Development of a composite scoring system to rank communities at high risk of zero-dose children in Cameroon: A geospatial analysis.

Background: Despite growing efforts to improve access to vaccination, millions of children, especially in developing countries, have not received a single dose of diphtheria, tetanus, and pertussis (DTP) vaccine. Consequently, they are often called zero-dose children (ZDC). With limited health resources, prioritising communities for rapid and mass zero-dose catch-up vaccination in missed communities to avert epidemic outbreaks is complicated by unreliable denominators used to compute vaccination coverages. Incorporating other indicators of access and utilisation of vaccination services can help with identifying and ranking missed communities based on the likelihood of finding ZDC. We described the process of generating a scoring method to rank health areas in Cameroon based on their likelihood of containing ZDC. Methods: We used geospatial analysis to compute and aggregate health area characteristics, including hard-to-reach (HTR) areas (defined as areas of settlement above a one- (for urban areas) or 15-kilometre radius (for rural areas) beyond a vaccinating health facility), amount of area covered by slums and new area settlement, and percentage of children unvaccinated for DTP-1. We attributed a weight based on the ability to limit accessibility or utilisation of vaccination services to each characteristic and computed the score as a weighted average of health area characteristics. The health area score ranged from 0 to 1, with higher scores representing a higher likelihood of containing ZDC. We stratified the analysis by rural and urban health areas. Results: We observed substantial district and regional variations in health area scores, with hotspots health areas (administrative level 4) observed in the Far North (0.83), North (0.81), Adamawa (0.80), East (0.75), and South West (0.67) regions. The Adamawa region had the highest percentage of health areas with the highest score (78%), followed by the East (50%), West (48%), and North (46%) regions. For most regions (Far North, South, South West, Littoral, West, and North West), DTP-1 contributed the most to the score. However, HTR settlement areas within a health area contributed substantially to the overall score in the East, North, and Adamawa regions. Conclusions: We found substantial variations in health area scores with hotspots in the Far North, North, Adamawa, East, and South West regions. Although DTP-1 could be used as an indicator to identify health areas with ZDC for most communities, HTR settlement area was a valuable indicator in ranking priority health areas in the East, North, and Adamawa regions, further emphasising the need to consider other indicators before prioritisation.

The performance of using dried blood spot specimens for HIV-1 viral load testing: A systematic review and meta-analysis.

BACKGROUND: Accurate routine HIV viral load testing is essential for assessing the efficacy of antiretroviral treatment (ART) regimens and the emergence of drug resistance. While the use of plasma specimens is the standard for viral load testing, its use is restricted by the limited ambient temperature stability of viral load biomarkers in whole blood and plasma during storage and transportation and the limited cold chain available between many health care facilities in resource-limited settings. Alternative specimen types and technologies, such as dried blood spots, may address these issues and increase access to viral load testing; however, their technical performance is unclear. To address this, we conducted a meta-analysis comparing viral load results from paired dried blood spot and plasma specimens analyzed with commonly used viral load testing technologies. METHODS AND FINDINGS: Standard databases, conferences, and gray literature were searched in 2013 and 2018. Nearly all studies identified (60) were conducted between 2007 and 2018. Data from 40 of the 60 studies were included in the meta-analysis, which accounted for a total of 10,871 paired dried blood spot:plasma data points. We used random effects models to determine the bias, accuracy, precision, and misclassification for each viral load technology and to account for between-study variation. Dried blood spot specimens produced consistently higher mean viral loads across all technologies when compared to plasma specimens. However, when used to identify treatment failure, each technology compared best to plasma at a threshold of 1,000 copies/ml, the present World Health Organization recommended treatment failure threshold. Some heterogeneity existed between technologies; however, 5 technologies had a sensitivity greater than 95%. Furthermore, 5 technologies had a specificity greater than 85% yet 2 technologies had a specificity less than 60% using a treatment failure threshold of 1,000 copies/ml. The study's main limitation was the direct applicability of findings as nearly all studies to date used dried blood spot samples prepared in laboratories using precision pipetting that resulted in consistent input volumes. CONCLUSIONS: This analysis provides evidence to support the implementation and scale-up of dried blood spot specimens for viral load testing using the same 1,000 copies/ml treatment failure threshold as used with plasma specimens. This may support improved access to viral load testing in resource-limited settings lacking the required infrastructure and cold chain storage for testing with plasma specimens.

Private health care market shaping and changes in inequities in childhood diarrhoea treatment coverage: evidence from the analysis of baseline and endline surveys of an ORS and zinc scale-up program in Nigeria.

