Female Partner Acceptance as a Predictor of Men’s Readiness to Undergo Voluntary Medical Male Circumcision in Zambia: The Spear and Shield Project

The World Health Organization has recommended the scale-up of voluntary medical male circumcision (VMMC) for HIV prevention in sub-Saharan Africa; however, men are often uninterested in undergoing VMMC. The Spear & Shield project enrolled 668 men and female partners from ten Zambian community health centers into parallel interventions promoting VMMC for HIV prevention or time-matched control conditions. A mediation model was utilized to examine the relationships between changes in women’s acceptance of VMMC and men’s readiness to undergo the procedure. Results demonstrated that, at 12 months post-intervention, a 5.9 % increase in the likelihood of undergoing VMMC among men in the experimental condition could be attributed to increased women’s acceptance. From a public health perspective, involving women in VMMC promotion interventions such as the Spear & Shield project could significantly impact the demand for VMMC in Zambia

Stages of Change for Voluntary Medical Male Circumcision and Sexual Risk Behavior in Uncircumcised Zambian Men: The Spear and Shield Project

Background: Dissemination and scale up of voluntary medical male circumcision (VMMC) programs is well supported by evidence that VMMC reduces HIV risk in populations with high HIV prevalence and low rates of circumcision, as is the case in Zambia. Purpose: At both individual and population levels, it is important to understand what stages of change for VMMC are associated with, especially across cultures. This study evaluated VMMC knowledge, misinformation, and stages of change for VMMC of uncircumcised men and boys (over 18 years), as well as the concurrent relationship between VMMC stages of change and sexual risk behaviors. Method: Uncircumcised (N = 800) adult men and boys (over 18) were screened and recruited from urban community health centers in Lusaka, Zambia, where they then completed baseline surveys assessing knowledge, attitudes, HIV risk behaviors, and stages of change for VMMC. A series of analyses explored cross-sectional relationships among these variables. Results: VMMC was culturally acceptable in half of the sample; younger, unmarried, and more educated men were more ready to undergo VMMC. Stage of change for VMMC was also related to knowledge, and those at greater HIV risk reported greater readiness to undergo VMMC. Conclusions: Efforts to increase VMMC uptake should address the role of perceived HIV risk, risk behaviors, readiness, accurate knowledge, cultural acceptance, and understanding of the significant degree of HIV protection conferred as part of the VMMC decision making process. These results support incorporating comprehensive HIV risk reduction in VMMC promotion programs

Chlamydia and gonorrhea infections in HIV-positive women in urban Lusaka, Zambia

Background: Sexually transmitted infections (STIs) remain an important public health issue in sub-Saharan Africa. STIs in HIV-positive women are associated not only with gynecological complications but with increased risk of HIV transmission to HIV-negative partners and newborns. Aims: The aims of this study are to determine the prevalence of chlamydia (CT) and gonorrhea (GC) and examine the demographic characteristics and risk behaviors associated with these STIs in a group of HIV-positive women in Lusaka, Zambia. Settings and Design: Cross-sectional study of a sample of HIV-infected women enrolled in two large studies conducted in urban Lusaka, Zambia. Materials and Methods: HIV-seropositive women (n = 292) were assessed for demographic and behavioral risk factors and tested for CT and GC. Univariate analysis was used to determine the demographic characteristics and risk behaviors associated with having CT or GC. Results: The identified prevalence of CT was 1% and of GC was 1.4%. There was an association of CT/GC with the use of alcohol before sex (OR = 9.I, CI = 0.59-0.15, P = 0.03). Conclusions: Rates of CT and GC are described in this sample of HIV-positive women. While being in HIV care may serve to increase medical care and condom use, alcohol use should be addressed in this population

The many faces of translational research: a tale of two studies

Translational research can take many forms: bench to bedside, across cultural groups, across geographical boundaries, among others. This case study will share how we addressed all three “translational” issues using two evidence-based studies (USA, Zambia) to illustrate these “roads less traveled.” Our implementation and dissemination efforts were anchored by the “train the trainer” strategy, and the Glasgow RE-AIM model provided programmatic guideposts and direction. Keeping all stakeholders (scientific, community, political) involved in the implementation and dissemination process was an essential, perhaps determining factor in the success of the translation process

Vaginal cleansing practices in HIV infected Zambian women

Vaginal practices are a variety of behavioral techniques that women use to manage their sexual life and personal hygiene. Women perceive vaginal practices as a beneficial practice. However, vaginal cleansing has been identified as one of the main risk factors for bacterial vaginosis and is potentially implicated in Human Immune Deficiency Virus (HIV) and sexually transmitted infection transmission. This study examined the prevalence of vaginal practices and the types of practices used among a sample of HIV positive women living in Lusaka, Zambia. Over 90% of all women recruited engaged in vaginal practices. Certain practices, such as use of water or soap, were more frequently used for hygiene reasons. Herbs and traditional medicines were mainly used to please sexual partner. Strategies to decrease VP appear urgently needed in the Zambian community

Antiretroviral Therapy in Zambia

BACKGROUND: Adherence to antiretroviral therapy (ART) is essential to optimize HIV treatment outcomes. Among individuals on ART, targeted peer support has been found to support adherence. This study of Zambian heterosexual couples living with HIV examined whether partners would exert a positive influence on each other's adherence, and compared adherence between couples in which either one or both members were on ART. METHODS: Couples (n = 446 participants), in which either or both member were on ART were assessed at baseline, 6 and 12 months. RESULTS: Most participants (64%, n = 263) were on ART; overall, uptake of ART increased to 74% at 12 months. At baseline, 76% reported near perfect adherence; at 6 and 12 months, 66% and 70% were adherent, respectively. A regression analysis indicated that the decline in adherence did not differ between those couples in which one or both partners were on ART [F (2, 624) = 0.37, p = .692]. Pairwise comparison indicated that adherence primarily decreased between baseline and 6 months (t = 2.72, p = .007), and was stable 6 to 12 months. CONCLUSIONS: This study of couples in Zambia found adherence was not enhanced by having a partner on ART, and that adherence declined over time. Partners on ART may not necessarily provide support for adherence to each other. Partners may represent an untapped resource for optimizing adherence; results highlight the need for provider guidance and structured adherence interventions targeting partner adherence support

