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Social network strategy (SNS) testing uses network connections to refer individuals at high risk to HIV testing services (HTS). In Tanzania, SNS testing is offered in communities and health facilities. In communities, SNS testing targets key and vulnerable populations (KVP), while in health facilities it complements index testing by reaching unelicited index contacts. Routine data were used to assess performance and trends over time in PEPFAR-supported sites between October 2021 and March 2023. Key indicators included SNS social contacts tested, and new HIV-positives individuals identified. Descriptive and statistical analysis were conducted. Univariable and multivariable analysis were applied, and variables with P -values <0.2 at univariable analysis were considered for multivariable analysis. Overall, 121,739 SNS contacts were tested, and 7731 (6.4%) previously undiagnosed individuals living with HIV were identified. Tested contacts and identified HIV-positives were mostly aged ≥15 years (>99.7%) and females (80.6% of tests, 79.4% of HIV-positives). Most SNS contacts were tested (78,363; 64.7%) and diagnosed (6376; 82.5%) in communities. SNS tests and HIV-positives grew 11.5 and 6.1-fold respectively, from October-December 2021 to January-March 2023, with majority of clients reached in communities vs. facilities (78,763 vs. 42,976). These results indicate that SNS testing is a promising HIV case-finding approach in Tanzania.

Background: There is limited evidence on COVID-19 vaccination uptake among people living with HIV (PLHIV) and health care workers (HCWs), with the current evidence concentrated in high-income countries. There is also limited documentation in the published literature regarding the feasibility and lessons from implementing targeted vaccination strategies to reach PLHIV and HCWs in low- and middle-income countries., Program Development, Piloting, and Implementation: We designed and implemented multifaceted strategies to scale up targeted COVID-19 vaccination among PLHIV and HCWs in 11 administrative regions on the mainland of Tanzania plus Zanzibar. An initial 6-week intensification strategy was implemented using a diverse partnership model comprising key stakeholders at the national- and subnational levels. A layered package of strategies included expanding the number of certified vaccinators, creating vaccination points within HIV clinics, engaging HCWs to address their concerns, and building the capacity of HCWs as "champions" to promote and facilitate vaccination. We then closely monitored COVID-19 vaccination uptake in 562 high-volume HIV clinics. Between September 2021 and September 2022, the proportion of fully vaccinated adult PLHIV increased from <1% to 97% and fully vaccinated HCWs increased from 23% to 80%., Lessons and Implications: Our intra-action review highlighted the importance of leveraging a strong foundation of existing partnerships and platforms, integrating COVID-19 vaccination points within HIV clinics, and refining strategies to increase vaccination demand while ensuring continuity of vaccine supply to meet the increased demand. Lessons from Tanzania can inform targeted vaccination of vulnerable groups in future health emergencies., (© Jalloh et al.)

Objective: User experience is an important aspect of quality of care that is highly valued by patients. However, there are currently no validated tools for measuring user experience among caregivers of sick children in low- and middle-income countries. We aimed to develop and validate a measure of user experience in this population in primary healthcare facilities in rural Tanzania, where major quality improvement efforts to date have not included a large focus on user experience. We then aimed to describe variation in user experience between and within facilities., Methods: Informed by theory and formative qualitative research, we developed questions to measure user experience across three domains: prompt care, respect, and communication. We then conducted interviewer-administered surveys with caregivers of sick children. Using survey data, we conducted psychometric analyses to inform the development of a composite measure of user experience. Finally, we used multilevel models to describe variation in user experience and examine associations with facility, patient, and caregiver characteristics., Results: Surveys were completed by 1085 caregivers across 75 facilities. In exploratory factor analysis, user experience items did not group according to theoretical domains. We therefore assessed items individually and designed a single 8-item additive measure of user experience. Using this composite measure, and adjusting for differences in case mix across facilities, we found that 69% of variation in user experience was within facilities and 31% was between facilities. Smaller facility size and more caregiver education were positively associated with user experience., Conclusions: We found that user experience varied significantly across health facilities in rural Tanzania, highlighting opportunities for improvement. Measurement tools are needed to inform efforts to improve user experience and monitor changes over time. The scale developed in this study could serve as a starting point for the measurement of user experience among caregivers in similar settings., (© 2022 John Wiley & Sons Ltd.)

