Use of a Sustainable Livelihood Framework-Based Measure to Estimate Socioeconomic Impact of Tuberculosis on Households.

Tuberculosis (TB) disproportionally affects impoverished members of society. The adverse socioeconomic impact of TB on households is mostly measured using money-centric approaches, which have been criticized as one-dimensional and risk either overestimating or underestimating the true socioeconomic impacts of TB. We propose the use of the sustainable livelihood framework, which includes 5 household capital assets (human, financial, physical, natural, and social) and conceptualizes that households employ accumulative strategies in times of plenty and coping (survival) strategies in response to shocks such as TB. The proposed measure ascertains to what extent the 5 capital assets are available to households affected by TB as well as the coping costs (reversible and nonreversible) that are incurred by households at different time points (intensive, continuation, and post-TB treatment phase). We assert that our approach is holistic and multidimensional and draws attention to multisectoral responses to mitigate the socioeconomic impact of TB on households.

Bloodstream infections and antibiotic resistance at a regional hospital, Colombia, 2019-2021.

Objectives: To assess antibiotic susceptibility of World Health Organization (WHO) priority bacteria (Acinetobacter baumannii, Escherichia coli, Klebsiella pneumoniae, Salmonella spp., Staphylococcus aureus, and Streptococcus pneumoniae) in blood cultures at the Orinoquía regional hospital in Colombia. Methods: This was cross-sectional study using routine laboratory data for the period 2019-2021. Data on blood samples from patients suspected of a bloodstream infection were examined. We determined: the total number of blood cultures done and the proportion with culture yield; the characteristics of patients with priority bacteria; and the type of bacteria isolated and antibiotic resistance patterns. Results: Of 25 469 blood cultures done, 1628 (6%) yielded bacteria; 774 (48%) of these bacteria were WHO priority pathogens. Most of the priority bacteria isolated (558; 72%) were gram-negative and 216 (28%) were gram-positive organisms. Most patients with priority bacteria (666; 86%) were hospitalized in wards other than the intensive care unit, 427 (55%) were male, and 321 (42%) were ≥ 60 years of age. Of the 216 gram-positive bacteria isolated, 205 (95%) were Staphylococcus aureus. Of the 558 gram-negative priority bacteria isolated, the three most common were Escherichia coli (34%), Klebsiella pneumoniae (28%), and Acinetobacter baumannii (20%). The highest resistance of Staphylococcus aureus was to oxacillin (41%). For gram-negative bacteria, resistance to antibiotics ranged from 4% (amikacin) to 72% (ampicillin). Conclusions: Bacterial yield from blood cultures was low and could be improved. WHO priority bacteria were found in all hospital wards. This calls for rigorous infection prevention and control standards and continued surveillance of antibiotic resistance.

Catastrophic costs among tuberculosis-affected households in Zimbabwe: A national health facility-based survey.

OBJECTIVES: To determine the incidence and major drivers of catastrophic costs among TB-affected households in Zimbabwe. METHODS: We conducted a nationally representative health facility-based survey with random cluster sampling among consecutively enrolled drug-susceptible (DS-TB) and drug-resistant TB (DR-TB) patients. Costs incurred and income lost due to TB illness were captured using an interviewer-administered standardised questionnaire. We used multivariable logistic regression to determine the risk factors for experiencing catastrophic costs. RESULTS: A total of 841 patients were enrolled and were weighted to 900 during data analysis. There were 500 (56%) males and 46 (6%) DR-TB patients. Thirty-five (72%) DR-TB patients were HIV co-infected. Overall, 80% (95% CI: 77-82) of TB patients and their households experienced catastrophic costs. The major cost driver pre-TB diagnosis was direct medical costs. Nutritional supplements were the major cost driver post-TB diagnosis, with a median cost of US$360 (IQR: 240-600). Post-TB median diagnosis costs were three times higher among DR-TB (US$1,659 [653-2,787]) than drug DS-TB-affected households (US$537 [204-1,134]). Income loss was five times higher among DR-TB than DS-TB patients. In multivariable analysis, household wealth was the only covariate that remained significantly associated with catastrophic costs: The poorest households had 16 times the odds of incurring catastrophic costs versus the wealthiest households (adjusted odds ratio [aOR: 15.7 95% CI: 7.5-33.1]). CONCLUSION: The majority of TB-affected households, especially those affected by DR-TB, experienced catastrophic costs. Since the major cost drivers fall outside the healthcare system, multi-sectoral approaches to TB control and linking TB patients to social protection may reduce catastrophic costs.

