National and provincial estimated costs and cost effectiveness of a programme to reduce mother-to-child HIV transmission in South Africa.

OBJECTIVE: To estimate the cost and cost effectiveness nationally and for each province of a programme to reduce mother-to-child transmission (MTCT) of HIV in South Africa. METHODS: A model developed to estimate cost and cost effectiveness of interventions in Hlabisa, KwaZulu-Natal, was modified and applied to each province. This model predicts a 37% reduction in paediatric HIV infections if short-course oral zidovudine (ZDV) plus infant formula feed for 4 months is provided within a strengthened health system. Estimates of the number of pregnancies and HIV prevalence among pregnant women per province in 1997 were combined with an estimated 30% MTCT rate. Costs were calculated from a health system perspective, and effectiveness was estimated as cost per infection averted and cost per disability-adjusted life year (DALY) gained. RESULTS: In 1997, 63,397 paediatric HIV infections were estimated to have occurred in South Africa, mainly in KwaZulu-Natal (18,513, 29%) and Gauteng (10,417, 16%). The cost of a national programme is estimated at R155.9 million (1997 rand costs, 0.94% of the national health budget). Major cost items are drugs (R46.4 m, 30%), staff salaries (R45.8 m, 29%), and formula feed (R37.1 m, 24%). Most money would need to be spent in KwaZulu-Natal (R37.6 m, 24% of national cost), Gauteng (R25.2 m, 16%) and the Eastern Cape (R24 m, 15%). National cost per infection averted is R6,724, and R213 per DALY gained. Provincial DALY costs range from R176 to R369. CONCLUSIONS: A national programme preventing 37% of expected paediatric HIV infections would cost a small fraction of the national health budget, at a cost equivalent to R3.89 per capita total population. The cost per DALY gained compares well with established public health and clinical interventions in middle-income countries, even without factoring in the care costs that would be saved through a successful programme. Cost effectiveness is greatest where HIV prevalence is highest.     

Determinants of HIV-1 mother-to-child transmission in Southern Brazil

Different human immunodeficiency virus type 1 (HIV-1) subtypes may have distinct biological, immunological and pathogenic properties. Efficiency of mother-to-child transmission (MTCT) may be among those properties, but few and controversial results have been described so far. In this study, 102 children born from HIV-1-infected mothers between 1998 and 2004 in the city of Rio Grande, Brazil were analyzed for potential risk factors associated with MTCT. That geographic region is characterized by a high proportion of subtype C-infected subjects, and it allowed comparison between subtypes B and C and their influence on MTCT. The analysis also included clinical, obstetric and immunological parameters. Multivariate regression analyses were conducted to evaluate the influence of the parameters on MTCT, and prevalence ratios (PR) and 95% confidence intervals (CI95) were also calculated. A surprisingly high prevalence of subtype C of over 70% was found. Only the HIV viral load and the use of ACTG 076 protocol were predictive of MTCT. HIV subtype and CD4 T-cell counts were not associated with increased risk of transmission. Although a clear expansion of subtype C is evident in southern Brazil, it does not seem to correlate with increased risk of vertical transmission.     

Acceptability and utilisation of voluntary HIV testing and nevirapine to reduce mother-to-child transmission of HIV-1 integrated into routine clinical care.

OBJECTIVES: Use of nevirapine for prevention of mother-to-child transmission (PMTCT) of HIV-1 has been routine clinical care at Coronation Women and Children's Hospital since April 2000. We assessed the effect of regular audit and targeted interventions on the utilisation of the PMTCT programme. METHODS: Review of antenatal cards and hospital records of women discharged following delivery, in three time periods between October 2000 and February 2002. Following the initial audit an intervention was implemented to eliminate weaknesses in our PMTCT service. Following the second audit the hospital became a pilot site for the Gauteng PMTCT programme. RESULTS: In the initial audit 53.2% of women (159/299) were tested for HIV and received their results, while 56% (14/25) of identified HIV-infected women, and 16% (4/25) of their infants, received nevirapine. By the third audit 74.3% of women (266/358) received their results, and 86% (43/50) of HIV-positive women and 74% (37/50) of newborns were documented to have received nevirapine. In all three audits over 90% of women initiating antenatal care at the hospital were tested for HIV, while women who initiated care at district community clinics were less likely to receive testing. CONCLUSIONS: Ongoing audit has been important for targeting obstacles to detection of HIV-infected women and documented nevirapine uptake by women and infants. Rates of HIV testing and nevirapine use have increased significantly. Voluntary counselling and testing for HIV and use of nevirapine are acceptable to pregnant women in our setting. Roll-out of the pilot programme to district community clinics is essential for further improvement.     

