Articles tagged as "Rwanda"

Linking cervical cancer prevention into infrastructure for HIV services in sub-Saharan Africa

Infrastructure requirements for human papillomavirus vaccination and cervical cancer screening in sub-Saharan Africa.

Sankaranarayanan R, Anorlu R, Sangwa-Lugoma G, Denny LA. Vaccine. 2013 Dec 29;31 Suppl 5:F47-52. doi: 10.1016/j.vaccine.2012.06.066.

The availability of both human papillomavirus (HPV) vaccination and alternative screening tests has greatly improved the prospects of cervical cancer prevention in sub-Saharan African (SSA) countries. The inclusion of HPV vaccine in the portfolio of new vaccines offered by the Global Alliance for Vaccines and Immunization (GAVI) to GAVI-eligible countries has vastly improved the chances of introducing HPV vaccination. Further investments to improve vaccine storage, distribution and delivery infrastructure and human resources of the Extended Programme of Immunization will substantially contribute to the faster introduction of HPV vaccination in SSA countries through both school- and campaign-based approaches. Alternative methods to cytology for the prevention of cervical cancer through the early detection and treatment of cervical cancer precursors have been extensively evaluated in the past 15 years, in Africa as well as in other low-resource settings. Visual inspection with 3-5% dilute acetic acid (VIA) and HPV testing are the two alternative screening methods that have been most studied, in both cross-sectional and randomised clinical trials. VIA is particularly suitable to low-resource settings; however, its efficacy in reducing cervical cancer is likely to be significantly lower than HPV testing. The introduction of VIA screening programmes will help develop the infrastructure that will, in turn, facilitate the introduction of affordable HPV testing in future. Links with the existing HIV/AIDS control programmes is another strategy to improve the infrastructure and screening services in SSA. Infrastructural requirements for an integrated approach aiming to vaccinate single-year cohorts of girls in the 9-13 years age-range and to screen women over 30 years of age using VIA or affordable rapid HPV tests are outlined in this manuscript.

Abstract access 

Editor’s notes: Infection with human papillomavirus (HPV) can lead to cervical cancer. HIV-positive women are more likely to acquire and have persistent HPV, so the high burden of HIV in sub-Saharan Africa (SSA) contributes to the burden of cervical cancer. This review article discusses the options for the prevention of cervical cancer in SSA. While this article is primarily focused on cervical cancer, it highlights the potential linkages of prevention activities with HIV/AIDS services with an emphasis on infrastructure to improve access to these services for women in SSA. The options for cervical cancer prevention in SSA include HPV vaccination, visual inspection tests, HPV DNA tests and cytology screening. These options and the infrastructure required for each are described in detail, and some of the barriers to delivery are highlighted. Treatment options are also described, including cryotherapy following visual inspection. 

Africa, Asia
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An integrated investment approach for women’s and children’s health

Advancing social and economic development by investing in women's and children's health: a new Global Investment Framework.

Stenberg K, Axelson H, Sheehan P, Anderson I, Gülmezoglu AM, Temmerman M, Mason E, Friedman HS, Bhutta ZA, Lawn JE, Sweeny K, Tulloch J, Hansen P, Chopra M, Gupta A, Vogel JP, Ostergren M, Rasmussen B, Levin C, Boyle C, Kuruvilla S, Koblinsky M, Walker N, de Francisco A, Novcic N, Presern C, Jamison D, Bustreo F; on behalf of the Study Group for the Global Investment Framework for Women's Children's Health. Lancet. 2013 Nov 18. doi: S0140-6736(13)62231-X. pii: 10.1016/S0140-6736(13)62231-X. [Epub ahead of print]

A new Global Investment Framework for Women's and Children's Health demonstrates how investment in women's and children's health will secure high health, social, and economic returns. We costed health systems strengthening and six investment packages for: maternal and newborn health, child health, immunisation, family planning, HIV/AIDS, and malaria. Nutrition is a cross-cutting theme. We then used simulation modelling to estimate the health and socioeconomic returns of these investments. Increasing health expenditure by just $5 per person per year up to 2035 in 74 high-burden countries could yield up to nine times that value in economic and social benefits. These returns include greater gross domestic product (GDP) growth through improved productivity, and prevention of the needless deaths of 147 million children, 32 million stillbirths, and 5 million women by 2035. These gains could be achieved by an additional investment of $30 billion per year, equivalent to a 2% increase above current spending.

