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INTRODUCTION: Rapid antiretroviral therapy (ART) initiation can improve patient outcomes such as viral suppression and prevent new infections. However, not everyone who can start ART does so immediately. METHODS: We conducted a qualitative study to inform interventions supporting rapid initiation in the 'Test and Start' era. We purposively sampled 20 adult patients living with HIV and a previous gap in care from ten health facilities in Lusaka, Zambia for interviews. We inductively analysed transcripts using a thematic, narrative approach. In their narratives, seven participants discussed delaying ART initiation. RESULTS: Drawing on messages gleaned from facility-based counselling and community information, many cited greater fear of rapid sickness or death due to imperfect adherence or treatment side effects than negative health consequences due to delayed initiation. Participants described needing time to 'prepare' their minds for a lifetime treatment commitment. Concerns about inadvertent HIV status disclosure during drug collection discouraged immediate initiation, as did feeling healthy, and worries about the impact of ART initiation on relationship dynamics. CONCLUSION: Findings suggest that counselling messages should accurately communicate treatment risks, without perpetuating fear-based narratives about HIV. Identifying and managing patient-specific concerns and reasons for the 'need for time' may be important for supporting individuals to rapidly accept lifelong treatment.Key messagesFear-based adherence messaging in health facilities about the dangers of missing a treatment dose or changing the time when ART is taken contributes to Zambian patients' refusals of immediate ART initiationResponsive health systems that balance a stated need for time to accept one's diagnosis and prepare to embark on a lifelong treatment plan with interventions to identify and manage patient-specific treatment related fears and concerns may support more rapid ART initiationPerceived social stigma around HIV continues to be a significant challenge for treatment initiation.

Summary Background Universal testing and treatment (UTT) for all people living with HIV has only been assessed under experimental conditions in cluster-randomised trials. The public health effectiveness of UTT policies on the HIV care cascade under real-world conditions is not known. We assessed the real-world effectiveness of universal HIV treatment policies that were implemented in Zambia on Jan 1, 2017. Methods We used data from Zambia's routine electronic health record system to analyse antiretroviral therapy (ART)-naive adults who newly enrolled in HIV care up to 1 year before and after the implementation of universal treatment (ie, Jan 1, 2016, to Jan 1, 2018) at 117 clinics supported by the Centre for Infectious Disease Research in Zambia. We used a regression discontinuity design to estimate the effects of implementing UTT on same-day ART initiation, ART initiation within 1 month, and retention on ART at 12 months (defined as clinic attendance 9–15 months after enrolment and at least 6 months on ART), under the assumption that patients presenting immediately before and after UTT implementation were balanced on both measured and unmeasured characteristics. We did an instrumental variable analysis to estimate the effect of same-day ART initiation under routine conditions on 12-month retention on ART. Findings 65 673 newly enrolled patients with HIV (40 858 [62·2%] female, median age 32 years [IQR 26–39], median CD4 count 287 cells per μL [IQR 147–466]) were eligible for inclusion in the analyses; 31 145 enrolled before implementation of UTT, and 34 528 enrolled after UTT. Implementation of universal treatment increased same-day ART initiation from 41·7% to 74·8% (risk difference [RD] 33·1%, 95% CI 30·5–35·7), ART initiation by 1 month from 69·6% to 87·0% (RD 17·4%, 15·5–19·3), and 12-month retention on ART from 56·2% to 63·3% (RD 7·1%, 4·3–9·9). ART initiation rates became more uniform across patient subgroups after implementation of universal treatment, but heterogeneity in 12-month retention on ART between subgroups was unchanged. Instrumental variable analyses indicated that same-day ART initiation in routine settings led to a 15·8% increase (95% CI 12·1–19·5) in 12-month retention on ART. Interpretation UTT policies implemented in Zambia increased the rapidity and uptake of ART, as well as retention on ART at 12 months, although overall retention on ART remained suboptimal. UTT policies reduced disparities in treatment initiation, but not 12-month retention on ART. Natural experiments reveal both the anticipated and unanticipated effects of real-world implementation and indicate the need for new strategies leveraging the short-term effects of UTT to cultivate long-term treatment success. Funding National Institutes of Health.

Background The novel COVID-19 pandemic threatened to disrupt access to human immunodeficiency (HIV) treatment for persons living with HIV (PLHIV), two-thirds of whom live in sub-Saharan Africa. To inform a health system response supportive of continuity of care, we sought to understand clients’ HIV care experiences and health priorities during the first wave of COVID-19 outbreak in Lusaka, Zambia. Methods Leveraging a study cohort of those who completed periodic SMS surveys on HIV care, we purposefully sampled 25 PLHIV after first confirmed COVID-19 case was reported in Zambia on 18th March 2020. We phone-interviewed participants, iteratively refining interview guide to capture emergent themes on COVID-19 awareness, health facility interactions, and social circumstances, which we analyzed using matrix analysis. Results All participants were aware of COVID-19, and HIV care experiences and health priorities of clients were affected by associated changes at health system, household, and individual level. The health system instituted early clinic visits to provide 6-months of antiretroviral therapy (ART) for stable patients and 3-months for unstable patients to reduce clinic visits and wait times. Most patients welcomed this long-desired extended appointment spacing. Some reported feeling respected and engaged when health care workers telephoned requesting their early clinic visit. However, others felt discouraged by an absence of physical distancing during their clinic visit due to ‘severe acute respiratory syndrome coronavirus 2’ (SARS-CoV-2) infection concerns. Several expressed a lack of clarity regarding next viral load monitoring date and means for receiving results. Patients suggested regular patient-facility communication by telephone and SMS. Patients emphasized that COVID-19 restrictions led to loss of employment and household income, exacerbating poverty and difficulties in taking ART. At individual level, most participants felt motivated to stay healthy during COVID-19 by ART adherence and regular laboratory monitoring. Conclusions Clients’ HIV care and health priorities during the first wave of COVID-19 in Lusaka province were varied with a combination of positive and negative experiences that occurred especially at health system and individual levels, while at household level, the experiences were all negative. More research is needed to understand how patients practice resiliency in the widespread context of socio-economic instability. Governments and patients must work together to find local, health systems solutions to support ART adherence and monitoring. Additionally, the health system should consider how to build on changes for long-term HIV management and service delivery.

