Articles tagged as "Strengthen HIV integration"

An integrated investment approach for women’s and children’s health

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

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

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

Abstract access 

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

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

Africa, Asia, Latin America, Oceania
Afghanistan, Angola, Azerbaijan, Bangladesh, Benin, Bolivia, Botswana, Brazil, Burkina Faso, Burundi, Cambodia, Cameroon, Central African Republic, Chad, China, Comoros, Congo, Côte d'Ivoire, Democratic People's Republic of Korea, Democratic Republic of the Congo, Djibouti, Egypt, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Guatemala, Guinea, Guinea-Bissau, Haiti, India, Indonesia, Iraq, Kenya, Kyrgyzstan, Lao People's Democratic Republic, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Mexico, Morocco, Mozambique, Myanmar, Nepal, Niger, Nigeria, Pakistan, Papua New Guinea, Peru, Philippines, Rwanda, Sao Tome and Principe, Senegal, Sierra Leone, Solomon Islands, Somalia, South Africa, Sudan, Swaziland, Tajikistan, Togo, Turkmenistan, Uganda, United Republic of Tanzania, Uzbekistan, Viet Nam, Yemen, Zambia, Zimbabwe
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Taking services to the community: the effective provision of TB, HIV and vertical HIV prevention services by community care workers

Community-based intervention to enhance provision of integrated TB-HIV and PMTCT services in South Africa.

Uwimana J, Zarowsky C, Hausler H, Swanevelder S, Tabana H, Jackson D. . Int J Tuberc Lung Dis. 2013 Oct;17(10 Suppl 1):48-55.doi: 10.5588/ijtld.13.0173.

Objective: To conduct an impact assessment of an intervention to enhance the provision of community-based integrated services for tuberculosis (TB), human immunodeficiency virus (HIV) and prevention of mother-to-child transmission (PMTCT).

Methods: The intervention consisted of a combination of training of community care workers (CCWs), structural adjustments, harmonisation of scope of practice and stipend of CCWs and enhanced supervision of CCWs to provide comprehensive TB-HIV/PMTCT services in a rural South African district. A before and after study design was used with a household survey to assess the operational effectiveness of the intervention. Six clusters were randomised into intervention and control arms. Quantitative data were analysed using logistic regression, adjusting for cluster design.

Results: Logistic regression analyses of the survey data show that CCWs from the intervention arm performed better in the provision of TB-HIV/PMTCT services, such as screening for TB and sexually transmitted infections, adherence to anti-tuberculosis treatment and antiretroviral therapy and counselling on infant feeding compared to the control CCWs (P < 0.05). However, intervention CCWs performed worse in the integrated management of childhood illnesses education and social welfare referrals (P < 0.05). The uptake of HIV testing increased significantly in the intervention arm, from 55% to 78% (P < 0.001).

Conclusion: The intervention was effective in enhancing the provision of community-based TB-HIV and PMTCT services. However, attention to other primary health care services is required to ensure that all key services are provided.

Abstract  Full-text [free] access 

Editor’s notes: Community care workers (CCWs) have the potential to expand primary health care beyond health facilities. However, in many settings where integrated TB-HIV services have mainly been promoted at facility level, there is little engagement of communities and community care workers. This is inefficient, and can lead to fragmented services. This clustered, before after study, assessed the impact of an intervention that trained/upskilled CCWs to provide comprehensive TB-HIV/vertical HIV prevention services. The intervention integrated CCWs into one cadre, established a facility-community linkage, harmonized the scope of practice of CCWs and improved CCW supervision. The findings are very positive, suggesting that the intervention increased the coverage of TB-HIV/STI case finding, infant feeding counselling and antiretroviral treatment adherence support, and improved anti-tuberculosis treatment adherence and outcomes. However, other outcomes were more mixed: with less education on the integrated management of childhood illnesses, referral for vital documents and referral for social grants, performance was worse; but there was improved referral for weighing and immunization. The findings highlight the feasibility and effectiveness of community-based integrated TB-HIV/PMTCT services provision, and the need to ensure that other outcomes are not adversely affected.  

