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Ugandan providers' views on the acceptability of contraceptive self-injection for adolescents: a qualitative study.
Reproductive Health. 2018 Oct 3; 15(1):165.BACKGROUND: Self-injection of subcutaneous depot medroxyprogesterone acetate may offer greater discretion and increase access to injectable contraception, particularly for those who face challenges accessing clinic services. In particular, unmarried adolescents often encounter stigma when seeking services, and may also lack the financial means to travel to clinics on the quarterly basis that injectable contraception requires. Whether self-injection is offered to women on a wide scale basis, and to adolescents specifically, will depend in part upon the willingness of providers to train clients of diverse ages and educational backgrounds. This study explores the views of providers with regard to self-injection as an option for women and adolescents in Uganda. METHODS: In-depth qualitative interviews were conducted with family planning providers in Gulu district, to understand their views on injectable self-injection for women, with a specific focus on unmarried adolescents ages 15 to 19 years. The in-depth interviews, which lasted up to 60 min were audio-recorded, translated and transcribed simultaneously, and analyzed using Atlas.ti software to identify key themes and common perspectives. RESULTS: A total of 40 health care providers were interviewed with equal numbers of each type (public, NGO, and private clinics, pharmacies, and community-based health workers). While most providers were receptive to self-injection for adult women, fewer than half were supportive of adolescent self-injection. Their reservations focused on age, marital status and parity concerns around adolescent use of the injectable more broadly, and concerns about the ability of adolescents to self-inject safely. CONCLUSIONS: Self-injection presents an opportunity to reduce the enormous burden on the public sector health system in Uganda, which is particularly compounded by the heavy reliance on injectable contraception requiring quarterly clinic visits. The results of this study reveal a level of cautious support for self-injection among providers when it comes to self-injection by adult women. With respect to adolescent clients, family planning policymakers and program implementers should design, implement, and evaluate self-injection interventions with the needs of adolescent clients uppermost in mind, recognizing that extra attention will likely be needed to reduce provider-imposed restrictions on adolescent access to this injectable delivery modality.
Journal of Global Oncology. 2018 Sep; (4):1-4.Add to my documents.
Guidance on ethical considerations in planning and reviewing research studies on sexual and reproductive health in adolescents.
Geneva, Switzerland, World Health Organization, 2018. 52 p.This document is intended to address commonly occurring situations and challenges that one faces in carrying out research with adolescents (people aged 10–19 years), the majority of whom are deemed not to have reached the recognized age of majority in their respective settings. To this end, adolescents aged 18 and 19 years are classified as adults in many settings and have the legal capacity to make autonomous decisions regarding their participation in research. In this document, the term “children” refers to people below the age of 18 years, and the term “minor adolescents” refers specifically to people aged 10-18 years.
Uptake of three doses of HPV vaccine by primary school girls in Eldoret, Kenya; a prospective cohort study in a malaria endemic setting.
BMC Cancer. 2018 May 11; 18(1):557.BACKGROUND: All women are potentially at risk of developing cervical cancer at some point in their life, yet it is avoidable cause of death among women in Sub- Saharan Africa with a world incidence of 530,000 every year. It is the 4th commonest cancer affecting women worldwide with over 260,000 deaths reported in 2012. Low resource settings account for over 75% of the global cervical cancer burden. Uptake of HPV vaccination is limited in the developing world. WHO recommended that 2 doses of HPV vaccine could be given to young girls, based on studies in developed countries. However in Africa high rates of infections like malaria and worms can affect immune responses to vaccines, therefore three doses may still be necessary. The aim of this study was to identify barriers and facilitators associated with uptake of HPV vaccine. METHODS: A cross-sectional survey was conducted at Eldoret, Kenya involving 3000 girls aged 9 to 14 years from 40 schools. Parents/guardians gave consent through a questionnaire. RESULTS: Of all 3083 the school girls 93.8% had received childhood vaccines and 63.8% had a second HPV dose, and 39.1% had a third dose. Administration of second dose and HPV knowledge were both strong predictors of completion of the third dose. Distance to the hospital was a statistically significant risk factor for non-completion (P: 0.01). CONCLUSIONS: Distance to vaccination centers requires a more innovative vaccine-delivery strategy and education of parents/guardians on cervical screening to increase attainment of the HPV vaccination.
