Self-care practice and associated factors among epileptic patients: a cross-sectional study, Ethiopia.

Introduction: epilepsy results in multidimensional and long term effect on the patients and society. Self-care practice is critical for epileptic patient. So far, the issue of self-care practice still considered as the most important cause of poorly controlled epilepsy. Yet comprehensive epilepsy self-care practice is not recognized, which is not addressed with medical treatment alone has not been studied particular in Ethiopia. The objective was to assess self-care practice and associated factors among epileptic patients on follow up at Jimma Town public hospitals, 2020. Methods: institution based cross-sectional study was conducted from April 08 - May 20/2020. Data was collected using structured interviewer administered questionnaire and data extraction checklist. Simple random sampling technique was used to select a total of 297 study participants. Data was entered to EPI data version 3.5.3 and exported to SPSS version 23.0 for analysis. Variables with p-value < 0.25 on bivariate analysis were candidated for multivariate analyses. Factors with p value < 0.05 on multivariate analyses were considered as statistically significant. Results: a total of 297 study participants were included in the study giving a response rate of 99.0%. Of study participants 146(49.2%) of them were had good self-care practice. Residence (AOR= 1.712, 95%CI: 1.034-2.836, P- 0.037), Seizure frequency (AOR = 0.288, 95% CI: 0.091-0.907, P-0.034), felt stigma (AOR=0.565, 95%CI: 0.342-0.935, P- 0.026) and medication adherence (AOR=0.391, 95%CI: 0.240-0.638, P-0.000) were significantly associated with self-management practice. Conclusion: this study found that half of the study participants were had poor self-care practice. Residence, felt stigma, increased seizure frequency and not adherence to medication were factors contributed for poor self-care practice. Therefore, intervention strategies focused on contributing factor for poor self-care practice should be considered.

Health-related quality of life among patients with chronic diseases during COVID-19 pandemic: a cross-sectional study.

Introduction: in the last two years, COVID-19 has largely changed the rhythm of human life and overwhelmed the healthcare systems globally. Patients with pre-existing chronic diseases have worse outcomes during the COVID-19 pandemic. Methods: an institution-based cross-sectional study was conducted from April 1-30, 2021. Data were collected using an interviewer-administered questionnaire and data extraction checklist. A systematic random sampling technique was used to select a total of 400 study participants. Data were entered into EPI data version 3.5.3 and exported to Statistical Package for the Social Science (SPSS) version 23.0 for analysis. Multivariable logistic regression was used and variables with a p-value < 0.05 were considered statistically significant. Results: three hundred and ten (77.5%) of the respondents had a poor overall health-related quality of life (HRQOL) during the COVID-19 pandemic. Younger age (AOR=0.10.95% CI: 0.04-0.27), no formal education (AOR=5.03, 95% CI: 1.92-13.22), shorter treatment duration(AOR=0.11, 95% CI: 0.04-0.29), presence of respiratory symptoms (AOR=9.69, 95% CI: 2.93-32.09) and missed health-care appointment during COVID-19 (AOR=3.68, 95%CI: 1.82-7.43) were significantly associated with health-related quality of life (HRQOL). Conclusion: most of the respondents had a poor overall health-related quality of life during the COVID-19 pandemic. Consideration of the influence of outbreaks on the continuity of care for a patient and focusing on contributing factors should be an essential concern of the healthcare system. The objective is to assess health-related quality and factors associated with health-related quality of life among patients with chronic diseases during the COVID-19 pandemic.

Impact of COVID-19 on Health Seeking Behavior of Patients with Chronic Disease at Public Hospitals in Jimma Zone, South West Ethiopia.

