Determinants of viral load non-suppression among adolescents in Mbale District, Eastern Rural Uganda

Background Adolescents are lagging behind in the “third 95” objective of the Joint United Nations Program on HIV/AIDS requiring 95% of individuals on antiretroviral therapy (ART) to have viral load (VL) suppression. This study aimed to describe factors associated with viral non-suppression among adolescents in Mbale district, Uganda. Methods We conducted a retrospective review of routinely collected HIV programme records. Data such as age, education, ART Regimen, ART duration, WHO Clinical stage, comorbidities, etc., were extracted from medical records for the period January 2018 to December 2018. Descriptive analysis was done for continuous variables using means and frequencies to describe study sample characteristics, and to determine the prevalence of outcome variables. We used logistic regression to assess factors associated with VL non-suppression among adolescents. Results The analysis included 567 HIV-infected adolescents, with 300 (52.9%) aged between 13 to 15 years, 335 (59.1%) female, and mean age of 15.6 years (interquartile range [IQR] 13.5–17.8. VL non-suppression was 31.4% (178/567). Male sex (AOR = 1.78, 95% CI 1.06, 2.99; p < 0.01), age 16–19 years (AOR = 1.78, 95% CI 1.06, 2.99; p < 0.05), No formal education (AOR = 3.67, 95% CI 1.48–9.09; p < 0.01), primary education (AOR = 2.23, 95% CI 1.05–2.32; p < 0.01), ART duration of > 12 months to 5 years (AOR = 3.20, 95% CI 1.31–7.82; p < 0.05), ART duration > 5 years (AOR = 3.47, 95% CI 1.39– 8.66; p < 0.01), WHO Clinical Stage II (AOR = 0.48, 95% CI: 0.28, 0.82; p < 0.01), second-line ART regimen (AOR = 2.38, 95% CI 1.53–3.72; p < 0.001) and comorbidities (AOR = 3.28, 95% CI 1.20–9.00; p < 0.05) were significantly associated with viral non-suppression. Conclusions VL non-suppression among adolescents was almost comparable to the national average. VL non-suppression was associated with being male, age 16–19 years, education level, duration on ART therapy, WHO Clinical Staging II, second-line ART regimen, and presence of comorbidities. Adolescent-friendly strategies to improve VL suppression e.g. peer involvement, VL focal persons to identify and actively follow-up non-suppressed adolescents, patient education on VL suppression and demand creation for ART are needed, especially for newly-initiated adolescents and adolescents on ART for protracted periods, to foster attainment of the UNAIDS 95–95–95 targets.

Feasibility of implementing formal long-distance mentorship for public health physicians: a case study of Association of Public Health Physicians of Nigeria

Background Conflicting schedules and geographic access limit prospects for mutually beneficial relationships between experts and early career professionals. A formal long-distance mentorship program could address these barriers and potentially bridge the gap of traditional face-to-face mentorship. This study was done to determine the feasibility of implementing a formal long-distance mentorship program amongst public health physicians of Nigeria. Method A mixed-method study comprising of in-depth interviews and surveys was used to collect information from members of the Association of Public Health Physicians in Nigeria. A total of 134 survey participants were recruited consecutively during an annual scientific meeting of the association. In-depth interviewees were purposively selected to ensure diversity in expertise, experience, and social stratifiers such as age. Quantitative data were analyzed using descriptive and inferential statistics, while qualitative data were analyzed using thematic content analysis. Results Public health physicians of Nigeria are willing to participate in a formal Long-Distance Mentorship Program, and four elements of feasibility were highlighted as necessary for implementing the program. Namely i) capacity to coordinate LDMP, ii) technical expertise and individual competence to provide mentorship, iii) financial capacity to implement and sustain LDMP, and iv) demand for mentorship by mentees. There is a consensus that the organizational structure of the National Postgraduate Medical College of Nigeria and West African College of Physicians provide an enabling environment to initiate a LDMP for public health physicians of Nigeria. The vast human resources with various expertise and the annual National conferences can be leveraged upon to champion and administer the program. However, there is a need for an administrative structure and technical expertise to enable proper coordination. More so, the need for demand creation and the financial requirement was considered gaps that need to be filled to be able to ensure feasibility. Bivariate analysis showed a significant relationship between the dependent variable (preferred role- mentor/mentee) and independent variables (age, year of graduation, and the number of years of practice), while the binary logistic regression model showed that physicians are more likely to participate as mentors with each unit increase in the number of years of practice. This further buttressed the need to commence the mentoring process as soon as trainees gain entrance into the program, as mentorship does not just prepare them for excellent public health practice, but also builds their capacity to mentor the younger and upcoming public health physicians. Conclusion There are enabling structures to incorporate a formal long-distance mentorship program for public health physicians in Nigeria, and physicians are willing to participate in such a program. However, the feasibility of establishing a successful and sustainable program will require robust coordination, technical expertise, demand creation, and financial commitment at both institutional and college levels.

