Journal of acquired immune deficiency syndromes (1999), Jan 15, 2018
The global HIV response is leaving children and adolescents behind. Because of a paucity of studi... more The global HIV response is leaving children and adolescents behind. Because of a paucity of studies on treatment and care models for these age groups, there are gaps in our understanding of how best to implement services to improve their health outcomes. Without this evidence, policymakers are left to extrapolate from adult studies, which may not be appropriate, and can lead to inefficiencies in service delivery, hampered uptake, and ineffective mechanisms to support optimal outcomes. Implementation science research seeks to investigate how interventions known to be efficacious in study settings are, or are not, routinely implemented within real-world programmes. Effective implementation science research must be a collaborative effort between government, funding agencies, investigators, and implementers, each playing a key role. Successful implementation science research in children and adolescents requires clearer policies about age of consent for services and research that conform...
Countries where adult male circumcision has reached high coverage should consider national early ... more Countries where adult male circumcision has reached high coverage should consider national early infant male circumcision (EIMC) programs where EIMC is feasible and culturally acceptable. Ministries of health that intend to set up a routine offer of EIMC should put systems in place to ensure that its introduction (1) does not compromise adult male circumcision programs, (2) does not weaken routine service delivery platforms, (3) is done safely, and (4) adheres to the rights of the child. BACKGROUND M ale circumcision involves the complete removal of the foreskin of the penis, the innermost layer of which is highly susceptible to HIV transmission. 1 According to the World Health Organization (WHO), in 2006 about 30% of males globally (665 million infants, adolescents, and adults) had been circumcised. 2 Male circumcision has historically been performed in infancy, adolescence, and adulthood in various regions of Africa for religious and cultural reasons or for ethnic identity. 2 Circumcision is mainly performed using traditional methods, either at birth or to initiate males into adulthood at puberty. Male circumcision also has medical benefits, including the prevention of penile cancer, reduction in the transmission of some sexually transmitted infections (STIs), including HIV, and reduction in vaginal infections and cancer of the cervix in female sex partners. 3,4 Scientific evidence and program data show that male circumcision prevents female-to-male sexual transmission of HIV. 5 Three randomized controlled trials conducted by trained health professionals in properly equipped settings concluded that adult male circumcision reduces transmission of HIV from women to circumcised men by up to 60%. 5-9 Based on these results, WHO and the Joint United Nations Programme on HIV/AIDS (UNAIDS) recommended in 2007 that voluntary medical male circumcision (VMMC) be made available in countries with a high HIV prevalence, generalized heterosexual HIV epidemics, and low levels of male circumcision. Fourteen countries in East and Southern Africa were prioritized for VMMC scale-up as an HIV prevention strategy:
JAIDS Journal of Acquired Immune Deficiency Syndromes, 2017
While the Interagency Task Team on the Prevention and Treatment of HIV Infection in Pregnant Wome... more While the Interagency Task Team on the Prevention and Treatment of HIV Infection in Pregnant Women, Mothers, and Children (IATT) partnership existed before the Global Plan Towards the Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive (Global Plan), its reconfiguration was critical to coordinating provision of technical assistance that positively influenced country decision-making and program performance. This article describes how the Global Plan anchored the work of the IATT and, in turn, how the IATT's technical assistance helped to accelerate achievement of the Global Plan targets and milestones. The technical assistance that will be discussed addressed a broad range of priority actions and milestones described in the Global Plan: (1) planning for and implementing Option B+; (2) strengthening monitoring and evaluation systems; (3) translating evidence into action and advocacy; and (4) promoting community engagement. This article also reviews the ongoing challenges and opportunities of providing technical assistance in a rapidly evolving environment that calls for ever more flexible and contextualized responses. The effectiveness of technical assistance facilitated by the IATT was defined by its timeliness, evidence base, and unique global perspective that built on the competencies of its partners and promoted synergies across program areas. Reaching the final goal of eliminating vertical transmission of HIV infection and achieving an AIDS-free generation in countries with the highest HIV burden requires that the IATT partnership and technical assistance remain responsive to country-specific needs while aligning with the current programmatic reality and new global goals such as the Sustainable Development Goals and 90-90-90 targets.
To maintain high circumcision prevalence, voluntary medical male circumcision programs in Eastern... more To maintain high circumcision prevalence, voluntary medical male circumcision programs in Eastern and Southern Africa need to plan for sustainability and conduct transition assessments early on, rather than waiting until the saturation of priority targets at the end of the program.
