Articles tagged as "United Republic of Tanzania"

Late antiretroviral therapy start persists for children under two years of age in low- and middle-income countries

Immunodeficiency in children starting antiretroviral therapy in low-, middle-, and high-income countries.

Koller M, Patel K, Chi BH, Wools-Kaloustian K, Dicko F, Chokephaibulkit K, Chimbetete C, Avila D, Hazra R, Ayaya S, Leroy V, Truong HK, Egger M, Davies MA, IeDEA, NISDI, PHACS and IMPAACT 219C studies.  J Acquir Immune Defic Syndr. 2015 Jan 1;68(1):62-72. doi: 10.1097/QAI.0000000000000380.

Background: The CD4 cell count or percent (CD4%) at the start of combination antiretroviral therapy (cART) is an important prognostic factor in children starting therapy and an important indicator of program performance. We describe trends and determinants of CD4 measures at cART initiation in children from low-, middle-, and high-income countries.

Methods: We included children aged <16 years from clinics participating in a collaborative study spanning sub-Saharan Africa, Asia, Latin America, and the United States. Missing CD4 values at cART start were estimated through multiple imputation. Severe immunodeficiency was defined according to World Health Organization criteria. Analyses used generalized additive mixed models adjusted for age, country, and calendar year.

Results: A total of 34 706 children from 9 low-income, 6 lower middle-income, 4 upper middle-income countries, and 1 high-income country (United States) were included; 20 624 children (59%) had severe immunodeficiency. In low-income countries, the estimated prevalence of children starting cART with severe immunodeficiency declined from 76% in 2004 to 63% in 2010. Corresponding figures for lower middle-income countries were from 77% to 66% and for upper middle-income countries from 75% to 58%. In the United States, the percentage decreased from 42% to 19% during the period 1996 to 2006. In low- and middle-income countries, infants and children aged 12-15 years had the highest prevalence of severe immunodeficiency at cART initiation.

Conclusions: Despite progress in most low- and middle-income countries, many children continue to start cART with severe immunodeficiency. Early diagnosis and treatment of HIV-infected children to prevent morbidity and mortality associated with immunodeficiency must remain a global public health priority.

Abstract access 

Editor’s notes: This article describes trends and determinants of CD4 cell measures at antiretroviral therapy (ART) initiation in about 35 000 children in low, middle, and high-income countries. Temporal trends in CD4 measures at ART initiation are a useful indicator of the health system’s ability to identify and treat eligible children in a timely fashion. They are also a useful measure of responsiveness to guideline changes.

Previous WHO guidelines recommended early ART initiation, regardless of immunologic or clinical thresholds. But the authors found that in 2010, approximately two-thirds of children below two years of age, in low- and middle-income countries were still starting ART with severe immunodeficiency.

Delayed country-level implementation of WHO guidelines, poor access to early infant diagnosis, slow turn-around time of test results, and limited ART availability for infants and young children are all contributing factors to this delayed ART initiation. The authors point out that timely diagnosis of paediatric HIV does not necessarily result in timely ART. The main reasons for this diagnosis to treatment gap include HIV diagnostic tests and paediatric ART being located at separate sites without robust referral mechanisms between services. There are challenges with CD4 measurement to determine eligibility. These include access to tests, turn-around time and interpretation of results and health care worker discomfort with treating children.

Currently, only 22% of children living with HIV in sub-Saharan Africa are receiving ART. To decrease the treatment gap among children, WHO 2013 guidelines recommend universal ART for all children living with HIV, aged below five years of age, irrespective of CD4 count or clinical stage. Removing the requirement for a CD4 measurement also removes the time lag while waiting for CD4 results. Thus the guidelines aim both to increase treatment accessibility and to accelerate treatment initiation for all children. 

HIV Treatment
Africa, Asia, Northern America
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Keeping adolescent girls in HIV prevention clinical trials: a focus on the effects of domestic violence

Domestic violence among adolescents in HIV prevention research in Tanzania: participant experiences and measurement issues.

Baumgartner JN, Kaaya S, Karungula H, Kaale A, Headley J, Tolley E. Matern Child Health J. 2015 Jan;19(1):33-9. doi: 10.1007/s10995-014-1492-1.

