Showing posts with label Zimbabwe. Show all posts
Showing posts with label Zimbabwe. Show all posts

Tuesday, May 10, 2016

Implementation and Operational Research: Cohort Analysis of Program Data to Estimate HIV Incidence and Uptake of HIV-Related Services among Female Sex Workers in Zimbabwe, 2009–2014

BACKGROUND:
HIV epidemiology and intervention uptake among female sex workers (FSW) in sub-Saharan Africa remain poorly understood. Data from outreach programs are a neglected resource.

METHODS:
Analysis of data from FSW consultations with Zimbabwe's National Sex Work program, 2009-2014. At each visit, data were collected on sociodemographic characteristics, HIV testing history, HIV tests conducted by the program and antiretroviral (ARV) history. Characteristics at first visit and longitudinal data on program engagement, repeat HIV testing, and HIV seroconversion were analyzed using a cohort approach.

RESULTS:
Data were available for 13,360 women, 31,389 visits, 14,579 reported HIV tests, 2750 tests undertaken by the program, and 2387 reported ARV treatment initiations. At first visit, 
  • 72% of FSW had tested for HIV; 
  • 50% of these reported being HIV positive. 
Among HIV-positive women, 
  • 41% reported being on ARV. 
  • 56% of FSW attended the program only once. 
FSW who had not previously had an HIV-positive test had been tested within the last 6 months 27% of the time during follow-up. After testing HIV positive, women started on ARV at a rate of 23/100 person years of follow-up. Among those with 2 or more HIV tests, the HIV seroconversion rate was 9.8/100 person years of follow-up (95% confidence interval: 7.1 to 15.9).

CONCLUSIONS:
Individual-level outreach program data can be used to estimate HIV incidence and intervention uptake among FSW in Zimbabwe. Current data suggest very high HIV prevalence and incidence among this group and help identify areas for program improvement. Further methodological validation is required.

Purchase full article at:  http://goo.gl/28H8rT

1*Centre for Evaluation, London School of Hygiene & Tropical Medicine, London, United Kingdom; †Centre for Sexual Health & HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe; ‡United Nations Population Fund, New York, NY; §Women's Global Health Imperative, RTI International, San Francisco, CA; ‖Gesellschaft für Internationale Zusammenarbeit, Bonn, Germany; National AIDS Council, Harare, Zimbabwe; #AIDS and TB Unit, Ministry of Health & Child Care, Harare, Zimbabwe; and **Research Department for Infection and Population Health, University College London, London, United Kingdom.
J Acquir Immune Defic Syndr. 2016 May 1;72(1):e1-8. doi: 10.1097/QAI.0000000000000920. 




Friday, March 25, 2016

Tuberculosis Incidence Is High in HIV-Infected African Children But Is Reduced by Co-Trimoxazole & Time on Antiretroviral Therapy

BACKGROUND:
There are few data on tuberculosis (TB) incidence in HIV-infected children on antiretroviral therapy (ART). Observational studies suggest co-trimoxazole prophylaxis may prevent TB, but there are no randomized data supporting this. The ARROW trial, which enrolled HIV-infected children initiating ART in Uganda and Zimbabwe and included randomized cessation of co-trimoxazole prophylaxis, provided an opportunity to estimate the incidence of TB over time, to explore potential risk factors for TB, and to evaluate the effect of stopping co-trimoxazole prophylaxis.

METHODS:
Of 1,206 children enrolled in ARROW, there were 969 children with no previous TB history. After 96 weeks on ART, children older than 3 years were randomized to stop or continue co-trimoxazole prophylaxis; 622 were eligible and included in the co-trimoxazole analysis. Endpoints, including TB, were adjudicated blind to randomization by an independent endpoint review committee (ERC). Crude incidence rates of TB were estimated and potential risk factors, including age, sex, center, CD4, weight, height, and initial ART strategy, were explored in multivariable Cox proportional hazards models.