Introduction: Integration of HIV into child survival platforms is an evolving territory with mult... more Introduction: Integration of HIV into child survival platforms is an evolving territory with multiple connotations. Most literature on integration of HIV into other health services focuses on adults; however promising practices for children are emerging. These include the Double Dividend (DD) framework, a new programming approach with dual goal of improving paediatric HIV care and child survival. In this commentary, the authors discuss why integrating HIV testing, treatment and care into child survival platforms is important, as well as its potential to advance progress towards global targets that call for, by 2020, 90% of children living with HIV to know their status, 90% of those diagnosed to be on treatment and 90% of those on treatment to be virally suppressed (90Á90Á90). Discussion: Integration is critical in improving health outcomes and efficiency gains. In children, integration of HIV in programmes such as immunization and nutrition has been associated with an increased uptake of HIV infant testing. Integration is increasingly recognized as a case-finding strategy for children missed from prevention of mother-to-child transmission programmes and as a platform for diffusing emerging technologies such as point-of-care diagnostics. These support progress towards the 90Á90Á90 targets by providing a pathway for early identification of HIV-infected children with co-morbidities, prompt initiation of treatment and improved survival. There are various promising practices that have demonstrated HIV outcomes; however, few have documented the benefits of integration on child survival interventions. The DD framework is well positioned to address the bidirectional impacts for both programmes. Conclusions: Integration provides an important programmatic pathway for accelerated progress towards the 90Á90Á90 targets. Despite this encouraging information, there are still challenges to be addressed in order to maximize the benefits of integration.
Objective.To improve PMTCT and antenatal care-related service delivery, a pack with centrally pre... more Objective.To improve PMTCT and antenatal care-related service delivery, a pack with centrally prepackaged medicine was rolled out to all pregnant women in Lesotho in 2011. This study assessed acceptability and feasibility of this copackaging mechanism for drug delivery among pregnant and postpartum women.Methods.Acceptability and feasibility were assessed in a mixed method, cross-sectional study through structured interviews (SI) and semistructured interviews (SSI) conducted in 2012 and 2013.Results.290 HIV-negative women and 437 HIV-positive women (n=727) participated. Nearly all SI participants found prepackaged medicines acceptable, though modifications such as size reduction of the pack were suggested. Positive experiences included that the pack helped women take pills as instructed and contents promoted healthy pregnancies. Negative experiences included inadvertent pregnancy disclosure and discomfort carrying the pack in communities. Implementation was also feasible; 85.2% of S...
Journal of acquired immune deficiency syndromes (1999), 2014
The global HIV epidemic in adolescents is not controlled, and this group has not received suffici... more The global HIV epidemic in adolescents is not controlled, and this group has not received sufficient attention in programming and research efforts addressing HIV prevention, treatment, and care. A global technical consultation on adolescents and HIV addressing services and research gaps was convened by United Nations Children's Fund and the London School of Hygiene and Tropical Medicine in July 2013. Proceedings from this meeting are presented in this issue of the Supplement. Several reviews highlight poor levels of coverage of critical HIV prevention, treatment, and care interventions for adolescents, disparities in HIV prevalence among adolescent girls, and low-risk perceptions associated with risk behaviors among key risk groups. Others underscore the significance of clear national targets and strengthening data, government involvement, enhanced systems capacity and policy, engagement of community and adolescent social networks, and of mobile and internet technologies to the ...
Background The number of HIV-positive pregnant women receiving antiretroviral drugs (ARVs) to pre... more Background The number of HIV-positive pregnant women receiving antiretroviral drugs (ARVs) to prevent mother-to-child transmission (MTCT) of HIV has increased rapidly. Objective To estimate the reduction in new child HIV infections resulting from prevention of MTCT (PMTCT) over the past decade. To project the potential impact of implementing the new WHO PMTCT guidelines between 2010 and 2015 and consider the efforts required to virtually eliminate MTCT, defined as <5% transmission of HIV from mother to child, or 90% reduction of infections among young children by 2015. Methods Data from 25 countries with the largest numbers of HIV-positive pregnant women were used to create five scenarios to evaluate different PMTCT interventions. A demographic model, Spectrum, was used to estimate new child HIV infections as a measure of the impact of interventions. Results Between 2000 and 2009 there was a 24% reduction in the estimated annual number of new child infections in the 25 countries, of which about one-third occurred in 2009 alone. If these countries implement the new WHO PMTCT recommendations between 2010 and 2015, and provide more effective ARV prophylaxis or treatment to 90% of HIV-positive pregnant women, 1 million new child infections could be averted by 2015. Reducing HIV incidence in reproductive age women, eliminating the current unmet need for family planning and limiting the duration of breastfeeding to 12 months (with ARV prophylaxis) could avert an additional 264 000 infections, resulting in a total reduction of 79% of annual new child infections between 2009 and 2015, approaching but still missing the goal of virtual elimination of MTCT. Discussion To achieve virtual elimination of new child infections PMTCT programmes must achieve high coverage of more effective ARV interventions and safer infant feeding practices. In addition, a comprehensive approach including meeting unmet family planning needs and reducing new HIV infections among reproductive age women will be required.