Under-representation of female adolescents in HIV clinical trials may inhibit their access to future prevention technologies. Domestic violence, broadly defined as violence perpetrated by intimate partners and/or family members, may affect trial participation. This study describes violence in the lives of adolescents and young women in Tanzania, explores use of the Women's Experience with Battering (WEB) Scale to measure battering, and examines the associations between battering and socio-demographic and HIV risk factors. Community formative research (CFR) and a mock clinical trial (MCT) were conducted to examine the challenges of recruiting younger (15-17) versus older (18-21) participants into HIV prevention trials. The CFR included qualitative interviews with 23 participants and there were 135 MCT participants. The WEB was administered in both the CFR and MCT. Nineteen CFR participants experienced physical and/or sexual violence and 17 % scored positive for battering. All married participants reported partner-related domestic violence, and half scored positive for battering. Many believed beatings were normal. None of the single participants scored positive on battering, but one-third reported abuse by relatives. Among MCT participants, 15 % scored positive for battering; most perpetrators were relatives. Younger participants were more likely to report battering. Adolescents experienced high rates of domestic violence and the WEB captured battering from both partners and relatives. The level of familial violence was unexpected and has implications for parental roles in study recruitment. Addressing adolescent abuse in HIV prevention trials and in the general population should be a public health priority.

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Editor’s notes: Despite their heightened HIV vulnerability, adolescent girls are under-represented in clinical trials on HIV prevention technologies. Domestic violence is a known HIV risk factor for adolescent girls and the authors posit that it may also be a barrier to their participation in clinical trials. This lack of participation may in turn inhibit their access to future prevention technologies. This paper contributes both methodological insights about the measures that can be applied in low-income settings to screen for domestic violence and substantive evidence about the high rates of familial as well as partner associated violence and battering among this group.

The paper draws on data from a larger study conducted in the United Republic of Tanzania which examined recruitment and retention of adolescent girls, aged 15-21 years, in HIV prevention trials. The paper examines the prevalence and type of domestic violence among this group and the capacity of the Women’s Experience with Battering (WEB) scale to measure this. Although the WEB scale has not been used in low income countries before, the authors report that it may have considerable value in identifying exposure to domestic violence and battering among trial participants. Certain adaptations may be necessary, to identify women who are subject to violence and battering but do no report being afraid of the perpetrator. The qualitative study component suggests that this may reflect how beatings are considered a normal aspect of intimate and familial relations. Although this assessment tool is likely to be able to inform trial retention initiatives, the adolescent girls need to be able to participate in these trials. So the use of the scale appears to be limited in its contribution to improving initial recruitment into trials.

The levels of familial battering were higher than expected. This is likely to have implications for parental roles in research and contributes to the ethical concerns of relying on parental consent in HIV prevention trials rather than pursuing the route of autonomy in consenting. This is illustrated by the study itself requiring parental consent for girls aged 15 years.  This paper’s focus was on how to address the under-representation of adolescent girls in HIV prevention trials. Further, it provides valuable evidence on the high rates of exposure of adolescent girls to domestic violence from partners and their relatives. This evidence contributes to the call for greater attention to adolescent domestic violence in global health. 

Africa
United Republic of Tanzania
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More research is needed for understanding predictors of internalized stigma among people living with HIV

Predictors of internalised HIV-related stigma: a systematic review of studies in sub-Saharan Africa.

Pantelic M, Shenderovich Y, Cluver L, Boyes M. Health Psychol Rev. 2015 Jan 3:1-45. [Epub ahead of print]

Objective: This systematic review aims to synthesize evidence on predictors of internalised HIV stigma amongst people living with HIV in sub-Saharan Africa.

Method: PRISMA guidelines were used. Studies were identified through electronic databases, grey literature, reference harvesting and contacts with key researchers. Quality of findings was assessed through an adapted version of the Cambridge Quality Checklists.

Results: A total of 590 potentially relevant titles were identified. Seventeen peer-reviewed articles and one draft book chapter were included. Studies investigated socio-demographic, HIV-related, intra-personal and inter-personal correlates of internalised stigma. Eleven articles used cross-sectional data, six articles used prospective cohort data and one used both prospective cohort and cross-sectional data to assess correlates of internalised stigma. Poor HIV-related health weakly predicted increases in internalized HIV stigma in three longitudinal studies. Lower depression scores and improvements in overall mental health predicted reductions in internalized HIV stigma in two longitudinal studies, with moderate and weak effects respectively. No other consistent predictors were found.

Conclusion: Studies utilizing analysis of change and accounting for confounding factors are necessary to guide policy and programming but are scarce. High-risk populations, other stigma markers that might layer upon internalised stigma, and structural drivers of internalised stigma need to be examined.

