Explore the vast range of titles available.

Despite a recent decline, Zimbabwe still has the fifth highest adult HIV prevalence in the world at 14.7%; 56% of the population are currently living in extreme poverty. Cross-sectional population-based survey of 18-22 year olds, conducted in 30 communities in south-eastern Zimbabwe in 2007. To examine whether the risk of HIV infection among young rural Zimbabwean women is associated with socio-economic position and whether different socio-economic domains, including food sufficiency, might be associated with HIV risk in different ways. Eligible participants completed a structured questionnaire and provided a finger-prick blood sample tested for antibodies to HIV and HSV-2. The relationship between poverty and HIV was explored for three socio-economic domains: ability to afford essential items; asset wealth; food sufficiency. Analyses were performed to examine whether these domains were associated with HIV infection or risk factors for infection among young women, and to explore which factors might mediate the relationship between poverty and HIV. 2593 eligible females participated in the survey and were included in the analyses. Overall HIV prevalence among these young females was 7.7% (95% CI: 6.7-8.7); HSV-2 prevalence was 11.2% (95% CI: 9.9-12.4). Lower socio-economic position was associated with lower educational attainment, earlier marriage, increased risk of depression and anxiety disorders and increased reporting of higher risk sexual behaviours such as earlier sexual debut, more and older sexual partners and transactional sex. Young women reporting insufficient food were at increased risk of HIV infection and HSV-2. This study provides evidence from Zimbabwe that among young poor women, economic need and food insufficiency are associated with the adoption of unsafe behaviours. Targeted structural interventions that aim to tackle social and economic constraints including insufficient food should be developed and evaluated alongside behaviour and biomedical interventions, as a component of HIV prevention programming and policy.

In 2016, under its new National Adherence Guidelines (AGL), South Africa formalized an existing model of fast-track HIV treatment initiation counselling (FTIC). Rollout of the AGL included an evaluation study at 24 clinics, with staggered AGL implementation. Using routinely collected data extracted as part of the evaluation study, we estimated and compared the costs of HIV care and treatment from the provider's perspective at the 12 clinics implementing the new, formalized model (AGL-FTIC) to costs at the 12 clinics continuing to implement some earlier, less formalized, model that likely varied across clinics (denoted here as early-FTIC). This was a cost-outcome analysis using standard methods and a composite outcome defined as initiated antiretroviral therapy (ART) within 30 days of treatment eligibility and retained in care at 9 months. Using patient-level, bottom-up resource-utilization data and local unit costs, we estimated patient-level costs of care and treatment in 2017 U.S. dollars over the 9-month evaluation follow-up period for the two models of care. Resource use and costs, disaggregated by antiretroviral medications, laboratory tests, and clinic visits, are reported by model of care and stratified by the composite outcome. A total of 350/343 patients in the early-FTIC/AGL-FTIC models of care are included in this analysis. Mean/median costs were similar for both models of care ($135/$153 for early-FTIC, $130/$151 for AGL-FTIC). For the subset achieving the composite outcome, resource use and therefore mean/median costs were similar but slightly higher, reflecting care consistent with treatment guidelines ($163/$166 for early-FTIC, $168/$170 for AGL-FTIC). Not surprisingly, costs for patients not achieving the composite outcome were substantially less, mainly because they only had two or fewer follow-up visits and, therefore, received substantially less ART than patients who achieved the composite outcome. The 2016 adherence guidelines clarified expectations for the content and timing of adherence counseling sessions in relation to ART initiation. Because clinics were already initiating patients on ART quickly by 2016, little room existed for the new model of fast-track initiation counseling to reduce the number of pre-ART clinic visits at the study sites and therefore to reduce costs of care and treatment. Clinical Trial Number: NCT02536768.

Global environmental governance today is grounded in a set of ontological assumptions that involve measurement and commodification of carbon emissions as tradeable units between countries for mitigating climate change and preventing deforestation. These ontological assumptions are not necessarily shared by communities that are targeted for implementing projects developed under such agendas. This article provides an ethnographic account of the tensions around a REDD+ Pilot Project and a Save the Forest conservation program in Central Suau, Papua New Guinea. Despite efforts by project proponents to conduct ‘awareness’ on the programs to local communities, people feared these interventions as attempts to steal their air and land to sell to other countries. The study shows that differing assumptions of reality between project proponents and communities are related to the politics of translation that are embedded in past histories of colonisation, missionisation, and ongoing resource extraction. The ensuing disagreements highlight failures to mediate ontological intersections, which are manifested in local fears of new forms of power and external appropriation of their land and air through global environmental governance mechanisms.

