Perinatal loss in Tanzania: Perspectives of maternal-child healthcare providers.

Over 98% of stillbirths and neonatal deaths occur in Low- and Middle-Income Countries, such as Tanzania. Despite the profound burden of perinatal loss in these regions, access to facility or community-based palliative and psychosocial care is poor and understudied. In this study we explore perinatal loss through the lens of front-line healthcare providers, to better understand the knowledge and beliefs that guide their engagement with bereaved families. A Knowledge Attitudes and Practices survey addressing perinatal loss in Tanzania was developed, translated into Swahili, and administered over a 4-month period to healthcare professionals working at the Kilimanjaro Christian Medical Center (KCMC). Results were entered into REDCap and analyzed in R Studio. 74 providers completed the survey. Pediatric providers saw a yearly average of 5 stillbirths and 32.7 neonatal deaths. Obstetric providers saw an average of 11.5 stillbirths and 13.12 neonatal deaths. Most providers would provide resuscitation beginning at 28 weeks gestational age. Respondents estimated that a 50% chance of survival for a newborn occurred at 28 weeks both nationally and at KCMC. Most providers felt that stillbirth and neonatal mortality were not the mother's fault (78.4% and 81.1%). However, nearly half (44.6%) felt that stillbirth reflects negatively on the woman and 62.2% agreed that women are at higher risk of abuse or abandonment after stillbirth. A majority perceived that women wanted hold their child after stillbirth (63.0%) or neonatal death (70.3%). Overall, this study found that providers at KCMC perceived that women are at greater risk of psychosocial or physical harm following perinatal loss. How women can best be supported by both the health system and their community remains unclear. More research on perinatal loss and bereavement in LMICs is needed to inform patient-level and health-systems interventions addressing care gaps unique to resource-limited or non-western settings.

Timing of maternal isoniazid preventive therapy on tuberculosis infection among infants exposed to HIV in low-income and middle-income settings: a secondary analysis of the TB APPRISE trial.

BACKGROUND: Infants born to women with HIV in settings with a high tuberculosis burden are at risk of tuberculosis infection and rapid progression to active disease. Maternal isoniazid preventive therapy might mitigate this risk, but optimal timing of therapy remains unclear. The TB APPRISE trial showed that initiation of isoniazid during pregnancy resulted in more frequent adverse pregnancy outcomes than when initiated postpartum. We aimed to determine the proportion of infants testing positive for tuberculosis infection born to mothers who initiated isoniazid therapy antepartum compared with postpartum using two commonly used tests, the test agreement, and predictors of test positivity. METHODS: TB APPRISE was a randomised, double-blind, placebo-controlled, non-inferiority trial done at 13 study sites across eight countries (Botswana, Haiti, India, South Africa, Tanzania, Thailand, Uganda, and Zimbabwe). Pregnant women with HIV on antiretroviral therapy were randomly assigned to receive immediate isoniazid preventive therapy (28 weeks isoniazid [300 mg daily], then placebo until week 40 after delivery) or deferred treatment (placebo until week 12 after delivery, then isoniazid [300 mg daily] for 28 weeks). Mother-infant pairs were followed up until 48 weeks after delivery. We included all liveborn infants with a tuberculin skin test or interferon-γ release assay (IGRA) at 44 weeks. The outcomes assessed in this secondary analysis were tuberculosis test positivity by study group, test agreement, and predictors of test positivity. This study was registered with ClinicalTrials.gov, NCT01494038. FINDINGS: Between Aug 19, 2014, and April 4, 2016, 956 mothers were randomly assigned, and 749 mother-child pairs were included in this secondary analysis. Of 749 infants, 694 (93%) received Bacille Calmette-Guérin (BCG) vaccination, 675 (90%) were born to mothers who had completed isoniazid treatment, 20 (3%) were exposed to tuberculosis, seven (1%) became HIV positive, and one (<1%) developed probable tuberculosis. 43 (6%; 95% CI 4-8]) of 732 infants had a positive IGRA test result and 55 (8%; 6-10) of 727 infants had a positive tuberculin skin test result. Test positivity did not differ by study group (p=0·88 for IGRA; p=0·44 for tuberculin skin test). Test agreement was poor (κ=0·107 [95% CI 0·002-0·212]). Infant tuberculin skin test positivity was associated with breastfeeding (adjusted odds ratio 6·63 [95% CI 1·57-27·9]), BCG vaccination (4·97 [1·50-16·43]), and maternal tuberculin skin test positivity at delivery (3·28 [1·70-6·33]); IGRA positivity was associated with female sex (2·09 [1·06-4·14]). INTERPRETATION: Deferral of maternal isoniazid preventive therapy to early postpartum had no effect on infant tuberculosis acquisition in our trial population, regardless of the diagnostic test used; however, tuberculosis test agreement is poor during infancy. FUNDING: US National Institutes of Health.

