'The tablets make a certain noise': uncovering barriers and enablers related to providing PMTCT services to adolescents and young women living with HIV in Zimbabwe.

BACKGROUND: Zimbabwe antenatal HIV prevalence rate is 16.1%. HIV-positive pregnant adolescent girls and young women (AYW) are at high risk to experience perinatal mental health challenges, attributed to a combination of factors including HIV status, stigma and perinatal depression. Perinatal depression and stigma among AYW is understudied in Zimbabwe and may affect short- and long-term health of HIV positive mothers and their children, and can impact treatment adherence. METHODS: Qualitative data was gathered from four focus group discussions with (2 urban and 2 rural) PMTCT providers (N = 17). Focus group discussions were also conducted among AYW clients (N = 20) from two clinics in Mashonaland East. RESULTS: Qualitative analyses identified patterns related to: (1) drop out and loss to follow up, (2) retention and adherence, (3) recurring feelings of internalized stigma; and (4) acceptability of potential MH interventions. MH services are not available and AYW have limited access to adherence counseling (1-2 times at onset). Psychological support was not available at either clinic, despite both providers and clients perceiving high rates of stigma, discrimination, and challenges with disclosure. Challenges related to long waits for ART distribution and gaps in disclosure support emerged as barriers. Providers noted that AYW present as anxious (non-diagnosed), and attribute depression to those clients who are lost to follow up, stating lack of time to screen for MH related issues or actively refer them for services. Challenges related to the ability to provide strong advice and support for disclosure also emerged among providers. CONCLUSIONS: This study can contribute to policy and practice recommendations to better integrate MH into HIV services and develop person-centered service models for HIV positive AYW. HIGHLIGHTSPerinatal adolescents and young women (AYW) living with HIV have gaps in retention and care in the current Zimbabwe PMTCT service model.Mental health stigma must be addressed to integrate mental health into HIV services.HIV providers are aware of the need to provide mental health support to reduce loss to follow-up.Mental health screening and referrals for services are not part of standard care for perinatal HIV positive AYW in Zimbabwe.Linkages between disclosure and AYW mental health was identified as a challenge by HIV providers.Context responsive interventions can support integration of mental health screening, services, and referrals.

Staff perspectives on the feasibility of the person-centered care assessment tool (PCC-at) in HIV treatment settings in Ghana: a mixed-methods study.

Person-centered care (PCC) aims to improve client's experiences in HIV care while advancing outcomes. This study team developed the PCC assessment tool (PCC-AT) to assess PCC service performance in HIV treatment settings in Ghana. Study objectives aimed to describe the range of PCC-AT scores within and across study facilities and examine the feasibility of PCC-AT implementation in diverse HIV treatment settings. The PCC-AT was piloted at five health facilities providing HIV services among 37 staff. Immediately following each pilot, focus group discussions (FGDs) were conducted to gather feasibility data. Thematic qualitative analysis was conducted on translated FGD transcripts. Across facilities, providers scored highest in the staffing domain, followed by service provision, and direct client support. Time required to implement the PCC-AT averaged 62 minutes. Providers described the tool as well-structured, user-friendly, relevant, reflective of the core PCC delivery elements, and useful in elucidating actions to improve PCC service delivery across domains. The PCC-AT holds potential to strengthen activities that support clients' broader clinical, mental and psychosocial wellbeing by offering friendly services that attend to each client's holistic needs while contributing progress towards epidemic control.

'The person cutting the path does not know his trail is crooked'. Drawing lessons learned from people accessing antiretroviral treatment services to propose a person-centered care (PCC) minimum practice standard.

Introduction: Person-centered care (PCC) in HIV services aims to improve client experiences, advance service accessibility and treatment outcomes and accelerate progress towards epidemic control. For PCC to be responsive, providers and clients must work together to identify clients' priorities. However, providers often neglect to identify non-clinical client concerns and clients may feel inhibited due to language or unequal power dynamics.Methods: While evaluating results from a mixed-methods study on implementation of a Person-Centered Care Assessment Tool (PCC-AT) in Ghana, our study team identified contrasting perspectives from people on antiretroviral treatment (ART) and providers that elucidated the need for a PCC minimum practice standard. Our team examined qualitative data to propose a five step PCC minimum practice standard.Discussion: Because PCC is a broad concept, with scarce practical implementable information to support a framework for its operationalization, its consistent and accurate implementation is unlikely without the presence and utilization of a Minimum Practice Standard. Future research should identify aims and further elucidate quality standards within each component of the minimum PCC practice standard.