Better care for babies: the added value of a modified reverse syphilis testing algorithm for the treatment of congenital syphilis in a maternity Hospital in Central African Republic.

BACKGROUND: In high syphilis prevalence settings, the syphilis testing and treatment strategy for mothers and newborns must be tailored to balance the risk of over treatment against the risk of missing infants at high-risk for congenital syphilis. Adding a non-treponemal test (Rapid Plasma Reagin - RPR) to a routine rapid treponemal test (SD Bioline Syphilis 3.0) for women giving birth can help distinguish between neonates at high and low-risk for congenital syphilis to tailor their treatment. Treatment for neonates born to RPR-reactive mothers (high-risk) is 10 days of intravenous penicillin, while one dose of intramuscular penicillin is sufficient for those born to RPR non-reactive mothers (low-risk). This strategy was adopted in March 2017 in a Médecins Sans Frontières supported hospital in Bangui, Central African Republic. This study examined the operational consequences of this algorithm on the treatment of newborns. METHODS: The study was a retrospective cohort study. Routine programmatic data were analysed. Descriptive statistical analysis was done. Total antibiotic days, hospitalization days and estimated costs were compared to scenarios without RPR testing and another where syphilis treatment was the sole reason for hospitalization. RESULTS: Of 202 babies born to SD Bioline positive mothers 89 (44%) and 111(55%) were RPR-reactive and non-reactive respectively (2 were unrecorded) of whom 80% and 88% of the neonates received appropriate antibiotic treatment respectively. Neonates born to RPR non-reactive mothers were 80% less likely to have sepsis [Relative risk (RR) = 0.20; 95% Confidence interval (CI) = 0.04-0.92] and 9% more likely to be discharged [RR = 1.09; 95% CI = 1.00-1.18] compared to those of RPR-reactive mothers. There was a 52%, and 49% reduction in antibiotic and hospitalization days respectively compared to a scenario with SD-Bioline testing only. Total hospitalization costs were also 52% lower compared to a scenario without RPR testing. CONCLUSIONS: This testing strategy can help identify infants at high and low risk for congenital syphilis and treat them accordingly at substantial cost savings. It is especially appropriate for settings with high syphilis endemicity, limited resources and overcrowded maternities. The babies additionally benefit from lower risks of exposure to unnecessary antibiotics and nosocomial infections.

Higher loss of livelihood and impoverishment in households affected by tuberculosis compared to non-tuberculosis affected households in Zimbabwe: A cross-sectional study.

Tuberculosis (TB) disproportionally affects poor people, leading to income and non-income losses. Measures of socioeconomic impact of TB, e.g. impoverishment and patient costs are inadequate to capture non-income losses. We applied impoverishment and a multidimensional measure on TB and non-TB affected households in Zimbabwe. We conducted a cross-sectional study in 270 households: 90 non-TB; 90 drug-susceptible TB (DS-TB), 90 drug-resistant TB (DR-TB) during the COVID-19 pandemic (2020-2021). Household data included ownership of assets, number of household members, income and indicators on five capital assets: financial, human, social, natural and physical. Households with incomes per capita below US$1.90/day were considered impoverished. We used principal component analysis on five capital asset indicators to create a binary outcome variable indicating loss of livelihood. Log-binomial regression was used to determine associations between loss of livelihood and type of household. TB-affected households were more likely to report episodes of TB and household members requiring care than non-TB households. The proportions of impoverished households were 81% (non-TB), 88% (DS-TB) and 94% (DR-TB) by the time of interview. Overall, 56% (152/270) of households sold assets: 44% (40/90) non-TB, 58% (52/90) DS-TB and 67% (60/90) DR-TB. Children's education was affected in 33% (55/168) of TB-affected compared to 14% (12/88) non-TB households. Overall, 133 (50%) households experienced loss of livelihood, with TB-affected households almost twice as likely to experience loss of livelihood; adjusted prevalence ratio (aPR = 1.78 [95%CI:1.09-2.89]). The effect of TB on livelihood was most pronounced in poorest households (aPR = 2.61, [95%CI:1.47-4.61]). TB-affected households experienced greater socioeconomic losses compared to non-TB households. Multisectoral social protection is crucial to mitigate impacts of TB and other shocks, especially targeting poorest households.