Background: COVID-19 is a global pandemic with unprecedented medical, economic and social consequences affecting nations across the world. This epidemic arises while chronic diseases are continued to be a public health concern. Though evidence is generated on its impact on the health care system, little is known about the Impact of COVID -19 on the care-seeking behavior of chronic patients. Objective: To assess the Impact of COVID-19 on healthcare-seeking behavior of patients with chronic diseases attending follow-up at public hospitals in Jimma zone, South West Ethiopia. Methods: Facility-based cross-sectional study design was employed. The sample was calculated using the single population proportion formula. Hospitals were selected by using simple random sampling. Then, the final calculated sample size for the study was proportionally allocated to each selected hospital. Data were collected from 400 participants through face-to-face interviews and card reviews. Data were entered into Epi-Data version 3.1 and then exported to SPSS version 23 for analysis. Binary and multivariable logistic regression analyses with 95% CI for odds ratio (OR) were used to identify significant factors. Results: Of the total respondents 156 (39.0%) of them had poor health-seeking behavior. Contact history with COVID -19 patient (AOR = 2.8; 95% CI = 1.1-7.0), perceived moderate depression (AOR = 2.3; 95% CI = 1.2-4.2), perceived extreme depression (AOR = 4.3; 95% CI = 1.8-10.5), shortage of medication (AOR = 2.4; 95% CI = 1.0-6.2) increases the odds of poor health-seeking behavior. In addition, the odds of poor health-seeking in patients with no formal education were higher compared to patients with higher educational status (AOR = 2.7; 95% CI = 1.0-9.0). Conclusion: COVID -19 outbreaks affected the health-seeking behavior of patients with chronic diseases. The impact was found to be more significant among patients who had a contact history with COVID -19 patients. Moreover, perceived depression, shortage of medication, and low educational status were significant predictors of poor health-seeking behavior. Therefore, working on the barriers to the health-seeking behavior of chronic patients may reduce the effect of COVID-19.

Adherence to Antiretroviral Treatment Among People Who Started Treatment on the Same-Day of HIV Diagnosis in Ethiopia: A Multicenter Observational Study.

INTRODUCTION: Since the launch of universal "test and treat" approach in 2016, there has been a significant increase in persons initiated on antiretroviral therapy (ART) on the same-day of human immunodeficiency virus (HIV) diagnosis in low-income settings. However, there are limited studies that investigated the effect of rapid treatment initiation on adherence. In this study, we compared adherence to ART in people who started ART on the same-day of HIV diagnosis and those started more than 7 days after HIV diagnosis. METHODS: We conducted a retrospective cohort analysis using routinely collected data from multiple ART clinics. Participants were at least 15 years old, were newly diagnosed and started on ART between October 2016 and July 2018 in the Amhara region of Ethiopia. We used doubly-robust multivariable logistic regression model to estimate the adjusted effects on adherence. RESULTS: A total of 415 individuals who started ART on the same-day of HIV diagnosis and 527 individuals who started 7 days after their HIV diagnosis were included in the analysis. The proportion of participants who reported optimal adherence was significantly lower in the same-day group at 6- and 12-months (absolute risk difference of 6.5%; 95% CI: 1.1%, 11.9% and 6.8%; 95% CI: 1.2%, 12.5%, respectively) compared to the >7 days group. After adjusting for baseline and non-baseline covariates, the same-day group was less likely to have optimal adherence both at 6- and 12-months (adjusted RR=0.90; 95% CI: 0.86, 0.94 and RR=0.89; 95% CI: 0.83, 0.95, respectively) compared to the >7 days group. CONCLUSION: We observed lower optimal adherence among individuals who started ART on the same-day of HIV diagnosis compared to those who started ART >7 days after their HIV diagnosis. Our findings highlight the importance of identifying adherence barriers, providing support, and ensuring treatment readiness before initiating individuals on same-day ART.

Clinical, ultrasonographic and histopathological diagnosis of ceruminous gland tumors in cats.

Ceruminous gland tumor is the most common tumor of the ear canal in cats. Otoscopic examination of the ear tumor is so difficult due to narrowing of the external ear canal. The present study aimed to investigate clinical, ultrasonographic and histopathological characteristics of feline ceruminous gland neoplasm in cats. Ten cats with unilateral ear canal swelling were subjected to thorough physical and clinical investigations. Ultrasound of the ear canal and parotid gland was performed using 8.00 MHz linear probe. Tissue specimens were collected after surgical excision (total ear canal ablation) for histopathological examination. Clinical examination of the ceruminous tumors revealed firm pinkish mass obliterated the ear canal with purulent or bloody aural discharge. Ultrasound examination of the ear tumor was helpful in detecting the size, shape, echogenicity and extension of the tumors to the surrounding structures as well as the nature of the feline ceruminous tumor. Histopathological examination was the main diagnostic tool for detecting the nature of the ceruminous neoplasms.

Virologic outcomes of people living with human immunodeficiency virus who started antiretroviral treatment on the same-day of diagnosis in Ethiopia: A multicenter observational study.

