IntroductionAs access to antiretroviral therapy (ART) increases, the success of treatment programmes depends on ensuring high patient retention in HIV care. We examined retention and attrition among adolescents in ART programmes across clinics operated by The AIDS Support Organization (TASO) in Uganda, which has operated both facility- and community-based distribution models of ART delivery since 2004.MethodsUsing a retrospective cohort analysis of patient-level clinical data, we examined attrition and retention in HIV care and factors associated with attrition among HIV-positive adolescents aged 10–19 years who initiated ART at 10 TASO clinics between January 2006 and December 2011. Retention in care was defined as the proportion of adolescents who had had at least one facility visit within the six months prior to 1 June 2013, and attrition was defined as the proportion of adolescents who died, were lost to follow-up, or stopped treatment. Descriptive statistics and Cox proportional hazards regression models were used to determine the levels of retention in HIV care and the factors associated with attrition following ART initiation.ResultsA total of 1228 adolescents began ART between 2006 and 2011, of whom 57% were female. The median duration in HIV care was four years (IQR=3–6 years). A total of 792 (65%) adolescents were retained in care over the five-year period; 36 (3%) had died or transferred out and 400 (32%) were classified as loss to follow-up. Factors associated with attrition included being older (adjusted hazard ratio (AHR)=1.38, 95% confidence interval (CI) 1.02–1.86), having a higher CD4 count (250+ cells/mm3) at treatment initiation (AHR=0.49, 95% CI 0.34–0.69) and HIV care site with a higher risk of attrition among adolescents in Gulu (AHR=2.26; 95% CI 1.27–4.02) and Masindi (AHR=3.30, 95% CI 1.87–5.84) and a lower risk of attrition in Jinja (AHR=0.24, 95% CI 0.08–0.70). Having an advanced WHO clinical stage at initiation was not associated with attrition.ConclusionsWe found an overall retention rate of 65%, which is comparable to rates achieved by TASO's adult patients and adolescents in other studies in Africa. Variations in the risk of attrition by TASO treatment site and by clinical and demographic characteristics suggest the need for early diagnosis of HIV infection, use of innovative approaches to reach and retain adolescents living with HIV in treatment and identifying specific groups, such as older adolescents, that are at high risk of dropping out of treatment for targeted care and support.

Despite recent progress, Sierra Leone’s lifetime risk of maternal death remains high (1 in 21), as does neonatal mortality (35 per 1000 live births). We present findings on maternal and neonatal care practices from a mixed methods study conducted in four districts during July–August 2012. We conducted a household cluster survey with data on maternal and newborn care practices collected from women ages 15–49 years who had ever given birth. We also conducted focus group discussions and in-depth interviews in two communities in each of the four districts. Participants included pregnant women, mothers of young children, older caregivers, fathers, community health volunteers, traditional birth attendants (TBAs) and health workers. We explored personal experiences and understandings of pregnancy, childbirth, the newborn period and social norms. Data analysis was conducted using STATA (quantitative) and thematic analysis using Dedoose software (qualitative). Antenatal care was high (84.2%, 95% CI: 82.0–86.3%), but not timely due to distance, transport, and social norms to delay care-seeking until a pregnancy is visible, particularly in the poorer districts of Kambia and Pujehun. Skilled delivery rates were lower (68.9%, 95% CI: 64.8–72.9%), particularly in Kambia and Tonkolili where TBAs are considered effective. Clean cord care, delaying first baths and immediate breastfeeding were inadequate across all districts. Timely postnatal checks were common among women with facility deliveries (94.1%, 95% CI: 91.9–96.6%) and their newborns (94.5%, 95% CI: 92.5–96.5%). Fewer women with home births received postnatal checks (53.6%, 95% CI: 46.2–61.3%) as did their newborns (75.8%, 95% CI: 68.9–82.8%). TBAs and practitioners are well-respected providers, and traditional beliefs impact many behaviours. Challenges remain with respect to maternal and neonatal health in Sierra Leone; these were likely exacerbated by service interruptions during the 2014–2016 Ebola Virus Disease epidemic. The reasons behind existing practices must be examined to identify appropriate strategies to improve maternal and newborn survival.

