Prevalence of and factors associated with zero-dose and under-immunized children in selected areas of Bangladesh: Findings from Lot Quality Assurance Sampling Survey.

BACKGROUND: In the era of Gavi's 5.0 vision of "leaving no one behind with immunization", childhood routine vaccination in missed communities is considered as a priority concern. Despite having a success story at the national level, low uptake of immunization is still persistent in selected pocket areas of Bangladesh. However, prevalence and the associated factors of zero-dose (ZD) and under-immunization (UI) are still unknown at those geo-pockets of Bangladesh. Thus, the study aims to report and identify the factors associated with ZD and UI in selected geographical locations. METHODS: This study used data from a Lot Quality Assurance Sampling (LQAS) survey where 504 households from 18 clusters of four hard to reach (HTR) and one urban slum were included. Caregivers of children aged 4.5 to 23 months were interviewed. Three outcome variables- ZD, UI and ZD/UI were considered and several related attributes were considered as independent variables. Data were analyzed through bivariate analysis, binary logistic regression and dominance analysis. RESULTS: Overall, 32% of the children were either ZD (8%) or UI (26%) in the selected areas. The adjusted odds of ZD/UI for urban slum and haor (wetlands) areas were 5.62 and 3.61 respectively considering coastal areas as reference. However, distance of nearest EPI center, availability of EPI card, age of caregivers, education and occupation of mother and number of earning members in household were influential factors for ZD/UI. According to dominance analysis, availability of EPI card can explain the most of the variation of ZD/UI in this study. CONCLUSION: The study findings highlight the high prevalence ZD/UI in certain geo-pockets of the country. It provided a powerful insight of current situation and associated factors in regards to ZD/UI in the country which will help policy-makers and programme managers in designing programmes to reduce missed communities in Bangladesh.

Measuring Zero-Dose Children: Reflections on Age Cohort Flexibilities for Targeted Immunization Surveys at the Local Level.

Zero-dose (ZD) children is a critical objective in global health, and it is at the heart of the Immunization Agenda 2030 (IA2030) strategy. Coverage for the first dose of diphtheria-tetanus-pertussis (DTP1)-containing vaccine is the global operational indicator used to estimate ZD children. When surveys are used, DTP1 coverage estimates usually rely on information reported from caregivers of children aged 12-23 months. It is important to have a global definition of ZD children, but learning and operational needs at a country level may require different ZD measurement approaches. This article summarizes a recent workshop discussion on ZD measurement for targeted surveys at local levels related to flexibilities in age cohorts of inclusion from the ZD learning Hub (ZDLH) initiative-a learning initiative involving 5 consortia of 14 different organizations across 4 countries-Bangladesh, Mali, Nigeria, and Uganda-and a global learning partner. Those considerations may include the need to generate insights on immunization timeliness and on catch-up activities, made particularly relevant in the post-pandemic context; the need to compare results across different age cohort years to better identify systematically missed communities and validate programmatic priorities, and also generate insights on changes under dynamic contexts such as the introduction of a new ZD intervention or for recovering from the impact of health system shocks. Some practical considerations such as the potential need for a larger sample size when including comparisons across multiple cohort years but a potential reduction in the need for household visits to find eligible children, an increase in recall bias when older age groups are included and a reduction in recall bias for the first year of life, and a potential reduction in sample size needs and time needed to detect impact when the first year of life is included. Finally, the inclusion of the first year of life cohort in the survey may be particularly relevant and improve the utility of evidence for decision-making and enable its use in rapid learning cycles, as insights will be generated for the population being currently targeted by the program. For some of those reasons, the ZDLH initiative decided to align on a recommendation to include the age cohort from 18 weeks to 23 months, with enough power to enable disaggregation of key results across the two different cohort years. We argue that flexibilities with the age cohort for inclusion in targeted surveys at the local level may be an important principle to be considered. More research is needed to better understand in which contexts improvements in timeliness of DTP1 in the first year of life will translate to improvements in ZD results in the age cohort of 12-23 months as defined by the global DTP1 indicator.

Assessing Potential Exemplars in Reducing Zero-Dose Children: A Novel Approach for Identifying Positive Outliers in Decreasing National Levels and Geographic Inequalities in Unvaccinated Children.

