"They have already thrown away their chicken": barriers affecting participation by HIV-infected women in care and treatment programs for their infants in Blantyre, Malawi

Caregivers' experiences of accessing HIV Early Infant Diagnosis (EID) services and its barriers and facilitators, India

BACKGROUND

India has rolled out Early Infant Diagnosis (EID) program for HIV infection in all states. EID program consists of testing of Infants exposed to HIV periodically over 18 months of age which is a multi-step complex testing cascade. Caregivers represent the primary beneficiary of EID program i.e., infants exposed to HIV and face multiple challenges to access EID services. As part of national EID program outcome assessment study, this study narrates caregivers' perspectives on barriers and facilitators to access and utilize EID services.

METHODS

The study was conducted in 31 integrated counselling and testing centres (ICTCs) located in 11 high burden HIV states. A total of 66 in-depth interviews were conducted with caregivers' of infants enrolled in EID program. Thematic analysis was carried out to help identify themes underlying barriers and facilitators to access EID services and utilization from caregivers' perspectives.

RESULTS

The stigma and discrimination prevalent in society about HIV remains a key demand side (caregiver-level) barrier. Non-disclosure or selective disclosure of HIV status led to missed or delayed EID tests and delayed HIV diagnosis and initiation of Anti-Retroviral Therapy (ART) for infants exposed to HIV. On supply side (health system-level), accessibility of healthcare facility with EID services was reported as a key barrier. The distance, time and cost were key concerns. Many caregivers faced difficulties to remember the details of complex EID test schedule and relied on a phone call from ICTC counsellor for next due EID test. Delayed EID test results and lack of communication of test results to caregiver were reported as primary barriers for completing the EID test cascade.

DISCUSSION

The study reports caregiver-level and health system-level barriers and facilitators for access to EID services from the caregivers' perspectives. While, decentralisation and single window approaches can improve the access, timely communication of test results to the caregiver also need to be built in with appropriate use of technology. A holistic intervention including PLHIV support networks and the peer-led support mechanisms would be useful to address societal factors.

CONCLUSION

The study findings have high significance for developing program implementation strategies to improve access and to build right-based and patient-centred EID services.

Prevalence and associated factors of intimate partner violence amongst women attending prevention of mother to child transmission services in Blantyre, Malawi

Background

Intimate partner violence (IPV) during the perinatal period and when one is HIV-positive is a great concern because of the physical and mental impacts it has on health and on adherence to prevention of mother to child transmission (PMTCT) services. However, factors associated with IPV amongst perinatal women on PMTCT services are not adequately explored in Malawi. The aim of this study was to estimate the various types of IPV and the associated factors amongst HIV-positive pregnant and postnatal women in selected health centres in Blantyre district.

Methods

In this cross-sectional study, we recruited 200 HIV-positive women from antenatal, postnatal and antiretroviral therapy (ART) clinics from four selected primary care facilities of Blantyre district. Data were collected between March and May 2018.

Results

A total of 50% of the participants reported to have experienced either physical, psychological or sexual violence from their partner in the last 12 months. The multivariate logistic regression model showed that feelings about safety of the relationship and depression were the only factors that were consistently associated with IPV in the last 12 months (p = 0.001, Pseudo R² = 0.20).

Conclusion

The presence of depression and safety concerns amongst our study participants calls for serious prioritisation of psychological interventions and risk assessment in the management of HIV-positive perinatal mothers who report IPV cases.

"We Need it the Same Day": A Qualitative Study of Caregivers and Community Members' Perspectives Toward the Use of Point-of-Care Early Infant Diagnosis

BACKGROUND

Only half of the infants tested for HIV ever receive results, leading to low uptake of treatment and increased mortality and morbidity rates. Point-of-care (POC) nucleic acid diagnostic machines allow for the possibility of same-day results. In Kenya and Zimbabwe, as part of an evaluation comparing standard of care with POC testing for early infant diagnosis, a qualitative substudy was undertaken to understand the acceptability of POC among caregivers of HIV-exposed infants and community members.

SETTING

Kenya and Zimbabwe.

METHODS

In Kenya, 74 interviews were conducted with caregivers, and 6 focus group discussions were conducted with male and female community members and elders. In Zimbabwe, we conducted 85 interviews and 8 focus group discussions. Data were collected in 2 rounds: 1 before the introduction of POC platforms and 1 after the platforms had been in use for at least 3 months. Interviews were conducted in local languages, and content analysis and constant comparison were used to identify key themes.

RESULTS

Reduced time to receive test results lowered caregiver anxiety about the child's HIV status and allowed families to put children on treatment earlier. Printed POC results were seen by some as more trustworthy than conventional handwritten results, believing this reduced the chance of human error; a few distrusted HIV results were generated too quickly. Community awareness of POC was lower among caregivers of HIV-exposed infants.

CONCLUSION

Caregivers are generally very accepting of receiving POC HIV test results; however, additional sensitization among influential community members about the benefits of POC testing is needed.

Factors influencing the delivery and uptake of early infant diagnosis of HIV services in Greater Accra, Ghana: A qualitative study

BACKGROUND

Early Infant Diagnosis (EID) of HIV and timely initiation of Antiretroviral Therapy (ART) can significantly reduce morbidity and mortality of HIV infected infants. Despite the benefits of early infant testing, the coverage of EID of HIV services is still low in Sub-Saharan Africa, including Ghana.

OBJECTIVES

To ascertain the factors that facilitate or hinder the delivery and uptake of EID of HIV services.

METHODS

The study is a cross-sectional exploratory qualitative research conducted in two health facilities in the Greater Accra Region of Ghana. Respondents (n = 50) comprising health workers (n = 20) and HIV positive mothers (n = 30) were purposively sampled and engaged in in-depth interviews. The Nvivo 11 software and the Braun and Clarke's stages of thematic analysis were used in coding data and data analysis respectively.

RESULTS

The study found that health system factors such as inadequate Staff with sample collection skills, unavailability of vehicles to convey samples to the reference laboratory for analysis, the long turnaround time for receipt of Polymerase Chain Reaction (PCR) results, inadequate and frequent breakdown of PCR machine hindered EID service delivery. On the other hand, adequate knowledge of health workers on EID, availability of Dried Blood Spot (DBS) cards and the adoption of task shifting strategies facilitated EID service delivery. Factors such as the denial of HIV status, non-completion of the EID process due to frustrations encountered whiles accessing service and delay in receipt of PCR results served as barriers to mother's utilisation of EID services for their exposed infants. The study also identified that adequate knowledge of EID, perceived importance of EID, financial stability as well as financial support from others and the positive attitudes of health workers facilitated HIV positive mother's uptake of EID services for their exposed infants.

CONCLUSION

The factors attributing to the low coverage of EID of HIV services must be promptly addressed to improve service delivery and uptake.

Administering human immunodeficiency virus post-exposure prophylaxis: challenges experienced by mothers in Lusaka, Zambia

Background

Mothers living with human immunodeficiency virus (HIV) should be guided to practise safe childbirth, provide appropriate infant feeding, return infants for repeat HIV testing and administer for the required period, protective antiretroviral (ARV) medication (post-exposure prophylaxis [PEP]) to their infants. Although several studies have explored challenges related to the prevention of mother-to-child transmission (PMTCT), no studies were found that focused specifically on the mother and PEP.

Objectives

To explore and understand the challenges experienced by mothers in Lusaka, Zambia, whilst providing their children with PEP.

Methods

This study utilised a qualitative methodology and a descriptive design. Fifteen semi-structured individual interviews were conducted with mothers who gave PEP to their infants. Study evaluation made use of Creswell’s six steps of data analysis.

Results

Women experienced numerous challenges. Challenges of an individual and social nature included ‘negative’ emotions, misconceptions and a lack of understanding of PEP. Post-exposure prophylaxis was sometimes burdensome and partner involvement often limited. Cultural, religious practices and stigma deterred some women from continuing PEP. Healthcare challenges included time-consuming appointments and protracted waiting periods. Clinic organisation was often inefficient and complicated by stock-outs of essential medication such as nevirapine. Healthcare workers were at times stigmatising towards mothers living with HIV and their infants. The counselling support provided by the healthcare workers was felt to be inadequate in the face of the burden of PEP.

Conclusion

Post-exposure prophylaxis as part of the PMTCT programme is key to eliminating mother-to-child transmission of HIV. Postnatal support for women administering PEP to their children can be enhanced through counselling that is person- and family-centred is culturally sensitive and offers differentiated services that include PEP, integrated mother-and-child healthcare and access to support groups.

Mother-child separation among women living with HIV and their children in the first four years postpartum in South Africa

OBJECTIVES

Mother-child pairs may separate during early life, yet the health impacts thereof are unclear. We explored the patterns and impact of separation among women living with HIV (WLHIV) and their children in South Africa.

