviews, consultation of HDSS data, and supplementary tracing. We calculated the proportion of patients per outcome category and performed competing risk survival analysis to estimate the cumulative incidence of death, transfer, migration, ART interruption, and re-engagement following LTFU. Results: Of 895/1017 patients LTFU with an outcome ascertained, 120 (13.4%) had died, 225 (25.1%) re-engaged, 50 (5.6%) migrated out of the HDSS, 75 (8.4%) were alive and not on treatment, and 315 (35.1%) transferred their treatment. These outcomes varied by sex and pregnancy status at ART initiation. Mortality was less likely among pregnant women, patients with higher baseline CD4, and more likely among older patients. Conclusions: Patient survival and transfers to other facilities are considerably higher than those suggested in earlier studies. Outcomes differ for women who were pregnant or postpartum when initiating ART, with this population less likely to have died and more likely to have migrated.

BackgroundReaching the 90–90-90 targets requires efficient resource use to deliver HIV testing and treatment services. We investigated the costs and efficiency of HIV services in relation to HIV testing yield in rural Karonga District, Malawi.MethodsCosts of HIV services were measured over 12 months to September 2017 in five health facilities, drawing on recognised health costing principles. Financial and economic costs were collected in Malawi Kwacha and United States Dollars (US$). Costs were calculated using a provider perspective to estimate average annual costs (2017 US$) per HIV testing episode, per HIV-positive case diagnosed, and per patient-year on antiretroviral therapy (ART), by facility. Costs were assessed in relation to scale of operation and facility-level annual HIV positivity rate. A one-way sensitivity analysis was undertaken to understand how staffing levels and the HIV positivity rate affected HIV testing costs.ResultsHIV testing episodes per day and per full-time equivalent HIV health worker averaged 3.3 (range 2.0 to 5.7). The HIV positivity rate averaged 2.4% (range 1.9 to 3.7%). The average cost per testing episode was US$2.85 (range US$1.95 to US$8.55), and the average cost per HIV diagnosis was US$116.35 (range US$77.42 to US$234.11), with the highest costs found in facilities with the lowest daily number of tests and lowest HIV yield respectively. The mean facility-level cost per patient-year on ART was approximately US$100 (range US$90.67 to US$115.42). ART drugs were the largest cost component averaging 71% (range 55 to 76%). The cost per patient-year of viral load tests averaged US$4.50 (range US$0.52 to US$7.00) with cost variation reflecting differences in the tests to ART patient ratio across facilities.ConclusionGreater efficiencies in HIV service delivery are possible in Karonga through increasing daily testing episodes among existing health workers or allocating health workers to tasks in addition to testing. Costs per diagnosis will increase as yields decline, and therefore, encouraging targeted testing strategies that increase yield will be more efficient. Given the contribution of drug costs to per patient-year treatment costs, it is critical to preserve the life-span of first-line ART regimens, underlining the need for continuing adherence support and regular viral load monitoring.

We explored how strategies to promote male partner engagement influenced HIV care-seeking among men and women living with HIV. In-depth interviews were conducted with 25 health workers, 66 female service users and 10 male partners in Ifakara (Tanzania), Karonga (Malawi) and uMkhanyakude (South Africa) to elicit experiences of offering, providing or receiving HIV care in the context of antenatal care. Data were coded inductively and analysed thematically. Participants reported benefits of couple testing during antenatal care, including facilitated HIV status disclosure and mutual support for HIV care-seeking. However, unintended consequences included women attending without partners, being refused or delayed access to antenatal services. Some women were required to obtain letters from village leaders to justify the absence of their partners, again to delaying or disrupting care-seeking. When partners attended antenatal care, consultations were reportedly more likely to focus on HIV testing, and less on antenatal or neonatal care. Strategies to increase men's attendance at HIV clinics with their partners can promote mutual support within couples for HIV care engagement, but may risk undermining engagement in pregnancy and HIV care for some women if over-stringently applied. Efforts are needed to address the underlying pervasive stigma associated with HIV care, both alone and as a couple.

We estimated the costs of Option B+ for HIV-infected pregnant women in 12 facilities in Morogoro Region, Tanzania, from a provider perspective. Costs of prevention of mother-to-child (PMTCT) HIV services were measured over 12 months to September 2017 to estimate the average costs per HIV testing episode, per HIV-positive case diagnosed, per patient-year on antiretroviral therapy (ART), and per neonatal HIV care. A one-way sensitivity analysis was undertaken to understand how staffing levels and other core resource inputs affected costs. The total number of HIV testing episodes was 25,593 with 279 HIV cases identified yielding a 1.1% positivity rate. The average cost per testing episode was US$5.49 (range US$2.13 to US$13.93), and the average cost per HIV case detected was US$503.29 (range US$230.61 to US$3330.38). The number of pregnant women initiated on ART was 278. The mean cost per patient-year on ART was US$159.89 (range US$100.91 to US$812.23). The average cost of neonatal HIV care was US$90.09 (range US$41.53 to US$180.26). PMTCT service costs varied widely across facilities due to variations in resource use, number of women testing, and HIV prevalence. The study provides further evidence against generalising cost estimates, and that budgeting and planning requires context specific cost information.

Background: Monitoring progress toward global treatment targets using HIV programme data in sub-Saharan Africa has proved challenging. Constraints in routine data collection and reporting can lead to biased estimates of treatment outcomes. In 2010, South Africa introduced an electronic patient monitoring system for HIV patient visits, TIER.Net. We compare treatment status and outcomes recorded in TIER.Net to outcomes ascertained through detailed record review and tracing in order to assess discrepancies and biases in retention and mortality rates.Methods: The Agincourt Health and Demographic Surveillance System (HDSS) in north-eastern South Africa is served by eight public primary healthcare facilities. Since 2014, HIV patient visits are logged electronically at these clinics, with patient records individually linked to their HDSS record. These data were used to generate a list of patients >90 days late for their last scheduled clinic visit and deemed lost to follow-up (LTFU). Patient outcomes were ascertained through a review of the TIER.Net database, physical patient files, registers kept by two non-government organizations that assist with patient tracing, cross-referencing with the HDSS records and supplementary physical tracing. Descriptive statistics were used to compare patient outcomes reported in TIER.Net to their outcome ascertained in the study.Results: Of 1,074 patients that were eligible for this analysis, TIER.Net classified 533 (49.6%) as LTFU, 80 (7.4%) as deceased, and 186 (17.3%) as transferred out. TIER.Net misclassified 36% of patient outcomes, overestimating LTFU and underestimating mortality and transfers out. TIER.Net missed 40% of deaths and 43% of transfers out. Patients categorized as LTFU in TIER.Net were more likely to be misclassified than patients classified as deceased or transferred out.Discussion: Misclassification of patient outcomes in TIER.Net has consequences for programme forecasting, monitoring and evaluation. Undocumented transfers accounted for the majority of misclassification, suggesting that the transfer process between clinics should be improved for more accurate reporting of patient outcomes. Processes that lead to correct classification of patient status including patient tracing should be strengthened. Clinics could cross-check all available data sources before classifying patients as LTFU. Programme evaluators and modelers could consider using correction factors to improve estimates of outcomes from TIER.Net.