BACKGROUND: Understanding past successes in reaching unvaccinated or "zero-dose" children can help inform strategies for improving childhood immunization in other settings. Drawing from positive outlier methods, we developed a novel approach for identifying potential exemplars in reducing zero-dose children. METHODS: Focusing on 2000-2019, we assessed changes in the percentage of under-one children with no doses of the diphtheria-tetanus-pertussis vaccine (no-DTP) across two geographic dimensions in 56 low- or lower-middle-income countries: (1) national levels; (2) subnational gaps, as defined as the difference between the 5th and 95th percentiles of no-DTP prevalence across second administrative units. Countries with the largest reductions for both metrics were considered positive outliers or potential 'exemplars', demonstrating exception progress in reducing national no-DTP prevalence and subnational inequalities. Last, so-called "neighborhood analyses" were conducted for the Gavi Learning Hub countries (Nigeria, Mali, Uganda, and Bangladesh), comparing them with countries that had similar no-DTP measures in 2000 but different trajectories through 2019. RESULTS: From 2000 to 2019, the Democratic Republic of the Congo, Ethiopia, and India had the largest absolute decreases for the two no-DTP dimensions-national prevalence and subnational gaps-while Bangladesh and Burundi registered the largest relative reductions for each no-DTP metric. Neighborhood analyses highlighted possible opportunities for cross-country learning among Gavi Learning Hub countries and potential exemplars in reducing zero-dose children. CONCLUSIONS: Identifying where exceptional progress has occurred is the first step toward better understanding how such gains could be achieved elsewhere. Further examination of how countries have successfully reduced levels of zero-dose children-especially across variable contexts and different drivers of inequality-could support faster, sustainable advances toward greater vaccination equity worldwide.

Mapping of Pro-Equity Interventions Proposed by Immunisation Programs in Gavi Health Systems Strengthening Grants.

Reaching zero-dose (ZD) children, operationally defined as children who have not received a first dose of the diphtheria, tetanus, and pertussis (DTP1) vaccine, is crucial to increase equitable immunisation coverage and access to primary health care. However, little is known about the approaches already taken by countries to improve immunisation equity. We reviewed all Health System Strengthening (HSS) proposals submitted by Gavi-supported countries from 2014 to 2021 inclusively and extracted information on interventions favouring equity. Pro-equity interventions were mapped to an analytical framework representing Gavi 5.0 programmatic guidance on reaching ZD children and missed communities. Data from keyword searches and manual screening were extracted into an Excel database. Open format responses were analysed using inductive and deductive thematic coding. Data analysis was conducted using Excel and R. Of the 56 proposals included, 51 (91%) included at least one pro-equity intervention. The most common interventions were conducting outreach sessions, tailoring the location of service delivery, and partnerships. Many proposals had "bundles" of interventions, most often involving outreach, microplanning and community-level education activities. Nearly half prioritised remote-rural areas and only 30% addressed gender-related barriers to immunisation. The findings can help identify specific interventions on which to focus future evidence syntheses, case studies and implementation research and inform discussions on what may or may not need to change to better reach ZD children and missed communities moving forward.

A learning agenda to build the evidence base for strengthening global health information systems.

BACKGROUND: Evidence-based interventions are necessary for planning and investing in health information systems (HIS) and for strengthening those systems to collect, manage, sort and analyse health data to support informed decision-making. However, evidence and guidance on HIS strengthening in low- and middle-income countries have been historically lacking. OBJECTIVE: This article describes the approach, methods, lessons learned and recommendations from 5 years of applying our learning agenda to strengthen the evidence base for effective HIS interventions. METHODS: The first step was to define key questions about characteristics, stages of progression, and factors and conditions of HIS performance progress. We established a team and larger advisory group to guide the implementation of activities to build the evidence base to answer questions. We strengthened learning networks to share information. RESULTS: The process of applying the learning agenda provided a unique opportunity to learn by doing, strategically collecting information about monitoring and evaluating HIS strengthening interventions and building a body of evidence. There are now models and tools to strengthen HIS, improved indicators and measures, country HIS profiles, documentation of interventions, a searchable database of HIS assessment tools and evidence generated through syntheses and evaluation results. CONCLUSION: The systematic application of learning agenda processes and activities resulted in increased evidence, information, guidance and tools for HIS strengthening and a resource centre, making that information accessible and available globally. IMPLICATIONS: We describe the inputs, processes and lessons learned, so that others interested in designing a successful learning agenda have access to evidence of how to do so.

Impact of the SARS-CoV-2 pandemic on routine immunisation services: evidence of disruption and recovery from 170 countries and territories.

