"Most of what they do, we cannot do!" How lay health workers respond to barriers to uptake and retention in HIV care among pregnant and breastfeeding mothers in Malawi

Background: In the era of Option B+ and 'treat all' policies for HIV, challenges to retention in care are well documented. In Malawi, several large community-facility linkage (CFL) models have emerged to address these challenges, training lay health workers (LHW) to support the national prevention of mother-to-child transmission (PMTCT) programme. This qualitative study sought to examine how PMTCT LHW deployed by Malawi's three most prevalent CFL models respond to known barriers to access and retention to antiretroviral therapy (ART) and PMTCT. Methods: We conducted a qualitative study, including 43 semi-structured interviews with PMTCT clients; 30 focus group discussions with Ministry of Health (MOH)-employed lay and professional providers and PMTCT LHWs; a facility CFL survey and 2–4 hours of onsite observation at each of 8 sites and in-depth interviews with 13 programme coordinators and MOH officials. Thematic analysis was used, combining inductive and deductive approaches. Results: Across all three models, PMTCT LHWs carried out a number of 'targeted' activities that respond directly to a range of known barriers to ART uptake and retention. These include: (i) fulfilling counselling and educational functions that responded to women's fears and uncertainties; (ii) enhancing women's social connectedness and participation in their own care and (iii) strengthening service function by helping clinic-based providers carry out duties more efficiently and effectively. Beyond absorbing workload or improving efficiency, however, PMTCT LHWs supported uptake and retention through foundational but often intangible work to strengthen CFL, including via efforts to strengthen facility-side responsiveness, and build community members' recognition of and trust in services. Conclusion: PMTCT LHWs in each of the CFL models examined, addressed social, cultural and health system factors influencing client access to, and engagement with, HIV care and treatment. Findings underscore the importance of person-centred design in the 'treat-all' era and the contribution LHWs can make to this, but foreground the challenges of achieving person-centredness in the context of an under-resourced health system. Further work to understand the governance and sustainability of these project-funded CFL models and LHW cadres is now urgently required

The effect of chest compression frequency on the quality of resuscitation by lifeguards. A prospective randomized crossover multicenter simulation trial

Background: The ability to perform high-quality cardiopulmonary resuscitation is one of the basicskills for lifeguards. The aim of the study was to assess the influence of chest compression frequency onthe quality of the parameters of chest compressions performed by lifeguards.Methods: This prospective observational, randomized, crossover simulation study was performed with40 lifeguards working in Warsaw, Wroclaw, and Poznan, Poland. The subjects then participated ina target study, in which they were asked to perform 2-min cycles of metronome-guided chest compressionsat different rates: 80, 90, 100, 110, 120, 130, 140, and 150 compressions per minute (CPM).Results: The study involved 40 lifeguards. Optimal chest compression score calculated by manikinsoftware was achieved for 110–120 CPM. Chest compression depth achieved 53 (interquartile range[IQR] 52–54) mm, 56 (IQR 54–57) mm, 52.5 (IQR 50–54) mm, 53 (IQR 52–53) mm, 50 (IQR 49–51)mm, 47 (IQR 44–51) mm, 41 (IQR 40–42) mm, 38 (IQR 38–43) mm for 80, 90, 100, 110, 120, 130,140 and 150 CPM, respectively. The percentage of chest compressions with the correct depth was lowerfor rates exceeding 120 CPM.Conclusions: The rate of 100–120 CPM, as recommended by international guidelines, is the optimalchest compression rate for cardiopulmonary resuscitation performed by lifeguards. A rate above 120 CPMwas associated with a dramatic decrease in chest compression depth and overall chest compressionquality. The role of full chest recoil should be emphasized in basic life support training

