Scopes of practice for advanced practice nursing and advanced practice midwifery in Kenya: A gap analysis.

BACKGROUND: There is increasing global evidence on the impact of advanced nursing and midwifery practitioners, and Kenya's healthcare system has an excellent opportunity to develop scopes of practice and other regulatory frameworks for the integration of these roles. OBJECTIVE: The primary purpose of this gap analysis was to explore the existing evidence on opportunities and threats toward the integration of the advanced practice nursing (APN) and advanced practice midwifery (APM) roles in Kenya's healthcare system. METHODS: The study team conducted a structured electronic database search of PubMed, CINAHL, Scopus, EBSCOhost Academic Search Complete, and PsycINFO to retrieve articles and credible websites for reports highlighting the opportunities and threats toward the integration of the APN and APM roles in Kenya's healthcare systems. The retrieved articles were screened for relevance and synthesized for reporting using the traditional literature review approach. RESULTS: The Kenya Health Policy Framework 2014-2030, growing population needs, and implementation of universal health coverage provide an opportunity to harness and leverage advanced practice roles in nursing and midwifery. There is also momentum to develop advanced practice because of strategic alliances and global evidence showing the contributions and quality of services offered by advanced practice nurses and advanced practice midwives. However, lack of financial support, structural challenges, and lack of national policies, regulations, and legislation continue to obstruct progress. CONCLUSION AND IMPLICATIONS FOR NURSING POLICY: Developing scopes of practice for APN and APM in Kenya will benefit the professions, the country's healthcare delivery system, and the population. Achieving universal health coverage depends on a health workforce trained and practicing at optimal levels in tandem with education and training to deliver quality care.

Corrigendum: Psychometric evaluation of PHQ-9 and GAD-7 among community health volunteers and nurses/midwives in Kenya following a nation-wide telephonic survey.

[This corrects the article DOI: 10.3389/fpsyt.2023.1123839.].

Psychometric evaluation of PHQ-9 and GAD-7 among community health volunteers and nurses/midwives in Kenya following a nation-wide telephonic survey.

Background: Nurses/midwives and Community Health Volunteers (CHVs) are exposed to chronic stressors putting them at risk of developing mental health problems. This has been exacerbated by the COVID-19 pandemic. There is limited empirical evidence of the burden of mental health problems among health care workers partly due to the lack of adequately standardized and validated measures for use among health care workers in Sub-Saharan Africa. This study aimed to perform the psychometric evaluation of the PHQ-9 and GAD-7 administered to nurses/midwives and CHVs across 47 counties in Kenya. Methods: Between June and November 2021, a national survey on mental well-being and resilience among nurses/midwives and CHVs was conducted via telephone interviews. The survey had a total sample size of 1907 nurses/midwives and 2027 CHVs. Cronbach's alpha and MacDonalds' omega were used to evaluate the scale's internal consistency. Confirmatory Factor Analysis (CFA) was used to test the one-factor structure of the scales. Multi-group CFA was applied to evaluate the generalizability of the scales across the Swahili and English versions, and among male and female health workers. The Spearman correlation was used to assess the tools' divergent and convergent validity. Results: The internal consistency of PHQ-9 and GAD-7 was good, with alpha and omega values above 0.7 across study samples. CFA results indicated a one-factor structure of the PHQ-9 and GAD-7 for both nurses/midwives and CHVs. Multi-group CFA showed that both scales were unidimensional across both language and sex. The PHQ-9 and GAD-7 were significantly negatively correlated with resilience and work engagement, supporting divergent validity. The PHQ-9 and GAD-7 were also significantly positively correlated with resilience and work engagement, supporting divergent validity. Conclusion: The PHQ-9 and GAD-7 are unidimensional, reliable, and valid tools for screening depression and anxiety among nurses/midwives and CHVs. The tools can be administered in a similar population or study setting using either Swahili or English.

Barriers and facilitators to anti-retroviral therapy adherence among adolescents aged 10 to 19 years living with HIV in sub-Saharan Africa: A mixed-methods systematic review and meta-analysis.