Beyond tuberculosis: a person-centred and rights-based approach to screening for household contacts.

Households affected by tuberculosis have syndemic vulnerability, reflecting a concentration of and interactions between multiple biomedical, psychosocial, and structural determinants of health. Traditional approaches to tuberculosis screening do not address pre-existing risks, such as undernutrition and other chronic conditions, or the indirect effects of tuberculosis, such as loss of livelihood. These pre-existing risks and consequences not only perpetuate the global tuberculosis epidemic but, for those affected, lead to poor health and deepen poverty. We propose reimagining tuberculosis screening as an opportunity to deliver a contextually relevant package of services that address the needs of households affected by tuberculosis. This approach puts people and their rights at the centre of efforts to end tuberculosis, and has equity at the core. This approach could support progress towards universal health coverage, benefiting communities and health systems. Leadership, flexibility in funding allocation, and innovative care models will be required to realise this approach at scale.

Correction: Sexual violence against migrants and asylum seekers. The experience of the MSF clinic on Lesvos Island, Greece.

[This corrects the article DOI: 10.1371/journal.pone.0239187.].

Treatment Outcomes of Tuberculosis Among Artisanal and Small-Scale Miners in Zimbabwe: A Follow-Up Observational Study Using Secondary Data.

In Zimbabwe, artisanal and small-scale miners (ASMs) are a key vulnerable group with high risk for tuberculosis (TB), HIV, and silicosis. The main purpose of this study was to investigate treatment outcomes of TB among ASMs. We conducted a follow-up observational study using secondary data. We analyzed data from 208 ASMs treated for TB at two occupational health clinics. We found a high treatment success rate of 87%, comparable to the national average for drug-sensitive TB. Unsuccessful outcomes were due to death (5%) and loss to follow-up (7%). Over a quarter of ASMs had unknown HIV status. Our study is the first to document treatment outcomes of TB among ASMs in Zimbabwe. Encouragingly, this study demonstrates the possibility of achieving good TB treatment outcomes even among highly mobile populations like ASMs. Further research is needed to analyze leakages across the whole TB patient pathway among ASMs. Additionally, addressing the high rate of unknown HIV statuses among ASMs is crucial to further improve overall TB treatment outcomes in this population.

Coping with drug resistant tuberculosis alongside COVID-19 and other stressors in Zimbabwe: a qualitative study.

Background: Households in low-resource settings are more vulnerable to events which adversely affect their livelihoods, including shocks such as the death of a family member, inflation, droughts and more recently COVID-19. Drug Resistant Tuberculosis (DR-TB) is also another shock that inflicts physical, psychological and socioeconomic burden on individuals and households. We describe experiences and coping strategies among people affected by DR-TB and their households in Zimbabwe during the COVID-19 pandemic, 2020 to 2021. Methods: We conducted 16 in-depth interviews with adults who had just completed or were completing treatment. Interview themes included health seeking behaviour, impact of DR-TB on livelihoods and coping strategies adopted during treatment. We analysed data using thematic analyses. Results: Health seeking from providers outside the public sector, extra-pulmonary TB and health system factors resulted in delayed DR-TB diagnosis and treatment and increased financial drain on households. DR-TB reduced productive capacity and narrowed job opportunities leading to income loss that continued even after completion of treatment. Household livelihood was further adversely affected by lockdowns due to COVID-19, outbreaks of bird flu and cattle disease. Stockouts of DR-TB medicines, common during COVID-19, exacerbated loss of productive time and transport costs as medication had to be accessed from other clinics that were further away. Reversible coping strategies included: reducing number of meals; relocating in search of caregivers and/or family support; spending savings; negotiating with school authorities to keep children in school. Some households had to adopt irreversible coping strategies such as selling productive assets and withdrawing children from school. Conclusion: DR-TB combined with COVID-19 and other stressors pushed households into deeper poverty, and vulnerability. Multi-sectoral approaches that combine health systems, psychosocial and economic interventions are crucial to mitigate diagnostic delays and suffering, and meaningfully support people with DR-TB and their households to compensate the loss of livelihoods during and post DR-TB treatment.

