Non-adherence to highly active antiretroviral therapy in children attending HIV treatment clinic at harare Children's Hospital, Zimbabwe.

Background: Non-adherence reduces the effectiveness of antiretroviral therapy. Knowledge of factors associated with non-adherence would assist clinicians and program planners to design and implement interventions to improve adherence and therefore treatment outcomes. Objective: To determine the prevalence and factors associated with non-adherence to Highly Active Antiretroviral Therapy (HAART) in children less than 10 years of age. Methods: A cross-sectional study of 216 caregivers and children less than 10 years of age who had received HAART for at least 60 days prior to this study. Non-adherence was defined as taking less than 95% of prescribed doses. Caregiver self-reports of missed doses in the 30 days preceding a clinic visit, and clinic based pill counts were used to determine non-adherence. Results: Of the 228 children selected, 216 (94.7%) study participants were assessed using the self-report method. Pill count assessment was done on only 96 (44%) participants who produced unused pills on their review dates. Caregiver self-reports (n=216) estimated the prevalence of non-adherence to be 7.4% (95%: CI 3.90 10.90) whereas clinic-based pill counts (n=96) yielded a higher estimate of 18.8% (95% CI 10.94 26.56). In a regression analysis based on pill count, two or fewer siblings (OR=6.26, 95% CI 1.64-23.95) or adults (OR=3.73, 95% CI: 1.01-13.78) in the household were independently associated with non-adherence to HAART. Of the 16 participants who were non adherent by pill count the reasons for missing doses were, attending gatherings (funeral, church), caregiver forgetting to give dose, medication running out, not understanding dosing instructions, concurrently taking other medicines such as anti tuberculosis drugs and cotrimoxazole, child visiting relatives during school vacation, and inconsistent supply of drugs in the hospital. Conclusion: The prevalence of non adherence using pill count method was high at this clinic. Caregiver reports of missed doses underestimated the prevalence of non-adherence to HAART. Having fewer siblings or adults in the household to assist with dosing are strongly associated with non-adherence to HAART in this population of children.

Barriers and facilitators to infection prevention and control in a neonatal unit in Zimbabwe - a theory-driven qualitative study to inform design of a behaviour change intervention.

BACKGROUND: Hospital-acquired infection (HAI) is an increasing cause of neonatal morbidity/mortality in low-income settings. Hospital staff behaviours (e.g., hand hygiene) are key contributors to HAI. Understanding the drivers of these can inform interventions to improve infection prevention and control (IPC). AIM: To explore barriers/facilitators to IPC in a neonatal unit in Harare, Zimbabwe. METHODS: Interviews were conducted with 15 staff members of neonatal and maternity units alongside ethnographic observations. The interview guide and data analysis were informed by the COM-B (Capability, Opportunity, Motivation-Behaviour) model and explored individual, socio-cultural, and organizational barriers/facilitators to IPC. Potential interventions were identified using the Behaviour-Change Wheel. FINDINGS: Enablers within Capability included awareness of IPC, and within Motivation beliefs that IPC was crucial to one's role, and concerns about consequences of poor IPC. Staff were optimistic that IPC could improve, contingent upon resource availability (Opportunity). Barriers included: limited knowledge of guidelines, no formal feedback on performance (Capability), lack of resources (Opportunity), often leading to improvization and poor habit formation. Further barriers included the unit's hierarchy, e.g., low engagement of cleaners and mothers in IPC, and staff witnessing implementation of poor practices by other team members (Opportunity). Potential interventions could include role-modelling, engaging mothers and staff across cadres, audit and feedback and flexible protocols (adaptable to water/handrub availability). CONCLUSIONS: Most barriers to IPC fell within Opportunity, whilst most enablers fell under Capability and Motivation. Theory-based investigation provides the basis for systematically identifying and developing interventions to address barriers and enablers to IPC in low-income settings.

Auditing use of antibiotics in Zimbabwean neonates.

BACKGROUND: Neonatal sepsis is a major cause of morbidity and mortality in low-income settings. As signs of sepsis are non-specific and deterioration precipitous, antibiotics are often used profusely in these settings where diagnostics may not be readily available. Harare Central Hospital, Zimbabwe, delivers 12000 babies per annum admitting ∼4800 to the neonatal unit. Overcrowding, understaffing and rapid staff turnover are consistent problems. Suspected sepsis is highly prevalent, and antibiotics widely used. We audited the impact of training and benchmarking intervention on rationalizing antibiotic prescription using local, World Health Organization-derived, guidelines as the standard. METHODS: An initial audit of admission diagnosis and antibiotic use was performed between 8th May - 6th June 2018 as per the audit cycle. An intern training programme, focusing on antimicrobial stewardship and differentiating between babies 'at risk of' versus 'with' clinically-suspected sepsis was instituted post-primary audit. Re-audit was conducted after 5 months. RESULTS: Sepsis was the most common admitting diagnosis by interns at both time points but reduced at repeat audit (81% versus 59%, P<0.0001). Re-audit after 5 months demonstrated a decrease in antibiotic prescribing at admission and discharge. Babies prescribed antibiotics at admission decreased from 449 (98%) to 96 (51%), P<0.0001. Inpatient days of therapy (DOT) reduced from 1243 to 1110/1000 patient-days. Oral amoxicillin prescription at discharge reduced from 349/354 (99%) to 1% 1/161 (P<0.0001). CONCLUSION: A substantial decrease in antibiotic use was achieved by performance feedback, training and leadership, although ongoing performance review will be key to ensuring safety and sustainability.

The levels of malnutrition and risk factors for mortality at Harare Central Hospital-Zimbabwe: an observation study.

OBJECTIVES: To determine the prevalence of malnutrition, and identify risk factors associated with mortality in acute severe malnutrition in a major referral hospital in Harare. DESIGN: Cross sectional analytical study. SETTING: Harare Central Hospital, paediatric wards. SUBJECTS: All children admitted to the general paediatric medical wards between 12 October 2003 and 19 January 2004 were surveyed. MAIN OUTCOME MEASURES: Prevalence and mortality in hospitalized children with acute severe malnutrition. STUDY FACTORS: Patient's age, sex, vaccination status, type of malnutrition, weight-for-height, breast feeding status (age <24 months), care giver details, orphanage, area of residence, new or re-admission, time of admission, admission temperature, co-morbidity conditions, HIV status and selected laboratory tests. RESULTS: A total of 784 infants and children were admitted during the study period, of whom 619 were eligible for the study. Of the 619 children, 259 (41.8%) had acute severe malnutrition, 79 (12.8%) moderate malnutrition and 281 (45.5%) had no malnutrition. Fatality rates were 42.9% (acute severe malnutrition), 32.9% (moderate malnutrition), and 21% (no malnutrition) respectively. Factors predictive of mortality by multivariate analysis were age <18 months (O.R=2.27; 95% CI 1.20-4.29), weight-for-height <70% (O.R=2.63; 95% CI=1.24-5.56), acute diarrhoea (O.R=3.42; 95% CI=1.53-7.65), persistent diarrhoea (O.R=2.67; 95% CI= 1.26-5.66), and pneumonia (O.R=2.21; 95% CI= 1.08-4.52). CONCLUSION: Mortality among children with acute severe malnutrition at this institution was unacceptably high. Case management needs strengthening particularly for malnutrition, diarrhoea and pneumonia. The role of high HIV prevalence rates on mortality in this population needs evaluating.