Objectives: Reduction in maternal and newborn mortality requires that women deliver in high quality health facilities. However, many facilities provide sub-optimal quality of care, which may be a reason for less than universal facility utilisation. We assessed the impact of a quality improvement project on facility utilisation for childbirth., Methods: In this cluster-randomised experiment in four rural districts in Tanzania, 12 primary care clinics and their catchment areas received a quality improvement intervention consisting of in-service training, mentoring and supportive supervision, infrastructure support, and peer outreach, while 12 facilities and their catchment areas functioned as controls. We conducted a census of all deliveries within the catchment area and used difference-in-differences analysis to determine the intervention's effect on facility utilisation for childbirth. We conducted a secondary analysis of utilisation among women whose prior delivery was at home. We further investigated mechanisms for increased facility utilisation., Results: The intervention led to an increase in facility births of 6.7 percentage points from a baseline of 72% (95% Confidence Interval: 0.6, 12.8). The intervention increased facility delivery among women with past home deliveries by 18.3 percentage points (95% CI: 10.1, 26.6). Antenatal quality increased in intervention facilities with providers performing an additional 0.5 actions across the full population and 0.8 actions for the home delivery subgroup., Conclusions: We attribute the increased use of facilities to better antenatal quality. This increased utilisation would lead to lower maternal mortality only in the presence of improvement in care quality., (© 2019 The Authors. Tropical Medicine & International Health Published by John Wiley & Sons Ltd.)

Background: Poor health system experiences negatively affect the lives of poor people throughout the world. In East Africa, there is a growing body of evidence of poor quality care that in some cases is so poor that it is disrespectful or abusive. This study will assess whether community feedback through report cards (with and without non-financial rewards) can improve patient experience, which includes aspects of patient dignity, autonomy, confidentiality, communication, timely attention, quality of basic amenities, and social support. Methods/Design: This cluster-randomized controlled study will randomize 75 primary health care facilities in rural Pwani Region, Tanzania to one of three arms: private feedback (intervention), social recognition reward through public reporting (intervention), or no feedback (control). Within both intervention arms, we will give the providers at the study facilities feedback on the quality of patient experience the facility provides (aggregate results from all providers) using data from patient surveys. The quality indicators that we report will address specific experiences, be observable by patients, fall into well-identified domains of patient experience, and be within the realm of action by healthcare providers. For example, we will measure the proportion of patients who report that providers definitely "explained things in a way that was easy to understand." This feedback will be delivered by a medical doctor to all the providers at the facility in a small group session. A formal discussion guide will be used. Facilities randomized to the social recognition intervention reward arm will have two additional opportunities for social recognition. First, a poster that displays their achieved level of patient experience will be publicly posted at the health facility and village government offices. Second, recognition from senior officials at the local NGO and/or the Ministry of Health will be given to the facility with the best or most-improved patient experience ratings at endline. We will use surveys with parents/guardians of sick children to measure patient experience, and surveys with healthcare providers to assess potential mechanisms of effect. Conclusion: Results from this study will provide evidence for whether, and through what mechanisms, patient reported feedback can affect interpersonal quality of care. Pan African Clinical Trials Registry (PACTR): 201710002649121 Protocol version 7, November 8, 2017.

Objectives To assess the prevalence of high blood pressure amongst postpartum women in rural Tanzania, and to explore factors associated with hypertension prevalence, awareness, treatment, and control. Methods 1849 women in Tanzania's Pwani Region who delivered a child in the prior year participated in the study. We measured blood pressure, administered a structured questionnaire and assessed factors associated with the prevalence, awareness, treatment, and control of hypertension (HTN) using bivariable and multivariable logistic regressions. Findings 26.7% of women had high blood pressure and/or were taking antihypertensive medication. Women were on average 27.5 years old (range 15-54). Nearly all women (99.5%) reported contact with the health system during their pregnancy and delivery, with an average of 5.2 visits for their own care in the past year. Only 23.5% of those with HTN were aware of their diagnosis, 17.4% were taking medication, and only 10.5% had controlled blood pressure. In multivariable analysis, facility delivery, health insurance, and increased distance from a hospital were associated with increased likelihood of HTN awareness; facility delivery and hospital distance were associated with current hypertensive treatment; younger age and increased hospital distance were associated with control of HTN. Conclusion The prevalence of high blood pressure in this postpartum population was high, and despite frequent recent contacts with the health system, awareness, treatment and control of HTN were low. These findings highlight an important missed opportunity to improve women's health during antenatal and postnatal care.

