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Background: HIV risk perception is an important cognition for prevention, theoretically engendering service-seeking and risk-reduction behaviors, but its composition remains poorly understood. We examined country-specific correlates of self-appraised HIV exposure risk among sexually active adolescent girls and young women (AGYW, aged 15-24 years) without HIV in Kenya, Malawi, and Zambia. We also explored overlaps between self-appraised HIV exposure risk and pre-exposure prophylaxis (PrEP) eligibility to identify engagement opportunities., Methods: We analyzed cross-sectional data (2016/2017) to estimate sexual-related correlates of self-appraised HIV exposure risk (likely vs. not, temporally framed as "ever") using log-Poisson models with robust standard errors. For sexual-related factors with an unadjusted p ≤ 0.10, individual adjusted models were fitted, controlling for sociodemographic and cognitive factors with an unadjusted p ≤ 0.10. PrEP eligibility was defined using national guidelines; since conditional criteria are in Malawi's (age-disparate sex + ever-pregnant) and Zambia's (multiple partners + condomless sex) guidelines, we also assessed PrEP eligibility after decoupling these factors., Results: Few AGYW reported likely HIV exposures (Kenya [N = 746]: 15.7%, Malawi [N = 1348]: 46.2%, Zambia [N = 349]: 9.5%) despite ubiquitous HIV risk (98.7%, 99.8%, and 98.9% of Kenyan, Malawian, and Zambian AGYW reported ≥ 1 sexual-related factor). However, the adjusted models found some actual-perceived risk concordance. Positive correlates of self-appraised likely HIV exposures included partner(s)' likely HIV exposure (all countries); partner(s)' unknown HIV status and other partners (Kenya, Malawi); STI symptoms and partner(s) living outside the community (Kenya); non-partner sexual violence (Zambia); and transactional sex, multiple partners, pre-coital alcohol use, and physical/sexual intimate partner violence (Malawi). Per national guidelines, PrEP eligibility criteria differentially identified HIV risk (Kenya: 93.6%, Malawi: 53.3%, Zambia: 44.6%), and self-appraised likely HIV exposures were low among PrEP-eligible AGYW (Kenya: 16.5%, Malawi: 48.5%, Zambia: 18.8%). Decoupling Malawi's and Zambia's conditional PrEP criteria could increase risk identification to > 85% and potential engagement by ~ 70% and ~ 30%, respectively., Conclusions: AGYW's HIV risk perceptions were mostly influenced by factors beyond their locus of control. Conditional PrEP eligibility criteria may inhibit AGYW's access and uptake in some settings: countries should consider decoupling these factors to minimize barriers. Intersections between autonomy, behaviors, and perceptions among AGYW in gender-inequitable settings warrants further investigation., (© 2024. The Author(s).)

Background: The number of COVID-19 deaths reported in Zambia (N = 4069) is most likely an underestimate due to limited testing, incomplete death registration and inability to account for indirect deaths due to socioeconomic disruption during the pandemic. We sought to assess excess mortality during the COVID-19 pandemic in Zambia., Methods: We conducted a retrospective analysis of monthly-death-counts (2017-2022) and individual-daily-deaths (2020-2022) of all reported health facility and community deaths at district referral health facility mortuaries in 12 districts in Zambia. We defined COVID-19 wave periods based on a sustained nationally reported SARS-CoV-2 test positivity of greater than 5%. Excess mortality was calculated as the difference between observed monthly death counts during the pandemic (2020-2022) and the median monthly death counts from the pre-pandemic period (2017-2019), which served as the expected number of deaths. This calculation was conducted using a Microsoft Excel-based tool. We compared median daily death counts, median age at death, and the proportion of deaths by place of death (health facility vs. community) by wave period using the Mann-Whitney-U test and chi-square test respectively in R., Results: A total of 112,768 deaths were reported in the 12 districts between 2020 and 2022, of which 17,111 (15.2%) were excess. Wave periods had higher median daily death counts than non-wave periods (median [IQR], 107 [95-126] versus 96 [85-107], p < 0.001). The median age at death during wave periods was older than non-wave periods (44.0 [25.0-67.0] versus 41.0 [22.0-63.0] years, p < 0.001). Approximately half of all reported deaths occurred in the community, with an even greater proportion during wave periods (50.6% versus 53.1%, p < 0.001), respectively., Conclusion: There was excess mortality during the COVID-19 pandemic in Zambia, with more deaths occurring within the community during wave periods. This analysis suggests more COVID-19 deaths likely occurred in Zambia than suggested by officially reported numbers. Mortality surveillance can provide important information to monitor population health and inform public health programming during pandemics., (© 2024. The Author(s).)

Background: Limited research has been conducted on the forms, manifestations and effects of intersectional stigma among young HIV-positive men who have sex with men (MSM) and transgender women (TGW) in Zambia. In this study, we aimed to address this gap by elucidating the experiences of these in a small group of young, HIV + MSM and TGW in Zambia., Methods: We applied a mixed-methods design. Data were collected from January 2022 to May 2022. Qualitative data were collected using in-depth interviews while quantitative data were collected using a questionnaire. Qualitative transcripts were coded using thematic analysis while paper-based questionnaire data were entered into Kobo Connect. Descriptive statistics, using chi-squared tests were calculated using Excel. In this paper, we provide a descriptive profile of the sample and then focus on the qualitative findings on intersectional stigma, depression, and contemplation of suicide., Results: We recruited 56 participants from three sites: Lusaka, Chipata, and Solwezi districts. Participants' mean age was 23 years. The study found that 36% of all participants had moderate to significant symptoms of depression, 7% had major depression, 30% had moderate signs of anxiety, 11% had high signs of anxiety, 4% had very high signs of anxiety and 36% had contemplated suicide at least once. A greater proportion of TGW had moderate to significant symptoms of depression (40%) or major depression (10%) compared to MSM, at 33% and 6%, respectively (X 2  = 0.65; p = 0.42). Similarly, more TGW (55%) had contemplated suicide than MSM peers (36%, X 2 =1.87; p = 0.17). In the qualitative data, four emergent themes about the forms, manifestations, and effects of intersectional stigma were (1) HIV, sexual orientation, and gender identity disclosure; (2) Dual identity; (3) Challenges of finding and maintaining sexual partners; (4) Coping and resilience. Overall, having to hide both one's sexuality and HIV status had a compounding effect and was described as living "a private lie.", Conclusion: Effectively addressing stigmas and poor mental health outcomes among young HIV-positive MSM and TGW will require adopting a socio-ecological approach that focuses on structural interventions, more trauma-informed and identity-supportive care for young people with HIV, as well as strengthening of authentic community-informed public health efforts., (© 2024. The Author(s).)

Background: Hypertension affects over one billion people globally and is one of the leading causes of premature death. Low- and middle-income countries, especially the sub-Saharan Africa region, bear a disproportionately higher share of hypertension globally. Recent evidence shows a steady shift in the burden of hypertension from more affluent and urban populations towards poorer and rural communities. Our study examined inequalities in self-rated health (SRH) among people with hypertension and whether there is a rural‒urban gap in the health of these patients. We then quantified factors driving the health gap. We also examined how much HIV accounts for differences in self-rated health among hypertension patients due to the relationship between HIV, hypertension and health in sub-Saharan Africa., Methods: We utilized the Zambia Household Health Expenditure and Utilization Survey for data on SRH and other demographic and socioeconomic controls. District HIV prevalence information was from the Zambia Population-Based HIV Impact Assessment (ZAMPHIA) survey. We applied the Linear Probability Model to assess the association between self-rated health and independent variables as a preliminary step. We then used the Blinder-Oaxaca decomposition to identify self-rated health inequality between urban and rural patients and determine determinants of the health gap between the two groups., Results: Advanced age, lower education and low district HIV prevalence were significantly associated with poor health rating among hypertension patients. The decomposition analysis indicated that 45.5% of urban patients and 36.9% of rural patients reported good self-rated health, representing a statistically significant health gap of 8.6%. Most of the identified health gap can be attributed to endowment effects, with education (73.6%), district HIV prevalence (30.8%) and household expenditure (4.8%) being the most important determinants that explain the health gap., Conclusions: Urban hypertension patients have better SRH than rural patients in Zambia. Education, district HIV prevalence and household expenditure were the most important determinants of the health gap between rural and urban hypertension patients. Policies aimed at promoting educational interventions, improving access to financial resources and strengthening hypertension health services, especially in rural areas, can significantly improve the health of rural patients, and potentially reduce health inequalities between the two regions., (© 2024. The Author(s).)

Background: Prevention of vertical (mother to child) transmission of HIV is one of the key strategies towards HIV epidemic control. Despite considerable progress over the past decade in Zambia, the country is yet to reach global and national target for elimination of vertical transmission of HIV. Avoidance of unintended pregnancy among women living with HIV is one of the cost-effective interventions in a comprehensive approach to prevent vertical transmission of HIV. Therefore, this study aimed at ascertaining trends in and predictors of unmet need for family planning among women living with HIV in Zambia., Methods: The study employed a repeated cross sectional (RCS) study design, using data from the three (3) most recent consecutive rounds of the Zambia Demographic and Health Survey (ZDHS) conducted in 2007, 2013/2014 and 2018. The study used data from a total of 27,153 women aged 15-49 years over the three survey periods among whom 4,113 had an HIV positive result following a rigorous HIV testing algorithm of the demographic and health surveys, and these constituted our sample size of women living with HIV. We used descriptive statistics and logistic regression analyses to respectively ascertain trends in and predictors of unmet need for family planning among women living with HIV., Results: Over the three survey points, unmet need for family planning among women living with HIV has largely remained unchanged from 20.8% in 2007 to 20.5% in 2013/14 and 21.1% in 2018 DHS. Residence, age of women, household wealth, woman's parity, employment, and age of spouse emerged as significant predictors of unmet need for family planning among women living with HIV in Zambia., Conclusion: Preventing HIV infection in a child preserves life, contributes to improving quality of life from its early stages and averts lifetime costs of HIV treatment and associated healthcare costs. There is need to consider optimization of interventions to prevent vertical transmission of HIV including shaping programming regarding preventing unintended pregnancies among women living with HIV. Among other aspects, policy and practice need to strengthen SRH/HIV integration and better target rural residents, younger women, those with high parity and consider positive male engagement to reduce unmet need for family planning among women living with HIV., (© 2024. The Author(s).)

