Frances M. Cowan

Chronic cough and its association with TB-HIV co-infection: factors affecting help-seeking behaviour in Harare, Zimbabwe.

Objectiveu2002 To qualitatively investigate reasons why individuals who reported chronic cough of 2u2003weeks or more in a cross‐sectional prevalence survey had not accessed community‐based outreach or other diagnostic services.

Acceptability and challenges of implementing voluntary counselling and testing (VCT) in rural Zimbabwe: evidence from the Regai Dzive Shiri Project

Abstract Voluntary counselling and testing (VCT) is an important component of HIV prevention and care. Little research exists on its acceptability and feasibility in rural settings. This paper examines the acceptability and feasibility of providing VCT using data from two sub-studies: (1) client-initiated VCT provided in rural health centres (RHCs) and (2) researcher-initiated VCT provided in a non-clinic community setting. Nurses provided client-initiated VCT in 39 RHCs in three Zimbabwean provinces (2004–2007). Demographic data and HIV status were collected. Qualitative data were also collected to assess rural communities’ impressions of services. In a second study in 2007, VCT was offered to participants in a population-based HIV prevalence survey. Quantitative data from clinic-based VCT show that of 3585 clients aged ≥18, 79.4% (95% CI: 78.0–80.7%) were female; young people (aged 18–24) comprised 21.1%. Overall, 32.9% (95% CI: 31.4–34.5%) tested HIV positive. Young people were less likely to be HIV positive 13.5% (95% CI: 11.1–16.1%) vs. 38.1% (95% CI: 36.3–39.9%). In the second study conducted in a non-clinic setting, 27.0% (n=1368/5052) of participants opted to test. Young people were as likely to test as adults (27.3% vs. 26.9%) and an equal proportion of men and women tested. Overall during the second survey, 18.8% (95% CI: 16.7–21.0%) of participants tested positive (youth = 8.4% (95% CI: 6.4–10.7%); adults = 29.1% (95% CI: 25.7–32.7%)). Qualitative data, unique to clinics only, suggested that adults identify RHCs as acceptable VCT sites, whereas young people expressed reservations around these venues. Males reported considering VCT only after becoming ill. While VCT offered through RHCs is acceptable to women, it seems that men and youth are less comfortable with this venue. When VCT was offered in a non-clinic setting, numbers of men and women testing were similar. These data suggest that it may be possible to improve testing uptake in rural communities using non-clinic settings.

Increased risk of HIV-infection among school-attending orphans in rural Zimbabwe

Abstract In Zimbabwe around 1.1 million children have been orphaned due to AIDS. We conducted a survey among school-attending youth in rural south-eastern Zimbabwe in 2003, and examined the association between orphaning and risk of HIV. We enrolled 30 communities in three provinces. All students attending Year 2 of secondary school were eligible. Each completed a questionnaire and provided a finger-prick blood specimen for testing for HIV-1 and HSV-2 antibodies. Female participants were tested for pregnancy. Six thousand seven hundred and ninety-one participants were recruited (87% of eligible); 35% had lost one or both parents (20% of participants had lost their father; 6% their mother; and 9% both parents). Orphans were not poorer than non-orphans based on reported access to income, household structure and ownership of assets. There was strong evidence that orphans, and particularly those who had lost both parents, were at increased sexual risk, being more likely to have experienced early sexual debut; to have been forced to have sex; and less likely to have used condoms. Fifty-one students were HIV positive (0.75%). Orphans were three times more likely to be HIV infected than non-orphans (adjusted odds ratio = 3.4; 95% confidence interval: 1.8–6.6). Over 60% of those HIV positive were orphaned. Among school-going youth, the rates of orphaning were very high; there was a strong association between orphaning and increased risk of HIV, and evidence of greater sexual risk taking among orphans. It is essential that we understand the mechanisms by which orphaned children are at increased risk of HIV in order to target prevention and support appropriately.

