Articles tagged as "National responses"

Health system barriers to achieving the potential of integrated service delivery

Integrated maternal and child health services in Mozambique: structural health system limitations overshadow its effect on follow-up of HIV-exposed infants.

Geelhoed D, Lafort Y, Chissale E, Candrinho B, Degomme O. BMC Health Serv Res. 2013 Jun 7;13:207. doi: 10.1186/1472-6963-13-207.

Background: The follow-up of HIV-exposed infants remains a public health challenge in many Sub-Saharan countries. Just as integrated antenatal and maternity services have contributed to improved care for HIV-positive pregnant women, so too could integrated care for mother and infant after birth improve follow-up of HIV-exposed infants. We present results of a study testing the viability of such integrated care, and its effects on follow-up of HIV-exposed infants, in Tete Province, Mozambique.

Methods: Between April 2009 and September 2010, we conducted a mixed-method, intervention-control study in six rural public primary healthcare facilities, selected purposively for size and accessibility, with random allocation of three facilities each for intervention and control groups. The intervention consisted of a reorganization of services to provide one-stop, integrated care for mothers and their children under five years of age. We collected monthly routine facility statistics on prevention of mother-to-child HIV transmission (PMTCT), follow-up of HIV-exposed infants, and other mother and child health (MCH) activities for the six months before (January-June 2009) and 13 months after starting the intervention (July 2009-July 2010). Staff were interviewed at the start, after six months, and at the end of the study. Quantitative data were analysed using quasi-Poisson models for significant differences between the periods before and after intervention, between healthcare facilities in intervention and control groups, and for time trends. The coefficients for the effect of the period and the interaction effect of the intervention were calculated with their p-values. Thematic analysis of qualitative data was done manually.

Results: One-stop, integrated care for mother and child was feasible in all participating healthcare facilities, and staff evaluated this service organisation positively. We observed in both study groups an improvement in follow-up of HIV-exposed infants (registration, follow-up visits, serological testing), but frequent absenteeism of staff and irregular supply of consumables interfered with healthcare facility performance for both intervention and control groups.

Conclusions: Despite improvement in various aspects of the follow-up of HIV-exposed infants, we observed no improvement attributable to one-stop, integrated MCH care. Structural healthcare system limitations, such as staff absences and irregular supply of essential commodities, appear to overshadow its potential effects. Regular technical support and adequate basic working conditions are essential for improved performance in the follow-up of HIV-exposed infants in peripheral public healthcare facilities in Mozambique.

Abstract   Full-text [free] access 

Editor’s notes: Despite rapid advances in the delivery of PMTCT services in many sub-Saharan African countries, the follow-up of HIV-exposed infants until the age of 18 months remains a critical challenge.  This mixed methods, quasi-experimental evaluation study evaluated the viability of providing one-stop, integrated care, its acceptability to healthcare providers, and its effect upon the follow-up of HIV-exposed infants and other MCH services, in the public health system. The intervention consisted of a reorganization of MCH services, to deliver integrated, one-stop consultations for mothers and their children up to 5 years of age. Absence of MCH staff occurred in 16% of months, and stock-outs of HIV testing commodities and MCH drugs occurred in almost half of all months. The improvements in both arms suggests that improving some of the basic working conditions of peripheral MCH staff and ensuring an adequate supply of commodities might be effective ways to improve the follow-up of HIV-exposed infants in peripheral public healthcare facilities in Mozambique. 

Africa
Mozambique
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Integration of ANC and ART services increases PMTCT uptake but provision remains sub-optimal

Integration of Antiretroviral Therapy Services into Antenatal Care Increases Treatment Initiation during Pregnancy: A Cohort Study.

Stinson K, Jennings K, Myer L. PLoS One. 2013 May 16;8(5):e63328. Print 2013

Objectives: Initiation of antiretroviral therapy (ART) during pregnancy is critical to promote maternal health and prevent mother-to-child HIV transmission (PMTCT). The separation of services for antenatal care (ANC) and ART may hinder antenatal ART initiation. We evaluated ART initiation during pregnancy under different service delivery models in Cape Town, South Africa.

Methods: A retrospective cohort study was conducted using routinely collected clinic data. Three models for ART initiation in pregnancy were evaluated ART 'integrated' into ANC, ART located 'proximal' to ANC, and ART located some distance away from ANC ('distal'). Kaplan-Meier methods and Poisson regression were used to examine the association between service delivery model and antenatal ART initiation.

