Access to digital media and devices among adolescents in sub-Saharan Africa: A multicountry, school-based survey.

Digital technologies provide unprecedented opportunities for health and nutrition interventions among adolescents. The use of digital media and devices among young adolescents across diverse settings in sub-Saharan Africa is unclear. This cross-sectional study aimed to assess the use of digital media and devices and the socioeconomic determinants of use among young adolescents in Burkina Faso, Ethiopia, South Africa, Sudan and Tanzania. The study included 4981 adolescents aged 10-15 from public schools selected by multistage sampling. Access to various digital media and devices was self-reported by adolescents. Logistic regression models were used to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) for the associations between sociodemographic characteristics and access to digital media and devices. Approximately 40% of the adolescents in Burkina Faso and South Africa, 36% in Sudan, 13% in Ethiopia and 3% in Tanzania owned mobile phones. Compared with boys, girls had a lower ownership of mobile phones (odds ratio [OR] = 0.79; 95% confidence interval [CI]: 0.68, 0.92; p = 0.002), computers (OR = 0.83; 95% CI: 0.70, 0.99; p = 0.04) and social media accounts (OR = 0.68; 95% CI: 0.56, 0.83; p < 0.001). Higher maternal education and greater household wealth were positively associated with access to digital media and devices. While digital media and devices are promising platforms for interventions in some settings due to relatively high levels of access, their utility in delivering health and nutrition interventions to adolescents in these contexts should be further examined.

Adolescent health and well-being in sub-Saharan Africa: Strengthening knowledge base and research capacity through a collaborative multi-country school-based study.

In Sub-Saharan Africa (SSA), adolescents make up around one-quarter of the population who are growing up in a rapidly urbanizing environment, with its associated risks and benefits, including impacts on health, psychosocial development, nutrition, and education. However, research on adolescents' health and well-being in SSA is limited. The ARISE (African Research, Implementation Science and Education) Network's Adolescent Health and Nutrition Study is an exploratory, school-based study of 4988 urban adolescents from five countries: Burkina Faso, Ethiopia, South Africa, Sudan, and Tanzania. A multistage random sampling strategy was used to select the schools and adolescents. Adolescent boys and girls aged 10-15 years were interviewed using a standardized questionnaire by trained enumerators. The questionnaire covered multiple domains including demographic and socioeconomic characteristics, water, sanitation and hygiene practices, antimicrobial resistance, physical activity, dietary behaviours, socioemotional development, educational outcomes, media use, mental health, and menstrual hygiene (only for girls). Additionally, a desk review of health and school meal policies and programs and a qualitative investigation into health and food environments in schools were conducted with students, administrators, and food vendors. In this paper, we describe the study design and questionnaire, present profiles of young adolescents who participated in the study, and share field experiences and lessons learned for future studies. We expect that this study along with other ARISE Network projects will be a first step toward understanding young people's health risks and disease burdens, identifying opportunities for interventions and improving policies, as well as developing potential research capacities on adolescent health and well-being in the SSA region.

An economic incentive package to support the wellbeing of caregivers of adolescents living with HIV during the COVID-19 pandemic in South Africa: a feasibility study protocol for a pilot randomised trial.

