Browsing by Author "Herce ME"

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(2020-Jun) Topp SM; Carbone NB; Tseka J; Kamtsendero L; Banda G; Herce ME; Division of Infectious Diseases, University of North Carolina School of Medicine, Chapel HIll, North Carolina, USA.; University of North Carolina Project, Lilongwe, Malawi.; Implementation Science Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia.; College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia globalstopp@gmail.com.
BACKGROUND: In the era of Option B+ and 'treat all' policies for HIV, challenges to retention in care are well documented. In Malawi, several large community-facility linkage (CFL) models have emerged to address these challenges, training lay health workers (LHW) to support the national prevention of mother-to-child transmission (PMTCT) programme. This qualitative study sought to examine how PMTCT LHW deployed by Malawi's three most prevalent CFL models respond to known barriers to access and retention to antiretroviral therapy (ART) and PMTCT. METHODS: We conducted a qualitative study, including 43 semi-structured interviews with PMTCT clients; 30 focus group discussions with Ministry of Health (MOH)-employed lay and professional providers and PMTCT LHWs; a facility CFL survey and 2-4 hours of onsite observation at each of 8 sites and in-depth interviews with 13 programme coordinators and MOH officials. Thematic analysis was used, combining inductive and deductive approaches. RESULTS: Across all three models, PMTCT LHWs carried out a number of 'targeted' activities that respond directly to a range of known barriers to ART uptake and retention. These include: (i) fulfilling counselling and educational functions that responded to women's fears and uncertainties; (ii) enhancing women's social connectedness and participation in their own care and (iii) strengthening service function by helping clinic-based providers carry out duties more efficiently and effectively. Beyond absorbing workload or improving efficiency, however, PMTCT LHWs supported uptake and retention through foundational but often intangible work to strengthen CFL, including via efforts to strengthen facility-side responsiveness, and build community members' recognition of and trust in services. CONCLUSION: PMTCT LHWs in each of the CFL models examined, addressed social, cultural and health system factors influencing client access to, and engagement with, HIV care and treatment. Findings underscore the importance of person-centred design in the 'treat-all' era and the contribution LHWs can make to this, but foreground the challenges of achieving person-centredness in the context of an under-resourced health system. Further work to understand the governance and sustainability of these project-funded CFL models and LHW cadres is now urgently required.
Addressing Common Mental Health Disorders Among Incarcerated People Living with HIV: Insights from Implementation Science for Service Integration and Delivery.
(2020-Oct) Smith HJ; Topp SM; Hoffmann CJ; Ndlovu T; Charalambous S; Murray L; Kane J; Sikazwe I; Muyoyeta M; Herce ME; Johns Hopkins University, Baltimore, MD, USA.; Columbia University, New York, NY, USA.; Implementation Science Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia.; Implementation Science Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia. michael.herce@cidrz.org.; Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. michael.herce@cidrz.org.; James Cook University, Townsville, Australia.; University of the Witwatersrand Johannesburg, Johannesburg, South Africa.; The Aurum Institute, Johannesburg, South Africa.
PURPOSE: Despite evidence of disproportionate burden of HIV and mental health disorders among incarcerated people, scarce services exist to address common mental health disorders, including major depressive and anxiety disorders, post-traumatic stress disorder, and substance use disorders, among incarcerated people living with HIV (PLHIV) in sub-Saharan Africa (SSA). This paper aims to summarize current knowledge on mental health interventions of relevance to incarcerated PLHIV and apply implementation science theory to highlight strategies and approaches to deliver mental health services for PLHIV in correctional settings in SSA. RECENT FINDINGS: Scarce evidence-based mental health interventions have been rigorously evaluated among incarcerated PLHIV in SSA. Emerging evidence from low- and middle-income countries and correctional settings outside SSA point to a role for cognitive behavioral therapy-based talking and group interventions implemented using task-shifting strategies involving lay health workers and peer educators. Several mental health interventions and implementation strategies hold promise for addressing common mental health disorders among incarcerated PLHIV in SSA. However, to deliver these approaches, there must first be pragmatic efforts to build corrections health system capacity, address human rights abuses that exacerbate HIV and mental health, and re-conceptualize mental health services as integral to quality HIV service delivery and universal access to primary healthcare for all incarcerated people.
An exploration of multi-level factors affecting routine linkage to HIV care in Zambia's PEPFAR-supported treatment program in the treat all era.
(2024) Chipungu J; Smith H; Mwamba C; Haambokoma M; Sharma A; Savory T; Musheke M; Pry J; Bolton C; Sikazwe I; Herce ME; Research Department, Social and Behavioral Science Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia.
Multiple steps from HIV diagnosis to treatment initiation and confirmed engagement with the health system are required for people living with HIV to establish full linkage to care in the modern treat all era. We undertook a qualitative study to gain an in-depth understanding of the impeding and enabling factors at each step of this linkage pathway. In-depth interviews were conducted with fifty-eight people living with HIV recruited from ten routine HIV care settings supported by the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) in Lusaka, Zambia. Using a semi-structured interview guide informed by an established conceptual framework for linkage to care, questions explored the reasons behind late, missed, and early linkage into HIV treatment, as well as factors influencing the decision to silently transfer to a different clinic after an HIV diagnosis. We identified previously established and intersecting barriers of internal and external HIV-related stigma, concerns about ART side effects, substance use, uncertainties for the future, and a perceived lack of partner and social support that impeded linkage to care at every step of the linkage pathway. However, we also uncovered newer themes specific to the current test and treat era related to the rapidity of ART initiation and insufficient patient-centered post-test counseling that appeared to exacerbate these well-known barriers, including callous health workers and limited time to process a new HIV diagnosis before treatment. Long travel distance to the clinic where they were diagnosed was the most common reason for silently transferring to another clinic for treatment. On the other hand, individual resilience, quality counseling, patient-centered health workers, and a supportive and empathetic social network mitigated these barriers. These findings highlight potential areas for strengthening linkage to care and addressing early treatment interruption and silent transfer in the test and treat era in Zambia.