Washington, D.C., Population Reference Bureau [PRB], 2018 Mar. 150 p.The Population Reference Bureau (PRB) has developed a “Youth Family Planning Policy Scorecard” to measure and compare countries’ youth FP policies and programming. The scorecard compiles and analyzes the evidence that identifies the most effective national policies and program interventions to promote uptake of contraception among youth, defined as people between the ages of 15 and 24. This report details the purpose of the new scorecard, describes its methodology and indicator selection process, and summarizes results for 16 countries.
Perception, acceptance and uptake of Human papillomavirus vaccine among female adolescents in selected secondary schools in Ibadan, Nigeria.
African Journal of Biomedical Research. 2017 Sep; 20(3):237-244.Infection with Human papillomavirus (HPV) contributes to malignant changes in the cervix leading to cancer mortality among women. HPV vaccine is now available for its prevention, yet the level of uptake is low. The study aimed at determining Perception, Acceptance and Uptake of Human papillomavirus Vaccine among female adolescents in selected secondary schools in Ibadan, Nigeria. This cross-sectional study was conducted among 296 female adolescent senior secondary school students in Ibadan, Nigeria. Respondents were selected using purposive sampling method and data were collected using self-administered questionnaire. The data were analysed using the Statistical Package for Social Sciences version 20.0. Variables were presented as frequency tables and hypotheses were tested using chi-square and Fisher’s exact test at P= 0.05. Most 142(48.0%) of the respondents were between ages 15-17. The respondents’ perception and knowledge about HPV vaccine, HPV infection and cervical cancer was generally poor. Furthermore, only 12(4.1%) of the respondents have received the HPV vaccine before the study. There is a significant association between adolescent’s perception and uptake of HPV vaccine p=0.000 as well as Perception and readiness for the use of HPV vaccine (p=0.007). Parental approval and readiness for HPV vaccine uptake were found to be significantly associated (p =0.000). Since knowledge about Human Papilloma Virus Vaccination is quite low, there is need to increase awareness about the Vaccination among female adolescents and their mothers. Also, peer educators in schools can be trained to improve awareness in schools so as to reduce the incidence of cervical cancer.
A Contraception Quality Improvement Initiative with Detained Young Women: Counseling, Initiation, and Utilization.
Journal of Pediatric and Adolescent Gynecology. 2018 Aug; 31(4):405-410.STUDY OBJECTIVE: To assess the effect of providing standardized counseling to improve the rates of contraception initiation and utilization among detained young women. This was a quality improvement (QI) project conducted at a large urban juvenile short-term detention center. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: The intervention included educating all staff and care providers, counseling detained young women on various contraceptive options, and offering contraception initiation with oral contraceptive pills or depot medroxyprogesterone acetate injection. Retrospective chart review before February 2012 established baseline contraception initiation and utilization rates. The QI intervention began in February 2012 and continued for 6 months followed by chart review. Outcomes measured included number of patients counseled about contraception, started contraception, and overall contraception utilization. RESULTS: We reviewed 120 and 186 charts before and after intervention, respectively. Compared with baseline data, the intervention group had statistically significant (P < .05) higher proportions of patients counseled (10% [10/120] baseline vs 84% [156/186] intervention) and who started contraception (7% [8/120] baseline vs 52% [97/186] intervention). CONCLUSION: This contraception QI intervention showed significant improvement in the rates of contraception counseling, contraception initiation, and utilization among detained young women. Most of youths' guardians were supportive and approved contraception initiation. This project showed it is feasible for health care providers to include contraception services for all intake assessments at juvenile detention facilities. Copyright (c) 2018 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.
Reviewing independent access to HIV testing, counselling and treatment for adolescents in HIV-specific laws in sub-Saharan Africa: implications for the HIV response.
