Multivariate mixed-effects ordinal logistic regression models with difference-in-differences estimator of the impact of WORTH Yetu on household hunger and socioeconomic status among OVC caregivers in Tanzania.

BACKGROUND: Although most of the livelihood programmes target women, those that involve women and men have been evaluated as though men and women were a single homogenous population, with a mere inclusion of gender as an explanatory variable. This study evaluated the impact of WORTH Yetu (an economic empowerment intervention to improve livelihood outcomes) on household hunger, and household socioeconomic status (SES) among caregivers (both women and men) of orphaned and vulnerable children (OVC) in Tanzania. The study hypothesized that women and men respond to livelihood interventions differently, hence a need for gender-disaggregated impact evaluation of such interventions. METHODS: This is a secondary analysis of longitudinal data, involving caregivers' baseline (2016-2019) and follow-up (2019-2020) data from the USAID Kizazi Kipya project in 25 regions of Tanzania. Two dependent variables (ie, outcomes) were assessed; household hunger which was measured using the Household Hunger Scale (HHS), and Socioeconomic Status (SES) using the Principal Component Analysis (PCA). WORTH Yetu, a livelihood intervention implemented by the USAID Kizazi Kipya project was the main independent variable whose impact on the two outcomes was evaluated using multivariate analysis with a multilevel mixed-effects, ordinal logistic regression model with difference-in-differences (DiD) estimator for impact estimation. RESULTS: The analysis was based on 497,293 observations from 249,655 caregivers of OVC at baseline, and 247,638 of them at the follow-up survey. In both surveys, 70% were women and 30% were men. Their mean age was 49.3 (±14.5) years at baseline and 52.7 (±14.8) years at the follow-up survey. Caregivers' membership in WORTH Yetu was 10.1% at the follow-up. After adjusting for important confounders there was a significant decline in the severity of household hunger by 46.4% among WORTH Yetu members at the follow-up compared to the situation at the baseline (adjusted Odds Ratio (aOR) = 0.536, 95% Confidence Interval (CI) [0.521, 0.553]). The decline was 45.7% among women (aOR = 0.543 [0.524, 0.563]) and 47.5% among men (aOR = 0.525 [0.497, 0.556]). Regarding SES, WORTH Yetu members were 15.9% more likely to be in higher wealth quintiles at the follow-up compared to the situation at the baseline (aOR = 1.159 [1.128, 1.190]). This impact was 20.8% among women (aOR = 1.208 [1.170, 1.247]) and 4.6% among men (aOR = 1.046 [0.995, 1.101]). CONCLUSION: WORTH Yetu was associated with a significant reduction in household hunger, and a significant increase in household SES among OVC caregivers in Tanzania within an average follow-up period of 1.6 years. The estimated impacts differed significantly by gender, suggesting that women and men responded to the WORTH Yetu intervention differently. This implied that the design, delivery, and evaluation of such programmes should happen in a gender responsive manner, recognising that women and men are not the same with respect to the programmes.

Factors affecting caregivers' participation in support groups for people living with HIV in Tanzania.

Introduction: Support groups for people living with HIV (PLHIV) are essential for increasing adherence, retention, addressing their psychosocial needs and improving patient literacy. However, factors that influence participation of caregivers living with HIV (LHIV) in these groups are scarcely documented, particularly for those caring for orphans and vulnerable children (OVC). Methods: This study used baseline data collected between 1st October 2021 and 30th September 2022 from the PEPFAR/USAID-funded Adolescents and Children HIV Incidence Reduction, Empowerment and Virus Elimination (ACHIEVE) project in Tanzania to investigate factors that affect participation of caregivers LHIV in support groups for PLHIV. A total of 74,249 HIV-positive OVC caregivers who were already receiving antiretroviral therapy (ART) and had a confirmed care and treatment centre identification number were included in the analysis. Factors affecting group participation were identified through multilevel analysis using multivariable mixed-effects logistic regression. Results: Results showed that 84.2% of the caregivers were participants in the support groups for PLHIV. Their mean age was 36 years, and the majority (82.1%) were female. Multivariable analysis revealed that participation in the groups was more likely among caregivers living in urban areas (aOR = 1.39 [1.24, 1.55]), with primary education (aOR = 1.17 [1.07, 1.28]), and without disabilities (aOR = 0.62 [0.47, 0.82]). However, participation was less likely among widowed (aOR = 0.91 [0.84, 0.999]), single or unmarried (aOR = 0.86 [0.78, 0.95]), and those with secondary education or higher levels than never attended (aOR = 0.69 [0.60, 0.80]), moderate hunger (aOR = 0.86 [0.79, 0.93]), and those aged 30 years or older (p< 0.001). Discussion: A sizeable proportion (15.8%) of the caregivers were not in support groups for PLHIV, ranging from 12.3% among those in households with severe hunger to 29.7% among disabled ones. The study highlights the need for tailored interventions to increase participation in support groups for PLHIV, particularly for caregivers who are disabled, live in rural areas, are older, widowed, and/or unmarried, and those in poor households.

The implementation and effectiveness of multi-tasked, paid community health workers on maternal and child health: A cluster-randomized pragmatic trial and qualitative process evaluation in Tanzania.

