Integrating Mental Health and HIV Services in Zimbabwean Communities: A Nurse and Community-led Approach to Reach the Most Vulnerable

Alcohol use and depression negatively impact adherence, retention in care, and HIV progression, and people living with HIV (PLWH) have disproportionately higher depression rates. In developing countries, more than 76% of people with mental health issues receive no treatment. We hypothesized that stepped-care mental health/HIV integration provided by multiple service professionals in Zimbabwe would be acceptable and feasible. A three-phase mixed-method design was used with a longitudinal cohort of 325 nurses, community health workers, and traditional medicine practitioners in nine communities. During Phase 3, 312 PLWH were screened by nurses for mental health symptoms; 28% were positive. Of 59 PLWH screened for harmful alcohol and substance use, 36% were positive. Community health workers and traditional medicine practitioners screened 123 PLWH; 54% were positive for mental health symptoms and 29% were positive for alcohol and substance abuse. Findings indicated that stepped-care was acceptable and feasible for all provider types

HIV self-testing among female sex workers in Zambia: A cluster randomized controlled trial

Background: HIV self-testing (HIVST) may play a role in addressing gaps in HIV testing coverage and as an entry point for HIV prevention services. We conducted a cluster randomized trial of 2 HIVST distribution mechanisms compared to the standard of care among female sex workers (FSWs) in Zambia. Methods and findings Trained peer educators in Kapiri Mposhi, Chirundu, and Livingstone, Zambia, each recruited 6 FSW participants. Peer educator–FSW groups were randomized to 1 of 3 arms: (1) delivery (direct distribution of an oral HIVST from the peer educator), (2) coupon (a coupon for collection of an oral HIVST from a health clinic/pharmacy), or (3) standard-of-care HIV testing. Participants in the 2 HIVST arms received 2 kits: 1 at baseline and 1 at 10 weeks. The primary outcome was any self-reported HIV testing in the past month at the 1- and 4-month visits, as HIVST can replace other types of HIV testing. Secondary outcomes included linkage to care, HIVST use in the HIVST arms, and adverse events. Participants completed questionnaires at 1 and 4 months following peer educator interventions. In all, 965 participants were enrolled between September 16 and October 12, 2016 (delivery, N = 316; coupon, N = 329; standard of care, N = 320); 20% had never tested for HIV. Overall HIV testing at 1 month was 94.9% in the delivery arm, 84.4% in the coupon arm, and 88.5% in the standard-of-care arm (delivery versus standard of care risk ratio [RR] = 1.07, 95% CI 0.99–1.15, P = 0.10; coupon versus standard of care RR = 0.95, 95% CI 0.86–1.05, P = 0.29; delivery versus coupon RR = 1.13, 95% CI 1.04–1.22, P = 0.005). Four-month rates were 84.1% for the delivery arm, 79.8% for the coupon arm, and 75.1% for the standard-of-care arm (delivery versus standard of care RR = 1.11, 95% CI 0.98–1.27, P = 0.11; coupon versus standard of care RR = 1.06, 95% CI 0.92–1.22, P = 0.42; delivery versus coupon RR = 1.05, 95% CI 0.94–1.18, P = 0.40). At 1 month, the majority of HIV tests were self-tests (88.4%). HIV self-test use was higher in the delivery arm compared to the coupon arm (RR = 1.14, 95% CI 1.05–1.23, P = 0.001) at 1 month, but there was no difference at 4 months. Among participants reporting a positive HIV test at 1 (N = 144) and 4 months (N = 235), linkage to care was non-significantly lower in the 2 HIVST arms compared to the standard-of-care arm. There were 4 instances of intimate partner violence related to study participation, 3 of which were related to HIV self-test use. Limitations include the self-reported nature of study outcomes and overall high uptake of HIV testing. Conclusions: In this study among FSWs in Zambia, we found that HIVST was acceptable and accessible. However, HIVST may not substantially increase HIV cascade progression in contexts where overall testing and linkage are already high. Trial registration ClinicalTrials.gov NCT0282724

Estimating health workforce needs for antiretroviral therapy in resource-limited settings

