Clinical Medicine
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- ItemPerceptions and barriers on the feasibility of decentralizing the collection of blood samples for testing in the community through the community art group model in Lusaka, Zambia.(The University of Zambia, 2019) Siwingwa, MpanjiThe focus of Community ART Group (CAG) model is on drug refill, adherence and support groups. The laboratory services are completely neglected in implementing this model in Zambia, and stable patients still have to go to the clinic for blood draws after collection of drugs from the community. In addition, phlebotomy delivery system is congested and has challenges with shortage of staff, insufficient funding, shortages of supplies and delivery services. The purpose of this study was to identify the perceptions, barriers and potential resources in decentralizing the collection of blood samples for routine testing into the CAG model. A qualitative case study design was used. Data was collected through ten Focused group discussions among CAG members, community and health care workers at ART clinics and in-depth interviews with five key informants. Data was analyzed using thematic method and this was done with the help of Nvivo version 10. Positive perceptions were identified as those which contributed to decongesting phlebotomy rooms, reduced missing appointments for blood draws, work Load, and lost results. Improved quality of phlebotomy service delivery and testing coverage, innovative way of bringing lab services closer to the people and inspire patients to monitor each other’s blood draws. The negative perceptions were compromised sample integrity and less contact with clinicians. The study also identified barriers to decentralize phlebotomy services within CAG and these included: long distance and transportation costs, inadequate community sensitization, lack of skills from the community to draw quality samples for testing, lack of privacy and confidentiality, CHWs not recognized by regulatory bodies, low level of literacy, shortage of qualified health workers and lack of remunerations. In summing up, the clinical psychosocial counsellors, volunteers, CHWs and HCWs were identified by all stake holders as prospective community phlebotomist in the decentralization of phlebotomy services. Decentralizing phlebotomy services into CAG model was perceived as decongesting and reducing work in the phlebotomy room, improved testing coverage and compromised sample integrity. This process incurred challenges due to lack of community sensitization and technical skills in phlebotomy, transportation cost and community health workers not recognition by regulatory bodies. The potential resources needed in community phlebotomy services were identifying prospective phlebotomist, materials for community sensitization, trainers and training materials, experts in quality assurance programs and financial support.
- ItemAcceptability and implementation experiences of the “test and treat” antiretroviral therapy policy guideline among patients and healthcare workers in Lusaka district of Zambia.(The University of Zambia, 2019) Mulinda, Mweemba BThe World Health Organization stated that there is now sufficient proof that earlier use of antiretroviral therapy results in better clinical outcomes for people living with human immunodeficiency virus compared with delayed treatment and thus recommended immediate antiretroviral therapy initiation irrespective of the stage of the disease or Cluster of Differentiation 4+ count for adults, adolescents and children. The new antiretroviral therapy policy is dubbed “Test and Treat” whose implementation started in October 2016 in Lusaka District of Zambia by the Ministry of health and cooperating partners. Test and Treat has since been rolled out to other districts. This is all to further accelerate efforts to meet the ambitious Fast-Track target for 2020, including achieving major reductions in the number of people dying from HIV-related causes. The main purpose of the study was to explore acceptability and implementation experiences of “Test and Treat” as a new antiretroviral therapy policy guideline among healthcare workers and patients in Lusaka District. The study further sought to investigate the health system’s capacity to support the policy in Lusaka District. This was a qualitative study that used exploratory case study. The research was undertaken in five Anti-retroviral therapy healthcare centres in Lusaka District, between July 2017 and May 2018. Five focus group discussions were conducted with individuals who were human immuno-deficiency virus positive and were on anti-retroviral therapy. Five In-depth interviews were held with at least two Psychosocial Counselors at each centre and twenty five key informant interviews with healthcare professionals involved in implementing the program. All interviews were audio-recorded and were conducted within the healthcare facility. From the information recorded in each discussion, major themes and sub-themes were identified which were linked to direct quotes from the respondents. Interviews were transcribed and accuracy was checked. Software called Nvivo 10 was used to analyze data and for easy information management. The findings of the study revealed that, there was high acceptability of “Test and Treat” among the patients and healthcare workers. They observed that the implementation of this policy has resulted in; improved health outcomes, no advancement to acquired immune-deficiency syndrome stage, higher productivity at work places and reduced hospital visits among the patients who were receiving treatment. The study however observed that; difficult disclosure; cultural implications; ethical implications; lack of initial physiological baseline parameters such as CD4 Count and Liver function test results and stigmatization and discrimination were major hindrances to acceptability and smooth implementation of the policy. “Test and Treat” was viewed to have relative advantage over other previous HIV/AIDS intervention strategies as it has been observed to be largely compatible with other health systems operations available in most healthcare facilities. It has been tried elsewhere with positive results according to literature reviewed as such there is no much complexities reported. Observed outcomes of clinical trials done so far reveal programme simplicity leading to high acceptability and smooth implementation.
