Articles tagged as "Preventing HIV infection in children"

Lifelong ART eligibility increases treatment rates for pregnant and breastfeeding women in Malawi

Impact of an innovative approach to prevent mother-to-child transmission of HIV - Malawi, July 2011 - September 2012.

Chimbwandira F, Mhango E, Makombe S, Midiani D, Mwansambo C, Njala J, et al. Centers for Disease Control and Prevention (CDC). MMWR Morb Mortal Wkly Rep. 2013 Mar 1;62(8):148-51.

Antiretroviral medications can reduce rates of mother-to-child transmission of human immunodeficiency virus (HIV) to less than 5%. However, in 2011, only 57% of HIV-infected pregnant women in low- and middle-income countries received a World Health Organization (WHO)-recommended regimen for prevention of mother-to-child transmission (PMTCT), and an estimated 300,000 infants acquired HIV infection from their mothers in sub-Saharan Africa; 15,700 (5.2%) of these infants were born in Malawi. An important barrier to PMTCT in Malawi is the limited laboratory capacity for CD4 cell count, which is recommended by WHO to determine which antiretroviral medications to start. In the third quarter of 2011, the Malawi Ministry of Health (MOH) implemented an innovative approach (called "Option B+"), in which all HIV-infected pregnant and breastfeeding women are eligible for lifelong antiretroviral therapy (ART) regardless of CD4 count. Since that time, several countries (including Rwanda, Uganda, and Haiti) have adopted the Option B+ policy, and WHO was prompted to release a technical update in April 2012 describing the advantages and challenges of this approach as well as the need to evaluate country experiences with Option B+. Using data collected through routine program supervision, this report is the first to summarize Malawi's experience implementing Option B+ under the direction of the MOH and supported by the Office of the Global AIDS Coordinator (OGAC) through the President's Emergency Plan for AIDS Relief (PEPFAR). In Malawi, the number of pregnant and breastfeeding women started on ART per quarter increased by 748%, from 1,257 in the second quarter of 2011 (before Option B+ implementation) to 10,663 in the third quarter of 2012 (1 year after implementation). Of the 2,949 women who started ART under Option B+ in the third quarter of 2011 and did not transfer care, 2,267 (77%) continue to receive ART at 12 months; this retention rate is similar to the rate for all adults in the national program. Option B+ is an important innovation that could accelerate progress in Malawi and other countries toward the goal of eliminating mother-to-child transmission of HIV worldwide.

Abstract access 

Editor’s notes: The efficacy of antiretroviral medications for the elimination of new infections among children is well demonstrated; however barriers including lack of trained personnel, lack of integrated ART and antenatal care services, and poor laboratory capacity mean that almost half of pregnant women living with HIV in low and middle income countries do not receive WHO-recommended regimens. This report from Malawi, where “option B+” was implemented, removing the need for CD4 cell count testing in HIV-infected pregnant and breastfeeding women, coupled with decentralization and integration of ART into antenatal clinics, task shifting policies, and extensive training and supervision, demonstrates that very rapid scale-ups in ART provision for the elimination of new infections among children  are possible in resource-limited settings. Encouragingly, these preliminary data suggest that retention in care at 12 months in women started on ART under “option B+” were comparable to rates in the Malawian adult ART programme (in marked contrast to data reviewed in last month’s issue from South Africa, where only 40% of women who initiated ART during pregnancy were retained in care at 6 months). Whilst longer term adherence and outcome data in the “option B+” cohort are required to ensure that lifelong ART adherence can be maintained, along with evaluation of its effectiveness in reducing vertical HIV transmission at a population level, these results provide important initial evidence for the feasibility of such an approach. Innovations such as this will be critical not just in meeting the goal of reducing new HIV infections in children by 90% by 2015, but also in serving as a model for how ART can be scaled up in other populations to prevent the ongoing high rates of mortality and onward HIV transmission seen in many African countries.

