Articles tagged as "Preventing HIV infection in children"

HIV-exposed uninfected children – why the increased mortality risk?

HIV-exposed children account for more than half of 24-month mortality in Botswana.

Zash R, Souda S, Leidner J, Ribaudo H, Binda K, Moyo S, Powis KM, Petlo C, Mmalane M, Makhema J, Essex M, Lockman S, Shapiro R. BMC Pediatr. 2016 Jul 21;16:103. doi: 10.1186/s12887-016-0635-5.

Background: The contribution of HIV-exposure to childhood mortality in a setting with widespread antiretroviral treatment (ART) availability has not been determined.

Methods: From January 2012 to March 2013, mothers were enrolled within 48 h of delivery at 5 government postpartum wards in Botswana. Participants were followed by phone 1-3 monthly for 24 months. Risk factors for 24-month survival were assessed by Cox proportional hazards modeling.

Results: Three thousand mothers (1499 HIV-infected) and their 3033 children (1515 HIV-exposed) were enrolled. During pregnancy 58% received three-drug ART, 23% received zidovudine alone, 11% received no antiretrovirals (8% unknown); 2.1% of children were HIV-infected by 24 months. Vital status at 24 months was known for 3018 (99.5%) children; 106 (3.5%) died including 12 (38%) HIV-infected, 70 (4.7%) HIV-exposed uninfected, and 24 (1.6%) HIV-unexposed. Risk factors for mortality were child HIV-infection (aHR 22.6, 95% CI 10.7, 47.5), child HIV-exposure (aHR 2.7, 95% CI 1.7, 4.5) and maternal death (aHR 8.9, 95% CI 2.1, 37.1). Replacement feeding predicted mortality when modeled separately from HIV-exposure (aHR 2.3, 95% CI 1.5, 3.6), but colinearity with HIV-exposure status precluded investigation of its independent effect. Applied at the population level (26% maternal HIV prevalence), an estimated 52% of child mortality occurs among HIV-exposed or HIV-infected children.

Conclusions: In a programmatic setting with high maternal HIV prevalence and widespread maternal and child ART availability, HIV-exposed and HIV-infected children still account for most deaths at 24 months. Lack of breastfeeding was a likely contributor to excess mortality among HIV-exposed children.

Abstract  Full-text [free] access 

Editor’s notes: It has been known for some time that HIV-exposed but uninfected children have a higher risk of death than HIV-unexposed children. There is now a need for prospective studies to explore the mechanisms underlying this observation. In this study from Botswana, one of every 20 HIV-exposed but uninfected children had died by 24 months. Four in every five deaths in the HIV-exposed but uninfected children were attributed to infectious diseases, most commonly diarrhoeal illness and respiratory infections.

The analysis was unfortunately not able to unpick the effect of infant feeding on mortality in the HIV-exposed uninfected children. Only 16% of HIV-exposed children were breastfed. This is consistent with national guidelines at the time, where formula feeding was recommended for mothers living with HIV. It is reassuring that in recently updated national guidelines, exclusive breastfeeding for six months is now recommended for mothers living with HIV on ART with virologic suppression.

Mother-to-child HIV transmission at 24 months was still around 2%, and further infections may have been undiagnosed in children who died before being tested. More than one in three children living with HIV died within 24 months. This reminds us that while there is increasing interest in HIV-exposed uninfected children, our priority for now should still be achieving elimination of mother-to-child HIV transmission.

Africa
Botswana
  • share
0 comments.

Identifying important proximal epidemiological parameters for HIV prevention

Prospects for HIV control in South Africa: a model-based analysis.

Johnson LF, Chiu C, Myer L, Davies MA, Dorrington RE, Bekker LG, Boulle A, Meyer-Rath G. Glob Health Action. 2016 Jun 8;9:30314. doi: 10.3402/gha.v9.30314. eCollection 2016.

Background: The goal of virtual elimination of horizontal and mother-to-child HIV transmission in South Africa (SA) has been proposed, but there have been few systematic investigations of which interventions are likely to be most critical to reducing HIV incidence.

Objective: This study aims to evaluate SA's potential to achieve virtual elimination targets and to identify which interventions will be most critical to achieving HIV incidence reductions.

