Centre for Infectious Disease Research in Zambia
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Hepatitis B and C Prevention, Screening, and Diagnostic Services at HIV Treatment Sites: International Epidemiology Databases to Evaluate AIDS.
(2026-Sep-01) Kuniholm MH; Murenzi G; Samala N; Yunihastuti E; Wandeler G; Kim HN; Plaisy MK; Perazzo H; Twizere C; Odhiambo F; Bopage R; Muula G; Lo Re V; Minga A; López-Iñiguez A; Nsonde DM; Kasozi C; Wati DK; Fox MP; Kirk GD; Messou E; Cesar C; Ebasone PV; Byakwaga H; Ross J; Chimbetete C; Yendewa GA; Jaquet A; Succi RCM; Maruri F; Brazier E
BACKGROUND: Prevention, screening, and diagnostic services for hepatitis B virus (HBV) and hepatitis C virus (HCV) can prevent morbidity and mortality in people receiving HIV care. However, there is limited information about the availability of HBV and HCV services at HIV clinics globally.
METHODS: The International epidemiology Databases to Evaluate AIDS (IeDEA) conducted surveys of service delivery and practices at participating HIV treatment centers from 7 regions. We used 2023 survey data to measure availability of HBV vaccination, HBV and HCV screening, HBV surface antigen (HBsAg), HBV DNA, HCV antibody, and HCV RNA testing. Multivariable logistic regression models were used to test associations of site characteristics with HBV and HCV services.
RESULTS: HBV vaccination was available on-site at 67.7% of 204 HIV treatment sites. Screening for HBV and HCV at HIV care enrollment was reported by 72.1% and 50% of sites, respectively. HBsAg, HBV DNA, HCV antibody, and HCV RNA testing were available on-site at 77%, 47.6%, 61.8%, and 44.6% of sites, respectively. Sites serving predominately rural (vs. urban) populations were less likely to report on-site availability of HBV DNA [odds ratio (OR):0.07; 95% confidence interval: 0.01 to 0.68; P = 0.02], HCV antibody (OR = 0.18; 95% CI: 0.04 to 0.92; P = 0.04), and HCV RNA (OR = 0.10; 95% CI: 0.01 to 0.90; P = 0.04) testing.
CONCLUSION: Life-saving services such as HBV vaccination, HBsAg, and HCV antibody testing were available on-site at most HIV treatment sites participating in the IeDEA network. Lower availability at rural sites suggests that expansion of services is important to eliminate HBV and HCV as public health problems in people receiving HIV care.
Screening, brief intervention, and referral to treatment compared with treatment as usual for alcohol use in an integrated refugee settlement in Zambia: a hybrid, type 1, randomised controlled trial.
(2026-Sep) Greene MC; Loongo H; Metz K; Shawa M; Mtongo N; Lukoma I; Chiluba P; Chibemba V; Kamono S; Mushabati N; Chibambula M; Watson K; Vaughan K; Demis L; Skavenski S; Murray LK; Ventevogel P; Busse A; Tol WA; Ezard N; Mwanza D; Lungu G; Kamanga M; Kane JC
BACKGROUND: Alcohol and other drug use represent a leading cause of preventable death and disability globally, disproportionately burdening low-resource settings. Alcohol and other drug use interventions remain neglected in humanitarian health research and programming. We evaluated the effectiveness of a multicomponent intervention in reducing alcohol use in a refugee setting in Zambia.
METHODS: We conducted a parallel, individually randomised trial in the Mantapala refugee settlement in Zambia. Eligible participants were Congolese refugees and Zambian host community members, aged 15 years and older, with Alcohol Use Identification Test (AUDIT) scores of 8 or more for males and 4 or more for females. Participants were allocated (1:1) to screening, brief intervention, and referral to treatment (SBIRT) or treatment as usual via a computer-generated randomisation scheme with allocation concealment by opaque envelopes. SBIRT included screening, a brief intervention, and indicated referral to psychotherapy for alcohol and other drug use and mental health conditions delivered by trained non-specialists. Treatment as usual comprised referral to primary health centre staff trained in basic management and care for alcohol use problems. The primary outcome was AUDIT score evaluated at 6 months. Linear mixed models and an intention-to-treat approach were used following multiple imputation. Implementation was assessed qualitatively and through cost-effectiveness analysis. Due to the nature of the trial, participants counsellors, and research assistants were unmasked at enrolment, although data analysts remained masked via dummy coding of the study group. The trial was registered on ClinicalTrials.gov (NCT05471921) and is completed.
