Partner Notification Approaches for Sex Partners and Children of Human Immunodeficiency Virus Index Cases in Côte d'Ivoire.

BACKGROUND: Four partner notification approaches were introduced in health facilities in Côte d'Ivoire to increase human immunodeficiency virus (HIV) testing uptake among the type of contacts (sex partners and biological children younger than 15 years). The study assessed the 4 approaches: client referral (index cases refer the contacts for HIV testing), provider referral (health care providers refer the contacts), contract referral (index case-provider hybrid approach), and dual referral (both the index and their partner are tested simultaneously). METHODS: Program data were collected at 4 facilities from October 2018 to March 2019 from index case files and HIV testing register. We compared uptake of the approaches, uptake of HIV testing, and HIV positivity percentages, stratified by contact type and gender. RESULTS: There were 1089 sex partners and 469 children from 1089 newly diagnosed index cases. About 90% of children were contacted through client referral: 85.2% of those were tested and 1.4% was positive. Ninety percent of the children came from female index cases. The provider referral brought in 56.3% of sex partners, of whom 97.2% were HIV-tested. The client referral brought in 30% of sex partners, of whom only 81.5% were HIV-tested. The HIV positivity percentages were 75.5% and 72.7%, respectively, for the 2 approaches. Male index cases helped to reach twice as many HIV-positive sexual contacts outside the household (115) than female index cases (53). The contract and dual referrals were not preferred by index cases. CONCLUSIONS: Provider referral is a successful and acceptable strategy for bringing in sex partners for testing. Client referral is preferred for children.

Identifying high or low risk of mother to child transmission of HIV: How Harare City, Zimbabwe is doing?

BACKGROUND: Despite high antiretroviral (ARV) treatment coverage among pregnant women for prevention of mother-to-child transmission (PMTCT) of Human Immunodeficiency Virus (HIV) in Zimbabwe, the MTCT rate is still high. Therefore in 2016, the country adopted World Health Organization recommendations of stratifying pregnant women into "High" or"Low" MTCT risk for subsequent provision of HIV exposed infant (HEI) with appropriate follow-up care according to risk status. OBJECTIVE: The study sought to ascertain, among pregnant women who delivered in clinics of Harare in August 2017: the extent to which high risk MTCT pregnancies were identified at time of delivery; and whether their newborns were initiated on appropriate ARV prophylaxis, cotrimoxazole prophylaxis, subjected to early HIV diagnostic testing and initiated on ARV treatment. METHODS: Cross-sectional study using review of records of routinely collected program data. RESULTS: Of the 1,786 pregnant women who delivered in the selected clinics, HIV status at the time of delivery was known for 1,756 (98%) of whom 197 (11%) were HIV seropositive. Only 19 (10%) could be classified as "high risk" for MTCT and the remaining 90% lacked adequate information to classify them into high or low risk for MTCT due to missing data. Of the 197 live births, only two (1%) infants had a nucleic-acid test (NAT) at birth and 32 (16%) infants had NAT at 6 weeks. Of all 197 infants, 183 (93%) were initiated on single ARV prophylaxis (Nevirapine), 15 (7%) infants' ARV prophylaxis status was not documented and one infant got dual ARV prophylaxis (Nevirapine+Zidovudine). CONCLUSION: There was paucity of data requisite for MTCT risk stratification due to poor recording of data; "high risk" women were missed in the few circumstances where sufficient data were available. Thus "high risk" HEI are deprived of dual ARV prophylaxis and priority HIV NAT at birth and onwards which they require for PMTCT. Health workers need urgent training, mentorship and supportive supervision to master data management and perform MTCT risk stratification satisfactorily.

Enhanced adherence counselling and viral load suppression in HIV seropositive patients with an initial high viral load in Harare, Zimbabwe: Operational issues.

