Articles tagged as "Preventing HIV infection in children"

Cash incentivises short-term retention in PMTCT services in Kinshasa

Conditional cash transfers and uptake of and retention in prevention of mother-to-child HIV transmission care: a randomised controlled trial.

Yotebieng M, Thirumurthy H, Moracco KE, Kawende B, Chalachala JL, Wenzi LK, Ravelomanana NL, Edmonds A, Thompson D, Okitolonda EW, Behets F. Lancet HIV. 2016 Feb;3(2):e85-93. doi: 10.1016/S2352-3018(15)00247-7.

Background: Novel strategies are needed to increase retention in and uptake of prevention of mother-to-child HIV transmission (PMTCT) services in sub-Saharan Africa. We aimed to determine whether small, increasing cash payments, which were conditional on attendance at scheduled clinic visits and receipt of proposed services can increase the proportions of HIV-infected pregnant women who accept available PMTCT services and remain in care.

Methods: In this randomised controlled trial, we recruited newly diagnosed HIV-infected women, who were 32 or less weeks pregnant, from 89 antenatal care clinics in Kinshasa, Democratic Republic of Congo, and randomly assigned (1:1) them to either the intervention group or the control group using computer-based randomisation with varying block sizes of four, six, and eight. The intervention group received compensation on the condition that they attended scheduled clinic visits and accepted offered PMTCT services (US$5, plus US$1 increment at every subsequent visit), whereas the control group received usual care. Outcomes assessed included retention in care at 6 weeks' post partum and uptake of PMTCT services, measured by attendance of all scheduled clinic visits and acceptance of proposed services up to 6 weeks' post partum. Analyses were by intention to treat. This trial is registered with, number NCT01838005.

Findings: Between April 18, 2013, and Aug 30, 2014, 612 potential participants were identified, 545 were screened, and 433 were enrolled and randomly assigned; 217 to the control group and 216 to the intervention group. At 6 weeks' post partum, 174 participants in the intervention group (81%) and 157 in the control group (72%) were retained in care (risk ratio [RR] 1.11; 95% CI 1.00-1.24). 146 participants in the intervention group (68%) and 116 in the control group (54%) attended all clinic visits and accepted proposed services (RR 1.26; 95% CI 1.08-1.48). Results were similar after adjustment for marital status, age, and education.

Interpretation: Among women with newly diagnosed HIV, small, incremental cash incentives resulted in increased retention along the PMTCT cascade and uptake of available services. The cost-effectiveness of these incentives and their effect on HIV-free survival warrant further investigation.

Abstract access

Editor’s notes: Eliminating new HIV infections in children and keeping their mothers alive is a crucial component in ending the AIDS epidemic. However, engaging and retaining women in prevention of mother-to-child transmission services can be problematic, with high rates of loss to follow up being documented in many sub-Saharan countries. Noting the success of financial incentives to promote positive health behaviours, this study applies this approach in antenatal care clinics in Kinshasa, Democratic Republic of Congo.   

Newly-diagnosed HIV-positive pregnant women were randomised to receive usual care versus small escalating cash payments. This payment started at $5, increasing by $1 each visit, on the proviso they attended scheduled appointments and adhered to medical advice until six weeks post-partum. This cash offer resulted in both increased attendance to all visits and increased retention at six weeks post-partum. As might be expected, the effect was strongest among the most vulnerable women, including women who walked to the clinic. This is in line with the rationale that addressing non-medical, structural barriers enables engagement with care.

It is worth noting that follow-up stopped at six weeks post-partum so the impact of the programme over a longer period needs further exploration. However, the study is reported to be the first of its kind in prevention of mother-to-child transmission of HIV and certainly supports the need for continued research into the use of financial incentives for prevention of mother-to-child transmission.

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Multifaceted approaches necessary to reduce HIV risk among orphaned and vulnerable adolescents

Psychological and behavioral interventions to reduce HIV risk: evidence from a randomized control trial among orphaned and vulnerable adolescents in South Africa.

