Spiritual and religious aspects influence mental health and viral load: a quantitative study among young people living with HIV in Zimbabwe.

INTRODUCTION: The role of religion and spirituality as social determinants of health has been widely discussed. Studies among people living with HIV describe positive and negative influences of religion and spirituality on health outcomes. With a HIV prevalence of 14.8% for females and 8.6% for males, and 22 000 AIDS-related deaths in 2020, HIV infection remains a life-threatening condition in Zimbabwe, especially in young people. The aim of this research was to measure the influence of religion and spirituality on the health outcomes of young people living with HIV in Zimbabwe. METHODS: A quantitative questionnaire with three different validated measures of religion and spirituality (Belief into Action Scale, Brief Religious Coping Index, Religious and Spiritual Struggles Scale), demographic, cultural, behavioural and health questions was administered to 804 young Zvandiri programme clients in rural, urban and peri-urban Zimbabwe between July and October 2021. Regression analysis established significant relations between the result of the three different measures and mental health and viral load results. RESULTS: Religious coping significantly reduced the probability of common mental disorder, while high religious activity increased the risk. The Religious and Spiritual Struggles Scale proved to be a reliable indicator of higher viral loads, risk for treatment failure and the probability of common mental disorder. CONCLUSIONS: All three measures of religion and spirituality related to health outcomes. More research is needed to generalise and further explore these findings. Because the Religious and Spiritual Struggles Scale was a strong indicator for both, higher viral loads and common mental disorder, we suggest that it should be used and validated in other sub-Saharan contexts. It could serve as a new diagnostic tool for the early detection and prevention of treatment failure as well as of common mental disorder.

Retracing loss of momentum for primary health care: can renewed political interest in the context of COVID-19 be a turning point?

The COVID-19 pandemic has revealed major weaknesses in primary health care (PHC), and how such weaknesses pose a catastrophic threat to humanity. As a result, strengthening PHC has re-emerged as a global health priority and will take centre stage at the 2023 United Nations High Level Meeting (UNHLM) on Universal Health Coverage (UHC). In this analysis, we examine why, despite its fundamental importance and incredible promise, the momentum for PHC has been lost over the years. The portrayal of PHC itself (policy image) and the dominance of global interests has undermined the attractiveness of intended PHC reforms, leading to legacy historical policy choices (critical junctures) that have become extremely difficult to dismantle, even when it is clear that such choices were a mistake. PHC has been a subject of several political declarations, but post-declarative action has been weak. The COVID-19 provides a momentous opportunity under which the image of PHC has been reconstructed in the context of health security, breaking away from the dominant social justice paradigms. However, we posit that effective PHC investments are those that are done under calm conditions, particularly through political choices that prioritise the needs of the poor who continue to face a crisis even in non-pandemic situations. In the aftermath of the 2023 UNHLM on UHC, country commitment should be evaluated based on the technical and financial resources allocated to PHC and tangible deliverables as opposed to the formulation of documents or convening of a gathering that simply (re) endorses the concept.

A validation of the religious and spiritual struggles scale among young people living with HIV in Zimbabwe: Mokken scale analysis and exploratory factor analysis.

Introduction: Religious/spiritual convictions and practices can influence health- and treatment-seeking behavior, but only few measures of religiousness or spirituality have been validated and used outside of the US. The Religious and Spiritual Struggles scale (RSS) measures internal and external conflict with religion and spirituality and has been validated mainly in different high-income contexts. The aim of this study was the validation of the RSS in the Zimbabwean context and among young people living with human immunodeficiency virus (YPLHIV) aged 14-24. Methods: Data collection with an Open Data Kit (ODK) questionnaire with 804 respondents took place in 2021. The validation was performed by confirmatory factor analysis (CFA), using statistical equation modeling (SEM), and Mokken scale analysis (MSA). After the low confirmability of the original scale sub-dimensions exploratory factor analysis (EFA) was applied. Results: The EFA resulted in four new sub-domains that were different from the original six domains in the RSS but culturally more relevant. The new sub-domains are significantly related to health. Discussion: The findings support the validity and relevance of the RSS and the new sub-domains in this context. As our study was limited to YPLHIV, further validation of the RSS among different population groups and contexts in the sub-Saharan region is encouraged.

