Factors influencing integration of mental health screening and treatment at HIV clinic settings in Cameroon: a qualitative study of health providers' perspectives.

BACKGROUND: Mental disorders are common among people with HIV (PWH) and are associated with poor HIV outcomes. Despite high unmet mental health needs among PWH, use of evidence-based mental health screening and treatment protocols remains limited at HIV treatment facilities across low-resource settings. Integrating mental health services into HIV care can reduce this gap. This study's objective was to explore factors that influence integration of mental health screening and treatment into HIV clinics in Cameroon. METHODS: We analyzed 14 in-depth interviews with clinic staff supporting PWH at three urban HIV treatment clinics in Cameroon. Interviews focused on current processes, barriers and facilitators, and types of support needed to integrate mental health care into HIV care. Interviews were recorded and transcribed. French transcripts were translated into English. We used thematic analysis to identify factors that influence integration of mental health screening and treatment into HIV care in these settings. Ethical review boards in the United States and Cameroon approved this study. RESULTS: Respondents discussed a lack of standardized mental health screening processes in HIV treatment facilities and generally felt ill-equipped to conduct mental health screening. Low community awareness about mental disorders, mental health-related stigma, limited physical space, and high clinic volume affected providers' ability to screen clients for mental disorders. Providers indicated that better coordination and communication were needed to support client referral to mental health care. Despite these barriers, providers were motivated to screen clients for mental disorders and believed that mental health service provision could improve quality of HIV care and treatment outcomes. All providers interviewed said they would feel more confident screening for mental disorders with additional training and resources. Providers recommended community sensitization, training or hiring additional staff, improved coordination to manage referrals, and leadership buy-in at multiple levels of the health system to support sustainable integration of mental health screening and treatment into HIV clinics in Cameroon. CONCLUSIONS: Providers reported enthusiasm to integrate mental health services into HIV care but need more support and training to do so in an effective and sustainable manner.

Responsible coordination of municipal health and care services for individuals with serious mental illness: a participatory qualitative study with service users and professionals.

BACKGROUND: Care coordination is crucial to ensure the health of individuals with serious mental illness. The aim of this study was to describe and analyze an inclusive innovation process for coordinating municipal health and care services for individuals with serious mental illness. METHODS: We conducted café dialogues with professionals and service users with serious mental illness. The café dialogues engaged participants in conversation and knowledge exchange about care coordination, adressing topics of efficiency, challenges, and improvement. We used a responsible innovation framework to analyze the innovation process. RESULTS: Responsible coordination requires promoting service users' health and ensuring communication and mutual awareness between professionals. Individual-level factors supporting responsible coordination included service users knowing their assigned professionals, personalized healthcare services, and access to meaningful activities. Provider-level factors included effective coordination routines, communication, information exchange, and professional familiarity. Results reflect professionals' and service users' perspectives on efficient care coordination, existing challenges, and measures to improve care coordination. CONCLUSION: Café dialogues are an inclusive, participatory method that can produce insights into the responsible coordination of municipal health and care services for individuals with serious mental illness. The responsible innovation framework is helpful in identifying care coordination challenges and measures for responsible coordination.

Availability and readiness of health facilities providing services for other infectious diseases to treat neglected tropical diseases in Ethiopia: implications for service integration in high burden areas.