BACKGROUND: The mental and financial strain linked to unpaid caregiving has been amplified during the COVID-19 pandemic. In sub-Saharan Africa, carers of adolescents living with HIV (ALHIV) are critical for maintenance of optimum HIV treatment outcomes. However, the ability of caregivers to provide quality care to ALHIV is undermined by their ability to maintain their own wellbeing due to multiple factors (viz. poverty, stigma, lack of access to social support services) which have been exacerbated by the COVID-19 pandemic. Economic incentives, such as cash incentives combined with SMS reminders, have been shown to improve wellbeing. However, there is a lack of preliminary evidence on the potential of economic incentives to promote caregiver wellbeing in this setting, particularly in the context of a pandemic. This protocol outlines the design of a parallel-group pilot randomised trial comparing the feasibility and preliminary effectiveness of an economic incentive package versus a control for improving caregiver wellbeing. METHODS: Caregivers of ALHIV will be recruited from public-sector HIV clinics in the south of the eThekwini municipality, KwaZulu-Natal, South Africa. Participants will be randomly assigned to one of the following groups: (i) the intervention group (n = 50) will receive three cash payments (of ZAR 350, approximately 23 USD), coupled with a positive wellbeing message over a 3-month period; (ii) the control group (n = 50) will receive a standard message encouraging linkage to health services. Participants will be interviewed at baseline and at endline (12 weeks) to collect socio-demographic, food insecurity, health status, mental health (stigma, depressive symptoms) and wellbeing data. The primary outcome measure, caregiver wellbeing, will be measured using the CarerQoL instrument. A qualitative study will be conducted alongside the main trial to understand participant views on participation in the trial and their feedback on study activities. DISCUSSION: This study will provide scientific direction for the design of a larger randomised controlled trial exploring the effects of an economic incentive for improving caregiver wellbeing. The feasibility of conducting study activities and delivering the intervention remotely in the context of a pandemic will also be provided. TRIAL REGISTRATION: PACTR202203585402090. Registry name: Pan African Clinical Trials Registry (PACTR); URL: https://pactr.samrc.ac.za/ ; Registration. date: 24 March 2022 (retrospectively registered); Date first participant enrolled: 03 November 2021.

Health Insurance Coverage In Low- And Middle-Income Countries Remains Far From The Goal Of Universal Coverage.

This study aimed to determine levels of health insurance coverage in low- and middle-income countries and how coverage varies by people's sociodemographic characteristics. We conducted a population size-weighted, one-stage individual participant data meta-analysis of health insurance coverage, using a population-based sample of 2,035,401 participants ages 15-59 from nationally representative household surveys in fifty-six countries during the period 2006-18. One in five people (20.3 percent) across the fifty-six countries in our study had health insurance. Health insurance coverage exceeded 50 percent in only seven countries and 70 percent in only three countries. Substantially more people had public health insurance than private health insurance (71.4 percent versus 28.6 percent). We found that men and older, more educated, and wealthier people were more likely to have health insurance; these sociodemographic gradients in health insurance coverage were strongest in sub-Saharan Africa and followed traditional lines of privilege. Low- and middle-income countries need to massively expand health insurance coverage if they intend to use insurance to achieve universal health coverage.

South African University Staff and Students' Perspectives, Preferences, and Drivers of Hesitancy Regarding COVID-19 Vaccines: A Multi-Methods Study.

COVID-19 vaccine hesitancy poses a threat to the success of vaccination programmes currently being implemented. Concerns regarding vaccine effectiveness and vaccine-related adverse events are potential barriers to vaccination; however, it remains unclear whether tailored messaging and vaccination programmes can influence uptake. Understanding the preferences of key groups, including students, could guide the implementation of youth-targeted COVID-19 vaccination programmes, ensuring optimal uptake. This study examined university staff and students' perspectives, preferences, and drivers of hesitancy regarding COVID-19 vaccines. A multi-methods approach was used-an online convenience sample survey and discrete choice experiment (DCE)-targeting staff and students at the University of KwaZulu-Natal, South Africa. The survey and DCE were available for staff and students, and data were collected from 18 November to 24 December 2021. The survey captured demographic characteristics as well as attitudes and perspectives of COVID-19 and available vaccines using modified Likert rating questions adapted from previously used tools. The DCE was embedded within the survey tool and varied critical COVID-19 vaccine programme characteristics to calculate relative utilities (preferences) and determine trade-offs. A total of 1836 staff and students participated in the study (541 staff, 1262 students, 33 undisclosed). A total of 1145 (62%) respondents reported that they had been vaccinated against COVID-19. Vaccination against COVID-19 was less prevalent among students compared with staff (79% of staff vs. 57% of students). The vaccine's effectiveness (22%), and its safety (21%), ranked as the two dominant reasons for not getting vaccinated. These concerns were also evident from the DCE, with staff and students being significantly influenced by vaccine effectiveness, with participants preferring highly effective vaccines (90% effective) as compared with those listed as being 70% or 50% effective (ß = -3.72, 95% CI = -4.39 to -3.04); this characteristic had the strongest effect on preferences of any attribute. The frequency of vaccination doses was also found to have a significant effect on preferences with participants deriving less utility from choice alternatives requiring two initial vaccine doses compared with one dose (ß = -1.00, 95% CI = -1.42 to -0.58) or annual boosters compared with none (ß = -2.35, 95% CI = -2.85 to -1.86). Notably, an incentive of ZAR 350 (USD 23.28) did have a positive utility (ß = 1.14, 95% CI = 0.76 to 1.53) as compared with no incentive. Given the slow take-up of vaccination among youth in South Africa, this study offers valuable insights into the factors that drive hesitancy among this population. Concerns have been raised around the safety and effectiveness of vaccines, although there remains a predilection for efficient services. Respondents were not enthusiastic about the prospect of having to take boosters, and this has played out in the roll-out data. Financial incentives may increase both the uptake of the initial dose of vaccines and see a more favourable response to subsequent boosters. Universities should consider tailored messaging regarding vaccine effectiveness and facilitate access to vaccines, to align services with the stated preferences of staff and students.

