Towards universal access to HIV prevention, treatment, care, and support: the role of tuberculosis/HIV collaboration

Tuberculosis is the oldest of the world's current pandemics and causes 8.9 million new cases and 1.7 million deaths annually. The disease is among the most common causes of morbidity and mortality in people living with HIV. However, tuberculosis is more than just part of the global HIV problem; well-resourced tuberculosis programmes are an important part of the solution to scaling-up towards universal access to comprehensive HIV prevention, diagnosis, care, and support. This article reviews the impact of the interactions between tuberculosis and HIV in resource-limited settings; outlines the recommended programmatic and clinical responses to the dual epidemics, highlighting the role of tuberculosis/HIV collaboration in increasing access to prevention, diagnostic, and treatment services; and reviews progress in the global response to the epidemic of HIV-related tuberculosis.     

HIV-related Stigma as a Barrier to Achievement of Global PMTCT and Maternal Health Goals: A Review of the Evidence

The global community has set goals of virtual elimination of new child HIV infections and 50 percent reduction in HIV-related maternal mortality by the year 2015. Although much progress has been made in expanding prevention of mother-to-child transmission (PMTCT) services, there are serious challenges to these global goals, given low rates of utilization of PMTCT services in many settings. We reviewed the literature from low-income settings to examine how HIV-related stigma affects utilization of the series of steps that women must complete for successful PMTCT. We found that stigma negatively impacts service uptake and adherence at each step of this “PMTCT cascade”. Modeling exercises indicate that these effects are cumulative and therefore significantly affect rates of infant HIV infection. Alongside making clinical services more available, effective, and accessible for pregnant women, there is also a need to integrate stigma-reduction components into PMTCT, maternal, neonatal, and child health services.     

Continuum of care for maternal, newborn, and child health: from slogan to service delivery

The continuum of care has become a rallying call to reduce the yearly toll of half a million maternal deaths, 4 million neonatal deaths, and 6 million child deaths. The continuum for maternal, newborn, and child health usually refers to continuity of individual care. Continuity of care is necessary throughout the lifecycle (adolescence, pregnancy, childbirth, the postnatal period, and childhood) and also between places of caregiving (including households and communities, outpatient and outreach services, and clinical-care settings). We define a population-level or public-health framework based on integrated service delivery throughout the lifecycle, and propose eight packages to promote health for mothers, babies, and children. These packages can be used to deliver more than 190 separate interventions, which would be difficult to scale up one by one. The packages encompass three which are delivered through clinical care (reproductive health, obstetric care, and care of sick newborn babies and children); four through outpatient and outreach services (reproductive health, antenatal care, postnatal care and child health services); and one through integrated family and community care throughout the lifecycle. Mothers and babies are at high risk in the first days after birth, and the lack of a defined postnatal care package is an important gap, which also contributes to discontinuity between maternal and child health programmes. Similarly, because the family and community package tends not to be regarded as part of the health system, few countries have made systematic efforts to scale it up or integrate it with other levels of care. Building the continuum of care for maternal, newborn, and child health with these packages will need effectiveness trials in various settings; policy support for integration; investment to strengthen health systems; and results-based operational management, especially at district level.     

Perinatal tuberculosis and HIV-1: considerations for resource-limited settings

Tuberculosis is the commonest HIV-1-related disease and the most frequent cause of mortality in young women in endemic regions. Tuberculosis and HIV-1 are independent risk factors for maternal mortality and adverse perinatal outcomes, and in combination have a greater impact on these parameters than their individual effects. In referral health centres in southern Africa around one-sixth of all maternal deaths are due to tuberculosis/HIV-1 coinfection. One-third (37%) of HIV-1-infected mothers with tuberculosis are severely immunocompromised, with CD4 counts of fewer than 200 cells/microL compared with 14-19% in mothers recruited into major mother-to-child intervention trials in Europe. Babies born to mothers with tuberculosis/HIV-1 also have higher rates of prematurity, low birthweight, and intrauterine growth restriction. Transmission rates of HIV-1 from mother to infant are around 25-45% in resource-limited settings, while that for mother-to-child-transmission of tuberculosis is 15% within 3 weeks of birth. We highlight this emergent problem, and discuss the dilemmas associated with diagnosis and management of pregnant HIV-1-infected mothers with tuberculosis, and their newborn babies.     

