High satisfaction among patients at HIV clinics in Harare, Zimbabwe: a time and motion evaluation and patient satisfaction study.

Patient satisfaction is an important component of health and healthcare utilization, which measures the perceived needs and expectations for healthcare services. Patient satisfaction surveys are effective in improving health outcomes by informing health facilities on service and provider gaps and guiding the development of effective action plans and policies for quality improvement within a healthcare organization. Although patient satisfaction and patient flow analyses have been conducted in Zimbabwe, the combination of these two quality improvement measures in the context of Human Immunodeficiency Virus (HIV) clinics has not previously been evaluated. This study assessed and evaluated patient flow and patient satisfaction to enhance care quality and improve HIV service delivery to optimize patient health. We collected time and motion data from HIV patients who attended three purposively selected City of Harare Polyclinics in Harare, Zimbabwe. All patients who sought care at the clinic were given time and motion forms to track their movement and the time spent at each service area. After services were completed, patients were invited to participate in a satisfaction survey regarding their services and care. The average waiting time from clinic arrival to see the provider was 2 hr and 14 min. The areas with the longest waiting time and bottlenecks occurred at registration (49 min) and the HIV clinic waiting area (44 min). Despite these extended times, the overall patient satisfaction for HIV services was high at 72%, with over half (59%) reporting that there was nothing they did not like about their services. Patients were most satisfied with services provided (34%), timely service (27%), and antiretroviral medications (19%). The areas of least satisfaction were related to time delays (24%) and cashier delays (6%). Despite prolonged waiting times, patients' overall satisfaction with their clinic experience remains high. Perceptions of satisfaction are influenced by experience, culture, and context. However, there are still several areas of recommendations to improve service, care, and quality. Specifically, reducing or eliminating service fees, increasing clinic hour times, and having available medication were most cited. Support from the Zimbabwe Ministry of Health and Child Care, City of Harare, and other decision-makers is needed to improve patient satisfaction and address patients' recommendations within the City of Harare Polyclinic organization in accordance with the 2016-20 National Health Strategies for Zimbabwe.

Factors associated with a malaria outbreak at Tongogara refugee camp in Chipinge District, Zimbabwe, 2021: a case-control study.

BACKGROUND: Malaria is a leading cause of morbidity and mortality among forcibly displaced populations, including refugees, approximately two-thirds of whom reside in malaria endemic regions. Data from the rapid disease notification system (RDNS) reports for Manicaland Province in Zimbabwe showed that despite implementation of malaria control initiatives, there was an increase in number of malaria cases above action thresholds at Tongogara refugee camp in Chipinge district during weeks 12-14 of 2021. An investigation that described the outbreak by person, place and time was conducted. Malaria emergency preparedness, response, and appropriateness of case management were assessed. The factors associated with contracting malaria were determined to enable the formulation of appropriate interventions, establish control, and prevent future malaria outbreaks among this vulnerable population. METHODS: A 1:1 unmatched case-control study involving 80 cases and 80 controls was conducted using interviewer-administered questionnaires at household level. Data was entered into Epi Data version 3.1 and quantitative analysis was done using Epi Info™ version 7.2.2.6 to generate medians, proportions, odds ratios and their 95% confidence intervals. RESULTS: Malaria cases were distributed throughout the 10 residential sections within Tongogara refugee camp, the majority being from section 7, 28 (35%). Despite constituting 11% of the total population, Mozambican nationals accounted for 36 (45%) cases. Males constituted 47 (59%) among cases which was comparable to controls 43 (54%), p = 0.524. The median age for cases was 15 years [Interquartile range (IQR), 9-26] comparable to controls, which was 17 years (IQR, 10-30) (p = 0.755). Several natural and man-made potential vector breeding sites were observed around the camp. Risk factors associated with contracting malaria were engaging in outdoor activities at night [AOR = 2.74 (95% CI 1.04-7.22), wearing clothes that do not cover the whole body during outdoor activities [AOR 4.26 (95% CI, 1.43-12.68)], while residing in a refugee housing unit reduced the risk of contracting malaria [AOR = 0.18 (CI, 0.06-0.55)]. CONCLUSIONS: The malaria outbreak at Tongogara refugee camp reemphasizes the role of behavioural factors in malaria transmission. Intensified health education to address human behaviours that expose residents to malaria, habitat modification, and larviciding to eliminate mosquito breeding sites were recommended.

Urethrocutaneous fistula following VMMC: a case series from March 2013 to October 2019 in ZAZIC's voluntary medical male circumcision program in Zimbabwe.

