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A growing number of people living with HIV (PLHIV) also have non-communicable diseases (NCDs). Shifting to an integrated delivery model may facilitate care-seeking and improve outcomes for people with a dual burden of HIV and NCDs. We describe the current state of integration of hypertension and diabetes care into HIV treatment in Malawi, South Africa and Zambia. We administered structured interviews to HIV treatment providers in 41 primary healthcare facilities to evaluate how NCD care is provided to PLHIV accessing antiretroviral therapy (ART). We defined integration as provision of NCD services within the HIV clinic. The potential degree of integration in HIV clinics ranged from not integrated at all (no NCD services) to fully integrated (all NCD services). We also surveyed a sample of ART clients about their access to integrated care. The degree of integration varied across the facilities and countries. All facilities in South Africa reported being fully integrated for HIV care and hypertension and diabetes, and most providers in South Africa identified no barriers to integration. Integration was much less complete in Malawi and Zambia, with most facilities offering hypertension and diabetes screening/diagnosis and support but limited treatment or disease monitoring services. Frequently cited barriers to integration in Malawi and Zambia were limited staff knowledge of integrated care provision and facility space constraints. ART clients' experience with integrated services mirrored provider responses. Over 90% of survey participants in South Africa reported HIV and non-HIV visit and medication collection alignment, compared to less than half in Malawi and Zambia. The level of integration of hypertension and diabetes care with HIV treatment varies widely across facilities in Malawi, South Africa, and Zambia, despite each country having national guidelines that promote integration. Interventions to increase integration must consider differences among facilities at baseline.

Many sub-Saharan Africa countries are scaling up differentiated service delivery (DSD) models for HIV treatment to increase access and remove barriers to care. We assessed factors associated with attrition after DSD model enrollment in Zambia, focusing on patient-level characteristics. We conducted a retrospective record review using electronic medical records (EMR) of adults (≥15 years) initiated on antiretroviral (ART) between 01 January 2018 and 30 November 2021. Attrition was defined as lost to follow-up (LTFU) or died by November 30, 2021. We categorized DSD models into eight groups: fast-track, adherence groups, community pick-up points, home ART delivery, extended facility hours, facility multi-month dispensing (MMD, 4-6-month ART dispensing), frequent refill care (facility 1-2 month dispensing), and conventional care (facility 3 month dispensing, reference group). We used Fine and Gray competing risk regression to assess patient-level factors associated with attrition, stratified by sex and rural/urban setting. Of 547,281 eligible patients, 68% (n = 372,409) enrolled in DSD models, most commonly facility MMD (n = 306,430, 82%), frequent refill care (n = 47,142, 13%), and fast track (n = 14,433, 4%), with <2% enrolled in the other DSD groups. Retention was higher in nearly all DSD models for all dispensing intervals, compared to the reference group, except fast track for the ≤2 month dispensing group. Retention benefits were greatest for patients in the extended clinic hours group and least for fast track dispensing. Although retention in HIV treatment differed by DSD type, dispensing interval, and patient characteristics, nearly all DSD models out-performed conventional care. Understanding the factors that influence the retention of patients in DSD models could provide an important step towards improving DSD implementation.

Background Many countries in sub-Saharan Africa are rapidly scaling up “differentiated service delivery” (DSD) models for HIV treatment to improve the quality of care, increase access, reduce costs, and support the continued expansion and sustainability of antiretroviral therapy (ART) programs. Although there is some published evidence about the health outcomes of patients in DSD models, little is known about their impacts on healthcare providers’ job satisfaction, patients’ quality of life, costs to providers or patients, or how DSD models affect resource allocation at the facility level. Methods SENTINEL is a multi-year observational study that will collect detailed data about DSD models for ART delivery and related services from 12 healthcare facilities in Malawi, 24 in South Africa, and 12 in Zambia. The first round of SENTINEL included a patient survey, provider survey, provider time-and-motion observations, and facility resource use inventory. A survey of clients testing for HIV and a supplement to the facility resource use component to describe service delivery integration will be added for the second round. The patient survey will ask up to 10 patients enrolled in each DSD model at each study site about their experiences in HIV care and in DSD models, costs incurred seeking treatment, and preferences for HIV service delivery. The provider survey will ask up to 10 providers per site about the impact of DSD models on their positions and clinics. The time-and-motion component will directly observe the time use of a sample of providers implementing DSD models. Finally, the resource utilization component will collect facility-level data about DSD model availability and enrollment and the human and other resources needed to implement them. SENTINEL is planned to include four or more approximately annual rounds of data collection between 2021 and 2026. Discussion As national DSD programs for HIV treatment mature, it is important to understand how individual healthcare facilities are interpreting and implementing national guidelines and how healthcare workers and clients are adapting to new models of service delivery. SENTINEL will help policy makers and program managers understand the benefits and costs of differentiated service delivery and improve resource allocation going forward.

