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James Samwel Mundamshimu,1 Kija Malale,1 Benson R Kidenya,1 Daniel W Gunda,1 Logious Bwemelo,1,* Mwakile Mwashiuya,1,* Salhida Shamnte Omar,1,* Neema Mlowe,1,* Magwa Kiyumbi,1 James S Ngocho,2,3 Emmanuel Balandya,4 Bruno Sunguya,4 Stephen E Mshana,1 Kien Mteta,2 John Bartlett,5,6 Eligius Lyamuya,4 Blandina Theophil Mmbaga,2,3 Samuel Kalluvya1 1Catholic University of Health and Allied Sciences, Mwanza, Tanzania; 2Kilimanjaro Christian Medical University College, Moshi, Tanzania; 3Kilimanjaro Clinical Research Institute, Moshi, Tanzania; 4Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; 5Kilimanjaro Christian Medical University College, Mosh, Tanzania; 6Duke Global Health Institute, Duke University Medical Center, Durham, NC, USA*These authors contributed equally to this workCorrespondence: James Samwel Mundamshimu, Tel +255746999249, Email jamessamwel913@yahoo.comBackground: Introduction and expansion of antiretroviral therapy (ART) have turned the tide of HIV pandemic, thus helping people living with HIV (PLHIV) achieve viral suppression. This success may need to be complemented by intensified adherence counseling (IAC) to improve adherence to treatment. However, some PLHIV still face higher than acceptable viral loads despite being on treatment.Purpose: We investigated the factors associated with the failure to suppress HIV viral load after three months of IAC sessions.Patients and Methods: This cross-sectional study analyzed secondary data from PLHIV-attended care and treatment clinics in Mwanza between January 2018 and December 2019 who had unsuppressed VL after being on ART for at least six months. We identified PLHIV in first-line ART with viral load evaluation before receiving IAC and had viral load results done at 90 days after IAC. We conducted descriptive statistics to examine the magnitude of viral suppression. Wilcoxon signed-rank test used to compare the median viral load before and after IAC sessions, and logistic regressions predicted the factors associated with failure.Results: This study included 212 subjects. After intervention, most participants 85.9% (182) had significantly improved adherence compared to baseline. More than half 75.5% (160) of the participants had viral suppression after the intervention. Participants aged 18– 25 years (AOR = 5.6, 95% CI, 1.1– 29.6), unstable client during ART initiation (AOR = 0.3, 95% CI, 0.13– 0.62), and poor adherence to ART (AOR = 4, 95% CI, 1.3– 12.3) remained the main predictors of virological failure after IAC intervention.Conclusion: Even though virological suppression is influenced by ART adherence, the findings in this study have shown co-existence of other factors to be addressed. Unstable during ART initiation is a new factor identified in this study.Keywords: people living with HIV, virological failure, intensified adherence counseling, factors, Tanzania

Lower respiratory tract infection (LRTI) is a common reason for hospitalization and antibacterial use globally. There is considerable overlap in the clinical presentation of bacterial and viral LRTIs. Low- or middle-income countries (LMICs) face the dual challenge of appropriately targeting antibacterials for bacterial LRTI while reducing inappropriate antibacterials for viral LRTI. We propose a framework by which an electronic clinical decision support tool (eCDST) for diagnosing LRTI and reducing unnecessary antibacterial use may be developed, validated, and prospectively evaluated in an LMIC. The developed tool would be data driven, low-cost, feasible in the local setting, adaptable based on resource availability, and updated in real time, with prospective assessment to identify its clinical impact. We draw upon our team's recent experience developing an eCDST for LRTI management in Sri Lanka. Publicly sharing such processes and data is valuable, such that we can collectively improve clinical care in LMICs and other settings.