BACKGROUND: The SARS-CoV-2 pandemic has revealed the vulnerability of immunisation systems worldwide, although the scale of these disruptions has not been described at a global level. This study aims to assess the impact of COVID-19 on routine immunisation using triangulated data from global, country-based, and individual-reported sources obtained during the pandemic period. METHODS: This report synthesised data from 170 countries and territories. Data sources included administered vaccine-dose data from January to December, 2019, and January to December, 2020, WHO regional office reports, and a WHO-led pulse survey administered in April, 2020, and June, 2020. Results were expressed as frequencies and proportions of respondents or reporting countries. Data on vaccine doses administered were weighted by the population of surviving infants per country. FINDINGS: A decline in the number of administered doses of diphtheria-pertussis-tetanus-containing vaccine (DTP3) and first dose of measles-containing vaccine (MCV1) in the first half of 2020 was noted. The lowest number of vaccine doses administered was observed in April, 2020, when 33% fewer DTP3 doses were administered globally, ranging from 9% in the WHO African region to 57% in the South-East Asia region. Recovery of vaccinations began by June, 2020, and continued into late 2020. WHO regional offices reported substantial disruption to routine vaccination sessions in April, 2020, related to interrupted vaccination demand and supply, including reduced availability of the health workforce. Pulse survey analysis revealed that 45 (69%) of 65 countries showed disruption in outreach services compared with 27 (44%) of 62 countries with disrupted fixed-post immunisation services. INTERPRETATION: The marked magnitude and global scale of immunisation disruption evokes the dangers of vaccine-preventable disease outbreaks in the future. Trends indicating partial resumption of services highlight the urgent need for ongoing assessment of recovery, catch-up vaccination strategy implementation for vulnerable populations, and ensuring vaccine coverage equity and health system resilience. FUNDING: US Agency for International Development.

Reliability, validity and measurement invariance of the Simplified Medication Adherence Questionnaire (SMAQ) among HIV-positive women in Ethiopia: a quasi-experimental study.

BACKGROUND: Adherence to antiretroviral therapy is critical to the achievement of the third target of the UNAIDS Fast-Track Initiative goals of 2020-2030. Reliable, valid and accurate measurement of adherence are important for correct assessment of adherence and in predicting the efficacy of ART. The Simplified Medication Adherence Questionnaire is a six-item scale which assesses the perception of persons living with HIV about their adherence to ART. Despite recent widespread use, its measurement properties have yet to be carefully documented beyond the original study in Spain. The objective of this paper was to conduct internal consistency reliability, concurrent validity and measurement invariance tests for the SMAQ. METHODS: HIV-positive women who were receiving ART services from 51 service providers in two sub-cities of Addis Ababa, Ethiopia completed the SMAQ in a HIV treatment referral network study between 2011 and 2012. Two cross-sections of 402 and 524 female patients of reproductive age, respectively, from the two sub-cities were randomly selected and interviewed at baseline and follow-up. We used Cronbach's coefficient alpha (α) to assess internal consistency reliability, Pearson product-moment correlation (r) to assess concurrent validity and multiple-group confirmatory factor analysis to analyze factorial structure and measurement invariance of the SMAQ. RESULTS: All participants were female with a mean age of 33; median: 34 years; range 18-45 years. Cronbach's alphas for the six items of the SMAQ were 0.66, 0.68, 0.75 and 0.75 for T1 control, T1 intervention, T2 control, and T2 intervention groups, respectively. Pearson correlation coefficients were 0.78, 0.49, 0.52, 0.48, 0.76 and 0.80 for items 1 to 6, respectively, between T1 compared to T2. We found invariance for factor loadings, observed item intercepts and factor variances, also known as strong measurement invariance, when we compared latent adherence levels between and across patient-groups. CONCLUSIONS: Our results show that the six-item SMAQ scale has adequate reliability and validity indices for this sample, in addition to being invariant across comparison groups. The findings of this study strengthen the evidence in support of the increasing use of SMAQ by interventionists and researchers to examine, pool and compare adherence scores across groups and time periods.

Organizational network strengthening effects on antiretroviral therapy initiation and adherence.

