Social & Clinical Attributes of Patients Who Restart Antiretroviral Therapy in Central & Copperbelt Provinces, Zambia

Background

About 30 % of the patients initiated on antiretroviral therapy in Zambia default treatment. Some of these patients later restart treatment; however, the characteristics of these patients have not been well described and documented. The aim of this study was to describe and document the socio-demographic and clinical characteristics of patients who default and restart antiretroviral therapy, and to determine the socio-demographic characteristics associated with CD4 count response at 6 and 24 months of restarting antiretroviral therapy.

Methods

A longitudinal retrospective analysis was performed on data from 535 adult patients restarting antiretroviral therapy in 2009 and 2010 at five antiretroviral therapy centres in Copperbelt and Central provinces of Zambia. To determine the association between the socio-demographic characteristics and CD4 cell count, quantile regression models were used.

Results

Older age above 45 years was associated with a significantly lower CD4 cell response by 38.1 cells/mm³ compared to the younger age (15–29 years). Patients in formal employment and self-employment gained significantly higher CD4 cells than those unemployed. In addition, baseline CD4 count, type of treatment, WHO staging, total duration on treatment and duration lost to follow-up were found to be strong predictors of CD4 cell count at 6 and 24 months after restarting antiretroviral therapy treatment.

Conclusion

Age and occupation were the only socio-demographic characteristics predicting CD4 count in the patients at 6 months after restarting antiretroviral therapy after adjusting for other confounding clinical variables.  

Below:  Boxplots of Interquartile range of CD4 count at restarting ART, 6 and 24 months after restaring ART

Full article at:  http://goo.gl/8P145h

By:  Chama Mulubwa, Oliver Mweemba, Patrick Katayamoyo, and Hikabasa Halwindi

Department of Public Health, School of Medicine, University of Zambia, PO Box 50110, Lusaka, Zambia

FHI 360, Plot 2374, Farmers Village, ZNFU Complex, Lusaka, Zambia

BMC Public Health. 2016; 16: 289.

Published online 2016 Mar 29. doi:  10.1186/s12889-016-2922-3

Department of Public Health, School of Medicine, University of Zambia, PO Box 50110, Lusaka, Zambia

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Integration of HIV Care into Community Management of Acute Childhood Malnutrition Permits Good Outcomes: Lusaka, Zambia

Background

While HIV has had a major impact on health care in southern Africa, there are few data on its impact on acute malnutrition in children in the community. We report an analysis of outcomes in a large programme of community management of acute malnutrition in the south of Lusaka.

Programme Activities and Analysis

Over 3 years, 68,707 assessments for undernutrition were conducted house-to-house, and children with severe acute malnutrition (SAM) or moderate acute malnutrition (MAM) were enrolled into either Outpatient Therapeutic Programme (OTP) or Supplementary Feeding Programme (SFP) respectively. Case records were analysed using tabulation and unconditional logistic regression.

Findings

1,859 children (889 boys, 970 girls; median age 16 months) with MAM (n = 664) or SAM (n = 1,195) were identified. Of 1,796 children whose parents consented to testing, 185 (10.3%) were HIV positive. Altogether 1,163 (62.6%) were discharged as recovered from acute malnutrition. Case fatality while in the programme was 4.2% in children with SAM and 0.5% in those with MAM, and higher in children with HIV infection. In multivariate analysis, HIV, MUAC <11.5cm and the first year of the program all increased mortality. Children with HIV infection who were able to initiate antiretroviral therapy had lower mortality.

Interpretation

Our programme suggests that a comprehensive community malnutrition programme, incorporating HIV care, can achieve low mortality even in a population heavily affected by HIV.

Below:  Flow of children with MAM through the program

Full article at:   http://goo.gl/N84AKd

By:  

Beatrice Amadi, Mercy Imikendu, Milika Sakala, Rosemary Banda 
Department of Paediatrics, University Teaching Hospital, Nationalist Road, Lusaka, Zambia

Beatrice Amadi, Paul Kelly 

Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia

Paul Kelly 

Blizard Institute, Barts & The London School of Medicine, Queen Mary University of London, 4 Newark Street, London, United Kingdom

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The Economic Benefits of High CD4 Counts among People Living with HIV/AIDS in Zambia

BACKGROUND:

The economic effects of poor immunologic recovery among HIV-infected patients receiving antiretroviral therapy (ART) in sub-Saharan Africa are not well understood. We examined the relationship between the CD4 counts of patients on long-term ART and employment outcomes in HIV-affected households in Lusaka, Zambia.

METHODS:

Administrative data and a household survey captured information on the clinical records, demographics and employment outcomes of the ART-treated adults and their adult family members (n = 311). Multivariable regression analyses were used to assess relationships between CD4 counts of ART-treated adults and household employment outcomes.