Community health worker programs have proliferated worldwide based on evidence that they help prevent mortality, particularly among children. However, there is limited evidence from randomized studies on the processes and effectiveness of implementing community health worker programs through public health systems. This paper describes the results of a cluster-randomized pragmatic implementation trial (registration number ISRCTN96819844) and qualitative process evaluation of a community health worker program in Tanzania that was implemented from 2011-2015. Program effects on maternal, newborn and child health service utilization, childhood morbidity and sick childcare seeking were evaluated using difference-in-difference regression analysis with outcomes measured through pre- and post-intervention household surveys in intervention and comparison trial arms. A qualitative process evaluation was conducted between 2012 and 2014 and comprised of in-depth interviews and focus group discussions with community health workers, community members, facility-based health workers and staff of district health management teams. The community health worker program reduced incidence of illness and improved access to timely and appropriate curative care for children under five; however, there was no effect on facility-based maternal and newborn health service utilization. The positive outcomes occurred because of high levels of acceptability of community health workers within communities, as well as the durability of community health workers' motivation and confidence. Implementation factors that generated these effects were the engagement of communities in program startup; the training, remuneration and supervision of the community health workers from the local health system and community. The lack of program effects on maternal and newborn health service utilization at facilities were attributed to lapses in the availability of needed care at facilities. Strategies that strengthen and align communities' and health systems core capacities, and their ability to learn, adapt and integrate evidence-based interventions, are needed to maximize the health impact of community health workers.

Determinants of viral load suppression among orphaned and vulnerable children living with HIV on ART in Tanzania.

Introduction: In Tanzania, only 66% children 0-14 years living with HIV know their HIV status, 66% are on treatment while 47% of children on ART are virally suppressed. Although retention on ART and poor adherence remain a challenge for children living with HIV, orphans and vulnerable children (OVC) face a greater limitation of access to and utilization of comprehensive HIV care and treatment. In response to this, the current study assessed the determinants of viral load suppression (VLS) among OVC aged 0-14 years living with HIV enrolled in HIV interventions. Methods: This was a cross-sectional study that used secondary data collected by the USAID Kizazi Kipya project in 81 district councils of Tanzania. Included in this study are 1,980 orphans and vulnerable children living with HIV (OVCLHIV) (0-14 years) enrolled and served by the project for 24 months. Data analysis involved multivariable logistic regression, with viral load suppression as the outcome of interest and HIV interventions as the main independent variables. Results: The overall VLS rate among the OVCLHIV was 85.3%. This rate increased from 85.3, 89.9, 97.6 to 98.8% after 6, 12, 18, and 24 months of retention on ART, respectively. Similar rates were observed as the duration of adherence to ART increased. In the multivariable analysis, OVCLHIV attending people living with HIV (PLHIV) support groups were 411 times more likely to be virally suppressed than those not attending (aOR = 411.25, 95% CI 168.2-1,005.4). OVCLHIV with health insurance were 6 times more likely to achieve viral suppression than those without (aOR = 6.05, 95% CI 3.28-11.15). OVCLHIV with >95% adherence to ART were 149 times more likely to be virally suppressed than those not adherent to ART (aOR = 148.96, 95% CI 42.6-520.6, p < 0.001). Other significant factors included food security and family size. OVCLHIV reached by the different HIV community-based interventions were more likely to be virally suppressed than those who were not. Discussion: To advance viral suppression, efforts should be made to ensure that all OVCLHIV are reached by community-based interventions as well as integrating food support in HIV treatment interventions.

Rates and Determinants of Retention on ART Among Orphans and Vulnerable Children Living With HIV in Tanzania.

Despite the global progress in response to HIV and AIDS, notable challenges remain for children, especially identification, linkage, and retention in HIV care and treatment services. To succeed in pediatric HIV programming requires the linkage and retention of the children in those services over time. This study assessed the level of retention to antiretroviral therapy (ART) and its associated factors among orphans and vulnerable children living with HIV (OVCLHIV) in Tanzania. Data were obtained from the USAID Kizazi Kipya project that collected pediatric ART data from October 2017 to October 2019 in 81 district councils of Tanzania. Community-based volunteers supported the linkage and retention of the OVCLHIV on ART. Analysis of on-ART status was conducted in a cohort of OVCLHIV aged 0-20 years enrolled in the project and monitored for 24 months. OVCLHIV who remained on ART until the end of the follow-up period were referred to as "retained," otherwise, "not retained". Multivariable analysis was conducted using logistic regression, adjusting for baseline characteristics. Of the 5,304 OVCLHIV analyzed, the mean age was 13.1 years, 51.5% were female, and 72.2% were living with female caregivers. Their overall rate of retention on ART over the 24 months was 86.7%. Multivariable analysis showed that as the higher frequency of home visit by the project staff increased, the likelihood of retention increased by 8% [adjusted odds ratio (aOR) = 1.08, 95% CI 1.06-1.11, p < 0.001]. Membership in people living with HIV (PLHIV) support groups was associated with a higher likelihood of retention compared to nonmembership (aOR = 3.31, 95% CI 2.60-4.21, p < 0.001). Children in larger family size were 22% less likely to sustain ART (aOR = 0.78, 95% CI 0.72-0.84, p < 0.001). Urban OVCLHIV were 18% less likely to remain on ART than their rural counterparts (aOR = 0.82, 95% CI 0.69-0.98, p = 0.030). Remaining on ART was 49% more likely for OVC in economically better-off households than those in destitute households (aOR = 1.49, 95% CI 1.22-1.81, p < 0.001). Male OVC were 17% less likely to be retained on ART than their female counterparts (aOR = 0.83, 95% CI 0.71-0.99, p = 0.033). Community-based OVC support resulted in a high pediatric retention rate over the 24 months of follow-up. While key enablers of retention were higher frequency of home visits by the project volunteer, participation in PLHIV support groups, and better economic status, large family sizes, urban place of residence, and male gender of the OVC were barriers. This study brings useful evidence to inform strategies for advancing retention of OVCLHIV on ART for their better health outcomes and overall wellbeing.

