Articles tagged as "Malawi"

In the market for drugs and alcohol: characterising a risk environment in Malawi

Substance use and risky sexual behaviors among young men working at a rural roadside market in Malawi.

Jere DL, Norr KF, Bell CC, Corte C, Dancy BL, Kaponda CP, Levy JA. J Assoc Nurses AIDS Care. 2015 Jul 13. pii: S1055-3290(15)00147-8. doi: 10.1016/j.jana.2015.07.003. [Epub ahead of print]

Using an ecological model, we describe substance use and sexual risk behaviors of young male laborers at a roadside market in Malawi. Data included observations and interviews with 18 key market leaders and 15 laborers (ages 18-25 years). Alcohol, marijuana, and commercial sex workers (CSWs) were widely available. We identified three patterns of substance use: 6 young men currently used, 6 formerly used, and 3 never used. Substance use was linked to risky sex, including sex with CSWs. The market supported risky behaviors through availability of resources; supportive norms, including beliefs that substance use enhanced strength; and lack of restraints. Community-level poverty, cultural support for alcohol, interpersonal family/peer influences, early substance use, and school dropout also contributed to risky behaviors. Parental guidance was protective but not often reported. Local programs addressing substance use and risky sex simultaneously and better national substance use policies and mental health services are needed.

Abstract access

Editor’s notes: There has been a global focus on how substance use and associated risk behaviours contribute to HIV acquisition. Over the last decade there has been emerging evidence to suggest that substance use is increasing in the sub-Saharan African region, which is leading people to engage in risky sexual behaviour associated with HIV transmission. Despite this, there is a continued absence of research which focuses on the causes and practices of substance use, the associated impact and the opportunities to ameliorate the associated harms. This has led to a considerable knowledge gap. This paper provides a case study which offers insights into the factors which promote and sustain the relatively heavy use of marijuana and alcohol in a rural Malawian roadside market among young male labourers.

Adopting Scribener’s ecological model framework, the authors start from the premise that there are multiple level factors (societal, neighbourhood, interpersonal and individual) which shape the behaviour of men working in these markets. Using an ethnographic approach, they provide a rich description of how these multiple levels of risk factors operate and interact to facilitate men’s substance use.

The study found that the availability and use of alcohol and marijuana within the market by young men was widespread and that this was known about and broadly tolerated by key actors and groups involved in the market. The environment of the market is characterised by an ease of opportunity to consume these substances. The environment exhibited cultural norms which appeared to promote the acceptability of this behaviour and the absence of protective mechanisms to minimise the harms. There were two novel findings in the study. The first was how the perceived benefits of alcohol and marijuana use was integrated into expectations that it would help people to gain work and then do their jobs better. The second was that participants often justified their own behaviour by illustrating that it was endorsed by Ngoni culture, predominately in the area where the market was located. As such drinking alcohol was a means to perform young masculinity. This thoughtful research provides valuable evidence to support the need for programmes to include a focus on structural changes, such as availability and regulation of substance use but also in engaging with the presumed cultural norms. These should be considered alongside a more individual orientated approach in order to design a programme that is likely to be successful in reducing the harm of these behaviours. 

Gender, Substance use
Africa
Malawi
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Provider-perceived barriers and facilitators to viral load monitoring for HIV-positive individuals in resource-limited settings

On the front line of HIV virological monitoring: barriers and facilitators from a provider perspective in resource-limited settings.

Rutstein SE, Golin CE, Wheeler SB, Kamwendo D, Hosseinipour MC, Weinberger M, Miller WC, Biddle AK, Soko A, Mkandawire M, Mwenda R, Sarr A, Gupta S, Mataya R. AIDS Care. 2015 Aug 17:1-10. [Epub ahead of print]