BACKGROUND: The burden of neglected tropical diseases (NTDs), HIV/AIDS, tuberculosis, and malaria pose significant public health challenges in Ethiopia. This study aimed to the explore service availability and readiness for NTD care among Ethiopian health facilities treating tuberculosis (TB), HIV/AIDS, and/or malaria. METHODS: This study utilized secondary data from the Ethiopian Service Provision Assessment 2021-22 survey. The availability of services was calculated as the percentage of HIV/AIDS, tuberculosis, or malaria facilities providing NTD services. Facilities were considered highly prepared to manage any type of NTD if they scored at least half (> 50%) of the tracer items listed in each of the three domains (staff training and guidelines, equipment, and essential medicines). Descriptive statistics and logistic regression models were employed to present the study findings and analyze factors influencing facility readiness, respectively. RESULTS: Out of 403 health facilities providing NTD care nationally, 179, 183, and 197 also offer TB, HIV/AIDS, and malaria services, respectively. The majority of TB (90.1%), HIV/AIDS (89.6%), and malaria (90.9%) facilities offer soil-transmitted helminth services, followed by trachoma (range 87-90%). The percentages of the aforementioned facilities with at least one trained staff member for any type of NTD were 87.2%, 88.4%, and 82.1%, respectively. The percentage of facilities with guidelines for any type of NTD was relatively low (range 3.7-4.1%). Mebendazole was the most widely available essential medicine, ranging from 69 to 70%. The overall readiness analysis indicated that none of the included facilities (TB = 11.9%; HIV/AIDS = 11.6%; and malaria = 10.6%) were ready to offer NTD care. Specifically, a higher level of readiness was observed only in the domain of medicines across these facilities. Hospitals had better readiness to offer NTD care than did health centers and clinics. Furthermore, a significant associations were observed between facility readiness and factors such as facility type, region, presence of routine management meetings, types of NTD services provided, and fixed costs for services. CONCLUSIONS: Ethiopian health facilities treating TB, HIV/AIDS, and malaria had an unsatisfactory overall service availability and a lack of readiness to provide NTD care. Given the existing epidemiological risks and high burden of TB, HIV/AIDS, malaria, and NTDs in Ethiopia, there is an urgent need to consider preparing and implementing a collaborative infectious disease care plan to integrate NTD services in these facilities.

Networking community health workers for service integration: role of social media.

Community health workers (CHW) can play an active role in providing integrated HIV and harm reduction services. We used social media to create a virtual network among Vietnamese CHW. This paper reports CHW's social media engagement and the relationships with other work-related indicators. Sixty CHW participated in an intervention for integrated HIV/drug use service delivery. Following two in-person sessions, Facebook groups were established for CHW to share information, seek consultation, and refer patients. CHW's levels of online engagements were tracked for six months and linked to their service provision confidence, interaction with patients and other providers, and job satisfaction. The CHW made 181 posts, which received 557 comments and 1,607 reactions during the six months. Among the 60 CHW, 22 (36.6%) had three or more posts, 19 (31.7%) had one or two posts, and 19 (31.7%) had no post. Comparing the baseline and 6-month follow-up data, we observed that those who posted three or more times showed better service provision confidence (p = 0.0081), more interaction with providers in other settings (p = 0.0071), and higher job satisfaction (p = 0.0268). Our study suggests using social media to engage CHW in virtual communications to improve service provision in communities.

Australian general practitioners' perspectives on integrating specialist diabetes care with primary care: qualitative study.

BACKGROUND: Improving the coordination and integration of health services is recognised nationally and internationally as a key strategy for improving the quality of diabetes care. The Australian Diabetes Alliance Program (DAP) is an integrated care model implemented in the Hunter New England Local Health District (HNELHD), New South Wales (NSW), in which endocrinologists and diabetes educators collaborate with primary care teams via case-conferencing, practice performance review, and education sessions. The objective of this study was to report on general practitioners' (GPs) perspectives on DAP and whether the program impacts on their skills, knowledge, and approach in delivering care to adult patients with type 2 diabetes. METHODS: Four primary care practices with high rates of monitoring haemoglobin A1c (HbA1c) levels (> 90% of patients annually) and five practices with low rates of monitoring HbA1c levels (< 80% of patients annually) from HNELHD, NSW provided the sampling frame. A total of nine GPs were interviewed. The transcripts from the interviews were reviewed and analysed to identify emergent patterns and themes. RESULTS: Overall, GPs were supportive of DAP. They considered that DAP resulted in significant changes in their knowledge, skills, and approach and improved the quality of diabetes care. Taking a more holistic approach to care, including assessing patients with diabetes for co-morbidities and risk factors that may impact on their future health was also noted. DAP was noted to increase the confidence levels of GPs, which enabled active involvement in the provision of diabetes care rather than referring patients for tertiary specialist care. However, some indicated the program could be time consuming and greater flexibility was needed. CONCLUSIONS: GPs reported DAP to benefit their knowledge, skills and approach for managing diabetes. Future research will need to investigate how to improve the intensity and flexibility of the program based on the workload of GPs to ensure long-term acceptability of the program.