Journal of the International AIDS Society. 2017 Aug 11; 20(1):21456.INTRODUCTION: AIDS is a leading cause of death among adolescents in sub-Saharan Africa. Yet, legal, policy and social barriers continue to restrict their access to HIV services. In recent years, access to independent HIV testing and treatment for adolescents has gained increased attention. The 2013 WHO Guidance on HIV testing and counselling and care for adolescents living with HIV (WHO Guidance) calls for reviewing legal and regulatory frameworks to facilitate adolescents' access to comprehensive HIV services. As of 31 March 2017, some 28 countries in sub-Saharan Africa have adopted HIV-specific legislation. But there is limited understanding of the provisions of these laws on access to HIV services for adolescents and their implication on efforts to scale up HIV prevention, testing, treatment and care among this population. METHODS: A desk review of 28 HIV-specific laws in sub-Saharan Africa complemented with the review of HIV testing policies in four countries using human rights norms and key public health recommendations from the 2013 WHO Guidance. These recommendations call on countries to (i) lower the age of consent to HIV testing and counselling and allow mature adolescents who have not reached the age of consent to independently access HIV testing, (ii) ensure access to HIV counselling for adolescents, (iii) protect the confidentiality of adolescents living with HIV and (iv) facilitate access to HIV treatment for adolescents living with HIV. RESULTS: Most HIV-specific laws fail to take into account human rights principles and public health recommendations for facilitating adolescents' access to HIV services. None of the countries with HIV-specific laws has adopted all four recommendations for access to HIV services for adolescents. Discrepancies exist between HIV laws and national policy documents. Inadequate and conflicting provisions in HIV laws are likely to hinder access to HIV testing, counselling and treatment for adolescents. CONCLUSIONS: Efforts to end legal barriers to access to HIV services for adolescents in sub-Saharan Africa should address HIV-specific laws. Restrictive provisions in these laws should be reformed, and their protective norms effectively implemented including by translating them into national policies and ensuring sensitization and training of healthcare workers and communities. This study reiterates the need for action in all countries across Africa and beyond to review their laws and policies to create an enabling environment to accelerate access to HIV prevention, testing and treatment services for adolescents.
Reducing undiagnosed HIV infection among adolescents in sub-Saharan Africa: Provider-initiated and opt-out testing are not enough.
PLoS Medicine. 2017 Jul; 14(7):e1002361.Community efforts and peer support programs are needed in addition to provider-initiated and opt-out HIV testing in adolescents, Sheri Weiser and colleagues discuss.
[Washington, D.C.], PRB, 2017 Feb. 52 p.Governments around the world have made great strides in creating policies that support the health and human rights of young people. Increasingly, countries have institutionalized the rights of adolescents and young people to access health services, including sexual and reproductive health (SRH), within formal laws and policies. Statements by the United Nations Population Fund (UNFPA), World Health Organization (WHO), and others have underscored the urgency for international organizations and governments to ensure that all young people have informed choice and full access to contraceptives. Despite growing commitment from decision- makers, many barriers remain for young people who want to use contraception. A limited evidence base has hampered systematic assessment and mapping of the key policies and programs that govern young people’s ability to access family planning (FP) information, services, and commodities. Governments and their partners lack clear guidance on supporting interventions that ensure their commitments to expanding FP use among young people are realized. Similarly, civil society needs to establish monitoring efforts to understand how countries address the needs of youth in their laws and policies and to identify areas for improvement. To address this evidence gap, the Population Reference Bureau (PRB) has developed a “Global Youth Family Planning Index” to measure and compare countries’ youth FP policies and programming. The index compiles and analyzes the evidence that identifies the most effective national policies and program interventions to promote uptake of contraception among youth, defined as people between the ages of 15 and 24. This report details the purpose of the new index, describes its methodology and indicator selection process, and summarizes results for nine countries.
South African Medical Journal. 2016 Dec 01; 106(12):1173-1176.With millions of adolescents becoming infected with HIV globally, it is essential that barriers to much-needed interventions are reduced for at-risk adolescents. In this article we review the legal and policy framework in South Africa for adolescent access to male circumcision. We are of the view that the framework does confer protection for adolescent boys while enabling access to male circumcision; however, we identify ambiguities and tensions that exist between the Children's Act, regulations and national guidelines. We recommend reform to further enable access by this vulnerable group to this prevention modality.
Journal of Epidemiology and Community Health. 2016 Feb; 70(2):109-10.Add to my documents.
HIV testing of children is not simple for health providers and researchers: Legal and policy frameworks guidance in South Africa.
