Optimizing paediatric HIV care in Kenya: challenges in early infant diagnosis

PROBLEM: In 2003, the goal of the Kenyan Ministry of Health was to avail antiretroviral treatment (ART) to 50% of the estimated 250 000 eligible individuals by the end of 2005. By July 2005, 45 000 adults and more than 2000 children were on treatment. A study was conducted to determine the barriers to identification of HIV-infected children. APPROACH: Existing government policies were reviewed and the ART register of the Kenya National AIDS Control Programme was used to identify facilities providing ART. This paper reports the findings around diagnosis and staging of HIV infection in children. LOCAL SETTING: At the time of the study, 58 health facilities were providing ART to children. Only one institution had achieved universal HIV testing in the antenatal clinics. Six facilities systematically followed up HIV-exposed children. HIV antibody testing was not readily available to the children. Although four research centres were capable of carrying out diagnostic HIV polymerase chain reaction (PCR), the services were restricted to research purposes. Other constraints were inadequate physical infrastructure, inadequate systems for quality control in the laboratories and shortage of staff. LESSONS LEARNT: The policy framework to support identification of HIV-infected children had been established, albeit with narrow focus on sick children. The assessment identified the weaknesses in the structures for systematic diagnosis of HIV through laboratory or clinical-based algorithms. The researchers concluded that health staff training and implementation of a systematic standard approach to identification of HIV-infected children is urgently required.     

Recently released with HIV/AIDS: primary care treatment needs and experiences

The research objectives of this study are to describe the re-entry experiences of people recently released from jail who were living with HIV/AIDS, and to identify factors that influence their access to primary care and adherence to a treatment regimen. The research used a mixed-method, qualitative and quantitative research design. The findings indicate that the overall instability in the lives of many of the former inmates studied hampered their ability to attend to their HIV/AIDS-related health care needs. Most former inmates returned to the community with co-occurring problems related to housing and substance abuse. Complicating their access to health care were fragmented health care and correctional systems. The study highlights the need for coordination and collaboration between correctional facilities and community-based health care and human service providers that leads to a deliberative and planned transition from jail to service systems in the community.     

HIV infection and fertility preferences in rural Malawi

Although HIV-prevalence and fertility rates in sub-Saharan Africa are among the highest in the world, little is known about how HIV infection affects the fertility preferences of men and women in the region. A quasi-experimental design and in-depth interviews conducted in rural Malawi are employed to examine how and through what pathways learning that one is HIV positive alters a person's childbearing desires. Among rural Malawians, particularly men, the desire to have more children decreases after receiving a positive HIV-test result. The motivations underlying this effect are greatly influenced by gender: women fear the physical health consequences of HIV-positive pregnancies and childbearing, whereas men see childbearing as futile because they anticipate their own early death and the deaths of their future children. Considerable ambivalence remains, nevertheless, particularly among women who strategize to live normal lives in spite of their infection, but whose definitions of "normal" vary.     

HIV and infant feeding in Malawi: public health simplicity in complex social and cultural contexts

ABSTRACT: BACKGROUND: The question of when and how to best wean infants born to mothers with HIV requires complex answers. There are clinical guidelines on best approaches but limitations persist when applying them in diverse low-income settings. In such settings, infant-feeding practices are not only dependent on individual women's choices but are also subject to social and cultural pressures. However, when developing infant-feeding policies little attention has been paid to these pressures, even though they may yield useful empirical knowledge on the various forces that shape the infant-feeding dilemmas confronting women with HIV. This study aimed to a) identify the infant-feeding challenges that women with HIV faced when they were advised to wean their children at an early age of six months and b) explore how the women adhered to their infant-feeding options while facing and managing these challenges. METHODS: This study was conducted between February 2008 and April 2009 at two public health facilities where services to prevent mother-to-child transmission of HIV were implemented. Repeated in-depth interviews were conducted with 20 HIV-positive women. Two of the 20 women were also chosen for case studies which included home visits. RESULTS: Several interdependent factors including the conflicting pressures of sexual morality and the demands of nurturing and motherhood, in conditions of abject poverty, impeded the participating women from following medical advice on infant feeding. If they adhered to the medical advice, the women would encounter difficulty maintaining their ascribed roles as respected wives, mothers and members of the society at large. The necessity of upholding their moral standing through continued breastfeeding, which signified HIV-negative status, put pressure on them to ignore the medical advice. CONCLUSIONS: The infant-feeding dilemmas for women with HIV are complex. The integration of public health efforts with context-specific socio-cultural understanding is essential. The recent 2010 WHO guidelines offer a possible way of resolving these challenges. They recommend breastfeeding for one year with an adaptation to two years for Malawi. Efforts in the PMTCT programmes to supplement existing support systems, e.g. through the mothers-to-mothers (M2M) programme or consultation with expert mothers may also help women overcome these challenges.     

