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Malaria accounts for the largest portion of healthcare demand in Angola. Cross-sectional health facility surveys were performed in low-transmission Huambo and high-transmission Uíge Provinces in early 2016. In each province, 45 health facilities were randomly selected from among all public health facilities stratified by level of care. The results reveal important diferences between provinces. Despite similar availability of testing and ACT, testing and treatment rates were lower in Huambo compared to Uíge. A majority of true malaria cases seeking care in health facilities in Huambo were not appropriately treated with anti-malarials, highlighting the importance of continued training and supervision of healthcare workers in malaria case management, particularly in areas with decreased malaria transmission.

Tuberculosis (TB) is a major public health problem in Afghanistan, but experience in implementing effective strategies to prevent and control TB in urban areas and conflict zones is limited. This study shares programmatic experience in implementing DOTS in the large city of Kabul. We analyzed data from the 2009–2015 reports of the National TB Program (NTP) for Kabul City and calculated treatment outcomes and progress in case notification. Between 2009 and 2015, the number of DOTS-providing centers in Kabul increased from 22 to 85. In total, 24,619 TB patients were enrolled in TB treatment during this period. The case notification rate for all forms of TB increased from 59 per 100,000 population to 125 per 100,000. The case notification rate per 100,000 population for sputum-smear-positive TB increased from 25 to 33. The treatment success rate for all forms of TB increased from 31% to 67% and from 47% to 77% for sputum-smear-positive TB cases. In 2013, contact screening was introduced, and the TB yield was 723 per 100,000—more than two times higher than the estimated national prevalence of 340 per 100,000. Contact screening contributed to identifying 2,509 child contacts of people with TB, and 76% of those children received isoniazid preventive therapy. The comprehensive urban DOTS program significantly improved service accessibility, TB case finding, and treatment outcomes in Kabul. Public- and private-sector involvement also improved treatment outcomes; however, the treatment success rate remains higher in private health facilities. While the treatment success rate increased significantly, it remains lower than the national average, and more efforts are needed to improve treatment outcomes in Kabul. We recommend that the urban DOTS approach be replicated in other countries and cities in Afghanistan with settings similar to Kabul.

Vitamin D is a fat-soluble vitamin that increases immunity against tuberculosis (TB), decreases the re-activation of latent TB and reduces the severity of active TB disease. Epidemiological studies on the prevalence of vitamin D deficiency and its association with TB have shown inconsistent results in different countries. This study aimed to determine the prevalence of vitamin D deficiency and its association with TB in Northwest Ethiopia. A case–control study was conducted among smear positive pulmonary TB patients and their household contacts without symptoms suggestive of TB. Study participants were recruited at 11 TB diagnostic health facilities in North and South Gondar zones of Amhara region between May 2013 and April 2015. Vitamin D deficiency is highly prevalent among TB patients and non-TB controls in Ethiopia, where there is year-round abundant sunshine. Study participants with TB, females, older age groups, and urban residents had significantly higher prevalence of vitamin D deficiency. These findings warrant further studies to investigate the role of vitamin D supplementation in the prevention and treatment of TB in high TB burden countries like Ethiopia.

This article presents Malawi’s experience with designing and implementing Option B+ and provides complementary narratives from Cameroon and Tanzania. Operationalizing Option B+ required several critical considerations, including the complete integration of ART and PMTCT programs, systematic reduction of barriers to facilitate doubling the number of ART sites in less than a year, building consensus with stakeholders, and securing additional resources. During the planning and implementation process, several lessons were learned which are considerations for countries transitioning to “treat-all”: Comprehensive change requires effective government leadership and coordination; national clinical guidelines must accommodate health system limitations; ART services and commodities should be decentralized within facilities; the general public should be well informed about major changes in the national HIV program; and patients should be educated on clinic processes to improve program monitoring.

