Browsing by Author "Chibwesha CJ"

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Clinical performance of digital cervicography and cytology for cervical cancer screening in HIV-infected women in Lusaka, Zambia.
(2014-Oct-01) Bateman AC; Parham GP; Sahasrabuddhe VV; Mwanahamuntu MH; Kapambwe S; Katundu K; Nkole T; Mulundika J; Pfaendler KS; Hicks ML; Shibemba A; Vermund SH; Stringer JS; Chibwesha CJ; *Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; †University of North Carolina at Chapel Hill, Chapel Hill, NC; ‡University Teaching Hospital, Lusaka, Zambia; §Vanderbilt University, Nashville, TN; ‖University of Cincinnati, Cincinnati, OH; and ¶Michigan Cancer Institute, Pontiac, MI.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
Although there is a growing literature on the clinical performance of visual inspection with acetic acid in HIV-infected women, to the best of our knowledge, none have studied visual inspection with acetic acid enhanced by digital cervicography. We estimated clinical performance of cervicography and cytology to detect cervical intraepithelial neoplasia grade 2 or worse. Sensitivity and specificity of cervicography were 84% [95% confidence interval (CI): 72 to 91) and 58% (95% CI: 52 to 64). At the high-grade squamous intraepithelial lesion or worse cutoff for cytology, sensitivity and specificity were 61% (95% CI: 48 to 72) and 58% (95% CI: 52 to 64). In our study, cervicography seems to be as good as cytology in HIV-infected women.
Contraceptive use among HIV-infected women and men receiving antiretroviral therapy in Lusaka, Zambia: a cross-sectional survey.
(2016-May-12) Hancock NL; Chibwesha CJ; Bosomprah S; Newman J; Mubiana-Mbewe M; Sitali ES; Bolton-Moore C; Mbwili-Muleya C; Chi BH; Centre for Infectious Disease Research in Zambia, PO Box 34681, 5032 Great North Road, Lusaka, Zambia.; Department of Obstetrics and Gynecology, UNC Global Women's Health, University of North Carolina School of Medicine, 3009 Old Clinic Building, Campus, Box 7577, Chapel Hill, NC, 27599-7577, USA.; Centre for Infectious Disease Research in Zambia, PO Box 34681, 5032 Great North Road, Lusaka, Zambia. NancyLHancock@gmail.com.; Department of Obstetrics and Gynecology, UNC Global Women's Health, University of North Carolina School of Medicine, 3009 Old Clinic Building, Campus, Box 7577, Chapel Hill, NC, 27599-7577, USA. NancyLHancock@gmail.com.; Lusaka District Community Health Office, Ministry of Community Development, Mother and Child Health, PO Box 50827, Lusaka, Zambia.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
BACKGROUND: Family planning (FP) is an essential health service and an important part of comprehensive HIV care. However, there is limited information about the contraceptive needs of people living with HIV in sub-Saharan Africa, which in turn has hampered efforts to expand and integrate FP services into existing HIV programs. METHODS: We performed a cross-sectional survey to determine FP prevalence and predictors among HIV-positive women and men attending 18 public antiretroviral therapy (ART) clinics in Lusaka, Zambia. Trained peer counselors administered the 10-question survey to those seeking care for five days at each of the target sites. RESULTS: From February to April 2014, we surveyed 7,046 HIV-infected patients receiving routine HIV services. Use of modern contraception was reported by 69 % of female ART patients and 79 % of male ART patients. However, highly effective contraceptive use and dual method use were low among women (38 and 25 %, respectively) and men (19 and 14 %, respectively). HIV disclosure status (adjusted odds ratio (AOR) = 4.91, 95 % confidence interval (CI) = 3.32-7.24 for women, AOR = 3.58, 95 % CI = 2.39-5.38 for men) and sexual activity in the last 6 months (AOR = 5.80, 95 % CI = 4.51-7.47 for women, AOR = 6.24, 95 % CI = 3.51-11.08 for men) were associated with modern contraceptive use in multivariable regression. Most respondents said they would access FP services if made available within ART clinic. CONCLUSIONS: While FP-ART integration may be a promising strategy for increasing FP service uptake, such services must focus on assessing sexual activity and advocating for dual method use to increase effective contraceptive use and prevent unintended pregnancies.
Duration of cART Before Delivery and Low Infant Birthweight Among HIV-Infected Women in Lusaka, Zambia.
