"I only seek treatment when I am ill": experiences of hypertension and diabetes care among adults living with HIV in urban Tanzania.

BACKGROUND: For adults living with HIV (ALHIV) and comorbidities, access to comprehensive healthcare services is crucial to achieving optimal health outcomes. This study aims to describe lived experiences, challenges, and coping strategies for accessing care for hypertension and/or diabetes (HTN/DM) in HIV care and treatment clinics (CTCs) and other healthcare settings. METHODOLOGY: We conducted a qualitative study that employed a phenomenological approach between January and April 2022 using a semi-structured interview guide in six HIV CTCs in Dar es Salaam, Tanzania. We purposively recruited 33 ALHIV with HTN (n = 16), DM (n = 10), and both (n = 7). Thematic content analysis was guided by the 5As framework of access to care. FINDINGS: The majority of the participants were females, between the ages of 54-73, and were recruited from regional referral hospitals. HIV CTCs at regional referral hospitals had more consistent provision of HTN screening services compared to those from district hospitals and health centers. Participants sought HTN/DM care at non-CTC health facilities due to the limited availability of such services at HIV CTCs. However, healthcare delivery for these conditions was perceived as unaccommodating and poorly coordinated. The need to attend multiple clinic appointments for the management of HTN/DM in addition to HIV care was perceived as frustrating, time-consuming, and financially burdensome. High costs of care and transportation, limited understanding of comorbidities, and the perceived complexity of HTN/DM care contributed to HTN/DM treatment discontinuity. As a means of coping, participants frequently monitored their own HTN/DM symptoms at home and utilized community pharmacies and dispensaries near their residences to check blood pressure and sugar levels and obtain medications. Participants expressed a preference for non-pharmaceutical approaches to comorbidity management such as lifestyle modification (preferred by young participants) and herbal therapies (preferred by older participants) because of concerns about side effects and perceived ineffectiveness of HTN/DM medications. Participants also preferred integrated care and focused patient education on multimorbidity management at HIV CTCs. CONCLUSION: Our findings highlight significant barriers to accessing HTN/DM care among ALHIV, mostly related to affordability, availability, and accessibility. Integration of NCD care into HIV CTCs, could greatly improve ALHIV health access and outcomes and align with patient preference.

Impact of a post-partum family planning intervention on contraception and fertility in Tanzania: two-year follow-up of a cluster-randomised controlled trial.

PURPOSE: We evaluate contraceptive use and pregnancy two years following an intervention in Tanzania, which provided antenatal post-partum family planning counselling and post-partum intrauterine device (PPIUD) services following delivery. METHODS: We analyse data from five hospitals in Tanzania using a difference-in-difference cluster randomised design, with randomisation at the hospital level. We use women-level data collected at the index birth and a follow-up survey two years later among 6,410 women. Outcomes (overall modern contraceptive use, contraceptive type, pregnancy) are modelled with an intent-to-treat (ITT) approach using linear regression. We compare with the complier average causal effect (CACE) of the intervention among those counselled. RESULTS: The intervention increased long-term PPIUD use by 5.8 percentage points (95% CI: 0.7-11.2%) through substitution away from other modern methods. There was no impact on overall modern contraceptive prevalence or pregnancy. Only 29% of women reported receiving PPIUD counselling. When accounting for this in the CACE analysis we saw a larger impact with 25.7% percentage point increase in PPIUD use (95% CI: 22.7-28.6%). CONCLUSION: The intervention provided women an additional contraceptive choice, resulting in higher use of PPIUD over two years. Increase in PPIUD use was brought about by shifting methods, not creating new modern contraceptive users.

The post-partum family planning intervention in Tanzania offered women a new contraceptive option and increased sustained use of post-partum IUD. The intervention did not attract new modern contraception users and could have a greater impact if implemented more widely.

A peer-facilitated psychological group intervention for perinatal women living with HIV and depression in Tanzania-Healthy Options: A cluster-randomized controlled trial.

