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Objectives: This study investigated antimicrobial susceptibility and genomic profiling of S. enterica isolated from bloodstream infections at a tertiary referral hospital in Lusaka, Zambia, 2018-2019.Method: This was a prospective hospital-based study involving routine blood culture samples submitted to the microbiology laboratory at the University Teaching Hospital. Identification of S. enterica and determination of antimicrobial susceptibility profiles was achieved through conventional and automated methods. Whole-genome sequencing (WGS) was conducted, and the sequence data outputs were processed for species identification, serotype determination, multilocus sequence typing (MLST) profile determination, identification of antimicrobial resistance determinants, and phylogeny.Results: Seventy-six Salmonella enterica were isolated and 64 isolates underwent WGS. Salmonella Typhi (72%) was the most prevalent serotype. Notable was the occurrence of invasive non-typhoidal Salmonella Typhimurium ST313 (3%), resistance to cephalosporins (4%) and ciprofloxacin (5%), multidrug resistance (46%), and reduced susceptibility to ciprofloxacin (30%) and imipenem (3%). Phylogenetic cluster analysis showed multiple Salmonella serovars with a wide range of genetic diversity.Conclusion: The genetic diversity of Salmonella Typhi, high prevalence of multidrug resistance, and the emergence of ciprofloxacin and cephalosporin resistance warrants improved hygiene and water and sanitation provision, continued surveillance to apprise antibiograms and inform policy, and the introduction of the typhoid conjugate vaccine.

Antiretroviral therapy (ART) uptake continues to increase across sub-Saharan Africa and emergence of drug-resistant HIV mutations poses significant challenges to management of treatment-experienced patients with virologic failure. In Zambia, new third-line ART (TLART) guidelines including use of dolutegravir (DTG) were introduced in 2018. We assessed virologic suppression, immunologic response, and HIV drug-resistant mutations (DRMs) among patients on TLART at the University Teaching Hospital (UTH) in Lusaka, Zambia. We conducted a retrospective review of patients enrolled at UTH on TLART for6 months between January 2010 and June 30, 2021. CD4 and HIV viral load (VL) at TLART initiation and post-initiation were assessed to determine virologic and immunologic outcomes. Regression analysis using bivariate and multivariate methods to describe baseline characteristics, virologic, and immunologic response to TLART was performed. A total of 345 patients met inclusion criteria; women comprised 57.6% (199/345) of the cohort. Median age at HIV diagnosis was 30 (interquartile range: 17.3-36.8). In 255 (73.8%) patients with at least two VLs, VL decreased from mean of 3.45 log

Background: Staphylococcus aureus and Enterococcus species cause invasive infections such as bacteremia and infective endocarditis. Despite vancomycin being the drug of choice for drug-resistant infections caused by these species, few studies have been conducted to ascertain vancomycin resistance in the African setting. This is crucial given the rising resistance in these organisms. This study aimed to isolate S. aureus and Enterococcus species and determine their susceptibility to vancomycin and other antibiotics at the University Teaching Hospitals in Lusaka, Zambia. Methods: This was a cross-sectional study in which S. aureus and Enterococcus spp isolates from the skin, soft tissue and bloodstream infections were included. Standard microbiological and Kirby-Baur (disc diffusion and E-strips) methods were used to identify and determine the susceptibility of the organisms, respectively. Results: From 59 S. aureus isolates, 37 were from the skin and soft tissue and 22 from blood culture. Twenty-six (44.1%) of these were Methicillin-resistant S. aureus. Thirty-nine Enterococcus were isolated from blood cultures only. Of the S. aureus (16) and Enterococcus (14) isolates tested with vancomycin E-strips, none were vancomycin-resistant. However, 12.5% S. aureus and 14.3% Enterococcus showed intermediate vancomycin susceptibility. S. aureus were resistant to penicillin (93.2%), erythromycin (52.5%) and tetracycline (50.8%). Enterococcus showed resistance to penicillin (83%) and tetracycline (84.6%). Conclusions: There was no vancomycin resistance among S. aureus and Enterococcus, implying vancomycin is still a viable treatment option for invasive infections. Given the intermediate vancomycin susceptibility, treatment guided by minimum inhibitory concentration results, continued surveillance and prudent use are key.

