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

Laboratory Evaluation of the VISITECT Advanced Disease Semiquantitative Point-of-Care CD4 Test

BACKGROUND

Advanced HIV disease (AHD; CD4 counts <200 cells/µL) remains common in many low- and middle-income settings. An instrument-free point-of-care test to rapidly identify patients with AHD would facilitate implementation of the World Health Organization (WHO) recommended package of care. We performed a laboratory-based validation study to evaluate the performance of the VISITECT CD4 Advanced Disease assay in Botswana.

SETTING

A laboratory validation study.

METHODS

Venous blood samples from people living with HIV having baseline CD4 testing in Gaborone, Botswana, underwent routine testing using flow cytometry, followed by testing with the VISITECT CD4 Advanced Disease assay by a laboratory scientist blinded to the flow cytometry result with a visual read to determine whether the CD4 count was below 200 cells/µL. A second independent investigator conducted a visual read blinded to the results of flow cytometry and the initial visual read. The sensitivity and specificity of the VISITECT for detection of AHD were determined using flow cytometry as a reference standard, and interrater agreement in VISITECT visual reads assessed.

RESULTS

One thousand fifty-three samples were included in the analysis. The VISITECT test correctly identified 112/119 samples as having a CD4 count <200 cells/µL, giving a sensitivity of 94.1% (95% confidence interval: 88.3% to 97.6%) and specificity of 85.9% (95% confidence interval: 83.5% to 88.0%) compared with flow cytometry. Interrater agreement between the 2 independent readers was 97.5%, Kappa 0.92 ( P < 0.001).

CONCLUSIONS

The VISITECT CD4 advanced disease reliably identified individuals with low CD4 counts and could facilitate implementation of the WHO recommended package of interventions for AHD.

Antibiotic prescription for HIV-positive patients in primary health care in Mozambique: A cross-sectional study

Background

Antibiotic overuse is a major public health challenge worldwide and it can result in the emergence and spread of drug resistance. In Mozambique, there are limited data related to primary care physicians’ antibiotic prescription patterns. The aim of this study was to assess the antibiotic prescription patterns for HIV- positive patients in primary health care.

Methods

A prospective cross-sectional quantitative study was conducted in eight primary health care units in Southern Mozambique. The study was based on recording outpatient prescriptions using a structured questionnaire. Three hundred and sixty-nine prescriptions and clinical records of HIV-positive patients from 31 prescribers were assessed. A total of eight general practitioners, 13 medical technicians and 10 nurses participated.

Results

Antibiotics were used in 65.9% of prescriptions, with an average of 0.9 antibiotics per prescription. Of a total of 334 prescribed antibiotics, 69.8% were for the treatment of infections and 30.2% for prophylaxis. Penicillin (29.2%), sulphonamides (19.7%), and quinolones (16.3%) were the most prescribed classes of antibiotics for treatment. For prophylaxis, only sulphonamides (93.1%) and macrolides (6.9%) were prescribed. The diagnosis was the only variable that had a significant association with antibiotic prescription (p < 0.001). Most of penicillins (68.0%) and sulphonamides (21.4%) were prescribed to treat infections related to the respiratory tract.

Conclusion

The prescription of antibiotics was high and influenced by patient clinical conditions. Antibiotics were prescribed either for treatment or prophylaxis of infections, mostly to treat respiratory tract infections. Prescribers should be encouraged to adopt a rational use of antibiotics to reduce unnecessary prescriptions.

Correlates of loss to follow-up and missed diagnosis among HIV-exposed infants throughout the breastfeeding period in southern Mozambique

Introduction

Complete follow-up of human immunodeficiency virus (HIV)-exposed infants (HEI) is crucial for a successful prevention of mother-to-child HIV transmission. This study analyzed the HEI follow-up and factors associated with loss to follow-up (LTFU) in southern Mozambique.

Methods

This retrospective cohort study used the data of HEI enrolled between June 2017 and June 2018, followed-up for 18 months. The outcomes were the proportion of infants with completed follow-up and a definitive diagnosis, and the presence of clinical events. Kaplan–Meier survival analysis was used to calculate the cumulative probability of LTFU and of clinical events. Factors associated with LTFU and clinical events were analyzed using Cox regression to calculate the hazard ratio (HR) and adjusted HR (AHR), with a 95% confidence interval (CI) and a significance cutoff of p<0.05.

Results

1413 infants were enrolled (49% males) at a median age of 32 days (IQR 31–41); the median follow-up time was 12 months (IQR 8.2–14.2); 1129 (80%) completed follow-up and had a definitive diagnosis, 58 (4%) were HIV-positive, 225 (16%) were LTFU; 266 (19%) presented a clinical event. Factors associated with LTFU were: age >2 months at entry (AHR, 1.58; 95% CI, 1.12–2.23), non-exclusive breastfeeding (AHR, 1.44; 95% CI, 1.01–2.06), poor cotrimoxazole adherence (AHR, 3.42; 95% CI, 1.59–7.35), and clinical events (AHR, 0.51; 95% CI, 0.34–0.77). Factors associated with clinical events were: malnutrition (AHR, 10.06; 95% CI, 5.92–17.09), non-exclusive breastfeeding (AHR, 1.98; 95% CI, 1.34–2.93), no nevirapine prophylaxis (AHR, 1.67; 95% CI, 1.18–2.36), and poor cotrimoxazole adherence (AHR, 2.62; 95% CI, 1.10–6.22).

