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Smith A, Leach G, Rossouw L. The timing of antenatal care access for adolescent pregnancies in Cape Town, South Africa. Afr J Prim Health Care Fam Med 2024; 16:e1-e10. [PMID: 38426770 PMCID: PMC10913161 DOI: 10.4102/phcfm.v16i1.4192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 11/02/2023] [Accepted: 11/12/2023] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND Late antenatal care (ANC)-seeking among pregnant adolescents threatens their health outcomes, and the health outcomes of their new-borns. South Africa has experienced a rapid increase in adolescent pregnancies during the COVID-19 pandemic, adding to the existing concerns around adolescent pregnancy care-seeking behaviour. AIM The main aim of this study was to investigate the causes and covariates of late ANC access among adolescents in the Cape Town Metropole, South Africa. SETTING Three public healthcare facilities in the Cape Town Metropole, 2018-2019. METHODS A retrospective, cross-sectional study on ANC seeking behaviour was conducted, surveying 202 adolescents. Late attendance was defined as attending ≥ 3 months. For this study, adolescents were defined as women aged 16-18 years. The sample was restricted to adolescents who used public healthcare facilities or who did not attend at all. Data were analysed using univariate, bivariate and multivariate methods. RESULTS A total of 50.8% (n = 99/195) of the pregnant adolescents in the sample had their first ANC visit 3 months. 14.9% (n = 29/195) did not attend at all. Major contributors to delayed care-seeking include poor pregnancy identification (n = 45/99, 45.5%), and a lack of information about ANC. Age, education, and alcohol consumption were significant predictors of delayed care-seeking. CONCLUSION Delayed ANC attendance contributes to negative long-term health outcomes for pregnant adolescents and their new-borns. Improving access to pregnancy tests in the public sector could benefit adolescents with earlier pregnancy identification. Adolescents need to be made aware of their care seeking options.Contribution: There is evidence of long-term health impacts of late ANC attendance by pregnant adolescents, but there is an absence of evidence on the timing and barriers of late care-seeking behaviour. In this study, late ANC attendance among adolescents was associated with late pregnancy identification and poor knowledge of care options.
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Affiliation(s)
- Anja Smith
- Department of Economics, Faculty of Economic Management and Business Sciences, Stellenbosch University, Stellenbosch.
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Brittain K, Gomba Y, Noholoza S, Pellowski J, Mellins CA, Bekker LG, Kagee A, Remien RH, Abrams EJ, Myer L. HIV-related stigma, disclosure and social support: experiences among young pregnant and postpartum women living with HIV in South Africa. AIDS Care 2023; 35:399-405. [PMID: 36102063 PMCID: PMC10011013 DOI: 10.1080/09540121.2022.2121957] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 09/01/2022] [Indexed: 10/14/2022]
Abstract
ABSTRACTYoung pregnant and postpartum women living with HIV (WLHIV) are at high risk of poor antiretroviral therapy (ART) outcomes, which may be driven partly by HIV-related stigma. We conducted in-depth interviews with 20 pregnant and postpartum WLHIV aged 19-24 years to understand how different forms of HIV-related stigma manifest in their lives, as well as their experiences of HIV-status disclosure and social support. Participants described profound levels of perceived stigma in their community, including gossip from other young women and judgement from older adults. Consequently, participants disclosed to a limited number of people to avoid being stigmatised, and disclosure to peers was especially uncommon. However, disclosure in certain situations was described as leading to emotional support and support for ART adherence, and disclosure to older WLHIV resulted in participants having a role model. Finally, participants expressed varied ways in which they accept, speak about, and live with their HIV diagnosis. These data provide a rich understanding of the experiences of HIV-related stigma in this population and point to the need for psychosocial interventions focussed on acceptance and coping with an HIV-positive diagnosis despite profound levels of perceived stigma, as well as navigating decisions around the targets and timing of disclosure.Trial registration: ClinicalTrials.gov identifier: NCT04036851.
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Affiliation(s)
- Kirsty Brittain
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Yolanda Gomba
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Sandisiwe Noholoza
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Jennifer Pellowski
- Department of Behavioral & Social Sciences, Brown University School of Public Health, Providence, RI, USA
- International Health Institute, Brown University School of Public Health, Providence, RI, USA
| | - Claude A. Mellins
- HIV Center for Clinical & Behavioral Studies, New York State Psychiatric Institute, Columbia University, New York, NY, USA
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, Institute of Infectious Diseases & Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Ashraf Kagee
- Department of Psychology, Stellenbosch University, Stellenbosch, South Africa
| | - Robert H. Remien
- HIV Center for Clinical & Behavioral Studies, New York State Psychiatric Institute, Columbia University, New York, NY, USA
| | - Elaine J. Abrams
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, USA
- Vagelos College of Physicians & Surgeons, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Landon Myer
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
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Kesande C, Bapolisi A, Kaggwa MM, Nakimuli-Mpungu E, Maling S, Ashaba S. Prevalence and factors associated with psychological distress among pregnant and non-pregnant youth living with HIV in rural Uganda: a comparative study. PSYCHOL HEALTH MED 2023; 28:344-358. [PMID: 35260003 PMCID: PMC9458768 DOI: 10.1080/13548506.2022.2050270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 03/01/2022] [Indexed: 02/08/2023]
Abstract
Youth living with HIV (YLHIV) are prone to psychological distress, which may have detrimental effects on health outcomes. Pregnant youth have poor access to HIV care increasing the risk of vertical transmission of HIV to their infants. Both HIV and pregnancy are independently associated with poor mental health among adolescents. The factors that predispose women to poor mental health may also increase their risk of contracting HIV. Despite their desire to have children YLHIV are at a high risk of psychological distress. However, factors associated with psychological distress among YLHIV in rural Uganda are not well explored. Therefore, the purpose of this study was to determine the prevalence of, and factors associated with psychological distress among pregnant and non-pregnant YLHIV in south western Uganda. We enrolled 224 YLHIV aged 15-24 years both pregnant and nonpregnant (ratio 1:1) between December 2018 and March 2019. We obtained information on psychological distress and factors hypothesized to affect mental health outcomes among people living with HIV including internalized HIV stigma, intimate partner violence, self-esteem and social support. Bivariate and multivariable logistic regression analysis were used to estimate factors independently associated with psychological distress. The prevalence of psychological distress was 48.2%% among pregnant YLHIV and 32.14% among non-pregnant YLHIV. Factors significantly associated with psychological distress among pregnant YLHIV were HIV stigma (AOR=4.61; 95% CI 1.63-13.84; P=0.004), physical abuse (AOR=4.97; 95% CI 1.41- 17.56; P= 0.013), and separation from partner (AOR =0.03; 95% CI 0.001-0.580; P=0.020).
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Affiliation(s)
- Claire Kesande
- Mbarara University of science and Technology, Mbarara, Uganda
| | - Achille Bapolisi
- Catholic University of Bukavu, Bukavu, Democratic Republic of Congo
| | | | | | - Samuel Maling
- Mbarara University of science and Technology, Mbarara, Uganda
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Laurenzi C, Ronan A, Phillips L, Nalugo S, Mupakile E, Operario D, Toska E. Enhancing a peer supporter intervention for young mothers living with HIV in Malawi, Tanzania, Uganda, and Zambia: Adaptation and co-development of a psychosocial component. Glob Public Health 2023; 18:2081711. [PMID: 35634944 PMCID: PMC9705607 DOI: 10.1080/17441692.2022.2081711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 05/03/2022] [Indexed: 11/04/2022]
Abstract
ABSTRACTYoung mothers living with HIV (YMHIV) experience heightened risks to their mental health, as their transition to adulthood is marked by social stigma, health and socioeconomic challenges. Targeted psychosocial interventions may improve the mental health of YMHIV; however, no evidence-based interventions have been developed for this group. Peer support models, more common for youth living with HIV, show promise as a design to reach YMHIV in a non-stigmatising way. This manuscript describes the process of adapting and co-developing an evidence-based psychosocial component (Boost) of a larger intervention called Ask-Boost-Connect-Discuss. Peer supporters in Malawi, Tanzania, Uganda, and Zambia used ABCD to guide group sessions with YMHIV. The research team partnered with an implementing partner, Paediatric-Adolescent Treatment Africa, to undertake this work in three phases: 1) formative research, 2) content adaptation and development, and 3) consultation, refinement, and modification. YMHIV (n = 4), peer supporters (n = 21), and technical advisors (n = 4) were engaged as co-developers, shaping the resulting Boost intervention component at each phase. Peer support models may effectively reach young mothers, and consultation, co-creation, and integration with existing programming can offer rich insights to inform these models. We discuss the implications and promise of this approach.
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Affiliation(s)
- Christina Laurenzi
- Institute for Life Course Health Research, Department of Global Health, Stellenbosch University, Tygerberg, South Africa
| | - Agnes Ronan
- Paediatric Adolescent Treatment Africa, Cape Town, South Africa
| | - Lynn Phillips
- Paediatric Adolescent Treatment Africa, Cape Town, South Africa
| | - Sharifah Nalugo
- Paediatric Adolescent Treatment Africa, Cape Town, South Africa
| | - Eugene Mupakile
- Paediatric Adolescent Treatment Africa, Cape Town, South Africa
| | - Don Operario
- Department of Behavior and Social Sciences, School of Public Health, Brown University, Providence, RI, USA
| | - Elona Toska
- Centre for Social Science Research, University of Cape Town, Cape Town, South Africa
- Department of Sociology, University of Cape Town, Cape Town, South Africa
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK
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5
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Toska E, Saal W, Chen Charles J, Wittesaele C, Langwenya N, Jochim J, Steventon Roberts KJ, Anquandah J, Banougnin BH, Laurenzi C, Sherr L, Cluver L. Achieving the health and well-being Sustainable Development Goals among adolescent mothers and their children in South Africa: Cross-sectional analyses of a community-based mixed HIV-status cohort. PLoS One 2022; 17:e0278163. [PMID: 36480550 PMCID: PMC9731463 DOI: 10.1371/journal.pone.0278163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 11/11/2022] [Indexed: 12/13/2022] Open
Abstract
The Sustainable Development Goals (SDGs) are a visionary and multi-sectoral agenda for human development. With less than a decade left to reach these targets, it is important to identify those at greatest risk of not meeting these ambitious targets. Adolescent mothers and their children are a highly vulnerable group. We mapped 35 SGD-related targets among 1,046 adolescent mothers and their oldest child (n = 1046). Questionnaires using validated scales were completed by 10- to 24-year-old adolescent girls and young women who had their first child before age 20 in an HIV-endemic district in the Eastern Cape province of South Africa. Maternal outcomes included 26 SDG-aligned indicators, while child-related outcomes included 9 indicators. Data was collected by trained researchers, following informed voluntary consent by the adolescent mothers and their caregivers. Frequencies and chi-square tests were conducted to compare progress along SDG-aligned indicators among adolescent mothers by HIV status. Overall, adolescent mothers reported low attainment of SDG-aligned indicators. While four in five adolescent mothers lived in poor households, nearly 93% accessed at least one social cash transfer and 80% accessed a child support grant for their children. Food security rates among adolescent mothers (71%) were lower than among their children (91%). Only two-thirds of adolescent mothers returned to school after childbirth, and only one-fifth were either studying or employed. Over half of adolescent mothers had experienced at least one type of violence (domestic, sexual or community). HIV-positive status was associated with higher rates of hunger and substance use, poorer school attendance, and higher rates of exposure to violence. Understanding progress and gaps in meeting the SDGs among highly vulnerable groups is critical, particularly for adolescent mothers and their children. These complex vulnerabilities suggest that programming for adolescent mothers must address their unique needs.
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Affiliation(s)
- Elona Toska
- Centre for Social Science Research, University of Cape Town, Cape Town, South Africa
- Department of Sociology, University of Cape Town, Cape Town, South Africa
| | - Wylene Saal
- Centre for Social Science Research, University of Cape Town, Cape Town, South Africa
- Department of Sociology, University of Cape Town, Cape Town, South Africa
| | - Jenny Chen Charles
- Department of Social Policy and Intervention, University of Oxford, Oxford, United Kingdom
| | - Camille Wittesaele
- Department of Social Policy and Intervention, University of Oxford, Oxford, United Kingdom
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Nontokozo Langwenya
- Department of Social Policy and Intervention, University of Oxford, Oxford, United Kingdom
| | - Janina Jochim
- Department of Social Policy and Intervention, University of Oxford, Oxford, United Kingdom
| | - Kathryn J. Steventon Roberts
- Department of Social Policy and Intervention, University of Oxford, Oxford, United Kingdom
- Institute for Global Health, University College London, London, United Kingdom
| | - Jason Anquandah
- Department of Statistics, University of Leeds, Leeds, United Kingdom
| | - Boladé Hamed Banougnin
- Centre for Social Science Research, University of Cape Town, Cape Town, South Africa
- Department of Sociology, University of Cape Town, Cape Town, South Africa
| | - Christina Laurenzi
- Institute for Life Course Health Research, Stellenbosch University, Stellenbosch, South Africa
| | - Lorraine Sherr
- Institute for Global Health, University College London, London, United Kingdom
| | - Lucie Cluver
- Department of Social Policy and Intervention, University of Oxford, Oxford, United Kingdom
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
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Groves AK, Gebrekristos LT, Smith PD, Stoebenau K, Stoner MC, Ameyan W, Ezeh AC. Adolescent Mothers in Eastern and Southern Africa: An Overlooked and Uniquely Vulnerable Subpopulation in the Fight Against HIV. J Adolesc Health 2022; 70:895-901. [PMID: 35172930 PMCID: PMC9113251 DOI: 10.1016/j.jadohealth.2021.12.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 12/01/2021] [Accepted: 12/03/2021] [Indexed: 12/02/2022]
Abstract
PURPOSE Adolescent girls (10-19 years) in Eastern and Southern Africa face a high risk of pregnancy and HIV infection. However, few studies have examined whether the profound developmental, social, and economic changes that accompany adolescent motherhood contribute to HIV risk. This study examines the intersection between adolescent motherhood and HIV infection across 10 Eastern and Southern African countries, where over half of all HIV infections occur among adolescent girls. METHODS To evaluate whether adolescent motherhood is associated with HIV infection, we used Demographic and Health Survey data on girls (15-19 years) with HIV test results (N = 19,932) from Eswatini, Kenya, Lesotho, Malawi, Mozambique, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe. We examined unweighted bivariate and multivariable associations between adolescent motherhood and HIV using mixed effects logistic regression models that included a country-level random intercept. We examined heterogeneity in the association by testing country-level random slopes using a likelihood ratio test and used intraclass correlation to measure the proportion of total variance explained at the country level. RESULTS Nearly one fifth of adolescent girls were mothers (range: 9.80%-38.90%), and the HIV prevalence among all adolescent girls was 3.3% (range: 1.03%-10.07%). Relative to nonmothers, adolescent mothers were, on average, older, poorer, and more likely to be married, rural dwellers, and household heads. Adolescent motherhood was positively associated with HIV infection in bivariate and multivariable analyses (odds ratio: 1.87; 95% confidence interval: 1.57-2.23; adjusted odds ratio: 1.53; 95% CI: 1.24-1.89). DISCUSSION Among adolescents with HIV test results, we observed a robust association between adolescent motherhood and HIV infection across 10 high-burden countries.
