Search

Evaluations of sub-national anti-retroviral therapy (ART) programmes’ performance are important to support regional programme planning and epidemic response. We constructed a four-year retrospective cohort of clients from 10 care and treatment clinics (CTC) in the Mbeya region of Tanzania using routinely collected data from patients initiating ART between January 1, 2008 and March 31, 2012. Our primary outcomes were mortality rate and lost to follow up. We calculated ART coverage based on regional prevalence estimates and used medical cards, drug registers and quarterly reports to assess data quality. We enrolled 17,813 participants into the cohort. More patients initiated ART at WHO stages 3 (58.9%), and at CD4 cell counts between 50-199 cells/µl (56%). The proportion of patients initiating ARTs at a CD4 counts

Prevention of exposure to the COVID-19 virus in the general population is an essential strategy to slow community transmission. This paper shares the experiences and challenges of community engagement in COVID-19 prevention in the Kilimanjaro region, Northern Tanzania implemented by our team from the Institute of Public Health (IPH), Kilimanjaro Christian Medical University College (KCMUCo) in collaboration with the COVID-19 response team in the Moshi Municipality. We conducted an education session with the COVID-19 response team and together brainstormed transmission hotspots and which interventions would be most feasible in their settings. The first hotspot identified was crowded local market spaces. Suggested interventions included targeted and mass public health education through the engagement of market opinion leaders, public announcements, and radio shows. We conducted participatory rural appraisal techniques to enable market vendors and clients to visualize two-meter distances and provided a prototype hand-washing facility that was foot operated. We found mass public health educational campaigns essential to inform and update the public about COVID-19 pandemic and to address rumors and misinformation, which hampers compliance with public health interventions. Coordinated efforts among stakeholders in the country are necessary to develop context-specific prevention and case management strategies following the national and international guidelines. Local ownership of recommended interventions is necessary to ensure compliance.

Background HIV-related stigma significantly impacts HIV care engagement, including in prevention of mother-to-child transmission of HIV (PMTCT) programs. Maisha is a stigma-based counseling intervention delivered during the first antenatal care (ANC) visit, complementing routine HIV counseling and testing. The goal of Maisha is to promote readiness to initiate and sustain treatment among those who are HIV-positive, and to reduce HIV stigmatizing attitudes among those who test negative. Methods A pilot randomized control trial will assess the feasibility and acceptability of delivering Maisha in a clinical setting, and the potential efficacy of the intervention on HIV care engagement outcomes (for HIV-positive participants) and HIV stigma constructs (for all participants). A total of 1000 women and approximately 700 male partners will be recruited from two study clinics in the Moshi municipality of Tanzania. Participants will be enrolled at their first ANC visit, prior to HIV testing. It is estimated that 50 women (5%) will be identified as HIV-positive. Following consent and a baseline survey, participants will be randomly assigned to either the control (standard of care) or the Maisha intervention. The Maisha intervention includes a video and counseling session prior to HIV testing, and two additional counseling sessions if the participant tests positive for HIV or has an established HIV diagnosis. A subset of approximately 500 enrolled participants (all HIV-positive participants, and a random selection of HIV-negative participants who have elevated stigma attitude scores) will complete a follow-up assessment at 3 months. Measures will include health outcomes (care engagement, antiretroviral adherence, depression) and HIV stigma outcomes. Quality assurance data will be collected and the feasibility and acceptability of the intervention will be described. Statistical analysis will examine potential differences between conditions in health outcomes and stigma measures, stratified by HIV status. Discussion ANC provides a unique and important entry point to address HIV stigma. Interventions are needed to improve retention in PMTCT care and to improve community attitudes toward people living with HIV. Results of the Maisha pilot trial will be used to generate parameter estimates and potential ranges of values to estimate power for a full cluster-randomized trial in PMTCT settings, with extended follow-up and enhanced adherence measurement using a biomarker. Trial registration ClinicalTrials.gov, NCT03600142. Registered on 25 July 2018.

