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I beg you...breastfeed the baby, things changed: infant feeding experiences among Ugandan mothers living with HIV in the context of evolving guidelines to prevent postnatal transmission.
BMC Public Health. 2018 Jan 29; 18(1):188.BACKGROUND: For women living with HIV (WLWH) in low- and middle-income countries, World Health Organization (WHO) infant feeding guidelines now recommend exclusive breastfeeding until six months followed by mixed feeding until 24 months, alongside lifelong maternal antiretroviral therapy (ART). These recommendations represent the sixth major revision to WHO infant feeding guidelines since 1992. We explored how WLWH in rural Uganda make infant feeding decisions in light of evolving recommendations. METHODS: We conducted semi-structured interviews with 20 postpartum Ugandan WLWH accessing ART, who reported pregnancy < 2 years prior to recruitment. Interviews were conducted between February-August 2014 with babies born between March 2012-October 2013, over which time, the regional HIV treatment clinic recommended lifelong ART for all pregnant and breastfeeding women (Option B+). Content analysis was used to identify major themes. Infant feeding experiences was an emergent theme. NVivo 10 software was used to organize analyses. RESULTS: Among 20 women, median age was 33 years [IQR: 28-35], number of livebirths was 3 [IQR: 2-5], years on ART was 2.3 [IQR: 1.5-5.1], and 95% were virally suppressed. Data revealed that women valued opportunities to reduce postnatal transmission. However, women made infant feeding choices that differed from recommendations due to: (1) perception of conflicting recommendations regarding infant feeding; (2) fear of prolonged infant HIV exposure through breastfeeding; and (3) social and structural constraints shaping infant feeding decision-making. CONCLUSIONS: WLWH face layered challenges navigating evolving infant feeding recommendations. Further research is needed to examine guidance and decision-making on infant feeding choices to improve postpartum experiences and outcomes. Improved communication about changes to recommendations is needed for WLWH, their partners, community members, and healthcare providers.
Trends in Antiretroviral Therapy Eligibility and Coverage Among Children Aged <15 Years with HIV Infection - 20 PEPFAR-Supported Sub-Saharan African Countries, 2012-2016.
MMWR. Morbidity and Mortality Weekly Report. 2018 May 18; 67(19):552-555.Rapid disease progression and associated opportunistic infections contribute to high mortality rates among children aged <15 years with human immunodeficiency virus (HIV) infection (1). Antiretroviral therapy (ART) has decreased childhood HIV-associated morbidity and mortality rates over the past decade (2). As accumulating evidence revealed lower HIV-associated mortality with early ART initiation, the World Health Organization (WHO) guidelines broadened ART eligibility for children with HIV infection (2). Age at ART initiation for children with HIV infection expanded sequentially in the 2010, 2013, and 2016 WHO guidelines to include children aged <2, <5, and <15 years, respectively, regardless of clinical or immunologic status (3-5). The United States President's Emergency Plan for AIDS Relief (PEPFAR) has supported ART for children with HIV infection since 2003 and, informed by the WHO guidelines and a growing evidence base, PEPFAR-supported countries have adjusted their national pediatric guidelines. To understand the lag between guideline development and implementation, as well as the ART coverage gap, CDC assessed national pediatric HIV guidelines and analyzed Joint United Nations Programme on HIV and AIDS (acquired immunodeficiency syndrome; UNAIDS) data on children aged <15 years with HIV infection and the numbers of these children on ART. Timeliness of WHO pediatric ART guideline adoption varied by country; >50% of children with HIV infection are not receiving ART, underscoring the importance of strengthening case finding and linkage to HIV treatment in pediatric ART programs.
Should trained lay providers perform HIV testing? A systematic review to inform World Health Organization guidelines.