Scaling up evidence-based approaches to tuberculosis screening in prisons

People deprived of liberty have among the highest rates of tuberculosis globally. The incidence of tuberculosis is ten times greater than the incidence of tuberculosis in the general population. In 2021, WHO updated its guidance to strongly recommend systematic screening for tuberculosis in prisons and penitentiary systems. Which case-finding strategies should be adopted, and how to effectively implement these strategies in these settings, will be crucial questions facing ministries of health and justice. In this Viewpoint, we review the evidence base for tuberculosis screening and diagnostic strategies in prisons, highlighting promising approaches and knowledge gaps. Drawing upon past experiences of implementing active case-finding and care programmes in settings with a high tuberculosis burden, we discuss challenges and opportunities for improving the tuberculosis diagnosis and treatment cascade in these settings. We argue that improved transparency in reporting of tuberculosis notifications and outcomes in prisons and renewed focus and resourcing from WHO and other stakeholders will be crucial for building the commitment and investments needed from countries to address the continued crisis of tuberculosis in prisons

"It's not like taking chocolates": factors influencing the feasibility and sustainability of universal test and treat in correctional health systems in Zambia and South Africa

Background: Sub-Saharan African correctional facilities concentrate large numbers of people who are living with HIV or at risk for HIV infection. Universal test and treat (UTT) is widely recognized as a promising approach to improve the health of individuals and a population health strategy to reduce new HIV infections. In this study, we explored the feasibility and sustainability of implementing UTT in correctional facilities in Zambia and South Africa. Methods: Nested within a UTT implementation research study, our qualitative evaluation of feasibility and sustainability used a case-comparison design based on data from 1 Zambian and 3 South African correctional facilities. Primary data from in-depth interviews with incarcerated individuals, correctional managers, health care providers, and policy makers were supplemented by public policy documents, study documentation, and implementation memos in both countries. Thematic analysis was informed by an empirically established conceptual framework for health system analysis. Results: Despite different institutional profiles, we were able to successfully introduce UTT in the South Africa and Zambian correctional facilities participating in the study. A supportive policy backdrop was important to UTT implementation and establishment in both countries. However, sustainability of UTT, defined as relevant government departments' capacity to independently plan, resource, and administer quality UTT, differed. South Africa's correctional facilities had existing systems to deliver and monitor chronic HIV care and treatment, forming a “scaffolding” for sustained UTT despite some human resources shortages and poorly integrated health information systems. Notwithstanding recent improvements, Zambia's correctional health system demonstrated insufficient material and technical capacity to independently deliver quality UTT. In the correctional facilities of both countries, inmate population dynamics and their impact on HIV-related stigma were important factors in UTT service uptake. Conclusion: Findings demonstrate the critical role of policy directives, health service delivery systems, adequate resourcing, and population dynamics on the feasibility and likely sustainability of UTT in corrections in Zambia and South Africa

Assessing and Responding to Palliative Care Needs in Rural Sub-Saharan Africa: Results from a Model Intervention and Situation Analysis in Malawi

Introduction: Palliative care is rarely accessible in rural sub-Saharan Africa. Partners In Health and the Malawi government established the Neno Palliative Care Program (NPCP) to provide palliative care in rural Neno district. We conducted a situation analysis to evaluate early NPCP outcomes and better understand palliative care needs, knowledge, and preferences. Methods: Employing rapid evaluation methodology, we collected data from 3 sources: 1) chart review of all adult patients from the NPCP’s first 9 months; 2) structured interviews with patients and caregivers; 3) semi-structured interviews with key stakeholders. Results: The NPCP enrolled 63 patients in its first 9 months. Frequent diagnoses were cancer (n = 50, 79%) and HIV/AIDS (n = 37 of 61, 61%). Nearly all (n = 31, 84%) patients with HIV/AIDS were on antiretroviral therapy. Providers registered 112 patient encounters, including 22 (20%) home visits. Most (n = 43, 68%) patients had documented pain at baseline, of whom 23 (53%) were treated with morphine. A majority (n = 35, 56%) had ≥1 follow-up encounter. Mean African Palliative Outcome Scale pain score decreased non-significantly between baseline and follow-up (3.0 vs. 2.7, p = 0.5) for patients with baseline pain and complete pain assessment documentation. Providers referred 48 (76%) patients for psychosocial services, including community health worker support, socioeconomic assistance, or both. We interviewed 36 patients referred to the NPCP after the chart review period. Most had cancer (n = 19, 53%) or HIV/AIDS (n = 10, 28%). Patients frequently reported needing income (n = 24, 67%) or food (n = 22, 61%). Stakeholders cited a need to make integrated palliative care widely available. Conclusions: We identified a high prevalence of pain and psychosocial needs among patients with serious chronic illnesses in rural Malawi. Early NPCP results suggest that comprehensive palliative care can be provided in rural Africa by integrating disease-modifying treatment and palliative care, linking hospital, clinic, and home-based services, and providing psychosocial support that includes socioeconomic assistance