RESULTS:

Patients with a CD4 count of at least 350 cells/µl were 22 percentage points more likely to be engaged in the labor force (P < 0.05) and worked ∼6 more days per month (P < 0.05) and 9 more hours per week (P = 0.05) compared with patients with a CD4 count <350 cells/µl. Non-patient adults in the HIV-affected household had significantly higher labor participation if the patient's CD4 count was ≥500 compared with <500 cells/µl (P < 0.05), but this was not significant for a CD4 ≥350 versus <350.

CONCLUSION:

These findings suggest that interventions to improve or maintain robust immune recovery during ART may confer economic benefits for both HIV-infected individuals and HIV-affected households.

Purchase full article at:   http://goo.gl/ZshgGL

By:  Tirivayi N1, Koethe JR2.

• 1UNU-MERIT (United Nations University), Maastricht 6211 TC, The Netherlands.
• 2Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, TN, USA. 
• J Public Health (Oxf). 2016 Jan 19. pii: fdv199.

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The Impact of Key HIV Intervention Components as Predictors of Sexual Barrier Use: The Zambia Partner Project

Behavioral interventions have utilized a variety of strategies and components to reduce HIV risk. This article describes the partner intervention, a couple-based group HIV risk reduction intervention implemented in 6 urban community health clinics in Lusaka, Zambia, and examines the components of the intervention and their relationship with condom use. 

Couple members completed assessments on condom use, acceptability, willingness to use condoms, communication, intimate partner violence (IPV), self-efficacy, and HIV information at baseline and 6 months' follow-up. This study examined the relative impact of elements of the intervention as predictors of condom use. Changes in acceptability had the greatest overall influence on condom use, followed by social support, relationship consensus, and willingness to use condoms. Changes in self-efficacy, IPV, negotiation, and information had no influence. 

Results support the use of multidimensional approaches in behavioral interventions and highlight the importance of identifying critical elements of interventions to maximize risk reduction outcomes.

…Changes in acceptability had the greatest overall influence on sexual barrier use, followed by social support, relationship consensus, and willingness to use sexual barriers. Self-efficacy was associated with the use of sexual barriers, but increased self-efficacy did not contribute to increased barrier use in multivariable analysis. Finally, negotiation, IPV, and information had no apparent influence on sexual barrier use.

Study results provide further support for the predictive relationship between acceptability and self-reported willingness to use barriers and sexual barrier use, in line with earlier findings by this team using individual rather than dyadic analyses.²⁸ One of the key elements of CB therapy is the premise that attitudes influence behavior, for example, acceptability of condoms will predict their use. In this study, acceptability may have been increased by CB strategies designed to promote positive attitudes and reduce negative opinions regarding condom use. Condoms are highly effective in the prevention of HIV transmission, but their impact as a prevention strategy has been limited by low acceptability and inconsistent use. Meta-analyses of positive prevention studies in developing countries have reported that interventions targeting HIV sero-positive individuals are successful in increasing condom use, in both seroconcordant and discordant relationships.²⁹ Recent studies, for example, microbicides and preexposure prophylaxis (PrEP), have highlighted the importance of assessing the acceptability of prevention strategies as a predictor of uptake. In fact, low product acceptability may be the Achilles' heel of HIV prevention. Enhancement of product acceptability is likely a critical intervention element and has important implications for the uptake of existing prevention strategies as well as new strategies such as PrEP.

Social support and relationship consensus also played a key role in the uptake of sexual barrier products. In psychotherapy, the group format is often used to increase the overall impact of the intervention by providing a variety of viewpoints on interpersonal issues, but the group format may also increase the perception of the availability of supportive like-minded peers. In addition, the supportive nature of the group format may be more comfortable for members of collective communities and cultures, although results of previous research regarding the impact of the group format on condom use are mixed.² Although no interaction was discovered, future studies should continue to explore the association between social support and relationship consensus. Both the elements of social support and the focus on achieving consensus appear to be critical intervention elements…

Full article at:  http://goo.gl/u4pTRv

By:  Ndashi Chitalu, MD,1 Mirriam Mumbi, CNM,1 Ryan Cook, BA,2 Stephen M. Weiss, PhD, MPH,2 and Deborah Jones, PhD2

¹Department of Pediatrics, University Teaching Hospital, University of Zambia School of Medicine, Lusaka, Zambia

²Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, USA

Corresponding Author: Deborah Jones, Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, 1400 NW 10th Ave, Suite 404A, Miami, FL 33136, USA, Email: ude.imaim.dem@senojd

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Assessing the Feasibility of Police Initiation of HIV Post-Exposure Prophylaxis for Sexual Violence Survivors in Lusaka, Zambia

Globally, more than 1 in 3 women have experienced physical or sexual violence (SV) from intimate partners or SV from non-partners [1]. Furthermore, over 10% of all girls are estimated to have experienced a forced sexual act, with the highest rates of SV against girls found in sub-Saharan Africa [2].

