Monitoring HIV Drug Resistance: Early Warning Indicators to Assess Performance of Thailand's Antiretroviral Treatment Program.

OBJECTIVE: To describe trends in Thailand's antiretroviral treatment (ART) program performance assessed by HIV drug resistance early warning indicators (EWIs), as recommended by WHO, between 2009 and 2013. MATERIAL AND METHOD: Seven EWIs were monitored, viral load (VL) testing coverage, VL suppression, retention in ART, lost to follow-up (LTFU), antiretrovirals (ARVs) dispensing practices, on-time pill pick-up, and pharmacy stock-outs. Data from ART adult patients in National Health Security Office Scheme were analyzed except for pharmacy stock-outs, which were reported from hospitals. Aggregated averages were calculated for each EWI. Chi-square for trend was applied to measure significant changes. RESULTS: By September 2013, 174,284 adults were receiving ART at 929 hospitals. Over time, improvement in VL testing coverage (53.8% in 2009 to 79.8% in 2013) was observed. VL suppression and on-time pill pick up rates were well above 90%. Rates of retention in ART declined from 84.0 to 82.9%, whereas LTFU rates increased from 8.3 to 9.2% (p<0.001). Prescriptions with inappropriate ARVs decreased from 0.32 to 0.10% (p<0.001). Of reporting hospitals, 96.1%, 96.3%, and 96.2% observed no ARVs stock-out between 2011 and 2013. CONCLUSION: EWI is a useful tool to monitor ART program performance and to identify area where improvement is needed.

Considerations for oral cholera vaccine use during outbreak after earthquake in Haiti, 2010-2011.

Oral cholera vaccines (OCVs) have been recommended in cholera-endemic settings and preemptively during outbreaks and complex emergencies. However, experience and guidelines for reactive use after an outbreak has started are limited. In 2010, after over a century without epidemic cholera, an outbreak was reported in Haiti after an earthquake. As intensive nonvaccine cholera control measures were initiated, the feasibility of OCV use was considered. We reviewed OCV characteristics and recommendations for their use and assessed global vaccine availability and capacity to implement a vaccination campaign. Real-time modeling was conducted to estimate vaccine impact. Ultimately, cholera vaccination was not implemented because of limited vaccine availability, complex logistical and operational challenges of a multidose regimen, and obstacles to conducting a campaign in a setting with population displacement and civil unrest. Use of OCVs is an option for cholera control; guidelines for their appropriate use in epidemic and emergency settings are urgently needed.

Rapid assessment of cholera-related deaths, Artibonite Department, Haiti, 2010.

We evaluated a high (6%) cholera case-fatality rate in Haiti. Of 39 community decedents, only 23% consumed oral rehydration salts at home, and 59% did not seek care, whereas 54% of 48 health facility decedents died after overnight admission. Early in the cholera epidemic, care was inadequate or nonexistent.

Risk factors early in the 2010 cholera epidemic, Haiti.

During the early weeks of the cholera outbreak that began in Haiti in October 2010, we conducted a case-control study to identify risk factors. Drinking treated water was strongly protective against illness. Our results highlight the effectiveness of safe water in cholera control.

Early diagnosis of human immunodeficiency virus in infants using polymerase chain reaction on dried blood spots in Botswana's national program for prevention of mother-to-child transmission.

BACKGROUND: Botswana has high antenatal human immunodeficiency virus (HIV) prevalence (33.4%). The public health system provides free services for prevention of mother to child transmission of HIV (PMTCT) and antiretroviral therapy, which can reduce vertical HIV transmission from 35% to <5%. Infant HIV diagnosis is challenging in resource-limited settings, and HIV prevalence among HIV-exposed infants in Botswana is unknown. Dried blood spot (DBS) polymerase chain reaction (PCR) provides a feasible method to assess PMTCT programs and identify HIV-infected children. METHODS: We trained staff in 15 clinics and a hospital to obtain DBS on HIV-exposed infants age 6 weeks to 17 months receiving routine care. Samples were sent to the national HIV reference laboratory. Roche Amplicor 1.5 DNA PCR testing was performed. RESULTS: Between June-December 2005, 1931 HIV-exposed infants age 6 weeks to 17 months were tested for HIV, of whom 136 (7.0%) were HIV infected. Among infants

Changes in plasma HIV-1-RNA viral load and CD4 cell counts, and lack of zidovudine resistance among pregnant women receiving short-course zidovudine.