Results: Among 14 617 women seeking antenatal care in the three services, 30% were HIV-infected and 17% were eligible for ART based on CD4 cell count <200 cells/µL. A higher proportion of women started ART antenatally in the integrated model compared to the proximal or distal models (55% vs 38% vs 45%, respectively, global p = 0.003). After adjusting for age and gestation at first ANC visit, women who at the integrated service were significantly more likely to initiate ART antenatally (rate ratio 1.33; 95% confidence interval: 1.09-1.64) compared to women attending the distal model; there was no difference between the proximal and distal models in antenatal ART initiation however (p = 0.704).

Conclusions: Integration of ART initiation into ANC is associated with higher levels of ART initiation in pregnancy. This and other forms of service integration may represent a valuable intervention to enhance PMTCT and maternal health. .

Abstract Full-text [free] access

Editor’s notes: This study highlights the challenges of successful delivery of effective PMTCT. The authors compare 3 PMTCT delivery sites with differing modes of care, principally with respect to distance between ANC and ART provision services. It must be noted that other baseline differences between study participants and site services also existed (such as algorithms of care and support from international agencies etc), however this is often seen in observational (and operational research) studies and the pertinence of the findings remain. An important result of this study is that even with integration of ANC and ART services, initiation of treatment was only achieved in just over half of eligible women. There was a notable trend in ART initiation by gestational age at presentation for ANC – the more advanced the gestational age at presentation, the less likely women were to start ART antenatally, reflecting delays in ART initiation even after a woman is in care. Many of the women proceeded to eventually start treatment postnatally. This is an important reminder of the missed opportunities that exist both for preventing HIV in infants and for earlier initiation of treatment in women for their own health.

Africa
South Africa
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Integrating HIV testing into routine infant immunization programmes

Evaluation of Using Routine Infant Immunization Visits to Identify and Follow-Up HIV-Exposed Infants and Their Mothers in Tanzania.

Goodson JL, Finkbeiner T, Davis NL, Lyimo D, Rwebembera A, Swartzendruber AL, Wallace AS, Kimambo S, Kimario CJ, Wiktor SZ, Luman ET. J Acquir Immune Defic Syndr. 2013 May 1;63(1):e9-e15

Background: Without treatment, approximately half of HIV-infected infants die by age 2 years, and 80% die before age 5 years. Early identification of HIV-infected and HIV-exposed infants provides opportunities for life-saving interventions. We evaluated integration of HIV-related services with routine infant immunization in Tanzania. METHODS: During April 2009 to March 2010, at 4 urban and 4 rural sites, mothers' HIV status was determined at first-month immunization using antenatal cards. HIV-exposed infants were offered HIV testing and follow-up care. Impact of integrated service delivery was assessed by comparing average monthly vaccine doses administered during the study period and a 2-year baseline period; acceptance was assessed by interviewing mothers and service providers. FINDINGS: During 7569 visits, 308 HIV-exposed infants were identified and registered; of these, 290 (94%) were tested, 15 (5%) were HIV infected. At urban sites, first-month vaccine doses remained stable (+2% for pentavalent vaccine and -4% for polio vaccine), and vaccine doses given later in life (pentavalent, polio, and measles) increased 12%, 8%, and 11%, respectively. At rural sites, first-month vaccine doses decreased 33% and 35% and vaccine doses given later in life decreased 23%, 28%, and 28%. Mothers and service providers generally favored integrated services; however, HIV-related stigma and inadequate confidentiality controls of HIV testing were identified, particularly at rural sites. INTERPRETATION: Integration of HIV-related services at immunization visits identified HIV-exposed infants, HIV-infected infants, and HIV-infected mothers; however, decreases in vaccine doses administered at rural sites were concerning. HIV-related service integration with immunization visits needs careful monitoring to ensure optimum vaccine delivery.

Abstract access 

Editor’s notes: One of the targets set in the Global Plan in 2009 was that there should be a 90% reduction in the number of children newly infected with HIV by 2015. Although progress has been made towards achieving this target, with a 24% reduction in HIV infections between 2009 and 2011, it is estimated that in 2011 alone 300 000 children in sub-Saharan Africa were newly infected with HIV. Despite the knowledge that antiretroviral therapy (ART) substantially reduces morbidity and mortality in children, only 23% of children eligible for treatment are estimated to be receiving ART; without access to ART these children will die. One of the major barriers to initiating ART, which urgently needs to be addressed, is access to HIV testing for children. This paper demonstrates the feasibility and acceptability of integrating routine HIV testing of mothers and infants into national immunization programmes. However, the implementation of such a strategy would have be to done with care, as the integration of HIV testing into immunization programmes may have a negative impact on vaccination uptake.

