The cascade of care to prevent mother-to-child transmission in Rio de Janeiro, Brazil, 1996-2013: improving but still some way to go.

OBJECTIVE: To describe the cascade of care to HIV mother-to-child transmission (PMTCT) in a Rio de Janeiro reference paediatric clinic and evaluate the main factors possibly associated with HIV transmission. METHODS: Data on antenatal care (ANC), perinatal and neonatal assistance to HIV-infected and HIV-exposed but uninfected children assisted in the clinic from 1996 to 2013 were collected. The cascade of care was graphically demonstrated, and possible factors associated with HIV infection were described using regression models for bivariate and multivariate analysis. We imputed missing values of explanatory variables for the final model. RESULTS: A total of 989 children were included in the analysis: 211 were HIV and 778 HEU. Graphically, the HIV PMTCT cascade of care improved from 1996/2000 to the later periods, but not from 2001/2006 to 2007/2013. The main factor independently associated with the HIV infection over time was breastfeeding. In the period 1996/2000, the lack of antiretroviral use during labour was associated HIV transmission. While in 2001/2007, other modes of delivery but elective Caesarean section, and lack of maternal antiretroviral use during ANC were associated with HIV transmission. In the last period, the main factor associated with transmission was the lack of maternal ANC. CONCLUSIONS: The HIV PMTCT cascade improved over time, but HIV vertical transmission remains a problem, and better access to ANC is needed.

Evaluation of HIV/AIDS clinical care quality: the case of a referral hospital in North West Ethiopia.

OBJECTIVE: To assess the quality of clinical care provided to patients with HIV in Felege Hiwot Referral Hospital. APPROACH AND DESIGN: Normative evaluation based on Donabedian's structure-process-outcome model of health care quality. Cross-sectional STUDY DESIGN: was employed to gather data in September 2007. SETTING: Felege Hiwot Referral Hospital is a government hospital in North West Ethiopia. The hospital is providing clinical care for patients infected with HIV free of patient charge since 2005. MEASURES: The evaluation used 10 process and 5 outcome indicators of quality measured by reviewing 351 randomly selected patient records and interview with 368 patients. Resource inventory was conducted to assess the availability of trained staff, laboratory facilities and drugs required for provision of HIV care. RESULTS: All resources recommended by the national antiretroviral therapy (ART) Implementation Guideline including trained staff, laboratory facilities and drugs were continuously available, except for a shortage of cotrimoxazole. Despite this, important components of care and treatment recommended by national treatment guidelines were not delivered for significant portion of patients. The study showed that only 45.9% of patients eligible for cotrimoxazole prophylactic therapy (CPT) and 76.8% of patients eligible for ART were actually taking CPT and ART, respectively. Compliance with national guidelines to monitor patients was also found to be a major problem. CONCLUSION: Availability of resources alone does not ensure the quality of HIV care and treatment. The study results indicate a need for regular monitoring and improvement of processes and outcomes of care in the Ethiopian Health System.

Ready or not--intrapartum prevention of perinatal HIV transmission in Illinois.

OBJECTIVES: The overall readiness of Illinois birthing hospitals to comply with the 2003 Illinois HIV Perinatal Prevention Act and prevent perinatal HIV transmission, and the hospital characteristics that predict readiness were examined. METHODS: Nurse Managers of all 137 Illinois birthing hospitals were surveyed regarding current labor and delivery (L&D) practices for HIV status identification, documentation, testing and zidovudine (AZT) availability in March 2004. Bivariate and multivariable regression analysis was performed. RESULTS: All 137 hospitals returned the surveys. Almost forty seven percent of Illinois birthing hospitals had adequate maternal HIV status documentation on arrival in L&D, 72.3% documented prenatal HIV results in the L&D chart, 65.7% documented prenatal HIV in the newborn chart, 38.7% ordered HIV tests on L&D if no prenatal HIV status was available, and 61.3% had AZT available. Only 17 hospitals (12.4%) met requirements for overall readiness to prevent perinatal HIV transmission. Sixteen hospitals (11.6%) met a minimal level of readiness (prenatal HIV status documentation and AZT availability). CONCLUSIONS: Despite passage of legislation to increase perinatal HIV testing and reduce transmission, Illinois birthing hospitals had an overall low level of readiness to implement the intrapartum interventions that are an essential part of eradicating pediatric HIV infection. Perinatal reduction protocols and implementation guidelines would improve the overall readiness of Illinois birthing hospitals to prevent perinatal HIV transmission.

AZT Availability in Illinois birthing hospitals: is the perinatal HIV prevention safety net in place?