Adolescent perspectives on peripartum mental health prevention and promotion from Kenya: Findings from a design thinking approach.

In Kenya, approximately one in five girls aged 15-19 years old are pregnant or already a mother. Adolescent girls and young women experience significant mental health vulnerabilities during the pregnancy and postpartum periods, leading to poor antenatal and postnatal care attendance and inferior infant and maternal health outcomes. Pregnant adolescents often experience stigma and disenfranchisement due to their pregnancy status and at the same time lack access to mental health support within health settings, schools, religious institutions, and communities. This paper presents the results of qualitative interviews embedded within the human-centered design (HCD) process used to adapt the Helping Adolescents Thrive (HAT) program for Kenyan peripartum adolescents including young fathers. This qualitative study used two phases. First, a HAT advisory group participated in a series of four workshops to help identify and articulate mental health promotion needs and deepened the team's understanding of youth-centered thinking. Second, qualitative interviews were conducted with 39 pregnant and parenting adolescents to understand their perspectives on mental health prevention and promotion. Pregnant and parenting adolescents articulated different needs including poor support, stigma, and psychological disturbances. Parenting adolescents reported disturbed relationships, managing motherhood, poor health, and social empowerment. Participants highlighted sources of stress including economic challenges, fear of delivery, strained relationships, rejection, and stigma. Participants described psychological disturbances such as feeling stressed, worthless, withdrawn, and suicidal. Coping mechanisms reported by participants included engaging in domestic activities, hobbies, and social networking. Peers, family and spirituality were identified as important sources of support, as well as school integration, livelihoods, support groups and mentorships. Findings from this study can be used to strengthen and adapt HAT program, policy and practice for mental health prevention and promotion for pregnant and parenting adolescents.

Assessing the person-centered care framework and assessment tool (PCC-AT) in HIV treatment settings in Ghana: A pilot study protocol.

INTRODUCTION: Evidence suggests that person-centered care (PCC) has the potential to overcome inequities in access to HIV services, support quality care that is responsive to diverse needs while increasing efficiencies and resilience of the health system. Despite emerging evidence on the effectiveness of PCC, there is limited information available on how to assess it in diverse clinical settings. This work builds upon a systematic literature review published elsewhere by this study team to develop a PCC framework for HIV treatment service delivery. OBJECTIVES: The PCC framework informed the development of the PCC assessment tool (PCC-AT) to assess the degree to which PCC activities are operationalized in diverse HIV treatment settings. The study objectives are to assess: (1) content validity of the PCC framework; (2) PCC-AT score consistency and reliability between health facility staff and clients; and (3) PCC-AT feasibility in HIV treatment settings. METHODS: The study team will pilot the PCC-AT among staff in five health facilities and conduct subsequent focus group discussions (FGDs) to determine PCC-AT feasibility. Key informant interviews (KIIs) with clients will explore content validity among PLHIV relative to each subdomain of the PCC-AT and provide a basis to compare score concordance. Quantitative data among health facility staff will examine how many and which cadres participated in the PCC-AT pilot and FGD, years of experience, gender, and the time required to complete the PCC-AT. Information on clients will include total time accessing treatment at the study health facility, years since diagnosis, age and gender. Qualitative data analysis, using descriptive coding with NVivo or a similar software, will be drawn from transcripts from the PCC-AT pilots, FGDs and KIIs. DISCUSSION: PCC assessment is a novel approach that aims to help health facilities assess and strengthen their ability to deliver PCC services to improve client outcomes.

Diverse policy maker perspectives on the mental health of pregnant and parenting adolescent girls in Kenya: Considerations for comprehensive, adolescent-centered policies and programs.

The pregnancy rate in Kenya among adolescent girls is among the highest in the world. Adolescent girls experience increased risk of anxiety and depression during pregnancy and postpartum which can result in poor health outcomes for both mother and baby, and negatively influence their life course. Mental health is often given low priority in health policy planning, particularly in Sub-Saharan Africa (SSA). There is an urgent need to address the treatment gap and provide timely mental health promotion and preventative services, there is a need to focus on the shifting demographic of SSA-the young people. To understand perspectives on policymakers on the mental health prevention and promotion needs of pregnant and parenting adolescent girls, we carried out a series of interviews as part of UNICEF funded helping pregnant and parenting adolescents thrive project in Kenya. We interviewed 13 diverse health and social policy makers in Kenya to understand their perspectives on the mental health experiences of pregnant and parenting adolescent girls and their ideas for optimizing mental health promotion. Six principal themes emerged including the mental health situation for adolescent girls, risk factors for poor mental health and barriers to accessing services for adolescent girls, health seeking behavior effect on maternal and child health outcomes, mental health promotion, protective factors for good mental health, and policy level issues. Examination of existing policies is required to determine how they can fully and effectively be implemented to support the mental health of pregnant and parenting adolescent girls.

