Eliminating mother-to-child transmission of the human immunodeficiency virus in sub-Saharan Africa: The journey so far and what remains to be done. J Infect Public Health. 2016;9:396-407. [PMID: 26194038 DOI: 10.1016/j.jiph.2015.06.010]

Building a Healthier Future: A Narrative Review on Early Infant Diagnosis's Role in HIV Prevention

Background and Aims

Early infant diagnosis (EID) is a critical intervention in the global fight against pediatric HIV, providing early identification and treatment for HIV-exposed infants. This narrative review examines the role of EID in reducing vertical transmission, improving health outcomes, and mitigating stigma in communities. The review also explores innovations, challenges, and strategies for optimizing EID programs.

Methods

A comprehensive literature search was conducted across databases such as PubMed, Scopus, and WHO reports to identify relevant studies, guidelines, and program evaluations. Key focus areas included diagnostic techniques, implementation strategies, and community impacts of EID programs, with an emphasis on their integration into broader HIV care frameworks.

Results

EID enables the early detection of HIV in infants, allowing timely initiation of antiretroviral therapy (ART), which reduces morbidity and mortality. It also indirectly prevents postnatal transmission during breastfeeding by lowering viral loads in treated infants. Innovations such as point-of-care testing and digital health tools have improved access and efficiency, particularly in resource-limited settings. EID programs have demonstrated a positive societal impact by raising awareness, reducing stigma, and fostering trust in healthcare systems. However, significant challenges persist, including logistical barriers, infrastructure limitations, and socioeconomic constraints that hinder program effectiveness.

Conclusion

EID is essential for addressing pediatric HIV, contributing to the elimination of vertical transmission and improving outcomes for HIV-exposed infants. To enhance its impact, stakeholders must prioritize expanding access to diagnostic tools, strengthening healthcare infrastructure, and engaging communities through education and advocacy. EID programs not only save lives but also foster societal shifts towards inclusivity and acceptance, paving the way for a healthier, HIV-free future.

Low effective coverage of HIV testing and counselling services during antenatal care in Ethiopia: evidence from the demographic and health survey and service provision assessment

Introduction

Prevention of mother-to-child transmission contributes to avert nearly 4000 new HIV infections in 2022. HIV testing and counselling (HTC) during antenatal care (ANC) is an effective strategy to reduce the vertical transmission of HIV. While the utilisation of HTC services in Ethiopia has been explored, there is limited evidence exploring the effective coverage of HTC during ANC. We aimed to assess the quality-adjusted (effective) coverage of HTC during ANC in Ethiopia.

Methods

We linked the 2016 Ethiopian Demographic Health Survey and the 2021-2022 Ethiopian Service Provision Assessment (ESPA) surveys to determine the crude coverage and assess the quality of HTC provision. The ESPA service quality framework, which has structural and process-related components, was used. We used a weighted additive approach of 61 indicators (38 structural and 23 process) to estimate the quality of care score. Administrative boundary linkage was used to link the two datasets. The effective coverage was calculated as the product of crude coverage and the quality of care score.

Results

During ANC contacts/visits, 17.2% (95% CI 16.0 to 18.4) of women received HTC. The effective coverage of HTC during ANC was 10.8 (95% CI 9.8 to 11.8), with substantial disparities among administrative regions, ranging from 1.6% (95% CI 1.3, 2.0) in the Somali region to 55.5% (95% CI 53.5 to 57.5) in Addis Ababa. The overall service quality was 45.2% (95% CI 42.8 to 47.1). Health facilities in Harari (31.4% (95% CI 19.0 to 43.8)), Somali (34.1% (95% CI 26.8 to 41.6)) and Dire Dawa (34.9% (95% CI 24.71 to 45.0)) demonstrated low-quality service provision. Health posts (5.8%, SD=8.4), health facilities located in rural areas (30.6%, SD=27.3) and public health facilities (44.2%, SD=29.4) had low-quality HTC provision.

Conclusion

Nearly 9 in 10 women did not receive quality HTC during ANC provision. The crude coverage, quality of services provision and effective coverage significantly vary across administrative regions. Afar and Somali regions lagged behind the Addis Ababa and Amhara administrative regions. To effectively mitigate mother-to-child transmission of HIV, policymakers need to prioritise enhancing the quality of care in HTC during ANC and expanding service delivery.

Treatment failure among Sub-Sahara African children living with HIV: a systematic review and meta-analysis

BACKGROUND

Antiretroviral treatment failure is a global issue, particularly in developing countries such as Sub-Saharan Africa. Prior research findings were highly variable and inconsistent across areas. As a result, the goal of this systematic review and meta-analysis was to determine the pooled prevalence of treatment failure among children receiving antiretroviral medication in Sub-Saharan Africa.

METHODS

To find qualifying papers, we searched databases (such as PubMed, Google Scholar, African Journals Online, Scopus, and the Cochrane Library). The data were retrieved using Microsoft Excel and exported to STATA Version 14 for analysis. To check for publication bias, we employed Egger and Begg's regression tests. A random-effects model was used to assess the pooled prevalence of treatment failure due to high levels of variability.

RESULTS

Following the removal of duplicated articles and quality screening, a total of 33 primary articles were determined to be appropriate for inclusion in the final analysis for this study. Overall, the pooled prevalence of treatment failure among HIV-infected children was 25.86% (95% CI: 21.46, 30.26). There is great variety across the included studies, with the majority of them being conducted in Ethiopia. Cameroon had the greatest pooled prevalence of treatment failure among HIV-infected children, at 39.41% (95% CI: 21.54, 57.28), while Ethiopia had the lowest, at 13.77% (95% CI: 10.08, 17.47).

CONCLUSIONS

The pooled estimate prevalence of treatment failure among HIV-infected children in Sub-Saharan Africa was high. The implementation of national and international policies and strategies on ART clinic care services should be given special focus in order to reduce treatment failure in children living with HIV/AIDS.

TRIAL REGISTRATION

The protocol has been registered in the PROSPERO database under the registration number CRD-429011.

Characterisation of HIV-1 reservoirs in paediatric populations: protocol for a systematic review and meta-analysis

INTRODUCTION

The success of antiretroviral therapy (ART) has changed HIV from a deadly to a chronic infection, thus increasing the transitioning from infancy toward adulthood. However, the virostatic nature of antiretrovirals maintains viruses in sanctuaries, with reactivation potentials. Because current ARTs are very limited for children, the emergence of new HIV epidemics driven by HIV drug-resistance mutations is favoured. Our systematic review aims to estimate the global burden of archived drug-resistance mutations (ADRMs) and the size of reservoir (HIV-1 DNA load), and their associated factors in children and adolescents.

METHODS AND ANALYSIS

Papers from the PubMed/MEDLINE, Google Scholar, ScienceDirect, African Journals Online and Academic Medical Education Databases will be systematically identified using the keywords: "HIV-1 reservoirs", "viral reservoirs", "HIV-1 DNA", infants, adolescents, child and children, linked by the following Boolean operators: 'OR' and 'AND'. Randomised and non-randomised trials, cohort studies and cross-sectional studies published in French or English from January 2002 will be included, while case reports, letters, comments, reviews, systematic reviews and meta-analyses, and editorials will be excluded. All studies describing data on ADRMs, HIV-1 DNA load and/or immunological markers among children/adolescents will be eligible. A random-effects model will be used to calculate the pooled prevalence of ADRMs. Data will be reported according to type of viral reservoir (peripheral blood mononuclear cells, CD4 cells), geographical location (country/continent), ethnicity/race, age (infants vs adolescents), gender, HIV-1 clades, ART exposure (naïve vs treated, drug class, type of regimen, age at ART initiation and treatment duration), WHO clinical staging (I, II, III, IV), immune status (immune compromised vs immune competent) and virological response (viraemic vs non-viraemic). Multivariate logistic regression will be performed to determine predictors of HIV reservoir profile in paediatric populations. The primary outcome will be to assess the genotypical and quantitative profile of HIV reservoirs, while the secondary outcomes will be to identify factors associated with ADRMs and reservoir size in paediatric populations.