Abstract access 

Editor’s notes: Over the past 20 years there have been substantial gains in maternal and child health (MCH). However, much still needs to be done – assuming a continuation of current rates of progress, there would nevertheless be shortfalls in the achievement of MDG 4 and 5 targets. Especially in sub-Saharan Africa, HIV is an important underlying cause of maternal and child ill health. This paper models the costs and benefits of an accelerated action on MCH, including for HIV, the prevention of mother to child HIV transmission; first line treatment for pregnant women; cotrimoxazole for children, and the provision of paediatric antiretroviral therapy (ART). These HIV services are complemented by health systems strengthening; increased family planning provision; and packages for malaria, immunisation, and child health. The paper is interesting for many reasons, including both the breadth of its intervention focus, and the detailed modelling of the likely health, social and economic benefits of such investments.

Although the direct HIV related benefits are not described in detail in the main paper, it is likely that these result both from increased contraceptive use (prong 2 for preventing vertical HIV transmission), as well as ART and cotrimoxazole provision. It also illustrates the potential value of developing a cross-disease investment approach, as a means to ensure that services effectively respond to the breadth of women’s and children’s health needs. This more ‘joined up’, integrated perspective on strategies for health investment can support core investments in health systems strengthening. It can also potentially achieve important cross-disease synergies, e.g., ensuring that a child who has not acquired HIV at birth does not then die from malaria. 

Africa, Asia, Latin America, Oceania
Afghanistan, Angola, Azerbaijan, Bangladesh, Benin, Bolivia, Botswana, Brazil, Burkina Faso, Burundi, Cambodia, Cameroon, Central African Republic, Chad, China, Comoros, Congo, Côte d'Ivoire, Democratic People's Republic of Korea, Democratic Republic of the Congo, Djibouti, Egypt, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Guatemala, Guinea, Guinea-Bissau, Haiti, India, Indonesia, Iraq, Kenya, Kyrgyzstan, Lao People's Democratic Republic, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Mexico, Morocco, Mozambique, Myanmar, Nepal, Niger, Nigeria, Pakistan, Papua New Guinea, Peru, Philippines, Rwanda, Sao Tome and Principe, Senegal, Sierra Leone, Solomon Islands, Somalia, South Africa, Sudan, Swaziland, Tajikistan, Togo, Turkmenistan, Uganda, United Republic of Tanzania, Uzbekistan, Viet Nam, Yemen, Zambia, Zimbabwe
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Intrauterine infections, but not obstetric complications, more common among pregnant women with HIV

HIV and the Risk of Direct Obstetric Complications: A Systematic Review and Meta-Analysis. 

Calvert C, Ronsmans C. PLoS One. 2013 Oct 4;8(10):e74848. doi:10.1371/journal.pone.0074848.

Background: Women of reproductive age in parts of sub-Saharan Africa are faced both with high levels of HIV and the threat of dying from the direct complications of pregnancy. Clinicians practicing in such settings have reported a high incidence of direct obstetric complications among HIV-infected women, but the evidence supporting this is unclear. The aim of this systematic review is to establish whether HIV-infected women are at increased risk of direct obstetric complications.