Scale-up of viral load (VL) monitoring for HIV-infected patients on antiretroviral therapy (ART) is a priority in many resource-limited settings, and ART providers are critical to effective program implementation. We explored provider-perceived barriers and facilitators of VL monitoring. We interviewed all providers (n = 17) engaged in a public health evaluation of dried blood spots for VL monitoring at five ART clinics in Malawi. All ART clinics were housed within district hospitals. We grouped themes at patient, provider, facility, system, and policy levels. Providers emphasized their desire for improved ART monitoring strategies, and frustration in response to restrictive policies for determining which patients were eligible to receive VL monitoring. Although many providers pled for expansion of monitoring to include all persons on ART, regardless of time on ART, the most salient provider-perceived barrier to VL monitoring implementation was the pressure of work associated with monitoring activities. The work burden was exacerbated by inefficient data management systems, highlighting a critical interaction between provider-, facility-, and system-level factors. Lack of integration between laboratory and clinical systems complicated the process for alerting providers when results were available, and these communication gaps were intensified by poor facility connectivity. Centralized second-line ART distribution was also noted as a barrier: providers reported that the time and expenses required for patients to collect second-line ART frequently obstructed referral. However, provider empowerment emerged as an unexpected facilitator of VL monitoring. For many providers, this was the first time they used an objective marker of ART response to guide clinical management. Providers' knowledge of a patient's virological status increased confidence in adherence counselling and clinical decision-making. Results from our study provide unique insight into provider perceptions of VL monitoring and indicate the importance of policies responsive to individual and environmental challenges of VL monitoring program implementation. Findings may inform scale-up by helping policy-makers identify strategies to improve feasibility and sustainability of VL monitoring.

Abstract access 

Editor’s notes: Viral load monitoring for HIV-positive individuals is gaining prominence as a method for monitoring responses to antiretroviral therapy (ART) and for identifying treatment failure. It is considered more accurate (in terms of its sensitivity and specificity) than alternative methods (e.g., CD4 cell counts). ART providers are critical to the implementation of viral load scale-up as it tends to be resource heavy and providers are tasked with numerous responsibilities in order to achieve individual and public health benefits. Using data from in-person interviews with providers on the frontline of ART management in five ART clinics in Malawi, this study explored multi-level barriers to, and facilitators for incorporating viral load monitoring into daily clinical practice. Study results illustrated a complex set of interconnected provider–identified barriers and facilitators that occurred at multiple levels. In terms of facilitators, high patient demand for viral load testing reinforced provider-perceived benefits of viral load monitoring. In addition, placing an emphasis on provider empowerment during viral load scale-up activities was thought to increase providers’ willingness to adopt additional responsibilities. Barriers identified by providers included the additional burden associated with viral load monitoring such as the time required in completing adherence assessment forms. Related to this was a barrier identified at the facility level by providers around shortage of staff. This was in particular identified as an impediment to completing viral load monitoring activities. Furthermore, inconsistent staffing alongside reluctance of rotating staff to participate in viral load monitoring activities were cited as contributors to people’s failure to return to scheduled clinic visits. Barriers at the system level were around time and expenses required for people to collect second-line ART which then obstructed referrals to viral load monitoring. Further, providers expressed frustration over a policy in Malawi that dictates only certain time points from ART exposure in order to be eligible for viral load monitoring. Hence, they felt forced to ration a service that was considered useful for guiding clinical practice and counselling people.

In order to address some of these barriers, the authors suggest that issues around workload burden and shortage of trained staff at facilities be addressed by expanding provider-to-patient ratios at ART clinics, broadening the scope of practice and training a lower cadre of health workers to facilitate programme sustainability. Furthermore, to synchronise facility, system and policy level interfaces, shortcomings in data management systems needed to be overcome. To that end, improving coverage of mobile networks and internet connectivity to outlying clinics would help facilitate reliable clinic-laboratory communication. Also, decentralised distribution of second-line ART drugs along with improved supply chain procedures should be considered to minimise stock-outs for individuals seeking viral load monitoring in more remote areas. Further, in order to address the issue around Malawi’s strict eligibility criteria, policy-makers need to make an effort to design provider trainings and patient education materials with clarity around the criteria in order to optimise access to limited viral load monitoring opportunities for people at highest risk of ART failure. Another option to improve access is ‘catch up’ testing where every individual on ART for more than two years receives a single test and then returns to biannual eligibility. Even though the results from this study are exploratory, they do provide useful insights into the perceived barriers and facilitators faced by providers around viral load monitoring. Overall, viral load monitoring can be used as a tool to help providers improve the quality of HIV care they deliver, if certain barriers are overcome.

Africa
Malawi
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Wide variation in national HIV policies associated with HIV testing and treatment across six African countries

A comparative analysis of national HIV policies in six African countries with generalized epidemics.

Church K, Kiweewa F, Dasgupta A, Mwangome M, Mpandaguta E, Gomez-Olive FX, Oti S, Todd J, Wringe A, Geubbels E, Crampin A, Nakiyingi-Miiro J, Hayashi C, Njage M, Wagner RG, Ario AR, Makombe SD, Mugurungi O, Zaba B. Bull World Health Organ. 2015 Jul 1;93(7):457-67. doi: 10.2471/BLT.14.147215. Epub 2015 Apr 28.

Objective: To compare national human immunodeficiency virus (HIV) policies influencing access to HIV testing and treatment services in six sub-Saharan African countries.

