Stability in care and risk of loss to follow-up among clients receiving community health worker-led differentiated HIV care: Results from a prospective cohort study in northern Tanzania

BACKGROUND

HIV services in Tanzania are facility-based but facilities are often overcrowded. Differentiated care models (DCM) have been introduced into the National Guidelines. We piloted a Community Health Worker (CHW)-led HIV treatment club model (CHW-DCM) in an urban region, and assessed its effectiveness in comparison to the standard of care (SoC, facility-based model), in terms of stability in care, loss to follow-up (LTFU) and treatment adherence.

METHODS

In two clinics in the Shinyanga region, clients established on ART (defined as stable clients by national guidelines as on first-line ART >6 months, undetectable viral load, no opportunistic infections or pregnancy, and good adherence) were offered CHW-DCM. This prospective cohort study included all stable clients who enrolled in CHW-DCM between July 2018 and March 2020 (CHW-DCM) and compared them to stable clients who remained in SoC during that period. Multivariable Cox regression models were used to analyse factors associated with continued stability in care and the risk of LTFU during 18 months of follow-up; treatment adherence was assessed by pill count and compared using Chi-square tests.

RESULTS

Of 2472 stable clients, 24.5% received CHW-DCM and 75.5% SoC. CHW-DCM clients were slightly older (mean 42.8 vs. 37.9 years) and more likely to be female (36.2% vs. 32.2%). Treatment adherence was better among CHW-DCM than SoC: 96.6% versus 91.9% and 98.5% versus 92.2%, respectively (both p = 0.001). SoC clients were more likely to not remain stable over time than CHW-DCM (adjusted Hazard ratio [AHR] = 2.68; 95% CI: 1.86-3.90). There was no difference in LTFU (adjusted hazard ratio [AHR] = 1.54; 95%CI: 0.82-2.93).

CONCLUSION

Clients attending CHW-DCM demonstrated better stability in care and treatment adherence than SoC, and the risk of LTFU was not increased. These findings demonstrate the potential of CHW in delivering community-based HIV services in the local Tanzanian context. These results could be used to extend this CHW-DCM model to similar settings.

Effectiveness of provider-initiated versus client-initiated HIV testing by different health facility departments in Northern Tanzania

BACKGROUND

HIV prevalence in Tanzania is still high at 4.7% among adults. Regular HIV testing is consistently advocated in the country to increase the level of awareness of HIV status, thus contributing to national HIV prevention. We report findings from three years of implementation of an HIV Test and Treat project utilizing provider-initiated and client-initiated testing and counselling (PITC and CITC). This study compared the effectiveness of PITC versus CITC in HIV case detection by the different departments of health facilities.

METHOD

This retrospective cross-sectional study used health facility-based HIV testing data collected from adults aged 18 years and above between June 2017 - July 2019 in the Shinyanga region, Tanzania. Chi-square and logistic regression analysis were used to assess determinants of yield (HIV positivity).

RESULTS

A total of 24,802 HIV tests were performed of which 15,814 (63.8%) were by PITC and 8,987 (36.2%) by CITC. Overall HIV positivity was 5.7%, higher among CITC at 6.6% than PITC at 5.2%. TB and IPD departments had the highest HIV positivity 11.8% and 7.8% respectively. Factors associated with a positive test were testing at a department in the facility compared to CITC, first-time test, and being or having been married compared to being single.

CONCLUSION

Success in identifying HIV + patients was highest among people visiting the clinic for HIV testing (CITC) and first-time testers. With PITC, HIV + patient detection differed between departments, suggesting divergent risk profiles of respective clients and/or divergent HIV alertness of staff. This underscores the importance of increased targeting for PITC to identify HIV + patients.

Ecological aspects shaping child labour in Tanzania's artisanal and small-scale gold mines: A qualitative inquiry

Background

This study describes factors promoting child labour in small-scale gold mines in rural Tanzania, a pernicious problem despite the country's adoption of laws and regulations intended to curb it.

Methods

Employing a phenomenological design, we collected qualitative data using focus group discussions and in-depth interviews to describe factors promoting children's engagement in small-scale gold mining activities in three districts in Tanzania. Data analysis applied constructs from the ecological system theory.