Background Women’s empowerment is a multidimensional construct which varies by context. These variations make it challenging to have a concrete definition that can be measured quantitatively. Having a standard composite measure of empowerment at the individual and country level would help to assess how countries are progressing in efforts to achieve gender equality (SDG 5), enable standardization across and within settings and guide the formulation of policies and interventions. The aim of this study was to develop a women’s empowerment index for Tanzania and to assess its evolution across three demographic and health surveys from 2004 to 2016. Results Women’s empowerment in Tanzania was categorized into six distinct domains namely; attitudes towards violence, decision making, social independence, age at critical life events, access to healthcare, and property ownership. The internal reliability of this six-domain model was shown to be acceptable by a Cronbach’s α value of 0.658. The fit statistics of the root mean squared error of approximation (0.05), the comparative fit index (0.93), and the standardized root mean squared residual (0.04) indicated good internal validity. The structure of women’s empowerment was observed to have remained relatively constant across three Tanzanian demographic and health surveys. Conclusions The use of factor analysis in this research has shown that women’s empowerment in Tanzania is a six-domain construct that has remained relatively constant over the past ten years. This could be a stepping stone to reducing ambiguity in conceptualizing and operationalizing empowerment and expanding its applications in empirical research to study different women related outcomes in Tanzania.

The modelling of HIV trends in Tanzania uses surveillance data from antenatal clinics after adjusting for the reduction in fertility of women living with HIV (WLWH). The rollout of HIV care and treatment services has enabled many WLWH to start on antiretroviral treatment (ART) earlier and are counselled on the options to prevent HIV transmission to their children. The assumption that being HIV positive leads to lower fertility needs to be revisited. This study aims to quantify the effect of ART program expansion on the fertility rate of WLWH in Tanzania. We used Cox regression model to estimate fertility rate and associated factors among WLWH of reproductive age (15-49 years) who enrolled in HIV care and treatment at 57 centers in Tabora from 2008 to 2014. A decomposition of Poisson regression was used to explore the reasons for fertility rate differences observed among WLWH. A total of 6,397 WLWH aged 15-49 years were followed for a median time of 2.0 years. The total fertility rate of 48.8/1,000 person years (95%CI: 44.6 to 52.9/1,000) was inversely proportional to age and WHO clinical staging. WLWH on ART had higher fertility compared to those not started on ART (aHR = 1.5, 95%CI: 1.2-1.9). Being married or cohabiting, having higher CD4 cell count and not using contraceptives were associated with higher fertility rate. The fertility rate after post-ART initiation was 54.95/1,000 and among pre-ART users was 40.52/1,000, a difference of 14.43/1,000 in fertility rate between the groups. In the decomposition analysis, proximate determinants of fertility rate among WLWH on ART accounted for a 93.8% smaller increase than expected. In an era of ART expansion in Tabora region, fertility rates of WLWH increased. Higher fertility rates in women on ART may alter the estimation of HIV prevalence and incidence.

HIV stigma has a profound impact on clinical outcomes and undermines the quality of life of people living with HIV (PLWH). Among HIV-negative individuals, misinformation and prejudicial attitudes about HIV can fuel stigma and contribute to discrimination against PLWH. Antenatal care (ANC), with its focus on universal HIV testing, provides a unique entry point to address HIV stigma. This study describes the development of a counseling intervention to address HIV stigma among women and their partners attending a first ANC appointment in Tanzania. Formative work to inform the intervention consisted of qualitative interviews with 32 pregnant and postpartum women (both women living with HIV and HIV-negative women) and 20 healthcare workers. Data were analyzed iteratively, using a thematic analysis approach, to identify intervention targets. The resulting intervention, Maisha (Swahili for “Life”), includes three sessions informed by the HIV Stigma Framework and Cognitive-Behavioral Therapy: a video and brief counseling session prior to HIV testing and, for those who test seropositive for HIV, two additional sessions building on the video content. A pilot test of the intervention is in process. Addressing HIV stigma at the first ANC visit can help individuals living with HIV to overcome stigma-related barriers to the initiation and maintenance of HIV care, and can reduce stigmatizing attitudes among those who test negative for HIV.

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.