A growing number of countries are moving to scale up interventions for prevention of mother-to-ch... more A growing number of countries are moving to scale up interventions for prevention of mother-to-child transmission (PMTCT) of HIV in maternal and child health services. Similarly, many are working to improve access to paediatric HIV treatment. This paper reviews national programme data for 2004-2005 from low-and middle-income countries to track progress in these programmes. The attainment of the UNGASS target of reducing HIV infections by 50% by 2010 necessitates that 80% of all pregnant women accessing antenatal care receive PMTCT services. In 2005, only seven of the 71 countries were on track to meet this target. However PMTCT coverage increased from 7% in 2004 (58 countries) to 11% in 2005 (71 countries). In 2005, 8% of all infants born to HIV positive mothers received antiretroviral prophylaxis for PMTCT, up from 5% in 2004, though only 4% received cotrimoxazole. 11% of HIV positive children in need received antiretroviral treatment in 2005. In 31 countries that had data, 28% of women who received an antiretroviral for PMTCT also reported receiving antiretroviral treatment for their own health. Achieving the UNGASS target is possible but will require substantial investments and commitment to strengthen maternal and child health services, the health workforce and health systems to move from pilot projects to a decentralised, integrated approach.
Introduction: Mother-to-child transmission of HIV can be reduced toB5% with appropriate antiretro... more Introduction: Mother-to-child transmission of HIV can be reduced toB5% with appropriate antiretroviral medications. Such reductions depend on multiple health system encounters during antenatal care (ANC), delivery and breastfeeding; in countries with limited access to care, transmission remains high. In Lesotho, where 28% of women attending ANC are HIV positive but where geographic and other factors limit access to ANC and facility deliveries, a Minimum PMTCT Package was launched in 2007 as an alternative to the existing facility-based approach. Distributed at the first ANC visit, it packaged together all necessary pregnancy, delivery and early postnatal antiretroviral medications for mother and infant. Methods: To examine the availability, feasibility, acceptability and possible negative consequences of the Minimum PMTCT Package, data from a 2009 qualitative and quantitative study and a 2010 facility assessment were used. To examine the effects on ANC and facility-based delivery rates, a difference-indifferences analytic approach was applied to 2009 Demographic and Health Survey data for HIV-tested women who gave birth before and after Minimum PMTCT Package implementation. Results: The Minimum PMTCT Package was feasible and acceptable to providers and clients. Problems with test kit and medicine stock-outs occurred, and 46% of women did not receive the Minimum PMTCT Package until at least their second ANC visit. Providing adequate instruction on the use of multiple medications represented a challenge. The proportion of HIV-positive women delivering in facilities declined after Minimum PMTCT Package implementation, although it increased among HIVnegative women (difference-indifferences 014.5%, p 00.05). The mean number of ANC visits declined more among HIVpositive women than among HIV-negative women after implementation, though the difference was not statistically significant (p00.09). Changes in the percentage of women receiving ]4 ANC visits did not differ between the two groups. Conclusions: If supply issues can be resolved and adequate client educational materials provided, takeaway co-packages have the potential to increase access to PMTCT commodities in countries where women have limited access to health services. However, efforts must be made to carefully monitor potential changes in ANC visits and facility deliveries, and further evaluation of adherence, safety and effectiveness are needed.
JAIDS Journal of Acquired Immune Deficiency Syndromes, 2012
In June 2011, the Joint United Nations Programme on HIV/AIDS, the US President's Emergency Plan f... more In June 2011, the Joint United Nations Programme on HIV/AIDS, the US President's Emergency Plan for AIDS Relief (PEPFAR), and other collaborators outlined a transformative plan to virtually eliminate pediatric AIDS worldwide. The ambitious targets of this initiative included a 90% reduction in new pediatric HIV infections and a 50% reduction in HIV-related maternal mortalityall by 2015. PEPFAR has made an unprecedented commitment to the expansion and improvement of prevention of mother-to-child HIV transmission (PMTCT) services globally and is expected to play a critical role in reaching the virtual elimination target. To date, PEPFAR has been instrumental in the success of many national programs, including expanded coverage of PMTCT services, an enhanced continuum of care between PMTCT and HIV care and treatment, provision of more efficacious regimens for antiretroviral prophylaxis, design of innovative but simplified PMTCT approaches, and development of new strategies to evaluate program effectiveness. These accomplishments have been made through collaborative efforts with host governments, United Nations agencies, other donors (eg, the Global Fund for AIDS, Tuberculosis, and Malaria), nongovernmental organizations, and private sector partners. To successfully meet the ambitious global targets to prevent new infant HIV infections, PEPFAR must continue to leverage the existing PMTCT platform, while developing innovative approaches to rapidly expand quality HIV services. PEPFAR must also carefully integrate PMTCT into the broader combination prevention agenda for HIV, so that real progress can be made toward an "AIDS-free generation" worldwide.