Background: Globally, at least 3 million TB patients are missed every year. In Zambia, the TB treatment coverage increased from 66% in 2020 to 92% in 2022. Involvement of all levels of health care service delivery is critical to finding all the missing TB patients., Methods: A survey was undertaken in 15 private facilities in Lusaka district of Zambia using a structured tool administered by project team and a district health team member. Data collected during the survey was analysed and results were used to determine the type of TB services that were offered as well as barriers and enablers to TB service provision. This was followed by a set of interventions that included; training and mentorship on active case finding and systematic TB screening, increased diagnostic capacity, provision of national recording and reporting tools and provision of TB medication through linkage with the National TB program (NTP). We report findings from the baseline survey and changes in presumptive TB identification and notification following interventions., Results: Major barriers to TB service delivery were the high cost of TB diagnostic testing and treatment in facilities where services were not supported by the National TB program; the mean cost was 33 (SD 33) and 93 (SD 148) for GeneXpert testing and a full course of treatment respectively. Pre-intervention, presumptive TB identification appeared to increase monthly by 4 (P = 0.000, CI=[3.00-5.00]). The monthly trends of presumptive TB identification during the intervention period increased by 5.32 (P = 0.000, [CI 4.31-6.33. Pre-intervention, the notification of TB appeared to decrease every month by -4.0 (P = 0.114, CI=[-9.00-0.10]) followed by an immediate increase in notifications of 13.94 TB patients (P = 0.001, CI [6.51, 21.36] in the first month on intervention. The monthly trends of notification during the intervention period changed by 0.34 (P = 0.000 [CI 0.19-0.48]). Private facility contribution to TB notification increased from 3 to 7%., Conclusion: Engagement and inclusion of private health facilities in TB service provision through a systems strengthening approach can increase contribution to TB notification by private health facilities., (© 2024. The Author(s).)

Background: Non-communicable diseases (NCDs) are the world's growing cause of preventable illness, disability, morbidity, and mortality which account for 71% of deaths. The aim of this study was to determine the factors associated with mortality from NCDs among persons aged 15 years and above in Zambia., Methodology: The study used data from Sample Vital Registration with Verbal Autopsy (SAVVY) 2015/16 (Zambia). A total of 3529 Verbal Autopsy were completed in the study, with only 2599 of death where among people aged 15 years and above. Three-level data analysis was applied; univariate analysis, bivariate analysis, and multivariate analysis (binary logistic regression)., Findings: The overall number of deaths from NCDs was 28.81%. Stratified analysis by gender showed that deaths from NCDs were higher among women (32.60%) as compared to men (26.25%). Among all persons, dying from NCDs was associated with tobacco use, age, and education. Tobacco use was negatively associated with mortality from NCDs (adjusted odds ratio [aOR] = 0.68; 95% confidence interval [CI]: 0.48-0.98). Age was positively associated with the odds of dying from NCDs among persons aged 45-59 years (aOR = 3.87, 95% CI: 2.13-7.01), 60-74 years (aOR = 12.05, 95% CI: 6.44-22.55), and 75 + years (aOR = 15.16, 95% CI: 7.93-28.97). The likelihood of dying from NCDs was higher among persons with secondary education as compared to those with no education (aOR = 1.93, 95% CI: 1.11-3.33)., Conclusion: The findings from this study suggest that public health interventions targeting NCDs need to consider behavioural factors, especially tobacco use which exposes people to second-hand smoke. We also recommend large-scale national-level studies to further examine the contribution of each factor leading to mortality from NCDs., (© 2024. The Author(s).)

Background: House screening remains conspicuously absent in national malaria programs despite its recognition by the World Health Organization as a supplementary malaria vector-control intervention. This may be attributed, in part, to the knowledge gap in screen durability or longevity in local climatic conditions and community acceptance under specific cultural practices and socio-economic contexts. The objectives of this study were to assess the durability of window and door wire mesh screens a year after full house screening and to assess the acceptability of the house screening intervention to the participants involved., Methods: This study was conducted in Nyimba district, Zambia and used both quantitative and qualitative methods of data collection and analysis. Both direct observation and questionnaires were employed to assess the durability of the screens and the main reasons for damage. Findings on damage were summarized as percentages. Focus group discussions were used to assess people's knowledge, perceptions, and acceptability of the closing eaves and house screening intervention. Deductive coding and inductive coding were used to analyse the qualitative data., Results: A total of 321 out of 400 (80.3%) household owners of screened houses were interviewed. Many window screens (90.3%) were intact. In sharp contrast, most door screens were torn (n = 150; 46.7%) or entirely removed (n = 55; 17.1%). Most doors (n = 114; 76%) had their wire mesh damaged or removed on the bottom half. Goats (25.4%), rust (17.6%) and children (17.1%) were cited most as the cause of damage to door screens. The focus group discussion elicited positive experiences from the participants following the closing of eaves and screening of their windows and doors, ranging from sleeping peacefully due to reduced mosquito biting and/or nuisance and having fewer insects in the house. Participants linked house screening to reduced malaria in their households and community., Conclusion: This study demonstrated that in rural south-east Zambia, closing eaves and screening windows and doors was widely accepted. Participants perceived that house screening reduced human-vector contact, reduced the malaria burden and nuisance biting from other potentially disease carrying insects. However, screened doors are prone to damage, mainly by children, domestic animals, rust, and termites., (© 2024. The Author(s).)

Background: Despite major improvements in child survival over the past decade, many children in low and middle-income countries (LMICs) remain at risk of not reaching their developmental potential due to malnutrition, poor health, and a lack of stimulation. Maternal engagement and stimulation have been identified as some of the most critical inputs for healthy development of children. However, relatively little evidence exists on the links between maternal stimulation and child development exists in sub-Saharan Africa (SSA). This current paper aims to identify the associations between maternal stimulation and child development in Kenya and Zambia, as well as the activities that are most predictive of developmental outcomes in these settings., Methods: We conducted a descriptive study using data from a prospective study in Kenya and Zambia. The study included three rounds of data collection. Children were on average 10 months old in round one, 25 months old in round two, and 36 months old in round three. The primary exposure variable of interest was maternal stimulation activities, which we grouped into cognitive, language, motor, and socio-emotional activities. The outcome of interest was child development measured through the Third Edition of the Ages and Stages Questionnaire (ASQ-3). Linear regression models were used to estimate the associations between overall maternal stimulation and domain-specific maternal stimulation and child development across the three rounds of the survey., Results: Higher maternal stimulation scores were associated with higher ASQ scores (effect size = 0.25; 95% CI: 0.19, 0.31) after adjusting for other confounders. For domain specific and child development (ASQ scores), the largest effect size (ES) was found for language stimulation (ES = 0.15) while weakest associations were found for socio-emotional domain activities (ES= -0.05). Overall maternal stimulation was most strongly associated with gross motor development (ES = 0.21) and the least associated with problem-solving (ES = 0.16)., Conclusion: Our study findings suggest a strong positive link between maternal stimulation activities and children's developmental outcomes among communities in poor rural settings., Trial Registration: NA (not a clinical trial)., (© 2023. The Author(s).)

Background: The resurgence of poliovirus infection in previously polio free regions and countries calls for renewed commitment to the global polio eradication efforts including strengthening of Acute Flaccid Paralysis (AFP) surveillance systems. Zambia is one of the countries substantially at risk for the importation of poliovirus infection from neighbouring countries including Malawi, Mozambique, and Democratic Republic of the Congo (DRC). This study describes a seven-year AFP surveillance, assesses the surveillance indicators, and highlights areas for improvement., Methods: We conducted retrospective analysis of the routinely collected AFP surveillance data from January 2015 to December 2022. The AFP surveillance indicators performance was assessed using the World Health Organisation's recommended minimum AFP surveillance indicators performance., Results: Cumulatively, a total of 1715 AFP cases were reported over the study period. More than half, 891 (52%) of reported cases were aged < 5 years with 917 (53.5%) of males. More than half, 1186 (69.2%) had fever at onset, 718 (41.9%) had asymmetric paralysis and 1164 (67.9%) had their paralysis progressed within 3 days of onset. The non-polio AFP rate ranges from 3.4 to 6.4 per 100,000 children < 15 years old and stool adequacy ranging from 70.9% to 90.2% indicating sensitive surveillance with late detection of cases. The percentage of cases with early stool collection, timely transportation was above the World Health Organisation (WHO) minimum of 80% but with declining proportion of stools arriving in the laboratory in optimal condition. Completeness of 60-days follow-up evaluation was suboptimal ranging from 0.9% to 28.2%., Conclusion: The AFP surveillance system in Zambia is doing well. However, additional efforts are needed to improve early detection of cases; stool sample collection, transportation and monitoring to ensure arrival in good condition in the laboratory; and improve 60-days follow-up evaluation for evidenced-based classification of inadequate AFP cases and proper care., (© 2023. The Author(s).)