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Affiliation(s)
- Allison K Groves
- Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania.
| | | | - Patrick D Smith
- Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania
| | - Kirsten Stoebenau
- Department of Behavioral and Community Health, School of Public Health, University of Maryland, College Park, Maryland
| | - Marie C Stoner
- Women's Global Health Imperative, RTI International, Berkeley, California
| | - Wole Ameyan
- Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, World Health Organization, Geneva, Switzerland
| | - Alex C Ezeh
- Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania
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Roberts KJ, Smith C, Cluver L, Toska E, Zhou S, Boyes M, Sherr L. Adolescent Motherhood and HIV in South Africa: Examining Prevalence of Common Mental Disorder. AIDS Behav 2022; 26:1197-1210. [PMID: 34570313 PMCID: PMC8940800 DOI: 10.1007/s10461-021-03474-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2021] [Indexed: 01/25/2023]
Abstract
The mental health of adolescents (10–19 years) remains an overlooked global health issue, particularly within the context of syndemic conditions such as HIV and pregnancy. Rates of pregnancy and HIV among adolescents within South Africa are some of the highest in the world. Experiencing pregnancy and living with HIV during adolescence have both been found to be associated with poor mental health within separate explorations. Yet, examinations of mental health among adolescents living with HIV who have experienced pregnancy/parenthood remain absent from the literature. As such, there exists no evidence-based policy or programming relating to mental health for this group. These analyses aim to identify the prevalence of probable common mental disorder among adolescent mothers and, among adolescents experiencing the syndemic of motherhood and HIV. Analyses utilise data from interviews undertaken with 723 female adolescents drawn from a prospective longitudinal cohort study of adolescents living with HIV (n = 1059) and a comparison group of adolescents without HIV (n = 467) undertaken within the Eastern Cape Province, South Africa. Detailed study questionnaires included validated and study specific measures relating to HIV, adolescent motherhood, and mental health. Four self-reported measures of mental health (depressive, anxiety, posttraumatic stress, and suicidality symptomology) were used to explore the concept of likely common mental disorder and mental health comorbidities (experiencing two or more common mental disorders concurrently). Chi-square tests (Fisher’s exact test, where appropriate) and Kruskal Wallis tests were used to assess differences in sample characteristics (inclusive of mental health status) according to HIV status and motherhood status. Logistic regression models were used to explore the cross-sectional associations between combined motherhood and HIV status and, likely common mental disorder/mental health comorbidities. 70.5% of participants were living with HIV and 15.2% were mothers. 8.4% were mothers living with HIV. A tenth (10.9%) of the sample were classified as reporting a probable common mental disorder and 2.8% as experiencing likely mental health comorbidities. Three core findings emerge: (1) poor mental health was elevated among adolescent mothers compared to never pregnant adolescents (measures of likely common mental disorder, mental health comorbidities, depressive, anxiety and suicidality symptoms), (2) prevalence of probable common mental disorder was highest among mothers living with HIV (23.0%) compared to other groups (Range:8.5–12.8%; Χ2 = 12.54, p = 0.006) and, (3) prevalence of probable mental health comorbidities was higher among mothers, regardless of HIV status (HIV & motherhood = 8.2%, No HIV & motherhood = 8.2%, Χ2 = 14.5, p = 0.002). Results identify higher mental health burden among adolescent mothers compared to never-pregnant adolescents, an increased prevalence of mental health burden among adolescent mothers living with HIV compared to other groups, and an elevated prevalence of mental health comorbidities among adolescent mothers irrespective of HIV status. These findings address a critical evidence gap, highlighting the commonality of mental health burden within the context of adolescent motherhood and HIV within South Africa as well as the urgent need for support and further research to ensure effective evidence-based programming is made available for this group. Existing antenatal, postnatal, and HIV care may provide an opportunity for mental health screening, monitoring, and referral.
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Affiliation(s)
| | - Colette Smith
- Institute for Global Health, University College London, London, UK
| | - Lucie Cluver
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Elona Toska
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK
- Centre for Social Science Research, University of Cape Town, Cape Town, South Africa
- Department of Sociology, University of Cape Town, Cape Town, South Africa
| | - Siyanai Zhou
- Centre for Social Science Research, University of Cape Town, Cape Town, South Africa
| | - Mark Boyes
- Curtin enAble Institute, Faculty of Health Sciences, Curtin University, Bentley, Perth, Australia
| | - Lorraine Sherr
- Institute for Global Health, University College London, London, UK
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Teasdale CA, Odondi J, Kidiga C, Choy M, Fayorsey R, Ngeno B, Ochanda B, Langat A, Ngugi C, Callahan T, Modi S, Hawken M, Odera D, Abrams EJ. Group antenatal care for improving retention of adolescent and young pregnant women living with HIV in Kenya. BMC Pregnancy Childbirth 2022; 22:208. [PMID: 35291978 PMCID: PMC8925235 DOI: 10.1186/s12884-022-04527-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 02/28/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pregnant and breastfeeding adolescents and young women living with HIV (AYWLH) have lower retention in prevention of mother-to-child transmission (PMTCT) services compared to older women. METHODS We evaluated a differentiated service model for pregnant and postnatal AYWLH at seven health facilities in western Kenya aimed at improving retention in antiretroviral treatment (ART) services. All pregnant AYWLH < 25 years presenting for antenatal care (ANC) were invited to participate in group ANC visits including self-care and peer-led support sessions conducted by health facility nurses per national guidelines. ART register data were used to assess loss to follow-up (LTFU) among newly-enrolled pregnant adolescent (< 20 years) and young women (20-24 years) living with HIV starting ART in the pre-period (January-December 2016) and post-period (during implementation; December 2017-January 2019). Poisson regression models compared LTFU incidence rate ratios (IRR) in the first six months after PMTCT enrollment and risk ratios compared uptake of six week testing for HIV-exposed infants (HEI) between the pre- and post-periods. RESULTS In the pre-period, 223 (63.2%) of 353 pregnant AYWLH newly enrolled in ANC had ART data, while 320 (71.1%) of 450 in the post-period had ART data (p = 0.02). A higher proportion of women in the post-period (62.8%) had known HIV-positive status at first ANC visit compared to 49.3% in the pre-period (p < 0.001). Among pregnant AYWLH < 20 years, the incidence rate of LTFU in the first six months after enrollment in ANC services declined from 2.36 per 100 person months (95%CI 1.06-5.25) in the pre-period to 1.41 per 100 person months (95%CI 0.53-3.77) in the post-period. In both univariable and multivariable analysis, AYWLH < 20 years in the post-period were almost 40% less likely to be LTFU compared to the pre-period, although this finding did not meet the threshold for statistical significance (adjusted incidence rate ratio 0.62, 95%CI 0.38-1.01, p = 0.057). Testing for HEI was 10% higher overall in the post-period (adjusted risk ratio 1.10, 95%CI 1.01-1.21, p = 0.04). CONCLUSIONS Interventions are urgently needed to improve outcomes among pregnant and postnatal AYWLH. We observed a trend towards increased retention among pregnant adolescents during our intervention and a statistically significant increase in uptake of six week HEI testing.
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Affiliation(s)
- Chloe A Teasdale
- Department of Epidemiology & Biostatistics, City University of New York (CUNY) Graduate School of Public Health & Health Policy, 55 W125th Street, Room 543, New York, NY, 10025, USA. .,ICAP-Columbia University, Mailman School of Public Health, New York, NY, USA. .,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.
| | - Judith Odondi
- ICAP-Columbia University, Mailman School of Public Health, New York, NY, USA
| | - Catherine Kidiga
- ICAP-Columbia University, Mailman School of Public Health, New York, NY, USA
| | - Michelle Choy
- ICAP-Columbia University, Mailman School of Public Health, New York, NY, USA
| | - Ruby Fayorsey
- ICAP-Columbia University, Mailman School of Public Health, New York, NY, USA
| | - Bernadette Ngeno
- Division of Global HIV and TB, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Agnes Langat
- US Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Catherine Ngugi
- National AIDS and STI Control Programme (NASCOP), Nairobi, Kenya
| | - Tegan Callahan
- Division of Global HIV and TB, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Surbhi Modi
- Division of Global HIV and TB, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Mark Hawken
- ICAP-Columbia University, Mailman School of Public Health, New York, NY, USA
| | - Doris Odera
- ICAP-Columbia University, Mailman School of Public Health, New York, NY, USA
| | - Elaine J Abrams
- ICAP-Columbia University, Mailman School of Public Health, New York, NY, USA.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.,Department of Pediatrics, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY, USA
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9
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Nyakato P, Schomaker M, Fatti G, Tanser F, Euvrard J, Sipambo N, Fox MP, Haas AD, Yiannoutsos CT, Davies MA, Cornell M. Virologic non-suppression and early loss to follow up among pregnant and non-pregnant adolescents aged 15-19 years initiating antiretroviral therapy in South Africa: a retrospective cohort study. J Int AIDS Soc 2022; 25:e25870. [PMID: 35032096 PMCID: PMC8760609 DOI: 10.1002/jia2.25870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 12/20/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction Older adolescents aged 15–19 years continue to have high rates of loss to follow up (LTFU), and high rates of virologic non‐suppression (VNS) compared to younger adolescents and adults. Adolescent females are at risk of pregnancy, which puts those living with HIV at a dual vulnerability. Our study assessed the factors associated with VNS and LTFU in older adolescents (including pregnant females) who initiated antiretroviral therapy (ART) in South Africa. Methods We included adolescents aged 15–19 years initiating ART between 2004 and 2019, with ≥ one viral load (VL) measurement between 4 and 24.5 months, and ≥ 6 months follow‐up, from six South African cohorts of the International epidemiology Databases to Evaluate AIDS‐Southern Africa (IeDEA‐SA). We defined VNS as VL ≥400 copies/ml and LTFU as not being in care for ≥180 days from ART start and not known as transferred out of the clinic or dead in the first 24 months on ART. We examined factors associated with VNS and LTFU using Fine&Gray competing risk models. Results We included a total of 2733 adolescents, 415 (15.2%) males, median (IQR) age at ART start of 18.6 (17.3, 19.4) years. Among females, 585/2318 (25.2%) were pregnant. Over the 24‐month follow‐up, 424 (15.5%) of all adolescents experienced VNS: range (11.1% pregnant females and 20.5% males). Over half of all adolescents were LTFU before any other event could occur. The hazard of VNS reduced with increasing age and CD4 count above 200 cells/μl at ART initiation among all adolescents having adjusted for all measured patient characteristics [adjusted sub‐distribution hazard ratio (aSHR) 19 vs. 15 years: 0.50 (95% CI: 0.36, 0.68), aSHR: >500 vs. ≤200 cells/μl: 0.22 (95% CI: 0.16, 0.31)]. The effect of CD4 count persisted in pregnant females. Increasing age and CD4 count >200 cells/μl were risk factors for LTFU among all adolescents. Conclusions Older adolescents had a high risk of LTFU shortly after ART start and a low risk of VNS, especially those initiating treatment during pregnancy. Interventions addressing adherence and retention should be incorporated into adolescent‐friendly services to prevent VNS and LTFU and endeavour to trace lost adolescents as soon as they are identified.