AIDS Care. 2017 Dec; 29(12):1473-1479.New strategies for HIV testing services (HTS) are needed to achieve UN 90-90-90 targets, including diagnosis of 90% of people living with HIV. Task-sharing HTS to trained lay providers may alleviate health worker shortages and better reach target groups. We conducted a systematic review of studies evaluating HTS by lay providers using rapid diagnostic tests (RDTs). Peer-reviewed articles were included if they compared HTS using RDTs performed by trained lay providers to HTS by health professionals, or to no intervention. We also reviewed data on end-users' values and preferences around lay providers preforming HTS. Searching was conducted through 10 online databases, reviewing reference lists, and contacting experts. Screening and data abstraction were conducted in duplicate using systematic methods. Of 6113 unique citations identified, 5 studies were included in the effectiveness review and 6 in the values and preferences review. One US-based randomized trial found patients' uptake of HTS doubled with lay providers (57% vs. 27%, percent difference: 30, 95% confidence interval: 27-32, p < 0.001). In Malawi, a pre/post study showed increases in HTS sites and tests after delegation to lay providers. Studies from Cambodia, Malawi, and South Africa comparing testing quality between lay providers and laboratory staff found little discordance and high sensitivity and specificity (>/=98%). Values and preferences studies generally found support for lay providers conducting HTS, particularly in non-hypothetical scenarios. Based on evidence supporting using trained lay providers, a WHO expert panel recommended lay providers be allowed to conduct HTS using HIV RDTs. Uptake of this recommendation could expand HIV testing to more people globally.
The continuum of HIV care in South Africa: implications for achieving the second and third UNAIDS 90-90-90 targets.
AIDS. 2017 Feb 20; 31(4):545-552.BACKGROUND: We characterize engagement with HIV care in South Africa in 2012 to identify areas for improvement towards achieving global 90-90-90 targets. METHODS: Over 3.9 million CD4 cell count and 2.7 million viral load measurements reported in 2012 in the public sector were extracted from the national laboratory electronic database. The number of persons living with HIV (PLHIV), number and proportion in HIV care, on antiretroviral therapy (ART) and with viral suppression (viral load <400 copies/ml) were estimated and stratified by sex and age group. Modified Poisson regression approach was used to examine associations between sex, age group and viral suppression among persons on ART. RESULTS: We estimate that among 6511 000 PLHIV in South Africa in 2012, 3300 000 individuals (50.7%) accessed care and 32.9% received ART. Although viral suppression was 73.7% among the treated population in 2012, the overall percentage of persons with viral suppression among all PLHIV was 23.8%. Linkage to HIV care was lower among men (38.5%) than among women (57.2%). Overall, 47.1% of those aged 0-14 years and 47.0% of those aged 15-49 years were linked to care compared with 56.2% among those aged above 50 years. CONCLUSION: Around a quarter of all PLHIV have achieved viral suppression in South Africa. Men and younger persons have poorer linkage to HIV care. Expanding HIV testing, strengthening prompt linkage to care and further expansion of ART are needed for South Africa to reach the 90-90-90 target. Focus on these areas will reduce the transmission of new HIV infections and mortality in the general population.
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.
Has the phasing out of stavudine in accordance with changes in WHO guidelines led to a decrease in single-drug substitutions in first-line antiretroviral therapy for HIV in sub-Saharan Africa?
AIDS. 2017 Jan 2; 31(1):147-157.OBJECTIVE: We assessed the relationship between phasing out stavudine in first-line antiretroviral therapy (ART) in accordance with WHO 2010 policy and single-drug substitutions (SDS) (substituting the nucleoside reverse transcriptase inhibitor in first-line ART) in sub-Saharan Africa. DESIGN: Prospective cohort analysis (International epidemiological Databases to Evaluate AIDS-Multiregional) including ART-naive, HIV-infected patients aged at least 16 years, initiating ART between January 2005 and December 2012. Before April 2010 (July 2007 in Zambia) national guidelines called for patients to initiate stavudine-based or zidovudine-based regimen, whereas thereafter tenofovir or zidovudine replaced stavudine in first-line ART. METHODS: We evaluated the frequency of stavudine use and SDS by calendar year 2004-2014. Competing risk regression was used to assess the association between nucleoside reverse transcriptase inhibitor use and SDS in the first 24 months on ART. RESULTS: In all, 33 441 (8.9%; 95% confience interval 8.7-8.9%) SDS occurred among 377 656 patients in the first 24 months on ART, close to 40% of which were amongst patients on stavudine. The decrease in SDS corresponded with the phasing out of stavudine. Competing risks regression models showed that patients on tenofovir were 20-95% less likely to require a SDS than patients on stavudine, whereas patients on zidovudine had a 75-85% decrease in the hazards of SDS when compared to stavudine. CONCLUSION: The decline in SDS in the first 24 months on treatment appears to be associated with phasing out stavudine for zidovudine or tenofovir in first-line ART in our study. Further efforts to decrease the cost of tenofovir and zidovudine for use in this setting is warranted to substitute all patients still receiving stavudine.