Impact of COVID-19 on Adolescent HIV Prevention and Treatment Services in the AHISA Network.

We investigated perceived impacts of COVID-19 on the delivery of adolescent HIV treatment and prevention services in sub-Saharan Africa (SSA) by administering a survey to members of the Adolescent HIV Prevention and Treatment Implementation Science Alliance (AHISA) from February to April 2021. We organized COVID-19 impacts, as perceived by AHISA teams, under three themes: service interruptions, service adjustments, and perceived individual-level health impacts. AHISA teams commonly reported interruptions to prevention programs, diagnostic testing, and access to antiretroviral therapy (ART). Common service adjustments included decentralization of ART refills, expanded multi-month ART distribution, and digital technology use. Perceived individual-level impacts included social isolation, loss to follow-up, food insecurity, poverty, and increases in adolescent pregnancies and sexually transmitted infections. The need for collaboration among stakeholders were commonly cited as lessons learned by AHISA teams. Survey findings highlight the need for implementation science research to evaluate the effects of pandemic-related HIV service adaptations in SSA.

Provider Perceptions on Bereavement Following Newborn Death: A Qualitative Study from Ethiopia and Ghana.

OBJECTIVE: The objective of this study was to explore how clinicians in low- and middle-income countries engage and support parents following newborn death. STUDY DESIGN: Qualitative interviews of 40 neonatal clinicians with diverse training were conducted in Addis Ababa, Ethiopia, and Kumasi, Ghana. Transcribed interviews were analyzed and coded through the constant comparative method. RESULTS: Three discrete themes around bereavement communication emerged. (1) Concern for the degree of grief experienced by mothers and apprehension to further contribute to it. This led to modified communication to shield her from emotional trauma. (2) Acknowledgment of cultural factors impacting neonatal loss. Clinicians reported that loss of a newborn is viewed differently than loss of an older child and is associated with a diminished degree of public grief; however, despite cultural expectations dictating private grief, interview subjects noted that mothers do suffer emotional pain when a newborn dies. (3) Barriers impeding communication and psychosocial support for families, often relating to language differences and resource limitations. CONCLUSIONS: Neonatal mortality remains the leading global cause of mortality under age 5, with the majority of these deaths occurring in low- and middle-income countries, yet scant literature exists on approaches to communication around end-of-life and bereavement care for neonates in these settings. We found that medical providers in Ghana and Ethiopia described structural and cultural challenges that they navigate following the death of a newborn when communicating and supporting bereaved parents.

Impact of COVID-19 on Adolescent HIV Prevention and Treatment Research in the AHISA Network.

Members of the Adolescent HIV Prevention and Treatment Implementation Science Alliance (AHISA) network conduct research aiming to close gaps between what is known to be impactful across the HIV prevention and treatment cascade, and services delivered to optimize outcomes for adolescents/young adults (AYA) in high HIV-prevalence settings. The COVID-19 pandemic introduced new challenges which threaten to exacerbate care and access disparities. We report results of a survey among AHISA teams with active AYA HIV research programs in African countries to determine how the pandemic has impacted their efforts. Results highlighted the detrimental impact of the pandemic on research efforts and the expanded need for implementation research to help provide evidence-based, context-specific pandemic recovery support. Key lessons learned included the viability of remote service delivery strategies and other innovations, the need for adaptive systems that respond to evolving contextual needs, and the need for organized documentation plans, within empathic and flexible environments.

Integrating Adolescent Mental Health into HIV Prevention and Treatment Programs: Can Implementation Science Pave the Path Forward?

