Predicting Lost to Follow-Up Status Using an Adolescent HIV Psychosocial Attrition Risk Assessment Tool: Results From a Mixed Methods Prospective Cohort Study in Uganda.

BACKGROUND: Low retention in care for adolescents living with HIV (ALHIV) has been a key driver of suboptimal viral load suppression rates in Uganda. The objective of this study was to develop a psychosocial risk assessment tool and evaluate its ability to predict the risk of attrition of ALHIV between the ages 15 and 19 years. SETTING: The study was conducted in 20 facilities in Central and Western Uganda from August 2021 through July 2022. METHODS: A mixed methods prospective cohort study was conducted in two phases. In the first phase, the Adolescent Psychosocial Attrition Risk Assessment tool was developed and revised using feedback from focus group discussions and interviews. In the second phase, the ability of the Adolescent Psychosocial Attrition Risk Assessment tool to predict attrition among ALHIV was evaluated using diagnostic accuracy tests. RESULTS: A total of 597 adolescents between the ages 15 and 19 years were enrolled, of which 6% were lost to follow-up at the end of the study period. A 20-question tool was developed, with 12 questions being responded to affirmatively by >50% of all participants. Using a cut-off score of 6 or more affirmative answers translated to an area under the curve of 0.58 (95% CI: 0.49 to 0.66), sensitivity of 55% (95% CI: 36% to 72%), and specificity of 61% (95% CI: 56% to 65%). CONCLUSION: Although the Adolescent Psychosocial Attrition Risk Assessment tool was not effective at predicting lost to follow-up status among ALHIV, the tool was useful for identifying psychosocial issues experienced by ALHIV and may be appropriate to administer during routine care visits to guide action.

Operational demonstration and process evaluation of non-pneumatic anti-shock garment (NASG) introduction to the public health system of Northern Province, Zambia.

BACKGROUND: A disproportionate burden of maternal deaths occurs in low- and middle-income countries (LMICs), and obstetric hemorrhage (OH) is a leading cause of excess mortality. In Zambia, most of maternal deaths are directly caused by OH. The Non-Pneumatic Anti-Shock Garment (NASG) is a first aid tool that uses compression to the abdomen and lower body to stop and reverse hypovolemic shock secondary to OH. We describe the process and experiences introducing the NASG into the Zambia public health system to encourage the development of national policies, clinical guidelines, and implementation plans that feature the NASG. METHODS: We conducted an observational study of NASG introduction to 143 public health facilities in Northern Province, Zambia, organizing observations into the five dimensions of the RE-AIM evaluation framework: reach, effectiveness, adoption, implementation, and maintenance. The NASG was introduced in August 2019, and the introduction was evaluated for 18 months. Data on healthcare worker training and mentorship, cases where NASG was used, and NASG availability and use during the study period were collected and analyzed. RESULTS: The NASG was successfully introduced and integrated into the Zambia public health system, and appropriately used by healthcare workers when responding to cases of OH. Sixteen months after NASG introduction, NASGs were available and functional at 99% of study sites and 88% reported ever using a NASG. Of the 68 cases of recorded OH where a NASG was applied, 66 were confirmed as clinically appropriate, and among cases where shock index (SI) could be calculated, 59% had SI ≥ 0.9. Feedback from healthcare providers revealed that 97% thought introducing the NASG was a good decision, and 92% felt confident in their ability to apply the NASG after initial training. The RE-AIM average for this study was 0.65, suggesting a public health impact that is not equivocal, and that NASG introduction had a positive population-based effect. CONCLUSIONS: A successful NASG demonstration took place over the course of 18 months in the existing health system of Northern Province, Zambia, suggesting that incorporation of NASG into the standard of care for obstetric emergency in the Zambia public sector is feasible and can be maintained without external support.

Equipping providers to offer novel MPTs: Developing counseling messages for the Dual Prevention Pill in clinical studies and beyond.