Thurman TR, Kidman R, Carton TW, Chiroro P. AIDS Care. 2016 Feb 17:1-8. [Epub ahead of print]

Evidence-based approaches are needed to address the high levels of sexual risk behavior and associated HIV infection among orphaned and vulnerable adolescents. This study recruited adolescents from a support program for HIV-affected families and randomly assigned them by cluster to receive one of the following: (1) a structured group-based behavioral health intervention; (2) interpersonal psychotherapy group sessions; (3) both interventions; or (4) no new interventions. With 95% retention, 1014 adolescents were interviewed three times over a 22-month period. Intent-to-treat analyses, applying multivariate difference-in-difference probit regressions, were performed separately for boys and girls to assess intervention impacts on sexual risk behaviors. Exposure to a single intervention did not impact behaviors. Exposure to both interventions was associated with risk-reduction behaviors, but the outcomes varied by gender: boys reported fewer risky sexual partnerships (beta = -.48, p = .05) and girls reported more consistent condom (beta = 1.37, p = .02). There was no difference in the likelihood of sexual debut for either gender. Providing both psychological and behavioral interventions resulted in long-term changes in sexual behavior that were not present when either intervention was provided in isolation. Multifaceted approaches for reducing sexual risk behaviors among vulnerable adolescents hold significant promise for mitigating the HIV epidemic among this priority population.

Abstract   Ful-text [free] access

Editor’s notes: HIV infection is the leading cause of mortality among adolescents in sub-Saharan Africa and this age group is a priority group for programmes. Within this age-group, orphaned adolescents are particularly vulnerable, and a major risk factor for HIV infection in this population is psychological distress, which is a key factor in sexual decision-making. This study suggests that a multifaceted approach that addresses both psychological well-being and sexual risk taking behaviour may reduce risky sexual behaviour. Such activities are more likely to be successful if other more basic needs, such as economic security, are already being met. However, the strength of the findings is limited by the reliance on self-reported behaviours rather than biological endpoints. The authors highlight a number of issues that could improve the efficacy of programmes, including introducing gender specific sessions and activities and supplemental school-based programmes.    

South Africa
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The power of PEPFAR programmes: estimates of infections averted and life years gained in Africa

Estimating the impact of the US President's Emergency Plan for AIDS Relief on HIV treatment and prevention programmes in Africa.

Heaton LM, Bouey PD, Fu J, Stover J, Fowler TB, Lyerla R, Mahy M. Sex Transm Infect. 2015 Dec;91(8):615-20. doi: 10.1136/sextrans-2014-051991. Epub 2015 Jun 8.

Background: Since 2004, the US President's Emergency Plan for AIDS Relief (PEPFAR) has supported the tremendous scale-up of HIV prevention, care and treatment services, primarily in sub-Saharan Africa. We evaluate the impact of antiretroviral treatment (ART), prevention of mother-to-child transmission (PMTCT) and voluntary medical male circumcision (VMMC) programmes on survival, mortality, new infections and the number of orphans from 2004 to 2013 in 16 PEPFAR countries in Africa.

Methods: PEPFAR indicators tracking the number of persons receiving ART for their own health, ART regimens for PMTCT and biomedical prevention of HIV through VMMC were collected across 16 PEPFAR countries. To estimate the impact of PEPFAR programmes for ART, PMTCT and VMMC, we compared the current scenario of PEPFAR-supported interventions to a counterfactual scenario without PEPFAR, and assessed the number of life years gained (LYG), number of orphans averted and HIV infections averted. Mathematical modelling was conducted using the SPECTRUM modelling suite V.5.03.

Results: From 2004 to 2013, PEPFAR programmes provided support for a cumulative number of     24 565 127 adults and children on ART, 4 154 878 medical male circumcisions, and ART for PMTCT among 4 154 478 pregnant women in 16 PEPFAR countries. Based on findings from the model, these efforts have helped avert 2.9 million HIV infections in the same period. During 2004-2013, PEPFAR ART programmes alone helped avert almost 9 million orphans in 16 PEPFAR countries and resulted in 11.6 million LYG.

Conclusions: Modelling results suggest that the rapid scale-up of PEPFAR-funded ART, PMTCT and VMMC programmes in Africa during 2004-2013 led to substantially fewer new HIV infections and orphaned children during that time and longer lives among people living with HIV. Our estimates do not account for the impact of the PEPFAR-funded non-biomedical interventions such as behavioural and structural interventions included in the comprehensive HIV prevention, care and treatment strategy used by PEPFAR countries. Therefore, the number of HIV infections and orphans averted and LYG may be underestimated by these models.

Abstract access

Editor’s notes: The President’s Emergency Plan for AIDS Relief (PEPFAR) was initiated in 2004 with $42 billion spent up until the end of 2013. Despite limitations in monitoring the overall contribution of PEPFAR to individual programmes, this article attempts to provide an overview of PEPFAR support for ART, prevention of mother to child transmission and voluntary medical male circumcision (VMMC) programmes using the 2014 version of Spectrum Software model. The Spectrum modules used included DemProj, AIDS Impact Model (AIM) and Goals, which interact to model the impact and future course of the HIV epidemic at the population level.  An estimate of PEPFAR’s contribution was obtained by subtracting it from the total for the national programme statistics reported by UNAIDS on ART, PMTCT and VMMC.