(2016-Apr-15) Bengtson AM; Chibwesha CJ; Westreich D; Mubiana-Mbewe M; Vwalika B; Miller WC; Mapani M; Musonda P; Pettifor A; Chi BH; *Department of Epidemiology, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina; †Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; ‡Department of Obstetrics and Gynecology, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina; §Department of Public Health, University of Zambia School of Medicine, Lusaka, Zambia; and ‖Department of Medicine, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
OBJECTIVE: To estimate the association between duration of combination antiretroviral therapy (cART) during pregnancy and low infant birthweight (LBW), among women ≥37 weeks of gestation. DESIGN: We conducted a retrospective cohort study of HIV-infected women who met eligibility criteria based on CD4 count ≤350 but had not started cART at entry into antenatal care. Our cohort was restricted to births that occurred ≥37 weeks of gestation. METHODS: We used Poisson models with robust variance estimators to estimate risk ratios (RRs) and 95% confidence intervals (CIs). RESULTS: Of 50,765 HIV-infected women with antenatal visits between January 2009 and September 2013, 4474 women met the inclusion criteria. LBW occurred in 302 pregnancies (7%). Nearly two-thirds of women (62%) eligible to initiate cART never started treatment. Overall, 14% were on cART for ≤8 weeks, 22% for 9-20 weeks, and 2% for 21-36 weeks. There was no evidence of an increased risk of LBW for women receiving cART for ≤8 weeks (RR = 1.22; 95% CI: 0.77 to 1.91), 9-20 weeks (RR = 1.23; 95% CI: 0.82 to 1.83), or 21-36 weeks (RR = 0.87; 95% CI: 0.22 to 3.46), compared with women who never initiated treatment. These findings were consistent across several sensitivity analyses. CONCLUSIONS: Longer duration of cART was not associated with poor fetal growth among term pregnancies in our cohort. However, the relationship between cART and adverse pregnancy outcomes remains complicated. Continued work is required to investigate causality. An understanding cART's impact on adverse pregnancy outcomes is essential as cART becomes the cornerstone of preventing mother-to-child transmission programs globally.
Identification of human papillomaviruses from formalin-fixed, paraffin-embedded pre-cancer and invasive cervical cancer specimens in Zambia: a cross-sectional study.
(2015-Jan-16) Bateman AC; Katundu K; Polepole P; Shibemba A; Mwanahamuntu M; Dittmer DP; Parham GP; Chibwesha CJ; Centre for Infectious Disease Research in Zambia, Plot 5032 Great North Road, Lusaka, Zambia. bateman.allen@gmail.com.; Centre for Infectious Disease Research in Zambia, Plot 5032 Great North Road, Lusaka, Zambia. professorparham@gmail.com.; University of Zambia Teaching Hospital, Lusaka, Zambia. mulindim@gmail.com.; Centre for Infectious Disease Research in Zambia, Plot 5032 Great North Road, Lusaka, Zambia. mulindim@gmail.com.; Department of Obstetrics and Gynecology, UNC School of Medicine, UNC, Chapel Hill, North Carolina, USA. Carla.Chibwesha@cidrz.org.; Department of Obstetrics and Gynecology, UNC School of Medicine, UNC, Chapel Hill, North Carolina, USA. professorparham@gmail.com.; Department of Medicine, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA. bateman.allen@gmail.com.; Centre for Infectious Disease Research in Zambia, Plot 5032 Great North Road, Lusaka, Zambia. Carla.Chibwesha@cidrz.org.; Centre for Infectious Disease Research in Zambia, Plot 5032 Great North Road, Lusaka, Zambia. Katundu.Katundu@cidrz.org.; University of Zambia Teaching Hospital, Lusaka, Zambia. poleman1981@gmail.com.; University of Zambia Teaching Hospital, Lusaka, Zambia. professorparham@gmail.com.; University of Zambia Teaching Hospital, Lusaka, Zambia. shibemba@yahoo.com.; Program in Global Oncology, UNC Lineberger Comprehensive Cancer Center and School of Medicine, UNC, Chapel Hill, North Carolina, USA. dirk_dittmer@med.unc.edu.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
BACKGROUND: The most common human papillomavirus (HPV) genotypes isolated from cervical cancer in select African countries are HPV-16, HPV-18, HPV-35, and HPV-45, but the most common genotypes in Zambia are unknown. The overall objective of this study was to assess the potential impact of current HPV vaccines in preventing cervical cancer in Zambia, by determining the combined prevalence of HPV-16 and/or HPV-18 in invasive cervical cancer (ICC) and high-grade pre-cancer [cervical intraepithelial neoplasia 2 or 3 (CIN2/3)] cases. FINDINGS: We compared DNA extraction techniques to determine which assay performs well in the Zambian context, where unbuffered formalin is used to fix specimens. We then tested specimens with the Abbott RealTime High-Risk HPV test to estimate the prevalence of HPV-16/18 in formalin-fixed, paraffin-embedded ICC and CIN2/3 specimens. DNA extraction using heat (without xylene) was more successful than xylene-based extraction. Over 80% of specimens tested using heat extraction and the Abbott RealTime HPV test were positive for HPV. HPV-16 and/or HPV-18 were identified in 65/93 (69.9%) ICC specimens positive for HPV and in 38/65 (58.5%) CIN2/3 specimens positive for HPV. CONCLUSIONS: To our knowledge this is the first report to identify HPV genotypes in cervical cancers in Zambia. A combined HPV-16/18 prevalence of 69.9% in ICC specimens suggests that current vaccines will be highly protective against cervical cancer in Zambia.