Allocation of antiretroviral drugs to HIV-infected patients in Togo: Perspectives of people living with HIV and healthcare providers.
Journal of Medical Ethics. 2017 Dec; 43(12):845-851.Aim To explore the way people living with HIV and healthcare providers in Togo judge the priority of HIV-infected patients regarding the allocation of antiretroviral drugs. Method From June to September 2015, 200 adults living with HIV and 121 healthcare providers living in Togo were recruited for the study. They were presented with stories of a few lines depicting the situation of an HIV-infected patient and were instructed to judge the extent to which the patient should be given priority for antiretroviral drugs. The stories were composed by systematically varying the levels of four factors: (a) the severity of HIV infection, (b) the financial situation of the patient, (c) the patient's family responsibilities and (d) the time elapsed since the first consultation. Results Five clusters were identified: 65% of the participants expressed the view that patients who are poor and severely sick should be treated as a priority, 13% prioritised treatment of patients who are poor and parents of small children, 12% expressed the view that the poor should be treated as a priority, 4% preferred that the sickest be treated as a priority and 6% wanted all patients to get treatment. Conclusions WHO's guideline regarding antiretroviral therapy allocation (the sickest first as the sole criterion) currently in use in many African countries does not reflect the preferences of Togolese people living with HIV. For most HIV-infected patients in Togo, patients who cannot get treatment on their own should be treated as a priority.
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.
Potential impact of multiple interventions on HIV incidence in a hyperendemic region in Western Kenya: a modelling study.
BMC Infectious Diseases. 2016 Apr 29; 16:189.BACKGROUND: Multiple prevention interventions, including early antiretroviral therapy initiation, may reduce HIV incidence in hyperendemic settings. Our aim was to predict the short-term impact of various single and combined interventions on HIV spreading in the adult population of Ndhiwa subcounty (Nyanza Province, Kenya). METHODS: A mathematical model was used with data on adults (15-59 years) from the Ndhiwa HIV Impact in Population Survey to compare the impacts on HIV prevalence, HIV incidence rate, and population viral load suppression of various interventions. These interventions included: improving the cascade of care (use of three guidelines), increasing voluntary medical male circumcision (VMMC), and implementing pre-exposure prophylaxis (PrEP) use among HIV-uninfected women. RESULTS: After four years, improving separately the cascade of care under the WHO 2013 guidelines and under the treat-all strategy would reduce the overall HIV incidence rate by 46 and 58 %, respectively, vs. the baseline rate, and by 35 and 49 %, respectively, vs. the implementation of the current Kenyan guidelines. With conservative and optimistic scenarios, VMMC and PrEP would reduce the HIV incidence rate by 15-25 % and 22-28 % vs. the baseline, respectively. Combining the WHO 2013 guidelines with VMMC would reduce the HIV incidence rate by 35-56 % and combining the treat-all strategy with VMMC would reduce it by 49-65 %. Combining the WHO 2013 guidelines, VMMC, and PrEP would reduce the HIV incidence rate by 46-67 %. CONCLUSIONS: The impacts of the WHO 2013 guidelines and the treat-all strategy were relatively close; their implementation is desirable to reduce HIV spread. Combining several strategies is promising in adult populations of hyperendemic areas but requires regular, reliable, and costly monitoring.
