Towards control of the global HIV epidemic: addressing the middle-90 challenge in the UNAIDS 90–90–90 target

In a Perspective, Collins Iwuji and Marie-Louise Newell discuss early findings from Richard Hayes and colleagues' PopART study on HIV testing and treatment.</p

HIV status, breastfeeding modality at 5 months and postpartum maternal weight changes over 24 months in rural South Africa

ObjectiveTo determine the effect of infant feeding practices on postpartum weight change among HIV-infected and -uninfected women in South Africa.MethodsIn a non-randomised intervention cohort study of antiretroviral therapy-naïve women in South Africa, infants were classified as exclusive (EBF), mixed (MF) or non-breastfed (NBF) at each visit. We analysed infant feeding cumulatively from birth to 5 months using 24-hour feeding history (collected weekly for each of the preceding 7 days). Using generalised estimating equation mixed models, allowing for repeated measures, we compared postpartum weight change (kg) from the first maternal postpartum weight within the first 6 weeks (baseline weight) to each subsequent visit through 24 months among 2340 HIV-infected and -uninfected women with live births and at least two postpartum weight measurements.ResultsHIV-infected (?0.2 kg CI: ?1.7 to 1.3 kg; P = 0.81) and -uninfected women (?0.5 kg; 95% CI: ?2.1 to 1.2 kg; P = 0.58) had marginal non-significant weight loss from baseline to 24 months postpartum. Adjusting for HIV status, socio-demographic, pregnancy-related and infant factors, 5-month feeding modality was not significantly associated with postpartum weight change: weight change by 24 months postpartum, compared to the change in the reference EBF group, was 0.03 kg in NBF (95% CI: ?2.5 to +2.5 kg; P = 0.90) and 0.1 kg in MF (95% CI: ?3.0 to +3.2 kg; P = 0.78).ConclusionHIV-infected and -uninfected women experienced similar weight loss over 24 months. Weight change postpartum was not associated with 5-month breastfeeding modality among HIV-infected and -uninfected women.ObjectifDéterminer l'effet des pratiques d'alimentation des nourrissons sur la variation du poids postpartum chez les femmes infectées et non infectées par le VIH en Afrique du Sud.MéthodesDans une étude de cohorte d'intervention non randomisée sur la thérapie aux antirétroviraux, les nourrissons de femmes naïves pour le traitement en Afrique du Sud, ont été classés comme allaités exclusivement au sein (EBF), recevant une alimentation mixte (MF) ou non allaités au sein (NBF), à chaque visite. Nous avons analysé l'alimentation du nourrisson cumulativement de la naissance à cinq mois, en utilisant l'historique de l'alimentation sur 24 heures (recueillies hebdomadairement pour chacun des sept jours précédents). En utilisant l’équation d'estimation des modèles mixtes généralisés, permettant des mesures répétées, nous avons comparé les changements de poids (kg) postpartum de la première mesure du poids postpartum de la mère endéans les six premières semaines (poids de base) au poids à chaque visite subséquente durant 24 mois chez 2340 femmes infectées et non infectées par le VIH, ayant eu des naissances vivantes et au moins deux mesures du poids postpartum.RésultatsLa perte de poids des femmes infectées (-0,2 kg; IC: -1,7 à 1,3 kg; P = 0,81) et non infectées (0,5 kg, IC95%: -2,1 à 1,2 kg; P = 0,58) par le VIH était marginalement non significative de la base à 24 mois postpartum. En ajustant pour le statut VIH et sociodémographique, pour les facteurs liés à la grossesse et infantiles, le mode d'alimentation sur cinq mois n’étaient pas significativement associé à la variation du poids postpartum; la variation de poids sur 24 mois postpartum comparée à celle dans le groupe EBF de référence, était de 0,03 kg chez les NBF (IC95%: -2,5 à 2,5 kg; P = 0,90) et 0,1 kg chez les MF (IC95%: -3,0 à 3,2 kg; P = 0,78).ConclusionLes femmes infectées et non infectées par le VIH connaissent une perte de poids similaire sur 24 mois. La variation du poids postpartum n'a pas été associée au mode d'allaitement à cinq mois chez les femmes infectées et non infectées par le VIH.ObjetivoDeterminar el efecto de las prácticas de alimentación de los bebés en la variación del peso materno postparto entre mujeres infectadas y no infectadas con VIH en Sudáfrica.MétodosEn una intervención en Sudáfrica no aleatorizada, dentro de un estudio de cohortes de mujeres que no habían recibido anteriormente terapia antirretroviral (naive) – los bebés de se clasificaron como recibiendo exclusivamente el pecho (EP), alimentación mixta (AM), o que no eran amamantados (NA) en cada visita. Hemos analizado la alimentación acumulativa del bebé, desde el nacimiento hasta los cinco meses de edad, utilizando un historial de alimentación de 24 horas (recogido semanalmente para los 7 días anteriores). Utilizando modelos mixtos de ecuaciones de estimación generalizadas, permitiendo medidas repetidas, hemos comparado el cambio de peso (kg) durante el postparto - desde la primera pesada dentro de las primeras seis semanas postparto (peso inicial) con cada visita subsiguiente, durante los 24 meses posteriores, para 2340 mujeres - infectadas con VIH y sin infectar – que dieron a luz bebés nacidos vivos y que tenían recogidas al menos dos pesadas postparto.ResultadosLas mujeres infectadas con VIH (-0.2 kg IC: -1.7 – 1.3 kg; P = 0.81) y aquellas no infectadas (-0.5kg; 95% IC: -2.1 – 1.2 kg; P =0.58) tenían una pérdida de peso marginal y no significativa entre el comienzo del estudio hasta los 24 meses después del parto. Ajustando para el estatus de VIH, los factores sociodemográficos y relacionados con el embarazo y el bebé, la modalidad de alimentación del bebé durante sus cinco primeros meses no estaba significativamente asociada con el cambio de peso postparto: el cambio de peso 24 meses después del parto, comparada con el cambio en referencia al grupo EP, era de 0.03 kg en NA (IC 95%: -2.5 – +2.5 kg; P = 0.90) y 0.1 kg en AM (IC 95%: -3.0 – +3.2 kg; P = 0.78).ConclusiónLas mujeres infectadas con VIH y aquellas sin infección experimentaron una pérdida de peso similar en los 24 meses postparto. El cambio de peso no estaba asociado con la modalidad de amamantamiento entre las mujeres VIH positivas y VIH negativas

