Browsing by Author "Moonga CN"

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Evaluation of a health system strengthening initiative in the Zambian prison system.
(2018) Topp SM; Sharma A; Moonga CN; Chileshe C; Magwende G; Henostroza G; Nossal Institute for Global Health, University of Melbourne, Melbourne, Victoria, Australia.; School of Medicine, University of Alabama, Tuscaloosa, Alabama, USA.; Zambia Correctional Service, Lusaka, Zambia.; College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
INTRODUCTION: In 2013, the Zambian Correctional Service (ZCS) partnered with the Centre for Infectious Disease Research in Zambia on the Zambian Prisons Health System Strengthening project, seeking to tackle structural, organisational and cultural weaknesses within the prison health system. We present findings from a nested evaluation of the project impact on high, mid-level and facility-level health governance and health service arrangements in the Zambian Correctional Service. METHODS: Mixed methods were used, including document review, indepth interviews with ministry (11) and prison facility (6) officials, focus group discussions (12) with male and female inmates in six of the eleven intervention prisons, and participant observation during project workshops and meetings. Ethical clearance and verbal informed consent were obtained for all activities. Analysis incorporated deductive and iterative inductive coding. CONCLUSION: While not a panacea, findings demonstrate that a 'systems' approach to seemingly intractable prison health system problems yielded a number of short-term tactical and long-term strategic improvements in the Zambian setting. Context-sensitive application of such an approach to other settings may yield positive outcomes.
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.
Exploring the drivers of health and healthcare access in Zambian prisons: a health systems approach.
(2016-Nov) Topp SM; Moonga CN; Luo N; Kaingu M; Chileshe C; Magwende G; Heymann SJ; Henostroza G; Centre for Infectious Disease Research in Zambia, PO Box 30346, Lusaka, Zambia.; ZPS Headquarters, PO Box 80926, Kabwe, Zambia.; Centre for Infectious Disease Research in Zambia, PO Box 30346, Lusaka, Zambia; James Cook University, School of Public Health Medical and Veterinary Sciences, Douglas, QLD, 4810, Australia, globalstopp@gmail.com stephanie.topp@jcu.edu.au.; Fielding of Public Health, University of Los Angeles, CA, 90095-1772, USA.; Centre for Infectious Disease Research in Zambia, University of Alabama at Birmingham, PO Box 30346, Lusaka, Zambia.; C/-CAPAH, National Assembly Parliament Buildings, PO Box 31299.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
BACKGROUND: Prison populations in sub-Saharan Africa (SSA) experience a high burden of disease and poor access to health care. Although it is generally understood that environmental conditions are dire and contribute to disease spread, evidence of how environmental conditions interact with facility-level social and institutional factors is lacking. This study aimed to unpack the nature of interactions and their influence on health and healthcare access in the Zambian prison setting. METHODS: We conducted in-depth interviews of a clustered random sample of 79 male prisoners across four prisons, as well as 32 prison officers, policy makers and health care workers. Largely inductive thematic analysis was guided by the concepts of dynamic interaction and emergent behaviour, drawn from the theory of complex adaptive systems. RESULTS: A majority of inmates, as well as facility-based officers reported anxiety linked to overcrowding, sanitation, infectious disease transmission, nutrition and coercion. Due in part to differential wealth of inmates and their support networks on entering prison, and in part to the accumulation of authority and material wealth within prison, we found enormous inequity in the standard of living among prisoners at each site. In the context of such inequities, failure of the Zambian prison system to provide basic necessities (including adequate and appropriate forms of nutrition, or access to quality health care) contributed to high rates of inmate-led and officer-led coercion with direct implications for health and access to healthcare. CONCLUSIONS: This systems-oriented analysis provides a more comprehensive picture of the way resource shortages and human interactions within Zambian prisons interact and affect inmate and officer health. While not a panacea, our findings highlight some strategic entry-points for important upstream and downstream reforms including urgent improvement in the availability of human resources for health; strengthening of facility-based health services systems and more comprehensive pre-service health education for prison officers.
Health and healthcare access among Zambia's female prisoners: a health systems analysis.