OBJECTIVE: To describe changes in HIV-1 plasma viral load (VL) and CD4 cell counts and to assess zidovudine resistance associated with a short course of oral zidovudine during late pregnancy. METHODS: From April 1996 to February 1998 in Abidjan, Côte d'Ivoire, 280 HIV-1-seropositive women were randomly assigned at 36 weeks' gestation to receive zidovudine (300 mg) or placebo twice a day, and then one tablet every 3 h from the onset of labor until delivery. Blood samples obtained every 2 weeks until delivery, then at 2 and 4 weeks, and 3 or 6 months after delivery were tested from selected women based on duration of therapy for plasma VL and CD4 cell counts, and samples from 20 women in the zidovudine group were tested by DNA sequencing for the presence of zidovudine resistance mutations. RESULTS: In the zidovudine group, the median reduction in plasma VL (log(10) copies/ml) was -0.48 after 2 weeks (P = 0.02 versus placebo), -0.48 after 4 weeks (P = 0.06), -0.80 after 6 weeks (P = 0.29) of treatment, -0.12 at delivery (P = 0.11), +0.21 at 2 weeks (P = 0.83), +0.17 at 4 weeks (P = 0.69), and +0.21 at 3 months (P = 0.56) postpartum. Median CD4 cell counts were higher in the zidovudine than in the placebo group after 2, 4, and 6 weeks of treatment (P < 0.05). No mutations associated with zidovudine resistance were identified in any of the samples tested. CONCLUSION: These findings suggest that a short course of zidovudine has no adverse HIV-1 virological consequences for the mother.

HIV prevalence and risk behavior among clients of female sex workers in Abidjan, Côte d'Ivoire.

OBJECTIVE: To assess socio-demographic and behavioural characteristics of clients of female sex workers in Abidjan, and to determine their HIV prevalence and related risk factors. DESIGN: A cross-sectional study among clients of female sex workers in Abidjan, Côte d'Ivoire. METHODS: A trained interviewer approached clients leaving the room of a female sex worker and invited them for an interview using a structured questionnaire, and to provide a saliva sample. Saliva was tested for HIV antibodies by the GACELISA assay (Murex, Dartford, UK). RESULTS: A total of 526 clients agreed to participate, and 423 (80.4%) provided a saliva sample. Reported condom use was very high, 92.7% said they always use condoms and 95.4% reported condom use during the visit preceding the interview. The overall HIV prevalence among the clients who provided a saliva sample was 13.4%. Older age and being married or cohabitating was significantly associated with HIV infection in multivariate analysis. CONCLUSIONS: HIV prevalence appears to be relatively low, and condom use is high among clients of female sex workers in Abidjan. Existing HIV prevention efforts among female sex workers and among the general population should be sustained and reinforced.

Differences in HIV-2 plasma viral load and immune activation in HIV-1 and HIV-2 dually infected persons and those infected with HIV-2 only in Abidjan, Côte D'Ivoire.

