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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 Mixed methods approach to examining the implementation experience of a phone-based survey for a SARS-CoV-2 test-negative case-control study in California.(2024) Fukui, Nozomi; Li, Sophia S.; DeGuzman, Jennifer; Myers, Jennifer F.; Openshaw, John; Sharma, Anjali; Watt, James; Lewnard, Joseph A.; Jain, Seema; Andrejko, Kristin L.; Pry, Jake M.OBJECTIVE: To describe the implementation of a test-negative design case-control study in California during the Coronavirus Disease 2019 (COVID-19) pandemic. STUDY DESIGN: Test-negative case-control study. METHODS: Between February 24, 2021 - February 24, 2022, a team of 34 interviewers called 38,470 Californians, enrolling 1,885 that tested positive for SARS-CoV-2 (cases) and 1,871 testing negative for SARS-CoV-2 (controls) for 20-minute telephone survey. We estimated adjusted odds ratios for answering the phone and consenting to participate using mixed effects logistic regression. We used a web-based anonymous survey to compile interviewer experiences. RESULTS: Cases had 1.29-fold (95% CI: 1.24-1.35) higher adjusted odds of answering the phone and 1.69-fold (1.56-1.83) higher adjusted odds of consenting to participate compared to controls. Calls placed from 4pm to 6pm had the highest adjusted odds of being answered. Some interviewers experienced mental wellness challenges interacting with participants with physical (e.g., food, shelter, etc.) and emotional (e.g., grief counseling) needs, and enduring verbal harassment from individuals called. CONCLUSIONS: Calls placed during afternoon hours may optimize response rate when enrolling controls to a case-control study during a public health emergency response. Proactive check-ins and continual collection of interviewer experience(s) and may help maintain mental wellbeing of investigation workforce. Remaining adaptive to the dynamic needs of the investigation team is critical to a successful study, especially in emergent public health crises, like that represented by the COVID-19 pandemic.Item An exploration of multi-level factors affecting routine linkage to HIV care in Zambia's PEPFAR-supported treatment program in the treat all era.(2024) Chipungu, Jenala; Smith, Helene; Mwamba, Chanda; Haambokoma, Mwiza; Sharma, Anjali; Savory, Theodora; Musheke, Maurice; Pry, Jake; Bolton, Carolyn; Sikazwe, Izukanji; Herce, Michael E.Multiple steps from HIV diagnosis to treatment initiation and confirmed engagement with the health system are required for people living with HIV to establish full linkage to care in the modern treat all era. We undertook a qualitative study to gain an in-depth understanding of the impeding and enabling factors at each step of this linkage pathway. In-depth interviews were conducted with fifty-eight people living with HIV recruited from ten routine HIV care settings supported by the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) in Lusaka, Zambia. Using a semi-structured interview guide informed by an established conceptual framework for linkage to care, questions explored the reasons behind late, missed, and early linkage into HIV treatment, as well as factors influencing the decision to silently transfer to a different clinic after an HIV diagnosis. We identified previously established and intersecting barriers of internal and external HIV-related stigma, concerns about ART side effects, substance use, uncertainties for the future, and a perceived lack of partner and social support that impeded linkage to care at every step of the linkage pathway. However, we also uncovered newer themes specific to the current test and treat era related to the rapidity of ART initiation and insufficient patient-centered post-test counseling that appeared to exacerbate these well-known barriers, including callous health workers and limited time to process a new HIV diagnosis before treatment. Long travel distance to the clinic where they were diagnosed was the most common reason for silently transferring to another clinic for treatment. On the other hand, individual resilience, quality counseling, patient-centered health workers, and a supportive and empathetic social network mitigated these barriers. These findings highlight potential areas for strengthening linkage to care and addressing early treatment interruption and silent transfer in the test and treat era in Zambia.Item Cervical cancer prevention and care in HIV clinics across sub-Saharan Africa: results of a facility-based survey.