Quality of Care is Perceived to be High with Community-based Antiretroviral Therapy (ART) Services for Female Sex Workers in Tanzania: Qualitative Findings from a Pilot Implementation Science Study.

This qualitative study reports on female sex workers' (FSWs) perceptions of the quality of antiretroviral therapy (ART) services they received as part of a community-based ART distribution intervention compared to services received by FSWs in the standard of care (SOC) arm. In-depth interviews were conducted with 24 participants to explore their perceptions of the quality of ART services. Data was analyzed using a quality-of-care framework that included but was not limited to, domains of accessibility, effective organization of care, package of services, and patient-centered care. Overall, FSWs in the intervention arm reported community-based ART services to be highly accessible, organized, and effective, and they highly valued the patient-centered care and high level of privacy. Community-based ART programs for FSWs can have high quality-of-care, which can have a positive effect on HIV treatment outcomes for FSWs.

Estimating the cost and efficiency gain of rolling out a multi-month dispensing programme for antiretroviral treatment in Tanzania.

Background: Globally, efforts to curtail the HIV pandemic are growing. The Joint United Nations Programme on HIV and AIDS (UNAIDS) and partners set the 95-95-95 targets to be achieved by 2025. Tanzania's ongoing transition from single-month ARV to longer multi-month dispensing (MMD) involves significant planning and shifts in existing resources, including health commodities, clinical staff and storage space. This study aimed at evaluating the costs and efficiency gains of rolling out MMD compared to the prior monthly dispending (MD) standard of care before the new guidelines.Methods: The analysis employed a health provider perspective utilising prior costing data collected to estimate cost of treatment for HIV/AIDS, including salaries, laboratory costs, antiretroviral drugs, other supplies and overhead costs. The projections were run from 2018 to 2030 using the Spectrum package for Tanzania.Results: Our model estimated that total treatment cost without MMD (including salaries, laboratory costs, antiretroviral drugs, other supplies, and overhead costs) is estimated to rise from USD 189 million in 2018 to USD 244 million in 2030. The introduction of a six-month MMD would lead to the total annual facility-based treatment costs being reduced to USD 205 million in 2030. When comparing MD to a six-month MMD, the total savings over the 13-year period would be USD 425 million. The introduction of six-month MMD for stable patients would reduce the average cost from USD 180 to USD 156 per patient per year if stable patients were only required to make six-monthly visit.Conclusions: The introduction of differentiated service delivery models (DSDMs) and MMD is already contributing to significant cost savings for Tanzania and will continue to do so as the country puts more stable patients on MMD. The potential gains from MMD implantation could further be harnessed if retention of treatment and viral suppression monitoring are prioritised.

Community-based antiretroviral therapy (ART) delivery for female sex workers in Tanzania: intervention model and baseline findings.

To increase linkage to and retention in antiretroviral therapy (ART) care, we piloted a community-based, ART service delivery intervention for female sex workers (FSWs). At baseline, we recruited and collected data from 617 FSWs (intervention: 309; comparison: 308) who were HIV positive and not on ART. This paper presents (1) the description of the intervention model, and (2) key descriptive and bivariate-level findings of the baseline FSW cohort. The data showed more than half of FSWs had a non-paying sex partner, and less than one-third used a condom at last sex with paying and non-paying clients, which suggest potentially high levels of HIV transmission. In addition, there is a gap in HIV testing and treatment because one-third learned about their HIV-positive status only at study enrollment, and among FSWs who had known their status for more than a month, half had not registered in care. This substantiates the importance of timely HIV diagnosis and treatment. A community-based ART program may serve as an important strategy in closing the HIV care and treatment gap for FSWs.

Characteristics of sex partners and sexual partnership correlates of inconsistent condom use among male injection drug users in India.

Previous studies have established the risky behaviors of IDUs in India, and that IDUs are sexually active; however, there is a need to better understand the nature of sexual partnerships of IDUs. A total of 783 (Delhi) and 766 (Imphal) male IDUs were recruited into the study through respondent-driven sampling. We examined characteristics of sex partners of male IDUs and individual and sexual partnership characteristics associated with unprotected sex in Delhi and Imphal. While 16.8% of sexual partnerships in Delhi were male-to-male, there were almost no male-to-male partnerships in Imphal. The majority of partners of male IDUs in Delhi (82.5%) and Imphal (92.3%) do not inject drugs, with the exception of male partners of male IDUs in Delhi. Commercial partners (females: 58.3%; males: 71.3%) were the most common type of sex partners of male IDUs in Delhi, while regular partners (65.2%) were the most common type of sex partners in Imphal. In Delhi, characteristics of sex partners significantly associated with unprotected sex were being male/transgender (AOR 2.2; 95% CI: 1.2-4.0), being a regular (AOR 5.1; 95% CI: 2.8-9.4) or non-regular partner (AOR 2.7; 95% CI: 1.7- 4.5), and sharing needles/syringes with the index IDU (AOR 2.8; 95% CI: 1.4-5.3). In Imphal, partner characteristics associated with unprotected sex were being a regular (AOR 10.1; 95% CI: 41-25.1) or non-regular partner (AOR 3.4; 95% CI: 1.5-7.6), and living outside of town or state (AOR 3.3; 95% CI: 1.2-9.6). Enhanced understanding of disassortative sexual mixing and context of unprotected sex within sexual partnerships may enhance sexual risk reduction interventions for IDUs.