Abstract access 

Editor’s notes: Internalized stigma can act as a barrier to HIV prevention and treatment. It can occur when a person living with HIV endorses negative attitudes associated with HIV and accepts these attitudes as applicable to themselves. Few stigma reduction programmes exist for people living with HIV. However, two recent studies have illustrated that internalized stigma reduction may be feasible through programmes targeting individual level factors. This paper systematically reviewed the evidence on predictors of internalized stigma among people living with HIV. The review included 18 papers looking at 13 unique studies in South Africa, Lesotho, Malawi, United Republic of Tanzania, Swaziland, Mozambique, Uganda, Kenya and Burkina Faso. All included studies were observational including prospective cohort and cross-sectional study designs. In all studies, participants were recruited through health facilities. Most included studies did not report on sampling methods.

All included studies defined internalized stigma as a negative self-perception due to HIV status and the resultant feelings of shame, difficulties around disclosure and self-exclusion. Only one study looked at the effect of antiretroviral therapy (ART) use on internalized stigma and found no evidence of an association. There was weak evidence across three studies that improved physical health (measured as improved physical functioning and fewer HIV-associated symptoms) lead to reductions in internalized HIV stigma. Two studies found some evidence that lower depression scores and improvements in overall mental health predicted reductions in internalized HIV stigma. There were inconsistent findings on whether time on ART had any association with internalized stigma. No other associations with socio-demographic or interpersonal factors were found. This is a field of new and emerging research and no implications for practice can be drawn given the inconsistent findings across studies. The cross-sectional nature of most of the included studies means that it is not possible to assess long-term associations. Further research is needed to understand the factors associated with internalized stigma and how these might change over time. Future research should use rigorous study methods and should focus on key populations, HIV transmission, and structural drivers of HIV.

Africa
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Increasing transmitted resistance to antiretroviral therapy in low/middle-income countries - highest prevalence in MSM

Global burden of transmitted HIV drug resistance and HIV-exposure categories: a systematic review and meta-analysis.

Pham QD, Wilson DP, Law MG, Kelleher AD, Zhang L. AIDS. 2014 Nov 28;28(18):2751-62. doi: 10.1097/QAD.0000000000000494.

Objectives: Our aim was to review the global disparities of transmitted HIV drug resistance (TDR) in antiretroviral-naive MSM, people who inject drugs (PWID) and heterosexual populations in both high-income and low/middle-income countries.

Design/methods: We undertook a systematic review of the peer-reviewed English literature on TDR (1999-2013). Random-effects meta-analyses were performed to pool TDR prevalence and compare the odds of TDR across at-risk groups.

Results: A total of 212 studies were included in this review. Areas with greatest TDR prevalence were North America (MSM: 13.7%, PWID: 9.1%, heterosexuals: 10.5%); followed by western Europe (MSM: 11.0%, PWID: 5.7%, heterosexuals: 6.9%) and South America (MSM: 8.3%, PWID: 13.5%, heterosexuals: 7.5%). Our data indicated disproportionately high TDR burdens in MSM in Oceania (Australia 15.5%), eastern Europe/central Asia (10.2%) and east Asia (7.8%). TDR epidemics have stabilized in high-income countries, with a higher prevalence (range 10.9-12.6%) in MSM than in PWID (5.2-8.3%) and heterosexuals (6.4-9.0%) over 1999-2013. In low/middle-income countries, TDR prevalence in all at-risk groups in 2009-2013 almost doubled than that in 2004-2008 (MSM: 7.8 vs. 4.2%, P = 0.011; heterosexuals: 4.1 vs. 2.6%, P < 0.001; PWID: 4.8 vs. 2.4%, P = 0.265, respectively). The risk of TDR infection was significantly greater in MSM than that in heterosexuals and PWID. We observed increasing trends of resistance to non-nucleoside reverse transcriptase and protease inhibitors among MSM.

Conclusion: TDR prevalence is stabilizing in high-income countries, but increasing in low/middle-income countries. This is likely due to the low, but increasing, coverage of antiretroviral therapy in these settings. Transmission of TDR is most prevalent among MSM worldwide.

Abstract access 

Editor’s notes: HIV mutates very rapidly, and many early antiretroviral agents had a low genetic barrier to the development of resistance. Thus the emergence of virus resistant to antiretroviral agents, particularly to early drug classes, was inevitable. Surveillance for drug-resistant virus among people with no prior history of taking antiretroviral drugs (transmitted drug resistance) is essential to monitor the spread of drug resistance at population level.