Background: Health protective behaviours are crucial in the prevention of the spread of COVID-19, particularly in university students who typically live and study in large groups. Depression and anxiety are common in students and can impact young people's motivations to follow health advice. The study aims to assess the relationship between mental health and COVID-19 health-protective behaviours in Zambian university students with symptoms of low mood., Methods: The study was a cross-sectional, online survey of Zambian university students. Participants were also invited to take part in a semi-structured interview to explore views about COVID-19 vaccination. Invitation emails were sent explaining the study aims and directed students who self-identified as having low mood in the past two weeks to an online survey. Measures included COVID-19 preventive behaviours, COVID-19-related self-efficacy, and Hospital and Anxiety Depression scale., Results: A total of 620 students (n=308 female, n=306 male) participated in the study, with a mean participant age of 22.47±3.29 years (range 18-51). Students reported a mean protective behaviour score of 74.09/105 and 74% scored above the threshold for possible anxiety disorder. Three-way ANOVA showed lower COVID-19 protective behaviours in students with possible anxiety disorder (p=.024) and those with low self-efficacy (p<0.001). Only 168 (27%) said they would accept vaccination against COVID-19, with male students being twice as likely to be willing to accept COVID-19 vaccination (p<0.001). Of 50 students interviewed. 30 (60%) expressed fears about the vaccination and 16 (32%) were concerned about a lack of information. Only 8 (16%) participants expressed doubts about effectiveness., Conclusion: Students who self-identify as having symptoms of depression have high levels of anxiety. The results suggest that interventions to reduce anxiety and promote self-efficacy might enhance students' COVID-19 protective behaviours. Qualitative data provided insight into the high rates of vaccine hesitancy in this population., (© 2023. The Author(s).)

Background: Four large community-randomized trials examining universal testing and treatment (UTT) to reduce HIV transmission were conducted between 2012-2018 in Botswana, Kenya, Uganda, Zambia and South Africa. In 2014, the UNAIDS 90-90-90 targets were adopted as a useful metric to monitor coverage. We systematically review the approaches used by the trials to measure intervention delivery, and estimate coverage against the 90-90-90 targets. We aim to provide in-depth understanding of the background contexts and complexities that affect estimation of population-level coverage related to the 90-90-90 targets., Methods: Estimates were based predominantly on "process" data obtained during delivery of the interventions which included a combination of home-based and community-based services. Cascade coverage data included routine electronic health records, self-reported data, survey data, and active ascertainment of HIV viral load measurements in the field., Results: The estimated total adult populations of trial intervention communities included in this study ranged from 4,290 (TasP) to 142,250 (Zambian PopART Arm-B). The estimated total numbers of PLHIV ranged from 1,283 (TasP) to 20,541 (Zambian PopART Arm-B). By the end of intervention delivery, the first-90 target (knowledge of HIV status among all PLHIV) was met by all the trials (89.2%-94.0%). Three of the four trials also achieved the second- and third-90 targets, and viral suppression in BCPP and SEARCH exceeded the UNAIDS target of 73%, while viral suppression in the Zambian PopART Arm-A and B communities was within a small margin (~ 3%) of the target., Conclusions: All four UTT trials aimed to implement wide-scale testing and treatment for HIV prevention at population level and showed substantial increases in testing and treatment for HIV in the intervention communities. This study has not uncovered any one estimation approach which is superior, rather that several approaches are available and researchers or policy makers seeking to measure coverage should reflect on background contexts and complexities that affect estimation of population-level coverage in their specific settings. All four trials surpassed UNAIDS targets for universal testing in their intervention communities ahead of the 2020 milestone. All but one of the trials also achieved the 90-90 targets for treatment and viral suppression. UTT is a realistic option to achieve 95-95-95 by 2030 and fast-track the end of the HIV epidemic., (© 2022. The Author(s).)

Background: The novel COVID-19 pandemic threatened to disrupt access to human immunodeficiency (HIV) treatment for persons living with HIV (PLHIV), two-thirds of whom live in sub-Saharan Africa. To inform a health system response supportive of continuity of care, we sought to understand clients' HIV care experiences and health priorities during the first wave of COVID-19 outbreak in Lusaka, Zambia., Methods: Leveraging a study cohort of those who completed periodic SMS surveys on HIV care, we purposefully sampled 25 PLHIV after first confirmed COVID-19 case was reported in Zambia on 18 th March 2020. We phone-interviewed participants, iteratively refining interview guide to capture emergent themes on COVID-19 awareness, health facility interactions, and social circumstances, which we analyzed using matrix analysis., Results: All participants were aware of COVID-19, and HIV care experiences and health priorities of clients were affected by associated changes at health system, household, and individual level. The health system instituted early clinic visits to provide 6-months of antiretroviral therapy (ART) for stable patients and 3-months for unstable patients to reduce clinic visits and wait times. Most patients welcomed this long-desired extended appointment spacing. Some reported feeling respected and engaged when health care workers telephoned requesting their early clinic visit. However, others felt discouraged by an absence of physical distancing during their clinic visit due to 'severe acute respiratory syndrome coronavirus 2' (SARS-CoV-2) infection concerns. Several expressed a lack of clarity regarding next viral load monitoring date and means for receiving results. Patients suggested regular patient-facility communication by telephone and SMS. Patients emphasized that COVID-19 restrictions led to loss of employment and household income, exacerbating poverty and difficulties in taking ART. At individual level, most participants felt motivated to stay healthy during COVID-19 by ART adherence and regular laboratory monitoring., Conclusions: Clients' HIV care and health priorities during the first wave of COVID-19 in Lusaka province were varied with a combination of positive and negative experiences that occurred especially at health system and individual levels, while at household level, the experiences were all negative. More research is needed to understand how patients practice resiliency in the widespread context of socio-economic instability. Governments and patients must work together to find local, health systems solutions to support ART adherence and monitoring. Additionally, the health system should consider how to build on changes for long-term HIV management and service delivery., (© 2022. The Author(s).)

Background: One of the outcomes of sexual violence is unintended pregnancy. In Zambia, 15% of married women age 15-49 years had experienced sexual violence from their husband or partner. The prevalence of unintended pregnancies among women age 15-49 years has risen from 33% in 1992 to 38% in 2018. The link between sexual violence and unintended pregnancy in Zambia was investigated in this study., Methods: This study used the women's dataset from the 2018 Zambia Demographic and Health Survey, a cross-sectional survey. The study looked at a weighted sample size of 4,465 women age 15 - 49 years. Unintended pregnancy was measured by combining response categories of mistimed and unwanted pregnancy. Multivariate binary logistic regression was performed to establish the net effects of sexual violence and each explanatory variable on unintended pregnancy., Results: The findings suggest that sexual violence does have a role in unintended pregnancies (AOR 1.74; CI 1.38-2.19). Ever use of contraception is also a significant predictor of unintended pregnancy (AOR 1.48; CI 1.16-1.88), even when other characteristics are taken into account. Results have shown that a woman who had ever used contraception and had experienced sexual violence was more likely to have an unintended pregnancy., Conclusion: Spousal sexual violence is highly associated with unintended pregnancies in Zambia. Addressing intimate partner sexual violence is among the ways to prevent unintended pregnancies. It is also important to sensitize women on reporting acts of sexual violence to relevant authorities as this will not only prevent reoccurrence of sexual violence but also reduce unintended pregnancies and associated long-term effects., (© 2022. The Author(s).)

Background: Mineworkers in Southern Africa have the highest rates of tuberculosis (TB) among working populations in the world (The World Bank, Benefits and costs associated with reducing tuberculosis among Southern Africa's mineworkers, 2014), making mineworkers a key population for TB program efforts. The current evaluation aimed to characterize mineworkers and former (ex-) mineworkers, and assess knowledge, attitudes and practices related to TB and HIV care among mineworkers and healthcare workers (HCWs) in Zambia., Methods: A mixed-methods evaluation of current and former (ex-) mineworkers and HCWs was conducted in the Copperbelt and North-Western provinces, Zambia. Knowledge, attitudes and practices (KAPs) related to TB care and policies were assessed using a structured survey. Focus Group Discussions (FGDs) were conducted with current and ex-mineworkers to understand perceptions, practices, and barriers related to accessing healthcare for TB., Results: Overall, 2,792 mineworkers and 94 HCWs completed the KAP survey, and 206 (171 current, 71 ex-) mineworkers participated in FGDs. Mineworkers and ex-mineworkers were knowledgeable about TB symptoms (cough; 94%), transmission (81.7%) and treatment (99.2%). Yet, barriers to seeking care were evident with 30% of mineworkers experiencing cough, and 19% reporting 2 or more TB symptoms at the time of the survey. The majority of mineworkers (70.9%) were aware of policies barring persons from working after a diagnosis of TB, and themes from FGDs and HCW comments (n = 32/62; 51.6%) recognized fear of job loss as a critical barrier to providing timely screening and appropriate care for TB among mineworkers. The majority (76.9%) of mineworkers indicated they would not disclose their TB status to their supervisor, but would be willing to share their diagnosis with their spouse (73.8%)., Conclusion: Fear of job loss, driven by governmental policy and mistrust in mining companies, is a major barrier to healthcare access for TB among mineworkers in Zambia. As a result of these findings, the government policy prohibiting persons from working in the mines following TB disease is being repealed. However, major reforms are urgently needed to mitigate TB among mineworkers, including ensuring the rights of mineworkers and their communities to healthy living and working environments, improved social responsibility of mining companies, and facilitating choice and access to affordable, timely, and high-quality healthcare services., (© 2022. The Author(s).)

