Spatial distribution and determinants of HIV high burden in the Southern African sub-region.

BACKGROUND: Spatial analysis at different levels can help understand spatial variation of human immunodeficiency virus (HIV) infection, disease drivers, and targeted interventions. Combining spatial analysis and the evaluation of the determinants of the HIV burden in Southern African countries is essential for a better understanding of the disease dynamics in high-burden settings. METHODS: The study countries were selected based on the availability of demographic and health surveys (DHS) and corresponding geographic coordinates. We used multivariable regression to evaluate the determinants of HIV burden and assessed the presence and nature of HIV spatial autocorrelation in six Southern African countries. RESULTS: The overall prevalence of HIV for each country varied between 11.3% in Zambia and 22.4% in South Africa. The HIV prevalence rate was higher among female respondents in all six countries. There were reductions in prevalence estimates in most countries yearly from 2011 to 2020. The hotspot cluster findings show that the major cities in each country are the key sites of high HIV burden. Compared with female respondents, the odds of being HIV positive were lesser among the male respondents. The probability of HIV infection was higher among those who had sexually transmitted infections (STI) in the last 12 months, divorced and widowed individuals, and women aged 25 years and older. CONCLUSIONS: Our research findings show that analysis of survey data could provide reasonable estimates of the wide-ranging spatial structure of the HIV epidemic in Southern African countries. Key determinants such as individuals who are divorced, middle-aged women, and people who recently treated STIs, should be the focus of HIV prevention and control interventions. The spatial distribution of high-burden areas for HIV in the selected countries was more pronounced in the major cities. Interventions should also be focused on locations identified as hotspot clusters.

Male partner unknown HIV status as a risk factor for HIV incidence and clinical outcomes in prevention of mother-to-child transmission of HIV programmes in 21 WHO priority countries: a systematic review protocol.

INTRODUCTION: Research has shown an association between increased disclosure of HIV status by pregnant and breastfeeding women and improved clinical health and that of their infant. Increasing awareness about their male partner's HIV status will no doubt lead to even better outcomes at the population level. Male partner involvement is important for improving outcomes of prevention of mother-to-child transmission of HIV (MTCT) as it improves social support and commitment from both parents of the baby to ensure sustained good health. Although lack of knowledge of the HIV status of a male partner is of great concern, limited research has been done to determine whether it remains one of the barriers to reaching the proposed goals of eliminating MTCT in pregnant or postpartum women. Our aim is to determine if lack of knowledge of a male partner's HIV status is a significant risk factor for HIV incidence and poor HIV clinical outcomes among pregnant women and postpartum women and their infants. METHODS AND ANALYSIS: A systematic review and meta-analysis of experimental and observational studies will be conducted. The review will focus on knowledge of male partner's HIV status in the 21 priority countries most affected by HIV in Africa. We will search electronic databases such as PubMed/Medline, Scopus, Web of Science and Cochrane library, Science Direct, CINAHL, LILACS and SciELO databases from January 2011 to December 2021. We will also search the Pan African and WHO clinical trial registries and conference archives. We will conduct a quality assessment of eligible studies and evaluate the heterogeneity of the pooled studies using the I 2 statistic. The statistical analysis will be performed using STATA statistical software V.16. ETHICS AND DISSEMINATION: The study will use publicly available data and ethics exemption has been obtained from Human Research Ethics Committees, Faculty of Medicine & Health Sciences, Stellenbosch University. The protocol was registered on Prospective Register of Systematic Reviews, registration number CRD42021247686, in May 2021. Findings of this systematic review will be disseminated in peer-review journals including various media platforms, that is, webinars, symposia, conferences or congresses. PROSPERO REGISTRATION NUMBER: Registration number CRD42021247686.

Classification Schemes of COVID-19 High Risk Areas and Resulting Policies: A Rapid Review.