Methods and findings: Studies comparing the frequency of obstetric haemorrhage, hypertensive disorders of pregnancy, dystocia and intrauterine infections in HIV-infected and uninfected women were identified. Summary estimates of the odds ratio (OR) for the association between HIV and each obstetric complication were calculated through meta-analyses. In total, 44 studies were included providing 66 data sets; 17 on haemorrhage, 19 on hypertensive disorders, five on dystocia and 25 on intrauterine infections. Meta-analysis of the OR from studies including vaginal deliveries indicated that HIV-infected women had over three times the risk of a puerperal sepsis compared with HIV-uninfected women [pooled OR: 3.43, 95% confidence interval (CI): 2.00-5.85]; this figure increased to nearly six amongst studies only including women who delivered by caesarean (pooled OR: 5.81, 95% CI: 2.42-13.97). For other obstetric complications the evidence was weak and inconsistent.

Conclusions: The higher risk of intrauterine infections in HIV-infected pregnant and postpartum women may require targeted strategies involving the prophylactic use of antibiotics during labour. However, as the huge excess of pregnancy-related mortality in HIV-infected women is unlikely to be due to a higher risk of direct obstetric complications, reducing this mortality will require non obstetric interventions involving access to ART in both pregnant and non-pregnant women.

Abstract  Full-text [free] access

Editor’s notes: Women with HIV are thought to have a higher risk of adverse outcomes during pregnancy. This review is valuable in summarizing available data on this topic. Many of the included studies predated the wide availability of antiretroviral therapy. There was a clear association between HIV infection and intrauterine infections, but not with the other obstetric complications, e.g., obstetric haemorrhage, hypertensive disorders of pregnancy, dystocia, examined in the review. Considering individual conditions analysed, HIV infection was associated with antepartum haemorrhage, (but not postpartum haemorrhage). It was also found to be associated with pregnancy-induced hypertension (but not pre-eclampsia or eclampsia), and uterine rupture or prolonged labour (but not other complications of dystocia). The authors note that the studies were generally of low quality, and there were too few studies to examine the effect of antiretroviral therapy on these complications.  

Given the excess of intrauterine infections in women with HIV, the authors suggest that these might be preventable with prophylactic antibiotics. Overall, where causes of maternal mortality are documented, pregnant women with HIV are more likely to die of non-pregnancy related infections, than of obstetric complications. Specifically, non-pregnancy related infections are tuberculosis, pneumonia or meningitis. Pregnant women living with HIV need access to antenatal services and a skilled attendant at delivery. But, the top priority with respect to reducing maternal mortality is effective antiretroviral therapy.

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High attrition rates pre- and post-ART initiation among youth in four African countries

High attrition before and after ART initiation among youth (15-24 years of age) enrolled in HIV care.

Lamb MR, Fayorsey R, Nuwagaba-Birbonwoha H, Viola V, Mutabazi V, Alwar T, Casalini C, Elul B. AIDS. 2013 Sep 26. [Epub ahead of print]

Objectives: To compare pre and post-ART attrition between youth (15-24 years) and other patients in HIV care, and to investigate factors associated with attrition among youth.

Design: Cohort study utilizing routinely collected patient-level data from 160 HIV clinics in Kenya, Mozambique, Tanzania, and Rwanda.

Methods: Patients at least 10 years of age enrolling in HIV care between 01/05 and 09/10 were included. Attrition (loss to follow-up or death 1 year after enrollment or ART initiation) was compared between youth and other patients using multivariate competing risk (pre-ART) and traditional (post-ART) Cox Proportional Hazards methods accounting for within-clinic correlation. Among youth, patient-level and clinic-level factors associated with attrition were similarly assessed.

Results: 312  335 patients at least 10 years of age enrolled in HIV care; 147  936 (47%) initiated ART, 17% enrolling in care and 10% initiating ART were youth. Attrition before and after ART initiation was substantially higher among youth compared with other age groups. Among youth, nonpregnant women experienced lower pre-ART attrition than men (sHR = 0.90, 95% CI:0.86-0.94), while both pregnant (AHR = 0.85, 95% CI:0.74-0.97) and nonpregnant (AHR = 0.79, 95% CI:0.73-0.86) female youth experienced lower post-ART attrition than men. Youth attending clinics providing sexual and reproductive health services including condoms (AHR = 0.47, 95% CI:0.32-0.70) and clinics offering adolescent support groups (AHR = 0.73, 95% CI:0.52-1.0) experienced significantly lower attrition after ART initiation.

