Processes and dynamics of linkage to care from mobile/outreach and facility‑based HIV testing models in hard‑to‑reach settings in rural Tanzania. Qualitative findings of a mixed methods study

BACKGROUND: Like other countries, Tanzania instituted mobile and outreach testing approaches to address low HIV testing rates at health facilities and enhance linkage to care. Available evidence from hard-to-reach rural settings of Mbeya region, Tanzania suggests that clients testing HIV+ at facility-based sites are more likely to link to care, and to link sooner, than those testing at mobile sites. This paper (1) describes the populations accessing HIV testing at mobile/outreach and facility-based testing sites, and (2) compares processes and dynamics from testing to linkage to care between these two testing models from the same study context. METHODS: An explanatory sequential mixed-method study (a) reviewed records of all clients (n = 11,773) testing at 8 mobile and 8 facility-based testing sites over 6 months; (b), reviewed guidelines; (c) observed HIV testing sites (n = 10) and Care and Treatment Centers (CTCs) (n = 8); (d) applied questionnaires at 0, 3 and 6 months to a cohort of 1012 HIV newly-diagnosed clients from the 16 sites; and (e) conducted focus group discussions (n = 8) and in-depth qualitative interviews with cohort members (n = 10) and health care providers (n = 20). RESULTS: More clients tested at mobile/outreach than facility-based sites (56% vs 44% of 11,733, p < 0.001). Mobile site clients were more likely to be younger and male (p < 0.001). More clients testing at facility sites were HIV positive (21.5% vs. 7.9% of 11,733, p < 0.001). All sites in both testing models adhered to national HIV testing and care guidelines. Staff at mobile sites showed more proactive efforts to support linkage to care, and clients report favouring the confidentiality of mobile sites to avoid stigma. Clients who tested at mobile/outreach sites faced longer delays and waiting times at treatment sites (CTCs). CONCLUSIONS: Rural mobile/outreach HIV testing sites reach more people than facility based sites but they reach a different clientèle which is less likely to be HIV +ve and appears to be less “linkage-ready”. Despite more proactive care and confidentiality at mobile sites, linkage to care is worse than for clients who tested at facility-based sites. Our findings highlight a combination of (a) patient-level factors, including stigma; and (b) well-established procedures and routines for each step between testing and initiation of treatment in facility-based sites. Long waiting times at treatment sites are a further barrier that must be addressed

Understanding factors influencing linkage to HIV care in a rural setting, Mbeya, Tanzania: qualitative findings of a mixed methods study

Abstract Background In remote rural Tanzania, the rate of linkage into HIV care was estimated at 28% in 2014. This study explored facilitators and barriers to linkage to HIV care at individual/patient, health care provider, health system, and contextual levels to inform eventual design of interventions to improve linkage to HIV care. Methods We conducted a descriptive qualitative study nested in a cohort study of 1012 newly diagnosed HIV-positive individuals in Mbeya region between August 2014 and July 2015. We conducted 8 focus group discussions and 10 in-depth interviews with recently diagnosed HIV-positive individuals and 20 individual interviews with healthcare providers. Transcripts were analyzed inductively using thematic content analysis. The emergent themes were then deductively fitted into the four level ecological model. Results We identified multiple factors influencing linkage to care. HIV status disclosure, support from family/relatives and having symptoms of disease were reported to facilitate linkage at the individual level. Fear of stigma, lack of disclosure, denial and being asymptomatic, belief in witchcraft and spiritual beliefs were barriers identified at individual’s level. At providers’ level; support and good patient-staff relationship facilitated linkage, while negative attitudes and abusive language were reported barriers to successful linkage. Clear referral procedures and well-organized clinic procedures were system-level facilitators, whereas poorly organized clinic procedures and visit schedules, overcrowding, long waiting times and lack of resources were reported barriers. Distance and transport costs to HIV care centers were important contextual factors influencing linkage to care. Conclusion Linkage to HIV care is an important step towards proper management of HIV. We found that access and linkage to care are influenced positively and negatively at all levels, however, the individual-level and health system-level factors were most prominent in this setting. Interventions must address issues around stigma, denial and inadequate awareness of the value of early linkage to care, and improve the capacity of HIV treatment/care clinics to implement quality care, particularly in light of adopting the ‘Test and Treat’ model of HIV treatment and care recommended by the World Health Organization

A prospective validation cohort study of baseline plasma cell-free DNA (cfDNA) as a prognostic biomarker in newly diagnosed glioblastoma (GBM).

