4. Discussion
The addition of program interns to health facilities was found to have little impact on facility-based HIV service delivery in this cluster randomized trial, although past research has suggested the program leads to improvements in HIV service delivery [While our findings may appear to contradict previous research of the YHA program, where an interrupted time series (ITS) analysis found the YHA program to be associated with significant increases in HIV testing and treatment initiation and significant reductions in loss to follow-up [Secondly, we hypothesize that the YHA program may be impactful, but in circumstances that were different than how it was implemented in the trial. The ITS included twenty-times more facilities than the intervention arm of the trial from numerous districts in which the intervention was implemented in a wide variety of manners (e.g., number and types of interns). The ITS analysis did not find change after the intervention in all facilities; generally, it found the largest difference in outcomes to occur among facilities with five or more interns and no differences in facilities with 1 or 2 interns. We hypothesize that the conditions of the trial—the location and size of facilities and the number of facilities placed—may not have been as conducive for change as the wider variety of conditions that existed in the ITS. For example, the intern dose used in the trial, where half of intervention facilities ended with only two interns, may have been insufficient to influence measurable change.Thirdly, some of the differences that were observed in the ITS analysis could have been due to differences in data quality, not program change. The trial measured the impact of program interns (in addition to one or more administrative interns), whereas the ITS measured the impact of the full YHA program (program and admin interns). It is possible that we saw less impact than the ITS because it observed changes due to improvements in data quality and not just service delivery, especially for retention in care indicators [Finally, differences in results between the ITS and the trial may have been due to COVID-19. The trial was implemented during the COVID-19 pandemic, while the ITS analysis reviewed data prior to this pandemic. COVID-19 could have impacted how frequently YHA interns were working in facilities. While YHA interns are essential personnel and were exempt from lockdowns, they were required to quarantine at home for up to two weeks if exposed to COVID-19, which was not an uncommon occurrence during the trial. There was also greater attrition than normal among the YHA interns in the trial, which could have been due to the stressors of COVID-19. Moreover, COVID-19 expanded the tasks that YHA program interns played at facilities during the trial. While their primary role was to support HIV programs, we know that they were also pulled into supporting COVID-19 related activities, such as COVID-19 testing. This may have diluted the time that program interns in the trial spent on traditional HIV program activities, in comparison to how time was spent by interns in the pre-COVID era. Finally, the ebb and flow of COVID-19 may have affected patient access to care, which could have resulted in challenges for testing, treatment initiation, and retention in care amongst patients in both intervention and control clinics.In reviewing the differences observed between the trial and the ITS, we believe the trial results likely underestimated the impact of YHA on HIV service delivery. However, the trial’s largely null findings are not necessarily surprising when reviewing the broader LHW literature. The most definitive impact of LHWs on HIV programs has been seen in HIV testing [