Articles tagged as "Preventing HIV infection in children"

Further evidence to support Option B+: good HIV-free survival among children breastfed for a year with mothers on triple ART

Early infant feeding patterns and HIV-free survival: findings from the Kesho-Bora trial (Burkina Faso, Kenya, South Africa).

Cournil A, Van de Perre P, Cames C, de Vincenzi I, Read JS, Luchters S, Meda N, Naidu K, Newell ML, Bork K, Kesho Bora Study G. Pediatr Infect Dis J. 2015 Feb;34(2):168-74. doi: 10.1097/INF.0000000000000512.

Objective: To investigate the association between feeding patterns and HIV-free survival in children born to HIV-infected mothers and to clarify whether antiretroviral (ARV) prophylaxis modifies the association.

Methods: From June 2005 to August 2008, HIV-infected pregnant women were counseled regarding infant feeding options, and randomly assigned to triple-ARV prophylaxis (triple ARV) until breastfeeding cessation (BFC) before age 6 months or antenatal zidovudine with single-dose nevirapine (short-course ARV). Eighteen-month HIV-free survival of infants HIV-negative at 2 weeks of age was assessed by feeding patterns (replacement feeding from birth, BFC <3 months, BFC ≥3 months).

Results: Of the 753 infants alive and HIV-negative at 2 weeks, 28 acquired infection and 47 died by 18 months. Overall HIV-free survival at 18 months was 0.91 [95% confidence interval (CI): 0.88-0.93]. In the short-course ARV arm, HIV-free survival (0.88; CI: 0.84-0.91) did not differ by feeding patterns. In the triple ARV arm, overall HIV-free survival was 0.93 (CI: 0.90-0.95) and BFC <3 months was associated with lower HIV-free survival than BFC ≥3 months (adjusted hazard ratio: 0.36; CI: 0.15-0.83) and replacement feeding (adjusted hazard ratio: 0.20; CI: 0.04-0.94). In the triple ARV arm, 4 of 9 transmissions occurred after reported BFC (and 5 of 19 in the short-course arm), indicating that some women continued breastfeeding after interruption of ARV prophylaxis.

Conclusions: In resource-constrained settings, early weaning has previously been associated with higher infant mortality. We show that, even with maternal triple-ARV prophylaxis during breastfeeding, early weaning remains associated with lower HIV-free survival, driven in particular by increased mortality.

Abstract access 

Editor’s notes: Evaluating the impact of feeding patterns on infant HIV-free survival is essential for HIV prevention. This large, multi-country study was nested within the Kesha Bora randomised trial which found that triple ARV prophylaxis until cessation of breastfeeding was associated with lower rates of mother-to-child transmission than short-course ARV prophylaxis. Further analyses showed that in both arms, mortality in infants was highest when breastfeeding was stopped before three months of age. This analysis considered HIV-free survival and found that among mothers receiving triple ARV prophylaxis during breastfeeding, weaning before three months was associated with significantly lower HIV-free survival than longer breastfeeding or replacement feeding from birth. Overall, the results support the WHO 2013 ART guidelines which recommend initiation of triple ARV prophylaxis early in pregnancy, continued either through the breast feeding period (option B) or for life (option B+), and WHO recommendations for continued breastfeeding up to at least one year of age while on ART. 

Africa
Burkina Faso, Kenya, South Africa
  • share
0 comments.

Incentives for orphans to stay in school: a structural programme for HIV prevention in Zimbabwe

The impact of school subsidies on HIV-related outcomes among adolescent female orphans.

Hallfors DD, Cho H, Rusakaniko S, Mapfumo J, Iritani B, Zhang L, Luseno W, Miller T. J Adolesc Health. 2015 Jan;56(1):79-84. doi: 10.1016/j.jadohealth.2014.09.004.

Purpose: We examine effects of school support as a structural HIV prevention intervention for adolescent female orphans in Zimbabwe after 5 years.