县级区域性艾滋病预防控制的策略与经验

云南省临沧县开展了艾滋病社区健康教育项目和艾滋病预防控制与关怀项目，对县级区域性艾滋病预防控制工作进行总结：1）以充分的组织领导为基础，强化艾滋病预防控制工作，将行政领导措施与具体业务工作有机结合：2）以大众宣教为基础，辅以社区关怀工作；3）营造一个良好的社会环境和氛围，突出“人性”，辅以必要的物质关怀和生活帮助；4）让HIV感染者主动参与艾滋病预防控制工作；5）学校对广大学生与青年开展健康教育。     

Surveillance of AIDS and HIV infection: opportunities and challenges

From 1980 to 1984 Americans with no health insurance increased from 13.9% to 17.1% of the non-elderly population. Non-elderly persons covered by Medicaid declined from 6.2% to 5.6%. Previous studies of the share of the burden of uncompensated care borne by various provider groups present opposing findings. The National Hospital Discharge survey data presented here demonstrate that for-profit hospitals serve significantly lower percentages of uninsured discharges than secular or church-affiliated non-profit hospitals and public hospitals. The same pattern of differentials is observed with respect to Medicaid. On the whole the results of the survey tend to support the argument that private non-profit hospitals do indeed render greater public services in treating indigent patients than do for-profit hospitals. It must also be emphasized, however, that the results show all private hospitals falling somewhat short of the standard set by public hospitals in treating indigents. Thus, the continued shrinkage of the public hospital sector has serious policy implications.     

Representations of primary care professionals about the occupational risk of HIV infection

This was a qualitative study, based on the Social Representations Theory, with professionals that work in primary care, about the risk of HIV infection to which they are exposed in their quotidian work routine. Twelve physicians and nurses who work in two Health Centers in the city of Belo Horizonte, MG, Brazil, were interviewed. The final analysis, carried out using the saturation of information criterion, was based on the method proposed by Structural Analysis of Narrative. The results show that the health professionals interviewed knew the infection risk in their work routine, representing it as very low in primary care, because they relate it to technological complexity which they consider does not exist in the level of assistance in which they work. They believed that the use of personal protection equipment may minimize the risks and that, nowadays, no primary care professional refuses to attend a patient due to fear of infection, even if not using all the recommended precautions.     

Methods of surveillance for HIV infection in primary care outpatients in the United States

Primary care outpatients provide a good sentinel population for monitoring levels and trends of HIV infection in the United States. Because a broad cross section of the population seeks primary medical care, excess blood from specimens routinely collected for other purposes is available for anonymous, unlinked HIV testing, and all age groups and both sexes can be sampled. The CDC family of surveys includes two surveys of primary care outpatients: (a) a survey of 100,000 blood specimens per year submitted by more than 6,000 primary care physicians to a national diagnostic laboratory for complete blood count or hematocrit and (b) a survey of approximately 10,000 blood specimens per year from a network of 242 primary care physicians. Each survey has different advantages: the laboratory-based survey has a large sample from a large population base, and the physician network survey has a well-defined patient population in which each patient's clinical condition can be determined. In the primary care physician network, a concurrent study of clinical patterns of disease in patients with recognized HIV infection provides additional information on the clinical syndromes associated with HIV infection and estimates of the occurrence of unrecognized HIV infection.     

2015－2017年中国HIV暴露儿童艾滋病感染早期诊断检测情况分析

目的 分析我国HIV暴露儿童接受儿童艾滋病感染早期诊断（early infant diagnosis,EID）检测服务情况并探讨其相关影响因素。方法 利用全国预防艾滋病母婴传播管理信息系统,收集HIV感染孕产妇分娩儿童随访卡,回顾性分析我国2015－2017年随访满18月龄的12 096例HIV暴露儿童队列数据。描述HIV暴露儿童EID检测特征,分析EID检测相关影响因素。结果 2015－2017年我国HIV暴露儿童EID检测率自65.6%增加至83.4%（趋势性χ²检验P<0.001）,出生后8周内EID检测比例自61.1%增加至76.8%（趋势性χ²检验P<0.001）,EID检测阳性率自8.7%降低至3.4%（趋势性χ²检验P<0.001）。2015－2017年死亡儿童EID检测阳性率分别为47.7%、36.9%和36.3%,差异无统计学意义。多因素分析发现HIV暴露儿童民族、地区、满18月龄和存活情况与接受EID检测之间存在关联,差异有统计学意义（P<0.001）。结论 我国EID检测工作逐步规范落实,EID检测阳性率逐年降低,但18月龄内死亡儿童,少数民族和HIV低发区儿童的EID检测比例较低。     

HIV and infant feeding counselling: challenges faced by nurse-counsellors in northern Tanzania

Background  

Infant feeding is a subject of worry in prevention of mother to child transmission (pMTCT) programmes in settings where breastfeeding is normative. Nurse-counsellors, expected to counsel HIV-positive women on safer infant feeding methods as defined in national/international guidelines, are faced with a number of challenges. This study aims to explore the experiences and situated concerns of nurses working as infant feeding counsellors to HIV-positive mothers enrolled in pMTCT programmes in the Kilimanjaro region, northern Tanzania.     

Marriage as a risk factor for HIV: Learning from the experiences of HIV-infected women in Malawi

Abstract

The gender inequalities that characterise intimate partner relationships in Malawi, a country with one of the highest HIV prevalence rates in the world, arguably place marriage as an important risk factor for HIV infection among women, yet few studies detail the complex interactions of marriage and risk. In order to develop HIV-prevention interventions that have lasting impacts in such communities, we need a deeper understanding of the intricacies of women's lives, how and why they are involved in marital relationships, and the implications of these relationships for HIV transmission or prevention. This article describes how women understand marriage's effects on their lives and their HIV risks. Drawing from focus group discussions with 72 women attending antiretroviral clinics in Malawi, we explore why women enter marriage, what women's experiences are within marriage and how they leave spouses for other relationships. Based on their narratives, we describe women's lives after separation, abandonment or widowhood, and report their reflections on marriage after being married two or three times. We then review women's narratives in light of published work on HIV, and provide recommendations that would minimise the risks of HIV attendant on marriage.