Effectiveness of an intervention to improve ART adherence among men who have sex with men living with HIV: a randomized controlled trial in three public HIV clinics in Mexico.

We conducted a parallel-group randomized controlled trial in three HIV clinics in Mexico to evaluate a user-centred habit-formation intervention to improve ART adherence among MSM living with HIV. We randomized 74 participants to the intervention group and 77 to the control group. We measured adherence at one, four, and ten months through medication possession ratio and self-reported adherence. Additionally, we measured viral load, CD4 cell count, major depression disorder symptoms, and alcohol and substance use disorder at baseline, fourth and tenth months. We found no statistically significant effect on adherence between groups. However, the intervention demonstrated positive results in major depression disorder symptoms (21% vs. 6%, p = 0.008) and substance use disorder (11% vs. 1%, p = 0.018) in the fourth month. The latter is relevant because, in addition to its direct benefit, it might also improve the chances of maintaining adequate adherence in the long term. This trial was retrospectively registered at ClinicalTrials.gov (trial number NCT03410680) on 8 January 2018.Trial registration: ClinicalTrials.gov identifier: NCT03410680.

Prevalence of Post-COVID conditions among Mexican COVID-19 survivors: a nationwide cross-sectional study.

BACKGROUND: There are limited population-representative data that describe the potential burden of Post-COVID conditions (PCC) in Mexico. We estimated the prevalence of PCC overall and by sociodemographic characteristics among a representative sample of adults previously diagnosed with COVID-19 in Mexico. We additionally, characterized the PCC symptoms, and estimated the association between diagnosed type-2 diabetes and hypertension with PCC. METHODS: We used data from the 2021 National Health and Nutrition Survey in Mexico, a nationally and regionally representative survey, from August 1st to October 31st, 2021. Using the WHO definition, we estimated the prevalence of PCC by sociodemographics and prevalence of PCC symptoms. We fit multivariable log-binomial regression models to estimate the associations. RESULTS: The prevalence of PCC was 37.0%. The most common persistent symptoms were fatigue (56.8%), myalgia or arthralgia (47.5%), respiratory distress and dyspnea (42.7%), headache (34.0%), and cough (25.7%). The prevalence was higher in older people, women, and individuals with low socioeconomic status. There was no significant association between hypertension and PCC or diabetes and PCC prevalence. CONCLUSIONS: About one-third of the adult Mexican population who had COVID-19 in 2021 had Post-COVID conditions. Our population-based estimates can help assess potential priorities for PCC-related health services, which is critical in light of our weak health system and limited funding.

The Preexposure Prophylaxis Care Continuum Among Mexican Men Who Have Sex With Men and Transwomen: A Qualitative Study.

BACKGROUND: This article describes perceptions and experiences related to the preexposure prophylaxis (PrEP) care continuum of Mexican men who have sex with men (MSM) and transwomen (TW). METHODS: Between June and July 2020, we applied 24 online semistructured interviews regarding PrEP use with 10 PrEP users, 6 ex-users, and 8 potential users (at risk, not enrolled). RESULTS: Awareness: TW did not always receive the information they needed from trusted people. Acceptability: Potential users were reluctant to use PrEP because of fear of adverse effects, and only a few participants worried about stigma. Uptake: Potential users missed their enrollment visit and did not know how to reschedule. Adherence: Barriers included routine changes interfering with PrEP-taking habits (arriving home later, traveling, etc.), whereas feeling protected was reported as a facilitator. Retention: Ex-users quit PrEP services, mostly without reducing their HIV risk, because of difficulties keeping appointments and fearing long-term effects. CONCLUSION: Inclusive awareness activities, tackling misbeliefs regarding adverse effects, and more flexible services may improve PrEP usage and enhance its impact.

Warning labels on alcoholic beverage containers: a pilot randomized experiment among young adults in Mexico.

