Achieving HIV Epidemic Control and Improving Maternal Healthcare Services with Community-Based HIV Service Delivery in Zambia: Mixed-Methods Assessment of the SMACHT Project.

Novel community-based approaches are needed to achieve and sustain HIV epidemic control in Zambia. Under the Stop Mother and Child HIV Transmission (SMACHT) project, the Community HIV Epidemic Control (CHEC) differentiated service delivery model used community health workers to support HIV testing, ART linkage, viral suppression, and prevention of mother-to-child transmission (MTCT). A multi-methods assessment included programmatic data analysis from April 2015 to September 2020, and qualitative interviews from February to March 2020. CHEC provided HIV testing services to 1,379,387 clients; 46,138 were newly identified as HIV-positive (3.3% yield), with 41,366 (90%) linked to ART. By 2020, 91% (60,694/66,841) of clients on ART were virally suppressed. Qualitatively, healthcare workers and clients benefitted from CHEC, with provision of confidential services, health facility decongestion, and increased HIV care uptake and retention. Community-based models can increase uptake of HIV testing and linkage to care, and help achieve epidemic control and elimination of MTCT.

Increase in Antiretroviral Therapy Enrollment Among Persons with HIV Infection During the Lusaka HIV Treatment Surge - Lusaka Province, Zambia, January 2018-June 2019.

Within Zambia, a landlocked country in southern-central Africa, the highest prevalence of human immunodeficiency virus (HIV) infection is in Lusaka Province (population 3.2 million), where approximately 340,000 persons are estimated to be infected (1). The 2016 Zambia Population-based HIV Impact Assessment (ZAMPHIA) estimated the adult HIV prevalence in Lusaka Province to be 15.7%, with a 62.7% viral load suppression rate (HIV-1 RNA <1,000 copies/mL) (2). ZAMPHIA results highlighted remaining treatment gaps in Zambia overall and by subpopulation. In January 2018, Zambia launched the Lusaka Province HIV Treatment Surge (Surge project) to increase enrollment of persons with HIV infection onto antiretroviral therapy (ART). The Zambia Ministry of Health (MoH), CDC, and partners analyzed the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) Monitoring and Evaluation Reporting data set to assess the effectiveness of the first 18 months of the Surge project (January 2018-June 2019). During this period, approximately 100,000 persons with positive test results for HIV began ART. These new ART clients were more likely to be persons aged 15-24 years. In addition, the number of persons with documented viral load suppression doubled from 66,109 to 134,046. Lessons learned from the Surge project, including collaborative leadership, efforts to improve facility-level performance, and innovative strategies to disseminate successful practices, could increase HIV treatment rates in other high-prevalence settings.

Integrating HIV care and treatment into tuberculosis clinics in Lusaka, Zambia: results from a before-after quasi-experimental study.

BACKGROUND: Patients with HIV-associated tuberculosis (TB) often have their TB and HIV managed in separate vertical programs that offer care for each disease with little coordination. Such "siloed" approaches are associated with diagnostic and treatment delays, which contribute to unnecessary morbidity and mortality. To improve TB/HIV care coordination and early ART initiation, we integrated HIV care and treatment into two busy TB clinics in Zambia. We report here the effects of our intervention on outcomes of linkage to HIV care, early ART uptake, and TB treatment success for patients with HIV-associated TB in Lusaka, Zambia. METHODS: We provided integrated HIV treatment and care using a "one-stop shop" model intervention. All new or relapse HIV-positive TB patients were offered immediate HIV program enrolment and ART within 8 weeks of anti-TB therapy (ATT) initiation. We used a quasi-experimental design, review of routine program data, and survival analysis and logistic regression methods to estimate study outcomes before (June 1, 2010-January 31, 2011) and after (August 1, 2011-March 31, 2012) our intervention among 473 patients with HIV-associated TB categorized into pre- (n = 248) and post-intervention (n = 225) cohorts. RESULTS: Patients in the pre- and post-intervention cohorts were mostly male (60.1% and 52.9%, respectively) and young (median age: 33 years). In time-to-event analyses, a significantly higher proportion of patients in the post-intervention cohort linked to HIV care by 4 weeks post-ATT initiation (53.9% vs. 43.4%, p = 0.03), with median time to care linkage being 59 and 25 days in the pre- and post-intervention cohorts, respectively. In Cox proportional hazard modelling, patients receiving the integration intervention started ART by 8 weeks post-ATT at 1.33 times the rate (HR = 1.33, 95% CI: 1.00-1.77) as patients pre-intervention. In logistic regression modelling, patients receiving the intervention were 2.02 times (95% CI: 1.11-3.67) as likely to have a successful TB treatment outcome as patients not receiving the intervention. CONCLUSIONS: Integrating HIV treatment and care services into routine TB clinics using a one-stop shop model increased linkage to HIV care, rates of early ART initiation, and TB treatment success among patients with HIV-associated TB in Lusaka, Zambia.