A novel tool to assess community norms and attitudes to multiple and concurrent sexual partnering in rural Zimbabwe: participatory attitudinal ranking

Abstract Concurrent sexual partnerships are important in understanding the evolution and maintenance of the HIV heterosexual epidemic in sub-Saharan Africa. While it is possible to measure individual attitudes around sensitive behaviours through questionnaire surveys, studies suggest that responses may be subject to social desirability bias and may not reflect community norms. This study used a novel tool to collect data on community norms relating to the acceptability of concurrency in rural Zimbabwe. Six questions exploring general concurrency concepts and 28 scenarios in which multiple-partnerships might occur were developed and translated into Shona. Participatory attitudinal ranking (PAR), an approach adapted from participatory wealth ranking, was used to conduct group discussions (n=24) with 170 participants recruited in a household survey. Participants discussed and ranked scenarios according to the acceptability of the multiple-partnering described in the short accounts. Data analysis followed grounded theory principles. Qualitative data were examined against quantitative survey data collected from a representative sample of 18–44-year olds. While discussants indicated that concurrency was common among both males and females, self-reports from survey participants indicated that 37.1% of males (n=717/1931; 95% CI: 35.0–39.3%) and only 7.3% of females (n=215/2948; 95% CI: 6.4–8.3%) were in concurrent relationships suggesting under-reporting of this behaviour, particularly by women. We found that concurrency is an accepted community norm for men but never for women. Concurrency is considered more acceptable in specific social contexts, including infertility and lack of a male heir. Having protected rather than unprotected sex with a concurrent partner does not render this behaviour more acceptable. Using PAR, we managed to gain a more nuanced understanding of socially sanctioned concurrency, knowledge that could prove useful for improving behaviour change interventions targeting this behaviour. PAR allowed us to rank attitudes in terms of acceptability, which would enable us to compare attitudes between communities and evaluate changes over time.

Difference in prevalence of common mental disorder as measured using four questionnaire delivery methods among young people in rural Zimbabwe

BACKGROUNDnPrevious studies have suggested that interviewer-administered questionnaires can under-estimate the prevalence of depression and suicidal ideation when compared with self-administered ones. We report here on differences in prevalence of reporting mental health between four questionnaire delivery modes (QDM).nnnMETHODSnMental health was assessed using the Shona Symptom Questionnaire (SSQ), a locally validated 14-item indigenous measure for common mental affective disorders. A representative sample of 1495 rural Zimbabwean adolescents (median age 18) was randomly allocated to one of four questionnaire delivery modes: self-administered questionnaire (SAQ), SAQ with audio (AASI), interviewer-administered questionnaire (IAQ), and audio computer-assisted survey instrument (ACASI).nnnRESULTSnPrevalence of common affective disorders varied between QDM (52.3%, 48.6%, 41.5%, and 63.6% for SAQ, AASI, IAQ, and ACASI respectively (P<0.001)). Fewer participants failed to complete SSQ using IAQ and ACASI than other methods (1.6% vs. 12.3%; P<0.001). Qualitative data suggested that respondents found it difficult answering questions honestly in front of an interviewer.nnnLIMITATIONSnDirection of accuracy cannot be ascertained due to lack of objective or clinical assessments of affective disorders.nnnCONCLUSIONSnEstimates of prevalence of psychosomatic symptoms and suicidal ideation varied according to mode of interview. As each modes direction of accuracy remains unresolved evaluations of interventions continue to be hampered.

Evaluating a multi-component, community-based program to improve adherence and retention in care among adolescents living with HIV in Zimbabwe: study protocol for a cluster randomized controlled trial