Africa
United Republic of Tanzania
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Feasibility and acceptability of routine HIV testing into a general paediatric out-patient clinic

The Acceptability and Feasibility of Routine Pediatric HIV Testing in an Outpatient Clinic in Durban, South Africa.

Ramirez-Avila L, Noubary F, Pansegrouw D, Sithole S, Giddy J, Losina E, Walensky RP, Bassett IV Pediatr Infect Dis J. 2013

Background: Limited access to HIV testing for children impedes early diagnosis and access to ART. Our objective was to evaluate the feasibility and acceptability of routine pediatric HIV testing in an urban, fee-for-service, outpatient clinic in Durban, South Africa. METHODS: We assessed the number of patients (0-15yrs) who underwent HIV testing upon physician referral during a baseline period. We then established a routine, voluntary HIV testing study for pediatric patients, regardless of symptoms. Parents/caretakers were offered free rapid fingerstick HIV testing for their child. For patients <18mo, the biological mother was offered HIV testing and HIV DNA PCR was used to confirm the infant's status. The primary outcome was the HIV testing yield, defined as the average number of positive tests per month during the routine compared to the baseline period. RESULTS: Over a 5-month baseline testing period, 931pediatric patients registered for outpatient care. Of the 124 (13%) patients who underwent testing upon physician referral, 21 (17%, 95% CI 11-25%) were HIV-infected. During a 13-month routine testing period, 2,790 patients registered for care and 2,106 (75%) were approached for participation. Of these, 1,234 were eligible and 771(62%) enrolled. Among those eligible, 637 (52%, 95% CI 49-54%) accepted testing for their child or themselves (biological mothers of infants <18 months).There was an increase in the average number of HIV tests during the routine compared to the baseline HIV testing periods (49 vs. 25 tests per month, p=0.001) but no difference in the HIV testing yield during the testing periods (3 vs. 4 positive HIV tests/month, p=0.06). However, during the routine testing period HIV prevalence remains extraordinarily high with 39 (6%, 95% CI 4-8%) newly-diagnosed HIV-infected children (median 7 years, 56% female). CONCLUSIONS: Targeted and symptom-based testing referral identifies an equivalent number of HIV-infected children as routine HIV testing. Routine HIV testing identifies a high burden of HIV and is a feasible and moderately acceptable strategy in an outpatient clinic in a high prevalence area.

Abstract access 

Editor’s notes: ART coverage of children in resource-limited settings is very low, in part because HIV positive children are being diagnosed late, or not at all. This has significant implications in terms of morbidity and mortality, as without access to treatment these children will die. Additionally late initiation of ART may result in irreversible conditions e.g. chronic lung disease. Routine HIV testing of children in an out-patient setting is one potential strategy which could be used to identify HIV positive children and link them into care. In this study the introduction of routine, voluntary HIV testing of children (0-15 years) into a general out-patient clinic in a high HIV prevalence setting, resulted in more children being tested than previously seen with provider-initiated testing. Despite this, no more HIV positive children were identified. One potential reason, as discussed in the paper, was selection bias; a significant proportion of children registering at the clinic did not have an HIV test. It is possible that children who were considered ineligible for testing, or whose caretakers either declined participation in the study or HIV testing, were at higher risk of being HIV positive. HIV positive children have the right to access life-saving ART; however as shown in this study routine voluntary testing was only moderately acceptable and as a result we may be failing to test those children who are at highest risk. Innovative solutions, such as opt-out testing need to be considered and debated at a national level.

Africa
South Africa
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Safe PrePex circumcision administered by nurses

One Arm, Open Label, Prospective, Cohort Field Study to Assess the Safety and Efficacy of the PrePex Device for Scale Up of Non-Surgical Circumcision when Performed by Nurses in Resource Limited Settings for HIV Prevention.