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Affiliation(s)
- Patience Nyakato
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Michael Schomaker
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Tyrol, Austria
| | - Geoffrey Fatti
- Kheth'Impilo AIDS-Free Living, Cape Town, South Africa.,Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Frank Tanser
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa
| | - Jonathan Euvrard
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Khayelitsha ART Programme and Medecins Sans Frontieres, Cape Town, South Africa
| | - Nosisa Sipambo
- Harriet Shezi Children's Clinic, Chris Hani Baragwanath Academic Hospital, Soweto, South Africa
| | - Matthew P Fox
- Department of Epidemiology, Boston University School of Public Health, Boston University, Boston, Massachusetts, USA.,Health Economics & Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Andreas D Haas
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Constantin T Yiannoutsos
- Department of Biostatistics, R.M. Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana, USA
| | - Mary-Ann Davies
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Morna Cornell
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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10
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Kose J, Tiam A, Siamba S, Lenz C, Okoth E, Wolters T, van de Vijver D, Rakhmanina N. Clinical outcomes among adolescents living with HIV in Kenya following initiation on antiretroviral treatment. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000094. [PMID: 36962291 PMCID: PMC10022018 DOI: 10.1371/journal.pgph.0000094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 02/01/2022] [Indexed: 11/19/2022]
Abstract
In Kenya, HIV/AIDS remains a leading cause of morbidity and mortality among adolescents living with HIV (ALHIV). Our study evaluated associations between demographic and healthcare factors and HIV treatment outcomes among ALHIV in care in Kenya. This retrospective cohort study evaluated the clinical outcomes of newly diagnosed ALHIV enrolled in HIV care during January 2017-June 2018 at 32 healthcare facilities in Homabay and Kakamega Counties. Demographic and clinical data were abstracted from patient clinical records and registers during the follow up study period January 2017-through May 2019. ALHIV were stratified by age (10-14 versus 15-19 years). Categorical variables were summarized using descriptive statistics; continuous variables were analyzed using mean values. The latest available treatment and virological outcomes for ALHIV were assessed. 330 ALHIV were included in the study (mean age 15.9 years; 81.8% female, 63.0% receiving HIV care at lower-level healthcare facilities). Most (93.2%) were initiated on ART within 14 days of diagnosis; 91.4% initiated EFV-based regimens. Of those on ART, only 44.6% were active on care at the end of the study period. Of those eligible for viral load testing, 83.9% were tested with 84.4% viral suppression rate. Retention in care was higher at higher-level facilities (67.5%) compared to lower-level facilities (28.6%). Factors associated with higher retention in care were school attendance (aRR = 1.453), receipt of disclosure support (aRR = 13.315), and receiving care at a high-level health facility (aRR = 0.751). Factors associated with viral suppression included older age (15-19 years) (aRR = 1.249) and pre-ART clinical WHO stage I/II (RR = .668). Viral suppression was higher among older ALHIV. Studies are needed to evaluate effective interventions to improve outcomes among ALHIV in Kenya.
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Affiliation(s)
- Judith Kose
- Elizabeth Glaser Pediatric AIDS Foundation, Nairobi, Kenya
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, United States of America
- Department of Medical and Scientific Affairs, Washington, DC, United States of America
- ErasmusMC, Department of Viroscience, Rotterdam University, Rotterdam, Netherlands
| | - Appolinaire Tiam
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, United States of America
- Department of Medical and Scientific Affairs, Washington, DC, United States of America
- University of Bergen, Centre for International Health, Bergen, Norway
| | - Stephen Siamba
- Elizabeth Glaser Pediatric AIDS Foundation, Nairobi, Kenya
| | - Cosima Lenz
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, United States of America
- Department of Medical and Scientific Affairs, Washington, DC, United States of America
| | | | - Theresa Wolters
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, United States of America
- Department of Medical and Scientific Affairs, Washington, DC, United States of America
| | - David van de Vijver
- ErasmusMC, Department of Viroscience, Rotterdam University, Rotterdam, Netherlands
| | - Natella Rakhmanina
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, United States of America
- Department of Medical and Scientific Affairs, Washington, DC, United States of America
- Department of Pediatrics, The George Washington University, School of Medicine and Health Sciences, Washington, DC, United States of America
- Children's National Hospital, Washington, DC, United States of America
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11
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Sexual and reproductive health needs of young people living with HIV in low- and middle-income countries: a scoping review. Reprod Health 2021; 18:219. [PMID: 34740379 PMCID: PMC8570025 DOI: 10.1186/s12978-021-01269-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 10/20/2021] [Indexed: 12/24/2022] Open
Abstract
Background Young people living with HIV(YPLWH) in low-and middle-income countries are entering adolescence and young adulthood in significant numbers. The majority of the HIV-related research on these young people has focused on clinical outcomes with less emphasis on their sexual and reproductive health (SRH). There is an increasing awareness of the importance of understanding and addressing their SRH needs, as many are at elevated risk of transmitting HIV to their sexual partners and young women, in particular, are at significant risk for transmitting HIV to their infants. The purpose of this scoping review is to synthesize research investigating the SRH needs of young people living with HIV in low- and middle-income countries. Methods We searched electronic databases for studies focusing on young people aged 10–24 years and 27 studies met inclusion criteria. Results This review identified four themes characterizing research on SRH among young people living with HIV: knowledge of SRH, access to SRH services, sexual practices, and future family planning and childrearing. Conclusions Our findings suggest a need for additional research on comprehensive sexuality education to equip YPLWH with knowledge to facilitate desirable SRH outcomes, interventions on sero-status disclosure and condom use, and health provider capacity to provide SRH services in their pre-existing HIV clinical care. Young people living with HIV(YPLWH) in low-and middle-income countries are entering adolescence and young adulthood in large numbers. The majority of the HIV-related research on these young people has focused on clinical outcomes with less emphasis on their sexual and reproductive health. It is important to understand and address their sexual and reproductive health (SRH) needs, as many are at a high risk of passing on HIV to their sexual partners and young women, in particular, are at significant risk for passing on HIV to their infants. The purpose of this scoping review is to summarize research examining the SRH needs of young people living with HIV in low- and middle-income countries. We searched online databases for studies focusing on young aged 10–24 years and 27 studies were included in the review. This review identified four themes characterizing research on SRH among young people living with HIV: knowledge of SRH, access to SRH services, sexual practices, and future family planning and childrearing. Our findings suggest a need for additional research on comprehensive sexuality education to equip YPLWH with knowledge to facilitate desirable SRH outcomes, interventions on sero-status disclosure and condom use, and health provider capacity to provide SRH services in their pre-existing HIV clinical care.
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12
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Laurenzi CA, du Toit S, Ameyan W, Melendez‐Torres GJ, Kara T, Brand A, Chideya Y, Abrahams N, Bradshaw M, Page DT, Ford N, Sam‐Agudu NA, Mark D, Vitoria M, Penazzato M, Willis N, Armstrong A, Skeen S. Psychosocial interventions for improving engagement in care and health and behavioural outcomes for adolescents and young people living with HIV: a systematic review and meta-analysis. J Int AIDS Soc 2021; 24:e25741. [PMID: 34338417 PMCID: PMC8327356 DOI: 10.1002/jia2.25741] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 04/15/2021] [Accepted: 04/26/2021] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Adolescents and young people comprise a growing proportion of new HIV infections globally, yet current approaches do not effectively engage this group, and adolescent HIV-related outcomes are the poorest among all age groups. Providing psychosocial interventions incorporating psychological, social, and/or behavioural approaches offer a potential pathway to improve engagement in care and health and behavioural outcomes among adolescents and young people living with HIV (AYPLHIV). METHODS A systematic search of all peer-reviewed papers published between January 2000 and July 2020 was conducted through four electronic databases (Cochrane Library, PsycINFO, PubMed and Scopus). We included randomized controlled trials evaluating psychosocial interventions aimed at improving engagement in care and health and behavioural outcomes of AYPLHIV aged 10 to 24 years. RESULTS AND DISCUSSION Thirty relevant studies were identified. Studies took place in the United States (n = 18, 60%), sub-Saharan Africa (Nigeria, South Africa, Uganda, Zambia, Zimbabwe) and Southeast Asia (Thailand). Outcomes of interest included adherence to antiretroviral therapy (ART), ART knowledge, viral load data, sexual risk behaviours, sexual risk knowledge, retention in care and linkage to care. Overall, psychosocial interventions for AYPLHIV showed important, small-to-moderate effects on adherence to ART (SMD = 0.3907, 95% CI: 0.1059 to 0.6754, 21 studies, n = 2647) and viral load (SMD = -0.2607, 95% CI -04518 to -0.0696, 12 studies, n = 1566). The psychosocial interventions reviewed did not demonstrate significant impacts on retention in care (n = 8), sexual risk behaviours and knowledge (n = 13), viral suppression (n = 4), undetectable viral load (n = 5) or linkage to care (n = 1) among AYPLHIV. No studies measured transition to adult services. Effective interventions employed various approaches, including digital and lay health worker delivery, which hold promise for scaling interventions in the context of COVID-19. CONCLUSIONS This review highlights the potential of psychosocial interventions in improving health outcomes in AYPLHIV. However, more research needs to be conducted on interventions that can effectively reduce sexual risk behaviours of AYPLHIV, as well as those that can strengthen engagement in care. Further investment is needed to ensure that these interventions are cost-effective, sustainable and resilient in the face of resource constraints and global challenges such as the COVID-19 pandemic.
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Affiliation(s)
- Christina A Laurenzi
- Institute for Life Course Health ResearchDepartment of Global HealthFaculty of Medicine and Health SciencesStellenbosch UniversityTygerbergSouth Africa
| | - Stefani du Toit
- Institute for Life Course Health ResearchDepartment of Global HealthFaculty of Medicine and Health SciencesStellenbosch UniversityTygerbergSouth Africa
| | - Wole Ameyan
- Global HIV, Hepatitis and Sexually Transmitted Infections ProgrammesWorld Health OrganizationGenevaSwitzerland
| | - GJ Melendez‐Torres
- Peninsula Technology Assessment GroupUniversity of ExeterExeterUnited Kingdom
| | - Tashmira Kara
- Institute for Life Course Health ResearchDepartment of Global HealthFaculty of Medicine and Health SciencesStellenbosch UniversityTygerbergSouth Africa
| | - Amanda Brand
- Institute for Life Course Health ResearchDepartment of Global HealthFaculty of Medicine and Health SciencesStellenbosch UniversityTygerbergSouth Africa
- Division of Epidemiology and BiostatisticsDepartment of Global HealthFaculty of Medicine and Health SciencesCentre for Evidence‐Based Health CareStellenbosch UniversityTygerbergSouth Africa
| | - Yeukai Chideya
- Institute for Life Course Health ResearchDepartment of Global HealthFaculty of Medicine and Health SciencesStellenbosch UniversityTygerbergSouth Africa
| | - Nina Abrahams
- Institute for Life Course Health ResearchDepartment of Global HealthFaculty of Medicine and Health SciencesStellenbosch UniversityTygerbergSouth Africa
| | - Melissa Bradshaw
- Institute for Life Course Health ResearchDepartment of Global HealthFaculty of Medicine and Health SciencesStellenbosch UniversityTygerbergSouth Africa
| | - Daniel T Page
- Institute for Life Course Health ResearchDepartment of Global HealthFaculty of Medicine and Health SciencesStellenbosch UniversityTygerbergSouth Africa
| | - Nathan Ford
- Global HIV, Hepatitis and Sexually Transmitted Infections ProgrammesWorld Health OrganizationGenevaSwitzerland
| | - Nadia A Sam‐Agudu
- Pediatric and Adolescent UnitPrevention, Care and Treatment DepartmentInstitute of Human Virology NigeriaAbujaNigeria
- Institute of Human Virology and Department of PediatricsUniversity of Maryland School of MedicineBaltimoreMDUSA
| | - Daniella Mark
- Paediatric Adolescent Treatment AfricaCape TownSouth Africa
| | - Marco Vitoria
- Global HIV, Hepatitis and Sexually Transmitted Infections ProgrammesWorld Health OrganizationGenevaSwitzerland
| | - Martina Penazzato
- Global HIV, Hepatitis and Sexually Transmitted Infections ProgrammesWorld Health OrganizationGenevaSwitzerland
| | | | - Alice Armstrong
- UNICEF Eastern and Southern Africa Regional OfficeNairobiKenya
| | - Sarah Skeen
- Institute for Life Course Health ResearchDepartment of Global HealthFaculty of Medicine and Health SciencesStellenbosch UniversityTygerbergSouth Africa
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13
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Brittain K, Teasdale CA, Ngeno B, Odondi J, Ochanda B, Brown K, Langat A, Modi S, Abrams EJ. Improving retention in antenatal and postnatal care: a systematic review of evidence to inform strategies for adolescents and young women living with HIV. J Int AIDS Soc 2021; 24:e25770. [PMID: 34449121 PMCID: PMC8395389 DOI: 10.1002/jia2.25770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 05/17/2021] [Accepted: 06/01/2021] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Young pregnant and postpartum women living with HIV (WLHIV) are at high risk of poor outcomes in prevention of mother-to-child transmission services. The aim of this systematic review was to collate evidence on strategies to improve retention in antenatal and/or postpartum care in this population. We also conducted a secondary review of strategies to increase attendance at antenatal care (ANC) and/or facility delivery among pregnant adolescents, regardless of HIV status, to identify approaches that could be adapted for adolescents and young WLHIV. METHODS Selected databases were searched on 1 December 2020, for studies published between January 2006 and November 2020, with screening and data abstraction by two independent reviewers. We identified papers that reported age-disaggregated results for adolescents and young WLHIV aged <25 years at the full-text review stage. For the secondary search, we included studies among female adolescents aged 10 to 19 years. RESULTS AND DISCUSSION Of 37 papers examining approaches to increase retention among pregnant and postpartum WLHIV, only two reported age-disaggregated results: one showed that integrated care during the postpartum period increased retention in HIV care among women aged 18 to 24 years; and another showed that a lay counsellor-led combination intervention did not reduce attrition among women aged 16 to 24 years; one further study noted that age did not modify the effectiveness of a combination intervention. Mobile health technologies, enhanced support, active follow-up and tracing and integrated services were commonly examined as standalone interventions or as part of combination approaches, with mixed evidence for each strategy. Of 10 papers identified in the secondary search, adolescent-focused services and continuity of care with the same provider appeared to be effective in improving attendance at ANC and/or facility delivery, while home visits and group ANC had mixed results. CONCLUSIONS This review highlights the lack of evidence regarding effective strategies to improve retention in antenatal and/or postpartum care among adolescents and young WLHIV specifically, as well as a distinct lack of age-disaggregated results in studies examining retention interventions for pregnant WLHIV of all ages. Identifying and prioritizing approaches to improve retention of adolescents and young WLHIV are critical for improving maternal and child health.