Impact of household economic strengthening intervention on food security among caregivers of orphans and vulnerable children in Tanzania.

About 2 billion people worldwide suffer moderate or severe forms of food insecurity, calling for correctional measures involving economic strengthening interventions. This study assessed the impact of household economic strengthening (HES) intervention on food security among caregivers of orphans and vulnerable children (OVC) in Tanzania. The study was longitudinal in design, based on OVC caregivers' baseline (2017-2018) and midline (2019) data from the USAID Kizazi Kipya project. Food security, the outcome, was measured using the Household Hunger Scale (HHS) in three categories: little to no hunger (food secure), moderate hunger, and severe hunger. Membership in the USAID Kizazi Kipya-supported economic strengthening intervention (i.e. WORTH Yetu) was the main independent variable. Data analysis involved generalized estimating equation (GEE) for multivariate analysis. With mean age of 50.3 years at baseline, the study analyzed 132,583 caregivers, 72.2% of whom were female. At midline, 7.6% of all caregivers enrolled at baseline were members in WORTH Yetu. Membership in WORTH Yetu was significantly effective in reducing household hunger among the caregivers: severe hunger dropped from 9.4% at baseline to 4.1% at midline; moderate hunger dropped from 65.9% at baseline to 62.8% at midline; and food security (i.e., little to no hunger households) increased from 25.2% at baseline to 33.1% at midline. In the multivariate analysis, membership in WORTH Yetu reduced the likelihood of severe hunger by 47% (OR = 0.53, 95% CI 0.48-0.59), and moderate hunger by 21% (OR = 0.79, 95% CI 0.76-0.83), but increased the likelihood of food security by 45% (OR = 1.45, 95% CI 1.39-1.51). The USAID Kizazi Kipya's model of household economic strengthening for OVC caregivers was effective in improving food security and reducing household hunger in Tanzania. This underscores the need to expand WORTH Yetu coverage. Meanwhile, these results indicate a potential of applying the intervention in similar settings to address household hunger.

A mixed methods evaluation of the large-scale implementation of a school- and community-based parenting program to reduce violence against children in Tanzania: a study protocol.

BACKGROUND: Despite the rapid dissemination of parenting programs aiming to reduce and prevent violence against children (VAC) worldwide, there is limited knowledge about and evidence of the implementation of these programs at scale. This study addresses this gap by assessing the quality of delivery and impact of an evidence-based parenting program for parents/caregivers and their adolescent girls aged 9 to 14-Parenting for Lifelong Health Teens (PLH-Teens), known locally as Furaha Teens-on reducing VAC at scale in Tanzania. The study will explore participating family and staff perspectives on program implementation and examine factors associated with implementation and how implementation quality is associated with intervention outcomes when the program is delivered to approximately 50,000 parent-child dyads (N = 100,000) in schools and community centers across eight districts of Tanzania. METHODS: This mixed-methods study will answer the following research questions: (1) what is the implementation quality and fidelity of PLH-Teens at scale in Tanzania; (2) what factors are associated with the quality of delivery and implementation fidelity of PLH-Teens; (3) how are implementation quality and fidelity associated with intervention outcomes; (4) what are participant and implementing staff perspectives on the acceptability, appropriateness, feasibility, benefits, and challenges of delivering PLH-Teens in their schools and communities; (5) what is the impact of PLH-Teens on VAC and participant well-being; and (6) how much does it cost to deliver PLH-Teens at scale? Qualitative and quantitative data will be collected directly from implementers, parents/caregivers, and adolescents using pre-post questionnaires, observational assessments, cost surveys, focus groups, and interviews. Qualitative data will be analyzed thematically with the aid of NVIVO software. Quantitative data will be cleaned and analyzed using methods such as correlation, regression, and structural equation models using Stata and R. COREQ and TREND guidelines will be used, where appropriate. DISCUSSION: Findings will provide vital insights into some of the factors related to quality implementation at scale. Lessons learned regarding the implementation of PLH-Teens at scale will be applied in Tanzania, and also in the delivery of PLH parenting programs globally.

The Science of Scale for Violence Prevention: A New Agenda for Family Strengthening in Low- and Middle-Income Countries.

Ending all violence against children by 2030 is a core part of Sustainable Development Goals 5 and 16. A number of promising violence reduction strategies have been identified in research studies. However, we lack an understanding of the implementation and impact of these programs in respect to their delivery at a large scale or within existing service systems, particularly in low- and middle-income countries (LMICs). We advocate for greater collaboration between researchers, policymakers, donors, governments, non-governmental organizations, and program managers and staff to study how violence prevention programs operate on a large scale. We describe a new initiative aiming to foster such collaborations in the field of family strengthening programs.

