Concurrent advanced HIV disease and viral load suppression in a high-burden setting: Findings from the 2015-6 ZIMPHIA survey.

BACKGROUND: As Zimbabwe approaches epidemic control of HIV, programs now prioritize viral load over CD4 monitoring, making it difficult to identify persons living with HIV (PLHIV) suffering from advanced disease (AD). We present an analysis of cross-sectional ZIMPHIA data, highlighting PLHIV with AD and concurrent viral load suppression (VLS). METHODS: ZIMPHIA collected blood specimens for HIV testing from 22,501 consenting adults (ages 15 years and older); 3,466 PLHIV had CD4 and VL results. Household HIV testing used the national serial algorithm, and those testing positive then received point-of-care CD4 enumeration with subsequent VL testing. We used logistic regression analysis to explore factors associated with concurrent AD and VLS (<1000 copies/mL). All analyses were weighted to account for complex survey design. RESULTS: Of the 3,466 PLHIV in the survey with CD4 and VL results, 17% were found to have AD (CD4<200cells/mm3). Of all AD patients, 30% had VLS. Concurrent AD and VLS was associated with male sex (aOR 2.45 95%CI 1.61-3.72), older age (35-49 years [aOR 2.46 95%CI 1.03-5.91] and 50+ years [aOR 4.82 95%CI 2.02-11.46] vs 15-24 years), and ART duration (<6 months [aOR 0.46 95%CI 0.29-0.76] and 6-24 months [aOR 2.07 95%CI 1.35-3.17] vs more than 2 years). The relationship between sex and AD is driven by age with significant associations among men aged 25-34, (aOR 3.37 95%CI 1.35-8.41), 35-49 (aOR 5.13 95%CI 2.16-12.18), and 50+ (aOR 12.56 95%CI 4.82-32.72) versus men aged 15-24. CONCLUSIONS: The percentage of PLHIV with AD and VLS illustrates the conundrum of decreased support for CD4 monitoring, as these patients may not receive appropriate clinical services for advanced HIV disease. In high-prevalence settings such as Zimbabwe, CD4 monitoring support warrants further consideration to differentiate care appropriately for the most vulnerable PLHIV. Males may need to be prioritized, given their over-representation in this sub-population.

Operationalizing Integrated Immunization and Family Planning Services in Rural Liberia: Lessons Learned From Evaluating Service Quality and Utilization.

BACKGROUND: Integration of family planning and immunization services provides an opportunity to meet women's need for postpartum family planning and infants' vaccination needs through client-centered care, while reducing financial and opportunity costs for families. The United States Agency for International Development's Maternal and Child Survival Program (MCSP) supported the Liberia Ministry of Health to scale up integrated family planning and immunization services as part of a broader service delivery and health systems recovery program after the Ebola epidemic. METHODS: We conducted a mixed-methods program evaluation in 22 health facilities in Grand Bassa and Lofa counties. Family planning uptake and immunization dropout rates at project sites were compared to rates at 18 matched health facilities in the same counties. We conducted 34 focus group discussions with community members and 43 key informant interviews with health care providers and managers to explore quality of care and contextual factors affecting provision and use of integrated services including postpartum family planning. RESULTS: From November 2016 to July 2017, 1,066 women accepted referrals from immunization to family planning counseling (10% of all vaccinator-caregiver interactions); the majority of women who were referred (75%) accepted a family planning method the same day. Trends indicated slightly higher family planning uptake in intervention over nonintervention facilities, but differences were not statistically significant. Pentavalent vaccine dropout rates did not increase in intervention compared to nonintervention facilities indicating no negative impact on utilization of immunization services. Clients and providers expressed that the integrated services reduced costs and time for the clients, educated mothers about postpartum family planning, and ensured infants were completing their vaccinations. Providers expressed the need for increased human resources to meet the elevated demand for family planning counseling services and additional focus on community-level social and behavior change activities. Both groups emphasized that social stigma and norms about postpartum sexual abstinence prevented many women from seeking postpartum family planning services. CONCLUSION: Although scaling up integrated family planning-immunization services may be programmatically feasible and acceptable to clients and providers, the intervention's success and ability to understand and quantify impact are driven by the effect of contextual factors and fidelity to the intervention approach. Contextual factors need to be understood before implementation, measured during implementation, and addressed throughout implementation to maximize the approach's impact on service utilization and health outcomes.