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Background Poor quality of care is a barrier to engagement in HIV care and treatment in low- and middle-income country settings. This study involved focus group discussions (FGD) with patients and health workers in two large urban hospitals to describe quality of patient education and psychosocial support services within Haiti’s national HIV antiretroviral therapy (ART) program. The purpose of this qualitative study was to illuminate key gaps and salient “ingredients” for improving quality of care. Methods The study included 8 FGDs with a total of 26 male patients and 32 female patients and 15 smaller FGDs with 57 health workers. The analysis used a directed content analysis method, with the goal of extending existing conceptual frameworks on quality of care through rich description. Results Dimension of safety, patient-centeredness, accessibility, and equity were most salient. Patients noted risks to privacy with both clinic and community-based services as well as concerns with ART side effects, while health workers described risks to their own safety in providing community-based services. While patients cited examples of positive interactions with health workers that centered their needs and perspectives, they also noted concerns that inhibited trust and satisfaction with services. Health workers described difficult working conditions that challenged their ability to provide patient-centered services. Patients sought favored relationships with health workers to help them navigate the health care system, but this undermined the sense of fairness. Both patients and health workers described frustration with lack of resources to assist patients in dire poverty, and health workers described great pressure to help patients from their “own pockets.” Conclusions These concerns reflected the embeddedness of patient – provider interactions within a health system marked by scarcity, power dynamics between patients and health workers, and social stigma related to HIV. Reinforcing a respectful and welcoming atmosphere, timely service, privacy protection, and building patient perception of fairness in access to support could help to build patient satisfaction and care engagement in Haiti. Improving working conditions for health workers is also critical to achieving quality.

Introduction Our study describes changes in HIV care service delivery and continuity of HIV antiretroviral therapy (ART) for people living with HIV (PLHIV) during the 8 weeks before and after diagnosis of the first coronavirus disease 2019 (COVID-19) cases in Haiti on March 19, 2020. Methods Using data from 96 out of 167 health facilities offering ART services, we compared four ART program indicators: (1) count of HIV visits; (2) proportion of ART dispenses in community-based settings (DAC); (3) proportion of multi-month dispensing of ART medications > 6 months (> 6 m MMD); and (4) proportion of timely ART refills. We used uncontrolled interrupted time series (ITS) models to estimate slope and level changes in each indicator with the arrival of COVID-19. Results and Discussion From week 1 to week 16, the average number of HIV visits fell from 121.5 to 92.5 visits, the proportion of DAC rose from 22.7% to 36.7%, the proportion of > 6 m MMD rose from 29.4% to 48.4%, and the proportion of timely ART refills fell from 51.9% to 43.8%. The ITS models estimated abrupt increases of 36% in > 6 m MMD (p

To promote HIV antiretroviral therapy (ART) outcomes in Haiti, we developed a culturally relevant intervention (InfoPlus Adherence) that combines an electronic medical record alert identifying patients at elevated risk of treatment failure and provider-delivered brief problem-solving counseling. We conducted a quasi-experimental mixed-methods study among 146 patients at two large ART clinics in Haiti with 728 historical controls. We conducted quantitative assessments of patients at baseline and intervention completion (6 months) as well as focus groups with health workers and exit interviews with patients. The primary quantitative outcome measures were HIV viral suppression according to medical record and ART adherence in terms of >=90% for “proportion of days covered” (PDC) according to pharmacy dispensing data. Results indicated that the proportion of intervention patients with suppressed VL during the study/historical periods was 80.0%/86.0% and 76.8%/87.4% for controls. In a difference-in-differences (DID) analytic model, the adjusted relative risk for viral suppression with the intervention was 1.15 (95% CI: 0.92 – 1.45, p=0.21), representing favorable but non-significant association between the intervention and the trajectory of VL outcomes. PDC >= 90% during the study/historical periods was 30.9%/11.0% among intervention participants and 16.9%/19.4% among controls. In the adjusted DID model, the relative risk for of PDC>=90% with the intervention was 4.00 (95% CI: 1.91–8.38, p

BACKGROUND The World Health Organization (WHO) recommends universal antiretroviral therapy (ART) for persons living with HIV (PLWH), but evidence about effects of expanded ART access on ART retention in low-resource settings is limited. SETTING Haiti's Ministry of Health endorsed universal ART for pregnant women in March 2013 (Option B+) and for all PLWH in July 2016. This study included 51,579 ART patients from 2011 to 2017 at 94 hospitals and clinics in Haiti. METHODS This observational, retrospective cohort study described time trends in 6-month ART retention using secondary data, and compared results during 3 periods using an interrupted time series model: pre-Option B+ (period 1: 1/11-2/13), Option B+ (period 2: 3/13-6/16), and Test and Start (TS 95% confidence interval: 1.002 to 1.026, P 30 days after HIV diagnosis (adjusted incidence rate ratio = 0.86; 95% confidence interval: 0.84-0.89, P < 0.001). CONCLUSIONS Achieving targets for HIV epidemic control will require increasing ART retention and reducing the disparity in retention for those with same-day ART.