ETHICS AND DISSEMINATION

Ethical approval is not applicable for this study as it will be based on published data. Results will be disseminated via a peer-reviewed scientific journal and relevant conferences.

PROSPERO REGISTRATION NUMBER

CRD42022327625.

Knowledge, attitude, and practice towards prevention of mother-to-child transmission of HIV among antenatal care attendees in Ethiopia, 2020

BACKGROUND

In 2020, globally approximately 37.6 million people living with HIV and 700,000 children are born infected from their parents. Every day there are nearly 1800 new Human Immune Virus (HIV) infections in children, more than 90% occurring in the developing world. Approximately 90% of these infections are associated with mother-to-child transmission (MTCT). In 2019, Ethiopia had over 100,000 pregnancies in HIV-positive women and over 12,000 HIV-positive. Therefore, this study aimed to assess the knowledge, attitude, and practice of pregnant mothers toward the prevention of mother-to-child transmission of HIV.ss.

METHODS

An institutional-based cross-sectional study was conducted among 216 antenatal care (ANC) attendees in Gurage zone hospitals from June to July 2020. Data were collected using a structured and pre-tested questionnaire through face-to-face interviews. A Systematic random sampling technique with proportional allocation to size was used to select study subjects. Data entry and analysis were performed using Epi Data version 4.1 and SPSS version 25 respectively.

RESULTS

The level of good knowledge, attitude, and practice towards Prevention of mother to child transmission (PMTCT) of HIV among antenatal care attendees was found to be 72.2%, 79%, and 62% respectively. This study has also shown that at the time of transmission of the virus from the infected mother to her child, 38.9% of the respondents responded that it could be through breastfeeding, 38.9% during pregnancy, 16.5% during labor and 5.7% did not know respectively. All the respondents have been tested and 0.92% was positive. Nearly half, 99 (45.8%) of the respondents had tested for HIV/AIDS with their partner/husband during their ANC follow-up.

CONCLUSION

In this study, the level of good knowledge, attitude, and practice towards PMTCT of HIV among antenatal care attendees were low. This finding also suggests that healthcare providers should consider the potential risk of mother-to-child transmission of HIV while providing clinical health assessments during antenatal care visits. Thus, improvement of counseling sessions and knowledge of PMTCT for pregnant women attending antenatal care is needed to increase their acceptance and use of PMTCT for HIV services.

The mother-to-child transmission of HIV-1 and profile of viral reservoirs in pediatric population: A systematic review with meta-analysis of the Cameroonian studies

BACKGROUND

The mother-to-child transmission of HIV-1 (MTCT) remains on the major route of HIV-transmission among pediatric populations in Africa. Though a prevention of MTCT (PMTCT) high-priority country, data on the MTCT burdens in Cameroon remains fragmented.

OBJECTIVE

We sought to assess the pooled MTCT rate, its risk-factors, and to characterize viral reservoirs of infected-children in Cameroon.

METHODS

All relevant observational cohort and cross-sectional studies conducted in Cameroon were searched from PubMed, African Journals Online, Google scholar, ScienceDirect and academic medical education databases. Heterogeneity and publication bias were respectively assessed by the I2 statistic and the Egger/funnel plot test. Meta-analysis was performed using the random effects model. MTCT rate >5% was considered as "high". This review was registered in the Prospero database, CRD42021224497.

RESULTS

We included a total of 29 studies and analyzed 46 684 children born from HIV-positive mothers. The overall rate of MTCT was 7.00% (95% CI = 6.07-8.51). According to regions, the highest burden was in Adamaoua-region (17.51% [95% CI:14.21-21.07]) with only one study found. PMTCT option-B+ resulted in about 25% reduction of MTCT (8.97% [95% CI: 8.71-9.24] without option-B+ versus 2.88% [95% CI: 5.03-9.34] with option-B+). Regarding risk-factors, MTCT was significantly associated with the absence of PMTCT-interventions both in children (OR:5.40 [95% CI: 2.58-11.27]) and mothers (OR: 3.59 [95% CI: 2.15-5.99]). Regarding viral reservoirs, a pro-viral DNA mean of 3.34±1.05 log10/mL was observed among 5/57 children and archived HIV drug resistance mutations were identified in pro-viral DNA marker among 21/79 infected-children.

CONCLUSION

In spite of the dropdown in MTCT following option-B+ implementation, MTCT remains high in Cameroon, with substantial disparities across regions. Thus, in this era of option-B+, achieving MTCT elimination requires interventions in northern-Cameroon. The variation in pro-viral load in infected-children underlines the relevance of characterizing viral reservoirs for possible infection control in tropical settings.

Adherence to option B+ and its association with disclosure status and counseling among HIV-positive pregnant and lactating women in Ethiopia: systematic review and meta-analysis

OBJECTIVES

This systematic review and meta-analysis aimed to assess the pooled estimate of option B+ level of adherence and its association with disclosure status and counseling among pregnant and lactation women in Ethiopia after option B+ implementation.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

We searched Web of Science, MEDLINE, PUBMED, Scopus, Embase, CINAHL, and Google Scholar databases for studies reporting adherence to option B+ and its association with disclosure status and counseling among pregnant and lactating women in Ethiopia. Heterogeneity was assessed by forest plot, Cochran's Q test, and I² test. A random effects model was calculated to estimate the pooled prevalence of adherence toward option B+.

RESULTS

We included eight studies, which gives a total of 1852 pregnant and lactating women in this systematic review and meta-analysis. The overall pooled estimate of good adherence toward option B+ antiretroviral therapy (ART) drug among pregnant and lactating women in Ethiopia was 84.23% (95% confidence interval [CI]: 80.79-87.66). Women who have disclosed their HIV status to their partner (adjusted odds ratio = 4.48, 95% CI: 1.86-10.76) and got counseling during the antenatal period (adjusted odds ratio = 5.02, 95% CI: 2.43-10.34) had a positive association with good adherence to option B+ ART drugs.

CONCLUSION

Four of five pregnant and lactating women have good adherence to option B+ ART drugs in Ethiopia. Therefore, promoting HIV disclosure status to partners and enhancing counseling services should be strengthened to improve adherence toward option B+ among pregnant and lactating women.

Training, confidence and knowledge of healthcare workers with regard to HIV and infant feeding in eThekwini, South Africa

Background. Healthcare workers play an important role in educating mothers living with HIV regarding appropriate infant and young child feeding (IYCF) practices. However, it is not known if healthcare workers in eThekwini, KwaZulu-Natal (KZN), have been adequately trained regarding IYCF in the context of HIV and how knowledgeable and confident they are. Objectives. To assess the training, confidence and knowledge of healthcare workers regarding IYCF in the context of HIV. Methods. This was a descriptive cross-sectional study, which used a self-administered questionnaire developed for this survey. Healthcare workers (n=188), primarily doctors and nurses in antiretroviral, antenatal and paediatric departments at three regional hospitals (Addington Hospital, Prince Mshiyeni Memorial Hospital and RK Khan Hospital) in eThekwini, KZN, participated. Results. Only 47.3% (n=89) of the participants had attended formal training on IYCF in the context of HIV. Most participants (n=171; 91.4%) felt they required more training. The mean overall confidence score of the group was 4.54 (standard deviation (SD) 1.28)%. The mean knowledge score of participants regarding IYCF in the context of HIV was 51.7%. The attendance of training did not equate to improved knowledge scores. Conclusions. Although the healthcare workers were confident with counselling on IYCF in the context of HIV, their knowledge levels were lower than expected. This could be attributed to a lack of training or outdated or inefficient training. There is a need to improve the coverage and quality of IYCF and HIV training. Training courses should address behaviour change and test for understanding.