OBJECTIVES: To prevent perinatal HIV transmission, providers must identify HIV status for all women in labor and newborns, and provide timely antiretroviral therapy if necessary. The objective of this study is to evaluate the availability and accessibility of zidovudine (AZT) in Illinois birthing hospitals. METHODS: We surveyed all Illinois birthing hospital pharmacies by telephone in February 2005 regarding availability, accessibility, and protocols surrounding AZT use in the perinatal period. RESULTS: All 137 pharmacies participated. Only 43.1% reported having syrup and IV AZT available and only 37.2% indicated the ability to have AZT available on labor and delivery within 30 min during off hours. Protocols for treating HIV positive women in labor and exposed newborns were available in only 37.2% of pharmacies while 72.4% had protocols for antiretroviral therapy for occupational post-exposure prophylaxis. Variables associated with pharmacies having AZT available included being a major academic hospital and serving a predominately (greater than 96%) white patient population. Timely provision of AZT was more likely to occur in urban, major academic hospitals serving a predominately white population. CONCLUSIONS: In order to further reduce perinatal HIV transmission, availability and timely access to both syrup and IV AZT must be improved in Illinois birthing hospitals.

U.N. drug initiative hits the ground.

AIDS: The Joint United Nations Programme on HIV/AIDS (UNAIDS) announced its HIV Drug Access Initiative in November 1997. Advisory boards oversee the Initiative, set national policy, and determine criteria for eligible participants. The program also provides drugs for opportunistic infections and sexually transmitted diseases. The initial phase of the program includes Uganda, the Ivory Coast, Chile, and Vietnam, although funding remains a problem. UNAIDS is helping with medical training in each country, and uses a computerized system to track participants and drug distribution. UNAIDS is also negotiating with pharmaceutical companies to provide drugs at subsidized costs. Glaxo Wellcome and Hoffman-LaRoche have committed to making their drugs and diagnostic kits available via the program; others are considering joining the effort. A major effort is underway by the program to reduce vertical transmission of HIV.^ieng

Sending HIV drugs to developing countries.

AIDS: Community-based organizations are involved in a program to recycle HIV drugs to patients in developing countries. Unused drugs from patients who have died or who have switched to other medications are donated to organizations which distribute them outside the United States. Initially, the program mostly provided drugs for opportunistic infections, but the scope of the program has expanded to include protease inhibitors and other drugs. A number of ethical and health care issues are involved, including the issue of treatment continuity.^ieng

Maternal AZT programs at the starting gate.

AIDS: The Joint United Nations Programme on HIV/AIDS (UNAIDS) is excited about the programs that developing countries are implementing to reduce mother-to-child HIV transmission. The countries interested in launching pilot projects include Zimbabwe, South Africa, and Chile. The interventions will include short-course AZT regimens and alternatives to breast feeding. Rapid testing will probably replace the existing systems to ensure that HIV-positive pregnant women are treated quickly. Glaxo-Wellcome, the manufacturer of AZT, promises to provide AZT at discounts of 50 to 75 percent. Formula makers are expected to follow suit, although there are no firm programs underway. Advocates of breast feeding were worried that formula feeding would undermine their worldwide efforts to improve children's nutrition. Now they are softening their opposition to formula feeding, due to the HIV risk associated with breast feeding.^ieng

Europe out of step with the US.

AIDS: The disparity in the availability of AIDS drugs between the United States and Europe is frustrating to members of the European AIDS Treatment Group, among others. It is hoped that the newly-created European Medicines Evaluation Agency (EMEA) will streamline drug approval for the European Union overall, since previous approvals were done on a country-by-country basis. Although alternative methods of drug approval in Europe cause apprehension, it is hoped that a system will be created that will deliver drugs quickly without sacrificing the physician and patient guideline requirements.^ieng

Survival and medical intervention in southern Brazilian AIDS patients.

The aim of the study was to describe survival patterns of Southern Brazilian AIDS patients: 224 predominantly working class AIDS patients were treated in an AIDS referral centre in Porto Alegre between October 1986 and September 1991. The caseload increased progressively, as did the number of female AIDS cases treated at the Hospital during the study period. Self-referred patients were more likely to present with an AIDS defining condition (P < 0.03) and they (n = 106) had significantly worse survival patterns compared with patients referred by other health care professionals (n = 112; P < 0.04). Median survival from the time of AIDS diagnosis was 5 months which did not change significantly during the study period (P = 0.38). Patients (n = 42) presenting with opportunistic infections other than mycobacterial disease (n = 42), Pneumocystis carinii pneumonia (n = 37) or candidiasis (n = 18), had significantly worse survival patterns (P = 0.001). Patients treated with zidovudine (n = 33) survived significantly longer from time of AIDS diagnosis than those not on zidovudine (n = 185; P = 0.0002). No significant survival differences were observed from time of AIDS diagnosis between those who commenced on zidovudine before developing AIDS (n = 17) and those who were treated with zidovudine since diagnosed with AIDS (n = 16; P = 0.80). During the study period zidovudine was only available through private prescriptions. Survival of Southern Brazilian AIDS patients has not improved: earlier access to HIV-related services and the provision of effective and affordable therapeutic interventions are two measures which could improve future survival patterns.