Methods: Three hundred twenty-eight orphan adolescent girls were followed in a clustered randomized controlled trial from 2007 to 2010. The experimental group received school fees, uniforms, and school supplies and were assigned a school-based "helper." In 2011-2012, the control group received delayed partial treatment of school fees only. At the final data point in 2012, survey, HIV, and Herpes Simplex Virus Type 2 (HSV-2) biomarker data were collected from approximately 88% of the sample. Bivariate and multivariate analyses were conducted on end point outcomes, controlling for age, religious affiliation, and baseline socioeconomic status.

Results: The two groups did not differ on HIV or HSV-2 biomarkers. The comprehensive 5-year intervention continued to reduce the likelihood of marriage, improve school retention, improve socioeconomic status (food security), and marginally maintain gains in quality of life, even after providing school fees to the control group.

Conclusions: Paying school fees and expenses resulted in significant improvements in life outcomes for orphan adolescent girls. Biological evidence of HIV infection prevention, however, was not observed. Our study adds to the growing body of research on school support as HIV prevention for girls in sub-Saharan Africa, but as yet, no clear picture of effectiveness has emerged.

Abstract access

Editor’s notes: Structural programmes for HIV prevention potentially offer a means to mitigate the risk factors which are thought to drive the substantially higher rates of HIV observed among adolescent women in low-income settings. In Zimbabwe, female orphans in the programme arm of this randomized control trial were offered a package of school support. This included payment of their school fees. There was low power to assess differences in HIV or HSV-2 prevalence by arm, but there were promising impacts on several important mediating factors for HIV infection. These included sexual debut, marriage, school drop-out, and socioeconomic status. The long follow-up period of five years and the high rate of retention in the study, 88%, are major strengths of this study. The study joins a limited evidence base on structural programmes for adolescent women in sub-Saharan Africa. Future research must re-consider the pathways by which structural determinants of HIV infection operate.

Africa
Zimbabwe
  • share
0 comments.

Abstinence from breastfeeding: further evidence of the risks

Morbidity in relation to feeding mode in African HIV-exposed, uninfected infants during the first 6 mo of life: the Kesho Bora study.

Bork KA, Cournil A, Read JS, Newell ML, Cames C, Meda N, Luchters S, Mbatia G, Naidu K, Gaillard P, de Vincenzi I. Am J Clin Nutr. 2014 Dec;100(6):1559-68. doi: 10.3945/ajcn.113.082149. Epub 2014 Oct 22.

Background: Refraining from breastfeeding to prevent HIV transmission has been associated with increased morbidity and mortality in HIV-exposed African infants.

Objective: The objective was to assess risks of common and serious infectious morbidity by feeding mode in HIV-exposed, uninfected infants ≤6 mo of age with special attention to the issue of reverse causality.

Design: HIV-infected pregnant women from 5 sites in Burkina Faso, Kenya, and South Africa were enrolled in the prevention of mother-to-child transmission Kesho Bora trial and counseled to either breastfeed exclusively and cease by 6 mo postpartum or formula feed exclusively. Maternal-reported morbidity (fever, diarrhea, and vomiting) and serious infectious events (SIEs) (gastroenteritis and lower respiratory tract infections) were investigated for 751 infants for 2 age periods (0-2.9 and 3-6 mo) by using generalized linear mixed models with breastfeeding as a time-dependent variable and adjustment for study site, maternal education, economic level, and cotrimoxazole prophylaxis.

Results: Reported morbidity was not significantly higher in nonbreastfed compared with breastfed infants [OR: 1.31 (95% CI: 0.97, 1.75) and 1.21 (0.90, 1.62) at 0-2.9 and 3-6 mo of age, respectively]. Between 0 and 2.9 mo of age, never-breastfed infants had increased risks of morbidity compared with those of infants who were exclusively breastfed (OR: 1.49; 95% CI: 1.01, 2.2; P = 0.042). The adjusted excess risk of SIEs in nonbreastfed infants was large between 0 and 2.9 mo (OR: 6.0; 95% CI: 2.2, 16.4; P = 0.001). Between 3 and 6 mo, the OR for SIEs was sensitive to the timing of breastfeeding status, i.e., 4.3 (95% CI: 1.2, 15.3; P = 0.02) when defined at end of monthly intervals and 2.0 (95% CI: 0.8, 5.0; P = 0.13) when defined at the beginning of intervals. Of 52 SIEs, 3 mothers reported changes in feeding mode during the SIE although none of the mothers ceased breastfeeding completely.

