Articles tagged as "National responses"

Young people and condoms

Making sense of condoms: social representations in young people's HIV-related narratives from six African countries

Winskell K, Obyerodhyambo O, Stephenson R. Soc Sci Med. 2011 Feb 4

Condoms are an essential component of comprehensive efforts to control the HIV epidemic, both for those who know their status and for those who do not. Although young people account for almost half of all new HIV infections, reported condom use among them remains low in many sub-Saharan African countries. In order to inform education and communication efforts to increase condom use, Winskell and colleagues examined social representations of condoms among young people aged 10-24 in six African countries/regions with diverse HIV prevalence rates: Swaziland, Namibia, Kenya, South-East Nigeria, Burkina Faso, and Senegal. They used a unique data source, namely 11,354 creative ideas contributed from these countries to a continent-wide scriptwriting contest, held from 1 February to 15 April 2005, on the theme of AIDS. The authors stratified each country sample by the sex, age (10-14, 15-19, 20-24), and urban/rural location of the author and randomly selected up to 10 narratives for each of the 12 resulting strata, netting a total sample of 586 texts for the six countries. They analyzed the narratives qualitatively using thematic data analysis and narrative-based methodologies. Differences were observed across settings in the prominence accorded to condoms, the assessment of their effectiveness, and certain barriers to and facilitators of their use. Moralization emerged as a key impediment to positive representations of condoms, while humour was an appealing means to normalize them. The social representations in the narratives identify communication needs in and across settings and provide youth-focused ideas and perspectives to inform future intervention efforts.

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Editors’ note: The ‘Scenarios for Africa’ contest invited young Africans to contribute scripts for 5-minute fiction films about HIV. Winning ideas were selected by national and international juries and thus far 35 films in over 25 languages have been produced by leading African directors. These researchers examined selected narrative scripts from 6 non-neighbouring countries for insights into how young people make sense of the role of condoms in the response to AIDS and how they would communicate their understanding to others. Social representations are not like attitudes that are based on conscious evaluative judgements. Rather, they are often pre-conscious and they communicate culturally-shared norms and values in symbolic form. This study assessed the social representations of condoms among young people through analysis of their spontaneous mentions of condoms, rather than through their answers to quantitative questions. The results are fascinating and should inform condom programming tailored to context-specific challenges. Although there was no consistent relationship between social representations of condoms and HIV prevalence or majority religion, there was a striking relationship between how prominent condoms are and how favourably they are viewed in the film scripts submitted by a country’s young people and the level of condom use reported by young people in the country’s Demographic and Health Survey. Among the many implications of the study findings are the urgent need to promote male role models who insist on condom use and refuse to concede under pressure and the importance of positive messages, drawing on humour, to overcome misinformation and moralisation.

National responses
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National responses

Strange bedfellows: the Catholic Church and Brazilian National AIDS Programme in the response to HIV/AIDS in Brazil

Murray LR, Garcia J, Muñoz-Laboy M, Parker RG. Soc Sci Med. 2011 Mar;72(6):945-52.

The HIV epidemic has raised important tensions in the relationship between Church and State in many parts of Latin America where government policies frequently negotiate secularity with religious belief and doctrine. Brazil represents a unique country in the region due to the presence of a national religious response to AIDS articulated through the formal structures of the Catholic Church. As part of an institutional ethnography on religion and HIV in Brazil, Murray and colleagues conducted an extended, multi-site ethnography from October 2005 through March 2009 to explore the relationship between the Catholic Church and the Brazilian National AIDS Programme. This case study links a national, macro-level response of governmental and religious institutions with the enactment of these politics and dogmas on a local level. Shared values in solidarity and citizenship, similar organizational structures, and complex interests in forming mutually beneficial alliances were the factors that emerged as the bases for the strong partnership between the two institutions. Dichotomies of Church and State and micro and macro forces were often blurred as social actors responded to the epidemic while also upholding the ideologies of the institutions they represented. The authors argue that the relationship between the Catholic Church and the National AIDS Programme was formalized in networks mediated through personal relationships and political opportunity structures that provided incentives for both institutions to collaborate.

