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Knowledge translation is the synthesis, exchange, and application of knowledge by relevant stakeholders to accelerate the benefits of global and local innovation in strengthening health systems. In Zambia, research evidence is recognized as a critical element for the development of sound policies. This requires deliberate efforts towards generating, harvesting, and utilizing evidence from research and program data to inform decision-making. In response, the National Health Research Authority with support from the Clinton Health Access Initiative adapted a data to policy curriculum for use at sub-national levels and conducted training for 17 healthcare workers. The objectives of the training were to build the capacity of healthcare workers in analyzing research and other data to inform policy and programming as well as to develop six policy briefs for presentation to policymakers.The curriculum combines epidemiology with economic analysis and modeling to develop informative policy briefs. Sixteen modules were covered and delivered during periodic interactive workshops led by facilitators and mentorship was done in-between sessions. This was done within 6 months from February to August 2022. To assess the participants understanding, Kirkpatrick learning evaluation model was adapted upto level 3; we utilized a pre and posttest method of assessment.At pre-test, about 71% of the participants scored below 50 percent, while at posttest, all the participants scored above 50%. Six policy briefs were successfully developed covering Sexual Reproductive Maternal Newborn Child Adolescent Health and Nutrition topics. Implementation of this program provided a lot of learnings for programs aimed at improving uptake of evidence into action. One of the key learnings was that conducting economic evaluations and mathematical modelling of proposed policy interventions was critical in informing the decision-makers of the cost and benefits of the interventions. Policy options proposed in the policy brief were largely accepted by key stakeholders and proposed for piloting.

Background: Increased attention has been put towards developing and implementing Community Health Management Information System (c-HMIS). It is for this reason that in 2012, Ministry of Health (MoH) with the support from Clinton Health Access Initiative (CHAI) developed a Community Health Management Information System (c-HMIS) in Zambia. There is limited data on the implementation, acceptability and use of c-HMIS in community health systems. Guided by the by Atun’s framework on integration of interventions in health systems. We explored the implementation and acceptability of c-HMIS in Mpongwe district. Methodology:Qualitative data collected with 66 respondents namely members of health committees, community health assistants and their supervisors were analysed using thematic analysis. Results: The nature of the problem which included poor quality of data /information due to lack of standardized data collection tools and delayed submission of reports motivated MoH and stakeholders to adopt the c-HMIS. Theattributes of the c-HMIS Intervention such as the provision of improved data collection tools, training stakeholders in using the tools, the perceived simplicity of the system and factors within the adoption system such as some health workers being familiar with c-HMIS, compatibility of the c-HMIS with existing tools, as well as improved collaboration and communication among actors facilitated the adoption process. Further, health system characteristics such as timely availability of data and improved health information feedback processes, improved mapping of key health issues in communities; as well as the broader context such as community engagement promoted community ownership of the c-HMIS. The c-HMIS implementation barriers included challenges with completing some sections in the tools due to missing data, limited gender inclusiveness in the tools, inadequate availability of digital platforms to enter and store data, limited incentives for community health workers, poor phone network/ internet connection as well as the COVID-19 pandemic. Conclusion: Strengthening the implementation and acceptability of c-HMIS may require introducing electronic data capture and transmission using simple digital tools such as android phones. Electronic systems would help address logical challenges related to inadequate data collection tools, data entry challenges, and delayed transmission of data.