Africa
Malawi
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Community health workers can improve PMTCT and other health outcomes

Outcomes of home visits for pregnant township mothers and their infants in South Africa: a cluster randomised controlled trial.

le Roux IM, Tomlinson M, Harwood JM, O'Connor MJ, Worthman CM, Mbewu N, Stewart J, Hartley M, Swendeman D, Comulada WS, Weiss RE, Rotheram-Borus MJ. AIDS. 2013 Feb 21. [Epub ahead of print]

To evaluate the effect of home visits by Community Health Workers (CHW) on maternal and infant well-being from pregnancy through the first six months of life for women living with HIV (WLH) and all neighbourhood mothers.  In a cluster randomised controlled trial in Cape Town townships, neighbourhoods were randomised within matched pairs to either: 1) Standard Care, comprehensive healthcare at clinics (SC; n = 12 neighbourhoods; n = 169 WLH; n = 594 total mothers), or 2) Philani Intervention Program, home visits by CHW in addition to SC (PIP; n = 12 neighbourhoods; n = 185 WLH; n = 644 total mothers). Participants were assessed during pregnancy (2% refusal) and reassessed at one week (92%) and six months (88%) post-birth. We analysed PIP's effect on 28 measures of maternal and infant well-being among WLH and among all mothers using random effects regression models. For each group, PIP's overall effectiveness was evaluated using a binomial test for correlated outcomes.  Significant overall benefits were found in PIP compared to SC among WLH and among all participants. Secondarily, compared to SC, PIP WLH were more likely to complete tasks to prevent vertical transmission, use one feeding method for 6 months, avoid birth-related medical complications, and have infants with healthy height-for-age measurements. Among all mothers, compared to SC, PIP mothers were more likely to use condoms consistently, breastfeed exclusively for 6 months, and have infants with healthy height-for-age measurements. PIP is a model for countries facing significant reductions in HIV funding whose families face multiple health risks.

Abstract access 

Editor’s notes: This article highlights the additive value of community health workers (CHW) on overall health outcomes. The results are most striking for HIV related measures such as adherence to PMTCT regimens and safe feeding practices to reduce post-natal HIV transmission. There was less impact on some other components of overall family health- further understanding on how  the CHW strategy may be modified to have broader health impacts is important. Despite not all indicators being impacted, this article also highlights that CHW that are not HIV-specific cadres can have beneficial impacts on HIV related measures of improved care. In generalized epidemics with relatively high HIV prevalence, stigma and secrecy may not be quite as burdensome as it has in the past, and offers optimism that HIV care can be successfully integrated into general health services, and that community stigma and secrecy may be diminishing.

Africa
South Africa
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Provision of PMTCT prophylaxis does not necessarily successfully link HIV positive women into long term HIV care

Loss to follow-up before and after delivery among women testing HIV positive during pregnancy in Johannesburg, South Africa.

Clouse K, Pettifor A, Shearer K, Maskew M, Bassett J, Larson B, Van Rie A, Sanne I, Fox MP. Trop Med Int Health. 2013 Feb 3. doi: 10.1111/tmi.12072. [Epub ahead of print]

HIV-positive pregnant women are at heightened risk of becoming lost to follow-up (LTFU) from HIV care.  LTFU was examined before and after delivery among pregnant women newly diagnosed with HIV. This is an observational cohort study of all pregnant women ≥18 years (N = 300) testing HIV positive for the first time at their first ANC visit between January and June 2010, at a primary healthcare clinic in Johannesburg, South Africa. Women (n = 27) whose delivery date could not be determined were excluded. Median (IQR) gestation at HIV testing was 26 weeks (21-30). Ninety-eight per cent received AZT prophylaxis, usually started at the first ANC visit. Of 139 (51.3%) patients who were ART eligible, 66.9% (95% CI 58.8-74.3%) initiated ART prior to delivery; median (IQR) ART duration pre-delivery was 9.5 weeks (5.1-14.2). Among ART-eligible patients, 40.5% (32.3-49.0%) were cumulatively retained through 6 months on ART. Of those ART-ineligible patients at HIV testing, only 22.6% (95% CI 15.9-30.6%) completed CD4 staging and returned for a repeat CD4 test after delivery. LTFU (≥1 month late for last scheduled visit) before delivery was 20.5% (95% CI 16.0-25.6%) and, among those still in care, 47.9% (95% CI 41.2-54.6%) within 6 months after delivery. Overall, 57.5% (95% CI 51.6-63.3%) were lost between HIV testing and 6 months post-delivery. These findings highlight the challenge of continuity of care among HIV-positive pregnant women attending antenatal services, particularly those ineligible for ART.

