Beyond health care providers’recommendations: understandinginfluences on infant feeding choices ofwomen with HIV in the Eastern Cape,South Africa

Background: Despite the array of studies on infant feeding practices of HIV-infected women, gaps still exist in the understanding of the underlying reasons for their infant feeding choices. Potential for behavioural change exists, especially in the light of the 2016 updated World Health Organization guideline on HIV and infant feeding. The aim of this paper is to determine the rate of adoption of exclusive breastfeeding in this cohort, examine the determinants of infant feeding choices of HIV-infected women and assess the underlying reasons for these choices. Methods: This was a mixed methods study conducted between September 2015 and May 2016. It analyses the quantitative and qualitative data of 1662 peripartum women enrolled in the East London Prospective Cohort Study across three large maternity services in the Eastern Cape. Women with HIV reported their preferred choices of infant feeding. In addition, participants explained the underlying reasons for their choices. Descriptive and inferential statistics summarised the quantitative data, while thematic content analysis was performed on qualitative data. Results: Of the 1662 women with complete responses, 80.3% opted to exclusively breastfeed their babies. In the adjusted model, up to grade 12 education level (AOR: 1.81; 95% CI: 1.14, 2.86), rural/peri-urban residence (AOR:1.44; 95% CI: 1.05, 1.96), alcohol use (AOR: 1.65; 95% CI: 1.25, 2.18), negative or unknown HIV status at booking (AOR:1.85; 95% CI:1.27, 2.70), currently married (AOR:1.43; 95% CI:1.01, 2.02) and WHO Clinical Stage 2–4 (AOR:1.77; 95% CI: 1.15, 2.72) were significantly associated with the decision to exclusively breastfeed. Health care providers’ recommendations, perceived benefits of breastfeeding, unaffordability of formula feeding, and coercion were the underlying reasons for wanting to breastfeed; while work/school-related demands, breast-related issues, and fear of infecting the baby influenced their decision to formula feed. Conclusion: The majority of HIV-infected women chose to breastfeed their babies in the Eastern Cape. Following up on these women to ensure they breastfeed exclusively, while also addressing their possible concerns, could be an important policy intervention. Future studies should focus on how early infant feeding decisions change over time, as well as the health outcomes for mother and child. Keywords: Exclusive breastfeeding, Infant feeding practice, infant formula feeding, HIV-infected peripartum women, South Africa, WHO guidelin

Integrating primary and secondary care to optimize hepatitis C treatment:development and evaluation of a multidisciplinary educational Masterclass series

[Background] It is increasingly being recognized that the elimination of HCV requires a multidisciplinary approach and effective cooperation between primary and secondary care.[Objectives] As part of a project (HepCare Europe) to integrate primary and secondary care for patients at risk of or infected with HCV, we developed a multidisciplinary educational Masterclass series for healthcare professionals (HCPs) working in primary care in Dublin and Bucharest. This article aims to describe and evaluate the series and examine how this model might be implemented into practice.[Methods] GPs and other HCPs working in primary care, addiction treatment services and NGOs were invited to eight 1 day symposia (HCV Masterclass series), examining the burden and management of HCV in key populations. Peer-support sessions were also conducted, to give people affected by HCV and community-based organizations working with those directly affected, an update on the latest developments in HCV treatment.[Results] One hundred percent of participants ‘strongly agreed’ or ‘agreed’ that the Masterclass helped them to appreciate the role of integrated services in ‘the management of patients with HCV’. One hundred percent of participants indicated the importance of a ‘designated nurse to liaise with hospital services’. An improvement of knowledge regarding HCV management of patients with high-risk behaviour was registered at the end of the course.[Conclusions] Integrated approaches to healthcare and improving the knowledge of HCPs and patients of the latest developments in HCV treatment are very important strategies that can enhance the HCV care pathway and treatment outcomes.This work was supported by the European Commission through its EU Third Health Programme (Grant Agreement Number 709844) and Ireland’s Health Services Executive.Peer reviewe

Integrated Hepatitis C Care for People Who Inject Drugs (Heplink):Protocol for a Feasibility Study in Primary Care

BACKGROUND: Hepatitis C virus (HCV) infection is a major cause of chronic liver disease and death. Drug use remains the significant cause of new infections in the European Union, with estimates of HCV antibody prevalence among people who inject drugs ranging from 5% to 90% in 29 European countries. In Ireland and the European Union, primary care is a key area to focus efforts to enhance HCV diagnosis and treatment among people who inject drugs. OBJECTIVE: The Heplink study aims to improve HCV care outcomes among opiate substitution therapy (OST) patients in general practice by developing an integrated model of HCV care and evaluating its feasibility, acceptability, and likely efficacy. METHODS: The integrated model of care comprises education of community practitioners, outreach of an HCV-trained nurse into general practitioner (GP) practices, and enhanced access of patients to community-based evaluation of their HCV disease (including a novel approach to diagnosis, that is, Echosens FibroScan Mini 430). A total of 24 OST-prescribing GP practices were recruited from the professional networks and databases of members of the research consortium. Patients were eligible if they are aged ≥18 years, on OST, and attend the practice for any reason during the recruitment period. Baseline data on HCV care processes and outcomes were extracted from the clinical records of participating patients. RESULTS: This study is ongoing and has the potential to make an important impact on patient care and provide high-quality evidence to help GPs make important decisions on HCV testing and onward referral. CONCLUSIONS: A substantial proportion of HCV-positive patients on OST in general practice are not engaged with specialist hospital services but qualify for direct-acting antiviral drugs treatment. The Heplink model has the potential to reduce HCV-related morbidity and mortality. REGISTERED REPORT IDENTIFIER: RR1-10.2196/9043