Background Zambia recently achieved UNAIDS 90-90-90 treatment targets for HIV epidemic control; however, inpatient facilities continue to face a large burden of patients with advanced HIV disease and HIV-related mortality. Management of advanced HIV disease, following guidelines from outpatient settings, may be more difficult within complex inpatient settings. We evaluated adherence to HIV guidelines during hospitalization, including opportunistic infection (OI) screening, treatment, and prophylaxis. Methods We reviewed inpatient medical records of people living with HIV (PLHIV) admitted to the University Teaching Hospital in Lusaka, Zambia between December 1, 2018 and April 30, 2019. We collected data on patient demographics, antiretroviral therapy (ART), HIV biomarkers, and OI screening and treatment—including tuberculosis (TB), Cryptococcus, and OI prophylaxis with co-trimoxazole (CTX). Screening and treatment cascades were constructed based on the 2017 WHO Advanced HIV Guidelines. Results We reviewed files from 200 charts of patients with advanced HIV disease; of these 92% (184/200) had been on ART previously; 58.1% (107/184) for more than 12 months. HIV viral load (VL) testing was uncommon but half of VL results were high. 39% (77/200) of patients had a documented CD4 count result. Of the 172 patients not on anti-TB treatment (ATT) on admission, TB diagnostic tests (either sputum Xpert MTB/RIF MTB/RIF or urine TB-LAM) were requested for 105 (61%) and resulted for 60 of the 105 (57%). Nine of the 14 patients (64%) with a positive lab result for TB died before results were available. Testing for Cryptococcosis was performed predominantly in patients with symptoms of meningitis. Urine TB-LAM testing was rarely performed. Conclusions At a referral hospital in Zambia, CD4 testing was inconsistent due to laboratory challenges and this reduced recognition of AHD and implementation of AHD guidelines. HIV programs can potentially reduce mortality and identify PLHIV with retention and adherence issues through strengthening inpatient activities, including reflex VL testing, TB-LAM and serum CrAg during hospitalization.

We present the case of a 23-year-old right-handed man who presented to an emergency department in Lusaka, Zambia, with new-onset headaches and focal seizures. He was on combination antiretroviral therapy (cART) for HIV and had been started on antituberculous therapy at his local clinic 2 weeks before presentation, based on chest X-ray findings. On examination, he had subtle weakness and hyperreflexia in his left upper extremity. The remainder of the neurologic examination was normal. Brain CT scan revealed a single, ring-enhancing, heterogenous mass in the right posterior parietal lobe with marked vasogenic edema. His laboratory results revealed severe virologic and immunologic failure, and CSF analysis was unremarkable. He was empirically managed as CNS tuberculosis (TB). Two months later, his symptoms worsened, and he developed new neurologic deficits, despite adherence to cART and TB treatment. Repeat imaging subsequently revealed progression of his underlying CNS process with multiple brain abscesses present, and subsequent investigations revealed an unusual cause of these lesions. In this case, we review the differential diagnosis for space-occupying lesions in the context of poorly controlled HIV infection. In particular, we highlight the approach to these patients in resource-limited settings in the context of diagnostic limitations and highlight the importance of considering the local epidemiology of neurologic infections. Finally, this case demonstrates the need to maintain a wide differential diagnosis and a close monitoring plan for prompt reevaluation of empiric diagnoses when response to empiric therapy is unexpected.

Antimicrobial resistance is a global challenge requiring reliable surveillance data collection and use. Prior studies on resistance in Zambia depended on laboratory methods with limited standardization. Since 2015, the University Teaching Hospital (UTH) microbiology laboratory has used the Vitek 2 Compact (bioMerieux, Inc., Marcy-l’Étoile, France) for standardized identification and susceptibility testing. We conducted a cross-sectional study of 2019 bacterial isolates collected from July 2015 to April 2017 to identify bacterial causes of infections, their susceptibility to commonly used antibiotics at UTH, and develop hospital antibiograms with a multidisciplinary team using World Health Organization guidance. We found high levels of antibiotic resistance among Gram negative bacteria. Escherichia coli and Klebsiella pneumoniae were highly resistant to all antibiotics except amikacin and carbapenems. E. coli had susceptibilities of 42.4% to amoxicillin/clavulanic acid, 41.4% to ceftriaxone, 40.2% to ciprofloxacin, and 10.4% to trimethoprim/sulfamethoxazole (TMP/SMX). K. pneumoniae had susceptibilities of 20.7% to amoxicillin/clavulanic acid, 15.6% to ceftriaxone, 48.5% to ciprofloxacin, and 12.3% to TMP/SMX. The high resistance to 3rd generation cephalosporins indicates high rates of beta-lactamase production. This is information that clinicians need to inform clinical decision making and choice of empiric antibiotics and that UTH requires to inform antimicrobial stewardship such as improvements in antibiotic use.