This systematic review aimed to compare transmitted drug resistance in different geographical regions and between subpopulations of HIV-positive people by likely route of transmission. Transmitted resistance was most prevalent in high income settings. This is not surprising given wide use of suboptimal drug regimens before effective triple therapy was available. Reassuringly, the prevalence of transmitted resistance seems to have stabilised in high-income settings. The increase in transmitted resistance in low and middle income countries is of more concern. It is not surprising, given that first-line regimens comprising two nucleoside reverse transcriptase inhibitors and a non-nucleoside reverse transcriptase inhibitor are vulnerable to the development of resistance if the drug supply is interrupted or adherence is suboptimal. In addition, if viral load monitoring is not available, people remain on failing drug regimens for longer, and thus have more risk of transmitting resistant virus.

Within the subpopulations examined in this review, transmitted resistance was consistently higher in men who have sex with men, suggesting that resistance testing prior to treatment is particularly valuable for this population.

Limitations of the review include exclusion of studies that did not compare transmitted resistance between the specified subpopulations, and small sample size in many subgroups.

Continued surveillance for transmitted drug resistance is critical. This is most important in settings where individualised resistance testing is not available. This will ensure that people starting antiretroviral therapy receive treatment that will suppress their viral load effectively. Wider use of viral load monitoring, combined with access to effective second and third line regimens, will also help limit spread of drug resistance.

HIV Treatment
Angola, Argentina, Australia, Austria, Belgium, Benin, Botswana, Brazil, Burkina Faso, Cambodia, Cameroon, Canada, Central African Republic, Chad, China, Côte d'Ivoire, Croatia, Cuba, Cyprus, Denmark, Dominican Republic, El Salvador, Estonia, Ethiopia, France, Gabon, Georgia, Germany, Greece, Guatemala, Honduras, Hong Kong Special Administrative Region of China, Hungary, India, Indonesia, Ireland, Israel, Italy, Japan, Kazakhstan, Kenya, Latvia, Malawi, Malaysia, Moldova, Mozambique, Netherlands, Peru, Philippines, Poland, Portugal, Republic of Korea, Romania, Russia, Rwanda, Slovenia, South Africa, Spain, Swaziland, Sweden, Switzerland, Taiwan, Thailand, Uganda, United Kingdom of Great Britain and Northern Ireland, United Republic of Tanzania, United States of America, Viet Nam, Zambia, Zimbabwe
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Reductions in risk taking behaviour among people who inject drugs in Zanzibar – but levels still high

HIV prevalence and risk behaviors among people who inject drugs in two serial cross-sectional respondent-driven sampling surveys, Zanzibar 2007 and 2012

Matiko E, Khatib A, Khalid F, Welty S, Said C, Ali A, Othman A, Haji S, Kibona M, Kim E, Broz D, Dahoma M.AIDS Behav. 2014 Nov 16. [Epub ahead of print]

People who inject drugs (PWID) are at higher risk of acquiring HIV due to risky injection and sexual practices. We measured HIV prevalence and behaviors related to acquisition and transmission risk at two time points (2007 and 2012) in Zanzibar, Tanzania. We conducted two rounds of behavioral and biological surveillance among PWID using respondent-driven sampling, recruiting 499 and 408 PWID, respectively. Through face to- face interviews, we collected information on demographics as well as sexual and injection practices. We obtained blood samples for biological testing. We analysed data using RDSAT and exported weights into STATA for multivariate analysis. HIV prevalence among sampled PWID in Zanzibar was 16.0% in 2007 and 11.3% in 2012; 73.2% had injected drugs for 7 years or more in 2007, while in the 2012 sample this proportion was 36.9%. In 2007, 53.6% reported having shared a needle in the past month, while in the 2012 sample, 29.1% reported having done so. While 13.3% of PWID in 2007 reported having been tested for HIV infection and received results in the past year, this proportion was 38.0% in 2012. Duration of injection drug use for 5 years or more was associated with higher odds of HIV infection in both samples. HIV prevalence and indicators of risk and preventive behaviors among PWID in Zanzibar were generally more favorable in 2012 compared to 2007—a period marked by the scale-up of prevention programs focusing on PWID. While encouraging, causal interpretation needs to be cautious and consider possible sample differences in these two cross sectional surveys. HIV prevalence and related risk behaviors persist at levels warranting sustained and enhanced efforts of primary prevention and harm reduction.

