Disparities in HIV screening among pregnant women--El Salvador, 2011.

OBJECTIVES: To provide an accurate estimate of antenatal HIV screening and its determinants among pregnant women in El Salvador and help local authorities make informed decisions for targeted interventions around mother-to-child transmission (MTCT). METHODS: A total sample of 4,730 women aged 15-49 years were interviewed from a random sample of 3,625 households. We collected data on antenatal care services, including HIV screening, during last pregnancy through a pre-established questionnaire. We used a backward elimination multivariate logistic regression model to examine the association between HIV screening and sociodemographic and health care-related factors. RESULTS: A total of 2,929 women were included in this analysis. About 98% of participants reported receiving antenatal care, but only 83% of these reported being screened for HIV. Screening was lower in geographic areas with higher HIV incidence and ranged from 69.1% among women who were not seen by a physician during antenatal care, to 93.7% among those who attended or completed college. Odds for screening varied also by age, employment status, household economic expenditure, possession of health care coverage, health care settings, and number of antenatal care visits. CONCLUSIONS: We found disparities in HIV screening during antenatal care at the environmental, social, demographic, and structural levels despite a high uptake of antenatal care in El Salvador. Our findings should urge health authorities to tailor and enhance current strategies implemented to eliminate MTCT and reduce inequities and HIV morbidity among women in El Salvador

Decreasing cost of public sector first-line ART services in India from 2007-2008 to 2015-2016.

INTRODUCTION:India has scaled-up antiretroviral treatment (ART) in public sector facilities, but data to understand time trends of average cost of ART are limited. MATERIALS AND METHODS:Cost and output data were collected at all public sector ART centres in undivided Andhra Pradesh (high-HIV burden state) and Rajasthan (low-HIV burden state) in India from fiscal year 2007-2008 to 2012-2013. Average cost per patient for first-line ART, and its relation with scale of services, were assessed. Using data on scale of services, the average cost was estimated up to 2015-2016. Break-even point was estimated from average and marginal cost functions. Costs were adjusted to 2015 constant price. RESULTS:The average cost per patient alive and on ART in 2015-2016 was US$162 in undivided Andhra Pradesh and US$186 in Rajasthan, which was 51.4% and 35.8% lower than in 2007-2008, respectively. Average ART drug cost declined by 27.2% during this period, and was 70.9% and 61.5% of the total ART cost in the two states in 2015-2016. The average cost other than ART drugs declined by 73.1% and 45.7%, with the number of patients served increasing 7 and 14.2 times, respectively. Average cost other than ART drugs had a significant negative relation with scale (R2 = 86.4%-82.8%, p<0.001). Break-even analysis suggested that 47.5% and 58.8% of the ART centres in undivided Andhra Pradesh and Rajasthan, respectively, were functioning below optimal scale in 2015-2016. The estimated total economic cost of first-line ART services provided in the public sector in India in fiscal year 2015-2016 was US$151 million; it would be US$ 216.1 million to provide this to all eligible persons in India. CONCLUSION:The average cost of providing first-line ART has declined in India, and further reduction is possible if the optimal scale of services is achieved. These findings can inform resource requirement for the ART programme in India

Distribution of HIV screening during pregnancy by socio-demographic and health care-related characteristics.

<p>Distribution of HIV screening during pregnancy by socio-demographic and health care-related characteristics.</p

Distribution of women from those eligible to be interviewed to those included in the analysis sample.

<p>Distribution of women from those eligible to be interviewed to those included in the analysis sample.</p

Coverage and timing of antenatal care among poor women in 6 Mesoamerican countries