Utilization of provider-initiated HIV testing and counselling in Ethiopia: a systematic review and meta-analysis

Background

Provider-initiated HIV testing, and counseling (PITC) is a service in which health professionals provide HIV testing to all patients in health facilities. Provider-initiated HIV testing, and counseling is an important opportunity for early screening of individuals, and it is fundamental for both HIV treatment and prevention. Although there are studies conducted in different parts of Ethiopia, their findings are variable. Therefore, this systematic review and meta-analysis aimed to summarize the pooled utilization of PITC in Ethiopia.

Method

All studies conducted on utilization of provider-initiated HIV testing and counseling at outpatient departments (OPD), inpatient departments (IPD), antenatal clinic care (ANC), and tuberculosis (TB) clinics in Ethiopia are eligible for these meta-analyses. A systematic search of the literature was conducted by the authors to identify all relevant primary studies. The databases used to search for studies were PubMed, Science Direct, POPLINE, HENARI, Google Scholar, and Scopus. The extracted data were imported into STATA version 14 software for statistical analysis. The risk of bias was assessed using the Joana Briggs Institute (JBI) criteria for prevalence studies. The heterogeneity among all included studies was assessed by I² statistics and the Cochran’s Q test. Pooled utilization along with its corresponding 95% CI was presented using a forest plot.

Result

About 1738 studies were retrieved from initial electronic searches using international databases and Google, and a total of 10,676 individual clients were included in the meta-analysis. The pooled utilization of PITC in Ethiopia using the random effects model was estimated to be 78.9% (95% CI 73.87–83.85) with a significant level of heterogeneity (I² = 98.5%; P < 0.001). Subgroup analysis conducted on PITC showed the highest percentage among studies conducted in Addis Ababa (93.5%), while lower utilization was identified from a study conducted in the Tigray Region (35%).

Limitation of the study

The drawbacks of this review and meta-analysis were being reported with significant heterogeneity, and the protocol was not registered.

Conclusion

About 21% of health facility clients missed opportunities for PITC in Ethiopia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41182-022-00420-9.

Mother-to-child HIV-2 transmission: comparison with HIV-1 and evaluation of factors influencing the rate of transmission. A systematic review

A review and collection of data on HIV-2 mother-to-child transmission (MTCT) is absent in the literature. This systematic review and meta-analysis aims to provide a pooled estimate of the rate of HIV-2 MTCT and to identify factors influencing the rate of transmission. PubMed and EMBASE were used to identify eligible publications using a sensitive search strategy. All publications until February 2021 were considered; 146 full-text articles were assessed. Observational studies describing the rate of HIV-2 MTCT in a defined HIV-2 infected study population were included. Other publication types and studies describing HIV-1 or dually infected populations were excluded. Nine studies consisting of 901 mother-child pairs in West Africa, France and Portugal were included in the meta-analysis. The pooled rate estimate of HIV-2 MTCT for antiretroviral therapy-naïve women was 0.2% (95% CI 0.03 to 1.47%), considerably lower than that for HIV-1. The levels of maternal HIV RNA and CD4 cell count were positively related to the vertical transmission rate. Maternal HIV-2 infection did not significantly affect perinatal mortality. It was concluded that the vertical transmission of HIV-2 is lower than that of HIV-1. Maternal viral load and CD4 cell count appear to influence the rate of HIV-2 MTCT.

"He is the Same as Me": Key Populations' Acceptability and Experience of a Community-Based Peer Navigator Intervention to Support Engagement in HIV Care in Tijuana, Mexico

Engagement in the HIV care continuum among people living with HIV is essential to prevent ongoing transmission. Although there is evidence for the need for comprehensive approaches (e.g., peer navigation) to improve the HIV care continuum, there is limited knowledge of how the peer navigation model might work to improve the HIV care continuum in low resource settings among Latinx key populations (e.g., persons who inject drugs, female sex workers, men who have sex with men, and transgender women). Therefore, this article aims to qualitatively assess members of key populations' acceptability of Conexiones Saludables (Healthy Connections), a community-based peer navigation intervention implemented in Tijuana, Mexico. This analysis draws upon the postintervention survey data from 34 participants and data from qualitative interviews with 10 participants. Participants found the intervention to be acceptable and discussed the ways in which peer navigators were influential in educating participants about HIV, antiretroviral therapy (ART), linking participants to existing HIV care and ancillary services in Tijuana, and in providing emotional and instrumental support to facilitate engagement in HIV treatment and ART adherence. The intervention emphasized the use of peer navigators who had a deep understanding of the sociostructural barriers (e.g., substance use, homelessness) that HIV-positive key populations face in Tijuana. Findings from this study may inform programs with highly vulnerable populations in similar settings.

Small-airway disease and its reversibility in human immunodeficiency virus-infected children on highly active antiretroviral therapy: A cross-sectional study in an African setting

BACKGROUND

Lung function abnormalities may occur in children with human immunodeficiency virus (HIV) infection. Small-airway disease (SAD) precedes abnormalities in forced expiratory volume in 1 s (FEV 1).

OBJECTIVE

This study aims to assess the presence and reversibility of SAD in HIV-infected children using the Global Lung Function Initiative standards.

METHODS

A cross-sectional study was conducted over 6 months at the Paediatric HIV Clinic of the University of Nigeria Teaching Hospital in Enugu, Southeast Nigeria. Eligible consenting children with HIV infection were recruited. Lung function was measured, and the reversibility of FEV1 and forced vital capacity (FVC) was assessed at 12% while that of forced expiratory flow between 25% and 75% (FEF25-75) was assessed at 12%, 15%, and 20%. Predictors of abnormal Z-score values were determined by multivariate linear and logistic regressions. Statistically significant values were set at P < 0.05.

RESULTS

The mean Z-score for FEV1, FVC, and FEF25-75 was - 2.19, -1.86, and - 1.60, respectively. Most patients (73%) had abnormal FEV1, while 52% had abnormal FEF25-75. Significant changes in FEV1 (P = 0.001) and FEF25-75 (P < 0.001) occurred after the bronchodilator response (BDR) test. Of the children whose FEV1 showed positive BDR, 70.9% had low zFEV1; 50% had low zFEF25-75, while all had low FEV1. Nutritional status (Z-score for body mass index) was significantly associated with low FEV1.

CONCLUSIONS

Abnormal FEF25-75 as a marker of SAD and FEV1 with a positive BDR are common in HIV-infected children. These lung function abnormalities justify long-term follow-up for these patients.

Epidemiological characterization and geographic distribution of human immunodeficiency virus/acquired immunodeficiency syndrome infection in North African countries

BACKGROUND

Human immunodeficiency virus (HIV) infection is a major global public health concern. North African countries carry a disproportionate burden of HIV representing one of the highest rates in Africa.

AIM

To characterize the epidemiological and spatial trends of HIV infection in this region.

METHODS

A systematic review was carried out on all the published data regarding HIV/acquired immunodeficiency syndrome in North African countries over ten years (2008-2017) following the PRISMA guidelines. We performed a comprehensive literature search using Medline PubMed, Embase, regional and international databases, and country-level reports with no language restriction. The quality, quantity, and geographic coverage of the data were assessed at both the national and regional levels. We used random-effects methods, spatial variables, and stratified results by demographic factors. Only original data on the prevalence of HIV infection were included and independently evaluated by professional epidemiologists.

RESULTS

A total of 721 records were identified but only 41 that met the criteria were included in the meta-analysis. There was considerable variability in the prevalence estimates of HIV within the countries of the region. The overall prevalence of HIV ranged from 0.9% [95% confidence interval (CI) 0.8-1.27] to 3.8% (95%CI 1.17-6.53). The highest prevalence was associated with vulnerable groups and particularly drug abusers and sexually promiscuous individuals. The dense HIV clustering noted varied from one country to another. At least 13 HIV subtypes and recombinant forms were prevalent in the region. Subtype B was the most common variant, followed by CRF02_AG.