Adolescent mental health (AMH) is a critical driver of HIV outcomes, but is often overlooked in HIV research and programming. The implementation science Exploration, Preparation, Implementation, Sustainment (EPIS) framework informed development of a questionnaire that was sent to a global alliance of adolescent HIV researchers, providers, and implementors working in sub-Saharan Africa with the aim to (1) describe current AMH outcomes incorporated into HIV research within the alliance; (2) identify determinants (barriers/gaps) of integrating AMH into HIV research and care; and (3) describe current AMH screening and referral systems in adolescent HIV programs in sub-Saharan Africa. Respondents reported on fourteen named studies that included AMH outcomes in HIV research. Barriers to AMH integration in HIV research and care programs were explored with suggested implementation science strategies to achieve the goal of integrated and sustained mental health services within adolescent HIV programs.

Early neonatal mortality is modulated by gestational age, birthweight and fetal heart rate abnormalities in the low resource setting in Tanzania - a five year review 2015-2019.

BACKGROUND: Early Neonatal mortality (ENM) (< 7 days) remains a significant problem in low resource settings. Birth asphyxia (BA), prematurity and presumed infection contribute significantly to ENM. The study objectives were to determine: first, the overall ENM rate as well as yearly ENM rate (ENMR) from 2015 to 2019; second, the influence of decreasing GA (< 37 weeks) and BW (< 2500 g) on ENM; third, the contribution of intrapartum and delivery room factors and in particular fetal heart rate abnormalities (FHRT) to ENM; and fourth, the Fresh Still Birth Rates (FSB) rates over the same time period. METHODS: Retrospective cohort study undertaken in a zonal referral teaching hospital located in Northern Tanzania. Labor and delivery room data were obtained from 2015 to 2019 and included BW, GA, fetal heart rate (FHRT) abnormalities, bag mask ventilation (BMV) during resuscitation, initial temperature, and antenatal steroids use. Abnormal outcome was ENM < 7 days. Analysis included t tests, odds ratios (OR), and multivariate regression analysis. RESULTS: The overall early neonatal mortality rate (ENMR) was 18/1000 livebirths over the 5 years and did not change significantly comparing 2015 to 2019. Comparing year 2018 to 2019, the overall ENMR decreased significantly (OR 0.62; 95% confidence interval (CI) 0.45-0.85) as well as infants ≥37 weeks (OR 0.45) (CI 0.23-0.87) and infants < 37 weeks (OR 0.57) (CI 0.39-0.84). ENMR was significantly higher for newborns < 37 versus ≥37 weeks, OR 10.5 (p < 0.0001) and BW < 2500 versus ≥2500 g OR 9.9. For infants < 1000 g / < 28 weeks, the ENMR was ~ 588/1000 livebirths. Variables associated with ENM included BW - odds of death decreased by 0.55 for every 500 g increase in weight, by 0.89 for every week increase in GA, ENMR increased 6.8-fold with BMV, 2.6-fold with abnormal FHRT, 2.2-fold with no antenatal steroids (ANS), 2.6-fold with moderate hypothermia (all < 0.0001). The overall FSB rate was 14.7/1000 births and decreased significantly in 2019 when compared to 2015 i.e., 11.3 versus 17.3/1000 live births respectively (p = 0.02). CONCLUSION: ENM rates were predominantly modulated by decreasing BW and GA, with smaller/ less mature newborns 10-fold more likely to die. ENM in term newborns was strongly associated with FHRT abnormalities and when coupled with respiratory depression and BMV suggests BA. In smaller newborns, lack of ACS exposure and moderate hypothermia were additional associated factors. A composite perinatal approach is essential to achieve a sustained reduction in ENMR.

A group-based mental health intervention for Tanzanian youth living with HIV: Secondary analysis of a pilot trial.