- ItemPrevalence, predictors and HIV disease progression in immunovirogical discordant HIV patients at 12 months of first line antiretroviral therapy in Zambia.(The University of Zambia, 2019) Sivile, SuilanjiCombined antiretroviral therapy (cART) has improved mortality and morbidity among HIV-infected patients. However, a third of HIV-infected patients still present to care with advanced disease despite the rollout of cART. Some of these patients fail to appropriately reconstitute their immune system despite being on effective cART signified by a suppressed viral load. This phenomenon is termed immunovirological discordance. These patients remain immunocompromised and could still be at risk of opportunistic infections and subsequent mortality. As the HIV population is getting older, immune senescence and its impact on discordance has become topical. Understanding the prevalence and predictors of this phenomenon is crucial for the HIV response. A cross-sectional study was conducted in 20 health facilities throughout Zambia selected based on probability proportion to size method. Adult HIV patients with a suppressed viral load at 12 months of first line cART were enrolled. Relevant blood samples were drawn and a questionnaire was completed with the aid of the hospital chart . Adequate immune response was defined as an increase of baselines CD4cell count to >200cells/μL at 12 months of ART and/or an absolute CD4cell count change of >150cells/μL. We used multivariate logistic models to identify predictors for immunovirological discordance. 360 patients were enrolled. 57% were females. 68% were 25-44 years old. 17% had a CD4cell count below 200cells/μL at 12 months of ART and 54% had an absolute CD4cell count change of less than 150cells/μL. Females were 2 times more likely to have a CD4cell count above 200cells/μL (OR 2: 95%CI 1.00-3.62;P=0.028) and patients with a body mass index >25kg/m2 were 4 times more likely to have a high CD4 count compared to those underweight (OR 4:95% CI 1.29-13.73; P=0.017) . A baseline CD4cell count below 200cells/μL was a predictor for an absolute CD4cell count change of less than 150cells/μL (OR12:95% CI 4.04-33.41; P= <0.0001). Hepatitis B virus positive status (OR 0.03:95% CI 0.003-0.25; P= 0.001) and baseline WHO stageIV/III disease (OR 0.01:95% CI 0.01-0.59; P=0.0001) were predictors for suboptimal CD4cell response. Patient’s age, Positive RPR, TNF levels and CRP levels were not associated with suboptimal CD4cell recovery. There was no association between WHO Clinical Stage at 12 months of cART with immunovirological discordance. In patients with viral load suppression at 12 months of cART, immunovirological discordance is common. Baseline CD4cell count, male sex, baseline low BMI, HBV infection and baseline WHO clinical stage III/IV could predict immunovirological discordance. Markers of morbidity such as high CRP levels and advanced WHO clinical staging at 12 months of cART are not necessarily associated with suboptimal immune response. Early commencement of cART may prevent immunovirological discordance, a finding which supports the ‘test and start’ strategy. Further investigation in understanding the immunology of discordance and its clinical outcomes are proposed.
- ItemFactors associated with obstetric fistula repair failures at St. Francis and Monze mission hospitals, Zambia, 2010—2016; a retrospective facility based cohort.(The University of Zambia, 2019) Kapaya, FredObstetric fistula causes significant maternal morbidity especially in sub-Saharan African. In Zambia the prevalence is about 0.53%. Despite a number of women receiving corrective surgery for fistula at a number of hospitals in Zambia, there is paucity of data on the quality of care. This study was conducted to determine the overall proportion of fistula repair failures and identify factors associated with failure in Eastern and Southern Provinces, Zambia. This was a retrospective cohort study using data extracted from hospital records of obstetric fistula repairs between January 2010 to December 2016 at St. Francis and Monze Mission Hospitals which are among the four major fistula repair hospitals in Zambia. All women who underwent repair for obstetric fistula between 2010 and 2016 were included while non obstetric fistulas and lack of dye test results at discharge were excluded from the study. The outcome of interest was failure of fistula repair at hospital discharge confirmed by a dye test. Descriptive statistics were calculated and STATA version 13 used to conduct multivariable logistic regression to determine factors associated with failure of fistula repair. A total of 453 obstetric fistula repairs were included in the analysis. Of these, 56 (12.4%) had failure of fistula repair at hospital discharge. The median age at fistula development was 23 years; at fistula repair was 27 years; and years with fistula was 1 (IQR: 0–5). In multivariable logistic regression, factors associated with increased odds of failure included having a fistula with urethral involvement (55.4 % versus 14.1%; AOR=6.0, 95% CI: 2.83—12.97; vaginal scarring (46.4% versus 18.6%; AOR=2.5, 95% CI: 1.17—5.35 ;) and experiencing post- operative complications (48.2% versus 2.3%; AOR=22.9, 95%CI: 9.33—55.97). Women with vaginal scarring, urethral involvement and post-operative complications, had greater odds of repair failure. It is therefore recommended that quality of post-operative care be improved and caution be paid to the repair of women who present with urethral damage, vaginal scarring and post-operative complications. The evidence generated would help the Ministry of Health to restructure and improve fistula care programs in Zambia.