BACKGROUND: Little is known about the potential impacts of visible and up-to-date health warning labels on alcoholic beverage containers on a range of outcomes in low- and middle-income countries. We conducted an experimental study to test the potential impacts of visible health warning labels (on the principal panel of the package) on thinking about health risks, product attractiveness, visual avoidance, and intention to change alcohol use among students in Mexico aged 18-30 years. METHODS: A double-blind, parallel-group, online randomized trial was conducted from November 2021 to January 2022 in 11 states in Mexico. In the control group, participants were presented with the image of a conventional beer can with a fictional design and brand. In the intervention groups, the participants observed pictograms with a red font and white backgrounds (health warning label in red-HWL red) or with a black font and yellow backgrounds (health warning label in yellow-HWL yellow), located at the top, covering around one-third of the beer can. We used Poisson regression models -unadjusted and adjusted for covariates- to assess differences in the outcomes across study groups. RESULTS: Using intention-to-treat analysis (n = 610), we found more participants in groups HWL red and HWL yellow thought about the health risks from drinking beer compared to the control group [Prevalence Ratio (PR) = 1.43, CI95%:1.05,1.93 for HWL red; PR = 1.25, CI95%: 0.91, 1.71 for HWL yellow]. A lower percentage of young adults in the interventions vs control group considered the product attractive (PR 0.74, 95%CI 0.51, 1.06 for HWL red; PR 0.56, 95%CI 0.38, 0.83 for HWL yellow). Although not statistically significant, a lower percentage of participants in the intervention groups considered buying or consuming the product than the control group. Results were similar when models were adjusted for covariates. CONCLUSIONS: Visible health warning labels could lead individuals to think about the health risks of alcohol, reducing the attractiveness of the product and decreasing the intention to purchase and consume alcohol. Further studies will be required to determine which pictograms or images and legends are most contextually relevant for the country. TRIAL REGISTRATION: The protocol of this study was retrospectively registered on 03/01/2023: ISRCTN10494244.

Estimating the cost of HIV services for key populations provided by the LINKAGES program in Kenya and Malawi.

BACKGROUND: Data remain scarce on the costs of HIV services for key populations (KPs). The objective of this study was to bridge this gap in the literature by estimating the unit costs of HIV services delivered to KPs in the LINKAGES program in Kenya and Malawi. We estimated the mean total unit costs of seven clinical services: post-exposure prophylaxis (PEP), pre-exposure prophylaxis (PrEP), HIV testing services (HTS), antiretroviral therapy (ART), sexually transmitted infection (STI) services, sexual and reproductive health (SRH) services, and management of sexual violence (MSV). These costs take into account the costs of non-clinical services delivered alongside clinical services and the pre-service and above-service program management integral to the LINKAGES program. METHODS: Data were collected at all implementation levels of the LINKAGES program including 30 drop-in-centers (DICs) in Kenya and 15 in Malawi. This study was conducted from the provider's perspective. We estimated economic costs for FY 2019 and cost estimates include start-up costs. Start-up and capital costs were annualized using a discount rate of 3%. We used a combination of top-down and bottom-up costing approaches. Top-down methods were used to estimate the costs of headquarters, country offices, and implementing partners. Bottom-up micro-costing methods were used to measure the quantities and prices of inputs used to produce services in DICs. Volume-weighted mean unit costs were calculated for each clinical service. Costs are presented in 2019 United States dollars (US$). RESULTS: The mean total unit costs per service ranged from US$18 (95% CI: 16, 21) for STI services to US$635 (95% CI: 484, 785) for PrEP in Kenya and from US$41 (95% CI: 37, 44) for STI services to US$1,240 (95% CI 1156, 1324) for MSV in Malawi. Clinical costs accounted for between 21 and 59% of total mean unit costs in Kenya, and between 25 and 38% in Malawi. Indirect costs-including start-up activities, the costs of KP interventions implemented alongside clinical services, and program management and data monitoring-made up the remaining costs incurred. CONCLUSIONS: A better understanding of the cost of HIV services is highly relevant for budgeting and planning purposes and for optimizing HIV services. When considering all service delivery costs of a comprehensive HIV service package for KPs, costs of services can be significantly higher than when considering direct clinical service costs alone. These estimates can inform investment cases, strategic plans and other budgeting exercises.