IntroductionSince 2017 global guidelines have recommended “same-day initiation” (SDI) of antiretroviral treatment (ART) for patients considered ready for treatment on the day of HIV diagnosis. Many countries in sub-Saharan Africa have incorporated a SDI option into national guidelines, but uptake of SDI is not well documented. We estimated average time to ART initiation at 12 public healthcare facilities in Malawi, 5 in South Africa, and 12 in Zambia.MethodsWe sequentially enrolled patients who were eligible to start ART between January 2018 and June 2019 and reviewed their medical records from the point of HIV treatment eligibility (HIV diagnosis or first HIV-related interaction with the clinic) to the earlier of treatment initiation or 6 months. We estimated the proportion of patients initiating ART at their original healthcare facilities on the same day or within 7, 14, 30, or 180 days of baseline, stratified by country and gender.ResultsWe enrolled 826 patients in Malawi, 534 in South Africa, and 1,984 in Zambia. 88% of patients in Malawi, 57% in South Africa, and 91% in Zambia were offered and accepted SDI. In Malawi, most patients who did not receive SDI had also not initiated ART ≤ 6 months. In South Africa, an additional 13% of patients initiated ≤ 1 week, but 21% still had no record of initiation ≤ 6 months. Among those who did initiate within 6 months in Zambia, most started ≤ 1 week. There were no major differences by gender. Both WHO Stage III/IV and tuberculosis symptoms were associated with delays in ART initiation.DiscussionAs of 2020, uptake of same-day ART initiation was widespread, if not nearly universal, in Malawi and Zambia but was considerably less common in South Africa. Limitations of the study include pre-COVID-19 data that do not reflect pandemic adaptations and potentially missing data for Zambia. South Africa may be able to increase overall ART coverage by reducing numbers of patients who do not initiate ≤ 6 months.RegistrationClinicaltrials.govNCT04468399(Malawi),NCT04170374(South Africa), andNCT04470011(Zambia).

Background: Since 2017 global guidelines have recommended “same-day initiation” (SDI) of antiretroviral treatment (ART) for patients considered ready for treatment on the day of HIV diagnosis. Many countries have incorporated a SDI option into national guidelines, but SDI uptake is not well documented. We estimated average time to ART initiation at 12 public healthcare facilities in Malawi, five in South Africa, and 12 in Zambia. Methods: We identified patients eligible to start ART between January 2018 and June 2019 from facility testing registers and reviewed their medical records from HIV diagnosis to the earlier date of treatment initiation or 6 months. We estimated the proportion of patients initiating ART on the same day or within 7, 14, 30, or 180 days of baseline. Results: We enrolled 825 patients in Malawi, 534 in South Africa, and 1,984 in Zambia. Overall, 88% of patients in Malawi, 57% in South Africa, and 91% in Zambia received SDI. In Malawi, most who did not receive SDI had not initiated ART ≤6 months. In South Africa, an additional 13% initiated ≤1 week, but 21% had no record of initiation ≤6 months. Among those who did initiate within 6 months in Zambia, most started ≤1 week. There were no major differences by sex. WHO Stage III/IV and tuberculosis symptoms were associated with delays in ART initiation; clinic size and having a CD4 count done were associated with an increased likelihood of SDI. Conclusions: As of 2020, SDI of ART was widespread, if not nearly universal, in Malawi and Zambia but considerably less common in South Africa. Limitations of the study include pre-COVID-19 data that do not reflect pandemic adaptations and potentially missing data for Zambia. South Africa may be able to increase overall ART coverage by reducing numbers of patients who do not initiate ≤6 months.

Background: Since 2017 global guidelines have recommended “same-day initiation” (SDI) of antiretroviral treatment (ART) for patients considered ready for treatment on the day of HIV diagnosis. Many countries have incorporated a SDI option into national guidelines, but SDI uptake is not well documented. We estimated average time to ART initiation at 12 public healthcare facilities in Malawi, five in South Africa, and 12 in Zambia. Methods: We sequentially enrolled patients eligible to start ART between January 2018 and June 2019 and reviewed their medical records from the point of HIV diagnosis or first HIV-related interaction with the clinic to the earlier date of treatment initiation or 6 months. We estimated the proportion of patients initiating ART on the same day or within 7, 14, 30, or 180 days of baseline. Results: We enrolled 826 patients in Malawi, 534 in South Africa, and 1,984 in Zambia. Overall, 88% of patients in Malawi, 57% in South Africa, and 91% in Zambia were offered and accepted SDI. In Malawi, most who did not receive SDI had not initiated ART ≤6 months. In South Africa, an additional 13% initiated ≤1 week, but 21% had no record of initiation ≤6 months. Among those who did initiate within 6 months in Zambia, most started ≤1 week. There were no major differences by sex. WHO Stage III/IV and tuberculosis symptoms were associated with delays in ART initiation. Conclusions: As of 2020, SDI of ART was widespread, if not nearly universal, in Malawi and Zambia but considerably less common in South Africa. Limitations of the study include pre-COVID-19 data that do not reflect pandemic adaptations and potentially missing data for Zambia. South Africa may be able to increase overall ART coverage by reducing numbers of patients who do not initiate ≤6 months. Registration: Clinicaltrials.gov (NCT04468399; NCT04170374; NCT04470011).