Background: Infants born HIV-exposed yet remain uninfected (HEU) are at increased risk of poorer growth and health compared to infants born HIV-unexposed (HU). Whether maternal antiretroviral treatment (ART) in pregnancy ameliorates this risk of poorer growth is not well understood. Furthermore, whether risks are similar across high burden HIV settings has not been extensively explored., Methods: We harmonized data from two prospective observational studies conducted in Cape Town, South Africa, and Lusaka, Zambia, to compare weight-for-age (WAZ), length-for-age (LAZ) and weight-for-length (WLZ) Z-scores between infants who were HEU and HU, converting infant anthropometric measures using World Health Organisation Growth Standards adjusted for age and sex. Linear mixed effects models were fit to identify risk factors for differences in anthropometrics at 6-10 weeks and 6 months by infant HIV exposures status and by timing of exposure to maternal ART, either from conception or later in gestation., Results: Overall 773 mother-infant pairs were included across two countries: women living with HIV (WLHIV), 51% (n = 395) with 65% on ART at conception and 35% initiating treatment in pregnancy. In linear mixed effects models, WAZ and WLZ at 6-10 weeks were lower among infants who were HEU vs HU [β = - 0.29 (95% CI: - 0.46, - 0.12) and [β = - 0.42 (95% CI: - 0.68, - 0.16)] respectively after adjusting for maternal characteristics and infant feeding with a random intercept for country. At 6 months, LAZ was lower [β = - 0.28 CI: - 0.50, - 0.06)] among infants who were HEU, adjusting for the same variables, with no differences in WAZ and WLZ. Within cohort evaluations identified different results with higher LAZ among infants who were HEU from Zambia at 6-10 weeks, [β = + 0.34 CI: + 0.01, + 0.68)] and lower LAZ among infants who were HEU from South Africa [β = - 0.30 CI: - 0.59, - 0.01)] at 6 months, without other anthropometric differences at either site., Conclusion: Infant growth trajectories differed by country, highlighting the importance of studying contextual influences on outcomes of infants who were HEU., (© 2022. The Author(s).)

Background: Although health care providers are beginning to focus on men's roles as fathers and husbands, there is limited understanding of how men view their ability to promote sexual and reproductive health in families affected by HIV and their experiences with receiving education through antenatal care. This paper aims to explore men's perceptions of the education they need regarding sexual and reproductive health within the family in the context of HIV., Methods: We interviewed a convenience sample of 18 male partners of pregnant women living with HIV in Lusaka, Zambia. Atlas.ti was used to facilitate data management and content analysis., Results: Men reported being the primary decision-makers regarding sexual and reproductive issues in the family; however, they admitted far-reaching unmet needs in terms of information on sexual and reproductive health in the context of HIV. Most men felt that antenatal care was not a conducive setting to fully educate men on sexual and reproductive health because it is a woman's space where their health concerns were generally neglected. There was a strong desire for more education that was specific to men's sexual and reproductive health, especially because all the couples were affected by HIV. Men especially requested education on sexual preparedness, safe sex, the use of condoms in sero-concordant and sero-discordant relationships and general health information. Although men stated they were the main decision-makers regarding sexual and reproductive issues such as pregnancy, most men were not confident in their ability to promote sexual and reproductive health in the family because of limited knowledge in this area., Conclusion: There is need to change the environment and messaging of antenatal care, as well as offer relevant education opportunities outside health facility settings to empower men with essential information for meaningful involvement in sexual and reproductive health in the context of HIV.

Background: The Ministry of Health Zambia recommends tuberculosis preventive treatment (TPT) with 6 months daily isoniazid for all people living with human immunodeficiency virus (HIV) after ruling out active tuberculosis disease. We sought to estimate the percentage of people living with HIV who progress through each stage of the tuberculosis case-finding and prevention cascade in two provinces with the highest tuberculosis burden in Zambia., Methods: In this cross-sectional survey, we used a two-stage cluster sampling method. We sampled 12 healthcare facilities with probability proportional to size. Patient volume determined facility cluster size. During October 2018, from each facility we systematically sampled medical records of adults and children living with HIV. Our primary outcome of interest was TPT initiation rate among eligible people living with HIV, weighted for complex survey design. The Rao-Scott adjusted chi-square test was used to test for differences in TPT initiation rate and other indicators from the tuberculosis prevention cascade by age group and province of residence. Additionally, we conducted semi-structured interviews with healthcare workers at each facility to assess TPT knowledge and identify challenges to its implementation., Results: We sampled 482 records of people living with HIV (including 128 children living with HIV). Excluding two people diagnosed with tuberculosis disease before enrollment in HIV care, 93.4% underwent tuberculosis symptom screening. Of those, 4.7% were diagnosed with tuberculosis disease and 95.3% were TPT-eligible, of whom 24.7% initiated TPT. TPT initiation was lower among eligible children (7.7%) compared with adults (25.2%, p = 0.03) and Copperbelt residents (3.1%) compared with Lusaka residents (35.8%, p < 0.01). TPT completion rate was 38.4% among people living with HIV who initiated the 6-month course. Among interviewed healthcare workers, 58.3% (unweighted) incorrectly relayed the number of symptoms needed for a positive tuberculosis symptom screen, 83.3% (unweighted) reported insufficient isoniazid stockpile for completion at the time of TPT initiation, and only 27.3% (unweighted) reported receiving TPT-specific training., Conclusions: TPT uptake among people living with HIV in Zambia is challenged by inconsistent tuberculosis screening, lack of TPT training for healthcare workers, and supply chain inefficiencies. Addressing these barriers may increase TPT initiations and improve outcomes among people living with HIV.

Introduction: Zambia is among the countries with the highest HIV burden and where youth remain disproportionally affected. Access to HIV testing and counselling (HTC) is a crucial step to ensure the reduction of HIV transmission. This study examines the changes that occurred between 2007 and 2018 in access to HTC, inequities in testing uptake, and determinants of HTC uptake among youth., Methods: We carried out repeated cross-sectional analyses using three Zambian Demographic and Health Surveys (2007, 2013-14, and 2018). We calculated the percentage of women and men ages 15-24 years old who were tested for HIV in the last 12 months. We analysed inequity in HTC coverage using indicators of absolute inequality. We performed bivariate and multivariate logistic regression analyses to identify predictors of HTC uptake in the last 12 months., Results: HIV testing uptake increased between 2007 and 2018, from 45 to 92% among pregnant women, 10 to 58% among non-pregnant women, and from 10 to 49% among men. By 2018 roughly 60% of youth tested in the past 12 months used a government health centre. Mobile clinics were the second most common source reaching up to 32% among adolescent boys by 2018. Multivariate analysis conducted among men and non-pregnant women showed higher odds of testing among 20-24 year-olds than adolescents (aOR = 1.55 [95%CI:1.30-1.84], among men; and aOR = 1.74 [1.40-2.15] among women). Among men, being circumcised (aOR = 1.57 [1.32-1.88]) and in a union (aOR = 2.44 [1.83-3.25]) were associated with increased odds of testing. For women greater odds of testing were associated with higher levels of education (aOR = 6.97 [2.82-17.19]). Education-based inequity was considerably widened among women than men by 2018., Conclusion: HTC uptake among Zambian youth improved considerably by 2018 and reached 65 and 49% tested in the last 12 months for women and men, respectively. However, achieving the goal of 95% envisioned by 2020 will require sustaining the success gained through government health centres, and scaling up the community-led approaches that have proven acceptable and effective in reaching young men and adolescent girls who are less easy to reach through the government facilities.

Background: More than 3 million children under 5 years in developing countries die from dehydration due to diarrhea, a preventable and treatable disease. We conducted a comparative analysis of two Demographic Health Survey (DHS) cycles to examine changes in ORS coverage in Zimbabwe, Zambia and Malawi. These surveys are cross-sectional conducted on a representative sample of the non-institutionalized individuals., Methods: The sample is drawn using a stratified two-stage cluster sampling design with census enumeration areas, typically, selected first as primary sampling units (PSUs) and then a fixed number of households from each PSU. We examined national and sub-regional prevalence of ORS use during a recent episode of diarrhea (within 2 weeks of survey) using DHSs for 2007-2010 (1st Period), and 2013-2016 (2nd Period). Weighted proportions of ORS were obtained and multivariable- design-adjusted logistic regression analysis was used to obtain Odds Ratios (aORs) and 95% confidence intervals (CIs) and weighted proportions of ORS coverage., Results: Crude ORS coverage increased from 21.0% (95% CI: 17.4-24.9) in 1st Period to 40.5% (36.5-44.6) in 2nd Period in Zimbabwe; increased from 60.8% (56.1-65.3) to 64.7% (61.8-67.5) in Zambia; and decreased from 72.3% (68.4-75.9) to 64.6% (60.9-68.1) in Malawi. The rates of change in coverage among provinces in Zimbabwe ranged from 10.3% over the three cycles (approximately 10 years) in Midlands to 44.2% in Matabeleland South; in Zambia from - 9.5% in Eastern Province to 24.4% in Luapula; and in Malawi from - 16.5% in the Northern Province to - 3.2% in Southern Province. The aORs for ORS use was 3.95(2.66-5.86) for Zimbabwe, 2.83 (2.35-3.40) for Zambia, and, 0.71(0.59-0.87) for Malawi., Conclusion: ORS coverage increased in Zimbabwe, stagnated in Zambia, but declined in Malawi. Monitoring national and province-level trends of ORS use illuminates geographic inequalities and helps identify priority areas for targeting resource allocation.. Provision of safe drinking-water, adequate sanitation and hygiene will help reduce the causes and the incidence of diarrhea. Health policies to strengthen access to appropriate treatments such as vaccines for rotavirus and cholera and promoting use of ORS to reduce the burden of diarrhea should be developed and implemented.

