Person-centred interventions to improve patient-provider relationships for HIV services in low- and middle-income countries: a systematic review.

INTRODUCTION: Person-centred care (PCC) has been recognized as a critical element in delivering quality and responsive health services. The patient-provider relationship, conceptualized at the core of PCC in multiple models, remains largely unexamined in HIV care. We conducted a systematic review to better understand the types of PCC interventions implemented to improve patient-provider interactions and how these interventions have improved HIV care continuum outcomes and person-reported outcomes (PROs) among people living with HIV in low- and middle-income countries. METHODS: We searched databases, conference proceedings and conducted manual targeted searches to identify randomized trials and observational studies published up to January 2023. The PCC search terms were guided by the Integrative Model of Patient-Centeredness by Scholl. We included person-centred interventions aiming to enhance the patient-provider interactions. We included HIV care continuum outcomes and PROs. RESULTS: We included 28 unique studies: 18 (64.3%) were quantitative, eight (28.6.%) were mixed methods and two (7.1%) were qualitative. Within PCC patient-provider interventions, we inductively identified five categories of PCC interventions: (1) providing friendly and welcoming services; (2) patient empowerment and improved communication skills (e.g. supporting patient-led skills such as health literacy and approaches when communicating with a provider); (3) improved individualized counselling and patient-centred communication (e.g. supporting provider skills such as training on motivational interviewing); (4) audit and feedback; and (5) provider sensitisation to patient experiences and identities. Among the included studies with a comparison arm and effect size reported, 62.5% reported a significant positive effect of the intervention on at least one HIV care continuum outcome, and 100% reported a positive effect of the intervention on at least one of the included PROs. DISCUSSION: Among published HIV PCC interventions, there is heterogeneity in the components of PCC addressed, the actors involved and the expected outcomes. While results are also heterogeneous across clinical and PROs, there is more evidence for significant improvement in PROs. Further research is necessary to better understand the clinical implications of PCC, with fewer studies measuring linkage or long-term retention or viral suppression. CONCLUSIONS: Improved understanding of PCC domains, mechanisms and consistency of measurement will advance PCC research and implementation.

Factors associated with enrollment into differentiated service delivery model among adults with HIV in Kenya.

INTRODUCTION: Differentiated service delivery (DSD) such as multimonth dispensing (MMD) aims to provide client-centered HIV services, while reducing the workload within health facilities. We assessed individual and facility factors associated with receiving more than three MMD and switching from ≥3MMD back to <3MMD in Kenya. METHODS: We conducted a retrospective cohort study of clients eligible for DSD between July 2017 and December 2019. A random sample of clients eligible for DSD was selected from 32 randomly selected facilities located in Nairobi, Kisii, and Migori counties. We used a multilevel Poisson regression model to assess the factors associated with receiving ≥3MMD, and with switching from ≥3MMD back to <3MMD. RESULTS: A total of 3501 clients eligible for ≥3MMD were included in our analysis: 1808 (51.6%) were receiving care in Nairobi County and the remaining 1693 (48.4%) in Kisii and Migori counties. Overall, 65% of clients were enrolled in ≥3MMD at the time of entry into the cohort. In the multivariable model, younger age (20-24; 25-29; 30-34 vs. 50 or more years) and switching ART regimen was significantly associated with a lower likelihood of ≥3MMD uptake. Factors associated with a higher likelihood of enrollment in ≥3MMD included receiving DTG vs. EFV-based ART regimen (aRR: 1.10; 95% confidence interval: 1.05-1.15). CONCLUSION: Client-level characteristics are associated with being on ≥3MMD and the likelihood of switching from ≥3MMD to <3MMD. Monitoring DSD enrollment across different populations is critical to successfully implementing these models continually.

Effect of Test and Treat on clinical outcomes in Nigeria: A national retrospective study.

BACKGROUND: In Nigeria, results from the pilot of the Test and Treat strategy showed higher loss to follow up (LTFU) among people living with HIV compared to before its implementation. The aim of this evaluation was to assess the effects of antiretroviral therapy (ART) initiation within 14 days on LTFU at 12 months and viral suppression. METHODS: We conducted a retrospective cohort study using routinely collected de-identified patient-level data hosted on the Nigeria National Data Repository from 1,007 facilities. The study population included people living with HIV age ≥15. We used multivariable Cox proportional frailty hazard models to assess time to LTFU comparing ART initiation strategy and multivariable log-binomial regression for viral suppression. RESULTS: Overall, 26,937 (38.13%) were LTFU at 12 months. Among individuals initiated within 14 days, 38.4% were LTFU by 12 months compared to 35.4% for individuals initiated >14 days (p<0.001). In the adjusted analysis, individuals who were initiated ≤14 days after HIV diagnosis had a higher hazard of being LTFU (aHR 1.15, 95% CI 1.10-1.20) than individuals initiated after 14 days of HIV diagnosis. Among individuals with viral load results, 86.2% were virally suppressed. The adjusted risk ratio for viral suppression among individuals who were initiated ≤14 days compared to >14 days was not statistically significant. CONCLUSION: LTFU was higher among individuals who were initiated within 14 days compared to greater than 14 days after HIV diagnosis. There was no difference for viral suppression. The provision of early tailored interventions to support newly diagnosed people living may contribute to reducing LTFU.