Introduction Many adolescents living with HIV in sub‐Saharan Africa struggle to achieve optimal adherence to antiretroviral therapy (ART), but few studies have investigated how their treatment‐taking decisions are influenced by their social interactions with providers, caregivers and community leaders. This study aims to explore the narratives that define expectations of adherence to ART among adolescents living with HIV in a rural Malawian setting. Methods Overall, 45 in‐depth interviews were conducted in 2016 with adolescents living with HIV, caregivers, health workers and community leaders, and four group sessions using participatory tools were undertaken with adolescents. Interviews and group sessions were audio‐recorded, transcribed and translated into English. Data were coded inductively and analysed thematically. Results Adolescents were given strict behavioural codes around optimal treatment adherence, which were often enforced through encouragement, persuasian and threats. In HIV clinics, some staff supported adolescents with broader concerns relating to living with HIV, but other measures to address sub‐optimal adherence in HIV clinics were perceived by patients as punitive, including pill‐counts and increased frequency of clinic visits. Community leaders felt responsible for young peoples' health, sometimes attempting to influence their treatment‐taking by threatening to withdraw services, or to publically “out” those deemed to be non‐adherent. At home, discussions with adolescents about HIV were often limited to dose reminders, and some caretakers resorted to physical punishment to ensure adherence. While some adolescents complied with strictly‐enforced adherence rules, others demonstrated resistance by hiding missed doses, secretly throwing away drugs, or openly refusing to take them. Conclusions The potential of young people to adhere to their ART may be undermined by restrictive messages and punitive approaches to enforce and control their engagement with treatment at home, in the clinic and in the wider community. Interventions should focus on creating safe spaces for adolescents to speak frankly about the adherence challenges that they face and support for caregivers including home‐based interventions.

Background Successful HIV testing, care and treatment policy implementation is essential for realising the reductions in morbidity and mortality those policies are designed to target. While adoption of new HIV policies is rapid, less is known about the facility-level implementation of new policies and the factors influencing this. Methods We assessed implementation of national policies about HIV testing, treatment and retention at health facilities serving two health and demographic surveillance sites (HDSS) (10 in Kyamulibwa, 14 in Rakai). Ugandan Ministry of Health HIV policy documents were reviewed in 2013, and pre-determined indicators were extracted relating to the content and nature of guidance on HIV service provision. Facility-level policy implementation was assessed via a structured questionnaire administered to in-charge staff from each health facility. Implementation of policies was classified as wide (≥75% facilities), partial (26–74% facilities) or minimal (≤25% facilities). Semi-structured interviews were conducted with key informants (policy-makers, implementers, researchers) to identify factors influencing implementation; data were analysed using the Framework Method of thematic analysis. Results Most policies were widely implemented in both HDSS (free testing, free antiretroviral treatment (ART), WHO first-line regimen as standard, Option B+). Both had notable implementation gaps for policies relating to retention on treatment (availability of nutritional supplements, support groups or isoniazid preventive therapy). Rakai implemented more policies relating to provision of antiretroviral treatment than Kyamulibwa and performed better on quality of care indicators, such as frequency of stock-outs. Factors facilitating implementation were donor investment and support, strong scientific evidence, low policy complexity, phased implementation and effective planning. Limited human resources, infrastructure and health management information systems were perceived as major barriers to effective implementation. Conclusions Most HIV policies were widely implemented in the two settings; however, gaps in implementation coverage prevail and the value of ensuring complete coverage of existing policies should be considered against the adoption of new policies in regard to resource needs and health benefits.

While 'procedural ethics' provides essential frameworks for governing global health research, reflecting on 'ethics in practice' offers important insights into addressing ethically important moments that arise in everyday research. Particularly for ethnographic research, renowned for it's fluid and spontaneous nature, engaging with 'ethics in practice' has the potential to enhance research practice within global health. We provide a case study for such reflexivity, exploring 'ethics in practice' of ethnographic research with middle-income young women living with HIV in Lusaka, Zambia. We explore the ethical issues arising from the layered interaction of the population (young women), the disease under investigation (HIV), the method of study (ethnographic), and the setting (Zambia, a lower middle income country). We describe how we navigated five key practical ethical tensions that arose, namely the psycho-emotional benefits of the research, the negotiated researcher-participant relationship, protecting participants' HIV status, confidentiality and data ownership, and researcher obligations after the end of the research. We exemplify reflexive engagement with 'ethics in practice' and suggest that engaging with ethics in this way can make important contributions towards developing more adequate ethical guidelines and research practice in global public health.