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.

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.

Differentiated antiretroviral therapy (ART) delivery models, in which patients are provided with care relevant to their current status (e.g., newly initiating, stable on treatment, or unstable on treatment) has become an essential part of patient-centered health systems. In 2015, the South African government implemented Chronic Disease Adherence Guidelines (AGLs), which involved five interventions: Fast Track Initiation Counseling for newly initiating patients, Enhanced Adherence Counseling for patients with an unsuppressed viral load, Early Tracing of patients who miss visits, and Adherence Clubs (ACs) and Decentralized Medication Delivery (DMD) for stable patients. We evaluated two of these interventions in 24 South African facilities: ACs, in which patients meet in groups outside usual clinic procedures and receive medication; and DMD, in which patients pick up their medication outside usual pharmacy queues. We compared those participating in ACs or receiving DMD at intervention sites to those eligible for ACs or DMD at control sites. Outcomes were retention and sustained viral suppression (<400 copies/mL) 12 months after AC or DMD enrollment (or comparable time for controls). 12 facilities were randomly allocated to intervention and 12 to control arms in four provinces (Gauteng, North West, Limpopo, and KwaZulu Natal). We calculated adjusted risk differences (aRDs) with cluster adjustment using generalized estimating equations (GEEs) using difference in differences (DiD) with patients eligible for ACs/DMD prior to implementation (Jan 1, 2015) for comparison. For DMD, randomization was not preserved, and the analysis was treated as observational. For ACs, 275 intervention and 294 control patients were enrolled; 72% of patients were female, 61% were aged 30-49 years, and median CD4 count at ART initiation was 268 cells/μL. AC patients had higher 1-year retention (89.5% versus 81.6%, aRD: 8.3%; 95% CI: 1.1% to 15.6%) and comparable sustained 1-year viral suppression (<400 copies/mL any time ≤ 18 months) (80.0% versus 79.6%, aRD: 3.8%; 95% CI: -6.9% to 14.4%). Retention associations were apparently stronger for men than women (men RD: 13.1%, 95% CI: 0.3% to 23.5%; women RD: 6.0%, 95% CI: -0.9% to 12.9%). For DMD, 232 intervention and 346 control patients were enrolled; 71% of patients were female, 65% were aged 30-49 years, and median CD4 count at ART initiation was 270 cells/μL. DMD patients had apparently lower retention (81.5% versus 87.2%, aRD: -5.9%; 95% CI: -12.5% to 0.8%) and comparable viral suppression versus standard of care (77.2% versus 74.3%, aRD: -1.0%; 95% CI: -12.2% to 10.1%), though in both cases, our findings were imprecise. We also noted apparently increased viral suppression among men (RD: 11.1%; 95% CI: -3.4% to 25.5%). The main study limitations were missing data and lack of randomization in the DMD analysis. In this study, we found comparable DMD outcomes versus standard of care at facilities, a benefit for retention of patients in care with ACs, and apparent benefits in terms of retention (for AC patients) and sustained viral suppression (for DMD patients) among men. This suggests the importance of alternative service delivery models for men and of community-based strategies to decongest primary healthcare facilities. Because these strategies also reduce patient inconvenience and decongest clinics, comparable outcomes are a potential success. The cost of all five AGL interventions and possible effects on reducing clinic congestion should be investigated. NCT02536768.