Feasibility and acceptability of peer-delivered interventions using mHealth for PrEP services among adolescent girls and young women in DREAMS program in Botswana.

BACKGROUND: Adolescent girls and young women accounted for 25% of all new HIV infections despite representing only 10% of the population in Sub Saharan Africa. PEPFAR has launched the Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe (DREAMS) initiative, a comprehensive HIV prevention program including PrEP services. Among adolescent girls and young women, PrEP adherence is currently sub-optimal. Tailored strategies for adolescent girls and young women to improve access and use of PrEP delivery are urgently needed to maximise its potential. Recommended interventions include peer-delivered interventions using mobile technology. However, data on the feasibility and acceptability of this approach is limited for SSA. OBJECTIVES: We assessed the feasibility and perceived acceptability of providing mHealth peer-delivered interventions to support PrEP services among adolescent girls and young women in Botswana. METHODS: This cross-sectional study included HIV-negative women aged 18-24 years old seeking health services at DREAMS-supported facilities. Participants completed a survey assessing the feasibility and perceived acceptability of the mHealth peer-delivered interventions, which included the Acceptability of Intervention Measure (AIM). Descriptive analyses were performed. RESULTS: A total of 131 participated in the study. Overall, 89% owned a mobile phone (feasibility). There was no difference in cell phone ownership between participants from rural and urban settings. Among participants, 85% reported interest in participating in a mHealth peer-delivered intervention if it was available to them. Regarding perceived acceptability for mHealthpeer support groups for PrEP, the average score on the AIM was 3.8 out of 5 (SD = 0.8). CONCLUSION: mHealthpeer-delivered interventions appear to be feasible and perceived acceptable among adolescent girls and young women in Botswana. This modality should be incorporated into PEPFAR's programmatic toolkit of implementation strategies to improve PrEP services.

Achieving HIV Epidemic Control and Improving Maternal Healthcare Services with Community-Based HIV Service Delivery in Zambia: Mixed-Methods Assessment of the SMACHT Project.

Novel community-based approaches are needed to achieve and sustain HIV epidemic control in Zambia. Under the Stop Mother and Child HIV Transmission (SMACHT) project, the Community HIV Epidemic Control (CHEC) differentiated service delivery model used community health workers to support HIV testing, ART linkage, viral suppression, and prevention of mother-to-child transmission (MTCT). A multi-methods assessment included programmatic data analysis from April 2015 to September 2020, and qualitative interviews from February to March 2020. CHEC provided HIV testing services to 1,379,387 clients; 46,138 were newly identified as HIV-positive (3.3% yield), with 41,366 (90%) linked to ART. By 2020, 91% (60,694/66,841) of clients on ART were virally suppressed. Qualitatively, healthcare workers and clients benefitted from CHEC, with provision of confidential services, health facility decongestion, and increased HIV care uptake and retention. Community-based models can increase uptake of HIV testing and linkage to care, and help achieve epidemic control and elimination of MTCT.

Addressing the Need for a Preexposure Prophylaxis Monitoring and Evaluation Implementation Guide: Experience From Zambia.

