Patients in rural Zambia can achieve adherence rates compatible with good clinical outcomes despite long travel distances. The MMH was able to provide quality HIV/AIDS care by implementing programmatic features selecting for a highly adherent population in this resource-limited setting.

Economic evaluations of differentiated service delivery should include savings and ancillary benefits, not only health system costs We write in reference to the study by Nichols et al.[1] that evaluated costs and outcomes of community-based differentiated service delivery (DSD) models for HIV treatment in Zambia. The authors compared conventional, facility-based care to mobile antiretroviral therapy (ART), community adherence groups (CAGs), urban adherence groups (UAGs), and home delivery of ART under the Community HIV Epidemic Control (CHEC) model. The authors found that conventional care was least expensive in terms of direct clinical service and medication costs, whereas mobile ART, CAGs, UAGs, and CHEC were more expensive, in that order.We appreciate this detailed costing analysis of DSD models in Zambia. At the University of Maryland Baltimore, we have nearly two decades of experience in the provision of medical/technical service delivery in Zambia [2]. Based on community-based approaches demonstrated to improve HIV case-finding and linkage [3], provide high-quality care [4], and improve retention in adult ART programs [5], we developed and implemented the CHEC model [6], which provides home delivery of ART and was one of the models evaluated in this analysis. CHEC was primarily implemented in the PEPFAR/CDC-funded Stop Mother and Child HIV Transmission (SMACHT) project, which was conducted in the Southern Province of Zambia from 2015 to 2020. Under SMACHT, CHEC significantly improved maternal/child HIVoutcomes [7] and achieved 90% linkage to ART and 91% viral suppression [8].We would like to discuss four key considerations that are relevant to the economic impacts: the models compared, the outcome selected, how retention is defined, and the ancillary benefits and savings that were not included.

Abstract. Zambia and other sub-Saharan nations suffer from a critical shortage of trained health-care professionals to combat the human immunodeficiency virus/acquired immunodeficiency syndrome crisis. The University of Maryland and the Zambian Ministry of Health have partnered over the past decade to develop health-care capacity among physicians, nurses, and community health workers. We describe novel interventions to train health-care workers at all levels and argue that our collaboration represents a successful model for such partnerships between western medical institutions and African governmental health agencies.

Introduction Transgender and gender‐diverse communities in Zambia are highly vulnerable and experience healthcare differently than cisgender persons. The University of Maryland, Baltimore (UMB) supports projects in Zambia to improve HIV case‐finding, linkage and antiretroviral treatment (ART) for Zambia's transgender community. We describe programme strategies and outcomes for HIV prevention, testing and ART linkage among transgender communities. Methods UMB utilizes a differentiated service delivery model whereby community health workers (CHWs) recruited from key populations (KPs) reach community members through a peer‐to‐peer approach, with the support of local transgender civil society organizations (CSOs) and community gatekeepers. Peer CHWs are trained and certified as HIV testers and psychosocial counsellors to offer counselling with HIV testing and prevention services in identified safe spaces. HIV‐negative people at risk of HIV infection are offered pre‐exposure prophylaxis (PrEP), while those who test positive for HIV are linked to ART services. CHWs collect data using the standardized facility and community tools and a dedicated DHIS2 database system. We conducted a descriptive analysis examining HIV testing and prevention outcomes using proportions and comparisons by time period and geographic strata. Results From October 2020 to June 2021, across Eastern, Lusaka, Western and Southern Provinces, 1860 transgender persons were reached with HIV prevention messages and services. Of these, 424 (23%) were tested for HIV and 78 (18%) tested positive. Of the 346 HIV‐negative persons, 268 (78%) eligible transgender individuals were initiated on PrEP. ART linkage was 97%, with 76 out of the 78 transgender individuals living with HIV initiating treatment. Programme strategies that supported testing and linkage included peer CHWs, social network strategy testing, same‐day ART initiation and local KP CSO support. Challenges included non‐transgender‐friendly environments, stigma and discrimination, the high transiency of the transgender community and the non‐availability of transgender‐specific health services, such as hormonal therapy. Conclusions Peer KP CHWs were able to reach many members of the transgender community, providing safe HIV testing, PrEP services and linkage to care. Focusing on community gatekeepers and CSOs to disburse health messages and employ welcoming strategies supported high linkage to both PrEP and ART for transgender people in Zambia.