Supplemental Digital Content is Available in the Text., Background: Dynamic movement of patients in and out of HIV care is prevalent, but there is limited information on patterns of patient re-engagement or predictors of return to guide HIV programs to better support patient engagement. Methods: From a probability-based sample of lost to follow-up, adult patients traced by peer educators from 31 Zambian health facilities, we prospectively followed disengaged HIV patients for return clinic visits. We estimated the cumulative incidence of return and the time to return using Kaplan–Meier methods. We used univariate and multivariable Cox proportional hazards regression to conduct a risk factor analysis identifying predictors of incident return across a social ecological framework. Results: Of the 556 disengaged patients, 73.0% [95% confidence interval (CI): 61.0 to 83.8] returned to HIV care. The median follow-up time from disengagement was 32.3 months (interquartile range: 23.6–38.9). The rate of return decreased with time postdisengagement. Independent predictors of incident return included a previous gap in care [adjusted Hazard Ratio (aHR): 1.95, 95% CI: 1.23 to 3.09] and confronting a stigmatizer once in the past year (aHR: 2.14, 95% CI: 1.25 to 3.65). Compared with a rural facility, patients were less likely to return if they sought care from an urban facility (aHR: 0.68, 95% CI: 0.48 to 0.96) or hospital (aHR: 0.52, 95% CI: 0.33 to 0.82). Conclusions: Interventions are needed to hasten re-engagement in HIV care. Early and differential interventions by time since disengagement may improve intervention effectiveness. Patients in urban and tertiary care settings may need additional support. Improving patient resilience, outreach after a care gap, and community stigma reduction may facilitate return. Future re-engagement research should include causal evaluation of identified factors.

Supplemental Digital Content is Available in the Text., Background: Patients report varied barriers to HIV care across multiple domains, but specific barrier patterns may be driven by underlying, but unobserved, behavioral profiles. Methods: We traced a probability sample of patients lost to follow-up (>90 days late) as of July 31, 2015 from 64 clinics in Zambia. Among those found alive, we ascertained patient-reported reasons for care disruptions. We performed latent class analysis to identify patient subgroups with similar patterns of reasons reported and assessed the association between class membership and care status (ie, disengaged versus silently transferred to a new site). Results: Among 547 patients, we identified 5 profiles of care disruptions: (1) “Livelihood and Mobility” (30.6% of the population) reported work/school obligations and mobility/travel as reasons for care disruptions; (2) “Clinic Accessibility” (28.9%) reported challenges with attending clinic; (3) “Mobility and Family” (21.9%) reported family obligations, mobility/travel, and transport-related reasons; (4) “Doubting Need for HIV care” (10.2%) reported uncertainty around HIV status or need for clinical care, and (5) “Multidimensional Barriers to Care” (8.3%) reported numerous (mean 5.6) reasons across multiple domains. Patient profiles were significantly associated with care status. The “Doubting Need for HIV Care” class were mostly disengaged (97.9%), followed by the “Multidimensional Barriers to Care” (62.8%), “Clinic Accessibility” (62.4%), “Livelihood and Mobility” (43.6%), and “Mobility and Family” (23.5%) classes. Conclusion: There are distinct HIV care disruption profiles that are strongly associated with patients' current engagement status. Interventions targeting these unique profiles may enable more effective and tailored strategies for improving HIV treatment outcomes.

Purpose of ReviewDespite the significant progress in the HIV response, gaps remain in ensuring engagement in care to support life-long medication adherence and viral suppression. This review sought to describe the different points in the HIV care cascade where people living with HIV were not engaging and highlight promising interventions.Recent FindingsThere are opportunities to improve engagement both between testing and treatment and to support re-engagement in care for those in a treatment interruption. The gap between testing and treatment includes people who know their HIV status and people who do not know their status. People in a treatment interruption include those who interrupt immediately following initiation, early on in their treatment (first 6 months) and late (after 6 months or more on ART). For each of these groups, specific interventions are required to support improved engagement.SummaryThere are diverse needs and specific populations of people living with HIV who are not engaged in care, and differentiated service delivery interventions are required to meet their needs and expectations. For the HIV response to realise the 2030 targets, engagement will need to be supported by quality care and patient choice combined with empowered patients who are treatment literate and have been supported to improve self-management.

Introduction Tracing patients lost to follow‐up (LTFU) from HIV care is widely practiced, yet we have little knowledge of its causal effect on care engagement. In a prospective, Zambian cohort, we examined the effect of tracing on return to care within 2 years of LTFU. Methods We traced a stratified, random sample of LTFU patients who had received HIV care between August 2013 and July 2015. LTFU was defined as a gap of >90 days from last scheduled appointment in the routine electronic medical record. Extracting 2 years of follow‐up visit data through 2017, we identified patients who returned. Using random selection for tracing as an instrumental variable (IV), we used conditional two‐stage least squares regression to estimate the local average treatment effect of tracer contact on return. We examined the observational association between tracer contact and return among patient sub‐groups self‐confirmed as disengaged from care. Results Of the 24,164 LTFU patients enumerated, 4380 were randomly selected for tracing and 1158 were contacted by a tracer within a median of 14.8 months post‐loss. IV analysis found that patients contacted by a tracer because they were randomized to tracing were no more likely to return than those not contacted (adjusted risk difference [aRD]: 3%, 95% CI: –2%, 8%, p = 0.23). Observational data showed that among contacted, disengaged patients, the rate of return was higher in the week following tracer contact (IR 5.74, 95% CI: 3.78–8.71) than in the 2 weeks to 1‐month post‐contact (IR 2.28, 95% CI: 1.40–3.72). There was a greater effect of tracing among patients lost for >6 months compared to those contacted within 3 months of loss. Conclusions Overall, tracer contact did not causally increase LTFU patient return to HIV care, demonstrating the limited impact of tracing in this program, where contact occurred months after patients were LTFU. However, observational data suggest that tracing may speed return among some LTFU patients genuinely out‐of‐care. Further studies may improve tracing effectiveness by examining the mechanisms underlying the impact of tracing on return to care, the effect of tracing at different times‐since‐loss and using more accurate identification of patients who are truly disengaged to target tracing.

