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Achieving optimal HIV outcomes, as measured by global 90-90-90 targets, that is awareness of HIV-positive status, receipt of antiretroviral (ARV) therapy among aware and viral load (VL) suppression among those on ARVs, respectively, is critical. However, few data from sub-Saharan Africa (SSA) are available on older people (50+) living with HIV (OPLWH). We examined 90-90-90 progress by age, 15-49 (as a comparison) and 50+ years, with further analyses among 50+ (55-59, 60-64, 65+ vs. 50-54), in 13 countries (Cameroon, Cote d'Ivoire, Eswatini, Ethiopia, Kenya, Lesotho, Malawi, Namibia, Rwanda, Tanzania, Uganda, Zambia and Zimbabwe).Using data from nationally representative Population-based HIV Impact Assessments, conducted between 2015and 2019, participants from randomly selected households provided demographic and clinical information and whole blood specimens for HIV serology, VL and ARV testing. Survey weighted outcomes were estimated for 90-90-90 targets. Country-specific Poisson regression models examined 90-90-90 variation among OPLWH age strata.Analyses included 24,826 HIV-positive individuals (15-49 years: 20,170; 50+ years: 4656). The first, second and third 90 outcomes were achieved in 1, 10 and 5 countries, respectively, by those aged 15-49, while OPLWH achieved outcomes in 3, 13 and 12 countries, respectively. Among those aged 15-49, women were more likely to achieve 90-90-90 targets than men; however, among OPLWH, men were more likely to achieve first and third 90 targets than women, with second 90 achievement being equivalent. Country-specific 90-90-90 regression models among OPLWH demonstrated minimal variation by age stratum across 13 countries. Among OLPWH, no first 90 target differences were noted by age strata; three countries varied in the second 90 by older age strata but not in a consistent direction; one country showed higher achievement of the third 90 in an older age stratum.While OPLWH in these 13 countries were slightly more likely than younger people to be aware of their HIV-positive status (first 90), this target was not achieved in most countries. However, OPLWH achieved treatment (second 90) and VL suppression (third 90) targets in more countries than PLWH50. Findings support expanded HIV testing, prevention and treatment services to meet ongoing OPLWH health needs in SSA.

The World Health Organization and national guidelines recommend HIV testing and counseling at tuberculosis (TB) clinics for all patients, regardless of TB diagnosis (1). Population-based HIV Impact Assessment (PHIA) survey data for 2015-2016 in Malawi, Zambia, and Zimbabwe were analyzed to assess HIV screening at TB clinics among persons who had positive HIV test results in the survey. The analysis was stratified by history of TB diagnosis* (presumptive versus confirmed†), awareness§ of HIV-positive status, antiretroviral therapy (ART)¶ status, and viral load suppression among HIV-positive adults, by history of TB clinic visit. The percentage of adults who reported having ever visited a TB clinic ranged from 4.7% to 9.7%. Among all TB clinic attendees, the percentage who reported that they had received HIV testing during a TB clinic visit ranged from 48.0% to 62.1% across the three countries. Among adults who received a positive HIV test result during PHIA and who did not receive a test for HIV at a previous TB clinic visit, 29.4% (Malawi), 21.9% (Zambia), and 16.2% (Zimbabwe) reported that they did not know their HIV status at the time of the TB clinic visit. These findings represent missed opportunities for HIV screening and linkage to HIV care. In all three countries, viral load suppression rates were significantly higher among those who reported ever visiting a TB clinic than among those who had not (p

Objective: To assess a home based continuum of pregnancy and neonatal care package, delivered by community based agents (CBAs), to improve maternal and neonatal outcomes. Method: The package was developed and tested in a randomized controlled trial conducted from 2009 to 2013. The unit of randomization was the Neighborhood Health Committee (NHC), within one hour from the client, and serving 150 -200 households with 900 to 1200 persons. The 48 CBAs in10 RHCs, made up 40 clusters. 3846 pregnant women were enrolled and tracked for one year. The intervention group received care from trained, equipped and supported CBAs while the control group received the Standard national health care. Results: The 3486 pregnant women were tracked, 2767 in the intervention group and 1079 in the control group. By the 12th month, 2000 women had delivered, with 1282 (33%) completing 28 days postnatal care, 934 in the intervention and 348 in the control group. A total of 673 (66%) women in the intervention group and 236 (58%) women in the control group were identified with danger signs, among whom 49.3% had institutional deliveries, availing newborn care in addition. The 2013 New Born Framework of the Ministry of Health utilised findings for policy. Conclusion: evidence shows that when trained, equipped and supported, community based caregivers are effective during pregnancy and early newborn care. Geographically disadvantaged populations can benefit from adopting the continuum of care as standard practice to improve maternal and newborn outcomes, within the community.

