Eliminating paediatric infections and keeping mothers alive

The global plan of reducing the number of new child HIV infections and a reduction in the number of HIV‐related maternal deaths by 2015 will require inordinate political commitment and strengthening of health systems in Sub‐Saharan Africa where the burden of HIV infections in pregnant women is the highest. Preventing HIV infection in women of child‐bearing age and unwanted pregnancies in HIV‐positive women forms the cornerstone of long‐term control of paediatric HIV infections. To achieve the goal of eliminating paediatric HIV infection by 2015, health systems strengthening to address prevention of mother‐to‐child HIV transmission cascade attrition and focusing on the elimination of breastmilk transmission is critical. Understanding the pathogenesis of breastmilk transmission and the mechanisms by which antiretroviral therapy impacts on transmission through this compartment will drive future interventions. Identifying and retaining HIV‐positive pregnant women in care and committed to long‐term antiretroviral therapy will improve maternal outcomes and concomitant reductions in maternal mortality. Research assessing the natural history of HIV infection and long‐term outcomes in women who interrupt antiretroviral therapy post‐weaning is urgently required. Data on the outcome of women who opt to continue the long‐term use of antiretroviral therapy after initiating therapy during pregnancy will determine future policy in countries considering option B+. The prevalence of antiretroviral resistance and impact on survival in infants who sero‐convert whilst receiving neonatal prophylaxis, or are exposed to maternal HAART through breastmilk at a population level, are currently unknown. In addition to the provision of biomedical interventions, healthcare workers and policy makers must address the structural, cultural and community issues that impact on treatment uptake, adherence to medication and retention in care.     

HIV transmission and retention in care among HIV‐exposed children enrolled in Malawi's prevention of mother‐to‐child transmission programme

Introduction : In Malawi, HIV‐infected pregnant and breastfeeding women are offered lifelong antiretroviral therapy (ART) regardless of CD4 count or clinical stage (Option B+). Their HIV‐exposed children are enrolled in the national prevention of mother‐to‐child transmission (PMTCT) programme, but many are lost to follow‐up. We estimated the cumulative incidence of vertical HIV transmission, taking loss to follow‐up into account. Methods : We abstracted data from HIV‐exposed children enrolled into care between September 2011 and June 2014 from patient records at 21 health facilities in central and southern Malawi. We used competing risk models to estimate the probability of loss to follow‐up, death, ART initiation and discharge, and used pooled logistic regression and inverse probability of censoring weighting to estimate the vertical HIV transmission risk. Results : A total of 11,285 children were included; 9285 (82%) were born to women who initiated ART during pregnancy. At age 30 months, an estimated 57.9% (95% CI 56.6–59.2) of children were lost to follow‐up, 0.8% (0.6–1.0) had died, 2.6% (2.3–3.0) initiated ART, 36.5% (35.2–37.9) were discharged HIV‐negative and 2.2% (1.5–2.8) continued follow‐up. We estimated that 5.3% (95% CI 4.7–5.9) of the children who enrolled were HIV‐infected by the age of 30 months, but only about half of these children (2.6%; 95% CI 2.3–2.9) were diagnosed. Conclusions : Confirmed mother‐to‐child transmission rates were low, but due to poor retention only about half of HIV‐infected children were diagnosed. Tracing of children lost to follow‐up and HIV testing in outpatient clinics should be scaled up to ensure that all HIV‐positive children have access to early ART.     

Pregnant adolescents living with HIV: what we know,what we need to know,where we need to go

Introduction : HIV‐infected pregnant and breastfeeding adolescents are a particularly vulnerable group that require special attention and enhanced support to achieve optimal maternal and infant outcomes. The objective of this paper is to review published evidence about antenatal care (ANC) service delivery and outcomes for HIV‐infected pregnant adolescents in low‐income country settings, identify gaps in knowledge and programme services and highlight the way forward to improve clinical outcomes of this vulnerable group. Discussion : Emerging data from programmes in sub‐Saharan Africa highlight that HIV‐infected pregnant adolescents have poorer prevention of mother‐to‐child HIV transmission (PMTCT) service outcomes, including lower PMTCT service uptake, compared to HIV‐infected pregnant adults. In addition, the limited evidence available suggests that there may be higher rates of mother‐to‐child HIV transmission among infants of HIV‐infected pregnant adolescents. Conclusions : While the reasons for the inferior outcomes among adolescents in ANC need to be further explored and addressed, there is sufficient evidence that immediate operational changes are needed to address the unique needs of this population. Such changes could include integration of adolescent‐friendly services into PMTCT settings or targeting HIV‐infected pregnant adolescents with enhanced retention and follow‐up activities.     