Conclusion

The high rate of HEI LTFU, associated with delayed linkage to postnatal care, poor prophylaxis adherence, non-exclusive breastfeeding, indicates the need to design a differentiated service delivery model that is tailored to the mothers’ and infants’ specific needs.

Streptococcus pneumoniae colonization in pneumococcal vaccine-naïve human immunodeficiency virus-exposed infected and -uninfected South African children

Pneumococcal nasopharyngeal colonization is a pre-requisite for pneumococcal disease; the risk for pneumococcal disease is high in children born to women living with human immunodeficiency virus (HIV). We investigated pneumococcal colonization, serotype distribution and antibiotic susceptibility of Streptococcus pneumoniae isolates carried by perinatal HIV-infected and HIV-exposed-uninfected (HEU) children.Serial nasopharyngeal swabs were collected from 331 HIV-infected and 491 HEU children, at up to 6 scheduled timepoints, between median ages of 25 to 181 weeks. Pneumococcus was identified by culture; serotyping and antibiotic susceptibility testing were done by conventional methods. No pneumococcal vaccine was given.HIV-infected children were less likely to be colonized with 7-valent pneumococcal conjugate vaccine 7 serotypes than HEU at a median of 25 weeks of age (23% vs 36%; P < .001); however, no differences in colonization between the 2 groups were observed at subsequent study-visits. Over the 36-months study-period pneumococcal colonization increased in both HIV-infected (from 45% to 77%) and HEU (from 57% to 61%) children. Over the study-period, pneumococcal isolates non-susceptible to cotrimoxazole decreased from 92% to 57% and had a similar trend to penicillin (from 65% to 42%) in HIV-infected children. Similarly, pneumococcal nonsusceptible to cotrimoxazole decreased from 93% to 57% and to penicillin from 69% to 37% in HEU children.Vaccine serotype colonization was common in this population and similar rates were observed in HIV-infected and HEU children. The prevalence of pneumococcal isolates non-susceptible to cotrimoxazole and penicillin decreased with age.

Appropriateness of Cotrimoxazole Prophylactic Therapy Among HIV/AIDS Patients in Public Hospitals in Eastern Ethiopia: A Retrospective Evaluation of Clinical Practice

Background: Cotrimoxazole prophylactic therapy (CPT) is a feasible, cost-effective, and safe way of using cotrimoxazole intervention to reduce HIV/AIDS related morbidities and mortalities associated with opportunistic infections. Despite its effectiveness in reducing the incidence of opportunistic infections, the actual drug utilization process has been shown to deviate from World Health Organization (WHO) guideline in Ethiopia. This study, therefore, aims to evaluate CPT among HIV/AIDS patients in Jugel Hospital (JH), Harar and Dilchora Referral Hospital (DRH), Dire Dawa, Eastern Ethiopia.

Methods: A cross sectional study was conducted to evaluate the use of cotrimoxazole as prophylactic therapy. In this study, 556 medical records (305 in JH and 251 in DRH) of HIV/AIDS patients who had been taking CPT within September 2015–August 2016 were reviewed. Systematic random sampling was employed to obtain medical records from the sampling frame. Data were abstracted from the patient medical records using structured checklist customized from the WHO guideline. The data were entered into Epi-data 3.1 and exported to and analyzed with statistical Package for Social Sciences (SPSS) version 20. The finding was evaluated against the WHO guideline on the use of cotrimoxazole prophylaxis in HIV/AIDS patients. Descriptive statistics was used to present the data in tables, figures and pie chart.

Results: Majority of the HIV/AIDS patients who had been taking CPT were adults (95.9%), female (61.2%), married (43.7%), Orthodox Christian (54.3%), and attended primary school (40.1%). At the initiation of CPT, most of the patients were at WHO clinical stage III (40.8%). The major comorbid illnesses identified were tuberculosis and pneumocystis-jiroveci pneumonia. Initially, majority of the patients were at CD₄ count of less than 350 cells/mm³ (n = 504, 90.6%). Greater proportion of patients started CPT prior to initiating antiretroviral therapy (ART). Most of the patients took CPT for greater than 6 months. The primary reasons for premature discontinuation of CPT were CD4 greater than 350 cells/mm³, severe sulfa allergy and first trimester of pregnancy. Generally, the use of cotrimoxazole prophylaxis was consistent with the WHO guideline for indication to start (n = 519, 93.3%) and dose (n = 552, 99.28%), despite the presence of contraindication in 6.65% patients.

Conclusion: In reference to the WHO guideline, the use of CPT was found to be fully appropriate in nearly two-thirds of HIV/AIDS patients. For the rest patients, inappropriate use of cotrimoxazole was observed based on the WHO criteria for initiation, discontinuation, continuation and dose with rate of discontinuation being the dominant one. Such practice may lead to adverse health outcomes including adverse drug reactions and negative treatment outcome.

