Tuberculosis treatment delays and associated factors within the Zimbabwe national tuberculosis programme.

BACKGROUND: Delayed presentation of pulmonary TB (PTB) patients for treatment from onset of symptoms remains a threat to controlling individual disease progression and TB transmission in the community. Currently, there is insufficient information about treatment delays in Zimbabwe, and we therefore determined the extent of patient and health systems delays and their associated factors in patients with microbiologically confirmed PTB. METHODS: A structured questionnaire was administered at 47 randomly selected health facilities in Zimbabwe by trained health workers to all patients aged ≥18 years with microbiologically confirmed PTB who were started on TB treatment and entered in the health facility TB registers between 01 January and 31 March 2013. Multivariate logistic regression was used to calculate adjusted odds ratios (aOR) and 95% confidence intervals (CIs) for associations between patient/health system characteristics and patient delay >30 days or health system delay >4 days. RESULTS: Of the 383 recruited patients, 211(55%) were male with an overall median age of 34 years (IQR, 28-43). There was a median of 28 days (IQR, 21-63) for patient delays and 2 days (IQR, 1-5) for health system delays with 184 (48%) and 118 (31%) TB patients experiencing health system delays >30 days and health system delays >4 days respectively. Starting TB treatment at rural primary healthcare vs district/mission facilities [aOR 2.70, 95% CI 1.27-5.75, p = 0.01] and taking self-medication [aOR 2.33, 95% CI 1.23-4.43, p = 0.01] were associated with encountering patient delays. Associated with health system delays were accessing treatment from lower level facilities [aOR 2.67, 95% CI 1.18-6.07, p = 0.019], having a Gene Xpert TB diagnosis [aOR 0.21, 95% CI 0.07-0.66, p = 0.008] and >4 health facility visits prior to TB diagnosis [(aOR) 3.34, 95% CI 1.11-10.03, p = 0.045]. CONCLUSION: Patient delays were longer and more prevalent, suggesting the need for strategies aimed at promoting timely seeking of appropriate medical consultation among presumptive TB patients. Health system delays were uncommon, suggesting a fairly efficient response to microbiologically confirmed PTB cases. Identified risk factors should be explored further and specific strategies aimed at addressing these factors should be identified in order to lessen patient and health system delays

Predictors of Positivity Yield among Index Contacts in Harare and Matabeleland South Provinces, Zimbabwe, 2022

Background: Zimbabwe’s Index Testing programme has failed to achieve targets since its inception in 2017. We determined the index testing implementation modalities to identify and recommend effective contact elicitation, tracking and testing modalities to enhance positivity yield. Subjects dan Method: This study conducted a cross-sectional study on 50 multistage selected health facilities. Dependent variables were all clients, (≥15 years) diagnosed with HIV in 2021, whilst independent variables were contact tracking. The study instrument of variable measure was cascade analysis to identify tracing modalities against yield. Quantitative data were summarized as proportions, odds ratios, and adjusted odds ratios at a 5% significance level. Results: Of 6,308 index cases identified, females constituted 53.9% (n=3,401 and 67.6% (n=4,265) were retests. Index testing was offered to 66.4% (n=4,190), accepted by 93.1% (n=3,899) and the elicitation rate was 1:1.3 (n=5,080). A positivity yield of 27.5% (n=1,736) was achieved from 78.6% (n= 3,991) contacts. Mixed method tracking yielded 46.7% (n=349) positivity from a testing rate of 99.5% (n=748) in an urban setup, with 41.4% (n=1,243) preferring health worker referrals. As high as 202 contacts were not tested following elicitation through client referrals. In a rural setup, client referrals accounted for 53.1%, (n=1,103) yet 122 of these were not tested. The highest positivity yield was obtained from health worker referrals at 65.6% (n=196). Being male (aOR=3.09; 95%CI= 2.74 to 3.49), first tester (aOR=1.65; 95%CI= 1.43 to 1.91), anonymous tracking (aOR=8.46; 95%CI:3.37 to 22.75) and testing contacts within 7 days of elicitation (aOR=2.78; 95%CI=2.44 to 3.18) were identified as high predictors of positivity yield among index contacts. Conclusion: The identified high positivity yield among men, first-time testers and contacts tested within 7 days of elicitation may inform index testing focussing to improve program performance. Implementation fidelity and differentiated contact referrals were recommended to mitigate attritions at each stage of the index cascade to yield the best results on index contact tracing and testing. Keywords: targeted testing, HIV testing services, index contact tracing and testing, index testing cascade Correspondence: Hamufare Dumisani Mugauri. Faculty of Medicine and Health Sciences, Department of Primary Healthcare Sciences, New Health Sciences Building, Parirenyatwa Complex, Mazowe Road, Harare, Zimbabwe. Email: [email protected]. Mobile: +263772314894

Gender-related differences in outcomes and attrition on antiretroviral treatment among an HIV-infected patient cohort in Zimbabwe: 2007-2010.

