Browsing by Author "Somwe, Paul"

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Accurate dried blood spots collection in the community using non-medically trained personnel could support scaling up routine viral load testing in resource limited settings.
(2019) Sikombe, Kombatende; Hantuba, Cardinal; Musukuma, Kalo; Sharma, Anjali; Padian, Nancy; Holmes, Charles; Czaicki, Nancy; Simbeza, Sandra; Somwe, Paul; Bolton-Moore, Carolyn; Sikazwe, Izukanji; Geng, Elvin
Regular plasma HIV-RNA testing for persons living with HIV on antiretroviral therapy (ART) is now the global standard, but as many as 60% of persons in Africa today on ART do not have access to standard laboratory HIV-RNA assays. As a result, patients in Zambia often receive treatment without any means of determining true virologic failure, which poses a risk of premature switch of ART regimens and widespread HIV drug resistance. Dry blood spots (DBS) on the other hand require unskilled personnel and less complex storage supply chain so are ideal to capture viral-load results from HIV patients outside clinic settings. We assess collection of DBS in the community using non-medically trained personnel (NMP) and documented challenges. We trained 23 NMP to collect DBS from lost to follow-up (LTFU) patients in 4 rural and urban Zambian districts. We developed a phlebotomy box to transport DBS without contamination at ambient temperature and concomitant training and standard operating procedures. We evaluated this through field observations, bi-weekly meetings, reports, and staff meetings. The laboratory assessed DBS quality for testing validity. We attempted to collect DBS from 357 participants in the community. Though individual reasons for refusal from the remaining 37% were not collected, NMPs reported privacy concerns, awkward box-size which drew attention in the community and fears of undisclosed uses of samples related to witchcraft and circulating narratives about past research. Successful DBS collection was not associated with patient gender, age, time on ART, enrolment CD4, facility. DBS viral-load collection by NMP is feasible in Zambia. Our training approach and assessments of NMP not part of the health system can be extended to patients by giving them more responsibility to manage their own differentiated care groups. Concerted efforts that compare collection of DBS by NMP to those collected by skilled-medical personnel are needed.
Active TB case finding in a high burden setting; comparison of community and facility-based strategies in Lusaka, Zambia.
(2020) Kagujje, Mary; Chilukutu, Lophina; Somwe, Paul; Mutale, Jacob; Chiyenu, Kanema; Lumpa, Mwansa; Mwanza, Winfrida; Muyoyeta, Monde
INTRODUCTION: We conducted an implementation science study to increase TB case detection through a combination of interventions at health facility and community levels. We determined the impact of the study in terms of additional cases detected and notification rate and compared the yield of bacteriologically confirmed TB of facility based and community based case finding. METHODOLOGY: Over a period of 18 months, similar case finding activities were conducted at George health facility in Lusaka Zambia and its catchment community, an informal peri-urban settlement. Activities included awareness and demand creation activities, TB screening with digital chest x-ray or symptom screening, sputum evaluation using geneXpert MTB/RIF, TB diagnosis and linkage to treatment. RESULTS: A total of 18,194 individuals were screened of which 9,846 (54.1%) were screened at the facility and 8,348 (45.9%) were screened in the community. The total number of TB cases diagnosed during the intervention period were 1,026, compared to 759 in the pre-intervention period; an additional 267 TB cases were diagnosed. Of the 563 bacteriologically confirmed TB cases diagnosed under the study, 515/563 (91.5%) and 48/563 (8.5%) were identified at the facility and in the community respectively (P<0.0001). The TB notification rate increased from 246 per 100,000 population pre-intervention to 395 per 100,000 population in the last year of the intervention. CONCLUSIONS: Facility active case finding was more effective in detecting TB cases than community active case finding. Strengthening health systems to appropriately identify and evaluate patients for TB needs to be optimised in high burden settings. At a minimum, provider initiated TB symptom screening with completion of the TB screening and diagnostic cascade should be provided at the health facility in high burden settings. Community screening needs to be systematic and targeted at high risk groups and communities with access barriers.
Alcohol consumption and tobacco smoking associated with decreased antiretroviral therapy adherence among people living with HIV in Zambia: Evidence from a 2023 national NCDs/ HIV survey.
