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BACKGROUND: Poverty-related diseases (PRD) remain amongst the leading causes of death in children under-5 years in sub-Saharan Africa (SSA). Clinical practice guidelines (CPGs) based on the best available evidence are key to strengthening health systems and helping to enhance equitable health access for children under five. However, the CPG development process is complex and resource-intensive, with substantial scope for improving the process in SSA, which is the goal of the Global Evidence, Local Adaptation (GELA) project. The impact of research on PRD will be maximized through enhancing researchers and decision makers' capacity to use global research to develop locally relevant CPGs in the field of newborn and child health. The project will be implemented in three SSA countries, Malawi, South Africa and Nigeria, over a 3-year period. This research protocol is for the monitoring and evaluation work package of the project. The aim of this work package is to monitor the various GELA project activities and evaluate the influence these may have on evidence-informed decision-making and guideline adaptation capacities and processes. The specific project activities we will monitor include (1) our ongoing engagement with local stakeholders, (2) their capacity needs and development, (3) their understanding and use of evidence from reviews of qualitative research and, (4) their overall views and experiences of the project. METHODS: We will use a longitudinal, mixed-methods study design, informed by an overarching project Theory of Change. A series of interconnected qualitative and quantitative data collections methods will be used, including knowledge translation tracking sheets and case studies, capacity assessment online surveys, user testing and in-depth interviews, and non-participant observations of project activities. Participants will comprise of project staff, members of the CPG panels and steering committees in Malawi, South Africa and Nigeria, as well as other local stakeholders in these three African countries. DISCUSSION: Ongoing monitoring and evaluation will help ensure the relationship between researchers and stakeholders is supported from the project start. This can facilitate achievement of common goals and enable researchers in South Africa, Malawi and Nigeria to make adjustments to project activities to maximize stakeholder engagement and research utilization. Ethical approval has been provided by South African Medical Research Council Human Research Ethics Committee (EC015-7/2022); The College of Medicine Research and Ethics Committee, Malawi (P.07/22/3687); National Health Research Ethics Committee of Nigeria (01/01/2007).
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Saúde da Criança , Guias de Prática Clínica como Assunto , Humanos , Recém-Nascido , Lactente , Malaui , Pré-Escolar , África do Sul , Nigéria , Medicina Baseada em Evidências , Pobreza , Tomada de Decisões , Fortalecimento Institucional , Participação dos Interessados , Saúde do Lactente , Prática Clínica Baseada em Evidências , Projetos de Pesquisa , Avaliação de Programas e Projetos de Saúde , Serviços de Saúde da Criança/normas , Serviços de Saúde da Criança/organização & administraçãoRESUMO
INTRODUCTION: Antiretroviral therapy (ART) initiation in infants living with HIV before 12 weeks of age can reduce the risk of mortality by 75%. Point-of-care (POC) diagnostic testing is critical for prompt ART initiation; however, despite its availability, rates of ART initiation are still relatively low before 12 weeks of age. This systematic review describes the barriers to ART initiation in infants before 12 weeks of age, despite the availability of POC. METHODS: This systematic review used a narrative synthesis methodology. We searched PubMed and Scopus using search strategies that combined terms of multiple variants of the keywords "early infant initiation on antiretroviral therapy," "barriers" and "sub-Saharan Africa" (initial search 18th January 2023; final search 1st August 2023). We included qualitative, observational and mixed methods studies that reported the influences of early infant initiation on ART. We excluded studies that reported influences on other components of the Prevention of Mother to Child Transmission cascade. Using a deductive approach guided by the updated Consolidated Framework of Implementation Research, we developed descriptive codes and themes around barriers to early infant initiation on ART. We then developed recommendations for interventions for the identified barriers using the action, actor, target and time framework from the codes. RESULTS: Of the 266 abstracts reviewed, 52 full-text papers were examined, of which 12 papers were included. South Africa had most papers from a single country (n = 3) and the most reported study design was retrospective (n = 6). Delays in ART initiation beyond 12 weeks in infants 0-12 months were primarily associated with health facility and maternal factors. The most prominent barriers identified were inadequate resources for POC testing (including human resources, laboratory facilities and patient follow-up). Maternal-related factors, such as limited male involvement and maternal perceptions of treatment and care, were also influential. DISCUSSION: We identified structural barriers to ART initiation at the health system, social and cultural levels. Improvements in the timely allocation of resources for POC testing operations, coupled with interventions addressing social and behavioural barriers among both mothers and healthcare providers, hold a promise for enhancing timely ART initiation in infants. CONCLUSIONS: This paper identifies barriers and proposes strategies for timely ART initiation in infants.