Presentation of life-threatening invasive nontyphoidal Salmonella disease in Malawian children: A prospective observational study

Nontyphoidal Salmonellae commonly cause invasive disease in African children that is often fatal. The clinical diagnosis of these infections is hampered by the absence of a clear clinical syndrome. Drug resistance means that empirical antibiotic therapy is often ineffective and currently no vaccine is available. The study objective was to identify risk factors for mortality among children presenting to hospital with invasive Salmonella disease in Africa. We conducted a prospective study enrolling consecutive children with microbiologically-confirmed invasive Salmonella disease admitted to Queen Elizabeth Central Hospital, Blantyre, in 2006. Data on clinical presentation, co-morbidities and outcome were used to identify children at risk of inpatient mortality through logistic-regression modeling. Over one calendar year, 263 consecutive children presented with invasive Salmonella disease. Median age was 16 months (range 0-15 years) and 52/256 children (20%; 95%CI 15-25%) died. Nontyphoidal serovars caused 248/263 (94%) of cases. 211/259 (81%) of isolates were multi-drug resistant. 251/263 children presented with bacteremia, 6 with meningitis and 6 with both. Respiratory symptoms were present in 184/240 (77%; 95%CI 71-82%), 123/240 (51%; 95%CI 45-58%) had gastrointestinal symptoms and 101/240 (42%; 95%CI 36-49%) had an overlapping clinical syndrome. Presentation at <7 months (OR 10.0; 95%CI 2.8-35.1), dyspnea (OR 4.2; 95%CI 1.5-12.0) and HIV infection (OR 3.3; 95%CI 1.1-10.2) were independent risk factors for inpatient mortality. Invasive Salmonella disease in Malawi is characterized by high mortality and prevalence of multi-drug resistant isolates, along with non-specific presentation. Young infants, children with dyspnea and HIV-infected children bear a disproportionate burden of the Salmonella-associated mortality in Malawi. Strategies to improve prevention, diagnosis and management of invasive Salmonella disease should be targeted at these children.

Bottlenecks and opportunities for delivering integrated pediatric HIV services in Nepal

BACKGROUND

In children, integration of HIV in MNCH services has been shown to incr. ease uptake of early infant diagnosis. This article examines bottlenecks and opportunities for scaling up integrated pediatric HIV services in Nepal.

METHODS

This is a descriptive study using both mixed qualitative and quantitative methods, conducted in January 2015 in 19 facilities in five regions of Nepal most affected by HIV epidemic. The qualitative methods comprised in-depth structured interviews with key informants (leadership of The National Center for AIDS and STD Control and National Public Health Laboratory, district management teams, medical officers in charge of health facilities and HIV clinics, frontline staff at antenatal care and HIV clinics and laboratory). The quantitative methods were used to abstract data of HIV-infected pregnant women seen between January and December 2014, HIV-exposed infants aged less than 12 months, and HIV infected children aged less than 15 years who were initiated HIV treatment from 2010 to 2014. Structured tools were used to collect data which were analysed using IBM SPSS.

RESULTS

Of the 19 facilities assessed, 18(98%), 18(98%), 14(75%), and 11(58%) provided prevention of mother-to-child transmission (PMTCT), Expanded Program on Immunization (EPI), pediatric ART and nutrition rehabilitation services, respectively. However, only 1(5%) facility collected onsite dried blood spots (DBS) for PCR HIV testing and 6(32%) facilities provided counselling and referral for DBS. In 2014, of the 121 HIV-exposed infants recorded, only 21(17%) received PCR test. The median turnaround time of the PCR test results was 54 days. Of the 21 records with PCR test, 11(52.5%) were from PMTCT clinics, 7(33%) from Nutritional rehabilitation clinics, and 3(14.5%) from pediatric outpatient clinic.Conversely, 934 children were initiated ART between 2010 and 2014, of which 5% were infants and 29% aged between 1 and 5 years. 298(32%) had comorbidities of which 64% had malnutrition. A total of 534(57%) had tuberculosis (TB) status assessed of which 58(11%) had active TB. Infants had lowest retention (63%), high mortality (17.4%), and loss to follow-up (10.9%).

CONCLUSION

Few facilities collect DBS and few children receive PCR tests with limited linkage to ART. This has led to late ART initiation, comorbidities, including TB coinfections and poor outcomes. The results indicate that there are opportunities for improving HIV case finding among HIV-exposed infants in PMTCT, EPI, TB, and nutrition services if provider initiated testing and counselling at the point of service delivery is institutionalized in these settings.

High Incidence of Tuberculosis in the Absence of Isoniazid and Cotrimoxazole Preventive Therapy in Children Living with HIV in Northern Ethiopia: A Retrospective Follow-Up Study

Objective

To identify the incidence of and predictors for tuberculosis in children living with HIV in Northern Ethiopia.

Design

Observational, retrospective follow-up study.

Methods

A total of 645 HIV-infected children were observed between September 2009 and September 2014. Cox regression analysis was used to identify predictors for developing TB.

Results

The incidence rate of tuberculosis was 4.2 per 100 child-years. Incidence of tuberculosis was higher for subjects who were not on cotrimoxazole preventive therapy, were not on isoniazid preventive therapy, had delayed motor development, had a CD4 cell count below the threshold, had hemoglobin level less than 10 mg/dl and were assessed as World Health Organization (WHO) clinical stage III or IV.

Conclusion

Incidence of TB in children living with HIV was high. This study reaffirmed that isoniazid preventive therapy is one of the best strategy to reduce incidence of TB in children living with HIV. All children living with HIV should be screened for TB but for children with delayed motor development, advanced WHO clinical stage, anemia or immune suppression, intensified screening is highly recommended.