Background: Newborn care is an emerging priority in children’s health. A pilot community based, continuum of mother-neonatal care was delivered by trained rural community health workers and traditional birth attendants. They provided appropriate care to the mother. They also instituted early breast feeding, kept the infant warm, cared for birth asphyxia, sepsis and postnatal care, up to 28 days of life. Methods: A baseline knowledge attitude and practice survey (KAP) and Randomised Control Trial (RCT) were conducted sequentially, 2007 to 2013. The KAP provided baseline information. The RCT recruited 3846 pregnant women in Mpongwe and Chongwe, following them to postnatal care. Training was conducted for all community based agents in control and intervention sites. Intervention agents were equipped, supervised, and retrained every four months. Control sites provided MOH standard care. 2000 infants were delivered in the year of follow up. Findings: An algorithm to prioritise interventions was designed. CBAs implemented the COC and were able to save 20 per 1000 newborns, or 58.8 % of all newborns who should have died without the interventions. They identified danger signs, implemented specific care and reduce morbidity, while saving lives, of mothers and babies. Interpretation Trained, equipped and supervised CBAs, are capable of saving infant’s life. 58.8 % newborns were saved by implementing a continuum of care. Our Government adopted these results for the Newborn Framework in 2013. Our work thus informs the newborn agenda and policy on rural maternal newborn care.51

Background: Providing care for pregnancy is compounded by high HIV prevalence in Zambia. Approximately 10% of new HIV infections in children 0-14 years old occur as mother to child transmission (MTCT). Objective: To establish the capacity of the community to screen for HIV in pregnant women with saliva test and provide PMTCT, in a continuum of care. Methods: This study is a sub-set of a community based prospective cluster randomized controlled trial, (RCT) conducted 2008 to 2013. Oraquick, an FDA approved technology uses saliva to screen for HIV1 and HIV2. CBAs were trained, supervised and provided with job aids. Results: From 3846 pregnant women in the RCT, 2018 were screened. Among the 2018, 1089 (45.8%) were screened using Oraquick saliva test. Of the total tested for HIV, 23.8% had Oraquick only testing, 46% routine tests only and 30.2% had both tests done. Of the 1089, 608 participants (55.85%) screened using Oraquick, also had their test results confirmed with routine antibody tests at nearby health centers. The community based agents counselled, screened, dispensed nevirapine and referred appropriately. Eighty two (4%) out of the 2018 women were recorded as HIV positive. These include 47 (5.93%) women tested with Oraquick and 35 who were tested at the health centres using routine HIV testing. Conclusion: CBAs demonstrated that when trained, equipped and supported with incentives, they are able to screen the community for HIV utilizing Oraquick saliva testing and provide PMTCT.They provided increased access to HIV screening and PMTCT services.

Introduction Logistical complexities of returning laboratory test results to participants have precluded most population‐based HIV surveys conducted in sub‐Saharan Africa from doing so. For HIV positive participants, this presents a missed opportunity for engagement into clinical care and improvement in health outcomes. The Population‐based HIV Impact Assessment (PHIA) surveys, which measure HIV incidence and the prevalence of viral load (VL) suppression in selected African countries, are returning VL results to health facilities specified by each HIV positive participant within eight weeks of collection. We describe the performance of the specimen and data management systems used to return VL results to PHIA participants in Zimbabwe, Malawi and Zambia. Methods Consenting participants underwent home‐based counseling and HIV rapid testing as per national testing guidelines; all confirmed HIV positive participants had VL measured at a central laboratory on either the Roche CAP/CTM or Abbott m2000 platform. On a bi‐weekly basis, a dedicated data management team produced logs linking the VL test result with the participants’ contact information and preferred health facility; project staff sent test results confidentially via project drivers, national courier systems, or electronically through an adapted short message service (SMS). Participants who provided cell phone numbers received SMS or phone call alerts regarding availability of VL results. Results and discussion From 29,634 households across the three countries, 78,090 total participants 0 to 64 years in Zimbabwe and Malawi and 0 to 59 years in Zambia underwent blood draw and HIV testing. Of the 8391 total HIV positive participants identified, 8313 (99%) had VL tests performed and 8245 (99%) of these were returned to the selected health facilities. Of the 5979 VL results returned in Zimbabwe and Zambia, 85% were returned within the eight‐week goal with a median turnaround time of 48 days (IQR: 33 to 61). In Malawi, where exact return dates were unavailable all 2266 returnable results reached the health facilities by 11 weeks. Conclusions The first three PHIA surveys returned the vast majority of VL results to each HIV positive participant's preferred health facility within the eight‐week target. Even in the absence of national VL monitoring systems, a system to return VL results from a population‐based survey is feasible, but it requires developing laboratory and data management systems and dedicated staff. These are likely important requirements to strengthen return of results systems in routine clinical care.