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Infecções por HIV , Testes Imediatos , Humanos , Infecções por HIV/tratamento farmacológico , Infecções por HIV/diagnóstico , África Subsaariana/epidemiologia , Lactente , Antirretrovirais/uso terapêutico , Recém-Nascido , Feminino , Fármacos Anti-HIV/uso terapêutico , Transmissão Vertical de Doenças Infecciosas/prevenção & controle , Acessibilidade aos Serviços de SaúdeRESUMO
BACKGROUND: Sub-Saharan Africa is the region with the highest under-five mortality rate globally. Child healthcare decisions should be based on rigorously developed evidence-informed guidelines. The Global Evidence, Local Adaptation (GELA) project is enhancing capacity to use global research to develop locally relevant guidelines for newborn and child health in South Africa (SA), Malawi, and Nigeria. The first step in this process was to identify national priorities for newborn and child health guideline development, and this paper describes our approach. METHODS: We followed a good practice method for priority setting, including stakeholder engagement, online priority setting surveys and consensus meetings, conducted separately in South Africa, Malawi and Nigeria. We established national Steering Groups (SG), comprising 10-13 members representing government, academia, and other stakeholders, identified through existing contacts and references, who helped prioritise initial topics identified by research teams and oversaw the process. Various stakeholders were consulted via online surveys to rate the importance of topics, with results informing consensus meetings with SGs where final priority topics were agreed. RESULTS: Based on survey results, nine, 10 and 11 topics were identified in SA, Malawi, and Nigeria respectively, which informed consensus meetings. Through voting and discussion within meetings, and further engagement after the meetings, the top three priority topics were identified in each country. In SA, the topics concerned anemia prevention in infants and young children and post-discharge support for caregivers of preterm and LBW babies. In Malawi, they focused on enteral nutrition in critically ill children, diagnosis of childhood cancers in the community, and caring for neonates. In Nigeria, the topics focused on identifying pre-eclampsia in the community, hand hygiene compliance to prevent infections, and enteral nutrition for LBW and preterm infants. CONCLUSIONS: Through dynamic and iterative stakeholder engagement, we identified three priority topics for guideline development on newborn and child health in SA, Malawi and Nigeria. Topics were specific to contexts, with no overlap, which highlights the importance of contextualised priority setting as well as of the relationships with key decisionmakers who help define the priorities.
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Assistência ao Convalescente , Saúde da Criança , Gravidez , Lactente , Feminino , Criança , Humanos , Recém-Nascido , Pré-Escolar , Nigéria , Malaui , África do Sul , Recém-Nascido Prematuro , Alta do Paciente , Prioridades em SaúdeRESUMO
BACKGROUND: Low and middle-income countries remain disproportionately affected by high rates of child mortality. Clinical practice guidelines are essential clinical tools supporting implementation of effective, safe, and cost-effective healthcare. High-quality evidence-based guidelines play a key role in improving clinical management to impact child mortality. We aimed to identify and assess the quality of guidelines for newborn and child health published in South Africa, Nigeria and Malawi in the last 5 years (2017-2022). METHODS: We searched relevant websites (June-July 2022), for publicly available national and subnational de novo or adapted guidelines, addressing newborn and child health in the three countries. Pairs of reviewers independently extracted information from eligible guidelines (scope, topic, target population and users, responsible developers, stakeholder consultation process, adaptation description, assessment of evidence certainty). We appraised guideline quality using the Appraisal of Guidelines for Research & Evaluation (AGREE II) instrument. RESULTS: We identified 40-guidelines from the three countries. Of these, 8/40 reported being adopted from a parent guideline. More guidelines (n = 19) provided guidance on communicable diseases than on non-communicable diseases (n = 8). Guidelines were most often developed by national health ministries (n = 30) and professional societies (n = 14). Eighteen guidelines reported on stakeholder consultation; with Nigeria (10/11) and Malawi (3/6) faring better than South Africa (5/23) in reporting this activity. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach was used in 1/7 guidelines that reported assessing certainty of evidence. Overall guidelines scored well on two AGREE II domains: scope and purpose median (IQR) score 68% (IQR 47-83), and clarity of presentation 81% (67-94). Domains critical for ensuring credible guidance scored below 20%: rigour of development 11% (4-32) and editorial independence 6% (0-27). CONCLUSION: National ministries and professional societies drive guideline activities in Malawi, Nigeria and South Arica. However, the methods and reporting do not adhere to global standards. We found low AGREE II scores for rigour of guideline development and editorial independence and limited use of GRADE or adaptation methods. This undermines the credibility of available guidelines to support evidence-informed care. Our findings highlight the importance of ongoing efforts to strengthen partnerships, capacity, and support for guideline development.
