Management of HIV and hepatitis B or C co-infection in 15 HIV treatment centres. Disparity between protocols and practice

Our aim was to ascertain current guidelines and clinical practices prevalent in HIV treatment centres in the North Thames Region of England on the care of patients co-infected with HIV and hepatitis B or C. A self-completed postal survey of clinic guidelines and retrospective case-note reviews was performed. Fifteen of the 27 units completed the survey and generally had clinic guidelines consistent with current national guidelines. Stated policy was usually to screen HIV patients for hepatitis B virus (HBV) and hepatitis C virus (HCV) and to offer specific therapy for the hepatitis as well as the HIV. Many units were unable to contribute cases to the case-note review, probably through lack of case-identification, and therefore 11 units contributed 27 case-note reviews on HIV/HBV and five units contributed 11 case-note reviews on HIV/HCV. Fifty-six percent (25/45) of patients of HBV patients were HBeAg+ve and 88% (22/25) of these had received specific hepatitis B therapy although for 59% (13/22) this was with lamivudine as part of a highly active antiretroviral therapy regimen. None of the HIV/HCV patients had received or been referred for HCV-specific therapy. Testing for hepatitis A immunity in HBV or HCV patients with a view to vaccination was done in only 50% although 96% of HIV/HCV patients had been screened for HBV. There are significant differences between the clinics' intended and actual management of HIV and chronic viral hepatitis co-infection.     

HIV and child-bearing: clinical outcome and aspects of mother-to-infant transmission

Forty-four HIV-1-seropositive women and their children were followed-up and examined in connection with the course of pregnancy, mother-to-infant transmission of HIV and clinical outcome. Twelve out of 48 children were known to be infected and two children were lost to follow-up. Of the remaining 34 children, 22 are not infected, and 12 are clinically and immunologically normal at less than 18 months. There was no difference in intrauterine growth between infected and uninfected children. Forty-six per cent of the 39 mothers seen after delivery progressed to a more advanced stage of HIV infection during a mean follow-up time of 33 months after delivery. Although comparable in age, clinical and immunological status at delivery, and follow-up time, mothers of infected children had longer durations of HIV infection and were symptomatic and/or had low CD4 cell counts to a significantly greater extent at follow-up than mothers of uninfected children.     

Prevention of mother to child transmission of HIV (PMTCT) programme in KwaZulu‐Natal,South Africa: an evaluation of PMTCT implementation and integration into routine maternal,child and women’s health services

Objectives To evaluate prevention of mother to child transmission of HIV (PMTCT) implementation and integration of PMTCT with routine maternal and child health services in two districts of KwaZulu‐Natal; to report PMTCT coverage, to compare recorded and reported information, and to describe responsibilities of nurses and lay counsellors. Methods Interviews were conducted with mothers in post‐natal wards (PNW) and immunisation clinics; antenatal and child health records were reviewed. Interviews were conducted with nurses and lay counsellors in primary health care clinics. Results Eight hundred and eighty‐two interviews were conducted with mothers: 398 in PNWs and 484 immunisation clinics. During their recent pregnancy, 98.6% women attended antenatal care (ANC); 60.8% attended their first ANC in the third trimester, and 97.3% were tested for HIV. Of 312 mothers reporting themselves HIV positive during ANC, 91.3% received nevirapine, 78.2% had a CD4 count carried out, and 33.1% had a CD4 result recorded. In the immunisation clinic, 47.6% HIV‐exposed babies had a PCR test, and 47.0% received co‐trimoxazole. Of HIV‐positive mothers, 42.1% received follow‐up care, mainly from lay counsellors. In 12/26 clinics, there was a dedicated PMTCT nurse, PCR testing was not offered in 14/26 clinics, and co‐trimoxazole was unavailable in 13/26 immunisation clinics. Nurses and lay counsellors disagreed about their roles and responsibilities, particularly in the post‐natal period. Conclusions There is high coverage of PMTCT interventions during pregnancy and delivery, but follow‐up of mothers and infants is poor. Poor integration of PMTCT services into routine care, lack of clarity about health worker roles and poor record keeping create barriers to accessing services post‐delivery.     