The prevention of mother-to-child HIV transmission programme and infant feeding practices.

Since the first cases of HIV transmission through breast-feeding were documented, a fierce debate has raged on appropriate guidelines for infant feeding in resource-poor settings. A major problem is determining when it is safe and feasible to formula-feed, as breast-milk protects against other diseases. A cross-sectional survey of 113 women attending the programme for the prevention of mother-to-child transmission in Khayelitsha, Cape Town, was conducted. Over 95% of women on the programme formula-fed their infants and did not breast-feed at all. Seventy per cent of women said that their infant had never had diarrhoea, and only 3% of children had had two episodes of diarrhoea. Focus groups identified the main reasons for not breast-feeding given by women to their families and those around them. Formula feeding is safe and feasible in an urban environment where sufficient potable water is available.     

Prevention of mother-to-child transmission of HIV programme: low vertical transmission in KwaZulu-Natal, South Africa

OBJECTIVE: To describe the operational effectiveness of the prevention of mother-to-child transmission (PMTCT) of HIV programme at McCord Hospital during the period 1 March 2004 - 31 August 2005. DESIGN: Observational cohort study. SETTING: McCord Hospital, Durban, South Africa. SUBJECTS: Antenatal patients attending the PMTCT clinic. MEASUREMENTS AND RESULTS: During the 18 months all 2 624 women (100%) attending the antenatal clinic received HIV counselling, resulting in 91% (2 388) being tested for HIV. The prevalence of HIV in the total cohort was 13% (95% confidence interval (CI) 11.6 - 14.2). Of the HIV-positive mothers 302 (89%) completed their pregnancy at the hospital, and in this group there were 3 intrauterine deaths, 1 miscarriage, 1 maternal death (with the baby in utero) and 297 live births with 1 early neonatal death. Only 11% (36 out of 338) were lost to follow-up. A quarter (668) of the partners of all women attending the antenatal clinic were tested for HIV. Delivery in 70% (209) of live births was by caesarean section. Nevirapine was administered to 98% (290) of live babies and 75% (224) received zidovudine (AZT) as well. The 6-week polymerase chain reaction (PCR) baby test uptake was 81% (239 out of 296 live babies). Of those tested, 2.9% (95% CI 1.3 - 6.2) tested HIV positive. CONCLUSION: Despite challenges faced by PMTCT providers in a resource-constrained setting, this state-aided hospital provides a comprehensive and integrated service and has achieved outcomes that compare favourably with those in the developed world.     

Antiretroviral therapy in a community clinic--early lessons from a pilot project.

OBJECTIVES: To report on operational and clinical problems encountered during the first 6 months of a community-based antiretroviral therapy (ART) programme. METHODS: ART was implemented in a primary care setting utilising an easily replicable service-delivery model based on a medical officer and nurse. Therapeutic counsellors, themselves HIV-infected, provided counselling and adherence support. Drug and monitoring costs were charitably funded and provincial health authorities supplied the medical infrastructure. The HIV Research Unit, University of Cape Town, supplied training and additional clinical support. Local HIV primary care clinics provided patient referrals. Standardised ART regimens were used with strict entry criteria (AIDS or CD4 count < 200 cells/microliter). RESULTS: Demand for the service was high. Referred patients had advanced disease (AIDS 57%, median CD4 count 96/microliter) and high pre-treatment mortality (83/100 person-years). Mycobacterial disease was a major contributor to this mortality (40%). Scheduled clinic visit hours were six times higher during recruitment than maintenance. Attributable costs were: drugs 61%, staff 27%, viral load and CD4 cell counts 10% and safety monitoring 2%. Viral load after 16 weeks of therapy was < 400 copies/ml in the first 16 patients. CONCLUSIONS: ART can be successfully implemented within a primary care setting. Drug purchases and staff salaries drive programme costing. The service model is capable of managing 250-300 patients on chronic ART, but staffing needs to be increased during recruitment. Attention must be given to the diagnosis of tuberculosis during screening and early ART. Incorporating therapeutic counsellors into the programme increased community involvement and utilised a valuable and previously untapped resource.     