Methods: We reviewed HIV policies as part of a multi-country study on adult mortality in sub-Saharan Africa. A policy extraction tool was developed and used to review national HIV policy documents and guidelines published in Kenya, Malawi, South Africa, Uganda, the United Republic of Tanzania and Zimbabwe between 2003 and 2013. Key informant interviews helped to fill gaps in findings. National policies were categorized according to whether they explicitly or implicitly adhered to 54 policy indicators, identified through literature and expert reviews. We also compared the national policies with World Health Organization (WHO) guidance.

Findings: There was wide variation in policies between countries; each country was progressive in some areas and not in others. Malawi was particularly advanced in promoting rapid initiation of antiretroviral therapy. However, no country had a consistently enabling policy context expected to increase access to care and prevent attrition. Countries went beyond WHO guidance in certain areas and key informants reported that practice often surpassed policy.

Conclusion: Evaluating the impact of policy differences on access to care and health outcomes among people living with HIV is challenging. Certain policies will exert more influence than others and official policies are not always implemented. Future research should assess the extent of policy implementation and link these findings with HIV outcomes.

Abstract  Full-text [free] access

Editor’s notes: Despite evidence on reduction in HIV attributable mortality, concerns still remain on the high attrition rates across the diagnosis-to-treatment cascade. This paper uses a comparative policy analysis to track differences in national HIV policy responses to the HIV epidemic. The methodology used is notable as it offers a helpful conceptual framework for the HIV policy and service factors influencing specific differences in HIV-associated adult mortality across the diagnosis-to-treatment cascade.

The range of policies between countries was unexpected, given the explanation offered by the authors that African countries tend to adopt standards and guidance from WHO. Furthermore, while countries showed progressive elements, no country had the comprehensive policy context necessary for a decisive impact on service access. Important differences were also noted in the influential weight given to some policies, in the timing of policy implementation in some indicators, and in whether WHO national standards were or were not adopted by countries.

These findings are particularly useful in better understanding the incentives and barriers to accessing antiretroviral therapy in different contexts.

Africa
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Switching to second-line ART – we need to do better

Monitoring and switching of first-line antiretroviral therapy in sub-Saharan Africa: collaborative analysis of adult treatment cohorts.

Haas AD, Keiser O, Balestre E, Brown S, Bissagnene E, Chimbetete C, Dabis F, Davies MA, Hoffmann CJ, Oyaro P, Parkes-Ratanshi R, Reynolds SJ, Sikazwe I, Wools-Kaloustian K, Zannou DM, Wandeler G, Egger M, for IeDea Southern Africa EA, West A. Lancet HIV. 2015 Jul 1;2(7):e271-e278.

Background: HIV-1 viral load testing is recommended to monitor antiretroviral therapy (ART) but is not universally available. The aim of our study was to assess monitoring of first-line ART and switching to second-line ART in sub-Saharan Africa.

Methods: We did a collaborative analysis of cohort studies from 16 countries in east Africa, southern Africa, and west Africa that participate in the international epidemiological database to evaluate AIDS (IeDEA). We included adults infected with HIV-1 who started combination ART between January, 2004, and January, 2013. We defined switching of ART as a change from a non-nucleoside reverse-transcriptase inhibitor (NNRTI)-based regimen to one including a protease inhibitor, with adjustment of one or more nucleoside reverse-transcriptase inhibitors (NRTIs). Virological and immunological failures were defined according to WHO criteria. We calculated cumulative probabilities of switching and hazard ratios with 95% CIs comparing routine viral load monitoring, targeted viral load monitoring, CD4 monitoring, and clinical monitoring, adjusting for programme and individual characteristics.

Findings: Of 297 825 eligible patients, 10 352 (3%) switched to second-line ART during 782 412 person-years of follow-up. Compared with CD4 monitoring, hazard ratios for switching were 3·15 (95% CI 2·92–3·40) for routine viral load monitoring, 1·21 (1·13–1·30) for targeted viral load monitoring, and 0·49 (0·43–0·56) for clinical monitoring. Of 6450 patients with confirmed virological failure, 58·0% (95% CI 56·5–59·6) switched by 2 years, and of 15 892 patients with confirmed immunological failure, 19·3% (18·5–20·0) switched by 2 years. Of 10 352 patients who switched, evidence of treatment failure based on one CD4 count or viral load measurement ranged from 86 (32%) of 268 patients with clinical monitoring to 3754 (84%) of 4452 with targeted viral load monitoring. Median CD4 counts at switching were 215 cells per μL (IQR 117–335) with routine viral load monitoring, but were lower with other types of monitoring (range 114–133 cells per μL).