Background Understanding patient-reported reasons for lapses of retention in human immunodeficiency virus (HIV) treatment can drive improvements in the care cascade. A systematic assessment of outcomes among a random sample of patients lost to follow-up (LTFU) from 32 clinics in Zambia to understand the reasons for silent transfers and disengagement from care was undertaken. Methods We traced a simple random sample of LTFU patients (>90 days from last scheduled visit) as determined from clinic-based electronic medical records from a probability sample of facilities. Among patients found in person, we solicited reasons for either stopping or switching care and predictors for re-engagement. We coded reasons into structural, psychosocial, and clinic-based barriers. Results Among 1751 LTFU patients traced and found alive, 31% of patients starting antiretroviral therapy (ART) between 1 July 2013 and 31 July 2015 silently transferred or were disengaged (40% male; median age, 35 years; median CD4 level, 239 cells/μL); median time on ART at LTFU was 480 days (interquartile range, 110–1295). Among the 544 patients not in care, median prevalences for patient-reported structural, psychosocial, and clinic-level barriers were 27.3%, 13.9%, and 13.4%, respectively, and were highly variable across facilities. Structural reasons, including, “relocated to a new place” were mostly cited among 289 patients who silently transferred (35.5%). We found that men were less likely to re-engage in care than women (odds ratio, .39; 95% confidence interval, .22–.67; P = .001). Conclusions Efforts to improve retention of patients on ART may need to be tailored at the facility level to address patient-reported barriers., Structural, psychosocial, and clinical reasons for disengagement are prevalent and highly variable across facilities. Men are less likely to re-engage in care than women. Patients reporting clinical barriers have less likelihood of returning to care if they report a psychosocial barrier.

Peter Ehrenkranz and co-authors present a cyclical cascade of care for people with HIV infection, aiming to facilitate assessment of outcomes.

Prognosis among those who are HIV infected has improved but long-term retention is challenging. Health systems may benefit from routinely measuring patient satisfaction which is a potential driver of engagement in HIV care, but it is not often measured in Africa, and Zambia in particular. This study aims to internally validate a patient satisfaction tool, assess satisfaction among patients previously lost-to-follow up (LTFU) from HIV care in Lusaka province and to measure association between patient satisfaction with their original clinic and re-engagement in HIV care. A cross-sectional assessment of satisfaction was conducted by tracing sampled patients drawn from public health facilities. Our findings suggest that satisfaction tool, previously validated in USA, exhibits high internal consistency for measuring patient satisfaction in the Zambian health system. Patient satisfaction with healthcare providers is associated with re-engagement in HIV care. Future interventions on patient-centred care are likely to optimize and support retention in care. Electronic supplementary material The online version of this article (10.1007/s10461-019-02712-4) contains supplementary material, which is available to authorized users.

