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UNICEF's contribution to the adoption and implementation of option B+ for preventing mother-to-child transmission of HIV: a policy analysis.
Globalization and Health. 2018 Jun 1; 14(1):55.BACKGROUND: Between 2011 and 2013, global and national guidelines for preventing mother-to-child transmission (PMTCT) of HIV shifted to recommend Option B+, the provision of lifelong antiretroviral treatment for all HIV-infected pregnant women. METHODS: We aimed to analyse how Option B+ reached the policy agenda, and unpack the processes, actors and politics that explain its adoption, with a focus on examining UNICEF's contribution to these events. Analysis drew on published articles and other documentation, 30 key informants interviews with staff at UNICEF, partner organisations and government officials, and country case studies. Cameroon, India, South Africa and Zimbabwe were each visited for 5-8 days. Interview transcripts were analysed using Dedoose software, reviewed several times and then coded thematically. RESULTS: A national policy initiative in Malawi in 2011, in which the country adopted Option B+, rather than existing WHO recommended regimens, irrevocably placed the policy on the global agenda. UNICEF and other organisations recognised the policy's potential impact and strategically crafted arguments to support it, framing these around operational considerations, cost-effectiveness and values. As 'policy entrepreneurs', these organisations vigorously promoted the policy through a variety of channels and means, overcoming concerted opposition. WHO, on the basis of scanty evidence, released a series of documents towards the policy's endorsement, paving the way for its widespread adoption. National-level policy transformation was rapid and definitive, distinct from previous incremental policy processes. Many organisations, including UNICEF, facilitated these changes in country, acting individually, or in concert. CONCLUSIONS: The adoption of the Option B+ policy marked a departure from established processes for PMTCT policy formulation which had been led by WHO with the support of technical experts, and in which recommendations were developed following shifts in evidence. Rather, changes were spurred by a country-level initiative, and a set of strategically framed arguments that resonated with funders and country-level actors. This bottom-up approach, supported by normative agencies, was transformative. For UNICEF, alignment between the organisation's country focus and the policy's underpinning values, enabled it to work with partners and accelerate widespread policy change.
Lancet. HIV. 2016 Sep; 3(9):e409.Add to my documents.
AIDS and Behavior. 2017 Jul; 21(Suppl 1):62-71.BACKGROUND: Nigeria accounts for 9% of the global HIV burden and is a signatory to Millennium Development Goals as well as the post-2015 Sustainable Development Goals. This paper reviews maturation of her HIV M&E system and preparedness for monitoring of the post-2015 agenda. METHODS: Using the UNAIDS criteria for assessing a functional M&E system, a mixed-methods approach of desk review and expert consultations, was employed. RESULTS: Following adoption of a multi-sectoral M&E system, Nigeria experienced improved HIV coordination at the National and State levels, capacity building for epidemic appraisals, spectrum estimation and routine data quality assessments. National data and systems audit processes were instituted which informed harmonization of tools and indicators. The M&E achievements of the HIV response enhanced performance of the National Health Management Information System (NHMIS) using DHIS2 platform following its re-introduction by the Federal Ministry of Health, and also enabled decentralization of data management to the periphery. CONCLUSION: A decade of implementing National HIV M&E framework in Nigeria and the recent adoption of the DHIS2 provides a strong base for monitoring the Post 2015 agenda. There is however a need to strengthen inter-sectoral data linkages and reduce the rising burden of data collection at the global level.
Progress Toward Eliminating Mother to Child Transmission of HIV in Kenya: Review of Treatment Guideline Uptake and Pediatric Transmission at Four Government Hospitals Between 2010 and 2012.
AIDS and Behavior. 2016 Nov; 20(11):2602-2611.We analyzed prevention of mother-to-child transmission (PMTCT) data from a retrospective cohort of n = 1365 HIV+ mothers who enrolled their HIV-exposed infants in early infant diagnosis services in four Kenyan government hospitals from 2010 to 2012. Less than 15 and 20 % of mother-infant pairs were provided with regimens that met WHO Option A and B/B+ guidelines, respectively. Annually, the gestational age at treatment initiation decreased, while uptake of Option B/B+ increased (all p's < 0.001). Pediatric HIV infection was halved (8.6-4.3 %), yet varied significantly by hospital. In multivariable analyses, HIV-exposed infants who received no PMTCT (AOR 4.6 [2.49, 8.62], p < 0.001), mixed foods (AOR 5.0 [2.77, 9.02], p < 0.001), and care at one of the four hospitals (AOR 3.0 [1.51, 5.92], p = 0.002) were more likely to be HIV-infected. While the administration and uptake of WHO PMTCT guidelines is improving, an expanded focus on retention and medication adherence will further reduce pediatric HIV transmission.