Established antiretroviral therapy (ART) programs in sub-Saharan Africa have well-defined first-and second-line therapies but no standard third-line ART regimen. The impact of third-line ART on patients with multiclass-resistant HIV in resource-limited settings has not been well characterized. We conducted a retrospective review of patients on third-line ART at the University Teaching Hospital in Lusaka, Zambia. We assessed virologic and immunologic outcomes following 6 months of third-line therapy and found among those with a documented viral load, viral suppression (≤1000 copies/ml) at 24 weeks was 95% (63/66) with a mean increase in CD4 count of 116 cells/mm3 and viral suppression of 63% (63/100) by imputation of missing data. This study suggests that third-line therapy is clinically and virologically effective among patients with multiclass-resistance in a resource-limited setting in sub-Saharan Africa.

ObjectiveTo identify the etiology of an outbreak of spastic paraparesis among women and children in the Western Province of Zambia suspected to be konzo.MethodsWe conducted an outbreak investigation of individuals from Mongu District, Western Province, Zambia, who previously developed lower extremity weakness. Cases were classified with the World Health Organization definition of konzo. Active case finding was conducted through door-to-door evaluation in affected villages and sensitization at local health clinics. Demographic, medical, and dietary history was used to identify common exposures in all cases. Urine and blood specimens were taken to evaluate for konzo and alternative etiologies.ResultsWe identified 32 cases of konzo exclusively affecting children 6 to 14 years of age and predominantly females >14 years of age. Fourteen of 15 (93%) cases ≥15 years of age were female, 11 (73%) of whom were breastfeeding at the time of symptom onset. Cassava was the most commonly consumed food (median [range] 14 [4–21] times per week), while protein-rich foods were consumed 136 μmol/L, the 95th percentile of the US population in 2013 to 2014.ConclusionThis investigation revealed the first documented cases of konzo in Zambia, occurring in poor communities with diets high in cassava and low in protein, consistent with previous descriptions from neighboring countries.

Background In Zambia, third-line regimens consist of a switch to darunavir/ritonavir (DRV/r) and/or raltegravir (RAL) and/or etravirine (ETV), and as of 2017, dolutegravir (DTG), from a failing second-line therapy.5 We assessed virologic suppression (HIV viral load (VL) ≤1000 copies/ml per Zambian national guidelines), immunological response, and patterns of HIV drug resistance mutation among patients on third-line ART at the University Teaching Hospital (UTH) in Lusaka, Zambia. Methods A retrospective evaluation of adults ≥18 years old on third-line ART regimens at UTH between January 2012 to June 30, 2020 was conducted. Patients were referred for second-line virologic failure defined as HIV RNA VL > 1000 copies/mL on two consecutive measurements after 6 months on second-line ART.5 We assessed virologic suppression VL ≤1000 copies/ml, CD4, mutations, and third-line regimens of this cohort. Patients were excluded if they were on third-line ART < 6 months or received RAL and/or ETV and/or DTG before starting third-line ART. Results A total of 539 patients were included; 231 males (42.9%) and 308 (57.1%) females. The mean age of third-line initiation was 29.8 years; mean time from ART initiation to third-line initiation was 9.9 years. Out of 25 combination 349 (64.7%) received DTG, 272 (50.5%) DRV/r, 85(15.8%) ETR, and 49 (9.1%) RAL. There were 215 (39.9%) genotypes; common mutations were to zidovudine (80%), non-nucleoside reverse transcriptase inhibitors (NNRTIs) (78%), and protease inhibitors (PIs) (41%). Patients with at least one viral load and CD4 upon third-line initiation was 296 (54.9%) and 350 (64.9%), respectively. Among patients with sufficient data (21%, n=115), VL suppression increased from 44 (38%) patients at baseline to 53 (46%) at next available follow-up; with mean baseline VL and follow-up VL of log10 3.60 and 3.33, respectively. The immunologic response revealed 49 (56.3%) had CD4 increase with mean increase of 61.1 cells/mm3. (See Table 1.) Conclusion We found moderate improvements in VL suppression and immunologic response. Nearly all third-line patients had genotypic resistance to first-line NNRTI and nearly half to second-line PI regimens. Quality improvement measures are needed to improve viral load timing following ART changes to better assess regimen efficacy. Disclosures All Authors: No reported disclosures