Background: Over one third of deaths in Zambian health facilities involve someone who has already died before arrival (i.e., Brough in Dead), and in most BiD cases, the CoD have not been fully analyzed. Therefore, this study was designed to evaluate the function of automated VA based on the Tariff Method 2.0 to identify the CoD among the BiD cases and the usefulness by comparing the data on the death notification form., Methods: The target site was one third-level hospital in the Republic of Zambia's capital city. All BiD cases who reached the target health facility from January to August 2017 were included. The deceased's closest relatives were interviewed using a structured VA questionnaire and the data were analyzed using the SmartVA to determine the CoD at the individual and population level. The CoD were compared with description on the death notification forms by using t-test and Cohen's kappa coefficient., Results: One thousand three hundred seventy-eight and 209 cases were included for persons aged 13 years and older (Adult) and those aged 1 month to 13 years old (Child), respectively. The top CoD for Adults were infectious diseases followed by non-communicable diseases and that for Child were infectious diseases, followed by accidents. The proportion of cases with a determined CoD was significantly higher when using the SmartVA (75% for Adult and 67% for Child) than the death notification form (61%). A proportion (42.7% for Adult and 46% for Child) of the CoD-determined cases matched in both sources, with a low concordance rate for Adult (kappa coefficient = 0.1385) and a good for Child(kappa coefficient = 0.635)., Conclusions: The CoD of the BiD cases were successfully analyzed using the SmartVA for the first time in Zambia. While there many erroneous descriptions on the death notification form, the SmartVA could determine the CoD among more BiD cases. Since the information on the death notification form is reflected in the national vital statistics, more accurate and complete CoD data are required. In order to strengthen the death registration system with accurate CoD, it will be useful to embed the SmartVA in Zambia's health information system.

Background: Despite rapid upscale of insecticide-treated nets (ITNs) and indoor residual spraying (IRS), malaria remains a major source of morbidity and mortality in Zambia. Uptake and utilization of these and novel interventions are often affected by knowledge, attitudes and practices (KAP) amongst persons living in malaria-endemic areas. The aims of this study were to assess malaria KAP of primary caregivers and explore trends in relation to ITN use, IRS acceptance and mosquito density in two endemic communities in Luangwa and Nyimba districts, Zambia., Methods: A cohort of 75 primary caregivers were assessed using a cross-sectional, forced-choice malaria KAP survey on ITN use, IRS acceptance and initial perception of a novel spatial repellent (SR) product under investigation. Entomological sampling was performed in participant homes using CDC Miniature Light Traps to relate indoor mosquito density with participant responses., Results: Ninety-nine percent of participants cited bites of infected mosquitoes as the route of malaria transmission although other routes were also reported including drinking dirty water (64%) and eating contaminated food (63%). All caregivers agreed that malaria was a life-threatening disease with the majority of caregivers having received malaria information from health centers (86%) and community health workers (51%). Cumulatively, self-reported mosquito net use was 67%. Respondents reportedly liked the SR prototype product but improvements on color, shape and size were suggested. Overall, 398 mosquitoes were captured from light-trap collections, including 49 anophelines and 349 culicines. Insecticide treated nets use was higher in households from which at least one mosquito was captured., Conclusions: The current study identified misconceptions in malaria transmission among primary caregivers indicating remaining knowledge gaps in educational campaigns. Participant responses also indicated a misalignment between a low perception of IRS efficacy and high stated acceptance of IRS, which should be further examined to better understand uptake and sustainability of other vector control strategies. While ITNs were found to be used in study households, misperceptions between presence of mosquitoes and bite protection practices did exist. This study highlights the importance of knowledge attitudes and practice surveys, with integration of entomological sampling, to better guide malaria vector control product development, strategy acceptance and compliance within endemic communities.

Background: Retention in care is critical for children living with HIV taking antiretroviral therapy (ART). Loss to follow-up (LTFU) is high in HIV treatment programs in resource limited settings. We estimated the cumulative incidence of LTFU and identified associated risk factors among children on ART at Livingstone Central Hospital (LCH), Zambia., Methods: Using a retrospective cohort study design, we abstracted data from medical records of children who received ART between 2003 and 2015. Loss to follow-up was defined as no clinical and pharmacy contact for at least 90 days after the child missed their last scheduled clinical visit. Non-parametric competing risks models were used to estimate the cumulative incidence of death, LTFU and transfer. Cause-specific Cox regression was used to estimate the hazard ratios of the risk factors of LTFU., Results: A total of 1039 children aged 0-15 years commenced ART at LCH between 2003 and 2015. Median duration of follow-up was 3.8 years (95% CI: 1.2-6.5), median age at ART initiation was 3.6 years (IQR: 1.3-8.6), 179 (17%) started treatment during their first year of life. At least 167 (16%) were LTFU and we traced 151 (90%). Of those we traced, 39 (26%) had died, 71 (47%) defaulted, 20 (13%) continued ART at other clinics and 21 (14%) continued treatment with gaps. The cumulative incidence of LTFU for the entire cohort was 2.7% (95% CI: 1.9-3.9) at 3 months, 4.1% (95% CI: 2.9-5.4) at 6 months and 14.1% (95% CI: 12.4-16.9) after 5 years on ART. Associated risk factors were: 1) non-disclosure of HIV status at baseline, aHR = 1.9 (1.2-2.9), 2) No phone ownership, aHR = 2.1 (1.6-2.9), 3) starting treatment between 2013 to 2015, aHR = 5.6 (2.2-14.1)., Conclusion: Among the children LTFU mortality and default were substantially high. Children who started treatment in recent years (2013-2015) had the highest hazard of LTFU. Lack of access to a phone and non-disclosure of HIV-status to the index child was associated with higher hazards of LTFU. We recommend re-enforcement of client counselling and focused follow-up strategies using modern technology such as mobile phones as adjunct to current approaches.

Background: In 2017, 64% of children living with HIV in Zambia accessed Antiretroviral Therapy (ART). Despite expanded ART coverage, there is paucity of information on effectiveness of pediatric ART in reducing mortality. The aim of this research is to describe treatment outcomes, measure mortality rates and assess predictors of mortality among children receiving ART., Methods: Using a retrospective cohort study design, we abstracted routinely collected clinical data from medical records of children from birth to 15 years old, who had received ART for at least 6 months at Livingstone Central Hospital in Southern Province Zambia, between January 2003 and June 2015. The primary outcome was death. Cause of death was ascertained from medical records and death certificates. Distribution of survival times according to baseline covariates were estimated using Kaplan Meier and Cox Proportional Hazards methods., Results: Overall, 1039 children were commenced on ART during the study period. The median age at treatment initiation was 3.6 years (IQR: 1.3-8.6) and 520 (50%) children were female. Of these, 71 (7%) died, 164 (16%) were lost to follow-up, 210 (20%) transferred and 594 (56%) were actively on treatment. After 4450 person years, mortality rate was 1.6/100 (95% CI: 1.4-1.8). Mortality was highest during the first 3 months of treatment (11.7/100 (95% CI: 7.6-16.3). In multivariable proportional hazards regression, the adjusted hazards of death were highest among children aged < 1 year (aHR = 3.1 (95% CI: 1.3-6.4), compared to those aged 6-15 years, WHO stage 4 (aHR =4.8 (95% CI: 2.3-10), compared to WHO stage 1 and 2. In the sensitivity analysis to address bias due to loss to follow-up, mortality increased 5 times when we assumed that all the children who were lost to follow up died within 90 days of their last visit., Conclusion: We observed low attrition due to mortality among children on ART. Loss to follow-up was high (16%). Mortality was highest during the first 3 months of treatment. Children aged less than one year and those with advanced WHO disease stage had higher mortality. We recommend effective interventions to improve retention in care and early diagnosis of HIV in children.

Background: Linear growth retardation is the most dominant nutritional problem globally. We aimed to describe linear growth trajectory among infants under 2 years of age using the WHO growth velocity standards., Method: This was a prospective cohort study of infants enrolled at 6 weeks of age and followed up for up to 24 months in Kamwala Urban Health Centre, Lusaka, Zambia. The study was conducted between April 2013 and March 2015. Infants were enrolled if they were 6-12 weeks of age and the mother was willing to participate voluntarily and provided informed consent. Anthropometric data were collected at scheduled clinic visits at 1 month, 2 months, 3 months, then quarterly until the infant was 24 months old. We defined linear growth velocity as the rate of change in height. We estimated linear growth velocity as the first derivative of the penalized cubic spline mixed effects model., Results: A total of 338 children were included in the analysis. Of these, 185 (54.7%) were female, 115 (34.1%) were born to HIV positive mothers and thus classified as HIV Exposed (HE). The mean age of children at enrollment was 1.6 months (SD = 0.15). On average, the growth velocity for 3-month length increments conditional on age were 0-3 months = 2.97 cm/3mo (95%CI = 2.69, 3.25); 3-6 months = 2.62 cm/3mo (95%CI = 2.38, 2.87); 6-9 months = 1.57 cm/3mo (95%CI = 1.43, 1.71); 9-12 months = 1.18 cm/3mo (95%CI = 1.08, 1.28); 12-15 month = 1.14 cm/3mo (95%CI = 1.02, 1.27); 15-18 months = 0.87 cm/3mo (95%CI = 0.79, 0.96); 18-21 months = 0.80 cm/3mo (95%CI = 0.72, 0.89); and 21-24 months = 0.86 cm/3mo (95%CI = 0.77, 0.96). For both boys and girls, the growth velocity in our cohort were consistently below the 3rd percentile of the WHO linear growth velocity standard. The estimated mean height and the age at which growth begins to falter were 68.6 cm (95%CI = 68.0, 69.2) and 13.6 months (95%CI = 13.2, 14.1) respectively., Conclusion: We found slower rate of growth among otherwise healthy Zambian infants. The data suggests that growth retardation is universal and profound in this cohort and may have already been occurring in utero.