Conclusions: Not breastfeeding was associated with increased risk of serious infections especially between 0 and 2.9 mo of age.

Abstract access 

Editor’s notes: Abstinence from breastfeeding or early weaning is known to be associated with higher mortality among infants born to women living with HIV. The risk of mother-to-child HIV transmission through breast-milk can be reduced by the use of antiretroviral therapies. Mothers living with HIV are advised to continue breastfeeding throughout infancy, while on therapy. The aim of this study was to investigate the association between breastfeeding and infection risk, accounting for reverse causality (i.e. mothers changing feeding mode in response to infant illness). Non-breastfed infants were at higher risk of serious infectious events than breastfed infants, as expected, and particularly among infants aged under three months. There was no evidence of a difference in reported morbidity. A qualitative assessment of the reverse causality found that some 94% of mothers reported not changing the feeding mode as a consequence of serious infectious events. The strengths of this study are that only HIV-exposed, but HIV-negative infants were included, and a range of sensitivity analyses were conducted. A limitation is that infant feeding data may be subject to reporting bias. This study has confirmed the findings of earlier research, and reassuringly found limited evidence to suggest reverse causality between breastfeeding and serious infectious outcomes.

Africa
Burkina Faso, Kenya, South Africa
  • share
0 comments.

Home visits by community workers in South Africa improve maternal and child outcomes

A cluster randomised controlled effectiveness trial evaluating perinatal home visiting among South African mothers/infants.

Rotheram-Borus MJ, Tomlinson M, le Roux IM, Harwood JM, Comulada S, O'Connor MJ, Weiss RE, Worthman CM. PLoS One. 2014 Oct 23;9(10):e105934. doi: 10.1371/journal.pone.0105934. eCollection 2014.

Background: Interventions are needed to reduce poor perinatal health. We trained community health workers (CHWs) as home visitors to address maternal/infant risks.

Methods: In a cluster randomised controlled trial in Cape Town townships, neighbourhoods were randomised within matched pairs to 1) the control, healthcare at clinics (n = 12 neighbourhoods; n = 594 women), or 2) a home visiting intervention by CBW trained in cognitive-behavioural strategies to address health risks (by the Philani Maternal, Child Health and Nutrition Programme), in addition to clinic care (n = 12 neighbourhoods; n = 644 women). Participants were assessed during pregnancy (2% refusal) and 92% were reassessed at two weeks post-birth, 88% at six months and 84% at 18 months later. We analysed 32 measures of maternal/infant well-being over the 18 month follow-up period using longitudinal random effects regressions. A binomial test for correlated outcomes evaluated overall effectiveness over time. The 18 month post-birth assessment outcomes also were examined alone and as a function of the number of home visits received.

Results: Benefits were found on 7 of 32 measures of outcomes, resulting in significant overall benefits for the intervention compared to the control when using the binomial test (p = 0.008); nevertheless, no effects were observed when only the 18 month outcomes were analyzed. Benefits on individual outcomes were related to the number of home visits received. Among women living with HIV, intervention mothers were more likely to implement the PMTCT regimens, use condoms during all sexual episodes (OR = 1.25; p = 0.014), have infants with healthy weight-for-age measurements (OR = 1.42; p = 0.045), height-for-age measurements (OR = 1.13, p<0.001), breastfeed exclusively for six months (OR = 3.59; p<0.001), and breastfeed longer (OR = 3.08; p<0.001). Number of visits was positively associated with infant birth weight ≥2500 grams (OR = 1.07; p = 0.012), healthy head-circumference-for-age measurements at 6 months (OR = 1.09, p = 0.017), and improved cognitive development at 18 months (OR = 1.02, p = 0.048).

Conclusions: Home visits to neighbourhood mothers by CHWs may be a feasible strategy for enhancing maternal/child outcomes. However, visits likely must extend over several years for persistent benefits.