Pathogens and pharmaceuticals in source-separated urine in eThekwini, South Africa

In eThekwini, South Africa, the production of agricultural fertilizers from human urine collected from urine-diverting dry toilets is being evaluated at a municipality scale as a way to help finance a decentralized, dry sanitation system. The present study aimed to assess a range of human and environmental health hazards in source-separated urine, which was presumed to be contaminated with feces, by evaluating the presence of human pathogens, pharmaceuticals, and an antibiotic resistance gene. Composite urine samples from households enrolled in a urine collection trial were obtained from urine storage tanks installed in three regions of eThekwini. Polymerase chain reaction (PCR) assays targeted 9 viral and 10 bacterial human pathogens transmitted by the fecal-oral route. The most frequently detected viral pathogens were JC polyomavirus, rotavirus, and human adenovirus in 100%, 34% and 31% of samples, respectively. Aeromonas spp. and Shigella spp. were frequently detected gram negative bacteria, in 94% and 61% of samples, respectively. The gram positive bacterium, Clostridium perfringens, which is known to survive for extended times in urine, was found in 72% of samples. A screening of 41 trace organic compounds in the urine facilitated selection of 12 priority pharmaceuticals for further evaluation. The antibiotics sulfamethoxazole and trimethoprim, which are frequently prescribed as prophylaxis for HIV-positive patients, were detected in 95% and 85% of samples, reaching maximum concentrations of 6800 μg/L and 1280 μg/L, respectively. The antiretroviral drug emtricitabine was also detected in 40% of urine samples. A sulfonamide antibiotic resistance gene (sul1) was detected in 100% of urine samples. By coupling analysis of pathogens and pharmaceuticals in geographically dispersed samples in eThekwini, this study reveals a range of human and environmental health hazards in urine intended for fertilizer production. Collection of urine offers the benefit of sequestering contaminants from environmental release and allows for targeted treatment of potential health hazards prior to agricultural application. The efficacy of pathogen and pharmaceutical inactivation, transformation or removal during urine nutrient recovery processes is thus briefly reviewed.

Protective efficacy of prolonged co-trimoxazole prophylaxis in HIV-exposed children up to age 4 years for the prevention of malaria in Uganda: a randomised controlled open-label trial

BACKGROUND

WHO recommends daily co-trimoxazole for children born to HIV-infected mothers from 6 weeks of age until breastfeeding cessation and exclusion of HIV infection. We have previously reported on the effectiveness of continuation of co-trimoxazole prophylaxis up to age 2 years in these children. We assessed the protective efficacy and safety of prolonging co-trimoxazole prophylaxis until age 4 years in HIV-exposed children.

METHODS

We undertook an open-label randomised controlled trial alongside two observational cohorts in eastern Uganda, an area with high HIV prevalence, malaria transmission intensity, and antifolate resistance. We enrolled HIV-exposed infants between 6 weeks and 9 months of age and prescribed them daily co-trimoxazole until breastfeeding cessation and HIV-status confirmation. At the end of breastfeeding, children who remained HIV-uninfected were randomly assigned (1:1) to discontinue co-trimoxazole or to continue taking it up to age 2 years. At age 2 years, children who continued co-trimoxazole prophylaxis were randomly assigned (1:1) to discontinue or continue prophylaxis from age 2 years to age 4 years. The primary outcome was incidence of malaria (defined as the number of treatments for new episodes of malaria diagnosed with positive thick smear) at age 4 years. For additional comparisons, we observed 48 HIV-infected children who took continuous co-trimoxazole prophylaxis and 100 HIV-unexposed uninfected children who never received prophylaxis. We measured grade 3 and 4 serious adverse events and hospital admissions. All children were followed up to age 5 years and all analyses were by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00527800.

FINDINGS

203 HIV-exposed infants were enrolled between Aug 10, 2007, and March 28, 2008. After breastfeeding ended, 185 children were not infected with HIV and were randomly assigned to stop (n=87) or continue (n=98) co-trimoxazole up to age 2 years. At age 2 years, 91 HIV-exposed children who had remained on co-trimoxazole prophylaxis were randomly assigned to discontinue (n=46) or continue (n=45) co-trimoxazole from age 2 years to age 4 years. We recorded 243 malaria episodes (2·91 per person-years) in the 45 HIV-exposed children assigned to continue co-trimoxazole until age 4 years compared with 503 episodes (5·60 per person-years) in the 46 children assigned to stop co-trimoxazole at age 2 years (incidence rate ratio 0·53, 95% CI 0·39-0·71; p< 0·0001). There was no evidence of malaria incidence rebound in the year after discontinuation of co-trimoxazole in the HIV-exposed children who stopped co-trimoxazole at age 2 years, but incidence increased significantly in HIV-exposed children who stopped co-trimoxazole at age 4 years (odds ratio 1·78, 95% CI 1·19-2·66; p= 0·005). Incidence of grade 3 or 4 serious adverse events, hospital admissions, or deaths did not significantly differ between HIV-exposed, HIV-unexposed, and HIV-infected children.

Tracing defaulters in HIV prevention of mother-to-child transmission programmes through community health workers: results from a rural setting in Zimbabwe

Introduction

High retention in care is paramount to reduce vertical human immunodeficiency virus (HIV) infections in prevention of mother-to-child transmission (PMTCT) programmes but remains low in many sub-Saharan African countries. We aimed to assess the effects of community health worker–based defaulter tracing (CHW-DT) on retention in care and mother-to-child HIV transmission, an innovative approach that has not been evaluated to date.