Objective: To determine the effective coverage of obstetric care in a rural Tanzanian region and to assess differences in effective coverage by wealth., Design: Cross-sectional structured interviews., Setting: Pwani Region, Tanzania., Participants: The study includes 24 rural, government-managed, primary healthcare clinics and their catchment populations. From January-April 2016, we conducted a household survey of a census of women with recent deliveries, health worker knowledge surveys and facility audits., Main Outcome Measures: We explored the proportion of women receiving quality care through the cascade and conducted an equity analysis by wealth., Results: In total, 2,910 of 3,564 women (81.6%) reported delivering their most recent child in a health facility, 1,096 of whom delivered in a study facility. Using a minimum threshold of quality, the effective coverage of obstetric care was 25%. Quality was lowest in the emergency care dimensions, with the average score on the provider knowledge tests at 47% and the average provision of basic emergency obstetric services below 50%. The wealthiest 20% of women were 4.1 times as likely to deliver in facilities offering at least the minimum threshold of quality care through the cascade compared to the poorest 80% of women (95% confidence interval: 1.5-11.3)., Conclusions: Effective coverage of delivery care is very low, particularly among poorer women. Health worker knowledge caused the sharpest decline in effective coverage. Measures of effective coverage are a better performance measure of under-resourced health systems than utilization. Equity analyses can further identify important discrepancies in quality across socio-economic levels., Trial Registration: ISRCTN 17107760., (© The Author 2016. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com)

Aim: To describe factors associated with pregnancy desire and dual method use among people living with HIV in clinical care in sub-Saharan Africa., Design: Sexually active HIV-positive adults were enrolled in 18 HIV clinics in Kenya, Namibia and Tanzania. Demographic, clinical and reproductive health data were captured by interview and medical record abstraction. Correlates of desiring a pregnancy within the next 6 months, and dual method use [defined as consistent condom use together with a highly effective method of contraception (hormonal, intrauterine device (IUD), permanent)], among those not desiring pregnancy, were identified using logistic regression., Results: Among 3375 participants (median age 37 years, 42% male, 64% on antiretroviral treatment), 565 (17%) desired a pregnancy within the next 6 months. Of those with no short-term fertility desire (n=2542), 686 (27%) reported dual method use, 250 (10%) highly effective contraceptive use only, 1332 (52%) condom use only, and 274 (11%) no protection. Respondents were more likely to desire a pregnancy if they were from Namibia and Tanzania, male, had a primary education, were married/cohabitating, and had fewer children. Factors associated with increased likelihood of dual method use included being female, being comfortable asking a partner to use a condom, and communication with a health care provider about family planning. Participants who perceived that their partner wanted a pregnancy were less likely to report dual method use., Conclusions: There was low dual method use and low use of highly effective contraception. Contraceptive protection was predominantly through condom-only use. These findings demonstrate the importance of integrating reproductive health services into routine HIV care., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

In sub-Saharan Africa, the prevalence of depressive symptoms among people living with HIV (PLHIV) is considerably greater than that among members of the general population. It is particularly important to treat depressive symptoms among PLHIV because they have been associated with poorer HIV care-related outcomes. This study describes overall psychosocial functioning and factors associated with depressive symptoms among PLHIV attending HIV care and treatment clinics in Kenya, Namibia, and Tanzania. Eighteen HIV care and treatment clinics (six per country) enrolled approximately 200 HIV-positive patients (for a total of 3,538 participants) and collected data on patients' physical and mental well-being, medical/health status, and psychosocial functioning. Although the majority of participants did not report clinically significant depressive symptoms (72 %), 28 % reported mild to severe depressive symptoms, with 12 % reporting severe depressive symptoms. Regression models indicated that greater levels of depressive symptoms were associated with: (1) being female, (2) younger age, (3) not being completely adherent to HIV medications, (4) likely dependence on alcohol, (5) disclosure to three or more people (versus one person), (6) experiences of recent violence, (7) less social support, and (8) poorer physical functioning. Participants from Kenya and Namibia reported greater depressive symptoms than those from Tanzania. Approximately 28 % of PLHIV reported clinically significant depressive symptoms. The scale-up of care and treatment services in sub-Saharan Africa provides an opportunity to address psychosocial and mental health needs for PLHIV as part of comprehensive care.

