Articles tagged as "Civil society and community responses / Resilience"

Encouraging results of community empowerment interventions among female sex workers

Community empowerment among female sex workers is an effective HIV prevention intervention: a systematic review of the peer-reviewed evidence from low- and middle-income countries.

Kerrigan DL, Fonner VA, Stromdahl S, Kennedy CE., AIDS Behav. 2013 Jul;17(6):1926-40. doi: 10.1007/s10461-013-0458-4.

We conducted a systematic review and meta-analysis of community empowerment interventions for HIV prevention among sex workers in low- and middle-income countries from 1990-2010. Two coders abstracted data using standardized forms. Of 6 664 citations screened, ten studies met inclusion criteria. For HIV infection, two observational studies showed a significantly protective combined effect [odds ratio (OR): 0.84, 95 % confidence interval (CI): 0.709-0.988]. For STI infection, one longitudinal study showed reduced gonorrhoea/chlamydia (OR: 0.51, 95 % CI: 0.26-0.99). Observational studies showed reduced gonorrhoea (OR: 0.65, 95 % CI: 0.47-0.90), but non-significant effects on chlamydia and syphilis. For condom use, one randomized controlled trial showed improvements with clients (ß: 0.3447, p = 0.002). One longitudinal study showed improvements with regular clients (OR: 1.9, 95 % CI: 1.1-3.3), but no change with new clients. Observational studies showed improvements with new clients (OR: 3.04, 95 % CI: 1.29-7.17), regular clients (OR: 2.20, 95 % CI: 1.41-3.42), and all clients (OR: 5.87, 95 % CI: 2.88-11.94), but not regular non-paying partners. Overall, community empowerment-based HIV prevention was associated with significant improvements across HIV outcomes and settings.

Abstract access

Editor’s notes: In contrast to individual behaviour change interventions, community empowerment is a structural intervention which seeks to address and alter social, political and material conditions surrounding sex work in a given setting.  This is the first systematic review to evaluate the impact of community empowerment as an HIV prevention strategy among sex worker in low- and middle-income countries. This systematic review was conducted as part of a larger World Health Organization (WHO) effort to develop technical guidelines for HIV/STI prevention among sex workers. The results were encouraging, with positive effects of empowerment interventions on outcomes including HIV/STI infection and consistent condom use with clients (but not with regular partners, with whom condom use is generally low).  Encouragingly, all of the studies involved included not only the community empowerment intervention elements as described above, but also core HIV prevention elements: HIV/STI peer education, some form of condom distribution (free or via social marketing), and STI screening, treatment and management. Of the 10 included studies, seven were from India, two from Brazil and one from the Dominican Republic.  The lack of such studies in southeast Asia, or Africa, is striking, and a rigorous evaluation of community empowerment among sex workers in sub-Saharan Africa is warranted.

Asia, Latin America
Brazil, Dominican Republic, India
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Integrating HIV treatment with primary care services

Integrating HIV treatment with primary care outpatient services: opportunities and challenges from a scaled-up model in Zambia.

Topp SM, Chipukuma JM, Chiko MM, Matongo E, Bolton-Moore C, Reid SE., Health Policy Plan. 2013; 4:347-57. doi: 10.1093/heapol/czs065

Background: Integration of HIV treatment with other primary care services has been argued to potentially improve effectiveness, efficiency and equity. However, outside the field of reproductive health, there is limited empirical evidence regarding the scope or depth of integrated HIV programmes or their relative benefits. Moreover, the body of work describing operational models of integrated service-delivery in context remains thin. Between 2008 and 2011, the Lusaka District Health Management Team piloted and scaled-up a model of integrated HIV and general outpatient department (OPD) services in 12 primary health care clinics. This paper examines the effect of the integrated model on the organization of clinic services, and explores service providers' perceptions of the integrated model.

Methods: We used a mixed methods approach incorporating facility surveys and key informant interviews with clinic managers and district officials. On-site facility surveys were carried out in 12 integrated facilities to collect data on the scope of integrated services, and 15 semi-structured interviews were carried out with 12 clinic managers and three district officials to explore strengths and weaknesses of the model. Quantitative and qualitative data were triangulated to inform overall analysis.

Findings: Implementation of the integrated model substantially changed the organization of service delivery across a range of clinic systems. Organizational and managerial advantages were identified, including more efficient use of staff time and clinic space, improved teamwork and accountability, and more equitable delivery of care to HIV and non-HIV patients. However, integration did not solve ongoing human resource shortages or inadequate infrastructure, which limited the efficacy of the model and were perceived to undermine service delivery.