BACKGROUND: Youth living with human immunodeficiency virus (YLWH) are vulnerable to incomplete adherence to antiretroviral therapy in the context of stigma, decreased hope for future, and mental health challenges. Despite these challenges, few mental health interventions have been developed to support YLWH. Previous randomized results from the Sauti ya Vijana (SYV; "The Voice of Youth") mental health intervention were indicative of the intervention's benefits in promoting virologic suppression. METHODS: SYV is a group-based mental health and life skills intervention (pilot, individually randomized group treatment trial) developed alongside YLWH. SYV was comprised of 10, 90-minute sessions based on evidence-based treatment models designed to improve coping, social support, and hope for future as a pathway to improved adherence and virologic suppression. At baseline, YLWH 12 to 24 years of age were randomized to SYV or standard of care. Participants included in this secondary analysis were enrolled in SYV's crossover waves due to either being randomized to standard of care or inability to attend an earlier group, and therefore delayed intervention exposure. Measured outcomes included self-reported mental health measures, self-reported human immunodeficiency virus measures (stigma and adherence), and human immunodeficiency virus ribonucleic acid. Data was collected at baseline, preintervention, and postintervention timepoints. Participants were included if they attended a crossover wave and had data at all 3 timepoints. RESULTS: Twenty-one crossover participants met inclusion criteria. Mean scores of self-reported mental health questionnaires were in an asymptomatic range both pre- and postintervention. Viral suppression was N = 15 (71%) preintervention compared to N = 17 (81%) postintervention. The participants who became virologically suppressed had no change in antiretroviral therapy. CONCLUSIONS: Despite the small sample size, findings from this study demonstrate that mental wellbeing may be an important pathway to improved HIV outcomes for YLWH. The same trend toward virologic suppression pre- to postintervention was demonstrated in the randomized pilot trial and suggests that SYV holds promise to improve HIV outcomes. Data from this analysis support the fully powered trial that is now underway.

Sauti ya Vijana (SYV; The Voice of Youth): Longitudinal Outcomes of an Individually Randomized Group Treatment Pilot Trial for Young People Living with HIV in Tanzania.

Sauti ya Vijana is a mental health and life skills intervention delivered by young adult group leaders for the improvement of HIV outcomes in young people living with HIV in Tanzania. This pilot randomized controlled trial estimated exploratory intervention effectiveness compared to standard of care. YPLWH (N = 105) were randomized to receive intervention or SOC. The mean age of participants was 18.1 years and 53% were female. Mean scores on mental health measures (Patient Health Questionnaire [PHQ-9], Strengths and Difficulties Questionnaire [SDQ], UCLA Trauma) were asymptomatic to mild in both study arms through 30-month follow-up with a non-significant fluctuation of 1-2 points. The mean self-reported adherence was higher in the intervention arm across all time points (but the confidence interval contained the null at all time points except 6 months). Risk ratio of virologic suppression (HIV RNA < 400 copies/mL) in the intervention arm compared to SOC was 1.15 [95% CI = 0.95, 1.39]) at 6-months, 1.17 [95% CI: 0.92, 1.48] at 12-months, and 0.99 [95% CI 0.76, 1.31] at 18-months. Though these findings were not powered for statistical significance, the trends in HIV outcomes suggest that SYV holds promise for improving antiretroviral therapy (ART) adherence and virologic suppression in YPLWH.

Using discrete choice experiments to design interventions for heterogeneous preferences: protocol for a pragmatic randomised controlled trial of a preference-informed, heterogeneity-focused, HIV testing offer for high-risk populations.

INTRODUCTION: Approximately one million undiagnosed persons living with HIV in Southern and Eastern Africa need to test for HIV. Novel approaches are necessary to identify HIV testing options that match the heterogeneous testing preferences of high-risk populations. This pragmatic randomised controlled trial (PRCT) will evaluate the efficacy of a preference-informed, heterogeneity-focused HIV counselling and testing (HCT) offer, for improving rates of HIV testing in two high-risk populations. METHODS AND ANALYSIS: The study will be conducted in Moshi, Tanzania. The PRCT will randomise 600 female barworkers and 600 male Kilimanjaro mountain porters across three study arms. All participants will receive an HIV testing offer comprised of four preference-informed testing options, including one 'common' option-comprising features that are commonly available in the area and, on average, most preferred among study participants-and three options that are specific to the study arm. Options will be identified using mixed logit and latent class analyses of data from a discrete choice experiment (DCE). Participants in Arm 1 will be offered the common option and three 'targeted' options that are predicted to be more preferred than the common option and combine features widely available in the study area. Participants in Arm 2 will be offered the common option and three 'enhanced' options, which also include HCT features that are not yet widely available in the study area. Participants in Arm 3, an active control arm, will be offered the common option and three predicted 'less preferred' options. The primary outcome will be uptake of HIV testing. ETHICS AND DISSEMINATION: Ethical approval was obtained from the Duke University Health System IRB, the University of South Carolina IRB, the Ethics Review Committee at Kilimanjaro Christian Medical University College, Tanzania's National Institute for Medical Research, and the Tanzania Food & Drugs Authority (now Tanzania Medicines & Medical Devices Authority). Findings will be published in peer-reviewed journals. The use of rigorous DCE methods for the preference-based design and tailoring of interventions could lead to novel policy options and implementation science approaches. TRIAL REGISTRATION NUMBER: NCT02714140.

