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OBJECTIVE: To evaluate the association of type and timing of prophylactic maternal and infant antiretroviral regimen with time to first positive HIV-1 DNA PCR test, in nonbreastfed HIV-infected infants, from populations infected predominantly with HIV-1 non-B subtype virus. DESIGN: Analysis of combined data on nonbreastfed HIV-infected infants from prospective cohorts in Botswana, Thailand, and the United Kingdom (Nâ=â405). METHODS: Parametric models appropriate for interval-censored outcomes estimated the time to first positive PCR according to maternal or infant antiretroviral regimen category and timing of maternal antiretroviral initiation, with adjustment for covariates. RESULTS: Maternal antiretroviral regimens included: no antiretrovirals (nâ=â138), single-nucleoside analog reverse transcriptase inhibitor (nâ=â165), single-dose nevirapine with zidovudine (nâ=â66), and combination prophylaxis with 3 or more antiretrovirals [combination antiretroviral therapy (cART), nâ=â36]. Type of maternal/infant antiretroviral regimen and timing of maternal antiretroviral initiation were each significantly associated with time to first positive PCR (multivariate Pâ<â0.0001). The probability of a positive test with no antiretrovirals compared with the other regimen/timing groups was significantly lower at 1 day after birth, but did not differ significantly after age 14 days. In a subgroup of 143 infants testing negative at birth, infant cART was significantly associated with longer time to first positive test (multivariate Pâ=â0.04). CONCLUSION: Time to first positive HIV-1 DNA PCR in HIV-1-infected nonbreastfed infants (non-B HIV subtype) may differ according to maternal/infant antiretroviral regimen and may be longer with infant cART, which may have implications for scheduling infant HIV PCR-diagnostic testing and confirming final infant HIV status.
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Antirretrovirales/uso terapéutico , Terapia Antirretroviral Altamente Activa/métodos , Quimioprevención/métodos , ADN Viral/sangre , Genotipo , Infecciones por VIH/prevención & control , VIH-1/aislamiento & purificación , Botswana , ADN Viral/genética , Femenino , Infecciones por VIH/diagnóstico , Infecciones por VIH/tratamiento farmacológico , Infecciones por VIH/virología , VIH-1/clasificación , VIH-1/genética , Humanos , Lactante , Recién Nacido , Masculino , Reacción en Cadena de la Polimerasa , Embarazo , Estudios Prospectivos , Tailandia , Factores de Tiempo , Reino UnidoRESUMEN
BACKGROUND: Retention in care is critical for improving HIV-infected maternal outcomes and reducing vertical transmission. Health systems' interventions such as continuous quality improvement (CQI) may support health services to address factors that affect the delivery of HIV-related care and thereby influence rates of retention-in-care. METHODOLOGY: We evaluated the effect of a CQI intervention on retention-in-care at 6 months postpartum of pregnant women and mothers living with HIV who had been started on lifelong antiretroviral treatment. Thirty-two health care facilities were randomized to either implement the intervention or not. We considered women fully retained in care when they attended the 6-month postpartum visit and did not miss any previous scheduled visit by more than 30 days. RESULTS: Five hundred eleven women living with HIV attending antenatal clinics at 26 facilities were included in the analysis. Median age at enrolment was 27 years and gestational age was 20 weeks. Seventy-one percent of women were seen at 6-month postpartum irrespective of missing any scheduled visit. However, 43% of women were fully retained at 6-month postpartum and did not miss any scheduled visit based on our stringent study definition of retention. There was no significant difference in retention at 6 months between the intervention and control arms [44% vs. 41%, relative risk: 1.08; 95% confidence interval (CI): 0.78 to 1.49]. Initiation of ARV prophylaxis among infants within 72 hours was not different by study arm (66.0% vs. 74.7%, relative risk = 0.95; 95% CI: 0.84 to 1.07) but rates of early infant testing at 4-6 weeks were higher in intervention sites (48.8% vs. 25.3%, adjusted relative risk: 1.76; 95% CI: 1.27 to 2.42). CONCLUSIONS: CQI as implemented in this study did not differ across study arms in the rates of retention. Several intervention design or implementation issues or other contextual constraints may explain the absence of effect.