In 2005, due to slow global progress in the scale-up of prevention of mother-to-child transmissio... more In 2005, due to slow global progress in the scale-up of prevention of mother-to-child transmission (PMTCT) and paediatric HIV programmes, the Inter-agency Task Team (IATT) on the Prevention of HIV infection among Pregnant Women, Mothers, and their Children initiated joint technical missions (JTMs) to countries of high HIV disease burden. The JTMs were intended to galvanize country actions for a more comprehensive response to PMTCT and paediatric HIV by bringing national and global stakeholders together to review national policies and programmes and develop country-specific recommendations for accelerating scale-up. Between 2005 and 2010, the IATT conducted JTMs in 18 low-and middle-income countries. In 2007, to assess the role played by the missions, a review in the first eight countries
Objective To assess the costs associated with the provision of services for the prevention of mot... more Objective To assess the costs associated with the provision of services for the prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus in two African countries. Methods In 2009, the costs to health-care providers of providing comprehensive PMTCT services were assessed in 20 public health facilities in Namibia and Rwanda. Information on prices and on the total amount of each service provided was collected at the national level. The costs of maternal testing and counselling, male partner testing, CD4+ T-lymphocyte (CD4+ cell) counts, antiretroviral prophylaxis and treatment, community-based activities, contraception for 2 years postpartum and early infant diagnosis were estimated in United States dollars (US$). Findings The estimated costs to the providers of PMTCT, for each mother-infant pair, were US$ 202.75-1029.55 in Namibia and US$ 94.14-342.35 in Rwanda. These costs varied with the drug regimen employed. At 2009 coverage levels, the maximal estimates of the national costs of PMTCT were US$ 3.15 million in Namibia and US$ 7.04 million in Rwanda (or < US$ 0.75 per capita in both countries). Adult testing and counselling accounted for the highest proportions of the national costs (37% and 74% in Namibia and Rwanda, respectively), followed by management and supervision. Treatment and prophylaxis accounted for less than 20% of the costs of PMTCT in both study countries. Conclusion The costs involved in the PMTCT of HIV varied widely between study countries and in accordance with the protocols used. However, since per-capita costs were relatively low, the scaling up of PMTCT services in Namibia and Rwanda should be possible.
Background There is a significant increase in survival for HIV-infected children who have early a... more Background There is a significant increase in survival for HIV-infected children who have early access to diagnosis and treatment. The goal of this multi-country review was to examine when and where HIV-exposed infants and children are being diagnosed, and whether the EID service is being maximally utilized to improve health outcomes for HIV-exposed children. Methods In four countries across Africa and Asia existing documents and data were reviewed and key informant interviews were conducted. EID testing data was gathered from the central testing laboratories and was then complemented by health facility level data extraction which took place using a standardized and validated questionnaire Results In the four countries reviewed from 2006 to 2009 EID sample volumes rose dramatically to an average of >100 samples per quarter in Cambodia and Senegal, >7,000 samples per quarter in Uganda, and >2,000 samples per quarter in Namibia. Geographic coverage of sites also rapidly expan...
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Background: Between 25 and 44% of mother-to-child transmission (MTCT) of the human immunodeficien... more Background: Between 25 and 44% of mother-to-child transmission (MTCT) of the human immunodeficiency virus (HIV) occurs through breastfeeding. As a result, feeding guidelines for infants of HIV-infected mothers are being formulated in many resource-poor countries. The impact of introducing these guidelines on mothers' actual feeding practices has not previously been examined. Infant-feeding practices of mothers of known HIV status who should have received advice during pre-and post-test HIV counselling were assessed and compared with those of uninfected mothers. Methods: Mothers of infants aged 2-12 months, 55 HIV-infected and 85 HIV-uninfected, were recruited from the HIV Family Support Unit in Lusaka, Zambia. HIV status was known to 121 of these mothers, who had all received pre-and post-test HIV counselling. Feeding practices were determined by verbal questionnaire. Results: All mothers breastfed but only 35% of infants below 4 months were exclusively breastfed (received breast milk only). HIV-infected mothers introduced fluids and weaned their infants significantly earlier than HIV-uninfected mothers (p = 0.03 and p = 0.002, respectively). Infants of HIV-infected mothers had significantly lower weight for age Z (WAZ) scores indicating poorer nutritional or health status (p = 0.004). Commercial formula milk and cow's milk were used by 36 mothers as breast milk substitutes, and were introduced at a median age of 2.5 months. Thirteen mothers gave cow's milk, and no mother added water to cow's milk (as recommended), with two adding sugar and four adding salt. Conclusion: Infant-feeding practices of HIV-infected mothers differed significantly from HIV-uninfected mothers, and this may contribute to their poorer growth. Paradoxically these mothers feeding practice could be putting these infants at greater risk of both non-HIV-related morbidity and HIV transmission, as early introduction of foods other than breast milk may increase MTCT.