Improvements in geospatial health data and tailored human immunodeficiency virus (HIV) testing, prevention and treatment have led to greater microtargeting of the HIV response, based on location, risk, clinical status and disease burden. These approaches show promise for achieving control of the HIV epidemic. At the same time, United Nations Member States have committed to achieving broader health and development goals by 2030, including universal health coverage (UHC). HIV epidemic control will facilitate UHC by averting the need to commit ever-increasing resources to HIV services. Yet an overly targeted HIV response could also distort health systems, impede integration and potentially threaten broader health goals. We discuss current approaches to achieving both UHC and HIV epidemic control, noting potential areas of friction between disease-specific microtargeting and integrated health systems, and highlighting opportunities for convergence that could enhance both initiatives. Examples of these programmatic elements that could be better aligned include: improved information systems with unique identifiers to track and monitor individuals across health services and the life course; strengthened subnational data use; more accountable supply chains that supply a broad range of services; and strengthened community-based services and workforces. We argue that the response both to HIV and to broader health threats should use these areas of convergence to increase health systems efficiency and mitigate the harm of any potential decrease in health funding. Further investments in implementation and monitoring of these programme elements will be needed to make progress towards both UHC and HIV epidemic control.Les améliorations des données sanitaires géospatiales et la personnalisation du dépistage, de la prévention et du traitement du virus de l'immunodéficience humaine (VIH) ont permis de développer le micro-ciblage de la réponse au VIH, en fonction du lieu, du risque, de la situation clinique et de la charge de morbidité. Ces approches sont prometteuses pour lutter contre l'épidémie de VIH. Dans le même temps, les États membres des Nations Unies se sont engagés à atteindre des objectifs plus larges de santé et de développement d'ici 2030, notamment la couverture sanitaire universelle. Cette dernière sera facilitée par la lutte contre l'épidémie de VIH, qui réduira la nécessité de consacrer toujours plus de ressources aux services liés au VIH. Cependant, une réponse au VIH trop ciblée pourrait également distordre les systèmes de santé, empêcher leur intégration et potentiellement nuire aux objectifs de santé plus vastes. Nous abordons ici les approches actuelles en matière de couverture sanitaire universelle et de lutte contre l'épidémie de VIH, en notant les points de friction potentiels entre un micro-ciblage spécifique à certaines maladies et des systèmes de santé intégrés, ainsi que les opportunités de convergence qui pourraient être bénéfiques aux deux initiatives. Parmi les éléments de programmes qui pourraient être mieux coordonnés, nous pouvons citer: l'amélioration des systèmes d'information avec des identifiants uniques permettant de suivre les personnes dans leur parcours de soins et tout au long de leur vie; la plus grande utilisation des données infranationales; la responsabilisation des chaînes d'approvisionnement qui fournissent un grand nombre de services; et le renforcement des services et des intervenants communautaires. Nous soutenons que la réponse au VIH et à d'autres menaces sanitaires devrait exploiter ces domaines de convergence pour accroître l'efficacité des systèmes de santé et atténuer le préjudice d'une éventuelle baisse des fonds alloués à la santé. Il sera nécessaire d'investir davantage dans la mise en œuvre et le suivi de ces éléments de programmes pour avancer, aussi bien vers la couverture sanitaire universelle que dans la lutte contre l'épidémie de VIH.Las mejoras en los datos geoespaciales de salud y las pruebas, la prevención y el tratamiento adaptados al virus de la inmunodeficiencia humana (VIH) han conducido a una mayor focalización de la respuesta al VIH, basada en la ubicación, el riesgo, el estado clínico y la carga de la enfermedad. Estos enfoques son prometedores para lograr el control de la epidemia del VIH. Al mismo tiempo, los Estados Miembros de las Naciones Unidas se han comprometido a alcanzar objetivos de salud y desarrollo de mayor alcance para 2030, incluida la cobertura universal de salud (universal health coverage, UHC). El control de la epidemia del VIH facilitará la UHC porque evitará la necesidad de comprometer recursos cada vez mayores para los servicios del VIH. Sin embargo, una respuesta al VIH demasiado específica también podría distorsionar los sistemas de salud, impedir la integración y amenazar potencialmente los objetivos de salud de mayor alcance. Se discuten los enfoques actuales para lograr tanto la atención primaria de salud como el control de la epidemia del VIH, se señalan las posibles áreas de fricción entre la focalización específica de la enfermedad y los sistemas integrados de salud, y se destacan las oportunidades de convergencia que podrían mejorar ambas iniciativas. Entre los ejemplos de estos elementos programáticos que podrían alinearse mejor se incluyen: sistemas de información mejorados con identificadores únicos para hacer un seguimiento y monitoreo de las personas a través de los servicios de salud y el curso de la vida; el fortalecimiento del uso de datos a nivel subnacional; cadenas de suministro más responsables que proveen una amplia gama de servicios; y el fortalecimiento de los servicios en la comunidad y las fuerzas de trabajo. Se argumenta que la respuesta tanto al VIH como a las amenazas para la salud en general debe utilizar estas áreas de convergencia para aumentar la eficiencia de los sistemas de salud y mitigar el daño de cualquier posible disminución en la financiación de la salud. Se necesitarán más inversiones en la ejecución y el monitoreo de estos elementos del programa para avanzar tanto en el control de la epidemia de VIH como en la UHC.أدت التحسينات في بيانات الصحة الجغرافية المكانية، واختبار فيروس نقص المناعة البشرية (HIV)، والوقاية منه وعلاجه، إلى زيادة الاستهداف الدقيق للاستجابة لفيروس نقص المناعة البشرية، بناءً على الموقع والمخاطر والحالة السريرية وعبء المرض.تمثل هذه الأساليب وعداً بتحقيق السيطرة على وباء فيروس نقص المناعة البشرية.وفي نفس الوقت، التزمت الدول الأعضاء في الأمم المتحدة بتحقيق أهدافاً أوسع للصحة وللتنمية بحلول عام 2030، بما يشمل التغطية الصحية الشاملة (UHC).سوف تؤدي مكافحة وباء فيروس نقص المناعة البشرية (HIV) إلى تسهيل التغطية الصحية الشاملة عن طريق تجنب الحاجة إلى تخصيص موارد متزايدة دائماً لخدمات فيروس نقص المناعة البشرية.إلا أن الاستجابة المفرطة المستهدفة لفيروس نقص المناعة البشرية قد تؤدي أيضاً لتشويه الأنظمة الصحية، وتعويق التكامل، ومن المحتمل أن تهدد الأهداف الصحية الأوسع نطاقاً.نحن نناقش الأساليب الحالية لتحقيق كل من التغطية الصحية الشاملة، ومكافحة وباء فيروس نقص المناعة البشرية، مع ملاحظة مجالات التداخل المحتملة بين الاستهداف الدقيق للأمراض المحددة، والنظم الصحية المتكاملة، وتسليط الضوء على فرص التقارب التي يمكن أن تعزز كلتا المبادرتين.من أمثلة هذه العناصر البرمجية التي يمكن تنسيقها بشكل أفضل:أنظمة معلومات محسّنة ذات معرّفات فريدة لتتبع ومراقبة الأفراد عبر الخدمات الصحية ومسار الحياة؛ وتعزيز استخدام البيانات دون الوطنية؛ وسلاسل إمداد أكثر مساءلة توفر مجموعة واسعة من الخدمات؛ وخدمات مجتمعية وقوى عاملة مدعمة.نحن نزعم أن الاستجابة لكل من فيروس نقص المناعة البشرية، والتهديدات الصحية الأوسع نطاقاً، ينبغي أن تعتمد على هذه المجالات للتقارب من أجل زيادة كفاءة النظم الصحية، وتخفيف ضرر أي انخفاض محتمل في التمويل الصحي.ستكون هناك حاجة إلى مزيد من الاستثمارات في تنفيذ ومراقبة عناصر هذه البرنامج، لإحراز تقدم نحو كل من التغطية الصحية الشاملة ومكافحة فيروس نقص المناعة البشرية.基于地点、风险、临床特征和疾病负担的地理空间健康数据的改进以及专门的艾滋病 (HIV) 检测、预防和治疗，使得应对艾滋病病毒的工作有了更为微观的目标。这些方法显示对艾滋病疫情的控制有望实现。同时，联合国各成员国已承诺到 2030 年实现更广泛的健康和发展目标，其中包括全民健康覆盖 (UHC)。对艾滋病疫情有所控制将避免对艾滋病服务需求投入资源的不断增加，从而推进全民健康覆盖。然而，过度针对性的艾滋病应对措施也会干扰医疗系统，阻碍一体化并可能危及更广泛健康目标的实现。我们讨论了当前实现全民健康覆盖和艾滋病疫情控制的方法，指明了针对特定疾病的微观目标与整合的医疗系统间可能会有冲突的领域，并着重强调了促进这两项举措融合的机会。更好地协调这些有关计划要素的示例有：改进的信息系统，具有可在医疗服务和整个生命历程中跟踪并监控个人的唯一标识符；强化对地方数据的使用；用于提供广泛服务的更负责任的供应链；并加强基于社区的服务和员工培养。我们认为，对艾滋病和更广泛的健康威胁的应对措施都应使用此类融合领域，以提高医疗系统的效率并减轻医疗资金可能减少的危害。为了在全民健康覆盖和艾滋病疫情控制方面取得进展，需要在此类计划要素的执行和监测方面进一步投资。.Совершенствование сбора геопространственных данных о состоянии здоровья населения и индивидуализация процессов тестирования, лечения и профилактики ВИЧ привели к повышению микроадресации мероприятий по борьбе с ВИЧ с учетом местоположения, риска, клинического состояния и бремени заболевания. Эти подходы позволяют надеяться на обеспечение эффективного контроля над эпидемией ВИЧ. В то же время государства-члены ООН взяли на себя обязательства по расширению целей в области здравоохранения и развития к 2030 году, включая обеспечение всеобщего охвата услугами здравоохранения (UHC). Контроль над эпидемией ВИЧ будет содействовать обеспечению UHC, поскольку отпадет необходимость направлять постоянно растущее количество ресурсов на борьбу с ВИЧ. Однако слишком целенаправленный характер мероприятий по борьбе с ВИЧ может перекосить системы здравоохранения, замедлить процессы интеграции и несет в себе потенциальную угрозу достижению более широких целей в сфере здравоохранения. Авторы обсуждают существующие подходы к обеспечению UHC и контроля над эпидемией ВИЧ, отмечая потенциальные области конфликта между микроадресацией для конкретных заболеваний и объединенными системами здравоохранения, а также выявляя возможности для конвергенции, которые бы содействовали реализации обеих инициатив. Необходимо обеспечить согласованность следующих элементов программы: усовершенствованных информационных систем с уникальными идентификаторами для отслеживания и мониторинга отдельных лиц и оказываемых им медицинских услуг на протяжении всей жизни; более активного использования данных на субнациональном уровне; обеспечения жесткого учета и контроля в цепочках поставок для широкого спектра услуг, а также укрепления системы услуг, оказываемых по месту проживания, и развития соответствующих трудовых ресурсов. Авторы отмечают, что меры по борьбе с ВИЧ и другими угрозами в области здравоохранения должны опираться на эти области конвергенции с целью повышения эффективности систем здравоохранения и уменьшения вреда в результате потенциального сокращения финансирования. Необходимы дальнейшие инвестиции в реализацию и мониторинг этих программных элементов, чтобы добиться прогресса в обеспечении UHC и контроля над эпидемией ВИЧ.