A qualitative exploration of Ugandan mental health care workers' perspectives and experiences on sexual and reproductive health of people living with mental illness in Uganda.

BACKGROUND: People with Mental Illness experience vast sexual and reproductive health challenges due to the affected mental health. Globally, prevalence of mental illness is on the rise with subsequent increase in the number of people with sexual and reproductive challenges warranting urgent public health intervention. However, information on the perceptions and experiences of mental health workers, the key health care providers for this population is generally lacking yet it's essential for formulation of appropriate policies and public health interventions. AIM: To explore Ugandan mental health care worker's perspectives and experiences on the sexual and reproductive health of people living with mental illness in Uganda in order to generate recommendations to the ministry of health on how it can be improved. MATERIALS AND METHODS: Qualitative study design was employed with utilization of phone call semi-structured in-depth interviews to collect data from 14 mental health workers from Uganda's National mental referral hospital, Butabika. Purposive sampling and convenience recruitment was done and the collected data was analyzed using Thematic content analysis. RESULTS: Four themes were generated which included people with Mental illness having normal sexual needs, mental illness effect on sexuality and relationships, practices for safeguarding sexuality of people with mental illness and the barriers encountered in the provision of sexual and reproductive health services at a mental hospital. CONCLUSION: People with mental illness experience a multitude of sexual and reproductive health challenges that need public health interventions. However, the integration of sexual and reproductive health services in a mental hospital are not yet successful making people with mental illness to remain with unaddressed health challenges. Policies should therefore be developed and implemented to ensure successful integration of sexual and reproductive health at all mental health service care provision points.

Missed opportunities for family planning counselling among postpartum women in eleven counties in Kenya.

BACKGROUND: Mothers may access medical facilities for their babies and miss opportunities to access family planning (FP) services. This study was undertaken to describe missed opportunities for FP among women within the extended (0-11 months) postpartum period from counties participating in Performance Monitoring and Accountability 2020 (PMA2020) surveys. DESIGN AND SETTING: This study analysed cross-sectional household survey data from 11 counties in Kenya between 2014 and 2018. PMA2020 uses questions extracted from the Demographic and Health survey (DHS) and DHS definitions were used. Multivariable logistic regression was used for inferential statistics with p-value of < 0.05 considered to be significant. PARTICIPANTS: Women aged 15-49 years from the households visited. PRIMARY OUTCOME MEASURE: Missed opportunity for family planning/contraceptives (FP/C) counselling. RESULTS: Of the 34,832 women aged 15-49 years interviewed, 10.9% (3803) and 10.8% (3746) were in the period 0-11 months and 12-23 months postpartum respectively, of whom, 38.8 and 39.6% respectively had their previous pregnancy unintended. Overall, 50.4% of women 0-23 months postpartum had missed opportunities for FP/C counselling. Among women who had contact with health care at the facility, 39.2% of women 0-11 months and 44.7% of women 12-23 months had missed opportunities for FP/C counselling. Less than half of the women 0-11 months postpartum (46.5%) and 64.5% of women 12 - 23 months postpartum were using highly efficacious methods. About 27 and 18% of the women 0-11 months and 12 - 23 months postpartum respectively had unmet need for FP/C. Multivariable analysis showed that being low parity and being from the low wealth quintile significantly increased the odds of missed opportunities for FP/C counselling among women in the extended postpartum period, p < 0.05. CONCLUSIONS: A large proportion of women have missed opportunities for FP/C counselling within 2 years postpartum. Programs should address these missed opportunities.

Integration of a menstrual health intervention in a community-based sexual and reproductive health service for young people in Zimbabwe: a qualitative acceptability study.