Journal of acquired immune deficiency syndromes (1999), Jan 15, 2018
The global HIV response is leaving children and adolescents behind. Because of a paucity of studi... more The global HIV response is leaving children and adolescents behind. Because of a paucity of studies on treatment and care models for these age groups, there are gaps in our understanding of how best to implement services to improve their health outcomes. Without this evidence, policymakers are left to extrapolate from adult studies, which may not be appropriate, and can lead to inefficiencies in service delivery, hampered uptake, and ineffective mechanisms to support optimal outcomes. Implementation science research seeks to investigate how interventions known to be efficacious in study settings are, or are not, routinely implemented within real-world programmes. Effective implementation science research must be a collaborative effort between government, funding agencies, investigators, and implementers, each playing a key role. Successful implementation science research in children and adolescents requires clearer policies about age of consent for services and research that conform...
Countries where adult male circumcision has reached high coverage should consider national early ... more Countries where adult male circumcision has reached high coverage should consider national early infant male circumcision (EIMC) programs where EIMC is feasible and culturally acceptable. Ministries of health that intend to set up a routine offer of EIMC should put systems in place to ensure that its introduction (1) does not compromise adult male circumcision programs, (2) does not weaken routine service delivery platforms, (3) is done safely, and (4) adheres to the rights of the child. BACKGROUND M ale circumcision involves the complete removal of the foreskin of the penis, the innermost layer of which is highly susceptible to HIV transmission. 1 According to the World Health Organization (WHO), in 2006 about 30% of males globally (665 million infants, adolescents, and adults) had been circumcised. 2 Male circumcision has historically been performed in infancy, adolescence, and adulthood in various regions of Africa for religious and cultural reasons or for ethnic identity. 2 Circumcision is mainly performed using traditional methods, either at birth or to initiate males into adulthood at puberty. Male circumcision also has medical benefits, including the prevention of penile cancer, reduction in the transmission of some sexually transmitted infections (STIs), including HIV, and reduction in vaginal infections and cancer of the cervix in female sex partners. 3,4 Scientific evidence and program data show that male circumcision prevents female-to-male sexual transmission of HIV. 5 Three randomized controlled trials conducted by trained health professionals in properly equipped settings concluded that adult male circumcision reduces transmission of HIV from women to circumcised men by up to 60%. 5-9 Based on these results, WHO and the Joint United Nations Programme on HIV/AIDS (UNAIDS) recommended in 2007 that voluntary medical male circumcision (VMMC) be made available in countries with a high HIV prevalence, generalized heterosexual HIV epidemics, and low levels of male circumcision. Fourteen countries in East and Southern Africa were prioritized for VMMC scale-up as an HIV prevention strategy:
JAIDS Journal of Acquired Immune Deficiency Syndromes, 2017
While the Interagency Task Team on the Prevention and Treatment of HIV Infection in Pregnant Wome... more While the Interagency Task Team on the Prevention and Treatment of HIV Infection in Pregnant Women, Mothers, and Children (IATT) partnership existed before the Global Plan Towards the Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive (Global Plan), its reconfiguration was critical to coordinating provision of technical assistance that positively influenced country decision-making and program performance. This article describes how the Global Plan anchored the work of the IATT and, in turn, how the IATT's technical assistance helped to accelerate achievement of the Global Plan targets and milestones. The technical assistance that will be discussed addressed a broad range of priority actions and milestones described in the Global Plan: (1) planning for and implementing Option B+; (2) strengthening monitoring and evaluation systems; (3) translating evidence into action and advocacy; and (4) promoting community engagement. This article also reviews the ongoing challenges and opportunities of providing technical assistance in a rapidly evolving environment that calls for ever more flexible and contextualized responses. The effectiveness of technical assistance facilitated by the IATT was defined by its timeliness, evidence base, and unique global perspective that built on the competencies of its partners and promoted synergies across program areas. Reaching the final goal of eliminating vertical transmission of HIV infection and achieving an AIDS-free generation in countries with the highest HIV burden requires that the IATT partnership and technical assistance remain responsive to country-specific needs while aligning with the current programmatic reality and new global goals such as the Sustainable Development Goals and 90-90-90 targets.
To maintain high circumcision prevalence, voluntary medical male circumcision programs in Eastern... more To maintain high circumcision prevalence, voluntary medical male circumcision programs in Eastern and Southern Africa need to plan for sustainability and conduct transition assessments early on, rather than waiting until the saturation of priority targets at the end of the program.