Interpretation: Overall, few patients switched to second-line ART and switching happened late in the absence of routine viral load monitoring. Switching was more common and happened earlier after initiation of ART with targeted or routine viral load testing.

Abstract access 

Editor’s notes: Routine viral load monitoring should allow the early identification of first-line antiretroviral therapy (ART) failure, allowing prompt switch to second-line ART. Prolongation of treatment with a failing regimen compromises future therapeutic options (through the accumulation of drug resistance mutations) and potentially leads to increased morbidity and mortality. Previous reports from Africa have suggested that surprisingly few people switch to second-line therapy, even in programmes with routine viral load monitoring. This raises concerns that there are challenges on the ground with identification and management of ART failure.

This is a comprehensive analysis bringing together data from a number of well-characterised cohorts in Africa. In this analysis, switching to second-line ART was rare (3% over an average of almost three years follow-up). In programmes with routine viral load monitoring, only half of the people with confirmed virologic failure on first-line ART (two viral loads >1000 copies/ml) were recorded as having been switched to second-line ART. Furthermore, half of the people that were switched to a second-line regimen did not have evidence of confirmed virologic failure, suggesting that some may have been switched too early without first attempting adherence programmes which may achieve re-suppression on first-line ART. Unsurprisingly, rates of switching were lower in programmes with CD4+ monitoring (with or without targeted viral load testing) or clinical monitoring alone. 

While guidelines and algorithms around identification and management of first-line ART failure are relatively clear and straightforward, translating this into action on the ground seems to be difficult. At least part of this is likely to be due to the lack of tools to reliably measure adherence and the consequent difficulty that frontline health care workers have in identifying people that truly require a switch to second-line ART. Moreover, most programmes still do not routinely monitor indicators relating to virologic suppression or treatment failure and so this might not be seen as a priority by health care workers and programme managers. There is a need for research to explore how best to maximise virologic suppression in resource-constrained settings, as well as studies to evaluate the impact of programmes such as point-of-care viral load testing.

Africa
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Tenofovir-based regimens improve outcomes in HIV-HBV co-infection

Comparison of HBV-active HAART regimens in an HIV-HBV multinational cohort: outcomes through 144 weeks.

Thio CL, Smeaton L, Hollabaugh K, Saulynas M, Hwang H, Saravanan S, Kulkarni S, Hakim J, Nyirenda M, Iqbal HS, Lalloo UG, Campbell TB, Lockman S, Currier JS. AIDS. 2015 Jun 19;29(10):1173-82. doi: 10.1097/QAD.0000000000000686.

Objectives: To explore factors associated with short and long-term hepatitis B virus (HBV) DNA suppression in a multinational cohort of HIV-HBV co-infected patients receiving HBV-active antiretrovirals.

Methods: One hundred and fifteen HIV-HBV co-infected patients participating in one of the two global randomized clinical trials conducted by the Adult AIDS Clinical Trials Group of different antiretroviral regimens received either HBV monotherapy with either lamivudine or emtricitabine (N = 56), or HBV dual therapy with tenofovir disoproxil fumarate (TDF) + lamivudine or emtricitabine (N = 59). Associations of pretreatment characteristics with the primary (HBV DNA <200 IU/ml at 24 weeks) and longitudinal outcomes through 144 weeks were explored using logistic regression. HBV drug-resistance mutations were determined by pol sequencing in those with viral rebound.

Results: The proportion with HBV DNA below 200 IU/ml was 60% (95% confidence interval 50-69%) at 24 weeks and 79% (95% confidence interval 69-88%) at 144 weeks. Pretreatment factors associated with the primary outcome were HBV DNA, CD4 T-cell count, and aspartate aminotransferase, but only pretreatment HBV DNA remained associated with long-term suppression (P < 0.0001). HBV therapy group was not significantly associated with the primary outcome at 24 weeks; however, longitudinally, a greater proportion in the dual-therapy group achieved HBV DNA below 200 IU/ml (P = 0.007). A higher proportion of hepatitis B e antigen-negative patients (n = 57) achieved HBV DNA below 200 IU/ml at any point, regardless of the therapy group. All 12 patients with emergence of lamivudine-resistant mutants were in the monotherapy group.

Conclusions: TDF-based dual HBV-active antiretroviral therapy is preferred to treat HIV-HBV co-infected patients. In resource-limited settings in which TDF may not be universally available, lamivudine or emtricitabine HBV monotherapy is a reasonable option in patients with low HBV replication.