COVID-19 vaccination effectively reduces disease severity, hospitalization, and mortality, particularly among individuals with chronic conditions who bear a disproportionate burden of disease complications. Vaccine confidence - belief in its safety, effectiveness, and importance - boosts uptake. However, limited data on vaccine confidence in this population hinders the development of targeted interventions. This study examined COVID-19 vaccine confidence and its impact on uptake among individuals with hypertension or diabetes mellitus in the Kilimanjaro region, Tanzania. A community-based cross-sectional study was conducted in March 2023 among 646 randomly selected adults aged ≥18 years with hypertension or diabetes mellitus in three districts of Kilimanjaro region, northern Tanzania. An interviewer-administered electronic questionnaire assessed confidence and uptake of COVID-19 vaccines in addition to related knowledge and demographic characteristics. Data analysis was done for 646 individuals who consented to participate. Multivariable logistic regression models determined the factors associated with COVID-19 vaccine confidence and its effect on vaccine uptake. The proportion of COVID-19 vaccine confidence among all 646 participants was 70% and was highest for perceived vaccine importance (80%), followed by perceived vaccine effectiveness (77%) and perceived vaccine safety (74%). Good knowledge of COVID-19 vaccines and living in the Mwanga municipal council (MC), a semi-urban district, was independently associated with confidence in the vaccines' importance, safety, effectiveness, and overall COVID-19 vaccine confidence. Confidence in COVID-19 vaccines increased the odds of vaccine uptake. Targeted interventions to boost vaccine confidence are therefore essential to enhance vaccine uptake in this high-risk population.

COVID-19 is a major public health threat associated with increased disease burden, mortality, and economic loss to countries and communities. Safe and efficacious COVID-19 vaccines are key in halting and reversing the pandemic. Low confidence in vaccines has been one of the factors leading to hesitancy. We aimed to assess the COVID-19 vaccine confidence (safety and effectiveness), associated factors, and its effects on vaccine uptake among general community members in Tanzania. This was a community-based cross-sectional survey conducted from December 2021 to April 2022 in six regions of Tanzania mainland and two regions in Zanzibar. Participants were interviewed using an electronic questionnaire. Multiple logistic regression models estimated odds ratios (ORs) and 95% confidence interval (CI) for factors associated with vaccine confidence. All analyses were performed using SPSS version 25.0. The study enrolled 3470 general Tanzanian community members; their mean age was 40.3 (standard deviation ±14.9) years, and 34% were males. The proportion of COVID-19 vaccine confidence was 54.6%. Geographical region, residence area, COVID-19 disease risk perception, and good knowledge of COVID-19 vaccines were significantly associated with COVID-19 vaccine confidence. Confidence in COVID-19 vaccines was associated with over three times higher odds of vaccine uptake. Confidence in COVID-19 vaccines was low in Tanzania. Innovative community engagement strategies and region-specific interventions are needed to improve comprehensive knowledge and address community perceptions and attitudes toward COVID-19 vaccines.

Introduction: Tuberculosis (TB) remains a major cause of morbidity and mortality, especially in sub-Saharan Africa. We qualitatively evaluated the implementation of an Evidence-Based Multiple Focus Integrated Intensified TB Screening package (EXIT-TB) in the East African region, aimed at increasing TB case detection and number of patients receiving care., Objective: We present the accounts of participants from Tanzania, Kenya, Uganda, and Ethiopia regarding the implementation of EXIT-TB, and suggestions for scaling up., Methods: A qualitative descriptive design was used to gather insights from purposefully selected healthcare workers, community health workers, and other stakeholders. A total of 27, 13, 14, and 19 in-depth interviews were conducted in Tanzania, Kenya, Uganda, and Ethiopia respectively. Data were transcribed and translated simultaneously and then thematically analysed., Results: The EXIT-TB project was described to contribute to increased TB case detection, improved detection of Multidrug-resistant TB patients, reduced delays and waiting time for diagnosis, raised the index of TB suspicion, and improved decision-making among HCWs. The attributes of TB case detection were: (i) free X-ray screening services; (ii) integrating TB case-finding activities in other clinics such as Reproductive and Child Health clinics (RCH), and diabetic clinics; (iii), engagement of CHWs, policymakers, and ministry level program managers; (iv) enhanced community awareness and linkage of clients; (v) cooperation between HCWs and CHWs, (vi) improved screening infrastructure, (vii) the adoption of the new simplified screening criteria and (viii) training of implementers. The supply-side challenges encountered ranged from disorganized care, limited space, the COVID-19 pandemic, inadequate human resources, inadequate knowledge and expertise, stock out of supplies, delayed maintenance of equipment, to absence of X-ray and GeneXpert machines in some facilities. The demand side challenges ranged from delayed care seeking, inadequate awareness, negative beliefs, fears towards screening, to financial challenges. Suggestions for scaling up ranged from improving service delivery, access to diagnostic equipment and supplies, and infrastructure, to addressing client fears and stigma., Conclusion: The EXIT-TB package appears to have contributed towards increasing TB case detection and reducing delays in TB treatment in the study settings. Addressing the challenges identified is needed to maximize the impact of the EXIT-TB intervention., (© 2023. The Author(s).)