Closing the gap in paediatric HIV infections: how available tools and technology can accelerate progress towards ending AIDS by 2030.
(2024-Apr-06) Mutale W; Herce ME; Implementation Science Unit, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.; Department of Health Policy and Management, University of Zambia School of Public Health, Lusaka, Zambia; Southern Africa Institute for Collaborative Research and Innovation Organisation, Lusaka, Zambia. Electronic address: wmutale@gmail.com.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
Coordinating the prevention, treatment, and care continuum for HIV-associated tuberculosis in prisons: a health systems strengthening approach.
(2018-Nov) Herce ME; Muyoyeta M; Topp SM; Henostroza G; Reid SE; Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, School of Medicine, Birmingham, Alabama, USA.; Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia.; College of Public Health, Medical and Veterinary Sciences, James Cook University, Queensland, Australia.; Division of Infectious Diseases, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.
PURPOSE OF REVIEW: To advance a re-conceptualized prevention, treatment, and care continuum (PTCC) for HIV-associated tuberculosis (TB) in prisons, and to make recommendations for strengthening prison health systems and reducing HIV-associated TB morbidity and mortality throughout the cycle of pretrial detention, incarceration, and release. RECENT FINDINGS: Despite evidence of increased HIV-associated TB burden in prisons compared to the general population, prisoners face entrenched barriers to accessing anti-TB therapy, antiretroviral therapy, and evidence-based HIV and TB prevention. New approaches, suitable for the complexities of healthcare delivery in prisons, have emerged that may address these barriers, and include: novel TB diagnostics, universal test and treat for HIV, medication-assisted treatment for opioid dependence, comprehensive transitional case management, and peer navigation, among others. SUMMARY: Realizing ambitious international HIV and TB targets in prisons will only be possible by first addressing the root causes of the TB/HIV syndemic, which are deeply intertwined with human rights violations and weaknesses in prison health systems, and, second, fundamentally re-organizing HIV and TB services around a coordinated PTCC. Taking these steps can help ensure universal access to comprehensive, good-quality, free and voluntary TB/HIV prevention, treatment, and care, and advance efforts to strengthen health resourcing, staffing, information management, and primary care access within prisons.
Costs of implementing universal test and treat in three correctional facilities in South Africa and Zambia.
(2022) Mukora R; Smith HJ; Herce ME; Chimoyi L; Hausler H; Fielding KL; Charalambous S; Hoffmann CJ; TB/HIV Care Association, Cape Town, South Africa.; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America.; London School of Hygiene & Tropical Medicine, London, United Kingdom.; School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.; The Aurum Institute, Aurum House, The Ridge, Johannesburg, South Africa.; School of Public Health & Community Medicine, University of New South Wales, Sydney, Australia.; Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America.; Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia.
INTRODUCTION: Universal test and treat (UTT) is a population-based strategy that aims to ensure widespread HIV testing and rapid antiretroviral therapy (ART) for all who have tested positive regardless of CD4 count to decrease HIV incidence and improve health outcomes. Little is known about the specific resources required to implement UTT in correctional facilities for incarcerated people. The primary aim of this study was to describe the resources used to implement UTT and to provide detailed costing to inform UTT scale-up in similar settings. METHODS: The costing study was a cross-sectional descriptive study conducted in three correctional complexes, Johannesburg Correctional Facility in Johannesburg (>4000 inmates) South Africa, and Brandvlei (~3000 inmates), South Africa and Lusaka Central (~1400 inmates), Zambia. Costing was determined through a survey conducted between September and December 2017 that identified materials and labour used for three separate components of UTT: HIV testing services (HTS), ART initiation, and ART maintenance. Our study participants were staff working in the correctional facilities involved in any activity related to UTT implementation. Unit costs were reported as cost per client served while total costs were reported for all clients seen over a 12-month period. RESULTS: The cost of HIV testing services (HTS) per client was $ 92.12 at Brandvlei, $ 73.82 at Johannesburg, and $ 65.15 at Lusaka. The largest cost driver for HIV testing at Brandvlei were staff costs at 55.6% of the total cost, while at Johannesburg (56.5%) and Lusaka (86.6%) supplies were the largest contributor. The cost per client initiated on ART was $917 for Brandvlei, $421.8 for Johannesburg, and $252.1 for Lusaka. The activity cost drivers were adherence counselling at Brandvlei (59%), and at Johannesburg and Lusaka it was the actual ART initiation at 75.6% and 75.8%, respectively. The annual unit cost for ART maintenance was $2,640.6 for Brandvlei, $710 for Johannesburg, and $385.5 for Lusaka. The activity cost drivers for all three facilities were side effect monitoring, and initiation of isoniazid preventive treatment (IPT), cotrimoxazole, and fluconazole, with this comprising 44.7% of the total cost at Brandvlei, 88.9% at Johannesburg, and 50.5% at Lusaka. CONCLUSION: Given the needs of this population, the opportunity to reach inmates at high risk for HIV, and overall national and global 95-95-95 goals, the UTT policies for incarcerated individuals are of vital importance. Our findings provide comparator costing data and highlight key drivers of UTT cost by facility.
Delivery of TB preventive therapy to incarcerated people living with HIV in southern African correctional facilities.
