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Providers disrespect and abuse of patients is a recognized but understudied issue affecting quality of care and likely affecting healthcare utilization. Little research has examined this issue among people living with HIV (PWH) who inject drugs, despite high stigmatization of this population. No research has examined this issue in the context of Russia. This study assesses patients reports of disrespect and abuse from providers as a barrier to healthcare and examines the association between these reports and HIV care outcomes.We conducted a cross-sectional analysis of the associations between disrespect/abuse from health providers as a barrier to care and the following HIV care outcomes: (i) anti-retroviral treatment (ART) uptake ever, (ii) past 6-month visit to HIV provider, and (iii) CD4 count. Participants (N = 221) were people living with HIV who injected drugs and were not on ART at enrollment.Two in five participants (42%) reported a history disrespect/abuse from a healthcare provider that they cited as a barrier to care. Those reporting this concern had lower odds of ever use of ART (adjusted odds ratio 0.46 [95% CI 0.22, 0.95]); we found no significant associations for the other HIV outcomes. We additionally found higher representation of women among those reporting prevalence of disrespect/abuse from provider as a barrier to care compared to those not reporting this barrier (58.1% versus 27.3%).Almost half of this sample of PWH who inject drugs report disrespect/abuse from a provider as a barrier to healthcare, and this is associated with lower odds of receipt of ART but not with other HIV outcomes studied. There is need for improved focus on quality of respectful and dignified care from providers for PWH who inject drugs, and such focus may improve ART uptake in Russia.

Food insecurity (FI) impacts people with HIV (PWH) and those who use substances (i.e. drugs and alcohol). We evaluated the longitudinal association between FI and HIV transmission risks (unprotected sexual contacts and shared needles/syringes). Among 351 PWH who use substances in Russia, 51.6% reported FI and 37.0% past month injection drug use. The mean number of unprotected sexual contacts in the past 90 days was 13.4 (SD 30.1); 9.7% reported sharing needles/syringes in the past month. We did not find a significant association between mild/moderate FI (adjusted IRR = 0.87, 95% CI 0.47, 1.61) or severe FI (aIRR = 0.84, 95% CI 0.46, 1.54; global p = 0.85) and unprotected sexual contacts. We observed a significant association between severe FI and sharing needles/syringes in the past month (adjusted OR = 3.27, 95% CI 1.45, 7.39; p = 0.004), but not between mild/moderate FI and sharing needles/syringes in the past month (aOR = 1.40,95% CI 0.58, 3.38; p = 0.45). These findings suggest that severe FI could be a potential target for interventions to lower HIV transmission.

People with HIV (PWH) who inject drugs often experience coexisting HIV- and substance use-related stigma manifestations. We assessed correlates of HIV stigma (Berger HIV stigma scale), substance use stigma (Substance Abuse Self-stigma scale) and intersectional HIV and substance use stigma in a cohort of PWH with a lifetime history of drug use in St. Petersburg, Russia. Intersectional stigma was defined as having a score greater than the median for both forms of stigma. Of the 208 participants, 56 (27%) had intersectional stigma. Depressive symptoms and alcohol dependence were significantly associated with a higher HIV and substance stigma score, but not with intersectional stigma. Individual and community interventions to reduce the impact of HIV stigma and substance use stigma affecting PWH who inject drugs should consider assessing and addressing mental health and unhealthy substance use. Further work with longitudinal data is needed to understand mechanisms leading to intersectional stigma.