Background: This exploratory analysis investigates the prevalence and risk factors of neurocognitive toxicity in postpartum women on HIV treatment in response to a concern of an Isoniazid Preventive Therapy (IPT)/Efavirenz interaction., Trial Design: Pregnant women on HIV treatment from countries with high TB prevalence were randomized in IMPAACT P1078 to 28 weeks of IPT started either during pregnancy or at 12 weeks postpartum. Partway through study implementation, the Patient Health Questionnaire 9, the cognitive complaint questionnaire, and the Pittsburg Sleep Quality Index were added to evaluate depression, cognitive function, and sleep quality at postpartum weeks. Screening for peripheral neuropathy was conducted throughout the study., Methods: We summarized percentages of women with depression symptoms, cognitive dysfunction, poor sleep quality and peripheral neuropathy and assessed the association of 11 baseline risk factors of neurotoxicity using logistic regression, adjusted for gestational age stratum., Results: Of 956 women enrolled, 749 (78%) had at least one neurocognitive evaluation. During the postpartum period, the percentage of women reporting at least mild depression symptoms, cognitive complaint and poor sleep quality peaked at 13%, 8% and 10%, respectively, at 12 weeks, and the percentage of women reporting peripheral neuropathy peaked at 13% at 24 weeks. There was no evidence of study arm differences in odds of all four neurotoxic symptoms., Conclusions: Timing of IPT initiation and EFV use were not associated with symptoms of neurotoxicity. Further study is advised to formally assess risk factors of neurotoxicity., (© 2023. The Author(s).)

Background: Universal coverage remains a challenging pursuit around the world, even among the highest-income countries. Strengthening financial management capacity is essential towards attaining the three universal health coverage (UHC) goals, namely, expanded coverage, quality service, and financial protection. In this regard, Tanzania introduced the Facility Financial Accounting and Reporting System (FFARS) in line with the introduction of the Direct Health Facility Financing (DHFF) initiative in primary health care (PHC) in 2017-2018. We aim to assess the functionality of the FFARS in management, accounting, and reporting funds received and disbursed in the stride forward strengthening public financial management in PHC facilities towards UHC., Methods: The study applied implementation research using a concurrent convergent mixed-methods design to assess sources of revenue, expenditure priorities, and changes of revenues and to explore the usability and benefits of FFARS in improving facility finance and reporting systems in more than 5,000 PHC facilities in Tanzania. Quantitative methods assessed the changes in revenues and expenditure between the financial years (FYs) 2017-2018 and 2018-2019, while the qualitative part explored the usability and the benefits FFARS offers in improving facility finances and reporting systems. Data analysis involved a thematic and descriptive analysis for qualitative and quantitative data, respectively., Results: Of the 5,473 PHC facilities, 88% were in rural areas; however, the annual average revenue was higher in urban facilities in FYs 2017-2018 and 2018-2019. Overall, district hospitals showed an increase whereas health centers reported a decline of more than 40% in revenue. The user fee was the predominant source of revenue, particularly in urban facilities, while revenue from health insurance was not among the top three highest sources of revenue. Expenditure priorities leaned more towards drugs and supplies (25%) followed by allowances and training (21%); these did not differ by facility geographies. In health centers, expenditure on facility infrastructure was predominant. Key Informant Interviews revealed an overall satisfaction and positive experiences related to the system., Conclusion: The implementation of FFARS in Tanzania demonstrated its high potential in improving facility financial management, including its ability to track revenue and expenditure at PHC facilities. Staffing shortages, ICT infrastructure, and limited opportunities for capacity building could be the limiting factors to reaching the potential of the implementation of FFARS and the attainment of its full impact on Tanzania's pursuit for UHC., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Ruhago, Ngalesoni, Kapologwe, Kengia, Ngocho, Kabusi, Kalolo, Kitali, Rwamiago and Mtei.)

