Laboratory services in the context of prevention of mother-to-child transmission of HIV testing requirements in Copperbelt Province, Zambia: a qualitative inquiry.

INTRODUCTION: Reliable and timely laboratory results are crucial for monitoring the Prevention of the Mother-to-Child Transmission (PMTCT) cascade, particularly to enable early HIV diagnosis and early intervention. We sought to explore whether and how laboratory services have been prepared to absorb new testing requirements following PMTCT Test-and-Treat policy changes in three districts of Zambia. METHOD: We employed in-depth interviews and thematic data analysis, informed by the health system dynamic framework. Twenty-Six health workers were purposively selected and a document review of laboratory services in the context of PMTCT was undertaken. All face-to-face interviews were conducted in three local government areas in the Copperbelt Province (one urban and two rural) between February 2019 and July 2020. We extracted notes and markings from the transcripts for coding. Different codes were sorted into potential themes and the data extracted were put within the identified themes. Trustworthiness was confirmed by keeping records of all data field notes, transcripts, and reflexive journals. RESULTS: The findings revealed that the health system inputs (infrastructure and supplies, human resources, knowledge, and information and finance) and service delivery were unequal between the rural and urban sites, and this affected the ability of health facilities to apply the new testing requirements, especially, in the rural-based health facilities. The major barriers identified include gaps in the capacity of the existing laboratory system to perform crucial PMTCT clinical and surveillance functions in a coordinated manner and insufficient skilled human resources to absorb the increased testing demands. The centralized laboratory system for HIV testing of mothers and exposed neonates meant facilities had to send specimens to other facilities and districts which resulted in high turnaround time and hence delayed HIV diagnosis. CONCLUSION: New guidelines implemented without sufficient capacitation of health system laboratory capacity severely limited the effectiveness of PMTCT program implementation. This study documented the areas relating to health system inputs and laboratory service delivery where greater support to enable the absorption of the new testing requirements is needed.

Big data- and artificial intelligence-based hot-spot analysis of COVID-19: Gauteng, South Africa, as a case study.

The coronavirus disease 2019 (COVID-19) has developed into a pandemic. Data-driven techniques can be used to inform and guide public health decision- and policy-makers. In generalizing the spread of a virus over a large area, such as a province, it must be assumed that the transmission occurs as a stochastic process. It is therefore very difficult for policy and decision makers to understand and visualize the location specific dynamics of the virus on a more granular level. A primary concern is exposing local virus hot-spots, in order to inform and implement non-pharmaceutical interventions. A hot-spot is defined as an area experiencing exponential growth relative to the generalised growth of the pandemic. This paper uses the first and second waves of the COVID-19 epidemic in Gauteng Province, South Africa, as a case study. The study aims provide a data-driven methodology and comprehensive case study to expose location specific virus dynamics within a given area. The methodology uses an unsupervised Gaussian Mixture model to cluster cases at a desired granularity. This is combined with an epidemiological analysis to quantify each cluster's severity, progression and whether it can be defined as a hot-spot.

Factors influencing the implementation of TB screening among PLHIV in selected HIV clinics in Ghana: a qualitative study.

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

Adherence of HIV clinics to guidelines for the delivery of TB screening among people living with HIV/AIDS in Ghana.