Implementation and Operational Research: Age Distribution and Determinants of Invasive Cervical Cancer in a "Screen-and-Treat" Program Integrated With HIV/AIDS Care in Zambia.
(2015-Sep-01) Kapambwe S; Sahasrabuddhe VV; Blevins M; Mwanahamuntu MH; Mudenda V; Shepherd BE; Chibwesha CJ; Pfaendler KS; Hicks ML; Vermund SH; Stringer JS; Parham GP; *Center for Infectious Disease Research in Zambia, Lusaka, Zambia; †University of Zambia, Lusaka, Zambia; ‡Vanderbilt University, Nashville, TN; §University of North Carolina at Chapel Hill, Chapel Hill, NC; ‖University of Cincinnati, Cincinnati, OH; ¶Michigan Cancer Institute, Pontiac, MI.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
BACKGROUND: Cervical cancer screening efforts linked to HIV/AIDS care programs are being expanded across sub-Saharan Africa. Evidence on the age distribution and determinants of invasive cervical cancer (ICC) cases detected in such programs is limited. METHODS: We analyzed program operations data from the Cervical Cancer Prevention Program in Zambia, the largest public sector programs of its kind in sub-Saharan Africa. We examined age distribution patterns by HIV serostatus of histologically confirmed ICC cases and used multivariable logistic regression to evaluate independent risk factors for ICC among younger (≤35 years) and older (>35 years) women. RESULTS: Between January 2006 and April 2010, of 48,626 women undergoing screening, 571 (1.2%) were diagnosed with ICC, including 262 (46%) HIV seropositive (median age: 35 years), 131 (23%) HIV seronegative (median age: 40 years), and 178 (31%) of unknown HIV serostatus (median age: 38 years). Among younger (≤35 years) women, being HIV seropositive was associated with a 4-fold higher risk of ICC [adjusted odds ratio = 4.1 (95% confidence interval: 2.8, 5.9)] than being HIV seronegative. The risk of ICC increased with increasing age among HIV-seronegative women and women with unknown HIV serostatus, but among HIV-seropositive women, the risk peaked around age 35 and nonsignificantly declined with increasing ages. Other factors related to ICC included being married (vs. being unmarried/widowed) in both younger and older women, and with having 2+ (vs. ≤1) lifetime sexual partners among younger women. CONCLUSIONS: HIV infection seems to have increased the risk of cervical cancer among younger women in Zambia, pointing to the urgent need for expanding targeted screening interventions.
Implementation and Operational Research: Distance From Household to Clinic and Its Association With the Uptake of Prevention of Mother-to-Child HIV Transmission Regimens in Rural Zambia.
