Determinants and rates of retention in HIV care among adolescents receiving antiretroviral therapy in Windhoek, Namibia: a baseline cohort analysis

BACKGROUND

Long-term engagement in HIV care is essential to achieving and maintaining viral suppression. Adolescents living with HIV (ALHIV) experience many barriers to remaining engaged in care and treatment programs. Higher attrition among adolescents compared to adults remains a huge concern due to unique psychosocial and health systems challenges adolescents face, and recently the COVID-19 pandemic effects. We report on determinants and rates of retention in care in adolescents aged 10-19 years enrolled on antiretroviral therapy (ART) in Windhoek, Namibia.

METHODS

A retrospective cohort analysis of routine clinical data of 695 adolescents aged 10-19 years enrolled for ART at 13 Windhoek district public healthcare facilities, between January 2019 and December 2021 was conducted. Anonymized patient data were extracted from an electronic database and registers. Bivariate and Cox proportional hazards analysis were performed to determine factors associated with retention in care among ALHIV at 6, 12, 18, 24 and 36 months. Retention in care trends were also described using the Kaplan-Meier survival analysis.

RESULTS

The retention in care rates at 6, 12, 18, 24 and 36 months were 97.7%, 94.1%, 92.4%, 90.2%, and 84.6%, respectively. Our study population had predominantly treatment-experienced adolescents, who initiated ART between birth and 9 years (73.5%), were on treatment for > 24 months (85.0%), and on first-line ART (93.1%). After controlling for confounders, the risk of dropping out of care was increased for older adolescents aged 15-19 years (aHR = 1.964, 95% CI 1.033-3.735); adolescents on switched ART regimens (Second line + Third line regimen) (aHR = 4.024, 95% CI 2.021-8.012); adolescents who initiated ART at 15-19 years (aHR = 2.179, 95%CI 1.100-4.316); and male adolescents receiving ART at a PHC clinic (aHR = 4.322, 1.332-14.024). Conversely, the risk of ALHIV dropping out of care decreased for adolescents whose TB screen results were negative (aHR = 0.215, 95% CI 0.095-0.489).

CONCLUSION

Retention in care rates among ALHIV in Windhoek do not meet the UNAIDS revised target of 95%. Gender-specific interventions are needed to keep male and older adolescents motivated and engaged in long-term care, and to promote adherence amongst those adolescents who were initiated on ART in late adolescence (15-19 years).

Estimating Income-Related Health Inequalities Associated with Tobacco and Alcohol Consumption in Namibia

Disparities in resources and access to material opportunities are important determinants of income-related health inequality. This paper hypothesises that the gradient of the inequality in health between the poor and the rich is likely to depend on differences in lifestyle practices including tobacco use and alcohol abuse. Using the 2015/16 Namibia Household Income and Expenditure Survey and the Erreygers corrected concentration index, we estimate the effect of tobacco and alcohol use on income-related health inequalities. A decomposition technique was used to estimate the separate and joint contribution of tobacco and alcohol use to income-related health inequalities. The results indicate that tobacco use widens the income-related health inequality gap while alcohol consumption reduces health disparities. The simultaneous consumption of these goods has a stronger multiplicative effect on income-related health inequality. For instance, the simultaneous consumption of both goods contribute up to 1.03% of the inequality in health while tobacco use alone contributed only 0.6%. While policy options for each of these goods could be essential in reducing inequalities in health, there is a need to advocate additional measures that could simultaneously control the consumption of both goods.

Risk factors for cardiovascular disease among people with mental illness in Namibia

Objectives

To determine the prevalence of risk factors for cardiovascular disease (CVD) among people with mental illness attending the Mental Health Care Centre, Windhoek, Namibia.

Design

Observational, cross-sectional study.

Setting

Mental health Care Centre, Windhoek Central Hospital. Namibia.

Participants

Adult patients with a mental illness attending the Mental Health Care Centre, Windhoek.

Data collection

Within a systematic random sampling method, 385 adult patients with mental illness were recruited between May and December 2017.

Statistical analysis

Validated assessment tools were used. Descriptive summary statistics and Chi-squared tests of association were conducted.

Results

One-third (31.7%) of participants used alcohol, 21% used nicotine, 21.3% had hypertension, 55% were over-weight or obese, 59.2% of females and 11.5% of males had abdominal obesity. About twenty per cent (19.9%) of participants did meet the World Health Organisation recommended level of activity, while more than two-thirds of participants did not participate in moderate or vigorous physical activities. The patient's psychiatric condition was significantly associated with alcohol use (Chi-square=20.450, p=0.002) and physical activity (Chi-square=20.989, p=0.002). The psychiatric condition was not associated with the waist circumference and gender of the participant.

Conclusions

The increased prevalence of CVD risk factors in people with mental illness calls for mental health practitioners to screen, monitor and manage these risk factors regularly. Systematically screening and monitoring for cardiovascular risk factors is likely to contribute to National targets and significantly impact cardiovascular morbidity and mortality in people with mental illness.

Funding

This work was financed by internal resources of the Mental Health Care Centre, Windhoek Central Hospital.