Use of neonatal post-exposure prophylaxis for prevention of mother-to-child HIV transmission in the UK and Ireland, 2001-2008

Objectives

To investigate changing clinical practice with regard to antiretroviral post‐exposure prophylaxis (PEP) and factors associated with the use of combination prophylaxis in infants born to HIV‐infected women in the UK and Ireland.

Methods

Surveillance of obstetric and paediatric HIV infection in the UK and Ireland is conducted through the National Study of HIV in Pregnancy and Childhood. Infants born to HIV‐infected women between 2001 and 2008 were included in the study.

Results

Ninety‐nine per cent of infants (8155 of 8205) received antiretroviral prophylaxis; 86% of those with information on type of prophylaxis (n=8050) received single, 3% dual and 11% triple drug prophylaxis. Among those who received prophylaxis, use of triple prophylaxis increased significantly between 2001–2004 and 2005–2008, from 9% (297 of 3243) to 13% (624 of 4807) overall (P<0.001); from 43% (41 of 95) to 71% (45 of 63) in infants born to untreated women; and from 13% (114 of 883) to 32% (344 of 1088) where mothers were viraemic despite highly active antiretroviral therapy (HAART) in pregnancy. In multivariable analysis, factors associated with receipt of triple prophylaxis included later time period, shorter duration or lack of antenatal antiretroviral therapy, receipt of antiretroviral drugs during labour, detectable maternal viral load, CD4 count<200 cells/μL in pregnancy, preterm delivery (<37 weeks) and unplanned (emergency caesarean or vaginal) delivery.

Conclusion

Between 2001 and 2008, almost all infants born to HIV‐infected women in the UK and Ireland received antiretroviral PEP, mostly with one drug. Use of triple PEP increased over time, particularly for infants whose mothers were untreated or viraemic despite HAART, in line with current guidelines.     

An assessment of current HIV treatment adherence services in the UK

The aim of this study was to examine current approaches to supporting adherence to antiretroviral therapy in UK HIV clinics. One hundred HIV/AIDS/GUM physicians were interviewed: 97% were personally involved in discussing adherence, spending 22% of consultation time on this issue and assessing adherence most commonly by patient self-report (88%). Other personnel involved included nurses (74%), other doctors (56%), health advisers (54%) and pharmacists (48%). Among criteria for achieving treatment success, adherence support ranked fourth after 'treatment fitting well into patient's lifestyle', regular viral load monitoring and the 'experience of the clinician/healthcare team'. A variety of tools were used to support adherence including dosette boxes (53%), written information (44%) and verbal communication (42%). Only 20% of physicians followed adherence protocols or formal guidelines. Three-quarters of physicians had received no training on adherence issues. The most common ways physicians kept informed about adherence matters were by attending conferences (87%), reading literature (71%) and learning from colleagues (51%). Eighty-seven per cent of physicians believed national adherence guidelines would be valuable. In conclusion, there is a need for training and direction within current adherence support services. National guidelines could provide a valuable framework for health care professionals.     

British HIV Association (BHIVA) national cohort outcomes audit of patients commencing antiretrovirals from naïve

Objectives

The aim of this work was to audit the extent to which routine HIV care in the UK conforms with British HIV Association (BHIVA) guidelines and specifically the proportion of patients starting highly active antiretroviral therapy (HAART) who achieve the outcome of virological suppression below 50 HIV‐1 RNA copies/mL within 6 months.

Methods

A prospective cohort review of adults with HIV infection who started antiretroviral therapy (ART) for the first time between April and September 2006 was carried out using structured questionnaire forms.

Results

A total of 1170 adults from 122 clinical sites participated in the review. Of these patients, 699 (59.7%) started ART at CD4 counts <200 cells/μL and 193 (16.5%) had not been tested for HIV drug resistance. Excluding patients with valid reasons for stopping short‐term ART, 795 (73.5%) of 1081 patients had an undetectable viral load (VL) at follow‐up. Detectable VL was strongly associated with pretreatment CD4 count below 50 cells/μL and pretreatment VL above 100 000 copies/mL, and was not associated with clinic location or case load. About a quarter of patients did not have a VL measurement during the first 6 weeks after starting ART.

