Delivery of index-linked HIV testing for children: learnings from a qualitative process evaluation of the B-GAP study in Zimbabwe

Background Index-linked HIV testing for children, whereby HIV testing is offered to children of individuals living with HIV, has the potential to identify children living with undiagnosed HIV. The “Bridging the Gap in HIV Testing and Care for Children in Zimbabwe” (B-GAP) study implemented and evaluated the provision of index-linked HIV testing for children aged 2–18 years in Zimbabwe. We conducted a process evaluation to understand the considerations for programmatic delivery and scale-up of this strategy. Methods We used implementation documentation to explore experiences of the field teams and project manager who delivered the index-linked testing program, and to describe barriers and facilitators to index-linked testing from their perspectives. Qualitative data were drawn from weekly logs maintained by the field teams, monthly project meeting minutes, the project coordinator’s incident reports and WhatsApp group chats between the study team and the coordinator. Data from each of the sources was analysed thematically and synthesised to inform the scale-up of this intervention. Results Five main themes were identified related to the implementation of the intervention: (1) there was reduced clinic attendance of potentially eligible indexes due to community-based differentiated HIV care delivery and collection of HIV treatment by proxy individuals; (2) some indexes reported that they did not live in the same household as their children, reflecting the high levels of community mobility; (3) there were also thought to be some instances of ‘soft refusal’; (4) further, delivery of HIV testing was limited by difficulties faced by indexes in attending health facilities with their children for clinic-based testing, stigma around community-based testing, and the lack of familiarity of indexes with caregiver provided oral HIV testing; (5) and finally, test kit stockouts and inadequate staffing also constrained delivery of index-linked HIV testing. Conclusions There was attrition along the index-linked HIV testing cascade of children. While challenges remain at all levels of implementation, programmatic adaptations of index-linked HIV testing approaches to suit patterns of clinic attendance and household structures may strengthen implementation of this strategy. Our findings highlight the need to tailor index-linked HIV testing to subpopulations and contexts to maximise its effectiveness

Process evaluation of an intervention to improve HIV treatment outcomes among children and adolescents.

SETTING: Children and adolescents with HIV encounter challenges in initiation and adherence to antiretroviral therapy (ART). A community-based support intervention of structured home visits, aimed at improving initiation, adherence and treatment, was delivered by community health workers (CHWs) to children and adolescents newly diagnosed with HIV. OBJECTIVES: To 1) describe intervention delivery, 2) explore CHW, caregiver and adolescents' perceptions of the intervention, 3) identify barriers and facilitators to implementation, and 4) ascertain treatment outcomes at 12 months' post-HIV diagnosis. DESIGN: We drew upon: 1) semi-structured interviews (n = 22) with 5 adolescents, 11 caregivers and 6 CHWs, 2) 28 CHW field manuals, and 3) quantitative data for study participants (demographic information and HIV clinical outcomes). RESULTS: Forty-one children received at least a part of the intervention. Of those whose viral load was tested, 26 (n = 32, 81.3%) were virally suppressed. Interviewees felt that the intervention supported ART adherence and strengthened mental health. Facilitators to intervention delivery were convenience and rapport between CHWs and families. Stigma, challenges in locating participants and inadequate resources for CHWs were barriers. CONCLUSION: This intervention was helpful in supporting HIV treatment adherence among adolescents and children. Facilitators and barriers may be useful in developing future interventions

Human immunodeficiency virus, smoking and self-rated health in Harare, Zimbabwe.

SETTING: Twenty-two urban factories in Harare. OBJECTIVE: To determine the relationship between the human immunodeficiency virus (HIV), smoking and self-rated health in a high HIV prevalence urban workforce. DESIGN: Cross-sectional survey. RESULTS: Of 7482 employees, 6111 (82%) consented to interview and anonymous HIV serology; 88% were male; median age was 34 years. HIV prevalence was 19%. Current (median 6 cigarettes per day) and former smoking were reported by 17% and 7%, respectively. Smoking (current or former) was more common among HIV-positive (27%) than -negative participants (17%; P < 0.001). Factors significantly associated with being a smoker on multivariate analysis were being HIV-infected (OR 1.5, 95% CI 1.4-1.7), older age (P < 0.001), non-Christian (OR 1.6, 95% CI 1.2-2.2) and manual job (OR 1.4, 95% CI 1.2-1.6). Women (OR 0.05, 95% CI 0.03-0.11) and the better educated (OR 0.7, 95% CI 0.5-0.9) were significantly less likely to smoke. HIV-positive smokers had the highest risk of reporting poor health (adjusted OR compared to HIV-negative non-smokers 3.4, 95% CI 2.3-5.0). CONCLUSIONS: Smoking was significantly more common among HIV-positive than -negative employees in this predominantly male workforce. There was evidence of a combined effect on self-rated poor health, a variable shown to be a strong independent predictor of mortality in industrialised countries. Interventions to encourage smoking cessation may be an important component of HIV care in Southern Africa