FINDINGS: Between April 26, 2023, and Feb 29, 2024, 443 participants were screened for eligibility, 43 were excluded, and 400 were enrolled and randomly assigned (199 to the SBIRT group and 201 to the treatment as usual group). 299 (75%) of the 400 participants completed the 6-month assessment and 310 (78%) completed the 12-month assessment. The mean age of participants was 36·9 years (SD 12·1) and 287 (72%) participants were male and 113 (28%) were female. 232 (58%) of the 400 participants were Congolese refugees. AUDIT scores reduced from baseline to 6 months among the SBIRT group (-12·6 [95% CI -14·3 to -11·0]) and the treatment as usual group (-8·1 [-9·8 to -6·3]). The difference in mean change between groups was significantly greater in the SBIRT group than in the treatment as usual group at 6 months (-4·6 [95% CI -6·9 to -2·2]; p<0·0001; d=0·56) and 12 months (-3·5 [95% CI -5·8 to -1·1]; p=0·0030; d=0·43). The incremental cost per improvement in AUDIT at 6 months was US$158. There were no study-related adverse events.
INTERPRETATION: To our knowledge, this is the first known trial in a humanitarian setting of an intervention finding a significant, sustained effect on reduced alcohol use. SBIRT is a feasible and effective strategy to reduce alcohol-related burden in humanitarian and low-resource settings, with potential for integration into national and global health policies and systems.
FUNDING: Elrha's Research for Health in Humanitarian Crises Programme.
Genetic characterization of M. tuberculosis isolates from participants in a Phase 2b randomized trial evaluating the M72/AS01E tuberculosis candidate vaccine.
(2026-Aug-28) Wattiau P; Omar SV; Joseph L; Demoitié MA; Gilbert M; Ayles HM; Diacon AH; Ginsberg AM; Hatherill M; Hellström E; Innes JC; Malahleha M; Martinson N; Muyoyeta M; Nduba V; Tait DR; Wilkinson RJ; Roman F
BACKGROUND: The efficacy and safety of the M72/AS01E tuberculosis (TB) candidate vaccine were evaluated in the phase 2b randomized, placebo-controlled trial NCT01755598. In the trial, participants with Mycobacterium tuberculosis sensitization by a positive interferon-gamma release assay received either M72/AS01E or placebo (randomized 1:1) and were followed for 3 years. In this descriptive study, we genetically characterized M. tuberculosis isolates from participants who developed pulmonary TB during the trial to assess variability among isolates and evaluate the possibility of preferential progression from infection to active TB by certain strains in M72/AS01E and placebo recipients.
METHODS: M. tuberculosis isolates were recovered from sputum samples and underwent DNA extraction and sequencing to assess lineage, antibiotic resistance profile, genetic variation, and genomic clusters.
RESULTS: One hundred isolates (37 M72/AS01E, 63 placebo) were genetically characterized from 50 participants who developed microbiologically confirmed active pulmonary TB during the trial (20 M72/AS01E, 30 placebo). Diverse M. tuberculosis lineages were identified in both M72/AS01E and placebo recipients. No multidrug-resistant strains were detected. Genetic sequences corresponding to the antigenic components of M72/AS01E, showed low variation in pepA and high variation in PPE18. However, no apparent preferential distribution of variants was observed in M72/AS01E or placebo recipients. Cluster analyses identified 10 genomic clusters with isolates from >1 participant, illustrating complex transmission dynamics and potential of co-infection by multiple strains within individuals.
CONCLUSION: This descriptive analysis showed no apparent preferential distribution of local M. tuberculosis strains in M72/AS01E or placebo recipients. These results support the continued development of this candidate vaccine.
Validation of a Point-Of-Care Ultrasound for Hepatitis Among Front-Line Healthcare Workers Managing Chronic Hepatitis B Virus Infection in Zambia.