METHODS

WLHIV who had initiated antiretroviral therapy (ART) during pregnancy received HIV viral load (VL) testing and completed a timeline questionnaire of mother-child separation since delivery at 3-5 years post-partum. Health care usage was abstracted from routine medical records. We examined associations between separation and (a) maternal health outcomes (engagement in HIV care and HIV viral suppression, [VS]) and (b) child health outcomes (post-breastfeeding HIV testing and immunisation completion), using logistic regression.

RESULTS

Of 346 mother-child pairs (median maternal age at antenatal ART initiation, 28 years), 24% were ever separated (median time to first separation 20 months, interquartile range [IQR] 9, 31). Most separated children were living with their grandmothers (65/83, 78%). Mothers who ever separated were younger, and more likely to be employed, and to reside in informal housing than those who never separated. Any separation reduced the odds of VS ≤ 50 copies/mL at four years post-partum (odds ratio 0.57; 95% CI 0.34-0.93); associations were similar for VL ≤ 1000 copies/mL and maternal engagement in care. No association was found between separation and child confirmatory HIV testing or immunisation completion.

CONCLUSIONS

In this setting, mother-child separation is common in the first four years of life and appears associated with suboptimal maternal outcomes. Further research is required to understand the drivers and implications of mother-child separation.

They are likely to be there: using a family-centered index testing approach to identify children living with HIV in Kenya

In Kenya, only half of children with a parent living with HIV have been tested for HIV. The effectiveness of family-centered index testing to identify children (0-14 years) living with HIV was examined. A retrospective record review was conducted among adult index patients newly enrolled in HIV care between May and July 2015; family testing, results, and linkage to treatment outcomes were followed through May 2016 at 60 high-volume clinics in Kenya. Chi square test compared yield (percentage of HIV tests positive) among children tested through family-centered index testing, outpatient and inpatient testing. Review of 1937 index client charts led to 3005 eligible children identified for testing. Of 2848 (94.8%) children tested through family-centered index testing, 127 (4.5%) had HIV diagnosed, 100 (78.7%) were linked to care, and 85 of those eligible (91.4%) initiated antiretroviral therapy (ART).Family testing resulted in higher yield compared to inpatient (1.8%, p < 0.001) or outpatient testing (1.6%, p < 0.001). The absolute number of children living with HIV identified was highest with outpatient testing. The relative contribution of testing approach to total children identified with HIV was outpatient testing (69%), family testing (26%), and inpatient testing (5%). The family testing approach demonstrated promise in achieving the first two "90s" (identification and ART initiation) of the 90-90-90 targets for children, with additional effort required to improve linkage from testing to treatment.

'If the results are negative, they motivate us'. Experiences of early infant diagnosis of HIV and engagement in Option B

Few studies have explored the relationship between early infant diagnosis (EID) of HIV and mothers' engagement in care under Option B+. We conducted in-depth interviews with 20 women who initiated antiretroviral therapy (ART) under Option B+ in rural South Africa to explore the interactions between EID and maternal care engagement. Drawing on practice theory, we identified themes relating to Option B+ care engagement and EID. Women's practice of engagement with HIV care shaped their decision-making around EID. Mothers who disengaged from care during pregnancy were less inclined to utilise EID as they lacked information about its availability and benefits. For some mothers, tensions between wanting to breastfeed and perceptions that it could facilitate transmission led to repeated utilisation of EID as reassurance that the child remained negative. Some mothers used their child's negative result as a proxy for their status, subsequently disengaging from care. For some participants, an HIV diagnosis of their infant and the subsequent double burden of treatment visits for themselves and their infant, contributed to their disengagement. Women's care-seeking practices for themselves and their infants work in a symbiotic ecosystem and should be viewed interdependently to tailor interventions to improve EID uptake and Option B+ care engagement.

High proportion of unknown HIV exposure status among children aged less than 2 years: An analytical study using the 2015 National AIDS Indicator Survey in Mozambique

Background

Determination of the human immunodeficiency virus (HIV) exposure status in infants and young children is required to guarantee timely diagnosis and access to appropriate care. HIV prevalence among Mozambican women aged 15–49 years is 15%, and vertical transmission rate is still high. The study investigated HIV exposure in children aged less than 2 years in Mozambique and the factors associated with unknown HIV exposure and with HIV exposure status in this population.

Methods

This was a cross-sectional analytical study using data from the 2015 Survey of Indicators on Immunization, Malaria and HIV/AIDS in Mozambique. A total of 2141 mothers (15–49 years) with children aged less than 2 years were interviewed. The dependent variables were “known HIV exposure status in a child” and “HIV-exposed child,” and the explanatory variables were mother’s social, demographic, economic, and reproductive health characteristics. We used binary and logistic regression, adjusted for complex sampling, to determine the association between variables.

Results

HIV exposure status was unknown in 27% of children (95% CI, 25.1–28.9). Mothers residing in the North (AOR, 4.41; 95% CI, 2.18–8.91), in rural area (AOR, 2.44; 95% CI, 1.33–4.35), with no education (AOR, 2.72; 95% CI, 1.38–5.36), and not having utilized any health services in the last pregnancy (AOR, 1.9; 95% CI, 1.42–2.55) were more likely to have a child with unknown HIV exposure status. Six percent of children were HIV-exposed (95% CI, 5–7). Children were less likely to be HIV-exposed if the head of the household was a male (AOR, 0.26; 95% CI, 0.08–0.86), if the mother was residing in the North (AOR, 0.41; 95% CI, 0.26–0.66) and did not utilize any health services in her last pregnancy (AOR, 0.52; 95% CI, 0.32–0.83).

Conclusion

The high proportion of children with unknown HIV exposure status and the associated socioeconomic factors suggests that HIV retesting of eligible women throughout breastfeeding should be intensified and identifies the urgent need to reach women without prior access to health care using a multisectoral approach.

eHealth Interventions for Early Infant Diagnosis: Mothers' Satisfaction with the HIV Infant Tracking System in Kenya

The HIV Infant Tracking System (HITSystem) is an eHealth intervention to improve early infant diagnosis (EID) through alerts to providers and text messages to mothers. This study explored mothers' experiences receiving standard and HITSystem-enhanced EID services to assess perceived intervention benefits, acceptability, and opportunities for improvement. This qualitative study was embedded within a cluster-randomized control trial to evaluate the HITSystem at six Kenyan government hospitals (3 intervention, 3 control). We conducted semi-structured interviews with 137 mothers attending EID follow-up visits. Compared to control sites, participants at HITSystem sites described enhanced EID quality; HITSystem-generated texts informed them of result availability and retesting needs, provided cues-to-action for clinic attendance, and engendered opportunities for patient support. They described improved EID efficiency through shorter waiting periods for results and fewer hospital visits. Participants reported high satisfaction with EID and acceptability of text messages; however, modifications to ensure text delivery, increase repeat testing reminders, include low literacy content options, and provide encouraging messages were suggested. These user experience data suggest improvements in EID at HITSystem sites when compared with control sites.

HIV stigma experiences and stigmatisation before and after a HIV stigma-reduction community "hub" intervention

This study sought to explore, describe and determine whether an HIV stigma-reduction community "hub" intervention would change the HIV stigma experiences of people living with HIV (PLWH) and the stigmatisation by the community in an urban area in South Africa. A convergent parallel mixed-method design with a single case pre-test post-test design and an interpretive description approach was utilised. The sample for this study included 62 PLWH recruited through accessibility sampling and 570 community members recruited through random voluntary sampling. A sub-sample of both groups, selected using purposive voluntary sampling, was utilised for the in-depth interviews about stigma experiences of PLWH, and for perceptions and attitudes of the community toward PLWH. Both quantitative and qualitative data showed that stigma is present. Although no statistically significant changes were found, small practically significant changes were demonstrated in the experiences of PLWH and in the perceptions and attitudes of the community. The extent of changes was much more obvious in the responses of the PLWH and the community during their post-intervention qualitative interviews than the changes found with the quantitative measures. This study thus concludes that the HIV stigma-reduction community hub intervention was successful in initiating the onset of changes in a community through the PLWH and people living close to PLWH (PLC) as community mobilisers active in the community hub to mobilise their own communities towards HIV stigma reduction through social change.

Mother-to-child transmission of HIV and its predictors among HIV-exposed infants at Bamenda Regional Hospital, Cameroon

Background

Mother-to-child transmission (MTCT) of HIV, has been a major global public health burden. Despite the use of antiretroviral prophylaxis by HIV-positive pregnant women and their infants, safe obstetric practice and safe infant feeding habits in the prevention of MTCT of HIV, the prevalence of HIV among HIV-exposed infants is still high in Cameroon.

Objective

Our objectives were to determine the prevalence, assess the predictors and determine the effect of combination antiretroviral therapy (cART) on MTCT of HIV at the regional hospital in Bamenda, Cameroon.

