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Uptake and performance of prevention of mother-to-child transmission and early infant diagnosis in pregnant HIV infected women and their exposed infants at seven health centres in Addis Ababa, Ethiopia.
Tropical Medicine and International Health. 2017 Jun; 22(6):765-775.Objective To assess the uptake of WHO-recommended PMTCT procedures in Ethiopia's health services. Methods Prospective observational study of HIV-positive pregnant mothers and their newborns attending PMTCT services at seven health centers in Addis Ababa. Women were recruited during antenatal care and followed-up with their newborns at delivery, day 6 and week 6 postpartum. Retention to PMCTC procedures, self-reported ART adherence, and HIV infant outcome were assessed. Turnaround times of HIV early infant diagnosis (EID) procedures were extracted from health registers. Results Of 494 women enrolled 4.9% did not complete PMTCT procedures due to active denial or loss to follow-up. HIV was first diagnosed in 223 (45.1%) and ART initiated in 321 (65.0%) women during pregnancy. ART was initiated in a median of 1.3 weeks (IQR 0-4.3) after HIV diagnosis. Poor self-reported treatment adherence was higher post-partum than during pregnancy (12.5% versus 7.0%, p=0.002), and significantly associated with divorced/separated marital status (RR 2.2, 95% CI 1.3-3.8), low family income (RR 2.1, 95% CI 1.1-4.1), low CD4-count (RR 1.7, 95% CI 1.0-3.0), and ART initiation during delivery (RR 2.5, 95% CI 1.1-5.6). Of 435 infants born alive 98.6% received nevirapine prophylaxis. The mother-to-child HIV transmission rate was 0.7% after a median of 6.7 weeks (IQR 6.4-10.4), but EID results were received for only 46.6% within 3 months of birth. Conclusion High retention in PMTCT services, triple maternal ART and high infant nevirapine prophylaxis coverage were associated with low mother-to-child HIV transmission. Declining post-partum ART adherence and challenges of EID linkage require attention.
Option B+ for prevention of vertical HIV transmission has no influence on adverse birth outcomes in a cross-sectional cohort in Western Uganda.
BMC Pregnancy and Childbirth. 2017 Mar 7; 17(82):1-12.Background While most Sub-Saharan African countries are now implementing the WHO-recommended Option B+ protocol for prevention of vertical HIV transmission, there is a lack of knowledge regarding the influence of Option B+ exposure on adverse birth outcomes (ABOs). Against this background, we assessed ABOs among delivering women in Western Uganda. Methods A cross-sectional, observational study was performed within a cohort of 412 mother-newborn-pairs in Virika Hospital, Fort Portal in 2013. The occurrence of stillbirth, pre-term delivery, and small size for gestational age (SGA) was analyzed, looking for influencing factors related to HIV-status, antiretroviral drug exposure and duration, and other sociodemographic and clinical parameters. Results Among 302 HIV-negative and 110 HIV-positive women, ABOs occurred in 40.5%, with stillbirth in 6.3%, pre-term delivery in 28.6%, and SGA in 12.2% of deliveries. For Option B+ intake (n = 59), no significant association was found with stillbirth (OR 0.48, p = 0.55), pre-term delivery (OR 0.97, p = 0.92) and SGA (OR 1.5, p = 0.3) compared to seronegative women. Women enrolled on antiretroviral therapy (ART) before conception (n = 38) had no different risk for ABOs than women on Option B+ or HIV-negative women. Identified risk factors for stillbirth included lack of formal education, poor socio-economic status, long travel distance, hypertension and anemia. Pre-term delivery risk was increased with poor socio-economic status, primiparity, Malaria and anemia. The occurrence of SGA was influenced by older age and Malaria. Conclusion In our study, women on Option B+ showed no difference in ABOs compared to HIV-negative women and to women on ART. We identified several non-HIV/ART-related influencing factors, suggesting an urgent need for improving early risk assessment mechanisms in antenatal care through better screening and triage systems. Our results are encouraging with regard to continued universal scale-up of Option B+ and ART programs.
Guideline: Updates on HIV and infant feeding. The duration of breastfeeding and support from health services to improve feeding practices among mothers living with HIV.