The COVID-19 pandemic has posed a significant global health threat since January 2020. Policies to reduce human mobility have been recognized to effectively control the spread of COVID-19; although the relationship between mobility, policy implementation, and virus spread remains contentious, with no clear pattern for how countries classify each other, and determine the destinations to- and from which to restrict travel. In this rapid review, we identified country classification schemes for high-risk COVID-19 areas and associated policies which mirrored the dynamic situation in 2020, with the aim of identifying any patterns that could indicate the effectiveness of such policies. We searched academic databases, including PubMed, Scopus, medRxiv, Google Scholar, and EMBASE. We also consulted web pages of the relevant government institutions in all countries. This rapid review's searches were conducted between October 2020 and December 2021. Web scraping of policy documents yielded additional 43 country reports on high-risk area classification schemes. In 43 countries from which relevant reports were identified, six issued domestic classification schemes. International classification schemes were issued by the remaining 38 countries, and these mainly used case incidence per 100,000 inhabitants as key indicator. The case incidence cut-off also varied across the countries, ranging from 20 cases per 100,000 inhabitants in the past 7 days to more than 100 cases per 100,000 inhabitants in the past 28 days. The criteria used for defining high-risk areas varied across countries, including case count, positivity rate, composite risk scores, community transmission and satisfactory laboratory testing. Countries either used case incidence in the past 7, 14 or 28 days. The resulting policies included restrictions on internal movement and international travel. The quarantine policies can be summarized into three categories: (1) 14 days self-isolation, (2) 10 days self-isolation and (3) 14 days compulsory isolation.

Health trends, inequalities and opportunities in South Africa's provinces, 1990-2019: findings from the Global Burden of Disease 2019 Study.

BACKGROUND: Over the last 30 years, South Africa has experienced four 'colliding epidemics' of HIV and tuberculosis, chronic illness and mental health, injury and violence, and maternal, neonatal, and child mortality, which have had substantial effects on health and well-being. Using data from the 2019 Global Burden of Diseases, Injuries and Risk Factors Study (GBD 2019), we evaluated national and provincial health trends and progress towards important Sustainable Development Goal targets from 1990 to 2019. METHODS: We analysed GBD 2019 estimates of mortality, non-fatal health loss, summary health measures and risk factor burden, comparing trends over 1990-2007 and 2007-2019. Additionally, we decomposed changes in life expectancy by cause of death and assessed healthcare system performance. RESULTS: Across the nine provinces, inequalities in mortality and life expectancy increased over 1990-2007, largely due to differences in HIV/AIDS, then decreased over 2007-2019. Demographic change and increases in non-communicable diseases nearly doubled the number of years lived with disability between 1990 and 2019. From 1990 to 2019, risk factor burdens generally shifted from communicable and nutritional disease risks to non-communicable disease and injury risks; unsafe sex remained the top risk factor. Despite widespread improvements in healthcare system performance, the greatest gains were generally in economically advantaged provinces. CONCLUSIONS: Reductions in HIV/AIDS and related conditions have led to improved health since 2007, though most provinces still lag in key areas. To achieve health targets, provincial governments should enhance health investments and exchange of knowledge, resources and best practices alongside populations that have been left behind, especially following the COVID-19 pandemic.

Predicting the environmental suitability for onchocerciasis in Africa as an aid to elimination planning.

Recent evidence suggests that, in some foci, elimination of onchocerciasis from Africa may be feasible with mass drug administration (MDA) of ivermectin. To achieve continental elimination of transmission, mapping surveys will need to be conducted across all implementation units (IUs) for which endemicity status is currently unknown. Using boosted regression tree models with optimised hyperparameter selection, we estimated environmental suitability for onchocerciasis at the 5 × 5-km resolution across Africa. In order to classify IUs that include locations that are environmentally suitable, we used receiver operating characteristic (ROC) analysis to identify an optimal threshold for suitability concordant with locations where onchocerciasis has been previously detected. This threshold value was then used to classify IUs (more suitable or less suitable) based on the location within the IU with the largest mean prediction. Mean estimates of environmental suitability suggest large areas across West and Central Africa, as well as focal areas of East Africa, are suitable for onchocerciasis transmission, consistent with the presence of current control and elimination of transmission efforts. The ROC analysis identified a mean environmental suitability index of 0·71 as a threshold to classify based on the location with the largest mean prediction within the IU. Of the IUs considered for mapping surveys, 50·2% exceed this threshold for suitability in at least one 5 × 5-km location. The formidable scale of data collection required to map onchocerciasis endemicity across the African continent presents an opportunity to use spatial data to identify areas likely to be suitable for onchocerciasis transmission. National onchocerciasis elimination programmes may wish to consider prioritising these IUs for mapping surveys as human resources, laboratory capacity, and programmatic schedules may constrain survey implementation, and possibly delaying MDA initiation in areas that would ultimately qualify.