Introduction: The pipeline for multi-purpose prevention technologies includes products that simultaneously prevent HIV, pregnancy and/or other sexually transmitted infections. Among these, the Dual Prevention Pill (DPP) is a daily pill co-formulating oral pre-exposure prophylaxis (PrEP), and combined oral contraception (COC). Clinical cross-over acceptability studies for the DPP require training providers to counsel on a combined product. From February 2021-April 2022, a working group of eight HIV and FP experts with clinical and implementation expertise developed counseling recommendations for the DPP based on existing PrEP/COC guidance. Assessment of policy/guidelines options and implications: The working group conducted a mapping of counseling messages from COC and oral PrEP guidance and provider training materials. Six topics were prioritized: uptake, missed pills, side effects, discontinuation and switching, drug interactions and monitoring. Additional evidence and experts were consulted to answer outstanding questions and counseling recommendations for the DPP were developed. Missed pills was the topic with the most complexity, raising questions about whether women could "double up" on missed pills or skip the last week of the pack to recover protection faster. Uptake required aligning the time to reach protective levels for both DPP components and explaining the need to take DPP pills during week 4 of the pack. The potential intensity of DPP side effects, given the combination of oral PrEP with COC, was an important consideration. Discontinuation and switching looked at managing risk of HIV and unintended pregnancy when stopping or switching from the DPP. Guidance on drug interactions contended with differing contraindications for COC and PrEP. Monitoring required balancing clinical requirements with potential user burden. Actionable recommendations: The working group developed counseling recommendations for the DPP to be tested in clinical acceptability studies. Uptake: Take one pill every day for the DPP until the pack is empty. Days 1-21 contain COC and oral PrEP. Days 22-28 do not contain COC to allow for monthly bleeding, but do contain oral PrEP and pills should be taken to maintain HIV protection. Take the DPP for 7 consecutive days to reach protective levels against pregnancy and HIV. Missed pills: If you miss 1 pill multiple times in a month or 2+ consecutive pills, take the DPP as soon as you remember. Do not take more than 2 pills in a day. If 2+ consecutive pills are missed, only take the last missed pill and discard the other missed pills. Side effects: You may experience side effects when you start using the DPP, including changes to monthly bleeding. Side effects are typically mild and go away without treatment. Discontinuation/switching: If you decide to discontinue use of the DPP, but want to be protected from HIV and/or unintended pregnancy, in most cases, you can begin using PrEP or another contraceptive method right away. Drug interactions: There are no drug-drug interactions from combining oral PrEP and COC in the DPP. Certain medications are not recommended due to their contraindication with oral PrEP or COC. Monitoring: You will need to get an HIV test prior to initiating or restarting the DPP, and every 3 months during DPP use. Your provider may recommend other screening or testing. Discussion: Developing recommendations for the DPP as a novel MPT posed unique challenges, with implications for efficacy, cost, and user and provider comprehension and burden. Incorporating counseling recommendations into clinical cross-over acceptability studies allows for real-time feedback from providers and users. Supporting women with information to use the DPP correctly and confidently is critically important for eventual scale and commercialization.

Optimizing and validating a pediatric screening tool to more efficiently test and identify children living with HIV.

OBJECTIVE: To develop and validate a screening tool to improve testing efficiency and increase case finding of children living with HIV. DESIGN: Cross-sectional study. METHODS: Between November 2020 and September 2021, children 18 months to 14 years presenting at outpatient departments in 30 health facilities in Zambia were administered a 14-question pediatric HIV screening tool and then tested for HIV. Data were analyzed using a randomly extracted 'validation' dataset and multivariable logistic regression to determine the highest performing and optimal number of screening questions. The final tool was then evaluated in the 'test' dataset. Sensitivity and specificity were calculated for both datasets. The final tool was then also implemented in 12 additional facilities to determine operational feasibility and uptake. RESULTS: A total of 9902 children were included in the final analysis. HIV prevalence was 1.3%. Six questions were significantly associated with HIV-positivity. The optimal screening cutoff score was to answer 'yes' to one or more of the six questions; using this cutoff sensitivity was 92.5% [95% confidence interval (CI) 85.7-96.7%] and specificity was 62.9% (95% CI 61.9-64%). In the test dataset, the same tool had a sensitivity of 84.6% (95% CI 65.1-95.6%) and specificity of 64.6% (95% CI 62.4-66.7%). Uptake was 89%. CONCLUSION: The results of this study show sensitivity and acceptable specificity in a six-question validated HIV screening tool. Implementing this screening tool in settings where universal testing is not feasible should more efficiently accelerate identification of children living with HIV (CLHIV) and their timely initiation onto life-saving drugs.

Applying the RE-AIM framework in a process evaluation of the introduction of the Non-Pneumatic Anti-Shock Garment in a rural district of Zimbabwe.