Design: A mathematical model was developed to simulate the population-level impact of different HIV interventions in SA. Probability distributions were specified to represent uncertainty around 32 epidemiological parameters that could be influenced by interventions, and correlation coefficients (r) were calculated to assess the sensitivity of the adult HIV incidence rates and mother-to-child transmission rates (2015-2035) to each epidemiological parameter.

Results: HIV incidence in SA adults (ages 15-49) is expected to decline from 1.4% in 2011-2012 to 0.29% by 2035 (95% CI: 0.10-0.62%). The parameters most strongly correlated with future adult HIV incidence are the rate of viral suppression after initiating antiretroviral treatment (ART) (r=-0.56), the level of condom use in non-marital relationships (r=-0.40), the phase-in of intensified risk-reduction counselling for HIV-positive adults (r=0.29), the uptake of medical male circumcision (r=-0.24) and the phase-in of universal ART eligibility (r=0.22). The paediatric HIV parameters most strongly associated with mother-to-child transmission rates are the relative risk of transmission through breastfeeding when the mother is receiving ART (r=0.70) and the rate of ART initiation during pregnancy (r=-0.16).

Conclusions: The virtual elimination target of a 0.1% incidence rate in adults will be difficult to achieve. Interventions that address the infectiousness of patients after ART initiation will be particularly critical to achieving long-term HIV incidence declines in South Africa.

Abstract  Full-text [free] access 

Editor’s notes: Despite substantial progress in controlling HIV in South Africa, incidence rates remain very high. There is a continued need to identify and prioritise HIV prevention programmes to improve the impact of existing programmes. A deterministic compartmental model was used to simulate the impact of HIV programmes in South Africa. The modeling study aimed at identifying proximal epidemiological parameters that are important in reducing HIV incidence. The authors of this paper also aimed to evaluate the possibility of achieving the ‘virtual elimination’ targets that have been suggested for both heterosexual and mother-to-child transmission and the UNAIDS 90-90-90 treatment target. The model was parameterised using behavioural and demographic data for South Africa.  The results from the study suggest that for the purpose of preventing heterosexual and mother-to-child transmission of HIV in South Africa, the most important proximal epidemiological parameter to focus on is the infectiousness of people receiving antiretroviral therapy. The model predicts that the virtual elimination target of a 0.1% incidence rate in adults will be difficult to achieve. The authors emphasized on the need to scale-up existing HIV prevention and treatment programmes in order to reduce HIV incidence in South Africa.

Africa
South Africa
  • share
0 comments.

Increased adolescent testing

Increased adolescent HIV testing with a hybrid mobile strategy in Uganda and Kenya.

Kadede K, Ruel T, Kabami J, Ssemmondo E, Sang N, Kwarisiima D, Bukusi E, Cohen CR, Liegler T, Clark TD, Charlebois ED, Petersen ML, Kamya MR, Havlir DV, Chamie G, SEARCH team. AIDS. 2016 Jun 1. [Epub ahead of print]

Objective: We sought to increase adolescent HIV testing across rural communities in east Africa and identify predictors of undiagnosed HIV.

Design: Hybrid mobile testing.

Methods: We enumerated 116 326 adolescents (10-24 years) in 32 communities of Uganda and Kenya (SEARCH: NCT01864603): 98 694 (85%) reported stable (≥6 months of prior year) residence. In each community we performed hybrid testing: 2- week multi-disease community health campaign (CHC) that included HIV testing, followed by home-based testing of CHC non-participants. We measured adolescent HIV testing coverage and prevalence, and determined predictors of newly-diagnosed HIV among HIV+ adolescents using multivariable logistic regression.

Results: 86 421 (88%) stable adolescents tested for HIV; coverage was 86%, 90%, and 88% in early (10-14), mid (15-17) and late (18-24) adolescents, respectively. Self- reported prior testing was 9%, 26%, and 55% in early, mid and late adolescents tested, respectively. HIV prevalence among adolescents tested was 1.6% and 0.6% in Ugandan women and men, and 7.1% and 1.5% in Kenyan women and men, respectively. Prevalence increased in mid-adolescence for women, and late adolescence for men. Among HIV+ adolescents, 58% reported newly-diagnosed HIV. In multivariate analysis of HIV+ adolescents, predictors of newly-diagnosed HIV included male gender (OR = 1.97 [95%CI: 1.42-2.73]), Ugandan residence (OR = 2.63 [95%CI: 2.08-3.31]), and single status (OR = 1.62 [95%CI: 1.23-2.14] vs. married).