INTRODUCTION: There have been tremendous achievements in scaling-up antiretroviral therapy (ART) for treatment of human immunodeficiency virus (HIV), following universal "test and treat" policy implementation in low- and middle-income countries. However, its effects on virologic outcomes is not yet well investigated. We compared low viral load status in people living with HIV between those who were initiated on ART on the same-day and after 7 days of being diagnosed with HIV infection. METHODS: We conducted a retrospective cohort study of persons age ≥15 years-old who were newly diagnosed and started on ART between October 2016 and July 2018 at 11 public health facilities in northwest Ethiopia. Exposure was initiation of ART on the same-day of HIV diagnosis. The outcome was low viral load at 12-months following ART initiation. We used double-robust estimator using inverse-probability-weighted regression adjustment to compare the groups. RESULTS: A total of 398 people who started ART on the same-day of HIV diagnosis and 479 people who started 7 days after the initial diagnosis were included in this study. By 12-months following ART initiation, 73.4% (292) in the same-day group vs 83.7% (401) in the >7 days group achieved low viral load (absolute difference = 10.3% (95% CI: 4.9%, 15.8%)). After adjusting for baseline and follow-up covariates, there was statistically significant difference in low viral load status (adjusted difference = 8.3% (95% CI: 3.5%, 13.0%)) between the same-day group and the >7 days group. CONCLUSIONS: Achievement of low viral load by 12-months post-initiation of ART was not optimal among participants who started ART on the same-day of HIV diagnosis. Efforts should be made to reinforce treatment adherence while initiating same-day ART.

Effectiveness of same-day antiretroviral therapy initiation in retention outcomes among people living with human immunodeficiency virus in Ethiopia: empirical evidence.

BACKGROUND: In August 2016, Ethiopia endorsed a universal "test and treat" strategy for people living with human immunodeficiency virus (PLHIV) based on World Health Organization recommendation. However, there is limited evidence on the routine application of the same-day "test and treat" recommendation in low-income settings. This study assessed the effect of same-day treatment initiation on individual-level retention at 6- and 12-months follow-up. METHODS: A multicenter facility-based retrospective cohort study was conducted to compare retention-in-care between PLHIV who started antiretroviral therapy (ART) on the same-day and those started ART > 7 days following HIV diagnoses. Participants were at least 15 years-old and were newly diagnosed and started on ART between October 2016 and July 2018 in 11 health facilities in the Amhara region of Ethiopia. Multivariable logistic regression controlling for potential confounders and Kaplan-Meier survival analysis were used to assess differences in outcomes between the groups. RESULTS: In total, 433 PLHIV started ART on the same-day of diagnosis and 555 PLHIV who started ART > 7 days after HIV diagnosis were included in the study. At 6-months, 82.0% (355) in the same-day group vs 89.4% (496) in the > 7 days group were retained-in-care (absolute risk difference (RD) = 7.4%; 95% confidence interval (CI): 2.9-11.8%). At 12-months, 75.8% (328) in the same-day group vs 82.0% (455) in the > 7 days group were retained-in-care (absolute RD = 6.2%; 95% CI: 1.1, 11.4%). The major drop in retention was in the first 30 days following ART initiation among same-day group. After adjusting for baseline and non-baseline covariates, the same-day group was less likely to be retained-in-care at 6- and 12-months (adjusted risk ratio (RR) = 0.89; 95% CI: 0.87, 0.90 and adjusted RR = 0.86; 95% CI: 0.83, 0.89, respectively). CONCLUSIONS: Reduced retention-in-care can threaten the benefit of the same-day "test and treat" policy. The policy needs to be implemented cautiously with greater emphasis on assessment and preparation of PLHIV for ART to ensure treatment readiness before starting them on same-day ART and close monitoring of patients during early follow-up periods.

Integrating mental health services into human immunodeficiency virus clinics: Lessons from task-sharing between clinical and lay healthcare providers in Ethiopia.

Background: Globally, mental health problems are more common among people living with human immunodeficiency virus (PLHIV) than among the general population. Mental health problems affect human immunodeficiency virus (HIV) treatment adherence and retention. To address this challenge, partners used a task-sharing approach among lay healthcare works and clinicians to integrate mental health services into HIV services at pilot hospitals in the Amhara and Tigray regions of Ethiopia. In this model, trained lay healthcare workers proactively screened patients using a mental health screening tool and subsequently linked potential clients with trained clinicians working at HIV clinics for further diagnosis and treatment. Methods: We retrospectively gathered secondary data, including demographic characteristics and diagnosis information, from mental health clinicians' and case managers' quarterly reports from HIV clinics during the implementation period (January 1, 2013 to March 31, 2014). Results: During the initial three-month implementation period of the project (January to March 2013), case managers screened 5,862 PLHIV for mental health disorders. Case managers referred 687 (11.7%) patients with suspected mental health disorders to clinicians for further evaluation and management. Of the total patients screened by case managers in this period, clinicians confirmed that 454 (7.7%) had a mental health disorder. Overall, the concordance between the case managers' screening results and the clinicians' diagnoses was 67.8% over the 15-month pilot implementation period. Conclusions: Routine screening of PLHIV for mental health disorders helps to proactively identify and manage patients with co-morbidities. The integration of mental health services into HIV care through a task-sharing approach is a feasible strategy that could increase access to mental health services among PLHIV.