How informed are clients who consent? A mixed-method evaluation of comprehension among clients of male circumcision services in Zambia and Swaziland.

Comprehension is fundamental for informed consent--an individual's right to choose a medical procedure, such as male circumcision (MC). Because optimal benefits depend on post-surgical behaviors, comprehension is particularly critical for MC programs. We evaluated clients' comprehension of MC's risks and benefits, wound care instructions, and risk reduction post-MC using a true/false test (n = 1181) and 92 semi-structured interviews (SSIs) in Zambia and Swaziland. Most participants (89% Zambia, 93% Swaziland) passed the true/false test, although adolescents scored lower (significantly so in Swaziland) than adults and one-third (including nearly half of adolescents in Zambia) said MC has no risks. SSIs indicated confusion between "risk" of adverse surgical outcomes and reduced "risk" of HIV; most respondents acknowledged the 6 week abstinence period post-MC, yet few said resuming sex early increases HIV risk. Providers should distinguish between surgical "risks" and reduced HIV "risk," and emphasize that HIV risk increases with sex before complete healing.

Assessment of unsafe injection practices and sexual behaviors among male injecting drug users in two urban cities of India using respondent driven sampling.

Designing interventions to reduce HIV transmission among injecting drug users (IDU) requires reliable estimates of risk behaviors. We present population-based estimates for unsafe injection practices and sexual risk behaviors among male IDUs recruited through respondent driven sampling in India (Delhi: 783; Imphal: 766). IDUs in Delhi, mostly street-based (68%), reported injecting pharmaceutical agents and a greater frequency of injections/day. IDUs in Imphal, mostly home-based (98%), used heroin/opioids and injected less frequently. Needle sharing was common (Delhi: 33%; Imphal: 43%). Sixty-five percent of IDUs in Delhi and 55% in Imphal were sexually active during the previous year. Multiple sexual partners were more frequent in Delhi (49% vs 21%); IDUs in Imphal reported more regular sex partners (82% vs 44%). Consistent condom use with regular partners was extremely low (Delhi: 8%; Imphal: 19%). HIV testing was infrequent (Delhi: 37%; Imphal: 49%). IDUs are a heterogeneous group with different prevention needs requiring need-based tailored prevention interventions.

Inroads for HIV prevention among men: findings from mixed methods research in the context of the DREAMS partnership in Southern Africa.

OBJECTIVE: To assess trends in men's HIV risk factors and service use, and their experiences with prevention programming, during an intensive HIV response for adolescent girls and young women and their male partners. DESIGN: Independent cross-sectional surveys in 2016-2017 and 2018 with men in Eswatini (20-34 years-old, n = 1391) and Durban, South Africa (20-40 years-old; n = 1665), complemented by 74 in-depth interviews (IDIs) with men exposed to HIV services/prevention programming. METHODS: Survey recruitment was primarily at hot-spot venues. We assessed Round 1-2 trends in HIV risk factors and service use, overall and by HIV risk profiles. IDI respondents were identified via survey responses or program partners. RESULTS: HIV risk factors were prevalent in both countries at each survey round, although there were reductions over time among the highest risk profiles in South Africa. Most men were engaged in HIV services (e.g. nearly two-thirds tested for HIV in the last year at round 2, with large increases in Eswatini). Qualitative data suggest HIV service uptake was facilitated by increased convenience and supportive information/messaging about HIV treatment efficacy. Men described eagerly receiving the information and support offered in HIV prevention programming, and effects on HIV risk reduction and newly engaging in HIV services. However, less than 15% of survey respondents reported being reached by such programming. CONCLUSION: Important inroads have been made to engage men in HIV services and prevention programming in the two countries, including among the high-risk profiles. Still, improving coverage of comprehensive HIV prevention programming is critical, particularly for men most at risk.

What Influences Girls' Age at Marriage in Burkina Faso and Tanzania? Exploring the Contribution of Individual, Household, and Community Level Factors.

PURPOSE: This comparative study explores the connections between potential drivers of child marriage among girls at the individual, household, and community levels. It provides insight into the multilevel influences on child marriage with the goal of informing policies and programs aimed at eliminating the practice. METHODS: We conducted a secondary analysis of baseline data from the Building Evidence to Delay Child Marriage Project, a large study undertaken in Burkina Faso and Tanzania. For each country, using data on adolescent girls and parents, we ran a series of nested logistic regression models to identify factors associated with having ever been married among girls aged 15-17 years. RESULTS: Findings indicate that child marriage among girls is shaped by a combination of factors at multiple levels and that the weight of influencing factors varies by context. At the household level, parental relationships were influential in both countries, although in different ways. The influence of the community varied considerably between countries, holding more importance in Burkina Faso than in Tanzania. In Burkina Faso, the importance of schooling and existence of alternative pathways for girls beyond marriage appears crucial to reducing child marriage. Other factors strongly associated with child marriage include girls' agency, the timing of girls' sexual initiation, and community norms, specifically views on child marriage among fathers. In Tanzania, early sexual initiation among girls was common and strongly associated with marriage during childhood; parents' fear of premarital sex and pregnancy also emerged as a significant factor.

