XVII International AIDS Conference: From Evidence to Action - Epidemiology

As the epidemic matures, accurate information about where new infections are occurring, and in which populations, is becoming increasingly critical in designing effective, targeted interventions relevant to current epidemiological trends. Although the quality and accuracy of HIV surveillance data and methodology have improved, in many cases the second generation WHO/UNAIDS surveillance system has not been fully implemented at the national level. National surveillance systems in many low and middle-income countries often do not collect disaggregated data on some most at risk populations, which is critical to developing targeted prevention interventions

Scaling-up co-trimoxazole prophylaxis in HIV-exposed and HIV-infected children in high HIV-prevalence countries.

Co-trimoxazole (trimethoprim-sulfamethoxazole) is a widely available antibiotic that substantially reduces HIV-related morbidity and mortality in both adults and children. Prophylaxis with co-trimoxazole is a recommended intervention of proven benefit that could serve not only as an initial step towards improving paediatric care in young children with limited access to antiretroviral treatment, but also as an important complement to antiretroviral therapy in resource-limited settings. Despite co-trimoxazole's known clinical benefits, the potential operational benefits, and favourable recommendations by WHO, UNAIDS, and UNICEF, its routine use in developing countries--particularly sub-Saharan Africa--has remained limited. Out of an estimated 4 million children in need of co-trimoxazole prophylaxis (HIV-exposed and HIV-infected), only 4% are currently receiving this intervention. We discuss some of the major barriers preventing the scale-up of co-trimoxazole prophylaxis for children in countries with a high prevalence of HIV and propose specific actions required to tackle these challenges

Operational research in Malawi: making a difference with cotrimoxazole preventive therapy in patients with tuberculosis and HIV.

BACKGROUND: In Malawi, high case fatality rates in patients with tuberculosis, who were also co-infected with HIV, and high early death rates in people living with HIV during the initiation of antiretroviral treatment (ART) adversely impacted on treatment outcomes for the national tuberculosis and ART programmes respectively. This article i) discusses the operational research that was conducted in the country on cotrimoxazole preventive therapy, ii) outlines the steps that were taken to translate these findings into national policy and practice, iii) shows how the implementation of cotrimoxazole preventive therapy for both TB patients and HIV-infected patients starting ART was associated with reduced death rates, and iv) highlights lessons that can be learnt for other settings and interventions. DISCUSSION: District and facility-based operational research was undertaken between 1999 and 2005 to assess the effectiveness of cotrimoxazole preventive therapy in reducing death rates in TB patients and subsequently in patients starting ART under routine programme conditions. Studies demonstrated significant reductions in case fatality in HIV-infected TB patients receiving cotrimoxazole and in HIV-infected patients about to start ART. Following the completion of research, the findings were rapidly disseminated nationally at stakeholder meetings convened by the Ministry of Health and internationally through conferences and peer-reviewed scientific publications. The Ministry of Health made policy changes based on the available evidence, following which there was countrywide distribution of the updated policy and guidelines. Policy was rapidly moved to practice with the development of monitoring tools, drug procurement and training packages. National programme performance improved which showed a significant decrease in case fatality rates in TB patients as well as a reduction in early death in people with HIV starting ART. SUMMARY: Key lessons for moving this research endeavour through to policy and practice were the importance of placing operational research within the programme, defining relevant questions, obtaining "buy-in" from national programme staff at the beginning of projects and having key actors or "policy entrepreneurs" to push forward the policy-making process. Ultimately, any change in policy and practice has to benefit patients, and the ultimate judge of success is whether treatment outcomes improve or not

Keeping health facilities safe: one way of strengthening the interaction between disease-specific programmes and health systems.

The debate on the interaction between disease-specific programmes and health system strengthening in the last few years has intensified as experts seek to tease out common ground and find solutions and synergies to bridge the divide. Unfortunately, the debate continues to be largely academic and devoid of specificity, resulting in the issues being irrelevant to health care workers on the ground. Taking the theme 'What would entice HIV- and tuberculosis (TB)-programme managers to sit around the table on a Monday morning with health system experts', this viewpoint focuses on infection control and health facility safety as an important and highly relevant practical topic for both disease-specific programmes and health system strengthening. Our attentions, and the examples and lessons we draw on, are largely aimed at sub-Saharan Africa where the great burden of TB and HIV ⁄ AIDS resides, although the principles we outline would apply to other parts of the world as well. Health care infections, caused for example by poor hand hygiene, inadequate testing of donated blood, unsafe disposal of needles and syringes, poorly sterilized medical and surgical equipment and lack of adequate airborne infection control procedures, are responsible for a considerable burden of illness amongst patients and health care personnel, especially in resource-poor countries. Effective infection control in a district hospital requires that all the components of a health system function well: governance and stewardship, financing,infrastructure, procurement and supply chain management, human resources, health information systems, service delivery and finally supervision. We argue in this article that proper attention to infection control and an emphasis on safe health facilities is a concrete first step towards strengthening the interaction between disease-specific programmes and health systems where it really matters – for patients who are sick and for the health care workforce who provide the care and treatment

The PROCESS study: a protocol to evaluate the implementation, mechanisms of effect and context of an intervention to enhance public health centres in Tororo, Uganda.