Geneva, Switzerland, WHO, 2016.  p.The objective of this guideline is to improve the HIV-free survival of HIV-exposed infants by providing guidance on appropriate infant feeding practices and use of ARV drugs for mothers living with HIV and by updating WHO-related tools and training materials. The guideline is intended mainly for countries with high HIV prevalence and settings in which diarrhoea, pneumonia and undernutrition are common causes of infant and child mortality. However, it may also be relevant to settings with a low prevalence of HIV depending on the background rates and causes of infant and child mortality. This guideline aims to help Member States and their partners in their efforts to make informed decisions on the appropriate nutrition actions to achieve the Sustainable Development Goals, the global targets set in the comprehensive implementation plan on maternal, infant and young child nutrition, the Global Strategy for Women’s, Children’s and Adolescents’ Health (2016-2030) and the Global Health Sector Strategy on Sexually Transmitted Infections 2016-2021. The target audience for this guideline includes: (1) national policy-makers in health ministries; (2) programme managers working in child health, essential drugs and health worker training; (3) health-care providers, researchers and clinicians providing services to pregnant women and mothers living with HIV at various levels of health care; and (4) development partners providing financial and/or technical support for child health programmes, including those in conflict and emergency settings. (Excerpt)
Implications of the new WHO guidelines on HIV and infant feeding for child survival in South Africa.
Bulletin of the World Health Organization. 2011 Jan 1; 89(1):62-7.The World Health Organization released revised principles and recommendations for HIV and infant feeding in November 2009. The recommendations are based on programmatic evidence and research studies that have accumulated over the past few years within African countries. This document urges national or subnational health authorities to decide whether health services should mainly counsel and support HIV-infected mothers to breastfeed and receive antiretroviral interventions, or to avoid all breastfeeding, based on estimations of which strategy is likely to give infants in those communities the greatest chance of HIV-free survival. South Africa has recently revised its clinical guidelines for prevention of mother-to-child HIV transmission, adopting many of the recommendations in the November 2009 World Health Organization's rapid advice on use of antiretroviral drugs for treating pregnant women and preventing HIV infection in infants. However, one aspect of the new South African guidelines gives cause for concern: the continued provision of free formula milk to HIV-infected women through public health facilities. This paper presents the latest evidence regarding mortality and morbidity associated with feeding practices in the context of HIV and suggests a modification of current policy to prioritize child survival for all South African children.
Antiretroviral resistance patterns and HIV-1 subtype in mother-infant pairs after the administration of combination short-course zidovudine plus single-dose nevirapine for the prevention of mother-to-child transmission of HIV.
Clinical Infectious Diseases. 2009 Jul 15; 49(2):299-305.BACKGROUND: World Health Organization guidelines for prevention of mother-to-child transmission of human immunodeficiency virus type 1 (HIV-1) recommend administration of zidovudine and single-dose nevirapine (NVP) for HIV-1-infected women who are not receiving treatment for their own health or if complex regimens are not available. This study assessed antiretroviral resistance patterns among HIV-infected women and infants receiving single-dose NVP in Thailand, where the predominant circulating HIV-1 strains are CRF01_AE recombinants and where the minority are subtype B. METHODS: Venous blood samples were obtained from (1) HIV-infected women who received zidovudine from 34 weeks' gestation and single-dose NVP plus oral zidovudine during labor and (2) HIV-infected infants who received single-dose NVP after birth plus zidovudine for 4 weeks after delivery. HIV-1 drug resistance testing was performed using the TruGene assay (Bayer HealthCare). RESULTS: Most mothers and infants were infected with CRF01_AE. NVP resistance was detected in 34 (18%) of 190 women and 2 (20%) of 10 infants. There was a significantly higher proportion of NVP mutations in women with delivery viral loads of >50,000 copies/mL (adjusted odds ratio, 8.5; 95% confidence interval, 2.2-32.8, [Formula: see text] for linear trend) and in those with subtype B rather than CRF01_AE infections (38% vs. 16%; adjusted odds ratio, 3.6; 95% confidence interval, 1.1-11.8; P = .038). CONCLUSIONS: The lower frequency of NVP mutations among mothers infected with subtype CRF01_AE, compared with mothers infected with subtype B, suggests that individuals infected with subtype CRF01_AE may be less susceptible to the induction of NVP resistance than are individuals infected with subtype B.
Towards universal access by 2010. How WHO is working with countries to scale-up HIV prevention, treatment, care and support.
