Articles tagged as "Preventing HIV infection in children"

Women know what they want, but need more reproductive health choices

Editor’s notes: Eliminating new HIV infections among children is often seen as a useful barometer of the overall success of the health systems as it relates to HIV.  Combination prevention approaches that include structural, behavioural and biomedical elements reduce the chance of women becoming HIV-positive.  Effective provision of a range of choices of modern contraceptive technology allow women to choose whether and when to have babies.  The option B+ approach should ensure that all pregnant women living with HIV are offered lifelong ART, which minimises the chance of mother to child transmission of HIV infection.  Continuing ART treatment for life keeps the mother healthy and allows her to support the development of her infant.

New HIV infections in children have declined by 46% since 2010, but there were still an estimated 160 000 new infections in 2016.  We know that in many settings the health system barometer is still forecasting plenty of clouds among the bright spells.  This month saw a range of papers describing reproductive health choices and HIV, as well as reflections on how option B+ is working, now that it is standard of care.

Contraceptive choices for women at high risk of HIV or living with HIV are complicated.  WHO recently reclassified long-acting progestin injections, such as DMPA, for women at high risk of HIV infection as category 2 in the Medical Eligibility for Contraception guidance. Category 2 means that, although the method is generally safe to use, clinical judgment and careful follow up may be required.  While the evidence comes from meta-analyses of observational studies, with inherent limitations, there is a reliable association between new HIV infection and the use of injectable progestins.  The ongoing randomized ECHO trial will provide higher quality evidence of causality, but results will not be reported until 2019. 

Mayhew et al. found that women living with HIV attending clinics in Kenya, were quite clear about their fertility intentions.  Many did not want more children, although they acknowledged pressure from partners and others.  Stigma around breast-feeding, worries about money and about possible health consequences of pregnancy were all reasons to decide not to have further children. The large majority used various sorts of contraception, but despite this 40% of pregnancies during the study were unintended.  The authors felt that the advice given by the clinics was not adequate and that choice of contraceptive method was limited.  In particular reliable long-acting methods, both reversible and not, were rarely taken up by the younger women.  Overall 16% of women used long-acting methods, and no pregnancies occurred in this group.

Chanda et al. focused on female sex workers in Zambia and found similar results.  Almost half the women had had terminations of pregnancies, and 62% of pregnancies were not planned.  Interestingly the availability of condoms at their places of work reduced the chances of unwanted pregnancy.  Approximately 39% used injectable long-acting contraceptives and only 18% used dual protection with a barrier in addition to a non-barrier method.  Less than one-third of the women reported that condoms were available often or always at work, and 23% reported using no contraception.  Providing access to condoms for sex workers in the highest transmission areas of countries like Zambia seems such an obvious pre-requisite for HIV programmes that it is extraordinary that in 2017 we still do not manage to do so.

Finally on this theme, Salters et al. demonstrate that contraceptive choice for women living with HIV is not only a challenge in sub-Saharan Africa.  The authors followed women in the Canadian HIV Women's Sexual and Reproductive Health Cohort Study and showed that 61% of reported pregnancies were unintended. Women with unintended pregnancies tended to be younger, single and born in Canada compared to women with planned pregnancies.  To support the second prong of the strategy to eliminate HIV infections in children, we need to improve on the integration between services for sexual and reproductive health and rights and services for women living with HIV.

Once women living with HIV are pregnant, the focus shifts to the third and fourth prong – preventing transmission to the infant and keeping the mother and infant healthy.  Option B+ has transformed the approach in most antenatal clinics with high rates of coverage of HIV testing and most women receiving ART during pregnancy.  In the One Stop Clinic in Ifakara, Tanzania, Gamell et al. show that almost all pregnant women, who do not already know that they are living with HIV, are offered an HIV test and that 94% accept it.  Retesting late in pregnancy is not yet routine, and only 3% were re-tested, of whom one (2%) had seroconverted.  Since acute HIV infection has such an important impact on the risk of transmission, re-testing later in pregnancy is now routine in many countries.  Coverage is far from complete, so it is not always clear whether the high rates of seroconversion observed reflect a selection bias in choosing women who are at particularly high risk.  This is an important area for research if we are to continue to drive down the already low transmission rates.  Similarly the authors found that women who slipped through the net and presented in labour, were not always tested and did have a higher prevalence of infection - 5.2% vs. 3.1%. The other significant finding in Ifakara was that, as in many cohort studies, women were happy to take ART during pregnancy to protect their infants, but retention in care thereafter was much less impressive.  Of women newly diagnosed with HIV infection during pregnancy, 27% were lost to follow up at the time of the analysis.

Chadambuka et al. used qualitative methods to understand what impact the shift to option B+ has had in their study area in Zimbabwe.  Overall, the women interviewed were very positive about treatment.  They believed that it was good for their babies and also good for them, making them look healthy and thus avoiding stigma.  However, women pointed out that their male partners are not exposed to as much information at the clinic or in the community.  As a result, many men are less keen to be tested and sometimes not keen for their partners to be taking medicine despite appearing healthy.  As one woman put it: “Very few men are supportive. You have to be strong. The men base their judgment on how healthy you appear to be as you carry yourself around and he also compares to how healthy he feels and opts to delay testing. But delaying only brings further harm. So when those men tell you to stop taking your medication, you need to tell them that they can stop if they want to, whilst you continue with your treatment.”  Within the power dynamics of many relationships, such a forthright approach may not be easy for all women.  So we need continued attention on how to engage men in the process and how to empower women to act as agents of change within their communities.

 

Fertility intentions and contraceptive practices among clinic-users living with HIV in Kenya: a mixed methods study

Mayhew SH, Colombini M, Kimani JK, Tomlin K, Warren CE; Integra Initiative, Mutemwa R. BMC Public Health. 2017 Jul 5;17(1):626. doi: 10.1186/s12889-017-4514-2.

Background: Preventing unwanted pregnancies in Women Living with HIV (WLHIV) is a recognised HIV-prevention strategy. This study explores the fertility intentions and contraceptive practices of WLHIV using services in Kenya.

Methods: Two hundred forty women self-identifying as WLHIV who attended reproductive health services in Kenya were interviewed with a structured questionnaire in 2011; 48 were also interviewed in-depth. STATA SE/13.1, Nvivo 8 and thematic analysis were used.

Results: Seventy one percent participants did not want another child; this was associated with having at least two living children and being the bread-winnerFP use was high (92%) but so were unintended pregnancies (40%) while living with HIV. 56 women reported becoming pregnant "while using FP": all were using condoms or short-term methods. Only 16% participants used effective long-acting reversible contraceptives or permanent methods (LARC-PM). Being older than 25 years and separated, widowed or divorced were significant predictors of long-term method use. Qualitative data revealed strong motivation among WLHIV to plan or prevent pregnancies to avoid negative health consequences. Few participants received good information about contraceptive choices.