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Saúde da Criança , Criança , Humanos , Recém-Nascido , Malaui , Nigéria , África do Sul , Guias de Prática Clínica como AssuntoRESUMO
CONTEXT: Food labelling is a global strategy recommended to reduce noncommunicable diseases. Few reviews, however, have focused on food label use in sub-Saharan Africa (SSA). OBJECTIVE: To determine the prevalence of food label use and describe determinants of food label use and purchasing decisions of adult consumers in SSA. DATA SOURCE: PubMed (Medline), Web of Science, Cochrane Central, and Google Scholar databases. DATA EXTRACTION: Search criteria included adults (aged ≥18 years), conducted in SSA, focusing on food label use or understanding and their determinants or determinants of food-purchasing decisions, and articles published in English. STUDY QUALITY AND DATA ANALYSIS: Risk-of-bias assessment of included studies was done using the Joann Briggs Institute checklist for prevalence studies. Publication bias was assessed using funnel plots and Egger's test. Analysis included narrative synthesis and moderator and meta-analyses of food label use. RESULTS: A total of 124 articles were found, of which 21 were included in the review. Of participants in the selected studies, 58% were female. About 80% reported food label use (either used sometimes or always) (70%-88%) (I2 = 97%; n = 6223), and regular use was estimated at 36% (28%-45%) (I2 = 97%; n = 5147). Food label use was influenced by level of income, education, employment status, and household size. Food-purchasing decisions were influenced by attributes such as expiry dates, price, and taste. Major recommendations reported were tailored education campaigns and reducing barriers to food label use. CONCLUSION: Most (80%) of adults in SSA reported using food labels; however, only about one-third used them consistently. Demographic and situation factors determined patterns in food label use, whereas product attributes influenced food purchasing decisions. Complexity of these determinants requires adopting tailored, multisectoral, theory-driven programs to improve food label use. SYSTEMATIC REVIEW REGISTRATION: Open Science Framework (https://osf.io/kc562).
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Compreensão , Alimentos , Adulto , Humanos , Feminino , Adolescente , Masculino , Prevalência , África Subsaariana/epidemiologia , Percepção GustatóriaRESUMO
BACKGROUND: Integrated knowledge translation (IKT) through strategic, continuous engagement with decision-makers represents an approach to bridge research, policy and practice. The Collaboration for Evidence-based Healthcare and Public Health in Africa (CEBHA +), comprising research institutions in Ethiopia, Malawi, Rwanda, South Africa, Uganda and Germany, developed and implemented tailored IKT strategies as part of its multifaceted research on prevention and care of non-communicable diseases and road traffic injuries. The objective of this article is to describe the CEBHA + IKT approach and report on the development, implementation and monitoring of site-specific IKT strategies. METHODS: We draw on findings derived from the mixed method IKT evaluation (conducted in 2020-2021), and undertook document analyses and a reflective survey among IKT implementers. Quantitative data were analysed descriptively and qualitative data were analysed using content analysis. The authors used the TIDieR checklist to report results in a structured manner. RESULTS: Preliminary IKT evaluation data (33 interviews with researchers and stakeholders from policy and practice, and 31 survey responses), 49 documents, and eight responses to the reflective survey informed this article. In each of the five African CEBHA + countries, a site-specific IKT strategy guided IKT implementation, tailored to the respective national context, engagement aims, research tasks, and individuals involved. IKT implementers undertook a variety of IKT activities at varying levels of engagement that targeted a broad range of decision-makers and other stakeholders, particularly during project planning, data interpretation, and output dissemination. Throughout the project, the IKT teams continued to tailor IKT strategies informally and modified the IKT approach by responding to ad hoc engagements and involving non-governmental organisations, universities, and communities. Challenges to using systematic, formalised IKT strategies arose in particular with respect to the demand on time and resources, leading to the modification of monitoring processes. CONCLUSION: Tailoring of the CEBHA + IKT approach led to the inclusion of some atypical IKT partners and to greater responsiveness to unexpected opportunities for decision-maker engagement. Benefits of using systematic IKT strategies included clarity on engagement aims, balancing of existing and new strategic partnerships, and an enhanced understanding of research context, including site-specific structures for evidence-informed decision-making.
