BackgroundDespite gains in HIV testing and treatment access in sub-Saharan Africa, patient attrition from care remains a problem. Evidence is needed of real-world implementation of low-cost, scalable, and sustainable solutions to reduce attrition. We hypothesized that more proactive patient follow-up and enhanced counseling by health facilities would improve patient linkage and retention.MethodsAt 20 health facilities in Central Uganda, we implemented a quality of care improvement intervention package that included training lay health workers in best practices for patient follow-up and counseling, including improved appointment recordkeeping, phone calls and home visits to lost patients, and enhanced adherence counseling strategies; and strengthening oversight of these processes. We compared patient linkage to and retention in HIV care in the 9 months before implementation of the intervention to the 9 months after implementation. Data were obtained from facility-based registers and files and analysed using multivariable logistic regression.ResultsAmong 1900 patients testing HIV-positive during the study period, there was not a statistically significant increase in linkage to care after implementing the intervention (52.9% versus 54.9%, p = 0.63). However, among 1356 patients initiating antiretroviral therapy during the follow-up period, there were statistically significant increases in patient adherence to appointment schedules (44.5% versus 55.2%, p = 0.01) after the intervention. There was a small increase in Ministry of Health-defined retention in care (71.7% versus 75.7%, p = 0.12); when data from the period of intervention ramp-up was dropped, this increase became statistically significant (71.7% versus 77.6%, p = 0.01). The increase in retention was more dramatic for patients under age 19 years (N = 84; 64.0% versus 83.9%, p = 0.01). The cost per additional patient retained in care was $47.ConclusionsImproving patient tracking and counseling practices was relatively low cost and enhanced patient retention in care, particularly for pediatric and adolescent patients. This approach should be considered for scale-up in Uganda and elsewhere. However, no impact was seen in improved patient linkage to care with this proactive follow-up intervention.Trial registrationPan African Clinical Trial Registry #PACTR201611001756166. Registered August 31, 2016.

Background Diarrhea is the second leading cause of infectious deaths in children under-five globally. Oral rehydration salts (ORS) and zinc could avert an estimated 93% of deaths, but progress to increase coverage of these interventions has been largely stagnant over the past several decades. The Clinton Health Access Initiative (CHAI), along with donors and country governments in India, Kenya, Nigeria, and Uganda, implemented programs to scale-up ORS and zinc coverage from 2012 to 2016. The programs sought to demonstrate that increases in pediatric diarrhea treatment rates are possible at scale in high-burden settings through a holistic approach addressing both supply and demand barriers. We describe the overall program model and the activities undertaken in each country. The overall goal of the paper is to share the program results and lessons learned to inform other countries aiming to scale-up ORS and zinc. Methods We used a triangulation approach, using population-based household surveys, public facility audits, and private outlet surveys, to evaluate the program model. We used pre- and post-program population-based household survey data to estimate the changes in coverage of ORS and zinc for treatment of diarrhea cases in children under-five in program areas. We also conducted secondary analysis of Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) surveys in surrounding regions and compared annual coverage changes in the CHAI-supported program geographies to the surrounding regions. Results Across CHAI-supported focal geographies, the average ORS coverage across the program areas increased from 35% to 48% and combined ORS and zinc coverage increased from 1% to 24%. ORS coverage increases were statistically significant in the program states in India, from 22% (95% confidence interval CI = 21–23%) to 48% (95% CI = 47–50%) and program states in Nigeria, from 38% (95% CI = 32–40%) to 55% (95% CI = 51–58%). For combined ORS and zinc, coverage increases were statistically significant in all program geographies. Compared to surrounding regions, the estimated annual changes in combined ORS and zinc coverage were greater in program geographies. Using the Lives Saved Tool and based on the coverage changes during the program period, we estimated 76 090 diarrheal deaths were averted in the program geographies. Conclusions Increasing ORS and zinc coverage at scale in high-burden countries and states is possible through a comprehensive approach that targets both demand and supply barriers, including pricing, optimal product qualities, provider dispensing practices, stocking rates, and consumer demand.

Little is known on integrating HIV and family planning (FP) services in community settings. Using a cluster randomized controlled design, we conducted a formative assessment in two districts in Uganda where community health workers, called VHTs, already offered FP. Thirty-six trained VHTs also provided HIV testing and counseling (HTC) during the intervention. We surveyed all 36 VHTs and 256 FP clients, and reviewed service statistics. In the intervention group, VHTs tested 80% of surveyed clients for HIV, including 76% they already saw for FP and 22% who first came to them for HTC before receiving FP. Comparing clients' experiences in the intervention and control groups, adding HTC does not appear to have negatively affected FP service quality. VHTs reported more monthly clients, but rated their workload as easy to manage. This integrated model seems feasible and beneficial for both VHTs and clients, while not resulting in any negative effects. This study was registered with ClinicalTrials.gov, number [NCT02244398]. (Afr J Reprod Health 2017; 21[2]: 73-80).Keywords: family planning, HIV, community health workers, integration, Uganda RésuméPeu d'informations sont disponibles sur l'intégration des services de planification familiale (PF) et du VIH dans les milieux communautaires. En utilisant un plan randomisé contrôlé par grappes, nous avons mené une évaluation formative dans deux districts en Ouganda dans lesquels les agents de santé communautaire qui sont appelés VHT offraient déjà des services de PF. Trente-six VHT formés ont également fourni des services de conseil et dépistage du VIH (CDV). Nous avons enquêté les 36 ASC et 256 clientes PF, et nous avons examiné les statistiques sur les services. Dans le groupe d'intervention, les VHT ont testé 80% des clients enquêtées pour le VIH, y compris 76% que les VHT voyaient déjà pour la PF et 22% qui sont d'abord venus pour le CDV avant avant de recevoir la PF. En comparant les expériences des clientes dans les groupes avec et sans intervention, l'ajout du CDV ne semble pas avoir affecté négativement la qualité des services PF. Les VHT ont signalé plus de clients mensuellement, mais ont évalué leur charge de travail comme étant aussi facile à gérer. Ce modèle intégré semble faisable et bénéfique pour les VHT et les clients, et sans entraîner d'effet négatif. Cette étude a été enregistrée auprès de ClinicalTrials.gov, numéro [NCT02244398]. (Afr J Reprod Health 2017; 21[2]: 73-80).