Tracing defaulters in HIV prevention of mother-to-child transmission programmes through community health workers: results from a rural setting in Zimbabwe.

INTRODUCTION: High retention in care is paramount to reduce vertical human immunodeficiency virus (HIV) infections in prevention of mother-to-child transmission (PMTCT) programmes but remains low in many sub-Saharan African countries. We aimed to assess the effects of community health worker-based defaulter tracing (CHW-DT) on retention in care and mother-to-child HIV transmission, an innovative approach that has not been evaluated to date. METHODS: We analyzed patient records of 1878 HIV-positive pregnant women and their newborns in a rural PMTCT programme in the Tsholotsho district of Zimbabwe between 2010 and 2013 in a retrospective cohort study. Using binomial regression, we compared vertical HIV transmission rates at six weeks post-partum, and retention rates during the perinatal PMTCT period (at delivery, nevirapine [NVP] initiation at three days post-partum, cotrimoxazole (CTX) initiation at six weeks post-partum, and HIV testing at six weeks post-partum) before and after the introduction of CHW-DT in the project. RESULTS: Median maternal age was 27 years (inter-quartile range [IQR] 23 to 32) and median CD4 count was 394 cells/µL(3) (IQR 257 to 563). The covariate-adjusted rate ratio (aRR) for perinatal HIV transmission was 0.72 (95% confidence intervals [95% CI] 0.27 to 1.96, p=0.504), comparing patient outcomes after and before the intervention. Among fully retained patients, 11 (1.9%) newborns tested HIV positive. ARRs for retention in care were 1.01 (95% CI 0.96 to 1.06, p=0.730) at delivery; 1.35 (95% CI 1.28 to 1.42, p<0.001) at NVP initiation; 1.78 (95% CI 1.58 to 2.01, p<0.001) at CTX initiation; and 2.54 (95% CI 2.20 to 2.93, p<0.001) at infant HIV testing. Cumulative retention after and before the intervention was 496 (85.7%) and 1083 (87.3%) until delivery; 480 (82.9%) and 1005 (81.0%) until NVP initiation; 303 (52.3%) and 517 (41.7%) until CTX initiation; 272 (47.0%) and 427 (34.4%) until infant HIV testing; and 172 (29.7%) and 405 (32.6%) until HIV test result collection. CONCLUSIONS: The CHW-DT intervention did not reduce perinatal HIV transmission significantly. Retention improved moderately during the post-natal period, but cumulative retention decreased rapidly even after the intervention. We showed that transmission in resource-limited settings can be as low as in resource-rich countries if patients are fully retained in care. This requires structural changes to the regular PMTCT services, in which community health workers can, at best, play a complementary role.

Using BD Vacutainer CD4 Stabilization Tubes for Absolute Cluster of Differentiation Type 4 Cell Count Measurement on BD FacsCount and Partec Cyflow Cytometers: A Method Comparison Study from Zimbabwe.

BACKGROUND: Blood collected in conventional EDTA tubes requires laboratory analysis within 48 hours to provide valid CD4 cell count results. This restricts access to HIV care for patients from rural areas in resource-constraint settings due to sample transportation problems. Stabilization Tubes with extended storage duration have been developed but not yet evaluated comprehensively. OBJECTIVE: To investigate stability of absolute CD4 cell count measurement of samples in BD Vacutainer CD4 Stabilization Tubes over the course of 30 days. METHODS: This was a laboratory-based method comparison study conducted at a rural district hospital in Beitbridge, Zimbabwe. Whole peripheral blood from 88 HIV positive adults was drawn into BD Vacutainer CD4 Stabilization Tubes and re-tested 1, 2, 3, 5, 7, 14 and 30 days after collection on BD FacsCount and Partec Cyflow cytometers in parallel. Absolute CD4 cell levels were compared to results from paired samples in EDTA tubes analysed on BD FacsCount at the day of sample collection (references methodology). Bland-Altman analysis based on ratios of the median CD4 counts was used, with acceptable variation ranges for Limits of Agreements of +/-20%. RESULTS: Differences in ratios of the medians remained below 10% until day 21 on BD FacsCount and until day 5 on Partec Cyflow. Variations of Limits of Agreement were beyond 20% after day 1 on both cytometers. Specimen quality decreased steadily after day 5, with only 68% and 40% of samples yielding results on BD FacsCount and Partec Cyflow at day 21, respectively. CONCLUSIONS: We do not recommend the use of BD Vacutainer CD4 Stabilization Tubes for absolute CD4 cell count measurement on BD FacsCount or Partec Cyflow due to large variation of results and decay of specimen quality. Alternative technologies for enhanced CD4 testing in settings with limited laboratory and sample transportation capacity still need to be developed.

