Articles tagged as "Lesotho"

Generalized HIV epidemics require generalized prevention efforts

Extra-couple HIV transmission in sub-Saharan Africa: a mathematical modelling study of survey data.

Bellan SE, Fiorella KJ, Melesse DY, Getz WM, Williams BG, Dushoff J. Lancet. 2013 Feb 4. pii: S0140-6736(12)61960-6. doi: 10.1016/S0140-6736(12)61960-6. [Epub ahead of print]

The proportion of heterosexual HIV transmission in sub-Saharan Africa that occurs within cohabiting partnerships, compared with that in single people or extra-couple relationships, is widely debated. The proportional contribution of different routes of transmission to new HIV infections was estimated. As plans to use antiretroviral drugs as a strategy for population-level prevention progress, understanding the importance of different transmission routes is crucial to target intervention efforts. A mechanistic model of HIV transmission was built with data from Demographic and Health Surveys (DHS) for 2003-2011, of 27 201 cohabiting couples (men aged 15-59 years and women aged 15-49 years) from 18 sub-Saharan African countries with information about relationship duration, age at sexual debut, and HIV serostatus. This model was combined with estimates of HIV survival times and country-specific estimates of HIV prevalence and coverage of antiretroviral therapy (ART). The proportion of recorded infections in surveyed cohabiting couples that occurred before couple formation was estimated, between couple members, and because of extra-couple intercourse. In surveyed couples, we estimated that extra-couple transmission accounted for 27-61% of all HIV infections in men and 21-51% of all those in women, with ranges showing intercountry variation. It was estimated that in 2011, extra-couple transmission accounted for 32-65% of new incident HIV infections in men in cohabiting couples, and 10-47% of new infections in women in such couples. These findings suggest that transmission within couples occurs largely from men to women; however, the latter sex have a very high-risk period before couple formation. Because of the large contribution of extra-couple transmission to new HIV infections, interventions for HIV prevention should target the general sexually active population and not only serodiscordant couples.

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Editor’s notes: Understanding the individual and population level risks for HIV transmission and acquisition is essential for designing HIV transmission prevention programmes that can lead to an AIDS-free generation. The frequency of pre-marital or extra-marital sexual activity is not necessarily different in high prevalence countries than in lower prevalence settings, a number of theories have been suggested, including frequency of multiple concurrent partnerships. Newer data has indicated that a significant percentage of people living with HIV are in serodiscordant couples with HIV-negative partners – hence a focus on identification of such serodiscordancy and promotion of condom use within cohabitating serodiscordant couples. While these interventions remain important, this article highlights that quite significant proportions of HIV transmission in couples occurs outside of the framework of the cohabitating couple. HIV prevention campaigns, for persons in couples as well as single individuals must remain focused on the general sexually active population.  

Africa
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Decentralizing pediatric HIV care and treatment into primary care centers

Decentralization of pediatric HIV Care and Treatment in Five sub-Saharan African Countries.

Fayorsey RN, Saito S, Carter RJ, Gusmao E, Frederix K, Koech-Keter E, Tene G, Panya M, Abrams EJ. J Acquir Immune Defic Syndr. 2013 Jan 18. [Epub ahead of print]

In resource-limited settings, decentralization of HIV care and treatment is a cornerstone of universal care and rapid scale-up. We compared trends in pediatric enrollment and outcomes at primary (PHF) versus secondary/tertiary health facilities (SHFs). Using aggregate program data reported quarterly from 274 public facilities in Kenya, Lesotho, Mozambique, Rwanda and Tanzania from January 2008- March 2010 trends were examined in the number of children < 15 years of age initiating antiretroviral treatment (ART) by facility type. Clinic-level lost to follow-up (LTFU) and mortality per 100 person years (PYs) on ART during the period by facility type were compared. During the two year period, 17,155 children enrolled in HIV care and 8,475 initiated ART in 182 (66%) PHFs and 92(34%) SHFs. PHFs increased from 56 to 182, while SHFs increased from 72 to 92 sites. SHFs accounted for 71% of children initiating ART; however, the proportion of children initiating ART each quarter at PHFs increased from 17% (129) to 44% (463) in conjunction with an increase in PHFs during observation period. The average LTFU and mortality rates for children on ART were 9.8/100PYs and 5.2/100PYs, respectively at PHFs and 20.2/100PYs and 6.0/100PYs at SHFs. Adjusted models show PHFs associated with lower LTFU (Adjusted Rate Ratio, ARR=0.55; p=0.022) and lower mortality (ARR=0.66; p=0.028). The expansion of pediatric services to PHFs has resulted in increased numbers of children on ART. Early findings suggest lower rates of LTFU and mortality at PHFs. Successful scale-up will require further expansion of pediatric services within PHFs.