Conclusion: While resource and allocative efficiencies are associated with this model of integration, a more important finding was the model's demonstrated potential for strengthening organizational culture and staff relationships, in turn facilitating more collaborative and motivated service delivery in chronically under-resourced primary healthcare clinics.

Abstract Full-text [free] access

Editor’s notes:  In recent years, there has been much debate about the relative benefits of disease-specific programs vs. broader strengthening of health systems, which may have the potential to improve effectiveness, cost-effectiveness and equity of health care.  

The integrated model in primary care services in this study involved 3 modifications: 1) amalgamation of physical space and patient flow; 2) standardisation of record keeping; 3) introduction of provider-initiated testing and counselling for all attendees.  Integration resulted in a single cadre of health-workers providing care jointly to HIV and OPD patients.

The equitable distribution of material and human resources improved the quality and efficiency of healthcare delivery. This approach provided an opportunity for systems of HIV care to strengthen care for other chronic diseases and healthcare providers were afforded the opportunity to learn different skills.  Shared responsibility of clinic functions improved staff relationships which facilitated more collaborative and motivated service delivery.

However, these advantages cannot offset the absolute underlying problem of limited infrastructural and human resources and weak health financing, which may ultimately make integrated care unsustainable. Hence, while this study demonstrates clear benefits of integration, these macro-level determinants need to be addressed.  The impact of integrated models of healthcare delivery on the quality of medical care merits consideration.   

Africa
Zambia
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HIV prevention laws based on moralistic judgements of lawmakers may increase stigma

'The intention may not be cruel... but the impact may be': understanding legislators' motives and wider public attitudes to a draft HIV Bill in Malawi.

Stackpool-Moore, L. Sex Transm Infect. 2013. June 89 (4)

Objectives: The law in relation to HIV has prominence in the formation and regulation of moral norms in regard to human rights, and in regard to criminalisation, the policing of sexuality and intimate behaviours, and the production of stigma. The research focuses on the potential and impotence of the law to govern for, and enable, the human right to health in the context of HIV in Malawi.

Methods: This one-country qualitative case study (Malawi) action research involved data collection during a 6-month period (October 2010-March 2011). Datasets include interviews with law commissioners (n=10), opinion leaders (n=22), life story participants who were people living with and closely affected by HIV (n=20), reflections of the action research team (n=6), and a review of the proposed HIV and AIDS (Prevention and Management) Bill, legal and policy documents.

Results: The analysis of the perspectives of the law commissioners, who formed the Special Law Commission and drafted the Bill, revealed that stigma was consciously invoked to delineate social norms and guide governance of notions of personal responsibility. The analysis of the perspectives of the life story participants, whose lives would be most directly impacted if these provisions came into force, reveals the extent to which the stigma associating criminality and HIV is falling on fertile ground through its engagement and generation of internalised stigma; unearthing an uneasy link between stigma and the law in response to HIV in Malawi.

Discussion: The results indicated that the proposed HIV Bill in Malawi manifests a tension between intention and impact. By incorporating criminal sanctions as part of the proposed HIV Bill, the lawmakers actively seek to use stigma to shape social attitudes and attempt to guide normative behaviour.

Abstract access 

Editor’s notes: This paper presents research that examines the impact of criminal law in relation to HIV on stigma in Malawi. Through interviews with lawmakers and life story interviews with people living with and closely affected by HIV, the author examined how participants understand the proposed draft HIV and AIDS (Prevention and Management) Bill. The legal initiative for the bill, whilst based on principles of non-discrimination, includes provision to imprison a person who knows that he (sic) is HIV positive and does not refrain from an act which is likely to infect another person or who deliberately infects another person. Of great concern, the interviews revealed that whilst participants stated a support for non-discrimination of people living with HIV, many supported criminalisation of HIV transmission. The lawmakers were almost unanimously in favour of criminalising HIV transmission as a way to seek retribution and justice rather than for prevention of HIV transmission. The author noted that the lawmakers were particularly judgemental and moralistic about the issue. The people living with or affected by HIV were less certain and provided arguments for and against criminalisation, especially in relation to deliberate transmission of HIV where knowledge of status is not known. They were particularly worried that this law may dissuade people from testing. This paper provides an important understanding of the tension between political level intent to reduce stigma around HIV and the moralizing position taken by law- and policy makers. More worryingly, the author suggests that the perpetuation of stigma through such means as this law could be used to maintain or establish social control. 