Challenges and facilitators of transition from adolescent to adult HIV care among young adults living with HIV in Moshi, Tanzania.

INTRODUCTION: Scale up of anti-retroviral therapy has enabled millions of children infected with HIV to survive into adulthood, requiring transition of care to the adult HIV clinic. This transition period is often met with anxiety and reluctance. Youth who fail to transition may create strain on capacity in the pediatric and adolescent clinics or result in individuals dropping out of care entirely. This study examined challenges and facilitators to the transition among young adults living with HIV in Moshi, Tanzania. METHODS: From April to June 2017, in-depth interviews were conducted with young adults aged 18 to 27 years living with HIV in order to capture the spectrum of experiences from pre-transitioning youth to those who successfully transitioned to adult care. Young adults were purposively recruited based on prior study enrollees and recommendations from healthcare staff. Recruitment occurred in the adolescent, adult HIV and the prevention of mother to child transition clinics at Kilimanjaro Christian Medical Centre. Two separate in-depth interviews were conducted with eligible participants. Medical records were reviewed retrospectively to collect information on HIV-related outcomes. RESULTS: In-depth interviews were held with 19 young adults. Participants mean age was 23.8 years (interquartile range 22.2 to 26.3 years); 53% were female. Most (78.9%) participants had been receiving anti-retroviral therapy for nearly a decade and 72.2% were virologically suppressed (HIV RNA <200 copies/mL). Barriers to transition included fear of losing peer networks formed in the adolescent clinic, the abrupt manner in which young adults were asked to transition, stigma, financial constraints and a lower quality of care in the adult clinic. Facilitators of transition included family and social support, positive perspectives on living with HIV and maintenance of good health. Recommendations for transition included transition preparation, transition as a group and adoption of desirable aspects of the adolescent clinic (peer networks and education) in the adult clinic. CONCLUSIONS: Transition is a complex process influenced by many factors. As the number of young adults living with HIV continues to grow, it is vital to develop a transition protocol that addresses these challenges and is feasible to implement in low-resource settings.

HIV-1 Drug Resistance and Virologic Outcomes Among Tanzanian Youth Living With HIV.

Adolescents living with HIV tend to have poor adherence that often breeds HIV resistance mutations and virologic failure (VF). This study evaluated risk behavior, virologic outcomes and HIV resistance mutations in Tanzanian youth living with HIV. Participants were primarily perinatally infected and of mean age 16.7 years; among them 41.5% had VF. Those receiving first-line therapy demonstrated over 90% resistance to their current therapy.

Feasibility of home-based HIV counselling and testing and linking to HIV services among women delivering at home in Geita, Tanzania: a household longitudinal survey.

BACKGROUND: Substantial number of women who deliver at home (WDH) are not captured in prevention of mother-to-child transmission (PMTCT) services. This delays HIV infection detection that negatively impacts endeavours to fight the HIV pandemic and the health of mothers and children. The study objective was to determine the feasibility of home-based HIV testing and linking to care for HIV services among WDH in Geita District Council, Tanzania. METHODS: A longitudinal household survey was conducted. The study involved all mentally-able women who delivered within 2 years (WDTY) preceding the survey and their children under the age of two. The study was conducted in Geita District Council in Geita Region, Tanzania from June to July 2017. Geita is among the region with high HIV prevalence and proportion of women delivering at home. RESULTS: Of the 993 women who participated in the study, 981 (98.8%) accepted household-based HIV counselling and testing (HBHCT) from the research team. HIV prevalence was 5.3% (52 women). HBHCT identified 26 (2.7%) new HIV infections; 23 (23.4%) were those tested negative at ANC and the remaining three (0.3%) were those who had no HIV test during the ANC visit. Among the 51 HIV+ women, 21 (40.4%) were enrolled in PMTCT services. Of the 32 HIV+ participants who delivered at home, eight (25.8%) were enrolled in the PMTCT compared to 100% (13/13) of the women who delivered at a health facility. CONCLUSION: HBHCT uptake was high. HBHCT detected new HIV infection among WDH as well as seroconversion among women with previously negative HIV tests. The study findings emphasize the importance of extending re-testing to women who breastfeed. HBHCT is feasible and can be used to improve PMTCT services among WDH.