Urbanisation and women's health in Khayelitsha. Part II. Health status and use of health services

A study was conducted among women in Khayelitsha to determine the relationship between urbanisation, health status and use of health services; 722 households were visited, and 659 female respondents provided information on acute and chronic illness for the 3,229 individuals who were members of their households. In addition, they provided information concerning their reproductive health, AIDS awareness, knowledge of cervical smears and use and knowledge of health services. Acute illness was reported for 4.3% of the study population, the commonest complaints being diarrhoea, abdominal pain and upper respiratory infections; 4.4% reported chronic illness, the commonest complaints being hypertension and tuberculosis; 16.2% of women reported gynaecological illness; 86% had of heard of AIDS (although their knowledge of transmission and prevention was poor); and 45% had heard of cervical smears. Patterns of illness and knowledge and use of health services vary in the different areas of residence of Khayelitsha. This appears to be related to urbanisation, age, and environmental and socio-economic factors.     

Tracing defaulters in HIV prevention of mother-to-child transmission programmes through community health workers: results from a rural setting in Zimbabwe

Introduction

High retention in care is paramount to reduce vertical human immunodeficiency virus (HIV) infections in prevention of mother-to-child transmission (PMTCT) programmes but remains low in many sub-Saharan African countries. We aimed to assess the effects of community health worker–based defaulter tracing (CHW-DT) on retention in care and mother-to-child HIV transmission, an innovative approach that has not been evaluated to date.

Methods

We analyzed patient records of 1878 HIV-positive pregnant women and their newborns in a rural PMTCT programme in the Tsholotsho district of Zimbabwe between 2010 and 2013 in a retrospective cohort study. Using binomial regression, we compared vertical HIV transmission rates at six weeks post-partum, and retention rates during the perinatal PMTCT period (at delivery, nevirapine [NVP] initiation at three days post-partum, cotrimoxazole (CTX) initiation at six weeks post-partum, and HIV testing at six weeks post-partum) before and after the introduction of CHW-DT in the project.

Results

Median maternal age was 27 years (inter-quartile range [IQR] 23 to 32) and median CD4 count was 394 cells/µL³ (IQR 257 to 563). The covariate-adjusted rate ratio (aRR) for perinatal HIV transmission was 0.72 (95% confidence intervals [95% CI] 0.27 to 1.96, p=0.504), comparing patient outcomes after and before the intervention. Among fully retained patients, 11 (1.9%) newborns tested HIV positive. ARRs for retention in care were 1.01 (95% CI 0.96 to 1.06, p=0.730) at delivery; 1.35 (95% CI 1.28 to 1.42, p<0.001) at NVP initiation; 1.78 (95% CI 1.58 to 2.01, p<0.001) at CTX initiation; and 2.54 (95% CI 2.20 to 2.93, p<0.001) at infant HIV testing. Cumulative retention after and before the intervention was 496 (85.7%) and 1083 (87.3%) until delivery; 480 (82.9%) and 1005 (81.0%) until NVP initiation; 303 (52.3%) and 517 (41.7%) until CTX initiation; 272 (47.0%) and 427 (34.4%) until infant HIV testing; and 172 (29.7%) and 405 (32.6%) until HIV test result collection.

Conclusions

The CHW-DT intervention did not reduce perinatal HIV transmission significantly. Retention improved moderately during the post-natal period, but cumulative retention decreased rapidly even after the intervention. We showed that transmission in resource-limited settings can be as low as in resource-rich countries if patients are fully retained in care. This requires structural changes to the regular PMTCT services, in which community health workers can, at best, play a complementary role.     

Survey of the health and nutrition status of a squatter community in Khayelitsha

The findings of a nutrition and health survey in Site B, a squatter area in Khayelitsha close to Cape Town, are reported. Of the children under 6 years, 16.8% were found to be under weight for age, 23.5% were stunted and 2.5% wasted, indicating a serious nutritional crisis in this community. Children with a low-birth-weight had a 3 times greater risk of being under weight for age and a 2 times greater risk of being stunted than children with birth-weights greater than 2,500 g. Of the children born outside Cape Town, 21.9% were under weight for age compared with 13.5% of children born in Cape Town. Of the pre-school children, 4.2% had completed or were on antituberculosis treatment compared with 2% of the children in the age group 6-18 years and 3.2% of adults. Sixty per cent of the pre-school children with tuberculosis were under weight for age. Half the adult population was fully employed, and 22% of households had no wage earners. Assuming literacy after 4 years of schooling, 76% of the adults were literate, but only 2.5% had completed Standard 10. Women were generally better qualified than men.     

