Operational assessment of access to ART in rural Africa: the example of Kisantu in Democratic Republic of the Congo

Socio-Structural Factors Influencing the Prevention of Mother-to-Child Transmission of HIV in the Democratic Republic of the Congo: A Systematic Review

Introduction The Democratic Republic of the Congo (DRC) had the second-highest mother-to-child HIV transmission rate in Sub-Saharan Africa at 29% in 2013, however the uptake of preventive services for mother-to-child transmission of HIV (PMTCT) remains suboptimal. This systematic review explores socio-cultural and structural factors influencing PMTCT service uptake in the DRC. Methods We conducted a search of electronic databases. The PEN-3 model was used as a framework to synthesize factors influencing PMTCT service uptake into perceptions, enablers, and nurturers. Results Sixteen studies, 14 quantitative and two qualitative, were retained. Maternal, socio-economic, structural, and cultural factors were found to influence PMTCT service uptake in the DRC. Cost, accessibility, and quality of PMTCT services were key barriers to service uptake. Integration, male partner involvement, and evolving PMTCT policies improved PMTCT service delivery and uptake. This review also revealed several socio-cultural challenges in involving male partners in PMTCT programs. Discussion Findings highlight the need to address barriers and reinforce enablers of PMTCT uptake. Creating culturally appropriate, male-friendly, and family-oriented PMTCT programs will improve service uptake in the DRC.

Morbidity and nutrition status of rural drug-naïve Kenyan women living with HIV

This paper describes morbidity in a group of HIV-positive drug-naïve rural women in western Kenya. A total of 226 drug-naïve HIV-positive women were evaluated for baseline morbidity, immune function, and anthropometry before a food-based nutrition intervention. Kenyan nurses visited women in their homes and conducted semi-structured interviews regarding symptoms and physical signs experienced at the time of the visit and during the previous week and physical inspection. Blood and urine samples were examined for determination of immune function (CD4, CD8, and total lymphocyte counts), anaemia, malaria, and pregnancy status. Intradermal skin testing with tuberculin (PPD), candida, and tetanus toxoid antigens was also performed to evaluate cell-mediated immunity. Anthropometry was measured, and body mass index (BMI) was calculated. Seventy-six per cent of the women reported being sick on the day of the interview or within the previous week. Illnesses considered serious were reported by 13.7% of women. The most frequent morbidity episodes reported were upper respiratory tract infections (13.3%), suspected malaria (5.85%), skeletal pain (4.87%), and stomach pain (4.42%). The most common morbidity signs on physical inspection were respiratory symptoms, most commonly rhinorrhea and coughing. Confirmed malaria and severe diarrhea were significantly associated with a higher BMI.

Implementation of a Peer HIV Community Support Worker Program in Rural Ethiopia to Promote Retention in Care

Retention in care is a major challenge for HIV treatment programs, including in rural and in resource-limited settings. To help reduce loss to follow-up (LTFU) for HIV-infected patients new to care in rural Ethiopia, 142 patients were assigned 1 of 13 trained community health support workers (CHSWs) who were HIV positive and from the same neighborhood/village. The CHSWs provided HIV and health education, counseling/social support, and facilitated communication with the HIV clinics. With 7 deaths and 3 transfers, the 12-month retention rate was 94% (95% CI = 89%-97%), and no client was LTFU in the project. Between enrollment and 12 months, clients had significant ( P ≤ .001) improvements in HIV knowledge (17% increase), physical and mental quality of life (81% and 21% increase), internalized stigma (97% decrease), and perceived social support (24% increase). In rural and resource-limited settings, community-based CHSW programs can complement facility-based care in reducing LTFU and improving positive outcomes for HIV-infected people who enter care.

Missed opportunities for early access to care of HIV-infected infants in Burkina Faso

OBJECTIVE

The World Health Organization (WHO) has recommended a universal antiretroviral therapy (ART) for all HIV-infected children before the age of two since 2010, but this implies an early identification of these infants. We described the Prevention of Mother-to-Child HIV Transmission (PMTCT) cascade, the staffing and the quality of infrastructures in pediatric HIV care facilities, in Ouagadougou, Burkina Faso.

METHODS

We conducted a cross-sectional survey in 2011 in all health care facilities involved in PMTCT and pediatric HIV care in Ouagadougou. We assessed them according to their coverage in pediatric HIV care and WHO standards, through a desk review of medical registers and a semi-structured questionnaire administered to health-care workers (HCW).

