This study describes the design, implementation and evaluation of Project Mwana, a pilot project in Zambia’s rural Southern Province. The main aim of this project was to reduce the time between blood sampling for the detection of infant HIV infection and notification of the test results to the relevant point-of-care health facility by using an SMS-based system. Ten public health facilities within two districts in Zambia’s Southern Province were purposively selected for inclusion in the pilot SMS project. Results from this study suggest that in Zambia, particularly in rural areas, mobile phone texting can overcome the logistical and distance barriers that can impede the early diagnosis of HIV infection in infants. An automated SMS allowed the results of PCR testing of infant dried blood samples to be reported to the relevant point-of-care health facility or infant caregivers much faster than would have been possible by using a courier to deliver the results on paper to the relevant health facility. In addition, the results delivered through SMS texting were highly accurate by comparison with the results recorded on paper.
Equity and HIV/AIDS
Treating HIV-infected infants with antiretroviral therapy (ART) as early as possible, within the first six to 12 weeks of life — rather than waiting until they show signs of immunological or clinical deterioration — dramatically decreases their risk of early death, according to findings from the Children with HIV Early Antiretroviral Therapy (CHER) trial, a South African study presented today at the 4th International AIDS Society Conference on HIV Treatment and Pathogenesis in Sydney.
The authors of this study assessed symptom prevalence, general health, ability to perform normal activities, and employment status among adult antiretroviral therapy (ART) patients in South Africa over three full years following ART initiation. A cohort of 855 adult pre-ART patients and patients on ATY for <6 months was enrolled and interviewed an average of 4.4 times each during routine clinic visits for up to three years after treatment initiation using an instrument designed for the study. The probability of pain in the previous week fell from 74% before ART initiation to 32% after three years on ART, fatigue from 66% to 12%, nausea from 28% to 4%, and skin problems from 55% to 10%. The probability of not feeling well physically yesterday fell from 46% to 23%. Before starting ART, 39% of subjects reported not being able to perform their normal activities sometime during the previous week; after three years, this proportion fell to 10%. Employment rose from 27% to 42% of the cohort. Improvement in all outcomes was sustained over three years and, for some outcomes, increased in the second and third year. Improvements in adult ART patients' symptom prevalence, general health, ability to perform normal activities and employment status were large and were sustained through the first three years on treatment. These results suggest that some of the positive economic and social externalities anticipated as a result of large-scale treatment provision, such as increases in workforce participation and productivity and the ability of patients to carry on normal lives, may indeed be accruing.
The Cash Transfer for Orphans and Vulnerable Children programme (CT-OVC) is Kenya's flagship social protection programme, reaching 150,000 poor families with OVC aged 17 or below. Households are provided a flat unconditional cash transfer of US$25 per month. The objective of this study is to assess whether the CT-OVC has reduced HIV-related behavioral risk among adolescents. Researchers included 1,912 households in seven districts across Kenya and gathered data on sexual behaviour and other risk-related behaviours for residents aged 15-25. Main study findings indicated that the CT-OVC programme has reduced the probability of sexual debut by 6.73%. This result appears to be driven by males. The programme also reduced the proportion of adolescents with two or more partners in the last 12 months by 7.2%, and reduced the probability of two or more unprotected sex acts in the last three months for females. The authors urge government to consider establishing a large-scale, national cash transfer programme aimed at preventing HIV among adolescents by postponing sexual debut, reducing the number of partners and reducing the number of unprotected sex acts.
A research article highlights how the combination of a microfinance initiative and an educational programme can empower women and reduce the incidence of intimate partner violence in rural South African communities. The study showed no effect, however, in reducing HIV.
Paediatric antiretroviral adherence is difficult to assess, the authors of this paper argue, and subjective measures are affected by reporting bias, which in turn may depend on psychosocial factors such as alcohol use and depression. In this study, they enrolled 56 child caregiver dyads from Cape Town, South Africa, and followed their adherence over one month via various methods. The Alcohol Use Disorder Inventory Tool and Beck Depression Inventory 1 were used to assess participants’ alcohol use and levels of depression and their effect on drug adherence. The median age of the children was four years, and median time on antiretroviral therapy (ART) was 20 months. Increased time on ART was associated with poorer adherence via three-day recall. Alcohol use was inversely associated with adherence. Having a mother as a caregiver and shorter time on highly active antiretroviral therapy (HAART) were significantly associated with better adherence. The authors conclude that paediatric adherence is affected by caregiver alcohol use, but the caregiver’s relationship to the child is most important. This small study suggests that interventions should aim to keep mothers healthy and alive, as well as alcohol-free.
