We conduct research on issues of public health importance to Zimbabwe and to the wider region. See below a description of our ongoing studies.

HIV and adolescent health

CHIEDZA: improving HIV outcomes in Zimbabweans aged 16-24

Lead researcher: Rashida Ferrand

Funding: Wellcome Trust, 2017-2022

Partner: OPHID

CHIEDZA, which stands for Community based interventions to improve HIV outcomes in adolescents: a cluster randomised trial in Zimbabwe, is a two-year study to develop and evaluate the impact of a community-based, youth-friendly reproductive and sexual health service on improving HIV outcomes in people aged 16-24.

Adolescents and young people aged 16-24 rarely visit health care facilities for help and advice about sexual and reproductive health. These facilities are often remote and therefore difficult or expensive to get to. Young people can also perceive them as intimidating places where they will be judged by health care staff, who may also not respect young people’s need for confidentiality.

In order to address these challenges, the CHIEDZA study will investigate the effectiveness of a community-based, youth-friendly approach that makes use of mobile clinics to deliver sexual and reproductive health services. A group of young Zimbabweans aged 16-24 will help us to design and configure the service, and the health team will be trained in respect, confidentiality and non-judgement.

CHIEDZA is a cluster-randomised trial, which means that we will deliver the new service in 12 randomly selected areas in Harare, Bulawayo and Mashonaland East. Other areas will have access to existing services only. The trial will run for two years, starting in 2019. In 2021, we will conduct a survey to measure levels of HIV viral suppression in the population and then compare the results to see whether the youth-friendly service has made a difference.

For more information see the CHIEDZA website.

Y-CHECK

Lead investigators: Rashida Ferrand, Grace McHugh

Funders: Fondation Botnar, World Health Organization

Partners: London School of Hygiene and Tropical Medicine, Biomedical Research & Training Institute, Ministry of Health and Child Welfare, City Health Chitungwiza, University of Ghana School of Public Health and Mwanza Intervention Trials Unit.

Accessing routine health care services is not something widely embedded within most health settings. The Y-CHECK study seeks to develop and evaluate, in Chitungwiza, an intervention programme to screen and treat/refer adolescents for a range of common health conditions using routine health check-ups undertaken at two time points (the first between the ages of 10 to 14 years, and the second between the ages of 15 to 19 years). The study is being conducted in two phases. Phase 1 is a process evaluation with the purpose of assess the fidelity, acceptability, and feasibility of conducting routine health check-ups, as well as to document the experiences and perceptions of routine health check-ups. It entails a detailed situation analysis that will include a review of existing programmes and their results, key informant interviews and workshops using participatory approaches with stakeholders (adolescents, parents, teachers, nongovernmental organizations, programme implementers and key stakeholders in the government). Results of the situation analysis will be critically reviewed and will inform the intervention and implementation of Phase 2, the effectiveness, costs and cost-effectiveness of the intervention, pending funding.

MAE study: Menstrual Hygiene Management for Young Women 

Lead Researcher: Mandi Tembo

Funding: Fogarty Grant

Partners: BRTI, Ministry of Health and Child Care

The MAE study, which stands for Menstrual health management Acceptability and Effectiveness, is a two-year study to investigate and evaluate the acceptability, uptake, and impact of a comprehensive menstrual health management intervention among women aged 16-24 in Zimbabwe.

Menstruation is a monthly occurrence in the life of almost every girl and woman between the age of puberty and menopause. However, due to a lack of access to appropriate education, affordable and accessible menstrual hygiene care products and adequate sanitation, many girls and women in low- or middle-income countries, such as Zimbabwe, struggle to manage menstruation safely and with dignity. This can result in women and girls being denied basic human rights, such as access to education, or access to work.

In order to address the need for menstrual health management (MHM), we worked with a group of young Zimbabwean women to develop a suitable MHM intervention. It will include comprehensive educational materials, analgesia and menstrual health products, such as the menstrual cup, reusable pads and period pants. 

We will implement, and then evaluate, the MHM intervention within the two-year CHIEDZA study, an ongoing cluster-randomised trial of community-based, youth-friendly services to improve HIV outcomes in people aged 16-24 in Zimbabwe.

We will investigate the uptake of the MHM intervention by looking at participants’ product choices and their use of the products over time. We will assess its effectiveness by looking – over time – at participants’ pain management and their MHM knowledge, practices, and perceptions. And we will assess the acceptability of the intervention via a comprehensive qualitative appraisal of the products within the intervention and a process evaluation of the MHM intervention overall.