Cycles of Violence Among Young Women in Namibia: Exploring the Links Between Childhood Violence and Adult Intimate Partner Violence From the Violence Against Children and Youth Survey

Background: Violence against children is a global public health crisis and is associated with poor mental and physical health outcomes. Childhood violence may also increase the risk of subsequent violence revictimization by an intimate partner. We aimed to understand cycles of violence among adolescent girls and young women in Namibia to inform violence prevention and treatment interventions. Methods: The 2019 Namibia Violence Against Children and Youth Survey (VACS) examined the prevalence of childhood violence and intimate partner violence among 18-24 year old adolescent girls and young women (N = 2434). Using the data, we assessed the prevalence of childhood violence, defined as any physical, sexual, or emotional violence victimization prior to age 18, and estimated the prevalence of intimate partner violence (IPV) after age 18. We used a weighted logistic regression to assess whether childhood violence exposure was associated with subsequent experience of IPV after age 18. Results: Adolescent girls and young women in Namibia had a statistically significant higher odds of experiencing IPV if they had experienced any childhood violence including physical, sexual, and/or emotional violence (adjusted odds ratio [aOR]: 2.93; 95% Confidence Interval [95% CI: 1.64-5.23). IPV was also significantly associated with childhood physical (aOR: 1.81; 95% CI: 1.07-3.05), sexual (aOR: 3.79; 95% CI: 2.54-5.67), or emotional (aOR: 2.39; 95% CI: 1.18-4.86) violence when each were considered separately. We also observed a dose-response relationship between the number of types of childhood violence and IPV experience as a young adult. Conclusions: Childhood violence is a significant predictor of subsequent violence revictimization by an intimate partner. This analysis provides unique insights on cycles of violence among adolescent girls and young women in Namibia and points to the need for interventions during childhood to prevent violence against children and break this cycle among young women in sub-Saharan Africa.

Closing the HIV Treatment Gap for Adolescents in Windhoek, Namibia: A Retrospective Analysis of Predictors of Viral Non-Suppression

Windhoek joined the Fast-Track Cities Initiative in 2017 to optimize HIV service delivery for adolescents, promoting adherence and sustaining viral suppression. Recent surveys and programmatic data show that the treatment gap remains greatest among children and adolescents living with HIV. A retrospective cohort analysis of adolescents living with HIV (ALHIV) receiving antiretroviral therapy (ART) at Windhoek healthcare facilities was conducted. Routine clinical data were extracted from the electronic Patient Monitoring System (ePMS). The SPSS statistical package was used to determine viral non-suppression and perform inferential statistics. 695 ALHIV were analysed with median age of 16 years (IQR = 13-18). Viral non-suppression at 1000 copies/mL threshold was 12%. Viral non-suppression was associated with age at ART initiation, duration on ART, current ART regimen and WHO Clinical Stage. In multivariate analysis, longer duration on ART was a protective factor for viral non-suppression (13-24 months vs. >24 months: aOR = 8.92, 95% CI 2.60-30.61), while being on third line regimen (vs. first line) was protective against viral non-suppression (aOR = 0.11, 95% CI 0.03-0.49). A significant treatment gap is evident for ALHIV with high viral non-suppression levels. Interventions are required to counter treatment fatigue to keep adolescents engaged in ART, and timely switching to rescue regimens for failing adolescents.

Gender relations and the utilization of contraceptives and antenatal care services in Kenya, Namibia and Nigeria

The impacts of gender relations (GR) on reproductive health in sub-Saharan Africa (SSA) have received little attention. Virtually non-existent are studies that take cognizance of the socio-cultural diversity of SSA countries in assessing the impacts. Using Demographic and Health Survey data from Namibia, Kenya and Nigeria, this study investigated whether feminine gender relations (FGR) predict higher uptake of contraceptives and antenatal care services (ANC) in SSA. Results from univariate, bivariate and multivariate analyses showed that Namibia had the highest prevalence of FGR (20.0%) and contraceptive use (57.8%) while Nigeria had the lowest FGR (5.7%) but highest ANC utilization (42.1%). At the unadjusted levels, FGR predicted higher contraceptive use in Namibia and Nigeria but became insignificant when sociodemographic confounders were controlled for. Masculine gender relations (MGR) however predicted increased contraceptive and ANC utilization in the three countries at the unadjusted levels and contraceptive use in Kenya and Nigeria when adjusted. That MGR predicted higher odds of using contraceptives in a largely gender egalitarian Kenya and patriarchal Nigeria while FGR was insignificant even in the largely feministic Namibia, suggests that promoting equality in GR, rather than emphasizing female autonomy, possesses greater capacity for improving reproductive health outcomes in SSA.