BACKGROUND: Despite significant investments into health improvement programmes in Uganda, health indicators and access to healthcare remain poor across the country. The PRIME trial aims to evaluate the impact of a complex intervention delivered in public health centres on health outcomes of children and management of malaria in rural Uganda. The intervention consists of four components: Health Centre Management; Fever Case Management; Patient- Centered Services; and support for supplies of malaria diagnostics and antimalarial drugs. METHODS: The PROCESS study will use mixed methods to evaluate the processes, mechanisms of change, and context of the PRIME intervention by addressing five objectives. First, to develop a comprehensive logic model of the intervention, articulating the project's hypothesised pathways to trial outcomes. Second, to evaluate the implementation of the intervention, including health worker training, health centre management tools, and the supply of artemether-lumefantrine (AL) and rapid diagnostic tests (RDTs) for malaria. Third, to understand mechanisms of change of the intervention components, including testing hypotheses and interpreting realities of the intervention, including resistance, in context. Fourth, to develop a contextual record over time of factors that may have affected implementation of the intervention, mechanisms of change, and trial outcomes, including factors at population, health centre and district levels. Fifth, to capture broader expected and unexpected impacts of the intervention and trial activities among community members, health centre workers, and private providers. Methods will include intervention logic mapping, questionnaires, recorded consultations, in-depth interviews, focus group discussions, and contextual data documentation. DISCUSSION: The findings of this PROCESS study will be interpreted alongside the PRIME trial results. This will enable a greater ability to generalise the findings of the main trial. The investigators will attempt to assess which methods are most informative in such evaluations of complex interventions in low-resource settings. TRIAL REGISTRATION: Clinicaltrials.gov, NCT01024426

Las políticas de lucha contra el VIH/SIDA en Mozambique: retos para la cooperación internacional

Este ARI analiza la evolución e impacto del VIH/SIDA en Mozambique, así como la idoneidad, logros y limitaciones de las políticas implementadas en el país con la colaboración de la cooperación internacional para hacer frente a dicha epidemia. Las más altas tasas de prevalencia a nivel mundial, y los más radicales descensos de la esperanza de vida en las últimas décadas en África Subsahariana, entre otros factores, han hecho que la lucha contra el VIH/SIDA se haya convertido en una de las principales prioridades de la agenda de los diferentes actores de la cooperación internacional (agencias bilaterales y multilaterales, ONGD, fundaciones privadas…). En este contexto, el presente trabajo explora las más recientes tendencias e iniciativas en las que participan actores locales y extranjeros en la lucha contra la enfermedad en un caso particular como el de Mozambique, con un Estado frágil y una fuerte participación por parte de la cooperación internacional. Asimismo, este trabajo pretende identificar las principales fortalezas y debilidades de las políticas implementadas hasta el momento en el país, como paso necesario de cara a estrategias y políticas futuras

The effect of HIV on the nutrient composition of breast milk

Thesis (M. Tech. (Biomedical technology)) - Central University of technology, Free State, 2013Thirty-one years after the discovery and isolation of the human immunodeficiency virus (HIV) by French and American scientists, much progress has been made in basic research, clinical treatment, and public heath prevention. Although, much evidence of mother-to-child-transmission (MTCT) of HIV has been amassed since then, not much of it describes the effects of HIV on the nutrient composition of breast milk. The aim of this study was to determine the effects of HIV on the nutrient composition of breast milk, by studying two groups of adult lactating respondents from the same socio-economic background, who were chosen randomly and participated voluntarily. The study population consisted of 60 breastfeeding mothers, divided into two groups of 30 mothers each. Group one represented the control group of HIV non-infected mothers whereas group two consisted of HIV-infected mothers who did not receive any treatment. After a registered medical nurse took blood and breast milk samples, analysis was done on ethylenediamine tetra-acetic acid (EDTA) whole blood to determine the haematological and immunological parameters and breast milk was analyzed for nutrient composition. Standard laboratory operating procedures (SOP) were followed, throughout, to determine the parameters of the blood and breast milk samples. Results showed that associations between the socio-economic statuses (SES) of the two respondent groups could be established. Albeit differences were not significant, some were, however, detected in the number of people contributing to the household income of the respondents (p = 0.0051), their employment status (p < 0.0001) and the availability of water sources (p = 0.1124). It is believed that factors, such as the prevalence of HIV, if related to the different levels of SES may play an important role in the outcome of the health statuses of individuals at different levels of society. By implication, it is not the different levels of SES, but rather factors related to the different levels of SES that have an impact. Significant differences could be seen in the haematological variables between the two respondent groups: Red blood cell count (RBC) (p < 0.0001), hemoglobin (Hb) levels (p = 0.0119), hematocrit (Hct) (p = 0.0031), mean corpuscular volume (MCV) (p = 0.0005), mean corpuscular hemoglobin (MCH) (p = 0.0043) and monocyte count (p = 0.0275). These differences, however, were not significant to this study. Other differences that were significant were immunological parameters between the two respondent groups: CD4 cell count (p < 0.0001) and viral load, done only on the blood of the HIV-infected respondent group. The CD4 cell count is used as a guideline for the initiation of treatment for HIV-infected persons and is required to accurately assess the immune status of any patient at any given time. The viral load has long been established as a strong predictor of the rate of disease progression. The only significant difference in the breast milk composition was reflected in the following variables between the two groups: percentage (%) proteins (p < 0.0001) and calcium levels (p = 0.0081). The median and mean values of the percentage proteins were elevated in the subject group of mothers living with HIV, while calcium levels in the same group showed a decrease in both median and mean values. The lack of significant differences between the groups might be due to the small study population. If nothing else, this study highlights the need for further trials to evaluate the true effects of HIV on the nutrient composition of breast milk

HIV Testing for Children in Resource-Limited Settings: What Are We Waiting For?

Scott Kellerman and Shaffiq Essajee argue that the time has come to increase access to HIV testing for children, especially in sub-Saharan Africa