South African Medical Journal. 2016 Mar 30; 106(5):451-453.Antiretroviral treatment coverage for children and adolescents is significantly lower than that for adults. A first step in improving this situation is ensuring increased access to HIV counselling and testing services. Current legal and policy frameworks outline four norms that should inform HIV testing of children in South Africa: limiting HIV testing to defined circumstances, and ensuring that consent is obtained, counselling is provided and confidentiality is maintained. Implementing these norms is not simple, and we discuss the challenges and opportunities they present for children, their families, health providers and researchers working in this area. Better alignment between evolving public health approaches and the HIV counselling and testing legal/policy frameworks (and the internal coherence of domestic frameworks) would better serve children, their parents and those who work with them.
Journal of Adolescent Health. 2016 May 28;The United States continues to have the highest adolescent birth rate of any industrialized country. Recently published guidelines by the American Academy of Pediatrics create a new consensus among professional organizations around the suitability of long-acting reversible contraceptives as first-line contraception for adolescents. Through a narrative review of U.S. studies published after 2000, this study seeks to summarize existing access barriers to long-acting reversible contraceptives for adolescents and highlight areas that warrant further intervention so that the recommendations of these professional organizations can be effectively integrated into clinical practice. Existing barriers include costs for institutions providing contraceptive care and for recipients; consent and confidentiality for adolescent patients; providers' attitudes, misconceptions and limited training; and patients' lack of awareness or misconceptions. Systemic policy interventions are required to address cost and confidentiality, such as the Affordable Care Act's mandate that contraceptive coverage be a part of essential health benefits for all insurance providers. Individual-level access barriers such as providers' misconceptions and gaps in technical training as well as patients' lack of awareness can be addressed directly by professional medical organizations, health care training programs, and other interventions. Copyright (c) 2016 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.
Public expectations concerning confidentiality protection of adolescents’ sexual and reproductive health care in Lithuania: Findings of the surveys conducted in 2005 and 2012.
European Journal of Contraception and Reproductive Health Care. 2014 Apr; 19(2):102-107.OBJECTIVE: An adolescent's right to confidential healthcare is protected by international law and professional consensus. However, parental and social support for confidential sexual and reproductive health (SRH) services, in particular, varies greatly. This study documents Lithuanian residents' expectations with regard to confidentiality protection for adolescents in this domain, and explores the factors related to the diversity of these expectations. METHODS: Two national surveys of Lithuanian residents completed in 2005 and 2012 using anonymous questionnaires. Participants rated their expectations for confidentiality using a five-point Likert scale for eight types of SRH consultations. RESULTS: Public anticipation for confidentiality depended on whether issues related to sexual behaviour or to its consequences were addressed during adolescent consultation. Only younger respondents had higher expectations for confidentiality in both contexts. Public expectations regarding confidentiality were less demanding in 2012 than in 2005. CONCLUSIONS: The expectation of confidentiality protection was greater for topics related to sexual behaviour than for the consequences of sexual behaviour, such as pregnancy, abortion or a sexually transmitted infection. This implies a need for targeted information strategies for the general population and explicit guidance for physicians on when and for whom care should remain confidential.
South African Journal of Child Health. 2016 Apr; 10(1):5-7.Background. HIV/AIDS is one of the most common underlying causes of death in children between the ages of 3 months and 5 years in sub-Saharan Africa. In Limpopo Province, South Africa, the prevention of mother-to-child transmission (PMTCT) programme introduced in early 2000 and paediatric ARV roll-out have had a poor uptake due to various factors. Objective. To establish the reasons why mothers decline HIV testing for their children. Methods. A cross-sectional descriptive study was conducted at the paediatric ward, Mankweng Hospital, Limpopo, for a period of 1 year (June 2009 - June 2010). All mothers who had declined HIV testing on their children were requested to participate. All the participants gave informed consent. Results. A total of 30 mothers participated. All women had attended antenatal care, 28 (93%) stated that their HIV results were negative and 2 (8%) had undergone PMTCT. The reasons mothers refused HIV testing on their children included the following: did not want to be stressed with a positive result (67%), did not want to know their status (7%) and could not consent as their partners had declined tests on both baby and mother (7%); 20% had other reasons including fear of HIV stigma. The median age of the children was 13 months (interquartile range 2 months - 10 years). Twenty-one (70%) of children were discharged home after treatment without HIV testing, five (16%) mothers signed refusal of hospital treatment, three (12%) started ARV after the mother reconsidered and signed consent, with good response to highly active antiretroviral treatment (HAART) and one child died after a month in the hospital. Conclusion. Fear of being stressed by a positive result was the main reason mothers refused an HIV test on their children. Better education about HIV transmission, prevention and the good response to HAART is needed to increase the uptake of HIV testing and antiretroviral therapy.