Abstract access 

Editor’s notes: The reach of HIV testing of pregnant women in antenatal care through PMTCT programming has expanded dramatically. Increasingly PMTCT programmes are able to provide CD4 testing in order to identify those women who are eligible for ART as treatment for their own health, as well as for its impact on preventing HIV transmission.  ART, rather than prophylaxis, is a life-long intervention, and the challenges for maintaining adherence and retention are therefore greater. The results of this study are quite concerning – while HIV testing rates, and CD4 testing of the women who were identified as HIV-positive were quite high, the retention of women placed onto ART was low. The retention in ‘pre-ART’ care was even lower. A deeper understanding of these issues is essential as Option B+ - initiation of ART for all pregnant women living with HIV – increasingly is adopted as standard of care. It is likely that there are programmatic and structural interventions that will increase retention in care, but understanding the attitudes, motivations and interests of the women living with HIV towards treatment will be essential.

Africa
South Africa
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Inclusion of fathers in PMTCT remains a challenge

Barriers to Male-Partner Participation in Programs to Prevent Mother-to-Child HIV Transmission in South Africa.

Koo K, Makin JD, Forsyth BW. AIDS Educ Prev. 2013 Feb;25(1):14-24. doi: 10.1521/aeap.2013.25.1.14.

Efforts to prevent mother-to-child HIV transmission (PMTCT) in sub-Saharan Africa have focused overwhelmingly on women, to the unintended exclusion of their male partners. A cross-sectional study was conducted in Tshwane, South Africa, to determine barriers to male-partner participation during PMTCT. In-depth interviews were conducted with 124 men whose partners had recently been pregnant, and five focus group discussions were held with physicians, nurses, HIV counselors, and community representatives. Qualitative analysis revealed that while most fathers believed that HIV testing is an important part of preparing for fatherhood, there are formidable structural and psychosocial barriers: the perception of clinics as not "male-friendly," a narrow focus on HIV testing instead of general wellness, and a lack of expectations and opportunities for fathers to participate in health care. Coupled with more family-oriented approaches to PMTCT, measurable improvements in the way that male partners are invited to and engaged in HIV prevention during pregnancy can help PMTCT programs to achieve their full potential.

Abstract access 

Editor’s notes: PMTCT programming is located within antenatal care settings in health centers, and PMTCT programmes have struggled to increase HIV testing among men along with their pregnant partners. Pilot programs have implemented innovations to increase male involvement, but the opinions and voices of men have not often been directly solicited to further understand how to overcome what men perceive as barriers to their inclusion. This qualitative study identified among men a relatively high value placed on testing in general, and couples-based testing in particular, and indicates a greater willingness to be engaged during their partner’s ANC services, if care delivery could be modified. A re-orientation of health services towards a ‘wellness’ framework, based upon men’s suggestions, may well be a useful technique to implement and evaluate.

Africa
South Africa
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Adverse events associated with nevirapine use in pregnancy

Adverse events associated with nevirapine use in pregnancy: a systematic review and meta-analysis.

Ford N, Calmy A, Andrieux-Meyer I, Hargreaves S, Mills EJ, Shubber Z. AIDS. 2013 Jan 5. [Epub ahead of print]

The risk of adverse drug events associated with nevirapine is suggested to be greater in pregnant women. The authors conducted a systematic review and meta-analysis of severe adverse events in HIV-positive women who initiated NVP while pregnant. Six databases were searched for studies reporting adverse events among HIV-positive pregnant women who had received nevirapine-based antiretroviral therapy for at least seven days. Data were pooled by the fixed-effects method. Twenty studies (3582 pregnant women) from 14 countries were included in the final review. The pooled proportion of patients experiencing a severe hepatotoxic event was 3.6% (95%CI 2.4-4.8%), severe rash was experienced by 3.3% of patients (95%CI 2.1-4.5%), and 6.2% (95%CI 4.0-8.4%) of patients discontinued nevirapine due to an adverse event. These results were comparable to frequencies observed in the general adult patient population, and to frequencies reported in non-pregnant women within the same cohort. For pregnant women with a CD4 cell count >250 cells/mm there was a non-significant tendency towards an increased likelihood of cutaneous events overall (OR 1.1, 95%CI 0.8-1.6) and severe cutaneous adverse events (OR 1.4, 95%CI 0.8-2.4) and consequently an increased risk of toxicity-driven regimen substitution (OR 1.7, 95%CI 1.1-2.6). These results suggest that the frequency of adverse events associated with nevirapine use in pregnant women, while high, is no higher than reported for nevirapine in the general adult population. Pregnant women with a high CD4 count may be at increased risk of adverse events, but evidence supporting this association is weak.