Background: In 2014, Tanzania adopted the Option B+ policy for the prevention of mother-to-child transmission of HIV (PMTCT), which stipulates lifelong antiretroviral therapy (ART) for HIV-infected pregnant, postpartum and breastfeeding women, irrespective of CD4 count or WHO clinical staging. Loss to follow-up (LTFU) during pregnancy and the postpartum period may undermine the effectiveness of Option B+. Factors associated with no follow-up (NFU) care, may differ from those associated with LTFU at later time points. This study aimed to identify factors associated with NFU and LTFU among women who initiate ART under Option B+ in Moshi, Tanzania. Methods: We conducted a retrospective chart review of patients initiating ART on Option B+ between February 2014 and December 2015 in Moshi Municipality, Tanzania. Multivariable log-binomial regression was used to analyse factors associated with NFU. Kaplan-Meier survival functions were used to estimate time to LTFU. Multivariable Cox proportion hazards regression models were used to evaluate variables associated with time to LTFU. Results: Among 468 women initiating ART under the option B+ programme, 109 (23.3%) had NFU after the initial appointment. Factors associated with increased risk of NFU were: age < 25 years (adjusted hazard ratio [aRR] 1.7; 95% CI, 1.2 to 2.3), initiating ART at a hospital compared to a lower level health facilities (aRR 2.9; 95% CI, 2.1 to 3.9), and having no treatment supporter (aRR 1.5; 95% CI, 1.1 to 2.1). LTFU was higher in women aged < 25 years (aHR 1.4; 95% CI, 1.1 to 1.9), and in women with no treatment supporter (aHR 1.8; 95% CI, 1.4 to 2.3). In women who returned to the clinic after ART initiation, no factor was significantly associated with LTFU. Conclusion: The factors associated with NFU (being young, not having a treatment supporter, and being diagnosed at hospitals) reflect a vulnerable and potentially highly mobile population. Additional interventions are needed to support and retain this group at ART initiation on Option B+.

