Sexually transmitted infection services as a component of HIV care: findings of a demonstration project among HIV-infected women in Thailand

OBJECTIVES: As Thailand scales up its antiretroviral treatment program, the role of sexually transmitted infection (STI) services to prevent HIV transmission has not been addressed. We provided STI services for HIV-infected women as a component of HIV care and assessed STI prevalence and risk behaviors. METHODS: HIV-infected women attending an infectious disease clinic and an STI clinic in Bangkok were screened for the presence of genital ulcers by visual inspection, for gonorrhea and chlamydial infection by polymerase chain reaction, for trichomoniasis by wet mount, and for syphilis by serology. Women were asked about sexual risk behavior and use of antiretroviral treatment. Risk-reduction counseling, condoms, and STI treatment were provided. RESULTS: Two-hundred ten HIV-infected women at an infectious disease clinic (n = 150) and an STI clinic (n = 60) received STI services from July 2003 through February 2004. The prevalence for any STI was 8.0% at the infectious disease clinic and 30.0% at the STI clinic (P < 0.01). Of the 116 (55.2%) sexually active women, 42 (36.2%) reported sex without a condom during the last 3 months. Women receiving antiretroviral treatment reported condom use during last sex more often compared with those not receiving antiretroviral treatment (82.2% vs. 58.8%; P = 0.03). CONCLUSION: STIs and sexual risk behavior were common among these HIV-infected women, and STI services for HIV-infected persons have been expanded to more clinics in Thailand. Further analysis of HIV transmission risk is necessary for developing a national strategy for prevention of HIV transmission among HIV-infected persons.     

PEPFAR support for the scaling up of collaborative TB/HIV activities

The US President's Emergency Plan for AIDS Relief (PEPFAR) has supported a comprehensive package of care in which interventions to address HIV-related tuberculosis (TB) have received increased funding and support in recent years. PEPFAR's TB/HIV programming is based on the World Health Organization's 12-point policy for collaborative TB/HIV activities, which are integrated into PEPFAR annual guidance. PEPFAR implementing partners have provided crucial support to TB/HIV collaboration, and as a result, PEPFAR-supported countries in sub-Saharan Africa have made significant gains in HIV testing and counseling of TB patients and linkages to HIV care and treatment, intensified TB case finding, and TB infection control. PEPFAR's support of TB/HIV integration has also included significant investment in health systems, including improved laboratory services and educating and enlarging the workforce. The scale-up of antiretroviral therapy along with support of programs to increase HIV counseling and testing and improve linkage and retention in HIV care may have considerable impact on TB morbidity and mortality, if used synergistically with isoniazid preventive therapy, intensified case finding, and infection control. Issues to be addressed by future programming include accelerating implementation of isoniazid preventive therapy, increasing access and ensuring appropriate use of new TB diagnostics, supporting early initiation of antiretroviral therapy for HIV-infected TB patients, and strengthening systems to monitor and evaluate program implementation.     

PEPFAR, health system strengthening, and promoting sustainability and country ownership

Evidence demonstrates that scale-up of HIV services has produced stronger health systems and, conversely, that stronger health systems were critical to the success of the HIV scale-up. Increased access to and effectiveness of HIV treatment and care programs, attention to long-term sustainability, and recognition of the importance of national governance, and country ownership of HIV programs have resulted in an increased focus on structures that compromise the broader health system. Based on a review published literature and expert opinion, the article proposes 4 key health systems strengthening issues as a means to promote sustainability and country ownership of President's Emergency Plan for AIDS Relief and other global health initiatives. First, development partners need provide capacity building support and to recognize and align resources with national government health strategies and operational plans. Second, investments in human capital, particularly human resources for health, need to be guided by national institutions and supported to ensure the training and retention of skilled, qualified, and relevant health care providers. Third, a range of financing strategies, both new resources and improved efficiencies, need to be pursued as a means to create more fiscal space to ensure sustainable and self-reliant systems. Finally, service delivery models must adjust to recent advancements in areas of HIV prevention and treatment and aim to establish evidence-based delivery models to reduce HIV transmission rates and the overall burden of disease. The article concludes that there needs to be ongoing efforts to identify and implement strategic health systems strengthening interventions and address the inherent tension and debate over investments in health systems.     