Investigation of the outbreaks of abortions and orchitis in livestock in Namibia during 2016-2018

This study investigated outbreaks of seemingly related abortions and orchitis which occurred in the Khomas, Omaheke and Otjozondjupa regions of Namibia from 2016 to 2018, affecting cattle, sheep and goats. Fifty-nine questionnaires were administered, and 48 were completed giving an 81.4% return. The outbreaks were limited to Namibia's east and central regions, mainly on farms rearing cattle, sheep and goats and on farms with a mixture of these species. There was no significant difference between Khomas and other regions on abortion reporting at the farm level [X2 (1, N = 48) = 0.0002, p = 0.987851]. However, there was a significant difference in the abortions at the animal level among the three regions [X2 (2, N = 6246) = 239.8339, p = .00001]. In addition, the proportions of abortions calculated at the animal level at each farm were significantly different when the Khomas region was compared to the other regions. Seventeen cattle sera, 35 sheep sera, 52 caprine sera, 18 bovine liver samples, one caprine liver, five aborted cattle foetuses, two cattle placentas, 18 testes (one bull, eight bucks and nine rams) and ten bull sheath scrapings were collected and tested. Histopathology, microbiology, serology, immunohistochemistry, real-time PCR and mineral analytical techniques were used to establish the aetiology of the abortion and orchitis outbreaks. The gross and histopathological findings on the 18 testicles were characteristic of chronic orchitis. In aborted foetuses, significant histopathological findings included meconium aspiration, funisitis and cardiomyopathy. Placentitis and endometritis were the primary pathologies observed in cows. The bacteria isolated from microbiological samples included Enterococcus spp. (65.5% [19/29]), Enterobacter spp. (6.9% [2/29]) and Streptococcus spp. (10.3% [3/29]), Trueperella pyogenes (3.4% [1/29]), Stenotrophomonas maltophilia (3.4% [1/29]), Staphylococcus epidermidis (3.4% [1/29]), Providencia rettgeri (3.4% [1/29]) and Acinetobacter lwoffii (3.4% [1/29]), mostly opportunistic bacteria. On mineral analysis, 28%, 33%, 83%, 33% and 17% (n = 18) of cattle livers were low in copper, zinc, manganese, selenium and iron, respectively. Twenty-three percent (12/52) of the caprine sera were positive for Brucella melitensis on the Rose Bengal and complement fixation tests. Thirty-five ovine sera were tested for B. melitensis, B. ovis and Coxiella burnetii, and the prevalence for each was 2.9% (1/35). PCR tests on foetuses were all negative for Brucella spp., Coxiella burnetii, Chlamydia spp., Listeria monocytogenes, Salmonella spp., Campylobacter fetus spp., Leptospira pathogenic strains, bovine viral diarrhoea virus, Rift Valley fever virus, Anaplasma phagocytophilum and bovine herpes virus 4 Campylobacter fetus spp. and Trichomonas foetus spp. The authors concluded that Brucella spp., Enterococcus spp., Escherichia coli, Streptococcus spp., Trueperella pyogenes and Coxiella burnetii could have contributed to this outbreak. Micronutrient imbalances and pathogenic abiotic nanoparticles were also identified as possible contributors to the abortion outbreaks.

Laboratory and field evaluation of the STANDARD Q and Panbio™ SARS-CoV-2 antigen rapid test in Namibia using nasopharyngeal samples

BACKGROUND

As new SARS-CoV-2 variants of concern emerge, there is a need to scale up testing to minimize transmission of the Coronavirus disease 2019 (COVID-19). Many countries especially those in the developing world continue to struggle with scaling up reverse transcriptase polymerase reaction (RT-PCR) to detect SARS-CoV-2 due to scarcity of resources. Alternatives such as antigen rapid diagnostics tests (Ag-RDTs) may provide a solution to enable countries scale up testing.

METHODS

In this study, we evaluated the Panbio™ and STANDARD Q Ag-RDTs in the laboratory using 80 COVID-19 RT-PCR confirmed and 80 negative nasopharyngeal swabs. The STANDARD Q was further evaluated in the field on 112 symptomatic and 61 asymptomatic participants.

RESULTS

For the laboratory evaluation, both tests had a sensitivity above 80% (Panbio™ = 86% vs STANDARD Q = 88%). The specificity of the Panbio™ was 100%, while that of the STANDARD Q was 99%. When evaluated in the field, the STANDARD Q maintained a high specificity of 99%, however the sensitivity was reduced to 56%.

CONCLUSION

Using Ag-RDTs in low resource settings will be helpful in scaling-up SARS-CoV-2 testing, however, negative results should be confirmed by RT-PCR where possible to rule out COVID-19 infection.

Experiences of a dedicated Heart and Maternal Health Service providing multidisciplinary care to pregnant women with cardiac disease in a tertiary centre in Namibia

OBJECTIVES

First, to describe the implementation process, benefits and challenges of a multidisciplinary service for pregnant women with cardiac disease in Namibia. Second, to assess pregnancy outcomes in this population.

METHODS

In a tertiary hospital in Namibia, a multidisciplinary service was implemented by staff of obstetric and cardiology departments and included preconception counselling, provision of antenatal care and reliable contraception. Management guidelines developed for high-income settings were used, since no locally adapted guidelines were available. A cohort study was performed to assess cardiac, obstetric and fetal outcomes. Included were pregnant women with cardiac disease, referred to this service between 1 August 2016 and 31 July 2018.