African based researchers' output on models for the transmission dynamics of infectious diseases and public health interventions: A scoping review.

BACKGROUND: Applied epidemiological models are used in predicting future trends of diseases, for the basic understanding of disease and health dynamics, and to improve the measurement of health indicators. Mapping the research outputs of epidemiological modelling studies concerned with transmission dynamics of infectious diseases and public health interventions in Africa will help to identify the areas with substantial levels of research activities, areas with gaps, and research output trends. METHODS: A scoping review of applied epidemiological models of infectious disease studies that involved first or last authors affiliated to African institutions was conducted. Eligible studies were those concerned with the transmission dynamics of infectious diseases and public health interventions. The review was consistent with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) extension for scoping reviews. Four electronic databases were searched for peer-reviewed publications up to the end of April 2020. RESULTS: Of the 5927 publications identified, 181 met the inclusion criteria. The review identified 143 publications with first authors having an African institutional affiliation (AIA), while 81 had both first and last authors with an AIA. The publication authors were found to be predominantly affiliated with institutions based in South Africa and Kenya. Furthermore, human immunodeficiency virus, malaria, tuberculosis, and Ebola virus disease were found to be the most researched infectious diseases. There has been a gradual increase in research productivity across Africa especially in the last ten years, with several collaborative efforts spread both within and beyond Africa. CONCLUSIONS: Research productivity in applied epidemiological modelling studies of infectious diseases may have increased, but there remains an under-representation of African researchers as leading authors. The study findings indicate a need for the development of research capacity through supporting existing institutions in Africa and promoting research funding that will address local health priorities.

Predictors of post-operative outcomes in patients with peripheral arterial disease and critical limb ischaemia: a systematic review and meta-analysis.

Background: A very small proportion (1%) of patients with peripheral artery disease (PAD) present with critical limb threatening ischaemia (CLTI) with poor prognosis. The present review showcased several pre-operative predictors and key post-operative outcomes. Identification of any modifiable predictors may impact positively on surgical outcomes. Design: PubMed/Medline, Google scholar and Cochrane databases were searched using terms such as "peripheral arterial disease" AND "critical limb ischemia," "post-operative outcome," AND "predictors of post-operative outcomes". Search was for relevant English-language articles published between January 1997 and December 2007 Selected articles were screened first by title and abstract, and selection of full articles was based on relevance using our inclusion and exclusion criteria and quality ratings performed with the MINORS score. Results: The included studies were published between 1997 and 2007. Only six (6) articles out of a total of 2,114 were deemed suitable for analysis. Ambulatory recovery was >70% at six months, 86.7% and 70.0% at one year and five years respectively. Rate of local wound complications was between 12% and 24%. Reported limb salvage rates were >90% at six months, >70% at one year and 70.0-90.0% at five years. Primary graft patency rate at one year ranged from 63% and 76.6%. Gangrene, diabetes and impaired pre-operative ambulatory function are associated with more wound complications, low limb salvage, reduced graft patency and poor functional outcome. Conclusion: Pre-operative ambulatory status was the most important predictor of post-operative ambulatory recovery. Diabetes mellitus was an important risk factor for prolonged wound healing, local wound complications and major amputation. Funding: None declared.

Implications of COVID-19 in high burden countries for HIV/TB: A systematic review of evidence.