BACKGROUND: Human Immunodeficiency Virus (HIV) significantly affects adolescents globally, with the sub-Saharan Africa (SSA) reporting a high burden of the disease. HIV testing, treatment, and retention to care are low among adolescents. We conducted a mixed-method systematic review to assess anti-retroviral therapy (ART) adherence; barriers and facilitators to ART adherence and ART outcomes among adolescents living with HIV and on ART in sub-Saharan Africa. METHODS: We conducted searches in four scientific databases for studies conducted between 2010 and March 2022 to identify relevant primary studies. Studies were screened against inclusion criteria and assessed for quality, and data was extracted. Meta-analysis of rates and odd ratios was used to plot the quantitative studies and meta-synthesis summarized the evidence from qualitative studies. RESULTS: A total of 10 431 studies were identified and screened against the inclusion/ exclusion criteria. Sixty-six studies met the inclusion criteria (41 quantitative, 16 qualitative, and 9 mixed-methods study designs). Fifty-three thousand two hundred and seventeen (53 217) adolescents (52 319 in quantitative studies and 899 in qualitative studies) were included in the review. Thirteen support focused interventions for improved ART adherence were identified from quantitative studies. The plotted results from the meta-analysis found an ART adherence rate of 65% (95%CI 56-74), viral load suppression was 55% (95%CI 46-64), un-suppressed viral load rate of 41% (95%CI 32-50), and loss to follow up of 17% (95%CI 10-24) among adolescents. Meta-synthesis found six themes of barriers to ART (social, patient-based, economic, health system-based, therapy-based, and cultural barriers) in both the qualitative and quantitative studies, and three themes of facilitators to ART were also identified (social support, counselling, and ART education and secrecy or confidentiality) from qualitative studies. CONCLUSION: ART adherence remains low among adolescents in SSA despite multiple interventions implemented to improve ART adherence. The low adherence rate may hinder the attainment of the UNAIDS 2030 targets. Additionally, various barriers to ART adherence due to lack of support have been reported among this age group. However, interventions aimed at improving social support, educating, and counselling adolescents may improve and sustain ART adherence. TRIAL REGISTRATION: Systematic review registration: PROSPERO CRD42021284891.

Factors shaping good and poor nurse-client relationships in maternal and child care: a qualitative study in rural Tanzania.

BACKGROUND: Evidence indicates that poor nurse-client relationships within maternal and child health (MCH) continues to impact trust in formal healthcare systems, service uptake, continuity with care and MCH outcomes. This necessitates contextualized innovative solutions that places both nurses and clients at the forefront as agents of change in optimizing intervention designs and implementation. This study explored nurses and clients' perspectives on the factors shaping nurse-client relationships in MCH care to generate evidence to guide subsequent steps of human centered design (HCD) that involve designing effective strategies for improving therapeutic relationships in Shinyanga, Tanzania. METHODS: Qualitative descriptive design was employed. About 9 Focus Group Discussions (FGDs) and 12 Key Informant Interviews (KIIs) with purposefully selected nurses and midwives, women attending MCH services and administrators were conducted using semi-structured interview guides in Swahili language. Data were transcribed and translated simultaneously, managed using Nvivo Software and analyzed thematically. RESULTS: Factors shaping nurse-client relationships were heuristically categorized into nurse, client and health system factors. Nurse contributors of poor relationship ranged from poor reception and hospitality, not expressing care and concern, poor communication and negative attitudes, poor quality of services, job dissatisfaction and unstable mental health. Client contributors of poor relationship include being 'much know', late attendance, non-adherence to procedures and instructions, negative attitudes, poor communication, inadequate education and awareness, poverty, dissatisfaction with care, faith in traditional healers and unstable mental health. Health system contributors were inadequate resources, poor management practices, inadequate policy implementation and absence of an independent department or agency for gathering and management of complaints. Suggestions for improving nurse-client relationship included awards and recognition of good nurses, improving complaints mechanisms, continued professional development, peer to peer learning and mentorship, education and sensitization to clients, improving service quality and working conditions, improving renumeration and incentives, strengthening nursing school's student screening and nursing curriculum and improving mental health for both nurses and clients. CONCLUSIONS: The factors shaping poor nurse- client relationships appear to extend beyond nurses to both clients and healthcare facilities and system. Implementation of effective interventions for addressing identified factors considering feasibility and acceptance to both nurses and clients using novel strategies such as HCD could pave the way for employing good nurse-client relationships as a tool for improving performance indicators and health outcomes within MCH care.

Barriers to anti-retroviral therapy adherence among adolescents aged 10 to 19 years living with HIV in sub-Saharan Africa: A mixed-methods systematic review protocol.