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Infecciones por VIH/prevención & control , Transmisión Vertical de Enfermedad Infecciosa/prevención & control , Cooperación del Paciente/estadística & datos numéricos , Complicaciones Infecciosas del Embarazo/prevención & control , Mejoramiento de la Calidad , Adulto , Fármacos Anti-VIH/uso terapéutico , Análisis por Conglomerados , Femenino , Infecciones por VIH/tratamiento farmacológico , Infecciones por VIH/transmisión , Humanos , Lactante , Masculino , Persona de Mediana Edad , Nigeria/epidemiología , Periodo Posparto , Embarazo , Complicaciones Infecciosas del Embarazo/tratamiento farmacológico , Evaluación de Programas y Proyectos de Salud , Adulto JovenRESUMEN
BACKGROUND: Continuous Quality Improvement (CQI) is a process where health teams systematically collect and regularly reflect on local data to inform decisions and modify local practices and so improve delivery of services. We implemented a cluster randomized trial to examine the effects of CQI interventions on Prevention of Mother-to-Child Transmission (PMTCT) services. Here, we report our experiences and challenges establishing CQI in 2 high HIV prevalence states in northern Nigeria. METHODS: Facility-based teams were trained to implement CQI activities, including structured assessments, developing change packages, and participation in periodic collaborative learning sessions. Locally evolved solutions (change ideas) were tested and measured using process data and intermediate process indicators were agreed including overall time spent accessing services, client satisfaction, and quality of data. RESULTS: Health workers actively participated in clinic activities and in the collaborative learning sessions. During the study, the mean difference in time spent accessing services during clinic visits increased by 40 minutes (SD = 93.4) in the control arm and decreased by 44 minutes (SD = 73.7) in the intervention arm. No significant difference was recorded in the mean client satisfaction assessment score by study arm. The quality of data was assessed using a standardized tool scored out of 100; compared with baseline data, quality at the end of study had improved at intervention sites by 6 points (95% CI: 2.0 to 10.1). CONCLUSIONS: Health workers were receptive to CQI process. A compendium of "change ideas" compiled into a single change package can be used to improve health care delivery.
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Fármacos Anti-VIH/uso terapéutico , Atención a la Salud/organización & administración , Infecciones por VIH/tratamiento farmacológico , Personal de Salud/normas , Transmisión Vertical de Enfermedad Infecciosa/prevención & control , Complicaciones Infecciosas del Embarazo/prevención & control , Mejoramiento de la Calidad , Adulto , Análisis por Conglomerados , Femenino , Infecciones por VIH/prevención & control , Infecciones por VIH/transmisión , Humanos , Lactante , Recién Nacido , Nigeria/epidemiología , Cooperación del Paciente , Embarazo , Complicaciones Infecciosas del Embarazo/tratamiento farmacológico , Desarrollo de Programa , Evaluación de Programas y Proyectos de SaludRESUMEN
INTRODUCTION: HIV testing is the entry point for the elimination of mother-to-child transmission of HIV. Decreasing external funding for the HIV response in some low- and middle-income countries has triggered the question of whether a focused approach to HIV testing targeting pregnant women in high-burden areas should be considered. This study aimed at determining and comparing the cost-effectiveness of universal and focused HIV testing approaches for pregnant women across high to very low HIV prevalence settings. METHODS: We conducted a modelling analysis on health and cost outcomes of HIV testing for pregnant women using four country-based case scenarios (Namibia, Kenya, Haiti and Viet Nam) to illustrate high, intermediate, low and very low HIV prevalence settings. We used subnational prevalence data to divide each country into high-, medium- and low-burden areas, and modelled different antenatal and testing coverage in each. RESULTS: When HIV testing services were only focused in high-burden areas within a country, mother-to-child transmission rates remained high ranging from 18 to 23%, resulting in a 25 to 69% increase in new paediatric HIV infections and increased future treatment costs for children. Universal HIV testing was found to be dominant (i.e. more QALYs gained with less cost) compared to focused approaches in the Namibia, Kenya and Haiti scenarios. The universal approach was also very cost-effective compared to focused approaches, with $ 125 per quality-adjusted life years gained in the Viet Nam-based scenario of very low HIV prevalence. Sensitivity analysis further supported the findings. CONCLUSIONS: Universal approach to antenatal HIV testing achieves the best health outcomes and is cost-saving or cost-effective in the long term across the range of HIV prevalence settings. It is further a prerequisite for quality maternal and child healthcare and for the elimination of mother-to-child transmission of HIV.