RESULTS

Important benefits of this service were the integrated approach, improved access to reliable contraception and insight into drivers of poor outcome. Several challenges with use of available guidelines were encountered, as contextual factors specific to lower-income settings were not taken into consideration, such as higher rates of infection or barriers to access care. The cohort consisted of 65 women. Cardiac disease was diagnosed for the first time in 16 (24.6%) women, of whom 11 had pre-existing cardiac disease. These women presented more often with heart failure than women with known heart disease (75.0% vs. 6.1%, RR 12.5, 95% CI 3.9-38.0). Five women died. Cardiac events occurred in twenty-two women of whom eight developed thromboembolic events and two endocarditis. The majority had no indication for prophylaxis, based on available guidelines. Fetal events occurred in 36 pregnancies. After pregnancy more than half of women (35/65, 53.8%) were using long-acting reversible contraception.

CONCLUSIONS

Despite several barriers, it was possible to implement a multidisciplinary service in a high-burden setting. Cardiac and fetal event rates in this cohort were high. To improve outcomes the focus should be on availability of context-specific guidelines and better detection of cardiac disease.

Sociocultural factors that influence the prevention of malaria in Ohangwena region, Namibia

Background

Namibia is undergoing an epidemiological transition after decline in local transmission of malaria, and the country is now in a position to move towards eliminating local transmission by 2030. However, malaria prevalence cannot be adequately explained from medical and modern prevention points of view alone. The persistence of malaria might appear as a result of not recognising sociocultural factors that seem useful in the prevention of malaria, Hence, studies on sociocultural factors are limited.

Aim

The aim of this study was to describe the sociocultural factors that influence the prevention of malaria in Ohangwena region.

Setting

The study was conducted in Ohangwena region of northern Namibia.

Methods

This study was a cross-sectional study and a mixed methods, convergent parallel design was employed.

Results

The major theme revealed that traditional prevention methods of malaria are widely available in rural communities. The best accepted traditional prevention methods include tumbleweed, bitter bush and animal dung. Quantitative findings indicated that 67.0% of participants felt that nets are expensive. Key barriers included the long distance to access health facilities (29.1%), long waiting times (25.8%) and the lack of money to pay for services and transport (22.5%).

Conclusion

The limited access to and cost of Western prevention methods minimise protection because of priority and resource allocations, but it could be mitigated with the use of locally available traditional prevention practices used for many years in curbing malaria. There is a need to create awareness about socioculturally congruent malaria care.

Contribution

This study has revealed the need to combine standard prevention with traditional prevention practices in the fight against malaria, and it intensified research focusing on interventions that address sociocultural factors for the prevention of malaria in endemic regions. In addition, part of the novelty of the study is establishing the need to test the efficacy of traditional practices used.

Importance of Candida infection and fluconazole resistance in women with vaginal discharge syndrome in Namibia

BACKGROUND

Vaginal discharge syndrome (VDS) is a common condition. Clinical management targets sexually transmitted infections (STIs) and bacterial vaginosis (BV); there is limited focus on Candida infection as cause of VDS. Lack of Candida treatment coverage and, if present, antifungal resistance may result in VDS treatment failure. This study aimed to determine the prevalence of Candida infection, antifungal resistance, and coinfections in Namibian women with VDS.

METHODS

A cross-sectional study was performed using 253 vaginal swabs from women with VDS in Namibia. Demographic data was collected, and phenotypic and molecular detection of Candida species was performed followed by fluconazole susceptibility testing of Candida isolates. BV was diagnosed using Nugent score microscopy; molecular detection of Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis was performed.

RESULTS

Candida species was detected in 110/253 women (43%). Ninety women (36%) had Candida albicans and 24 (9.5%) had non-albicans Candida species. The non-albicans species detected were 19 (17%) Candida glabrata, 4.0 (3.5%) Candida krusei, and 1.0 (0.9%) Candida parapsilosis. Candida albicans were more frequently isolated in younger (p = 0.004) and pregnant women (p = 0.04) compared to non-albicans Candida species. Almost all (98%) Candida albicans isolates were susceptible to fluconazole while all non-albicans Candida species were fluconazole resistant. STIs were diagnosed in 92 women (36%): 30 (12%) with C. trachomatis, 11 (4.3%) N. gonorrhoeae, and 70 (28%) T. vaginalis; 98 (39%) women had BV. Candida infection alone was diagnosed in 30 women (12%), combined with STIs in 42 women (17%) and was concurrent with BV in 38 women (15%). Candida infection was more often detected in swabs from women without C. trachomatis detected (6.4% vs. 16%; OR 0.30; 95% CI 0.10-0.77, p = 0.006).

CONCLUSIONS

The high prevalence of Candida infection, especially those due to non-albicans Candida species that are resistant to fluconazole, is a great concern in our setting and may lead to poor treatment outcomes. Access to microbiological testing for Candida species in the context of syndromic management is warranted.

Integrating hypertension and HIV care in Namibia: A quality improvement collaborative approach

Background

Hypertension (HTN) is highly prevalent among people with HIV (PWH) in Namibia, but screening and treatment for HTN are not routinely offered as part of HIV care delivery. We report the implementation of a quality improvement collaborative (QIC) to accelerate integration of HTN and HIV care within public-sector health facilities in Namibia.

