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The CIDRZ Research Repository serves as an open-access archive for peer-reviewed publications, conference papers, and other scholarly outputs from CIDRZ researchers. Our goal is to promote the dissemination of knowledge and support evidence-based public health initiatives.
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Item Effectiveness of a city-wide program to prevent mother-to-child HIV transmission in Lusaka, Zambia.(2005-Aug-12) Stringer, Jeffrey S.; Sinkala, Moses; Maclean, Courtney C.; Levy, Jens; Kankasa, Chipepo; Degroot, Alain; Stringer, Elizabeth M.; Acosta, Edward P.; Goldenberg, Robert L.; Vermund, Sten H.OBJECTIVE: To determine the population effectiveness of a city-wide perinatal HIV prevention program. DESIGN: An anonymous surveillance of newborn cord blood for HIV serology and nevirapine (NVP). METHODS: All 10 public-sector delivery centers in Lusaka, Zambia participated. All mother-infant pairs delivering during the 12-week surveillance period at the participating centers and who received antenatal care at a public-sector facility in Lusaka were included in the study. The main outcome measure was population NVP coverage, defined as the proportion of HIV-infected women and HIV-exposed infants in the population that ingested NVP. RESULTS: Of 8787 women in the surveillance population, 7204 (82%) had been offered antenatal HIV testing, of which 5149 (71%) had accepted, and of which 5129 (99%) had received a result. Overall, 2257 of 8787 (26%) were cord seropositive. Of the 1246 (55%) cord blood seropositive women who received an antenatal HIV test result, 1112 (89%) received a positive result; the other 134 comprise seroconverters and clerical errors. Only 751 of 1112 (68%) women who received a positive antenatal test result and a NVP tablet for ingestion at labor onset had NVP detected in the cord blood (i.e., maternal non-adherence rate was 32%). A total of 675 infants born to 751 adherent mothers (90%) received NVP before discharge. Thus, only 675 of 2257 (30%) seropositive mother-infant pairs in the surveillance population received both a maternal and infant dose of NVP. CONCLUSIONS: Successful perinatal HIV prevention requires each mother-infant pair to negotiate a cascade of events that begins with offering HIV testing and continues through adherence to the prescribed regimen. This novel surveillance demonstrates that failures occur at each step, resulting in reduced coverage and diminished program effectiveness.Item Perceptions toward HIV, HIV screening, and the use of antiretroviral medications: a survey of maternity-based health care providers in Zambia.(2004-Oct) Chi, Benjamin H.; Chansa, Kayula; Gardner, Michael O.; Sangi-Haghpeykar, Haleh; Goldenberg, Robert L.; Sinkala, Moses; Muchimba, Maureen; Stringer, Jeffrey S.Mother-to-child transmission of HIV (MTCT) is a major contributor to Zambia's HIV burden. Based on our experience in Zambia, we felt that provider perceptions, knowledge base, and practice patterns toward HIV-positive mothers may pose as significant obstacles to preventing MTCT. Two hundred and twenty-five health care providers throughout Zambia were surveyed in 2002. Providers reported widespread stigma associated with HIV. Physicians (OR = 1.9), providers with research affiliations (OR = 2.3), and those located in Lusaka (OR = 9.0) were more likely to offer HIV testing. Only 30% routinely prescribed antiretroviral treatment (ART) to reduce MTCT. Practitioners from district facilities, those from Lusaka, and those employed at research facilities were more likely to prescribe ART routinely (OR = 2.8, 10.1 and 3.4 respectively). Among those never prescribing ART, most cited a lack of availability (83%). Our results highlight the need for further provider education, critical appraisal of the current system for HIV testing, and widespread distribution of ART.Item Cost and enrollment implications of targeting different source population for an HIV treatment program.