BACKGROUND: The HIV care continuum comprises well-defined steps and indicators. In contrast, indicators along the preexposure prophylaxis (PrEP) cascade are still in the early stages of implementation. Monitoring and evaluation (M&E) of PrEP services is critical to optimizing PrEP uptake and adherence during periods of HIV risk. We provide an overview of global indicators for PrEP, describe the development process and outcomes of Zambia's 2022 National Pre-Exposure Prophylaxis (PrEP) Program Monitoring & Evaluation Implementation Guide, and discuss the guide's implications for other countries in sub-Saharan Africa. NATIONAL M&E GUIDE DEVELOPMENT PROCESS: During the scale-up of PrEP, the Zambia Ministry of Health (MOH) and the National HIV/AIDS/STI/TB Council recognized the need for a national unified monitoring system to guide the effective implementation of PrEP services. Stakeholders from the MOH, civil society, professional organizations, funding agencies, and implementing partners developed the National Pre-Exposure Prophylaxis (PrEP) Program Monitoring & Evaluation Implementation Guide. This guide is aligned with the existing global indicators from the World Health Organization and the U.S. President's Emergency Plan for AIDS Relief and adapted to the country's needs, context, and health information systems. Zambia's experience in developing the guide has highlighted the importance of strengthening client-level monitoring systems for HIV prevention, ensuring flexibility of the PrEP monitoring system to accommodate PrEP delivery modalities and differentiated service delivery models, and training health workers to enhance PrEP services and deliver care PrEP services along the continuum to prevent HIV acquisition effectively. CONCLUSIONS: Using a collaborative and consensus-based approach, Zambia developed its first national PrEP M&E implementation guide to provide standardized guidelines for optimizing the delivery, monitoring, and evaluation of PrEP service delivery. Zambia's experience can inform other countries in sub-Saharan Africa as they develop national M&E implementation approaches for PrEP.

Scale-up of HIV index testing in an urban population: Experiences and achievements from Nairobi County, Kenya.

OBJECTIVE: To describe the implementation strategies of the index testing program across Nairobi County in Kenya, assess outcomes along the HIV index testing cascade (acceptance, elicitation ratio, HIV positivity and linkage to treatment), and assess annual changes along the HIV index testing cascade during the first 2 years of implementation. METHODS: Retrospective analysis of programmatic aggregate data collected from October 2017 to September 2019 after the roll-out of index testing services in 48 health facilities in Nairobi County. Proportions and ratios were calculated for acceptance, elicitation ratio, testing uptake and HIV positivity. We compared these outcomes between years using a chi-squared test, Fisher's exact test or Wilcoxon sign test, and we assessed trends using the Mann-Kendall test. RESULTS: Testing among eligible partners increased from 42.4% (1471/3470) to 74.9% (6114/8159) in the general population, and the positivity yield remained high across both years (25.2% in year 1 and 24.1% in year 2). Index testing positivity yield remained significantly higher than other testing modalities (24.3% vs. 1.3%, p < 0.001). The contribution of index testing services to the total number of HIV-positive individuals identified increased from 7.5% in the first year to 28.6% in the second year (p < 0.001). More men were tested, but the positivity yield was higher among women (30.0%) and those aged 50 years or older (32.4%). Testing eligible partners in key populations (KPs) decreased from 52.4% (183/349) to 40.7% (109/268) (p = 0.674); however, the HIV positivity yield increased from 8.6% to 23.9% (p < 0.001) by the second year of implementation. The HIV positivity yield from index testing remained higher than other testing modalities (14% vs. 0.9%, p < 0.001) for KPs. CONCLUSION: Index testing was well-accepted and effective in identifying individuals living with HIV in a Kenyan urban setting across both general populations and KPs. Ongoing adaptations to the strategies deployed as part of index testing services helped improve most of the outcomes along the index testing cascade.

Individual and household factors associated with non-disclosure of positive HIV status in a population-based HIV serosurvey.

OBJECTIVES: Non-disclosure of positive HIV status in population-based surveys causes underestimation of national HIV diagnosis and biases inferences about engagement in the care continuum. This study investigated individual and household factors associated with HIV non-disclosure to survey interviewers in Nigeria. DESIGN: Secondary analysis of a cross sectional population-based household HIV survey. METHODS: We analyzed data from adults aged 15-64 years who tested positive for HIV and had antiretroviral drugs (ARVs) in their blood from a nationally representative HIV sero-survey conducted in Nigeria in 2018. We considered ARV use as a proxy for knowledge of HIV diagnosis; thus, respondents who self-reported to be unaware of their HIV status were classified as non-disclosers. We estimated the associations between non-disclosure and various sociodemographic, clinical, and household characteristics using weighted logistic regression. RESULTS: Among 1266 respondents living with HIV who were taking ARVs, 503 (40%) did not disclose their HIV status to interviewers. In multivariable statistical analyses, the adjusted odds of non-disclosure were highest among respondents aged 15-24 years, those with less than a primary school education, and those who were the only person living with HIV in their household. CONCLUSIONS: Non-disclosure of positive HIV status to survey personnel is common among adults who are receiving treatment in Nigeria. These findings highlight the importance of validating self-reported HIV status in surveys using biomarkers of ARV use. Meanwhile, it is crucial to improve disclosure by strengthening interview procedures and tailoring strategies towards groups that are disproportionately likely to underreport HIV diagnoses.