CONCLUSION

This comprehensive review indicates that HIV infection in North African countries is an increasing threat. Effective national and regional strategies are needed to improve monitoring and control of HIV transmission, with particular emphasis on geographic variability and HIV clustering.

Factors associated with the timely uptake of initial HIV virologic test among HIV-exposed infants attending clinics within a faith-based HIV program in Kenya; a cross-sectional study

BACKGROUND

Early infant diagnosis (EID) of HIV, followed by effective care including antiretroviral therapy (ART), reduces infant mortality by 76% and HIV progression by 75%. In 2015, 50% of 1.2 million HIV-exposed infants (HEI) in 21 priority countries received a virologic test within the recommended 2 months of birth. We sought to identify factors associated with timely uptake of virologic EID among HEI and gain insight into missed opportunities.

METHODS

This was a cross-sectional study that used de-identified data from electronic medical records of 54 health facilities within the Christian Health Association of Kenya (CHAK) HIV Project database. All HEI who had their first HIV virologic test done between January 2015 and December 2017 were included in the study and categorized as either having the test within or after 8 weeks of birth. Multivariate linear mixed effects regression model was used to determine factors associated with uptake of the first HIV EID polymerase chain reaction (PCR). Predictor variables studied include sex, birth weight, the entry point into care, provision of ART prophylaxis for the infant, maternal ART at time of EID, mode of delivery, and place of delivery.

RESULTS

We included 2020 HEI of whom 1018 (50.4%) were female. A majority, 1596 (79.0%) had their first HIV PCR within 2 months of birth at a median age of 6.4 weeks (interquartile range 6-7.4). Overall, HIV positivity rate at initial test among this cohort was 1.2%. Delayed HIV PCR testing for EID was more likely to yield a positive result [adjusted odds ratio (aOR) = 1.29 (95% confidence interval (CI) 1.09-1.52) p = 0.003]. Infants of mothers not on ART at the time of HIV PCR test and infants who had not received prophylaxis to prevent vertical HIV transmission had significant increased odds of a delayed initial test [aOR = 1.27 (95% CI = 1.18-1.37) p = < 0.0001] and [aOR = 1.43 (95% CI 1.27-1.61) p = < 0.001] respectively.

CONCLUSION

An initial HIV PCR test done after 8 weeks of birth is likely to yield a positive result. Barriers to accessing ART for treatment among HIV-infected pregnant and breastfeeding women, and prophylaxis for the HEI were associated with delayed EID. In order to ensure timely EID, programs need to incorporate both facility and community strategy interventions to ensure all pregnant women seek antenatal care and deliver within health facilities.

Factors influencing the delivery and uptake of early infant diagnosis of HIV services in Greater Accra, Ghana: A qualitative study

BACKGROUND

Early Infant Diagnosis (EID) of HIV and timely initiation of Antiretroviral Therapy (ART) can significantly reduce morbidity and mortality of HIV infected infants. Despite the benefits of early infant testing, the coverage of EID of HIV services is still low in Sub-Saharan Africa, including Ghana.

OBJECTIVES

To ascertain the factors that facilitate or hinder the delivery and uptake of EID of HIV services.

METHODS

The study is a cross-sectional exploratory qualitative research conducted in two health facilities in the Greater Accra Region of Ghana. Respondents (n = 50) comprising health workers (n = 20) and HIV positive mothers (n = 30) were purposively sampled and engaged in in-depth interviews. The Nvivo 11 software and the Braun and Clarke's stages of thematic analysis were used in coding data and data analysis respectively.

RESULTS

The study found that health system factors such as inadequate Staff with sample collection skills, unavailability of vehicles to convey samples to the reference laboratory for analysis, the long turnaround time for receipt of Polymerase Chain Reaction (PCR) results, inadequate and frequent breakdown of PCR machine hindered EID service delivery. On the other hand, adequate knowledge of health workers on EID, availability of Dried Blood Spot (DBS) cards and the adoption of task shifting strategies facilitated EID service delivery. Factors such as the denial of HIV status, non-completion of the EID process due to frustrations encountered whiles accessing service and delay in receipt of PCR results served as barriers to mother's utilisation of EID services for their exposed infants. The study also identified that adequate knowledge of EID, perceived importance of EID, financial stability as well as financial support from others and the positive attitudes of health workers facilitated HIV positive mother's uptake of EID services for their exposed infants.

CONCLUSION

The factors attributing to the low coverage of EID of HIV services must be promptly addressed to improve service delivery and uptake.

Policy and practice suggestions to improve performance on the UNAIDS 90-90-90 targets: Results from a nominal group technique with HIV experts in Southwest Ethiopia

OBJECTIVE

This paper aims to evaluate the potential solutions to address negative outcomes of HIV care and treatment, that were proposed by HIV care providers, researchers and HIV programme managers in Southwest Ethiopia.

METHODS

A nominal group technique (NGT) was conducted with 25 experts in December 2017 in Jimma, Southwest Ethiopia. The NGT process included (a) an analysis of the previously qualitative study conducted with various Ethiopian HIV stakeholders who proposed possible solutions for HIV care and treatment; (b) recruitment of a panel of HIV experts in policy and practice to rate the proposed solutions in Ethiopia before a discussion (first round rating); (c) discussion with the panel of experts on the suggested solutions; and (d) conducting a second round of rating of proposed solutions. Content analysis and Wilcoxon signed rank test were applied to analyse the data.

RESULTS

Eighteen of the 25 invited panel of experts participated in the NGT. The following proposed solutions were rated and discussed as relevant, feasible and acceptable. In order of decreasing importance, the solutions were as follows: filling gaps in legislation, HIV self-testing, the teach-test-link-trace strategy, house-to-house HIV testing, community antiretroviral therapy (ART) groups, providing ART in private clinics and providing ART at health posts.

CONCLUSIONS

The current study findings suggested that, to address HIV negative outcomes, priority solutions could include mandatory notification of partner's HIV status, HIV self-testing and the involvement of peer educators on the entire HIV care programme.

Changing Childbearing Norms During an Era of ART Expansion in Malawi, 2009 to 2015

Community norms shape the childbearing goals and behaviors of persons living with HIV/AIDS (PLWHA) but little is known about how norms around HIV-positive childbearing have changed with expanded access to antiretroviral treatment (ART). We analyze data collected in 2009 and 2015 by the Tsogolo la Thanzi (TLT) project-a longitudinal, population-based study of young adults in southern Malawi. Respondents were asked about the acceptability of childbearing using vignettes that varied a hypothetical couple's HIV status and number of children. We assess mean differences in support for childbearing over time and by respondent gender and serostatus. The acceptability of childbearing for PLWHA increased dramatically over the 6-year period; however, support levels varied based on a couple's current number of children and whether they were seropositive concordant or discordant. Differences in attitudes by gender and HIV status diminished over time, pointing to a population-level convergence in norms about acceptable childbearing.

Male partner approval on the use of modern contraceptive methods: factors determining usage among couples in Kibaha district, Tanzania

Background

Men in developing countries play an important role in the adoption of family planning (FP), either as actual users or supporters of their partners. Notwithstanding the universal knowledge on the contraceptive methods, their approval and use have been low among men in Tanzania. This study determined the magnitude and factors that influence men to use or approve the use of modern contraceptive methods with their spouses.

Methods

A cross sectional, community-based study was conducted in Kibaha, Pwani region in 2014. A total of 365 randomly selected married and cohabiting men; aged 18 to 60 years who had at least a child below the age of 5 years were interviewed using a structured questionnaire. Descriptive statistics were performed and associations between status of men using modern FP with their partners and potential factors were tested using Chi-square and Fisher’s exact tests as appropriate. Logistic regression model was fitted to determine significant factors associated with male use of the methods with their partners.