Conclusion: Youth experienced substantially higher attrition before and after ART initiation compared with younger adolescents and older adults. Adolescent-friendly services were associated with reduced attrition among youth, particularly after ART initiation.

Abstract access 

Editor’s notes: HIV places a disproportionate burden on young people in many settings, with approximately 40% of new infections occurring among those aged 15-24 years old. Previous studies have shown that young people on antiretroviral therapy have poorer treatment outcomes than older adults, due to worse adherence, retention and survival. This paper is one of the first to examine outcomes before antiretroviral therapy initiation as well as after antiretroviral therapy initiation. It is also the first multi-country and largest study to date on attrition among HIV-positive youth enrolled in HIV care in sub-Saharan Africa. The results confirm earlier studies, showing higher attrition one year after antiretroviral therapy initiation in this age group, compared with older adults, and also show higher risks of death prior to starting antiretroviral therapy. More positively, the study highlights the potential benefit of youth-friendly services, including for example, adolescent support groups and peer educators. Further work to evaluate the effectiveness of such services on improving retention is warranted.

Africa
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Decentralised HIV treatment is no worse than hospital based care, and in some cases better

Decentralising HIV treatment in lower- and middle-income countries.

Kredo T, Ford N, Adeniyi FB, Garner P. Cochrane Database Syst Rev. 2013 Jun 27;6:CD009987. doi: 10.1002/14651858.CD009987.pub2.

Background:  Policy makers, health staff and communities recognise that health services in lower- and middle-income countries need to improve people's access to HIV treatment and retention to treatment programmes. One strategy is to move antiretroviral delivery from hospitals to more peripheral health facilities or even beyond health facilities. This could increase the number of people with access to care, improve health outcomes, and enhance retention in treatment programmes. On the other hand, providing care at less sophisticated levels in the health service or at community-level may decrease quality of care and result in worse health outcomes. To address these uncertainties, we summarised the research studies examining the risks and benefits of decentralising antiretroviral therapy service delivery.

Objectives: To assess the effects of various models that decentralised HIV treatment and care to more basic levels in the health system for initiating and maintaining antiretroviral therapy.

Search methods: We conducted a comprehensive search to identify all relevant studies regardless of language or publication status (published, unpublished, in press, and in progress) from 1 January 1996 to 31 March 2013, and contacted relevant organisations and researchers. The search terms included 'decentralisation', 'down referral', 'delivery of health care', and 'health services accessibility'.

Selection criteria: Our inclusion criteria were controlled trials (randomised and non-randomised), controlled-before and after studies, and cohorts (prospective and retrospective) in which HIV-infected people were either initiated on antiretroviral therapy or maintained on therapy in a decentralised setting in lower- and middle-income countries. We define decentralisation as providing treatment at a more basic level in the health system to the comparator.

Data collection and analysis: Two authors applied the inclusion criteria and extracted data independently. We designed a framework to describe different decentralisation strategies, and then grouped studies against these strategies. Data were pooled using random-effects meta-analysis. Because loss to follow up in HIV programmes is known to include some deaths, we used attrition as our primary outcome, defined as death plus loss to follow-up. We assessed evidence quality with GRADE methodology.