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Lista de Checagem , Ciência Translacional Biomédica , Humanos , Confiabilidade dos Dados , Análise Documental , EtiópiaRESUMO
Background: Malawi's National Malaria Control Programme (NMCP) is developing a new strategic plan for 2023-2030 to combat malaria and recognizes that a blanket approach to malaria interventions is no longer feasible. To inform this new strategy, the NMCP set up a task force comprising 18 members from various sectors, which convened a meeting to stratify the malaria burden in Malawi and recommend interventions for each stratum. Methods: The burden stratification workshop took place from November 29 to December 2, 2022, in Blantyre, Malawi, and collated essential data on malaria burden indicators, such as incidence, prevalence, and mortality. Workshop participants reviewed the malaria burden and intervention coverage data to describe the current status and identified the districts as a appropriate administrative level for stratification and action. Two scenarios were developed for the stratification, based on composites of three variables. Scenario 1 included incidence, prevalence, and under-five all-cause mortality, while Scenario 2 included total malaria cases, prevalence, and under-five all-cause mortality counts. The task force developed four burden strata (highest, high, moderate, and low) for each scenario, resulting in a final list of districts assigned to each stratum. Results: The task force concluded with 10 districts in the highest-burden stratum (Nkhotakota, Salima, Mchinji, Dowa, Ntchisi, Mwanza, Likoma, Lilongwe, Kasungu and Mangochi) 11 districts in the high burden stratum (Chitipa, Rumphi, Nkhata Bay, Dedza, Ntcheu, Neno, Thyolo, Nsanje, Zomba, Mzimba and Mulanje) and seven districts in the moderate burden stratum (Karonga, Chikwawa, Balaka, Machinga, Phalombe, Blantyre, and Chiradzulu). There were no districts in the low-burden stratum. Conclusion: The next steps for the NMCP are to review context-specific issues driving malaria transmission and recommend interventions for each stratum. Overall, this burden stratification workshop provides a critical foundation for developing a successful malaria strategic plan for Malawi.
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Young women in sub-Saharan Africa are a group at increased risk for malaria in pregnancy. Early antenatal care (ANC) seeking makes it more likely that women will receive the recommended doses of intermittent preventive treatment of malaria in pregnancy. This study used data from national Malaria Behavior Surveys conducted in Malawi and the Democratic Republic of the Congo (DRC) in 2021 to explore the association between intention to attend ANC in the first trimester for a future pregnancy (early ANC intention) and psychosocial factors among women aged 15-49 years. Eight psychosocial factors related to ANC and based on the ideation model were included, including knowledge, attitudes, and self-efficacy. The study used multivariable logistic regression models controlling for demographic characteristics to evaluate associations between early ANC intention and the individual ideational factors and the composite measure. Analysis included 2,148 women aged 15-49 years (Malawi: 827, DRC: 1,321). Antenatal care ideation was lower among young (aged 15-20 years) than among older (aged 21-49 years) women in Malawi. Young mothers with higher ANC ideation were more likely to intend to attend ANC early in their next pregnancy in both countries. Specific ideational factors associated with intention to attend ANC early varied by country and included positive attitudes, knowledge of ANC, and positive self-efficacy. In Malawi and the DRC, youth-friendly social and behavior change interventions to increase ANC-related ideation could increase future early ANC attendance among young women to improve malaria and birth outcomes.
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Malária , Cuidado Pré-Natal , Adolescente , Gravidez , Feminino , Humanos , Idade Materna , República Democrática do Congo , Intenção , Malaui/epidemiologia , Malária/epidemiologia , Malária/prevenção & controleRESUMO
Background: Malaria remains a public health problem in Malawi and has a serious socio-economic impact on the population. In the past two decades, available malaria control measures have been substantially scaled up, such as insecticide-treated bed nets, artemisinin-based combination therapies, and, more recently, the introduction of the malaria vaccine, the RTS,S/AS01. In this paper, we describe the epidemiology of malaria for the last two decades to understand the past transmission and set the scene for the elimination agenda. Methods: A collation of parasite prevalence surveys conducted between the years 2000 and 2022 was done. A spatio-temporal geostatistical model was fitted to predict the yearly malaria risk for children aged 2-10 years (PfPR 2-10) at 1×1 km spatial resolutions. Parameter estimation was done using the Monte Carlo maximum likelihood method. District-level prevalence estimates adjusted for population are calculated for the years 2000 to 2022. Results: A total of 2,595 sampled unique locations from 2000 to 2022 were identified through the data collation exercise. This represents 70,565 individuals that were sampled in the period. In general, the PfPR2_10 declined over the 22 years. The mean modelled national PfPR2_10 in 2000 was 43.93 % (95% CI:17.9 to 73.8%) and declined to 19.2% (95%CI 7.49 to 37.0%) in 2022. The smoothened estimates of PfPR2_10 indicate that malaria prevalence is very heterogeneous with hotspot areas concentrated on the southern shores of Lake Malawi and the country's central region. Conclusions: The last two decades are associated with a decline in malaria prevalence, highly likely associated with the scale-up of control interventions. The country should move towards targeted malaria control approaches informed by surveillance data.
