"Health regains but livelihoods lag": findings from a study with people on ART in Zambia and Kenya.

Although ART is increasingly accessible and eases some stresses, it creates other challenges including the importance of food security to enhance ART-effectiveness. This paper explores the role livelihood strategies play in achieving food security and maintaining nutritional status among ART patients in Kenya and Zambia. Ongoing quantitative studies exploring adherence to ART in Mombasa, Kenya (n=118) and in Lusaka, Zambia (n=375) were used to identify the relationship between BMI and adherence; an additional set of in-depth interviews with people on ART (n=32) and members of their livelihood networks (n=64) were undertaken. Existing frameworks and scales for measuring food security and a positive deviance approach was used to analyse data. Findings show the majority of people on ART in Zambia are food insecure; similarly most respondents in both countries report missing meals. Snacking is important for dietary intake, especially in Kenya. Most food is purchased in both countries. Having assets is key for achieving livelihood security in both Kenya and Zambia. Food supplementation is critical to survival and for developing social capital since most is shared amongst family members and others. Whilst family and friends are key to an individual's livelihood network, often more significant for daily survival is proximity to people and the ability to act immediately, characteristics most often found amongst neighbours and tenants. In both countries findings show that with ART health has rebounded but livelihoods lag. Similarly, in both countries respondents with high adherence and high BMI are more self-reliant, have multiple income sources and assets; those with low adherence and low BMI have more tenuous livelihoods and were less likely to have farms/gardens. Food supplementation is, therefore, not a long-term solution. Building on existing livelihood strategies represents an alternative for programme managers and policy-makers as do other strategies including supporting skills and asset accumulation.

Implementation of clinic-based modified-directly observed therapy (m-DOT) for ART; experiences in Mombasa, Kenya.

The effectiveness of modified-directly observed therapy (m-DOT), an adherence support intervention adapted from TB DOTS programmes, has been documented. Describing the implementation process and acceptability of this intervention is important for scaling up, replication in other settings and future research. In a randomised trial in Mombasa, Kenya, patients were assigned to m-DOT or standard of care for 24 weeks. m-DOT entailed twice weekly visits to a health centre for medication collection, ongoing adherence counselling and nurse-observed pill ingestion. Community health workers (CHWs) traced non-attendees, observing pill taking at participant's home. Using process indicators and a semi-structured questionnaire, implementation of m-DOT was evaluated among 94 participants who completed 24 weeks m-DOT (81%; 94/116). Two-thirds of m-DOT recipients were female (64%; 74/116) and a mean 37 years (SD = 7.8). Selection of the m-DOT observation site was determined by proximity to home for 73% (69/94), with the remainder choosing sites near their workplace, or due to perceived high-quality services. A median 42 of 48 scheduled m-DOT visits (IQR = 28-45) were attended. Most found m-DOT is very useful (87%; 82/94) and had positive attitudes to the services. A high proportion received CHWs home visits (96%; 90/94) and looked forward to these. Use of CHWs and several satellite observation sites facilitated provision of services closer to patient's homes. A substantial number, however, thought 24 weeks of m-DOT was too long (43%; 42/94). Our experience suggests that m-DOT services could be implemented widely and are acceptable if delivered with adequate attention to coordination, provision of a broad set of interventions, shifting tasks to less-specialised workers and integration within the health system. m-DOT programmes should utilise existing resources while simultaneously expanding capacity within communities and the public sector. These findings could be used to inform replication of such services and to improve the design of m-DOT in future studies.

Implementing programs for the prevention of mother-to-child HIV transmission in resource-constrained settings: Horizons studies, 1999-2007.

An estimated 430,00 new human immunodeficiency virus (HIV) infections occurred among children younger than 15 years of age in 2008, most in sub-Saharan Africa and most due to mother-to-child transmission (MTCT). In marked contrast, MTCT of HIV has been virtually eliminated in well-resourced settings through the use of combinations of antiretroviral (ARV) drugs for the mother during pregnancy and labor and for the infant postpartum; cesarean delivery to reduce the infant's exposure to trauma and infection in the birth canal; and formula feeding to protect the infant from transmission from breastfeeding. While effective, these interventions are costly and require strong health-care systems. From 1999 to 2003, Horizons conducted operations research to determine how interventions successful in the clinical trial setting would translate to the real-world environments of maternal and child healthcare delivery in low-resource settings. A second set of Horizons studies (2004-2007) sought to address gaps in adherence to ARV prophylaxis; examine roles of family planning in prevention of MTCT (PMTCT) programs; show the value of psychosocial support for HIV-positive mothers; and identify ways to improve the quality of care and follow-up for women in the postpartum period. This article provides an assessment of the findings of Horizons studies on PMTCT interventions from 1999 to 2007 and identifies needs for follow-on efforts.