The next generation of the World Health Organization's global antiretroviral guidance

The 2013 World Health Organization’s (WHO) Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection provide more than 50 new recommendations across the continuum of HIV care, including recommendations on HIV testing, using antiretroviral drugs for prevention, linking individuals to HIV care and treatment services, initiating and maintaining antiretroviral therapy (ART) and monitoring treatment. Guidance is provided across all age groups and populations of adults, pregnant and breastfeeding women, adolescents and key populations. The guidelines are based on a public health approach to expanding the use of ARV drugs for HIV treatment and prevention, with a particular focus on resource‐limited settings. The most important new clinical recommendations include: treating adults, adolescents and older children earlier – starting ART in all individuals with a CD4 cell count of 500 cells/mm³ or less (but giving priority to those with advanced clinical disease or a CD4 cell count less than 350 cells/mm³); starting ART at any CD4 cell count in certain populations, including those with active TB (existing recommendation), Hepatitis B infection and severe chronic liver disease, HIV‐positive partners in serodiscordant couples (existing recommendation), pregnant and breastfeeding women, and children younger than 5 years of age; a preferred first‐line ART regimen of Tenofovir+3TC or FTC+ Efavirenz as a once‐daily fixed‐dose combination for adults, pregnant women, and children aged 3 years and older; and the use of viral load testing as the preferred approach to monitoring the response to ART and to diagnose treatment failure. Guidance is also provided on enhancing the efficiency and effectiveness of HIV services, including strategies to improve retention in care, and adherence to ART; task‐shifting to address human resource gaps; decentralizing delivery of ART to primary health care, and integrating ART services within maternal and child health, TB or drug dependency clinics. There is additional guidance for programme managers on how to plan HIV programmes and use resources most efficiently.     

Combination HIV prevention during pregnancy and the post-partum period in Malawi and Zambia: a mathematical modelling analysis

Introduction

Despite widespread success in reducing vertical HIV transmission, most antenatal care (ANC) programmes in eastern and southern Africa have not emphasized primary prevention of maternal HIV acquisition during pregnancy and lactation/breastfeeding. We hypothesized that combination HIV prevention interventions initiated alongside ANC could substantially reduce maternal HIV incidence.

Methods

We constructed a multi-state model describing male-to-female HIV transmission in steady heterosexual partnerships during pregnancy and lactation/breastfeeding, with initial conditions based on population distribution estimates for Malawi and Zambia in 2020. We modelled individual and joint increases in three HIV prevention strategies at or soon after ANC initiation: (1) HIV testing of male partners, resulting in HIV diagnosis and less condomless sex among those with previously undiagnosed HIV; (2) initiation (or re-initiation) of suppressive antiretroviral therapy (ART) for male partners with diagnosed but unsuppressed HIV; and (3) adherent pre-exposure prophylaxis (PrEP) for HIV-negative female ANC patients with HIV-diagnosed or unknown-status male partners. We estimated the percentage of within-couple, male-to-female HIV transmissions that could be averted during pregnancy and lactation/breastfeeding with these strategies, relative to base-case conditions in which 45% of undiagnosed male partners become newly HIV diagnosed via testing, 75% of male partners with diagnosed but unsuppressed HIV initiate/re-initiate ART and 0% of female ANC patients start PrEP.

Results

Increasing uptake of any single strategy by 20 percentage points above base-case levels averted 10%−11% of maternal HIV acquisitions during pregnancy and lactation/breastfeeding in the model. Joint uptake increases of 20 percentage points in two interventions averted an estimated 19%−23% of transmissions, and with a 20-percentage-point increase in uptake of all three interventions, 29% were averted. Strategies achieving 95% male testing, 90% male ART initiation/re-initiation and 40% female PrEP use reduced incident infections by 45%.

Conclusions

Combination HIV prevention strategies provided alongside ANC and sustained through the post-partum period could substantially reduce maternal HIV incidence during pregnancy and lactation/breastfeeding in eastern and southern Africa.     