In Malawi, malaria continues to be a significant health issue, affecting people's well-being and the economy. Over the past twenty years, efforts to control malaria, such as using bed nets, specific medications, and introducing a malaria vaccine, have increased substantially. This paper explores malaria transmission patterns during this time to better understand the past situation and prepare for future efforts to eliminate the disease. We collected and analyzed data from various surveys conducted between 2000 and 2022, focusing on malaria risk for children aged 210 years. We used a detailed statistical model to predict yearly malaria risk. The results show a decline in malaria prevalence over the 22 years. The analysis also reveals variations in malaria prevalence, with hotspot areas particularly concentrated in the southern shores of Lake Malawi and the country's central region. This decline in malaria prevalence is likely linked to the increased implementation of control measures. The findings emphasize the importance of targeted approaches informed by ongoing surveillance data for continued progress in malaria control.
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In the high HIV-burden country of Malawi, female sex workers (FSW) are one of the populations most profoundly affected by HIV. The Malawi Priorities for Local AIDS Control Efforts (PLACE) surveyed 1,004 self-identified FSW, 213 other FSW (OFSW), and 130 other high risk women (OHRW) at social venues. Analyses compared the three groups using survey-weighted log binomial regression models. Each group had a distinct pattern of usage and access to services: OFSW and FSW had greater access to condoms, while using a condom ever was greatest among FSW. Nearly all women knew where to get tested for HIV but very few used FSW drop-in centers. HIV prevalence was high in all three groups (35% FSW, 20% OFSW, 20% OHRW). Given these results, HIV services should be targeted to all women at social venues in Malawi, regardless of sex worker status to improve health outcomes and limit onward transmission of HIV.
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Infecções por HIV , Profissionais do Sexo , Preservativos , Feminino , Infecções por HIV/epidemiologia , Infecções por HIV/prevenção & controle , Humanos , Prevalência , Trabalho Sexual , Comportamento SexualRESUMO
Public health benefits of childhood vaccinations risk being derailed by low vaccination coverage in low and middle-income countries. One reason for the low coverage is poor parental knowledge of the importance of completing vaccination schedules. We therefore assessed the effects on childhood vaccination coverage, of educating parents and other persons assuming the parental role. We prospectively registered the systematic review, published the protocol, and used standard Cochrane methods to collect and synthesise the evidence. We found six eligible randomised trials with 4248 participants. Three trials assessed health-facility based education of mothers on the importance of completing vaccination schedules; immediately after birth and three months later (one study) or during the first vaccination visit (two studies). The other trials assessed community-based education, including information campaigns on the importance of vaccines using audiotaped presentations and leaflet distributions (one study); structured group discussions on benefits and costs of childhood vaccination and local action plans for improving vaccine uptake (one study); and home-based information sessions using graphic cards showing benefits and costs of childhood vaccinations and location of vaccination centres (one study). Combining the data shows that these interventions lead to substantial improvements in childhood vaccination coverage (relative increase 36%, 95% confidence interval 14% to 62%). There was no difference between the effects of community-based and facility-based education. Therefore, education in communities and health facilities on the importance of childhood vaccinations should be integrated into all vaccination programmes in low and middle-income countries; accompanied by robust monitoring of impacts and use of data for action.
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Países em Desenvolvimento , Educação em Saúde/métodos , Vacinação em Massa/métodos , Pais/educação , Cobertura Vacinal/métodos , Criança , Participação da Comunidade , Humanos , Esquemas de Imunização , Renda , Vacinação em Massa/economia , Avaliação de Programas e Projetos de Saúde , Cobertura Vacinal/economiaRESUMO
OBJECTIVES: Lay people or non-pharmacy health workers with training could dispense antiretroviral therapy (ART) in resource-constrained countries, freeing up time for pharmacists to focus on more technical tasks. We assessed the effectiveness of such task-shifting in low-income and middle-income countries. METHOD: We conducted comprehensive searches of peer-reviewed and grey literature. Two authors independently screened search outputs, selected controlled trials, extracted data and resolved discrepancies by consensus. We performed random-effects meta-analysis and assessed certainty of evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. RESULTS: Three studies with 1993 participants met the inclusion criteria, including two cluster trials conducted in Kenya and Uganda and an individually randomised trial conducted in Brazil. We found very low certainty evidence regarding mortality due to the low number of events. Therefore, we are uncertain whether there is a true increase in mortality as the effect size suggests, or a reduction in mortality between pharmacy and non-pharmacy models of dispensing ART (risk ratio (RR) 1.86, 95% CI 0.44 to 7.95, n=1993, three trials, very low certainty evidence). There may be no differences between pharmacy and non-pharmacy models of dispensing ART on virological failure (risk ratio (RR) 0.92, 95% CI 0.73 to 1.15, n=1993, three trials, low certainty evidence) and loss to follow-up (RR 1.13, 95% CI 0.68 to 1.91, n=1993. three trials, low certainty evidence). We found some evidence that costs may be reduced for the patient and health system when task-shifting is undertaken. CONCLUSIONS: The low certainty regarding the evidence implies a high likelihood that further research may find the effects of the intervention to be substantially different from our findings. If resource-constrained countries decide to shift ART dispensing and distribution from pharmacy to non-pharmacy personnel, this should be accompanied by robust monitoring and impact evaluation.