Methods

We analyzed patient records of 1878 HIV-positive pregnant women and their newborns in a rural PMTCT programme in the Tsholotsho district of Zimbabwe between 2010 and 2013 in a retrospective cohort study. Using binomial regression, we compared vertical HIV transmission rates at six weeks post-partum, and retention rates during the perinatal PMTCT period (at delivery, nevirapine [NVP] initiation at three days post-partum, cotrimoxazole (CTX) initiation at six weeks post-partum, and HIV testing at six weeks post-partum) before and after the introduction of CHW-DT in the project.

Results

Median maternal age was 27 years (inter-quartile range [IQR] 23 to 32) and median CD4 count was 394 cells/µL³ (IQR 257 to 563). The covariate-adjusted rate ratio (aRR) for perinatal HIV transmission was 0.72 (95% confidence intervals [95% CI] 0.27 to 1.96, p=0.504), comparing patient outcomes after and before the intervention. Among fully retained patients, 11 (1.9%) newborns tested HIV positive. ARRs for retention in care were 1.01 (95% CI 0.96 to 1.06, p=0.730) at delivery; 1.35 (95% CI 1.28 to 1.42, p<0.001) at NVP initiation; 1.78 (95% CI 1.58 to 2.01, p<0.001) at CTX initiation; and 2.54 (95% CI 2.20 to 2.93, p<0.001) at infant HIV testing. Cumulative retention after and before the intervention was 496 (85.7%) and 1083 (87.3%) until delivery; 480 (82.9%) and 1005 (81.0%) until NVP initiation; 303 (52.3%) and 517 (41.7%) until CTX initiation; 272 (47.0%) and 427 (34.4%) until infant HIV testing; and 172 (29.7%) and 405 (32.6%) until HIV test result collection.

Conclusions

The CHW-DT intervention did not reduce perinatal HIV transmission significantly. Retention improved moderately during the post-natal period, but cumulative retention decreased rapidly even after the intervention. We showed that transmission in resource-limited settings can be as low as in resource-rich countries if patients are fully retained in care. This requires structural changes to the regular PMTCT services, in which community health workers can, at best, play a complementary role.

Sulfonamide and tetracycline resistance genes in total- and culturable-bacterial assemblages in South African aquatic environments

Antibiotic resistant bacteria are ubiquitous in the natural environment. The introduction of effluent derived antibiotic resistance genes (ARGs) into aquatic environments is of concern in the spreading of genetic risk. This study showed the prevalence of sulfonamide and tetracycline resistance genes, sul1, sul2, sul3, and tet(M), in the total bacterial assemblage and colony forming bacterial assemblage in river and estuarine water and sewage treatment plants (STP) in South Africa. There was no correlation between antibiotic concentrations and ARGs, suggesting the targeted ARGs are spread in a wide area without connection to selection pressure. Among sul genes, sul1 and sul2 were major genes in the total (over 10(-2) copies/16S) and colony forming bacteria assemblages (∼10(-1) copies/16S). In urban waters, the sul3 gene was mostly not detectable in total and culturable assemblages, suggesting sul3 is not abundant. tet(M) was found in natural assemblages with 10(-3) copies/16S level in STP, but was not detected in colony forming bacteria, suggesting the non-culturable (yet-to-be cultured) bacterial community in urban surface waters and STP effluent possess the tet(M) gene. Sulfamethoxazole (SMX) resistant (SMX(r)) and oxytetracycline (OTC) resistant (OTC(r)) bacterial communities in urban waters possessed not only sul1 and sul2 but also sul3 and tet(M) genes. These genes are widely distributed in SMX(r) and OTC(r) bacteria. In conclusion, urban river and estuarine water and STP effluent in the Durban area were highly contaminated with ARGs, and the yet-to-be cultured bacterial community may act as a non-visible ARG reservoir in certain situations.

A review of the role of food insecurity in adherence to care and treatment among adult and pediatric populations living with HIV and AIDS

Adherence to antiretroviral therapy (ART) is critical for reducing HIV/AIDS morbidity and mortality. Food insecurity (FI) is emerging as an important barrier to adherence to care and treatment recommendations for people living with HIV (PLHIV), but this relationship has not been comprehensively examined. Therefore, we reviewed the literature to explore how FI may impact ART adherence, retention in medical care, and adherence to health care recommendations among PLHIV. We found data to support FI as a critical barrier to adherence to ART and to other health care recommendations among HIV-infected adults, HIV-infected pregnant women and their HIV-exposed infants, and child and adolescent populations of PLHIV. Associations between FI and ART non-adherence were seen in qualitative and quantitative studies. We identified a number of mechanisms to explain how food insecurity and ART non-adherence may be causally linked, including the exacerbation of hunger or ART side effects in the absence of adequate food and competing resource demands. Interventions that address FI may improve adherence to care and treatment recommendations for PLHIV.

Perceived barriers to the implementation of Isoniazid preventive therapy for people living with HIV in resource constrained settings: a qualitative study

Introduction

Isoniazid preventive therapy (IPT) reduces the risk of active TB. IPT is a key public health intervention for the prevention of TB among people living with HIV and has been recommended as part of a comprehensive HIV and AIDS care strategy. However, its implementation has been very slow and has been impeded by several barriers. Objective: The Objective of the study is to assess the perceived barriers to the implementation of Isoniazid preventive therapy for people living with HIV in resource constrained settings in Addis Ababa, Ethiopia in 2010.

Methods

A qualitative study using a semi-structured interviewed guide was used for the in-depth interview. A total of 12 key informants including ART Nurse, counselors and coordinators found in four hospitals were included in the interview. Each session of the in-depth interview was recorded via audio tape and detailed notes. The interview was transcribed verbatim. The data was analyzed manually.