Abstract access 

Editor’s notes: The selection of antiretroviral drug regimens has been particularly challenging for HIV-positive pregnant women. Adverse events are less frequent for men and women with efavirenz use compared to nevirapine, and increasingly efavirenz is a preferred choice. However, due to concerns about the safety of efavirenz in pregnancy, nevirapine continues to be widely used as a component of antiretroviral treatment for pregnant women. However, there have been suggestions that HIV-positive pregnant women have higher rates of nevirapine-associated adverse events, especially for those women with high CD4, compared to non-pregnant women on nevirapine. This meta-analysis of 20 studies did demonstrate a relatively high frequency of adverse events in women who use nevirapine, but not at rates higher than among non-pregnant women on HIV treatment with nevirapine. The data about efavirenz safety for the fetus is being carefully reviewed to elucidate if widespread use of efavirenz is preferable to nevirapine during pregnancy.

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Increasing HIV testing among male partners in PMTCT settings

Increasing HIV testing among male partners. The Prenahtest ANRS 12127 multi-country randomised trial.

Orne-Gliemann J, Balestre E, Tchendjou P, Miric M, Darak S, Butsashvili M, Perez-Then E, Eboko F, Plazy M, Kulkarni S, Loû AD, Dabis F; for the Prenahtest ANRS 12127 Study Group. AIDS. 2013 Jan 22. [Epub ahead of print]

Couple-oriented post-test HIV counselling (COC) provides pregnant women with tools and strategies to invite her partner to HIV counselling and testing. A randomised trial of the efficacy of COC on partner HIV testing in low/medium HIV prevalence settings (Cameroon, Dominican Republic, Georgia, India) was conducted. Pregnant women were randomised to receive standard post-test HIV counselling (SC) or COC and followed until six months postpartum. Partner HIV testing events were notified by site laboratories, self-reported by women or both combined. Impact of COC on partner HIV testing was measured in intention-to-treat analysis. Socio-behavioural factors associated with partner HIV testing were evaluated using multivariable logistic regression. Among 1943 pregnant women enrolled, partner HIV testing rates (combined indicator) were 24.7% among women from COC group vs 14.3% in SC group in Cameroon (Odds Ratio [OR] = 2.0 95%CI [1.2-3.1]), 23.1% vs 20.3% in Dominican Republic (OR = 1.2 [0.8-1.8]), 26.8% vs 1.2% in Georgia (OR = 29.6 [9.1-95.6]) and 35.4% vs 26.6% in India (OR = 1.5 [1.0-2.2]). Women having received COC did not report more conjugal violence or union break-ups than in the SC group. The main factors associated with partner HIV testing were a history of HIV testing among men in Cameroon, Dominican Republic and Georgia and the existence of couple communication around HIV testing in Georgia and India. A simple prenatal intervention taking into account the couple relationship increases the uptake of HIV testing among men in different socio-cultural settings. COC could contribute to the efforts towards eliminating mother-to-child transmission of HIV.

Abstract access 

Editor’s notes: Programmes geared towards the elimination of new HIV infections in children and keeping their mothers alive worldwide have grappled with the challenge to increase partner testing. Partner HIV discordancy is common, and interventions can be tailored to the couple status categories. Antenatal care settings have not necessarily oriented their programming to be male-friendly. It is notable that generally couples-oriented counseling and testing (COC) did increase uptake of HIV testing by male partners, though there was wide variation between countries. In addition, male testing rates remained relatively low in the intervention couples.   It is clear that additional strategies to augment partner testing will need to be implemented and evaluated. This study did provide some reassuring information that conjugal violence and union break-ups were not more common in the COC group. The study sites were in low and medium HIV prevalence settings and these results need to be compared to similar interventions in high prevalence settings.

Africa, Asia, Latin America
Cameroon, Dominican Republic, Georgia, India
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Getting to zero: from option B to option B+

Cost-effectiveness of World Health Organization 2010 Guidelines for Prevention of Mother-to-Child HIV Transmission in Zimbabwe.