Patient’s gender may impact pharmacokinetics and play a role in viral suppression. Existing literature has focused on treatment-naïve patients and produced inconclusive results, often implicating differences in adherence as the driver of gender-based outcome differences. The present analysis assessed whether viral suppression on third-line HIV treatment among a closely followed population differs by gender. A retrospective cohort study of patients on third-line HIV treatment was initiated at the HIV Advanced Treatment Centre in Lusaka, Zambia between January 2012 and December 2015. The association between gender and viral suppression was assessed using log binomial regression adjusted for core drug, number of drug mutations, and baseline viral load. Of the 80 included patients (56% female; median age: 40 years), 50 (62%) were virally suppressed at six months. After adjustment, females were less likely to be virologically suppressed at six months on third-line treatment compared to male HIV patients (relative risk 0.82, 95% confidence interval: 0.56, 1.20). Our data suggest that women were less likely to be suppressed following six months of third-line therapy compared to men; however, the difference was not statistically significant. Larger studies are needed to determine whether women are at increased risk of viral failure on third-line therapy compared to men.

Antimicrobial resistance is a growing global health concern. Antimicrobial stewardship (AMS) curbs resistance rates by encouraging rational antimicrobial use. However, data on antimicrobial stewardship in developing countries is scarce. The objective of this study was to characterize antimicrobial use at the University Teaching Hospital (UTH) in Lusaka, Zambia as a guiding step in the development of an AMS program. This was a cross-sectional, observational study evaluating antimicrobial appropriateness and consumption in non-critically ill adult medicine patients admitted to UTH. Appropriateness was defined as a composite measure based upon daily chart review. Sixty percent (88/146) of all adult patients admitted to the general wards had at least one antimicrobial ordered and were included in this study. The most commonly treated infectious diseases were tuberculosis, pneumonia, and septicemia. Treatment of drug sensitive tuberculosis is standardized in a four-drug combination pill of rifampicin, isoniazid, pyrazinamide and ethambutol, therefore appropriateness of therapy was not further evaluated. The most common antimicrobials ordered were cefotaxime (n = 45), ceftriaxone (n = 28), and metronidazole (n = 14). Overall, 67% of antimicrobial orders were inappropriately prescribed to some extent, largely driven by incorrect dose or frequency in patients with renal dysfunction. Antimicrobial prescribing among hospitalized patients at UTH is common and there is room for optimization of a majority of antimicrobial orders. Availability of certain antimicrobials must be taken into consideration during AMS program development.

Suicidal ideation has long been associated with HIV infected populations worldwide. It has been found that HIV does not only attack the immune system of an individual but also the nervous system leading to psychological dysfunction of an individual. Objective: To establish the prevalence of suicidal ideation among people living with HIV and AIDS. Method: A cross sectional quantitative design was adopted. Systematic random sampling method was used to select the sample. The total sample comprised of 280 participants. A social demographic questionnaire and Suicidal Risk Screening Scale (SRSS) were used to collect data. Results: The study findings from the SRSS test revealed that (n=193, 69%) of the participants had lower suicide risk while (n=87, 31%) fell into the higher suicide risk category. The study therefore showed that the prevalence of suicidal ideation was 31%. Conclusion- Suicidal ideation was prevalent among people living with HIV and Aids.