Tuberculosis and HIV infection in Brazil -- update and overview

In Brazil, tuberculosis (TB) has become an important public health problem with approximately 90,000 cases reported annually. Compounding the TB problem is the interaction of the growing HIV/AIDS epidemic with TB, with potential implications for intranosocomial transmission to immunodeficient patients and health care workers, as well as for the emergence of multidrug-resistant strains. The increased number of reported TB cases is attributed to the deterioration in socioeconomic conditions, the decentralization and restructuring of local TB programs, and the HIV epidemic. TB is the third most common AIDS-defining event; hence, increase in TB cases could be attributed to coinfection with HIV. To this effect, the Tuberculosis and AIDS Programs created a joint committee in order to define national guidelines for the prevention, case management, and treatment of HIV-associated TB. These guidelines recommend 1) preventive therapy with Isoniazid (300 mg daily for 6 months); and 2) Rifampicin-Isoniazid-Pyrazinamide daily for 2 months plus Rifampicin-Isoniazid for the following 7 months for those with active TB. In addition to these strategies, Bacillus-Calmette Guerin vaccination is mandatory for newborns and children under age 4 years, especially for all HIV positive asymptomatic newborns of HIV-infected or AIDS mothers.     

Perinatal transmission in developing countries: new developments,new challenges

In Africa, about 30% of all infants born to HIV-infected mothers become infected with HIV. About 4 million women of reproductive age in Africa are infected with HIV. Africa lacks HIV counseling and testing facilities. Family sizes are large. Asia has paid less attention to perinatal transmission than has Africa. Heterosexual transmission is also the predominant mode of HIV infection in Asia. Interventions that might prevent perinatal transmission have recently emerged. HIV/AIDS programs, maternal and child health (MCH) programs, and family planning providers must collaborate to reduce perinatal transmission. HIV/AIDS, MCH, and reproductive health specialists; women's health advocates; and pregnant women must discuss complex policy and ethics issues as they consider interventions. Women in developing countries familiar with their HIV status would arrive at more informed decisions about reproduction than those ignorant of their HIV status. Rapidly falling prices of HIV tests may mean access to testing for more women in developing countries. Availability of safe, effective contraception and abortion services would contribute to the success of counseling and testing to reduce the number of births at risk of perinatal transmission. In areas where infectious diseases and malnutrition cause most infant deaths, mothers should breast feed regardless of HIV status. In areas where this is not the case, mothers should use breast milk substitutes. Some evidence suggests that cesarean sections reduce the rate of perinatal transmission. Vaginal cleansing before and during labor may also reduce it. Since maternal vitamin A deficiency may facilitate perinatal transmission, vitamin A supplementation in pregnant women may reduce the risk of perinatal transmission. Administration of zidovudine to HIV-infected pregnant women reduced the risk of perinatal transmission by 67% in a recent clinical trial.     

Leveraging HIV programs to deliver an integrated package of health services: some words of caution

Over the past decade, HIV programs have been successfully scaled up in many developing countries, leading some to wonder how the investments made into HIV infrastructure could be leveraged to deliver additional health services. Although the concept is appealing from many perspectives, integrating additional health services into existing vertical HIV infrastructure may not mitigate some of the challenges these programs have introduced in implementing countries. In addition, this approach to integration may countervail parallel efforts of the global health community to strengthen health systems and improve aid effectiveness. It might also undermine the HIV programs themselves. International donors and health system planners should carefully consider whether the benefits outweigh the potential costs of these well-intentioned integration efforts.     

Mycobacterium tuberculosis transmission in a country with low tuberculosis incidence: role of immigration and HIV infection

Immigrants from high-burden countries and HIV-coinfected individuals are risk groups for tuberculosis (TB) in countries with low TB incidence. Therefore, we studied their role in transmission of Mycobacterium tuberculosis in Switzerland. We included all TB patients from the Swiss HIV Cohort and a sample of patients from the national TB registry. We identified molecular clusters by spoligotyping and mycobacterial interspersed repetitive-unit-variable-number tandem-repeat (MIRU-VNTR) analysis and used weighted logistic regression adjusted for age and sex to identify risk factors for clustering, taking sampling proportions into account. In total, we analyzed 520 TB cases diagnosed between 2000 and 2008; 401 were foreign born, and 113 were HIV coinfected. The Euro-American M. tuberculosis lineage dominated throughout the study period (378 strains; 72.7%), with no evidence for another lineage, such as the Beijing genotype, emerging. We identified 35 molecular clusters with 90 patients, indicating recent transmission; 31 clusters involved foreign-born patients, and 15 involved HIV-infected patients. Birth origin was not associated with clustering (adjusted odds ratio [aOR], 1.58; 95% confidence interval [CI], 0.73 to 3.43; P = 0.25, comparing Swiss-born with foreign-born patients), but clustering was reduced in HIV-infected patients (aOR, 0.49; 95% CI, 0.26 to 0.93; P = 0.030). Cavitary disease, male sex, and younger age were all associated with molecular clustering. In conclusion, most TB patients in Switzerland were foreign born, but transmission of M. tuberculosis was not more common among immigrants and was reduced in HIV-infected patients followed up in the national HIV cohort study. Continued access to health services and clinical follow-up will be essential to control TB in this population.     

