Browsing by Author "Pry, Jake M."

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A pilot case-control study using a one health approach to evaluate behavioral, environmental, and occupational risk factors for chronic kidney disease of unknown etiology in Sri Lanka.
(2021) Pry, Jake M.; Jackson, Wendi; Rupasinghe, Ruwini; Lishanthe, Guneratne; Badurdeen, Zied; Abeysekara, Tilak; Chandrajith, Rohana; Smith, Woutrina; Wickramasinghe, Saumya
BACKGROUND: Chronic kidney disease of unknown etiology (CKDu) was first recognized in Sri Lanka in the early 1990s, and since then it has reached epidemic levels in the North Central Province of the country. The prevalence of CKDu is reportedly highest among communities that engage in chena and paddy farming, which is most often practiced in the dry zone including the North Central and East Central Provinces of Sri Lanka. Previous studies have suggested varied hypotheses for the etiology of CKDu; however, there is not yet a consensus on the primary risk factors, possibly due to disparate study designs, sample populations, and methodologies. METHODS: The goal of this pilot case-control study was to evaluate the relationships between key demographic, cultural, and occupational variables as risk factors for CKDu, with a primary interest in pesticide exposure both occupationally and through its potential use as an ingredient in brewed kasippu alcohol. An extensive one health focused survey was developed with in cooperation with the Centre for Research, Education, and Training on Kidney Diseases of Sri Lanka. RESULTS: A total of 56 CKDu cases and 54 control individuals were surveyed using a proctored, self-reported questionnaire. Occupational pesticide exposure and alcohol consumption were not found to be significant risk factors for CKDu. However, a statistically significant association with CKDu was observed with chewing betel (adjusted odds ratio [aOR]: 6.11, 95% confidence interval [CI]: 1.93, 19.35), age (aOR: 1.07, 95% CI: 1.02, 1.13), owning a pet dog (aOR: 3.74, 95% CI: 1.38, 10.11), water treatment (aOR: 3.68, 95% CI: 1.09, 12.43) and pests in the house (aOR: 5.81, 95% CI: 1.56, 21.60). CONCLUSIONS: The findings of this study suggest future research should focus on practices associated with chewing betel, potential animal interactions including pests in the home and pets, and risk factors associated with water. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s42522-020-00034-3.
Admission to the kangaroo mother care ward and maternal postpartum depression in Lusaka, Zambia: a randomised controlled trial study protocol
(2026-10-26) Manasyan, Albert; Lakhwani, Jyoti; Kapesa, Herbert; Menon, Anitha J.; Sharma, Anjali; Pry, Jake M.; Brown, Catherine; Tembo, Taniya; Carlo, Waldemar A.
Abstract Introduction: Postpartum depression (PPD) is a serious public health problem affecting 17% of women globally with higher rates (up to 40%) recorded in southern Africa. Admission to the neonatal intensive care unit (NICU) is a risk factor for PPD. The study aims to determine whether initiation of Kangaroo Mother Care (KMC) at the NICU followed by admission to the KMC Ward for continued support for more than 2 days before discharge home reduces maternal PPD and other maternal and infant adverse outcomes in low-resource settings. Methods and analysis: This study will enrol mother-infant dyads (n=612), fathers (up to n=612) and a purposive subset of mothers (n=24), fathers (n=24) and family members (n=24) who will complete in-depth interviews (IDIs). Mother-infant dyads will be recruited from the NICU at the Women and Newborn Hospital - University Teaching Hospitals in Lusaka, Zambia. Once deemed stable for admission to the KMC Ward as part of step-down care, mother-infant dyads will be randomised to either the control arm where they will remain at the KMC Ward ≤2 days per standard of care or the intervention arm where they will remain at the KMC Ward for >2 days. The primary outcome is maternal PPD at 6–8 weeks postnatal screened using the Edinburgh Postnatal Depression Scale (EPDS) screening tool. IDIs will explore the feasibility and barriers to practising KMC post-discharge from the perspective of the parents and other family members. Ethics and dissemination: The study was approved by the University of Zambia Biomedical Research Ethics Committee, the National Health Research Authority and the University of Alabama at Birmingham Institutional Review Board. A Data Safety Monitoring Board (DSMB) has been constituted. Dissemination will be via publications in peer-reviewed journals, conferences, social media and revision of national guidelines.
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.
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, Albert; Tembo, Tannia; Dale, Helen; Pry, Jake M.; Itoh, Megumi; Williamson, Dhelia; Kapesa, Herbert; Derado, Josip; Beard, Rachel S.; Iyer, Shilpa; Gass, Salome; Mwila, Annie; Herce, Michael E.
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.
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.
