Cost Analysis of Short Messaging Service and Peer Navigator Interventions for Linking and Retaining Adults Recently Diagnosed With HIV in Care in South Africa.

INTRODUCTION: Large proportions of people living with HIV (PLHIV) in sub-Saharan Africa are not linked to or retained in HIV care. There is a critical need for cost-effective interventions to improve engagement and retention in care and inform optimal allocation of resources. METHODS: We estimated costs associated with a short message service (SMS) plus peer navigation (SMS+PN) intervention; an SMS-only intervention; and standard of care (SOC), within the I-Care cluster-randomized trial to improve HIV care engagement for recently diagnosed PLHIV. We employed a uniform cost data-collection protocol to quantify resources used and associated costs for each intervention. RESULTS: Compared with SOC, the SMS+PN intervention cost $1284 ($828-$2859) more per additional patient linked to care within 30 days and $1904 ($1158-$5343) more per additional patient retained in care at 12 months, while improving linkage by 24% (95% CI: 11 to 36) and retention by 16% (95% CI: 6 to 26). By contrast, the SMS-only intervention cost $198 ($93-dominated) more per additional patient linked to care and $697 ($171-dominated) more per additional patient retained in care but was not significantly associated with improvements in linkage (12%; 95% CI: -1 to 25) or retention (3%; 95% CI: -7 to 14) compared with SOC. The efficiency of the SMS+PN intervention could be improved by 46%, to $690 more per additional patient linked and $1023 more per additional patient retained in care, if implemented within the Department of Health using more efficient distribution of staff resources. DISCUSSION: Findings suggest that scale-up of the SMS+PN intervention could benefit patients, improving care and health outcomes while being cost-effective.

Depression and HIV Care-seeking Behaviors in a Population-based Sample in North West Province, South Africa.

Depression is associated with key HIV-related prevention and treatment behaviors in sub-Saharan Africa. We aimed to identify the association of depressive symptoms with HIV testing, linkage to care, and ART adherence among a representative sample of 18-49 year-olds in a high prevalence, rural area of South Africa. Utilizing logistic regression models (N = 1044), depressive symptoms were inversely associated with reported ever HIV testing (AOR 0.92, 95% CI 0.85-0.99; p = 0.04) and ART adherence (AOR 0.82, 95% CI: 0.73-0.91; p < 0.01) among women. For men, depressive symptoms were positively associated with linkage to care (AOR: 1.21, 95% CI: 1.09-1.34; p < 0.01). Depression may adversely impact ART adherence for HIV-positive women and reduce the likelihood of HIV testing for women not aware of their HIV status which, in settings with high HIV prevalence, carries severe consequences. For HIV-positive men, findings suggest that depression may encourage help-seeking behavior, thereby impacting their health system interactions. These findings underscore the need for health-care settings to factor mental health, such as depression, into their programs to address health-related outcomes, particularly for women.

RESUMEN: La depresión está asociada con conductas clave de prevención y tratamiento relacionadas con el VIH en África subsahariana. Nuestro objetivo fue identificar la asociación de los síntomas depresivos con los resultados relacionados con el VIH entre una muestra representativa de personas de 18 a 49 años en Sudáfrica. Utilizando modelos de regresión logística (N = 1044), los síntomas depresivos se asociaron inversamente con los que se informaron que habían probado de VIH alguna vez (AOR 0,92, IC del 95%: 0,85 a 0,99; p = 0,04) y la adherencia al TAR (AOR 0,82, IC del 95%: 0,73 a 0,91; p < 0,01) entre las mujeres. Para los hombres, los síntomas depresivos se asociaron positivamente con la vinculación con cuidado (AOR: 1,21, IC del 95%: 1,09­1,34; p < 0,01). La depresión puede tener un impacto adverso en la adherencia al TAR para las mujeres VIH-positivas y reducir la probabilidad de que las mujeres se hagan la prueba del VIH. Para los hombres VIH-positivos, los resultados sugieren que la depresión fomente una conducta de búsqueda de ayuda, afectando así sus interacciones con el sistema de salud. Estos resultados subrayan la necesidad de que los que proveen servicios médicos tengan en cuenta la salud mental en sus programas que abordan los resultados relacionados con la salud.