Elección de proveedores de servicios de atención y necesidades de salud de la población mexicana, 2021.

OBJETIVO: Estimar la asociación entre la elección de pro-veedores de servicios de atención y las necesidades de salud de la población. Material y métodos. Se utilizaron datos de la Encuesta Nacional de Salud y Nutrición 2021 sobre Covid-19. RESULTADOS: Las necesidades agudas (infeccio-nes respiratorias, diarrea y Covid-19) representan 48% del total; 21% crónicas (control, seguimiento o diagnóstico de diabetes, hipertensión, gastritis, cáncer); 12% necesidades de prevención (vacunación, chequeo, control prenatal); 7% eventos agudos no infecciosos que incluyen lesión física, dolor de cabeza, fiebre, y 4% el resto. La población elige atención privada o pública de forma diferenciada dependiendo del tipo de necesidad de salud. Para necesidades agudas sólo 25% se atiende en el sector público. Para enfermedades crónicas, agudas no infecciosas y de prevención, la proporción que se atiende en sector público es mayor, incluida la población sin seguridad social. CONCLUSIONES: Los resultados de este estudio serán de utilidad para que la reforma en el sistema de salud pueda reforzar los servicios públicos que requieran más recursos.

Utilización de servicios de salud en México: cascada de atención primaria en 2022.

OBJETIVO: Presentar un panorama descriptivo de las elecciones de la población mexicana frente a una necesidad de salud en 2022. Material y métodos. Se utilizaron datos de la Encuesta Nacional de Salud y Nutrición Continua 2022. RESULTADOS: De 24.6% de la población que informó haber tenido una necesidad de salud en los últimos tres meses, 44% recibió atención en servicios públicos. El uso de servicios privados es extensivo a toda la población, pero fue más elevado en aquellos sin derechohabiencia. Se encontró que 71% de los motivos por los que las personas no se atendieran en el lugar que les correspondía de acuerdo con su derechohabiencia tuvo que ver con el acceso y 21% con la percepción de calidad. Entre los motivos de acceso para elegir el lugar donde se atendieron destacan la afiliación, la cercanía y el costo. En cuanto a la calidad, resaltan la atención rápida y la satisfacción con la atención. CONCLUSIONES: Con el fin de reducir la desigualdad de acceso y el gasto de bolsillo asociado con un mayor uso de servicios privados, sobre todo entre la población sin seguridad social, mejorar el acceso (como la distancia, los horarios de atención, las barreras burocráticas) puede ayudar a avanzar en este objetivo.

The impact of the Covid-19 vaccination policy in Mexico. A quasi-experimental effectiveness evaluation of a multi-vaccine strategy.

OBJECTIVE: To assess the impact of a vaccination campaign that administered five different technologies in a middle-income country with one of the largest Covid-19 epidemics. MATERIALS AND METHODS: Using data from Mexico's Epidemiological Surveillance System for Viral Respiratory Disease (Sisver) and the design of the vaccine policy in Mexico as a natural experiment, we applied difference-in-differences econometric methods to assess the strategy's effectiveness on transmission, hospitalizations, and mortality rates among adults 60 to 64 years old in Mexico between April and June 2021. RESULTS: We estimated average effectiveness levels of 60.9% against confirmed cases of Covid-19. Vaccination also decreased hospitalizations and deaths by 62.7 and 62.6%, respectively. After adjusting for vaccination coverage, we found an impact of 79.1, 80.9, and 81.3% reduction in new cases, hospitalizations, and deaths among the vaccinated. CONCLUSION: Despite the significant progress in our knowledge of Covid-19 vaccination effectiveness, the available evidence relies mostly on experiences from high-income countries. This study contributes to the scientific literature of Covid-19 vaccination effectiveness in a middle-income country with a multi-vaccine scheme.

Barriers, refusal and a hypothetical monetary incentive for Covid-19 vaccination in Mexican adults.

