Quality of Care is Perceived to be High with Community-based Antiretroviral Therapy (ART) Services for Female Sex Workers in Tanzania: Qualitative Findings from a Pilot Implementation Science Study.

This qualitative study reports on female sex workers' (FSWs) perceptions of the quality of antiretroviral therapy (ART) services they received as part of a community-based ART distribution intervention compared to services received by FSWs in the standard of care (SOC) arm. In-depth interviews were conducted with 24 participants to explore their perceptions of the quality of ART services. Data was analyzed using a quality-of-care framework that included but was not limited to, domains of accessibility, effective organization of care, package of services, and patient-centered care. Overall, FSWs in the intervention arm reported community-based ART services to be highly accessible, organized, and effective, and they highly valued the patient-centered care and high level of privacy. Community-based ART programs for FSWs can have high quality-of-care, which can have a positive effect on HIV treatment outcomes for FSWs.

Operationalizing the distribution of oral HIV self-testing kits to men who have sex with men (MSM) in a highly homophobic environment: the Nigerian experience.

BACKGROUND: Self-care health interventions are innovative approaches for improving health and achieving the sustainable development goals (SDGs). Men who have sex with men (MSM) have been disproportionately affected by Human Immunodeficiency Virus (HIV). In spite of this, stigma from healthcare workers has reportedly prevented MSM from accessing HIV testing in health facilities. This paper explored the operationalization of using key opinion leaders (KOLs) to distribute HIVST (HIV self-test) kits to MSM. This qualitative survey used a combination of in-depth interviews (IDI) with HIVST users and focus group discussions (FGDs) with KOLs to collect data three months after the distribution of the test kits by the KOLs. Thematic analysis of the data was carried out. RESULT: Three themes were generated namely: KOLs serve as a trusted resource to promote and support HIVST for the MSM community; Skills and qualifications required for KOLs to effectively distribute and promote uptake of HIVST; and Effective strategies used to create demand and promote uptake of HIVST. CONCLUSION: This study showed the practical steps involved in operationalizing KOL support system distribution of HIVST that positively influenced the testing experience for the participants irrespective of the HIV status and engagement in care. KOLs are a reliable resource to leverage for ensuring that HIV self-test kit is utilized and HIV positive individuals are linked to treatment and care in homophobic environments.

Community-based antiretroviral therapy (ART) delivery for female sex workers in Tanzania: intervention model and baseline findings.

To increase linkage to and retention in antiretroviral therapy (ART) care, we piloted a community-based, ART service delivery intervention for female sex workers (FSWs). At baseline, we recruited and collected data from 617 FSWs (intervention: 309; comparison: 308) who were HIV positive and not on ART. This paper presents (1) the description of the intervention model, and (2) key descriptive and bivariate-level findings of the baseline FSW cohort. The data showed more than half of FSWs had a non-paying sex partner, and less than one-third used a condom at last sex with paying and non-paying clients, which suggest potentially high levels of HIV transmission. In addition, there is a gap in HIV testing and treatment because one-third learned about their HIV-positive status only at study enrollment, and among FSWs who had known their status for more than a month, half had not registered in care. This substantiates the importance of timely HIV diagnosis and treatment. A community-based ART program may serve as an important strategy in closing the HIV care and treatment gap for FSWs.

'I will welcome this one 101%, I will so embrace it': a qualitative exploration of the feasibility and acceptability of HIV self-testing among men who have sex with men (MSM) in Lagos, Nigeria.

Men who have sex with men (MSM) are disproportionately affected by HIV in Nigeria. A key strategy in reducing transmission is to increase HIV testing uptake and linkage to treatment for those who test positive. HIV self-testing (HIVST) is an innovative strategy with the potential to increase uptake of HIV testing among key populations at higher risk for HIV. We conducted 23 in-depth-interviews with MSM and two focus group discussions with key opinion leaders to explore perceptions about the feasibility and acceptability of oral HIVST among MSM in Lagos, Nigeria. HIVST was highly acceptable because it was considered convenient to use, painless, private and addressed concerns about stigma. Concerns cited by participants included comprehensibility of instructions to perform and interpret results correctly, as well as lack of support mechanisms to facilitate post-test follow-up and linkage to care. Provision of adequate pre-test information was considered vital as part of the kit distribution process to ensure seamless use of HIVST kits. One-on-one peer-to-peer distribution strategies and retail outlets that facilitate anonymous pick-up are potential distribution channels identified in this study. Overall, our findings suggest that an HIVST program that incorporates these considerations would improve access to HIV testing among MSM in Nigeria.

