Integrating 3HP-based tuberculosis preventive treatment into Zimbabwe's Fast Track HIV treatment model: experiences from a pilot study.

INTRODUCTION: Tuberculosis (TB) causes one-third of HIV-related deaths worldwide, making TB preventive treatment (TPT) a critical element of HIV programmes. Approximately 16% of people living with HIV (PLHIV) on antiretrovirals in Zimbabwe are enrolled in the Fast Track (FT) differentiated service delivery model, which includes multi-month dispensing of antiretrovirals and quarterly health facility (HF) visits. We assessed the feasibility and acceptability of utilizing FT to deliver 3HP (3 months of once-weekly rifapentine and isoniazid) for TPT by aligning TPT and HIV visits, providing multi-month dispensing of 3HP, and using phone-based monitoring and adherence support. METHODS: We recruited a purposive sample of 50 PLHIV enrolled in FT at a high-volume HF in urban Zimbabwe. At enrolment, participants provided written informed consent, completed a baseline survey, and received counselling, education and a 3-month supply of 3HP. A study nurse mentor called participants at weeks 2, 4 and 8 to monitor and support adherence and side effects. When participants returned for their routine 3-month FT visit, they completed another survey, and study staff conducted a structured medical record review. In-depth interviews were conducted with providers who participated in the pilot. RESULTS: Participants were enrolled between April and June 2021 and followed through September 2021. Median age = 32 years (IQR 24,41), 50% female, median time in FT 1.8 years (IQR 0.8,2.7). Forty-eight participants (96%) completed 3HP in 13 weeks; one completed in 16 weeks, and one stopped due to jaundice. Most participants (94%) reported "always" or "almost always" taking 3HP correctly. All reported they were very satisfied with the counselling, education, support and quality of care they received from providers and FT service efficiency. Almost all (98%) said they would recommend it to other PLHIV. Challenges reported included pill burden (12%) and tolerability (24%), but none had difficulty with phone-based counselling or wished for additional HF-based visits. DISCUSSION: Using FT to deliver 3HP was feasible and acceptable. Some reported tolerability challenges but 98% completed 3HP, and all appreciated the efficiency of aligning TPT and HIV HF visits, multi-month dispensing and phone-based counselling. CONCLUSIONS: Scaling up this approach could expand TPT coverage in Zimbabwe.

Implementing six multi-month dispensing of antiretroviral therapy in Ethiopia: perspectives of clients and healthcare workers.

BACKGROUND: Multi-month dispensing (MMD) of antiretroviral therapy (ART) is an integral component of differentiated HIV service delivery for people living with HIV (PLHIV). Although many countries have scaled up ART dispensing to 3-month intervals, Ethiopia was the first African country to implement six-month dispensing (6-MMD) at scale, introducing its Appointment Spacing Model (ASM) for people doing well on ART in 2017. As of June 2021, 51.4% (n = 215,101) of PLHIV on ART aged ≥ 15 years had enrolled in ASM. Since little is known about the benefits and challenges of ASM perceived by Ethiopian clients and their healthcare workers (HCWs), we explored how the ASM was being implemented in Ethiopia's Oromia region in September 2019. METHODS: Using a parallel convergent mixed-methods study design, we conducted 6 focus groups with ASM-eligible enrolled clients, 6 with ASM-eligible non-enrolled clients, and 22 in-depth interviews with HCWs. Data were audio-recorded, transcribed and translated into English. We used thematic analysis, initially coding deductively, followed by inductive coding of themes that emerged from the data, and compared the perspectives of ASM-enrolled and non-enrolled clients and their HCWs. RESULTS: Participants enrolled in ASM and HCWs perceived client-level ASM benefits to include time and cost-savings, fewer work disruptions, reduced stigma due to fewer clinic visits, better medication adherence and improved overall health. Perceived health system-level benefits included improved quality of care, decongested facilities, reduced provider workloads, and improved record-keeping. Although non-enrolled participants anticipated many of the same benefits, their reasons for non-enrollment included medication storage challenges, concerns over less frequent health monitoring, and increased stress due to the large quantities of medicines dispensed. Enrolled participants and HCWs identified similar challenges, including client misunderstandings about ASM and initial ART stock-outs. CONCLUSIONS: ASM with 6-MMD was perceived to have marked benefits for clients and health systems. Clients enrolled in the ASM and their HCWs had positive experiences with the model, including perceived improvements in efficiency, quality and convenience of HIV treatment services. The concerns of non-ASM enrolled participants suggest the need for enhanced client education about the model and more discreet and efficiently packaged ART and highlight that ASM is not ideal for all clients.

