Results from a proactive follow-up intervention to improve linkage and retention among people living with HIV in Uganda: a pre-/post- study.

BACKGROUND: Despite gains in HIV testing and treatment access in sub-Saharan Africa, patient attrition from care remains a problem. Evidence is needed of real-world implementation of low-cost, scalable, and sustainable solutions to reduce attrition. We hypothesized that more proactive patient follow-up and enhanced counseling by health facilities would improve patient linkage and retention. METHODS: At 20 health facilities in Central Uganda, we implemented a quality of care improvement intervention package that included training lay health workers in best practices for patient follow-up and counseling, including improved appointment recordkeeping, phone calls and home visits to lost patients, and enhanced adherence counseling strategies; and strengthening oversight of these processes. We compared patient linkage to and retention in HIV care in the 9 months before implementation of the intervention to the 9 months after implementation. Data were obtained from facility-based registers and files and analysed using multivariable logistic regression. RESULTS: Among 1900 patients testing HIV-positive during the study period, there was not a statistically significant increase in linkage to care after implementing the intervention (52.9% versus 54.9%, p = 0.63). However, among 1356 patients initiating antiretroviral therapy during the follow-up period, there were statistically significant increases in patient adherence to appointment schedules (44.5% versus 55.2%, p = 0.01) after the intervention. There was a small increase in Ministry of Health-defined retention in care (71.7% versus 75.7%, p = 0.12); when data from the period of intervention ramp-up was dropped, this increase became statistically significant (71.7% versus 77.6%, p = 0.01). The increase in retention was more dramatic for patients under age 19 years (N = 84; 64.0% versus 83.9%, p = 0.01). The cost per additional patient retained in care was $47. CONCLUSIONS: Improving patient tracking and counseling practices was relatively low cost and enhanced patient retention in care, particularly for pediatric and adolescent patients. This approach should be considered for scale-up in Uganda and elsewhere. However, no impact was seen in improved patient linkage to care with this proactive follow-up intervention. TRIAL REGISTRATION: Pan African Clinical Trial Registry #PACTR201611001756166 . Registered August 31, 2016.

Integrating Family Planning and HIV Services at the Community Level: Formative Assessment with Village Health Teams in Uganda.

Little is known on integrating HIV and family planning (FP) services in community settings. Using a cluster randomized controlled design, we conducted a formative assessment in two districts in Uganda where community health workers, called VHTs, already offered FP. Thirty-six trained VHTs also provided HIV testing and counseling (HTC) during the intervention. We surveyed all 36 VHTs and 256 FP clients, and reviewed service statistics. In the intervention group, VHTs tested 80% of surveyed clients for HIV, including 76% they already saw for FP and 22% who first came to them for HTC before receiving FP. Comparing clients' experiences in the intervention and control groups, adding HTC does not appear to have negatively affected FP service quality. VHTs reported more monthly clients, but rated their workload as easy to manage. This integrated model seems feasible and beneficial for both VHTs and clients, while not resulting in any negative effects. This study was registered with ClinicalTrials.gov, number [NCT02244398].

A retrospective mixed-methods evaluation of a national ORS and zinc scale-up program in Uganda between 2011 and 2016.