Conclusions

The majority of patients who initiated ART at sites participating in this UK national audit were managed within the BHIVA guidelines and achieved virological suppression below 50 copies/mL around 6 months after commencing treatment. Poor VL outcomes were associated with very low CD4 cell count and/or high VL at baseline but not with clinic case load or location. There is an urgent need to diagnose patients at an earlier stage of their HIV disease.     

Vaccination against hepatitis B in an HIV outpatients' department: an audit against national vaccination guidelines

Practice related to hepatitis B vaccination of HIV outpatients in a London teaching hospital was audited against the British HIV Association (BHIVA) immunization guidelines 2004 and 2008, both before and after the implementation of a vaccination record sheet in the patients' notes. Adherence to the guidelines in the original audit was poor - only 67% of patients requiring vaccination for hepatitis B received a full course of vaccination. Following the introduction of the vaccination record sheet, this vaccination completion rate increased to 79% (BHIVA target 95%). Overall the percentage of patients managed according to BHIVA guidelines, including those who did not require vaccination, improved from 33% in the original audit to 61% in the re-audit. Introduction of a simple hepatitis B vaccination record sheet improved the quality of care for our HIV outpatients. Further modification of this system is warranted, perhaps by the introduction of a computerized reminder system.     

Findings from the first national clinical audit of treatment for people with HIV

Objectives

We reviewed the impact of and assessed adherence to British HIV Association (BHIVA) guidelines in routine clinical practice. Feedback has been provided to clinical centres to facilitate any necessary change.

Methods

We used a questionnaire to gauge clinicians' views on the guidelines and availability of antiretroviral therapy (ART) drugs and specialized tests. A case note review of 2044 patients was conducted to assess adherence to guideline recommendations plus patterns of use of HIV resistance testing.

Results

Most clinicians (74.1%) report that BHIVA guidelines have influenced care at their centres. A significant minority report problems with access to specialized tests. Most patients who started ART did so at CD4 counts lower than guidelines recommend but in most cases this reflected the CD4 count at diagnosis of HIV. Of patients on ART, an overwhelming majority (97.6%) were receiving three or more drugs. Of those on three or more drugs, 58.9% had latest viral load (VL) below 50 HIV‐1 RNA copies/mL and a further 18.1% below 500 copies/mL. Only 19.3% of patients had been tested for HIV resistance, of whom more than half showed resistance to more than one class of drugs.

Conclusions

This clinical audit provides encouraging evidence of the quality of care offered to people with diagnosed HIV in the UK. However late diagnosis means most people start ART at a more advanced stage than guidelines recommend.

     

An audit of HIV testing and HIV serostatus in tuberculosis patients,Blantyre, Malawi

Setting: Queen Elizabeth Central Hospital, Blantyre, Malawi.Objective: An audit of voluntary HIV testing, with pre- and post-test counselling, of adult patients diagnosed with all types of tuberculosis.Design: A review of case files of adult patients with tuberculosis registered with the District Tuberculosis Officer, Blantyre, between April 1993 and March 1994.Results: There were 1095 tuberculosis patients, mean age 32 years, of whom 665 (60.7%) had HIV-serological testing. 496 patients (74.6% of those tested) were HIV seropositive. 73% of patients who were hospitalized for the initial intensive phase of treatment were HIV-tested compared with 37% of patients who received ambulatory chemotherapy (P < 0.001). In patients HIV-tested, 5 did not wish to know their results and post-test counselling was done in 516 (78%). 23 patients refused HIV testing. 362 (84%) patients not HIV-tested never received pre-test counselling. Of 664 patients who received 2SRHZ/6HT(E) in hospital, 84 (12.6%) patients died and 8 (1.2%) absconded. The abscondee rate was unrelated to HIV serostatus.Conclusion: A large proportion of tuberculosis patients who receive supervised treatment in hospital accept confidential HIV testing and the abscondee rate is low. The clinical management of patients is improved.     