Introduction: East Africa countries (Tanzania, Kenya, and Uganda) are among tuberculosis high burdened countries globally. As we race to accelerate progress towards a world free of tuberculosis by 2035, gaps related to screening and diagnosis in the cascade care need to be addressed., Methods: We conducted a three-year (2015-2017) retrospective study using routine program data in 21 health facilities from East Africa. Data abstraction were done at tuberculosis clinics, outpatient departments (OPD), human immunodeficiency virus (HIV) and diabetic clinics, and then complemented with structured interviews with healthcare providers to identify possible gaps related to integration, screening, and diagnosis of tuberculosis. Data were analyzed using STATA™ Version 14.1., Results: We extracted information from 49,454 presumptive TB patients who were registered in the 21 facilities between January 2015 and December 2017. A total of 9,565 tuberculosis cases were notified; 46.5% (4,450) were bacteriologically confirmed and 31.5% (3,013) were HIV-infected. Prevalence of tuberculosis among presumptive pulmonary tuberculosis cases was 17.4%. The outcomes observed were as follows: 79.8% (7,646) cured or completed treatment, 6.6% (634) died, 13.3% (1,270) lost to follow-up or undocumented and 0.4% (34) treatment failure. In all countries, tuberculosis screening was largely integrated at OPD and HIV clinics. High patient load, weak laboratory specimen referral system, shortage of trained personnel, and frequent interruption of laboratory supplies were the major cited challenges in screening and diagnosis of tuberculosis., Conclusion: Screening and diagnostic activities were frequently affected by scarcity of human and financial resources. Tuberculosis screening was mainly integrated at OPD and HIV clinics, with less emphasis on the other health facility clinics. Closing gaps related to TB case finding and diagnosis in developing countries requires sustainable investment for both human and financial resources and strengthen the integration of TB activities within the health system., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2021 The Author(s).)

Background: International Maternal Pediatric Adolescent AIDS Clinical Trials (IMPAACT) P1078, a randomized noninferiority study designed to compare the safety of starting isoniazid preventive therapy (IPT) in women living with human immunodeficiency virus (HIV) either during pregnancy or after delivery, showed that IPT during pregnancy increased the risk of composite adverse pregnancy outcomes, but not individual outcomes. Many known factors are associated with adverse pregnancy outcomes: these factors' associations and effect modifications with IPT and pregnancy outcomes were examined., Methods: Pregnant women living with HIV from 8 countries with tuberculosis incidences >60/100 000 were randomly assigned to initiate 28 weeks of IPT either during pregnancy or at 12 weeks after delivery. Using univariable and multivariable logistic regression and adjusting for factors associated with pregnancy outcomes, composite and individual adverse pregnancy outcome measures were analyzed., Results: This secondary analysis included 925 mother-infant pairs. All mothers were receiving antiretrovirals. The adjusted odds of fetal demise, preterm delivery (PTD), low birth weight (LBW), or a congenital anomaly (composite outcome 1) were 1.63 times higher among women on immediate compared to deferred IPT (95% confidence interval [CI], 1.15-2.31). The odds of fetal demise, PTD, LBW, or neonatal death within 28 days (composite outcome 2) were 1.62 times higher among women on immediate IPT (95% CI, 1.14-2.30). The odds of early neonatal death within 7 days, fetal demise, PTD, or LBW (composite outcome 3) were 1.74 times higher among women on immediate IPT (95% CI, 1.22-2.49)., Conclusions: We confirmed higher risks of adverse pregnancy outcomes associated with the initiation of IPT during pregnancy, after adjusting for known risk factors for adverse pregnancy outcomes., (© The Author(s) 2020. Published by Oxford University Press for the Infectious Diseases Society of America.)

