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South Africa has been rated as having the most severe HIV epidemic in the world since it has one of the largest populations of people living with HIV (PLHIV). KwaZulu-Natal (KZN) is the epicentre of the HIV epidemic. The HIV test and treat services in the public health sector are critical to managing the epidemic and responding to the increase in HIV infections. The KwaZulu-Natal Department of Health (DOH) commissioned a review of the provision of HIV testing services in the province and aimed to investigate its impact on the HIV positivity rate over a ten-year period. The study was an ecological study design using data extracted from the Department's District Health Information System (DHIS). Descriptive analysis was conducted in addition to ANOVA and multiple regression analysis. The results of this study have shown that the total number of HIV tests conducted over the ten-year period in the province has increased with the highest number of HIV tests being conducted in the 2018/2019 MTEF year. ANOVA analysis indicates that there was a statistically significant difference in the total number of HIV tests conducted and the number of HIV tests per 100 000 population across the province's 11 districts (p < 0.001). Statistically significant differences were observed in the HIV testing rate and in the HIV positivity rate over the period (p < 0.001). Results from multiple regression analysis showed that the HIV testing rate per 100 000 population was the strongest predictor of the HIV positivity rate. HIV positivity among clients correlated negatively with the number of HIV tests conducted per 100 000 population (r = −0.823; p < 0.001) and the HIV testing rate (r = −0.324; p < 0.01). This study has found that HIV testing could have an impact on reducing the positivity rate of HIV in the province and is therefore an effective strategy in curbing the HIV epidemic. The KwaZulu-Natal Department of Health should ensure that strategies for implementing and maintaining HIV testing and treating services should continue at an accelerated rate in order to achieve the first 95 of the UNAIDS 2025 SDG target.

Introduction Key populations (KP) continue to account for high HIV incidence globally. Still, prioritization of KP in the national HIV prevention response remains insufficient, leading to their suboptimal access to HIV programmes. This commentary aims to share Kenya’s challenges and successes in achieving 2020 global HIV targets and scaling up the KP programme in the last decade. Discussion The KP programme in Kenya has scaled up in the last decade with the inclusion of female sex workers (FSW), men who have sex with men (MSM), people who inject drugs (PWID), transgender people and people in prisons as priority populations in the national HIV response. KP coverage based on official size estimates for FSW is 73%, for MSM is 82%, for PWID through needle syringe programme (NSP) is 71%, and through opioid substitution therapy (OST) is 26% and for transgender people is 5%. The service outcomes for KP have been relatively strong in prevention with high condom use at last paid sex for FSW (92%) and use of sterile equipment among PWID (88%), though condom use at last sex with a non‐regular partner among MSM (78%) is still low. The KP programme has not met care continuum targets for all subpopulations with low case findings. The national KP programme led by the Ministry of Health has scaled up the programme through (a) strategic partnerships with KP‐led and competent organizations, researchers and donors; (b) development of policy guidance and programme standards; (c) continuous sensitization and advocacy to garner support; (d) development of national reporting systems, among others. However, the programme is still struggling with uncertain size estimates; lack of updated bio‐behavioural survey data; inadequate scale‐up of interventions among transgender people and people in prison settings; gaps in reaching adolescent and young KP, and effectively addressing structural barriers like violence and stigma. Conclusions To reach the ambitious global HIV targets, sufficient coverage of KP with quality HIV programmes is critical. Despite scaling up the KP programme, Kenya has not yet achieved the 2020 global HIV targets and needs more efforts to scale‐up quality programmes for KP who are underserved in the HIV response.