BACKGROUND: Perinatal women living with HIV (PWLH) have a greater risk of depression compared to other women; however, there are limited specialized mental health services available to them. We aimed to determine whether a stepped-care intervention facilitated by trained lay providers can improve mental health outcomes postpartum for PWLH. METHODS AND FINDINGS: Healthy Options is a cluster-randomized controlled study conducted in 16 government-managed antenatal care clinics that provided HIV care for pregnant women in urban Tanzania. Recruitment occurred from May 2015 through April 2016, with the final round of data collection completed in October 2017. Participants included a consecutive sample of pregnant women under 30 weeks of gestation, living with HIV and depression, and attending the study clinics. Control sites received enhanced usual care for depression (EUDC). Intervention sites received EUDC plus the Healthy Options intervention, which includes prenatal group sessions of problem-solving therapy (PST) plus cognitive behavioral therapy (CBT) sessions for individuals showing depressive symptoms at 6 weeks postdelivery. We assessed depressive symptoms comparable to major depressive disorder (MDD) using the Patient Health Questionnaire-9 (PHQ-9) with a locally validated cutoff at 9 months and 6 weeks postpartum. The primary time point is 9 months postpartum. We examined differences in outcomes using an intent-to-treat analysis with a complete case approach, meaning those with data at the relevant time point were included in the analysis. We used generalized estimating equations accounting for clustering. Of 818 women screened using the PHQ-9, 742 were determined eligible and enrolled (395 intervention; 347 control); 649 women (87.5%) participated in the first follow-up and 641 women (86.4%) in the second. A majority (270, 74.6%) of women in the intervention arm attended 5 or more PST sessions. Women enrolled in Healthy Options demonstrated a 67% (RR 0.33; 95% CI: 0.22, 0.51; p-value: <0.001; corresponding to a 25.7% difference in absolute risk) lower likelihood of depressive symptoms than women in control clusters at 6 weeks postpartum. At 9 months postpartum, women enrolled in Healthy Options demonstrated a nonsignificant 26% (RR 0.74; 95% CI: 0.42, 1.3; p-value: 0.281; corresponding to a 3.2% difference in absolute risk) lower likelihood of depressive symptoms than women in control clusters. Study limitations include not using diagnostic interviews to measure depression and not blinding data collectors to intervention status during follow-up. CONCLUSIONS: The Healthy Options intervention did not demonstrate reduction in depressive symptoms at 9 months postpartum, the primary outcome. Significant reductions were seen in depression symptoms at 6 weeks postpartum, the secondary outcome. Stepped-care interventions may be relevant for improving outcomes in the critical early postpartum window. TRIAL REGISTRATION: Clinical Trial registration number (closed to new participants) NCT02039973.

Prevalence and determinants of non-communicable diseases including depression among HIV patients on antiretroviral therapy in Dar es Salaam, Tanzania.

OBJECTIVE: People living with HIV/AIDS (PLHA) are experiencing growing co-morbidities due to an increase in life expectancy and the use of long-term antiretroviral therapy (ART). The lack of integrated non-communicable diseases (NCDs) screening and management at the HIV care and treatment centres (CTCs) make it difficult to determine the trends of NCD co-morbidity among patients with HIV. This study aimed to assess the burden and determinants of common NCDs, including depression among patients with HIV. METHODS: Analytical cross-sectional study of 1318 HIV patients enrolled using systematic random sampling conducted from April to November 2020. Five large CTCs in district referral hospitals were selected representing the five districts of Dar es Salaam including Mwananyamala, Temeke, and Amana regional referral hospitals and Sinza and Vijibweni hospitals. The study population consisted of adult PLHA aged 18 years and above. The primary outcome measure was the prevalence of NCDs among HIV patients. Observation of actual NCD medications or their purchase receipts or booked NCD clinic appointments that PLHA had during the study period was used to verify the reported presence of NCDs. The secondary outcome measure was the prevalence of probable depression among PLHA. The locally validated Swahili Patient Health Questionnaire (PHQ-9) was used to screen for depressive symptom severity. A logistic regression model was used to identify factors associated with common NCDs and those associated with probable depression. Potential risk factors that were statistically significant at a P-value of 0.2 or less in univariable analysis were included as potential confounders in multivariable models. RESULTS: The median age of participants was 42 (IQR 35-49) years, with 32.7% in the 36-45 years age group. The majority of patients were women (69%). Most (80.5%) had achieved HIV viral (VL) suppression (a serum HIV VL of <1000 copies/ml). Overall, 14.3% of self-reported an NCD with evidence of their current medication for the NCD from receipts for medication purchased and appointments from NCD clinics they attended. In the multivariable analyses, higher odds of NCDs were in older patients (>45 years) and those with a weight above 75 kg (P < 0.05). Male patients had 51% reduced odds of NCDs (aOR 0.49; 95% CI: 0.32-0.74) than females (P < 0.001). Probable depression prevalence was 11.8%, and depressed patients had more than twice the odds of having NCDs than those without depression (aOR 2.26; 95% CI: 1.45-3.51; P < 0.001). CONCLUSION: This study determined co-existing previously diagnosed NCDs among PLHA accessing care and high levels of depressive symptom severity. We recommend additional research on the feasibility, acceptability, and cost implications of screening and treating NCDs on HIV care platforms to provide evidence for Tanzania's integrated HIV/NCD care model.