A meta-analysis approach for estimating average unit costs for ART using pooled facility-level primary data from African countries.

Objective: To estimate facility-level average cost for ART services and explore unit cost variations using pooled facility-level cost estimates from four HIV empirical cost studies conducted in five African countries .Methods: Through a literature search we identified studies reporting facility-level costs for ART programmes. We requested the underlying data and standardised the disparate data sources to make them comparable. Subsequently, we estimated the annual cost per patient served and assessed the cost variation among facilities and other service delivery characteristics using descriptive statistics and meta-analysis. All costs were converted to 2017 US dollars ($). Results: We obtained and standardised data from four studies across five African countries and 139 facilities. The weighted average cost per patient on ART was $251 (95% CI: 193-308). On average, 46% of the mean unit cost correspond to antiretroviral (ARVs) costs, 31% to personnel costs, 20% other recurrent costs, and 2% to capital costs. We observed a lot of variation in unit cost and scale levels between countries. We also observed a negative relationship between ART unit cost and the number of patients served in a year.Conclusion: Our approach allowed us to explore unit cost variation across contexts by pooling ART costs from multiple sources. Our research provides an example of how to estimate costs based on heterogeneous sources reconciling methodological differences across studies and contributes by giving an example on how to estimate costs based on heterogeneous sources of data. Also, our study provides additional information on costs for funders, policy-makers, and decision-makers in the process of designing or scaling-up HIV interventions.

High Burden of HIV, Syphilis and HSV-2 and Factors Associated with HIV Infection Among Female Sex Workers in Tanzania: Implications for Early Treatment of HIV and Pre-exposure Prophylaxis (PrEP).

This paper estimates population-based prevalence of HIV, syphilis, HSV-2 and factors influencing HIV infection using a national sample of 1914 female sex workers (FSWs) in 7 regions in Tanzania. Additionally, HIV incidence was estimated by comparing biological HIV results with self-reported HIV status. The average HIV prevalence among FSWs in all 7 regions was 28%, ranging from 14% in Tabora to 38% in Shinyanga. HIV incidence was found to be 13 per 100 person-years. Syphilis prevalence was 8% with significantly higher burden found in Iringa (11%), Mbeya (13%), and Shinyanga (12%). Nearly 60% of the study population was infected with HSV-2. The high HIV prevalence and incidence coupled with suboptimal condom use indicate an urgent need to roll out the "Treat-All" approach and provide antiretroviral therapy to FSWs living with HIV regardless of their CD4 count. In addition, antiretroviral-based prevention technologies such as oral pre-exposure prophylaxis and microbicides should be piloted and evaluated.

Randomized evaluation and cost-effectiveness of HIV and sexual and reproductive health service referral and linkage models in Zambia.

BACKGROUND: Provision of HIV prevention and sexual and reproductive health services in Zambia is largely characterized by discrete service provision with weak client referral and linkage. The literature reveals gaps in the continuity of care for HIV and sexual and reproductive health. This study assessed whether improved service delivery models increased the uptake and cost-effectiveness of HIV and sexual and reproductive health services. METHODS: Adult clients 18+ years of age accessing family planning (females), HIV testing and counseling (females and males), and male circumcision services (males) were recruited, enrolled and individually randomized to one of three study arms: 1) the standard model of service provision at the entry point (N = 1319); 2) an enhanced counseling and referral to add-on service with follow-up (N = 1323); and 3) the components of study arm two, with the additional offer of an escort (N = 1321). Interviews were conducted with the same clients at baseline, six weeks and six months. Uptake of services for HIV, family planning, male circumcision, and cervical cancer screening at six weeks and six months were the primary endpoints. Pairwise chi-square and multivariable logistic regression statistical tests assessed differences across study arms, which were also assessed for incremental cost-efficiency and cost-effectiveness. RESULTS: A total of 3963 clients, 1920 males and 2043 females, were enrolled; 82 % of participants at six weeks were tracked and 81 % at six months; follow-up rates did not vary significantly by study arm. The odds of clients accessing HIV testing and counseling, cervical cancer screening services among females, and circumcision services among males varied significantly by study arm at six weeks and six months; less consistent findings were observed for HIV care and treatment. Client uptake of family planning services did not vary significantly by study arm. Integrated services were found to be more efficiently provided than vertical service provision; the cost-effectiveness for HIV/AIDS and cervical cancer was high in the enhanced service models. CONCLUSIONS: Study results provide evidence for increasing the linkages and integration of a selection of HIV and sexual and reproductive health services. The study provided cost-effective service delivery models that enhanced the likelihood of clients accessing some additional needed health services. TRIAL REGISTRATION: ISRCTN84228514 Retrospectively registered. The study was retrospectively registered in the ISRCTN clinical trials registry on 06 October 2015. The first recruitment of participants occurred on 17 December 2013.

