Browsing by Author "Pry JM"

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A controlled study to assess the effects of a Fast Track (FT) service delivery model among stable HIV patients in Lusaka Zambia.
(2022) Bolton Moore C; Pry JM; Mukumbwa-Mwenechanya M; Eshun-Wilson I; Topp S; Mwamba C; Roy M; Sohn H; Dowdy DW; Padian N; Holmes CB; Geng EH; Sikazwe I
Fast Track models-in which patients coming to facility to pick up medications minimize waiting times through foregoing clinical review and collecting pre-packaged medications-present a potential strategy to reduce the burden of treatment. We examine effects of a Fast Track model (FT) in a real-world clinical HIV treatment program on retention to care comparing two clinics initiating FT care to five similar (in size and health care level), standard of care clinics in Zambia. Within each clinic, we selected a systematic sample of patients meeting FT eligibility to follow prospectively for retention using both electronic medical records as well as targeted chart review. We used a variety of methods including Kaplan Meier (KM) stratified by FT, to compare time to first late pick up, exploring late thresholds at >7, >14 and >28 days, Cox proportional hazards to describe associations between FT and late pick up, and linear mixed effects regression to assess the association of FT with medication possession ratio. A total of 905 participants were enrolled with a median age of 40 years (interquartile range [IQR]: 34-46 years), 67.1% were female, median CD4 count was 499 cells/mm3 (IQR: 354-691), and median time on ART was 5 years (IQR: 3-7). During the one-year follow-up period FT participants had a significantly reduced cumulative incidence of being >7 days late for ART pick-up (0.36, 95% confidence interval [CI]: 0.31-0.41) compared to control participants (0.66; 95% CI: 0.57-0.65). This trend held for >28 days late for ART pick-up appointments, at 23% (95% CI: 18%-28%) among intervention participants and 54% (95% CI: 47%-61%) among control participants. FT models significantly improved timely ART pick up among study participants. The apparent synergistic relationship between refill time and other elements of the FT suggest that FT may enhance the effects of extending visit spacing/multi-month scripting alone. ClinicalTrials.gov Identifier: NCT02776254 https://clinicaltrials.gov/ct2/show/NCT02776254.
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 K; Pry JM; Mody A; Rice B; Bukankala C; Eshun-Wilson I; Mutale J; Simbeza S; Beres LK; Mukamba N; Mukumbwa-Mwenechanya M; Mwamba D; Sharma A; Wringe A; Hargreaves J; Bolton-Moore C; Holmes C; Sikazwe IT; Geng E
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).
Corrigendum to "Drivers of decision-making for future adult vaccines: a best-worst scaling among community members and health care workers in Zambia" [Vaccine 70 (2026) 128003].
(2026-Jun-03) Le Tourneau N; Sharma A; Pry JM; Haambokoma M; Shamoya B; Sikombe K; Simbeza SS; Zulu N; Geng EH; Eshun-Wilson I; Kerkhoff AD
Corrigendum to "Intention to receive new vaccines post-COVID-19 pandemic among adults and health workers in Lusaka, Zambia" ["Vaccine 50 (2025) 126846].
(2026-May-31) Sharma A; Kerkhoff AD; Haambokoma M; Shamoya B; Sikombe K; Simbeza SS; Zulu N; Geng EH; Eshun-Wilsonova I; Le Tourneau N; Pry JM
Cross-sectional study to assess depression among healthcare workers in Lusaka, Zambia during the COVID-19 pandemic.
(2023-Apr-05) Simbeza S; Mutale J; Mulabe M; Jere L; Bukankala C; Sikombe K; Sikazwe I; Bolton-Moore C; Mody A; Geng EH; Sharma A; Beres LK; Pry JM
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.
Estimating potential silent transfer using baseline viral load measures among people presenting as new to HIV care in Lusaka, Zambia: a cross-sectional study.
(2023-May-25) Pry JM; Mwila C; Kapesa H; Mulabe M; Frimpong C; Moono M; Savory T; Bolton-Moore C; Herce ME; Iyer S
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.