Africa
South Africa
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Strengthening the provision of PITC in STI clinics: operational insights

Implementing a provider-initiated testing and counselling (PITC) intervention in Cape town, South Africa: a process evaluation using the normalisation process model.

Leon N, Lewin S, Mathews C Implement Sci. 2013 Aug 26;8(1):97. [Epub ahead of print] 

Background:  Provider-initiated HIV testing and counselling (PITC) increases HIV testing rates in most settings, but its effect on testing rates varies considerably. This paper reports the findings of a process evaluation of a controlled trial of PITC for people with sexually transmitted infections (STI) attending publicly funded clinics in a low-resource setting in South Africa, where the trial results were lower than anticipated compared to the standard Voluntary Counselling and Testing (VCT) approach.

Method:  This longitudinal study used a variety of qualitative methods, including participant observation of project implementation processes, staff focus groups, patient interviews, and observation of clinical practice. Data were content analysed by identifying the main influences shaping the implementation process. The Normalisation Process Model (NPM) was used as a theoretical framework to analyse implementation processes and explain the trial outcomes.

Results:  The new PITC intervention became embedded in practice (normalised) during a two-year period (2006 to 2007). Factors that promoted the normalising include strong senior leadership, implementation support, appropriate accountability mechanisms, an intervention design that was responsive to service needs and congruent with professional practice, positive staff and patient perceptions, and a responsive organisational context. Nevertheless, nurses struggled to deploy the intervention efficiently, mainly because of poor sequencing and integration of HIV and STI tasks, a focus on HIV education, tension with a patient-centred communication style, and inadequate training on dealing with the operational challenges. This resulted in longer consultation times, which may account for the low test coverage outcome.

Conclusion:  Leadership and implementation support, congruent intervention design, and a responsive organisational context strengthened implementation. Poor compatibility with nurse skills on the level of the clinical consultation may have contributed to limiting the size of the trial outcomes. A close fit between the PITC intervention design and clinical practices, as well as appropriate training, are needed to ensure sustainability of the programme. The use of a theory-driven analysis promotes transferability of the results, and the findings are therefore relevant to the implementation of HIV testing and to the design and evaluation of complex interventions in other settings. Trial registration: Current controlled trials ISRCTN93692532.

Abstract Full-text [free] access

Editor’s notes: HIV testing is the main entry point for HIV prevention and treatment, and it is important that provider initiated HIV testing is integrated into a range of health care services. This paper uses a combination of qualitative methods to describe what factors influenced the coverage of HIV testing in STI clinics in South Africa. They identify a range of factors that help to support and normalize HIV testing, and the challenges that some nurses faced in trying to deploy the intervention effectively.  These challenges include issues related to the levels of institutional support and commitment, how to sequence STI and HIV tasks, the content of training, and tensions with a patient centred communication model. The research not only provides practical insights into the operational issues that need to be considered when integrating PITC care into services, but also illustrates the value of process evaluation methods, as a complement to trial research.

Africa
South Africa
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Integrating HIV treatment with primary care services

Integrating HIV treatment with primary care outpatient services: opportunities and challenges from a scaled-up model in Zambia.

Topp SM, Chipukuma JM, Chiko MM, Matongo E, Bolton-Moore C, Reid SE., Health Policy Plan. 2013; 4:347-57. doi: 10.1093/heapol/czs065

Background: Integration of HIV treatment with other primary care services has been argued to potentially improve effectiveness, efficiency and equity. However, outside the field of reproductive health, there is limited empirical evidence regarding the scope or depth of integrated HIV programmes or their relative benefits. Moreover, the body of work describing operational models of integrated service-delivery in context remains thin. Between 2008 and 2011, the Lusaka District Health Management Team piloted and scaled-up a model of integrated HIV and general outpatient department (OPD) services in 12 primary health care clinics. This paper examines the effect of the integrated model on the organization of clinic services, and explores service providers' perceptions of the integrated model.

Methods: We used a mixed methods approach incorporating facility surveys and key informant interviews with clinic managers and district officials. On-site facility surveys were carried out in 12 integrated facilities to collect data on the scope of integrated services, and 15 semi-structured interviews were carried out with 12 clinic managers and three district officials to explore strengths and weaknesses of the model. Quantitative and qualitative data were triangulated to inform overall analysis.

