HIV & AIDS

Treatment 2.0 is an initiative launched by UNAIDS and WHO in 2011 to catalyze the next phase of treatment scale-up for HIV. The initiative defines strategic activities in 5 key areas--drugs, diagnostics, commodity costs, service delivery and community engagement--in an effort to simplify treatment, expand access and maximize program efficiency. For adults, many of these activities have already been turned into treatment policies. The recent WHO recommendation to use a universal first line regimen regardless of gender, pregnancy and TB status is a treatment simplification very much in line with Treatment 2.0. But despite that fact that Treatment 2.0 encompasses all people living with HIV, we have not seen the same evolution in policy development for children. In this paper we discuss how Treatment 2.0 principles can be adapted for the pediatric population.

As of 2012, only 34% of treatment eligible children in low- and middle-income countries were receiving antiretroviral treatment (ART) despite proven benefits of early initiation of antiretroviral treatment (ART) on child survival. We reviewed routine EID (early infant diagnosis) laboratory and paediatric ART patient records to determine missed opportunities for optimizing EID and current status of linkage between EID entry points to paediatric ART initiation in Tanzania, Uganda, and Zimbabwe. These are three countries with EID coverage of 22, 11 and 14%, respectively and ART coverage rates of 18, 16 and 32%, respectively. This article examines the most likely delivery points for collection of blood samples for EID testing for infant and young children and the most likely referral points for ART initiation of HIV-infected children in these three countries. This data provides evidence of consistent missed opportunities for linking HIV-infected children identified during EID to early ART treatment. We also argue for expanding the provision of EID to other service delivery points beyond PMTCT platform and provide suggestions for better linkages from EID to care and treatment.

Roughly 70% of infected children are not receiving live-saving HIV care and treatment. Strengthening case finding through improved diagnosis strategies and actively linking identified HIV-infected children to care and treatment are essential to ensuring that these children benefit from the care and treatment available to them. This article summarizes the challenges of identifying HIV-infected infants and children, reviews currently available evidence and guidance, describes promising new strategies for case finding, and makes recommendations for future research and interventions to improve identification of HIV-infected infants and children.

Estimating the size of populations most affected by HIV such as men who have sex with men (MSM) though crucial for structuring responses to the epidemic presents significant challenges, especially in a developing society. Using capture-recapture methodology, the size of MSM-SW in Nigeria was estimated in three major cities (Lagos, Kano and Port Harcourt) between July and December 2009. Following interviews with key informants, locations and times when MSM-SW were available to male clients were mapped and designated as "hotspots." Port Harcourt had the largest estimated population of MSM sex workers, 723, followed by Lagos state with 620, and Kano with 353. This study documents a large population of MSM-SW in three Nigerian cities where higher HIV prevalence among MSM compared to the general population has been documented. Research and programming are needed to better understand and address the health vulnerabilities that MSM-SW and their clients face.

Our objective in this study was to identify the missed opportunities for the integration of HIV care and family planning services and to inform future network strengthening. In two sub-cities of Addis Ababa, we identified each organization providing either HIV care or family planning services. We interviewed representatives of each of them about exchanges of clients with each of the others. With network analysis, we identified network characteristics in each sub-city network, such as referral density and centrality; and gaps in the referral patterns. Representatives from the networks confirmed the results reflected their experience and expressed an interest in establishing more links between organizations. Because of organizations not working together, women in the two sub-cities were at risk of not receiving needed family planning or HIV care services. Facilitating referrals among a few organizations that are most often working in isolation could remedy the problem, but the overall referral densities suggests that improved connections throughout might benefit conditions in addition to HIV and family planning that need service integration.

Prevention of mother-to-child transmission of HIV (PMTCT) programs can greatly reduce the vertical transmission rate (VTR) of HIV, and Malawi is expanding PMTCT access by offering HIV-infected pregnant women life-long antiretroviral therapy (Option B+). There is currently no empirical data on the effectiveness of Malawian PMTCT programs. This study describes a surveillance approach to obtain population-based estimates of the VTR of infants

A major strategy for preventing transmission of HIV and other STIs is the consistent use of condoms during sexual intercourse. Condom use among youths is particularly important to reduce the number of new cases and the national prevalence. Although a number of studies have established an association between condom use at one’s sexual debut and future condom use, few studies have explored this association over time, and whether the results are generalizable across multiple locations. This multi time point, multi district study assesses the relationship between sexual debut and condom use and consistent use of condoms thereafter. Uganda has used Lot Quality Assurance Sampling surveys since 2003 to monitor district level HIV programs and improve access to HIV health services. This study includes 4518 sexually active youths interviewed at five time points (2003–2010) in up to 23 districts located across Uganda. Using logistic regression, we measured the association of condom use at first sexual intercourse on recent condom usage, controlling for several factors including: age, sex, education, marital status, age at first intercourse, geographical location, and survey year. The odds of condom use at last intercourse, using a condom at last intercourse with a non-regular partner, and consistently using a condom are, respectively, 9.63 (95%WaldCI = 8.03–11.56), 3.48 (95%WaldCI = 2.27–5.33), and 11.12 (95%WaldCI = 8.95–13.81) times more likely for those individuals using condoms during their sexual debut. The results suggest that HIV prevention programs should encourage condom use among youth during sexual debut. Success with this outcome may have a lasting influence on preventing HIV and other STIs later in life.

Increasing coverage of isoniazid preventive therapy and cotrimoxazole preventive therapy reduced risk of TB among HIV patients who started treatment. All people living with HIV should be screened for TB, but for patients who have advanced disease (WHO clinical stage III/IV, bedridden, and with hemoglobin level of 10 mg/dl), intensified screening is highly recommended during treatment follow-up.

The aim of this study was to assess predictors of mortality among TB-HIV co-infected patients being treated for TB in Northwest Ethiopia. An institution-based retrospective cohort study was conducted between April, 2009 and January, 2012. Despite the availability of free ART from health institutions in Northwest Ethiopia, mortality was high among TB-HIV co-infected patients, and strongly associated with the absence of ART during TB treatment. In addition cotrimoxazole prophylactic therapy remained important factor in reduction of mortality during TB treatment. The study also noted importance of early ART even at higher CD4 counts.

Lessons learned from treating patients with HIV infection can inform care systems for other chronic conditions. For antiretroviral treatment, attending appointments on time correlates with medication adherence; however, HIV clinics in East Africa, where attendance rates vary widely, rarely include systems to schedule appointments or to track missed appointments or patient follow-up.

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