(2021-Dec-21) Chimoyi L; Smith H; Hausler H; Fielding K; Hoffmann CJ; Herce ME; Charalambous S; London School of Tropical Hygiene & Medicine, London, UK.; Johns Hopkins University, Baltimore, MD, USA.; School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.; School of Population Health, University of New South Wales, Sydney, NSW, Australia.; Institute for Global Health & Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, NC, USA.; TB HIV Care, Cape Town, South Africa.; The Aurum Institute, Parktown, Johannesburg, South Africa.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
TB preventive treatment (TPT) is recommended for high-risk and hard-to-reach populations such as incarcerated people living with HIV (PLHIV). To assess implementation of TPT delivery in correctional settings, we conducted an exploratory analysis of data from a multisite cohort study in South Africa and Zambia. From 975 participants, 648 were screened for TB, and 409 initiated TPT mostly within a month after initiation of antiretroviral therapy (190/409, 46.5%). We observed a median gap of one month (IQR 0.6-4.7) in TPT delivery to incarcerated PLHIV. Future research should examine standardised quality improvement tools and new strategies such as short-course regimens to improve TPT initiation in this population.
Diagnosis of Concurrent Pulmonary Tuberculosis and Tuberculous Otitis Media Confirmed by Xpert MTB/RIF in the United States.
(2016-May) Tompkins KM; Reimers MA; White BL; Herce ME; University of North Carolina at Chapel Hill, Department of Internal Medicine.; The University of North Carolina at Chapel Hill School of Medicine.; University of North Carolina at Chapel Hill School of Medicine, Department of Medicine, Division of infectious diseases; Centre for Infectious Disease Research in Zambia (CIDRZ).; University of North Carolina at Chapel Hill School of Medicine, Department of Medicine, Division of infectious diseases.
Tuberculosis (TB) remains an important cause of infectious morbidity in the United States (US), necessitating timely and accurate diagnosis. We report a case of concurrent pulmonary and extrapulmonary TB presenting as tuberculous otitis media in a hospitalized US patient admitted with cough, night sweats, and unilateral purulent otorrhea. Diagnosis was made by smear microscopy and rapidly confirmed by Xpert MTB/RIF-a novel, automated nucleic acid amplification test for the rapid detection of drug-susceptible and drug-resistant TB. This case adds to the growing body of evidence validating Xpert MTB/RIF as an effective tool for the rapid diagnosis of extrapulmonary TB, even in low TB-prevalence settings such as the US, when testing is performed on non-respiratory specimens.
Differentiated community-based point-of-care early infant diagnosis to improve HIV diagnosis and ART initiation among infants and young children in Zambia: a quasi-experimental cohort study.
(2025-Feb-20) Manasyan A; Tembo T; Dale H; Pry JM; Itoh M; Williamson D; Kapesa H; Derado J; Beard RS; Iyer S; Gass S; Mwila A; Herce ME; Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.; U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, USA.; University of Alabama at Birmingham, Birmingham, Alabama, USA albertmanasyan@uabmc.edu.; University of California, Davis, California, USA.; Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia.; U.S. Centers for Disease Control and Prevention, Lusaka, Zambia.
INTRODUCTION: An estimated 800 000 children (<15 years) globally living with HIV remain undiagnosed. To reach these children with timely HIV testing services during infancy, we implemented a community-based differentiated care model using mobile point-of-care (POC) technology for early infant diagnosis (EID) of HIV, and assessed its effects on EID positivity, antiretroviral therapy (ART) initiation and 3-month retention in care. METHODS: Between 1 June 2019 and 31 May 2020 at six health facilities in Lusaka, Zambia, we enrolled mother-infant pairs (MIPs) at high risk for vertical transmission of HIV based on missing or late infant EID testing or other maternal risk factors. We offered these MIPs community POC EID testing (post-intervention), and compared their outcomes to historical high-risk controls at the same sites (1 June 2017-31 May 2018; pre-intervention). We used propensity score matched weighting and mixed effects regression modelling to estimate outcome differences pre-intervention and post-intervention, and to identify MIP characteristics predictive of vertical transmission of HIV. RESULTS: 2577 MIPs were included in the analysis: 1763 and 814 high-risk MIPs from the pre-intervention and post-intervention periods, respectively. Infant HIV positivity was significantly higher in the post-intervention (2.2%) vs pre-intervention (1.1%) period (p=0.038), however this difference was attenuated (0.83%, 95% CI: -0.50%, 2.15%) after adjusting for differences in maternal age, maternal antenatal care visits, infant birth month and facility. During the post-intervention period, MIPs where the mother disengaged from care were 12.97 (95% CI: 2.41, 69.98) times as likely to have an infant diagnosed with HIV vs those in which the infant received late EID testing without maternal care disengagement. Among 18 infants diagnosed with HIV by the intervention, 16 (88.9%) initiated same-day ART and all continued ART at 3-month follow-up. CONCLUSION: Community-based differentiated care employing POC EID technology increased testing positivity in unadjusted analyses, and resulted in high ART initiation and early care retention, suggesting it may be a promising approach for reaching infants and young children living with HIV being missed by current facility-based approaches. TRIAL REGISTRATION NUMBER: This trial is registered under the following Clinicaltrials.gov Identifier: NCT03133728.
Effects of implementing universal and rapid HIV treatment on initiation of antiretroviral therapy and retention in care in Zambia: a natural experiment using regression discontinuity.