Effectiveness of Behavior Change Communications for Reducing Transmission Risks Among People Living with HIV in 6 Countries in Central America.

This first region-wide study (N = 2,818) aims to estimate prevalence of HIV-related risks (sexual behavior, HIV disclosure, number of sex partners, violence) and factors associated with these risks as well as evaluate a behavior change communications program targeted to PLHIV in 6 countries in Central America. After 2 years, the program achieved moderate coverage, with 21 % of the sample reporting exposure to interpersonal communications (IPC) and 52 % to mass media program components. The odds of condom use, HIV disclosure, and participation in a self-help group increased by 1.4-1.8 times with exposure to mass media. Exposure to IPC increased odds of condom use by 2.7 and participation in self-help groups by 4.4 times. In addition, being in HIV care or taking ART was associated with condom use and HIV-status disclosure. About 30 % experienced physical or sexual violence, and those who did were 4 times less likely to use condoms. Findings suggest that behavioral interventions for PLHIV can reduce HIV-transmission risks and increase access to care.

Comparing Estimates of Multiple and Concurrent Partnerships Across Population Based Surveys: Implications for Combination HIV Prevention.

We compare estimates of multiple and concurrent sexual partnerships from Demographic and Health Surveys (DHS) with comparable Population Services International (PSI) surveys in four African countries (Kenya, Lesotho, Uganda, Zambia). DHS data produce significantly lower estimates of all indicators for both sexes in all countries. PSI estimates of multiple partnerships are 1.7 times higher [1.4 for men (M), 3.0 for women (W)], cumulative prevalence of concurrency is 2.4 times higher (2.2 M, 2.7 W), the point prevalence of concurrency is 3.5 times higher (3.5 M, 3.3 W), and the fraction of multi-partnered persons who report concurrency last year is 1.4 times higher (1.6 M, 0.9 W). These findings provide strong empirical evidence that DHS surveys systematically underestimate levels of multiple and concurrent partnerships. The underestimates will contaminate both empirical analyses of the link between sexual behavior and HIV infection, and theoretical models for combination prevention that use these data for inputs.

High levels of bisexual behavior and factors associated with bisexual behavior among men having sex with men (MSM) in Nigeria.