BACKGROUND: Despite being fundamental to the health and well-being of women, menstrual health is often overlooked as a health priority and access to menstrual health education, products, and support is limited. Consequently, many young women are unprepared for menarche and face challenges in accessing menstrual health products and support and in managing menstruation in a healthy and dignified way. In this paper, we examine the acceptability of a comprehensive menstrual health and hygiene (MHH) intervention integrated within a community-based sexual and reproductive health (SRH) service for young people aged 16-24 years in Zimbabwe called CHIEDZA. METHODS: We conducted focus group discussions, that included participatory drawings, with CHIEDZA healthcare service providers (N = 3) and with young women who had attended CHIEDZA (N = 6) between June to August 2020. Translated transcripts were read for familiarisation and thematic analysis was used to explore acceptability. We applied Sekhon's thematic framework of acceptability that looks at seven key constructs (affective attitudes, burden, ethicality, intervention coherence, opportunity costs, perceived effectiveness, and self-efficacy). Data from FGDs and meeting minutes taken during the study time period were used to triangulate a comprehensive understanding of MHH intervention acceptability. RESULTS: The MHH intervention was acceptable to participants as it addressed the severe prevailing lack of access to menstrual health education, products, and support in the communities, and facilitated access to other SRH services on site. In addition to the constructs defined by Sekhon's thematic framework, acceptability was also informed by external contextual factors such as sociocultural norms and the economic environment. Providers highlighted the increased burden in their workload due to demand for MHH products, and how sociocultural beliefs around insertable menstrual products compromising virginity can negatively affect acceptability among young people and community members. CONCLUSIONS: MHH interventions are acceptable to young women in community-based settings in Zimbabwe as there is great unmet need for comprehensive MHH support. The integration of MHH in SRH services can serve as a facilitator to female engagement with SRH services. However, it is important to note that contextual external factors can affect the implementation and acceptability of integrated SRH and MHH services within communities. TRIAL REGISTRATION: Registry: Clinicaltrials.gov, Registration Number: NCT03719521 , Registration Date: October 25, 2018.

A scoping review examining the integration of exercise services in clinical oncology settings.

BACKGROUND: Addressing questions surrounding the feasibility of embedding exercise service units in clinical oncology settings is imperative for developing a sustainable exercise-oncology clinical pathway. We examined available literature and offered practical recommendations to support evidence-based practice, policymaking, and further investigations. METHODS: Four thousand eight hundred sixty-three unique records identified in Embase, CINAHL, MEDLINE, Web of Science Core Collection, and ProQuest (Health and Medicine) were screened for studies that recruited cancer patients, assessed the co-location of exercise service and cancer treatment units, and reported findings on service implementation. Evidence from six studies providing data from over 30 programs was integrated using narrative synthesis. RESULTS: Service implementation was relatively modest across the included studies. Exercise services were delivered by physiotherapists, exercise physiologists, and kinesiologists and funded mainly through grants and private donations, with staff salaries accruing as the major expense. Service penetration, adoption, and acceptability were generally low. However, studies recorded high clinician/patient satisfaction. Major barriers to service integration were limited funding, lack of detailed implementation plan, and low organizational buy-in. Common reasons for non-utilization, missed sessions, and dropouts were lack of interest, unwellness, hospital readmission, disease progression, and adverse skeletal events. CONCLUSION: Implementing exercise services in clinical oncology settings seems an effective approach for increasing access to exercise-based rehabilitation for individuals on cancer treatment. While this model appears feasible for patients/clinicians, efforts are required to optimize service integration both in the short and long term. Key priorities include seeking [local] actions to address issues relating to funding and organizational buy-in. Important considerations may include developing an implementation plan to guide the implementation process, expanding the patient core management team to include staff from the exercise rehabilitation unit, and exploring the role of patient feedback in increasing clinician participation (e.g., treating oncologists and nurses) in the referral process. Future research should consider effective strategies to promote patients' sense of self-efficacy and behavioral control and, further, the place of audit and feedback in improving exercise service delivery and overall service implementation.

Intersecting substance use treatment and harm reduction services: exploring the characteristics and service needs of a community-based sample of people who use drugs.