(2026) Zyambo, Cosmas; Somwe, Paul; Musukuma, Mwiche; Mandyata, Chomba; Bwembya, Phoebe; Phiri, Henry; Chavula, Malizgani; Halwindi, Hikabasa; Zulu, Joseph; Mutale, Wilbroad
BACKGROUND: In order to achieve the 95-95-95 goals and obtain optimal benefits from ART, PLWH must adhere to prescribed medication. AIM: Investigate factors associated with ART adherence in a clinical setting in Zambia. METHODS: National cross-sectional study involving 193 clinics across all 10 provinces of Zambia. The primary outcomes assessed were ART adherence status, associated behavioral factors, and clinical characteristics. Logistic regression analysis was conducted to evaluate associations between these factors and ART adherence. Both unadjusted odds ratios (UOR) and adjusted odds ratios (AOR) were calculated, with adjustments made for relevant covariates, and all estimates reported with 95% confidence intervals. RESULTS: Of the 5,204 PLWH, 7.1% were non-adherent to ART (9.7% males vs 5.9% females). Of those who were non adherent, 60% and 22% consumed alcohol and smoked tobacco respectively. In adjusted analysis, age; 45-59 (AOR: 0.5, 95% CI:0.32-0.79), 60+ (AOR: 0.26, 95% CI: 0.12-0.59) and education; Primary (AOR: 0.6, 95% CI: 0.4-0.9), secondary (AOR: 0.57, 95% CI: 0.4-0.82), college/university (AOR: 0.5, 95% CI: 0.29-0.89) were associated with decreased odds of being non-adherence to ART. In contrast, being male (AOR: 1.45, 95% CI:1.07-1.98), being in informal employment (AOR:1.65, 95% CI:1.15-2.36), having average yearly income; > $160 (AOR: 1.55, 95% CI: 1.16-2.06), Alcohol consumption; healthy consumption (AOR: 2.72, 95% CI: 1.9-3.89), unhealthy consumption (AOR: 2.76, 95% CI: 1.8-4.22), indeterminant consumption (AOR: 3.03, 95% CI: 2.04-4.5) and tobacco smoking (AOR: 95% CI: 2.03 1.42-2.9) were associated with increased odds of being non-adherence to ART. CONCLUSIONS: ART non-adherence among PLWH in Zambia is 7.1%, with higher rates in males. Substance use especially alcohol and tobacco are common among the non-adherent. The associations between alcohol consumption, tobacco smoking, and ART adherence highlight the potential value of targeted support strategies. These results can inform future longitudinal research and contribute to the development of evidence-based interventions.
Cross-sectional assessment of tuberculosis and HIV prevalence in 13 correctional facilities in Zambia.
(2021-Sep-27) Kagujje, Mary; Somwe, Paul; Hatwiinda, Sisa; Bwalya, Joel; Zgambo, Tamala; Thornicroft, Moomba; Bozzani, Fiammetta M.; Moonga, Clement; Muyoyeta, Monde
OBJECTIVE: To determine the prevalence of tuberculosis (TB) and HIV in 13 Zambian correctional facilities. METHODS: Cross-sectional study. SETTING: 13 correctional facilities in seven of the 10 provinces in Zambia. PARTICIPANTS: All incarcerated individuals were eligible for TB and HIV screening and testing. Of the total study population of 9695 individuals, which represent 46.2% of total correctional population at the beginning of the study, 8267 and 8160 were screened for TB and HIV, respectively. INTERVENTIONS: TB and HIV screening and testing was done between July 2018 and February 2019. PRIMARY OUTCOME MEASURES: All forms of TB, bacteriologically confirmed TB, drug-resistant TB, HIV. RESULTS: Prevalence of all forms of TB and bacteriologically confirmed TB was 1599 (1340-1894) per 100 000 population and 1056 (847-1301) per 100 000 population, respectively. Among those with bacteriologically confirmed TB, 4.6% (1.3%-11.4%) had drug-resistant TB.There was no statistically significant difference in the prevalence of all forms of TB, bacteriologically confirmed TB and drug resistant TB between adults and juveniles: (p=0.82), (p=0.23), (p=0.68) respectively. Of the bacteriologically confirmed TB cases, 28.7% were asymptomatic. The prevalence of HIV was 14.3% (13.6%-15.1%). The prevalence of HIV among females was 1.8 times the prevalence of HIV among males (p=0.01). CONCLUSION: Compared with the study in 2011 which screened inmates representing 30% of the country's inmate population, then the prevalence of all forms of TB and HIV in correctional facilities has reduced by about 75% and 37.6%, respectively. However, compared with the general population, the prevalence of all forms of TB and HIV was 3.5 and 1.3 times higher, respectively. TB/HIV programmes in correctional facilities need further strengthening to include aspects of juvenile-specific TB programming and gender responsive HIV programming.
Evaluating InferVision's Computer-Aided Detection (CAD) algorithm for Tuberculosis (TB) screening, Lusaka, Zambia.
