Prioritizing Mental Health within HIV and Tuberculosis Services in PEPFAR.

Underprioritization of mental health is a global problem and threatens the decades-long progress of the US President's Emergency Plan for AIDS Relief (PEPFAR) program. In recent years, mental health has become globally recognized as a part of universal healthcare, making this an opportune moment for the global community to integrate mental health services into routine programming. PEPFAR is well positioned to lead by example. We conceptualized 5 key strategies that might help serve as a framework to support mental health programming as part of PEPFAR's current 5-year strategic plan. PEPFAR and the global community have an opportunity to identify mental health service gaps and interweave global mental health priorities with actions to end the HIV and TB epidemics by 2030.

The impact of shifts in PEPFAR funding policy on HIV services in Eastern Uganda (2015-21).

Although donor transitions from HIV programmes are increasingly common in low-and middle-income countries, there are limited analyses of long-term impacts on HIV services. We examined the impact of changes in President's Emergency Plan for AIDS Relief (PEPFAR) funding policy on HIV services in Eastern Uganda between 2015 and 2021.We conducted a qualitative case study of two districts in Eastern Uganda (Luuka and Bulambuli), which were affected by shifts in PEPFAR funding policy. In-depth interviews were conducted with PEPFAR officials at national and sub-national levels (n = 46) as well as with district health officers (n = 8). Data were collected between May and November 2017 (Round 1) and February and June 2022 (Round 2). We identified four significant donor policy transition milestones: (1) between 2015 and 2017, site-level support was withdrawn from 241 facilities following the categorization of case study districts as having a 'low HIV burden'. Following the implementation of this policy, participants perceived a decline in the quality of HIV services and more frequent commodity stock-outs. (2) From 2018 to 2020, HIV clinic managers in transitioned districts reported drastic drops in investments in HIV programming, resulting in increased patient attrition, declining viral load suppression rates and increased reports of patient deaths. (3) District officials reported a resumption of site-level PEPFAR support in October 2020 with stringent targets to reverse declines in HIV indicators. However, PEPFAR declared less HIV-specific funding. (4) In December 2021, district health officers reported shifts by PEPFAR of routing aid away from international to local implementing partner organizations. We found that, unlike districts that retained PEPFAR support, the transitioned districts (Luuka and Bulambuli) fell behind the rest of the country in implementing changes to the national HIV treatment guidelines adopted between 2017 and 2020. Our study highlights the heavy dependence on PEPFAR and the need for increasing domestic financial responsibility for the national HIV response.

Equity of the HIV epidemic response in 13 African countries.

For over 25 years, new programs to attempt to stem the HIV epidemic have been developed in Africa by country governments as well as external donors. These programs and activities have built and operated facilities, trained clinicians, financed drugs and commodities, supported and helped finance government health planning and operations, and contributed in other ways. Who has benefited from this massive mobilization? While some single country and narrowly focused studies have been done, the issue of equity of HIV programs for vulnerable populations has not been examined in a large set of countries. Using Population-based HIV Impact Assessment (PHIA) data, we examine equity of the HIV programs in 13 African countries to determine if vulnerable groups (such as those with low wealth, rural populations, young adults, and females) have achieved comparable levels of access to HIV program services. In contrast, we also compare the equity of the HIV response to rural and low-wealth populations with the equity of corresponding domestic health systems using Demographic and Health Survey data.This study found that in over half of the countries, the HIV response indicators were equitable for vulnerable population segments including the low-wealth population (in seven countries) and rural population segment (in nine countries). In no country was the domestic health system equitable for these two groups. However, HIV programming does show some clear patterns of inequity for low-wealth and rural populations in some countries. For gender and young adults, the HIV response indicators show that in all 13 countries men and young adults are consistently underserved relative to their counterparts.

Assessing sex differences in viral load suppression and reported deaths using routinely collected program data from PEPFAR-supported countries in sub-Saharan Africa.