Findings: Implementation of the integrated model substantially changed the organization of service delivery across a range of clinic systems. Organizational and managerial advantages were identified, including more efficient use of staff time and clinic space, improved teamwork and accountability, and more equitable delivery of care to HIV and non-HIV patients. However, integration did not solve ongoing human resource shortages or inadequate infrastructure, which limited the efficacy of the model and were perceived to undermine service delivery.

Conclusion: While resource and allocative efficiencies are associated with this model of integration, a more important finding was the model's demonstrated potential for strengthening organizational culture and staff relationships, in turn facilitating more collaborative and motivated service delivery in chronically under-resourced primary healthcare clinics.

Abstract Full-text [free] access

Editor’s notes:  In recent years, there has been much debate about the relative benefits of disease-specific programs vs. broader strengthening of health systems, which may have the potential to improve effectiveness, cost-effectiveness and equity of health care.  

The integrated model in primary care services in this study involved 3 modifications: 1) amalgamation of physical space and patient flow; 2) standardisation of record keeping; 3) introduction of provider-initiated testing and counselling for all attendees.  Integration resulted in a single cadre of health-workers providing care jointly to HIV and OPD patients.

The equitable distribution of material and human resources improved the quality and efficiency of healthcare delivery. This approach provided an opportunity for systems of HIV care to strengthen care for other chronic diseases and healthcare providers were afforded the opportunity to learn different skills.  Shared responsibility of clinic functions improved staff relationships which facilitated more collaborative and motivated service delivery.

However, these advantages cannot offset the absolute underlying problem of limited infrastructural and human resources and weak health financing, which may ultimately make integrated care unsustainable. Hence, while this study demonstrates clear benefits of integration, these macro-level determinants need to be addressed.  The impact of integrated models of healthcare delivery on the quality of medical care merits consideration.   

Africa
Zambia
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Health system barriers to achieving the potential of integrated service delivery

Integrated maternal and child health services in Mozambique: structural health system limitations overshadow its effect on follow-up of HIV-exposed infants.

Geelhoed D, Lafort Y, Chissale E, Candrinho B, Degomme O. BMC Health Serv Res. 2013 Jun 7;13:207. doi: 10.1186/1472-6963-13-207.

Background: The follow-up of HIV-exposed infants remains a public health challenge in many Sub-Saharan countries. Just as integrated antenatal and maternity services have contributed to improved care for HIV-positive pregnant women, so too could integrated care for mother and infant after birth improve follow-up of HIV-exposed infants. We present results of a study testing the viability of such integrated care, and its effects on follow-up of HIV-exposed infants, in Tete Province, Mozambique.

Methods: Between April 2009 and September 2010, we conducted a mixed-method, intervention-control study in six rural public primary healthcare facilities, selected purposively for size and accessibility, with random allocation of three facilities each for intervention and control groups. The intervention consisted of a reorganization of services to provide one-stop, integrated care for mothers and their children under five years of age. We collected monthly routine facility statistics on prevention of mother-to-child HIV transmission (PMTCT), follow-up of HIV-exposed infants, and other mother and child health (MCH) activities for the six months before (January-June 2009) and 13 months after starting the intervention (July 2009-July 2010). Staff were interviewed at the start, after six months, and at the end of the study. Quantitative data were analysed using quasi-Poisson models for significant differences between the periods before and after intervention, between healthcare facilities in intervention and control groups, and for time trends. The coefficients for the effect of the period and the interaction effect of the intervention were calculated with their p-values. Thematic analysis of qualitative data was done manually.

Results: One-stop, integrated care for mother and child was feasible in all participating healthcare facilities, and staff evaluated this service organisation positively. We observed in both study groups an improvement in follow-up of HIV-exposed infants (registration, follow-up visits, serological testing), but frequent absenteeism of staff and irregular supply of consumables interfered with healthcare facility performance for both intervention and control groups.

Conclusions: Despite improvement in various aspects of the follow-up of HIV-exposed infants, we observed no improvement attributable to one-stop, integrated MCH care. Structural healthcare system limitations, such as staff absences and irregular supply of essential commodities, appear to overshadow its potential effects. Regular technical support and adequate basic working conditions are essential for improved performance in the follow-up of HIV-exposed infants in peripheral public healthcare facilities in Mozambique.