To describe trends in timing of ART initiation for newly diagnosed people living with HIV before and after Haiti adopted its Test and Start policy for universal HIV antiretroviral therapy (ART) in July 2016, and to explore predictors of timely ART initiation for both newly and previously diagnosed people living with HIV following Test and Start adoption.This retrospective cohort study explored timing of ART initiation among 147 900 patients diagnosed with HIV at 94 ART clinics in 2004-2018 using secondary electronic medical record data. The study used survival analysis methods to assess time trends and risk factors for ART initiation.Timely uptake of ART expanded with Test and Start, such that same-day ART initiation rates increased from 3.7% to 45.0%. However, only 11.0% of previously diagnosed patients initiated ART after Test and Start. In adjusted analyses among newly diagnosed people living with HIV, factors negatively associated with timely ART initiation included being a pediatric patient aged 0-14 years (HR = 0.23,Haiti has made substantial progress in scaling up Test and Start, but further work is needed to enroll previously diagnosed patients and to ensure rapid ART in key patient subgroups. Further research is needed on facility and geographic factors and on strategies for improving timely ART initiation among vulnerable subgroups.Describir las tendencias en cuanto al momento de iniciar el tratamiento antirretroviral (TAR) de personas con infección por el VIH recién diagnosticadas antes y después de julio del 2016, cuando Haití adoptó la política de prueba e inicio del tratamiento con el TAR universal contra el VIH, y explorar los factores predictivos del inicio oportuno del TAR en personas con infección por el VIH recién diagnosticada y diagnosticada con anterioridad después de la adopción de esta política.En este estudio de cohortes retrospectivo se exploró el momento en que se inició el TAR en 147 900 pacientes con diagnóstico de infección por el VIH en 94 consultorios que administran TAR del 2004 al 2018 mediante datos secundarios de expedientes médicos electrónicos. El estudio empleó métodos de análisis de supervivencia para evaluar las tendencias temporales y los factores de riesgo del inicio del TAR.La observancia oportuna del TAR se amplió con la política de prueba e inicio del tratamiento, de tal manera que el inicio del TAR en el mismo día aumentó de 3,7 % a 45,0 %. Sin embargo, solo 11,0 % de los pacientes anteriormente diagnosticados iniciaron el TAR tras la adopción de la política. En los análisis ajustados con personas con infección por el VIH recién diagnosticadas, los factores asociados negativamente con el inicio oportuno del TAR comprendían ser un paciente pediátrico entre 0 y 14 años de edad (HR = 0,23, p0,001), ser varón (HR = 0,92, p = 0,03), tener más de 50 años (HR = 0,87, p = 0,03), tener un peso bajo (HR = 0,79,p0.001) y estar en el estadio 3 (de HR = 0,73, p0,001) o en estadio 4 (HR = 0,49, p0,001) de la enfermedad según la OMS. Se consideró la variación en el inicio oportuno del TAR según departamento geográfico y establecimiento de salud.Haití ha logrado avances considerables en la ampliación a mayor escala de la política de prueba e inicio del tratamiento, pero es necesario seguir trabajando para registrar a los pacientes diagnosticados con anterioridad y para asegurar el inicio rápido del TAR en los subgrupos de pacientes clave. Es preciso llevar a cabo investigaciones adicionales sobre los factores geográficos y los relacionados con los establecimientos y sobre las estrategias para mejorar el inicio oportuno del TAR en los subgrupos vulnerables.Descrever as tendências para o momento do início da terapia antirretroviral (TAR) em pessoas recém diagnosticadas vivendo com HIV antes de e após o Haiti adotar a política Testar e Tratar com a TAR universal para HIV, em julho de 2016, e analisar os preditores do início precoce da TAR em pessoas recém ou previamente diagnosticadas que vivem com HIV após a adoção da política Testar e Tratar.Este estudo de coorte retrospectivo analisou o momento do início da TAR de 147 900 pacientes diagnosticados com HIV em 94 ambulatórios de TAR entre 2004 e 2018, usando dados de registros médicos eletrônicos secundários. O estudo usou métodos de análise de sobrevivência para avaliar as tendências temporais e os fatores de risco para o início da TAR.A adoção precoce da TAR foi ampliada com a política Testar e Tratar de tal maneira que as taxas do início da TAR no mesmo dia do diagnóstico aumentaram de 3,7% para 45%. Porém, somente 11% dos pacientes previamente diagnosticados iniciaram a TAR após a política Testar e Tratar. Nas análises ajustadas entre as pessoas recém diagnosticadas vivendo com HIV, os fatores negativamente associados ao início precoce da TAR incluíram: ser paciente pediátrico de 0 a 14 anos de idade (HR = 0,23,O Haiti obteve avanços substanciais na ampliação da política Testar e Tratar, mas é necessário mais trabalho para inscrever pacientes previamente diagnosticados e para assegurar a TAR rápida em subgrupos-chave de pacientes. Mais pesquisas são necessárias sobre fatores geográficos e de instituições de saúde e sobre estratégias para a melhoria do início precoce da TAR entre subgrupos vulneráveis.