Results

The findings revealed that poor patient adherence was a major factor; with the following issues cited as the reasons for poor adherence; forgetfulness; lack of understanding of condition and patient non- disclosure of HIV sero-status leading to insubstantial social support; underlying mental health issues resulting in missed or irregular patient appointments; weak patient/healthcare provider relationship due to limited quality interaction; lack of patient information, patient empowerment and proper counseling on IPT; and the deficient reinforcement by health officials and other stakeholders on the significance of IPT medication adherence as a critical for positive health outcomes.

Conclusion

Uptake of the implementation of IPT is facing a challenge in resource limited settings. This recalled provision of training/capacity building and awareness creation mechanism for the health workers, facilitating disclosure and social support for the patients is recommended.

Referral success among HIV-infected women and HIV-exposed children referred for monitoring and treatment in Tanga, Tanzania

Long-term retention of patients in the rapidly expanding antiretroviral programs against HIV/AIDS is essential for the success of these programs. Unfortunately, high percentages of patients in need of treatment are lost to follow up in resource-poor settings. From June 2006 to March 2007 269 HIV-infected pregnant women were screened for participation in a Prevention of Mother to Child Transmission (PMTCT) study in Tanga, Tanzania. Ninety-one women were referred to Care and Treatment Center (CTC) for monitoring and antiretroviral therapy regardless of inclusion in the PMTCT study. Both women and HIV-exposed children were traced at CTC from mid-February to mid-March 2008. Follow-up visits for all patients were examined. Only 10% (9/91) of the referred women were still attending CTC by February/March 2008 and 64% (58/91) never attended CTC. Not a single child could be traced at CTC. The largest loss of patients occurs between referral and the first attendance at CTC. Every effort must be made to clarify reasons for loss of patients at this point. Further, measures to improve patient retention must be increased as must initiatives to improve the ability to trace and retain children within the clinics.

Improving survival of children with severe acute malnutrition in HIV-prevalent settings

The care of severely malnourished children in sub-Saharan Africa is challenging, especially in HIV-prevalent settings. Recent improvements to facility-based individual case management, and increased community-based management focusing on early identification and high programme coverage have led to reductions in mortality. Further interventions are urgently needed to address resistant mortality, mostly attributable to HIV. This paper explores strategies in three main areas to improve survival for children with severe acute malnutrition (SAM): identifying HIV and improving case management for HIV-infected children; strengthening existing strategies to improve outcomes for all children with SAM, regardless of HIV status; and improving early identification and increasing programme coverage. Although interventions to further improve survival among children with SAM in sub-Saharan Africa must firstly ensure best care for all children, HIV-infected children are at particular risks for mortality. Integration of specific interventions for HIV testing and treatment into SAM care is essential. International guidelines should reflect best evidence, and are in urgent need of updating and adapting to local country context. Effective interventions already exist that can improve survival in children with SAM in HIV-prevalent settings. The challenge is to implement what we know and to research what we do not.

Surveillance of molecular markers of Plasmodium falciparum resistance to sulphadoxine-pyrimethamine 5 years after the change of malaria treatment policy in Ghana

In 2005, sulphadoxine-pyrimethamine (SP) became the drug of choice for intermittent preventive treatment of Plasmodium falciparum malaria in pregnancy (IPTp) in Ghana. Reports suggest the use of SP by others to treat uncomplicated malaria. Because of the increased use of SP, the prevalence of mutations in the genes, dihydrofolate reductase (dhfr), and dihydropteroate synthetase (dhps), linked to SP resistance in P. falciparum were determined. Blood samples from 945 children with uncomplicated malaria collected at nine sites from 2003 to 2010 were analyzed using polymerase chain reaction and restriction fragment length polymorphism. Prevalence of the dhfr triple and dhfr plus dhps quadruple mutations showed significant increase in trend from 2003 to 2010 (χ(2) = 18.78, P < 0.001, χ(2) = 15.11, P < 0.001, respectively). For dhps double mutant G437 + E540 the prevalence was low (1.12%) caused by the very low prevalence of E540. Our findings show the wide use of SP in Ghana and therefore its use for IPTp needs to be closely monitored.

Assessing the efficiency of mother-to-child HIV prevention in low- and middle-income countries using data envelopment analysis

AIDS is one of the most significant health care problems worldwide. Due to the difficulty and costs involved in treating HIV, preventing infection is of paramount importance in controlling the AIDS epidemic. The main purpose of this paper is to explore the potential of using Data Envelopment Analysis (DEA) to establish international comparisons on the efficiency of implementation of HIV prevention programmes. To do this we use data from 52 low- and middle-income countries regarding the prevention of mother-to-child transmission of HIV. Our results indicate that there is a remarkable variation in the efficiency of prevention services across nations, suggesting that a better use of resources could lead to more and improved services, and ultimately, prevent the infection of thousands of children. These results also demonstrate the potential strategic role of DEA for the efficient and effective planning of scarce resources to fight the epidemic.

Prophylactic treatment uptake and compliance with recommended follow up among HIV exposed infants: a retrospective study in Addis Ababa, Ethiopia

BACKGROUND

Children are being infected by HIV/AIDS mainly through mother-to-child transmission. In Ethiopia currently more than 135,000 children are living with HIV/AIDS. The aim of this study was to describe the pattern of ARV uptake after birth, co-trimoxazole prophylaxis and follow up compliance, and to examine which factors are associated with the intervention outcome.