Abstract   Full-text [free] access 

Editor’s notes: Despite rapid advances in the delivery of PMTCT services in many sub-Saharan African countries, the follow-up of HIV-exposed infants until the age of 18 months remains a critical challenge.  This mixed methods, quasi-experimental evaluation study evaluated the viability of providing one-stop, integrated care, its acceptability to healthcare providers, and its effect upon the follow-up of HIV-exposed infants and other MCH services, in the public health system. The intervention consisted of a reorganization of MCH services, to deliver integrated, one-stop consultations for mothers and their children up to 5 years of age. Absence of MCH staff occurred in 16% of months, and stock-outs of HIV testing commodities and MCH drugs occurred in almost half of all months. The improvements in both arms suggests that improving some of the basic working conditions of peripheral MCH staff and ensuring an adequate supply of commodities might be effective ways to improve the follow-up of HIV-exposed infants in peripheral public healthcare facilities in Mozambique. 

Africa
Mozambique
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Integration of ANC and ART services increases PMTCT uptake but provision remains sub-optimal

Integration of Antiretroviral Therapy Services into Antenatal Care Increases Treatment Initiation during Pregnancy: A Cohort Study.

Stinson K, Jennings K, Myer L. PLoS One. 2013 May 16;8(5):e63328. Print 2013

Objectives: Initiation of antiretroviral therapy (ART) during pregnancy is critical to promote maternal health and prevent mother-to-child HIV transmission (PMTCT). The separation of services for antenatal care (ANC) and ART may hinder antenatal ART initiation. We evaluated ART initiation during pregnancy under different service delivery models in Cape Town, South Africa.

Methods: A retrospective cohort study was conducted using routinely collected clinic data. Three models for ART initiation in pregnancy were evaluated ART 'integrated' into ANC, ART located 'proximal' to ANC, and ART located some distance away from ANC ('distal'). Kaplan-Meier methods and Poisson regression were used to examine the association between service delivery model and antenatal ART initiation.

Results: Among 14 617 women seeking antenatal care in the three services, 30% were HIV-infected and 17% were eligible for ART based on CD4 cell count <200 cells/µL. A higher proportion of women started ART antenatally in the integrated model compared to the proximal or distal models (55% vs 38% vs 45%, respectively, global p = 0.003). After adjusting for age and gestation at first ANC visit, women who at the integrated service were significantly more likely to initiate ART antenatally (rate ratio 1.33; 95% confidence interval: 1.09-1.64) compared to women attending the distal model; there was no difference between the proximal and distal models in antenatal ART initiation however (p = 0.704).

Conclusions: Integration of ART initiation into ANC is associated with higher levels of ART initiation in pregnancy. This and other forms of service integration may represent a valuable intervention to enhance PMTCT and maternal health. .

Abstract Full-text [free] access

Editor’s notes: This study highlights the challenges of successful delivery of effective PMTCT. The authors compare 3 PMTCT delivery sites with differing modes of care, principally with respect to distance between ANC and ART provision services. It must be noted that other baseline differences between study participants and site services also existed (such as algorithms of care and support from international agencies etc), however this is often seen in observational (and operational research) studies and the pertinence of the findings remain. An important result of this study is that even with integration of ANC and ART services, initiation of treatment was only achieved in just over half of eligible women. There was a notable trend in ART initiation by gestational age at presentation for ANC – the more advanced the gestational age at presentation, the less likely women were to start ART antenatally, reflecting delays in ART initiation even after a woman is in care. Many of the women proceeded to eventually start treatment postnatally. This is an important reminder of the missed opportunities that exist both for preventing HIV in infants and for earlier initiation of treatment in women for their own health.

Africa
South Africa
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Almost a quarter of deaths in pregnant and post-partum women may be attributable to HIV

Effect of HIV infection on pregnancy-related mortality in sub-Saharan Africa: secondary analyses of pooled community-based data from the network for Analysing Longitudinal Population-based HIV/AIDS data on Africa (ALPHA).