BACKGROUND: Nearly 90,000 under-five children die from diarrhoea annually in Nigeria. Over 90% of the deaths can be prevented with oral rehydration salt (ORS) and zinc treatment but coverage nationally was less than 34% for ORS and 3% for zinc with wide inequities. A program was implemented in eight states to address critical barriers to the optimal functioning of the health care market to deliver these treatments. In this study, we examine changes in the inequities of coverage of ORS and zinc over the intervention period. METHODS: Baseline and endline household surveys were used to measure ORS and zinc coverage and household assets. Principal component analysis was used to construct wealth quintiles. We used multi-level logistic regression models to estimate predictive coverage of ORS and zinc by wealth and urbanicity at each survey period. Simple measures of disparity and concentration indices and curves were used to evaluate changes in ORS and zinc coverage inequities. RESULTS: At baseline, 28% (95% CI: 22-35%) of children with diarrhoea from the poorest wealth quintile received ORS compared to 50% (95% CI: 52-58%) from the richest. This inequality reduced at endline as ORS coverage increased by 21%-points (P <  0.001) for the poorest and 17%-points (P <  0.001) for the richest. Zinc coverage increased significantly for both quintiles at endline from an equally low baseline coverage level. Consistent with the findings of the pairwise comparison of the poorest and the richest, the summary measure of disparity across all wealth quintiles showed a narrowing of inequities from baseline to endline. Concentration curves shifted towards equality for both treatments, concentration indices declined from 0.1012 to 0.0480 for ORS and from 0.2640 to 0.0567 for zinc. Disparities in ORS and zinc coverage between rural and urban at both time points was insignificant except that the use of zinc in the rural at endline was significantly higher at 38% (95%CI: 35-41%) compared to 29% (95%CI, 25-33%) in the urban. CONCLUSION: The results show a pro-rural improvement in coverage and a reduction in coverage inequities across wealth quintiles from baseline to endline. This gives an indication that initiatives focused on shaping healthcare market systems may be effective in reducing health coverage gaps without detracting from equity as a health policy objective.

Improving the quality of childbirth services in Zambia through introduction of the Safe Childbirth Checklist and systems-focused mentorship.

Although strong evidence exists about the effectiveness of basic childbirth services in reducing maternal and newborn mortality, these services are not provided in every childbirth, even those at health facilities. The WHO Safe Childbirth Checklist (SCC) was developed as a job aide to remind health workers of evidenced-based practices to be provided at specific points in the childbirth process. The Zambian government requested context-specific evidence on the feasibility and outcomes associated with introducing the checklist and related mentorship. A study was conducted on use of the SCC in four facilities in Nchelenge District of Zambia. Observations of childbirth services were conducted just before and six months after the introduction of the intervention. Observers used a structured tool to record adherence to essential services indicated on the checklist. The primary outcome of interest was the change in the average proportion of essential childbirth practices completed. Feedback questionnaires were administered to health workers before and six months after the intervention. At baseline and endline, 108 and 148 pause points were observed, respectively. There was an increase from 57% to 76% of tasks performed (p = 0.04). Considering only these cases where necessary supplies were available, health workers completed 60% of associated tasks at baseline compared to 84% at endline (p<0.01). Some tasks, such as taking an infant's temperature and hand washing, were never or rarely performed at baseline. Feedback from the health workers indicated that nearly all health workers agreed or strongly agreed with positive statements about the intervention. The performance of health workers in Zambia in completing essential practices in childbirth was low at baseline but improvements were observed with the introduction of the SCC and mentorship. Our results suggest that such interventions could improve quality of care for facility-based childbirth. However, national-level commitment to ensuring availability of trained staff and supplies is essential for success. Trial registration Clinical Trials.gov (NCT03263182) Registered August 28, 2017 This study adheres to CONSORT guidelines.

Key barriers and enablers associated with uptake and continuation of oral pre-exposure prophylaxis (PrEP) in the public sector in Zimbabwe: Qualitative perspectives of general population clients at high risk for HIV.