(2021-Dec) Mody A; Sikazwe I; Namwase AS; Wa Mwanza M; Savory T; Mwila A; Mulenga L; Herce ME; Mweebo K; Somwe P; Eshun-Wilson I; Sikombe K; Beres LK; Pry J; Holmes CB; Bolton-Moore C; Geng EH; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; Division of Infectious Diseases, University of North Carolina, Chapel Hill, NC, USA.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; Department of Public Health Environments and Society, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK.; Department of Medicine, Georgetown University, Washington, DC, USA.; Zambian Ministry of Health, Lusaka, Zambia.; Division of Infectious Diseases, Washington University School of Medicine, St Louis, MO, USA; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; Division of Infectious Diseases, Washington University School of Medicine, St Louis, MO, USA.; Center for Disease Control, Lusaka, Zambia.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; Division of Infectious Diseases, University of Alabama, Birmingham, AL, USA.; Division of Infectious Diseases, Washington University School of Medicine, St Louis, MO, USA. Electronic address: aaloke.mody@wustl.edu.; Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
BACKGROUND: Universal testing and treatment (UTT) for all people living with HIV has only been assessed under experimental conditions in cluster-randomised trials. The public health effectiveness of UTT policies on the HIV care cascade under real-world conditions is not known. We assessed the real-world effectiveness of universal HIV treatment policies that were implemented in Zambia on Jan 1, 2017. METHODS: We used data from Zambia's routine electronic health record system to analyse antiretroviral therapy (ART)-naive adults who newly enrolled in HIV care up to 1 year before and after the implementation of universal treatment (ie, Jan 1, 2016, to Jan 1, 2018) at 117 clinics supported by the Centre for Infectious Disease Research in Zambia. We used a regression discontinuity design to estimate the effects of implementing UTT on same-day ART initiation, ART initiation within 1 month, and retention on ART at 12 months (defined as clinic attendance 9-15 months after enrolment and at least 6 months on ART), under the assumption that patients presenting immediately before and after UTT implementation were balanced on both measured and unmeasured characteristics. We did an instrumental variable analysis to estimate the effect of same-day ART initiation under routine conditions on 12-month retention on ART. FINDINGS: 65 673 newly enrolled patients with HIV (40 858 [62·2%] female, median age 32 years [IQR 26-39], median CD4 count 287 cells per μL [IQR 147-466]) were eligible for inclusion in the analyses; 31 145 enrolled before implementation of UTT, and 34 528 enrolled after UTT. Implementation of universal treatment increased same-day ART initiation from 41·7% to 74·8% (risk difference [RD] 33·1%, 95% CI 30·5-35·7), ART initiation by 1 month from 69·6% to 87·0% (RD 17·4%, 15·5-19·3), and 12-month retention on ART from 56·2% to 63·3% (RD 7·1%, 4·3-9·9). ART initiation rates became more uniform across patient subgroups after implementation of universal treatment, but heterogeneity in 12-month retention on ART between subgroups was unchanged. Instrumental variable analyses indicated that same-day ART initiation in routine settings led to a 15·8% increase (95% CI 12·1-19·5) in 12-month retention on ART. INTERPRETATION: UTT policies implemented in Zambia increased the rapidity and uptake of ART, as well as retention on ART at 12 months, although overall retention on ART remained suboptimal. UTT policies reduced disparities in treatment initiation, but not 12-month retention on ART. Natural experiments reveal both the anticipated and unanticipated effects of real-world implementation and indicate the need for new strategies leveraging the short-term effects of UTT to cultivate long-term treatment success. FUNDING: National Institutes of Health.
Estimating potential silent transfer using baseline viral load measures among people presenting as new to HIV care in Lusaka, Zambia: a cross-sectional study.
(2023-May-25) Pry JM; Mwila C; Kapesa H; Mulabe M; Frimpong C; Moono M; Savory T; Bolton-Moore C; Herce ME; Iyer S; Institute for Global Health & Infectious Diseases, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA.; Public Health Sciences, University of California Davis School of Medicine, Sacramento, California, USA.; Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; Division of Infectious Disease, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA.; Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia jmpry@ucdavis.edu.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
OBJECTIVES: To estimate potential silent transfer using baseline viral load measures among individuals presenting as new to HIV care in routine HIV clinical settings in Lusaka, Zambia. DESIGN: Cross-sectional study. SETTING: Two large, urban government-operated health facilities supported by the Centre for Infectious Disease Research in Zambia. PARTICIPANTS: A total of 248 participants with an incident positive HIV rapid test. OUTCOME MEASURES: The primary outcome measure was HIV viral suppression at baseline (i.e., potential silent transfer), defined as having a viral load ≤1000 RNA copies(c)/mL at the time of initiating HIV care. We also examined viral suppression at ≤60 c/mL. METHODS: We surveyed and measured baseline HIV viral load as part of the national recent infection testing algorithm among people living with HIV (PLWH) presenting as new to care. Using mixed effects Poisson regression, we identified characteristics among PLWH associated with potential silent transfer. RESULTS: Among the 248 PLWH included, 63% were women with median age of 30, and 66 (27% (66/248)) had viral suppression at ≤1000 c/mL and 53 (21% (53/248)) at ≤60 c/mL thresholds, respectively. Participants aged 40+ years had a significantly higher adjusted prevalence of potential silent transfer (adjusted prevalence ratio (aPR): 2.10; 95% CI: 2.08, 2.13) compared with participants aged 18-24 years. Participants reporting no formal education had a significantly higher adjusted prevalence of potential silent transfer (aPR: 1.63; 95% CI: 1.52, 1.75) compared with those completing primary education. Among 57 potential silent transfers who completed a survey, 44 (77%) indicated having tested positive previously at ≥1 of 38 clinics in Zambia. CONCLUSIONS: The high proportion of PLWH with potential silent transfer points to clinic shopping and/or co-enrolment at multiple care sites simultaneously, suggesting an opportunity to improve care continuity at the time of HIV care entry.
Evaluating a multifaceted implementation strategy and package of evidence-based interventions based on WHO PEN for people living with HIV and cardiometabolic conditions in Lusaka, Zambia: protocol for the TASKPEN hybrid effectiveness-implementation stepped wedge cluster randomized trial.