STITCH Study: STI in CHIEDZA

Lead Researcher: Suzanna Francis

Funders: MRC/DfID/NIHR

The STITCH study aims to evaluate the effectiveness of community-based screening for STIs using newer diagnostic technologies among youth in Zimbabwe. The study measures the uptake and yield of STI screening and comprehensive case management including partner notification. The impact of this intervention on population level prevalence of STIs will be measured in a subset in the CHIEDZA end line survey.

FAST: HIV self-testing for young people

Lead researcher: Grace McHugh

Funding: European & Developing Countries Clinical Trials Partnership (EDCTP), 2018-2020

Partners: SolidarMed, PSI, Ministry of Health and Child Care

Young people have the highest incidence of HIV in sub-Saharan Africa, but the lowest rates of testing. The Feasibility and Acceptability of HIV Self-Testing in adolescents and young people (FAST) study will investigate whether self-testing using oral mucosal transudate (OMT) tests could be a solution. An OMT test is a small oral swab that can be used to detect HIV antibodies in the inside cheek and around the gums.

We will distribute 5,000 OMT self-testing kits to young people aged 16-24 at tertiary education institutions. We will measure the proportion of people who complete a test and, if necessary, are referred for health care. We will also conduct qualitative interviews to understand young people’s experiences of HIV self-testing and the referral process.

Young people who receive the test kits will have the option of downloading a mobile app, ITHAKA, which gives step-by-step instructions on how to carry out the OMT test and allows users to submit their test results via the app; the cost of which will be  covered by pre-paid mobile phone data. Alternatively, they can choose to test at the distribution point, in a private booth.

B-GAP: identifying and supporting children with HIV

Lead researcher: Chido Dziva Chikwari

Funding: UK Medical Research Council and DfID, 2017-2020. Also supported by Orasure.

Partners: OPHID, PSI, MMPZ, Duke Global Health Institute

B-GAP (Bridging the Gap) aims to investigate the impact and feasibility of interventions to identify and support children aged 2­–18 years who may have HIV.

The interventions are: 

• Counselling and HIV tests for children identified as living in households with HIV positive individuals (known as targeted testing, or index-linked testing)
• Visits by community health workers to support children who test positive for HIV, and their caregivers

By also estimating the costs and cost-effectiveness of the interventions, we will be able to determine what may be needed for these interventions to be implemented on a much wider scale and sustainable in the long term.

We will investigate the effectiveness of the HIV counselling and testing in identifying children with undiagnosed HIV, and we will also investigate the effectiveness of the community health worker visits in improving the children’s links with health care services and suppressing their viral load.

Another important component of the study is for us to learn as much as possible about the process of implementing the interventions, including the local context and the ‘mechanisms of impact’: the interplaying factors that determine to what extent the interventions will achieve the desired outcomes. These are: identifying children with HIV who are undiagnosed, improving their access to health care, and lowering their viral load.

 

Sub-studies

As part of the bigger B-GAP study, we are carrying out a sub-study on behalf of the World Health Organization (WHO) that involves evaluating whether caregivers can use a self-test kit to to test children and adolescents for HIV. The WHO will use our results to determine whether to approve the test kit or to make changes.

Another sub-study took place in 2018, when Chris Grundy and MSc student Edom Wessenyeleh did a mixed-methods pilot study to assess the feasibility and acceptability of strategies that would help allow people to record the location of their home in urban and rural areas using their own smartphones, a borrowed smartphone or a borrowed GPS device. This information is useful in many studies, for example to assess how far people have to travel to reach health services.

ZENITH: supporting families to help suppress children's HIV viral load

Lead researcher: Rashida Ferrand

Funding: Wellcome Trust

Partner: Child Protection Society

Older children and adolescents with HIV need help from their families to stay in care and adhere to treatment, but families do not always know how to support them.

In the ZENITH study (Zimbabwe study for Enhancing Testing and Improving Treatment of HIV in Children), we worked with a group of volunteers who visited the households of children aged 6-15 years who were newly diagnosed with HIV and discussed issues such as how to get access to other resources, the importance of adherence to treatment, and how to tell the child about their HIV status. We carried out a randomised controlled trial to test whether these visits could help children take their medication and stay virally suppressed.

In the group of families who were visited (the intervention group), 67% of children were virally suppressed a year after starting ART, compared to 51% in the control group. This is the first trial ever to show that community health workers could improve HIV viral suppression.

