Clinical Medicine

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Acceptability 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 B
The 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.
Access to sexual reproductive health services among HIV positive adolescents attending university teaching hospital (UTH) – PCOE (Pediatric Center of Excellence) Lusaka-Zambia.
(The University of Zambia, 2019) Ndongmo, Therese Ntigwa
An estimated 80,000 adolescents (10-19 years) are living with HIV in Zambia (UNICEF, 2011). As they mature into adulthood, adolescents encounter challenges related to sexuality and sexual reproductive health (SRH), coupled with dealing with a complex condition such as HIV infection. The current study aimed at exploring the experience, challenges and barriers encountered by adolescents in accessing reproductive health services at the Pediatric Center Of Excellence (PCOE) - University Teaching Hospital (UTH). It is hypothesized that adolescents living with HIV are also beginning to experience their sexuality, may have some challenges in accessing SRH services. The study was conducted using a mixed-method whereby adolescents aged 15-19 years were surveyed using a semi-structured questionnaire, about their needs and access to SRH. Services offered at the study setting (UTH PCOE) were also investigated through key informants’ in-depth interviews of healthcare workers. Emerging themes from open-ended questions qualitative data were explored using content analysis. The data was entered into an access database and exported to SPSS for analyses. Ethical clearance was obtained from the UNZABREC. A total of 148 adolescents aged 15-19 years were interviewed, including 63.5% females and 36.5% males. The majority (77%) had secondary education level. Those currently in school were 77.2%. About 68.9 % expressed intention to have children; 40.1 % admitted to having a boy or girl friends. Overall 15.1 % (21/139) have ever had sex. Of those sexually experienced, only 61.1 % reported consistent condom use. Two (2.1%) of the girls had been pregnant before. Ten out of 52 respondents indicated having had an STI before. Not being in school was found to be a positive predictor, not only for knowing where to go to talk about sex (OR= 2.53; 95% CI:1.10-5.82; p=0.02), but also for having ever gone to seek advice on sexual issues (OR=2.61; 95% CI:1.04-6.58; p=0.03). While SRH services are available, although not covering the full spectrum of needs at the PCOE, healthcare workers expressed challenges in terms of time and resources dedicated to these services. Overall access to SRH services (at least a counseling, FP, or STI service) was 31.5% in terms of availability and utilization combined. There was no significant factor that predicted access or not. We find evidence of reported “sexuality experience” illustrated by their expressed sexual desire and needs, presence of social friendships, and desire to have healthy children. HIV infected adolescent sexual reproductive needs were found to be similar to those of general population of the same age in terms of counseling in sexual matters, Family Planning (FP) and Sexual Transmitted Infection (STI) services. ALHIV face additional challenges within their family and social environments. This suggests that efforts should be made to provide one-stop center for all adolescent overall health care needs and to create an environment that is more aware, responsive, and tolerant of adolescent sexuality not only at tertiary but also a lower levels of healthcare settings. HCWs are available at the UTH PCOE to provide the services but still face challenges in terms of adequate training, time and recourses dedicated to these services.
Burden attributable to childhood and adolescent primary headache disorders in Lusaka and Ndola school children aged 7 - 17 years.
(The University of Zambia, 2019) Kawatu, Nfwama
Headache is a common complaint in the paediatric and adult populations. However, the prevalence, types and effects on the quality of life of the children that suffer from headache is not known. This study assessed the prevalence and burden of primary headache disorders in children and adolescents. The data collected and analysed produced a preliminary report of an ongoing study. This was a cross sectional study, conducted over a 6-month period which targeted participants aged 7-17 years in Lusaka and Ndola schools. It was conducted using a standardized questionnaire that was administered with the guidance of the principal investigator for ages 7-11 years and by self-administration for ages 12-17 years. Questions of interest included the prevalence, duration, intensity and frequency of any headache. Lost school days and parental work days highlighted the quality of life of these children in general. The data was analysed using a validated algorithm of classification of headache which is based on the International Classification of Headache Disorders III. The 1 year prevalence of headache in general was at 87.3% of the study population. Probable migraine was most common at 44.5% followed by migraine 19.6%. Girls (68.6%) suffered more migraine; boys displayed a high prevalence in tension type headache (39.9%), followed by probable migraine headache at 39.9%. A reduction in the quality of life was significantly associated with a longer duration of headache days, migraine headache and probable migraine headache whereas there was no significant association with other headache types. The prevalence of primary headache disorders in Zambia is significantly high at 873% with highest prevalences of migraine headache in girls and tension type headache in boys. The quality of life was not significantly altered in these children that suffered headache.
Determinants of underweight among under- five children in Zambia - evidence from 2001, 2007 and 2014 Zambia demographic and health surveys.
(The University of Zambia, 2019) Nakawala, Tamika S.