Impact of short message service and peer navigation on linkage to care and antiretroviral therapy initiation in South Africa.

OBJECTIVE: We examine the efficacy of short message service (SMS) and SMS with peer navigation (SMS + PN) in improving linkage to HIV care and initiation of antiretroviral therapy (ART). DESIGN: I-Care was a cluster randomized trial conducted in primary care facilities in North West Province, South Africa. The primary study outcome was retention in HIV care; this analysis includes secondary outcomes: linkage to care and ART initiation. METHODS: Eighteen primary care clinics were randomized to automated SMS ( n  = 7), automated and tailored SMS + PN ( n  = 7), or standard of care (SOC; n  = 4). Recently HIV diagnosed adults ( n  = 752) were recruited from October 2014 to April 2015. Those not previously linked to care ( n  = 352) contributed data to this analysis. Data extracted from clinical records were used to assess the days that elapsed between diagnosis and linkage to care and ART initiation. Cox proportional hazards models and generalized estimating equations were employed to compare outcomes between trial arms, overall and stratified by sex and pregnancy status. RESULTS: Overall, SMS ( n  = 132) and SMS + PN ( n  = 133) participants linked at 1.28 [95% confidence interval (CI): 1.01-1.61] and 1.60 (95% CI: 1.29-1.99) times the rate of SOC participants ( n  = 87), respectively. SMS + PN significantly improved time to ART initiation among non-pregnant women (hazards ratio: 1.68; 95% CI: 1.25-2.25) and men (hazards ratio: 1.83; 95% CI: 1.03-3.26) as compared with SOC. CONCLUSION: Results suggest SMS and peer navigation services significantly reduce time to linkage to HIV care in sub-Saharan Africa and that SMS + PN reduced time to ART initiation among men and non-pregnant women. Both should be considered candidates for integration into national programs. TRIAL REGISTRATION: NCT02417233, registered 12 December 2014; closed to accrual 17 April 2015.

Prevalence, motivation, and outcomes of clinic transfer in a clinical cohort of people living with HIV in North West Province, South Africa.

INTRODUCTION: Continuity of care is an attribute of high-quality health systems and a necessary component of chronic disease management. Assessment of health information systems for HIV care in South Africa has identified substantial rates of clinic transfer, much of it undocumented. Understanding the reasons for changing sources of care and the implications for patient outcomes is important in informing policy responses. METHODS: In this secondary analysis of the 2014 - 2016 I-Care trial, we examined self-reported changes in source of HIV care among a cohort of individuals living with HIV and in care in North West Province, South Africa. Individuals were enrolled in the study within 1 year of diagnosis; participants completed surveys at 6 and 12 months including items on sources of care. Clinical data were extracted from records at participants' original clinic for 12 months following enrollment. We assessed frequency and reason for changing clinics and compared the demographics and care outcomes of those changing and not changing source of care. RESULTS: Six hundred seventy-five (89.8%) of 752 study participants completed follow-up surveys with information on sources of HIV care; 101 (15%) reported receiving care at a different facility by month 12 of follow-up. The primary reason for changing was mobility (N=78, 77%). Those who changed clinics were more likely to be young adults, non-citizens, and pregnant at time of diagnosis. Self-reported clinic attendance and ART adherence did not differ based on changing clinics. Those on ART not changing clinics reported 0.66 visits more on average than were documented in clinic records. CONCLUSION: At least 1 in 6 participants in HIV care changed clinics within 2 years of diagnosis, mainly driven by mobility; while most appeared lost to follow-up based on records from the original clinic, self-reported visits and adherence were equivalent to those not changing clinics. Routine clinic visits could incorporate questions about care at other locations as well as potential relocation, particularly for younger, pregnant, and non-citizen patients, to support existing efforts to make HIV care records portable and facilitate continuity of care across clinics. TRIAL REGISTRATION: The original trial was registered with ClinicalTrials.gov , NCT02417233, on 12 December 2014.