Conclusions: The SEARCH hybrid strategy tested 88% of stable adolescents for HIV, a substantial increase over the 28% reporting prior testing. The majority (57%) of HIV+ adolescents were new diagnoses. Mobile HIV testing for adults should be leveraged to reach adolescents for HIV treatment and prevention.

Abstract access 

Editor’s notes: Ending the AIDS epidemic requires much greater focus on adolescents, among whom HIV associated deaths is a leading cause of death in sub-Saharan Africa. Critical behaviours that are likely to impact on future health, such as risky sexual behaviour, often begin in adolescence. However, it is estimated that less than a third of adolescents in sub-Saharan Africa have been tested for HIV. In this paper, the authors report the impact of a hybrid community-based mobile testing approach to increase HIV testing among adolescents in rural communities in East Africa. This model, which does not rely on accessing schools or clinics, is very suitable for this age group, given the low rates of school attendance among female adolescents and the low use of clinic-based services by adolescents. A high rate of HIV testing was achieved, and testing for HIV in a multi-disease context may have enabled adolescents to access testing without fear of being stigmatised. However, uptake of testing is only the first stage in the HIV prevention and treatment cascade, and further data on the proportion of people testing positive who link to care and start treatment, and people testing negative who link to prevention services, are necessary. 

Africa
Kenya, Uganda
  • share
0 comments.

A booster dose of HIV prevention

Adolescent HIV risk reduction in the Bahamas: results from two randomized controlled intervention trials spanning elementary school through high school.

Stanton B, Dinaj-Koci V, Wang B, Deveaux L, Lunn S, Li X, Rolle G, Brathwaite N, Marshall S, Gomez P. AIDS Behav. 2016 Jun;20(6):1182-96. doi: 10.1007/s10461-015-1225-5.

To address global questions regarding the timing of HIV-prevention efforts targeting youth and the possible additional benefits of parental participation, researchers from the USA and The Bahamas conducted two sequential longitudinal, randomized trials of an evidence-based intervention spanning the adolescent years. The first trial involved 1360 grade-6 students and their parents with three years of follow-up and the second 2564 grade-10 students and their parents with two years of follow-up. Through grade-12, involvement in the combined child and parent-child HIV-risk reduction interventions resulted in increased consistent condom-use, abstinence/ protected sex, condom-use skills and parent-child communication about sex. Receipt of the grade-6 HIV-prevention intervention conferred lasting benefits regarding condom-use skills and self-efficacy. Youth who had not received the grade-six intervention experienced significantly greater improvement over baseline as a result of the grade-10 intervention. The HIV-risk reduction intervention delivered in either or both grade-6 and grade-10 conferred sustained benefits; receipt of both interventions appears to confer additional benefits.

Abstract access

Editor’s notes: Prevention of HIV infection in adolescents is key to combating HIV. In the Bahamas, two school-based programmes for adolescents were evaluated to answer key questions about the effect of school-based activities at different ages in adolescence, and the effect of including parental participation. This paper focused on the additional effect of a programme in mid-adolescence (age 15 to16) following an earlier programme (at age 10 to11). The early- and mid-adolescent programmes were similar. There were eight-sessions based on Protection Motivation Theory, using discussion and role play to increase knowledge and skills regarding sexual-risk avoidance, with the aim of changing behaviour. Both included a component for parents and children together, and both were effective at improving HIV knowledge, and reported condom-use skills and intentions.

Results illustrated that the early-adolescent programme had sustained effects throughout the following six years, and the mid-adolescent programme acted as a ‘booster’, conferring additional benefits including increased rates of reported consistent condom use and abstinence/protected sexual intercourse and increased condom-use skills. Participants who did not receive the early-adolescent programme gained more benefit from the mid-adolescent programme but had lower scores than youth who had both. Parental involvement was important, especially regarding condom-use skills. Although the results are promising, there is potential for biased reporting of self-reported behavioural outcomes, and it would be good to confirm these findings with biological outcomes including unplanned pregnancy and HSV-2 infection. 

Latin America
Bahamas
  • share
0 comments.

Minimal evidence for serious adverse events resulting from in utero ARV exposure

The PHACS SMARTT Study: assessment of the safety of in utero exposure to antiretroviral drugs.

Van Dyke RB, Chadwick EG, Hazra R, Williams PL, Seage GR, 3rd. Front Immunol. 2016 May 23;7:199. doi: 10.3389/fimmu.2016.00199. eCollection 2016.