Introduction Differentiated service delivery (DSD) models aim to improve the access of human immunodeficiency virus treatment on clients and reduce requirements for facility visits by extending dispensing intervals. With the advent of the COVID-19 pandemic, minimising client contact with healthcare facilities and other clients, while maintaining treatment continuity and avoiding loss to care, has become more urgent, resulting in efforts to increase DSD uptake. We assessed the extent to which DSD coverage and antiretroviral treatment (ART) dispensing intervals have changed during the COVID-19 pandemic in Zambia. Methods We used client data from Zambia's electronic medical record system (SmartCare) for 737 health facilities, representing about three-fourths of all ART clients nationally. We compared the numbers and proportional distributions of clients enrolled in DSD models in the 6 months before and 6 months after the first case of COVID-19 was diagnosed in Zambia in March 2020. Segmented linear regression was used to determine whether the outbreak of COVID-19 in Zambia further accelerated the increase in DSD scale-up. Results and discussion Between September 2019 and August 2020, 181,317 clients aged 15 or older (81,520 and 99,797 from 1 September 2019 to 1 March 2020 and from 1 March to 31 August 2020, respectively) enrolled in DSD models in Zambia. Overall participation in all DSD models increased over the study period, but uptake varied by model. The rate of acceleration increased in the second period for home ART delivery (152%), ≤ 2-month fast-track (143%) and 3-month MMD (139%). There was a significant reduction in the enrolment rates for 4- to 6-month fast-track (-28%) and "other" models (-19%). Conclusions Participation in DSD models for stable ART clients in Zambia increased after the advent of COVID-19, but dispensing intervals diminished. Eliminating obstacles to longer dispensing intervals, including those related to supply chain management, should be prioritized to achieve the expected benefits of DSD models and minimize COVID-19 risk.

Reducing maternal and neonatal mortality is a critical health priority within Zambia and globally. Although evidence-based clinical interventions can prevent a majority of these deaths, scalable and sustainable delivery of interventions across low-resource settings remains uneven, particularly across rural and marginalized communities. The Zambian Ministry of Health and the Clinton Health Access Initiative implemented an integrated sexual, reproductive, maternal, and newborn health (SRMNH) program in Northern Province aimed at dramatically reducing mortality over four years. Interventions were implemented between 2018 and 2021 across 141 government-owned health facilities covering all 12 districts of Northern Province, the poorest performing province nationwide and home to over 1.4 million people, around six pillars of an integrated health system. Data on institutional delivery and antenatal and postnatal care were collected through the national Health Management Information System (HMIS). A community-based system for capturing birth outcomes was established using existing government tools and community volunteers since HMIS did not include community-based mortality. Baseline and endline population-based mortality rates were compared for program-supported areas. From the earliest period of population-based mortality reporting in 2019 to program end in 2021, there were statistically significant decreases of 41%, 45%, and 43% in maternal, neonatal, and perinatal mortality rates respectively. Between 2017 to 2021, institutional maternal, neonatal, and perinatal mortality rates across entirety of Northern Province reduced by 12%, 40%, and 41%, respectively. Service readiness and coverage for SRMNH services improved dramatically, supporting increased numbers of patients. Significant mortality reductions were achieved over a relatively short period, reinforced through an emphasis on sustainability and strengthening existing government systems. These results were attained through a consciously cost-efficient approach backed by substantially lower levels of external investment relative to prior programs, allowing many of the interventions to be successfully adopted by government within public sector budgets.

ObjectivesPatient attrition is high the first 6 months after antiretroviral therapy (ART) initiation. Patients with DesignRetrospective cohort study using routinely collected electronic medical record data.SettingParticipantsAdults (≥15 years) who initiated ART between 1 January 2019 and 31 December 2020.OutcomesLTFU (>30 days late for scheduled visit) at 18 months for ‘early enrollers’ (DSD enrolment after ResultsFor 6340 early enrollers and 25 857 established enrollers, there were no differences in sex (61% female), age (median 37 years) or location (65% urban). ART refill intervals were longer for established versus early enrollers (72% vs 55% were given 4–6 months refills). LTFU at 18 months was 3% (192 of 6340) for early enrollers and 5% (24 646 of 25 857) for established enrollers. Early enrollers were 41% less likely to be LTFU than established patients (adjusted risk ratio 0.59, 95% CI 0.50 to 0.68).ConclusionsPatients enrolled in DSD after Trial registeration numberNCT04158882.