Hosting ICASA 2021 in South Africa amidst the global Omicron scare.

The 21st International Conference on HIV/AIDS and STI's in Africa (ICASA) was successfully held from the 6th to 11t h December 2021 in Durban, South Africa. Little did we know at the time of planning that COVID-19 could become such a formidable force in eroding the progress made to bring lifesaving therapies among vulnerable communities in Africa. The conference also highlighted Africa's openness to the world, also shown in the way South Africa shared data on its discovery of the Omicron variant. Arguably the most important of lessons is that integrated HIV/TB services have become a platform on which to provide other services. We also saw how HIV and TB services were used as leverage for COVID-19 services. Much was also discussed about the need to adopt more self-care approaches, as was demonstrated with the increased use of self-testing technologies for HIV, and potentially other health needs. It's clear that Africa needs to increase its capacity to support and enable innovation, particularly in the design and manufacturing of new technologies including diagnostics, vaccines and therapeutics.

COVID-19 and resilience of healthcare systems in ten countries.

Declines in health service use during the Coronavirus Disease 2019 (COVID-19) pandemic could have important effects on population health. In this study, we used an interrupted time series design to assess the immediate effect of the pandemic on 31 health services in two low-income (Ethiopia and Haiti), six middle-income (Ghana, Lao People's Democratic Republic, Mexico, Nepal, South Africa and Thailand) and high-income (Chile and South Korea) countries. Despite efforts to maintain health services, disruptions of varying magnitude and duration were found in every country, with no clear patterns by country income group or pandemic intensity. Disruptions in health services often preceded COVID-19 waves. Cancer screenings, TB screening and detection and HIV testing were most affected (26-96% declines). Total outpatient visits declined by 9-40% at national levels and remained lower than predicted by the end of 2020. Maternal health services were disrupted in approximately half of the countries, with declines ranging from 5% to 33%. Child vaccinations were disrupted for shorter periods, but we estimate that catch-up campaigns might not have reached all children missed. By contrast, provision of antiretrovirals for HIV was not affected. By the end of 2020, substantial disruptions remained in half of the countries. Preliminary data for 2021 indicate that disruptions likely persisted. Although a portion of the declines observed might result from decreased needs during lockdowns (from fewer infectious illnesses or injuries), a larger share likely reflects a shortfall of health system resilience. Countries must plan to compensate for missed healthcare during the current pandemic and invest in strategies for better health system resilience for future emergencies.

A Continuous Quality Improvement Intervention to Improve Antenatal HIV Care Testing in Rural South Africa: Evaluation of Implementation in a Real-World Setting.