Results

About 60 % of men (59.7%) reported to use modern FP methods. In the bivariate analysis, education level (odds ratio (OR) = 2.6, CI = 1.4–4.8; p = 0.002); men knowledge on any contraceptive method (OR = 24.1, CI = 7.3–79.9; p < 0.001); awareness of a nearby FP clinic (OR = 6.2, CI = 3.1–12.3; p < 0.001); number of children (OR = 2, CI = 1.1–3.6; p < 0.025) and presence of a provider during clinic visit (OR = 12.0, CI = 2.26–63.7; p < 0.004) were significantly associated with the use of FP. However, in the multivariable analysis, only knowledge on FP methods (adjusted odds ratios (AOR) =26.4; CI = 7.9–88.4, p < 0.001) and number of children a man had (AOR = 1.9; CI = 1.0–3.6, p = 0.039) remained significantly associated with the use of modern FP methods.

Conclusion

This study has shown that for men to use family planning methods with their partners, knowledge of FP methods and number of children are critical factors. Visiting a FP center alone or with a spouse, and availability of FP provider (during visit) also influence this practice. These findings emphasize a need to increase knowledge on contraception and family planning services access among men.

The value of hope: development and validation of a contextual measure of hope among people living with HIV in urban Tanzania a mixed methods exploratory sequential study

BACKGROUND

Hope or hopefulness enhances coping and improves quality of life in persons with chronic or incurable illnesses. Lack of hope is associated with depression and anxiety, which impact negatively on quality of life. In Tanzania, where HIV prevalence is high, the rates of depression and anxiety are over four times higher among people living with HIV (PLH) compared to persons not infected and contribute annual mortality among PLH. Tanzania has a shortage of human resources for mental health, limiting access to mental health care. Evidence-based psychosocial interventions can complement existing services and improve access to quality mental health services in the midst of human resource shortages. Facilitating hope can be a critical element of non-pharmacological interventions which are underutilized, partly due to limited awareness and lack of hope measures, adapted to accommodate cultural context and perspectives of PLH. To address this gap, we developed and validated a local hope measure among PLH in Tanzania.

METHODS

Two-phased mixed methods exploratory sequential study among PLH. Phase I was Hope-related items identification using deductive, inductive approaches and piloting. Phase II was an evaluation of psychometric properties at baseline and 24 months. Classical test theory, exploratory, confirmatory factor analysis (CFA) were used.

RESULTS

Among 722 PLH, 59% were women, mean age was 39.3 years, and majority had primary school level of education. A total of 40 hope items were reduced to 10 in a three-factor solution, explaining 69% of variance at baseline, and 93% at follow-up. Internal consistency Cronbach's alpha was 0.869 at baseline and 0.958 at follow-up. The three-factor solution depicted: positive affect; cognition of effectiveness of HIV care; and goals/plans/ future optimism. Test-retest reliability was good (r = 0.797) and a number of indices were positive for CFA model fit, including Comparative Fit Index of 0.984.

CONCLUSION

The developed local hope scale had good internal reliability, validity, and its dimensionality was confirmed against expectations. The fewer items for hope assessment argue well for its use in busy clinical settings to improve HIV care in Tanzania. Hope in this setting could be more than cognitive goal thinking, pathway and motivation warranting more research.

TRIAL REGISTRATION

The intervention was registered in USA ClinicalTrials.gov on September 26, 2012, Registration number: NCT01693458.

A Systematic Review and Meta-analysis of Antiretroviral Therapy (ART) Adherence Interventions for Women Living with HIV

A systematic review and meta-analysis was conducted to determine the efficacy of women-focused ART adherence interventions. Included studies (a) reported on a behavioral ART adherence intervention for cis-women living with HIV, (b) measured ART adherence as an outcome, and (c) employed a randomized controlled trial design. Thirteen studies were included in the meta-analysis. Overall, interventions significantly improved ART adherence compared to control conditions (random-effects d = 0.82, 95% CI [0.18, 1.45], p = 0.01), however, this was largely driven by two studies that had effect sizes greater than 3 standard errors above the mean effect size. Key moderators were location, recruitment method, group-based intervention, and alteration of the healthcare system. Innovative behavioral interventions that focus on young women and adolescents, target the critical periods of pregnancy and postpartum and test the integration of multiple levels of intervention to create lasting effects on ART adherence are needed.

Male Partner Involvement in the Utilization of Hospital Delivery Services by Pregnant Women Living with HIV in Sub Saharan Africa: A Systematic Review and Meta-analysis

Objective The level of male partner involvement in hospital delivery by pregnant women living with HIV in sub Saharan Africa (SSA) is low. We conducted a systematic review and meta-analysis to identify the approaches that are used in improving male partner involvement and their impact on the utilization of hospital delivery services by pregnant women living with HIV in SSA. Methods Ovid Medline, Embase, PsycINFO, Cochrane library, ClinicalTrials.gov, Web of Science and Current Controlled Trials were searched. Only studies carried out in SSA that reported an approach used in involving male partners and the impact on the uptake of hospital delivery services irrespective of the language and date of publication were included. Odds ratios were extracted or calculated from studies and combined in a meta-analysis using the statistical package Stata version 11.0. A forest plot was used to show the impact of various male involvement approaches. A funnel plot was used to report publication bias. Results From an initial 2316 non-duplicate articles, 08 articles were included in the systematic review and meta-analysis. The overall pooled OR was 1.56 (95% CI 1.45-1.68). After stratification, the odds ratios were: 1.51 (95% CI 1.38-1.65), 1.58 (95% CI 1.38-1.80), 3.47 (95% CI 2.16-5.58) for complex community interventions without community health workers (CHWs), complex community interventions with community health workers, and verbal encouragement respectively. The overall I-square was 91.0% but after stratification into the three different approaches, the I-squared within the complex community intervention without CHWs group was 0.0%. Conclusions for Practice Complex community interventions and verbal encouragement increase the utilization of hospital delivery services by pregnant women living with HIV in SSA. The overall heterogeneity was high but very low for studies that used complex community interventions without CHWs. More well conducted studies (including randomized controlled trials) are needed in future to add to the quality of evidence.

Development and Implementation of a Mobile Phone-Based Prevention of Mother-To-Child Transmission of HIV Cascade Analysis Tool: Usability and Feasibility Testing in Kenya and Mozambique

BACKGROUND

Prevention of mother-to-child HIV transmission (PMTCT) care cascade failures drive pediatric HIV infections in sub-Saharan Africa. As nurses' clinical and management role in PMTCT expand, decision-support tools for nurses are needed to facilitate identification of cascade inefficiencies and solutions. The mobile phone-based PMTCT cascade analysis tool (mPCAT) provides health facility staff a quick summary of the number of patients and percentage drop-off at each step of the PMCTC care cascade, as well as how many women-infant pairs would be retained if a step was optimized.

OBJECTIVE

The objective of this study was to understand and improve the mPCAT's core usability factors and assess the health workers' experience with using the mPCAT.

METHODS

Overall, 2 rounds of usability testing were conducted with health workers from 4 clinics and leading experts in maternal and child health in Kenya and Mozambique using videotaped think aloud assessment techniques. Semistructured group interviews gauged the understanding of mPCAT's core usability factors, based on the Nielsen Usability Framework, followed by development of cognitive demand tables describing the needed mPCAT updates. Post adaptation, feasibility was assessed in 3 high volume clinics over 12 weeks. Participants completed a 5-point Likert questionnaire designed to measure ease of use, convenience of integration into work, and future intention to use the mPCAT. Focus group discussions with nurse participants at each facility and in-depth interviews with nurse managers were also conducted to assess the acceptability, use, and recommendations for adaptations of the mPCAT.

