"I Have to Do It in Secrecy": Provider Perspectives on HIV Service Delivery and Quality of Care for Key Populations in Zambia

ABSTRACT

Key populations (KPs) experience suboptimal outcomes along the HIV care and prevention continua, but there is limited study of the challenges service providers encounter delivering HIV services to KPs, particularly in settings like Zambia, where provision of these services remains legally ambiguous. Seventy-seven providers completed in-depth interviews exploring constraints to HIV service delivery for KPs and recommendations for improving access and care quality. Thematic analysis identified salient challenges and opportunities to service delivery and quality of care for KPs, spanning interpersonal, institutional, and structural domains. Limited provider training in KP-specific needs was perceived to influence KP disclosure patterns in clinical settings, impeding service quality. The criminalization of KP sexual and drug use behaviors, coupled with perceived institutional and legal ambiguities to providing HIV services to KPs, cultivated unwelcoming service delivery environments for KPs. Findings elucidate opportunities for improving HIV service delivery/quality, from decentralized care to expanded legal protections for KPs and service providers.

Development of the FAST-M maternal sepsis bundle for use in low-resource settings: a modified Delphi process

Objective

To develop a sepsis care bundle for the initial management of maternal sepsis in low resource settings.

Design

Modified Delphi process.

Setting

Participants from 34 countries.

Population

Healthcare practitioners working in low resource settings (n = 143; 34 countries), members of an expert panel (n = 11) and consultation with the World Health Organization Global Maternal and Neonatal Sepsis Initiative technical working group.

Methods

We reviewed the literature to identify all potential interventions and practices around the initial management of sepsis that could be bundled together. A modified Delphi process, using an online questionnaire and in‐person meetings, was then undertaken to gain consensus on bundle items. Participants ranked potential bundle items in terms of perceived importance and feasibility, considering their use in both hospitals and health centres. Findings from the healthcare practitioners were then triangulated with those of the experts.

Main outcome measure

Consensus on bundle items.

Results

Consensus was reached after three consultation rounds, with the same items deemed most important and feasible by both the healthcare practitioners and expert panel. Final bundle items selected were: (1) Fluids, (2) Antibiotics, (3) Source identification and control, (4) Transfer (to appropriate higher‐level care) and (5) Monitoring (of both mother and neonate as appropriate). The bundle was given the acronym ‘FAST‐M’.

Conclusion

A clinically relevant maternal sepsis bundle for low resource settings has been developed by international consensus.

Tweetable abstract

A maternal sepsis bundle for low resource settings has been developed by international consensus.

A maternal sepsis bundle for low resource settings has been developed by international consensus.

Quality of care and HIV service utilization among key populations in Zambia: a qualitative comparative analysis among female sex workers, men who have sex with men and people who use drugs

HIV epidemic control requires improving access and uptake of HIV services by key populations (KPs). In Zambia, the behaviors of female sex workers (FSWs), men who have sex with men (MSM), and people of who use drugs (PWUD) are criminalized, and little information exists about their HIV/STI service use. Using a quality of care (QOC) framework, we compared barriers to and opportunities for HIV/STI service access and uptake among the three KPs. We conducted in-depth interviews and focus group discussions with 314 KP members between July 2013 and September 2015 in eight districts. Poorer QOC was received at public health facilities compared to private, NGOs and traditional healers. Stigma and discrimination, confidentiality, and legal prosecution were barriers to service use and more salient among MSM than FSWs and PWUD. Invasive facility policies were barriers and more prominent among FSWs than MSM and PWUD. Service unavailability was of equally high salience among MSM and PWUD than FSWs. Comfort in the clinic and perceived treatment effectiveness were facilitators for all three KPs. The health care experiences of KPs are not monolithic; HIV/STI service improvement strategies should address the concerns and be tailored to the needs of each key population.

High rates of sexual violence by both intimate and non-intimate partners experienced by adolescent girls and young women in Kenya and Zambia: Findings around violence and other negative health outcomes

BACKGROUND

While links between intimate-partner violence (IPV) and HIV risk have been established, less is known about violence perpetrated by people other than intimate partners. In addition, much of the research on IPV has been conducted with adults, while relatively little is known about violence experienced by adolescent girls and young women (AGYW). We examined experiences of sexual violence and associated sexual and mental health among AGYW in Kenya and Zambia.

METHODS

Using cross-sectional surveys with women aged 15-24 years, we assessed experience of partner sexual violence among respondents who reported a boyfriend/husband in the last 12 months (Kenya N = 597; Zambia N = 426) and non-partner sexual violence among all respondents (Kenya N = 1778; Zambia N = 1915). We conducted logistic regression analyses to examine experiences of sexual violence and health outcomes.

RESULTS

Sexual violence from intimate partners over the last year was reported by 19.1 percent of AGYW respondents in Kenya and 22.2 percent in Zambia; sexual violence from non-partners was reported by 21.4 percent in Kenya and 16.9 percent in Zambia. Experience of sexual violence was associated with negative health outcomes. Violence from non-partners was associated with increased odds of STI symptoms and increased levels of anxiety and depression. Results were similar for violence from partners, although only significant in Kenya. While sexual violence from a non-partner was associated with increased HIV risk perception, it was not associated when the violence was experienced from an intimate partner.

CONCLUSIONS

AGYW reported high levels of sexual violence from both intimate partners and non-partners. These experiences were associated with negative health outcomes, though there were some differences by country context. Strengthening sexual violence prevention programs, increasing sexual violence screening, and expanding the provision of post-violence care are needed to reduce intimate and non-partner violence and the effects of violence on AGYW.