Increased mortality risk for motherless children aged less than 5 years:a systematic review and meta-analysis

Objective: To investigate, within so-called general populations, the relationship between maternal survival and mortality of children younger than five years.Methods: We conducted a systematic review of literature published between January 1990 and November 2016 that reported maternal vital status and the corresponding mortality of children younger than five years. Seven studies were included in a qualitative analysis and four in a random-effects meta-analysis. Summary estimates of the odds of dying by maternal survival were obtained and statistical heterogeneity estimated. Quality of the included studies and evidence was assessed using a Cochrane tool for assessing risk of bias and the Grading of Recommendations Assessment, Development and Evaluation criteria, respectively.Findings: Among children younger than five years, those whose mother had died were found to be 4.09 times (95% confidence interval, CI: 2.40–6.98) more likely to die than those with surviving mothers. Due to heterogeneity (I2: 83%), further pooled estimates were not possible. For children that were motherless as a result of maternal mortality, the increased odds of dying ranged from 1.40 (95% CI: 0.47–4.21) to 2.92 (95% CI: 1.21–7.04) among those aged between two and four years, 6.1 (95% CI: 2.27–16.77) to 33.78 (95% CI: 24.21–47.14) for those younger than one year and 4.39 (95% CI: 3.34–5.78) to 51.68 (95% CI: 20.26–131.80) for those younger than six months.Conclusion: The loss of a mother was associated with increased mortality among children, especially when maternal death occurred in the first year of the child’s life

Verbal autopsy-based cause-specific mortality trends in rural KwaZulu-Natal, South Africa, 2000-2009

<p>Abstract</p> <p>Background</p> <p>The advent of the HIV pandemic and the more recent prevention and therapeutic interventions have resulted in extensive and rapid changes in cause-specific mortality rates in sub-Saharan Africa, and there is demand for timely and accurate cause-specific mortality data to steer public health responses and to evaluate the outcome of interventions. The objective of this study is to describe cause-specific mortality trends based on verbal autopsies conducted on all deaths in a rural population in KwaZulu-Natal, South Africa, over a 10-year period (2000-2009).</p> <p>Methods</p> <p>The study used population-based mortality data collected by a demographic surveillance system on all resident and nonresident members of 12,000 households. Cause of death was determined by verbal autopsy based on the standard INDEPTH/WHO verbal autopsy questionnaire. Cause of death was assigned by physician review and the Bayesian-based InterVA program.</p> <p>Results</p> <p>There were 11,281 deaths over 784,274 person-years of observation of 125,658 individuals between Jan. 1, 2000 and Dec. 31, 2009. The cause-specific mortality fractions (CSMF) for the population as a whole were: HIV-related (including tuberculosis), 50%; other communicable diseases, 6%; noncommunicable lifestyle-related conditions, 15%; other noncommunicable diseases, 2%; maternal, perinatal, nutritional, and congenital causes, 1%; injury, 8%; indeterminate causes, 18%. Over the course of the 10 years of observation, the CSMF of HIV-related causes declined from a high of 56% in 2002 to a low of 39% in 2009 with the largest decline starting in 2004 following the introduction of an antiretroviral treatment program into the population. The all-cause age-standardized mortality rate (SMR) declined over the same period from a high of 174 (95% confidence interval [CI]: 165, 183) deaths per 10,000 person-years observed (PYO) in 2003 to a low of 116 (95% CI: 109, 123) in 2009. The decline in the SMR is predominantly due to a decline in the HIV-related SMR, which declined in the same period from 96 (95% CI: 89, 102) to 45 (95% CI: 40, 49) deaths per 10,000 PYO.</p> <p>There was substantial agreement (79% kappa = 0.68 (95% CI: 0.67, 0.69)) between physician coding and InterVA coding at the burden of disease group level.</p> <p>Conclusions</p> <p>Verbal autopsy based methods enabled the timely measurement of changing trends in cause-specific mortality to provide policymakers with the much-needed information to allocate resources to appropriate health interventions.</p