Zaba B, Calvert C, Marston M, Isingo R, Nakiyingi-Miiro J, Lutalo T, Crampin A, Robertson L, Herbst K, Newell ML, Todd J, Byass P, Boerma T, Ronsmans C. Lancet. 2013 May 18;381(9879):1763-71.

Background: Model-based estimates of the global proportions of maternal deaths that are in HIV-infected women range from 7% to 21%, and the effects of HIV on the risk of maternal death is highly uncertain. We used longitudinal data from the Analysing Longitudinal Population-based HIV/AIDS data on Africa (ALPHA) network to estimate the excess mortality associated with HIV during pregnancy and the post-partum period in sub-Saharan Africa.

Methods: The ALPHA network pooled data gathered between June, 1989 and April, 2012 in six community-based studies in eastern and southern Africa with HIV serological surveillance and verbal-autopsy reporting. Deaths occurring during pregnancy and up to 42 days post partum were defined as pregnancy related. Pregnant or post-partum person-years were calculated for HIV-infected and HIV-uninfected women, and HIV-infected to HIV-uninfected mortality rate ratios and HIV-attributable rates were compared between pregnant or post-partum women and women who were not pregnant or post partum.

FINDINGS: 138,074 women aged 15-49 years contributed 636,213 person-years of observation. 49,568 women had 86,963 pregnancies. 6760 of these women died, 235 of them during pregnancy or the post-partum period. Mean prevalence of HIV infection across all person-years in the pooled data was 17.2% (95% CI 17.0-17.3), but 60 of 118 (50.8%) of the women of known HIV status who died during pregnancy or post partum were HIV infected. The mortality rate ratio of HIV-infected to HIV-uninfected women was 20.5 (18.9-22.4) in women who were not pregnant or post partum and 8.2 (5.7-11.8) in pregnant or post-partum women. Excess mortality attributable to HIV was 51.8 (47.8-53.8) per 1000 person-years in women who were not pregnant or post partum and 11.8 (8.4-15.3) per 1000 person-years in pregnant or post-partum women.

Interpretation: HIV-infected pregnant or post-partum women had around eight times higher mortality than did their HIV-uninfected counterparts. On the basis of this estimate, we predict that roughly 24% of deaths in pregnant or post-partum women are attributable to HIV in sub-Saharan Africa, suggesting that safe motherhood programmes should pay special attention to the needs of HIV-infected pregnant or post-partum women.

Abstract access 

Editor’s notes: This study is the first to estimate the contribution of HIV to mortality in pregnant and post-partum women using HIV sero-surveillance and verbal autopsy data from a network of studies in eastern and southern Africa. While there is variation by country, excess mortality due to HIV was considerably higher in non-pregnant women compared with pregnant/post-partum women. This is not entirely surprising as fertility falls with advancing HIV, so only healthier women with HIV conceive – the so-called ‘healthy pregnant woman effect’. They are therefore less likely to die while pregnant/post-partum. However, the study estimates that almost a quarter of deaths in pregnant/post-partum women are attributable to HIV. This highlights the importance of integrating HIV into safe motherhood programmes. It is noteworthy that the majority of women at the time of this study would not have had access to antiretroviral treatment to benefit their own health (as opposed to single dose treatment to reduce mother-to-child transmission alone). While pointing to the potential benefits of the WHO PMTCT B option, the study emphasizes the potential further advantage of PMTCT B+ to reduce HIV related morbidity and mortality, both for women’s own health and their unborn infants, with implications for current and future pregnancies.

Africa
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Integrating HIV testing into routine infant immunization programmes

Evaluation of Using Routine Infant Immunization Visits to Identify and Follow-Up HIV-Exposed Infants and Their Mothers in Tanzania.