Peer community health workers improve HIV testing and ART linkage among key populations in Zambia: retrospective observational results from the Z-CHECK project, 2019-2020.

INTRODUCTION: Zambia has made tremendous progress towards HIV epidemic control; however, gaps remain among key populations (KPs), such as female sex workers (FSWs), men who have sex with men (MSM), people who inject drugs (PWID) and people in prisons and enclosed settings due to cultural, social and legal barriers. The University of Maryland, Baltimore Zambia Community HIV Epidemic Control for Key Populations (Z-CHECK) project aimed to improve HIV case-finding, linkage and treatment adherence at the community level for KPs in Zambia. We describe Z-CHECK strategies and examine HIV positivity yield and antiretroviral therapy (ART) linkage among KPs to inform ongoing programme improvement. METHODS: Z-CHECK recruited, trained and deployed peer community health workers (CHWs) for KP groups, with ongoing mentorship in community engagement. CHWs offered HIV testing in safe spaces and escorted newly HIV-diagnosed clients for same-day ART initiation. Z-CHECK also reached out to KP community leaders and gatekeepers for KP mobilization and trained healthcare workers (HCWs) on KP services and sensitivity. We conducted a retrospective observational review of routinely collected aggregate data for KPs aged ≥15 years at high risk for HIV transmission across five districts in Zambia from January 2019 to December 2020. RESULTS: Z-CHECK provided HIV testing for 9211 KPs, of whom 2227 were HIV positive (positivity yield, 24%). Among these, 1901 (85%) were linked to ART; linkage for MSM, FSW, PWID and people in prisons and enclosed settings was 95%, 89%, 86% and 65%, respectively. Programme strategies that contributed to high positivity yield and linkage included the use of peer KP CHWs, social network testing strategies and opportunities for same-day ART initiation. Challenges to programme implementation included stigma and discrimination among HCWs, as well as KP CHW attrition, which may be explained by high mobility. CONCLUSIONS: Peer CHWs were highly effective at reaching KP communities, identifying persons living with HIV and linking them to care. Engaging KP community gatekeepers resulted in high diffusion of health messages and increased access to health resources. The mobility of CHWs and HCWs is a challenge for programme implementation. Innovative interventions are needed to support PWID and people in prisons and enclosed settings.

Reaching transgender populations in Zambia for HIV prevention and linkage to treatment using community-based service delivery.

INTRODUCTION: Transgender and gender-diverse communities in Zambia are highly vulnerable and experience healthcare differently than cisgender persons. The University of Maryland, Baltimore (UMB) supports projects in Zambia to improve HIV case-finding, linkage and antiretroviral treatment (ART) for Zambia's transgender community. We describe programme strategies and outcomes for HIV prevention, testing and ART linkage among transgender communities. METHODS: UMB utilizes a differentiated service delivery model whereby community health workers (CHWs) recruited from key populations (KPs) reach community members through a peer-to-peer approach, with the support of local transgender civil society organizations (CSOs) and community gatekeepers. Peer CHWs are trained and certified as HIV testers and psychosocial counsellors to offer counselling with HIV testing and prevention services in identified safe spaces. HIV-negative people at risk of HIV infection are offered pre-exposure prophylaxis (PrEP), while those who test positive for HIV are linked to ART services. CHWs collect data using the standardized facility and community tools and a dedicated DHIS2 database system. We conducted a descriptive analysis examining HIV testing and prevention outcomes using proportions and comparisons by time period and geographic strata. RESULTS: From October 2020 to June 2021, across Eastern, Lusaka, Western and Southern Provinces, 1860 transgender persons were reached with HIV prevention messages and services. Of these, 424 (23%) were tested for HIV and 78 (18%) tested positive. Of the 346 HIV-negative persons, 268 (78%) eligible transgender individuals were initiated on PrEP. ART linkage was 97%, with 76 out of the 78 transgender individuals living with HIV initiating treatment. Programme strategies that supported testing and linkage included peer CHWs, social network strategy testing, same-day ART initiation and local KP CSO support. Challenges included non-transgender-friendly environments, stigma and discrimination, the high transiency of the transgender community and the non-availability of transgender-specific health services, such as hormonal therapy. CONCLUSIONS: Peer KP CHWs were able to reach many members of the transgender community, providing safe HIV testing, PrEP services and linkage to care. Focusing on community gatekeepers and CSOs to disburse health messages and employ welcoming strategies supported high linkage to both PrEP and ART for transgender people in Zambia.

Factors Associated with Retention in HIV Prevention and Treatment Clinical Services Among Female Sex Workers Enrolled in a Sex Workers' Outreach Program (SWOP) in Nairobi, Kenya.