Supplemental Digital Content is Available in the Text., Background: Although differentiated service delivery (DSD) models for stable patients on antiretroviral therapy (ART) offer a range of health systems innovations, their comparative desirability to patients remains unknown. We conducted a discrete choice experiment to quantify service attributes most desired by patients to inform model prioritization. Methods: Between July and December 2016, a sample of HIV-positive adults on ART at 12 clinics in Zambia were asked to choose between 2 hypothetical facilities that differed across 6 DSD attributes. We used mixed logit models to explore preferences, heterogeneity, and trade-offs. Results: Of 486 respondents, 59% were female and 85% resided in urban locations. Patients strongly preferred infrequent clinic visits [3- vs. 1-month visits: β (ie, relative utility) = 2.84; P < 0.001]. Milder preferences were observed for waiting time for ART pick-up (1 vs. 6 hours.; β = −0.67; P < 0.001) or provider (1 vs. 3 hours.; β = −0.41; P = 0.002); “buddy” ART collection (β = 0.84; P < 0.001); and ART pick-up location (clinic vs. community: β = 0.35; P = 0.028). Urban patients demonstrated a preference for collecting ART at a clinic (β = 1.32, P < 0.001), and although most rural patients preferred community ART pick-up (β = −0.74, P = 0.049), 40% of rural patients still preferred facility ART collection. Conclusions: Stable patients on ART primarily want to attend clinic infrequently, supporting a focus in Zambia on optimizing multimonth prescribing over other DSD features—particularly in urban areas. Substantial preference heterogeneity highlights the need for DSD models to be flexible, and accommodate both setting features and patient choice in their design.

Differentiated service delivery (DSD) models were initially developed as a means to combat suboptimal long-term retention in HIV care, and to better titrate limited health systems resources to patient needs, primarily in low-income countries. The models themselves are designed to streamline care along the HIV care cascade and range from individual to group-based care and facility to community-based health delivery systems. However, much remains to be understood about how well and for whom DSD models work and whether these models can be scaled, are sustainable, and can reach vulnerable and high-risk populations. Implementation science is tasked with addressing some of these questions through systematic, scientific inquiry. We review the available published evidence on the implementation of DSD and suggest further health systems innovations needed to maximize the public health impact of DSD and future implementation science research directions in this expanding field. While early observational data supported the effectiveness of various DSD models, more recently published trials as well as evaluations of national scale-up provide more rigorous evidence for effectiveness and performance at scale. Deeper understanding of the mechanism of effect of various DSD models and generalizability of studies to other countries or contexts remains somewhat limited. Relative implementability of DSD models may differ based on patient preference, logistical complexity of model adoption and maintenance, human resource and pharmacy supply chain needs, and comparative cost-effectiveness. However, few studies to date have evaluated comparative implementation or cost-effectiveness from a health systems perspective. While DSD represents an exciting and promising “next step” in HIV health care delivery, this innovation comes with its own set of implementation challenges. Evidence on the effectiveness of DSD generally supports the use of most DSD models, although it is still unclear which models are most relevant in diverse settings and populations and which are the most cost-effective. Challenges during scale-up highlight the need for accurate differentiation of patients, sustainable inclusion of a new cadre of health care worker (the community health care worker), and substantial strengthening of existing pharmacy supply chains. To maximize the public health impact of DSD, systems need to be patient-centered and adaptive, as well as employ robust quality improvement processes.

Malawi has led a highly successful human immunodeficiency virus (HIV) treatment response that has brought the country close to achieving international goals regarding knowledge of infection status, treatment, and viral suppression. However, new HIV infections persist and the country has much work to do to reduce the rate of infection. Accordingly, a new approach for HIV prevention is needed to accelerate the decline in new HIV infections and sustain epidemic control. The city of Blantyre is the oldest urban center in Malawi and represents the commercial and industrial capital of the country – attracting many young people and migrant workers to the city in search of economic opportunities. Still, within the city, formal employment rates remain low and poverty rates remain high. This has resulted in a unique local-level HIV risk environment. As a result of this, the city’s HIV burden is much higher than that experienced elsewhere in the country. This chapter details an innovative effort to enhance Blantyre’s HIV prevention programs through the development of a multisectoral, district-level system for reducing the transmission and risk of HIV at the local-level.