Timing of HIV testing among pregnant and breastfeeding women and risk of mother‐to‐child HIV transmission in Malawi: a sampling‐based cohort study

IntroductionPregnant women living with HIV can achieve viral suppression and prevent HIV mother‐to‐child transmission (MTCT) with timely HIV testing and early ART initiation and maintenance. Although it is recommended that pregnant women undergo HIV testing early in antenatal care in Malawi, many women test positive during breastfeeding because they did not have their HIV status ascertained during pregnancy, or they tested negative during pregnancy but seroconverted postpartum. We sought to estimate the association between the timing of last positive HIV test (during pregnancy vs. breastfeeding) and outcomes of maternal viral suppression and MTCT in Malawi’s PMTCT programme.MethodsWe conducted a two‐stage cohort study among mother–infant pairs in 30 randomly selected high‐volume health facilities across five nationally representative districts of Malawi between 1 July 2016 and 30 June 2017. Log‐binomial regression was used to estimate prevalence ratios (PR) and risk ratios (RR) for associations between timing of last positive HIV test (i.e. breastfeeding vs. pregnancy) and maternal viral suppression and MTCT, controlling for confounding using inverse probability weighting.ResultsOf 822 mother–infant pairs who had available information on the timing of the last positive HIV test, 102 mothers (12.4%) had their last positive test during breastfeeding. Women who lived one to two hours (PR = 2.15; 95% CI: 1.29 to 3.58) or >2 hours (PR = 2.36; 95% CI: 1.37 to 4.10) travel time to the nearest health facility were more likely to have had their last positive HIV test during breastfeeding compared to women living <1 hour travel time to the nearest health facility. The risk of unsuppressed VL did not differ between women who had their last positive HIV test during breastfeeding versus pregnancy (adjusted RR [aRR] = 0.87; 95% CI: 0.48 to 1.57). MTCT risk was higher among women who had their last positive HIV test during breastfeeding compared to women who had it during pregnancy (aRR = 6.57; 95% CI: 3.37 to 12.81).ConclusionsMTCT in Malawi occurred disproportionately among women with a last positive HIV test during breastfeeding. Testing delayed until the postpartum period may lead to higher MTCT. To optimize maternal and child health outcomes, PMTCT programmes should focus on early ART initiation and providing targeted testing, prevention, treatment and support to breastfeeding women.     

Antiretroviral postnatal prophylaxis to prevent HIV vertical transmission: present and future strategies

Introduction

Maternal antiretroviral therapy (ART) with viral suppression prior to conception, during pregnancy and throughout the breastfeeding period accompanied by infant postnatal prophylaxis (PNP) forms the foundation of current approaches to preventing vertical HIV transmission. Unfortunately, infants continue to acquire HIV infections, with half of these infections occurring during breastfeeding. A consultative meeting of stakeholders was held to review the current state of PNP globally, including the implementation of WHO PNP guidelines in different settings and identifying the key factors affecting PNP uptake and impact, with an aim to optimize future innovative strategies.

Discussion

WHO PNP guidelines have been widely implemented with adaptations to the programme context. Some programmes with low rates of antenatal care attendance, maternal HIV testing, maternal ART coverage and viral load testing capacity have opted against risk-stratification and provide an enhanced PNP regimen for all infants exposed to HIV, while other programmes provide infant daily nevirapine antiretroviral (ARV) prophylaxis for an extended duration to cover transmission risk throughout the breastfeeding period. A simplified risk stratification approach may be more relevant for high-performing vertical transmission prevention programmes, while a simplified non-risk stratified approach may be more appropriate for sub-optimally performing programmes given implementation challenges. In settings with concentrated epidemics, where the epidemic is often driven by key populations, infants who are found to be exposed to HIV should be considered at high risk for HIV acquisition. All settings could benefit from newer technologies that promote retention during pregnancy and throughout the breastfeeding period. There are several challenges in enhanced and extended PNP implementation, including ARV stockouts, lack of appropriate formulations, lack of guidance on alternative ARV options for prophylaxis, poor adherence, poor documentation, inconsistent infant feeding practices and in inadequate retention throughout the duration of breastfeeding.

Conclusions

Tailoring PNP strategies to a programmatic context may improve access, adherence, retention and HIV-free outcomes of infants exposed to HIV. Newer ARV options and technologies that enable simplification of regimens, non-toxic potent agents and convenient administration, including longer-acting formulations, should be prioritized to optimize the effect of PNP in the prevention of vertical HIV transmission.     

Optimal breastfeeding durations for HIV‐exposed infants: the impact of maternal ART use,infant mortality and replacement feeding risk

Introduction

In 2010, the WHO recommended women living with HIV breastfeed for 12 months while taking antiretroviral therapy (ART) to balance breastfeeding benefits against HIV transmission risks. To inform the 2016 WHO guidelines, we updated prior research on the impact of breastfeeding duration on HIV‐free infant survival (HFS) by incorporating maternal ART duration, infant/child mortality and mother‐to‐child transmission data.