Key results paper

Ferrand RA, Simms V, Dauya E, Bandason T, McHugh G et al (2017). The effect of community-based support for caregivers on the risk of virological failure in children and adolescents with HIV in Harare, Zimbabwe (ZENITH): an open-label, randomised controlled trial. Lancet Child and Adolescent Health 1(3): 175-183

https://doi.org/10.1016/S2352-4642(17)30051-2

HIV and co-morbidities

• Determine the prevalence of low BMD among children with HIV compared to children without HIV
• Analyse the risk factors for low BMD among children with HIV Compare the rate of bone mass accrual between children with and without HIV

MENOPAUSE

Lead Researchers: Rashida Ferrand (Zimbabwe), Celia Gregson (UK), Lisa Micklesfield (South Africa)

Funders: University of Bristol Global Challenges Research Fund (GCRF) Investment Grant Scheme (UK)

Partners: BRTI, University of Bristol, University of the Witwatersrand, MRC Lifecourse Epidemiology Unit, University of Southampton, MRC Nutrition and Bone Health Research Group, Cambridge

Summary:  MENOPAUSE study: Understanding the impact of HIV infection and its treatment on the effect menopause has on the musculoskeletal health of African women

The scale-up of antiretroviral treatment has dramatically improved survival, such that across Africa, increasing numbers of women with chronic HIV are now reaching the menopause and beyond. The menopause is a period of metabolic change with effects on the skeleton associated with increased fracture risk. Research has seldom focused on African woman at this stage of life. We are investigating whether HIV infection and its treatments worsen menopausal bone loss, and whether good viral suppression, achieved through antiretroviral treatment (ART), attenuates this HIV effect. We are examining whether certain ARTs, eg. tenofovir, may have more detrimental effects on bone mass and architecture, and if HIV infection is associated with earlier menopause. Understanding patterns and mechanisms of bone loss in the context of HIV infection will help inform future interventions and guidelines.

The study has three work packages, firstly we will analyse data already collected 471 women followed-up over a 4 year period in Soweto, Johannesburg, secondly we will collect new data from 320 pre-, peri- and post-menopausal women in Harare in whom we will measure bone mineral density (BMD), muscle mass and function, amongst a wide range of co-morbidities. Thirdly we will interview women at different stages of menopause to understand country-specific contexts and women’s priorities at this stage in life. This body of work will involve team training and build musculoskeletal research capability in these areas, and expand the Sub-Saharan African MuSculOskeletal Network (SAMSON).
 

VITALITY

Principal Investigator: Rashida Ferrand

Funders: European & Developing Countries Clinical Trials Partnership (EDCTP)

Partners: University of Bristol, University Teaching Hospital of Zambia, Research Centre Borstel Leibniz Lung Center, Biomedical Research & Training Institute, University of Oxford, London School of Hygiene & Tropical Medicine, Sub-Saharan African Musculoskeletal Network, Ministry of Health & Child Welfare

One of the adverse effects of the HIV infection among children are bone deficiencies (skeletal development). Therefore, the purpose of this trial is to establish whether supplementation with vitamin D3 (weekly) and calcium carbonate (daily) improves musculoskeletal health among peripubertal CWH (children living with HIV) aged 10-19 years in Zambia and Zimbabwe over a period of 48 weeks. In addition to this, the study will also investigate the intervention's effect on muscle mass and strength and to determine the sustainability of the intervention's effects by performing a follow-up at 96 weeks after the supplementation period.

BREATHE: antibiotic trial for adolescents with HIV and chronic lung disease

Lead researcher: Grace McHugh

Funding: Medical Research Council of Norway, 2014-2019

Partners: Malawi-Liverpool Wellcome Programme

Nuffield Department of Medicine, University of Oxford

IDM, University of Cape Town

University of Tromso - the Arctic University of Norway

One of the most common conditions in children and adolescents with perinatal HIV is chronic lung disease, which may be caused by repeated infections that damage lung function over time.

In the BREATHE study (Bronchopulmonary function in response to azithromycin treatment for chronic lung disease in HIV-infected children), we are carrying out a randomised placebo-controlled trial of the antibiotic azithromycin, which is used in adolescents in Malawi and Zimbabwe who have HIV and symptoms of chronic lung disease. The trial is due to end in August 2019.