BACKGROUND: Understanding the perspectives and preferences of clients eligible for pre-exposure prophylaxis (PrEP) is essential to designing programs that meet clients' needs. To date, most PrEP programs in limited-resource settings have been implemented by partner organizations for specific target populations, but the government of Zimbabwe aims to make PrEP available to the broader population at substantial risk in public sector clinics. However, there is limited information on general population perspectives about PrEP in Zimbabwe. METHODS: A qualitative study was conducted to explore clients' motivation to take or decline PrEP and continue or discontinue PrEP. Through a PrEP pilot in one urban family planning clinic and one rural youth center in Zimbabwe, 150 HIV-negative clients screened as being at high risk of HIV and were offered PrEP between January and June 2018. Sixty semi-structured interviews were conducted with clients who agreed to follow-up (including 5 decliners, all from the rural youth center, and 55 accepters, with 42 from the rural youth center and 13 from the urban family planning clinic). Interviews were conducted after either the first or second PrEP follow-up appointment or after the client declined PrEP. Interviews were audio recorded, de-identified, transcribed, and coded thematically. RESULTS: PrEP uptake was driven by risk perception for HIV, and in many cases, that risk was introduced by the unsafe behavior or HIV-positive status of a partner. Among sero-discordant couples (SDCs), the desire to safely conceive a child was also cited as a factor in taking PrEP. Clients who opted for PrEP preferred it to other forms of HIV prevention. SDCs reported decreased condom use after PrEP initiation and in some cases were using PrEP while trying to conceive a child. After initiating PrEP, clients had more confidence in their sexual relationships and less stress associated with negotiating condom use. Family and partner support was critical to starting and continuing PrEP, but some clients stopped PrEP or missed appointments due to side effects or logistical challenges such as transportation. CONCLUSIONS: Results of this study can be used to provide operational guidance for national public sector roll-out of PrEP as part of combination HIV prevention in Zimbabwe. Based on feedback and experiences of clients, the training materials for health workers can be refined to ensure that health workers are prepared to counsel clients on the decision to start and/or continue PrEP and answer common client questions. Program advertisements should also be targeted with key messages that speak to client experiences. TRIAL REGISTRATION: Clinical Trial Registry Number: PACTR201710002651160.

Impact of the Umoyo mother-infant pair model on HIV-positive mothers' social support, perceived stigma and 12-month retention of their HIV-exposed infants in PMTCT care: evidence from a cluster randomized controlled trial in Zambia.

BACKGROUND: Public health systems in resource-constrained settings have a critical role to play in the elimination of HIV transmission but are often financially constrained. This study is an evaluation of a mother-infant-pair model called "Umoyo," which was designed to be low cost and scalable in a public health system. Facilities with the Umoyo model dedicate a clinic day to provide services to only HIV-exposed infants (HEIs) and their mothers. Such models are in operation with reported success in Zambia but have not been rigorously tested. This work establishes whether the Umoyo model would improve 12-month retention of HEIs. METHODS: A cluster randomized trial including 28 facilities was conducted across two provinces of Zambia to investigate the impact on 12-month retention of HEIs in care. These facilities were offering Prevention of Mother-to-Child-Transmission (PMTCT) services and supported by the same implementing partner. Randomization was achieved by use of the covariate-constrained optimization technique. Secondary outcomes included the impact of Umoyo clinics on social support and perceived HIV stigma among mothers. For each of the outcomes, a difference-in-difference analysis was conducted at the facility level using the unweighted t test. RESULTS: From 13 control (12-month retention at endline: 45%) and 11 intervention facilities (12-month retention at endline: 33%), it was found that Umoyo clinics had no impact on 12-month retention of HEIs in the t test (- 11%; 99% CI - 40.1%, 17.2%). Regarding social support and stigma, the un-weighted t test showed no impact though sensitivity tests showed that Umoyo had an impact on increasing social support (0.31; 99% CI 0.08, 0.54) and reducing perceived stigma from health care workers (- 0.27; 99% CI - 0.46, - 0.08). CONCLUSION: The Umoyo approach of having a dedicated clinic day for HEIs and their mothers did not improve retention of HEIs though there are indications that it can increase social support among mothers and reduce stigma. Without further support to the underlying health system, based on the evidence generated through this evaluation, the Umoyo clinic day approach on its own is not considered an effective intervention to increase retention of HIV-exposed infants. TRIAL REGISTRATION: Pan African Clinical Trial Registry, ID: PACTR201702001970148 . Prospectively registered on 13 January 2017.

Program evaluation of an ORS and zinc scale-up program in 8 Nigerian states.