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Infecciones por VIH/diagnóstico , Complicaciones Infecciosas del Embarazo/diagnóstico , Diagnóstico Prenatal/economía , Serodiagnóstico del SIDA , Adolescente , Adulto , Análisis Costo-Beneficio , Femenino , Infecciones por VIH/economía , Infecciones por VIH/epidemiología , Haití , Humanos , Transmisión Vertical de Enfermedad Infecciosa/economía , Kenia , Tamizaje Masivo/economía , Persona de Mediana Edad , Namibia , Embarazo , Complicaciones Infecciosas del Embarazo/epidemiología , Prevalencia , Años de Vida Ajustados por Calidad de Vida , Vietnam , Adulto JovenRESUMEN
OBJECTIVES: We examined uptake of prevention of mother-to-child HIV transmission (PMTCT) services, predictors of missed opportunities, and infant HIV transmission attributable to missed opportunities along the PMTCT cascade across South Africa. METHODS: A cross-sectional survey was conducted among 4-8 week old infants receiving first immunisations in 580 nationally representative public health facilities in 2010. This included maternal interviews and testing infants' dried blood spots for HIV. A weighted analysis was performed to assess uptake of antenatal and perinatal PMTCT services along the PMTCT cascade (namely: maternal HIV testing, CD4 count test/result, and receiving maternal and infant antiretroviral treatment) and predictors of dropout. The population attributable fraction associated with dropouts at each service point are estimated. RESULTS: Of 9,803 mothers included, 31.7% were HIV-positive as identified by reactive infant antibody tests. Of these 80.4% received some form of maternal and infant antiretroviral treatment. More than a third (34.9%) of mothers dropped out from one or more steps in the PMTCT service cascade. In a multivariable analysis, the following characteristics were associated with increased dropout from the PMTCT cascade: adolescent (<20 years) mothers, low socioeconomic score, low education level, primiparous mothers, delayed first antenatal visit, homebirth, and non-disclosure of HIV status. Adolescent mothers were twice (adjusted odds ratio: 2.2, 95% confidence interval: 1.5-3.3) as likely to be unaware of their HIV-positive status and had a significantly higher rate (85.2%) of unplanned pregnancies compared to adults aged ≥20 years (55.5%, p = 0.0001). A third (33.8%) of infant HIV infections were attributable to dropout in one or more steps in the cascade. CONCLUSION: A third of transmissions attributable to missed opportunities of PMTCT services can be prevented by optimizing the uptake of PMTCT services. Identified risk factors for low PMTCT service uptake should be addressed through health facility and community-level interventions, including raising awareness, promoting women education, adolescent focused interventions, and strengthening linkages/referral-system between communities and health facilities.
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Infecciones por VIH/prevención & control , Transmisión Vertical de Enfermedad Infecciosa/prevención & control , Servicios de Salud Materna/estadística & datos numéricos , Complicaciones Infecciosas del Embarazo , Atención Prenatal/estadística & datos numéricos , Serodiagnóstico del SIDA/estadística & datos numéricos , Adolescente , Adulto , Fármacos Anti-VIH/uso terapéutico , Recuento de Linfocito CD4/estadística & datos numéricos , Estudios Transversales , Países en Desarrollo , Femenino , Infecciones por VIH/congénito , Infecciones por VIH/diagnóstico , Infecciones por VIH/tratamiento farmacológico , Infecciones por VIH/epidemiología , Infecciones por VIH/transmisión , Parto Domiciliario/estadística & datos numéricos , Humanos , Recién Nacido , Edad Materna , Servicios de Salud Materna/organización & administración , Nevirapina/uso terapéutico , Paridad , Pacientes Desistentes del Tratamiento , Embarazo , Complicaciones Infecciosas del Embarazo/diagnóstico , Complicaciones Infecciosas del Embarazo/tratamiento farmacológico , Complicaciones Infecciosas del Embarazo/epidemiología , Embarazo en Adolescencia , Factores de Riesgo , Factores Socioeconómicos , Sudáfrica/epidemiología , Zidovudina/uso terapéuticoRESUMEN
BACKGROUND: Given the ambitious targets to reduce pediatric AIDS worldwide, ongoing assessment of programs to prevent mother-to-child HIV transmission (PMTCT) is critical. The concept of a "PMTCT cascade" has been used widely to identify bottlenecks in program implementation; however, most efforts to reconstruct the cascade have relied on facility-based approaches that may limit external validity. METHODS: We analyzed data from the PEARL household survey, which measured PMTCT effectiveness in 26 communities across Zambia, South Africa, Cote d'Ivoire, and Cameroon. We recruited women who reported a delivery in the past 2 years. Among mothers confirmed to be HIV infected at the time of survey, we reconstructed the PMTCT cascade with self-reported participant information. We also analyzed data about the child's vital status; for those still alive, HIV testing was performed by DNA polymerase chain reaction testing. RESULTS: Of the 976 eligible women, only 355 (36%) completed every step of the PMTCT cascade. Among the 621 mother-child pairs who did not, 22 (4%) reported never seeking antenatal care, 103 (17%) were not tested for HIV during pregnancy, 395 (64%) reported testing but never received their HIV-positive result, 48 (8%) did not receive maternal antiretroviral prophylaxis, and 53 (9%) did not receive infant antiretroviral prophylaxis. The lowest prevalence of infant HIV infection or death was observed in those completing the cascade (10%, 95% confidence interval: 7% to 12%). CONCLUSIONS: Future efforts to measure population PMTCT impact should incorporate dimensions explored in the PEARL study-including HIV testing of HIV-exposed children in household surveys-to better understand program effectiveness.
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Control de Enfermedades Transmisibles/métodos , Infecciones por VIH/prevención & control , Infecciones por VIH/transmisión , Transmisión Vertical de Enfermedad Infecciosa/prevención & control , Adulto , África , Preescolar , Control de Enfermedades Transmisibles/organización & administración , Estudios Transversales , Composición Familiar , Femenino , Humanos , Lactante , Recién Nacido , Masculino , Embarazo , Adulto JovenRESUMEN
The World Health Organization's (WHO) Strategic Framework for the Elimination of New HIV Infections among Children in Africa by 2015 identifies important synergies for the elimination of mother-to-child transmission of HIV and syphilis in terms of prevention interventions, implementation logistics and service delivery, monitoring and evaluation systems, and need for sustained political commitment. The WHO advocates the use of an integrated, rights-based dual approach with partnerships and collaboration to make the best use of available resources. Through a consultative approach, six countries in the African Region committed to dual elimination and developed and implemented action plans for this purpose. Where interest and commitment are high, this may also be possible and effective in other African countries.