To assess adoption of World Health Organization (WHO) guidance into national policies for prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV) and to monitor implementation of guidelines at facility level in rural Malawi, South Africa and the United Republic of Tanzania.We summarized national PMTCT policies and WHO guidance for 15 indicators across the cascades of maternal and infant care over 2013-2016. Two survey rounds were conducted (2013-2015 and 2015-2016) in 46 health facilities serving five health and demographic surveillance system populations. We administered structured questionnaires to facility managers to describe service delivery. We report the proportions of facilities implementing each indicator and the frequency and durations of stock-outs of supplies, by site and survey round.In all countries, national policies influencing the maternal and infant PMTCT cascade of care aligned with WHO guidelines by 2016; most inter-country policy variations concerned linkage to routine HIV care. The proportion of facilities delivering post-test counselling, same-day antiretroviral therapy (ART) initiation, antenatal care and ART provision in the same building, and Option B+ increased or remained at 100% in all sites. Progress in implementing policies on infant diagnosis and treatment varied across sites. Stock-outs of HIV test kits or antiretroviral drugs in the past year declined overall, but were reported by at least one facility per site in both rounds.Progress has been made in implementing PMTCT policy in these settings. However, persistent gaps across the infant cascade of care and supply-chain challenges, risk undermining infant HIV elimination goals.Évaluer la transposition des recommandations de l'Organisation mondiale de la Santé (OMS) dans les politiques nationales de prévention de la transmission mère-enfant (PTME) du virus de l'immunodéficience humaine (VIH) et contrôler l'application de ces politiques dans les centres de santé de zones rurales d'Afrique du Sud, du Malawi et de République-Unie de Tanzanie.Nous avons répertorié les politiques nationales de PTME et les recommandations de l'OMS pour 15 indicateurs, sur toute la chaîne de soins de santé de la mère et du nourrisson, sur la période comprise entre 2013 et 2016. Deux séries d'enquêtes ont été réalisées (2013-2015 et 2015-2016) dans 46 centres de santé au service des populations de cinq systèmes de surveillance démographique et de santé. Nous avons interrogé les responsables de ces centres à l'aide de questionnaires directifs afin d'obtenir une description de la prestation des soins. Nous avons calculé la proportion de centres ayant appliqué chaque indicateur ainsi que la fréquence et la durée des ruptures de stock de fournitures, pour chaque zone étudiée et chaque série d'enquêtes.En 2016, dans tous les pays étudiés, les lignes directrices de l'OMS avaient été prises en compte dans les politiques nationales relatives à la chaîne des soins de PTME du VIH; la plupart des différences constatées entre les politiques de ces différents pays concernaient la liaison avec les soins de routine contre le VIH. La proportion des centres offrant des conseils après dépistage, proposant de débuter une thérapie antirétrovirale (TAR) le jour même, fournissant dans un même endroit des soins prénataux et des TAR et appliquant l'Option B+ a augmenté ou est restée à 100% dans toutes les zones étudiées. Les progrès dans l'application des politiques en matière de diagnostic et de traitement du nourrisson ont été variables d'une zone à une autre. Les ruptures de stock de kits de dépistage du VIH ou de médicaments antirétroviraux au cours de l'année précédente ont généralement diminué, mais dans chaque zone, sur les deux périodes étudiées, au moins une structure a été confrontée à ce problème.Des progrès ont été faits dans l'application des politiques de PTME dans ces régions. Néanmoins, des manquements persistants dans la chaîne de soins de santé du nourrisson et les problèmes des chaînes d'approvisionnement risquent de compromettre l'atteinte des objectifs d'élimination du VIH chez le nourrisson.Evaluar la adopción de las directrices de la Organización Mundial de la Salud (OMS) en las políticas nacionales de prevención de la transmisión del virus de la inmunodeficiencia humana (VIH) de madre a hijo y supervisar la aplicación de las directrices a nivel de las instalaciones sanitarias en las zonas rurales de Malawi, la República Unida de Tanzanía y Sudáfrica.Resumimos las políticas nacionales de PTMI y las directrices de la OMS para 15 indicadores en toda la serie de servicios de atención maternoinfantil durante el período 2013-2016. Se realizaron dos rondas de encuestas (2013-2015 y 2015-2016) en 46 instalaciones sanitarias que atienden a cinco poblaciones del sistema de vigilancia sanitaria y demográfica. Se administraron cuestionarios estructurados a los gestores de las instalaciones para describir la prestación de servicios. Informamos las proporciones de las instalaciones que aplican cada indicador y la frecuencia y duración de la falta de existencias de suministros, por emplazamiento y ronda de encuestas.En todos los países, las políticas nacionales que influyen en la serie de servicios de atención maternoinfantil de la PTMI se ajustaron a las directrices de la OMS para 2016; la mayoría de las variaciones de las políticas entre países se referían a la vinculación con la atención habitual de la infección por el VIH. La proporción de instalaciones que ofrecen asesoramiento posterior a la prueba, iniciación de la terapia antirretrovírica en el mismo día, atención prenatal y suministro de terapia antirretrovírica en el mismo edificio, y la Opción B+ aumentaron o se mantuvieron en el 100 % en todos los emplazamientos. El progreso en la aplicación de las políticas de diagnóstico y tratamiento del lactante varió de un emplazamiento a otro. Las existencias de kits de pruebas del VIH o de medicamentos antirretrovirales se redujeron en general en el último año, pero en ambas rondas se informó de la existencia de al menos una instalación por emplazamiento.Se ha progresado en la aplicación de la política de PTMI en estos ámbitos. Sin embargo, las persistentes brechas en la serie de servicios de atención infantil y los desafíos de la cadena de suministro pueden socavar los objetivos de eliminación del VIH infantil.تقييم اعتماد منظمة الصحة العالمية (WHO) في السياسات الوطنية للوقاية من انتقال العدوى من الأم إلى الطفل (PMTCT) لفيروس نقص المناعة البشرية (HIV) ومراقبة تنفيذ المبادئ التوجيهية على مستوى المرافق في المناطق الريفية في جنوب أفريقيا وجمهورية تنزانيا المتحدة وملاوي.لقد قمنا بتلخيص السياسات الوطنية للوقاية من انتقال العدوى من الأم إلى الطفل (PMTCT) وتوجيهات منظمة الصحة العالمية من أجل 15 مؤشر عبر سلسلة أجهزة رعاية الأمومة والطفولة خلال الفترة ما بين 2013 و2016. أُجريت جولتا مسح (2013-2015 و2015-2016) في 46 مرفقاً صحياً يخدم خمسة مجتمعات نظام مراقبة صحية وديموغرافية. قمنا بإدارة استبيانات منظمة لمديري المرافق لوصف تقديم الخدمة. وقمنا بالإبلاغ عن نسب التسهيلات المطبقة لكل مؤشر وتكرار ومدد مخزون اللوازم حسب الموقع وجولة المسح.في جميع البلدان، اهتمت السياسات الوطنية التي تؤثر على سلسلة الرعاية للأمهات والرضع للوقاية من انتقال العدوى من الأم إلى الطفل (PMTCT) والمتوافقة مع المبادئ التوجيهية لمنظمة الصحة العالمية بحلول عام 2016؛ ومعظم التغيرات في السياسات بين البلدان أيضًا بالارتباط بالرعاية الروتينية لفيروس نقص المناعة البشرية (HIV). وارتفعت نسبة المرافق التي تقدم المشورة بعد الاختبار، والبدء في العلاج بمضادات الفيروسات الرجعية (ART) في نفس اليوم، والرعاية السابقة للولادة، وتوفير العلاج بمضادات الفيروسات الرجعية في نفس المبنى، والخيار ب + الذي زاد أو بقى بنسبة 100٪ في جميع المواقع. وقد تفاوت التقدم في تنفيذ السياسات المتعلقة بتشخيص الرضع وعلاجهم بين المواقع. كما انخفض مخزون مجموعات اختبار فيروس نقص المناعة البشرية (HIV) أو العقاقير المضادة للفيروسات الرجعية في العام الماضي بشكل عام، ولكن تم الإبلاغ عن ذلك من قبل مرفق واحد على الأقل لكل موقع في كلتا الجولتين.تم إحراز تقدم في تنفيذ سياسة الوقاية من انتقال العدوى من الأم إلى الطفل (PMTCT) في هذه الظروف. ومع ذلك، فإن الثغرات المستمرة عبر سلسلة رعاية الرضع وتحدّيات سلسلة التوريد تقوّض أهداف القضاء على فيروس نقص المناعة البشرية لدى الرضع.旨在评估将世界卫生组织 (WHO) 的指导方针纳入艾滋病毒 (HIV) 母婴传播预防 (PMTCT) 政策，并监测马拉维、南非和坦桑尼亚联合共和国的农村地区医疗机构层面指导方针的实施情况。.我们总结了国家艾滋病毒母婴传播预防政策和世界卫生组织指南自 2013-2016 年为孕产妇和婴儿护理联动提供的 15 项指标。在 2013 年至 2015 年和 2015 年至 2016 期间分别对 46 个医疗机构、服务于五大医疗和人口监控系统的人群进行了两轮调查。我们对机构管理者进行了结构式问卷调查，以描述服务的提供情况。我们根据地点和调查轮次，报告实施各项指标的机构比例以及缺货的频率和持续时间。.所有国家中，影响产妇和预防艾滋病毒母婴传播的国家政策应符合截至 2016 年的世界卫生组织的指导方针；大多数国家间政策的变化都与常规艾滋病毒护理有关。在同一栋楼内提供检测后咨询、当日启动抗逆转录病毒疗法 (ART)、产前护理并提供抗逆转录病毒疗法，以及在所有站点增加“Option B+”计划或保持 100% 覆盖。各站点在实施婴儿诊断和治疗政策方面的进展各不相同。过去一年，艾滋病毒检测试剂盒或抗逆转录病毒药物的缺货量整体下降，但在这两轮调查中，每个站点至少有一个机构存在缺货现象。.此类情况下，实施艾滋病毒母婴传播预防政策取得进展。然而，婴儿联动护理和供应链挑战之间的持续差距有可能破坏消除婴儿感染艾滋病毒的目标。.Оценка включения рекомендаций Всемирной организации здравоохранения (ВОЗ) в национальные стратегии профилактики передачи вируса иммунодефицита человека (ВИЧ) от матери ребенку (РМТСТ) и отслеживание внедрения таких рекомендаций на уровне объектов здравоохранения в сельских районах Малави, Объединенной Республики Танзания и Южной Африки.Авторы суммировали национальные стратегии в отношении PMTCT и рекомендации ВОЗ по 15 индикаторам в цепочке мероприятий по оказанию помощи матери и ребенку на протяжении 2013–2016 гг. Исследование проводилось в виде двух раундов опросов (2013–2015 гг. и 2015–2016 гг.) в 46 учреждениях здравоохранения, которые обслуживали пять популяций систем надзора за здоровьем и демографической ситуацией. Руководителям учреждения здравоохранения были выданы структурированные анкеты для описания оказания услуг. В статье приведены сведения о доле учреждений, внедривших каждый из индикаторов, а также о частоте и продолжительности случаев нехватки ресурсов с разбивкой по зонам оказания услуг и раунду опросов.Во всех странах национальные стратегии, влияющие на цепочку предоставления услуг в отношении материнского и детского РМТСТ, были приведены в соответствие с рекомендациями ВОЗ к 2016 г. Большинство вариантов стратегий в разных странах касались привязки к плановому лечению ВИЧ-инфицированных. Доля медицинских учреждений, предоставляющих возможность консультации после тестирования, начала антиретровирусной терапии (АРТ) в тот же день, дородового лечения и АРТ в том же здании, а также предоставляющих вариант В+, выросла или осталась на уровне 100% во всех обследованных зонах. Прогресс во внедрении стратегий диагностики и лечения младенцев различался в зависимости от зоны исследования. Дефицит тест-систем для выявления антител к ВИЧ или антиретровирусных препаратов за последний год в целом уменьшился, но сообщения о нехватке поступали по меньшей мере из одного учреждения в каждой зоне в течение обоих опросов.Наблюдается прогресс во внедрении стратегий PMTCT в указанных условиях. Однако постоянные недочеты в цепочке предоставления услуг младенцам и проблемы с поставками могут поставить под угрозу цели по устранению ВИЧ у младенцев.