Chest radiograph reading and recording system: evaluation in frontline clinicians in Zambia.

BACKGROUND: In Zambia the vast majority of chest radiographs (CXR) are read by clinical officers who have limited training and varied interpretation experience, meaning lower inter-rater reliability and limiting the usefulness of CXR as a diagnostic tool. In 2010-11, the Zambian Prison Service and Ministry of Health established TB and HIV screening programs in six prisons; screening included digital radiography for all participants. Using front-line clinicians we evaluated sensitivity, specificity and inter-rater agreement for digital CXR interpretation using the Chest Radiograph Reading and Recording System (CRRS). METHODS: Digital radiographs were selected from HIV-infected and uninfected inmates who participated in a TB and HIV screening program at two Zambian prisons. Two medical officers (MOs) and two clinical officers (COs) independently interpreted all CXRs. We calculated sensitivity and specificity of CXR interpretations compared to culture as the gold standard and evaluated inter-rater reliability using percent agreement and kappa coefficients. RESULTS: 571 CXRs were included in analyses. Sensitivity of the interpretation "any abnormality" ranged from 50-70 % depending on the reader and the patients' HIV status. In general, MO's had higher specificities than COs. Kappa coefficients for the ratings of "abnormalities consistent with TB" and "any abnormality" showed good agreement between MOs on HIV-uninfected CXRs and moderate agreement on HIV-infected CXRs whereas the COs demonstrated fair agreement in both categories, regardless of HIV status. CONCLUSIONS: Sensitivity, specificity and inter-rater agreement varied substantially between readers with different experience and training, however the medical officers who underwent formal CRRS training had more consistent interpretations.

Tuberculosis and the risk of opportunistic infections and cancers in HIV-infected patients starting ART in Southern Africa.

OBJECTIVES: To investigate the incidence of selected opportunistic infections (OIs) and cancers and the role of a history of tuberculosis (TB) as a risk factor for developing these conditions in HIV-infected patients starting antiretroviral treatment (ART) in Southern Africa. METHODS: Five ART programmes from Zimbabwe, Zambia and South Africa participated. Outcomes were extrapulmonary cryptococcal disease (CM), pneumonia due to Pneumocystis jirovecii (PCP), Kaposi's sarcoma and Non-Hodgkin lymphoma. A history of TB was defined as a TB diagnosis before or at the start of ART. We used Cox models adjusted for age, sex, CD4 cell count at ART start and treatment site, presenting results as adjusted hazard ratios (aHR) with 95% confidence intervals (CI). RESULTS: We analysed data from 175,212 patients enrolled between 2000 and 2010 and identified 702 patients with incident CM (including 205 with a TB history) and 487 with incident PCP (including 179 with a TB history). The incidence per 100 person-years over the first year of ART was 0.48 (95% CI 0.44-0.52) for CM, 0.35 (95% CI 0.32-0.38) for PCP, 0.31 (95% CI 0.29-0.35) for Kaposi's sarcoma and 0.02 (95% CI 0.01-0.03) for Non-Hodgkin lymphoma. A history of TB was associated with cryptococcal disease (aHR 1.28, 95% CI 1.05-1.55) and Pneumocystis jirovecii pneumonia (aHR 1.61, 95% CI 1.27-2.04), but not with Non-Hodgkin lymphoma (aHR 1.09, 95% CI 0.45-2.65) or Kaposi's sarcoma (aHR 1.02, 95% CI 0.81-1.27). CONCLUSIONS: Our study suggests that there may be interactions between different OIs in HIV-infected patients.

HIV test-and-treat policy improves clinical outcomes in Zambian adults from Southern Province: a multicenter retrospective cohort study.