Integrating hepatitis C care for at-risk groups (HepLink):baseline data from a multicentre feasibility study in primary and community care

OBJECTIVES To examine HCV prevalence and management among people who inject drugs (PWID) attending primary care and community-based health services at four European sites using baseline data from a multicentre feasibility study of a complex intervention (HepLink). METHODS Primary care and community-based health services in Dublin, London, Bucharest and Seville were recruited from the professional networks of the HepLink consortium. Patients were eligible to participate if aged ≥18 years, on opioid substitution treatment or at risk of HCV (i.e. injecting drug use, homeless or incarcerated), and attended the service. Data on patient demographics and prior HCV management were collected on participants at baseline. RESULTS Twenty-nine primary care and community-based health services and 530 patients were recruited. Baseline data were collected on all participants. Participants' mean age ranged from 35 (Bucharest) to 51 years (London), with 71%-89% male. Prior lifetime HCV antibody testing ranged from 65% (Bucharest) to 95% (Dublin) and HCV antibody positivity among those who had been tested ranged from 78% (Dublin) to 95% (Bucharest). Prior lifetime HCV RNA testing among HCV antibody-positive participants ranged from 17% (Bucharest) to 84% (London). Among HCV antibody- or RNA-positive participants, prior lifetime attendance at a hepatology/infectious disease service ranged from 6% (London) to 50% (Dublin) and prior lifetime HCV treatment initiation from 3% (London) to 33% (Seville). CONCLUSIONS Baseline assessment of the HCV cascade of care among PWID attending primary care and community-based health services at four European sites identified key aspects of the care cascade at each site that need to be improved

'HepCheck Dublin': An Intensified Hepatitis C Screening Programme in a Homeless Population Demonstrates the Need for Alternative Models of Care

Background: Hepatitis C virus (HCV) is one of the main causes of chronic liver disease worldwide. Prevalence of HCV in homeless populations ranges from 3.9% to 36.2%. The HepCheck study sought to investigate and establish the characterisation of HCV burden among individuals who attended an intensified screening programme for HCV in homeless services in Dublin, Ireland. Methods: The HepCheck study was conducted as part of a larger European wide initiative called HepCare Europe. The study consisted of three phases; 1) all subjects completed a short survey and were offered a rapid oral HCV test; 2) a convenience sample of HCV positive participants from phase 1 were selected to complete a survey on health and social risk factors and 3) subjects were tracked along the referral pathway to identify whether they were referred to a specialist clinic, attended the specialist clinic, were assessed for cirrhosis by transient elastography (Fibroscan) and were treated for HCV. Results: 597 individuals were offered HCV screening, 73% were male and 63% reported having had a previous HCV screening. We screened 538 (90%) of those offered screening, with 37% testing positive. Among those who tested positive, 112 (56%) were ‘new positives’ and 44% were ‘known positives’. Undiagnosed HCV was prevalent in 19% of the study sample. Active past 30-day drug use was common, along with attendance for drug treatment. Unstable accommodation was the most common barrier to attending specialist appointments and accessing treatment. Depression and anxiety, dental problems and respiratory conditions were common reported health problems. 46 subjects were referred to specialised services and two subjects completed HCV treatment. Conclusions: This study demonstrates that the current hospital-based model of care is inadequate in addressing the specific needs of a homeless population and emphasises the need for a community-based treatment approach. Findings are intended to inform HepCare Europe in their development of a community-based model of care in order to engage with homeless individuals with multiple co-morbidities including substance abuse, who are affected by or infected with HCV

An In-Depth Review of the Benefits of Antibiotic Use in the Treatment of Borreliosis in Pregnancy

Evidence of congenital transmission of Lyme disease from mother to fetus has been investigated since the 1980s. This study reports the results of a retrospective analysis of 31 studies described in 27 papers published in a 2018 review article. Analysis of these identified statistically probable transmission in 13 (42%) of the 31 studies and possible transmission in 2 (6%). Most studies included mothers who had been treated with antimicrobials. When no antimicrobials were used, 74% of the pregnancies had adverse outcomes. When oral antimicrobials were used, 29% of pregnancies had adverse outcomes. When intravenous (IV) antimicrobials were used, adverse outcomes dropped to 12% of the pregnancies. This is a six-fold reduction in risk compared with no antimicrobial treatment. Some studies did not define whether oral or IV antimicrobials were used. When these results were included, adverse outcomes were 30 times higher for untreated mothers. Adverse outcomes included deaths, heart anomalies, and preterm births

Hepatitis C prevalence and management among patients receiving opioid substitution treatment in general practice in Ireland: baseline data from a feasibility study.