AIDS. 2016 Nov 28; 30(18):2865-2873.OBJECTIVE: In 2015, the WHO recommended initiation of antiretroviral therapy (ART) in all HIV-positive patients regardless of CD4 cell count. We evaluated the cost-effectiveness of immediate versus deferred ART initiation among patients with CD4 cell counts exceeding 500cells/mul in four resource-limited countries (South Africa, Nigeria, Uganda, and India). DESIGN: A 5-year Markov model with annual cycles, including patients at CD4 cell counts more than 500 cells/mul initiating ART or deferring therapy until historic ART initiation criteria of CD4 cell counts more than 350 cells/mul were met. METHODS: The incidence of opportunistic infections, malignancies, cardiovascular disease, unscheduled hospitalizations, and death, were informed by the START trial results. Risk of HIV transmission was obtained from a systematic review. Disability weights were based on published literature. Cost inputs were inflated to 2014 US dollars and based on local sources. Results were expressed in cost per disability-adjusted life years averted and measured against WHO cost-effectiveness thresholds. RESULTS: Immediate initiation of ART is associated with a cost per disability-adjusted life years averted of -$317 [95% confidence interval (CI): -$796-$817] in South Africa; -$507 (95% CI: -$765-$837) in Nigeria; -$136 (-$382-$459) in Uganda; and -$78 (-$256-$374) in India. The results are largely driven by the impact of ART on reducing the risk of new HIV transmissions. CONCLUSIONS: In HIV-positive patients with CD4 counts above 500 cells/mul in the four studied countries, immediate initiation of ART versus deferred therapy until historic eligibility criteria are met is cost-effective and likely even cost-saving over time.
Do countries rely on the World Health Organization for translating research findings into clinical guidelines? A case study.
Globalization and Health. 2016 Oct 6; 12(1):58.BACKGROUND: The World Health Organization's (WHO) antiretroviral therapy (ART) guidelines have generally been adopted rapidly and with high fidelity by countries in sub-Saharan Africa. Thus far, however, WHO has not published specific guidance on nutritional care and support for (non-pregnant) adults living with HIV despite a solid evidence base for some interventions. This offers an opportunity for a case study on whether national clinical guidelines in sub-Saharan Africa provide concrete recommendations in the face of limited guidance by WHO. This study, therefore, aims to determine if national HIV treatment guidelines in sub-Saharan Africa contain specific guidance on nutritional care and support for non-pregnant adults living with HIV. METHODS: We identified the most recent national HIV treatment guidelines in sub-Saharan African countries with English as an official language. Using pre-specified criteria, we determined for each guideline whether it provides guidance to clinicians on each of five components of nutritional care and support for adults living with HIV: assessment of nutritional status, dietary counseling, micronutrient supplementation, ready-to-use therapeutic or supplementary foods, and food subsidies. RESULTS: We found that national HIV treatment guidelines in sub-Saharan Africa generally do not contain concrete recommendations on nutritional care and support for non-pregnant adults living with HIV. CONCLUSIONS: Given that decisions on nutritional care and support are inevitably being made at the clinician-patient level, and that clinicians have a relative disadvantage in systematically identifying, summarizing, and weighing up research evidence compared to WHO and national governments, there is a need for more specific clinical guidance. In our view, such guidance should at a minimum recommend daily micronutrient supplements for adults living with HIV who are in pre-ART stages, regular dietary counseling, periodic assessment of anthropometric status, and additional nutritional management of undernourished patients. More broadly, our findings suggest that countries in sub-Saharan Africa look to WHO for guidance in translating evidence into clinical guidelines. It is, thus, likely that the development of concrete recommendations by WHO on nutritional interventions for people living with HIV would lead to more specific guidelines at the country-level and, ultimately, better clinical decisions and treatment outcomes.