Effect of a mother-to-child HIV prevention programme on infant feeding and caring practices in South Africa.

OBJECTIVES: To conduct a rapid assessment of the impact of the Khayelitsha Prevention of Mother-to-Child Transmission (MTCT) programme on infant care practices among programme participants and the local population. STUDY DESIGN: Cross-sectional survey and qualitative in-depth interviews. SETTING. Khayelitsha, a large formal and informal settlement of about 300,000 people on the outskirts of Cape Town. At the time of the study the HIV seroprevalence rate among antenatal women was about 15% and the MTCT programme had enrolled nearly 800 infected women. SUBJECTS: Seventy randomly selected caregivers with young children in the survey; in-depth structured interviews with 11 nutrition counsellors and 11 mothers enrolled in the programme. RESULTS: Caregivers have good knowledge of the spread and prevention of HIV. A majority knew that breast-feeding can transmit HIV but 90% stated that this did not affect their feeding decisions. Over 80% had stopped exclusively breast-feeding by the time their infants were 3 months of age. All of the respondents felt that being diagnosed HIV-positive would result in serious social and domestic consequences. None of the health workers could correctly estimate the risk of spreading HIV through breast-feeding and many reported feeling confused about what they should counsel mothers. All the mothers on the programme reported exclusive formula-feeding. Some had serious problems with preparation and feeding of formula milk. Nearly all reported running out of feeds before being able to fetch new supplies. None reported any negative social effects of not breast-feeding. Most of the mothers endorsed the programme and felt that it had given them strength to face up to and plan for the consequences of their diagnosis. CONCLUSION: This rapid appraisal of the infant feeding and care component of the MTCT programme has raised a number of important challenges which health managers and policymakers need to address. Similar assessments in the new pilot sites will be important.     

Perinatal health in the peri-urban township of Khayelitsha, Cape Town. Part II. Infant mortality

Estimates of infant mortality suggest that the rate during the past 14 years for families living in Khayelitsha at present was approximately 130-160/1,000. In contrast, the infant mortality rate for infants born in Khayelitsha during 1986 was 50.3/1,000. The highest rates occurred in the post-neonatal period in 'squatter' families, infection being a common cause of death. Mortality rates should fall further with improved housing.     

Evaluation of training programme uptake in an attempt to reduce obstetric anal sphincter injuries: the SUPPORT programme

Introduction and hypothesis

The objective was to assess the feedback from a quality improvement training programme to reduce obstetric anal sphincter injuries (OASIS).

Methods

Training sessions were organised that included evidence-based information on OASIS risk factors and training on models to measure perineal body length (PBL), perform episiotomies with standard and 60° fixed angle scissors (EPISCISSORS-60®), and measure post-delivery episiotomy suture angles with protractor transparencies. Feedback forms using a Likert scale (1–4) were completed and analysed. The setting was an evidence-based quality improvement programme (Strategy for Using Practical aids for Prevention of OASIS, Recording episiotomies and clinician Training [SUPPORT]) at two National Health Service (NHS) Hospitals in the UK. The participants were midwives and doctors attending the SUPPORT training programme

Results

All of the participants (100 %) would recommend the training programme to a friend or colleague. 92 % felt that the training session improved their knowledge of the impact of PBL and perineal distension and their knowledge of the relationship between episiotomy angle and OASIS “a lot” or “somewhat”.

Conclusion

Based on this feedback, we recommend the addition of the knowledge content of the SUPPORT programme to other centres providing perineal assessment and repair courses.

     

Mortality in a cohort of children born to HIV-1 infected women from Durban, South Africa.

OBJECTIVES: To describe mortality in a cohort of infants with vertically transmitted HIV-1 infection. PATIENTS AND METHODS: Children of HIV-1 infected women were followed up from birth and a record was made at each visit of growth, development and all illnesses. Details surrounding death were obtained from hospital records. RESULTS: The final cohort comprised 48 infected and 93 uninfected children; there were 25 deaths, 17 of which (35%) were regarded as being HIV-related. The mean age at death of HIV-related cases was 10.1 months (range 1-48 months), with 83% of HIV-related deaths occurring before the age of 10 months. The commonest diagnoses at the time of death were diarrhoea, pneumonia, failure to thrive and severe thrush. These findings, together with neurological abnormalities, often presaged rapid deterioration and death. CONCLUSIONS: Mortality among children with vertically acquired HIV infection is high in the first year of life. Death in these subjects was due to the common causes of morbidity and mortality among all children in developing countries. A combination of diarrhoea, pneumonia, failure to thrive, and neurological abnormalities should alert one to the possibility of rapidly progressive disease and death.     