Methods

Twenty-four facilities participated in the QIC with the aim of increasing HTN screening and treatment among adult PWH (>15 years). HTN was defined according to national treatment guidelines (i.e., systolic blood pressure >140 and/or diastolic blood pressure >90 across three measurements and at least two occasions), and decisions regarding initiation of treatment were made by physicians only. Teams from participating hospitals used quality improvement methods, monthly measurement of performance indicators, and small-scale tests of change to implement contextually tailored interventions. Coaching of sites was performed on a monthly basis by clinical officers with expertise in QI and HIV, and sites were convened as part of learning sessions to facilitate diffusion of effective interventions.

Results

Between March 2017 and March 2018, hypertension screening occurred as part of 183,043 (86%) clinical encounters at participating facilities. Among 1,759 PWH newly diagnosed with HTN, 992 (56%) were initiated on first-line treatment. Rates of treatment initiation were higher in facilities with an on-site physician (61%) compared to those without one (51%). During the QIC, facility teams identified fourteen interventions to improve HTN screening and treatment. Among barriers to implementation, teams pointed to malfunctions of blood pressure machines and stock outs of antihypertensive medications as common challenges.

Conclusions

Implementation of a QIC provided a structured approach for integrating HTN and HIV services across 24 high-volume facilities in Namibia. As rates of HTN treatment remained low despite ongoing facility-level changes, policy-level interventions—such as task sharing and supply chain strengthening—should be pursued to further improve delivery of HTN care among PWH beyond initial screening.

Cost and cost effectiveness of reactive case detection (RACD), reactive focal mass drug administration (rfMDA) and reactive focal vector control (RAVC) to reduce malaria in the low endemic setting of Namibia: an analysis alongside a 2×2 factorial design cluster randomised controlled trial

OBJECTIVES

To estimate the cost and cost effectiveness of reactive case detection (RACD), reactive focal mass drug administration (rfMDA) and reactive focal vector control (RAVC) to reduce malaria in a low endemic setting.

SETTING

The study was part of a 2×2 factorial design cluster randomised controlled trial within the catchment area of 11 primary health facilities in Zambezi, Namibia.

PARTICIPANTS

Cost and outcome data were collected from the trial, which included 8948 community members that received interventions due to their residence within 500 m of malaria index cases.

OUTCOME MEASURES

The primary outcome was incremental cost effectiveness ratio (ICER) per in incident case averted. ICER per prevalent case and per disability-adjusted life years (DALY) averted were secondary outcomes, as were per unit interventions costs and personnel time. Outcomes were compared as: (1) rfMDA versus RACD, (2) RAVC versus no RAVC and (3) rfMDA+RAVC versus RACD only.

RESULTS

rfMDA cost 1.1× more than RACD, and RAVC cost 1.7× more than no RAVC. Relative to RACD only, the cost of rfMDA+RAVC was double ($3082 vs $1553 per event). The ICERs for rfMDA versus RACD, RAVC versus no RAVC and rfMDA+RAVC versus RACD only were $114, $1472 and $842, per incident case averted, respectively. Using prevalent infections and DALYs as outcomes, trends were similar. The median personnel time to implement rfMDA was 20% lower than for RACD (30 vs 38 min per person). The median personnel time for RAVC was 34 min per structure sprayed.

CONCLUSION

Implemented alone or in combination, rfMDA and RAVC were cost effective in reducing malaria incidence and prevalence despite higher implementation costs in the intervention compared with control arms. Compared with RACD, rfMDA was time saving. Cost and time requirements for the combined intervention could be decreased by implementing rfMDA and RAVC simultaneously by a single team.

TRIAL REGISTRATION NUMBER

NCT02610400; Post-results.

Rheumatic heart disease prevalence in Namibia: a retrospective review of surveillance registers

BACKGROUND

Rheumatic heart disease (RHD) is the most commonly acquired heart disease in children and young people in low and middle-income settings. Fragile health systems and scarcity of data persist to limit the understanding of the relative burden of this disease. The aims of this study were to estimate the prevalence of RHD and to assess the RHD-related health care systems in Namibia.

METHODS

Data was retrieved from outpatient and inpatient registers for all patients diagnosed and treated for RHD between January 2010 to December 2020. We used descriptive statistics to estimate the prevalence of RHD. Key observations and engagement with local cardiac clinicians and patients helped to identify key areas of improvement in the systems.

RESULTS

The outpatient register covered 0.032% of the adult Namibian population and combined with the cumulative incidence from the inpatient register we predict the prevalence of clinically diagnosed RHD to be between 0.05% and 0.10% in Namibia. Young people (< 18 years old) are most affected (72%), and most cases are from the north-eastern regions. Mitral heart valve impairment (58%) was the most common among patients. We identified weaknesses in care systems i.e., lack of patient unique identifiers, missing data, and clinic-based prevention activities.

CONCLUSION

The prevalence of RHD is expected to be lower than previously reported. It will be valuable to investigate latent RHD and patient follow-ups for better estimates of the true burden of disease. Surveillance systems needs improvements to enhance data quality. Plans for expansions of the clinic-based interventions must adopt the "Awareness Surveillance Advocacy Prevention" framework supported by relevant resolutions by the WHO.