Developing World Bioethics. 2015 Dec; 15(3):191-198.There is increasing interest in the need to address the ethical dilemmas related to the engagement of adolescents in sexual and reproductive health (SRH) research. Research projects, including those that address issues related to STIs and HIV, adverse pregnancy outcomes, violence, and mental health, must be designed and implemented to address the needs of adolescents. Decisions on when an individual has adequate capacity to give consent for research most commonly use age as a surrogate rather than directly assessing capacity to understand the issues and make an informed decision on whether to participate in research or not. There is a perception that adolescents participating in research are more likely to be coerced and may therefore not fully comprehend the risk they may be taking when engaging in research. This paper examines the various ethical issues that may impact stakeholders' decision making when considering engaging adolescents in SRH research in Nigeria. It makes a case for lowering the age of consent for adolescents. While some experts believe it is possible to extrapolate relevant information from adult research, studies on ethical aspects of adolescents' participation in research are still needed, especially in the field of sexual and reproductive health where there are often differences in knowledge, attitudes and practices compared to adults. The particular challenges of applying the fundamental principles of research ethics to adolescent research, especially research about sex and sexuality, will only become clear if more studies are conducted.
BMC Medical Ethics. 2015; 16:62.BACKGROUND: Medical care of critically ill and injured infants and children globally should be based on best research evidence to ensure safe, efficacious treatment. In South Africa and other low and middle-income countries, research is needed to optimise care and ensure rational, equitable allocation of scare paediatric critical care resources. Ethical oversight is essential for safe, appropriate research conduct. Informed consent by the parent or legal guardian is usually required for child research participation, but obtaining consent may be challenging in paediatric critical care research. Local regulations may also impede important research if overly restrictive. By narratively synthesising and contextualising the results of a comprehensive literature review, this paper describes ethical principles and regulations; potential barriers to obtaining prospective informed consent; and consent options in the context of paediatric critical care research in South Africa. DISCUSSION: Voluntary prospective informed consent from a parent or legal guardian is a statutory requirement for child research participation in South Africa. However, parents of critically ill or injured children might be incapable of or unwilling to provide the level of consent required to uphold the ethical principle of autonomy. In emergency care research it may not be practical to obtain consent when urgent action is required. Therapeutic misconceptions and sociocultural and language issues are also barriers to obtaining valid consent. Alternative consent options for paediatric critical care research include a waiver or deferred consent for minimal risk and/or emergency research, whilst prospective informed consent is appropriate for randomised trials of novel therapies or devices. We propose that parents or legal guardians of critically ill or injured children should only be approached to consent for their child's participation in clinical research when it is ethically justifiable and in the best interests of both child participant and parent. Where appropriate, alternatives to prospective informed consent should be considered to ensure that important paediatric critical care research can be undertaken in South Africa, whilst being cognisant of research risk. This document could provide a basis for debate on consent options in paediatric critical care research and contribute to efforts to advocate for South African law reform.
The vaccine and cervical cancer screen (VACCS) project: acceptance of human papillomavirus vaccination in a school-based programme in two provinces of South Africa.