Main results: Sixteen studies met the inclusion criteria, all but one were from Africa, comprising two cluster randomised trials and 14 cohort studies. Antiretroviral therapy started at a hospital and maintained at a health centre (partial decentralisation) probably reduces attrition (RR 0.46, 95% CI 0.29 to 0.71, 4 studies, 39 090 patients, moderate quality evidence). There may be fewer patients lost to care with this model (RR 0.55, 95% CI 0.45 to 0.69, low quality evidence).We are uncertain whether there is a difference in attrition for antiretroviral therapy started and maintained at a health centre (full decentralisation) compared to a hospital at 12 months (RR 0.70, 95% CI 0.47 to 1.02; four studies, 56 360 patients, very low quality evidence), but there are probably fewer patients lost to care with this model (RR 0.3, 95% CI 0.17 to 0.54, moderate quality evidence). When antiretroviral maintenance therapy is delivered at home by trained volunteers, there is probably no difference in attrition at 12 months (RR 0.95, 95% CI 0.62 to 1.46, two trials, 1453 patients, moderate quality evidence).

Authors' conclusions: Decentralisation of HIV care aims to improve patient access and retention in care. Most data were from good quality cohort studies but confounding between site of treatment and outcomes cannot be excluded. Nevertheless, this review found that attrition appears to be lower in partial decentralisation models of treatment, where antiretrovirals were started at hospital and continued in the health centre; with antiretroviral drugs started and continued at health centres, no difference in attrition was detected, but there were fewer patients lost to care. For antiretroviral therapy provided at home by trained volunteers, no difference in outcomes was detected when compared to facility-based care.

Abstract   Full-text [free] access

Editor’s notes: As we aim to reach targets of 15 million people on ART by 2015, there is a great need to expand ART services and make them more accessible and to use models that can be scaled up given the constraints within the health sector. One approach is to decentralise care and provide follow up care to patients in health centres or at home. This is a systematic review of the impact of three models of decentralised care on patient attrition (the sum of lost to follow up and mortality) over time, with varying degree of transferring initiation and follow-up to peripheral service levels (from hospital to health centre or community base care). All three analyses showed that decentralised services are at least as good as more centralised approaches for patient retention; while the two health centre based models appear to significantly improve retention relative to a hospital based model. This provides important evidence the potential of decentralised ART to greatly expand treatment access, in particular to rural areas. 

Africa, Asia
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Disproportionately high HIV risk and gender disparity in prevalence among urban poor in Sub-Saharan Africa

The disproportionate high risk of HIV infection among the urban poor in sub-Saharan Africa.

Magadi MA. AIDS Behav. 2013 Jun;17(5):1645-54. doi: 10.1007/s10461-012-0217-y.

The link between HIV infection and poverty in sub-Saharan Africa (SSA) is rather complex and findings from previous studies remain inconsistent. While some argue that poverty increases vulnerability, existing empirical evidence largely support the view that wealthier men and women have higher prevalence of HIV. In this paper, we examine the association between HIV infection and urban poverty in SSA, paying particular attention to differences in risk factors of HIV infection between the urban poor and non-poor. The study is based on secondary analysis of data from the Demographic and Health Surveys from 20 countries in SSA, conducted during 2003-2008. We apply multilevel logistic regression models, allowing the urban poverty risk factor to vary across countries to establish the extent to which the observed patterns are generalizable across countries in the SSA region. The results reveal that the urban poor in SSA have significantly higher odds of HIV infection than urban non-poor counterparts, despite poverty being associated with a significantly lower risk among rural residents. Furthermore, the gender disparity in HIV infection (i.e. the disproportionate higher risk among women) is amplified among the urban poor. The paper confirms that the public health consequence of urban poverty that has been well documented in previous studies with respect to maternal and child health outcomes does apply to the risk of HIV infection. The positive association between household wealth and HIV prevalence observed in previous studies largely reflects the situation in the rural areas where the majority of the SSA populations reside.