Community-facility linkage models and maternal and infant health outcomes in Malawi’s PMTCT/ART program: a cohort study

Background: In sub-Saharan Africa, 3 community-facility linkage (CFL) models—Expert Clients, Community Health Workers (CHWs), and Mentor Mothers—have been widely implemented to support pregnant and breastfeeding women (PBFW) living with HIV and their infants to access and sustain care for prevention of mother-to-child transmission of HIV (PMTCT), yet their comparative impact under real-world conditions is poorly understood. Methods and findings: We sought to estimate the effects of CFL models on a primary outcome of maternal loss to follow-up (LTFU), and secondary outcomes of maternal longitudinal viral suppression and infant “poor outcome” (encompassing documented HIV-positive test result, LTFU, or death), in Malawi’s PMTCT/ART program. We sampled 30 of 42 high-volume health facilities (“sites”) in 5 Malawi districts for study inclusion. At each site, we reviewed medical records for all newly HIV-diagnosed PBFW entering the PMTCT program between July 1, 2016 and June 30, 2017, and, for pregnancies resulting in live births, their HIV-exposed infants, yielding 2,589 potentially eligible mother–infant pairs. Of these, 2,049 (79.1%) had an available HIV treatment record and formed the study cohort. A randomly selected subset of 817 (40.0%) cohort members underwent a field survey, consisting of a questionnaire and HIV biomarker assessment. Survey responses and biomarker results were used to impute CFL model exposure, maternal viral load, and early infant diagnosis (EID) outcomes for those missing these measures to enrich data in the larger cohort. We applied sampling weights in all statistical analyses to account for the differing proportions of facilities sampled by district. Of the 2,049 mother–infant pairs analyzed, 62.2% enrolled in PMTCT at a primary health center, at which time 43.7% of PBFW were ≤24 years old, and 778 (38.0%) received the Expert Client model, 640 (31.2%) the CHW model, 345 (16.8%) the Mentor Mother model, 192 (9.4%) ≥2 models, and 94 (4.6%) no model. Maternal LTFU varied by model, with LTFU being more likely among Mentor Mother model recipients (adjusted hazard ratio [aHR]: 1.45; 95% confidence interval [CI]: 1.14, 1.84; p = 0.003) than Expert Client recipients. Over 2 years from HIV diagnosis, PBFW supported by CHWs spent 14.3% (95% CI: 2.6%, 26.1%; p = 0.02) more days in an optimal state of antiretroviral therapy (ART) retention with viral suppression than women supported by Expert Clients. Infants receiving the Mentor Mother model (aHR: 1.24, 95% CI: 1.01, 1.52; p = 0.04) and ≥2 models (aHR: 1.44, 95% CI: 1.20, 1.74; p < 0.001) were more likely to undergo EID testing by age 6 months than infants supported by Expert Clients. Infants receiving the CHW and Mentor Mother models were 1.15 (95% CI: 0.80, 1.67; p = 0.44) and 0.84 (95% CI: 0.50, 1.42; p = 0.51) times as likely, respectively, to experience a poor outcome by 1 year than those supported by Expert Clients, but not significantly so. Study limitations include possible residual confounding, which may lead to inaccurate conclusions about the impacts of CFL models, uncertain generalizability of findings to other settings, and missing infant medical record data that limited the precision of infant outcome measurement. Conclusions: In this descriptive study, we observed widespread reach of CFL models in Malawi, with favorable maternal outcomes in the CHW model and greater infant EID testing uptake in the Mentor Mother model. Our findings point to important differences in maternal and infant HIV outcomes by CFL model along the PMTCT continuum and suggest future opportunities to identify key features of CFL models driving these outcome differences