Differentiated service delivery (DSD)—a “patient-centered approach that simplifies and adapts HIV services across the cascade to serve the needs of people living with HIV (PLHIV) better and reduce unnecessary burdens on the health system1”— has emerged as a core tenet of HIV programs in resource-limited settings.2–4 Practically speaking, DSD is operationalized by adjusting the frequency of visits, the location of service delivery, the cadre of health care worker, and the package of services according to the needs of different groups of PLHIV. Varying the configuration of these factors results in DSD treatment models that often separate clinical visits from antiretroviral therapy (ART) refills including “fast track” refill pick-ups in the facility or community, client-managed community adherence groups and health care worker managed groups.5 Efforts are ongoing to define the extent and impact of DSD scale-up in sub-Saharan Africa.6,7 Current data are sufficient to show that the numbers of people receiving extended medication refills, which is one component of DSD, has risen dramatically. A recent analysis of US President's Emergency Plan for AIDS Relief (PEPFAR)-supported countries (excluding South Africa) reported an increase in the percentage of patients receiving 3 or more months of refills from 46% to 69% between October 2019 and June 2020.8 The COVID-19 epidemic accelerated this rapid change in dispensing practices and the uptake and adaptation of various DSD models across sub-Saharan Africa.9 Preliminary data evaluating the outcomes of DSD treatment programs across multiple countries10 support the concept that continued scale-up of DSD is critical to attaining the ambitious coverage, retention, and quality targets of the global HIV response.11 However, simplifying ART delivery for clinically stable PLHIV is not sufficient to meet all of their health care needs, which often include prevention and treatment of tuberculosis (TB), routine preventive and primary care, family planning (FP), and noncommunicable disease (NCD) services. Providing for these comprehensive needs is essential to the goals of the growing movement to implement Universal Health Care (UHC),12 and integrating some of these services into DSD platforms is a promising avenue to achieve such coverage.13 In this commentary, we highlight opportunities to address the unmet need for coordination of HIV and other priority services and propose a transition from an HIV-focused “DSD 1.0” to a truly patient-centered “DSD 2.0” that is inclusive of additional chronic care services. An initial focus could be on PLHIV, but DSD 2.0 provides a platform for offering any longitudinal or chronic care service to the general population. The goal would remain the same: to scale-up an evidence-based patient-centered approach that reduces unnecessary burdens for individuals and the health system. The proposed DSD framework thus provides an opportunity for the HIV and UHC agendas—which can seem to be at odds at first glance—to leverage each other and achieve greater collective impact.14 A Call for DSD 2.0 UNAIDS has set aspirational goals to end the AIDS epidemic by 2030.11 Global stakeholders are further proposing plans to sustain HIV epidemic control, but the definition of sustainability and the roadmap for achieving it remain unresolved.2,15 It is clear that the historically vertical approach to HIV programming does not naturally lend itself to sustainability in a world whose attention is rapidly shifting toward UHC goals. This shift away from vertical programming is likely to be accelerated by the COVID-19 pandemic, which has emphasized the importance of resilient and integrated national health systems.16 DSD 1.0's intentionally narrow focus on simplifying HIV services and reducing unnecessary burdens on the health care system was critical for building consensus, establishing an evidence base, and driving efforts to achieve scale. However, it does not enhance access to the full range of prevention and treatment services needed by recipients of care. Strategically addressing these needs for the long-term will be critical to maintaining patients' experience of quality of care and maximizing retention,17 and to ensuring both HIV viral suppression and healthy aging for PLHIV.18 This expanded focus is the essence of what we call “DSD 2.0.” WHO's 2016 HIV guidelines provide a template for DSD 2.0. They emphasize the importance of integrating ART services with the most common vertical programs that require repeated follow-up: TB prevention and treatment, FP, and chronic NCDs.4 A majority of adults with HIV will require longitudinal care for such non-HIV services. All PLHIV are eligible for a course of TB preventive therapy (TPT) and between 5% and 10% will develop TB at some point in their lifetimes.19 The unmet need for contraception among women on ART is well-documented, approaching 50% in some settings.20 Chronic NCDs such as diabetes, hypertension, and mental health disorders are also a major issue. Among adults on ART in South Africa, more than 15% have hypertension, more than 5% have diabetes,21 and, as a recent review emphasized, there is a real risk that poor quality of care for such NCDs may undermine the investments made to strengthen HIV programs.22 In most sub-Saharan African countries, PLHIV requiring care for any of these other health needs (with the intermittent exception of TB services) usually seek them in physical locations other than the HIV clinic and often on a different appointment schedule. FP programs are usually run vertically. Clinicians providing HIV services are not always trained in provision of FP nor do they routinely have the commodities available to provide FP at the point of HIV care.23 Women living with HIV are routinely referred to FP clinics, but there is often no communication between the 2 programs to align appointments or to determine best approaches to managing potential interactions between ART and contraceptives.24 The situation is worse for integration with chronic NCD programs. Some countries with strong HIV programs do not have updated national guidelines for hypertension or diabetes, let alone consistent supplies of medications outside of referral facilities. Although HIV commodities are prioritized and often paid for by external donors, NCD commodities must be borne by the country and, as a result, are often accompanied by user fees. Where NCD guidelines and medications are available, there is likely little alignment of appointment scheduling or refills with the ART program,25,26 let alone the provision of NCD screening and treatment within HIV programs. The lack of coordination between these critical services and HIV care puts an unnecessary and, to date, unquantified burden on both the patients and the health system. The burden on patients is experienced in 2 ways—once because a concurrent condition like hypertension often goes undiagnosed in any resource-poor setting and again because, once diagnosed, treatment services are only available in a parallel setting. For example, a patient with both HIV and hypertension may only need to visit an HIV clinic twice a year, but could be required to visit a different clinic monthly for hypertension care. The patient may also be required to pay out-of-pocket for the hypertension services. This fragmented care may prove to be frustrating for many patients and actually disincentivize them to remain engaged in any health services. If DSD remains narrowly focused on ART, it may make HIV treatment more convenient and efficient, but will not comprehensively address the health needs of people engaged in HIV treatment. This outcome may diminish the actual and perceived quality of care, and push patients closer to a “tipping point” where they choose to disengage from the health system altogether, leading to worse outcomes for both conditions.27 The burden on the health system results from having to maintain parallel systems to manage HIV, FP, hypertension, diabetes, and other chronic NCD programs. For example, HIV medical record systems may be robust, but few of them contain information about need for or use of other health services by PLHIV, limiting their usefulness for quality improvement or planning. Meanwhile, few countries have longitudinal record keeping for non-HIV services at all. This blind spot is critical, and reflects similar inefficiencies in supply chain, laboratory, human resources, and other key health system building blocks.28

Introduction While there is a global consensus on monitoring Human Immunodeficiency Virus (HIV) treatment progress, there has been less attention to the degree of consistency of the measurement of HIV prevention programmes—and the global prevention response is not on‐track to achieve 2020 goals. In this paper, we assess the degree of variability in primary prevention indicators selected by national strategic plans (NSPs) and global stakeholder monitoring and evaluation (M&E) strategies. Methods We obtained the most recent NSPs from low and middle income Joint United Nations Programme on HIV/AIDS (UNAIDS) Fast‐Track countries, and M&E documents from The Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund), President’s Emergency Plan for AIDS Relief (PEPFAR), UNAIDS, the Global HIV Prevention Coalition and the World Health Organization (WHO). We extracted HIV primary prevention indicators from each document, standardized and aggregated them by age/ sex, categorized indicators by topic, and evaluated the frequency of matched indicators between countries and stakeholders. Data were collected between February and April of 2019. Results Twenty‐one NSPs and five global stakeholder documents were assessed; 736 primary prevention indicators were identified; 284 remained following standardization and aggregation. NSPs contained from 3 to 48 primary prevention indicators, with an average of 23; categories included: HIV education and outreach (17.6%), testing (17.3%) and condom use (16.2%). Of unique national indicators, only 34% was shared between two or more countries. Sixty‐nine per cent was applied in a single country only. 56% of NSP indicators did not appear in any global stakeholder document. Conversely, 42% of global indicators did not appear in any surveyed NSPs. Within global indicators, 63% was only measured by one global body, and no single indicator was measured by all five. Conclusions These analyses reveal a lack of consensus both between and within countries’ and global stakeholders' measurement of HIV prevention. Though some variability is expected, these findings point to a need to refocus attention on achieving greater consensus on a global measurement framework for HIV prevention.