Background: Globally, most countries have implemented a test-and-treat policy to reduce morbidity and mortality associated with HIV infection. However, the impact of this strategy has not been critically appraised in many settings, including Zambia. We evaluated the retention and clinical outcomes of adults enrolled in antiretroviral therapy (ART) and assessed the impact of the test-and-treat policy. Methods: We conducted a retrospective cohort study among 6,640 individuals who initiated ART between January 1, 2014 and July 31, 2016 [before test-and-treat cohort (BTT), n = 2,991] and between August 1, 2016 and October 1, 2020 [after test-and-treat cohort (ATT), n = 3,649] in 12 districts of the Southern province. To assess factors associated with retention, we used logistic regression (xtlogit model). Results: The median age [interquartile range (IQR)] was 34.8 years (28.0, 42.1), and 60.2% (n = 3,995) were women. The overall retention was 83.4% [95% confidence interval (CI) 82.6, 84.4], and it was significantly higher among the ATT cohort, 90.6 vs. 74.8%, p < 0.001. The reasons for attrition were higher in the BTT compared to the ATT cohorts: stopped treatment (0.3 vs. 0.1%), transferred out (9.3 vs. 3.2%), lost to follow-up (13.5 vs. 5.9%), and death (1.4 vs. 0.2%). Retention in care was significantly associated with the ATT cohort, increasing age and baseline body mass index (BMI), rural residence, and WHO stage 2, while non-retention was associated with never being married, divorced, and being in WHO stage 3. Conclusion: The retention rate and attrition factors improved in the ATT compared to the BTT cohorts. Drivers of retention were test-and-treat policy, older age, high BMI, rural residence, marital status, and WHO stage 1. Therefore, there is need for interventions targeting young people, urban residents, non-married people, and those in the symptomatic WHO stages and with low BMI. Our findings highlight improved ART retention after the implementation of the test-and-treat policy.

Reaching transgender populations in Zambia for HIV prevention and linkage to treatment using community-based service delivery.

INTRODUCTION: Transgender and gender-diverse communities in Zambia are highly vulnerable and experience healthcare differently than cisgender persons. The University of Maryland, Baltimore (UMB) supports projects in Zambia to improve HIV case-finding, linkage and antiretroviral treatment (ART) for Zambia's transgender community. We describe programme strategies and outcomes for HIV prevention, testing and ART linkage among transgender communities. METHODS: UMB utilizes a differentiated service delivery model whereby community health workers (CHWs) recruited from key populations (KPs) reach community members through a peer-to-peer approach, with the support of local transgender civil society organizations (CSOs) and community gatekeepers. Peer CHWs are trained and certified as HIV testers and psychosocial counsellors to offer counselling with HIV testing and prevention services in identified safe spaces. HIV-negative people at risk of HIV infection are offered pre-exposure prophylaxis (PrEP), while those who test positive for HIV are linked to ART services. CHWs collect data using the standardized facility and community tools and a dedicated DHIS2 database system. We conducted a descriptive analysis examining HIV testing and prevention outcomes using proportions and comparisons by time period and geographic strata. RESULTS: From October 2020 to June 2021, across Eastern, Lusaka, Western and Southern Provinces, 1860 transgender persons were reached with HIV prevention messages and services. Of these, 424 (23%) were tested for HIV and 78 (18%) tested positive. Of the 346 HIV-negative persons, 268 (78%) eligible transgender individuals were initiated on PrEP. ART linkage was 97%, with 76 out of the 78 transgender individuals living with HIV initiating treatment. Programme strategies that supported testing and linkage included peer CHWs, social network strategy testing, same-day ART initiation and local KP CSO support. Challenges included non-transgender-friendly environments, stigma and discrimination, the high transiency of the transgender community and the non-availability of transgender-specific health services, such as hormonal therapy. CONCLUSIONS: Peer KP CHWs were able to reach many members of the transgender community, providing safe HIV testing, PrEP services and linkage to care. Focusing on community gatekeepers and CSOs to disburse health messages and employ welcoming strategies supported high linkage to both PrEP and ART for transgender people in Zambia.

Peer community health workers improve HIV testing and ART linkage among key populations in Zambia: retrospective observational results from the Z-CHECK project, 2019-2020.