Integrating isoniazid preventive therapy into the fast-track HIV treatment model in urban Zambia: A proof-of -concept pilot project.

Most people living with HIV (PLHIV) established on treatment in Zambia receive multi-month prescribing and dispensing (MMSD) antiretroviral therapy (ART) and are enrolled in less-intensive differentiated service delivery (DSD) models such as Fast Track (FT), where clients collect ART every 3-6 months and make clinical visits every 6 months. In 2019, Zambia introduced Isoniazid Preventive Therapy (IPT) with scheduled visits at 2 weeks and 1, 3, and 6 months. Asynchronous IPT and HIV appointment schedules were inconvenient and not client centered. In response, we piloted integrated MMSD/IPT in FT HIV treatment model. We implemented and evaluated a proof-of-concept project at one purposively selected high-volume facility in Lusaka, Zambia between July 2019 and May 2020. We sensitized stakeholders, adapted training materials, standard operating procedures, and screened adults in FT for TB as per national guidelines. Participants received structured TB/IPT education, 6-month supply of isoniazid and ART, aligned 6th month IPT/MMSD clinic appointment, and phone appointments at 2 weeks and months 1-5 following IPT initiation. We used descriptive statistics to characterize IPT completion rates, phone appointment keeping, side effect frequency and Fisher's exact test to determine variation by participant characteristics. Key lessons learned were synthesized from monthly meeting notes. 1,167 clients were screened with 818 (70.1%) enrolled, two thirds (66%) were female and median age 42 years. 738 (90.2%) completed 6-month IPT course and 66 (8.1%) reported IPT-related side effects. 539 clients (65.9%) attended all 7 telephone appointments. There were insignificant differences of outcomes by age or sex. Lessons learnt included promoting project ownership, client empowerment, securing supply chain, adapting existing processes, and cultivating collaborative structured learning. Integrating multi-month dispensing and telephone follow up of IPT into the FT HIV treatment model is a promising approach to scaling-up TB preventive treatment among PLHIV, although limited by barriers to consistent phone access.

Healthcare system responses to non-communicable diseases' needs of Syrian refugees: The cases of Jordan and Lebanon.

Introduction: Since the start of the Syrian conflict in 2011, Jordan and Lebanon have hosted large refugee populations, with a high pre-conflict burden of non-communicable diseases (NCDs). We aimed to explore NCD service provision to Syrian refugees in these two host countries and to identify lessons learned that may inform the global response to the changing health needs of refugees. Methods: Between January 2017 and June 2018, we conducted 36 in-depth interviews with stakeholders from Jordan and Lebanon, as well as global stakeholders, to understand the context, the achievements, gaps and priorities in the provision and uptake of NCD prevention, testing and treatment services to Syrian refugees. Findings: Both countries succeeded in embedding refugee health care within national health systems, yet coverage and quality of NCD health services offered to Syrian refugees in both contexts were affected by under-funding and consequent policy constraints. Changes in policies relating to cost sharing, eligibility and vulnerability criteria led to difficulties navigating the system and increased out-of-pocket payments for Syrians. Funding shortages were reported as a key barrier to NCD screening, diagnosis and management, including at the primary care level and referral from primary to secondary healthcare, particularly in Lebanon. These barriers were compounded by suboptimal implementation of NCD guidelines and high workloads for healthcare providers resulting from the large numbers of refugees. Conclusions: Despite the extraordinary efforts made by host countries, provision and continuity of high quality NCD services at scale remains a tremendous challenge given ongoing funding shortfalls and lack of prioritization of NCD care for refugees. The development of innovative, effective and sustainable solutions is necessary to counter the threat of NCDs.

"They are our eyes outside there in the community": Implementing enhanced training, management and monitoring of South Africa's ward-based primary healthcare outreach teams.