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Affiliation(s)
- Kirsty Brittain
- Division of Epidemiology & BiostatisticsSchool of Public Health & Family MedicineUniversity of Cape TownCape TownSouth Africa
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public Health & Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Chloe A Teasdale
- Mailman School of Public HealthICAP‐Columbia UniversityNew YorkNYUSA
- Department of EpidemiologyMailman School of Public HealthNew YorkNYUSA
- Department of Epidemiology and BiostatisticsCUNY Graduate School of Public Health & Health PolicyNew YorkNYUSA
| | - Bernadette Ngeno
- Division of Global HIV and Tuberculosis (DGHT)US Centers for Disease Control and PreventionAtlantaGAUSA
| | - Judith Odondi
- Mailman School of Public HealthICAP‐Columbia UniversityNew YorkNYUSA
| | - Boniface Ochanda
- Division of Global HIV and Tuberculosis (DGHT)US Centers for Disease Control and PreventionNairobiKenya
| | - Karryn Brown
- Division of Epidemiology & BiostatisticsSchool of Public Health & Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Agnes Langat
- Division of Global HIV and Tuberculosis (DGHT)US Centers for Disease Control and PreventionNairobiKenya
| | - Surbhi Modi
- Division of Global HIV and Tuberculosis (DGHT)US Centers for Disease Control and PreventionAtlantaGAUSA
| | - Elaine J Abrams
- Mailman School of Public HealthICAP‐Columbia UniversityNew YorkNYUSA
- Department of EpidemiologyMailman School of Public HealthNew YorkNYUSA
- Department of PediatricsVagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNYUSA
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14
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Remera E, Mugwaneza P, Chammartin F, Mulindabigwi A, Musengimana G, Forrest JI, Mwanyumba F, Kondwani N, Condo JU, Riedel DJ, Mills EJ, Nsanzimana S, Bucher HC. Towards elimination of mother-to-child transmission of HIV in Rwanda: a nested case-control study of risk factors for transmission. BMC Pregnancy Childbirth 2021; 21:339. [PMID: 33910502 PMCID: PMC8082927 DOI: 10.1186/s12884-021-03806-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 04/13/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Mother-to-child HIV transmission (MTCT) has substantially declined since the scale-up of prevention programs around the world, including Rwanda. To achieve full elimination of MTCT, it is important to understand the risk factors associated with residual HIV transmission, defined as MTCT at the population-level that still occurs despite universal access to PMTCT. METHODS We performed a case control study of children born from mothers with HIV with known vital status at 18 months from birth, who were followed in three national cohorts between October and December 2013, 2014, and 2015 in Rwanda. Children with HIV were matched in a ratio of 1:2 with HIV-uninfected children and a conditional logistic regression model was used to investigate risk factors for MTCT. RESULTS In total, 84 children with HIV were identified and matched with 164 non-infected children. The median age of mothers from both groups was 29 years (interquartile range (IQR): 24-33). Of these mothers, 126 (51.4 %) initiated antiretroviral therapy (ART) before their pregnancy on record. In a multivariable regression analysis, initiation of ART in the third trimester (Adjusted Odds Ratio [aOR]: 9.25; 95 % Confidence Interval [95 % CI]: 2.12-40.38) and during labour or post-partum (aOR: 8.87; 95 % CI: 1.92-40.88), compared to initiation of ART before pregnancy, increased the risk of MTCT. Similarly, offspring of single mothers (aOR: 7.15; 95 % CI: 1.15-44.21), and absence of postpartum neonatal ART prophylaxis (aOR: 7.26; 95 % CI: 1.66-31.59) were factors significantly associated with MTCT. CONCLUSIONS Late ART initiation for PMTCT and lack of postpartum infant prophylaxis are still the most important risk factors to explain MTCT in the era of universal access. Improved early attendance at antenatal care, early ART initiation, and enhancing the continuum of care especially for single mothers is crucial for MTCT elimination in Rwanda.
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Affiliation(s)
- Eric Remera
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Centre, Kigali, Rwanda. .,Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, Basel, Switzerland. .,University of Basel, Basel, Switzerland. .,Swiss Tropical and Public Health Institute, Basel, Switzerland.
| | - Placidie Mugwaneza
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Centre, Kigali, Rwanda
| | - Frédérique Chammartin
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Augustin Mulindabigwi
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Centre, Kigali, Rwanda
| | - Gentille Musengimana
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Centre, Kigali, Rwanda
| | - Jamie I Forrest
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Fabian Mwanyumba
- United Nations International Children's Emergency Fund, Kampala, Uganda
| | - Ng'oma Kondwani
- United Nations International Children's Emergency Fund, Kigali, Rwanda
| | - Jeanine U Condo
- School of Public Health, College of Medicine & Health Sciences, University of Rwanda, Kigali, Rwanda.,Tulane University, New Orleans, USA
| | - David J Riedel
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, USA
| | - Edward J Mills
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Sabin Nsanzimana
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Centre, Kigali, Rwanda
| | - Heiner C Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, Basel, Switzerland.,University of Basel, Basel, Switzerland
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15
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Mbeya Munkhondya TE, Smyth RMD, Lavender T. Facilitators and barriers to retention in care under universal antiretroviral therapy (Option B+) for the Prevention of Mother to Child Transmission of HIV (PMTCT): A narrative review. INTERNATIONAL JOURNAL OF AFRICA NURSING SCIENCES 2021. [DOI: 10.1016/j.ijans.2021.100372] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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16
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Millar HC, Keter AK, Musick BS, Apondi E, Wachira J, MacDonald KR, Spitzer RF, Braitstein P. Decreasing incidence of pregnancy among HIV-positive adolescents in a large HIV treatment program in western Kenya between 2005 and 2017: a retrospective cohort study. Reprod Health 2020; 17:191. [PMID: 33267899 PMCID: PMC7709285 DOI: 10.1186/s12978-020-01031-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 10/29/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The objective of this study was to estimate the prevalence, incidence and risk factors for pregnancy among HIV-positive adolescents in a large HIV treatment program in western Kenya. METHODS The Academic Model Providing Access to Healthcare (AMPATH) program is a partnership between Moi University, Moi Teaching and Referral Hospital and a consortium of 11 North American academic institutions. AMPATH currently provides care to 85,000 HIV-positive individuals in western Kenya. Included in this analysis were adolescents aged 10-19 enrolled in AMPATH between January 2005 and February 2017. Socio-demographic, behavioural, and clinical data at baseline and time-updated antiretroviral treatment (ART) data were extracted from the electronic medical records and summarized using descriptive statistics. Follow up time was defined as time of inclusion in the cohort until the date of first pregnancy or age 20, loss to follow up, death, or administrative censoring. Adolescent pregnancy rates and associated risk factors were determined. RESULTS There were 8565 adolescents eligible for analysis. Median age at enrolment in HIV care was 14.0 years. Only 17.7% had electricity at home and 14.4% had piped water, both indicators of a high level of poverty. 12.9% (1104) were pregnant at study inclusion. Of those not pregnant at enrolment, 5.6% (448) became pregnant at least once during follow-up. Another 1.0% (78) were pregnant at inclusion and became pregnant again during follow-up. The overall pregnancy incidence rate was 21.9 per 1000 woman years or 55.8 pregnancies per 1000 women. Between 2005 and 2017, pregnancy rates have decreased. Adolescents who became pregnant in follow-up were more likely to be older, to be married or living with a partner and to have at least one child already and less likely to be using family planning. CONCLUSIONS A considerable number of these HIV-positive adolescents presented at enrolment into HIV care as pregnant and many became pregnant as adolescents during follow-up. Pregnancy rates remain high but have decreased from 2005 to 2017. Adolescent-focused sexual and reproductive health and ante/postnatal care programs may have the potential to improve maternal and neonatal outcomes as well as further decrease pregnancy rates in this high-risk group.
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Affiliation(s)
- Heather C Millar
- Academic Model Providing Access to Healthcare (AMPATH), PO Box 4606, Eldoret, 30100, Kenya. .,Section of Gynaecology, Division of Endocrinology, SickKids Hospital, 555 University Avenue, 7th Floor, Black Wing, Toronto, ON, M5G 1X8, Canada. .,Department of Obstetrics and Gynaecology, University of Toronto Faculty of Medicine, 123 Edward Street, Suite 1200, Toronto, ON, M5G 1E2, Canada.
| | - Alfred K Keter
- Academic Model Providing Access to Healthcare (AMPATH), PO Box 4606, Eldoret, 30100, Kenya
| | - Beverly S Musick
- Academic Model Providing Access to Healthcare (AMPATH), PO Box 4606, Eldoret, 30100, Kenya.,Department of Biostatistics, Indiana University School of Medicine, 410 West 10th Street, Suite 3000, Indianapolis, IN, 46202, USA
| | - Edith Apondi
- Academic Model Providing Access to Healthcare (AMPATH), PO Box 4606, Eldoret, 30100, Kenya.,Moi Teaching and Referral Hospital, Nandi Road, Uasin Gishu County, PO Box 3-30100, Eldoret, Kenya
| | - Juddy Wachira
- Academic Model Providing Access to Healthcare (AMPATH), PO Box 4606, Eldoret, 30100, Kenya.,Department of Behavioral Sciences, Moi University, College of Health Sciences, PO Box 4606, Eldoret, 30100, Kenya
| | - Katherine R MacDonald
- Academic Model Providing Access to Healthcare (AMPATH), PO Box 4606, Eldoret, 30100, Kenya.,Department of Pediatrics, Indiana University School of Medicine, 705 Riley Hospital Drive, Riley Hospital 5900, Indianapolis, IN, 46202, USA
| | - Rachel F Spitzer
- Academic Model Providing Access to Healthcare (AMPATH), PO Box 4606, Eldoret, 30100, Kenya.,Section of Gynaecology, Division of Endocrinology, SickKids Hospital, 555 University Avenue, 7th Floor, Black Wing, Toronto, ON, M5G 1X8, Canada.,Department of Obstetrics and Gynaecology, University of Toronto Faculty of Medicine, 123 Edward Street, Suite 1200, Toronto, ON, M5G 1E2, Canada
| | - Paula Braitstein
- Academic Model Providing Access to Healthcare (AMPATH), PO Box 4606, Eldoret, 30100, Kenya.,Department of Epidemiology, University of Toronto Dalla Lana School of Public Health, Health Sciences Building, 155 College Street, 6th Floor, Toronto, ON, M5T 3M7, Canada.,Moi University, College of Health Sciences, School of Medicine, PO Box 4606, Eldoret, 30100, Kenya
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Mejia-Pailles G, Berrington A, McGrath N, Hosegood V. Trends in the prevalence and incidence of orphanhood in children and adolescents <20 years in rural KwaZulu-Natal South Africa, 2000-2014. PLoS One 2020; 15:e0238563. [PMID: 33232331 PMCID: PMC7685426 DOI: 10.1371/journal.pone.0238563] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 08/19/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND In South Africa, large increases in early adult mortality during the 1990s and early 2000s have reversed since public HIV treatment rollout in 2004. In a rural population in KwaZulu-Natal, we investigate trends in parental mortality and orphanhood from 2000-2014. METHODS Using longitudinal demographic surveillance data for a population of approximately 90,000, we calculated annual incidence and prevalence of maternal, paternal and double orphanhood in children and adolescents (<20 years) and, overall and cause-specific mortality of parents by age. RESULTS The proportion of children and adolescents (<20 years) for whom one or both parents had died rose from 26% in 2000 to peak at 36% in 2010, followed by a decline to 32% in 2014. The burden of orphanhood remains high especially in the oldest age group: in 2014, 53% of adolescents 15-19 years had experienced the death of one or both parents. In all age groups and years, paternal orphan prevalence was three-five times higher than maternal orphan prevalence. Maternal and paternal orphan incidence peaked in 2005 at 17 and 27 per 1,000 person years respectively (<20 years) before declining by half through 2014. The leading cause of parental death throughout the period, HIV/AIDS and TB cause-specific mortality rates declined substantially in mothers and fathers from 2007 and 2009 respectively. CONCLUSIONS The survival of parents with children and adolescents <20 years has improved in tandem with earlier initiation and higher coverage of HIV treatment. However, comparatively high levels of parental deaths persist in this rural population in KwaZulu-Natal, particularly among fathers. Community-level surveillance to estimate levels of orphanhood remains important for monitoring and evaluation of targeted state welfare support for orphans and their guardians.