(2024-Jun-06) Herce ME; Bosomprah S; Masiye F; Mweemba O; Edwards JK; Mandyata C; Siame M; Mwila C; Matenga T; Frimpong C; Mugala A; Mbewe P; Shankalala P; Sichone P; Kasenge B; Chunga L; Adams R; Banda B; Mwamba D; Nachalwe N; Agarwal M; Williams MJ; Tonwe V; Pry JM; Musheke M; Vinikoor M; Mutale W; Institute of Public Health, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA.; Department of Epidemiology, University of North Carolina, Chapel Hill, NC, USA.; Department of Biostatistics, School of Public Health, University of Ghana, Accra, Ghana.; Department of Health Promotion and Education, School of Public Health, University of Zambia, Ridgeway Campus, Lusaka, Zambia.; Department of Epidemiology, School of Medicine, University of California at Davis, Davis, CA, USA.; Department of Medicine, Division of Infectious Diseases, University Teaching Hospital, Lusaka, Zambia.; Division of Infectious Diseases, Department of Medicine, University of Alabama, Birmingham, AL, USA.; Department of Health Economics, School of Public Health, University of Zambia, Ridgeway Campus, Lusaka, Zambia.; Institute for Global Health and Infectious Diseases, University of North Carolina, Chapel Hill, NC, USA. michael.herce@cidrz.org.; Department of Paediatrics and Child Health, School of Medicine, University of Zambia, Lusaka, Zambia.; Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, U.S. National Institutes of Health, Bethesda, MD, USA.; Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia.; Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia. michael.herce@cidrz.org.; Department of Health Policy and Management, School of Public Health, University of Zambia, Lusaka, Zambia.
BACKGROUND: Despite increasing morbidity and mortality from non-communicable diseases (NCD) globally, health systems in low- and middle-income countries (LMICs) have limited capacity to address these chronic conditions, particularly in sub-Saharan Africa (SSA). There is an urgent need, therefore, to respond to NCDs in SSA, beginning by applying lessons learned from the first global response to any chronic disease-HIV-to tackle the leading cardiometabolic killers of people living with HIV (PLHIV). We have developed a feasible and acceptable package of evidence-based interventions and a multi-faceted implementation strategy, known as "TASKPEN," that has been adapted to the Zambian setting to address hypertension, diabetes, and dyslipidemia. The TASKPEN multifaceted implementation strategy focuses on reorganizing service delivery for integrated HIV-NCD care and features task-shifting, practice facilitation, and leveraging HIV platforms for NCD care. We propose a hybrid type II effectiveness-implementation stepped-wedge cluster randomized trial to evaluate the effects of TASKPEN on clinical and implementation outcomes, including dual control of HIV and cardiometabolic NCDs, as well as quality of life, intervention reach, and cost-effectiveness. METHODS: The trial will be conducted in 12 urban health facilities in Lusaka, Zambia over a 30-month period. Clinical outcomes will be assessed via surveys with PLHIV accessing routine HIV services, and a prospective cohort of PLHIV with cardiometabolic comorbidities nested within the larger trial. We will also collect data using mixed methods, including in-depth interviews, questionnaires, focus group discussions, and structured observations, and estimate cost-effectiveness through time-and-motion studies and other costing methods, to understand implementation outcomes according to Proctor's Outcomes for Implementation Research, the Consolidated Framework for Implementation Research, and selected dimensions of RE-AIM. DISCUSSION: Findings from this study will be used to make discrete, actionable, and context-specific recommendations in Zambia and the region for integrating cardiometabolic NCD care into national HIV treatment programs. While the TASKPEN study focuses on cardiometabolic NCDs in PLHIV, the multifaceted implementation strategy studied will be relevant to other NCDs and to people without HIV. It is expected that the trial will generate new insights that enable delivery of high-quality integrated HIV-NCD care, which may improve cardiovascular morbidity and viral suppression for PLHIV in SSA. This study was registered at ClinicalTrials.gov (NCT05950919).
Experiences of Justice-Involved People Transitioning to HIV Care in the Community After Prison Release in Lusaka, Zambia: A Qualitative Study.
(2023-Apr-28) Smith HJ; Herce ME; Mwila C; Chisenga P; Yenga C; Chibwe B; Mai V; Kashela L; Nanyagwe M; Hatwiinda S; Moonga CN; Musheke M; Lungu Y; Sikazwe I; Topp SM; Zambia Correctional Service, Government of the Republic of Zambia, Lusaka, Zambia.; Institute for Global Health and Infectious Diseases, University of North Carolina, Chapel Hill, NC, USA.; School of Population Health, University of New South Wales, Sydney, Australia.; College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Australia.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
INTRODUCTION: In sub-Saharan Africa (SSA), incarcerated people experience a higher HIV burden than the general population. While access to HIV care and treatment for incarcerated people living with HIV (PLHIV) in SSA has improved in some cases, little is known about their transition to and post-release experience with care in the community. To address this gap, we conducted a qualitative study to describe factors that may influence post-release HIV care continuity in Zambia. METHODS: In March-December 2018, we recruited study participants from a larger prospective cohort study following incarcerated and newly released PLHIV at 5 correctional facilities in 2 provinces in Zambia. We interviewed 50 participants immediately before release; 27 (54%) participated in a second interview approximately 6 months post-release. Demographic and psychosocial data were collected through a structured survey. RESULTS: The pre-release setting was strongly influenced by the highly structured prison environment and assumptions about life post-release. Participants reported accessible HIV services, a destigmatizing environment, and strong informal social supports built through comradery among people facing the same trying detention conditions. Contrary to their pre-release expectations, during the immediate post-release period, participants struggled to negotiate the health system while dealing with unexpected stressors. Long-term engagement in HIV care was possible for participants with strong family support and a high level of self-efficacy. CONCLUSION: Our study highlights that recently released PLHIV in Zambia face acute challenges in meeting their basic subsistence needs, as well as social isolation, which can derail linkage to and retention in community HIV care. Releasees are unprepared to face these challenges due to a lack of community support services. To improve HIV care continuity in this population, new transitional care models are needed that develop client self-efficacy, facilitate health system navigation, and pragmatically address structural and psychosocial barriers like poverty, gender inequality, and substance use.
Gone But Not Lost: Implications for Estimating HIV Care Outcomes When Loss to Clinic Is Not Loss to Care.