The Surveillance Monitoring for ART Toxicities (SMARTT) cohort of the Pediatric HIV/AIDS Cohort Study includes over 3500 HIV-exposed but uninfected infants and children at 22 sites in the US, including Puerto Rico. The goal of the study is to determine the safety of in utero exposure to antiretrovirals (ARVs) and to estimate the incidence of adverse events. Domains being assessed include metabolic, growth and development, cardiac, neurological, neurodevelopmental (ND), behavior, language, and hearing. SMARTT employs an innovative trigger-based design as an efficient means to identify and evaluate adverse events. Participants who met a predefined clinical or laboratory threshold (trigger) undergo additional evaluations to define their case status. After adjusting for birth cohort and other factors, there was no significant increase in the likelihood of meeting overall case status (case in any domain) with exposure to combination ARVs (cARVs), any ARV class, or any specific ARV. However, several individual ARVs were significantly associated with case status in individual domains, including zidovudine for a metabolic case, first trimester stavudine for a language case, and didanosine plus stavudine for a ND case. We found an increased rate of preterm birth with first trimester exposure to protease inhibitor-based cARV. Although there was no overall increase in congenital anomalies with first trimester cARV, a significant increase was seen with exposure to atazanavir, ritonavir, and didanosine plus stavudine. Tenofovir exposure was associated with significantly lower mean whole-body bone mineral content in the newborn period and a lower length and head circumference at 1 year of age. With ND testing at 1 year of age, specific ARVs (atazanavir, ritonavir-boosted lopinavir, nelfinavir, and tenofovir) were associated with lower performance, although all groups were within the normal range. No ARVs or classes were associated with lower performance between 5 and 13 years of age. Atazanavir and saquinavir exposure were associated with late language emergence at 1 year, but not at 2 years of age. The results of the SMARTT study are generally reassuring, with little evidence for serious adverse events resulting from in utero ARV exposure. However, several findings of concern warrant further evaluation, and new ARVs used in pregnancy need to be evaluated.

Abstract  Full-text [free] access 

Editor’s notes: The SMARTT study set out to determine the safety of in utero exposure to antiretroviral (ARV) therapy using a trigger-based surveillance design to identify adverse events in a cohort of HIV-positive mothers and their HIV-exposed but HIV-negative children in the United States of America and Puerto Rico. A ‘trigger’ was set off if participants met a predefined clinical or laboratory threshold, with additional specified evaluations to determine if they met a predefined adverse event “case” definition.  After adjusting for birth cohort and other factors, there was no significant increase in the likelihood of meeting overall case status (case in any domain, such as growth and development or language etc.) with exposure to combination ARVs or any ARV class. No single ARV prophylaxis was associated with an increased risk of overall case status on adjusted analysis. However, several ARVs had significant associations in unadjusted analysis, namely between (1) maternal PI-based ARV prophylaxis during pregnancy and premature delivery and low birth weight; and (2) exposure to atazanavir and a twofold-higher risk of congenital anomalies. Overall the results from this study are reassuring, but some of the findings warrant further evaluation.

Latin America, Northern America
  • share
0 comments.

Family-focused, integrated prevention of mother-to-child HIV transmission care packages: the way forward for Nigeria?

Integrated prevention of mother-to-child HIV transmission services, antiretroviral therapy initiation, and maternal and infant retention in care in rural north-central Nigeria: a cluster-randomised controlled trial.

Aliyu MH, Blevins M, Audet CM, Kalish M, Gebi UI, Onwujekwe O, Lindegren ML, Shepherd BE, Wester CW, Vermund SH. Lancet HIV. 2016 May;3(5):e202-11. doi: 10.1016/S2352-3018(16)00018-7. Epub 2016 Feb 24.

Background: Antiretroviral therapy (ART) and retention in care are essential for the prevention of mother-to-child HIV transmission (PMTCT). We aimed to assess the effect of a family-focused, integrated PMTCT care package.