Burden of HIV-related stigma and associated factors among women living with depression accessing PMTCT services in Dar es Salaam, Tanzania.

HIV-related stigma represents a potent risk factor for a range of poor health outcomes, including mental health symptoms, treatment non-adherence, and substance use. Understanding the role of HIV-related stigma in promoting healthcare outcomes is critical for vulnerable populations, such as pregnant women living with HIV, in contexts with continued high rates of HIV and associated stigma, such as sub-Saharan Africa. The current study examined a range of risk and protective factors for HIV-related stigma with 742 pregnant women (M age = 29.6 years) living with depression and HIV accessing prevention of mother-to-child transmission of HIV (PMTCT) services in Dar es Salaam, Tanzania. Risk factors included depressive symptoms, ART non-adherence, intimate partner violence, food insecurity, and alcohol problems. Protective factors included disclosure of HIV status, social support, an appreciative relationship with their partner, hope, and self-efficacy. Findings highlight key psychosocial and behavioral determinants of HIV-related stigma for pregnant women living with HIV in Tanzania, and can inform perinatal care programming and interventions to optimize mental health and adherence outcomes.

Prevalence and factors associated with intimate partner violence after HIV status disclosure among pregnant women with depression in Tanzania.

Intimate partner violence (IPV) exacts a heavy burden on women, resulting in poor health outcomes. This study had the following aims: (1) estimate the prevalence of IPV post-disclosure of HIV status among pregnant women living with HIV and depression; and (2) evaluate risk and protective factors for IPV post-disclosure. Participants were women accessing PMTCT services at 16 health facilities in Dar es Salaam and screened at the threshold of 9 on the PHQ-9. Generalized linear equations with a log link and standard errors clustered at the facility level were used to calculate associations between predictors and IPV post-disclosure. Among 659 women who were in an intimate relationship, 10.2% had experienced physical violence and 11.6% had reported sexual violence from their partner in the past six months; 327 had disclosed their HIV status to their partners. After disclosure to their partners 279 women (85.3%) experienced IPV. HIV-related stigma was associated with increased risk of IPV following disclosure and appreciative relationships with partners and higher hope were associated with reduced risk of IPV. There is a need to identify and advance approaches to HIV disclosure that prevent IPV. Interventions should be developed based on known risk and protective factors for IPV following HIV disclosure in Tanzania and similar settings.

Barriers and Facilitators to Effective Implementation of the NAMWEZA Intervention in Dar es Salaam, Tanzania.

The NAMWEZA intervention was implemented, using a ten-session group format, to build skills targeting psychosocial vulnerabilities and enhancing HIV prevention among people living with HIV (PLH) and their social networks. The overall goal of this intervention is to improve psychological wellbeing and reduce HIV risk behaviours. These analyses aim to describe the barriers and facilitators of implementing the NAMWEZA intervention from the perspective of participants and trained peer group facilitators. Twenty-four in-depth interviews were conducted with NAMWEZA participants, and 50 pooled peer facilitator self-assessment reports were obtained from 16 trained peers. Participants identified personal and structural barriers, including fear of inadvertent HIV status disclosure, time constraints, level of participant reimbursements, and limited space available for group sessions. Factors facilitating effective implementation included perceived benefits of the program, such as reduction in HIV-related risk behaviours, increased self-esteem, and improvement in confidence in HIV prevention communications. Scaling up the NAMWEZA intervention to other areas of Tanzania or regionally should take into account these facilitators and barriers to implementation.

Healthy Options: study protocol and baseline characteristics for a cluster randomized controlled trial of group psychotherapy for perinatal women living with HIV and depression in Tanzania.