Conclusions: WLHIV need better access to FP advice and a wider range of contraceptives including LARC to enable informed choices that will protect their fertility intentions, ensure planned pregnancies and promote safe child-bearing.

Trial registration: Integra is a non-randomised pre-post intervention trial registered with Current Controlled Trials ID: NCT01694862.

Abstract  Full-text [free] access

 

Contraceptive use and unplanned pregnancy among female sex workers in Zambia

Chanda MM, Ortblad KF, Mwale M, Chongo S, Kanchele C, Kamungoma N, Barresi LG, Harling G, Bärnighausen T, Oldenburg CE. Contraception. 2017 Sep;96(3):196-202. doi: 10.1016/j.contraception.2017.07.003. Epub 2017 Jul 12.

Objectives: Access to reproductive healthcare, including contraceptive services, is an essential component of comprehensive healthcare for female sex workers (FSW). Here, we evaluated the prevalence of and factors associated with contraceptive use, unplanned pregnancy, and pregnancy termination among FSW in three transit towns in Zambia.

Study design: Data arose from the baseline quantitative survey from a randomized controlled trial of HIV self-testing among FSW. Eligible participants were 18 years of age or older, exchanged sex for money or goods at least once in the past month, and were HIV-uninfected or status unknown without recent HIV testing (<3 months). Logistic regression models were used to assess factors associated with contraceptive use and unplanned pregnancy.

Results: Of 946 women eligible for this analysis, 84.1% had been pregnant at least once, and among those 61.6% had an unplanned pregnancy, and 47.7% had a terminated pregnancyIncarceration was associated with decreased odds of dual contraception use (aOR=0.46, 95% CI 0.32-0.67) and increased odds of unplanned pregnancy (aOR=1.75, 95% CI 1.56-1.97). Condom availability at work was associated with increased odds of using condoms only for contraception (aOR=1.74, 95% CI 1.21-2.51) and decreased odds of unplanned pregnancy (aOR=0.63, 95% CI 0.61-0.64).

Conclusions: FSW in this setting have large unmet reproductive health needs. Structural interventions, such as increasing condom availability in workplaces, may be useful for reducing the burden of unplanned pregnancy.

Abstract  Full-text [free] access

 

Pregnancy incidence and intention after HIV diagnosis among women living with HIV in Canada

Salters K, Loutfy M, de Pokomandy A, Money D, Pick N, Wang L, Jabbari S, Carter A, Webster K, Conway T, Dubuc D, O'Brien N, Proulx-Boucher K, Kaida A; CHIWOS Research Team. PLoS One. 2017 Jul 20;12(7):e0180524. doi: 10.1371/journal.pone.0180524. eCollection 2017.

Background: Pregnancy incidence rates among women living with HIV (WLWH) have increased over time due to longer life expectancy, improved health status, and improved access to and HIV prevention benefits of combination antiretroviral therapy (cART). However, it is unclear whether intended or unintended pregnancies are contributing to observed increases.

Methods: We analyzed retrospective data from the Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS). Kaplan-Meier methods and GEE Poisson models were used to measure cumulative incidence and incidence rate of pregnancy after HIV diagnosis overall, and by pregnancy intention. We used multivariable logistic regression models to examine independent correlates of unintended pregnancy among the most recent/current pregnancy.

Results: Of 1165 WLWH included in this analysis, 278 (23.9%) women reported 492 pregnancies after HIV diagnosis, 60.8% of which were unintendedUnintended pregnancy incidence (24.6 per 1000 women-years (WYs); 95% CI: 21.0, 28.7) was higher than intended pregnancy incidence (16.6 per 1000 WYs; 95% CI: 13.8, 20.1) (Rate Ratio: 1.5, 95% CI: 1.2-1.8). Pregnancy incidence among WLWH who initiated cART before or during pregnancy (29.1 per 1000 WYs with 95% CI: 25.1, 33.8) was higher than among WLWH not on cART during pregnancy (11.9 per 1000 WYs; 95% CI: 9.5, 14.9) (Rate Ratio: 2.4, 95% CI: 2.0-3.0). Women with current or recent unintended pregnancy (vs. intended pregnancy) had higher adjusted odds of being single (AOR: 1.94; 95% CI: 1.10, 3.42), younger at time of conception (AOR: 0.95 per year increase, 95% CI: 0.90, 0.99), and being born in Canada (AOR: 2.76, 95% CI: 1.55, 4.92).

Conclusion: Nearly one-quarter of women reported pregnancy after HIV diagnosis, with 61% of all pregnancies reported as unintended. Integrated HIV and reproductive health care programming is required to better support WLWH to optimize pregnancy planning and outcomes and to prevent unintended pregnancy.

Abstract  Full-text [free] access

 

Prevention of mother-to-child transmission of HIV Option B+ cascade in rural Tanzania: the One Stop Clinic model

Gamell A, Luwanda LB, Kalinjuma AV, Samson L, Ntamatungiro AJ, Weisser M, Gingo W, Tanner M, Hatz C, Letang E, Battegay M; KIULARCO Study Group. PLoS One. 2017 Jul 12;12(7):e0181096. doi: 10.1371/journal.pone.0181096. eCollection 2017.

Background: Strategies to improve the uptake of Prevention of Mother-To-Child Transmission of HIV (PMTCT) are needed. We integrated HIV and maternal, newborn and child health services in a One Stop Clinic to improve the PMTCT cascade in a rural Tanzanian setting.

Methods: The One Stop Clinic of Ifakara offers integral care to HIV-infected pregnant women and their families at one single place and time. All pregnant women and HIV-exposed infants attended during the first year of Option B+ implementation (04/2014-03/2015) were includedPMTCT was assessed at the antenatal clinic (ANC), HIV care and labour ward, and compared with the pre-B+ period. We also characterised HIV-infected pregnant women and evaluated the MTCT rate.

Results: 1579 women attended the ANC. Seven (0.4%) were known to be HIV-infectedOf the remainder, 98.5% (1548/1572) were offered an HIV test94% (1456/1548) accepted and 38 (2.6%) tested HIV-positive51 were re-screened for HIV during late pregnancy and one had seroconvertedThe HIV prevalence at the ANC was 3.1% (46/1463). Of the 39 newly diagnosed women, 35 (90%) were linked to care. HIV test was offered to >98% of ANC clients during both the pre- and post-B+ periods. During the post-B+ period, test acceptance (94% versus 90.5%, p<0.0001) and linkage to care (90% versus 26%, p<0.0001) increasedTen additional women diagnosed outside the ANC were linked to care. 82% (37/45) of these newly-enrolled women started antiretroviral treatment (ART). After a median time of 17 months, 27% (12/45) were lost to follow-up. 79 women under HIV care became pregnant and all received ART. After a median follow-up time of 19 months, 6% (5/79) had been lost. 5727 women delivered at the hospital, 20% (1155/5727) had unknown HIV serostatus. Of these, 30% (345/1155) were tested for HIV, and 18/345 (5.2%) were HIV-positive. Compared to the pre-B+ period more women were tested during labour (30% versus 2.4%, p<0.0001). During the study, the MTCT rate was 2.2%.