OBJECTIVE: To determine whether blood plasma levels of HIV-2 RNA viral loads and immune activation markers differ between persons infected with HIV-2 only and those dually infected with HIV-1 and HIV-2. METHODS: Between September 1996 and February 2000, we collected, analyzed and compared levels of HIV-2 RNA in plasma and immune activation markers among 52 persons infected with HIV-2 alone and 75 with confirmed dual infection. We also compared viral load and immune activation in patients who were infected with HIV-1 only and those who were dually infected. RESULTS: When we conducted a CD4 T-cell count-stratified multivariate analysis of HIV-2 viral load, controlling for difference in CD4 T-cell counts, age and sex: at < 200 x 10 CD4 T cells/l, HIV-2 viral load was 2.0 log10 copies/ml lower in dually infected patients than in HIV-2 only patients (P < 0.0001). At CD4 T-cell counts between 200 x 10 and 500 x 10/l, HIV-2 viral load was 0.3 log10 copies/ml lower in dually infected patients (P = 0.45). However, at CD4 T-cells counts > 500 x 10/l, HIV-2 viral load was 0.9 log10 copies/ml higher in dually infected patients (P < 0.0001). Dually infected persons with undetectable HIV-2 viral loads had significantly higher median levels of CD8 T cells expressing CD38 (P < 0.001) and HLA-DR (P = 0.01) than HIV-2 only infected patients. CONCLUSION: These results suggest that in dual infection, the level of HIV-2 replication depends on the immune status of the patients, with HIV-1 out-replicating HIV-2 as disease progress.

Changes in levels of immune activation and reconstitution markers among HIV-1-infected Africans receiving antiretroviral therapy.

OBJECTIVE: To describe changes in immune activation and reconstitution markers among HIV-1-infected patients receiving antiretroviral therapy (ART) in Abidjan, Côte d'Ivoire. METHODS: Between November 1998 and February 2001, we analyzed changes in immune activation and reconstitution markers among 52 patients. Good virologic responders (n = 26) were defined as those who had suppressed and maintained plasma viral load (VL) below the detection limit of the assay for at least 12 months. Poor virologic responders (n = 26) were defined as those with a detectable VL at 6 and 12 months after beginning ART. RESULTS: Of the 26 good virologic responders, 20 (77%) were on highly active antiretroviral therapy (HAART) compared with one (4%) of the poor responders. Among the 26 good responders, baseline median levels of CD38+CD8+ T cells were elevated, but had decreased significantly at 6 months (P < 0.001) and at 12 months of therapy (P < 0.001). Median levels of HLA-DR+CD8+ T cells also decreased from baseline at 6 months (P < 0.001) and at 12 months of therapy (P < 0.001). Levels of CD62L+CD4+ T cells increased steadily during the 6 and 12 months of therapy and reached levels observed among HIV-negative blood donors (P = 0.07). Among the 26 poor responders, median levels of CD38+CD8+ T cells decreased significantly at 12 months of therapy (P = 0.006), but were higher than levels in blood donors (P = 0.005). Levels of HLA-DR+CD8+ T cells decreased significantly at 12 months of therapy (P < 0.001). Levels of CD62L+CD4+ decreased over time. CONCLUSION: Our results suggest that HAART can be successfully used in African populations with elevated baseline immune activation markers.

Prevalence of genotypic and phenotypic HIV-1 drug-resistant strains among patients who have rebound in viral load while receiving antiretroviral therapy in the UNAIDS-Drug Access Initiative in Abidjan, Côte d'Ivoire.

