Articles tagged as "Zambia"

Reproductive rights of women living with HIV

Community attitudes towards childbearing and abortion among HIV-positive women in Nigeria and Zambia.

Kavanaugh ML, Moore AM, Akinyemi O, Adewole I, Dzekedzeke K, Awolude O, Arulogun O. Cult Health Sex. 2013 Feb;15(2):160-74. doi: 10.1080/13691058.2012.745271. Epub 2012 Nov 23

Although stigma towards HIV-positive women for both continuing and terminating a pregnancy has been documented, to date few studies have examined relative stigma towards one outcome versus the other. This study seeks to describe community attitudes towards each of two possible elective outcomes of an HIV-positive woman's pregnancy - induced abortion or birth - to determine which garners more stigma and document characteristics of community members associated with stigmatising attitudes towards each outcome. Data come from community-based interviews with reproductive-aged men and women, 2401 in Zambia and 2452 in Nigeria. Bivariate and multivariate analyses revealed that respondents from both countries overwhelmingly favoured continued childbearing for HIV-positive pregnant women, but support for induced abortion was slightly higher in scenarios in which anti-retroviral therapy (ART) was unavailable. Zambian respondents held more stigmatising attitudes towards abortion for HIV-positive women than did Nigerian respondents. Women held more stigmatising attitudes towards abortion for HIV-positive women than men, particularly in Zambia. From a sexual and reproductive health and rights perspective, efforts to assist HIV-positive women in preventing unintended pregnancy and to support them in their pregnancy decisions when they do become pregnant should be encouraged in order to combat the social stigma documented in this paper.

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Editor’s notes: Women’s rights to make reproductive health choices extend fully to women living with HIV. The World Health Organization (WHO), the Joint United Nations Programme on HIV/AIDS (UNAIDS), and the Office of the High Commissioner on Human Rights (OHCHR) all affirm the reproductive rights of HIV-positive individuals to choose between continuing and terminating a pregnancy, calling for access to safe abortion services in countries where it is legal for individuals who choose the latter option. This study primarily focused on attitudes towards continued childbearing versus induced abortion in two relatively high prevalence countries, in particular in contexts where induced abortion is not generally viewed favorably. However it does reflect the continued interest overall in childbearing regardless of HIV status for many women. Interestingly, the findings also indicated greater favorability towards a continuation of pregnancy for women on ART – perhaps reflecting a growing understanding that effective PMTCT interventions significantly lower the risk of vertical HIV transmission.

Nigeria, Zambia
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HIV care in resource limited settings: not just a matter of drugs

Clinic-Based Food Assistance is Associated with Increased Medication Adherence among HIV-Infected Adults on Long-Term Antiretroviral Therapy in Zambia.

Tirivayi N, Koethe JR, Groot W. J AIDS Clin Res. 2012;3(7):171. Epub 2012 Sep 24.

Background: There has been limited research to date on the effects of food assistance provided to HIV-infected adults in resource-constrained settings with a high prevalence of malnutrition and chronic food insecurity. We compare antiretroviral therapy (ART) adherence, weight gain, and CD4+ lymphocyte count change among HIV-infected adults enrolled in a clinic-based food assistance program in Lusaka, Zambia versus a control group of non-recipients.

Methods: We conducted a cohort study incorporating interviewer-administered surveys and retrospective clinical data to compare ART patients receiving food assistance with a control group of non-recipients. Medication adherence was assessed using pharmacy dispensation records. We use propensity score matching to assess the effect of food assistance on outcome measures.

Results: After 6 months, food assistance recipients (n=145) had higher ART adherence compared to non-recipients (n=147, 98.3% versus 88.8%, respectively; p<0.01), but no significant effects were observed for weight or CD4+ lymphocyte count change. The improvement in adherence rates was greater for participants on ART for less than 230 days, and those with BMI<18.5 kg/m(2), a higher HIV disease stage, or a CD4+ lymphocyte count ≤ 350 cells/μl.

Conclusions: Promoting optimal medication adherence among persons on ART is relevant to public health and the success of HIV control efforts. The provision of food assistance to HIV-infected adults on ART may have an incentivizing effect which can improve medication adherence, particularly among patients recently initiated on treatment and those with poor nutrition or advanced disease. The effects on body weight and immune reconstitution appear minimal.