Results

Child labour was reported to be common in the small-scale gold mines and abject household poverty was reported as the main factor pushing children to work in the mines because of their respective households' inability to provide for their basic needs. Other underlying factors stated included divorce and family disintegration and limited diversification of income-earning activities. The migratory nature of artisanal mining led some miner parents to not prioritize the education of their children. Furthermore, peer pressure and parental influence, especially of mothers, promoted entry into mining or reinforced its continuation. Early socialisation of children as future miners and lack of perspective and societal expectations of other life trajectories contributed to persistent child labour within mining communities. At the government level, the study participants mentioned poor reinforcement of mining regulations as another factor that legitimised child labour in the mines.

Conclusion

Since factors promoting child labour in small-scale gold mines are multifaceted, efforts for its elimination require a multi-layered approach aimed at addressing the root-causes at the micro-, meso-, exo- and macro-level systems.

Hunger and Adherence to Antiretroviral Therapy: Learning From HIV Positive Caregivers of Orphans and Vulnerable Children in Tanzania

The association between hunger and adherence to antiretroviral therapy (ART) is less known especially in vulnerable populations receiving HIV care and treatment services. Caregivers of orphans and vulnerable children (OVC) are vulnerable and likely to experience hunger due to additional economic pressure in caring for OVC. Using data from the community–based, USAID–funded Kizazi Kipya project, this study assesses the association between hunger and ART adherence among caregivers of OVC in Tanzania. HIV positive caregivers enrolled in the project from January to July 2017 were analyzed. The outcome variable was adherence to ART, defined as “not having missed any ART dose in the last 30 days,” and household hunger, measured using the Household Hunger Scale (HHS), was the main independent variable. Data analysis included multivariable logistic regression. The study analyzed 11,713 HIV positive caregivers who were on ART at the time of enrollment in the USAID Kizazi Kipya project in 2017. Aged 48.2 years on average, 72.9% of the caregivers were female. While 34.6% were in households with little to no hunger, 59.4 and 6.0% were in moderate hunger and severe hunger households, respectively. Overall, 90.0% of the caregivers did not miss any ART dose in the last 30 days. ART adherence rates declined as household hunger increased (p < 0.001). Multivariable analysis showed that the odds of adhering to ART was significantly lower by 42% among caregivers in moderate hunger households than those in little to no hunger households (OR = 0.58, 95% CI 0.50–0.68). The decline increased to 47% among those in severe hunger households (OR = 0.53, 95% CI 0.41–0.69). Hunger is an independent and a significant barrier to ART adherence among caregivers LHIV in Tanzania. Improving access to adequate food as part of HIV care and treatment services is likely to improve ART adherence in this population.

Evaluation of Long-Lasting Insecticidal Net Distribution Through Schools in Southern Tanzania

Universal coverage with effective vector control remains the mainstay of malaria vector control in sub-Saharan Africa Tanzania has utilized a number of mechanisms for the maintenance of long-lasting insecticidal net (LLIN) coverage over time. Schools have been identified as one potential channel for continuous distribution of LLIN. This research aims to evaluate an annual school based LLIN distribution programme in Tanzania which began in 2013, called the School Net Programme (SNP). Following each of the first four rounds of SNP distribution, a household survey was conducted in intervention and comparison districts in Southern and Lake zones of Tanzania (N = 5083 households). Measures of ownership, access, and use were compared between intervention and comparison districts. Determinants of reach were assessed in intervention districts. Population access to an LLIN increased from 63.1% (95% CI: 58.8, 67.5) to 76.5% (95% CI: 72.9, 80.0) in the intervention districts between the first and last surveys. Access also rose in the comparison districts from 51.4% (95% CI: 46.9, 55.9) to 79.8% (95% CI: 77.3, 82.0) following a mass distribution and implementation of school-based distribution during the study period. LLIN use increased in intervention districts from 44.9% (95% CI: 40.5, 49.3) to 65.6% (95% CI: 59.4, 71.8) and from 57.2% (95% CI: 49.7, 64.7) to 77.4% (95% CI: 69.3, 85.5) specifically amongst primary school-aged children. Households reached by the SNP were wealthier households with children enrolled in school. The SNP in Tanzania was able to maintain population level LLIN ownership, use, and access in the absence of a mass distribution. The SNP successfully reached households which housed school-aged children. Alternative delivery strategies may need to be considered to reach households without children enrolled in school which experienced less benefit from the program.

Poor linkage to care for HIV-positive OVC with disabled caregivers: a longitudinal study in Tanzania

Background

Despite extensive efforts to scale up counseling and testing services and care and treatment clinics (CTCs) in Tanzania, linkage between points of diagnosis and CTCs remains low. Studies have looked at barriers such as lack of trained health providers, poor referral system, economic costs or distance to health facilities, but fewer assessed the association between caregivers’ vulnerability such as disability and linkage of orphans and vulnerable children (OVCs) in their care to health facilities. This study describes the magnitude of caregivers’ disability and assesses its relationship with successful linkage to care of their OVC living with HIV/AIDS in Tanzania.

