A Patient-Centered, Combination Intervention to Support Adherence to HIV Pre-exposure Prophylaxis During Pregnancy and Breastfeeding: A Randomized Pilot Study in Malawi.

BACKGROUND: Daily oral pre-exposure prophylaxis (PrEP) can reduce HIV incidence in pregnant and breastfeeding women, but adherence is essential. METHODS: We conducted a pilot randomized trial to evaluate an intervention package to enhance antenatal and postnatal PrEP use in Lilongwe, Malawi. The intervention was based on patient-centered counseling adapted from previous PrEP studies, with the option of a participant-selected adherence supporter. Participants were locally eligible for PrEP and randomized 1:1 to intervention or standard counseling (ie, control) and followed for 6 months. Participants received the intervention package or standard counseling at enrollment, 1, 3, and 6 months. Adherence was measured through plasma and intracellular tenofovir concentrations and scored using a published algorithm. Our primary outcome was retention in care with concentrations consistent with 4-7 doses/week. RESULTS: From June to November 2020, we enrolled 200 pregnant women with the median gestational age of 26 (interquartile range: 19-33) weeks. Study retention was high at 3 months (89.5%) and 6 months (85.5%). By contrast, across the 2 time points, 32.8% of participants retained in the study had adherence scores consistent with 2-5 doses/week while 10.3% had scores consistent with daily dosing. For the composite primary end point, no substantial differences were observed between the intervention and control groups at 3 months (28.3% vs. 29.0%, probability difference: -0.7%, 95% confidence interval: -13.3%, 11.8%) or at 6 months (22.0% vs. 26.3%, probability difference: -4.3%, 95% confidence interval: -16.1%, 7.6%). CONCLUSIONS: In this randomized trial of PrEP adherence support, retention was high, but less than one-third of participants had pharmacologically confirmed adherence of ≥4 doses/week. Future research should focus on antenatal and postnatal HIV prevention needs and their alignment across the PrEP continuum, including uptake, persistence, and adherence.

"PrEP protects us": Behavioural, normative, and control beliefs influencing pre-exposure prophylaxis uptake among pregnant and breastfeeding women in Zambia.

Background: Although pre-exposure prophylaxis (PrEP) is recommended for pregnant and breastfeeding women at elevated HIV risk, uptake has been low in Zambia. Methods: In in-depth interviews, we explored beliefs about PrEP among 24 HIV-negative pregnant and breastfeeding Zambian women. Thematic analysis was used to identify behavioural, normative and control beliefs likely to influence PrEP uptake. Results: Most women viewed PrEP as a good method of protecting themselves and their babies from HIV infection. Partners were cited as key referents in decision making about PrEP use. Many women felt that PrEP use was not entirely in their control. Most reported that they would not use PrEP if their partners did not approve. Health care providers with negative attitudes, long distance to clinics, and extended waiting times were cited as barriers to PrEP uptake. Conclusion: HIV-negative pregnant and breastfeeding women had a positive attitude towards PrEP but barriers to uptake are multifaceted.

Salient beliefs and intention to use pre-exposure prophylaxis among pregnant and breastfeeding women in Zambia: Application of the Theory of Planned Behaviour.

Primary HIV prevention is a priority for pregnant and breastfeeding women in sub-Saharan Africa; however, such services should be designed to optimise uptake and continuation. Between September and December 2021, we enrolled 389 women who were not living with HIV into a cross-sectional study from antenatal/postnatal settings at Chipata Level 1 Hospital. We used the Theory of Planned Behaviour to study the relationship between salient beliefs and intention to use pre-exposure prophylaxis (PrEP) among eligible pregnant and breastfeeding women. On a seven-point scale, participants had positive attitudes towards PrEP (mean = 6.65, SD = 0.71), anticipated approval of PrEP use from significant others (mean = 6.09, SD = 1.51), felt confident that they could take PrEP if they desired (mean = 6.52, SD = 1.09) and had favourable intentions to use PrEP (mean = 6.01, SD = 1.36). Attitude, subjective norms, and perceived behavioural control significantly predicted intention to use PrEP respectively (ß = 0.24; ß = 0.55; ß = 0.22, all p < 0.01). Social cognitive interventions are needed to promote social norms supportive of PrEP use during pregnancy and breastfeeding.

Unmet need for family planning among married women in Zambia: lessons from the 2018 Demographic and Health Survey.

