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BackgroundThe UNAIDS 90-90-90 targets, aimed at ending the AIDS pandemic by 2030, have increased ART initiation among people living with HIV (PLWH). However, retention in care remains a challenge in some settings due to the growing patient load on already overwhelmed health systems. Decentralizing HIV services to the community is critical to decongest facilities and improve access. This study explored the experiences of patients and healthcare workers (HCWs) with retention in care under Zambia’s Community Adherence Group (CAG) model.MethodThis qualitative study was nested within a community ART retention project that implemented three decentralized ART models across five communities in Zambia. Between September and December 2018, data were collected through audio-recorded focus group discussions (FGDs) with purposively selected PLWH (8 FGDs, n = 42) enrolled in the CAG model and interviews with healthcare providers (n = 6). Recordings were transcribed verbatim, translated into English, and analyzed thematically using the Social Ecological Model to explore participants’ experiences.ResultsPatient retention in CAGs was influenced by factors across different levels of the Social Ecological Model. At the individual level, participants noted increased free time and reduced opportunity costs, enabling them to access ART while continuing with livelihood activities. Interpersonal factors, such as peer support and shared knowledge during group meetings, further enhanced engagement. At the organizational level, reduced clinic-based stigma encouraged continued care. Although the CAG helped with patient retention in care, a few participants felt it didn’t address conflicts with patients’ livelihood activities, particularly business ventures, which required patients to travel outside the community for an extended period.ConclusionsCAG models were perceived as practical models for improving ART patient retention because they provided an important option for PLWH to access ART services as close as possible to their homes. For the models to be effective, it is important to consider the socio-economic context, including various livelihood situations for PLWH.

ObjectivesWe sought to assess depression among healthcare workers (HCWs) in the context of COVID-19 in Lusaka Province, Zambia.DesignThis cross-sectional study is nested within a larger study, the Person-Centred Public Health for HIV Treatment in Zambia (PCPH), a cluster-randomised trial to assess HIV care and outcomes.SettingThe research was conducted in 24 government-run health facilities from 11 August to 15 October 2020 during the first wave of the COVID-19 pandemic in Lusaka, Zambia.ParticipantsWe used convenience sampling to recruit HCW participants who were previously enrolled in the PCPH study, had more than 6 months’ experience working at the facility and were voluntarily willing to participate.Primary outcome measuresWe implemented the well-validated 9-question Patient Health Questionnaire (PHQ-9) to assess HCW depression. We used mixed-effects, adjusted Poisson regression to estimate the marginal probability of HCWs experiencing depression that may warrant intervention (PHQ-9 score ≥5) by healthcare facility.ResultsWe collected PHQ-9 survey responses from 713 professional and lay HCWs. Overall, 334 (46.8%, 95% CI 43.1%, 50.6%) HCWs recorded a PHQ-9 score ≥5, indicating the need for further assessment and potential intervention for depression. We identified significant heterogeneity across facilities and observed a greater proportion of HCWs with symptoms of depression in facilities providing COVID-19 testing and treatment services.ConclusionsDepression may be a concern for a large proportion of HCWs in Zambia. Further work to understand the magnitude and aetiologies of depression among HCWs in the public sector is needed to design effective prevention and treatment interventions to meet the needs for mental health support and to minimise poor health outcomes.

Introduction Implementation of patient‐centred care (PCC) practices in HIV treatment depends on healthcare workers’ (HCWs) perceptions of the acceptability, appropriateness and feasibility of such practices (e.g. use of intentional, metric‐driven activities to improve patient experiences). Methods We applied rapid, rigorous formative research methods to refine a PCC intervention for future trial. In 2018, we conducted focus group discussions (FGDs) with 46 HCWs purposefully selected from two pilot sites. We elicited HCW perceptions of HIV service delivery, HCW motivation and perceived value of patient experience measures intended to improve PCC. FGDs utilized participatory methods to understand HCW responses to patient‐reported care engagement challenges and Scholl's PCC Framework principles (e.g. seeing a patient as a unique person), enablers (e.g. care coordination) and activities (e.g. patient involvement). Our rapid analysis used analytic memos, thematic analysis, research team debriefs and HCW feedback to inform time‐sensitive trial implementation. Results While HCWs nearly universally identified with and supported principles of PCC in both facilities, they raised practical barriers given the practice environment. HCWs described motivation to help patients, attached value to seeing positive health outcomes and the importance of teamwork. However, HCWs reported challenges with enablers needed to deliver PCC. HCWs cited a work culture characterized by differential power dynamics between cadres and departments restricting HCW autonomy and resource access. Barriers included inflexibility in accommodating individual patient needs due to high patient volumes, limited human resources, laboratory capacity, infrastructure and skills translating patient perspectives into practice. HCW motivation was negatively influenced by encounters with “difficult patients,” and feeling “unappreciated” by management, resulting in cognitive dissonance between HCW beliefs and behaviours. However, the enactment of PCC values also occurred. Results suggested that PCC interventions should reduce practice barriers, highlighting the value of mentors who could help HCWs dynamically engage with health system constraints, to facilitate PCC. Conclusions While HCWs perceived PCC principles as acceptable, they did not think it universally appropriate or feasible given the practice environment. Participatory and rapid methods provided timely insight that PCC interventions must provide clear and effective systems enabling PCC activities by measuring and mitigating relational and organizational constraints amenable to change such as inter‐cadre coordination.