Improving PMTCT outcomes for mother-infant pairs through community-facility linkage: Results from a mixed methods study in Malawi

To improve MIP care retention in Malawi, several prevention of mother-to-child transmission of HIV (PMTCT) care delivery models have emerged to strengthen community-facility linkage (CFL), a concept defined as any “formalized connection between a health facility and the communities it serves to support improved health outcomes.” Similar to other settings in sub-Saharan Africa, three models have been widely implemented to complement Malawi’s National PMTCT Programme: 1) mentor mothers; 2) expert clients; and 3) community health workers. While the rationale underpinning these models has been substantiated by evidence generated from general antiretroviral therapy and PMTCT programs across SSA, a clear and rigorous description of each model, including characterization of supervisory structures, training, and relationships with clinical services, is currently unavailable. Equally important, the comparative impact of these models and their components on MIP care retention and other health outcomes have not been well characterized, particularly in the era of test and start. In the USAID-funded Project SOAR “Maternal-Infant Retention Study” reported here, we have attempted to address these existing evidence gaps by rigorously characterizing these community-facility linkage models and comparing their impact against each other and the “traditional” standard of care according to routinely collected health outcomes for mother-infant pairs (MIPs), including maternal retention in care and viral suppression, and infant HIV-free survival. To this end, specific objectives of this study were to: (1) establish a clear typology for CFL models by describing the main components of, and patient and key stakeholder perspectives on, three such models in Malawi; (2) describe MIP health outcomes in each model, and compare outcomes across models; and (2a) examine associations between individual components of CFL models and MIP health outcomes, controlling for confounding

Experiences of Justice-Involved People Transitioning to HIV Care in the Community After Prison Release in Lusaka, Zambia: A Qualitative Study

Introduction: In sub-Saharan Africa (SSA), incarcerated people experience a higher HIV burden than the general population. While access to HIV care and treatment for incarcerated people living with HIV (PLHIV) in SSA has improved in some cases, little is known about their transition to and post-release experience with care in the community. To address this gap, we conducted a qualitative study to describe factors that may influence post-release HIV care continuity in Zambia. Methods: In March-December 2018, we recruited study participants from a larger prospective cohort study following incarcerated and newly released PLHIV at 5 correctional facilities in 2 provinces in Zambia. We interviewed 50 participants immediately before release; 27 (54%) participated in a second interview approximately 6 months post-release. Demographic and psychosocial data were collected through a structured survey. Results: The pre-release setting was strongly influenced by the highly structured prison environment and assumptions about life post-release. Participants reported accessible HIV services, a destigmatizing environment, and strong informal social supports built through comradery among people facing the same trying detention conditions. Contrary to their pre-release expectations, during the immediate post-release period, participants struggled to negotiate the health system while dealing with unexpected stressors. Long-term engagement in HIV care was possible for participants with strong family support and a high level of self-efficacy. Conclusion: Our study highlights that recently released PLHIV in Zambia face acute challenges in meeting their basic subsistence needs, as well as social isolation, which can derail linkage to and retention in community HIV care. Releasees are unprepared to face these challenges due to a lack of community support services. To improve HIV care continuity in this population, new transitional care models are needed that develop client self-efficacy, facilitate health system navigation, and pragmatically address structural and psychosocial barriers like poverty, gender inequality, and substance use

Mitigating the effects of COVID-19 on HIV treatment and care in Lusaka, Zambia: A before-after cohort study using mixed effects regression