Abstract  Full-text [free] access

Editor’s notes: This trial combines two major trends in the delivery of health care. These include the shift of HIV services from specialist to generalist providers, and task-sharing between generalist and community providers. Community-based workers (CBW) from the Philani Maternal, Child Health and Nutrition Programme in Cape Town, South Africa were recruited to provide and apply health information about maternal and child health, HIV, alcohol use and nutrition to 644 perinatal women in the programme communities. The CBWs complemented the standard of care for health services, which were also available to 594 perinatal women in the control communities. About a quarter of participants were living with HIV. This study is notable for its real-world applicability through its trial design, provision of services to the entire population of eligible perinatal women, range of behavioural and clinical outcomes and rigorous analytic methods. At six months post-partum, women living with HIV in the programme arm were more likely to implement the prevention of mother-to-child regimen and to use condoms with their sex partners. Additionally, the children of these women had improved growth characteristics. Future research must determine whether CBWs can improve the other outcomes assessed in this trial, the cost-effectiveness of the CBWs, and how these gains can be extended to 18 months post-partum.

Africa
South Africa
  • share
0 comments.

Mother’s HIV status has a major impact on child, but not neonatal mortality

Maternal HIV status associated with under-five mortality in rural northern Malawi: A prospective cohort study

Chihana ML, Price A, Floyd S, Mboma S, Mvula H, Branson K, Saul J, Zaba B, French N, Crampin AC, Glynn JR. J Acquir Immune Defic Syndr. 2014 Oct 15. [Epub ahead of print]

Background: Under-five mortality is decreasing but with little change in neonatal mortality rates. We examined the effect of maternal HIV-status on under-five mortality and cause of death since widespread availability of antiretroviral therapy in rural Malawi.

Methods: Children born in 2006-2011 in the Karonga demographic surveillance area were included. Maternal HIV-status was available from HIV sero-surveys. Age-specific mortality rate ratios for children born to HIV-positive and HIV-negative mothers were obtained by fitting a Poisson model accounting for child clustering by mother and adjusting for potential confounders. Cause of death was ascertained by verbal autopsy.

Findings: There were 352 deaths among 6913 under-five singleton children followed for 20 754 person-years (py), giving a mortality rate of 17.0/1000py overall, 218/1000py (16.5/1000 live births) in neonates, 20/1000py (17.4/1000 live births) in post-neonatal infants and 8/1000py in 1-4 year-olds. Comparing those born to HIV-positive and HIV-negative mothers, the rate ratio, adjusted for child age, sex, maternal age, parity and drinking water source was 1.5 (95%CI 0.6-3.7) in neonates, 11.5 (95%CI 7.2-18.5) in post-neonatal infants and 4.6 (95%CI 2.7-7.9) in 1-4 year-olds. Birth injury/asphyxia, neonatal sepsis and prematurity contributed >70% of neonatal deaths, while acute infections, malaria, diarrhoea and pneumonia accounted for most deaths in older children.

Conclusions: Maternal HIV status had little effect on neonatal mortality but was associated with much higher mortality in the post-neonatal period and among older children. Greater attention to HIV care in pregnant women and mothers should help improve child survival but broader interventions are needed to reduce neonatal mortality.

Abstract access 

Editor’s notes: Child mortality remains a major public health problem in sub-Saharan Africa. A substantial proportion of under-five deaths are attributable to HIV in some countries, estimated as 13% in Malawi, where HIV prevalence is 10-14%.  Child mortality has declined in Malawi, and this large population-based study looked at causes of death from 2006-2012 when antiretroviral therapy (ART) was widely available.  Overall, child mortality was higher in children born to women living with HIV than women without HIV, but this effect was only seen after the neonatal period.  As expected, there were clear differences in causes of death by age. About half of the neonatal deaths were due to infections or prematurity, where HIV status may play a role. Therefore the small effect of the mother’s HIV status in this age group is interesting, although in line with other studies from sub-Saharan Africa.  Older children tended to die from acute infections such as pneumonia, diarrhoea and acute febrile diseases. Maternal HIV positive status was estimated to account for most of these deaths. Strengths of this study are the large number of children included and the length of follow up. The study was not designed to define the mechanisms underlying the excess mortality, and did not include data on child HIV status and other programmes such as vitamin supplementation, vaccination and duration of breast feeding. Optimisation of Option B+ will prevent further children from acquiring HIV and maintain the health of their mothers, but this study illustrates the need for a continued focus on other causes of neonatal mortality.