深圳市宝安区预防与控制HIV/AIDS母婴传播的研究

目的　了解深圳市孕产妇艾滋病病毒 (HIV)感染情况 ,探索阻断艾滋病 (AIDS)母婴传播的方法。方法　采取政府行为 ,建立监测网络 ,对全部首次做孕期检查的孕产妇免费进行HIV检测及规范化的干预措施。结果　 2 0 0 2年、2 0 0 3年的监测率分别为 95 .0 9%、95 .12 % ;孕产妇HIV感染率分别为 0 .0 0 2 %、0 .0 0 9%。通过健康教育干预 ,孕产妇AIDS预防知识知晓率从项目实施前的 2 8.5 %～ 5 8.6 %上升到实施后的 85 .6 %～ 10 0 .0 % (P <0 .0 0 1% )。结论　深圳市孕产妇的HIV感染率远低于云南等省 ,但有逐年升高的趋势 ;建立监测网络 ,免费对首次孕期检查的孕产妇做HIV检测并实施预防性干预 ,以阻断HIV垂直传播的方法是成功可行的。     

感染HIV的孕产妇预防艾滋病母婴传播服务利用及影响因素分析

目的了解感染艾滋病病毒（HIV）的孕产妇对预防艾滋病母婴传播（PMTCT）服务的利用状况，分析影响因素。方法在河南、广西、新疆、云南省（自治区）的15个县／市／区，对2004年1月至2006年6月检测发现的感染HIV的孕产妇346人，通过问卷调查方式，结合相关医疗记录在孕期、产时和产后分阶段完成调查。调查内容包括人口学特征、相关行为、感染途径、PMTCT服务的利用情况等。结果346名感染HIV的孕产妇中94.80％接受过产前检查，95．95％住院分娩，其希望住院分娩的原因是医院医疗技术水平高（58．28％），服务质量好（47．27％），收费低（33．33％），能够提供PMTCT服务（33．03％），保密性好（26．97％），交通方便（23.33％）等。87．57％的母婴应用抗艾滋病病毒药物，规范应用抗病毒药物者占46.82％。感染HIV的孕产妇所娩婴儿中，89．02％采取人工喂养方式，满18月龄时进行HIV检测者占93.75％。检测后咨询包含PMTCT内容、民族和文化程度对规范应用抗病毒药物有影响作用（P〈0.05）。结论感染HIV的孕产妇对PMTCT服务的需求特殊，PMTCT服务利用尚不足，检测后咨询及咨询内容影响抗病毒药物的规范应用。建议加强HIV／ADIS高发地区基础妇幼保健服务，提高妊娠妇女早期和孕中期HIV抗体检测水平，重视感染HIV孕产妇抗病毒药物的规范应用和安全助产，为感染HIV的孕产妇及所娩婴儿提供个性化的、综合的PMTCT服务。     

Effectiveness of HIV counseling services on knowledge, attitude, behavior and practice (KABP) among pregnant women attending PPTCT program