A care bundle including antenatal corticosteroids reduces preterm infant mortality in Tanzania a low resource country.

BACKGROUND: Preterm neonatal mortality (NM) has remained high and unchanged for many years in Tanzania, a resource-limited country. Major causes of mortality include birth asphyxia, respiratory insufficiency and infections. Antenatal corticosteroids (ACS) have been shown to significantly reduce mortality in developed countries. There is inconsistent use of ACS in Tanzania. OBJECTIVE: To determine whether implementation of a care bundle that includes ACS, maternal antibiotics (MA), neonatal antibiotics (NA) and avoidance of moderate hypothermia (temperature < 36°C) targeting infants of estimated gestational age (EGA) 28 to 34 6/7 weeks would reduce NM (< 7 days) by 35%. METHODS: A Pre (September 2014 to May 2015) and Post (June 2015 to June 2017) Implementation strategy was used and introduced at three University-affiliated and one District Hospital. Dexamethasone, as the ACS, was added to the national formulary in May 2015, facilitating its free use down to the district level. FINDINGS: NM was reduced 26% from 166 to 122/1000 livebirths (P = 0.005) and fresh stillbirths (FSB) 33% from 162/1000 to 111/1000 (p = 0.0002) Pre versus Post Implementation. Medications including combinations increased significantly at all sites (p<0.0001). By logistic regression, combinations of ACS, maternal and NA (odds ratio (OR) 0.33), ACS and NA (OR 0.30) versus no treatment were significantly associated with reduced NM. NM significantly decreased per 250g birthweight increase (OR 0.59), and per one week increase in EGA (OR 0.87). Moderate hypothermia declined pre versus post implementation (p<0.0001) and was two-fold more common in infants who died versus survivors. INTERPRETATION: A low-cost care bundle, ~$6 per patient, was associated with a significant reduction in NM and FSB rates. The former presumably by reducing respiratory morbidity with ACS and minimizing infections with antibiotics. If these findings can be replicated in other resource-limited settings, the potential for further reduction of <5 year mortality rates becomes enormous.

Antiretroviral drug concentrations in hair are associated with virologic outcomes among young people living with HIV in Tanzania.

OBJECTIVE: We assessed the relationship of self-reported adherence versus antiretroviral therapy (ART) concentrations in hair with virologic outcomes among young people living with HIV. DESIGN: This was a cross-sectional study that enrolled young people living with HIV age 11-24 years, who attended a youth HIV clinic in Moshi, Tanzania. METHODS: ART adherence was assessed by self-report, drug concentration in hair samples, and plasma HIV-1 RNA measurements. Those with virologic failure, defined as plasma HIV-1 RNA more than 400 copies/ml, had genotypic resistance assessed. Receiver operating characteristic curves were used to evaluate ART-concentration threshold cutoffs for virologic suppression, after excluding those with known high-level resistance mutations. RESULTS: Among 280 young people enrolled, 227 were included in the final analysis. Seventy-two (32%) self-reported inadequate adherence and 91 (40%) had virologic failure. Hair ART-concentration (P < 0.001), but not self-reported adherence (P = 0.53), was associated with virologic outcome. Sixty-seven (74%) of those with virologic failure had resistance testing performed, of whom 60% had high-level resistance. Receiver operating characteristic curves demonstrated moderate or high classification performance for association with virologic suppression with specific hair ART-concentration cutoffs for lopinavir (1.8 ng/mg), efavirenz (1.04 ng/mg), and nevirapine (33.2 ng/mg). CONCLUSION: Hair ART-concentrations were significantly associated with virologic outcomes among young people living with HIV. ART-concentration thresholds associated with virologic suppression are proposed. Hair analysis may provide a noninvasive, cost-effective adherence assessment tool in settings with limited second and third-line treatment options.