The WHO recommends antiretroviral therapy (ART) initiation immediately after HIV diagnosis. When HIV services are fragmented and poorly coordinated, initiation of ART can be delayed. MEASURE Evaluation conducted an organizational network intervention in Addis Ababa, Ethiopia, which increased referral network density and client satisfaction in the intervention versus control networks. The objective of our study was to extend the parent study by assessing effects of network density on the speed of ART initiation and adherence to ART. Measures of client-time since HIV diagnosis, use of ART, satisfaction with HIV-related services, and adherence were obtained from cross-sectional interviews with female service recipients with HIV/AIDS at baseline (T1, 402) and at 18-month follow-up (T2, 524) and compared between network sites. We used weighted least squares estimation with probit regression techniques in a structural equation modeling framework for analyses. On average at follow-up, clients in the intervention network were more likely to have quicker ART initiation, and were initiated on ART 15 days faster than clients in the control network. Moreover, quicker ART initiation was associated with higher adherence. A unit increase in speed of ART initiation was associated with 0.5 points increase in latent adherence score in the intervention group (p < .05). Satisfaction with care positively predicted adherence to ART. Network density had no direct effect on ART adherence. This quasi-experiment demonstrated that increased referral network density, through improved HIV client referrals, can enhance speed of ART initiation, resulting in improved adherence.

Improving referrals and integrating family planning and HIV services through organizational network strengthening.

BACKGROUND: The service needs of people with human immunodeficiency virus (HIV) in low-income settings are wide-ranging. Service provision in a community is often disjointed among a variety of providers. We sought to reduce unmet patient needs by increasing referral coordination for HIV and family planning, measured as network density, with an organizational network approach. METHODS: We conducted organizational network analysis on two networks in sub-cities of Addis Ababa, Ethiopia. There were 25 organizations in one sub-city network and 26 in the other. In one of them we sought to increase referrals through three network strengthening meetings. We then conducted the network analysis again in both sub-cities to measure any changes since baseline. We also quantitatively measured reported client service needs in both sub-cities before and after the intervention with two cross-sectional samples of face-to-face interviews with clients (459 at baseline and 587 at follow-up). RESULTS: In the sub-city with the intervention, the number of referral connections between organizations, measured as network density, increased 55%. In the control community, the density decreased over the same period. Reported unmet client service needs declined more consistently across services in the intervention community. DISCUSSION: This quasi experiment demonstrated that (1) an organizational network analysis can inform an intervention, (2) a modest network strengthening intervention can enhance client referrals in the network, (3) improvement in client referrals was accompanied by a decrease in atient-reported unmet needs and (4) a series of network analyses can be a useful evaluation tool.

The effect of women's property rights on HIV: a search for quantitative evidence.

In recent years, efforts to reduce HIV transmission have begun to incorporate a structural interventions approach, whereby the social, political, and economic environment in which people live is considered an important determinant of individual behaviors. This approach to HIV prevention is reflected in the growing number of programs designed to address insecure or nonexistent property rights for women living in developing countries. Qualitative and anecdotal evidence suggests that property ownership may allow women to mitigate social, economic, and biological effects of HIV for themselves and others through increased food security and income generation. Even so, the relationship between women's property and inheritance rights (WPIR) and HIV transmission behaviors is not well understood. We explored sources of data that could be used to establish quantitative links between WPIR and HIV. Our search for quantitative evidence included (1) a review of peer-reviewed and "gray" literature reporting on quantitative associations between WPIR and HIV, (2) identification and assessment of existing data-sets for their utility in exploring this relationship, and (3) interviews with organizations addressing women's property rights in Kenya and Uganda about the data they collect. We found no quantitative studies linking insecure WPIR to HIV transmission behaviors. Data-sets with relevant variables were scarce, and those with both WPIR and HIV variables could only provide superficial evidence of associations. Organizations addressing WPIR in Kenya and Uganda did not collect data that could shed light on the connection between WPIR and HIV, but the two had data and community networks that could provide a good foundation for a future study that would include the collection of additional information. Collaboration between groups addressing WPIR and HIV transmission could provide the quantitative evidence needed to determine whether and how a WPIR structural intervention could decrease HIV transmission.

Development of a Nationally Coordinated Evaluation Plan for the Ghana National Strategy for Key Populations.