BACKGROUND: The triple burden of COVID-19, tuberculosis and human immunodeficiency virus is one of the major global health challenges of the twenty-first century. In high burden HIV/TB countries, the spread of COVID-19 among people living with HIV is a well-founded concern. A thorough understanding of HIV/TB and COVID-19 pandemics is important as the three diseases interact. This may clarify HIV/TB/COVID-19 as a newly related field. However, several gaps remain in the knowledge of the burden of COVID-19 on patients with TB and HIV. This study was conducted to review different studies on SARS-CoV, MERS-CoV or COVID-19 associated with HIV/TB co-infection or only TB, to understand the interactions between HIV, TB and COVID-19 and its implications on the burden of the COVID-19 among HIV/TB co-infected or TB patients, screening algorithm and clinical management. METHODS: We conducted an electronic search of potentially eligible studies published in English in the Cochrane Controlled Register of Trials, PubMed, Medrxiv, Google scholar and Clinical Trials Registry databases. We included case studies, case series and observational studies published between January, 2002 and July, 2020 in which SARS-CoV, MERS-CoV and COVID-19 co-infected to HIV/TB or TB in adults. We screened titles, abstracts and full articles for eligibility. Descriptive and meta-analysis were done and results have been presented in graphs and tables. RESULTS: After removing 95 duplicates, 58 out of 437 articles were assessed for eligibility, of which 14 studies were included for descriptive analysis and seven studies were included in the meta-analysis. Compared to the descriptive analysis, the meta-analysis showed strong evidence that current TB exposure was high-risk COVID-19 group (OR 1.67, 95% CI 1.06-2.65, P = 0.03). The pooled of COVID-19/TB severity rate increased from OR 4.50 (95% CI 1.12-18.10, P = 0.03), the recovery rate was high among COVID-19 compared to COVID-19/TB irrespective of HIV status (OR 2.23, 95% CI 1.83-2.74, P < 0.001) and the mortality was reduced among non-TB group (P < 0.001). CONCLUSION: In summary, TB was a risk factor for COVID-19 both in terms of severity and mortality irrespective of HIV status. Structured diagnostic algorithms and clinical management are suggested to improve COVID-19/HIV/TB or COVID-19/TB co-infections outcomes.

Immunogenicity and safety of fractional dose yellow fever vaccination: A systematic review and meta-analysis.

BACKGROUND: Recent upsurges in yellow fever outbreaks are increasing the demand for yellow fever vaccine, while enormously straining global vaccine supply. Fractional dose yellow fever vaccination is being considered as a dose-sparing strategy to address current vaccine shortages. This systematic review and meta-analysis aimed to assess the effects of fractional dose yellow fever vaccination, in comparison with those of standard dose vaccination. METHODS: We registered this review on the International Prospective Register of Systematic Reviews (PROSPERO, registration number: CRD42018084214), developed the protocol in line with the Preferred Reporting Items for Systematic Review and Meta-Analyses Protocols (PRISMA-P) and synthesised the evidence in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA). We stratified meta-analyses by vaccine dose. RESULTS: We retrieved 2524 records from the literature search, eleven of them potentially eligible. From these studies, we included eight eligible trials, with a total of 2371 participants. Seroconversion rates at four to five weeks following vaccination were similar between participants who received standard doses and participants who received fractional doses containing one-third (547 participants: risk ratio [RR] 1.02, 95% confidence interval [CI] 1.00-1.04), one-fifth (155 participants: RR 1.00, 95% CI 0.98-1.03), one-tenth (890 participants: RR 0.99, 95% CI 0.96-1.01), and one-fiftieth (661 participants: RR 0.97, 95% CI 0.92-1.02) of the standard dose. However, the rates of seroconversion were substantially lower among participants who received fractional doses containing one-hundredth and lower fractions of the standard dose. Immunogenicity similarly persisted 8-10 years following both fractional and standard dose vaccination. Minor adverse events following vaccination did not differ across doses, and no serious adverse events were reported in any study arm. CONCLUSIONS: These findings support the use of fractional dosing as a strategy for mitigating vaccine shortages. The strategy should be specifically considered for individuals who are young, immuno-competent and well nourished.

A multilevel analysis of the determinants of missed opportunities for vaccination among children attending primary healthcare facilities in Kano, Nigeria: Findings from the pre-implementation phase of a collaborative quality improvement programme.