Evaluation of kidney function among people living with HIV initiating antiretroviral therapy in Zambia.
(2022) Pry JM; Vinikoor MJ; Bolton Moore C; Roy M; Mody A; Sikazwe I; Sharma A; Chihota B; Duran-Frigola M; Daultrey H; Mutale J; Kerkhoff AD; Geng EH; Pollock BH; Vera JH
As the response to the HIV epidemic in sub-Saharan Africa continues to mature, a growing number of people living with HIV (PLHIV) are aging and risk for non-communicable diseases increases. Routine laboratory tests of serum creatinine have been conducted to assess HIV treatment (ART) suitability. Here we utilize those measures to assess kidney function impairment among those initiating ART. Identification of non-communicable disease (NCD) risks among those in HIV care creates opportunity to improve public health through care referral and/or NCD/HIV care integration. We estimated glomerular filtration rates (eGFR) using routinely collected serum creatinine measures among a cohort of PLHIV with an HIV care visit at one of 113 Centre for Infectious Disease Research Zambia (CIDRZ) supported sites between January 1, 2011 and December 31, 2017, across seven of the ten provinces in Zambia. We used mixed-effect Poisson regression to assess predictors of eGFR <60ml/min/1.73m2 allowing random effects at the individual and facility level. Additionally, we assessed agreement between four eGFR formulae with unadjusted CKD-EPI as a standard using Scott/Fleiss method across five categories of kidney function. A total of 72,933 observations among 68,534 individuals met the inclusion criteria for analysis. Of the 68,534, the majority were female 41,042 (59.8%), the median age was 34 (interquartile range [IQR]: 28-40), and median CD4 cell count was 292 (IQR: 162-435). The proportion of individuals with an eGFR <60ml/min/1.73m2 was 6.9% (95% CI: 6.7-7.1%) according to the unadjusted CKD-EPI equation. There was variation in agreement across eGFR formulas considered compared to unadjusted CKD-EPI (χ2 p-value <0.001). Estimated GFR less than 60ml/min/1.73m2, per the unadjusted CKD-EPI equation, was significantly associated with age, sex, body mass index, and blood pressure. Using routine serum creatinine measures, we identified a significant proportion of individuals with eGFR indicating moderate or great kidney function impairment among PLHIV initiating ART in Zambia. It is possible that differentiated service delivery models could be developed to address this subset of those in HIV care with increased risk of chronic kidney disease.
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 K; Le Tourneau N; Rice B; Pry JM; Simbeza S; Beres LK; Sharma A; Mukamba N; Wringe A; Hargreaves JR; Mutale J; Moore CB; Sikazwe I; Geng E; Mody A
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.
Improving PrEP access for adolescent girls and young women: a descriptive analysis of community-based PrEP delivery in the DREAMS programme in Zambia.
(2025-Jul) Musheke M; Pry JM; Sikazwe I; Muyunda WJ; Chiyenu K; Siame CM; Khondowe WK; Mushiki B; Mwaba MM; Zulu P; Mwape F; Siamasuku B; Shula D; Mweemba MB; Kanene C; Phiri A; Herce ME
INTRODUCTION: Despite being at high risk of HIV acquisition, access to pre-exposure prophylaxis (PrEP) among adolescent girls and young women (AGYW) is low in Zambia because PrEP is traditionally delivered in clinical settings. We describe the effects of community centres supported by the Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe (DREAMS) initiative on PrEP outcomes in Zambia and examine factors associated with PrEP continuation. METHODS: We collected individual-level PrEP data for AGYW aged 15-24 years at risk of HIV acquisition and enrolled in DREAMS in seven districts of Zambia between August 2022 and August 2024. We used Pearson's Chi-squared test to examine differences in beneficiary characteristics between clients with a PrEP initiation visit and ≥ 2 PrEP visits (i.e. an initiation plus ≥ 1 return visit), and mixed effects Poisson regression modelling to estimate the association between DREAMS enrolment criteria and PrEP continuation (defined as ≥ 1 PrEP visit within 180 days of initiation). We also estimated the marginal probability of PrEP continuation by number of DREAMS enrolment criteria and used Kaplan-Meier methods to estimate the time to the first PrEP return visit by client age band. RESULTS: Between 11 August 2022 and 23 August 2024, 15,502 AGYW aged 15-24 years were screened for PrEP eligibility, of whom 15,072 (97.2%) initiated PrEP per national guidelines. Of those initiating PrEP, 9807 (65.1%) had sufficient follow-up time to allow for observation of a PrEP return visit. The proportion of AGYW who had ≥ 1 PrEP return visit within 180 days of initiation was 59.0% (n/N = 5706/9675). Across age bands, the percent probability of having a PrEP return visit within 180 days of initiation was highest among clients who reported ≥ 4 DREAMS enrolment criteria at 91.7% (95% CI: 70.7, 112.7%) for clients aged 15-19 years and 83.6% (95% CI: 61.1, 106.2%) for clients aged 20-24 years. Overall, 41.5% of clients had a first PrEP return visit between 21 and 42 days of PrEP initiation. CONCLUSIONS: The high number and proportion of AGYW initiated on PrEP suggests that decentralising PrEP services to DREAMS community centres has the potential to improve PrEP access among AGYW. Increasing HIV risk perception among AGYW may improve PrEP continuation.
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 JM; Sikombe K; Mody A; Iyer S; Mutale J; Vlahakis N; Savory T; Wa Mwanza M; Mweebo K; Mwila A; Mwale C; Mukumbwa-Mwenechanya M; Kerkhoff AD; Sikazwe I; Bolton Moore C; Mwamba D; Geng EH; Herce ME
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.
Neonatal mortality risk of vulnerable newborns by fine stratum of gestational age and birthweight for 230 679 live births in nine low- and middle-income countries, 2000-2017.
(2024-Jan-16) Hazel EA; Erchick DJ; Katz J; Lee ACC; Diaz M; Wu LSF; West KP; Shamim AA; Christian P; Ali H; Baqui AH; Saha SK; Ahmed S; Roy AD; Silveira MF; Buffarini R; Shapiro R; Zash R; Kolsteren P; Lachat C; Huybregts L; Roberfroid D; Zhu Z; Zeng L; Gebreyesus SH; Tesfamariam K; Adu-Afarwuah S; Dewey KG; Gyaase S; Poku-Asante K; Boamah Kaali E; Jack D; Ravilla T; Tielsch J; Taneja S; Chowdhury R; Ashorn P; Maleta K; Ashorn U; Mangani C; Mullany LC; Khatry SK; Ramokolo V; Zembe-Mkabile W; Fawzi WW; Wang D; Schmiegelow C; Minja D; Msemo OA; Lusingu JPA; Smith ER; Masanja H; Mongkolchati A; Keentupthai P; Kakuru A; Kajubi R; Semrau K; Hamer DH; Manasyan A; Pry JM; Chasekwa B; Humphrey J; Black RE
OBJECTIVE: To describe the mortality risks by fine strata of gestational age and birthweight among 230 679 live births in nine low- and middle-income countries (LMICs) from 2000 to 2017. DESIGN: Descriptive multi-country secondary data analysis. SETTING: Nine LMICs in sub-Saharan Africa, Southern and Eastern Asia, and Latin America. POPULATION: Liveborn infants from 15 population-based cohorts. METHODS: Subnational, population-based studies with high-quality birth outcome data were invited to join the Vulnerable Newborn Measurement Collaboration. All studies included birthweight, gestational age measured by ultrasound or last menstrual period, infant sex and neonatal survival. We defined adequate birthweight as 2500-3999 g (reference category), macrosomia as ≥4000 g, moderate low as 1500-2499 g and very low birthweight as <1500 g. We analysed fine strata classifications of preterm, term and post-term: ≥42 MAIN OUTCOME MEASURES: Median and interquartile ranges by study for neonatal mortality rates (NMR) and relative risks (RR). We also performed meta-analysis for the relative mortality risks with 95% confidence intervals (CIs) by the fine categories, stratified by regional study setting (sub-Saharan Africa and Southern Asia) and study-level NMR (≤25 versus >25 neonatal deaths per 1000 live births). RESULTS: We found a dose-response relationship between lower gestational ages and birthweights with increasing neonatal mortality risks. The highest NMR and RR were among preterm babies born at <28 weeks (median NMR 359.2 per 1000 live births; RR 18.0, 95% CI 8.6-37.6) and very low birthweight (462.8 per 1000 live births; RR 43.4, 95% CI 29.5-63.9). We found no statistically significant neonatal mortality risk for macrosomia (RR 1.1, 95% CI 0.6-3.0) but a statistically significant risk for all preterm babies, post-term babies (RR 1.3, 95% CI 1.1-1.5) and babies born at 37 CONCLUSIONS: In addition to tracking vulnerable newborn types, monitoring finer categories of birthweight and gestational age will allow for better understanding of the predictors, interventions and health outcomes for vulnerable newborns. It is imperative that all newborns from live births and stillbirths have an accurate recorded weight and gestational age to track maternal and neonatal health and optimise prevention and care of vulnerable newborns.