Female sex workers (FSWs) are among the key populations (KP) prioritized for comprehensive HIV programming in Kenya. Retention in the program is critical for prevention of HIV acquisition and transmission among FSWs and their sexual partners. We conducted a retrospective cohort analysis of data collected from FSWs enrolled between October 2016 and September 2017 at seven drop-in centers (DICs) in Nairobi, Kenya, to assess factors associated with retention in HIV prevention and treatment services. We found a 3- and 12- month retention of 24% and 17%, respectively. FSWs aged 20-34 years old were less likely to be retained compared to those 50 years or older. FSWs enrolled in a DIC located in their sub-county of residence or reporting ever using HIV pre- or post-exposure prophylaxis were more likely to be retained. Engaging young FSWs to identify strategies to enhance retention should be prioritized. Strengthening the referral system across DICs may provide opportunities to enhance retention in facilities closer to their residence. Implementation research is needed to gain an additional understanding of the health services needs and preferences among FSWs to optimize retention for this population.

Testing modality associated with fast-track ART initiation in Botswana.

OBJECTIVES: The aim of this study was to identify community testing modalities associated with fast-track ART initiation in Botswana. METHODS: We conducted a retrospective cohort study that included all Botswana citizens 15 years or older who were newly identified as HIV-positive from 1 May 2017 to 31 January 2019, in Mahalapye and Southern districts. We used Poisson regression with robust error variance and generalised linear mixed models to control for cluster effects to model risk of ART initiation within 7 and 30 days of HIV diagnosis, testing modality factors. RESULTS: A total of 1436 individuals were newly identified HIV-positive, with men accounting for 60% across all testing modalities. 22% of all HIV-positive individuals were initiated on ART within 7 days. Clients diagnosed through index testing were more likely to be started on ART within 7 days (adjusted risk ratio [aRR] = 1.38, 95% CI 1.37-1.38) and 30 days (aRR = 1.17, 95% CI 1.09-1.26) than those diagnosed through mobile/outreach testing. CONCLUSIONS: Community HIV testing can complement facility-based testing by reaching individuals who may be less likely to seek HIV services at a facility, such as men. Monitoring ART initiation by testing modalities is critical to identify the optimal ones and to guide continuous programme improvement.

Re-Engagement into HIV Care: A Systematic Review.

Identifying evidence-based interventions that can optimize the re-engagement into care of people living with HIV is necessary to achieve and sustain HIV epidemic control. We conducted a systematic review of interventions for re-engagement into HIV care to examine the accumulated evidence and to identify similarities and differences across studies. Between January and March 2020, we searched MEDLINE, Embase, CINAHL, and PsycINFO databases for publications from 1996 to 2020. We screened 765 references and selected 125 publications for full-text review. For the nine included studies, the intervention centered on (1) integration of clinic and HIV surveillance data; (2) additional or different levels of support provided by healthcare workers; or (3) multi-component intervention. Irrespective of the interventions, mixed results were found for re-engagement into care or ART re-initiation. None of the studies led to an improvement in viral suppression. Re-engagement in HIV care is critical for longitudinal HIV and national program success. Standardizing definitions for out-of-care and re-engagement would facilitate the comparison of interventions. Rigorous study designs to assess strategies to enhance HIV re-engagement are warranted.

Improving same-day antiretroviral therapy in Botswana: effects of a multifaceted national intervention.

BACKGROUND: In 2019, the Botswana Ministry of Health and Wellness (MOHW) implemented an HIV national Reboot program, which was needed for refocusing and intensifying efforts for achieving epidemic control. The strategies deployed as part of Reboot were reviewed and evaluated for their effect on same-day and within-seven-days (fast-track initiation) antiretroviral therapy (ART) initiation among adults newly identified with HIV. METHODS: We conducted a retrospective cohort analysis of patients aged 18 years or older who were newly diagnosed with HIV from October 2018 to September 2019 across 41 health facilities. We used generalized linear mixed models, adjusting for clustering by facility, to assess the association of the Reboot with same-day or within-seven-days ART initiation (fast-track initiation). RESULTS: From October 2018 to January 2019, 28% (636/2269) of newly diagnosed HIV patients were initiated the same day of diagnosis, and 56% (1260/2269) were initiated within seven days. Following the launch of Reboot (February to September 2019), 59% (2092/3553) were initiated the same day of diagnosis, and 77% (2752/3553) were initiated within seven days. Clients were 2.08 (adjusted risk ratio 95% confidence interval 1.79-2.43) times more likely to be initiated the same day of diagnosis and 1.39 (adjusted risk ratio 95% confidence interval 1.28-1.52) times more likely to be initiated within seven days than before Reboot after adjusting for sex and age. CONCLUSION: In Botswana, a multifaceted national intervention improved timely ART initiation. Identifying and implementing different client-centered strategies to facilitate ART initiation is critical to preventing AIDS-related complications and prevent ongoing transmission.