Abstract access 

Editor’s notes: People who inject drugs (PWID) are a marginalized or key population in Africa, and throughout the world. They suffer from disproportionately high rates of HIV infection and other diseases. Like other key populations such as sex workers, the criminalization of PWID makes it difficult to provide specialized services. Members of this community are often fearful of programmes which might identify them. This dynamic causes viruses such as HIV to go undetected and unmanaged. This is evidenced by the difference in HIV prevalence through this study in Zanzibar, United Republic of Tanzania between the general population at 1% and the rates in PWID at 16.0% and 11.3% in 2007 and 2012 respectively. Although the study highlighted where HIV prevalence might be reducing and behaviours such as HIV testing might be improving, multi-person use of contaminated injecting equipment went slightly up. These data are confounded by the fact that it is unclear whether the same segment of the population was surveyed, and by the fact that so few females participated. Issues with recruitment shed light on how difficult it can be to reach these communities. This can usually be attributed to criminalization and distrust, but also to mobility and the lack of engagement generally of governments and local health programmes in acknowledging the need to address and support the specialized needs of PWID communities. To date, there has been little recognition of injection drug use in Africa and the related health needs of these communities, which can vary depending on context and country. Studies such as this one, even with the limitations of recruitment and comparability of samples, should be undertaken more often and with in-depth qualitative components, as mentioned by the authors, to further explore how these communities might be accessed and their needs addressed.

Africa
United Republic of Tanzania
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Which activities promote adherence to antiretroviral therapy?

Interventions to promote adherence to antiretroviral therapy in Africa: a network meta-analysis.

Mills EJ, Lester R, Thorlund K, Lorenzi M, Muldoon K, Kanters S, Linnemayr S, Gross R, Calderon Y, Amico KR, Thirumurthy H, Pearson C, Remien RH, Mbuagbaw L, Thabane L, Chung MH, Wilson IB, Liu A, Uthman OA, Simoni J, Bangsberg D, Yaya S, Bärnighausen T, Ford N, Nachega JB, Lancet HIV 2014; 1: e104–11 doi:10.1016/S2352-3018(14)00003-4.

Background: Adherence to antiretroviral therapy (ART) is necessary for the improvement of the health of patients and for public health. We sought to determine the comparative effectiveness of different interventions for improving ART adherence in HIV-infected people living in Africa.

Methods: We searched for randomised trials of interventions to promote antiretroviral adherence within adults in Africa. We searched AMED, CINAHL, Embase, Medline (via PubMed), and ClinicalTrials.gov from inception to Oct 31, 2014, with the terms “HIV”, “ART”, “adherence”, and “Africa”. We created a network of the interventions by pooling the published and individual patients' data for comparable treatments and comparing them across the individual interventions with Bayesian network meta-analyses. The primary outcome was adherence defined as the proportion of patients meeting trial defined criteria; the secondary endpoint was viral suppression.

Findings: We obtained data for 14 randomised controlled trials, with 7110 patients. Interventions included daily and weekly short message service (SMS; text message) messaging, calendars, peer supporters, alarms, counselling, and basic and enhanced standard of care (SOC). Compared with SOC, we found distinguishable improvement in self-reported adherence with enhanced SOC (odds ratio [OR] 1·46, 95% credibility interval [CrI] 1·06–1·98), weekly SMS messages (1·65, 1·25–2·18), counselling and SMS combined (2·07, 1·22–3·53), and treatment supporters (1·83, 1·36–2·45). We found no compelling evidence for the remaining interventions.

Results: were similar when using viral suppression as an outcome, although the network contained less evidence than that for adherence. Treatment supporters with enhanced SOC (1·46, 1·09–1·97) and weekly SMS messages (1·55, 1·01–2·38) were significantly better than basic SOC.

Interpretation: Several recommendations for improving adherence are unsupported by the available evidence. These findings can inform future intervention choices for improving ART adherence in low-income settings.

Abstract access 

Editor’s notes: To maximise the impact of antiretroviral therapy (ART), people living with HIV should be diagnosed early, enrolled and retained in pre-ART care, initiated on ART and retained in ART care. Long-term adherence to achieve and maintain viral load suppression is the last step in the continuum of HIV care. Engagement along the complete treatment cascade will determine the long-term success of the global response to HIV.

A large number of potential programmes aimed at the improvement of engagement with care are available. While there is an urgent need for research on these programmes and on the effect of combined programmes, there is also the reality of a resource constrained environment. Network meta-analysis is a method to synthesise the evidence of programmes. The meta-analysis uses common comparators when these activities have not been compared head-to-head (resulting in indirect evidence), combined with evidence from head-to-head comparisons (direct evidence).