Conclusions: The implementation of Option B+ through an integrated service delivery model resulted in universal HIV testing in the ANC, high rates of linkage to care, and MTCT below the elimination threshold. However, HIV testing in late pregnancy and labour, and retention during early ART need to be improved.

Abstract  Full-text [free] access

 

Acceptability of lifelong treatment among HIV-positive pregnant and breastfeeding women (Option B+) in selected health facilities in Zimbabwe: a qualitative study

Chadambuka A, Katirayi L, Muchedzi A, Tumbare E, Musarandega R, Mahomva AI, Woelk G BMC Public Health. 2017 Jul 25;18(1):57. doi: 10.1186/s12889-017-4611-2.

Background: Zimbabwe's Ministry of Health and Child Care (MOHCC) adopted 2013 World Health Organization (WHO) prevention of mother-to-child HIV transmission (PMTCT) guidelines recommending initiation of HIV-positive pregnant and breastfeeding women (PPBW) on lifelong antiretroviral treatment (ART) irrespective of clinical stage (Option B+). Option B+ was officially launched in Zimbabwe in November 2013; however the acceptability of life-long ART and its potential uptake among women was not known.

Methods: A qualitative study was conducted at selected sites in Harare (urban) and Zvimba (rural) to explore Option B+ acceptability; barriers, and facilitators to ART adherence and service uptake. In-depth interviews (IDIs), focus group discussions (FGDs) and key informant interviews (KIIs) were conducted with PPBW, healthcare providers, and community members. All interviews were audio-recorded, transcribed, and translated; data were coded and analyzed in MaxQDA v10.

Results: Forty-three IDIs, 22 FGDs, and five KIIs were conducted. The majority of women accepted lifelong ART. There was however, a fear of commitment to taking lifelong medication because they were afraid of defaulting, especially after cessation of breastfeeding. There was confusion around dosage; and fear of side effects, not having enough food to take drugs, and the lack of opportunities to ask questions in counseling. Participants reported the need for strengthening community sensitization for Option B+. Facilitators included receiving a simplified pill regimen; ability to continue breastfeeding beyond 6 months like HIV-negative women; and partner, community and health worker support. Barriers included distance of health facility, non-disclosure of HIV status, poor male partner support and knowing someone who had negative experience on ART.

Conclusions: This study found that Option B+ is generally accepted among PPBW as a means to strengthen their health and protect their babies. Consistent with previous literature, this study demonstrated the importance of male partner and community support in satisfactory adherence to ART and enhancing counseling techniques. Strengthening community sensitization and male knowledge is critical to encourage women to disclose their HIV status and ensure successful adherence to ART. Targeting and engaging partners of women will remain key determinants to women's acceptance and adherence on ART under Option B+

Abstract  Full-text [free] access

Africa, Northern America
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Increasing HIV testing by sharing the load and updating tasks and traditions for traditional birth attendants and lay providers

Editor’s notes: Nigeria still has the highest number of new HIV infections among children in the world, around 40 000 annually, with the large majority arising from mother to child transmission.  In Nigeria, less than 20% of pregnant women receive HIV testing. This is due to several issues which include a limited number of HIV testing service delivery points and a limited number of deliveries taking place at health facilities.  Around two thirds of deliveries take place at home, traditionally supported by traditional birth attendants (TBAs).  Many TBAs in Nigeria have little knowledge of either the benefits or practice of HIV testing, nor of ways to reduce transmission of HIV to infants.

Chizoba and colleagues have developed and tested a model of antenatal care that aims to integrate TBAs within the government primary health care (PHC) network.  The intervention consisted of PHC clinics identifying a few TBAs who operated in the catchment area of the clinic. Between one and five of these TBAs was invited to the PHC clinic for a one-day training on HIV point of care testing, and asked to refer all women found to be positive to the clinic for confirmation and follow up.  Once a month TBAs came to the clinic for encouragement and to provide data on tests performed.  Once a quarter, the clinic visited the TBAs to provide supervision, mentoring and quality improvement training.  The TBAs were also paid $2 for every pregnant woman whom they tested for HIV, in order to compensate them for any loss of earnings from pregnant women living with HIV who would now be seen in the clinic rather than delivering at home. 

The authors used a quasi-experimental design for this study. Out of the 74 PEPFAR supported PHC clinics that provided HIV services in their antenatal clinics in Ebonyi state of Nigeria, 34 were interested in this new integrated approach, whereas 40 expressed no interest.  20 clinics were chosen at random from each of these categories, to avoid additional selection bias.  (Although as the authors state, there may already be considerable differences between the clinics that were interested and clinics that were not).  Comparisons were made before and after the programme was put in place, and also between clinics in the intervention group and those in the group that had not been interested to integrate services with the TBAs.

Despite this non-randomized design, the results are quite striking with more than twice as many women receiving HIV testing in the intervention clinics in the six months after the intervention began (going up from 2501 to 5346 across the 20 clinics).  There was no such increase in the non-intervention areas (which saw a change from 1770 to 1892 across the 20 clinics).  Furthermore the large majority of the increase was among women who had been tested by the TBAs. 

While this is hugely encouraging and a big increase, it will be important to see if the increase can be sustained as it is a significant change in the way that the TBAs and the PHC clinic staff work.  It is also not clear how much the increase is a result of the integration model and how much it relates to the additional payment that TBAs receive, which seems to amount to around $100 per TBA over the 6 month period of the assessment.

A thorough review of the role of trained lay providers in performing HIV tests was carried out as part of the WHO process that led to the guidance in 2015 that “Lay providers who are trained and supervised to use rapid diagnostic tests (RDTs) can independently conduct safe and effective HIV testing services.” Kennedy and colleagues now present the details of that systematic review.

Many national policies, particularly in African countries allow for HIV testing by trained lay providers using rapid diagnostic tests (RDTs) and even more allow lay providers to perform pre- and post-test counselling (around 80% of African countries in one survey of policies).  However, some countries limit these roles to trained healthcare providers due to concerns about lay providers’ ability to perform the tests accurately and reliably and to deliver high quality pre- and post-test counselling, linkage to appropriate prevention and clinical care services, and coordination with laboratory services to ensure the delivery of correct test results.

Despite widespread use of lay providers, there are actually rather few studies that directly compare the outcomes of testing between lay and professional providers.  The authors reviewed over 6000 titles, abstracts or full articles and found only five that allowed a direct comparison, while an additional six studies allowed the values and preferences of clients and providers to be assessed.