Mutabazi V, Kaplan SA, Rwamasirabo E, Bitega JP, Ngeruka ML, Savio D, Karema C, Binagwaho A. J Acquir Immune Defic Syndr. 2013 Mar 5. [Epub ahead of print]]

To assess the safety and efficacy of the PrePex device when circumcision is performed by lower cadre nurses, among healthy adult men scheduled for voluntary circumcision, in preparation for scale up. Single-center 3-month non-randomized field study was conducted in Rwanda. Ten nurses were trained for 3 days on the PrePex circumcision method. Healthy, non-circumcised adult male volunteers (n=590) were enrolled, distributed between 5 teams of 2 nurses each, and underwent circumcision using the PrePex device, which employs radial elastic pressure to the foreskin, leading to distal necrosis. Adverse event (AE) data was gathered for 6 weeks post-removal. All 518 subjects from the pilot and pivotal phases achieved complete circumcision. There were 5 AEs on 4 subjects (rate of 0.96%, 95% Confidence Interval: 0.31-2.24). There were 4 device-related AEs, including 1 case of bleeding post- removal, 1 case of high pain the night before the removal (which resulted in subject self-removal of the device and caused mild bleeding), 1 erroneous placement, and 1 subject partial removal of the device. There was 1 non-device related AE. AEs were moderate and were resolved with simple intervention. The study demonstrated that circumcision performed by nurses using the PrePex device is safe, effective and easy to train. The procedure was minimally invasive and did not require injected anesthesia, sutures, or sterile settings. PrePex has the potential to help facilitate rapid, safe, non-physician male circumcision scale-up programs for HIV prevention, an imminent need in Sub Saharan Africa where physicians are limited.

Abstract Access

Editor’s notes: Scale-up of voluntary medical male circumcision (VMMC) for HIV prevention has been quite modest to date, and new strategies are needed to meet the goal of circumcising 80% of adult males aged 15-49 years, by 2016, in areas of high HIV and low circumcision prevalence. There is much interest in circumcision devices which can be used by non-physicians in non-sterile, rural  settings, to reduce the burden of VMMC scale-up on existing healthcare systems.  Previous studies in Rwanda showed that the PrePex device appeared safe and efficacious for adult male circumcision.  The current study found that the device was safe and effective when used by trained lower cadre nurses. The adverse event rate in this study was lower than in many studies of surgical circumcision, but not zero, and care would be needed to ensure adequate medical (or surgical) back-up if the device was used in remote settings. 

Africa
Rwanda
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Achievement and maintenance of viral suppression in persons newly diagnosed with HIV, New York City, 2006-2009

Achievement and maintenance of viral suppression in persons newly diagnosed with HIV, New York City, 2006-2009: using population surveillance data to measure the treatment part of ‘test and treat’.

Torian LV, Xia Q; J Acquir Immune Defic Syndr. 2013 Mar 26. [Epub ahead of print]

Viral suppression reduces HIV-related morbidity and transmission to uninfected partners. Models suggest that the transmission benefit may extend to whole communities. New York City (NYC) surveillance data was used to analyze viral suppression among persons newly diagnosed with HIV 2006—2009. The Kaplan-Meier product limit method was used to estimate the cumulative proportion achieving suppression and experiencing failure. Cox proportional hazards regression was used to identify factors associated with time to achieve suppression and duration of suppression, and to calculate hazard ratios (HRs). Among the 12,122 new diagnoses, 7,663 (63.2%) ever achieved suppression by June 30, 2011, 26.6% within 6 and 39.8% within 12 months of diagnosis. 89.2% of those ever achieving suppression maintained it for 6 months and 81.9% for 12 months. The proportion achieving and maintaining suppression improved with each successive diagnostic year (P < 0.0001). Patients with initial CD4 <350 achieved suppression more rapidly (P < 0.0001) and maintained it longer. Those with the highest nadir CD4 before suppression (≥ 500 cells/mm3) were least likely to maintain it (HR = 0.72 for men, 95% confidence interval [CI]: 0.61, 0.82, and HR = 0.67 for women, 95% CI: 0.53, 0.87). Persons in successively later diagnostic cohorts and those with nadir CD4 at the federal ART threshold had larger proportions suppressed, faster time to suppression, and longer duration. New guidelines recommending therapy independent of CD4 may result in improvements in proportion suppressed in future diagnostic cohorts.