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Prestación Integrada de Atención de Salud/normas , Infecciones por VIH/transmisión , Transmisión Vertical de Enfermedad Infecciosa/prevención & control , Guías de Práctica Clínica como Asunto/normas , Atención Prenatal/normas , Sífilis/transmisión , Adulto , África del Sur del Sahara , Conducta Cooperativa , Erradicación de la Enfermedad , Femenino , Infecciones por VIH/prevención & control , Humanos , Recién Nacido , Embarazo , Complicaciones Infecciosas del Embarazo/inmunología , Atención Prenatal/métodos , Sífilis/prevención & control , Organización Mundial de la SaludRESUMEN
BACKGROUND: Mother-to-child transmission of HIV (MTCT) depends on the timing of HIV infection. We estimated HIV-seroconversion during pregnancy (HSP) after having a HIV-negative result antenatally, and its contribution to early MTCT in South Africa (SA). METHODS AND FINDINGS: Between August 2011 and March 2012, we recruited a nationally representative sample of mother-infant pairs with infants aged 4-to-8 weeks from 578 health facilities. Data collection included mother interviews, child health-card reviews, and infant dried-blood-spots sample (iDBS). iDBS were tested for HIV antibodies and HIV-deoxyribonucleic-acid (HIV-DNA). HSP was defined as maternal self-report of an HIV-negative test during this pregnancy, no documented use of antiretroviral drugs and a matched HIV sero-positive iDBS. We used 20 imputations from a uniform distribution for time from reported antenatal HIV-negative result to delivery to estimate time of HSP. Early MTCT was defined based on detection of HIV-DNA in iDBS. Estimates were adjusted for clustering, nonresponse, and weighted by SA's 2011 live-births. RESULTS: Of 9802 mother-infant pairs, 2738 iDBS were HIV sero-positive, including 212 HSP, resulting in a nationally weighted estimate of 3.3% HSP (95% Confidence Interval: 2.8%-3.8%). Median time of HIV-seroconversion was 32.8weeks gestation;28.3% (19.7%- 36.9%) estimated to be >36 weeks. Early MTCT was 10.7% for HSP (6.2%-16.8%) vs. 2.2% (1.7%-2.8%) for mothers with known HIV-positive status. Although they represent 2.2% of all mothers and 6.7% of HIV-infected mothers, HSP accounted for 26% of early MTCT. Multivariable analysis indicated the highest risk for HSP was among women who knew the baby's father was HIV-infected (adjusted-hazard ratio (aHR) 4.71; 1.49-14.99), or who had been screened for tuberculosis (aHR 1.82; 1.43-2.32). CONCLUSIONS: HSP risk is high and contributes significantly to early MTCT. Identification of HSP by repeat-testing at 32 weeks gestation, during labor, 6 weeks postpartum, in tuberculosis-exposed women, and in discordant couples might reduce MTCT.
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Infecciones por VIH/diagnóstico , Infecciones por VIH/transmisión , Transmisión Vertical de Enfermedad Infecciosa/prevención & control , Complicaciones Infecciosas del Embarazo/diagnóstico , Adulto , Anticuerpos Antivirales/sangre , Femenino , Infecciones por VIH/prevención & control , Humanos , Lactante , Recién Nacido , Lactancia , Periodo Posparto , Embarazo , Seroconversión , SudáfricaRESUMEN
BACKGROUND: There is a paucity of data on the national population-level effectiveness of preventing mother-to-child transmission (PMTCT) programmes in high-HIV-prevalence, resource-limited settings. We assessed national PMTCT impact in South Africa (SA), 2010. METHODS: A facility-based survey was conducted using a stratified multistage, cluster sampling design. A nationally representative sample of 10â 178 infants aged 4-8â weeks was recruited from 565 clinics. Data collection included caregiver interviews, record reviews and infant dried blood spots to identify HIV-exposed infants (HEI) and HIV-infected infants. During analysis, self-reported antiretroviral (ARV) use was categorised: 1a: triple ARV treatment; 1b: azidothymidine >10â weeks; 2a: azidothymidine ≤10â weeks; 2b: incomplete ARV prophylaxis; 3a: no antenatal ARV and 3b: missing ARV information. Findings were adjusted for non-response, survey design and weighted for live-birth distributions. RESULTS: Nationally, 32% of live infants were HEI; early mother-to-child transmission (MTCT) was 3.5% (95% CI 2.9% to 4.1%). In total 29.4% HEI were born to mothers on triple ARV treatment (category 1a) 55.6% on prophylaxis (1b, 2a, 2b), 9.5% received no antenatal ARV (3a) and 5.5% had missing ARV information (3b). Controlling for other factors groups, 1b and 2a had similar MTCT to 1a (Ref; adjusted OR (AOR) for 1b, 0.98, 0.52 to 1.83; and 2a, 1.31, 0.69 to 2.48). MTCT was higher in group 2b (AOR 3.68, 1.69 to 7.97). Within group 3a, early MTCT was highest among breastfeeding mothers 11.50% (4.67% to 18.33%) for exclusive breast feeding, 11.90% (7.45% to 16.35%) for mixed breast feeding, and 3.45% (0.53% to 6.35%) for no breast feeding). Antiretroviral therapy or >10â weeks prophylaxis negated this difference (MTCT 3.94%, 1.98% to 5.90%; 2.07%, 0.55% to 3.60% and 2.11%, 1.28% to 2.95%, respectively). CONCLUSIONS: SA, a high-HIV-prevalence middle income country achieved <5% MTCT by 4-8â weeks post partum. The long-term impact on PMTCT on HIV-free survival needs urgent assessment.