METHODS

A retrospective quantitative study design was used for data collection through two hospitals. All infants who were delivered by HIV infected mothers between October 2008 and August 2009 were included and information regarding treatment adherence during their first 6 months of age was collected.

FINDINGS

118 HIV exposed infant-mother pairs were included in the study. 107 (90.7%) infants received ARV prophylaxis at birth. Sixty six (56%) of the infants were found to be adherent to co-trimoxazole prophylactic treatment. The majority (n = 110(93.2%)) of infants were tested HIV negative with DNA/PCR HIV test at the age of sixth weeks. Infants who took ARV prophylaxis at birth were found to be more likely to adhere with co-trimoxazole treatment: [OR = 9.43(95% CI: 1.22, 72.9)]. Similarly, infants whose mothers had been enrolled for HIV/ART care in the same facility [OR = 14(95% CI: 2.6, 75.4)], and children whose fathers were tested and known to be HIV positive [OR = 3.0(95% CI: 1.0, 9.0)] were more likely to adhere than their counterparts. Infants feeding practice was also significantly associated with adherence χ2 -test, p < 0.01.

CONCLUSION

The proportion of ARV uptake at birth among HIV exposed infants were found to be high compared to other similar settings. Mother-infant pair enrolment in the same facility and the infant's father being tested and knew their HIV result were major predictors of infants adhering to treatment and follow up. However, large numbers of infants were lost to follow up.

Does trimethoprim-sulfamethoxazole prophylaxis for HIV induce bacterial resistance to other antibiotic classes? Results of a systematic review

BACKGROUND

Trimethoprim-sulfamethoxazole (TMP-SMX) prophylaxis has long been recommended for immunosuppressed HIV-infected adults and children born to HIV-infected women. Despite this, many resource-limited countries have not implemented this recommendation, partly because of fear of widespread antimicrobial resistance not only to TMP-SMX, but also to other antibiotics. We aimed to determine whether TMP-SMX prophylaxis in HIV-infected and/or exposed individuals increases bacterial resistance to antibiotics other than TMP-SMX.

METHODS

A literature search was conducted in Medline, Global Health, Embase, Web of Science, ELDIS, and ID21.

RESULTS

A total of 501 studies were identified, and 17 met the inclusion criteria. Only 8 studies were of high quality, of which only 2 had been specifically designed to answer this question. Studies were classified as (1) studies in which all participants were infected and/or colonized and in which rates of bacterial resistance were compared between those taking or not taking TMP-SMX and (2) studies comparing those who had a resistant infection with those who were not infected. Type 1 studies showed weak evidence that TMP-SMX protects against resistance. Type 2 studies provided more convincing evidence that TMP-SMX protects against infection.

CONCLUSION

There was some evidence that TMP-SMX prophylaxis protects against resistance to other antibiotics. However, more carefully designed studies are needed to answer the question conclusively.

National policy development for cotrimoxazole prophylaxis in Malawi, Uganda and Zambia: the relationship between Context, Evidence and Links

Background

Several frameworks have been constructed to analyse the factors which influence and shape the uptake of evidence into policy processes in resource poor settings, yet empirical analyses of health policy making in these settings are relatively rare. National policy making for cotrimoxazole (trimethoprim-sulfamethoxazole) preventive therapy in developing countries offers a pertinent case for the application of a policy analysis lens. The provision of cotrimoxazole as a prophylaxis is an inexpensive and highly efficacious preventative intervention in HIV infected individuals, reducing both morbidity and mortality among adults and children with HIV/AIDS, yet evidence suggests that it has not been quickly or evenly scaled-up in resource poor settings.

Methods

Comparative analysis was conducted in Malawi, Uganda and Zambia, using the case study approach. We applied the ‘RAPID’ framework developed by the Overseas Development Institute (ODI), and conducted a total of 47 in-depth interviews across the three countries to examine the influence of context (including the influence of donor agencies), evidence (both local and international), and the links between researcher, policy makers and those seeking to influence the policy process.

Results

Each area of analysis was found to have an influence on the creation of national policy on cotrimoxazole preventive therapy (CPT) in all three countries. In relation to context, the following were found to be influential: government structures and their focus, donor interest and involvement, healthcare infrastructure and other uses of cotrimoxazole and related drugs in the country. In terms of the nature of the evidence, we found that how policy makers perceived the strength of evidence behind international recommendations was crucial (if evidence was considered weak then the recommendations were rejected). Further, local operational research results seem to have been taken up more quickly, while randomised controlled trials (the gold standard of clinical research) was not necessarily translated into policy so swiftly. Finally the links between different research and policy actors were of critical importance, with overlaps between researcher and policy maker networks crucial to facilitate knowledge transfer. Within these networks, in each country the policy development process relied on a powerful policy entrepreneur who helped get cotrimoxazole preventive therapy onto the policy agenda.

Conclusions

This analysis underscores the importance of considering national level variables in the explanation of the uptake of evidence into national policy settings, and recognising how local policy makers interpret international evidence. Local priorities, the ways in which evidence was interpreted, and the nature of the links between policy makers and researchers could either drive or stall the policy process. Developing the understanding of these processes enables the explanation of the use (or non-use) of evidence in policy making, and potentially may help to shape future strategies to bridge the research-policy gaps and ultimately improve the uptake of evidence in decision making.

