Characterizing hepatitis B virus infection in children in the Democratic Republic of Congo to inform elimination efforts.

Objective: Despite global reductions in hepatitis B virus (HBV) prevalence, an estimated 6.2 million children are infected, two-thirds of whom live in the WHO Africa region. We sought to characterize childhood HBV to inform elimination efforts in the Democratic Republic of Congo (DRC), one of the largest and most populous African countries. Methods: Using the most recent (2013-14) nationally representative Demographic and Health Survey in the DRC, we analyzed HBV surface antigen (HBsAg) on dried blood spots and associated survey data from children aged 6-59 months. We estimated HBsAg-positivity prevalence nationally, regionally, and by potential correlates of infection. We evaluated spatial variation in HBsAg-positivity prevalence, overall and by age, sex, and vaccination status. Findings: Using data from 5,679 children, we found national HBsAg-positivity prevalence was 1.3% (95% CI: 0.9%-1.7%), but ranged from 0.0% in DRC's capital city province, Kinshasa, to 5.6% in northwestern Sud-Ubangi Province. Prevalence among boys (1.8%, 95% CI: 1.2%-2.7%) was double that among girls (0.7%, 95%CI: 0.4%-1.3%). Tetanus antibody-negativity, rurality, and lower household wealth were also significantly associated with higher HBsAg-positivity prevalence. We observed no difference in prevalence by age. Children had higher HBsAg-positivity odds if living with ≥1 HBsAg-positive adult household member (OR: 2.3, 95%CI: 0.7-7.8), particularly an HBsAg-positive mother (OR: 7.2, 95%CI:1.6-32.2). Conclusion: In the largest national survey of HBV among children and household contacts in the DRC, we found that childhood HBV prevalence was 10-60 times the global target of 0.1%. We highlight specific regions and populations for further investigation and focused prevention efforts.

Xpert(®) MTB/RIF for smear-negative presumptive TB: impact on case notification in DR Congo.

SETTING: The impact of Xpert(®) MTB/RIF as a follow-on diagnostic test after smear microscopy on tuberculosis (TB) notification has not yet been well defined. DESIGN: Quasi-experimental design with 86 evaluation and 49 control clinics in Kinshasa, Democratic Republic of Congo. Smear microscopy was supported at all 135 clinics, Xpert was placed in 15 evaluation clinics and a sputum transport system was implemented for 25 satellite clinics. The number of cases notified before and during the project (July 2012-June 2013) was obtained from the National TB Program. RESULTS: Of 27,147 presumptive TB cases presenting in clinics with access to Xpert, 5922 (21.8%) were smear-positive. Of 18,636 individuals with ⩾ 3 negative microscopy results, 6920 (37.1%) underwent Xpert testing, 991 (14.3%) of whom tested positive. The number of bacteriologically positive cases increased equally in evaluation clinics (15.1%, 95%CI -2.3 to 32.6) and control clinics (13.6%, 95%CI 2.6-29.3), for a difference in increase of 1.5% (95%CI -28.8 to 31.8). There was no difference in the change in smear-negative cases (-42.4%, 95%CI -111.5 to 26.6), nor in all types of TB notified (-6.1%, 95%CI -32.5 to 20.4) between the evaluation and control clinics. CONCLUSION: In part due to a restrictive algorithm, Xpert as follow-on to smear microscopy did not increase the overall number of TB notifications, nor the number of bacteriologically positive cases.

Delayed antiretroviral therapy despite integrated treatment for tuberculosis and HIV infection.

SETTING: Five primary health care clinics in Kinshasa, Democratic Republic of Congo. OBJECTIVE: To examine timing and predictors of delayed initiation of antiretroviral therapy (ART) during anti-tuberculosis treatment. DESIGN: Prospective observational cohort of adult patients receiving integrated treatment for tuberculosis (TB) and human immunodeficiency virus (HIV) who are expected to initiate ART at 1 month if CD4 count is <100 cells/mm(3) or if patient is World Health Organization (WHO) Clinical Stage 4 for reasons other than extra-pulmonary TB, at 2 months if CD4 count is 100-350 cells/mm(3), or at completion of anti-tuberculosis treatment if subsequently CD4 count is ≤ 350 cells/mm(3) or patient has WHO Clinical Stage 4. RESULTS: Of 492 patients, 235 (47.8%) experienced delayed initiation of ART: 171 (72.8%) initiated ART late, after a median delay of 12 days (interquartile range [IQR] 4-27) and 64 (27.2%) never initiated ART. Contraindication to any antiretroviral drug (aOR 2.91, 95%CI 1.22-6.95), lower baseline CD4 count (aOR 1.20, 95%CI 1.08-1.33/100 cells/mm(3)), TB drug intolerance (aOR 1.93, 95%CI 1.23-3.02) and non-disclosure of HIV infection (aOR 1.50, 95%CI 1.03-2.18) predicted delayed ART initiation. CONCLUSION: Despite fully integrated treatment, half of all patients experienced delayed ART initiation. Pragmatic approaches to ensure timely ART initiation in those at risk of delayed ART initiation are needed.