(2015-Nov-01) Escamilla V; Chibwesha CJ; Gartland M; Chintu N; Mubiana-Mbewe M; Musokotwane K; Musonda P; Miller WC; Stringer JS; Chi BH; *Department of Obstetrics and Gynecology, University of Chicago, Chicago, IL; †Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; ‡Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC; §Institute for Global Health, Vanderbilt University, Nashville, TN; ‖Society for Family Health, Lusaka, Zambia; ¶Zambian Ministry of Community Development and Mother-Child Health, Lusaka, Zambia; #Department of Public Health, University of Zambia School of Medicine, Lusaka, Zambia; **Division of Infectious Diseases, Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC; ††Department of Epidemiology, Gillings School of Public Health, University of North Carolina, Chapel Hill, NC; and ‡‡Currently at Departments of Medicine and Pediatrics, Massachusetts General Hospital; Boston, MA.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
BACKGROUND: In rural settings, HIV-infected pregnant women often live significant distances from facilities that provide prevention of mother-to-child transmission (PMTCT) services. METHODS: We offered universal maternal combination antiretroviral regimens in 4 pilot sites in rural Zambia. To evaluate the impact of services, we conducted a household survey in communities surrounding each facility. We collected information about HIV status and antenatal service utilization from women who delivered in the past 2 years. Using household Global Positioning System coordinates collected in the survey, we measured Euclidean (i.e., straight line) distance between individual households and clinics. Multivariable logistic regression and predicted probabilities were used to determine associations between distance and uptake of PMTCT regimens. RESULTS: From March to December 2011, 390 HIV-infected mothers were surveyed across four communities. Of these, 254 (65%) had household geographical coordinates documented. One hundred sixty-eight women reported use of a PMTCT regimen during pregnancy including 102 who initiated a combination antiretroviral regimen. The probability of PMTCT regimen initiation was the highest within 1.9 km of the facility and gradually declined. Overall, 103 of 145 (71%) who lived within 1.9 km of the facility initiated PMTCT versus 65 of 109 (60%) who lived farther away. For every kilometer increase, the association with PMTCT regimen uptake (adjusted odds ratio: 0.90, 95% confidence interval: 0.82 to 0.99) and combination antiretroviral regimen uptake (adjusted odds ratio: 0.88, 95% confidence interval: 0.80 to 0.97) decreased. CONCLUSIONS: In this rural African setting, uptake of PMTCT regimens was influenced by distance to health facility. Program models that further decentralize care into remote communities are urgently needed.
Implementation of the Zambia electronic perinatal record system for comprehensive prenatal and delivery care.
(2011-May) Chi BH; Vwalika B; Killam WP; Wamalume C; Giganti MJ; Mbewe R; Stringer EM; Chintu NT; Putta NB; Liu KC; Chibwesha CJ; Rouse DJ; Stringer JS; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. bchi@cidrz.org; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
OBJECTIVE: To characterize prenatal and delivery care in an urban African setting. METHODS: The Zambia Electronic Perinatal Record System (ZEPRS) was implemented to record demographic characteristics, past medical and obstetric history, prenatal care, and delivery and newborn care for pregnant women across 25 facilities in the Lusaka public health sector. RESULTS: From June 1, 2007, to January 31, 2010, 115552 pregnant women had prenatal and delivery information recorded in ZEPRS. Median gestation age at first prenatal visit was 23weeks (interquartile range [IQR] 19-26). Syphilis screening was documented in 95663 (83%) pregnancies: 2449 (2.6%) women tested positive, of whom 1589 (64.9%) were treated appropriately. 111108 (96%) women agreed to HIV testing, of whom 22% were diagnosed with HIV. Overall, 112813 (98%) of recorded pregnancies resulted in a live birth, and 2739 (2%) in a stillbirth. The median gestational age was 38weeks (IQR 35-40) at delivery; the median birth weight of newborns was 3000g (IQR 2700-3300g). CONCLUSION: The results demonstrate the feasibility of using a comprehensive electronic medical record in an urban African setting, and highlight its important role in ongoing efforts to improve clinical care.
Minimizing verification bias in cervical cancer screening of HIV-infected women.
(2015-Mar) Bateman AC; Chibwesha CJ; Parham GP; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; Department of Obstetrics and Gynecology, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; Department of Medicine, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. Electronic address: bateman.allen@gmail.com.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; Department of Obstetrics and Gynecology, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; University Teaching Hospital, Lusaka, Zambia.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
Approximately one-third of cervical intraepithelial neoplasia 2 and above can be missed by only biopsying quadrants of the cervix with visible lesions by digital cervicography.
Modern contraceptive and dual method use among HIV-infected women in Lusaka, Zambia.
(2011) Chibwesha CJ; Li MS; Matoba CK; Mbewe RK; Chi BH; Stringer JS; Stringer EM; University of Alabama School of Medicine, Birmingham, AL 35294, USA. carla.chibwesha@cidrz.org; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
HIV-infected women in sub-Saharan Africa are at substantial risk of unintended pregnancy and sexually transmitted infections (STIs). Linkages between HIV and reproductive health services are advocated. We describe implementation of a reproductive health counseling intervention in 16 HIV clinics in Lusaka, Zambia. Between November 2009 and November 2010, 18,407 women on antiretroviral treatment (ART) were counseled. The median age was 34.6 years (interquartile range (IQR): 29.9-39.7), and 60.1% of women were married. The median CD4(+) cell count was 394 cells/uL (IQR: 256-558). Of the women counseled, 10,904 (59.2%) reported current modern contraceptive use. Among contraceptive users, only 17.7% reported dual method use. After counseling, 737 of 7,503 women not previously using modern contraception desired family planning referrals, and 61.6% of these women successfully accessed services within 90 days. Unmet contraceptive need remains high among HIV-infected women. Additional efforts are needed to promote reproductive health, particularly dual method use.