IntroductionAttrition from HIV treatment is high during patients’ first 6 months after antiretroviral therapy (ART) initiation and patients with less than 6 months on ART are systematically excluded from most differentiated service delivery (DSD) models, which are intended to reduce attrition. Despite eligibility criteria requiring greater than 6 months on ART, some patients enroll earlier. Using routinely-collected medical record data in Zambia, we compared loss to follow-up (LTFU) among patients enrolling in DSD models early (MethodsWe extracted data from electronic medical records for adults (≥15 years) who initiated ART between 01/01/2019 and 31/12/2019 and evaluated LTFU, defined as >90 days late for last scheduled medication pickup, at 18 months for “early enrollers” (DSD enrolment after ResultsFor 6,340 early enrollers and 25,857 established enrollers there were no important differences between the groups in sex (61% female), age (median 37 years), or setting (65% urban). ART refill intervals were longer for established vs early enrollers (72% vs 55% were given 4–6-month refills). LTFU at 18 months was 3% (192/6,340) for early enrollers and 5% (24,646/25,857) for established enrollers. Early enrollers were 41% less likely to be LTFU than established patients (adjusted risk ratio [95% confidence interval] 0.59 [0.50-0.68]).ConclusionsPatients enrolled in DSD models in Zambia with < 6 months on ART were more likely to be retained in care than patients referred after they were established on ART. A limitation of the analysis is that early enrollers may have been selected for DSD participation due to providers’ and patients’ expectations about future retention. Offering DSD model entry to at least some ART patients

Although strong evidence exists about the effectiveness of basic childbirth services in reducing maternal and newborn mortality, these services are not provided in every childbirth, even those at health facilities. The WHO Safe Childbirth Checklist (SCC) was developed as a job aide to remind health workers of evidenced-based practices to be provided at specific points in the childbirth process. The Zambian government requested context-specific evidence on the feasibility and outcomes associated with introducing the checklist and related mentorship. A study was conducted on use of the SCC in four facilities in Nchelenge District of Zambia. Observations of childbirth services were conducted just before and six months after the introduction of the intervention. Observers used a structured tool to record adherence to essential services indicated on the checklist. The primary outcome of interest was the change in the average proportion of essential childbirth practices completed. Feedback questionnaires were administered to health workers before and six months after the intervention. At baseline and endline, 108 and 148 pause points were observed, respectively. There was an increase from 57% to 76% of tasks performed (p = 0.04). Considering only these cases where necessary supplies were available, health workers completed 60% of associated tasks at baseline compared to 84% at endline (p Trial registration Clinical Trials.gov (NCT03263182) Registered August 28, 2017 This study adheres to CONSORT guidelines.

Background Public health systems in resource-constrained settings have a critical role to play in the elimination of HIV transmission but are often financially constrained. This study is an evaluation of a mother-infant-pair model called “Umoyo”, which was designed to be low cost and scalable in a public health system. Facilities with the Umoyo model dedicate a clinic day to provide services to only HIV-exposed-infants (HEIs) and their mothers. Such models are in operation with reported success in Zambia but have not been rigorously tested. This work establishes whether the Umoyo model would improve 12-month retention of HEIs. Methods A cluster randomized trial including 28 facilities was conducted across two provinces of Zambia to investigate the impact on 12-month retention of HEIs in care. These facilities were offering prevention of mother to child transmission (PMTCT) services and supported by the same implementing partner. Randomization was achieved by use of the covariate constrained optimization technique. Secondary outcomes included the impact of Umoyo clinics on social support and perceived HIV stigma among mothers. For each of the outcomes, a difference-in-difference analysis was conducted at the facility level using the unweighted t-test. Results From 13 control (12-month retention at endline: 45%) and 11 intervention facilities (12-month retention at endline: 33%), it was found that Umoyo clinics had no impact on 12-month retention of HEIs in the t-test (-11%; 99% CI: -40.1%, 17.2%). Regarding social support and stigma, the un-weighted t-test showed no impact though sensitivity tests showed that Umoyo had an impact on increasing social support (0.31; 99% CI: 0.08, 0.54) and reducing perceived stigma from health care workers (-0.27: 99% CI: -0.46, -0.08). Conclusion The Umoyo approach of having a dedicated clinic day for HEIs and their mothers did not improve retention of HEIs though there are indications that it can increase social support among mothers and reduce stigma. Without further support to the underlying health system, based on the evidence generated through this evaluation, the Umoyo clinic day approach on its own is not considered an effective intervention to increase retention of HIV-exposed infants.