OBJECTIVE: To estimate vaccine uptake and assess sociodemographic conditions associated with vaccination barriers and refusal and to explore the effect of a monetary incentive to overcome them. MATERIALS AND METHODS: We used data from adults from the 2021 National Continuous Health and Nutrition Survey conducted during August-October 2021. We evaluated if an hypothetical monetary incentive between 50-650 MXN (~2.5-31 USD) would overcome barriers or refusal. RESULTS: 73.9% were vaccinated with at least one dose, 7.5% refused, 4.8% reported barriers and 13.8% were ineligible at the time of the survey. Refusal and barriers were more frequent in men, older age, lower education and socioeconomic status, unemployed and informal workers. In people with barriers and refusal, the hypothetical incentive increased the acceptance in 57.6% (95%CI 50.7,64.4%) and 17.4% (95%CI 13.2,21.7%) in people with barriers and refusal, respectively. CONCLUSION: Understanding the reasons for barriers and refusal is crucial for future Covid-19 vaccination campaigns or epidemics. A monetary incentive might increase vaccination uptake, although, cost-effectiveness analyses are needed.

¿Agua para todos? La intermitencia en el suministro de agua en los hogares en México.

OBJETIVO: Medir el acceso a través de la intermitencia en el suministro de agua potable en hogares mexicanos. Material y métodos. A través de la Encuesta Nacional de Salud y Nutrición 2022 (Ensanut 2022), se recolectó información sobre intermitencia en días por semana y horas por día durante las últimas cuatro semanas y el suministro de agua durante el año para la temporada de mayor escasez. RESULTADOS: 31.5% de los hogares recibieron agua los siete días de la semana, las 24 horas del día. De estos, 17.4% no tuvo escasez en los últimos 12 meses. La intermitencia es más común entre hogares de las regiones en el sur del país y entre los más pobres. El 81% de las familias almacena agua y 16% almacena en contenedores portátiles como cubetas. Conclusión. En este artículo se presentan por primera vez patrones de intermitencia en el suministro de agua a nivel nacional en México. La gran mayoría de las familias no reciben agua de forma continua y tienen que almacenar agua. El almacenamiento podría disminuir la calidad del agua y la falta de confianza para su consumo con consecuencias para la salud. La conexión al sistema potable no refleja el acceso real de las familias al agua.

Encuesta Nacional de Salud y Nutrición 2023: metodología y avances de la Ensanut Continua 2020-2024.

OBJETIVO: Presentar la metodología de la Encuesta Nacional de Salud y Nutrición 2023 (Ensanut 2023) y describir los procedimientos de inferencia para conjuntar la información colectada por la Ensanut Continua 2020-2024. Material y métodos. La Ensanut 2023 es la cuarta encuesta de la serie Ensanut Continua. Se describe el alcance de la Ensanut 2023 junto con sus procedimientos de muestreo, estimación, medición y organización logística. Además, se discute el procedimiento básico de estimación para analizar la integración de las encuestas Ensanut Continua 2020-2024. RESULTADOS: La Ensanut 2023 obtendrá a nivel nacional al menos 11 720 entrevistas completas de hogar y 13 378 cuestionarios completos de adulto. La unión de las Ensanut Continua 2020-2023 permitirá, en general, estimar a nivel estatal prevalencias p≥5% en adultos, con confiabilidad tolerable según las recomendaciones del Instituto Nacional de Estadística y Geografía. CONCLUSIONES: El análisis de la unión de la Ensanut Continua 2020-2023 permitirá iniciar la generación de estimaciones nacionales y estatales sobre el estado de salud y nutrición de la población mexicana.

Prevalencia de anticuerpos y vacunación contra SARS-CoV-2 en 2022 en México.