Methods

This was a retrospective study. Secondary data from 877 HIV-exposed infants aged ≤ 72 weeks were extracted from the records between January 2008 and December 2014. The predictors and effect of cART on MTCT of HIV were analysed using a multivariable logistic regression model and risk analysis, respectively.

Results

Out of 877 HIV-exposed infants, 62 were positive for HIV, giving a prevalence of 7.1%. Maternal antiretroviral intervention and infant age group were statistically significant predictors of MTCT of HIV. HIV-positive mothers who were on cART were 2.49 times less likely to transmit HIV than those who were not on cART.

Conclusion

In order to reduce the prevalence of HIV among HIV-exposed infants, maternal antiretroviral intervention should be targeted and the use of cART by HIV-positive pregnant women should be encouraged.

A qualitative analysis of the barriers to antiretroviral therapy initiation among children 2 to 18 months of age in Swaziland

HIV/AIDS remains one of the leading causes of death among children under 5 years old in Swaziland. Although studies have shown that early initiation of infants and children diagnosed with HIV on antiretroviral therapy (ART) significantly reduces mortality, many children do not initiate ART until the later stages of disease. This study was designed to collect qualitative data from mothers and caregivers of HIV-positive children to identify the barriers to ART initiation. Focus group discussion (FGD) sessions were conducted in siSwati between July and September 2014 among caregivers of aged children 2-18 months in Swaziland who did or did not initiate ART between January 2011 and December 2012 after HIV DNA PCR-positive diagnosis of the infants. Denial, guilt, lack of knowledge, tuberculosis (TB)/HIV co-infection, HIV-related stigma, lack of money, and distance to clinics were reported by the participants as barriers to ART initiation. The findings further revealed that non-initiation on ART was not linked to a negative perception of the treatment. Findings suggest a need to improve sensitivity among healthcare workers as well as education and counselling services that will facilitate the ART initiation process.

Prevention of Mother-to-Child Transmission of HIV in Yaounde: Barrier to Care

Most HIV-infected children in Sub-Saharan Africa are born where programs for the prevention of mother-to-child transmission of HIV (PMTCT) exist but are not universally operational. The expansion of PMTCT programs in Cameroon was among the largest in francophone Africa, but despite highly variable estimates of PMTCT uptake (ranging from 20% to 66%), it is clear that not enough HIV-infected pregnant Cameroonian women benefit from treatment to prevent HIV transmission to their children. The reasons why HIV-infected women in Cameroon do not use treatments to prevent this transmission remain partially unidentified. We conducted a qualitative study of the therapeutic itineraries (treatments taken and motivations) followed by HIV-infected pregnant women in Cameroon to understand the barriers to accessing high-quality PMTCT care. Here we construct the therapeutic itinerary for HIV-infected pregnant women, and identify the barriers at each step. Lack of financial independence, personal support, and empowering information were the primary obstacles at multiple steps.

Early Antiretroviral Therapy Initiation and Mortality Among Infants Diagnosed With HIV in the First 12 Weeks of Life: Experiences From Kinshasa, DR Congo and Blantyre, Malawi

BACKGROUND

Based on clinical trial results, the World Health Organization recommends infant HIV testing at age 4-6 weeks and immediate antiretroviral therapy (ART) initiation in all HIV-infected infants. Little is known about the outcomes of HIV-infected infants diagnosed with HIV in the first weeks of life in resource-limited settings. We assessed ART initiation and mortality in the first year of life among infants diagnosed with HIV by 12 weeks of age.

METHODS

Cohort of HIV-infected infants in Kinshasa and Blantyre diagnosed before 12 weeks to estimate 12-month cumulative incidences of ART initiation and mortality, accounting for competing risks. Multivariate models were used to estimate associations between infant characteristics and timing of ART initiation.

RESULTS

One hundred and twenty-one infants were diagnosed at a median age of 7 weeks (interquartile range, 6-8). The cumulative incidence of ART initiation was 46% [95% confidence interval (CI), 36%, 55%] at 6 months and 70% (95% CI 60%, 78%) at 12 months. Only age at HIV diagnosis was associated with ART initiation by age 6 months, with a subdistribution hazard ratio of 0.70 (95% CI 0.52, 0.91) for each week increase in age at DNA polymerase chain reaction test. The 12-month cumulative incidence of mortality was 20% (95% CI 13%, 28%).

CONCLUSIONS

Despite early diagnosis of HIV, ART initiation was slow and mortality remained high, underscoring the complexity in translating clinical trial findings and World Health Organization's guidance into real-life practice. Novel and creative health system interventions will be required to ensure that all HIV-infected infants achieve optimal treatment outcomes under routine care settings.

Understanding the acceptability and adherence to paediatric antiretroviral treatment in the new formulation of pellets (LPV/r): the protocol of a realist evaluation

BACKGROUND

Improving access to paediatric HIV treatment requires both large-scale treatment programmes and medication that is adapted to infants and children's needs. The WHO recommends lopinavir/ritonavir as first-line antiretroviral therapy for all HIV-infected children younger than 3 years. There is currently little evidence on the acceptability of, and adherence to, a formulation of this combination treatment if given in the form of pellets. This protocol presents how we will carry a realist evaluation to assess the factors that contribute to the acceptability and adherence to the new pellets formulation in 3 hospitals in Kenya.

METHODS

We structured the protocol along the realist evaluation cycle following 4 steps: (1) the initial programme theory, (2) the study design, (3) the data collection methods and (4) the data analysis plan. Theories of behavioural sciences were reviewed for frames that could provide insights into how using such new formulations may contribute to better acceptability and adherence.

ETHICS AND DISSEMINATION

This study was approved by the Institutional Review Board of the Institute of Tropical Medicine, the Ethical Committee of the University Hospital Antwerp and the Kenyatta National Hospital/University of Nairobi Ethics and Research Committee. We aim to disseminate the findings through international conferences and peer-reviewed journals and to share them with Drugs for Neglected Diseases initiative's (DNDi) programme managers and with the Kenyan healthcare providers.

DISCUSSION

In developing this study, we encountered some challenges. First, methods to measure the acceptability of any formulation and adherence to it are not standardised. The second challenge is common in realist evaluation and relates to how to choose from different potentially interesting theoretical frameworks. We identified relevant and empirically tested theories from behavioural science that may be helpful in our study. We will test them in 3 settings by exploring the multilevel factors that influence acceptability and adherence of this new paediatric Antiretroviral (ARV) formulation.

Barriers to uptake of early infant HIV testing in Zambia: the role of intimate partner violence and HIV status disclosure within couples

BACKGROUND

Early detection of pediatric HIV through uptake of infant HIV testing is critical for access to treatment and child survival. While structural barriers have been well described, a greater understanding of social and behavioral factors that may relate to maternal uptake of early infant HIV testing services is urgently needed. The aim of this study was to explore how gender power dynamics within couples affect HIV-positive women's uptake of early infant HIV testing at a large health center in Lusaka, Zambia.

METHODS

In 2014, 320 HIV-positive married postpartum women were recruited at a large public health facility in Lusaka to participate in a cross-sectional survey. Data on uptake of early infant HIV testing by 4-6 weeks of age was collected through medical records. Simple and multiple logistic regression models determined significant predictors of maternal uptake of early infant HIV testing.

RESULTS

In the adjusted model, uptake of early infant HIV testing was associated with female-directed emotional intimate partner violence (aOR 0.41; 95% CI 0.21-0.79; p < 0.01), HIV status disclosure to the male partner (aOR 13.73, 95% CI 3.59-52.49, p < 0.001), and maternal postpartum ART adherence (aOR 2.28, 95% CI 1.15-4.55, p < 0.05).

CONCLUSIONS

Domestic relationship dynamics, including emotional violence and HIV status disclosure to the male partner, may play an important role in maternal uptake of early infant HIV testing. These findings provide additional evidence for the link between intimate partner violence against women and poor HIV-related health outcomes. Programs that adequately screen for and address various forms of intimate partner violence within the context of prevention of mother-to-child transmission are recommended.