Nigerian men who have sex with men (MSM) have a high burden of HIV infection and are known to engage in bisexual behavior. This study presents the first data on characteristics and correlates of Nigerian men having sex with men and women (MSMW) in three Nigerian cities. Five hundred and fifty-seven MSM who engaged in anal sex with men completed a behavioral survey; 48.1% of these MSM also engaged in sex with women in the previous 2 months. MSMW displayed high levels of risky sexual behavior with female sex partners; casual (56.0%) and multiple female partners were common (69.0%) and 66.0% had unprotected vaginal sex. As much as 45.1% MSMW had anal sex with female partners of which 74.0% did not use protection in the 2 months prior. In bivariate analyses, bisexual behavior was associated (p<0.05) with being married or living with a women (OR 5.0, 95% CI = 2.6-9.4), less education (OR 2.0, 95% CI = 1.4-3.0), bisexual/straight identity (OR 2.3, 95% CI = 1.6-3.2), being an insertive partner (OR 3.0, 95% CI = 1.9-4.5), being HIV-negative (OR 1.6, 95% CI = 1.1-2.5), living in Lagos (OR 2.3, 95% CI = 1.7-2.2), being Muslim (OR 1.7, 95% CI = 1.1-2.5), and being away from home (OR 1.5, 95% CI = 1.0-2.1). In the multivariate model, being married to or living with a woman (AOR = 5.1; 95% CI = 2.5-10.3), bisexual/straight identity (AOR = 2.2; 95% CIs = 1.5-3.3), being an insertive partner (AOR = 3.0; 95% CI = 1.9-4.9), being away from home (AOR = 1.6; 95% CI = 1.1-2.3) and living in Lagos (AOR = 1.7; 95% CI = 1.0-2.8) remained significant (p< 0.05). High levels of bisexual behavior exist among Nigerian MSM, and these men engage in risky sexual behaviors with both male and female sex partners. While decriminalization of same-sex behavior in Nigeria will promote access to HIV prevention programs, current MSM interventions must incorporate information on safe sex with both male and female sex partners.

Effectiveness of a combination prevention strategy for HIV risk reduction with men who have sex with men in Central America: a mid-term evaluation.

BACKGROUND: Despite over a decade of research and programming, little evidence is available on effective strategies to reduce HIV risks among Central American men who have sex with men (MSM). The Pan-American Social Marketing Organization (PASMO) and partners are implementing a HIV Combination Prevention Program to provide key populations with an essential package of prevention interventions and services: 1) behavioral, including interpersonal communications, and online outreach; 2) biomedical services including HIV testing and counseling and screening for STIs; and 3) complementary support, including legal support and treatment for substance abuse. Two years into implementation, we evaluated this program's effectiveness for MSM by testing whether exposure to any or a combination of program components could reduce HIV risks. METHODS: PASMO surveyed MSM in 10 cities across Guatemala, El Salvador, Nicaragua, Costa Rica, and Panama in 2012 using respondent-driven sampling. We used coarsened exact matching to create statistically equivalent groups of men exposed and non-exposed to the program, matching on education, measures of social interaction, and exposure to other HIV prevention programs. We estimated average treatment effects of each component and all combined to assess HIV testing and condom use outcomes, using multivariable logistic regression. We also linked survey data to routine service data to assess program coverage. RESULTS: Exposure to any program component was 32% in the study area (n = 3531). Only 2.8% of men received all components. Men exposed to both behavioral and biomedical components were more likely to use condoms and lubricant at last sex (AOR 3.05, 95% CI 1.08, 8.64), and those exposed to behavioral interventions were more likely to have tested for HIV in the past year (AOR 1.76, 95% CI 1.01, 3.10). CONCLUSIONS: PASMO's strategies to reach MSM with HIV prevention programming are still achieving low levels of population coverage, and few men are receiving the complete essential package. However, those reached are able to practice HIV prevention. Combination prevention is a promising approach in Central America, requiring expansion in coverage and intensity.

High levels of unprotected anal intercourse and never testing for HIV among men who have sex with men in Nigeria: evidence from a cross-sectional survey for the need for innovative approaches to HIV prevention.

OBJECTIVES: To describe sexual risk behaviour, correlates of unprotected anal intercourse (UAI) and never testing for HIV and its implications for HIV prevention interventions among men who have sex with men (MSM) in Nigeria and other similar contexts. METHODS: A cross-sectional survey was administered to 712 MSM in Abuja, Ibadan and Lagos, recruited through respondent-driven sampling (RDS). Levels of sexual risk behaviour and never having tested for HIV prior to the survey were calculated using weighted data for each city and unweighted data for the pooled sample. Correlates of UAI and never testing for HIV were determined using multiple logistic regression. RESULTS: The risk for HIV and STI among MSM in Nigeria is high, with 43.4% reporting UAI at last sex, 45.1% never having been tested for HIV and 53.9% reporting exchange of sex for resources in the past 6 months. Correlates of UAI in multivariate analysis included living in Ibadan, marriage or cohabitation with a woman, identification as bisexual, not having tested for HIV and being HIV-positive. Correlates of not having tested for HIV in multivariate analysis included living in Ibadan, young age, less education, unemployment and report of UAI. CONCLUSIONS: HIV testing is low and associated with UAI. Findings merit targeted and innovative approaches for HIV prevention for MSM, especially access to HIV self-testing. Attention to social and structural determinants of health-seeking and sexual risk behaviour is also needed, including the criminalisation of homosexuality and social marginalisation of MSM.