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Affiliation(s)
| | - Ann Berrington
- Department of Social Statistics & Demography, University of Southampton, Southampton, United Kingdom
| | - Nuala McGrath
- Department of Social Statistics & Demography, University of Southampton, Southampton, United Kingdom
- Department of Population Sciences & Primary Care, University of Southampton, Southampton, United Kingdom
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Victoria Hosegood
- Department of Social Statistics & Demography, University of Southampton, Southampton, United Kingdom
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Toska E, Cluver L, Laurenzi CA, Wittesaele C, Sherr L, Zhou S, Langwenya N. Reproductive aspirations, contraception use and dual protection among adolescent girls and young women: the effect of motherhood and HIV status. J Int AIDS Soc 2020; 23 Suppl 5:e25558. [PMID: 32869543 PMCID: PMC7459160 DOI: 10.1002/jia2.25558] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 05/12/2020] [Accepted: 06/03/2020] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION There is a growing interest in adolescent motherhood and HIV among policymakers and programme implementers. To better shape services and health outcomes, we need evidence on reproductive aspirations and contraception use in this high-risk group, including the effect of motherhood and HIV status. We report data from a large survey of adolescent girls and young women conducted in a mixed rural-urban district in South Africa. METHODS Quantitative interviews were conducted with 1712 adolescent girls and young women (ages 10 to 24): 336 adolescent mothers living with HIV (AMLHIV), 454 nulliparous adolescent girls living with HIV (ALHIV), 744 HIV-negative adolescent mothers (control adolescent mothers) and 178 HIV-negative nulliparous adolescent girls (nulliparous controls) in 2018 to 2019. Standardized questionnaires included socio-demographic measures, reproductive health and contraception experiences. Reproductive aspirations were measured as the number of children participants wanted to have. Dual protection was computed as use of both hormonal and barrier contraception or abstinence. Multivariate logistic regression and marginal effects models in STATA 15 were used to test associations between HIV status, adolescent motherhood and outcomes of reproductive aspirations, contraception use and dual protection, controlling for covariates. RESULTS AND DISCUSSION Nearly 95% of first pregnancies were unintended. Over two-thirds of all participants wanted two or more children. Hormonal contraception, condom use and dual protection were low across all groups. In multivariate regression modelling, ALHIV were less likely to report hormonal contraception use (aOR 0.55 95% CI 0.43 to 0.70 p ≤ 0.001). In marginal effects modelling, adolescent mothers - independent of HIV status - were least likely to report condom use at last sex. Despite higher probabilities of using hormonal contraception, rates of dual protection were low: 17.1% among control adolescent mothers and 12.4% among AMLHIV. Adolescent mothers had the highest probabilities of not using any contraceptive method: 29.0% among control mothers and 23.5% among AMLHIV. CONCLUSIONS Among adolescent girls and young women in HIV-endemic communities, reproductive aspirations and contraceptive practices affect HIV risk and infection. Tailored adolescent-responsive health services could help young women plan their pregnancies for when they are healthy and well-supported, and help interrupt the cycle of HIV transmission by supporting them to practice dual protection.
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Affiliation(s)
- Elona Toska
- Centre for Social Science ResearchUniversity of Cape TownCape TownSouth Africa
- Department of SociologyUniversity of Cape TownCape TownSouth Africa
- Department of Social Policy and InterventionUniversity of OxfordOxfordUnited Kingdom
| | - Lucie Cluver
- Department of Social Policy and InterventionUniversity of OxfordOxfordUnited Kingdom
- Department of Child and Adolescent PsychiatryUniversity of Cape TownCape TownSouth Africa
| | - Christina A Laurenzi
- Department of Global HealthInstitute for Life Course Health ResearchStellenbosch UniversityCape TownSouth Africa
| | - Camille Wittesaele
- Department of Social Policy and InterventionUniversity of OxfordOxfordUnited Kingdom
- Department of Infectious Disease EpidemiologyFaculty of Epidemiology and Population HealthLondon School of Hygiene & Tropical MedicineLondonUnited Kingdom
| | - Lorraine Sherr
- Institute for Global HealthUniversity College LondonLondonUnited Kingdom
| | - Siyanai Zhou
- Centre for Social Science ResearchUniversity of Cape TownCape TownSouth Africa
- Department of StatisticsUniversity of Cape TownCape TownSouth Africa
| | - Nontokozo Langwenya
- Centre for Social Science ResearchUniversity of Cape TownCape TownSouth Africa
- Oxford Research South AfricaEast LondonSouth Africa
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Toska E, Laurenzi CA, Roberts KJ, Cluver L, Sherr L. Adolescent mothers affected by HIV and their children: A scoping review of evidence and experiences from sub-Saharan Africa. Glob Public Health 2020; 15:1655-1673. [PMID: 32507031 DOI: 10.1080/17441692.2020.1775867] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
While adolescents have received increasing attention in the global HIV response and international strategies and commitments, adolescent mothers and their children remain largely overlooked in research, funding and, programming for health-related outcomes. We conducted an extensive scoping review of current evidence on the experiences of adolescent mothers affected by HIV and their children in this region. We included published literature and conference abstracts, complemented by consultations with key stakeholders, and a review of documents through grey literature searching. First, we summarise the experiences of adolescent mothers and their children related to HIV and key health and development indicators. The syndemic of early motherhood and HIV in sub-Saharan Africa increases the vulnerability of adolescent mothers and their children. We then highlight lessons from a series of promising programmes focused on supporting adolescent mothers through novel approaches. In sub-Saharan Africa, supporting adolescent mothers living in high HIV-risk communities is critical not only to eliminate HIV/AIDS, but also to attain the Sustainable Development Goals. While research on and programming for adolescent mothers and their children is growing, the complex needs for this vulnerable group remain unmet. We conclude with evidence gaps and programming priorities for adolescent mothers affected by HIV and their children.
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Affiliation(s)
- Elona Toska
- Centre for Social Science Research, University of Cape Town, Cape Town, South Africa.,Department of Social Policy and Intervention, University of Oxford, Oxford, UK.,Department of Sociology, University of Cape Town, Cape Town, South Africa
| | - Christina A Laurenzi
- Institute for Life Course Health Research, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | | | - Lucie Cluver
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK.,Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Lorraine Sherr
- Institute for Global Health, University College London, London, UK
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20
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Burrage AB, Mushavi A, Shiraishi RW, Barr BT, Shambira G, Nyakura J, Balachandra S, Kilmarx PH, Dinh TH. Mother-To-Child Transmission of HIV in Adolescents and Young Women: Findings From a National Prospective Cohort Survey, Zimbabwe, 2013-2014. J Adolesc Health 2020; 66:455-463. [PMID: 31964611 PMCID: PMC8740363 DOI: 10.1016/j.jadohealth.2019.10.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 09/21/2019] [Accepted: 10/18/2019] [Indexed: 11/19/2022]
Abstract
PURPOSE We assessed 18-month cumulative mother-to-child HIV transmission (MTCT) risk and risk factors for no antiretroviral medication use during pregnancy among adolescent, young women, and adult mothers in Zimbabwe. METHODS We analyzed data from a prospective survey of 1,171 mother-infant pairs with HIV-exposed infants aged 4-12 weeks who were recruited from 151 immunization clinics from February to August 2013. HIV-exposed infants were followed until diagnosed with HIV, death, or age 18 months. Findings were weighted and adjusted for complex survey design and nonresponse. RESULTS The 18-month cumulative MTCT risk was highest among adolescent aged ≤19 years (12%) followed by young women aged 20-24 years (7.5%) and adult women aged ≥25 years (6.9%). Across these groups, more than 94% had ≥1 antenatal care visit by 21 weeks of gestation, more than 95% had ≥1 HIV test, and more than 98% knew their HIV status. Of known HIV-positive mothers, maternal antiretroviral medication coverage during pregnancy was 76.8% (95% confidence interval: 65.1-85.5), 83.8% (78.6-87.9), and 87.8% (84.6-90.4) among adolescent, young women, and adult mothers, respectively. Among HIV-positive mothers diagnosed prenatally, the adjusted odds ratio of no ARV use during pregnancy was increased among those who had no antenatal care attendance (adjusted odds ratio: 7.7 [3.7-16.0]), no HIV testing (7.3 [2.3-23.5]), no prepartum CD4 count testing (2.1 [1.3-3.4]), and maternal HIV identification during pregnancy (2.9 [1.8-4.8]). Age was not a risk factor. CONCLUSIONS With similar coverage of prevention of MTCT services, the 18-month cumulative MTCT risk was higher among adolescents and young women, compared with adults. Additional research should examine the causes to develop targeted interventions.
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Affiliation(s)
- Amanda B Burrage
- Division of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Center for Global Health, Atlanta, Georgia
| | - Angela Mushavi
- AIDS and TB Department, Ministry of Health and Child Care of Zimbabwe, Harare, Zimbabwe
| | - Ray W Shiraishi
- Division of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Center for Global Health, Atlanta, Georgia
| | - Beth Tippett Barr
- Division of Global HIV/AIDS, U.S. Centers for Disease Control and Prevention, Center for Global Health, Harare, Zimbabwe
| | - Geral Shambira
- Department of Community Health, University of Zimbabwe, Harare, Zimbabwe
| | - Justice Nyakura
- Department of Community Health, University of Zimbabwe, Harare, Zimbabwe
| | - Shirish Balachandra
- Division of Global HIV/AIDS, U.S. Centers for Disease Control and Prevention, Center for Global Health, Harare, Zimbabwe
| | - Peter H Kilmarx
- Division of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Center for Global Health, Atlanta, Georgia; Division of Global HIV/AIDS, U.S. Centers for Disease Control and Prevention, Center for Global Health, Harare, Zimbabwe
| | - Thu-Ha Dinh
- Division of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Center for Global Health, Atlanta, Georgia.
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Program implementation gaps and ethical issues in the prevention of HIV infection among infants, children, and adolescents in sub-Saharan Africa. Pediatr Res 2020; 87:406-413. [PMID: 31663519 DOI: 10.1038/s41390-019-0645-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 08/31/2019] [Accepted: 10/23/2019] [Indexed: 12/30/2022]
Abstract
Strategies for HIV prevention among infants, children, and adolescents have evolved significantly over the past 20 years. These include the global scale-up of simplified multidrug HIV regimens for pregnant women, leading to impressive reductions in new child HIV infections. However, significant gaps remain, especially in high HIV-burden sub-Saharan African countries. For example, many pregnant women living with HIV (WLHIV) are unable to access and sustain HIV testing and treatment partly due to low agency and harmful gender norms. Among pregnant WLHIV, adolescent girls face an additional layer of societal and health-system barriers in accessing care for themselves and their exposed infants. Legal and structural barriers limit access to HIV prevention-related sexual and reproductive health services among high-risk adolescents, including girls and young men who have sex with men. Key ethical issues underlying HIV prevention gaps for infants, children, and adolescents prevail. This narrative review explores these issues and highlights counter-measures for programming and policy, including gender empowerment, improving access to and appropriateness of critical health services, rights-based policy and legislation, closing research gaps, and considering the values and preferences of young people for HIV prevention and treatment services.
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22
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Ng’eno B, Rogers B, Mbori-Ngacha D, Essajee S, Hrapcak S, Modi S. Understanding the uptake of prevention of mother-to-child transmission services among adolescent girls in Sub-Saharan Africa: a review of literature. INTERNATIONAL JOURNAL OF ADOLESCENCE AND YOUTH 2019. [DOI: 10.1080/02673843.2019.1699124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Affiliation(s)
- Bernadette Ng’eno
- Division of Global HIV and Tuberculosis, U.S Centers for Disease Control and Prevention (CDC) , Atlanta, GA, USA
| | - Braeden Rogers
- Health Section, UNICEF Eastern and Southern Africa Regional Office , Nairobi, Kenya
| | | | | | - Susan Hrapcak
- Division of Global HIV and Tuberculosis, U.S Centers for Disease Control and Prevention (CDC) , Atlanta, GA, USA
| | - Surbhi Modi
- Division of Global HIV and Tuberculosis, U.S Centers for Disease Control and Prevention (CDC) , Atlanta, GA, USA
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Engel DMC, Paul M, Chalasani S, Gonsalves L, Ross DA, Chandra-Mouli V, Cole CB, de Carvalho Eriksson C, Hayes B, Philipose A, Beadle S, Ferguson BJ. A Package of Sexual and Reproductive Health and Rights Interventions-What Does It Mean for Adolescents? J Adolesc Health 2019; 65:S41-S50. [PMID: 31761003 DOI: 10.1016/j.jadohealth.2019.09.014] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 09/24/2019] [Indexed: 12/28/2022]
Abstract
This article analyzes the relevance of the comprehensive definition of sexual and reproductive health and rights (SRHR) to adolescents and identifies adolescent-specific implications for the implementation of an essential package of SRHR interventions. The delivery of a comprehensive approach to SRHR targeting adolescents is underpinned by five principles-equity, quality, accountability, multisectorality, and meaningful engagement. All SRHR interventions included in the package are relevant to adolescents, given the diversity of adolescents' SRHR needs and considering their specific attributes, circumstances, and experiences. Ensuring that this package is available, accessible, and acceptable to adolescents requires an approach that looks at adolescents as being biologically and socially distinct from other age groups and acknowledges that they face some specific barriers when accessing SRHR services. This article provides cross-cutting strategies for the implementation of a comprehensive approach to SRHR for adolescents and specific considerations in delivering each intervention in the package of essential SRHR interventions. To further implement the International Conference on Population and Development Programme of Action, a prerequisite for achieving the Sustainable Development Goals, SRHR interventions must be adolescent responsive, delivered through multiple platforms, leveraging multisectoral collaboration, and strengthening accountability and participation.