Africa
Malawi
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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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High uptake of HIV testing and linkage to care using comprehensive community-based monitoring

High HIV testing uptake and linkage to care in a novel program of home-based HIV counseling and testing with facilitated referral in KwaZulu-Natal, South Africa.

van Rooyen H, Barnabas RV, Baeten JM, Phakathi Z, Joseph P, Krows M, Hong T, Murnane PM, Hughes J, Celum C J Acquir Immune Defic Syndr. 2013 May 24. [Epub ahead of print]

Objective: Home-based counseling and testing (HBCT) has demonstrated high HIV testing uptake in Africa. We piloted expanded HBCT-Plus, with point-of-care CD4 count testing and follow-up visits, as a strategy to increase linkage to HIV care and antiretroviral therapy (ART) uptake.

Methods: We conducted universal, adult HBCT-Plus among contiguous households in rural KwaZulu-Natal, South Africa; HIV-infected individuals received point-of-care CD4 testing which was compared to CD4 results by flow cytometry, counseling and referral to care. Follow-up visits at months 1, 3 and 6 evaluated linkage to care and ART uptake. Plasma viral load was measured at baseline and month 6.

Results: 671 adults were tested for HIV (91% coverage) and 201 (30%) were HIV-infected. Median CD4 count was 435 cells/μL by point-of-care testing. There was high agreement between the point-of-care and flow cytometry CD4 test results; the mean difference was 16 cells/μL (CI: -1 to 32 cells/μL). By month 3, 86% of those eligible (CD4 ≤200 cells/μL) had initiated ART. Among 196 HIV-infected participants, mean viral load decreased by 0.31 log10 copies/mL (p=0.009) between baseline and month 6 and among those eligible for ART, mean PVL decreased by 2.46 log10 copies/mL (p=<0.001).

Conclusions: HBCT-Plus pilot achieved approximately 90% uptake of HIV testing, linkage to care and ART initiation, thus providing clinical and public health benefits, as demonstrated by a significantly decreased mean viral load. These data indicate a significant impact of HBCT-Plus on knowledge of HIV serostatus, linkage to HIV care, uptake of ART, adherence and reduced HIV infectiousness.

Abstract access 

Editor’s notes: This pilot study of integrated HBCT, with same day point-of-care CD4 testing, referral and follow-up provide encouraging data for future universal test and treat interventions. A high proportion of individuals linked into care upon the HBCT-plus intervention in this study - both amongst newly diagnosed individuals and those who previously knew their HIV positive status but had not accessed care. It is promising that the point-of-care CD4-count results and flow cytometry CD4-count results showed excellent agreement. Further, the authors describe the method as being feasible in a rural South African setting. The follow-up work on cost and cost-effectiveness will be highly pertinent to the potential wider roll out of this method. Finally, while the viral load reductions seen with this “cascade-enhancing” model may be modest overall given the ART initiation criteria in South Africa at the time of the study, they point to a beneficial effect. Further gains on viral load reduction would be reasonably expected with higher ART initiation thresholds.

Africa
South Africa
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Multi-faceted community-based intervention for improving retention in care

Improved retention associated with community-based accompaniment for antiretroviral therapy delivery in rural Rwanda.

Franke MF, Kaigamba F, Socci AR, Hakizamungu M, Patel A, Bagiruwigize E, Niyigena P, Walker KD, Epino H, Binagwaho A, Mukherjee J, Farmer PE, Rich ML. Clin Infect Dis. 2013 May;56(9):1319-26.

Background: Minimizing death and ensuring high retention and good adherence remain ongoing challenges for human immunodeficiency virus (HIV) treatment programs. We examined whether the addition of community-based accompaniment (characterized by daily home visits from a community health worker, directly observed treatment, nutritional support, transportation stipends, and other support as needed) to the Rwanda national model for antiretroviral therapy (ART) delivery would improve retention in care, viral load suppression, and change in CD4 count, relative to the national model alone.

Methods: We conducted a prospective observational cohort study among 610 HIV-infected adults initiating ART in 1 of 2 programs in rural Rwanda. Psychosocial and clinical characteristics were recorded at ART initiation. Death, treatment retention, and plasma viral load were assessed at 1 year. CD4 count was evaluated at 6-month intervals. Multivariable regression models were used to adjust for baseline differences between the 2 populations.