OBJETIVO: Describir la prevalencia de anticuerpos contra SARS-CoV-2, vacunación, barreras y rechazo a la vacunación Covid-19 en población mexicana. Material y métodos. Se utilizó información de los integrantes del hogar de uno y más años, incluidos en la Encuesta Nacional de Salud y Nutrición Continua 2022 (Ensanut Continua 2022) realizada de agosto-noviembre. Se estimó la prevalencia de anticuerpos antiproteínas N y S de SARS-CoV-2 en muestras de sangre capilar, dosis reportadas de vacunación a Covid-19 y las razones de barreras y rechazo a la vacunación. RESULTADOS: La prevalencia de anticuerpos anti-N fue de 94.4% y de anti-S 98.1%. La prevalencia de anticuerpos anti-S fue mayor en personas vacunadas con una, dos o tres o más dosis que en no vacunadas. Dentro de la población elegible a vacunación, 20.2% no estaba vacunada, 16.2% tenía una dosis, 30% dos dosis y 33.6% tres dosis o más. El 11.2% de la población elegible rechazó la vacunación, 5.5% reportó una barrera y 3.2% reportó que la vacuna no había llegado a su localidad. Conclusión. La prevalencia de anticuerpos por infección natural y por vacunación Covid-19 es alta en México. Las variaciones de rechazo y barreras a la vacunación entre grupos de edad y regiones deben tomarse en cuenta para intensificar esfuerzos específicos para la vacunación.

Density of alcohol-selling outlets and prices are associated with frequent binge drinking in Mexico.

Despite the increase in the prevalence of binge drinking in Mexico studies focus on sociodemographic factors and little attention is paid on contextual factors. We estimated the association between density of alcohol outlets, price of alcoholic beverages, and binge drinking in Mexico among the population aged 12 to 65 years old who consumed alcohol during the last 12 months. Data come from different sources for alcohol consumption; availability of bar, nightclubs, saloons and stores that sell alcohol and prices of alcoholic beverages. We estimated generalized linear models for binary outcomes for the relationship between density of alcohol outlets and prices of alcoholic beverages with binge drinking at least once per year, at least once per month, and at least once per week controlling for sex, age, religion, household income and municipality size. Living in areas with a high density of alcohol-selling outlets was associated with a higher risk of binge drinking, at least once a year (RR 1.0, 95% CI: 1.0,1.1) at least once a month (RR 1.3, 95% CI: 1.2, 1.4) and weekly (RR 1.9, 95% CI: 1.6, 2.2). Living in States with lower alcohol prices was marginally associated to binge drinking at least once a year (RR 1.0, 95% CI: 1.0, 1.1) but more strongly associated to monthly (RR 1.2, 95% CI: 1.2, 1.4) and weekly binge drinking (RR 1.4, 95% CI: 1.3, 1.6). Along with strong fiscal policies, the implementation of spatial restrictions to the number of alcohol-selling outlets could help decrease binge drinking.

Changes in sexual behavior, PrEP use, and COVID-19 experience among men who have sex with men in Mexico.

This study aimed to explore the impact of COVID-19 lockdown on sexual behavior and PrEP use among a sample of men who have sex with men (MSM) in Mexico. Between April 20th and 27th, 2020 - well into Mexico's lockdown - we conducted a virtual survey among 637 MSM exploring sexual behavior during the first month of the COVID-19 epidemic in Mexico and the impact of lockdown on PrEP use. We applied logistic regression models to assess predictors of PrEP use continuation. Over half the participants (52%) reported having a sexual encounter in the last two weeks. 75% of participants reported a decrease in the number of sexual partners because of COVID-19. The use of PrEP dropped from 90% to 64% during the first month of lockdown. Multivariate logistic regression models showed that younger participants were less likely to continue using PrEP than those 25 + years. Also, those who perceived themselves as not likely to acquire COVID-19 and those who reported using a condom in their last sexual encounter were more likely to continue using PrEP during the lockdown. This study provides evidence of the impact of COVID-19 on sexual behavior and PrEP use among MSM in Mexico during the lockdown. Sexual and reproductive health services will need to consider the risk of COVID-19 in providing HIV and PrEP programs to guarantee participants' and health care providers' safety.

The role of social determinants on unhealthy eating habits in an urban area in Mexico: A qualitative study in low-income mothers with a young child at home.