(2016-Sep-26) Topp SM; Moonga CN; Mudenda C; Luo N; Kaingu M; Chileshe C; Magwende G; Heymann JS; Henostroza G; University of Alabama at Birmingham, Birmingham, AL, USA.; College of Public Health Medical and Veterinary Sciences, James Cook University, Townsville, 4812, Australia. globalstopp@gmail.com.; ZPS Headquarters, PO Box 80926, Kabwe, Zambia.; College of Public Health Medical and Veterinary Sciences, James Cook University, Townsville, 4812, Australia.; School of Public Health, University of California, LA, Los Angeles, CA, USA.; c/- CAPAH, National Assembly Parliament Buildings, PO Box 31299, Lusaka, Zambia.; Centre for Infectious Disease Research in Zambia, PO Box 30346, Lusaka, Zambia. globalstopp@gmail.com.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
BACKGROUND: Research exploring the drivers of health outcomes of women who are in prison in low- and middle-income settings is largely absent. This study aimed to identify and examine the interaction between structural, organisational and relational factors influencing Zambian women prisoners' health and healthcare access. METHODS: We conducted in-depth interviews of 23 female prisoners across four prisons, as well as 21 prison officers and health care workers. The prisoners were selected in a multi-stage sampling design with a purposive selection of prisons followed by a random sampling of cells and of female inmates within cells. Largely inductive thematic analysis was guided by the concepts of dynamic interaction and emergent behaviour, drawn from the theory of complex adaptive systems. RESULTS: We identified compounding and generally negative effects on health and access to healthcare from three factors: i) systemic health resource shortfalls, ii) an implicit prioritization of male prisoners' health needs, and iii) chronic and unchecked patterns of both officer- and inmate-led victimisation. Specifically, women's access to health services was shaped by the interactions between lack of in-house clinics, privileged male prisoner access to limited transport options, and weak responsiveness by female officers to prisoner requests for healthcare. Further intensifying these interactions were prisoners' differential wealth and access to family support, and appointments of senior 'special stage' prisoners which enabled chronic victimisation of less wealthy or less powerful individuals. CONCLUSIONS: This systems-oriented analysis revealed how Zambian women's prisoners' health and access to healthcare is influenced by weak resourcing for prisoner health, administrative biases, and a prevailing organisational and inmate culture. Findings highlight the urgent need for investment in structural improvements in health service availability but also interventions to reform the organisational culture which shapes officers' understanding and responsiveness to women prisoners' health needs.
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.
Mapping the Zambian prison health system: An analysis of key structural determinants.
(2017-Jul) Topp SM; Moonga CN; Luo N; Kaingu M; Chileshe C; Magwende G; Henostroza G; a College of Public Health, Medical and Veterinary Sciences, James Cook University , Townsville , QLD , Australia.; e School of Medicine, University of Alabama at Birmingham , Birmingham , AL , USA.; c Coalition of African Parliamentarians Against HIV/AIDS (CAPAH) , National Assembly Parliament Buildings , Lusaka , Zambia.; b Centre for Infectious Disease Research in Zambia , Lusaka , Zambia.; d ZPS Headquarters , Kabwe , Zambia.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
Health and health service access in Zambian prisons are in a state of 'chronic emergency'. This study aimed to identify major structural barriers to strengthening the prison health systems. A case-based analysis drew on key informant interviews (n = 7), memos generated during workshops (n = 4) document review and investigator experience. Structural determinants were defined as national or macro-level contextual and material factors directly or indirectly influencing prison health services. The analysis revealed that despite an favourable legal framework, four major and intersecting structural factors undermined the Zambian prison health system. Lack of health financing was a central and underlying challenge. Weak health governance due to an undermanned prisons health directorate impeded planning, inter-sectoral coordination, and recruitment and retention of human resources for health. Outdated prison infrastructure simultaneously contributed to high rates of preventable disease related to overcrowding and lack of basic hygiene. These findings flag the need for policy and administrative reform to establish strong mechanisms for domestic prison health financing and enable proactive prison health governance, planning and coordination.
Peer community health workers improve HIV testing and ART linkage among key populations in Zambia: retrospective observational results from the Z-CHECK project, 2019-2020.
(2022-Nov) Lindsay BR; Mwango L; Toeque MG; Malupande SL; Nkhuwa E; Moonga CN; Chilambe A; Sakala H; Kafunda I; Olowski P; Olufunso A; Okuku J; Kancheya N; Mumba D; Hachaambwa L; Sheneberger R; Blanco N; Lavoie MC; Claassen CW; Center for International Health Education and Biosecurity, MGIC-an affiliate of the University of Maryland Baltimore, Lusaka, Zambia.; U.S. Centers for Disease Control and Prevention Zambia, Lusaka, Zambia.; Centre for Infectious Disease, Research in Zambia (CIDRZ), Lusaka, Zambia.; National AIDS/TB/STI Council Zambia, Lusaka, Zambia.; Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, Maryland, USA.; Ciheb Zambia, Lusaka, Zambia.