Neutralising antibodies to West Nile virus detected in horses in Windhoek, Namibia

West Nile virus (WNV) is a vector-borne virus maintained in nature by a bird-mosquito cycle. However, it can occasionally and accidentally infect horses and human beings, leading to sometimes severe or even fatal outcomes in these species. Therefore, the monitoring of its circulation and disease occurrence is of relevance. Unfortunately, it is underdiagnosed or not diagnosed in several African counties, including Namibia, where no data is currently available for horses. In this study, 98 horses in three different stables in the Windhoek city area were investigated. They were found to have a seroprevalence of approximately 7%. Positive reactions were seen at all three stables, suggesting a greater than expected prevalence of the virus. This is the first report of serological evidence for the presence of the virus in horses in Nambia. Even though clinical signs were not reported in any of the stables from which the sera were derived, the seroprevalence to the virus suggests that horses with high genetic and/or economic value could benefit from vaccination against WNV. Because of the zoonotic potential of the virus, these findings are also of significance to human health authorities.

Cystic echinococcosis of ruminant livestock in Namibia

Cystic echinococcosis (CE) is widespread and locally frequent in southern Africa where it affects humans, livestock, and wild mammals. However, most data from the region are old and do not provide information on the causative Echinococcus species. For Namibian livestock only anecdotal records were available prior to this preliminary survey. Our retrospective analysis of slaughterhouse records of CE in cattle from the commercial farming area in central and southern Namibia resulted in 1.65% CE prevalence among 35,143 slaughtered cattle in the period 2015-2016. For comparison, carcasses of ruminant livestock were prospectively examined in the communal farming areas of northern Namibia, resulting in three CE cases among only 12 cattle, and no cases among nine goats. To determine the Echinococcus species affecting Namibian livestock, a total of 53 cysts were collected from all parts of the country and analysed for species and genotype by amplification and sequencing of the nad1 gene. All 50 cattle cysts (isolated from 40 cattle), both from the commercial and communal farming areas, were Echinococcus ortleppi (all fertile, and 42/50 from the lungs), while three opportunistically collected cysts from three sheep in southern Namibia were E. canadensis G7. Our data suggest that E. ortleppi is the only CE agent that is relevant for cattle infection in Namibia, and that low prevalence in the commercial farming areas contrasts with high CE burden in the northern traditional husbandry systems. The present data provide baseline information to stimulate epidemiological studies on the transmission pathways of various CE agents in livestock, wildlife, and humans in Namibia and neighbouring countries.

Correlates of Substance Misuse, Transactional Sex, and Depressive Symptomatology Among Partnered Gay, Bisexual and Other Men Who Have Sex with Men in South Africa and Namibia

Despite having some of the world's highest rates of HIV, there is a lack of knowledge on correlates of transmission risk among gay, bisexual and other men who have sex with men in Southern Africa. There is even less known about the factors that shape HIV risk in male-male couples. Using data from Together Tomorrow, a study of partnered GBMSM in South Africa and Namibia, this study assessed the individual and dyadic correlates of three major HIV risk factors in this population: substance misuse, transactional sex, and depressive symptomatology. Data were collected during November 2016-March 2017 via a quantitative survey conducted with 140 partnered MSM (70 couples) in Windohoek, Keetmanshoop, Walvis Bay, and Swakopmund, Namibia and 300 partnered MSM (150 couples) in Pietermaritzburg and Durban, KwaZulu-Natal, South Africa for a total sample size of 440 partnered MSM (220 couples). Results of multilevel modeling analyses show several significant factors present in partnered GBMSM that differ from studies of single GBMSM, with intimate partner violence being a significant correlate across all three risk factors. Future interventions should consider dyadic approaches and integrate IPV prevention and mitigation efforts to reduce HIV in this population as part of a multisectoral approach. To reduce rates of HIV in partnered GBMSM in Namibia and South Africa multilevel, multisectoral work is needed in policy, social norms change, and relationship-focused dyadic interventions to reduce the social and structural stigma facing male couples.

Disclosure and help-seeking behaviors related to sexual and physical violence in childhood and adolescence: Results from the Namibia Violence Against Children and Youth Survey

BACKGROUND

Violence disclosure and help-seeking can mitigate adverse health effects associated with childhood violence, but little is known about facilitators and barriers of disclosure and help-seeking behaviors in sub-Saharan Africa.

OBJECTIVE

To understand factors associated with disclosure and help-seeking to inform care.

PARTICIPANTS AND SETTING

Participants aged 13-24 years old in the 2019 Namibia Violence Against Children and Youth Survey (VACS).

METHODS

We assessed the prevalence of victimization, disclosure, and help-seeking and examined factors associated with violence disclosure and help-seeking, separately, by gender.