BACKGROUND: Unmet need for family planning among married women is still a public health concern in sub-Saharan Africa. In Zambia, one in every five married women had an unmet need for family planning in 2018. Unmet need for family planning has the potential to increase the number of unintended pregnancies and unsafe abortions. These factors can increase the proportion of women of child bearing age, who are at high risk of birth complications. This study was therefore conducted to understand the determinants of unmet need for family planning among married women in Zambia based on recent cross-sectional data. METHODS: The study analysed data extracted from the Zambia Demographic and Health Survey, which was a representative cross-sectional survey conducted in 2018. The analysis was done on a sample of 7598 currently married women aged 15-49 years. Multivariate logistic regression was used to examine determinants of unmet need for family planning in Zambia. The analyses was weighted to account for complex sample design. RESULTS: Prevalence of unmet need for family planning is still high in Zambia at 20%. Women in the age groups 25-34 and 35-49 were less likely to have total unmet need for family planning (AOR = 0.61; 95% CI 0.47, 0.78) and (AOR = 0.63; 95% CI 0.45, 0.86) respectively, compared with those aged 15-24 years. Age of a woman, parity, household wealth and exposure to media-based family planning messages were found to be significantly associated with unmet need for family planning among married women. CONCLUSION: There were significant differences in unmet need for family planning based on a woman's age, number of children ever born, wealth level, and exposure to media-based family planning messaging. Improving access to family planning messages and addressing underlying structural factors that improve the wealth status, particularly among young women, may help to reduce unmet need for family planning in Zambia.

Predictors of alcohol consumption among adolescents and young adults in Lusaka, Zambia.

Background: Alcohol consumption among young people in schools and communities presents a major problem of public health concern. We determined the predictors of alcohol consumption among adolescents and young adults in Lusaka, Zambia. Methods: A cross-sectional study design was adopted. A total of 196 participants took part in the quantitative study. For the qualitative part, there were 13 participants. The study used multistage and purposive sampling methods. A semi-structured questionnaire and in-depth interviews were used. Quantitative data were analysed using STATA version 14. Ordered logistic regression analysis was used to assess the actual predictors, with confidence interval set at 95% and p-value at 0.05. Qualitative data were analysed thematically. Results: The older age category (20-24) had a greater prevalence of alcohol consumption (63.3%) than the younger age category (36.7%). Age, being employed, unconducive learning environment, limited recreation and sports activities, and adult alcohol drinking culture decreased the odds of consuming alcohol. Limited parental care support increased the odds of alcohol consumption [AOR= 4.21; 95% CI: 1.32-13.45, p=0.015]. Futile alcohol regulatory measures were cited to be contributing to alcohol consumption. Conclusion: Alcohol consumption was highly prevalent among young adults aged 20-24 years. There is need for continuous sensitization on substance abuse and its adverse effects in schools and communities at large. The strengthening, reviewing and amendment of the alcohol regulatory measures and policies should be considered.

Vaginal douching in Zambia: a risk or benefit to women in the fight against cervical cancer: a retrospective cohort study.

BACKGROUND: Cervical cancer was the most commonly diagnosed cancer and the leading cause of cancer related deaths in 2013 among women in Zambia. We determined factors associated with vaginal douching with any solution other than water and examined its role as a risk factor for abnormal cervical lesions among Zambian women. METHODS: We conducted a retrospective cohort study using data from the Cervical Cancer Prevention Program in Zambia among 11,853 women (15 years or older) who had screened for cervical cancer from 6 provinces of Zambia. Stata version 15 was used to analyze the data. Investigator led stepwise logistic regression was used to estimate adjusted odds ratios and 95% confidence intervals for various characteristics, with vaginal douching with any solution as primary outcome and abnormal cervical lesions as secondary outcome. RESULTS: Douching with any solution other than water was practiced by 8.1% (n = 960) of the study participants. Older women (35-44 and 45 years or older) vs young women (15-24 years old) were less likely to douche with a solution (AOR 0.74; 95% CI: 0.57-0.97, p = 0.027 and AOR 0.65; 95% CI: 0.49-0.87, P = 0.004), respectively, and so were women in informal employment compared to housewives (AOR 0.72; 95% CI: 0.58-0.89, p = 0.002). Odds of douching were higher among women with secondary vs. no formal education (AOR 1.64; 95% CI: 1.15-2.35, P = 0.007), and among women who used condoms sometimes compared to those who never with their regular sexual partners (AOR 1.19; 95% CI: 1.01-1.40, PP = 0.037). About 12.2% of study participants had abnormal cervical lesions. The use of either vinegar, ginger, lemon, salt or sugar solution was associated with increased risk of abnormal cervical lesions (AOR 7.37; 95% CI: 1.43-38.00, p = 0.017) compared to using water. CONCLUSION: We find an association between douching with a solution and a woman's age, educational attainment, occupation and condom use. Vaginal douching with either vinegar, ginger, lemon, salt or sugar solution was associated with increased risk for abnormal cervical lesions. We recommend further research on ever vs never douching and the risk for abnormal cervical lesions.