Optimal time on HAART for prevention of mother-to-child transmission of HIV.
(2011-Oct-01) Chibwesha CJ; Giganti MJ; Putta N; Chintu N; Mulindwa J; Dorton BJ; Chi BH; Stringer JS; Stringer EM; University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA. Carla.Chibwesha@cidrz.org; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
OBJECTIVES: To determine the impact of time between initiating highly active antiretroviral therapy (HAART) and delivery-duration of antenatal HAART-on perinatal HIV infection. DESIGN: We conducted a retrospective cohort analysis of pregnant HIV-infected women in Lusaka, Zambia. Women in our cohort were receiving HAART and had an infant HIV polymerase chain reaction test between 3 and 12 weeks of life. METHODS: We examined factors associated with infant HIV infection and performed a locally weighted regression analysis to examine the effect of duration of antenatal HAART on perinatal HIV infection. RESULTS: : From January 2007 to March 2010, 1813 HIV-infected pregnant women met inclusion criteria. Mean gestational age at first antenatal visit was 21 weeks (SD ± 6), median CD4+ cell count was 231 cells per microliter (interquartile range: 164-329), and median duration of antenatal HAART was 13 weeks (interquartile range 8-19). Fifty-nine (3.3%) infants were HIV infected. Duration of antenatal HAART was the most important predictor of perinatal HIV transmission. Compared with women initiating HAART at least 13 weeks before delivery, women on HAART for ≤4 weeks had a 5.5-fold increased odds of HIV transmission (95% confidence interval: 2.6 to 11.7). Locally weighted regression analysis suggested limited additional prophylactic benefit beyond 13 weeks on antenatal HAART. CONCLUSIONS: Low rates of mother-to-child HIV transmission can be achieved within programmatic settings in Africa. Maximal effectiveness of prevention of mother-to-child transmission programs is achieved by initiating HAART at least 13 weeks before delivery.
Population-level scale-up of cervical cancer prevention services in a low-resource setting: development, implementation, and evaluation of the cervical cancer prevention program in Zambia.
(2015) Parham GP; Mwanahamuntu MH; Kapambwe S; Muwonge R; Bateman AC; Blevins M; Chibwesha CJ; Pfaendler KS; Mudenda V; Shibemba AL; Chisele S; Mkumba G; Vwalika B; Hicks ML; Vermund SH; Chi BH; Stringer JS; Sankaranarayanan R; Sahasrabuddhe VV; Center for Infectious Disease Research in Zambia, Lusaka, Zambia; University of California, Irvine, Irvine, California, United States of America.; Center for Infectious Disease Research in Zambia, Lusaka, Zambia; University of Zambia, Lusaka, Zambia.; International Agency for Research on Cancer, Lyon, France.; Vanderbilt University, Nashville, Tennessee, United States of America; National Cancer Institute, Bethesda, Maryland, United States of America.; Center for Infectious Disease Research in Zambia, Lusaka, Zambia; University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America.; Michigan Cancer Institute, Pontiac, Michigan, United States of America.; University of Zambia, Lusaka, Zambia.; Vanderbilt University, Nashville, Tennessee, United States of America.; Center for Infectious Disease Research in Zambia, Lusaka, Zambia; University of Zambia, Lusaka, Zambia; University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America; International Agency for Research on Cancer, Lyon, France.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
BACKGROUND: Very few efforts have been undertaken to scale-up low-cost approaches to cervical cancer prevention in low-resource countries. METHODS: In a public sector cervical cancer prevention program in Zambia, nurses provided visual-inspection with acetic acid (VIA) and cryotherapy in clinics co-housed with HIV/AIDS programs, and referred women with complex lesions for histopathologic evaluation. Low-cost technological adaptations were deployed for improving VIA detection, facilitating expert physician opinion, and ensuring quality assurance. Key process and outcome indicators were derived by analyzing electronic medical records to evaluate program expansion efforts. FINDINGS: Between 2006-2013, screening services were expanded from 2 to 12 clinics in Lusaka, the most-populous province in Zambia, through which 102,942 women were screened. The majority (71.7%) were in the target age-range of 25-49 years; 28% were HIV-positive. Out of 101,867 with evaluable data, 20,419 (20%) were VIA positive, of whom 11,508 (56.4%) were treated with cryotherapy, and 8,911 (43.6%) were referred for histopathologic evaluation. Most women (87%, 86,301 of 98,961 evaluable) received same-day services (including 5% undergoing same-visit cryotherapy and 82% screening VIA-negative). The proportion of women with cervical intraepithelial neoplasia grade 2 and worse (CIN2+) among those referred for histopathologic evaluation was 44.1% (1,735/3,938 with histopathology results). Detection rates for CIN2+ and invasive cervical cancer were 17 and 7 per 1,000 women screened, respectively. Women with HIV were more likely to screen positive, to be referred for histopathologic evaluation, and to have cervical precancer and cancer than HIV-negative women. INTERPRETATION: We creatively disrupted the 'no screening' status quo prevailing in Zambia and addressed the heavy burden of cervical disease among previously unscreened women by establishing and scaling-up public-sector screening and treatment services at a population level. Key determinants for successful expansion included leveraging HIV/AIDS program investments, and context-specific information technology applications for quality assurance and filling human resource gaps.