(2020-Jul) Edwards JK; Lesko CR; Herce ME; Murenzi G; Twizere C; Lelo P; Anastos K; Tymejczyk O; Yotebieng M; Nash D; Adedimeji A; Edmonds A; From the Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC.; Kalembelembe Pediatric Hospital, Kinshasa, Democratic Republic of the Congo.; Departments of Medicine and Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, NY.; Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC.; Rwanda Military Hospital, Kigali, Rwanda.; Centre Hospitalo, Universitaire de Kamenge, Bujumbura, Burundi.; Institute for Implementation Science in Population Health, City University of New York, New York, NY.; Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, NY.; Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia.; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
BACKGROUND: In some time-to-event analyses, it is unclear whether loss to follow up should be treated as a censoring event or competing event. Such ambiguity is particularly common in HIV research that uses routinely collected clinical data to report the timing of key milestones along the HIV care continuum. In this setting, loss to follow up may be viewed as a censoring event, under the assumption that patients who are "lost" from a study clinic immediately enroll in care elsewhere, or a competing event, under the assumption that people "lost" are out of care all together. METHODS: We illustrate an approach to address this ambiguity when estimating the 2-year risk of antiretroviral treatment initiation among 19,506 people living with HIV who enrolled in the IeDEA Central Africa cohort between 2006 and 2017, along with published estimates from tracing studies in Africa. We also assessed the finite sample properties of the proposed approach using simulation experiments. RESULTS: The estimated 2-year risk of treatment initiation was 69% if patients were censored at loss to follow up or 59% if losses to follow up were treated as competing events. Using the proposed approach, we estimated that the 2-year risk of antiretroviral therapy initiation was 62% (95% confidence interval: 61, 62). The proposed approach had little bias and appropriate confidence interval coverage under scenarios examined in the simulation experiments. CONCLUSIONS: The proposed approach relaxes the assumptions inherent in treating loss to follow up as a censoring or competing event in clinical HIV cohort studies.
HIV and tuberculosis in prisons in sub-Saharan Africa.
(2016-Sep-17) Telisinghe L; Charalambous S; Topp SM; Herce ME; Hoffmann CJ; Barron P; Schouten EJ; Jahn A; Zachariah R; Harries AD; Beyrer C; Amon JJ; College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, QLD, Australia; Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia.; International Union Against Tuberculosis and Lung Disease, Paris, France; London School of Hygiene & Tropical Medicine, London, UK.; Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi; International Training and Education Center for Health, Department of Global Health, University of Washington, Seattle, WA, USA.; School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.; The Aurum Institute, Johannesburg, South Africa; School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Health and Human Rights Division, Human Rights Watch, New York, NY, USA.; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.; Johns Hopkins University School of Medicine, Baltimore, MD, USA.; Médecins Sans Frontières, Brussels Operational Centre, Operational Research Unit, Luxembourg City, Luxembourg.; Field Epidemiology Services, Public Health England, Bristol, UK; University of Bristol, Bristol, UK. Electronic address: lily.telisinghe@phe.gov.uk.; Management Sciences for Health, Lilongwe, Malawi.; Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia; University of North Carolina School of Medicine, Chapel Hill, NC, USA.
Given the dual epidemics of HIV and tuberculosis in sub-Saharan Africa and evidence suggesting a disproportionate burden of these diseases among detainees in the region, we aimed to investigate the epidemiology of HIV and tuberculosis in prison populations, describe services available and challenges to service delivery, and identify priority areas for programmatically relevant research in sub-Saharan African prisons. To this end, we reviewed literature on HIV and tuberculosis in sub-Saharan African prisons published between 2011 and 2015, and identified data from only 24 of the 49 countries in the region. Where data were available, they were frequently of poor quality and rarely nationally representative. Prevalence of HIV infection ranged from 2·3% to 34·9%, and of tuberculosis from 0·4 to 16·3%; detainees nearly always had a higher prevalence of both diseases than did the non-incarcerated population in the same country. We identified barriers to prevention, treatment, and care services in published work and through five case studies of prison health policies and services in Zambia, South Africa, Malawi, Nigeria, and Benin. These barriers included severe financial and human-resource limitations and fragmented referral systems that prevent continuity of care when detainees cycle into and out of prison, or move between prisons. These challenges are set against the backdrop of weak health and criminal-justice systems, high rates of pre-trial detention, and overcrowding. A few examples of promising practices exist, including routine voluntary testing for HIV and screening for tuberculosis upon entry to South African and the largest Zambian prisons, reforms to pre-trial detention in South Africa, integration of mental health services into a health package in selected Malawian prisons, and task sharing to include detainees in care provision through peer-educator programmes in Rwanda, Zimbabwe, Zambia, and South Africa. However, substantial additional investments are required throughout sub-Saharan Africa to develop country-level policy guidance, build human-resource capacity, and strengthen prison health systems to ensure universal access to HIV and tuberculsosis prevention, treatment, and care of a standard that meets international goals and human rights obligations.
Improving HIV outreach testing yield at cross-border venues in East Africa.
(2020-May-01) Edwards JK; Arimi P; Ssengooba F; Herce ME; Mulholland G; Markiewicz M; Babirye S; Ssendagire S; Weir SS; Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.; U.S. Agency for International Development, Kenya/East Africa Regional Mission, Nairobi, Kenya.; Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.; Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia.; Institute for Global Health & Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.; Makerere University School of Public Health, Kampala, Uganda.
OBJECTIVE: The aim of this study was to evaluate HIV testing yield under several candidate strategies for outreach testing at venues (i.e. places where people socialize and meet new sex partners) in East Africa cross-border areas. DESIGN: Population-based cross-sectional biobehavioural survey of people who had not been previously diagnosed with HIV found in venues. METHODS: We identified participants who would have been tested for HIV under each of 10 hypothetical outreach testing strategies and calculated the proportion who would have newly tested positive for HIV under each strategy. On the basis of this proportion, we calculated the 'number needed to test' (NNT) to identify one new case of HIV under each strategy. All estimates were obtained by applying survey sampling weights to account for the complex sampling design. RESULTS: If testing was performed at a random sample of venues, 35 people would need to be tested to identify one new case of HIV, but higher yield could be found by limiting testing to venues with specific characteristics. Strategies focusing on women had higher testing yield. Testing women employed by venues would result in highest yield of all strategies examined (NNT = 15), while testing men under age 24 would result in the lowest yield (NNT = 99). CONCLUSION: Quantitatively evaluating HIV testing strategies prior to implementation using survey data presents a new opportunity to refine and prioritize outreach testing strategies for the people and places most likely to result in high HIV testing yield.