(2024-Jul) Asangbeh-Kerman, Serra L. ; Davidović, Maša ; Taghavi, Katayoun; Dhokotera, Tafadzwa; Manasyan, Albert; Sharma, Anjali; Jaquet, Antoine; Musick, Beverly ; Twizere, Christella; Chimbetete, Cleophas; Murenzi, Gad; Tweya, Hannock ; Muhairwe, Josephine; Wools-Kaloustian, Kara; Technau, Karl-Gunter ; Anastos, Kathryn; Yotebieng, Marcel; Jousse, Marielle; Ezechi, Oliver; Orang'o, Omenge ; Bosomprah, Samuel ; Pierre, Simon B.; Basu, Partha; Bohlius, JuliaINTRODUCTION: To eliminate cervical cancer (CC), access to and quality of prevention and care services must be monitored, particularly for women living with HIV (WLHIV). We assessed implementation practices in HIV clinics across sub-Saharan Africa (SSA) to identify gaps in the care cascade and used aggregated patient data to populate cascades for WLHIV attending HIV clinics. METHODS: Our facility-based survey was administered between November 2020 and July 2021 in 30 HIV clinics across SSA that participate in the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium. We performed a qualitative site-level assessment of CC prevention and care services and analysed data from routine care of WLHIV in SSA. RESULTS: Human papillomavirus (HPV) vaccination was offered in 33% of sites. Referral for CC diagnosis (42%) and treatment (70%) was common, but not free at about 50% of sites. Most sites had electronic health information systems (90%), but data to inform indicators to monitor global targets for CC elimination in WLHIV were not routinely collected in these sites. Data were collected routinely in only 36% of sites that offered HPV vaccination, 33% of sites that offered cervical screening and 20% of sites that offered pre-cancer and CC treatment. CONCLUSIONS: Though CC prevention and care services have long been available in some HIV clinics across SSA, patient and programme monitoring need to be improved. Countries should consider leveraging their existing health information systems and use monitoring tools provided by the World Health Organization to improve CC prevention programmes and access, and to track their progress towards the goal of eliminating CC.Item Mixed-methods protocol for the WiSSPr study: Women in Sex work, Stigma and psychosocial barriers to Pre-exposure prophylaxis in Zambia.(2024-Sep-05) Kumar, Ramya; Rao, Deepa ; Sharma, Anjali; Phiri, Jamia; Zimba, Martin; Phiri, Maureen; Zyambo, Ruth; Kalo, Gwen M.; Chilembo, Louise; Kunda, Phidelina M. ; Mulubwa, Chama; Ngosa, Benard ; Mugwanya, Kenneth K.; Barrington, Wendy E.; Herce, Michael E.; Musheke, MauriceINTRODUCTION: Women engaging in sex work (WESW) have 21 times the risk of HIV acquisition compared with the general population. However, accessing HIV pre-exposure prophylaxis (PrEP) remains challenging, and PrEP initiation and persistence are low due to stigma and related psychosocial factors. The WiSSPr (Women in Sex work, Stigma and PrEP) study aims to (1) estimate the effect of multiple stigmas on PrEP initiation and persistence and (2) qualitatively explore the enablers and barriers to PrEP use for WESW in Lusaka, Zambia. METHODS AND ANALYSIS: WiSSPr is a prospective observational cohort study grounded in community-based participatory research principles with a community advisory board (CAB) of key population (KP) civil society organi sations (KP-CSOs) and the Ministry of Health (MoH). We will administer a one-time psychosocial survey vetted by the CAB and follow 300 WESW in the electronic medical record for three months to measure PrEP initiation (#/% ever taking PrEP) and persistence (immediate discontinuation and a medication possession ratio). We will conduct in-depth interviews with a purposive sample of 18 women, including 12 WESW and 6 peer navigators who support routine HIV screening and PrEP delivery, in two community hubs serving KPs since October 2021. We seek to value KP communities as equal contributors to the knowledge production