Background. Diabetes mellitus (DM) is known to be associated with active tuberculosis (TB). Zambia is a low-income sub-Saharan African country with a high TB burden and increasing numbers of newly diagnosed DM patients. Materials and Methods. This was an observational study conducted at the University Teaching Hospital in Lusaka, Zambia, from October 2014 to February 2016. Adult patients with active TB were screened for DM. Results. A total of 127 individuals were enrolled in the study. Six patients (5%) were found to have diabetes. Of these, three had a prior diagnosis of diabetes and were on medication while three were newly diagnosed. Low education level was significantly associated with DM (p=0.001; 95% CI 0.001–0.148). Conclusion. The prevalence of DM among individuals with smear positive TB in our study population was similar to that of the general population in Zambia.

Background Antibiotic resistance is a worldwide problem. Prior studies on patterns of resistance in Zambia depended on laboratory methods that lacked standardization. UTH is a 1,655-bed quaternary care hospital and the primary teaching hospital of Zambia. Since 2015, the microbiology laboratory has used Vitek 2 Compact (bioMerieux, Inc., France) for standardized detection of resistance. Methods We conducted a retrospective cross-sectional study of data collected on bacterial isolates analyzed from July 2015 to April 2017. We entered the data into WHONET 5.6 and aggregated it to develop hospital antibiograms. Due to high levels of resistance, we defined susceptible, intermediate, and resistant as >70%, 40–70%, and

Background To mitigate the HIV pandemic and increasing outbreaks of infectious diseases, sub-Saharan African countries need increased healthcare worker capacity at all levels. We describe a successful collaboration between the Ministry of Health (MOH), the University Teaching Hospital (UTH), the University of Zambia (UNZA), and the University of Maryland Baltimore (UMB) to train Zambian physicians in advanced HIV medicine and infectious diseases. Methods Recognizing the need for advanced HIV clinical care expertise in Zambia, UNZA, UTH and UMB partnered in 2008 to create a 1-year Postgraduate Diploma in HIV Medicine. The consortium extended this to an 18-month Master of Science in HIV Medicine to better align with existing professional advancement schema. In 2012, UNZA and UMB started a 4-year Master of Medicine in infectious diseases (MMedID), which was then expanded to a 5-year training program combining internal medicine and infectious disease (MMed IM/ID) in order to produce a cadre with wider expertise in internal medicine and infectious diseases. Instruction consists of bedside teaching, didactic lectures, case conferences, and journal clubs. The bulk of teaching came from UMB clinical faculty with expertise in HIV and ID; faculty are either based in Zambia or visit from the United States. Results The MSc HIV program trained 27 physicians; of these, 24 (89%) are in health leadership positions in Zambia, with 17 (63%) directly involved in clinical care (mostly in the public sector), while 7 (15%) work for international implementing partners in Zambia. 1 physician emigrated to another African country, another one died and the third is in clinical nonleadership position in Zambia. The MMed ID program has enrolled 14 physicians. The first two graduates of the program completed the program in 2017 and took health leadership roles within the MOH as well as teaching positions at UNZA. Conclusion Educational collaborations embedded within local institutions and structures can provide advanced healthcare expertise within resource-limited settings. The UNZA/UMB MMed IM/ID collaboration is a model example of a successful university partnership that has resulted in retaining health leadership and clinical care expertise in Zambia. Disclosures L. Hachaambwa, Centers for Disease Control and Prevention (CDC): Cooperative Agreement to Institution, Financial support for the work described in this abstract was made possible by a cooperative agreement award from the Centers for Disease Control and Prevention (CDC) to the University of Zambia and to the University of Maryland School of Medicine.

Zambia and other sub-Saharan nations suffer from a critical shortage of trained health-care professionals to combat the human immunodeficiency virus/acquired immunodeficiency syndrome crisis. The University of Maryland and the Zambian Ministry of Health have partnered over the past decade to develop health-care capacity among physicians, nurses, and community health workers. We describe novel interventions to train health-care workers at all levels and argue that our collaboration represents a successful model for such partnerships between western medical institutions and African governmental health agencies.