BACKGROUND: In Nigeria, diarrhea is the second leading killer of children under five. Between 2012-2017, the Clinton Health Access Initiative, Inc. (CHAI) and the Government of Nigeria implemented a comprehensive program in eight states aimed at increasing the percentage of children under five with diarrhea who were treated with zinc and oral rehydration solution (ORS). The program addressed demand, supply, and policy barriers to ORS and zinc uptake through interventions in both public and private sectors. The interventions included: (1) policy revision and partner coordination; (2) market shaping to improve availability of affordable, high-quality ORS and zinc; (3) provider training and mentoring; and (4) caregiver demand generation. METHODS: We conducted cross-sectional household surveys in program states at baseline, midline, and endline and constructed logistic regression models with generalized estimating equations to assess changes in ORS and zinc treatment during the program period. RESULTS: In descriptive analysis, we found 38% (95% CI = 34%-42%) received ORS at baseline and 4% (95% CI = 3%-5%) received both ORS and zinc. At endline, we found 55% (95% CI = 51%-58%) received ORS and 30% (95% CI = 27%-33%) received both ORS and zinc. Adjusting for other covariates, the odds of diarrhea being treated with ORS were 1.88 (95% CI = 1.46, 2.43) times greater at endline. The odds of diarrhea being treated with ORS and zinc combined were 15.14 (95% CI = 9.82, 23.34) times greater at endline. When we include the interaction term to investigate whether the odds ratios between the endline and baseline survey were modified by source of care, we found statistically significant results among diarrhea episodes that sought care in the public and private sector. Among cases that sought care in the public sector, the predictive probability of treatment with ORS increased from 57% (95% CI = 50%-65%) to 83% (95% CI = 79%-87%). Among cases that sought care in the private sector, the predictive probability increased from 41% (95% CI = 34%-48%) to 58% (95% CI = 54%-63%). CONCLUSIONS: Use of ORS and combined ORS and zinc for treatment of diarrhea significantly increased in program states during the program period.

Effect of enhanced detailing and mass media on community use of oral rehydration salts and zinc during a scale-up program in Gujarat and Uttar Pradesh.

BACKGROUND: The Clinton Health Access Initiative implemented a program from 2012-2016 to increase use of oral rehydration salts (ORS) and zinc to treat diarrhea in children under five in three states in India: Gujarat, Madhya Pradesh, and Uttar Pradesh. The program interventions included detailing and development of a rural supply chain to reach private rural health care providers, training of Accredited Social Health Activists (ASHAs), technical support to the state governments, and a mass media campaign targeted at caregivers. In Gujarat and Uttar Pradesh, some of the program activities, such as detailing and ASHA trainings, were targeted to high-burden focal districts, thus providing an opportunity to study their effect compared to statewide activities that covered all districts, such as the mass media campaign. Our study aimed to estimate the effect of activities on ORS and zinc use. METHODS: Household surveys were conducted at two points during the program and in both focal and non-focal districts. We used a difference-in-difference quasi-experimental approach to estimate the effect of the enhanced activities in focal districts and mass media campaign on the odds of a child being treated with ORS and zinc. FINDINGS: Focal district interventions were associated with a significant increase in the odds of a diarrhea episode receiving ORS in Gujarat and Uttar Pradesh. Living in focal districts increased the odds of receiving ORS in Gujarat and Uttar Pradesh by factors of 3.42 (95% CI = 1.39-8.33) and 2.29 (95% CI = 1.19-4.39), respectively. Focal district interventions were also associated with 15.02 (95% CI = 2.97-75.19) greater odds of receiving both ORS and zinc in Gujarat. In Uttar Pradesh, where the mass media campaign was focused, exposure to the campaign further modified the odds of receiving ORS and combined ORS and zinc by 1.38 (95% CI = 1.04-1.84) and 1.57 (95% CI = 1.01-2.46), respectively. CONCLUSION: Comprehensive public and private provider interventions combined with mass media are effective strategies for increasing ORS and zinc use.

Impact of the Safe Childbirth Checklist on health worker childbirth practices in Luapula province of Zambia: a pre-post study.

BACKGROUND: A strong evidence base exists regarding routine and emergency services that can effectively prevent or reduce maternal and new-born mortality. However, even when skilled providers care for women in labour, many of the recommended services are not provided, despite being available. Barriers to the provision of appropriate childbirth services may include lack of availability of supplies, limited health worker knowledge and confidence, or inadequate time. The WHO Safe Childbirth Checklist (SCC) includes reminders for evidenced-based practices at specific points in the childbirth process. Zambia is currently considering nation-wide adoption of the SCC, but there is a need for context-specific evidence. Beginning in September 2017, a program is being implemented in Nchelenge District to pilot use of the SCC, along with coaching that focuses on strengthening the systems that allow the essential practices in childbirth to be performed. METHODS: This study will use a pre-post study design to measure health worker adherence to the essential practices for delivery care outlined in the SCC. Data will be collected through observations of health workers as they care for mothers during childbirth at four facilities. Data collection will take place before the start of the intervention, at 3 months, and at 6 months post-intervention. The primary outcome interest is the change in the average proportion of essential childbirth practices completed. A health worker questionnaire will be administered at the time that the SCC is introduced and 6 months later to gather their perspectives on incorporating the SCC into clinical practice in Zambia. DISCUSSION: Findings are expected to inform plans for introducing the SCC in Zambia. This evaluation will aim to understand uptake and impact of the SCC and associated coaching in the context of a basic level of mentorship that the government could feasibly provide at a national scale. TRIAL REGISTRATION: Clinical Trials.gov ( NCT03263182 ) Registered August 28, 2017.