INTRODUCTION Eastern Europe and central Asia (EECA) has the world's fastest‐growing HIV epidemic with a 43.0% increase in incident cases of HIV acquisition from 2010 to 2020 [1] and for [...], : Introduction: Kazakhstan has one of the fastest‐growing HIV epidemics in the world, with increasing rates among adolescents and young adults (AYA). Innovative strategies are needed to increase HIV testing uptake and decrease HIV stigma among AYA. Citizen science, defined as the active engagement of the general public in scientific research tasks, promotes and facilitates community engagement throughout the research process. This citizen science study used crowdsourcing to engage AYA in Kazakhstan to develop a digital intervention to reduce HIV stigma and promote HIV self‐testing. Our objectives in this paper are to describe the approach used, its feasibility and acceptability, and AYA motivations for and lessons learned collaborating on the study. Methods: From October 2021 to July 2022, in collaboration with a Community Collaborative Research Board and a Youth Advisory Board, we developed an open call requesting multimedia submissions to reduce HIV testing stigma. Eligible submissions were separated by age group (13−19 or 20−29 years) and judged by a panel composed of AYA (n = 23), healthcare professionals (n = 12), and representatives from the local government and non‐governmental organizations (n = 17). Each entry was reviewed by at least four judges and ranked on a 5‐point scale. The top 20 open call contestants were asked to submit self‐recordings sharing their motivation for and experience participating in the contest and lessons learned. Descriptive statistics were calculated for quantitative data. Qualitative data were coded using open coding. Results: We received 96 submissions from 77 youth across Kazakhstan. Roughly, three‐quarters (n = 75/96) of entries met judging eligibility criteria. Of the eligible entries, over half (n = 39/75) scored 3.5 or higher on a 5‐point scale (70.0%). The most frequent types of entries were video (n = 36/96, 37.5%), image (n = 28/96, 29.2%) and text (n = 24/96, 25.0%). AYA's primary motivations for collaborating on the study included a desire to improve society and help youth. The main challenges included creating content to address complex information using simple language, finding reliable information online and technological limitations. Conclusions: Crowdsourcing was feasible and highly acceptable among AYA in Kazakhstan. Citizen science approaches hold great promise for addressing the increasingly complex health and social challenges facing communities today.

Little is known about the intersection of HIV stigma and substance use stigma. Using data from 188 HIV-positive people who inject drugs (PWID) in Russia, we examined the associations of these stigmas and their interaction with access and utilization of healthcare. While substance use stigma was significantly associated with poor access to care (AOR 2.31, 95%CI 1.50-3.57), HIV stigma was not. HIV stigma was associated with lower inpatient care utilization (AOR 0.32, 95%CI 0.14-0.65), while substance use stigma was not. We did not detect a significant interaction between the two forms of stigma for either of the primary outcomes. However, those with high levels of both substance use stigma and HIV stigma had higher odds of poor general access to healthcare (AOR 1.86, 95%CI 1.19-2.92), and lower odds of recent general outpatient (AOR 0.52, 95%CI 0.32-0.85) and any inpatient (AOR 0.48, 95%CI 0.22-0.99) care utilization compared to those with low levels of both types of stigma. Interventions addressing both substance use and HIV stigma in general healthcare settings might improve care in this HIV key population.

Author(s): Lucy Thairu [sup.1] , Hanna Gehling [sup.2] , Sarah Kafwanda [sup.3] [sup.4] , Kojo Yeboah-Antwi [sup.5] , Davidson H. Hamer [sup.6] , Karsten Lunze [sup.7] Author Affiliations: (1) grid.419747.8, [...], Objectives Mothers in resource-limited areas face barriers in initiating care for ill newborns, leading to delays that may contribute to newborn mortality. This qualitative study conducted in rural Lufwanyama District in Zambia aimed to (1) explore mothers' healthcare-seeking related to newborn illness and (2) identify reasons for delaying care-seeking for ill newborns. Methods We examined the perspectives of 60 mothers and 77 grandmothers of children under three years of age in 14 focus group discussions as part of the Lufwanyama Integrated Neonatal and Child Health Program study. We conducted a thematic analysis of verbatim transcripts using dedicated software. Results Mothers and grandmothers were generally able to identify newborn danger signs and established a hierarchy of care-seeking based on the perceived severity of danger signs. However, inability to afford transportation, inaccessible health care facilities, high costs of medication prescribed at the health clinics, lack of respectful treatment and fear of newborns dying in the hospital prevented participants from seeking timely care. As traditional birth attendants (TBAs) and community health care workers (CHWs) have limited roles in newborns care beyond the immediate delivery setting, mothers often resorted to traditional healers for newborn care. Conclusions Based on cultural beliefs and influenced by traditions, mothers in Lufwanyama have developed hierarchical strategies to seek care for ill newborns. Barriers to treatment at health facilities often resulted in traditional care. Training both TBAs and CHWs in providing community-based newborn care and appropriate referrals could improve care-seeking and prevent newborn mortality in rural Zambia.