Governing a pandemic: biopower and the COVID-19 response in Zimbabwe.

INTRODUCTION: The extraordinary explosion of state power towards the COVID-19 response has attracted scholarly and policy attention in relation to pandemic politics. This paper relies on Foucault's theoretical differentiation of the political management of epidemics to understand how governmental framing of COVID-19 reflects biopolitical powers and how power was mobilised to control the pandemic in Zimbabwe. METHODS: We conducted a scoping review of published literature, cabinet resolutions and statutory instruments related to COVID-19 in Zimbabwe. RESULTS: The COVID-19 response in Zimbabwe was shaped by four discursive frames: ignorance, denialism, securitisation and state sovereignty. A slew of COVID-19-related regulations and decrees were promulgated, including use of special presidential powers, typical of the leprosy model (sovereign power), a protracted and heavily policed lockdown was effected, typical of the plague model (disciplinary power) and throughout the pandemic, there was reference to statistical data to justify the response measures whilst vaccination emerged as a flagship strategy to control the pandemic, typical of the smallpox model (biopower). The securitisation frame had a large influence on the overall pandemic response, leading to an overly punitive application of disciplinary power and cases of infidelity to scientific evidence. On the other hand, a securitised, geopolitically oriented sovereignty model positively shaped a strong, generally well execucted, domestically financed vaccination (biopower) programme. CONCLUSIONS: The COVID-19 response in Zimbabwe was not just an exercise in biomedical science, rather it invoked wider governmentality aspects shaped by the country's own history, (geo) politics and various mechanisms of power. The study concludes that whilst epidemic securitisation by norm-setting institutions such as WHO is critical to stimulate international political action, the transnational diffusion of such charged frames needs to be viewed in relation to how policy makers filter the policy and political consequences of securitisation through the lenses of their ideological stances and its potential to hamper rather than bolster political action.

Beyond political will: unpacking the drivers of (non) health reforms in sub-Saharan Africa.

BACKGROUND: Lack of political will is frequently invoked as a rhetorical tool to explain the gap between commitment and action for health reforms in sub-Saharan Africa (SSA). However, the concept remains vague, ill defined and risks being used as a scapegoat to actually examine what shapes reforms in a given context, and what to do about it. This study sought to go beyond the rhetoric of political will to gain a deeper understanding of what drives health reforms in SSA. METHODS: We conducted a scoping review using Arksey and O'Malley (2005) to understand the drivers of health reforms in SSA. RESULTS: We reviewed 84 published papers that focused on the politics of health reforms in SSA covering the period 2002-2022. Out of these, more than half of the papers covered aspects related to health financing, HIV/AIDS and maternal health with a dominant focus on policy agenda setting and formulation. We found that health reforms in SSA are influenced by six; often interconnected drivers namely (1) the distribution of costs and benefits arising from policy reforms; (2) the form and expression of power among actors; (3) the desire to win or stay in government; (4) political ideologies; (5) elite interests and (6) policy diffusion. CONCLUSION: Political will is relevant but insufficient to drive health reform in SSA. A framework of differential reform politics that considers how the power and beliefs of policy elites is likely to shape policies within a given context can be useful in guiding future policy analysis.

Lessons learnt from implementing the Good Governance for Medicines Programme in Zimbabwe.