Methods: In this parallel, cluster-randomised controlled trial, we pair-matched 12 primary and secondary level health-care facilities located in rural north-central Nigeria. Clinic pairs were randomly assigned to intervention or standard of care (control) by computer-generated sequence. HIV-infected women (and their infants) presenting for antenatal care or delivery were included if they had unknown HIV status at presentation (there was no age limit for the study, but the youngest participant was 16 years old); history of antiretroviral prophylaxis or treatment, but not receiving these at presentation; or known HIV status but had never received treatment. Standard of care included health information, opt-out HIV testing, infant feeding counselling, referral for CD4 cell counts and treatment, home-based services, antiretroviral prophylaxis, and early infant diagnosis. The intervention package added task shifting, point-of-care CD4 testing, integrated mother and infant service provision, and male partner and community engagement. The primary outcomes were the proportion of eligible women who initiated ART and the proportion of women and their infants retained in care at 6 weeks and 12 weeks post partum (assessed by generalised linear mixed effects model with random effects for matched clinic pairs). The trial is registered with ClinicalTrials.gov, number NCT01805752.

Findings: Between April 1, 2013, and March 31, 2014, we enrolled 369 eligible women (172 intervention, 197 control), similar across groups for marital status, duration of HIV diagnosis, and distance to facility. Median CD4 count was 424 cells per µL (IQR 268-606) in the intervention group and 314 cells per µL (245-406) in the control group (p<0.0001). Of the 369 women included in the study, 363 (98%) had WHO clinical stage 1 disease, 364 (99%) had high functional status, and 353 (96%) delivered vaginally. Mothers in the intervention group were more likely to initiate ART (166 [97%] vs 77 [39%]; adjusted relative risk 3.3, 95% CI 1.4-7.8). Mother and infant pairs in the intervention group were more likely to be retained in care at 6 weeks (125 [83%] of 150 vs 15 [9%] of 170; adjusted relative risk 9.1, 5.2-15.9) and 12 weeks (112 [75%] of 150 vs 11 [7%] of 168 pairs; 10.3, 5.4-19.7) post partum.

Interpretation: This integrated, family-focused PMTCT service package improved maternal ART initiation and mother and infant retention in care. An effective approach to improve the quality of PMTCT service delivery will positively affect global goals for the elimination of mother-to-child HIV transmission.

Abstract access

Editor’s notes: Nigeria currently has the highest prevalence of mother-to-child HIV transmission in the world. This is predominantly due to the limited coverage and delivery of effective prevention of mother-to-child HIV transmission programmes. Reported barriers to the scale up of effective prevention programmes include a shortage of skilled health care workers, fragmented maternal and child health services and an absence of male participation in antenatal care. This parallel, cluster-randomised controlled study aimed to address these barriers. It explored the potential benefit of providing an innovative combination of prevention of mother-to-child HIV transmission programmes to pregnant women living with HIV in rural north-central Nigeria.

Standard care comprised of health information, opt-out HIV testing, infant feeding counselling, referral for CD4 cell counts and treatment, home-based services, antiretroviral prophylaxis, and early infant diagnosis. The design of the programme package took a family-focused approach. It also included integrated mother and infant service provision, male partner and community engagement, task shifting and point-of-care CD4 testing. The impact of this approach was positive. Women who were in the programme were more likely to initiate antiretroviral therapy and be retained in care at six weeks and twelve weeks post-partum. Of particular significance was a 74% reduction in incident HIV infection in infants born to women who were in the programme.

This study demonstrates an effective package but it is difficult to identify which specific components were the most beneficial. Nevertheless, the findings highlight Nigeria’s need to develop holistic packages of care if it is to achieve elimination of mother-to-child HIV transmission goals.

Africa
Nigeria
  • share
0 comments.

Greater HIV-free survival for infants when the father attends antenatal care

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, Betz B, Gatuguta A, Kiarie JN, Nduati R, John-Stewart G, Farquhar C. J Acquir Immune Defic Syndr. 2016 Apr 26. [Epub ahead of print]

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

Methods: From 2009-2013, HIV-infected pregnant women were enrolled from six antenatal clinics (ANC) in Nairobi, Kenya and followed with their infants until six weeks postpartum. Male partners were encouraged to attend antenatally through invitation letters. Males 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 were 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 via outreach. In multivariate analysis, male report of prior HIV testing was associated with maternal ANC attendance (aOR=3.7; 95% CI:1.5-8.9, p=0.003). Thirty-five (6.6%) of 501 infants acquired HIV or died by six 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 to those born to women with partner attendance (HR=3.95, 95% CI:1.21-12.89, p=0.023). Adjusting for antiretroviral use, the risk of death or infection remained significantly greater for infants born to mothers without male participation (aHR=3.79, 95% CI:1.15-12.42, p=0.028).