Mortality among pediatric patients on HIV treatment in sub-Saharan African countries: a systematic review and meta-analysis.

BACKGROUND: Despite substantial improvements in accessibility of Anti-Retroviral Treatment (ART), death of children on ART remains a prevailing challenge in sub-Saharan African (SSA) countries. However, the pooled magnitude of mortality at different ART follow-up periods remains unknown for the region. We estimated the pooled proportion of all-cause mortality for pediatric patients receiving first-line ART at 3, 6, 12, and 24 months follow-up period in SSA. METHODS: We searched for relevant articles published between January 2014 and June 2018 on PubMed, Hinari and Google scholar databases. We searched for additional articles from reference lists and 2014-2018 abstracts archived by the Conference on Retroviruses and Opportunistic Infections (CROI) and the International AIDS Society Conference on HIV Science (IAS). RESULTS: We reviewed 29 articles reporting mortality among pediatric ART patients at different follow-up periods in countries from 2001 to 2016. Among the 51,619 pediatric ART patients in these cohorts, studies reported 4061 (7.9%) all-cause cumulative death. The cumulative pooled proportion of mortality at 3, 6, 12 and 24 months of ART were 3% (95% CI: 3.0-4.0), 5% (95% CI: 4.0-6.0), 6% (95% CI: 5.0-7.0) and 7% (95% CI: 6.0-8.0), respectively. CONCLUSIONS: In SSA, significant proportion of mortality among children occurs in the first 3-6 months of ART initiation. Western Africa has a little higher estimate of mortality among pediatric ART patients at 6 and 12 months of follow-up. Strategies to prevent early mortality including thorough screening and management of opportunistic infections before ART initiation are needed.

Magnitude of opportunistic diseases and their predictors among adult people living with HIV enrolled in care: national level cross sectional study, Ethiopia.

BACKGROUND: Opportunistic diseases cause morbidity and mortality among human immunodeficiency virus (HIV) infected persons. There is dearth of evidence on the magnitude and predictors of opportunistic diseases among PLHIV in Ethiopia. This study was conducted to determine the magnitude and predictors of opportunistic diseases among adults enrolled in the national HIV/AIDS care and treatment services and generate information for program planning and medicine quantification in the country. METHODS: A health facility-based cross-sectional study was conducted. Probability proportional to size and random sampling methods were employed to select health facilities and medical records of adult HIV-infected patients respectively. A total of 7826 medical records were reviewed from 60 health facilities nationwide. Socio-demographic and clinical data including diagnosis of opportunistic diseases were collected from the medical records. Period prevalence of opportunistic diseases over one year period was determined. Bivariate and multivariate logistic regression was used to measure associations between independent variables and the dependent variable, occurrence of opportunistic diseases. RESULTS: Of the total of 7826 study participants, 3748 (47.9%) were from hospitals and 4078 were from health centers. The majority (61.8%) were female. The median age was 32 years with interquartile range (IQR) of 27-40. The median duration of stay in HIV care was 56 (IQR = 28-80) months; 7429 (94.9%) were on antiretroviral treatment. A total of 1665 cases of opportunistic diseases were recorded with an overall prevalence estimated at 21.3% (95% confidence interval (CI): 20.36, 22.18%). Skin diseases (4.1%), diarrhea (4.1%), bacterial pneumonia (3.6%), recurrent upper respiratory tract infections (3.1%) and tuberculosis (2.7%) were the leading opportunistic diseases. Isoniazid preventive therapy coverage among eligible patients was 24.8%. Persons with a CD4 count < 200 cells/mm3 [adjusted odds ratio (AOR) 1.80, 95% CI: 1.45, 2.23]; and who were bed ridden or ambulatory functional status [AOR (95% CI) = 3.19 (2.32, 4.39)] were independent predictors of diagnosis of opportunistic diseases. CONCLUSION: Opportunistic diseases were found to be pervasive among HIV infected adults in Ethiopia. Proactive identification and management, and prevention of opportunistic diseases should be strengthened especially among females, ambulatory or bed-ridden, and patients with low CD4 cell count.

