Early identification and entry into care is critical to reducing morbidity and mortality in children with HIV. The objective of this report is to describe the impact of the Tingathe programme, which utilises community health workers (CHWs) to improve identification and enrolment into care of HIV-exposed and -infected infants and children. Three programme phases are described. During the first phase, Mentorship Only (MO) (March 2007–February 2008) on-site clinical mentorship on paediatric HIV care was provided. In the second phase, Tingathe-Basic (March 2008–February 2009), CHWs provided HIV testing and counselling to improve case finding of HIV-exposed and -infected children. In the final phase, Tingathe-PMTCT (prevention of mother-to-child transmission) (March 2009–February 2011), CHWs were also assigned to HIV-positive pregnant women to improve mother-infant retention in care. The authors reviewed routinely collected programme data from HIV testing registers, patient mastercards and clinic attendance registers from March 2005 to March 2011. During MO, 42 children (38 HIV-infected and 4 HIV-exposed) were active in care. During Tingathe-Basic, 238 HIV-infected children (HIC) were newly enrolled, a six-fold increase in rate of enrolment from 3.2 to 19.8 per month. The number of HIV-exposed infants (HEI) increased from 4 to 118. During Tingathe-PMTCT, 526 HIC were newly enrolled over 24 months, at a rate of 21.9 patients per month. There was also a seven-fold increase in the average number of exposed infants enrolled per month (9.5–70 patients per month), resulting in 1667 enrolled with a younger median age at enrolment (5.2 vs. 2.5 months). During the Tingathe-Basic and Tingathe-PMTCT periods, CHWs conducted 44,388 rapid HIV tests, 7658 (17.3%) in children aged 18 months to 15 years; 351 (4.6%) tested HIV-positive. Over this time, 1781 HEI were enrolled, with 102 (5.7%) found HIV-infected by positive PCR. Additional HIC entered care through various mechanisms (including positive linkage by CHWs and transfer-ins) such that by February 2011, a total of 866 HIC were receiving care, a 23-fold increase from 2008. A multipronged approach utilising CHWs to conduct HIV testing, link HIC into care and provide support to PMTCT mothers can dramatically improve the identification and enrolment into care of HIV-exposed and -infected children.
Equity and HIV/AIDS
The prevention of HIV/AIDS in the Armed Forces is a critical task in Central Africa. Since 2002 the US Department of Defense HIV/AIDS Prevention Program has been providing support through the Johns Hopkins Cameroon Program to assist these countries to improve surveillance and prevention of HIV/AIDS in Cameroon, Chad, Congo Brazzaville, Congo Kinshasa, Equatorial Guinea, Gabon, and Sao Tome. The study describes interventions whose innovative effort in the Armed Forces in Central Africa is the first integrated HIV/AIDS prevention program in this region and will allow effective implementation of long-term strategies to fight the disease in this population.
Education contributes toward the knowledge and personal skills essential for the prevention of HIV, and the mitigation of the impacts caused by AIDS. Produced by the Joint United Nations Programme on HIV/AIDS (UNAIDS)'s Inter-Agency Task Team (IATT) on Education, this report synthesises case study exercises undertaken to examine the quality, effectiveness, and coordination of the education sector's response to the HIV epidemic in 4 countries - Jamaica, Kenya, Thailand, and Zambia. In each country, stakeholders assessed: critical achievements and gaps in the education sector response to HIV and AIDS; the evolution and effectiveness of coordination mechanisms and structures; progress toward harmonisation and alignment; information-sharing on HIV & AIDS and education; key resources for the response; and monitoring and evaluation. This report presents the overall findings from the study and makes recommendations for the IATT on Education and its partners to improve coordination in support of country level and to facilitate global actions.
In Uganda, the areas worst affected by the violence were close to the border with Sudan, far from the urban centres around which most camps for internally displaced persons (IDP) grew. It is the urban areas, such as Gulu in northern Uganda and Yei in southern Sudan, which have the highest HIV prevalence rates. Years of encampment and dependency on relief handouts have had a profound effect on the traditionally conservative Acholi. Alcoholism and sexual violence have become particular problems, and the heavy presence of soldiers, with money in their pockets, has also helped give rise to a sex industry. Many areas of southern Sudan and northern Uganda are rapidly opening up to trade, and health workers are worried that unless information about HIV reaches these populations early enough, they will be unprepared for the possibility of a rapid spread of HIV.
Scarce data are available on the epidemiology of hypertension among HIV patients in rural sub-Saharan Africa. The authors explored the prevalence, incidence and risk factors for incident hypertension among patients who were enrolled in a rural HIV cohort in Tanzania. A prospective longitudinal study including HIV patients enrolled in the Kilombero and Ulanga Antiretroviral Cohort was carried out between 2013 and 2015. Non-ART subjects at baseline and pregnant women during follow-up were excluded from the analysis. Incident hypertension was defined as systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg on two consecutive visits. Cox proportional hazards models were used to assess the association of baseline characteristics and incident hypertension. Among 955 ART-naïve, eligible subjects, 111 (11.6%) were hypertensive at recruitment. Ten women were excluded due to pregnancy. Of the remaining individuals, 9.6% developed hypertension during a median follow-up of 144 days from time of enrolment into the cohort. ART was started in 75.5% of patients, with a median follow-up on ART of 7 months. Cox regression models identified age, body mass index and estimated glomerular filtration rate as independent risk factors for hypertension development. Traditional cardiovascular risk factors predicted incident hypertension, but no association was observed with immunological or ART status. These data support the implementation of routine hypertension screening and integrated management into HIV programmes in rural sub-Saharan Africa.