Access to CD4 Testing for Rural HIV Patients: Findings from a Cohort Study in Zimbabwe.

BACKGROUND: CD4 cell count measurement remains an important diagnostic tool for HIV care in developing countries. Insufficient laboratory capacity in rural Sub-Saharan Africa is frequently mentioned but data on the impact at an individual patient level are lacking. Urban-rural discrepancies in CD4 testing have not been quantified to date. Such evidence is crucial for public health planning and to justify new yet more expensive diagnostic procedures that could circumvent access constraints in rural areas. OBJECTIVE: To compare CD4 testing among rural and urban HIV patients during the first year of treatment. METHODS: Records from 2,145 HIV positive adult patients from a Médecins sans Frontières (Doctors without Borders) HIV project in Beitbridge, Zimbabwe, during 2011 and 2012 were used for a retrospective cohort analysis. Covariate-adjusted risk ratios were calculated to estimate the effects of area of residence on CD4 testing at treatment initiation, six and 12 months among rural and urban patients. FINDINGS: While the proportion of HIV patients returning for medical consultations at six and 12 months decreased at a similar rate in both patient groups, CD4 testing during consultations dropped to 21% and 8% for urban, and 2% and 1% for rural patients at six and 12 months, respectively. Risk ratios for missing CD4 testing were 0.8 (95% CI 0.7-0.9), 9.2 (95% CI 5.5-15.3), and 7.6 (95% 3.7-17.1) comparing rural versus urban patients at treatment initiation, six and 12 months, respectively. CONCLUSIONS: CD4 testing was low overall, and particularly poor in rural patients. Difficulties with specimen transportation were probably a major factor underlying this difference and requires new diagnostic approaches. Our findings point to severe health system constraints in providing CD4 testing overall that need to be addressed if effective monitoring of HIV patients is to be achieved, whether by alternative CD4 diagnostics or newly-recommended routine viral load testing.

Risk of death among those awaiting treatment for HIV infection in Zimbabwe: adolescents are at particular risk.

INTRODUCTION: Mortality among HIV-positive adults awaiting antiretroviral therapy (ART) has previously been found to be high. Here, we compare adolescent pre-ART mortality to that of adults in a public sector HIV care programme in Bulawayo, Zimbabwe. METHODS: In this retrospective cohort study, we compared adolescent pre-ART outcomes with those of adults enrolled for HIV care in the same clinic. Adolescents were defined as those aged 10-19 at the time of registration. Comparisons of means and proportions were carried out using two-tailed sample t-tests and chi-square tests respectively, for normally distributed data, and the Mann-Whitney U-tests for non-normally distributed data. Loss to follow-up (LTFU) was defined as missing a scheduled appointment by three or more months. RESULTS: Between 2004 and 2010, 1382 of 1628 adolescents and 7557 of 11,106 adults who registered for HIV care met the eligibility criteria for ART. Adolescents registered at a more advanced disease stage than did adults (83% vs. 73% WHO stage III/IV, respectively, p<0.001), and the median time to ART initiation was longer for adolescents than for adults [21 (10-55) days vs. 15 (7-42) days, p<0.001]. Among the 138 adolescents and 942 adults who never commenced ART, 39 (28%) of adolescents and 135 (14%) of adults died, the remainder being LTFU. Mortality among treatment-eligible adolescents awaiting ART was significantly higher than among adults (3% vs. 1.8%, respectively, p=0.004). CONCLUSIONS: Adolescents present to ART services at a later clinical stage than adults and are at an increased risk of death prior to commencing ART. Improved and innovative HIV case-finding approaches and emphasis on prompt ART initiation in adolescents are urgently needed. Following registration, defaulter tracing should be used, whether or not ART has been commenced.