Methods

Using the Cost‐Effectiveness of Preventing AIDS Complications (CEPAC)‐Infant model, we simulated the impact of breastfeeding duration on 24‐month HFS among HIV‐exposed, uninfected infants. We defined “optimal” breastfeeding durations as those maximizing 24‐month HFS. We varied maternal ART duration, mortality rates among breastfed infants/children, and relative risk of mortality associated with replacement feeding (“RRRF”), modelled as a multiplier on all‐cause mortality for replacement‐fed infants/children (range: 1 [no additional risk] to 6). The base‐case simulated RRRF = 3, median infant mortality, and 24‐month maternal ART duration.

Results

In the base‐case, HFS ranged from 83.1% (no breastfeeding) to 90.2% (12‐months breastfeeding). Optimal breastfeeding durations increased with higher RRRF values and longer maternal ART durations, but did not change substantially with variation in infant mortality rates. Optimal breastfeeding durations often exceeded the previous WHO recommendation of 12 months.

Conclusions

In settings with high RRRF and long maternal ART durations, HFS is maximized when mothers breastfeed longer than the previously‐recommended 12 months. In settings with low RRRF or short maternal ART durations, shorter breastfeeding durations optimize HFS. If mothers are supported to use ART for longer periods of time, it is possible to reduce transmission risks and gain the benefits of longer breastfeeding durations.

     

HIV treatment for prevention

“No virus, no transmission.” Studies have repeatedly shown that viral load (the quantity of virus present in blood and sexual secretions) is the strongest predictor of HIV transmission during unprotected sex or transmission from infected mother to child. Effective treatment lowers viral load to undetectable levels. If one could identify and treat all HIV‐infected people immediately after infection, the HIV/AIDS epidemic would eventually disappear. Such a radical solution is currently unrealistic. In reality, not all people get tested, especially when they fear stigma and discrimination. Thus, not all HIV‐infected individuals are known. Of those HIV‐positive individuals for whom the diagnosis is known, not all of them have access to therapy, agree to be treated, or are taking therapy effectively. Some on effective treatment will stop, and in others, the development of resistance will lead to treatment failure. Furthermore, resources are limited: should we provide drugs to asymptomatic HIV‐infected individuals without indication for treatment according to guidelines in order to prevent HIV transmission at the risk of diverting funding from sick patients in urgent need? In fact, the preventive potential of anti‐HIV drugs is unknown. Modellers have tried to fill the gap, but models differ depending on assumptions that are strongly debated. Further, indications for antiretroviral treatments expand; in places like Vancouver and San Francisco, the majority of HIV‐positive individuals are now under treatment, and the incidence of new HIV infections has recently fallen. However, correlation does not necessarily imply causation. Finally, studies in couples where one partner is HIV‐infected also appear to show that treatment reduces the risk of transmission. More definite studies, where a number of communities are randomized to either receive the “test‐and‐treat” approach or continue as before, are now in evaluation by funding agencies. Repeated waves of testing would precisely measure the incidence of HIV infection. Such trials face formidable logistical, practical and ethical obstacles. However, without definitive data, the intuitive appeal of “test‐and‐treat” is unlikely to translate into action on a global scale. In the meantime, based on the available evidence, we must strive to provide treatment to all those in medical need under the current medical guidelines. This will lead to a decrease in HIV transmission while “test‐and‐treat” is fully explored in prospective clinical trials.     

Bidirectional links between HIV and intimate partner violence in pregnancy: implications for prevention of mother-to-child transmission

Introduction

Prevention of mother-to-child transmission (PMTCT) has the potential to eliminate new HIV infections among infants. Yet in many parts of sub-Saharan Africa, PMTCT coverage remains low, leading to unacceptably high rates of morbidity among mothers and new infections among infants. Intimate partner violence (IPV) may be a structural driver of poor PMTCT uptake, but has received little attention in the literature to date.

Methods

We conducted qualitative research in three Johannesburg antenatal clinics to understand the links between IPV and HIV-related health of pregnant women. We held focus group discussions with pregnant women (n=13) alongside qualitative interviews with health care providers (n=10), district health managers (n=10) and pregnant abused women (n=5). Data were analysed in Nvivo10 using a team-based approach to thematic coding.