BACKGROUND: We aimed to determine the factors that are responsible for missed opportunities for vaccination (MOV) among children aged 0-23 months attending primary health care (PHC) facilities in Nassarawa, Kano State, Nigeria. METHODS: This cross-sectional study was conducted in the pre-implementation phase of a quality improvement programme. One-stage cluster sampling technique was employed. Data were collected from caregivers of children aged 0-23 months in ten randomly selected PHC facilities in Nassarawa Local Government Area of Kano State. Semi-structured, interviewer administered questionnaires were used. Frequencies and percentages were used to summarize the data. Multilevel logistic regression model with fixed effect and random effect component was fitted to obtain measures of association and variation respectively. RESULTS: Caregivers of 675 children responded. Among these children, the prevalence of MOV (for at least one antigen) was 36.15%. MOV (for individual antigens) was highest for inactivated polio vaccine followed by measles vaccine. The random effect model yielded an intraclass correlation coefficient of 9.60% for the empty model. The fixed effect model revealed that MOV was more likely among children that were accompanying a caregiver to the health facility (OR = 2.86, 95%CrI: 1.28 to 5.80) compared to those that were visiting the health facility for medical consultation. Failure to receive vaccination on the day of health facility visit (OR = 2.32, 95%CrI: 1.12 to 4.12) and visiting a clinic with three or more vaccinators (OR = 12.91, 95%CrI: 4.82 to 27.14) increased the likelihood of MOV. CONCLUSION: The study identified important local factors that are responsible for MOV which can be addressed in the QI programme.

The burden of vaccine-preventable diseases among HIV-infected and HIV-exposed children in sub-Saharan Africa: a systematic review and meta-analysis.

There are knowledge gaps regarding evidence-based research on the burden of vaccine-preventable diseases among human immunodeficiency virus (HIV)-infected and HIV-exposed children aged <18 years in sub-Saharan Africa. It is therefore essential to determine the trend and burden of vaccine-preventable diseases. We completed a systematic review and meta-analysis to identify the incidence, prevalence and case-fatality rates (CFR) attributed to various vaccine-preventable diseases among HIV-infected and HIV-exposed children in sub-Saharan Africa. The trends in the prevalence of vaccine-preventable diseases among HIV-infected and HIV-exposed children were also determined. Nine studies on tuberculosis (TB) were pooled to give an overall incidence rate estimate of 60 (95% confidence interval [CI] 30-70) per 1,000 child-years. The incidence of pneumococcal infections varied between 109-1509 per 100,000 while pertussis was between 2.9 and 3.7 per 1000 child-year. Twenty-two TB prevalence studies reported an estimated prevalence of 16%. Fifteen prevalence studies on hepatitis B infection were pooled together with an estimated prevalence of 5%. The pooled prevalence for pneumococcal infections was 2% while rotavirus diarrhoea reported a prevalence of 13%. Twenty-nine studies on TB were pooled to give an overall CFR estimate of 17% while pneumococcal infections in HIV-infected and exposed children were pooled together with a resultant rate of 15%. Some of the vaccine-preventable diseases still have high incidences, prevalence and CFR among HIV-infected and HIV-exposed children. There is also a dearth of research data on the burden of several vaccine-preventable diseases among HIV-infected and exposed children and a need for more studies in this area.

Vaccination among HIV-infected, HIV-exposed uninfected and HIV-uninfected children: a systematic review and meta-analysis of evidence related to vaccine efficacy and effectiveness.

