Transmission of nevirapine-resistant HIV type 1 via breast milk to infants after single-dose nevirapine in Beira, Mozambique.

Acquisition of nevirapine (NVP)-resistant human immunodeficiency virus type 1 (HIV-1) by breast-feeding infants after receipt of single-dose NVP to prevent mother-to-child transmission is not well defined. A prospective observational study of 307 infants evaluated the rate of breast milk transmission of NVP-resistant HIV and the concentrations of mutants over time. NVP resistance was detected in 9 of 24 infants (37.5%; 95% confidence interval, 18.8%-59.4%) infected via breast milk. Eight had a pure mutant HIV population at the time infection was first detected, and majority mutant populations persisted in all 6 infants with follow-up specimens. Infection of breast-feeding infants with NVP-resistant HIV resulted in mutants persisting as the dominant virus, which may indefinitely compromise treatment with NVP-based antiretroviral regimens.

Successful management of prolonged abdominal pregnancy in low-resource setting: a case report.

Ectopic pregnancy is a life-threatening complication of pregnancy and represents the leading cause of maternal mortality in the first trimester. In developing countries early diagnosis, necessary for favorable outcomes, is often unavailable and women are often not aware of possible conditions and associated complications. Moreover, access to sexual and reproductive health services and antenatal care are limited in such settings. Finally, management options are restricted and often performed in emergency with higher risk of complications and mortality. We report here a 33-year-old woman presenting a 41 weeks abdominal pregnancy successfully managed in a low-resource setting.

Effects of short-course zidovudine on the selection of nevirapine-resistant HIV-1 in women taking single-dose nevirapine.

Single-dose nevirapine (sdNVP) given to prevent mother-to-child-transmission of HIV-1 selects NVP-resistance. Short-course zidovudine (ZDV) was hypothesized to lower rates of NVP-resistance. HIV-1 infected pregnant women administered sdNVP with or without short-course ZDV were assessed for HIV-1 mutations (K103N, Y181C, G190A, and V106M) prior to delivery and postpartum. Postpartum NVP-resistance was lower among 31 taking ZDV+sdNVP compared to 33 taking only sdNVP (35.5% vs. 72.7%; χ2 P = .003). NVP mutants decayed to <2% in 24/35 (68.6%) at a median 6 months postpartum, with no differences based on ZDV use (logrank P = .99). Short-course ZDV was associated with reduced NVP-resistance mutations among women taking sdNVP.

Discussion and revision of the mathematical modeling tool described in the previously published article "Modeling HIV Transmission risk among Mozambicans prior to their initiating highly active antiretroviral therapy".

Mathematical models are increasingly used in social and behavioral studies of HIV transmission; however, model structures must be chosen carefully to best answer the question at hand and conclusions must be interpreted cautiously. In Pearson et al. (2007), we presented a simple analytically tractable deterministic model to estimate the number of secondary HIV infections stemming from a population of HIV-positive Mozambicans and to evaluate how the estimate would change under different treatment and behavioral scenarios. In a subsequent application of the model with a different data set, we observed that the model produced an unduly conservative estimate of the number of new HIV-1 infections. In this brief report, our first aim is to describe a revision of the model to correct for this underestimation. Specifically, we recommend adjusting the population-level sexually transmitted infection (STI) parameters to be applicable to the individual-level model specification by accounting for the proportion of individuals uninfected with an STI. In applying the revised model to the original data, we noted an estimated 40 infections/1000 HIV-positive persons per year (versus the original 23 infections/1000 HIV-positive persons per year). In addition, the revised model estimated that highly active antiretroviral therapy (HAART) along with syphilis and herpes simplex virus type 2 (HSV-2) treatments combined could reduce HIV-1 transmission by 72% (versus 86% according to the original model). The second aim of this report is to discuss the advantages and disadvantages of mathematical models in the field and the implications of model interpretation. We caution that simple models should be used for heuristic purposes only. Since these models do not account for heterogeneity in the population and significantly simplify HIV transmission dynamics, they should be used to describe general characteristics of the epidemic and demonstrate the importance or sensitivity of parameters in the model.

