Articles tagged as "Strengthen HIV integration"

Keeping children living with HIV on antiretroviral therapy in Zimbabwe: barriers and facilitators

I don't want financial support but verbal support. How do caregivers manage children's access to and retention in HIV care in urban Zimbabwe?

Busza J, Dauya E, Bandason T, Mujuru H, Ferrand RA. J Int AIDS Soc. 2014 May 9;17:18839. doi: 10.7448/IAS.17.1.18839. eCollection 2014.

Introduction: Children living with HIV experience particular challenges in accessing HIV care. Children usually rely on adult caregivers for access to care, including timely diagnosis, initiation of treatment and sustained engagement with HIV services. The aim of this study was to inform the design of a community-based intervention to support caregivers of HIV-positive children to increase children's retention in care as part of a programme introducing decentralized HIV care in primary health facilities.

Methods: Using an existing conceptual framework, we conducted formative research to identify key local contextual factors affecting children's linkages to HIV care in Harare, Zimbabwe. We conducted semi-structured interviews with 15 primary caregivers of HIV-positive children aged 6-15 years enrolled at a hospital clinic for at least six months, followed by interviews with nine key informants from five community-based organizations providing adherence support or related services.

Results: We identified a range of facilitators and barriers that caregivers experience. Distance to the hospital, cost of transportation, fear of disclosing HIV status to the child or others, unstable family structure and institutional factors such as drug stock-outs, healthcare worker absenteeism and unsympathetic school environments proved the most salient limiting factors. Facilitators included openness within the family, availability of practical assistance and psychosocial support from community members.

Conclusions: The proposed decentralization of HIV care will mitigate concerns about distance and transport costs but is likely to be insufficient to ensure children's sustained retention. Following this study, we developed a package of structured home visits by voluntary lay workers to proactively address other determinants such as disclosure within families, access to available services and support through caregivers' social networks. A randomized controlled trial is underway to assess impact on children's retention in care over two years.

 Abstract   Full-text [free] access

Editor’s notes: Children living with HIV who are taking antiretroviral therapy (ART) are often reliant on adult carers to support them so they can attend appointments, collect their medicine and take it regularly. This study explored the barriers and facilitators experienced by caregivers of children living with HIV in sustaining HIV treatment and care in Zimbabwe.

The study was conducted in 2012 at the Harare Central Hospital clinic, which is where children diagnosed with HIV are referred to for ART eligibility screening, treatment and follow-up care. The study interviewed 12 females including eight mothers, two aunts, one grandmother and one cousin. It also included three male care-givers, all fathers, as well as nine community-based organisation respondents.

A number of barriers were identified in attending appointments: the costs of travel, the loss of income while away from work and the risk of losing their job. Stigma could lead to the disruption of treatment particularly when visitors came to the house and the fear of discrimination of the child and the family if the child’s status was known. Institutional level factors like long queues at HIV clinics; pharmacies with drug stock outs, long waiting times and staff shortages all affect adherence. Further, how a child was treated at school affected adherence to medication, ability to attend appointments and overall well-being.

The authors highlight issues that affect many children living with HIV in Africa.  They suggest that in their study setting the decentralisation of HIV care to primary health clinics together with a volunteer lay worker programme should help overcome these barriers. A randomized control trial will evaluate the effectiveness of these measures in increasing ART uptake and retention among children living with HIV in Harare.

Africa
Zimbabwe
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Rural schools in Zimbabwe provide less than optimal support of HIV-affected children

Children's representations of school support for HIV-affected peers in rural Zimbabwe.

Campbell C, Andersen L, Mutsikiwa A, Madanhire C, Skovdal M, Nyamukapa C, Gregson S. BMC Public Health. 2014 Apr 26;14(1):402. [Epub ahead of print]

Background: HIV has left many African children caring for sick relatives, orphaned or themselves HIV-positive, often facing immense challenges in the absence of significant support from adults. With reductions in development funding, public sector budgetary constraints, and a growing emphasis on the importance of indigenous resources in the HIV response, international policy allocates schools a key role in 'substituting for families' (Ansell, 2008) in supporting child health and well-being. We explore children's own accounts of the challenges facing their HIV-affected peers and the role of schools in providing such support.

Methods: Contextualised within a multi-method study of school support for HIV-affected children in rural Zimbabwe, and viewing children's views as a key resource for child-relevant intervention and policy, 128 school children (10-14) wrote a story about an HIV-affected peer and how school assisted them in tackling their problems.