Systematic review: Development of a person-centered care framework within the context of HIV treatment settings in sub-Saharan Africa.

OBJECTIVES: Person-centred care (PCC) meets the needs of individuals by increasing convenience, providing supportive and culturally appropriate services to diverse populations, and engaging families, communities, and stakeholders in planning and provision of care. While the evidence demonstrates that PCC approaches can lead to clinical improvements across the HIV care continuum, it is not yet well defined in the context of HIV service delivery. METHODS: A systematic review was conducted to define PCC practices for HIV treatment services in health facilities in sub-Saharan Africa. Data synthesis led to the development of a PCC framework including domain and sub-domain development. The study team used the Effective Public Health Project Practice tool for quantitative studies to assess the quality of the included studies. RESULTS: Thirty-one studies from 12 countries met the inclusion criteria, including 56,586 study participants (females 42%-100% and males 0%-58%), resulting in three major domains and 11 sub-domains. These include staffing (sub-domains of composition, availability, and competency); service delivery standards (sub-domains of client feedback mechanisms; service efficiency and integration; convenience and access; and digital health worker support tools); and direct client support services (sub-domains of psychosocial services, logistics support, client-agency, and digital client support tools). Twenty-five of the person-centred interventions within these domains resulted in improvements in linkage to care, treatment retention, and/or viral suppression. CONCLUSIONS: The PCC framework can help to provide a more consistent classification of HIV treatment interventions and will support improved assessment of these interventions to ensure that people receive personalised care.

Coordinating Systems of Care for HIV and Opioid Use Disorder: A Systematic Review of Enablers and Barriers to Integrated Service Access, and Systems and Tools Required for Implementation.

Individuals who have HIV who also use drugs experience increased age-matched morbidity and mortality in comparison with those with HIV who do not use drugs. A systematic review was conducted to describe models of integrated HIV and opioid use disorder (OUD) services, enablers of and barriers to integrated service access, and the coordinated systems and tools at the state and service delivery levels required for implementation. Database searches yielded 235 candidate articles, of which 22 studies met the inclusion criteria. Analysis found that integrated programs operated with minimal coordinated policy and systems guidance at the state level. Service delivery systems and tools used for integration, including use of integrated protocols, risk assessment tools, case management tools, and referral systems, were similar across integration models. Concerted efforts to coordinate state-level systems and develop supportive policies, guidelines, and standardized tools may facilitate integration at the service delivery level.

Health and social outcomes of HIV-vulnerable and HIV-positive pregnant and post-partum adolescents and infants enrolled in a home visiting team programme in Kenya.

OBJECTIVES: HIV-positive and HIV-vulnerable pregnant adolescent girls and adolescent mothers face significant barriers and vulnerabilities. Infants born to adolescent mothers are also more likely to die and be exposed to life-threatening conditions. This paper presents findings from an evaluation of a programme that used a home visitation model and offered a case-management, team-focused approach to increase family and community supportiveness to enhance health and social service uptake among pregnant adolescent girls and adolescent mothers in Kenya. METHODS: The study used a quasi-experimental design with before and after comparisons among a non-randomised population to examine the effectiveness of bi-monthly household visits to 384 enrolled pregnant adolescent girls, adolescent mothers (ages 10-19) and their infants (0-24 months) between March 2018 and February 2019 in three counties in Kenya. RESULTS: During the programme, household support increased from 57% to 85%, while 100% of eligible participants were on ART and virally suppressed (total of 20 adolescents). Nearly all pregnant adolescent girls (94%) delivered under skilled care vs. 78% of those who were post-partum at the time of enrolment (P < 0.001); 100% of infants (total of 17 infants) had an up-to-date PCR test with no seroconversions. Uptake of modern family planning increased from 39% at baseline to 64% at end line (P < 0.001). The referral rate declined from 84% to 78% from baseline to end line with low uptake of referrals for mental health services (17.3%). CONCLUSIONS: A team-focused approach of home visits to HIV-vulnerable and HIV-positive pregnant and post-partum adolescent girls and their infants combined with efforts to reduce stigma and increase supportiveness of households and the community can help address critical socio-cultural and behavioural barriers to accessing and using health and social services.