BACKGROUND: In Uganda, diarrhoea was the third leading cause of mortality among children under the age of five in 2010. To address this issue, the Ministry of Health (MOH) formed a national Diarrhoea and Pneumonia Coordination Committee (DPCC) in 2011. One of the objectives of the DPCC for reducing diarrhoea mortality was to increase the use of oral rehydration salts (ORS) and zinc. This study aimed to describe and evaluate efforts by the DPCC to increase ORS and zinc coverage. METHODS: We conducted a retrospective mixed-methods evaluation to describe the activities conducted under the DPCC and evaluate the extent to which the committee's goal of increasing ORS and zinc use was achieved. We conducted secondary analysis using Uganda's Demographic and Health Survey from 2011 and 2016, analyzed cross-sectional private medicine outlet surveys from 2014 and 2016, analyzed ORS and zinc distribution data from the Uganda National Medical Stores, and reviewed program documents from DPCC partners. RESULTS: Nationally, the proportion of children under five with diarrhoea treated with ORS and zinc increased from 1% (95% confidence interval (CI) = 1%, 2%) in 2011 to 30% (95% CI = 27%, 32%) in 2016. Among private medicine outlets, the adjusted odds of having any zinc in-stock was 1.5 (95% CI = 1.14, 1.97) times higher in 2016 than in 2014, and the retail price for a complete treatment (2 ORS sachets and 10 zinc tablets) declined by $0.19 (95% CI = -0.31, -0.06), or 14%. CONCLUSIONS: Use of combined ORS and zinc for treatment of diarrhoea in children under five significantly increased in Uganda during the program period. The range of activities conducted by the various members of the DPCC likely contributed to the increase in the use of combined ORS and zinc.

Increasing coverage of pediatric diarrhea treatment in high-burden countries.

BACKGROUND: Diarrhea is the second leading cause of infectious deaths in children under-five globally. Oral rehydration salts (ORS) and zinc could avert an estimated 93% of deaths, but progress to increase coverage of these interventions has been largely stagnant over the past several decades. The Clinton Health Access Initiative (CHAI), along with donors and country governments in India, Kenya, Nigeria, and Uganda, implemented programs to scale-up ORS and zinc coverage from 2012 to 2016. The programs sought to demonstrate that increases in pediatric diarrhea treatment rates are possible at scale in high-burden settings through a holistic approach addressing both supply and demand barriers. We describe the overall program model and the activities undertaken in each country. The overall goal of the paper is to share the program results and lessons learned to inform other countries aiming to scale-up ORS and zinc. METHODS: We used a triangulation approach, using population-based household surveys, public facility audits, and private outlet surveys, to evaluate the program model. We used pre- and post-program population-based household survey data to estimate the changes in coverage of ORS and zinc for treatment of diarrhea cases in children under-five in program areas. We also conducted secondary analysis of Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) surveys in surrounding regions and compared annual coverage changes in the CHAI-supported program geographies to the surrounding regions. RESULTS: Across CHAI-supported focal geographies, the average ORS coverage across the program areas increased from 35% to 48% and combined ORS and zinc coverage increased from 1% to 24%. ORS coverage increases were statistically significant in the program states in India, from 22% (95% confidence interval CI = 21-23%) to 48% (95% CI = 47-50%) and program states in Nigeria, from 38% (95% CI = 32-40%) to 55% (95% CI = 51-58%). For combined ORS and zinc, coverage increases were statistically significant in all program geographies. Compared to surrounding regions, the estimated annual changes in combined ORS and zinc coverage were greater in program geographies. Using the Lives Saved Tool and based on the coverage changes during the program period, we estimated 76 090 diarrheal deaths were averted in the program geographies. CONCLUSIONS: Increasing ORS and zinc coverage at scale in high-burden countries and states is possible through a comprehensive approach that targets both demand and supply barriers, including pricing, optimal product qualities, provider dispensing practices, stocking rates, and consumer demand.

Expanding HIV testing and counselling into communities: Feasibility, acceptability, and effects of an integrated family planning/HTC service delivery model by Village Health Teams in Uganda.

Improving HIV testing and counselling (HTC) requires a range of strategies. This article reports on HTC service delivery by Village Health Teams (VHTs) in Uganda in the context of a model integrating this new component into pre-existing family planning services. Eight health centres from matched pairs were randomly allocated to intervention or control. After being trained, 36 VHTs reporting to selected facilities in the intervention group started offering HTC along with family planning, while VHTs in the control group provided family planning only. Proficiency testing was conducted as external quality assurance. A survey of all 36 VHTs and 137 family planning clients in the intervention group and 119 clients in the control group and a review of record data were conducted after 10 months. Survey responses by VHTs and their clients in the intervention group demonstrate knowledge of counselling messages and safe testing. External quality assessment results provide additional evidence of competency. Eighty per cent of the family planning clients surveyed in the intervention group received an HIV test during the intervention; 27% of those were first-time testers. More clients had ever tested for HIV in the intervention group compared with the control; clients also retested more often. Findings indicate that this model is feasible and acceptable for expanding quality HTC into communities. This study was registered with ClinicalTrials.gov, number [NCT02244398].