BACKGROUND: Perinatal women accessing prevention of mother-to-child transmission of HIV (PMTCT) services are at an increased risk of depression; however, in Tanzania there is limited access to services provided by mental health professionals. This paper presents a protocol and baseline characteristics for a study evaluating a psychosocial support group intervention facilitated by lay community-based health workers (CBHWs) for perinatal women living with HIV and depression in Dar es Salaam. METHODS: A cluster randomized controlled trial (RCT) is conducted comparing: 1) a psychosocial support group intervention; and 2) improved standard of mental health care. The study is implemented in reproductive and child health (RCH) centers providing PMTCT services. Baseline characteristics are presented by comparing sociodemographic characteristics and primary as well as secondary outcomes for the trial for intervention and control groups. The trial is registered under clinicaltrials.gov (NCT02039973). RESULTS: Among 742 women enrolled, baseline characteristics were comparable for intervention and control groups, although more women in the control group had completed secondary school (25.2% versus 18.2%). Overall, findings suggest that the population is highly vulnerable with over 45% demonstrating food insecurity and 17% reporting intimate partner violence in the past 6 months. CONCLUSIONS: Baseline characteristics for the cluster RCT were comparable for intervention and control groups. The trial will examine the effectiveness of a psychosocial support group intervention for the treatment of depression among women living with HIV accessing PMTCT services. A reduction in the burden of depression in this vulnerable population has implications in the short-term for improved HIV-related outcomes and for potential long-term effects on child growth and development. TRIAL REGISTRATION: The trial is registered under clinicaltrials.gov (NCT02039973). Retrospectively registered on January 20, 2014.

Community health workers to improve uptake of maternal healthcare services: A cluster-randomized pragmatic trial in Dar es Salaam, Tanzania.

BACKGROUND: Home delivery and late and infrequent attendance at antenatal care (ANC) are responsible for substantial avoidable maternal and pediatric morbidity and mortality in sub-Saharan Africa. This cluster-randomized trial aimed to determine the impact of a community health worker (CHW) intervention on the proportion of women who (i) visit ANC fewer than 4 times during their pregnancy and (ii) deliver at home. METHODS AND FINDINGS: As part of a 2-by-2 factorial design, we conducted a cluster-randomized trial of a home-based CHW intervention in 2 of 3 districts of Dar es Salaam from 18 June 2012 to 15 January 2014. Thirty-six wards (geographical areas) in the 2 districts were randomized to the CHW intervention, and 24 wards to the standard of care. In the standard-of-care arm, CHWs visited women enrolled in prevention of mother-to-child HIV transmission (PMTCT) care and provided information and counseling. The intervention arm included additional CHW supervision and the following additional CHW tasks, which were targeted at all pregnant women regardless of HIV status: (i) conducting home visits to identify pregnant women and refer them to ANC, (ii) counseling pregnant women on maternal health, and (iii) providing home visits to women who missed an ANC or PMTCT appointment. The primary endpoints of this trial were the proportion of pregnant women (i) not making at least 4 ANC visits and (ii) delivering at home. The outcomes were assessed through a population-based household survey at the end of the trial period. We did not collect data on adverse events. A random sample of 2,329 pregnant women and new mothers living in the study area were interviewed during home visits. At the time of the survey, the mean age of participants was 27.3 years, and 34.5% (804/2,329) were pregnant. The proportion of women who reported having attended fewer than 4 ANC visits did not differ significantly between the intervention and standard-of-care arms (59.1% versus 60.7%, respectively; risk ratio [RR]: 0.97; 95% CI: 0.82-1.15; p = 0.754). Similarly, the proportion reporting that they had attended ANC in the first trimester did not differ significantly between study arms. However, women in intervention wards were significantly less likely to report having delivered at home (3.9% versus 7.3%; RR: 0.54; 95% CI: 0.30-0.95; p = 0.034). Mixed-methods analyses of additional data collected as part of this trial suggest that an important reason for the lack of effect on ANC outcomes was the perceived high economic burden and inconvenience of attending ANC. The main limitations of this trial were that (i) the outcomes were ascertained through self-report, (ii) the study was stopped 4 months early due to a change in the standard of care in the other trial that was part of the 2-by-2 factorial design, and (iii) the sample size of the household survey was not prespecified. CONCLUSIONS: A home-based CHW intervention in urban Tanzania significantly reduced the proportion of women who reported having delivered at home, in an area that already has very high uptake of facility-based delivery. The intervention did not affect self-reported ANC attendance. Policy makers should consider piloting, evaluating, and scaling interventions to lessen the economic burden and inconvenience of ANC. TRIAL REGISTRATION: ClinicalTrials.gov NCT01932138.

Women's Perspectives on Postpartum Intrauterine Devices in Tanzania.