While this evidence base is very limited, findings from the single randomized trial (in the US) and one observational study (in Malawi), that compared pre- and post-intervention time periods, suggest that using trained lay providers can increase HIV testing uptake.  Three studies compared the quality of testing between lay providers and professional providers and found that both can achieve similar testing quality. Unfortunately, no studies measured adverse events following testing, nor linkage to care. The six values and preferences studies, also found support for lay providers.

This is the key evidence that underpins the strong recommendation from WHO and now also from many national authorities, that trained lay providers are an essential component in the efforts to scale up HIV testing in order to reach the first 90.

Increasing HIV testing among pregnant women in Nigeria: evaluating the traditional birth attendant and primary health center integration (TAP-In) model.

Chizoba AF, Pharr JR, Oodo G, Ezeobi E, Ilozumb J, Egharevba J, Ezeanolue EE, Nwandu A. AIDS Care. 2017 Apr 18:1-5. doi: 10.1080/09540121.2017.1317325. [Epub ahead of print]

Engaging Traditional Birth Attendants (TBAs) may be critical to preventing mother-to-child transmission of HIV (PMTCT) in Nigeria. We integrated TBAs into Primary Health Centers (PHCs) and provided the TBAs with HIV counseling and testing (HCT) training for PMTCT (TAP-In). The purpose of this study was to evaluate the impact of TAP-In on HCT uptake among pregnant women. A quasi-experimental design was used for this study. Twenty PHCs were assigned to the intervention group that integrated TAP-In and 20 were assigned to the control group. Data were collected six months prior to the initiation of TAP-In and six months post, using antenatal clinic registries. Intervention PHCs more than doubled the number of pregnant women who received HCT in their catchment area post TAP-In while control PHCs had no significant change. After initiating TAP-In, intervention PHCs provided almost three times more HCT than the control PHCs (p < 0.01) with TBA provided over half of the HCT post TAP-In. The TAP-In model was effective for increasing HCT among pregnant women.

Abstract access 

Should trained lay providers perform HIV testing? A systematic review to inform World Health Organization guidelines.

Kennedy CE, Yeh PT, Johnson C, Baggaley R. AIDS Care. 2017 Apr 24:1-7. doi:10.1080/09540121.2017.1317710. [Epub ahead of print.]

New strategies for HIV testing services (HTS) are needed to achieve UN 90-90-90 targets, including diagnosis of 90% of people living with HIV. Task-sharing HTS to trained lay providers may alleviate health worker shortages and better reach target groups. We conducted a systematic review of studies evaluating HTS by lay providers using rapid diagnostic tests (RDTs). Peer-reviewed articles were included if they compared HTS using RDTs performed by trained lay providers to HTS by health professionals, or to no intervention. We also reviewed data on end-users' values and preferences around lay providers preforming HTS. Searching was conducted through 10 online databases, reviewing reference lists, and contacting experts. Screening and data abstraction were conducted in duplicate using systematic methods. Of 6113 unique citations identified, 5 studies were included in the effectiveness review and 6 in the values and preferences review. One US-based randomized trial found patients' uptake of HTS doubled with lay providers (57% vs. 27%, percent difference: 30, 95% confidence interval: 27-32, p < 0.001). In Malawi, a pre/post study showed increases in HTS sites and tests after delegation to lay providers. Studies from Cambodia, Malawi, and South Africa comparing testing quality between lay providers and laboratory staff found little discordance and high sensitivity and specificity (≥98%). Values and preferences studies generally found support for lay providers conducting HTS, particularly in non-hypothetical scenarios. Based on evidence supporting using trained lay providers, a WHO expert panel recommended lay providers be allowed to conduct HTS using HIV RDTs. Uptake of this recommendation could expand HIV testing to more people globally.

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Africa, Asia
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Adolescents and PMTCT services: where are the gaps?

PMTCT service uptake among adolescents and adult women attending antenatal care in selected health facilities in Zimbabwe.

Musarandega R, Machekano R, Chideme M, Muchuchuti C, Mushavi A, Mahomva A, Guay L. J Acquir Immune Defic Syndr. 2017 Feb 20. doi: 10.1097/QAI.0000000000001327. [Epub ahead of print]

Background: Age-disaggregated analyses of prevention of mother-to-child transmission (PMTCT) program data to assess the uptake of HIV services by pregnant adolescent women are limited but are critical to understanding the unique needs of this vulnerable, high risk population.

Methods: We conducted a retrospective analysis of patient-level PMTCT data collected from 2011 to 2013 in 36 health facilities in 5 districts of Zimbabwe using an electronic database. We compared uptake proportions for PMTCT services between adolescent (< 19 years) and adult (> 19 years) women. Multivariable binomial regression analysis was used to estimate the association of the women's age group with each PMTCT service indicator.

Results: The study analysed data from 22 215 women aged 12 to 50 years (22.5% adolescents). Adolescents were more likely to present to ANC before 14 weeks gestational age compared to older women (adjusted relative risk (aRR)=1.34; 95% confidence interval (CI): 1.22-1.47) with equally low rates of completion of four ANC visits. Adolescents were less likely to present with known HIV status (aRR=0.34; 95% CI: 0.29-0.41) but equally likely to be HIV tested in ANC. HIV prevalence was 5.5% in adolescents versus 20.1% in adults. While > 84% of both HIV-positive groups received ARVs for PMTCT, 44% of eligible adolescents were initiated on ART versus 51.3% of eligible adults, though not statistically significant.

Conclusions: Pregnant adolescents must be a priority for primary HIV prevention services and expanded HIV treatment services among pregnant women to achieve an AIDS-free generation in Zimbabwe and similar high HIV burden countries.

Abstract access  

Editor’s notes: Young women continue to be a key population at risk of acquiring HIV, and contribute approximately one-third of all new infections in sub-Saharan Africa. Young women face multiple legal, economic and social vulnerabilities that place them not only at higher risk of acquiring HIV but may also have an impact on their ability to access antenatal care (ANC) services and programmes to prevent mother-to-child HIV transmission (PMTCT) if they get pregnant. This in turn has implications for the goal of eliminating paediatric HIV infection.

This retrospective study compared the uptake of PMTCT services between adolescents (people aged 19 years and below) and older women accessing ANC in 36 public sector services across Zimbabwe. The study was conducted between 2011 and 2013, when PMTCT guidelines recommended Option A. Option A called for life-long antiretroviral therapy (ART) for women who were ART-eligible based on immunological or clinical criteria; or, for people ineligible, zidovudine monotherapy through pregnancy followed by single dose nevirapine at the onset of labour. It is no longer formally recommended by World Health Organization (WHO), although it is still used in some countries.      