BACKGROUND: Tuberculosis screening of people living with HIV (PLHIV) - an intervention to reduce the burden of TB among PLHIV - is being implemented at HIV clinics in Ghana since 2007, but TB screening coverage remains low. Facility adherence to intervention guidelines may be a factor but is missing in implementation science literature. This study assesses the level of HIV clinic adherence to the guidelines and related facility characteristics in selected district hospitals in Ghana. METHODS: This cross-sectional study was conducted in all 27 district hospitals with HIV clinics, X-ray and geneXpert machines in Ghana. These hospitals are in 27 districts representing about 27% of the 100 district hospitals with HIV clinics in Ghana. A data collection tool with 18-items (maximum score of 29) was developed from the TB/HIV collaborative guidelines to assess facility adherence to four interrelated components of the TB screening programme as stated in the guidelines: intensive TB case-finding among PLHIV (ITCF), Isoniazid preventive therapy initiation (IPT), TB infection control (TIC), and programme review meetings (PRM). Data were collected through record review and interviews with 27 key informants from each hospital. Adherence scores per component were summed to determine an overall adherence score per facility and summarized using medians and converted to proportions. Facility characteristics were assessed and compared across facilities with high (above median) versus low (below median) overall adherence scores, using nonparametric test statistics. RESULTS: From the 27 key interviews and facility records reviewed, the median adherence scores for ITCF, IPT, TIC, and PRM components were 85.7% (IQR: 85.5-100.0), 0% (IQR: 0-66.7), 33.3% (IQR: 33.3-50.0), and 90.0% (IQR: 70.0-90.0), respectively. The overall median adherence score was 62.1% (IQR: 58.6-65.1), and 17 clinics (63%) with overall adherence score above the median were categorized as high adherence. Compared to low adherence facilities, high adherence facilities had statistically significant lower PLHIV clinic attendees per month (256 (IQR: 60-904) vs. 900 (IQR: 609-2622); p = 0.042), and lower HIV provider workloads (28.6 (IQR: 8.6-113) vs. 90 (IQR: 66.7-263.5); p = 0.046), and most had screening guidelines (76%, p < 0.01) and questionnaire (80%, p < 0.01) available on-site. CONCLUSION: PRM had highest score while the IPT component had the lowest score. Almost a third of the facilities implemented the TB screening programme activities with a high level of adherence to the guidelines. We suggest to ensure adherence to all four components, reducing staff workloads and making TB screening questionnaires and guidelines available on-site would increase facility adherence to the intervention and ultimately achieve intervention targets.

A mixed methods approach to exploring the moderating factors of implementation fidelity of the integrated chronic disease management model in South Africa.

BACKGROUND: Chronic care models like the Integrated Chronic Disease Management (ICDM) model strive to improve the efficiency and quality of care for patients with chronic diseases. However, there is a dearth of studies assessing the moderating factors of fidelity during the implementation of the ICDM model. The aim of this study is to assess moderating factors of implementation fidelity of the ICDM model. METHODS: This was a cross-sectional mixed method study conducted in two health districts in South Africa. The process evaluation and implementation fidelity frameworks were used to guide the assessment of moderating factors influencing implementation fidelity of the ICDM model. We interviewed 30 purposively selected healthcare workers from four facilities (15 from each of the two facilities with lower and higher levels of implementation fidelity of the ICDM model). Data on facility characteristics were collected by observation and interviews. Linear regression and descriptive statistics were used to analyse quantitative data while qualitative data were analysed thematically. RESULTS: The median age of participants was 36.5 (IQR: 30.8-45.5) years, and they had been in their roles for a median of 4.0 (IQR: 1.0-7.3) years. The moderating factors of implementation fidelity of the ICDM model were the existence of facilitation strategies (training and clinical mentorship); intervention complexity (healthcare worker, time and space integration); and participant responsiveness (observing operational efficiencies, compliance of patients and staff attitudes). One feature of the ICDM model that seemingly compromised fidelity was the inclusion of tuberculosis patients in the same stream (waiting areas, consultation rooms) as other patients with non-communicable diseases and those with HIV/AIDS with no clear infection control guidelines. Participants also suggested that poor adherence to any one component of the ICDM model affected the implementation of the other components. Contextual factors that affected fidelity included supply chain management, infrastructure, adequate staff, and balanced patient caseloads. CONCLUSION: There are multiple (context, participant responsiveness, intervention complexity and facilitation strategies) interrelated moderating factors influencing implementation fidelity of the ICDM model. Augmenting facilitation strategies (training and clinical mentorship) could further improve the degree of fidelity during the implementation of the ICDM model.

Innovation diffusion: how homogenous networks influence the uptake of community-based injectable contraceptives.