Willingness to use HIV self-test kits and willingness to pay among urban antenatal clients in Cote d'Ivoire and Tanzania: a cross-sectional study.

OBJECTIVES: To generate evidence on willingness to use HIV self-test kits and willingness to pay among antenatal care clients in public and private facilities in Cote d'Ivoire and Tanzania. METHODS: Cross-sectional survey data were collected from 414 clients recruited from 35 high-volume facilities in Cote d'Ivoire and from 385 clients in 33 high-volume facilities in Tanzania. Surveys covered willingness to use HIV self-test kits, prices clients were willing to pay, advantages and disadvantages and views on specific qualities of HIV self-tests. Market data on availability of proxy self-testing products (e.g. pregnancy and malaria tests) and attitudes of pharmacists towards HIV self-test kits were collected from 51 pharmacies in Cote d'Ivoire and 59 in Tanzania. RESULTS: Willingness to use HIV self-test kits was 65% in Cote d'Ivoire and 69% in Tanzania. Median ideal prices women would pay ranged from USD 1.77 in Cote d'Ivoire to USD 0.87 in Tanzania. Proxy self-test kits were available in pharmacies, and interest was high in stocking HIV self-test kits. CONCLUSIONS: Implications for national HIV self-test policy and planning include keeping prices low, providing psychological and HIV counselling, and ensuring linkage to HIV care and treatment services. Private pharmacies will play a key role in providing access to HIV self-test kits.

OBJECTIFS: Générer des données sur la volonté d'utiliser des kits d'auto-dépistage du VIH et la volonté de payer chez les clients des soins prénatals dans les établissements publics et privés en Côte d'Ivoire et en Tanzanie. MÉTHODES: Les données de l'enquête transversale ont été recueillies auprès de 414 patientes enrôlées dans 35 établissements de santé à volume élevé en Côte d'Ivoire et de 385 patientes dans 33 établissements de santé à volume élevé en Tanzanie. Les enquêtes ont porté sur la volonté d'utiliser des kits d'auto-dépistage du VIH, les prix que les clients étaient prêts à payer, les avantages et les inconvénients et les opinions sur les qualités spécifiques des auto-tests du VIH. Les données du marché sur la disponibilité des proxyse des produits d'auto-test (par exemple, les tests de grossesse et du paludisme) et les attitudes des pharmaciens envers les kits d'auto-test du VIH ont été collectées dans 51 pharmacies en Côte d'Ivoire et 59 en Tanzanie. RÉSULTATS: La volonté d'utiliser des kits d'auto-test VIH était de 65% en Côte d'Ivoire et de 69% en Tanzanie. Le prix médian idéal que les femmes paieraient allait de 1,77 USD en Côte d'Ivoire à 0,87 USD en Tanzanie. Des proxys de kits d'auto-test étaient disponibles dans les pharmacies et l'intérêt pour le stockage des kits d'auto-test du VIH était élevé. CONCLUSIONS: Les implications pour la politique et la planification nationales d'auto-test du VIH incluent le maintien de prix bas, la fourniture de conseils psychologiques et sur le VIH, et la garantie d'un lien avec les services de soins et de traitement du VIH. Les pharmacies privées joueront un rôle clé en donnant accès aux kits d'autotest du VIH.

Differentiated Antiretroviral Therapy Distribution Models: Enablers and Barriers to Universal HIV Treatment in South Africa, Uganda, and Zimbabwe.

Emerging HIV treatment distribution models across sub-Saharan Africa seek to overcome barriers to attaining antiretroviral therapy and to strengthen adherence in people living with HIV. We describe enablers, barriers, and benefits of differentiated treatment distribution models in South Africa, Uganda, and Zimbabwe. Data collection included semistructured interviews and focus group discussions with 163 stakeholders from policy, program, and patient levels. Four types of facility-based and 3 types of community-based models were identified. Enablers included policy, leadership, and guidance; functional information systems; strong care linkages; steady drug supply; patient education; and peer support. Barriers included insufficient drug supply, stigma, discrimination, and poor care linkages. Benefits included perceived improved adherence, peer support, reduced stigma and discrimination, increased time for providers to spend with complex patients, and travel and cost savings for patients. Differentiated treatment distribution models can enhance treatment access for patients who are clinically stable.

Differentiated Antiretroviral Therapy Delivery: Implementation Barriers and Enablers in South Africa.