BACKGROUND: Antiretroviral therapy (ART) adherence is fundamental in achieving viral load suppression and consequently attaining positive health outcomes among people living with HIV. However, ART adherence is sub-optimum among adolescents living with HIV (ALHIV) thus the high AIDS-related mortality even after World Health Organization (WHO) revised HIV treatment eligibility guidelines in 2010, 2013 and 2016. Consolidated trends of barriers to ART adherence among ALHIV aged 10 to 19 years in sub-Saharan countries post each eligibility guidelines revision to date are unknown. METHODS AND ANALYSIS: We will conduct comprehensive search of peer-reviewed and grey literature databases publishing observational studies reporting data adherence and barriers to ART among ALHIV on ART. We will further search the reference lists of included studies and other relevant reviews. We will also do a citation search for included studies in the review. We will search in the following databases PubMed, Cochrane Review, Scopus on Excerpta Medica Database (Embase) and Cumulated Index to Nursing and Allied Health Literature (CINAHL). Furthermore WHO, Joint United Nations Programme on HIV/AIDS (UNAIDS) websites, conference proceedings and country reports will be searched to identify relevant literature. Data will be extracted from eligible studies and synthesis will be through categorizing studies by year of study, barriers, and outcomes. Meta-analysis and meta-synthesis will be conducted for quantitative and qualitative data, respectively. Where meta-synthesis is impossible, narrative synthesis will be conducted. We will only include studies conducted between 2010 and 2022 within sub-Saharan Africa countries. DISCUSSION: Adherence to ART at a high level is required to achieve adequate viral suppression and improve quality of life in ALHIV. The knowledge of barriers to ART among ALHV may aid in the design of interventions aimed at improving ART adherence. TRAIL REGISTRATION: Systematic review protocol registration: PROSPERO CRD42021284891.

Factors associated with adherence to HIV testing guidelines among HIV-negative female sex workers in Kampala, Uganda.

Background: Frequent human immunodeficiency virus (HIV) testing is recommended among female sex workers. This study examined the extent to which HIV-negative female sex workers (FSWs) in Kampala adhere to the HIV testing guidelines, and identified associated factors. Methods: This cross-sectional study used a simple random sampling method to select 12 sex work hotspots. Two hundred participants were allocated proportionally in each hotspot. Frequencies were used to describe categorical characteristics of FSWs, and a multivariable logistic regression model was used to determine the factors associated with adherence to the HIV testing guidelines. Results: Eighty-eight percent of the 200 study participants reported their HIV testing status; of these, 56% had tested three or more times in the 12 months preceding the survey. Attaining a secondary education was associated with adherence to the HIV testing guidelines [odds ratio (OR) 1.86, 95% confidence interval (CI) 1.01-3.44; P=0.047]. Sexually transmitted infection testing in the preceding 3 months (OR 2.13, 95% CI 0.95-4.74; P=0.065) and accessing HIV testing at a drop-in centre (OR 5.90, 95% CI 0.71-49.1; P=0.101) were associated with higher odds of adherence to the HIV testing guidelines. Conclusion: Adherence to the HIV testing guidelines was suboptimal, indicating the need to scale up interventions to improve access to HIV testing, including rigorous behaviour change communication.

Current State of Critical Care Nursing Worldwide: Current Training, Roles, Barriers, and Facilitators.

This review provides insights on the current state of roles and responsibilities, on-the-job training, barriers, and facilitators of critical care nursing (CCN) practice. Some of the established roles and training of CCN were providing care for acutely ill patients, delivering expert and specialist care, working as a part of a multidisciplinary team, monitoring, and initiating timely treatment, and providing psychosocial support and advanced system treatment, especially in high-income countries. In low-resource settings, critical care nurses work as health care assistants, technical or ancillary staff, and clinical educators; manage medications; care for mechanically ventilated patients; and provide care to deteriorating patients.

A retrospective cross sectional study assessing factors associated with retention and non-viral suppression among HIV positive FSWs receiving antiretroviral therapy from primary health care facilities in Kampala, Uganda.