BACKGROUND: Studies have shown that social networks influence health behaviors, including the adoption of health innovations. This study explored the potential for early adopters of community health worker-delivered injectable contraceptives (CHWDIC) to influence the uptake of this innovation by women in their social networks. METHODS: This Social Network Analysis (SNA) study was conducted in Gombe, Nigeria. Twenty women who were early adopters of the CHWDIC were recruited. Each participant (ego) listed ten women of reproductive age (alters) with whom they related. An interviewer-administered questionnaire was used to collect from each ego, data about the nature of her relationship with each alter (ego-alter relationship), whether she talked about CHWDIC with each alter, and whether her listed alters talked to each other about CHWDIC (alter-alter relationship). Data were also collected on age, marital status and education level for each ego and alter. Data were analyzed with UCINET social network analysis software. Variables of interest include homophilia (similarity), density (number of ties as a proportion of possible ties), degree (popularity) and betweeness (frequency of connecting actor pairs who otherwise might not communicate). RESULTS: There were 20 egos and 200 alters. Between two thirds (alters) and three quarters (egos) of the women were 30 years or older. All of the egos and 196 (98%) of alters were married. Most of the networks had similar (homophilic) actors according to certain sociodemographic characteristics - ethnicity, age, education and type of marriage. More than 90% of the networks had density greater than 50%, suggesting high cohesion in most networks. The majority of actors in these networks used injectable contraceptives. In some of the networks, few actors with the highest prominence (betweeness centrality) were not users of injectable contraceptives. CONCLUSION: The study illustrates the application and feasibility of ego SNA in identifying champions and opinion leaders among women of reproductive age group. It also shows the influence of social networks on the diffusion of community-based injectable contraceptives, and how homophilic and dense networks may have positive health externality. The interrelatedness of network members' decision to adopt a health innovation was also demonstrated by the findings of this study.

Health system readiness for innovation scale-up: the experience of community-based distribution of injectable contraceptives in Nigeria.

BACKGROUND: Following the successful pilot of the community-based distribution of injectable contraceptives (CBDIC) by community health extension workers (CHEWs) in Gombe, northern Nigeria in 2010, there was a policy decision to scale-up the innovation to other parts of the country. However, there is limited understanding of health system factors that may facilitate or impede the successful scale-up of this innovation beyond the pilot site. Thus, this study assessed the health system readiness to deliver CBDIC in Nigeria and how this may influence the scale-up process. METHODS: This study was conducted in two Local Government Areas in Gombe State in September 2016. Seven key informant interviews were held with purposively sampled senior officials of the ministries of health at the federal and state levels as well as NGO program managers. Also, 10 in-depth interviews were carried out with health workers. All transcripts were analyzed using the thematic framework analysis approach. RESULT: The availability of a policy framework that supports task-shifting and task-sharing, as well as application of evidence from the pilot programme and capacity building programmes for health workers provided a favourable environment for scale-up. Health system challenges for the scale-up process included insufficient community health workers, resistance to the task-shifting policy from professional health groups (who should support the CHEWs), limited funding and poor logistics management which affected commodity distribution and availability. However, there were also a number of health worker innovations which kept the scale-up going. Health workers sometimes used personal resources to make up for logistics failures and poor funding. They often modify the process in order to adapt to the realities on the ground. CONCLUSION: This study shows health system weaknesses that may undermine scale-up of CBDIC. The study also highlights what happens when scale-up is narrowly focused on the intervention without considering system context, capacity and readiness. However, agency and discretionary decision-making among frontline health workers facilitated the process of scaling up, although the sustainability of this is questionable. Benefits observed during the pilot may not be realised on a larger scale if health system challenges are not addressed.

Process evaluation of implementation fidelity of the integrated chronic disease management model in two districts, South Africa.

BACKGROUND: The Integrated Chronic Disease Management (ICDM) model has been implemented in South Africa to enhance quality of clinical services in Primary Healthcare (PHC) clinics in a context of a high prevalence of chronic conditions and multi-morbidity. This study aimed to assess the implementation fidelity (adherence to guidelines) of the ICDM model. METHODS: A cross-sectional study in 16 PHC clinics in two health districts in South Africa: Dr. Kenneth Kaunda (DKK) and West Rand (WR). A fidelity assessment tool with 89 activities and maximum score of 158 was developed from the four interrelated ICDM model components: facility re-organization, clinical supportive management, assisted self-management and strengthening of support systems. Value stream mapping of patient flow was conducted to analyse waiting time and identify operational inefficiencies. ICDM items were scored based on structured observations, facility document reviews and structured questionnaires completed by healthcare workers. Fidelity scores were summarized using medians and proportions and compared by facilities and districts using Chi-Square and Kruskal Wallis test. RESULTS: The monthly patient headcount over a six-month period in these 16 PHC clinics was a median of 2430 (IQR: 1685-2942) individuals over 20 years. The DKK district had more newly diagnosed TB patients per month [median 5.5 (IQR: 4.00-9.33) vs 2.0 (IQR: 1.67-2.92)], and fewer medical officers per clinic [median 1 (IQR: 1-1) vs 3.5 (IQR:2-4.5)] compared to WR district. The median fidelity scores in both districts for facility re-organization, clinical supportive management, assisted self-management and strengthening of support systems were 78% [29/37, IQR: 27-31)]; 77% [30/39 (IQR: 27-34)]; 77% [30/39 (IQR: 28-34)]; and 80% [35/44 (IQR: 30-37)], respectively. The overall median implementation fidelity of the ICDM model was 79% (125/158, IQR, 117-132); WR was 80% (126/158, IQR, 123-132) while DKK was 74% (117/158, IQR, 106-130), p = 0.1409. The lowest clinic fidelity score was 66% (104/158), while the highest was 86% (136/158). A patient flow analysis showed long (2-5 h) waiting times and one stream of care for acute and chronic services. CONCLUSION: There was some variability of scores on components of the ICDM model by PHC clinics. More research is needed on contextual adaptations of the model.

