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Abstract 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.

OBJECTIVE: Despite the huge financial investment in the free maternal healthcare policy (FMHCP) by the Governments of Ghana and Burkina Faso, no study has quantified the impact of FMHCP on the relative reduction in neonatal and infant mortality rates using a more rigorous matching procedure with the difference in differences (DID) analysis. This study used several rounds of publicly available population-based complex survey data to determine the impact of FMHCP on neonatal and infant mortality rates in these two countries. DESIGN: A quasi-experimental study to evaluate the FMHCP implemented in Burkina Faso and Ghana between 2007 and 2014. SETTING: Demographic and health surveys and maternal health surveys conducted between 2000 and 2014 in Ghana, Burkina Faso, Nigeria and Zambia. PARTICIPANTS: Children born 5 years preceding the survey in Ghana, Burkina Faso, Nigeria and Zambia. PRIMARY OUTCOME MEASURES: Neonatal and infant mortality rates. RESULTS: The Propensity Score Kernel Matching coupled with DID analysis with modified Poisson showed that the FMHCP was associated with a 45% reduction in the risk of neonatal mortality rate in Ghana and Burkina Faso compared with Nigeria and Zambia (adjusted relative risk (aRR)=0.55, 95% CI: 0.40 to 0.76, p<0.001). In addition, infant mortality rate has reduced significantly in both Ghana and Burkina Faso by approximately 54% after full implementation of FMHCP compared with Nigeria and Zambia (aRR=0.46, 95% CI: 0.36 to 0.59, p<0.001). CONCLUSION: The FMHCP had a significant impact and still remains relevant in achieving Sustainable Development Goal 3 and could provide lessons for other sub-Saharan countries in the design and implementation of a similar policy.

BackgroundAccording to the Global Strategy to Accelerate the Elimination of Cervical Cancer launched by the World Health Organizations (WHO), 70% of all women should undergo cervical cancer (CC) screening by 2030. While integrated HIV care and CC screening services exist, lack of unified data and patient management systems hinder reaching the set WHO goals. We used record linkage methods to assess the number of women receiving HIV care and visual inspection with acetic acid (VIA) based CC screening at Kanyama First Level Hospital (FLH) in Lusaka, Zambia.
MethodsWe retrieved HIV patient records from SmartCare, Zambia's National Electronic Health Records system, and the CC screening database for the years 2004 to 2018, and 2010 to 2018, respectively. We restricted this pilot study to women attending Kanyama FLH for HIV services, and its surrounding clinics for CC screening. We used the following linkage variables: first name, last name, facility, and year of birth. We used a machine learning based approach with Random Forest classifiers to identify records from the HIV and CC screening services belonging to the same person. We created synthetic patient record datasets to train and test the linkages. After the linkage, we anonymized the data and retrieved screening status from the CC screening database. We assessed the percentage of women in HIV care undergoing CC screening and the respective screening results. We calculated the time to CC screening with reference to the start of the HIV Antiretroviral Therapy treatment (ART).
ResultsWe retrieved a total of 32,970 records from SmartCare and 176,736 records from CC screening databases. With the linkage we determined that of all women that ever accessed HIV treatment services at Kanyama FLH between 2004 and 2018, 2,999 (9%) received CC screening. Of those that were screened, 30% received the CC service at Kanyama FLH, while the rest from 13 surrounding facilities. 61% of women accessed CC services before starting ART. Of the women screened for CC, 371 had a positive VIA result (12%), 2,395 (80%) a negative and 233 (8%) had a missing or indeterminate result. When we restricted the analysis to women, who were eligible for screening (aged 25 to 59 years), the screening coverage was 9.6%.
ConclusionOur study demonstrates the significance of record linkage efforts in determining CC screening coverage among women living with HIV. According to these findings, CC screening coverage among patients receiving ART services between 2004 and 2018 was at 9%, showing the depth of effort required to meet WHO targets at the time. The linkage output was primarily influenced by the scarcity of available linkage variables and data missingness, resulting in potentially overestimating or underestimating the CC coverage. This is typical of data systems in low- and middle-income countries; however, this study demonstrates that record linkage is useful in bridging these widespread data gaps.

Background: With the limited availability of quality emergency obstetric and newborn care (EmONC) in Ghana, and a lack of dialogue on the issue at district level, the Evidence for Action (E4A) program (2011-2015) initiated a pilot intervention using a social accountability approach in two regions of Ghana. Objective: Using scorecards to assess and improve maternal and newborn health services, the intervention study evaluated the effectiveness of engaging multiple, health and non-health sector stakeholders at district level to improve the enabling environment for quality EmONC. Methods: The quantitative study component comprised two rounds of assessments in 37 health facilities. The qualitative component is based on an independent prospective policy study. Results: Results show a marked growth in a culture of accountability, with heightened levels of community participation, transparency, and improved clarity of lines of accountability among decision-makers. The breadth and type of quality of care improvements were dependent on the strength of community and government engagement in the process, especially in regard to more complex systemic changes. Conclusion: Engaging a broad network of stakeholders to support MNH services has great potential if implemented in ways that are context-appropriate and that build around full collaboration with government and civil society stakeholders.