Results: Eighty-five percent and 79% of participants in the community-based and clinic-based programs, respectively, were retained with viral load suppression at 1 year. After adjusting for CD4 count, depression, physical health quality of life, and food insecurity, community-based accompaniment was protective against death or loss to follow-up during the first year of ART (hazard ratio, 0.17; 95% confidence interval [CI], .09-.35; P < .0001). In a second multivariable analysis, individuals receiving accompaniment were more likely to be retained with a suppressed viral load at 1 year (risk ratio: 1.15; 95% CI, 1.03-1.27; P = .01).

Conclusions: These findings indicate that community-based accompaniment is effective in improving retention, when added to a clinic-based program with fewer patient support mechanisms.

Abstract access 

Editor’s notes: One of the critical challenges facing ART programmes in resource-limited settings is ensuring that patients achieve high levels of adherence and remain engaged in care.  This is important not only from an individual perspective, but also from a public health perspective by making best use of current investments, and minimizing the potential for emergence and transmission of resistance. Evaluations of interventions for improving adherence and retention have largely focused on single interventions (e.g. treatment supporters, mobile phone text reminders, or food supplements) and have had varying degrees of success. This may partly be because patients’ adherence and retention in care is influenced by multiple factors acting at the level of the individual patient, healthcare system and community. In this prospective cohort study the authors demonstrate that a multi-faceted community intervention, which assists patients overcome structural barriers to accessing ART, can result in improved retention in care. Regardless of the intervention, >90% of patients in care at 12 months achieved viral suppression. This intervention was complex and labour intensive, involving daily visits by community healthcare workers (CHW) for monitoring of side effects and directly observed therapy, nutritional support, transport allowance and social support ranging from school fees to advice on micro-financing initiatives. The authors argue that the cost of such interventions, which may also have indirect benefits for the family, needs to be weighed up against the future cost of second-line ART and emerging resistance.

Africa
Rwanda
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High CD4 count on initiating ART associated with unstructured treatment interruptions

Long-Term Health Care Interruptions Among HIV-Positive Patients in Uganda.

Mills EJ, Funk A, Kanters S, Kawuma E, Cooper C, Mukasa B, Odit M, Karamagi Y, Mwehire D, Nachega J, Yaya S, Featherstone A, Ford N. J Acquir Immune Defic Syndr. 2013 May 1;63(1):e23-7

Background: Retaining patients in clinical care is necessary to ensure successful antiretroviral treatment (ART) outcomes. Among patients who discontinue care, some reenter care at a later stage, whereas others are or will be lost from follow-up. We examined risk factors for health care interruptions and loss to follow-up within a cohort receiving ART in Uganda.

Methods: Using a large hospital cohort providing free universal ART and HIV clinical care, we assessed characteristics and risk factors for treatment interruptions, defined as a 12-month absence from care at Mildmay, and loss to follow-up, defined as absence from care greater than 12 months without reengagement in care at Mildmay. We included patients aged 14 years and above. We assessed these outcomes over time using Kaplan-Meier analysis and multivariable regression.

Results: Of 6970 eligible patients, 784 (11.2%) had a health care interruption of at least 12 months and 217 (3.1%) were lost to follow-up. Patients experiencing health care interruptions had higher baseline CD4 T-cell counts at ART initiation, defined as ≥ 250 cells per cubic millimeter [odds ratio (OR): 1.29, 95% confidence intervals (CI): 1.11 to 1.50], and lower levels of education (OR: 1.32, 95% CI: 1.09 to 1.61). Adolescents were much more likely to be lost to follow-up (OR: 3.11, 95% CI: 2.23 to 4.34). In contrast, having a partner (OR: 0.22, 95% CI: 0.16 to 0.31) or being sexually active at baseline (OR: 0.40, 95% CI: 0.28 to 0.55) was protective of loss to follow-up.

Conclusions: Within this cohort, long periods of unsupervised health care interruptions were common.

Abstract access 

Editor’s notes: If the individual and public health benefits of antiretroviral therapy are to be realized then it is essential that patients remain engaged in care and adhere to antiretroviral therapy over the longer-term. Whilst some patients default from care and never return (loss to follow-up), others will return to care at a later time-point (unstructured treatment interruptions).Such treatment interruptions not only lead to increased morbidity and mortality, as demonstrated in the SMART study, but can also promote the development of drug resistance; however our understanding of the frequency, duration and determinants of unstructured treatment interruptions in resource-limited settings is limited.