Selecting and Tailoring Implementation Strategies to Improve Human Papillomavirus Vaccine Uptake in Zambia: A Nominal Group Technique Approach.

The human papillomavirus (HPV) vaccine is effective in cervical cancer prevention. However, many barriers to uptake exist and strategies to overcome them are needed. Therefore, this study aimed to select and tailor implementation strategies to barriers identified by multiple stakeholders in Zambia. The study was conducted in Lusaka district between January and February 2023. Participants were purposively sampled from three stakeholder groups namely, adolescent girls, parents, and teachers and healthcare workers. With each of the stakeholders' groups (10-13 participants per group), we used the nominal group technique to gain consensus to tailor feasible and acceptable implementation strategies for mitigating the identified contextual barriers. The identified barriers included low levels of knowledge and awareness about the HPV vaccine, being out of school, poor community sensitisation, lack of parental consent to vaccinate daughters, and myths and misinformation about the HPV vaccine. The lack of knowledge and awareness of the HPV vaccine was a common barrier across the three groups. Tailored strategies included conducting educational meetings and consensus-building meetings, using mass media, changing service sites, re-examining implementation, and involving patients/consumers and their relatives. Our study contributes to the available evidence on the process of selecting and tailoring implementation strategies to overcome contextual barriers. Policymakers should consider these tailored strategies to mitigate barriers and improve HPV vaccine uptake.

Implementation Strategies Used to Increase Human Papillomavirus Vaccination Uptake by Adolescent Girls in Sub-Saharan Africa: A Scoping Review.

Barriers to successful implementation of the human papillomavirus vaccination exist. However, there is limited evidence on implementation strategies in sub-Saharan Africa (SSA). Therefore, this scoping review aimed to identify implementation strategies used in SSA to increase HPV vaccination uptake for adolescent girls. This scoping review was guided by Joanna Briggs Institute guidelines for scoping reviews and an a priori protocol and reported based on the Preferred Reporting Items for Systematic Reviews and Metanalysis for Scoping Reviews (PRISMA-ScR). We searched PubMed, EMBASE, CINAHL, Scopus, Google Scholar, and gray literature. Two independent reviewers screened article titles and abstracts for possible inclusion, reviewed the full text, and extracted data from eligible articles using a structured data charting table. We identified strategies as specified in the Expert Recommendation for Implementing Change (ERIC) and reported their importance and feasibility. We retrieved 246 articles, included 28 of these, and identified 63 of the 73 ERIC implementation strategies with 667 individual uses, most of which were highly important and feasible. The most frequently used discrete strategies included the following: Build a coalition and change service sites 86% (24/28), distribute educational materials and conduct educational meetings 82% (23/28), develop educational materials, use mass media, involve patients/relatives and families, promote network weaving and stage implementation scale up 79% (22/28), as well as access new funding, promote adaptability, and tailor strategies 75% (21/28). This scoping review shows that implementation strategies of high feasibility and importance were frequently used, suggesting that some strategies may be cross-cutting, but should be contextualized when planned for use in any region.

Correlates of Parental Consent to Human Papillomavirus Vaccine Uptake by Their Adolescent Daughters in ZAMBIA: Application of the Health Belief Model.