The Association Between HIV Disclosure Status and Perceived Barriers to Care Faced by Women Living with HIV in Latin America, China, Central/Eastern Europe, and Western Europe/Canada

Generally, women are less likely than men to disclose their HIV status. This analysis examined the relationship between HIV disclosure and (1) perceived barriers to care and (2) quality of life (QoL) for women with HIV. The ELLA (EpidemioLogical study to investigate the popuLation and disease characteristics, barriers to care, and quAlity of life for women living with HIV) study enrolled HIV-positive women aged ≥18 years. Women completed the 12-item Barriers to Care Scale (BACS) questionnaire. QoL was assessed using the Health Status Assessment. BACS and QoL were stratified by dichotomized HIV disclosure status (to anyone outside the healthcare system). Multilevel logistic regression analysis was used to identify factors associated with disclosure. Of 1945 patients enrolled from Latin America, China, Central/Eastern Europe, and Western Europe/Canada between July 2012 and September 2013, 1929 were included in the analysis (disclosed, n = 1724; nondisclosed, n = 205). Overall, 55% of patients lived with a husband/partner, 53% were employed, and 88% were receiving antiretroviral therapy. Patients who were with a serodiscordant partner were more likely to disclose (p = 0.0003). China had a disproportionately higher percentage of participants who did not disclose at all (nearly 30% vs. <15% for other regions). Mean BACS severity scores for medical/psychological service barriers and most personal resource barriers were significantly lower for the disclosed group compared with the nondisclosed group (p ≤ 0.02 for all). Compared with the disclosed group, the nondisclosed group reported statistically significantly higher (p ≤ 0.03) BACS item severity scores for 8 of the 12 potential barriers to care. The disclosed group reported better QoL. Overall, HIV nondisclosure was associated with more severe barriers to accessing healthcare by women with HIV.

Non-Uptake of HIV Testing in Children at Risk in Two Urban and Rural Settings in Zambia: A Mixed-Methods Study

This article investigates reasons why children who were considered at risk of HIV were not taken for HIV testing by their caregivers. Qualitative and quantitative data collected in Zambia from 2010–11 revealed that twelve percent of caregivers who stated that they had been suspecting an HIV infection in a child in their custody had not had the child tested. Fears of negative reactions from the family were the most often stated reason for not testing a child. Experience of pre-existing conflicts between the couple or within the family (aOR 1.35, 95% CI 1.00–1.82) and observed stigmatisation of seropositive children in one’s own neighbourhood (aOR 1.69, 95% CI1.20–2.39) showed significant associations for not testing a child perceived at risk of HIV. Although services for HIV testing and treatment of children have been made available through national policies and programmes, some women and children were denied access leading to delayed diagnosis and treatment–not on the side of the health system, but on the household level. Social norms, such as assigning the male household head the power to decide over the use of healthcare services by his wife and children, jeopardize women’s bargaining power to claim their rights to healthcare, especially in a conflict-affected relationship. Social norms and customary and statutory regulations that disadvantage women and their children must be addressed at every level–including the community and household–in order to effectively decrease barriers to HIV related care.

Knowledge and Attitudes toward HIV, Hepatitis B Virus, and Hepatitis C Virus Infection among Health-care Workers in Malawi

Objective:

The highest prevalence of HIV infection occurs in Sub-Saharan Africa and hepatitis B virus (HBV), and hepatitis C virus (HCV) prevalence are the second highest in Sub-Saharan Africa including Malawi. Health-care workers (HCWs) play an important role in the prevention of, response to, and management of these infectious diseases. There is, however, no published research about the level of knowledge and attitudes toward HIV, HBV, and HCV infection among Malawian HCWs. The purpose of this study was to explore and determine the knowledge of and attitudes toward HIV, HBV, and HCV among a targeted population of Malawian HCWs.

Methods:

A cross-sectional community-based participatory research with 194 HCWs was completed employing health survey method. The project was a collaborative effort between nursing faculties in the USA and Malawian. A one-way analysis of variance (ANOVA) with the Bonferroni adjustment for multiple comparisons was used to assess the differences in knowledge and attitude among three subgroups of HCWs.

Results:

Of 194 of Malawian HCWs surveyed, 41% were support staff, 37% were nursing students, and 22% were health-care professionals. Both health-care professionals and support staff had high knowledge scores related to HIV/AIDS, and their attitudes were mainly positive. However, a series of one-way ANOVAs revealed significant differences in knowledge and attitude toward HIV/AIDs, HBV, and HCV among HCWs (P < 0.01). The majority had less knowledge about HBV and HCV and more negative attitudes toward hepatitis.

Conclusions:

This study highlights the ongoing need for reducing negative attitudes toward HIV, HBV, and HCV; and providing health education among HCWs, especially focusing on HBV and HCV prevention. The findings of the research project can be used to develop interventions addressing low HBV- and HCV-related knowledge and attitudes.

Implementation and Operational Research: Maternal Combination Antiretroviral Therapy Is Associated With Improved Retention of HIV-Exposed Infants in Kinshasa, Democratic Republic of Congo

BACKGROUND

Programs to prevent mother-to-child HIV transmission are plagued by loss to follow-up (LTFU) of HIV-exposed infants. We assessed if providing combination antiretroviral therapy (cART) to HIV-infected mothers was associated with reduced LTFU of their HIV-exposed infants in Kinshasa, DR Congo.

METHODS

We constructed a cohort of mother-infant pairs using routinely collected clinical data. Maternal cART eligibility was based on national guidelines in effect at the time. Infants were considered LTFU after 3 failed tracking attempts after a missed visit or if more than 6 months passed since they were last seen in clinic. Statistical methods accounted for competing risks (eg, death).

RESULTS

A total of 1318 infants enrolled at a median age of 2.6 weeks (interquartile range: 2.1-6.9), at which point 24% of mothers were receiving cART. Overall, 5% of infants never returned to care after enrollment and 18% were LTFU by 18 months. The 18-month cumulative incidence of LTFU was 8% among infants whose mothers initiated cART by infant enrollment and 20% among infants whose mothers were not yet on cART. Adjusted for baseline factors, infants whose mothers were not on cART were over twice as likely to be LTFU, with a subdistribution hazard ratio of 2.75 (95% confidence limit: 1.81 to 4.16). The association remained strong regardless of maternal CD4 count at infant enrollment.

CONCLUSIONS

Increasing access to cART for pregnant women could improve retention of HIV-exposed infants, thereby increasing the clinical and population-level impacts of prevention of mother-to-child HIV transmission interventions and access to early cART for HIV-infected infants.

Manuscript title: Facilitators and barriers to cotrimoxazole prophylaxis among HIV exposed babies: a qualitative study from Harare, Zimbabwe

BACKGROUND

Implementation of cotrimoxazole prophylaxis (CTX-p) among HIV-exposed infants (HEI) is poor in southern Africa. We conducted a study to investigate barriers to delivery of CTX-p to HEI in Zimbabwe at each step of the care cascade. Here we report findings of the qualitative component designed to investigate issues related to adherence conducted among women identified as HIV positive whose babies were started on CTX-p postnatally. Of note, Zimbabwe also provided nevirapine prophylaxis for HIV exposed babies, so the majority were giving nevirapine and CTX-p to their babies.

METHODS

Between Feb-Dec 2011, the first 20 HIV infected mothers identified were invited for in-depth interview 4-5months postnatally. Interviews were recorded, transcribed, translated and analysed thematically.

RESULTS

All women desired their baby's health above all else, and were determined to do all they could to ensure their wellbeing. They did not report problems remembering to give drugs. The baby's apparent good health was a huge motivator for continued adherence. However, most women reported that their husbands were less engaged in HIV care, refusing to be HIV tested and in some cases stealing drugs prescribed for their wives for themselves. In two instances the man stopped the woman from giving CTX-p to the baby either because of fear of side effects or not appreciating its importance. Stigma continues to be an important issue. Mothers reported being reluctant to disclose their HIV status to other people so found it difficult to collect prescription refills from the HIV clinic for fear of being seen by friends/relatives. Some women reported that it was hard to administer the drugs if there were people around at home. Other challenges faced were stock-outs of CTX-p at the clinic, which occurred three times in 2011. The baby would then go without CTX-p if the woman could not afford buying at a private pharmacy.

CONCLUSIONS

The study highlights that adherence knowledge and desire alone is insufficient to overcome the familial and structural barriers to maintaining CTX-p. Improving adherence to CTX-p among HEI will require interventions to improve male involvement, reduce HIV stigma in communities and ensure adequate supply of drugs.

Early diagnosis is critical to ensure good outcomes in HIV-infected children: outlining barriers to care

HIV-infected children require early initiation of antiretroviral therapy (ART) to ensure good outcomes. The aim was to investigate missed opportunities in childhood HIV diagnosis leading to delayed ART initiation. Baseline data were reviewed of all children aged <15 years referred over a 1-year period for ART initiation to the Kalafong Hospital HIV services in Gauteng, South Africa. Of the 250 children, one-quarter (24.5%) was of school-going age, 34.5% in the preschool group, 18% between 6 and 12 months old and 23% below 6 months of age (median age = 1.5 years [interquartile range 0.5-4.8]). Most children (82%) presented with advanced/severe HIV disease, particularly those aged 6-12 months (95%). Malnutrition was prominent and referrals were mostly from hospital inpatient services (61%). A structured caregiver interview was conducted in a subgroup, with detailed review of medical records and HIV results. The majority (≥89%) of the 65 interviewed caregivers reported good access to routine healthcare, except for postnatal care (26%). Maternal HIV-testing was mostly done during the second and third pregnancy trimesters (69%). Maternal non-disclosure of HIV status was common (63%) and 83% of mothers reported a lack of psychosocial support. Routine infant HIV-testing was not done in 66%, and inadequate reporting on patient-held records (Road-to-Health Cards/Booklets) occurred frequently (74%). Children with symptomatic HIV disease were not investigated at primary healthcare in 53%, and in 68% of families the siblings were not tested. One-third of children (35%) had a previous HIV diagnosis, with 77% of caregivers aware of these prior results, while 50% acknowledged failing to attend ART services despite referral. In conclusion, a clear strategy on paediatric HIV case finding, especially at primary healthcare, is vital. Multiple barriers need to be overcome in the HIV care pathway to reach high uptake of services, of which especially maternal reasons for not attending paediatric ART services need further exploration.