Index and targeted community-based testing to optimize HIV case finding and ART linkage among men in Zambia.
(2020-Jun) Mwango LK; Stafford KA; Blanco NC; Lavoie MC; Mujansi M; Nyirongo N; Tembo K; Sakala H; Chipukuma J; Phiri B; Nzangwa C; Mwandila S; Nkwemu KC; Saadani A; Mwila A; Herce ME; Claassen CW; Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia.; Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA.; Institute for Global Health and Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, NC, USA.; Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA.; Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia.; U.S. Center for Disease Control and Prevention, Lusaka, Zambia.; Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, USA.
INTRODUCTION: Current healthcare systems fail to provide adequate HIV services to men. In Zambia, 25% of adult men living with HIV were unaware of their HIV status in 2018, and 12% of those who were unaware of their HIV statu were not receiving antiretroviral therapy (ART) due to pervasive barriers to HIV testing services (HTS) and linkage to ART. To identify men and key and priority populations living with HIV in Zambia, and link them to care and treatment, we implemented the Community Impact to Reach Key and Underserved Individuals for Treatment and Support (CIRKUITS) project. We present HTS and ART linkage results from the first year of CIRKUITS. METHODS: CIRKUITS aimed to reach beneficiaries by training, mentoring, and deploying community health workers to provide index testing services and targeted community HTS. Community leaders and workplace supervisors were engaged to enable workplace HTS for men. To evaluate the effects of these interventions, we collected age- and sex-disaggregated routinely collected programme data for the first 12 months of the project (October 2018 to September 2019) across 37 CIRKUITS-supported facilities in three provinces. We performed descriptive statistics and estimated index cascades for indicators of interest, and used Chi square tests to compare indicators by age, sex, and district strata. RESULTS: Over 12 months, CIRKUITS tested 38,255 persons for HIV, identifying 10,974 (29%) new people living with HIV, of whom 10,239 (93%) were linked to ART. Among men, CIRKUITS tested 18,336 clients and identified 4458 (24%) as HIV positive, linked 4132 (93%) to ART. Men who tested HIV negative were referred to preventative services. Of the men found HIV positive, and 13.0% were aged 15 to 24 years, 60.3% were aged 25 to 39, 20.9% were aged 40 to 49 and 5.8% were ≥50 years old. Index testing services identified 2186 (49%) of HIV-positive men, with a positivity yield of 40% and linkage of 88%. Targeted community testing modalities accounted for 2272 (51%) of HIV-positive men identified, with positivity yield of 17% and linkage of 97%. CONCLUSIONS: Index testing and targeted community-based HTS are effective strategies to identify men living with HIV in Zambia. Index testing results in higher yield, but lower linkage and fewer absolute men identified compared to targeted community-based HTS.
Initial implementation of HIV pre-exposure prophylaxis for people who are incarcerated in Zambia: a cross-sectional observational study.
(2023-Jan) Lindsay B; Nyirongo N; Mwango L; Toeque MG; Masumba C; Litongola JP; Sikanyika J; Kabombo H; Moyo M; Siachibila S; Mudenda J; Tembo K; Olowski P; Olufunso A; Muchinda E; Musonda B; Okuku J; Mwila A; Moonga CN; Herce ME; Claassen CW; Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia; Institute for Global Health and Infectious Diseases, University of North Carolina, Chapel Hill, NC, USA.; Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia; Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, USA.; Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia.; US Centers for Disease Control and Prevention, Lusaka, Zambia.; Health Directoriate, Zambia Correctional Services, Lusaka, Zambia.; Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia; Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, USA. Electronic address: brianna.lindsay@ihv.umaryland.edu.; Department of Public Health, Ministry of Health, Lusaka, Zambia.; Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia.; Ciheb-Zambia, Lusaka, Zambia.
BACKGROUND: There are over 23 000 incarcerated people in Zambia, a population which has higher HIV prevalence than the general population yet has no access to HIV prevention. To evaluate the feasibility of HIV pre-exposure prophylaxis (PrEP) implementation in Zambian criminal justice facilities, we offered PrEP services to incarcerated people and aimed to describe early implementation outcomes. METHODS: In this cross-sectional observational study, we implemented a PrEP programme between Oct 1, 2020, and March 31, 2021, supporting 16 criminal justice facilities in four Zambian provinces. Before implementation, we held stakeholder engagement meetings with Zambia Correctional Service officials to discuss PrEP benefits, and trained Zambia Correctional Service health-care workers in PrEP management using the national PrEP training package. People who were incarcerated and screened positive for substantial HIV risk by use of a standardised HIV risk assessment tool were offered voluntary HIV testing and counselling. Those who tested positive were linked to antiretroviral therapy, and those who tested negative and met national HIV prevention eligibility criteria were offered PrEP. We assessed PrEP uptake and used descriptive statistics to characterise programme beneficiaries and the cascade of PrEP services. FINDINGS: During the study period, we reached 12 367 people older than 15 years with HIV risk assessment and counselling, including 11 794 (95·4%) men and 573 (4·6%) women. Of these, 2610 people received HIV testing, with 357 (13·7%) testing HIV positive; positivity was significantly higher in women (20·6%) than men (13·2%, p=0·011). 1276 people were identified as HIV negative and PrEP eligible. Of these, 1190 (93·3%) initiated PrEP. The age group with the highest proportion reached and initiated on PrEP was those aged 25-29 years, representing 19·2% (2377 of 12 367) of all people reached and 24·1% (287 of 1190) of those who initiated PrEP. INTERPRETATION: Delivery of PrEP to people who are incarcerated is feasible with adequate resourcing and support to the criminal justice health system, and can result in high uptake among eligible individuals. Further assessment is needed of PrEP persistence and adherence, and the perceptions of people who are incarcerated regarding their HIV risk and preferences for combination HIV prevention services. FUNDING: US President's Emergency Plan for AIDS Relief through the US Centers for Disease Control and Prevention.