Breastmilk Output in a Disadvantaged Community with High HIV Prevalence as Determined by the Deuterium Oxide Dose-to-Mother Technique.
Breastfeeding Medicine. 2016 Mar; 11(2):64-9.INTRODUCTION: World Health Organization breastfeeding guidelines for HIV-infected mothers are exclusive breastfeeding for 6 months and then continued breastfeeding for 12 months, provided the mother is receiving antiretroviral prophylaxis. Many African women perceive that breastmilk alone is not sufficient for their infant's nutritional requirements for the first 6 months of life, and mixed feeding is a common practice. METHODOLOGY: A stable isotope technique was used to determine breastmilk output volumes and maternal body composition objectively at five different time points in the first year of the infant's life. RESULTS: Breastmilk output volumes were high for HIV-infected mothers: 831 +/- 185 g/day at 6 weeks; 899 +/- 188 g/day at 3 months; 871 +/- 293 g/day at 6 months; 679 +/- 281 g/day at 9 months; and 755 +/- 287 g/day at 12 months. These high output volumes had no negative impact on the mother's fat-free mass. The breastmilk output volumes for HIV-uninfected mothers were not significantly different to the outputs for HIV-infected mothers at any of the time points (p > 0.05): 948 +/- 223 g/day at 6 weeks; 925 +/- 227 g/day at 3 months; 902 +/- 286 g/day at 6 months; 746 +/- 263 g/day at 9 months; and 713 +/- 264 g/day at 12 months. CONCLUSION: This study using objective methodology shows that breastmilk outputs of HIV-infected mothers were relatively high (and within published reference ranges), and mothers are able to provide sufficient breastmilk for their infants without compromising their own fat-free mass.
Lancet. Psychiatry. 2015 Jun; 2(6):487-8.Add to my documents.
Health outcomes and cost impact of the new WHO 2013 guidelines on prevention of mother-to-child transmission of HIV in Zambia.
PloS One. 2014; 9(3):e90991.BACKGROUND: Countries are currently progressing towards the elimination of new paediatric HIV infections by 2015. WHO published new consolidated guidelines in June 2013, which now recommend either 'Antiretroviral drugs (ARVs) for women living with HIV during pregnancy and breastfeeding (Option B)' or 'Lifelong antiretroviral therapy (ART) for all pregnant and breastfeeding women living with HIV (Option B+)', while de facto phasing out Option A. This study examined health outcomes and cost impact of the shift to WHO 2013 recommendations in Zambia. METHODS: A decision analytic model was developed based on the national health system perspective. Estimated risk and number of cases of HIV transmission to infants and to serodiscordant partners, and proportions of HIV-infected pregnant women with CD4 count of =350 cells/mm3 to initiate ART were compared between 2010 Option A and the 2013 recommendations. Total costs of prevention of mother-to-child transmission of HIV (PMTCT) services per annual cohort of pregnant women, incremental cost-effectiveness ratio (ICER) per infection averted and quality-adjusted life-year (QALY) gained were examined. RESULTS: Our analysis suggested that the shift from 2010 Option A to the 2013 guidelines would result in a 33% reduction of the risk of HIV transmission among exposed infants. The risk of transmission to serodiscordant partners for a period of 24 months would be reduced by 72% with 'ARVs during pregnancy and breastfeeding' and further reduced by 15% with 'Lifelong ART'. The probability of HIV-infected pregnant women to initiate ART would increase by 80%. It was also suggested that while the shift would generate higher PMTCT costs, it would be cost-saving in the long term as it spares future treatment costs by preventing infections in infants and partners. CONCLUSION: The shift to the WHO 2013 guidelines in Zambia would positively impact health of family and save future costs related to care and treatment.