Neonatal mortality risk of vulnerable newborns: A descriptive analysis of subnational, population-based birth cohorts for 238 203 live births in low- and middle-income settings from 2000 to 2017.
(2023-May-08) Hazel EA; Erchick DJ; Katz J; Lee ACC; Diaz M; Wu LSF; West KP; Shamim AA; Christian P; Ali H; Baqui AH; Saha SK; Ahmed S; Roy AD; Silveira MF; Buffarini R; Shapiro R; Zash R; Kolsteren P; Lachat C; Huybregts L; Roberfroid D; Zhu Z; Zeng L; Gebreyesus SH; Tesfamariam K; Adu-Afarwuah S; Dewey KG; Gyaase S; Poku-Asante K; Boamah Kaali E; Jack D; Ravilla T; Tielsch J; Taneja S; Chowdhury R; Ashorn P; Maleta K; Ashorn U; Mangani C; Mullany LC; Khatry SK; Ramokolo V; Zembe-Mkabile W; Fawzi WW; Wang D; Schmiegelow C; Minja D; Msemo OA; Lusingu JPA; Smith ER; Masanja H; Mongkolchati A; Keentupthai P; Kakuru A; Kajubi R; Semrau K; Hamer DH; Manasyan A; Pry JM; Chasekwa B; Humphrey J; Black RE
OBJECTIVE: We aimed to understand the mortality risks of vulnerable newborns (defined as preterm and/or born weighing smaller or larger compared to a standard population), in low- and middle-income countries (LMICs). DESIGN: Descriptive multi-country, secondary analysis of individual-level study data of babies born since 2000. SETTING: Sixteen subnational, population-based studies from nine LMICs in sub-Saharan Africa, Southern and Eastern Asia, and Latin America. POPULATION: Live birth neonates. METHODS: We categorically defined five vulnerable newborn types based on size (large- or appropriate- or small-for-gestational age [LGA, AGA, SGA]), and term (T) and preterm (PT): T + LGA, T + SGA, PT + LGA, PT + AGA, and PT + SGA, with T + AGA (reference). A 10-type definition included low birthweight (LBW) and non-LBW, and a four-type definition collapsed AGA/LGA into one category. We performed imputation for missing birthweights in 13 of the studies. MAIN OUTCOME MEASURES: Median and interquartile ranges by study for the prevalence, mortality rates and relative mortality risks for the four, six and ten type classification. RESULTS: There were 238 203 live births with known neonatal status. Four of the six types had higher mortality risk: T + SGA (median relative risk [RR] 2.6, interquartile range [IQR] 2.0-2.9), PT + LGA (median RR 7.3, IQR 2.3-10.4), PT + AGA (median RR 6.0, IQR 4.4-13.2) and PT + SGA (median RR 10.4, IQR 8.6-13.9). T + SGA, PT + LGA and PT + AGA babies who were LBW, had higher risk compared with non-LBW babies. CONCLUSIONS: Small and/or preterm babies in LIMCs have a considerably increased mortality risk compared with babies born at term and larger. This classification system may advance the understanding of the social determinants and biomedical risk factors along with improved treatment that is critical for newborn health.