BACKGROUND: Urethrocutaneous fistula (subsequently, fistula) is a rare adverse event (AE) in voluntary medical male circumcision (VMMC) programs. Global fistula rates of 0.19 and 0.28 per 100,000 VMMCs were reported. Management of fistula can be complex and requires expert skills. We describe seven cases of fistula in our large-scale VMMC program in Zimbabwe. We present fistula rates; provide an overview of initial management, surgical interventions, and patient outcomes; discuss causes; and suggest future prevention efforts. RESULTS: Case details are presented on fistulas identified between March 2013 and October 2019. Among the seven fistula clients, ages ranged from 10 to 22 years; 6 cases were among boys under 15 years of age. All clients received surgical VMMC by trained providers in an outreach setting. Clients presented with fistulae 2-42 days after VMMC. Secondary infection was identified in 6 of 7 cases. Six cases were managed through surgical repair. The number of repair attempts ranged from 1 to 10. One case healed spontaneously with conservative management. Fistula rates are presented as cases/100,000 VMMCs. CONCLUSION: Fistula is an uncommon but severe AE that requires clinical expertise for successful management and repair. High-quality AE surveillance should identify fistula promptly and include consultation with experienced urologists. Strengthening provider surgical skills and establishment of standard protocols for fistula management would aid future prevention efforts in VMMC programs.

An evaluation of childhood tuberculosis program in Chegutu District, Zimbabwe, 2020: a descriptive cross-sectional study.

BACKGROUND: Childhood tuberculosis (TB) is a major global public health concern contributing to significant child morbidity and mortality. A records review of the TB notification for Chegutu District Health Information System 2 (DHIS2) showed a low childhood TB case detection rate. For 2018 and 2019, childhood TB notifications were 4% and 7% respectively against the annual national childhood 12% case detection rate. We evaluated the performance of the childhood TB program in Chegutu. METHODS: We conducted a descriptive cross-sectional study. Sixty-six health workers (HW) participated in the study. Interviewer-administered questionnaires and checklists were used to collect data on reasons for low TB case detection, HW childhood TB knowledge, program inputs, processes, and outputs. Strengths, Weaknesses, Opportunities and Threats analysis was used to assess the childhood TB processes. We analyzed the data using Epi Info 7™ to generate frequencies, proportions and means. A Likert scale was used to assess health worker knowledge. RESULTS: The majority 51/66(77%) of HW were nurses and 51/66(67%) of respondents were females. Reasons for the low childhood TB case detection were lack of HW confidence in collecting gastric aspirates 55/66(83%) and HW's negative attitudes towards gastric aspirate collection 23/66(35%). HW 24/66 (37%) had a fair knowledge of childhood TB notification. The district had only one functional X-ray machine for 34 health facilities. Only 6/18 motorcycles were functional with inadequate fuel supply. No desk guide for the management of TB in children for HW (2018) was available in 34 health facilities. Ethambutol 400 mg was out of stock and adult 800 mg tablets were used. Funds allocated for motor vehicle and motorcycles service ($1612USD/year) were inadequate. The district failed to perform planned quarterly TB review meetings, contact tracing and childhood TB training due to funding and COVID-19 lockdown restrictions. CONCLUSION: The childhood TB program failed to meet its targets due to inadequate inputs, HW suboptimal knowledge and COVID-19 lockdown measures. Case detection and notification can be improved through on-job training, mentorship, support and supervision and adequate resources.

Investigation of an anthrax outbreak in Makoni District, Zimbabwe.

BACKGROUND: Anthrax continues to be a disease of public health importance in Zimbabwe, with sporadic outbreaks reported annually in many parts of the country. A human anthrax outbreak occurred in wards 22 and 23 of Makoni District from mid-June 2013 to end of January 2014, following cattle deaths in the wards. Laboratory tests confirmed anthrax as the cause for the cattle deaths. This study investigated the clinical characteristics, distribution of cases (places, person and time) and risk factors for contracting the anthrax disease. We also assessed the environment, district preparedness and response, and outbreak prevention and control measures. METHODS: We conducted an outbreak investigation using a mixed-methods design. A 1:1 case-control study was used to assess risk factors for contracting anthrax. The controls were frequency matched to cases by sex. Data were collected using a structured interviewer-administered questionnaire. Environmental assessment, district preparedness and response, and outbreak prevention and control measures were assessed using a checklist, observations, and key informant interviews. Multivariable unconditional logic regression analysis was performed to identify independent risk factors associated with contracting anthrax. RESULTS: We interviewed 37 of the 64 cases, along with 37 controls. All the cases had cutaneous anthrax, with the hand being the most common site of the eschar (43%). Most of the cases (89%) were managed according to the national guidelines. Multivariable analysis demonstrated that meat sourced from other villages [vs butchery, OR = 15.21, 95% CI (2.32-99.81)], skinning [OR = 4.32, 95% CI (1.25-14.94)], and belonging to religions that permit eating meat from cattle killed due to unknown causes or butchered after unobserved death [OR = 6.12, 95% CI (1.28-29.37)] were associated with contracting anthrax. The poor availability of resources in the district caused a delayed response to the outbreak. CONCLUSION: The described anthrax outbreak was caused due to contact with infected cattle meat. Although the outbreak was eventually controlled through cattle vaccination and health education and awareness campaigns, the response of the district office was initially delayed and insufficient. The district should strengthen its emergency preparedness and response capacity, revive zoonotic committees, conduct awareness campaigns and improve surveillance, especially during outbreak seasons.