Large-scale whole genome sequencing of M. tuberculosis provides insights into transmission in a high prevalence area

To improve understanding of the factors influencing tuberculosis transmission and the role of pathogen variation, we sequenced all available specimens from patients diagnosed over 15 years in a whole district in Malawi. Mycobacterium tuberculosis lineages were assigned and transmission networks constructed, allowing ≤10 single nucleotide polymorphisms (SNPs) difference. We defined disease as due to recent infection if the network-determined source was within 5 years, and assessed transmissibility from forward transmissions resulting in disease. High-quality sequences were available for 1687 disease episodes (72% of all culture-positive episodes): 66% of patients linked to at least one other patient. The between-patient mutation rate was 0.26 SNPs/year (95% CI 0.21–0.31). We showed striking differences by lineage in the proportion of disease due to recent transmission and in transmissibility (highest for lineage-2 and lowest for lineage-1) that were not confounded by immigration, HIV status or drug resistance. Transmissions resulting in disease decreased markedly over time.

DOI:http://dx.doi.org/10.7554/eLife.05166.001

Tuberculosis is an important public health threat around the globe and is particularly common in developing countries. It is difficult to control the spread of the disease because the bacteria that cause it can spread when an infected individual coughs or sneezes. It may take years for an infected individual to develop symptoms of tuberculosis so it can be hard to trace the source of an outbreak, and people infected with HIV are particularly susceptible to the disease.

The bacterium that causes the majority of cases of tuberculosis is called Mycobacterium tuberculosis. There are several different varieties or ‘lineages’ of M. tuberculosis, and it is thought that they may vary in their ability to spread and cause disease. However, the results of previous studies have been inconsistent and there also seems to be a lot of variation between strains within the same lineage.

In this study, Guerra-Assunção et al. used an approach called whole genome sequencing alongside more traditional methods to study the spread of tuberculosis in Malawi. They sequenced the genomes of every available sample of M. tuberculosis collected from patients in the Karonga district of Malawi over a 15-year period. This produced high-quality DNA sequence data about the bacteria responsible for almost 1700 cases of disease.

Using this massive amount of data, Guerra-Assunção et al. constructed networks that showed how the bacteria had spread in the community. This revealed that there were differences between the ability of the various M. tuberculosis lineages to cause disease and to spread in communities. For example, lineage 1 was less likely than the other lineages to cause disease soon after infecting an individual and was less able to spread.

The data also show that the proportion of cases of disease due to recent infection declined substantially during the 15-year period. This indicates that the tuberculosis and HIV control programmes in the area have been successful.

Guerra-Assunção et al.'s findings show that it is possible to understand how tuberculosis is transmitted on a large scale. The next challenge is to understand why the lineages differ in their ability to cause disease and spread between individuals.

DOI:http://dx.doi.org/10.7554/eLife.05166.002

Gastric Malignancy Survival in Zambia, Southern Africa: A Two Year Follow up Study

Background

Gastric cancer poses a significant global health burden. It is the second most common cause of cancer death worldwide and the ninth leading cause of cancer mortality in Zambia, at a rate of 3.8/100,000; comparable to USA (2/100,000) and UK (3.4/100,000). Survival data on gastric malignancy in Zambia is not known.

Objectives

To provide preliminary survival rates of patients with histologically proven gastric adenocarcinoma in Zambia.

Study Design

Using our prospective gastric cancer research database, we conducted a retrospective audit of patients diagnosed with gastric cancer at the University Teaching Hospital, Zambia, from June 2010 until January 2012. We contacted patients or their relatives using phone numbers provided at time of enrollment.

Main Outcomes

We reviewed age, sex, demographic data (income, education), body mass index, symptoms, duration of symptoms, treatment (surgery, chemotherapy, radiotherapy or combination) and survival outcome. Analysis was performed using Kaplan-Meier models and log rank test.

Results

Fifty one patients were diagnosed with gastric adenocarcinoma during the study period, but follow-up data were available for 50. Median survival was 142 days. Age, sex, income, education, BMI, tumor location, and treatment modality were not significantly associated with overall survival. In Cox regression models, covariates associated with survival were a history of regular alcohol intake (HR 0.49, 95%CI 0.26,0.92; P=0.025) and intestinal type cancer histology (HR 0.40, 95%CI 0.19,0.83; P=0.01).

Conclusion

Prognosis of newly diagnosed gastric cancer in Zambia is poor with significant mortality within 1 year of diagnosis, particularly among patients with weight loss and dysphagia.

Spectrum of childhood cancers in Malawi 1985-1993

An analysis of seven hundred and ninety one children aged 0.2 to 14 years with confirmed malignant disease recorded by the Malawi National Cancer Registry over a period of 9 years is presented. Childhood cancer constituted 6.9% of all malignancies recorded during the study period. The top ten neoplasms in descending order of frequency were: non-Hodgkin's lymphoma 434 (54.9%), retinoblastoma 89 (11.3%), nephroblastoma 50 (6.3%), epithelial carcinoma 45 (5.7%), Hodgkin's disease 38 (4.8%), soft tissue sarcoma (excluding Kaposi): 34(4.3%), Kaposi's sarcoma 32 (4.0%), malignant tumours (not specified): 20 (2.5%), acute leukaemias 18(2.3%) and osteogenic sarcoma 16 (2.0%). Some differences noted in the pattern of neoplasms in this study from those of developed and developing African countries are discussed. The findings highlight the most common childhood malignancies in Malawi where intense research should be directed so that meaningful and cost effective therapeutic intervention programmes can be planned and developed.