Outbreaks of plague have been recognized in Zambia since 1917 (1). On April 10, 2015, Zambia's Ministry of Health was notified by the Eastern Provincial Medical Office of possible bubonic plague cases in Nyimba District. Eleven patients with acute fever and cervical lymphadenopathy had been evaluated at two rural health centers during March 28-April 9, 2015; three patients died. To confirm the outbreak and develop control measures, the Zambia Ministry of Health's Field Epidemiology Training Program (ZFETP) conducted epidemiologic and laboratory investigations in partnership with the University of Zambia's schools of Medicine and Veterinary Medicine and the provincial and district medical offices. Twenty-one patients with clinically compatible plague were identified, with symptom onset during March 26-May 5, 2015. The median age was 8 years, and all patients were from the same village. Blood specimens or lymph node aspirates from six (29%) patients tested positive for Yersinia pestis by polymerase chain reaction (PCR). There is an urgent need to improve early identification and treatment of plague cases. PCR is a potential complementary tool for identifying plague, especially in areas with limited microbiologic capacity. Twelve (57%) patients, including all six with PCR-positive plague and all three who died, also tested positive for malaria by rapid diagnostic test (RDT). Plague patients coinfected with malaria might be misdiagnosed as solely having malaria, and appropriate antibacterial treatment to combat plague might not be given, increasing risk for mortality. Because patients with malaria might be coinfected with other pathogens, broad spectrum antibiotic treatment to cover other pathogens is recommended for all children with severe malaria, until a bacterial infection is excluded.

In 1891, Winter1 described the first 4 cases of tuberculous meningitis (TBM), in which “paracenteses of the theca vertebralis was performed to relieve cerebrospinal fluid (CSF) fluid pressure.” Since this original description of the lumbar puncture (LP) procedure, neurologists worldwide have relied on LPs for both diagnostic and therapeutic purposes. In resource-limited settings, LPs are often the only neurologic test available to aid the clinician in neurologic diagnosis. In sub-Saharan Africa, a large number of patients present to hospitals with acute neurologic symptoms, including those who are HIV-infected and have opportunistic infections such as cryptococcal meningitis and TBM. In these clinical scenarios, LPs are an essential point-of-care diagnostic and therapeutic procedure.2 The benefits of the LP as a diagnostic tool are well-known, but it is important to emphasize that therapeutic LPs are a low-cost measure to monitor and treat intracranial pressure (ICP) due to nonobstructive hydrocephalus in regions of the world where more sophisticated testing and treatment are unavailable due to limitations of medical equipment, medication supplies, and clinical personnel, including specialized neurologists and neurosurgeons.

Loop-mediated isothermal amplification (LAMP) is a rapid and sensitive tool used for the diagnosis of a variety of infectious diseases. One of the advantages of this method over the polymerase chain reaction is that DNA amplification occurs at a constant temperature, usually between 60–65°C; therefore, expensive devices are unnecessary for this step. However, LAMP still requires complicated sample preparation steps and a well-equipped laboratory to produce reliable and reproducible results, which limits its use in resource-poor laboratories in most developing countries. In this study, we made several substantial modifications to the technique to carry out on-site diagnosis of Human African Trypanosomiasis (HAT) in remote areas using LAMP. The first essential improvement was that LAMP reagents were dried and stabilized in a single tube by incorporating trehalose as a cryoprotectant to prolong shelf life at ambient temperature. The second technical improvement was achieved by simplifying the sample preparation step so that DNA or RNA could be amplified directly from detergent-lysed blood samples. With these modifications, diagnosis of HAT in local clinics or villages in endemic areas becomes a reality, which could greatly impact on the application of diagnosis not only for HAT but also for other tropical diseases., Author Summary Human African trypanosomiasis (HAT) is an endemic protozoan disease affecting many African countries, predominantly in rural areas where the tsetse fly vector is present. HAT diagnosis currently relies on conventional microscopy techniques, which provide relatively low sensitivity and are often unable to distinguish between the two different HAT-causing subspecies, T. b. rhodesiense and T. b. gambiense. A delay in HAT diagnosis can result in disease progression from an early stage (hemolymphatic) to a late stage (meningoencephalitic); therefore, a rapid and sensitive diagnostic test is crucial to its successful treatment. In this study, we developed a simple and highly sensitive molecular technique for HAT diagnosis. Loop-mediated isothermal amplification (LAMP) is a method that rapidly amplifies DNA with high sensitivity under isothermal conditions. We optimized and modified the technique by stabilizing the reagents and simplifying the sample preparation for the diagnosis of HAT. The whole protocol is so simple that local staff can perform it without the need for costly equipment and expertise.