Objective To monitor the effectiveness of the prevention of mother-to-child transmission (PMTCT) components in reducing mother-to-child transmission of HIV in Kilimanjaro region, Tanzania. Methods We conducted a retrospective registry-based cohort study of HIV-exposed children aged 4 weeks to 18 months. Eligible children had a DNA polymerase chain reaction HIV antigen test between January 2009 and August 2012. We collected and analysed the data on the PMTCT components provided. We used logistic regression to explore factors associated with successful PMTCT usage and with infant infection. Results We studied 561 children; 283 (50.5%) were from rural areas. Breastfeeding was reported by 519 (92.5%) of mothers. In 469 (83.6%) mother–baby pairs, both received chemoprophylaxis, whereas in 9 (1.6%) pairs, neither mother nor baby received any chemoprophylaxis. Of the 522 (93.0%) infants with known outcomes at 6 months, 227 (43.5%) were alive, 258 (49.4%) were lost to follow-up, 34 (6.5%) had transferred and 3 (0.6%) had died. A total of 54 (9.6%) children were infected. Transmission rates of HIV when only the mother (adjusted odds ratio [aOR] 1.49, 95% CI: 0.47–4.77) or only the baby (aOR 1.06, 95% CI: 0.23–5.01) received chemoprophylaxis were not significantly different from transmission rates when both mother and baby received antiretroviral chemoprophylaxis. Mixed feeding practices were not associated with significantly increased risk (aOR 4.09, 95% CI: 0.58–28.76) compared with exclusive breastfeeding. Conclusion This study showed that rate of MTCT of HIV was 9.6% in Tanzania between 2009 and 2012. The intrapartum and child chemoprophylaxis components of the PMTCT programme were well implemented with 84% of both mothers and their babies getting full chemoprophylaxis, and effective in reducing mother-to-child transmission. Objectif Surveiller l'efficacite des composantes de la PTME dans la reduction de la transmission mere-enfant du VIH dans la region du Kilimandjaro, en Tanzanie. Methodes Nous avons mene une etude de cohorte retrospective sur base de registre, sur des enfants exposes au VIH âges de quatre semaines a 18 mois. Les enfants admissibles avaient recu un test PCR de l'ADN de l'antigene du VIH entre janvier 2009 et aout 2012. Nous avons collecte et analyse les donnees sur les composantes fournies de la PTME. Nous avons utilise la regression logistique pour etudier les facteurs associes a un usage reussi de la PTME et a l'infection du nourrisson. Resultats Nous avons etudie 561 enfants; 283 (50,5%) provenaient de zones rurales. L'allaitement maternel a ete rapporte par 519 (92,5%) meres. Chez 469 (83,6%) paires mere-enfant, tous les deux de la paire ont recu la chimioprophylaxie, tandis que chez 9 (1,6%) paires, ni la mere, ni le bebe n'a recu de chimioprophylaxie. Sur les 522 (93,0%) nourrissons avec des resultats connus a 6 mois, 227 (43,5 %) etaient en vie, 258 (49,4%) etaient perdus au suivi, 34 (6,5%) avait ete transferes et 3 (0,6 %) etaient morts. 54 (9,6%) enfants etaient infectes. Le taux de transmission du VIH lorsque la mere (AOR: 1,49; IC95%: 0,47 a 4,77) ou seulement le bebe (AOR: 1,06; IC95%: 0,23 a 5,01) a recu une chimioprophylaxie ne sont pas significativement differents des taux de transmission lorsque la mere et le bebe avaient recu une chimioprophylaxie ARV. Les pratiques d'alimentation mixtes n'ont pas ete associees a un accroissement significatif du risque (AOR: 4,09; IC95%: 0,58 a 28,76) par rapport a l'allaitement maternel exclusif. Conclusion Cette etude a montre que le taux de transmission mere-enfant du VIH etait de 9,6% en Tanzanie entre 2009 et 2012. Les composantes du programme PTME visant le stade intrapartum et la chimioprophylaxie des enfants ont ete bien implementees avec 84% des meres et leurs bebes recevant une chimioprophylaxie complete, et elles ont ete efficaces dans la reduction de la transmission mere-enfant. Objetivo Monitorizar la efectividad de los componentes de los programas de prevencion de la transmision vertical (PTV) en la reduccion de la transmision madre-hijo del VIH en la region del Kilimanjaro, Tanzania. Metodos Hemos realizado un estudio retrospectivo de cohortes, basado en registros, de ninos con edades comprendidas entre las 4 semanas y los 18 meses y expuestos al VIH. A los ninos que cumplian criterios se les realizo mediante PCR una prueba de deteccion de antigeno del VIH, entre Enero 2009 y Agosto 2012. Recogimos y analizamos datos sobre los componentes de PTV ofrecidos. Utilizamos una regresion logistica para explorar los factores asociados con el uso exitoso de la PTV y con la infeccion de los bebes. Resultados Estudiamos a 561 ninos; 283 (50.5%) provenian de areas rurales. 519 (92.5%) de las madres reportaron haber amamantado a sus hijos. En 469 (83.6%) parejas madre-hijo, ambos habian recibido profilaxis, mientras que en 9 (1.6%) parejas ni la madre ni el hijo habian recibido quimioprofilaxis. De los 522 (93.0%) bebes con resultados conocidos a los 6 meses, 227 (43.5%) continuaban vivos, 258 (49.4%) habian sido perdidos durante el seguimiento, 34 (6.5%) habian salido del area de estudio y 3 (0.6%) habian muerto. 54 (9.6%) ninos estaban infectados. Las tasas de transmision del VIH cuando solo la madre (AOR 1.49, IC 95%: 0.47–4.77) o solo el bebe (AOR 1.06, IC 95%: 0.23–5.01) habian recibido quimioprofilaxis no eran significativamente diferentes de la tasa de transmision cuando ambos (madre e hijo) recibian TAR. Las practicas de alimentacion mixtas no estaban asociadas con un riesgo significativamente aumentado (AOR 4.09, IC 95%: 0.58–28.76) comparado con el amamantamiento exclusivo. Conclusion Este estudio muestra que la tasa de transmision del VIH entre madre e hijo era del 9.6% en Tanzania entre el 2009 y el 2012. Los componentes de quimioprofilaxis dentro del parto y para el bebe del programa para la PTV estaban bien implementados, con un 84% de las madres e hijos recibiendo una quimioprofilaxis completa, y eran efectivos a la hora de reducir la transmision vertical.