Introduction With the rapid spread of COVID-19, many governments put various measures in place to contain the spread of the pandemic. These measures, such as travel restrictions, curfews, and public gatherings, may affect health service delivery, including monitoring of viral load and CD4 for People Living with HIV (PLHIV) on antiretroviral therapy (ART). Lesotho is a lower-middle-income country with one of the world’s highest prevalence of HIV (22%). This study aims to examine the effect of COVID-19 on viral load and CD4 monitoring of PLHIV on ART in Lesotho. Methods We employed routine data from seven Ministry of Health health centers supported by Partners In Health from March 2017 to February 2023. We extracted de-identified data for all patients with HIV on ART who were followed by the health centers, including demographic variables of interest, viral load, and CD4 count. We analyzed the data using the chi-squared tests of independence to compare before and after COVID-19, and we used a logistic regression model predicting a result of “suppressed” and advanced disease as binary outcome variables. Results We observed significantly higher rates of viral load suppression and CD4 counts > 200 with p-values < 0.001 during the COVID-19 pandemic, March 2020, 2021, 2022, and 2023, versus before the pandemic in March 2017, 2018, 2019, and February 2020. Fewer patients seen during the pandemic were classified as having “advanced HIV” based on CD4 count (< 200 cells/ml) test results during COVID (7.0%) than before (8.0%), though it was no significant and likewise, fewer PLHIV seen during the COVID-19 pandemic were “unsuppressed” based on viral load (> 1000 copies/ml) (11.1%) vs. before the pandemic (15.8%) which was significant with p-value < 0.001. Conclusions Maintaining high viral load suppression in remote and rural communities during the pandemic is possible. A robust primary health system and strong pandemic preparation and response plans are crucial for effective HIV program response. Measures and communication introduced into the viral load and CD4 monitoring during the pandemic outbreak are paramount for sustaining the viral load suppression and ultimately reducing new HIV transmission.

To accelerate COVID-19 vaccination delivery, Zambia integrated COVID-19 vaccination into HIV treatment centers and used World AIDS Day 2021 to launch a national vaccination campaign. This campaign was associated with significantly increased vaccinations, demonstrating that HIV programs can be leveraged to increase COVID-19 vaccine uptake.

Background Ethiopia Population-based HIV Impact Assessment findings showed that in Addis Ababa, only 65.2% of people living with HIV (PLHIV) know their status. We present the enhanced HIV/AIDS data management and systematic monitoring experience in Addis Ababa City Administration Health Bureau (AACAHB). Methods AACAHB established a command-post with leadership and technical team members from the health bureau, 10 sub-city health offices, and non-governmental stakeholders. The command-post improved governance, standardized HIV program implementation, and established accountability mechanism. A web-based database was established at each health facility, sub-city, and AACAHB level. Performance was scored (green, ≥75%; yellow, 50–74%; red, < 50%). The command-post reviewed performance on weekly basis. A mentorship team provided a weekly site-level support at underperforming public and private health facilities. At facility level, quality of data on recording tools such as registers, and individual medical records were maintained through continued review, feedback mechanisms and regular consistency check of data. Percentage and 95% confidence interval were computed to compare the improvement in program performance over time. Results After 6 months of intervention period, the monthly New HIV case finding in 47 health facilities increased from 422 to 734 (1.7 times) and treatment initiation increased from 302 to 616 (2 times). After 6 months, the aggregate scoring for HIV testing at city level improved from yellow to green, HIV case finding improved from red to green, and treatment initiation improved from red to yellow. An increasing trend was noted in HIV positive case finding with statistically significant improvement from 43.4% [95% Confidence Interval: 40.23–46.59%] in May 2019 to 74.9% [95% Confidence Interval: 72.03–77.6%] in September 2019. Similarly, significant improvement was recorded for new HIV treatment from 30.9% [95% Confidence Interval: 28.01–33.94%] in May 2019 to 62.5% [95% Confidence Interval: 59.38–65.6%] in September 2019. Conclusions Regular data driven HIV program review was institutionalized at city, sub-city and health facility levels which further improved HIV program monitoring and performance. The performance of HIV case finding and treatment initiation improved significantly via using intensified monitoring, data driven performance review, targeted site-level support based on the gap, and standardized approaches.