BACKGROUND: Substance use treatment and harm reduction services are essential components of comprehensive strategies for reducing the harms of drug use and overdose. However, these services have been historically siloed, and there is a need to better understand how programs that serve people who use drugs (PWUD) are integrating these services. In this study, we compared treatment and harm reduction services offered by a multistate sample of substance use service providers and assessed how well they align with characteristics and needs of clients they serve early in the COVID-19 pandemic. METHODS: We recruited a convenience sample of programs that deliver harm reduction and/or treatment services in ten US states. Program directors participated in a survey assessing the services offered at their program. We also recruited clients of these programs to participate in a survey assessing a range of sociodemographic and health characteristics, substance use behaviors, and health service utilization. We then cross-compared client characteristics and behaviors relative to services being offered through these programs. RESULTS: We collected and analyzed data from 511 clients attending 18 programs that we classified as either offering treatment with medications for opioid use disorder (MOUD) (N = 6), syringe service programs (SSP) (N = 8), or offering both MOUD and SSP (N = 4). All programs delivered a range of treatment and harm reduction services, with MOUD & SSP programs delivering the greatest breadth of services. There were discrepancies between services provided and characteristics and behaviors reported by clients: 80% of clients of programs that offered MOUD without SSP actively used drugs and 50% injected drugs; 40% of clients of programs that offered SSP without MOUD sought drug treatment services. Approximately half of clients were unemployed and unstably housed, but few programs offered direct social services. CONCLUSIONS: In many ways, existing programs are not meeting the service needs of PWUD. Investing in innovative models that empower clients and integrate a range of accessible and flexible treatment, harm reduction and social services can pave the way for a more effective and equitable service system that considers the long-term health of PWUD.

Vertical integration in the Australian community care setting: Can it work? A theoretical review of current literature.

Vertical integration (VI) is considered a strategic management plan whereby an organisation has ownership of its supply chain. It is utilised as a method for managing the economic needs and approaches of an organisation and ensuring that a product is readily available for use. From a healthcare perspective, this pertains to the coordination of services or levels of care and allows for adaptation to changing circumstances. This study reviews existing literature on VI in a healthcare setting to assess feasibility and effectiveness of this proposed solution. A theoretical literature review was performed utilising conceptual categorisation to understand how VI may benefit community care organisations, using the needs of a local organisation as an example. Seventeen articles were included from a range of databases and grey literature with findings categorised according to two research questions. The findings suggest that for VI to be effective and efficient it is important to consider the following themes: market failure, barriers to entry, productive capabilities and specific healthcare issues. In conclusion, from a management and economic perspective, when markets are not functioning efficiently and are in disequilibrium, VI may provide an appropriate avenue to address these problems, in particular for community care organisations.

Strengthening access to long-acting reversible contraception within postabortion care in Tanzania: A pre-post evaluation.

Postabortion care services provide lifesaving treatment for abortion-related complications and addresses women's needs by offering family planning (FP) counseling and voluntary access to contraception. Between 2016 and 2020, the Government of Tanzania sought to strengthen its PAC program by enhancing FP counseling and clients' access to a wide range of contraceptive options. The project team conducted a pre-post evaluation in 17 public sector healthcare facilities in mainland Tanzania and 8 in Zanzibar. It comprised structured client exit interviews (CEIs), completed first in 2016 (n=412) and again in 2020 (n=484). These data complemented an evaluation that used routine service statistics to demonstrate the intervention's effects on client-reported outcomes. Primary outcomes of the CEIs reflected client experience and satisfaction with services, and researchers compared pre-post differences using chi-square tests. There were improvements in numerous indicators, including client waiting times, recall of emergency procedure counseling, contraceptive uptake, and satisfaction with the quality of overall counseling and FP information and services; however, triangulation of CEI data with service statistics indicated that some outcomes, though still improved since baseline, attenuated. Strengthening the FP component of PAC is feasible in Tanzania and Zanzibar, but strategies to sustain quality improvements over time are needed.

Self-rated mental health among sexual health service clients during the first months of the COVID-19 pandemic, British Columbia, Canada.