Despite the numerous benefits of the postpartum copper intrauterine device (PPIUD), which is inserted within 48 hours after giving birth, it is underutilized in many resource-constrained settings, including Tanzania. We conducted in-depth interviews with 20 pregnant women who received contraceptive counseling during routine antenatal care in 2016-2017 and 27 postpartum women who had a PPIUD inserted in 2018 to understand reasons for use versus nonuse and continuation versus discontinuation. Primary motivators for using a PPIUD included: convenience, effectiveness, perceived lack of side effects, and duration of pregnancy protection. Barriers to use included: fear of insertion, concerns related to sexual experiences post-insertion, and limited knowledge. Women who had a PPIUD inserted continued use when their expectations matched their experience, while discontinuation resulted from unexpected expulsion and experience of unanticipated side effects. Frequent follow-up and guidance on side-effect management influenced women's decisions to continue use. To support uptake and continued utilization of the PPIUD, postpartum contraceptive counseling should explicitly address side effects and risk of expulsion.

The effect of a community health worker intervention on public satisfaction: evidence from an unregistered outcome in a cluster-randomized controlled trial in Dar es Salaam, Tanzania.

BACKGROUND: There is a dearth of evidence on the causal effects of different care delivery approaches on health system satisfaction. A better understanding of public satisfaction with the health system is particularly important within the context of task shifting to community health workers (CHWs). This paper determines the effects of a CHW program focused on maternal health services on public satisfaction with the health system among women who are pregnant or have recently delivered. METHODS: From January 2013 to April 2014, we carried out a cluster-randomized controlled health system implementation trial of a CHW program. Sixty wards in Dar es Salaam, Tanzania, were randomly allocated to either a maternal health CHW program (36 wards) or the standard of care (24 wards). From May to August 2014, we interviewed a random sample of women who were either currently pregnant or had recently delivered a child. We used five-level Likert scales to assess women's satisfaction with the CHW program and with the public-sector health system in Dar es Salaam. RESULTS: In total, 2329 women participated in the survey (response rate 90.2%). Households in intervention areas were 2.3 times as likely as households in control areas to have ever received a CHW visit (95% CI 1.8, 3.0). The intervention led to a 16-percentage-point increase in women reporting they were satisfied or very satisfied with the CHW program (95% CI 3, 30) and a 15-percentage-point increase in satisfaction with the public-sector health system (95% CI 3, 27). CONCLUSIONS: A CHW program for maternal and child health in Tanzania achieved better public satisfaction than the standard CHW program. Policy-makers and implementers who are involved in designing and organizing CHW programs should consider the potential positive impact of the program on public satisfaction. TRIAL REGISTRATION: ClinicalTrials.gov, EJF22802.

Validating the Patient Health Questionnaire-9 (PHQ-9) for screening of depression in Tanzania.

BACKGROUND: Major depression has a significant impact on years lived with disability (YLD) globally. In resource-limited countries, depression may accompany daily challenges of economic security that people face, hence there is a critical need to develop depression screening tools at primary levels of health care. The overall goal of the study is to validate the PHQ-9 in Tanzania. METHODS: A validation study was conducted from August to October 2014 among adults accessing primary health care at public clinics in Dar es Salaam. The Mini-International Neuropsychiatric Interview (MINI) was used as the gold standard for current major depressive episode. RESULTS: Among 180 patients recruited, six were not included in the analysis since the PHQ-9 and MINI assessments were conducted more than two weeks apart (n=174). The PHQ-9 demonstrated reasonable reliability in this setting (α=0.83). Evidence for construct validity was observed through expected associations with female gender (r=0.16, p=0.04) and food insecurity (r=0.30, p<0.0001). Receiver Operating Characteristic analysis demonstrated good overall accuracy of the PHQ-9 (AOC=0.87, 95%CI: 0.77, 0.96). The optimal cut-off score in this population was 9, with a sensitivity of 78% and specificity of 87%. LIMITATIONS: The study sample is from a primary health care setting, hence the findings may have some limited generalizability at the community level. CONCLUSIONS: The PHQ-9 demonstrated reliability and validity among adults accessing primary health care in Dar es Salaam, indicating that it can serve as a useful tool in identifying patients with depression in primary care clinics in Tanzania and similar settings.

CLINICAL outcomes and loss to follow-up among people living with HIV participating in the NAMWEZA intervention in Dar es Salaam, Tanzania: a prospective cohort study.