OBJECTIVE: To determine the prevalence of genotypic and phenotypic antiretroviral (ARV) drug-resistant HIV-1 strains among patients with viral load rebound while receiving ARV therapy in Abidjan, Côte d'Ivoire. METHODS: Between August 1998 and April 2000, we selected all patients (n = 241) who had received ARV drug therapy for at least 6 months in the UNAIDS-Drug Access Initiative (DAI), in Abidjan. We analyzed for genotypic and phenotypic drug resistance among 97 (40%) of the 241 patients who had a rebound in plasma viral load, defined as an initial decrease of > 0.5 log10 copies/ml followed by a subsequent increase of > 0.25 log10 copies/ml. RESULTS: Of the viruses isolated from the 97 patients, 86 (88.7%) had usable sequences and 68 (79%) of the 86 patients had genotypic resistance to at least one reverse transcriptase inhibitor (RTI) or protease inhibitor (PI). Resistant mutations were found for zidovudine in 50 (78%) of 64 patients who had received the drug, 11 (68.7%) of 16 patients on lamivudine, for nevirapine in two (2%), for indinavir in one (1%), and for ritonavir in one (1%). Phenotypic resistance to at least one nucleoside RTI was seen in 45 (56%) of the 80 patients tested, to non-nucleoside RTIs in eight (10%), and to PIs in one (1.3%). Multivariate regression analysis showed factors associated with resistance to be initial treatment with dual therapy (P = 0.04) compared with highly active antiretroviral therapy, and maximal initial viral load response (P = 0.006). CONCLUSION: Our results demonstrate a high prevalence of ARV drug resistance associated with dual ARV therapy. These results indicate the limited role for dual ARV therapy.

Positive association between beta-chemokine-producing T cells and HIV type 1 viral load in HIV-infected subjects in Abidjan, Côte d'Ivoire.

The role of beta-chemokines in controlling HIV replication in vivo is still controversial. Therefore, the association between HIV-1 plasma viral load and the capacity of CD4(+) and CD8(+) T cells to produce beta-chemokines was studied in 28 antiretroviral drug-naïve HIV-1-infected female sex workers in Abidjan, Côte d'Ivoire. Percentages of beta-chemokine-positive T cells were measured in peripheral blood mononuclear cells by flow cytometry after intracellular staining for RANTES (regulated on activation, normal T expressed and secreted), macrophage inflammatory protein (MIP)-1alpha, and MIP-1beta. HIV-1-infected subjects had higher percentages of MIP-1alpha- and MIP-1beta-positive CD4(+) and CD8(+) T cells (p < 0.02) and of RANTES-positive CD8(+) T cells (p = 0.054) than uninfected controls. Percentages of RANTES- and MIP-1beta-positive CD8(+) T cells correlated directly with HIV-1 plasma viral load (p < 0.02). Percentages of beta-chemokine-positive CD4(+) and CD8(+) T cells correlated directly with percentages of HLA-DR-positive T cells (p < 0.02) and inversely (except RANTES in CD4(+) T cells) with absolute numbers of CD4(+) T cells (p < 0.05) in peripheral blood. These data indicate that increased percentages of beta-chemokine-producing T cells in HIV-1-infected subjects correlate with disease progression and are a sign of viremia-driven chronic T cell activation.

Prevalence of transmitted HIV drug resistance in Botswana: lessons learned from the HIVDR-Threshold Survey conducted among women presenting for routine antenatal care as part of the 2007 national sentinel survey.

The emergence and spread of transmitted drug resistance (TDR) poses a major threat to the success of the rapidly expanding antiretroviral treatment (ART) programs in resource-limited countries. The World Health Organization recommends the use of the HIV Drug Resistance Threshold Survey (HIVDR-TS) as an affordable means to monitor the presence of TDR in these settings. We report our experiences and results of the 2007 HIVDR-TS in Botswana, a country with one of the longest-existing national public ART programs in Africa. The HIVDR-TS and HIV-1 incidence testing were performed in the two largest national sites as part of the 2007 antenatal Botswana Sentinel Survey. The HIVDR-TS showed no significant drug resistance mutations (TDR less than 5%) in one site. TDR prevalence, however, could not be ascertained at the second site due to low sample size. The agreement between HIVDR-TS eligibility criteria and laboratory-based methodologies (i.e., BED-CEIA and LS-EIA) in identifying recently HIV-1 infected adults was poor. Five years following the establishment of Botswana's public ART program, the prevalence of TDR remains low. The HIVDR-TS methodology has limitations for low-density populations as in Botswana, where the majority of antenatal sites are too small to recruit sufficient numbers of patients. In addition, the eligibility criteria (age <25 years and parity (first pregnancy)) of the HIVDR-TS performed poorly in identifying recent HIV-1 infections in Botswana. An alternative sampling strategy should be considered for the surveillance of HIVDR in Botswana and similar geographic settings.