Objectives The nature of patient–provider interactions and communication is widely documented to significantly impact on patient experiences, treatment adherence and health outcomes. Yet little is known about the broader contextual factors and dynamics that shape patient–provider interactions in high HIV prevalence and limited-resource settings. Drawing on qualitative research from five sub-Saharan African countries, we seek to unpack local dynamics that serve to hinder or facilitate productive patient–provider interactions. Methods This qualitative study, conducted in Kisumu (Kenya), Kisesa (Tanzania), Manicaland (Zimbabwe), Karonga (Malawi) and uMkhanyakude (South Africa), draws upon 278 in-depth interviews with purposively sampled people living with HIV with different diagnosis and treatment histories, 29 family members of people who died due to HIV and 38 HIV healthcare workers. Data were collected using topic guides that explored patient testing and antiretroviral therapy treatment journeys. Thematic analysis was conducted, aided by NVivo V.8.0 software. Results Our analysis revealed an array of inter-related contextual factors and power dynamics shaping patient–provider interactions. These included (1) participants’ perceptions of roles and identities of ‘self’ and ‘other’; (2) conformity or resistance to the ‘rules of HIV service engagement’ and a ‘patient-persona’; (3) the influence of significant others’ views on service provision; and (4) resources in health services. We observed that these four factors/dynamics were located in the wider context of conceptualisations of power, autonomy and structure. Conclusion Patient–provider interaction is complex, multidimensional and deeply embedded in wider social dynamics. Multiple contextual domains shape patient–provider interactions in the context of HIV in sub-Saharan Africa. Interventions to improve patient experiences and treatment adherence through enhanced interactions need to go beyond the existing focus on patient–provider communication strategies.

Objective In view of expanding ‘test and treat’ initiatives, we sought to elicit how the experience of HIV testing influenced subsequent engagement in HIV care among people diagnosed with HIV. Methods As part of a multisite qualitative study, we conducted in-depth interviews in Uganda, South Africa, Tanzania, Kenya, Malawi and Zimbabwe with 5–10 health workers and 28–59 people living with HIV, per country. Topic guides covered patient and provider experiences of HIV testing and treatment services. Themes were derived through deductive and inductive coding. Results Various practices and techniques were employed by health workers to increase HIV testing uptake in line with national policies, some of which affected patients’ subsequent engagement with HIV services. Provider-initiated testing was generally appreciated, but rarely considered voluntary, with instances of coercion and testing without consent, which could lead to disengagement from care. Conflicting rationalities for HIV testing between health workers and their clients caused tensions that undermined engagement in HIV care among people living with HIV. Although many health workers helped clients to accept their diagnosis and engage in care, some delivered static, morally charged messages regarding sexual behaviours and expectations of clinic use which discouraged future care seeking. Repeat testing was commonly reported, reflecting patients’ doubts over the accuracy of prior results and beliefs that antiretroviral therapy may cure HIV. Repeat testing provided an opportunity to develop familiarity with clinical procedures, address concerns about HIV services and build trust with health workers. Conclusion The principles of consent and confidentiality that should underlie HIV testing and counselling practices may be modified or omitted by health workers to achieve perceived public health benefits and policy expectations. While such actions can increase HIV testing rates, they may also jeopardise efforts to connect people diagnosed with HIV to long-term care, and undermine the potential of test and treat interventions.

Objectives This article considers the potential of ‘theories of practice’ for studying and understanding varied (dis)engagement with HIV care and treatment services and begins to unpack the assemblage of elements and practices that shape the nature and duration of individuals’ interactions with HIV services. Methods We obtained data from a multicountry qualitative study that explores the use of HIV care and treatment services, with a focus on examining the social organisation of engagement with care as a practice and as manifested in the lives of people living with HIV in sub-Saharan Africa. The dataset comprised of 356 interviews with participants from six countries. Results We noted fluctuating interactions with HIV services in all countries. In line with theories of practice, we found that such varied engagement can be explained by (1) the availability, absence and connections between requisite ‘materialities’ (eg, health infrastructure, medicines), ‘competencies’ (eg, knowing how to live with HIV) and ‘meanings’ (eg, trust in HIV services, stigma, normalisation of HIV) and (2) a host of other life practices, such as working or parenting. These dynamics either facilitated or inhibited engagement with HIV services and were intrinsically linked to the discursive, cultural, political and economic fabric of the participating countries. Conclusion Practice theory provides HIV researchers and practitioners with a useful vocabulary and analytical tools to understand and steer people’s differentiated HIV service (dis)engagement. Our application of practice theory to engagement in HIV care, as experienced by HIV service users and providers in six sub-Saharan African countries, highlights the need for a practice-based approach in the delivery of differentiated and patient-centred HIV services.