Methods

Data for this analysis came from the USAID Kizazi Kipya project in 79 councils of Tanzania. Data on HIV risk, service use and ART adherence among OVC aged 0–19 years were collected during the project’s quarterly routine data collection (Oct 2017-Sep 2018). Characteristics of caregivers were collected during the project beneficiary screening and enrollment process. Generalized estimating equation models were used to analyze the factors that are associated with linkage of 14,538 HIV positive OVC to CTC, who were taken care of by 11,834 caregivers.

Results

The majority of caregivers (70%) were females, had completed primary education (67%), 54% were married or cohabiting. Of all the OVC, 3% were living with disabled caregivers; of whom 89% were physically disabled while 11% were mentally disabled. OVCs living with disabled caregivers were less likely to be linked to care (OR 0.76, 95% CI 0.58, 0.99). Factors positively associated with OVC linkage to care were high caregivers’ education level (OR 1.99, 95% CI 1.51, 2.63) and OVC living with a HIV positive caregivers (OR 1.25, 95% CI 1.12, 1.41). OVC living in household with high socio-economic status were less likely to be linked to care (OR 0.76, 95% CI 0.67, 0.86) than those in low-SES households.

Conclusion

These results suggest HIV positive OVC living with disabled caregivers had poor linkage to care. The findings highlighted the need to focus attention to the disabilities-led household to promote inclusion and improve access to the HIV services.

Preparedness of health facilities providing HIV services during COVID-19 pandemic and assessment of their compliance to COVID-19 prevention measures: findings from the Tanzania Service Provision Assessment (SPA) survey

Introduction

the increased demands of health facilities and workers due to coronavirus overwhelm the already burdened Tanzanian health systems. This study evaluates the current capacity of facilities and providers for HIV care and treatment services and their preparedness to adhere to the national and global precaution guidelines for HIV service providers and patients.

Methods

data for this study come from the latest available, Tanzania Service Provision Assessment survey 2014-15. Frequencies and percentages described the readiness and availability of HIV services and providers. Chi-square test compared the distribution of services by facility location and availability and readiness of precaution commodities and HIV services by managing authorities.

Results

availability of latex gloves was high (83% at OPD and 95.3% laboratory). Availability of medical masks, alcohol-based hand rub and disinfectants was low. Availability of medical mask at outpatient department (OPD) was 28.7% urban (23.5% public; 33.8% private, p=0.02) and 13.5% rural (10.1% public; 25.4% private, p=0.001) and lower at laboratories. Fewer facilities in rural area (68.4%) had running water in OPD than urban (86.3%). Higher proportions of providers at public than private facilities in urban (82.8% versus 73.1%) and rural (88.2% versus 81.6%) areas provided HIV test counseling and at least two other HIV services.

Conclusion

availability of commodities such as medical masks, alcohol-based hand rub, and disinfectant was low while the readiness of providers to multitask HIV related services was high. Urgent distribution and re-assessment of these supplies are necessary, to protect HIV patients, their caregivers, and health providers from COVID-19.

Programmatic determinants of successful referral to health and social services for orphans and vulnerable children: A longitudinal study in Tanzania

Background

Trained community workers (CWs) successfully deliver health and social services, especially due to greater community acceptance. Orphans and vulnerable children (OVC) and their caregivers (CG) often need support from several sectors. We identified CW, program and referral characteristics that were associated with success of referrals provided to OVC and their CG in Tanzania in a cross-sectoral bi-directional referral system.

Methods

Data for this secondary analysis come from the first two years (2017–2018) of the USAID funded Kizazi Kipya project. Referral success was defined as feedback and service received within 90 days post-referral provision. We analyzed factors that are associated with the referral success of HIV related, education, nutrition, parenting, household economic strengthening, and child protection services among OVC and CG, using generalized estimating equations.