Food insecurity (FI) has been associated with HIV disease progression among people on antiretroviral therapy (ART), presumably a consequence of poor medication adherence. We assessed whether there is a longitudinal association between FI and two primary outcomes reflecting on HIV disease progression (i.e., CD4 count and time to ART initiation) among people not on ART. Analyses used linear mixed effects and Cox models controlling for confounders. In this cohort (n = 310) FI was common (53%). Most (71.3%) reported past month heavy alcohol use and 37.1% reported past month injection drug use. Only 50 participants initiated ART during the study and mean time to ART was 128 days (SD 120). There were no significant differences in CD4 cell count between the groups with mild/moderate FI or severe FI versus those with no FI [adjusted mean difference, mild/moderate insecurity versus no FI -32.5 (95% CI -94.3, 29.3); severe versus no FI -45.5 (95% CI -124.1, 33.0); global p = 0.42]. We found no significant association between FI and longer time to ART initiation (p = 0.36). Food security is a desirable goal for overall health and shown beneficial for those on ART, however it does not appear to be associated with HIV disease progression among those with high prevalence of substance use and not yet on ART.

1 | INTRODUCTION Stigma, the social exclusion of individuals labelled with an undesirable trait, remains one of the key barriers discouraging people from seeking and receiving services for HIV and [...], Introduction: Co-located treatment for HIV and opioid use disorder has been shown to improve care outcomes for HIV-positive people who inject drugs (PWID) in Ukraine. However, patients continue to be stigmatized for both HIV and substance use. This study aimed to assess whether co-located care for HIV-positive PWID receiving opioid agonist treatment (OAT) services in Ukraine is associated with less stigma and better perceived quality of HIV services. Methods: This cross-sectional study enrolled 191 HIV-positive PWID who received OAT services at three healthcare facilities providing substance use treatment (OAT only) and at four facilities that provided co-located care (both OAT and HIV treatment) in six regions in Ukraine during July-September, 2017. Primary outcomes were HIV stigma (Berger scale), substance use stigma (Substance Abuse Stigma Scale) and intersectional stigma (both stigma forms above 75th percentile). Secondary outcome was quality of HIV care, a composite score based on a package of received services. Linear and ordinal regressions were used to assess the predictors of selected outcomes. Results: Study participants were 75% male, mean age 40 [ +or -] 7 years; 47% received co-located care, and 10.5% had both high HIV and substance use stigma. Co-located care was neither associated with HIV nor substance use stigma but it was linked to better quality of HIV care (adjusted odds ratio: 4.13; 95% CI: 2.31, 7.54). HIV stigma was associated with suicide attempts (adjusted beta (a[beta]): 5.90; 95% CI: 2.05, 9.75), and substance use stigma was linked to poor mental health (a[beta]: -0.26; 95% CI: -0.44, -0.08) and lower ikelihood of receipt of services from non-governmental organization (NGO; a[beta]: -6.40; 95% CI: -10.23, -2.57). Conclusion: One in ten people with HIV in this cohort who received OAT services experienced high levels of both HIV and substance use stigma, which was associated with poorer mental health and less NGO support. Co-located HIV and OAT services were linked to better perceived quality of HIV care, but did not seem to reduce stigma for this key population. Stigma interventions for PWID, possibly delivered involving NGOs, may be an approach to mitigate this challenge. Keywords: discrimination; bias; HIV; injection drug use; quality of care; co-located care