Scale-up of antiretroviral therapy (ART) for people living with HIV requires differentiated models of ART delivery to improve access and contribute to achieving viral suppression for 95% of people on ART. We examined barriers and enablers in South Africa via semistructured interviews with 33 respondents (program implementers, nurses, and other health care providers) from 11 organizations. The interviews were recorded, transcribed, and analyzed for emerging themes using NVivo 11 software. Major enablers of ART delivery included model flexibility, provision of standardized guidance, and an increased focus on person-centered care. Major barriers were related to financial, human, and space resources and the need for time to allow buy-in. Stigma emerged as both a barrier and an enabler. Findings suggest that creating and strengthening models that cater to client needs can achieve better health outcomes. South Africa's efforts can inform emerging models in other settings to achieve epidemic control.

Non-communicable diseases and HIV care and treatment: models of integrated service delivery.

OBJECTIVES: Non-communicable diseases (NCD) are a growing cause of morbidity in low-income countries including in people living with human immunodeficiency virus (HIV). Integration of NCD and HIV services can build upon experience with chronic care models from HIV programmes. We describe models of NCD and HIV integration, challenges and lessons learned. METHODS: A literature review of published articles on integrated NCD and HIV programs in low-income countries and key informant interviews were conducted with leaders of identified integrated NCD and HIV programs. Information was synthesised to identify models of NCD and HIV service delivery integration. RESULTS: Three models of integration were identified as follows: NCD services integrated into centres originally providing HIV care; HIV care integrated into primary health care (PHC) already offering NCD services; and simultaneous introduction of integrated HIV and NCD services. Major challenges identified included NCD supply chain, human resources, referral systems, patient education, stigma, patient records and monitoring and evaluation. The range of HIV and NCD services varied widely within and across models. CONCLUSIONS: Regardless of model of integration, leveraging experience from HIV care models and adapting existing systems and tools is a feasible method to provide efficient care and treatment for the growing numbers of patients with NCDs. Operational research should be conducted to further study how successful models of HIV and NCD integration can be expanded in scope and scaled-up by managers and policymakers seeking to address all the chronic care needs of their patients.

Integrating Mental Health and HIV Services in Zimbabwean Communities: A Nurse and Community-led Approach to Reach the Most Vulnerable.

Alcohol use and depression negatively impact adherence, retention in care, and HIV progression, and people living with HIV (PLWH) have disproportionately higher depression rates. In developing countries, more than 76% of people with mental health issues receive no treatment. We hypothesized that stepped-care mental health/HIV integration provided by multiple service professionals in Zimbabwe would be acceptable and feasible. A three-phase mixed-method design was used with a longitudinal cohort of 325 nurses, community health workers, and traditional medicine practitioners in nine communities. During Phase 3, 312 PLWH were screened by nurses for mental health symptoms; 28% were positive. Of 59 PLWH screened for harmful alcohol and substance use, 36% were positive. Community health workers and traditional medicine practitioners screened 123 PLWH; 54% were positive for mental health symptoms and 29% were positive for alcohol and substance abuse. Findings indicated that stepped-care was acceptable and feasible for all provider types.

Quality improvement practices to institutionalize supply chain best practices for iCCM: Evidence from Rwanda and Malawi.

BACKGROUND: Supply chain bottlenecks that prevent community health workers (CHWs) from accessing essential medicines significantly increase under-5 child mortality, particularly in poor and rural areas. OBJECTIVE: Using implementation research, interventions aimed at improving supply chain practices and access to medicines were tested in Malawi and Rwanda. These interventions included simple demand-based resupply procedures, using mobile technology and traditional methods for communication, and multilevel, performance-driven quality improvement (QI) teams. METHODS: Mixed-method evaluations were conducted at baseline (2010), midline (2013), and endline (2014). Baseline assessments identified common bottlenecks and established performance levels. Midline assessments identified which intervention package had the greatest impact. Endline surveys measured the progress of scale-up and institutionalization of each innovation. RESULTS: In both Rwanda and Malawi CHWs, health center staff, and district managers all cited many benefits of the establishment of resupply procedures and QI teams: such as providing structure and processes, a means to analyze and discuss problems and enhance collaboration between staff. CONCLUSIONS: Implementing simple, streamlined, demand-based resupply procedures formed the basis for informed and regular resupply, and increased the visibility of appropriate and timely community logistics data. QI teams played a critical role in reinforcing resupply procedures and routinely unlocking the bottlenecks that prevent the continuous flow of critical health products. While simple, streamlined, demand-based resupply procedures provide the basis for regular, functional, and efficient resupply of CHWs, the procedures alone are not sufficient to create consistent change in product availability. Supporting these procedures with multilevel QI teams reinforces the correct and consistent use of resupply procedures.