Results

During the study period, 19,502 CWs in 68 councils provided 146,996 referrals to 132,640 beneficiaries. OVC had much lower referral success for HIV related services (48.1%) than CG (81.2%). Adjusted for other covariates, CW age (26–49 versus 18–25 years, for OVC aOR = 0.83, 95%CI (0.78, 0.87) and CW gender (males versus females, for OVC aOR = 1.12, 95%CI (1.08, 1.16); CG aOR = 0.84, 95%CI (0.78, 0.90)) were associated with referral success. CWs who had worked > 1 year in the project (aOR = 1.52, 95%CI 1.46, 1.58) and those with previous work experience as CW (aOR = 1.57, 95%CI (1.42, 1.74) more successfully referred OVC. Referrals provided to OVC for all other services were more successful compared to HIV referrals, with aORs ranging from 2.99 to 7.22. Longer project duration in the district council was associated with increased referral success for OVC (aOR = 1.16 per month 95%CI 1.15,1.17), but decreased for CG (aOR = 0.96, 95%CI 0.94, 0.97). Referral success was higher for OVC and CGs with multiple (versus single) referrals provided within the past 30 days (aOR = 1.28 95%CI 1.21, 1.36) and (aOR = 1.17, 95%CI (1.06, 1.30)) respectively.

Conclusion

CW characteristics, referral type and project maturity had different and often contrasting associations with referral success for OVC versus for CG. These findings could help policymakers decide on the recruitment and allocation of CWs in community based multi-sectoral intervention programs to improve referral successes especially for OVC.

Determinants of undisclosed HIV status to a community-based HIV program: findings from caregivers of orphans and vulnerable children in Tanzania

Background

HIV status disclosure facilitates receipt of HIV prevention and treatment services. Although disclosure to sexual partners, family members or friends has been extensively studied, disclosure to community-based HIV programs is missing. This study assesses the magnitude of, and factors associated with undisclosed HIV status to a community-based HIV prevention program among caregivers of orphans and vulnerable children (OVC) in Tanzania.

Methods

Data are from the USAID-funded Kizazi Kipya project that seeks to increase uptake of HIV, health, and social services by OVC and their caregivers in Tanzania. Data on OVC caregivers who were enrolled in the project during January–March 2017 in 18 regions of Tanzania were analyzed. Caregivers included were those who had complete information on their HIV status disclosure, household socioeconomic status, and sociodemographic characteristics. HIV status was self-reported, with undisclosed status representing all those who knew their HIV status but did not disclose it. Multilevel mixed-effects logistic regression, with caregivers’ HIV status disclosure being the outcome variable was conducted.

Results

The analysis was based on 59,683 OVC caregivers (mean age = 50.4 years), 71.2% of whom were female. Of these, 37.2% did not disclose their HIV status to the USAID Kizazi Kipya program at the time of enrollment. Multivariate analysis showed that the likelihood of HIV status non-disclosure was significantly higher among: male caregivers (odds ratio (OR) = 1.22, 95% confidence interval (CI) 1.16–1.28); unmarried (OR = 1.12, 95% CI 1.03–1.23); widowed (OR = 1.12, 95% CI 1.07–1.18); those without health insurance (OR = 1.36, 95% CI 1.28–1.45); age 61 + years (OR = 1.72, 95% CI 1.59–1.88); those with physical or mental disability (OR = 1.14, 95% CI 1.04–1.25); and rural residents (OR = 1.58, 95% CI 1.34–1.86). HIV status non-disclosure was less likely with higher education (p < 0.001); and with better economic status (p < 0.001).

Conclusion

While improved education, economic strengthening support and expanding health insurance coverage appear to improve HIV status disclosure, greater attention may be required for men, unmarried, widowed, rural residents, and the elderly populations for their higher likelihood to conceal HIV status. This is a clear missed opportunity for timely care and treatment services for those that may be HIV positive. Further support is needed to support disclosure in this population.

Preparedness of health facilities providing HIV services during COVID-19 pandemic and assessment of their compliance to COVID-19 prevention measures: findings from the Tanzania Service Provision Assessment (SPA) survey

Introduction

the increased demands of health facilities and workers due to coronavirus overwhelm the already burdened Tanzanian health systems. This study evaluates the current capacity of facilities and providers for HIV care and treatment services and their preparedness to adhere to the national and global precaution guidelines for HIV service providers and patients.

Methods

data for this study come from the latest available, Tanzania Service Provision Assessment survey 2014-15. Frequencies and percentages described the readiness and availability of HIV services and providers. Chi-square test compared the distribution of services by facility location and availability and readiness of precaution commodities and HIV services by managing authorities.

Results

availability of latex gloves was high (83% at OPD and 95.3% laboratory). Availability of medical masks, alcohol-based hand rub and disinfectants was low. Availability of medical mask at outpatient department (OPD) was 28.7% urban (23.5% public; 33.8% private, p=0.02) and 13.5% rural (10.1% public; 25.4% private, p=0.001) and lower at laboratories. Fewer facilities in rural area (68.4%) had running water in OPD than urban (86.3%). Higher proportions of providers at public than private facilities in urban (82.8% versus 73.1%) and rural (88.2% versus 81.6%) areas provided HIV test counseling and at least two other HIV services.