Endovascular Management of Microcerebral Aneurysms with Diameter Smaller than 3 mm: Is It Feasible and Safe?

BACKGROUND: The neurosurgical management of microcerebral aneurysms with diameter smaller than 3 mm remains a great challenge as many complications can occur. AIM: Our target was to assess the efficacy and usefulness of endovascular treatment of these lesions. METHODS: We did a prospective and retrospective gathering of the results of endovascular treatments for a group of 16 patients with 16 microcerebral aneurysms. Four patients were treated by direct coil embolization, and 12 patients were managed by remodeling techniques. RESULTS: Coil embolization was technically accessible in all cases. Initial complete occlusion is achieved in 12 patients. We did not face major technical complications such as aneurysmal rupture or coil migration during the endovascular management in 15 patients. Only in 1 case the second and last coil (2/1 mm) migrated distally and could not be retrieved. In this case clinical evidence of neurologic deterioration and weakness in left lower limb due to right anterior cerebral artery territory stroke was evidenced in the follow-up computed tomography scan. Follow-up clinical and radiological studies were available for 9 of 12 surviving patients and showed complete occlusion in 7 cases, and in 1 case aneurysm tiny recanalization was demonstrated after 1 year, which was retreated with complete occlusion, and in another case tiny aneurysm recanalization at the neck appeared after 2 years, which was left under observation. CONCLUSIONS: Endovascular treatment is a beneficial and effective therapeutic alternative to microsurgery for microaneurysms. The long-term assessment of endovascular management for these lesions was not included in that study.

Knowledge and Awareness of Cervical Cancer among HIV-Infected Women in Ethiopia.

Introduction. Cervical cancer is one of the leading causes of cancer death among Ethiopian women. Low awareness of cervical cancer, in combination with low health care seeking behavior, is a key challenge for cervical cancer prevention. This study assessed the knowledge of cervical cancer among HIV-infected women in Ethiopia. Methods. A facility-based cross-sectional survey was conducted from August to September 2012 among HIV-infected women between 21 and 49 years of age. Basic descriptive statistics were performed using SPSS. Results. A total of 432 HIV-infected women participated in this study. About 71% of participants had ever heard of cervical cancer. Among women who had ever heard of cervical cancer, 49% did not know the cause while 74% were able to identify at least one risk factor for cervical cancer. Only 33% of women were able to correctly address when women should seek care and 33% identified at least one treatment option for cervical cancer. Conclusion. This study revealed that knowledge about cervical cancer was generally low, in particular for health care seeking behavior and treatment of cervical cancer. Health awareness programs should be strengthened at both community and health facility levels with emphasis highlighting the causes, risk factors, care seeking behaviors, and treatment options for cervical cancer.

Effect of cadmium toxicity on Vertebrates.

This short article reviews the effect of the toxicity of the heavy metal, cadmium, which, as a contaminant of freshwater, is a threat to human health and can cause itai-itai disease.

The Single-Visit Approach as a Cervical Cancer Prevention Strategy Among Women With HIV in Ethiopia: Successes and Lessons Learned.

INTRODUCTION: Cervical cancer is the second most common form of cancer for women in Ethiopia. Using a single-visit approach to prevent cervical cancer, the Addis Tesfa (New Hope) project in Ethiopia tested women with HIV through visual inspection of the cervix with acetic acid wash (VIA) and, if tests results were positive, offered immediate cryotherapy of the precancerous lesion or referral for loop electrosurgical excision procedure (LEEP). The objective of this article is to review screening and treatment outcomes over nearly 4 years of project implementation and to identify lessons learned to improve cervical cancer prevention programs in Ethiopia and other resource-constrained settings. METHODS: We analyzed aggregate client data from August 2010 to March 2014 to obtain the number of women with HIV who were counseled, screened, and treated, as well as the number of annual follow-up visits made, from the 14 tertiary- and secondary-level health facilities implementing the single-visit approach. A health facility assessment (HFA) was also implemented from August to December 2013 to examine the effects of the single-visit approach on client flow, staff workload, and facility infrastructure 3 years after initiating the approach. RESULTS: Almost all (99%) of the 16,632 women with HIV counseled about the single-visit approach were screened with VIA during the study period; 1,656 (10%) of them tested VIA positive (VIA+) for precancerous lesions. Among those who tested VIA+ and were thus eligible for cryotherapy, 1,481 (97%) received cryotherapy treatment, but only 80 (63%) women eligible for LEEP actually received the treatment. The HFA results showed frequent staff turnover, some shortage of essential supplies, and rooms that were judged by providers to be too small for delivery of cervical cancer prevention services. CONCLUSION: The high proportions of VIA screening and cryotherapy treatment in the Addis Tesfa project suggest high acceptance of such services by women with HIV and feasibility of implementation in secondary- and tertiary-level health facilities. However, success of cervical cancer prevention programming must address wider health system challenges to ensure sustainability and appropriate scale-up to the general population of Ethiopia and other resource-constrained settings.