RESULTS

4211 girls and 980 boys participated in the Namibia VACS. The prevalence of childhood sexual violence differed significantly by gender (15.7% among girls, 9.8% among boys), but physical violence prevalence did not differ by gender. Among victims of sexual violence, 57.3% of girls disclosed and 10.4% sought help, compared with only 30.7% and 3.2% of boys. Among victims of physical violence, 61.1% of girls and 53.4% of boys disclosed, and 16.9% of girls and 17.7% of boys sought help. Older age, social support, and experiencing more types of violence were associated with sexual violence disclosure among boys, but none of these factors were associated with sexual violence disclosure among girls. Lower education, perpetrator type, and witnessing violence were associated with physical violence disclosure among girls, while peer support and perpetrator type were associated with physical violence disclosure among boys.

CONCLUSIONS

Factors associated with childhood violence differed by gender and violence type in Namibia, highlighting a need for gender-specific violence services to facilitate violence disclosure and help-seeking.

A Cross-Sectional Study on Hypertension Medication Adherence in a High-Burden Region in Namibia: Exploring Hypertension Interventions and Validation of the Namibia Hill-Bone Compliance Scale

In Namibia, the prevalence of hypertension among women and men aged 35−64 years is high, ranging from 44% to 57%. In this study, we aimed to determine adherence and predictors to antihypertensive therapy in Khomas region, Namibia. A cross-sectional study was performed to consecutively sample 400 patients from urban and peri-urban settings in Namibia. Results were validated using the Hill-Bone Compliance to High Blood Pressure Therapy Scale. Crude associations between predictors of adherence and compliance were tested using the Pearson chi-square test. A multivariable logistic regression analysis was then performed on adherence variables found to be significant to adjust for confounders, and the results are presented as adjusted odds ratios (aOR) with 95% confidence intervals. A total of 400 patients participated in this study. The participants’ mean age and standard deviation were Mean ± SD = 48.9 ± 12.5. In this study, 351 (87.7%) patients were estimated to have good adherence. Education, employment, and the presence of other chronic diseases were associated with adherence. Following multivariate adjustment, the following factors were significantly associated and are therefore predictors of adherence (95%CI, p < 0.005): receiving enough medication at last check-up until next one (OR = 5.44, CI 1.76−16.85), lack of encouragement from family and friends (OR = 0.11 (0.03−0.42)), and attendance of follow-ups on schedule (OR = 8.49, CI = 3.82−18.85). The success of hypertension therapy is dependent on the healthcare systems and healthcare professionals in supplying enough medication, support of friends/family, and maintaining scheduled follow-ups. A combination of interventions using low-cost mobile technology led by healthcare professionals could be endorsed. To fully practice universal access to medication, public and private hospitals in Namibia should collaborate.

Physical comorbidity among patients attending mental health services at Windhoek Central Hospital, Namibia

Introduction

physical health problems are common among people with mental illness. Understanding common co-occurring mental and physical conditions can aid health providers to effectively screen individuals and also integrate care for both conditions. The study aimed to determine the prevalence and types of comorbidity among patients attending the outpatient section of the Mental Health Care Centre, Windhoek Central Hospital.

Methods

a cross-sectional survey of 385 patients attending the Mental Health Care Centre of Windhoek Central Hospital was carried out using structured questionnaire.

Results

the study found that 33.8% of participants had comorbid physical and mental conditions. The most common co-occurring physical conditions were from the cardiovascular system (40.8%), infections (30.8%), and neurological conditions (13.0%). Female patients were more likely to have comorbidity compared to their male counterparts (OR=2.8; CI = 1.5-5.0; p=0.001), and the risk of comorbidity increased with age (OR=1.1; CI = 1.0-1.1; p<0.001).

Conclusion

the study emphasizes the inseparability of mental and physical health, and the bidirectional association between mental and physical conditions. The high prevalence of somatic disorder points to the need of integration of physical and mental health services. Mental health and somatic services must be adjusted to the fact that most of the people who come to seek help are likely to suffer from more than one illness.

Risk and protective factors for depressive symptoms among the youth living with HIV in Namibia

BACKGROUND

: Namibia has one of the highest HIV prevalence rates among young people living with HIV and AIDS. The study of mental well-being among this vulnerable population is emerging as an important area of public health research.

METHODS

: This study examined how gender, social support, food insecurity, HIV-related stigma, HIV treatment adherence and HIV transmission knowledge are related to depressive symptoms among young people living with HIV in rural northern Namibia. Data were collected from 188 participants from the Zambezi region.

RESULTS

: The hierarchical regression analysis revealed that being a female infected with HIV, having perceived food insecurity, experiencing more HIV-related stigma and having low levels of social support can exacerbate the severity of depressive symptoms in this sample of Namibian youth.

DISCUSSION

: Our findings point to the need to expand social support interventions, enhance socio-economic programmes and reduce HIV-related stigma among young people living with HIV, especially those residing in rural, HIV endemic, resource-limited communities in developing countries.