Parental consent for adolescent human papillomavirus (HPV) vaccine uptake is important; however, refusal is prevalent. Therefore, this study aimed to understand factors associated with parental consent for their adolescent daughter's HPV vaccination. A cross-sectional study was conducted in Lusaka, Zambia, between September and October 2021. We recruited parents from different social settings. The means and standard deviations or median and interquartile ranges were used as appropriate to summarise continuous variables. Simple and multiple logistic regression models were fitted with robust estimation of standard errors. The odds ratios are presented with 95% CI. Mediation analysis was conducted using a generalised structural equation model. The study enrolled 400 parents, mean age 45.7 years [95% CI, 44.3-47.1]. Two hundred and fifteen (53.8%) parents reported consenting to their daughters' HPV vaccination, and their daughters received it. None of the health belief model (HBM) construct scores showed an independent association with parental consent. Higher, compared to lower wealth index (AOR; 2.32, 95% CI: 1.29-4.16), knowing someone with genital warts (AOR = 2.23, 95 CI: 1.04-4.76), cervical cancer screening uptake (AOR = 1.93, 95% CI: 1.03-3.62) were associated with increased odds of parental consent. This study highlights factors influencing parental consent for their daughters' HPV vaccination. Ongoing sensitisation programs are important to improve their decision-making.

"When you get the HPV vaccine, it will prevent cervical cancer; it will act as a shield": adolescent girls' knowledge and perceptions regarding the human papillomavirus vaccine in Zambia.

Introduction: The human papillomavirus (HPV) vaccination is an important preventive measure for HPV-related conditions such as cervical cancer. In 2019, Zambia introduced a free national HPV vaccination program for 14-year-old girls. However, the adolescents' knowledge and perceptions regarding the HPV vaccine are not well understood. Therefore, this study aimed to understand adolescent girls' knowledge and perceptions regarding the HPV vaccine and discuss its acceptability and uptake implications. Methods: We conducted a qualitative study in the Lusaka district between June 2021 and November 2021 using semi-structured interviews with adolescent girls aged 15-18 years regardless of their HPV vaccination status. Interviews were transcribed verbatim, and NVIVO 12 was used for data management and analysis. We coded transcripts deductively and inductively based on emerging themes. Perceptions were coded using the health belief model constructs. Results: We interviewed 30 adolescent girls to reach saturation. Seventeen girls reported having received at least one dose of the HPV vaccine. Participants expressed variable knowledge and awareness about HPV and the HPV vaccine. Participants exhibited positive attitudes towards the HPV vaccine and perceived it as beneficial. However, there were multiple perceived barriers to vaccination, such as the need for parental consent, not being in school, concerns about vaccine side effects, and belief in myths and misinformation. Conclusion: The adolescent girls in this study showed variable knowledge and positive attitudes toward the HPV vaccine despite the many perceived barriers. To support increased HPV vaccine acceptability and uptake among adolescent girls in Zambia, it is critical to actively engage stakeholders involved in HPV vaccination, such as adolescents and their parents, and debunk myths and misconceptions about HPV vaccination. Health education in schools and communities should be implemented to increase knowledge about HPV and HPV vaccination among adolescents and their parents.

Determinants of the Implementation of Human Papillomavirus Vaccination in Zambia: Application of the Consolidated Framework for Implementation Research.

Cervical cancer can be prevented, primarily by the administration of the human papillomavirus (HPV) vaccine. Healthcare workers (HCWs) and teachers play important roles when schools are used for vaccine delivery; however, challenges exist. This study aimed to understand the barriers and facilitators to HPV vaccination that are perceived by HCWs and teachers. Guided by the consolidated framework for implementation research (CFIR), key informant interviews were conducted in Lusaka district between June 2021 and November 2021 using a semi-structured questionnaire. Recorded interviews were transcribed verbatim and imported into NVIVO 12 for data management and analysis. We coded transcripts inductively and deductively based on the adapted CFIR codebook. We reached saturation with 23 participants. We identified barriers and facilitators across the five CFIR domains. Facilitators included offering the HPV vaccine free of charge, HPV vaccine effectiveness, stakeholder engagement, and timely planning of the HPV vaccination. Barriers included vaccine mistrust due to its perceived novelty, low levels of parental knowledge, myths and misinformation about the vaccine, lack of parental consent to vaccinate daughters, lack of transport for vaccination outreach, lack of staff incentives, and inadequate sensitisation. Using the CFIR as a guiding framework, we have identified implementation barriers and facilitators to HPV vaccination among HCWs and teachers. Most of the identified barriers are modifiable, hence it is prudent that these are addressed for a high HPV vaccine uptake.

Aligning vertical interventions to health systems: a case study of the HIV monitoring and evaluation system in South Africa.