嘉兴市292507例孕产妇HIV感染状况

目的为了解嘉兴市孕产妇艾滋病病毒（HIV）感染状况,探索适合当地的预防艾滋病母婴传播的运行模式和服务方式,最大程度地减少母婴传播。方法对孕产妇检测HIV抗体,初筛阳性标本进行确认试验;对感染HIV的孕产妇进行监测与管理。结果2006—2012年,孕产妇HIV抗体阳性率为0．19‰（57／292507）,其中本地户籍为0．02％（3／130 299）,流动人口为0．33％0（54／162208）,差异有统计学意义（P〈0．01）。分娩的22例活产婴儿中追踪到18个月的有12例,其中11例HIV抗体阴性,1例阳性。结论嘉兴市孕产妇HIV感染处于较低水平,流动人口是艾滋病防治的重点人群。妇幼保健机构和疾病预防控制中心要明确各自职责、加强合作,加强对感染HIV的孕产妇进行监测管理。     

实施预防HIV母婴传播措施效果分析

目的了解实施预防艾滋病母婴传播措施对艾滋病病毒(HIV)母婴传播的影响。方法对实施干预试点地区阳性孕产妇及所生幼儿干预状况进行调查,调查幼儿出生时服药情况、喂养方式,及其母亲的分娩方式、服用抗病毒药物等情况,采用单因素χ2分析,比较干预组与未干预组幼儿HIV感染率的差异。结果实施综合干预措施组HIV母婴传播率为2.75%,没有采取任何干预措施组的母婴传播率为50.00%,两组间存在显著性差异。结论对HIV阳性孕产妇及所生婴儿及时服用抗病毒药物,并对婴儿实施纯人工喂养等措施,可有效降低HIV的母婴传播率。     

感染HIV的孕产妇预防艾滋病母婴传播服务需求与障碍分析

目的了解艾滋病病毒(HIV)感染孕产妇的预防艾滋病母婴传播服务需求与服务利用障碍。方法对某艾滋病高发地区,自2003年以来截至2004年10月发现并分娩的HIV感染孕产妇进行问卷调查。结果13.79%的孕产妇不愿意接受产前检查,5.17%的孕产妇不愿意住院分娩,怕歧视、担心检查和住院分娩费用高等是孕产妇不接受孕产期保健的主要原因;96.43%的孕产妇愿意本人和给孩子服用抗逆转录病毒药物预防艾滋病母婴传播,但只有87.50%的孕产妇服用了抗HIV药物,未服药的原因为临产急诊分娩,未得到检测结果,延误了孕产妇和婴儿的服药时机;89.29%的孕产妇希望其所生婴幼儿获得随访服务,但只有58.93%的婴幼儿得到过随访服务,其中51.52%的婴幼儿在出生后3个月内得到首次随访;怕别人知道自己的感染情况是不愿意接受随访的主要原因;近7%的孕产妇不愿意或不知道要给所生的婴幼儿进行HIV抗体检测。结论育龄妇女和孕产妇艾滋病检测不及时、非住院分娩、婴幼儿随访服务薄弱、经济负担、社会歧视等问题,是预防艾滋病母婴传播服务利用的主要障碍,预防艾滋病母婴传播综合能力亟待加强。     

Towards the complete eradication of mother-to-child HIV/HBV coinfection at Saint Camille Medical Centre in Burkina Faso,Africa

The coinfection of HIV and hepatitis B virus (HBV) and their vertical transmission constitute a public health problem in sub-Saharan countries of Africa. The objectives of this research are: i) identify the pregnant women that are coinfected by HIV and HBV at Saint Camille Medical Centre; ii) use three antiretroviral drugs (zidovudine, nevirapine and lamivudine) to interrupt the vertical transmission of HIV and HBV from infected mothers; and iii) use the PCR technique to diagnose children who are vertically infected by these viruses in order to offer them an early medical assistance. At Saint Camille Medical Centre, 115 pregnant women, aged from 19 to 41 years, were diagnosed as HIV-positive and, among them, 14 coinfected with HBV. They had at least 32 weeks of amenorrhoea and all of them received the HAART, which contained lamivudine. Two to six months after childbirth, the babies underwent PCR diagnosis for HIV and HBV. The results revealed that, among these mothers, 64.4% were housewives, 36.5% were illiterates, and only 1.7% had a university degree. The rate of vertical transmission of HIV and HBV was 0.0% (0/115) and 21.4% (3/14), respectively. The 3 mothers who transmitted the HBV to their children had all HBsAg, HbeAg, and HBV DNA positive. An antiretroviral therapy that in addition to zidovudine and nevirapine includes lamivudine could, as in the present study, block or reduce the vertical transmission in HIV positive pregnant women who are coinfected with HBV.     