Patterns of person-centred communications in public HIV clinics: a latent class analysis using the Roter interaction analysis system.
(2023-Jul) Mukamba N; Mwamba C; Redkar S; Foloko M; Lumbo K; Nyirenda H; Roter DL; Mulabe M; Sharma A; Simbeza S; Sikombe K; Beres LK; Pry JM; Christopoulos K; Holmes CB; Geng EH; Sikazwe I; Bolton-Moore C; Mody A
INTRODUCTION: Poor client-provider communication is a critical barrier to long-term retention in care among people living with HIV. However, standardized assessments of this key metric are limited in Africa. We used the Roter Interaction Analysis System (RIAS) to quantitatively characterize patterns of person-centred communication (PCC) behaviours in Zambia. METHODS: We enrolled pairs of people living with HIV making routine HIV follow-up visit and their providers at 24 Ministry of Health-facilities supported by the Centre for Infectious Disease Research in Zambia in Lusaka province between August 2019 and November 2021. Client-provider encounters were audio-recorded and coded using RIAS by trained research staff. We performed latent class analysis to identify interactions with distinctive patterns of provider PCC behaviours (i.e. rapport building, person-centred counselling, PCC micropractices [e.g. brief empathy statements], assessing barriers to care, shared decision-making and leveraging discretionary power) and compared their distribution across client, provider, interaction and facility characteristics. RESULTS: We enrolled 478 people living with HIV and 139 providers (14% nurses, 73.6% clinical officers, 12.3% were medical officers). We identified four distinct profiles: (1) "Medically Oriented Interaction, Minimal PCC Behaviours" (47.6% of interactions) was characterized by medical discussion, minimal psychosocial/non-medical talk and low use of PCC behaviours; (2) "Balanced Medical/Non-medical Interaction, Low PCC Behaviours" (21.0%) was characterized by medical and non-medical discussion but limited use of other PCC behaviours; (3) "Medically Oriented Interaction, Good PCC Behaviours" (23.9%) was characterized by medically oriented discussion, more information-giving and increased use of PCC behaviours; and (4) "Highly person-centred Interaction" (7.5%) was characterized by both balanced medical/non-medical focus and the highest use of PCC behaviours. Nurse interactions were more likely to be characterized by more PCC behaviours (i.e. Class 3 or 4) (44.8%), followed by medical officers (33.9%) and clinical officers (27.3%) (p = 0.031). Longer interactions were also more likely to integrate more PCC behaviours (p < 0.001). CONCLUSIONS: PCC behaviours are relatively uncommon in HIV care in Zambia, and often limited to brief rapport-building statements and PCC micropractices. Strengthening PCC, such as shared decision-making and leveraging discretionary power to better accommodate client needs and preferences, may be an important strategy for improving the quality in HIV treatment programmes.
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 A; Mwamba C; Ng'andu M; Kamanga V; Zoonadi Mendamenda M; Azgad Y; Jabbie Z; Chipungu J; Pry JM
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.
Provider perspectives on patient-centredness: participatory formative research and rapid analysis methods to inform the design and implementation of a facility-based HIV care improvement intervention in Zambia.