INTRODUCTION: In 2018, South Africa's National Department of Health provided additional resources for ward-based primary healthcare outreach teams (OT) with support from the U.S. President's Emergency Plan for AIDS Relief. The intervention package included a new training curriculum, enhanced staffing, revised management and supervisory structures, and more intensive monitoring and evaluation (M&E). The goal was to strengthen OT and their impact on both primary healthcare and HIV-specific services. We conducted a process evaluation of this intervention package during its second year and examined implementation successes and challenges. METHODS: We conducted a mixed-methods evaluation at 20 purposively selected facilities in Bojanala and City of Tshwane districts, including surveys with 222 community health workers (CHWs) and outreach team leaders (OTLs); key informant interviews and online surveys with 28 policy and program stakeholders; 70 in-depth interviews with health facility staff; 20 focus group discussions with 194 CHWs; 20 structured health facility assessments; directly-observed time-motion studies; and review of program documents. RESULTS: Most participants highlighted the hiring and training of CHWs and OTLs as a key implementation success because this had partially alleviated staffing shortages and helped clarify CHWs' and OTLs' responsibilities and supervisory structures. The new monitoring tools were welcomed for their potential to improve data collection and program tracking. However, participants highlighted many program challenges: short-lived gains in CHWs' knowledge and skills due to lack of ongoing training and mentoring; insufficient integration of OT into health facility management structures; persistent shortages of equipment, supplies, transportation, and workspace for CHWs; and insufficient remuneration for staff. CONCLUSION: Strengthening and expanding CHW programs, such as OT, requires intensive support and continuous investments. To sustain improvements in training, supervision, and job satisfaction, CHWs must be equipped with needed resources, provided with ongoing supportive supervision, and strengthened by optimized program management, monitoring and processes.

Improving viral load utilisation to enhance care for Kenyan adolescents with HIV.

Improving the use of viral load (VL) testing for adolescents and young people living with HIV (AYPLWH) is a priority for Kenya's Ministry of Health (MOH). Despite expansion of VL testing coverage and rollout of national policies, guidelines and training, VL result utilisation for AYPLWH remains suboptimal, with inadequate adherence to national guidelines recommending everyone on antiretroviral therapy (ART) with unsuppressed viral load (UVL) (≥401 copies/mL) receive three enhanced adherence counselling (EAC) sessions and a repeat VL test within 3 months. In March 2019, ICAP at Columbia University partnered with the MOH to launch a Quality Improvement Collaborative (QIC) at 22 health facilities in the Eastern Province to optimise management of AYPLWH on ART with UVL. Over 17 months, facility QI teams tested interventions targeting client education, workflow modifications, commodity management, community engagement and improved documentation. The QIC led to marked improvement in the proportion of clients completing three EAC sessions and repeat VL testing. Median completion rate was 16% (n=479) at baseline (from March 2018 to February 2019) and rose to 73% (n=755) during the implementation period (from March 2019 to July 2020). In the final month (July 2020), rates rose to 90% (n=31). Another success was the increase in the proportion of clients whose VL was resuppressed on repeat testing, which improved from 34% (n=273) at baseline to 62% (n=710) during the implementation period and 77% (n=44) in the final month. The QIC also led to improvement in the proportion of AYPLWH on first-line ART whose regimens were switched within 2 months of recorded UVL results, which rose from 58% (n=48) at baseline to 94% (n=128) during the implementation period. In summary, the QIC helped facility teams to identify and prioritise local, contextually appropriate innovations which led to swift improvement in three critical indicators of VL utilisation.

Rapid scale-up of COVID-19 training for frontline health workers in 11 African countries.

