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CHIP Presentation A Community Health Improvement Plan: HIV Prevention in Zambian Couples Emily Downey & Emily Newhouse St. Paul’s Missionary Hospital Kashikishi, Zambia Objectives Emily Downey-- Address the knowledge, Emily Newhouse- To explore and attitudes, and beliefs of Zambian expand my knowledge on a unique couples ages 18-44 and implement culture and experience health care in a appropriate HIV prevention interventions new setting; to gain insight and for optimal health outcomes in an knowledge about HIV-positive adults, international community. ages 18-44, and create a community health intervention plan aimed toward HIV prevention. 2 Background Information Zambia is located in Southern Africa, with a total population of 16,212,000, as of 2016 (Chisala, 2019). It is a landlocked country surrounded by eight countries, which include the following: Angola, Tanzania, Zimbabwe, Namibia, the Democratic Republic of Congo, Mozambique, Malawi and Botswana. The capital city is Lusaka. As for the different vital statistics of Zambia, there are 98.47 males per 100 females. 46.4% of the population is under the age of 15. The Gross Domestic Product per capita in 2017 was $1,646.14 in US dollars. Completion rate of primary education is 74% (UNICEF, 2016). About 24% of the population attended upper secondary education (UNICEF, 2016). Many of the people are part of the Christianity religion, with a small percentage being Atheist, Muslim and Mormon. The Zambian people place a great emphasis on family and togetherness. Everyone is kind and welcoming to one another. The three major sources of employment for the Zambian people are farming, fishing and market business, where people sell their farmed or homemade goods (Chisala, 2019). The official language of Zambia is English. However, there are 70 other indigenous languages spoken throughout the country, the main ones include Bemba, Lozi, Lunda, Luvale, Nyanja, and Tonga (Loryman, 2018). Many of the poorly educated villagers do not speak any English. Notable health disparities between people groups: Zambian primary care is more pro-poor populations while hospital utilization for healthcare is primarily more prevalent in populations with higher socioeconomic status (Phiri & Ataguba, 2014). There is a need to improve primary facilities to serve the poor and remove barriers that prevent them from obtaining care (Phiri & Ataguba, 2014). 3 Description of Kashikishi, Zambia Kashikishi is located in the Nchelenge district, the This hospital and community clinics provide free northern part of Luapula province of Zambia. It lies antiretroviral therapy to all HIV-positive patients, on eastern shores of Lake Mweru, bordering the however transportation is often a barrier. People Democratic Republic of Congo (Chisala, 2019). often walk many miles to treatment locations. ● Kashikishi population--185,146 people ● Males to female ratio--52:48. ● Annual growth rate--4.6% ● Fertility rate--7.2% ● Average income-- $3,860 per capita St. Paul’s Missionary Hospital is a Catholic-based hospital. Many of the residents of the community are also Catholic. 4 Description of Kashikishi, Zambia Top Five Health Issues Incidence and Prevalence Mortality Co-Morbidities United States Data 1. Physical Activity and 1. 48.3% 1. 8.3% 1. Obesity, High Nutrition 2. 23.6% 2. 24.8% Cholesterol, Diabetes, 2. Overweight and Obesity 3. 14% 3. 7 million deaths per Heart Disease 3. Tobacco 4. 9.4% year 2. Cancer, Diabetes, 4. Substance Abuse 5. 1.1 million people 4. 70,237 Hyperlipidemia 5. HIV/AIDS 5. 15,807 deaths per year 3. Cancer, COPD, Stroke (University of Rochester Medical 4. Mental Illness Center, 2019) 5. TB Zambia Data 1. HIV/AIDS 1. Incidence of 13.3% 1. Many of deaths are 1. Immunosuppression 2. Neonatal diseases 2. 45 deaths per 1,000 live caused by HIV-related causes opportunistic 3. Upper respiratory infections births illnesses infections 4. Diarrheal diseases 3. N/A 2. 24.8% 2. Maternal Complications 5. Tuberculosis 4. N/A 3. N/A and Fetal Death 5. 85% cure rate 4. N/A 3. HIV/Immunosuppressed (Chisala, 2019) 5. Cure rate: 85% 4. Malnutrition 5. HIV Kashikishi Data 1. Malaria 1. 39.4% 1. 15.2 deaths per 1. Malnutrition and failure 2. ARI/Pneumonia 2. N/A 100,000 to thrive 3. Trauma 3. N/A 2. 24.8% 2. Malnutrition 4. Non-blood diarrheal 4. N/A 3. N/A 3. Malnutrition diseases 5. Under 5 years old:7.5% 4. N/A 4. Malnutrition 5. Anemia 5. N/A 5. Malnutrition and malaria (Chisala, 2019) (Chisala, 2019) 5 Couples In Zambia Our at-risk population is Zambian adults, ages 18 to 44, with a focus on couplet pairs. The health issue we are focusing on is HIV prevention. ● The aim is to reach 90% of couples in Zambia in accordance with the UNAIDS 90- 90-90: Treatment for all campaign (UNAIDS, 2017). ● This goal is to increase to 95% by 2030 (UNAIDS, 2017). ● Zambian couples in the community will ● Aggregate population: heterosexual couples ages 18-45 come together to overcome the ● The intervention does not individually differentiate community stigma and protect their gender. We aim to address couples as a joint unit and health and wellbeing 6 connect within all of