An extensive body of work on access to and use of medicines has resulted in an assortment of tools measuring various elements of pharmaceutical systems. Until now however, there has been little attempt to conceptualize a pharmaceutical system as an entity and define its strengthening in a way that allows for measuring systems strengthening. The narrow focus of available tools limits their value in ascertaining which interventions result in stronger, more resilient systems. We sought to address this shortcoming by revisiting the current definitions, frameworks and assessment tools related to pharmaceutical systems. We conducted a comprehensive literature review and consulted with select pharmaceutical experts. On the basis of our review, we propose that a pharmaceutical system consists of all structures, people, resources, processes, and their interactions within the broader health system that aim to ensure equitable and timely access to safe, effective, quality pharmaceutical products and related services that promote their appropriate and cost-effective use to improve health outcomes. We further propose that pharmaceutical systems strengthening is the process of identifying and implementing strategies and actions that achieve coordinated and sustainable improvements in the critical components of a pharmaceutical system to make it more responsive and resilient and to enhance its performance for achieving better health outcomes. Finally, we established that, in addition to system performance and resilience, seven components of the pharmaceutical system are critical for measuring pharmaceutical systems strengthening: pharmaceutical products and related services; policy, laws and governance; regulatory systems; innovation, research and development, manufacturing, and trade; financing; human resources; and information.

A cross-sectional qualitative study was conducted to explore early experiences surrounding "Option B+" for patients and health care workers in Malawi. As "Option B+" continues to be rolled out, novel interventions to support and retain women in care must be implemented. These include providing space, time, and support to accept a diagnosis before starting ART, engaging partners and families, and addressing the need for peer support and confidentiality.

Despite Namibia's robust medicine use systems and policies, antibiotic use indicators remain suboptimal. Recent medicine use surveys rank cotrimoxazole, amoxicillin and azithromycin (CAA) among the most used medicines. However, there is rising resistance to CAA (55.9%-96.7%). A quantitative text analysis found that policy and guidelines for antibiotic use in Namibia are not comprehensive and are skewed towards PHCs. Existing policies promote the wide use of CAA antibiotics, which may inadvertently result in their inappropriate use, enhancing resistance rates. This calls for the development of more comprehensive antibiotic guidelines and essential medicine lists in tandem with local antimicrobial resistance patterns. 

HIV among people who inject drugs (PWID) is a serious public health problem in Tajikistan and other Central Asian republics, yet relatively few studies have been conducted among PWID in Tajikistan and almost nothing is known about females who inject drugs. This presentation will examine gender differences in HIV status, injection risk behaviors and sex risk behaviors among PWID in Tajikistan.

The Global Burden of Disease 2015 article on maternal mortality by Nicholas Kassebaum and colleagues (Oct. 8, p. 1775) contains a serious error reflecting a basic misunderstanding of the Sustainable Development Goal (SDG) target for maternal mortality. The report states that “only ten countries achieved MDG 5, but 122 of 195 countries have already met SDG 3.1”. This is a dangerous and inaccurate interpretation of the global goal. The SDG target is a global target, not a country target. To achieve the global target for maternal mortality reduction requires every country to reduce its national maternal mortality ratio from baseline by two-thirds in that timeframe. It is probably safe to assume that no country has succeeded in reducing its maternal mortality ratio by two-thirds since the SDGs were launched in September 2015.

The objective of this study was to assess the feasibility and effectiveness of the nationally approved ambulatory service delivery model for MDR-TB treatment in two regions of Ethiopia. We used routinely reported data to describe the process and outcomes of implementing an ambulatory model for MDR-TB services in a resource-limited setting. Between 2012 and 2015, the number of MDR-TB treatment-initiating centers increased from 1 to 23. The number of sputum samples tested for MDR-TB increased 20-fold, from 662 to 14,361 per year. The backlog of patients on waiting lists was cleared. The cumulative number of MDR-TB patients put on treatment increased from 56 to 790, and the treatment success rate was 75%. Rapid expansion of the ambulatory model of MDR-TB care was feasible and achieved a high treatment success rate in two regions of Ethiopia.

The Ethiopian Paediatric HIV Cohort was established to identify clinical and laboratory predictors of virological treatment failure to ultimately develop a clinical–immunological prediction rule with area under the curve of >0.80 for detecting first-line antiretroviral therapy failure (ARTF). It will also assess the performance of the current WHO guidelines for detection of first-line ARTF in children. Using a prospective cohort design, HIV-infected children and adolescents below the age of 18 years are followed every 6 months with a set of clinical and laboratory parameters at 6 hospitals in southern Ethiopia. From October 2015 through April 2016, 628 children have been enrolled. The cohort will be completed in September 2017. The successful completion of this study will allow for better targeting of viral-load testing to those at highest risk in resource-poor settings and provide clinicians and policymakers with a practical prediction rule.