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Editor’s notes: The combination of infectious diseases and malnutrition is one of the most dramatic public health problems in sub-Saharan Africa. The relationship is negatively synergistic: malnutrition compromises natural immunity, leading to increased susceptibility to infection, more frequent and prolonged episodes and increased severity of disease. Likewise, infection can aggravate or precipitate malnutrition through decreased appetite and food intake, malabsorption, nutrient loss or increased metabolic needs. In addition, severe malnutrition often masks the signs and symptoms of infectious diseases, making prompt clinical diagnosis and early treatment very difficult. The overall impact of malnutrition on mortality from infectious diseases is devastating and it is therefore crucial that nutritional and HIV interventions be integrated. This observational study conducted in Zambia in a resource-limited setting, found a significant positive impact of food assistance on patients’ adherence to HIV medications. As the same authors suggest, further studies would be necessary to investigate the beneficial impact on retention to care of integrating nutritional supplementation and HIV care in resource-limited settings. Due to the relevance of this topic it would be sensible for countries to integrate nutritional aspects into HIV response plans, e.g., develop national guidelines on nutrition and HIV, and appoint nutrition focal points in national AIDS control committees.

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

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

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

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

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

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

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

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

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

Africa, Asia, Europe, Latin America
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Preventing new paediatric infections

Health facility characteristics and their relationship to coverage of PMTCT of HIV services across four African countries: The PEARL Study

Ekouevi DK, Stringer E, Coetzee D, Tih P, Creek T, Stinson K, Westfall AO, Welty T, Chintu N, Chi BH, Wilfert C, Shaffer N, Stringer J, Dabis F. PLoS One. 2012;7(1):e29823. Epub 2012 Jan 20

Health facility characteristics associated with effective prevention of mother-to-child transmission of HIV (PMTCT) coverage in sub-Saharan are poorly understood. Ekouevi and colleagues conducted surveys in health facilities with active PMTCT services in Cameroon, Cote d'Ivoire, South Africa, and Zambia. Data was compiled via direct observation and exit interviews. The authors constructed composite scores to describe provision of PMTCT services across seven topical areas: antenatal quality, PMTCT quality, supplies available, patient satisfaction, patient understanding of medication, and infrastructure quality. Pearson correlations and Generalized Estimating Equations (GEE) to account for clustering of facilities within countries were used to evaluate the relationship between the composite scores, total time of visit and select individual variables with PMTCT coverage among women delivering. Between July 2008 and May 2009, they collected data from 32 facilities; 78% were managed by the government health system. An opt-out approach for HIV testing was used in 100% of facilities in Zambia, 63% in Cameroon, and none in Côte d'Ivoire or South Africa. Using Pearson correlations, PMTCT coverage (median of 55%, (IQR: 33-68) was correlated with PMTCT quality score (rho = 0.51; p = 0.003); infrastructure quality score (rho = 0.43; p = 0.017); time spent at clinic (rho = 0.47; p = 0.013); patient understanding of medications score (rho = 0.51; p = 0.006); and patient satisfaction quality score (rho = 0.38; p = 0.031). PMTCT coverage was marginally correlated with the antenatal quality score (rho = 0.304; p = 0.091). Using GEE adjustment for clustering, the, antenatal quality score became more strongly associated with PMTCT coverage (p<0.001) and the PMTCT quality score and patient understanding of medications remained marginally significant. The authors observed a positive relationship between an antenatal quality score and PMTCT coverage but did not identify a consistent set of variables that predicted PMTCT coverage.

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Editor’s note: The PEARL Study (PMTCT Effectiveness in Africa: Research and Linkages to Care) was conducted from 2007-2009 in 32 health facilities with PMTCT services in four countries: Cameroon (8), Cote d’Ivoire (9), South Africa (6), and Zambia (9). It found that coverage of single-dose nevirapine of both mother and baby was variable and reached only 55% overall. In this first study to do so systematically, the researchers assessed antenatal clinic and service characteristics to see if they would predict coverage. One factor stood out as distinguishing the worst-performing sites from the others and that was the lack of registers with PMTCT information. Although some other obvious variables were associated with coverage, variables related to general antenatal care were more predictive of PMTCT coverage. This supports the importance of strengthening health care in general in order to improve PMCTC coverage. But it does not in anyway decrease the need for quality assessments and creative improvements in PMTCT programmes themselves.

Cameroon, Côte d'Ivoire, South Africa, Zambia
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