Differentiated service delivery (DSD) models for antiretroviral therapy (ART) for HIV aim to increase patient-centeredness, a concept that incorporates patient choice of service delivery options. We explored choice in DSD model enrollment at 42 public sector clinics in Malawi, South Africa, and Zambia. From 09/2022-05/2023, we surveyed people receiving HIV treatment to ask if they had a choice about DSD model enrollment and healthcare providers about their practices in offering choice. We estimated risk differences for ART clients' self-reported offer of choice and report risk differences. We thematically analyzed open-ended questions and report key themes. We enrolled 1049 people receiving HIV treatment (Malawi 409, South Africa 362, Zambia 278) and 404 providers (Malawi 110, South Africa 175, Zambia 119). The proportion of study participants indicating that they had been offered a choice ranged from 4% in Malawi to 17% in Zambia to 47% in South Africa. Over 90% of people receiving HIV treatment in all three countries reported that they were happy to be enrolled in their current DSD model. Participants from urban (ARD 0.94 [0.90-0.99]) and medium-volume facilities (2000-4000 ART clients, 0.91 [0.84-0.98]) were slightly less likely to be offered DSD enrollment. Participants in community-based models 1.21 [1.12-1.30] and those satisfied with their current model 1.06 [1.01-1.13] were more likely to be offered a choice. Among providers, 64% in Malawi, 80% in South Africa, and 59% in Zambia said they offered clients the choice to enroll in DSD or remain in conventional care. As of 2023, relatively few people receiving HIV treatment in Malawi, South Africa, and Zambia reported being offered a choice about enrolling in a DSD model, despite most providers reporting offering such a choice. The value of patient choice in improving clinical outcomes and satisfaction should be explored further.

Although strong evidence exists about the effectiveness of basic childbirth services in reducing maternal and newborn mortality, these services are not provided in every childbirth, even those at health facilities. The WHO Safe Childbirth Checklist (SCC) was developed as a job aide to remind health workers of evidenced-based practices to be provided at specific points in the childbirth process. The Zambian government requested context-specific evidence on the feasibility and outcomes associated with introducing the checklist and related mentorship. A study was conducted on use of the SCC in four facilities in Nchelenge District of Zambia. Observations of childbirth services were conducted just before and six months after the introduction of the intervention. Observers used a structured tool to record adherence to essential services indicated on the checklist. The primary outcome of interest was the change in the average proportion of essential childbirth practices completed. Feedback questionnaires were administered to health workers before and six months after the intervention. At baseline and endline, 108 and 148 pause points were observed, respectively. There was an increase from 57% to 76% of tasks performed (p = 0.04). Considering only these cases where necessary supplies were available, health workers completed 60% of associated tasks at baseline compared to 84% at endline (p<0.01). Some tasks, such as taking an infant’s temperature and hand washing, were never or rarely performed at baseline. Feedback from the health workers indicated that nearly all health workers agreed or strongly agreed with positive statements about the intervention. The performance of health workers in Zambia in completing essential practices in childbirth was low at baseline but improvements were observed with the introduction of the SCC and mentorship. Our results suggest that such interventions could improve quality of care for facility-based childbirth. However, national-level commitment to ensuring availability of trained staff and supplies is essential for success. Trial registration Clinical Trials.gov ( NCT03263182 ) Registered August 28, 2017 This study adheres to CONSORT guidelines.

