9 research outputs found
Strategies to improve male involvement in PMTCT option B plus in four African countries : a qualitative rapid appraisal
BACKGROUND : The World Health Organization recommends that antiretroviral therapy be started as soon as
possible, irrespective of stage of HIV infection. This ‘test and treat’ approach highlights the need to ensure that
men are involved in prevention of mother-to-child HIV transmission (PMTCT). This article presents findings
from a rapid appraisal of strategies to increase male partner involvement in PMTCT services in Uganda,
Democratic Republic of Congo, Malawi, and Coˆ te d’Ivoire in the context of scale-up of Option B protocol.
DESIGN : Data were collected through qualitative rapid appraisal using focus groups and individual interviews
during field visits to the four countries. Interviews were conducted in the capital city with Ministry of Health
staff and implementing partners (IPs) and at district level with district management teams, facility-based
health workers and community health cadres in each country.
RESULTS : Common strategies were adopted across the countries to effect social change and engender greater
participation of men in maternal, child and women’s health, and PMTCT services. Community-based
strategies included engagement of community leaders through dialogue and social mobilization, involving
community health workers and the creation and strengthening of male peer cadres. Facility-based strategies
included provision of incentives such as shorter waiting time, facilitating access for men by altering clinic
hours, and creation of family support groups.
CONCLUSIONS : The approaches implemented at both community and facility levels were tailored to the local
context, taking into account cultural norms and geographic regional variations. Although intentions behind
such strategies aim to have positive impacts on families, unintended negative consequences do occur, and
these need to be addressed and strategies adapted.
A consistent definition of ‘male involvement’ in PMTCT services and a framework of indicators would be
helpful to capture the impact of strategies on cultural and behavioral shifts. National policies around male
involvement would be beneficial to streamline approaches across IPs and ensure wide-scale implementation,
to achieve significant improvements in family health outcomes.UNICEF New York through a
grant from Sweden and Norad, the South African Medical
Research Council and TD is supported by the National Research
Foundation, South Africa.http://www.sherpa.ac.uk/romeo/issn/1748-2623/am2017Paediatrics and Child Healt
Infrastructural and human-resource factors associated with return of infant HIV test results to caregivers: secondary analysis of a nationally representative situational assessment, South Africa, 2010
Abstract
Background
In June 2015, South Africa introduced early infant HIV diagnosis (EID) at birth and ten weeks postpartum. Guidelines recommended return of birth results within a week and ten weeks postpartum results within four weeks. Task shifting was also suggested to increase service coverage. This study aimed to understand factors affecting return of EID results to caregivers.
Methods
Secondary analysis of data gathered from 571 public-sector primary health care facilities (PHCs) during a nationally representative situational assessment, was conducted. The assessment was performed one to three months prior to facility involvement in the 2010 evaluation of the South African programme to prevent mother-to-child HIV transmission (SAPMTCTE). Self-reported infrastructural and human resource EID-related data were collected from managers and designated staff using a structured questionnaire. The main outcome variable was ‘EID turn-around-time (TAT) to caregiver’ (caregiver TAT), measured as reported number of weeks from infant blood draw to caregiver receipt of results. This was dichotomized as either short (≤3 weeks) or delayed (> 3 weeks) caregiver TAT. Logit-based risk difference analysis was used to assess factors associated with short caregiver TAT. Analysis included TAT to facility (facility TAT), defined as reported number of weeks from infant blood draw to facility receipt of results.
Results
Overall, 26.3% of the 571 PHCs reported short caregiver TAT. In adjusted analyses, short caregiver TAT was less achieved when facility TAT was > 7 days (versus ≤7 days) (adjusted risk difference (aRD): − 0.2 (95% confidence interval − 0.3-(− 0.1)), p = 0.006 for 8–14 days and − 0.3 (− 0.5-(− 0.1)), p = 0.006 for > 14 days), and in facilities with staff nurses (compared to those without) (aRD: − 9.4 (− 16.6-(− 2.2), p = 0.011).