How to do (or not to do) health resource allocations using constrained mathematical optimization.

Despite the push towards evidence-based health policy, decisions about how to allocate health resources are all too often made on the basis of political forces or a continuation of the status quo. This results in wastage in health systems and loss of potential population health. However, if health systems are to serve people best, then they must operate efficiently and equitably, and appropriate valuation methods are needed to determine how to do this. With the advances in computing power over the past few decades, advanced mathematical optimization algorithms can now be run on personal computers and can be used to provide comprehensive, evidence-based recommendations for policymakers on how to prioritize health spending considering policy objectives, interactions of interventions, real-world system constraints and budget envelopes. Such methods provide an invaluable complement to traditional or extended cost-effectiveness analyses or league tables. In this paper, we describe how such methods work, how policymakers and programme managers can access them and implement their recommendations and how they have changed health spending in the world to date.

Levels and correlates of internalized homophobia among men who have sex with men in Pretoria, South Africa.

This study examines levels and correlates of internalized homophobia among men who have sex with men (MSM) in Pretoria, South Africa. Using respondent-driven sampling, we recruited 324 MSM from February to August 2009. Results were adjusted using RDSAT analysis to yield population-based estimates. High levels of internalized homophobia exist among South African MSM: 10-15% reported "often/very often" and over 20% reported "sometimes" having feelings of internalized homophobia. A greater level of internalized homophobia was significantly associated with a lower level of education [Adjusted Odds Ratio = 2.2; 95% CI = 1.1-4.9], a higher level of HIV misinformation [AOR = 2.7; 95% CI: 1.3-5.3], bisexual identity (vs. homosexual) [AOR = 5.5; 95% CI: 2.5-12.0], and HIV-related conspiracy beliefs [AOR = 2.4; 95% CI: 1.02-5.8]. These findings contribute valuable information to our understanding of internalized homophobia in South Africa, highlighting the need to empower the gay community, promote self-acceptance of homosexual identity, and address conspiracy beliefs among MSM to reduce internalized homophobia and increase access to HIV prevention interventions.

Disclosure of HIV status to sex partners among HIV-infected men and women in Cape Town, South Africa.

This study examines factors influencing HIV sero-status disclosure to sex partners among a sample of 630 HIV-infected men and women with recent sexual contact attending anti-retroviral therapy (ART) clinics in Cape Town, South Africa, with a focus on sex partner type, HIV-related stigma, and ART as potential correlates. About 20% of the sample had not disclosed their HIV status to their most recent sex partners. HIV disclosure to sex partner was more likely among participants who had a steady sex partner [Adjusted odds ratio (AOR) = 2.7; 95% CI: 1.6-4.6], had a partner with known-HIV status [AOR = 7.8; 95% CI: 3.2-18.7]; perceived less stigma [AOR = 1.9; 95% CI: 1.2-2.9]; and were on ART [AOR = 1.6; 95% CI: 1.1-2.3]. Stratified analyses by the type of sex partner further reveals that stigma and ART were significantly associated with HIV disclosure within steady relationships but were not significant correlates of HIV disclosure with casual sex partners. The findings support a positive prevention strategy that emphasizes increased access to ART, and behavioral interventions to reduce casual sex partnerships for persons who are HIV-positive. Mitigating the influence of HIV stigma on HIV status disclosure particularly within steady sex partnerships is also important and may be accomplished through individual and couple counseling.

HIV-related conspiracy beliefs and its relationships with HIV testing and unprotected sex among men who have sex with men in Tshwane (Pretoria), South Africa.