Patient and health worker experiences of differentiated models of care for stable HIV patients in Malawi: A qualitative study.

INTRODUCTION: Several models of differentiated care for stable HIV patients on antiretroviral therapy (ART) in Malawi have been introduced to ensure that care is efficient and patient-centered. Three models have been prioritized by the government for a deeper and broader understanding: adjusted appointment spacing through multi-month scripting (MMS); fast-track drug refills (FTRs) on alternating visits; and community ART groups (CAGs) where rotating group members collect medications at the facility for all members. This qualitative study aimed to understand the challenges and successes of implementing these models of care and of the process of patient differentiation. METHODS: A qualitative study was conducted as a part of a broader process evaluation in 30 purposefully selected ART facilities between February and May 2016. Semi-structured, in-depth interviews with 32 health workers that managed and coordinated ART clinics and 30 focus groups were held with 216 ART patients. Interviews and focus groups were audio recorded, transcribed, and coded thematically. RESULTS: Participants reported that the models of differentiated care have yielded key benefits, including: reduced patients' travel and visit time, decongestion of facilities, and enhanced social support. Participants suggested that these benefits could lead to improved HIV treatment outcomes for patients. At the same time, some challenges were reported, such as inconsistent stocks of drugs, which can inhibit implementation of MMS. For CAGs, the group-based nature of the model presented some unique problems, such as conflicts within groups or concerns about privacy. Health workers also described some of the reasons why eligible patients may not receive the models or conversely why ineligible patients sometimes get the models. CONCLUSIONS: Documenting patient and health worker perspectives on models of differentiated care is critical to understanding and improving these models. While these models can offer important benefits, the models may not be appropriate for all sites or patients, and patient status and needs may change over time. Key challenges should be recognized and addressed for optimal utilization of the models.

Impact of passenger engagement through road safety bus stickers in public service vehicles on road traffic crashes in Zambia: a randomized controlled trial.

BACKGROUND: Road Traffic Crashes (RTCs) are the third highest cause of death in Zambia, claiming about 2000 lives annually, with pedestrians and cyclists being the most vulnerable. Human error accounts for 87.3% of RTCs. Minibus and big bus public service vehicles (PSVs) are among the common vehicle types involved in these crashes. Given the alarmingly high rate of road traffic crashes involving PSV minibuses and big buses within Zambia, there is a need to mitigate this through innovative solutions. In other settings, it has been shown that stickers in PSVs encouraging passengers to speak out against reckless driving can reduce RTCs, but it is unclear whether such an intervention could work in Zambia. Based on this evidence, the Zambia Road Transport and Safety Agency (RTSA) has developed a road safety bus sticker campaign for PSVs and before national scale-up, RTSA is interested in evidence of the impact of these stickers. METHODS: This evaluation will be a stratified two-arm randomized controlled trial with a one-to-one ratio. The sample will be stratified by vehicle type, thus creating a two-arm trial for minibuses and a separate two-arm trial for big buses. The sample will include 2110 minibuses and 300 big buses from four towns in Zambia. The primary outcome of interest will be the difference in the rate of RTCs over a 14-month period (7-months before the intervention and 7 months after) between buses with and without the new RTSA road safety bus stickers. DISCUSSION: This study will provide evidence on the impact of the Zambian sticker program on road traffic crashes as implemented through minibuses and big buses, that can help inform the scale up of a national 'Zambia road safety bus sticker campaign'. TRIAL REGISTRATION: PACT-R, PACTR201711002758216 . Registered 13 November 2017-Retrospectively registered.

Impact of a Family Clinic Day intervention on paediatric and adolescent appointment adherence and retention in antiretroviral therapy: A cluster randomized controlled trial in Uganda.