Effectiveness of a city-wide program to prevent mother-to-child HIV transmission in Lusaka, Zambia

OBJECTIVE: To determine the population effectiveness of a city-wide perinatal HIV prevention program. DESIGN: An anonymous surveillance of newborn cord blood for HIV serology and nevirapine (NVP). METHODS: All 10 public-sector delivery centers in Lusaka, Zambia participated. All mother-infant pairs delivering during the 12-week surveillance period at the participating centers and who received antenatal care at a public-sector facility in Lusaka were included in the study. The main outcome measure was population NVP coverage, defined as the proportion of HIV-infected women and HIV-exposed infants in the population that ingested NVP. RESULTS: Of 8787 women in the surveillance population, 7204 (82%) had been offered antenatal HIV testing, of which 5149 (71%) had accepted, and of which 5129 (99%) had received a result. Overall, 2257 of 8787 (26%) were cord seropositive. Of the 1246 (55%) cord blood seropositive women who received an antenatal HIV test result, 1112 (89%) received a positive result; the other 134 comprise seroconverters and clerical errors. Only 751 of 1112 (68%) women who received a positive antenatal test result and a NVP tablet for ingestion at labor onset had NVP detected in the cord blood (i.e., maternal non-adherence rate was 32%). A total of 675 infants born to 751 adherent mothers (90%) received NVP before discharge. Thus, only 675 of 2257 (30%) seropositive mother-infant pairs in the surveillance population received both a maternal and infant dose of NVP. CONCLUSIONS: Successful perinatal HIV prevention requires each mother-infant pair to negotiate a cascade of events that begins with offering HIV testing and continues through adherence to the prescribed regimen. This novel surveillance demonstrates that failures occur at each step, resulting in reduced coverage and diminished program effectiveness.     

The British HIV Association national audit on the management of subjects co-infected with HIV and hepatitis B/C

The aim of this work was to survey current service provision and adherence to the British HIV Association (BHIVA) guidelines for the management of HIV and hepatitis B/C co-infected patients in the UK. Sites were invited to complete a survey of local care arrangements for co-infected patients. A case-note audit of all co-infected attendees during a six-month period in 2009 was performed. Data including demographics, clinical parameters, hepatitis disease status, antiretroviral and hepatitis B/C therapy were collected. Using BHIVA guidelines as audit standards, the proportion of sites and subjects meeting each standard was calculated. One-hundred and forty sites (75%) responded and data from 973 eligible co-infected patients were submitted. Approximately a third of sites reported not re-checking hepatitis serology or vaccination titres annually. Of all co-infected patients, 122 (13%) were neither vaccinated nor immune to hepatitis A and 26 (5%) of patients with hepatitis C were neither vaccinated nor naturally immune to hepatitis B. Of HBsAg-positive subjects, 25 (6%) were receiving lamivudine as the sole drug with antihepatitis B activity. In the UK, the management of HIV and hepatitis B/C co-infection remains highly variable. Optimizing the care of this high-risk patient group is a priority.     

Prevalence of HIV infection and AIDS symptomatology in malnourished children--a hospital based study

One hundred and seventy five malnourished children aged between 1(1/2) and 12 years attending pediatric department of Regional Institute of Medical Sciences Hospital, Imphal from January 2001 to June 2002 were screened for human immunodeficiency virus (HIV) infection along with their biological mothers after pretest counselling and informed consent. The prevalence rate of HIV seropositivity among malnourished children was 21.7%. Children aged between 1(1/2) and 3 years had the highest seroprevalence (47.4%) and male to female ratio was 1.5: 1. Underweight children showed the highest seroprevalence (47.4%) and children with kwashiorkor showed least seroprevalence (10.5%). Mode of HIV transmission was vertical in 94.7%. The causative agent was HIV-I in all the cases. AIDS defining children features were seen more frequently among HIV seropositive malnourished children as compared to the seronegative children. Prolonged fever (p 0.001), oropharyngeal candidiasis (p<0.001), generalised lymphadenopathy (p<0.001) and disseminated maculopapular dermatitis (p<0.001) were significantly related to HIV infection. Among seronegative children 18.2% fulfilled the clinical criteria for AIDS and among seropositive children 94.7% had AIDS. The total mortality encountered among seropositive children was 34.2%. It is suggested to confirm findings based on larger community based data before recommending mandatory HIV testing in all malnourished children. Specific guidelines on the nutritional management of children with HIV/AIDS is needed in Manipur where HIV is spreading rapidly.     