Abstract access 

Editor’s notes: The latest US guidelines (DHSS 2013) emphasise the benefits of ‘treatment as prevention’ and advise initiating ART in all HIV positive patients, regardless of CD4 count. This paper describes the baseline situation in New York City prior to the implementation of these guidelines. Less than 40% of patients newly diagnosed with HIV (2006-2009) achieved viral suppression within 12 months; however, it was not known how many of these had initiated ART, nor was it reported how many were engaged in care. Certainly, for the community of patients accessing HIV tests, there appears to be considerable scope to increase viral suppression with the new guidelines. Of particular interest in this study was the finding that patients with a high nadir CD4 count (>500 cells/mm3) prior to achieving viral suppression were the least likely to maintain viral suppression. This suggests that those patients, who benefit least in terms of reduced risk of disease progression, are at the highest risk of viral rebound and potentially resistance, and should be considered a high-risk group in terms of the need for targeted adherence support. In high-income settings, where viral load monitoring occurs every 3-6 months, viral rebound can be detected early and targeted adherence interventions implemented. However, were this finding to be replicated in resource-limited settings, many of which have limited or no access to viral load monitoring, the implications of initiating ART at higher CD4 count thresholds could be considerable.

Northern America
United States of America
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Declines in HIV incidence and risk behaviours among drug users in Amsterdam

Drug Users in Amsterdam: Are They Still at Risk for HIV?

Nienke van der Knaap, Bart P. X. Grady, Maarten F. Schim van der Loeff, Titia Heijman, Arjen Speksnijder, Ronald Geskus, Maria Prins. PLoS One. 2013;8(3):e59125. doi: 10.1371/journal.pone.0059125. Epub 2013 Mar 18.

Background and Aims: To examine whether drug users (DU) in the Amsterdam Cohort Study (ACS) are still at risk for HIV, we studied trends in HIV incidence and injecting and sexual risk behaviour from 1986 to 2011.

Methods: The ACS is an open, prospective cohort study on HIV. Calendar time trends in HIV incidence were modelled using Poisson regression. Trends in risk behaviour were modelled via generalized estimating equations. In 2010, a screening for STI (chlamydia, gonorrhoea and syphilis) was performed. Determinants of unprotected sex were studied using logistic regression analysis.

Results: The HIV incidence among 1298 participants of the ACS with a total follow-up of 12,921 person-years (PY) declined from 6.0/100 PY (95% confidence interval [CI] 3.2–11.1) in 1986 to less than 1/100 PY from 1997 onwards. Both injection and sexual risk behaviour declined significantly over time. Out of 197 participants screened for STI in 2010–2011, median age 49 years (IQR 43–59), only 5 (2.5%) were diagnosed with an STI. In multivariable analysis, having a steady partner (aOR 4.1, 95% CI 1.6–10.5) was associated with unprotected sex. HIV-infected participants were less likely to report unprotected sex (aOR 0.07, 95% CI 0.02–0.37).

Conclusions: HIV incidence and injection risk behaviour declined from 1986 onwards. STI prevalence is low; unprotected sex is associated with steady partners and is less common among HIV-infected participants. These findings indicate a low transmission risk of HIV and STI, which suggests that DU do not play a significant role in the current spread of HIV in Amsterdam.

Abstract access   

Editor’s notes: Drug users are at high risk of HIV, both from the risk of HIV arising from sharing injecting paraphernalia, along with HIV risks from sexual behaviour – including the increased risk of unprotected sex associated with the use of cocaine and other stimulants, or if drug users work as commercial sex workers. Earlier research showed a decline in injecting risk behaviour up to 2005, but a remaining risk of HIV transmission from sexual risk behaviour. This analysis shows that risk from injecting has continued to decline. The prevalence of unprotected sex was substantial, but mainly associated with having a steady partner, and was less common in HIV-infected participants. Taken together, the findings indicate a low transmission risk of HIV and STI in this population cohort, and suggest that drug use no longer plays a significant role in the spread of HIV in Amsterdam. This is in contrast to the increasing levels of HIV infection among drug users in other Eastern European settings, and underscores the importance of effective harm reduction programmes for drug users.  

Europe
Netherlands
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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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The challenge of integrating Tuberculosis (TB) and HIV services in South Africa

Current Integration of Tuberculosis (TB) and HIV Services in South Africa, 2011.

Chehab JC, Vilakazi-Nhlapo AK, Vranken P, Peters A, Klausner JD. Current Integration of Tuberculosis (TB) and HIV Services in South Africa, 2011. PLoS One. 2013;8(3):e57791. doi: 10.1371/journal.pone.0057791. Epub 2013 Mar 4.

SETTING: Public Health Facilities in South Africa.

OBJECTIVE: To assess the current integration of TB and HIV services in South Africa, 2011.