Safer conception for female sex workers living with HIV in Dar es Salaam, Tanzania: Cross-sectional analysis of needs and opportunities in integrated family planning/HIV services.

BACKGROUND: With the advent of effective treatment, women living with HIV can plan for pregnancy while minimizing risk of transmission to infants and seronegative partners. Family planning (FP) services tend to focus solely on addressing contraceptive need, but HIV-positive women-including female sex workers-often plan to have children someday. Various "safer conception" strategies are now available to support women living with HIV achieve fertility intentions, and integrated HIV/FP services may be a promising platform to offer these services. METHODS: At integrated community-based HIV/FP service delivery sites operated by Jhpiego's Sauti project in Dar es Salaam, we conducted exit interviews with 300 HIV-positive female sex workers. Descriptive analyses were conducted to describe their desire for children, use of condoms and other modern contraceptive methods, self-reported viral suppression, and knowledge of and interest in safer conception strategies. We conducted bivariate and multivariate logistic regression analysis to examine correlates of fertility desire among respondents. RESULTS: Median age of participants was 32. Nearly one-third wished to have a child within two years. Seventy-two percent had heard of having the HIV-positive partner taking ART to reduce sexual transmission during pregnancy attempts. Thirty-one percent felt the amount of FP content covered in the consultation was "too little." Factors significantly associated with desire for children were having a nonpaying partner (adjusted odds ratio [AOR] 2.18, 95% confidence interval [CI]1.13-4.20) and having fewer children (AOR 0.65, 95% CI 0.48-0.87). Viral suppression was not associated with fertility desire. CONCLUSIONS: Sex workers living with HIV attending integrated HIV/FP services have need for both contraception as well as safer conception counseling. This integrated service delivery modality is a promising platform for providing safer conception services. FP counseling for HIV-positive women should be broadened to broach the topic of safer pregnancy, as well as explicit counseling on strategies to minimize risk of sexual transmission to partners.

Making the cut: evidence-based lessons for improving the informed consent process for voluntary medical male circumcision in Swaziland and Zambia.

The informed consent (IC) process for voluntary medical male circumcision (VMMC) was evaluated in Zambia and Swaziland as VMMC programs scaled up. In-depth interviews (IDIs) were conducted with clients 1 week after surgery to explore understanding of IC and gauge how expectations of MC surgery compared to actual experiences. In Zambia, key opinion leaders (KOLs) were also interviewed. Some clients equated written IC with releasing the clinic from liability. Most clients felt well prepared for the procedure, although many were surprised by the level of pain experienced during anesthesia and postsurgery. Clients were highly motivated to adhere to wound care, but some were overwhelmed by extensive instructions. Adolescents described barriers to accessing follow-up care and the need for support in overcoming adult gatekeepers. KOLs indicated that IC is not well understood in poorly educated communities. Results led to concrete programmatic changes, including revised patient education materials and more effective anesthesia for longer-lasting pain relief.

An overview of adverse events reported by participants in CDC's anthrax vaccine and antimicrobial availability program.

PURPOSE: The CDC's Anthrax Vaccine and Antibiotic Availability Program was implemented under an Investigational New Drug (IND) application to provide additional post-exposure prophylaxis for individuals potentially exposed to Bacillus anthracis in the fall of 2001. Participants were provided with two options: (1) 40 additional days of antimicrobial prophylaxis (i.e., ciprofloxacin, doxycycline, or amoxicillin); or (2) 40 additional days of antimicrobial prophylaxis plus three doses of anthrax vaccine adsorbed (AVA). METHODS: Participants were monitored for adverse events (AEs). Participants were asked to complete 2-week AE diaries for 6 weeks post-enrollment, and approximately 2 months after enrollment, active surveillance was conducted through telephone interviews with 1113 (64%) participants. RESULTS: A total of 1727 of approximately 10 000 previously prophylaxed persons enrolled to receive 40 additional days of antibiotics. Of these, 199 opted at enrollment to receive three doses of AVA in addition to the additional 40 days of antibiotic. Overall, 28% of participants reported at least one AE on their diaries. Results varied by surveillance mechanism, the diary data indicated differences in the proportion reporting AEs between participants receiving antibiotic only and participants receiving antibiotic and AVA. However, during the active 2-month telephone follow-up, the rates of AEs reported for both the antibiotic only and antibiotic plus AVA treatment regimens were similar. Additionally, ciprofloxacin and doxycycline had similar AE profiles, with only rigors reported significantly more often among ciprofloxacin recipients. CONCLUSIONS: Overall, the rates of AEs experienced by all participants were acceptable given the seriousness of potential B. anthracis exposure.