Accelerating caregivers' HIV status disclosure to community-based lay social welfare volunteers in Tanzania.

BACKGROUND: HIV status disclosure facilitates access to HIV-related prevention and treatment services and increases opportunities for social support, HIV risk reduction with partners, and index testing for sexual partners or children. This study assessed the effect of a program model of community-based social welfare volunteers on HIV status disclosure among caregivers of orphans and vulnerable children (OVC). METHODS: This was a longitudinal study, which was based on OVC caregivers who were beneficiaries of the USAID Kizazi Kipya project in Tanzania. They were enrolled (baseline) by community social welfare volunteers during 2017-2018, received services, and reassessed at midline in 2019. Caregivers who reported having been HIV tested, were asked to voluntarily report the status in order for the volunteers to establish and provide needed services. Those who reported their HIV status as negative or positive were grouped as "disclosed", and those who knew their status but did not report it were documented as "undisclosed". McNemar's tests compared disclosure rates at baseline and midline. Multivariable analysis was conducted using generalized estimating equation (GEE). RESULTS: The study analyzed 140,664 caregivers (72% female) from 81 district councils of Tanzania. Their mean age at enrollment was 47.4 years. Overall, 81.3% of the caregivers disclosed their HIV status to the project staff at baseline; this increased significantly to 96.1% at midline (p < 0.001). Disclosure at baseline varied significantly by sociodemographic characteristic (p < 0.05), with higher disclosure in females, among urban residents, and higher educated caregivers. However, the observed disclosure variations by sociodemographic characteristics at baseline disappeared at midline and disclosure reached around 96% across the characteristics (p > 0.05). In the multivariable analysis, caregivers' likelihood of HIV status disclosure was nearly 6 times higher at midline than at baseline, when baseline characteristics were adjusted for (OR = 5.76, 95% CI 5.59-5.94, p < 0.001). There were 26,329 caregivers who did not disclose their HIV status at baseline (i.e., 0% diclosure rate at baseline), but 94.7% (n = 24,933) had disclosed by midline, and their disclosure trend was rapidly increasing as their duration of exposure to the project increased. CONCLUSIONS: This study detected an increased caregivers' HIV status disclosure to the USAID Kizazi Kipya project staff by 14.8%, from 81.3% at baseline to 96.1% at midline within an average project exposure period of 1.4 years. The observed loss of sociodemographic differences in HIV status disclosure rate at midline implies that community-based interventions may be well-positioned to successfully address and eliminate sociodemographic barriers to service uptake and consequently improve services coverage and health outcomes.

Poor linkage to care for HIV-positive OVC with disabled caregivers: a longitudinal study in Tanzania.

BACKGROUND: Despite extensive efforts to scale up counseling and testing services and care and treatment clinics (CTCs) in Tanzania, linkage between points of diagnosis and CTCs remains low. Studies have looked at barriers such as lack of trained health providers, poor referral system, economic costs or distance to health facilities, but fewer assessed the association between caregivers' vulnerability such as disability and linkage of orphans and vulnerable children (OVCs) in their care to health facilities. This study describes the magnitude of caregivers' disability and assesses its relationship with successful linkage to care of their OVC living with HIV/AIDS in Tanzania. METHODS: Data for this analysis came from the USAID Kizazi Kipya project in 79 councils of Tanzania. Data on HIV risk, service use and ART adherence among OVC aged 0-19 years were collected during the project's quarterly routine data collection (Oct 2017-Sep 2018). Characteristics of caregivers were collected during the project beneficiary screening and enrollment process. Generalized estimating equation models were used to analyze the factors that are associated with linkage of 14,538 HIV positive OVC to CTC, who were taken care of by 11,834 caregivers. RESULTS: The majority of caregivers (70%) were females, had completed primary education (67%), 54% were married or cohabiting. Of all the OVC, 3% were living with disabled caregivers; of whom 89% were physically disabled while 11% were mentally disabled. OVCs living with disabled caregivers were less likely to be linked to care (OR 0.76, 95% CI 0.58, 0.99). Factors positively associated with OVC linkage to care were high caregivers' education level (OR 1.99, 95% CI 1.51, 2.63) and OVC living with a HIV positive caregivers (OR 1.25, 95% CI 1.12, 1.41). OVC living in household with high socio-economic status were less likely to be linked to care (OR 0.76, 95% CI 0.67, 0.86) than those in low-SES households. CONCLUSION: These results suggest HIV positive OVC living with disabled caregivers had poor linkage to care. The findings highlighted the need to focus attention to the disabilities-led household to promote inclusion and improve access to the HIV services.

Hunger and Adherence to Antiretroviral Therapy: Learning From HIV Positive Caregivers of Orphans and Vulnerable Children in Tanzania.