BACKGROUND: In people living with HIV (PLHIV) who are on anti-retroviral therapy (ART), it is essential to identify persons with high blood viral loads (VLs) (≥1000 copies/ml), provide enhanced adherence counselling (EAC) for 3 months and assess for VL suppression (<1000 copies/ml). OBJECTIVE: Our study objectives were to determine the proportion who had a high viral load in those people who underwent viral load testing between 1 August 2016-31 July 2017 at Wilkins Hospital, Harare, Zimbabwe. Of those with high viral load to assess; a) the proportion who enrolled for EAC, the demographic and clinical characteristics associated with enrolment for EAC and, b) the proportion who achieved viral load suppression and demographic, clinical characteristics associated with viral load suppression. DESIGN: Retrospective cohort study using routinely collected programme data. Data was collected from PLHIV who were on ART and had a high viral load from 1 August 2016 to 31 July 2017. RESULTS: Of 5,573 PLHIV on ART between 1 August 2016 and 31 July 2017, 4787 (85.9%) had undergone VL testing and 646 (13.5%) had high VLs. Of these 646, only 489 (75.7%) were enrolled for EAC, of whom 444 (69%) underwent a repeat VL test at ≥ 3 months with 201 (31.2%) achieving VL suppression. The clinical characteristics that were independently associated with higher probability of VL suppression were: a) undergoing 3 sessions of EAC; b) being on 2nd line ART. Initial VL levels >5,000 copies/ml were associated with lower probability of viral suppression. CONCLUSION: The routine VL testing levels were high, but there were major programmatic gaps in enrolling PLHIV with high VLs into EAC and achieving VL suppression. The full potential of EAC on achieving viral load suppression has not been achieved in this setting. The reasons for these gaps need to be assessed in future research studies and addressed by suitable changes in policies/practices.

Can a Village Headman Use an Electronic Village Register and a Simplified Community-Based Verbal Autopsy Tool to Record Numbers and Causes of Death in Rural Malawi?

Introduction: Most people in Africa die without appearing in official vital statistics records. To improve this situation, Malawi has introduced solar-powered electronic village registers (EVR), managed by village headmen, to record birth and death information for production of vital statistics. The EVR is deployed in 83 villages in Traditional Authority Mtema, Lilongwe, which is an area without electricity. In 17 villages, village headmen were also trained to use a simple verbal autopsy (VA) tool adapted from one developed by the World Health Organization (WHO). Study objectives were to (i) document numbers and causes of death occurring in 17 villages between April 2016 and September 2017, and (ii) assess percentage measures of agreement on causes of death as recorded by village headmen using a simple VA tool and by a team of health surveillance assistant (HSA)/medical doctor using the WHO VA tool. Methods: The study was in two-parts: (i) a cross-sectional study using secondary data from the EVR; (ii) primary data collection study comparing causes of death obtained by village headmen using a simple VA tool and by HSA/medical doctor using the WHO VA tool. Results: Over 18 months, 120 deaths were recorded by EVR in 14,264 residents - crude annual death rate 5.6/1,000 population. Median age at death was 43 years with 69 (58%) deaths being in males. Death occurred at home (75%) and at health facility (25%). Malaria, diarrhoeal disease, pulmonary tuberculosis, acute respiratory infection, and stroke accounted for 56% of deaths recorded by village headmen using the simple VA tool. Causes of death between village headmen and the HSA/medical doctor team were compared for 107 deaths. There was full agreement in causes of death in 33 (31%) deaths, mostly for malaria, severe anemia, intentional self-harm, cancer, and epilepsy. Unknown-sudden death and sepsis recorded by the HSA/medical doctor team were responsible for most disagreements. Conclusion: It is feasible for village headmen in rural Malawi to use an EVR and simple VA tool to document numbers and causes of deaths. More work is needed to improve accuracy of causes of death by village headmen.

How well does the process of screening and diagnosis work for HIV-infected persons identified with presumptive tuberculosis who are attending HIV care and treatment clinics in Harare city, Zimbabwe?