Coping with drug resistant tuberculosis alongside COVID-19 and other stressors in Zimbabwe: A qualitative study.

Households in low-resource settings are more vulnerable to events which adversely affect their livelihoods, including shocks e.g. death of family members, droughts and more recently COVID-19. Drug Resistant Tuberculosis (DR-TB) is another shock that inflicts physical, psychological and socioeconomic burden on individuals and households. We describe experiences and coping strategies among people affected by DR-TB and their households in Zimbabwe during the COVID-19 pandemic, 2020-2021. We purposively selected 16 adults who had just completed or were completing treatment for DR-TB for in-depth interviews. We transcribed audio-recordings verbatim and translated the transcripts into English. Data were coded both manually and using NVivo 12 (QSR International), and were analysed thematically. Health seeking from providers outside the public sector, extra-pulmonary TB and health system factors resulted in delayed DR-TB diagnosis and treatment and increased financial drain on households. DR-TB reduced productive capacity and narrowed job opportunities leading to income loss that continued even after completion of treatment. Household livelihood was further adversely affected by lockdowns due to COVID-19, outbreaks of bird flu and cattle disease. Stockouts of DR-TB medicines, common during COVID-19, exacerbated loss of productive time and transport costs as medication had to be accessed from other clinics. Reversible coping strategies included: reducing number of meals; relocating in search of caregivers and/or family support; spending savings; negotiating with school authorities to keep children in school. Some households adopted irreversible coping strategies e.g. selling productive assets and withdrawing children from school. DR-TB combined with COVID-19 and other stressors and pushed households into deeper poverty and vulnerability. Multisectoral approaches that combine health systems and socioeconomic interventions are crucial to mitigate diagnostic delays and suffering, and meaningfully support people with DR-TB and their households to compensate the loss of livelihoods during and post DR-TB treatment.

Time to Treatment and Risk Factors for Unsuccessful Treatment Outcomes among People Who Started Second-Line Treatment for Rifampicin-Resistant or Multi-Drug-Resistant Tuberculosis in the Kyrgyz Republic, 2021.

The Kyrgyz Republic is a high-burden country for rifampicin resistant/multi-drug resistant tuberculosis (RR/MDR-TB). TB control efforts rely on early diagnosis and initiation of people on effective regimens. We studied the interval from diagnosis of RR-TB to starting treatment and risk factors for unsuccessful outcomes among people who started RR/MDR-TB treatment in 2021. We conducted a cohort study using country-wide programme data and used binomial regression to determine associations between unsuccessful outcomes and predictor variables. Of the 535 people included in the study, three-quarters were in the age category 18-59 years, and 68% had past history of TB. The median (IQR) time from onset of TB symptoms to diagnosis was 30 (11-62) days, 1 (0-4) days from diagnosis to starting treatment, and 35 (24-65) days from starting treatment to receipt of second-line drug susceptibility test (SL-DST) results. Overall, 136 (25%) had unsuccessful outcomes. Risk factors for unsuccessful outcomes were being homeless, fluroquinolone resistance, having unknown HIV status, past TB treatment, male gender and being unemployed. Treatment outcomes and the interval from diagnosis to starting treatment were commendable. Further reductions in unsuccessful outcomes by be achieved through ensuring timely diagnosis and access to SL-DSTs and by reducing the proportion of people who are lost to follow-up.

Quality of Data Recording and Antimicrobial Use in a Municipal Veterinary Clinic in Ghana.