Over the past ten years, underweight levels in Zambia have remained static at 15%. Literature has shown that the mortality risk of children who are even mildly underweight is increased and this risk increases for those children who are severely underweight. The main objective of the study was to assess the determinants of underweight in under-five children over the last two decades in Zambia. This was a cross sectional study using data from the 2001, 2007 and 2013-14 Zambia Demographic and Health Survey’s. The study included a pooled estimate of about 26,735 under-five children, 6877 in the 2001 survey, 6401 in the 2007 survey and 13, 457 children in the 2013-14 survey. Multiple logistic regression showed that female children were 25% less likely to be underweight than male children [0R=0.75, 95% CI (0.69-0.82), p˂0.0001]. Children from rural areas had reduced odds of being underweight than those from urban areas [OR=0.77, 95%CI (0.68-0.89), p˂0.0001], Children aged 13-24 and 25-36 months had increased odds of being underweight [OR=1.71, 95% CI (1.48-1.98), p˂0.0001] and [OR=1.90, 95% CI (1.64-2.20), p˂0.0001] respectively than children aged 0-12 months. Having had diarrhoea [OR=1.33, 95% CI (1.18-1.50), p˂0.0001] or fever [OR=1.19, 95% CI (1.07-1.32), P=0.001] increased the odds of a child below five being underweight. The odds of underweight in under-five children reduced with an increase in the mother’s education and wealth index. Children whose mothers had tertiary education, came from the richest wealth quintile and children who were large at birth had the lowest odds of being underweight [OR=0.41 95% CI (0.27-0.64), p˂0.0001], [OR=0.40, 95%CI (0.32-0.50), p˂0.0001] and [OR=0.38, 95%CI (0.33-0.44), p˂0.0001] respectively. The study established that mothers with higher education, from the richest wealth index, an average sized child at birth, being female and residing in rural area were protective factors for underweight in children. On the other hand having had diarrhoea and fever was a disadvantage to the child as this promoted being underweight. In addition, older children were more likely to be underweight.
Factors 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, Fred
Obstetric 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.
Factors associated with unfavourable tuberculosis treatment outcomes in Lusaka, Zambia, 2015: a secondary analysis of routine surveillance data.
(The University of Zambia, 2019) Nanzaluka, Francis H.
Tuberculosis (TB) is a major public health challenge in low and middle income countries. Factors associated with unfavourable treatment outcomes have been known to affect treatment and control of the disease. However, analysis of routine data in Zambia does not show the factors associated. We determined the proportion of tuberculosis treatment outcomes and factors associated. Unfavourable outcome was defined as death, lost-to-follow-up, treatment-failure, or not-evaluated, and favourable outcome as a patient cured or completed-treatment. Data were abstracted from treatment registers at a referral hospital, an urban-clinic and peri-urban (purposively selected) for all TB cases on treatment from 1st January to 31st December, 2015. Proportions were calculated for treatment outcomes, and associations between unfavourable outcome and factors including age, HIV status, health facility, and patient type, were analysed using univariate logistics regression. Multivariable stepwise logistic regression was used to control for confounding, report adjusted odds ratios (AOR), and 95% confidence intervals (CI). A total of 1724 registered TB patients from the urban-clinic (40%), 1st Level Hospital (38%) and peri-urban-clinic (22%) were included in the study. Of the total patients overall unfavourable outcome was 43%. Total unfavourable outcome was treatment-failure (0.3%), lost-to-follow-up (5%), death (9%) and not-evaluated (29%). The odds of unfavourable outcome were higher among patients >59 years (AOR=2.9, 95%CI:1.44–5.79), among relapses (AOR=1.65, 95%CI:1.15–2.38), patients who sought treatment at the Urban clinic (AOR=1.76, 95%CI:1.27–2.42) and among TB/HIV co-infected patients (AOR=1.56, 95%CI:1.11–2.19). The overall unfavourable treatment outcome found in the study was high in the selected facilities. Being >59years old, being a relapse case, being HIV positive and seeking treatment at the urban clinic were factors found to be associated with unfavourable treatment outcomes. Special attention to patients of >59years old, relapse cases and HIV positive in the TB treatment is recommended and also close monitoring of health facilities in increasing efforts aimed at evaluating all the outcomes. Studies are required to identify and test interventions aimed at improving treatment outcomes.
Perceptions 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, Mpanji
The 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.
Prevalence, 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, Suilanji
Combined 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.
The clinical associations of dyslipidaemia among hypertensive adults presenting to the university teaching hospital (UTH), Lusaka adult hospital, Zambia.
(The University of Zambia, 2019) Mutengo, Katongo Hope
Co-existence of hypertension and dyslipidaemia, also referred to as dyslipidaemic hypertension (DH), is known to have synergistic effect on the development of cardiovascular disease (CVD). In Zambia, there is scanty information on distinguishing features of dyslipidaemic hypertension. The study aimed at identifying factors associated with dyslipidaemic hypertension in adults at a tertiary hospital in Zambia. This was a cross-sectional study conducted from January 2017 to July, 2017. One hundred and sixty-one (161) participants were enrolled comprising 88 hypertensives and 73 controls. Relevant demographics, physical examinations, bio-electric impedance analysis and laboratory investigations were performed. Fasting lipid and lipoprotein parameters which included fasting serum total cholesterol (TC), high density lipoprotein cholesterol (HDL-C), low density lipoprotein cholesterol (LDC-C) and triglycerides (TG) were analysed for lipid abnormalities. Data was analyzed using Stata version 15. The median age was 47 years (IQR; 39, 58) and 38 years (IQR; 38, 48) for the hypertensive and control groups, respectively. 53.3% of hypertensive and 46.7% of controls had at least one lipid abnormality. The factors associated with dyslipidaemic hypertension were; TC [aOR 2.41; 95%CI 1.57, 3.69; p<0.001], TG [aOR 3.28; 95%CI 1.12, 9.63; p=0.031] and HDL-C [aOR 0.10; 95%CI 0.03, 0.39; p=0.001]. On the other hand, the factors noted to be associated with dyslipidaemia only were; TC [aOR 3.61; 95%CI 2.08, 6.28; p<0.001], male gender [aOR 0.22; 95%CI 0.09, 0.53, p=0.001] and HDL-C [aOR 0.03; 95%CI 0.01, 0.11; p<0.001]. Traditional risk factors such as age, body mass index, waist circumference, waist-to-hip ratio did not show strong associations on multi-variate analysis. The study showed that increase in total cholesterol and triglycerides, and a reduction in high density lipoprotein cholesterol was significantly associated with dyslipidaemic hypertension. It is therefore imperative that management of hypertension should also focus on identifying and correcting associated lipid disorders.

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