Impact of SMS and peer navigation on retention in HIV care among adults in South Africa: results of a three-arm cluster randomized controlled trial.

INTRODUCTION: Few interventions have demonstrated improved retention in care for people living with HIV (PLHIV) in sub-Saharan Africa. We tested the efficacy of two personal support interventions - one using text messaging (SMS-only) and the second pairing SMS with peer navigation (SMS+PN) - to improve HIV care retention over one year. METHODS: In a cluster randomized control trial (NCT# 02417233) in North West Province, South Africa, we randomized 17 government clinics to three conditions: SMS-only (6), SMS+PN (7) or standard of care (SOC; 4). Participants at SMS-only clinics received appointment reminders, biweekly healthy living messages and twice monthly SMS check-ins. Participants at SMS+PN clinics received SMS appointment reminders and healthy living messages and spoke at least twice monthly with peer navigators (PLHIV receiving care) to address barriers to care. Outcomes were collected through biweekly clinical record extraction and surveys at baseline, six and 12 months. Retention in HIV care over one year was defined as clinic visits every three months for participants on antiretroviral therapy (ART) and CD4 screening every six months for pre-ART participants. We used generalized estimating equations, adjusting for clustering by clinic, to test for differences across conditions. RESULTS: Between October 2014 and April 2015, we enrolled 752 adult clients recently diagnosed with HIV (SOC: 167; SMS-only: 289; SMS+PN: 296). Individuals in the SMS+PN arm had approximately two more clinic visits over a year than those in other arms (p < 0.01) and were more likely to be retained in care over one year than those in SOC clinics (54% vs. 38%; OR: 1.77, CI: 1.02, 3.10). Differences between SMS+PN and SOC conditions remained significant when restricting analyses to the 628 participants on ART (61% vs. 45% retained; OR: 1.78, CI: 1.08, 2.93). The SMS-only intervention did not improve retention relative to SOC (40% vs. 38%, OR: 1.12, CI: 0.63, 1.98). CONCLUSIONS: A combination of SMS appointment reminders with personalized, peer-delivered support proved effective at enhancing retention in HIV care over one year. While some clients may only require appointment reminders, the SMS+PN approach offers increased flexibility and tailored, one-on-one support for patients struggling with more substantive challenges.

Sexual and Physical Violence in Childhood Is Associated With Adult Intimate Partner Violence and Nonpartner Sexual Violence in a Representative Sample of Rural South African Men and Women.

Intimate partner violence, nonpartner sexual violence, and physical and sexual violence against children are significant public health issues in South Africa. Theory suggests that experiencing violence in childhood plays a role in propensity to perpetrate violence or vulnerability to violence in adulthood. Most research to date on this topic has been conducted in high-resource countries or within urban or high-risk populations. We explore the relationship between violence in childhood and violence in adulthood in a community-based sample of 18- to 49-year-old adults in rural South Africa using data from a population-based survey (N = 1,044) in North West province in 2014. We measured childhood violence before age 15 years, experience of nonpartner sexual violence in adulthood, and IPV victimization and perpetration in the last 12 months. We conducted multivariate logistic regression; gender was tested as an effect modifier. All estimates are weighted to the subdistrict population. More women (2.7%) than men (0.8%) reported childhood forced sex, whereas fewer women (2.0%) than men (7.9%) reported childhood physical violence. Women and men reported similar rates of IPV victimization (6.8% vs. 5.4%), IPV perpetration (3.3% vs. 4.8%), and forced sex by a nonpartner (1.6% vs. 1.2%). We found that men and women who experienced childhood violence (combined physical and/or sexual) were significantly more likely to experience forced sex by a nonpartner (men: adjusted odds ratio [aOR] = 5.53, 95% confidence interval [CI] = [1.27, 24.0], p < .05; women: aOR = 51.1, 95% CI = [10.58, 246.3], p < .01) compared with those who did not experience childhood violence. They were also 2.5 times as likely to perpetrate recent IPV (aOR = 2.5, 95% CI = [0.97, 6.7], p = .06) or experience recent IPV (aOR = 2.5, 95% CI = [0.9, 6.9], p = .07), although this finding was marginally significant. These results align with the literature from other settings and population groups.