BACKGROUND: In sub-Saharan Africa, more women than men access HIV testing and treatment and may have better viral load suppression (VLS). We utilized routinely reported aggregated HIV program data from 21 sub-Saharan African countries to examine sex differences in VLS and death rates within antiretroviral therapy (ART) programs supported by the United States President's Emergency Plan for AIDS Relief (PEPFAR). METHODS: We included VLS and reported death data for persons aged 15 + years on ART from October-December 2020 disaggregated by sex and age for each subnational unit (SNU). We used linear mixed-model regression to estimate VLS proportion and negative binomial mixed-model regression to estimate the rates of death and death plus interruptions in treatment (IIT). All models were weighted for SNU-level ART population size and adjusted for sex, age, HIV/tuberculosis coinfection, country, and SNU; models for reported deaths and deaths plus IIT were also adjusted for SNU-level VLS. RESULTS: Mean VLS proportion was higher among women than men (93.0% vs. 92.0%, p-value < 0.0001) and 50 + than 15-49 age group (93.7% vs. 91.2%, p-value < 0.0001). The mean rate of reported deaths was higher among men than women (2.37 vs. 1.51 per 1000 persons, p-value < 0.0001) and 50 + than 15-49 age group (2.39 vs. 1.50 per 1000, p-value < 0.0001); the mean rate of reported deaths plus IIT was higher among men (30.1 in men vs. 26.0 in women per 1000, p-value < 0.0001) and higher among 15-49 than 50 + age group (34.7 vs. 22.6 per 1000, p-value < 0.0001). CONCLUSIONS: The mean rate of reported deaths was higher among men in most models despite adjusting for VLS. Further exploration into differences in care-seeking behaviors; coverage of screening, prophylaxis, and/or treatment of opportunistic infections; and more extensive testing options for men to include CD4 is recommended.

Drivers of retention of the HIV workforce transitioned from PEPFAR support to the Uganda government payroll.

BACKGROUND: Health worker (HW) retention in the public health sector in Uganda is an enduring health system constraint. Although previous studies have examined the retention of in-service HWs, there is little research focusing on donor-recruited HWs. The objective of this study was to explore drivers of retention of the HIV workforce transitioned from PEPFAR support to the Uganda government payroll between 2015 and 2017. METHODS: We conducted ten focus group discussions with HWs (n = 87) transitioned from PEPFAR support to the public sector payroll in 10 purposively selected districts across Uganda. In-depth interviews were conducted with national-level stakeholders (n = 17), district health and personnel officers (n = 15) and facility in-charges (n = 22). Data were analyzed by a hybrid approach of inductive and deductive thematic development based on the analytical framework by Schaefer and Moos regarding individual-level and organizational-context drivers. RESULTS: At the individual level, job security in the public sector was the most compelling driver of health worker retention. Community embeddedness of HWs in the study districts, opportunities for professional development and career growth and the ability to secure salary loans due to 'permanent and pensionable' terms of employment and the opportunity to work in 'home districts', where they could serve their 'kinsmen' were identified as enablers. HWs with prior private sector backgrounds perceived public facilities as offering more desirable challenging professional work. Organizational context enablers identified include perceptions that public facilities had relaxed supervision regimes and more flexible work environments. Work environment barriers to long-term retention include frequent stock-out of essential commodities, heavy workloads, low pay and scarcity of rental accommodation, particularly in rural Northern Uganda. Compared to mid-cadres (such as nurses and midwives), higher calibre cadres, such as physicians, pharmacists and laboratory technologists, expressed a higher affinity for seeking alternative employment in the private sector in the immediate future. CONCLUSIONS: Overall, job security was the most compelling driver of retention in public service for the health workforce transitioned from PEPFAR support to the Uganda government payroll. Monetary and non-monetary policy strategies are needed to enhance the retention of upper cadre HWs, particularly physicians, pharmacists and laboratory technologists in rural districts of Uganda.

Tuberculosis Preventive Therapy among Persons Living with HIV, Uganda, 2016-2022.

During October 2016-March 2022, Uganda increased tuberculosis (TB) preventive therapy coverage among persons living with HIV from 0.6% to 88.8%. TB notification rates increased from 881.1 to 972.5 per 100,000 persons living with HIV. Timely TB screening, diagnosis, and earlier treatment should remain high priorities for TB/HIV prevention programming.

Evaluation of the impact of PEPFAR transition on retention in care in South Africa's Western Cape.