Ciaranello AL, Perez F, Engelsmann B, Walensky RP, Mushavi A, Rusibamayila A, Keatinge J, Park JE, Maruva M, Cerda R, Wood R, Dabis F, Freedberg KA. Clin Infect Dis. 2012 Nov 30. [Epub ahead of print]

Background. In 2010, the World Health Organization (WHO) released revised guidelines for prevention of mother-to-child human immunodeficiency virus (HIV) transmission (PMTCT). We projected clinical impacts, costs, and cost-effectiveness of WHO-recommended PMTCT strategies in Zimbabwe.

Methods. We used Zimbabwean data in a validated computer model to simulate a cohort of pregnant, HIV-infected women (mean age, 24 years; mean CD4 count, 451 cells/µL; subsequent 18 months of breastfeeding). We simulated guideline-concordant care for 4 PMTCT regimens: single-dose nevirapine (sdNVP); WHO-recommended Option A, WHO-recommended Option B, and Option B+ (lifelong maternal 3-drug antiretroviral therapy regardless of CD4).

Outcomes included maternal and infant life expectancy (LE) and lifetime healthcare costs (2008 US dollars [USD]). Incremental cost-effectiveness ratios (ICERs, in USD per year of life saved [YLS]) were calculated from combined (maternal + infant) discounted costs and LE.

Results. Replacing sdNVP with Option A increased combined maternal and infant LE from 36.97 to 37.89 years and would reduce lifetime costs from $5760 to $5710 per mother-infant pair. Compared with Option A, Option B further improved LE (38.32 years), and saved money within 4 years after delivery ($5630 per mother-infant pair). Option B+ (LE, 39.04 years; lifetime cost, $6620 per mother-infant pair) improved maternal and infant health, with an ICER of $1370 per YLS compared with Option B.

Conclusions. Replacing sdNVP with Option A or Option B will improve maternal and infant outcomes and save money; Option B increases health benefits and decreases costs compared with Option A. Option B+ further improves maternal outcomes, with an ICER (compared with Option B) similar to many current HIV-related healthcare interventions.

Abstract access

Editor's notes: This very important paper tackles one of the aspects (the differential cost-effectiveness of different interventions) of the current debate around prevention of mother to child transmission. Particularly for women with CD4 cells higher than 350 (below this level, triple therapy is already the rule) progressively switching from option A (AZT/3TC plus single dose nevirapine) to option B or B+ (starting triple therapy as soon as diagnosed and continue it for life) is considered by many countries the way forward, and may soon be translated in the new WHO guidelines. Advantages of option B+ may include: a) the simplification of regimen and service delivery; b) the harmonization with ART programmes; c) the potential use of once daily, single-pill, fixed dose combinations; and d) the independence from CD4 testing for initial decision. In addition, option B+ can assure protection against MTCT in future pregnancies and may prevent sexual transmission to serodiscordant partners. Finally, it avoids the danger of stopping and starting ARV drugs and there is probably a benefit to the mother's health (because of early ART). When comparing the cost-effectiveness of the different options and looking at them in a clinical perspective, the paper suggests that the health benefit of option B+ clearly outweigh the marginal augmentation of its cost as compared with option B.

Africa
Zimbabwe
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Breastfeeding

Children who acquire HIV infection perinatally are at higher risk of early death than those acquiring infection through breastmilk: A meta-analysis

Becquet R, Marston M, Dabis F, Moulton LH, Gray G, Coovadia HM, Essex M, Ekouevi DK, Jackson D, Coutsoudis A, Kilewo C, Leroy V, Wiktor SZ, Nduati R, Msellati P, Zaba B, Ghys PD, Newell ML; the UNAIDS Child survival group. PLoS One. 2012;7(2):e28510. Epub 2012 Feb 23