Objective To explore barriers and facilitators to accessing postdiagnosis HIV care in five sub-Saharan African countries. Methods In-depth interviews were conducted with 77 people living with HIV (PLHIV) in pre-antiretroviral therapy care or not-yet-in care and 46 healthcare workers. Participants were purposely selected from health and demographic surveillance sites in Karonga (Malawi), Manicaland (Zimbabwe), uMkhanyakude (South Africa), Kisesa (Tanzania) and Rakai and Kyamulibwa (Uganda). Thematic content analysis was conducted, guided by the constructs of affordability, availability and acceptability of care.- Results Affordability: Transport and treatment costs were a barrier to HIV care, although some participants travelled to distant clinics to avoid being seen by people who knew them or for specific services. Broken equipment and drug stock-outs in local clinics could also necessitate travel to other facilities. Availability: Some facilities did not offer full HIV care, or only offered all services intermittently. PLHIV who frequently travelled complained that care was seldom available to them in places they visited. Acceptability: Severe pain or sickness was a key driver for accessing postdiagnosis care, whereas asymptomatic PLHIV often delayed care-seeking. A belief in witchcraft was a deterrent to accessing clinical care following diagnosis. Changing antiretroviral therapy guidelines generated uncertainty among PLHIV about when to start treatment and delayed postdiagnosis care. PLHIV reported that healthcare workers’ knowledge, attitudes and behaviours, and their ability to impart health education, also influenced whether they accessed HIV care. Conclusion Despite efforts to decentralise services over the past decade, many barriers to accessing HIV care persist. There is a need to increase sustained access to care for PLHIV not yet on treatment, with initiatives that encompass biomedical aspects of care alongside considerations for individual and collective challenges they faced. A failure to do so may undermine efforts to achieve universal access to antiretroviral therapy.

Objectives To explore the bodily and relational experience of taking antiretroviral therapy (ART) and the subsequent effect on retention in HIV care in six sub-Saharan African countries. Methods In-depth interviews were conducted with 130 people living with HIV (PLHIV) who had initiated ART, 38 PLHIV who were lost to follow-up and 53 healthcare workers (HCWs) in Kenya, Uganda, Tanzania, Malawi, Zimbabwe and South Africa. PLHIV were purposely selected to include a range of HIV treatment histories. Deductive and inductive analysis was guided by aspects of practice theory; retention in HIV care following ART initiation was the practice of interest. Results PLHIV who were engaged in HIV care took ART every day, attended clinic appointments and ate as well as possible. For PLHIV, biomedical markers acted as reassurance for their positive treatment progression. However, many described ART side effects ranging from dizziness to conditions severe enough to prevent them from leaving home or caring for themselves or others. In all settings, the primary concern of HCW was ensuring patients achieved viral suppression, with management of side effects seen as a lower priority. Where PLHIV tolerated side effects, they were deemed the lesser of two evils compared with their pre-ART illnesses. Participants who reported feeling well prior to starting ART were often less able to tolerate side effects, and in many cases these events triggered their disengagement from HIV care. Conclusions Retention in ART care is rarely an outcome of rational decision-making, but the consequence of bodily and relational experiences. Initiatives to improve retention should consider how bodily experiences of PLHIV relate to the rest of their lives and how this can be respected and supported by service providers to subsequently improve retention in care.

Background Hypertension is a major contributor to ill health in sub-Saharan Africa. Developing countries need to increase access for screening. This study assesses the feasibility and acceptability of using private sector drug retail outlets to screen for hypertension in Mwanza region, Tanzania. Methods A pilot study took place in eight drug retail outlets from August 2013 to February 2014. Customers ≥18 years were invited for screening. Socio-demographic characteristics, hypertension knowledge, hypertension screening and treatment history were collected. Subjects with systolic blood pressure over 140 mmHg were referred for follow up. Referral slips captured attendance. Mystery client visits and follow up phone calls were conducted to assess service quality. Results A total of 971 customers were screened, one person refused; 109 (11.2%) had blood pressure over 140/90 mmHg and were referred for ongoing assessment; 85/109 (78.0%) were newly diagnosed. Customers reported that the service was acceptable. Service providers were able to follow the protocol. Only 18/85 (21%) newly diagnosed participants visited the referral clinic within two weeks. Conclusions Blood pressure screening was feasible and acceptable to customers of private drug retail outlets. However many who were referred failed to attend at a referral centre and further research is needed in this area.