Findings

We found qualitative evidence of strong bidirectional links between IPV and HIV among pregnant women. HIV diagnosis during pregnancy, and subsequent partner disclosure, were noted as a common trigger of IPV. Disclosure leads to violence because it causes relationship conflict, usually related to perceived infidelity and the notion that women are “bringing” the disease into the relationship. IPV worsened HIV-related health through poor PMTCT adherence, since taking medication or accessing health services might unintentionally alert male partners of the women''s HIV status. IPV also impacted on HIV-related health via mental health, as women described feeling depressed and anxious due to the violence. IPV led to secondary HIV risk as women experienced forced sex, often with little power to negotiate condom use. Pregnant women described staying silent about condom negotiation in order to stay physically safe during pregnancy.

Conclusions

IPV is a crucial issue in the lives of pregnant women and has bidirectional links with HIV-related health. IPV may worsen access to PMTCT and secondary prevention behaviours, thereby posing a risk of secondary transmission. IPV should be urgently addressed in antenatal care settings to improve uptake of PMTCT and ensure that goals of maternal and child health are met in sub-Saharan African settings.     

HIV infection in Africa. Clinical and therapeutical research

A MAJOR HEALTH PROBLEM: Human Immunodeficiency Virus (HIV) infection is a major public health problem in sub-Saharan Africa and the care of HIV-infected patients is limited by the lack of resources. Clinical research can play a major role to assess the benefit of preventive and/or curative measures adapted to the context of these countries. To illustrate advances and gaps in HIV/AIDS clinical research in Africa, we explored three issues relevant to this research: opportunistic infections in adults, mother-to-child transmission of HIV and the ethical questions. EPIDEMIOLOGY: Epidemiological African studies have shown: the omnipresence of tuberculosis, first cause of death among HIV+ patients; the frequency of bacterial infections, first cause of serious morbidity and second cause of death; the high frequency of toxoplasmosis, cryptococcal meningitis, isosporiasis, cryptosporidiasis, and other infectious syndromes of unknown etiology. More research efforts need to be done for improving tuberculosis diagnosis, compliance to treatment (evaluation of Directed Observed Therapy), resistance to treatment and primary chemoprophylaxis which has shown clear short term benefit but median term interest remains to be demonstrated. Chemoprophylaxis of opportunistic infections other than tuberculosis needs also to be evaluated: cotrimoxazole reduces the short term mortality of HIV+ patients with tuberculosis and the early serious morbidity of HIV+ patients without tuberculosis. TRANSMISSION: Mother-to-child transmission of HIV can occur during pregnancy, during delivery and the postnatal period by breastfeeding, a common practice in Africa. The overall risk of vertical transmission is estimated to be 30% but the attributable part of breastfeeding needs to be further explored. Beyond the prevention of sexual transmission of HIV among childbearing women and family planning for HIV+ women, interventions aimed to reduce mother-to-child transmission depend on the availability or not of a proposing and realising an HIV counselling and testing: antiretroviral treatments and/or breastfeeding alternatives which reduce efficaciously transmission require HIV testing, while vaginal disinfection and vitamin supplementation whom efficacy needs to be demonstrated do not. PREVENTION: Prevention of mother-to-child transmission and care of HIV+ adults in the area of opportunistic infections are feasible in Africa with an acceptable cost. This requires first to train and inform health care providers and the populations. Lots of uncertainties in these areas are likely to be alleviated by reinforcing clinical and therapeutic research of good quality including the questions of antiretroviral treatment. Ethical issues raised by the design and conduct of clinical research in Africa need a positive thinking to face the HIV African pandemic.     

Targeted HIV testing at birth supported by low and predictable mother‐to‐child transmission risk in Botswana

Introduction

Most African countries perform infant HIV testing at 6 weeks or later. The addition of targeted testing at birth may improve retention in care, treatment outcomes and survival for HIV‐infected infants.

Methods

HIV‐exposed infants were screened as part of the Early Infant Treatment (EIT) study in Botswana. Screened infants were ≥35 weeks gestational age and ≥2000 g at birth. Risk factors for mother‐to‐child transmission (MTCT) were assessed by maternal obstetric card or verbally. Risk factors included <8 weeks ART in pregnancy, last known CD4 <250 cells/mm³, last known HIV RNA >400 copies/mL, poor maternal ART adherence, lack of maternal zidovudine (ZDV) in labour, or lack of infant post‐exposure prophylaxis. Infants underwent dried blood spot testing by Roche Cobas Ampliprep/Cobas Taqman HIV‐1 qualitative PCR.