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Antirretrovirais/uso terapêutico , Infecções por HIV/tratamento farmacológico , Farmácias , Países em Desenvolvimento , Humanos , Adesão à Medicação , Ensaios Clínicos Controlados Aleatórios como Assunto , Recursos HumanosRESUMO
BACKGROUND: Cotrimoxazole (CTX) prophylaxis, recommended in HIV-exposed uninfected (HEU) children primarily against HIV-related opportunistic infections, has been shown to have some efficacy against Plasmodium falciparum malaria. The effects of CTX prophylaxis on the acquisition of P. falciparum antigen specific CD4(+) T cells-mediated immunity in HEU children is still not fully understood. METHODS: Peripheral blood was collected from HEU and HIV-unexposed uninfected (HUU) children at 6, 12 and 18 months of age. Proportion of CD4(+) T cells subsets were determined by immunophenotyping. P. falciparum antigen-specific CD4(+) T cells responses were measured by intracellular cytokine staining assay. RESULTS: There were no differences in the proportions of naïve, effector and memory CD4(+) T cell subsets between HEU and HUU children at all ages. There was a trend showing acquisition of P. falciparum-specific IFN-γ and TNF-producing CD4(+) T cells with age in both HUU and HEU children. There was, however, lower frequency of P. falciparum-specific IFN-γ-producing CD4(+) T cells in HEU compared to HUU at 6 and 12 months, which normalized 6 months after stopping CTX prophylaxis. CONCLUSION: The results demonstrate that there is delayed acquisition of P. falciparum-specific IFN-γ-producing CD4(+) T cells in HEU children on daily cotrimoxazole prophylaxis, which is evident at 6 and 12 months of age in comparison to HUU age-matched controls. However, whether this delayed acquisition of P. falciparum-specific IFN-γ-producing CD4(+) T cells leads to higher risk to malaria disease remains unknown and warrants further investigation.
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Antimaláricos/administração & dosagem , Linfócitos T CD4-Positivos/imunologia , Quimioprevenção/métodos , Malária Falciparum/imunologia , Exposição Materna , Plasmodium falciparum/imunologia , Combinação Trimetoprima e Sulfametoxazol/administração & dosagem , Citocinas/análise , Feminino , Infecções por HIV/imunologia , Humanos , Imunofenotipagem , Lactente , Malaui , Masculino , GravidezRESUMO
INTRODUCTION: Shifting selected antiretroviral therapy (ART) tasks from specialised healthcare workers to those with shorter or less formal training has been implemented in resource-limited settings to alleviate critical shortages of human resources for health. However, the specifics of shifting ART dispensing from pharmacy to non-pharmacy personnel have not been addressed in a systematic review, although this can potentially increase access to ART. We will assess the effects of shifting dispensing and distribution of ART and adherence assessment from pharmacy to non-pharmacy personnel in low and middle-income countries. METHODS AND ANALYSIS: We will search PubMed, CENTRAL, EMBASE, WHO Global Health Library and relevant grey literature for eligible controlled trials. Two authors will screen the search output, select eligible studies, assess risk of bias and extract data from included studies, resolving discrepancies by discussion and consensus. We will perform meta-analysis using both fixed and random effects models, investigate clinical and statistical heterogeneity, and assess our confidence in the overall evidence using standard Cochrane methods, including GRADE. ETHICS AND DISSEMINATION: Only secondary data will be included in this review and ethics approval is not required. We will disseminate the review findings in various scientific fora, including peer-reviewed journals. The findings may help to inform policy makers in defining the scope of work of healthcare workers, and global recommendations for shifting the dispensing and distribution of ART from pharmacy to non-pharmacy personnel. TRIAL REGISTRATION NUMBER: CRD42015017034.