Results: Children presented harrowing accounts of negative impacts of HIV on the social, physical and mental well-being of peers, and how these manifested in the school setting. Whilst relationships with fellow learners and teachers were said to provide a degree of support, this was patchy and minimal, generally limited to small-scale and often one-off acts of material help or kindness (e.g. teachers giving children pens and exercise books or peers sharing school lunches), with little potential to impact significantly on the wider social drivers of children's daily challenges. Despite having respect for the enormity of the challenges many HIV-affected peers were coping with, children tended to keep a distance from them. School was depicted as a source of the very bullying, stigma and social exclusion that undermined children's opportunities for well-being in their lives more generally.

Conclusions: Our findings challenge glib assumptions that schools can serve as a significant 'indigenous' supports of the health and well-being of HIV-affected children in the absence of a very significant increase in outside training, support and additional resources. Schools are an extension of communities, with members of school communities subject to many of the same deprivations, anxieties and prejudices that drive the health-limiting exclusion, impoverishment and stigmatisation of HIV-affected children in their households and wider communities.

Abstract  Full-text [free] access 

Editor’s notes: This is an important study exploring children’s narrative accounts of school support for HIV-affected children in a rural area in Zimbabwe. This research arose from an assumption that Zimbabwean schools and teachers may be supporting children in informal ways. The underlying assumptions of this research were that participation in community networks/schools can yield health and welfare benefits (social capital) but can also be a source of negative social norms, social exclusion and discrimination. This qualitative study took an interesting approach by asking 128 children aged 10 to 14 years old, to write stories and draw pictures over 90 minutes without a teacher present. This was to articulate their experiences, understandings and feelings about HIV-affected peers and their challenges and how they overcome them. The stories revealed children’s understandings of the lives of HIV-affected children. The key issues that arose were a lack of supportive adults in households living with HIV. Children were depicted as neglected and abused and carrying the burden of household responsibilities. There was a negative impact on school attendance and ability to pay for uniform and school equipment, as well as their poor physical and emotional health. HIV-affected children were depicted as experiencing bullying and social exclusion at school. However, HIV-affected children were seen to gain some guidance and material support provided by NGOs linked to the school and from teachers, as well as emotional support from peers. Finally, children described school as a place where HIV-affected children could forget about their HIV status. The authors conclude that the children’s stories emphasised both anti-social capital of the school environment including social isolation, bullying and HIV-stigma, with some support from teachers and peers as well as support from linked NGOs. The authors suggest that to enable schools to provide effective support, teachers should be allocated time and provided with external support, resources and training to support HIV-affected children. 

Africa
Zimbabwe
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Addressing cognitive delay in children living with and affected by HIV

A systematic review examining whether interventions are effective in reducing cognitive delay in children infected and affected with HIV.

Sherr L, Croome N, Bradshaw K, Parra Castaneda K. AIDS Care. 2014 Apr 10. [Epub ahead of print]

Cognitive delay has been recorded in children infected and affected by HIV. This finding is well established, yet few countries report provision of special educational interventions for this group of children. The general rehabilitation literature describes an array of effective interventions for children with learning difficulties. These have rarely been adapted for children affected by HIV, despite their growing numbers. A systematic review was conducted to examine effective interventions for cognitive delay in children (under 18 years) infected with HIV and/or exposed to HIV (HIV-negative child born to an HIV-positive mother). A keyword search of electronic databases with reference follow-up generated 1 745 hits. These abstracts were screened for relevance, resulting in 17 papers available for shortlisting. Studies were then included if they were randomised control trials, were longitudinal, pre/post or cohort studies and presented empirical data on an intervention for children infected by HIV or exposed to HIV and had at least one cognitive measure. Carer interventions were included if they had at least one child cognitive measure. Of the 17 papers, 4 met the inclusion criteria based on design and quality. Interventions included cognitive rehearsal, home-based stimulation and parental support. All four interventions showed at least one significant child improvement at follow-up. Despite such improvements, many children still scored within the disability range at follow-up. These results show that the effective interventions are available and should be scaled up to meet the needs of children. Complex interventions are not sufficiently studied. This review suggests an ongoing need to build evidence-based interventions, but calls on evidence-based programmes to be initiated for HIV-positive and HIV-affected children.

 Abstract access 

Editor’s notes: Delay in cognitive development is well recognised in HIV-positive and HIV-affected children, and can affect long-term achievement. Cognitive development can be affected by HIV itself or its treatment, as well as social and economic deprivation which may result from a child’s parents living with HIV.