Evaluation of intensified provider initiated testing and counselling program in Harare City, 2017-2018.

BACKGROUND: Knowledge of HIV status remains a challenge despite implementation of various testing strategies including provider-initiated HIV testing (PITC). Harare City intensified provider-initiated HIV testing by targeting testing all eligible clients visiting facilities to achieve the UNAIDS first 95. This study aimed at evaluating the intervention to improve its effectiveness and inform programming decisions for universal access to HIV testing. METHODS: A descriptive cross-sectional study was conducted in Harare from April to June 2019. Evaluation of the intervention was conducted using the logic model approach to assess the inputs, processes and outputs. Health workers were interviewed using an interviewer administered questionnaire. Exit interviews were conducted for eligible clients > 18 years who refused to be tested. A checklist was used to assess the inputs used and a desk review of HIV screening and testing records was done. RESULTS: A total of (n-45) health care workers and (n = 70) clients were interviewed with a response rate of (92%) and (84%) respectively. The median age for clients was 31(Q1 = 24: Q3 = 38) and median years in service for health workers was 2 (Q1 = 1;Q3 = 26). Of the 133,899 clients who were eligible for testing after screening, 98,587 (74%) accepted the test leaving a gap of 35,312 (26%). However, 21/45 (47%) of health workers indicated high workload in the morning as the major reason for the leakage. In addition, 25/70 (36%) of the clients indicated long waiting time as the reason for opting out of HIV testing. CONCLUSION AND RECOMMENDATION: HIV testing coverage for eligible clients was not optimal, 26% opted out. We recommend strengthening of health facility systems such as review of patient flow, re-allocation of staff during busy HIV testing time and scaling up the use of HIV self-test kits for clients concerned with waiting time to improve HIV testing coverage.

Trends in antimicrobial resistance of bacterial pathogens in Harare, Zimbabwe, 2012-2017: a secondary dataset analysis.

BACKGROUND: Antimicrobial resistance is one of the most serious public health threats of the twenty-first century. The implementation of AMR surveillance in Zimbabwe is limited. However, data from a private laboratory in Harare revealed increasing resistance rates to common antibiotics like ampicillin (i.e., from 73.9% in 2011 to 74.6% in 2015). The increasing resistance rates indicate that Zimbabwe is affected by AMR. This study was done to determine the magnitude of AMR in Harare and determine the trends of AMR to first-line and to last-resort antibiotics and make recommendations to mitigate the problem. METHODS: A retrospective record review of data collected from the microbiology department at a private laboratory between January 2012 and December 2017 was done. The outcome of interest was the antibiotic susceptibility of bacterial isolates. Microsoft Excel 2016 was used to plot trends from 2012 to 2017 and Epi Info™7 was used for statistical analysis. RESULTS: A total of 23,432 isolates, of 12 medically important bacteria were analysed. Forty-three percent of the isolates were from urines, 36.7% were from pus swabs and 7% were from blood. The most common pathogen was Escherichia coli (43.2%), followed by Staphylococcus aureus (15.8%) and the least common was Neisseria gonorrhoea (0.2%). Resistance was highest to ampicillin followed by penicillin, both ranging between 70 and 100% over the six years. Statistically significant increases in resistance to commonly used antibiotics were observed in amoxicillin-resistant E. coli and Streptococcus pneumonia and third generation cephalosporin-resistant E. coli. There was an increase in resistance to last-line antibiotics i.e., fluoroquinolone-resistant Salmonella spp. and carbapenem-resistant Pseudomonas aeruginosa and Acinetobacter baumannii. However, methicillin-resistant S. aureus showed a decreasing trend. CONCLUSIONS: There is a high burden of drug resistance to common antibiotics in Harare and an emergence of resistance to last-line antibiotics.

Evaluation of the Maternal Death Surveillance and response system in Hwange District, Zimbabwe, 2017.