Paediatric antiretroviral adherence is difficult to assess, the authors of this paper argue, and subjective measures are affected by reporting bias, which in turn may depend on psychosocial factors such as alcohol use and depression. In this study, they enrolled 56 child caregiver dyads from Cape Town, South Africa, and followed their adherence over one month via various methods. The Alcohol Use Disorder Inventory Tool and Beck Depression Inventory 1 were used to assess participants’ alcohol use and levels of depression and their effect on drug adherence. The median age of the children was four years, and median time on antiretroviral therapy (ART) was 20 months. Increased time on ART was associated with poorer adherence via three-day recall. Alcohol use was inversely associated with adherence. Having a mother as a caregiver and shorter time on highly active antiretroviral therapy (HAART) were significantly associated with better adherence. The authors conclude that paediatric adherence is affected by caregiver alcohol use, but the caregiver’s relationship to the child is most important. This small study suggests that interventions should aim to keep mothers healthy and alive, as well as alcohol-free.
Concurrent sexual partnerships are widely believed to be one of the main drivers of the HIV epidemic in sub-Saharan Africa. For this population-based cohort study, researchers used data from the Africa Centre demographic surveillance site in KwaZulu-Natal, South Africa, to try to find support for the concurrency hypothesis. A total of 2,153 sexually active men and 7,284 HIV-negative women from the surrounding local community were included in the study. During five years' follow-up, 693 new female HIV infections occurred and the researchers found that - after adjustment for individual-level sexual behaviour and demographic, socioeconomic and environmental factors associated with HIV acquisition - mean lifetime number of partners of men in the immediate local community was predictive of hazard of HIV acquisition in women. A high prevalence of partnership concurrency in the same local community was not associated with any increase in risk of HIV acquisition. The researchers argue that, in similar hyperendemic sub-Saharan African settings, there is a need for straightforward, unambiguous messages aimed at the reduction of multiple partnerships, irrespective of whether those partnerships overlap in time.
The World Health Organisation recommends initiating antiretroviral therapy (ART) regardless of CD4 count. The authors assessed the effect of ART eligibility on treatment uptake and simulated the impact of WHO’s recommendations in South Africa, through an empirical analysis of cohort data using a regression discontinuity design, used for policy simulation. They enrolled all patients (n = 19,279) diagnosed with HIV between August 2011 and December 2013 in the Hlabisa HIV Treatment and Care Programme in rural South Africa. Patients were ART-eligible with CD4<350 cells/mm3 or Stage III/IV illness. The authors estimated: (1) distribution of first CD4 counts in 2013; (2) probability of initiating ART ≤6 months of HIV diagnosis under existing criteria at each CD4 count; (3) probability of initiating ART by CD4 count if thresholds were eliminated; and (4) number of expected new initiators if South Africa eliminates thresholds. In 2013, 39% of patients diagnosed had a CD4 count ≥500. 8% of these patients initiated even without eligible CD4 counts. If CD4 criteria were eliminated, the authors project that an additional 19% of patients with CD4 ≥500 would initiate ART; and 73% would not initiate ART despite being eligible. Eliminating CD4 criteria would increase the number starting ART by 27%. If these numbers hold nationally, this would represent an additional 164,000 initiators per year, a 5% increase in patients receiving ART and 5% increase in programme costs. Removing CD4 criteria alone will modestly increase timely uptake of ART. However, the authors results suggest the majority of newly-eligible patients will not initiate. Improved testing, linkage, and initiation procedures are needed to achieve 90-90-90 targets.
This paper’s aim is to review facility-based maternal deaths at a tertiary-level centre in Johannesburg, South Africa, from 2003 to 2007, and to investigate the proportion of deaths attributable to human immunodeficiency virus (HIV), the etiology of deaths, and the effects of antiretroviral treatment introduced in late 2004. Patient case files, birth registers, death certificates, and mortality summaries were reviewed. Cause of death was assigned through clinical case discussion. Annual maternal mortality ratios were calculated and disaggregated by HIV status. During the period reviewed, 106 maternal deaths occurred out of 36,708 births. In 72% of cases, HIV status was known, with the majority being HIV-infected (78%). Maternal mortality ratios in HIV-infected women were 95%, 6.2-fold higher than in HIV-negative women. Changes in mortality over time were not detected. Although HIV testing increased 1.4-fold each year and estimated coverage of antiretroviral treatment for pregnant women reached 59.2% in 2007, levels remain suboptimal. In Johannesburg, HIV remains the major cause of maternal mortality despite integration of antiretroviral treatment into prenatal services. Maternal health services should target barriers to uptake of HIV treatment and care.