Demand Side Factors Associated With Quality Antenatal Care Services: A Case Study of Lusaka District, Zambia.

Background: The quality of antenatal care (ANC) a woman receives during pregnancy is crucial to both the child and the mother's life. It has been established that providing high-quality ANC can save lives and has a positive impact on postnatal health care services. However, the quality of ANC in Zambia requires attention as maternal and neonatal mortality rates are still unacceptably high with Lusaka district not being left out of the problem. Methods: Using a cross-sectional study design, the main aim of this study was to determine the demand side factors associated with high-quality antenatal care among pregnant women in Lusaka. It also estimated the proportion of women who received high-quality ANC during their last antenatal visit. Multifactorial logistic regression model was fitted in STATA version 13 to predict the demographic, socio and economic factors that influence the quality of ANC. Results: It was established that only 47.1% of pregnant women received high-quality ANC while 52.9% received low quality. Six key ANC interventions were considered, among which urine (36.7%) and blood (46.8%) testing were the least received basic components of ANC. After adjusting for the effect of other factors, women with secondary education had higher odds of receiving high-quality ANC than women with primary level of education (OR = 1.98; 95% CI: 1.24-3.14). Women staying with their husband/partners had lesser odds of receiving high quality ANC compared to those that were not staying with their partners (OR = 0.47; 95% CI: 0.28-0.79). Conclusion: The quality of antenatal care received by pregnant women in Lusaka is low. Continued efforts to improve the delivery of basic ANC services such as blood and urine testing is required to improve the quality of healthcare services provided by medical personnel at all levels.

Higher educational attainment associated with reduced likelihood of abnormal cervical lesions among Zambian women - a cross sectional study.

BACKGROUND: The high burden of cervical cancer in Zambia prompted the Ministry of Health and partners to develop the cervical cancer prevention program in Zambia (CCPPZ) in 2006. Despite this intervention more women continue to die from the disease and there is little understanding of factors that may be linked with abnormal cervical lesions in the general population. We therefore examined if educational attainment is associated with abnormal cervical lesions among Zambian women aged 15 to 49 years. METHODS: This study used data from the cervical cancer prevention program in Zambia, where a total of 14,294 women aged 15 to 49 years were screened for cervical cancer at nine health facilities between October 2013 and September 2014. The data represents women from six provinces of Zambia, namely Southern, Central, Copperbelt, Luapula, North-western and Eastern provinces. Step-wise logistic regression analysis using the Statistical Package for the Social Sciences (SPSS) version 21 was used to estimate adjusted odds ratios (AOR) and 95% confidence intervals (CIs) for educational attainment with presence of abnormal cervical lesions as outcome. Multiple imputation was further used to obtain the imputed stabilized estimates for educational attainment. RESULTS: The prevalence of abnormal cervical lesions, using the Visual Inspection with Acetic-acid (VIA) test was 10.7% (n = 1523). Educational attainment was inversely associated with abnormal cervical lesions (AOR = 0.75; 95% CI:0.70-0.81, AOR = 0.74; 95% CI:0.68-0.81 and AOR = 0.46; 95% CI:0.41-0.51) among women with primary, secondary and tertiary education, respectively, compared to those with no formal education. CONCLUSION: We find reduced likelihood of abnormal cervical lesions in educated women, suggesting a differential imbalance with women who have no formal education. These findings may be a reflection of inequalities associated with access to cervical cancer screening, making the service inadequately accessible for lower educated groups. This might also indicate serious limitations in awareness efforts instituted in the formative phases of the program. These findings underline the prevailing need for urgent concerted efforts in repackaging cervical cancer awareness programs targeting women with low or no formal education in whom the risk may be even higher.