(2026-Sep) Bertoni C; Kanunga A; Sinkala E; Syabbalo E; Chitundu H; Chikwezi A; Chibundi C; Muula GK; Bosomprah S; Capra N; Lolatto R; Morsica G; Castagna A; Wallrauch C; Heller T; Vinikoor MJ
To close gaps in implementing care of people with hepatitis B virus (HBV) infection in resource-limited settings, we evaluated the accuracy of a novel liver point-of-care ultrasound (POCUS) protocol for hepatitis (PUSH) among front-line non-radiology healthcare workers in Zambia. At University Teaching Hospital in Lusaka, Zambia, from March to June 2024, we trained four nurses and six physicians with experience in HBV management, but not in ultrasound (US), in the PUSH protocol, which includes visualizing the liver in three windows (epigastric, subcostal and right transcostal) to identify cirrhosis-suggestive features and liver lesions suspicious for hepatocellular carcinoma (HCC). Then, consecutive adult participants with chronic hepatitis B (PWHB) alone or HBV/HIV coinfection underwent PUSH with operators blinded to clinical data. We evaluated the accuracy of PUSH for significant fibrosis and cirrhosis using transient elastography (TE) as the reference standard test (RST) and for liver lesions that were possible HCC using a comprehensive abdominal ultrasound by an experienced radiographer as the RST. Nonparametric analysis of the receiver operating curve (ROC) for PUSH was adjusted for operator type (doctor vs. nurse), sex and HIV status. Among 197 PWHBs analysed, 69.5% were taking HBV antivirals and 27.9% had HBV/HIV. According to RSTs, 17.7% of PWHBs had significant fibrosis, 11.6% had cirrhosis and 3.5% had liver lesions. PUSH had low accuracy for significant fibrosis, with sensitivity of 8.3% (17.5-41.4), specificity of 100.0% (96.1-100) and an area under the curve (AUROC) of 0.54 (0.43-0.65), moderate accuracy for cirrhosis, with sensitivity of 60.9% (38.5-80.3), specificity of 97.7% (94.2-99.4) and AUROC of 0.79 (0.69-0.89), and higher accuracy for liver lesions, with 85.7% (42.1-99.6) sensitivity, 98.4% (95.5-99.7) specificity, AUROC of 0.92 (0.78-1.00). After an expedited training, front-line nurses and physicians treating HBV in Zambia were able to use PUSH to diagnose cirrhosis with moderate accuracy and liver lesions with high accuracy, although confidence intervals around performance estimates were wide. Liver POCUS including PUSH may be useful in HBV management when laboratory systems and TE are lacking.
Measuring the composition and availability of human resources for health by sex in 204 countries and territories, 1990-2023, and workforce gaps for universal health coverage: a systematic analysis for the Global Burden of Disease Study 2023.
(2026-Sep)
BACKGROUND: Understanding the size, gender composition, and cadre mix of the health workforce and how it has evolved across time and locations can inform policies for planning, recruitment, training, and retention of human resources for health (HRH), and improvement of access to the health-care workforce among populations. Using comparable and standardised data sources, we aim to describe the composition and density of health workers by sex among 20 cadres for 204 countries and territories over 1990-2023 and quantify workforce shortfalls relative to universal health coverage (UHC) attainment.
METHODS: We used 1816 country-years of data from population-based surveys, 82 from censuses, 3888 from administrative sources, and 96 from scientific literature. We harmonised reported occupation in all sources with the International Standard Classification of Occupations 2008. We produced estimates for 20 cadres and the total health workforce disaggregated by sex using spatiotemporal Gaussian process regression, a standardised method in the Global Burden of Diseases, Injuries, and Risk Factors study. Finally, stochastic frontier meta-regression was used to estimate the minimum density of doctors, nurses and midwives, dentists, and pharmacists required to reach a score of 80 out of 100 on the UHC effective coverage index.
FINDINGS: In 2023, there were 122·1 million (95% uncertainty interval 115·4-130·5) health workers across 20 cadres, an increase of 81·2 million (72·0-90·5) or 198·5% (161·9-245·6) relative to 1990. Of that total, there were 15·1 million (13·1-18·2) doctors, 33·2 million (30·8-36·3) nurses, 2·4 million (2·0-2·9) midwives, and 7·6 million (6·7-8·6) community health workers (CHWs). 68·9% (66·9-70·6) of all health workers in 2023 were female, and female health workers accounted for 71·4% (64·5-77·4) of net HRH workforce growth. Less than half of doctors were female (43·9%, 34·5-53·2) and most nurses (80·7%, 76·2-83·1), midwives (96·0%, 83·9-98·5), and CHWs (89·5%, 83·6-93·7) were female. Substantial differences in HRH density remained into 2023: sub-Saharan Africa had the lowest HRH densities across cadres, with the exception of CHWs, while high-income countries had the highest HRH densities. To reach 80 out of 100 on the UHC index, an additional 7·1 million (6·6-7·5) doctors, 23·9 million (21·8-26·1) nurses and midwives, 1·8 million (1·6-1·9) dentists, and 1·6 million (1·4-1·9) pharmacists are required globally.
INTERPRETATION: The global health workforce has expanded substantially since 1990, largely due to women entering the formal health workforce. However, this expansion has been uneven across regions and persistent shortfalls remain in doctors, nurses and midwives, dentists, and pharmacists relative to moderate UHC attainment. Addressing these gaps will require expansion of training capacity, retention and remuneration policies for early-career workers, and gender-responsive workforce arrangements.
FUNDING: Gates Foundation.