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Editors’ note: Latin America is a region with one of the strongest organized religious movements worldwide and Brazil is the country with the world’s largest population—125 million people or 73% of the population—that reports being Catholic. The first cases of AIDS were reported in the early 1980s when Brazil was in the midst of countrywide political discussion about its future. This discussion’s result was a vision of political solidarity that shaped an economically, socially, and politically democratic Brazil. Religious community organisations had been active in confronting the country’s dictatorship, based on principles anchored in Liberation Theology that emphasised grass-roots involvement, emancipation, building individual self-esteem, and people’s ownership of social problems and solutions. This 5-year ethnographic study examines the ebb and flow of the relationships between the Catholic Church and government structures responding to AIDS through data collected at 5 field sites in Sao Paulo, Rio de Janeiro, Porto Alegre, Brasilia, and Recife. Common ground was found early in the epidemic around the theme of care and support, with the Church providing care for needy people living with HIV, with HIV-positive priests reaching out to the civil society and human rights department of the National AIDS Programme, and with the relative autonomy of church dioceses to respond to local needs with a degree of autonomy. Although solidarity took precedence over ideology in these partnerships, the topic of prevention was fraught with debate, with the ‘lesser evil’ argument about condoms seen as supporting decadence which contrasted with the view that ‘it’s a sin not to use it’. This case study of Brazil provides useful insights into the role of historical political processes and social actors in constructing religious responses to the HIV epidemic.

National responses
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National responses

The integration of multiple HIV/AIDS projects into a coordinated national programme in China

Wu Z, Wang Y, Mao Y, Sullivan SG, Juniper N, Bulterys M. Bull World Health Organ. 2011 Mar 1;89(3):227-33.

External financial support from developed countries is a major resource for any developing country's national AIDS programme. The influence of donors on the content and implementation of these programmes is thus inevitable. China is a large developing country that has received considerable international support for its AIDS programme. In the early stage of the response, each large HIV project independently implemented their activities according to their project framework. When internationally funded projects were few and the quantity of domestic support was minimal, their independent implementation did not pose a problem. When many HIV projects were simultaneously implemented in the same locations, problems emerged such as inconsistency and overlap in data collection. China has thus coordinated and integrated all large international and domestic HIV projects into one national programme. The process of integration began slowly and initially consisted of unified data collection. Integration is now complete and encompasses the processes of project planning, budgeting, implementation, monitoring and evaluation. The process was facilitated by having a single coordinating body, cooperation from international agencies, and financial commitment from the government. Some problems were encountered during this process, such as initial reluctance from health-care staff to allocate additional time to coordinate projects. This paper describes that process of integrating domestic and foreign HIV projects and may serve as a useful example for other developing countries for management of scarce resources.

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Editors’ note: China has made striking changes in its response to AIDS, following the ‘Three Ones’ key principles of one agreed action framework that provides the basis for coordinating the work of all partners, one national AIDS coordinating authority, and one agreed country level monitoring and evaluation system. Local AIDS authorities had become inundated with report writing to a multitude of different donors, a problem of misspent or unspent funds emerged in areas with many overlapping projects, and inconsistencies in data collection, coding schemes, and data reliability hampered government-led planning. The first step was to unify and standardize data collection with the result that 56 forms with 225 variables were reduced to 25 forms and 19 indicators. The online comprehensive HIV data system that became operational in January 2008 includes data on newly identified HIV infections, drug users in the methadone programme, and people living with HIV on the national free antiretroviral therapy programme. It was analysis of data in this database that led China to the decision to offer antiretroviral therapy to HIV-positive people in discordant couples, regardless of CD4 count, when linkages revealed significant levels of HIV transmission prior to medical eligibility for antiretroviral therapy. Budget integration has helped ensure adequate funding for full implementation of activities complementary to the national programme. For example, the national harm reduction programme uses government funds for the purchase of equipment, methadone, and personnel training and Global Fund funds for methadone treatment and needle exchange service delivery. Although integration means up-front investment in coordinating planning, budgeting, implementation, and evaluation of multiple projects, it reaps dividends in time and effort saved later in project management and in increased effectiveness of the AIDS response.