OBJECTIVES: To determine (1) gender-related differences in antiretroviral therapy (ART) outcomes, and (2) gender-specific characteristics associated with attrition. METHODS: This was a retrospective patient record review of 3919 HIV-infected patients aged ≥15 years who initiated ART between 2007 and 2009 in 40 randomly selected ART facilities countrywide. RESULTS: Compared to females, males had more documented active tuberculosis (12% vs. 9%; p60kg), initiating ART at an urban health facility, and care at central/provincial or district/mission hospitals vs. primary healthcare facilities. CONCLUSIONS: Our findings show that males presented late for ART initiation compared to females. Similar to other studies, males had higher patient attrition and mortality compared to females and this may be attributed in part to late presentation for HIV treatment and care. These observations highlight the need to encourage early HIV testing and enrolment into HIV treatment and care, and eventually patient retention on ART, particularly amongst men

Factors Associated with Ever Being HIV-Tested in Zimbabwe: An Extended Analysis of the Zimbabwe Demographic and Health Survey (2010-2011).

INTRODUCTION: Zimbabwe has a high human immunodeficiency virus (HIV) burden. It is therefore important to scale up HIV-testing and counseling (HTC) as a gateway to HIV prevention, treatment and care. OBJECTIVE: To determine factors associated with being HIV-tested among adult men and women in Zimbabwe. METHODS: Secondary analysis was done using data from 7,313 women and 6,584 men who completed interviewer-administered questionnaires and provided blood specimens for HIV testing during the Zimbabwe Demographic and Health Survey (ZDHS) 2010-11. Factors associated with ever being HIV-tested were determined using multivariate logistic regression. RESULTS: HIV-testing was higher among women compared to men (61% versus 39%). HIV-infected respondents were more likely to be tested compared to those who were HIV-negative for both men [adjusted odds ratio (AOR) = 1.53; 95% confidence interval (CI) (1.27-1.84)] and women [AOR = 1.42; 95% CI (1.20-1.69)]. However, only 55% and 74% of these HIV-infected men and women respectively had ever been tested. Among women, visiting antenatal care (ANC) [AOR = 5.48, 95% CI (4.08-7.36)] was the most significant predictor of being tested whilst a novel finding for men was higher odds of testing among those reporting a sexually transmitted infection (STI) in the past 12 months [AOR = 1.86, 95%CI (1.26-2.74)]. Among men, the odds of ever being tested increased with age ≥ 20 years, particularly those 45-49 years [AOR = 4.21; 95% CI (2.74-6.48)] whilst for women testing was highest among those aged 25-29 years [AOR = 2.01; 95% CI (1.63-2.48)]. Other significant factors for both sexes were increasing education level, higher wealth status and currently/formerly being in union. CONCLUSIONS: There remains a high proportion of undiagnosed HIV-infected persons and hence there is a need for innovative strategies aimed at increasing HIV-testing, particularly for men and in lower-income and lower-educated populations. Promotion of STI services can be an important gateway for testing more men whilst ANC still remains an important option for HIV-testing among pregnant women

Provision of HIV viral load testing services in Zimbabwe: Secondary data analyses using data from health facilities using the electronic Patient Monitoring System

Introduction Routine viral load (VL) testing among persons living with Human Immunodeficiency Virus (PLHIV) enables earlier detection of sub-optimal antiretroviral therapy (ART) adherence and for appropriate management of treatment failure. Since adoption of this policy by Zimbabwe in 2016, the extent of implementation is unclear. Therefore we set out to determine among PLHIV ever enrolled on ART from 2004-2017 and in ART care for ≥12 months at health facilities providing ART in Zimbabwe: numbers (proportions) with VL testing uptake, VL suppression and subsequently switched to 2nd-line ART following confirmed virologic failure. Materials and methods We used retrospective data from the electronic Patient Monitoring System (ePMS) in which PLHIV on ART are registered at 525 public and 4 private health facilities. Results Among the 392,832 PLHIV in ART care for ≥12 months, 99,721 (25.4%) had an initial VL test done and results available of whom 81,932 (82%) were virally suppressed. Among those with a VL>1000 copies/mL; 6,689 (37.2%) had a follow-up VL test and 4,086 (61%) had unsuppressed VLs of whom only 1,749 (42.8%) were switched to 2nd-line ART. Lower age particularly adolescents (10-19 years) were more likely (ARR 1.34; 95%CI: 1.25-1.44) to have virologic failure. Conclusion: The study findings provide insights to implementation gaps including limitations in VL testing; low identification of high- risk PLHIV in care and lack of prompt utilization of test results. The use of electronic patient-level data has demonstrated its usefulness in assessing the performance of the national VL testing program. By end of 2017 implementation of VL testing was sub-optimal, and virological failure was relatively common, particularly among adolescents. Of concern is evidence of failure to act on VL test results that were received. A quality improvement initiative has been planned in response to these findings and its effect on patient management will be monitored