We investigated self-reported mental health during the first three months of the COVID-19 pandemic (March-May 2020), using a survey of HIV-testing and sexual health service clients from British Columbia, Canada (N = 1198). Over half (55%) reported their mental health as poor at the beginning of the COVID-19 pandemic, more than double that of the general Canadian population in the same time frame (22%). Acknowledging that this burden of poor mental health that is likely to persist in the coming years, we propose that sexual health clinics should facilitate access to mental health supports as a low-barrier point of primary care contact.

Correlates of Self-Reported HIV Testing Among Patients in Specialized Substance Abuse Treatment Centers in South Africa.

Substance use is a recognized risk factor for HIV acquisition, transmission and progression in South Africa. Persons who use drugs (PWUD) and access specialist substance abuse treatment centers (SSATCs) are a potentially critical target group for HIV services because of the severity of their substance use and associated health risks. SSATCs represent an opportunity for integrated programming, particularly HIV testing services (HTS), to reach PWUD who are at an increased risk of or living with HIV. This analysis of national SSATC admission data explores self-reported HIV testing and associated factors to identify coverage gaps and integration opportunities. The South African Community Epidemiology Network on Drug Use (SACENDU) collects routine surveillance data to monitor national treatment admission trends in alcohol and other drug use. SACENDU data from 2012 to 2017 was analyzed using chi-square test of independence and logistic regression to examine associations between HTS, demographic characteristics and substances of use. Of 87,339 treatment admissions, 47.5% (n = 41,481) of patients had not accessed HTS in the prior 12 months. HTS was reported less frequently by patients whose primary substance of use was cannabis or those with polysubstance use (36.9% and 41.1%, respectively). None of the substance use sub-groups reported a testing rate above 70%. Compared to specific reference groups, logistic regression showed those with lower odds of HTS were: 15-19 years (OR = 0.59); had primary-level education (OR = 0.51); were scholars/learners (OR = 0.27); and primarily cannabis users (OR = 0.64). Patients whose primary drug was heroin had higher odds of testing (OR = 2.45) as did those who injected drugs (OR = 2.86). Given the low coverage and decreased odds of self-reported HTS among sub-groups of patients in SSATCs, the integration of HIV services for PWUD should be a priority in South Africa and a focus of the national HIV strategy.

Improving interagency service integration of the Australian Nurse Family Partnership Program for First Nations women and babies: a qualitative study.

BACKGROUND: The Australian Nurse Family Partnership Program (ANFPP) is an evidence-based, home visiting program that offers health education, guidance, social and emotional support to first-time mothers having Aboriginal and/or Torres Strait Islander (First Nations) babies. The community-controlled sector identified the need for specialised support for first time mothers due to the inequalities in birthing and early childhood outcomes between First Nations' and other babies in Australia. The program is based on the United States' Nurse Family Partnership program which has improved long-term health outcomes and life trajectories for mothers and children. International implementation of the Nurse Family Partnership program has identified interagency service integration as key to program recruitment, retention, and efficacy. How the ANFPP integrates with other services in an Australian urban setting and how to improve this is not yet known. Our research explores the barriers and enablers to interagency service integration for the Australian Nurse Family Partnership Program ANFPP in an urban setting. METHODS: A qualitative study using individual and group interviews. Purposive and snowball sampling was used to recruit clients, staff (internal and external to the program), Elders and family members. Interviews were conducted using a culturally appropriate 'yarning' method with clients, families and Elders and semi-structured interview guide for staff. Interviews were audio-recorded and transcribed prior to reflexive thematic analysis. RESULTS: Seventy-six participants were interviewed: 26 clients, 47 staff and 3 Elders/family members. Three themes were identified as barriers and three as enablers. Barriers: 1) confusion around program scope, 2) duplication of care, and 3) tensions over 'ownership' of clients. Enablers (existing and potential): 1) knowledge and promotion of the program; 2) cultural safety; and 3) case coordination, co-location and partnership forums. CONCLUSION: Effective service integration is essential to maximise access and acceptability of the ANFPP; we provide practical recommendations to improve service integration in this context.

Community-based organizations' perspectives on improving health and social service integration.