BACKGROUND: The global spread of the SARS-CoV-2 virus highlights both the importance of frontline healthcare workers (HCW) in pandemic response and their heightened vulnerability during infectious disease outbreaks. Adequate preparation, including the development of human resources for health (HRH) is essential to an effective response. ICAP at Columbia University (ICAP) partnered with Resolve to Save Lives and MOHs to design an emergency training initiative for frontline HCW in 11 African countries, using a competency-based backward-design approach and tailoring training delivery and health facility selection based on country context, location and known COVID-19 community transmission. METHODS: Pre- and post-test assessments were conducted on participants completing the COVID-19 training. Parametric and non-parametric methods were used to examine average individual-level changes from pre- to post-test, and compare performance between countries, cadres, sex and facility types. A post-evaluation online training survey using Qualtrics was distributed to assess participants' satisfaction and explore training relevance and impact on their ability to address COVID-19 in their facilities and communities. RESULTS: A total of 8797 HCW at 945 health facilities were trained between June 2020 and October 2020. Training duration ranged from 1 to 8 days (median: 3 days) and consisted of in person, virtual or self guided training. Of the 8105 (92%) HCW working at health facilities, the majority (62%) worked at secondary level facilities as these were the HF targeted for COVID-19 patients. Paired pre- and post-test results were available for 2370 (25%) trainees, and 1768 (18%) participants completed the post-evaluation training survey. On average, participants increased their pre- to post-test scores by 15 percentage points (95% CI 0.14, 0.15). While confidence in their ability to manage COVID-19 was high following the training, respondents reported that lack of access to testing kits (55%) and PPE (50%), limited space in the facility to isolate patients (45%), and understaffing (39%) were major barriers. CONCLUSION: Ongoing investment in health systems and focused attention to health workforce capacity building is critical to outbreak response. Successful implementation of an emergency response training such as this short-term IPC training initiative in response to the COVID-19 pandemic, requires speed, rigor and flexibility of its design and delivery while building on pre-existing systems, resources, and partnerships.

Client and healthcare worker experiences with differentiated HIV treatment models in Eswatini.

INTRODUCTION: Universal access to antiretroviral therapy (ART) is a cornerstone of Eswatini's national HIV strategy, and the number of people on ART in the country more than tripled between 2010 and 2019. Building on these achievements, the Ministry of Health (MOH) is scaling up differentiated service delivery, including less-intensive differentiated ART (DART) models for people doing well on treatment. We conducted a mixed-methods study to explore client and health care worker (HCW) perceptions of DART in Eswatini. METHODS: The study included structured site assessments at 39 purposively selected health facilities (HF), key informant interviews with 20 HCW, a provider satisfaction survey with 172 HCW and a client satisfaction survey with 270 adults. RESULTS: All clients had been on ART for more than a year; 69% were on ART for ≥ 5 years. The most common DART models were Fast-Track (44%), Outreach (26%) and Community ART Groups (20%). HCW and clients appreciated DART, noting that the models often decrease provider workload and client wait time. Clients also reported that DART models helped them to adhere to ART, 96% said they were "very satisfied" with their current model, and 90% said they would recommend their model to others, highlighting convenience, efficiency and cost savings. The majority of HCW (52%) noted that implementation of DART reduced their workload, although some models, such as Outreach, were more labor-intensive. Each model had advantages and disadvantages; for example, clients concerned about stigma and inadvertent disclosure of HIV status were less interested in group models. CONCLUSIONS: Clients in DART models were very satisfied with their care. HCW were also supportive of the new approach to HIV treatment delivery, noting its advantages to HF, HCW and to clients. Given the heterogeneous needs of people living with HIV, no single DART model will suit every client; a diverse portfolio of DART models is likely the best strategy.

Coronary artery aneurysm, ectasia and stenosis in a 53-year-old man with HIV infection.

The impact of long-standing human immunodeficiency virus infection (HIV) and potent anti-retroviral therapy on the coronary circulation is unknown; however, scattered reports are emerging of coronary aneurysms in this population. We report what we believe to be the first described case of both coronary stenosis and coronary artery aneurysms in a person living with HIV and discuss management options.

Acceptability of Community-Based Tuberculosis Preventive Treatment for People Living with HIV in Zimbabwe.