Factors Associated with Loss to Follow-Up Among Patients Receiving HIV Treatment in Nairobi, Kenya.

We investigated factors associated with loss to follow-up (LTFU) in 24 urban health facilities in Nairobi, Kenya. We conducted a retrospective analysis of routinely collected data to assess factors associated with LTFU in the period October 1, 2016, to June 30, 2017. LTFU was defined as no antiretroviral therapy (ART) refill for ≥90 days and no documentation of transfer, death, or treatment cessation in the patient chart, and if no lapse of ≥90 days between ART refills, patients were considered retained in care. Multivariable logistic regression modeling was used to compute odds ratios and 95% confidence interval (CI) for LTFU. Our analysis included 633 individuals who were LTFU and 13,098 individuals retained in care. Most participants (69.6%) were women, and median age was 33.0 years (interquartile range, 27.2-38.3 years). Median ART duration was shorter among those LTFU (0.4 years) than retained patients (2.5 years, p < .0001). Being male [adjusted odds ratio (aOR) 1.30; 95% CI: 1.04-1.63, p = .02], transferring into facilities while already receiving ART (aOR 11.58; 95% CI: 8.23-16.29, p < .0001), and having a shorter ART duration (<6 months) were associated with increased odds of LTFU. Patients who transferred into a facility while already receiving ART had the highest adjusted odds of being LTFU compared with those retained in care. In this urban and highly mobile population, transferring into facilities while already receiving ART was strongly associated with LTFU. Focusing programming efforts on patients transferring between urban clinics to identify reasons for transfer and potential barriers to treatment adherence could help improve patient outcomes. Supplementary case management and support may be needed to promote a seamless transition and ensure uninterrupted engagement in HIV care and treatment.

Index and targeted community-based testing to optimize HIV case finding and ART linkage among men in Zambia.

INTRODUCTION: Current healthcare systems fail to provide adequate HIV services to men. In Zambia, 25% of adult men living with HIV were unaware of their HIV status in 2018, and 12% of those who were unaware of their HIV statu were not receiving antiretroviral therapy (ART) due to pervasive barriers to HIV testing services (HTS) and linkage to ART. To identify men and key and priority populations living with HIV in Zambia, and link them to care and treatment, we implemented the Community Impact to Reach Key and Underserved Individuals for Treatment and Support (CIRKUITS) project. We present HTS and ART linkage results from the first year of CIRKUITS. METHODS: CIRKUITS aimed to reach beneficiaries by training, mentoring, and deploying community health workers to provide index testing services and targeted community HTS. Community leaders and workplace supervisors were engaged to enable workplace HTS for men. To evaluate the effects of these interventions, we collected age- and sex-disaggregated routinely collected programme data for the first 12 months of the project (October 2018 to September 2019) across 37 CIRKUITS-supported facilities in three provinces. We performed descriptive statistics and estimated index cascades for indicators of interest, and used Chi square tests to compare indicators by age, sex, and district strata. RESULTS: Over 12 months, CIRKUITS tested 38,255 persons for HIV, identifying 10,974 (29%) new people living with HIV, of whom 10,239 (93%) were linked to ART. Among men, CIRKUITS tested 18,336 clients and identified 4458 (24%) as HIV positive, linked 4132 (93%) to ART. Men who tested HIV negative were referred to preventative services. Of the men found HIV positive, and 13.0% were aged 15 to 24 years, 60.3% were aged 25 to 39, 20.9% were aged 40 to 49 and 5.8% were ≥50 years old. Index testing services identified 2186 (49%) of HIV-positive men, with a positivity yield of 40% and linkage of 88%. Targeted community testing modalities accounted for 2272 (51%) of HIV-positive men identified, with positivity yield of 17% and linkage of 97%. CONCLUSIONS: Index testing and targeted community-based HTS are effective strategies to identify men living with HIV in Zambia. Index testing results in higher yield, but lower linkage and fewer absolute men identified compared to targeted community-based HTS.

Outbreak of Escherichia coli O157:H7 Infections Linked to Mechanically Tenderized Beef and the Largest Beef Recall in Canada, 2012.