Although public recognition of SV is growing in Zambia, reliable data on the nature and extent of such violence is limited. Approximately 20% of Zambian women aged 15 to 49 have experienced some form of sexual violence; however, this is likely underestimated due to underreporting [3]. Previous research in Zambia suggests that exposure to SV is equally pervasive among adolescent girls [4,5].

The risks associated with SV, especially among young women, are numerous. Immediate health consequences include unwanted pregnancy, physical trauma, mental distress and acquisition of HIV and other sexually-transmitted infections. The linkage between sexual and gender-based violence (SGBV) and risk of HIV has been well documented in Africa and is especially pronounced in countries with high HIV prevalence, such as Zambia [3,6-8].

Growing awareness of these negative consequences of SGBV led the Government of Zambia to develop a set of national guidelines for the management of SGBV, highlighting the need for a response system linking the health, police, and social services sectors. A critical component of this response is the prevention of HIV infection in SV survivors through the provision of preventive anti-retroviral therapy, or HIV post-exposure prophylaxis (PEP). The initial dose of PEP must be taken within 72 hours of exposure to HIV [9].

Given the time sensitivity of PEP and the fact that police and health services are often the first points of contact for SV survivors, strong coordination between these two sectors is central to the effective medical management of SV cases in Zambia [10]. Building on the results of previous research in Zambia, which demonstrated that trained Victim Support Unit (VSU) police officers could effectively administer the emergency contraception pill to SV survivors, the Population Council, Zambia Police Service, and Ministry of Health aimed to assess the feasibility of having trained VSU police officers safely and effectively provide a PEP starter dose to SV survivors with immediate referral to comprehensive medical services [10].

Below:  Police delivery of PEP (November 2012 - October 2013)

Full article at:   http://goo.gl/MxNSrU

By:   Mary T Zama¹, Mardieh Dennis^1*, Jessica Price¹ and Stephanie M Topp²³

¹Population Council, Private Bag 319X, Ridgeway, Lusaka, Zambia

²Centre for Infectious Disease Research in Zambia, PO Box 34681, Lusaka, Zambia

³Nossal Institute for Global Health, University of Melbourne, Level 4, 161 Barry Street, Alan Gilbert Building, Carlton 3010, VIC, Australia

  

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A Cross-Sectional Study of Bacterial Vaginosis, Intravaginal Practices & HIV Genital Shedding; Implications for HIV Transmission & Women's Health

Bacterial vaginosis (BV) is associated with an increased risk of HIV transmission, and intravaginal practices (IVP) are an important risk factor for developing BV. The relationship between IVP, BV and HIV lower genital shedding, responsible for HIV transmission, has not been examined in women receiving antiretrovirals in Zambia.

Setting: Community Health Center in Lusaka, Zambia.

Participants were HIV-infected women receiving antiretroviral therapy and engaging in IVP (n=128). Participants completed audio computer-administered self-interviews to assess IVP and underwent a vaginal examination. BV was diagnosed using Nugent criteria. HIV-1 lower genital shedding was assessed by measuring HIV-1 RNA in cervicovaginal lavages.

Most women engaged in IVP daily (114, 89.0%) and 81 (63.3%) of the participants had BV. HIV-1 genital shedding was detected in 18 (14.2%) participants. BV was associated with daily use of IVP and weekly use of traditional medicines for IVP. The only factor associated with HIV-1 lower genital shedding was plasma viraemia. Neither IVP nor BV were associated with HIV shedding.

Despite the frequency of IVP and high prevalence of BV, plasma viraemia was the primary factor associated with HIV lower genital shedding. These findings support early initiation of antiretrovirals as an HIV prevention tool. Given adverse health outcomes associated with BV, the association between frequent IVP and BV, and the powerful local norms and traditions encouraging IVP, there is a need for studies assessing culturally tailored interventions to decrease BV in high-prevalence settings.

Full article at:  http://goo.gl/EmtqVd

By: Alcaide ML1, Chisembele M2, Malupande E2, Arheart K3, Fischl M1, Jones DL4.

• 1Division of Infectious Diseases, University of Miami, Miller School of Medicine, Miami, Florida, USA.
• 2University of Zambia, University Teaching Hospital, Lusaka, Zambia.
• 3Department of Epidemiology and Public Health, University of Miami, Miller School of Medicine, Miami, Florida, USA.
• 4Department of Psychiatry and Behavioral Sciences, University of Miami, Miller School of Medicine, Miami, Florida, USA. 

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