Introduction HIV prevalence is declining in key populations in Armenia including in people who inject drugs (PWID), men who have sex with men, prison inmates, and female sex workers (FSWs); however, prevalence is increasing among Armenians who seasonally migrate to work in countries with higher HIV prevalence, primarily to the Russian Federation. Methods We conducted a modelling study using the Optima model to assess the optimal resource allocation to meet targets from the 2013 to 2016 national strategic plan to minimize HIV incidence and AIDS‐related deaths by 2020. Demographic, epidemiological, behavioural, and programme cost data from 2000 through 2014 were used to inform the model. The levels of coverage that could be attained among targeted populations with different investments, as well as their expected outcomes, were determined. In the absence of evidence of the efficacy of HIV programmes targeted at seasonal labour migrants, we conducted a sensitivity analysis to determine the cost‐effective funding threshold for the seasonal labour migrant programme. Results The optimization analysis revealed that shifts in funding allocations could further minimize incidence and deaths by 2020 within the available resource envelope. The largest emphasis should be on antiretroviral therapy (ART), with the optimal investment to increase treatment coverage by 40%. Optimal investments also involve increases in opiate substitution therapy and FSW programmes, as well as maintenance of other prevention programmes for PWID and prevention of mother‐to‐child transmission. Additional funding for these increases should come from budgets for general population programmes. This is projected to avert 17% of new infections and 29% of AIDS‐related deaths by 2020 compared to a baseline scenario of maintaining 2013 spending. Our sensitivity analysis demonstrated that, at current spending, coverage of annual testing among migrants of at least 43% should be achieved to warrant continuation of funding for this programme. Conclusions Optimization of HIV/AIDS investment in Armenia, with a main priority for scaling‐up ART, and less emphasis on primary prevention in the general non‐key population could significantly reduce incidence and deaths by 2020.

Background The global concern of suboptimal viral load suppression (VLS) rates falling below the 95% target among older adolescents living with HIV (OALHIV) and young adults living with HIV (YALHIV) remains a critical concern, particularly in Namibia and other regions of Africa. These low suppression rates are influenced by multiple factors, including the unique developmental circumstances of this age group, limitations within healthcare systems, and broader socio-environmental determinants. The absence of targeted HIV programmes that address the specific needs of OALHIV and YALHIV highlights a significant gap in care. In response, this study aimed to develop an HIV programme specifically designed to enhance adherence and improve VLS outcomes among this population. Methods The study employed an explanatory sequential mixed-methods approach, conducted in four distinct phases. Participants included OALHIV, YALHIV, HCPs, and HIV, all selected through purposive sampling. Findings from the initial phases were synthesised into key elements, which informed the development of an HIV programme guided by Dickoff's Practice-Oriented Theory and validated following the online Delphi technique. Data was collected through a semi-structured online questionnaire and analysed using IBM SPSS version 28. Consensus was achieved with 15 HIV experts. Results The study identified various individual, health system, and community-level barriers negatively impacting OALHIV and YALHIV, reinforcing the necessity for a tailored HIV programme to enhance treatment adherence and VLS. The findings emphasised the importance of multi-sectoral collaboration, involving diverse stakeholders and multiple levels of government, in addressing the specific needs of this demographic. Additionally, the study revealed a 45.4% (75/165) consensus on the theories, tools, strategies, and guidelines required for the effective management of this age group. Conclusion The development of an HIV programme tailored for OALHIV and YALHIV is a critical step toward optimising interventions to achieve VLS targets (95%) set for this age group. This process necessitates a collaborative effort that integrates appropriate theoretical frameworks, evidence-based strategies, standardised guidelines and tools. Nevertheless, its feasibility and impact require further evaluation.