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Fármacos Anti-VIH/uso terapéutico , Lactancia Materna/efectos adversos , Infecciones por VIH/prevención & control , Transmisión Vertical de Enfermedad Infecciosa/prevención & control , Programas Nacionales de Salud/estadística & datos numéricos , Complicaciones Infecciosas del Embarazo/tratamiento farmacológico , Lactancia Materna/estadística & datos numéricos , Femenino , Infecciones por VIH/epidemiología , Infecciones por VIH/transmisión , Humanos , Lactante , Recién Nacido , Transmisión Vertical de Enfermedad Infecciosa/estadística & datos numéricos , Madres , Programas Nacionales de Salud/organización & administración , Evaluación de Resultado en la Atención de Salud/métodos , Embarazo , Prevalencia , Sudáfrica/epidemiologíaRESUMEN
The government of Canada, through the Department of Foreign Affairs, Trade and Development (DFATD) has supported global efforts to reduce the impact of the HIV pandemic. In 2012, WHO and DFATD launched an implementation research initiative to increase access to interventions that were known to be effective in the prevention of mother-to-child transmission of HIV and to learn how these could be successfully integrated with other essential services for mothers and children. In addition to facilitating the implementation research projects, DFATD and WHO promoted four approaches: (1) Country-specific implementation research prioritization exercises, (2) Ministry of Health involvement, (3) Country-led, innovative, high-quality research, and (4) Leveraging regional networks and learning opportunities. While no single aspect of INSPIRE is unique, the process endeavors to promote and support high-quality, rigorous, locally-led implementation research that will have a substantial impact on the health and survival of HIV-infected women and their children.
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Agencias Gubernamentales/organización & administración , Infecciones por VIH/transmisión , Transmisión Vertical de Enfermedad Infecciosa/prevención & control , Cooperación Internacional , Complicaciones Infecciosas del Embarazo/prevención & control , Organización Mundial de la Salud/organización & administración , Canadá , Femenino , Infecciones por VIH/complicaciones , Infecciones por VIH/prevención & control , Humanos , Recién Nacido , Embarazo , Desarrollo de ProgramaRESUMEN
Countries with high HIV prevalence face the challenge of achieving high coverage of antiretroviral drug regimens interventions including for the prevention of mother-to-child transmission of HIV (PMTCT). In 2011, the World Health Organization and the Department of Foreign Affairs, Trade and Development, Canada, launched a joint implementation research (IR) initiative to increase access to effective PMTCT interventions. Here, we describe the process used for prioritizing PMTCT IR questions in Malawi, Nigeria, and Zimbabwe. Policy makers, district health workers, academics, implementing partners, and persons living with HIV were invited to 2-day workshops in each country. Between 42 and 70 representatives attended each workshop. Using the Child Health Nutrition Research Initiative process, stakeholder groups systematically identified programmatic barriers and formulated IR questions that addressed these challenges. IR questions were scored by individual participants according to 6 criteria: (1) answerable by research, (2) likely to reduce pediatric HIV infections, (3) addresses main barriers to scaling-up, (4) innovation and originality, (5) improves equity among underserved populations, and (6) likely value to policy makers. Highest scoring IR questions included health system approaches for integrating and decentralization services, ways of improving retention-in-care, bridging gaps between health facilities and communities, and increasing male partner involvement. The prioritized questions reflect the diversity of health care settings, competing health challenges and local and national context. The differing perspectives of policy makers, researchers, and implementers illustrate the value of inclusive research partnerships. The participatory Child Health Nutrition Research Initiative approach effectively set national PMTCT IR priorities, promoted country ownership, and strategically allocated research resources.