Contaminated beef is a known vehicle of Escherichia coli O157:H7 infection, although more attention is given to the control of E. coli O157:H7 in ground, rather than whole-cut, beef products. In September 2012, an investigation was initiated at an Alberta, Canada, beef plant after the detection of E. coli O157:H7 in two samples of trim cut from beef originating from this plant. Later in September 2012, Alberta Health Services identified five laboratory-confirmed infections of E. coli O157:H7, and case patients reported eating needle-tenderized beef steaks purchased at a store in Edmonton, Alberta, produced with beef from the Alberta plant. In total, 18 laboratory-confirmed illnesses in Canada in September and October 2012 were linked to beef from the Alberta plant, including the five individuals who ate needle-tenderized steaks purchased at the Edmonton store. A unique strain of E. coli O157:H7, defined by molecular subtyping and whole genome sequencing, was detected in clinical isolates, four samples of leftover beef from case patient homes, and eight samples of Alberta plant beef tested by industry and food safety partners. Investigators identified several deficiencies in the control of E. coli O157:H7 at the plant; in particular, the evaluation of, and response to, the detection of E. coli O157 in beef samples during routine testing were inadequate. To control the outbreak, 4,000 tons of beef products were recalled, making it the largest beef recall in Canadian history. This outbreak, in combination with similar outbreaks in the United States and research demonstrating that mechanical tenderization can transfer foodborne pathogens present on the surface into the interior of beef cuts, prompted amendments to Canada's Food and Drug Regulations requiring mechanically tenderized beef to be labeled as such and to provide safe cooking instructions to consumers. A detailed review of this event also led to recommendations and action to improve the safety of Canada's beef supply.

Devices for preventing percutaneous exposure injuries caused by needles in healthcare personnel.

BACKGROUND: Percutaneous exposure injuries from devices used for blood collection or for injections expose healthcare workers to the risk of blood borne infections such as hepatitis B and C, and human immunodeficiency virus (HIV). Safety features such as shields or retractable needles can possibly contribute to the prevention of these injuries and it is important to evaluate their effectiveness. OBJECTIVES: To determine the benefits and harms of safety medical devices aiming to prevent percutaneous exposure injuries caused by needles in healthcare personnel versus no intervention or alternative interventions. SEARCH METHODS: We searched CENTRAL, MEDLINE, EMBASE, NHSEED, Science Citation Index Expanded, CINAHL, Nioshtic, CISdoc and PsycINFO (until 11 November 2016). SELECTION CRITERIA: We included randomised controlled trials (RCT), controlled before and after studies (CBA) and interrupted time-series (ITS) designs of the effect of safety engineered medical devices on percutaneous exposure injuries in healthcare staff. DATA COLLECTION AND ANALYSIS: Two of the authors independently assessed study eligibility and risk of bias and extracted data. We synthesized study results with a fixed-effect or random-effects model meta-analysis where appropriate. MAIN RESULTS: We included six RCTs with 1838 participants, two cluster-RCTs with 795 participants and 73,454 patient days, five CBAs with approximately 22,000 participants and eleven ITS with an average of 13.8 data points. These studies evaluated safe modifications of blood collection systems, intravenous (IV) systems, injection systems, multiple devices, sharps containers and legislation on the implementation of safe devices. We estimated the needlestick injury (NSI) rate in the control groups to be about one to five NSIs per 1000 person-years. There were only two studies from low- or middle-income countries. The risk of bias was high in 20 of 24 studies. Safe blood collection systems:We found one RCT that found a safety engineered blood gas syringe having no considerable effect on NSIs (Relative Risk (RR) 0.2, 95% Confidence Interval (95% CI) 0.01 to 4.14, 550 patients, very low quality evidence). In one ITS study, safe blood collection systems decreased NSIs immediately after the introduction (effect size (ES) -6.9, 95% CI -9.5 to -4.2) but there was no further decrease over time (ES -1.2, 95% CI -2.5 to 0.1, very low quality evidence). Another ITS study evaluated an outdated recapping shield, which we did not consider further. Safe Intravenous systemsThere was very low quality evidence in two ITS studies that NSIs were reduced with the introduction of safe IV devices, whereas one RCT and one CBA study provided very low quality evidence of no effect. However, there was moderate quality evidence produced by four other RCT studies that these devices increased the number of blood splashes when the safety system had to be engaged actively (relative risk (RR) 1.6, 95% CI 1.08 to 2.36). In contrast there was low quality evidence produced by two RCTs of passive systems that showed no effect on blood splashes. Yet another RCT produced low quality evidence that a different safe active IV system also decreased the incidence of blood leakages. Safe injection devicesThere was very low quality evidence provided by one RCT and one CBA study showing that introduction of safe injection devices did not considerably change the NSI rate. One ITS study produced low quality evidence showing that the introduction of safe passive injection systems had no effect on NSI rate when compared to safe active injection systems. Multiple safe devicesThere was very low quality evidence from one CBA study and two ITS studies. According to the CBA study, the introduction of multiple safe devices resulted in a decrease in NSI,whereas the two ITS studies found no change. Safety containersOne CBA study produced very low quality evidence showing that the introduction of safety containers decreased NSI. However, two ITS studies evaluating the same intervention found inconsistent results. LegislationThere was low to moderate quality evidence in two ITS studies that introduction of legislation on the use of safety-engineered devices reduced the rate of NSIs among healthcare workers. There was also low quality evidence which showed a decrease in the trend over time for NSI rates.Twenty out of 24 studies had a high risk of bias and the lack of evidence of a beneficial effect could be due to both confounding and bias. This does not mean that these devices are not effective. AUTHORS' CONCLUSIONS: For safe blood collection systems, we found very low quality evidence of inconsistent effects on NSIs. For safe passive intravenous systems, we found very low quality evidence of a decrease in NSI and a reduction in the incidence of blood leakage events but moderate quality evidence that active systems may increase exposure to blood. For safe injection needles, the introduction of multiple safety devices or the introduction of sharps containers the evidence was inconsistent or there was no clear evidence of a benefit. There was low to moderate quality evidence that introduction of legislation probably reduces NSI rates.More high-quality cluster-randomised controlled studies that include cost-effectiveness measures are needed, especially in countries where both NSIs and blood-borne infections are highly prevalent.

