Capacity of non-tertiary Kenyan health facilities selected for decentralised dental training

Objective: To determine the capacity of six non-tertiary Kenyan hospitals enrolled as sites for decentralised dental education.Design: A descriptive cross-sectional study.Setting: The Dental departments of six non-tertiary Kenyan health facilities.Main outcome measures: Capacity of the hospitals to be used as sites for decentralised dental education.Results: Five out of the six facilities had capacity for final year undergraduate students to gain learning experiences in more than 60% of the clinical disciplines studied. All the selected facilities had challenges of lack of specialists, broken down dental equipment and inadequate materials.Conclusion: Although the six hospitals faced various challenges in maintenance of equipment, availability of dental materials and specialist staff, five out of the six facilities had the capacity for dental student learning in more than 60% of the clinical disciplines studied

Reminder systems for self uterine massage in the prevention of postpartum blood loss

Background: Uterine massage may significantly reduce post partum blood loss and could be patient-driven.Objective: To assess the effectiveness of an alarm reminder system for self uterine massage in the prevention of post partum blood loss.Design: A random controlled trial.Setting: Meru District Hospital, Kenya.Subjects: One hundred and twenty seven (127) women were randomly assigned to a 15 minute alarm reminder system (71) and non-alarm (56) control arm during the fourth stage of labour.Results: Uterine massage compliance was better in the alarm group compared to the non-alarm group ( Average massage of seven and two in two hours respectively P-value <0.0001), however the difference in blood loss was not significant 45.6 ml (95% CI 43-46) vs 47.1 ml (95% CI 43-52)ml p-value 0.892.Conclusion: Uterine massage compliance is remarkably increased by the use of an alarm reminder

Reminder Systems for Self uterine massage in the prevention of postpartum blood loss

Background: Uterine massage may significantly reduce post partum blood loss and could be patient-driven. Objective: To assess the effectiveness of an alarm reminder system for self uterine massage in the prevention of post partum blood loss. Design: A random controlled trial. Setting: Meru District Hospital, Kenya. Subjects: One hundred and twenty seven (127) women were randomly assigned to a 15 minute alarm reminder system (71) and non-alarm (56) control arm during the fourth stage of labour. Results: Uterine massage compliance was better in the alarm group compared to the non-alarm group ( Average massage of seven and two in two hours respectively P-value Conclusion: Uterine massage compliance is remarkably increased by the use of an alarm reminder

Maternal valacyclovir and infant cytomegalovirus acquisition: a randomized controlled trial among HIV-infected women.

Background Studies in HIV-1-infected infants and HIV-1-exposed, uninfected infants link early cytomegalovirus (CMV) acquisition with growth delay and cognitive impairment. We investigated maternal valacyclovir to delay infant acquisition of CMV. Methods Pregnant women with HIV-1, HSV-2 and CD4 count >250 cells/µl were randomized at 34 weeks gestation to 500 mg twice-daily valacyclovir or placebo for 12 months. Maternal CMV DNA was measured in plasma at 34 weeks gestation, in cervical secretions at 34 and 38 weeks gestation, and in breast milk at 7 postpartum timepoints; infant CMV DNA was measured in dried blood spots at 8 timepoints including birth. Results Among 148 women, 141 infants were compared in intent-to-treat analyses. Maternal and infant characteristics were similar between study arms. Infant CMV acquisition did not differ between study arms, with 46/70 infants (66%) in placebo arm and 47/71 infants (66%) in the valacyclovir arm acquiring CMV; median time to CMV detection did not differ. CMV DNA was detected in 92% of 542 breast milk specimens with no difference in CMV level between study arms. Change in cervical shedding of CMV DNA between baseline and 38 weeks was 0.40-log greater in the placebo arm than the valacyclovir arm (p = 0.05). Conclusions In this cohort of HIV-1-seropositive mothers, two-thirds of infants acquired CMV by one year. Maternal valacyclovir had no effect on timing of infant CMV acquisition or breast milk CMV viral loads, although it modestly reduced cervical CMV shedding. Maternal prophylaxis to reduce infant CMV acquisition warrants further evaluation in trials with antiviral agents

Is 'Opt-Out HIV Testing' a real option among pregnant women in rural districts in Kenya?