Barriers to access to care reported by women living with HIV across 27 countries

Increased access to successful antiretroviral therapy (ART) is necessary in order to achieve an AIDS-free generation. Importantly, slightly over half of the people living with HIV are women. Small studies have described many barriers to accessing treatment and care among women living with HIV. This cross-sectional, non-interventional, epidemiological study assessed the prevalence of barriers to accessing care for women living with HIV across 27 countries, divided into four global regions. HIV-positive women attending routine clinical visits were offered the opportunity to participate in the study. Data describing the study sites and demographic characteristics of the participating women were collected. Participating women filled out questionnaires including the Barriers to Care Scale (BACS) questionnaire, on which they reported the extent to which they found each of the 12 potential barriers to accessing health care problematic. A total of 1931 women living with HIV were included in the study: 760 from Western Europe and Canada (WEC), 532 from Central and Eastern Europe (CEE), 519 from Latin America (LA), and 120 from China. The mean age of participating women was 40.1 ± 11.4 years. A total of 88.2% were currently taking ART. A total of 81.8% obtained HIV treatment under a government health plan. The most prevalent barrier to care was community HIV/AIDS stigma. Community HIV/AIDS knowledge, lack of supportive/understanding work environments, lack of employment opportunities, and personal financial resources were also highly prevalent barriers to accessing care. These findings indicate that, more than 30 years after the start of the AIDS epidemic, stigma is still a major issue for women living with HIV. Continued efforts are needed to improve community education on HIV/AIDS in order to maximize access to health care among women living with HIV.

Improving early infant HIV diagnosis in Kenya: study protocol of a cluster-randomized efficacy trial of the HITSystem

Background

Early infant diagnosis among human immunodeficiency virus (HIV)-exposed infants is a critical component of prevention of mother-to-child transmission programs. Barriers to early infant diagnosis include poor uptake, low retention at designated re-testing intervals, delayed test results, passive systems of communication, and poor linkage to treatment. This study will evaluate the HIV Infant Tracking System (HITSystem), an eHealth intervention that streamlines communication and accountability between the key early infant diagnosis stakeholders: HIV+ mothers and their HIV-exposed infants, healthcare providers, and central laboratory personnel. It is hypothesized that the HITSystem will significantly improve early infant diagnosis retention at 9 and 18 months postnatal and the timely provision of services.

Methods/design

Using a phased cluster-randomized controlled trial design, we will evaluate the impact of the HITSystem on eight primary benchmarks in the 18-month long cascade of care for early infant diagnosis. Study sites are six government hospitals in Kenya matched on geographic region, resource level, and patient volume. Early infant diagnosis outcomes of mother-infant dyads (n = 120 per site) at intervention hospitals (n = 3) where the HITSystem is deployed at baseline will be compared to the matched control sites providing standard care. After allowing for sufficient time for enrollment and 18-month follow-up of dyads, the HITSystem will be deployed at the control sites in the end of Year 3. Primary outcomes are retention among mother-infant dyads, initiation of antiretroviral therapy among HIV-infected infants, and the proportion of services delivered within the optimal time window indicated by national and study guidelines. Satisfaction interviews with participants and providers will inform intervention improvements. Cost-effectiveness analyses will be conducted to inform the sustainability of the HITSystem. Hypothesized outcomes include significantly higher retention throughout the 18-month early infant diagnosis process, significantly more services provided on-time at intervention sites, and a potential savings to the healthcare system.

Discussion

This study will evaluate the public health impact of the HITSystem to improve critical early infant diagnosis outcomes in low-resource settings. Cost-effectiveness analyses will inform the feasibility of scale-up in other settings.

Trial registration

ClinicalTrials.gov: NCT02072603

Boundaries of confidentiality in nursing care for mother and child in HIV programmes

BACKGROUND

Confidentiality lies at the core of medical ethics and is the cornerstone for developing and keeping a trusting relationship between nurses and patients. In the wake of the HIV epidemic, there has been a heightened focus on confidentiality in healthcare contexts. Nurses' follow-up of HIV-positive women and their susceptible HIV-exposed children has proved to be challenging in this regard, but the ethical dilemmas concerning confidentiality that emerge in the process of ensuring HIV-free survival of the third party - the child - have attracted limited attention.

OBJECTIVE

The study explores challenges of confidentiality linked to a third party in nurse-patient relationships in a rural Tanzanian HIV/AIDS context.

STUDY CONTEXT

The study was carried out in rural and semi-urban settings of Tanzania where the population is largely agro-pastoral, the formal educational level is low and poverty is rife. The HIV prevalence of 1.5% is low compared to the national prevalence of 5.1%.

METHODS

Data were collected during 9 months of ethnographic fieldwork and consisted of participant observation in clinical settings and during home visits combined with in-depth interviews. The main categories of informants were nurses employed in prevention of mother-to-child transmission of HIV programmes and HIV-positive women enrolled in these programmes.

ETHICAL CONSIDERATIONS

Based on information about the study aims, all informants consented to participate. Ethical approval was granted by ethics review boards in Tanzania and Norway.

FINDINGS AND DISCUSSION

The material indicates a delicate balance between the nurses' attempt to secure the HIV-free survival of the babies and the mothers' desire to preserve confidentiality. Profound confidentiality-related dilemmas emerged in actual practice, and indications of a lack of thorough consideration of the implication of a patient's restricted disclosure came to light during follow-up of the HIV-positive women and the third party - the child who is at risk of HIV infection through mother's milk. World Health Organization's substantial focus on infant survival (Millennium Development Goal-4) and the strong calls for disclosure among the HIV-positive are reflected on in the discussion.

The burden of disease on HIV-infected orphaned and non-orphaned children accessing primary health facilities in a rural district with poor resources in South Africa: a cross-sectional survey of primary caregivers of HIV-infected children aged 5-18 years

Background

Provider-initiated HIV testing and counseling (PITC) is offered as part of the normal standard of care to increase access to treatment for HIV-infected children. In practice, HIV diagnosis occurs in late childhood following recurrent and chronic infections. We investigated primary caregivers’ reported reasons for seeking HIV testing for children aged 5–18 years, determined the orphan status of the children, and compared the clinical profile and disease burden of orphans and non-orphans.

Methods

This was a cross-sectional survey of primary caregivers of HIV-infected children accessing antiretroviral treatment (ART) from two community hospitals and 34 primary healthcare facilities in a rural district in Mpumalanga province, South Africa.

Results

The sample consisted of 406 primary caregivers: 319 (78.6%) brought the child to the health facility for HIV testing because of chronic and recurrent infections. Almost half (n = 183, 45.1%) of the children were maternal orphans, 128 (31.5%) were paternal orphans, and 73 (39.9%) were double orphans. A univariate analysis showed that maternal orphans were significantly more likely to be older (OR = 2.57, p = 0.000, CI: 1.71–3.84), diagnosed late (OR = 2.48, p = 0.009, CI: 1.26–4.88), and to start ART later (OR = 2.5, p = 0.007, CI: 1.28–4.89) than non-orphans. There was a high burden of infection among the children prior to HIV diagnosis; 274 (69.4%) presented with multiple infections. Multiple logistic regression showed that ART start age (aOR = 1.19, p = 0.000, CI: 1.10–1.29) and time on ART (aOR = 2.30, p = 0.000, CI: 1.45–3.64) were significantly associated with orphanhood status. Half (n = 203, (50.2%) of the children were admitted to hospital prior to start of ART, and hospitalization was associated with multiple infections (OR = 1.27, p = 0.004, CI: 1.07–1.51).

Conclusions

The study found late presentation with undiagnosed perinatal HIV infection and high prevalence of orphanhood among the children. The health of maternal orphans was more compromised than non-orphans. Routine PICT should be strengthened to increase community awareness about undiagnosed HIV among older children and to encourage primary caregivers to accept HIV testing for children.