OBJECTIVE: Just as HIV prevention programs need to be tailored to the local epidemic, so should evaluations be country-owned and country-led to ensure use of those results in decision making and policy. The objective of this paper is to describe the process undertaken in Ghana to develop a national evaluation plan for the Ghana national strategy for key populations. METHODS: This was a participatory process that involved meetings between the Ghana AIDS Commission (GAC), other partners in Ghana working to prevent HIV among key populations, and MEASURE Evaluation. The process included three two-day, highly structured yet participatory meetings over the course of 12 months during which participants shared information about on-going and planned data and identified research questions and methods. RESULTS: An evaluation plan was prepared to inform stakeholders about which data collection activities need to be prioritized for funding, who would implement the study, the timing of data collection, the research question the data will help answer, and the analysis methods. The plan discusses various methods that can be used including the recommendation for the study design using multiple data sources. It has an evaluation conceptual model, proposed analyses, proposed definition of independent variables, estimated costs for filling data gaps, roles and responsibilities of stakeholders to carry out the plan, and considerations for ethics, data sharing and authorship. CONCLUSION: The experience demonstrates that it is possible to design an evaluation responsive to national strategies and priorities with country leadership, regardless of stakeholders' experiences with evaluations. This process may be replicable elsewhere, where stakeholders want to plan and implement an evaluation of a large-scale program at the national or subnational level that is responsive to national priorities and part of a comprehensive monitoring and evaluation system.

A systematic approach to the planning, implementation, monitoring, and evaluation of integrated health services.

BACKGROUND: Because of the current emphasis and enthusiasm focused on integration of health systems, there is a risk of piling resources into integrated strategies without the necessary systems in place to monitor their progress adequately or to measure impact, and to learn from these efforts. The rush to intervene without adequate monitoring and evaluation will continue to result in a weak evidence base for decision making and resource allocation. Program planning and implementation are inextricability linked to monitoring and evaluation. Country level guidance is needed to identify country-specific integrated strategies, thereby increasing country ownership. DISCUSSION: This paper focuses on integrated health services but takes into account how health services are influenced by the health system, managed by programs, and made up of interventions. We apply the principles in existing comprehensive monitoring and evaluation (M&E) frameworks in order to outline a systematic approach to the M&E of integration for the country level. The approach is grounded by first defining the country-specific health challenges that integration is intended to affect. Priority points of contact for care can directly influence health, and essential packages of integration for all major client presentations need to be defined. Logic models are necessary to outline the plausible causal pathways and define the inputs, roles and responsibilities, indicators, and data sources across the health system. Finally, we recommend improvements to the health information system and in data use to ensure that data are available to inform decisions, because changes in the M&E function to make it more integrated will also facilitate integration in the service delivery, planning, and governance components. SUMMARY: This approach described in the paper is the ideal, but its application at the country level can help reveal gaps and guide decisions related to what health services to prioritize for integration, help plan for how to strengthen systems to support health services, and ultimately establish an evidence base to inform investments in health care. More experience is needed to understand if the approach is feasible; similarly, more emphasis is needed on documenting the process of designing and implemented integrated interventions at the national level.

Improving the use of health data for health system strengthening.

BACKGROUND: Good quality and timely data from health information systems are the foundation of all health systems. However, too often data sit in reports, on shelves or in databases and are not sufficiently utilised in policy and program development, improvement, strategic planning and advocacy. Without specific interventions aimed at improving the use of data produced by information systems, health systems will never fully be able to meet the needs of the populations they serve. OBJECTIVE: To employ a logic model to describe a pathway of how specific activities and interventions can strengthen the use of health data in decision making to ultimately strengthen the health system. DESIGN: A logic model was developed to provide a practical strategy for developing, monitoring and evaluating interventions to strengthen the use of data in decision making. The model draws on the collective strengths and similarities of previous work and adds to those previous works by making specific recommendations about interventions and activities that are most proximate to affect the use of data in decision making. The model provides an organizing framework for how interventions and activities work to strengthen the systematic demand, synthesis, review, and use of data. RESULTS: The logic model and guidance are presented to facilitate its widespread use and to enable improved data-informed decision making in program review and planning, advocacy, policy development. Real world examples from the literature support the feasible application of the activities outlined in the model. CONCLUSIONS: The logic model provides specific and comprehensive guidance to improve data demand and use. It can be used to design, monitor and evaluate interventions, and to improve demand for, and use of, data in decision making. As more interventions are implemented to improve use of health data, those efforts need to be evaluated.

Consistent condom use among men with non-marital partners in four sub-Saharan African countries.