BACKGROUND: Psychosocial factors have been linked with loss to follow-up (LTFU) and clinical outcomes among people living with HIV (PLH), however little is known about the effect of psychosocial support on LTFU among PLH in treatment and care. The purpose of this study was to explore the effect of NAMWEZA ("Yes, together we can") friends' psychosocial support intervention on clinical outcomes and LTFU among PLH. NAMWEZA is based on a novel program using "appreciative inquiry", positive psychology approaches to empower, promote positive attitudes and foster hope. METHODS: PLH participating in the NAMWEZA intervention in HIV care clinics in Dar es Salaam Tanzania were compared with non-exposed PLH obtained from facilities that routinely collect clinical information and both followed longitudinally for 24 months. Baseline sociodemographic, clinical measures (CD4 cell count, hemoglobin (HGB), weight), and LTFU measures were collected. Chi square, Fisher's exact tests, and t-tests were used to compare the frequencies for categorical variables and the means of continuous variables from the intervention and the comparison groups to identify variables that were significantly different across the two groups. Random effects models were performed to examine the bivariate associations between the intervention status and clinical outcomes. RESULTS: At the end of 24 months of follow-up mean CD4 count and HGB levels increased significantly in both intervention and comparison groups (p = 0.009 and p < 0.0001, respectively). Weight increased significantly only in the intervention group (p = 0.003). Cumulative LTFU was three times higher in the comparison compared to the intervention (p < 0.001) group. Having a low CD4 count, extremes of weight, low HGB, younger age, and male gender were significantly associated with LTFU among the unexposed group, while being on ART for duration of 12 months or more was protective against LTFU in those intervened. CONCLUSION: Among PLH on ART, exposed or not exposed to NAMWEZA intervention, clinical care outcomes improved over time. LTFU was much higher in the comparison group with factors commonly known to predict LTFU only apparent in the comparison group. NAMWEZA could be a promising peer-facilitated model to reduce LTFU among PLH in care that can be integrated in ART services; however, more research is needed to evaluate its longer term effects.

Preparedness of HIV care and treatment clinics for the management of concomitant non-communicable diseases: a cross-sectional survey.

BACKGROUND: In Sub-Saharan Africa, epidemiological studies have reported an increasing burden of non-communicable diseases (NCD) among people living with HIV. NCD management can be feasibly integrated into HIV care; however, clinic readiness to provide NCD services in these settings should first be assessed and gaps in care identified. METHODS: A cross-sectional survey conducted in July 2013 assessed the resources available for NCD care at 14 HIV clinics in Dar es Salaam, Tanzania. Survey items related to staff training, protocols, and resources for cardiovascular disease risk factor screening, management, and patient education. RESULTS: 43 % of clinics reported treating patients with hypertension; however, only 21 % had a protocol for NCD management. ECHO International Health standards for essential clinical equipment were used to measure clinic readiness; 36 % met the standard for blood pressure cuffs, 14 % for glucometers. Available laboratory tests for NCD included blood glucose (88 %), urine dipsticks (78 %), and lipid panel (57 %). 21 % had a healthcare worker with NCD training. All facilities provided some form of patient education, but only 14 % included diabetes, 57 % tobacco cessation, and 64 % weight management. CONCLUSIONS: A number of gaps were identified in this sample of HIV clinics that currently limit the ability of Tanzanian healthcare workers to diagnose and manage NCD in the context of HIV care. Integrated NCD and HIV care may be successfully achieved in these settings with basic measures incorporated into existing infrastructures at minimal added expense, i.e., improving access to basic functioning equipment, introducing standardized treatment guidelines, and improving healthcare worker education.

Mental health screenings for couples at churches in Nigeria: a strategy for enhancing community-based maternal mental health services in low-resource settings.

The burden of perinatal mental disorders among women in low- and middle-income countries is substantial. The current integration of mental health into maternal, neonatal and child health service platforms is limited, despite global calls to prioritize such service integration. The study by Iheanacho and colleagues (2014) entitled "Integrating mental health screening into routine community maternal and child health activity: experience from a prevention of mother-to-child HIV transmission (PMTCT) trial in Nigeria" provides promising evidence about the feasibility of a church-based strategy for screening pregnant women and their partners for mental health problems through a PMTCT program.

Patient satisfaction with HIV/AIDS care at private clinics in Dar es Salaam, Tanzania.

Health system responsiveness (HSR) measures quality of care from the patient's perspective, an important component of ensuring adherence to medication and care among HIV patients. We examined HSR in private clinics serving HIV patients in Dar es Salaam, Tanzania. We surveyed 640 patients, 18 or older receiving care at one of 10 participating clinics, examining socioeconomic factors, HIV regimen, and self-reported experience with access and care at the clinic. Ordered logistic regression, adjusted for clustering of the clinic sites, was used to measure the relationships between age, gender, education, site size, and overall quality of care rating, as well as between the different HSR domains and overall rating. Overall, patients reported high levels of satisfaction with care received. Confidentiality, communication, and respect were particularly highly rated, while timeliness received lower ratings despite relatively short wait times, perhaps indicating high expectations when receiving care at a private clinic. Respect, confidentiality, and promptness were significantly associated with overall rating of health care, while provider skills and communication were not significantly associated. Patients reported that quality of service and confidentiality, rather than convenience of location, were the most important factors in their choice of a clinic. Site size (patient volume) was also positively correlated with patient satisfaction. Our findings suggest that, in the setting of urban private-sector clinics, flexible clinics hours, prompt services, and efforts to improve respect, privacy and confidentiality may prove more helpful in increasing visit adherence than geographic accessibility. While a responsive health system is valuable in its own right, more work is needed to confirm that improvements in HSR in fact lead to improved adherence to care.