BACKGROUND: Maternal Death Surveillance and Response (MDSR) system was established to provide information that effectively guides actions to eliminate preventable maternal mortality. In 2016, Hwange district sent six maternal death notification forms (MDNF) to the province without maternal death audit reports. Timeliness of MDNF reaching the province is a challenge. Two MDNF for deaths that occurred in February and May 2016 only reached the provincial office in September 2016 meaning the MDNF were seven and four months late respectively. We evaluated the MDSR system in Hwange district. METHODS: A descriptive cross-sectional study was conducted. Health workers in the sampled facilities were interviewed using questionnaires. Resource availability was assessed through checklists. Epi Info 7 was used to calculate frequencies, means and proportions. RESULTS: We recruited 36 respondents from 11 facilities, 72.2% were females. Inadequate health worker knowledge, lack of induction on MDSR, unavailability of guidelines and notification forms and lack of knowledge on the flow of information in the system were reasons for late notification of maternal deaths. Workers trained in MDSR were 83.8%. Only 36.1% of respondents had completed an MDNF before. Respondents who used MDSR data at their level were 91.7%, and they reported that MDSR system was useful. Responsibility to complete the MDNF was placed on health workers. Maternal death case definitions were available in 2/11 facilities, 4/11 facilities had guidelines for maternal death audits. It costs $60.78 to notify a maternal death. CONCLUSION: Reasons for late notification of maternal deaths were inadequate knowledge, lack of induction, unavailability of guidelines and notification forms at facilities. The MDSR system is useful, acceptable, flexible, unstable, reliable but not simple. Maternal case definitions and maternal death audit guidelines should be distributed to all facilities. Training of all health workers involved in MDSR is recommended.

Utilization and outcomes of cervical cancer screening services in Harare City, 2012-2016: a secondary data analysis.

BACKGROUND: Visual inspection with acetic acid and cervicography (VIAC) is a method used to screen for cervical cancer. VIAC can be used as part of a "see and treat" strategy. Nine Harare city council health facilities offer VIAC free of charge with the aim of reducing morbidity and mortality from cervical cancer. Between 2014 and 2016, the number of women utilising VIAC dropped by 35%. We analysed records of clients who utilise VIAC at Harare city health facilities to characterise women accessing VIAC and their outcomes to make recommendations for improving the services. METHODS: We conducted a descriptive cross-sectional study using data collected for the Harare city VIAC program. We analysed all records of clients who utilised VIAC services at nine Harare city health facilities from 1 May 2012 to 31 December 2016. RESULTS: We analysed 46,217 records, the median age of the clients was 34 years [Q1 = 27: Q3 = 42]. Of the 46,217 clients screened, 3001 (6.5%) were VIAC positive, and 512 (1.1%) had suspicious of cancer lesions. The prevalence of VIAC positive ranged from 58 to 74 per 1000-screened clients over the 5 years. The prevalence of suspected cancer ranged from 9 to 14 per 1000-screened clients, and there was a general decrease in the prevalence between 2012 and 2016. Of the 3513 clients with VIAC positive or had suspicious of cancer lesions, 2090 (74.1%) did not receive treatment at the site where the screening took place. CONCLUSION: The majority of women who are accessing VIAC services in Harare are middle-aged, multiparous and married women. There is a treatment gap at most of the VIAC centres such that clients are referred to other centres for management. The objective of "see and treat" is not being realised.

Impact of Timing of Antiretroviral Treatment and Birth Weight on Mother-to-Child Human Immunodeficiency Virus Transmission: Findings From an 18-Month Prospective Cohort of a Nationally Representative Sample of Mother-Infant Pairs During the Transition From Option A to Option B+ in Zimbabwe.

Background: Preventing mother-to-child transmission of human immunodeficiency virus transmission (MTCT) depends on early initiation of antiretroviral therapy (ART). We report the 18-month MTCT risk during the transition from Option A to Option B+ in Zimbabwe, and assess whether ART preconception could eliminate MTCT in breastfeeding populations. Methods: In 2013, we consecutively recruited a nationally representative sample of 6051 infants aged 4-12 weeks and their mothers from 151 immunization clinics using a multistage stratified cluster sampling method. We identified 1172 human immunodeficiency virus (HIV)-exposed infants and evaluated them at baseline and every 3 months until the child became HIV-infected, died, or reached age 18 months. Results: The cumulative MTCT risk through 18 months postdelivery was 7.0%. Of the HIV-infected mothers, 35.3% started ART preconception, 28.9% during pregnancy, and 9.7% after delivery, and 16.0% received zidovudine during pregnancy. Compared to mothers without antiretroviral drug use, MTCT among those starting ART preconception and during pregnancy was lower by 88% (adjusted hazard ratio [aHR], 0.12; 95% confidence interval [CI], .06-.24) and 75% (aHR, 0.25; 95% CI, .14-.45), respectively. HIV-exposed infants with birth weight <2.5 kg (low birth weight) were 2.6-fold more likely to acquire HIV infection compared to those with birth weight ≥2.5 kg (aHR, 2.57; 95% CI, 1.44-4.59). Controlling for other factors, breastfeeding was not significantly associated with MTCT. Conclusions: ART preconception has the highest impact on reducing MTCT, indicating that HIV-infected, reproductive-age women should be prioritized in "treat-all" strategies. HIV-infected mothers without ART use should be identified at the first immunization visit and treatment initiated to reduce postdelivery MTCT. MTCT risk is higher in mothers with low-birth-weight deliveries.