Predictors and outcomes of low birth weight in Lusaka, Zambia.
(2016-Sep) Chibwesha CJ; Zanolini A; Smid M; Vwalika B; Phiri Kasaro M; Mwanahamuntu M; Stringer JS; Stringer EM; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; Department of Obstetrics and Gynaecology, University of Zambia School of Medicine, Lusaka, Zambia.; Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. Electronic address: carla_chibwesha@med.unc.edu.; Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; Department of Obstetrics and Gynaecology, University of Zambia School of Medicine, Lusaka, Zambia.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
OBJECTIVE: To determine factors associated with low birth weight (LBW) in an urban Zambian cohort and investigate risk of adverse outcomes for LBW neonates. METHODS: The present retrospective cohort analysis used data recorded between February 2006 and December 2012 for singletons and first-born twins delivered in the public health system of Lusaka, Zambia. Routine clinical data and generalized estimating equations were used to examine covariates associated with LBW (<2500 g) and describe outcomes of LBW. RESULTS: In total, 200 557 neonates were included, 21 125 (10.5%) of whom were LBW. Placental abruption, delivery before 37 weeks, and twin pregnancy were associated with LBW in multivariable analysis (P<0.01 for all). Compared with neonates weighing more than 2500 g, LBW neonates were at higher risk of stillbirth (adjusted odds ratio [AOR] 8.6, 95% confidence interval [CI] 6.5-11.5), low Apgar score (AOR 5.7, 95% CI 4.6-7.2), admission to the neonatal intensive care unit (AOR 5.4, 95% CI 3.5-8.3), and very early neonatal death (AOR 6.2, 95% CI 3.7-10.3). CONCLUSION: LBW neonates are at increased risk of adverse outcomes, including stillbirth and neonatal death, independent of pregnancy duration at delivery and multiple pregnancy. These findings underscore the need for early, comprehensive, and high-quality prenatal care.
Renewing focus on family planning service quality globally.
(2016) Hancock NL; Stuart GS; Tang JH; Chibwesha CJ; Stringer JSA; Chi BH; Centre for Infectious Disease Research in Zambia, PO Box 34681, 5032 Great North Road, Lusaka, Zambia.; Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Campus Box 7577, Chapel Hill, NC 27599-7577 USA.; UNC Project-Malawi, Tidziwe Centre, Private Bag A-104, Lilongwe, Malawi.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
Reducing the global unmet need for contraception is currently a priority for many governments, multi-lateral initiatives, non-governmental organizations, and donors. Evidence strongly suggests that the provision of quality family planning services can increase uptake, prevalence, and continuation of contraception. While an accepted framework to define the components of family planning service quality exists, translating this framework into assessment tools that are accessible, easily utilized, and valid for service providers has remained a challenge. We propose new approaches to improve the standardization and accessibility of family planning service quality assessment tools to simplify family planning service quality evaluation. With easier approaches to program evaluation, quality improvements can be performed more swiftly to help increase uptake and continuation of contraception to improve the health of women and their families.
See-and-treat approaches to cervical cancer prevention for HIV-infected women.