Background: Research on the impact of the PEPFAR transition in South Africa (SA) in 2012 found varying results in retention in care (RIC) of people living with HIV (PLWH). Objectives: We investigated the factors that impacted RIC during the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) transition in Western Cape, South Africa in 2012. Methods: We used aggregate data from 61 facilities supported by four non-governmental organizations from to 2007-2015. The main outcome was RIC at 12-months after antiretroviral therapy initiation for two time periods. We used quantile regression to estimate the effect of the PEPFAR pull-out and other predictors on RIC. The models were adjusted for various covariates. Results: Regression models (50th quantile) for 12-month RIC showed a 4.6% (95%CI: -8.4, -0.8%) decline in RIC post direct service. Facilities supported by Anova/Kheth'impilo fared worst post PEFPAR; a decline in RIC of (-5.8%; 95% CI: -9.7, -1.8%), while that'sit fared best (6.3% increase in RIC; 95% CI:2.5,10.1%). There was a decrease in RIC when comparing urban to rural areas (-5.8%; 95% CI: -10.1, -1.5%). City of Cape town combined with Western Cape Government Health facilities showed a substantial decrease (-9.1%; 95% CI: -12.3, -5.9%), while community health clinic (vs. primary health clinic) declined slightly (-4.4; 95% CI: -9.6, 0.9%) in RIC. We observed no RIC difference by facility size and a slight increase when two or more human resources transitioned from PEPFAR to the government. Conclusions: When PEPFAR funding decreased in 2012, there was a decrease in RIC. To ensure the continuity of HIV care when a major funder withdraws sufficient and stable transition resources, investment in organizations that understand the local context, joint planning, and coordination are required.

Preliminary Evaluation of Stability Data for Dolutegravir-Containing Triple Active Formulations Intended for PEPFAR. Degradation of Tenofovir Disoproxil Fumarate and Tenofovir Alafenamide as the Limiting Factor.

FDA reviews applications that are filed under the PEPFAR program to ensure that these products are manufactured to FDA's stringent requirements. Dolutegravir is a comparatively recent molecular entity that represents an advance over previous products. The stability behaviors of tablets that contain dolutegravir, lamivudine, and tenofovir disoproxil fumarate and tablets that contain dolutegravir, emtricitabine and tenofovir alafenamide were surveyed and it was found that tenofovir-related degradants increase the most and are the parameters most likely to result in product failure. A desiccant is advantageous and this desiccant should remain in the bottle after it has been opened. In-use studies simulate consumer use. Bottles are stored at 30 °C/75% RH and opened for about 1 min a day. Water content increased significantly and the rate of degradation was faster than the degradation rate observed during long-term storage. The data predict that most formulations containing TDF will stay within specification over 4 years of long-term storage followed by dispensing one tablet per day. With the current data it appears that some TAF-containing formulations may fail under similar conditions. However, the data are limited and preliminary and it is possible that the situation may improve as more stability data are acquired.

Adapting Longstanding Public Health Collaborations between Government of Kenya and CDC Kenya in Response to the COVID-19 Pandemic, 2020-2021.

Kenya's Ministry of Health (MOH) and the US Centers for Disease Control and Prevention in Kenya (CDC Kenya) have maintained a 40-year partnership during which measures were implemented to prevent, detect, and respond to disease threats. During the COVID-19 pandemic, the MOH and CDC Kenya rapidly responded to mitigate disease impact on Kenya's 52 million residents. We describe activities undertaken jointly by the MOH and CDC Kenya that lessened the effects of COVID-19 during 5 epidemic waves from March through December 2021. Activities included establishing national and county-level emergency operations centers and implementing workforce development and deployment, infection prevention and control training, laboratory diagnostic advancement, enhanced surveillance, and information management. The COVID-19 pandemic provided fresh impetus for the government of Kenya to establish a national public health institute, launched in January 2022, to consolidate its public health activities and counter COVID-19 and future infectious, vaccine-preventable, and emerging zoonotic diseases.

Contribution of PEPFAR-Supported HIV and TB Molecular Diagnostic Networks to COVID-19 Testing Preparedness in 16 Countries.

The US President's Emergency Plan for AIDS Relief (PEPFAR) supports molecular HIV and tuberculosis diagnostic networks and information management systems in low- and middle-income countries. We describe how national programs leveraged these PEPFAR-supported laboratory resources for SARS-CoV-2 testing during the COVID-19 pandemic. We sent a spreadsheet template consisting of 46 indicators for assessing the use of PEPFAR-supported diagnostic networks for COVID-19 pandemic response activities during April 1, 2020, to March 31, 2021, to 27 PEPFAR-supported countries or regions. A total of 109 PEPFAR-supported centralized HIV viral load and early infant diagnosis laboratories and 138 decentralized HIV and TB sites reported performing SARS-CoV-2 testing in 16 countries. Together, these sites contributed to >3.4 million SARS-CoV-2 tests during the 1-year period. Our findings illustrate that PEPFAR-supported diagnostic networks provided a wide range of resources to respond to emergency COVID-19 diagnostic testing in 16 low- and middle-income countries.