Introduction In response to suboptimal adherence and retention, South Africa’s National Department of Health developed and implemented National Adherence Guidelines for Chronic Diseases. We evaluated the effect of a package of adherence interventions beginning in January 2016 and report on the impact of Fast‐Track Treatment Initiation Counselling (FTIC) on ART initiation, adherence and retention. Methods We conducted a cluster‐randomized mixed‐methods evaluation in 4 provinces at 12 intervention sites which implemented FTIC and 12 control facilities providing standard of care. Follow‐up was by passive surveillance using clinical records. We included data on subjects eligible for FTIC between 08 Jan 2016 and 07 December 2016. We adjusted for pre‐intervention differences using difference‐in‐differences (DiD) analyses controlling for site‐level clustering. Results We enrolled 362 intervention and 368 control arm patients. Thirty‐day ART initiation was 83% in the intervention and 82% in the control arm (RD 0.5%; 95% CI: −5.0% to 6.0%). After adjusting for baseline ART initiation differences and covariates using DiD we found a 6% increase in ART initiation associated with FTIC (RD 6.3%; 95% CI: −0.6% to 13.3%). We found a small decrease in viral suppression within 18 months (RD −2.8%; 95% CI: −9.8% to 4.2%) with no difference after adjustment (RD: −1.9%; 95% CI: −9.1% to 5.4%) or when considering only those with a viral load recorded (84% intervention vs. 86% control). We found reduced crude 6‐month retention in intervention sites (RD −7.2%; 95% CI: −14.0% to −0.4%). However, differences attenuated by 12 months (RD: −3.6%; 95% CI: −11.1% to 3.9%). Qualitative data showed FTIC counselling was perceived as beneficial by patients and providers. Conclusions We saw a short‐term ART‐initiation benefit to FTIC (particularly in districts where initiation prior to intervention was lower), with no reductions but also no improvement in longer‐term retention and viral suppression. This may be due to lack of fidelity to implementation and delivery of those components that support retention and adherence. FTIC must continue to be implemented alongside other interventions to achieve the 90‐90‐90 cascade and fidelity to post‐initiation counselling sessions must be monitored to determine impact on longer‐term outcomes. Understanding the cost‐benefit and role of FTIC may then be warranted.

Introduction In 2014, the South African government adopted a differentiated service delivery (DSD) model in its “National Adherence Guidelines for Chronic Diseases (HIV, TB and NCDs)” (AGL) to strengthen the HIV care cascade. We describe the barriers and facilitators of the AGL implementation as experienced by various stakeholders in eight intervention and control sites across four districts. Methods Embedded within a cluster‐randomized evaluation of the AGL, we conducted 48 in‐depth interviews (IDIs) with healthcare providers, 16 IDIs with Department of Health and implementing partners and 24 focus group discussions (FGDs) with three HIV patient groups: new, stable and those not stable on treatment or not adhering to care. IDIs were conducted from August 2016 to August 2017; FGDs were conducted in January to February 2017. Content analysis was guided by the Consolidated Framework for Implementation Research. Findings were triangulated among respondent types to elicit barriers and facilitators to implementation. Results New HIV patients found counselling helpful but intervention respondents reported sub‐optimal counselling and privacy concerns as barriers to initiation. Providers felt insufficiently trained for this intervention and were confused by the simultaneous rollout of the Universal Test and Treat strategy. For stable patients, repeat prescription collection strategies (RPCS) were generally well received. Patients and providers concurred that RPCS reduced congestion and waiting times at clinics. There was confusion though, among providers and implementers, around implementation of RPCS interventions. For patients not stable on treatment, enhanced counselling and tracing patients lost‐to‐follow‐up were perceived as beneficial to adherence behaviours but faced logistical challenges. All providers faced difficulties accessing data and identifying patients in need of tracing. Congestion at clinics and staff attitude were perceived as barriers preventing patients returning to care. Conclusions Implementation of DSD models at scale is complex but this evaluation identified several positive aspects of AGL implementation. The positive perception of RPCS interventions and challenges managing patients not stable on treatment aligned with results from the larger evaluation. While some implementation challenges may resolve with experience, ensuring providers and implementers have the necessary training, tools and resources to operationalize AGL effectively is critical to the overall success of South Africa’s HIV control strategy.