Nearly a quarter of all women were adolescents and over 80% were on their first pregnancy or primigravid. Adolescent women were 34% more likely to attend their first ANC visit by 14 weeks of gestational age compared to adult women. But among both groups, only about 10% attended their first ANC visit in the first trimester and less than 40% attended the four antenatal visits recommended by WHO. Notably, knowledge of HIV status prior to the first ANC attendance was 66% lower in adolescent women, even after adjusting for parity and facility type, with only 3.1% aware of their HIV status. In addition, the proportion of women who were known HIV-positive and taking ART was also lower, although this may be due partly to fewer adolescents being eligible for ART. The uptake of HIV testing (over 95%) and uptake of zidovudine prophylaxis was high among all women. However, there was a suggestion that adolescents were less likely than older women to start ART if they were eligible, although this was not statistically significant. Indeed, several studies in the region have demonstrated lower levels of ART initiation among pregnant adolescents compared to older women.  

Older women would have been more likely to have undergone HIV testing in previous pregnancies. However, even after adjusting for parity, this study demonstrates that adolescents are less likely to have previously accessed HIV testing. Common barriers to testing highlighted by other studies include lack of information, unavailability of HIV testing services, unfriendly HIV testing environments in health facilities and the need for parental consent. Lack of knowledge of HIV status prior to pregnancy is also a missed opportunity for family planning, and initiation of ART prior to pregnancy. The substantial difference in HIV prevalence among adolescents compared to older women highlights the critical need for implementing prevention programmes such as pre-exposure prophylaxis among young women in high HIV prevalence settings. While adolescents are less likely to be tested for HIV in the general population than adults, this study illustrates that when HIV testing is offered in appropriate, supportive environments, uptake is high.

Overall, the uptake of HIV testing and of prophylaxis were high, demonstrating the potential for eliminating infections in children. A major limitation is that this analysis was limited to women who had sought antenatal care. Promoting early ANC attendance is important to allow early ART initiation, to reduce the risk of intrauterine HIV transmission. Following a positive HIV test result, particular attention is necessary to ensure linkage to care and support for sustained adherence to ART.

Africa
Zimbabwe
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Creating welcoming spaces for men’s active involvement

What do you need to get male partners of pregnant women tested for HIV in resource limited settings? The baby shower cluster randomized trial.

Ezeanolue EE, Obiefune MC, Yang W, Ezeanolue CO, Pharr J, Osuji A, Ogidi AG, Hunt AT, Patel D, Ogedegbe G, Ehiri JE. AIDS Behav. 2016 Dec 8. [Epub ahead of print]

Male partner involvement has the potential to increase uptake of interventions to prevent mother-to-child transmission of HIV (PMTCT). Finding cultural appropriate strategies to promote male partner involvement in PMTCT programs remains an abiding public health challenge. We assessed whether a congregation-based intervention, the Healthy Beginning Initiative (HBI), would lead to increased uptake of HIV testing among male partners of pregnant women during pregnancy. A cluster-randomized controlled trial of forty churches in Southeastern Nigeria randomly assigned to either the HBI (intervention group; IG) or standard of care referral to a health facility (control group; CG) was conducted. Participants in the IG received education and were offered onsite HIV testing. Overall, 2498 male partners enrolled and participated, a participation rate of 88.9%. Results showed that male partners in the IG were 12 times more likely to have had an HIV test compared to male partners of pregnant women in the CG (CG = 37.71% vs. IG = 84.00%; adjusted odds ratio = 11.9; p < .01). Culturally appropriate and community-based interventions can be effective in increasing HIV testing and counseling among male partners of pregnant women.

Abstract  Full-text [free] access

Editor’s notes: Barriers to male partner participation in antenatal care in sub-Saharan Africa include the timing of antenatal services during work hours and negative health care provider attitudes. Importantly, they also include gender norms against male participation that are anchored in deep-seated perceptions that pregnancy is a woman’s affair. This highly successful trial resulted in verified HIV testing by 84% of male partners in the programme group and 38% in the control group, well above the overall HIV testing uptake by males in Nigeria at the time of 23%. What were the elements of the programme that contributed to its success? Critically, it was conducted in communities where religious institutions and their leaders have strong community influence and where nearly 90% of the population attends places of worship. Next, it proposed integrated testing (haemoglobin, malaria, sickle cell genotype, HIV, hepatitis B, and syphilis) to reduce stigma associated with HIV testing. It included the haemoglobin test because men indicated in the formative stages that they wanted this test to find out how strong they were. Then, it engaged the couples publically, with the religious leader inviting all pregnant women and their partners each Sunday to approach the altar for a prayer, accompanied by information about the baby shower programme and the importance of antenatal care. The programme ran baby showers monthly for all participants with the programme group playing an educational game and being offered free integrated HIV testing. The control group was referred to a local health facility for antenatal care and free HIV testing. At baby receptions held every two to three months, the control groups were offered free integrated HIV testing. All in all, HIV testing for male partners was convenient, free, and integrated with other tests that men wanted. It was provided in a family-centred, congregation-based enabling environment that supported men to step forward with their pregnant partners to learn their HIV status. Such a strategy could work in other settings where influential community leaders are prepared to lead the design and implementation of innovative HIV prevention programmes that resonate with community cultural and spiritual values.

Africa
Nigeria
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Is universal antenatal HIV testing still cost-effective?

Should HIV testing for all pregnant women continue? Cost-effectiveness of universal antenatal testing compared to focused approaches across high to very low HIV prevalence settings.

Ishikawa N, Dalal S, Johnson C, Hogan DR, Shimbo T, Shaffer N, Pendse RN, Lo YR, Ghidinelli MN, Baggaley R. J Int AIDS Soc. 2016 Dec 14;19(1):21212. doi: 10.7448/IAS.19.1.21212. eCollection 2016.

Introduction: HIV testing is the entry point for the elimination of mother-to-child transmission of HIV. Decreasing external funding for the HIV response in some low- and middle-income countries has triggered the question of whether a focused approach to HIV testing targeting pregnant women in high-burden areas should be considered. This study aimed at determining and comparing the cost-effectiveness of universal and focused HIV testing approaches for pregnant women across high to very low HIV prevalence settings.

Methods: We conducted a modelling analysis on health and cost outcomes of HIV testing for pregnant women using four country-based case scenarios (Namibia, Kenya, Haiti and Viet Nam) to illustrate high, intermediate, low and very low HIV prevalence settings. We used subnational prevalence data to divide each country into high-, medium- and low-burden areas, and modelled different antenatal and testing coverage in each.

Results: When HIV testing services were only focused in high-burden areas within a country, mother-to-child transmission rates remained high ranging from 18 to 23%, resulting in a 25 to 69% increase in new paediatric HIV infections and increased future treatment costs for children. Universal HIV testing was found to be dominant (i.e. more QALYs gained with less cost) compared to focused approaches in the Namibia, Kenya and Haiti scenarios. The universal approach was also very cost-effective compared to focused approaches, with $ 125 per quality-adjusted life years gained in the Viet Nam-based scenario of very low HIV prevalence. Sensitivity analysis further supported the findings.