BackgroundWorld Health Organization (WHO) adolescent HIV-testing and treatment guidelines recommend community-based interventions to support antiretroviral therapy (ART) adherence and retention in care, while acknowledging that the evidence to support this recommendation is weak. This cluster randomized controlled trial aims to evaluate the effectiveness and cost-effectiveness of a psychosocial, community-based intervention on HIV-related and psychosocial outcomes.Methods/designWe are conducting the trial in two districts. Sixteen clinics were randomized to either enhanced ART-adherence support or standard of care. Eligible individuals (HIV-positive adolescents aged 13–19 years and eligible for ART) in both arms receive ART and adherence support provided by adult counselors and nursing staff. Adolescents in the intervention arm additionally attend a monthly support group, are allocated to a designated community adolescent treatment supporter, and followed up through a short message service (SMS) and calls plus home visits. The type and frequency of contact is determined by whether the adolescent is “stable” or in need of enhanced support. Stable adolescents receive a monthly home visit plus a weekly, individualized SMS. An additional home visit is conducted if participants miss a scheduled clinic appointment or support-group meeting. Participants in need of further, enhanced, support receive bi-weekly home visits, weekly phone calls and daily SMS. Caregivers of adolescents in the intervention arm attend a caregiver support group. Trial outcomes are assessed through a clinical, behavioral and psychological assessment conducted at baseline and after 48 and 96xa0weeks. The primary outcome is the proportion who have died or have virological failure (viral loadu2009≥1000 copies/ml) at 96xa0weeks. Secondary outcomes include virological failure at 48xa0weeks, retention in care (proportion of missed visits) and psychosocial outcomes at both time points. Statistical analyses will be conducted and reported in line with CONSORT guidelines for cluster randomized trials, including a flowchart.DiscussionThis study provides a unique opportunity to generate evidence of the impact of the on-going Zvandiri program, for adolescents living with HIV, on virological failure and psychosocial outcomes as delivered in a real-world setting. If found to reduce rates of treatment failure, this would strengthen support for further scale-up across Zimbabwe and likely the region more widely.Trial registrationPan African Clinical Trial Registry database, registration number PACTR201609001767322 (the Zvandiri trial). Retrospectively registered on 5 September 2016.

Evaluating the impact of DREAMS on HIV incidence among young women who sell sex: protocol for a non-randomised study in Zimbabwe.

Background“Determined, Resilient, AIDS-free, Mentored and Safe” (DREAMS) is a package of biomedical, social and economic interventions offered to adolescent girls and young women aged 10–24xa0years with the aim of reducing HIV incidence. In four of the six DREAMS districts in Zimbabwe, DREAMS includes an offer of oral pre-exposure prophylaxis (DREAMS+PrEP), alongside interventions to support demand and adherence, to women aged 18–24 who are at highest risk of HIV infection, including young women who sell sex (YWSS). This evaluation study addresses the question: does the delivery of DREAMS+PrEP through various providers reduce HIV incidence among YWSS Zimbabwe? We describe our approach to designing a rigorous study to assess whether DREAMS+PrEP had an impact on HIV incidence.MethodsThe study design needed to account for the fact that: 1) DREAMS+PrEP was non-randomly allocated; 2) there is no sampling frame for the target population for the evaluation; 3) there are a small number of DREAMS districts (Nu2009=u20096), and 4) DREAMS+PrEP is being implemented by various providers. The study will use a cohort analysis approach to compare HIV incidence among YWSS in two DREAMS+PrEP districts to HIV incidence among YWSS in non-DREAMS comparison sites. YWSS will be referred to services and recruited into the cohort through a network-based (respondent-driven) recruitment strategy, and followed-up 12- and 24-months after enrolment. Women will be asked to complete a questionnaire and offered HIV testing. Additional complications of this study include identifying comparable populations of YWSS in the DREAMS+PrEP and non-DREAMS comparison sites, and retention of YWSS over the 24-month period. The primary outcome is HIV incidence among YWSS HIV-negative at study enrolment measured by repeat, rapid HIV testing over 24-months. Inference will be based on plausibility that DREAMS+PrEP had an impact on HIV incidence. A process evaluation will be conducted to understand intervention implementation, and document any contextual factors determining the success or failure of intervention delivery.DiscussionHIV prevention products of known efficacy are available. Innovative studies are needed to provide evidence of how to optimise product use through combination interventions to achieve population impact within different contexts. We describe the design of such a study.