Decision making and situational awareness in neonatal resuscitation in low resource settings.

INTRODUCTION: Data on non-technical skills (i.e. task management, team working, situation awareness and decision-making) of healthcare providers during real-life newborn resuscitation in low-resource settings are lacking. We aimed to assess non-technical skills of trained midwives during real-life newborn resuscitation in a low-resource setting before and after participation in a modified NRP course, and after a low-dose/high-frequency training. METHODS: One-hundred and fifty video-recorded resuscitations (50 before and 50 after participation in a modified NRP course, and 50 after a low-dose/high-frequency training) collected at the Beira Central Hospital (Mozambique) were independently viewed and rated by two neonatologists with expertise in high fidelity simulation. Non-technical skills regarding task management, situation awareness and decision-making were evaluated using the modified Anesthetists' Non-Technical Skills tool. RESULTS: Overall, most non-technical skills were scored as poor or marginal. Small improvements were observed in task management (planning and preparing p = 0.02; providing/maintaining standards p = 0.03) after the course. Limited improvements were observed in task management (prioritizing p = 0.03; providing/maintaining standards p = 0.04; identifying and utilizing resources p = 0.02) and decision-making (identifying options p = 0.04; balancing risk/selecting options p = 0.02) after the low-dose/high-frequency training. No differences were observed in situation awareness, apart from a small improvement in recognizing/understanding (p = 0.04) after the low-dose/high-frequency training. CONCLUSION: An educational intervention including a modified NRP course and a low-dose/high-frequency training on neonatal resuscitation had a limited impact on non-technical skills of participants. All items remained significantly under the recommended standards. Behavioral skills should be considered in training programs in order to improve the quality of neonatal resuscitation in low resource settings.

Effect of a Neonatal Resuscitation Course on Healthcare Providers' Performances Assessed by Video Recording in a Low-Resource Setting.

BACKGROUND: We assessed the effect of an adapted neonatal resuscitation program (NRP) course on healthcare providers' performances in a low-resource setting through the use of video recording. METHODS: A video recorder, mounted to the radiant warmers in the delivery rooms at Beira Central Hospital, Mozambique, was used to record all resuscitations. One-hundred resuscitations (50 before and 50 after participation in an adapted NRP course) were collected and assessed based on a previously published score. RESULTS: All 100 neonates received initial steps; from these, 77 and 32 needed bag-mask ventilation (BMV) and chest compressions (CC), respectively. There was a significant improvement in resuscitation scores in all levels of resuscitation from before to after the course: for "initial steps", the score increased from 33% (IQR 28-39) to 44% (IQR 39-56), p<0.0001; for BMV, from 20% (20-40) to 40% (40-60), p = 0.001; and for CC, from 0% (0-10) to 20% (0-50), p = 0.01. Times of resuscitative interventions after the course were improved in comparison to those obtained before the course, but remained non-compliant with the recommended algorithm. CONCLUSIONS: Although resuscitations remained below the recommended standards in terms of quality and time of execution, clinical practice of healthcare providers improved after participation in an adapted NRP course. Video recording was well-accepted by the staff, useful for objective assessment of performance during resuscitation, and can be used as an educational tool in a low-resource setting.

Nevirapine-Resistant HIV-1 DNA in Breast Milk After Single-Dose Nevirapine With or Without Zidovudine for Prevention of Mother-to-Child Transmission.

Among 30 human immunodeficiency virus type 1 (HIV-1)-infected women who received single-dose nevirapine (NVP), 17 (57%) had NVP-resistant HIV-1 detected in breast milk. NVP resistance in breast milk persisted for at least 8 months postpartum and was apparently transmitted to at least 1 infant. NVP resistance was detected less often in women who also received zidovudine.

Loss to follow-up of adults in public HIV care systems in central Mozambique: identifying obstacles to treatment.