Abstract access 

Editor’s notes: Hepatitis B virus infection remains a leading cause of preventable morbidity and mortality globally, through cirrhosis and liver cancer. In settings with a high prevalence of HIV-HBV coinfection, there is an opportunity to optimise clinical management within the public health approach to antiretroviral therapy. This study adds to the evidence base suggesting that antiretroviral regimens containing lamivudine/emtricitabine and tenofovir are associated with better virologic outcomes than regimens without tenofovir for people co-infected with HIV and HBV. In this study, a post hoc analysis of two multicentre randomised controlled trials, regimens with two HBV-active agents provided more durable virologic suppression and limited the emergence of lamivudine-resistant HBV strains. Although recommendations about the treatment of HIV-HBV coinfection are incorporated into WHO antiretroviral guidelines, testing for HBV infection within antiretroviral programmes is still uncommon and tenofovir is not universally employed in standard first-line antiretroviral regimens. With an increasing number of people switching to second-line antiretroviral regimens, there is the additional challenge of identifying HBV infection in order to maintain HBV-active agents within the second-line regimen. There is now a need for better evidence around how to operationalise these recommendations within national antiretroviral programmes.        

Comorbidity, HIV Treatment
Africa, Asia, Latin America
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Men who have sex with men in sub-Saharan Africa: a review of the evidence

Emerging themes for sensitivity training modules of African healthcare workers attending to men who have sex with men: a systematic review.

Dijkstra M, van der Elst EM, Micheni M, Gichuru E, Musyoki H, Duby Z, Lange JM, Graham SM, Sanders EJ. Int Health. 2015 May;7(3):151-162. Epub 2015 Jan 16.

Sensitivity training of front-line African health care workers (HCWs) attending to men who have sex with men (MSM) is actively promoted through national HIV prevention programming in Kenya. Over 970 Kenyan-based HCWs have completed an eight-modular online training free of charge (http://www.marps-africa.org) since its creation in 2011. Before updating these modules, we performed a systematic review of published literature of MSM studies conducted in sub-Saharan Africa (sSA) in the period 2011-2014, to investigate if recent studies provided: important new knowledge currently not addressed in existing online modules; contested information of existing module topics; or added depth to topics covered already. We used learning objectives of the eight existing modules to categorise data from the literature. If data could not be categorised, new modules were suggested. Our review identified 142 MSM studies with data from sSA, including 34 studies requiring module updates, one study contesting current content, and 107 studies reinforcing existing module content. ART adherence and community engagement were identified as new modules. Recent MSM studies conducted in sSA provided new knowledge, contested existing information, and identified new areas of MSM service needs currently unaddressed in the online training.

Abstract  Full-text [free] access

Editor’s notes: Same sex practices remain criminalised in sub-Saharan Africa. Gay men and other men who have sex with men face stigma, discrimination, harassment and arrest. Health care workers frequently have no training on issues affecting gay men and other men who have sex with men and are ill-prepared to work sensitively with them. Together these can deter these men from accessing health care and HIV/STI services, increasing their risk of HIV and other poor health outcomes.

This study conducted a systematic review of gay men and other men who have sex with men in sub-Saharan Africa. The findings were used to update an on-line training programme for health care workers in Kenya. This previously comprised modules on i) men who have sex with men and HIV in Africa ii) homophobia: stigma and its effects; iii) sexual identity, coming out and disclosure; iv) anal sex and common sexual practices; v) HIV and STIs; vi) condom and lubricant use; vii) mental health: anxiety, depression and substance use; and viii) risk-reduction counselling. The review updated the training programme with new evidence and two new modules were introduced: ix) ART adherence; and x) community engagement.

Health care workers play a crucial role in reducing stigma and discrimination facing gay men and other men who have sex with men. This systematic review provided a valuable step in updating an important, accessible training programme. Reducing homoprejudice and ensuring health care workers have accurate and up-to-date knowledge are key to improving service uptake by gay men and other men who have sex with men.

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Early postnatal cytomegalovirus infection may predict subsequent HIV transmission through breastfeeding

Effect of cytomegalovirus infection on breastfeeding transmission of HIV and on the health of infants born to HIV-infected mothers.

Chang TS, Wiener J, Dollard SC, Amin MM, Ellington S, Chasela C, Kayira D, Tegha G, Kamwendo D, Jamieson DJ, van der Horst C, Kourtis AP; BAN Study Team. AIDS. 2015 Apr 24;29(7):831-6. doi: 10.1097/QAD.0000000000000617

Background: Cytomegalovirus (CMV) infection can be acquired in utero or postnatally through horizontal transmission and breastfeeding. The effect of postnatal CMV infection on postnatal HIV transmission is unknown.