PMTCT allows people living with HIV to actualize childbearing. However, it also complicates motherhood, as the medical consequences and public health implications of non-adherence to PMTCT service recommendations disrupt socio-cultural expectations of childbearing and parenthood. This thesis aimed to study childbearing and adherence to PMTCT interventions focusing on how women living with HIV realize motherhood in Kenya. We sought to answer how women on ART experience motherhood and how motherhood aggravate adherence to PMTCT services Methods: A quantitative cross sectional study (I) with a questionnaire survey conducted among pregnant women at their first visit to antenatal clinic to study consent to HIV testing and three qualitative studies analyzed with content analysis (II and IV) and narrative structuring (III) were included. Qualitative interviews were performed with women living with HIV who were pregnant, recently delivered and those actively planning a pregnancy to explore views and experiences when seeking a pregnancy (II), the reasoning and deciding about adherence to PMTCT (III) and how motherhood interferes with HIV treatment (IV). Results: ‘Striving for motherhood’ was the overriding theme describing the desire of women on ART to be parents while negotiating the challenges of living with HIV (IIV). Children improve women’s position in society and are a sign of a happy and fulfilled life (II-IV). Of 900 pregnant women surveyed at their first visit to antenatal care clinic, only 17% understood that HIV testing is optional (I). Making an informed decision to decline HIV testing was associated with knowing that testing was optional (OR=5.44, 95%CI 3.44-8.59), not having a stable relationship with the child’s father (OR=1.76, 95%CI 1.02-3.03), and not having discussed HIV testing with a partner before the ANC visit (OR=2.64 95%CI 1.79-3.86). Socio-economic affluence and residence influence behaviors such as no condom use, non-disclosure of HIV infection, use of traditional medicine simultaneously with ART, home delivery and stigma and discrimination from partners, family and community, all of which undermine adherence to PMTCT services (II-IV). Structural shortcomings in PMTCT result in the lack of antiretroviral HIV medicines, practice of mixed infant feeding and missed appointments (I, III, IV). Conclusion: Motherhood is achieved at the cost of striving to balance socio-cultural expectations of childbearing that also conceals their HIV infection at the cost of nonadherence to PMTCT recommendations. Being infected with HIV does not remove the desire of motherhood and related socio-cultural demands. It is important to acknowledge the significance childbearing among women infected with HIV to improve adherence. Women with chronic illness such as HIV-infection who are dependent on continuous medication and health check-ups struggle to balance the desire for children with the needs related to their illness and the expectations of being a ‘good mother’

Increasing the uptake of prevention of mother-to-child transmission of HIV services in a resource-limited setting

<p>Abstract</p> <p>Background</p> <p>As in other resource limited settings, the Ministry of Health in Zambia is challenged to make affordable and acceptable PMTCT interventions accessible and available. With a 14.3% HIV prevalence, the MOH estimates over one million people are HIV positive in Zambia. Approximately 500,000 children are born annually in Zambia and 40,000 acquire the infection vertically each year if no intervention is offered. This study sought to review uptake of prevention of mother-to-child (PMTCT) services in a resource-limited setting following the introduction of context-specific interventions.</p> <p>Methods</p> <p>Interventions to improve PMTCT uptake were introduced into 38 sites providing PMTCT services in Zambia in July 2005. Baseline and follow up service data were collected on a monthly basis through September 2008. Data was checked for internal and external consistency using logic built into databases used for data management. Data audits were conducted to determine accuracy and reliability. Trends were analyzed pre- and post- intervention.</p> <p>Results</p> <p>Uptake among pregnant women increased across the 13 quarters (39 months) of observation, particularly in the case of acceptance of counseling and HIV testing from 45% to 90% (p value = 0.00) in the first year and 99% by year 3 (p value = 0.00). Receipt of complete course of antiretroviral (ARV) prophylaxis increased from 29% to 66% (p = 0.00) in the first year and 97% by year 3 (p value = 0.00). There was also significant improvement in the percentage of HIV positive pregnant women referred for clinical care.</p> <p>Conclusions</p> <p>Uptake of PMTCT services in resource-limited settings can be improved by utilizing innovative alternatives to mitigate the effects of human resource shortage such as by providing technical assistance and mentorship beyond regular training courses, integrating PMTCT services into existing maternal and child health structures, addressing information gaps, mobilizing traditional and opinion leaders and building strong relationships with the government. These health system based approaches provide a sustainable improvement in the capacity and uptake of services.</p