Follow-up and programmatic outcomes of HIV-exposed infants registered in a large HIV centre in Lilongwe, Malawi: 2012-2014.

OBJECTIVE: To assess follow-up and programmatic outcomes of HIV-exposed infants at Martin Preuss Centre, Lilongwe, from 2012 to 2014. METHODS: Retrospective cohort study using routinely collected HIV-exposed infant data. Data were analysed using frequencies and percentages in Stata v.13. RESULTS: Of 1035 HIV-exposed infants registered 2012-2014, 79% were available to be tested for HIV and 76% were HIV-tested either with DNA-PCR or rapid HIV test serology by 24 months of age. Sixty-five infants were found to be HIV-positive and 43% were started on antiretroviral therapy (ART) at different ages from 6 weeks to 24 months. Overall, 48% of HIV-exposed infants were declared lost-to-follow-up in the database. Of these, 69% were listed for tracing; of these, 78% were confirmed as lost-to-follow-up through patient charts; of these, 51% were traced; and of these, 62% were truly not in care, the remainder being wrongly classified. Commonest reasons for being truly not in care were mother/guardian unavailability to bring infants to Martin Preuss Centre, forgetting clinic appointments and transport expenses. Of these 86 patients, 36% were successfully brought back to care and 64% remained lost-to-follow-up. CONCLUSION: Loss to follow-up remains a huge challenge in the care of HIV-exposed infants. Active tracing facilitates the return of some of these infants to care. However, programmatic data documentation must be urgently improved to better follow-up and link HIV-positive children to ART

Predictors of Positivity Yield among Index Contacts in Harare and Matabeleland South Provinces, Zimbabwe, 2022

Background: Zimbabwe’s Index Testing programme has failed to achieve targets since its inception in 2017. We determined the index testing implementation modalities to identify and recommend effective contact elicitation, tracking and testing modalities to enhance positivity yield. Subjects dan Method: This study conducted a cross-sectional study on 50 multistage selected health facilities. Dependent variables were all clients, (≥15 years) diagnosed with HIV in 2021, whilst independent variables were contact tracking. The study instrument of variable measure was cascade analysis to identify tracing modalities against yield. Quantitative data were summarized as proportions, odds ratios, and adjusted odds ratios at a 5% significance level. Results: Of 6,308 index cases identified, females constituted 53.9% (n=3,401 and 67.6% (n=4,265) were retests. Index testing was offered to 66.4% (n=4,190), accepted by 93.1% (n=3,899) and the elicitation rate was 1:1.3 (n=5,080). A positivity yield of 27.5% (n=1,736) was achieved from 78.6% (n= 3,991) contacts. Mixed method tracking yielded 46.7% (n=349) positivity from a testing rate of 99.5% (n=748) in an urban setup, with 41.4% (n=1,243) preferring health worker referrals. As high as 202 contacts were not tested following elicitation through client referrals. In a rural setup, client referrals accounted for 53.1%, (n=1,103) yet 122 of these were not tested. The highest positivity yield was obtained from health worker referrals at 65.6% (n=196). Being male (aOR=3.09; 95%CI= 2.74 to 3.49), first tester (aOR=1.65; 95%CI= 1.43 to 1.91), anonymous tracking (aOR=8.46; 95%CI:3.37 to 22.75) and testing contacts within 7 days of elicitation (aOR=2.78; 95%CI=2.44 to 3.18) were identified as high predictors of positivity yield among index contacts. Conclusion: The identified high positivity yield among men, first-time testers and contacts tested within 7 days of elicitation may inform index testing focussing to improve program performance. Implementation fidelity and differentiated contact referrals were recommended to mitigate attritions at each stage of the index cascade to yield the best results on index contact tracing and testing. Keywords: targeted testing, HIV testing services, index contact tracing and testing, index testing cascade Correspondence: Hamufare Dumisani Mugauri. Faculty of Medicine and Health Sciences, Department of Primary Healthcare Sciences, New Health Sciences Building, Parirenyatwa Complex, Mazowe Road, Harare, Zimbabwe. Email: [email protected]. Mobile: +263772314894

Ending the HIV/AIDS epidemic in low- and middle-income countries by 2030: is it possible?

