HIV Resistance and Prevention of Mother-to-Child Transmission Regimen in HIV-Infected Infants in Northern Tanzania.

Prevention of mother-to-child transmission (PMTCT) guidelines recommend that all HIV-infected pregnant women receive antiretroviral therapy (Option B) and HIV-infected infants should initiate therapy with a protease inhibitor-based regimen; however, implementation of these guidelines has lagged in many resource-limited settings. Tanzania only recently implemented these guidelines with little country-specific data to inform whether HIV non-nucleoside reverse transcriptase inhibitor (NNRTI) resistance was present among infected infants under the Option A guidelines. This study aimed to identify primary resistance mutations in HIV-infected infants and to identify risk of nevirapine (NVP) resistance based on maternal and infant NVP exposure. Infant dried blood spots (DBSs) were sent to the zonal reference laboratory at Kilimanjaro Christian Medical Centre Clinical Laboratory and underwent DNA polymerase chain reaction testing for HIV as standard of care. Using the clinical laboratory registry, HIV-positive DBS cards, stored at ambient temperature, were identified and sent for further viral load testing, nucleotide sequencing, and analysis. Clinical information was obtained from the PMTCT clinical sites and the National PMTCT registry for information regarding maternal and infant demographics and PMTCT treatment regimen. Results demonstrated that infants exposed to NVP were more likely to have high level resistance mutations (HLRMs) to NVP than those infants not exposed to NVP (p = .002). The most common HLRMs to NVP were K103 N, Y181C, and Y188 L. HIV subtype A was most common, followed by subtype C. Approximately one-third of HIV-infected infants had documented referral to HIV care. This study demonstrated the ongoing need to scale up and strengthen points along the PMTCT continuum and supported the recommendation for all HIV-infected infants to initiate a lopinavir/ritonavir-based antiretroviral therapy regimen.

Laboratory quality improvement in Tanzania.

OBJECTIVES: The article describes the implementation and improvement in the first groups of medical laboratories in Tanzania selected to participate in the training program on Strengthening Laboratory Management Toward Accreditation (SLMTA). METHODS: As in many other African nations, the selected improvement plan consisted of formalized hands-on training (SLMTA) that teaches the tasks and skills of laboratory management and provides the tools for implementation of best laboratory practice. Implementation of the improvements learned during training was verified before and after SLMTA with the World Health Organization African Region Stepwise Laboratory Improvement Process Towards Accreditation checklist. RESULTS: During a 4-year period, the selected laboratories described in this article demonstrated improvement with a range of 2% to 203% (cohort I) and 12% to 243% (cohort II) over baseline scores. CONCLUSIONS: The article describes the progress made in Tanzania's first cohorts, the obstacles encountered, and the lessons learned during the pilot and subsequent implementations.

One laboratory's progress toward accreditation in Tanzania.

INTRODUCTION: The Amana Regional Hospital Laboratory in Tanzania was selected, along with 11 other regional and district laboratories, to participate in a pilot programme for laboratory quality improvement using the Strengthening Laboratory Management Toward Accreditation (SLMTA) training programme. PROGRAMME IMPLEMENTATION: The SLMTA programme entailed hands-on learning, improvement projects between and after a three-workshop series, supervisory visits from an oversight team and an expert laboratory mentor to facilitate and coach the process. Audits were conducted at baseline, exit (approximately one year after baseline) and follow-up (seven months after exit) using the Stepwise Laboratory Quality Improvement Process Towards Accreditation (SLIPTA) checklist. Quality stars (zero to five) were awarded based on audit scores. RESULTS: With a dedicated staff and strong leadership from laboratory management, Amana Laboratory implemented processes, policies and procedures recommended as elements of best laboratory practices. The laboratory improved from zero stars (36%) at baseline to successfully achieving three stars (81%) at exit. This was the highest score achieved by the 12 laboratories in the programme (the median exit score amongst the other laboratories was 58%). Seven months after completion of the programme, the laboratory regressed to one star (62%). DISCUSSION: As the SLMTA improvement programme progressed, Amana Laboratory's positive attitude and hard work prevailed. With the assistance of a mentor and the support of the facility's management a strong foundation of good practices was established. Although not all improvements were maintained after the conclusion of the programme and the laboratory dropped to a one-star rating, the laboratory remained at a higher level than most laboratories in the programme.

Progress in the prevention of mother to child transmission of HIV in three regions of Tanzania: a retrospective analysis.

BACKGROUND: Mother to child transmission (MTCT) of HIV-1 remains an important problem in sub-Saharan Africa where most new pediatric HIV-1 infections occur. Early infant diagnosis of HIV-1 using dried blood spot (DBS) PCR among exposed infants provides an opportunity to assess current MTCT rates. METHODS: We conducted a retrospective data analysis on mother-infant pairs from all PMTCT programs in three regions of northern Tanzania to determine MTCT rates from 2008-2010. Records of 3,016 mother-infant pairs were assessed to determine early transmission among HIV-exposed infants in the first 75 days of life. RESULTS: Of 2,266 evaluable infants in our cohort, 143 had a positive DBS PCR result at ≤ 75 days of life, for an overall transmission rate of 6.3%. Transmission decreased substantially over the period of study as more effective regimens became available. Transmission rates were tightly correlated to maternal regimen: 14.9% (9.5, 20.3) of infants became infected when women received no therapy; 8.8% (6.9, 10.7) and 3.6% (2.4, 4.8) became infected when women received single-dose nevirapine (sdNVP) or combination prophylaxis, respectively; the lowest MTCT rates occurred when women were on HAART, with 2.1% transmission (0.3, 3.9). Treatment regimens changed dramatically over the study period, with an increase in combination prophylaxis and a decrease in the use of sdNVP. Uptake of DBS PCR more than tripled over the period of study for the three regions surveyed. CONCLUSIONS: Our study demonstrates significant reductions in MTCT of HIV-1 in three regions of Tanzania coincident with increased use of more effective PMTCT interventions. The changes we demonstrate for the period of 2008-2010 occurred prior to major changes in WHO PMTCT guidelines.