Using a network meta-analysis of randomized trials of programmes to improve ART adherence in Africa, the authors simultaneously compared eight groups of activities against standard care and against each other. The authors found that standard care augmented with intensified adherence counselling, or enhanced standard care, improved adherence to ART. Also weekly SMS messages, enhanced standard care combined with SMS, and enhanced standard care combined with having a treatment supporter were superior to standard care, with regards to self-reported adherence and viral suppression. The authors speculate that combinations of cognitive and behavioural programmes maximise the activity efficacy. Interestingly, their study found a large benefit for weekly but not for daily SMS messages. However the heterogeneity in the published treatment effects could be attributed to heterogeneity of the implemented programmes, especially of behavioural interventions. For example, the authors point out that there is a wide variability in the definition of standard care, and in the definition of treatment supporters.

The authors also note that several recommendations for improving adherence are unsupported by the evidence they examined using network meta-analysis.

Health care delivery
Africa
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Antiretroviral therapy alone not enough to reduce TB incidence where HIV- and TB- prevalence is high

Incidence of HIV-associated tuberculosis among individuals taking combination antiretroviral therapy: a systematic review and meta-analysis.

Kufa T, Mabuto T, Muchiri E, Charalambous S, Rosillon D, Churchyard G, Harris RC. PLoS One. 2014 Nov 13;9(11):e111209. doi: 10.1371/journal.pone.0111209. eCollection 2014.

Background: Knowledge of tuberculosis incidence and associated factors is required for the development and evaluation of strategies to reduce the burden of HIV-associated tuberculosis.

Methods: Systematic literature review and meta-analysis of tuberculosis incidence rates among HIV-infected individuals taking combination antiretroviral therapy.

Results: From PubMed, EMBASE and Global Index Medicus databases, 42 papers describing 43 cohorts (32 from high/intermediate and 11 from low tuberculosis burden settings) were included in the qualitative review and 33 in the quantitative review. Cohorts from high/intermediate burden settings were smaller in size, had lower median CD4 cell counts at study entry and fewer person-years of follow up. Tuberculosis incidence rates were higher in studies from sub-Saharan Africa and from World Bank low/middle income countries. Tuberculosis incidence rates decreased with increasing CD4 count at study entry and duration on combination antiretroviral therapy. Summary estimates of tuberculosis incidence among individuals on combination antiretroviral therapy were higher for cohorts from high/intermediate burden settings compared to those from the low tuberculosis burden settings (4.17 per 100 person-years [95% Confidence Interval (CI) 3.39-5.14 per 100 person-years] vs. 0.4 per 100 person-years [95% CI 0.23-0.69 per 100 person-years]) with significant heterogeneity observed between the studies.

Conclusions: Tuberculosis incidence rates were high among individuals on combination antiretroviral therapy in high/intermediate burden settings. Interventions to prevent tuberculosis in this population should address geographical, socioeconomic and individual factors such as low CD4 counts and prior history of tuberculosis.

Abstract Full-text [free] access

Editor’s notes: This systematic review and meta-analysis looks at tuberculosis (TB) incidence rates among adults living with HIV on antiretroviral treatment (ART). The review reinforces and quantifies what we already know about the disparities between low-burden and high-burden settings. TB incidence rates in high and intermediate burden settings are ten times higher than those in low burden settings.

The authors draw attention to the need for implementation of programmes that address the social determinants of TB. Low socio-economic conditions are associated with higher TB incidence rates in individuals on ART. Interestingly, the meta-analysis found that TB incidence rates were higher among individuals on ART who had a previous history of TB, than individuals who did not have a history of previous TB. The epidemiological association between previous TB treatment and active TB was one of the foundations for the emphasis on case retention and cure rates with the Directly Observed Treatment, Short-Course (DOTS) strategy. Yet prevalence surveys conducted in Zimbabwe, South Africa and Zambia in the pre-ART and early ART era did not find an association between a history of previous TB and prevalent active undiagnosed TB in individuals living with HIV. The finding from this meta-analysis suggests that individuals on ART are now surviving long enough to develop recurrent TB disease.

The overall message of the study is that ART alone is not sufficient to reduce TB incidence in high HIV prevalence settings. Additional strategies are required to prevent TB focussing on individuals with low CD4 counts, a history of previous TB disease and people who have recently initiated ART.

Avoid TB deaths
Africa, Asia, Europe, Northern America
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Why pregnant women and mothers living with HIV do not access, or do not stay in care

A systematic review of individual and contextual factors affecting ART initiation, adherence, and retention for HIV-infected pregnant and postpartum women.