IntroductionDrug policing practices in the Russian Federation (Russia) are often punitive and have been shown to be associated with HIV risk behaviors among people who inject drugs (PWID). Less is known about strategies to address the problem in that setting, where substance use stigma is highly persistent. A better understanding of forms, causes and consequences of drug policing in Russia could inform drug policy in a context of substantial policy resistance. This qualitative study's goal is to characterize the phenomenon of police involvement with Russian PWID and to explore strategies for drug policing in the Russian country context.MethodsUsing a semi-structured interview guide, we collected data from a purposive sample of 23 key informants including PWID, police officers, and experts from civil society and international organizations in Russia. We used a thematic analysis approach to inductively generate new insight into the phenomenon of police involvement and potential strategies to address it.ResultsPolicing practices involving PWID include unjustified arrests, planting of false evidence and extrajudicial syringe confiscations, and often constitute human rights violations. Russian PWID personally experienced police violence as ubiquitous, taking on various forms such as beating, unjustified arrests, verbal harassment, and coercion. The persistent societal stigma dehumanizes PWID, and such stigmatization facilitates police abuse. To address stigma and overcome the PWID-police adversity, study participants suggested fostering a mutual understanding between the police and public health sectors.ConclusionsParticipants describe substantial human rights violations as part of policing illicit drug use in Russia. Police should include principles of effective prevention of substance use and HIV risk reduction in their trainings. Alignment of public safety and public health goals could address drug use-related risks and HIV prevention among key populations in Russia.

Opioid overdose deaths are dramatically increasing in the United States and disproportionately affecting minority communities, with the increasing presence of fentanyl exacerbating this crisis. Developing community coalitions is a long-standing strategy used to address public health issues. However, there is a limited understanding of how coalitions operate amid a serious public health crisis. To address this gap, we leveraged data from the HEALing Communities Study (HCS)—a multisite implementation study aiming to reduce opioid overdose deaths in 67 communities. Researchers analyzed transcripts of 321 qualitative interviews conducted with members of 56 coalitions in the four states participating in the HCS. There were no a priori interests in themes, and emergent themes were identified through inductive thematic analysis and then mapped to the constructs of the Community Coalition Action Theory (CCAT). Themes emerged related to coalition development and highlighted the role of health equity in the inner workings of coalitions addressing the opioid epidemic. Coalition members reported seeing the lack of racial and ethnic diversity within their coalitions as a barrier to their work. However, when coalitions focused on health equity, they noted that their effectiveness and ability to tailor their initiatives to their communities' needs were strengthened. Based on our findings, we suggest two additions to enhance the CCAT: (a) incorporating health equity as an overarching construct that affects all stages of development, and (b) ensuring that data about individuals served are included within the pooled resource construct to enable monitoring of health equity. [ABSTRACT FROM AUTHOR]

IntroductionDrug law enforcement is part of the HIV risk environment among people who inject drugs (PWID). Punitive policing practices such as extrajudicial arrests for needle possession and police planting of drugs have been described anecdotally in Russia, but these experiences and their associations with risky drug behaviours have not been quantified. This study aims to quantify the burden of extrajudicial police arrests among a cohort of HIV-positive PWID in Russia and to explore its links to drug-related health outcomes.MethodsIn a cross-sectional study of 582 HIV-positive people with lifetime injection drug use (IDU) in St. Petersburg, Russia, we estimated the prevalence of self-reported extrajudicial police arrests. We used multiple logistic regression to evaluate associations between arrests and the following outcomes: overdose, recent IDU and receptive needle sharing.FindingsThis cohort's mean age was 29.8 years, 60.8% were male; 75.3% reported non-fatal drug overdose, 50.3% recent IDU and 47.3% receptive needle sharing. Extrajudicial arrests were reported by more than half (60.5%, 95% confidence interval [CI]: 56.5-64.5) and were associated with higher odds of non-fatal drug overdose (AOR 1.52, 95% CI: 1.02-2.25) but not with recent IDU (AOR 1.17, arrests were associated with receptive needle sharing (AOR 1.84, 95% CI: 1.09-3.09).ConclusionsExtrajudicial police arrests were common among this cohort of Russian HIV-positive PWID and associated with non-fatal overdose and, among those with recent IDU, receptive needle sharing. As a part of the HIV risk environment of PWIDs, these practices might contribute to HIV transmission and overdose mortality. Further research is needed to relate these findings to the operational environment of law enforcement and to better understand how police interventions among PWIDs can improve the HIV risk environment.