Integrating HIV care and treatment into tuberculosis clinics in Lusaka, Zambia: results from a before-after quasi-experimental study.
(2018-Oct-26) Herce ME; Morse J; Luhanga D; Harris J; Smith HJ; Besa S; Samungole G; Kancheya N; Muyoyeta M; Reid SE; Lusaka District Health Office, Ministry of Health, Government of the Republic of Zambia, Lusaka, Zambia.; Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA.; Division of Infectious Diseases, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA. michael.herce@cidrz.org.; Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia.; Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia. michael.herce@cidrz.org.
BACKGROUND: Patients with HIV-associated tuberculosis (TB) often have their TB and HIV managed in separate vertical programs that offer care for each disease with little coordination. Such "siloed" approaches are associated with diagnostic and treatment delays, which contribute to unnecessary morbidity and mortality. To improve TB/HIV care coordination and early ART initiation, we integrated HIV care and treatment into two busy TB clinics in Zambia. We report here the effects of our intervention on outcomes of linkage to HIV care, early ART uptake, and TB treatment success for patients with HIV-associated TB in Lusaka, Zambia. METHODS: We provided integrated HIV treatment and care using a "one-stop shop" model intervention. All new or relapse HIV-positive TB patients were offered immediate HIV program enrolment and ART within 8 weeks of anti-TB therapy (ATT) initiation. We used a quasi-experimental design, review of routine program data, and survival analysis and logistic regression methods to estimate study outcomes before (June 1, 2010-January 31, 2011) and after (August 1, 2011-March 31, 2012) our intervention among 473 patients with HIV-associated TB categorized into pre- (n = 248) and post-intervention (n = 225) cohorts. RESULTS: Patients in the pre- and post-intervention cohorts were mostly male (60.1% and 52.9%, respectively) and young (median age: 33 years). In time-to-event analyses, a significantly higher proportion of patients in the post-intervention cohort linked to HIV care by 4 weeks post-ATT initiation (53.9% vs. 43.4%, p = 0.03), with median time to care linkage being 59 and 25 days in the pre- and post-intervention cohorts, respectively. In Cox proportional hazard modelling, patients receiving the integration intervention started ART by 8 weeks post-ATT at 1.33 times the rate (HR = 1.33, 95% CI: 1.00-1.77) as patients pre-intervention. In logistic regression modelling, patients receiving the intervention were 2.02 times (95% CI: 1.11-3.67) as likely to have a successful TB treatment outcome as patients not receiving the intervention. CONCLUSIONS: Integrating HIV treatment and care services into routine TB clinics using a one-stop shop model increased linkage to HIV care, rates of early ART initiation, and TB treatment success among patients with HIV-associated TB in Lusaka, Zambia.
"It's Not Like Taking Chocolates": Factors Influencing the Feasibility and Sustainability of Universal Test and Treat in Correctional Health Systems in Zambia and South Africa.
(2019-Jun) Topp SM; Chetty-Makkan CM; Smith HJ; Chimoyi L; Hoffmann CJ; Fielding K; Reid SE; Olivier AJ; Hausler H; Herce ME; Charalambous S; Johns Hopkins University, Baltimore, MD, USA.; TB/HIV Care Association, Cape Town, South Africa.; London School of Hygiene & Tropical Medicine, London, UK.; College of Public Health, Medical and Veterinary Sciences, James Cook University, Queensland, Australia. globalstopp@gmail.com.; Institute for Global Health & Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, NC, USA.; The Aurum Institute, Johannesburg, South Africa.; Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, School of Medicine, Birmingham, AL, USA.; Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia.; School of Public Health, University of Witwatersrand, Johannesburg, South Africa.
BACKGROUND: Sub-Saharan African correctional facilities concentrate large numbers of people who are living with HIV or at risk for HIV infection. Universal test and treat (UTT) is widely recognized as a promising approach to improve the health of individuals and a population health strategy to reduce new HIV infections. In this study, we explored the feasibility and sustainability of implementing UTT in correctional facilities in Zambia and South Africa. METHODS: Nested within a UTT implementation research study, our qualitative evaluation of feasibility and sustainability used a case-comparison design based on data from 1 Zambian and 3 South African correctional facilities. Primary data from in-depth interviews with incarcerated individuals, correctional managers, health care providers, and policy makers were supplemented by public policy documents, study documentation, and implementation memos in both countries. Thematic analysis was informed by an empirically established conceptual framework for health system analysis. RESULTS: Despite different institutional profiles, we were able to successfully introduce UTT in the South Africa and Zambian correctional facilities participating in the study. A supportive policy backdrop was important to UTT implementation and establishment in both countries. However, sustainability of UTT, defined as relevant government departments' capacity to independently plan, resource, and administer quality UTT, differed. South Africa's correctional facilities had existing systems to deliver and monitor chronic HIV care and treatment, forming a "scaffolding" for sustained UTT despite some human resources shortages and poorly integrated health information systems. Notwithstanding recent improvements, Zambia's correctional health system demonstrated insufficient material and technical capacity to independently deliver quality UTT. In the correctional facilities of both countries, inmate population dynamics and their impact on HIV-related stigma were important factors in UTT service uptake. CONCLUSION: Findings demonstrate the critical role of policy directives, health service delivery systems, adequate resourcing, and population dynamics on the feasibility and likely sustainability of UTT in corrections in Zambia and South Africa.