RESULTS

Usability testing with software engineers enabled real-time feedback to build a tool following empathic design principles. The revised mPCAT had improved navigation and simplified data entry interface, with only 1 data entry field per page. Improvements to the results page included a data visualization feature and the ability to share results through WhatsApp. Coding was simplified to enable future revisions by nontechnical staff-critical for context-specific adaptations for scale-up. Health care workers and facility managers found the tool easy to use (mean=4.3), used the tool very often (mean=4.1), and definitely intended to continue to use the tool (mean=4.8). Ease of use was the most common theme identified, with emphasis on how the tool readily informed system improvement decision making.

CONCLUSIONS

The mPCAT was well accepted by frontline health workers and facility managers. The collaborative process between software developer and user led to the development of a more user-friendly, context-specific tool that could be easily integrated into routine clinical practice and workflow. The mPCAT gave frontline health workers and facility managers an immediate, direct, and tangible way to use their clinical documentation and routinely reported data for decision making for their own clinical practice and facility-level improvements.

Correlates of antiretroviral coverage for prevention of mother-to-child transmission of HIV in sub-Saharan Africa

Antiretroviral (ARV) drugs are effective in the prevention of mother-to-child transmission of HIV (PMTCT), however many sub-Saharan African countries are yet to achieve universal ARV coverage among pregnant women living with HIV. This study examined factors associated with ARV coverage for PMTCT in 41 sub-Saharan Africa countries. Country-level aggregated data were obtained from the Joint United Nations Programme on HIV/AIDS, World Health Organization, and United Nations Children's Fund. Using Spearman's rho and point-biserial correlation, we conducted bivariate analyses between ARV coverage for PMTCT and the following variables: stigma, antenatal care (ANC) uptake, institutional delivery, community delivery of ARV drugs, number of HIV testing and counselling (HTC) facilities, and density of skilled health workers. We also performed a multivariate median regression with the significant correlates. P < .05 was considered statistically significant for all the tests. The median ARV coverage for PMTCT was 76% (IQR: 55-85%). ARV coverage for PMTCT was significantly associated with HTC facilities (r = 0.46, p = .004), institutional delivery (r = 0.48, p = .002), ANC uptake: at least one visit (r = 0.54, p = .001), and stigma (r=-0.52, p = .003). In the multivariate analysis, only stigma remained statistically significant (β = -0.6, 95% CI = -1.13, -0.07, p = .03). To eliminate perinatal transmission of HIV in sub-Saharan Africa, interventions that will address stigma-related barriers to uptake of PMTCT services are needed. More research on country-specific population-level correlates of ARV coverage for PMTCT is recommended.

Retention of health care workers at health facility, trends in the retention of knowledge and correlates at 3rd year following training of health care workers on the prevention of mother-to-child transmission (PMTCT) of HIV-National Assessment

BACKGROUND

Knowledgeable Health Care Workers (HCWs) are indispensable for the proper management of clients. We investigated retention of HCWs at health facility and retention of knowledge at 18, 24 and 36 months after training and correlates for retention of knowledge at 3rd year.

METHODS

A cross-sectional study was conducted among 1000 HCWs, 710 were trained and 290 untrained working at the PMTCT of HIV services in health facilities of the ten regions of Cameroon. A Multiple Choice Questionnaire (MCQ) on HIV management with focus on PMTCT of HIV was used to assess retention of HCWs at the health facility and retention of knowledge. Summary statistics described mean scores for retention of HCWs and retention of knowledge. One-way Analysis of Variance summarized the differences in retention of knowledge over time after training. Correlates for retention of knowledge were investigated by logistic regression analysis.

RESULTS

The retention of HCWs at health facilities in PMTCT of HIV services was 85%. Trained HCWs had higher mean scores for retention of knowledge than untrained HCWs, p < 0.001. Knowledge attrition was observed from 18, 24 to 36 months following training. Differences in the mean scores for retention of knowledge were observed between state-owned with private and confessionary health facilities but not among trained HCWs at 18, 24 or 36 months. Highest mean scores for retention of knowledge were observed in District Hospitals, Sub-Divisional Hospitals, and Integrated Health Centres. Correlates for retention of knowledge were: gender, type of health facility, location, longevity at PMTCT services, trained others and had means to apply what was trained to do.

CONCLUSION

Retention of trained HCWs at health facilities was high, mean scores for retention of knowledge was average and knowledge attrition was observed over time. This research is critical to understand where interventions may be most effective.

Factors associated with the utilization of antenatal care and prevention of mother-to-child HIV transmission services in Ethiopia: applying a count regression model

BACKGROUND

Prevention of Mother-to-Child HIV Transmission (PMTCT) coverage has been low in Ethiopia and the service has been implemented in a fragmented manner. Solutions to this problem have mainly been sought on the supply-side in the form of improved management and allocation of limited resources. However, this approach largely ignores the demand-side factors associated with low PMTCT coverage in the country. The study assesses the factors associated with the utilization of PMTCT services taking into consideration counts of visits to antenatal care (ANC) services in urban high-HIV prevalence and rural low-HIV prevalence settings in Ethiopia.

METHODS

A multivariate regression model was employed to identify significant factors associated with PMTCT service utilization. Poisson and negative binomial regression models were applied, considering the number of ANC visits as a dependent variable. The explanatory variables were age; educational status; type of occupation; decision-making power in the household; living in proximity to educated people; a neighborhood with good welfare services; location (urban high-HIV prevalence and rural low-HIV prevalence); transportation accessibility; walking distance (in minutes); and household income status. The alpha dispersion test (a) was performed to measure the goodness-of-fit of the model. Significant results were reported at p-values of < 0.05 and < 0.001.

RESULTS

Household income, socio-economic setting (urban high-HIV prevalence and rural low-HIV prevalence) and walking distance (in minutes) had a statistically significant relationship with the number of ANC visits by pregnant women (p < 0.05). A pregnant woman from an urban high-HIV prevalence setting would be expected to make 34% more ANC visits (counts) than her rural low-HIV prevalence counterparts (p < 0.05). Holding other variables constant, a unit increase in household income would increase the expected ANC visits by 0.004%. An increase in walking distance by a unit (a minute) would decrease the number of ANC visits by 0.001(p < 0.001).

CONCLUSION

Long walking distance, low household income and living in a rural setting are the significant factors associated with low PMTCT service utilization. The primary strategies for a holistic policy to improve ANC/PMTCT utilization should thus include improving the geographical accessibility of ANC/PMTCT services, expanding household welfare and paying more attention to remote rural areas.

Perceptions and decision-making with regard to pregnancy among HIV positive women in rural Maputo Province, Mozambique - a qualitative study

Background

In preventing the transfer of HIV to their children, the Ministry of Health in Mozambique recommends all couples follow medical advice prior to a pregnancy. However, little is known about how such women experience pregnancy, nor the values they adhere to when making childbearing decisions. This qualitative study explores perceptions and decision-making processes regarding pregnancy among HIV positive women in rural Maputo Province.

Methods

In-depth interviews and five focus group discussions with fifty-nine women who had recently become mothers were carried out. In addition, six semi-structured interviews were held with maternity and child health nurses. The ethnographic methods employed here were guided by Bourdieu’s practice theory.

Results

The study indicated that women often perceived pregnancy as a test of fertility and identity. It was not only viewed as a rite of passage from childhood to womanhood, but also as a duty for married women to have children. Most women did not follow recommended medical advice prior to gestation. This was primarily due to perceptions that decision-making about pregnancy was regarded as a private issue not requiring consultation with a healthcare provider. Additionally, stigmatisation of women living with HIV, lack of knowledge about the need to consult a healthcare provider prior to pregnancy, and unintended pregnancy due to inadequate use of contraceptive were crucial factors.

Conclusion

Women’s experiences and decisions regarding pregnancy are more influenced by social and cultural norms than medical advice. Therefore, education concerning sexual and reproductive health in relation to HIV/AIDS and childbearing is recommended. In particular, we recommend maternal and child healthcare nurses need to be sensitive to women’s perceptions and the cultural context of maternity when providing information about sexual and reproductive health.