Africa
Malawi
  • share
0 comments.

Mefloquine not suitable as intermittent preventive treatment of malaria, in pregnant women living with HIV

Intermittent preventive treatment of malaria in pregnancy with mefloquine in HIV-infected women receiving cotrimoxazole prophylaxis: a multicenter randomized placebo-controlled trial.

Gonzalez R, Desai M, Macete E, Ouma P, Kakolwa MA, Abdulla S, Aponte JJ, Bulo H, Kabanywanyi AM, Katana A, Maculuve S, Mayor A, Nhacolo A, Otieno K, Pahlavan G, Ruperez M, Sevene E, Slutsker L, Vala A, Williamsom J, Menendez C. PLoS Med. 2014 Sep 23;11(9):e1001735. doi: 10.1371/journal.pmed.1001735. eCollection 2014.

Background: Intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) is recommended for malaria prevention in HIV-negative pregnant women, but it is contraindicated in HIV-infected women taking daily cotrimoxazole prophylaxis (CTXp) because of potential added risk of adverse effects associated with taking two antifolate drugs simultaneously. We studied the safety and efficacy of mefloquine (MQ) in women receiving CTXp and long-lasting insecticide treated nets (LLITNs).

Methods and findings: A total of 1071 HIV-infected women from Kenya, Mozambique, and Tanzania were randomized to receive either three doses of IPTp-MQ (15 mg/kg) or placebo given at least one month apart; all received CTXp and a LLITN. IPTp-MQ was associated with reduced rates of maternal parasitemia (risk ratio [RR], 0.47 [95% CI 0.27-0.82]; p = 0.008), placental malaria (RR, 0.52 [95% CI 0.29-0.90]; p = 0.021), and reduced incidence of non-obstetric hospital admissions (RR, 0.59 [95% CI 0.37-0.95]; p = 0.031) in the intention to treat (ITT) analysis. There were no differences in the prevalence of adverse pregnancy outcomes between groups. Drug tolerability was poorer in the MQ group compared to the control group (29.6% referred dizziness and 23.9% vomiting after the first IPTp-MQ administration). HIV viral load at delivery was higher in the MQ group compared to the control group (p = 0.048) in the ATP analysis. The frequency of perinatal mother to child transmission of HIV was increased in women who received MQ (RR, 1.95 [95% CI 1.14-3.33]; p = 0.015). The main limitation of the latter finding relates to the exploratory nature of this part of the analysis.

Conclusions: An effective antimalarial added to CTXp and LLITNs in HIV-infected pregnant women can improve malaria prevention, as well as maternal health through reduction in hospital admissions. However, MQ was not well tolerated, limiting its potential for IPTp and indicating the need to find alternatives with better tolerability to reduce malaria in this particularly vulnerable group. MQ was associated with an increased risk of mother to child transmission of HIV, which warrants a better understanding of the pharmacological interactions between antimalarials and antiretroviral drugs.

Abstract  Full-text [free] access

Editor’s notes: The gold standard for intermittent preventive treatment of malaria in pregnancy (IPTp) is at least three doses of sulfadoxine-pyrimethamine, along with the use of insecticide-treated nets. In resource-limited, high HIV prevalent areas, all HIV-positive pregnant women are recommended to take co-trimoxazole prophylaxis. This rules out the concomitant use of sulfadoxine-pyrimethamine because of the increased risk of drug toxicity. However, the effectiveness of co-trimoxazole alone to prevent malaria in pregnant women living with HIV has not been established.   