Data from the Demographic and Health Surveys for Namibia, Swaziland, and Zambia and the AIDS Indicator Survey from Tanzania were used to examine the influence of marital status and number of partners on consistent condom use among men with casual sexual partnerships in four generalized HIV epidemic settings. We restrict the sample to the 26% (Zambia), 29% (Tanzania), 35% (Swaziland), and 42% (Namibia) of men, who, in the last 12 months before the survey, had any non-marital/non-cohabiting (i.e., casual) sexual partners. We use "condom always used with any partner in the last 12 months" as a dichotomous-dependent measure of consistent condom use. Analyses were stratified by country. Of men with casual partners, 41% (Zambia) to 70% (Namibia) used a condom every time with at least one partner. The majority of men were unmarried/non-cohabiting with one casual partner in the last year. In Swaziland and Zambia, multivariate results suggest that unmarried/non-cohabiting men with one casual partner had significantly lower odds than married/cohabiting men with casual partners to use condoms consistently (odds ratio [OR]=0.56, p=0.01 and OR=0.41, p<0.001, respectively.). In Namibia, unmarried/non-cohabiting men with two or more casual partners had significantly greater odds than married/cohabiting men with casual partners to use condoms consistently (OR=2.80, p<0.01). With some exceptions by country, higher education, religious group, wealth, having no children, knowing HIV results, having an STI, having one lifetime partner, and positive condom knowledge and beliefs also were significantly associated with using a condom every time with any partner. We conclude that consistent condom use remains an elusive goal even among men with casual sexual relationships. Condom use messages should be refined and targeted to men based on their number and types of relationships and combined with other messages to decrease concurrent relationships.

Service delivery characteristics associated with contraceptive use among youth clients in integrated voluntary counseling and HIV testing clinics in Kenya.

Youth attending voluntary counseling and HIV testing (VCT) services often have unmet need for contraception. Integrated family planning (FP) and HIV services can address dual HIV and unintended pregnancy prevention needs. However, little is known about which VCT service characteristics, such as quality of care, strength of FP-HIV service integration, and youth-friendliness, affect contraceptive behavior. This study explores the facility- and provider-level characteristics that may be associated with same day uptake or intention to use contraception after a VCT visit, and contraceptive use three months later among youth clients, controlling for client characteristics. This was a descriptive study conducted in 20 integrated VCT clinics across Kenya. Data collection included 20 structured clinic observations, 349 baseline interviews with male and female clients aged 15-24 after their VCT visit plus 277 follow-up interviews with clients three months later, and interviews with 46 providers who served the clients at the study clinics. Client, provider, and structured observation data were linked and multi-level logistic path models were used for analyses. Results revealed little evidence of specific service characteristics being associated with contraceptive behavior. However, VCT providers were not routinely screening for risk of unintended pregnancy or counseling on contraception. Results are likely a reflection of suboptimal integrated services. The clinics were serving youth with unmet contraceptive need and therefore integrated services should be strengthened overall to ensure no missed opportunities.

The measurement of condom use in four countries in East and southern Africa.

Measurement of condom use is important to assess progress in increasing use. Since 2003, the Demographic and Health Surveys (DHS) and AIDS Indicator Surveys (AIS) have included new measures of self-reported condom use. We use data from Namibia, Swaziland, Tanzania, and Zambia to compare measures of condom use accounting for type of sexual partner. Condom use at last sex ranged from 20% in Tanzania to 57% in Namibia for men, and from 12% in Tanzania to 41% in Namibia for women. Reported condom use was lower in response to questions about condom use every time with last partner (from 13 to 47% for men and from 8 to 33% for women). Condom use was highest among people with two or more partners in the last year and lowest with marital partners. Overall, the prevalence of condom use was low, and there was wide variability across the various measures, countries, sexes, and types of partner. Promotion of condom use in all partnerships, but especially in non-marital relationships and among individuals with multiple partners, remains a critical strategy. New condom use questions in the DHS and AIS expand options for measuring and studying condom use.

Benefits and costs of expanding access to family planning programs to women living with HIV.