Methods: The Breastfeeding, Antiretrovirals and Nutrition study, conducted in Malawi, randomized 2369 mothers and their infants to three antiretroviral prophylaxis arms - mother (triple regimen), infant (nevirapine), or neither - for 28 weeks of breastfeeding, followed by weaning. Stored plasma and peripheral blood mononuclear cell specimens were available for 492 infants at 24 weeks and were tested with CMV PCR. Available samples from infants who were CMV PCR-positive at 24 weeks were also tested at birth (N = 242), and from infants PCR-negative at 24 weeks were tested at 48 weeks (N = 96). Cox proportional-hazards models were used to determine if CMV infection was associated with infant morbidity, mortality, or postnatal HIV acquisition.

Results: At 24 weeks of age, CMV DNA was detected in 345/492 infants (70.1%); the estimated congenital CMV infection rate was 2.3%, and the estimated rate of CMV infection at 48 weeks was 78.5%. CMV infection at 24 weeks was associated with subsequent HIV acquisition through breastfeeding or infant death between 24 and 48 weeks of age (hazard ratio 4.27, P = 0.05).

Conclusion: Most breastfed infants of HIV-infected mothers in this resource-limited setting are infected with CMV by 24 weeks of age. Early CMV infection may be a risk factor for subsequent infant HIV infection through breastfeeding, pointing to the need for comprehensive approaches in order to achieve elimination of breastfeeding transmission of HIV.

Abstract access 

Editor’s notes: Studies have illustrated that mother-to-child HIV transmission is more frequent among neonates with congenital cytomegalovirus (CMV) infection. Infants co-infected with HIV and CMV have higher rates of HIV disease progression and death. This study using data and samples of infant plasma and peripheral blood mononuclear cells are from the Breastfeeding, Antiretrovirals and Nutrition (BAN) randomised, controlled clinical trial (RCT). The study examines whether postnatal CMV infection in the infant is associated with HIV transmission through breastfeeding. The study investigates the relationship between postnatal antiretroviral therapy and postnatal CMV acquisition. The data suggests that early postnatal CMV infection in an HIV-exposed uninfected infant may predict subsequent HIV transmission through breastfeeding and infant mortality. The study confirmed previous findings that approximately 70% of breastfed infants born to mothers living with HIV in low-income settings acquire CMV infection by six months of age. However, the study did not find an association between maternal antiretroviral therapy and the risk of postnatal CMV transmission. It is important to note that in the RCT, antiretroviral therapy was only initiated at the onset of labour.  The effect of maternal antiretroviral therapy taken earlier in pregnancy on the prevention or delay of CMV acquisition remains unknown, although a few observational studies have found that maternal antiretroviral therapy reduces congenital and early postnatal CMV infection. It is biologically plausible that antiretroviral therapy reduces or prevents CMV reactivation in the mother, thus preventing transient episodes of maternal CMV viraemia. This mechanism could explain reduced CMV transmission to the infant (be that before or after birth). HIV-exposed but uninfected infants experience higher morbidity and mortality; any such disease attributable to CMV could therefore potentially be reduced by initiation of antiretroviral therapy earlier in pregnancy.

Africa
Malawi
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Elimination of mother-to-child HIV transmission: still a pipe dream?

HIV testing among pregnant women who attend antenatal care in Malawi.

Tenthani L, Haas AD, Egger M, van Oosterhout JJ, Jahn A, Chimbwandira F, Tal K, Myer L, Estill J, Keiser O. J Acquir Immune Defic Syndr. 2015 May 6. [Epub ahead of print] 

Malawi adopted the Option B+ strategy in 2011. Its success in reducing MTCT depends on coverage and timing of HIV testing. We assessed HIV status ascertainment and its predictors during pregnancy. HIV status ascertainment was 82.3% (95%-CI 80.2-85.9) in the pre-Option B+ period and 85.7% (95%-CI 83.4-88.0) in the Option B+ period. Higher HIV ascertainment was independently associated with higher age, attending ANC more than once, and registration in 2010. The observed high variability of HIV ascertainment between sites (50.6%-97.7%) and over time suggests that HIV test kits shortages and insufficient numbers of staff posed major barriers to reducing MTCT.