The role of drug resistance in poor viral suppression in rural South Africa: findings from a population-based study.

BACKGROUND: Understanding factors driving virological failure, including the contribution of HIV drug resistance mutations (DRM), is critical to ensuring HIV treatment remains effective. We examine the contribution of drug resistance mutations for low viral suppression in HIV-positive participants in a population-based sero-prevalence survey in rural South Africa. METHODS: We conducted HIV drug resistance genotyping and ART analyte testing on dried blood spots (DBS) from HIV-positive adults participating in a 2014 survey in North West Province. Among those with virologic failure (> 5000 copies/mL), we describe frequency of DRM to protease inhibitors (PI), nucleoside reverse transcriptase inhibitors (NRTI), and non-nucleoside reverse transcriptase inhibitors (NNRTI), report association of resistance with antiretroviral therapy (ART) status, and assess resistance to first and second line therapy. Analyses are weighted to account for sampling design. RESULTS: Overall 170 DBS samples were assayed for viral load and ART analytes; 78.4% of men and 50.0% of women had evidence of virologic failure and were assessed for drug resistance, with successful sequencing of 76/107 samples. We found ≥1 DRM in 22% of participants; 47% were from samples with detectable analyte (efavirenz, nevirapine or lopinavir). Of those with DRM and detectable analyte, 60% showed high-level resistance and reduced predicted virologic response to ≥1 NRTI/NNRTI typically used in first and second-line regimens. CONCLUSIONS: DRM and predicted reduced susceptibility to first and second-line regimens were common among adults with ART exposure in a rural South African population-based sample. Results underscore the importance of ongoing virologic monitoring, regimen optimization and adherence counseling to optimize durable virologic suppression.

Improvements in the South African HIV care cascade: findings on 90-90-90 targets from successive population-representative surveys in North West Province.

INTRODUCTION: To achieve epidemic control of HIV by 2030, countries aim to meet 90-90-90 targets to increase knowledge of HIV-positive status, initiation of antiretroviral therapy (ART) and viral suppression by 2020. We assessed the progress towards these targets from 2014 to 2016 in South Africa as expanded treatment policies were introduced using population-representative surveys. METHODS: Data were collected in January to March 2014 and August to November 2016 in Dr. Ruth Segomotsi Mompati District, North West Province. Each multi-stage cluster sample included 46 enumeration areas (EA), a target of 36 dwelling units (DU) per EA, and a single resident aged 18 to 49 per DU. Data collection included behavioural surveys, rapid HIV antibody testing and dried blood spot collection. We used weighted general linear regression to evaluate differences in the HIV care continuum over time. RESULTS: Overall, 1044 and 971 participants enrolled in 2014 and 2016 respectively with approximately 77% undergoing HIV testing. Despite increases in reported testing, known status among people living with HIV (PLHIV) remained similar at 68.7% (95% Confidence Interval (CI) = 60.9-75.6) in 2014 and 72.8% (95% CI = 63.6-80.4) in 2016. Men were consistently less likely than women to know their status. Among those with known status, PLHIV on ART increased significantly from 80.9% (95% CI = 71.9-87.4) to 91.5% (95% CI = 84.4-95.5). Viral suppression (<5000 copies/mL using DBS) among those on ART increased significantly from 55.0% (95% CI = 39.6-70.4) in 2014 to 81.4% (95% CI = 72.0-90.8) in 2016. Among all PLHIV an estimated 72.0% (95% CI = 63.8-80.1) of women and 45.8% (95% CI = 27.0-64.7) of men achieved viral suppression by 2016. CONCLUSIONS: Over a period during which fixed-dose combination was introduced, ART eligibility expanded, and efforts to streamline treatment were implemented, major improvements in the second and third 90-90-90 targets were achieved. Achieving the first 90 target will require targeted and improved testing models for men.