OBJECTIVE: This analysis models the potential benefits and costs of adding family planning to national strategies for achieving universal access to programs to prevent mother-to-child HIV transmission. METHODS: We assume a service delivery perspective and estimate the cost-effectiveness of programs to reduce the number of HIV-infected children through using antiretroviral prophylaxis to prevent perinatal transmission, and of family planning programs to avert additional infant infections not already averted by antiretroviral prophylaxis, as well as of family planning to reduce the number of total unintended births to women living with HIV. Data are presented from the 139 countries included in the 2008 Annual United Nations Joint Programme on HIV/AIDS Report, although the main results are for the 14 countries with the largest number of HIV-infected pregnant women. RESULTS: Programs to prevent perinatal HIV transmission would, if accessed by all women in need with the most efficacious antiretroviral regimen available, prevent over 240,000 dollars infant HIV infections in the top 14 countries (over 300,000 globally) at an estimated cost of over 131 million dollars (208 million dollars globally). However, almost 72,000 infant HIV infections would still occur in the 14 countries (over 90,000 globally) that could have been averted by preventing unintended pregnancies at a cost of only about 26 million dollars (over 33 million dollars globally). If all unintended births (whether or not resulting in HIV-infected children) to HIV-positive women were prevented with family planning, the cost per birth averted would be 61 dollars in the 14 countries (63 dollars globally). CONCLUSION: This analysis suggests that national strategies should adopt a comprehensive approach to preventing mother-to-child transmission and thus focus on preventing perinatal HIV transmission as well as unintended pregnancies. Family planning is cost-effective for preventing HIV transmission and unintended pregnancies and will also reduce infant and maternal mortality and result in fewer orphans.

Effectiveness of training supervisors to improve reproductive health quality of care: a cluster-randomized trial in Kenya.

Health facility supervisors are in a position to increase motivation, manage resources, facilitate communication, increase accountability and conduct outreach. This study evaluated the effectiveness of a training intervention for on-site, in-charge reproductive health supervisors in Kenya using an experimental design with pre- and post-test measures in 60 health facilities. Cost information and data from supervisors, providers, clients and facilities were collected. Regression models with the generalized estimating equation approach were used to test differences between study groups and over time, accounting for clustering and matching. Total accounting costs per person trained were calculated. The intervention resulted in significant improvements in quality of care at the supervisor, provider and client-provider interaction levels. Indicators of improvements in the facility environment and client satisfaction were not apparent. The costs of delivering the supervision training intervention totalled US$2113 per supervisor trained. In making decisions about whether to expand the intervention, the costs of this intervention should be compared with other interventions designed to improve quality.

Adolescents' use of maternal and child health services in developing countries.

CONTEXT: Because of high levels of early childbearing in developing countries, pregnancy and childbirth are the leading causes of death among women aged 15-19. Use of skilled antenatal and delivery care improves maternal outcomes through the prevention, management and treatment of obstetric complications, and infant immunizations prevent many childhood diseases. METHODS: Logistic regression analysis of Demographic and Health Survey data for 15 developing countries examined adolescents' use of antenatal care, delivery care and infant immunization services compared with use by older women. RESULTS: In general, the use of maternal and child health care did not vary by mother's age. In five of the 15 countries, women aged 18 or younger were less likely than women aged 19-23 to use either antenatal care or delivery care, or both (odds ratios, 0.5-0.9). Younger mothers in six countries were less likely than older mothers to have their infants immunized, particularly for diphtheria, pertussis and tetanus and for measles (0.5-0.8). The association of age and health care use was largely limited to Bangladesh, India, Indonesia, Nicaragua, Peru and Uganda. In Latin America, controlling for parity allowed differences between adolescents and older women to emerge. Except in Uganda, there were no differences in health care use by mother's age in the African countries. CONCLUSION: Country-specific investigations are needed in Asia to better understand the reasons for differences in service use by age. In general, further systematic evidence would help identify long-term interventions that will be most effective in increasing adolescents' use of maternal and child health services.

The value of contraception to prevent perinatal HIV transmission.

OBJECTIVE: The objective of this study was to highlight the value of preventing unintended pregnancies among HIV-infected women as a strategy to prevent perinatal HIV transmission. GOAL: The goal of this study was to assess the cost-effectiveness of family planning programs to avert HIV-positive births with the current programmatic emphasis: prenatal care services that provide and promote nevirapine for prevention of mother-to-child transmission of HIV. STUDY DESIGN: Cost-effectiveness analyses were conducted from the health system perspective during 1 year with a hypothetical sub-Saharan African population. Expected program costs were combined with number of HIV-positive births averted for each strategy. RESULTS: At the same level of expenditure, the contraceptive strategy averts 28.6% more HIV-positive births than nevirapine for prevention of mother-to-child transmission of HIV. CONCLUSIONS: Increasing contraceptive use among nonusers of contraception who do not want to get pregnant is cost-effective and is an equally important strategy to prevent perinatal transmission as prenatal care programs that provide and promote nevirapine to HIV-infected mothers.