Evidence-based approaches were used in making recommendations for vaccination against vaccine-preventable diseases for HIV-infected and HIV-exposed individuals but with limited substantiation. We conducted a systematic review and meta-analysis with randomized-controlled trials (RCTs), cohort and case-control studies that have efficacy and effectiveness of vaccines in HIV-infected and HIV-exposed children as outcomes. Web of Science, Cochrane Library, PubMed and Scopus databases were searched for articles. Efficacy of 9-valent pneumococcal conjugate vaccine (PCV9) against total vaccine serotype invasive pneumococcal disease was 32% in HIV-infected children and 78% among HIV-uninfected children. Vaccine effectiveness of Bacillus Calmette-Guérin vaccine in preventing tuberculosis in HIV-infected children was zero compared to 59% protection in HIV-unexposed children. Likewise, HIV-uninfected children have better protection against invasive Haemophilus influenzae type b disease than the HIV-infected children. Effectiveness studies of rotavirus vaccines show that HIV-exposed uninfected children have similar protection against rotavirus gastroenteritis compared to the non-exposed children. Children who are severely immunosuppressed are poorly protected against invasive pneumococcal diseases. HIV-infected children tend to have lesser vaccine protection against vaccine-preventable diseases when compared to unexposed children. HIV-infected children who are immunocompetent are more likely to have better vaccine protection against vaccine-preventable diseases than those who are immunosuppressed. The overall quality of the observational studies was very low with very little confidence in the effect estimate. The overall quality of evidence for the RCT outcomes was mainly high. This study reveals a dearth of efficacy and effectiveness studies among HIV-infected and exposed children.

Non-specific effects of childhood vaccines on acute childhood morbidity among HIV-exposed children in sub-Saharan Africa: a multilevel analysis.

We examined the roles of determining factors responsible for acute respiratory infections and diarrhoea among immunised human immunodeficiency virus (HIV)-exposed children in sub-Saharan Africa. This study used demographic and health surveys obtained from 27 sub-Saharan African countries. The outcome variable is defined as symptoms of acute respiratory infections or episode of diarrhoea in the child of an HIV-infected mother who is vaccinated with the third dose of diphtheria-tetanus-pertussis containing vaccines. Multivariable logistic regression models were used to analyse the association between individual and contextual factors. The odds of developing symptoms of acute respiratory infections increased among those living in communities with high unemployment rate (Odds ratio = 1.15, 95% credible interval 1.05 to 1.26). The odds of developing diarrhoea increased among young mothers such that children of women aged 15-24 years were two times likely to develop diarrhoea compared to children of women aged 35-49 years (Odds ratio = 2.22, 95% credible interval 1.66 to 2.93). Public healthcare programmes should target adolescent and young women, and their family members on how to prevent diarrhoea. Efforts should be made to identify the hotspots for development of acute respiratory diseases especially in communities with high rate of unemployment and to develop strategies to combat the diseases in such communities. Initiatives such as the integrated Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea which recommends an interrelated approach for the elimination of preventable diarrhoea and pneumonia deaths should be adopted.

Morbidity benefit conferred by childhood immunisation in relation to maternal HIV status: a meta-analysis of demographic and health surveys.

The study determined the prevalence of acute respiratory infections and diarrhoea among sub-Saharan African children. It also examined if there was any significant morbidity benefit conferred by three doses of diphtheria-tetanus-pertussis containing vaccines (DTP3) with respect to maternal HIV status. Data were obtained from the Demographic and Health Survey (DHS) program, United Nations Development Programs, World Bank and Joint United Nations Programme on HIV/AIDS. Pooled odds ratio (OR) and 95% confidence intervals (CI) were calculated for the countries. Test of heterogeneity, sensitivity analyses and meta-regression were also conducted. The prevalence of acute respiratory infections and diarrhoea were similar between the children that were vaccinated and those who were not vaccinated with DTP3. The pooled result shows that children who did not receive DTP3 were more likely to have symptoms of acute respiratory infections than children who had DTP3 (OR 1.09, 95% CI 1.02 to 1.17); with low heterogeneity across the countries. The combined result for diarrhoea shows that children who did not receive DTP3 were less likely to have episodes of diarrhoea than children who received DTP3 (OR 0.83, 95% CI 0.74 to 0.92); with substantial heterogeneity across the countries. There was no difference between the estimates of DTP3 vaccinated and unvaccinated children of HIV seropositive mothers with respect to symptoms of acute respiratory infections or episodes of diarrhoea. Tackling various causes and risk factors for respiratory tract infections and diarrhoeal diseases should be a priority for various stakeholders in sub-Saharan Africa.