The recording of antimicrobial use data is critical for the development of interventions for the containment of antimicrobial resistance. This cross-sectional study assessed whether dissemination activities and recommendations made after an operational research (OR) study in 2021 resulted in better data recording and improved the use of antimicrobials in a rural veterinary clinic. Routinely collected data from treatment record books were compared between 2013 and 2019 (pre-OR) and from July 2021 to April 2023 (post-OR). The most common animals presenting for care in the the pre - and post OR periods were dogs (369 and 206, respectively). Overall, antimicrobial use in animals increased from 53% to 77% between the two periods. Tetracycline was the most commonly used antimicrobial (99%) during the pre-OR period, while Penicillin-Streptomycin was the most commonly used antimicrobial (65%) during the post-OR period. All animals that received care at the clinic were documented in the register during both periods. Whereas the diagnosis was documented in 269 (90%) animals in the post-OR period compared to 242 (47%) in the pre-OR period, the routes and dosages were not adequately recorded during the both periods. Therefore, the quality of data recording was still deficient despite the dissemination and the recommendations made to some key stakeholders. Recommendations are made for a standardized antimicrobial reporting tool, refresher training, and continuous supervisory visits to the clinic.

Higher loss of livelihood and impoverishment in households affected by tuberculosis compared to non-tuberculosis affected households in Zimbabwe: a cross-sectional study.

Introduction: Tuberculosis (TB) disproportionally affects poor people, leading to income and non-income losses. Measures of socioeconomic impact of TB, e.g. impoverishment and patient costs are inadequate to capture non-income losses. We applied impoverishment and a multidimensional measure on TB and non-TB affected households in Zimbabwe. Methods: We conducted a cross-sectional study in 270 households: 90 non-TB; 90 drug-susceptible TB (DS-TB), 90 drug-resistant TB (DR-TB) during the COVID-19 pandemic (2020-2021). Household data included ownership of assets, number of household members, income and indicators on five capital assets: financial, human, social, natural and physical. We determined proportions of impoverished households for periods 12 months prior and at the time of the interview. Households with incomes below US$1.90/day were considered to be impoverished. We used principal component analysis on five capital asset indicators to create a binary outcome variable indicating loss of livelihood. Log-binomial regression was used to determine associations between loss of livelihood and type of household. Results: TB-affected households reported higher previous episodes of TB and household members requiring care than non-TB households. Households that were impoverished 12 months prior to the study were: 21 non-TB (23%); 40 DS-TB (45%); 37 DR-TB (41%). The proportions increased to 81%, 88% and 94%, respectively by the time of interview. Overall, 56% (152/270) of households sold assets: 44% (40/90) non-TB, 58% (52/90) DS-TB and 67% (60/90) DR-TB. Children's education was affected in 31% (56/180) of TB-affected compared to 13% (12/90) non-TB households. Overall, 133(50%) households experienced loss of livelihood, with TB-affected households twice as likely to experience loss of livelihood; adjusted prevalence ratio (aPR=2.02 (95%CI:1.35-3.03)). The effect of TB on livelihood was most pronounced in poorest households (aPR=2.64, (95%CI:1.29-5.41)). Conclusions: TB-affected households experienced greater socioeconomic losses compared to non-TB households. Multidimensional measures of TB are crucial to inform multisectoral approaches to mitigate impacts of TB and other shocks.

Assessing Changes in Bacterial Load and Antibiotic Resistance in the Legon Sewage Treatment Plant between 2018 and 2023 in Accra, Ghana.

Wastewater treatment plants are efficient in reducing bacterial loads but are also considered potential drivers of environmental antimicrobial resistance (AMR). In this study, we determined the effect of increased influent wastewater volume (from 40% to 66%) in the Legon sewage treatment plant (STP) on the removal of E. coli from sewage, along with changes in AMR profiles. This before and after study compared E. coli loads and AMR patterns in influent and effluent samples from a published baseline study (January-June 2018) with a follow-up study (March-May 2023). Extended-spectrum beta-lactamase (ESBL) E. coli were measured pre- and post-sewage treatment during the follow-up study. The follow-up study showed 7.4% and 24% ESBL E. coli proportions in influent and effluent, respectively. In both studies, the STP was 99% efficient in reducing E. coli loads in effluents, with no significant difference (p = 0.42) between the two periods. More E. coli resistance to antimicrobials was seen in effluents in the follow-up study versus the baseline study. The increased influent capacity did not reduce the efficiency of the STP in removing E. coli from influent wastewater but was associated with increased AMR patterns in effluent water. Further studies are required to determine whether these changes have significant effects on human health.

Knowledge, Attitudes, and Practices of Artisanal and Small-Scale Miners regarding Tuberculosis, Human Immunodeficiency Virus, and Silicosis in Zimbabwe.