Abstract access 

Editor’s notes: UNAIDS has called for an end to mother-to-child HIV transmission through the Global Plan towards the elimination of new infections among children and keeping their mothers alive. WHO guidelines on the use of antiretroviral medicines for treating and preventing HIV infection in 2013 recommends two options for pregnant and breastfeeding women. One of which is lifelong antiretroviral therapy (ART) for all pregnant women living with HIV regardless of CD4 count or disease stage, commonly referred to as Option B+. The Global Plan requires that 90% of all women living with HIV have access to ART. The success of the Global Plan will depend on sufficient numbers of women being tested for HIV.

This study includes data from 19 secondary and primary health facilities offering antenatal care in Malawi, the first country to introduce the Option B+ strategy in 2011. Introduction of the Option B+ strategy did not result in a significant change in the proportion of women who underwent HIV testing.  HIV ascertainment varied widely across facilities from 50% to 98%, and fluctuated greatly within sites over short time periods. The observed sudden decreases in numbers of women who received an HIV test suggest that important barriers to HIV testing exist at facility level. Previous studies have illustrated that temporary shortages of HIV testing kits and staff interrupt regular antenatal (ANC) HIV testing in health facilities. Women who had had multiple ANC visits were more likely to have had their HIV status ascertained, likely because multiple visits increased their chance to attend when staff and kits were available. Unfortunately, this study was unable to determine individual-level factors associated with HIV testing not having occurred.

We now have highly effective programmes that can virtually eliminate new HIV infections  among children globally. To attain this goal, urgent attention must be paid to strengthening health systems. Elimination of new infections among children will require attention to the whole cascade of care from diagnosis of HIV, through to provision of results and treatment and supporting women to take ART consistently.   

Africa
Malawi
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People living with HIV at higher risk of developing disabilities in sub-Saharan Africa

The relationship between HIV and prevalence of disabilities in sub-Saharan Africa: systematic review.

Banks LM, Zuurmond M, Ferrand R, Kuper H. Trop Med Int Health. 2015 Apr;20(4):411-29. doi: 10.1111/tmi.12449. Epub 2015 Jan 14.

Objective: To systematically review evidence on the prevalence and risk of disabilities among children and adults living with HIV in sub-Saharan Africa.

Methods: Articles were identified from 1980 to June 2013 through searching seven electronic databases. Epidemiological studies conducted in sub-Saharan Africa that explored the association between HIV status and general disability or specific impairments, with or without an HIV-uninfected comparison group, were eligible for inclusion.

Results: Of 12 867 records initially identified, 61 papers were deemed eligible for inclusion. The prevalence of disability was high across age groups, impairment types and study locations. Furthermore, 73% of studies using an HIV- comparator found significantly lower levels of functioning in people living with HIV (PLHIV). By disability type, the results were as follows: (i) for studies measuring physical impairments (n = 14), median prevalence of limitations in mobility and motor function among PLHIV was 25.0% (95% CI: 21.8-28.2%). Five of eight comparator studies found significantly reduced functioning among PLHIV; for arthritis, two of three studies which used an HIV- comparison group found significantly increased prevalence among PLHIV; (ii) for sensory impairment studies (n = 17), median prevalence of visual impairment was 11.2% (95%CI: 9.5-13.1%) and hearing impairment was 24.1% (95%CI: 19.2-29.0%) in PLHIV. Significantly increased prevalence among PLHIV was found in one of four (vision) and three of three studies (hearing) with comparators; (iii) for cognitive impairment in adults (n = 30), median prevalence for dementia was 25.3% (95% CI: 22.0-28.6%) and 40.9% (95% CI: 37.7-44.1%) for general cognitive impairment. Across all types of cognitive impairment, twelve of fourteen studies found a significant detrimental effect of HIV infection; (iv) for developmental delay in children with HIV (n = 20), median prevalence of motor delay was 67.7% (95% CI: 62.2-73.2%). All nine studies that included a comparator found a significant difference between PLHIV and controls; for cognitive development and global delay, a significant detrimental effect of HIV was found in five of six and one of two studies, respectively. In the nine cohort studies comparing vertically infected and uninfected children, eight showed a significant gap in development over time in children with HIV. Finally, fifteen of thirty-one (48%) studies found a statistically significant dose-response relationship between indicators of disease progression (CD4 or WHO stage) and disability.

Conclusions: HIV is widespread in sub-Saharan Africa and the evidence suggests that it is linked to disabilities, affecting a range of body structures and functions. More research is needed to better understand the implications of HIV-related disability for individuals, their families as well as those working in the fields of disability and HIV so that appropriate interventions can be developed.