Validation of AIDS-related mortality in Botswana.

BACKGROUND: Mortality data are used to conduct disease surveillance, describe health status and inform planning processes for health service provision and resource allocation. In many countries, HIV- and AIDS-related deaths are believed to be under-reported in government statistics. METHODS: To estimate the extent of under-reporting of HIV- and AIDS-related deaths in Botswana, we conducted a retrospective study of a sample of deaths reported in the government vital registration database from eight hospitals, where more than 40% of deaths in the country in 2005 occurred. We used the consensus of three physicians conducting independent reviews of medical records as the gold standard comparison. We examined the sensitivity, specificity and other validity statistics. RESULTS: Of the 5276 deaths registered in the eight hospitals, 29% were HIV- and AIDS-related. The percentage of HIV- and AIDS-related deaths confirmed by physician consensus (positive predictive value) was 95.4%; however, the percentage of non-HIV- and non-AIDS-related deaths confirmed (negative predictive value) was only 69.1%. The sensitivity and specificity of the vital registration system was 55.7% and 97.3%, respectively. After correcting for misclassification, the percentage of HIV- and AIDS--related deaths was estimated to be in the range of 48.8% to 54.4%, depending on the definition. CONCLUSION: Improvements in hospitals and within government offices are necessary to strengthen the vital registration system. These should include such strategies as training physicians and coders in accurate reporting and recording of death statistics, implementing continuous quality assurance methods, and working with the government to underscore the importance of using mortality statistics in future evidence-based planning.

Entertainment-education radio serial drama and outcomes related to HIV testing in Botswana.

Makgabaneng is an entertainment-education radio serial drama written and produced in Botswana to promote prevention of HIV. This effort is part of the national response to HIV/AIDS. Broadcast of the serial drama began in August 2001, and two new 15-minute episodes air each week. We examined associations between exposure to Makgabaneng and outcomes related to HIV testing, including stigmatizing attitudes, intention to be tested, talking with a partner about testing, and testing for HIV, among 555 sexually active respondents. The four measures of exposure to Makgabaneng were frequency of listening, duration of listening, talking about the program, and attentiveness to and identification with relevant characters. Data were collected approximately 18 months after the drama began airing. We found positive associations between exposure to the program and intermediate outcomes, including lower level of stigmatizing attitudes, stronger intention to have HIV testing, and talking to a partner about testing. Although associations were identified with all four measures of exposure, increased duration of listening was associated with more positive outcomes than the other measures. This finding suggests that longer term exposure to entertainment-education programming may be important for behavior change.

"A bull cannot be contained in a single kraal": concurrent sexual partnerships in Botswana.

To inform efforts to curb HIV in Botswana, we describe sexual concurrency and related norms and behaviors among a sample of 807 Batswana age 15-49 years who participated in a 2003 population-based survey. Of 546 sexually active respondents, 23% reported ever having a concurrent sexual partnership with any of the last three partners from the last 12 months. Multivariate analysis found that men and youth (age <25 years), and non-religious people were more likely than their respective counterparts to report concurrency. Respondents reporting concurrency were more likely than those not, to have norms that support multiple partnerships and report low self-efficacy to be faithful to one partner. However, a majority of both groups reported believing that fidelity is important and that they would be looked down upon by family and friends if discovered to have multiple partnerships. The findings suggest that concurrency in Botswana is not uncommon, and yet may not be generally acceptable.

Faithfulness to partners: a means to prevent HIV infection, a source of HIV infection risks, or both? A qualitative study of women's experiences in Abidjan, Côte d'Ivoire.