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Fármacos Anti-HIV/uso terapêutico , Infecções por HIV/tratamento farmacológico , Cooperação do Paciente/estatística & dados numéricos , Farmácias , Projetos de Pesquisa , Humanos , Metanálise como Assunto , Pobreza , Revisões Sistemáticas como Assunto , Recursos HumanosRESUMO
BACKGROUND: As a result of successful PMTCT programs, children born from HIV-infected mothers are now effectively protected from contracting the infection. However, it is not well known whether in utero exposure to the virus and the subsequent exposure to Cotrimoxazole (CTX) prophylaxis affect the cell mediated immune system of the children. This observational prospective study was aimed at determining how CD4(+) T, CD8(+) T and B cell subsets varied in HIV-exposed but uninfected (HEU) children at different ages. METHODS: We recruited HEU and HIV-unexposed and uninfected (HUU) children from 6 months of age and followed them up until they were 18 months old. HEU children received daily CTX prophylaxis beginning at 6 weeks of age until when 12 months of age. Venous blood samples were collected 6 monthly and analysed for different subsets of CD8(+) T, B cells and totalCD4(+) T cells. RESULTS: At 6 months of age, HEU children had a lower percentage of total CD4(+) T cells compared to HUU children and a lower proportion of naïve CD8(+) T cells but higher percentage of effector memory CD8(+) T cells compared to HUU children. HEU and HUU children had similar proportions of all B cell subsets at all ages. CONCLUSIONS: The study showed that the subtle variations in CD4(+) and CD8(+) T cell subsets observed at 6 months do not last beyond 12 months of age, suggesting that HEU children have a robust cell-mediated immune system during first year of life. TRIAL REGISTRATION: This article report is not based on results of a controlled health-care intervention.
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Subpopulações de Linfócitos B/imunologia , Linfócitos T CD4-Positivos/imunologia , Linfócitos T CD8-Positivos/imunologia , Infecções por HIV/imunologia , Infecções por HIV/prevenção & controle , HIV-1/imunologia , Combinação Trimetoprima e Sulfametoxazol/uso terapêutico , Infecções por HIV/tratamento farmacológico , Humanos , Lactente , Contagem de Linfócitos , MalauiRESUMO
INTRODUCTION: Despite their proven effectiveness in reducing childhood infectious diseases, the uptake of vaccines remains suboptimal in low and middle-income countries. Identifying strategies for transmitting accurate vaccine information to caregivers would boost childhood vaccination coverage in these countries. The purpose of this review is to assess the effects on childhood vaccination coverage of interventions for informing or educating caregivers about the importance of vaccines in low and middle-income countries, as defined by the World Bank. METHODS AND ANALYSIS: Eligible study designs include randomised controlled trials (RCTs) as well as non-randomised controlled trials (non-RCTs). We will conduct a comprehensive search of both peer-reviewed and grey literature available up to 31 May 2015. We will search PubMed, Scopus, Cochrane Central Register of Controlled Trials, Web of Science, Cumulative Index of Nursing and Allied Health, prospective trial registries and reference lists of relevant publications. Two authors will independently screen the search output, retrieve full texts of potentially eligible studies and assess the latter against predefined inclusion criteria. Disagreements between the two authors will be resolved through consensus and arbitration by a third author. We will pool data from studies with homogenous interventions and outcomes, using random-effects meta-analysis. We will assess statistical heterogeneity using the χ(2) test of homogeneity (with signiï¬cance defined at the 10% α-level) and quantify it using Higgins' inconsistency index. We will explore the cause of any observed statistical heterogeneity using subgroup analysis, with subgroups defined by study design (RCTs vs non-RCTs) and type of intervention (information vs educational interventions). ETHICS AND DISSEMINATION: The proposed systematic review will collect and analyse secondary data that are not associated with individuals. The review will make a significant contribution to the knowledge base of interventions for improving childhood vaccination coverage in low and middle-income countries. PROTOCOL REGISTRATION NUMBER: PROSPERO, CRD42014010141.