National responses
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National responses

Decision making for HIV prevention and treatment scale up: bridging the gap between theory and practice

Alistar SS, Brandeau ML. Med Decis Making. 2010 Dec 29

Effectively controlling the HIV epidemic will require efficient use of limited resources. Despite ambitious global goals for HIV prevention and treatment scale up, few comprehensive practical tools exist to inform such decisions. Alistar and colleagues briefly summarize modelling approaches for resource allocation for epidemic control, and discuss the practical limitations of these models. They describe typical challenges of HIV resource allocation in practice and some of the tools used by decision makers. The authors identify the characteristics needed in a model that can effectively support planners in decision making about HIV prevention and treatment scale up. An effective model to support HIV scale-up decisions will be flexible, with capability for parameter customization and incorporation of uncertainty. Such a model needs certain key technical features: it must capture epidemic effects; account for how intervention effectiveness depends on the target population and the level of scale up; capture benefit and cost differentials for packages of interventions versus single interventions, including both treatment and prevention interventions; incorporate key constraints on potential funding allocations; identify optimal or near-optimal solutions; and estimate the impact of HIV interventions on the health care system and the resulting resource needs. Additionally, an effective model needs a user-friendly design and structure, ease of calibration and validation, and accessibility to decision makers in all settings. Resource allocation theory can make a significant contribution to decision making about HIV prevention and treatment scale up. What remains now is to develop models that can bridge the gap between theory and practice.

Abstract

Editors’ note: This helpful review describes the variety of modelling approaches that have been developed since the field of resource allocation for epidemic control became a topic of interest in the 1920s. It focuses on three broad categories of models (linear, dynamic, and simulation), providing examples of each from the HIV prevention literature. Issues that models often do not address include the impact of joint interventions on HIV infections averted—not additive because you cannot prevent the same HIV infection twice—decreasing/increasing returns to scale, allocation of resources to treatment programmes, ethical and equity concerns, human and financial resource implications for the entire healthcare system, and being user-friendly for decision-makers. A practical resource allocation model would have input flexibility, pertinent technical capabilities, and usability—the challenge now is to translate the theory into practice. The time is ripe—good investment decisions are essential to reap returns.

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National Responses

Scale-up and Continuation of Antiretroviral Therapy in South African Treatment Programs, 2005-2009

Klausner JD, Serenata C, Obra H, Mattson CL, Brown J, Wilson M, Mbengashe T, Goldman TM. J Acquir Immune Defic Syndr. 2010 Nov 23.

South Africa has the greatest burden of HIV-infection in the world with about 5.2 million HIV-infected adults. In 2003, the South African Government launched a comprehensive HIV and AIDS care treatment program supported by the United States in 2004 through the President's Emergency Plan for AIDS Relief (PEPFAR). To describe the scale-up and continuation of antiretroviral therapy in South African Government and PEPFAR-supported sites in South Africa, Klausner and colleagues conducted a retrospective analysis of routinely collected program reporting data, 2005-2009. From 2005 through 2009, the average rate of persons initiated on antiretroviral therapy in PEPFAR-supported South African Government treatment programmes increased nearly four-fold from 6,327 a month in 2005-2006 to 24,622 a month in 2008-2009 resulting in an increase from 33,543 patients on continued treatment in April-June 2005 to 631,985 patients in July-September 2009. Of those 631,985 patients receiving treatment, 65% were women. Men were more likely to be lost to follow-up (9.2% vs. 7.8%, PR 1.18, 95% CI 1.17-1.19) and more likely to die (5.6% vs. 4.1%, PR 1.36, 95% CI 1.35-1.37) than women. Scale-up and continuation of antiretroviral therapy in South Africa has been a remarkable medical accomplishment. Because more women receive and continue treatment, more efforts are needed to treat and retain men.