Electronic supplementary material

The online version of this article (doi:10.1186/s40249-015-0049-x) contains supplementary material, which is available to authorized users.

Missed opportunities for early infant HIV diagnosis: results of a national study in South Africa

BACKGROUND

Services to diagnose early infant HIV infection should be offered at the 6-week immunization visit. Despite high 6-week immunization attendance, the coverage of early infant diagnosis (EID) is low in many sub-Saharan countries. We explored reasons for such missed opportunities at 6-week immunization visits.

METHODS

We used data from 2 cross-sectional surveys conducted in 2010 in South Africa. A national assessment was undertaken among randomly selected public facilities (n = 625) to ascertain procedures for EID. A subsample of these facilities (n = 565) was revisited to assess the HIV status of 4- to 8-week-old infants receiving 6-week immunization. We examined potential missed opportunities for EID. We used logistic regression to assess factors influencing maternal intention to report for EID at 6-week immunization visits.

RESULTS

EID services were available in >95% of facilities and 72% of immunization service points (ISPs). The majority (68%) of ISPs provide EID for infants with reported or documented (on infant's Road-to-Health Chart/booklet-iRtHC) HIV exposure. Only 9% of ISPs offered provider-initiated counseling and testing for infants of undocumented/unknown HIV exposure. Interviews with self-reported HIV-positive mothers at ISPs revealed that only 55% had their HIV status documented on their iRtHC and 35% intended to request EID during 6-week immunization. Maternal nonreporting for EID was associated with fear of discrimination, poor adherence to antiretrovirals, and inadequate knowledge about mother-to-child HIV transmission.

CONCLUSIONS

Missed opportunities for EID were attributed to poor documentation of HIV status on iRtHC, inadequate maternal knowledge about mother-to-child HIV transmission, fear of discrimination, and the lack of provider-initiated counseling and testing service for undocumented, unknown, or undeclared HIV-exposed infants.

Barriers to successful early infant diagnosis of HIV infection at primary care level in Malawi

HIV-infected women seeking early infant HIV diagnosis (EID) services in Malawi were asked about factors potentially associated with returning for EID results. Many (33.3%) infants failed to complete the EID process because of time and costs required for multiple visits. Infants of mothers receiving antiretroviral treatment were less likely to drop out (adjusted risk ratio 0.51), suggesting that EID completion may improve in programs providing antiretroviral treatment to all pregnant women.

HIV-seropositivity is not important in childbearing decision-making among HIV-positive Ghanaian women receiving antiretroviral therapy

Women in their reproductive years make up about 50% of all HIV-positive persons globally. These women, just as their HIV-negative counterparts, wield the right to procreate. However, HIV infection and lack of appropriate information on reproductive options may negatively impact women's procreative decision-making. This study assessed fertility intentions of HIV-positive women receiving antiretroviral therapy (ART) in southern Ghana. Quantitative methods were used to collect data from HIV-positive women receiving ART at four treatment centers. HIV-positive aged 18-49 years, and receiving ART were selected using systematic random sampling technique. Three hundred eighteen women were interviewed after informed consent. We used univariate analysis to generate descriptive tabulations for key variables. Bivariate analysis and logistic regression modeling respectively produced unadjusted and adjusted associations between background attributes of respondents and their childbearing decision-making. All analyses were performed using IBM SPSS Statistics for Windows, Version 20.0. Irrespective of age, reproductive history, and duration of HIV diagnosis, 46% of the women were desirous of procreating. The bivariate level analysis shows that women in their late reproductive ages (30-39 years) had the strongest desire to procreate (p < 0.001). After controlling for a number of covariates, primiparous and secundiparious women were about twice as likely to desire children (aOR = 2.553; 95% CI 1.480-4.401), and so were women aged 30-39 years (aOR = 2.149; 95% CI 1.202-3.843). Of 54% women who do not wish to procreate, achievement of desired family size (64.3%) was more popular a reason than fear of vertical transmission of HIV (7.5%), poor health status (5%), and pregnancy-related complications (1.6%).

Access to HIV prevention and care for HIV-exposed and HIV-infected children: a qualitative study in rural and urban Mozambique

Background

Follow-up of HIV-exposed children for the delivery of prevention of mother-to-child transmission services and for early diagnosis and treatment of HIV infection is critical to their survival. Despite efforts, uptake of postnatal care for these children remains low in many sub-Saharan African countries.

Methods

A qualitative study was conducted in three provinces in Mozambique to identify motivators and barriers to improve uptake of and retention in HIV prevention, care and treatment services for HIV-exposed and HIV-infected children. Participant recommendations were also gathered. Individual interviews (n = 79) and focus group discussions (n = 32) were conducted with parents/caregivers, grandmothers, community leaders and health care workers. Using a socioecological framework, the main themes identified were organized into multiple spheres of influence, specifically at the individual, interpersonal, institutional, community and policy levels.

Results

Study participants reported factors such as seeking care outside of the conventional health system and disbelief in test results as barriers to use of HIV services. Other key barriers included fear of disclosure at the interpersonal level and poor patient flow and long waiting time at the institutional level. Key facilitators for accessing care included having hope for children’s future, symptomatic illness in children, and the belief that health facilities were the appropriate places to get care.

Conclusions

The results suggest that individual-level factors are critical drivers that influence the health-seeking behavior of caregivers of HIV-exposed and HIV-infected children in Mozambique. Noted strategies are to provide more information and awareness on the benefits of early pediatric testing and treatment with positive messages that incorporate success stories, to reach more pregnant women and mother-child pairs postpartum, and to provide counseling during tracing visits. Increasing uptake and retention may be achieved by improving patient flow at the institutional level at health facilities, by addressing concerns with family decision makers, and by working with community leaders to support the uptake of services for HIV-exposed children for essential preventive care.

Shame, guilt, and stress: Community perceptions of barriers to engaging in prevention of mother to child transmission (PMTCT) programs in western Kenya

While global scale-up of prevention of mother-to-child transmission of HIV (PMTCT) services has been expansive, only half of HIV-infected pregnant women receive antiretroviral regimens for PMTCT in sub-Saharan Africa. To evaluate social factors influencing uptake of PMTCT in rural Kenya, we conducted a community-based, cross-sectional survey of mothers residing in the KEMRI/CDC Health and Demographic Surveillance System (HDSS) area. Factors included referrals and acceptability, HIV-related stigma, observed discrimination, and knowledge of violence. Chi-squared tests and multivariate regression analyses were used to detect stigma domains associated with uptake of PMTCT services. Most HIV-positive women (89%) reported blame or judgment of people with HIV, and 46% reported they would feel shame if they were associated with someone with HIV. In multivariate analyses, shame was significantly associated with decreased likelihood of maternal HIV testing (Prevalence Ratio 0.91, 95% Confidence Interval 0.84-0.99), a complete course of maternal antiretrovirals (ARVs) (PR 0.73, 95% CI 0.55-0.97), and infant HIV testing (PR 0.86, 95% CI 0.75-0.99). Community perceptions of why women may be unwilling to take ARVs included stigma, guilt, lack of knowledge, denial, stress, and despair or futility. Interventions that seek to decrease maternal depression and internalization of stigma may facilitate uptake of PMTCT.

Validation of 2 Spanish-Language Scales to Assess HIV-Related Stigma in Communities

We report the psychometric properties of 2 Spanish-language scales designed to measure (1) opinions about HIV in the community and particularly among health care workers and (2) observed acts of stigma toward people living with HIV/AIDS (PLWHA) by health care workers. The Opinions about HIV Scale included 3 components (policy, avoidance, and empathy) and 9 items, while an adapted version of the HIV/AIDS Stigma Instrument-Nurse, designed to capture acts of stigma, included 2 components (discrimination related to clinical care and refusal to share or exchange food/gifts). Scales demonstrated good reliability and construct validity. Relative to community health workers, treatment supporters were more likely to have stigmatizing opinions related to avoidance and empathy. We offer 2 Spanish-language scales that could be used to identify populations with high levels of stigmatizing opinions and behaviors toward PLWHA. Formal training of health care workers, especially treatment supporters, may raise awareness and reduce stigma toward HIV.

Temporal changes in the outcomes of HIV-exposed infants in Kinshasa, Democratic Republic of Congo during a period of rapidly evolving guidelines for care (2007-2013)

OBJECTIVE

Guidelines for prevention of mother-to-child transmission of HIV have developed rapidly, yet little is known about how outcomes of HIV-exposed infants have changed over time. We describe HIV-exposed infant outcomes in Kinshasa, Democratic Republic of Congo, between 2007 and 2013.

DESIGN

Cohort study of mother-infant pairs enrolled in family-centered comprehensive HIV care.

METHODS

Accounting for competing risks, we estimated the cumulative incidences of early infant diagnosis, HIV transmission, death, loss to follow-up, and combination antiretroviral therapy (cART) initiation for infants enrolled in three periods (2007-2008, 2009-2010, and 2011-2012).