Conclusion

availability of commodities such as medical masks, alcohol-based hand rub, and disinfectant was low while the readiness of providers to multitask HIV related services was high. Urgent distribution and re-assessment of these supplies are necessary, to protect HIV patients, their caregivers, and health providers from COVID-19.

Assessment of the impact of availability and readiness of malaria services on uptake of intermittent preventive treatment in pregnancy (IPTp) provided during ANC visits in Tanzania

BACKGROUND

Intermittent preventive treatment during pregnancy (IPTp) is a highly-recommended intervention to prevent maternal and neonatal complications associated with malaria infection. Despite fairly high antenatal care (ANC) coverage in Tanzania, low IPTp uptake rates represent a gap in efforts to decrease complications attributed to malaria in pregnancy. The objective of this study was to examine if availability, readiness and managing authority are associated with uptake of IPTp during ANC.

METHODS

Data for this analysis come from a cross-sectional survey, the Tanzania Service Provision Assessment conducted between 2014 and 2015. Principal component analysis was used to create scores for availability of malaria services and readiness for the provision of services. Generalized estimating equation models with logit link and the binomial distribution assessed factors that impact the uptake of IPTp by pregnant women attending ANC.

RESULTS

Higher fraction of women in their third trimester than second (68% versus 49%, OR = 2.6; 95% CI (2.1-3.3)), had received at least one dose of IPTp. There was a wide variation in the availability and readiness of malaria services provision and diagnostic tools by managing authorities. Public facilities were more likely than private to offer malaria rapid diagnostic test, and more providers at public facilities than private diagnosed and/or treated malaria. Women who attended facilities where direct observation therapy was practiced were more likely to have received at least one dose of IPTp (64% versus 46% who received none; p < 0.001). Women who attended ANC at a facility with a high readiness score were more likely to take IPTp than those attending facilities with low readiness scores (OR = 2.1; 95% CI (1.4-3.3)). Reported stock out on the day of interview was negatively associated with IPTp uptake (OR 0.09; 95% CI 0.07-0.1).

CONCLUSION

Readiness of health facilities to provide malaria related services, the number of ANC visits and gestational age were associated with uptake of IPTp among women attending ANC. There are disparities in malaria service availability and readiness across geographical location and managing authorities. These findings could be used to assist the malaria programme and policymakers to appropriately decide when planning for malaria service deliveries and interventions.

Prevalence of self-reported symptoms of sexually transmitted infections, knowledge and sexual behaviour among youth in semi-rural Tanzania in the period of adolescent friendly health services strategy implementation

Background

Global evidence shows that sexually transmitted infections (STIs) prevalence and sexual risk behaviours are high among youth, and knowledge about STIs is low. In Tanzania, there is limited recent evidence regarding these issues. The aim of this study was to describe the health seeking behaviour of youth reporting STI symptoms in semi-rural Tanzania and to evaluate the association of socio-demographic characteristics, STI knowledge and sexual risk behaviour with STI symptom reporting.

Methods

This was a cross-sectional study involving 2251 sexually experienced youth (15–24 years), who participated in a larger baseline survey of a cohort within Ifakara town. Interview data were electronically collected by trained field workers. Logistic regression analysis was used to identify factors that influence the risk of reporting STI symptoms within the past year, using Stata 12.1.

Results

The prevalence of self-reported STI symptoms in the past year was 19.9%. Almost all of youth had heard of STIs and 32.7% of youth could mention at least one sign. 34.4% had sought care for their STI symptoms, the majority at private facilities. Only 20% of HIV-STI co-infected youth was aware of their HIV status.

Youth with more knowledge of STI symptoms reported to have had symptoms more often (OR = 1.28; 95% CI 1.01–1.62), and those reporting having first sex at 16 or under were more likely to report STI symptoms than those who delayed to 17–19 years (OR 1.27; 95% CI 1.003–1.62).

Conclusion

These findings highlight the need to improve the implementation of Adolescent Friendly Health Services available in Tanzania (especially in semi-rural areas). The inclusion of private facilities and pharmacies in AFHS scale-up would potentially raise the level of STI knowledge, lower the STI prevalence and reduce HIV incidence among youth.

