Despite good progress towards elimination, malaria continues to contribute substantially to the sub-Saharan African disease burden. Sustaining previous gains requires continued readiness to deliver malaria services in response to actual disease burden, which in turn contributes to health systems strengthening. This study investigates a health system innovation. We examined whether malaria prevalence, or endemicity, is a driver of health facility readiness to deliver malaria services. To estimate this association, we geo-linked cross-sectional facility survey data to endemicity data for Kenya, Namibia and Senegal. We tested the validity and reliability of the primary study outcome, the malaria service readiness index and mapped service readiness components in a geographic information system. We conducted a weighted multivariable linear regression analysis of the relationship between endemicity and malaria service readiness, stratified for urban or rural facility location. As endemicity increased in rural areas, there was a concurrent, modest increase in service readiness at the facility level [β: 0.028; (95% CI 0.008, 0.047)], whereas no relationship existed in urban settings. Private-for-profit facilities were generally less prepared than public [β: -0.102; (95% CI - 0.154, -0.050)]. Most facilities had the necessary supplies to diagnose malaria, yet availability of malaria guidelines and adequately trained staff as well as medicines and commodities varied. Findings require cautious interpretation outside the study sample, which was a more limited subset of the original surveys' sampling schemes. Our approach and findings may be used by national malaria programs to identify low performing facilities in malarious areas for targeted service delivery interventions. This study demonstrates use of existing data sources to evaluate health system performance and to identify within- and cross-country variations for targeted interventions.
Background Children and adolescents living with HIV (CALHIV) face unique challenges, including poorer treatment outcomes, risk for drug resistance mutations (HIVDRM), and limited drug formulations. We estimated viral suppression (VS) prevalence, and evaluated predictors of VS and HIVDRMs in Kenya. Methods From 2018-2020, CALHIV 1-19 years on ART for >6 months were enrolled in this cross-sectional study. Participants underwent viral load (VL) testing; those with VL ≥1000 copies/mL had HIVDRM testing. Sociodemographic questionnaires and medical record abstraction were completed. VS prevalence (VL <1000 copies/mL) was estimated and robust Poisson regression models were used to estimate prevalence ratios (PRs) and 95% confidence intervals (CIs) for associations between potential predictors of VS. Results 969 participants were enrolled. VS prevalence was 0.80 (95% CI:0.78-0.83). Being on ART >24 months (aPR 1.22, 95% CI:1.06-1.41), an Integrase Strand Transfer Inhibitor containing regimen (aPR 1.13, 95% CI:1.02-1.26), and attending a level three health facility (aPR 1.23, 95% CI:1.11-1.36) were associated with VS. Missing 3+ doses of ART in the past month (aPR 0.73, 95% CI:0.58-0.92), having a viremic mother living with HIV (aPR 0.72, 95% CI:0.53-0.98), and having 3-7 (aPR 0.90, 95% CI:0.83-0.97), 8-13 (aPR 0.89, 95% CI:0.82-0.97) or 14+ (aPR 0.84, 95% CI:0.77-0.92) as compared to ≤2 adherence counseling referrals were inversely associated with VS. A high proportion (n=119, 81.5%) of unsuppressed participants had evidence of any major HIVDRM. Conclusions HIV treatment programs should target interventions for pediatric patients at risk for treatment failure, namely those experiencing food insecurity and malnutrition and those struggling with adherence.
Abstract.Although immigrants who visit friends and relatives (VFRs) account for most of the travel-acquired malaria cases in the United States, there is limited evidence on community-level risk factors and best practices for prevention appropriate for various VFR groups. Using 2010–2014 malaria case reports, sociodemographic census data, and health services data, we explored and mapped community-level characteristics to understand who is at risk and where imported malaria infections occur in Minnesota. We examined associations with malaria incidence using Poisson and negative binomial regression. Overall, mean incidence was 0.4 cases per 1,000 sub-Saharan African (SSA)–born in communities reporting malaria, with cases concentrated in two areas of Minneapolis–St. Paul. We found moderate and positive associations between imported malaria and counts of SSA- and Asian-born populations, respectively. Our findings may inform future studies to understand the knowledge, attitudes, and practices of VFR travelers and facilitate and focus intervention strategies to reduce imported malaria in the United States.
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