2508 Background: Due to significant interpatient heterogeneity, survival outcomes vary widely in patients with GBM. Novel prognostic biomarkers are needed. We aimed to determine the prognostic impact of baseline plasma cfDNA concentration in patients with GBM. Methods: We analyzed 84 patients with newly diagnosed GBM and at least 7 months of follow-up time. The first 41 patients comprised a previously published derivation cohort (Bagley, Clin Cancer Res 2020). The subsequent 43 patients served as an independent validation cohort. cfDNA was extracted from plasma collected prior to initial surgical resection and quantified by qPCR for a 115 bp amplicon of the human ALU repeat element. Receiver operating characteristic (ROC) curve analysis was used in the derivation cohort to (1) assess the accuracy of plasma cfDNA concentration for predicting progression-free survival status at 7 months (PFS-7), a landmark based on the median PFS for newly diagnosed GBM (Stupp, N Engl J Med 2005), and (2) derive the optimal cutoff for dichotomizing patients into high- and low-cfDNA groups. In the validation cohort, logistic regression was used to measure the association of plasma cfDNA concentration (high vs. low) with PFS-7, adjusted for age, isocitrate dehydrogenase ( IDH) 1/2 mutational status, 0-6-methylguanine-methyltransferase ( MGMT) methylation, extent of resection, and performance status. Multivariate Cox regression was used for overall survival (OS) analysis. Results: In the derivation cohort, the optimal cutoff for plasma cfDNA was 25.0 ng/mL (area under the curve [AUC] = 0.663), with inferior PFS and OS in patients with cfDNA above this cutoff (PFS, median 4.9 vs. 9.5 months, log-rank p = 0.001; OS, median 8.5 vs. 15.5 months, log-rank p = 0.03). In the validation cohort, baseline plasma cfDNA concentration over the cutoff was independently associated with a lower likelihood of being alive and progression-free at 7 months (adjusted OR 0.13, 95% CI 0.02 – 0.75, p = 0.02). OS was also worse in in the validation cohort in patients with high plasma cfDNA (adjusted HR 3.0, 95% CI 1.1 – 8.0, p = 0.03). Conclusions: In patients with newly diagnosed GBM, high baseline plasma cfDNA concentration is associated with worse survival outcomes independent of other prognostic factors. Further validation in a larger, multicenter study is warranted. </jats:p

OC 8713 MAXIMISING RESEARCH IMPACT TO STRENGTHEN PUBLIC HEALTHCARE

BackgroundBillions of dollars are spent on research globally every year, yet little is translated to public use through policy and/or commercialisation. For the few research findings that make it to policy, evidence in most LMICs shows they hardly see the light of implementation. Our EDCTP-funded TWENDE consortium used implementation of tuberculosis (TB) molecular diagnostics as a model to investigate the barriers, and opportunities to unlock them in order to maximise uptake of health research innovations into policy and practice.MethodsMixed methods approach including surveys, audits, in-depth interviews and focus group discussions (FGDs), policymaker dialogues to unravel the bottlenecks and how to overcome them.Results1119 respondents representing from Uganda, Kenya and Tanzania participated in the study. 19% were district/county health officers, 12% healthcare audits, 58% one-on-one interviews and FGDs with healthcare practitioners, community leaders, TB patients and survivors, and care givers, and 11% policymaker workshops. Barriers: government poverty, family/individual poverty, incompatibility of technologies to existing infrastructure, low awareness and socio-cultural beliefs in the community were found. Stigma at community and healthcare levels was rife. Consequently, TB diagnostics were underimplemented and underutilised. Xpert MTB/RIF test was fully utilised in ∼10% of healthcare facilities (conducting 8 tests per day) whilst Line probe assay was implemented in less than 1% of the facilities.ConclusionBased on our findings, we believe overcoming the barriers presents the opportunity to maximise research impact of public healthcare. This could be achieved through sustained public and practitioners’ sensitisation to remove stigma to increase demand and utilisation of services; early interaction of researchers and policymakers to increase sense of ownership and acceptability of research innovations; early communication between developers and end-users to align the tools with the needs and existing infrastructure capacity; and increased affordability of innovations through socioeconomic empowerment programmes.</jats:sec

Abstracts of Tanzania Health Summit 2020

This book contains the abstracts of the papers/posters presented at the Tanzania Health Summit 2020 (THS-2020) Organized by the Ministry of Health Community Development, Gender, Elderly and Children (MoHCDGEC); President Office Regional Administration and Local Government (PORALG); Ministry of Health, Social Welfare, Elderly, Gender, and Children Zanzibar; Association of Private Health Facilities in Tanzania (APHFTA); National Muslim Council of Tanzania (BAKWATA); Christian Social Services Commission (CSSC); &amp; Tindwa Medical and Health Services (TMHS) held on 25–26 November 2020. The Tanzania Health Summit is the annual largest healthcare platform in Tanzania that attracts more than 1000 participants, national and international experts, from policymakers, health researchers, public health professionals, health insurers, medical doctors, nurses, pharmacists, private health investors, supply chain experts, and the civil society. During the three-day summit, stakeholders and decision-makers from every field in healthcare work together to find solutions to the country’s and regional health challenges and set the agenda for a healthier future. Summit Title: Tanzania Health SummitSummit Acronym: THS-2020Summit Date: 25–26 November 2020Summit Location: St. Gasper Hotel and Conference Centre in Dodoma, TanzaniaSummit Organizers: Ministry of Health Community Development, Gender, Elderly and Children (MoHCDGEC); President Office Regional Administration and Local Government (PORALG); Ministry of Health, Social Welfare, Elderly, Gender and Children Zanzibar; Association of Private Health Facilities in Tanzania (APHFTA); National Muslim Council of Tanzania (BAKWATA); Christian Social Services Commission (CSSC); &amp; Tindwa Medical and Health Services (TMHS)