A cross-sectional study was carried out at a programme to prevent mother-to-child transmission of HIV (MTCT) at a public antenatal clinic in Abidjan, Côte d'Ivoire. The objectives were to obtain information from women concerning their reactions to HIV test results received through the programme, their experiences with faithfulness to partners as a means of primary HIV prevention for themselves and their infants, their relationships with partners, their own and their partners' experiences with HIV testing, and their knowledge of their partners' HIV serostatus. The participants were a purposive sample of 87 women who had received HIV-1-positive test results and 30 women who had received HIV-1-negative test results through the clinic's programme. Eighty-five per cent of the HIV-positive women were surprised by their test result; 52% of those who tested HIV-negative anticipated that result. Nearly two-thirds of those who were surprised to be HIV-positive and a similar proportion of those who expected to be HIV-negative explained their reactions by referring to faithfulness to their partners. Only five of the 117 women interviewed expressed a belief that their partners were faithful to them; and only two, and none of those who received an HIV-positive test result, reported using condoms with partners. No more than one-fourth of either the HIV-positive or the HIV-negative groups of women had been previously tested for HIV; less than one-fourth of the women in each group reported having partners who had been tested for HIV, or knew their partners' serostatus. Relationship characteristics of some HIV-positive women may have increased their vulnerability to HIV infection. Although being faithful to partners can be effective for the primary prevention of HIV infection, the manner in which it was practiced by many of the women in our study may have further increased their risk of infection. Organisations that choose to fund HIV prevention programmes that promote faithfulness to partners, and the programmes that stress faithfulness, must ensure that women are informed about the conditions that can influence the effectiveness of faithfulness as a protective action. However, women need more than information. Prevention programmes, whether concerned primarily with prevention of MTCT or with HIV prevention more broadly, must promote and elicit cooperation from women's sexual partners to support women's efforts to be tested for HIV, to be tested for HIV themselves, to disclose their test results, to reciprocate women's faithfulness and, if HIV serodiscordant or unwilling to be faithful, to use condoms. These steps may increase the likelihood that women will be able to protect themselves and their infants from HIV infection by being faithful to their partners.

Botswana's Tebelopele voluntary HIV counseling and testing network: use and client risk factors for HIV infection, 2000-2004.

BACKGROUND: : HIV services, including voluntary counseling and testing (VCT) and antiretroviral (ARV) therapy, expanded rapidly in Botswana from 2000 through 2004. METHODS: : Client data from Botswana's Tebelopele VCT network were analyzed to describe clients, factors associated with HIV infection, and trends in VCT use. RESULTS: : Tebelopele provided free, anonymous, same-day HIV tests for 117,234 clients from 2000 through 2004. Before ARV therapy was available, 8.3% of clients sought a test because of illness, and 26.3% were HIV-positive. After ARV therapy became available, 20.1% of clients sought a test because of illness, and 38.8% were HIV-positive. Most VCT clients (82.7%) were unmarried; 89.8% reported no or 1 sexual partner in the last 3 months; and 50.2% of unmarried clients reported always using condoms in the last 3 months. In multivariate analysis, higher educational level, marriage, and always using condoms were associated with a lower risk of HIV. Having only 1 recent sexual partner was associated with less condom use and a higher risk of being HIV-positive for men. CONCLUSIONS: : VCT has been well accepted in Botswana. Analysis of this data set supports efforts to promote 100% condom use and to emphasize that partner reduction must be combined with condom use and HIV testing to protect against HIV.

Cellular human immunodeficiency virus (HIV)-protective factors: a comparison of HIV-exposed seronegative female sex workers and female blood donors in Abidjan, Côte d'Ivoire.