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Cuidadores/educação , Países em Desenvolvimento , Educação em Saúde , Aceitação pelo Paciente de Cuidados de Saúde , Vacinação , Criança , Saúde da Criança , Pré-Escolar , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Lactente , Ensaios Clínicos Controlados Aleatórios como Assunto , Projetos de Pesquisa , Revisões Sistemáticas como AssuntoRESUMO
BACKGROUND AND OBJECTIVES: Co-trimoxazole prophylaxis, currently recommended in HIV-exposed, uninfected (HEU) children as protection against opportunistic infections, also has some anti-malarial efficacy. We determined whether daily co-trimoxazole prophylaxis affects the natural development of antibody-mediated immunity to blood-stage Plasmodium falciparum malaria infection. METHODS: Using an enzyme-linked immunosorbent assay, we measured antibodies to 8 Plasmodium falciparum antigens (AMA-1, MSP-119, MSP-3, PfSE, EBA-175RII, GLURP R0, GLURP R2 and CSP) in serum samples from 33 HEU children and 31 HIV-unexposed, uninfected (HUU) children, collected at 6, 12 and 18 months of age. RESULTS: Compared to HIV-uninfected children, HEU children had significantly lower levels of specific IgG against AMA-1 at 6 months (p = 0.001), MSP-119 at 12 months (p = 0.041) and PfSE at 6 months (p = 0.038), 12 months (p = 0.0012) and 18 months (p = 0.0097). No differences in the IgG antibody responses against the rest of the antigens were observed between the two groups at all time points. The breadth of specificity of IgG response was reduced in HEU children compared to HUU children during the follow up period. CONCLUSIONS: Co-trimoxazole prophylaxis seems to reduce IgG antibody responses to P. falciparum blood stage antigens, which could be as a result of a reduction in exposure of those children under this regime. Although antibody responses were regarded as markers of exposure in this study, further studies are required to establish whether these responses are correlated in any way to clinical immunity to malaria.
Assuntos
Antibacterianos/uso terapêutico , Antibioticoprofilaxia , Infecções por HIV/imunologia , Imunidade Ativa/efeitos dos fármacos , Malária Falciparum/prevenção & controle , Combinação Trimetoprima e Sulfametoxazol/uso terapêutico , Antibacterianos/farmacologia , Formação de Anticorpos/imunologia , Feminino , Humanos , Imunoglobulina G/imunologia , Lactente , Malária Falciparum/imunologia , Malaui , Masculino , Combinação Trimetoprima e Sulfametoxazol/farmacologiaRESUMO
OBJECTIVES: Cotrimoxazole prophylactic treatment (CPT) prevents opportunistic infections in HIV-infected or HIV-exposed children, but estimates of the effectiveness in preventing malaria vary. We reviewed studies that examined the effect of CPT on incidence of malaria in children in sub-Saharan Africa. METHODS: We searched PubMed and EMBASE for randomised controlled trials (RCTs) and cohort studies on the effect of CPT on incidence of malaria and mortality in children and extracted data on the prevalence of sulphadoxine-pyrimethamine resistance-conferring point mutations. Incidence rate ratios (IRR) from individual studies were combined using random effects meta-analysis; confounder-adjusted estimates were used for cohort studies. The importance of resistance was examined in meta-regression analyses. RESULTS: Three RCTs and four cohort studies with 5039 children (1692 HIV-exposed; 2800 HIV-uninfected; 1486 HIV-infected) were included. Children on CPT were less likely to develop clinical malaria episodes than those without prophylaxis (combined IRR 0.37, 95% confidence interval: 0.21-0.66), but there was substantial between-study heterogeneity (I-squared = 94%, P < 0.001). The protective efficacy of CPT was highest in an RCT from Mali, where the prevalence of antifolate resistant plasmodia was low. In meta-regression analyses, there was some evidence that the efficacy of CPT declined with increasing levels of resistance. Mortality was reduced with CPT in an RCT from Zambia, but not in a cohort study from Côte d'Ivoire. CONCLUSIONS: Cotrimoxazole prophylactic treatment reduces incidence of malaria and mortality in children in sub-Saharan Africa, but study designs, settings and results were heterogeneous. CPT appears to be beneficial for HIV-infected and HIV-exposed as well as HIV-uninfected children.
Assuntos
Antimaláricos/uso terapêutico , Resistência a Medicamentos , Infecções por HIV/complicações , Malária/prevenção & controle , Pirimetamina/uso terapêutico , Sulfadoxina/uso terapêutico , Combinação Trimetoprima e Sulfametoxazol/uso terapêutico , África Subsaariana/epidemiologia , Criança , Combinação de Medicamentos , Resistência a Medicamentos/genética , Humanos , Malária/complicações , Malária/mortalidade , MutaçãoRESUMO
We measured enteric parasitic infection prevalence and the effect of treatment on human immunodeficiency virus (HIV) RNA levels to assess their importance to HIV primary care in resource-limited settings. Adults in Lilongwe, Malawi, were evaluated, treated, and followed-up for parasitic and HIV infections. Of 389 patients, 266 (68%) were HIV infected. Helminth infections were more common in HIV-uninfected than in HIV-infected patients (39% vs. 17%). Among HIV-infected patients, helminth infections were associated with higher CD4 cell counts but not with higher HIV RNA levels. Successful treatment of parasitic infections had no effect on HIV RNA levels. Although common, parasitic infections did not impact HIV RNA levels.