An assessment of staffing needs at a HIV clinic in a Western Kenya using the WHO workload indicators of staffing need WISN, 2011.
Human Resources For Health. 2017 Jan 26; 15(1):9.BACKGROUND: An optimal number of health workers, who are appropriately allocated across different occupations and geographical regions, are required to ensure population coverage of health interventions. Health worker shortages in HIV care provision are highest in areas that are worst hit by the HIV epidemic. Kenya is listed among countries that experience health worker shortages (<2.5 health workers per 1000 population) and have a high HIV burden (HIV prevalence 5.6 with 15.2% in Nyanza province). We set out to determine the optimum number of clinicians required to provide quality consultancy HIV care services at the Jaramogi Oginga Odinga Teaching and Referral Hospital, JOOTRH, HIV Clinic, the premier HIV clinic in Nyanza province with a cumulative client enrolment of PLHIV of over 20,000 persons. CASE PRESENTATION: The World Health's Organization's Workload Indicators of Staffing Needs (WISN) was used to compute the staffing needs and sufficiency of staffing needs at the JOOTRH HIV clinic in Kisumu, Kenya, between January and December 2011. All people living with HIV (PLHIV) who received HIV care services at the HIV clinic at JOOTRH and all the clinicians attending to them were included in this analysis. The actual staffing was divided by the optimal staff requirement to give ratios of staffing excesses or shortages. A ratio of 1.0 indicated optimal staffing, less than 1.0 indicated suboptimal staffing, and more than 1 indicated supra optimal staffing. The HIV clinic is served by 56 staff of various cadres. Clinicians (doctors and clinical officers) comprise approximately one fifth of this population (n = 12). All clinicians (excluding the clinic manager, who is engaged in administrative duties and supervisory roles that consumes approximately one third of his time) provide full-time consultancy services. To operate at maximum efficiency, the clinic therefore requires 19 clinicians. The clinic therefore operates with only 60% of its staffing requirements. CONCLUSIONS: Our assessment revealed a severe shortage of clinicians providing consultation services at the HIV clinic. Human resources managers should oversee the rational planning, training, retention, and management of human resources for health using the WISN which is an objective and reliable means of estimating staffing needs.
Decreased emergence of HIV-1 drug resistance mutations in a cohort of Ugandan women initiating option B+ for PMTCT.
PloS One. 2017; 12(5):e0178297.BACKGROUND: Since 2012, WHO guidelines for the prevention of mother-to-child transmission (PMTCT) of HIV-1 in resource-limited settings recommend the initiation of lifelong antiretroviral combination therapy (cART) for all pregnant HIV-1 positive women independent of CD4 count and WHO clinical stage (Option B+). However, long-term outcomes regarding development of drug resistance are lacking until now. Therefore, we analysed the emergence of drug resistance mutations (DRMs) in women initiating Option B+ in Fort Portal, Uganda, at 12 and 18 months postpartum (ppm). METHODS AND FINDINGS: 124 HIV-1 positive pregnant women were enrolled within antenatal care services in Fort Portal, Uganda. Blood samples were collected at the first visit prior starting Option B+ and postpartum at week six, month six, 12 and 18. Viral load was determined by real-time RT-PCR. An RT-PCR covering resistance associated positions in the protease and reverse transcriptase HIV-1 genomic region was performed. PCR-positive samples at 12/18 ppm and respective baseline samples were analysed by next generation sequencing regarding HIV-1 drug resistant variants including low-frequency variants. Furthermore, vertical transmission of HIV-1 was analysed. 49/124 (39.5%) women were included into the DRM analysis. Virological failure, defined as >1000 copies HIV-1 RNA/ml, was observed in three and seven women at 12 and 18 ppm, respectively. Sequences were obtained for three and six of these. In total, DRMs were detected in 3/49 (6.1%) women. Two women displayed dual-class resistance against all recommended first-line regimen drugs. Of 49 mother-infant-pairs no infant was HIV-1 positive at 12 or 18 ppm. CONCLUSION: Our findings suggest that the WHO-recommended Option B+ for PMTCT is effective in a cohort of Ugandan HIV-1 positive pregnant women with regard to the low selection rate of DRMs and vertical transmission. Therefore, these results are encouraging for other countries considering the implementation of lifelong cART for all pregnant HIV-1 positive women.