Results

From April 2015 to April 2016, 2303 HIV‐exposed infants were tested for HIV in the EIT study. Of these, 369 (16%) were identified as high risk for HIV infection by information available at birth, and 12 (0.5% overall, 3.25% of high risk) were identified as HIV positive at birth. All 12 positive infants were identified as high risk at the time of screening, and only 2 risk factors were required to identify all positive infants: either <8 weeks of maternal ART in pregnancy (75%) or lack of maternal HIV suppression at last test (25%).

Conclusions

In utero MTCT occurred only among infants identified as high risk at delivery, using information available from the mother or obstetric record. Birth testing that targets high‐risk infants based on maternal ART receipt is likely to identify the majority of in utero HIV transmissions, and allows early ART initiation for these infants.

     

Postnatal HIV transmission in breastfed infants of HIV‐infected women on ART: a systematic review and meta‐analysis

Introduction : To systematically review the literature on mother‐to‐child transmission in breastfed infants whose mothers received antiretroviral therapy and support the process of updating the World Health Organization infant feeding guidelines in the context of HIV and ART. Methods : We reviewed experimental and observational studies; exposure was maternal HIV antiretroviral therapy (and duration) and infant feeding modality; outcomes were overall and postnatal HIV transmission rates in the infant at 6, 9, 12 and 18 months. English literature from 2005 to 2015 was systematically searched in multiple electronic databases. Papers were analysed by narrative synthesis; data were pooled in random effects meta‐analyses. Postnatal transmission was assessed from four to six weeks of life. Study quality was assessed using a modified Newcastle‐Ottawa Scale (NOS) and GRADE. Results and discussion : Eleven studies were identified, from 1439 citations and review of 72 abstracts. Heterogeneity in study methodology and pooled estimates was considerable. Overall pooled transmission rates at 6 months for breastfed infants with mothers on antiretroviral treatment (ART) was 3.54% (95% CI: 1.15–5.93%) and at 12 months 4.23% (95% CI: 2.97–5.49%). Postnatal transmission rates were 1.08 (95% CI: 0.32–1.85) at six and 2.93 (95% CI: 0.68–5.18) at 12 months. ART was mostly provided for PMTCT only and did not continue beyond six months postpartum. No study provided data on mixed feeding and transmission risk. Conclusions : There is evidence of substantially reduced postnatal HIV transmission risk under the cover of maternal ART. However, transmission risk increased once PMTCT ART stopped at six months, which supports the current World Health Organization recommendations of life‐long ART for all.     

Frontloading HIV financing maximizes the achievable impact of HIV prevention

Introduction

Due to the nature of funding, national planners and international donors typically balance budgets over short time periods when designing HIV programmes (˜5‐year funding cycles). We aim to explicitly quantify the cost of short‐term funding arrangements on the success of future HIV prevention programmes.

Methods

Using mathematical models of HIV transmission in Kenya, we compare the impact of optimized combination prevention strategies under different constraints on investment over time. Each scenario has the same total budget for the 30‐year intervention period but the pattern of spending over time is allowed to vary. We look at the impact of programmes with decreasing, increasing or constant spending across 5‐year funding cycles for a 30‐year period. Interventions are optimized within each funding cycle such that strategies take a short‐term view of the epidemic. We compare these with two strategies with no spending pattern constraints: one with static intervention choices and another flexible strategy with interventions changed in year ten.

Results and Discussion

For the same total 30‐year budget, greatest impact is achieved if larger initial prevention spending is offset by later treatment savings which leads to accumulating benefits in reduced infections. The impact under funding cycle constraints is determined by the extent to which greater initial spending is permitted. Short‐term funding constraints and funds held back to later years may reduce impact by up to 18% relative to the flexible long‐term strategy.

Conclusions

Ensuring that funding arrangements are in place to support long‐term prevention strategies will make spending most impactful. Greater prevention spending now will bring considerable returns through reductions in new infections, greater population health and reductions in the burden on health services in the future.

     

Antenatal care and uptake of HIV testing among pregnant women in sub-Saharan Africa: a cross-sectional study

Introduction

Current guidelines recommend inclusion of HIV testing in routine screening tests for all pregnant women. For this reason, antenatal care (ANC) represents a vital component of efforts to prevent mother-to-child transmission (PMTCT) of HIV. To elucidate the relationship between ANC services and HIV testing among pregnant women in sub-Saharan Africa, we undertook an analysis of data from four countries.