The baseline scenario of PEPFAR-supported programmes in 2013 was compared to a counterfactual scenario, which subtracts the direct contribution of PEPFAR. The results estimate that the combined programmes have averted 2.7 million infections in Africa, with over 11.5 million life years gained and the aversion of almost nine million orphans. Other key population programmes that the funding supported including gender equity and health strengthening were not evaluated and therefore, the estimate for impact may be conservative. A limitation of the analysis is that it is unable to predict the national response without PEPFAR and the impact of ART calculated by the model is sensitive to the distribution of new ART patients by CD4 count at the initiation of treatment. In addition, few countries have sufficient death registration systems to validate mortality estimates, which may result in the accomplishments of PEPFAR’s impact being overestimated. However, with the operation of PEPFAR in a larger context of partnership consortiums, an improvement in evaluation methods will be necessary. 

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Untreated maternal HIV infection and poor perinatal outcomes

Perinatal outcomes associated with maternal HIV infection: a systematic review and meta-analysis.

Wedi CO, Kirtley S, Hopewell S, Corrigan R, Kennedy SH, Hemelaar J. Lancet HIV. 2016 Jan;3(1):e33-48. doi: 10.1016/S2352-3018(15)00207-6. Epub 2015 Nov 27.

Background: The HIV pandemic affects 36.9 million people worldwide, of whom 1.5 million are pregnant women. 91% of HIV-positive pregnant women reside in sub-Saharan Africa, a region that also has very poor perinatal outcomes. We aimed to establish whether untreated maternal HIV infection is associated with specific perinatal outcomes.

Methods: We did a systematic review and meta-analysis of the scientific literature by searching PubMed, CINAHL (Ebscohost), Global Health (Ovid), EMBASE (Ovid), and the Cochrane Central Register of Controlled Trials and four clinical trial databases (WHO International Clinical Trials Registry Platform, the Pan African Clinical Trials Registry, the database, and the ISRCTN Registry) for studies published from Jan 1, 1980, to Dec 7, 2014. Two authors independently reviewed the studies retrieved by the scientific literature search, identified relevant studies, and extracted the data. We investigated the associations between maternal HIV infection in women naive to antiretroviral therapy and 11 perinatal outcomes: preterm birth, very preterm birth, low birthweight, very low birthweight, term low birthweight, preterm low birthweight, small for gestational age, very small for gestational age, miscarriage, stillbirth, and neonatal death. We included prospective and retrospective cohort studies and case-control studies reporting perinatal outcomes in HIV-positive women naive to antiretroviral therapy and HIV-negative controls. We used a random-effects model for the meta-analyses of specific perinatal outcomes. We did subgroup and sensitivity analyses and assessed the effect of adjustment for confounders. This systematic review and meta-analysis is registered with PROSPERO, number CRD42013005638.

Findings: Of 60 750 studies identified, we obtained data from 35 studies (20 prospective cohort studies, 12 retrospective cohort studies, and three case-control studies) including 53 623 women. Our meta-analyses of prospective cohort studies show that maternal HIV infection is associated with an increased risk of preterm birth (relative risk 1.50, 95% CI 1.24-1.82), low birthweight (1.62, 1.41-1.86), small for gestational age (1.31, 1.14-1.51), and stillbirth (1.67, 1.05-2.66). Retrospective cohort studies also suggest an increased risk of term low birthweight (2.62, 1.15-5.93) and preterm low birthweight (3.25, 2.12-4.99). The strongest and most consistent evidence for these associations is identified in sub-Saharan Africa. No association was identified between maternal HIV infection and very preterm birth, very small for gestational age, very low birthweight, miscarriage, or neonatal death, although few data were available for these outcomes. Correction for confounders did not affect the significance of these findings.

Interpretation: Maternal HIV infection in women who have not received antiretroviral therapy is associated with preterm birth, low birthweight, small for gestational age, and stillbirth, especially in sub-Saharan Africa. Research is needed to assess how antiretroviral therapy regimens affect these perinatal outcomes.