RESULTS

In 2011, there was no offer of care in primary health care facilities for HIV-infected children in Ouagadougou. Six district hospitals and two university hospitals provided pediatric HIV care. Among the 67 592 pregnant women attending antenatal clinics in 2011, 85.9% were tested for HIV. The prevalence of HIV was 1.8% (95% Confidence Interval: 1.7%-1.9%). Among the 1 064 HIV-infected pregnant women attending antenatal clinics, 41.4% received a mother-to-child HIV transmission prevention intervention. Among the HIV-exposed infants, 313 (29.4%) had an early infant HIV test, and 306 (97.8%) of these infants tested received their result within a four-month period. Among the 40 children initially tested HIV-infected, 33 (82.5%) were referred to a health care facility, 3 (9.0%) were false positive, and 27 (90.0%) were initiated on ART. Although health care facilities were adequately supplied with HIV drugs, they were hindered by operational challenges such as shortage of infrastructures, laboratory reagents, and trained HCW.

CONCLUSIONS

The PMTCT cascade revealed bottle necks in PMTCT intervention and HIV early infant diagnosis. The staffing in HIV care and quality of health care infrastructures were also insufficient in 2011 in Ouagadougou.

TB and HIV in the Central African region: current knowledge and knowledge gaps

PURPOSE

Reliable and comprehensive data on the HIV/AIDS and TB co-pandemics from Central Africa remain scarce. This systematic review provides a comprehensive overview on current and past research activities in the region and provides a basis for future research work to close knowledge gaps.

METHODS

The scientific literature was searched for publications meeting the following search terms: "tuberculosis" or "HIV" or "acquired immunodeficiency syndrome", combined with "Central Africa", or the names of individual countries within the region. Original studies, reviews and case series were included, and a selection of relevant articles was made.

RESULTS

Most research in the field of HIV and TB has been conducted in Cameroon, where the epidemics have been described fairly well. The Democratic Republic of Congo ranked second on the amount of publications, despite the civil wars over the past several decades. Very little has been published on HIV and TB in the other countries, possibly due to the poor infrastructure of health care systems, lack of scientific capacity building or shortage of laboratory equipment.

CONCLUSIONS

Despite the relatively high burden of HIV and TB in the Central African region, the amount of research activities on these topics is limited. A better understanding of the co-epidemics in this region is urgently needed. The occurrence of opportunistic infections, treatment complications and drug resistance in TB and HIV need to be better described; the failure of public health systems needs to be understood, and research infrastructure needs to be developed. Only then will it be possible to turn the tide against the HIV and TB epidemics in this region.

[Socio-demographic, biological and clinical profile of patients living with HIV during screening in a voluntary counselling and screening centre in a rural area of Mbanza-Ngungu, Democratic Republic of Congo, in 2006-2011]

AIDS remains a public health problem in the Democratic Republic of Congo (DRC). However, there is little information on the medical situation of the disease in rural areas. The objective of this study is to describe the HIV infection in a rural zone in the province of Bas-Congo, DRC. The medical records of patients with a diagnosis of HIV/AIDS, followed in the centre of voluntary counselling and testing (VCT) of the general hospital Nsona-Nkulu in the city of Mbanza-Ngungu, DRC, from January 2006 to June 2011, were retrospectively reviewed. Socio-demographic profile, laboratory data and mode of detection were analyzed. During this study, 167 patients were identified as HIV positive (112 females and 54 males). The majority of patients were aged between 30 and 44 years and two out of three patients were not married; 77.3% had primary schooling. Testing for HIV was performed in 78% of patients during an episode of illness. Screening for unprotected sex was a rare event (0.7%). Co-infection with tuberculosis was present in 32% of our patients while 26% had shingles and 44.5% had sexually transmitted infection. Smoking was found slightly (14%) and alcoholism was reported in 37% of patients. Weight loss greater than 10% was found in 61% of patients. Over 80% of people tested positive for HIV were in later stages (stages 3 and 4). This study demonstrates that HIV infection remains a serious public health problem in rural zone. The factors militating for the use of awareness program for preventive measures need to be urgently addressed.