An approach to measuring dispersed families with a particular focus on children 'left behind' by migrant parents: findings from rural South Africa

There is growing policy and academic interest in the conditions, experiences, and well-being of migrant families stretched across origin and destination households. In South Africa, the dispersal of children and migrant parents across multiple households is a commonplace childhood experience. However, in common with the broader international context, quantitative analyses of the social and residential connections between children and migrant parents in South Africa have been limited by the lack of available data that document family arrangements from the perspective of more than one household. This paper describes a new data collection effort in the origin and destination households of migrants from rural KwaZulu-Natal and explains the methodology for using this data to examine multiple household contexts for children and parents. In order to illustrate the contribution that this form of data collection effort could make to family migration studies, the paper also presents results on the living arrangements of children ‘left behind’ by migrant parents; a potentially vulnerable group whose arrangements are challenging to examine with existing data sources. The empirical results show the majority (75%) of left behind children have previously migrated and a significant proportion of migrants' children (25%) were not living in their parent's origin or destination household. The findings highlight the need for careful measurement of the circumstances of left behind children and demonstrate the contribution of linked data for providing insights into the residential arrangements of migrants' children

Use of antiretroviral therapy in households and risk of HIV acquisition in rural KwaZulu-Natal, South Africa, 2004–12: a prospective cohort study

Background Studies of HIV-serodiscordant couples in stable sexual relationships have provided convincing evidence that antiretroviral therapy can prevent the transmission of HIV. We aimed to quantify the preventive eff ect of a publicsector HIV treatment and care programme based in a community with poor knowledge and disclosure of HIV status, frequent migration, late marriage, and multiple partnerships. Specifi cally, we assessed whether an individual’s hazard of HIV acquisition was associated with antiretroviral therapy coverage among household members of the opposite sex. Methods In this prospective cohort study, we linked patients’ records from a public-sector HIV treatment programme in rural KwaZulu-Natal, South Africa, with population-based HIV surveillance data collected between 2004 and 2012. We used information about coresidence to construct estimates of HIV prevalence and antiretroviral therapy coverage for each household. We then regressed the time to HIV seroconversion for 14 505 individuals, who were HIV-uninfected at baseline and individually followed up over time regarding their HIV status, on opposite-sex household antiretroviral therapy coverage, controlling for household HIV prevalence and a range of other potential confounders. Findings 2037 individual HIV seroconversions were recorded during 54 845 person-years of follow-up. For each increase of ten percentage points in opposite-sex household antiretroviral therapy coverage, the HIV acquisition hazard was reduced by 6% (95% CI 2–9), after controlling for other factors. This eff ect size translates into large reductions in HIV acquisition hazards when household antiretroviral therapy coverage is substantially increased. For example, an increase of 50 percentage points in household antiretroviral therapy coverage (eg, from 20% to 70%) reduced the hazard of HIV acquisition by 26% (95% CI 9–39). Interpretation Our fi ndings provide further evidence that antiretroviral therapy signifi cantly reduces the risk of onward transmission of HIV in a real-world setting in sub-Saharan Africa. Awareness that antiretroviral therapy can prevent transmission to coresident sexual partners could be a powerful motivator for HIV testing and antiretroviral treatment uptake, retention, and adherence. Funding Wellcome Trust and National Institute of Child Health and Human Development (US National Institutes of Health)

HIV prevention for South African youth: which interventions work? A systematic review of current evidence

In South Africa, HIV prevalence among youth aged 15-24 is among the world's highest. Given the urgent need to identify effective HIV prevention approaches, this review assesses the evidence base for youth HIV prevention in South Africa

Understanding family migration in rural South Africa: exploring children's inclusion in the destination households of migrant parents