RESULTS:
After a median of 4 years follow-up (3,632 child-years), 69 children had an ERC-confirmed TB diagnosis. The overall TB incidence was 1.9/100 child-years (95 % CI, 1.5-2.4), and was highest in the first 12 weeks following ART initiation (8.8/100 child-years (5.2-13.4) versus 1.2/100 child-years (0.8-1.6) after 52 weeks). A higher TB risk was independently associated with younger age (<3 years), female sex, lower pre-ART weight-for-age Z-score, and current CD4 percent; fewer TB diagnoses were observed in children on maintenance triple nucleoside reverse transcriptase inhibitor (NRTI) ART compared to standard non-NRTI + 2NRTI. Over the median 2 years of follow-up, there were 20 ERC-adjudicated TB cases among 622 children in the co-trimoxazole analysis: 5 in the continue arm and 15 in the stop arm (hazard ratio (stop: continue) = 3.0 (95 % CI, 1.1-8.3), P = 0.028). TB risk was also independently associated with lower current CD4 percent (P <0.001).

CONCLUSIONS:
TB incidence varies over time following ART initiation, and is particularly high during the first 3 months post-ART, reinforcing the importance of TB screening prior to starting ART and use of isoniazid preventive therapy once active TB is excluded. HIV-infected children continuing co-trimoxazole prophylaxis after 96 weeks of ART were diagnosed with TB less frequently, highlighting a potentially important role of co-trimoxazole in preventing TB.

Below:  Tuberculosis incidence over time after antiretroviral therapy initiation



Full article at:   http://goo.gl/vd6abn

  • 1MRC Clinical Trials Unit at UCL, London, UK. angela.crook@ucl.ac.uk.
  • 2MRC Clinical Trials Unit at UCL, London, UK.
  • 3Joint Clinical Research Centre, Kampala, Uganda.
  • 4Makerere University College of Health Sciences, Kampala, Uganda.
  • 5Department of Paediatrics and Child Health, University of Zimbabwe Medical School, Harare, Zimbabwe.
  • 6Baylor College of Medicine Children's Foundation, Kampala, Uganda.
  • 7MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda.
  • 8MU-JHU Care Ltd, Kampala, Uganda.
  • 9Blizard Institute, Queen Mary University of London, London, UK. 
  •  2016 Mar 23;14(1):50. doi: 10.1186/s12916-016-0593-7.



Saturday, March 19, 2016

Factors Shaping the HIV-Competence of Two Primary Schools in Rural Zimbabwe

We present multi-method case studies of two Zimbabwean primary schools – one rural and one small-town. The rural school scored higher than the small-town school on measures of child well-being and school attendance by HIV-affected children. The small-town school had superior facilities, more teachers with higher morale, more specialist HIV/AIDS activities, and an explicit religious ethos. The relatively impoverished rural school was located in a more cohesive community with a more critically conscious, dynamic and networking headmaster. The current emphasis on HIV/AIDS-related teacher training and specialist school-based activities should be supplemented with greater attention to impacts of school leadership and the nature of the school-community interface on the HIV-competence of schools…

Below:  Draw-and-write. She is sitting while the others are playing. I feel sorry for Mona because the other girls don’t want to play with her because they say that she has HIV.



I wish to argue that poverty is a major contributor … It affects everyone’s morals, health and participation in school work. Teachers’ morale is also affected. Teachers’ status in the community is affected, as they appear to be depending on parents’ gifts/incentives … . Almost all schools closed in 2008 … At no other time had we experienced the same hardships. Since then, conditions of service have been poor. The teachers’ morale and commitment is very low. Moonlighting is common among teachers. The headmaster’s legitimate power over teachers is affected because his reports have no rewards in such an economy. Generally, trust is reduced because of the hardships. When school-based health workshops are offered, adoption and implementation is slow in difficult times. The influence of the teacher is comparatively lower when the job has a lower dignity. (Letter from Rural Headmaster to Researchers)…

Compared to the small-town school, the rural school was associated with many more references to morally bad teachers, varying described as drunk at work, absent or liable to administer harsh physical punishment to children.
Some teachers even come to school drunk. Sometimes one might can come drunk for a week, not coming for lessons. Another may be drunk and come for lessons but be very harsh towards the children, even if they have not done anything wrong, the teacher may beat them. (Rural focus group with HIV-affected pupils)…