BACKGROUND: Patient retention in care and sustained viral load suppression are a cornerstone to improved health and quality of life, among people living with HIV. However, challenges of retention on ART remain among female sex workers (FSWs). We report lost to follow up (LTFU), viral load suppression, and the associated factors among FSWs that access HIV treatment at primary health care facilities in Kampala. METHODS: We retrospectively abstracted and analysed patient management data of HIV positive FSWs who enrolled in care between January 2018 to December 2020. LTFU was defined as failure of a FSW to return for treatment at least 90 days from the date of their last clinic appointment. We defined viral suppression as having a last viral load of ≤ 1000 copies/ml preceding data abstraction. Data were analysed using Stata 15.1 software. RESULTS: A total of 275 FSWs were included in our study sample. We found low retention of 85.1% (n = 234) at six months, corresponding to LTFU of 14.9 (n = 41) within the same period. Retention decreased with duration of being in care up to 73.5% (n = 202) at 24 months, and this translates to LTFU of 26.5% (n = 73). Viral load testing coverage was 62% (n = 132) and of these, 90.9% (n = 120) were virally suppressed. Factors associated with LTFU in univariable logistic regression; and viral load suppression in multivariable logistic regression models were; having a telephone contact (OR: 0.3, 95% CI: 0.1-0.9 p = 0.031), having enrolled in HIV care aged ≥ 35 years (OR: 0.5, 95% CI: 0.2-1.0 p = 0.048), (OR:0.03, 95%CI: 0.00-0.5, p = 0.016); and having good ART adherence (OR: 0.2, 95% CI: 0.1-0.5 p = 0.001), (OR:24.0, 95% CI: 3.7-153.4 p = 0.001) respectively. Having good ART adherence remained statistically significant (OR: 0.2, 95% CI: 0.08-0.53 p = 0.001) in multivariable logistic regression for LTFU. CONCLUSION: This study found low retention among HIV diagnosed FSWs in care. Viral load suppression was acceptable and comparable to that of the general population, however viral load coverage was low. Strategies that increase retention in care and access to viral load testing such as individual client centred care models are vital to improve retention and viral load coverage among FSWs.

Strengthening Interpersonal Relationships in Maternal and Child Health Care in Rural Tanzania: Protocol for a Human-Centered Design Intervention.

BACKGROUND: Evidence indicates that clients' dissatisfaction with providers' competencies within maternal and child health (MCH) continues to impact trust in formal health care systems, service uptake, continuity with care, and MCH outcomes. A major problem with existing interventions is the failure to address all the complexities of provider-client relationships necessitating targeted, contextualized, innovative solutions that place providers and clients at the forefront as agents of change in optimizing intervention design and implementation. To improve the provider-client relationship, the Aga Khan University is piloting a human-centered design (HCD) intervention where MCH nurses and clients are invited to partner with researchers in the intervention design and evaluation process. OBJECTIVE: The objective of this research is to co-design an intervention package (prototype) for improving nurse-client relationships in the rural Shinyanga region of Tanzania using a series of iterative HCD steps, involving key stakeholders to tailor solutions for complex problems impacting provider-client interactions in MCH care. METHODS: The following 5-step HCD approach will be implemented: (1) community-driven discovery through qualitative descriptive research methods using focus group discussions and key informant interviews; (2) co-design of an intervention package through consultative ideation and cocreation meetings with nurses, clients, and other stakeholders; (3) prototype validation through qualitative insight gathering using focus group discussions; (4) refinement and adaptation meeting; and (5) documentation and sharing of lessons learned before the final prototype is tested and validated in a broader community. RESULTS: A prototype characterized by a package of interventions for improving nurse-client relationships in MCH care in rural contexts is expected to be developed from the co-design process. CONCLUSIONS: An HCD approach provides a novel entry point for strengthening provider-client relationships, where clients are invited to partner with providers in the design of acceptable and feasible interventions. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/37947.

"My condition is my secret": perspectives of HIV positive female sex workers on differentiated service delivery models in Kampala Uganda.

BACKGROUND: Differentiated service delivery (DSD) models for female sex workers (FSWs) continue to be scaled up with the goal of expanding access to HIV services and treatment continuity. However, little is known about FSWs' perspectives on their preferences, facilitators, and barriers to the effective utilization of various DSD models. METHODS: We conducted 24 in-depth interviews among FSWs on antiretroviral therapy for at least one year in two drop-in centres and two public health facilities in Kampala, Uganda in January 2021. RESULTS: The facility-based individual management model was most preferred, due to a wide array of comprehensive health services, privacy, and professional health workers. Community DSD models were physically accessible, but least preferred due to stigmatization and discrimination, lack of privacy and confidentiality, and limited health services offered. CONCLUSION: Targeted strategies to reduce stigma and discrimination and the provision of high-quality services have potential to optimise FSWs' access to HIV services.