Introduction : Observational studies have shown considerable attrition among adolescents living with HIV across the “cascade” of HIV care in sub-Saharan Africa, leading to higher mortality rates compared to HIV-infected adults or children. We synthesized evidence from qualitative studies on factors that promote or undermine engagement with HIV services among adolescents living with HIV in sub-Saharan Africa. Methods : We systematically searched five databases for studies published between 2005 and 2016 that met pre-defined inclusion criteria. We used a meta-ethnographic approach to identify first, second and third order constructs from eligible studies, and applied a socio-ecological framework to situate our results across different levels of influence, and in relation to each stage of the HIV cascade. Results and discussion : We identified 3089 citations, of which 24 articles were eligible for inclusion. Of these, 17 were from Southern Africa while 11 were from Eastern Africa. 6 explored issues related to HIV testing, 11 explored treatment adherence, and 7 covered multiple stages of the cascade. Twelve third-order constructs emerged to explain adolescents’ engagement in HIV care. Stigma was the most salient factor impeding adolescents’ interactions with HIV care over the past decade. Self-efficacy to adapt to life with HIV and support from family or social networks were critical enablers supporting uptake and retention in HIV care and treatment programmes. Provision of adolescent-friendly services and health systems issues, such as the availability of efficient, confidential and comfortable services, were also reported to drive sustained care engagement. Individual-level factors, including past illness experiences, identifying mechanisms to manage pill-taking in social situations, financial (in)stability and the presence/absence of future aspirations also shaped adolescents HIV care engagement. Conclusions : Adolescents’ initial and ongoing use of HIV care was frequently undermined by individual-level issues; although family, community and health systems factors played important roles. Interventions should prioritise addressing psychosocial issues among adolescents to promote individual-level engagement with HIV care, and ultimately reduce mortality. Further research should explore issues relating to care linkage and ART initiation in different settings, particularly as “test and treat” policies are scaled up. Keywords adolescents; HIV /AIDS; sub-Saharan Africa; antiretroviral therapy; HIV care cascade; HIV care continuum; qualitative research; meta-ethnography; stigma (Published: 15 September 2017) Williams S et al. Journal of the International AIDS Society 2017, 20 :21922 http://www.jiasociety.org/index.php/jias/article/view/21922 | http://dx.doi.org/10.7448/IAS.20.1.21922

Background\ud While there are a number of examples of successful small-scale, youth-friendly services interventions aimed at improving reproductive health service provision for young people, these projects are often short term and have low coverage. In order to have a significant, long-term impact, these initiatives must be implemented over a sustained period and on a large scale. We conducted a process evaluation of the 10-fold scale up of an evaluated youth-friendly services intervention in Mwanza Region, Tanzania, in order to identify key facilitating and inhibitory factors from both user and provider perspectives.\ud \ud Methods\ud The intervention was scaled up in two training rounds lasting six and 10 months. This process was evaluated through the triangulation of multiple methods: (i) a simulated patient study; (ii) focus group discussions and semi-structured interviews with health workers and trainers; (iii) training observations; and (iv) pre- and post-training questionnaires. These methods were used to compare pre- and post-intervention groups and assess differences between the two training rounds.\ud \ud Results\ud Between 2004 and 2007, local government officials trained 429 health workers. The training was well implemented and over time, trainers' confidence and ability to lead sessions improved. The district-led training significantly improved knowledge relating to HIV/AIDS and puberty (RR ranged from 1.06 to 2.0), attitudes towards condoms, confidentiality and young people's right to treatment (RR range: 1.23-1.36). Intervention health units scored higher in the family planning and condom request simulated patient scenarios, but lower in the sexually transmitted infection scenario than the control health units. The scale up faced challenges in the selection and retention of trained health workers and was limited by various contextual factors and structural constraints.\ud \ud Conclusions\ud Youth-friendly services interventions can remain well delivered, even after expansion through existing systems. The scaling-up process did affect some aspects of intervention quality, and our research supports others in emphasizing the need to train more staff (both clinical and non-clinical) per facility in order to ensure youth-friendly services delivery. Further research is needed to identify effective strategies to address structural constraints and broader social norms that hampered the scale up.