(2011-Sep) Chibwesha CJ; Cu-Uvin S; University of Alabama at Birmingham School of Medicine, USA. Carla.Chibwesha@cidrz.org; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
Cervical cancer remains the second commonest cancer among women worldwide, and more than 85% of the global burden of this disease occurs in the developing world. HIV-infected women have a higher likelihood of developing persistent high-risk human papillomavirus (HPV) infection, precancer, and invasive cervical cancer than seronegative women. Although highly effective primary and secondary prevention strategies are currently available, they remain inaccessible to the vast majority of women. Because of their simplicity and affordability, see-and-treat cervical cancer screening modalities have the potential to substantially improve women's access to cancer prevention, as well as to create much needed infrastructure for future molecular-based cervical screening and HPV vaccination programs. Additional data addressing the effectiveness of see-and-treat approaches for HIV-infected women are urgently needed. Studies informing best practice guidelines on when to start, when to stop, and how frequently to screen HIV-infected women within the see-and-treat paradigm would be of great value.
Temporal Trends and Predictors of Modern Contraceptive Use in Lusaka, Zambia, 2004-2011.
(2015) Hancock NL; Chibwesha CJ; Stoner MC; Vwalika B; Rathod SD; Kasaro MP; Stringer EM; Stringer JS; Chi BH; Department of Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E7HT, UK.; Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, 3009 Old Clinic Building, Campus Box 7570, Chapel Hill, NC 27599-7570, USA; Centre for Infectious Disease Research in Zambia, 5032 Great North Road, P.O. Box 34681, 10101 Lusaka, Zambia.; Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, 3009 Old Clinic Building, Campus Box 7570, Chapel Hill, NC 27599-7570, USA.; Department of Obstetrics and Gynecology, University Teaching Hospital, P.O. Box 50110, Lusaka, Zambia.; Department of Epidemiology, University of North Carolina School of Public Health, 2101 McGavran-Greenberg Hall, CB No. 7435, Chapel Hill, NC 27599-7435, USA.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
INTRODUCTION: Although increasing access to family planning has been an important part of the global development agenda, millions of women continue to face unmet need for contraception. MATERIALS AND METHODS: We analyzed data from a repeated cross-sectional community survey conducted in Lusaka, Zambia, over an eight-year period. We described prevalence of modern contraceptive use, including long-acting reversible contraception (LARC), among female heads of household aged 16-50 years. We also identified predictors of LARC versus short-term contraceptive use among women using modern methods. RESULTS AND DISCUSSION: Twelve survey rounds were completed between November 2004 and September 2011. Among 29,476 eligible respondents, 17,605 (60%) reported using modern contraception. Oral contraceptive pills remained the most popular method over time, but use of LARC increased significantly, from less than 1% in 2004 to 9% by 2011 (p < 0.001). Younger women (OR: 0.46, 95% CI: 0.34, 0.61) and women with lower levels of education (OR: 0.70, 95% CI: 0.56, 0.89) were less likely to report LARC use compared to women using short-term modern methods. CONCLUSIONS: Population-based assessments of contraceptive use over time can guide programs and policies. To achieve reproductive health equity and reduce unmet contraceptive need, future efforts to increase LARC use should focus on young women and those with less education.
The burden of cervical pre-cancer and cancer in HIV positive women in Zambia: a modeling study.
(2015-Jul-24) Bateman AC; Katundu K; Mwanahamuntu MH; Kapambwe S; Sahasrabuddhe VV; Hicks ML; Chi BH; Stringer JS; Parham GP; Chibwesha CJ; University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. professorparham@gmail.com.; Michigan Cancer Institute, Pontiac, MI, USA. mrhicks2@comcast.net.; University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. Benjamin.Chi@cidrz.org.; University of Zambia, Lusaka, Zambia. mulindim@gmail.com.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. mulindim@gmail.com.; University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. Jeffrey_Stringer@med.unc.edu.; Vanderbilt University, Nashville, Tennessee, USA. vikrant.sahasrabuddhe@vanderbilt.edu.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. Katundu.Katundu@cidrz.org.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. sharon.kapambwe@cidrz.org.; University of Zambia, Lusaka, Zambia. professorparham@gmail.com.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. Carla.Chibwesha@cidrz.org.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. Benjamin.Chi@cidrz.org.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. bateman.allen@gmail.com.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. professorparham@gmail.com.; University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. bateman.allen@gmail.com.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
BACKGROUND: HIV infection is associated with a higher incidence of precancerous cervical lesions and their progression to invasive cervical cancer (ICC). Zambia is a global epicenter of HIV and ICC, yet the overall burden of cervical pre-cancer [cervical intraepithelial neoplasia 3 (CIN3)] and ICC among its HIV positive adult female population is unknown. The objective of this study was to determine the burden of cervical disease among HIV positive women in Zambia by estimating the number with CIN3 and ICC. METHODS: We conducted a cross-sectional study among 309 HIV positive women attending screening in Lusaka (Zambia's most populated province) to measure the cervical disease burden by visual inspection with acetic acid enhanced by digital cervicography (DC), cytology, and histology. We then used estimates of the prevalence of CIN3 and ICC from the cross-sectional study and Spectrum model-based estimates for HIV infection among Zambian women to estimate the burden of CIN3 and ICC among HIV positive women nationally. RESULTS: Over half (52 %) of the study participants screened positive by DC, while 45 % had cytologic evidence of high grade squamous intraepithelial lesions (SIL) or worse. Histopathologic evaluation revealed that 20 % of women had evidence of CIN2 or worse, 11 % had CIN3 or worse, and 2 % had ICC. Using the Spectrum model, we therefore estimate that 34,051 HIV positive women in Zambia have CIN3 and 7,297 have ICC. CONCLUSIONS: The DC, cytology, and histology results revealed a large cervical disease burden in this previously unscreened HIV positive population. This very large burden indicates that continued scale-up of cervical cancer screening and treatment is urgently needed.