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Infecciones por VIH/transmisión , Prioridades en Salud , Transmisión Vertical de Enfermedad Infecciosa/prevención & control , Complicaciones Infecciosas del Embarazo/prevención & control , Fármacos Anti-VIH/uso terapéutico , Canadá , Femenino , Infecciones por VIH/complicaciones , Infecciones por VIH/tratamiento farmacológico , Infecciones por VIH/prevención & control , Humanos , Malaui/epidemiología , Nigeria/epidemiología , Cooperación del Paciente , Embarazo , Zimbabwe/epidemiologíaRESUMEN
The prevent mother-to-child transmission (PMTCT) "cascade" describes the programmatic steps for pregnant and breastfeeding women that influence HIV transmission rates. To this end, HIV-infected pregnant women and mothers need access to health services and adhere to antiretroviral (ARV) prophylaxis or lifetime treatment. Within the cascade, the concept of "retention-in-care" is commonly used as a proxy for adherence to ARV interventions and, even, viral suppression. Yet surprisingly, there is no standard definition of retention-in-care either for the purposes of HIV surveillance or implementation research. Implicit to the concept of retention-in-care is the sense of continuity and receipt of care at relevant time points. In the context of PMTCT, the main challenge for surveillance and implementation research is to estimate effective coverage of ARV interventions over a prolonged period of time. These data are used to inform program management and also to estimate postnatal MTCT rates. Attendance of HIV-infected mothers at clinic at 12-month postpartum is often equated with full retention in PMTCT programs over this period. Yet, measurement approaches that fail to register missed visits, or inconsistent attendance or other missing data in the interval period, fail to capture patterns of attendance and care received by mothers and children and risk introducing systematic errors and bias. More importantly, providing only an aggregated rate of attendance as a proxy for retention-in-care fails to identify specific gaps in health services where interventions to improve retention along the PMTCT cascade are most needed. In this article, we discuss how data on retention-in-care can be understood and analyzed, and what are the implications and opportunities for programs and implementation research.
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Fármacos Anti-VIH/uso terapéutico , Lactancia Materna , Infecciones por VIH/tratamiento farmacológico , Evaluación de Resultado en la Atención de Salud , Cooperación del Paciente , Complicaciones Infecciosas del Embarazo/tratamiento farmacológico , Femenino , Infecciones por VIH/complicaciones , Humanos , EmbarazoRESUMEN
BACKGROUND: New WHO guidelines recommend initiation of antiretroviral therapy for HIV-positive adults with CD4 counts of 500 cells per µL or less, a higher threshold than was previously recommended. Country decision makers have to decide whether to further expand eligibility for antiretroviral therapy accordingly. We aimed to assess the potential health benefits, costs, and cost-effectiveness of various eligibility criteria for adult antiretroviral therapy and expanded treatment coverage. METHODS: We used several independent mathematical models in four settings-South Africa (generalised epidemic, moderate antiretroviral therapy coverage), Zambia (generalised epidemic, high antiretroviral therapy coverage), India (concentrated epidemic, moderate antiretroviral therapy coverage), and Vietnam (concentrated epidemic, low antiretroviral therapy coverage)-to assess the potential health benefits, costs, and cost-effectiveness of various eligibility criteria for adult antiretroviral therapy under scenarios of existing and expanded treatment coverage, with results projected over 20 years. Analyses assessed the extension of eligibility to include individuals with CD4 counts of 500 cells per µL or less, or all HIV-positive adults, compared with the previous (2010) recommendation of initiation with CD4 counts of 350 cells per µL or less. We assessed costs from a health-system perspective, and calculated the incremental cost (in US$) per disability-adjusted life-year (DALY) averted to compare competing strategies. Strategies were regarded very cost effective if the cost per DALY averted was less than the country's 2012 per-head gross domestic product (GDP; South Africa: $8040; Zambia: $1425; India: $1489; Vietnam: $1407) and cost effective if the cost per DALY averted was less than three times the per-head GDP. FINDINGS: In South Africa, the cost per DALY averted of extending eligibility for antiretroviral therapy to adult patients with CD4 counts of 500 cells per µL or less ranged from $237 to $1691 per DALY averted compared with 2010 guidelines. In Zambia, expansion of eligibility to adults with a CD4 count threshold of 500 cells per µL ranged from improving health outcomes while reducing costs (ie, dominating the previous guidelines) to $749 per DALY averted. In both countries results were similar for expansion of eligibility to all HIV-positive adults, and when substantially expanded treatment coverage was assumed. Expansion of treatment coverage in the general population was also cost effective. In India, the cost for extending eligibility to all HIV-positive adults ranged from $131 to $241 per DALY averted, and in Vietnam extending eligibility to patients with CD4 counts of 500 cells per µL or less cost $290 per DALY averted. In concentrated epidemics, expanded access for key populations was also cost effective. INTERPRETATION: Our estimates suggest that earlier eligibility for antiretroviral therapy is very cost effective in low-income and middle-income settings, although these estimates should be revisited when more data become available. Scaling up antiretroviral therapy through earlier eligibility and expanded coverage should be considered alongside other high-priority health interventions competing for health budgets. FUNDING: Bill & Melinda Gates Foundation, WHO.