The Impact of Key HIV Intervention Components as Predictors of Sexual Barrier Use: The Zambia Partner Project

Behavioral interventions have utilized a variety of strategies and components to reduce HIV risk. This article describes the partner intervention, a couple-based group HIV risk reduction intervention implemented in 6 urban community health clinics in Lusaka, Zambia, and examines the components of the intervention and their relationship with condom use. Couple members completed assessments on condom use, acceptability, willingness to use condoms, communication, intimate partner violence (IPV), self-efficacy, and HIV information at baseline and 6 months' follow-up. This study examined the relative impact of elements of the intervention as predictors of condom use. Changes in acceptability had the greatest overall influence on condom use, followed by social support, relationship consensus, and willingness to use condoms. Changes in self-efficacy, IPV, negotiation, and information had no influence. Results support the use of multidimensional approaches in behavioral interventions and highlight the importance of identifying critical elements of interventions to maximize risk reduction outcomes

Determinants of Engagement in HIV Treatment and Care Among Zambians New to Antiretroviral Therapy

This pilot study assessed the determinants of engagement in HIV care among Zambian patients new to antiretroviral (ARV) therapy, and the effect of an intervention to increase medication adherence. Participants (n = 160) were randomized to a 3-month group or individual intervention utilizing a crossover design. Psychophysiological (depression, cognitive functioning, health status), social (social support, disclosure, stigma), and structural (health care access, patient-provider communication) factors and treatment engagement (adherence to clinic visits and medication) were assessed. Participants initially receiving group intervention improved their adherence, but gains were not maintained following crossover to the individual intervention. Increased social support and patient-provider communication and decreased concern about HIV medications predicted increased clinic attendance across both arms. Results suggest that early participation in a group intervention may promote increased adherence among patients new to therapy, but long-term engagement in care may be sustained by both one-on-one and group interventions by health care staff

The Spear and Shield intervention to increase the availability and acceptability of voluntary medical male circumcision in Zambia: a cluster randomised controlled trial

Background Widespread voluntary medical male circumcision in Africa could avert an estimated 3·436 million HIV infections and 300 000 deaths over the next 10 years. Most Zambian men have expressed little interest in the procedure. We tested the effect of the Spear and Shield intervention designed to increase demand for voluntary medical male circumcision among these hard-to-reach men. Methods This cluster randomised controlled trial was done between Feb 1, 2012, and Oct 31, 2014, in Lusaka, Zambia, where HIV prevalence is 20·8%. 13 community health centres were stratified by HIV voluntary counselling and testing rates and patient census, and randomly assigned (5:5:3) to experimental (the intervention), control, or observation-only conditions. Community health centre health-care providers at all 13 sites received training in voluntary medical male circumcision. Eligible participants were aged at least 18 years, HIV-negative, uncircumcised, and had not proactively requested or planned for voluntary medical male circumcision at the time of enrolment. Trial statisticians did not participate in randomisation. After voluntary counselling and HIV testing, participants were recruited; female partners were invited to participate. The primary outcomes at the individual level were the likelihood of voluntary medical male circumcision by 12 months post-intervention, and condom use after voluntary medical male circumcision among participants receiving the intervention. The trial is registered with ClinicalTrials.gov, number NCT01688167. Findings 800 uncircumcised HIV-negative men (400 in the experimental group, 400 in the control group) were enrolled. 161 participants in the experimental group and 96 in the control group had voluntary medical male circumcision (adjusted odds ratio 2·45, 95% CI 1·24–4·90; p=0·02). Condom use was examined in participants who had voluntary medical male circumcision and reported sexual activity within 1 month of a post-circumcision assessment (88 in the experimental group and 64 in the control group). Condom use over time increased in the experimental group (p=0·03) but not in the control group (p=0·2). One patient died in each group; no adverse events related to study participation were reported. Interpretation Comprehensive HIV prevention programmes can increase the demand for and uptake of voluntary medical male circumcision services. Funding US National Institutes of Health/National Institute of Mental Health (R01MH095539)

Sexual Risk Intervention In Multiethnic Drug And Alcohol Users

An estimated 38.6 million persons globally are living with HIV, of whom over 1.1 million reside in Zambia. Of the 2 million cases in the US, 64% of new cases among women are among African Americans. Alcohol and drug use represents a significant risk factor for HIV transmission among both Zambians and African Americans. In addition, gender dynamics in both the US and Zambia promote transmission. This study examines two interventions targeting HIV risk behavior among HIV positive substance users, women in Miami, USA (the New Opportunities for Women (NOW) Project) and men in Lusaka, Zambia (the Partner Project). The study compares the efficacy of these two culturally tailored sexual behavior interventions provided in group and individual session formats. US and Zambian participants increased sexual barrier use and reduced substance-related sexual risk. Comparatively greater gains were made by higher risk Zambian males than US females in both group and individual conditions. Among lower risk participants, women in the group condition achieved and sustained the greatest comparative risk reductions. Results suggest that cost effective group HIV transmission risk reduction interventions for multiethnic individuals can be successfully implemented among both female and male drug and alcohol users in multinational settings