Counseling services is an important component of National AIDS Control Program which aims at creating awareness and promoting changes in reducing high risk behavior against HIV/AIDS. Pregnant women attending antenatal clinics are being counseled about HIV/AIDS under prevention of parent to child transmission (PPTCT) program. The objective of this study was to assess (KABP) regarding HIV/AIDS among pregnant women attending PPTCT program before and after counseling at Lok Nayak Hospital, New Delhi. A Quasi-experimental study was conducted. Data was collected by interviewing 600 pregnant women attending ANC clinic during May 2006 to May 2007 using a pre-test and post-test interview schedule. About 69.2% of the pregnant women had heard about AIDS before the counseling. Knowledge regarding mother to child transmission of HIV was 53.5%. 38.2% knew that mother to child transmission can be reduced by drugs. The knowledge of pregnant women about AIDS was significantly different in pre-test (mean score = 15.3) and post test (mean score = 35.6) (P < 0.0001). Attitude of study participants towards people living with HIV/AIDS (PLWHA) indicated that individuals with HIV should be allowed to work (79.9%) and all commercial sex workers should compulsorily be tested for HIV (55.1%). There was significant difference between in pre-test and post-test attitude about PLWHA and HIV testing (p < 0.0001). The condom use among the study participants significantly improved after counseling (1.2% in pre-test and 58.6% after counseling) (p < 0.0001). Counseling services were effective in increasing knowledge and changes in attitude and behavior among pregnant women and the efforts needs to be sustained.     

Every death counts: use of mortality audit data for decision making to save the lives of mothers, babies, and children in South Africa

South Africa is one of the few developing countries with a national confidential inquiry into maternal deaths. 164 health facilities obtain audit data for stillbirths and neonatal deaths, and a new audit network does so for child deaths. Three separate reports have been published, providing valuable information about avoidable causes of death for mothers, babies, and children. These reports make health-system recommendations, many of which overlap and are intertwined with the scarcity of progress in addressing HIV/AIDS. The leaders of these three reports have united to prioritise actions to save the lives of South Africa's mothers, babies, and children. The country is off-track for the health-related Millennium Development Goals. Mortality in children younger than 5 years has increased, whereas maternal and neonatal mortality remain constant. This situation indicates the challenge of strengthening the health system because of high inequity and HIV/AIDS. Coverage of services is fairly high, but addressing the gaps in quality and equity is essential to increasing the number of lives saved. Consistent leadership and accountability to address crosscutting health system and equity issues, and to prevent mother-to-child transmission of HIV, would save tens of thousands of lives every year. Audit is powerful, but only if the data lead to action.     

Tuberculosis deaths in countries with high HIV prevalence: what is their use as an indicator in tuberculosis programme monitoring and epidemiological surveillance?

Although the reduction of tuberculosis deaths is one of the aims of tuberculosis control, it has not always been a priority for National Tuberculosis Programmes (NTPs). The usual explanation is that death as a treatment outcome not associated with ongoing tuberculosis transmission is not relevant to the public health objective of cutting the cycle of disease transmission. However, death as an adverse outcome for tuberculosis patients and their families is an important indicator in NTP monitoring. Global health targets agreed as part of the Millennium Development Goals include the reduction of tuberculosis deaths. Tuberculosis deaths as an indicator of the impact of tuberculosis control measures are therefore important in the epidemiological surveillance of progress towards these targets. These considerations are particularly important in countries with high human immunodeficiency virus (HIV) prevalence where HIV has exacerbated the tuberculosis epidemic and is now the single best predictor of tuberculosis incidence. Tuberculosis deaths are also closely linked to HIV prevalence. Routine NTP data on tuberculosis cohort deaths are important in programme monitoring, and improvements in recording and reporting of deaths would help to overcome limitations in their accuracy. As routine NTP data on tuberculosis cohort deaths are insufficient as an indicator in epidemiological surveillance regarding the impact of NTPs on tuberculosis mortality, measuring progress towards targets for reduced tuberculosis deaths depends on improved national vital registration systems for a more accurate determination of tuberculosis mortality.     