Conclusions: Universal approach to antenatal HIV testing achieves the best health outcomes and is cost-saving or cost-effective in the long term across the range of HIV prevalence settings. It is further a prerequisite for quality maternal and child healthcare and for the elimination of mother-to-child transmission of HIV.

Abstract  Full-text [free] access 

Editor’s notes: This paper describes research undertaken to support the consolidated guidelines on HIV testing services, published by World Health Organization in 2015. This analysis was conducted in response to growing questions as to whether focused HIV testing in high prevalence areas can improve value for money in investment for HIV testing.

A model was parameterized to represent four scenarios with high, intermediate, low, and very low HIV prevalence settings (Namibia, Kenya, Haiti, and Viet Nam). Three approaches to HIV testing in antenatal care are considered in comparison with current coverage in each setting. These three approaches were: a very focused approach, a targeted approach, and a universal testing approach for all pregnant women.  The authors estimate the costs and effects of each scenario, including the future costs of treating paediatric HIV for 20 years. Universal testing was found to be cost-saving in Namibia, Kenya and Haiti and was found to be cost-effective in Viet Nam ($125 per QALY gained).  The targeted testing approach was also more cost-effective than current coverage in all settings.

The clear policy implication from this analysis is that HIV testing for pregnant women saves both money and lives in the long term. Universal HIV testing in antenatal care can be regarded as a good investment in almost any HIV prevalence setting. However, it is also important to note that targeted testing was more cost-effective than current coverage in all settings. Countries that are currently struggling to provide testing in antenatal care may need to consider factors other than cost-effectiveness in their planning and strategy for scaling up. This is important in order to address HIV at a national scale.  

Africa, Asia, Latin America
Haiti, Kenya, Namibia, Viet Nam
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Antiretroviral therapy in pregnancy is not associated with an increased risk of preterm delivery

PMTCT Option B+ does not increase preterm birth risk and may prevent extreme prematurity: A retrospective cohort study in Malawi.

Chagomerana MB, Miller WC, Pence BW, Hosseinipour MC, Hoffman IF, Flick RJ, Tweya H, Mumba S, Chibwandira F, Powers KA. J Acquir Immune Defic Syndr. 2016 Nov 21. [Epub ahead of print]

Objective: To estimate preterm birth risk among infants of HIV-infected women in Lilongwe, Malawi according to maternal antiretroviral therapy (ART) status and initiation time under Option B+.

Design: Retrospective cohort study of HIV-infected women delivering at ≥27 weeks of gestation, April 2012- November 2015. Among women on ART at delivery, we restricted our analysis to those who initiated ART before 27 weeks of gestation.

Methods: We defined preterm birth as a singleton live birth at ≥27 and <37 weeks of gestation, with births at <32 weeks classified as extremely to very preterm. We used log-binomial models to estimate risk ratios (RR) and 95% confidence intervals (CIs) for the association between ART and preterm birth.

Results: Among 3074 women included in our analyses, 731 preterm deliveries were observed (24%). Overall preterm birth risk was similar in women who had initiated ART at any point before 27 weeks and those who never initiated ART (RR = 1.14; 95% CI: 0.84 - 1.55), but risk of extremely to very preterm birth was 2.33 (1.39 - 3.92) times as great in those who never initiated ART compared to those who did at any point before 27 weeks. Among women on ART before delivery, ART initiation before conception was associated with the lowest preterm birth risk.

Conclusions: ART during pregnancy was not associated with preterm birth, and it may in fact be protective against severe adverse outcomes accompanying extremely to very preterm birth. As pre-conception ART initiation appears especially protective, long-term retention on ART should be a priority to minimize preterm birth in subsequent pregnancies.

Abstract access  

Editor’s notes: Effectively delivered antiretroviral therapy (ART) in pregnancy virtually eliminates the risk of mother-to-child HIV transmission and has been widely adopted. Option B+ is a strategy to start all HIV-positive pregnant women on ART regardless of their CD4 count or other HIV parameters and to continue it indefinitely after delivery to further protect the mother’s health. Balanced against the substantial health gains from the use of ART in pregnancy have been concerns that they may make some adverse pregnancy outcomes more common. Concerns about teratogenicity and birth defects with commonly-used drugs have largely gone as more data has accumulated but prematurity has remained an issue. There has been conflicting evidence from previous studies. Some have suggested an increased risk of preterm birth but others, including meta-analysis, have not. Many earlier studies were predominantly of women with advanced HIV disease, a group with an already-increased risk of preterm birth, and included single- or dual-drug regimens that are no longer recommended. Thus, the results of earlier studies may not be generalizable to women with early stage HIV disease who are being offered newer ART regimens in the context of Option B+.

This study has shown no increase in preterm birth associated with ART in pregnancy, and in fact a statistically and clinically significant protective effect for very early birth (before 32 weeks gestational age). It is a large, thorough and impressive piece of work but has the limitations of any observational study. The risk of unmeasured confounders can never be eliminated; in this case perhaps economic status or level of education. No precise data are presented on the ARV combinations used but it is implied that the great majority of women received efavirenz-based treatment, in accordance with national guidelines in Malawi. Previous studies have suggested that protease inhibitors may be responsible for increased preterm birth. The present study cannot address this question.

This large study of pregnancy outcomes from Option B+ should reassure HIV-positive women and their clinicians that no significant harms were found to be associated with this strategy.  

Africa
Malawi
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School-based HIV prevention programmes appear ineffective

School-based interventions for preventing HIV, sexually transmitted infections, and pregnancy in adolescents.

Mason-Jones AJ, Sinclair D, Mathews C, Kagee A, Hillman A, Lombard C. Cochrane Database Syst Rev. 2016 Nov 8;11:CD006417.

Background: School-based sexual and reproductive health programmes are widely accepted as an approach to reducing high-risk sexual behaviour among adolescents. Many studies and systematic reviews have concentrated on measuring effects on knowledge or self-reported behaviour rather than biological outcomes, such as pregnancy or prevalence of sexually transmitted infections (STIs).

Objectives: To evaluate the effects of school-based sexual and reproductive health programmes on sexually transmitted infections (such as HIV, herpes simplex virus, and syphilis), and pregnancy among adolescents.

Search methods: We searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) for published peer-reviewed journal articles; and ClinicalTrials.gov and the World Health Organization's (WHO) International Clinical Trials Registry Platform for prospective trials; AIDS Education and Global Information System (AEGIS) and National Library of Medicine (NLM) gateway for conference presentations; and the Centers for Disease Control and Prevention (CDC), UNAIDS, the WHO and the National Health Service (NHS) centre for Reviews and Dissemination (CRD) websites from 1990 to 7 April 2016. We hand searched the reference lists of all relevant papers.