BACKGROUND: Efforts to increase access to life-saving treatment, including antiretroviral therapy (ART), for people living with HIV/AIDS in resource-limited settings has been the growing focus of international efforts. One of the greatest challenges to scaling up will be the limited supply of adequately trained human resources for health, including doctors, nurses, pharmacists and other skilled providers. As national treatment programmes are planned, better estimates of human resource needs and improved approaches to assessing the impact of different staffing models are critically needed. However there have been few systematic assessments of staffing patterns in existing programmes or of the estimates being used in planning larger programmes. METHODS: We reviewed the published literature and selected plans and scaling-up proposals, interviewed experts and collected data on staffing patterns at existing treatment sites through a structured survey and site visits. RESULTS: We found a wide range of staffing patterns and patient-provider ratios in existing and planned treatment programmes. Many factors influenced health workforce needs, including task assignments, delivery models, other staff responsibilities and programme size. Overall, the number of health care workers required to provide ART to 1000 patients included 1–2 physicians, 2–7 nurses, <1 to 3 pharmacy staff, and a much wider range of counsellors and treatment supporters. We estimate from these data that the equivalent of 20 000 to 100 000 physicians, nurses, pharmacists and other core clinical staff will be needed to meet the WHO target of treating 3 million people by the end of 2005. The total number of staff, including counsellors, administrators and other cadres, could be substantially higher. DISCUSSION: These data are consistent with other estimates of human resource requirements for antiretroviral therapy, but highlight the considerable variability of current staffing models and the importance of a broad range of factors in determining personnel needs. Few outcome or cost data are currently available to assess the effectiveness and efficiency of different staffing models, and it will be important to develop improved methods for gathering this information as treatment programmes are scaled up

Enhanced pyroelectric crystal D-D nuclear fusion using tungsten nanorods

Summary Thin films of vertically aligned tungsten nanorods were used to enhance field ionization in pyroelectric crystal D-D fusion experiments resulting in increased neutron production. The tungsten nanorods were deposited on a single LiTaO 3 crystal using sputter deposition at glancing angles. The combination of a single tungsten tip with a thin film of nanorods on the face of the crystal yielded about four times the number of neutrons than did either a single tip or nanorods alone

The Zambian Peer Educators for HIV Self-Testing (ZEST) Study: A randomized controlled trial of HIV self-test provision for female sex workers in Zambia

Background: HIV testing is the critical first step for realization of the 90-90-90 targets, which aim to have 90% of people living with HIV aware of their status, 90% of those linked to care, and 90% of those virally suppressed. However, HIV testing among female sex workers (FSWs) in sub-Saharan Africa remains below the 90% target. The objective of this study was thus to evaluate 1) the effectiveness of HIV self-test provision compared to standard of care HIV testing for increasing HIV testing coverage among FSW and 2) the effectiveness of two delivery models for HIV self-test provision. Methods: This study was a cluster randomized trial conducted in three transit towns in Zambia: Livingstone, Chirundu, and Kapiri Mposhi. FSWs were recruited by a peer educator. FSW-peer educator groups were randomized in a 1:1:1 ratio to one of three groups: 1) standard-of-care, which consisted of referral to existing HIV testing facilities 2) direct delivery of an HIV self-test kit from the peer educator to the participant or 3) distribution of a coupon from the peer educator, which could be used to collect an HIV self-test kit at a participating distribution point. Results: At one month, 94.9% and 84.4% of participants in the delivery and coupon arms reported testing for the past month, compared to 88.5% in the standard-of-care arm. Participants in the delivery arm were significantly more likely to report testing for HIV in the past month compared to the coupon arm but not compared with standard of care (Direct vs SOC: RR 1.07, P=0.29, Coupon vs SOC: RR 1.05 P=0.10, Direct vs Coupon RR 1.13, P=0.005). At four months, 84.1%, 79.8%, and 75.1% of participants reported testing for HIV in the past month in the delivery, coupon, and standard-of-care arms. There were no statistically significant differences in HIV testing at four months. Conclusion: Although HIV self-testing did not increase HIV testing, high reported use of HIV self-tests indicate that it is acceptable to FSWs in Zambia. Although directly providing the HIV self-test may increase use in the short-term, delivery models utilizing distribution via existing distribution points (e.g., clinics or pharmacies) will likely be successful in distributing kits

Effect of HIV self-testing on the number of sexual partners among female sex workers in Zambia.

OBJECTIVES: To assess the effect of two health system approaches to distribute HIV self-tests on the number of female sex workers client and nonclient sexual partners. DESIGN: Cluster randomized controlled trial. METHODS: Peer educators recruited 965 participants. Peer educator-participant groups were randomized 1 : 1 : 1 to one of three arms: delivery of HIV self-tests directly from a peer educator, free facility-based delivery of HIV self-tests in exchange for coupons, or referral to standard-of-care HIV testing. Participants in all three arms completed four peer educator intervention sessions, which included counseling and condom distribution. Participants were asked the average number of client partners they had per night at baseline, 1 and 4 months, and the number of nonclient partners they had in the past 12 months (at baseline) and in the past month (at 1 month and 4 months). RESULTS: At 4 months, participants reported significantly fewer clients per night in the direct delivery arm (mean difference -0.78 clients, 95% CI -1.28 to -0.28, P = 0.002) and the coupon arm (-0.71, 95% CI -1.21 to -0.21, P = 0.005) compared with standard of care. Similarly, they reported fewer nonclient partners in the direct delivery arm (-3.19, 95% CI -5.18 to -1.21, P = 0.002) and in the coupon arm (-1.84, 95% CI -3.81 to 0.14, P = 0.07) arm compared with standard of care. CONCLUSION: Expansion of HIV self-testing may have positive behavioral effects enhancing other HIV prevention efforts among female sex workers in Zambia. TRIAL REGISTRATION: ClinicalTrials.gov NCT02827240