The association between hunger and adherence to antiretroviral therapy (ART) is less known especially in vulnerable populations receiving HIV care and treatment services. Caregivers of orphans and vulnerable children (OVC) are vulnerable and likely to experience hunger due to additional economic pressure in caring for OVC. Using data from the community-based, USAID-funded Kizazi Kipya project, this study assesses the association between hunger and ART adherence among caregivers of OVC in Tanzania. HIV positive caregivers enrolled in the project from January to July 2017 were analyzed. The outcome variable was adherence to ART, defined as "not having missed any ART dose in the last 30 days," and household hunger, measured using the Household Hunger Scale (HHS), was the main independent variable. Data analysis included multivariable logistic regression. The study analyzed 11,713 HIV positive caregivers who were on ART at the time of enrollment in the USAID Kizazi Kipya project in 2017. Aged 48.2 years on average, 72.9% of the caregivers were female. While 34.6% were in households with little to no hunger, 59.4 and 6.0% were in moderate hunger and severe hunger households, respectively. Overall, 90.0% of the caregivers did not miss any ART dose in the last 30 days. ART adherence rates declined as household hunger increased (p < 0.001). Multivariable analysis showed that the odds of adhering to ART was significantly lower by 42% among caregivers in moderate hunger households than those in little to no hunger households (OR = 0.58, 95% CI 0.50-0.68). The decline increased to 47% among those in severe hunger households (OR = 0.53, 95% CI 0.41-0.69). Hunger is an independent and a significant barrier to ART adherence among caregivers LHIV in Tanzania. Improving access to adequate food as part of HIV care and treatment services is likely to improve ART adherence in this population.

Programmatic determinants of successful referral to health and social services for orphans and vulnerable children: A longitudinal study in Tanzania.

BACKGROUND: Trained community workers (CWs) successfully deliver health and social services, especially due to greater community acceptance. Orphans and vulnerable children (OVC) and their caregivers (CG) often need support from several sectors. We identified CW, program and referral characteristics that were associated with success of referrals provided to OVC and their CG in Tanzania in a cross-sectoral bi-directional referral system. METHODS: Data for this secondary analysis come from the first two years (2017-2018) of the USAID funded Kizazi Kipya project. Referral success was defined as feedback and service received within 90 days post-referral provision. We analyzed factors that are associated with the referral success of HIV related, education, nutrition, parenting, household economic strengthening, and child protection services among OVC and CG, using generalized estimating equations. RESULTS: During the study period, 19,502 CWs in 68 councils provided 146,996 referrals to 132,640 beneficiaries. OVC had much lower referral success for HIV related services (48.1%) than CG (81.2%). Adjusted for other covariates, CW age (26-49 versus 18-25 years, for OVC aOR = 0.83, 95%CI (0.78, 0.87) and CW gender (males versus females, for OVC aOR = 1.12, 95%CI (1.08, 1.16); CG aOR = 0.84, 95%CI (0.78, 0.90)) were associated with referral success. CWs who had worked > 1 year in the project (aOR = 1.52, 95%CI 1.46, 1.58) and those with previous work experience as CW (aOR = 1.57, 95%CI (1.42, 1.74) more successfully referred OVC. Referrals provided to OVC for all other services were more successful compared to HIV referrals, with aORs ranging from 2.99 to 7.22. Longer project duration in the district council was associated with increased referral success for OVC (aOR = 1.16 per month 95%CI 1.15,1.17), but decreased for CG (aOR = 0.96, 95%CI 0.94, 0.97). Referral success was higher for OVC and CGs with multiple (versus single) referrals provided within the past 30 days (aOR = 1.28 95%CI 1.21, 1.36) and (aOR = 1.17, 95%CI (1.06, 1.30)) respectively. CONCLUSION: CW characteristics, referral type and project maturity had different and often contrasting associations with referral success for OVC versus for CG. These findings could help policymakers decide on the recruitment and allocation of CWs in community based multi-sectoral intervention programs to improve referral successes especially for OVC.

ART use and associated factors among HIV positive caregivers of orphans and vulnerable children in Tanzania.

BACKGROUND: Utilization of antiretroviral therapy (ART) is crucial for better health outcomes among people living with the human immunodeficiency virus (PLHIV). Nearly 30% of the 1.6 million PLHIV in Tanzania are not on treatment. Since HIV positive status is the only eligibility criterion for ART use, it is critical to understand the obstacles to ART access and uptake to reach universal coverage of ART among PLHIV. For the caregivers of orphans and vulnerable children (OVC) LHIV and not on ART, attempts to identify them and ensure that they initiate and continue using ART is critical for their wellbeing and their ability to care for their children. METHODS: Data are from the community-based, United States Agency for International Development (USAID)-funded Kizazi Kipya project that aims at scaling up the uptake of HIV/AIDS and other health and social services by orphans and vulnerable children (OVC) and their caregivers. HIV positive caregivers of OVC who were enrolled in the USAID Kizazi Kipya project between January 2017 and June 2018 were included in this cross-sectional study. The caregivers were drawn from 11 regions: Arusha, Iringa, Katavi, Kigoma, Mara, Mbeya, Morogoro, Ruvuma, Simiyu, Singida, and Tanga. The outcome variable was ART status (either using or not), which was enquired of each OVC caregiver LHIV at enrollment. Data analysis involved multivariable analysis using random-effects logistic regression to identify correlates of ART use. RESULTS: In total, 74,999 caregivers living with HIV with mean age of 44.4 years were analyzed. Of these, 96.4% were currently on ART at enrollment. In the multivariable analysis, ART use was 30% lower in urban than in rural areas (adjusted odds ratio (OR) = 0.70, 95% confidence interval (CI) 0.61-0.81). Food security improved the odds of being on ART (OR = 1.29, 95% CI 1.15-1.45). Disabled caregivers were 42% less likely than non-disabled ones to be on ART (OR = 0.58, 95% CI 0.45-0.76). Male caregivers with health insurance were 43% more likely than uninsured male caregivers to be on ART (OR = 1.43, 95% CI 1.11-1.83). Caregivers aged 40-49 years had 18% higher likelihood of being on ART than the youngest ones. Primary education level was associated with 26% increased odds of being on ART than no education (OR = 1.26, 95% CI 1.13-1.41). CONCLUSIONS: Although nearly all the caregivers LHIV in the current study were on ART (96.4%), more efforts are needed to achieve universal coverage. The unreached segments of the population LHIV, even if small, may lead to worse health outcomes, and also spur further spread of the HIV epidemic due to unachieved viral suppression. Targeting caregivers in urban areas, food insecure households, who are uninsured, and those with mental or physical disability can improve ART coverage among caregivers LHIV.