Abstract access 

Editor’s notes:  Maternal HIV infection is associated with maternal morbidity and mortality and risk of mother-to-child transmission of HIV. Whether maternal HIV infection affects perinatal outcomes, which are major contributors to poor health worldwide, is less well understood. This systematic review and meta-analysis of retrospective and prospective cohort studies and case-control studies demonstrates that untreated maternal HIV infection is associated with increased risk of pre-term birth, low birthweight, small for gestational age and stillbirth. The risk of adverse perinatal outcomes appeared to increase with more advanced HIV disease, although only three of the 35 studies reported perinatal outcomes according to HIV disease stage. These findings persisted even after controlling for potential confounding factors and irrespective of the method used for determining gestational age. None of the studies used a first trimester ultrasound scan, the gold standard for determining gestational age. The association of perinatal outcomes with the infant’s HIV status was not investigated. The strongest evidence for these associations was found in sub-Saharan Africa, where the majority of the studies were conducted.

These findings suggest that HIV is an important contributor to the global burden of perinatal and child morbidity and mortality particularly in countries with the highest burden of maternal HIV infection.     Sub-Saharan Africa has the highest rates of stillbirths and neonatal deaths and is also the region where more than 90% of the world’s pregnant women living with HIV reside.

This study has important implications. Firstly, the coverage of antiretroviral therapy (ART) among pregnant women worldwide still remains suboptimal (estimated to be 68% in 2013), exposing women living with untreated HIV to an increased risk of adverse perinatal outcomes. The biological mechanisms underlying adverse perinatal outcomes in the context of HIV infection are not understood. ART in pregnancy may also adversely affect perinatal outcomes, and there is a pressing need to investigate this as ART is rapidly scaled up.     

Africa, Europe, Northern America
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Evidence for large regional disparities in the quality of PMTCT provision across Ghana (2011-2013)

Towards elimination of mother-to-child transmission of HIV in Ghana: an analysis of national programme data.

Dako-Gyeke P, Dornoo B, Ayisi Addo S, Atuahene M, Addo NA, Yawson AE. Int J Equity Health. 2016 Jan 13;15(1):5. doi: 10.1186/s12939-016-0300-5.

Background: Despite global scale up of interventions for Preventing Mother-to-Child HIV Transmissions (PMTCT), there still remain high pediatric HIV infections, which result from unequal access in resource-constrained settings. Sub-Saharan Africa alone contributes more than 90% of global Mother-to-Child Transmission (MTCT) burden. As part of efforts to address this, African countries (including Ghana) disproportionately contributing to MTCT burden were earmarked in 2009 for rapid PMTCT interventions scale-up within their primary care system for maternal and child health. In this study, we reviewed records in Ghana, on ANC registrants eligible for PMTCT services to describe regional disparities and national trends in key PMTCT indicators. We also assessed distribution of missed opportunities for testing pregnant women and treating those who are HIV positive across the country. Implications for scaling up HIV-related maternal and child health services to ensure equitable access and eliminate mother-to-child transmissions by 2015 are also discussed.

Methods: Data for this review is from the National AIDS/STI Control Programme (NACP) regional disaggregated records on registered antenatal clinic (ANC) attendees across the country, who are also eligible to receive PMTCT services. These records cover a period of 3 years (2011-2013). Number of ANC registrants, utilization of HIV Testing and Counseling among ANC registrants, number of HIV positive pregnant women, and number of HIV positive pregnant women initiated on ARVs were extracted. Trends were examined by comparing these indicators over time (2011-2013) and across the ten administrative regions. Descriptive statistics were conducted on the dataset and presented in simple frequencies, proportions and percentages. These are used to determine gaps in utilization of PMTCT services. All analyses were conducted using Microsoft Excel 2010 version.

Results: Although there was a decline in HIV prevalence among pregnant women, untested ANC registrants increased from 17 % in 2011 to 25 % in 2013. There were varying levels of missed opportunities for testing across the ten regions, which led to a total of 487 725 untested ANC clients during the period under review. In 2013, Greater Accra (31 %), Northern (27 %) and Volta (48 %) regions recorded high percentages of untested ANC clients. Overall, HIV positive pregnant women initiated onto ARVs remarkably increased from 57% (2011) to 82 % (2013), yet about a third (33 %) of them in the Volta and Northern regions did not receive ARVs in 2013.

Conclusions: Missed opportunities to test pregnant women for HIV and also initiate those who are positive on ARVs across all the regions pose challenges to the quest to eliminate mother-to-child transmission of HIV in Ghana. For some regions these missed opportunities mimic previously observed gaps in continuous use of primary care for maternal and child health in those areas. Increased national and regional efforts aimed at improving maternal and child healthcare delivery, as well as HIV-related care, is paramount for ensuring equitable access across the country.