We assessed community awareness about cervical cancer risk factors and symptoms and perceptions about prevention and cure of cervical cancer in order to contribute data to inform interventions to improve cervical cancer survival. The study was conducted in Gulu, a post-conflict district in Uganda in 2012. The sample included 448 adults. Recognition of cervical cancer risk factors and symptoms was high among study participants. Targeted interventions including increasing availability of HPV vaccination, population-based cervical screening and diagnostic services can translate high awareness into actual benefits.

Our objective was to demonstrate the feasibility of integrated care for TB, HIV and diabetes mellitus (DM) in a pilot project in Ethiopia. Of 3439 study participants, 888 were patients with DM, 439 patients with TB and 2112 from HIV clinics. Tri-directional screening was feasible for detecting and managing previously undiagnosed TB and DM.

An intervention brought together community health workers, health facility staff, and accredited drug dispensing outlet (ADDO) dispensers to improve maternal and newborn health through a mechanism of collaboration and referral. Relationships among the three levels of care improved after the linkage intervention, especially for ADDO dispensers and health facility staff who previously had no formal communication pathway. The study participants' perceptions of success included improved knowledge of case management and relationships among the three levels of care, more timely access to care, increased numbers of patients/customers, more meetings between community health workers and health facility staff, and a decrease in child and maternal mortality.

In 1997, Milstien, Batson, and Meaney published ‘‘A Systematic Method for Evaluating the Potential Viability of Local Vaccine Producers.” The paper identified characteristics of successful vaccine manufacturers and developed a viability framework to evaluate their performance. This paper revisits the original study after two decades to determine the ability of the framework to predict manufacturer success. Considering the marked changes in the market and technology landscape since 1997, the authors find the viability framework to be predictive and a useful lens through which to evaluate manufacturer success or failure.

In October 2014, UNAIDS set treatment targets to help end the AIDS epidemic, known as the 90:90:90 goals.They seek to achieve the following by 2020: 90% of HIV infected persons know their status, 90% of HIV positive persons are placed on treatment, and 90% of those on treatment are virally suppressed.

Human resources for health challenges related to training, deploying, and sustaining an effective health workforce have remained a barrier to successful program implementation at different levels of the health system.As health facilities are now required to treat all identi ed HIV positive clients in line with the newTest and Treat guidelines for achieving the UNAIDS 90:90:90 goals, addressin

The strides made in Malawi's Chiradzulu District demonstrate improved data use at the facility level and that using performance charts can go a long way in improving program performance. As a result of the success in Chiradzulu, the initiative has been scaled up in all of the DHSS program areas.

The patient tracing system improved the delivery of HIV services in MSH-supported facilities in Malawi's Blantyre District. More than 50% of patients who had missed an appointment were brought back to care. Some patients who had self- transferred out to other facilities were identi ed and their outcomes recorded in the register.

Management Sciences for Health (MSH) has been assisting Malawi since 2003 to strengthen health care systems, increase disease preven- tion education, reduce maternal and childhood mortality rates, and expand access to quality HIV/AIDS services.

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To improve quality of HIV care in targeted districts, STAR-E scaled up the Ministery of Health quality improvement framework in March 2013. STAR-E targeted 66 facilities, including high volume and smaller facilities that were underperforming on key indicators.

Key populations, including sex workers, prisoners, and men who have sex with men (MSM), are disproportionately infected with and affected by HIV and AIDS. In 2014, HIV prevalence among sex workers globally was 12 times the prevalence of the mainstream population. Sex workers and other key and priority populations contribute substantially to new HIV infections in Uganda.

Uganda ranks among the top 20 countries in the world with the highest number of TB/HIV co-infection cases and the highest rate of TB cases among people living with HIV(PLHIV). In 2015, HIV prevalence was estimated at 7.1%, and approximately 45% of TB patients were co-infected with HIV.


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