Mother-to-child transmission of HIV infection and its prevention

An estimated 800,000 children acquired HIV-infection in 2002, most as a result of mother-to-child transmission (MTCT), and vertically-acquired HIV infection continues to be of major public health importance. Prevention of MTCT is possible with a combination of interventions including antiretroviral therapy (ART) (usually in highly active combinations), elective caesarean section and avoidance of breastfeeding, and where infected women are identified before or in pregnancy and have access to these interventions, risk of MTCT is now below 1-2%. However, prompt identification of pregnant women with HIV infection remains pressing in many developed countries; additionally, concerns have arisen regarding adherence to complex treatment regimens in pregnancy and the potential impact of HIV drug resistance. More disturbingly, most HIV-infected women live in developing countries where many pregnant women even when tested do not return for their HIV results for a variety of reasons including stigma, and where most, if not all, strategies for prevention of MTCT have been of limited accessibility and/or feasibility. However, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and other initiatives including pharmaceutical companies' donation programmes and generic antiretroviral drug production have made prevention of MTCT in resource-poor settings an increasingly realistic goal, coupled with new evidence from clinical trials on the efficacy of abbreviated regimens of antiretroviral prophylaxis, including combination therapy, to prevent MTCT. Research is additionally focussing on reducing the risk of postnatal transmission through breastfeeding, with exclusive breastfeeding, early cessation and antiretroviral prophylaxis to breastfeeding women or breastfed infants under investigation. However, the key to prevention of paediatric HIV infections is adequate prevention of infection in women of reproductive age.     

The cost-effectiveness of elective Cesarean delivery for HIV-infected women with detectable HIV RNA during pregnancy

OBJECTIVES: To determine the net health consequences, costs, and cost-effectiveness of alternative delivery strategies for HIV-infected pregnant women with detectable HIV RNA in the USA. DESIGN: Cost-effectiveness analysis using a probabilistic decision model. METHODS: The model compared two strategies: elective Cesarean section and vaginal delivery. Data for HIV transmission rate, maternal death rate, health-related quality of life and costs were obtained from the literature, national databases, and a tertiary hospital's cost accounting system. Model outcomes included total lifetime costs, quality-adjusted life expectancy, maternal death rate, HIV transmission rate, and incremental cost-effectiveness ratios. RESULTS: Elective Cesarean section resulted in a vertical HIV transmission rate of 34.9 per 1000 births compared with 62.3 per 1000 births for vaginal delivery. Elective Cesarean section was more effective (38.7 quality adjusted life years per mother and child pair) and less costly ($10600 per delivery) than trial of labor (38.2 combined quality adjusted life years at a cost of $14500 per delivery). However, elective Cesarean section increased maternal mortality by 2.4 deaths per 100000 deliveries. The results were consistent over a wide range of the variables, but were sensitive to the risk of HIV transmission with vaginal delivery and the relative risk of HIV transmission with elective Cesarean section. CONCLUSIONS: In pregnant HIV-infected women with detectable HIV RNA, elective Cesarean section would reduce total costs and increase overall quality-adjusted life expectancy for the mother-child pair, albeit at a slight loss of quality adjusted life expectancy to the mother.     

Providers' Awareness of HIV Testing Policies and Perceived Testing Practices

The objective of this study was to examine providers' awareness of state guidelines regarding HIV testing of pregnant women and their perceptions of access to care for HIV-positive pregnant women. State health departments, county health clinics, and other health care practitioners (private physicians, nurse practitioners, and health educators) were surveyed regarding awareness of state policies on HIV testing, particularly of pregnant women, as well as perceptions of current practices in the care of HIV-positive pregnant women. About two thirds of state offices of public health (70%), county public health providers (62.7%), and private providers (66.7%) were able accurately to describe the HIV reporting policy of their state, and providers across settings perceived that only about half of pregnant women were being provided with information regarding the prevention of vertical transmission during pregnancy. A mechanism is needed to routinely update public health departments and providers regarding state HIV reporting policies.     