Background: HIV workplace policies have become an important tool in addressing the HIV Pandemic in Sub-Saharan Africa. In Zambia, the National AIDS Council has been advocating for establishing of HIV/AIDS workplace policies to interested companies, however no formal evaluation has been done to assess uptake and implementation. The study aimed to establish the existence of HIV/AIDS policies and programs in the private sector and to understand implementation factors and experiences in addressing HIV epidemic drivers through these programs., Methods: A mixed method assessment of the availability of policies was conducted in 128 randomly selected member companies of Zambia Federation of Employers in Lusaka. Categorized variables were analysed on Policy and programs using Stata version 12.0 for associations: Concurrently, 28 in-depth interviews were conducted on purposively sampled implementers. Qualitative results were analysed thematically before integrating them with qualitative findings., Results: Policies were found in 47/128 (36.72%) workplaces and the private sector accounted for 34/47 (72.34%) of all workplaces with a policy. Programs were available in 56/128 (43.75%) workplaces. The availability of policy was 2.7 times more likely to occur with increased size of a workplace, P value = 0.0001, (P < 0.05). Management support was 0.253 times more likely to occur in workplaces with policy, P value = 0.013, (P < 0.05) compared to those without. Having a specific budget for programs was 0.23 times more likely to occur in workplaces with a policy (P < 0.05) than those without a policy. Implementation was hindered by reduced funding, lack of time, sensitisation and lack of monitoring/evaluation systems. HIV awareness (56/56, 100%) and HIV/AIDS/Stigma (47/56, 83.93%) were the most addressed epidemic drivers through programs while Mother to Child Transmission (30/56 53.57%) and Males having sex with males were the least addressed (18/56, 32.14%)., Conclusion: HIV/AIDS policies exist in the private sector at a very low proportion but policy translation was very high suggesting that workplaces with polices are likely to implement programs. The eradication of HIV/AIDS by 2030, requires addressing epidemic drivers with a focus on marginalised populations, gender integration, a wellness and rights based approach within the context of the legal framework.

Background: The 2010 Global Burden of Disease estimates show that 57% of all TB deaths globally occurred among adults older than 50 years of age. Few studies document the TB burden among older adults in Southern Africa. We focused on adults older than 55 years to assess the relative TB burden and associated demographic factors., Methods: A cross sectional nationally representative TB prevalence survey conducted of Zambian residents aged 15 years and above from 66 clusters across all the 10 provinces of Zambia. Evaluation included testing for TB as well as an in-depth questionnaire. We compared survey data for those aged 55 and older to those aged 15-54 years. Survey results were also compared with 2013 routinely collected programmatic notification data to generate future hypotheses regarding active and passive case finding., Results: Among older adults with TB, 30/ 54 (55.6%) were male, 3/27 (11.1%) were HIV infected and 35/54 (64.8%) lived in rural areas. TB prevalence was higher in those aged ≥55 (0.7%) than in the 15-54 age group (0.5%). Males had higher rates of TB across both age groups with 0.7% (15-54) and 1.0% (≥55) compared with females 0.4% (15-54) and 0.6% (≥55). In rural areas, the prevalence of TB was significantly higher among older than younger adults (0.7% vs 0.3%), while the HIV infection rate was among TB patients was lower (11.1% vs 30.8%). The prevalence survey detected TB in 54/7484 (0.7%) of older adults compared to 3619/723,000 (0.5%) reported in 2013 programmatic data., Conclusion: High TB rates among older adults in TB endemic areas justify consideration of active TB case finding and prevention strategies.

Background: Many health care workers (HCWs) are at increased risk for tuberculosis (TB). The World Health Organization (WHO) recommends screening HCWs for TB in high burden settings but this is often not implemented in countries with a high TB incidence. We assessed the feasibility of TB screening among HCWs, including participation rate and yield, as part of a project introducing facility specific TB interventions., Methods: This study had a cross-sectional design. HCWs (including paid staff and community volunteers) from 13 clinics and two hospitals in the Ndola district of Zambia participated. HCWs were screened by a designated person in their own facility. The agreed screening algorithm for HCWs included annual symptom screening, with sputum smear, culture (or Xpert) and chest x-ray offered to HCWs with at least one TB symptom, i.e. those with presumptive TB., Results: A total of 1011 out of 1619 (62%) staff and 71 out of 138 (51%) community volunteers were screened within one year, total 1082/1757 (62%). Five percent (52/1082) of those screened were presumptive TB patients. Seventy-three percent (38/52) of presumptive TB patients received all diagnostic tests according to the agreed algorithm. Eighteen out of 1757 staff and volunteers combined were diagnosed with TB within a calendar year, showing a notified TB incidence of 1%. At least five of them were diagnosed during the screening appointment (0.5% of those screened). One of the 18 HCWs died of TB. Seventy-six percent (822/1082) of screened HCWs indicated that they already knew their HIV status. Screening was considered feasible if confidentiality can be guaranteed although challenges such as the time required for screening and sample transport were reported., Conclusions: It is feasible to conduct and implement screening programs for TB among HCWs in hospitals and clinics, and the notified incidence and yield is high. Advocacy is needed to educate managers and HCWs on the importance of screening and the implementation of locally relevant screening algorithms. It is essential to ensure access to TB infection control, diagnostics, treatment and confidential registration for HCW.

Background: The objective of the study was to estimate the prevalence of HIV among teenagers in Zambia and determine whether age, sex, setting, educational level, marital and socioeconomic status were associated with being HIV positive., Methods: A cross sectional population based survey of the prevalence of HIV among teenagers aged 15-18 years old who were also participants in a national Tuberculosis (TB) prevalence survey. Consenting teenagers were counselled and tested for HIV. The HIV prevalence was estimated using a logistic regression model. Associations of social demographic characteristics with HIV were determined using univariate and multivariate., Results: The study involved 6,395 teenagers aged 15-18 years where 2,532 declined HIV testing, 44 tested positive and 3,806 tested negative. The HIV prevalence was estimated to be 1.1 % (95 % CI 0.71-1.60); in females the HIV prevalence was 1.6 % (95 % CI 0.99-2.20) whereas in males it was 0.58 % (95 % CI 0.10-1.10). The prevalence of HIV was twice as high among the urban (1.90 %; 95 % CI 0.99-2.90) than the rural teenagers (0.89 %; 95 % CI 0.46-1.30), and being divorced or widowed was associated with higher risk of HIV regardless of residence. The risk of HIV was lower among students or those who were in school compared to those who were unemployed and not in school., Conclusion: HIV prevalence among teenagers was lower than the overall national level prevalence. The patterns of HIV risk among the young population will require further monitoring in order to identify appropriate tools for intervention.

Background: The Programme for the Awareness and Elimination of Diarrhoea (PAED) was a pilot comprehensive diarrhoea prevention and control programme aimed to reduce post-neonatal, all-cause under-five mortality by 15 % in Lusaka Province. Interventions included introduction of the rotavirus vaccine, improved clinical case management of diarrhoea, and a comprehensive community prevention and advocacy campaign on hand washing with soap, exclusive breastfeeding up to 6 months of age, and the use of ORS and Zinc. This study aimed to assess the impact of PAED on under-5 mortality., Methods: The study was a pre-post evaluation design. The Demographic and Health Survey style population-based two-stage approach was used to collect data at the beginning of the intervention and 3 years following the start of intervention implementation in Lusaka province. The primary outcome of interest was an all-cause, post-neonatal under-five mortality rate defined as the probability of dying after the 28th day and before the fifth birthday among children aged 1-59 months. The Kaplan-Meier time to event analysis was used to estimate the probability of death; multiplying this probability by 1000 to yield the post-neonatal mortality rate. Survival-time inverse probability weighting model was used to estimate Average Treatment Effect (ATE)., Results: The percentage of children under age 5 who had diarrhoea in the last 2 weeks preceding the survey declined from 15.8 % (95 % CI: 15.2 %, 16.4 %) in 2012 to 12.7 % (95 % CI: 12.3 %, 13.2 %) in 2015. Over the same period, mortality in post-neonatal children under 5 years of age declined by 34 %, from an estimated rate of 29 deaths per 1000 live births (95 % CI: (26, 32) death per 1000 live births) to 19 deaths per 1000 live births (95 % CI: (16, 21) death per 1000 live births). When every child in the population of children aged 1-59 months is exposed to the intervention, the average time-to-death was estimated to be about 8 months more than when no child is exposed (ATE = 7.9; 95 % CI: 4.4,11.5; P < 0.001)., Conclusion: Well-packaged diarrhoea preventive and treatment interventions delivered at the clinic and community-level could potentially reduce probability of death among children aged 1-59 months.

Background: About 30% of the patients initiated on antiretroviral therapy in Zambia default treatment. Some of these patients later restart treatment; however, the characteristics of these patients have not been well described and documented. The aim of this study was to describe and document the socio-demographic and clinical characteristics of patients who default and restart antiretroviral therapy, and to determine the socio-demographic characteristics associated with CD4 count response at 6 and 24 months of restarting antiretroviral therapy., Methods: A longitudinal retrospective analysis was performed on data from 535 adult patients restarting antiretroviral therapy in 2009 and 2010 at five antiretroviral therapy centres in Copperbelt and Central provinces of Zambia. To determine the association between the socio-demographic characteristics and CD4 cell count, quantile regression models were used., Results: Older age above 45 years was associated with a significantly lower CD4 cell response by 38.1 cells/mm(3) (95% Confidence interval [CI]: -109.4 to -0.2) compared to the younger age (15-29 years). Patients in formal employment (Adjusted Coefficient [AC] 29.5, 95% CI: 22.8 to 81.1) and self-employment (AC 48.1, 95% CI: 18.6 to 77.4) gained significantly higher CD4 cells than those unemployed. In addition, baseline CD4 count, type of treatment, WHO staging, total duration on treatment and duration lost to follow-up were found to be strong predictors of CD4 cell count at 6 and 24 months after restarting antiretroviral therapy treatment., Conclusion: Age and occupation were the only socio-demographic characteristics predicting CD4 count in the patients at 6 months after restarting antiretroviral therapy after adjusting for other confounding clinical variables.