Geneva, Switzerland, WHO, Department of HIV / AIDS, 2006. 32 p.In 2005, leaders of the G8 countries agreed to «work with WHO, UNAIDS and other international bodies to develop and implement a package for HIV prevention, treatment and care, with the aim of as close as possible to universal access to treatment for all those who need it by 2010». This goal was endorsed by United Nations Member States at the High-Level Plenary Meeting of the 60th Session of the United Nations General Assembly in September 2005. At the June 2006 General Assembly High Level Meeting on AIDS, United Nations Member States agreed to work towards the broad goal of "universal access to comprehensive prevention programmes, treatment, care and support" by 2010. Working towards universal access is a very ambitious challenge for the international community, and will require the commitment and involvement of all stakeholders, including governments, donors, international agencies, researchers and affected communities. Among the most important priorities is the strengthening of health services so that they are able to provide a comprehensive range of HIV/AIDS services to all those who need them. This document describes the contribution that the World Health Organization (WHO) will make, as the United Nations agency responsible for health, in working towards universal access to HIV prevention, treatment, care and support in the period 2006-2010. It proposes an evidence-based Model Essential Package of integrated health sector interventions for HIV/AIDS that WHO recommends be scaled up in countries, using a public health approach, and provides an overview of the strategic directions and priority intervention areas that will guide WHO's technical work and support to its Member States as they work towards universal access over the next four years. (excerpt)
Antiretroviral therapy for HIV infection in adults and adolescents: recommendations for a public health approach. 2006 revision.
Geneva, Switzerland, WHO, 2006. 127 p.This publication is intended to serve as a reference tool for countries with limited resources as they develop or revise national guidelines for the use of ART in adults and postpubertal adolescents (see Annex 9 for pubertal Tanner staging; prepubertal adolescents should follow the WHO paediatric guidelines). The material presented takes updated evidence into account, including new ART treatment options, and draws on the experience of established ART scale-up programmes. The simplified approach, with evidence-based standards, continues to be the basis of WHO recommendations for the initiation and monitoring of ART. The guidelines are primarily intended for use by national and regional HIV programme managers, managers of nongovernmental organizations delivering HIV care services, and other policy-makers who are involved in the scaling up of comprehensive HIV care and ART in resource-limited countries. The comprehensive, up-to-date technical and clinical information on the use of ART, however, also makes these guidelines useful for clinicians in resource-limited settings. The recommendations contained in these guidelines are made on the basis of different levels of evidence from randomized clinical trials, high-quality scientific studies, observational cohort data and, where insufficient evidence is available, expert opinion. The strengths of the recommendations in Table 1 are intended to indicate the degrees to which the recommendations should be considered by regional and country programmes. Cost-effectiveness is not explicitly considered as part of the recommendations, although the realities of human resources, health system infrastructures and socioeconomic issues should be taken into account when the recommendations are being adapted to regional and country programmes. (excerpt)
BMJ. British Medical Journal. 2007 Mar 10; 334(7592):487-488.Recently, the World Health Organization updated its recommendations of 2000 on infant feeding in the context of HIV. At that time, data had just been published quantifying the risk of infection through breast feeding so avoiding breast feeding was acknowledged as the only effective way of avoiding transmission. WHO had also just published a meta-analysis of the mortality risks of not breast feeding, but in non-HIV infected populations. Considerations of these data resulted in the statement that, "When replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding by HIV-infected mothers is recommended." Since the 2000 recommendations, the main emphasis of most national programmes aimed at preventing mother to child transmission of HIV has been to avert transmission of HIV in young infants. The most difficult challenge has been how to make breast feeding safer in communities with a high prevalence of HIV where breast feeding is the traditional mode of feeding. Remarkably, the dilemma of infant feeding and HIV has split scientific communities and programme managers into opposing camps. Even with the risk of HIV transmission, some maintain that breast feeding may still be the best option for many mothers infected with HIV because of its anti-infective and nutritional advantages. Others promote commercial infant formula, arguing that the risks of diarrhoea and malnutrition associated with formula feeding are lower in most urban communities, or that the risks of not breast feeding may not be as great for infants born to mothers infected with HIV who, to prevent transmission, choose to give formula milk from birth; it has been suggested that this active decision making and motivation may result in safer preparation and use of formula milk. (excerpt)
PLoS Medicine. 2007 Jan; 4(1):e30.In this issue of PLoS Medicine, Renaud Becquet and colleagues report their findings from a new study looking at the long-term safety of infant feeding interventions aimed at reducing mother-to-child HIV transmission in Africa. Over two years, the researchers studied the safety of infant feeding interventions (either formula feeding or shortened breastfeeding) among infants of HIV-infected mothers in Abidjan, Côte d'Ivoire. The authors chose to examine this issue because of the continued challenges faced by HIV-infected mothers regarding infant feeding. Breastmilk transmission of HIV contributes substantially to the risk of infant HIV infection; consequently HIV-infected mothers in Europe and the United States are counseled not to breast-feed their infants. However, avoiding breastfeeding or shortening the term of breast-feeding may be risky for infants in settings with inadequate sanitation, limited access to breast-milk substitutes, or unsafe water. Thus, UNAIDS (the Joint United Nations Programme on HIV/AIDS) recommends that HIV-infected women "replacement feed" their infants when it is acceptable, feasible, affordable, sustainable, and safe ("replacement feeding" is a term used to refer to feeding infants with milk other than breast milk, such as formula). (excerpt)
[New guidelines for preventing mother-to-child transmission of the human immunodeficiency virus] Nuevas orientaciones para prevenir la transmisión maternofilial del virus de la inmunodeficiencia humana.