Conclusion
Although short caregiver TAT for EID was only reported in approximately 26% of facilities, these facilities demonstrate that achieving EID TAT of ≤3 weeks is possible, making timely ART initiation within 3 weeks of diagnosis feasible within the public health sector. Our adjusted analyses underpin the need for quick return of results to facilities. They also raise questions around staff mentoring: we hypothesise that facilities with staff nurses were likely to have fewer professional nurses, and thus inadequate senior support
Enhancing HIV treatment access and outcomes amongst HIV infected children and adolescents in resource limited settings
INTRODUCTION : Increasing access to HIV-related
care and treatment for children aged 0–18 years in
resource-limited settings is an urgent global priority. In
2011–2012 the percentage increase in children accessing
antiretroviral therapy was approximately half that of adults
(11 vs. 21 %). We propose a model for increasing access
to, and retention in, paediatric HIV care and treatment in
resource-limited settings. METHODS : Following a rapid
appraisal of recent literature seven main challenges in
paediatric HIV-related care and treatment were identified:
(1) lack of regular, integrated, ongoing HIV-related diagnosis;
(2) weak facility-based systems for tracking and
retention in care; (3) interrupted availability of dried blood
spot cards (expiration/stock outs); (4) poor quality control
of rapid HIV testing; (5) supply-related gaps at health
facility-laboratory interface; (6) poor uptake of HIV testing,
possibly relating to a fatalistic belief about HIV infection; (7) community-associated reasons e.g. non-disclosure
and weak systems for social support, resulting in
poor retention in care. RESULTS : To increase sustained access
to paediatric HIV-related care and treatment, regular
updating of Policies, review of inter-sectoral Plans (at
facility and community levels) and evaluation of Programme
implementation and impact (at national, subnational,
facility and community levels) are non-negotiable
critical elements. Additionally we recommend the intensified
implementation of seven main interventions: (1)
update or refresher messaging for health care staff and
simple messaging for key staff at early childhood development
centres and schools; (2) contact tracing, disclosure
and retention monitoring; (3) paying particular attention to
infant dried blood spot (DBS) stock control; (4) regular
quality assurance of rapid HIV testing procedures; (5)
workshops/meetings/dialogues between health facilities
and laboratories to resolve transport-related gaps and to
facilitate return of results to facilities; (6) community leader
and health worker advocacy at creches, schools, religious
centres to increase uptake of HIV testing and dispel
fatalistic beliefs about HIV; (7) use of mobile communication
technology (m-health) and peer/community supporters
to maintain contact with patients. DISCUSSION AND CONCLUSION : We propose that this package of facility,community and family-orientated interventions are needed to change the trajectory of the paediatric HIV epidemic and its associated patterns of morbidity and mortality, thus achieving the double dividend of improving HIV-free
survival.South African Medical Research Council.http://link.springer.com/journal/10995hb2016Paediatrics and Child Healt
How ready are our health systems to implement prevention of mother to child transmission Option B+?
In January 2015, the South African National Department of Health released new consolidated
guidelines for the prevention of mother to child transmission (PMTCT) of HIV, in line with
the World Health Organization’s (WHO) PMTCT Option B+. Implementing these guidelines
should make it possible to eliminate mother to child transmission (MTCT) of HIV and
improve long-term maternal and infant outcomes. The present article summarises the key
recommendations of the 2015 guidelines and highlights current gaps that hinder optimal
implementation; these include late antenatal booking (as a result of poor staff attitudes towards
‘early bookers’ and foreigners, unsuitable clinic hours, lack of transport to facilities, quota
systems being applied to antenatal clients and clinic staff shortages); poor compliance with
rapid HIV testing protocols; weak referral systems with inadequate follow-up; inadequate
numbers of laboratory staff to handle HIV-related monitoring procedures and return of results
to the correct facility; and inadequate supply chain management, leading to interrupted
supplies of antiretroviral drugs. Additionally, recommendations are proposed on how to
address these gaps. There is a need to evaluate the implementation of the 2015 guidelines and
proactively communicate with ground-level implementers to identify operational bottlenecks,
test solutions to these bottlenecks, and develop realistic implementation plans.The South African
Medical Research Councilhttp://www.sajhivmed.org.zaam201
Population-level effectiveness of PMTCT Option A on early mother-to-child (MTCT) transmission of HIV in South Africa: implications for eliminating MTCT.