BACKGROUND: Like many low- and middle-income countries, South Africa established a dedicated HIV monitoring and evaluation (M&E) system to track the national response to HIV/AIDS. Its implementation in the public health sector has however not been assessed. Since responsibility for health services management lies at the district (sub-national) level, this study aimed to assess the extent to which the HIV M&E system is integrated with the overall health system M&E function at district level. This study describes implementation of the HIV M&E system, determines the extent to which it is integrated with the district health information system (DHIS), and evaluates factors influencing HIV M&E integration. METHODS: The study was conducted in one health district in South Africa. Data were collected through key informant interviews with programme and health facility managers and review of M&E records at health facilities providing HIV services. Data analysis assessed the extent to which processes for HIV data collection, collation, analysis and reporting were integrated with the DHIS. RESULTS: The HIV M&E system is top-down, over-sized, and captures a significant amount of energy and resources to primarily generate antiretroviral treatment (ART) indicators. Processes for producing HIV prevention indicators are integrated with the DHIS. However processes for the production of HIV treatment indicators by-pass the DHIS and ART indicators are not disseminated to district health managers. Specific reporting requirements linked to ear-marked funding, politically-driven imperatives, and mistrust of DHIS capacity are key drivers of this silo approach. CONCLUSIONS: Parallel systems that bypass the DHIS represent a missed opportunity to strengthen system-wide M&E capacity. Integrating HIV M&E (staff, systems and process) into the health system M&E function would mobilise ear-marked HIV funding towards improving DHIS capacity to produce quality and timely HIV indicators that would benefit both programme and health system M&E functions. This offers a practical way of maximising programme-system synergies and translating the health system strengthening intents of existing HIV policies into tangible action.

Providing HIV Prevention of Mother to Child Transmission (PMTCT) Services to Migrants During the COVID-19 Pandemic in South Africa: Insights of Healthcare Providers.

BACKGROUND: In March 2020, COVID-19 entered South Africa, resulting in 2.9 million cases, the country took preventative and precautionary measures to control the spread of COVID-19 infection. These measures limited population mobility especially for migrant women living with HIV (WLWH) and the provision of PMTCT services. The purpose of this research was to explore the challenges of the COVID-19 pandemic on PMTCT provision by healthcare providers and understand what strategies could be implemented with lifelong antiretroviral therapy (ART) for migrants to better manage the program. METHODS: Twelve in-depth interviews were conducted with healthcare providers across city and provincial levels on how the changes to the healthcare system with COVID-19 affected highly mobile patients' adherence and utilization of PMTCT services. A thematic content analysis was used for emerging themes and guided by The Utilization of PMTCT Services conceptual framework. RESULTS: Five main themes emerged: (1) Facilitators and barriers to adherence, which included the need for multi-month dispensing for the long term supply of antiretrovirals (ARVs) and the fear of contracting COVID-19 at the hospital that disrupted patients' continuum of care; (2) Healthcare providers work environment, where participants felt overwhelmed with the high patient demand and the lack of infrastructural resources to follow social distancing protocols; (3) Financial challenges and opportunity costs, PMTCT proved difficult for migrants due to border closures and documentation required to receive care, this resulted in treatment interruption and left many unable to receive support at the facility due to capacity restrictions; (4) Interpersonal interactions, mistreatment, and xenophobic attitudes existed toward the migrant HIV population; and (5) "Program sustainability" revealed three key areas for strengthening: longer duration of time allocated with counseling for same-day initiation, the increased use of technology, and translation services for migrants. CONCLUSIONS: It is important to take what was learned during the pandemic and integrate it into routine service delivery, which includes long-term medication supply to reduce risk with multiple visits to collect medication, and the use of technology to alleviate the high-burden of patient demand. Healthcare policies that work toward inclusion and sustainability for migrants are needed to improve the integration of safer and practical methods of PMTCT provision into health systems.

Addressing the migrant gap: maternal healthcare perspectives on utilising prevention of mother to child transmission (PMTCT) services during the COVID-19 pandemic, South Africa.