Background: Intensified TB case finding is recommended for all HIV-infected persons regularly attending HIV care and treatment clinics. The authors aimed to determine how well this system worked among HIV-infected patients diagnosed with presumptive TB in 14 health facilities of Harare province, Zimbabwe, between January and December 2016. Methods: Retrospective review using routine programme records. Results: Of 47 659 HIV-infected persons enrolled in HIV care, 102 were identified with presumptive TB through the programmatic electronic database. Of these, 23% (23/102) were recorded in presumptive TB registers and, of these 65% (15/23) were traced to laboratory registers. Of 79 patients not recorded in presumptive TB registers, 9% (7/79) were traced to laboratory registers. Of 22 patients in the laboratory register, all had negative sputum smears for acid-fast bacilli and 45% (10/22) had Xpert MTB/RIF assays with one positive result. Six patients altogether started anti-tuberculosis treatment, the median time from presumptive tuberculosis diagnosis to treatment being 12 days. The only significant risk factor for loss-to-follow-up between presumptive TB diagnosis and laboratory registration was not being recorded in presumptive TB registers. Conclusions: Follow-up mechanisms for presumptive TB cases diagnosed in HIV care clinics in Harare city need strengthening, particularly through improved documentation in presumptive TB registers and better Xpert MTB/RIF use.

HIV testing uptake and retention in care of HIV-infected pregnant and breastfeeding women initiated on 'Option B+' in rural Zimbabwe.

OBJECTIVES: Zimbabwe has started to scale up Option B+ for the prevention of mother-to-child transmission of HIV, but there is little published information about uptake or retention in care. This study determined the number and proportion of pregnant and lactating women in rural districts diagnosed with HIV infection and started on Option B+ along with six-month antiretroviral treatment (ART) outcomes. METHODS: This was a retrospective record review of women presenting to antenatal care or maternal and child health services at 34 health facilities in Chikomba and Gutu rural districts, Zimbabwe, between January and March 2014. RESULTS: A total of 2728 women presented to care of whom 2598 were eligible for HIV testing: 76% presented to antenatal care, 20% during labour and delivery and 4% while breastfeeding. Of 2097 (81%) HIV-tested women, 7% were HIV positive. Lower HIV testing uptake was found with increasing parity, late presentation to antenatal care, health centre attendance and in women tested during labour. Ninety-one per cent of the HIV-positive women were started on Option B+. Six-month ART retention in care, including transfers, was 83%. Loss to follow-up was the main cause of attrition. Increasing age and gravida status ≥2 were associated with higher six-month attrition. CONCLUSION: The uptake of HIV testing and Option B+ is high in women attending antenatal and post-natal clinics in rural Zimbabwe, suggesting that the strategy is feasible for national scale-up in the country.

Patient retention, clinical outcomes and attrition-associated factors of HIV-infected patients enrolled in Zimbabwe's National Antiretroviral Therapy Programme, 2007-2010.

BACKGROUND: Since establishment of Zimbabwe's National Antiretroviral Therapy (ART) Programme in 2004, ART provision has expanded from <5,000 to 369,431 adults by 2011. However, patient outcomes are unexplored. OBJECTIVE: To determine improvement in health status, retention and factors associated with attrition among HIV-infected patients on ART. METHODS: A retrospective review of abstracted patient records of adults ≥ 15 years who initiated ART from 2007 to 2009 was done. Frequencies and medians were calculated for rates of retention in care and changes in key health status outcomes at 6, 12, 24 and 36 months respectively. Cox proportional hazards models were used to determine factors associated with attrition. RESULTS: Of the 3,919 patients, 64% were female, 86% were either WHO clinical stage III or IV. Rates of patient retention at 6, 12, 24 and 36 months were 90.7%, 78.1%, 68.8% and 64.4%, respectively. After ART initiation, median weight gains at 6, 12, and 24 months were 3, 4.5, and 5.0 kgs whilst median CD4+ cell count gains at 6, 12 and 24 months were 122, 157 and 279 cells/µL respectively. Factors associated with an increased risk of attrition included male gender (AHR 1.2; 95% CI, 1.1-1.4), baseline WHO stage IV (AHR 1.7; 95% CI, 1.1-2.6), lower baseline body weight (AHR 2.0; 95% CI, 1.4-2. 8) and accessing care from higher level healthcare facilities (AHR 3.5; 95% 1.1-11.2). CONCLUSIONS: Our findings with regard to retention as well as clinical and immunological improvements following uptake of ART, are similar to what has been found in other settings. Factors influencing attrition also mirror those found in other parts of sub-Saharan Africa. These findings suggest the need to strengthen earlier diagnosis and treatment to further improve treatment outcomes. Whilst decentralisation improves ART coverage it should be coupled with strategies aimed at improving patient retention.