Voluntary Male Circumcision for HIV Prevention in Rural Non-Circumcising Provinces of Northern, Muchinga and Luapula, 2018–2020. A Cross Sectional Survey

IntroductionWe describe the VMMC uptake across in Rural Non-circumcising provinces of Luapula, Northern and Muchinga 2018 to 2020. Method This was cross sectional analysis of routine programme data targeting males 10 years older (from October 2018 to April 2020), 15 years (from May 2020) and above VMMC was undertaken using both static and outreach activities. A multi-pronged strategy was adopted that included procurement of VMMC kits to supplement the government’s shortfall, training of VMMC providers (doctors, clinical officers and nurses) dedicated space for circumcision in each facility, logistics support ( fuel and allowances) for outreach programs, mapping of catchment areas for community mobilization and demand creation. All circumcisions performed were recorded in MOH VMMC registers. Data collected was verified by Provincial Health Office. Daily Situation Room (DSR) reports were used to monitor performance. Poor performing districts were followed up and challenges addressed to improve performance. ResultsA total of 2,130 focused outreach activities were carried out between 2018 and 2020 across the three provinces and 486,750 participants were reached. Of the 486,750 participants reached, 151, 428 were circumcised; 56136 (37%) from Northern, 49297 (33%) from Muchinga, and 45995 (30%) from Luapula. There was a three-fold increase in circumcision between 2018 and 2019 (14,746 circumcisions in 2018 vs 54,287 circumcisions in 2019) and a 14% increase from 2019 (38%) to 2020 (52%; 58,287 circumcisions). Most (76%) of the circumcision were done in the age group 15 to 29 years. HIV testing was undertaken among 6,319 participants giving a positivity rate of 2.4% (149). Improved results were associated with logistical support such as transport, VMMC commodity supplies, and increased dedicated VMMC providers. ConclusionHealth systems support including training, logistical support, dedicated space and supply of commodities assisted in increase of VMMC uptake in these rural non-traditional circumcision provinces. even amidst the outbreak of COVID19. Health systems strengthening and community outreach programmes are recommended for building health programs resilience in era of the COVID pandemic.

Girl Champ in eSwatini: A Strategic Marketing Campaign to Promote Demand for Sexual and Reproductive Health Services Among Young Women

Efforts to engage adolescent girls and young women (AGYW) in HIV services have struggled, in part, due to limited awareness of services and stigma. Strategic marketing is a promising approach, but the impact on youth behavior change is unclear. We report findings from a mixed methods evaluation of the Girl Champ campaign, designed to generate demand for sexual and reproductive services among AGYW, and piloted in three clinics in the Manzini region of eSwatini. We analyzed and integrated data from longitudinal, clinic-level databases on health service utilization among AGYW before and after the pilot, qualitative interviews with stakeholders responsible for the implementation of the pilot, and participant feedback surveys from attendees of Girl Champ events. Girl Champ was well received by most stakeholders based on event attendance and participant feedback, and associated with longitudinal improvements in demand for HIV services. Findings can inform future HIV demand creation interventions for youth.

Barriers to the uptake of community-based curative child health services in Ethiopia

Background Uptake of services to treat newborns and children has been persistently low in Ethiopia, despite being provided free-of-charge by Health Extension Workers (HEWs). In order to increase the uptake of these services, the Optimizing the Health Extension Project was designed to be implemented in four regions in Ethiopia. This study was carried out to identify barriers to the uptake of these services and potential solutions to inform the project. Methods Qualitative data were collected in October and November 2015 in 15 purposely selected districts in four regions. We conducted 90 focus group discussions and 60 in-depth interviews reaching a total of 664 participants. Thematic analysis was used to identify key barriers and potential solutions. Results Five demand-side barriers to utilization of health services were identified. Misconceptions about illness causation, compounded with preference for traditional healers has affected service uptake. Limited awareness of the availability of free curative services for children at health posts; along with the prevailing perception that HEWs were providing preventive services only had constrained uptake. Geographic challenge that made access to the health post difficult was the other barrier. Four supply-side barriers were identified. Health post closure and drug stock-out led to inconsistent availability of services. Limited confidence and skill among HEWs and under-resourced physical facilities affected the service delivery. Study participants suggested demand creation solutions such as increasing community awareness on curative service availability and educating them on childhood illness causation. Maintaining consistent supplies and ensuring service availability; along with regular support to build HEWs’ confidence were the suggested supply-side solutions. Creating community feedback mechanisms was suggested as a way of addressing community concerns on the health services. Conclusion This study explored nine demand- and supply-side barriers that decreased the uptake of community-based services. It indicated the importance of increasing awareness of new services and addressing prevailing barriers that deprioritize health services. At the same time, supply-side barriers would have to be tackled by strengthening the health system to uphold newly introduced services and harness sustainable impact.