Prevalence of Malnutrition and Associated Factors among Hospitalized Patients with Acquired Immunodeficiency Syndrome in Jimma University Specialized Hospital, Ethiopia.
Ethiopian Journal of Health Sciences. 2016 May; 26(3):217-26.BACKGROUND: HIV/AIDS predisposes to malnutrition. Malnutrition exacerbates HIV/AIDS progression resulting in increased morbidity and mortality. The magnitude of malnutrition in HIV/AIDS patients has not been well studied in Ethiopian setup. Our objective was to assess the prevalence of malnutrition and associated factors among HIV/AIDS patients admitted to Jimma University Specialized Hospital (JUSH). METHOD: A cross-sectional study was conducted to assess the nutritional status of 109 HIV/AIDS patients admitted from November 2013 to July 2014. Cohort design was also used for outcome assessment. Serum levels of hemoglobin, albumin and CD4 counts were determined. Data were organized, coded, cleaned, entered into a computer and analyzed using SPSS version 16.0. Descriptive analysis was done initially. Those variables in the bivariate analysis with P-value < 0.25 were then considered as candidates to be included in the multivariable logistic regression model. A P-vale of < 0.05 was considered as statistically significant. RESULTS: The mean age of the patients was 32.7+/-8.12 with male to female ratio of 1:1.9. Patients were in either clinical stage, 3(46.8%), or stage, 4(53.2%). Forty nine (45%) of the respondents had a CD4 count of < 200 cells/microL. The overall prevalence of malnutrition was 46.8% (BMI<18.5kg/m2) and 44.1% (MUAC= 20cm). Eighty four (77.1%) of the patients had a serum albumin level of =3.5g/dl while 76 (69.6%) of the patients had anemia (Hg<12g/dl). CONCLUSION: The prevalence of malnutrition was found to be high. WHO Stage 4 disease and CD4 count <200cells/microl were independent predictors of malnutrition.
Delivering HIV services in partnership: factors affecting collaborative working in a South African HIV programme.
Globalization and Health. 2017 Jan 13; 13(1):3.BACKGROUND: The involvement of Global Health Initiatives (GHIs) in delivering health services in low and middle income countries (LMICs) depends on effective collaborative working at scales from the local to the international, and a single GHI is effectively constructed of multiple collaborations. Research is needed focusing on how collaboration functions in GHIs at the level of health service management. Here, collaboration between local implementing agencies and departments of health involves distinct power dynamics and tensions. Using qualitative data from an evaluation of a health partnership in South Africa, this article examines how organisational power dynamics affected the operation of the partnership across five dimensions of collaboration: governance, administration, organisational autonomy, mutuality, and norms of trust and reciprocity. RESULTS: Managing the tension between the power to provide resources held by the implementing agency and the local Departments' of Health power to access the populations in need of these resources proved critical to ensuring that the collaboration achieved its aims and shaped the way that each domain of collaboration functioned in the partnership. CONCLUSIONS: These findings suggest that it is important for public health practitioners to critically examine the ways in which collaboration functions across the scales in which they work and to pay particular attention to how local power dynamics between partner organisations affect programme implementation.
Progress with Scale-Up of HIV Viral Load Monitoring - Seven Sub-Saharan African Countries, January 2015-June 2016.