Sexually Transmitted Infections. 2010 Dec; 86 Suppl 2:ii62-6.BACKGROUND: In 2010 the WHO issued a revision of the guidelines on antiretroviral therapy (ART) for HIV infection in adults and adolescents. The recommendations included earlier diagnosis and treatment of HIV in the interest of a longer and healthier life. The current analysis explores the impact on the estimates of treatment needs of the new criteria for initiating ART compared with the previous guidelines. METHODS: The analyses are based on the national models of HIV estimates for the years 1990-2009. These models produce time series estimates of ART treatment need and HIV-related mortality. The ART need estimates based on ART eligibility criteria promoted by the 2010 WHO guidelines were compared with the need estimates based on the 2006 WHO guidelines. RESULTS: With the 2010 eligibility criteria, the proportion of people living with HIV currently in need of ART is estimated to increase from 34% to 49%. Globally, the need increases from 11.4 million (10.2-12.5 million) to 16.2 million (14.8-17.1 million). Regional differences include 7.4 million (6.4-8.4 million) to 10.6 million (9.7-11.5 million) in sub-Saharan Africa, 1.6 million (1.3-1.7 million) to 2.4 million (2.1-2.5 million) in Asia and 710 000 (610 000-780 000) to 950 000 (810 000-1.0 million) in Latin America and the Caribbean. CONCLUSIONS: When adopting the new recommendations, countries have to adapt their planning process in order to accelerate access to life saving drugs to those in need. These recommendations have a significant impact on resource needs. In addition to improving and prolonging the lives of the infected individuals, it will have the expected benefit of reducing HIV transmission and the future HIV/AIDS burden.
Paris, France, United Nations Educational, Scientific and Cultural Organization [UNESCO], 2012. 158 p.The education sector has a significant role to play in the response to HIV and AIDS. The sector can help to prevent the spread of HIV through education, and, in countries that are highly affected by HIV, by taking steps to protect itself from the effects of the epidemic. It can also make a significant contribution by supporting health improvement more generally and by helping to improve the sexual and reproductive health of young people in particular.This framework is designed to help those working in the education sector at a national level to understand the need for a robust response to HIV and AIDS in order to achieve Education for All (EFA) and the education-related Millennium Development Goals (MDGs). The document also highlights the education sector’s role in contributing to universal access to HIV and AIDS prevention, treatment, care and support.
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.
Comparison of previous and present World Health Organization clinical staging criteria in HIV-infected Malawian children.
AIDS. 2009 Sep 10; 23(14):1913-6.In many settings, HIV infected children are looked after with limited access to CD4 cell count or viral load. The decision to initiate antiretroviral therapy (ART) is made clinically, based on the WHO paediatric staging criteria, which were revised in 2006. Results of using new and old criteria were compared. Of 694 children, 626 (90.2%) fulfilled criteria to start ART when applying the new WHO staging guidelines, whereas 330 (47.6%) children were eligible for ART when using the old WHO criteria. This signifies a marked rise in the number of paediatric patients qualifying for ART on clinical grounds.
Expert Opinion On Pharmacotherapy. 2009 Aug; 10(11):1783-91.BACKGROUND: Treating HIV-infected children remains a challenge due to a lack of treatment options, appropriate drug formulations and, in countries with limited resources, insufficient access to diagnostic tests and treatment. OBJECTIVE: To summarize current data concerning new opportunities to improve the treatment of HIV-infected children. METHODS: This review includes data from the most recently published peer-reviewed publications, guidelines or presentations at international meetings concerning new ways to treat HIV-infected children. RESULTS/CONCLUSIONS: New WHO guidelines recommend starting combination antiretroviral treatment in all infants aged < 1 year. Although this is common practice in some high-income countries, implementation of these recommendations in countries with limited resources is still a challenge. There is still an important gap between the availability of licensed drugs in children compared with adults. There remains a need for further pharmacokinetic studies, and for more pediatric formulations of antiretroviral drugs with improved palatability.
Total lymphocyte count and World Health Organization pediatric clinical stage as markers to assess need to initiate antiretroviral therapy among human immunodeficiency virus-infected children in Moshi, Northern Tanzania.