Institutionalizing Quality Declared Seed in Uganda

Farmer-led seed enterprises can produce good quality seed and market it. However, for them to thrive, they need a conducive policy and regulatory framework that is inclusive and less stringent than existing regulatory frameworks. One way to provide a more enabling environment for farmer-led enterprises is through the Quality Declared Seed (QDS) production and marketing system. In Uganda, this seed class is specifically introduced for farmer-led enterprises to produce and market quality assured seed of crops and varieties not served by the private sector. The class is anchored in the Ugandan National Seed Policy and its seed regulations and its operationalization plan. We identified a combination of three strategies that enabled the QDS class to be incorporated into the National Seed Policy. These were: (i) to generate evidence to demonstrate that local seed businesses (farmer groups) can produce and market quality seed; (ii) to engage stakeholders towards an inclusive seed policy; and (iii) to develop a separate QDS regulatory framework. By 2021, institutionalization has reached a critical mass. Areas of attention for full institutionalization are the decentralization of inspection services, awareness and demand creation for quality seed, increasing the number of seed producers, and solving shortages of basic seed (starting material for producing seed).

Innovative demand creation strategies to increase voluntary medical male circumcision uptake: a pragmatic randomised controlled trial in Zimbabwe

IntroductionReaching men aged 20–35 years, the group at greatest risk of HIV, with voluntary medical male circumcision (VMMC) remains a challenge. We assessed the impact of two VMMC demand creation approaches targeting this age group in a randomised controlled trial (RCT).MethodsWe conducted a 2×2 factorial RCT comparing arms with and without two interventions: (1) standard demand creation augmented by human-centred design (HCD)-informed approach; (2) standard demand creation plus offer of HIV self-testing (HIVST). Interpersonal communication (IPC) agents were the unit of randomisation. We observed implementation of demand creation over 6 months (1 May to 31 October 2018), with number of men circumcised assessed over 7 months. The primary outcome was the number of men circumcised per IPC agent using the as-treated population of actual number of months each IPC agent worked. We conducted a mixed-methods process evaluation within the RCT.ResultsWe randomised 140 IPC agents, 35 in each arm. 132/140 (94.3%) attended study training and 105/132 (79.5%) reached at least one client during the trial period and were included in final analysis. There was no evidence that the HCD-informed intervention increased VMMC uptake versus no HCD-informed intervention (incident rate ratio (IRR) 0.87, 95% CI 0.38 to 2.02; p=0.75). Nor did offering men a HIVST kit at time of VMMC mobilisation (IRR 0.65, 95% CI 0.28 to 1.50; p=0.31). Among IPC agents that reported reaching at least one man with demand creation, both the HCD-informed intervention and HIVST were deemed useful. There were some challenges with trial implementation; <50% of IPC agents converted any men to VMMC, which undermined our ability to show an effect of demand creation and may reflect acceptability and feasibility of the interventions.ConclusionThis RCT did not show evidence of an effect of HCD-informed demand intervention or HIVST on VMMC uptake. Findings will inform future design and implementation of demand creation evaluations.Trial registration numberPACTR201804003064160.

Relative efficiency of demand creation strategies to increase voluntary medical male circumcision uptake: a study conducted as part of a randomised controlled trial in Zimbabwe

BackgroundSupply and demand-side factors continue to undermine voluntary medical male circumcision (VMMC) uptake. We assessed relative economic costs of four VMMC demand creation/service-delivery modalities as part of a randomised controlled trial in Zimbabwe.MethodsInterpersonal communication agents were trained and incentivised to generate VMMC demand across five districts using four demand creation modalities (standard demand creation (SDC), demand creation plus offer of HIV self-testing (HIVST), human-centred design (HCD)-informed approach, HCD-informed demand creation approach plus offer of HIVST). Annual provider financial expenditure analysis and activity-based-costing including time-and-motion analysis across 15 purposively selected sites accounted for financial expenditures and donated inputs from other programmes and funders. Sites represented three models of VMMC service-delivery: static (fixed) model offering VMMC continuously to walk-in clients at district hospitals and serving as a district hub for integrated mobile and outreach services, (2) integrated (mobile) modelwhere staff move from the district static (fixed) site with their commodities to supplement existing services or to recently capacitated health facilities, intermittently and (3) mobile/outreach model offering VMMC through mobile clinic services in more remote sites.ResultsTotal programme cost was $752 585 including VMMC service-delivery costs and average cost per client reached and cost per circumcision were $58 and $174, respectively. Highest costs per client reached were in the HCD arm—$68 and lowest costs in standard demand creation ($52) and HIVST ($55) arms, respectively. Highest cost per client circumcised was observed in the arm where HIVST and HCD were combined ($226) and the lowest in the HCD alone arm ($160). Across the three VMMC service-delivery models, unit cost was lowest in static (fixed) model ($54) and highest in integrated mobile model ($63). Overall, economies of scale were evident with unit costs lower in sites with higher numbers of clients reached and circumcised.ConclusionsThere was high variability in unit costs across arms and sites suggesting opportunities for cost reductions. Highest costs were observed in the HCD+HIVST arm when combined with an integrated service-delivery setting. Mobilisation programmes that intensively target higher conversion rates as exhibited in the SDC and HCD arms provide greater scope for efficiency by spreading costs.Trial registration numberPACTR201804003064160.