Increasing numbers of people living with HIV (PLHIV) in sub-Saharan Africa are experiencing failure of first-line antiretroviral therapy and transitioning onto second-line regimens. However, there is a dearth of research on their treatment experiences. We conducted in-depth interviews with 43 PLHIV on second- or third-line antiretroviral therapy and 15 HIV health workers in Kenya, Malawi and Mozambique to explore patients' and health workers' perspectives on these transitions. Interviews were audio-recorded, transcribed and translated into English. Data were coded inductively and analysed thematically. In all settings, experiences of treatment failure and associated episodes of ill-health disrupted daily social and economic activities, and recalled earlier fears of dying from HIV. Transitioning onto more effective regimens often represented a second (or third) chance to (re-)engage with HIV care, with patients prioritising their health over other aspects of their lives. However, many patients struggled to maintain these transformations, particularly when faced with persistent social challenges to pill-taking, alongside the burden of more complex regimens and an inability to mobilise sufficient resources to accommodate change. Efforts to identify treatment failure and support regimen change must account for these patients' unique illness and treatment histories, and interventions should incorporate tailored counselling and social and economic support.

The Network for Analysing Longitudinal Population-based HIV/AIDS data on Africa (ALPHA Network, http://alpha.lshtm.ac.uk/) brings together ten population-based HIV surveillance sites in eastern and southern Africa, and is coordinated by the London School of Hygiene and Tropical Medicine (LSHTM). It was established in 2005 and aims to (i) broaden the evidence base on HIV epidemiology for informing policy, (ii) strengthen the analytical capacity for HIV research, and (iii) foster collaboration between network members. All study sites, some starting in the late 1980s and early 1990s, conduct demographic surveillance in populations that range from approximately 20 to 220 thousand individuals. In addition, they conduct population-based surveys with HIV testing, and verbal autopsy interviews with relatives of deceased residents. ALPHA Network datasets have been used for studying HIV incidence, sexual behaviour and the effects of HIV on mortality, fertility, and household composition. One of the network’s substantive focus areas is the monitoring of AIDS mortality and HIV services coverage in the era of antiretroviral therapy. Service use data are retrospectively recorded in interviews and supplemented by information from record linkage with medical facilities in the surveillance areas. Data access is at the discretion of each of the participating sites, but can be coordinated by the network.

Introduction Longer intervals between clinic consultations for clinically stable antiretroviral therapy (ART) patients may improve retention in care and reduce facility workload. We assessed long‐term retention among clinically stable ART patients attending six‐monthly clinical consultations (SMCC) with three‐monthly fast‐track drug refills, and estimated the number of consultations “saved” by this model of ART delivery in rural Malawi. Methods Stable patients (aged ≥18 years, on first‐line ART ≥12 months, CD4 count ≥300 cells/mL 3, without opportunistic infections, not pregnant/breastfeeding) were eligible for SMCC, with three‐monthly drug refills from community health workers. Early enrollees were those starting SMCC within six months of eligibility, while late enrollees started at least 6 months after first eligibility. Kaplan–Meier methods were used to calculate cumulative probabilities of retention, stratified by timing of their enrolment and from first six‐monthly clinical consultation. Cox regression was used to measure attrition hazards from the first six‐monthly clinical consultation and risk factors for attrition, accounting for the time‐varying nature of their eligibility and enrolment in this model of care. Results From 2008 to 2015, 22,633 clinically stable patients from 11 facilities were eligible for SMCC for at least three months, contributing 74,264 person‐years of observation, and 18,363 persons (81%) initiated this model of care. The median time from eligibility to enrolment was 12 months and the median cumulative time on SMCC was 14.5 months. Five years after first SMCC eligibility, cumulative probabilities of retention were 85.5% (95% CI: 84.0% to 86.9%) among early enrollees and 93% (95% CI: 92.8% to 94.0%) among late enrollees. The cumulative probability of retention from first SMCC was 97.0% (95% CI: 96.7% to 97.3%) and 86% (95% CI: 85% to 87%) at one and five years respectively. Among eligible patients initiating SMCC, the adjusted hazards of attrition were 2.4 (95% CI: 2.0 to 2.8) times higher during periods of SMCC discontinuation compared to periods on SMCC. Male sex, younger age, more recent SMCC eligibility and WHO Stage 3/4 conditions in the past year were also independently associated with attrition from SMCC. Approximately 26,000 consultations were “saved” during 2014. Conclusion After five years, retention among patients attending SMCC was high, especially among women and older patients, and its scale‐up could facilitate universal access to ART.

Introduction Treat‐all is being implemented in several African settings, in accordance with 2015 World Health Organisation guidelines. The factors known to undermine adherence to antiretroviral therapy (ART) may change in the context of Treat‐all, where people living with HIV (PLHIV) increasingly initiate ART at earlier, asymptomatic stages of disease, soon after diagnosis. This paper aimed to examine the asymptomatic PLHIV's experiences engaging with early ART initiation under the Treat‐all policy, including how they navigate treatment‐taking over the longer term. Methods A longitudinal qualitative study was conducted within a Médecins Sans Frontières/Ministry of Health Treat‐all pilot in Shiselweni, southern Eswatini. The Treat‐all pilot began in October 2014, adopted into national policy in October 2016. Participants were recruited purposively to include newly diagnosed, clinically asymptomatic PLHIV with a range of treatment‐taking experiences, and healthcare workers (HCW) with various roles. This analysis drew upon a sub‐sample of 17 PLHIV who had been on ART for at least 12 months, with mean 20 months on ART at first interview, and who undertook three interviews each. Additionally, 20 HCWs were interviewed once. Interviews were conducted from August 2016 to September 2017. Data were analysed thematically using coding, drawing upon principles of grounded theory, and aided by Nvivo 11. Results It was important for PLHIV to perceive the need for treatment, and to have evidence of its effectiveness to motivate their treatment‐taking, thereby supporting engagement with care. For some, coming to terms with a HIV diagnosis or re‐interpreting past illnesses as signs of HIV could point to the need for ART to prevent health deterioration and prolong life. However, others doubted the accuracy of an HIV diagnosis and the need for treatment in the absence of symptoms or signs of ill health, with some experimenting with treatment‐taking as a means of seeking evidence of their need for treatment and its effect. Viral load monitoring appeared important in offering a view of the effect of treatment on the level of the virus, thereby motivating continued treatment‐taking. Conclusions These findings highlight the importance of PLHIV perceiving need for treatment and having evidence of the difference that ART is making to them for motivating treatment‐taking. Patient support should be adapted to address these concerns, and viral load monitoring made routinely available within Treat‐all care, with communication of suppressed results emphasized to patients.