The Non-Pneumatic Anti-Shock Garment (NASG) is a first aid tool that can halt and reverse hypovolemic shock secondary to obstetric hemorrhage. The World Health Organization recommended the NASG for use as a temporizing measure in 2012, but uptake of the recommendation has been slow, partially because operational experience is limited. The study is a process evaluation of the introduction of NASG in a public sector health facility network in rural Zimbabwe utilizing an adapted RE-AIM, categorizing observations into the domains of: reach, effectiveness, adoption, implementation and maintenance. The location of the study was Hurungwe district, where staff members of 34 health facilities at primary (31), secondary (2) and tertiary (1) levels of care participated. We found that all facilities became skilled in using the NASG, and that the NASG was used in 10 of 11 instances of severe hemorrhage. In the cases of hypovolemic shock where the NASG was used, there were no maternal deaths and no extreme adverse outcomes related to obstetric hemorrhage in the study period. Among the 10 NASG uses, the garment was used correctly in each case. Fidelity to processes was high, especially in regard to training and cascading skills, but revisions of the NASG rotation and replacement operating procedures were required to keep clean garments stocked. Clinical documentation was also a key challenge. NASG introduction dovetailed very well with pre-existing systems for obstetric emergency response, and improved clinical outcomes. Scale-up of the NASG in the Zimbabwean public health system can be undertaken with careful attention to mentorship, drills, documentation and logistics.

Applying a Client-centered Approach to Maternal and Neonatal Networks of Care: Case Studies from Urban and Rural Nigeria.

In Nigeria, two maternal and neonatal health Networks of Care (NOC) focus on extending the reach and quality of routine and emergency maternal and neonatal health services tailored to the different contexts. This paper uses the four domains of the NOC framework-Agreements and Enabling Environment, Operational Standards, Quality, Efficiency and Responsibility, and Learning and Adaptation-to describe the NOC, highlighting how each developed to address specific local needs. In Northern Nigeria, the NOC were established in collaboration among Clinton Health Access Initiative and the government to reduce maternal and neonatal morbidity and mortality. Health centers and communities in the network were supported to be better prepared to provide maternal and neonatal care, while birth attendants at all levels were empowered and equipped to stabilize and treat complications. The approach brought services closer to the community and facilitated rapid referrals. The NOC in Lagos State extended the reach of routine and emergency maternal and neonatal health services through organically developed linkages among registered traditional birth attendant clinics, private and public sector facilities, the Primary Healthcare Board, and the Traditional Medicine Board. Traditional birth attendants are registered, trained, and monitored by Apex Community Health Officers, whose responsibilities include collection and review of data and ensuring linkages to postpartum services, such as family planning and immunizations. While differing in their approaches, both NOC provide locally appropriate, pragmatic approaches to supporting women birthing in the community and encouraging institutional delivery to ensure that women and their babies have access to timely, appropriate, and safe services.

Averting Maternal Death and Disability in an Urban Network of Care in Dar es Salaam, Tanzania: A Descriptive Case Study.

The non-governmental organization Comprehensive Community Based Rehabilitation in Tanzania (CCBRT) developed a multi-facility maternal and neonatal Network of Care (NOC) among 22 government hospitals and catchment facilities operating across Dar es Salaam. While facility delivery rates were above 90% in the Dar es Salaam region, the quality of services was substandard, leading to an excess of preventable maternal and neonatal morbidity and mortality. In partnership with the Dar es Salaam regional health authorities CCBRT developed a plan to improve the quality of service delivery at childbirth by through a system strengthening approach, capacitating lower-level facilities to provide routine care during pregnancy and uncomplicated deliveries, as well as improving care at secondary level referral hospitals and developing an inter-connected strengthened referral system. The Regional-CCBRT partnership implemented interventions across the continuum of care that included clinical training in basic and comprehensive emergency obstetric care, investments in infrastructure, and a rigorous maternal and perinatal death audit and follow-up program. Routine data generated were reflected upon at quarterly quality improvement meetings to follow up on problems identified. The government has initiated the replication of the model. This descriptive case study uses the four domains of the Networks of Care framework to document the wide-ranging efforts made to build and maintain the CCBRT Network of Care in order to solve for specific challenges in maternal and neonatal health service delivery in the urban context of the Dar es Salaam region.

Harnessing the Power of Networks of Care for Universal Health Coverage.

On the global health agenda, Universal Health Coverage has been displaced by the COVID-19 pandemic while disparities in COVID-19 outcomes have exposed stark gaps in quality, access, equity, and financial risk protection. These disparities highlight the importance of the core goals of Universal Health Coverage and the need for innovative approaches to working toward them. The newly codified concept of "Networks of Care" offers a promising option for implementation. The articles in this special issue present the Networks of Care lexicon and framework and demonstrate the development of leadership, responsibility, intra- and inter-facility cooperation, and dynamic cycles of quality improvement. These elements are associated with better access to services and better health outcomes, the ultimate goals of Universal Health Coverage. Increases in poverty, food insecurity, and deleterious impact on the status of women secondary to the COVID-19 pandemic add urgency to Universal Health Coverage, while the economic impact of pandemic mitigation may reduce availability of resources for years to come. The need for Universal Health Coverage and efficiency and flexibility in health spending, including the ability to contract directly, has become even more important. Countries where Universal Health Coverage efforts have yet to carry through to provision of good quality, accessible and equitable service delivery could potentially benefit from concurrent Networks of Care implementation. Documentation of Networks of Care in the context of Universal Health Coverage should be prioritized to understand how Networks of Care can be used to help realize the goals of Universal Health Coverage around the world.