BACKGROUND: Collaborations between health systems and community-based organizations (CBOs) are increasingly common mechanisms to address the unmet health-related social needs of high-risk populations. However, there is limited evidence on how to develop, manage, and sustain these partnerships, and implementation rarely incorporates perspectives of community social service organizations. To address these gaps, we elicited CBOs' perspectives on service delivery for clients, the impact of the Whole Person Care-Los Angeles (WPC-LA) initiative to integrate health and social care, and their suggestions for improving health system partnerships. METHODS: Using stakeholder engaged principles and a qualitative Rapid Assessment Process, we conducted brief surveys and in-depth semi-structured interviews with 65 key informants from 36 CBOs working with WPC-LA. RESULTS: Major themes identified by CBOs included: 1) the importance of a holistic, client-centered, continuously engaged approach that is reliant on regional partnerships; 2) benefits of WPC-LA expanding capacity and networks; 3) concerns about communication and redundancy hindering WPC-LA; and 4) a need for more equitable partnerships incorporating their approaches. CONCLUSIONS: CBOs value opportunities for integration with health systems, bring critical expertise to these partnerships, and seek to strengthen cross-sector collaborations. Early, equitable, and inclusive participation in the development and implementation of these partnerships may enhance their effectiveness, but requires policy that prioritizes and incentivizes sustainable and mutually beneficial partnerships.

Exploring the feasibility and acceptability of integrating screening for gender-based violence into HIV counselling and testing for adolescent girls and young women in Tanzania and South Africa.

BACKGROUND: Gender-based violence (GBV) undermines HIV prevention and treatment cascades, particularly among women who report partner violence. Screening for violence during HIV testing, and prior to offering pre-exposure prophylaxis (PrEP) to HIV uninfected women, provides an opportunity to identify those at heightened HIV risk and greater potential for non-adherence or early discontinuation of PrEP. The paper describes our experience with offering integrated GBV screening and referral as part of HIV counselling and testing. This component was implemented within EMPOWER, a demonstration project offering combination HIV prevention, including daily oral PrEP, to young women in South Africa and Tanzania. METHODS: Between February 2017 and March 2018, a process evaluation was conducted to explore views, experiences and practices of stakeholders (study participants and study clinical staff) during implementation of the GBV screening component. This article assesses the feasibility and acceptability of the approach from multiple stakeholder perspectives, drawing on counselling session observations (n = 10), in-depth interviews with participants aged 16-24 (n = 39) and clinical staff (n = 13), and notes from debriefings with counsellors. Study process data were also collected (e.g. number of women screened and referred). Following a thematic inductive approach, qualitative data were analysed using qualitative software (NVivo 11). RESULTS: Findings show that 31% of young women screened positive for GBV and only 10% requested referrals. Overall, study participants accessing PrEP were amenable to being asked about violence during HIV risk assessment, as this offered the opportunity to find emotional relief and seek help, although a few found this traumatic. In both sites, the sensitive and empathetic approach of the staff helped mitigate distress of GBV disclosure. In general, the delivery of GBV screening in HCT proved to be feasible, provided that the basic principles of confidentiality, staff empathy, and absence of judgment were observed. However, uptake of linkage to further care remained low in both sites. CONCLUSION: Most stakeholders found GBV screening acceptable and feasible. Key principles that should be in place for young women to be asked safely about GBV during HIV counselling and testing included respect for confidentiality, a youth-friendly and non-judgmental environment, and a functioning referral network.

Using Social Media to Enhance Provider Network for HIV and Harm Reduction Service Integration in Vietnam.

Social media can potentially serve as a platform to coordinate medical care among fragmented health sectors. This paper describes procedures of using social media to enhance antiretroviral therapy (ART) and methadone maintenance treatment (MMT) providers' virtual network for integrated service for HIV-positive people who inject drugs (PWID) in Vietnam. A total of 88 ART and MMT treatment providers participated in person group sessions followed by online virtual support to improve service integration. In-person reunions were held to reinforce Facebook participation and network activities. Content analysis was used to identify keywords and topic categories of the online information exchange. Both MMT and ART providers were actively engaged in online communications. Referral and treatment adherence were the two most frequently discussed topic areas by both the MMT and ART providers. Frequent cross-agency connections were observed. Online provider networks and communities could be built and useful to support treatment providers to improve service integration.