Overall, our case study findings suggest that neither school was providing much support for HIV-affected children. Yet, as reported above, the statistical analysis found the rural school to have significantly higher levels of school attendance and well-being of HIV-affected children than the rural one. Whilst our research design prevents us from making linear claims or causal connections between our case study findings and these quantitative outcomes, our case studies have thrown up a series of interesting correlations. We use these as the basis for a series of tentative claims about the way in which features of the school and context might clash or support one another in ways that promote or hinder the likelihood of HIV-competence in schools. We look at features of the schools and their surrounding communities in turn, using the concepts of bonding and bridging social capital as a frame of integrating our findings. Bonding social capital refers to solidarity within a group (in this case the school), and bridging social capital to links between a group and external networks (in this case the school and the community) ()…

Full article at:    http://goo.gl/bhsE6v

aDepartment of Social Psychology, The London School of Economics and Political Science, United Kingdom
bBiomedical Research and Training Institute, Zimbabwe
cSchool of Applied Human Sciences, University of KwaZulu Natal, South Africa
dDepartment of Public Health, University of Copenhagen, Denmark
eDepartment of Infectious Disease Epidemiology, Imperial College School of Public Health, United Kingdom
*Corresponding author. Tel.: +44 207 955 7701.




Friday, March 11, 2016

Re-Thinking Children’s Agency in Extreme Hardship: Zimbabwean Children’s Draw-and-Write About Their HIV-Affected Peers

We compare two analyses of the same ‘draw-and-write’ exercises in which 128 Zimbabwean children represented their HIV-affected peers. The first, informed by the ‘New Social Studies of Childhood’, easily identified examples of independent reflection and action by children. The second, informed by Sen’s understandings of agency, drew attention to the negative consequences of many of the choices available to children, and the contextual limits on outcomes children themselves would value: the support of caring adults, adequate food, and opportunities to advance their health and safety. Conceptualisations of agency need to take greater account of children’s own accounts of outcomes they value, rather than identifying agency in any form of independent reflection and action per se.

…In line with the New Social Studies of Childhood, our first analysis dutifully sought out and documented instances of independent reflection and action by children. To what extent might we regard these as evidence for agency? Children were depicted as exercising agency in the sense of reflecting and acting, but because they often had so little access to significant power, resources or support, the actions they performed did not bring them closer to the outcomes they would value. We argue for the need for renewed debate about how best to conceptualise children’s actions in contexts that (i) provide them with a highly constrained set of options for exercising initiative, (ii) where the exercise of choice in one arena of their lives might be associated with negative long term outcomes in another; and/or (iii) where the outcomes of their actions may not take them any closer to their own perceptions of a good life. In conceptualising agency, instead of positing independent action as an end in itself, we prefer to regard independent action as the means to end that actors themselves would value.

In a tangentially related debate in the field of gender studies, critical researchers of women in the global south are increasingly concerned by a tendency to exaggerate the agency of women in situations of extreme subordination and coercion. Attempts by well-meaning academics, activists and policy makers to avoid depicting marginalised women as victims have led to a situation where “the search for agency in the least favourable situations has reached almost epidemic proportions” (: loc 554). In the process, they argue that feminist scholars – motivated by the desire to avoid potentially offensive depictions of ‘third world women’ as passive victims – have sometimes unwittingly aligned themselves with individualistic neoliberal understandings of agency and personhood. They have done this through advancing understandings of agency as any form of decontextualised individual choice and through celebrating actions by women that lead to nothing more than their basic survival. In the process they “neglect the oppressive structures of material and discursive power”, generating understandings of agency that undermine attention to, and analysis of, gendered oppression (): loc 2253)…

There is no doubt that, as the NSCC has now firmly established, children are able to act, show resourcefulness and survive, often with little help or input from adults. To that extent they are ‘competent social actors’. This was a vitally important point to make in the 1990s. However in the light of the strong body of research generated by the NSCC tradition, we believe this can now be taken as a given. We argue that the next step for researchers is to pay greater attention to the factors that mediate between so-called agency and its outcomes, and, most important, pay particular attention to children’s own accounts of their hopes for the future, and children’s own visions of what would constitute a ‘good life’ from one social setting to another.