The Etiology of Male Urethral Discharge in Zimbabwe: Results from the Zimbabwe STI Etiology Study.

INTRODUCTION: Sexually transmitted infections (STIs) are managed syndromically in most developing countries. In Zimbabwe, men presenting with urethral discharge are treated with a single intramuscular dose of kanamycin or ceftriaxone in combination with a week's course of oral doxycycline. This study was designed to assess the current etiology of urethral discharge and other STIs to inform current syndromic management regimens. METHODS: We conducted a study among 200 men with urethral discharge presenting at 6 regionally diverse STI clinics in Zimbabwe. Urethral specimens were tested by multiplex polymerase chain reaction testing for Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium, and Trichomonas vaginalis. In addition, serologic testing for syphilis and HIV was performed. RESULTS: Among the 200 studied men, one or more pathogens were identified in 163 (81.5%) men, including N. gonorrhoeae in 147 (73.5%), C. trachomatis in 45 (22.5%), T. vaginalis in 8 (4.0%), and M. genitalium in 7 (3.5%). Among all men, 121 (60%) had a single infection, 40 (20%) had dual infections, and 2 (1%) had 3 infections. Among the 45 men with C. trachomatis, 36 (80%) were coinfected with N. gonorrhoeae. Overall, 156 (78%) men had either N. gonorrhoeae or C. trachomatis identified. Of 151 men who consented to HIV testing, 43 (28.5%) tested positive. There were no differences in HIV status by study site or by urethral pathogen detected. CONCLUSIONS: Among men presenting at Zimbabwe STI clinics with urethral discharge, N. gonorrhoeae and C. trachomatis are the most commonly associated pathogens. Current syndromic management guidelines seem to be adequate for the treatment for symptomatic men, but future guidelines must be informed by ongoing monitoring of gonococcal resistance.

The Etiology of Genital Ulcer Disease and Coinfections With Chlamydia trachomatis and Neisseria gonorrhoeae in Zimbabwe: Results From the Zimbabwe STI Etiology Study.

BACKGROUND: In many countries, sexually transmitted infections (STIs) are treated syndromically. Thus, patients diagnosed as having genital ulcer disease (GUD) in Zimbabwe receive a combination of antimicrobials to treat syphilis, chancroid, lymphogranuloma venereum (LGV), and genital herpes. Periodic studies are necessary to assess the current etiology of GUD and assure the appropriateness of current treatment guidelines. MATERIALS AND METHODS: We selected 6 geographically diverse clinics in Zimbabwe serving high numbers of STI cases to enroll men and women with STI syndromes, including GUD. Sexually transmitted infection history and risk behavioral data were collected by questionnaire and uploaded to a Web-based database. Ulcer specimens were obtained for testing using a validated multiplex polymerase chain reaction (M-PCR) assay for Treponema pallidum (TP; primary syphilis), Haemophilus ducreyi (chancroid), LGV-associated strains of Chlamydia trachomatis, and herpes simplex virus (HSV) types 1 and 2. Blood samples were collected for testing with HIV, treponemal, and nontreponemal serologic assays. RESULTS: Among 200 GUD patients, 77 (38.5%) were positive for HSV, 32 (16%) were positive for TP, and 2 (1%) were positive for LGV-associated strains of C trachomatis. No H ducreyi infections were detected. No organism was found in 98 (49.5%) of participants. The overall HIV positivity rate was 52.2% for all GUD patients, with higher rates among women compared with men (59.8% vs 45.2%, P < 0.05) and among patients with HSV (68.6% vs 41.8%, P < 0.0001). Among patients with GUD, 54 (27.3%) had gonorrhea and/or chlamydia infection. However, in this latter group, 66.7% of women and 70.0% of men did not have abnormal vaginal or urethral discharge on examination. CONCLUSIONS: Herpes simplex virus is the most common cause of GUD in our survey, followed by T. pallidum. No cases of chancroid were detected. The association of HIV infections with HSV suggests high risk for cotransmission; however, some HSV ulcerations may be due to HSV reactivation among immunocompromised patients. The overall prevalence of gonorrhea and chlamydia was high among patients with GUD and most of them did not meet the criteria for concomitant syndromic management covering these infections.

The Etiology of Vaginal Discharge Syndrome in Zimbabwe: Results from the Zimbabwe STI Etiology Study.