Abstract  Full-text [free] access

Despite substantial improvement in antiretroviral therapy coverage in many countries over the last decade, over 200 000 infants still acquire the virus each year. Prevention of mother- to-child-transmission can, in theory, eliminate these infant infections and must be an essential component of HIV prevention strategies, particularly in countries with high HIV prevalence. In Ghana, prevention of mother-to-child-transmission activities is integrated with other maternal, neonatal and child health services, to achieve the highest possible level of coverage.

The goal of this study was to see how effectively the prevention of mother- to-child-transmission has been implemented across Ghana. Using data from antenatal care (ANC) clinics, two key metrics were assessed. They are: 1) the percentage of ANC attendees who are not tested for HIV and 2) the percentage of HIV positive ANC attendees who are not initiated on treatment. The percentage of missed opportunities for HIV testing among ANC attendees nationally increased from 17% to 25% between 2011 and 2013. This overall increase is worrying, and masks regional variations including an 84% increase in the central region. Overall the percentage of pregnant women living with HIV who are not initiated on treatment decreased substantially from 43% to 18%. However, there were still large geographical differences.

The authors suggest that the regional variation is indicative of inequities in the provision of health care. The evidence for attrition over time in the provision of HIV testing in ANC clinics is of particular concern. Perhaps this is a reflection of fatigue in HIV testing efforts among this group, even over this short period. The study highlights the importance of a timely and geographically disaggregated analysis of key metrics associated with a national HIV programme. This is vital in order to ensure effective and equitable coverage and to address deficiencies in the provision of HIV services. It also emphasises that efforts to achieve the UNAIDS 90:90:90 targets need sustained generalised programmes of health systems strengthening. 

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Effective pre-conception ART eliminates mother-to-child transmission

No perinatal hiv-1 transmission from women with effective antiretroviral therapy starting before conception.

Mandelbrot L, Tubiana R, Le Chenadec J, Dollfus C, Faye A, Pannier E, Matheron S, Khuong MA, Garrait V, Reliquet V, Devidas A, Berrebi A, Allisy C, Elleau C, Arvieux C, Rouzioux C, Warszawski J, Blanche S, Group A-ES. Clin Infect Dis. 2015 Dec 1;61(11):1715-25. doi: 10.1093/cid/civ578. Epub 2015 Jul 21.

Background: The efficacy of preventing perinatal transmission (PT) of human immunodeficiency virus type 1 (HIV-1) depends on both viral load (VL) and treatment duration. The objective of this study was to determine whether initiating highly active antiretroviral therapy (ART) before conception has the potential to eliminate PT.

Methods: A total of 8075 HIV-infected mother/infant pairs included from 2000 to 2011 in the national prospective multicenter French Perinatal Cohort (ANRS-EPF) received ART, delivered live-born children with determined HIV infection status, and did not breastfeed. PT was analyzed according to maternal VL at delivery and timing of ART initiation.

Results: The overall rate of PT was 0.7% (56 of 8075). No transmission occurred among 2651 infants born to women who were receiving ART before conception, continued ART throughout the pregnancy, and delivered with a plasma VL <50 copies/mL (upper 95% confidence interval [CI], 0.1%). VL and timing of ART initiation were independently associated with PT in logistic regression. Regardless of VL, the PT rate increased from 0.2% (6 of 3505) for women starting ART before conception to 0.4% (3 of 709), 0.9% (24 of 2810), and 2.2% (23 of 1051) for those starting during the first, second, or third trimester (P < .001). Regardless of when ART was initiated, the PT rate was higher for women with VLs of 50-400 copies/mL near delivery than for those with <50 copies/mL (adjusted odds ratio, 4.0; 95% CI, 1.9-8.2).

Conclusions: Perinatal HIV-1 transmission is virtually zero in mothers who start ART before conception and maintain suppression of plasma VL.

Abstract access 

Editor’s notes: The risk of HIV transmission from mother-to-child is around 15-45% in the absence of maternal antiretroviral therapy (ART). This study illustrates that the risk of mother-to-child transmission is virtually eliminated when ART is started prior to conception and plasma viral load (VL) is undetectable at delivery. These findings provide further evidence supporting the implementation of Option B+ (lifelong ART as early as possible in all HIV-positive pregnant women regardless of CD4 count and VL) in low-income countries. In these settings, effectiveness of pre-conception ART will be dependent on retention in care so that women remain virologically suppressed for subsequent pregnancies. Robust surveillance data of pregnancy outcomes and other short-term and long-term risks of ART on the foetus, such as congenital malformations, and on the infant, such as pre-term birth, are also necessary to confirm that the benefit of pre-conception ART outweighs any harm.