Overweight and obesity are a severe public health problem in Mexico. National policies to fight unhealthy eating have been implemented but they don't target social and family environment determinants. Our study aimed to gain a deeper understanding of the determinants of unhealthy eating by exploring the perspectives and experiences of low-income Mexican women with a young child at home. We conducted a purposeful sampling to include participating kindergartens in Morelos, México. Women with a child enrolled in the kindergarten were invited to focus group discussions. Afterward, women with specific profiles were invited to in-depth interviews. During analysis we applied Dahlgren and Whitehead's model of social determinants of health (SDH). Overall, we found that participants have unhealthy habits, for example: low variability in consumption patterns, regular sugar-sweetened beverages intake and insufficient fruit and vegetable intake. By low variability we mean frequently consumed products (on most days of the week) limited to a restricted food set. As for the determinants of unhealthy habits, we found at the community level that families encourage unhealthy eating. At the household and work level, tight schedules for food preparation determine unhealthy eating. And, at a socio-economic level, lack of access and money constraints shape unhealthy habits. Unhealthy habits are determined by factors on multiple levels and using an SDH approach can be an effective way to inform comprehensive strategies targeting the overweight and obesity epidemic in Mexico and other low- and middle-income countries.

Coordinación y cooperación de las redes formadas detrás del continuo de atención a personas que viven con VIH en México.

OBJETIVO: Describir y caracterizar las redes formadas detrás del continuo de atención a personas que viven con VIH en México. Material y métodos. Bajo un enfoque de análisis de redes sociales se analizó información sobre las relaciones que establecen los actores que participan en el continuo de atención del VIH. RESULTADOS: Existe una formación de re-des de atención con distintos actores y, conforme se avanza en el continuo de atención, las redes tienden a fragmentarse y se observa una baja conectividad. CONCLUSIONES: La provisión de servicios para VIH en México es un proceso de gober-nanza múltiple; sin embargo, la configuración de las redes no implica que la provisión de servicios sea óptima. No obstante, la formación de redes es una potencial herramienta que los Centros Ambulatorios para la Prevención y Atención de Sida e Infecciones de Transmisión Sexual y Servicios de Atención Integral Hospitalaria han establecido para lograr su objetivo de ofrecer atención oportuna y continua, ante un contexto de recursos limitados y de gestión pública por resultados.

Metodología de una encuesta por internet para hombres que tienen sexo con hombres en México.

OBJETIVO: Describir el diseño, implementación y el perfil de los participantes de la Encuesta de Sexo Entre Hombres (ES Entre Hombres). Material y métodos. ES Entre Hombres es una encuesta en línea no probabilística aplicada a nivel nacional a hombres de 18 años o más, que tienen sexo con hombres (HSH) y que usan internet. La población de estudio se reclutó a través de publicidad en diversos sitios de encuentro en línea y los cuestionarios se autoaplicaron con SurveyGizmo. RESULTADOS: Durante 11 semanas se registró un total de 15 875 autoaplicaciones elegibles y completas de las 32 entidades del país. La mayoría de los participantes fueron jóvenes (<29 años; 65.7%) y personas que acceden a internet diariamente (94.3%). Conclusión. Las encuestas realizadas por internet para poblaciones como los HSH representan un método costoefectivo de estudio poblacional, ya que tienen el potencial de ahorrar recursos y alcanzar muestras grandes, lo que a la vez facilita la cobertura geográfica a un bajo costo.

Patient characteristics and determinants of CD4 at diagnosis of HIV in Mexico from 2008 to 2017: a 10-year population-based study.