As Zimbabwe expands tuberculosis preventive treatment (TPT) for people living with HIV (PLHIV), the Ministry of Health and Child Care is considering making TPT more accessible to PLHIV via less-intensive differentiated service delivery models such as Community ART Refill Groups (CARGs). We designed a study to assess the feasibility and acceptability of integrating TPT into CARGs among key stakeholders, including CARG members, in Zimbabwe. We conducted 45 key informant interviews (KII) with policy makers, implementers, and CARG leaders; 16 focus group discussions (FGD) with 136 PLHIV in CARGs; and structured observations of 8 CARG meetings. KII and FGD were conducted in English and Shona. CARG observations were conducted using a structured checklist and time-motion data capture. Ninety six percent of participants supported TPT integration into CARGs and preferred multi-month TPT dispensing aligned with ART dispensing schedules. Participants noted that the existing CARG support systems could be used for TB symptom screening and TPT adherence monitoring/support. Other perceived advantages included convenience for PLHIV and decreased health facility provider workloads. Participants expressed concerns about possible medication stockouts and limited knowledge about TPT among CARG leaders but were confident that CARGs could effectively provide community-based TPT education, adherence monitoring/support, and TB symptom screening provided that CARG leaders received appropriate training and supervision. These results are consistent with findings from pilot projects in other African countries that are scaling up both differentiated service delivery for HIV and TPT and suggest that designing contextually appropriate approaches to integrating TPT into less-intensive HIV treatment models is an effective way to reach people who are established on ART but who may have missed out on access to TPT.

Integrating HIV services and other health services: A systematic review and meta-analysis.

BACKGROUND: Integration of HIV services with other health services has been proposed as an important strategy to boost the sustainability of the global HIV response. We conducted a systematic and comprehensive synthesis of the existing scientific evidence on the impact of service integration on the HIV care cascade, health outcomes, and cost-effectiveness. METHODS AND FINDINGS: We reviewed the global quantitative empirical evidence on integration published between 1 January 2010 and 10 September 2021. We included experimental and observational studies that featured both an integration intervention and a comparator in our review. Of the 7,118 unique peer-reviewed English-language studies that our search algorithm identified, 114 met all of our selection criteria for data extraction. Most of the studies (90) were conducted in sub-Saharan Africa, primarily in East Africa (55) and Southern Africa (24). The most common forms of integration were (i) HIV testing and counselling added to non-HIV services and (ii) non-HIV services added to antiretroviral therapy (ART). The most commonly integrated non-HIV services were maternal and child healthcare, tuberculosis testing and treatment, primary healthcare, family planning, and sexual and reproductive health services. Values for HIV care cascade outcomes tended to be better in integrated services: uptake of HIV testing and counselling (pooled risk ratio [RR] across 37 studies: 1.67 [95% CI 1.41-1.99], p < 0.001), ART initiation coverage (pooled RR across 19 studies: 1.42 [95% CI 1.16-1.75], p = 0.002), time until ART initiation (pooled RR across 5 studies: 0.45 [95% CI 0.20-1.00], p = 0.050), retention in HIV care (pooled RR across 19 studies: 1.68 [95% CI 1.05-2.69], p = 0.031), and viral suppression (pooled RR across 9 studies: 1.19 [95% CI 1.03-1.37], p = 0.025). Also, treatment success for non-HIV-related diseases and conditions and the uptake of non-HIV services were commonly higher in integrated services. We did not find any significant differences for the following outcomes in our meta-analyses: HIV testing yield, ART adherence, HIV-free survival among infants, and HIV and non-HIV mortality. We could not conduct meta-analyses for several outcomes (HIV infections averted, costs, and cost-effectiveness), because our systematic review did not identify sufficient poolable studies. Study limitations included possible publication bias of studies with significant or favourable findings and comparatively weak evidence from some world regions and on integration of services for key populations in the HIV response. CONCLUSIONS: Integration of HIV services and other health services tends to improve health and health systems outcomes. Despite some scientific limitations, the global evidence shows that service integration can be a valuable strategy to boost the sustainability of the HIV response and contribute to the goal of 'ending AIDS by 2030', while simultaneously supporting progress towards universal health coverage.

Patient-Centered, Sustainable Hypertension Care: The Case for Adopting a Differentiated Service Delivery Model for Hypertension Services in Low- and Middle-Income Countries.

Expanding hypertension services in low- and middle-income countries requires efficient and effective service delivery approaches that meet the needs and expectations of people living with hypertension within the resource constraints of existing national health systems. Ideally, a hypertension program will extend treatment coverage while maintaining service quality, maximizing efficient resource utilization and improving clinical outcomes. In this article, we discuss lessons learned from HIV differentiated service delivery initiatives, and make the case that the same approach should be adopted for hypertension programs.