Objectives To investigate the relative effectiveness of different HIV testing and counselling (HTC) services in improving HIV diagnosis rates and increasing HTC coverage in African settings. Methods Patient records from three HTC services [community outreach HTC during cohort study rounds (CO‐HTC), walk‐in HTC at the local health centre (WI‐HTC) and antenatal HIV testing (ANC‐HTC)] were linked to records from a community cohort study using a probabilistic record linkage algorithm. Characteristics of linked users of each HTC service were compared to those of cohort participants who did not use the HTC service using logistic regression. Data from three cohort study rounds between 2003 and 2010 were used to assess trends in the proportion of persons testing at different service types. Results The adjusted odds ratios for HTC use among men with increasing numbers of sexual partners in the past year, and among HIV‐positive men and women compared to HIV‐negative men and women, were higher at WI‐HTC than at CO‐HTC and ANC‐HTC. Among sero‐survey participants, the largest numbers of HIV‐positive men and women learned their status via CO‐HTC. However, we are likely to have underestimated the numbers diagnosed at WI‐HTC and ANC‐HTC, due to low sensitivity of the probabilistic record linkage algorithm. Conclusions Compared to CO‐HTC or ANC‐HTC, WI‐HTC was most likely to attract HIV‐positive men and women, and to attract men with greater numbers of sexual partners. Further research should aim to optimise probabilistic record linkage techniques, and to investigate which types of HTC services most effectively link HIV‐positive people to treatment services relative to the total cost per diagnosis made.

OBJECTIVES: This study aimed to identify factors associated with access to HIV care and antiretroviral (ARV) drugs for prevention of mother-to-child transmission (PMTCT) of HIV among HIV-positive pregnant women in a community cohort in rural Tanzania (Kisesa). METHODS: Kisesa-resident women who tested HIV-positive during HIV serosurveillance and were pregnant (while HIV-positive) between 2005 and 2012 were eligible. Community cohort records were linked to PMTCT and HIV clinic data from four facilities (PMTCT programme implemented in 2009; referrals to city-based hospitals since 2005) to ascertain service use. Factors associated with access to HIV care and ARVs during pregnancy were analysed using logistic regression. RESULTS: Overall, 24% of women accessed HIV care and 12% accessed ARVs during pregnancy (n=756 pregnancies to 420 women); these proportions increased over time. In multivariate analyses for 2005-2012, being married, prior voluntary counselling and testing, increasing age, increasing year of pregnancy and increasing duration of infection were independently associated with access to care and ARVs. Residence in roadside areas was an independent predictor of access to care but not ARVs. There was no evidence of an interaction with time period. CONCLUSIONS: Access to PMTCT services was low in this rural setting but improved markedly over time. There were fairly few sociodemographic differentials although support for young women and those without partners may be needed. Further decentralisation of HIV services to more remote areas, promotion of voluntary counselling and testing and implementation of Option B+ are likely to improve uptake and may bring women into care and treatment sooner after infection.