Seeing the Forest for the Trees: A Set of Descriptive Case Studies Presented with the Networks of Care Framework.

Durable solutions for daunting problems in global health can be elusive. The global health literature tends to present aggregated data and highlight clinical outcomes but fails to describe the systems that buttress the interventions. The common idiom about "missing the forest for the trees" is apropos: by focusing on individual examples, we may miss the bigger picture. How implementation of policies and innovations plays out on the front lines of service delivery often goes uncommunicated. The Networks of Care scoping study takes a different approach, looking at diverse programs to seek out common patterns. Using the four domains of the Networks of Care framework to structure descriptions of six operational programs reveals commonalities in their designs and shows the utility of the framework's components. The commonalities increase our conviction that the framework can be used as a practical approach to strengthen service-level health systems. The case studies are followed by a commentary about the potential synergy of Networks of Care with Universal Health Coverage efforts, to deliver on the core promises to increase access and quality of care for all, especially the persistently underserved. These case studies help define a practical toolkit to promote enduring positive changes, forging a path for the Networks of Care framework to move anecdotes of individual successes to health policy and broader implementation, enabling global health practitioners at all levels to keep the big picture in focus while working toward ensuring healthy lives and well-being for all.

The Logarithmic Spiral of Networks of Care for Expectant Families in Rural Nepal: A Descriptive Case Study.

This case study utilizes the four domains of effective Networks of Care (NOC) as a lens to describe the suite of interventions of a biosocial approach to maternal and neonatal health services in rural Nepal: The Network of Safety model, created by the non-governmental organization One Heart Worldwide (OHW) in collaboration with the government health system in Nepal. This approach provides essential guidance in the areas of health financing, governance, sustainability, reflection of user preference, and scalability. OHW addresses the reproductive health needs of women living in remote areas of Nepal in collaboration with local-level health and government workers by emphasizing clinical skill development and mentorship in management and leadership. With Nepal's shift to Federalism, the OHW approach proved flexible and able to deepen its support to leaders in new local-level government structures. The results on the ground were remarkable: using analytic skills gained from their OHW partnership, municipality leaders and health workers demonstrated effective communication and proactive responses to challenges, while maintaining fidelity to the Network of Safety model. The six-year commitment made by OHW to partner municipalities promoted active learning and adaptation and is a clear contributor to the scalability of the OHW Network of Safety. Observing the Network of Safety work through the domains of NOC highlights the interdisciplinary effort required to successfully transform Maternal and Neonatal Health (MNH) services in rural Nepal.

Developing a Common Understanding of Networks of Care through a Scoping Study.

The phrase "Networks of Care" seems familiar but remains poorly defined. A health system that exemplifies effective Networks of Care (NOC) purposefully and effectively interconnects service delivery touch points within a catchment area to fill critical service gaps and create continuity in patient care. To more fully elaborate the concept of Networks of Care, we conducted a multi-method scoping study that included a literature review, stakeholder interviews, and descriptive case studies from five low- and middle-income countries. Our extended definition of a Network of Care features four overlapping and interdependent domains of activity at multiple levels of health systems, characterized by: 1) Agreement and Enabling Environment, 2) Operational Standards, 3) Quality, Efficiency and Responsibility, and 4) Learning and Adaptation. There are a series of key interrelated themes within each domain. Creating a common understanding of what characterizes and fosters an effective Network of Care can drive the evolution and strengthening of national health programs, especially those incorporating universal health coverage and promoting comprehensive care and integrated services. An understanding of the Networks of Care model can help guide efforts to move health service delivery toward goals that can benefit a diversity of stakeholders, including a variety of health system actors, such as health care workers, users of health systems, and the wider community at large. It can also contribute to improving poor health outcomes and reducing waste originating from fragmented services and lack of access.

Building Trust to Save Lives in a Metro Manila Public-Private Network of Care: A Descriptive Case Study of Quirino Recognized Partners in Quezon City, Philippines.