Background: Across sub-Saharan Africa, men's levels of HIV-testing remain inadequate relative to women's. Men are less likely to access anti-retroviral therapy and experience higher levels of morbidity and mortality once initiated on treatment. More frequent HIV-testing by men at continued risk of HIV-infection is required to facilitate earlier diagnosis. This study explored the frequency of HIV-testing among a rural population of men and the factors associated with more frequent HIV-testing., Methods: We conducted a secondary analysis of a population-based survey in three rural district in Zambia, from February-November, 2013. Households (N = 300) in randomly selected squares from 42 study sites, defined as a health facility and its catchment area, were invited to participate. Individuals in eligible households were invited to complete questionnaires regarding demographics and HIV-testing behaviours. Men were defined as multiple HIV-testers if they reported more than one lifetime test. Upon questionnaire completion, individuals were offered rapid home-based HIV-testing., Results: Of the 2376 men, more than half (61%) reported having ever-tested for HIV. The median number of lifetime tests was 2 (interquartile range = 1-3). Just over half (n = 834; 57%) of ever-testers were defined as multiple-testers. Relative to never-testers, multiple-testers had higher levels of education and were more likely to report an occupation. Among the 719 men linked to a spouse, multiple-testing was higher among men whose spouse reported ever-testing (adjusted prevalence ratio = 3.02 95% CI: 1.37-4.66). Multiple-testing was higher in study sites where anti-retroviral therapy was available at the health facility on the day of a health facility audit. Among ever-testers, education and occupation were positively associated with multiple-testing relative to reporting one lifetime HIV-test. Almost half (49%) of ever-testers accepted the offer of home-based HIV-testing., Discussion: Reported HIV-testing increased among this population of men since a 2011/12 survey. Yet, only 35% of all men reported multiple lifetime HIV-tests. The factors associated with multiple HIV-testing were similar to factors associated with ever-testing for HIV. Men living with HIV were less likely to report multiple HIV-tests and employment and education were associated with multiple-testing. The offer of home-based HIV-testing increased the frequency of HIV-testing among men., Conclusion: Although men's levels of ever-testing for HIV have increased, strategies need to increase the lifetime frequency of HIV-testing among men at continued risk of HIV-infection.

Background: Hypertension constitutes a growing burden of illness in developing countries like Zambia. Adequately screening and treating hypertension could greatly reduce the complications of stroke and coronary disease. Our objective was to determine the prevalence of hypertension and identify current treatment practices among adult patients presenting for routine care to rural health facilities in the Better Health Outcomes through Mentoring and Assessments (BHOMA) project., Methods: We conducted a retrospective analysis of routinely collected clinical data from 46 rural government clinics in Zambia. Our analysis cohort comprised patients ≥ 25 years with recorded blood pressure measurements, who sought care at primary health centers. Consistent with prior research, in our primary analysis, we only included data from first visits. Hypertension was defined as a systolic blood pressure ≥140 mmHg, or diastolic blood pressure ≥90 mmHg, or reported use of antihypertensive medication. A sensitivity analysis was performed using median blood pressure for individuals with multiple visits., Results and Discussion: From January 2011 to December 2014, 116,130 first visits by adult patients met eligibility criteria. The crude prevalence of hypertension by onsite measurement or reported use of antihypertensive medication was 23.1% [95% CI: 22.8-23.3] (23.6% in females, 22.3% in males). The age standardized prevalence of hypertension across participating sites was 28.0 [95% CI: 27.7-28.3] (29.7% in females, 25.8% in males). Sensitivity analysis revealed a similar prevalence using data from all visits. Only 5.6% of patients had a diagnosis of hypertension documented in their medical record. Among patients with hypertension, only 18.0% had any antihypertensive drug prescribed, with nifedipine (8.9%), furosemide (8.3%), and propranolol (2.4%) as the most common., Conclusions: Age standardized prevalence of hypertension in rural primary health clinics in Zambia was high compared to other studies in rural Africa; however, we diagnosed hypertension with only one measurement and this may have biased our findings. Future efforts to improve hypertension control should focus on population preventive care and primary healthcare provider education on individual management.

Initiatives such as the Country Countdown to 2015 Conference on Millennium Development Goals (MDGs) have provided countries with high maternal and child deaths like Zambia a platform to assess progress, discuss challenges and share lessons learnt as a conduit for national commitment to reaching and attaining the MDGs four and five. This paper discusses and highlights the process of holding a successful country countdown conference and shares Zambia's experience with other countries planning to organise country countdown to 2015 Conferences on MDGs.

Background: Genital ulcers (GU) are associated with an increased risk of HIV transmission. Understanding risk factors for genital ulcers and sexual behaviour patterns after onset of symptoms and health seeking behaviour among GU-patients can provide useful information to aid design effective prevention strategies for genital ulcers. We investigated risk factors of self-reported GUs and care-seeking in the general population, and assessed GU patients regarding past care-seeking, recent sexual behaviour and partner awareness of the disease., Methods: We analysed national data on genital ulcers from the 2007 Zambia Demographic and Health Survey, and data from a cross-sectional survey of genital ulcer patients from primary health care facilities in Lusaka, Zambia., Results: The prevalence of GU in 2007 in the general population of Lusaka was 3.6%. Important predictors for genital ulcers were age 25-29 years, being widowed/separated/divorced and having a high number of life-time sexual partners. No differences in care-seeking were observed by residence, wealth and gender, and 60% of the respondents sought care from public health facilities. Among patients with GUs in Lusaka, 14% sought care >2 weeks after symptom onset. Forty-two percent were not aware of their HIV status, 57% reported sex after onset of symptoms and only 15% reported consistent condom use., Conclusions: Low awareness of HIV status despite high probability of being infected and low condom use after onset of genital ulcer symptoms leads to a high potential for transmission to sexual partners. This, combined with the fact that many patients with GUs delayed seeking care, shows a need for awareness campaigns about GUs and the importance of abstinence or use of condoms when experiencing such symptoms.

Background: Investigations of the association between socio-economic position indicators and HIV in East, Central and Southern Africa have chiefly focused on factors that pertain to individual-level characteristics. This study investigated the effect of neighbourhood educational attainment on HIV prevalence among young women in selected urban and rural areas in Zambia., Methods: This study re-analysed data from a cross-sectional population survey conducted in Zambia in 2003. The analyses were restricted to women aged 15-24 years (n = 1295). Stratified random cluster sampling was used to select 10 urban and 10 rural clusters. A measure for neighbourhood-level educational attainment was constructed by aggregating individual-level years-in-school. Multi-level mixed effects regression models were run to examine the neighbourhood-level educational effect on HIV prevalence after adjusting for individual-level underlying variables (education, currently a student, marital status) and selected proximate determinants (ever given birth, sexual activity, lifetime sexual partners)., Results: HIV prevalence among young women aged 15-24 years was 12.5% in the urban and 6.8% in the rural clusters. Neighbourhood educational attainment was found to be a strong determinant of HIV infection in both urban and rural population, i.e. HIV prevalence decreased substantially by increasing level of neighbourhood education. The likelihood of infection in low vs. high educational attainment of neighbourhoods was 3.4 times among rural women and 1.8 times higher among the urban women after adjusting for age and other individual-level underlying variables, including education. However, the association was not significant for urban young women after this adjustment. After adjusting for level of education in the neighbourhood, the effect of the individual-level education differed by residence, i.e. a strong protective effect among urban women whereas tending to be a risk factor among rural women., Conclusion: The findings suggested structural effects on HIV prevalence. Future research should include more detailed mapping of neighbourhood factors of relevance to HIV transmission as part of the effort to better understand the causal mechanisms involved.

Background: Population level data on mental health from Africa are limited, but available data indicate mental problems to represent a substantial public health problem. The negative impact of HIV on mental health suggests that this could particularly be the case in high prevalence populations. We examined the prevalence of mental distress, distribution patterns and the ways HIV might influence mental health among men and women in a general population., Methods: The relationship between HIV infection and mental distress was explored using a sample of 4466 participants in a population-based HIV survey conducted in selected rural and urban communities in Zambia in 2003. The Self-reporting questionnaire-10 (SRQ-10) was used to assess global mental distress. Weights were assigned to the SRQ-10 responses based on DSM IV criteria for depression and a cut off point set at 7/20 for probable cases of mental distress. A structural equation modeling (SEM) was established to assess the structural relationship between HIV infection and mental distress in the model, with maximum likelihood ratio as the method of estimation., Results: The HIV prevalence was 13.6% vs. 18% in the rural and urban populations, respectively. The prevalence of mental distress was substantially higher among women than men and among groups with low educational attainment vs. high. The results of the SEM showed a close fit with the data. The final model revealed that self-rated health and self perceived HIV risk and worry of being HIV infected were important mediators between underlying factors, HIV infection and mental distress. The effect of HIV infection on mental distress was both direct and indirect, but was particularly strong through the indirect effects of health ratings and self perceived risk and worry of HIV infection., Conclusion: These findings suggest a strong effect of HIV infection on mental distress. In this population where few knew their HIV status, this effect was mediated through self-perceptions of health status, found to capture changes in health perceptions related to HIV, and self-perceived risk and worry of actually being HIV infected.

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.