Changes in sexual risk taking with antiretroviral treatment: influence of context and gender norms in Mombasa, Kenya.

In-depth interviews were conducted with 23 sexually-active adults receiving antiretroviral treatment (ART) in Mombasa Kenya to understand changes in sexual behaviour after treatment initiation and factors influencing condom use. Advanced HIV disease had previously led to marked decreases in sexual desire and function. After HIV testing, numbers of partners reduced and monogamous relationships began to predominate. Receipt of ART strengthened these changes, while improving sexual health. However, concurrent sexual partnerships continue within polygamous marriage and unprotected sex occurs with regular partners, even those who are HIV-negative. Those who used condoms inconsistently prior to ART often remained inconsistent users thereafter. While disclosure of HIV status appeared to support condom use, this does not always predict protected sex. In addition to classic perceptions about condom's effect on intimacy and trust, traditional gender roles, misconceptions about potential harm from condoms and fertility desires hinder condom use.

Safer sexual behaviors after 12 months of antiretroviral treatment in Mombasa, Kenya: a prospective cohort.

Roll-out of antiretroviral treatment (ART) raises concerns about the potential for unprotected sex if sexual activity increases with well-being, resulting in continued HIV spread. Beliefs about reduced risk for HIV transmission with ART may also influence behavior. From September 2003 to November 2004, 234 adults enrolled in a trial assessing the efficacy of modified directly observed therapy in improving adherence to ART. Unsafe sexual behavior (unprotected sex with an HIV-negative or unknown status partner) before starting ART and 12 months thereafter was compared. Participants were a mean 37.2 years (standard deviation [SD] = 7.9 years) and 64% (149/234) were female. Nearly half (107/225) were sexually active in the 12 months prior to ART, the majority (96/107) reporting one sexual partner. Unsafe sex was reported by half of those sexually active in the 12 months before ART (54/107), while after 12 months ART, this reduced to 28% (30/107). Unsafe sex was associated with nondisclosure of HIV status to partner; recent HIV diagnosis; not being married or cohabiting; stigma; depression and body mass index <18.5 kg/m(2). ART beliefs, adherence, and viral suppression were not associated with unsafe sex. After adjusting for gender and stigma, unsafe sex was 0.59 times less likely after 12 months ART than before initiation (95% confidence interval [CI] = 0.37-0.94; p = 0.026). In conclusion, although risky sexual behaviors had decreased, a considerable portion do not practice safe sex. Beliefs about ART's effect on transmission, viral load, and adherence appear not to influence sexual behavior but require long-term surveillance. Positive prevention interventions for those receiving ART must reinforce safer sex practices and partner disclosure.

Short- and long-term efficacy of modified directly observed antiretroviral treatment in Mombasa, Kenya: a randomized trial.

OBJECTIVES: To determine short- and long-term efficacy of modified directly observed therapy (m-DOT) on antiretroviral adherence. DESIGN: Randomized controlled trial. SETTING AND ANALYTIC APPROACH: From September 2003 to November 2004, 234 HIV-infected adults were assigned m-DOT (24 weeks of twice weekly health center visits for nurse-observed pill ingestion, adherence support, and medication collection) or standard care. Follow-up continued until week 72. Self-reported and pill-count adherence and, secondarily, viral suppression and body mass index measures are reported. Generalized estimating equations adjusted for intraclient clustering and covariates were used. RESULTS: During weeks 1-24, 9.1% (9/99) of m-DOT participants reported missing doses compared with 19.1% (20/105) of controls (P = 0.04) and 96.5% (517/571) of m-DOT pill-count measures were >or=95% compared with 86.1% (445/517) in controls [adjusted odds ratio = 4.4; 95% confidence interval (CI) = 2.6 to 7.5; P < 0.001. Adherence with m-DOT was 4.8 times greater (95% CI = 2.7 to 8.6; P < 0.001) with adjustment for depression and HIV-related hospitalization. In weeks 25-48, adherence with m-DOT (488/589) was similar to controls (507/630). Viral suppression at 48 weeks was 2.0 times (95% CI = 0.8 to 5.2; P = 0.13) as likely in m-DOT participants as controls. M-DOT patients had larger body mass index increases at 24 weeks (2.2 vs 1.4 kg/m3; P = 0.014). Viral suppression was more likely at week 48 (21/25 vs 13/22; P = 0.057) and week 72 (27/30 vs 15/23; P = 0.027) among depressed participants receiving m-DOT. CONCLUSIONS: M-DOT increased adherence, most notably among depressed participants.