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Editor’s notes: Early during treatment scale up pediatric ART remained a referral clinic intervention, limiting the enrollment of children and disrupting efforts to provide ‘one-stop’ visits for families with adults and children living with HIV. Barriers such as provider discomfort with pediatric ART have been addressed by increased training efforts as well as a public health approach of algorithm-based treatment. Increasingly pediatric ART is being provided in the same sites and by the same providers as other primary health services.

Africa
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Integration of HIV and TB services: a model to shift from "vertical to horizontal"

Integrating tuberculosis and HIV services in low- and middle-income countries: a systematic review.

Legido-Quigley H, Montgomery CM, Khan P, Atun R, Fakoya A, Getahun H, Grant AD. Trop Med Int Health. 2012 Dec 10. [Epub ahead of print]

Objectives: Given the imperative to scale up integrated tuberculosis (TB) and HIV services in settings where both are of major public health importance, we aimed to synthesise knowledge concerning implementation of TB/HIV service integration.

Methods: Systematic review of studies describing a strategy to facilitate TB and HIV service integration, searching 15 bibliographic databases including Medline, Embase and the Cochrane library; and relevant conference abstracts.

Results: Sixty-three of 1936 peer-reviewed articles and 70 of 170 abstracts met our inclusion criteria. We identified five models: entry via TB service, with referral for HIV testing and care; entry via TB service, on-site HIV testing, and referral for HIV care; entry via HIV service with referral for TB screening and treatment; entry via HIV service, on-site TB screening, and referral for TB diagnosis and treatment; and TB and HIV services provided at a single facility. Referral-based models are most easily implemented, but referral failure is a key risk. Closer integration requires more staff training and additional infrastructure (e.g. private space for HIV counselling; integrated records). Infection control is a major concern. More integrated models hold potential efficiencies from both provider and user perspective. Most papers report 'outcomes' (e.g. proportion of TB patients tested for HIV); few report downstream 'impacts' such as outcomes of TB treatment or antiretroviral therapy. Very few studies address the perspectives of service users or staff, or costs or cost-effectiveness.

Conclusions: While scaling up integrated services, robust comparisons of the impacts of different models are needed using standardised outcome measures.

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Editor’s notes:This study emphasizes the need to implement the most effective integrated services for the prevention and cure of HIV and TB.  TB remains one of the most deadly infectious diseases that dramatically impacts on people in sub-Saharan Africa and represent the major cause of death in those living with HIV in the region. In fact, the progressive weakening of the immune system in HIV-positive people increases the likelihood of contracting/reactivating tuberculosis. Already in 2004, the WHO published "A Interim Policy on TBV/HIV Collaborative Activities" with the purpose of providing a guide to establish integration of TB and HIV services, and to reduce the TB load in people living with HIV. An updated document "WHO policy on collaborative TB/HIV activities: guidelines for national programmes and other stakeholders" is now available. The document provides guidance for integrating care activities between TB and HIV health services. However, to put this paper into perspective, a consensus can be reached by saying that integration shall not just be about HIV and TB. Indeed, the old debate between "vertical approaches (e.g. disease focused)" and horizontal approaches (e.g. health systems focused) shall now be concluded and integration of services shall expand to care of other diseases, particularly when, at the horizon, an epidemic of chronic non-communicable diseases is slowly but surely rising in Africa. In summary, HIV is a chronic infection impacting the lifecycle; with periods of illness and wellness, with multiple clinical and psychosocial needs, requiring lifelong care and treatment with a secure supply of medicines and laboratory tests.

It is evident that HIV care may inform appropriate responses to other health threats which share the same demand for services, training of health care workers, support for adherence, infrastructure and equipment, programme management, drug and laboratory supplies, linkage to care and community involvement. In other words, there is a wide recognition of the spillover effect of HIV interventions towards health systems strengthening, not only to the benefit of other communicable diseases, but also of child and maternal health and of chronic non-communicable diseases (like diabetes, hypertension and cancer).

Africa, Asia, Europe, Latin America
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