Addressing the fear and consequences of stigmatization - a necessary step towards making HAART accessible to women in Tanzania: a qualitative study

<p>Abstract</p> <p>Background</p> <p>Highly Active Antiretroviral Therapy (HAART) has been available free of charge in Tanga, Tanzania since 2005. However we have found that a high percentage of women referred from prevention of mother-to-child transmission services to the Care and Treatment Clinics (CTC) for HAART never registered at the CTCs. Few studies have focused on the motivating and deterring factors to presenting for HAART particularly in relation to women. This study seeks to remedy this gap in knowledge.</p> <p>Methodology</p> <p>A qualitative approach using in-depth interviews and focus group discussions was chosen to understand these issues as perceived and interpreted by HIV infected women themselves.</p> <p>Results</p> <p>The main deterrent to presenting for treatment appears to be fear of stigmatization including fear of ostracism from the community, divorce and financial distress. Participants indicated that individual counselling and interaction with other people living with HIV encourages women, who are disinclined to present for HAART, to do so, and that placing the entrance to the CTC so as to provide discrete access increases the accessibility of the clinic.</p> <p>Conclusion</p> <p>Combating stigma in the community, although it is essential, will take time. Therefore necessary steps towards encouraging HIV infected women to seek treatment include reducing self-stigma, assisting them to form empowering relationships and to gain financial independence and emphasis by example of the beneficial effect of treatment for themselves and for their children. Furthermore ensuring a discrete location of the CTC can increase its perceived accessibility.</p

Early Infant Diagnosis of HIV in Three Regions in Tanzania; Successes and Challenges.

By the end of 2009 an estimated 2.5 million children worldwide were living with HIV-1, mostly as a consequence of vertical transmission, and more than 90% of these children live in sub-Saharan Africa. In 2008 the World Health Organization (WHO), recommended early initiation of Highly Active Antiretroviral Therapy (HAART) to all HIV infected infants diagnosed within the first year of life, and since 2010, within the first two years of life, irrespective of CD4 count or WHO clinical stage. The study aims were to describe implementation of EID programs in three Tanzanian regions with differences in HIV prevalences and logistical set-up with regard to HIV DNA testing. Data were obtained by review of the prevention from mother to child transmission of HIV (PMTCT) registers from 2009-2011 at the Reproductive and Child Health Clinics (RCH) and from the databases from the Care and Treatment Clinics (CTC) in all the three regions; Kilimanjaro, Mbeya and Tanga. Statistical tests used were Poisson regression model and rank sum test. During the period of 2009 - 2011 a total of 4,860 exposed infants were registered from the reviewed sites, of whom 4,292 (88.3%) were screened for HIV infection. Overall proportion of tested infants in the three regions increased from 77.2% in 2009 to 97.8% in 2011. A total of 452 (10.5%) were found to be HIV infected (judged by the result of the first test). The prevalence of HIV infection among infants was higher in Mbeya when compared to Kilimanjaro region RR = 1.872 (95%CI = 1.408 - 2.543) p < 0.001. However sample turnaround time was significantly shorter in both Mbeya (2.7 weeks) and Tanga (5.0 weeks) as compared to Kilimanjaro (7.0 weeks), p=<0.001. A substantial of loss to follow-up (LTFU) was evident at all stages of EID services in the period of 2009 to 2011. Among the infants who were receiving treatment, 61% were found to be LFTU during the review period. The study showed an increase in testing of HIV exposed infants within the three years, there is large variations of HIV prevalence among the regions. Challenges like; sample turnaround time and LTFU must be overcome before this can translate into the intended goal of early initiation of lifelong lifesaving antiretroviral therapy for the infants

Nevirapine, Sodium Concentration and HIV-1 RNA in Breast Milk and Plasma among HIV-Infected Women Receiving Short-Course Antiretroviral Prophylaxis

<div><p>Introduction</p><p>Risk factors for breast milk transmission of HIV-1 from mother to child include high plasma and breast milk viral load, low maternal CD4 count and breast pathology such as mastitis.</p><p>Objective</p><p>To determine the impact of nevirapine and subclinical mastitis on HIV-1 RNA in maternal plasma and breast milk after intrapartum single-dose nevirapine combined with either 1-week tail of Combivir (zidovudine/lamivudine) or single-dose Truvada (tenofovir/emtricitabine).</p><p>Methods</p><p>Maternal plasma and bilateral breast milk samples were collected between April 2008 and April 2011 at 1, 4 and 6 weeks postpartum from HIV-infected Tanzanian women. Moreover, plasma samples were collected at delivery from mother and infant.</p><p>Results</p><p>HIV-1 RNA was quantified in 1,212 breast milk samples from 273 women. At delivery, 96% of the women and 99% of the infants had detectable nevirapine in plasma with a median (interquartile range, IQR) of 1.5 μg/mL (0.75–2.20 μg/mL) and 1.04 μg/mL (0.39–1.71 μg/mL), respectively (P < 0.001). At 1 week postpartum, 93% and 98% of the women had detectable nevirapine in plasma and breast milk, with a median (IQR) of 0.13 μg/mL (0.13–0.39 μg/mL) and 0.22 μg/mL (0.13–0.34 μg/mL), respectively. Maternal plasma and breast milk HIV-1 RNA correlated at all visits (R = 0.48, R = 0.7, R = 0.59; all P = 0.01). Subclinical mastitis was detected in 67% of the women at some time during 6 weeks, and in 38% of the breast milk samples. Breast milk samples with subclinical mastitis had significantly higher HIV-1 RNA at 1, 4 and 6 weeks (all P < 0.05).</p><p>Conclusion</p><p>After short-course antiretroviral prophylaxis, nevirapine was detectable in most infant cord blood samples and the concentration in maternal plasma and breast milk was high through week 1 accompanied by suppressed HIV-1 RNA in plasma and breast milk.</p></div

Sodium Concentration in Bilateral Breast Milk Samples from 273 HIV-Infected Women.

<p>Sodium Concentration in Bilateral Breast Milk Samples from 273 HIV-Infected Women.</p

Mean log₁₀ HIV-1 RNA in Maternal Plasma and Breast Milk from 273 HIV-Infected Women.

<p>Ranges are represented with error bars. The mean at delivery is based on 223 plasma samples. The means at 1 week postpartum are based on 227 plasma samples and 207 breast milk samples. The means at 4 weeks postpartum are based on 228 plasma samples and 198 breast milk samples. The means at 6 weeks postpartum are based on 252 plasma samples and 208 breast milk samples.</p

CONSORT Diagram.

<p>The flow chart indicates the number of women included from the ComTru study. The women were allocated to Combivir (zidovudine/lamivudine) or Truvada (tenofovir/emtricitabine) treatment before inclusion in the present study. There were no differences in nevirapine concentration, HIV-1 RNA or sodium concentration between the two trial arms of the ComTru study.</p

Breast Milk HIV-1 RNA in Samples from Breasts with and without Subclinical Mastitis.

<p>Subclinical mastitis is defined as sodium (Na⁺) concentrations >12 mmol/L. All breast milk samples with HIV-1 RNA and Na⁺ concentrations were used (744 samples with Na⁺ concentration ≤ 12 mmol/L and 453 samples with Na⁺ concentration >12 mmol/L). Box plots display medians, quartiles and outliers.</p