Failure to test for HIV in rural Ethiopia: knowledge and belief correlates and implications for universal test and treat strategies

Goals of universal "test and treat" will never be fully realized if testing acceptance remains low, including rural areas, where HIV is increasingly recognized. We surveyed 250 randomly selected households from a rural Ethiopian town (Arba Minch) and surrounding villages about HIV testing experience, knowledge, and attitudes. Of the 558 adults, 45% were never HIV tested. Those never tested for HIV were more likely to be (P < .05) ≥45 years, rural villagers, and unaware of the benefits of antiretroviral therapy treatment and that persons with HIV can appear healthy; they were more likely to believe HIV-infected persons would be stigmatized and unsupported by their communities. Of those never tested, 70% were interested in HIV testing if offered. Despite recommendations that all persons be HIV tested, almost half of the adult residents in this rural community were never tested. Programs to increase HIV testing must include measures to address stigma/discrimination and knowledge deficits including benefits of early diagnosis and treatment.

Patient enrolment into HIV care and treatment within 90 days of HIV diagnosis in eight Rwandan health facilities: a review of facility-based registers

Introduction

Access to antiretroviral therapy (ART) has increased greatly in sub-Saharan Africa. However many patients do not enrol timely into HIV care and treatment after HIV diagnosis. We studied enrolment into care and treatment and determinants of non-enrolment in Rwanda.

Methods

Data were obtained from routine clinic registers from eight health facilities in Rwanda on patients who were diagnosed with HIV at the antenatal care, voluntary counselling-and-testing, outpatient or tuberculosis departments between March and May 2009. The proportion of patients enrolled into HIV care and treatment was calculated as the number of HIV infected patients registered in ART clinics for follow-up care and treatment within 90 days of HIV diagnosis divided by the total number of persons diagnosed with HIV in the study period.

Results

Out of 482 patients diagnosed with HIV in the study period, 339 (70%) were females, and the median age was 29 years (interquartile range [IQR] 24–37). 201 (42%) enrolled into care and treatment within 90 days of HIV diagnosis. The median time between testing and enrolment was six days (IQR 2–14). Enrolment in care and treatment was not significantly associated with age, sex, or department of testing, but was associated with study site. None of those enrolled were in WHO stage 4. The median CD4 cell count among adult patients was 387 cells/mm³ (IQR: 242–533 cells/mm³); 81 of 170 adult patients (48%) were eligible to start ART (CD4 count<350 cells/mm³ or WHO stage 4). Among those eligible, 45 (56%) started treatment within 90 days of HIV diagnosis.

Conclusion

Less than 50% of diagnosed HIV patients from eight Rwandan health facilities had enrolled into care and treatment within 90 days of diagnosis. Improving linkage to care and treatment after HIV diagnosis is needed to harness the full potential of ART.

HIV/AIDS stigma-associated attitudes in a rural Ethiopian community: characteristics, correlation with HIV knowledge and other factors, and implications for community intervention

Background

Whether scale-up of HIV prevention and care will reduce negative attitudes and discriminatory practices towards persons living with HIV/AIDS (PLWH) is uncertain. An HIV knowledge and attitude survey was conducted in a rural Ethiopian community where HIV prevention and treatment was being rapidly scaled up. Data were analyzed to identify prevalence of and factors associated with stigma-associated attitudes towards PLWH.

Methods

We surveyed 561 adults from 250 randomly selected households in the rural town of Arba Minch and surrounding villages about positive or negative attitudes towards PLWH, as well as demographic characteristics, and knowledge about HIV transmission and treatment.

Results

Eighty percent of respondents agreed with ≥ 1 negative statements indicating blame or shame towards PLWH and 41% agreed with ≥ 1 negative statements associated with distancing themselves from PLWH. However, only 14% expressed negative responses about whether PLWH should receive support from their communities. In multivariate analysis, a greater number of negative attitudes towards PLWH was significantly (p < 0.05) associated with: female gender (Odds Ratio [OR] = 1.51), living in a rural village (vs. town neighborhood) (OR = 3.44), not knowing PLWH can appear healthy (OR = 1.78), lack of knowledge about perinatal transmission (OR = 1.49), lack of knowledge about how HIV is not transmitted (e.g. casual contact) (OR = 2.05), lack of knowledge about HIV treatment (OR = 1.80), and not personally knowing a PLWH (OR = 1.41).

Conclusions

In a rural Ethiopian setting in which rapid scale-up of HIV treatment occurred, many respondents still characterized HIV as associated with shame or blame, or indicated PLWH would be isolated or discriminated against. HIV stigma can hamper both prevention and treatment programs. We identified multiple issues which, if addressed, can help promote a more positive cycle in which PLWH are appreciated as members of one’s own community who are affirmatively interacted with and supported. Stigma reduction programs should address knowledge gaps such as fears of casual contact contagion, and lack of awareness of medical interventions to help prevent HIV disease, as well as building upon community-based attitudes of the importance of supporting and showing compassion for PLWH.