BACKGROUND: In 2013, Uganda adopted a test-and-treat policy for HIV patients 15 years or younger. Low retention rates among paediatric and adolescent antiretroviral therapy (ART) initiates could severely limit the impact of this new policy. This evaluation tested the impact of a differentiated care model called Family Clinic Day (FCD), a family-centered appointment scheduling and health education intervention on patient retention and adherence to monthly appointment scheduling. METHODS: We conducted a cluster randomized controlled trial, from October 2014 to March 2015. Forty-six facilities were stratified by implementing partner and facility type and randomly assigned to the control or intervention arm. Primary outcomes included the proportion of patients retained in care at 6 months and the proportion adherent to their appointment schedule at last study period scheduled visit. Data collection occurred retrospectively in May 2015. Six patient focus group discussions and 17 health workers interviews were conducted to understand perspectives on FCD successes and challenges. RESULTS: A total of 4,715 paediatric and adolescent patient records were collected, of which 2,679 (n = 1,319 from 23 control facilities and 1,360 from 23 intervention facilities) were eligible for inclusion. The FCD did not improve retention (aOR 1.11; 90% CI 0.63-1.97, p = 0.75), but was associated with improved adherence to last appointment schedule (aOR 1.64; 90% CI 1.27-2.11, p<0.001). Qualitative findings suggested that FCD patients benefited from health education and increased psychosocial support. CONCLUSION: FCD scale-up in Uganda may be an effective differentiated care model to ensure patient adherence to ART clinic appointment schedules, a key aspect necessary for viral load suppression. Patient health outcomes may also benefit following an increase in knowledge based on health education, and peer support. Broad challenges facing ART clinics, such as under-staffing and poor filing systems, should be addressed in order to improve patient care.

Multi-month prescriptions, fast-track refills, and community ART groups: results from a process evaluation in Malawi on using differentiated models of care to achieve national HIV treatment goals.

INTRODUCTION: In order to facilitate scale-up of antiretroviral therapy (ART) in Malawi, innovative and pragmatic models have been developed to optimize the efficiency of HIV service delivery. In particular, three models of differentiated care have emerged for stable patients: adjusted appointment spacing through multi-month scripting (MMS); fast-track drug refills (FTRs) on alternating visits; and community ART groups (CAGs) where group members rotate in collecting medications at the facility for all members. This study aimed to assess the extent to which ART patients in Malawi are differentiated based on clinical stability and describe the characteristics and costs associated with the models of differentiated care offered. METHODS: A mixed methods process evaluation was conducted from 30 purposefully selected ART facilities. Cross-sectional data for this evaluation was collected between February and May 2016. The following forms of data collection are reported here: structured surveys with 136 health care workers; reviews of 75,364 patient clinical records; 714 observations of visit time and flow; and 30 questionnaires on facility characteristics. RESULTS: Among ART patients, 77.5% (95% confidence interval [CI] 74.1-80.6) were eligible for differentiated models of care based on criteria for clinical stability from national guidelines. Across all facilities, 69% of patients were receiving MMS. In facilities offering FTRs and CAGs, 67% and 6% of patients were enrolled in the models, respectively. However, eligibility criteria were used inconsistently: 72.9% (95% CI 66.3-78.6) of eligible patients and 42.3% (95% CI 33.1-52.0) ineligible patients received MMS. Results indicated that patient travel and time costs were reduced by 67%, and the unit costs of ART service delivery through the MMS, FTR and CAG models were similar, representing a reduction of approximately 10% in the annual unit cost of providing care to stable patients that receive no model. CONCLUSIONS: MMS is being implemented nationally and has already generated cost savings and efficiencies in Malawi for patients and the health system, but could be improved by more accurate patient differentiation. While expanding FTRs and CAGs may not offer significant further cost savings in Malawi, future studies should investigate if such alternative models lead to improvements in patient satisfaction or clinical outcomes that might justify their implementation.

Quality improvement intervention to increase adherence to ART prescription policy at HIV treatment clinics in Lusaka, Zambia: A cluster randomized trial.