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Contraception for women on ART – a balancing act

Pregnancy rates in HIV-positive women using contraceptives and efavirenz-based or nevirapine-based antiretroviral therapy in Kenya: a retrospective cohort study.

Patel RC, Onono M, Gandhi M, Blat C, Hagey J, Shade SB, Vittinghoff E, Bukusi EA, Newmann SJ, Cohen CR. Lancet HIV. 2015 Nov;2(11):e474-82. doi: 10.1016/S2352-3018(15)00184-8. Epub 2015 Oct 22.

Background: Concerns have been raised about efavirenz reducing the effectiveness of contraceptive implants. We aimed to establish whether pregnancy rates differ between HIV-positive women who use various contraceptive methods and either efavirenz-based or nevirapine-based antiretroviral therapy (ART) regimens.

Methods: We did this retrospective cohort study of HIV-positive women aged 15-45 years enrolled in 19 HIV care facilities supported by Family AIDS Care and Education Services in western Kenya between Jan 1, 2011, and Dec 31, 2013. Our primary outcome was incident pregnancy diagnosed clinically. The primary exposure was a combination of contraceptive method and efavirenz-based or nevirapine-based ART regimen. We used Poisson models, adjusting for repeated measures, and demographic, behavioural, and clinical factors, to compare pregnancy rates among women receiving different contraceptive and ART combinations.

Findings: 24 560 women contributed 37 635 years of follow-up with 3337 incident pregnancies. In women using implants, adjusted pregnancy incidence was 1.1 per 100 person-years (95% CI 0.72-1.5) for nevirapine-based ART users and 3.3 per 100 person-years (1.8-4.8) for efavirenz-based ART users (adjusted incidence rate ratio [IRR] 3.0, 95% CI 1.3-4.6). In women using depot medroxyprogesterone acetate, adjusted pregnancy incidence was 4.5 per 100 person-years (95% CI 3.7-5.2) for nevirapine-based ART users and 5.4 per 100 person-years (4.0-6.8) for efavirenz-based ART users (adjusted IRR 1.2, 95% CI 0.91-1.5). Women using other contraceptive methods, except for intrauterine devices and permanent methods, had 3.1-4.1 higher rates of pregnancy than did those using implants, with 1.6-2.8 higher rates in women using efavirenz-based ART.

Interpretation: Although HIV-positive women using implants and efavirenz-based ART had a three-times higher risk of contraceptive failure than did those using nevirapine-based ART, these women still had lower contraceptive failure rates than did those receiving all other contraceptive methods except for intrauterine devices and permanent methods. Guidelines for contraceptive and ART combinations should balance the failure rates for each contraceptive method and ART regimen combination against the high effectiveness of implants.

Abstract access 

Editor’s notes: Contraceptive use by women living with HIV who wish to prevent pregnancy remains a key component of the strategy to eliminate new HIV infections among children. Progesterone-based implants are the most effective reversible contraceptive method, but there is some evidence to suggest that their efficacy may be reduced in women receiving efavirenz (EFV)-based antiretroviral therapy (ART).

Overall contraceptive use in these women of childbearing age was low – 70% of the time women were using no contraception or less effective methods only (condoms or natural methods). Overall pregnancy rates were low with the hormonal implant, broadly equivalent to women with intrauterine devices and much lower than with depot injectable and oral contraceptive methods. There was some evidence that the rate of pregnancy in women using the implant was higher for women on EFV-based ART compared to women on nevirapine-based ART. However, the rate of pregnancy remained lower than with injectable or oral contraceptives.

Although this may provide some support to the evidence of reduced implant efficacy with EFV-based ART, it is clear that this can still be an effective contraceptive method. This evidence seems unlikely to change existing WHO recommendations that all forms of contraception should be available to women living with HIV. The low rate of contraceptive use highlights the need to improve access for women living with HIV to quality integrated sexual and reproductive health services. The data from this study suggest that for women wishing to avoid pregnancy, the choice of contraceptive method may be more important than the choice of ART regimen.  

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Vulnerabilities of children living with HIV positive adults

Children living with HIV-infected adults: estimates for 23 countries in sub-Saharan Africa.

Short SE, Goldberg RE. PLoS One. 2015 Nov 17; 10(11): e0142580.

Background: In sub-Saharan Africa many children live in extreme poverty and experience a burden of illness and disease that is disproportionately high. The emergence of HIV and AIDS has only exacerbated long-standing challenges to improving children's health in the region, with recent cohorts experiencing pediatric AIDS and high levels of orphan status, situations which are monitored globally and receive much policy and research attention. Children's health, however, can be affected also by living with HIV-infected adults, through associated exposure to infectious diseases and the diversion of household resources away from them. While long recognized, far less research has focused on characterizing this distinct and vulnerable population of HIV-affected children.