Prevention of severe contractures might replace multilevel surgery in cerebral palsy: results of a population-based health care programme and new techniques to reduce spasticity

During the 1990s three new techniques to reduce spasticity and dystonia in children with cerebral palsy (CP) were introduced in southern Sweden: selective dorsal rhizotomy, continuous intrathecal baclofen infusion and botulinum toxin treatment. In 1994 a CP register and a health care programme, aimed to prevent hip dislocation and severe contractures, were initiated in the area. The total population of children with CP born 1990-1991, 1992-1993 and 1994-1995 was evaluated and compared at 8 years of age. In non-ambulant children the passive range of motion in hip, knee and ankle improved significantly from the first to the later age groups. Ambulant children had similar range of motion in the three age groups, with almost no severe contractures. The proportion of children treated with orthopaedic surgery for contracture or skeletal torsion deformity decreased from 40 to 15% (P = 0.0019). One-fifth of the children with spastic diplegia had been treated with selective dorsal rhizotomy. One-third of the children born 1994-1995 had been treated with botulinum toxin before 8 years of age. With early treatment of spasticity, early non-operative treatment of contracture and prevention of hip dislocation, the need for orthopaedic surgery for contracture or torsion deformity is reduced, and the need for multilevel procedures seems to be eliminated.     

Human immunodeficiency virus transmission in health care settings. Risks to health care workers.

Taken together, studies of seroconversion, exposure incidents, and compliance with Universal Precautions Policy help researchers understand the risks to health care workers of occupationally acquired HIV infection. The seroconversion studies show that the risk of infection is low (1 in 250) even when the incident is a percutaneous exposure to blood from a known HIV-positive patient. When the exposure is to blood from a patient whose HIV-status is unknown, or if the exposure is not through the skin, or if the exposure is to a body substance other than blood, the risk is considerably lower. The studies of exposure incidents show that for most health care workers, percutaneous exposures to blood are infrequent. Studies of compliance with Universal Precautions Policy show that exposure incidents that do occur can be prevented nearly half the time. The risk of patient-to-provider transmission of HIV is small but not completely negligible. This small risk can be made even smaller by adhering to recommended infection control guidelines, but it cannot be eliminated completely. Although most health care workers enter the medical field accepting that their work may expose them to infectious agents, there is still a desire for risk-free practice. Achieving an entirely risk-free practice is probably impossible; it is certainly not within reach today. For the foreseeable future, the only reasonable course is to fully understand the risks, to enter into practice psychologically prepared to accept these risks, and to practice in a way that minimizes exposures without compromising patient care.     

Perinatal health in the peri-urban township of Khayelitsha, Cape Town. Part I. Mothers and their newborn infants

The satellite 'city' of Khayelitsha lies some 40 km south-east of the centre of metropolitan Cape Town. The first phase of the development, Town 1, including a large 'squatter' area, accommodates approximately 150,000 people at present. It is envisaged that ultimately the entire 3,200 ha site will house between 250,000 and 350,000 people. In order to obtain useful planning information for future community obstetric and neonatal health care services, a survey of all births within the Peninsula Maternal and Neonatal Service (PMNS) during 1986 was undertaken. Of a total of 2,113 mothers from Khayelitsha, 2,000 (94.7%) gave birth to a live singleton infant. The mean maternal age was 26.2 years, 15.1% of mothers being under 20 years of age. The mean parity was 3.03, and 18.3% of mothers were having their first baby. Only 3.1% of mothers booked early (in the first trimester); however, 91.9% were booked before delivery. The average number of prenatal visits was 3. The largest proportion of mothers (43.1%) delivered at the Heideveld midwife obstetric unit (MOU). There was an overall pre-term rate of 7.6%, while 8.8% of infants were of low birth weight (LBW) (less than 2,500 g). In addition, 51.4% of the LBW infants were born at term. The mean birth weight was 3,160 g. The largest proportion of mothers (53.6%) were residents of the 'squatter' area. No statistically significant differences in obstetric features, maternal characteristics and pregnancy outcome were discernible between the squatter, site-and-service, and core housing areas of Khayelitsha, with the exception of higher maternal weight, earlier booking and more antenatal visits in the group from the core housing area.