"We never speak about death." Healthcare professionals' views on palliative care for inpatients in Tanzania: A qualitative study.

ABSTRACTObjective:Little is known about the current views and practices of healthcare professionals (HCPs) in Sub-Saharan Africa (SSA) regarding delivery of hospital palliative care. The present qualitative study explored the views of nursing staff and medical professionals on providing palliative and end-of-life care (EoLC) to hospital inpatients in Tanzania. METHOD: Focus group discussions were conducted with a purposive sample of HCPs working on the medical and pediatric wards of the Kilimanjaro Christian Medical Centre, a tertiary referral hospital in northern Tanzania. Transcriptions were coded using a thematic approach. RESULTS: In total, 32 healthcare workers were interviewed via 7 focus group discussions and 1 semistructured interview. Four major themes were identified. First, HCPs held strong views on what factors were important to enable individuals with a life-limiting diagnosis to live and die well. Arriving at a state of "acceptance" was the ultimate goal; however, they acknowledged that they often fell short of achieving this for inpatients. Thus, the second theme involved identifying the "barriers" to delivering palliative care in hospital. Another important factor identified was difficulty with complex communications, particularly "breaking bad news," the third theme. Fourth, participants were divided about their personal preferences for "place of EoLC," but all emphasized the benefits of the hospital setting so as to enable better symptom control. SIGNIFICANCE OF RESULTS: Despite the fact that all the HCPs interviewed were regularly involved in providing palliative and EoLC, they had received limited formal training in its provision, although they identified such training as a universal requirement. This training gap is likely to be present across much of SSA. Palliative care training, particularly in terms of communication skills, should be comprehensively integrated within undergraduate and postgraduate education. Research is needed to develop culturally appropriate curricula to equip HCPs to manage the complex communication challenges that occur in caring for a diverse inpatient group with palliative care needs.

Adherence to Exclusive Breastfeeding and Associated Factors in Mothers of HIV-Exposed Infants Receiving Care at Kilimanjaro Christian Medical Centre, Tanzania.

BACKGROUND: More than 90% of HIV in children occurs through mother-to-child transmission. Breastfeeding is one of several factors associated with transmission of HIV, and, because of this, infant feeding practice is one of the cornerstones in the effort to reduce HIV transmission in children. World Health Organization guidelines from 2012 recommend exclusive breastfeeding to all infants for first 6 months of life. However, many factors contribute to the adherence of mothers to exclusive breastfeeding (EBF) recommendations. The aim of this study was to determine what factors likely influence adherence to exclusive breastfeeding in mothers of HIV-exposed infants receiving care at Kilimanjaro Christian Medical Centre. METHODS: A cross-sectional hospital-based study was conducted from September 2012 to March 2013 at Kilimanjaro Christian Medical Centre in Moshi. All mothers of HIV-exposed infants aged 6 to 12 months receiving care at child-centred family care clinic who consented to participate in the study were included. Data were collected using a pretested structured questionnaire and analysed using SPSS version 16.0 statistical package. RESULTS: Of the 128 mothers of HIV-exposed infants enrolled in the study, 71 (55.5%) adhered to EBF for 6 months. No statistical significance was seen between adherence status and maternal characteristics in bivariate analysis (P>.05). The mean age and standard deviation of initiating other foods by mothers who did not adhere was 3.32 months ± 1.24. Of 57 (44.5%) non-adherent mothers, one-tenth of them practised mixed breastfeeding and the rest stopped breastfeeding completely. Fear of postnatal transmission of HIV through breastfeeding and inadequate breast milk production were the most common reasons for non-adherence to EBF. CONCLUSION: Adherence to the recommended duration for EBF by mothers to their HIV-exposed infants is still a challenge. Ongoing intensive feeding counselling and education on EBF may increase the number of mother who can adhere to EBF in our society.

Caregiver role in HIV medication adherence among HIV-infected orphans in Tanzania.

