HIV burden and the global fast-track targets progress among pregnant women in Tanzania calls for intensified case finding: Analysis of 2020 antenatal clinics HIV sentinel site surveillance.

BACKGROUND: For successful HIV response, updated information on the burden and progress toward HIV elimination targets are required to guide programmatic interventions. We used data from the 2020 HIV sentinel surveillance to update on the burden and factors associated with HIV infection, HIV status awareness, and ART coverage among pregnant women in Tanzania mainland. METHODOLOGY: We conducted the surveillance in 159 antenatal clinics (ANC) from all 26 regions of Tanzania's mainland from September to December 2020. This cross-sectional study included all pregnant women (≥15 years) on their first ANC visit in the current pregnancy during the survey period. Routine HIV counselling and testing were done at the facility. A multivariable logistic regression model accounting for the survey design was used to examine factors associated with HIV infections. RESULTS: 38,783 pregnant women were enrolled (median age (IQR) = 25 (21-30) years). HIV prevalence was 5.9% (95%CI: 5.3% - 6.6%), ranging from 1.9% in the Manyara region to 16.4% in the Njombe region. Older age, lower and no education, not being in a marital union, and living in urban or semi-urban areas were associated with higher odds of HIV infection. HIV status awareness among women who tested positive was 70.9% (95% CI: 67.5%- 74.0%). ART coverage among those aware of their status was 91.6% (86.5%- 94.9%). Overall, 66.6% (95% CI: 62.4%- 70.6%) of all pregnant women who tested positive for HIV knew their HIV status and were on ART. CONCLUSION: HIV is increasingly prevalent among pregnant women in Tanzania mainland especially among older, those with lower or no formal education, those outside marital union, and pregnant women living in urban and semi-urban areas. Behind the global fast-target to end HIV/ AIDS, about a third of pregnant women living with HIV initiating ANC were not on ART. Interventions to increase HIV testing and linkage to care among women of reproductive age should be intensified.

Epidemiology of syphilis infections among pregnant women in Tanzania: Analysis of the 2020 national representative sentinel surveillance.

BACKGROUND: Syphilis has detrimental effects on the health of the mother and that of both fetuses and newborns exposed in utero or at delivery. Understanding its local epidemiology is essential for policies, planning, and implementation of targeted preventive interventions. Using data from the 2020 National Sentinel Surveillance of pregnant women attending antenatal clinics (ANCs) in Tanzania we determined the prevalence and determinants of syphilis among pregnant women in Tanzania mainland. METHODOLOGY: The ANC surveillance was conducted in 159 ANC sites from all 26 regions of Tanzania's mainland from September to December 2020. It included all pregnant women 15 years and above on their first ANC visit in the current pregnancy during the survey period. Counseling for syphilis was done using standard guidelines at the ANC and testing was done using rapid SD Bioline HIV/Syphilis Duo test kits. Analysis was done using both descriptive statistics to determine the prevalence and characteristics of syphilis, whereas, logistic regressions were used to examine the independent association between syphilis and dependent variables. RESULTS: A total of 38,783 women [median age (Interquartile range (IQR)) = 25 (21-30) years] participated in the surveillance. Of them, 582 (1.4%) tested positive for syphilis. A wide regional variation was observed with the highest burden in Kagera (4.5%) to the lowest burden in Kigoma (0.3%). The odds of syphilis infections were higher among older women and those with no formal education. Compared with primigravids, women with 1-2, those with 3-4 and those with more than four previous pregnancies had 1.8 (aOR = 1.8, 95% CI: 1.2-2.5), 2.1 (aOR = 2.1, 95% CI: 1.4-3.1) and 2.6 (aOR = 2.6, 95% CI: 1.7-3.9) higher odds of syphilis infection respectively. CONCLUSION: Syphilis is still prevalent among pregnant women in Tanzania with a wide regional disparity. Efforts to prevent new infections, screen pregnant women, and treat those infected should be strategized to include all regions and renewed emphasis on regions with high burden, and importantly among women who are multipara, with a low level of education, and advanced age.

Enhancing Tuberculosis Case-Finding: A Case of Quality Improvement Initiative in Tanzania.

BACKGROUND: Tanzania is 1 of the 30 high TB burden countries and 1 of the 13 countries in which 75% of people with TB are unaccounted for and that is prioritized for the Global Fund Catalytic investment and Strategic Initiative support. Tanzania decided to strengthen its National TB Programme to find these people with TB who are unaccounted for by identifying evidence-driven innovations to deliver high-quality services and to improve the efficiency of TB case-finding. A quality improvement (QI) initiative was implemented by the National Tuberculosis and Leprosy Programme to enhance TB case-finding. The initiative involved identifying gaps in the quality of services, introducing new tools, improving the work capacity of health care workers through training and mentorship sessions, strengthening laboratory and referral services, and implementing mandatory TB screening of all patients attending health facilities. We aimed to assess the effectiveness of QI initiative to enhance TB case-findings at the health facility level. METHOD: A cross-sectional design, and intervention and control facilities randomly selected for an evaluation of the QI initiative were used. Twenty facilities from the Dodoma region across all health care system levels (dispensaries, health centres, and hospitals) were involved in this evaluation. The facilities were randomly divided into either the intervention or control groups at a 1:1 ratio (10 intervention and 10 control facilities). Data routinely collected from program registers from January 2016 to June 2017 were used. RESULT: The evaluation registered a 52% increase in TB case notification in Q1 of 2017 compared with in Q1 of 2016 and, similarly, a 52% increase in Q2 of 2017 compared with in Q2 of 2016, with 9 out of 10 intervention sites reporting increases in their quarterly TB case notifications. There were no positive changes in the 'control facilities' where routine services were provided, with half of the facilities showing a decrease in TB case notification from baseline. CONCLUSION: This QI initiative has the potential to support a long-term comprehensive approach to ending TB and to improve the quality of the foundations of the health care system. This initiative sets a reliable pace for health facilities to efficiently respond to and manage TB case-finding interventions put into action. Tanzania's experience with implementing QI interventions could serve as a model for improving TB case notifications in other settings.