This article reports a randomised double-blind placebo-controlled trial. The trial compares the efficacy of three-monthly doses of mefloquine (a long-acting efficacious antimalarial, considered to be safe throughout pregnancy) with placebo, in pregnant women living with HIV taking daily co-trimoxazole. Women in the mefloquine arm had a reduced risk of maternal malarial parasitaemia, a reduced rate of placental malaria and reduced incidence of non-obstetric hospital admissions. However, mefloquine was poorly tolerated. Unexpectedly, women in the mefloquine arm had a higher HIV viral load at delivery and were more likely to transmit HIV to their child. Since this finding was based on an exploratory, rather than a pre-planned analysis, its validity is uncertain. If other data support this finding, a better understanding of the underlying mechanism (biological/immunological) will be important to inform future alternative drug regimens for pregnant women living with HIV. 

This trial suggests that an effective antimalarial drug combined with co-trimoxazole can offer additional protection against malaria in pregnant women living with HIV, but mefloquine is not the drug of choice for this purpose. 

Avoid TB deaths
Africa
  • share
0 comments.

HIV education programme replicates success in national Kenyan roll-out

Replicating impact of a primary school HIV prevention programme: primary school action for better health, Kenya.

Maticka-Tyndale E, Mungwete R, Jayeoba O. Health Educ Res. 2014 Aug;29(4):611-23. doi: 10.1093/her/cyt088. Epub 2013 Aug 20.

School-based programmes to combat the spread of HIV have been demonstrated to be effective over the short-term when delivered on a small scale. The question addressed here is whether results obtained with small-scale delivery are replicable in large-scale roll-out. Primary School Action for Better Health (PSABH), a programme to train teachers to deliver HIV-prevention education in upper primary-school grades in Kenya demonstrated positive impact when tested in Nyanza Province. This article reports pre-, 10-month post- and 22-month post-training results as PSABH was delivered in five additional regions of the country. A total of 26 461 students from 110 primary schools in urban and rural, middle- and low-income settings participated in this repeated cross-sectional study. Students ranged in age from 11 to 16 years, were predominantly Christian (10% Muslim), and the majority were from five different ethnic groups. Results demonstrated positive gains in knowledge, self-efficacy related to changes in sexual behaviours and condom use, acceptance of HIV+ students, endorsement of HIV-testing and behaviours to postpone sexual debut or decrease sexual activity. These results are as strong as or stronger than those demonstrated in the original impact evaluation conducted in Nyanza Province. They support the roll-out of the programme across Kenyan primary schools.

Abstract access 

Editor’s notes: There are school-based HIV education programmes, demonstrated to be effective in improving knowledge and reported behaviours in trials. But few have been implemented and evaluated across an entire school system. After a successful trial in Nyanza Province, the Kenyan Ministry of Education, Science and Technology implemented the Primary School Action for Better Health (PSABH) nationwide. The national implementation is notable for its commitment to quality control. Quality Assurance Officers conducted teacher trainings and monitored the strength of programme implementation at each school. At scale, the national PSABH programme replicated and sustained the successes of the Nyanza trial. These included increased HIV-related knowledge and communications, condom and sexual self-efficacy but not reported condom use at last intercourse.  This raises the larger question of whether these improvements in knowledge and reported behaviours translate into actual behaviour change, and reduced HIV transmission. And there is little evidence for successful programmes on this.

Africa
Kenya
  • share
0 comments.

Per-act HIV transmission risk during anal sex may be higher than previously thought

Estimating per-act HIV transmission risk: a systematic review.

Patel P, Borkowf CB, Brooks JT, Lasry A, Lansky A, Mermin J. AIDS. 2014 Jun 19;28(10):1509-19. doi: 10.1097/QAD.0000000000000298.

Background: Effective HIV prevention programs rely on accurate estimates of the per-act risk of HIV acquisition from sexual and parenteral exposures. We updated the previous risk estimates of HIV acquisition from parenteral, vertical, and sexual exposures, and assessed the modifying effects of factors including condom use, male circumcision, and antiretroviral therapy.