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

Abstract access  

Editor’s notes: Male partners of pregnant women are usually not involved in antenatal care in Africa, and this is now recognised as a missed opportunity. In addition to providing an opportunity to offer HIV testing and counselling to men, prevention of mother-to-child HIV transmission is easier with the acceptance and support of the male partner. This study investigated whether involving the male partner was associated with improved infant survival and reduced mother-to-child HIV transmission.

Men who had previously tested for HIV, especially as a couple, and who knew their partner’s status were more likely to attend antenatal care. Notably, 14% of men who did not attend the ANC did not know that mother-to-child HIV transmission is preventable.  

Six weeks after birth, infants born to women living with HIV, whose fathers had been involved in ANC care had greater HIV-free survival than infants whose fathers had not been involved. However, male involvement was rare. Over a quarter of women who had a male partner did not want him to be involved, and of the partners who were encouraged to come via letter, only a quarter did attend.

The results should be interpreted cautiously as it is not possible to disentangle the characteristics that prompted male involvement from the effect of prior counselling and testing on willingness to be involved in antenatal care. Men who attended antenatal care may have been more supportive to their partner. Mixed-methods research may help to identify the process and how outcomes can be improved. Overall, the results support investment in programmes aimed at enhancing male HIV testing and ANC engagement to improve infant health outcomes. 

Africa
Kenya
  • share
0 comments.

Option B+: the way forward for Malawi

Comparative cost-effectiveness of Option B+ for prevention of mother-to-child transmission of HIV in Malawi.

Tweya H, Keiser O, Haas AD, Tenthani L, Phiri S, Egger M, Estill J. AIDS. 2016 Mar 27;30(6):953-62. doi: 10.1097/QAD.0000000000001009.

Objective: To estimate the cost-effectiveness of prevention of mother-to-child transmission (MTCT) of HIV with lifelong antiretroviral therapy (ART) for pregnant and breastfeeding women ('Option B+') compared with ART during pregnancy or breastfeeding only unless clinically indicated ('Option B').

Design: Mathematical modelling study of first and second pregnancy, informed by data from the Malawi Option B+ programme.

Methods: Individual-based simulation model. We simulated cohorts of 10 000 women and their infants during two subsequent pregnancies, including the breastfeeding period, with either Option B+ or B. We parameterized the model with data from the literature and by analysing programmatic data. We compared total costs of antenatal and postnatal care, and lifetime costs and disability-adjusted life-years of the infected infants between Option B+ and Option B.

Results: During the first pregnancy, 15% of the infants born to HIV-infected mothers acquired the infection. With Option B+, 39% of the women were on ART at the beginning of the second pregnancy, compared with 18% with Option B. For second pregnancies, the rates MTCT were 11.3% with Option B+ and 12.3% with Option B. The incremental cost-effectiveness ratio comparing the two options ranged between about US$ 500 and US$ 1300 per DALY averted.

Conclusion: Option B+ prevents more vertical transmissions of HIV than Option B, mainly because more women are already on ART at the beginning of the next pregnancy. Option B+ is a cost-effective strategy for PMTCT if the total future costs and lost lifetime of the infected infants are taken into account.

Abstract access

Editor’s notes: Nearly a quarter of a million children acquire HIV from their mothers every year. Antiretroviral therapy (ART) in pregnant women greatly reduces the risk of mother-to-child HIV transmission to less than two percent. Malawi was the first country to introduce ‘Option B+’, a programme eliminating new HIV infections among children and keeping their mothers alive, in which all pregnant and breastfeeding women living with HIV start lifelong ART regardless of CD4 count or clinical staging. This study compares the cost-effectiveness of Option B+ in Malawi, with Option B, in which ART is recommended only for the duration of pregnancy or breastfeeding, unless the woman qualifies for ART for her own health. Both options have been recommended by World Health Organisation prevention of mother-to-child HIV transmission strategies.

The model simulated a cohort of 10 000 women pregnant for the first time, from conception to the time when the infants were two years old. The authors found that although the total costs of implementing Option B+ were higher than those of Option B, the former can reduce the costs of HIV care and treatment in the future by preventing new infections. The incremental cost-effectiveness ratio of Option B+ compared to Option B, ranged from USD 500 to USD 1300 per disability-adjusted life-years averted, depending on key assumptions around survival and care. The results support the implementation of Option B+ as it is likely to be a cost-effective strategy in the long term and the authors suggest it should be considered as the preferred strategy in low-income, high-fertility settings.