(2005-Nov-01) Chi, Benjamin H.; Fusco, Harmony; Sinkala, Moses; Goldenberg, Robert L.; Stringer, Jeffrey S.BACKGROUND: Rapid scale-up of antiretroviral therapy (ART) is a worldwide priority, and ambitious targets for numbers on ART have been set. Antenatal clinics (ANCs) and tuberculosis (TB) clinics have been targeted as entry points into HIV care. METHODS: We developed a conditional probability model to evaluate the effects of ANC and TB clinic populations on ART program enrollment. RESULTS: To start 1 individual on ART, 3 TB patients have to be screened at a crude program cost of 36 US dollars per patient initiated on therapy. By contrast, 48 ANC patients have to be screened at a cost of US 214 US dollars per patient on therapy. In an incremental analysis in which ANC HIV testing was borne by a program to prevent mother-to-child transmission, recruitment efficiency increased (8 screened per patient starting ART) and cost decreased (114 US dollars per patient on therapy). Absolute numbers starting ART, however, remained fixed. If all 60,000 ANC patients seen yearly in the Lusaka District were screened, 1247 would start ART. Approaching the district's 35,000 annual TB patients would generate 11,947 patients on ART. CONCLUSION: In areas with high HIV prevalence, targeting chronically ill populations for HIV treatment may have significant short-term benefits in cost savings and recruitment efficiency.Item Use of traditional medicine among pregnant women in Lusaka, Zambia.(2007) Banda, Yolan; Chapman, Victoria; Goldenberg, Robert L.; Stringer, Jeffrey S.; Culhane, Jennifer F.; Sinkala, Moses; Vermund, Sten H.; Chi, Benjamin H.OBJECTIVE: We studied the prevalence of and predictors for traditional medicine use among pregnant women seeking care in the Lusaka, Zambia public health system. SUBJECTS: We surveyed 1128 pregnant women enrolled in a clinical trial of perinatal human immunodeficiency virus (HIV) prevention strategies at two district delivery centers. OUTCOME MEASURES: Postpartum questionnaires were administered to determine demographic characteristics, behavioral characteristics, HIV knowledge, and prior use of traditional medicines. RESULTS: Of the 1128 women enrolled, 335 (30%) reported visiting a traditional healer in the past; 237 (21%) reported using a traditional healer during the current pregnancy. Overall, 54% believed that admitting to a visit to a traditional healer would result in worse medical care. When women who had used traditional medicines were compared to those who had not, no demographic differences were noted. However, women who reported use of traditional medicine were more likely to drink alcohol during pregnancy, have >or=2 sex partners, engage in "dry sex," initiate sex with their partner, report a previously treated sexually transmitted disease, and use contraception (all p < 0.01). HIV-infected women who reported using traditional healers were also less likely to adhere to a proven medical regimen to reduce HIV transmission to their infant (25% versus 50%, p = 0.048). CONCLUSIONS: Use of traditional medicine during pregnancy is common, stigmatized, and may be associated with nonadherence to antiretroviral regimens. Health care providers must open lines of communication with traditional healers and with pregnant women themselves to maximize program success.Item A randomized trial of the intrauterine contraceptive device vs hormonal contraception in women who are infected with the human immunodeficiency virus.(2007-Aug) Stringer, Elizabeth M.; Kaseba, Christine; Levy, Jens; Sinkala, Moses; Goldenberg, Robert L.; Chi, Benjamin H.; Matongo, Inutu; Vermund, Sten H.; Mwanahamuntu, Mulindi; Stringer, Jeffrey S.OBJECTIVE: The purpose of this study was to determine whether the intrauterine contraceptive device (IUD) is effective and safe among women who are infected with the human immunodeficiency virus (HIV). STUDY DESIGN: We randomly assigned 599 postpartum, HIV-infected women in Zambia to receive either a copper IUD or hormonal contraception and followed them for at least 2 years. RESULTS: Women who were assigned randomly to hormonal contraception were more likely to become pregnant than those who were assigned randomly to receive an IUD (rate, 4.6/100 vs 2.0/100 woman-years; hazards ratio, 2.4; 95% CI, 1.3-4.7). One woman who was assigned to the IUD experienced pelvic inflammatory disease (crude rate, 0.16/100 woman-years; 95% CI, 0.004-868); there was no pelvic inflammatory disease among those women who were assigned to hormonal contraception. Clinical disease progression (death or CD4+ lymphocyte count dropping below 200 cells/microL) was more common in women who were allocated to hormonal contraception (13.2/100 woman-years) than in women who were allocated to the IUD (8.6/100 woman-years; hazard ratio, 1.5; 95% CI, 1.04-2.1). CONCLUSION: The IUD is effective and safe in HIV-infected women. The unexpected observation that hormonal contraception was associated with more rapid HIV disease progression requires urgent further study.Item Predictors of stillbirth in sub-saharan Africa.