BACKGROUND: We evaluated continuous quality improvement (CQI) targeting antenatal HIV care quality in rural South Africa using a stepped-wedge cluster-randomised controlled trial (Management and Optimisation of Nutrition, Antenatal, Reproductive, Child health, MONARCH) and an embedded process evaluation. Here, we present results of the process evaluation examining determinants of CQI practice and 'normalisation.' METHODS: A team of CQI mentors supported public-sector health workers in seven primary care clinics to (1) identify root causes of poor HIV viral load (VL) monitoring among pregnant women living with HIV and repeat HIV testing among pregnant women not living with HIV, and (2) design and iteratively test their own solutions. We used a mixed methods evaluation with field notes from CQI mentors ('dose' and 'reach' of CQI, causes of poor HIV care testing rates, implemented change ideas); patient medical records (HIV care testing by clinic and time step); and semi-structured interviews with available health workers. We analysed field notes andsemi-structured interviews for determinants of CQI implementation and 'normalisation' using Normalisation Process Theory (NPT) and Tailored Implementation of Chronic Diseases (TICD) frameworks. RESULTS: All interviewed health workers found the CQI mentors and methodology helpful for quality improvement. Total administered 'dose' was higher than planned but 'reach' was limited by resource constraints, particularly staffing shortages. Simple workable improvements to identified root causes were implemented, such as a patient tracking notebook and results filing system. VL monitoring improved over time, but not repeat HIV testing. Besides resource constraints, gaps in knowledge of guidelines, lack of leadership, poor clinical documentation, and data quality gaps reduced CQI implementation fidelity and normalisation. CONCLUSION: While CQI holds promise, we identified several health system challenges. Priorities for policy makers include improving staffing and strategies to improve clinical documentation. Additional support with implementing clinical guidelines and improving routine data quality are needed. Normalising CQI may be challenging without concurrent health system improvements.

A Perspective on Implementation Outcomes and Strategies to Promote the Uptake of COVID-19 Vaccines.

Recent articles have highlighted the importance of incorporating implementation science concepts into pandemic-related research. However, limited research has been documented to date regarding implementation outcomes that may be unique to COVID-19 vaccinations and how to utilize implementation strategies to address vaccine program-related implementation challenges. To address these gaps, we formed a global COVID-19 implementation workgroup of implementation scientists who met weekly for over a year to review the available literature and learn about ongoing research during the pandemic. We developed a hierarchy to prioritize the applicability of "lessons learned" from the vaccination-related implementation literature. We identified applications of existing implementation outcomes as well as identified additional implementation outcomes. We also mapped implementation strategies to those outcomes. Our efforts provide rationale for the utility of using implementation outcomes in pandemic-related research. Furthermore, we identified three additional implementation outcomes: availability, health equity, and scale-up. Results include a list of COVID-19 relevant implementation strategies mapped to the implementation outcomes.

The role of emergent champions in policy implementation for decentralised drug-resistant tuberculosis care in South Africa.

OBJECTIVE: Champions are recognised as important to driving organisational change in healthcare quality improvement initiatives in high-income settings. In low-income and middle-income countries with a high disease burden and constrained human resources, their role is highly relevant yet understudied. Within a broader study on policy implementation for decentralised drug-resistant tuberculosis care in South Africa, we characterised the role, strategies and organisational context of emergent policy champions. DESIGN: Interviews with 34 healthcare workers in three South African provinces identified the presence of individuals who had a strong influence on driving policy implementation forward. Additional interviews were conducted with 13 participants who were either identified as champions in phase II or were healthcare workers in facilities in which the champions operated. Thematic analyses using a socio-ecological framework further explored their strategies and the factors enabling or obstructing their agency. RESULTS: All champions occupied senior managerial posts and were accorded legitimacy and authority by their communities. 'Disease-centred' champions had a high level of clinical expertise and placed emphasis on clinical governance and clinical outcomes, while 'patient-centred' champions promoted pathways of care that would optimise patients' recovery while minimising disruption in other spheres of their lives. Both types of champions displayed high levels of resourcefulness and flexibility to adapt strategies to the resource-constrained organisational context. CONCLUSION: Policymakers can learn from champions' experiences regarding barriers and enablers to implementation to adapt policy. Research is needed to understand what factors can promote the sustainability of champion-led policy implementation, and to explore best management practices to support their initiatives.