Goodson JL, Finkbeiner T, Davis NL, Lyimo D, Rwebembera A, Swartzendruber AL, Wallace AS, Kimambo S, Kimario CJ, Wiktor SZ, Luman ET. J Acquir Immune Defic Syndr. 2013 May 1;63(1):e9-e15

Background: Without treatment, approximately half of HIV-infected infants die by age 2 years, and 80% die before age 5 years. Early identification of HIV-infected and HIV-exposed infants provides opportunities for life-saving interventions. We evaluated integration of HIV-related services with routine infant immunization in Tanzania. METHODS: During April 2009 to March 2010, at 4 urban and 4 rural sites, mothers' HIV status was determined at first-month immunization using antenatal cards. HIV-exposed infants were offered HIV testing and follow-up care. Impact of integrated service delivery was assessed by comparing average monthly vaccine doses administered during the study period and a 2-year baseline period; acceptance was assessed by interviewing mothers and service providers. FINDINGS: During 7569 visits, 308 HIV-exposed infants were identified and registered; of these, 290 (94%) were tested, 15 (5%) were HIV infected. At urban sites, first-month vaccine doses remained stable (+2% for pentavalent vaccine and -4% for polio vaccine), and vaccine doses given later in life (pentavalent, polio, and measles) increased 12%, 8%, and 11%, respectively. At rural sites, first-month vaccine doses decreased 33% and 35% and vaccine doses given later in life decreased 23%, 28%, and 28%. Mothers and service providers generally favored integrated services; however, HIV-related stigma and inadequate confidentiality controls of HIV testing were identified, particularly at rural sites. INTERPRETATION: Integration of HIV-related services at immunization visits identified HIV-exposed infants, HIV-infected infants, and HIV-infected mothers; however, decreases in vaccine doses administered at rural sites were concerning. HIV-related service integration with immunization visits needs careful monitoring to ensure optimum vaccine delivery.

Abstract access 

Editor’s notes: One of the targets set in the Global Plan in 2009 was that there should be a 90% reduction in the number of children newly infected with HIV by 2015. Although progress has been made towards achieving this target, with a 24% reduction in HIV infections between 2009 and 2011, it is estimated that in 2011 alone 300 000 children in sub-Saharan Africa were newly infected with HIV. Despite the knowledge that antiretroviral therapy (ART) substantially reduces morbidity and mortality in children, only 23% of children eligible for treatment are estimated to be receiving ART; without access to ART these children will die. One of the major barriers to initiating ART, which urgently needs to be addressed, is access to HIV testing for children. This paper demonstrates the feasibility and acceptability of integrating routine HIV testing of mothers and infants into national immunization programmes. However, the implementation of such a strategy would have be to done with care, as the integration of HIV testing into immunization programmes may have a negative impact on vaccination uptake.

Africa
United Republic of Tanzania
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Feasibility and acceptability of routine HIV testing into a general paediatric out-patient clinic

The Acceptability and Feasibility of Routine Pediatric HIV Testing in an Outpatient Clinic in Durban, South Africa.

Ramirez-Avila L, Noubary F, Pansegrouw D, Sithole S, Giddy J, Losina E, Walensky RP, Bassett IV Pediatr Infect Dis J. 2013

Background: Limited access to HIV testing for children impedes early diagnosis and access to ART. Our objective was to evaluate the feasibility and acceptability of routine pediatric HIV testing in an urban, fee-for-service, outpatient clinic in Durban, South Africa. METHODS: We assessed the number of patients (0-15yrs) who underwent HIV testing upon physician referral during a baseline period. We then established a routine, voluntary HIV testing study for pediatric patients, regardless of symptoms. Parents/caretakers were offered free rapid fingerstick HIV testing for their child. For patients <18mo, the biological mother was offered HIV testing and HIV DNA PCR was used to confirm the infant's status. The primary outcome was the HIV testing yield, defined as the average number of positive tests per month during the routine compared to the baseline period. RESULTS: Over a 5-month baseline testing period, 931pediatric patients registered for outpatient care. Of the 124 (13%) patients who underwent testing upon physician referral, 21 (17%, 95% CI 11-25%) were HIV-infected. During a 13-month routine testing period, 2,790 patients registered for care and 2,106 (75%) were approached for participation. Of these, 1,234 were eligible and 771(62%) enrolled. Among those eligible, 637 (52%, 95% CI 49-54%) accepted testing for their child or themselves (biological mothers of infants <18 months).There was an increase in the average number of HIV tests during the routine compared to the baseline HIV testing periods (49 vs. 25 tests per month, p=0.001) but no difference in the HIV testing yield during the testing periods (3 vs. 4 positive HIV tests/month, p=0.06). However, during the routine testing period HIV prevalence remains extraordinarily high with 39 (6%, 95% CI 4-8%) newly-diagnosed HIV-infected children (median 7 years, 56% female). CONCLUSIONS: Targeted and symptom-based testing referral identifies an equivalent number of HIV-infected children as routine HIV testing. Routine HIV testing identifies a high burden of HIV and is a feasible and moderately acceptable strategy in an outpatient clinic in a high prevalence area.