Methods: Using Demographic and Health Survey data from 23 countries collected between 2003 and 2011, we estimate the percentage of children living in a household with at least one HIV-infected adult. We assess overlaps with orphan status and investigate the relationship between children and the adults who are infected in their households.

Results: The population of children living in a household with at least one HIV-infected adult is substantial where HIV prevalence is high; in Southern Africa, the percentage exceeded 10% in all countries and reached as high as 36%. This population is largely distinct from the orphan population. Among children living in households with tested, HIV-infected adults, most live with parents, often mothers, who are infected; nonetheless, in most countries over 20% live in households with at least one infected adult who is not a parent.

Conclusion: Until new infections contract significantly, improvements in HIV/AIDS treatment suggest that the population of children living with HIV-infected adults will remain substantial. It is vital to on-going efforts to reduce childhood morbidity and mortality to consider whether current care and outreach sufficiently address the distinct vulnerabilities of these children.

Abstract Full-text [free] access

Editor’s notes: This paper is an important contribution to the literature on the impact of the HIV epidemic. Using Demographic and Health Survey (DHS) data from 23 countries it highlights the considerable number of children living with HIV-positive adults in sub-Saharan Africa. However, notable exceptions from the analysis (no DHS data available) included South Africa. This, coupled with specific issues related to DHS data collection methods and response rates, means that the number of children living with HIV-positive adults is much higher. Reductions in mortality from HIV due to increased treatment availability and the addition of adults newly acquiring HIV means that population of children living with an HIV-positive adult will continue to increase in the near future.

Children living with HIV-positive adults are clearly vulnerable and like all vulnerable children should be focussed on in efforts to promote child wellbeing. The authors suggest, however, that children living with HIV-positive adults may have distinct vulnerabilities that need to be considered. These include direct exposure to opportunistic infections, social stigma and disrupted networks, as well as increases in poverty. The challenge for many countries is how to identify these children and ensure that focussed programmes are delivered effectively.

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Some success in improving infant-feeding practices in South Africa

Effect of an integrated community-based package for maternal and newborn care on feeding patterns during the first 12 weeks of life: a cluster-randomized trial in a South African township.

Ijumba P, Doherty T, Jackson D, Tomlinson M, Sanders D, Swanevelder S, Persson LA. Public Health Nutr. 2015 Oct;18(14):2660-8. doi: 10.1017/S1368980015000099. Epub 2015 Feb 9.

Objective: To analyse the effect of community-based counselling on feeding patterns during the first 12 weeks after birth, and to study whether the effect differs by maternal HIV status, educational level or household wealth.

Design: Cluster-randomized trial with fifteen clusters in each arm to evaluate an integrated package providing two pregnancy and five postnatal home visits delivered by community health workers. Infant feeding data were collected using 24 h recall of nineteen food and fluid items.

Setting: A township near Durban, South Africa.

Subjects: Pregnant women (1894 intervention and 2243 control) aged 17 years or more.

Results: Twelve weeks after birth, 1629 (intervention) and 1865 (control) mother-infant pairs were available for analysis. Socio-economic conditions differed slightly across intervention groups, which were considered in the analyses. There was no effect on early initiation of breast-feeding. At 12 weeks of age the intervention doubled exclusive breast-feeding (OR=2.29; 95 % CI 1.80, 2.92), increased exclusive formula-feeding (OR=1.70; 95 % CI 1.28, 2.27), increased predominant breast-feeding (OR=1.71; 95 % CI 1.34, 2.19), decreased mixed formula-feeding (OR=0.68; 95 % CI 0.55, 0.83) and decreased mixed breast-feeding (OR=0.54; 95 % CI 0.44, 0.67). The effect on exclusive breast-feeding at 12 weeks was stronger among HIV-negative mothers than HIV-positive mothers (P=0.01), while the effect on mixed formula-feeding was significant only among HIV-positive mothers (P=0.03). The effect on exclusive feeding was not different by household wealth or maternal education levels.

Conclusions: A perinatal intervention package delivered by community health workers was effective in increasing exclusive breast-feeding, exclusive formula-feeding and decreasing mixed feeding.

