Browsing by Author "Mody, Aaloke"

Now showing 1 - 6 of 6

Comparison of patient exit interviews with unannounced standardised patients for assessing HIV service delivery in Zambia: a study nested within a cluster randomised trial.
(2023-Jul-05) Sikombe, Kombatende ; Pry, Jake M.; Mody, Aaloke; Rice, Brian; Bukankala, Chama; Eshun-Wilson, Ingrid; Mutale, Jacob; Simbeza, Sandra; Beres, Laura K.; Mukamba, Njekwa; Mukumbwa-Mwenechanya, Mpande ; Mwamba, Daniel; Sharma, Anjali; Wringe, Alison ; Hargreaves, James; Bolton-Moore, Carolyn; Holmes, Charles; Sikazwe, Izukanji; Geng, Elvin
OBJECTIVES: To compare unannounced standardised patient approach (eg, mystery clients) with typical exit interviews for assessing patient experiences in HIV care (eg, unfriendly providers, long waiting times). We hypothesise standardised patients would report more negative experiences than typical exit interviews affected by social desirability bias. SETTING: Cross-sectional surveys in 16 government-operated HIV primary care clinics in Lusaka, Zambia providing antiretroviral therapy (ART). PARTICIPANTS: 3526 participants aged ≥18 years receiving ART participated in the exit surveys between August 2019 and November 2021. INTERVENTION: Systematic sample (every n OUTCOME MEASURES: We compared patient experience among patients who received brief training prior to their care visit (explaining each patient experience construct in the exit survey, being anonymous, without manipulating behaviour) with those who did not undergo training on the survey prior to their visit. RESULTS: Among 3526 participants who participated in exit surveys, 2415 were untrained (56% female, median age 40 (IQR: 32-47)) and 1111 were trained (50% female, median age 37 (IQR: 31-45)). Compared with untrained, trained patients were more likely to report a negative care experience overall (adjusted prevalence ratio (aPR) for aggregate sum score: 1.64 (95% CI: 1.39 to 1.94)), with a greater proportion reporting feeling unwelcome by providers (aPR: 1.71 (95% CI: 1.20 to 2.44)) and witnessing providers behaving rude (aPR: 2.28 (95% CI: 1.63 to 3.19)). CONCLUSION: Trained patients were more likely to identify suboptimal care. They may have understood the items solicited better or felt empowered to be more critical. We trained existing patients, unlike studies that use 'standardised patients' drawn from outside the patient population. This low-cost strategy could improve patient-centred service delivery elsewhere. TRIAL REGISTRATION NUMBER: Assessment was nested within a parent study; www.pactr.org registered the parent study (PACTR202101847907585).
Cross-sectional study to assess depression among healthcare workers in Lusaka, Zambia during the COVID-19 pandemic.
(2023-Apr-05) Simbeza, Sandra; Mutale, Jacob; Mulabe, Musunge; Jere, Lazarus; Bukankala, Chama; Sikombe, Kombatende; Sikazwe, Izukanji; Bolton-Moore, Carolyn; Mody, Aaloke; Geng, Elvin H.; Sharma, Anjali; Beres, Laura K.; Pry, Jake M.
OBJECTIVES: We sought to assess depression among healthcare workers (HCWs) in the context of COVID-19 in Lusaka Province, Zambia. DESIGN: This cross-sectional study is nested within a larger study, the Person-Centred Public Health for HIV Treatment in Zambia (PCPH), a cluster-randomised trial to assess HIV care and outcomes. SETTING: The research was conducted in 24 government-run health facilities from 11 August to 15 October 2020 during the first wave of the COVID-19 pandemic in Lusaka, Zambia. PARTICIPANTS: We used convenience sampling to recruit HCW participants who were previously enrolled in the PCPH study, had more than 6 months' experience working at the facility and were voluntarily willing to participate. PRIMARY OUTCOME MEASURES: We implemented the well-validated 9-question Patient Health Questionnaire (PHQ-9) to assess HCW depression. We used mixed-effects, adjusted Poisson regression to estimate the marginal probability of HCWs experiencing depression that may warrant intervention (PHQ-9 score ≥5) by healthcare facility. RESULTS: We collected PHQ-9 survey responses from 713 professional and lay HCWs. Overall, 334 (46.8%, 95% CI 43.1%, 50.6%) HCWs recorded a PHQ-9 score ≥5, indicating the need for further assessment and potential intervention for depression. We identified significant heterogeneity across facilities and observed a greater proportion of HCWs with symptoms of depression in facilities providing COVID-19 testing and treatment services. CONCLUSIONS: Depression may be a concern for a large proportion of HCWs in Zambia. Further work to understand the magnitude and aetiologies of depression among HCWs in the public sector is needed to design effective prevention and treatment interventions to meet the needs for mental health support and to minimise poor health outcomes.