Non-uptake of childhood vaccination among the children of HIV-infected mothers in sub-Saharan Africa: A multilevel analysis.

The aim of this study was to develop and test models for non-uptake of three doses of diphtheria-tetanus-pertussis containing vaccines (DTP3) among children of women living with HIV in sub-Saharan Africa. The study used demographic and health survey data from 27 sub-Saharan African countries that have the required HIV and immunization data sets. Multivariable logistic regression models were used to assess the relationship between individual and contextual factors associated with non-uptake of DTP3 among the children. At the individual level, the odds of non-uptake of DTP3 decreased with formal education, increasing age and access to media. The full model shows that the odds of non-uptake of DTP3 is increased among unemployed women, those living in communities with high illiteracy rate and in countries with low adult literacy level. For a child who moved to another country or community with a higher probability of DTP3 non-uptake, the median increase for the odds of DTP3 non-uptake would be 2.24% and 1.22% respectively for country and community. This study shows that individual and contextual factors contributed significantly to non-uptake of DTP3 among the children of women living with HIV. Interventions should be focused on women living with HIV who are young mothers, unemployed women, those without formal education, individuals living in communities with high illiteracy rate and in countries with low adult literacy rate. The use of mass media tools and creation of more employment opportunities for HIV-infected women could improve vaccination coverage among their children.

Effect of maternal HIV status on vaccination coverage among sub-Saharan African children: A socio-ecological analysis.

We investigated the relationship between maternal HIV status and uptake of the full series of three doses of diphtheria-tetanus-pertussis containing vaccines (DTP3) in sub-Saharan African children. We used data obtained from demographic and health surveys conducted in sub-Saharan Africa. We conducted meta-analysis and calculated pooled odds ratios (OR) for the association between maternal HIV status and DTP3 vaccination status for each country. A total of 4,187 out of 5,537 children of women living with HIV received DTP3 (75.6%), compared to 71,290 of 113,513 (62.8%) children of HIV negative women. National DTP3 coverage among children of HIV-positive women varied between 24% and 96% while among children of HIV negative women it was between 26% and 92%. Overall pooled result showed no significant difference in DTP3 coverage between the two groups (OR = 1.05; 95% confidence interval 0.91 - 1.22), with statistically significant heterogeneity (Chi 2 = 91.63, P = 0.000, I2 = 71.6%). There was no significant association between DTP3 coverage and maternal HIV status in sub-Saharan Africa. However, DTP3 coverage for both HIV-exposed and non-exposed children were below the required target. Meta-regression revealed no significant association between DTP3 coverage and country characteristics (e.g. HIV prevalence among women, antiretroviral therapy coverage, gross domestic product per capita, human development index, adult literacy rate and sub-region). Improved prevention of mother-to-child transmission services might have contributed to some extent to the higher DTP3 vaccination coverage among the HIV-exposed children. There is also need to address barriers impeding uptake of vaccination among HIV-exposed and non-exposed children.

Eliminating mother-to-child transmission of the human immunodeficiency virus in sub-Saharan Africa: The journey so far and what remains to be done.

This review was carried out to provide a comprehensive overview of efforts toward elimination of mother-to-child transmission (MTCT) of human immunodeficiency virus (HIV) with respect to progress, challenges, and recommendations in 21 sub-Saharan African priority countries. We reviewed literature published from 2011 to April 2015 using 3 databases; PubMed, Scopus, and Web of Science, as well as the 2014 Global Plan Progress Report. A total of 39 studies were included. Between 2009 and 2013, there was a 43% reduction in new HIV infections, the final MTCT rate was reduced from 28% to 18%, and antiretroviral therapy (ART) coverage increased from 11% to 24%. Challenges included poor adherence to antiretroviral therapy, poor linkage between mother-child pairs and post-natal healthcare services low early infant diagnosis coverage, low pediatric ART coverage, and high unmet needs for contraceptive services. Future recommendations include identification of key barriers, health system strengthening, strengthening community involvement, and international collaboration. There has been significant progress toward eliminating MTCT of HIV, but more effort is still needed.