MMWR. Morbidity and Mortality Weekly Report. 2016 Dec 02; 65(47):1332-1335.The World Health Organization (WHO) recommends viral load testing as the preferred method for monitoring the clinical response of patients with human immunodeficiency virus (HIV) infection to antiretroviral therapy (ART) (1). Viral load monitoring of patients on ART helps ensure early diagnosis and confirmation of ART failure and enables clinicians to take an appropriate course of action for patient management. When viral suppression is achieved and maintained, HIV transmission is substantially decreased, as is HIV-associated morbidity and mortality (2). CDC and other U.S. government agencies and international partners are supporting multiple countries in sub-Saharan Africa to provide viral load testing of persons with HIV who are on ART. This report examines current capacity for viral load testing based on equipment provided by manufacturers and progress with viral load monitoring of patients on ART in seven sub-Saharan countries (Cote d'Ivoire, Kenya, Malawi, Namibia, South Africa, Tanzania, and Uganda) during January 2015-June 2016. By June 2016, based on the target numbers for viral load testing set by each country, adequate equipment capacity existed in all but one country. During 2015, two countries tested >85% of patients on ART (Namibia [91%] and South Africa [87%]); four countries tested <25% of patients on ART. In 2015, viral suppression was >80% among those patients who received a viral load test in all countries except Cote d'Ivoire. Sustained country commitment and a coordinated global effort is needed to reach the goal for viral load monitoring of all persons with HIV on ART.
Current Opinion In HIV and AIDS. 2015 Nov 16;PURPOSE OF REVIEW: We summarize key lessons learned from contraceptive development and introduction, and implications for preexposure prophylaxis (PrEP). RECENT FINDINGS: New approaches to HIV prevention are urgently needed. PrEP is a new technology for HIV prevention. Uncertainty remains about its acceptance, use and potential to have an impact on the HIV epidemic. Despite imperfect use and implementation of programs, the use of modern contraception has led to significant reproductive health and social gains, making it one of the public health's major achievements. Guided by the WHO strategic approach to contraception introduction, we identified the following lessons for PrEP introduction from contraception: the importance of a broader focus on the method mix rather than promotion of a single technology, new technologies alone do not increase choice - service delivery systems and providers are equally important to success, and that failure to account for user preferences and social context can undermine the potential of new methods to provide benefit. SUMMARY: Taking a strategic approach to PrEP introduction that includes a broader focus on the technology/user interface, the method mix, delivery strategies, and the context in which methods are introduced will benefit HIV prevention programs, and will ensure greater success.
Towards the WHO target of zero childhood tuberculosis deaths: an analysis of mortality in 13 locations in Africa and Asia.
International Journal of Tuberculosis and Lung Disease. 2013 Dec; 17(12):1518-23.SETTING: Achieving the World Health Organization (WHO) target of zero paediatric tuberculosis (TB) deaths will require an understanding of the underlying risk factors for mortality. OBJECTIVE: To identify risk factors for mortality and assess the impact of human immunodeficiency virus (HIV) testing during anti-tuberculosis treatment in children in 13 TB-HIV programmes run by Medecins Sans Frontieres. DESIGN: In a retrospective cohort study, we recorded mortality and analysed risk factors using descriptive statistics and logistic regression. Diagnosis was based on WHO algorithm and smear microscopy. RESULTS: A total of 2451 children (mean age 5.2 years, SD 3.9) were treated for TB. Half (51.0%) lived in Asia, the remainder in sub-Saharan Africa; 56.0% had pulmonary TB; 6.4% were diagnosed using smear microscopy; 211 (8.6%) died. Of 1513 children tested for HIV, 935 (61.8%) were positive; 120 (12.8%) died compared with 30/578 (5.2%) HIV-negative children. Risk factors included being HIV-positive (OR 2.6, 95%CI 1.6-4.2), age <5 years (1.7, 95%CI 1.2-2.5) and having tuberculous meningitis (2.6, 95%CI 1.0-6.8). Risk was higher in African children of unknown HIV status than in those who were confirmed HIV-negative (1.9, 95%CI 1.1-3.3). CONCLUSIONS: Strategies to eliminate childhood TB deaths should include addressing the high-risk groups identified in this study, enhanced TB prevention, universal HIV testing and the development of a rapid diagnostic test.
Comparative effectiveness of congregation- versus clinic-based approach to prevention of mother-to-child HIV transmission: Study protocol for a cluster randomized controlled trial.