INTRODUCTION: Symptomatic vaginal discharge is a common gynecological condition managed syndromically in most developing countries. In Zimbabwe, women presenting with symptomatic vaginal discharge are treated with empirical regimens that commonly cover both sexually transmitted infections (STIs) and reproductive tract infections, typically including a combination of an intramuscular injection of kanamycin, and oral doxycycline and metronidazole regimens. This study was conducted to determine the current etiology of symptomatic vaginal discharge and assess adequacy of current syndromic management guidelines. METHODS: We enrolled 200 women with symptomatic vaginal discharge presenting at 6 STI clinics in Zimbabwe. Microscopy was used to detect bacterial vaginosis and yeast infection. Nucleic acid amplifications tests were used to detect Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, and Mycoplasma genitalium. In addition, serologic testing was performed to detect human immunodeficiency virus (HIV) infection. RESULTS: Of the 200 women, 146 (73%) had an etiology detected, including bacterial vaginosis (24.7%); N. gonorrhoeae (24.0%); yeast infection (20.7%); T. vaginalis (19.0%); C. trachomatis (14.0%) and M. genitalium (7.0%). Among women with STIs (N = 90), 62 (68.9%) had a single infection, 18 (20.0%) had a dual infection, and 10 (11.1%) had 3 infections.Of 158 women who consented to HIV testing, 64 (40.5%) were HIV infected.The syndromic management regimen covered 115 (57.5%) of the women in the sample who had gonorrhea, chlamydia, M. genitalium, or bacterial vaginosis, whereas 85 (42.5%) of women were treated without such diagnosis. CONCLUSIONS: Among women presenting with symptomatic vaginal discharge, bacterial vaginosis was the most common etiology, and gonorrhea was the most frequently detected STI. The current syndromic management algorithm is suboptimal for coverage of women presenting with symptomatic vaginal discharge; addition of point of care testing could compliment the effectiveness of the syndromic approach.

Evidence-Based Identification of Key Beliefs Explaining Infant Male Circumcision Motivation Among Expectant Parents in Zimbabwe: Targets for Behavior Change Messaging.

Slow adult male circumcision uptake is one factor leading some to recommend increased priority for infant male circumcision (IMC) in sub-Saharan African countries. This research, guided by the integrated behavioral model (IBM), was carried out to identify key beliefs that best explain Zimbabwean parents' motivation to have their infant sons circumcised. A quantitative survey, designed from qualitative elicitation study results, was administered to independent representative samples of 800 expectant mothers and 795 expectant fathers in two urban and two rural areas in Zimbabwe. Multiple regression analyses found IMC motivation among fathers was explained by instrumental attitude, descriptive norm and self-efficacy; while motivation among mothers was explained by instrumental attitude, injunctive norm, descriptive norm, self-efficacy, and perceived control. Regression analyses of beliefs underlying IBM constructs found some overlap but many differences in key beliefs explaining IMC motivation among mothers and fathers. We found differences in key beliefs among urban and rural parents. Urban fathers' IMC motivation was explained best by behavioral beliefs, while rural fathers' motivation was explained by both behavioral and efficacy beliefs. Urban mothers' IMC motivation was explained primarily by behavioral and normative beliefs, while rural mothers' motivation was explained mostly by behavioral beliefs. The key beliefs we identified should serve as targets for developing messages to improve demand and maximize parent uptake as IMC programs are rolled out. These targets need to be different among urban and rural expectant mothers and fathers.

Identification of Key Beliefs Explaining Male Circumcision Motivation Among Adolescent Boys in Zimbabwe: Targets for Behavior Change Communication.

Male circumcision (MC) significantly reduces HIV acquisition among men, leading WHO/UNAIDS to recommend high HIV and low MC prevalence countries circumcise 80% of adolescents and men age 15-49. Despite significant investment to increase MC capacity only 27% of the goal has been achieved in Zimbabwe. To increase adoption, research to create evidence-based messages is greatly needed. The Integrated Behavioral Model (IBM) was used to investigate factors affecting MC motivation among adolescents. Based on qualitative elicitation study results a survey was designed and administered to a representative sample of 802 adolescent boys aged 13-17 in two urban and two rural areas in Zimbabwe. Multiple regression analysis found all six IBM constructs (2 attitude, 2 social influence, 2 personal agency) significantly explained MC intention (R2 = 0.55). Stepwise regression analysis of beliefs underlying each IBM belief-based construct found 9 behavioral, 6 injunctive norm, 2 descriptive norm, 5 efficacy, and 8 control beliefs significantly explained MC intention. A final stepwise regression of all the significant IBM construct beliefs identified 12 key beliefs best explaining intention. Similar analyses were carried out with subgroups of adolescents by urban-rural and age. Different sets of behavioral, normative, efficacy, and control beliefs were significant for each sub-group. This study demonstrates the application of theory-driven research to identify evidence-based targets for the design of effective MC messages for interventions to increase adolescents' motivation. Incorporating these findings into communication campaigns is likely to improve demand for MC.

Virological failure among adolescents on ART, Harare City, 2017- a case-control study.