Abstract:

Editors’ note: In 2009, 918,407 patients were on antiretroviral treatment in South Africa representing 61% of those in need based on 2009 criteria – a dramatic increase from the 10% coverage of 2005. Now the goal posts have changed to CD4 cell counts of 350 cells/µl and HIV incidence remains alarmingly high with over 400,000 new infections in 2009. In its strategic plan for 2007 to 2011, the South African government stated its aim to treat 80% of those in need by 2011. However, if 40% of those estimated to be living with HIV in South Africa today have CD4 counts less than 350 cells/µl, it is likely that over 2 million people are in need to treatment. South Africa has increased its monthly treatment initiation rate nearly 4-fold from 6327 in 2006-7 to 24,622 in 2008-9 and has launched a large-scale health campaign that includes HIV testing and counselling. Critical to ramping up treatment coverage is acceleration of the growth rate in new treatment initiations. Mounting effective HIV prevention strategies now will help reduce future treatment demand. Reducing the price of drugs and diagnostics, developing innovative efficient service delivery models, and confronting stigma to increase willingness to learn one’s serostatus are among the building blocks for continued expansion of the treatment programme in South Africa.

National responses
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Monitoring and Evaluation

Evaluation of three sampling methods to monitor outcomes of antiretroviral treatment programmes in low- and middle-income countries

Tassie JM, Malateste K, Pujades-Rodríguez M, Poulet E, Bennett D, Harries A, Mahy M, Schechter M, Souteyrand Y, Dabis F; ART Linc of IeDEA and MSF Collaborations PLoS One. 2010 Nov 10;5(11):e13899

Retention of patients on antiretroviral therapy over time is a proxy for quality of care and an outcome indicator to monitor antiretroviral therapy programmes. Using existing databases (Antiretroviral in Lower Income Countries of the International Databases to Evaluate AIDS and Médecins sans Frontières), Tassie and colleagues evaluated three sampling approaches to simplify the generation of outcome indicators. The researchers used individual patient data from 27 antiretroviral therapy sites and included 27,201 antiretroviral therapy naive adults (≥15 years) who initiated antiretroviral therapy in 2005. For each site, they generated two outcome indicators at 12 months, retention on antiretroviral therapy and proportion of patients lost to follow-up, first using all patient data and then within a smaller group of patients selected using three sampling methods (random, systematic, and consecutive sampling). For each method and each site, 500 samples were generated, and the average result was compared with the unsampled value. The 95% sampling distribution was expressed as the 2.5(th) and 97.5(th) percentile values from the 500 samples. Overall, retention on antiretroviral therapy was 76.5% (range 58.9-88.6) and the proportion of patients lost to follow-up, 13.5% (range 0.8-31.9). Estimates of retention from sampling (n = 5696) were 76.5% (95% sampling distribution 75.4-77.7) for random, 76.5% (75.3-77.5) for systematic and 76.0% (74.1-78.2) for the consecutive method. Estimates for the proportion of patients lost to follow-up were 13.5% (12.6-14.5), 13.5% (12.6-14.3) and 14.0% (12.5-15.5), respectively. With consecutive sampling, 50% of sites had sampling distribution within ±5% of the unsampled site value. The results suggest that random, systematic, or consecutive sampling methods are feasible for monitoring antiretroviral therapy indicators at national level. However, sampling may not produce precise estimates in some sites.

Abstract:

Editor’s note : Patient retention in antiretroviral therapy 12 months after starting treatment is a core UNGASS indicator and 47% of 149 low- and middle-income countries reported their progress on this indicator in 2009. Producing these statistics is a challenge. Some countries have automated information systems based on electronic medical records but most countries struggle to generate their statistics for the national level and often have no site-specific data to suggest needed programme improvements. This study used existing databases to compare the findings when all the data are used or a sampling strategy is used. In random sampling, each patient had an equal probability of being included in the data. In systematic sampling, the first patient was randomly chosen and then the next one was chosen according to a preset interval until 500 were selected. In consecutive sampling, after the random selection of the first patient, the next 499 consecutive patients were included. The results were comparable, suggesting that sampling could be a user-friendly technique to reduce workload, to improve the sustainability of local and national monitoring systems, both in tracking yearly retention in antiretroviral therapy programmes and assessing loss to follow-up, and to produce information for improving performance locally.