Determining if Positive Predictive Value using Laboratory Risk Indicator for Necrotising Fasciitis is Applicable in Malaysian Patients with Necrotising Fasciitis

Introduction: Necrotising fasciitis (NF) is a rapidly progressive infection of the subcutaneous tissue and fascia which spreads rapidly. The scoring system of Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) developed by Wong et al has been proposed as a tool for distinguishing NF and other soft tissue infections (STI) in Singapore. We set out to establish whether the LRINEC score is applicable in our Malaysian setting.

Materials and Methods: A cross sectional study of all patients admitted to our hospital diagnosed with NF or To Rule Out NF (TRO NF) between January 1st 2016 to 30th June 2016. The sensitivity, specificity, positive and negative predictive values were then calculated for LRINEC score of ≥ 6 and ≥ 8.

Results: Fourty-four patients were identified with the diagnosis of NF or TRO NF in the study. Twenty-seven patients (61.4%) were deemed post-operatively as having NF and 17 patients (38.6%) not having NF. A sensitivity of 59.3% and specificity of 47.1% when a LRINEC score of ≥ 6 was taken with positive predictive value (PPV) of 64.0% and the negative predictive value (NPV) of 42.1%. When score ≥ 8 was taken, the sensitivity was 48.1% and specificity of 58.8% with PPV of 65% and NPV of 41.7%.

Conclusion: The low sensitivity and low PPV achieved in this study as well as other studies makes the LRINEC score unsuitable to be used solely to distinguish NF with other soft tissue infections.

Incentivising safe sex: a randomised trial of conditional cash transfers for HIV and sexually transmitted infection prevention in rural Tanzania

OBJECTIVE

The authors evaluated the use of conditional cash transfers as an HIV and sexually transmitted infection prevention strategy to incentivise safe sex.

DESIGN

An unblinded, individually randomised and controlled trial.

SETTING

10 villages within the Kilombero/Ulanga districts of the Ifakara Health and Demographic Surveillance System in rural south-west Tanzania.

PARTICIPANTS

The authors enrolled 2399 participants, aged 18-30 years, including adult spouses.

INTERVENTIONS

Participants were randomly assigned to either a control arm (n=1124) or one of two intervention arms: low-value conditional cash transfer (eligible for $10 per testing round, n=660) and high-value conditional cash transfer (eligible for $20 per testing round, n=615). The authors tested participants every 4 months over a 12-month period for the presence of common sexually transmitted infections. In the intervention arms, conditional cash transfer payments were tied to negative sexually transmitted infection test results. Anyone testing positive for a sexually transmitted infection was offered free treatment, and all received counselling.

MAIN OUTCOME MEASURES

The primary study end point was combined prevalence of the four sexually transmitted infections, which were tested and reported to subjects every 4 months: Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis and Mycoplasma genitalium. The authors also tested for HIV, herpes simplex virus 2 and syphilis at baseline and month 12.

RESULTS

At the end of the 12-month period, for the combined prevalence of any of the four sexually transmitted infections, which were tested and reported every 4 months (C trachomatis, N gonorrhoeae, T vaginalis and M genitalium), unadjusted RR for the high-value conditional cash transfer arm compared to controls was 0.80 (95% CI 0.54 to 1.06) and the adjusted RR was 0.73 (95% CI 0.47 to 0.99). Unadjusted RR for the high-value conditional cash transfer arm compared to the low-value conditional cash transfer arm was 0.76 (95% CI 0.49 to 1.03) and the adjusted RR was 0.69 (95% CI 0.45 to 0.92). No harm was reported.

CONCLUSIONS

Conditional cash transfers used to incentivise safer sexual practices are a potentially promising new tool in HIV and sexually transmitted infections prevention. Additional larger study would be useful to clarify the effect size, to calibrate the size of the incentive and to determine whether the intervention can be delivered cost effectively.

TRIAL REGISTRATION NUMBER

NCT00922038 ClinicalTrials.gov.

Surgical audit in day care myringoplasty

Day-case surgery is preferred for adults, allowing post-operative fast recovery in family environment and support. Myringoplasty using the traditional method of underlay temporalis fascia or tragal perichondrium is usually performed as an in-patient. From 2003 to 2004, 22 myringoplasty procedures were performed in a dedicated day surgery unit at the Hospital Melaka. We report the retrospectively review of the outcome results of these procedures. None of the patients need admission overnight. There were no surgical or anesthetic complications noted and this series suggests that day-case surgery is a safe and desirable practice for patients undergoing myringoplasty. However, there should be the facility for admission if required.