Correlates of Uptake of Antiretroviral Therapy in HIV-Positive Orphans and Vulnerable Children Aged 0-14 Years in Tanzania.

BACKGROUND: In 2018, only 65% of Tanzanian children aged 0-14 years living with human immunodeficiency virus (HIV) were on treatment, suggesting that challenges exist. This study explores factors associated with uptake of antiretroviral therapy (ART) among HIV-positive orphans and vulnerable children (OVC). METHODS: Data are from the USAID Kizazi Kipya project that aims to increase the uptake of HIV/AIDS and other health and social services by OVC and their caregivers. HIV-positive OVC aged 0-14 years who were enrolled in the project from January 2017 to September 2018 were analyzed. ART status (off ART or on ART) was the outcome variable. Multivariate analysis was performed using multilevel logistic regression. RESULTS: Of the 10,047 HIV-positive OVC aged 0-14 years analyzed, 93.5% were currently on ART at enrollment. In the multivariate analysis, OVC with male caregivers were 4-times more likely than those with female caregivers to be on ART (OR=4.03, 95% CI=1.49-10.90). OVC with HIV-positive caregivers were 12-times more likely than those with HIV-negative caregivers to be on ART (OR=12.0, 95% CI=3.81-37.70). OVC with caregivers who did not disclose their HIV status were 74% less likely to be on ART than OVC of HIV-negative caregivers (OR=0.26, 95% CI=0.08-0.90). OVC living in urban areas were more than 5-times as likely as their rural counterparts to be on ART (OR=5.55, 95% CI=2.21-14.0). CONCLUSION: The majority of the OVCLHIV in the current study were currently on ART (93.5%) at enrollment. However, uptake of ART by the OVC was dependent on factors external to themselves. Advancing ART uptake may require targeting OVC of female caregivers, OVC of HIV-negative caregivers, as well as OVC of caregivers of undisclosed HIV statu, and rural areas.

Relationship Between Food Insufficiency and HIV Infection Among Caregivers of Orphans and Vulnerable Children in Tanzania.

BACKGROUND: Although Tanzania experiences a general decline in HIV prevalence, some populations such as caregivers of orphans may be at a higher risk than the general population, suggesting that infection pathways still need further exploration. This study examines how food insufficiency relates to HIV infection among caregivers of orphans and vulnerable children (OVC) in Tanzania. DATA AND METHODS: Data are from a community-based, USAID-funded Kizazi Kipya project that aims at increasing the uptake of HIV services, as well as other health and social services by OVC and their caregivers in Tanzania. Caregivers who were enrolled in the project from January to July 2017 in seven regions of Tanzania, and had reported their HIV status to the project, were included in the analysis. While HIV status was the outcome, the main independent variable was food insufficiency which was assessed using the Household Hunger Scale (HHS). Using Stata (version 14.0; StataCorp LP, College Station, TX, USA), data analysis involved multilevel mixed-effects logistic regression.. RESULTS: Of the 47,617 caregivers analyzed (73.7% females), 61.8% and 4.6% were experiencing moderate and severe hunger, respectively. The overall HIV prevalence among the caregivers was 28.3%. Nevertheless, the prevalence was as high as 34.2% among caregivers in severe hunger households. Multivariate analysis revealed an increasing likelihood of being HIV positive as hunger increased (moderate hunger: OR=1.10, 95%CI: 1.03-1.18; severe hunger: OR=1.51, 95%CI: 1.32-1.74). These observations were adjusted for marital status, age, sex, education, place of residence, family size, disability status, and health insurance. CONCLUSION: Food insufficiency is associated with a higher likelihood of HIV infection among OVC caregivers in Tanzania, suggesting that improving access to adequate food has a potential to reduce HIV risks among them. Furthermore, food insufficiency could be considered an important criterion for targeting HIV testing and treatment services to expand coverage.

Determinants of undisclosed HIV status to a community-based HIV program: findings from caregivers of orphans and vulnerable children in Tanzania.