Like all models, this model has some limitations. It only considers women’s first two pregnancies, but the fertility rate in Malawi is high (5.5 births per woman). The model limits itself to mother-to-child HIV transmission, and does not take into account sexual transmission, which is likely to be lower in Option B+. Further research in these two areas would be worthwhile. The landscape is quickly changing, as World Health Organization guidelines now suggest testing and treatment strategies. However, until that policy is fully implemented and absorbed across the world, Option B+ will remain a key element in the HIV response.

Africa
Malawi
  • share
0 comments.

Tackling taboos and preventing HIV: family programmes to prevent HIV in adolescence

Developing family interventions for adolescent HIV prevention in South Africa. 

Kuo C, Atujuna M, Mathews C, Stein DJ, Hoare J, Beardslee W, Operario D, Cluver L, L KB. AIDS Care. 2016 Mar;28 Suppl 1:106-10. doi: 10.1080/09540121.2016.1146396. Epub 2016 Feb 26.

Adolescents and young people account for 40% of all new HIV infections each year, with South Africa one of the hardest hit countries, and having the largest population of people living with HIV. Although adolescent HIV prevention has been delivered through diverse modalities in South Africa, and although family-based approaches for adolescent HIV prevention have great potential for highly affected settings such as South Africa, there is a scarcity of empirically tested family-based adolescent HIV preventive interventions in this setting. We therefore conducted focus groups and in-depth interviews with key informants including clinicians, researchers, and other individuals representing organizations providing HIV and related health services to adolescents and parents (N = 82). We explored family perspectives and interactions around topics such as communication about sex, HIV, and relationships. Participants described aspects of family interactions that presented both challenges and opportunities for family-based adolescent HIV prevention. Parent-child communication on sexual topics were taboo, with these conversations perceived by some adults as an invitation for children to engage in HIV risk behavior. Parents experienced social sanctions for discussing sex and adolescents who asked about sex were often viewed as disrespectful and needing discipline. However, participants also identified context-appropriate strategies for addressing family challenges around HIV prevention including family meetings, communal parenting, building efficacy around parent-adolescent communication around sexual topics, and the need to strengthen family bonding and positive parenting. Findings indicate the need for a family intervention and identify strategies for development of family-based interventions for adolescent HIV prevention. These findings will inform design of a family intervention to be tested in a randomized pilot trial.

Abstract  Full-text [free] access

Editor’s notes: This short paper presents a qualitative study about family discussions about HIV and sex in Khayelitsha, South Africa. The results illustrate that sex is considered by many adults a taboo subject with adolescents younger than 18 years old. Young people who initiate discussion about sex, HIV risk or pregnancy can be scolded for being disrespectful. Sex is often discussed as a problem after young people have already started being sexually active. Study participants identified ‘family conferences’, with parents but also relatives more broadly, as promising settings for programmes. The activities should facilitate discussions that frame communication about sex and HIV prevention as positive. 

Africa
South Africa
  • share
0 comments.

Understanding barriers and facilitators to uptake and adherence of ART under Option B+ in Lilongwe, Malawi

Why did I stop? Barriers and facilitators to uptake and adherence to ART in option B+ HIV care in Lilongwe, Malawi.

Kim MH, Zhou A, Mazenga A, Ahmed S, Markham C, Zomba G, Simon K, Kazembe PN, Abrams EJ. PLoS One. 2016 Feb 22;11(2):e0149527. doi: 10.1371/journal.pone.0149527. eCollection 2016.

Causes for loss-to-follow-up, including early refusals of and stopping antiretroviral therapy (ART), in Malawi's Option B+ program are poorly understood. This study examines the main barriers and facilitators to uptake and adherence to ART under Option B+. In depth interviews were conducted with HIV-infected women who were pregnant or postpartum in Lilongwe, Malawi (N = 65). Study participants included women who refused ART initiation (N = 10), initiated ART and then stopped (N = 26), and those who initiated ART and remained on treatment (N = 29). The barriers to ART initiation were varied and included concerns about partner support, feeling healthy, and needing time to think. The main reasons for stopping ART included side effects and lack of partner support. A substantial number of women started ART after initially refusing or stopping ART. There were several facilitators for re-starting ART, including encouragement from community health workers, side effects subsiding, decline in health, change in partner, and fear of future sickness. Amongst those who remained on ART, desire to prevent transmission and improve health were the most influential facilitators. Reasons for refusing and stopping ART were varied. ART-related side effects and feeling healthy were common barriers to ART initiation and adherence. Providing consistent pre-ART counseling, early support for patients experiencing side effects, and targeted efforts to bring women who stop treatment back into care may improve long term health outcomes.