BACKGROUND: In 2007-2012 the Mexican government launched the National HIV program and there was a major change in HIV policies implemented in 2013-2018, when efforts focused on prevention, increase in early diagnosis and timely treatment. Still, late HIV diagnosis is a major concern in Mexico due to its association with the development of AIDS development and mortality. Thus, the objectives of this study were to identify the determinants of late HIV diagnosis (i.e. CD4 count less than 200 cells/mm3) in Mexico from 2008 to 2017 and to evaluate the impact of the 2013-2017 National HIV program. METHODS: Using patient level data from the SALVAR database, which includes 64% of the population receiving HIV care in Mexico, an adjusted logistic model was conducted. Main study outcomes were HIV late diagnosis which was defined as CD4 count less than 200 cells/mm3 at diagnosis. RESULTS: The study included 106,830 individuals newly diagnosed with HIV and treated in Mexican public health facilities between 2008 and 2017 (mean age: 33 years old, 80% male). HIV late diagnosis decreased from 45 to 43% (P < 0.001) between 2008 and 2012 and 2013-2017 (i.e. before and after the implementation of the 2013-2017 policy). Multivariable logistic regressions indicated that being diagnosed between 2013 and 2017 (odds ratio [OR] = 0.96 [95% Confidence interval [CI] [0.93, 0.98]) or in health facilities specialized in HIV care (OR = 0.64 [95% CI 0.60, 0.69]) was associated with early diagnosis. Being male, older than 29 years old, diagnosed in Central East, the South region of Mexico or in high-marginalized locality increased the odds of a late diagnosis. CONCLUSIONS: The results of this study indicate that the 2013-2017 National HIV program in Mexico has been marginally successful in decreasing the proportion of individuals with late HIV diagnosis in Mexico. We identified several predictors of late diagnosis which could help establishing health policies. The main determinants for late diagnosis were being male, older than 29 years old, and being diagnosed in a Hospital or National Institute.

Efficiency, quality, and management practices in health facilities providing outpatient HIV services in Kenya, Nigeria, Rwanda, South Africa and Zambia.

Few studies have assessed the efficiency and quality of HIV services in low-resource settings or considered the factors that determine both performance dimensions. To provide insights on the performance of outpatient HIV prevention units, we used benchmarking methods to identify best-practices in terms of technical efficiency and process quality and uncover management practices with the potential to improve efficiency and quality. We used data collected in 338 facilities in Kenya, Nigeria, Rwanda, South Africa, and Zambia. Data envelopment analysis (DEA) was used to estimate technical efficiency. Process quality was estimated using data from medical vignettes. We mapped the relationship between efficiency and quality scores and studied the managerial determinants of best performance in terms of both efficiency and quality. We also explored the relationship between management factors and efficiency and quality independently. We found levels of both technical efficiency and process quality to be low, though there was substantial variation across countries. One third of facilities were mapped in the best-performing group with above-median efficiency and above-median quality. Several management practices were associated with best performance in terms of both efficiency and quality. When considering efficiency and quality independently, the patterns of associations between management practices and the two performance dimensions were not necessarily the same. One management characteristic was associated with best performance in terms of efficiency and quality and also positively associated with efficiency and quality independently: number of supervision visits to HIV units.

Developing HIV assisted partner notification services tailored to Mexican key populations: a qualitative approach.

BACKGROUND: Assisted partner notification services (APNS) may increase HIV testing, early diagnosis, and treatment, but they are not formally implemented in Mexico, where the HIV epidemic is concentrated in men who have sex with men (MSM) and transwomen (TW). This study aimed to explore the awareness of and need for HIV partner notification, as well as to outline potential strategies for APNS based on identified barriers and facilitators. METHODS: We conducted semi-structured interviews to explore partner notification with MSM, TW, and counselors. Afterwards, brainstorm sessions were carried out to produce strategies for implementing APNS. RESULTS: Most participants reported experiences with informal partner notification and serostatus disclosure, but not with APNS. Only one counselor indicated assisting notification systematically. The main barriers for notifying or disclosing mentioned by both MSM and TW included fear of (violent) reactions, discrimination and lacking contact information of casual partners. Participants thought it was easier to inform a formal partner, conditional of being well informed about HIV. Given current stigma and lack of awareness, it was suggested that APNS should be preceded by HIV awareness efforts, and be provided by counselors or peers to mitigate potential rejection or violent reactions. CONCLUSIONS: While APNS are not formally implemented in Mexico, all participants supported the service, indicating that APNS could potentially enhance early HIV diagnosis in Mexico. Strategies to implement such services need to be flexible addressing the individual needs of participants, guaranteeing the safety of more vulnerable participants.