Determinants of male involvement in the prevention of mother-to-child transmission of HIV programme in Eastern Uganda: a cross-sectional survey

Background: Mother-to-child transmission of HIV (MTCT) accounts for over 95% of all paediatric HIV infections worldwide. Several studies have shown that male participation in the antenatal care of their spouses together with couple counselling and testing for HIV, increases use of the interventions for HIV prevention. The prevention programme of MTCT (PMTCT) was launched in Uganda in 2000 and Mbale in 2002. Less than 10% of the pregnant women accepted antenatal HIV testing at Mbale Regional Referral Hospital in 2003; couple counselling and testing for HIV was low. Therefore, we conducted the study to determine the level of male involvement and identify its determinants in the PMTCT programme. Methods: A cross-sectional survey of 388 men aged 18 years or more, whose spouses were attending antenatal care at Mbale Regional Referral Hospital, was conducted in Mbale district, Eastern Uganda. A male involvement index was constructed based on 6 questions. The survey was complemented by eight focus group discussions and five in-depth interviews. Results: The respondents had a median age of 32 years (inter-quartile range, IQR: 28-37). The majority (74%) had a low male involvement index and only 5% of men accompanied their spouses to the antenatal clinic. Men who had attained secondary education were more likely to have a high male involvement index (OR: 1.9, 95% CI: 1.1-3.3) than those who had primary or no formal education. The respondents, whose occupation was driver (OR: 0.3, 95% CI: 0.1-0.7) or those who had fear of disclosure of their HIV sero-status results to their spouses (OR: 0.4, 95% CI: 0.2-0.8), were less likely to have a high male involvement index. Barriers to male involvement in the PMTCT programme were related to both the poor health system, to socio-economic factors and to cultural beliefs. Conclusions: Structural and cultural barriers to men's involvement in the PMTCT programme in Mbale district were complex and interrelated. Community sensitization of men about the benefits of antenatal care and PMTCT and improving client-friendliness in the clinics needs to be prioritised in order to improve low male participation and mitigate the effect of socio-economic and cultural factors

Predictors of HIV Serostatus Disclosure to Partners among HIV-Positive Pregnant women in Morogoro, Tanzania.

Prevention of mother to child transmission of HIV (PMTCT) has been scaled, to more than 90% of health facilities in Tanzania. Disclosure of HIV results to partners and their participation is encouraged in the program. This study aimed to determine the prevalence, patterns and predictors of HIV sero-status disclosure to partners among HIV positive pregnant women in Morogoro municipality, Tanzania. A cross sectional study was conducted in March to May 2010 among HIV-positive pregnant women who were attending for routine antenatal care in primary health care facilities of the municipality and had been tested for HIV at least one month prior to the study. Questionnaires were used to collect information on possible predictors of HIV disclosure to partners. A total of 250 HIV-positive pregnant women were enrolled. Forty one percent (102) had disclosed their HIV sero-status to their partners. HIV-disclosure to partners was more likely among pregnant women who were < 25 years old [Adjusted odds ratio (AOR) = 2.2; 95% CI: 1.2--4.1], who knew their HIV status before the current pregnancy [AOR = 3.7; 95% CI: 1.7--8.3], and discussed with their partner before testing [AOR = 6.9; 95% CI: 2.4--20.1]. Dependency on the partner for food/rent/school fees, led to lower odds of disclosure to partners [AOR = 0.4; 95% CI: 0.1--0.7]. Nine out of ten women reported to have been counseled on importance of disclosure and partner participation. Six in ten HIV positive pregnant women in this setting had not disclosed their results of the HIV test to their partners. Empowering pregnant women to have an individualized HIV-disclosure plan, strengthening of the HIV provider initiated counseling and testing and addressing economic development, may be some of the strategies in improving HIV disclosure and partner involvement in this setting