INTRODUCTION: Zambia has made tremendous progress towards HIV epidemic control; however, gaps remain among key populations (KPs), such as female sex workers (FSWs), men who have sex with men (MSM), people who inject drugs (PWID) and people in prisons and enclosed settings due to cultural, social and legal barriers. The University of Maryland, Baltimore Zambia Community HIV Epidemic Control for Key Populations (Z-CHECK) project aimed to improve HIV case-finding, linkage and treatment adherence at the community level for KPs in Zambia. We describe Z-CHECK strategies and examine HIV positivity yield and antiretroviral therapy (ART) linkage among KPs to inform ongoing programme improvement. METHODS: Z-CHECK recruited, trained and deployed peer community health workers (CHWs) for KP groups, with ongoing mentorship in community engagement. CHWs offered HIV testing in safe spaces and escorted newly HIV-diagnosed clients for same-day ART initiation. Z-CHECK also reached out to KP community leaders and gatekeepers for KP mobilization and trained healthcare workers (HCWs) on KP services and sensitivity. We conducted a retrospective observational review of routinely collected aggregate data for KPs aged ≥15 years at high risk for HIV transmission across five districts in Zambia from January 2019 to December 2020. RESULTS: Z-CHECK provided HIV testing for 9211 KPs, of whom 2227 were HIV positive (positivity yield, 24%). Among these, 1901 (85%) were linked to ART; linkage for MSM, FSW, PWID and people in prisons and enclosed settings was 95%, 89%, 86% and 65%, respectively. Programme strategies that contributed to high positivity yield and linkage included the use of peer KP CHWs, social network testing strategies and opportunities for same-day ART initiation. Challenges to programme implementation included stigma and discrimination among HCWs, as well as KP CHW attrition, which may be explained by high mobility. CONCLUSIONS: Peer CHWs were highly effective at reaching KP communities, identifying persons living with HIV and linking them to care. Engaging KP community gatekeepers resulted in high diffusion of health messages and increased access to health resources. The mobility of CHWs and HCWs is a challenge for programme implementation. Innovative interventions are needed to support PWID and people in prisons and enclosed settings.

Progress towards the UNAIDS 90-90-90 targets among persons aged 50 and older living with HIV in 13 African countries.

INTRODUCTION: Achieving optimal HIV outcomes, as measured by global 90-90-90 targets, that is awareness of HIV-positive status, receipt of antiretroviral (ARV) therapy among aware and viral load (VL) suppression among those on ARVs, respectively, is critical. However, few data from sub-Saharan Africa (SSA) are available on older people (50+) living with HIV (OPLWH). We examined 90-90-90 progress by age, 15-49 (as a comparison) and 50+ years, with further analyses among 50+ (55-59, 60-64, 65+ vs. 50-54), in 13 countries (Cameroon, Cote d'Ivoire, Eswatini, Ethiopia, Kenya, Lesotho, Malawi, Namibia, Rwanda, Tanzania, Uganda, Zambia and Zimbabwe). METHODS: Using data from nationally representative Population-based HIV Impact Assessments, conducted between 2015and 2019, participants from randomly selected households provided demographic and clinical information and whole blood specimens for HIV serology, VL and ARV testing. Survey weighted outcomes were estimated for 90-90-90 targets. Country-specific Poisson regression models examined 90-90-90 variation among OPLWH age strata. RESULTS: Analyses included 24,826 HIV-positive individuals (15-49 years: 20,170; 50+ years: 4656). The first, second and third 90 outcomes were achieved in 1, 10 and 5 countries, respectively, by those aged 15-49, while OPLWH achieved outcomes in 3, 13 and 12 countries, respectively. Among those aged 15-49, women were more likely to achieve 90-90-90 targets than men; however, among OPLWH, men were more likely to achieve first and third 90 targets than women, with second 90 achievement being equivalent. Country-specific 90-90-90 regression models among OPLWH demonstrated minimal variation by age stratum across 13 countries. Among OLPWH, no first 90 target differences were noted by age strata; three countries varied in the second 90 by older age strata but not in a consistent direction; one country showed higher achievement of the third 90 in an older age stratum. CONCLUSIONS: While OPLWH in these 13 countries were slightly more likely than younger people to be aware of their HIV-positive status (first 90), this target was not achieved in most countries. However, OPLWH achieved treatment (second 90) and VL suppression (third 90) targets in more countries than PLWH <50. Findings support expanded HIV testing, prevention and treatment services to meet ongoing OPLWH health needs in SSA.