Revista Panamericana de Salud Pública / Pan American Journal of Public Health. 2004; 16(4):289-294.During a meeting in Geneva, Switzerland, on 5 and 6 February 2004, a working group of experts from the World Health Organization (WHO) and other scientists, health officials, and community representatives from throughout the world revised the guidelines developed by WHO in 2000 on the use of antiretroviral agents. Special attention was paid to the role of such agents in the prevention of HIV transmission from mother to infant during pregnancy, labor, and breast-feeding. This paper summarizes the newly developed guidelines, which contain specific recommendations for low-resource settings. It is hoped that the information provided will help curb HIV transmission from mother to child in developing countries, where it accounts for the majority of cases of HIV infection in childhood. (author's)
Geneva, Switzerland, World Health Organization [WHO], 2003. 13 p. (Perspectives and Practice in Antiretroviral Treatment)The primary objective of the MTCT-Plus Initiative is to provide lifelong care and treatment for HIV/AIDS to families in resource-limited settings. In addition to reducing mortality and morbidity, the Initiative hopes to further reduce the mother-to-child-transmission of HIV; to promote voluntary counselling and testing and other preventive strategies; to strengthen local health care capacity; to decrease stigma among, enhance support for and empower people living with HIV/AIDS; and to develop a model for HIV care in resource-limited settings that can be generalized. An international review committee selected the initial sites after a request for applications was widely distributed in early 2002. Of the 47 eligible applicants – all of whom had ongoing programmes to prevent the mother-to-child-transmission of HIV, HIV prevalence of at least 5% and the ability to enroll at least 250 people per year – the committee selected 12 demonstration sites. An additional 13 sites were given planning grants. (excerpt)
Lancet. 2003 Nov 29; 362(9398):1850-1853.Each year, about 2 million babies are born to HIV-1- infected women. Despite widespread knowledge of proven methods to prevent mother-to-child transmission (MTCT) of the virus, most infants at risk of contracting the infection from their mothers receive no prophylactic intervention. This inaction leads to the infection and ultimate death of about 800 000 children per year. It has been known since 1994 that MTCT is largely preventable, and interventions appropriate for use in the developing world have been available since 1999. Singledose intrapartum and neonatal nevirapine—the simplest and perhaps most effective of the short-course antiretroviral regimens studied—has been available free of charge from the manufacturer since 2000. Nevertheless, few women have access to MTCT-prevention services. In the more than 3 years since its inception, the donation programme has shipped only 189 000 courses of the drug, a tiny fraction (<5%) of the estimate worldwide need. Why this feasible10 and cost-effective intervention has failed to reach so many of the women and infants who need it is a difficult question with no simple answers. Whatever the reasons, we believe that the continued low level of coverage of MTCT-prevention services is no longer acceptable from either a public health or a humanitarian perspective. We argue for a goal-directed approach to scaling-up of such services, in which we first acknowledge that the guiding objective should be to save babies from HIV-1 infection. To meet this objective, it will be necessary in many settings to dissociate the complex business of expanding HIV-1 testing services from the simpler matter of providing nevirapine prophylaxis. (author's)