Below:  Draw-and-write of a child suffering with HIV/AIDS




Below:  Draw-and-write about a child carer



Full article at:   http://goo.gl/w98rLE

aDepartment of Social Psychology, The London School of Economics and Political Science, London WC2A 2AE, United Kingdom
bBiomedical Research and Training Institute, Harare, Zimbabwe
cSchool of Applied Human Sciences, University of KwaZulu Natal, Durban, South Africa
dDepartment of Public Health, University of Copenhagen, Copenhagen, Denmark
eDepartment of Infectious Disease Epidemiology, Imperial College School of Public Health, London SW7 2AZ, United Kingdom
*Corresponding author. Tel.: +44 207 955 7701. 




Monday, February 1, 2016

Factors Associated with Ever Being HIV-Tested in Zimbabwe

INTRODUCTION:
Zimbabwe has a high human immunodeficiency virus (HIV) burden. It is therefore important to scale up HIV-testing and counseling (HTC) as a gateway to HIV prevention, treatment and care.

OBJECTIVE:
To determine factors associated with being HIV-tested among adult men and women in Zimbabwe.

METHODS:
Secondary analysis was done using data from 7,313 women and 6,584 men who completed interviewer-administered questionnaires and provided blood specimens for HIV testing during the Zimbabwe Demographic and Health Survey (ZDHS) 2010-11. Factors associated with ever being HIV-tested were determined using multivariate logistic regression.

RESULTS:
HIV-testing was higher among women compared to men (61% versus 39%). HIV-infected respondents were more likely to be tested compared to those who were HIV-negative for both men [adjusted odds ratio (AOR) = 1.53; 95% confidence interval (CI) (1.27-1.84)] and women [AOR = 1.42; 95% CI (1.20-1.69)]. However, only 55% and 74% of these HIV-infected men and women respectively had ever been tested. Among women, visiting antenatal care (ANC) [AOR = 5.48, 95% CI (4.08-7.36)] was the most significant predictor of being tested whilst a novel finding for men was higher odds of testing among those reporting a sexually transmitted infection (STI) in the past 12 months [AOR = 1.86, 95%CI (1.26-2.74)]. Among men, the odds of ever being tested increased with age ≥20 years, particularly those 45-49 years [AOR = 4.21; 95% CI (2.74-6.48)] whilst for women testing was highest among those aged 25-29 years [AOR = 2.01; 95% CI (1.63-2.48)]. Other significant factors for both sexes were increasing education level, higher wealth status and currently/formerly being in union.

CONCLUSIONS:
There remains a high proportion of undiagnosed HIV-infected persons and hence there is a need for innovative strategies aimed at increasing HIV-testing, particularly for men and in lower-income and lower-educated populations. Promotion of STI services can be an important gateway for testing more men whilst ANC still remains an important option for HIV-testing among pregnant women.

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

  • 1AIDS and TB Department, Ministry of Health and Child Care, Harare, Zimbabwe.
  • 2International Union Against Tuberculosis and Lung Disease, Paris, France.
  • 3National AIDS Council, Harare, Zimbabwe.
  • 4Department of Community Medicine, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe.
  • 5Centre for Research and Training in Clinical Epidemiology, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe.
  • 6Division of Global HIV/AIDS, Centers for Disease Control and Prevention (CDC), Harare, Zimbabwe.
  • 7Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom. 
  •  2016 Jan 25;11(1):e0147828. doi: 10.1371/journal.pone.0147828. eCollection 2016.




Saturday, January 30, 2016

Zimbabwe's National AIDS Levy: A Case Study

BACKGROUND:
We conducted a case study of the Zimbabwe National AIDS Trust Fund ('AIDS Levy') as an approach to domestic government financing of the response to HIV and AIDS.

METHODS:
Data came from three sources: a literature review, including a search for grey literature, review of government documents from the Zimbabwe National AIDS Council (NAC), and key informant interviews with representatives of the Zimbabwean government, civil society and international organizations.