Hodgson I, Plummer ML, Konopka SN, Colvin CJ, Jonas E, Albertini J, Amzel A, Fogg KP. PLoS One. 2014 Nov 5;9(11):e111421. doi: 10.1371/journal.pone.0111421. eCollection 2014.

Background: Despite progress reducing maternal mortality, HIV-related maternal deaths remain high, accounting, for example, for up to 24 percent of all pregnancy-related deaths in sub-Saharan Africa. Antiretroviral therapy (ART) is effective in improving outcomes among HIV-infected pregnant and postpartum women, yet rates of initiation, adherence, and retention remain low. This systematic literature review synthesized evidence about individual and contextual factors affecting ART use among HIV-infected pregnant and postpartum women.

Methods: Searches were conducted for studies addressing the population (HIV-infected pregnant and postpartum women), intervention (ART), and outcomes of interest (initiation, adherence, and retention). Quantitative and qualitative studies published in English since January 2008 were included. Individual and contextual enablers and barriers to ART use were extracted and organized thematically within a framework of individual, interpersonal, community, and structural categories.

Results: Thirty-four studies were included in the review. Individual-level factors included both those within and outside a woman's awareness and control (e.g., commitment to child's health or age). Individual-level barriers included poor understanding of HIV, ART, and prevention of mother-to-child transmission, and difficulty managing practical demands of ART. At an interpersonal level, disclosure to a spouse and spousal involvement in treatment were associated with improved initiation, adherence, and retention. Fear of negative consequences was a barrier to disclosure. At a community level, stigma was a major barrier. Key structural barriers and enablers were related to health system use and engagement, including access to services and health worker attitudes.

Conclusions: To be successful, programs seeking to expand access to and continued use of ART by integrating maternal health and HIV services must identify and address the relevant barriers and enablers in their own context that are described in this review. Further research on this population, including those who drop out of or never access health services, is needed to inform effective implementation.

Abstract Full-text [free] access

Editor’s notes: This systematic review is one of three by the same team, related to HIV and maternal mortality. The review findings illustrate that the individual and contextual factors which affect antiretroviral therapy (ART) initiation, adherence and retention for pregnant/postpartum women living with HIV are numerous. Fears over disclosure, and consequent stigma and discrimination feature in many of the studies reviewed. Practical barriers might be overcome, by making services more accessible. The lack of knowledge about HIV and treatment among some women may be addressed through information campaigns. However, the fear of negative consequences as a result of disclosure, even to health workers, presents significant barriers to care. This is something that is of particular note as Option B+ is rolled out. An important strength of this review is the combination of qualitative and quantitative studies. The meticulous description of the approach to the review is also welcome. The authors’ call for ‘consistent, standardised and appropriate measures of adherence and retention’ with a ‘longitudinal component’, is a valuable suggestion as the performance of countries in providing Option B+ begins to be compared.

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Tensions between the role of motherhood and the role of sex worker

'If you have children, you have responsibilities': motherhood, sex work and HIV in southern Tanzania.

Beckham SW, Shembilu CR, Winch PJ, Beyrer C, Kerrigan DL. Cult Health Sex. 2014 Oct 1:1-15. [Epub ahead of print]

Many female sex workers begin sex work as mothers, or because they are mothers, and others seek childbearing. Motherhood may influence women's livelihoods as sex workers and their subsequent HIV risks. We used qualitative research methods (30 in-depth interviews and three focus group discussions) and employed Connell's theory of Gender and Power to explore the intersections between motherhood, sex work, and HIV-related risk. Participants were adult women who self-reported exchanging sex for money within the past month and worked in entertainment venues in southern Tanzania. Participants had two children on average, and two-thirds had children at home. Women situated their socially stigmatised work within their respectable identities as mothers caring for their children. Being mothers affected sex workers' negotiating power in complex manners, which led to both reported increases in HIV-related risk behaviours (accepting more clients, accepting more money for no condom, anal sex), and decreases in risk behaviours (using condoms, demanding condom use, testing for HIV). Sex workers/mothers were aware of risks at work, but with children to support, their choices were constrained. Future policies and programming should consider sex workers' financial and practical needs as mothers, including those related to their children such as school fees and childcare.