A Qualitative Endline Evaluation Study of Male Engagement in Promoting Reproductive, Maternal, Newborn, and Child Health Services in Rural Kenya.

Background: Globally, male involvement in reproductive, maternal, newborn, and child health (RMNCH) is associated with increased benefits for women, their children, and their communities. Between 2016 and 2020, the Aga Khan University implemented the Access to Quality of Care through Extending and Strengthening Health Systems (AQCESS), project funded by the Government of Canada and Aga Khan Foundation Canada (AKFC). A key component of the project was to encourage greater male engagement in RMNCH in rural Kisii and Kilifi, two predominantly patriarchal communities in Kenya, through a wide range of interventions. Toward the end of the project, we conducted a qualitative evaluation to explore how male engagement strategies influenced access to and utilization of RMNCH services. This paper presents the endline evaluative study findings on how male engagement influenced RMNCH in rural Kisii and Kilifi. Methods: The study used complementing qualitative methods in the AQCESS intervention areas. We conducted 10 focus group discussions (FGDs) with 82 community members across four groups including adult women, adult men, adolescent girls, and adolescent boys. We also conducted 11 key informant interviews (KIIs) with facility health managers, and sub-county and county officials who were aware of the AQCESS project. Results: Male engagement activities in Kisii and Kilifi counties were linked to improved knowledge and uptake of family planning (FP), spousal/partner accompaniment to facility care, and defeminization of social and gender roles. Conclusion: This study supports the importance of male involvement in RMNCH in facilitating decisions on women and children's health as well as in improving spousal support for use of FP methods.

Effect of community-based interventions targeting female sex workers along the HIV care cascade in sub-Saharan Africa: a systematic review and meta-analysis.

BACKGROUND: Female sex workers are extremely vulnerable and highly susceptible to being infected with human immunodeficiency virus. As a result, community-based targeted interventions have been recommended as one of the models of care to improve access to HIV services and continued engagement in care. We conducted a systematic review to (1) assess the effect of FSW-targeted community interventions on the improvement of HIV services access along the treatment cascade and (2) describe community-based interventions that positively affect continuation in HIV care across the HIV treatment cascade for FSWs in sub-Saharan Africa. METHODS: We defined the 5 steps that make up the HIV care cascade and categorized them as outcomes, namely, HIV testing and diagnosis, linkage to care, receipt of ART, and achievement of viral suppression. We conducted a systematic search of randomized controlled trials, cohort, and cross-sectional studies done in sub-Saharan African countries and published from 2004 to 2020. The period was selected based on the time span within which ART was scaled up through widespread roll-out of comprehensive HIV programs in sub-Saharan Africa. We reviewed studies with data on the implementation of community interventions for any of the HIV care cascade stage. The data were analyzed using random effects meta-analysis where possible, and for the rest of the studies, data were synthesized using summary statistics. RESULTS: The significant impact of the community interventions was observed on HIV testing, HIV diagnosis, and ART use. However, for HIV testing and ART use, the improvement was not sustained for the entire period of implementation. There were minimal interventions that had impact on HIV diagnosis, with only one community service delivery model showing significance. Generally, the interventions that had reasonable impact are those that implemented targeted and comprehensive package of HIV services provided at one location, and with unique strategies specific to each cascade stage. CONCLUSIONS: The evidence brought forward from this review shows that the effect of community-based interventions varies across the different stages of HIV care cascade. A broad package of interventions including a combination of behavioral, biomedical, and structural, designed with specific strategies, unique to each cascade stage appears to be more effective, although information on long-term treatment outcomes and the extent to which FSWs remain engaged in care is sparse. There is need to conduct a further research to deepen the assessment of the effectiveness of community-based interventions on HIV care cascade for FSWs. This will enhance identification of evidence-based optimal interventions that will guide effective allocation of scarce resources for strategies that would have a significant impact on HIV service delivery. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42020157623.

Male Involvement in Reproductive and Maternal and New Child Health: An Evaluative Qualitative Study on Facilitators and Barriers From Rural Kenya.