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, Jake M.; Mwila, Chilambwe ; Kapesa, Herbert; Mulabe, Musunge; Frimpong, Christiana ; Moono, Misinzo; Savory, Theodora; Bolton-Moore, Carolyn; Herce, Michael E.; Iyer, Shilpa
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, Michael E.; Bosomprah, Samuel; Masiye, Felix; Mweemba, Oliver; Edwards, Jessie K.; Mandyata, Chomba; Siame, Mmamulatelo ; Mwila, Chilambwe; Matenga, Tulani; Frimpong, Christiana ; Mugala, Anchindika; Mbewe, Peter; Shankalala, Perfect; Sichone, Pendasambo; Kasenge, Blessings; Chunga, Luanaledi ; Adams, Rupert; Banda, Brain; Mwamba, Daniel; Nachalwe, Namwinga; Agarwal, Mansi; Williams, Makeda J.; Tonwe, Veronica; Pry, Jake M.; Musheke, Maurice; Vinikoor, Michael; Mutale, Wilbroad
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).
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.
Pilot Implementation of a User-Driven, Web-Based Application Designed to Improve Sexual Health Knowledge and Communication Among Young Zambians: Mixed Methods Study.
(2022-Jul-07) Sharma, Anjali; Mwamba, Chanda; Ng'andu, Mwila; Kamanga, Vikwato ; Mendamenda, Mayamiko Z.; Azgad, Yael; Jabbie, Zainab; Chipungu, Jenala; Pry, Jake M.
BACKGROUND: Digital health interventions show promise in improving the uptake of HIV services among adolescents and young people aged 15 to 24 years in sub-Saharan Africa. OBJECTIVE: This study aimed to pilot-test a theory-based, empirically grounded web-based application designed to increase condom-related knowledge, sexual and reproductive health (SRH) communication, and healthier choices among young Zambians. METHODS: We conducted a pre-post quasi-experimental evaluation of the user-driven Be in the Know Zambia (BITKZ) web application using web-based surveys and in-depth interviews (IDIs) on the phone. We enrolled participants using social media advertisements. Our final analysis set comprised 46.04% (749/1627) of participants in the intervention group (which received the BITKZ link) and 53.96% (878/1627) of participants in the comparison group (no intervention). We collected survey data at study enrollment (baseline) and 5 weeks after the first enrollment in each group. Approximately 85% (637/749) of BITKZ users completed a user survey, of whom 9.3% (59/637) participated in IDIs. We calculated the time interfacing with BITKZ using the application log files. We conducted descriptive analyses to describe baseline characteristics and the user experience. At the endline, we assessed association using a t test and adjusted logistic regression for binary outcomes and ordinal regression for ordered outcomes, conditioning on age, sex, marital status, and employment status. We used adjusted average treatment effects (aATE) to assess the effects of BITKZ intervention. We conducted rapid matrix analyses of IDI transcripts in Microsoft Excel, sorting the data by theme, gender, and experience rating. RESULTS: Users rated BITKZ highly (excellent: 352/609, 57.8%; good: 218/609, 35.8%). At the endline, the intervention group had a higher level of knowledge related to condoms (adjusted odds ratio [aOR]: 1.35, 95% CI 1.06-1.69) and on wearing condoms correctly (aOR: 1.23, 95% CI 1.02-1.49). Those who had full-time employment had increased odds of knowing how to wear condoms correctly (aOR: 1.67, 95% CI 1.06-2.63) compared with those who reported being unemployed, as did men when compared with women (aOR: 1.92, 95% CI 1.59-2.31). Those in the intervention group were more likely to score higher for intention to test for sexually transmitted infections (STIs; aATE 0.21; P=.01) and HIV (aATE 0.32; P=.05), as well as for resisting peer pressure (aATE 2.64; P=.02). IDIs corroborated increased knowledge on correct condom use among men and female condoms among women, awareness of STIs and testing, and resistance to peer pressure. Interviewees provided examples of more open SRH communication with partners and peers and of considering, adopting, and influencing others to adopt healthier behaviors. CONCLUSIONS: Despite the high baseline awareness of SRH among Zambian adolescents and young people with internet access, BITKZ provided modest gains in condom-related knowledge, resistance to peer pressure, and intention to test for STIs and HIV.
Programme science in action: lessons from an observational study of HIV prevention programming for key populations in Lusaka, Zambia.
(2024-Jul) Sikazwe, Izukanji; Musheke, Maurice; Chiyenu, Kanema ; Ngosa, Benard; Pry, Jake M.; Mulubwa, Chama; Zimba, Martin; Sakala, Martin; Sakala, Mphatso; Somwe, Paul; Nyirenda, Goodwin; Savory, Theodora; Bolton, Carolyn; Herce, Michael E.