DESIGN: Cross-sectional study of 49 randomly selected health facilities in South Africa. Trained interviewers administered a standardized questionnaire to one staff member responsible for TB and HIV in each facility on aspects of TB/HIV policy, integration and recording and reporting. We calculated and compared descriptive statistics by province and facility type.

RESULTS: Of the 49 health facilities 35 (71%) provided isoniazid preventive therapy (IPT) and 35 (71%) offered antiretroviral therapy (ART). Among assessed sites in February 2011, 2,512 patients were newly diagnosed with HIV infection, of whom 1,913 (76%) were screened for TB symptoms, and 616 of 1,332 (46%) of those screened negative for TB were initiated on IPT. Of 1,072 patients newly registered with TB in February 2011, 144 (13%) were already on ART prior to Tb clinical diagnosis, and 451 (42%) were newly diagnosed with HIV infection. Of those, 84 (19%) were initiated on ART. Primary health clinics were less likely to offer ART compared to district hospitals or community health centers (p<0.001).

CONCLUSION: As of February 2011, integration of TB and HIV services is taking place in public medical facilities in South Africa. Among these services, IPT in people living with HIV and ART in TB patients are the least available.

Abstract access 

Editor’s notes: South Africa has decentralised HIV care with impressive speed. This study aimed to quantify TB/HIV integration at a sample of health facilities in South Africa. The investigators measured service integration using a study-specific tool, which highlights the lack of an agreed way of recording and reporting integration of these services. The study highlights that there are still some primary care clinics where ART is not available, and provision of isoniazid preventive therapy remains suboptimal. The investigators do not report the proportion of clinics providing HIV and TB treatment in a single consultation by a single provider for patients requiring both treatments simultaneously. This level of integration, which intuitively would have many advantages for patients, remains rare. Full integration of TB and HIV services may be difficult to achieve while the two services are run as separate vertical programmes with separate reporting systems.

Africa
South Africa
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National HIV strategies shortchange men who have sex with men

Men who have sex with men inadequately addressed in African AIDS National Strategic Plans.

Makofane K, Gueboguo C, Lyons D, Sandfort T. Glob Public Health. 2013 Feb;8(2):129-43. doi: 10.1080/17441692.2012.749503. Epub 2012 Dec 20

Through an analysis of AIDS National Strategic Plans (NSPs), this study investigated the responses of African governments to the HIV epidemics faced by men who have sex with men (MSM). National Strategic Plans from 46 African countries were systematically analysed, with attention focused on (1) the representation of MSM and their HIV risk, (2) the inclusion of epidemiologic information on the HIV epidemic among MSM and (3) government-led interventions addressing MSM. Out of 46 NSPs, 34 mentioned MSM. While two-thirds of these NSPs acknowledged the vulnerability of MSM to HIV infection, fewer than half acknowledged the role of stigma or criminalisation. Four NSPs showed estimated HIV prevalence among MSM, and one included incidence. Two-thirds of the NSPs proposed government-led HIV interventions that address MSM. Those that did plan to intervene planned to do so through policy interventions, social interventions, HIV-prevention interventions, HIV-treatment interventions and monitoring activities. Overall, the governments of the countries included in the study exhibited little knowledge of HIV disease dynamics among MSM and little knowledge of the social dynamics behind MSM's HIV risk. Concerted action is needed to integrate MSM into NSPs and governmental health policies in a way that acknowledges this population and its specific HIV/AIDS-related needs.

Abstract access 

Editor’s notes: Increasingly it is recognized that prior dichotomies of generalized versus concentrated epidemics can interfere with good program planning. More specifically, ‘know your epidemic’ analyses identify specific key populations at significant risk of HIV infection within broader generalized epidemics. Men who have sex with men are a key population that usually will benefit from tailored and focused prevention, testing, and care and treatment interventions, often by non-governmental organizations. The Global Fund, and PEPFAR, to name two funding mechanisms, are supporting such efforts. National strategic plans (NSP), globally, and more specifically in Africa, are acknowledging unique vulnerabilities of men who have sex with men. This review of NSP is notable for highlighting that recognition of particular vulnerability is often not appropriately connected to key population-specific interventions that would mitigate this risk- such as decriminalization and antidiscrimination efforts. It is significant that men who have sex with men are recognized in most NSP, and that there are some MSM specific interventions recommended – further training and understanding of successful strategies to reduce this key population’s HIV risk seem warranted.

Africa
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