Abstract access 

Editor’s notes: ART coverage of children in resource-limited settings is very low, in part because HIV positive children are being diagnosed late, or not at all. This has significant implications in terms of morbidity and mortality, as without access to treatment these children will die. Additionally late initiation of ART may result in irreversible conditions e.g. chronic lung disease. Routine HIV testing of children in an out-patient setting is one potential strategy which could be used to identify HIV positive children and link them into care. In this study the introduction of routine, voluntary HIV testing of children (0-15 years) into a general out-patient clinic in a high HIV prevalence setting, resulted in more children being tested than previously seen with provider-initiated testing. Despite this, no more HIV positive children were identified. One potential reason, as discussed in the paper, was selection bias; a significant proportion of children registering at the clinic did not have an HIV test. It is possible that children who were considered ineligible for testing, or whose caretakers either declined participation in the study or HIV testing, were at higher risk of being HIV positive. HIV positive children have the right to access life-saving ART; however as shown in this study routine voluntary testing was only moderately acceptable and as a result we may be failing to test those children who are at highest risk. Innovative solutions, such as opt-out testing need to be considered and debated at a national level.

Africa
South Africa
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The challenge of integrating Tuberculosis (TB) and HIV services in South Africa

Current Integration of Tuberculosis (TB) and HIV Services in South Africa, 2011.

Chehab JC, Vilakazi-Nhlapo AK, Vranken P, Peters A, Klausner JD. Current Integration of Tuberculosis (TB) and HIV Services in South Africa, 2011. PLoS One. 2013;8(3):e57791. doi: 10.1371/journal.pone.0057791. Epub 2013 Mar 4.

SETTING: Public Health Facilities in South Africa.

OBJECTIVE: To assess the current integration of TB and HIV services in South Africa, 2011.

DESIGN: Cross-sectional study of 49 randomly selected health facilities in South Africa. Trained interviewers administered a standardized questionnaire to one staff member responsible for TB and HIV in each facility on aspects of TB/HIV policy, integration and recording and reporting. We calculated and compared descriptive statistics by province and facility type.

RESULTS: Of the 49 health facilities 35 (71%) provided isoniazid preventive therapy (IPT) and 35 (71%) offered antiretroviral therapy (ART). Among assessed sites in February 2011, 2,512 patients were newly diagnosed with HIV infection, of whom 1,913 (76%) were screened for TB symptoms, and 616 of 1,332 (46%) of those screened negative for TB were initiated on IPT. Of 1,072 patients newly registered with TB in February 2011, 144 (13%) were already on ART prior to Tb clinical diagnosis, and 451 (42%) were newly diagnosed with HIV infection. Of those, 84 (19%) were initiated on ART. Primary health clinics were less likely to offer ART compared to district hospitals or community health centers (p<0.001).

CONCLUSION: As of February 2011, integration of TB and HIV services is taking place in public medical facilities in South Africa. Among these services, IPT in people living with HIV and ART in TB patients are the least available.

Abstract access 

Editor’s notes: South Africa has decentralised HIV care with impressive speed. This study aimed to quantify TB/HIV integration at a sample of health facilities in South Africa. The investigators measured service integration using a study-specific tool, which highlights the lack of an agreed way of recording and reporting integration of these services. The study highlights that there are still some primary care clinics where ART is not available, and provision of isoniazid preventive therapy remains suboptimal. The investigators do not report the proportion of clinics providing HIV and TB treatment in a single consultation by a single provider for patients requiring both treatments simultaneously. This level of integration, which intuitively would have many advantages for patients, remains rare. Full integration of TB and HIV services may be difficult to achieve while the two services are run as separate vertical programmes with separate reporting systems.

Africa
South Africa
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