WHO launched the Good Governance for Medicines (GGM) programme in 2004 with the aim of fighting the problem of corruption in the pharmaceutical sector. Zimbabwe adopted the GGM programme in 2015 and developed its own implementation framework (GGM-IF) in 2017 based on the WHO global guidelines and recommendations. Zimbabwe's GGM-IF emerged from; (1) home-based expertise, (2) extensive local consultations and (3) effective incorporation into existing institutions. The GGM-IF committed to implementing a focused programme over a 5-year period from 2017 to 2022 with the expressed goal of improving transparency and accountability in the pharmaceutical sector as a key enabler to improve access to medicines. Midway through its projected lifespan, some notable achievements materialised attributed to key success drivers, including mutual collaboration with the Ministry of Health and Child Care's existing Global Fund supported Quality Assurance Programme. Key challenges faced include limited funding for the programme, a shifting policy environment driven by a political transition and reorientation of priorities in the wake of the COVID-19 pandemic. This manuscript articulates 3-year operationalisation of Zimbabwe's GGM-IF highlighting the success drivers, implementation challenges and lessons learnt.

Chemoradiation in Stage IIIB Cancer of the Uterine Cervix: A Review of the Zimbabwean Experience.

PURPOSE: Cervical cancer remains the leading cause of cancer morbidity and mortality among Zimbabwean women. Many patients present with stage IIIB disease. Although definitive concurrent chemoradiation (CCRT) is the standard of care, there is a paucity of data on the effect(s) of this intervention in resource-constrained and high HIV-prevalence settings. We investigated the differences in CCRT initiation practices, tolerability, and outcomes in this group. PATIENTS AND METHODS: We performed a retrospective analysis of data from hospital records for patients with stage IIIB disease who were treated over a 2-year period at Parirenyatwa Group of Hospitals. Outcome measures were documented treatment-related adverse events and early clinical tumor response. RESULTS: One hundred twenty-eight (37%) of 346 patients received CCRT, and 65 (51%) of 128 patients were infected with HIV. CCRT was prescribed mostly in patients with less extensive disease-not involving lower third vaginal walls, minimal pelvic sidewall involvement (P = .002), and higher CD4+ count (P = .02). Eighteen percent of recorded adverse events were high grade (≥ 3). One patient did not complete treatment, and 68.5% achieved complete clinical tumor response at 3 months post-CCRT. A higher proportion of complete clinical tumor response was noted in those patients who were young, HIV uninfected, had less extensive disease, CD4+ of 500 cells/mm3 or greater, received four or more cycles of chemotherapy, received brachytherapy, and had no treatment breaks. CONCLUSION: The study revealed that the use of CCRT to treat stage IIIB cervical cancer is low in Zimbabwe. Although several factors contribute, low CCRT uptake is mostly attributed to financial barriers. Well-selected patients tolerate the treatment and have good early clinical tumor response as expected. The role of CCRT for this patient group (and methods to make it available in resource-limited settings) must be further evaluated.

Quality and labeling information of Moringa oleifera products marketed for HIV-infected people in Zimbabwe.

Labeling information and quality of marketed Moringa oleifera products were assessed. Personnel in 60 pharmacies and 11 herbal shops were interviewed about the sources, dosages, indications and counseling information of Moringa oleifera products. Content analysis of written information provided on Moringa oleifera products was also done. Three samples of Moringa from popular sources were acquired to determine heavy metal content and microbial contamination. The results were compared to specified limits in the European and Chinese pharmacopeia, World Health Organization guidelines and Bureau of Indian Standards. Moringa was available as capsules or powder in 73% of the premises. Moringa was recommended for seven different disease conditions. Four different dosage regimens were prescribed. The main references cited for the counseling information were unscientific literature (62%). The selected Moringa samples were contaminated with bacteria and fungi above the European Pharmacopeia specified limits. Escherichia coli and Salmonella species were present in all three samples. All three samples contained arsenic, nickel and cadmium above the permissible limits. Moringa oleifera with variable labeling information and poor microbial and heavy metal quality is widely available in Zimbabwe.