Leveraging PEPFAR-Supported Health Information Systems for COVID-19 Pandemic Response.

Since 2003, the US President's Emergency Plan for AIDS Relief (PEPFAR) has supported implementation and maintenance of health information systems for HIV/AIDS and related diseases, such as tuberculosis, in numerous countries. As the COVID-19 pandemic emerged, several countries conducted rapid assessments and enhanced existing PEPFAR-funded HIV and national health information systems to support COVID-19 surveillance data collection, analysis, visualization, and reporting needs. We describe efforts at the US Centers for Disease Control and Prevention (CDC) headquarters in Atlanta, Georgia, USA, and CDC country offices that enhanced existing health information systems in support COVID-19 pandemic response. We describe CDC activities in Haiti as an illustration of efforts in PEPFAR countries. We also describe how investments used to establish and maintain standards-based health information systems in resource-constrained settings can have positive effects on health systems beyond their original scope.

Individual and household risk factors for COVID-19 infection among household members of COVID-19 patients in home-based care in western Uganda, 2020.

Objective: To investigate factors associated with COVID-19 among household members of patients in home-based care (HBC) in western Uganda. Methods: We conducted a case-control and cohort study. Cases were reverse transcriptase-polymerase chain reaction-confirmed SARS-CoV-2 diagnosed 1-30 November 2020 among persons in HBC in Kasese or Kabarole districts. We compared 78 case-households (≥1 secondary case) with 59 control-households (no secondary cases). The cohort included all case-household members. Data were captured by in-person questionnaire. We used bivariate regression to calculate odds and risk ratios. Results: Case-households were larger than control-households (mean 5.8 vs 4.3 members, P<0.0001). Having ≥1 household member per room (adjusted odds ratio (aOR)=4.5, 95% CI 2.0-9.9), symptom development (aOR=2.3, 95% CI 1.1-5.0), or interaction with primary case-patient (aOR=4.6, 95% CI 1.4-14.7) increased odds of case-household status. Households assessed for suitability for HBC reduced odds of case-household status (aOR=0.4, 95% CI=0.2-0.8). Interacting with a primary case-patient increased the risk of individual infection among household members (adjusted risk ratio=1.7, 95% CI 1.1-2.8). Conclusion: Household and individual factors influence secondary infection risk in HBC. Decisions about HBC should be made with these in mind.

Providing differentiated service delivery to the ageing population of people living with HIV.

INTRODUCTION: Differentiated service delivery (DSD) models for HIV are a person-centred approach to providing services across the HIV care cascade; DSD has an increasing policy and implementation support in high-burden HIV countries. The life-course approach to DSD for HIV treatment has focused on earlier life phases, childhood and adolescence, families, and supporting sexual and reproductive health during childbearing years. Older adults, defined as those over the age of 50, represent a growing proportion of HIV treatment cohorts with approximately 20% of those supported by PEPFAR in this age band and have specific health needs that differ from younger populations. Despite this, DSD models have not been designed or implemented to address the health needs of older adults. DISCUSSION: Older adults living with HIV are more likely to have significant co-morbid medical conditions. In addition to the commonly discussed co-morbidities of hypertension and diabetes, they are at increased risk of cognitive impairment, frailty and mental health conditions. Age and HIV-related cognitive impairment may necessitate the development of adapted educational materials. Identifying the optimal package of differentiated services to this population, including the frequency of clinical visits, types and location of services is important as is capacitating the healthcare cadres to adapt to these challenges. Technological advances, which have made remote monitoring of adherence and other aspects of disease management easier for younger populations, may not be as readily available or as familiar to older adults. To date, adaptations to service delivery have not been scaled and are limited to nascent programmes working to integrate treatment of common co-morbidities. CONCLUSIONS: Older individuals living with HIV may benefit from a DSD approach that adapts care to the specific challenges of ageing with HIV. Models could be developed and validated using outcome measures, such as viral suppression and treatment continuity. DSD models for older adults should consider their specific health needs, such as high rates of co-morbidities. This may require educational materials, health worker capacity building and outreach designed specifically to treat this age group.