Introduction: Integration of HIV into child survival platforms is an evolving territory with mult... more Introduction: Integration of HIV into child survival platforms is an evolving territory with multiple connotations. Most literature on integration of HIV into other health services focuses on adults; however promising practices for children are emerging. These include the Double Dividend (DD) framework, a new programming approach with dual goal of improving paediatric HIV care and child survival. In this commentary, the authors discuss why integrating HIV testing, treatment and care into child survival platforms is important, as well as its potential to advance progress towards global targets that call for, by 2020, 90% of children living with HIV to know their status, 90% of those diagnosed to be on treatment and 90% of those on treatment to be virally suppressed (90Á90Á90). Discussion: Integration is critical in improving health outcomes and efficiency gains. In children, integration of HIV in programmes such as immunization and nutrition has been associated with an increased uptake of HIV infant testing. Integration is increasingly recognized as a case-finding strategy for children missed from prevention of mother-to-child transmission programmes and as a platform for diffusing emerging technologies such as point-of-care diagnostics. These support progress towards the 90Á90Á90 targets by providing a pathway for early identification of HIV-infected children with co-morbidities, prompt initiation of treatment and improved survival. There are various promising practices that have demonstrated HIV outcomes; however, few have documented the benefits of integration on child survival interventions. The DD framework is well positioned to address the bidirectional impacts for both programmes. Conclusions: Integration provides an important programmatic pathway for accelerated progress towards the 90Á90Á90 targets. Despite this encouraging information, there are still challenges to be addressed in order to maximize the benefits of integration.
Objective.To improve PMTCT and antenatal care-related service delivery, a pack with centrally pre... more Objective.To improve PMTCT and antenatal care-related service delivery, a pack with centrally prepackaged medicine was rolled out to all pregnant women in Lesotho in 2011. This study assessed acceptability and feasibility of this copackaging mechanism for drug delivery among pregnant and postpartum women.Methods.Acceptability and feasibility were assessed in a mixed method, cross-sectional study through structured interviews (SI) and semistructured interviews (SSI) conducted in 2012 and 2013.Results.290 HIV-negative women and 437 HIV-positive women (n=727) participated. Nearly all SI participants found prepackaged medicines acceptable, though modifications such as size reduction of the pack were suggested. Positive experiences included that the pack helped women take pills as instructed and contents promoted healthy pregnancies. Negative experiences included inadvertent pregnancy disclosure and discomfort carrying the pack in communities. Implementation was also feasible; 85.2% of S...
Journal of acquired immune deficiency syndromes (1999), 2014
The global HIV epidemic in adolescents is not controlled, and this group has not received suffici... more The global HIV epidemic in adolescents is not controlled, and this group has not received sufficient attention in programming and research efforts addressing HIV prevention, treatment, and care. A global technical consultation on adolescents and HIV addressing services and research gaps was convened by United Nations Children's Fund and the London School of Hygiene and Tropical Medicine in July 2013. Proceedings from this meeting are presented in this issue of the Supplement. Several reviews highlight poor levels of coverage of critical HIV prevention, treatment, and care interventions for adolescents, disparities in HIV prevalence among adolescent girls, and low-risk perceptions associated with risk behaviors among key risk groups. Others underscore the significance of clear national targets and strengthening data, government involvement, enhanced systems capacity and policy, engagement of community and adolescent social networks, and of mobile and internet technologies to the ...
Background The number of HIV-positive pregnant women receiving antiretroviral drugs (ARVs) to pre... more Background The number of HIV-positive pregnant women receiving antiretroviral drugs (ARVs) to prevent mother-to-child transmission (MTCT) of HIV has increased rapidly. Objective To estimate the reduction in new child HIV infections resulting from prevention of MTCT (PMTCT) over the past decade. To project the potential impact of implementing the new WHO PMTCT guidelines between 2010 and 2015 and consider the efforts required to virtually eliminate MTCT, defined as <5% transmission of HIV from mother to child, or 90% reduction of infections among young children by 2015. Methods Data from 25 countries with the largest numbers of HIV-positive pregnant women were used to create five scenarios to evaluate different PMTCT interventions. A demographic model, Spectrum, was used to estimate new child HIV infections as a measure of the impact of interventions. Results Between 2000 and 2009 there was a 24% reduction in the estimated annual number of new child infections in the 25 countries, of which about one-third occurred in 2009 alone. If these countries implement the new WHO PMTCT recommendations between 2010 and 2015, and provide more effective ARV prophylaxis or treatment to 90% of HIV-positive pregnant women, 1 million new child infections could be averted by 2015. Reducing HIV incidence in reproductive age women, eliminating the current unmet need for family planning and limiting the duration of breastfeeding to 12 months (with ARV prophylaxis) could avert an additional 264 000 infections, resulting in a total reduction of 79% of annual new child infections between 2009 and 2015, approaching but still missing the goal of virtual elimination of MTCT. Discussion To achieve virtual elimination of new child infections PMTCT programmes must achieve high coverage of more effective ARV interventions and safer infant feeding practices. In addition, a comprehensive approach including meeting unmet family planning needs and reducing new HIV infections among reproductive age women will be required.