Non-uptake of childhood vaccination among the children of HIV-infected mothers in sub-Saharan Africa: A multilevel analysis

The aim of this study was to develop and test models for non–uptake of three doses of diphtheria-tetanus-pertussis containing vaccines (DTP3) among children of women living with HIV in sub-Saharan Africa. The study used demographic and health survey data from 27 sub-Saharan African countries that have the required HIV and immunization data sets. Multivariable logistic regression models were used to assess the relationship between individual and contextual factors associated with non-uptake of DTP3 among the children. At the individual level, the odds of non-uptake of DTP3 decreased with formal education, increasing age and access to media. The full model shows that the odds of non-uptake of DTP3 is increased among unemployed women, those living in communities with high illiteracy rate and in countries with low adult literacy level. For a child who moved to another country or community with a higher probability of DTP3 non-uptake, the median increase for the odds of DTP3 non-uptake would be 2.24% and 1.22% respectively for country and community. This study shows that individual and contextual factors contributed significantly to non-uptake of DTP3 among the children of women living with HIV. Interventions should be focused on women living with HIV who are young mothers, unemployed women, those without formal education, individuals living in communities with high illiteracy rate and in countries with low adult literacy rate. The use of mass media tools and creation of more employment opportunities for HIV-infected women could improve vaccination coverage among their children.

Immunological failure in HIV-infected adults from 2003 to 2015 in Southwest Ethiopia: a retrospective cohort study

OBJECTIVE

To assess the prevalence, trend and associated factors for immunological failure (IF), and the magnitude of antiretroviral therapy (ART) shift among adults infected with HIV in Southwest Ethiopia.

SETTING

A retrospective cohort study was undertaken using the data from ART clinic at Jimma University Teaching Hospital from 21 June 2003 to 15 March 2015.

PARTICIPANTS

Retrospective analysis of 4900 HIV-infected adult patient records dating from June 2003 to March 2015 was conducted.

PRIMARY OUTCOME MEASURE

The primary outcome was IF defined when cluster for differentiation 4 (CD4) count falls to the baseline (or below) or persistent CD4 levels below 100 cells/mm³ after 6 months of ART treatment. The analyses included descriptive and inferential statistics.

RESULTS

546 (19.5%) adults had developed clinical failure (CF), 775 (19.7%) adults had developed IF and 1231 (25.1%) had developed either CF or IF or both. The prevalence of IF was consistently high throughout the decade. Age 25 to ≤50 years adjusted OR (AOR 1.5, 9% CI 1.2 to 2.4), being female (AOR 1.8, 95% CI 1.3 to 1.9), late presenter for HIV care (AOR 2.2, 95% CI 1.6 to 2.7) and having baseline CD4 count below 200 cells/mm³ (AOR 5.5, 95% CI 4.1 to 7.4), and having no history of HIV testing before diagnosis (AOR 0.7, 95% CI 0.5 to 0.9) were the predictors for IF. Only 29 (0.9%) adults infected with HIV were shifted to second-line ART regimen.

CONCLUSIONS

The magnitude of CF or IF or both was found significant and consistently high throughout the calendar year although ART shift was found minimal. HIV-infected adult patients with IF were early age adults, females, late presenters for HIV care, and those who had low baseline CD4 counts and history of HIV testing before diagnosis.

A systematic review and meta-analysis of vertical transmission route of HIV in Ethiopia

BACKGROUND

The burden of mother-to-child transmission rate of HIV is high and risk factors are common in Ethiopia. This systematic review and meta-analysis intended to provide the pooled estimation of mother-to-child transmission rate and its risk factors in Ethiopia.

METHODS

We searched PubMed, Google Scholar, EMBASE and Web of Science electronic databases for all available references. We included observational studies including case-control, cohort, and cross-sectional studies. The search was further limited to studies conducted in Ethiopia and publish in English. Heterogeneity was checked using the I² statistic. Egger's test and the funnel plot were used to assess publication bias. A meta-analysis using a weighted inverse variance random-effects model was performed.

RESULTS

A total of 18 studies with 6253 individuals were included in this systematic review and meta-analysis. Of these, 14 studies with 4624 individuals were used to estimate the prevalence. The estimated pooled prevalence of mother-to-child transmission of HIV was 11.4% (95% CI = 9.1-13.7). The pooled adjusted odds ratio (AOR) of mother-to-child transmission of HIV for the infants from rural area was 3.8 (95% CI = 1.4 to 6.3), infants delivered at home was 3.2 (95% CI = 1.2 to 5.2), infant didn't take antiretroviral prophylaxis was 5.8 (95% CI = 1.5 to 10.3), mother didn't take antiretroviral prophylaxis was 6.1 (95% CI = 2.5 to 9.6), mothers didn't receive PMTCT intervention was 5.1 (95% CI = 1.6, 8.6), and on mixed feeding was 4.3 (95% CI = 1.8 to 6.7).

CONCLUSIONS

This systematic review and meta-analysis showed that mother-to-child transmission rate of HIV was high in Ethiopia. Being from the rural residence, home delivery, not taking antiretroviral prophylaxis, the absence of PMTCT intervention, and mixed infant feeding practices increased the risk of HIV transmission.

TRIAL REGISTRATION

It is registered in the Prospero database: (PROSPERO 2017: CRD42017078232 ).

Effect of maternal HIV status on vaccination coverage among sub-Saharan African children: A socio-ecological analysis

We investigated the relationship between maternal HIV status and uptake of the full series of three doses of diphtheria-tetanus-pertussis containing vaccines (DTP3) in sub-Saharan African children. We used data obtained from demographic and health surveys conducted in sub-Saharan Africa. We conducted meta-analysis and calculated pooled odds ratios (OR) for the association between maternal HIV status and DTP3 vaccination status for each country. A total of 4,187 out of 5,537 children of women living with HIV received DTP3 (75.6%), compared to 71,290 of 113,513 (62.8%) children of HIV negative women. National DTP3 coverage among children of HIV-positive women varied between 24% and 96% while among children of HIV negative women it was between 26% and 92%. Overall pooled result showed no significant difference in DTP3 coverage between the two groups (OR = 1.05; 95% confidence interval 0.91 – 1.22), with statistically significant heterogeneity (Chi² = 91.63, P = 0.000, I² = 71.6%). There was no significant association between DTP3 coverage and maternal HIV status in sub-Saharan Africa. However, DTP3 coverage for both HIV-exposed and non-exposed children were below the required target. Meta-regression revealed no significant association between DTP3 coverage and country characteristics (e.g. HIV prevalence among women, antiretroviral therapy coverage, gross domestic product per capita, human development index, adult literacy rate and sub-region). Improved prevention of mother-to-child transmission services might have contributed to some extent to the higher DTP3 vaccination coverage among the HIV-exposed children. There is also need to address barriers impeding uptake of vaccination among HIV-exposed and non-exposed children.

Evidence of accessibility and utility of point-of-care diagnostics as an integral part of prevention of mother-to-child transmission services: systematic scoping review protocol

INTRODUCTION

Point-of-care (POC) testing has been shown to help improve healthcare access in resource-limited settings. However, there is paucity of evidence on accessibility of POC testing for prevention of mother-to-child transmission (PMTCT) in resource-limited settings. We propose to conduct a systematic scoping review to map the evidence on POC testing services for PMTCT.

METHODS AND ANALYSIS

A scoping review framework, proposed by Arksey and O'Malley, will guide the study. A comprehensive literature search will be performed in the following electronic databases: PubMed, Science Direct, Cochrane Central, Google Scholar and databases within EBSCOhost (Medline and CINAHL). The primary research articles published in peer-reviewed journals and grey articles addressing our question will be included. One reviewer will conduct title screening and the results will be exported to endnote library. Two independent reviewers will perform abstract, then full article screening in parallel. The same process shall be employed to extract data from eligible studies. Data analysis will involve a narrative summary of included studies and thematic content analysis aided by NVIVO software V.11. The mixed methods assessment tool will be used to assess the quality of studies that will be included.