Efficacy and safety of abacavir-containing combination antiretroviral therapy as first-line treatment of HIV infected children and adolescents: a systematic review and meta-analysis.

BACKGROUND: Abacavir is one of the recommended nucleoside reverse transcriptase inhibitors (NRTIs) for the treatment of HIV infections among children and adolescents. However, there are concerns that the antiviral efficacy of abacavir might be low when compared to other NRTIs especially among children. There are also concerns that abacavir use may lead to serious adverse events such as hypersensitivity reactions and has potential predisposition to developing cardiovascular diseases METHODS: We searched four electronic databases, four conference proceedings and two clinical trial registries in August 2014, without language restrictions. Experimental and observational studies with control groups that examined the efficacy and safety of abacavir-containing regimens in comparison with other NRTIs as first-line treatment for HIV-infected children and adolescents aged between one month and eighteen years were eligible. Two authors independently screened search results, extracted data and assessed the risk of bias of included studies using a pre-specified, standardised data extraction form and validated risk of bias tools. We also assessed the quality of evidence per outcome with the GRADE tool. RESULTS: We included two randomised controlled trials (RCTs) and two analytical cohort studies with a total of 10,595 participants. Among the RCTs we detected no difference in virologic suppression after a mean duration of 48 weeks between abacavir- and stavudine-containing regimens (2 trials; n = 326: RR 1.28; 95 % CI 0.67-2.42) with significant heterogeneity (P = 0.02; I(2) = 81 %). We also found no significant differences between the two groups for adverse events and death. After five years of follow-up, virologic suppression improved with abacavir (1 trial; n = 69: RR 1.96; 95 % CI 1.11-3.44). For cohort studies, we detected that the virologic suppression activity of abacavir was less effective than stavudine in both the lopinavir/ritonavir (1 study, n = 2165: RR 0.79, 95 % CI 0.67-0.92) and efavirenz sub-groups (1 study, n = 3204: RR 0.79, 95 % CI 0.67-0.92) respectively. The quality of evidence from RCTs was moderate for virologic suppression but low for death and adverse events, while that of cohort studies was low for all three these outcomes. CONCLUSIONS: Available evidence showed little or no difference between abacavir-containing regimen and other NRTIs regarding efficacy and safety when given to children and adolescents as a first-line antiretroviral therapy.

Antiviral efficacy and safety of abacavir-containing combination antiretroviral therapy as first-line treatment of HIV-infected children and adolescents: a systematic review protocol.

BACKGROUND: Abacavir is one of the recommended nucleoside reverse transcriptase inhibitors (NRTIs) for the treatment of HIV infections among children and adolescents. However, there are concerns that the antiviral efficacy of abacavir might be low when compared to other NRTIs especially among children. There are also concerns that abacavir use may lead to serious adverse events such as hypersensitivity reactions and has potential predisposition to developing cardiovascular diseases. METHODS: We plan to do a systematic review to evaluate the antiviral efficacy and safety of abacavir-containing combination antiretroviral therapy as first-line treatment of HIV-infected children aged between 3 months and 18 years, compared with other NRTIs. We will search Scopus, Cochrane Central Register of Controlled Trials, MEDLINE, and Web of Science databases for eligible studies regardless of language or publication status. We will check the reference lists of included studies, search relevant conference proceedings, email the authors of included studies and also look for unpublished and ongoing trials in prospective clinical trial registries. Two authors will independently screen search outputs, select studies, extract data and assess the risk of bias in included studies. All disagreements will be resolved by discussion and consensus. Where data allow, we will conduct meta-analysis for similar types of participants, study designs, interventions, and outcome measures. If the results are statistically homogeneous, we will use the fixed-effect model; otherwise, we will use the random-effects model and explore the reasons for heterogeneity using subgroup analyses. Heterogeneity will be assessed with the Chi-squared test and quantified with the I-squared statistic. DISCUSSION: The findings will be useful to policy makers and programme managers to inform treatment and management of HIV in children and adolescents and to point out research gaps for future research. TRIAL REGISTRATION: This review is registered with PROSPERO, registration number CRD42014009157.