Methods: We conducted literature searches to identify new studies reporting data regarding per-act HIV transmission risk and modifying factors. Of the 7 339 abstracts potentially related to per-act HIV transmission risk, three meta-analyses provided pooled per-act transmission risk probabilities and two studies provided data on modifying factors. Of the 8 119 abstracts related to modifying factors, 15 relevant articles, including three meta-analyses, were included. We used fixed-effects inverse-variance models on the logarithmic scale to obtain updated estimates of certain transmission risks using data from primary studies, and employed Poisson regression to calculate relative risks with exact 95% confidence intervals for certain modifying factors.

Results: Risk of HIV transmission was greatest for blood transfusion, followed by vertical exposure, sexual exposures, and other parenteral exposures. Sexual exposure risks ranged from low for oral sex to 138 infections per 10 000 exposures for receptive anal intercourse. Estimated risks of HIV acquisition from sexual exposure were attenuated by 99.2% with the dual use of condoms and antiretroviral treatment of the HIV-infected partner.

Conclusion: The risk of HIV acquisition varied widely, and the estimates for receptive anal intercourse increased compared with previous estimates. The risk associated with sexual intercourse was reduced most substantially by the combined use of condoms and antiretroviral treatment of HIV-infected partners.

Abstract access 

Editor’s notes: The study updates the 2005 Centres for Disease Control (CDC) per-act HIV transmission risks with estimates from recent publications. In addition, it summarizes the effects of various co-factors that modify the transmission risks during sexual exposure. These include genital ulcer disease, viral load, disease stage, use of antiretrovirals, condom use and male circumcision. However, estimates from low-income countries on sexual and mother-to-child transmission are very heterogeneous and not included in the analyses. In general, the updated estimates of transmission risks are comparable to figures from the 2005 CDC study. But they also suggest that the transmission probabilities for both receptive and insertive anal intercourse could be higher than previously thought. Further, the study reasserts that the per-act risk for all sexual exposures is substantially attenuated through the use of condoms and antiretrovirals. These new estimates will be important for both modelling studies and prevention programmes. But a better understanding of HIV transmission risks in low-income countries is needed. 

Asia, Northern America, Oceania
  • share
0 comments.

HIV prevalence of HIV among children in Zimbabwe, justifies the need for provider initiated testing and counselling

Barriers to provider-initiated testing and counselling for children in a high HIV prevalence setting: a mixed methods.

Kranzer K, Meghji J, Bandason T, Dauya E, Mungofa S, Busza J, Hatzold K, Kidia K, Mujuru H, Ferrand RA. PLoS Med. 2014 May 27;11(5):e1001649. doi: 10.1371/journal.pmed.1001649. eCollection 2014.

Background: There is a substantial burden of HIV infection among older children in sub-Saharan Africa, the majority of whom are diagnosed after presentation with advanced disease. We investigated the provision and uptake of provider-initiated HIV testing and counselling (PITC) among children in primary health care facilities, and explored health care worker (HCW) perspectives on providing HIV testing to children.

Methods and findings: Children aged 6 to 15 y attending six primary care clinics in Harare, Zimbabwe, were offered PITC, with guardian consent and child assent. The reasons why testing did not occur in eligible children were recorded, and factors associated with HCWs offering and children/guardians refusing HIV testing were investigated using multivariable logistic regression. Semi-structured interviews were conducted with clinic nurses and counsellors to explore these factors. Among 2 831 eligible children, 2 151 (76%) were offered PITC, of whom 1 534 (54.2%) consented to HIV testing. The main reasons HCWs gave for not offering PITC were the perceived unsuitability of the accompanying guardian to provide consent for HIV testing on behalf of the child and lack of availability of staff or HIV testing kits. Children who were asymptomatic, older, or attending with a male or a younger guardian had significantly lower odds of being offered HIV testing. Male guardians were less likely to consent to their child being tested. 82 (5.3%) children tested HIV-positive, with 95% linking to care. Of the 940 guardians who tested with the child, 186 (19.8%) were HIV-positive.

Conclusions: The HIV prevalence among children tested was high, highlighting the need for PITC. For PITC to be successfully implemented, clear legislation about consent and guardianship needs to be developed, and structural issues addressed. HCWs require training on counselling children and guardians, particularly male guardians, who are less likely to engage with health care services. Increased awareness of the risk of HIV infection in asymptomatic older children is needed.