Methods

Four countries (Congo, Mozambique, Nigeria and Uganda) were purposively selected to represent unique geographical regions of sub-Saharan Africa. Using Demographic and Health Survey datasets, weighted crude and adjusted logistic regression models were used to explore factors that influenced HIV testing as part of ANC services. The study was approved by the Institutional Review Board of the University of Arizona.

Results

Pooled results showed that 60.7% of women received HIV testing as part of ANC. Ugandan women had the highest rate of HIV testing as part of ANC (81.5%) compared with women in Mozambique (69.4%), Nigeria (54.4%) and Congo (45.4%). Difficulty reaching a health facility was a barrier in Congo and Mozambique but not Nigeria or Uganda. HIV testing rates were lower in rural areas, among the poorest women, the least educated and those with limited knowledge of HIV. In every country, crude regression analyses showed higher odds of being tested for HIV if women received their ANC services from a skilled attendant compared with an unskilled attendant. After adjusting for confounders, women in the total sample had 1.78 (99% CI: 1.45–2.18) times the odds of having an HIV test as part of their ANC if they went to a skilled attendant compared with an unskilled attendant.

Conclusions

There is a need for integration of HIV testing into routine ANC service to increase opportunities for PMTCT programmes to reach HIV-positive pregnant women. Attention should be paid to the expansion of outreach services for women in rural settings, and to the training, supervision and integration of unskilled attendants into formal maternal and child health programmes. Education of pregnant women and their communities is needed to increase HIV knowledge and reduce HIV stigma.     

What works to meet the sexual and reproductive health needs of women living with HIV/AIDS

It is critical to include a sexual and reproductive health lens in HIV programming as most HIV transmission occurs through sexual intercourse. As global attention is focusing on the sexual and reproductive health needs of women living with HIV, identifying which interventions work becomes vitally important. What evidence exists to support sexual and reproductive health programming related to HIV programmes? This article reviews the evidence of what works to meet the sexual and reproductive health needs of women living with HIV in developing countries and includes 35 studies and evaluations of eight general interventions using various methods of implementation science from 15 countries. Data are primarily from 2000‐2009. Searches to identify effective evaluations used SCOPUS, Popline, Medline, websites and consultations with experts. Evidence was ranked using the Gray Scale. A range of successful and promising interventions to improve the sexual and reproductive health and rights of women living with HIV include: providing contraceptives and family planning counselling as part of HIV services; ensuring early postpartum visits providing family planning and HIV information and services; providing youth‐friendly services; supporting information and skills building; supporting disclosure; providing cervical cancer screening; and promoting condom use for dual protection against pregnancy and HIV. Provision of antiretrovirals can also increase protective behaviours, including condom use. While many gaps in programming and research remain, much can be done now to operationalize evidence‐based effective interventions to meet the sexual and reproductive health needs of women living with HIV.     

HIV and incarceration: prisons and detention

The high prevalence of HIV infection among prisoners and pre‐trial detainees, combined with overcrowding and sub‐standard living conditions sometimes amounting to inhuman or degrading treatment in violation of international law, make prisons and other detention centres a high risk environment for the transmission of HIV. Ultimately, this contributes to HIV epidemics in the communities to which prisoners return upon their release. We reviewed the evidence regarding HIV prevalence, risk behaviours and transmission in prisons. We also reviewed evidence of the effectiveness of interventions and approaches to reduce the risk behaviours and, consequently, HIV transmission in prisons. A large number of studies report high levels of risk behaviour in prisons, and HIV transmission has been documented. There is a large body of evidence from countries around the world of what prison systems can do to prevent HIV transmission. In particular, condom distribution programmes, accompanied by measures to prevent the occurrence of rape and other forms of non‐consensual sex, needle and syringe programmes and opioid substitution therapies, have proven effective at reducing HIV risk behaviours in a wide range of prison environments without resulting in negative consequences for the health of prison staff or prisoners. The introduction of these programmes in prisons is therefore warranted as part of comprehensive programmes to address HIV in prisons, including HIV education, voluntary HIV testing and counselling, and provision of antiretroviral treatment for HIV‐positive prisoners. In addition, however, action to reduce overcrowding and improve conditions in detention is urgently needed.     