(2007-Nov) Chi, Benjamin H.; Wang, Lei; Read, Jennifer S.; Taha, Taha E.; Sinkala, Moses; Brown, Elizabeth R.; Valentine, Megan; Martinson, Francis; Goldenberg, Robert L.OBJECTIVE: To describe the incidence and predictors of stillbirth in a predominantly human immunodeficiency virus (HIV)-infected African cohort. METHODS: Human Immunodeficiency Virus (HIV) Prevention Trials Network (HPTN) 024 was a randomized controlled trial of empiric antibiotics to reduce chorioamnionitis-related perinatal HIV transmission. A proportion of HIV-uninfected individuals were enrolled to reduce community-based stigma surrounding the trial. For this analysis, only women who gave birth to singleton infants were included. RESULTS: Of 2,659 women enrolled, 2,434 (92%) mother- child pairs met inclusion criteria. Of these, 2,099 (86%) infants were born to HIV-infected women, and 335 (14%) were born to HIV-uninfected women. The overall stillbirth rate was 32.9 per 1,000 deliveries (95% confidence interval [CI] 26.1-40.7). In univariable analyses, predictors for stillbirth included previous stillbirth (odds ratio [OR] 2.3, 95% CI 1.2-4.3), antenatal hemorrhage (OR 14.4, 95% CI 4.3-47.9), clinical chorioamnionitis (OR 20.9, 95% CI 5.1-86.2), and marked polymorphonuclear infiltration on placental histology (OR 2.9, 95% CI 1.7-5.2). When compared with pregnancies longer than 37 weeks, those at 34-37 weeks (OR 1.7, 95% CI 0.8-3.4) and those at less than 34 weeks (OR 22.8, 95% CI 13.6-38.2) appeared more likely to result in stillborn delivery. Human immunodeficiency virus infection was not associated with a greater risk for stillbirth in either univariable (OR 1.5, 95% CI 0.7-3.0) or multivariable (adjusted OR 1.11, 95% CI 0.38-3.26) analysis. Among HIV-infected women, however, decreasing CD4 cell count was inversely related to stillbirth risk (P=.009). CONCLUSION: In this large cohort, HIV infection was not associated with increased stillbirth risk. Further work is needed to elucidate the relationship between chorioamnionitis and stillbirth in African populations. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00021671 LEVEL OF EVIDENCE: II.Item Do targeted HIV programs improve overall care for pregnant women?: Antenatal syphilis management in Zambia before and after implementation of prevention of mother-to-child HIV transmission programs.(2008-Jan-01) Potter, Dara; Goldenberg, Robert L.; Chao, Ann; Sinkala, Moses; Degroot, Alain; Stringer, Jeffrey S.; Bulterys, Marc; Vermund, Sten H.BACKGROUND: The implementation of disease-specific research or service programs may have an ancillary beneficial or harmful impact on routine clinical services. METHODS: We reviewed the records of 5801 first visits to 22 antenatal clinics from 1997 to 2004 in Lusaka, Zambia and examined documented syphilis rapid plasma reagin (RPR) screening and syphilis treatment before and after implementation of research and/or service programs in prevention of mother-to-child (PMTCT) HIV transmission. FINDINGS: Compared with before PMTCT program implementation, the prevalence odds ratios (PORs) and 95% confidence intervals (CIs) for documented RPR screening were 0.9 (0.7 to 1.1) after implementation of research, 0.7 (0.6 to 0.8) after service, and 2.5 (2.1 to 3.0) after research and service programs. CONCLUSIONS: Documented RPR screening was improved after implementation of PMTCT research and service were operating simultaneously and not with research or service alone. Health policy makers and researchers should plan explicitly for how the targeted HIV programs, service, and/or research can have a broader primary care impact.