This article, from a well-established ART clinic in Uganda, helps improve our understanding of this issue. Despite very low levels of loss to follow-up, which the authors ascribed to the clinics’ strong adherence support system,  unstructured treatment interruptions of over 12 months duration were common (11.2%). Initiating ART at a higher CD4 count (>250 cells/mm3), presumably whilst the patient was still relatively well, was a risk factor for treatment interruption. This finding may become even more pertinent in the future if the CD4 count threshold for initiating ART rises to 500 cells/mm3. Whilst this study has focused on patient-level risk factors for unstructured treatment interruptions, future research must also explore contextual-level determinants, including those relating to the healthcare system itself. A greater understanding of these factors will help inform the successful development of interventions to support patients’ long-term engagement in care.

Africa
Uganda
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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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Almost a quarter of deaths in pregnant and post-partum women may be attributable to HIV

Effect of HIV infection on pregnancy-related mortality in sub-Saharan Africa: secondary analyses of pooled community-based data from the network for Analysing Longitudinal Population-based HIV/AIDS data on Africa (ALPHA).

Zaba B, Calvert C, Marston M, Isingo R, Nakiyingi-Miiro J, Lutalo T, Crampin A, Robertson L, Herbst K, Newell ML, Todd J, Byass P, Boerma T, Ronsmans C. Lancet. 2013 May 18;381(9879):1763-71.

Background: Model-based estimates of the global proportions of maternal deaths that are in HIV-infected women range from 7% to 21%, and the effects of HIV on the risk of maternal death is highly uncertain. We used longitudinal data from the Analysing Longitudinal Population-based HIV/AIDS data on Africa (ALPHA) network to estimate the excess mortality associated with HIV during pregnancy and the post-partum period in sub-Saharan Africa.

Methods: The ALPHA network pooled data gathered between June, 1989 and April, 2012 in six community-based studies in eastern and southern Africa with HIV serological surveillance and verbal-autopsy reporting. Deaths occurring during pregnancy and up to 42 days post partum were defined as pregnancy related. Pregnant or post-partum person-years were calculated for HIV-infected and HIV-uninfected women, and HIV-infected to HIV-uninfected mortality rate ratios and HIV-attributable rates were compared between pregnant or post-partum women and women who were not pregnant or post partum.

FINDINGS: 138,074 women aged 15-49 years contributed 636,213 person-years of observation. 49,568 women had 86,963 pregnancies. 6760 of these women died, 235 of them during pregnancy or the post-partum period. Mean prevalence of HIV infection across all person-years in the pooled data was 17.2% (95% CI 17.0-17.3), but 60 of 118 (50.8%) of the women of known HIV status who died during pregnancy or post partum were HIV infected. The mortality rate ratio of HIV-infected to HIV-uninfected women was 20.5 (18.9-22.4) in women who were not pregnant or post partum and 8.2 (5.7-11.8) in pregnant or post-partum women. Excess mortality attributable to HIV was 51.8 (47.8-53.8) per 1000 person-years in women who were not pregnant or post partum and 11.8 (8.4-15.3) per 1000 person-years in pregnant or post-partum women.

Interpretation: HIV-infected pregnant or post-partum women had around eight times higher mortality than did their HIV-uninfected counterparts. On the basis of this estimate, we predict that roughly 24% of deaths in pregnant or post-partum women are attributable to HIV in sub-Saharan Africa, suggesting that safe motherhood programmes should pay special attention to the needs of HIV-infected pregnant or post-partum women.

Abstract access 

Editor’s notes: This study is the first to estimate the contribution of HIV to mortality in pregnant and post-partum women using HIV sero-surveillance and verbal autopsy data from a network of studies in eastern and southern Africa. While there is variation by country, excess mortality due to HIV was considerably higher in non-pregnant women compared with pregnant/post-partum women. This is not entirely surprising as fertility falls with advancing HIV, so only healthier women with HIV conceive – the so-called ‘healthy pregnant woman effect’. They are therefore less likely to die while pregnant/post-partum. However, the study estimates that almost a quarter of deaths in pregnant/post-partum women are attributable to HIV. This highlights the importance of integrating HIV into safe motherhood programmes. It is noteworthy that the majority of women at the time of this study would not have had access to antiretroviral treatment to benefit their own health (as opposed to single dose treatment to reduce mother-to-child transmission alone). While pointing to the potential benefits of the WHO PMTCT B option, the study emphasizes the potential further advantage of PMTCT B+ to reduce HIV related morbidity and mortality, both for women’s own health and their unborn infants, with implications for current and future pregnancies.

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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