ETHICS AND DISSEMINATION

Ethical approval is not applicable to this study. The study findings will be disseminated through publication in a peer-reviewed journal and presentations at conferences related to syphilis, HIV, PMTCT, bacterial infections and POC diagnostics.

TRIAL REGISTRATION NUMBER

CRD42017056267.

Using the PMTCT Cascade to Accelerate Achievement of the Global Plan Goals

BACKGROUND

Development of country plans for prevention of mother-to-child HIV transmission (PMTCT), including expansion of comprehensive, integrated services, was key to Global Plan achievements.

APPROACHES

Use of the PMTCT cascade, an evolving series of sequential steps needed to maximize the health of women and HIV-free survival of infants, was critical for development and implementation of PMTCT plans. Regular review of cascade data at national/subnational levels was a tool for evidence-based decision making, identifying areas of greatest need at each level, and targeting program interventions to address specific gaps. Resulting improvements in PMTCT service delivery contributed to success. Populating the cascade highlighted limitations in data availability and quality that focused attention on improving national health information systems.

LIMITATIONS

Use of aggregate, cross-sectional data in the PMTCT cascade presents challenges in settings with high mobility and weak systems to track women and children across services. Poor postnatal follow-up and losses at each step of the cascade have limited use of the cascade approach to measure maternal and child health outcomes beyond the early postnatal period.

LESSONS LEARNED

A cascade approach was an effective means for countries to measure progress, identify suboptimal performance areas, and be held accountable for progress toward achievement of Global Plan goals. Using the cascade requires investment of time and effort to identify the type, source, and quality of data needed as programs evolve. Ongoing review of cascade data, with interventions to address discontinuities in the continuum of care, can translate across health areas to improve health care quality and outcomes.

Randomized trial of stopping or continuing ART among postpartum women with pre-ART CD4 ≥ 400 cells/mm3

Background

Health benefits of postpartum antiretroviral therapy (ART) for human immunodeficiency virus (HIV) positive women with high CD4+ T-counts have not been assessed in randomized trials.

Methods

Asymptomatic, HIV-positive, non-breastfeeding women with pre-ART CD4+ T-cell counts ≥ 400 cells/mm³ started on ART during pregnancy were randomized up to 42 days after delivery to continue or discontinue ART. Lopinavir/ritonavir plus tenofovir/emtricitabine was the preferred ART regimen. The sample size was selected to provide 88% power to detect a 50% reduction from an annualized primary event rate of 2.07%. A post-hoc analysis evaluated HIV/AIDS-related and World Health Organization (WHO) Stage 2 and 3 events. All analyses were intent to treat.

Results

1652 women from 52 sites in Argentina, Botswana, Brazil, China, Haiti, Peru, Thailand and the US were enrolled (1/2010-11/2014). Median age was 28 years and major racial categories were Black African (28%), Asian (25%) White (15%). Median entry CD4 count was 696 cells/mm³ (IQR 575–869), median ART exposure prior to delivery was 19 weeks (IQR 13–24) and 94% had entry HIV-1 RNA < 1000 copies/ml. After a median follow-up of 2.3 years, the primary composite endpoint rate was significantly lower than expected, and not significantly different between arms (continue arm 0.21 /100 person years(py); discontinue 0.31/100 py, Hazard ratio (HR) 0.68, 95% CI: 0.19, 2.40). WHO Stage 2 and 3 events were significantly reduced with continued ART (2.08/100 py vs. 4.36/100 py in the discontinue arm; HR 0.48, 95%CI: 0.33, 0.70). Toxicity rates did not differ significantly between arms. Among women randomized to continue ART, 189/827 (23%) had virologic failure; of the 155 with resistance testing, 103 (66%) failed without resistance to their current regimen, suggesting non-adherence.

Conclusions

Overall, serious clinical events were rare among young HIV-positive post-partum women with high CD4 cell counts. Continued ART was safe and was associated with a halving of the rate of WHO 2/3 conditions. Virologic failure rates were high, underscoring the urgent need to improve adherence in this population.

Trial registration

ClinicalTrials.gov NCT00955968

Community-Based Interventions to Improve and Sustain Antiretroviral Therapy Adherence, Retention in HIV Care and Clinical Outcomes in Low- and Middle-Income Countries for Achieving the UNAIDS 90-90-90 Targets

Little is known about the effect of community versus health facility-based interventions to improve and sustain antiretroviral therapy (ART) adherence, virologic suppression, and retention in care among HIV-infected individuals in low- and middle-income countries (LMICs). We systematically searched four electronic databases for all available randomized controlled trials (RCTs) and comparative cohort studies in LMICs comparing community versus health facility-based interventions. Relative risks (RRs) for pre-defined adherence, treatment engagement (linkage and retention in care), and relevant clinical outcomes were pooled using random effect models. Eleven cohort studies and eleven RCTs (N = 97,657) were included. Meta-analysis of the included RCTs comparing community- versus health facility-based interventions found comparable outcomes in terms of ART adherence (RR = 1.02, 95 % CI 0.99 to 1.04), virologic suppression (RR = 1.00, 95 % CI 0.98 to 1.03), and all-cause mortality (RR = 0.93, 95 % CI 0.73 to 1.18). The result of pooled analysis from the RCTs (RR = 1.03, 95 % CI 1.01 to 1.06) and cohort studies (RR = 1.09, 95 % CI 1.03 to 1.15) found that participants assigned to community-based interventions had statistically significantly higher rates of treatment engagement. Two studies found community-based ART delivery model either cost-saving or cost-effective. Community- versus facility-based models of ART delivery resulted in at least comparable outcomes for clinically stable HIV-infected patients on treatment in LMICs and are likely to be cost-effective.

Clinical, Virologic, Immunologic Outcomes and Emerging HIV Drug Resistance Patterns in Children and Adolescents in Public ART Care in Zimbabwe

OBJECTIVE

To determine immunologic, virologic outcomes and drug resistance among children and adolescents receiving care during routine programmatic implementation in a low-income country.

METHODS

A cross-sectional evaluation with collection of clinical and laboratory data for children (0-<10 years) and adolescents (10-19 years) attending a public ART program in Harare providing care for pediatric patients since 2004, was conducted. Longitudinal data for each participant was obtained from the clinic based medical record.

RESULTS

Data from 599 children and adolescents was evaluated. The participants presented to care with low CD4 cell count and CD4%, median baseline CD4% was lower in adolescents compared with children (11.0% vs. 15.0%, p<0.0001). The median age at ART initiation was 8.0 years (IQR 3.0, 12.0); median time on ART was 2.9 years (IQR 1.7, 4.5). On ART, median CD4% improved for all age groups but remained below 25%. Older age (≥ 5 years) at ART initiation was associated with severe stunting (HAZ <-2: 53.3% vs. 28.4%, p<0.0001). Virologic failure rate was 30.6% and associated with age at ART initiation. In children, nevirapine based ART regimen was associated with a 3-fold increased risk of failure (AOR: 3.5; 95% CI: 1.3, 9.1, p = 0.0180). Children (<10 y) on ART for ≥4 years had higher failure rates than those on ART for <4 years (39.6% vs. 23.9%, p = 0.0239). In those initiating ART as adolescents, each additional year in age above 10 years at the time of ART initiation (AOR 0.4 95%CI: 0.1, 0.9, p = 0.0324), and each additional year on ART (AOR 0.4, 95%CI 0.2, 0.9, p = 0.0379) were associated with decreased risk of virologic failure. Drug resistance was evident in 67.6% of sequenced virus isolates.

CONCLUSIONS

During routine programmatic implementation of HIV care for children and adolescents, delayed age at ART initiation has long-term implications on immunologic recovery, growth and virologic outcomes.