Background: Improvements in child survival have been very poor in sub-Saharan Africa (SSA). Since the 1990 s, declines in child mortality have reversed in many countries in the region, while in others, they have either slowed or stalled, making it improbable that the target of reducing child mortality by two thirds by 2015 will be reached. This paper highlights the implications of urban population growth and access to health and social services on progress in achieving MDG 4. Specifically, it examines trends in childhood mortality in SSA in relation to urban population growth, vaccination coverage and access to safe drinking water., Methods: Correlation methods are used to analyze national-level data from the Demographic and Health Surveys and from the United Nations. The analysis is complemented by case studies on intra-urban health differences in Kenya and Zambia., Results: Only five of the 22 countries included in the study have recorded declines in urban child mortality that are in line with the MDG target of about 4% per year; five others have recorded an increase; and the 12 remaining countries witnessed only minimal decline. More rapid rate of urban population growth is associated with negative trend in access to safe drinking water and in vaccination coverage, and ultimately to increasing or timid declines in child mortality. There is evidence of intra-urban disparities in child health in some countries like Kenya and Zambia., Conclusion: Failing to appropriately target the growing sub-group of the urban poor and improve their living conditions and health status - which is an MDG target itself - may result in lack of improvement on national indicators of health. Sustained expansion of potable water supplies and vaccination coverage among the disadvantaged urban dwellers should be given priority in the efforts to achieve the child mortality MDG in SSA.

Background: Evidence suggests that HIV prevalence amongst young Zambians has declined recently, especially in higher-education groups. We studied trends in key sexual behaviour indicators among 15-24 year-olds from 1995 to 2003, including the associations between sexual behaviour change and education., Methods: The data stem from a series of three population-based surveys conducted in 1995 (n = 1720), 1999 (n = 1946) and 2003 (n = 2637). Logistic regression and Extended Mantel Haenszel Chi Square for linear trends were used to compare the three surveys., Results: Men and lower-education groups reported more than one sexual partner in the year immediately prior to the survey more frequently than did women and higher-education groups (p < 0.01), but these proportions declined regardless of sex and residence. Substantial delays in child-bearing were observed, particularly among higher-education and urban respondents. Condom use at least for casual sexual intercourse increased from 1995 to 2003; the level was highest among urban and higher-education groups. The number of women reporting frequent dry sex using traditional agents fell during the period. Participants from the rural area and those with less education reported more sexual experience than urban and higher-education participants in 2003. The reported number of sexual partners during the year immediately prior to the survey was a factor that reduced the association between HIV and survey times among sexually active young urban men and women., Conclusion: High risk behaviours clearly decreased, especially in higher-educated and urban groups, and there is a probable association here with the decline in HIV prevalence in the study population. Fewer sexual partners and condom use were among the core factors involved for both sexes; and for women a further factor was delayed child-bearing.

Background: Understanding the epidemiological HIV context is critical in building effective setting-specific preventive strategies. We examined HIV prevalence patterns in selected communities of men and women aged 15-59 years in Zambia., Methods: Population-based HIV surveys in 1995 (n = 3158), 1999 (n = 3731) and 2003 (n = 4751) were conducted in selected communities using probability proportional to size stratified random-cluster sampling. Multivariate logistic regression and trend analyses were stratified by residence, sex and age group. Absence, <30% in men and <15% in women in all rounds, was the most important cause of non-response. Saliva was used for HIV testing, and refusal was <10%., Results: Among rural groups aged 15-24 years, prevalence declined by 59.2% (15.7% to 6.4%, P < 0.001) in females and by 44.6% (5.6% to 3.1%, P < 0.001) in males. In age-group 15-49 years, declines were less than 25%. In the urban groups aged 15-24, prevalence declined by 47% (23.4% to 12.4%, P < 0.001) among females and 57.3% (7.5% to 3.2%, P = 0.001) among males but were 32% and 27% in men and women aged 15-49, respectively. Higher educated young people in 2003 had lower odds of infection than in 1995 in both urban [men: AOR 0.29(95% CI 0.14-0.60); women: AOR 0.38(95% CI 0.19-0.79)] and rural groups [men: AOR 0.16(95% CI 0.11-0.25), women: AOR 0.10(95% CI 0.01-7.34)]. Although higher mobility was associated with increased likelihood of infection in men overall, AOR, 1.71(95% CI 1.34-2.19), prevalence declined in mobile groups also (OR 0.52 95% CI 0.31-0.88). In parallel, urban young people with > or =11 school years were more likely to use condoms during the last casual sex (OR 2.96 95% CI 1.93-4.52) and report less number of casual sexual partners (AOR 0.33 95% CI 0.19-0.56) in the last twelve months than lower educated groups., Conclusion: Steep HIV prevalence declines in young people, suggesting continuing declining incidence, were masked by modest overall declines. The concentration of declines in higher educated groups suggests a plausible association with behavioural change.

Background: The premise for using antenatal care (ANC) clinic data for estimating HIV prevalence in the general population is the finding from community studies in sub-Saharan Africa that total HIV prevalence in pregnant women attending ANC clinics closely approximate levels in the total general population of both women and men aged 15-49 years. In this study, the validity of national level HIV prevalence estimates for the total general population 15-49 years made from ANC clinic and population survey data was assessed., Methods: In 2001-2002, a national population HIV prevalence survey for women 15-49 years and men 15-59 years was conducted in Zambia. In the same period, a national HIV sentinel surveillance survey among pregnant women attending ANC clinics was carried out., Results: The ANC HIV prevalence estimates for age-group 15-49 years (rural: 11.5%; 95% CI, 11.2-11.8; urban: 25.4%; 95% CI, 24.8-26.0; adjusted national: 16.9%; 95% CI, 16.6-17.2) were similar to the population survey estimates (rural: 10.8%; 95% CI, 9.6-12.1; urban: 23.2%; 95% CI 20.7-25.6; national: 15.6%; 95% CI, 14.4-16.9). The HIV prevalence urban to rural ratio was 2.2 in ANC and 2.1 in population survey estimates., Conclusion: The HIV prevalence estimate for the total general population 15-49 years derived from testing both women and men in the population survey was similar to the estimate derived from testing women attending ANC clinics. It shows that national HIV prevalence estimates for adults aged 15-49 years can also be obtained from ANC HIV sentinel surveillance surveys with good coverage when ANC attendance and fertility are high.

Background: Malaria is a serious illness among children aged 5 years and below in Zambia, which carries with it many adverse effects including anemia and high parasites exposure that lead to infant and childhood mortality. Due to poor accessibility to modern health facilities, malaria is normally managed at home using indigenous and cosmopolitan medicines. In view of problems and implications associated with management of severe malaria at home, rectal artesunate is being proposed as a first aid drug to slow down multiplication of parasites in children before accessing appropriate treatment., Methods: A qualitative study using standardised in-depth and Focus Group Discussions (FGDs) guides to collect information from four (4) villages in Nakonde district, was conducted between February and March 2004. The guides were administered on 29 key informants living in the community and those whose children were admitted in the health facility. Participants in the 12 FGDs came from the 4 participating villages. Participants and key informants were fathers, younger and older mothers including grandmothers and other influential people at household level. Others were traditional healers, headmen, village secretaries, traditional birth attendants, church leaders and blacksmiths. FGDs and interview transcriptions were coded to identify common themes that were related to recognition, classification and naming of malaria illness, care-seeking behaviour and community treatment practices for severe malaria., Results: Parental prior knowledge of the disease was important as the majority of informants (23 out of 29) and participants (69 out of 97) mentioned four combined symptoms that were used to recognise severe malaria. The symptoms were excessive body hotness, convulsions, vomiting yellow things and bulging of the fontanelle. On the other hand, all informants mentioned two or more of symptoms associated with severe malaria. In all 12 FGDs, participants reported that treatment of severe malaria commenced with the family and moved into the community as the illness progressed. Although treatment of severe diarrheal effects, were common among the Winamwanga, no rectal medicines to treat severe malaria were identified. Apart from the anti-malarial fansidar, which was mentioned by 23 in IDIs and 40 in FGDs, participants and informants also frequently mentioned indigenous medicines provided by healers and other respectable herbalists for repelling evil spirits, once a child had severe malaria. Mothers were the important arms for administration of ant-malarial drugs in the villages. Referrals began with healers to CHWs, where no CHWs existed healers directly referred sick children to the health facility., Conclusion: Our findings showed that there is a precedent for rectal application of traditional medicine for childhood illness. Therefore rectal artesunate may be a well-received intervention in Nakonde District, provided effective sensitisation, to mothers and CHWs is given which will strengthen the health care delivery system at community level.

Background: The treatment guidelines for tuberculosis treatment under Directly Observed Treatment, Short-course (DOTS) have been a common strategy for TB treatment in Zambia. The study was carried out in Ndola, Zambia, to investigate factors contributing to treatment non-adherence and knowledge of TB transmission among patients on TB treatment, in order to design a community-based intervention, that would promote compliance., Methods: A household-based survey was conducted in six randomly selected catchment areas of Ndola, where 400 out of 736 patients receiving TB treatment within the six months period, were recruited through the District's Health Management Board (DHMB) clinics. All patients were interviewed using a pre-tested structured questionnaire, consisting of i. Socio-demographic characteristics ii. Socio-economic factors iii. Knowledge about TB transmission and prevention iv. Patterns in health seeking behaviour and v. TB treatment practices at household level., Results: Most male TB patient respondents tended to be older and more educated than the female TB patient respondents. Overall, 29.8% of the patients stopped taking their medication. There were 39.1% of the females and 33.9% of the males, who reported that TB patients stopped taking their medication within the first 2 months of commencing treatment. Age, marital status and educational levels were not significantly associated with compliance. The major factors leading to non-compliance included patients beginning to feel better (45.1% and 38.6%), lack of knowledge on the benefits of completing a course (25.7%), running out of drugs at home (25.4%) and TB drugs too strong (20.1% and 20.2%). There was a significant difference [OR = 1.66, 95% CI 1.23, 2.26] in TB knowledge, with more males than females reporting sharing of cups as a means for TB transmission, after adjusting for age, marital status and educational levels. Significantly [p = 0.016] more patients who had resided in the study for less than two years (59%) were more likely to report mother to child transmission of TB, compared to 41.2% of those who had been in the area for more than 2 years., Conclusion: This study established that 29.8% of TB patients failed to comply with TB drug taking regimen once they started feeling better.