INTRODUCTION: The Zambian Ministry of Health (MoH) issued COVID-19 mitigation guidance for HIV care immediately after the first COVID-19 case was confirmed in Zambia on 18 March 2020. The Centre for Infectious Disease Research in Zambia implemented MoH guidance by: 1) extending antiretroviral therapy (ART) refill duration to 6 multi-month dispensation (6MMD) and 2) task-shifting communication and mobilisation of those in HIV care to collect their next ART refill early. We assessed the impact of COVID-19 mitigation guidance on HIV care 3 months before and after guidance implementation. METHODS: We reviewed all ART pharmacy visit data in the national HIV medical record for PLHIV in care having ≥1 visit between 1 January-30 June 2020 at 59 HIV care facilities in Lusaka Province, Zambia. We undertook a before-after evaluation using mixed-effects Poisson regression to examine predictors and marginal probability of early clinic return (pharmacy visit \u3e7 days before next appointment), proportion of late visit (\u3e7 days late for next appointment) and probability of receiving a 6MMD ART refill. RESULTS: A total of 101 371 individuals (64% female, median age 39) with 130 486 pharmacy visits were included in the analysis. We observed a significant increase in the adjusted prevalence ratio (4.63; 95% CI 4.45 to 4.82) of early return before compared with after guidance implementation. Receipt of 6MMD increased from a weekly mean of 47.9% (95% CI 46.6% to 49.2%) before to 73.4% (95% CI 72.0% to 74.9%) after guidance implementation. The proportion of late visits (8-89 days late) was significantly higher before (18.8%, 95% CI17.2%to20.2%) compared with after (15.1%, 95% CI13.8%to16.4%) guidance implementation . CONCLUSIONS: Timely issuance and implementation of COVID-19 mitigation guidance involving task-shifted patient communication and mobilisation alongside 6MMD significantly increased early return to ART clinic, potentially reducing interruptions in HIV care during a global public health emergency

Costs of implementing universal test and treat in three correctional facilities in South Africa and Zambia.

INTRODUCTION: Universal test and treat (UTT) is a population-based strategy that aims to ensure widespread HIV testing and rapid antiretroviral therapy (ART) for all who have tested positive regardless of CD4 count to decrease HIV incidence and improve health outcomes. Little is known about the specific resources required to implement UTT in correctional facilities for incarcerated people. The primary aim of this study was to describe the resources used to implement UTT and to provide detailed costing to inform UTT scale-up in similar settings. METHODS: The costing study was a cross-sectional descriptive study conducted in three correctional complexes, Johannesburg Correctional Facility in Johannesburg (>4000 inmates) South Africa, and Brandvlei (~3000 inmates), South Africa and Lusaka Central (~1400 inmates), Zambia. Costing was determined through a survey conducted between September and December 2017 that identified materials and labour used for three separate components of UTT: HIV testing services (HTS), ART initiation, and ART maintenance. Our study participants were staff working in the correctional facilities involved in any activity related to UTT implementation. Unit costs were reported as cost per client served while total costs were reported for all clients seen over a 12-month period. RESULTS: The cost of HIV testing services (HTS) per client was $92.12 at Brandvlei,$ 73.82 at Johannesburg, and $65.15 at Lusaka. The largest cost driver for HIV testing at Brandvlei were staff costs at 55.6$917 for Brandvlei, $421.8 for Johannesburg, and$252.1 for Lusaka. The activity cost drivers were adherence counselling at Brandvlei (59%), and at Johannesburg and Lusaka it was the actual ART initiation at 75.6% and 75.8%, respectively. The annual unit cost for ART maintenance was $2,640.6 for Brandvlei,$710 for Johannesburg, and $385.5 for Lusaka. The activity cost drivers for all three facilities were side effect monitoring, and initiation of isoniazid preventive treatment (IPT), cotrimoxazole, and fluconazole, with this comprising 44.7% of the total cost at Brandvlei, 88.9% at Johannesburg, and 50.5% at Lusaka. CONCLUSION: Given the needs of this population, the opportunity to reach inmates at high risk for HIV, and overall national and global 95-95-95 goals, the UTT policies for incarcerated individuals are of vital importance. Our findings provide comparator costing data and highlight key drivers of UTT cost by facility