Introduction: The LINC‐II randomized controlled trial in St. Petersburg, Russia for HIV‐positive adults who inject drugs found that a multi‐component intervention including initiation of antiretroviral therapy (ART) during admission to an addiction hospital, strengths‐based case management and naltrexone significantly increased 12‐month HIV viral suppression and ART retention. We conducted a comparative cost analysis to determine if the 12‐month cost of the intervention is affordable within the current Russian health system. Methods: We used LINC‐II trial records and questionnaire responses to calculate the resources utilized by each participant in the study, including inpatient days, medications, laboratory tests, outpatient consultations, case manager interactions and opioid medication treatment. Quantities of resources utilized were multiplied by unit costs for each resource estimated from the service fee or price lists used by the study facilities for each specific service delivered. We report the average cost/study primary (viral suppression at 12 months) or secondary (retention in care at 12 months) outcome/participant in 2021 USD and compare costs between study arms. Results: The trial enrolled 225 participants (111 intervention, 114 control) between September 2018 and December 2020. Viral suppression, non‐suppression and missing suppression results were 28% and 14%, 49% and 37%, and 31% and 41% for the control and intervention arms, respectively. Retention results were 35% and 51% for the control and intervention arms, respectively. The average cost per study participant was $2714 in the control arm and $4342 in the intervention arm. The average cost per participant virally suppressed at 12 months was $3662 (control) and $6355 (intervention). The average cost per participant retained at 12 months was $4050 (control) and $5448 (intervention). For those retained, the cost difference between the arms was comprised of opioid treatment (35%), case management (31%), outpatient visits (18%) and additional days of ART (12%). Conclusions: The LINC‐II intervention increased the cost of care for HIV‐positive people who inject drugs in Russia significantly, but some components of the intervention, particularly earlier initiation of ART and case management, may be justifiable due to their success in reaching a challenging subgroup of the population in need. Clinical Trial Number: NCT03290391 [ABSTRACT FROM AUTHOR]

Stigma that people with HIV who inject drugs experience negatively impacts HIV and substance use care, but stigma's association with sharing injection equipment is not known. This is a cross-sectional analysis of data from two studies of people with HIV reporting drug injection (N = 319) in St. Petersburg, Russia (September 2018-December 2020). We used logistic regression to examine associations between HIV stigma and substance use stigma scores (categorised into quartiles) and past 30-day equipment sharing, adjusting for demographic and clinical characteristics. Secondary analyses examined associations of arrest history and social support with sharing equipment. Almost half (48.6%) of participants reported sharing injection equipment. Among groups who did and did not share, mean HIV stigma (2.3 vs 2.2) and substance use stigma (32 vs 31) scores were similar. Adjusted analyses detected no significant associations between HIV stigma quartiles (global p-value = 0.85) or substance use stigma quartiles (global p-value = 0.51) and sharing equipment. Neither arrest history nor social support were significantly associated with sharing equipment. In this cohort, sharing injection equipment was common and did not vary based on stigma, arrest history, or social support. To reduce equipment sharing, investments in sterile injection equipment access in Russia should be prioritised over interventions to address stigma. [ABSTRACT FROM AUTHOR]

This article presents the findings of a study on the experiences of Community Advisory Board (CAB) members in a large multistate cluster randomized controlled trial (RCT) focused on addiction. The study found that CAB members expressed a strong commitment to the study's goals but had unmet expectations for influencing study decisions within their advisory role. There were also lower levels of satisfaction with communication and power-sharing within the research teams. The study suggests that building a remote CAB within a community engagement strategy presents challenges and provides insights for enhancing CAB engagement in future research. [Extracted from the article]