'How Poor Are You?' - A Comparison of Four Questionnaire Delivery Modes for Assessing Socio- Economic Position in Rural Zimbabwe

Background Assessing socio-economic position can be difficult, particularly in developing countries. Collection of socio-economic data usually relies on interviewer-administered questionnaires, but there is little research exploring how questionnaire delivery mode (QDM) influences reporting of these indicators. This paper reports on results of a trial of four QDMs, and the effect of mode on poverty reporting. Methods This trial was nested within a community-randomised trial of an adolescent reproductive health intervention conducted in rural Zimbabwe. Participants were randomly allocated to one of four QDMs (three different self-administered modes and one interviewer-administered mode); a subset was randomly selected to complete the questionnaire twice. Questions covered three socio-economic domains: i) ownership of sellable and fixed assets; ii) ability to afford essential items; and iii) food sufficiency. Statistical analyses assessed the association between QDM and reporting of poverty, and compared the extent of response agreement between questionnaire rounds. Results 96% (nu200a=u200a1483) of those eligible took part; 395 completed the questionnaire twice. Reported levels of poverty were high. Respondents using self-administered modes were more likely to report being unable to afford essential items and having insufficient food. Among those completing the questionnaire twice using different modes, higher levels of poverty and food insufficiency were reported when they completed the questionnaire using a self-administered mode. Conclusion These data suggest that QDM plays a significant role in how different socio-economic indicators are reported, and reminds us to consider the mode of collection when identifying indicators to determine socio-economic position.

Causes and Timing of Mortality and Morbidity Among Late Presenters Starting Antiretroviral Therapy in the REALITY Trial

Abstract Background In sub-Saharan Africa, 20%–25% of people starting antiretroviral therapy (ART) have severe immunosuppression; approximately 10% die within 3 months. In the Reduction of EArly mortaLITY (REALITY) randomized trial, a broad enhanced anti-infection prophylaxis bundle reduced mortality vs cotrimoxazole. We investigate the contribution and timing of different causes of mortality/morbidity. Methods Participants started ART with a CD4 count <100 cells/µL; enhanced prophylaxis comprised cotrimoxazole plus 12 weeks of isoniazid + fluconazole, single-dose albendazole, and 5 days of azithromycin. A blinded committee adjudicated events and causes of death as (non–mutually exclusively) tuberculosis, cryptococcosis, severe bacterial infection (SBI), other potentially azithromycin-responsive infections, other events, and unknown. Results Median pre-ART CD4 count was 37 cells/µL. Among 1805 participants, 225 (12.7%) died by week 48. Fatal/nonfatal events occurred early (median 4 weeks); rates then declined exponentially. One hundred fifty-four deaths had single and 71 had multiple causes, including tuberculosis in 4.5% participants, cryptococcosis in 1.1%, SBI in 1.9%, other potentially azithromycin-responsive infections in 1.3%, other events in 3.6%, and unknown in 5.0%. Enhanced prophylaxis reduced deaths from cryptococcosis and unknown causes (P < .05) but not tuberculosis, SBI, potentially azithromycin-responsive infections, or other causes (P > .3); and reduced nonfatal/fatal tuberculosis and cryptococcosis (P < .05), but not SBI, other potentially azithromycin-responsive infections, or other events (P > .2). Conclusions Enhanced prophylaxis reduced mortality from cryptococcosis and unknown causes and nonfatal tuberculosis and cryptococcosis. High early incidence of fatal/nonfatal events highlights the need for starting enhanced-prophylaxis with ART in advanced disease. Clinical Trials Registration ISRCTN43622374.

Effect of non-monetary incentives on uptake of couples' counselling and testing among clients attending mobile HIV services in rural Zimbabwe: a cluster-randomised trial

BACKGROUNDnCouples HIV testing and counselling (CHTC) is associated with greater engagement with HIV prevention and care than individual testing and is cost-effective, but uptake remains suboptimal. Initiating discussion of CHTC might result in distrust between partners. Offering incentives for CHTC could change the focus of the pre-test discussion. We aimed to determine the impact of incentives for CHTC on uptake of couples testing and HIV case diagnosis in rural Zimbabwe.nnnMETHODSnIn this cluster-randomised trial, 68 rural communities (the clusters) in four districts receiving mobile HIV testing services were randomly assigned (1:1) to incentives for CHTC or not. Allocation was not masked to participants and researchers. Randomisation was stratified by district and proximity to a health facility. Within each stratum random permutation was done to allocate clusters to the study groups. In intervention communities, residents were informed that couples who tested together could select one of three grocery items worth US