Keeping community health workers in Uganda motivated: key challenges, facilitators, and preferred program inputs.

INTRODUCTION: In the face of global health worker shortages, community health workers (CHWs) are an important health care delivery strategy for underserved populations. In Uganda, community-based programs often use volunteer CHWs to extend services, including family planning, in rural areas. This study examined factors related to CHW motivation and level of activity in 3 family planning programs in Uganda. METHODS: Data were collected between July and August 2011, and sources comprised 183 surveys with active CHWs, in-depth interviews (IDIs) with 43 active CHWs and 5 former CHWs, and service statistics records. Surveys included a discrete choice experiment (DCE) to elicit CHW preferences for selected program inputs. RESULTS: Service statistics indicated an average of 56 visits with family planning clients per surveyed CHW over the 3-month period prior to data collection. In the survey, new skills and knowledge, perceived impact on the community, and enhanced status were the main positive aspects of the job reported by CHWs; the main challenges related to transportation. Multivariate analyses identified 2 correlates of CHWs being highly vs. less active (in terms of number of client visits): experiencing problems with supplies and not collaborating with peers. DCE results showed that provision of a package including a T-shirt, badge, and bicycle was the program input CHWs preferred, followed by a mobile phone (without airtime). IDI data reinforced and supplemented these quantitative findings. Social prestige, social responsibility, and aspirations for other opportunities were important motivators, while main challenges related to transportation and commodity stockouts. CHWs had complex motivations for wanting better compensation, including offsetting time and transportation costs, providing for their families, and feeling appreciated for their efforts. CONCLUSION: Volunteer CHW programs in Uganda and elsewhere need to carefully consider appropriate combinations of financial and nonfinancial inputs for optimal results.

Getting closer to people: family planning provision by drug shops in Uganda.

BACKGROUND: Private-sector drug shops are often the first point of health care in sub-Saharan Africa. Training and supporting drug shop and pharmacy staff to provide a wide range of contraceptive methods and information is a promising high-impact practice for which more information is needed to fully document implementation experience and impact. METHODS: Between September 2010 and March 2011, we trained 139 drug shop operators (DSOs) in 4 districts of Uganda to safely administer intramuscular DMPA (depot medroxyprogesterone acetate) contraceptive injections. In 2012, we approached 54 of these DSOs and interviewed a convenience sample of 585 of their family planning clients to assess clients' contraceptive use and perspectives on the quality of care and satisfaction with services. Finally, we compared service statistics from April to June 2011 from drug shops, community health workers (CHWs), and government clinics in 3 districts to determine the drug shop market share of family planning services. RESULTS: Most drug shop family planning clients interviewed were women with low socioeconomic status. The large majority (89%) were continuing family planning users. DMPA was the preferred contraceptive. Almost half of the drug shop clients had switched from other providers, primarily from government health clinics, mostly as a result of more convenient locations, shorter waiting times, and fewer stock-outs in drug shops. All clients reported that the DSOs treated them respectfully, and 93% trusted the drug shop operator to maintain privacy. Three-quarters felt that drug shops offered affordable family planning services. Most of the DMPA clients (74%) were very satisfied with receiving their method from the drug shop and 98% intended to get the next injection from the drug shop. Between April and June 2011, clinics, CHWs, and drug shops in 3 districts delivered equivalent proportions of couple-years of protection, with drug shops leading marginally at 36%, followed by clinics (33%) and CHWs (31%). CONCLUSION: Drug shops can be a viable and convenient source of short-acting contraceptive methods, including DMPA, serving as a complement to government services. Family planning programs in Uganda and elsewhere should consider including drug shops in the network of community-based family planning providers.