Tuberculosis and HIV: Implications in the developing world

Developing countries bear the brunt of the epidemics of AIDS and tuberculosis (TB), and the management of patients with both diseases poses a particular challenge in these settings. In this article, we review implications for the twin epidemics of HIV and TB for the developing world with respect to diagnosis, prevention, treatment and integration of national TB and HIV programs.     

The feasibility,demand, and effect of integrating primary care services with HIV voluntary counseling and testing: evaluation of a 15-year experience in Haiti, 1985-2000

BACKGROUND: HIV voluntary counseling and testing (VCT) may be an effective strategy to prevent transmission of HIV in developing countries. Hypothesizing that primary care services and HIV VCT have synergistic benefits, we examine the feasibility, the demand, and the effect of integrating on-site primary care services into VCT at a stand-alone VCT center in Port au Prince, Haiti. METHODS: Through a retrospective review of patient records, we describe the integration of primary care services at the Groupe Haitien d'Etude du Sarcome de Kaposi et des Infections Opportunistes (GHESKIO) VCT center between1985 and 2000. RESULTS: Between 1985 and 1999, services for HIV care, tuberculosis care, treatment of sexually transmitted diseases, and reproductive health were sequentially integrated into HIV VCT at GHESKIO. The number of new people seeking voluntary counseling and testing at GHESKIO increased from 142 in 1985 to 8175 in 1999, with an increasing percentage of women, adolescents, symptom-free clients, and self-referred clients. Of new adults seeking VCT in 1999, the center was able to provide AIDS care to 17%, tuberculosis treatment to 6%, sexually transmitted infection management to 18%, and family planning to 19%. HIV transmission between discordant couples was 0 infections/100 follow-up years (95% CI, 0-3.2); vertical transmission from mother to child was 11 infections/100 live births (95% CI, 4.6-21.9); These rates are significantly lower than expected rates of transmission in Haiti. CONCLUSIONS: This report demonstrates the feasibility, demand, and effective synergy of integrating on-site primary care services into HIV VCT in Haiti. VCT is a good entry point for people in need of services for communicable diseases and reproductive health, and, reciprocally, services attract more people to VCT, including populations that are at high risk for HIV infection. This program is being duplicated elsewhere in Haiti and can serve as a model for other countries.     

Policy implications of integrating buprenorphine/naloxone treatment and HIV care

Researchers, practitioners, and policymakers have long recognized the potential benefits of providing integrated substance abuse and medical care services, particularly for special populations such as people living with HIV/AIDS. Buprenorphine, an office-based pharmacological treatment for opioid dependence, offers new opportunities for integrating drug treatment into HIV care settings. However, the historical separation between the drug treatment and medical care systems has resulted in a host of policy barriers. The Buprenorphine and HIV Care Evaluation and Support initiative, a multisite demonstration project to assess the feasibility and effectiveness of integrating buprenorphine/naloxone into HIV care settings, provided an opportunity to evaluate if and how policy barriers affect efforts to integrate HIV care and addiction treatment. We found that financing issues, workforce and training issues, and the operational consequences of some conceptual differences between HIV care and addiction treatment are barriers to the full integration of buprenorphine into HIV care. We recommend changes to financing and reimbursement policies, programs to strengthen the addiction treatment skills of physicians, and cross training between the fields of addiction, medicine, drug treatment, and HIV medicine. By addressing some of the policy barriers to integration, this promising new treatment can help the thousands of people living with HIV/AIDS who are also opioid dependent.     

HIV and health systems: research to bridge the divide

Concern that HIV programs in low-income countries may strain weak health systems and undermine achievement of other priority health goals has resulted in a research agenda focused on measuring the effects of past HIV investments on non-HIV services and outcomes. However, this research has limited value for informing future health policies and programs, which increasingly view health systems as the common platform for delivery of HIV and other health services. These policies reflect a shift in the framing of HIV care and treatment from emergency response to routine health service. In this paradigm, relevant areas for research are strengthening, scaling, and sustaining health systems in low-income countries to reduce all-cause mortality and morbidity, including deaths from HIV. To build an evidence base to support current and future health systems and policy, researchers need to move from retrospective studies to prospective research and adopt innovative study designs and analytic methods.     