Improving Services for HIV-Exposed Infants in Zambia and Cameroon Using a Quality Improvement Collaborative Approach.

INTRODUCTION: Early infant diagnosis (EID) and rapid antiretroviral therapy (ART) initiation are lifesaving interventions for HIV-infected infants. In Cameroon and Zambia, EID coverage for HIV-exposed infants (HEIs) is suboptimal and the time to ART initiation for infants infected with HIV often exceeds national standards despite numerous policy and training initiatives. METHODS: ICAP at Columbia University supported the Cameroon and Zambia Ministries of Health (MOHs) and local partners to implement quality improvement collaboratives (QICs) to improve EID coverage and ART initiation at 17 health facilities (HFs) in Cameroon (March 2016 to June 2017) and 15 HFs in Zambia (March 2017 to June 2018). In each country, MOH led project design and site selection. MOH and ICAP provided quality improvement training and monthly supportive supervision, which enabled HF teams to conduct root cause analyses, design and implement contextually appropriate interventions, conduct rapid tests of change, analyze monthly progress, and convene at quarterly learning sessions to compare performance and share best practices. RESULTS: In Cameroon, EID testing coverage improved from 57% (113/197 HEIs tested) during the 5-month baseline period to 80% (165/207) in the 5-month endline period. In Zambia, EID testing coverage improved from 77% (4,773/6,197) during the 12-month baseline period to 89% (2,144/2,420) during the 3-month endline period. In a comparison of the same baseline and endline periods, the return of positive test results to caregivers improved from 18% (36/196 caregivers notified) to 86% (182/211) in Cameroon and from 44% (94/214) to 79% (44/56) in Zambia. ART initiation improved from 44% (94/214 HIV-infected infants) to 80% (45/56) in Zambia; the numbers of HIV-infected infants in Cameroon were too small to detect meaningful differences. CONCLUSIONS: QICs improved coverage of timely EID and ART initiation in both countries. In addition to building quality improvement capacity and improving outcomes, the QICs resulted in a "change package" of successful initiatives that were disseminated within each country.

Financial burdens of HIV and chronic disease on people living with HIV in Côte d'Ivoire: A cross-sectional out-of-pocket expenditure study.

BACKGROUND: Although people living with HIV in Côte d'Ivoire receive antiretroviral therapy (ART) at no cost, other out-of-pocket (OOP) spending related to health can still create a barrier to care. METHODS: A convenience sample of 400 adults living with HIV for at least 1 year in Côte d'Ivoire completed a survey on their health spending for HIV and chronic non-communicable diseases (NCDs). In addition to descriptive statistics, we performed simple linear regression analyses with bootstrapped 95% confidence intervals. FINDINGS: 365 participants (91%) reported OOP spending for HIV care, with a median of $16/year (IQR 5-48). 34% of participants reported direct costs with a median of $2/year (IQR 1-41). No participants reported user fees for HIV services. 87% of participants reported indirect costs, with a median of $17/year (IQR 7-41). 102 participants (26%) reported at least 1 NCD. Of these, 80 (78%) reported OOP spending for NCD care, with a median of $50/year (IQR 6-107). 76 participants (95%) with both HIV and NCDs reported direct costs, and 48% reported paying user fees for NCD services. Participants had missed a median of 2 HIV appointments in the past year (IQR 2-3). Higher OOP costs were not associated with the number of HIV appointments missed. 21% of participants reported spending over 10% of household income on HIV and/or NCD care. DISCUSSION AND CONCLUSIONS: Despite the availability of free ART, most participants reported OOP spending. OOP costs were much higher for participants with co-morbid NCDs.

Bringing HIV services to key populations and their communities in Tanzania: from pilot to scale.