BACKGROUND: HIV status disclosure facilitates receipt of HIV prevention and treatment services. Although disclosure to sexual partners, family members or friends has been extensively studied, disclosure to community-based HIV programs is missing. This study assesses the magnitude of, and factors associated with undisclosed HIV status to a community-based HIV prevention program among caregivers of orphans and vulnerable children (OVC) in Tanzania. METHODS: Data are from the USAID-funded Kizazi Kipya project that seeks to increase uptake of HIV, health, and social services by OVC and their caregivers in Tanzania. Data on OVC caregivers who were enrolled in the project during January-March 2017 in 18 regions of Tanzania were analyzed. Caregivers included were those who had complete information on their HIV status disclosure, household socioeconomic status, and sociodemographic characteristics. HIV status was self-reported, with undisclosed status representing all those who knew their HIV status but did not disclose it. Multilevel mixed-effects logistic regression, with caregivers' HIV status disclosure being the outcome variable was conducted. RESULTS: The analysis was based on 59,683 OVC caregivers (mean age = 50.4 years), 71.2% of whom were female. Of these, 37.2% did not disclose their HIV status to the USAID Kizazi Kipya program at the time of enrollment. Multivariate analysis showed that the likelihood of HIV status non-disclosure was significantly higher among: male caregivers (odds ratio (OR) = 1.22, 95% confidence interval (CI) 1.16-1.28); unmarried (OR = 1.12, 95% CI 1.03-1.23); widowed (OR = 1.12, 95% CI 1.07-1.18); those without health insurance (OR = 1.36, 95% CI 1.28-1.45); age 61 + years (OR = 1.72, 95% CI 1.59-1.88); those with physical or mental disability (OR = 1.14, 95% CI 1.04-1.25); and rural residents (OR = 1.58, 95% CI 1.34-1.86). HIV status non-disclosure was less likely with higher education (p < 0.001); and with better economic status (p < 0.001). CONCLUSION: While improved education, economic strengthening support and expanding health insurance coverage appear to improve HIV status disclosure, greater attention may be required for men, unmarried, widowed, rural residents, and the elderly populations for their higher likelihood to conceal HIV status. This is a clear missed opportunity for timely care and treatment services for those that may be HIV positive. Further support is needed to support disclosure in this population.

Understanding the association between caregiver sex and HIV infection among orphans and vulnerable children in Tanzania: learning from the USAID Kizazi Kipya project.

BACKGROUND: Tanzania has met only 50.1% of the 90% target for diagnosing HIV in children. The country's pediatric case finding strategy uses global best practices of index testing, provider-initiated counselling and testing, and targeted community testing of at-risk populations to find about 50,000 children living with HIV (CLHIV) who are undiagnosed. However, context-specific strategies are necessary to find the hidden children to meet the full 90% target. This study assesses whether sex of the caregiver is associated with HIV status of orphans and vulnerable children (OVC) as a valuable strategy for enhanced pediatric case findings. METHODS: Data originate from the community-based, United States Agency for International Development (USAID)-funded Kizazi Kipya Project, which works towards increasing OVC's and their caregivers' uptake of HIV/AIDS and other health and social services in Tanzania. Included in this study are 39,578 OVC ages 0-19 years who the project enrolled during January through March 2017 in 18 regions of Tanzania and who voluntarily reported their HIV status. Data analysis involved multi-level logistic regression, with OVC HIV status as the outcome of interest and caregiver's sex as the main independent variable. RESULTS: Three-quarters (74.3%) of the OVC included in the study had female caregivers, and their overall HIV prevalence was 7.1%. The prevalence was significantly higher (p < 0.001) among OVC with male caregivers (7.8%) than among OVC with female caregivers (6.8%), and indeed, multivariate analysis showed that OVC with male caregivers were significantly 40% more likely to be HIV-positive than those with female caregivers (OR = 1.40, 95% CI 1.08-1.83). This effect was the strongest among 0-4 year-olds (OR = 4.02, 95% CI 1.61-10.03), declined to 1.72 among 5-9 year-olds (OR = 1.72, 95% CI 1.02-2.93), and lost significance for children over age 9 years. Other significant factors included OVC age and nutritional status; caregiver HIV status and marital status; household health insurance status, and family size; and rural versus urban residence. CONCLUSIONS: OVC in Tanzania with male caregivers have a 40% higher likelihood of being HIV-positive than those with female caregivers. HIV risk assessment activities should target OVC with male caregivers, as well as OVC who have malnutrition, HIV-positive caregivers, or caregivers who do not disclose their HIV status to community volunteers. Further, younger HIV-positive OVC are more likely to live in rural areas, while older HIV-positive OVC are more likely to live in urban areas. These factors should be integrated in HIV risk assessment algorithms to enhance HIV testing yields and pediatric case-finding in the OVC population in Tanzania.

Factors Associated with HIV Status Disclosure to Orphans and Vulnerable Children Living with HIV: Results from a Longitudinal Study in Tanzania.