Assumptions about survival of HIV-infected children in Africa without antiretroviral therapy need to be updated to inform ongoing UNAIDS modelling of paediatric HIV epidemics among children. Improved estimates of infant survival by timing of HIV-infection (perinatally or postnatally) are thus needed. A pooled analysis was conducted of individual data of all available intervention cohorts and randomized trials on prevention of HIV mother-to-child transmission in Africa. Studies were right-censored at the time of infant antiretroviral initiation. Overall mortality rate per 1000 child-years of follow-up was calculated by selected maternal and infant characteristics. The Kaplan-Meier method was used to estimate survival curves by child's HIV infection status and timing of HIV infection. Individual data from 12 studies were pooled, with 12,112 children of HIV-infected women. Mortality rates per 1,000 child-years follow-up were 39.3 and 381.6 for HIV-uninfected and infected children respectively. One year after acquisition of HIV infection, an estimated 26% postnatally and 52% perinatally infected children would have died; and 4% uninfected children by age 1 year. Mortality was independently associated with maternal death (adjusted hazard ratio 2.2, 95%CI 1.6-3.0), maternal CD4<350 cells/ml (1.4, 1.1-1.7), postnatal (3.1, 2.1-4.1) or peri-partum HIV-infection (12.4, 10.1-15.3). These results update previous work and inform future UNAIDS modelling by providing survival estimates for HIV-infected untreated African children by timing of infection. The authors highlight the urgent need for the prevention of peri-partum and postnatal transmission and timely assessment of HIV infection in infants to initiate antiretroviral care and support for HIV-infected children.

For abstract access click here.

Editor’s note: Although this analysis was done with a view to improving UNAIDS’ mortality estimates, the policy implications for programmes aimed at preventing paediatric HIV infection are clear. Of the 12 trials or studies investigating ways to reduce the risk of paediatric HIV acquisition that were included in this analysis, only one made paediatric HIV treatment available at the time of the study. Thus these findings represent baseline child survival by timing of HIV infection - and they are striking. Children who acquired HIV during pregnancy and delivery were 12 times more likely to die by age 1 than were uninfected children born to mothers living with HIV infection. For children infected through breastfeeding, mortality risk was 3 times higher, and for those with an unknown timing of HIV infection it was intermediate, at 7 times higher. Children who were never breastfed were twice as likely to die than ever breastfed children, as were children whose mothers died during follow-up. We have known for a long time that without antiretroviral treatment and care 50% of children infected perinatally do not survive to age 2. These findings of differential survival by timing of infection underscore the importance of early detection of HIV infection in pregnant women with timely initiation of antiretroviral prophylaxis to prevent HIV transmission in utero, labour, and delivery. But ideally this should be full antiretroviral therapy for life to keep mothers alive and healthy so that they can breastfeed their infants and care for them.

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Breastfeeding

Feasibility of using flash-heated breastmilk as an infant feeding option for HIV-exposed, uninfected infants after 6 Months of age in urban Tanzania

Chantry CJ, Young SL, Rennie W, Ngonyani M, Mashio C, Israel-Ballard K, Peerson J, Nyambo M, Matee M, Ash D, Dewey K, Koniz-Booher P. J Acquir Immune Defic Syndr. 2012 May 1;60(1):43-50

Heat-treating expressed breastmilk is recommended as an interim feeding strategy for HIV-exposed infants in resource-poor countries, but data on its feasibility are minimal. Flash-heating is a simple in-home technique for heating breastmilk that inactivates HIV while preserving its nutritional and anti-infective properties. Chantry and colleagues’ primary objective was to determine, among HIV-infected mothers, the feasibility and protocol adherence of flash-heating expressed breastmilk after 6 months of exclusive breastfeeding. Peer counsellors provided in-home counselling and support on infant feeding from 2 to 9 months postpartum. Mothers were encouraged to exclusively breastfeed for 6 months followed by flash-heating expressed breastmilk if her infant was HIV-negative. Clinic-based staff measured infant growth and morbidity monthly and mothers kept daily logs of infant morbidity. Flash-heating behaviour was tracked until 9 months postpartum using daily logs, in-home observations, and clinic-and home-based surveys. Bacterial cultures of unheated and heated milk samples were performed. Thirty-seven of 72 eligible mothers (51.4%) chose to flash-heat. Median (range) frequency of milk expression was 3 (1-6) times daily and duration of method use on-study was 9.7 (0.1-15.6) weeks. Mean (SD) daily milk volume was 322 (201) mL (range 25-1120). No heated and 32 (30.5%) unheated samples contained bacterial pathogens. Flash-heating is a simple technology that many HIV-positive women can successfully use after exclusive breastfeeding to continue to provide the benefits of breastmilk while avoiding maternal-to-child transmission associated with non-exclusive breastfeeding. Based on these feasibility data, a clinical trial of the effects of flash-heated breastmilk on infant health outcomes is warranted.