The effectiveness of the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) in responding to HIV/AIDS in Four African Countries.

BACKGROUND: The purpose of this study is to examine how PEPFAR's policies have changed and how these affects Human Immunodeficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS) issue in two focus countries (Botswana and Ethiopia) and two non-focus countries (Zimbabwe and the Democratic Republic of Congo, or DR of Congo). METHOD: This study investigates one country with the highest HIV rate (Botswana) and one with the lowest rates (Ethiopia) among the focus countries, as well as one each with the highest rate (Zimbabwe) and the lowest rate (DR Congo) among the non-focus countries. RESULTS: This study finds that President's Emergency Plan for AIDS Relief (PEPFAR) has tended to change its strategies depending on a recipient country's epidemiology and has spent less in non-focus than in focus countries. CONCLUSIONS: But by revealing the contributions and limitations of PEPFAR in four African countries, this study shows how PEPFAR can improve its future policies in these countries.

PEPFAR's Role in Protecting and Leveraging HIV Services in the COVID-19 Response in Africa.

PURPOSE OF REVIEW: We describe the impact of COVID-19 on PEPFAR programs in Africa and how PEPFAR adapted and leveraged its interventions to the changing landscape of the COVID-19 pandemic. RECENT FINDINGS: To mitigate the potential impact of COVID-19 on the HIV response and protect the gains, continuity of treatment was the guiding principle regarding the provision of services in PEPFAR-supported countries. As the COVID-19 pandemic matured, PEPFAR's approach evolved from a strictly "protect and salvage" approach to a "restore and accelerate" approach that embraced innovative adaptations in service and "person-centered" care. The impact of service delivery interruptions caused by COVID-19 on progress towards HIV epidemic control in PEPFAR-supported African countries remains undetermined. With COVID vaccine coverage many months away and more transmissible variants being reported, Africa may experience more pandemic surges. HIV programs will depend on nimble and innovative adaptations in prevention and treatment services in order to advance epidemic control objectives.

The impact of COVID-19 on multi-month dispensing (MMD) policies for antiretroviral therapy (ART) and MMD uptake in 21 PEPFAR-supported countries: a multi-country analysis.

INTRODUCTION: Increasing access to multi-month dispensing (MMD) of antiretroviral therapy (ART) supports treatment continuity and viral load suppression for people living with HIV (PLHIV) and reduces burden on health facilities. During the COVID-19 response, PEPFAR worked with ministries of health to scale up MMD and expand eligibility to new groups of PLHIV, including children and pregnant/breastfeeding women. We analysed PEPFAR program data to understand the impact of the policy changes on actual practice. METHODS: We conducted a desk review in 21 PEPFAR-supported countries to identify and collect official documentation released between March and June 2020 addressing changes to MMD guidance during the COVID-19 response. MMD coverage, the proportion of all ART clients on MMD, was assessed in the calendar quarters preceding the COVID-19 response (Q4 2019, October-December 2019; and Q1, January-March 2020) and the quarters following the start of the response (Q2 2020, April-June 2020; Q3 2020, July-September, 2020; Q4 2020, October-December 2020). We used the two-proportion Z-test to test for differences in MMD coverage pre-COVID-19 (Q4 2019) and during implementation of COVID-19 policy adaptations (Q2 2020). RESULTS AND DISCUSSION: As of June 2020, 16 of the 21 PEPFAR-supported countries analysed adapted MMD policy or promoted intensified scale-up of MMD in response to COVID-19. MMD coverage for all clients on ART grew from 49% in Q4 2019 pre-COVID-19 to 72% in Q2 2020 during COVID-19; among paediatric clients (< 15), MMD coverage increased from 27% to 51% in the same period. Adaptations to MMD policy were associated with a significantly accelerated growth in the proportion of clients on MMD (p < 0.001) for all populations, irrespective of age and dispensing interval. CONCLUSIONS: Access to MMD markedly expanded during the COVID-19 pandemic, supporting treatment continuity while mitigating exposure to COVID-19 at health facilities. This model is beneficial in public health emergencies and during disruptions to the healthcare system. Outside emergency contexts, expanded MMD eligibility extends client-centred care to previously excluded populations. The success in expanding MMD access during COVID-19 should motivate countries to recommend broader MMD access as a new standard of care.