Abstract access 

Editor’s notes: This trial assesses the provision of an integrated package of motivational interviewing-based counselling during home visits by systematically supervised, remunerated full-time community health workers on breastfeeding practices. It found stronger effects among HIV negative mothers than mothers living with HIV. This is particularly important in the context of a setting where exclusive breast feeding is practised by only 8% of mothers and where messages have been mixed about the safety of breastfeeding among mothers living with HIV. The smaller effect among mothers living with HIV may be a legacy of the free provision of formula to these mothers from 2002 to 2011, and cultural feeding practices. Exit interviews with the community health workers revealed that no mothers had exclusively breast-fed their babies, and this may have influenced their delivery of the programme. Further work is necessary to communicate messages on the need for exclusive breast feeding among mothers living with HIV.

Avoid TB deaths
South Africa
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Integrated care: necessary but not sufficient to improve the PMTCT cascade

Implementation and operational research: effects of antenatal care and HIV treatment integration on elements of the PMTCT cascade: results from the SHAIP cluster-randomized controlled trial in Kenya.

Turan JM, Onono M, Steinfeld RL, Shade SB, Owuor K, Washington S, Bukusi EA, Ackers ML, Kioko J, Interis EC, Cohen CR. J Acquir Immune Defic Syndr. 2015 Aug 15;69(5):e172-81. doi: 10.1097/QAI.0000000000000678.

Background: Integrating antenatal care (ANC) and HIV care may improve uptake and retention in services along the prevention of mother-to-child transmission (PMTCT) cascade. This study aimed to determine whether integration of HIV services into ANC settings improves PMTCT service utilization outcomes.

Methods: ANC clinics in rural Kenya were randomized to integrated (6 clinics, 569 women) or nonintegrated (6 clinics, 603 women) services. Intervention clinics provided all HIV services, including highly active antiretroviral therapy (HAART), whereas control clinics provided PMTCT services but referred women to HIV care clinics within the same facility. PMTCT utilization outcomes among HIV-infected women (maternal HIV care enrollment, HAART initiation, and 3-month infant HIV testing uptake) were compared using generalized estimating equations and Cox regression.

Results: HIV care enrollment was higher in intervention compared with control clinics [69% versus 36%; odds ratio = 3.94, 95% confidence interval (CI): 1.14 to 13.63]. Median time to enrollment was significantly shorter among intervention arm women (0 versus 8 days, hazard ratio = 2.20, 95% CI: 1.62 to 3.01). Eligible women in the intervention arm were more likely to initiate HAART (40% versus 17%; odds ratio = 3.22, 95% CI: 1.81 to 5.72). Infant testing was more common in the intervention arm (25% versus 18%), however, not statistically different. No significant differences were detected in postnatal service uptake or maternal retention.

Conclusions: Service integration increased maternal HIV care enrollment and HAART uptake. However, PMTCT utilization outcomes were still suboptimal, and postnatal service utilization remained poor in both study arms. Further improvements in the PMTCT cascade will require additional research and interventions.

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Editor’s notes: WHO recommends a combination approach to prevention of mother-to-child transmission that includes primary prevention of HIV among women of childbearing age, prevention of unintended pregnancies among women living with HIV, prevention of HIV transmission from a woman living with HIV to her infant and the provision of appropriate treatment, care and support to mothers living with HIV, their children and families.

Prevention of mother-to-child transmission programmes in sub-Saharan Africa experience high rates of maternal and infant loss to follow-up at each step of the cascade. The largest losses occur with failure of linkage to and retention in HIV care services.

This article reports on a cluster randomized trial that assessed whether integration of HIV services into antenatal care (ANC) settings improved the uptake of prevention of mother-to-child transmission services (maternal HIV care enrolment, ART initiation, and three-month infant HIV testing) and retention in care along the prevention of mother-to-child transmission cascade.

The integration of HIV services into ANC settings improved HIV care enrolment, time to enrolment, and ART initiation among eligible women compared with control clinics. Retention in care was lower in the programme clinics.

However, even at the programme sites only 70% (and not 100%) of HIV-positive women enrolled in HIV care, indicating that women’s hesitations about initiating HIV care continue to be a barrier for a substantial proportion of women. The authors found that internalized HIV-associated stigma was a significant issue, and hypothesise that women from integrated clinics were even more at risk for unwanted disclosure and of stigmatization.

Early infant diagnosis was inadequate in both arms of the study. The inadequate systems to identify HIV exposed infants in postnatal clinics, and the continuing stigma associated with HIV were cited as the main challenges. Integrated point of care electronic maternal and child health registers that provide timely access to data on women and infants falling out of the cascade could help to address this.

The authors conclude that integration of clinical services is necessary but not sufficient to address all barriers to utilization of prevention of mother-to-child transmission services. 

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