National responses
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Monitoring and Evaluation

Protecting HIV information in countries scaling up HIV services: a baseline study

Beck EJ, Mandalia S, Harling G, Santas XM, Mosure D, De Lay PR J Int AIDS Soc. 2011 Feb 6;14(1):6

Individual-level data are needed to optimize clinical care and monitor and evaluate HIV services. Confidentiality and security of such data must be safeguarded to avoid stigmatization and discrimination of people living with HIV. Beck and colleagues set out to assess the extent that countries scaling up HIV services have developed and implemented guidelines to protect the confidentiality and security of HIV information. Questionnaires were sent to UNAIDS field staff in 98 middle- and lower-income countries, some reportedly with guidelines (G-countries) and others intending to develop them (NG-countries). Responses were scored, aggregated and weighted to produce standard scores for six categories: information governance, country policies, data collection, data storage, data transfer and data access. Responses were analyzed using regression analyses for associations with national HIV prevalence, gross national income per capita, OECD income, receiving US PEPFAR funding, and being a G- or NG-country. Differences between G- and NG-countries were investigated using non-parametric methods. Higher information governance scores were observed for G-countries compared with NG-countries; no differences were observed between country policies or data collection categories. However, for data storage, data transfer and data access, G-countries had lower scores compared with NG-countries. No significant associations were observed between country score and HIV prevalence, per capita gross national income, OECD economic category, and whether countries had received PEPFAR funding. Few countries, including G-countries, had developed comprehensive guidelines on protecting the confidentiality and security of HIV information. Countries must develop their own guidelines, using established frameworks to guide their efforts, and may require assistance in adapting, adopting and implementing them.

Abstract:

Editor’s note: Concerns about confidentiality may deter people from coming forward for HIV testing or entering antiretroviral therapy. Whether a medical information system is paper-based or electronic, the confidentiality and security of its data must be assured: At the same time, the information has to be appropriately accessible for patient management and service monitoring and evaluation. Privacy is both a legal and an ethical concept and it provides the framework for implementing confidentiality and security guidelines. Physical protection of data includes protection against environmental threats, such as floods and fire and power outages, and protection from inadvertent or deliberate use of sensitive information. As this baseline study reveals, this is a neglected policy area in many countries. The process of this evaluation may have provoked needed policy discussions in participating countries. Beyond global reporting requirements, countries need accurate, contemporary information to improve clinical care and to monitor and evaluate services. They need to ensure that medical records and the data extracted from them are truly confidential and secure – interim guidelines are available to assist in establishing the balance between maximising benefit and minimising harm.

National responses
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National responses

AIDS in Asia amid competing priorities: a review of national responses to HIV

Rao PJ, Mboi N, Phoolcharoen W, Sarkar S, Carael M. AIDS. 2010 Sep;24 Suppl 3:S41-8.

The paper reviews progress in addressing the HIV epidemic and questions whether at the midway mark to the conclusion of the Millennium Development Goal set for 2015, the goal number 6 of halting and reversing the HIV epidemic will be reached. Fourteen 2008 United Nations General Assembly Special Session on HIV/AIDS country progress reports and 18 country reports on Universal Access 2009 were analyzed. Data on national HIV strategic plans were also provided by 18 countries that participated in a regional training on costed national strategic plans held 15-16 September, in Bangkok in 2008. Four countries with substantial populations in Asia are on track to achieve Millennium Development Goal 6. Elsewhere, elements of a potentially effective response are being introduced, but the degree of urgency and scale needed to curb the epidemics are not yet evident. Most national programmes still lack key planning components for the operation and financing of the response. Only 13 national strategic plans explicitly address three key populations at higher risk for HIV. One third of the countries that have designed plans for effective interventions have not costed them. Early successes in controlling HIV epidemics in Asia may not be sustainable in the future. There is an urgent need to make prevention scale-up as robust as treatment scale-up and to focus programmes on high impact prevention, which directly contributes to reduction of new HIV infection. A necessary objective is to convince policy makers that the emergency posed by HIV continues.

