Evaluation of care and treatment clinics using a four-year retrospective cohort of patients receiving anti-retroviral therapy in Mbeya Region, Tanzania

Evaluations of sub-national anti-retroviral therapy (ART) programmes’ performance are important to support regional programme planning and epidemic response. We constructed a four-year retrospective cohort of clients from 10 care and treatment clinics (CTC) in the Mbeya region of Tanzania using routinely collected data from patients initiating ART between January 1, 2008 and March 31, 2012. Our primary outcomes were mortality rate and lost to follow up. We calculated ART coverage based on regional prevalence estimates and used medical cards, drug registers and quarterly reports to assess data quality. We enrolled 17,813 participants into the cohort. More patients initiated ART at WHO stages 3 (58.9%), and at CD4 cell counts between 50-199 cells/µl (56%). The proportion of patients initiating ARTs at a CD4 counts <50 cells/µl decreased from 40.7% in 2008 to 33.8% in 2012 (p-value <0.001). A total of 10,155 (57.0%) patients were lost to follow up (LTFU) during the 4 years of follow up; 59.2% were female. The overall mortality rate was 17.8 per 1000 person years; the six-month mortality was 6.2 per 1000 person years. The risk of mortality for patients at WHO stage III and IV was more than twice as high (hazard ratio [HR] 2.15; 95% confidence interval [CI], 1.05-4.39 and HR 2.29; 95% CI, 1.39-6.37, respectively) as compared to stage I and II. Those patients initiating ART with CD4 cell count between 50 and 199 cells/µl had significantly lower hazard of death compared to those initiating ART with CD4 cells counts <50 cells/µl (HR 0.51, 95% CI 0.34-0.78). In conclusion, during the study, a high proportion of patients were lost to follow up, and the majority of them were female. Most patients initiated ARTs at lower CD4 count (<200 cells/mm3) and at WHO stages III and IV, and they had higher risk of mortality compared to those initiated at higher CD4 counts and WHO stage I and II. Emphasis needs to be placed on strategies of early diagnosis of HIV infection, prompt initiation of ART, and support for ART adherence to minimise lost to follow up

"The phone number tells us good things we didn't know before." Use of interactive voice response calling for improving knowledge and uptake of family planning methods among Maasai in Tanzania.

Maasai living in the Arusha region, Tanzania, face challenges in feeding their children because of decreasing grazing grounds for their cattle. Therefore, they requested birth control methods. Previous studies have shown that lack of knowledge about, and poor access to, family planning (FP) may worsen the situation. We developed an interactive voice response calling (IVRC) platform for Maasai and health care workers (HCW) to create a venue for communication about FP to increase knowledge and access to FP. The objective of this study was to explore the effect of the platform on knowledge, access and use of family planning methods. We applied a participatory action research approach using mixed methods for data collection to develop and pilot-test an mHealth-platform with IVRC using Maa language. We enrolled Maasai-couples and HCW in Monduli District (Esilalei ward), Arusha Region, and followed them for 20 months. A baseline assessment was done to explore knowledge about FP. Furthermore, we abstracted information on FP clinic visits. Based on that, we developed a system called Embiotishu. A toll-free number was provided to interact with the system by calling with their phone. The system offers pre-recorded voice messages with information about FP and reproductive health to educate Maasai. The system recorded the number of calls and the type of information accessed. We measured the outcome by (1) a survey investigating the knowledge of contraceptive methods before and after Embiotishu and (2) counting the number of clinic visits (2018-2020) from medical records and feedback from qualitative data for FP used among Maasai. The acceptability and feasibility were explored through focus group discussions (FGDs) with Maasai and in-depth interviews (IDIs) with HCW. We recruited 76 Maasai couples whom we interviewed during the baseline assessment. The overall knowledge of contraceptives increased significantly (p<0.005) in both men and women. The number of clinic visits rose from 137 in 2018 to 344 in 2019 and 228 in the first six months of 2020. Implants were the most prescribed family planning method, followed by injections and pills, as found in medical records. The number of incoming calls, missed calls, and questions were 24,033 over 20 months. Out of these calls, 14,547 topics were selected. The most selected topics were modern contraceptives (mainly implants, condoms, tubal ligation, and vasectomy). Natural methods of contraception (vaginal fluid observations, calendar, and temperature). Our study has shown that the IVRC system led to an improvement in knowledge about and access to contraceptives. Furthermore, it has potential to increase access to health information as well as improve dialogue between Health workers and Maasai