Coerced and forced sexual initiation and its association with negative health outcomes among youth: Results from the Nigeria, Uganda, and Zambia Violence Against Children Surveys.

INTRODUCTION: Coerced and forced sexual initiation (FSI) can have detrimental effects on children and youth. Understanding health outcomes that are associated with experiences of FSI is important for developing appropriate strategies for prevention and treatment of FSI and its consequences. METHODS: The Violence Against Children Surveys were conducted in Nigeria, Uganda, and Zambia in 2014 and 2015. We examined the prevalence of FSI and its consequences (sexual high-risk behaviors, violence experiences, mental health outcomes, and sexually transmitted infections (STI)) associated with FSI among youth aged 13-24 years in three countries in sub-Saharan Africa. RESULTS: Over one in ten youth aged 13-24 years who had ever had sex experienced FSI in Nigeria, Uganda, and Zambia. In multivariable logistic regression, FSI was significantly associated with infrequent condom use (OR = 1.4, 95%CI = 1.1-2.1), recent experiences of sexual violence (OR = 1.6, 95%CI: 1.1-2.3), physical violence (OR = 2.2, 95%CI: 1.6-3.0), and emotional violence (OR = 2.0, 95%CI: 1.3-2.9), moderate/serious mental distress (OR = 1.5, 95%CI: 1.1-2.0), hurting oneself (OR = 2.0, 95%CI: 1.3-3.1), and thoughts of suicide (OR = 1.5, 95%CI: 1.1-2.3), after controlling for demographic characteristics. FSI was not statistically associated with engaging in transactional sex, having multiple sex partners, or having a STI. CONCLUSION: FSI is associated with infrequent condom use, recent experiences of violence and mental health outcomes among youth in sub-Saharan Africa, which may increase the risk for HIV and other consequences. Developing strategies for prevention is important for reducing the prevalence of FSI and its effects on children and youth.

Promotion of couples' voluntary counselling and testing for HIV through influential networks in two African capital cities.

BACKGROUND: Most new HIV infections in Africa are acquired from cohabiting heterosexual partners. Couples' Voluntary Counselling and Testing (CVCT) is an effective prevention strategy for this group. We present our experience with a community-based program for the promotion of CVCT in Kigali, Rwanda and Lusaka, Zambia. METHODS: Influence Network Agents (INAs) from the health, religious, non-governmental, and private sectors were trained to invite couples for CVCT. Predictors of successful promotion were identified using a multi-level hierarchical analysis. RESULTS: In 4 months, 9,900 invitations were distributed by 61 INAs, with 1,411 (14.3%) couples requesting CVCT. INAs in Rwanda distributed fewer invitations (2,680 vs. 7,220) and had higher response rates (26.9% vs. 9.6%), than INAs in Zambia. Context of the invitation event, including a discreet location such as the INA's home (OR 3.3-3.4), delivery of the invitation to both partners in the couple (OR 1.6-1.7) or to someone known to the INA (OR 1.7-1.8), and use of public endorsement (OR 1.7-1.8) were stronger predictors of success than INA or couple-level characteristics. CONCLUSION: Predictors of successful CVCT promotion included strategies that can be easily implemented in Africa. As new resources become available for Africans with HIV, CVCT should be broadly implemented as a point of entry for prevention, care and support.

Transmission of HIV-1 and HLA-B allele-sharing within serodiscordant heterosexual Zambian couples.

Factors that might increase risk of HIV-1 transmission include age, sex, and amount of HIV-1 RNA in plasma, but findings for HLA allele-sharing are not in agreement. We tested the hypothesis that allele sharing at HLA loci is associated with increased risk of transmission of HIV-1 infection in cohabiting heterosexual Zambian couples. We studied 125 initially serodiscordant partners with sequence-confirmed interpartner HIV-1 transmission and 104 couples who were persistently serodiscordant, and we analysed relations with molecularly typed HLA-A, B, and C alleles by survival techniques. After adjustment for other genetic and non-genetic risk factors seen with heterosexual transmission of HIV-1 in this cohort, sharing of HLA-B alleles was independently associated with accelerated intracouple transmission (relative hazard 2.23, 95% CI 1.52-3.26, p<0.0001). Selective pressure by HLA-B alleles on transmitted viruses accords with current understanding of the effect of B locus polymorphism in HIV-1 and perhaps other infections.