(2023-Jul) Mwamba C; Beres LK; Mukamba N; Jere L; Foloko M; Lumbo K; Sikombe K; Simbeza S; Mody A; Pry JM; Holmes CB; Sikazwe I; Moore CB; Christopoulos K; Sharma A; Geng EH
INTRODUCTION: Implementation of patient-centred care (PCC) practices in HIV treatment depends on healthcare workers' (HCWs) perceptions of the acceptability, appropriateness and feasibility of such practices (e.g. use of intentional, metric-driven activities to improve patient experiences). METHODS: We applied rapid, rigorous formative research methods to refine a PCC intervention for future trial. In 2018, we conducted focus group discussions (FGDs) with 46 HCWs purposefully selected from two pilot sites. We elicited HCW perceptions of HIV service delivery, HCW motivation and perceived value of patient experience measures intended to improve PCC. FGDs utilized participatory methods to understand HCW responses to patient-reported care engagement challenges and Scholl's PCC Framework principles (e.g. seeing a patient as a unique person), enablers (e.g. care coordination) and activities (e.g. patient involvement). Our rapid analysis used analytic memos, thematic analysis, research team debriefs and HCW feedback to inform time-sensitive trial implementation. RESULTS: While HCWs nearly universally identified with and supported principles of PCC in both facilities, they raised practical barriers given the practice environment. HCWs described motivation to help patients, attached value to seeing positive health outcomes and the importance of teamwork. However, HCWs reported challenges with enablers needed to deliver PCC. HCWs cited a work culture characterized by differential power dynamics between cadres and departments restricting HCW autonomy and resource access. Barriers included inflexibility in accommodating individual patient needs due to high patient volumes, limited human resources, laboratory capacity, infrastructure and skills translating patient perspectives into practice. HCW motivation was negatively influenced by encounters with "difficult patients," and feeling "unappreciated" by management, resulting in cognitive dissonance between HCW beliefs and behaviours. However, the enactment of PCC values also occurred. Results suggested that PCC interventions should reduce practice barriers, highlighting the value of mentors who could help HCWs dynamically engage with health system constraints, to facilitate PCC. CONCLUSIONS: While HCWs perceived PCC principles as acceptable, they did not think it universally appropriate or feasible given the practice environment. Participatory and rapid methods provided timely insight that PCC interventions must provide clear and effective systems enabling PCC activities by measuring and mitigating relational and organizational constraints amenable to change such as inter-cadre coordination.
The Asanté™ HIV-1 Rapid Recency® Assay is reliable, feasible, and acceptable for use at the point-of-care in Lusaka, Zambia.
(2026) Iyer SS; Pry JM; Kapesa H; Moono M; Mwila C; Frimpong C; Nanyangwe M; Phiri L; Ngandu R; Sakanya P; Mwansa S; Phiri T; Haciwa M; Maritim P; Lee K; Arons M; Aholou T; Minchella P; Savory-van Huis T; Bolton C; Herce ME
BACKGROUND: Zambia established a recent infection testing algorithm (RITA) incorporating a novel point-of-care (POC) rapid test-the Asanté™ HIV-1 Rapid Recency® Assay (RTRI)-plus a HIV-1 viral load (VL) test to distinguish recent (≤12 months) from long-term (>12 months) HIV acquisition. This study evaluated the field performance of RTRI when implemented by healthcare workers at the POC. METHODS: We enrolled individuals newly diagnosed with HIV between 20 May 2021 and 10 March 2022 at two Ministry of Health facilities in Lusaka, Zambia. Participants received on-site RTRI testing and provided an additional sample for repeat RTRI and VL testing at a central laboratory. Final recent infection testing algorithm (RITA) results were returned to the study sites and were made available to clients at their study follow-up visit. Agreement between POC- and laboratory-RTRI was assessed using Cohen's Kappa. We compared recent versus long-term HIV classification across testing locations using the national RITA as the reference standard. Four focus group discussions (FGDs) with health staff explored perceptions surrounding POC-RTRI implementation. RESULTS: Agreement between POC and laboratory RTRI was 96.5%, with a Kappa of 0.812 (95% CI: 0.704-0.920). The POC-RTRI results indicated numerically more recent infections than laboratory-RTRI (30 vs 27), with three POC-RTRI false positives resulting in reduced sensitivity 85.0% for the POC-RTRI compared to 100.0% sensitivity for the laboratory-RTRI against the RITA reference standard. FGD participants (n = 28) agreed that POC RTRI was feasible and acceptable with adequate training, human resources, client counselling, and quality assurance measures. CONCLUSION: There was strong concordance between POC- and laboratory-RTRI results. The findings support the feasibility of implementing RTRI at POC by non-laboratory health workers, provided adequate training and health system resources are in place.