the community. Health Issue: HIV Prevention ● Sub-saharan Africa is disproportionately affected by HIV/AIDS (Kelley et. al, 2016) ● Occurs in 12.3% of the Zambian population (UNAIDS, 2017) ● 35% to 80% of all heterosexual HIV transmissions occur in stable relationships (Kelley et. al, 2016) ● Couples are a primary target group in HIV prevention Global Health Objective 4: Increase the number of public health professionals trained by Global Disease Detection (GDD) programs worldwide https://www.undp.org/content/undp/en/home/sustainable- https://www.healthypeople.gov/2020/topics- 7 development-goals/goal-3-good-health-and-well-being.html objectives/topic/global-health/objectives Zambian Adults and HIV Prevention Prior knowledge: Stigma is a barrier within the community that prevents the population from seeking treatment and receiving care. Obtaining care can become difficult if affordable transportation is not available, particularly in the rainy season when the poorly constructed dirt roads become difficult to travel on. Readiness to learn: The health professionals did a fantastic job of assessing the learning needs of the community. During their initial testing, they tested each patient for HIV. If found positive, they performed a second test. Before explaining the diagnosis, they would assess the complete knowledge of the illness before explaining how to live with this disease and the treatment associated with it. Characteristics of group: The Catholic Church had a large influence on the local area that created a barrier to promotion of birth control and family planning. Most of the relationships were heterosexual, since homosexuality is illegal in Zambia. Modified environment: Further work in the women empowerment and family planning programs can change the perceptions to allow for interventions to be better implemented. Family planning programs are vital for many reasons, 8 including reducing malnutrition in children and overpopulation (Chisala, 2019). What does the literature say? Promotion of Couples’ Voluntary HIV Counseling and Testing: A Comparison of Influence Networks in Rwanda and Zambia Why is this health issue a problem for this population? ● Heterosexual transmission accounts for the majority of HIV infections in sub-Saharan Africa ● 35% to 80% of all heterosexual HIV transmissions occur in stable relationships What are the current interventions for this problem? ● WHO recommends for couples’ voluntary counselinG ● However, only 10% of couples have been jointly tested and counseled What interventions have been successful and what interventions have not been successful? ● Voluntary counselinG and testinG proGrams are an effective and feasible approach to increasinG serostatus awareness and decreasing hiGh-risK behavior ● ConductinG the voluntary counselinG and testinG proGrams with couples effectively tarGets one of the most critical prevention points in sub-Saharan Africa ● Even thouGh this is an effective intervention, it has not had success beinG implemented in communities ● Measures are needed to increase the communities access to these proGrams, combat stiGma, and increase utilization of these services How does the literature compare to what the team learned specific to the health issue identified in the learninG objectives? ● The UNAIDS 90-90-90: Treatment for all campaiGn aims to ensure 90% of people livinG with HIV Know their status, 90% receive treatment, and 90% have suppressed viral loads. The intervention utilized in this literature promotes testinG to increase serostatus 9 awareness, which aliGns with the 90-90-90 campaiGn. What does the literature say? Female Partner Acceptance as a Predictor of Men’s Readiness to Undergo Voluntary Medical Male Circumcision in Zambia: The Spear and Shield Project Why is this health issue a problem for this population? ● Women have misconceptions and fears of voluntary medical male circumcision (VMMC) which lead men towards Interventions: feeling uncertain about receiving VMMC ● 35% to 80% of all heterosexual HIV transmissions occur in stable relationships Individual level- What are the current interventions for this problem? Voluntary Male ● Currently, circumcision is not required, but the intervention in this study was increased counseling to both sides of Medical Circumcision the relationship to promote female acceptance of VMMC and readiness for men to VMMC Community- What interventions have been successful and what interventions have not been successful? Community/Couple ● Educational sessions with females increased their acceptance of VMMC ● Female acceptance led to increased readiness for men to complete the desired action: VMMC Counseling about ● Some men still had hesitation to complete the desired action due to time spent contemplating the benefits vs. VMMC costs Systems- How does the literature compare to what the team learned specific to the health issue identified in the learning objectives? Implementing policies ● The UNAIDS 90-90-90: Treatment for all campaign aims to ensure 90% of people living with HIV know their status, 90% receive treatment, and 90% have suppressed viral loads.
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