Case Management Interventions for HIV-Infected Individuals

Engagement of HIV-positive persons into care and achieving optimal antiretroviral treatment outcomes is a fundamental HIV prevention strategy. Case management model was recommended as a beneficial model of care for patients with a new HIV diagnosis, focusing on individuals with unmet needs, and linking them with the coordinated health and social services to achieve desired outcomes. HIV case management is population-driven and programs are designed to respond to the unique needs of the client population they serve, such as substance users, homeless, youth, and prison inmates. This view found 28 studies addressing effectiveness and impacts of case management intervention for people living with or at risk of HIV/AIDS. Effectiveness of case management intervention was categorized as follows: decreased mortality and improve health outcomes, linkage to and retention in care, decreased unmet needs, and reducing risky behaviors.     

Laboratory Innovation Towards Quality Program Sustainability

Laboratory innovation significantly affects program sustainability of HIV programs in low and middle income countries (LMICs) far beyond its immediate sphere of impact. Innovation in rapid development of diagnostic technologies, improved quality management systems, strengthened laboratory management, affordable external quality assurance and accreditation schemes, and building local capacity have reduced costs, brought quality improvement to point-of-care testing, increased access to testing services, reduced treatment and prevention costs and opened the door to the real possibility of ending the AIDS epidemic. However, for effectively implemented laboratory innovation to contribute to HIV quality program sustainability, it must be implemented within the overall context of the national strategic plan and HIV treatment programs. The high quality of HIV rapid diagnostic test was a breakthrough that made it possible for more persons to learn their HIV status, receive counseling, and if infected to receive treatment. Likewise, the use of dried blood spots made the shipment of samples easier for the assessment of different variables of HIV infection—molecular diagnosis, CD4+ cell counts, HIV antibodies, drug resistance surveillance, and even antiretroviral drug level measurements. Such advancement is critical for to reaching the UNAIDS target of 90-90-90 and for bringing the AIDS epidemic to an end, especially in LMICs.     

Prevention of sexually transmitted HIV infections through the President's Emergency Plan for AIDS Relief: a history of achievements and lessons learned

HIV prevention in the President's Emergency Plan for AIDS Relief (PEPFAR) began when both data on HIV prevalence and the toolbox of interventions for prevention of sexual transmission were relatively limited. PEPFAR's early focus was on scaling-up information, education, and communication programs that included messaging on abstinence for youth and faithfulness primarily through nongovernmental organizations, including faith-based organizations. Additional activities included condom promotion, distribution, and social marketing. In epidemics concentrated within key populations, PEPFAR's prevention efforts focused on a minimum package of services including outreach, information, education, and communication programs, STI treatment (where appropriate), and condom promotion and distribution. As more epidemiological data became available and with experience gleaned in these early efforts, the need for tailored and flexible approaches became evident. The next iteration of prevention efforts still emphasized behavioral interventions, but incorporated a sharper focus on key epidemic drivers, especially multiple partners; a data-driven emphasis on high transmission areas and populations, including prevention with people living with HIV; and a more strategic and coordinated approach at the national level. Recently, the paradigm for prevention efforts has shifted yet again. Evidence that biomedical interventions such as male circumcision, treatment for prevention of vertical and horizontal transmission, and treatment itself could lead to declines in incidence has refocused PEPFAR's prevention portfolio. New guidance on sexually transmitted HIV focuses on combination prevention, emphasizing biomedical, behavioral and structural approaches. Landmark speeches by the President and the Secretary of State and new ambitious targets for PEPFAR point toward a new goal: an AIDS-free generation.     

HIV Prevention Interventions for Young Male Commercial Sex Workers

The sex industry, where men sell sexual services to other men or women, has grown in recent years. These men who offer sexual services are particularly vulnerable to HIV infection due to such factors as: frequency of risky sexual practices, number of sex partners, drug-taking, prevalence of sexually-transmitted infections (STI) and their specific situation of social exclusion which may hinder access to health services. These multi-faceted realities faced by sex workers explain the burgeoning interest in new avenues of scientific research. There are too few preventive programs however aimed at this population group and the studies that evaluate their effectiveness are fewer still. In this article we survey more recent studies on the difficulties of implementing programs for HIV prevention in male sex workers (MSW), as well as the studies that have gauged the impact of preventive programs in this group.     