Background Current models of HIV service delivery, with frequent facility visits, have led to facility congestion, patient and healthcare provider dissatisfaction, and suboptimal quality of services and retention in care. The Zambian urban adherence club (AC) is a health service innovation designed to improve on-time drug pickup and retention in HIV care through off-hours facility access and pharmacist-led group drug distribution. Similar models of differentiated service delivery (DSD) have shown promise in South Africa, but observational analyses of these models are prone to bias and confounding. We sought to evaluate the effectiveness and implementation of ACs in Zambia using a more rigorous study design. Methods and findings Using a matched-pair cluster randomized study design (ClinicalTrials.gov: NCT02776254), 10 clinics were randomized to intervention (5 clinics) or control (5 clinics). At each clinic, between May 19 and October 27, 2016, a systematic random sample was assessed for eligibility (HIV+, age ≥ 14 years, on ART >6 months, not acutely ill, CD4 count not 7 days late). Intervention effect was estimated using unadjusted Kaplan–Meier survival curves and a Cox proportional hazards model to derive an adjusted hazard ratio (aHR). Medication possession ratio (MPR) and implementation outcomes (adoption, acceptability, appropriateness, feasibility, and fidelity) were additionally evaluated as secondary outcomes. Baseline characteristics were similar between 571 intervention and 489 control participants with respect to median age (42 versus 41 years), sex (62% versus 66% female), median time since ART initiation (4.8 versus 5.0 years), median CD4 count at study enrollment (506 versus 533 cells/mm3), and baseline retention (53% versus 55% with at least 1 late drug pickup in previous 12 months). The rate of late drug pickup was lower in intervention participants compared to control participants (aHR 0.26, 95% CI 0.15–0.45, p < 0.001). Median MPR was 100% in intervention participants compared to 96% in control participants (p < 0.001). Although 18% (683/3,734) of AC group meeting visits were missed, on-time drug pickup (within 7 days) still occurred in 51% (350/683) of these missed visits through alternate means (use of buddy pickup or early return to the facility). Qualitative evaluation suggests that the intervention was acceptable to both patients and providers. While patients embraced the convenience and patient-centeredness of the model, preference for traditional adherence counseling and need for greater human resources influenced intervention appropriateness and feasibility from the provider perspective. The main limitations of this study were the small number of clusters, lack of viral load data, and relatively short follow-up period. Conclusions ACs were found to be an effective model of service delivery for reducing late ART drug pickup among HIV-infected adults in Zambia. Drug pickup outside of group meetings was relatively common and underscores the need for DSD models to be flexible and patient-centered if they are to be effective. Trial registration ClinicalTrials.gov NCT02776254., Monika Roy and colleagues study methods to streamline delivery of antiretrovirals to people with HIV infection in Zambia., Author summary Why was this study done? The adherence club intervention was designed to decrease burden on the health system and improve retention in care among treatment-experienced, clinically stable HIV-infected adults by providing off-hours facility access and streamlined (group-based, pharmacist-led) drug delivery. To date, published data on adherence clubs have been primarily limited to observational data from a similar intervention in South Africa. This study was done to learn about the effectiveness of the intervention and challenges with implementation in other settings in sub-Saharan Africa. What did the researchers do and find? We conducted a matched-pair cluster randomized study to estimate the effect of participating in adherence clubs on on-time drug pickup in Zambia. We additionally used a mixed-methods approach to evaluate the implementation of the intervention. We found that participation in the adherence club led to a reduction in the occurrence and rate of experiencing a late drug pickup. However, on-time drug pickups outside of adherence club meetings were relatively common. Both patients and providers found the intervention to be acceptable, but while patients embraced the patient-centered aspects of adherence clubs, some providers questioned the appropriateness and feasibility of the model. What do these findings mean? The urban adherence club intervention decreased late drug pickup among treatment-experienced adults living with HIV in Zambia. However, patients commonly missed their club meeting, seeking alternative means to pick up their medication on time. While club participation was associated with greater retention in care, flexibility in drug pickup and patient-centeredness were likely important factors.

Coronavirus disease 2019 (COVID-19) has revealed how strikingly unprepared the world is for a pandemic and how easily viruses spread in our interconnected world. A governance crisis is unfolding alongside the pandemic as health officials around the world compete for access to scarce medical supplies. As governments of African countries, and those in low-income and middle-income countries around the world, seek to avoid potentially catastrophic epidemics and learn from what has worked in other countries, testing and other medical resources are of concern. With accelerating spread, funding is urgently needed. Yet even where there is enough money, many African health authorities are unable to obtain the supplies needed as geopolitically powerful countries mobilise economic, political, and strategic power to procure stocks for their populations.1, 2 We have seen this before. In the AIDS pandemic lifesaving diagnostics and drugs came to many African countries long after they were available in Europe and North America. In 2020, this situation can be avoided. Although health system weakness remains acute in many places, investments by national governments, the African Union, and international initiatives to tackle AIDS, tuberculosis, malaria, polio, and post-Ebola global health security have built important public health capacities. Global leaders have an ethical obligation to avoid needless loss of life due to the foreseeable prospect of slow and inadequate access to supplies in Africa.

Background Retention in human immunodeficiency virus (HIV) care is dynamic, with patients frequently transitioning in and out of care. Analytical approaches (eg, survival analyses) commonly used to assess HIV care cascade outcomes fail to capture such transitions and therefore incompletely represent care outcomes over time. Methods We analyzed antiretroviral therapy (ART)-eligible adults newly linking to care at 64 clinics in Zambia between 1 April 2014 and 31 July 2015. We used electronic medical record data and supplemented these with updated care outcomes ascertained by tracing a multistage random sample of patients lost to follow-up (LTFU, >90 days late for last appointment). We performed multistate analyses, incorporating weights from sampling, to estimate the prevalence of 9 care states over time since linkage with respect to ART initiation, retention in care, transfers, and mortality. Results In sum, 23 227 patients (58% female; median age 34 years [interquartile range 28–41]) were ART-eligible at enrollment. At 1 year, 75.2% had initiated ART and were in care: 61.8% were continuously retained, 6.1% had reengaged after LTFU, and 7.3% had transferred. Also, 10.1% were LTFU within 7 days of enrollment, and 15.2% were LTFU at 1 year (6.7% prior to ART). One year after LTFU, 51.6% of those LTFU prior to ART remained out of care compared to 30.2% of those LTFU after initiating ART. Overall, 6.9% of patients had died by 1 year with 3.0% dying prior to ART. Conclusion Multistate analyses provide more complete assessments of longitudinal HIV cascade outcomes and reveal treatment gaps at distinct timepoints in care that will still need to be addressed even with universal treatment., Multistate analyses that account for patient transitions across human immunodeficiency virus (HIV) care cascade steps over time can provide more complete depictions of longitudinal treatment outcomes and highlight care gaps that will still need to be addressed even with universal HIV treatment.