RESULTS

1707 HIV-exposed infants enrolled at a median age of 2.6 weeks. Among infants whose mothers had recently enrolled into HIV care (N = 1411), access to EID by age two months increased from 28% (95% confidence limits [CL]: 24,34%) among infants enrolled in 2007-2008 to 63% (95% CL: 59,68%) among infants enrolled in 2011-2012 (Gray's p-value <0.01). The 18-month cumulative incidence of HIV declined from 16% (95% CL: 11,22%) for infants enrolled in 2007-2008 to 11% (95% CL: 8,16%) for infants enrolled in 2011-2012 (Gray's p-value = 0.19). The 18-month cumulative incidence of death also declined, from 8% (95% CL: 5,12%) to 3% (95% CL: 2,5%) (Gray's p-value = 0.02). LTFU did not improve, with 18-month cumulative incidences of 19% (95% CL: 15,23%) for infants enrolled in 2007-2008 and 22% (95% CL: 18,26%) for infants enrolled in 2011-2012 (Gray's p-value = 0.06). Among HIV-infected infants, the 24-month cumulative incidence of cART increased from 61% (95% CL: 43,75%) to 97% (95% CL: 82,100%) (Gray's p-value <0.01); the median age at cART decreased from 17.9 to 9.3 months. Outcomes were better for infants whose mothers enrolled before pregnancy.

CONCLUSIONS

We observed encouraging improvements, but continued efforts are needed.

Burden of HIV infection among children aged 18 months to 14 years in Kenya: results from a nationally representative population-based cross-sectional survey

BACKGROUND

In Kenya, mathematical models estimate that there are approximately 220,000 children aged less than 15 years infected with HIV. We analyzed data from the second Kenya AIDS Indicator Survey (KAIS 2012) to estimate the prevalence of HIV infection among children aged 18 months to 14 years.

METHODS

KAIS 2012 was a nationally representative 2-stage cluster sample household survey. We studied children aged 18 months to 14 years whose parents or guardians answered questions pertaining to their children by interview. Blood specimens were collected for HIV serology and viral load measurement.

RESULTS

We identified 5162 children who were eligible for the study. Blood was obtained for 3681 (71.3%) children. Among child participants, 16.4% had been tested for HIV infection in the past, and among children with parents or guardians who self-reported HIV-positive status, 52.9% had been tested for HIV infection. Twenty-eight (0.9%) children tested HIV-positive in the survey. Of these, 11 had been previously diagnosed with HIV infection before the survey. All 11 children were in HIV care and receiving cotrimoxazole; 8 were on antiretorivral therapy (ART). Among those on ART, 4 were virologically suppressed.

CONCLUSIONS

HIV causes a substantial burden of disease in the Kenyan pediatric population. Although most children who had been diagnosed with HIV before the survey were engaged in care and treatment, they represented less than half of HIV-infected children identified in the survey. Future efforts should focus on identifying infected children and getting them into care and on suppressive ART as early as possible.

Barriers to provider-initiated testing and counselling for children in a high HIV prevalence setting: a mixed methods study

BACKGROUND

There is a substantial burden of HIV infection among older children in sub-Saharan Africa, the majority of whom are diagnosed after presentation with advanced disease. We investigated the provision and uptake of provider-initiated HIV testing and counselling (PITC) among children in primary health care facilities, and explored health care worker (HCW) perspectives on providing HIV testing to children.

METHODS AND FINDINGS

Children aged 6 to 15 y attending six primary care clinics in Harare, Zimbabwe, were offered PITC, with guardian consent and child assent. The reasons why testing did not occur in eligible children were recorded, and factors associated with HCWs offering and children/guardians refusing HIV testing were investigated using multivariable logistic regression. Semi-structured interviews were conducted with clinic nurses and counsellors to explore these factors. Among 2,831 eligible children, 2,151 (76%) were offered PITC, of whom 1,534 (54.2%) consented to HIV testing. The main reasons HCWs gave for not offering PITC were the perceived unsuitability of the accompanying guardian to provide consent for HIV testing on behalf of the child and lack of availability of staff or HIV testing kits. Children who were asymptomatic, older, or attending with a male or a younger guardian had significantly lower odds of being offered HIV testing. Male guardians were less likely to consent to their child being tested. 82 (5.3%) children tested HIV-positive, with 95% linking to care. Of the 940 guardians who tested with the child, 186 (19.8%) were HIV-positive.

CONCLUSIONS

The HIV prevalence among children tested was high, highlighting the need for PITC. For PITC to be successfully implemented, clear legislation about consent and guardianship needs to be developed, and structural issues addressed. HCWs require training on counselling children and guardians, particularly male guardians, who are less likely to engage with health care services. Increased awareness of the risk of HIV infection in asymptomatic older children is needed.

'If I am given antiretrovirals I will think I am nearing the grave': Kenyan HIV serodiscordant couples' attitudes regarding early initiation of antiretroviral therapy

OBJECTIVES

Early initiation of antiretroviral therapy (ART) - that is, at higher CD4 cell counts (>350 cells/μl) - is a potent HIV prevention strategy. The WHO recommends ART initiation by all HIV-infected individuals in HIV serodiscordant relationships to prevent HIV transmission, yet the acceptability of early ART among couples has not been well studied.

DESIGN

Qualitative study exploring HIV serodiscordant couples' attitudes toward early initiation of ART.

METHODS

We conducted eight focus group discussions and 20 in-depth interviews with members of heterosexual HIV serodiscordant couples in Kenya. Investigators iteratively applied inductive and deductive codes, developed matrices to identify patterns in codes, and reached consensus on key attitudes (motivations and barriers) related to early ART and one central, emerging theme.

RESULTS

Most participants expressed interest in early initiation of ART, with maintaining health and preventing HIV transmission as key benefits. However, many identified personal concerns and potential barriers to wider community acceptance, including side-effects, adherence to life-long treatment, and stigma. The meaning of ART emerged as a fundamental consideration, with initiating therapy perceived as emblematic of the final stage of AIDS, when one was 'nearing the grave.' One particular challenge was what early ART might signify for someone who looks and feels healthy.

CONCLUSION

HIV serodiscordant couples recognized the potential benefits of early ART, but ART was frequently viewed as signifying AIDS and approaching mortality. Potential implementation of early ART presents challenges and an opportunity to re-orientate individuals toward a new image of ART as health-preserving for patients and partners.

The magnitude of loss to follow-up of HIV-exposed infants along the prevention of mother-to-child HIV transmission continuum of care: a systematic review and meta-analysis

Introduction:

Although prevention of mother-to-child HIV transmission (PMTCT) programs are widely implemented, many children do not benefit from them because of loss to follow-up (LTFU). We conducted a systematic review to determine the magnitude of infant/baby LTFU along the PMTCT cascade.

Methods:

Eligible publications reported infant LTFU outcomes from standard care PMTCT programs (not intervention studies) at any stage of the cascade. Literature searches were conducted in Medline, Embase, Web of Knowledge, CINAHL Plus, and Maternity and Infant Care. Extracted data included setting, methods of follow-up, PMTCT regimens, and proportion and timing of LTFU. For programs in sub-Saharan Africa, random-effects meta-analysis was done using Stata v10. Because of heterogeneity, predictive intervals (PrIs; approximate 95% confidence intervals of a future study based on extent of observed heterogeneity) were computed.

Results:

A total of 826 papers were identified; 25 publications were eligible. Studies were published from 2001 to 2012 and were mostly from sub-Saharan Africa (three were from India, one from UK and one from Ireland). There was extensive heterogeneity in findings. Eight studies reported on LTFU of pregnant HIV-positive women between antenatal care (ANC) registration and delivery, which ranged from 10.9 to 68.1%, pooled proportion 49.08% [95% confidence interval (CI) 39.6–60.9%], and PrI 22.0–100%. Fourteen studies reported LTFU of infants within 3 months of delivery, range 4.8–75%, pooled proportion 33.9% (27.6–41.5), and PrI 15.4–74.2. Children were also lost after HIV testing; this was reported in five studies, pooled estimate 45.5% (35.9–57.6), PrI 18.7–100%. Programs that actively tracked defaulters had better retention outcomes.

Conclusion:

There is unacceptable infant LTFU from PMTCT programs. Countries should incorporate defaulter-tracking as standard to improve retention.

Beyond early infant diagnosis: case finding strategies for identification of HIV-infected infants and children

There are 3.4 million children infected with HIV worldwide, with up to 2.6 million eligible for treatment under current guidelines. However, roughly 70% of infected children are not receiving live-saving HIV care and treatment. Strengthening case finding through improved diagnosis strategies, and actively linking identified HIV-infected children to care and treatment is essential to ensuring that these children benefit from the care and treatment available to them. Without attention or advocacy, the majority of these children will remain undiagnosed and die from complications of HIV. In this article, we summarize the challenges of identifying HIV-infected infants and children, review currently available evidence and guidance, describe promising new strategies for case finding, and make recommendations for future research and interventions to improve identification of HIV-infected infants and children.