INTRODUCTION: Despite the global scale-up of HIV testing, prevention and treatment, these services remain inaccessible to groups most vulnerable to HIV. Globally, most new HIV infections are concentrated among members of key populations (KP), including female sex workers, men who have sex with men, transgender people, people who inject drugs and their sexual partners. These populations lag in access to HIV prevention and antiretroviral therapy (ART) and have less favourable HIV outcomes compared to the general population. Intersecting behavioural and structural factors contribute to these gaps in service access for at-risk KP and those living with HIV; corresponding comprehensive approaches to improving service delivery for KP are urgently needed. Differentiated service delivery (DSD) models tailor HIV programmes to the needs and preferences of specific groups but are rarely implemented at scale for KP. We describe the FIKIA Project, which implemented innovative approaches to scaling up DSD models to reach and engage KP in Tanzania. METHODS: The FIKIA Project worked with diverse KP communities in Tanzania to tailor HIV services to their needs and to pair healthcare workers with trained peer educators and expert client counsellors to expand uptake of community-based HIV testing and ART services. We analysed routine aggregate project data from 2016 to 2020 to describe project implementation, outcomes and best practices. RESULTS AND DISCUSSION: The FIKIA Project conducted 1,831,441 HIV tests in community settings; of the 98,349 (5.4%) individuals with new HIV diagnoses, 89,640 (91.1%) initiated ART. The project reached substantial numbers of KP: 203,233 received HIV tests, 28,830 (14.2%) received a new HIV diagnosis and 25,170 KP (87.3%) initiated ART at the point of diagnosis. Over time, HIV testing increased by 1.6 times overall (2.3 times among KP), HIV diagnoses increased by 8.7 times (10.9 times among KP) and ART initiation at the point of diagnosis increased from 80.0% to 95.9% overall (from 69.6% to 94.9% among KP). CONCLUSIONS: Over four years, the FIKIA Project scaled up HIV testing, diagnosis and treatment by using DSD principles to design services that meet the needs of KP and their communities.

Core components of infection prevention and control programs at the facility level in Georgia: key challenges and opportunities.

BACKGROUND: The Georgia Ministry of Labor, Health, and Social Affairs is working to strengthen its Infection Prevention and Control (IPC) Program, but until recently has lacked an assessment of performance gaps and implementation challenges faced by hospital staff. METHODS: In 2018, health care hospitals were assessed using a World Health Organization (WHO) adapted tool aimed at implementing the WHO's IPC Core Components. The study included site assessments at 41 of Georgia's 273 hospitals, followed by structured interviews with 109 hospital staff, validation observations of IPC practices, and follow up document reviews. RESULTS: IPC programs for all hospitals were not comprehensive, with many lacking defined objectives, workplans, targets, and budget. All hospitals had at least one dedicated IPC staff member, 66% of hospitals had IPC staff with some formal IPC training; 78% of hospitals had IPC guidelines; and 55% had facility-specific standard operating procedures. None of the hospitals conducted structured monitoring of IPC compliance and only 44% of hospitals used IPC monitoring results to make unit/facility-specific IPC improvement plans. 54% of hospitals had clearly defined priority healthcare-associated infections (HAIs), standard case definitions and data collection methods in their HAI surveillance systems. 85% hospitals had access to a microbiology laboratory. All reported having posters or other tools to promote hand hygiene, 29% had them for injection safety. 68% of hospitals had functioning hand-hygiene stations available at all points of care. 88% had single patient isolation rooms; 15% also had rooms for cohorting patients. 71% reported having appropriate waste management system. CONCLUSIONS: Among the recommended WHO IPC core components, existing programs, infrastructure, IPC staffing, workload and supplies present within Georgian healthcare hospitals should allow for implementation of effective IPC. Development and dissemination of IPC Guidelines, implementation of an effective IPC training system and systematic monitoring of IPC practices will be an important first step towards implementing targeted IPC improvement plans in hospitals.

Evaluation of health system readiness and coverage of intermittent preventive treatment of malaria in infants (IPTi) in Kambia district to inform national scale-up in Sierra Leone.