Field experiences integrating family planning into programs to prevent mother-to-child transmission of HIV.

This article reviews field experiences with provision of family planning services in prevention of mother-to-child transmission (PMTCT) programs in ten countries in Africa, Asia, and Latin America. Family planning is a standard component of most antenatal care and maternal-child health programs within which PMTCT programs are offered. Yet PMTCT sites often miss opportunities to provide HIV-positive clients with family planning counseling. Demand for family planning among HIV-positive women varies depending on the extent of communities' openness about HIV/AIDS, fertility norms, and knowledge of PMTCT programs. In Kenya and Zambia, no differences were observed in use of contraceptives between HIV-positive and HIV-negative women in the study communities, but HIV-positive women have more affirmative attitudes about condoms and use them significantly more frequently than do their HIV-negative counterparts. In the Dominican Republic, India, and Thailand, where HIV prevalence is low and sterilization rates are high, HIV-positive women are offered sterilization, which most women accept. This article draws out the policy implications of these findings and recommends that policies be based on respect for women's right to informed reproductive choice in the context of HIV/AIDS.

Understanding perceptions of HIV risk among adolescents in KwaZulu-Natal.

Risk perception has been theorized to be an important antecedent for adopting protective behavior. It is a key construct of research applying the Health Belief Model and other behavior change models. In relation to HIV, risk perception is an indicator of perceived susceptibility to infection, a measure for one's understanding of AIDS transmission as well as willingness to consider behavioral changes. However, there remains much we do not know about what drives risk perception, especially among youth. This study identifies factors that influence the calculation of HIV-risk perception among a group of adolescents in South Africa. Data, collected in 1999 from 2,716 adolescents aged 14-22, are used to explore factors predicting risk perception. Logistic regression models suggest connectedness to parents and community for males and females, self-efficacy to use a condom among males, and living in a household with a chronically ill member for females are associated with HIV risk perception. We conclude that a greater understanding of the connection of adolescents to their communities and adults in their lives is needed, and ways in which programs can alter the environments in which adolescents form opinions, make choices, and act should be incorporated into program design.

Pregnant or positive: adolescent childbearing and HIV risk in KwaZulu Natal, South Africa.

In communities where early age of childbearing is common and HIV prevalence is high, adolescents may place themselves at risk of HIV because positive or ambivalent attitudes towards pregnancy reduce their motivation to abstain from sex, have sex less often or use condoms. In this study, we analyse cross-sectional survey data from KwaZulu Natal, South Africa, to explore whether an association exists between the desire for pregnancy and perceptions of HIV risk among 1,426 adolescents in 110 local communities. Our findings suggest that some adolescents, girls more than boys, were more concerned about a pregnancy if they lived in environments where youth were perceived to be at high risk of HIV infection. The probability that pregnancy was considered a problem by boys was positively correlated with the proportion of adult community members who thought youth were at risk of acquiring HIV, and for girls by the proportion of peers in the community who thought youth were at risk of HIV. We also found that becoming pregnant would be a bigger problem for the African girls than the white and Indian girls. The analysis suggests that for some adolescents, in addition to effects on educational and employment opportunities, the danger of HIV infection is becoming part of the calculus of the desirability of a pregnancy.

Pesquisa Nacional sobre saude materno-infantil e planejamento familiar-PNSMIPF-Brasil, 1986 / Pesquisa nacional sobre salud materno infantil y planificacion familiar - PNSMIPF - Brasil, 1986

Esta publicacion es un estudio pionero, a nivel nacional, que contiene informaciones sobre el comportamiento reproductivo de las mujeres en edad fertil, incluyendo la planificacion familiar. Tambien abarca informacion sobre servicios de salud materno-infantil, mortalidad , alimentacion maternal, nupcialidad etc. El objetivo de este estudio es dar datos mas precisos sobre la realidad nacional en las areas de salud materno infantil, reproduccion humana y palnificacion familiar. Contiene datos sobre el estudio llevado a cabo en los hogares, sobre el estado nutricional y antropometrico de los ninos menores de 5 anos.