To compare national human immunodeficiency virus (HIV) policies influencing access to HIV testing and treatment services in six sub-Saharan African countries.We reviewed HIV policies as part of a multi-country study on adult mortality in sub-Saharan Africa. A policy extraction tool was developed and used to review national HIV policy documents and guidelines published in Kenya, Malawi, South Africa, Uganda, the United Republic of Tanzania and Zimbabwe between 2003 and 2013. Key informant interviews helped to fill gaps in findings. National policies were categorized according to whether they explicitly or implicitly adhered to 54 policy indicators, identified through literature and expert reviews. We also compared the national policies with World Health Organization (WHO) guidance.There was wide variation in policies between countries; each country was progressive in some areas and not in others. Malawi was particularly advanced in promoting rapid initiation of antiretroviral therapy. However, no country had a consistently enabling policy context expected to increase access to care and prevent attrition. Countries went beyond WHO guidance in certain areas and key informants reported that practice often surpassed policy.Evaluating the impact of policy differences on access to care and health outcomes among people living with HIV is challenging. Certain policies will exert more influence than others and official policies are not always implemented. Future research should assess the extent of policy implementation and link these findings with HIV outcomes.Comparer les politiques nationales de lutte contre le virus de l'immunodéficience humaine (VIH) qui influencent l'accès aux services de dépistage et de traitement du VIH dans six pays d'Afrique subsaharienne.Nous avons examiné les politiques de lutte contre le VIH dans le cadre d'une étude multi-pays sur la mortalité des adultes en Afrique subsaharienne. Un outil d'extraction de données a été mis au point et utilisé afin d'examiner les documents et les directives des politiques nationales de lutte contre le VIH publiés en Afrique du Sud, au Kenya, au Malawi, en Ouganda, en République-Unie de Tanzanie et au Zimbabwe entre 2003 et 2013. Des entretiens avec des informateurs clés ont permis de combler les carences de ces résultats. Les politiques nationales ont été classées suivant leur degré de correspondance, explicite ou implicite, avec 54 indicateurs relatifs aux politiques, déterminés d'après des analyses documentaires et des examens d'experts. Nous avons également comparé les politiques nationales avec les recommandations de l'Organisation mondiale de la Santé (OMS).Nous avons observé de grandes différences entre les politiques de ces pays ; chaque pays était avancé dans certains domaines et pas dans d'autres. Le Malawi l'était particulièrement en matière de promotion du démarrage rapide du traitement antirétroviral. Cependant, aucun pays n'avait un contexte politique pouvant systématiquement permettre d'augmenter l'accès aux soins et d'éviter l'arrêt du traitement. Dans certains domaines, les pays allaient plus loin que les recommandations de l'OMS et les informateurs ont indiqué que la pratique dépassait souvent le cadre des politiques.Évaluer l'impact des différentes politiques sur l'accès aux soins et les résultats en termes de santé des personnes qui vivent avec le VIH n'est pas chose simple. Certaines politiques exercent une influence plus forte que d'autres et les politiques officielles ne sont pas toujours mises en œuvre. Des recherches ultérieures devraient évaluer le degré de mise en œuvre des politiques et mettre en lien leurs conclusions avec les résultats de la lutte contre le VIH.Comparar las políticas nacionales relativas al virus de la inmunodeficiencia humana (VIH) que influencian el acceso a las pruebas del VIH y a los tratamientos en seis países sub-saharianos.Se revisaron las políticas relativas al VIH como parte de un estudio multinacional sobre la mortalidad de adultos en África Subsahariana. Se desarrolló una herramienta de extracción de políticas y se utilizó para revisar los documentos y guías de las políticas nacionales relativas al VIH publicadas en Kenia, Malawi, República Unida de Tanzania, Sudáfrica, Uganda y Zimbabue entre 2003 y 2013. Se hicieron entrevistas a informantes claves que ayudaron a llenar los vacíos en los resultados. Las políticas nacionales se clasificaron según si se adhirieron explícita o implícitamente a 54 indicadores de políticas, identificados mediante bibliografía y opiniones de expertos. Asimismo, se compararon las políticas nacionales con las directrices de la Organización Mundial de la Salud (OMS).Se descubrió que había una amplia variedad entre las políticas de los países. Cada país estaba más avanzado en algunas áreas que en otras. Malawi estaba especialmente avanzado en la promoción de empezar rápidamente la terapia antirretroviral. Sin embargo, ningún país tenía un contexto de introducción de políticas consistente que incrementara el acceso a la atención primaria y evitara la deserción. Algunos países iban más allá de las orientaciones de la OMS en algunas áreas e informantes clave informaron de que la práctica a menudo superaba la política.Evaluar el impacto de las diferencias en las políticas relativas en el acceso a la atención primaria y los resultados en la salud entre aquellas personas con VIH es un reto. Algunas políticas ejercerán más influencia que otras y las políticas oficiales no siempre se aplican. Las investigaciones futuras deberían evaluar el grado de aplicación de las políticas y vincular estos resultados con los resultados del VIH.الغرض旨在对比在撒哈拉沙漠以南的六个非洲国家中能够影响艾滋病病毒测试和治疗服务的国家艾滋病病毒 (HIV) 政策。.在撒哈拉沙漠以南的非洲国家中进行有关成人死亡率的多国研究期间,我们评审了艾滋病病毒政策。 当时开发了一种政策提取工具并将其用于评审津巴布韦、肯尼亚、马拉维、南非、坦桑尼亚联合共和国以及乌干达在 2003 年和 2013 年期间出版的国家艾滋病病毒政策文件和指南。关键知情人访谈帮助我们弥补了调查结果中的不足之处。 我们依据国家政策是否以明确或隐含的方式遵循 54 项政策指标来对其进行分类,并且通过文献和专家评审加以确认。 同时,我们还对比了国家政策和世界卫生组织 (WHO) 指南。.各国的政策差异很大;每个国家都在一些方面达到先进水平,而在另一些方面却没有达到先进水平。 马拉维在推动抗逆转录病毒疗法的快速启动方面尤为先进。 然而,没有一个国家能够终保持一贯有利的政策环境,难以按预期提高护理普及率和预防消耗。 各国在某些方面超出了世界卫生组织指南的范围,并且据关键知情人报告,实际情况往往超越政策范围。.评估政策差异对艾滋病病毒患者的护理普及率和医疗效果的影响具有挑战性。 某些政策会比其他政策产生更大的影响,并且官方政策并不总是能够得到落实。 今后的研究应评估政策实施的程度,并将这些调查结果与艾滋病病毒的医疗效果联系起来。.Сравнить политику в отношении вируса иммунодефицита человека (ВИЧ) в шести странах Африки к югу от Сахары. Оценивается доступность анализа на ВИЧ и услуг по лечению.Политики в отношении ВИЧ были рассмотрены в рамках многонационального исследования смертности взрослого населения в странах Африки к югу от Сахары. Для анализа политик был разработан специальный инструмент, который использовался для проверки официальных документов и рекомендаций, связанных с государственной политикой в отношении ВИЧ, опубликованных в Кении, Малави, Южной Африке, Уганде, Объединенной Республике Танзания и Зимбабве в период между 2003 и 2013 гг. Неясные моменты уточнялись благодаря ключевым информаторам. Национальные политики распределялись по категориям в зависимости от того, придерживались ли они явным или косвенным образом 54 показателей, выявленных в ходе оценки публикаций и отчетов специалистов. Было также проведено сравнение национальных политик с рекомендациями Всемирной организации здравоохранения (ВОЗ).Политики в разных странах отличались друг от друга; в каждой из стран отмечался прогресс в одних областях и отставание в других. В частности, Малави значительно выделялась продвижением раннего начала антиретровирусной терапии. Тем не менее ни в одной стране не была реализована эффективная политика, которая облегчала бы доступ к медицинской помощи и препятствовала бы оттоку персонала. В некоторых областях страны пошли дальше рекомендаций ВОЗ и основные информаторы сообщили, что практика часто опережала политику.Оценить, насколько отличия в государственной политике влияют на доступ к лечению и результаты мероприятий по охране здоровья для лиц, живущих с ВИЧ, довольно сложно. Некоторые из политик имеют сравнительно больший эффект, и официальная политика не всегда выполняется. В будущих исследованиях необходимо оценить степень выполнения политик и связать полученные данные с результатами лечения ВИЧ.

Objectives Rates of first-line treatment failure and switches to second-line therapy are key indicators for national HIV programmes. We assessed immunological treatment failure defined by WHO criteria in the Tanzanian national HIV programme. Methods We included adults initiating first-line therapy in 2004–2011 with a pre-treatment CD4 count, and ≥6-months of follow-up. We assessed subhazard ratios (SHR) for immunological treatment failure, and subsequent switch to second-line therapy, using competing risks methods to account for deaths. Results Of 121 308 adults, 7% experienced immunological treatment failure, and 2% died without observed immunological treatment failure, over a median 1.7 years. The 6-year cumulative probability of immunological treatment failure was 19.0% (95% CI 18.5, 19.7) and of death, 5.1% (4.8, 5.4). Immunological treatment failure predictors included earlier year of treatment initiation (P

Current HIV policies in Tanzania have adopted the three long-term impact results of zero new infections, zero HIV deaths and zero stigma and discrimination. Strategies to reach these results include scaling-up HIV Testing and Counselling (HTC); Preventing Mother-To-Child Transmission (PMTCT); and strengthening Care and Treatment Clinic (CTC) services. Previous studies showed that HIV policy and guideline recommendations were not always implemented in rural South Tanzania. This study aims to identify the determinants of HIV guideline implementation. A qualitative study of 23 semi-structured interviews with facility in-charges; healthcare workers; district, regional and national HIV coordinators was conducted. Five health facilities were purposively selected by level, ownership and proximity to district headquarters. Interviews were analysed according to Fleuren’s five determinants of innovation uptake related to: strategies used in guideline development and dissemination; guideline characteristics; the guideline implementing organization; guideline users; and the socio-cultural and regulatory context. None of the facilities had the HTC national guideline document. Non-involvement of providers in revisions and weak planning for guideline dissemination impeded their implementation. Lengthy guidelines and those written in English were under-used, and activities perceived to be complicated, like WHO-staging, were avoided. Availability of staff and lack of supplies like test kits and medication impeded implementation. Collaboration between facilities enhanced implementation, as did peer-support among providers. Provider characteristics including education level, knowledge of, and commitment to the guideline influenced implementation. According to providers, determinants of clients’ service use included gender norms, stigma, trust and perceived benefits. The regulatory context prohibited private hospitals from buying HIV supplies. Being tools for bringing policies to practice, national guidelines are crucial in the efforts towards the three zeros. Strategies to improve providers’ adherence to guidelines should include development of clearer guideline dissemination plans, strengthening of the health system, and possibly addressing of provider-perceived patient-level barriers to utilizing HIV services.