Youth living with HIV in sub-Saharan Africa face numerous challenges in adhering to HIV treatment. The AIDS epidemic has left many of these youth orphaned due to AIDS-related death of one or both parents. It is imperative to understand the family context of youth living with HIV in order to develop responsive interventions to improve adherence to antiretroviral therapy. We conducted qualitative in-depth interviews with 17 HIV-infected AIDS orphans, ages 13-24 years, screened positive for mental health difficulties according to the Patient Health Questionaire-9 (PHQ-9) or UCLA PTSD Reaction Index (PTSD-RI), and receiving outpatient HIV care at an adolescent medical clinic in Moshi, Tanzania. Treatment-related support varied by orphan status. Paternal orphans cared for by their biological mothers and maternal orphans cared for by grandmothers described adherence support such as assistance taking medication and attending clinic. Double orphans did not report adherence support. Several maternal and double orphans faced direct interference from caregivers and household members when they attempted to take their medications. Caregivers play a significant role in treatment adherence and must be considered in interventions to increase medication adherence in HIV-infected orphans. Findings from this study informed caregiver participation in Sauti ya Vijana (The Voice of Youth), a mental health intervention for youth living with HIV in Tanzania.

HIV Resistance and Prevention of Mother-to-Child Transmission Regimen in HIV-Infected Infants in Northern Tanzania.

Prevention of mother-to-child transmission (PMTCT) guidelines recommend that all HIV-infected pregnant women receive antiretroviral therapy (Option B) and HIV-infected infants should initiate therapy with a protease inhibitor-based regimen; however, implementation of these guidelines has lagged in many resource-limited settings. Tanzania only recently implemented these guidelines with little country-specific data to inform whether HIV non-nucleoside reverse transcriptase inhibitor (NNRTI) resistance was present among infected infants under the Option A guidelines. This study aimed to identify primary resistance mutations in HIV-infected infants and to identify risk of nevirapine (NVP) resistance based on maternal and infant NVP exposure. Infant dried blood spots (DBSs) were sent to the zonal reference laboratory at Kilimanjaro Christian Medical Centre Clinical Laboratory and underwent DNA polymerase chain reaction testing for HIV as standard of care. Using the clinical laboratory registry, HIV-positive DBS cards, stored at ambient temperature, were identified and sent for further viral load testing, nucleotide sequencing, and analysis. Clinical information was obtained from the PMTCT clinical sites and the National PMTCT registry for information regarding maternal and infant demographics and PMTCT treatment regimen. Results demonstrated that infants exposed to NVP were more likely to have high level resistance mutations (HLRMs) to NVP than those infants not exposed to NVP (p = .002). The most common HLRMs to NVP were K103 N, Y181C, and Y188 L. HIV subtype A was most common, followed by subtype C. Approximately one-third of HIV-infected infants had documented referral to HIV care. This study demonstrated the ongoing need to scale up and strengthen points along the PMTCT continuum and supported the recommendation for all HIV-infected infants to initiate a lopinavir/ritonavir-based antiretroviral therapy regimen.

A Qualitative Exploration of the Mental Health and Psychosocial Contexts of HIV-Positive Adolescents in Tanzania.

Although 85% of HIV-positive adolescents reside in sub-Saharan Africa, little is known about the psychosocial and mental health factors affecting their daily well-being. Identifying these contextual variables is key to development of culturally appropriate and effective interventions for this understudied and high-risk population. The purpose of this study was to identify salient psychosocial and mental health challenges confronted by HIV-positive youth in a resource-poor Tanzanian setting. A total of 24 qualitative interviews were conducted with a convenience sample of adolescents aged 12-24 receiving outpatient HIV care at a medical center in Moshi, Tanzania. All interviews were audio-recorded, transcribed, and coded using thematic analysis. Psychosocial challenges identified included loss of one or more parents, chronic domestic abuse, financial stressors restricting access to medical care and education, and high levels of internalized and community stigma among peers and other social contacts. Over half of youth (56%) reported difficulties coming to terms with their HIV diagnosis and espoused related feelings of self-blame. These findings highlight the urgent need to develop culturally proficient programs aimed at helping adolescents cope with these manifold challenges. Results from this study guided the development of Sauti ya Vijana (The Voice of Youth), a 10-session group mental health intervention designed to address the psychosocial and mental health needs of HIV-positive Tanzanian youth.