ObjectivesPatient attrition is high the first 6 months after antiretroviral therapy (ART) initiation. Patients with <6 months of ART are systematically excluded from most differentiated service delivery (DSD) models, which are intended to support retention. Despite DSD eligibility criteria requiring ≥6 months on ART, some patients enrol earlier. We compared loss to follow-up (LTFU) between patients enrolling in DSD models early with those enrolled according to guidelines, assessing whether the ART experience eligibility criterion is necessary.DesignRetrospective cohort study using routinely collected electronic medical record data.SettingParticipantsAdults (≥15 years) who initiated ART between 1 January 2019 and 31 December 2020.OutcomesLTFU (>30 days late for scheduled visit) at 18 months for ‘early enrollers’ (DSD enrolment after <6 months on ART) and ‘established enrollers’ (DSD enrolment after ≥6 months on ART). We used a log-binomial model to compare LTFU risk, adjusting for age, sex, location, ART refill interval and DSD model.ResultsFor 6340 early enrollers and 25 857 established enrollers, there were no differences in sex (61% female), age (median 37 years) or location (65% urban). ART refill intervals were longer for established versus early enrollers (72% vs 55% were given 4–6 months refills). LTFU at 18 months was 3% (192 of 6340) for early enrollers and 5% (24 646 of 25 857) for established enrollers. Early enrollers were 41% less likely to be LTFU than established patients (adjusted risk ratio 0.59, 95% CI 0.50 to 0.68).ConclusionsPatients enrolled in DSD after <6 months of ART were more likely to be retained than patients established on ART prior to DSD enrolment. A limitation is that early enrollers may have been selected for DSD due to providers’ and patients’ expectations about future retention. Offering DSD models to ART patients soon after ART initiation may help address high attrition during the early treatment period.Trial registeration numberNCT04158882.

Introduction In 2023, over 210,000 new HIV acquisitions occurred in Kenya, Mozambique, Nigeria, Uganda and Zambia. While uptake of oral pre‐exposure prophylaxis (oral PrEP) and coverage of voluntary medical male circumcision increased significantly over the past decade, post‐exposure prophylaxis (PEP) has received less attention and remains an underused HIV prevention intervention. In 2024, the World Health Organization (WHO) released new guidance emphasizing the need for timely access to PEP, including through community‐based channels and task‐sharing to mitigate barriers such as stigma and ensure timely access. We conducted a comparative analysis of PEP implementation planning to understand how PEP is currently integrated into HIV prevention programmes, and to identify barriers and opportunities for optimizing the impact of PEP in the method mix. Methods We analysed Global Fund country proposals from Grant Cycle 6 (GC6) (2021−2023) and Grant Cycle 7 (GC7) (2024−2026) for five countries in Africa with high HIV burden and established PrEP programmes: Kenya, Mozambique, Nigeria, Uganda and Zambia. To understand how PEP implementation planning evolved across these two cycles, we used quantitative and qualitative analysis to identify trends. We extracted all PEP activities, coding them by focal population and activity type. Results We found over a five‐fold increase in the number of PEP activities in GC7 compared to GC6, where there were only 10 PEP activities, and an expanded population focus, including people in prisons and pregnant and breastfeeding people. Proposals increasingly emphasized PEP not only as an intervention for occupational and sexual violence exposures but as a vital component of comprehensive HIV prevention strategies. Proposals described strategies for increasing access to PEP through differentiated service delivery models, including community‐led and pharmacy‐delivered approaches. However, PEP activities were not well defined, with PEP often included in product lists without articulating product‐specific activities to address barriers or increase access. Conclusions All five countries demonstrated an increased focus on PEP from GC6 to GC7. While this reflects an ambition to expand access to PEP, product‐specific activities were not clearly articulated. Practical guidance and tools, as well as focused cross‐country learning to support the operationalization of WHO's recommendations, will be critical to increasing access and achieving impact.