FINDINGS:
The literature search yielded 139 sources, and 20 key informants were interviewed. Established by legislation in 1999, the AIDS Levy entails a 3% income tax for individuals and 3% tax on profits of employers and trusts (which excluded the mining industry until 2015). It is managed by the parastatal NAC through a decentralized structure of AIDS Action Committees. Revenues increased from inception to 2006 through 2008, a period of economic instability and hyperinflation. Following dollarization in 2009, annual revenues continued to increase, reaching US$38.6 million in 2014. By policy, at least 50% of funds are used for purchase of antiretroviral medications. Other spending includes administration and capital costs, HIV prevention, and monitoring and evaluation. Several financial controls and auditing systems are in place. Key informants perceived the AIDS Levy as a 'homegrown' solution that provided country ownership and reduced dependence on donor funding, but called for further increased transparency, accountability, and reduced administrative costs, as well as recommended changes to increase revenue.

CONCLUSIONS:
The Zimbabwe AIDS Levy has generated substantial resources, recently over US$35 million per year, and signals an important commitment by Zimbabweans, which may have helped attract other donor resources. Many key informants considered the Zimbabwe AIDS Levy to be a best practice for other countries to follow.

Below:  AIDS Levy budget allocations – 2009–2012



Full article at:   http://goo.gl/YqM2kR

By:  Bhat N1, Kilmarx PH2,3, Dube F4, Manenji A5, Dube M6, Magure T7.
  • 1 is an International Experience and Technical Assistance Fellow affiliated to US Centers for Disease Control and Prevention , Harare.
  • 2 MD, is a medical epidemiologist affiliated to US Centers for Disease Control and Prevention , Harare . Email: peter.kilmarx@nih.gov.
  • 3 is affiliated to Division of Global HIV/AIDS, US Centers for Disease Control and Prevention , Atlanta.
  • 4 is a Research and Documentation Coordinator affiliated to National AIDS Council of Zimbabwe , Harare.
  • 5 is a Finance Director affiliated to National AIDS Council of Zimbabwe , Harare.
  • 6 is a Communications Director affiliated to National AIDS Council of Zimbabwe , Harare.
  • 7 MBcHB, MPH, MBA, is a Chief Executive Officer affiliated to National AIDS Council of Zimbabwe , Harare. 
  •  2016 Dec;13(1):1-7. doi: 10.1080/17290376.2015.1123646.




Thursday, January 28, 2016

Can Schools Support HIV/AIDS-Affected Children? Exploring the 'Ethic of Care' amongst Rural Zimbabwean Teachers

How realistic is the international policy emphasis on schools 'substituting for families' of HIV/AIDS-affected children? We explore the ethic of care in Zimbabwean schools to highlight the poor fit between the western caring schools literature and daily realities of schools in different material and cultural contexts. 

Interviews and focus groups were conducted with 44 teachers and 55 community members, analysed in light of a companion study of HIV/AIDS-affected pupils' own accounts of their care-related experiences. We conceptualise schools as spaces of engagement between groups with diverse needs and interests (teachers, pupils and surrounding community members), with attention to the pathways through which extreme adversity impacts on those institutional contexts and social identifications central to giving and receiving care. 

Whilst teachers were aware of how they might support children, they seldom put these ideas into action. Multiple factors undermined caring teacher-pupil relationships in wider contexts of poverty and political uncertainty: loss of morale from low salaries and falling professional status; the inability of teachers to solve HIV/AIDS-related problems in their own lives; the role of stigma in deterring HIV/AIDS-affected children from disclosing their situations to teachers; authoritarian teacher-learner relations and harsh punishments fuelling pupil fear of teachers; and lack of trust in the wider community. 

These factors undermined: 

  • teacher confidence in their skills and capacity to support affected pupils and motivation to help children with complex problems; 
  • solidarity and common purpose amongst teachers, and between teachers and affected children; and effective bridging alliances between schools and their surrounding communities-all hallmarks of HIV-competent communities. 