No Association between HIV and Intimate Partner Violence among Women in 10 Developing Countries

Intimate Partner Violence (IPV) has been reported to be a determinant of women's risk for HIV. We examined the relationship between women's self-reported experiences of IPV in their most recent relationship and their laboratory-confirmed HIV serostatus in ten low- to middle-income countries.Data for the study came from the most recent Demographic and Health Surveys conducted in Dominican Republic, Haiti, India, Kenya, Liberia, Malawi, Mali, Rwanda, Zambia and Zimbabwe. Each survey population was a cross-sectional sample of women aged 15-49 years. Information on IPV was obtained by a face-to-face interview with the mother with an 81.1% response rate; information on HIV serostatus was obtained from blood samples with an 85.3% response rate. Demographic and socioeconomic variables were considered as potentially confounding covariates. Logistic regression models accounting for multi-stage survey design were estimated individually for each country and as a pooled total with country fixed effects (n = 60,114). Country-specific adjusted odds ratios (OR) for physical or sexual IPV compared to neither ranged from 0.45 [95% confidence interval (CI): 0.23-0.90] in Haiti to 1.35 [95% CI: 0.95-1.90] in India; the pooled association was 1.03 [95% CI: 0.94-1.13]. Country-specific adjusted ORs for physical and sexual IPV compared to no sexual IPV ranged from 0.41 [95% CI: 0.12-1.36] in Haiti to 1.41 [95% CI: 0.26-7.77] in Mali; the pooled association was 1.05 [95% CI: 0.90-1.22].IPV and HIV were not found to be consistently associated amongst ever-married women in national population samples in these lower income countries, suggesting that IPV is not consistently associated with HIV prevalence worldwide. More research is needed to understand the circumstances in which IPV and HIV are and are not associated with one another

Potential impact of infant feeding recommendations on mortality and HIV-infection in children born to HIV-infected mothers in Africa: a simulation

<p>Abstract</p> <p>Background</p> <p>Although breast-feeding accounts for 15–20% of mother-to-child transmission (MTCT) of HIV, it is not prohibited in some developing countries because of the higher mortality associated with not breast-feeding. We assessed the potential impact, on HIV infection and infant mortality, of a recommendation for shorter durations of exclusive breast-feeding (EBF) and poor compliance to these recommendations.</p> <p>Methods</p> <p>We developed a deterministic mathematical model using primarily parameters from published studies conducted in Uganda or Kenya and took into account non-compliance resulting in mixed-feeding practices. Outcomes included the number of children HIV-infected and/or dead (cumulative mortality) at 2 years following each of 6 scenarios of infant-feeding recommendations in children born to HIV-infected women: Exclusive replacement-feeding (ERF) with 100% compliance, EBF for 6 months with 100% compliance, EBF for 4 months with 100% compliance, ERF with 70% compliance, EBF for 6 months with 85% compliance, EBF for 4 months with 85% compliance</p> <p>Results</p> <p>In the base model, reducing the duration of EBF from 6 to 4 months reduced HIV infection by 11.8% while increasing mortality by 0.4%. Mixed-feeding in 15% of the infants increased HIV infection and mortality respectively by 2.1% and 0.5% when EBF for 6 months was recommended; and by 1.7% and 0.3% when EBF for 4 months was recommended. In sensitivity analysis, recommending EBF resulted in the least cumulative mortality when the a) mortality in replacement-fed infants was greater than 50 per 1000 person-years, b) rate of infection in exclusively breast-fed infants was less than 2 per 1000 breast-fed infants per week, c) rate of progression from HIV to AIDS was less than 15 per 1000 infected infants per week, or d) mortality due to HIV/AIDS was less than 200 per 1000 infants with HIV/AIDS per year.</p> <p>Conclusion</p> <p>Recommending shorter durations of breast-feeding in infants born to HIV-infected women in these settings may substantially reduce infant HIV infection but not mortality. When EBF for shorter durations is recommended, lower mortality could be achieved by a simultaneous reduction in the rate of progression from HIV to AIDS and or HIV/AIDS mortality, achievable by the use of HAART in infants.</p