Outcomes of integrated treatment for tuberculosis and HIV in children at the primary health care level.

BACKGROUND: Little is known about the integration of tuberculosis (TB) and human immunodeficiency virus (HIV) treatment in pediatric populations. METHODS: Prospective cohort of 31 HIV-infected children aged 3-18 years initiating anti-tuberculosis treatment at five primary health care (PHC) clinics in Kinshasa, Democratic Republic of Congo, to describe survival, clinical and immunological outcomes of nurse-centered integrated TB-HIV treatment. RESULTS: Almost all of the children (87.1%) were diagnosed with HIV during TB diagnosis. Most (87.0%) were successfully treated for TB. Two (6.5%) died during anti-tuberculosis treatment; both presented with low CD4 counts (36 and 59 cells/mm(3) compared to a median of 228 cells/mm(3) in the entire cohort). Most (74.2%) initiated antiretroviral therapy (ART) during anti-tuberculosis treatment. Overall, a median CD4 count increase of 106 cells/mm(3) was observed (P = 0.014), an increase of 113 cells/mm(3) among children on ART and of 71.5 cells/mm(3) in those not on ART (P = 0.78). Median body mass index increase during anti-tuberculosis treatment was 2.1 kg/m(2) overall (P = 0.002), 2.2 kg/m(2) among children on ART and 0.72 kg/m(2) in those not on ART (P = 0.08). CONCLUSION: Integrated, nurse-centered, pediatric TB-HIV treatment at the PHC level in highly resource-limited settings is feasible and effective in achieving successful outcomes, including high ART uptake, low mortality, and immunological and clinical improvement.

Correlates of condom use among sexually experienced secondary-school male students in Nairobi, Kenya.

This study aimed to examine perceptual factors associated with condom use, and the relationship between condom use and the timing of sexual debut among male secondary school students in Nairobi, Kenya. Data are from the TeenWeb study, a school-based project that used the World Wide Web to assess the health needs of secondary school students, and tested the web's utility as a teaching and research modality. Analyses are based on 214 sexually experienced males aged 14 - 20 years who completed web-based questionnaires about their sexual attitudes and behaviour. Results indicate that students did not see themselves as susceptible to HIV/AIDS and believed condom effectiveness in preventing HIV to be low. Consequently, only a marginal association was found between agreeing that buying condoms is embarrassing and condom use at first sexual intercourse. However, contrary to expectation, agreeing that condoms often break (almost half of participants) was associated with a higher likelihood of condom use at first sex. Each year of delay in sexual debut increased the likelihood of using a condom at first sex by 1.44 times. In turn, having used a condom at first sex increased the likelihood of using one at the most recent sex by 4.81 times, and elevated general condom use ('most or all the time') by 8.76 times. Interventions to increase awareness about the role of condoms in preventing HIV, delay sexual initiation, and teach proper condom use among secondary-school students in Nairobi are needed.

Correlates of Condom use among Sexually Experienced Secondary School Male Students in Nairobi; Kenya

This study aimed to examine perceptual factors associated with condom use; and the relationship between condom use and the timing of sexual debut among male secondary school students in Nairobi; Kenya. Data are from the TeenWeb study; a school-based project that used the World Wide Web to assess the health needs of secondary school students; and tested the web's utility as a teaching and research modality. Analyses are based on 214 sexually experienced males aged 14 - 20 years who completed web-based questionnaires about their sexual attitudes and behaviour. Results indicate that students did not see themselves as susceptible to HIV/AIDS and believed condom effectiveness in preventing HIV to be low. Consequently; only a marginal association was found between agreeing that buying condoms is embarrassing and condom use at first sexual intercourse. However; contrary to expectation; agreeing that condoms often break (almost half of participants) was associated with a higher likelihood of condom use at first sex. Each year of delay in sexual debut increased the likelihood of using a condom at first sex by 1.44 times. In turn; having used a condom at first sex increased the likelihood of using one at the most recent sex by 4.81 times; and elevated general condom use (`most or all the time') by 8.76 times. Interventions to increase awareness about the role of condoms in preventing HIV; delay sexual initiation; and teach proper condom use among secondary-school students in Nairobi are needed