Background: To evaluate the on-going scale-up of HIV programs, we assessed trends in patient characteristics at enrolment and ART initiation over 7 years of implementation., Methods: Data were from Optimal Models, a prospective open cohort study of HIV-infected (HIV+) adults (≥15 years) and children (<15 years) enrolled from January 2005 to December 2011 at 44 HIV clinics in 3 regions of mainland Tanzania (Kagera, Kigoma, Pwani) and Zanzibar. Comparative statistics for trends in characteristics of patients enrolled in 2005-2007, 2008-2009 and 2010-2011 were examined., Results: Overall 62,801 HIV + patients were enrolled: 58,102(92.5%) adults, (66.5% female); 4,699(7.5%) children.Among adults, pregnant women enrolment increased: 6.8%, 2005-2007; 12.1%, 2008-2009; 17.2%, 2010-2011; as did entry into care from prevention of mother-to-child HIV transmission (PMTCT) programs: 6.6%, 2005-2007; 9.5%, 2008-2009; 12.6%, 2010-2011. WHO stage IV at enrolment declined: 27.1%, 2005-2007; 20.2%, 2008-2009; 11.1% 2010-2011. Of the 42.5% and 29.5% with CD4+ data at enrolment and ART initiation respectively, median CD4+ count increased: 210 cells/μL, 2005-2007; 262 cells/μL, 2008-2009; 266 cells/μL 2010-2011; but median CD4+ at ART initiation did not change (148 cells/μL overall). Stavudine initiation declined: 84.9%, 2005-2007; 43.1%, 2008-2009; 19.7%, 2010-2011.Among children, median age (years) at enrolment decreased from 6.1(IQR:2.7-10.0) in 2005-2007 to 4.8(IQR:1.9-8.6) in 2008-2009, and 4.1(IQR:1.5-8.1) in 2010-2011 and children <24 months increased from 18.5% to 26.1% and 31.5% respectively. Entry from PMTCT was 7.0%, 2005-2007; 10.7%, 2008-2009; 15.0%, 2010-2011. WHO stage IV at enrolment declined from 22.9%, 2005-2007, to 18.3%, 2008-2009 to 13.9%, 2010-2011. Proportion initiating stavudine was 39.8% 2005-2007; 39.5%, 2008-2009; 26.1%, 2010-2011. Median age at ART initiation also declined significantly., Conclusions: Over time, the proportion of pregnant women and of adults and children enrolled from PMTCT programs increased. There was a decline in adults and children with advanced HIV disease at enrolment and initiation of stavudine. Pediatric age at enrolment and ART initiation declined. Results suggest HIV program maturation from an emergency response.

Unlabelled: HIV care and treatment settings provide an opportunity to reach people living with HIV/AIDS (PLHIV) with prevention messages and services. Population-based surveys in sub-Saharan Africa have identified HIV risk behaviors among PLHIV, yet data are limited regarding HIV risk behaviors of PLHIV in clinical care. This paper describes the baseline sociodemographic, HIV transmission risk behaviors, and clinical data of a study evaluating an HIV prevention intervention package for HIV care and treatment clinics in Africa. The study was a longitudinal group-randomized trial in 9 intervention clinics and 9 comparison clinics in Kenya, Namibia, and Tanzania (N = 3538). Baseline participants were mostly female, married, had less than a primary education, and were relatively recently diagnosed with HIV. Fifty-two percent of participants had a partner of negative or unknown status, 24% were not using condoms consistently, and 11% reported STI symptoms in the last 6 months. There were differences in demographic and HIV transmission risk variables by country, indicating the need to consider local context in designing studies and using caution when generalizing findings across African countries. Baseline data from this study indicate that participants were often engaging in HIV transmission risk behaviors, which supports the need for prevention with PLHIV (PwP)., Trial Registration: ClinicalTrials.gov NCT01256463.