Key paper

Gonzalez-Martinez C, Kranzer K, McHugh G, Corbett EL, Mujur H et al (2017). Azithromycin versus placebo for the treatment of HIV-associated chronic lung disease in children and adolescents (BREATHE trial): study protocol for a randomised controlled trial. Trials 18(1):622

doi: 10.1186/s13063-017-2344-2

IMVASK: the impact of HIV on bone density in children

Lead Researcher: Ruramayi Rukuni

Funder: Wellcome Trust UK, 2018-2020

Impaired linear growth (stunting) is one of the most common manifestations of perinatally-acquired HIV and can adversely impact bone and muscle development and function, particularly during adolescence – a critical period of growth.

We hypothesise that children with HIV may have reduced bone mass accrual during adolescence, which will put them at increased risk of adverse musculoskeletal outcomes such as osteoporosis and fracture.

In the IMVASK study (the IMpact of Vertical HIV infection on child and Adolescent SKeletal development), we aim to determine the impact of HIV infection on bone mineral density (BMD) in peri-pubertal children aged 8–16 years who are established on antiretroviral therapy (ART).

 

We are part of the Sub-Saharan African Musculoskeletal Network (SAMSON), a research partnership across West, East and Southern Africa.

We will recruit two groups of children aged 8–16 years in Harare: 300 children with HIV and who are established on ART, and 300 HIV-negative children, who will be followed up over time in a prospective cohort study. Detailed musculoskeletal assessments including dual-energy X-ray absorptiometry (DXA) will be conducted at baseline and one year.

 

INHALE: chronic lung and cardiac disease in children and adolescents with HIV

Lead researcher: Edith Majonga

Funders: Wellcome Trust, Nina Ireland Program for Lung Health

Partners: University of Oxford, UCL Institute of Cardiovascular Science

Chronic lung and cardiac disease are very common in children and adolescents with perinatal HIV. The INHALE study: (Investigation of Heart and Lung Diseases in HIV among older children) aims to explore the features and causes of chronic lung and cardiac disease among older children and adolescents with perinatally-acquired HIV.

We aim to:

• Understand the risk factors clinical features, prevalence and progression of lung and cardiac disease in older children and adolescents (aged 6-16 years) living with perinatally-acquired HIV
• Explore the possible pathogenic mechanisms that may be associated with chronic lung disease in these children
• Determine normal ranges for heart structure and lung capacity among older children in Zimbabwe who do not have HIV, using echocardiography and spirometry

Key Papers

Majonga ED, Rehman AM, McHugh G, Mujuru HA, Nathoo K, Patel MS, Munyati S, Odland JO, Kranzer K, Kaski JP and Ferrand RA. Echocardiographic reference ranges in older children and adolescents in sub-Saharan Africa. International Journal of Cardiology. 2017; 248: 409-13.

DOI: https://doi.org/10.1016/j.ijcard.2017.06.109

http://researchonline.lshtm.ac.uk/4121180/

 

Majonga ED, Rehman AM, Simms V, McHugh G, Mujuru HA, Nathoo K, Odland JO, Patel MS, Kaski J and Ferrand RA. High prevalence of echocardiographic abnormalities in older HIV-infected children taking antiretroviral therapy. AIDS. 2018.

DOI: https://doi.org/10.1097/QAD.0000000000002031

http://researchonline.lshtm.ac.uk/4649646/

Infection and AMR

ICAROZ

 Impact of the COVID-19 pandemic on health care workers and the health care system in Zimbabwe

Lead researcher: Prof Katharina Kranzer

Funder: University of Bristol 

Host institute: Biomedical Research & Training Institute (BRTI)

Collaborators: Dr Justen Manasa (BRTI), Prof Chiratidzo Ndhlovu (University of Zimbabwe), Dr Hilda Mujuru (University of Zimbabwe), Prof Simbarashe Rusakaniko (University of Zimbabwe)

We hypothesise that frontline health care workers are pivotal to SARS-CoV-2 response and establishing rapid SARS-CoV-2 testing and communication of results for healthcare workers will help to prevent nosocomial transmission, reduce transmission in the community and lay the foundation for an effective and robust surveillance system.
The aim of this study is to implement comprehensive occupational health services including SAR-CoV-2 testing integrated with screening for major causes of morbidity and mortality in frontline health care workers, with rapid feedback of results to reduce nosocomial spread and trace household contacts.