BACKGROUND: Zimbabwe is on track towards achieving viral suppression among adults (87%). However, adolescents have only achieved 44% by 2016. In Harare city, 57% of adolescents had attained viral suppression after 12 months on ART compared to 88% among adults. We determined factors associated with virological failure among adolescents (age 10-19 years) on antiretroviral therapy (ART) in Harare city. METHODS: We conducted a one to one unmatched case control study among 102 randomly recruited case: control pairs at the two main infectious disease hospitals in Harare. A case was any adolescent who presented with VL > 1000c/ml after at least 12 months on ART. A control was any adolescent who presented with VL < 1000c/ml after at least 12 months on ART. Interviewer administered questionnaires were used to collect data. Epi Info 7 was used to generate frequencies, means, proportions, ORs and p-values at 95% CI. RESULTS: We interviewed 102 case-control pairs. Poor adherence to ART [aOR = 8.15, 95% CI (2.80-11.70)], taking alcohol [aOR = 8.46, 95% CI (3.22-22.22)] and non- disclosure of HIV status [aOR = 4.56, 95% CI (2.20-9.46)] were independent risk factors for virological failure. Always using a condom [aOR = 0.04, 95% CI (0.01-0.35)], being on second line treatment [aOR = 0.04, 95% CI (0.23-0.81)] and belonging to a support group [aOR = 0.41, 95% CI (0.21-0.80)] were protective. CONCLUSION: Poor adherence, alcohol consumption and non-disclosure increased the odds of virological failure. Based on these findings support should focus on behavior change and strengthening of peer to peer projects to help address issues related to disclosure and adherence. Further operational research should aim to define other components of effective adherence support for adolescents with virological failure.

Factors associated with late presentation for HIV/AIDS care in Harare City, Zimbabwe, 2015.

BACKGROUND: Despite widespread awareness and publicity concerning Human Immunodeficiency Virus (HIV) care and advances in treatment, many patients still present late in their HIV disease. Preliminary review of the Antiretroviral Therapy (ART) registers at Wilkins and Beatrice Road Hospitals, both located in Harare, indicated that 67 and 71 % of patients enrolled into HIV/AIDS care presented late with baseline CD4 of <200 cells/uL and/or WHO stage 3 and 4 respectively. We therefore sought to explore factors associated with late presentation in Harare City. METHODS: We conducted a 1:1 unmatched case control study where a case was an HIV positive individual (>18 years) with a baseline CD4 of <200/uL or who had WHO clinical stage 3 or 4 at first presentation to OI/ART centres in 2014 and; a control was HIV positive individual (>18 years) who had a baseline CD4 of >200/uL or WHO clinical stage 1 or 2 at first presentation in 2014. Written informed consent was obtained from all study participants. RESULTS: A total of 268 participants were recruited (134 cases and 134 controls). Independent risk factors for late presentation for HIV/AIDS care were illness being reason for test (Adjusted Odds Ratio [aOR] =7.68, 95 % CI = 4.08, 14.75); Being male (aOR = 2.84, 95 % CI = 1.50, 5.40) and; experienced HIV stigma (aOR = 2.99, 95 % CI = 1.54, 5.79). Independent protective factors were receiving information on HIV (aOR = 0.37, 95 % CI = 0.18, 0.78) and earning more than US$250 per month (aOR = 0.32, 95 % CI = 0.76, 0.67). Median duration between first reported HIV positive test result and enrolment into pre-ART care was 2 days (Q1 = 1 day; Q3 = 30 days) among cases and 30 days (Q1 = 3 days; Q3 = 75 days) among controls. CONCLUSION: Late presentation for HIV/AIDS care in Harare City was a result of factors that relate to the patient's sex, reason for getting a test, receiving HIV related information, experiencing stigma and monthly income. Based on this evidence we recommended targeted interventions to optimize early access to testing and enrolment into care.

Factors associated with male involvement in the prevention of mother to child transmission of HIV, Midlands Province, Zimbabwe, 2015 - a case control study.