BACKGROUND: The COVID-19 pandemic has interrupted the prevention of mother-to-child transmission of HIV (PMTCT) programming in South Africa. In 2020, it was estimated that there were 4 million cross-border migrants in South Africa, some of whom are women living with HIV (WLWH), who are highly mobile and located within peripheral and urban areas of Johannesburg. Little is known about the mobility typologies of these women associated with different movement patterns, the impact of the COVID-19 pandemic on mobility typologies of women utilising PMTCT services and on how changes to services might have affected adherence. OBJECTIVE: To qualitatively explore experiences of different mobility typologies of migrant women utilising PMTCT services in a high mobility context of Johannesburg and how belonging to a specific typology might have affected the health care received and their overall experiences during the COVID-19 pandemic. METHODS: Qualitative semi-structured interviews with 40 pregnant migrant WLWH were conducted from June 2020-June 2021. Participants were recruited through purposive sampling at a public hospital in Johannesburg. A thematic approach was used to analyse interviews. RESULTS: Forty interviews were conducted with 22 cross-border and 18 internal migrants. Women in cross-border migration patterns compared to interprovincial and intraregional mobility experienced barriers of documentation, language availability, mistreatment, education and counselling. Due to border closures, they were unable to receive ART interrupting adherence and relied on SMS reminders to adhere to ART during the pandemic. All 40 women struggled to understand the importance of adherence because of the lack of infrastructure to support social distancing protocols and to provide PMTCT education. CONCLUSIONS: COVID-19 amplified existing challenges for cross-border migrant women to utilise PMTCT services. Future pandemic preparedness should be addressed with differentiated service delivery including multi-month dispensing of ARVs, virtual educational care, and language-sensitive information, responsive to the needs of mobile women to alleviate the burden on the healthcare system.

Evolution of prevention of mother to child transmission of HIV policy in Zambia: Application of the policy triangle to understand the roles of actors, process and power.

The Prevention of Mother-to-child Transmission (PMTCT) of HIV program in Zambia has undergone several policy iterations over the past 10 years. This qualitative study aimed to contribute towards addressing this knowledge gap by analysing the evolution and actors' influence during the policy process using the Walt and Gilson policy triangle as our evaluation framework. Document review and key informant interviews with policy makers were undertaken to identify the contextual factors that had shaped the PMTCT policy evolution in Zambia. Overall, the study revealed that over the past decade, at least five PMTCT policy changes have occurred, averaging three years per policy with extensive overlap between policies. This resulted in more than two policies being implemented at a given time. Pressure from the international community and scientific evidence were the main drivers of policy change in Zambia, with local actors being mainly reactive. Among international agencies, UNICEF and WHO were the key actors who had driven the policy changes as they had the power and resources. The rapid changes, negatively impacted the health system, disrupted service delivery, which was unprepared to effectively and efficiently shift from one policy to another.

Health system response to preventing mother-to-child transmission of HIV policy changes in Zambia: a health system dynamics analysis of primary health care facilities.

BACKGROUND: Zambia is focusing on attaining HIV epidemic control by 2021, including eliminating Mother to Child Transmission (eMTCT) of HIV. However, there is little evidence to understand frontline healthcare workers' experience with the policy changes and the readiness of different health system elements to contribute to this goal. OBJECTIVE: To understand frontline healthcare workers' experience of preventing mother-to-child transmission (PMTCT) of human immunodeficiency (HIV) policy changes and to explore the health system readiness to respond to rapid changes in PMTCT policy by using the health system dynamic framework. METHOD: We conducted a qualitative study in which 35 frontline healthcare workers were selected and interviewed using a snowball sampling technique. All transcripts were analysed through thematic content analysis and deductive coding. Themes were derived and presented according to the health system dynamics framework. RESULTS: Among the ten elements of the health system dynamics framework, service delivery, context, and resources (i.e. infrastructure and supplies, knowledge and information, human resource, and finance) were critical in implementing the continuously evolving PMTCT policies. Furthermore, due to the fragmented primary health care platform in Zambia, non-governmental organisations (NGOs) were instrumental in ensuring that the PMTCT programme met the demand and requirements of the general population. Frontline healthcare workers who participated in the study described inequity in access to ART services due to the service delivery model employed in the selected study sites. CONCLUSION: The study highlights challenges when policies are implemented without consideration for the readiness, context, and capacity in which the policy is implemented. We offer lessons that can inform implementation of universal health coverage of antiretroviral therapy (ART), a strategy many countries have adopted, despite weak health systems.

Implementation strategies to increase human papillomavirus vaccination uptake for adolescent girls in sub-Saharan Africa: A scoping review protocol.