Background: The implementation of nurse-initiated management of antiretroviral therapy (NIMART) management training is a challenge in the primary health care (PHC). It is evident from the literature reviewed and the data obtained from the North West province that gaps still exist. There is no conceptual framework providing guidance to NIMART training and implementation. Aim: Therefore, the aim of this study was to develop a conceptual framework to strengthen NIMART training and implementation in the North West province to improve patients and human immunodeficiency virus (HIV) programme outcomes. Setting: The study was conducted in the North West Province, South Africa. Methods: A pragmatic, explanatory, sequential, mixed-methods research design was followed. A descriptive and explorative programme evaluation design was used. Data were collected from two sources: antiretroviral therapy (ART) statistics from District Health Information System (DHIS) & Tier.net of 10 PHC facilities to evaluate and determine the impact of NIMART on the HIV programme and five focus group discussions conducted amongst 28 NIMART nurses and three HIV programme managers to describe challenges influencing NIMART training and implementation. Results: The study revealed that there was low ART initiation compared to the number of clients who tested HIV-positive. There was poor monitoring of patients on ART, which was evident in the low viral load collection and suppression, high loss to follow-up and deaths related to HIV. Challenges exist and this was confirmed by the qualitative findings, including human resource ratios, training and mentoring and the entire absence of a conceptual framework or model that guides training and implementation. Conclusion: The study findings were conceptualised to describe and develop a framework needed to facilitate and influence NIMART training and implementation to improve the HIV programme and patient outcomes. Dickoff, James and Wiedenbach’s practice-oriented theory and Donabedian’s structure process outcomes model provided a starting point in the ultimate development of the framework. Although the study was limited to the North West province’s PHC clinics and community health centres and did not include hospitals, it is of high significance as there is no such conceptual framework in the province or in even South Africa.

Background: The increasing number of people testing human immunodeficiency virus positive and who demand antiretroviral therapy (ART) prompted the Department of Health to adopt World Health Organization’s task shifting where professional nurses (PNs) initiate ART rather than doctors. This resulted in decentralisation of services to primary healthcare (PHC), generating a need to capacitate PNs on nurse-initiated-management of ART (NIMART). The impact of NIMART was assessed and even though there was an increased number of patients on ART, the quality of care is of serious concern. Aim: The aim of this study was to explore and describe the challenges influencing NIMART training and implementation amongst PNs and programme managers. Setting: The study was conducted from the PHC facilities, in the rural districts of the North West province. Methods: An exploratory programme evaluation and contextual research design was used in the study. Purposive sampling was used. Focus group discussion (n = 28) and individual interviews were used to collect data. Data was analysed using ATLAS.ti software. Results: The results revealed two themes: inadequacy in NIMART training and the healthcare system challenges that influence NIMART training and implementation. Theme 1 included among others the lack of standardised curriculum and model or conceptual framework to strengthen NIMART training. And theme 2 included patient and district healthcare structural system. Conclusion: There a need to improve NIMART training and implementation through the standardisation of NIMART curriculum, introduction of pre-service NIMART training in institutions of higher learning, addressing staff shortages and negative attitude of PNs providing ART.

Background Comprehensive sexual reproductive health (SRH) programs for female sex workers (FSW) offering clinical, behavioural, and structural interventions have contributed to declining rates of HIV in this population. However, data on costs and cost drivers is needed to support programs and their donors to better allocate resources, make an investment case for continued funding, and to identify areas of improvement in program design and implementation. We aimed to estimate the annual per-FSW costs of comprehensive services for a standalone FSW program in Kenya. Methods We implemented a top–bottom and activity-based costing study of comprehensive FSW services at two drop-in centres (DICs), Mtwapa and Kilifi town, in Kilifi County, Kenya. Service costs were obtained from routinely collected patient data during FSW scheduled and unscheduled visits using Kenyan Ministry of Health records. Costing data were from the program and organization’s expenditure reports, cross checked against bank documents and supported by information from in-depth interviews. Data were collected retrospectively for the fiscal year 2019. We obtained approval from the AMREF Research Ethics Committee (AMREF-ESRC P862/2020). Results In 2019, the unit cost of comprehensive services was 105.93 USD per FSW per year, roughly equivalent to 10,593 Kenya shillings. Costs were higher at Mtwapa DICs compared to Kilifi town DIC; 121.90 USD and 89.90 USD respectively. HIV counselling and testing cost 63.90 USD per person, PrEP was 34.20 USD and family planning was 9.93 USD. Of the total costs, staff salaries accounted for about 60%. Adjusted for inflation, costs in 2024 would be approximately 146.60. Conclusion Programs should strive to maximize the number of FSW served to benefit from economies of scale. Given that personnel costs contribute most to the unit costs, programs should consider alternative designs which reduce personnel and other costs.