Beyond Social Desirability Bias: Investigating Inconsistencies in Self-Reported HIV Testing and Treatment Behaviors Among HIV-Positive Adults in North West Province, South Africa.

This mixed-methods study used qualitative interviews to explore discrepancies between self-reported HIV care and treatment-related behaviors and the presence of antiretroviral medications (ARVs) in a population-based survey in South Africa. ARV analytes were identified among 18% of those reporting HIV-negative status and 18% of those reporting not being on ART. Among participants reporting diagnosis over a year prior, 19% reported multiple HIV tests in the past year. Qualitative results indicated that participant misunderstandings about their care and treatment played a substantial role in reporting inaccuracies. Participants conflated the term HIV test with CD4 and viral load testing, and confusion with terminology was compounded by recall difficulties. Data entry errors likely also played a role. Frequent discrepancies between biomarkers and self-reported data were more likely due to poor understanding of care and treatment and biomedical terminology than intentional misreporting. Results indicate a need for improving patient-provider communication, in addition to incorporating objective measures of treatment and care behaviors such as ARV analytes, to reduce inaccuracies.

Context matters: Community social cohesion and health behaviors in two South African areas.

BACKGROUND: Understanding how social contexts shape HIV risk will facilitate development of effective prevention responses. Social cohesion, the trust and connectedness experienced in communities, has been associated with improved sexual health and HIV-related outcomes, but little research has been conducted in high prevalence settings. METHODS: We conducted population-based surveys with adults 18-49 in high HIV prevalence districts in Mpumalanga (n = 2057) and North West Province (n = 1044), South Africa. Community social cohesion scores were calculated among the 70 clusters. We used multilevel logistic regression stratified by gender to assess individual- and group-level associations between social cohesion and HIV-related behaviors: recent HIV testing, heavy alcohol use, and concurrent sexual partnerships. RESULTS: Group-level cohesion was protective in Mpumalanga, where perceived social cohesion was higher. For each unit increase in group cohesion, the odds of heavy drinking among men were reduced by 40% (95%CI 0.25, 0.65); the odds of women reporting concurrent sexual partnerships were reduced by 45% (95%CI 0.19, 1.04; p = 0.06); and the odds of reporting recent HIV testing were 1.6 and 1.9 times higher in men and women, respectively. CONCLUSIONS: We identified potential health benefits of cohesion across three HIV-related health behaviors in one region with higher overall evidence of group cohesion. There may be a minimum level of cohesion required to yield positive health effects.

Engaging HIV-positive clients in care: acceptability and mechanisms of action of a peer navigation program in South Africa.

Antiretroviral therapy (ART) could curtail the HIV epidemic, but its impact is diminished by low uptake. We developed a peer navigation program to enhance engagement in HIV care, ART adherence, and behavioral prevention. In preparation for a randomized controlled trial, the program was piloted over four months at two primary health clinics in South Africa's North West Province. Newly diagnosed, HIV-positive clients met regularly with navigators to address barriers to care, adherence, and prevention. To assess program acceptability and feasibility and characterize the mechanisms of action, we surveyed 25 clients who completed navigation services and conducted interviews with 10 clients, four navigators, and five clinic providers. Clients expressed near universal approval for the program and were satisfied with the frequency of contact with navigators. HIV stigma emerged as a primary driver of barriers to care. Navigators helped clients overcome feelings of shame through education and by modeling how to live successfully with HIV. They addressed discrimination fears by helping clients disclose to trusted individuals. These actions, in turn, facilitated clients' care engagement, ART adherence, and HIV prevention efforts. The findings suggest peer navigation is a feasible approach with potential to maximize the impact of ART-based HIV treatment and prevention strategies.

Pre/post evaluation of a pilot prevention with positives training program for healthcare providers in North West Province, Republic of South Africa.