Background Voluntary counselling and testing (VCT) for HIV first evolved in Western settings, with one aim being to promote behaviours which lower the risk of onward transmission or acquisition of HIV. However, although quantitative studies have shown that the impact of VCT on sexual behaviour change has been limited in African settings, there is a lack of qualitative research exploring perceptions of HIV prevention counselling messages, particularly among clients testing HIV-negative. We conducted a qualitative study to explore healthcare worker, community and both HIV-negative and HIV-positive clients’ perceptions of HIV prevention counselling messages in rural Tanzania. Methods This study was carried out within the context of an ongoing community HIV cohort study in Kisesa, northwest Tanzania. Nine group sessions incorporating participatory learning and action (PLA) activities were conducted in order to gain general community perspectives of HIV testing and counselling (HTC) services. Thirty in-depth interviews (IDIs) with HIV-negative and HIV-positive service users explored individual perceptions of HIV prevention counselling messages, while five IDIs were carried out with nurses or counsellors offering HTC in order to explore provider perspectives. Results Two key themes revolving around socio-cultural and contextual factors emerged in understanding responses to HIV prevention counselling messages. The first included constraints to client-counsellor interactions, which were impeded as a result of difficulties discussing private sexual behaviours during counselling sessions, a hierarchical relationship between healthcare providers and clients, insufficient levels of training and support for counsellors, and client concerns about confidentiality. The second theme related to imbalanced gender-power dynamics, which constrained the extent to which women felt able to control their HIV-related risk. Conclusion Within the broader social context of a rural African setting, HIV prevention counselling based on a Western model of individual-level agency seems unlikely to make a significant contribution to sexual behaviour change until there is greater recognition by counsellors of the ways in which power dynamics within many relationships influence behaviour change. More culturally relevant counselling strategies and messages and infrastructural improvements such as additional training for counsellors and counselling rooms which ensure privacy and confidentiality, may lead to better outcomes in terms of sexual risk reduction.

Malawi is a global leader in the design and implementation of progressive HIV policies. However, there continues to be substantial attrition of people living with HIV across the “cascade” of HIV services from diagnosis to treatment, and program outcomes could improve further. Ability to successfully implement national HIV policy, especially in rural areas, may have an impact on consistency of service uptake. We reviewed Malawian policies and guidelines published between 2003 and 2013 relating to accessibility of adult HIV testing, prevention of mother-to-child transmission and HIV care and treatment services using a policy extraction tool, with gaps completed through key informant interviews. A health facility survey was conducted in six facilities serving the population of a demographic surveillance site in rural northern Malawi to investigate service-level policy implementation. Survey data were analyzed using descriptive statistics. Policy implementation was assessed by comparing policy content and facility practice using pre-defined indicators covering service access: quality of care, service coordination and patient tracking, patient support, and medical management. ART was rolled out in Malawi in 2004 and became available in the study area in 2005. In most areas, practices in the surveyed health facilities complied with or exceeded national policy, including those designed to promote rapid initiation onto treatment, such as free services and task-shifting for treatment initiation. However, policy and/or practice were/was lacking in certain areas, in particular those strategies to promote retention in HIV care (e.g., adherence monitoring and home-based care). In some instances, though, facilities implemented alternative progressive practices aimed at improving quality of care and encouraging adherence. While Malawi has formulated a range of progressive policies aiming to promote rapid initiation onto ART, increased investment in policy implementation strategies and quality service delivery, in particular to promote long-term retention on treatment may improve outcomes further.

Background Estimates of population-level coverage with prevention of mother-to-child transmission (PMTCT) services are vital for monitoring programmes but are rarely undertaken. This study describes uptake of PMTCT services among HIV-positive pregnant women in a community cohort in rural Tanzania. Methods Kisesa cohort incorporates demographic and HIV sero-surveillance rounds since 1994. Cohort data were linked retrospectively to records from four Kisesa clinics with PMTCT services from 2009 (HIV care and treatment clinic (CTC) available in one facility from 2008; referrals to city hospitals for PMTCT and antiretroviral treatment (ART) from 2005). The proportion of HIV-positive pregnant women residing in Kisesa in 2005–2012 who accessed PMTCT service components (based on linkage to facility records) was calculated per HIV-positive pregnancy and by year, with adjustments made to account for the sensitivity of the linkage algorithm. Results Out of 1497 HIV-positive pregnancies overall (to 849 women), 26 % (n = 387/1497) were not linked to any facility records, 35 % (n = 519/1497) registered for ANC but not HIV services (29 % (n = 434/1497) were not tested at ANC or diagnosed previously), 8 % (n = 119/1497) enrolled in PMTCT but not CTC services (6 % (n = 95/1497) received antiretroviral prophylaxis), and 32 % (n = 472/1497) registered for CTC (14 % (n = 204/1497) received ART or prophylaxis) (raw estimates). Adjusted estimates for coverage with ANC were 92 %, 57 % with HIV care, and 29 % with antiretroviral drugs in 2005–2012, trending upwards over time. Conclusions Population-level coverage with PMTCT services was low overall, with weaknesses throughout the service continuum, but increased over time. Option B+ should improve coverage with antiretrovirals for PMTCT through simplified decisions for initiating ART, but will rely on strengthening access to CTC services. Electronic supplementary material The online version of this article (doi:10.1186/s12913-015-1249-6) contains supplementary material, which is available to authorized users.

Integration of HIV with other primary health services, including sexual and reproductive health (SRH) care, is being widely promoted in sub-Saharan Africa. However, evidence on its benefits is equivocal, and some studies indicate client preferences for stand-alone HIV services. A comparative case study investigated the relationship between integration and client satisfaction across different models of care in Swaziland: two clinics integrated with SRH services, and two stand-alone HIV clinics. An exit survey (n=602) measured satisfaction across model using logistic regression. In-depth interviews (n=22), repeated three times, explored satisfaction and how it was influenced by integration or not. Satisfaction was highest at the fully stand-alone clinic; in multivariable models, clients there were more satisfied than partially integrated and partially stand-alone sites (adjusted odds ratio [aOR] 0.45, 95% confidence interval [CI] 0.25-0.81; and aOR 0.53, 95% CI 0.31-0.90, respectively); there was no difference between the fully integrated and fully stand-alone sites. Qualitative analysis suggested that satisfaction was constituted by eleven dimensions of care, including access to HIV medication, interpersonal care, efficiency, and confidentiality. Some dimensions were positively influenced by integration, while others were positively influenced by stand-alone care; some were not influenced by integration at all. Assumptions on the inherent value of integrated care were challenged in this high HIV prevalence setting, where stand-alone HIV care could be equally if not more satisfying to many clients. Those aiming to scale-up access to HIV care in this region may need to consider providing a variety of treatment models for clients with different health care needs.

OBJECTIVE: To compare socio-demographic patterns in access to antiretroviral therapy (ART) across four community HIV cohort studies in Africa. METHODS: Data on voluntary counselling and testing and ART use among HIV-infected persons were analysed from Karonga (Malawi), Kisesa (Tanzania), Masaka (Uganda) and Manicaland (Zimbabwe), where free ART provision started between 2004 and 2007. ART coverage was compared across sites by calculating the proportion on ART among those estimated to need treatment, by age, sex and educational attainment. Logistic regression was used to identify socio-demographic characteristics associated with undergoing eligibility screening at an ART clinic within 2 years of being diagnosed with HIV, for three sites with information on diagnosis and screening dates. RESULTS: Among adults known to be HIV-infected from serological surveys, the proportion who knew their HIV status was 93% in Karonga, 37% in Kisesa, 46% in Masaka and 25% in Manicaland. Estimated ART coverage was highest in Masaka (68%) and lowest in Kisesa (2%). The proportion of HIV-diagnosed persons who were screened for ART eligibility within 2 years of diagnosis ranged from 14% in Kisesa to 84% in Masaka, with the probability of screening uptake increasing with age at diagnosis in all sites. CONCLUSIONS: Higher HIV testing rates among HIV-infected persons in the community do not necessarily correspond with higher uptake of ART, nor more equitable treatment coverage among those in need of treatment. In all sites, young adults tend to be disadvantaged in terms of accessing and initiating ART, even after accounting for their less urgent need.