Perceived Usefulness, Competency, and Associated Factors in Using District Health Information System Data Among District Health Managers in Tanzania: Cross-sectional Study.

BACKGROUND: Tanzania introduced District Health Information Software (version 2; DHIS2) in 2013 to support existing health management information systems and to improve data quality and use. However, to achieve these objectives, it is imperative to build human resource capabilities to address the challenges of new technologies, especially in resource-constrained countries. OBJECTIVE: This study aimed to determine the perceived usefulness, competency, and associated factors in using DHIS2 data among district health managers (DHMs) in Tanzania. METHODS: This descriptive cross-sectional study used a quantitative approach, which involved using a self-administered web-based questionnaire. This study was conducted between April and September 2019. We included all core and co-opted members of the council or district health management teams (DHMTs) from all 186 districts in the country. Frequency and bivariate analyses were conducted, and the differences among categories were measured by using a chi-square test. P values of <.05 were considered significant. RESULTS: A total of 2667 (77.96%) of the expected 3421 DHMs responded, of which 2598 (97.41%) consented and completed the questionnaires. Overall, the DHMs were satisfied with DHIS2 (2074/2596, 79.83%) because of workload reduction (2123/2598, 81.72%), the ease of learning (1953/2598, 75.17%), and enhanced data use (2239/2598, 86.18%). Although only half of the managers had user accounts (1380/2598, 53.12%) and were trained on DHIS2 data analysis (1237/2598, 47.61%), most claimed to have average to advanced skills in data validation (1774/2598, 68.28%), data visualization (1563/2598, 60.16%), and DHIS2 data use (1321/2598, 50.85%). The biggest challenges facing DHMs included the use of a paper-based system as the primary data source (1890/2598, 72.75%) and slow internet speed (1552/2598, 59.74%). Core members were more confident in using DHIS2 compared with other members (P=.004), whereas program coordinators were found to receive more training on data analysis and use (P=.001) and were more confident in using DHIS2 data compared with other DHMT members (P=.001). CONCLUSIONS: This study showed that DHMs have appreciable competencies in using the DHIS2 and its data. However, their skill levels have not been commensurate with the duration of DHIS2 use. This study recommends improvements in the access to and use of DHIS2 data. More training on data use is required and should involve using cost-effective approaches to include both the core and noncore members of the DHMTs. Moreover, enhancing the culture and capacity of data use will ensure the better management and accountability of health system performance.

Transformation of the Tanzania medical store department through global fund support: an impact assessment study.

BACKGROUND: The Tanzania government sought support from The Global Fund to Fight AIDs, Tuberculosis and Malaria to reform its Medical Stores Department, with the aim of improving performance. The study sought to assess the impact of the reforms and document the lessons learnt. METHODS: Quantitative and qualitative research methods were applied to assess the impact of the reforms. The quantitative part entailed a review of operational and financial data covering the period before and after the implementation of the reforms. Interrupted time series analysis was used to determine the change in average availability of essential health commodities at health zones. Qualitative data were collected through 41 key informant interviews. Participants were identified through stakeholder mapping, purposive and snowballing sampling techniques and responses were analysed through thematic content analysis. RESULTS: Availability of essential health commodities increased significantly by 12.6% (95% CI 9.6% to 15.6%) after the reforms and continued to increase on a monthly basis by 0.2% (95%CI 0.0% to 0.3%) relative to the preintervention trend. Sales increased by 56.6% while the cost of goods sold increased by 88.6% between 2014/2015 and 2017/2018. Surplus income increased by 56.4% between 2014/2015 and 2017/2018 with reductions in rent and fuel expenditure. There was consensus among study participants that the reforms were instrumental in improving performance of the Medical Stores Department. CONCLUSION: Positive results were realised through the reforms. However, despite the progress, there were risks such as the increasing government receivable that could jeopardise the sustainability of the gains. Therefore, multistakeholder efforts are necessary to make progress and expand public health.

Can Changes in Service Delivery Models Improve Program Quality and Efficiency? A Closer Look at HIV Programs in Kenya and Uganda.

BACKGROUND: With the scale-up of antiretroviral treatment, many health facilities in low- and middle-income countries have implemented innovative practices targeted at overcoming operational challenges and delivering efficient quality HIV services. However, many of these practices remain largely unexplored as a means to better reach the global 90-90-90 targets. SETTING: A study was conducted on selected facilities in districts of country programs supported by The Global Fund to Fight AIDS, Tuberculosis, and Malaria. The aims of the study were to understand how facilities seek to improve the delivery and uptake of HIV services and to examine what innovative practices might be contributing to their success. METHODS: The study used a qualitative approach through observations, document reviews, and semistructured interviews with site management and clinical staff to identify service delivery innovations in 30 health facilities in Kenya and Uganda. RESULTS: Eleven innovative practices were observed along the HIV care cascade. These practices led to improvements in the quality of testing, treatment, and retention across the facilities. Effective human resource and data management processes also enabled the implementation of these innovative practices. CONCLUSIONS: Many facilities use innovative practices along the HIV care cascade to address bottlenecks and challenges. These have the potential to improve the quality and efficiency of service delivery and support the attainment of the 90-90-90 treatment targets. Replicating these practices would require further implementation research and a mind shift of donors, governments, and implementers from a metric of coverage to a stronger focus on efficiency and impact.