The burden of human papillomavirus infections and related diseases in sub-saharan Africa.
(2013-Dec-29) De Vuyst H; Alemany L; Lacey C; Chibwesha CJ; Sahasrabuddhe V; Banura C; Denny L; Parham GP; Department of Obstetrics and Gynaecology and Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Groote Schuur Hospital, Observatory, Cape Town, South Africa.; Unit of Infections and Cancer (UNIC), Cancer Epidemiology Research Program (CERP), Institut Català d'Oncologia - Catalan Institute of Oncology (ICO), L'Hospitalet de Llobregat (Barcelona), Spain; CIBER en Epidemiología y Salud Pública (CIBERESP), Spain.; Department of Obstetrics and Gynecology, UNC Global Women's Health, University of North Carolina - Chapel Hill, North Carolina, USA. Electronic address: groesbeck.parham@cidrz.org.; Department of Child Health and Development Centre, Makerere University College of Health Sciences, Kampala, Uganda.; Hormonal and Reproductive Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA.; Infection and Cancer Epidemiology Group, International Agency for Research on Cancer (WHO-IARC), Lyon, France.; University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, U.S.A and Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; Centre for Immunology and Infection, Hull York Medical School, University of York, York, UK.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
Despite the scarcity of high quality cancer registries and lack of reliable mortality data, it is clear that human papillomavirus (HPV)-associated diseases, particularly cervical cancer, are major causes of morbidity and mortality in sub-Saharan Africa (SSA). Cervical cancer incidence rates in SSA are the highest in the world and the disease is the most common cause of cancer death among women in the region. The high incidence of cervical cancer is a consequence of the inability of most countries to either initiate or sustain cervical cancer prevention services. In addition, it appears that the prevalence of HPV in women with normal cytology is higher than in more developed areas of the world, at an average of 24%. There is, however, significant regional variation in SSA, with the highest incidence of HPV infection and cervical cancer found in Eastern and Western Africa. It is expected that, due to aging and growth of the population, but also to lack of access to appropriate prevention services and the concomitant human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) epidemic, cervical cancer incidence and mortality rates in SSA will rise over the next 20 years. HPV16 and 18 are the most common genotypes in cervical cancer in SSA, although other carcinogenic HPV types, such as HPV45 and 35, are also relatively more frequent compared with other world regions. Data on other HPV-related anogenital cancers including those of the vulva, vagina, anus, and penis, are limited. Genital warts are common and associated with HPV types 6 and 11. HIV infection increases incidence and prevalence of all HPV-associated diseases. Sociocultural determinants of HPV-related disease, as well as the impact of forces that result in social destabilization, demand further study. Strategies to reduce the excessive burden of HPV-related diseases in SSA include age-appropriate prophylactic HPV vaccination, cervical cancer prevention services for women of the reproductive ages, and control of HIV/AIDS. This article forms part of a regional report entitled "Comprehensive Control of HPV Infections and Related Diseases in the Sub-Saharan Africa Region" Vaccine Volume 31, Supplement 5, 2013. Updates of the progress in the field are presented in a separate monograph entitled "Comprehensive Control of HPV Infections and Related Diseases" Vaccine Volume 30, Supplement 5, 2012.