(2025) Somwe, Paul; Maimbolwa, Minyoi; Chiyenu, Kanema; Lumpa, Mwansa; Kagujje, Mary; Muyoyeta, Monde
The objective of this study was to evaluate the diagnostic performance of InferRead DR Chest for tuberculosis (TB) screening in a high HIV and TB burden setting. The study assessed the performance of InferRead DR Chest using anonymized chest X-ray images from an active TB case finding study in Lusaka, Zambia, for individuals aged 15 and older. The Xpert MTB/RIF or MTB culture was the composite reference standard. Performance was evaluated using the Area Under the Receiver Operating Characteristic Curve (AUC), and a binary classification point was selected where the sensitivity aligned with the WHO target product profile for TB screening tools. Of the 1,890 chest X-ray images that met the inclusion criteria, 91.5% of participants reported at least one TB symptom. The median age was 38 years (IQR: 29-47), and 1,186 (62.8%) were male. From the study sample, 449 participants (23.8%) reported a history of previous TB, and 704 (37.2%) were HIV positive. Among the analyzed images, 289 (15.3%) were classified as TB positive based on the composite reference standard test results. The overall area under the curve (AUC) was 0.81 (95% CI: 0.78-0.83). Among individuals with a history of previous TB and those who were HIV positive, the AUCs were 0.71 (95% CI: 0.63-0.79) and 0.77 (95% CI: 0.72-0.82), respectively. At a sensitivity of 90.3% (95% CI: 86.3%-93.5%), InferRead DR Chest achieved a specificity of 39.2% (95% CI: 36.8%-41.7%) at TB score cut point of 0.12. InferRead DR Chest had acceptable performance in our population. Additional training and piloting of InferRead DR Chest in this population is recommended.
One Health Baseline Study Report
(Centre for Infectious Disease Research in Zambia (CIDRZ), 2026-12-17) Somwe, Paul; Barry Walsh, Paula; Riblet, Michelle; Butler, David; Lumpa, Mwansa; Sharma, Anjali; Rios, Rafaella; Whelan, Niamh; Chipungu, Jenala; Banda, Humphrey; Mataa, Liywalii
The One Health Baseline Research Study was conducted to assess knowledge, practices, and regulatory frameworks related to food safety, animal health and disease surveillance, and the control of animal medicines in Zambia. The study aimed to inform a just transition toward a sustainable and resilient food system by strengthening One Health interventions that reduce production and consumption shocks and mitigate crisis risks. Using a mixed-methods approach, quantitative and qualitative data were collected from 340 stakeholders, including livestock and crop farmers, food processors, buyers and retailers, and regulators across six districts in Eastern, Lusaka, Northern, and Southern Provinces. Findings indicate that stakeholders possess a holistic understanding of One Health, recognising the interdependence of food safety, animal health, environmental sustainability, and socio-economic factors. Positive progress was observed, including strong awareness of zoonotic diseases among livestock farmers, high compliance with food business registration requirements, and recognition of inspectors as trusted information sources. However, significant challenges persist, particularly related to limited institutional capacity, regulatory overlaps, inadequate risk management skills, weak oversight of animal medicines, and insufficient infrastructure and training. Misuse of veterinary drugs and pesticides poses risks to public health, animal health, and the environment, contributing to antimicrobial resistance and undermining disease control efforts. The study highlights the importance of strengthened institutional coordination, improved policy communication, risk-based approaches, and inclusive stakeholder engagement from farm to fork. Digital innovations such as the Zambia Animal Health Information System demonstrate potential for enhancing disease surveillance and evidence-based decision-making. Overall, the findings underscore the need for integrated, risk-based, and community-informed One Health strategies to improve food safety, support sustainable livelihoods, and strengthen Zambia’s agri-food system resilience.
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.
Retention and viral suppression in a cohort of HIV patients on antiretroviral therapy in Zambia: Regionally representative estimates using a multistage-sampling-based approach.