BACKGROUND: The Tanzanian national guideline for pediatric HIV disclosure recommends beginning disclosure as early as age 4-6 years; full disclosure is recommended at the age of 8-10 years. Despite clear procedures, the disclosure rate in Tanzania remains relatively low. This study assessed the factors associated with HIV status disclosure to orphans and vulnerable children living with HIV (OVCLHIV). METHODS: Data for this analysis come from the USAID-funded Kizazi Kipya program in Tanzania that provides health and social services to OVC and caregivers of HIV-affected households. Data were collected between January 2018 and March 2019. Disclosure status was self-reported by caregivers of children aged 8 years or above. Beneficiary characteristics were included as independent variables. Generalized estimating equations took into account the clustering effect of the study design. RESULTS: Of the 10673 OVCLHIV, most were females (52.43%), and 80.67% were enrolled in school. More than half (54.89%) were from households in rural areas. Caregivers were mostly females (70.66%), three quarters were between 31 and 60 years old and had a complete primary education (67.15%), and 57.75% were HIV-infected. Most of the OVCLHIV (87.31%) had a disclosed HIV status. Greater OVCLHIV age (p < 0.001), school enrollment (OR = 1.22; 95% CI 1.06, 1.41), urban location of household (OR = 1.64; 95% CI 1.44, 1.86), caregivers' higher education level (p < 0.001), and caregiver HIV-positive status (OR = 1.25; 95% CI 1.09, 1.43) were positively associated with disclosure status. OVCLHIV of female caregivers were 27% less likely to have been disclosed than those of male caregivers. CONCLUSION: The disclosure rate among OVCLHIV in this study was high. Disclosure of HIV status is crucial and beneficial for OVCLHIV continuum of care. Caregivers should be supported for the disclosure process through community-based programs and involvement of health volunteers. Policymakers should take into consideration the characteristics of children, their caregivers, and location of households in making disclosure guidelines as adaptable as possible.

The impact of paid community health worker deployment on child survival: the connect randomized cluster trial in rural Tanzania.

BACKGROUND: This paper reports on a rigorously designed non-masked randomized cluster trial of the childhood survival impact of deploying paid community health workers to provide doorstep preventive, promotional, and curative antenatal, newborn, child, and reproductive health care in three rural Tanzanian districts. METHODS: From August, 2011 to June 2015 ongoing demographic surveillance on 380,000 individuals permitted monitoring of neonatal, infant and under-5 mortality rates for 50 randomly selected intervention and 51 comparison villages. Over the initial 2 years of the project, logistics and supply support systems were managed by the Ifakara Health Institute. In 2013, the experiment transitioned its operational design to logistical support managed by the Ministry of Health and Social Welfare with the goal of enhancing government operational ownership and utilization of results for policy. RESULTS: The baseline under 5 mortality rate was 81.3 deaths per 1000 live births with a 95% confidence interval (CI) of 77.2-85.6 in the intervention group and 82.7/1000 (95% CI 78.5-87.1) in the comparison group yielding an adjusted hazard ratio (HR) of 0.99 (95% CI 0.88-1.11, p = 0.867). After 4 years of implementation, the under 5 mortality rate was 73.2/1000 (95% CI 69.3-77.3) in the intervention group and 77.4/1000 (95% CI 73.8-81.1) in the comparison group (adjusted HR 0.95 [95% CI 0.86-1.07], p = 0.443). The intervention had no impact on neonatal mortality in either the first 2 years (HR 1.10 [95% CI 0.89-1.36], p = .392) or last 2 years of implementation (HR 0.98 [95% CI 0.74-1.30], p = .902). Although community health worker deployment significantly reduced mortality among children aged 1-59 months during the first 2 years of implementation (HR 0.85 [95% CI 0.76-0.96], p = 0.008), mortality among post neonates was the same in both groups in years three and four (HR 1.03 [95% CI 0.85-1.24], p = 0.772). Results adjusted for stock-out effects show that diminishing impact was associated with logistics system lapses that constrained worker access to essential drugs and increased post-neonatal mortality risk in the final two project years (HR 1.42 [95% CI 1·07-1·88], p = 0·015). CONCLUSIONS: Community health worker home-visit deployment had a null effect among neonates, and 2 years of initial impact among children over 1 month of age, but a null effect when tests were based on over 1 month of age data merged for all four project years. The atrophy of under age five effects arose because workers were not continuously equipped with essential medicines in years three and four. Analyses that controlled for stock-out effects suggest that adequately supplied workers had survival effects on children aged 1 to 59 months. TRIAL REGISTRATION: Registration for trial number ISRCTN96819844 was retrospectively completed on June 21, 2012.

A time-use study of community health worker service activities in three rural districts of Tanzania (Rufiji, Ulanga and Kilombero).

BACKGROUND: Despite expanding international commitment to community health worker (CHW) deployment, little is known about how such workers actually use their time. This paper investigates this issue for paid CHWs named "Community Health Agents," which in Swahili is "Wawezeshaji wa Afya ya Jamii" ("WAJA"), trained for 9 months in primary health care service delivery and deployed to villages as subjects of a randomized trial of their impact on childhood survival in three rural districts of Tanzania. METHODS: To capture information about time allocation, 30 WAJA were observed during conventional working hours by research assistants for 5 days each over a period of 4 weeks. Results were presented in term of percentage time allocation for direct client treatment, documentation activities, health education, health promotion non-work-related activities and personal activities. RESULTS: During routine 8-h workdays, 59.5 % of WAJA time was spent on the provision of health services and other work-related activities. Overall, WAJA spent 27.8 % of their work on traveling from home to home, 33.1 % on health education, 9.9 % of health promotion and only 12.3 % on direct patient care. Other activities related to documentation (7.8 %) and supervision (2.5 %). CONCLUSIONS: Results reflect the pressing obligations of WAJA to engage in activities other than direct work responsibilities during routine work hours. Time spent on work activities is primarily used for health education, promotion, moving between households, and direct patient care. However, greater effort should be directed to strengthening supervisory systems and follow-up of challenges WAJAs facing in order to increase proportion of working hours.