In 2013, Tanzania adopted the World Health Organization's Option B+ guidelines for prevention of mother-to-child transmission of HIV (PMTCT), whereby all HIV-infected pregnant women initiate lifelong antiretroviral therapy. This study examined retention in PMTCT across critical junctures in the care continuum. This was a retrospective study of patient-level data for a cohort of women enrolled in PMTCT during the first year of Option B+ in Tanzania. Retention in care was described across three periods: (1) the first month of antenatal care (ANC), (2) pregnancy, and (3) the postpartum period. Logistic regression was used to identify factors associated with loss to follow up (LTFU) during the first month of ANC. Survival analyses were used to identify factors associated with LTFU during pregnancy and the postpartum periods. 650 participants were included in the cohort; 262 (40.3%) were newly diagnosed with HIV. Two years after delivery, 383/650 (58.7%) were LTFU. Of the 383 LTFU, 73 (19.1%) were lost during the first month of ANC, 44 (11.5%) during pregnancy, and 266 (69.5%) after delivery. Being newly diagnosed with HIV predicted higher LTFU during the first month of ANC (aOR 1.76; 95% CI 1.06-2.94) and faster time to LTFU during the postpartum period (adjusted relative time, 0.68; 95% CI 0.51-0.89). High LTFU occurred across the PMTCT continuum, including immediately after enrollment into ANC and the postpartum period. Ongoing research is needed to encourage treatment uptake and sustained engagement after delivery.

Prevention of mother-to-child transmission of HIV (PMTCT) is a foundational component of a comprehensive HIV treatment program. In addition to preventing vertical transmission to children, PMTCT is an important catch-point for universal test-and-treat strategies that can reduce community viral load and slow the epidemic. However, systematic reviews suggest that care engagement in PMTCT programs is sub-optimal. This study enrolled a cohort of 200 women initiating PMTCT in Kilimanjaro, Tanzania, and followed them to assess HIV care engagement and associated factors. Six months after delivery, 42/200 (21%) of participants were identified as having poor care engagement, defined as HIV RNA >200 copies/mL or, if viral load was unavailable, being lost-to-follow-up in the clinical records or self-reporting being out of care. In a multivariable risk factor analysis, younger women were more likely to have poor postpartum care engagement; with each year of age, women were 7% less likely to have poor care engagement (aRR: 0.93; 95% CI: 0.89, 0.98). Additionally, women who had told at least one person about their HIV status were 47% less likely to have poor care engagement (aRR: .53; 95% CI: 0.29, 0.97). Among women who entered antenatal care with an established HIV diagnosis, those who were pregnant for the first time had increased risk of poor care engagement (aRR 4.16; 95% CI 1.53, 11.28). The findings suggest that care engagement remains a concern in PMTCT programs, and must be addressed to realize the goals of PMTCT. Comprehensive counseling on HIV disclosure, along with community-based stigma reduction programs to provide a supportive environment for people living with HIV, are crucial to address barriers to care engagement and support long-term treatment. Women presenting to antenatal care with an established HIV status require support for care engagement during the crucial period surrounding childbirth, particularly those pregnant for the first time.