BACKGROUND: Intermittent preventive treatment of malaria in infants (IPTi) with sulfadoxine-pyrimethamine (SP) is a proven strategy to protect infants against malaria. Sierra Leone is the first country to implement IPTi nationwide. IPTi implementation was evaluated in Kambia, one of two initial pilot districts, to assess quality and coverage of IPTi services. METHODS: This mixed-methods evaluation had two phases, conducted 3 (phase 1) and 15-17 months (phase 2) after IPTi implementation. Methods included: assessments of 18 health facilities (HF), including register data abstraction (phases 1 and 2); a knowledge, attitudes and practices survey with 20 health workers (HWs) in phase 1; second-generation sequencing of SP resistance markers (pre-IPTi and phase 2); and a cluster-sample household survey among caregivers of children aged 3-15 months (phase 2). IPTi and vaccination coverage from the household survey were calculated from child health cards and maternal recall and weighted for the complex sampling design. Interrupted time series analysis using a Poisson regression model was used to assess changes in malaria cases at HF before and after IPTi implementation. RESULTS: Most HWs (19/20) interviewed had been trained on IPTi; 16/19 reported feeling well prepared to administer it. Nearly all HFs (17/18 in phase 1; 18/18 in phase 2) had SP for IPTi in stock. The proportion of parasite alleles with dhps K540E mutations increased but remained below the 50% WHO-recommended threshold for IPTi (4.1% pre-IPTi [95%CI 2-7%]; 11% post-IPTi [95%CI 8-15%], p < 0.01). From the household survey, 299/459 (67.4%) children ≥ 10 weeks old received the first dose of IPTi (versus 80.4% for second pentavalent vaccine, given simultaneously); 274/444 (62.5%) children ≥ 14 weeks old received the second IPTi dose (versus 65.4% for third pentavalent vaccine); and 83/217 (36.4%) children ≥ 9 months old received the third IPTi dose (versus 52.2% for first measles vaccine dose). HF register data indicated no change in confirmed malaria cases among infants after IPTi implementation. CONCLUSIONS: Kambia district was able to scale up IPTi swiftly and provide necessary health systems support. The gaps between IPTi and childhood vaccine coverage need to be further investigated and addressed to optimize the success of the national IPTi programme.

A Quality Improvement Collaborative for Adolescents Living With HIV to Improve Immediate Antiretroviral Therapy Initiation at 25 Health Facilities in Lusaka, Zambia.

ABSTRACT: HIV testing with rapid antiretroviral therapy (ART) initiation are life-saving interventions for adolescents living with HIV. However, in Zambia, HIV diagnosis and immediate ART initiation among adolescents living with HIV is lagging. In collaboration with the Zambian Ministry of Health, the U.S. Health Resources and Services Administration, the U.S. Centers for Disease Control and Prevention in Zambia, and ICAP at Columbia University designed and implemented a quality improvement collaborative (QIC) to improve adolescent immediate ART initiation at 25 health facilities in Lusaka. Over the 12-month implementation period, quality improvement teams tested and identified targeted intervention, that significantly improved ART initiation within 14 days of receiving positive test results, from 24% at baseline to more than 93% for the final 6 months of implementation. The quality improvement collaborative approach empowered health care workers to innovate addressing the root causes of suboptimal performance and produced a package of successful interventions that will be shared throughout Zambia.

Expanding the Vision for Differentiated Service Delivery: A Call for More Inclusive and Truly Patient-Centered Care for People Living With HIV.

BACKGROUND: Simplifying antiretroviral therapy for clinically stable people living with HIV (PLHIV) is important but insufficient to meet their health care needs, including prevention and treatment of tuberculosis and noncommunicable diseases, routine primary care, and family planning. Integrating these services into differentiated service delivery (DSD) platforms is a promising avenue to achieve such coverage. We propose a transition from an HIV-focused "DSD 1.0" to a patient-centered "DSD 2.0" that is inclusive of additional chronic care services for PLHIV. DISCUSSION: The lack of coordination between HIV programs and these critical services puts a burden on both PLHIV and health systems. For individual patients, fractionated services increase cost and time, diminish the actual and perceived quality of care, and increase the risk that they will disengage from health care altogether. The burden on the health system is one of inefficiency and suboptimal outcomes resulting from the parallel systems required to manage multiple vertical programs. CONCLUSIONS: DSD 2.0 provides an opportunity for the HIV and Universal Health Coverage agendas-which can seem to be at odds-to achieve greater collective impact for patients and health systems by integrating strong vertical HIV, tuberculosis and family planning programs, and relatively weaker noncommunicable disease programs. Increasing coordination of care for PLHIV will increase the likelihood of achieving and sustaining UNAIDS' goals of retention on antiretroviral therapy and viral suppression. Eventually, this shift to DSD 2.0 for PLHIV could evolve to a more person-centered vision of chronic care services that would also serve the general population.