Predictors of HIV serostatus among HIV discordant couples in Lusaka, Zambia and female antenatal clinic attendants in Kigali, Rwanda.

Clinical manifestations of HIV disease in Africa are nonspecific and easily confused with other endemic diseases. Several studies have compared the prevalence of HIV-related signs and symptoms in infected versus uninfected populations, but little is known about differences in HIV disease manifestations between African men and women across geographic areas. We conducted a cross-sectional study to define predictors of HIV status and assess their differences by gender and country in two African cohorts: 1351 heterosexual couples recruited from a voluntary HIV counseling and testing center in Lusaka, Zambia, and 1458 women recruited from antenatal and pediatric clinics in Kigali, Rwanda. HIV-positive Zambian men and women differed most with respect to prevalence of wasting syndrome (48.1% vs. 35.5%, p < 0.01). Zambian women were more likely to have a disseminated adenopathy than Rwandan women (33.2% vs. 7.8%, p < 0.01) and had a much higher median erythrocyte sedimentation rate (ESR) than either of the two other groups (78 mm/hr vs. 47 mm/hr, p < 0.01). Multivariable logistic regression modeling showed a history of tuberculosis [odds ratio (OR): 2.8-20.7], adenopathy on examination (OR: 4.0-6.3), and an ESR of >65 mm/hr (OR: 3.1-5.9) to be strongly predictive of HIV status in all groups. These screening tools, though highly predictive of HIV infection, were insensitive, as most infected persons were asymptomatic. Given these differences in HIV disease manifestation, screening tools based on signs and symptoms should be adapted accordingly. Additional studies are required to evaluate clinical markers as predictors of HIV disease progression and adjust them according to regional and gender differences.

A model of tuberculosis screening for pregnant women in resource-limited settings using Xpert MTB/RIF.

Timely diagnosis and treatment of maternal tuberculosis (TB) is important to reduce morbidity and mortality for both the mother and child, particularly in women who are coinfected with HIV. The World Health Organization (WHO) recommends the integration of TB/HIV screening into antenatal services but available diagnostic tools are slow and insensitive, resulting in delays in treatment initiation. Recently the WHO endorsed Xpert MTB/RIF, a highly sensitive, real-time PCR assay for Mycobacterium tuberculosis that simultaneously detects rifampicin resistance directly from sputum and provides results within 100 minutes. We propose a model for same-day TB screening and diagnosis of all pregnant women at antenatal care using Xpert MTB/RIF. Pilot studies are urgently required to evaluate strategies for the integration of TB screening into antenatal clinics using new diagnostic technologies.

Improved HIV testing coverage after scale-up of antiretroviral therapy programs in urban Zambia: Evidence from serial hospital surveillance.

BACKGROUND: We evaluated changing HIV testing coverage and prevalence rates before and after expanding city-wide antiretroviral therapy (ART) programs in Lusaka, Zambia. METHODS: We conducted serial cross-sectional surveys on the University Teaching Hospital medical ward to assess HIV prevalence among inpatients of unknown status in 2003 and 2006. Willing participants received counseling and dual HIV rapid tests. We compared the proportion of inpatients receiving their test results in 2003 (off-the-ward testing) to 2006 (on-the-ward). RESULTS: In 2003, none of 103 inpatients knew their HIV status or took ART; 99.0% (102/103) agreed to testing. In 2006, 49.3% (99 of 201) patients knew they were HIV-infected and were on ART; of those with unknown status, 98.0% (100/102) agreed to testing. In 2003, only 54.9% (56/102) received post-test counseling and 98.2% (55/56) learned their status. In 2006, 99.0% (99/100) received post-test counseling and 99.1% (98 of 99) learned their status. In 2003, 62.8% (64 of 102) of status-unknown inpatients who agreed to testing were seropositive by dual rapid test, compared to 48.0% (48 of 100) of status-unknown inpatients in 2006. When including inpatients who already knew their seropositive status plus those unknowns who tested seropositive, the proportion of inpatients that was seropositive in 2006 was 73.1% (147 of 201), higher than in 2003. CONCLUSIONS: After ART program expansion, inpatients in 2006 were far more likely than their 2003 counterparts to know their HIV status and to be taking ART. In both years, 63-73% of medical inpatients were HIV-infected and 98.5% of inpatients agreed to testing. On-the-ward testing in 2006 avoided the 2003 problem of patient discharge before learning of their test results. Hospital-based HIV testing is an essential clinical service in high prevalence settings and can serve further as a surveillance system to help track the community impact of outpatient AIDS services in Africa.