The objective of this study was to assess the extent to which children may be falsely diagnosed as HIV-infected, using data from an antiretroviral therapy (ART) site in Pretoria, South Africa, between April 2004 and March 2010. Researchers analysed 1,526 patient files, with a male-to-female ratio of 1.01:1 and median age at first visit of 20 months. Nearly half (47%) of the children were aged less than 18 months. Fifty-one children (3.3%) were found to be HIV-uninfected after repeated diagnostic tests. Incorrect laboratory results for children aged less than 18 months included 40 false-positive HIV DNA PCR tests (6.3%) and one false-positive HIV p24Ag test. An additional four children were inappropriately referred after being incorrectly labelled as HIV-infected and one child aged younger than 18 months was referred after an inappropriate diagnostic test for age was used. The authors acknowledge that urgency in ART initiation in HIV-infected children is life-saving, especially in infants, but HIV tests may produce false-positive results so health care workers should meticulously check a child’s HIV-positive status before committing them to lifelong ART.
In this paper, researchers describe the increase in the treatment of South African pediatric HIV-infected patients assisted by the United States President’s Emergency Plan for AIDS Relief (PEPFAR) from 2004 to 2010. They reviewed routine programme data from PEPFAR-funded implementing partners among persons receiving antiretroviral treatment (ART) aged 15 years old and less. From October 2004 through September 2010, the number of children newly initiated on ART in PEPFAR-assisted programmes increased from 154 to 2,641 per month resulting in an increase from 2,412 children on ART in September 2005 to 79,416 children in September 2010. Of those children who initiated ART before September 2009, 0–4 year olds were 1.4 times as likely to transfer out of the programme or die as 5–14 year olds; males were 1.3 times as likely to stop treatment as females. Approximately 27,548 years of life were added to children under-five years old from PEPFAR-assisted antiretroviral treatment. While pediatric antiretroviral treatment in South Africa has increased substantially, the authors call for additional case-finding and a further acceleration in the implementation of pediatric care and treatment services to meet the current treatment need.
The aim of this study was to determine the proportion, characteristics and outcomes of patients who transfer-out from an antiretroviral therapy (ART) service in a South African township. Researchers included all patients aged ≥15 years who enrolled between September 2002 and December 2009. Follow-up data were censored in December 2010. A total of 4,511 patients received ART during the study period. Overall, 597 (13.2%) transferred out. The probability of transferring out by one year of ART steadily increased from 1.4% in 2002/2004 cohort to 8.9% for the 2009 cohort. Independent risk factors for transfer-out were more recent calendar year of enrolment, younger age (≤25 years) and being ART non-naïve at baseline (i.e., having previously transferred into this clinic from another facility). The proportions of patients transferred out who had a CD4 cell count <200 cells/µL and/or a viral load ≥1000 copies/mL were 19% and 20%, respectively. With scale-up of ART over time, an increasing proportion of patients are transferring between ART services and the authors argue that information systems are needed to track patients. Approximately one-fifth of these have viral loads >1000 copies/mL around the time of transfer, suggesting the need for careful adherence counselling and assessment of medication supplies among those planning transfer.
It is the inequalities between women and men that are driving the global HIV/AIDS pandemic and in turn this pandemic is exacerbating existing gender inequalities. However, it is the women of Africa who are particularly vulnerable and bearing the burden of this pandemic. As Stephen Lewis, UN Special Envoy for HIV/AIDS in Africa, so often illustrates, HIV/AIDS in Africa has a female face, and this female face will be eradicated from Africa if we do not respond adequately. As a direct result of these gender inequalities, women and girls are the most vulnerable to infection — 57 per cent of persons who are HIV positive in sub-Saharan Africa are female, according to the AIDS Epidemic Update 2005 — and at the same time it is women and girls who carry the burden of caring for the sick and dying.
This policy brief draws on evidence from a recent study that investigated the factors influencing the choices of infant feeding of HIV-positive mothers in Ghana through an assessment of the perspectives of HIV-positive mothers and family members (i.e., fathers and grandmothers) in two districts in Ghana. Results from the study showed that HIV-positive mothers had good knowledge and understanding of exclusive breastfeeding and exclusive replacement feeding, however adherence to these feeding options was poor and mixed feeding was common. HIV-positive mothers had access to counseling on replacement infant feeding options but there was an emphasis on exclusive breastfeeding and exclusive replacement feeding and not on other replacement options. HIV-positive mothers faced various obstacles (socio-economic, familial and stigma) in carrying out replacement feeding. Family members and communities have a strong influence on mothers’ infant feeding practices. The authors of the study recommend introducing a multi-dimensional behaviour change strategy which involves mothers, family members and significant community members in order to change perceptions, understanding and attitudes to exclusive replacement feeding and exclusive breastfeeding and at the same time, explicitly deal with the risk in terms of infant survival associated with mixed feeding. Male partners should be involved and counselors should explore why the full range of feeding options (like heat-treated breast milk, animal milk and wetnursing) are not discussed.