Mental Health: A Focus on Stress, Coping, and Mental Illness as it Relates to Treatment Retention, Adherence, and Other Health Outcomes

Mental health problems are prevalent among HIV-infected individuals, with some estimates that 50% likely meet criteria for one or more psychiatric disorders. The mental health of HIV-infected individuals is important not only for quality-of-life concerns, but also in regard to HAART adherence and biological disease progression. The current review focuses on research published between 2009 and April of 2011, exploring mental health, coping, and stress in relation to HIV care behaviors including HAART adherence, quality of life, treatment retention, health care utilization, and disease progression amongst HIV-infected individuals. Specifically, we reviewed the most prevalent and interfering concerns among HIV-infected individuals—depression, post-traumatic stress disorder, interpersonal violence, stigma and shame, and body image concerns. Despite advances over the last 2 years documenting the deleterious effects of mental health on important HIV self-care behaviors, there is continued need for developing and disseminating evidence-based psychosocial interventions that integrate treating mental health problems with improving self-care behaviors for those living with HIV.     

Opportunities and barriers for implementation of integrated TB and HIV care in lower level health units: experiences from a rural western Ugandan district

Background

As countries with a high burden of TB and HIV roll out integrated TB/HIV care, there is need to assess possibility of lower level health units treating TB to provide integrated TB/HIV care.

Objective

To determine barriers and opportunities for provision of integrated TB/HIV care in lower level health units offering TB treatment in Mbarara district, Uganda.

Methods

Conducted key informant interviews, interviewed health workers and observed services offered.

Results

22 health units were assessed and 88 health workers were interviewed. Of the 18 health units mandated to offer laboratory services, 55.6% and 38.9% were able to offer rapid HIV-testing and ZN staining respectively. Understaffing, lack of capacity to diagnose HIV and TB, lack of guidelines to inform care options of TB/HIV co-infected patients and insufficient knowledge and skills among health workers towards provision of integrated TB/HIV care were mentioned as barriers to provision of integrated TB/HIV services.

Conclusion

To offer integrated TB/HIV services at lower level health units currently offering TB stand alone services, there is need to address gaps in knowledge and skills among health workers, laboratory diagnostics, staffing levels, medical supplies and infrastructure.     

Progress, challenges, and new opportunities for the prevention of mother-to-child transmission of HIV under the US President's Emergency Plan for AIDS Relief

In June 2011, the Joint United Nations Programme on HIV/AIDS, the US President's Emergency Plan for AIDS Relief (PEPFAR), and other collaborators outlined a transformative plan to virtually eliminate pediatric AIDS worldwide. The ambitious targets of this initiative included a 90% reduction in new pediatric HIV infections and a 50% reduction in HIV-related maternal mortality--all by 2015. PEPFAR has made an unprecedented commitment to the expansion and improvement of prevention of mother-to-child HIV transmission (PMTCT) services globally and is expected to play a critical role in reaching the virtual elimination target. To date, PEPFAR has been instrumental in the success of many national programs, including expanded coverage of PMTCT services, an enhanced continuum of care between PMTCT and HIV care and treatment, provision of more efficacious regimens for antiretroviral prophylaxis, design of innovative but simplified PMTCT approaches, and development of new strategies to evaluate program effectiveness. These accomplishments have been made through collaborative efforts with host governments, United Nations agencies, other donors (eg, the Global Fund for AIDS, Tuberculosis, and Malaria), nongovernmental organizations, and private sector partners. To successfully meet the ambitious global targets to prevent new infant HIV infections, PEPFAR must continue to leverage the existing PMTCT platform, while developing innovative approaches to rapidly expand quality HIV services. PEPFAR must also carefully integrate PMTCT into the broader combination prevention agenda for HIV, so that real progress can be made toward an "AIDS-free generation" worldwide.     

Sexual, reproductive health needs and rights of young people with perinatally acquired HIV in Uganda

Background

Numbers of young people with perinatally acquired HIV is growing significantly. With antiretroviral drugs, children who get infected at birth with HIV have an opportunity to graduate into adolescence and adulthood. This achievement notwithstanding, new challenges have emerged in their care and support needs. The most dynamic being, their sexual and reproductive health needs and rights (SRHR).

Objectives

This paper aimed at establishing the gaps at policy, program and health systems level as far as addressing sexual and reproductive health needs of young people who have lived with HIV since infancy is concerned.

Methods

This paper is based on a desk review of existing literature on sexual and reproductive health needs and rights of young positives.

Results

The results indicate young positives are sexually active and are engaging in risky sexual encounters. Yet, existing policies, programs and services are inadequate in responding to their sexual and reproductive health needs and rights.

Conclusion

Against these findings, it is important, that policies specifically targeting this subgroup are formulated and to make sure that such policies result in programs and services that are youth friendly. It is also important that integration of Sexual Reproductive Health (SRH) and HIV services is prioritized.