Acceptability of a Microbicide Among Women and Their Partners in a 4-Country Phase I Trial

Objectives. We analyzed qualitative and quantitative data for 98 HIV-negative, low-risk women in Malawi, Zimbabwe, India, and Thailand who participated in a safety and acceptability study of BufferGel, a vaginal microbicide to determine the across-country acceptability of vaginal microbicides among women and their partners. Methods. Quantitative survey data were collected at 7 and 14 days after use among enrolled women, and exit interviews were conducted with women and their partners in separate focus group discussions. Results. Acceptability was high in all sites (73% of women approved of the microbicide). Women in Africa, where HIV infection rates are highest, were virtually unanimous in their desire for such a product, suggesting that an individual’s perception of being at risk for HIV will outweigh concerns about side effects, problems applying a product, or other factors, when products are shown to be efficacious. But men and women reported that use, which was kept secret from an intimate partner, would be difficult and might “break the trust” of a relationship. Conclusions. Acceptability research across diverse settings through all stages of microbicide research, development, and postlicensure dissemination can help maximize acceptability and use

Zambian Peer Educators for HIV Self-Testing (ZEST) study: rationale and design of a cluster randomised trial of HIV self-testing among female sex workers in Zambia

Background: HIV testing and knowledge of status are starting points for HIV treatment and prevention interventions. Among female sex workers (FSWs), HIV testing and status knowledge remain far from universal. HIV self-testing (HIVST) is an alternative to existing testing services for FSWs, but little evidence exists how it can be effectively and safely implemented. Here, we describe the rationale and design of a cluster randomised trial designed to inform implementation and scale-up of HIVST programmes for FSWs in Zambia. Methods: The Zambian Peer Educators for HIV Self-Testing (ZEST) study is a 3-arm cluster randomised trial taking place in 3 towns in Zambia. Participants (N=900) are eligible if they are women who have exchanged sex for money or goods in the previous 1 month, are HIV negative or status unknown, have not tested for HIV in the previous 3 months, and are at least 18 years old. Participants are recruited by peer educators working in their communities. Participants are randomised to 1 of 3 arms: (1) direct distribution (in which they receive an HIVST from the peer educator directly); (2) fixed distribution (in which they receive a coupon with which to collect the HIVST from a drug store or health post) or (3) standard of care (referral to existing HIV testing services only, without any offer of HIVST). Participants are followed at 1 and 4 months following distribution of the first HIVST. The primary end point is HIV testing in the past month measured at the 1-month and 4-month visits. Ethics and dissemination This study was approved by the Institutional Review Boards at the Harvard T.H. Chan School of Public Health in Boston, USA and ERES Converge in Lusaka, Zambia. The findings of this trial will be presented at local, regional and international meetings and submitted to peer-reviewed journals for publication. Trial registration number Pre-results; NCT02827240

Effect of HIV self-testing on the number of sexual partners among female sex workers in Zambia

Objectives: To assess the effect of two health system approaches to distribute HIV self-tests on the number of female sex workers’ client and nonclient sexual partners. Design: Cluster randomized controlled trial. Methods: Peer educators recruited 965 participants. Peer educator–participant groups were randomized 1 : 1 : 1 to one of three arms: delivery of HIV self-tests directly from a peer educator, free facility-based delivery of HIV self-tests in exchange for coupons, or referral to standard-of-care HIV testing. Participants in all three arms completed four peer educator intervention sessions, which included counseling and condom distribution. Participants were asked the average number of client partners they had per night at baseline, 1 and 4 months, and the number of nonclient partners they had in the past 12 months (at baseline) and in the past month (at 1 month and 4 months). Results: At 4 months, participants reported significantly fewer clients per night in the direct delivery arm (mean difference −0.78 clients, 95% CI −1.28 to −0.28, P = 0.002) and the coupon arm (−0.71, 95% CI −1.21 to −0.21, P = 0.005) compared with standard of care. Similarly, they reported fewer nonclient partners in the direct delivery arm (−3.19, 95% CI −5.18 to −1.21, P = 0.002) and in the coupon arm (−1.84, 95% CI −3.81 to 0.14, P = 0.07) arm compared with standard of care. Conclusion: Expansion of HIV self-testing may have positive behavioral effects enhancing other HIV prevention efforts among female sex workers in Zambia. Trial Registration: ClinicalTrials.gov NCT02827240