Quality and labeling information of Moringa oleifera products marketed for HIV-infected people in Zimbabwe

Labeling information and quality of marketed Moringa oleifera products were assessed. Personnel in 60 pharmacies and 11 herbal shops were interviewed about the sources, dosages, indications and counseling information of Moringa oleifera products. Content analysis of written information provided on Moringa oleifera products was also done. Three samples of Moringa from popular sources were acquired to determine heavy metal content and microbial contamination. The results were compared to specified limits in the European and Chinese pharmacopeia, World Health Organization guidelines and Bureau of Indian Standards. Moringa was available as capsules or powder in 73% of the premises. Moringa was recommended for seven different disease conditions. Four different dosage regimens were prescribed. The main references cited for the counseling information were unscientific literature (62%). The selected Moringa samples were contaminated with bacteria and fungi above the European Pharmacopeia specified limits. Escherichia coli and Salmonella species were present in all three samples. All three samples contained arsenic, nickel and cadmium above the permissible limits. Moringa oleifera with variable labeling information and poor microbial and heavy metal quality is widely available in Zimbabwe

Implementing a pharmacovigilance program to evaluate cutaneous adverse drug reactions in an antiretroviral access program.

INTRODUCTION: Cutaneous adverse drug reactions (cADRs) can cause significant morbidity and distress in patients, especially in the HIV-infected population on antiretroviral therapy. Adverse drug reaction monitoring and ascertaining causality in resource-limited settings remain serious challenges. This study was conducted to evaluate causality and measure the incidence of cADRs in HIV-infected patients on highly active antiretroviral therapy. The study was also designed to test a three-step approach in the monitoring and evaluation of ADRs in resource-limited settings. METHODOLOGY: A retrospective review of patient medical records was performed at the Parirenyatwa Family Care Centre, Harare, Zimbabwe. Cases of cADRs were reported to the Medicines Control Authority of Zimbabwe, the main drug regulating body in Zimbabwe, for assessment and causality classification. RESULTS: We reviewed 221 randomly selected patient records to determine whether any diagnoses of cADRs were made by clinicians. Causality assessment revealed that 13.1% of cADRs were due to an offending agent in the antiretroviral therapy versus an initial incidence of 17.6% which had been determined by the physicians. CONCLUSIONS: cADRs had an incidence of 13.1% within the population under study due to non nucleoside reverse transcriptase inhibitors (NNRTIs). Most reactions were caused by the NNRTIs which contributed 72.4 % of all cADRs. A panel of experts from the drug regulatory authority can be used as an implementation based mechanism in ascertaining causality objectively in settings where resources are constrained.

Prevalence and patterns of Moringa oleifera use among HIV positive patients in Zimbabwe: a cross-sectional survey.

Supplementation of conventional medicines with herbs is increasing globally, including among people infected with HIV. Yet there is little data systematically describing the prevalence and patterns of this supplementation and on which counseling scripts can be based. Moringa oleifera is an herb found in the tropics and sub-tropics commonly used for medicinal and nutritional purposes. This survey determined the prevalence and patterns of use of M. oleifera among HIV positive patients. The study was a cross-sectional survey. HIV-infected adults were enrolled from an opportunistic infections clinic of a referral hospital. Using a previously piloted researcher administered questionnaire; patients who reported to the clinic over three months were interviewed about their use of herbal medicines. The focus was on M. oleifera use, and included plant part, dosage, prescribers and the associated medical conditions. Sixty-eight percent (68%) of the study participants consumed M. oleifera. Of these, 81% had commenced antiretroviral drugs. Friends or relatives were the most common source of a recommendation for use of the herb (69%). Most (80%) consumed M. oleifera to boost the immune system. The leaf powder was mainly used, either alone or in combination with the root and/or bark. M. oleifera supplementation is common among HIV positive people. Because it is frequently prescribed by non-professionals and taken concomitantly with conventional medicine, it poses a potential risk for herb-drug interactions. Further experimental investigations into its effect on drug metabolism and transport would be useful in improving clinical outcome of HIV positive patients.