Nathan Ford and co-authors discuss global priorities in the provision of HIV prevention and treatment services.

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.

BACKGROUND: Differentiated service delivery (DSD) for human immunodeficiency virus (HIV)–infected persons who are clinically stable on antiretroviral therapy (ART) has been embraced as a solution to decrease access barriers and improve quality of care. However, successful DSD implementation is dependent on understanding the prevalence, incidence, and durability of clinical stability. METHODS: We evaluated visit data in a cohort of HIV-infected adults who made at least 1 visit between 1 March 2013 and 28 February 2015 at 56 clinics in Zambia. We described visit frequency and appointment intervals using conventional stability criteria and used a mixed-effects linear regression model to identify predictors of appointment interval. We developed a multistate model to characterize patient stability over time and calculated incidence rates for transition between states. RESULTS: Overall, 167819 patients made 3418018 post–ART initiation visits between 2004 and 2015. Fifty-four percent of visits were pharmacy refill-only visits, and 24% occurred among patients on ART for >6 months and whose current CD4 was >500 cells/mm(3). Median appointment interval at clinician visits was 59 days, and time on ART and current CD4 were not strong predictors of appointment interval. Cumulative incidence of clinical stability was 66.2% at 2 years after enrollment, but transition to instability (31 events per 100 person-years) and lapses in care (41 events per100 person-years) were common. CONCLUSIONS: Current facility-based care was characterized by high visit burden due to pharmacy refills and among treatment-experienced patients. Differentiated service delivery models targeted toward stable patients need to be adaptive given that clinical stability was highly transient and lapses in care were common.

OBJECTIVES The distribution of adherence to antiretroviral therapy (ART) can indicates whether barriers are concentrated or more distributed. We quantified the medication possession ratio (MPR) and characterized the distribution of medication nonpossession in a network of clinics in Zambia to identify 'hotspots' and predictors of poorer adherence. METHODS We analyzed a population of adults on ART for more than 3 months who made at least one clinic visit between 1 January 2013 and 28 February 2015. Pharmacy refill and clinical information were obtained through the electronic medical record system used in routine care. We constructed a Lorenz curve to visualize the distribution of poor adherence and used a multilevel logistic regression model to examine factors associated with MPR. RESULTS Among 131 767 patients in 56 clinics [64% women, median age 34 years (interquartile range (IQR) 29-41), median CD4 cell count at ART initiation 351 cells/μl (IQR 220-517)], the median MPR was 85.8% (IQR 70.8-96.8). During months 7-12 on ART, 45.6% of patients had 100% MPR and 10.5% accounted for 50% of medication nonpossession. Across clinics, median MPR ranged from 49.1 to 98.5, and clinic accounted for 12% of the variability in adherence after adjusting for individual and clinic-level characteristics. CONCLUSION A small fraction of patients account for the majority of days of medication nonpossession. Further characterization of these subpopulations is needed to target interventions. Clinic also accounted for much variability in MPR. Health systems interventions targeting clinic 'hot spots' may represent an efficient use of resources to improve ART adherence.

[This corrects the article DOI: 10.1371/journal.pmed.1002811.].

Background We characterized the extent of antiretroviral therapy (ART) experience and postdischarge mortality among hospitalized HIV-infected adults in Zambia. Methods At a central hospital with an opt-out HIV testing program, we enrolled HIV-infected adults (18+ years) admitted to internal medicine using a population-based sampling frame. Critically ill patients were excluded. Participants underwent a questionnaire regarding their HIV care history and CD4 count and viral load (VL) testing. We followed participants to 3 months after discharge. We analyzed prior awareness of HIV-positive status, antiretroviral therapy (ART) use, and VL suppression (VS; 6 months on ART, 74.4% had VS. The majority (92.5%) were discharged, and by 3 months, 48 (21.7%) had died. Risk of postdischarge mortality increased with decreasing CD4, and there was a trend toward reduced risk in those treated for active tuberculosis. Conclusions Most HIV-related hospitalizations and deaths may now occur among ART-experienced vs -naïve individuals in Zambia. Development and evaluation of inpatient interventions are needed to mitigate the high risk of death in the postdischarge period., In Zambia, 86% of hospitalized HIV-infected adults were antiretroviral therapy–experienced, 50% were virally suppressed, and 71% had advanced HIV disease. Mortality within 3 months of discharge was 20%. Advanced HIV disease interventions should target inpatients in sub-Saharan Africa.

Introduction Accurate costing is key for programme planning and policy implementation. Since 2011, there have been major changes in eligibility criteria and treatment regimens with price reductions in ART drugs, programmatic changes resulting in clinical task‐shifting and decentralization of ART delivery to peripheral health centres making existing evidence on ART care costs in Zambia out‐of‐date. As decision makers consider further changes in ART service delivery, it is important to understand the current drivers of costs for ART care. This study provides updates on costs of ART services for HIV‐positive patients in Zambia. Methods We evaluated costs, assessed from the health systems perspective and expressed in 2016 USD, based on an activity‐based costing framework using both top‐down and bottom‐up methods with an assessment of process and capacity. We collected primary site‐level costs and resource utilization data from government documents, patient chart reviews and time‐and‐motion studies conducted in 10 purposively selected ART clinics. Results The cost of providing ART varied considerably among the ten clinics. The average per‐patient annual cost of ART service was $116.69 (range: $59.38 to $145.62) using a bottom‐up method and $130.32 (range: $94.02 to $162.64) using a top‐down method. ART drug costs were the main cost driver (67% to 7% of all costs) and are highly sensitive to the types of patient included in the analysis (long‐term vs. all ART patients, including those recently initiated) and the data sources used (facility vs. patient level). Missing capacity costs made up 57% of the total difference between the top‐down and bottom‐up estimates. Variability in cost across the ten clinics was associated with operational characteristics. Conclusions Real‐world costs of current routine ART services in Zambia are considerably lower than previously reported estimates and sensitive to operational factors and methods used. We recommend collection and monitoring of resource use and capacity data to periodically update cost estimates.