Abstract  Full-text [free] access

Editor’s notes: An estimated 700 infant HIV infections occur every day. In many priority countries, relatively few of these are diagnosed in early infancy. Subsequent diagnosis largely depends on HIV testing in health care facilities during childhood and adolescence. This is the first study examining Provider Initiated Testing and Counselling (PITC) provision among older children, aged six to 15 years. The study shows high prevalence of HIV infection among those attending primary care services in Harare, Zimbabwe, and among their accompanying caregivers. The paper highlights the challenges of implementing PITC to this age-group, including lack of consent from the guardian, especially male guardians, counsellor non-availability or unwillingness to perform the test. Policy implications from this work include the need to develop clear HIV testing policies and guidance around consent and testing of older children, and the need to address supply-side challenges around the PITC process. An example might be by way of task-shifting through use of lay counsellors or opt-out HIV testing.

Africa
Zimbabwe
  • share
0 comments.

High levels of nonnucleoside reverse transcriptase inhibitor resistance in newly diagnosed children

Drug resistance among newly diagnosed HIV-infected children in the era of more efficacious antiretroviral prophylaxis.

Kuhn L, Hunt G, Technau KG, Coovadia A, Ledwaba J, Pickerill S, Penazzato M, Bertagnolio S, Mellins CA, Black V, Morris L, Abrams EJ. AIDS. 2014 Apr 30. [Epub ahead of print]

Background: In the era of more efficacious prevention of mother-to-child transmission (PMTCT) regimens, documenting the profile of drug resistance in HIV-infected infants and young children is critical to our efforts to improve care and treatment for children.

Methods: HIV drug resistance mutations in plasma virus were ascertained using population sequencing among 230 newly diagnosed HIV-infected children under 2 years of age recruited in Johannesburg, South Africa, during 2011. By this time, more effective PMTCT regimens, including combination antiretroviral therapy for pregnant women, were being implemented.

Results: Two-thirds (67.4%) of HIV-infected children had been exposed to some form of maternal (89%) and/or infant (97%) PMTCT. Among PMTCT-exposed, 56.8% had nonnucleoside reverse transcriptase inhibitor (NNRTI), 14.8% nucleoside reverse transcriptase inhibitor (NRTI), and 1.3% protease inhibitor mutations. NNRTI mutations were strongly related to younger age. The remaining third (32.6%) had no reported or recorded PMTCT exposures, but resistance to NNRTI was detected in 24.0%, NRTI in 10.7%, and protease inhibitor in 1.3%.

Conclusion: The new PMTCT strategies dramatically reduce the number of children who acquire infection, but among those who do become infected, NNRTI resistance prevalence is high. In this South African setting with high PMTCT coverage, almost a quarter of children with no reported or recorded PMTCT also have drug resistance mutations. PMTCT history is an inadequate means of ruling out pretreatment drug resistance. Our results support the use of protease inhibitor-based first-line regimens in HIV-infected infants and young children regardless of PMTCT history.

Abstract access

Editor’s notes: This study describes HIV drug resistance mutations among newly-diagnosed, treatment-naive children younger than two years of age. HIV was diagnosed in 2011 through routine clinical services at five centres in Johannesburg, South Africa. Out of the 385 children identified with a median age of 19 weeks, some 230 went on to be successfully genotyped. Of these, two-thirds had a history of exposure to antiretroviral drugs (ART). Some 89% to maternal ART (combination ART n=28, mono/dual prophylaxis n=110) and some 97% to infant ART (mono/dual prophylaxis n=151). High levels of resistance to non-nucleoside reverse transcriptase inhibitors (NNRTI) were found in both those ‘exposed’ and ‘non-exposed’ to ART, 57% and 24% respectively. The authors hypothesise that poor maternal recall and poor record keeping could explain why nearly one quarter of ‘non-exposed’ infants had NNRTI resistance. Given these findings the authors conclude that boosted protease inhibitor-based regimens should be used as first-line ART in all infants, regardless of history of exposure to ART. 

Africa
South Africa
  • share
0 comments.