INTRODUCTION: In urban areas, crowded HIV treatment facilities with long patient wait times can deter patients from attending their clinical appointments and picking up their medications, ultimately disrupting patient care and compromising patient retention and adherence. METHODS: Formative research at eight facilities in Lusaka revealed that only 46% of stable HIV treatment patients were receiving a three-month refill supply of antiretroviral drugs, despite it being national policy for stable adult patients. We designed a quality improvement intervention to improve the operationalization of this policy. We conducted a cluster-randomized controlled trial in sixteen facilities in Lusaka with the primary objective of examining the intervention's impact on the proportion of stable patients receiving three-month refills. The secondary objective was examining whether the quality improvement intervention reduced facility congestion measured through two proxy indicators: daily volume of clinic visits and average clinic wait times for services. RESULTS: The mean change in the proportion of three-month refills among control facilities from baseline to endline was 10% (from 38% to 48%), compared to a 25% mean change (an increase from 44% to 69%) among intervention facilities. This represents a significant 15% mean difference (95% CI: 2%-29%; P = 0.03) in the change in proportion of patients receiving three-month refills. On average, control facilities had 15 more visits per day in the endline than in the baseline, while intervention facilities had 20 fewer visits per day in endline than in baseline, a mean difference of 35 fewer visits per day (P = 0.1). The change in the mean facility total wait time for intervention facilities dropped 19 minutes between baseline and endline when compared to control facilities (95% CI: -10.2-48.5; P = 0.2). CONCLUSION: A more patient-centred service delivery schedule of three-month prescription refills for stable patients is viable. We encourage the expansion of this sustainable intervention in Zambia's urban clinics.

Correction: The BD FACSPresto Point of Care CD4 Test accurately enumerates CD4+ T cell counts.

[This corrects the article DOI: 10.1371/journal.pone.0145586.].

The composition of demand for newly launched vaccines: results from the pneumococcal and rotavirus vaccine introductions in Ethiopia and Malawi.

Understanding post-launch demand for new vaccines can help countries maximize the benefits of immunization programmes. In particular, low- and middle-income countries (LMICs) should ensure adequate resource planning with regards to stock consumption and service delivery for new vaccines, whereas global suppliers must produce enough vaccines to meet demand. If a country underestimates the number of children seeking vaccination, a stock-out of commodities will create missed opportunities for saving lives. We describe the post-launch demand for the first dose of pneumococcal conjugate vaccine (PCV1) in Ethiopia and Malawi and the first dose of rotavirus vaccine (Rota1) in Malawi, with focus on the new birth cohort and the 'backlog cohort', comprised of older children who are still eligible for vaccination at the time of launch. PCV1 and Rota1 uptake were compared with the demand for the first dose of pentavalent vaccine (Penta1), a routine immunization that targets the same age group and immunization schedule. In the first year, the total demand for PCV1 was 37% greater than that of Penta1 in Ethiopia and 59% greater in Malawi. In the first 6 months, the demand of Rota1 was only 5.9% greater than Penta1 demand in Malawi. Over the first three post-introduction months, 70.7% of PCV1 demand in Ethiopia and 71.5% of demand in Malawi came from children in the backlog cohort, whereas only 28.0% of Rota1 demand in Malawi was from the backlog cohort. The composition of demand was impacted by time elapsed since vaccine introduction and age restrictions. Evidence suggests that countries' plans should account for the impact of backlog demand, especially in the first 3 months post-introduction. LMICs should request for higher stock volumes when compared with routine needs, plan social mobilization activities to reach the backlog cohort and allocate human resources and cold chain capacity to accommodate high demand following vaccine introduction.

Adverse Childhood Events and the Risk for New-Onset Depression and Post-Traumatic Stress Disorder Among U.S. National Guard Soldiers.

This article examines the relationship between childhood adversity and postdeployment new-onset psychopathology among a sample of U.S. National Guard personnel deployed during Operation Iraqi Freedom and Operation Enduring Freedom with no history of post-traumatic stress disorder (PTSD) or depression. We recruited a sample of 991 Ohio Army National Guard soldiers and conducted structured interviews to assess traumatic event exposure, a history of childhood adversity, and postdeployment depression, and PTSD, consistent with the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition. We assessed childhood adversity by using questions from the Childhood Adverse Events Survey. In multivariable logistic models, a history of any childhood adversity was significantly associated with new-onset depression, but not PTSD, postdeployment. This finding suggests that a history of childhood adversity is predisposing for new-onset depression, among U.S. National Guard soldiers who were deployed with no prior history of PTSD or depression. This highlights the centrality of childhood experience for the production of mental health among soldiers.

Baseline prevalence of Axis I diagnosis in the Ohio Army National Guard.