This review summarises the effect of four different types of activities for children aged below 18 years, with cognitive delay. The children were HIV-positive and/or exposed to HIV (HIV-negative child born to an HIV-positive mother). These included provision of i) family-based coping skills to parents living with HIV and their children, ii) home-based stimulation for children, iii) sessions of computerised cognitive rehearsal and iv) training caregivers on strategies to enhance their children’s cognitive and emotional development through daily interactions. While all these activities showed improvement in at least one cognitive measure, many of the scores remained in the disability range. There are, hence, promising activities that can help improve cognitive performance.  The activities can be directed at the child or at the family or caregiver. Direct comparison of different types of activities to address cognitive delay is not possible as they utilise different measures and approaches.

Unlike in adults, the range of neurocognitive disabilities in children is far less well defined, and the causes are multifactorial. It is unlikely that one single activity will address the different domains of cognitive disability. There are no data on combined approaches, and the activities required are intensive and complex. There is no doubt that special programmes to address cognitive delay are urgently needed to enable children to attain their full potential. The main challenge is to adapt the activities that are effective, so that they can be delivered at low cost and by people with relatively little training, enabling scale-up. 

Africa, Northern America
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Advocacy, sensitisation, and capacity building are key to integrating services

Development and pilot testing of HIV screening program integration within public/primary health centers providing antenatal care services in Maharashtra, India.

Bindoria SV, Devkar R, Gupta I, Ranebennur V, Saggurti N, Ramesh S, Deshmukh D, Gaikwad S. BMC Res Notes. 2014 Mar 26;7:177. doi: 10.1186/1756-0500-7-177.

Background: The objectives of this paper are: (1) to study the feasibility and relative benefits of integrating the prevention of parent-to-child transmission (PPTCT) component of the National AIDS Control Program with the maternal and child health component of the National Rural Health Mission (NRHM) by offering HIV screening at the primary healthcare level; and (2) to estimate the incremental cost-effectiveness ratio to understand whether the costs are commensurate with the benefits.

Methods: The intervention included advocacy with political, administrative/health heads, and capacity building of health staff in Satara district, Maharashtra, India. The intervention also conducted biannual outreach activities at primary health centers (PHCs)/sub-centers (SCs); initiated facility-based integrated counseling and testing centers (FICTCs) at all round-the-clock PHCs; made the existing FICTCs functional and trained PHC nurses in HIV screening. All "functional" FICTCs were equipped to screen for HIV and trained staff provided counseling and conducted HIV testing as per the national protocol. Data were collected pre- and post- integration on the number of pregnant women screened for HIV, the number of functional FICTCs and intervention costs. Trend analyses on various outcome measures were conducted. Further, the incremental cost-effectiveness ratio per pregnant woman screened was calculated.

Results: An additional 27% of HIV-infected women were detected during the intervention period as the annual HIV screening increased from pre- to post-intervention (55% to 79%, p < 0.001) among antenatal care (ANC) attendees under the NRHM. A greater increase in HIV screening was observed in PHCs/SCs. The proportions of functional FICTCs increased from 47% to 97% (p < 0.001). Additionally, 93% of HIV-infected pregnant women were linked to anti-retroviral therapy centers; 92% of mother-baby pairs received Nevirapine; and 89% of exposed babies were enrolled for early infant diagnosis. The incremental cost-effectiveness ratio was estimated at INR 44 (less than 1 US$) per pregnant woman tested.

Conclusions: Integrating HIV screening with the broader Rural Health Mission is a promising opportunity to scale up the PPTCT program. However, advocacy, sensitization, capacity building and the judicious utilization of available resources are key to widening the reach of the PPTCT program in India and elsewhere.

Abstract   Full-text [free] access 

Editor’s notes: This article evaluates the incremental unit cost of integrating rapid HIV testing into existing maternal and child health (MCH) and primary health care services. This approach is interesting in that it can be described as political as well as clinical.  These approaches included substantial advocacy with district political and administrative health heads, sensitisation and mobilization of health workers, and supply chain support to ensure that existing counselling and testing facilities were “functional” - equipped to provide the service.

The programme also included a number of activities intended to generate demand for HIV testing and counselling in antenatal care. These included integration of HIV screening with regular village health and nutrition days, and utilisation of community health workers (ASHAs) to mobilise people for testing. 