Male involvement in reproductive, maternal, newborn and child health (RMNCH) is known to improve maternal and child health outcomes. However, there is sub-optimal adoption of male involvement strategies in several low- and middle-income countries such as Kenya. Aga Khan University implemented Access to Quality of Care through Extending and Strengthening Health Systems (AQCESS), a project funded by the Government of Canada and Aga Khan Foundation Canada (AKFC), between 2016 and 2020 in rural Kisii and Kilifi counties, Kenya. A central element in the interventions was increasing male engagement in RMNCH. Between January and March 2020, we conducted an endline qualitative study to examine the perspectives of different community stakeholders, who were aware of the AQCESS project, on the facilitators and barriers to male involvement in RMNCH. We found that targeted information sessions for men on RMNCH are a major facilitator to effective male engagement, particularly when delivered by male authority figures such as church leaders, male champions and teachers. Sub-optimal male engagement arises from tensions men face in directly contributing to the household economy and participating in RMNCH activities. Social-cultural factors such as the feminization of RMNCH and the associated stigma that non-conforming men experience also discourage male engagement.

Duty versus distributive justice during the COVID-19 pandemic.

The COVID-19 pandemic exposed vulnerabilities in inadequately prioritized healthcare systems in low- and middle-income countries such as Kenya. In this prolonged pandemic, nurses and midwives working at the frontline face multiple ethical problems, including their obligation to care for their patients and the risk for infection with severe acute respiratory syndrome coronavirus 2. Despite the frequency of emergencies in Africa, there is a paucity of literature on ethical issues during epidemics. Furthermore, nursing regulatory bodies in African countries such as Kenya have primarily adopted a Western code of ethics that may not reflect the realities of the healthcare systems and cultural context in which nurses and midwives care for patients. In this article, we discuss the tension between nurses' and midwives' duty of care and resource allocation in the context of the COVID-19 pandemic. There is an urgent need to clarify nurses' and midwives' rights and responsibilities, especially in the current political setting, limited resources, and ambiguous professional codes of ethics that guide their practice.

A systematic review of epidemiological patterns and proposed interventions to address pediatric burns in Nigeria.

BACKGROUND: Unintentional injuries from burns comprise a significant proportion of public health morbidity in Nigeria. In order to understand the type and impact of burns on youth in Low-and-Middle-Income countries, the epidemiology of burns must be adequately assessed. METHODS: This review describes the epidemiological patterns of burn occurrences in the pediatric populations and proposes interventions using the Haddon Matrix to address injuries in specific populations in Nigeria. A literature search was conducted using the Proquest, CINAHL, and PubMed databases at the Johns Hopkins University library (January 1, 1990 to August 14, 2018), on burns or thermal injury among pediatric populations in Nigeria. The review focused on the forms of injury, risk factors and potential interventions. RESULTS: Ten studies were identified and the main risk factors for burns were socioeconomic status, overcrowding, and involving young girls in traditional cooking roles. The main types of injuries include scald injuries (50%) and fire burns (45%) affecting mainly children aged 14 and below with significant regional epidemiological variations. We created a novel intervention to develop countermeasures and reduce the number of pediatric burns based on biological, physical and sociocultural environment.. CONCLUSION: Interventions such as improved supervision of children, improved emergency infrastructure and culturally sensitive first aid education and treatment can help ensure a reduction in morbidity and mortality resulting from burns. Epidemiological studies can provide an accurate depiction of the burden of burn injuries in different regions of Nigeria.

Health Care Workers' Perspectives of the Influences of Disrespectful Maternity Care in Rural Kenya.

While disrespectful treatment of pregnant women attending health care facilities occurs globally, it is more prevalent in low-resource countries. In Kenya, a large body of research studied disrespectful maternity care (DMC) from the perspective of the service users. This paper examines the perspective of health care workers (HCWs) on factors that influence DMC experienced by pregnant women at health care facilities in rural Kisii and Kilifi counties in Kenya. We conducted 24 in-depth interviews with health care workers (HCWs) in these two sites. Data were analyzed deductively and inductively using NVIVO 12. Findings from HCWs reflective narratives identified four areas connected to the delivery of disrespectful care, including poor infrastructure, understaffing, service users' sociocultural beliefs, and health care workers' attitudes toward marginalized women. Investments are needed to address health system influences on DMC, including poor health infrastructure and understaffing. Additionally, it is important to reduce cultural barriers through training on HCWs' interpersonal communication skills. Further, strategies are needed to affect positive behavior changes among HCWs directed at addressing the stigma and discrimination of pregnant women due to socioeconomic standing. To develop evidence-informed strategies to address DMC, a holistic understanding of the factors associated with pregnant women's poor experiences of facility-based maternity care is needed. This may best be achieved through an intersectional approach to address DMC by identifying systemic, cultural, and socioeconomic inequities, as well as the structural and policy features that contribute and determine peoples' behaviors and choices.