Background: Poor women in the developing world have a heightened need for antenatal care (ANC) but are often the least likely to attend it. This study examines factors associated with the number and timing of ANC visits for poor women in Guatemala, Honduras, Mexico, Nicaragua, Panama, and El Salvador. Methods: We surveyed 8366 women regarding the ANC they attended for their most recent birth in the past two years. We conducted logistic regressions to examine demographic, household, and health characteristics associated with attending at least one skilled ANC visit, four skilled visits, and a skilled visit in the first trimester. Results: Across countries, 78 % of women attended at least one skilled ANC visit, 62 % attended at least four skilled visits, and 56 % attended a skilled visit in the first trimester. The proportion of women attending four skilled visits was highest in Nicaragua (81 %) and lowest in Guatemala (18 %) and Panama (38 %). In multiple countries, women who were unmarried, less-educated, adolescent, indigenous, had not wanted to conceive, and lacked media exposure were less likely to meet international ANC guidelines. In countries with health insurance programs, coverage was associated with attending skilled ANC, but not the timeliness. Conclusions: Despite significant policy reforms and initiatives targeting the poor, many women living in the poorest regions of Mesoamérica are not meeting ANC guidelines. Both supply and demand interventions are needed to prioritize vulnerable groups, reduce unplanned pregnancies, and reach populations not exposed to common forms of media. Top performing municipalities can inform effective practices across the region

Missed Opportunities for Measles, Mumps, and Rubella (MMR) Immunization in Mesoamerica: Potential Impact on Coverage and Days at Risk

<div><p>Background</p><p>Recent outbreaks of measles in the Americas have received news and popular attention, noting the importance of vaccination to population health. To estimate the potential increase in immunization coverage and reduction in days at risk if every opportunity to vaccinate a child was used, we analyzed vaccination histories of children 11–59 months of age from large household surveys in Mesoamerica.</p><p>Methods</p><p>Our study included 22,234 children aged less than 59 months in El Salvador, Guatemala, Honduras, Mexico, Nicaragua, and Panama. Child vaccination cards were used to calculate coverage of measles, mumps, and rubella (MMR) and to compute the number of days lived at risk. A child had a missed opportunity for vaccination if their card indicated a visit for vaccinations at which the child was not caught up to schedule for MMR. A Cox proportional hazards model was used to compute the hazard ratio associated with the reduction in days at risk, accounting for missed opportunities.</p><p>Results</p><p>El Salvador had the highest proportion of children with a vaccine card (91.2%) while Nicaragua had the lowest (76.5%). Card MMR coverage ranged from 44.6% in Mexico to 79.6% in Honduras while potential coverage accounting for missed opportunities ranged from 70.8% in Nicaragua to 96.4% in El Salvador. Younger children were less likely to have a missed opportunity. In Panama, children from households with higher expenditure were more likely to have a missed opportunity for MMR vaccination compared to the poorest (OR 1.62, 95% CI: 1.06–2.47). In Nicaragua, compared to children of mothers with no education, children of mothers with primary education and secondary education were less likely to have a missed opportunity (OR 0.46, 95% CI: 0.24–0.88 and OR 0.25, 95% CI: 0.096–0.65, respectively). Mean days at risk for MMR ranged from 158 in Panama to 483 in Mexico while potential days at risk ranged from 92 in Panama to 239 in El Salvador.</p><p>Conclusions</p><p>Our study found high levels of missed opportunities for immunizing children in Mesoamerica. Our findings cause great concern, as they indicate that families are bringing their children to health facilities, but these children are not receiving all appropriate vaccinations during visits. This points to serious problems in current immunization practices and protocols in poor areas in Mesoamerica. Our study calls for programs to ensure that vaccines are available and that health professionals use every opportunity to vaccinate a child.</p></div

Descriptive characteristics comparing children with and without coverage for MMR at the time of the survey (% unless otherwise noted).

<p>† N varies by variable due to missing values.</p><p>* p<0.05</p><p>** p<0.01</p><p>*** p<0.001</p><p>Descriptive characteristics comparing children with and without coverage for MMR at the time of the survey (% unless otherwise noted).</p

Child, maternal, and household characteristics associated with a child having a vaccine card^†.

<p>OR: odds ratio. CI: confidence interval.</p><p>Exponentiated coefficients; 95% confidence intervals in brackets</p><p>* p<0.05</p><p>** p<0.01</p><p>*** p<0.001</p><p>†Models adjusted for all variables in the table</p><p>Child, maternal, and household characteristics associated with a child having a vaccine card<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0139680#t002fn006" target="_blank">^†</a>.</p