We evaluated the association of the number of late antiretroviral therapy (ART) refills with patient outcomes in a large public-sector human immunodeficiency virus treatment program in Lusaka, Zambia. Using pharmacy data routinely collected during 2004–2010, we calculated the number of late refills during the initial year of ART. We used multivariable Cox proportional hazard regression to examine the association between the number of late refills and death or program failure (i.e., death, loss to follow-up, or program withdrawal) >12 months after ART initiation, with and without stratification by the medication possession ratio (MPR) during the initial year of ART. Of 53,015 adults who received ART for ≥12 months (median follow-up duration, 86.1 months; interquartile range, 53.2–128.2 months), 26,847 (50.6%) had 0 late refills, 16,762 (31.6%) had 1, 6,505 (12.3%) had 2, and 2,901 (5.5%) had ≥3. Kaplan–Meier analysis revealed that ≥3 late refills was associated with a greater mortality risk than 1 and 2 late refills (p

Human African Trypanosomiasis (HAT) is a neglected tropical disease [1] caused by Trypanosoma brucei rhodesiense (eastern and southern Africa) or Trypanosoma brucei gambiense (western and central Africa) and is transmitted through the bite of an infected tsetse fly (Glossina species) [2,3]. The tsetse flies acquire their infections from humans or animals harbouring the human pathogenic parasites [2]. The disease is endemic in tropical and subtropical Africa [4], where it affects low-income populations [3]. Whereas T. b. rhodesiense causes acute HAT [5,6], T. b. gambiense causes a more chronic form of the disease [5]. Although HAT has been re-emerging in most of the old foci within sub-Saharan Africa since the 1970s, with T. b. gambiense accounting for more than 98% of the reported cases [7], the latest World Health Organization (WHO) reports suggest that the number of new cases have been reduced [1]. In the year 2009, after continued control efforts, the number of cases of HAT reported dropped below 10,000 (9,878) for the first time in 50 years. This decline in number of cases has continued with 6,314 new cases reported in 2012 [1]. However, the estimated number of actual cases is about 20,000 and the estimated population at risk is 65 million people. Despite such progress, only a fraction of the population at risk for contracting HAT in sub-Saharan Africa is under surveillance and relatively few cases are diagnosed annually [8,9]. In particular, there is considerable underdiagnosis of rhodesiense HAT in sub-Saharan Africa, including Zambia, mainly due to lack of HAT surveillance and control programmes [10,11]. Historically, epidemics of rhodesiense HAT were reported from the northern and southern regions of the Luangwa Valley and the Kafue River Valley in the 1960s and early 1970s [12]. According to WHO [1], Zambia currently reports

Background Loop-mediated isothermal amplification (LAMP) is a novel strategy which amplifies DNA with high sensitivity and rapidity under isothermal conditions. In the present study, the performance of the repetitive insertion mobile element (RIME)-LAMP and human serum resistance-associated gene (SRA)-LAMP assays were evaluated using clinical specimens obtained from four male patients from Luangwa and Zambezi valleys in Zambia and Zimbabwe, respectively. Findings The cases reported in this preliminary communication were all first diagnosed by microscopy, through passive surveillance, and confirmed by both RIME-LAMP and SRA-LAMP. A good correlation between microscopy and LAMP was observed and contributed to staging and successful treatment of patient. RIME-LAMP and SRA-LAMP complimented each other well in all the cases. Conclusions Both RIME-LAMP and SRA-LAMP were able to detect Trypanosoma brucei rhodesiense DNA in patient blood and CSF and hence confirmed HAT in the parasitaemic patients. Our study indicates that the LAMP technique is a potential tool for HAT diagnosis, staging and may be useful for making therapeutic decisions. However, no statistically significant conclusion may be drawn due to the limited sample size used in the present study. It is thus imperative to conduct a detailed study to further evaluate the potential of LAMP as a bedside diagnostic test for HAT.