The goal of this study is to determine the pre-existing lifetime and current prevalence of DSM-IV Axis I disorders within the Ohio Army National Guard (OHARNG). Data was analyzed from the clinical subsample of the Ohio Army National Guard Mental Health Initiative (OHARNG MHI). Five hundred participants were provided with an in-depth clinical assessment using the Clinician-Administered PTSD Scale (CAPS) and the Structured Clinical Interview for DSM-IV-TR (SCID). Logistic regression examined the relationship between Axis I disorders and the number of deployments and gender. Prevalence of at least one DSM-IV lifetime disorder was 66.2%; substance use disorders were 52.2%, followed by mood disorders (30.0%) and anxiety disorders (22.0%). Prevalence of at least one current disorder was 24.8%; anxiety disorders (13.2%), mood disorders (7.6%), and substance use disorders (7.0%) were most frequent. Number of deployments was associated with PTSD (OR=8.27, 95% CI 2.10-32.59, p=0.003), alcohol use disorder (OR=1.77, 95% CI 1.07-2.92, p=0.025), and any substance use disorder (OR=1.85, 95% CI 1.12-3.05, p=0.016). Gender (OR=2.02, 95% CI 1.10-3.73, p=0.024) was associated with any mood disorder. The results provide baseline information on the most prevalent mental disorders within the OHARNG.

The BD FACSPresto Point of Care CD4 Test Accurately Enumerates CD4+ T Cell Counts.

OBJECTIVE: Currently 50% of ART eligible patients are not yet receiving life-saving antiretroviral therapy (ART). Financial constraints do not allow most developing countries to adopt a universal test and offer ART strategy. Decentralizing CD4+ T cell testing may, therefore, provide greater access to testing, ART, and better patient management. We evaluated the technical performance of a new point-of-care CD4+ T cell technology, the BD FACSPresto, in a field methods comparison study. METHODS: 264 HIV-positive patients were consecutively enrolled and included in the study. The BD FACSPresto POC CD4+ T cell technology was placed in two rural health care facilities and operated by health care facility staff. We compared paired finger-prick and venous samples using the BD FACSPresto and several existing reference technologies, respectively. RESULTS: The BD FACSPresto had a mean bias of 67.29 cells/ul and an r(2) of 0.9203 compared to the BD FACSCalibur. At ART eligibility thresholds of 350 and 500 cells/ul, the sensitivity to define treatment eligibility were 81.5% and 77.2% and the specificities were 98.9% and 100%, respectively. Similar results were observed when the BD FACSPresto was compared to the BD FACSCount and Alere Pima. The coefficient of variation (CV) was less than 7% for both the BD FACSCalibur and BD FACSPresto. CD4+ T cell testing by nurses using the BD FACSPresto at rural health care facilities showed high technical similarity to test results generated by laboratory technicians using the BD FACSPresto in a high functioning laboratory. CONCLUSIONS: The BD FACSPresto performed favorably in the laboratory setting compared to the conventional reference standard technologies; however, the lower sensitivities indicated that up to 20% of patients tested in the field in need of treatment would be missed. The BD FACSPresto is a technology that can allow for greater decentralization and wider access to CD4+ T cell testing and ART.

The prevalence and correlates of risky driving behavior among National Guard soldiers.

OBJECTIVE: Previous studies have reported that risky driving is associated with deployment and combat exposure in military populations, but there is limited research on risky driving among soldiers in the National Guard and Reserves, a group increasingly deployed to active international conflicts. The goal of this analysis was to assess the prevalence of risky driving and its demographic, mental health, and deployment-related correlates among members of the Ohio Army National Guard (OHARNG). METHODS: The study group comprised 2,616 eligible OHARNG soldiers enlisted as of June 2008, or who enlisted between June 2008 and February 2009. The main outcome of interest was the prevalence of risky driving behavior assessed using six questions: "How often do you use seat belts when you drive or ride in a car?"; "In the past 30 days, how many times have you driven when you've had perhaps too much to drink?"; "In the past year, have you ever become impatient with a slow driver in the fast lane and passed them on the right?"; "In the past year have you crossed an intersection knowing that the traffic lights have already changed from yellow to red?"; "In the past year have you disregarded speed limits late at night or early in the morning?"; and "In the past year have you underestimated the speed of an oncoming vehicle when attempting to pass a vehicle in your own lane?" We fit multiple logistic regression models and derived the adjusted prevalence of risky driving behavior for soldiers with mental health conditions, deployment experience, exposure to combat or trauma, and psychosocial stressors or supports. RESULTS: The prevalence of risky driving was higher in soldiers with a history of mental health conditions, deployment to a conflict area, deployment-related traumatic events, and combat or post-combat stressors. In contrast, the prevalence of risky driving was lower for soldiers who reported high levels of psychosocial support. CONCLUSIONS: Efforts to mitigate risky driving in military populations may be more effective if they incorporate both targeted messages to remediate dangerous learned driving behaviors and psychosocial interventions to build resilience and address underlying stressors and mental health symptoms.