BACKGROUND: Uptake of and adherence to the prevention of mother to child transmission of HIV (PMTCT) interventions are a challenge to most women if there is no male partner involvement. Organizations which include the National AIDS Council and the Zimbabwe AIDS Prevention Project- University of Zimbabwe have been working towards mobilizing men for couple HIV testing and counseling (HTC) in antenatal care (ANC). In 2013, Midlands province had 19 % males who were tested together with their partners in ANC, an increase by 9 % from 2011. However, this improvement was still far below the national target, hence this study was conducted to determine the associated factors. METHODS: A1:1 unmatched case control study was conducted. A case was a man who did not receive HIV testing and counseling together with his pregnant wife in ANC in Midlands province from January to June 2015. A control was a man who received HIV testing and counseling together with his pregnant wife in ANC in Midlands province from January to June 2015. Simple random sampling was used to select 112 cases and 112 controls. Epi Info statistical software was used to analyze data. Written informed consent was obtained from each study participant. RESULTS: Independent factors that predicted male involvement in PMTCT were: having been previously tested as a couple (aOR) 0.22, 95 % CI = 0.12, 0.41) and having time to visit the clinic (aOR) 0.41, 95 % CI = 0.21, 0.80). Being afraid of knowing one's HIV status (aOR 2.22, 95 % CI = 1.04, 4.76) was independently associated with low male involvement in PMTCT. CONCLUSION: Multiple factors were found to be associated with male involvement in PMTCT. Routine PMTCT educational campaigns in places where men gather, community based couple HTC and accommodating the working class during weekends are essential in fostering male involvement in PMTCT thereby reducing HIV transmission to the baby.

Prevalence of pregnancy induced hypertension and pregnancy outcomes among women seeking maternity services in Harare, Zimbabwe.

BACKGROUND: Pregnancy induced hypertension (PIH) is one of the most common causes of both maternal and neonatal morbidity, affecting about 5 - 8 % of pregnant women. It is associated with adverse pregnancy outcomes as well as maternal morbidity and mortality. Harare City experienced an increase in referrals due to PIH to central hospitals from 2009 to 2011. We conducted a study to determine the prevalence of PIH and pregnancy outcomes among women with PIH. METHODS: An analytic cross sectional study was conducted. Interviewer administered questionnaires were used to capture demographic data, obstetric history and knowledge on PIH management. Records were reviewed for pregnancy outcomes while key informants were also interviewed on patient management. RESULTS: PIH prevalence was 19.4 %. Women with PIH were three times more likely to deliver a low birth weight baby (OR 3.00, p = 0.0115), 4.3 times more likely to have still birth (OR 4.34, p = 0.0517) and four times more likely to have a baby with low Apgar score at 5 minutes (OR 4.47, p = 0.0155) compared to women without PIH. There was no statistically significant difference in delivery before 37 weeks gestation between women with PIH and those without (OR 1.70, p = 0.1251). 12,5 % of the women delivered by caesarean section. Methyldopa was the drug of choice for management of PIH. Less than half of the health workers had sufficient knowledge on definition or management of PIH. Delay in seeking care and shortage of resources were the major reported challenges in the proper management of PIH. CONCLUSION: PIH prevalence was high. Women with PIH were at higher risk of adverse pregnancy outcomes than those without. Poor knowledge of management of PIH and inadequate resources are a threat to the proper management of PIH. This underscores the need for increased human resources and capacity building as well as resource mobilisation for proper management of pregnant women. Urinalysis must be routinely done for all pregnant women regardless of their blood pressure.

Effectiveness of short message services reminder on childhood immunization programme in Kadoma, Zimbabwe - a randomized controlled trial, 2013.

BACKGROUND: Globally, non-attendance for immunization appointments remains a challenge to healthcare providers. A review of the 2011 immunization coverage for Kadoma City, Zimbabwe was 74% for Oral Polio Vaccine (OPV), Pneumococcal and Pentavalent antigens. The immunization coverage was less than 90%, which is the target for Kadoma City. Adoption of short message services (SMS) reminders has been shown to enhance attendance in some medical settings. The study was conducted to determine the effectiveness of SMS reminders on immunization programme for Kadoma City. METHODS: A randomized controlled trial was conducted at Kadoma City clinics in Zimbabwe. Women who delivered and were residents of Kadoma City were recruited into the study. In the intervention group, SMS reminders were sent at 6, 10 and 14 weeks in addition to routine health education. In the non-intervention no SMS reminders were used, however routine health education was offered. Data were collected using interviewer administered questionnaire. Data were analyzed using Epi Info 7™, where frequencies, means, risk ratios and risk differences were generated. RESULTS: A total of 304 participants were recruited, 152 for the intervention group and 152 for the non-intervention group. The immunization coverage at 6 weeks was 97% in the intervention group and 82% in the non-intervention group (p < 0.001). At 14 weeks immunization coverage was 95% for intervention and 75% for non-intervention group (p < 0.001). Those who did not delay receiving immunization at 14 weeks was 82% for the intervention and 8% for non-intervention group. Median delay for intervention was 0 days (Q1 = 0; Q3 = 0) and 10 days (Q1 = 6; Q3 = 17) for non-intervention group. The risk difference (RD) for those who received SMS reminders than those in the non intervention group was 16.3% (95% CI: 12.5-28.0) at 14 weeks. CONCLUSION: Immunization coverage in the intervention group was significantly higher than in non-intervention group. Overall increase in immunization coverage can be attributed to use of SMS. TRIAL REGISTRATION: ISRCTN70918594 . Registration Date: 28 August 2014.