In Zimbabwe, artisanal and small-scale miners (ASMs) have a high prevalence of tuberculosis (TB), human immunodeficiency virus (HIV), and silicosis. Previous studies on ASMs utilised programme data, and it was not possible to understand reasons for the high prevalence of these comorbidities. We conducted a cross-sectional study to investigate the knowledge, attitudes, and practices of ASMs regarding TB, HIV, and silicosis. We enrolled a convenience sample of 652 ASMs. Their mean (standard deviation) age was 34.2 (10.8) years. There were 602 (92%) men and over 75% had attained secondary education. A total of 504 (80%) of the ASMs knew that TB is a curable disease, and 564 (87%) knew that they were at higher risk of TB than the general population. However, they were less likely to know that HIV increases the risk of TB disease, 340 (52%), with only 226 (35%) who perceived the risk of TB infection to be high among ASMs. Only 564 (59%) were aware that silica dust causes permanent and incurable lung diseases. Six hundred and twenty (97%) showed a positive attitude towards healthcare when they were sick, and 97% were willing to use special respirators to prevent dust inhalation. On practices, only 159 (30%) reported consistent use of either cloth or respirators to prevent dust inhalation. Three hundred and five (49%) ASMs reported consistent use of condoms outside their homes and 323 (50%) reported use of water to suppress dust. Only 480 (75%) of ASMs sought healthcare services when sick. ASMs cited challenges of accessing healthcare services due to lack of money to pay for healthcare (50%), long distances to clinics (17%), and the shortage of medicines at clinics (11%). Effective control of TB, silicosis, and HIV among ASMs requires addressing the identified knowledge gaps and barriers that are faced by ASMs in accessing personal protective equipment and healthcare services. This will require multisector collaboration and the involvement of ASMs in co-designing a package of healthcare services that are tailored for them.

Pattern of Antimicrobial Susceptibility and Antimicrobial Treatment of Neonates Admitted with Suspected Sepsis in a Teaching Hospital in Ghana, 2021.

Neonatal sepsis is a life-threatening emergency, and empirical antimicrobial prescription is common. In this cross-sectional study of neonates admitted with suspected sepsis in a teaching hospital in Ghana from January-December 2021, we described antimicrobial prescription patterns, compliance with national standard treatment guidelines (STG), blood culture testing, antimicrobial resistance patterns and treatment outcomes. Of the 549 neonates admitted with suspected sepsis, 283 (52%) were males. Overall, 529 (96%) received empirical antimicrobials. Most neonates (n = 407, 76.9%) were treated empirically with cefuroxime + gentamicin, while cefotaxime was started as a modified treatment in the majority of neonates (46/68, 67.6%). Only one prescription complied with national STGs. Samples of 257 (47%) neonates underwent blood culture testing, of which 70 (27%) were positive. Isolates were predominantly Gram-positive bacteria, with coagulase-negative Staphylococcus and Staphylococcus aureus accounting for 79% of the isolates. Isolates showed high resistance to most penicillins, while resistance to aminoglycosides and quinolones was relatively low. The majority of neonates (n = 497, 90.5%) were discharged after successfully completing treatment, while 50 (9%) neonates died during treatment. Strengthening of antimicrobial stewardship programmes, periodic review of STGs and increased uptake of culture and sensitivity testing are needed to improve management of sepsis.

Performance of an Emergency Road Ambulance Service in Bhutan: Response Time, Utilization, and Outcomes.

Background: An efficient ambulance service is a vital component of emergency medical services. We determined the emergency ambulance response and transport times and ambulance exit outcomes in Bhutan. Methods: A cross-sectional study involving real-time monitoring of emergency ambulance deployments managed by a central toll-free (112) hotline (20 October 2021 to 20 January 2022) was carried out. Results: Of 5092 ambulance deployments, 4291 (84%) were inter-facility transfers, and 801 (16%) were for emergencies. Of the latter, 703 (88%) were for non-pregnancy-related emergencies (i.e., medical, surgical, and accidents), while 98 (12%) were for pregnancy-related emergencies. The median ambulance response and patient transport times were 42 (IQR 3-271) and 41 (IQR 2-272) minutes, respectively. The median round-trip distance travelled by ambulances was 18 km (range 1-186 km). For ambulance exit outcomes that were pregnancy-related (n = 98), 89 (91%) reached the health facility successfully, 8 delivered prior to ambulance arrival at the scene or in the ambulance during transport, and 1 had no outcome record. For the remaining 703 non-pregnancy deployments, 29 (4.1%) deployments were deemed not required or refusals, and 656 (93.3%) reached the health facility successfully; 16 (2.3%) died before the ambulance's arrival at the scene, and 2 (0.3%) were not recorded. Conclusions: This first countrywide real-time operational research showed acceptable ambulance exit outcomes. Improving ambulance response and transport times might reduce morbidities and mortalities further.