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Terapia Antirretroviral Altamente Activa , Infecciones por VIH/tratamiento farmacológico , Adulto , Terapia Antirretroviral Altamente Activa/economía , Recuento de Linfocito CD4 , Análisis Costo-Beneficio , Determinación de la Elegibilidad/métodos , Femenino , Infecciones por VIH/inmunología , Costos de la Atención en Salud , Humanos , India , Masculino , Modelos Teóricos , Años de Vida Ajustados por Calidad de Vida , Sudáfrica , Vietnam , ZambiaRESUMEN
INTRODUCTION: Primate studies and some observational human data have raised concern regarding an association of first-trimester efavirenz exposure with central nervous system congenital anomalies. The objective of this review is to update evidence on efavirenz safety in HIV-infected pregnant women to inform revision of the 2013 WHO guidelines for antiretroviral therapy in low and middle-income countries. DESIGN: A systematic review and meta-analysis. METHODS: We searched for studies reporting birth outcomes among women exposed to efavirenz during the first trimester of pregnancy up to 10 January 2014. Relative risks of congenital anomalies comparing women exposed to efavirenz and nonefavirenz-based antiretroviral regimens were pooled using random effects meta-analysis. RESULTS: Twenty-three studies were included in this review, among which 21 reported the birth outcomes of 2026 live births among women exposed to efavirenz during the first trimester of pregnancy. Forty-four congenital anomalies were reported, giving a pooled proportion of 1.63% [95% confidence interval (95% CI) 0.78-2.48], with only one neural tube defect. Twelve studies reported birth outcomes of women exposed to efavirenz or nonefavirenz-containing regimens during the first trimester of pregnancy. Pooled analysis found no differences in overall risks congenital anomalies between these two groups (relative risk 0.78, 95% CI 0.56-1.08). The incidence of neural tube defects was low, 0.05% (95% CI <0.01-0.28), and similar to incidence in the general population. DISCUSSION: This updated analysis found no evidence of an increased risk of overall or central nervous system congenital anomalies associated with first-trimester exposure to efavirenz, similar to previous systematic reviews. This review contributed to the evidence base for the revised 2013 WHO guidelines on antiretroviral therapy, which recommend that efavirenz can be included as part of first-line therapy in adults regardless of sex, and that it can be used throughout pregnancy, including during the first trimester. However, because of the low incidence of central nervous system anomalies in the overall population and relatively small number of exposures in the current literature, continued birth outcomes prospective surveillance is warranted.
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Anomalías Inducidas por Medicamentos/epidemiología , Benzoxazinas/efectos adversos , Enfermedades del Sistema Nervioso Central/inducido químicamente , Infecciones por VIH/tratamiento farmacológico , Complicaciones Infecciosas del Embarazo/tratamiento farmacológico , Inhibidores de la Transcriptasa Inversa/efectos adversos , Alquinos , Enfermedades del Sistema Nervioso Central/congénito , Ciclopropanos , Femenino , Humanos , Transmisión Vertical de Enfermedad Infecciosa/prevención & control , Embarazo , Primer Trimestre del Embarazo , Resultado del TratamientoRESUMEN
OBJECTIVE: To determine the status of key national policies on the use of antiretroviral therapy (ART) at the time of the launch of the 2013 WHO consolidated guidelines as well as to track early progress towards adoption of these recommendations following dissemination. DESIGN: Descriptive analysis of global data on baseline ART policies as of June 2013 and early intentions to adopt the 2013 WHO for use of antiretroviral drugs guidelines as of November 2013. METHODS: Compilation of existing global reports on key HIV policies, review of national guidelines, data collection through annual drug procurement surveys and through guidelines dissemination meetings in each of the six WHO regions. RESULTS: Data were available from 124 low- and middle-income countries, including 97% of the 57 high-priority countries that have been identified by WHO and the Joint United Nations Program on HIV/AIDS (UNAIDS). At baseline, only one country reported recommending antiretroviral therapy (ART) at a CD4 T-cell count 250 cells/µl or less for adults and adolescents in 2013, whereas nine countries already recommended using CD4 T-cell count 500 cells/µl or less. Recommendations for ART initiation regardless of CD4 T-cell count for HIV-infected patients with tuberculosis (86%), hepatitis B (75%), all HIV-infected women who were pregnant or breastfeeding (option B+: 40%) or HIV-infected persons in a serodiscordant relationship (26%) had been nationally adopted as of June 2013. Eight of 67 countries (12%) already recommended treating all children less than 5 years of age. The triple antiretroviral combination of tenofovir + lamivudine (or emtricitabine) + efavirenz was recommended as the preferred first-line option for adults and adolescents more frequently (51%) than for pregnant women (38%), or for both adults/adolescents and pregnant women (28%; P < 0.05). Fewer than half (37%) of all countries reported recommending lopinavir/ritonavir for all HIV-infected children less than 3 years of age; 54% of countries reported recommending routine viral load monitoring, whereas only 41% recommended nurse-initiated ART. CONCLUSIONS: A number of key WHO policy recommendations on antiretroviral drug use were adopted rapidly by countries in advance of or shortly following the launch of the 2013 guidelines. Efforts are needed to support and track ongoing policy adoption and ensure that it is accompanied by the scale-up of evidence-based interventions.