For abstract access click here.

Editor’s note: In 2000 WHO recommended heat-treating expressed breast milk as an infant feeding option for mothers living with HIV. The 2010 WHO guidelines on HIV and infant feeding recommend heat treatment as an interim feeding strategy during mastitis, to assist in weaning, and when prophylactic antiretroviral drugs are not available. In this feasibility study, peer counsellors visited mothers weekly when the infants were 2 months of age, reinforcing the notion of exclusive breastfeeding to age 6 months. If the infant was HIV-negative on PCR testing at 5 months, and the mothers were willing to participate in the study, they learned flash-heating techniques and introduced flash-heated expressed breast milk to their infant before any complementary foods were begun. For flash-heating, milk is placed in a glass jar in a pan with water 2 finger-widths above the level of the milk and heated over high heat. When the water reaches a rolling boil, the milk is removed, cooled, and cup-fed to the infant. Mothers’ techniques were excellent on observation, post-flash heated samples were bacteriologically safe, and the quantity of breast milk constituted approximately 34% of infants’ daily caloric needs. Mothers who expressed breast milk more frequently had higher total daily milk volumes. Antiretroviral treatment for all HIV-positive breastfeeding mothers and/or extended prophylaxis for breastfeeding babies are preferable for several reasons but flash-heating techniques are important to know, when there is no access yet or, in a pinch, when prescription refills are delayed for patient reasons or due to drug stockouts.

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Health care delivery

Listening to health workers: lessons from Eastern Uganda for strengthening the programme for the prevention of mother-to-child transmission of HIV

Rujumba J, Tumwine JK, Tylleskar T, Neema S, Heggenhougen HK. BMC Health Serv Res. 2012 Jan 5;12:3

The implementation and utilization of programmes for the prevention of mother-to-child transmission (PMTCT) of HIV in most low-income countries has been described as sub-optimal. As planners and service providers, the views of health workers are important in generating priorities to improve the effectiveness of the PMTCT programme in Uganda. Rujumba and colleagues explored the lessons learnt by health workers involved in the provision of PMTCT services in eastern Uganda to better understand what more needs to be done to strengthen the PMTCT programme. A qualitative study was conducted at Mbale Regional Referral Hospital, The AIDS Support Organisation (TASO) Mbale and at eight neighbouring health centres in eastern Uganda, between January and May 2010. Data were collected through 24 individual interviews with the health workers involved in the PMTCT programme and four key informants (2 district officials and 2 officials from TASO). Data were analyzed using the content thematic approach. Study themes and sub-themes were identified following multiple reading of interview transcripts. Relevant quotations have been used in the presentation of study findings. The key lessons for programme improvement were: ensuring constant availability of critical PMTCT supplies, such as HIV testing kits, antiretroviral drugs (ARVs) for mothers and their babies, regular in-service training of health workers to keep them abreast with the rapidly changing knowledge and guidelines for PMTCT, ensuring that lower level health centres provide maternity services and antiretroviral drugs for women in the PMTCT programme and provision of adequate facilities for effective follow-up and support for mothers. The voices of health workers in this study revealed that it is imperative for government, civil society organizations and donors that the PMTCT programme addresses the challenges of shortage of critical PMTCT supplies, continuous health worker training and follow-up and support for mothers as urgent needs to strengthen the PMTCT programme.

For abstract access click here.

Editor’s note: This rich article, full of the views of health care workers (nurses/midwives, counsellors, clinical officers, and medical doctors) working in programmes to prevent mother-to-child transmission (PMTCT) in Mbale, Uganda, makes for interesting reading. The semi-structured interviews with front-line workers took place before those with key informants, in order that suggestions made by the health care workers on how to strengthen the PMTCT programme could be fed back to district officials planning, implementing, and monitoring the programme. In addition to the key lessons for programme improvement that were identified, the inability of poor women to purchase the ‘Maama’ kits required for health facility delivery is undermining attempts to promote linkages between PMTCT, maternal and child health, and reproductive health. As well, persistent stigma and limited integration of services is keeping women away from services such as the PEPFAR-funded TASO programme that is less affected by shortages. But the biggest lesson is that health care workers are key stakeholders in the design, implementation, and strengthening of services¾their voices should be sought and listened to.

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