Abstract  Full-text [free] access 

Editor’s notes: Option B+ is a policy recommendation of World Health Organisation (WHO) that offers all pregnant and breast-feeding women living with HIV, life-long antiretroviral therapy (ART), regardless of CD4 count or clinical stage. Few studies have examined the challenges faced by pregnant and breast-feeding women, as they navigate the prevention of mother-to-child transmission cascade. The objective of this study was to identify the main barriers and facilitators to uptake and adherence to ART under Option B+ in Lilongwe, Malawi. This was done by conducting qualitative interviews (n=65) with women living with HIV who were pregnant or post-partum and had initiated ART, and women who refused or had stopped treatment.

The most important facilitator for initially starting and remaining on ART was the need to prevent transmission to their infants and to maintain health (prevent illness). Furthermore, ART was viewed as a solution to women’s health issues. This was especially the case when women believed that their health problems were associated with their HIV infection. There were a number of reasons that emerged for refusing ART. For most women the urgency of having to initiate ART under Option B+ was a major challenge. Women felt that they needed time, either to discuss their status with their partner or to accept their own status. In particular, the desire to speak to their partners emerged quite prominently reflecting a fear of disclosure and concern about their partner’s reaction. Another reason was generally feeling healthy before initiating treatment. Women wanted to wait until their health declined before initiating treatment. Religious beliefs did not play a significant role for most women. Only one woman refused because she believed that God, not healthcare providers, would tell her when she needed to start treatment. Side effects were the most commonly reported reason for stopping ART. Half of the 26 (N = 13) respondents who stopped ART did so because they experienced side effects, which included dizziness, nausea or vomiting, nightmares and hallucinations (9%). Women who had side effects also expressed challenges with food security. Side effects made some women question the efficacy of ART. The lack of partner support was another important barrier to ART adherence as women reported fear of disclosing their status to their husbands. Interestingly, although partner support was factored into women’s decision making, in most cases it was not the main consideration. The majority of partners (n=44) accepted their wives’ status, often sending reminders to take ART every night. However, many women did not return to the clinic even though their partners accepted their status (N = 17). One woman, for instance, took the money her husband gave her for transport to the clinic and spent it on other things. Forgetting to take pills or losing pills were other reasons given for lack of adherence. Stigma within the community was acknowledged as an issue, but there were few reports of overt discrimination. Further, even though some women refused or stopped ART, many of them re-started for reasons such as, feeling encouraged by a community health worker (CHW) or someone like a CHW. This was through their monthly home visits to check on women’s use of ART and to provide treatment support such as explaining the side-effects, counselling husbands and encouraging women to re-start. Decline in health, fear of future sickness, as well as reduction in side-effects were mentioned as reasons for re-starting on ART.

Overall, study authors mention that in the context of Option B+, inadequate time in preparing to initiate ART, as well as side effects emerged as more significant barriers as compared to previous studies on barriers and facilitators in non-Option B+ contexts. Economic barriers to care did not emerge as very significant in this study when comparted to other studies; however, a lack of food affects the severity of side effects. This suggests that economic barriers may manifest as an indirect mechanism that affects ART use. A strength of this study is the use of in-depth interviews with a range of women; not just women who stayed on ART, but also women who refused, stopped and re-started in the context of Option B+. Even though there might be overlap between the findings here and other qualitative research, particular barriers become more salient for women initiating ART in the context of Option B+. In prior assessments, women were only initiated on ART after being immunologically compromised, an assessment which often took longer than a month. This gave women time to reflect and accept their condition and communicate with their partner. In the case of Option B+ women felt they needed this time to prepare. The study demonstrates that challenges with uptake and adherence to ART remain. More time and support for women in decision-making, consistent pre-ART counselling, and support with side-effects may contribute to improvements in the long-run. As ART becomes increasingly normalised, some of these barriers may disappear.

Africa
Malawi
  • share
0 comments.