Cervical cancer screening and treatment, HIV infection, and age: Program implementation in seven regions of Namibia

The aim of this study was to assess differences in cervical cancer screening and treatment outcomes by HIV status in a routine programmatic setting with a high generalized HIV prevalence. Women living with HIV (WLHIV) are at heightened risk of developing cervical cancer and the World Health Organization recommends all WLHIV who are sexually active be screened, regardless of age. In 2018, Namibia's Ministry of Health and Social Services introduced a screen-and-treat approach using visual inspection with acetic acid (VIA) and ablative treatment with cryotherapy or thermocoagulation with a focus on screening HIV-positive women due to Namibia's 11.5% prevalence of HIV in women aged 15-49. Using program data from October 2018 to March 2020 from seven of the country's 14 regions, we calculated descriptive statistics and chi-square tests to test the statistical significance of differences in VIA-positivity, ineligibility for ablative treatment, treatment completion, and same day treatment completion by HIV status. Between October 2018 and March 2020, the program conducted 14,786 cervical cancer screenings. Among 8,150 women who received their first VIA screening, more WLHIV screened VIA-positive (17%) than HIV-negative women (15%). This difference was statistically significant (p = 0.02). Among 2,272 women who screened VIA-positive at any screening, 1,159 (82%) completed ablative treatment. This suggests ablative treatment is feasible and acceptable in resource-limited settings. WLHIV were also more likely to complete treatment than HIV-negative women (p<0.01). Differences in health seeking behavior of sub-populations as well as resource availability between service delivery points should be considered for further investigation. Going forward in order to strengthen program implementation and expand screening access and uptake further investigation is needed to determine cancer incidence by HIV status, age, and time since last screening to assess cases that are averted as well as potential rates of overtreatment.

HIV Prevention Program Eligibility Among Adolescent Girls and Young Women - Namibia, 2019

The U.S. President's Emergency Plan for AIDS Relief (PEPFAR) relies on comprehensive and reliable population data to implement interventions to reduce HIV transmission in high-incidence areas among populations disproportionately affected by the HIV epidemic. Adolescent girls and young women in sub-Saharan Africa account for a disproportionate number of new HIV infections compared with their male peers (1). The DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe) program includes multisectoral, layered interventions aimed at reducing factors that contribute to vulnerability to HIV infection among adolescent girls and young women in PEPFAR-supported sub-Saharan African countries (1). Namibia, a southern African country with a population of approximately 2.55 million among whom approximately 8% live with HIV infection, had their DREAMS program first implemented in 2017* (2,3). Data from the 2019 Namibia Violence Against Children and Youth Survey (VACS), the most recent and comprehensive nationally representative data source available to study the epidemiology of violence and other HIV risk factors, were used to estimate the percentage of adolescent girls and young women aged 13-24 years who would be eligible for DREAMS program services. The prevalence of individual DREAMS eligibility criteria, which comprise known age-specific risk factors associated with HIV acquisition, were estimated by age group. Among all adolescent girls and young women in Namibia, 62% were eligible for DREAMS based on meeting at least one criterion. Common eligibility criteria included adverse childhood experiences, specifically exposure to physical, emotional, and sexual violence and being an orphan;^† and high-risk behaviors, such as early alcohol use,^§ recent heavy alcohol use,^¶ and infrequent condom use.** Using VACS data to estimate the prevalence of HIV risk factors and identify adolescent girls and young women at elevated risk for HIV acquisition in countries like Namibia with high HIV-incidence can inform programs and policies aimed at improving the well-being of these adolescent girls and young women and help control the HIV epidemics in these countries.

Improving the benefits of HIV testing and referrals in large household surveys through active linkages to care: lessons and recommendations from the Namibia population-based HIV impact assessment (NAMPHIA), 2017

In household-based surveys that include rapid HIV testing services (HTS), passive referral systems that give HIV-positive participants information about how and where to access ART but minimal follow-up support from survey staff may result in suboptimal linkage. In the 2017 Namibia Population-based HIV Impact Assessment (NAMPHIA), we piloted a system of active linkage to care and ART (ALCART) that utilized the infrastructure of existing community-based partner organizations (CBPOs). All HIV-positive participants age 15-64 years not on ART were given standard passive referrals to ART plus the option to participate in ALCART. Cases were assigned to CBPOs in participants' localities. Healthcare workers from the CBPO's contacted cases and facilitated their linkage to facility-based ART. A total of 510 participants were eligible and consented to ALCART. The majority were new diagnoses (80.8%), while the remainder were previously diagnosed but not on ART (19.2%). Of the 510, 473 (92.7%) were successfully linked into care. Of these, all but one initiated ART. Our ALCART system used existing CBPOs and contributed to >90% linkage-to-care and >99% ART-initiation among linked participants in a large, nationally-representative survey. This approach can be used to improve the potential benefits of HTS in other large population-based surveys.

The availability of psychological support following road travel injuries in Namibia: A qualitative study

Road traffic injuries (RTIs) are a major problem worldwide with a high burden of mental health problems and the importance of psychological support following road injury is well documented. However, globally there has been very little research on the accessibility of psychological services following road injury. Namibia is one of the countries most affected by RTIs but no previous studies have been done on this. In this qualitative study we investigated the availability of psychological services to RTI injured in Namibia. Our study findings are in line with those of other global studies in showing inadequate access to psychological support for injury survivors and we discuss the reasons. It is hoped these findings will help policymakers develop ways of enhancing access to psychological support for the many people injured in RTIs in Namibia. The models they develop may also be of use to other LMICs countries with high RTI rates.