Effect of a person-centered care intervention on return and sustained reengagement after treatment interruptions from HIV care in Zambia: A post-hoc analysis of a stepped-wedged cluster randomized trial.
(2026-Sep) Mody, Aaloke; Sikombe, Kombatende; Simbeza, Sandra ; Mukamba, Njekwa ; Beres, Laura K.; Pry, Jake M.; Sharma, Anjali; Mutale, Jacob; Dube, Alida Z.; Mulabe, Musunge; Mulenga, Lloyd ; Sivile, Suilanji; Ratliff, April; Goss, Charles W.; Holmes, Charles B.; Bolton-Moore, Carolyn ; Sikazwe, Izukanji; Geng, Elvin H.
BACKGROUND: Poor client-provider interactions lead to reinforcing cycles of treatment interruptions (TIs) from HIV care and fear of return, undermining sustained retention. We previously demonstrated a multi-component person-centered care intervention (PCC) targeting healthcare worker (HCW) behavior improved client experience and retention in HIV care. To understand mechanisms of improved retention, we evaluated the effect of the PCC intervention on return after TIs and sustained retention after return in a post-hoc analysis, hypothesizing that friendlier HCW attitudes enable successful reengagement into care. METHODS AND FINDINGS: We implemented the PCC intervention at 24 clinics in Zambia in a stepped-wedge, cluster randomized trial from Aug 2019 to Nov 2021. Clinics were allocated into 4 groups (8 clinics in Groups 1 and 4, and 4 each in Groups 2 and 3) and randomly assigned to crossover from control to intervention every 6 months. Under control, clinics provided routine HIV care without additional support. Afterwards, clinics received the PCC intervention targeting caring aspects of HCW behavior with 1) training and coaching on PCC practices, 2) measurement and feedback of client experience (via exit interviews), and 3) small facility-level incentives. We examined individuals living with HIV who became >30 days late to a scheduled visit (i.e., TI), categorizing intervention exposure based on the last visit prior to TI. We used electronic health records to assess the effect of the PCC intervention on 1) return to HIV care after a TI, and 2) repeat TIs among those who returned. We used multistate analytic methods to estimate crude incidence of return and repeat TIs and prevalence of being in care at 1-year. We used shared frailty Cox proportional hazards and mixed-effects Poisson models to obtain formal comparisons that accounted for the stepped-wedge design. Individuals were censored at intervention crossover or database closure. During the study period, 128,910 clients (n = 69,671 control, n = 59,239 intervention) became >30 days late (64.3% female, median age 38y [IQR 31,45], median years in care 2.5y [IQR 0.6,6.7]). The PCC intervention increased incidence of return after TI at 12-months (72.3% intervention versus 67.7% control, crude risk difference [RD] +4.6% [CI 4.1,5.2], adjusted hazard ratio [aHR] 1.16 [CI 1.12,1.20]; p < 0.001). Among returners, the intervention decreased incidence of repeat TIs (44.3% versus 55.6%, RD -11.4% [CI -12.2,-10.6], aHR 0.50 [CI 0.45,0.55]; p < 0.001) and increased the proportion in care (with or without repeat TIs) (82.7% versus 73.4%, RD +9.3% [CI 8.6,10.0], adjusted risk ratio [aRR] 1.14 [CI 1.05,1.25]; p = 0.002) at 12-months after return. Overall, the PCC intervention increased the proportion in care 12-months after a TI from 51.5% to 60.1% (RD +8.7% [CI 8.0,9.3], aRR 1.19 [CI 1.05,1.35]; p = 0.008). Effect sizes were similar in direction and magnitude in multiple sensitivity analyses with varying precision. Limitations included post-hoc analysis and those associated with stepped-wedge design. CONCLUSIONS: The PCC intervention likely improved rates of return to care after TIs, sustained reengagement after return, and overall retention among individuals with TIs. Strategies targeting caring aspects of HCW behavior and client experience may help lower barriers to and address persistent challenges with reengagement in care.
Identifying care gaps along the HIV treatment failure cascade: A multistate analysis of viral load monitoring, re-suppression, and regimen switches in Zambia.