Replacing conventional, facility-based HIV treatment with less intensive differentiated service delivery (DSD) models could benefit DSD clients and the health system, but its value depends on maintaining or improving clinical outcomes. We compared retention and viral suppression between antiretroviral therapy (ART) clients enrolled in DSD models to those eligible for but not enrolled in DSD models in South Africa. We applied a target trial emulation (TTE) methodology to data from South Africa's electronic medical record system (TIER.Net) for 24 public-sector health facilities across three provinces and estimated retention in care (attended facility visit within 12 months) and viral suppression (<400 copies/ml3) at 12, 24, and 36 months after follow-up start date, defined as DSD enrollment date for the intervention arm and the first trial enrollment period facility visit for the comparison arm. Clients were eligible for DSD models if they were ≥18 years old, on ART ≥12 months, and had two suppressed viral load (VL) measurements, per prevailing national guidelines. For the TTE, we designated eight 6-month target trial enrollment periods between 1 July 2017 and 1 July 2021. For each period, we estimated the risk differences for retention in care and viral suppression by comparing those enrolled in DSD models to those not enrolled, using a Poisson distribution with an identity link function. We report adjusted and unadjusted risk differences for clients enrolled in DSD models and for DSD-eligible clients not enrolled in a DSD model. Estimates were adjusted for age, sex, urban/rural facility setting, province, WHO stage at ART initiation, and years on ART at trial enrollment. 49,595 unique individuals were eligible for DSD enrollment over eight target trials, contributing to a total of 148,943 trial-clients, of whom 17% (25,775) were enrolled in DSD models. The pooled adjusted risk difference for retention in care between clients enrolled in DSD and those not enrolled in DSD was 3.2% (95% confidence interval (CI) [1.6%,4.7%]) at 12 months, 4.2% (95% CI [2.4%,6.0%]) at 24 months, and 4.4% (95% CI [2.0%,6.8%]) at 36 months. For viral suppression, the adjusted risk difference comparing DSD to non-DSD was estimated to be 1.4% (95% CI [-0.5%,3.2%]) at 12 months, 1.7% (95% CI [-0.5%,4.0%]) at 24 months, and 1.4% (95% CI [-0.6%,4.4%]) at 36 months. Results remained consistent across target trials. Clients who were younger, received care from a facility in an urban settings, or had less ART experience at trial enrollment had lower retention. Study limitations include reliance on routinely collected medical records and the likely presence of residual confounding. Clients enrolled in DSD models in South Africa had slightly better retention in care and similar viral suppression to those who were eligible for but not enrolled in DSD. With better or equivalent outcomes, DSD models can be assessed on the basis of non-clinic costs and benefits, such as changes in quality of care and resource utilization. Clinicaltrials.gov NCT04149782.

Introduction Global and national guidelines recommend the integration of care for HIV and other chronic conditions to improve individual and public health outcomes. South Africa's differentiated service delivery (DSD) models extend beyond HIV care, relying on pickup points that also distribute hypertension (HTN) medications. We assessed the alignment between antiretroviral treatment (ART) and HTN medication collection visits and dispensing intervals as an indicator of integration progress. Methods The AMBIT project conducted a SENTINEL survey across 18 public clinics in three South African districts between September 2022 and April 2023, enrolling adult clients ≥ 6 months on ART. We recruited up to 180 clients across each model of care: conventional care‐not DSD eligible (conventional‐not‐eligible); conventional care‐DSD eligible but not enrolled (conventional‐eligible); facility‐ (FAC‐PuP) and external (EX‐PuP) pickup points. Healthcare interaction data were extracted from paper and electronic sources for clients with a 12‐month observation period. We analysed both self‐reported alignment and actual visit data. We estimated the number and proportion of HTN visits aligned with ART dispensing. Log‐binomial regression estimated adjusted risk ratios (ARR) to assess the association with a higher visit burden (> 5 interactions). Results Of 724 enrolled, 644 (90%) client records were successfully linked (76% female; median age 42; 15% Conventional‐not‐eligible; 17% Conventional‐eligible; 18% FAC‐PuP; 28% EX‐PuP). Among these, 85 (13%) with HTN (81 self‐reported, 4 from medical records), self‐reported 94% and 95% aligned facility visits and medication pickups, respectively. Visit data was retrieved for self‐reported HTN diagnoses. Of 477 visits for HIV/HTN comorbid clients, 83% (395) dispensed both ART and HTN medication, and 97% had aligned dispensing durations (Conventional‐not‐eligible 97%, Conventional‐eligible 95%, FAC‐PuP 98%, EX‐PuP 100%). Comorbid clients had a similar visit burden to ART‐only clients (ARR 1.05, 95% CI: 0.80−1.39). FAC‐PuP (ARR 0.55, 95% CI: 0.40−0.78) and EX‐PuP (ARR 0.75, 95% CI: 0.57−0.98) clients were less likely than Conventional‐E clients to have high annual visit burden. Conclusions Aligning medication visits and dispensing for HIV and other chronic diseases marks an initial step towards integrated service delivery. Our results demonstrate achievable medication visit alignment without increased visit burden for comorbid clients and those in DSD models, suggesting that HIV‐HTN integration is feasible within DSD models, matching client preferences for comprehensive care.