BACKGROUND: Prevention interventions for people living with HIV/AIDS are an important component of HIV programs. We report the results of a pilot evaluation of a four-hour, clinic-based training for healthcare providers in South Africa on HIV prevention assessments and messages. This pre/post pilot evaluation examined whether the training was associated with providers delivering more prevention messages. METHODS: Seventy providers were trained at four public primary care clinics with a high volume of HIV patients. Pre- and post-training patient exit surveys were conducted using Audio-Computer Assisted Structured Interviews. Seven provider appropriate messaging outcomes and one summary provider outcome were compared pre- and post-training using Poisson regression. RESULTS: Four hundred fifty-nine patients pre-training and 405 post-training with known HIV status were interviewed, including 175 and 176 HIV positive patients respectively. Among HIV positive patients, delivery of all appropriate messages by providers declined post-training. The summary outcome decreased from 56 to 50%; adjusted rate ratio 0.92 (95% CI = 0.87-0.97). Sensitivity analyses adjusting for training coverage and time since training detected fewer declines. Among HIV negative patients the summary score was stable at 32% pre- and post-training; adjusted rate ratio 1.05 (95% CI = 0.98-1.12). CONCLUSIONS: Surprisingly, this training was associated with a decrease in prevention messages delivered to HIV positive patients by providers. Limited training coverage and delays between training and post-training survey may partially account for this apparent decrease. A more targeted approach to prevention messages may be more effective.

Attrition and Opportunities Along the HIV Care Continuum: Findings From a Population-Based Sample, North West Province, South Africa.

BACKGROUND: Attrition along the HIV care continuum slows gains in mitigating the South African HIV epidemic. Understanding population-level gaps in HIV identification, linkage, retention in care, and viral suppression is critical to target programming. METHODS: We conducted a population-based household survey, HIV rapid testing, point-of-care CD4 testing, and viral load measurement from dried blood spots using multistage cluster sampling in 2 subdistricts of North West Province from January to March, 2014. We used weighting and multiple imputation of missing data to estimate HIV prevalence, undiagnosed infection, linkage and retention in care, medication adherence, and viral suppression. RESULTS: We sampled 1044 respondents aged 18-49. HIV prevalence was 20.0% (95% confidence interval: 13.7 to 26.2) for men and 26.7% (95% confidence interval: 22.1 to 31.4) for women. Among those HIV positive, 48.4% of men and 75.7% of women were aware of their serostatus; 44.0% of men and 74.8% of women reported ever linking to HIV care; 33.1% of men and 58.4% of women were retained in care; and 21.6% of men and 50.0% of women had dried blood spots viral loads <5000 copies per milliliter. Among those already linked to care, 81.7% on antiretroviral treatment (ART) and 56.0% of those not on ART were retained in care, and 51.8% currently retained in care on ART had viral loads <5000 copies per milliliter. CONCLUSIONS: Despite expanded treatment in South Africa, attrition along the continuum of HIV care is slowing prevention progress. Improved detection is critically needed, particularly among men. Reported linkage and retention is reasonable for those on ART; however, failure to achieve viral suppression is worrisome.

Evaluation of short message service and peer navigation to improve engagement in HIV care in South Africa: study protocol for a three-arm cluster randomized controlled trial.