Evolution of couples' voluntary counseling and testing for HIV in Lusaka, Zambia.

BACKGROUND: : We describe promotional strategies for couples' voluntary HIV counseling and testing (CVCT) and demographic risk factors for couples in Lusaka, Zambia, where an estimated two thirds of new infections occur in cohabiting couples. PRINCIPAL FINDINGS: : CVCT attendance as a function of promotional strategies is described over a 6-year period. Cross-sectional analyses of risk factors associated with HIV in men, women, and couples are presented. Community workers (CWs) recruited from couples seeking CVCT promoted testing in their communities. Attendance dropped when CW outreach ended, despite continued mass media advertisements. In Lusaka, 51% of 8500 cohabiting couples who sought HIV testing were concordant negative for HIV (MF) and 26% concordant positive (MF); 23% had 1 HIV-positive partner and one HIV-negative partner, with 11% HIV-positive man/HIV-negative woman (MF) and 12% HIV-negative man/HIV-positive woman (FM). HIV infection was associated with men's age 30 to 39, women's age 25 to 34, duration of union <3 years, and number of children <2. Even among couples with either 1 or 2 or no risk factors, HIV prevalence was 45% and 29%, respectively. CONCLUSIONS: : Many married African adults do not have high-risk profiles, nor realize that only 1 may be HIV positive. Active and sustained promotion is needed to encourage all couples to be jointly tested and counseled.

Enrollment and retention of HIV discordant couples in Lusaka, Zambia.

BACKGROUND: Biased enrollment and attrition compromise the power of clinical trials and limit generalizability of findings. We identify predictors of enrollment and retention for HIV-discordant couples enrolled in prospective studies in Zambia. PRINCIPAL FINDINGS: A total of 1995 discordant couples were invited to enroll. Predictors of nonenrollment, loss to follow-up, and missed appointments were evaluated using multivariate models. MF couples were more likely to be eligible and to enroll and less likely to be lost to follow-up than FM couples. Substantial losses to follow-up occurred between testing and enrollment (21.3% of MF and 28.1% of FM) and between enrollment and the first follow-up visit (24.9% of MF and 30.5% of FM). Among MF and FM couples, residence far from the clinic, younger age, and women's age at first intercourse

Modified Kigali combined staging predicts risk of mortality in HIV-infected adults in Lusaka, Zambia.

We assessed the utility of the modified Kigali combined (MKC) staging system for predicting survival in HIV-infected Zambian adults in a prospective, longitudinal, open cohort. From 1995 to 2004, HIV-discordant couples (one HIV-infected partner and one HIV-negative partner) were recruited from couples' voluntary counseling and testing centers in Lusaka, Zambia and followed at 3-month intervals. MKC stage, which incorporates clinical stage with erythrocyte sedimentation rate (ESR), hematocrit, and body mass index (BMI), was determined at enrollment. Kaplan-Meier survival and Cox proportional hazard methods were used to calculate median survival and relative hazards. We enrolled 1479 HIV-discordant couples with a combined 7305 person-years of follow-up. Among HIV-infected participants over the 9-year study period, there were 333 confirmed deaths. The time to 50% mortality was 8.5 years with MKC stage 1 and 2 disease compared to 3.7 years with MKC stage 4 disease at enrollment. Survival rates at 3 years were 85% with MKC stage 1 and 2 disease, 74% with MKC stage 3 disease, and 51% with MKC stage 4 disease. A total of 275 HIV-negative partners seroconverted during follow-up. In comparison, survival rates at 3 years were 94% for HIV-negative participants and 92% for participants who seroconverted during follow-up. In multivariate analysis, MKC stage 4 disease (HR = 3.7, 95% CI = 2.7-5.0) remained a strong predictor of mortality. Incorporating ESR, hematocrit, and BMI with clinical staging is a powerful, low-cost tool to identify HIV-infected adults at high risk for mortality.