This article provides much-needed evidence on the cost-effectiveness of integrating HIV counselling and testing into primary and antenatal health care services in India. It also encourages us to think about integration more broadly as a health systems activity, rather than simply a clinical programme. It highlights the importance of demand creation and mobilization of political will through advocacy, sensitisation and capacity building as part of the integration process.

Asia
India
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Need for increased focus on mental health among HIV-positive pregnant women

Mental health of HIV-seropositive women during pregnancy and postpartum period: a comprehensive literature review.

Kapetanovic S, Dass-Brailsford P, Nora D, Talisman N. AIDS Behav. 2014 Mar 2. [Epub ahead of print]

With growing numbers of HIV-seropositive (HIV+) women of child-bearing age and increased access to effective clinical protocols for preventing mother-to-child transmission (MTCT) of HIV, mental health-related factors have become increasingly relevant due to their potential to affect the women's quality of life, obstetric outcomes and risk of MTCT. This review synthesizes evidence from 53 peer-reviewed publications examining mental health-related variables in pregnant and postpartum HIV+ women. The presentation of results is organized by the level of socioeconomic resources in the countries where studies were conducted (i.e., high-, middle-, and low-income countries). It is concluded that psychiatric symptoms, particularly depression, and mental health vulnerabilities (e.g., inadequate coping skills) are widespread among pregnant HIV+ women globally and have a potential to affect psychological well-being, quality of life and salient clinical outcomes. The current body of evidence provides rationale for developing and evaluating clinical and structural interventions aimed at improving mental health outcomes and their clinical correlates in pregnant HIV+ women.

Abstract access 

Editor’s notes: The comprehensive review summarises evidence from over fifty studies on a range of mental health variables in pregnant and post-partum HIV-positive women. The results highlight the need to screen for depression among pregnant HIV-positive women, and to provide appropriate referrals and programmes. Five randomised controlled trials were identified (all from low- and middle-income countries), with encouraging results of activities such as culturally-adapted psycho-educational programmes. Future randomised trials are needed to build on this evidence and assess the impact of such programmes not only on mental health outcomes, but also HIV-related factors such as antiretroviral therapy adherence and mother-to-child transmission of HIV. The absence of trials from high-income countries is noticeable, indicating the need for further focus on mental health needs of HIV-positive pregnant women in these settings.

Africa, Asia, Europe, Northern America
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Promising results from integrating depression treatment with HIV care in Cameroon

Feasibility, safety, acceptability, and preliminary efficacy of measurement-based care depression treatment for HIV patients in Bamenda, Cameroon.

Pence, B. W. G., B. N. Atashili, J. O'Donnell, J. K. Kats, D. Whetten, K. Njamnshi, A. K. Mbu, T. Kefie, C. Asanji, S. Ndumbe, P. AIDS Behav. 2014 Feb 21. [Epub ahead of print]

Depression affects 18-30 % of HIV-infected patients in Africa and is associated with greater stigma, lower antiretroviral adherence, and faster disease progression. However, the region's health system capacity to effectively identify and treat depression is limited. Task-shifting models may help address this large mental health treatment gap. Measurement-Based Care (MBC) is a task-shifting model in which a Depression Care Manager guides a non-psychiatric (e.g., HIV) provider in prescribing and managing antidepressant treatment. We adapted MBC for depressed HIV-infected patients in Cameroon and completed a pilot study to assess feasibility, safety, acceptability, and preliminary efficacy. We enrolled 55 participants; all started amitriptyline 25-50 mg daily at baseline. By 12 weeks, most remained at 50 mg daily (range 25-125 mg). Median (interquartile range) PHQ-9 depressive severity scores declined from 13 (12-16) (baseline) to 2 (0-3) (week 12); 87 % achieved depression remission (PHQ-9 <5) by 12 weeks. Intervention fidelity was high: HIV providers followed MBC recommendations at 96 % of encounters. Most divergences reflected a failure to increase dose when indicated. No serious and few bothersome side effects were reported. Most suicidality (prevalence 62 % at baseline; 8 % at 12 weeks) was either passive or low-risk. Participant satisfaction was high (100 %), and most participants (89 %) indicated willingness to pay for medications if MBC were implemented in routine care. The adapted MBC intervention demonstrated high feasibility, safety, acceptability, and preliminary efficacy in this uncontrolled pilot study. Further research should assess whether MBC could improve adherence and HIV outcomes in this setting.