Cellular factors that may protect against human immunodeficiency virus (HIV) infection were investigated in 27 HIV-exposed seronegative (ESN) female sex workers (FSWs) and 27 HIV-seronegative female blood donors. Compared with blood donors, ESN FSWs had significantly decreased expression levels of C-X-C chemokine receptor 4 (CXCR4), but not of C-C chemokine receptor 5, on both memory (P<.001) and naive (P=.041) CD4(+) T cells. CXCR4 down-regulation was associated with prolonged duration of commercial sex work by ESN FSWs. CD38 expression on CD8(+) T cells was significantly increased among ESN FSWs, compared with that among blood donors (P=.017). There were no differences in HLA-DR and CD62L expression between blood donors and ESN FSWs. Proportions of T cells producing the beta-chemokines RANTES (regulated on activation, normally T cell-expressed and -secreted), macrophage inflammatory protein (MIP)-1alpha, and MIP-1beta or the cytokines interleukin (IL)-2, IL-4, interferon-gamma, and tumor necrosis factor-alpha, were similar in the 2 groups. These data indicate that ESN FSWs differ from HIV-seronegative female blood donors with respect to immunological factors that have no clear protective potential against HIV transmission.

HIV-1 viral load and other risk factors for mother-to-child transmission of HIV-1 in a breast-feeding population in Cote d'Ivoire.

Short-course antiretroviral regimens have been evaluated to reduce mother-to-child transmission of HIV in resource-limited settings. This report from Abidjan, Cote d'Ivoire, examines the risk factors for HIV transmission by 1 and 24 months among breast-feeding women. Eligible HIV-1-seropositive pregnant women enrolled in this randomized double-blind clinical trial were randomly assigned to receive either oral zidovudine (ZDV) (n = 126) prophylaxis or placebo (n = 124). Maternal prophylaxis began at 36 weeks of gestation (300 mg ZDV twice daily antepartum and 300 mg every 3 hours intrapartum); there was no neonatal prophylaxis component. The cumulative risk of transmission in the treatment group was 11.9% and 22.1% by 1 and 24 months, respectively. In adjusted analyses, viral load at enrollment was the strongest predictor of transmission (per log increment: odds ratio [OR] = 4.8, 95% confidence interval [CI]: 2.5-9.5 at 1 month; OR = 5.7; 95% CI: 3.1-10.8 at 24 months). Overall, ZDV prophylaxis was not significantly protective for infection at 1 or 24 months. Comparing ZDV with placebo following dichotomization of viral load (<50,000 vs. > or =50,000 copies/mL) at enrollment, however, there was a significant effect of ZDV seen only among those women with a low viral load at enrollment. The substantial risk of transmission despite ZDV prophylaxis, particularly among those with higher viral loads, underscores the need to find more effective regimens appropriate for use in resource-limited settings.

Women's reasons for not participating in follow up visits before starting short course antiretroviral prophylaxis for prevention of mother to child transmission of HIV: qualitative interview study.

OBJECTIVE: To find out why pregnant women who receive HIV-1 positive test results and are offered short course antiretroviral prophylaxis to prevent transmission of HIV from mother to child do not participate in necessary follow up visits before starting prophylaxis. DESIGN: Qualitative interview study. SETTING: A programme aiming to prevent transmission of HIV from mother to child at a public antenatal clinic in Abidjan, Côte d'Ivoire. PARTICIPANTS: Purposive sample of 27 women who had received HIV-1 positive test results and were invited to return for monthly follow up visits before starting prophylaxis with zidovudine at 36 weeks' gestation, but who had either refused or discontinued the visits. None of the women started prophylaxis. RESULTS: Most of the women explained their non-participation in follow up visits by referring to negative experiences that they had had while interacting with programme staff or to their views about the programme. Additional reasons concerned their disbelief of HIV positive test results and personal factors. CONCLUSIONS: Difficulties experienced by women during their contacts with staff working on the prevention programme and negative views that they have about the programme can contribute to their non-participation in prophylaxis. Training and supervision of programme staff may increase the likelihood of positive interactions between staff and clients, thereby facilitating women's participation in preventing transmission of HIV from mother to child. Outreach and mobilisation in communities that are served by prevention programmes may complement these measures at programme level by contributing to increased social support for women's efforts to prevent transmission of HIV from mother to child.