The effect of tracer contact on return to care among adult, "lost to follow-up" patients living with HIV in Zambia: an instrumental variable analysis.
(2021-Dec) Beres LK; Mody A; Sikombe K; Nicholas LH; Schwartz S; Eshun-Wilson I; Somwe P; Simbeza S; Pry JM; Kaumba P; McGready J; Holmes CB; Bolton-Moore C; Sikazwe I; Denison JA; Geng EH
INTRODUCTION: Tracing patients lost to follow-up (LTFU) from HIV care is widely practiced, yet we have little knowledge of its causal effect on care engagement. In a prospective, Zambian cohort, we examined the effect of tracing on return to care within 2 years of LTFU. METHODS: We traced a stratified, random sample of LTFU patients who had received HIV care between August 2013 and July 2015. LTFU was defined as a gap of >90 days from last scheduled appointment in the routine electronic medical record. Extracting 2 years of follow-up visit data through 2017, we identified patients who returned. Using random selection for tracing as an instrumental variable (IV), we used conditional two-stage least squares regression to estimate the local average treatment effect of tracer contact on return. We examined the observational association between tracer contact and return among patient sub-groups self-confirmed as disengaged from care. RESULTS: Of the 24,164 LTFU patients enumerated, 4380 were randomly selected for tracing and 1158 were contacted by a tracer within a median of 14.8 months post-loss. IV analysis found that patients contacted by a tracer because they were randomized to tracing were no more likely to return than those not contacted (adjusted risk difference [aRD]: 3%, 95% CI: -2%, 8%, p = 0.23). Observational data showed that among contacted, disengaged patients, the rate of return was higher in the week following tracer contact (IR 5.74, 95% CI: 3.78-8.71) than in the 2 weeks to 1-month post-contact (IR 2.28, 95% CI: 1.40-3.72). There was a greater effect of tracing among patients lost for >6 months compared to those contacted within 3 months of loss. CONCLUSIONS: Overall, tracer contact did not causally increase LTFU patient return to HIV care, demonstrating the limited impact of tracing in this program, where contact occurred months after patients were LTFU. However, observational data suggest that tracing may speed return among some LTFU patients genuinely out-of-care. Further studies may improve tracing effectiveness by examining the mechanisms underlying the impact of tracing on return to care, the effect of tracing at different times-since-loss and using more accurate identification of patients who are truly disengaged to target tracing.
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 LA; Mulubwa C; Chiu C; Chipungu J; Coakley C; Smith H; Upadhyay UD; Chilambe C; Chibwe B; Pry JM; Mkandawire B; Musonda M; Moore CB; Liu J
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.
The Social Construction of Aging Among a Clinic-Based Population and Their Healthcare Workers in Zambia.
(2024) Sharma A; Mwamba C; St Clair-Sullivan N; Chihota BV; Pry JM; Bolton-Moore C; Vinikoor MJ; Muula GK; Daultrey H; Gittelsohn J; Mulenga LB; Siyumbwa N; Wandeler G; Vera JH
OBJECTIVES: We sought to understand the social construction of aging in a clinic-based population, with and without HIV, to address gaps in care for older individuals living with HIV in Zambia. METHODS: Our exploratory qualitative study included 36 in-depth interviews with clinic clients and four focus group discussions with 36 professional and lay healthcare workers providing services to the clients. We identified themes based on social construction theory. RESULTS: At the individual level, aging was multidimensional, perceived both as an achievement in the HIV era and as a period of cognitive, physical, and economic decline. In social interactions, older individuals were often stereotyped and treated as helpless, poor, and "witches." Those living with HIV faced the additional stigma of being labeled as promiscuous. Some of the participants living without HIV refused to take daily medication for non-communicable diseases to avoid being mistaken for taking antiretroviral therapy for HIV. Older individuals wanted quality healthcare and family support to address the intersectional stigma of aging, poverty, and chronic illness. CONCLUSION: Multifaceted interventions are required to combat age-related prejudice, intersectional stigma, and discriminatory practices, particularly for people living with HIV.