process by actively engaging KP-CSOs throughout the research process. Expected outcomes include quantitative measures of PrEP initiation and persistence among WESW, and qualitative insights into the enablers and barriers to PrEP use informed by participants' lived experiences. ETHICS AND DISSEMINATION: WiSSPr was approved by the Institutional Review Boards of the University of Zambia (#3650-2023) and University of North Carolina (#22-3147). Participants must give written informed consent. Findings will be disseminated to the CAB, who will determine how to relay them to the community and stakeholders.Item Measuring alcohol consumption with biomarkers in intervention studies: A scoping review.(2025-Aug-13) Kane, Jeremy C.; Chirayil, Priya; Pawar, Rhea; Inoue, Sachi; Hofer, Tamara; McDonell, Michael; Latkin, Carl; Chander, Geetanjali ; Martins, Silvia S.; Greene, Claire M.; Vinikoor, Michael; Sharma, Anjali; Hahn, Judith A.In intervention studies, alcohol consumption is often measured by self-report alone, which can be impacted by social desirability, recall, and other biases. Biomarkers and biosensors have gained popularity as objective measurements of alcohol consumption that can improve the accuracy of results. This scoping review provides a narrative overview and describes the use of biomarkers in alcohol intervention studies to inform future research. We conducted a review of alcohol intervention literature including published studies and Clinicaltrials.gov registrations (2000-2021). Randomized controlled trials, quasi-experimental, and nonexperimental studies were included if they piloted or evaluated an intervention aimed at reducing unhealthy alcohol consumption and if an alcohol biomarker was used. Data charting included type of biomarker(s), the country and context of the study location, and a description of how the biomarker was used in analysis. We identified 168 alcohol intervention studies that included at least one biomarker. Blood alcohol content was the most used (N = 76). There was an upward trend in biomarker use over time; 24% of studies were published between 2000 and 2010, and 76% between 2011 and 2021. The use of direct biomarkers, phosphatidylethanol and ethyl glucuronide, and biosensors has increased in frequency over time relative to indirect biomarkers, such as aspartate aminotransferase, carbohydrate-deficient transferrin, and alanine aminotransferase. Most studies were conducted in high-income countries; only 15% were conducted in a low- or middle-income country. More than half of completed studies did not report on comparisons between self-report and biomarker results even when both were collected. Among studies that did report a comparison, 26% reported discordance between self-report and biomarker results. The use of direct biomarkers and biosensors is accelerating. There is a need for more consistency in reporting biomarker/self-report concordance results, more comparisons between multiple biomarkers, and for greater geographic representation within the alcohol biomarker literature.Item The pattern of diabetic care and glycemic control among the ambulatory diabetic patients in tertiary care settings in Bangladesh.(2024-Nov-25) Farzana, Noshin; Islam, Saimul ; Selim, Shahjada ; Lakshmi, Josyula K.; Kappor, Deksha; Sharma, Anjali; Abdullah ABM; Naheed, AliyaDiabetes mellitus is a major public health concern in Bangladesh. The pattern of diabetic care and control of blood sugar among diabetic patients are not well described. We assessed the pattern of diabetic care among ambulatory diabetic patients attending tertiary care hospitals in Bangladesh, and explored the relationship of glycemic control with behavioral and metabolic risks. Any patient 18 years and older attending the medicine outpatient department (OPD) at randomly selected three government tertiary hospitals in three divisions in Bangladesh were examined by hospital doctors. If a patient who was diagnosed as having diabetes and produced any medical document to support the diagnosis was recruited following an informed consent. Data on socio-demographic characteristics, diabetic care plan and behavioral risks, including tobacco use, physical activity, healthy diet (daily fruits and vegetable