Introduction Differentiated service delivery (DSD) models for antiretroviral treatment (ART) have been scaled up in many settings in sub‐Saharan Africa to improve client‐centred care and increase service delivery efficiency. However, given the multitude of models of care currently available, identifying cost‐effective combinations of DSD models that maximize benefits and minimize costs remains critical for guiding their expansion. Methods We developed an Excel‐based mathematical model using retrospective retention and viral suppression data from a national cohort of ART clients (≥15 years) in Zambia between January 2018 and March 2022 stratified by age, sex, setting (urban/rural) and model of ART delivery. Outcomes (viral suppression and retention in care), provider costs and costs to clients were estimated from the cohort and published data. The base case reflects the outcomes observed in 2022 for all DSD models for each population sub‐group. For different combinations of nine DSD models and over 1‐year time horizon from the provider perspective, we evaluated the incremental cost‐effectiveness ratio (ICER) per additional client virally suppressed compared to the 2022 base case. Deterministic sensitivity analyses were conducted on key input parameters. Results Among 125 scenarios evaluated, six were on the cost‐effectiveness frontier: (1) 6‐month dispensing (6MMD)‐only; (2) 6MMD and adherence groups (AGs); (3) AGs‐only; (4) fast track refills (FTRs) and AGs; (5) FTRs‐only; and 6) AGs and home ART delivery. 6MMD‐only was cost‐saving compared to the base case, increasing retention by 1.2% (95% CI: 0.7−1.8), viral suppression by 1.6% (95% CI: 1.0−2.7) and reducing client costs by 12.0% (95% CI: 10.8−12.4). The next cost‐effective scenarios, 6MMD + AGs and AGs‐only, cost $245 per additional person virally suppressed, increased viral suppression by 2.8% (95% CI: 2.2−3.3) and 4.0% (95% CI: 3.5−4.0) and increased client costs by 20.1% (95% CI: 9.5−28.1) and 52.3% (95% CI: 29.868.7), respectively. ART cost and laboratory test costs were the most influential parameters on provider costs and the ICERs. Conclusions Mathematical modelling using existing data can identify cost‐effective DSD model mixes while ensuring all client sub‐populations are considered. In Zambia, scaling up 6MMD to all eligible clients is likely cost‐saving, with further health gains achievable by targeting sub‐populations with selected DSD models.

Background: Adolescents in Zambia face interrelated health challenges, including human immunodeficiency virus (HIV), substance abuse and mental health disorders (MHDs). These issues have significant public health implications, as substance abuse and MHDs are known to increase the risk of HIV incidence.Aim: This study aimed to analyse trends in HIV incidence, substance abuse and MHDs among Zambian adolescents aged 10–19 years from 2021 to 2023.Setting: Data were retrieved from the Health Management Information System under Zambia’s Ministry of Health, covering all 10 provinces.Methods: A retrospective analysis of secondary data was conducted using District Health Information Software 2 (DHIS2), the Ministry of Health’s primary data system. Microsoft Excel and Stata were used for descriptive statistics and regression analysis to examine potential associations.Results: Findings indicate an increase in national HIV incidence rates from 1.89 in 2021 to 1.99 in 2022, before a decrease to 1.73 in 2023. Substance abuse also showed an upward trend, rising from 0.35 to 0.68 per 1000 adolescents. Incidence of MHDs more than doubled from 0.7 in 2021 to 1.54 in 2023, with Lusaka and Northwestern provinces showing the most significant increases. Our linear correlational analysis showed a positive relationship among the key variables.Conclusion: The results underscore the interconnectedness of HIV, substance abuse and mental health issues among adolescents in Zambia, emphasising the need for integrated interventions.Contribution: This study contributes valuable insights for policy and programme development, highlighting the need for targeted, holistic approaches in adolescent health services to address these interconnected issues effectively.

Background The proportion of HIV-positive individuals who present for initiation or re-initiation of antiretroviral therapy (ART) with advanced HIV disease (AHD) and are at risk for morbidity and mortality remains high throughout sub-Saharan Africa. In Zambia, where 20% of ART initiators are diagnosed with AHD, little is known about the characteristics of those starting ART with AHD, why treatment initiation is delayed, how AHD clinical management influences clinical and non-clinical outcomes, or implementation of national AHD guidelines at facility level. Protocol AHD-Zambia is a mixed-methods observational study to describe AHD clients and care during the first six months after starting or re-starting ART in Zambia. The study will be conducted at 24 public sector primary health facilities in four provinces. It will enroll ART clients screened for AHD during a three-month data collection period (Cohort 1), clients screened for AHD in the 12 months prior to the data collection period (Cohort 2), patients hospitalized for AHD-related conditions (Cohort 3); and clinical providers at the study sites who manage clients with AHD (Cohort 4). Data collection will include quantitative surveys, medical record review during the 12 months before and after enrollment, qualitative interviews, and focus group discussions. Facility-level indicators will also be collected. Outcomes will include detailed profiles of AHD clients and their 6 and 12-month retention in care and viral suppression, provider and client views on barriers to and preferences for AHD care, and assessment of facility fidelity to AHD guidelines. Discussion This study will generate a comprehensive profile of clients presenting with AHD in Zambia, including clinical, demographic, social, and behavioral characteristics, treatment outcomes, and barriers to providing guideline-compliant care. Findings will provide insight into the delivery of AHD services, identify gaps in implementation, and support improvements to retention and care during the early treatment period. Registration Clinicaltrials.gov NCT06904456.