The objective of this study was to determine extent of HIV conspiracy belief endorsement among men who have sex with men (MSM) in Pretoria, and assess whether endorsement of HIV conspiracy beliefs are associated with inconsistent condom use and never testing for HIV. A cross-sectional survey using respondent-driven sampling was conducted between February and August 2009. A high proportion of respondents endorsed HIV conspiracy beliefs. MSM commonly endorsed beliefs related to AIDS information being held back from the general public (51.0%), HIV being a man-made virus (25.5%), and people being used as guinea pigs in HIV research and with HIV treatments (approximately 20%). Bisexually- or heterosexually-identified MSM were significantly more likely to endorse conspiracy beliefs compared to homosexually-identified MSM (38.5% vs. 14.7%). Endorsing conspiracy beliefs was not associated with unprotected anal intercourse; however, it was significantly associated with not having been HIV tested (AOR: 2.4; 95% CI: 1.1-5.7). Endorsing beliefs in HIV conspiracies reflects a mistrust in government institutions and systems which could be an impediment to seeking HIV-related services, including HIV counseling and testing.

Impacts of COVID-19-related service disruptions on TB incidence and deaths in Indonesia, Kyrgyzstan, Malawi, Mozambique, and Peru: Implications for national TB responses.

Initial global-level estimates reported in June 2020 by the World Health Organization suggested that levels of disruption to TB service delivery could be as high as 25%-50% and result in an additional 6·3 million cases of tuberculosis (TB) and an additional 1·4 million TB-related deaths attributable to COVID-19 between 2020 and 2025. Quarterly epidemiological estimates and programmatic TB data capturing disruption levels to each TB service were collected by National TB Programmes in Indonesia, Kyrgyzstan, Malawi, Mozambique, and Peru. Data from 2019, for a pre-COVID-19 baseline, and throughout 2020, together with the NTP's COVID-19 response plans, were used within Optima TB models to project TB incidence and deaths over five years because of COVID-19-related disruptions, and the extent to which those impacts may be mitigated through proposed catch-up strategies in each country. Countries reported disruptions of up to 64% to demand-driven TB diagnosis. However, TB service availability disruptions were shorter and less severe, with TB treatment experiencing levels of disruption of up to 21%. We predicted that under the worse-case scenario cumulative new latent TB infections, new active TB infections, and TB-related deaths could increase by up to 23%, 11%, and 20%, respectively, by 2024. However, three of the five countries were on track to mitigate these increases to 3% or less by maintaining TB services in 2021 and 2022 and by implementing proposed catch-up strategies. Indonesia was already experiencing the worse-case scenario, which could lead to 270,000 additional active TB infections and 36,000 additional TB-related deaths by the end of 2024. The COVID-19 pandemic is projected to negatively affect progress towards 2035 End TB targets, especially in countries already off-track. Findings highlight both successful TB service delivery adaptions in 2020 and the need to proactively maintain TB service availability despite potential future waves of more transmissible COVID-19 variants.

Cost-Effectiveness of Peer-Delivered HIV Self-Tests for MSM in Uganda.

Introduction: Distribution of HIV self-testing (HIVST) kits through MSM peer networks is a novel and effective strategy to increase HIV testing coverage in this high-risk population. No study has evaluated the cost or cost effectiveness of peer distribution of HIVST strategies among MSM in sub-Saharan Africa. Methods: From June to August 2018, we conducted a pilot study of secondary MSM peer HIVST kit distribution at The AIDS Support Organization at Entebbe and Masaka. We used an ingredients approach to estimate the cost of MSM peer HIVST kit distribution relative to standard-of-care (SOC) hotspot testing using programme expenditure data reported in US dollars. The provider perspective was used to estimate incremental cost-effective ratios per HIV infection averted using the difference in HIV annual transmission rates between MSM with HIV who knew their status and were not virologically suppressed and MSM with HIV who did not know their status. Results: We enrolled 297 participants of whom 150 received MSM peer HIVST kit distribution (intervention group) and 147 received TASO standard of care HIV testing (control group). Provider cost for the intervention was $2,276 compared with $1,827 for SOC during the 3-month study period. Overall, the intervention resulted in higher HIV positivity yield (4.9 vs. 1.4%) and averted more HIV infections per quarter (0.364 vs. 0.104) compared with SOC. The cost per person tested was higher for the intervention compared to SOC ($15.90 vs. $12.40). Importantly, the cost per new HIV diagnosis ($325 vs. $914) and cost per transmission averted ($6,253 vs. $ 17,567) were lower for the intervention approach relative to SOC. The incremental cost per HIV transmission averted by the self-testing program was $1,727. The incremental cost to providers per additional HIV-positive person identified by the intervention was $147.30. Conclusion: The intervention strategy was cost-effective, and identified more undiagnosed HIV infections than SOC hotspot testing at a cost-effectiveness threshold of US $2,129. Secondary distribution of HIVST kits through peers should further be evaluated with longer duration aimed at diagnosing 95% of all persons with HIV by 2030; the first UNAIDS 95-95-95 target.