Abstract  Full-text [free] access

Editor’s notes: As ART is scaled-up, and people living with HIV live longer, an increasing number of people will face challenges of HIV-associated disability. Disability may be partly a direct effect of living with HIV, but may also be an indirect effect, for example due to side effects of treatment. There has been relatively little research on this topic, particularly in low and middle-income countries and this is the first systematic review of the prevalence of disability among people living with HIV in sub-Saharan Africa. The review found a high prevalence of all categories of disability. The majority of studies had an HIV-negative comparison group among whom levels of disability were lower than among people living with HIV. Developmental delay was the impairment most strongly linked to HIV, with prevalence as high as 78% in children living with HIV. To minimize the chance that the observed association was due to reverse causality, the review excluded studies which clearly focused on disability as a risk factor for HIV, although it is likely that some studies still included individuals in whom disability preceded HIV infection. There was also relatively little data on ART status and duration in many studies, which may impact on the association of HIV and disability.  Despite these limitations, this study highlights the need to focus on prevention and management of HIV-associated disability in sub-Saharan Africa and development of effective, low-cost evidence-informed activities.

Africa
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Hepatitis B virus co-infection: a challenge to successful ART in sub-Saharan Africa?

Prevalence of HIV and hepatitis B virus co-infection in sub-Saharan Africa and the potential impact and program feasibility of hepatitis B surface antigen screening in resource-limited settings.

Stabinski L, OʼConnor S, Barnhart M, Kahn RJ, Hamm TE. J Acquir Immune Defic Syndr. 2015 Apr 15;68 Suppl 3:S274-85. doi: 10.1097/QAI.0000000000000496.

Background: Screening people living with HIV for hepatitis B virus (HBV) co-infection is recommended in resource-rich settings to optimize HIV antiretroviral therapy (ART) and mitigate HBV-related liver disease. This review examines the need, feasibility, and impact of screening for HBV in resource-limited settings (RLS).

Methods: We searched 6 databases to identify peer-reviewed publications between 2007 and 2013 addressing (1) HIV/HBV co-infection frequency in sub-Saharan Africa (SSA); (2) performance of hepatitis B surface antigen (HBsAg) rapid strip assays (RSAs) in RLS; (3) impact of HBV co-infection on morbidity, mortality, or liver disease progression; and/or (4) impact of HBV-suppressive antiretroviral medications as part of ART on at least one of 5 outcomes (mortality, morbidity, HIV transmission, retention in HIV care, or quality of life). We rated the quality of individual articles and summarized the body of evidence and expected impact of each intervention per outcome addressed.

Results: Of 3940 identified studies, 85 were included in the review: 55 addressed HIV/HBV co-infection frequency; 6 described HBsAg RSA performance; and 24 addressed the impact of HIV/HBV co-infection and ART. HIV/HBV frequency in sub-Saharan Africa varied from 0% to >28.4%. RSA performance in RLS showed good, although variable, sensitivity and specificity. Quality of studies ranged from strong to weak. Overall quality of evidence for the impact of HIV/HBV co-infection and ART on morbidity and mortality was fair and good to fair, respectively.

Conclusions: Combined, the body of evidence reviewed suggests that HBsAg screening among people living with HIV could have substantial impact on preventing morbidity and mortality among HIV/HBV co-infected individuals in RLS.

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Editor’s notes: The routes of transmission for hepatitis B virus (HBV) and HIV are the same, and they frequently co-infect individuals in high HIV prevalence settings. HIV has also been shown to accelerate the progression of HBV. This has important implications for ART programmes, given also the potential for hepatotoxicity of ART. The response of both infections to certain antivirals gives an opportunity to treat both infections simultaneously, but also the potential to engender resistant strains of virus if treatment is optimised for one and not the other.

This paper reviews the evidence that might support inclusion of HBV screening as part of HIV care programmes. No clinical trials have been done in this area, so the review is based on observational studies. The data are incomplete and geographically patchy, largely from Nigeria and South Africa. However, this does not prevent the authors from concluding that the co-infection risk is sufficiently high and the consequences of lack of treatment sufficiently severe to consider allocation of scarce resources to identify and manage HBV co-infection in HIV programmes. Appropriate validated screening tools - rapid tests for hepatitis B surface antigen - are available. The potential benefit warrants consideration of this issue in sub-Saharan Africa, and inclusion of HBV surveillance alongside HIV to resolve the paucity of data in most countries. This should be rapidly followed by further consideration of the cost- and risk-benefit of introduction of an HBV screening and treatment programme.

Interested readers might also refer to a review by Matthews et al. (J Clin Virol 2014;6:20-33) which considers similar questions and also discusses hepatitis C co-infection.

Avoid TB deaths
Africa
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