BACKGROUND: Eliminating mother-to-child transmission of HIV (EMTCT), defined as ≤50 infant HIV infections per 100 000 live births, is a global priority. Since 2011 policies to prevent mother-to-child transmission of HIV (PMTCT) shifted from maternal antiretroviral (ARV) treatment or prophylaxis contingent on CD4 cell count to lifelong maternal ARV treatment (cART). We sought to measure progress with early (4-8 weeks postpartum) MTCT prevention and elimination, 2011-2013, at national and sub-national levels in South Africa, a high antenatal HIV prevalence setting ( ≈ 29%), where early MTCT was 3.5% in 2010. METHODS: Two surveys were conducted (August 2011-March 2012 and October 2012-May 2013), in 580 health facilities, randomly selected after two-stage probability proportional to size sampling of facilities (the primary sampling unit), to provide valid national and sub-national-(provincial)-level estimates. Data collectors interviewed caregivers of eligible infants, reviewed patient-held charts, and collected infant dried blood spots (iDBS). Confirmed positive HIV enzyme immunoassay (EIA) and positive total HIV nucleic acid polymerase chain reaction (PCR) indicated infant HIV exposure or infection, respectively. Weighted survey analysis was conducted for each survey and for the pooled data. FINDINGS: National data from 10 106 and 9120 participants were analyzed (2011-12 and 2012-13 surveys respectively). Infant HIV exposure was 32.2% (95% confidence interval (CI) 30.7-33.6%), in 2011-12 and 33.1% (95% CI 31.8-34.4%), provincial range of 22.1-43.6% in 2012-13. MTCT was 2.7% (95% CI 2.1%-3.2%) in 2011-12 and 2.6% (95% CI 2.0-3.2%), provincial range of 1.9-5.4% in 2012-13. HIV-infected ARV-exposed mothers had significantly lower unadjusted early MTCT (2.0% [2011-12: 1.6-2.5%; 2012-13:1.5-2.6%]) compared to HIV-infected ARV-naive mothers [10.2% in 2011-12 (6.5-13.8%); 9.2% in 2012-13 (5.6-12.7%)]. Pooled analyses demonstrated significantly lower early MTCT among exclusive breastfeeding (EBF) mothers receiving >10 weeks ARV prophylaxis or cART compared with EBF and no ARVs: (2.2% [95% CI 1.25-3.09%] vs 12.2% [95% CI 4.7-19.6%], respectively); among HIV-infected ARV-exposed mothers, 24.9% (95% CI 23.5-26.3%) initiated cART during or before the first trimester, and their early MTCT was 1.2% (95% CI 0.6-1.7%). Extrapolating these data, assuming 32% EIA positivity and 2.6% or 1.2% MTCT, 832 and 384 infants per 100 000 live births were HIV infected, respectively. CONCLUSIONS: Although we demonstrate sustained national-level PMTCT impact in a high HIV prevalence setting, results are far-removed from EMTCT targets. Reducing maternal HIV prevalence and treating all maternal HIV infection early are critical for further progress
Strategies to improve male involvement in PMTCT Option B+ in four African countries: a qualitative rapid appraisal
BACKGROUND: The World Health Organization recommends that antiretroviral therapy be started as soon as
possible, irrespective of stage of HIV infection. This ‘test and treat’ approach highlights the need to ensure that
men are involved in prevention of mother-to-child HIV transmission (PMTCT). This article presents findings
from a rapid appraisal of strategies to increase male partner involvement in PMTCT services in Uganda,
Democratic Republic of Congo, Malawi, and Coˆ te d’Ivoire in the context of scale-up of Option B protocol.
DESIGN: Data were collected through qualitative rapid appraisal using focus groups and individual interviews
during field visits to the four countries. Interviews were conducted in the capital city with Ministry of Health
staff and implementing partners (IPs) and at district level with district management teams, facility-based
health workers and community health cadres in each country.
RESULTS: Common strategies were adopted across the countries to effect social change and engender greater
participation of men in maternal, child and women’s health, and PMTCT services. Community-based
strategies included engagement of community leaders through dialogue and social mobilization, involving
community health workers and the creation and strengthening of male peer cadres. Facility-based strategies
included provision of incentives such as shorter waiting time, facilitating access for men by altering clinic
hours, and creation of family support groups.
CONCLUSIONS: The approaches implemented at both community and facility levels were tailored to the local
context, taking into account cultural norms and geographic regional variations. Although intentions behind
such strategies aim to have positive impacts on families, unintended negative consequences do occur, and
these need to be addressed and strategies adapted.
