Identifying gaps in HIV service delivery across the diagnosis-to-treatment cascade: findings from health facility surveys in six sub-Saharan countries.

INTRODUCTION: Despite the rollout of antiretroviral therapy (ART), challenges remain in ensuring timely access to care and treatment for people living with HIV. As part of a multi-country study to investigate HIV mortality, we conducted health facility surveys within 10 health and demographic surveillance system sites across six countries in Eastern and Southern Africa to investigate clinic-level factors influencing (i) use of HIV testing services, (ii) use of HIV care and treatment and (iii) patient retention on ART. METHODS: Health facilities (n = 156) were sampled within 10 surveillance sites: Nairobi and Kisumu (Kenya), Karonga (Malawi), Agincourt and uMkhanyakude (South Africa), Ifakara and Kisesa (Tanzania), Kyamulibwa and Rakai (Uganda) and Manicaland (Zimbabwe). Structured questionnaires were administered to in-charge staff members of HIV testing, prevention of mother-to-child transmission (PMTCT) and ART units within the facilities. Forty-one indicators influencing uptake and patient retention along the continuum of HIV care were compared across sites using descriptive statistics. RESULTS: The number of facilities surveyed ranged from six in Malawi to 36 in Zimbabwe. Eighty percent were government-run; 73% were lower-level facilities and 17% were district/referral hospitals. Client load varied widely, from less than one up to 65 HIV testing clients per provider per week. Most facilities (>80%) delivered services or interventions that would support patient retention in care such as delivering free services, offering PMTCT within antenatal care, pre-ART monitoring and adherence counselling. Many facilities under-delivered in several areas, however, such as targeted testing for high-risk groups (21%) and mobile testing (36%). There were also intra-site and inter-site differences, including in the delivery of Option B+ (ranging from 6% in Kisumu to 93% in Kyamulibwa), and nurse-led ART initiation (ranging from 50% in Kisesa to 100% in Karonga and Agincourt). Only facilities in Malawi did not require additional lab tests for ART initiation. Stock-outs of HIV test kits and antiretroviral drugs were particularly common in Tanzania. CONCLUSION: We identified a high standard of health facility performance in delivering strategies that may support progression through the continuum of HIV care. HIV testing policy and practice was particularly weak. Inter- and intra-country differences in quality and coverage represent opportunities to improve the delivery of comprehensive services to people living with HIV

Continuum of care in maternal, newborn and child health in Pakistan: analysis of trends and determinants from 2006 to 2012

Iqbal S, Maqsood S, Zakar R, Zakria Zakar M, Fischer F. Continuum of care in maternal, newborn and child health in Pakistan: analysis of trends and determinants from 2006 to 2012. BMC Health Services Research. 2017;17(1): 189.Background Pakistan, being a developing country, presents the dismal picture of maternal and neonatal mortality and morbidity. The majority of maternal and neonatal deaths could be avoided if Continuum of Care (CoC) is provided in a structured pathway from pregnancy to birth and to the first week of life of the newborn child. This study aimed to analyse the trends of CoC at all three levels (antenatal care, skilled delivery and postpartum care) and to identify various factors affecting the continuation in receiving CoC in Pakistan during 2006 to 2012. Methods Secondary data analysis was performed on nationally representative data from the last two iterations of Pakistan Demographic and Health Survey (PDHS), conducted during 2006/07 to 2012/13. The analysis is limited to women of the reproductive age group (15–49 years) who gave birth during the last five years preceding both surveys. This leads to a sample size of 5,724 and 7,461 respondents from PDHS 2006/07 and 2012/13 respectively. The association between CoC and several factors, including individual attributes (reproductive status), family influences, community context, as well as cultural and social values was assessed in bivariate analyses in a first step. Furthermore, odds ratios and adjusted odds ratios with 95% confidence intervals using a binary and multivariable logistic regression were calculated. Results Our research presents the trends of a composite measure of CoC including antenatal care, delivery assistance and postpartum care. The largest gap in CoC was observed at antenatal care followed by delivery and postnatal care within 48 h after delivery. Results show that CoC completion rate has increased from 15% to 27% amongst women in Pakistan over time from 2006 to 2012. Women with high age at first birth, having less number of children, with higher education, belonging to richest quintile, living in Sindh province and urban areas, having high autonomy and exposure to mass media were most likely to avail complete CoC. Conclusions The findings show that women in Pakistan still lack the CoC. This calls for attention to develop and implement tailored interventions, focusing on the needs of women in Pakistan to provide CoC in an integrated manner, involving both public and private sectors by appropriately addressing the factors hindering CoC completion rates

Lay-screeners and Use of WHO Growth Standards Increase Case Finding of Hospitalized Malawian Children with Severe Acute Malnutrition

Objectives: Strategies to effectively identify and refer children with severe acute malnutrition (SAM) to Nutritional Rehabilitation units (NRU) can reduce morbidity and mortality

Is chronic malnutrition associated with an increase in malaria incidence? A cohort study in children aged under 5 years in rural Gambia

Background Malnutrition is common in children in sub-Saharan Africa and is thought to increase the risk of infectious diseases, including malaria. The relationship between malnutrition and malaria was examined in a cohort of 6–59 month-old children in rural Gambia, in an area of seasonal malaria transmission. The study used data from a clinical trial in which a cohort of children was established and followed for clinical malaria during the 2011 transmission season. A cross-sectional survey to determine the prevalence of malaria and anaemia, and measure the height and weight of these children was carried out at the beginning and end of the transmission season. Standard anthropometric indices (stunting, wasting and underweight) were calculated using z-scores. Results At the beginning of the transmission season, 31.7% of children were stunted, 10.8% wasted and 24.8% underweight. Stunting was more common in Fula children than other ethnicities and in children from traditionally constructed houses compared to more modern houses. Stunted children and underweight children were significantly more likely to have mild or moderate anaemia. During the transmission season, 13.7% of children had at least one episode of clinical malaria. There was no association between stunting and malaria incidence (odds ratio = 0.79, 95% CI: 0.60–1.05). Malaria was not associated with differences in weight or height gain. Conclusions Chronic malnutrition remains a problem in rural Gambia, particularly among the poor and Fula ethnic group, but it was not associated with an increased risk of malaria. Trial registration Trial registration: ISRCTN, ISRCTN01738840, registered: 27/08/2010 (Retrospectively registered)