To evaluate an experiential student clinical addiction research program by analyzing its components, evaluation survey data, and scientific outputs. In 1995, we established a summer research program supporting trainees to gain exposure to clinical addiction research careers. This curriculum employed a three-pronged approach that combined mentored research training, didactic education, and clinical observerships for medical students and other trainees to acquire experience with addiction medicine and research. Utilizing the Kirkpatrick model as program evaluation framework, we analyzed evaluation data from programmatic surveys (didactic seminar evaluations, overall program surveys) and conducted qualitative feedback exploration. Between 2007 and 2019, 56 trainees and 26 faculty mentors participated in the curriculum. To date, 25 students published 38 papers with their faculty mentor. Analysis of the past 12 years of program evaluation data demonstrated that students highly valued individually-mentored research experiences. They indicated that seminars familiarized them with the foundations of different clinical care models and career trajectories in addiction medicine. Clinical observerships provided students with patient contacts in various multidisciplinary addiction treatment settings. These experiences, perhaps most importantly hearing about patients' lived experiences, meaningfully informed various research and didactic activities. This summer student research program successfully introduced students to addiction medicine and research, manifested by high peer-reviewed publication productivity. While our program engaged and involved committed mentors and inspired mentees to pursue professional paths in addiction research, it did not specifically incorporate attention to equity and diversity into program planning and implementation. Going forward, the program will improve equity by increasing the recruitment of trainees from disadvantaged groups and engaging underrepresented faculty. Summer programs can be effective in engaging medical students and trainees in research early in their trajectory and inspire them to incorporate research into their careers. Programs that integrate experiential addiction research learning, i.e. mentored research activities, didactic sessions, and clinical observerships, can provide trainees with a profound understanding of substance use disorder treatment and research. [ABSTRACT FROM AUTHOR]