Translating evidence into policy in low-income countries: lessons from co-trimoxazole preventive therapy

In the April 2010 issue of this journal, Date et al. expressed concern over the slow scale-up in low-income settings of two therapies for the prevention of opportunistic infections in people living with the human immunodeficiency virus: co-trimoxazole prophylaxis and isoniazid preventive therapy. This short paper discusses the important ways in which policy analysis can be of use in understanding and explaining how and why certain evidence makes its way into policy and practice and what local factors influence this process. Key lessons about policy development are drawn from the research evidence on co-trimoxazole prophylaxis, as such lessons may prove helpful to those who seek to influence the development of national policy on isoniazid preventive therapy and other treatments. Researchers are encouraged to disseminate their findings in a manner that is clear, but they must also pay attention to how structural, institutional and political factors shape policy development and implementation. Doing so will help them to understand and address the concerns raised by Date et al. and other experts. Mainstreaming policy analysis approaches that explain how local factors shape the uptake of research evidence can provide an additional tool for researchers who feel frustrated because their research findings have not made their way into policy and practice.

Scaling up antiretroviral therapy for HIV-infected children in Côte d'Ivoire: determinants of survival and loss to programme

OBJECTIVE

To investigate deaths and losses to follow-up in a programme designed to scale up antiretroviral therapy (ART) for HIV-infected children in Côte d'Ivoire.

METHODS

Between 2004 and 2007, HIV-exposed children at 19 centres were offered free HIV serum tests (polymerase chain reaction tests in those aged < 18 months) and ART. Computerized monitoring was used to determine: (i) the number of confirmed HIV infections, (ii) losses to the programme (i.e. death or loss to follow-up) before ART, (iii) mortality and loss-to-programme rates during 12 months of ART, and (iv) determinants of mortality and losses to the programme.

FINDINGS

The analysis included 3876 ART-naïve children. Of the 1766 with HIV-1 infections (17% aged < 18 months), 124 (7.0%) died, 52 (2.9%) left the programme, 354 (20%) were lost to follow-up before ART, 259 (15%) remained in care without ART, and 977 (55%) started ART (median age: 63 months). The overall mortality rate during ART was significantly higher in the first 3 months than in months 4-12: 32.8 and 6.9 per 100 child-years of follow-up, respectively. Loss-to-programme rates were roughly double mortality rates and followed the same trend with duration of ART. Independent predictors of 12-month mortality on ART were pre-ART weight-for-age z-score < -2, percentage of CD4+ T lymphocytes < 10, World Health Organization HIV/AIDS clinical stage 3 or 4, and blood haemoglobin < 8 g/dl.

CONCLUSION

The large-scale programme to scale up paediatric ART in Côte d'Ivoire was effective. However, ART was often given too late, and early mortality and losses to programme before and just after ART initiation were major problems.

Adherence to isoniazid prophylaxis among HIV-infected children: a randomized controlled trial comparing two dosing schedules

BACKGROUND

Tuberculosis contributes significantly to morbidity and mortality among HIV-infected children in sub-Saharan Africa. Isoniazid prophylaxis can reduce tuberculosis incidence in this population. However, for the treatment to be effective, adherence to the medication must be optimized. We investigated adherence to isoniazid prophylaxis administered daily, compared to three times a week, and predictors of adherence amongst HIV-infected children.

METHODS

We investigated adherence to study medication in a two centre, randomized trial comparing daily to three times a week dosing of isoniazid. The study was conducted at two tertiary paediatric care centres in Cape Town, South Africa. Over a 5 year period, we followed 324 HIV-infected children aged >or= 8 weeks. Adherence information based on pill counts was available for 276 children. Percentage adherence was calculated by counting the number of pills returned. Adherence >or= 90% was considered to be optimal. Analysis was done using summary and repeated measures, comparing adherence to the two dosing schedules. Mean percentage adherence (per child during follow-up time) was used to compare the mean of each group as well as the proportion of children achieving an adherence of >or= 90% in each group. For repeated measures, percentage adherence (per child per visit) was dichotomized at 90%. A logistic regression model with generalized estimating equations, to account for within-individual correlation, was used to evaluate the impact of the dosing schedule. Adjustments were made for potential confounders and we assessed potential baseline and time-varying adherence determinants.

RESULTS

The overall adherence to isoniazid was excellent, with a mean adherence of 94.7% (95% confidence interval [CI] 93.5-95.9); similar mean adherence was achieved by the group taking daily medication (93.8%; 95% CI 92.1-95.6) and by the three times a week group (95.5%; 95% CI 93.8-97.2). Two-hundred and seventeen (78.6%) children achieved a mean adherence of >or= 90%. Adherence was similar for daily and three times a week dosing schedules in univariate (odds ratio [OR] 0.88; 95% CI 0.66-1.17; P = 0.38) and multivariate (adjusted OR 0.85; 95% CI 0.64-1.11; P = 0.23) models. Children from overcrowded homes were less adherent (adjusted OR 0.71; 95% CI 0.54-0.95; P = 0.02). Age at study visit was predictive of adherence, with better adherence achieved in children older than 4 years (adjusted OR 1.96; 95% CI 1.16-3.32; P = 0.01).

CONCLUSION

Adherence to isoniazid was excellent regardless of the dosing schedule used. Intermittent dosing of isoniazid prophylaxis can be considered as an alternative to daily dosing, without compromising adherence or efficacy.

TRIAL REGISTRATION

Clinical Trials NCT00330304.