The social and gender context of HIV disclosure in sub-Saharan Africa: a review of policies and practices

This paper reviews the legal and policy context of HIV disclosure in sub-Saharan Africa, as well as what is known about rates, consequences and social context of disclosure, with special attention to gender issues and the role of health services. Persistent rates of nondisclosure by those diagnosed with HIV raise difficult ethical, public health and human rights questions about how to protect the medical confidentiality, health and well-being of people living with HIV on the one hand, and how to protect partners and children from HIV transmission on the other. Both globally and within the sub-Saharan African region, a spate of recent laws, policies and programmes have tried to encourage or - in some cases - mandate HIV disclosure. These policies have generated ethical and policy debates. While there is consensus that the criminalization of transmission and nondisclosure undermines rights while serving little public health benefit, there is less clarity about the ethics of third party notification, especially in resource-constrained settings. Despite initiatives to encourage voluntary HIV disclosure and to increase partner testing in sub-Saharan Africa, health workers continue to grapple with difficult challenges in the face of nondisclosure, and often express a need for more guidance and support in this area. A large body of research indicates that gender issues are key to HIV disclosure in the region, and must be considered within policies and programmes. Taken as a whole, this evidence suggests a need for more attention to the challenges and dilemmas faced by both clients and providers in relation to HIV disclosure in this region and for continued efforts to consider the perspectives and rights of all those affected.

Health care resource utilization in untreated HIV-infected children in a pediatric programme, Abidjan, Côte d'Ivoire, 2004-2009

BACKGROUND

We describe health care resource utilization among HIV-1-infected children who have not yet undergone antiretroviral treatment (ART) in Abidjan, Côte d'Ivoire.

METHODS

HIV-infected children enrolled prospectively in an HIV care programme in 2 health facilities in Abidjan (2004-2009) were followed up from date of inclusion until database closeout, death, ART initiation, or loss to follow-up (no clinical contact for more than 6 months). Incidences of health care resource utilization (outpatient care, inpatient day care, and hospitalization) were described according to severe morbidity and mixed effect log linear models were computed to identify associated factors.

RESULTS

Overall, 405 children were included, entering care at a median age of 4.5 years, 66.9% were receiving cotrimoxazole prophylaxis, and 27.7% met 2006 WHO criteria for immunodeficiency by age. The median follow-up time was 11.6 months (interquartile range: 1.4; 30.7). Overall, 371 clinical events occurred in 162 children yielding to an incidence rate (IR) of 60.9/100 child-years (CY) [95% confidence interval (CI): 55.1 to 67.2]: 57% of clinical events led to outpatient care (IR: 33/100 CY), 38% to inpatient day care (IR: 22/100 CY), and 10% to hospitalization (IR: 5.9/100 CY). Further medical examinations were made allowing confirmed diagnoses in 40% of those (IR: 22.4/100 CY). Outpatient care was less common among immunodeficient children than those not (relative risk [RR] = 0.32, 95% CI: 0.18 to 0.56), in those whose main caregivers are both parents compared with those who are primarily cared for by their mother only (RR = 0.34, 95% CI: 0.15 to 0.77).

CONCLUSION

Untreated HIV-infected children require substantial inpatient and outpatient care in a context where ART is scaling up but still not available to all.

HIV testing and care in Burkina Faso, Kenya, Malawi and Uganda: ethics on the ground

BACKGROUND

The ethical discourse about HIV testing has undergone a profound transformation in recent years. The greater availability of antiretroviral therapy (ART) has led to a global scaling up of HIV testing and counseling as a gateway to prevention, treatment and care. In response, critics raised important ethical questions, including: How do different testing policies and practices undermine or strengthen informed consent and medical confidentiality? How well do different modalities of testing provide benefits that outweigh risks of harm? To what degree do current testing policies and programs provide equitable access to HIV services? And finally, what lessons have been learned from the field about how to improve the delivery of HIV services to achieve public health objectives and protections for human rights? This article reviews the empirical evidence that has emerged to answer these questions, from four sub-Saharan African countries, namely: Burkina Faso, Kenya, Malawi and Uganda.

DISCUSSION

Expanding access to treatment and prevention in these four countries has made the biomedical benefits of HIV testing increasingly clear. But serious challenges remain with regard to protecting human rights, informed consent and ensuring linkages to care. Policy makers and practitioners are grappling with difficult ethical issues, including how to protect confidentiality, how to strengthen linkages to care, and how to provide equitable access to services, especially for most at risk populations, including men who have sex with men.

SUMMARY

The most salient policy questions about HIV testing in these countries no longer address whether to scale up routine PITC (and other strategies), but how. Instead, individuals, health care providers and policy makers are struggling with a host of difficult ethical questions about how to protect rights, maximize benefits, and mitigate risks in the face of resource scarcity.

Positive attitudes to pediatric HIV testing: findings from a nationally representative survey from Zimbabwe

OBJECTIVE

Early HIV testing and diagnosis are paramount for increasing treatment initiation among children, necessary for their survival and improved health. However, uptake of pediatric HIV testing is low in high-prevalence areas. We present data on attitudes towards pediatric testing from a nationally representative survey in Zimbabwe.

METHODS

All 18-24 year olds and a proportion of 25-49 year olds living in randomly selected enumeration areas from all ten Zimbabwe provinces were invited to self-complete an anonymous questionnaire on a personal digital assistant, and 16,719 people agreed to participate (75% of eligibles).

RESULTS

Most people think children can benefit from HIV testing (91%), 81% of people who looked after children know how to access testing for their children and 92% would feel happier if their children were tested. Notably, 42% fear that, if tested, children may be discriminated against by some community members and 28% fear their children are HIV positive. People who fear discrimination against children who have tested for HIV are more likely than their counterparts to perceive their community as stigmatizing against HIV positive people (43% vs. 29%). They are also less likely to report positive attitudes to HIV themselves (49% vs. 74%). Only 28% think it is possible for children HIV-infected at birth to live into adolescence without treatment. Approximately 70% of people (irrespective of whether they are themselves parents) think HIV-infected children in their communities can access testing and treatment.

CONCLUSIONS

Pediatric HIV testing is the essential gateway to prevention and care services. Our data indicate positive attitudes to testing children, suggesting a conducive environment for increasing uptake of pediatric testing in Zimbabwe. However, there is a need to better understand the barriers to pediatric testing, such as stigma and discrimination, and address the gaps in knowledge regarding HIV/AIDS in children.

Facilitating HIV testing, care and treatment for orphans and vulnerable children aged five years and younger through community-based early childhood development playcentres in rural Zimbabwe

Introduction

Early diagnosis of children living with HIV is a prerequisite for accessing timely paediatric HIV care and treatment services and for optimizing treatment outcomes. Testing of HIV-exposed infants at 6 weeks and later is part of the national prevention of mother to child transmission (PMTCT) of HIV programme in Zimbabwe, but many opportunities to test infants and children are being missed. Early childhood development (ECD) playcentres can act as an entry point providing multiple health and social services for orphans and vulnerable children (OVC) under 5 years, including facilitating access to HIV treatment and care.

Methods

Sixteen rural community-based, community-run ECD playcentres were established to provide health, nutritional and psychosocial support for OVC aged 5 years and younger exposed to or living with HIV, coupled with family support groups (FSGs) for their families/caregivers. These centres were located in close proximity to health centres giving access to nurse-led monitoring of 697 OVC and their caregivers. Community mobilisers identified OVC within the community, supported their registration process and followed up defaulters. Records profiling each child's attendance, development and health status (including illness episodes), vaccinations and HIV status were compiled at the playcentres and regularly reviewed, updated and acted upon by nurse supervisors. Through FSGs, community cadres and a range of officers from local services established linkages and built the capacity of parents/caregivers and communities to provide protection, aid psychosocial development and facilitate referral for treatment and support.

Results

Available data as of September 2011 for 16 rural centres indicate that 58.8% (n=410) of the 697 children attending the centres were tested for HIV; 18% (n=74) tested positive and were initiated on antibiotic prophylaxis. All those deemed eligible for antiretroviral therapy were commenced on treatment and adherence was monitored.

Conclusions

This community-based playcentre model strengthens comprehensive care (improving emotional, cognitive and physical development) for OVC younger than 5 years and provides opportunities for caregivers to access testing, care and treatment for children exposed to, affected by and infected with HIV in a secure and supportive environment. More research is required to evaluate barriers to counselling and testing of young children and the long-term impact of playcentres upon specific health and developmental outcomes.