Browsing by Author "Mulenga, Lloyd"

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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.
Geospatial Patterns of Progress towards UNAIDS "95-95-95" Targets and Community Vulnerability in Zambia.
(2023-Apr-26) Cuadros, Diego F.; Chowdhury, Tuhin; Milali, Masabho; Citron, Daniel; Nyimbili, Sulani; Vlahakis, Natalie; Savory, Theodora; Mulenga, Lloyd; Sivile, Suilanji; Zyambo, Khozya; Bershteyn, Anna
In sub-Saharan Africa, HIV/AIDS remains a leading cause of death. The UNAIDS established the "95-95-95" targets to improve HIV care continuum outcomes. Using geospatial data from the Zambia Population-based HIV Impact Assessment (ZAMPHIA), this study aims to investigate geospatial patterns in the "95-95-95" indicators and individual-level determinants that impede HIV care continuum in vulnerable communities, providing insights into the factors associated with gaps. This study used data from the 2016 ZAMPHIA to investigate the geospatial distribution and individual-level determinants of engagement across the HIV care continuum in Zambia. Gaussian kernel interpolation and optimized hotspot analysis were used to identify geospatial patterns in the HIV care continuum, while geospatial k-means clustering was used to partition areas into clusters. The study also assessed healthcare availability, access, and social determinants of healthcare utilization. Multiple logistic regression models were used to examine the association between selected sociodemographic and behavioral covariates and the three main outcomes of study. Varied progress towards the "95-95-95" targets were observed in different regions of Zambia. Each "95" displayed a unique geographic pattern, independent of HIV prevalence, resulting in four distinct geographic clusters. Factors associated with gaps in the "95s" include younger age, male sex, and low wealth, with younger individuals having higher odds of not being on ART and having detectable viral loads. Our study revealed significant spatial heterogeneity in the HIV care continuum in Zambia, with different regions exhibiting unique geographic patterns and levels of performance in the "95-95-95" targets, highlighting the need for geospatial tailored interventions to address the specific needs of different subnational regions. These findings underscore the importance of addressing differential regional gaps in HIV diagnosis, enhancing community-level factors, and developing innovative strategies to improve local HIV care continuum outcomes.
Geospatial patterns of progress towards UNAIDS '95-95-95' targets and community vulnerability in Zambia: insights from population-based HIV impact assessments.
(2023-Oct) Cuadros, Diego F.; Chowdhury, Tuhin; Milali, Masabho; Citron, Daniel T.; Nyimbili, Sulani; Vlahakis, Natalie ; Savory, Theodora; Mulenga, Lloyd; Sivile, Suilanji; Zyambo, Khozya D.; Bershteyn, Anna
INTRODUCTION: In sub-Saharan Africa, HIV/AIDS remains a leading cause of death. The UNAIDS established the '95-95-95' targets to improve HIV care continuum outcomes. Using geospatial data from the Zambia Population-based HIV Impact Assessment (ZAMPHIA), this study aims to investigate geospatial patterns in the '95-95-95' indicators and individual-level determinants that impede HIV care continuum in vulnerable communities, providing insights into the factors associated with gaps. METHODS: This study used data from the 2016 ZAMPHIA to investigate the geospatial distribution and individual-level determinants of engagement across the HIV care continuum in Zambia. Gaussian kernel interpolation and optimised hotspot analysis were used to identify geospatial patterns in the HIV care continuum, while geospatial k-means clustering was used to partition areas into clusters. The study also assessed healthcare availability, access and social determinants of healthcare utilisation. Multiple logistic regression models were used to examine the association between selected sociodemographic and behavioural covariates and the three main outcomes of study. RESULTS: Varied progress towards the '95-95-95' targets were observed in different regions of Zambia. Each '95' displayed a unique geographical pattern, independent of HIV prevalence, resulting in four distinct geographical clusters. Factors associated with gaps in the '95s' include younger age, male sex, and low wealth, with younger individuals having higher odds of not being on antiretroviral therapy and having detectable viral loads. CONCLUSIONS: Our study revealed significant spatial heterogeneity in the HIV care continuum in Zambia, with different regions exhibiting unique geographical patterns and levels of performance in the '95-95-95' targets, highlighting the need for geospatial tailored interventions to address the specific needs of different subnational regions. These findings underscore the importance of addressing differential regional gaps in HIV diagnosis, enhancing community-level factors and developing innovative strategies to improve local HIV care continuum outcomes.