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Affiliation(s)
| | - Mandira Paul
- Technical Division, United Nations Population Fund, New York, New York
| | - Satvika Chalasani
- Technical Division, United Nations Population Fund, New York, New York
| | - Lianne Gonsalves
- Department of Reproductive Health and Research, World Health Organization/Human Reproduction Programme, Geneva, Switzerland
| | - David Anthony Ross
- Department of Maternal, Newborn, Child, and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Venkatraman Chandra-Mouli
- Department of Reproductive Health and Research, World Health Organization/Human Reproduction Programme, Geneva, Switzerland
| | | | | | - Brendan Hayes
- Global Financing Facility, World Bank, Washington, DC
| | - Anandita Philipose
- Eastern and Southern Regional Office, United Nations Population Fund, Johannesburg, South Africa
| | - Sally Beadle
- Section of Health and Education, United Nations Educational, Scientific and Cultural Organization, Paris, France
| | - B Jane Ferguson
- Independent Consultant, Adolescent Health and Development, Tannay, Switzerland
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Ngandu NK, Jackson D, Lombard C, Nsibande DF, Dinh TH, Magasana V, Mogashoa M, Goga AE. Factors associated with non-attendance at scheduled infant follow-up visits in an observational cohort of HIV-exposed infants in South Africa, 2012-2014. BMC Infect Dis 2019; 19:788. [PMID: 31526372 PMCID: PMC6745773 DOI: 10.1186/s12879-019-4340-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background Since 2001 the South African guidelines to improve child health and prevent vertical HIV transmission recommended frequent infant follow-up with HIV testing at 18 months postpartum. We sought to understand non-attendance at scheduled follow-up study visits up to 18 months, and for the 18-month infant HIV test amongst a nationally representative sample of HIV exposed uninfected (HEU) infants from a high HIV-prevalence African setting. Methods Secondary analysis of data drawn from a nationally representative observational cohort study (conducted during October 2012 to September 2014) of HEU infants and their primary caregivers was undertaken. Participants were eligible (N = 2650) if they were 4–8 weeks old and HEU at enrolment. All enrolled infants were followed up every 3 months up to 18 months. Each follow-up visit was scheduled to coincide with each child’s routine health visit, where possible. The denominator at each time point comprised HEU infants who were alive and HIV-free at the previous visit. We assessed baseline maternal and early HIV care characteristics associated with the frequency of ‘Missed visits’ (MV-frequency), using a negative binomial regression model adjusting for the follow-up time in the study, and associated with missed visits at 18 months (18-month MV) using a logistic regression model. Results The proportion of eligible infants with MV was lowest at 3 months (32.7%) and 18 months (31.0%) and highest at 12 months (37.6%). HIV-positive mothers not on triple antiretroviral therapy (ART) by 6-weeks postpartum had a significantly increased occurrence rate of ‘MV-frequency’ (adjusted incidence rate ratio, 1.2 (95% confidence interval (CI), 1.1–1.4), p < 0.0001). Compared to those mothers with ART, these mothers also increased the risk of ‘18-month-MV’ (adjusted odds ratio, 1.3 (CI, 1.1–1.6), p = 0.006). Unknown infant nevirapine-intake status increased the rate of ‘MV-frequency’ (p = 0.02). Mothers > 24 years had a significantly reduced rate of ‘MV-frequency’ (p ≤ 0.01) and risk of ‘18-month-MV’ (p < 0.01) compared to younger women. Shorter travel time to health facility lowered the occurrence of ‘MV-frequency’ (p ≤ 0.004). Conclusion Late initiation of maternal ART and infant prophylaxis under the Option- A policy and extended travel time to clinics (measured at 6 weeks postpartum), contributed to higher postnatal MV rates. Mothers older than 24 years had lower MV rates. Targeted interventions may be needed during the current PMTCT Option B+ (lifelong ART to pregnant and lactating women at HIV diagnosis) to circumvent these risk factors and reduce missed visits during HIV-care. Electronic supplementary material The online version of this article (10.1186/s12879-019-4340-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nobubelo Kwanele Ngandu
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa.
| | - Debra Jackson
- UNICEF, New York, NY, USA.,School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Carl Lombard
- Biostatistics Unit, South African Medical Research Council, Cape Town, South Africa.,School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Duduzile Faith Nsibande
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Thu-Ha Dinh
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Center for Global Health, Atlanta, GA, USA
| | - Vuyolwethu Magasana
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Mary Mogashoa
- US Center for Disease Control and Prevention, Pretoria, South Africa
| | - Ameena Ebrahim Goga
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa.,Department of Paediatrics, University of Pretoria, Pretoria, South Africa
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Luseno WK, Iritani BJ, Maman S, Mbai I, Ongili B, Otieno FA, Hallfors DD. "If the mother does not know, there is no way she can tell the adolescent to go for drugs": Challenges in promoting health and preventing transmission among pregnant and parenting Kenyan adolescents living with HIV. CHILDREN AND YOUTH SERVICES REVIEW 2019; 103:100-106. [PMID: 31308586 PMCID: PMC6628199 DOI: 10.1016/j.childyouth.2019.05.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Adolescents living with HIV (ALHIV) who are pregnant, or parenting, are an important but understudied group. This study explores the challenges in promoting the health of these adolescents and preventing onward transmission. We used existing semi-structured interview data from a 2014 study conducted among Kenyan ALHIV (ages 15-19), their family members, and local health staff to examine adolescent HIV-testing, disclosure, and treatment engagement, focusing on participants who were pregnant, had given birth, or had fathered a child. A total of 28 participant interviews were analyzed, including those conducted with nine ALHIV, four family members, and 15 HIV providers. Four adolescent participants were not in care at the time of their interview. Our analysis also included a transcript from a stakeholder meeting involving HIV providers and associated administrators, held to disseminate and garner feedback on, preliminary findings from the original study. Based on our analysis, adolescents frequently reported being alone during testing, experiencing fear and denial on receiving their results, and delaying disclosure to family and linkage to treatment. They also mentioned a lack of contraceptive counseling, with some reporting multiple pregnancies. Providers voiced misgivings and uncertainty about disclosing HIV diagnoses to minor adolescents without a family member present and reported severe shortages of personnel and resources to adequately serve ALHIV in rural clinics. These findings highlight gaps in services that limit adolescent engagement in HIV treatment prior to sexual debut and conceiving a child, and in PMTCT during and after pregnancy. Greater research attention is needed to address ALHIV reproductive health needs, improve linkage to HIV treatment, and prevent onward sexual transmission. Empirical ethics studies of current adolescent disclosure policies are also warranted to examine cultural and developmental appropriateness, and effectiveness in fostering support and engagement in HIV services.
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Affiliation(s)
- Winnie K. Luseno
- Pacific Institute for Research and Evaluation (PIRE), 101
Conner Dr., Ste 200, Chapel Hill, NC 27514, United States of America
| | - Bonita J. Iritani
- Pacific Institute for Research and Evaluation (PIRE), 101
Conner Dr., Ste 200, Chapel Hill, NC 27514, United States of America
| | - Suzanne Maman
- Department of Health Behavior and Health Education,
University of North Carolina, Chapel Hill 27599, United States of America
| | - Isabella Mbai
- College of Health Sciences, School of Nursing, Moi
University, P.O. Box 4606, Eldoret, Kenya
| | - Barrack Ongili
- Centre for Global Health Research, Kenya Medical Research
Institute (KEMRI), Busia Road, P.O. Box 1578, 40100 Kisumu, Kenya
| | - Florence Anyango Otieno
- Centre for Global Health Research, Kenya Medical Research
Institute (KEMRI), Busia Road, P.O. Box 1578, 40100 Kisumu, Kenya
| | - Denise Dion Hallfors
- Pacific Institute for Research and Evaluation (PIRE), 101
Conner Dr., Ste 200, Chapel Hill, NC 27514, United States of America
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Carbone NB, Njala J, Jackson DJ, Eliya MT, Chilangwa C, Tseka J, Zulu T, Chinkonde JR, Sherman J, Zimba C, Mofolo IA, Herce ME. "I would love if there was a young woman to encourage us, to ease our anxiety which we would have if we were alone": Adapting the Mothers2Mothers Mentor Mother Model for adolescent mothers living with HIV in Malawi. PLoS One 2019; 14:e0217693. [PMID: 31173601 PMCID: PMC6555548 DOI: 10.1371/journal.pone.0217693] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Accepted: 05/12/2019] [Indexed: 12/03/2022] Open
Abstract
Background Pregnant and post-partum adolescent girls and young women (AGYW) living with HIV in sub-Saharan Africa experience inferior outcomes along the prevention of mother-to-child transmission of HIV (PMTCT) cascade compared to their adult counterparts. Yet, despite this inequality in outcomes, scarce data from the region describe AGYW perspectives to inform adolescent-sensitive PMTCT programming. In this paper, we report findings from formative implementation research examining barriers to, and facilitators of, PMTCT care for HIV-infected AGYW in Malawi, and explore strategies for adapting the mothers2mothers (m2m) Mentor Mother Model to better meet AGYW service delivery-related needs and preferences. Methods Qualitative researchers conducted 16 focus group discussions (FGDs) in 4 Malawi districts with HIV-infected adolescent mothers ages 15–19 years categorized into two groups: 1) those who had experience with m2m programming (8 FGDs, n = 38); and 2) those who did not (8 FGDs, n = 34). FGD data were analyzed using thematic analysis to assess major and minor themes and to compare findings between groups. Results Median participant age was 17 years (interquartile range: 2 years). Poverty, stigma, food insecurity, lack of transport, and absence of psychosocial support were crosscutting barriers to PMTCT engagement. While most participants highlighted resilience and self-efficacy as motivating factors to remain in care to protect their own health and that of their children, they also indicated a desire for tailored, age-appropriate services. FGD participants indicated preference for support services delivered by adolescent HIV-infected mentor mothers who have successfully navigated the PMTCT cascade themselves. Conclusions HIV-infected adolescent mothers expressed a preference for peer-led, non-judgmental PMTCT support services that bridge communities and facilities to pragmatically address barriers of stigma, poverty, health system complexity, and food insecurity. Future research should evaluate implementation and health outcomes for adolescent mentor mother services featuring these and other client-centered attributes, such as provision of livelihood assistance and peer-led psychosocial support.
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Affiliation(s)
| | - Joseph Njala
- University of North Carolina Project/Malawi, Lilongwe, Malawi
| | - Debra J. Jackson
- UNICEF/New York, New York, New York, United States of America
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Michael T. Eliya
- Department of HIV and AIDS, Ministry of Health, Government of the Republic of Malawi, Lilongwe, Malawi
| | | | - Jennifer Tseka
- University of North Carolina Project/Malawi, Lilongwe, Malawi
| | - Tasila Zulu
- University of North Carolina Project/Malawi, Lilongwe, Malawi
| | | | | | - Chifundo Zimba
- University of North Carolina Project/Malawi, Lilongwe, Malawi
| | | | - Michael E. Herce
- University of North Carolina Project/Malawi, Lilongwe, Malawi
- Institute for Global Health & Infectious Diseases, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, United States of America
- * E-mail:
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Landes M, van Lettow M, Nkhoma E, Tippett Barr B, Truwah Z, Shouten E, Jahn A, Auld A, Kalua T, van Oosterhout JJ. Low detectable postpartum viral load is associated with HIV transmission in Malawi's prevention of mother-to-child transmission programme. J Int AIDS Soc 2019; 22:e25290. [PMID: 31180186 PMCID: PMC6556977 DOI: 10.1002/jia2.25290] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 05/08/2019] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION In 2011, Malawi implemented "Option B+," a test-and-treat strategy for the prevention of maternal to child transmission of HIV (PMTCT); however limited data on viral load (VL) suppression exist. We describe VL suppression in HIV-infected women at four to twenty-six weeks postpartum, factors associated with VL suppression and the impact of VL suppression levels on MTCT. METHODS HIV-positive mothers at four to twenty-six weeks postpartum were enrolled in a nested cross-sectional study within the "National Evaluation of Malawi's PMTCT Programme" cohort study between October 2014 and May 2016. HIV-exposed infants received HIV-1 DNA testing and venous samples determined maternal VL, classified as unsuppressed (>1000 copies/mL), low-detectable (40 to 1000 copies/mL) or undetectable (<40 copies/mL). Socio-demographic and PMTCT indicators were collected. Suboptimal adherence was defined as self-reported ≥2 days missed ART in the month prior to visit. RESULTS Of the 1274 women, 1191 (93.5%) knew their HIV status and 1154/1191 (96.9%) were on ART. VL was available for 1124/1154 (97.4%) of women on ART: 988/1124 (87.9%) had VL suppression of whom 86 (8.7%) had low-detectable and 902 (91.3%) undetectable VL. Suboptimal adherence was associated with unsuppressed VL (vs. suppressed VL; aOR 3.1, 95% CI 2.0 to 4.9; p < 0.001). Women with low-detectable VL were more likely to be adolescent (vs. undetectable VL; aOR 3.0, 95% CI 1.4 to 6.6), on ART <6 months (aOR 4.4, 95% CI 2.3 to 8.6), report suboptimal adherence (aOR 2.1, 95% CI 1.1 to 3.8; p = 0.02), and less likely to have primary or secondary education (vs. none; aOR 0.3, 95% CI 0.2 to 0.7 or aOR 0.3, 95% 0.1 to 0.6). MTCT ratios among women on ART who had undetectable VL, low-detectable VL and unsuppressed VL were 0.9% (8/902; 95% CI 0.3 to 1.5), 7.0% (6/86; 95% CI 1.5 to 12.5) and 14.0% (19/136; 95% CI 8.1 to 20.0). Unsuppressed VL and low-detectable VL (vs. undetectable VL) increased the risk of MTCT 17-fold (aOR 17.4, 95% CI 7.4 to 41.1; p = 0.002) and ninefold (aOR 8.5, 95% CI 2.9 to 25.2; p < 0.001). CONCLUSIONS Unsuppressed and low-detectable VL was strongly predictive of MTCT among women on ART and associated with suboptimal adherence. This urges further consideration of optimal VL monitoring and target levels to reach elimination of paediatric infection.