Prevalence and Risk Factors for Renal Insufficiency among Adults Living with HIV in Tanzania: Results from a Cross-Sectional Study in 2020-2021.

With improved survival, adults living with HIV (ALHIV) are increasingly likely to experience age-related and HIV-related comorbidities, including renal insufficiency. Other risk factors for renal insufficiency (high blood pressure (BP), obesity, diabetes, and dyslipidemia) are also growing more common among ALHIV. To determine the prevalence of renal insufficiency (defined as an eGFR < 60 mL/min/1.73 m2) and factors associated with reduced eGFR, we conducted a cross-sectional study at six HIV clinics in Dar-es-Salaam, Tanzania. We applied multivariable (MV) ordinal logistic regression models to identify factors associated with reduced eGFR and examined the interaction of age with BP levels. Among the 450 ALHIV on ART analyzed [26% males; median age 43 (IQR: 18-72) years; 89% on tenofovir-containing ART; 88% HIV viral load ≤50 copies/mL], 34 (7.5%) had renal insufficiency. Prevalence was higher among males (12%) vs. females (6%), p = 0.03; ALHIV ≥50 (21%) vs. <50 years (2.5%), p < 0.001; those with high [≥130/80 mmHg (15%)] vs. normal [<120/80 mmHg (4%)] BP, p < 0.01 and those with dyslipidemia (10%) vs. those without (4.5%), p < 0.03. After adjusting for covariates, age (in years) was the only covariate with a statistically significant association with reduced eGFR (OR = 1.09 (1.07-1.12), p < 0.001). No significant interaction between age and BP was found. Interventions to increase routine screening for renal insufficiency, especially among older ALHIV, and improve BP control are critical to reducing kidney disease-related morbidity and mortality.

Generalized and COVID related anxiety as risk factors for health outcomes among adolescents with HIV during COVID-19 in Tanzania.

The COVID-19 pandemic and associated prevention strategies caused widespread interruptions to care and treatment for people living with HIV. Adolescents living with HIV (AWHIV) were particularly vulnerable to poor mental and physical health during COVID-19. We assessed the burden of generalized and COVID-19-related anxiety and associations with adherence to HIV care and treatment and viral load suppression (VLS) among AWHIV during the peak of the COVID-19 pandemic in Tanzania. Methods: This cross-sectional study was conducted among AWHIV aged 15-19 years attending 10 clinics in Dar es Salaam from April 2022-February 2023. Study participants completed a self-administered questionnaire including Generalized Anxiety Disorder (GAD), COVID-19-related anxiety, and other psychosocial and physical health and support measures. HIV visit adherence, viral load and sociodemographic data were abstracted from patient health records.Analysis:: Multivariable (MV) quasibinomial and logistic regression models examined associations of Generalized and COVID-19-related anxiety with visit adherence and HIV virologic suppression (HIV VL < 50 copies/mL). Data were analyzed using R software. Results: 658 AWHIV (52% male) were included in this analysis. Most (86%) had been on antiretroviral treatment (ART) for at least four years, 55% attended at least 75% of their scheduled clinic visits, and 78% were HIV virologically suppressed. The median GAD and COVID-19-related anxiety scores were 2 (IQR: 0-5, and 26 (IQR: 13-43; respectively. Only 2% scored moderate-severe generalized anxiety (score 10-21). We found no significant associations between COVID-19-related anxiety or GAD and visit adherence. Higher GAD was inversely associated with VLS (adjusted odds ratio (AOR): 0.89 (95% CI 0.81, 0.98)). Female gender and higher quality of physical life were significantly associated with VLS. Conclusion: Low levels of generalized and COVID-19 related anxiety were reported among Tanzanian AWHIV. Integrating screening and management of generalized anxiety screening into HIV care for AWHIV could improve VLS among this population.

Vertical HIV transmission within 18 months post partum among women on lifelong antiretroviral therapy for HIV in Dar es Salaam, Tanzania: a prospective cohort study.