Implementation Science. 2013 Jun 8; 8(62):p.Background: A total of 22 priority countries have been identified by the WHO that account for 90% of pregnant women living with HIV. Nigeria is one of only 4 countries among the 22 with an HIV testing rate for pregnant women of less than 20%. Currently, most pregnant women must access a healthcare facility (HF) to be screened and receive available prevention of mother-to-child HIV transmission (PMTCT) interventions. Finding new approaches to increase HIV testing among pregnant women is necessary to realize the WHO/ President's Emergency Plan for AIDS Relief (PEPFAR) goal of eliminating new pediatric infections by 2015. Methods: This cluster randomized trial tests the comparative effectiveness of a congregation-based Healthy Beginning Initiative (HBI) versus a clinic-based approach on the rates of HIV testing and PMTCT completion among a cohort of church attending pregnant women. Recruitment occurs at the level of the churches and participants (in that order), while randomization occurs only at the church level. The trial is unblinded, and the churches are informed of their randomization group. Eligible participants, pregnant women attending study churches, are recruited during prayer sessions. HBI is delivered by trained community health nurses and church-based health advisors and provides free, integrated on-site laboratory tests (HIV plus hemoglobin, malaria, hepatitis B, sickle cell gene, syphilis) during a church-organized 'baby shower.' The baby shower includes refreshments, gifts exchange, and an educational game show testing participants' knowledge of healthy pregnancy habits in addition to HIV acquisition modes, and effective PMTCT interventions. Baby receptions provide a contact point for follow-up after delivery. This approach was designed to reduce barriers to screening including knowledge, access, cost and stigma. The primary aim is to evaluate the effect of HBI on the HIV testing rate among pregnant women. The secondary aims are to evaluate the effect of HBI on the rate of HIV testing among male partners of pregnant women and the rate of PMTCT completion among HIV-infected pregnant women. Discussion: Results of this study will provide further understanding of the most effective strategies for increasing HIV testing among pregnant women in hard-to-reach communities.
[Prevalence of HIV infection and associated factors in the Central African Republic in 2010] Prévalence de l’infection VIH et facteurs associés en République Centrafricaine en 2010.
Calverton, Maryland, ICF International, 2012 Apr.  p.Nearly 68 percent of all HIV-positive individuals worldwide live in Sub-Saharan Africa. The region remains the most severely affected in the world, even though only 12 percent of the world's population lives there. Central Africa, which is less afflicted than Southern and Eastern Africa, nevertheless has a high enough level of infection for it to be characterized as a generalized epidemic. This is the case in the Central African Republic. The Central African Republic has long lacked reliable data on the epidemic, which has slowed the national response that otherwise would have occurred with more factual data. In response to the perceived need, the United Nations Population Fund (UNFPA), World Bank, World Health Organization (WHO), and Joint United Nations Program on HIV/AIDS (UNAIDS) have financed HIV testing in two multiple indicator cluster surveys--the 2006 MICS and 2010 MICS. This partnership has led to collection of reliable data to monitor trends in HIV prevalence and distribution among the population age 15 to 49. Also monitored are distribution of the epidemic by geographic region and population group. Because the decrease in HIV prevalence between 2006 and 2010 will be interpreted as an encouraging sign of progress, it is important to remain vigilant. The disaggregated results show that the epidemic continues to grow in scope and provokes disastrous consequences in certain groups. For the first time since 2006, the Central African Republic has reliable data to inform decision-making and intervention planning. These data have permitted the pandemic areas in the Central African Republic to emerge from the shadows. For the future, we wish to put in place systematic HIV testing similar to that of the Demographic and Health Surveys (DHS) and the Multiple Indicator Cluster Surveys (MICS). The UNFPA office in the Central African Republic is committed to improving knowledge about HIV and reinforcing the availability of information for planning, implementation, and follow-up of the country's National Strategic Plan for the Fight against AIDS.
Impact of cotrimoxazole prophylaxis on the health of breast-fed, HIV-exposed, HIV-negative infants in a resource-limited setting.
AIDS. 2011 Sep 10; 25(14):1797-9.WHO guidelines recommend cotrimoxazole prophylaxis (CTXP) in all HIV-exposed negative infants who are still breastfeeding. This is based on the evidence of efficacy in HIV-infected infants, but there is no evidence of benefit in HIV-negative, breast-fed infants. We assessed the impact of CTXP on diarrhoeal and respiratory morbidity in breast-fed, HIV-exposed negative infants in a community programme. CTXP for more than 60 days showed no consistent evidence of benefit for incidence of lower respiratory tract infection [incidence rate ratio (IRR) 0.71, 95% confidence interval (CI) 0.39-1.26; P = 0.241] but an increased incidence of diarrhoea (IRR = 1.38, 95% CI 0.98-1.94; P = 0.065). The guidelines should be reconsidered by conducting a randomized control trial.