A growing number of countries are moving to scale up interventions for prevention of mother-to-ch... more A growing number of countries are moving to scale up interventions for prevention of mother-to-child transmission (PMTCT) of HIV in maternal and child health services. Similarly, many are working to improve access to paediatric HIV treatment. This paper reviews national programme data for 2004-2005 from low-and middle-income countries to track progress in these programmes. The attainment of the UNGASS target of reducing HIV infections by 50% by 2010 necessitates that 80% of all pregnant women accessing antenatal care receive PMTCT services. In 2005, only seven of the 71 countries were on track to meet this target. However PMTCT coverage increased from 7% in 2004 (58 countries) to 11% in 2005 (71 countries). In 2005, 8% of all infants born to HIV positive mothers received antiretroviral prophylaxis for PMTCT, up from 5% in 2004, though only 4% received cotrimoxazole. 11% of HIV positive children in need received antiretroviral treatment in 2005. In 31 countries that had data, 28% of women who received an antiretroviral for PMTCT also reported receiving antiretroviral treatment for their own health. Achieving the UNGASS target is possible but will require substantial investments and commitment to strengthen maternal and child health services, the health workforce and health systems to move from pilot projects to a decentralised, integrated approach.
Introduction: Mother-to-child transmission of HIV can be reduced toB5% with appropriate antiretro... more Introduction: Mother-to-child transmission of HIV can be reduced toB5% with appropriate antiretroviral medications. Such reductions depend on multiple health system encounters during antenatal care (ANC), delivery and breastfeeding; in countries with limited access to care, transmission remains high. In Lesotho, where 28% of women attending ANC are HIV positive but where geographic and other factors limit access to ANC and facility deliveries, a Minimum PMTCT Package was launched in 2007 as an alternative to the existing facility-based approach. Distributed at the first ANC visit, it packaged together all necessary pregnancy, delivery and early postnatal antiretroviral medications for mother and infant. Methods: To examine the availability, feasibility, acceptability and possible negative consequences of the Minimum PMTCT Package, data from a 2009 qualitative and quantitative study and a 2010 facility assessment were used. To examine the effects on ANC and facility-based delivery rates, a difference-indifferences analytic approach was applied to 2009 Demographic and Health Survey data for HIV-tested women who gave birth before and after Minimum PMTCT Package implementation. Results: The Minimum PMTCT Package was feasible and acceptable to providers and clients. Problems with test kit and medicine stock-outs occurred, and 46% of women did not receive the Minimum PMTCT Package until at least their second ANC visit. Providing adequate instruction on the use of multiple medications represented a challenge. The proportion of HIV-positive women delivering in facilities declined after Minimum PMTCT Package implementation, although it increased among HIVnegative women (difference-indifferences 014.5%, p 00.05). The mean number of ANC visits declined more among HIVpositive women than among HIV-negative women after implementation, though the difference was not statistically significant (p00.09). Changes in the percentage of women receiving ]4 ANC visits did not differ between the two groups. Conclusions: If supply issues can be resolved and adequate client educational materials provided, takeaway co-packages have the potential to increase access to PMTCT commodities in countries where women have limited access to health services. However, efforts must be made to carefully monitor potential changes in ANC visits and facility deliveries, and further evaluation of adherence, safety and effectiveness are needed.
JAIDS Journal of Acquired Immune Deficiency Syndromes, 2012
In June 2011, the Joint United Nations Programme on HIV/AIDS, the US President's Emergency Plan f... more In June 2011, the Joint United Nations Programme on HIV/AIDS, the US President's Emergency Plan for AIDS Relief (PEPFAR), and other collaborators outlined a transformative plan to virtually eliminate pediatric AIDS worldwide. The ambitious targets of this initiative included a 90% reduction in new pediatric HIV infections and a 50% reduction in HIV-related maternal mortalityall by 2015. PEPFAR has made an unprecedented commitment to the expansion and improvement of prevention of mother-to-child HIV transmission (PMTCT) services globally and is expected to play a critical role in reaching the virtual elimination target. To date, PEPFAR has been instrumental in the success of many national programs, including expanded coverage of PMTCT services, an enhanced continuum of care between PMTCT and HIV care and treatment, provision of more efficacious regimens for antiretroviral prophylaxis, design of innovative but simplified PMTCT approaches, and development of new strategies to evaluate program effectiveness. These accomplishments have been made through collaborative efforts with host governments, United Nations agencies, other donors (eg, the Global Fund for AIDS, Tuberculosis, and Malaria), nongovernmental organizations, and private sector partners. To successfully meet the ambitious global targets to prevent new infant HIV infections, PEPFAR must continue to leverage the existing PMTCT platform, while developing innovative approaches to rapidly expand quality HIV services. PEPFAR must also carefully integrate PMTCT into the broader combination prevention agenda for HIV, so that real progress can be made toward an "AIDS-free generation" worldwide.