Integrating safer conception services into primary care: providers' perspectives.

BACKGROUND: In 2012, South Africa adopted the Contraception and Fertility Planning guidelines to incorporate safer conception services into care for HIV-affected couples trying to conceive. These guidelines lacked clear implementation and training recommendations. The objective of this study was to investigate factors influencing integration of safer conception services in a clinical setting. METHODS: Twenty in-depth interviews were conducted between October-November 2017 with providers and staff at Witkoppen Clinic in Johannesburg, where the Sakh'umndeni safer conception demonstration project had enrolled patients from July 2013-July 2017. Semi-structured interview guides engaged providers on their perspectives following the Sakh'umndeni project and possible integration plans to inform the translation of the stand-alone Sakh'umndeni services into a routine service. A grounded theory approach was used to code interviews and an adaptation of the Atun et al. (2010) 'Integration of Targeted Interventions into Health Systems' conceptual framework was applied as an analysis tool. RESULTS: Five themes emerged: (1) The need for safer conception training; (2) The importance of messaging and demand generation; (3) A spectrum of views around the extent of integration of safer conception services; (4) Limitations of family planning services as an integration focal point; and (5) Benefits and challenges of a "couples-based" intervention. In-depth interviews suggested that counselors, as the first point of contact, should inform patients about safer conceptions services, followed by targeted reinforcement of safer conception messaging by all clinicians, and referral to more intensively trained safer conception providers. CONCLUSION: A safer conception counseling guide would facilitate consultations. While many providers felt that the services belonged in family planning, lack of HIV management skills, men and women trying to conceive within family planning may pose barriers.

Delivery of integrated infectious disease control services under the new antenatal care guidelines: a service availability and readiness assessment of health facilities in Tanzania.

BACKGROUND: Tanzania remains among the countries with the highest burden of infectious diseases (notably HIV, Malaria and Tuberculosis) during pregnancy. In response, the country adopted World Health Organization's (WHO) latest antenatal care (ANC) guidelines which recommend comprehensive services including diagnostic screening and treatment for pregnant women during antenatal. However, as Tanzania makes efforts to scale up these services under the existing health system resources, it is crucial to understand its capacity to deliver these services in an integrated fashion. Using the WHO's service availability and readiness assessment(SARA) framework, this study assesses the capacity of the Tanzanian Health System to provide integrated Malaria, Tuberculosis and HIV services. METHODS: Composite indicators of the five components of integration were constructed from primary datasets of the Tanzanian Service Provision Assessments (SPA) under the Demographic and Health Survey (DHS) programs. Chi-squared analysis, T test and ANOVA were conducted to determine the associations of each of the defined components and background characteristics of facilities/health workers. A logistic regression model was further used to explore strength of relationships between availability of service readiness components and a pregnant women's receipt of HIV, Malaria and TB services by reporting adjusted odds ratios. RESULTS: Generally, capacity to integrate malaria services was significantly higher (72.3 95% CI 70.3-74.4 p = 0.02) compared to Tuberculosis (48.9 95% CI 48.4-50.7) and HIV (54.8 95% CI 53.1-56.9) services. Diagnostic capacity was generally higher than treatment commodities. Regarding the components of SARA integration, logistic regression found that the adjusted odds ratio of having all five components of integration and receiving integrated care was 1.9 (95% CI 0.8-2.7). Among these components, the strongest determinant (predictor) to pregnant women's receipt of integrated care was having trained staff on site (AOR 2.6 95% CI 0.6-4.5). CONCLUSION: Toward a successful integration of these services under the new WHO guidelines in Tanzania, efforts should be channelled into strengthening infectious disease care especially HIV and TB. Channelling investments into training of health workers (the strongest determinant to integrated care) is likely to result in positive outcomes for the pregnant woman and unborn child.