Mothers and babies: widening the HIV safety net

A national health policy of exclusive breastfeeding is finally imminent while routine re-testing of initially HIV-negative pregnant women at 32 weeks could soon become standard practice. These two simple measures would boost the already impressive gains in prevention of HIV transmission from mothers to infants (PMTCT) -- a major highlight of the fifth South African AIDS conference in Durban from 7 to 10 June this year. National surveys presented at the conference showed that the MTCT rate among babies 4 - 6 weeks old has dropped to 3.5%, potentially saving some 67 000 infants from HIV infection. This is a dramatic acceleration from the 8.8% MTCT rate under the previous regime of a single dose of nevirapine to mothers and their newborns. The impressive gains are almost exclusively due to a much-awaited policy change last April when all HIV-positive pregnant women began receiving AZT from 14 weeks of pregnancy (instead of at 28 weeks) and triple therapy (nevirapine, tenofovir and 3TC) during labour (when most infections take place). Those women with CD4 cell counts below 350 were also put onto triple therapy within 2 weeks of getting their CD4 cell results and all HIV-positive newborns were given nevirapine syrup for as long as their mothers were breastfeeding them (or for 6 weeks if not breastfed), regardless of CD4 cell count. Together these measures have put South Africa on track to meet this part of its 2007 - 2011 National Strategic Plan on HIV/AIDS (i.e. reducing MTCT to less than 5%), with the latest policy changes likely to edge the country even closer towards European and United States MTCT rates, where paediatric HIV infections are 1% or less.     

Breastfeeding: the hidden barrier in Côte d'Ivoire's quest to eliminate mother‐to‐child transmission of HIV

Introduction

Côte d''Ivoire has one of the worst HIV/AIDS epidemics in West Africa. This study sought to understand how HIV-positive women''s life circumstances and interactions with the public health care system in Bouaké, Côte d''Ivoire, influence their self-reported ability to adhere to antiretroviral prophylaxis during pregnancy.

Methods

Semistructured interviews were conducted with 24 HIV-positive women not eligible for antiretroviral therapy and five health care workers recruited from four public clinics in which prevention of mother-to-child transmission services had been integrated into routine antenatal care.

Results

Self-reported adherence to prophylaxis is high, but women struggle to observe (outdated) guidelines for rapid infant weaning. Women''s positive interactions with health providers, their motivation to protect their infants and the availability of free antiretrovirals seem to override most potential barriers to prophylaxis adherence.

Conclusions

This study reveals the importance of considering the full continuum of prevention of mother-to-child transmission interventions, including infant feeding, instead of focussing primarily on prophylaxis for the mother and newborn.     

Barriers and facilitating factors to the uptake of antiretroviral drugs for prevention of mother-to-child transmission of HIV in sub-Saharan Africa: a systematic review

Objectives

To investigate and synthesize reasons for low access, initiation and adherence to antiretroviral drugs by mothers and exposed babies for prevention of mother-to-child transmission (PMTCT) of HIV in sub-Saharan Africa.

Methods

A systematic literature review was conducted. Four databases were searched (Medline, Embase, Global Health and Web of Science) for studies conducted in sub-Saharan Africa from January 2000 to September 2012. Quantitative and qualitative studies were included that met pre-defined criteria. Antiretroviral (ARV) prophylaxis (maternal/infant) and combination antiretroviral therapy (ART) usage/registration at HIV care and treatment during pregnancy were included as outcomes.

Results

Of 574 references identified, 40 met the inclusion criteria. Four references were added after searching reference lists of included articles. Twenty studies were quantitative, 16 were qualitative and eight were mixed methods. Forty-one studies were conducted in Southern and East Africa, two in West Africa, none in Central Africa and one was multi-regional. The majority (n=25) were conducted before combination ART for PMTCT was emphasized in 2006. At the individual-level, poor knowledge of HIV/ART/vertical transmission, lower maternal educational level and psychological issues following HIV diagnosis were the key barriers identified. Stigma and fear of status disclosure to partners, family or community members (community-level factors) were the most frequently cited barriers overall and across time. The extent of partner/community support was another major factor impeding or facilitating the uptake of PMTCT ARVs, while cultural traditions including preferences for traditional healers and birth attendants were also common. Key health-systems issues included poor staff-client interactions, staff shortages, service accessibility and non-facility deliveries.

Conclusions

Long-standing health-systems issues (such as staffing and service accessibility) and community-level factors (particularly stigma, fear of disclosure and lack of partner support) have not changed over time and continue to plague PMTCT programmes more than 10 years after their introduction. The potential of PMTCT programmes to virtually eliminate vertical transmission of HIV will remain elusive unless these barriers are tackled. The prominence of community-level factors in this review points to the importance of community-driven approaches to improve uptake of PMTCT interventions, although packages of solutions addressing barriers at different levels will be important.