The effect of eligibility for antiretroviral therapy on body mass index and blood pressure in KwaZulu-Natal, South Africa.

We use a regression discontinuity design to estimate the causal effect of antiretroviral therapy (ART) eligibility according to national treatment guidelines of South Africa on two risk factors for cardiovascular disease, body mass index (BMI) and blood pressure. We combine survey data collected in 2010 in KwaZulu-Natal, South Africa, with clinical data on ART. We find that early ART eligibility significantly reduces systolic and diastolic blood pressure. We do not find any significant effects on BMI. The effect on blood pressure can be detected up to three years after becoming eligible for ART.

Undisclosed Antiretroviral Therapy Use at Primary Health Care Clinics in Rural KwaZulu Natal South Africa: A DO-ART Trial Sub-study.

Accurate reporting of antiretroviral therapy (ART) uptake is crucial for measuring the success of epidemic control. Programs without linked electronic medical records are susceptible to duplicating ART initiation events. We assessed the prevalence of undisclosed ART use at the time of treatment initiation and explored its correlates among people presenting to public ambulatory clinics in South Africa. Data were analyzed from the community-based delivery of ART (DO ART) clinical trial, which recruited people living with HIV who presented for ART initiation at two clinics in rural South Africa. We collected data on socioeconomic factors, clinical factors, and collected blood as part of study screening procedures. We estimated the proportion of individuals presenting for ART initiation with viral load suppression (< 20 copies/mL) and fitted regression models to identify social and clinical correlates of non-disclosure of ART use. We also explored clinical and national databases to identify records of ART use. Finally, to confirm surreptitious ART use, we measured tenofovir (TDF) and emtricitabine (FTC) levels in dried blood spots. A total of 193 people were screened at the two clinics. Approximately 60% (n = 114) were female, 40% (n = 78) reported a prior HIV test, 23% (n = 44) had disclosed to a partner, and 31% (n = 61) had a partner with HIV. We found that 32% (n = 62) of individuals presenting for ART initiation or re-initiation had an undetectable viral load. In multivariable regression models, female sex (AOR 2.16, 95% CI 1.08-4.30), having a prior HIV test and having disclosed their HIV status (AOR 2.48, 95% CI 1.13-5.46), and having a partner with HIV (AOR 1.94, 95% CI 0.95-3.96) were associated with having an undetectable viral load. In records we reviewed, we found evidence of ART use from either clinical or laboratory databases in 68% (42/62) and detected either TDF or FTC in 60% (37/62) of individuals with an undetectable viral load. Undisclosed ART use was present in approximately one in three individuals presenting for ART initiation or re-initiation at ambulatory HIV clinics in South Africa. These results have important implications for ART resource use and planning in the region. A better understanding of reasons for non-disclosure of ART at primary health care clinics in such settings is needed.

Determinants of Confidence in Overall Knowledge About COVID-19 Among Healthcare Workers in South Africa: Results From an Online Survey.