Selection criteria: We included randomized controlled trials (RCTs), both individually randomized and cluster-randomized, that evaluated school-based programmes aimed at improving the sexual and reproductive health of adolescents.

Data collection and analysis: Two review authors independently assessed trials for inclusion, evaluated risk of bias, and extracted data. When appropriate, we obtained summary measures of treatment effect through a random-effects meta-analysis and we reported them using risk ratios (RR) with 95% confidence intervals (CIs). We assessed the certainty of the evidence using the GRADE approach.

Main results: We included eight cluster-RCTs that enrolled 55,157 participants. Five trials were conducted in sub-Saharan Africa (Malawi, South Africa, Tanzania, Zimbabwe, and Kenya), one in Latin America (Chile), and two in Europe (England and Scotland). Sexual and reproductive health educational programmes. Six trials evaluated school-based educational interventions. In these trials, the educational programmes evaluated had no demonstrable effect on the prevalence of HIV (RR 1.03, 95% CI 0.80 to 1.32, three trials; 14 163 participants; low certainty evidence), or other STIs (herpes simplex virus prevalence: RR 1.04, 95% CI 0.94 to 1.15; three trials, 17 445 participants; moderate certainty evidence; syphilis prevalence: RR 0.81, 95% CI 0.47 to 1.39; one trial, 6977 participants; low certainty evidence). There was also no apparent effect on the number of young women who were pregnant at the end of the trial (RR 0.99, 95% CI 0.84 to 1.16; three trials, 8280 participants; moderate certainty evidence). Material or monetary incentive-based programmes to promote school attendance. Two trials evaluated incentive-based programmes to promote school attendance. In these two trials, the incentives used had no demonstrable effect on HIV prevalence (RR 1.23, 95% CI 0.51 to 2.96; two trials, 3805 participants; low certainty evidence). Compared to controls, the prevalence of herpes simplex virus infection was lower in young women receiving a monthly cash incentive to stay in school (RR 0.30, 95% CI 0.11 to 0.85), but not in young people given free school uniforms (data not pooled, two trials, 7229 participants; very low certainty evidence). One trial evaluated the effects on syphilis and the prevalence was too low to detect or exclude effects confidently (RR 0.41, 95% CI 0.05 to 3.27; one trial, 1291 participants; very low certainty evidence). However, the number of young women who were pregnant at the end of the trial was lower among those who received incentives (RR 0.76, 95% CI 0.58 to 0.99; two trials, 4200 participants; low certainty evidence). Combined educational and incentive-based programmes. The single trial that evaluated free school uniforms also included a trial arm in which participants received both uniforms and a programme of sexual and reproductive education. In this trial arm herpes simplex virus infection was reduced (RR 0.82, 95% CI 0.68 to 0.99; one trial, 5899 participants; low certainty evidence), predominantly in young women, but no effect was detected for HIV or pregnancy (low certainty evidence).

Authors' conclusions: There is a continued need to provide health services to adolescents that include contraceptive choices and condoms and that involve them in the design of services. Schools may be a good place in which to provide these services. There is little evidence that educational curriculum-based programmes alone are effective in improving sexual and reproductive health outcomes for adolescents. Incentive-based interventions that focus on keeping young people in secondary school may reduce adolescent pregnancy but further trials are needed to confirm this.

Abstract  Full-text [free] access 

Editor’s notes: School-based HIV prevention programmes are widespread worldwide. These programmes use educational institutions as a venue to reach a population that is entering sexual maturity. Several systematic reviews have found beneficial effects of these programmes on HIV-associated knowledge and behaviours, though a subsequent effect of reduced HIV incidence remains unconfirmed. In this systematic review and meta-analysis, the authors included eight randomized controlled trials from sub-Saharan Africa, Europe, and Latin America. Whether using a curriculum- or incentive-based programme, the trials did not provide evidence of an effect of school-based programmes on reducing HIV infection. Nor was there compelling evidence of an effect of these programmes on reducing sexually transmitted infection or pregnancy. This paper highlights the difficulty of translating knowledge and reported behaviors into reductions in HIV infection and other biological outcomes. Further thought is necessary to deliver effective sexual and reproductive health programmes in schools – possibly including incentives, which show some promise but need further evidence on effectiveness. 

Africa, Europe, Latin America
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Engaging men in antenatal care: a win-win for healthy families

Male partner participation in antenatal clinic services is associated with improved HIV-free survival among infants in Nairobi, Kenya: a prospective cohort study.

Aluisio AR, Bosire R, Bourke B, Gatuguta A, Kiarie JN, Nduati R, John-Stewart G, Farquhar C. J Acquir Immune Defic Syndr. 2016 Oct 1;73(2):169-76. doi: 10.1097/QAI.0000000000001038.

Objective: This prospective study investigated the relationship between male antenatal clinic (ANC) involvement and infant HIV-free survival.

Methods: From 2009 to 2013, HIV-infected pregnant women were enrolled from 6 ANCs in Nairobi, Kenya and followed with their infants until 6 weeks postpartum. Male partners were encouraged to attend antenatally through invitation letters. Men who failed to attend had questionnaires sent for self-completion postnatally. Multivariate regression was used to identify correlates of male attendance. The role of male involvement in infant outcomes of HIV infection, mortality, and HIV-free survival was examined.

Results: Among 830 enrolled women, 519 (62.5%) consented to male participation and 136 (26.2%) men attended the ANC. For the 383 (73.8%) women whose partners failed to attend, 63 (16.4%) were surveyed through outreach. In multivariate analysis, male report of previous HIV testing was associated with maternal ANC attendance (adjusted odds ratio = 3.7; 95% CI: 1.5 to 8.9, P = 0.003). Thirty-five (6.6%) of 501 infants acquired HIV or died by 6 weeks of life. HIV-free survival was significantly greater among infants born to women with partner attendance (97.7%) than those without (91.3%) (P = 0.01). Infants lacking male ANC engagement had an approximately 4-fold higher risk of death or infection compared with those born to women with partner attendance (HR = 3.95, 95% CI: 1.21 to 12.89, P = 0.023). Adjusting for antiretroviral use, the risk of death or infection remained significantly greater for infants born to mothers without male participation (adjusted hazards ratio = 3.79, 95% CI: 1.15 to 12.42, P = 0.028).

Conclusions: Male ANC attendance was associated with improved infant HIV-free survival. Promotion of male HIV testing and engagement in ANC/prevention of mother-to-child transmission services may improve infant outcomes.