云南省4个地区780名孕产妇预防HIV/AIDS母婴垂直传播知识态度调查

目的 了解云南省艾滋病病毒(HIV)不同流行地区孕妇时艾滋病(AIDS)的知识、态度及行为，为开展宣传教育、阻断母曼垂直传播自愿咨询、检测提供依据。方法 选择省、地区、县不同地理分布，孕妇HIV感染率高、中、低的4个地区孕产妇为调查对象，用问卷调查表收集关于AIDS，特别是母婴垂直传播有关的知识、态度及行为方面资料。结果 4个地区共调查780名孕产妇，其中641人听说过AIDS，占82．2％，有关三种传播途径的正确回答率为55．0％一83．7％，但73％的孕产妇认为日常生活中共餐、接吻、握手或入厕等会传播，37．2％的人对婚前姓行为的观念表示接受，77．2％一81．8％的孕产妇认为婚检及产前检查中应加入HIV检测，91．4％的孕产妇愿意医生为其提供有关HIV知识宣传；83．6％一84．5％孕产妇愿意接受人工流产术、剖腹产及降低垂直传播的药物治疗。62．1％的孕产妇认识到安全套可预防AIDS传播。结论 孕产妇对AIDS的认识比较低，但愿意积极参与降低HIV垂直传播的工作。应加强预防AIDS宣传教育，特别是尽快在重点地区探索开展降低孕妇HIV垂直传播的工作，以预防AIDS的母婴垂直传播。     

Calls made for improvements in Bangladeshis' physical health

Bangladesh is one of the few countries in the world where women have a shorter life expectancy than men, mainly because women are discriminated against in the provision of food and health care. A report released by the World Bank revealed that less than 40% of the population has access to modern primary health services beyond immunization and family planning; only 25% of pregnant women receive antenatal care; and the country's maternal mortality rate of 4.5 deaths per 1000 is one of the highest in the world. In addition, more than a third of the 3.33 million infants born each year are underweight and 60% of children aged 6-17 months are either stunted or wasted. The report highlighted new threats including accidents, HIV, and tuberculosis. The report recommended systemic changes in the Ministry of Health and Family Welfare to promote accountability to the community, improve productivity of health care staff, encourage decentralization, improve quality of care, and increase the involvement of donors and nongovernmental organizations.     

Preconception health care for HIV-infected women

The advent of potent antiretroviral therapy coupled with the dramatic reduction in mother-to-child transmission seen over the past decade has allowed women with HIV infection to live longer, healthier lives and has affected their fertility desires. As a result, preconception health care for HIV-infected women should be a routine part of primary health care. Such counseling includes health recommendations and counseling for safer sexual practices, contraception, and pregnancy planning, identifies individual risks and corresponding interventions, provides personalized and nonjudgmental education, and provides access to integrated services that address all of a woman's health and psychological needs. The goals are: (1) to improve the health of the woman before conception; (2) to identify risk factors for adverse maternal or fetal outcomes and initiate interventions to optimize outcomes; and (3) to prevent transmission of HIV to infants as well as sexual partners. This article will review the components of preconception health care for HIV-infected women.     

四川省不同地区孕产妇HIV抗体检测情况分析

目的了解四川省孕产妇接受艾滋病病毒（HIV）抗体检测服务的情况,为扩大预防母婴传播覆盖面而制定全省相关政策提供依据。方法2008-2010年,收集四川省所有县（市、区）接受孕产期保健的孕产妇艾滋病检测情况,按不同地区进行分析。结果全省孕产妇HIV抗体检测率、孕产妇孕期HIV抗体检测率、住院分娩产妇HIV抗体检测率逐年提高（P〈0．0001）,不同地区的孕产妇HIV抗体检测率、孕产妇孕期HIV抗体检测率、住院分娩产妇HIV抗体检测率不同（P〈0．0001）。按照全省社会经济发展状况由高到低,将全省分为三类区域,一类地区孕产妇的HIV抗体检测率为97．07％,孕产妇孕期HIV抗体检测率为87．42％,住院分娩产妇HIV抗体检测率为97．13%;二类地区孕产妇的HIV抗体检测率为79．70％,孕产妇孕期HIV抗体检测率为44．62％,住院分娩产妇HIV抗体检测率为80．90％;三类地区孕产妇的住院分娩率为56．08％,孕产妇HIV抗体检测率为54．99％,孕产妇孕期HIV抗体检测率为31．06％,住院分娩产妇HIV抗体检测率为88．02％,非住院分娩产妇HIV抗体检测率仅13．13％。结论不同地区孕产妇HIV抗体检测情况差距明显,应采取区域化的应对措施,进一步扩大预防母婴传播覆盖面。     