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Antirretrovirales/uso terapéutico , Salud Global , Infecciones por VIH/tratamiento farmacológico , Política de Salud , Transmisión Vertical de Enfermedad Infecciosa/prevención & control , Guías de Práctica Clínica como Asunto , Adolescente , Adulto , Recuento de Linfocito CD4 , Niño , Femenino , Infecciones por VIH/transmisión , Humanos , Masculino , Embarazo , Factores de Riesgo , Organización Mundial de la SaludRESUMEN
OBJECTIVE: The objective was to evaluate community and healthcare worker (HCW) values and preferences on key topics to inform the development of the 2013 WHO consolidated guidelines for antiretroviral therapy in low and middle income countries. DESIGN: Cross-sectional e-survey and e-forum discussion; focus group discussions (FGDs) METHODS: : Data were collected on community perspectives regarding a range of potential clinical and operational recommendations in the 2013 guidelines between November 2012 and January 2013 through an e-survey (n = 1088) and e-forum (n = 955). Additional FGDs were held with people living with HIV (PLHIV) in Malawi and Uganda (n = 88) on antiretroviral therapy (ART) use among pregnant women. Two surveys were also undertaken on similar topics covered in the e-survey for health care workers caring for adults (n = 98) and children (n = 348). RESULTS: There were 1088 e-survey respondents from 117 countries: of whom 37.7% (298/791) were females, 49.9% (431/864) PLHIV, and 20.9% (174/831) from low-income countries. The proportion of e-survey respondents who supported raising the CD4 T-cell threshold for ART initiation in adults from 350 to 500 cells/µl was 51.0% (355/696), and regardless of CD4 T-cell count for all pregnant females 89.8% (607/676), HIV serodiscordant partners 71.9% (486/676), and all children on diagnosis of infection 47.4% (212/447). E-survey respondents strongly supported discontinuing use of stavudine (72.7%, 416/572), task-shifting/sharing from doctors to nurses (75.2%, 275/365) and from nurses to community health workers (71.1%, 261/367) as strategies to expand access to HIV testing, care, and treatment. Focus group discussion respondents identified service capacity, and social and legal concerns as key considerations influencing the decisions of women living with HIV to continue ART after the risk of vertical transmission has passed. Key lessons learnt in these consultations included the need for piloting and validation of questions; sufficient time to adequately disseminate the survey; and consideration of using FGDs and mobile phone technology to improve participation of people with limited internet access. CONCLUSION: Community participation in guideline development processes is important to ensure that their perspectives are considered in the resulting recommendations. Communities should be actively involved in the adaptation, implementation, and accountability processes related to the guidelines.
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Antirretrovirales/uso terapéutico , Actitud del Personal de Salud , Infecciones por VIH/tratamiento farmacológico , Conocimientos, Actitudes y Práctica en Salud , Adolescente , Adulto , Factores de Edad , Anciano , Niño , Estudios Transversales , Femenino , Grupos Focales , Humanos , Masculino , Persona de Mediana Edad , Embarazo , Encuestas y Cuestionarios , Adulto JovenRESUMEN
OBJECTIVE: To estimate the incremental cost over 5 years of a policy switch from the Option B to the Option B+ protocol for the prevention of mother-to-child transmission (PMTCT) of the human immunodeficiency virus (HIV). METHODS: Data from cost studies and other published sources were used to determine the cost, per woman and per cohort (1000 breastfeeding and 1000 non-breastfeeding women), of switching from Option B (maternal triple antiretroviral [ARV] regimen during pregnancy and breastfeeding plus daily nevirapine for the infant for 6 weeks) to Option B+ (maternal triple ARV regimen initiated during pregnancy and continued for life). The variables used to model the different scenarios were maternal CD4+ T lymphocyte (CD4+ cell) count (350-500 versus > 500 cells/µl), rate of decline in CD4+ cells (average, rapid, slow), breastfeeding status (yes, no) and breastfeeding duration (12, 18 or 24 months). FINDINGS: For women with CD4+ cell counts of 350-500 cells/µl, the incremental cost per 1000 women was 157,345 United States dollars (US$) for breastfeeding women and US$ 92,813 for non-breastfeeding women. For women with CD4+ cell counts > 500 cells/µl, the incremental cost per 1000 women ranged from US$ 363,443 to US$ 484,591 for breastfeeding women and was US$ 605,739 for non-breastfeeding women. CONCLUSION: From a cost perspective, a policy switch from Option B to Option B+ is feasible in PMTCT programme settings where resources are currently being allocated to Option B.