Despite the removal of restrictions on movement and increasing female participation in migration, only a minority of migrant parents in South Africa include their children in their destination household. Quantitative analyses of the circumstances in which children accompany a migrant parent have been limited by the lack of available data that document family arrangements from the perspective of more than one household. This paper uses data about members of rural households in a demographic surveillance population in KwaZulu-Natal and a linked sample survey of adult migrants to examine factors associated with children's inclusion in the destination household of migrant parents, analyse the timing and sequence of children's moves to parental destination households, and describe the composition of parental origin and destination households. The findings confirm that in contemporary South Africa, only a small percentage (14%) of migrants' children who are members of the parental origin household are also members of the parental destination household. Membership of the parental destination household is associated with parental characteristics and the child's age, but not measures of socio-economic status, and children most commonly migrate several years after their migrant parent. Children included in the destination household of migrant fathers frequently live in small households, which also include their mother, whereas children included in the destination household of migrant mothers live in larger households. This study contributes to understanding the contexts of children's inclusion in parental destination households in South Africa and demonstrates the potential of data collected in migrants' origin and destination households

The association between self-reported stigma and loss-to-follow up in treatment eligible HIV positive adults in rural KwaZulu-Natal, South Africa

The relationship between loss-to-follow-up (LTFU) in HIV treatment and care programmes and psychosocial factors, including self-reported stigma, is important to understand. This prospective cohort study explored stigma and LTFU in treatment eligible adults who had yet not started antiretroviral therapy (ART).Psychosocial, clinical and demographic data were collected at a baseline interview. Self-reported stigma was measured with a multi-item scale. LTFU was defined as not attending clinic in the 90 days since last appointment or before death. Data was collected between January 2009 and January 2013 and analysed using Cox Regression.380 individuals were recruited (median time in study 3.35 years, total time at risk 1065.81 person-years). 203 were retained (53.4%), 109 were LTFU (28.7%), 48 had died and were not LTFU at death (12.6%) and 20 had transferred out (5.3%). The LTFU rate was 10.65 per 100 person-years (95% CI: 8.48-12.34). 362 individuals (95.3%) started ART. Stigma total score (categorised in quartiles) was not significantly associated with LTFU in either univariable or multivariable analysis (adjusting for other variables in the final model): second quartile aHR 0.77 (95%CI: 0.41-1.46), third quartile aHR 1.20(95%CI: 0.721-2.04), fourth quartile aHR 0.62 (95%CI: 0.35-1.11). In the final multivariable model, higher LTFU rates were associated with male gender, increased openness with friends/family and believing that community problems would be solved at higher levels. Lower LTFU rates were independently associated with increased year of age, greater reliance on family/friends, and having children.Demographic and other psychosocial factors were more closely related to LTFU than self-reported stigma. This may be consistent with high levels of social exposure to HIV and ART and with stigma affecting LTFU less than other stages of care. Research and clinical implications are discussed

Hypertension and Obesity in Adults Living in a High HIV Prevalence Rural Area in South Africa

Hypertension and excess body weight are major risk factors of cardiovascular morbidity and mortality in developing countries. In countries with a high HIV prevalence, it is unknown how increased antiretroviral treatment and care (ART) coverage has affected the prevalence of overweight, obesity, and hypertension. We conducted a health survey in 2010 based on the WHO STEPwise approach in 14,198 adult resident participants of a demographic surveillance area in rural South Africa to investigate factors associated with hypertension and excess weight including HIV infection and ART status. Women had a significantly higher median body mass index (BMI) than men (26.4 vs. 21.2 kg/$m^2$, p<0.001). The prevalence of obesity (BMI≥30 kg/$m^2$) in women (31.3%, 95% confidence interval (CI) 30.2–32.4) was 6.5 times higher than in men (4.9%, 95% CI 4.1–5.7), whereas prevalence of hypertension (systolic or diastolic blood pressure≥140 or 90 mm Hg, respectively) was 1.4 times higher in women than in men (28.5% vs 20.8%, p<0.001). In multivariable regression analysis, both hypertension and obesity were significantly associated with sex, age, HIV and ART status. The BMI of women and men on ART was on average 3.8 (95% CI 3.2–3.8) and 1.7 (95% CI 0.9–2.5) kg/$m^2$ lower than of HIV-negative women and men, respectively. The BMI of HIV-infected women and men not on ART was on average 1.2 (95% CI 0.8–1.6) and 0.4 (95% CI -0.1–0.9) kg/m2 lower than of HIV-negative women and men, respectively. Obesity was a bigger risk factor for hypertension in men (adjusted odds ratio (aOR) 2.99, 95% CI 2.00–4.48) than in women (aOR 1.64, 95% CI 1.39–1.92) and overweight (25≤BMI<30) was a significant risk factor for men only (aOR 1.53 95% CI 1.14–2.06). Our study suggests that, cardiovascular risk factors of hypertension and obesity differ substantially between women and men in rural South Africa