Vulnerable newborn types: analysis of subnational, population-based birth cohorts for 541 285 live births in 23 countries, 2000-2021.
(2023-May-08) Erchick DJ; Hazel EA; Katz J; Lee ACC; Diaz M; Wu LSF; Yoshida S; Bahl R; Grandi C; Labrique AB; Rashid M; Ahmed S; Roy AD; Haque R; Shaikh S; Baqui AH; Saha SK; Khanam R; Rahman S; Shapiro R; Zash R; Silveira MF; Buffarini R; Kolsteren P; Lachat C; Huybregts L; Roberfroid D; Zeng L; Zhu Z; He J; Qiu X; Gebreyesus SH; Tesfamariam K; Bekele D; Chan G; Baye E; Workneh F; Asante KP; Kaali EB; Adu-Afarwuah S; Dewey KG; Gyaase S; Wylie BJ; Kirkwood BR; Manu A; Thulasiraj RD; Tielsch J; Chowdhury R; Taneja S; Babu GR; Shriyan P; Ashorn P; Maleta K; Ashorn U; Mangani C; Acevedo-Gallegos S; Rodriguez-Sibaja MJ; Khatry SK; LeClerq SC; Mullany LC; Jehan F; Ilyas M; Rogerson SJ; Unger HW; Ghosh R; Musange S; Ramokolo V; Zembe-Mkabile W; Lazzerini M; Rishard M; Wang D; Fawzi WW; Minja DTR; Schmiegelow C; Masanja H; Smith E; Lusingu JPA; Msemo OA; Kabole FM; Slim SN; Keentupthai P; Mongkolchati A; Kajubi R; Kakuru A; Waiswa P; Walker D; Hamer DH; Semrau KEA; Chaponda EB; Chico RM; Banda B; Musokotwane K; Manasyan A; Pry JM; Chasekwa B; Humphrey J; Black RE
OBJECTIVE: To examine prevalence of novel newborn types among 541 285 live births in 23 countries from 2000 to 2021. DESIGN: Descriptive multi-country secondary data analysis. SETTING: Subnational, population-based birth cohort studies (n = 45) in 23 low- and middle-income countries (LMICs) spanning 2000-2021. POPULATION: Liveborn infants. METHODS: Subnational, population-based studies with high-quality birth outcome data from LMICs were invited to join the Vulnerable Newborn Measurement Collaboration. We defined distinct newborn types using gestational age (preterm [PT], term [T]), birthweight for gestational age using INTERGROWTH-21st standards (small for gestational age [SGA], appropriate for gestational age [AGA] or large for gestational age [LGA]), and birthweight (low birthweight, LBW [<2500 g], nonLBW) as ten types (using all three outcomes), six types (by excluding the birthweight categorisation), and four types (by collapsing the AGA and LGA categories). We defined small types as those with at least one classification of LBW, PT or SGA. We presented study characteristics, participant characteristics, data missingness, and prevalence of newborn types by region and study. RESULTS: Among 541 285 live births, 476 939 (88.1%) had non-missing and plausible values for gestational age, birthweight and sex required to construct the newborn types. The median prevalences of ten types across studies were T+AGA+nonLBW (58.0%), T+LGA+nonLBW (3.3%), T+AGA+LBW (0.5%), T+SGA+nonLBW (14.2%), T+SGA+LBW (7.1%), PT+LGA+nonLBW (1.6%), PT+LGA+LBW (0.2%), PT+AGA+nonLBW (3.7%), PT+AGA+LBW (3.6%) and PT+SGA+LBW (1.0%). The median prevalence of small types (six types, 37.6%) varied across studies and within regions and was higher in Southern Asia (52.4%) than in Sub-Saharan Africa (34.9%). CONCLUSIONS: Further investigation is needed to describe the mortality risks associated with newborn types and understand the implications of this framework for local targeting of interventions to prevent adverse pregnancy outcomes in LMICs.