BACKGROUND: In countries with a high burden of HIV, such as South Africa, where the epidemic remains the world's largest, improving early uptake of and consistent adherence to antiretroviral therapy could bring substantial HIV prevention gains. However, patients are not linked to or retained in care at rates needed to curtail the epidemic. Two strategies that have demonstrated a potential to stem losses along the HIV care cascade in the sub-Saharan African context are use of text messaging or short message service (SMS) and peer-navigation services. METHODS/DESIGN: We designed a cluster randomized trial to assess the efficacy of an SMS intervention and a peer-navigation intervention to improve retention in care and treatment, timely linkage to care and treatment, medication adherence, and prevention behaviors in South Africa. Eighteen primary and community healthcare clinics in Rustenburg and Moses Kotane Sub-districts in the North West Province were randomized to one of three conditions: SMS intervention (n = 7), peer navigation intervention (n = 7), or standard of care (n = 4). Approximately 42 participants are being recruited at each clinic, which will result in a target of 750 participants. Eligible participants include patients accessing HIV testing or care in a study clinic, recently diagnosed with HIV, aged 18 years or older, and with access to a cellular telephone where they are willing to receive automated SMS with HIV-related messaging. Data collection includes extraction of visit information from clinical files and participant surveys at baseline, 6 months, and 12 months. Intent-to-treat (ITT) analysis will explore differences between randomization arms and the primary outcome of patient retention in care at 12 months following enrollment. We will also explore secondary outcomes including participants' a) timely linkage to care (within 3 months of HIV diagnosis), b) adherence to treatment based on self-report and clinic's medication dispensation dates, and c) condom-use behaviors. DISCUSSION: The findings will allow us to compare the efficacy of two complementary interventions, one that requires fewer resources to implement (SMS) and one (peer navigation) that offers more flexibility in terms of the patient barriers to care that it can address. TRIAL REGISTRATION: NCT02417233, registered 12 December 2014.

Scaling-up voluntary medical male circumcision - what have we learned?

In 2007, the World Health Organization (WHO) and the joint United Nations agency program on HIV/AIDS (UNAIDS) recommended voluntary medical male circumcision (VMMC) as an add-on strategy for HIV prevention. Fourteen priority countries were tasked with scaling-up VMMC services to 80% of HIV-negative men aged 15-49 years by 2016, representing a combined target of 20 million circumcisions. By December 2012, approximately 3 million procedures had been conducted. Within the following year, there was marked improvement in the pace of the scale-up. During 2013, the total number of circumcisions performed nearly doubled, with approximately 6 million total circumcisions conducted by the end of the year, reaching 30% of the initial target. The purpose of this review article was to apply a systems thinking approach, using the WHO health systems building blocks as a framework to examine the factors influencing the scale-up of the VMMC programs from 2008-2013. Facilitators that accelerated the VMMC program scale-up included: country ownership; sustained political will; service delivery efficiencies, such as task shifting and task sharing; use of outreach and mobile services; disposable, prepackaged VMMC kits; external funding; and a standardized set of indicators for VMMC. A low demand for the procedure has been a major barrier to achieving circumcision targets, while weak supply chain management systems and the lack of adequate financial resources with a heavy reliance on donor support have also adversely affected scale-up. Health systems strengthening initiatives and innovations have progressively improved VMMC service delivery, but an understanding of the contextual barriers and the facilitators of demand for the procedure is critical in reaching targets. There is a need for countries implementing VMMC programs to share their experiences more frequently to identify and to enhance best practices by other programs.

Strengthening monitoring and evaluation (M&E) and building sustainable health information systems in resource limited countries: lessons learned from an M&E task-shifting initiative in Botswana.

BACKGROUND: The demand for quality data and the interest in health information systems has increased due to the need for country-level progress reporting towards attainment of the United Nations Millennium Development Goals and global health initiatives. To improve monitoring and evaluation (M&E) of health programs in Botswana, 51 recent university graduates with no experience in M&E were recruited and provided with on-the-job training and mentoring to develop a new cadre of health worker: the district M&E officer. Three years after establishment of the cadre, an assessment was conducted to document achievements and lessons learnt. METHODS: This qualitative assessment included in-depth interviews at the national level (n = 12) with officers from government institutions, donor agencies, and technical organizations; and six focus group discussions separately with district M&E officers, district managers, and program officers coordinating different district health programs. RESULTS: Reported achievements of the cadre included improved health worker capacity to monitor and evaluate programs within the districts; improved data quality, management, and reporting; increased use of health data for disease surveillance, operational research, and planning purposes; and increased availability of time for nurses and other health workers to concentrate on core clinical duties. Lessons learnt from the assessment included: the importance of clarifying roles for newly established cadres, aligning resources and equipment to expectations, importance of stakeholder collaboration in implementation of sustainable programs, and ensuring retention of new cadres. CONCLUSION: The development of a dedicated M&E cadre at the district level contributed positively to health information systems in Botswana by helping build M&E capacity and improving data quality, management, and data use. This assessment has shown that such cadres can be developed sustainably if the initiative is country-led, focusing on recruitment and capacity-development of local counterparts, with a clear government retention plan.