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Editors’ note: This article on national responses to HIV in Asia is one of a series included in an AIDS supplement on HIV in Asia that covers costing, men who have sex with men, people who inject drugs, and other topics. The HIV epidemic in this region, home to 60% of the world’s population, is diverse and responses to it vary markedly. Where political commitment has been evident, great strides have been made. Although it is difficult to generalise, the authors do point to the need for increased domestic resources for HIV across the region - the proportion has increased at a far slower rate than in other regions. They single out China and India as having made progress, now contributing 80% and 65% of total AIDS expenditure in their countries, respectively. Structural barriers to effective HIV prevention programming include criminalisation of same sex relations in 15 countries (India has decriminalised such relationships), sex work being illegal in 18 countries (the Philippines now licenses sex work and has a focused programme), and poor progress on harm reduction for people who inject drugs (promising in countries such as Malaysia; Nepal, Bangladesh, and China). If you work in HIV in Asia, this would be a good overview article to orient you to the challenges of planning, appropriately costing, and efficiently implementing effective HIV programming across the region before you delve into others in this supplement.

 

 

National responses
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National responses

National poverty reduction strategies and HIV/AIDS governance in Malawi: A preliminary study of shared health governance.

Wachira C, Ruger JP.  Soc Sci Med. 2010 Jun 9. [Epub ahead of print]

The public health and development communities understand clearly the need to integrate anti-poverty efforts with HIV programs. This article reports findings about the impact of the Poverty Reduction Strategy Paper (PRSP) process on Malawi's National HIV/AIDS Strategic Framework. Wachira and Ruger ask, how does the Poverty Reduction Strategy Paper process support National HIV/AIDS Strategic Framework accountability, participation, access to information, funding, resource planning and allocation, monitoring, and evaluation? In 2007, they developed and conducted a survey of Malawian government ministries, United Nations agencies, members of the Country Coordination Mechanism, the Malawi National AIDS Commission (NAC), and National AIDS Commission grantees (N = 125, 90% response rate), seeking survey respondents' retrospective perceptions of National HIV/AIDS Strategic Framework resource levels, participation, inclusion, and governance before, during, and after Malawi's Poverty Reduction Strategy Paper process (2000-2004). The authors also assessed health sector and economic indicators and budget allocations for HIV. These indicators are part of a new conceptual framework called shared health governance, which seeks congruence among the values and goals of different groups and actors to reflect a common purpose. Under this framework, global health policy should encompass: (i) consensus among global, national, and sub-national actors on goals and measurable outcomes; (ii) mutual collective accountability; and (iii) enhancement of individual and group health agency. Indicators to assess these elements included: (i) goal alignment; (ii) adequate resource levels; (iii) agreement on key outcomes and indicators for evaluating those outcomes; (iv) meaningful inclusion and participation of groups and institutions; (v) special efforts to ensure participation of vulnerable groups; and (vi) effectiveness and efficiency measures. Results suggest that the Poverty Reduction Strategy Paper process supported accountability for National HIV/AIDS Strategic Framework resources. However, the process may have marginalized key stakeholders, potentially undercutting the implementation of HIV Action Plans.

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Editors’ note: In addressing the heavy burden that debt servicing imposes on government budgets, the Poverty Reduction Strategy Paper (PRSP) process, unlike the previous Structural Adjustment Programmes, engages domestic stakeholders, government-related institutions, and external development partners. In determining the macroeconomic, structural, and social policies and programmes that a country will use to promote growth and reduce poverty, five core principles are paramount: the process must be country-driven, results-oriented, comprehensive, partnership-oriented, and long term. With support from UNDP, Malawi allocated 30% of its debt relief savings to HIV when it became clear that HIV affected all four strategic pillars of the PRSP: sustainable pro-poor economic growth, human capital development, improvement in the quality of life of the most vulnerable, and good governance. This retrospective study uses the concept of shared health governance as a conceptual framework to assess whether good governance and participation were developed and strengthened through PRSP support to the National AIDS Strategy. With several countries facing development challenges exacerbated by HIV and in the process of developing next-generation PRSPs which could influence future HIV budgeting, this article on lessons learned makes for essential reading for policy makers, programme planners, economists, and advocates.