INTRODUCTION: Optimizing uptake of pre-exposure prophylaxis (PrEP) for individuals at risk of HIV acquisition has been challenging despite clear scientific evidence and normative guidelines, particularly for key populations (KPs) such as men who have sex with men (MSM), female sex workers (FSWs), transgender (TG) people and persons who inject drugs (PWID). Applying an iterative Programme Science cycle, building on the effective programme coverage framework, we describe the approach used by the Centre for Infectious Disease Research in Zambia (CIDRZ) to scale up PrEP delivery and address inequities in PrEP access for KP in Lusaka, Zambia. METHODS: In 2019, CIDRZ partnered with 10 local KP civil society organizations (CSOs) and the Ministry of Health (MOH) to offer HIV services within KP-designated community safe spaces. KP CSO partners led KP mobilization, managed safe spaces and delivered peer support; MOH organized clinicians and clinical commodities; and CIDRZ provided technical oversight. In December 2021, we introduced a community-based intervention focused on PrEP delivery in venues where KP socialize. We collected routine programme data from September 2019 to June 2023 using programme-specific tools and the national electronic health record. We estimated the before-after effects of our intervention on PrEP uptake, continuation and equity for KP using descriptive statistics and interrupted time series regression, and used mixed-effects regression to estimate marginal probabilities of PrEP continuity. RESULTS: Most (25,658) of the 38,307 (67.0%) Key Population Investment Fund beneficiaries were reached with HIV prevention services at community-based venues. In total, 23,527 (61.4%) received HIV testing services, with 15,508 (65.9%) testing HIV negative and found PrEP eligible, and 15,241 (98.3%) initiating PrEP. Across all programme quarters and KP types, PrEP uptake was >90%. After introducing venue-based PrEP delivery, PrEP uptake (98.7% after vs. 96.5% before, p < 0.001) and the number of initiations (p = 0.014) increased significantly. The proportion of KP with ≥1 PrEP continuation visit within 6 months of initiation was unchanged post-intervention (46.7%, 95% confidence interval [CI]: 45.7%, 47.6%) versus pre-intervention (47.2%, 95% CI: 45.4%, 49.1%). CONCLUSIONS: Applying Programme Science principles, we demonstrate how decentralizing HIV prevention services to KP venues and safe spaces in partnership with KP CSOs enabled successful community-based PrEP delivery beyond the reach of traditional facility-based services.
The impact of the SKILLZ intervention on sexual and reproductive health empowerment among Zambian adolescent girls and young women: results of a cluster randomized controlled trial.
(2025-Jun-05) Sheira, Lila A.; Mulubwa, Chama; Chiu, Calvin; Chipungu, Jenala; Coakley, Chelsea; Smith, Helene; Upadhyay, Ushma D.; Chilambe, Chansa; Chibwe, Besa; Pry, Jake M.; Mkandawire, Boyd; Musonda, Maggie; Bolton-Moore, Carolyn ; Liu, Jenny
BACKGROUND: Zambian adolescent girls and young women (AGYW, age 15–24) experience a disproportionate burden of HIV and unintended pregnancy. Sports-based interventions, which affect sexual health behaviors via improving sexual and reproductive empowerment, may be an innovative and effective approach for promoting HIV and unintended pregnancy prevention. We sought to evaluate the impact of a peer-led, sports-based intervention on sexual and reproductive empowerment among in-school Zambian adolescent girls and young women. METHODS: Data come from the ‘SKILLZ’ study, a cluster randomized controlled trial evaluating the impact of a peer-led, sports-based health education program. Sexual and reproductive empowerment, a secondary outcome of SKILLZ, was measured via the 23-item Sexual and Reproductive Empowerment for adolescents and young adults scale (range 0–92, higher = more sexual and reproductive empowerment) three times over approximately 24 months. We conducted a difference-in-differences analysis to evaluate intervention impact over time. RESULTS: The study enrolled 2,153 AGYW (1134 intervention; 1019 control) across 46 secondary schools in Lusaka. Median age at baseline was 17; participants were largely unmarried (96%), with 20% reporting any sexual activity. By endline, nearly 40% reported being sexually active. Between baseline and midline, attending an intervention school was associated with a 6.21-point increase in overall score calculated using the imputed sample (standard error [SE]: 0.75, CONCLUSION: The intervention moderately impacted Sexual and Reproductive Empowerment scores; results were magnified among sexually active AGYW. Given adolescence is a critical period for sexuality and gender programming, as well as for sexual debut, empowerment interventions at schools may support downstream sexual health behaviors that will impact the life-course of AGYW. TRIAL REGISTRATION: This study was registered in ClinicalTrials.gov (NCT04429061) on March 17th, 2020. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12978-025-02046-6.