INTRODUCTION: Zambia has made tremendous progress towards HIV epidemic control; however, gaps remain among key populations (KPs), such as female sex workers (FSWs), men who have sex with men (MSM), people who inject drugs (PWID) and people in prisons and enclosed settings due to cultural, social and legal barriers. The University of Maryland, Baltimore Zambia Community HIV Epidemic Control for Key Populations (Z-CHECK) project aimed to improve HIV case-finding, linkage and treatment adherence at the community level for KPs in Zambia. We describe Z-CHECK strategies and examine HIV positivity yield and antiretroviral therapy (ART) linkage among KPs to inform ongoing programme improvement. METHODS: Z-CHECK recruited, trained and deployed peer community health workers (CHWs) for KP groups, with ongoing mentorship in community engagement. CHWs offered HIV testing in safe spaces and escorted newly HIV-diagnosed clients for same-day ART initiation. Z-CHECK also reached out to KP community leaders and gatekeepers for KP mobilization and trained healthcare workers (HCWs) on KP services and sensitivity. We conducted a retrospective observational review of routinely collected aggregate data for KPs aged ≥15 years at high risk for HIV transmission across five districts in Zambia from January 2019 to December 2020. RESULTS: Z-CHECK provided HIV testing for 9211 KPs, of whom 2227 were HIV positive (positivity yield, 24%). Among these, 1901 (85%) were linked to ART; linkage for MSM, FSW, PWID and people in prisons and enclosed settings was 95%, 89%, 86% and 65%, respectively. Programme strategies that contributed to high positivity yield and linkage included the use of peer KP CHWs, social network testing strategies and opportunities for same-day ART initiation. Challenges to programme implementation included stigma and discrimination among HCWs, as well as KP CHW attrition, which may be explained by high mobility. CONCLUSIONS: Peer CHWs were highly effective at reaching KP communities, identifying persons living with HIV and linking them to care. Engaging KP community gatekeepers resulted in high diffusion of health messages and increased access to health resources. The mobility of CHWs and HCWs is a challenge for programme implementation. Innovative interventions are needed to support PWID and people in prisons and enclosed settings.
The health system accountability impact of prison health committees in Zambia.
(2018-Sep-24) Topp SM; Sharma A; Chileshe C; Magwende G; Henostroza G; Moonga CN; Centre for Infectious Disease Research in Zambia, PO Box 30346, Lusaka, Zambia.; Department of Global Health, University of Washington, Harris Hydraulics Laboratory, Box 357965, Seattle, WA, USA.; James Cook University, College of Public Health, Medical and Veterinary Sciences, Townsville, QLD, 4810, Australia. globalstopp@gmail.com.; University of Alabama at Birmingham, School of Medicine, Birmingham, AL, 35233, USA.; ZCS Headquarters, PO Box 80926, Kabwe, Zambia.; Centre for Infectious Disease Research in Zambia, PO Box 30346, Lusaka, Zambia. globalstopp@gmail.com.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
BACKGROUND: From 2013, the Zambian Corrections Service (ZCS) worked with partners to strengthen prison health systems and services. One component of that work led to the establishment of facility-based Prison Health Committees (PrHCs) comprising of both inmates and officers. We present findings from a nested evaluation of the impact of eight PrHCs 18 months after programme initiation. METHODS: In-depth-interviews were conducted with 11 government ministry and Zambia Corrections Service officials and 6 facility managers. Sixteen focus group discussions were convened separately with PrHC members (21 females and 51 males) and non-members (23 females and 46 males) in 8 facilities. Memos were generated from participant observation in workshops and meetings preceding and after implementation. We sought evidence of PrHC impact, refined with reference to Joshi's three domains of impact for social accountability interventions - state (represented by facility-based prison officials), society (represented here by inmates), and state-society relations (represented by inmate-prison official relations). Further analysis considered how project outcomes influenced structural dimensions of power, ability and justice relating to accountability. RESULTS: Data pointed to a compelling series of short- and mid-term outcomes, with positive impact on access to, and provision of, health services across most facilities. Inmates (members and non-members) reported being empowered via a combination of improved health literacy and committee members' newly-given authority to seek official redress for complaints and concerns. Inmates and officers described committees as improving inmate-officer relations by providing a forum for information exchange and shared decision making. Contributing factors included more consistent inmate-officer communications through committee meetings, which in turn enhanced trust and co-production of solutions to health problems. Nonetheless, long-term sustainability of accountability impacts may be undermined by permanently skewed power relations, high rates of inmate (and thus committee member) turnover, variable commitment from some officers in-charge, and the anticipated need for more oversight and resources to maintain members' skills and morale. CONCLUSION: Our study shows that PrHCs do have potential to facilitate improved social accountability in both state and societal domains and at their intersection, for an extremely vulnerable population. However, sustained and meaningful change will depend on a longer-term strategy that integrates structural reform and is delivered through meaningful cross-sectoral partnership.