Abstract access

Editor’s notes: Although new HIV infections among children have declined by a striking 50% since 2010, 150 000 children [110 000–190 000] worldwide became newly infected with HIV in 2015. Getting to zero and achieving virtual elimination of mother-to-child HIV transmission will require all hands on deck – and that includes fathers. This study has several limitations but its findings stand: lack of involvement by fathers in the antenatal care (ANC) of their HIV-positive pregnant partner increased four-fold their offspring’s risk of death or HIV infection by six weeks of life. How exactly ANC involvement of fathers might increase the HIV-free survival of their babies is unclear. In multivariate analysis, only male report of previous HIV testing was associated with men’s ANC engagement. However, factors found significant in univariate analysis were: disclosure of HIV-positive status by women, mutual discussion of mother-to-child transmission, having undergone couples voluntary counselling and testing, and being in a monogamous partnership. There was no difference between men who attended and men who did not in terms of age, employment status, or level of education – all of which one might think could be associated with male engagement in ANC. These results beg more questions. Given the HIV-survival benefits for children, how can we enhance male HIV testing and ANC involvement? In country after country, men living with HIV are less likely to know their serostatus than are women. They are therefore less likely to start antiretroviral treatment in a timely manner to reap its clinical benefits for themselves and reduce the risk of HIV transmission for others. Trials are necessary to test innovative strategies to reach men with HIV testing, on their own or through couples testing and by location such as at work sites, in community service settings, at sporting and other special events, through home-based testing, and in the context of antenatal care. Mixed methods studies are necessary to better understand beneficial partnership characteristics and individual barriers and facilitators of male involvement in antenatal care. The results would inform the design of effective programmes and approaches. The benefits for the father, mother, and baby of enhanced male engagement in ANC might go well beyond HIV to encompass the health of all family members. 

 

Africa
Kenya
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Street children are vulnerable to HIV in Tehran, Iran

Prevalence of HIV, HBV and HCV among street and labour children in Tehran, Iran.

Foroughi M, Moayedi-Nia S, Shoghli A, Bayanolhagh S, Sedaghat A, Mohajeri M, Mousavinasab SN, Mohraz M. Sex Transm Infect. 2016 Sep 6. pii: sextrans-2016-052557. doi: 10.1136/sextrans-2016-052557. [Epub ahead of print]

Objectives: The existence of street and working children in Iran is undeniable. The precarious conditions of these children (including disrupted family, poverty, high prevalence of crime among relatives, family members and peers) cause social harm and high-risk behaviours, including drug addiction, selling sex or having sex with adolescents or peers. Here we explore the HIV, hepatitis B and hepatitis C status of street and working children in Tehran.

Methods: One thousand street and labour children, aged 10-18 years, were recruited by using the time-location sampling method, and semistructured questionnaires were used to find demographic information and information on HIV/AIDS-related high-risk sexual behaviours. Blood samples were collected from children, with use of the dried blood sampling method.

Results: 4.5% of children were HIV infected, 1.7% were infected with hepatitis B virus and 2.6% were infected with hepatitis C virus (HCV). Having parents who used drug, infected with HCV and having experience in trading sex significantly increased the likelihood of getting HIV among the street children of Tehran.

Conclusion: HIV prevalence among street children is much higher than general population (<0.1%), and in fact, the rate of positivity comes close to that among female sex workers in Iran. These findings must be an alarm for HIV policymakers to consider immediate and special interventions for this at-risk group.

Abstract access 

Editor’s notes: Relatively few studies have been published on the prevalence of HIV and other communicable diseases in vulnerable populations in Iran. This paper presents results from a prevalence study among street children in Tehran, Iran. Researchers were able to survey 1000 street children, and children exploited by labour between the ages of 10-18, finding an HIV prevalence of 4.5%. The survey data revealed high rates of physical abuse, drug use, and school dropout, but it is not clear whether any of the children were already aware of their HIV status, or how many had acquired HIV perinatally. These important findings point to the imperative for programmes to address the needs of street children in Tehran, and additional research in other areas within the country where similar issues may be prevalent. 

Asia
Iran (Islamic Republic of)
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‘Scared of going there’ – barriers to HIV treatment for pregnant women in Tanzania

Stigma, facility constraints, and personal disbelief: why women disengage from HIV care during and after pregnancy in Morogoro region, Tanzania.

McMahon SA, Kennedy CE, Winch PJ, Kombe M, Killewo J, Kilewo C. AIDS Behav. 2016 Aug 17. [Epub ahead of print]

Millions of children are living with HIV in sub-Saharan Africa, and the primary mode of these childhood infections is mother-to-child transmission. While existing interventions can virtually eliminate such transmission, in low- and middle-income settings, only 63% of pregnant women living with HIV accessed medicines necessary to prevent transmission. In Tanzania, HIV prevalence among pregnant women is 3.2%. Understanding why HIV-positive women disengage from care during and after pregnancy can inform efforts to reduce the impact of HIV on mothers and young children. Informed by the tenets of Grounded Theory, we conducted qualitative interviews with 40 seropositive postpartum women who had disengaged from care to prevent mother-to-child transmission (PMTCT). Nearly all women described antiretroviral treatment (ART) as ultimately beneficial but effectively inaccessible given concerns related to stigma. Many women also described how their feelings of health and vitality coupled with concerns about side effects underscored a desire to forgo ART until they deemed it immediately necessary. Relatively fewer women described not knowing or forgetting that they needed to continue their treatment regimens. We present a theory of PMTCT disengagement outlining primary and ancillary barriers. This study is among the first to examine disengagement by interviewing women who had actually discontinued care. We urge that a combination of intervention approaches such as mother-to-mother support groups, electronic medical records with same-day tracing, task shifting, and mobile technology be adapted, implemented, and evaluated within the Tanzanian setting.

Abstract access  

Editor’s notes: The push for universal access to antiretroviral therapy for everyone living with HIV faces many obstacles.  In many parts of the world, pregnant women are offered HIV testing as a part of antenatal care. Treatment is then offered if a woman is found to be HIV-positive. Many women accept this care, having been provided with the information that this is beneficial for their baby and also themselves. Some women who accept treatment take themselves out of care. This can be detrimental not only for the HIV status of their baby, but also for their general antenatal care. As the authors of this paper note, there is a growing body of literature that describes losses to care from the provider perspective. There are also a number of papers about women who have accepted care, who describe why others refuse treatment.  It is unusual to find detailed findings from interviews with women who have dropped out of or refused HIV treatment while pregnant. While the findings are not particularly surprising, the authors of this paper have captured the individual reasons why the 40 women interviewed in their study, left or never entered care. The reasons given underline the challenge of ‘prompt treatment’. Many women were not ready for immediate treatment.  Fears of the clinic layout ‘betraying’ a woman’s status are described. So too are the negative attitudes of health providers as well as family and community members. The authors provide an excellent example of how good qualitative research, conducted and analysed in an exemplary manner, offers valuable insights. This paper provides valuable information on an often hidden minority of women who are not ready or able ‘to test and treat’.

Africa
United Republic of Tanzania
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