Pediatric Infectious Disease Journal. 2009 Jun; 28(6):493-7.BACKGROUND: The World Health Organization (WHO) has recommended the use of clinical staging alone and with total lymphocyte count to identify HIV infected children in need of antiretroviral therapy (ART) in resource-limited settings, when CD4 cell count is not available.METHODS: We prospectively enrolled children obtaining care for HIV infection at the Kilimanjaro Christian Medical Centre Pediatric Infectious Diseases Clinic in Moshi, Tanzania between March 2004 and May 2006 for this cohort study.RESULTS: One hundred ninety two (89.7%) of 214 children met WHO ART initiation criteria based on clinical staging or CD4 cell count. Several low-cost measures identified individuals who met WHO ART initiation criteria to the following degree: WHO stages 3 or 4 had 87.5% (95% CI, 82.8-92.1) sensitivity and, by definition, 100% (CI, 100-100) specificity; WHO recommended advance disease TLC cutoffs: sensitivity = 23.9% (95% CI, 17.3-30.5) specificity = 78.2% (95% CI, 67.3-89.1). Low TLC was a common finding, (50 of 214; 23%); however, it did not improve the sensitivity or specificity of clinical staging in identifying the severely immunosuppressed stage 2 children. Growth failure or use of total lymphocyte counts in isolation were not reliable indicators of severe immunosuppression or need to initiate ART.CONCLUSION: The use of total lymphocyte count does not improve the ability to identify children in need of ART compared with clinical staging alone. Low absolute lymphocyte count did not correlate with severe immunosuppression based on CD4 cell count in this cohort.
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.
International guidelines on HIV / AIDS and human rights. 2006 consolidated version. Second International Consultation on HIV / AIDS and Human Rights, Geneva, 23-25 September 1996. Third International Consultation on HIV / AIDS and Human Rights, Geneva, 25-26 July 2002. Organized jointly by the Office of the United Nations High Commissioner for Human Rights and the Joint United Nations Programme on HIV / AIDS.
Geneva, Switzerland, Office of the United Nations High Commissioner for Human Rights, 2006. 115 p. (HR/PUB/06/9)The International Guidelines on HIV/AIDS and Human Rights arose because of various calls for their development in light of the need for guidance for Governments and others on how to best promote, protect and fulfill human rights in the context of the HIV epidemic. During the first International Consultation on AIDS and Human Rights, organized by the United Nations Centre for Human Rights, in cooperation with the World Health Organization, in Geneva, from 26 to 28 July 1989, participants discussed the possible elaboration of guidelines to assist policymakers and others in complying with international human rights standards regarding law, administrative practice and policy. Several years later, in his report to the Commission at its fifty-first session (E/CN.4/1995/45, para.135), the United Nations Secretary-General stated that "the development of such guidelines or principles could provide an international framework for discussion of human rights considerations at the national, regional and international levels in order to arrive at a more comprehensive understanding of the complex relationship between the public health rationale and the human rights rationale of HIV/AIDS. In particular, Governments could benefit from guidelines that outline clearly how human rights standards apply in the area of HIV/AIDS and indicate concrete and specific measures, both in terms of legislation and practice, that should be undertaken". (excerpt)
Scaling up HIV / AIDS prevention, treatment and care: a report on WHO support to countries in implementing the “3 by 5” Initiative, 2004-2005.
