Introduction The Harambee randomised trial tested the extent to which integrating community-based care with microfinance improves viral suppression and retention in care among people with HIV in Kenya.Methods Using a two-arm parallel-cluster randomised controlled trial, we randomised 57 microfinance groups (29 to intervention, 28 to usual (facility-based) care) with 855 members living with HIV (407 in intervention, 448 in usual care). We enrolled n=300 frequency-matched, prospectively followed usual HIV care patients without microfinance. Delivered quarterly during community-based microfinance meetings, the intervention included clinical consultations, diabetes and/or hypertension management, distribution of antiretroviral therapy and non-communicable diseases medications, health education and facility referrals. The primary outcome was viral suppression (<400 HIV-RNA/mL before 1 January 2023; <200 HIV-RNA/mL on or after 1 January 2023) at 18 months. The secondary outcome was retention-in-care (attending >1 scheduled HIV care visit/quarter over 18 months). Between-arm comparisons were done using doubly-robust generalised estimating equations accounting for dropout and confounding (for comparisons to the non-randomised arm).Results At enrolment, 94% of participants were virally suppressed. Viral suppression at 18 months was not significantly different between microfinance group members receiving community care versus facility care (OR 1.23, 95% CI 0.51 to 2.95, p=0.64). Viral suppression at 18 months was higher among community-care microfinance members (OR 2.16, 1.48 to 3.19, p<0.001) and facility-care microfinance members (OR 1.42, 1.05 to 1.92, p=0.023), compared with matched facility-care patients not engaged in microfinance. There was evidence of better quarterly retention comparing microfinance group members receiving community care versus facility care (OR 3.79, 2.96 to 4.86, p<0.001). Retention was higher among community-care microfinance members (OR 9.13, 7.13 to 11.70, p<0.001) and facility-care microfinance members (OR 2.40, 2.03 to 2.85, p<0.001), compared with matched facility-care patients.Conclusion More convenient services can improve retention in HIV care, while economic strengthening likely helps improve clinical HIV outcomes. Research to identify impact mechanisms and scale-up potential is needed.Trial registration number NCT04417127.
Introduction Poor maternal and child health remains a major challenge, particularly in low- and middle-income countries (LMICs). This study assessed differences in the reproductive, maternal and child health (RMCH) continuum of care between insured and uninsured populations across nine LMICs.Methods We analysed the latest two Demographic and Health Survey waves collected in Cambodia, Dominican Republic, Ghana, Guatemala, India, Indonesia, Jordan, Kyrgyz Republic and Peru, constituting around 23% of the global population. Propensity score matching assessed associations between health insurance and effective coverage across the care cascade for family planning, antenatal care (ANC), maternal delivery and postnatal care (PNC). Average treatment effect on the treated with 95% CIs was reported.Results Insurance effects varied substantially across countries. Family planning service contact was significantly higher among insured population in five of seven countries with available data, with the largest effect in Ghana (16.9 percentage points (pp), 95% CI 11.2 to 22.5). ANC quality-adjusted coverage was significantly higher among insured women in six countries, with the largest effect in India (17.2 pp, 95% CI 15.8 to 18.6). Maternal delivery service contact was significantly associated with insurance coverage in five countries, with the largest effect in Ghana (10.5 pp, 95% CI 6.1 to 14.9). PNC service contact showed significant associations in four countries, with the largest effect in Cambodia (10.3 pp, 95% CI 4.3 to 16.4). Pooled analyses showed positive associations across all outcomes, largest for ANC quality-adjusted coverage (9.9 pp, 95% CI 8.6 to 11.2) and family planning service contact (7.7 pp, 95% CI 6.0 to 9.4). Importantly, insurance coverage was concentrated among more educated women in seven countries and wealthier populations in five, highlighting persistent equity concerns.Conclusions Health insurance coverage was associated with higher RMCH coverage and quality, but persistent socioeconomic inequalities raise equity concerns. Expanding insurance coverage without ensuring inclusivity risks exacerbating disparities and undermining progress towards universal health coverage.
Introduction Reducing unintended pregnancies in low-income and middle-income countries requires enhancing the use of modern contraceptives. Country level evidence on the role of the media and counselling in this process is scanty. The aim of the study is to estimate the impact of family planning messages received through mass media and counselling by health workers on modern contraceptive use among women of reproductive age in Zambia over the study period of 2007 to 2018.Methods We analysed three rounds of Zambia Demographic and Health Survey data (2007, 2013/14, 2018). We used different modelling approaches, including logistic regressions, probability weighting and propensity score matching to determine the average treatment effects (ATE) of media messages and counselling by health workers. ATE were also estimated by year. Post-estimation and robustness checks were conducted using overlap plots and bootstrapping.Findings Across all surveys, a total of 19 958 women of reproductive age (15–49 years) were identified for inclusion in the study. The magnitude of impact of family planning messages varied by mode of delivery of the messages. Receiving family planning messages through a combination of health worker counselling and mass media had the most significant positive impact on contraceptive use (ATE 17.06%) followed by counselling (ATE 14.55%) and mass media messages only (ATE 3.37%). The impact of the different modes of delivery of family planning varied by year, showing a decreasing trend.Conclusion The mode of delivery influences the impact of family planning messages on modern contraceptive use among women. Family planning counselling and combined approaches outperform mass media messages only. A declining impact over time raises concerns and highlights the need for further investigation into delivery effectiveness.
Background Tuberculosis preventive treatment (TPT) is recommended for household contacts of tuberculosis (TB) patients, yet implementation gaps persist, particularly in high-burden settings. We evaluated the TB preventive care cascade and determinants of TPT initiation among household contacts of patients with TB across five Southern African countries.Methods In a prospective cohort study within the International Epidemiology Database to Evaluate AIDS Southern Africa (IeDEA-SA), we enrolled all individuals aged ≥ 15 years with pulmonary TB starting treatment between October 2022 and March 2023 at five TB/HIV care clinics in Malawi, Mozambique, South Africa, Zambia and Zimbabwe. We analysed the preventive care cascade of their household contacts along sequential outcomes: healthcare visit, TB symptom reporting, microbiological testing, diagnosis and TPT initiation and completion. Determinants of TPT initiation were assessed using multivariable logistic regression.Results Among 1438 index patients with TB, 1369 (95%) reported at least one household contact, yielding 5805 contacts: 4529/5805 (78%) visited a healthcare facility and 877/4529 (19%) reported current TB symptoms, 297/4529 (7%) tested for TB, which was confirmed, latent or suspected in 74/4529 (2%). Among 4455 contacts visiting a healthcare facility with no confirmed, suspected or latent TB, only 223 (5%) initiated TPT, more frequently among people with HIV (OR 3.28, 95% CI 1.78 to 6.02) and children under 5 years (OR 3.27, 95% CI 1.42 to 7.54). At study end, 137 (61%) completed TPT, 84 (38%) were still on treatment, only 1 contact interrupted treatment and 1 had unknown status.Conclusion Despite high healthcare engagement among index patients, TPT initiation among household contacts in Southern Africa was low although relatively higher among priority groups such as people with HIV and young children. Strengthening the link between household contact screening and TPT uptake is essential to close the preventive care cascade gap in the region.