(2019-May) Sikazwe, Izukanji; Eshun-Wilson, Ingrid; Sikombe, Kombatende; Czaicki, Nancy; Somwe, Paul; Mody, Aaloke; Simbeza, Sandra; Glidden, David V.; Chizema, Elizabeth; Mulenga, Lloyd B.; Padian, Nancy; Duncombe, Chris J.; Bolton-Moore, Carolyn; Beres, Laura K.; Holmes, Charles B.; Geng, Elvin
BACKGROUND: Although the success of HIV treatment programs depends on retention and viral suppression, routine program monitoring of these outcomes may be incomplete. We used data from the national electronic medical record (EMR) system in Zambia to enumerate a large and regionally representative cohort of patients on treatment. We traced a random sample with unknown outcomes (lost to follow-up) to document true care status and HIV RNA levels. METHODS AND FINDINGS: On 31 July 2015, we selected facilities from 4 provinces in 12 joint strata defined by facility type and province with probability proportional to size. In each facility, we enumerated adults with at least 1 clinical encounter after treatment initiation in the previous 24 months. From this cohort, we identified lost-to-follow-up patients (defined as 90 or more days late for their last appointment), selected a random sample, and intensively reviewed their records and traced them via phone calls and in-person visits in the community. In 1 of 4 provinces, we also collected dried blood spots (DBSs) for plasma HIV RNA testing. We used inverse probability weights to incorporate sampling outcomes into Aalen-Johansen and Cox proportional hazards regression to estimate retention and viremia. We used a bias analysis approach to correct for the known inaccuracy of plasma HIV RNA levels obtained from DBSs. From a total of 64 facilities with 165,464 adults on ART, we selected 32 facilities with 104,966 patients, of whom 17,602 (17%) were lost to follow-up: Those lost to follow-up had median age 36 years, 60% were female (N = 11,241), they had median enrollment CD4 count of 220 cells/μl, and 38% had WHO stage 1 clinical disease (N = 10,690). We traced 2,892 (16%) and found updated outcomes for 2,163 (75%): 412 (19%) had died, 836 (39%) were alive and in care at their original clinic, 457 (21%) had transferred to a new clinic, 255 (12%) were alive and out of care, and 203 (9%) were alive but we were unable to determine care status. Estimates using data from the EMR only suggested that 42.7% (95% CI 38.0%-47.1%) of new ART starters and 72.3% (95% CI 71.8%-73.0%) of all ART users were retained at 2 years. After incorporating updated data through tracing, we found that 77.3% (95% CI 70.5%-84.0%) of new initiates and 91.2% (95% CI 90.5%-91.8%) of all ART users were retained (at original clinic or transferred), indicating that routine program data underestimated retention in care markedly. In Lusaka Province, HIV RNA levels greater than or equal to 1,000 copies/ml were present in 18.1% (95% CI 14.0%-22.3%) of patients in care, 71.3% (95% CI 58.2%-84.4%) of lost patients, and 24.7% (95% CI 21.0%-29.3%). The main study limitations were imperfect response rates and the use of self-reported care status. CONCLUSIONS: In this region of Zambia, routine program data underestimated retention, and the point prevalence of unsuppressed HIV RNA was high when lost patients were accounted for. Viremia was prevalent among patients who unofficially transferred: Sustained engagement remains a challenge among HIV patients in Zambia, and targeted sampling is an effective strategy to identify such gaps in the care cascade and monitor programmatic progress.
Sensitivity and specificity of CRP and symptom screening as tuberculosis screening tools among HIV-positive and negative outpatients at a primary healthcare facility in Lusaka, Zambia: a prospective cross-sectional study.
(2023-Apr-18) Kagujje, Mary; Mwanza, Winnie; Somwe, Paul; Chilukutu, Lophina; Creswell, Jacob; Muyoyeta, Monde
OBJECTIVES: To evaluate the performance of point-of-care C-reactive protein (CRP) as a screening tool for tuberculosis (TB) using a threshold of 10 mg/L in both people living with HIV (PLHIV) and HIV-negative individuals and compare it to symptom screening using a composite reference for bacteriological confirmation of TB. METHODS: Prospective cross-sectional study. SETTING: A primary healthcare facility in Lusaka, Zambia. PARTICIPANTS: Consecutive adults (≥18 years) presenting for routine outpatient healthcare were enrolled. Of the 816 individuals approached to participate in the study, 804 eligible consenting adults were enrolled into the study, of which 783 were included in the analysis. PRIMARY OUTCOME MEASURES: Sensitivity, specificity, positive predictive value and negative predictive value (NPV) of CRP and symptom screening. RESULTS: Overall, sensitivity of WHO-recommended four-symptom screen (W4SS) and CRP were 87.2% (80.0-92.5) and 86.6% (79.6-91.8) while specificity was 30.3% (26.7-34.1) and 34.8% (31.2-38.6), respectively. Among PLHIV, sensitivity of W4SS and CRP was 92.2% (81.1-97.8) and 94.8% (85.6-98.9) while specificity was 37.0% (31.3-43.0) and 27.5% (22.4-33.1), respectively. Among those with CD4≥350, the NPV for CRP was 100% (92.9-100). In the HIV negative, sensitivity of W4SS and CRP was 83.8% (73.4-91.3) and 80.3% (69.5-88.5) while specificity was 25.4% (20.9-30.2) and 40.5% (35.3-45.6), respectively. Parallel use of CRP and W4SS yielded a sensitivity and NPV of 100% (93.8-100) and 100% (91.6-100) among PLHIV and 93.3% (85.1-97.8) and 90.0% (78.2-96.7) among the HIV negatives, respectively. CONCLUSION: Sensitivity and specificity of CRP were similar to symptom screening in HIV-positive outpatients. Independent use of CRP offered limited additional benefit in the HIV negative. CRP can independently accurately rule out TB in PLHIV with CD4≥350. Parallel use of CRP and W4SS improves sensitivity irrespective of HIV status and can accurately rule out TB in PLHIV, irrespective of CD4 count.