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。     

Cascade of access to interventions to prevent HIV mother to child transmission in the metropolitan area of Rio de Janeiro,Brazil

ObjectivesTo describe the access to the interventions for the prevention of Human Immunodeficiency Virus (HIV) mother to child transmission and mother to child transmission rates in the outskirts of Rio de Janeiro, from 1999 to 2009.MethodsThis is a retrospective cohort study. Prevention of HIV mother to child transmission interventions were accessed and mother to child transmission rates were calculated.ResultsThe study population is young (median: 26 years; interquartile range: 22.0–31.0), with low monthly family income (40.4% up to one Brazilian minimum wage) and schooling (62.1% less than 8 years). Only 47.1% (n = 469) knew the HIV status of their partner; of these women, 39.9% had an HIV-seronegative partner. Among the 1259 newborns evaluated, access to the antenatal, intrapartum and postpartum prevention of HIV mother to child transmission components occurred in 59.2%, 74.2%, and 97.5% respectively; 91.0% of the newborns were not breastfed. Overall 52.7% of the newborns have benefited from all the recommended interventions. In subsequent pregnancies (n = 289), 67.8% of the newborns received the full package of interventions. The overall rate of HIV vertical transmission was 4.7% and the highest annual rate occurred in 2005 (7.4%), with no definite trend in the period.ConclusionsAccess to the full package of interventions for the prevention of HIV vertical transmission was low, with no significant trend of improvement over the years. The vertical transmission rates observed were higher than those found in reference services in the municipality of Rio de Janeiro and in the richest regions of the country.     

HIV/AIDS and maternity care in Kenya: how fears of stigma and discrimination affect uptake and provision of labor and delivery services

Although policies and programs exist to promote safe motherhood in sub-Saharan Africa, maternal health has not improved and may be deteriorating in some countries. Part of the explanation may be the adverse effects of HIV/AIDS on maternity care. We conducted a study in Kisumu, Kenya to explore how fears related to HIV/AIDS affect women's uptake and health workers' provision of labor and delivery services. In-depth qualitative interviews with 17 maternity workers, 14 pregnant or postpartum women, four male partners and two traditional birth attendants; as well as structured observations of 22 births; were conducted at four health facilities. Participants reported that fears of HIV testing; fears of involuntary disclosure of HIV status to others, including spouses; and HIV/AIDS stigma are among the reasons that women avoid delivering in health facilities. Maternity workers now have to take into account the HIV status of the women they serve (as well as their own fears of becoming infected and stigmatized) but do not seem to be adequately prepared to handle issues related to consent, confidentiality and disclosure. Importantly, it appeared that women of unknown HIV status during labor and delivery were likely to be targets of stigma and discriminatory practices and that these women were not receiving needed counseling services. The findings suggest that increasing infection control precautions will not be enough to address the challenges faced by maternity care providers in caring for women in high-HIV-prevalence settings. Maternity workers need enhanced culturally sensitive training regarding consent, confidentiality and disclosure. Furthermore, this study points to the necessity of paying more attention to the care of women of unknown HIV-serostatus during labor and delivery. Such interventions may improve the quality of maternity care, increase utilization and contribute to overall improvements in maternal health, while also enhancing prevention of mother-to-child-transmission and HIV care.