BACKGROUND: The UNAIDS estimate of vertical HIV transmission in Tanzania is high (11%), despite 84% uptake of antiretroviral therapy (ART) among pregnant women with HIV. We aimed to evaluate vertical transmission and its determinants by 18 months post partum among women on lifelong ART in routine health-care settings in Tanzania. METHODS: We conducted a prospective cohort study in 226 health facitilies across Dar-es-Salaam, Tanzania. Eligible participants were pregnant women of any age with HIV, and later their infants, who enrolled in routine health-care services for the prevention of vertical transmission. We prospectively followed up mother-infant pairs at routine monthly visits until 18 months post partum and extracted data from the care and treatment clinic (CTC2) database, a national electronic database that stores patient-level HIV care and treatment clinic data. The primary outcome was time from birth to HIV diagnosis, defined as a positive infant HIV DNA PCR or antibody test from age 18 months. We used the Kaplan-Meier method to estimate cumulative risk of vertical transmission by 18 months post partum and Cox proportional hazards regression with shared frailties to account for potential clustering in health facilities to evaluate predictors of transmission. FINDINGS: Between Jan 1, 2015, and Dec 31, 2017, 22 930 pregnant women with HIV (median age 30 years, IQR 25-34) enrolled on a care programme. After excluding 9140 (39·9%) women and 539 (2·4%) infants with missing outcome data, 13 251 (59·0%) mother-infant pairs were analysed, of whom 6072 (45·8%) women were already on ART before pregnancy. By 18 months post partum, 159 (1·2%) of 13 251 infants were diagnosed with HIV, equivalent to a risk of vertical transmission of 1·4% (95% CI 1·2-1·6). In the complete case analysis, the rates of vertical transmission were higher among women who enrolled in the third trimester of pregnancy than among those who enrolled in the first trimester (adjusted hazard ratio 3·01, 95% CI 1·59-5·70; p=0·0003), among women with advanced HIV disease than among those with early-stage disease (1·89, 1·22-2·93; p=0·0046), and among women who were on a second-line ART regimen than among those on a first-line regimen (3·58, 1·08-11·82; p=0·037). By contrast, the rate of vertical transmission was lower among women who were already on ART at enrolment than among those starting ART at enrolment (0·39, 0·25-0·60; p<0·0001) as well as among women in high-volume clinics than among those in low-volume clinics (0·46 (0·24-0·90; p<0·0097). INTERPRETATION: Provision of ART for life (WHO's option B+ recommendation) has reduced the risk of vertical transmission to less than 2% among pregnant women with HIV in routine care settings in urban Tanzania. There is still a need to improve timely HIV diagnosis and ART uptake, and to optimise follow-up for the prevention of vertical transmission and the uptake of infant HIV testing. FUNDING: Swedish International Development Cooperation Agency.

The impact of a community health worker intervention on uptake of antenatal care: a cluster-randomized pragmatic trial in Dar es Salaam.

The provision of high-quality antenatal care (ANC) is important for preventing maternal and newborn mortality and morbidity, but only around half of pregnant women in Tanzania attended four or more ANC visits in 2019. Although there is emerging evidence on the benefit of community health worker (CHW) interventions on ANC uptake, few large-scale pragmatic trials have been conducted. This pragmatic cluster-randomized trial, implemented directly through the public sector health system, assessed the impact of an intervention that trained public sector CHWs to promote the uptake of ANC. We randomized 60 administrative wards in Dar es Salaam to either a targeted CHW intervention or a standard of care. The impact of the intervention was assessed using generalized estimating equations with an independent working correlation matrix to account for clustering within wards. A total of 243 908 women were included in the analysis of our primary outcome of four or more ANC visits. The intervention significantly increased the likelihood of attending four or more ANC visits [relative risk (RR): 1.42; 95% confidence interval (CI): 1.05, 1.92] and had a modest beneficial effect on the total number of ANC visits (percent change: 7.7%; 95% CI: 0.2%, 15.5%). While slightly more women in the intervention arm attended ANC in their first trimester compared with the standard-of-care arm (19% vs 18.7%), the difference was not significant (RR: 1.02; 95% CI: 0.84, 1.22). Our findings suggest that trained CHWs can increase attendance of ANC visits in Dar es Salaam and similar settings. However, additional interventions appear necessary to promote the early initiation of ANC. This study demonstrates that routine health system data can be leveraged for outcome assessment in trials and programme evaluation and that the results are likely superior, both in terms of bias and precision, to data that are collected specifically for science.