Abstract access

Editor’s notes: Task sharing for mental health care services has been shown effective for the general population in several low-income settings. However, its effectiveness for an HIV-positive population remains in question. By supervising HIV physicians in the provision of depression care, there is increased access to a critical mental health service.  In addition, there are likely to be positive effects for HIV treatment outcomes. The results of this study provide compelling grounds for further research, specifically for a randomized control trial of the Measurement-Based Care treatment protocol.

Africa
Cameroon
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Integrated routine screening for syphilis and HIV in antenatal care is cost-effective in China

Cost-effectiveness of integrated routine offering of prenatal HIV and syphilis screening in China.

Owusu-Edusei, K., Jr. Tao, G. Gift, T. L. Wang, A. Wang, L. Tun, Y. Wei, X. Wang, L. Fuller, S. Kamb, M. L. Bulterys, M. Sex Transm Dis. 2014 Feb;41(2):103-10. doi: 10.1097/OLQ.0000000000000085.

Background: In China, recent rises in syphilis and HIV cases have increased the focus on preventing mother-to-child transmission of these infections. We assess the health and economic outcomes of different strategies of prenatal HIV and syphilis screening from the local health department's perspective.

Methods: A Markov cohort decision analysis model was used to estimate the health and economic outcomes of pregnancy using disease prevalence and cost data from local sources and, if unavailable, from published literature. Adverse pregnancy outcomes included induced abortion, stillbirth, low birth weight, neonatal death, congenital syphilis in live-born infants, and perinatal HIV infection. We examined 4 screening strategies: no screening, screening for HIV only, for syphilis only, and for both HIV and syphilis. We estimated disability-adjusted life years (DALYs) for each health outcome using life expectancies and infections for mothers and newborns.

Results: For a simulated cohort of 10 000 pregnant women (0.07% prevalence for HIV and 0.25% for syphilis; 10% of HIV-positives were coinfected with syphilis), the estimated costs per DALY prevented were as follows: syphilis-only, $168; HIV-and-syphilis, $359; and HIV-only,    $5 636. The estimated incremental cost-effectiveness ratio if an existing HIV-only strategy added syphilis screening (i.e., move from the HIV-only strategy to the HIV-and-syphilis strategy) was $140 per additional DALY prevented.

Conclusions: Given the increasing prevalence of syphilis and HIV among pregnant women in China, prenatal HIV screening programs that also include syphilis screening are likely to be substantially more cost-effective than HIV screening alone and prevent many more adverse pregnancy outcomes.

Abstract access 

Editor’s notes: This study uses a Markov cohort model to estimate the cost-effectiveness of combined HIV and syphilis screening in antenatal care, as compared to HIV-only screening, syphilis-only screening, or no screening. This is the first study to examine cost-effectiveness of antenatal syphilis screening in China. This is particularly interesting as existing studies modelling the cost-effectiveness of syphilis screening in antenatal care have largely focused on settings with high syphilis prevalence amongst pregnant women, such as sub-Saharan Africa. This study found that even in a low syphilis prevalence setting, combined HIV/syphilis screening is substantially cost-effective at $359 per DALY averted, and more cost-effective than HIV-only screening.

Asia
China
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Successful integration of HIV and TB care into a methadone programme

Lessons from Tanzania on the integration of HIV and tuberculosis treatments into methadone assisted treatment.

Bruce RD, Lambdin B, Chang O, Masao F, Mbwambo J, Mteza I, Nyandindi C, Zamudio-Haas S, Buma D, Dunbar MS, Kilonzo G. Int J Drug Policy 2014 Jan;25(1):22-5. doi: 10.1016/j.drugpo.2013.09.005. Epub 2013 Sep 19.

To successfully address HIV and TB in the world, we must address the healthcare needs of key populations, such as drug users, and we must do this urgently. Currently in Tanzania, as in many countries, the care for these medical disorders is separated into disease specific clinical environments. Our consortium began working to integrate HIV and TB clinical services into the methadone program in Dar es Salaam, Tanzania. We present the key lessons learned in this process of integration and the importance of integrating HIV/TB into the methadone program, which serves as a critical anchor for adherence to clinical services. Integrated healthcare for people who use drugs is clearly a long-term goal and different health systems will progress upon this continuum at different rates. What is clear is that every health system that interacts with drug users must aspire to achieve some level of integrated healthcare if the incidence rates of HIV and TB are to decline.