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.
Turning gender and HIV commitments into action for results: an update on United Nations interagency activities on women, girls, gender equality and HIV.
[Geneva, Switzerland], UNAIDS, 2009 Dec. 4 p.In September 2000, 189 UN Member States committed to achieving the Millennium Development Goals (MDGs) by 2015. Among these goals is a commitment to promoting gender equality and empowering women and combating HIV, malaria, and other diseases. Today, almost 10 years on, addressing gender inequality and AIDS remains the most significant challenge to achieving the MDGs, as well as broader health, human rights, and development goals. This update highlights key 2009 interagency initiatives, all of which operate at the intersection of gender equality, women's empowerment, and HIV.
Early initiation of antiretroviral therapy and universal HIV testing in sub-Saharan Africa: has WHO offered a milestone for HIV prevention?
Journal of Public Health Policy. 2010 Dec; 31(4):385-400.The majority of new HIV infections occur in sub-Saharan Africa and other developing countries with scarce financial resources and meagre health system infrastructure. Expansion of Antiretroviral Therapy (ART) may overwhelm health services capacity, result in suboptimal care, and divert attention from crucial preventive measures. A 2009 WHO guideline recommends earlier initiation of ART for adults and adolescents, treatment at CD4 counts of 350 cells/mm(3) along with universal testing. For sub-Saharan Africa, WHO previously recommended a threshold of 200 cells/mm(3). Despite vast potential benefits of early ART initiation at individual and community levels, it does not necessary follow that clinical experience in industrialised countries can be replicated in resource-limited settings with moderate to high HIV burdens. Adherence to the 2009 WHO guidelines is unlikely to be sustainable without guarantees of adequate national and donor support--something all developing countries need to consider before adoption of the new policy.
WHO guidelines for antimicrobial treatment in children admitted to hospital in an area of intense Plasmodium falciparum transmission: prospective study.
BMJ. British Medical Journal. 2010; 340:c1350.OBJECTIVES: To assess the performance of WHO's "Guidelines for care at the first-referral level in developing countries" in an area of intense malaria transmission and identify bacterial infections in children with and without malaria. DESIGN: Prospective study. SETTING: District hospital in Muheza, northeast Tanzania. PARTICIPANTS: Children aged 2 months to 13 years admitted to hospital for febrile illness. MAIN OUTCOME MEASURES: Sensitivity and specificity of WHO guidelines in diagnosing invasive bacterial disease; susceptibility of isolated organisms to recommended antimicrobials. RESULTS: Over one year, 3639 children were enrolled and 184 (5.1%) died; 2195 (60.3%) were blood slide positive for Plasmodium falciparum, 341 (9.4%) had invasive bacterial disease, and 142 (3.9%) were seropositive for HIV. The prevalence of invasive bacterial disease was lower in slide positive children (100/2195, 4.6%) than in slide negative children (241/1444, 16.7%). Non-typhi Salmonella was the most frequently isolated organism (52/100 (52%) of organisms in slide positive children and 108/241 (45%) in slide negative children). Mortality among children with invasive bacterial disease was significantly higher (58/341, 17%) than in children without invasive bacterial disease (126/3298, 3.8%) (P<0.001), and this was true regardless of the presence of P falciparum parasitaemia. The sensitivity and specificity of WHO criteria in identifying invasive bacterial disease in slide positive children were 60.0% (95% confidence interval 58.0% to 62.1%) and 53.5% (51.4% to 55.6%), compared with 70.5% (68.2% to 72.9%) and 48.1% (45.6% to 50.7%) in slide negative children. In children with WHO criteria for invasive bacterial disease, only 99/211(47%) of isolated organisms were susceptible to the first recommended antimicrobial agent. CONCLUSIONS: In an area exposed to high transmission of malaria, current WHO guidelines failed to identify almost a third of children with invasive bacterial disease, and more than half of the organisms isolated were not susceptible to currently recommended antimicrobials. Improved diagnosis and treatment of invasive bacterial disease are needed to reduce childhood mortality.