(2025-Sep) Sikombe, Kombatende; Le Tourneau, Noelle; Rice, Brian; Pry, Jake M.; Simbeza, Sandra; Beres, Laura K.; Sharma, Anjali; Mukamba, Njekwa; Wringe, Alison; Hargreaves, James R.; Mutale, Jacob; Bolton-Moore, Carolyn ; Sikazwe, Izukanji; Geng, Elvin; Mody, Aaloke
BACKGROUND: Timely response to treatment failure is critical for improved outcomes and viral re-suppression among people living with HIV, but care gaps along the treatment failure cascade can occur due to delays by both clients (e.g., retention and adherence) and health systems (e.g., fidelity to viral load [VL] monitoring guidelines). We used multistate analysis to identify drivers of implementation gaps in the treatment failure cascade, including time to HIV VL monitoring, re-suppression, and regimen switches, in Zambia. METHODS AND FINDINGS: We used national electronic HIV health records to identify adults on antiretroviral therapy (ART) for more than 6 months who experienced treatment failure (VL ≥ 1,000 copies/ml) at 24 clinics in Lusaka, Zambia, between August 2019 and November 2021. Using multistate analyses, we examined how care evolved after treatment failure, accounting for transitions across the treatment failure cascade over time, such as return visits, repeat VL testing, treatment interruptions (>60 days late for visit), and viral re-suppression. Analyses were stratified by ART regimen at cohort entry: tenofovir disoproxil fumarate/lamivudine or emtricitabine/dolutegravir TDF/XTC/DTG (TLD) and tenofovir disoproxil fumarate/lamivudine or emtricitabine/efavirenz TDF/XTC/EFV (TLE). We repeated analyses to assess switch to second-line therapy among those with consecutively unsuppressed VL test results who were due for regimen switch. Among 179,855 individuals on ART (143,857 with documented VL), 7,916 (4.4%) had a documented elevated VL and drug regimen at the time of treatment failure (52.3% female, median age was 36.7 years (IQR 29.9-43.6), median time on ART 3.3 years (IQR 1.7-6.6), 54.6% on TLD and 45.4% on TLE). Among those with treatment failure, 72.2% (CI 71.3, 73.0%) had returned to clinic 6 months after initial elevated VL was drawn. After one year, 70.1% (CI 69.3, 70.9%) had a repeat VL, 16.6% (CI 15.9, 17.2%) experienced treatment interruption, and 11.4% (CI 10.3, 12.4%) returned to care without repeat VL testing. Among those with a repeat VL, 85.0% (CI 83.9, 86.1%) on TLD and 58.2% (CI 56.8, 59.8%) on TLE had resuppressed. Among those due for second-line switch, 27.9% (CI 24.1, 31.5%) on TLD and 66.6% (CI 64.5, 68.9%) on TLE had changed regimens after one year while 52.4% on TLD had a third VL repeated prior to switch (CI 47.2, 57.4%) (68.0% CI 61.6, 75.2% suppressed of those with repeated VL) compared to 32.1% (CI 29.9, 34.1%) (40.7% CI 36.1, 45.4% suppressed) on TLE. This study was limited by the inability to capture all aspects of care delivery related to treatment failure, such as outreach, enhanced adherence counseling confirmation, and provider rationale for delayed VL rechecking. CONCLUSION: After treatment failure, we identified substantial delays in returning for adherence counseling, treatment interruptions, and missed opportunities in rechecking VL status or switching to second-line therapy in routine care in Zambia. Among those who did have VL tests rechecked, re-suppression rates were significantly higher among individuals on TLD compared to TLE. To optimize response and outcomes after treatment failure, strategies must prioritize and target both client and health systems behaviors to meet the care needs in the modern era of TLD.
Mitigating the effects of COVID-19 on HIV treatment and care in Lusaka, Zambia: a before-after cohort study using mixed effects regression.
(2022-Jan) Pry, Jake M.; Sikombe, Kombatende; Mody, Aaloke; Iyer, Shilpa; Mutale, Jacob; Vlahakis, Natalie; Savory, Theodora; Wa Mwanza, Mwanza; Mweebo, Keith; Mwila, Annie; Mwale, Consity; Mukumbwa-Mwenechanya, Mpande; Kerkhoff, Andrew D.; Sikazwe, Izukanji; Bolton-Moore, Carolyn; Mwamba, Daniel; Geng, Elvin H.; Herce, Michael E.