OBJECTIVE: To describe the impact of antiretroviral therapy (ART) on mortality rates among adults participating in an HIV community cohort study in north-west Tanzania. METHODS: Serological and demographic surveillance rounds have been undertaken in a population of approximately 30000 people since 1994. Free HIV care including ART has been available since 2005. Event history analysis was used to compare mortality rates among HIV-negative and HIV-positive adults in the 5-year period before and after the introduction of ART. Crude and adjusted hazard ratios were calculated using exponential regression models. Interaction between time period and HIV status was assessed to investigate whether there was a non-linear relationship between these two variables. RESULTS: Male and female mortality patterns varied over the pre- and post-ART period. In women the crude death rate fell for both HIV negatives and HIV positives hazard rate ratio (HRR = 0.71; 95%CI 0.51-0.99 and HRR = 0.68; 95%CI: 0.46-0.99 respectively). For men the mortality among the HIV negatives increased (HRR = 1.47; 95%CI: 1.06-2.03) while the decline in mortality among the HIV positives (HRR = 0.77; 95%CI 0.52-1.13) was not statistically significant. The largest decrease in HIV-positive mortality over the two periods was among the 30- to 44-year-old age group for women and among the 45- to 59-year-old age group for men. CONCLUSION: There has been a modest effect on mortality in the study population following the introduction of free ART 5 years ago. Improving access to treatment and placing greater focus on retaining individuals on treatment are essential if the full potential of treatment for reducing HIV-related mortality is to be realised. (c) 2012 Blackwell Publishing Ltd.

objective To provide a broad and up-to-date picture of the effect of antiretroviral therapy (ART) provision on population-level mortality in Southern and East Africa. methods Data on all-cause, AIDS and non-AIDS mortality among 15–59 year olds were analysed from demographic surveillance sites (DSS) in Karonga (Malawi), Kisesa (Tanzania), Masaka (Uganda) and the Africa Centre (South Africa), using Poisson regression. Trends over time from up to 5 years prior to ART roll-out, to 4–6 years afterwards, are presented, overall and by age and sex. For Masaka and Kisesa, trends are analysed separately for HIV-negative and HIV-positive individuals. For Karonga and the Africa Centre, trends in AIDS and non-AIDS mortality are analysed using verbal autopsy data. results For all-cause mortality, overall rate ratios (RRs) comparing the period 2–6 years following ART roll-out with the pre-ART period were 0.58 (5.9 vs. 10.2 deaths per 1000 person-years) in Karonga, 0.79 (7.2 vs. 9.1 deaths per 1000 person-years) in Kisesa, 0.61 (6.7 compared with 11.0 deaths per 1000 person-years) in Masaka and 0.79 (14.8 compared with 18.6 deaths per 1000 person-years) in the Africa Centre DSS. The mortality decline was seen only in HIV-positive individuals ⁄ AIDS mortality, with no decline in HIV-negative individuals ⁄ non-AIDS mortality. Less difference was seen in Kisesa where ART uptake was lower. conclusions Falls in all-cause mortality are consistent with ART uptake. The largest falls occurred where ART provision has been decentralised or available locally, suggesting that this is important.

OBJECTIVE To analyse survival and retention rates of the Tanzanian care and treatment programme. METHODS: Routine patient-level data were available from 101 of 909 clinics. Kaplan-Meier probabilities of mortality and attrition after ART initiation were calculated. Mortality risks were corrected for biases from loss to follow-up using Eggers nomogram. Smoothed hazard rates showed mortality and attrition peaks. Cox regression identified factors associated with death and attrition. Median CD4 counts were calculated at 6 month intervals. RESULTS: In 88875 adults 18% were lost to follow up 12 months after treatment initiation and 36% after 36 months. Cumulative mortality reached 10% by 12 months (15% after correcting for loss to follow-up) and 14% by 36 months. Mortality and attrition rates both peaked within the first six months and were higher among males those under 45 kg and those with CD4 counts below 50 cells/mul at ART initiation. In the first year on ART median CD4 count increased by 126 cells/mul with similar changes in both sexes. CONCLUSION: Earlier diagnoses through expanded HIV testing may reduce high mortality and attrition rates if combined with better patient tracing systems. Further research is needed to explore reasons for attrition. (c) 2012 Blackwell Publishing Ltd.

Irregular or delayed attendance at HIV treatment clinics among HIV-positive individuals can have negative implications for clinical outcomes and may ultimately undermine the effectiveness of national treatment programmes. This study explores factors influencing attendance at HIV clinic appointments among patients in a rural ward in north-west Tanzania. Forty-two in-depth interviews (IDI) and four focus group discussions were conducted with HIV-infected persons who had been referred to a nearby antiretroviral therapy (ART) clinic, and IDI were undertaken with 11 healthcare workers involved in diagnosis, referral and care of HIV-positive patients. The Health Belief Model was applied to explore the role of health-related beliefs and the perceived barriers and benefits associated with regular clinic attendance. Perceived susceptibility to HIV-related illnesses emerged as an important factor influencing clinic attendance, and was often manifest through expressions of acceptance or denial of HIV status and knowledge of HIV disease progression. Denial of HIV status was often associated with using alternative healers, and could occur prior to, during, or after starting ART. Perceptions of illness severity also influenced HIV clinic attendance, and often evolved in relation to changes in physical symptoms. Barriers to clinic attendance frequently included health systems factors, while physical and social benefits encouraged regular clinic attendance. Self-confidence in being able to sustain clinic attendance was often determined by patients' expectations or experiences of family support. These findings suggest that multi-faceted interventions are required to promote regular HIV clinic attendance, including on-going education, counselling and support in both clinic and community settings. These interventions also need to recognise the evolving needs of patients that accompany changes in physical health, and should address local beliefs around HIV aetiology. Decentralisation of HIV services to rural communities should be considered as a priority to redress the balance between perceived barriers to, and benefits of accessing HIV treatment programmes.

Objective: To compare reported numbers of sexual partners in Eastern and Southern Africa. Methods: Sexual partnership data from four longitudinal population-based surveys (1998–2007) in Zimbabwe, Uganda and South Africa were aggregated and overall proportions reporting more than one lifetime sexual partner calculated. A lexis-style table was used to illustrate the average lifetime sexual partners by site, sex, age group and birth cohort. The male-to-female ratio of mean number of partnerships in the last 12 months was calculated by site and survey. For each single year of age, the proportion sexually active in the past year, the mean number of partners in the past year and the proportion with more than one partner in the past year were calculated. Results: Over 90% of men and women between 25 and 45 years of age reported being sexually active during the past 12 months, with most reporting at least one sexual partner. Overall, men reported higher numbers of lifetime sexual partners and partners in the last year than women. The male-to-female ratio of mean partnerships in the last year ranged from 1.41 to 1.86. In southern African cohorts, individuals in later birth cohorts reported fewer sexual partners and a lower proportion reported multiple partnerships compared with earlier birth cohorts, whereas these behavioural changes were not observed in the Ugandan cohorts. Across the four sites, reports of sexual partnerships followed a similar pattern for each sex. Conclusions: The longitudinal results show that reductions in the number of partnerships were more evident in southern Africa than in Uganda.