South African Medical Journal. 2015 Jan; 105(1):40-3.BACKGROUND: The incidence of cervical cancer in South Africa (SA) remains high, and the current screening programme has had limited success. New approaches to prevention and screening tactics are needed. OBJECTIVES: To investigate acceptance of school-based human papillomavirus (HPV) vaccination, as well as the information provided, methods of obtaining consent and assent, and completion rates achieved. METHODS: Information on cervical cancer and HPV vaccination was provided to 19 primary schools in Western Cape and Gauteng provinces participating in the study. Girls with parental consent and child assent were vaccinated during school hours at their schools. RESULTS: A total of 3 465 girls were invited to receive HPV vaccine, of whom 2 046 provided written parental consent as well as child assent. At least one dose of vaccine was delivered to 2 030 girls (99.2% of the consented cohort), while a total of 1 782 girls received all three doses. Sufficient vaccination was achieved in 91.6% of the vaccinated cohort. Of all invited girls, 56.9% in Gauteng and 50.7% in the Western Cape were sufficiently vaccinated. CONCLUSION: This implementation project demonstrated that HPV vaccination is practical and safe in SA schools. Political and community acceptance was good, and positive attitudes towards vaccination were encountered. During the study, which mimicked a governmental vaccine roll-out programme, high completion rates were achieved in spite of several challenges encountered.
Perspectives On Sexual and Reproductive Health. 2015 Jun; 47(2):63-70.CONTEXT: Little is known about low-income women's and teenagers' experiences accessing publicly funded family planning services, particularly after policy changes are made that affect the cost of and access to such services. METHODS: Eleven focus groups were conducted with 92 adult women and 15 teenagers in nine Texas metropolitan areas in July-October 2012, a year after legislation that reduced access to subsidized family planning was enacted. Participants were recruited through organizations that serve low-income populations. At least two researchers independently coded the transcripts of the discussions and identified main themes. RESULTS: Although most women were not aware of the legislative changes, they reported that in the past year, they had had to pay more for previously free or low-cost services, use less effective contraceptive methods or forgo care. They also indicated that accessing affordable family planning services had long been difficult, that applying and qualifying for programs was a challenge and that obtaining family planning care was harder than obtaining pregnancy-related care. As a result of an inadequate reproductive health safety net, women experienced unplanned pregnancies and were unable to access screening services and follow-up care. Teenagers experienced an additional barrier, the need to obtain parental consent. Some women preferred to receive family planning services from specialized providers, while others preferred more comprehensive care. CONCLUSION: Women in Texas have long faced challenges in obtaining subsidized family planning services. Legislation that reduced access to family planning services for low-income women and teenagers appears to have added to those challenges. Copyright (c) 2015 by the Guttmacher Institute.
Journal of the International Association of Providers of AIDS Care. 2014 Jul-Aug; 13(4):379-83.Realization of the right to health occurs along a continuum including national ratification of international treaties such as the Convention on the Rights of the Child, passage of domestic laws and policies that may specify modes of implementation and enforcement such as Kenya's Constitution and HIV and AIDS Prevention and Control Act, and actual implementation of domestic laws and policies such as through the regulation and delivery of health services. The stages heuristic theoretical framework describes the public policy continuum as consisting of marked stages: agenda setting, policy formulation, policy implementation, and evaluation. This case study illustrates the continuum in Kenya with regard to pediatric HIV testing. Kenya has made progress applying law, policy, and science to reduce vertical transmission of HIV and increase HIV testing of infants, although several challenges remain. Progress in policy implementation may reduce mother-to-child transmission and increase pediatric HIV testing.
Clinical trials of contraceptive agents in those under 16 years of age: Are they necessary, ethical or legal?
Archives of Disease In Childhood. 2014 Dec; 99(12):1070-1073.Add to my documents.
Universal HIV screening at postnatal points of care: which public health approach for early infant diagnosis in Cote d'Ivoire?