Background: Adequate information and knowledge about COVID-19 has been shown to induce the confidence and positive performance among healthcare workers (HCWs). Therefore, assessing the relationship between confidence in knowledge and associated factors among HCWs is vital in the fight against COVID-19. This paper investigates factors associated with HCWs' confidence in their overall knowledge about COVID-19 in South Africa in the early stages of the epidemic. Methods: Data utilized in this paper were from an online survey conducted among HCWs using a structured questionnaire on a data free online platform. The study population were all the medical fraternity in South Africa including medical and nurse practitioners as well as other healthcare professionals. Bivariate and multivariate logistic regression models were performed to examine the factors associated with confidence in HCWs' overall knowledge about COVID-19. Results: Overall, just below half (47.4%) of respondents indicated that they had confidence in their overall knowledge about COVID-19. Increased odds of having confidence in the knowledge about COVID-19 were significantly associated with being male [aOR = 1.31 95% CI (1.03-1.65), p < 0.05], having a doctorate degree [aOR = 2.01 (1.23-3.28), p < 0.05], being satisfied with the information about COVID-19 guidelines [aOR = 6.01 (4.89-7.39), p < 0.001], having received training in 6-8 areas [aOR = 2.54 (1.89-3.43), p < 0.001] and having received training in 9-11 areas [aOR = 5.33 (3.81-7.47), p < 0.001], and having already treated COVID-19 patients [aOR = 1.43 (1.08-1.90), p < 0.001]. Those who were highly concerned with the levels of training of HCWs [aOR = 0.47 (0.24-0.92), p < 0.05] had decreased odds of having confidence in their overall knowledge about COVID-19. Conclusion: This study sheds light on the importance of capacitating HCWs with knowledge and adequate relevant training as part of infection prevention control measures during pandemics. Future training and information sharing should be sensitive to knowledge gaps by age, gender, qualifications, professional categories, and experience.

Healer-led vs. clinician-led training to improve personal protective equipment use among traditional healers in South Africa: a randomized controlled trial protocol.

There are estimated two million traditional healers in sub-Saharan Africa (SSA), with more than 10% (200,000) working in South Africa. Traditional healers in SSA are frequently exposed to bloodborne pathogens through the widespread practice of traditional 'injections', in which the healers perform dozens of subcutaneous incisions to rub herbs directly into the bloodied tissue with their hands. Healers who report exposure to patient blood have a 2.2-fold higher risk of being HIV-positive than those who do not report exposure. We propose a randomized controlled trial (61 healers in the intervention group and 61 healers in the control group) in Mpumalanga Province. Healers will receive personal protective equipment (PPE) education and training, general HIV prevention education, and three educational outreach visits at the healer's place of practice to provide advice and support for PPE use and disposal. Healers in the control arm will be trained by health care providers, while participants in the intervention arm will receive training and outreach from a team of healers who were early adopters of PPE. We will evaluate intervention implementation using data from surveys, observation, and educational assessments. Implementation outcomes of interest include acceptability and feasibility of PPE use during clinical encounters and fidelity of PPE use during treatments that involve blood exposure. We will test our two intervention strategies to identify an optimal strategy for PPE education in a region with high HIV prevalence.

'We had to manage what we had on hand, in whatever way we could': adaptive responses in policy for decentralized drug-resistant tuberculosis care in South Africa.

In 2011, the South African National TB Programme launched a policy of decentralized management of drug-resistant tuberculosis (DR-TB) in order to expand the capacity of facilities to treat patients with DR-TB, minimize delays to access care and improve patient outcomes. This policy directive was implemented to varying degrees within a rapidly evolving diagnostic and treatment landscape for DR-TB, placing new demands on already-stressed health systems. The variable readiness of district-level systems to implement the policy prompted questions not only about differences in health systems resources but also front-line actors' capacity to implement change in resource-constrained facilities. Using a grounded theory approach, we analysed data from in-depth interviews and small group discussions conducted between 2016 and 2018 with managers (n = 9), co-ordinators (n = 15), doctors (n = 7) and nurses (n = 18) providing DR-TB care. Data were collected over two phases in district-level decentralized sites of three South African provinces. While health systems readiness assessments conventionally map the availability of 'hardware', i.e. resources and skills to deliver an intervention, a notable absence of systems 'hardware' meant that systems 'software', i.e. health care workers (HCWs) agency, behaviours and interactions provided the basis of locally relevant strategies for decentralized DR-TB care. 'Software readiness' was manifest in four areas of DR-TB care: re-organization of service delivery, redressal of resource shortages, creation of treatment adherence support systems and extension of care parameters for vulnerable patients. These strategies demonstrate adaptive capacity and everyday resilience among HCW to withstand the demands of policy change and innovation in stressed systems. Our work suggests that a useful extension of health systems 'readiness' assessments would include definition and evaluation of HCW 'software' and adaptive capacities in the face of systems hardware gaps.