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Affiliation(s)
- Megan Landes
- Dignitas InternationalZombaMalawi
- Department of Family and Community MedicineUniversity of TorontoTorontoCanada
| | - Monique van Lettow
- Dignitas InternationalZombaMalawi
- Dalla Lana School of Public HealthUniversity of TorontoTorontoCanada
| | | | | | | | | | | | - Andrew Auld
- Centers for Disease Control and PreventionLilongweMalawi
| | | | - Joep J van Oosterhout
- Dignitas InternationalZombaMalawi
- Department of MedicineCollege of MedicineBlantyreMalawi
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Govender D, Naidoo S, Taylor M. Nurses' perception of the multidisciplinary team approach of care for adolescent mothers and their children in Ugu, KwaZulu-Natal. Afr J Prim Health Care Fam Med 2019; 11:e1-e11. [PMID: 31038339 PMCID: PMC6489148 DOI: 10.4102/phcfm.v11i1.1936] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 11/12/2018] [Accepted: 11/15/2018] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Adolescent childbearing has numerous consequences on maternal health, child health and the well-being of society. Because of the high-risk nature of adolescent pregnancy, a multidisciplinary team (MDT) approach is recommended to achieve satisfactory pregnancy outcomes. AIM The aim of this study was to explore nurses' perceptions of the MDT approach in the continuum of care for adolescent mothers and their children. SETTING The study was conducted in a local district hospital in Ugu, KwaZulu-Natal. METHODS An explorative and descriptive qualitative study design was used. The first author and hospital staff (clinical midwives and the clinical manager of obstetrics and gynaecology) collaborated on the development of the focus group discussion (FGD) guide to explore nurses' perception of the MDT approach of care for adolescent mothers and their children. A total of three FGDs were conducted. Data were analysed using thematic analysis. RESULTS Six overarching themes emerged from the data analysis which included professional benefits of adopting the MDT approach of care for adolescent mothers and their children, barriers to the multidisciplinary collaboration, clinical benefits of adopting the MDT approach of care for parenting adolescent mothers, problems and needs of adolescent mothers, and nurses' reasons regarding their willingness to participate in a multidisciplinary collaboration in the care of parenting adolescent mothers. CONCLUSION In the opinion of nurses, the MDT approach of care for adolescent mothers and their children is an important strategy to improve maternal and child health outcomes. This study has important implications for the design of an intervention.
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Affiliation(s)
- Desiree Govender
- KwaZulu-Natal Department of Health, Ugu District, South Africa; and, School of Nursing and Public Health, Discipline of Public Health Medicine, University of KwaZulu-Natal, Durban.
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Thindwa D, Landes M, van Lettow M, Kanyemba A, Nkhoma E, Phiri H, Kalua T, van Oosterhout JJ, Kim EJ, Barr BAT. Pregnancy intention and contraceptive use among HIV-positive Malawian women at 4-26 weeks post-partum: A nested cross-sectional study. PLoS One 2019; 14:e0215947. [PMID: 31013338 PMCID: PMC6478345 DOI: 10.1371/journal.pone.0215947] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 04/12/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Avoiding unintended pregnancies through family planning is a WHO strategy for preventing mother to child transmission of HIV (PMTCT) and maternal morbidity/mortality. We investigated factors associated with unintended index pregnancy, unmet contraceptive need, future pregnancy intention and current contraceptive use among Malawian women living with HIV in the Option B+ era. METHODS Women who tested HIV positive at 4-26 weeks postpartum were enrolled into a cross-sectional study at high-volume Under-5 clinics. Structured baseline interviews included questions on socio-demographics, HIV knowledge, partner's HIV status/disclosure, ART use, pregnancy intention and contraceptive use. Logistic regression was used to determine factors associated with outcomes. RESULTS We enrolled 578 HIV-positive women between May 2015-May 2016; median maternal age was 28 years (y) (interquartile-range [IQR]: 23-32), median parity was 3 deliveries (IQR: 2-4) and median infant age was 7 weeks (IQR: 6-12). Overall, 41.8% women reported unintended index pregnancy, of whom 35.0% reported unmet contraceptive need and 65.0% contraceptive failure. In multivariable analysis, unintended index pregnancy was higher in ≥35y vs. 14-24y (adjusted Odds Ratio [aOR]: 2.1, 95% Confidence Interval [95%CI]: 1.0-4.2) and in women with parity ≥3 vs. primiparous (aOR: 2.9, 95%CI: 1.5-5.6). Unmet contraceptive need at conception was higher in 14-24y vs. ≥35y (aOR: 4.2, 95%CI: 1.8-9.9), primiparous vs. ≥3 (aOR: 8.3, 95%CI: 1.8-39.5), and women with a partner of unknown HIV-status (aOR: 2.2, 95%CI: 1.2-4.0). Current contraceptive use was associated with being on ART in previous pregnancy (aOR: 2.5, 95%CI: 1.5-3.9). CONCLUSIONS High prevalence of unintended index pregnancy and unmet contraceptive need among HIV-positive women highlight the need for improved access to contraceptives. To help achieve reproductive goals and elimination of MTCT of HIV, integration of family planning into HIV care should be strengthened to ensure women have timely access to a wide range of family planning methods with low failure risk.
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Affiliation(s)
- Deus Thindwa
- Management Sciences for Health, Lilongwe, Malawi
| | - Megan Landes
- Dignitas International, Zomba, Malawi
- Department of Family and Community Medicine, University of Toronto, Ontario, Canada
| | - Monique van Lettow
- Dignitas International, Zomba, Malawi
- Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
| | | | | | - Happy Phiri
- Management Sciences for Health, Lilongwe, Malawi
| | | | - Joep J. van Oosterhout
- Dignitas International, Zomba, Malawi
- Department of Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Evelyn J. Kim
- Centers for Disease Control and Prevention, Lilongwe, Malawi
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Govender K, Masebo WGB, Nyamaruze P, Cowden RG, Schunter BT, Bains A. HIV Prevention in Adolescents and Young People in the Eastern and Southern African Region: A Review of Key Challenges Impeding Actions for an Effective Response. Open AIDS J 2018; 12:53-67. [PMID: 30123385 PMCID: PMC6062910 DOI: 10.2174/1874613601812010053] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 04/27/2018] [Accepted: 05/07/2018] [Indexed: 11/22/2022] Open
Abstract
The global commitment to ending the AIDS epidemic by 2030 places HIV prevention at the centre of the response. With the disease continuing to disproportionately affect young populations in the Eastern and Southern African Region (ESAR), particularly adolescent girls and young women, reducing HIV infections in this group is integral to achieving this ambitious target. This paper examines epidemiological patterns of the HIV epidemic among adolescents and young people, indicating where HIV prevention efforts need to be focused (i.e., adolescent girls and young women, adolescent boys and young men and young key populations). Key innovations in the science of HIV prevention and strategies for dealing with programme implementation are reviewed. The paper also discusses the value of processes to mitigate HIV vulnerability and recommends actions needed to sustain the HIV prevention response. Stemming the tide of new HIV infections among young people in the ESAR requires an amplification of efforts across all sectors, which will safeguard past achievements and advance actions towards eliminating AIDS as a public health threat.
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Affiliation(s)
- Kaymarlin Govender
- Health Economics and HIV and AIDS Research Division, University of KwaZulu-Natal, Durban, South Africa
| | - Wilfred G B Masebo
- Health Economics and HIV and AIDS Research Division, University of KwaZulu-Natal, Durban, South Africa
| | - Patrick Nyamaruze
- School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Richard G Cowden
- Department of Psychology, Middle Tennessee State University, Murfreesboro, United States of America
| | | | - Anurita Bains
- UNICEF, Eastern and Southern Africa Regional Office, Nairobi, Kenya
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Groves AK, Maman S, Stankard PH, Gebrekristos LT, Amon JJ, Moodley D. Addressing the unique needs of adolescent mothers in the fight against HIV. J Int AIDS Soc 2018; 21:e25155. [PMID: 29956491 PMCID: PMC6024120 DOI: 10.1002/jia2.25155] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 06/11/2018] [Indexed: 11/12/2022] Open
Affiliation(s)
- Allison K Groves
- Department of Community Health and PreventionDrexel UniversityPhiladelphiaPAUSA
| | - Suzanne Maman
- Department of Health BehaviorUniversity of North Carolina at Chapel HillsChapel HillNCUSA
| | | | | | - Joseph J Amon
- Woodrow Wilson School of Public and International AffairsPrinceton UniversityPrincetonNJUSA
| | - Dhayendre Moodley
- Department of Obstetrics and GynaecologyUniversity of KwaZulu‐NatalNelson Mandela School of MedicineDurbanSouth Africa
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Ramraj T, Jackson D, Dinh TH, Olorunju S, Lombard C, Sherman G, Puren A, Ramokolo V, Noveve N, Singh Y, Magasana V, Bhardwaj S, Cheyip M, Mogashoa M, Pillay Y, Goga AE. Adolescent Access to Care and Risk of Early Mother-to-Child HIV Transmission. J Adolesc Health 2018; 62:434-443. [PMID: 29269045 PMCID: PMC6004498 DOI: 10.1016/j.jadohealth.2017.10.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 09/06/2017] [Accepted: 10/13/2017] [Indexed: 11/27/2022]
Abstract
PURPOSE Adolescent females aged 15-19 account for 62% of new HIV infections and give birth to 16 million infants annually. We quantify the risk of early mother-to-child transmission (MTCT) of HIV among adolescents enrolled in nationally representative MTCT surveillance studies in South Africa. METHODS Data from 4,814 adolescent (≤19 years) and 25,453 adult (≥20 years) mothers and their infants aged 4-8 weeks were analyzed. These data were gathered during three nationally representative, cross-sectional, facility-based surveys, conducted in 2010, 2011-2012, and 2012-2013. All infants were tested for HIV antibody (enzyme immunoassay), to determine HIV exposure. Enzyme immunoassay-positive infants or those born to self-reported HIV-positive mothers were tested for HIV infection (total nucleic acid polymerase chain reaction). Maternal HIV positivity was inferred from infant HIV antibody positivity. All analyses were weighted for sample realization and population live births. RESULTS Adolescent mothers, compared with adult mothers, have almost three times less planned pregnancies 14.4% (95% confidence interval [CI]: 12.5-16.5) versus 43.9% (95% CI: 42.0-45.9) in 2010 and 15.2% (95% CI: 13.0-17.9) versus 42.8% (95% CI: 40.9-44.6) in 2012-2013 (p < .0001), less prevention of MTCT uptake (odds ratio [OR] in favor of adult mothers = 3.36, 95% CI: 2.95-3.83), and higher early MTCT (adjusted OR = 3.0, 95% CI: 1.1-8.0), respectively. Gestational age at first antenatal care booking was the only significant predictor of early MTCT among adolescents. CONCLUSIONS Interventions that appeal to adolescents and initiate sexual and reproductive health care early should be tested in low- and middle-income settings to reduce differential service uptake and infant outcomes between adolescent and adult mothers.
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Affiliation(s)
- Trisha Ramraj
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa.
| | - Debra Jackson
- School of Public Health, University of the Western Cape, Cape Town, South Africa,UNICEF, Health Section, New York, New York
| | - Thu-Ha Dinh
- Center for Global Health, Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Steve Olorunju
- Biostatistics Unit, South African Medical Research Council, Cape Town, South Africa
| | - Carl Lombard
- Biostatistics Unit, South African Medical Research Council, Cape Town, South Africa,School of Public Health and Family Medicine, University of Cape Town, Cape Town South Africa
| | - Gayle Sherman
- Centre for HIV and STI, National Institute of Communicable Diseases, Johannesburg, South Africa,Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Adrian Puren
- Centre for HIV and STI, National Institute of Communicable Diseases, Johannesburg, South Africa,Division of Virology and Communicable Diseases, School of Pathology, University of the Witwatersrand Medical School, Johannesburg, South Africa
| | - Vundli Ramokolo
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Nobuntu Noveve
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Yages Singh
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Vuyolwethu Magasana
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | | | - Mireille Cheyip
- Center for Global Health, Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Pretoria, South Africa
| | - Mary Mogashoa
- Center for Global Health, Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Pretoria, South Africa
| | - Yogan Pillay
- National Department of Health, HIV/AIDS, TB & Maternal, Child, and Women’s Health, Pretoria, South Africa
| | - Ameena E. Goga
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa,Department of Paediatrics, University of Pretoria, Pretoria, South Africa
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van Lettow M, Landes M, van Oosterhout JJ, Schouten E, Phiri H, Nkhoma E, Kalua T, Gupta S, Wadonda N, Jahn A, Tippett-Barr B. Prevention of mother-to-child transmission of HIV: a cross-sectional study in Malawi. Bull World Health Organ 2018; 96:256-265. [PMID: 29695882 PMCID: PMC5872011 DOI: 10.2471/blt.17.203265] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 01/09/2018] [Accepted: 02/06/2018] [Indexed: 12/03/2022] Open
Abstract
Objective To estimate the use and outcomes of the Malawian programme for the prevention of mother-to-child transmission (MTCT) of human immunodeficiency virus (HIV). Methods In a cross-sectional analysis of 33 744 mother–infant pairs, we estimated the weighted proportions of mothers who had received antenatal HIV testing and/or maternal antiretroviral therapy and infants who had received nevirapine prophylaxis and/or HIV testing. We calculated the ratios of MTCT at 4–26 weeks postpartum for subgroups that had missed none or at least one of these four steps. Findings The estimated uptake of antenatal testing was 97.8%; while maternal antiretroviral therapy was 96.3%; infant prophylaxis was 92.3%; and infant HIV testing was 53.2%. Estimated ratios of MTCT were 4.7% overall and 7.7% for the pairs that had missed maternal antiretroviral therapy, 10.7% for missing both maternal antiretroviral therapy and infant prophylaxis and 11.4% for missing maternal antiretroviral therapy, infant prophylaxis and infant testing. Women younger than 19 years were more likely to have missed HIV testing (adjusted odds ratio, aOR: 4.9; 95% confidence interval, CI: 2.3–10.6) and infant prophylaxis (aOR: 6.9; 95% CI: 1.2–38.9) than older women. Women who had never started maternal antiretroviral therapy were more likely to have missed infant prophylaxis (aOR: 15.4; 95% CI: 7.2–32.9) and infant testing (aOR: 13.7; 95% CI: 4.2–83.3) than women who had. Conclusion Most women used the Malawian programme for the prevention of MTCT. The risk of MTCT increased if any of the main steps in the programme were missed.