BACKGROUND: Hepatitis C virus (HCV) infection is a major cause of chronic liver disease and death. Injection drug use is now one of the main routes of transmission of HCV in Ireland and globally with an estimated 80% new infections occurring among people who inject drugs (PWID). OBJECTIVE: We aimed to examine whether patients receiving opioid substitution therapy in primary care practices in Ireland were receiving guideline-adherent care regarding HCV screening. Ireland has developed a model of care for delivering opioid substitution treatment in the primary care setting. We conducted this study given the shift of providing care for PWID from secondary to primary care settings, in light of current guidelines aimed at scaling up interventions to reduce chronic HCV infection and associated mortality. METHODS: We included baseline data from the Dublin site of the Heplink study, a feasibility study focusing on developing complex interventions to enhance community-based HCV treatment and improve the HCV care pathway between primary and secondary care. We recruited 14 opioid substitution treatment-prescribing general practices that employed the administration of opioid substitution therapy from the professional networks and databases of members of the research consortium. A standardized nonprobability sampling framework was used to identify 10 patients from each practice to participate in the study. Patients were eligible if aged ≥18 years, on opioid substitution treatment, and attending the practice for any reason during the recruitment period. The baseline data were collected from the clinical records of participating patients. We collected and analyzed data on demographic characteristics, care processes and outcomes regarding HCV and other blood-borne viruses, urinalysis test results, alcohol use disorders, chronic illness, and health service utilization. We examined whether patients received care concordant with guidelines related to HCV screening and care. RESULTS: The baseline data were collected from clinical records of 134 patients; 72.2% (96/134) were males; (mean age 43, SD 7.6; range 27-71 years); 94.8% (127/134) of patients had been tested for anti-HCV antibody in their lifetime; of those, 77.9% (99/127) tested positive. Then, 83.6% (112/134) of patients had received an HIV antibody test in their lifetime; of those, 6.3% (7/112) tested HIV positive. Moreover, 66.4% (89/134) of patients had been tested for hepatitis B virus in their lifetime and 8% (7/89) of those were positive. In the 12 months before the study, 30.6% (41/134) of patients were asked about their alcohol use by their general practitioner, 6.0% (8/134) received a brief intervention, and 2.2% (3/134) were referred to a specialist addiction or alcohol treatment service. CONCLUSIONS: With general practice and primary care playing an increased role in HCV care, this study highlights the importance of prioritizing the development and evaluation of real-world clinical solutions that support patients from diagnosis to treatment completion

High rate of unplanned pregnancy in the context of integrated family planning and HIV care services in South Africa

Abstract Background Integration of family planning services into HIV care was implemented in South Africa as a core strategy aimed at reducing unintended pregnancies among childbearing women living with HIV. However, it is unclear whether this strategy has made any significant impact at the population level. This paper describes the prevalence and correlates of self-reported unplanned pregnancy among HIV-infected parturient women attending three large maternity centres in the Eastern Cape, South Africa. We also compare unplanned pregnancy rates between HIV-infected parturient women already in care (who have benefitted from services’ integration) and newly diagnosed parturient women (who have not benefitted from services’ integration). Methods Drawing from the baseline data of the East London Prospective Cohort Study (ELPCS), data of 594 parturient women living with HIV in the Eastern Cape were included. Chi-square statistics and binary logistics regression were employed to determine the correlates of unplanned pregnancy among the cohort. Results The prevalence of unplanned pregnancy was 71% (n = 422) with a higher rate among parturient women newly diagnosed during the index pregnancy (87%). Unplanned pregnancy was significantly associated with younger age, single status, HIV diagnosis at booking, high parity and previous abortion. Women who reported unplanned pregnancy were more likely to book late and have lower CD4 counts. After adjusting for confounding variables, having one child and five to seven children (AOR = 2.2; CI = 1.3–3.1), age less than 21 years (AOR = 3.3; CI = 1.1–9.8), late booking after 27 weeks (AOR = 2.7; CI = 1.5–5.0), not married (AOR = 4.3; CI = 2.7–6.8) and HIV diagnosis at booking (AOR = 3.0; CI = 1.6–5.8) were the significant correlates of unplanned pregnancy in the cohort. Conclusion Unplanned pregnancy remains high overall among parturient women living with HIV in the region, however, with significant reduction among those who were exposed to integrated services. The study confirms that integration of HIV care and family planning services is an important strategy to reduce unplanned pregnancy among women living with HIV. The study’s findings have significant implications for the elimination of mother-to-child transmission of HIV in South Africa. Innovative interventions are needed to further consolidate and maximise the benefit of the integration of family planning services with HIV care