Maximizing the benefit of health workforce secondment in Botswana: an approach for strengthening health systems in resource-limited settings.

To address health systems challenges in limited-resource settings, global health initiatives, particularly the President's Emergency Plan for AIDS Relief, have seconded health workers to the public sector. Implementation considerations for secondment as a health workforce development strategy are not well documented. The purpose of this article is to present outcomes, best practices, and lessons learned from a President's Emergency Plan for AIDS Relief-funded secondment program in Botswana. Outcomes are documented across four World Health Organization health systems' building blocks. Best practices include documentation of joint stakeholder expectations, collaborative recruitment, and early identification of counterparts. Lessons learned include inadequate ownership, a two-tier employment system, and ill-defined position duration. These findings can inform program and policy development to maximize the benefit of health workforce secondment. Secondment requires substantial investment, and emphasis should be placed on high-level technical positions responsible for building systems, developing health workers, and strengthening government to translate policy into programs.

Improving the quality of health information: a qualitative assessment of data management and reporting systems in Botswana.

BACKGROUND: Ensuring that data collected through national health information systems are of sufficient quality for meaningful interpretation is a challenge in many resource-limited countries. An assessment was conducted to identify strengths and weaknesses of the health data management and reporting systems that capture and transfer routine monitoring and evaluation (M&E) data in Botswana. METHODS: This was a descriptive, qualitative assessment. In-depth interviews were conducted at the national (n = 27), district (n = 31), and facility/community (n = 71) levels to assess i) M&E structures, functions, and capabilities; ii) indicator definitions and reporting guidelines; iii) data collection forms and tools; iv) data management processes; and v) links with the national reporting system. A framework analysis was conducted using ATLAS.ti v6.1. RESULTS: Health programs generally had standardized data collection and reporting tools and defined personnel for M&E responsibilities at the national and district levels. Best practices unique to individual health programs were identified and included a variety of relatively low-resource initiatives such as attention to staffing patterns, making health data more accessible for evidence-based decision-making, developing a single source of information related to indicator definitions, data collection tools, and management processes, and utilization of supportive supervision visits to districts and facilities. Weakness included limited ownership of M&E-related duties within facilities, a lack of tertiary training programs to build M&E skills, few standard practices related to confidentiality and document storage, limited dissemination of indicator definitions, and limited functionality of electronic data management systems. CONCLUSIONS: Addressing fundamental M&E system issues, further standardization of M&E practices, and increasing health services management responsiveness to time-sensitive information are critical to sustain progress related to health service delivery in Botswana. In addition to high-resource initiatives, such as investments in electronic medical record systems and tertiary training programs, there are a variety of low-resource initiatives, such as regular data quality checks, that can strengthen national health information systems. Applying best practices that are effective within one health program to data management and reporting systems of other programs is a practical approach for strengthening health informatics and improving data quality.

Introduction to special issue: advancing the ethics of community-based participatory research.

Increasingly communities are engaging in community-based participatory research (CBPR) to address their pressing health concerns, frequently in partnership with institutions. CBPR with its underlying values challenges us to expand the traditional framework of ethical analysis to include community-level and partnership-oriented considerations. This special issue considers ethical considerations inherent in CBPR, presents examples of how communities have created their own processes for research ethics review, and identifies challenges CBPR teams may encounter with institution-based research ethics committees. Drawing upon the special issue articles and the work conducted by Community-Campus Partnerships for Health and the Tuskegee University National Center for Bioethics in Research and Health Care, we propose an approach and a set of strategies to create a system of research ethics review that more fully accounts for individual and community-level considerations.