Erase TB

Principal Investigators: Dr Theodora Mbunda, Dr Celso Khosa, Dr Junior Mutsvanga

Funders: European & Developing Countries Clinical Trials Partnership (EDCPT), European Union

Partners: London School of Hygiene & Tropical Medicine, Biomedical Research & Training Institute, Mbeya Medical Research Centre, Karolinska Institutet, Medical Center of the University of Munich, Instituto Nacional de Saúde, Ministry of Health & Child Welfare, Harare City Health, National TB Program, Cepheid, Biomerieux, Beckman Coulter, SD Biosensor

Erase TB is a study that seeks to evaluate new diagnostic tests for detecting tuberculosis (TB) in its early stages. Recent studies demonstrate that the infection transitions between less active and more active states and therefore if the disease is detected in its early stages, we can prevent it from becoming infectious.

The study will enrol 2100 household contacts, people living in close proximity with someone recently diagnosed with TB. We will perform a follow-up every six months over a minimum period of 18 months and a maximum period of 24 months. We will actively diagnose TB using CXR and WHO symptom screen followed by Xpert MTB/RIF testing, if screened positive. All participants will have blood and urine samples stored for investigation at a later point in time.

FIEBRE: causes of fever and antimicrobial resistance

Principal Investigator: Dr Katharina Kranzer

Lead researcher: Ioana Olaru

Social scientist: Salome Manyau

Funding: UK Department for International Development (DfID)

Across sub-Saharan Africa and Asia, one of the most common symptoms to prompt someone to seek healthcare or be admitted to hospital is fever. With limited diagnostic facilities the cause of fever can be difficult to determine, and often patients are given antibiotics they may not need. The aim of FIEBRE is to identify the causes of fever, and the antimicrobial susceptibility of bacterial pathogens causing fever, in low- and middle-income country settings where few data are available.

Listen to Dr Katharina Kranzer explain the study:

Thu, 11/28/2019 - 10:11

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The Febrile Illness Evaluation in a Broad Range of Endemicities (FIEBRE) study will investigate the causes of fever in five countries: Zimbabwe, Lao PDR, Malawi, Mozambique and Myanmar. The results will help to inform updated, evidence-based algorithms for the management of febrile illnesses and provide data that may be used to design new diagnostics and rational approaches to disease surveillance. These outputs will ultimately help health systems and providers to provide more appropriate care to patients and lead to better clinical outcomes. In Zimbabwe, the FIEBRE study has contributed to the detection of ciprofloxacin-resistance in Salmonella Typhi which will lead to collaborations with the National Microbiology Reference Laboratory.

FIEBRE also includes social science research to understand how fever and antimicrobial use are understood and conceptualised, and how social factors shape access to and use of antimicrobials.

ARGUS

Lead researcher: Ioana Olaru

Funder: UK Department for International Development (DfID), 2018-2021

Antimicrobial Resistance in Gram-negative bacteria from Urinary Specimens (ARGUS) is a study of the prevalence, risk factors and molecular mechanisms of AMR. The aims of this study are

• to determine prevalence of and underlying molecular mechanisms for antimicrobial resistance in gram negative bacteria causing urinary tract infections in Zimbabwe
• to investigate risk factors for antimicrobial resistance
• to examine how antimicrobial resistance impacts on clinical outcome
• to evaluate antibiotic consumption and prescribing practices at the primary clinic level

The study is expected to provide valuable information on the prevalence of antibiotic resistance and will inform treatment guidelines, as well as strategies to prevent development of antibiotic resistance. The information on antibiotic consumption will be used to optimise prescription practices and contribute to limiting the spread of antimicrobial resistance.

Neonatal sepsis: reducing mortality of babies in hospital

 

Lead researcher: Felicity Fitzgerald

Funding: Healthcare Infection Society

The Neonatal Sepsis study will investigate ways of reducing mortality from infection (sepsis), usually bacterial, in newborn babies (neonates) in Zimbabwe.

This pilot study uses a mixed-methods approach and will include ethnographic observations and in-depth interviews to:

• Identify key factors that limit effective infection prevention and control (IPC) in the neonatal unit at Harare Children’s Hospital
• Examine how these factors can be modified to improve IPC

 

We will also evaluate the impact of NeoTree, a tablet-based application that allows health professionals to collect data in real time, receive blood culture results as soon as they are available, and receive support when making decisions about management and treatment.

We want to know whether the use of NeoTree:

• Reduces the length of stay in the neonatal unit
• Increases the use of appropriate antibiotics – i.e. the correct antibiotic for a particular blood culture result
• Reduces the mortality rate