Abstract access 

 Editor’s notes: This important research sought to understand how sex workers negotiate this identity alongside their identity as mothers. Sex workers in sub-Saharan Africa have a greater risk of acquiring HIV than the general population. Many of these women are mothers. The authors conducted qualitative research with sex workers in southern Tanzania and using Cornell’s theory of Gender and Power as a theoretical frame, explored the intersections between motherhood, sex work and HIV related risk behaviours. This theory outlines four structures of gender: labour, power, emotional, and symbolic relations. Their analysis revealed three key themes. These included motherhood/respectability versus sex work/stigma; for the children; and motherhood/power, and HIV risk. The first theme highlights how for these women that motherhood denotes respect in contrast to the stigma evoked by sex work. Thus women often emphasised their role as mothers over that as sex workers. The second theme emphasised that for these women the ideal mother has the financial support of a husband and their role is to care for their children. However, as many of these women were unable to rely on partners, sex work enabled them to care for their children and ensure their well-being. The third theme, revealed a contradiction. Being a mother could either empower their role as a sex worker, drawing on this respectability and enabling them to negotiate higher payments from clients; or seeking higher payments for risky sexual acts such as anal sex or sex without a condom to ensure the well-being of their children. The authors conclude that in relation to Cornell’s theory these women are compromised in terms of labour both as mothers and as stigmatised sex workers and this is also related to lack of power in both of these areas. In emotional relations, women’s bond with their children is highly important and drove their need to earn money through sex work. Further, in terms of symbolic relations women used the role of motherhood to ensure their dignity and respect.

Africa
United Republic of Tanzania
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Integration of HIV testing into cervical cancer screening requires overcoming commodity supply challenges

Integrating HIV testing into cervical cancer screening in Tanzania: an analysis of routine service delivery statistics.

Plotkin M, Besana GV, Yuma S, Kim YM, Kulindwa Y, Kabole F, Lu E, Giattas MR. BMC Womens Health 2014 Sept 30: 14:120: doi:10.1186/1472-6874-14-120

Background: While the lifetime risk of developing cervical cancer (CaCx) and acquiring HIV is high for women in Tanzania, most women have not tested for HIV in the past year and most have never been screened for CaCx. Good management of both diseases, which have a synergistic relationship, requires integrated screening, prevention, and treatment services. The aim of this analysis is to assess the acceptability, feasibility and effectiveness of integrating HIV testing into CaCx prevention services in Tanzania, so as to inform scale-up strategies.

Methods: We analysed 2010-2013 service delivery data from 21 government health facilities in four regions of the country, to examine integration of HIV testing within newly introduced CaCx screening and treatment services, located in the reproductive and child health (RCH) section of the facility. Analysis included the proportion of clients offered and accepting the HIV test, reasons why testing was not offered or was declined, and HIV status of CaCx screening clients.

Results: A total of 24 966 women were screened for CaCx; of these, approximately one-quarter (26%) were referred in from HIV care and treatment clinics. Among the women of unknown HIV status (n = 18 539), 60% were offered an HIV test. The proportion of women offered an HIV test varied over time, but showed a trend of decline as the program expanded. Unavailability of HIV test kits at the facility was the most common reason for a CaCx screening client not to be offered an HIV test (71% of 6 321 cases). Almost all women offered (94%) accepted testing, and 5% of those tested (582 women) learned for the first time that they were HIV-positive.

Conclusion: Integrating HIV testing into CaCx screening services was highly acceptable to clients and was an effective means of reaching HIV-positive women who did not know their status; effectiveness was limited, however, by shortages of HIV test kits at facilities. Integration of HIV testing into CaCx screening services should be prioritized in HIV-endemic settings, but more work is needed to eliminate logistical barriers. The coverage of CaCx screening among HIV care and treatment-enrolled women in Tanzania may be low and should be examined.

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Editor’s notes: This study discusses the integration of HIV testing into cervical cancer screening services in government health facilities in Tanzania, over a period of four years. The authors examined the acceptability (expressed as the acceptance of the HIV test by clients) and effectiveness (expressed as the number and proportion of women being offered an HIV test) of this approach.

Almost all women accepted testing, some 94%, but among the women of unknown HIV status only 60% were offered an HIV test. Insufficient supply of HIV test kits at health facilities together with a shortage of health care providers was the biggest challenge, limiting the effectiveness of the programme.

Due to their increased risk of cervical cancer, women in HIV care should be accessing screening services. However, data from this study suggested that integration in this direction was not as effective. The proportion of women in HIV care and treatment centres screened for cervical cancer varied between three percent and 46%. 

This study also demonstrates that data collected routinely as part of service delivery can be valuable for research purposes, especially when steps have been taken to strengthen the health information management system.

HIV testing
Africa
United Republic of Tanzania
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