Retention and performance of peer educators and sustainability of HIV prevention services for adolescents in the Zimbabwe Smart-LyncAges project: an ecological study.

Introduction: in 2016, the partner-funded Smart-LyncAges participatory learning project explored the feasibility of a youth-friendly package including incentivized peer educators (PEs) to enhance adolescent sexual and reproductive health (ASRH) and voluntary medical male circumcision (VMMC) linkages. After 12 months of implementation, funding reduction resulted in reduced direct project monitoring and discontinuation of monetary incentives for PEs. We assessed if reduced funding after one year of implementation affected the performance and retention of PEs and uptake of VMMC and HIV testing in ASRH services by adolescents in Bulawayo City (urban) and Mount (Mt) Darwin District (rural) in Zimbabwe. Methods: our study was an ecological study using routine data collected from March 2016 to February 2017 (intensive support) and March 2017 to February 2018 (reduced support). All the ASRH and VMMC sites in Mt Darwin and Bulawayo were involved. Participants included 58 PEs and all adolescents accessing VMMC and ASRH services. Retention of PEs measured by the submission of monthly reports and uptake of VMMC and HIV testing were the primary outcome measures. Results: the Smart-LyncAges project engaged 58 PEs with 80% aged 20-24 years. Two-thirds were male and 60% were engaged in peer education before the project. Retention of PEs was not negatively affected by funding reduction, with 70% retained up to 11 months after funding reduction. However, their performance, measured by submission of monthly activity reports and the number of adolescents reached with VMMC and HIV messages, declined while uptake of both VMMC and HIV testing was sustained. Conclusion: sustained uptake of services was possibly due to heightened awareness of service availability and demand generation in the first year of implementation. Peer-led interventions are effective for health information dissemination. Monetary incentives determine performance, but are not the only reason for retention.

Coverage and effectiveness of conditional cash transfer for people with drug resistant tuberculosis in Zimbabwe: A mixed methods study.

The End TB strategy recommends social protection to mitigate socio-economic impacts of tuberculosis. Zimbabwe started implementing a conditional cash transfer (CCT) programme for people on drug resistant tuberculosis (DR-TB) treatment in 2013. We aimed to determine the proportion of people receiving CCT and effectiveness of CCT in improving treatment outcomes, explore their experiences with registering for CCT and understand the impact of CCT from the perspective of beneficiaries. Data from 2014-2021 were extracted from TB registers and CCT payment records within the National TB Programme. Sixteen in-depth interviews were conducted with people who were completing treatment or had completed treatment within two months. Poisson regression, adjusted for province, year of treatment, age and sex was used to investigate associations between receiving CCT and successful treatment outcomes among people who were in DR-TB care for ≥3 months after treatment initiation. Qualitative data were analyzed using thematic analysis. A total of 481 people were included in the quantitative study. Of these, 53% (254/481) received CCT at some point during treatment. People who exited DR-TB care within three months were 73% less likely to receive CCT than those who did not (prevalence ratio (PR) = 0.27 [95%CI: 0.18-0.41]). Among those who were alive and in care three months after treatment initiation, CCT recipients were 32% more likely to have successful outcomes than those who did not (adjusted PR = 1.32, [95%CI: 1.00-1.75]). Qualitative results revealed lack of knowledge about availability of CCT among people with DR-TB and missed opportunities by healthcare providers to provide information about availability of CCT. Delays and inconsistencies in disbursements of CCT were frequent themes. CCT were associated with successful treatment outcomes. Improvements in coverage, timeliness and predictability of disbursements are recommended.