Abstract   Full-text [free] access 

Editor’s notes: Evidence on the association between socio-economic position and HIV incidence in sub-Saharan Africa (SSA) has been mixed and appears to be changing over time. Although wealth was previously a predictor of HIV infection, it has recently been suggested that poverty is increasingly driving new infections in mature epidemics, especially in rural areas, where the majority of the population in SSA resides. With high rates of urbanisation both in SSA and globally (according to UNAIDS 2 of every 3 people living with HIV will be living in urban areas by 2030), this article provides important disaggregated evidence of the higher risk of HIV infection among the urban poor as well, and particularly among poor urban women. Even after controlling for sexual behaviour, the results suggest that other structural factors that characterise the environment, in which the urban poor live, such as unemployment, discrimination and violence, may be playing a key role. Interestingly, higher educational attainment was found to be associated with higher HIV risk among the urban poor, while it appeared to be protective among the better-off urban population. This may be pointing towards the ‘inverse equity hypothesis’, discussed in another paper this month (Hargreaves et al.), whereby groups with higher socio-economic position (wealth and/or education) are expected to benefit first from HIV/health interventions, thereby initially widening the gap in health outcomes until the poor catch up. 

Africa
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Identifying hotspots of HIV infection in sub-Saharan Africa

Mapping HIV clustering: a strategy for identifying populations at high risk of HIV infection in sub-Saharan Africa.

Cuadros DF, Awad SF, Abu-Raddad LJ. Int J Health Geogr. 2013 May 22;12:28.

Background: The geographical structure of an epidemic is ultimately a consequence of the drivers of the epidemic and the population susceptible to the infection. The know your epidemicconcept recognizes this geographical feature as a key element for identifying populations at higher risk of HIV infection where prevention interventions should be targeted. In an effort to clarify specific drivers of HIV transmission and identify priority populations for HIV prevention interventions, we conducted a comprehensive mapping of the spatial distribution of HIV infection across sub-Saharan Africa (SSA).

Methods: The main source of data for our study was the Demographic and Health Survey conducted in 20 countries from SSA. We identified and compared spatial clusters with high and low numbers of HIV infections in each country using Kulldorff spatial scan test. The test locates areas with higher and lower numbers of HIV infections than expected under spatial randomness. For each identified cluster, a likelihood ratio test was computed. A P-value was determined through Monte Carlo simulations to evaluate the statistical significance of each cluster.

Results: Our results suggest stark geographic variations in HIV transmission patterns within and across countries of SSA. About 14% of the population in SSA is located in areas of intense HIV epidemics. Meanwhile, another 16% of the population is located in areas of low HIV prevalence, where some behavioral or biological protective factors appear to have slowed HIV transmission.

Conclusions: Our study provides direct evidence for strong geographic clustering of HIV infection across SSA. This striking pattern of heterogeneity at the micro-geographical scale might reflect the fact that most HIV epidemics in the general population in SSA are not far from their epidemic threshold. Our findings identify priority geographic areas for HIV programming, and support the need for spatially targeted interventions in order to maximize the impact on the epidemic in SSA.

 Abstract   Full-text [free] access

Editor’s notes: This novel study used DHS data to map the clustering of HIV at a local level in 20 sub-Saharan African countries. The method identifies ‘hotspots’ and ‘cool spots’ of HIV infection within each country, mapping the results in a visually striking way.  The data show marked geographical variation within countries. For example, in Senegal, where overall prevalence is 0.75%, a hotspot with general population prevalence of 4.35% was identified. Conversely, within some countries with substantial HIV epidemics (Tanzania, Kenya, Malawi), the study identified settings with very low HIV prevalence. The authors present a ‘relative risk’ (ratio of HIV prevalence within the cluster to that outside the cluster) and, not surprisingly, find that this was higher in low prevalence countries.  It may also be interesting to see an absolute risk, and estimated excess number of cases. The authors hypothesize that the spatial variation may be less to do with variation in behavioural and biological factors than to the fact that HIV infection transmission in SSA is close to the epidemic (or sustainability) threshold – which means that small changes in risk factors can generate substantial changes in HIV prevalence. The implication of this is that, by focusing on the HIV ‘hotspots’, even modest intervention-driven changes in risk behaviour may have considerable impact in reducing HIV prevalence.