Context: There are concerns that malaria control measures such as use of insecticide-treated bed nets, by delaying acquisition of immunity, might result in an increase in the more severe manifestations of malaria. An understanding of the relationships among the level of exposure to Plasmodium falciparum, age, and severity of malaria can provide evidence of whether this is likely., Objective: To describe the clinical manifestations and case fatality of severe P falciparum malaria at varying altitudes resulting in varying levels of transmission., Design, Setting, and Patients: A total of 1984 patients admitted for severe malaria to 10 hospitals serving populations living at levels of transmission varying from very low (altitude >1200 m) to very high (altitude <600 m) in a defined area of northeastern Tanzania, studied prospectively from February 2002 to February 2003. Data were analyzed in a logistic regression model and adjusted for potential clustering within hospitals., Main Outcome Measures: Specific syndromes of severe malaria; mortality., Results: The median age of patients was 1 year in high transmission, 3 years in moderate transmission, and 5 years in low transmission areas. The odds of severe malarial anemia (hemoglobin <5 g/dL) peaked at 1 year of age at high transmission and at 2 years at moderate and low transmission intensities and then decreased with increasing age (P = .002). Odds were highest in infants (0-1 year: referent; 2-4 years: odds ratio [OR], 0.83; 95% confidence interval [CI], 0.72-0.96), 5 to <15 years: OR, 0.44; 95% CI, 0.27-0.72; > or =15 years: OR, 0.44; 95% CI, 0.27-0.73; P<.001) and high transmission intensity areas (altitude <600 m: referent; 600 m to 1200 m: OR, 0.55; 95% CI, 0.35-0.84; >1200 m: OR, 0.55; 95% CI, 0.26-1.15; P for trend = .03). The odds of cerebral malaria were significantly higher in low transmission intensity areas (altitude of residence <600 m: referent; 600 m to 1200 m: OR, 3.17; 95% CI, 1.32-7.60; >1200 m: OR, 3.76; 95% CI, 1.96-7.18; P for trend = .003) and with age 5 years and older (0-1 year: referent; 2-4 years: OR, 1.57; 95% CI, 0.82-2.99; 5 to <15 years: OR, 6.07; 95% CI, 2.98-12.38; > or =15 years: OR, 6.24; 95% CI, 3.47-11.21; P<.001). The overall case-fatality rate of 7% (139 deaths) was similar at high and moderate levels of transmission but increased to 13% in low transmission areas (P = .03), an increase explained by the increase in the proportion of cases with cerebral malaria., Conclusions: Age and level of exposure independently influence the clinical presentation of severe malaria. Our study suggests that an increase in the proportion of cases with more fatal manifestations of severe malaria is likely to occur only after transmission has been reduced to low levels where the overall incidence is likely to be low.

Objective: To study the diagnosis and outcomes in people admitted to hospital with a diagnosis of severe malaria in areas with differing intensities of malaria transmission., Design: Prospective observational study of children and adults over the course a year., Setting: 10 hospitals in north east Tanzania., Participants: 17,313 patients were admitted to hospital; of these 4474 (2851 children aged under 5 years) fulfilled criteria for severe disease., Main Outcome Measure: Details of the treatment given and outcome. Altitudes of residence (a proxy for transmission intensity) measured with a global positioning system., Results: Blood film microscopy showed that 2062 (46.1%) of people treated for malaria had Plasmodium falciparum (slide positive). The proportion of slide positive cases fell with increasing age and increasing altitude of residence. Among 1086 patients aged > or = 5 years who lived above 600 metres, only 338 (31.1%) were slide positive, while in children < 5 years living in areas of intense transmission (< 600 metres) most (958/1392, 68.8%) were slide positive. Among 2375 people who were slide negative, 1571 (66.1%) were not treated with antibiotics and of those, 120 (7.6%) died. The case fatality in slide negative patients was higher (292/2412, 12.1%) than for slide positive patients (142/2062, 6.9%) (P < 0.001). Respiratory distress and altered consciousness were the strongest predictors of mortality in slide positive and slide negative patients and in adults as well as children., Conclusions: In Tanzania, malaria is commonly overdiagnosed in people presenting with severe febrile illness, especially in those living in areas with low to moderate transmission and in adults. This is associated with a failure to treat alternative causes of severe infection. Diagnosis needs to be improved and syndromic treatment considered. Routine hospital data may overestimate mortality from malaria by over twofold.