The British HIV Association national clinical audit 2021: Management of HIV and hepatitis C coinfection

Objectives

We aimed to describe clinical policies for the management of people with HIV/hepatitis C virus (HCV) coinfection and to audit routine monitoring and assessment of people with HIV/HCV coinfection attending UK HIV care.

Methods

This was a clinic survey and retrospective case-note review. HIV clinics in the UK participated in the audit from May to July 2021 by completing an online questionnaire regarding their clinic's policies for the management of people with HIV/HCV coinfection, and by contributing to a case-note review of people living with HIV with detectable HCV RNA who were under the care of their service.

Results

Ninety-five clinics participated in the clinic survey; of these, 15 (15.8%) were regional specialist centres, 19 (20.0%) were HIV services with their own coinfection clinics, 40 (42.1%) were HIV services that referred coinfected individuals to a local hepatology service and 20 (21.1%) were HIV services that referred to a regional specialist centre. Eighty-one clinics provided full caseload estimates; of the approximately 3951 people with a history of HIV/HCV coinfection accessing their clinics, only 4.9% were believed to have detectable HCV RNA, 3.15% of whom were already receiving or approved for direct-acting antiviral (DAA) treatment. In total, 29 (30.5%) of the clinics reported an impact of COVID-19 on coinfection care, including delays or reductions in the frequency of services, monitoring, treatment initiation and appointments, and changes to the way that treatment was dispensed. Case-note reviews were provided for 283 people with detectable HCV RNA from 74 clinics (median age 42 years, 74.6% male, 56.2% HCV genotype 1, 22.3% HCV genotype 3). Overall, 56% had not received treatment for HCV, primarily due to lack of engagement in care (54.7%) and/or being uncontactable (16.4%).

Conclusions

Our findings show that the small number of people with HIV with detectable HCV RNA in the UK should mean that it is possible to achieve HCV micro-elimination. However, more work is needed to improve engagement in care for those who are untreated for HCV.     

Adoption of safer infant feeding and postpartum sexual practices and their relationship to maternal HIV status and risk of acquiring HIV in Zimbabwe

OBJECTIVE: To examine the relationships between maternal knowledge and concern about HIV status, adoption of preventive practices and risk of acquiring HIV in Zimbabwe. METHODS: Knowledge and behavioural data were collected via interview from 2595 mothers enrolled in ZVITAMBO, a randomized trial of postpartum vitamin A supplementation that also offered education on safer infant feeding and sexual practices. Mothers were tested for HIV at delivery; those uninfected at baseline were retested during study follow-up. Logistic regression methods were used to identify variables associated with adoption of preventive behaviours and, for HIV-negative mothers, their relationship to risk of acquiring HIV post-delivery. RESULTS: A total of 518 mothers (20%) reported practicing safer sex and 289 mothers (11%) reported modifying their feeding behaviour because of HIV. Fear of transmitting HIV (50.4%) and protecting the baby's health (30.9%) were the most frequently cited reasons for behaviour change. Forty-nine HIV-negative mothers acquired HIV during the first postpartum year. After taking into account other significant covariates, mothers who were concerned about their own HIV status were 1.9 times more likely (95% CI: 1.05-3.52; P = 0.03), and those reporting safer sex practices were 58% less likely to become infected (adjusted odds ratio: 0.42; 95% CI: 0.17-1.04; P = 0.06). Married women who reported practicing abstinence to prevent HIV were 3.2 times more likely to become infected than non-abstaining mothers (P = 0.01), while there were no new HIV infections among abstaining single mothers. CONCLUSIONS: Greater emphasis should be given to safer sex practices among women who test negative in mother-to-child HIV prevention programmes.     