In 2005, due to slow global progress in the scale-up of prevention of mother-to-child transmissio... more In 2005, due to slow global progress in the scale-up of prevention of mother-to-child transmission (PMTCT) and paediatric HIV programmes, the Inter-agency Task Team (IATT) on the Prevention of HIV infection among Pregnant Women, Mothers, and their Children initiated joint technical missions (JTMs) to countries of high HIV disease burden. The JTMs were intended to galvanize country actions for a more comprehensive response to PMTCT and paediatric HIV by bringing national and global stakeholders together to review national policies and programmes and develop country-specific recommendations for accelerating scale-up. Between 2005 and 2010, the IATT conducted JTMs in 18 low-and middle-income countries. In 2007, to assess the role played by the missions, a review in the first eight countries
Objective To assess the costs associated with the provision of services for the prevention of mot... more Objective To assess the costs associated with the provision of services for the prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus in two African countries. Methods In 2009, the costs to health-care providers of providing comprehensive PMTCT services were assessed in 20 public health facilities in Namibia and Rwanda. Information on prices and on the total amount of each service provided was collected at the national level. The costs of maternal testing and counselling, male partner testing, CD4+ T-lymphocyte (CD4+ cell) counts, antiretroviral prophylaxis and treatment, community-based activities, contraception for 2 years postpartum and early infant diagnosis were estimated in United States dollars (US$). Findings The estimated costs to the providers of PMTCT, for each mother-infant pair, were US$ 202.75-1029.55 in Namibia and US$ 94.14-342.35 in Rwanda. These costs varied with the drug regimen employed. At 2009 coverage levels, the maximal estimates of the national costs of PMTCT were US$ 3.15 million in Namibia and US$ 7.04 million in Rwanda (or < US$ 0.75 per capita in both countries). Adult testing and counselling accounted for the highest proportions of the national costs (37% and 74% in Namibia and Rwanda, respectively), followed by management and supervision. Treatment and prophylaxis accounted for less than 20% of the costs of PMTCT in both study countries. Conclusion The costs involved in the PMTCT of HIV varied widely between study countries and in accordance with the protocols used. However, since per-capita costs were relatively low, the scaling up of PMTCT services in Namibia and Rwanda should be possible.
Background There is a significant increase in survival for HIV-infected children who have early a... more Background There is a significant increase in survival for HIV-infected children who have early access to diagnosis and treatment. The goal of this multi-country review was to examine when and where HIV-exposed infants and children are being diagnosed, and whether the EID service is being maximally utilized to improve health outcomes for HIV-exposed children. Methods In four countries across Africa and Asia existing documents and data were reviewed and key informant interviews were conducted. EID testing data was gathered from the central testing laboratories and was then complemented by health facility level data extraction which took place using a standardized and validated questionnaire Results In the four countries reviewed from 2006 to 2009 EID sample volumes rose dramatically to an average of >100 samples per quarter in Cambodia and Senegal, >7,000 samples per quarter in Uganda, and >2,000 samples per quarter in Namibia. Geographic coverage of sites also rapidly expan...
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Background: Between 25 and 44% of mother-to-child transmission (MTCT) of the human immunodeficien... more Background: Between 25 and 44% of mother-to-child transmission (MTCT) of the human immunodeficiency virus (HIV) occurs through breastfeeding. As a result, feeding guidelines for infants of HIV-infected mothers are being formulated in many resource-poor countries. The impact of introducing these guidelines on mothers' actual feeding practices has not previously been examined. Infant-feeding practices of mothers of known HIV status who should have received advice during pre-and post-test HIV counselling were assessed and compared with those of uninfected mothers. Methods: Mothers of infants aged 2-12 months, 55 HIV-infected and 85 HIV-uninfected, were recruited from the HIV Family Support Unit in Lusaka, Zambia. HIV status was known to 121 of these mothers, who had all received pre-and post-test HIV counselling. Feeding practices were determined by verbal questionnaire. Results: All mothers breastfed but only 35% of infants below 4 months were exclusively breastfed (received breast milk only). HIV-infected mothers introduced fluids and weaned their infants significantly earlier than HIV-uninfected mothers (p = 0.03 and p = 0.002, respectively). Infants of HIV-infected mothers had significantly lower weight for age Z (WAZ) scores indicating poorer nutritional or health status (p = 0.004). Commercial formula milk and cow's milk were used by 36 mothers as breast milk substitutes, and were introduced at a median age of 2.5 months. Thirteen mothers gave cow's milk, and no mother added water to cow's milk (as recommended), with two adding sugar and four adding salt. Conclusion: Infant-feeding practices of HIV-infected mothers differed significantly from HIV-uninfected mothers, and this may contribute to their poorer growth. Paradoxically these mothers feeding practice could be putting these infants at greater risk of both non-HIV-related morbidity and HIV transmission, as early introduction of foods other than breast milk may increase MTCT.
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