Introduction In Africa, historically, fever in children younger than 5 years has been considered to be due to malaria and has been treated immediately with antimalarial drugs without laboratory confirmation [...], Objective To evaluate current practices and standards of evaluation and treatment of childhood febrile illness in Southern Province, Zambia. Methods From November to December 2013, we conducted a cross-sectional survey of facilities and health workers and we observed the health workers' interactions with febrile children and their caregivers. The facility survey recorded level of staffing, health services provided by the facility, availability and adequacy of medical equipment, availability of basic drugs and supplies and availability of treatment charts and guidelines. The health worker survey assessed respondents' training, length of service, access to national guidelines and job aids for managing illnesses, and their practice and knowledge on management of neonatal and child illnesses. We also conducted exit interviews with caregivers to collect information on demographic characteristics, chief complaints, counselling and drug dispensing practices. Findings This study included 24 health facilities, 53 health workers and 161 children presenting with fever. Facilities were insufficiently staffed, stocked and equipped to adequately manage childhood fever. Children most commonly presented with upper respiratory tract infections (46%; 69), diarrhoea (31%; 27) and malaria (10%; 16). Health workers insufficiently evaluated children for danger signs, and less than half (47%; 9/19) of children with pneumonia received appropriate antibiotic treatment. Only 57% (92/161) were tested for malaria using either rapid diagnostic tests or microscopy. Conclusion Various health system challenges resulted in a substantial proportion of children receiving insufficient management and treatment of febrile illness. Interventions are needed including strengthening the availability of commodities and improving diagnosis and treatment of febrile illness. Objectif Evaluer les pratiques et les normes actuelles (revaluation et de traitement des maladies febriles infantiles dans la Province meridionale de la Zambie. Methodes De novembre a decembre2013, nous avons mene une enquete transversale aupres d'etablissements et de professionnels de sante et nous avons observe les interactions entre les professionnels de sante, les enfants fievreux et leurs proches. L'enquete realisee dans les etablissements s'est interessee a la dotation en personnel, aux services sanitaires dispenses par l'etablissement, a la disponibilite et a la convenance des equipements medicaux, a la disponibilite de medicaments et de fournitures elementaires et a la presence de directives et de feuilles d'observation. L'enquete realisee aupres des professionnels de sante a analyse la formation des repondants, leur nombre d'annees de service, leur acces aux directives nationales et aux aide-memoires pour la prise en charge des maladies, ainsi que leur pratique et leurs connaissances en matiere de prise en charge des maladies infantiles et neonatales. Nous avons egalement interroge les proches a leur sortie afin de recueillir des informations sur les caracteristiques demographiques, les principales plaintes, les conseils et les pratiques d'administration des medicaments. Resultats Cette etude a examine 24 etablissements de sante, 53 professionnels de sante et 161 enfants atteints de fievre. Les etablissements manquaient de personnel, de produits en stock et d'equipements pour prendre en charge correctement les cas de fievre infantile. Les enfants etaient le plus souvent atteints d'infections des voies respiratoires superieures (46%; 69), de diarrhee (31 %; 27) et de paludisme (10%; 16). Les professionnels de sante n'evaluaient pas suffisamment les signes de danger chez les enfants, et moins de la moitie (47%; 9/19) des enfants atteints de pneumonie ont recu un traitement antibiotique adapte. Seuls 57% (92/161) ont fait l'objet d'un depistage du paludisme, au moyen de tests de diagnostic rapide ou par microscopie. Conclusion A cause des differents problemes du systeme sanitaire, une part importante d'enfants ne beneficie pas d'une prise en charge et d'un traitement suffisants des maladies febriles. Des interventions sont necessaires, notamment pour augmenter la disponibilite des produits et ameliorer le diagnostic et le traitement des maladies febriles. Objetivo Evaluar las practicas y los estandares de evaluation y tratamiento actuales de las enfermedades febriles en los ninos en la Provincia del Sur, Zambia. Metodos De noviembre a diciembre de 2013, se realizo una encuesta transversal de centros y trabajadores sanitarios y se observaron las interacciones de los trabajadores sanitarios con ninos con fiebre y sus cuidadores. La encuesta de los centros registro el nivel de personal y servicios de salud ofreddos en el centra, la disponibilidad e idoneidad de los equipos medicos, la disponibilidad de medicamentos y suministros basicosy la disponibilidad decronogramasy directrices de tratamiento. La encuesta a los trabajadores sanitarios evaluo la formation de los encuestados, la duration del servicio, el acceso a directrices nadonales y ayudas laborales para la gestion de enfermedades y su practica y conocimiento acerca de la gestion de las enfermedades neonatales e infantiles. Tambien se realizaron entrevistas de salida con cuidadores para recopilar information acerca de las caracteristicas demograficas, los motivos de consulta, asesoramiento y practicas de distribution de lidad de la atencion en la Zambia rural medicamentos. Resultados Este estudio abarco 24 centros sanitarios, 53 trabajadores sanitarios y 161 ninos con fiebre. Los centros no contaban con personal, suministros y equipos suficientes para gestionar de forma adecuada la fiebre en ninos. Las afecciones mas comunes presentadas por los ninos eran infecciones del tracto respiratorio superior (46%; 69), diarrea (31 %; 27) y malaria (10%; 16). Los trabajadores sanitarios evaluaron a los ninos de forma insuficiente en busca de signos de peligro, y menos de la mitad (47%; 9/19) de los ninos con neumonia recibieron el tratamiento antibiotico adecuado. Solo el 57% (92/161) fue sometido a pruebas de malaria utilizando pruebas de diagnostico rapido o microscopicas. Conclusion Varios desafios del sistema sanitario llevan a un gran porcentaje de ninos que reciben una gestion y tratamiento insuficientes de las enfermedades febriles. Es necesario intervenir para fortalecer la disponibilidad de productos basicos y mejorar el diagnostico y el tratamiento de las enfermedades febriles.