Geneva, Switzerland, WHO, 2006. 143 p.In September 2003, LEE Jong-wook, Director-General of WHO, and Peter Piot, Executive Director of UNAIDS, declared the lack of access to antiretroviral therapy for HIV/AIDS in low- and middle-income countries to be a global health emergency. Shortly after this declaration, WHO and its partners launched a global initiative to scale up antiretroviral therapy with the objective of having 3 million people receiving antiretroviral therapy - representing half the total number of those globally in need - by the end of 2005 ("3 by 5"). Although the actual target of putting 3 million people on antiretroviral therapy was not reached by the end of 2005, countries have made significant progress in the past two years in expanding treatment coverage, strengthening prevention and building the capacity of health systems to deliver long-term, chronic care. Overall, in the two-year period, antiretroviral therapy coverage in low- and middle-income countries increased from 7% of those in need at the end of 2003 (400 000 people) to 20% of those in need at the end of 2005 (1.3 million people). Eighteen countries managed to increase antiretroviral therapy coverage to half or more of the people who needed it, consistent with the "3 by 5" target. (excerpt)
Lancet Infectious Diseases. 2007 Aug; 7(8):508.New guidance has been issued to ensure that patient confidentiality is not compromised in the process of collecting and storing information on HIV/AIDS. "Ensuring that HIV information is securely stored and confidentiality is maintained will avoid potential stigmatisation and discrimination of individuals and communities as countries are scaling up HIV prevention, treatment, care, and support services", Eduard Beck (UNAIDS, Geneva, Switzerland) told TLID. "The development of these guidelines is part of the standards work that UNAIDS has been involved in, together with the US-funded President's Emergency Plan for AIDS Relief (PEPFAR) and WHO...it is aimed at those who provide and use HIV services, and managers who need to monitor and evaluate the services provided." (excerpt)
Lancet. 2007 Jun 23; 369(9579):2075.In our Comment on Coovadia and Colleagues' study, we did not discuss the implications for the infant feeding choice of HIV-positive pregnant women, but drew attention to the new WHO Consensus Statement of 2006. This statement endorses the recommendation that HIV-positive mothers should avoid all breastfeeding when it is acceptable, feasible, affordable, sustainable, and safe. We agree that some mothers can safely avoid breastfeeding if they can afford or are provided with a sustained supply of formula. It is worth noting that these infants are vulnerable to unpredict able events such as outbreaks of diarrhoea, natural disasters, civil disturbance, or other interruption to the formula supply. But the understandable desire to prevent transmission of HIV has led to promotion of replacement feeding in many situations where it is not acceptable, feasible, affordable, sustainable, or safe (for example in many Indian settings), and it turns out to be more dangerous than expected. In these situations, exclusive breast feeding is recommended for the first 6 months of life, the decision depending on the family's individual circumstances. (excerpt)
Are a past history of tuberculosis and WHO clinical stage associated with incident tuberculosis in adults receiving antiretroviral therapy? [letter [reply]
AIDS. 2007 Jan; 21(3):389-390.In two recent excellent articles, Lawn and colleagues [1,2] reported the incidence and risk factors for active tuberculosis among HIV-infected adults receiving antiretroviral therapy (ART) in South Africa. In both studies, they found contradictory results regarding the association between the baseline World Health Organization (WHO) clinical stage and the occurrence of incident tuberculosis during follow-up, and contradictory trends towards an association between a past history of tuberculosis at enrolment and a lower (first study) or higher (second study) incidence of tuberculosis during follow-up. (excerpt)
Past history of tuberculosis is not a risk factor for incident tuberculosis during antiretroviral treatment in South Africa [letter] [reply]
AIDS. 2007 Jan 30; 21(3):388-389.We thank Ouattara and colleagues for their letter concerning risk factors for incident tuberculosis during antiretroviral treatment (ART) in sub-Saharan Africa. In a study from Abidjan that included 12 cases, Seyler et al. identified a past history of tuberculosis as the sole risk factor for incident tuberculosis. We reported a larger number of cases (n = 27) within a hospital-based study cohort in Cape Town and, in contrast, a low baseline CD4 cell count and advanced World Health Organization (WHO) stage of disease were the principal risk factors. In a second, much larger community-based study, we found that the current CD4 cell count was the sole independent risk factor for incident tuberculosis (n = 81). In both our studies, a history of previous tuberculosis was consistently found not to be a significant risk factor, agreeing with other unpublished studies from South Africa, Uganda and Senegal; a further study from Uganda reported a strong but statistically nonsignificant trend towards an association. (excerpt)