Effect of female sex work-targeted community-based interventions along the HIV treatment cascade in sub-Saharan Africa: a systematic review protocol.

INTRODUCTION: Female sex workers (FSWs) are a known high-risk group that are at increased risk of HIV transmission due to exposure to multiple sexual partners and inability to negotiate safe sex attributed to challenging economic circumstances. Previous systematic reviews have examined the effectiveness of HIV interventions prioritising FSWs and have shown that targeted interventions improve access to HIV prevention and treatment services. Interventions that increase FSWs' uptake of services are well documented; however, evidence on specific interventions aimed at improving FSWs' continuity in HIV care along the treatment cascade is lacking. This systematic review aims to document the performance of community-based interventions along the HIV treatment cascade. METHODS AND ANALYSIS: We will use a sensitive search strategy for electronic bibliographic databases, bibliographies of included articles and grey literature sources. In addition, the Joint United Nations Programme on HIV/AIDS and the WHO websites, peer-reviewed conference papers and grey literature sources will be searched for additional reports of sex work programmes. We will include randomised controlled trials, cross-sectional surveys and cohort interventions where community-based HIV services were provided to FSWs and measure the performance of the HIV intervention on one or more cascade stages. We will conduct a systematic review of studies published from 2004 to present within the sub-Saharan Africa region. We will report quantitative study outcomes of HIV testing and diagnosis, linkage to care, initiation on antiretroviral therapy and viral suppression. We will analyse the data using the random-effects meta-analysis method, and funnel plots will be used to assess the publication bias. ETHICS AND DISSEMINATION: This systematic review will not require ethical approval; we will publish data from manuscripts. The results of this study will be disseminated in peer-reviewed journals and conference presentations. PROSPERO REGISTRATION NUMBER: CRD42020157623.

Implications of COVID-19 in high burden countries for HIV/TB: A systematic review of evidence.

BACKGROUND: The triple burden of COVID-19, tuberculosis and human immunodeficiency virus is one of the major global health challenges of the twenty-first century. In high burden HIV/TB countries, the spread of COVID-19 among people living with HIV is a well-founded concern. A thorough understanding of HIV/TB and COVID-19 pandemics is important as the three diseases interact. This may clarify HIV/TB/COVID-19 as a newly related field. However, several gaps remain in the knowledge of the burden of COVID-19 on patients with TB and HIV. This study was conducted to review different studies on SARS-CoV, MERS-CoV or COVID-19 associated with HIV/TB co-infection or only TB, to understand the interactions between HIV, TB and COVID-19 and its implications on the burden of the COVID-19 among HIV/TB co-infected or TB patients, screening algorithm and clinical management. METHODS: We conducted an electronic search of potentially eligible studies published in English in the Cochrane Controlled Register of Trials, PubMed, Medrxiv, Google scholar and Clinical Trials Registry databases. We included case studies, case series and observational studies published between January, 2002 and July, 2020 in which SARS-CoV, MERS-CoV and COVID-19 co-infected to HIV/TB or TB in adults. We screened titles, abstracts and full articles for eligibility. Descriptive and meta-analysis were done and results have been presented in graphs and tables. RESULTS: After removing 95 duplicates, 58 out of 437 articles were assessed for eligibility, of which 14 studies were included for descriptive analysis and seven studies were included in the meta-analysis. Compared to the descriptive analysis, the meta-analysis showed strong evidence that current TB exposure was high-risk COVID-19 group (OR 1.67, 95% CI 1.06-2.65, P = 0.03). The pooled of COVID-19/TB severity rate increased from OR 4.50 (95% CI 1.12-18.10, P = 0.03), the recovery rate was high among COVID-19 compared to COVID-19/TB irrespective of HIV status (OR 2.23, 95% CI 1.83-2.74, P < 0.001) and the mortality was reduced among non-TB group (P < 0.001). CONCLUSION: In summary, TB was a risk factor for COVID-19 both in terms of severity and mortality irrespective of HIV status. Structured diagnostic algorithms and clinical management are suggested to improve COVID-19/HIV/TB or COVID-19/TB co-infections outcomes.