Effect of Maryland's 2011 Alcohol Sales Tax Increase on Alcohol-Positive Driving.

INTRODUCTION: The 2011 Maryland alcohol sales tax increase from 6% to 9% provided an opportunity to evaluate the impact on rates of alcohol-positive drivers involved in injury crashes. METHODS: Maryland police crash reports from 2001 to 2013 were analyzed using an interrupted time series design and a multivariable analysis employing generalized estimating equations models with a negative binomial distribution. Data were analyzed in 2014-2015. RESULTS: There was a significant gradual annual reduction of 6% in the population-based rate of all alcohol-positive drivers (p<0.03), and a 12% reduction for drivers aged 15-20 years (p<0.007), and 21-34 years (p<0.001) following the alcohol sales tax increase. There were no significant changes in rates of alcohol-positive drivers aged 35-54 years (rate ratio, 0.98; 95% CI=0.89, 1.09). Drivers aged ≥55 years had a significant immediate 10% increase in the rate of alcohol-positive drivers (rate ratio, 1.10; 95% CI=1.04, 1.16) and a gradual increase of 4.8% per year after the intervention. Models using different denominators and controlling for multiple factors including a proxy for unmeasured factors found similar results overall. CONCLUSIONS: The 2011 Maryland alcohol sales tax increase led to a significant reduction in the rate of all alcohol-positive drivers involved in injury crashes especially among drivers aged 15-34 years. This is the first study to examine the impact of alcohol sales taxes on crashes; previous research focused on excise tax. Increasing alcohol taxes is an important but often neglected intervention to reduce alcohol-impaired driving.

Evidence for the benefits of food chain interventions on E. coli O157:H7/NM prevalence in retail ground beef and human disease incidence: A success story.

OBJECTIVES: Human infection with Escherichia coli O157:H7/NM has historically been associated with consumption of undercooked ground beef. The purpose of this paper is to investigate the correlation of the decline in E. coli O157:H7/NM infections in Canada with the introduction of control efforts in ground beef by industry. METHODS: The human incidence of E. coli O157:H7/NM, prevalence in ground beef and interventions from 1996 to 2014 were analyzed. Pathogen prevalence data were obtained from federal government and industry surveillance and inspection/compliance programs. A survey of the largest ground beef producers in Canada was conducted to identify when interventions were implemented. RESULTS: The incidence of E. coli O157:H7/NM infections in Canada declined from ≈4 cases/100 000 to ≈1 case/100000 from 2000 to 2010. Verotoxigenic Escherichia coli (VTEC) prevalence in ground beef sold at retail declined from about 30% around the year 2000 to <2% since 2012. Other measures of the prevalence of E. coli, VTEC, and E. coli O157:H7/NM in beef and ground beef also declined. The number and types of interventions implemented in the major beef processing establishments in Canada increased from 1996 to 2016. CONCLUSION: The observed decline in human illnesses and pathogen levels in relation to retail meats was associated with the introduction of control efforts by industry, federal and provincial/territorial governments, and the general population. Industry-led changes in beef processing along with the introduction of food safety policies, regulations, and public education have led to improved food safety in Canada.