PloS One. 2013; 8(8):e67996.BACKGROUND: Universal HIV pediatric screening offered at postnatal points of care (PPOC) is an entry point for early infant diagnosis (EID). We assessed the parents' acceptability of this approach in Abidjan, Cote d'Ivoire. METHODS: In this cross-sectional study, trained counselors offered systematic HIV screening to all children aged 6-26 weeks attending PPOC in three community health centers with existing access to HAART during 2008, as well as their parents/caregivers. HIV-testing acceptability was measured for parents and children; rapid HIV tests were used for parents. Both parents' consent was required according to the Ivorian Ethical Committee to perform a HIV test on HIV-exposed children. Free HIV care was offered to those who were diagnosed HIV-infected. FINDINGS: We provided 3,013 HIV tests for infants and their 2,986 mothers. While 1,731 mothers (58%) accepted the principle of EID, only 447 infants had formal parental consent 15%; 95% confidence interval (CI): [14%-16%]. Overall, 1,817 mothers (61%) accepted to test for HIV, of whom 81 were HIV-infected (4.5%; 95% CI: [3.5%-5.4%]). Among the 81 HIV-exposed children, 42 (52%) had provided parental consent and were tested: five were HIV-infected (11.9%; 95% CI: [2.1%-21.7%]). Only 46 fathers (2%) came to diagnose their child. Parental acceptance of EID was strongly correlated with prenatal self-reported HIV status: HIV-infected mothers were six times more likely to provide EID parental acceptance than mothers reporting unknown or negative prenatal HIV status (aOR: 5.9; 95% CI: [3.3-10.6], p = 0.0001). CONCLUSIONS: Although the principle of EID was moderately accepted by mothers, fathers' acceptance rate remained very low. Routine HIV screening of all infants was inefficient for EID at a community level in Abidjan in 2008. Our results suggest the need of focusing on increasing the PMTCT coverage, involving fathers and tracing children issued from PMTCT programs in low HIV prevalence countries.
Barriers to provider-initiated testing and counselling for children in a high HIV prevalence setting: a mixed methods study.
Plos Medicine. 2014 May 27; 11(5):e1001649.Background: There is a substantial burden of HIV infection among older children in sub-Saharan Africa, the majority of whom are diagnosed after presentation with advanced disease. We investigated the provision and uptake of provider-initiated HIV testing and counseling (PITC) among children in primary health care facilities, and explored health care worker (HCW) perspectives on providing HIV testing to children. Methods and Findings: Children aged 6 to 15 y attending six primary care clinics in Harare, Zimbabwe, were offered PITC, with guardian consent and child assent. The reasons why testing did not occur in eligible children were recorded, and factors associated with HCWs offering and children/guardians refusing HIV testing were investigated using multivariable logistic regression. Semi-structured interviews were conducted with clinic nurses and counselors to explore these factors. Among 2,831 eligible children, 2,151 (76%) were offered PITC, of whom 1,534 (54.2%) consented to HIV testing. The main reasons HCWs gave for not offering PITC were the perceived unsuitability of the accompanying guardian to provide consent for HIV testing on behalf of the child and lack of availability of staff or HIV testing kits. Children who were asymptomatic, older, or attending with a male or a younger guardian had significantly lower odds of being offered HIV testing. Male guardians were less likely to consent to their child being tested. 82 (5.3%) children tested HIV-positive, with 95% linking to care. Of the 940 guardians who tested with the child, 186 (19.8%) were HIV-positive. Conclusions: The HIV prevalence among children tested was high, highlighting the need for PITC. For PITC to be successfully implemented, clear legislation about consent and guardianship needs to be developed, and structural issues addressed. HCWs require training on counseling children and guardians, particularly male guardians, who are less likely to engage with health care services. Increased awareness of the risk of HIV infection in asymptomatic older children is needed.
Plos Medicine. 2014 May 27; 11(5):e1001650.While prevention of mother-to-child transmission (PMTCT) interventions have made significant impacts on the reduction of vertical HIV transmission, coverage is uneven and substantial gaps remain. The success of these programs indicates that most ongoing transmission probably remains to be postnatal from mothers, and not diagnosed antenatally. There is evidence that half of HIV-infected infants die before their second birthday. Since early antiretroviral treatment (ART) significantly reduces morbidity and mortality, this has led to an appropriate focus on early infant diagnoses (EID) with less emphasis on later testing. However, some vertically-infected children may be “slow progressors” and may present late, already with health immune system suppression and organ damage. In 2007, WHO therefore recommended routine testing among older children, though while this is feasible and acceptable, its implementation and uptake are not necessarily universal. Several barriers to testing beyond infancy exist, and they are multifactorial and operate on various levels of the health system. Common misconceptions include the belief that HIV testing is only for symptomatic children, and disclosure and stigma are frequently reported reasons for children not being tested. At the facility level, lack of child-friendly services, negative health care worker attitudes, cost and transportation issues and insufficient staff and equipment are frequently noted. A new study of barriers to HIV testing in older children in presented in this series, the results of which urge for strengthening later provider-initatived HIV testing and counseling (PITC) and to focus on identifying “best practices” for PITC.