consumption) and salt intake were obtained from study participants by recall. Three milliliters of venous blood were tested to determine uncontrolled diabetes by measuring glycated hemoglobin (HbA1C > 7.0), and hyperlipidemia by measuring total cholesterol (> 200 mg/dL), high density lipoprotein/HDL (< 40 Mg/dL, low density lipoprotein/ LDL (> 200 mg/dL), and Triglyceride (> 160 mg/dL). A Total of 465 patients were enrolled. The Mean age was 49 years (SD:11) and 58% were women. Sixty percent patients were on a treatment plan of anti-diabetic drugs (drug), healthy diet (diet) and physical activity (PA), 13.3% diet and drug, 9.7% on drug only, 6.4% on diet and PA, 3.9% on PA and drug, 1.3% on PA only and 0.9% on diet only. Two- third of the patients (68.6%) had uncontrolled diabetes, which was three times higher, if a patient had diabetes for more than five years than otherwise (OR: 3.31, 95% CI 2.06-5.33), two times higher if a patient did not consume fruits (OR: 2.28, 1.34-3.87), or three times higher, if a patient did not consume vegetables (OR: 3.70, 95% CI 1.80-7.59) than otherwise, 78% higher, if a patient had taken extra salt in meal than otherwise (OR: 1.78, 95% CI 1.13-2.80) and nine times higher, if a patient had a raised total cholesterol level (> 200 mg/dL) than otherwise (OR: 9.60, 95% CI 2.60-35.40) and three times higher, if a patient had a raised LDL level compared than otherwise (OR: 3.33, 95% CI: 1.93-5.70). Diabetic patients seeking care at tertiary hospitals in Bangladesh follow diverse diabetic care plans and the majority of them do not have diabetes under control. Unhealthy dietary practice and hyperlipidemia among diabetic patients contribute to uncontrolled diabetes. Routine monitoring of blood glucose and enforcing lifestyle modifications could promote effective control of diabetes among diabetic patients in Bangladesh.Item Effect of a multicomponent, person-centred care intervention on client experience and HIV treatment outcomes in Zambia: a stepped-wedge, cluster-randomised trial.(2025-Jan) Sikombe, Kombatende; Mody, Aaloke; Goss, Charles W.; Simbeza, Sandra; Beres, Laura K.; Pry, Jake M.; Eshun-Wilson, Ingrid; Sharma, Anjali; Mukamba, Njekwa; Mulenga, Lloyd B.; Rice, Brian; Mutale, Jacob; Zulu, Alida D.; Mulabe, Musunge; Hargreaves, James; Bolton-Moore, Carolyn; Holmes, Charles B.; Sikazwe, Izukanji ; Geng, Elvin H.BACKGROUND: Recipients of health services value not only convenience but also respectful, kind, and helpful providers. To date, research to improve person-centred HIV treatment has focused on making services easier to access (eg, differentiated service delivery) rather than the interpersonal experience of care. We developed and evaluated a person-centred care (PCC) intervention targeting practices of health-care workers. METHODS: Using a stepped-wedge, cluster-randomised design, we randomly allocated 24 HIV clinics stratified by size in Zambia into four groups and introduced a PCC intervention that targeted caring aspects of the behaviour of health-care workers in one group every 6 months. The intervention entailed training and coaching for health-care workers on PCC practices (to capacitate), client experience assessment with feedback to facilities (to create opportunities), and small performance-based incentives (to motivate). In a probability sample of clients who were pre-trained on a client experience exit survey and masked to facility intervention status, we evaluated effects on client experience by use of mean score change and also proportion with poor encounters (ie, score of ≤8 on a 12-point survey instrument). We examined effects on missed visits (ie, >30 days late for next scheduled encounter) in all groups and retention in care at 15 months in group 1 and group 4 by use of electronic health records. We assessed effects on treatment success at 15 months (ie, HIV RNA concentration <400 copies per mL or adjudicated care status) in a prospectively enrolled subset of clients from group 1 and group 4. We estimated treatment effects with mixed-effects logistic regression, adjusting for sex, age, and baseline care status. This trial is registered at the Pan-African Clinical Trials Registry (202101847907585), and is completed. FINDINGS: Between Aug 12, 2019, and Nov 30, 2021, 177 543 unique clients living with HIV made at least one visit to one of the 24 study clinics. The PCC intervention reduced the proportion of poor visits based on exit surveys from 147 (23·3%) of 632 during control periods to 33 (13·3%) of 249 during the first 6 months of intervention, and then to eight (3·5%) of 230 at 6 months or later (adjusted risk difference [aRD] for control vs ≥6 months intervention -16·9 percentage points, 95% CI -24·8 to -8·9). Among all adult scheduled appointments, the PCC intervention reduced the proportion of missed visits from 90 593 (25·3%) of 358 741 during control periods to 40 380 (22·6%) of 178 523 in the first 6 months, and then 52 288 (21·5%) of 243 350 at 6 months or later (aRD for control vs the intervention -4·2 percentage points, 95% CI -4·8 to -3·7). 15-month retention improved from 33 668 (80·2%) of 41 998 in control to 35 959 (83·6%) of 43 005 during intervention (aRD 5·9 percentage points, 95% CI 0·6 to 11·2), with larger effects in clients newly starting treatment (aRD 12·7 percentage points, 1·4 to 23·9). We found no effect on treatment success (based on viral load) in a nested subcohort (379 [83·7%] of 453 in the control phase vs 402 [83·8%] of 480 in the intervention phase; aRD 0·9 percentage points, -5·4 to 7·2). INTERPRETATION: Improving the caring aspects of health-care worker behaviour is feasible in public health settings, enhances client experience, reduces missed appointments, and increases retention. FUNDING: The Bill & Melinda Gates Foundation.Item Contextual factors and implementation strategies for a biomarker-augmented alcohol screening with brief intervention and referral to treatment (SBIRT) program for HIV-affected adolescents in Zambia: a qualitative study guided by RE-AIM / PRISM.(2025-Aug-11) Paniagua-Avila, Alejandra; Kanguya, Tukiya; Mwamba, Chanda; Hahn, Judith A.; Latkin, Carl; Chander, Geetanjali; Martins, Silvia S.; Munthali, Saphira; McDonell, Michael G.; Sharma, Anjali; Kane, JeremyINTRODUCTION: Screening, Brief Interventions and Referral to Treatment (SBIRT) programs reduce unhealthy alcohol use among adolescents. However, self-report screening alone may lead to false negatives and low service use, especially in HIV care settings. This study explored the contextual implementation factors and strategies of an alcohol biomarker-augmented SBIRT program for HIV-affected adolescents in Zambia, where alcohol use and HIV prevalence are high. METHODS: We conducted key informant interviews (n=7) with mental health providers and policymakers and focus groups (n=16 groups; 10-11 participants each) with healthcare providers, adolescents, and caregivers, guided by a case vignette of the biomarker-augmented SBIRT program. Thematic analysis followed the implementation frameworks Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) and Practical, Robust Implementation and Sustainability Model (PRISM). RESULTS: Participants perceived the SBIRT program as appropriate for adolescent alcohol use. Key contextual factors included: lack of alcohol treatment programs, community stigma against HIV and alcohol use, and robust implementation infrastructure through HIV healthcare. Strategies to enhance acceptability included making alcohol screening universal to avoid labeling adolescents, privacy and confidentiality during biomarker sampling, and peer-led age-matched counseling at screening. To enhance reach, participants suggested designing the program with attention to gender-specific needs and integrating it into HIV healthcare and alcohol use hotspots (e.g. schools). CONCLUSIONS: Implementation strategies should be designed to reduce stigma, build trust, engage adolescents across genders, and reach youth through clinical and community channels. Future research should define how to select, train, and evaluate peer counselors and assess the effectiveness of alcohol biomarkers within SBIRT programs in motivating behavior change.Item Designing community-based strategies to reach non-household contacts of people with tuberculosis in Lusaka, Zambia: a rapid qualitative study among key stakeholders.