INTRODUCTION: Access to antiretroviral treatment (ART) has expanded dramatically in resource-limited settings. Evaluating loss to follow-up from HIV testing through post-ART care can help identify obstacles to care. METHODS: Routine data were analyzed for adults receiving services in 2 public HIV care systems in central Mozambique. The proportion of people passing through the following steps was determined: (1) HIV testing, (2) enrollment at an ART clinic, (3) CD4 testing, (4) starting ART if eligible, and (5) adhering to ART. RESULTS: During the 12-month study period (2004-2005), an estimated 23,430 adults were tested for HIV and 7005 (29.9%) were HIV positive. Only 3956 (56.5%) of those HIV positive enrolled at an ART clinic < or =30 days after testing. CD4 testing was obtained in 77.1% < or =30 days of enrollment. Of 1506 eligible for ART, 471 (31.3%) started ART < or =90 days after CD4 testing. Of 382 with > or =180 days of potential follow-up time on ART, 317 (83.0%) had pharmacy-based adherence rates > or =90%. DISCUSSION: Substantial drop-offs were observed for each step between HIV testing and treatment but were highest for referral from HIV testing to treatment sites and for starting ART. Interventions are needed to improve follow-up and ensure that people benefit from available HIV services.

Randomized control trial of peer-delivered, modified directly observed therapy for HAART in Mozambique.

OBJECTIVE: To assess the efficacy of a peer-delivered intervention to promote short-term (6-month) and long-term (12-month) adherence to HAART in a Mozambican clinic population. DESIGN: A 2-arm randomized controlled trial was conducted between October 2004 and June 2006. PARTICIPANTS: Of 350 men and women (> or = 18 years) initiating HAART, 53.7% were female, and 97% were on 1 fixed-dose combination pill twice a day. INTERVENTION: Participants were randomly assigned to receive 6 weeks (Monday through Friday; 30 daily visits) of peer-delivered, modified directly observed therapy (mDOT) or standard care. Peers provided education about treatment and adherence and sought to identify and mitigate adherence barriers. OUTCOME: Participants' self-reported medication adherence was assessed 6 months and 12 months after starting HAART. Adherence was defined as the proportion of prescribed doses taken over the previous 7 days. Statistical analyses were performed using intention-to-treat (missing = failure). RESULTS: Intervention participants, compared to those in standard care, showed significantly higher mean medication adherence at 6 months (92.7% vs. 84.9%, difference 7.8, 95% confidence interval [CI]: 0.0.02, 13.0) and 12 months (94.4% vs. 87.7%, difference 6.8, 95% CI: 0.9, 12.9). There were no between-arm differences in chart-abstracted CD4 counts. CONCLUSIONS: A peer-delivered mDOT program may be an effective strategy to promote long-term adherence among persons initiating HAART in resource-poor settings.

Modified directly observed therapy to facilitate highly active antiretroviral therapy adherence in Beira, Mozambique. Development and implementation.

As resource-limited countries expand access to highly active antiretroviral therapy (HAART) treatment, innovative programs are needed to support adherence in the context of significant health system barriers. Modified directly observed therapy (mDOT) is one such strategy, but little is known about the process of designing and implementing mDOT programs for HAART in resource-limited settings. In this descriptive study, we used a mixed-methods approach to describe the process of implementing mDOT for an ongoing randomized control trial (RCT) in Beira, Mozambique. Interviews with clinic staff, mDOT peers, and participants provided information on design elements, problems with implementation, satisfaction, and benefits. Acceptability and feasibility measures were obtained from the RCT. Most (81%, N = 350) eligible persons agreed to participate, and of those randomized to mDOT (n = 174), 95% reported that their time with peers was beneficial. On average, participants kept 93% of the 30 required daily mDOT visits. Key components of the intervention's success included using peers who were well accepted by clinic staff, adequate training and retention of peers, adapting daily visit requirements to participants' work schedules and physical conditions, and reimbursing costs of transportation. This study identified aspects of mDOT that are effective and can be adopted by other clinics treating HIV patients.