Predictors of loss to follow-up before HIV treatment initiation in Northwest Ethiopia: a case control study.

BACKGROUND: In Ethiopia, there is a growing concern about the increasing rates of loss to follow-up (LTFU) in HIV programs among people waiting to start HIV treatment. Unlike other African countries, there is little information about the factors associated with LTFU among pre-antiretroviral treatment (pre-ART) patients in Ethiopia. We conducted a case-control study to investigate factors associated with pre-ART LTFU in Ethiopia. METHODS: Charts of HIV patients newly enrolled in HIV care at Gondar University Hospital (GUH) between September 11, 2008 and May 8, 2011 were reviewed. Patients who were "loss to follow-up" during the pre-ART period were considered to be cases and patients who were "in care" during the pre-ART period were controls. Logistic regression analysis was used to explore factors associated with pre-ART LTFU. RESULTS: In multivariable analyses, the following factors were found to be independently associated with pre-ART LTFU: male gender [Adjusted Odds Ratio (AOR) = 2.00 (95% CI: 1.15, 3.46)], higher baseline CD4 cell count (251-300 cells/µl [AOR = 2.64 (95% CI: 1.05, 6.65)], 301-350 cells/µl [AOR = 5.21 (95% CI: 1.94, 13.99)], and >350 cells/µl [AOR = 12.10 (95% CI: 6.33, 23.12)] compared to CD4 cell count of ≤ 200 cells/µl) and less advanced disease stage (WHO stage I [AOR = 2.81 (95% CI: 1.15, 6.91)] compared to WHO stage IV). Married patients [AOR = 0.39 (95% CI: 0.19, 0.79)] had reduced odds of being LTFU. In addition, patients whose next visit date was not documented on their medical chart [AOR = 241.39 (95% CI: 119.90, 485.97)] were more likely to be LTFU. CONCLUSION: Our study identified various factors associated with pre-ART LTFU. The findings highlight the importance of giving considerable attention to pre-ART patients' care from the time that they learn of their positive HIV serostatus. The completeness of the medical records, the standard of record keeping and obstacles to retrieving charts also indicate a serious problem that needs due attention from clinicians and data personnel.

Case management to improve adherence for HIV-infected patients receiving antiretroviral therapy in Ethiopia: a micro-costing study.

BACKGROUND: Adherence to antiretroviral medication regimens is essential to good clinical outcomes for HIV-infected patients. Little is known about the costs of case management (CM) designed to improve adherence for patients identified as being at risk for poor adherence in resource-constrained settings. This study analyzed the costs, outputs, unit costs and correlates of unit cost variation for CM services in 14 ART sites in Ethiopia from October 2008 through September 2009. METHODS: This study applied standard micro-costing methods to identify the incremental costs of the CM program. We divided total CM-attributable costs by three output measures (patient-quarters of CM services delivered, number of patients served and successful patient exits) to derive three separate indices of unit costs. The relationships between unit costs and two operational factors (scale and service-volume to staff ratios) were quantified through bivariate analyses. RESULTS: The CM program delivered 4,598 patient-quarters of services, serving 5,056 patients and 1,995 successful exits at a cost of $167,457 over 12 months, or $36 per patient-quarter, $33 per patient served and $84 per successful exit from the CM program. Among the 14 sites, mean costs were $11,961 (sd, $3,965) for the 12-month study period, and $51 (sd, $36) per patient-quarter; $48 (sd, $32) per patient served; and $183 (sd, $157) per successful exit. Unit costs varied inversely with scale (r, -0.70 for cost per patient-quarter versus patient-quarters of service) and with the service-volume to staff ratio (r, -0.68 for cost per patient-quarter versus staff per patient-quarter). CONCLUSIONS: For those receiving CM, the program adds 0.52% to the lifetime cost of ART. These data reflect wide variation in unit costs among the study sites and suggest that high patient volume may be a major determinant of CM program efficiency. The observed variations in unit costs also indicate that there may be opportunities to identify staffing patterns that increase overall program efficiency.