INTRODUCTION: The human papillomavirus (HPV) is sexually transmitted and infects approximately 75% of sexually active people early in their sexual life. Persistent infection with oncogenic HPV types can lead to malignant conditions such as cervical cancer. In 2006, the World Health Organisation approved the use of an efficacious HPV vaccine for girls aged 9 to 14 to prevent HPV-related conditions. Despite the HPV vaccine being available for about 15 years, dose completion remains as low as 20% in sub-Saharan African (SSA) countries implementing the vaccination program compared to 77% in Australia and New Zealand. A fraught of barriers to implementation exist which prevent adequate coverage. Achieving success for HPV vaccination in real-world settings requires strategies to overcome implementation bottlenecks. Therefore, a better understanding and mapping of the implementation strategies used in sub-Saharan Africa to increase HPV vaccination uptake is critical. This review aims to identify implementation strategies to increase HPV vaccination uptake for adolescent girls in sub-Saharan Africa and provide a basis for policy and future research, including systematic reviews to evaluate effective strategies as we accelerate the elimination of cervical cancer. MATERIALS AND METHODS: This scoping review will consider studies pertaining to implementation strategies to increase HPV vaccination uptake for adolescent girls in sub-Saharan Africa. Studies targeted at different stakeholders to increase adolescent vaccine uptake will be included. Studies using interventions not fitting the definition of implementation strategies as defined by the refined compilation of implementation strategies from the Expert Recommendations for Implementing Change project will be excluded. MEDLINE (via PubMed), Embase, CINAHL (via EBSCO), Scopus and Google Scholar will be searched. Two independent reviewers will screen titles and abstracts for studies that meet the review's inclusion criteria, and the full text of eligible studies will be reviewed. Data will be extracted from eligible studies using a structured data charting table developed by this team for inclusion by two independent reviewers and presented in a table and graphical form with a narrative summary.

Estimated SARS-CoV-2 infection rate and fatality risk in Gauteng Province, South Africa: a population-based seroepidemiological survey.

BACKGROUND: Limitations in laboratory testing capacity undermine the ability to quantify the overall burden of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. METHODS: We undertook a population-based serosurvey for SARS-CoV-2 infection in 26 subdistricts, Gauteng Province (population 15.9 million), South Africa, to estimate SARS-CoV-2 infection, infection fatality rate (IFR) triangulating seroprevalence, recorded COVID-19 deaths and excess-mortality data. We employed three-stage random household sampling with a selection probability proportional to the subdistrict size, stratifying the subdistrict census-sampling frame by housing type and then selecting households from selected clusters. The survey started on 4 November 2020, 8 weeks after the end of the first wave (SARS-CoV-2 nucleic acid amplification test positivity had declined to <10% for the first wave) and coincided with the peak of the second wave. The last sampling was performed on 22 January 2021, which was 9 weeks after the SARS-CoV-2 resurgence. Serum SARS-CoV-2 receptor-binding domain (RBD) immunoglobulin-G (IgG) was measured using a quantitative assay on the Luminex platform. RESULTS: From 6332 individuals in 3453 households, the overall RBD IgG seroprevalence was 19.1% [95% confidence interval (CI): 18.1-20.1%] and similar in children and adults. The seroprevalence varied from 5.5% to 43.2% across subdistricts. Conservatively, there were 2 897 120 (95% CI: 2 743 907-3 056 866) SARS-CoV-2 infections, yielding an infection rate of 19 090 per 100 000 until 9 January 2021, when 330 336 COVID-19 cases were recorded. The estimated IFR using recorded COVID-19 deaths (n = 8198) was 0.28% (95% CI: 0.27-0.30) and 0.67% (95% CI: 0.64-0.71) assuming 90% of modelled natural excess deaths were due to COVID-19 (n = 21 582). Notably, 53.8% (65/122) of individuals with previous self-reported confirmed SARS-CoV-2 infection were RBD IgG seronegative. CONCLUSIONS: The calculated number of SARS-CoV-2 infections was 7.8-fold greater than the recorded COVID-19 cases. The calculated SARS-CoV-2 IFR varied 2.39-fold when calculated using reported COVID-19 deaths (0.28%) compared with excess-mortality-derived COVID-19-attributable deaths (0.67%). Waning RBD IgG may have inadvertently underestimated the number of SARS-CoV-2 infections and conversely overestimated the mortality risk. Epidemic preparedness and response planning for future COVID-19 waves will need to consider the true magnitude of infections, paying close attention to excess-mortality trends rather than absolute reported COVID-19 deaths.