AbstractIntroductionChronic viral replication has been linked to an increased risk of cardiovascular and metabolic diseases in people living with HIV (PLWH), but few studies have evaluated this association in Southern Africa. We explored the determinants of metabolic syndrome (MetS) among treatment‐naïve adults living with and without HIV in Southern Africa.MethodsTreatment‐naïve PLWH and people living without HIV (PLWOH) ≥30 years were consecutively enrolled from primary care clinics in Zambia and Zimbabwe. PLWOH were seronegative partners or persons presenting for HIV testing. We defined MetS as the presence of central obesity plus any two of the following: raised blood pressure, impaired fasting glucose, reduced high‐density lipoprotein cholesterol and raised triglycerides, as defined by the International Diabetes Federation. We used logistic regression to determine factors associated with MetS.ResultsBetween August 2019 and March 2022, we screened 1285 adults and enrolled 420 (47%) PLWH and 481 (53%) PLWOH. The median age was similar between PLWH and PLWOH (40 vs. 38 years, p < 0.24). In PLWH, the median CD4+ count was 228 cells/mm3 (IQR 108–412) and the viral load was 24,114 copies/ml (IQR 277–214,271). Central obesity was present in 365/523 (70%) females and 57/378 males (15%). MetS was diagnosed in 172/901 (19%, 95% confidence interval [CI] 17–22%), and prevalence was higher among females than males (27% vs. 9%). In multivariable analyses, HIV status was not associated with MetS (adjusted odds ratio [aOR] 1.05, 95% CI 0.74–1.51). Risk factors for MetS included age older than 50 years (aOR 2.31, 95% CI 1.49–3.59), female sex (aOR 3.47, 95% CI 2.15–5.60), highest income (aOR 2.19, 95% CI 1.39–3.44) and less than World Health Organization recommended weekly physical activity (aOR 3.35, 95% CI 1.41–7.96).ConclusionsWe report a high prevalence of MetS and central obesity among females in urban Zambia and Zimbabwe. Lifestyle factors and older age appear to be the strongest predictors of MetS in our population, with no evident difference in MetS prevalence between treatment‐naïve PLWH and PLWOH.

AbstractIntroductionThe World Health Organization (WHO) recommends a CD4 cell count before starting antiretroviral therapy (ART) to detect advanced HIV disease, and routine viral load (VL) testing following ART initiation to detect treatment failure. Donor support for CD4 testing has declined to prioritize access to VL monitoring. We examined trends in CD4 and VL testing among adults (≥15 years of age) starting ART in Southern Africa.MethodsWe analysed data from 14 HIV treatment programmes in Lesotho, Malawi, Mozambique, South Africa, Zambia and Zimbabwe in 2005 to 2018. We examined the frequency of CD4 and VL testing, the percentage of adults with CD4 or VL tests, and among those having a test, the percentage starting ART with advanced HIV disease (CD4 count <200 cells/mm3) or failing to suppress viral replication (>1000 HIV‐RNA copies/mL) after ART initiation. We used mixed effect logistic regression to assess time trends adjusted for age and sex.ResultsAmong 502,456 adults, the percentage with CD4 testing at ART initiation decreased from a high of 78.1% in 2008 to a low of 38.0% in 2017; the probability declined by 14% each year (odds ratio (OR) 0.86; 95% CI 0.86 to 0.86). Frequency of CD4 testing also declined. The percentage starting ART with advanced HIV disease declined from 83.3% in 2005 to 23.5% in 2018; each year the probability declined by 20% (OR 0.80; 95% CI 0.80 to 0.81). VL testing after starting ART varied; 61.0% of adults in South Africa and 10.7% in Malawi were tested, but fewer than 2% were tested in the other four countries. The probability of VL testing after ART start increased only modestly each year (OR 1.06; 95% CI 1.05 to 1.06). The percentage with unsuppressed VL was 8.6%. There was no evidence of a decrease in unsuppressed VL over time (OR 1.00; 95% CI 0.99 to 1.01).ConclusionsCD4 cell counting declined over time, including testing at the start of ART, despite the fact that many patients still initiated ART with advanced HIV disease. Without CD4 testing and expanded VL testing many patients with advanced HIV disease and treatment failure may go undetected, threatening the effectiveness of ART in sub‐Saharan Africa.

AbstractINTRODUCTIONTo eliminate cervical cancer (CC), access to and quality of prevention and care services must be monitored, particularly for women living with HIV (WLHIV). We assessed implementation practices in HIV clinics across sub‐Saharan Africa (SSA) to identify gaps in the care cascade and used aggregated patient data to populate cascades for WLHIV attending HIV clinics.METHODSOur facility‐based survey was administered between November 2020 and July 2021 in 30 HIV clinics across SSA that participate in the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium. We performed a qualitative site‐level assessment of CC prevention and care services and analysed data from routine care of WLHIV in SSA.RESULTSHuman papillomavirus (HPV) vaccination was offered in 33% of sites. Referral for CC diagnosis (42%) and treatment (70%) was common, but not free at about 50% of sites. Most sites had electronic health information systems (90%), but data to inform indicators to monitor global targets for CC elimination in WLHIV were not routinely collected in these sites. Data were collected routinely in only 36% of sites that offered HPV vaccination, 33% of sites that offered cervical screening and 20% of sites that offered pre‐cancer and CC treatment.CONCLUSIONSThough CC prevention and care services have long been available in some HIV clinics across SSA, patient and programme monitoring need to be improved. Countries should consider leveraging their existing health information systems and use monitoring tools provided by the World Health Organization to improve CC prevention programmes and access, and to track their progress towards the goal of eliminating CC.