Trends in all-cause mortality during the scale-up of an antiretroviral therapy programme: a cross-sectional study in Lusaka, Zambia.

OBJECTIVE: To follow the trends in all-cause mortality in Lusaka, Zambia, during the scale-up of a national programme of antiretroviral therapy (ART). METHODS: Between November 2004 and September 2011, we conducted 12 survey rounds as part of a cross-sectional study in Lusaka, with independent sampling in each round. In each survey, we asked the heads of 3600 households to state the number of deaths in their households in the previous 12 months and the number of orphans aged less than 16 years in their households and investigated the heads' knowledge, attitudes and practices related to human immunodeficiency virus (HIV). FINDINGS: The number of deaths we recorded - per 100 person-years - in each survey ranged from 0.92 (95% confidence interval, CI: 0.78-1.09) in September 2011, to 1.94 (95% CI: 1.60-2.35) in March 2007. We found that mortality decreased only modestly each year (mortality rate ratio: 0.98; 95% CI: 0.95-1.00; P = 0.093). The proportion of households with orphans under the age of 16 years decreased from 17% in 2004 to 7% in 2011. The proportions of respondents who had ever been tested for HIV, had a comprehensive knowledge of HIV, knew where to obtain free ART and reported that a non-pregnant household member was receiving ART gradually increased. CONCLUSION: The expansion of ART services in Lusaka was not associated with a reduction in all-cause mortality. Coverage, patient adherence and retention may all have to be increased if ART is to have a robust and lasting impact at population level in Lusaka.

The impact of a hybrid social marketing intervention on inequities in access, ownership and use of insecticide-treated nets.

BACKGROUND: An ITN intervention was initiated in three predominantly rural districts of Eastern Province, Zambia, that lacked commercial distribution and communication infrastructures. Social marketing techniques were used for product and message development. Public sector clinics and village-based volunteers promoted and distributed subsidized ITNs priced at 2.5 dollars per net. A study was conducted to assess the effects of the intervention on inequities in knowledge, access, ownership and use of ITNs. METHODS: A post-test only quasi-experimental study design was used to compare intervention and comparison districts. A total of 2,986 respondents were interviewed. Survey respondents were grouped into four socio-economic (SES) categories: low, medium-low, medium and high. Knowledge, access, ownership and use indicators are compared. Concentration index scores are calculated. Interactions between intervention status and SES help determine how different SES groups benefited from the intervention. RESULTS: Although overall use of nets remained relatively low, post-test data show that knowledge, access, ownership and use of mosquito nets was higher in intervention districts. A decline in SES inequity in access to nets occurred in intervention districts, resulting from a disproportionately greater increase in access among the low SES group. Declines in SES inequities in net ownership and use of nets were associated with the intervention. The largest increases in net ownership and use occurred among medium and high SES categories. CONCLUSION: Increasing access to nets among the poorest respondents in rural areas may not lead to increases in net use unless the price of nets is no longer a barrier to their purchase.

Methods and baseline results of a repeated cross-sectional survey to assess the public health impact of antiretroviral therapy in Lusaka, Zambia.

Although the individual-level impact of antiretroviral therapy (ART) is well documented, there are few available data describing the public health impact of services for persons infected with human immunodeficiency virus in resource-constrained settings. We describe the methods and baseline results of a household survey that assessed the population-level impact of the national program for HIV care in Zambia and treatment in the city of Lusaka. The survey was timed with the staggered expansion of services and repeated cross-sectional surveys planned for pre-implementation and post-implementation comparisons made by community. In the initial survey round, which was performed during the early phases of the program (November-December 2004), 18,110 persons were enumerated from 3,600 households surveyed. Respondents were asked questions designed to evaluate community-level mortality and respondent knowledge and attitudes towards HIV. These findings will serve as a reliable reference in the future analysis of the population-level impact of this HIV treatment and care program in Zambia.

The effects of religious affiliation on sexual initiation and condom use in Zambia.

PURPOSE: To determine whether religious affiliation reduces HIV risk among young women in Zambia, and to examine the effects of religious affiliation on sexual initiation and on condom use during first sexual experience. METHODS: Data from a representative probability sample of 5534 women aged 13-20 years was analyzed. The instrument included questions on sexual initiation, condom use during first sex, religious affiliation, and sociodemographic characteristics of respondents. Statistical tests were performed at the bivariate and multivariate levels. Cox proportional hazards and logistic regression were used at the multivariate levels. Standard errors were adjusted for the "clustering" effect found in data from multistage cluster samples. RESULTS: Affiliation with religious groups that excommunicate members for engaging in premarital sex, and that oppose condom use has both positive and negative effects on behaviors that carry the risk of HIV infection; young women affiliated with conservative groups are more likely to delay sexual initiation but less likely to use condoms during first sex. CONCLUSIONS: Denominations that are not only strongly opposed to premarital sex and condom use, but are able to exercise control over adolescents through socialization or the threat of social exclusion, are likely to create conflicting behaviors among adolescents that cancel each other in terms of HIV risk. Overall, these findings suggest that affiliation with conservative religious groups is unlikely to reduce the risk of HIV infection. Additional studies are recommended.

Equity in access to condoms in urban Zambia.

OBJECTIVE: This article examines the degree of equity in access to condoms in urban Zambia. METHODOLOGY: This study uses data from representative samples of a). men and women in households in urban Zambia and b). providers at retail outlets in urban Zambia. RESULTS: A substantial proportion of outlets in urban Zambia (39%) stocked social marketing condoms in 1999. More than 30% of groceries and kiosks - outlets commonly found in low-income residential areas - stocked social marketing condoms. Consumer access to condoms (defined as estimated walking time to a condom source) was greater for poorer compared to wealthier respondents: compared to men with 7-13 assets (wealthier men), men with 2-6 assets were 1.5 times as likely and men with up to one asset were 1.8 times as likely to be within 10 minutes walk of a condom source. Multivariate analysis indicated that greater access to condoms among the poor was a function of greater condom availability in poorer neighbourhoods. CONCLUSIONS: Making condoms available in non-traditional outlet types that are commonly found in low-income areas (such as kiosks and groceries) can eliminate socioeconomic inequities in condom access.