(2024) Kerkhoff, Andrew D.; Foloko, Marksman; Kundu-Ng'andu, Evelyn; Nyirenda, Herbert; Jabbie, Zainab; Syulikwa, Mainza; Mwamba, Chanda; Kagujje, Mary; Muyoyeta, Monde; Sharma, AnjaliBACKGROUND: In high-burden settings, most tuberculosis (TB) transmission likely occurs outside the home. Our qualitative study in Zambia explored the acceptability and preferences for designing TB active case finding (ACF) strategies to reach non-household contacts of people with TB. METHODS: We conducted 56 in-depth interviews with persons with TB ( RESULTS: All participants felt that TB was an important issue in their community and that new detection strategies were needed. A "social-network strategy" was perceived as acceptable and feasible, where participants noted it was a caring act and could facilitate early diagnosis. For a "venue-based strategy," most participants suspected TB transmission occurred at bars/taverns due to heavy alcohol use and prolonged time spent in crowded spaces; churches and betting halls were also commonly mentioned locations. Nearly all owners/leaders and patrons/attendees of bars, churches, and betting halls expressed acceptance of a venue-based strategy. They also indicated an interest in participating, citing many benefits, including increased TB knowledge/awareness, early diagnosis, convenience, and possibly reduced transmission, and recommended that the strategy incorporate sensitization, consent, volunteerism, and respectful, confidential, private services. For both strategies, most participants preferred the use of and being approached by trained peer TB survivors to facilitate ACF, given their prior TB patient experience and trust among community members. CONCLUSION: Stakeholders found social-network and venue-based TB-ACF strategies highly acceptable, recognizing their potential benefits for individuals and the broader community. Future research should evaluate the feasibility and effectiveness of TB ACF strategies for reaching non-household contacts.Item Intention to receive new vaccines post-COVID-19 pandemic among adults and health workers in Lusaka, Zambia.(2025-Mar-19) Sharma, Anjali; Kerkhoff, Andrew D.; Haambokoma, Mwiza; Shamoya, Bertha; Sikombe, Kombatende ; Simbeza, Sandra S.; Zulu, Nelly; Geng, Elvin H.; Eshun-Wilsonova, Ingrid; Le Tourneau, Noelle ; Pry, Jake M.OBJECTIVES: To estimate intention to receive newly introduced adult vaccines among community members and healthcare workers (HCWs) in Lusaka, Zambia in the context of previous COVID-19 vaccine uptake and perceived disease threat and, identify trusted sources of vaccine information. METHODS: We conducted a cross-sectional survey among a random sample of community members and a convenience sample of HCWs from 13 November to 15 December 2023. We evaluated future vaccination intentions by self-reported COVID-19 vaccine uptake, community role, vaccine type (COVID-19 booster, HIV, tuberculosis, malaria, pneumonia, diarrheal disease) and source of information using adjusted, mixed effects Poisson regression and adjusted probability models. RESULTS: We enrolled 395 (79.2 %) community members and 104 (20.8 %) HCWs (N = 499). There was high intention to receive new vaccines among community members (mean score = 83.6 %) and HCWs (mean score = 86.0 %), though intentions varied by vaccine type. Prior COVID-19 vaccine uptake (0, 1, 2+ doses) impacted intentions to receive a novel COVID-19 vaccine among community members (43.3 %, 62.8 %, 79.7 %, respectively) but were not associated with any other vaccine types. Intention to receive a vaccine was strongly associated with perceived disease severity and susceptibility as well as age, sex, education, and household income. Social media as a vaccine information source was associated with lower overall vaccine intention among community members, while health system and community sources were associated with higher overall intention to receive new vaccines. Government was a highly trusted source of vaccine information among all participants. CONCLUSION: Prior COVID-19 vaccination uptake did not predict future non-COVID-19 vaccine intention in Zambia. Perceived threat and select socio-demographic factors were key predictors, suggesting the need for rapid research to design communication strategies and identify trusted sources per target population.