Investigating the implementation of differentiated HIV services and implications for pregnant and postpartum women: A mixed methods multi-country study.

Universal antiretroviral therapy (ART) for pregnant and postpartum women in sub-Saharan Africa has required adaptations to service delivery. We compared national policies on differentiated HIV service delivery with facility-level implementation, and explored provider and user experiences in rural Malawi, Tanzania and South Africa. Four national policies and two World Health Organization guidelines on HIV treatment for pregnant and postpartum women published between 2013 and 2017 were reviewed and summarised. Results were compared with implementation data from surveys undertaken in 34 health facilities. Eighty-seven in-depth interviews were conducted with pregnant and post-partum women living with HIV, their partners and providers. In 2018, differentiated service policies varied across countries. None specifically accounted for pregnant or postpartum women. Malawian policies endorsed facility-based multi-month scripting for clinically-stable adult ART patients, excluding pregnant or breastfeeding women. In Tanzania and South Africa, national policies proposed community-based and facility-based approaches, for which pregnant women were not eligible. Interview data suggested some implementation of differentiated services for pregnant and postpartum women beyond stipulated policies in all settings. Although these adaptations were appreciated by pregnant and postpartum women, they could lead to frustrations among other users when criteria for fast-track services or multi-month prescriptions were not clear.

Influence of evolving HIV treatment guidance on CD4 counts and viral load monitoring: A mixed-methods study in three African countries.

Little is known about how CD4 and viral load testing have evolved following implementation of universal test and treat (UTT) in African settings. We reviewed World Health Organization (WHO) guidance from 2013 to 2018, and compared it against national HIV policies in Malawi, Tanzania and South Africa. Three surveys rounds were conducted in 2013, 2016 and 2017-2018 in 33 health facilities across the three settings to assess implementation of national policies on the use of biological markers. Qualitative interviews were conducted with 26 HIV policymakers or programme managers, 21 providers and 66 people living with HIV to explore understandings and experiences of these tests. Various factors influenced adoption and implementation of WHO guidance, including historical policies on CD4 counts, governance issues, supply chain challenges and funding mechanisms. Facility-level practices relating to the use of these tests often diverged from national policies. Patients and providers valued both tests, but did not always understand their roles. In addition to continued support for scaling-up viral load testing, renewed focus should be placed on the ongoing value of point-of-care CD4 tests in the UTT era, including its role in assessing disease progression and informing clinical management of cases to reduce HIV-related mortality.

Consequences of male partner engagement policies on HIV care-seeking in three African countries: Findings from the SHAPE UTT study.

We explored how strategies to promote male partner engagement influenced HIV care-seeking among men and women living with HIV. In-depth interviews were conducted with 25 health workers, 66 female service users and 10 male partners in Ifakara (Tanzania), Karonga (Malawi) and uMkhanyakude (South Africa) to elicit experiences of offering, providing or receiving HIV care in the context of antenatal care. Data were coded inductively and analysed thematically. Participants reported benefits of couple testing during antenatal care, including facilitated HIV status disclosure and mutual support for HIV care-seeking. However, unintended consequences included women attending without partners, being refused or delayed access to antenatal services. Some women were required to obtain letters from village leaders to justify the absence of their partners, again to delaying or disrupting care-seeking. When partners attended antenatal care, consultations were reportedly more likely to focus on HIV testing, and less on antenatal or neonatal care. Strategies to increase men's attendance at HIV clinics with their partners can promote mutual support within couples for HIV care engagement, but may risk undermining engagement in pregnancy and HIV care for some women if over-stringently applied. Efforts are needed to address the underlying pervasive stigma associated with HIV care, both alone and as a couple.