The short-term effects of the implementation of the "Treat All" guidelines on ART service delivery costs in Namibia.

The introduction of "Treat All" (TA) has been promoted to increase the effectiveness of HIV/AIDS treatment by having patients initiate antiretroviral therapy at an earlier stage of their illness. The impact of introducing TA on the unit cost of treatment has been less clear. The following study evaluated how costs changed after Namibia's introduction of TA in April 2017. A two-year analysis assessed the costs of antiretroviral therapy (ART) during the 12 months before TA (Phase I-April 1, 2016 to March 31, 2017) and the 12 months following (Phase II-April 1, 2017 to March 31, 2018). The analysis involved interviewing staff at ten facilities throughout Namibia, collecting data on resources utilized in the treatment of ART patients and analyzing how costs changed before and after the introduction of TA. An analysis of treatment costs indicated that the unit cost of treatment declined from USD360 per patient per year in Phase I to USD301 per patient per year in Phase II, a reduction of 16%. This decline in unit costs was driven by 3 factors: 1) shifts in antiretroviral (ARV) regimens that resulted in lower costs for drugs and consumables, 2) negotiated reductions in the cost of viral load tests and 3) declines in personnel costs. It is unlikely that the first two of these factors were significantly influenced by the introduction of TA. It is unclear if TA might have had an influence on personnel costs. The reduction in personnel costs may have either represented a positive development (fewer personnel costs associated with increased numbers of healthier patients and fewer visits required) or alternatively may reflect constraints in Namibia's staffing. Prior to this study, it was expected that the introduction of TA would lead to a significant increase in the number of ART patients. However, there was less than a 4% increase in the number of adult patients at the 10 studied facilities. From a financial point of view, TA did not significantly increase the resources required in the ten sampled facilities, either by raising unit costs or significantly increasing the number of ART patients.

Effects of the implementation of the HIV Treat All guidelines on key ART treatment outcomes in Namibia.

BACKGROUND: This study aimed to help the Namibian government understand the impact of Treat All implementation (started on April 1, 2017) on key antiretroviral therapy (ART) outcomes, and how this transition impacts progress toward the UNAIDS's 90-90-90 HIV targets. METHODS: We collected clinical records from two separate cohorts (before and after treat-all) of ART patients in 10 high- and medium-volume facilities in 6 northern Namibia districts. Each cohort contains 12-month data on patients' scheduled appointments and visits, health status, and viral load results. We also measured patients' wait time and perceptions of service quality using exit interviews with 300 randomly selected patients (per round). We compared ART outcomes of the two cohorts: ART initiation within 7 days from diagnosis, loss to follow-up (LTFU), missed scheduled appointments for at least 30 days, and viral suppression using unadjusted and adjusted analyses. RESULTS: Among new ART clients (on ART for less than 3 months or had not yet initiated treatment as of the start date for the ART record review period), rapid ART initiation (within 7 days from diagnosis) was 5.2 times higher after Treat All than that among clients assessed before the policy took effect [AOR: 5.2 (3.8-6.9)]. However, LTFU was higher after Treat All roll-out compared to before Treat All [AOR: 1.9 (1.3-2.8)]. Established ART clients (on ART treatment for at least three months at the start date of the ART record review period) had over 3 times greater odds of achieving viral suppression after Treat All roll-out compared to established ART clients assessed before Treat All [AOR: 3.1 (1.6-5.9)]. CONCLUSIONS AND RECOMMENDATIONS: The findings indicate positive effect of the "Treat All" implementation on ART initiation and viral suppression, and negative effect on LTFU. Additionally, by April 2018, Namibia seems to have reached the UNAIDS's 90-90-90 targets.