The international community has committed to ending the epidemics of HIV/AIDS, tuberculosis, malaria, and neglected tropical infections by 2030, and this bold stance deserves universal support. In this paper, we discuss whether this ambitious goal is achievable for HIV/AIDS and what is needed to further accelerate progress. The joint United Nations Program on HIV/AIDS (UNAIDS) 90-90-90 targets and the related strategy are built upon currently available health technologies that can diagnose HIV infection and suppress viral replication in all people with HIV. Nonetheless, there is much work to be done in ensuring equitable access to these HIV services for key populations and those who remain outside the rims of the traditional health services. Identifying a cure and a preventive vaccine would further help accelerate progress in ending the epidemic. Other disease control programmes could learn from the response to the HIV/AIDS epidemic

Trend analysis of tuberculosis case notifications with scale-up of antiretroviral therapy and roll-out of isoniazid preventive therapy in Zimbabwe, 2000-2018.

OBJECTIVES: Antiretroviral therapy (ART) and isoniazid preventive therapy (IPT) are known to have a tuberculosis (TB) protective effect at the individual level among people living with HIV (PLHIV). In Zimbabwe where TB is driven by HIV infection, we have assessed whether there is a population-level association between IPT and ART scale-up and annual TB case notification rates (CNRs) from 2000 to 2018. DESIGN: Ecological study using aggregate national data. SETTING: Annual aggregate national data on TB case notification rates (stratified by TB category and type of disease), numbers (and proportions) of PLHIV in ART care and of these, numbers (and proportions) ever commenced on IPT. RESULTS: ART coverage in the public sector increased from 1.1 million PLHIV patients) by December 2018, while IPT coverage among PLHIV in ART care increased from <1% (98 PLHIV) in 2012 to ~33% (373 917 PLHIV) by December 2018. These HIV-related interventions were associated with significant declines in TB CNRs: between the highest CNR prior to national roll-out of ART (in 2004) to the lowest recorded CNR after national IPT roll-out from 2012, these were (1) for all TB case (510 to 173 cases/100 000 population; 66% decline, p<0.001); (2) for those with new TB (501 to 159 cases/100 000 population; 68% decline, p<0.001) and (3) for those with new clinically diagnosed PTB (284 to 63 cases/100 000 population; 77.8% decline, p<0.001). CONCLUSIONS: This study shows the population-level impact of the continued scale-up of ART among PLHIV and the national roll-out of IPT among those in ART care in reducing TB, particularly clinically diagnosed TB which is largely associated with HIV. There are further opportunities for continued mitigation of TB with increasing coverage of ART and in particular IPT which still has a low coverage

Sexual violence against migrants and asylum seekers. The experience of the MSF clinic on Lesvos Island, Greece.

Sexual violence can have destructive impact on the lives of people. It is more common in unstable conditions such as during displacement. On the Greek island of Lesvos, Médecins Sans Frontières provided medical care to survivors of sexual violence among the population of asylum seekers arriving there. This study aimed to describe the patterns of sexual violence reported by migrants and asylum seekers and the clinical care provided to them. Methods This is s a descriptive study using routine program data. The study population consisted of migrants and asylum seekers treated for conditions related to sexual violence at the Médecins Sans Frontières clinic on Lesvos Island (September 2017-January 2018). Results We enrolled 215 survivors of sexual violence who reported and were treated, of whom 60 (28%) were male. The majority of incidents reported (90%) were cases of rape; 174 (81%) of survivors were from Africa and 185 (86%) occurred over a month before presentation. Half the incidents (118) occurred in transit, mainly in Turkey, and 76 (35%) in the country of origin; 10 cases (5%) on Lesvos were also observed. The perpetrator was known in 23% of the cases. Only XXX received mental health care, and the need exceeded the capacity of available mental care services. Conclusion Even though the majority of cases delayed seeking medical care after the incident, it is crucial that access to mental health services is guaranteed for those in need. Such access and protection measures for people in transit need to be put in place along migration routes, including in countries nominally considered safe, and secure routes need to be developed