Parental HIV serodiscordance: implications for the care of the HIV seropositive child in a resource-poor setting

This prospective study compared the care and support provided for symptomatic HIV seropositive children of HIV serodiscordant parents (only the mother of the child is HIV infected) with children of seroconcordant parents (both parents are HIV infected) during admission and after discharge from a tertiary health institution in southwestern Nigeria. Information was collected from parents of eligible children by semi-structured questionnaires and observation of the children and their parents while on admission and at home. Of the 51 couples who met the study criteria, there were 27 seroconcordant couples and 24 serodiscordant couples. The children from serodiscordant couples were more frequently discharged against medical advice, abandoned, lost to follow-up, cared for by their mothers alone and were not up-to-date with their immunization schedule when compared with children from seroconcordant parents. These were statistically significant (p < 0.05). There was a higher mortality among these children and their mothers (p < 0.05). Paternal reasons for not providing adequate care for the children from serodiscordant parents included fear of being infected, doubt of child's paternity and waste of family resources on a 'child who is dying'. None of the children from both groups received support from governmental and non-governmental agencies. It is concluded that the care of sick HIV seropositive children of serodiscordant parents poses special challenges for clinicians working in Nigeria where there is no social support system.     

Prevention of Mother-to-Child Transmission of HIV: Compliance with the Recommendations of the Brazilian National STD/AIDS Control Program for Prenatal and Perinatal HIV Testing in Porto Alegre, Brazil

In order to benefit from antiretroviral therapy, pregnant women infected with HIV must be tested and diagnosed. Not infrequently, however, women present in labor without prior prenatal care and are thus unable to benefit fully from HIV testing and, if infected, antiretroviral therapy. In this study we evaluated the need for rapid perinatal HIV testing for untested mothers presenting in labor in a public maternal–child hospital that provides care for metropolitan Porto Alegre, Brazil, and potentially modifiable risk factors for noncompliance with national recommendations. We surveyed a consecutive sample of women who gave birth at Hospital Materno–Infantil Presidente Vargas (Presidente Vargas Mother-and-child Hospital) in August–October 2001and administered a structured questionnaire to consenting participants. The questionnaire consisted of demographic data, information on health-seeking behavior, knowledge of HIV infection, and testing during pregnancy. We confirmed information on HIV testing, syphilis, and hepatitis B by examination of the patient's prenatal records. We also obtained data regarding laboratory testing and treatment during labor and delivery (e.g., HIV testing, antiretroviral treatment, and suppression of lactation) from hospital inpatient charts. Of 214 eligible participants, 209 (98%) agreed to participate in the study. Overall 173 (83%) of the 209 participants had had a previous HIV test and 36 (17%) had not. Women with fewer pregnancies were more likely to have been tested (p = .017), as were women with lower family incomes (p = .007). No women had received rapid tests in the delivery room. Of the 209 participants, 201 (96%) had had at least one prenatal visit and 169 (81%) had had three or more visits; 12 (6%) of these reported that they had not been offered an HIV test, 5 (2%) did not know if testing had been offered or not, and 191 (95%) reported that they had been offered a test. We were able to obtain prenatal records for 190 (95%) of the 201participants who had received prenatal care. HIV testing was not mentioned in 9% of charts. Results of syphilis tests were recorded on prenatal records or hospital charts for 167 (80%)participants, and results of hepatitis B surface antigen were found for 93 (45%). Women who to 30pchad had three or more prenatal visits were significantly more likely to have been tested for to 30pcHIV (OR 46.96, 95% CI, 15.92–144.85, .0001), syphilis (OR 31.64, 95% CI, 11.81–87.42, p < .0001) or HBsAg (OR, 4.88, 95% CI, 1.91–12.99, p < .0001) than women who had had two prenatal visits or fewer. Our study showed shown that in 12% of the pregnancies included in our sample national recommendations for prenatal or perinatal testing were not followed, and in an additional 5%, HIV testing, though offered, was not obtained. These women could potentially have benefited from rapid HIV testing. As knowledge of HIV and risk factors for transmission were almost universal in our sample, we believe that the passive health-seeking behavior we observed may offer an opportunity for targeting new efforts to promote the importance of prenatal care and prenatal diagnosis of HIV.