INTRODUCTION: The Zambian Ministry of Health (MoH) issued COVID-19 mitigation guidance for HIV care immediately after the first COVID-19 case was confirmed in Zambia on 18 March 2020. The Centre for Infectious Disease Research in Zambia implemented MoH guidance by: 1) extending antiretroviral therapy (ART) refill duration to 6 multi-month dispensation (6MMD) and 2) task-shifting communication and mobilisation of those in HIV care to collect their next ART refill early. We assessed the impact of COVID-19 mitigation guidance on HIV care 3 months before and after guidance implementation. METHODS: We reviewed all ART pharmacy visit data in the national HIV medical record for PLHIV in care having ≥1 visit between 1 January-30 June 2020 at 59 HIV care facilities in Lusaka Province, Zambia. We undertook a before-after evaluation using mixed-effects Poisson regression to examine predictors and marginal probability of early clinic return (pharmacy visit >7 days before next appointment), proportion of late visit (>7 days late for next appointment) and probability of receiving a 6MMD ART refill. RESULTS: A total of 101 371 individuals (64% female, median age 39) with 130 486 pharmacy visits were included in the analysis. We observed a significant increase in the adjusted prevalence ratio (4.63; 95% CI 4.45 to 4.82) of early return before compared with after guidance implementation. Receipt of 6MMD increased from a weekly mean of 47.9% (95% CI 46.6% to 49.2%) before to 73.4% (95% CI 72.0% to 74.9%) after guidance implementation. The proportion of late visits (8-89 days late) was significantly higher before (18.8%, 95% CI17.2%to20.2%) compared with after (15.1%, 95% CI13.8%to16.4%) guidance implementation . CONCLUSIONS: Timely issuance and implementation of COVID-19 mitigation guidance involving task-shifted patient communication and mobilisation alongside 6MMD significantly increased early return to ART clinic, potentially reducing interruptions in HIV care during a global public health emergency.
Retention and viral suppression in a cohort of HIV patients on antiretroviral therapy in Zambia: Regionally representative estimates using a multistage-sampling-based approach.
(2019-May) Sikazwe, Izukanji; Eshun-Wilson, Ingrid; Sikombe, Kombatende; Czaicki, Nancy; Somwe, Paul; Mody, Aaloke; Simbeza, Sandra; Glidden, David V.; Chizema, Elizabeth; Mulenga, Lloyd B.; Padian, Nancy; Duncombe, Chris J.; Bolton-Moore, Carolyn; Beres, Laura K.; Holmes, Charles B.; Geng, Elvin
BACKGROUND: Although the success of HIV treatment programs depends on retention and viral suppression, routine program monitoring of these outcomes may be incomplete. We used data from the national electronic medical record (EMR) system in Zambia to enumerate a large and regionally representative cohort of patients on treatment. We traced a random sample with unknown outcomes (lost to follow-up) to document true care status and HIV RNA levels. METHODS AND FINDINGS: On 31 July 2015, we selected facilities from 4 provinces in 12 joint strata defined by facility type and province with probability proportional to size. In each facility, we enumerated adults with at least 1 clinical encounter after treatment initiation in the previous 24 months. From this cohort, we identified lost-to-follow-up patients (defined as 90 or more days late for their last appointment), selected a random sample, and intensively reviewed their records and traced them via phone calls and in-person visits in the community. In 1 of 4 provinces, we also collected dried blood spots (DBSs) for plasma HIV RNA testing. We used inverse probability weights to incorporate sampling outcomes into Aalen-Johansen and Cox proportional hazards regression to estimate retention and viremia. We used a bias analysis approach to correct for the known inaccuracy of plasma HIV RNA levels obtained from DBSs. From a total of 64 facilities with 165,464 adults on ART, we selected 32 facilities with 104,966 patients, of whom 17,602 (17%) were lost to follow-up: Those lost to follow-up had median age 36 years, 60% were female (N = 11,241), they had median enrollment CD4 count of 220 cells/μl, and 38% had WHO stage 1 clinical disease (N = 10,690). We traced 2,892 (16%) and found updated outcomes for 2,163 (75%): 412 (19%) had died, 836 (39%) were alive and in care at their original clinic, 457 (21%) had transferred to a new clinic, 255 (12%) were alive and out of care, and 203 (9%) were alive but we were unable to determine care status. Estimates using data from the EMR only suggested that 42.7% (95% CI 38.0%-47.1%) of new ART starters and 72.3% (95% CI 71.8%-73.0%) of all ART users were retained at 2 years. After incorporating updated data through tracing, we found that 77.3% (95% CI 70.5%-84.0%) of new initiates and 91.2% (95% CI 90.5%-91.8%) of all ART users were retained (at original clinic or transferred), indicating that routine program data underestimated retention in care markedly. In Lusaka Province, HIV RNA levels greater than or equal to 1,000 copies/ml were present in 18.1% (95% CI 14.0%-22.3%) of patients in care, 71.3% (95% CI 58.2%-84.4%) of lost patients, and 24.7% (95% CI 21.0%-29.3%). The main study limitations were imperfect response rates and the use of self-reported care status. CONCLUSIONS: In this region of Zambia, routine program data underestimated retention, and the point prevalence of unsuppressed HIV RNA was high when lost patients were accounted for. Viremia was prevalent among patients who unofficially transferred: Sustained engagement remains a challenge among HIV patients in Zambia, and targeted sampling is an effective strategy to identify such gaps in the care cascade and monitor programmatic progress.