Objectives The aim of this case study was to compare two alternative strategies for prioritizing data elements for data quality assessment (DQA) in a routine health management information system. The study used data from iSante, a multi-site electronic medical record implemented by the Haitian Ministry of Health. We described and compared two prioritization strategies: (1) a Delphi process drawing iterative feedback from clinicians and stakeholders responsible for monitoring and evaluation (ME and (2) a process using burden of disease estimates from Haiti to establish priorities for data on primary care patients. Methods The Delphi process included 26 individuals across 6 institutions, including clinicians and M&E specialists. Through three rounds of questionnaires, the stakeholders provided input for prioritization of 13 indicators for completeness, accuracy and timeliness of HIV data. The burden of disease prioritization process revealed that cardiovascular disease contributed to the greatest number of disability-adjusted life-years (DALYs). This resulted in the selection of 16 data quality indicators for primary care data. Results Both methods informed the definition of a set of automated data quality queries to assess internal validity, completeness, and timeliness using logic and clinical plausibility. The Delphi process benefited from stakeholder input, but was lengthy in process. The burden of disease prioritization process was objective and easier to implement, but lacked stakeholder buy-in. Conclusions A hybrid approach guided by both disease burden and stakeholder input may be most beneficial for prioritizing data elements for DQA.

Background Haiti has one of the world's highest maternal mortality ratios. Comprehensive obstetric services could prevent many of these deaths, though most births in Haiti occur outside health facilities. Demand-side factors like a mother's socioeconomic status are understood to affect her access or choice to deliver in a health facility. However, analyses of the role of supply-side factors like health facility readiness have been constrained by limited data and methodological challenges. We sought to address these challenges and determine whether Haiti could increase rates of facility-based birth by improving facility readiness to provide delivery services. # Methods Our task was to characterize facility delivery readiness and link it to nearby births. We used birth data from the 2012 Haiti DHS and facility data from the 2013 Haiti SPA. Our outcome of interest was facility-based birth. Our predictor of interest was delivery readiness at the DHS sampling cluster level. We derived a novel likelihood function that used Kernel Density Estimation to estimate cluster-level readiness alongside the coefficients of a logistic regression. # Results We analyzed data from 389 facilities and 1,991 births. Rural facilities were less ready than urban facilities to provide delivery services. Women delivering in health facilities were younger, more educated, wealthier, less likely to live in rural areas, and had fewer previous children. Our model estimated that rural facilities (bandwidth (h)=12.28, standard error (SE)=0.16) spread their readiness over larger areas than urban facilities (h=7.14, SE=0.016). Cluster-level readiness was strongly associated with facility-based birth (adjusted log-odds=0.031; *P*=0.005), as was socioeconomic status (adjusted log-odds=0.78; *P*\

This study assessed whether a violence-prevention curriculum was associated with increased knowledge of dating violence (DV) among students in grades 10–12 in two high schools in Port-au-Prince, Haiti. A one-group pretest–posttest study was conducted from November to December 2013. Two hundred and nine students with non-missing data completed a pretest exam and a posttest exam five weeks later. Multivariable logistic and simple linear regression models were used to test for differences in knowledge outcomes over time and interactive associations, with controls for student and school characteristics. Pretest levels of knowledge of DV were low. The analysis revealed that the probability of each binary DV knowledge outcome and the adjusted number of correctly identified DV myths and facts were significantly higher at posttest than at pretest. Gender differences were observed, with female students having a significantly higher probability than male students of knowing two warning signs of DV perpetrat...

Background Option B+ is a strategy wherein pregnant or breastfeeding women with HIV are enrolled in lifelong antiretroviral therapy (ART) for prevention of mother-to-child transmission (PMTCT) of HIV. In Haiti, attrition from Option B+ is problematic and variable across health care facilities. This study explores service readiness and other facility factors as predictors of Option B+ attrition in Haiti. Methods This analysis used longitudinal data from 2012 to 2014 from the iSante electronic medical record system and cross-sectional data from Haiti's 2013 Service Provision Assessment. Predictors included Service Availability and Readiness Assessment (SARA) measures for antenatal care (ANC), PMTCT, HIV care services and ART services; general facility characteristics and patient-level factors. Multivariable Cox proportional hazards models modelled the time to first attrition. Results Analysis of data from 3147 women at 63 health care facilities showed no significant relationships between SARA measures and attrition. Having integrated ANC/PMTCT care and HIV-related training were significant protective factors. Being a public-sector facility, having a greater number of quality improvement activities and training in ANC were significant risk factors. Conclusion Several facility-level factors were associated with Option B+ attrition. Future research is needed to explore unmeasured facility factors, clarify causal relationships, and incorporate community-level factors into the analysis of Option B+ attrition.

Sexual violence is a public health problem in Haiti, potentially augmenting HIV transmission. Reports from L'Hopital de l'Universite d'Etat d'Haiti (HUEH) suggest severe underutilization of antiretroviral post-exposure prophylaxis (ARV-PEP) among rape survivors. Cross-sectional design using mixed methods. Informational interviews were conducted with HUEH personnel to learn about post-rape service offerings. HUEH surveillance data were used to estimate the sexual assault reporting rate/100,000 and to examine the proportion of survivors receiving ARV-PEP within 72 hr, stratified by age (