A consistent definition of ‘male involvement’ in PMTCT services and a framework of indicators would be
helpful to capture the impact of strategies on cultural and behavioral shifts. National policies around male
involvement would be beneficial to streamline approaches across IPs and ensure wide-scale implementation,
to achieve significant improvements in family health outcomes.IS
Adolescent access to care and risk of early mother-to-child HIV transmission
PURPOSE: Adolescent females aged 15–19 account for 62% of new HIV infections and give birth to
16 million infants annually. We quantify the risk of early mother-to-child transmission (MTCT) of
HIV among adolescents enrolled in nationally representative MTCT surveillance studies in South Africa.
METHODS: Data from 4,814 adolescent (≤19 years) and 25,453 adult (≥20 years) mothers and their
infants aged 4–8 weeks were analyzed. These data were gathered during three nationally representative,
cross-sectional, facility-based surveys, conducted in 2010, 2011–2012, and 2012–
2013. All infants were tested for HIV antibody (enzyme immunoassay), to determine HIV exposure.
Enzyme immunoassay-positive infants or those born to self-reported HIV-positive mothers were
tested for HIV infection (total nucleic acid polymerase chain reaction). Maternal HIV positivity was
inferred from infant HIV antibody positivity. All analyses were weighted for sample realization
and population live births.
RESULTS: Adolescent mothers, compared with adult mothers, have almost three times less planned
pregnancies 14.4% (95% confidence interval [CI]: 12.5–16.5) versus 43.9% (95% CI: 42.0–45.9) in
2010 and 15.2% (95% CI: 13.0–17.9) versus 42.8% (95% CI: 40.9–44.6) in 2012–2013 (p < .0001),
less prevention of MTCT uptake (odds ratio [OR] in favor of adult mothers = 3.36, 95% CI: 2.95–
3.83), and higher early MTCT (adjusted OR = 3.0, 95% CI: 1.1–8.0), respectively. Gestational age at
first antenatal care booking was the only significant predictor of early MTCT among adolescents.
CONCLUSIONS: Interventions that appeal to adolescents and initiate sexual and reproductive health
care early should be tested in low- and middle-income settings to reduce differential service uptake
and infant outcomes between adolescent and adult mothers.IS
First population-level effectiveness evaluation of a national programme to prevent HIV transmission from mother to child, South Africa
Background: There is a paucity of data on the national population-level effectiveness of preventing mother-tochild transmission (PMTCT) programmes in high-HIVprevalence, resource-limited settings. We assessed national PMTCT impact in South Africa (SA), 2010. Methods: A facility-based survey was conducted using a stratified multistage, cluster sampling design. A nationally representative sample of 10 178 infants aged 4-8 weeks was recruited from 565 clinics. Data collection included caregiver interviews, record reviews and infant dried blood spots to identify HIV-exposed infants (HEI) and HIV-infected infants. During analysis, self-reported antiretroviral (ARV) use was categorised: 1a: triple ARV treatment; 1b: azidothymidine \u3e10 weeks; 2a: azidothymidine ≤10 weeks; 2b: incomplete ARV prophylaxis; 3a: no antenatal ARV and 3b: missing ARV information. Findings were adjusted for non-response, survey design and weighted for live-birth distributions. Results: Nationally, 32% of live infants were HEI; early mother-to-child transmission (MTCT) was 3.5% (95% CI 2.9% to 4.1%). In total 29.4% HEI were born to mothers on triple ARV treatment (category 1a) 55.6% on prophylaxis (1b, 2a, 2b), 9.5% received no antenatal ARV (3a) and 5.5% had missing ARV information (3b). Controlling for other factors groups, 1b and 2a had similar MTCT to 1a (Ref; adjusted OR (AOR) for 1b, 0.98, 0.52 to 1.83; and 2a, 1.31, 0.69 to 2.48). MTCT was higher in group 2b (AOR 3.68, 1.69 to 7.97). Within group 3a, early MTCT was highest among breastfeeding mothers 11.50% (4.67% to 18.33%) for exclusive breast feeding, 11.90% (7.45% to 16.35%) for mixed breast feeding, and 3.45% (0.53% to 6.35%) for no breast feeding). Antiretroviral therapy or \u3e10 weeks prophylaxis negated this difference (MTCT 3.94%, 1.98% to 5.90%; 2.07%, 0.55% to 3.60% and 2.11%, 1.28% to 2.95%, respectively). Conclusions: SA, a high-HIV-prevalence middle income country achieved \u3c5% MTCT by 4-8 weeks post partum. The long-term impact on PMTCT on HIV-free survival needs urgent assessment