We caution against ambitious policy expansions of teachers' roles without recognition of the personal and social costs of emotional labour, and the need for significant increases in resources and institutional recognition to enable teachers to adopt support roles. We highlight the need for research into how best to create opportunities for teacher recognition in deprived and disorganised institutional settings, and the development of more culturally appropriate notions of caring.

Below:  Analysis of teacher data


Below:  Analysis of community data



Full article at:   http://goo.gl/3do3hz

  • 1Department of Social Psychology, The London School of Economics and Political Science, London, United Kingdom.
  • 2Biomedical Research and Training Institute, Harare, Zimbabwe.
  • 3School of Applied Human Sciences, University of KwaZulu Natal, Durban, South Africa.
  • 4Department of Infectious Disease Epidemiology, Imperial College School of Public Health, London, United Kingdom.
  •  2016 Jan 20;11(1):e0146322. doi: 10.1371/journal.pone.0146322. eCollection 2016. 




Tuesday, December 29, 2015

Facility-Based Delivery in the Context of Zimbabwe's HIV Epidemic - Missed Opportunities for Improving Engagement with Care: A Community-Based Serosurvey

BACKGROUND:
In developing countries, facility-based delivery is recommended for maternal and neonatal health, and for prevention of mother-to-child HIV transmission (PMTCT). However, little is known about whether or not learning one's HIV status affects one's decision to deliver in a health facility. We examined this association in Zimbabwe.

METHODS:
We analyzed data from a 2012 cross-sectional community-based serosurvey conducted to evaluate Zimbabwe's accelerated national PMTCT program. Eligible women (≥16 years old and mothers of infants born 9-18 months before the survey) were randomly sampled from the catchment areas of 157 health facilities in five of ten provinces. Participants were interviewed about where they delivered and provided blood samples for HIV testing.

RESULTS:
Overall 8796 (77 %) mothers reported facility-based delivery; uptake varied by community (30-100 %). The likelihood of facility-based delivery was not associated with maternal HIV status. Women who self-reported being HIV-positive before delivery were as likely to deliver in a health facility as women who were HIV-negative, irrespective of when they learned their status - before (adjusted prevalence ratio (PRa) = 1.04, 95 % confidence interval (CI) = 1.00-1.09) or during pregnancy (PRa = 1.05, 95 % CI = 1.01-1.09). Mothers who had not accessed antenatal care or tested for HIV were most likely to deliver outside a health facility (69 %). Overall, however 77 % of home deliveries occurred among women who had accessed antenatal care and were HIV-tested.

CONCLUSIONS:
Uptake of facility-based delivery was similar among HIV-infected and HIV-uninfected mothers, which was somewhat unexpected given the substantial technical and financial investment aimed at retaining HIV-positive women in care in Zimbabwe.

Full article at:   http://goo.gl/HouI0a

  • 1University of California Berkeley, School of Public Health, 779 University Hall, MS 7360, Berkeley, CA, 94720, USA. rbuzdugan@berkeley.edu.
  • 2University of California Berkeley, School of Public Health, 779 University Hall, MS 7360, Berkeley, CA, 94720, USA. smccoy@berkeley.edu.
  • 3University College London, London, United Kingdom. kwebb@ophid.co.zw.
  • 4Organisation for Public Health Interventions and Development Trust, 20 Cork Road, Belgravia, Harare, Zimbabwe. kwebb@ophid.co.zw.
  • 5Ministry of Health and Child Care, Harare, Zimbabwe. mushavia@yahoo.co.uk.
  • 6Elizabeth Glaser Pediatric AIDS Foundation, 107 King George Road, Avondale, Harare, Zimbabwe. amahomva@pedaids.org.
  • 7University of California Berkeley, School of Public Health, 779 University Hall, MS 7360, Berkeley, CA, 94720, USA. nancy.padian@gmail.com.
  • 8University College London, London, United Kingdom. f.cowan@ucl.ac.uk.
  • 9Centre for Sexual Health and HIV/AIDS Research Zimbabwe, 9 Monmouth Road, Avondale West, Harare, Zimbabwe. f.cowan@ucl.ac.uk.