Liver steatosis and metabolic dysfunction-associated fatty liver disease among HIV-positive and negative adults in urban Zambia.
(2022-Jul) Chihota, Belinda V.; Riebensahm, Carlotta; Muula, Guy; Sinkala, Edford; Chilengi, Roma; Mulenga, Lloyd; Bosomprah, Samuel; Vinikoor, Michael J.; Bolton-Moore, Carolyn; Egger, Matthias; Rauch, Andri; Berzigotti, Annalisa; Wandeler, Gilles
INTRODUCTION: The growing importance of non-communicable diseases (NCDs) and high HIV prevalence in urban African settings may increase the burden of metabolic dysfunction-associated fatty liver disease (MAFLD). We assessed liver steatosis among HIV-positive and negative adults in urban Zambia. METHODS: Adults 30 years and older who were newly diagnosed with HIV, or tested HIV-negative at two primary care clinics in Lusaka, Zambia, were assessed for liver steatosis. Cardiometabolic data were collected through comprehensive clinical and laboratory assessments. Transient elastography was performed to measure controlled-attenuation parameter (≥248 dB/m). We used multivariable logistic regression models to determine the factors associated with the presence of steatosis. RESULTS: We enrolled 381 patients, including 154 (40%) antiretroviral therapy-naïve people living with HIV (PLWH) with a median CD4+ count of 247 cells/mm CONCLUSIONS: The prevalence of liver steatosis in this urban cohort of HIV-positive and negative adults in Zambia was low, despite a large proportion of patients with high BMI and central obesity. Our study is among the first to report data on MAFLD among adults in Africa, demonstrating that metabolic risk factors are key drivers of liver steatosis and supporting the adoption of the criteria for MAFLD in African populations.
Validation of a National Pediatric HIV Risk Screening Tool at 31 Health Facilities in Zambia
(2026-9-7) Canepa, Hannah M.; Medley, Amy; Gutreuter, Steve; Connolly, Helen; Itoh, Megumi; Aholou, Tiffiany; Rabold, Elizabeth; Torre, Lindsey; Nkwemu, Kennedy; Chisuwo, Edgar; Haamuleya, Francis; Lungu, Catherine; Hansombo, Moono; Nelson, Rob; Vlahakis, Natalie; Chisenga, Tina; Mulenga, Lloyd; Mbulo, Levi; Gross, Jessica
Background: To improve testing efficiency, Zambia introduced a national pediatric human immunodeficiency virus (HIV) Risk Screening Tool (HRST) in 2019. However, concerns about its sensitivity led to its suspension in 2021 pending formal evaluation. We therefore undertook a formal validation of this tool to assess its diagnostic performance. Methods: We conducted a cross-sectional evaluation from February 2021 to March 2022 in 31 health facilities across Lusaka, Southern and Western Provinces. Children aged 2-14 years were screened using the HRST, and all subsequently underwent HIV testing to estimate the tool's sensitivity and specificity. L1-regularized logistic regression was used to identify the most predictive screening questions to develop an optimized tool. Focus group discussions with 85 healthcare providers explored implementation experiences. We also estimated unit costs for HRST-based screening and universal testing and compared these with published cost estimates for provider-assisted HIV self-testing. Results: Among 15,431 children tested, 90 (0.58%) were HIV-positive. The 6-question HRST demonstrated 80.0% sensitivity and 71.0% specificity. An optimized 4-question tool showed similar performance (77.8% sensitivity, 73.2% specificity). Providers reported that the HRST supported targeted testing and workflow efficiency, but highlighted challenges related to consent, disclosure and caregiver knowledge. Estimated unit costs per child tested were $2.25 for universal testing, $0.39 for HRST-based screening and $3.08 for HIV self-testing. Conclusion: Although the HRST improves testing efficiency, its moderate sensitivity underscores the risk of missed diagnoses when used alone. Cost and implementation findings support a differentiated pediatric HIV testing strategy that deploys universal testing, risk-based screening, or HIV self-testing based on local capacity and resource constraints.