Abstractobjective To examine whether community health volunteers induced significant changes in care seeking and treatment of ill children under five 2 years after their deployment in two underserved districts of Sierra Leone.methods A pre-test-post-test study with intervention and comparison groups was used. A household cluster survey was conducted among caregivers of 5643 children at baseline and of 5259 children at endline.results In the intervention districts, treatments provided by community health volunteers increased from 0 to 14.3% for all three conditions combined (P < 0.001). Care seeking from an appropriate provider was not statistically significant (OR = 1.50, 95% CI: 0.88-2.54) between intervention and comparison districts and coverage of appropriate treatment increased in both study groups for all three illnesses. However, the presence of community health volunteers was associated with a 105% increase in appropriate treatment for pneumonia (OR = 2.05, 95% CI: 1.22-3.42) and a 55% drop in traditional treatment for diarrhoea (OR = 0.45, 95% CI: 0.21-0.96). Community health volunteers were also associated with fewer facility treatments for malaria (OR = 0.21, 95% CI: 0.07-0.62).conclusion After implementing free care, coverage for treatment for all three illnesses in both study groups improved. Deployment of community health volunteers was associated with a reduced treatment burden at facilities and less reliance on traditional treatments.keywords community health workers/volunteers, community case management, health care seeking

Capacity building in implementation science is integral to PEPFAR’s mission and to meeting the 90–90–90 goals. The USAID funded Project SOAR sponsored a 4 day workshop for investigators and governmental and non-governmental partners from 12 African countries. The workshop was designed to address both findings from a pre-workshop online needs assessment as well as capacity challenges across the capacity building pyramid, from individual skills to institutional systems and resources. Activities were output-oriented and skill based. An online survey evaluated sessions and changes in perceptions of needs; a majority of respondents strongly agreed that after the workshop, they better understood their personal and institutional capacity strengthening needs. Participants ‘strongly agreed’ that workshop content was relevant to their jobs (90%) and that they left the workshop with a specific plan for conducting future research (65%). Workshop results suggest that skill-building should be done in conjunction with systems capacity building within the cultural context.

During a pilot project in Tanzania’s Iringa region, more than 2,000 male infants were circumcised in less than 2 years in 8 facilities, representing 16.4% of all male births in those facilities. The age of the infant at circumcision and the time of return for follow-up visits varied significantly between urban and rural dwellers. Early infant male circumcision (EIMC) outreach activities and use of health outposts for follow-up visits should be explored to overcome these geographic barriers. EIMC programs will also require targeted investments in demand creation, especially among fathers, to expand and thrive in traditionally non-circumcising settings such as Iringa.

In 2010, at the same time as the national roll out of the Free Health Care Initiative (FHCI), which removed user fees for facility based health care, trained community health volunteers (CHVs) were deployed to provide integrated community case management of diarrhea, malaria and pneumonia to children under 5 years of age (U5) in Kambia and Pujehun districts, Sierra Leone. After 2 years of implementation and in the context of FHCI, CHV utilization rate was 14.0 %. In this study, we examine the factors associated with this level of CHV utilization. A cross-sectional household-cluster survey of 1590 caregivers of 2279 children U5 was conducted in 2012; with CHV utilization assessed using a multiple logistic regression model. Focus groups and in-depth interviews were also conducted to understand communities' experiences with CHVs. Children with diarrhea (OR = 3.17, 95 % CI: 1.17-8.60), from female-headed households (OR = 4.55, 95 % CI: 1.88-11.00), and whose caregivers reported poor quality of care as a barrier to facility care-seeking (OR = 8.53, 95 % CI: 3.13-23.16) were more likely to receive treatment from a CHV. Despite low utilization, caregivers were highly familiar and appreciative of CHVs, but were concerned about the lack of financial remuneration for CHVs. CHVs remained an important source of care for children from female-headed households and whose caregivers reported poor quality of care at health facilities. CHVs are an important strategy for certain populations even when facility utilization is high or when facility services are compromised, as has happened with the recent Ebola epidemic in Sierra Leone.

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Background: Stakeholders question whether implementation science (IS) is successful in conducting rigorous science that expedites the inclusion of health innovations into policies and accelerates the pace and scale of health service delivery into clinical and public health practice. Using the Payback Framework (PF) for research utilization (RU), we assessed the impact of USAID's IS investment on a subset of studies examining HIV prevention, care, and treatment. Setting: Selected USAID-funded IS awards implemented between 2012 and 2017 in 9 sub-Saharan African countries. Methods: A modified version of a RU framework, the PF, was applied to 10 USAID-funded IS awards. A semistructured, self-administered/interviewer-administered questionnaire representing operational items for the 5 categories of the modified PF was used to describe the type and to quantify the level of payback achieved. The raw score was tallied within and across the 5 PF categories, and the percentage of “payback” achieved by category was tabulated. Distribution of payback scores was summarized by tertiles. Results: Knowledge production had the highest level of payback (75%), followed by benefits to future research (70%), benefits to policy (45%), benefits to health and the health system (18%), and broader economic benefits (5%). Conclusions: All awards achieved some level of knowledge production and benefits to future research, but translation to policy and programs was low and variable. We propose the use of policy, health system, and economic monitoring indicators of RU throughout the research process to increase IS studies' impact on health practice, programs, and policy.