HIV, HCV, HBV and syphilis rate of positive donations among blood donations in Mali: lower rates among volunteer blood donors.
Transfusion Clinique Et Biologique. 2009 Nov-Dec; 16(5-6):444-7.Good data on background seroprevalence of major transfusion transmitted infections is lacking in Mali. We gathered data on the rate of positive donations of human immunodeficiency virus (HIV), hepatitis C virus (HCV), hepatitis B virus (HBV) and syphilis among blood donations in Mali for calendar year 2007. Donations with repeatedly reactive results on screening enzyme immunoassay (EIA) were considered to be seropositive. Rate of positive donations per blood unit collected was 2.6% for HIV, 3.3% for HCV, 13.9% for hepatitis B surface antigen (HBsAg) and 0.3% for syphilis. For HIV, HBsAg and syphilis, rate of positive donations was significantly (p<0.001) higher among donations from replacement donors than those from volunteer donors, while HCV rate of positive donations was similar in the two groups. Rate of positive donations was also significantly (p<0.0001) lower in blood units from regular than from first-time donors. These data reinforce WHO recommendations for increasing the number of regular, volunteer blood donors in Africa.
High prevalence of antiretroviral drug resistance mutations in HIV-1 non-B subtype strains from African children receiving antiretroviral therapy regimen according to the 2006 revised WHO recommendations [letter]
Journal of Acquired Immune Deficiency Syndromes. 2008 Dec 15; 49(5):566-9.Add to my documents.
International Journal of Gynecology and Obstetrics. 2008 Sep; 102(3):223-225.The editors of Contemporary Issues in Women's Health solicited reporters and correspondents from throughout the world to make contributions to this feature. Items submitted were stories on breastfeeding, FGM, Saudi women and ban on female drivers, and useful sources for women's health information.
South African Journal of Obstetrics and Gynaecology. 2007 Apr; 13(2):34-35.The standard of reproductive medicine in South Africa compares very favorably with that in the rest of the world. In keeping with other countries, reproductive medicine is now recognised as a sub-specialty by the Colleges of Medicine of South Africa and the fellowship curriculum comprises two years' full-time training. In contrast to the First World it is of concern that in this country reproductive technologies are mainly concentrated in the private sector, but we have a number of centres that have made substantial scientific contributions. In addition the private sector has gradually started to play an important role, participating in the training of specialists with an interest in this discipline. The South African Tissue Act, concerning gametes/ embryos, is extremely lenient, which has brought about some interesting challenges. We have seen a surge of infertility clinics in the USA exploiting young South African students for their genetic material. Furthermore, we have no legal limits regarding the number of embryos that can be transferred, in contradistinction to Europe where such constraints have had a marked impact on pregnancy rates. (excerpt)
Social Science and Medicine. 2007 Mar; 64(5):1015-1018.This special issue of Social Science and Medicine contains a set of papers that were presented at the 30th Annual Spring Colloquium of the Center for African Studies at the University of Illinois at Urbana-Champaign and held on April 24, 2004. Focusing on gender, agency and empowerment, the colloquium brought together an interdisciplinary group of researchers to interrogate issues concerning HIV/AIDS in Africa. Together, the papers elucidate the role of poverty and economic deprivation in HIV transmission as complex, regionally specific, involving different scales (global to local), and manifesting through migration, gender and cultural politics. It has long been recognized that differences in health levels across gender and socioeconomic standing are mainly a result of inequality resulting from social and economic health determinants. As such the social, cultural, economic, political, ethnic, gender and environmental factors are just as important as the biological factors when attempting to find solutions or devise strategies to combat disease. Consequently, linking both the biomedical sciences with the social sciences in our approaches to public health is critically important. Incorporating integrated, cross-disciplinary and multi-scalar approaches may allow for better comprehension of disease dynamics and produce more effective intervention strategies. The papers in this volume highlight the social science aspects of HIV/AIDS and emphasize that solutions based on the natural sciences alone are inadequate to stem the tide. AIDS in Africa represents a crucial arena where there is a need for the natural and social sciences to come together, join forces, and effectively tackle this disease. (excerpt)