Background Little is known about how to implement promising small-scale projects to reduce reproductive ill health and HIV vulnerability in young people on a large scale. This evaluation documents and explains how a partnership between a non-governmental organization (NGO) and local government authorities (LGAs) influenced the LGA-led scale-up of an innovative NGO programme in the wider context of a new national multisectoral AIDS strategy. Methods Four rounds of semi-structured interviews with 82 key informants, 8 group discussions with 49 district trainers and supervisors (DTS), 8 participatory workshops involving 52 DTS, and participant observations of 80% of LGA-led and 100% of NGO-led meetings were conducted, to ascertain views on project components, flow of communication and decision-making and amount of time DTS utilized undertaking project activities. Results Despite a successful ten-fold scale-up of intervention activities in three years, full integration into LGA systems did not materialize. LGAs contributed significant human resources but limited finances; the NGO retained control over finances and decision-making and LGAs largely continued to view activities as NGO driven. Embedding of technical assistants (TAs) in the LGAs contributed to capacity building among district implementers, but may paradoxically have hindered project integration, because TAs were unable to effectively transition from an implementing to a facilitating role. Operation of NGO administration and financial mechanisms also hindered integration into district systems. Conclusions Sustainable intervention scale-up requires operational, financial and psychological integration into local government mechanisms. This must include substantial time for district systems to try out implementation with only minimal NGO support and modest output targets. It must therefore go beyond the typical three- to four-year project cycles. Scale-up of NGO pilot projects of this nature also need NGOs to be flexible enough to adapt to local government planning cycles and ongoing evaluation is needed to ensure strategies employed to do so really do achieve full intervention integration.

Purpose There is little evidence from the developing world of the effect of scale-up on model adolescent sexual and reproductive health (ASRH) programmes. In this article, we document the effect of scaling up a school-based intervention (MEMA kwa Vijana) from 62 to 649 schools on the coverage and quality of implementation. Methods Observations of 1,111 students' exercise books, 11 ASRH sessions, and 19 peer-assistant role plays were supplemented with interviews with 47 ASRH-trained teachers, to assess the coverage and quality of ASRH sessions in schools. Results Despite various modifications, the 10-fold scale-up achieved high coverage. A total of 89% (989) of exercise books contained some MEMA kwa Vijana 2 notes. Teachers were enthusiastic and interacted well with students. Students enjoyed the sessions and scripted role plays strengthened participation. Coverage of the biological topics was higher than the psycho-social sessions. The scale-up was facilitated by the structured nature of the intervention and the examined status of some topics. However, delays in the training, teacher turnover, and a lack of incentive for teaching additional activities were barriers to implementation. Conclusions High coverage of participatory school-based reproductive health interventions can be maintained during scale-up. However, this is likely to be associated with significant changes in programme content and delivery. A greater emphasis should be placed on improving teachers' capacity to teach more complex-skills–related activities. Future intervention scale-up should also include an increased level of supervision and may be strengthened by underpinning from national level directives and inclusion of behavioral topics in national examinations.

The expansion in the provision of life-saving antiretroviral therapy (ART) in sub-Saharan Africa over the past 15 years has been an unprecedented achievement for public health. By the end of 2015, an estimated 10.3 million persons living with HIV (PLHIV) were receiving ART in southern and eastern Africa, the most affected region in the world. Just over half of all PLHIV in the region are now receiving ART, more than double the number just 3 years earlier.1 ART scale-up has dramatically reduced HIV-related mortality and morbidity, bringing countless social and economic benefits to communities that had been hard hit by the epidemic. The network for Analysing Longitudinal Population data on HIV/AIDS (ALPHA), a collaboration among 10 health and demographic surveillance system (HDSS) sites in east and southern Africa, has been investigating declines in adult mortality and their causes in seven countries (www.lshtm.ac.uk/alpha).2 Recent analyses from seven sites indicate a substantial impact of HIV treatment programmes on adult mortality following the expansion of ART, with declines ranging from 58% to 84%.3 Despite this progress, there remains a substantial deficit in overall life expectancy among adults living with HIV, with their survival between 5 and 10 years less than among uninfected adults.4 These ‘excess’ deaths among PLHIV are occurring due to late diagnosis, poor linkage to care and treatment, and ART interruptions.5 By the end of 2015, an estimated 44% of PLHIV in southern and eastern Africa remained undiagnosed,6 and rates of linkage to care after diagnosis range widely from 17% to 78%, while ART initiation among those eligible for treatment ranges from 14% to 95%.7 A number of studies have documented reasons for delays in testing, and initiating and adhering to treatment including beliefs that treatment is for people who are sick, fear of side …