Abstract access 

Editor’s notes: The prevalence of injecting drug use is unknown in many resource-limited settings, but is increasing in some African countries. Harm reduction programmes for people who inject drugs are generally less well-developed in resource-limited settings, and, where available, such programmes are usually delivered separately from HIV care services. People living with HIV who inject drugs are at high risk of tuberculosis. Moreover, concurrent treatment for all three conditions is complicated, with potential for drug-drug interactions. Integration of opiate substitution therapy with treatment for HIV and, when necessary, tuberculosis treatment, has many advantages for service users.

This article describes lessons learned from a case study of successful integration of HIV and tuberculosis treatment into a methadone programme in Dar es Salaam, United Republic of Tanzania. Initially, HIV testing was offered to clients attending for methadone: around one-third were found to be HIV-positive. Antiretroviral treatment was made available as directly-observed therapy from the pharmacist dispensing daily methadone. Subsequently, screening for tuberculosis and directly-observed tuberculosis treatment were introduced. This is an encouraging example of patient-centred, integrated care.

Africa
United Republic of Tanzania
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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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Integrated paediatric services can improve uptake of HIV care but are still affected by stigma

Qualitative assessment of the integration of HIV services with infant routine immunization visits in Tanzania.

Wallace A, Kimambo S, Dafrossa L, Rusibamayila N, Rwebembera A, Songoro J, Arthur G, Luman E, Finkbeiner T, Goodson JL. J Acquir Immune Defic Syndr. 2013 Dec 8. [Epub ahead of print]

Background: In 2009, a project was implemented in 8 primary health clinics throughout Tanzania to explore the feasibility of integrating pediatric HIV prevention services with routine infant immunization visits.

Methods: We conducted interviews with 66 conveniently sampled mothers of infants who had received integrated HIV and immunization services and 16 providers who delivered the integrated services to qualitatively identify benefits and challenges of the intervention midway through project implementation.

Findings: Mothers' perceived benefits of the integrated services included time savings, opportunity to learn their child's HIV status and receive HIV treatment if necessary. Providers' perceived benefits included reaching mothers who usually would not come for only HIV testing. Mothers and providers reported similar challenges, including mothers' fear of HIV testing, poor spousal support, perceived mandatory HIV testing, poor patient flow affecting confidentiality of service delivery, heavier provider workloads, and community stigma against HIV-infected persons; the latter a more frequent theme in rural compared to urban locations.

Interpretation: Future scale-up should ensure privacy of these integrated services received at clinics and community outreach to address stigma and perceived mandatory testing. Increasing human resources for health to address higher workloads and longer waiting times for proper patient flow is necessary in the long term.

Abstract access 

Editor’s notes: In response to the poor uptake of antiretroviral therapy (ART) by children in Tanzania the Tanzanian Ministry of Health and Social Welfare and the US Centres for Disease Control and Prevention implemented a project to integrate early infant HIV diagnosis (EID) into routine immunisation visits in four urban and four rural clinics. The authors conducted a qualitative study to explore perceptions of this integrated service by mothers and health care providers. They conducted a large number of in depth interviews with mothers (66) and with health care providers (16). The majority of mothers and providers perceived the integrated services to be beneficial in relation to improving the uptake of HIV care and treatment. This is especially so as existing trust in immunisation services ensured that women were attending these services. However, they found a number of mixed messages about benefits for the mothers in terms of reduced costs and time in accessing both services together. Whilst most women reported cost and time savings, other women and providers reported that women spent a long time at the clinic, especially when queuing for both services. There were also issues in relation to confidentiality at the clinics concerning HIV status. Whilst many women trusted the staff to keep their information confidential, there were a number of ways in which the clinic processes were seen to compromise confidentiality. These included providing HIV services to groups of mothers together or providing care in designated HIV treatment rooms, which could be identified by other women at the clinic. This concern with confidentiality was important as women reported issues about stigma within their communities and fear of disclosure to partners or husbands who may be violent or leave them. There are concerns that this may impact on the uptake of immunization and the authors reported evidence of this in the rural clinics, from quantitative studies.

This paper highlights that future planning to provide more efficient services and increased uptake of HIV care and treatment needs to be highly sensitive to the ongoing issue of disclosure and stigma. Integrated services may provide a way to address this by providing all the services (such as immunisation and HIV care) in one session. In this way, other patients or mothers are not aware who is receiving HIV care. As the authors note though, this has implications for resource allocation.

Africa
United Republic of Tanzania
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