Background Public health systems in resource constrained settings have a critical role to play in the elimination of vertical HIV transmission but are unable to carry out some of the promising interventions such as mother-to-mother peer support programs due to financial constraints. This study is an evaluation of a mother-infant-pair clinic called Umoyo, which was designed to be scalable in a public health system due to the relatively low costs required. Umoyo clinics dedicate a clinic day to provide services to only HIV-exposed-infants (HEIs) and their mothers. Such models are in operation with reported success in Zambia but have not been rigorously tested. Methods A cluster randomized trial including 28 facilities was conducted across two provinces of Zambia to investigate 12-month retention of HEIs in care. These were facilities that were offering prevention of mother to child transmission (PMTCT) services and supported by the same implementing partner. Random allocation was achieved by use of the covariate constrained optimization technique. The primary outcome of interest was to establish whether Umoyo clinic days would improve 12-month retention of HEIs. Secondary outcomes included the impact of Umoyo clinics on social support and perceived HIV stigma among mothers. For each of the outcomes, a difference-in-difference analysis was conducted at the facility level using unweighted t-test. Results From 13 control and 11 intervention facilities, it was found that Umoyo clinics had no impact on 12-month retention of HEIs in the t-test (-11%; 99% CI: -40.1%, 17.2%). Regarding social support and stigma, the un-weighted t-test showed no impact though sensitivity tests showed that Umoyo had an impact on increasing social support and reducing perceived stigma from health care workers. Conclusion The Umoyo approach of having a dedicated clinic day for HEIs and their mothers did not improve retention of HEIs though there are indications that it can increase social support among mothers and reduce stigma. Without further support to the underlying health system, based on the evidence generated through this evaluation, the Umoyo clinic day approach on its own is not considered an effective intervention to increase retention of HIV-exposed infants.Trial Registration Pan African Clinical Trial Registry (PACTR201702001970148) Prospectively registered on January 13, 2017. URL https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=1970

Road Traffic Crashes (RTCs) are the third highest cause of death in Zambia, claiming about 2000 lives annually, with pedestrians and cyclists being the most vulnerable. Human error accounts for 87.3% of RTCs. Minibus and big bus public service vehicles (PSVs) are among the common vehicle types involved in these crashes. Given the alarmingly high rate of road traffic crashes involving PSV minibuses and big buses within Zambia, there is a need to mitigate this through innovative solutions. In other settings, it has been shown that stickers in PSVs encouraging passengers to speak out against reckless driving can reduce RTCs, but it is unclear whether such an intervention could work in Zambia. Based on this evidence, the Zambia Road Transport and Safety Agency (RTSA) has developed a road safety bus sticker campaign for PSVs and before national scale-up, RTSA is interested in evidence of the impact of these stickers. This evaluation will be a stratified two-arm randomized controlled trial with a one-to-one ratio. The sample will be stratified by vehicle type, thus creating a two-arm trial for minibuses and a separate two-arm trial for big buses. The sample will include 2110 minibuses and 300 big buses from four towns in Zambia. The primary outcome of interest will be the difference in the rate of RTCs over a 14-month period (7-months before the intervention and 7 months after) between buses with and without the new RTSA road safety bus stickers. This study will provide evidence on the impact of the Zambian sticker program on road traffic crashes as implemented through minibuses and big buses, that can help inform the scale up of a national ‘Zambia road safety bus sticker campaign’. PACT-R, PACTR201711002758216 . Registered 13 November 2017-Retrospectively registered.