Mother to Mother (M2M) peer support for women in Prevention of Mother to Child Transmission (PMTCT) programmes: a qualitative study.

INTRODUCTION: Mother-to-Mother (M2M) or "Mentor Mother" programmes utilise HIV positive mothers to provide support and advice to HIV positive pregnant women and mothers of HIV exposed babies. Médecins Sans Frontières (MSF) supported a Mentor Mother programme in Bulawayo, Zimbabwe from 2009 to 2012; with programme beneficiaries observed to have far higher retention at 6-8 weeks (99% vs 50%, p<0.0005) and to have higher adherence to Prevention of Mother to Child Transmission (PMTCT) guidelines, compared to those not opting in. In this study we explore how the M2M progamme may have contributed to these findings. METHODS: In this qualitative study we used thematic analysis of in-depth interviews (n = 79). This study was conducted in 2 urban districts of Bulawayo, Zimbabwe's second largest city. RESULTS: Interviews were completed by 14 mentor mothers, 10 mentor mother family members, 30 beneficiaries (women enrolled both in PMTCT and M2M), 10 beneficiary family members, 5 women enrolled in PMTCT but who had declined to take part in the M2M programme and 10 health care staff members. All beneficiaries and health care staff reported that the programme had improved retention and provided rich information on how this was achieved. Additionally respondents described how the programme had helped bring about beneficial behaviour change. CONCLUSIONS: M2M programmes offer great potential to empower communities affected by HIV to catalyse positive behaviour change. Our results illustrate how M2M involvement may increase retention in PMTCT programmes. Non-disclosure to one's partner, as well as some cultural practices prevalent in Zimbabwe appear to be major barriers to participation in M2M programmes.

HIV-infected adolescents in southern Africa can achieve good treatment outcomes: results from a retrospective cohort study.

OBJECTIVES: In this study we examine whether adolescents treated for HIV/AIDS in southern Africa can achieve similar treatment outcomes to adults. DESIGN: We have used a retrospective cohort study design to compare outcomes for adolescents and adults commencing antiretroviral therapy (ART) between 2004 and 2010 in a public sector hospital clinic in Bulawayo, Zimbabwe. METHODS: Cox proportional hazards modelling was used to investigate risk factors for death and loss to follow-up (LTFU) (defined as missing a scheduled appointment by ≥3months). RESULTS: One thousand, seven hundred and seventy-six adolescents commenced ART, 94% having had no previous history of ART. The median age at ART initiation was 13.3 years. HIV diagnosis in 97% of adolescents occurred after presentation with clinical disease and a higher proportion had advanced HIV disease at presentation compared with adults [WHO Stage 3/4 disease (79.3 versus 65.2%, P < 0.001)]. Despite this, adolescents had no worse mortality than adults, assuming 50% mortality among those LTFU (6.4 versus 7.3 per 100 person-years, P = 0.75) with rates of loss to follow-up significantly lower than in adults (4.8 versus 9.2 per 100 person-years, P < 0.001). Among those who were followed for 5 years or more, 5.8% of adolescents switched to a second-line regimen as a result of treatment failure, compared with 2.1% of adults (P < 0.001). CONCLUSION: With adolescent-focused services, it is feasible to achieve good outcomes for adolescents in large-scale ART programs in sub-Saharan Africa. However, adolescents are at high risk of treatment failure, which compromises future drug options. Interventions to address poor adherence in adolescence should be prioritized.