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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Adherence amongst perinatally-infected HIV positive adolescents in Rwanda challenged by a number of barriers that are heightened by stigma

Living Situation Affects Adherence to Combination Antiretroviral Therapy in HIV-Infected Adolescents in Rwanda: A Qualitative Study

Mutwa PR, Van Nuil JI, Asiimwe-Kateera B, Kestelyn E, Vyankandondera J, PoolR, Ruhirimbura J, Kanakuze C, Reiss P, Geelen S, van de Wijgert J, Boer KR.PLoS One 2013;8(4):e60073. doi: 10.1371/journal.pone.0060073. Epub 2013 Apr 3

Introduction:  Adherence to combination antiretroviral therapy (cART) is vital for HIV-infected adolescents for survival and quality of life. However, this age group faces many challenges to remain adherent. We used multiple data sources (role-play, focus group discussions (FGD), and in-depth interviews (IDI)) to better understand adherence barriers for Rwandan adolescents. Forty-two HIV positive adolescents (ages 12–21) and a selection of their primary caregivers were interviewed. All were perinatally-infected and received (cART) for 12 months. Topics discussed during FGDs and IDIs included learning HIV status, disclosure and stigma, care and treatment issues, cART adherence barriers.

Results: Median age was 17 years, 45% female, 45% orphaned, and 48% in boarding schools. We identified three overarching but inter-related themes that appeared to influence adherence. Stigma, perceived and experienced, and inadvertent disclosure of HIV status hampered adolescents from obtaining and taking their drugs, attending clinic visits, carrying their cARTs with them in public. The second major theme was the need for better support, in particular for adolescents with different living situations, (orphanages, foster-care, and boarding schools). Lack of privacy to keep and take medication came out as major barrier for adolescents living in congested households, as well the institutionalization of boarding schools where privacy is almost non-existent. The third important theme was the desire to be ‘normal’ and not be recognized as an HIV-infected individual, and to have a normal life not perturbed by taking a regimen of medications or being forced to disclose where others would treat them differently.

Conclusions: We propose better management of HIV-infected adolescents integrated into boarding school, orphanages, and foster care; training of school-faculty on how to support students and allow them privacy for taking their medications. To provide better care and support, HIV programs should stimulate caregivers of HIV-infected adolescents to join them for their clinic visits.

Abstract Full text [free] access

Editor’s notes: In Rwanda, there are large numbers of children living with HIV and on cART (combination ART). This raises concerns about maintaining adherence to life-long cART therapy. This is challenging in a region where treatment failure amongst children can be as high as 38%. Using qualitative methods including role-playing, focus group discussions and in depth interviews with adolescents attending  an HIV outpatient clinic and their caregivers, this study explored issues related to adherence to cART for adolescents, including those who live in orphanages or in boarding schools. The findings revealed that for these adolescents there were a number of important positive and negative issues in relation to adherence to cART including: the desire to be healthy, HIV stigma, disclosure and acceptance of HIV status, availability or lack of social support, isolation and depression, cART medication regimen demands, and lack of privacy in boarding school or orphanages. The adolescents highlighted that stigma impacts on the other barriers to adherence, such as disclosure of HIV status to others in the family or at the boarding school, depression, or lack of privacy. Interestingly, in this period of physical and psychological development, stigma affects their desire to be ‘normal’ that is being similar to their peers who are not living with HIV. However, for these HIV positive adolescents, feelings of being ‘normal’ are achieved if they are treated as ‘normal’ by those that know their status. Whilst this study is not alone in showing the importance of stigma in adherence to treatment, it adds a nuanced understanding of stigma for adolescents living with HIV, and how effective measures taken to address stigma can impact on other barriers to adherence for adolescents.

Africa
Rwanda
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Safe PrePex circumcision administered by nurses

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

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

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

Abstract Access

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

Africa
Rwanda
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