National responses
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National Programmes

Introducing a multi-site program for early diagnosis of HIV infection among HIV-exposed infants in Tanzania.

Nuwagaba-Biribonwoha H, Werq-Semo B, Abdallah A, Cunningham A, Gamaliel JG, Mtunga S, Nankabirwa V, Malisa I, Gonzalez LF, Massambu C, Justman J, Nash D, Abrams EJ. BMC Pediatr. 2010;10:44.

In Tanzania, less than a third of HIV infected children estimated to be in need of antiretroviral therapy are receiving it. In this setting where other infections and malnutrition mimic signs and symptoms of AIDS, early diagnosis of HIV among HIV-exposed infants without specialized virologic testing can be a complex process. The study aimed to introduce an Early Infant Diagnosis pilot program using HIV DNA Polymerase Chain Reaction (PCR) testing with the intent of making Early Infant Diagnosis nationally available based on lessons learned in the first 6 months of implementation. In September 2006, a molecular biology laboratory at Bugando Medical Center was established in order to perform HIV DNA PCR testing using Dried Blood Spots. Ninety- six health workers from 4 health facilities were trained in the identification and care of HIV-exposed infants, HIV testing algorithms and collection of dried blood spot samples. Paper-based tracking systems for monitoring the program that fed into a simple electronic database were introduced at the sites and in the laboratory. Time from birth to first HIV DNA PCR testing and to receipt of test results were assessed using Kaplan-Meier curves. From October 2006 to March 2007, 510 HIV-exposed infants were identified from the 4 health facilities. Of these, 441(87%) infants had an HIV DNA PCR test at a median age of 4 months (IQR 1 to 8 months) and 75(17%) were PCR positive. Parents/guardians for a total of 242(55%) HIV-exposed infants returned to receive PCR test results, including 51/75 (68%) of those PCR positive, 187/361 (52%) of the PCR negative, and 4/5 (80%) of those with indeterminate PCR results. The median time between blood draw for PCR testing and receipt of test results by the parent or guardian was 5 weeks (range <1week to 14 weeks) among children who tested PCR positive and 10 weeks (range <1 week to 21 weeks) for those that tested PCR negative. The Early Infant Diagnosis pilot program successfully introduced systems for identification of HIV-exposed infants. There was a high response as hundreds of HIV-exposed infants were registered and tested in a 6 month period. Challenges included the large proportion of parents not returning for PCR test results. Experience from the pilot phase has informed the national roll-out of the Early Infant Diagnosis program currently underway in Tanzania.

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Editors’ note: This service delivery programme in the Lake region of Tanzania for early infant HIV diagnosis is the first for the country – similar programmes are being rolled out in Kenya and Botswana. With only a third of Tanzanian children estimated to be eligible for antiretroviral treatment actually receiving it, timely diagnosis of infant HIV infection is a priority. The critical processes set in motion to make this pilot programme a reality were: community preparation, health facility selection and preparation, capacity building, laboratory establishment, definition of the HIV testing algorithm, and registration and follow-up of HIV-exposed infants with data collection. Delays of 5 weeks for receipt of positive results and 10 weeks for negative results by parents should be shortened by all possible means, including electronic and telephone transmission of results back to facilities if this is not currently being done. Nonetheless, these times are much shorter than the wait for the disappearance of maternal antibodies at 18 months of age. To increase the proportion of parents who actually receive results beyond the 55% seen here, the first step is to explore the factors inhibiting them from returning for results and the acceptability of possible solutions. Infants with HIV infection need life-saving cotrimoxasole and initiation of antiretroviral therapy as per the new WHO paediatric treatment guidelines as soon as they are diagnosed. Better linkages between prevention of mother-to-child transmission programmes and the follow-up of HIV-exposed infants will reduce the number of infants presenting with advanced HIV disease or dying before anything can be done.

 

National responses
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