At an overcrowded government multi-specialty hospital serving the most densely populated area of Metro Manila, inward referrals of women in a moribund state and high volumes of low-risk maternity cases added to significant overcrowding and quality challenges in the maternity wards, resulting in high rates of maternal and neonatal death and near-miss. This case study of the public-private Network of Care, Quirino Recognized Partners (QRP), describes a series of pragmatic steps taken to build and maintain the network, particularly: building trust through agreements with private and public birth centers within a ten-kilometer radius, rolling out antenatal use of a clinical and socio-economic risk scoring tool, reaching out to potential clients, and establishing clear communication channels and protocols for care. These actions, consistent with the schematic of an effective Network of Care, helped decongest the hospital, build rapport and teamwork among health providers, and improve maternal and neonatal outcomes throughout the network. The purpose of this descriptive case study was to explore how QRP was established to solve for particular contextual problems, especially congestion and poor maternal and neonatal health outcomes, with express attention to how actions taken related to the domains of Networks of Care. Data collected through semi-structured interviews with relevant health care and other workers, institutional documents, observations, and field notes were interpreted through the domains of Networks of Care and reported through rich description.

Partner testing, linkage to care, and HIV-free survival in a program to prevent parent-to-child transmission of HIV in the Highlands of Papua New Guinea.

BACKGROUND: To eliminate new pediatric HIV infections, interventions that facilitate adherence, including those that minimize stigma, enhance social support, and mitigate the influence of poverty, will likely be required in addition to combination antiretroviral therapy (ART). We examined the relationship between partner testing and infant outcome in a prevention of parent-to-child transmission of HIV program, which included a family-centered case management approach and a supportive environment for partner disclosure and testing. DESIGN: We analyzed routinely collected data for women and infants who enrolled in the parent-to-child transmission of HIV program at Goroka Family Clinic, Eastern Highlands Provincial Hospital, Papua New Guinea, from 2007 through 2011. RESULTS: Two hundred and sixty five women were included for analysis. Of these, 226 (85%) had a partner, 127 (56%) of whom had a documented HIV test. Of the 102 HIV-infected partners, 81 (79%) had been linked to care. In adjusted analyses, we found a significantly higher risk of infant death, infant HIV infection, or loss to follow-up among mother-infant pairs in which the mother reported having no partner or a partner who was not tested or had an unknown testing status. In a second multivariable analysis, infants born to women with more time on ART or who enrolled in the program in later years experienced greater HIV-free survival. CONCLUSIONS: In a program with a patient-oriented and family-centered approach to prevent vertical HIV transmission, the majority of women's partners had a documented HIV test and, if positive, linkage to care. Having a tested partner was associated with program retention and HIV-free survival for infants. Programs aiming to facilitate diagnosis disclosure, partner testing, and linkage to care may contribute importantly to the elimination of pediatric HIV.

Retention among ART patients in the Highlands of Papua New Guinea: evaluating the PAPUA model.

BACKGROUND: Despite more than 10,000 patients on antiretroviral therapy (ART), there remains a dearth of operational research in Papua New Guinea related to HIV service delivery. This study examined the effectiveness of a locally developed model of HIV service delivery called PAPUA (Patient and Provider Unified Approach) in the Highlands of Papua New Guinea. The model emphasizes coordinated patient and provider support along with decentralized services to rural districts in the Highlands. METHODS: We conducted a chart review among HIV-infected adults on ART at clinics in Eastern Highlands Province, where the PAPUA model was implemented in addition to the standard of care, and in Western Highlands Province, where the standard of care was implemented. We calculated yearly retention rates and used multivariable Cox proportional hazards regression analyses to compare retention rates across the provinces. RESULTS: Data for 2457 patients from the 2 provinces were analyzed. Among patients receiving ART under the PAPUA model in Eastern Highlands, the 12-, 24-, 36-, and 48-month retention proportions were 0.79, 0.73, 0.68, and 0.63, respectively. When we compared retention probabilities across the 2 provinces, patients receiving care under the PAPUA model had a 15% lower rate of attrition from care during the first 4 years of ART (hazard ratio, 0.85; 95% confidence interval: 0.74 to 0.99; P = 0.03), after adjusting for age, gender, and year of enrollment. CONCLUSIONS: The PAPUA model seems to be a promising intervention although it is inextricably linked to the limitations posed by a resource-constrained health system.

Support for bereaved owners of pets.

TOPIC: The bond that exists between people and their pets and its impact on physical and mental health. PURPOSE: To review the current literature and explore the clinical implications of bereavement related to pets. SOURCES: A comprehensive review of the bereavement, veterinarian, and agricultural literature related to attitudes and response patterns to pet and animal death. CONCLUSIONS: The death or loss of a beloved pet can be a life-changing event.