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Affiliation(s)
- M van Lettow
- Dignitas International, PO Box 1071, Zomba, Malawi
| | - M Landes
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
| | | | - E Schouten
- Management Sciences for Health, Lilongwe, Malawi
| | - H Phiri
- Management Sciences for Health, Lilongwe, Malawi
| | - E Nkhoma
- Management Sciences for Health, Lilongwe, Malawi
| | - T Kalua
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi
| | - S Gupta
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi
| | - N Wadonda
- United States Centers for Disease Control and Prevention - Lilongwe, Lilongwe, Malawi
| | - A Jahn
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi
| | - B Tippett-Barr
- United States Centers for Disease Control and Prevention - Zimbabwe, Harare, Zimbabwe
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Jama NA, Wilford A, Haskins L, Coutsoudis A, Spies L, Horwood C. Autonomy and infant feeding decision-making among teenage mothers in a rural and urban setting in KwaZulu-Natal, South Africa. BMC Pregnancy Childbirth 2018; 18:52. [PMID: 29454323 PMCID: PMC5816555 DOI: 10.1186/s12884-018-1675-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 01/29/2018] [Indexed: 11/18/2022] Open
Abstract
Background The nutritional status of infants born to teenage mothers can be sub-optimal compared to those born to older mothers. One contributing factor is inappropriate feeding practices adopted by teenage mothers. Little is known about how infant feeding decisions are made among teenage mothers, particularly in under resourced settings. In this study we prospectively explored autonomy and infant feeding decision-making among teenage mothers in a rural and urban setting in KwaZulu-Natal, South Africa. Methods This study adopted a qualitative longitudinal design. Thirty pregnant participants were recruited to the study cohort, from the catchment area of two hospitals (one urban and one rural). Participants were purposively selected to include teenagers, HIV positive, and working pregnant women. We report findings from ten teenage mothers, aged between 15 and 19 years, who participated in the larger cohort (n = 5 rural; n = 5 urban). Monthly in-depth interviews were conducted with participating mothers for 6 months starting 2 weeks after delivery. All interviews were conducted in the local language, transcribed verbatim and translated into English. Data was coded using NVivo v10 and framework analysis was used. Results Findings from this study showed that teenage mothers had knowledge about recommended feeding practices. However, our findings suggest that these mothers were not involved in infant feeding decisions once they were at home, because infant feeding decision-making was a role largely assumed by older mothers in the family. Further, the age of the mother and financial dependency diminished her autonomy and ability to influence feeding practices or challenge incorrect advice given at home. Most feeding advice shared by family members was inappropriate, leading to poor infant feeding practices among teenage mothers. Returning to school and fear of breastfeeding in public were also barriers to exclusive breastfeeding. Conclusion Teenage mothers had a limited role in the infant feeding decision-making process. Health workers have an important role to play in ensuring that knowledge about infant feeding is shared with the mother’s family where infant feeding choices are made. This will improve support for teenage mothers, and may also positively impact on the nutritional status of children.
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Affiliation(s)
| | - Aurene Wilford
- Centre for Rural Health, University of KwaZulu-Natal, Durban, South Africa
| | - Lyn Haskins
- Centre for Rural Health, University of KwaZulu-Natal, Durban, South Africa
| | - Anna Coutsoudis
- Department of Pediatrics & Child Health, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Lenore Spies
- Department of Health, Pietermaritzburg, South Africa
| | - Christiane Horwood
- Centre for Rural Health, University of KwaZulu-Natal, Durban, South Africa
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Abstract
Introduction: HIV-infected pregnant and breastfeeding adolescents are a particularly vulnerable group that require special attention and enhanced support to achieve optimal maternal and infant outcomes. The objective of this paper is to review published evidence about antenatal care (ANC) service delivery and outcomes for HIV-infected pregnant adolescents in low-income country settings, identify gaps in knowledge and programme services and highlight the way forward to improve clinical outcomes of this vulnerable group. Discussion: Emerging data from programmes in sub-Saharan Africa highlight that HIV-infected pregnant adolescents have poorer prevention of mother-to-child HIV transmission (PMTCT) service outcomes, including lower PMTCT service uptake, compared to HIV-infected pregnant adults. In addition, the limited evidence available suggests that there may be higher rates of mother-to-child HIV transmission among infants of HIV-infected pregnant adolescents. Conclusions: While the reasons for the inferior outcomes among adolescents in ANC need to be further explored and addressed, there is sufficient evidence that immediate operational changes are needed to address the unique needs of this population. Such changes could include integration of adolescent-friendly services into PMTCT settings or targeting HIV-infected pregnant adolescents with enhanced retention and follow-up activities.
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Abstract
Introduction: HIV has been reported to be the leading cause of mortality amongst adolescents in Africa. This has brought attention to the changes in service provision and health management that many adolescents living with HIV experience when transferring from specialized paediatric- or adolescent-focused services to adult care. When transition is enacted poorly, adherence may be affected and the continuum of care disrupted. As the population of HIV-infected adolescents grows, effective and supported transition increases in significance as an operational imperative. Discussion: Considerable gaps remain in moving policy to practice at global, national, and local levels. Policies that give clear definition to transition and provide standard operating procedures or tools to support this process are lacking. National guidelines tend to neglect transition. Beyond transition itself, there has been slow progress on the inclusion of adolescents in national policies and strategies. Guidance often overlooks the specific needs and rights of adolescents, in particular for those living with HIV. In some cases, prohibitive laws can impede adolescent access by applying age of consent restriction to HIV testing, counselling and treatment, as well as SRH services. Where adolescent-focused policies do exist, they have been slow to emerge as tangible operating procedures at health facility level. A key barrier is the nature of existing transition guidance, which tends to recommend an individualized, client-centred approach, driven by clinicians. In low- and middle-income settings, flexible responses are resource intensive and time consuming, and therefore challenging to implement amidst staff shortages and administrative challenges. First, national governments must adopt transition-specific policies to ensure that adolescents seamlessly receive appropriate and supportive care. Second, transition policies must form part of a broader adolescent-centred policy landscape and adolescent-friendly orientation and approach at health system level. Third, national actors must ensure that transition policies are supported at implementation level. Fourth, youth involvement and community mobilization are essential. Finally, further implementation research is urgently needed to better understand how to support young people and providers in achieving smooth transitions. Conclusions: Only by moving from policy to practice through supportive policies and their implementation will we be closer to including adolescents in the 2030 goal of ending AIDS.
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HIV treatment and care services for adolescents: a situational analysis of 218 facilities in 23 sub-Saharan African countries. J Int AIDS Soc 2017; 20:21591. [PMID: 28530038 PMCID: PMC5719719 DOI: 10.7448/ias.20.4.21591] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction: In 2013, an estimated 2.1 million adolescents (age 10–19 years) were living with HIV globally. The extent to which health facilities provide appropriate treatment and care was unknown. To support understanding of service availability in 2014, Paediatric‐Adolescent Treatment Africa (PATA), a non‐governmental organisation (NGO) supporting a network of health facilities across sub‐Saharan Africa, undertook a facility‐level situational analysis of adolescent HIV treatment and care services in 23 countries. Methods: Two hundred and eighteen facilities, responsible for an estimated 80,072 HIV‐infected adolescents in care, were surveyed. Sixty per cent of the sample were from PATA's network, with the remaining gathered via local NGO partners and snowball sampling. Data were analysed using descriptive statistics and coding to describe central tendencies and identify themes. Results: Respondents represented three subregions: West and Central Africa (n = 59; 27%), East Africa (n = 77, 35%) and southern Africa (n = 82, 38%). Half (50%) of the facilities were in urban areas, 17% peri‐urban and 33% rural settings. Insufficient data disaggregation and outcomes monitoring were critical issues. A quarter of facilities did not have a working definition of adolescence. Facilities reported non‐adherence as their key challenge in adolescent service provision, but had insufficient protocols for determining and managing poor adherence and loss to follow‐up. Adherence counselling focused on implications of non‐adherence rather than its drivers. Facilities recommended peer support as an effective adherence and retention intervention, yet not all offered these services. Almost two‐thirds reported attending to adolescents with adults and/or children, and half had no transitioning protocols. Of those with transitioning protocols, 21% moved pregnant adolescents into adult services earlier than their peers. There was limited sexual and reproductive health integration, with 63% of facilities offering these services within their HIV programmes and 46% catering to the special needs of HIV‐infected pregnant adolescents. Conclusions: Results indicate that providers are challenged by adolescent adherence and reflect an insufficiently targeted approach for adolescents. Guidance on standard definitions for adherence, retention and counselling approaches is needed. Peer support may create an enabling environment and sensitize personnel. Service delivery gaps should be addressed, with standardized transition and quality counselling. Integrated, comprehensive sexual reproductive health services are needed, with support for pregnant adolescents.
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Ngandu NK, Van Malderen C, Goga A, Speybroeck N. Wealth-related inequality in early uptake of HIV testing among pregnant women: an analysis of data from a national cross-sectional survey, South Africa. BMJ Open 2017; 7:e013362. [PMID: 28706083 PMCID: PMC5577866 DOI: 10.1136/bmjopen-2016-013362] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 04/01/2017] [Accepted: 04/18/2017] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVES Wealth-related inequality across the South African antenatal HIV care cascade has not been considered in detail as a potential hindrance to eliminating mother-to-child HIV transmission (EMTCT). We aimed to measure wealth-related inequality in early (before enrolling into antenatal care) uptake of HIV testing and identify the contributing determinants. DESIGN Cross-sectional survey. SETTINGS South African primary public health facilities in 2012. PARTICIPANTS A national-level sample of 8618 pregnant women. OUTCOME MEASURES Wealth-related inequality in early uptake of HIV testing was measured using the Erreygers concentration index (CI) further adjusted for inequality introduced by predicted healthcare need (ie, need-standardised). Determinants contributing to the observed inequality were identified using the Erreygers and Wagstaff decomposition methods. RESULTS Participants were aged 13 to 49 years. Antenatal HIV prevalence was 33.2%, of which 43.7% came from the lowest 40% wealth group. A pro-poor wealth-related inequality in early HIV testing was observed. The need-standardised concentration index was -0.030 (95% confidence interval -0.038 to -0.022). The proportion of early HIV testing was significantly better in the lower 40% wealth group compared with the higher 40% wealth group (p value=0.040). The largest contributions to the observed inequality were from underlying inequalities in province (contribution, 65.27%), age (-44.38%), wealth group (24.73%) and transport means (21.61%). CONCLUSIONS Our results on better early uptake of HIV testing among the poorer subpopulation compared with the richer highlights inequity in uptake of HIV testing in South Africa. This socioeconomic difference could contribute to fast-tracking EMTCT given the high HIV prevalence among the lower wealth group. The high contribution of provinces and age to inequality highlights the need to shift from reliance on national-level estimates alone but identify subregional-specific and age-specific bottlenecks. Future interventions need to be context specific and tailored for specific subpopulations and subregional settings.
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Affiliation(s)
- Nobubelo Kwanele Ngandu
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Carine Van Malderen
- Institute of Health and Society (IRSS), Université catholique de Louvain, Brussels, Belgium
| | - Ameena Goga
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
- Department of Paediatrics and Child Health, Kalafong Hospital, University of Pretoria, Pretoria, South Africa
| | - Niko Speybroeck
- Institute of Health and Society (IRSS), Université catholique de Louvain, Brussels, Belgium
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PMTCT Service Uptake Among Adolescents and Adult Women Attending Antenatal Care in Selected Health Facilities in Zimbabwe. J Acquir Immune Defic Syndr 2017; 75:148-155. [PMID: 28234687 PMCID: PMC5427987 DOI: 10.1097/qai.0000000000001327] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background: Age-disaggregated analyses of prevention of mother-to-child transmission (PMTCT) program data to assess the uptake of HIV services by pregnant adolescent women are limited but are critical to understanding the unique needs of this vulnerable high-risk population. Methods: We conducted a retrospective analysis of patient-level PMTCT data collected from 2011 to 2013 in 36 health facilities in 5 districts of Zimbabwe using an electronic database. We compared uptake proportions for PMTCT services between adolescent (≤19 years) and adult (>19 years) women. Multivariable binomial regression analysis was used to estimate the association of the women's age group with each PMTCT service indicator. Results: The study analyzed data from 22,215 women aged 12–50 years (22.5% adolescents). Adolescents were more likely to present to antenatal care (ANC) before 14 weeks of gestational age compared with older women [adjusted relative risk (aRR) = 1.34; 95% confidence interval: 1.22 to 1.47] with equally low rates of completion of 4 ANC visits. Adolescents were less likely to present with known HIV status (aRR = 0.34; 95% confidence interval: 0.29 to 0.41) but equally likely to be HIV tested in ANC. HIV prevalence was 5.5% in adolescents vs 20.1% in adults. While >84% of both HIV-positive groups received antiretroviral drugs for PMTCT, 44% of eligible adolescents were initiated on antiretroviral therapy vs 51.3% of eligible adults, though not statistically significant. Conclusions: Pregnant adolescents must be a priority for primary HIV prevention services and expanded HIV treatment services among pregnant women to achieve an AIDS-free generation in Zimbabwe and similar high HIV burden countries.
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Prevention of HIV in Adolescent Girls and Young Women: Key to an AIDS-Free Generation. J Acquir Immune Defic Syndr 2017; 75 Suppl 1:S17-S26. [PMID: 28398993 DOI: 10.1097/qai.0000000000001316] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The Global Plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive (Global Plan) has ensured that more infants in high-HIV burden countries survive childhood HIV-free. Although equal numbers of boy and girl children have survived to age 10, a gender divergence starts to emerge as they enter adolescence. Up to 3 times as many young women aged 15-24 years in eastern and southern Africa are living with HIV compared with their male peers. Further, more adolescent girls and young women are sick and/or dying from AIDS-related or HIV-related complications during pregnancy and in the postpartum period, underscoring the importance of strengthening HIV treatment and prevention services for this group. Failure to prevent HIV in adolescent girls and young women and keep them alive will reverse the infant HIV prevention and survival gains made under the Global Plan. The promising global declines in HIV infection in young women need to be strengthened to realize the goals of an AIDS-free generation. The DREAMS initiative of the United States President's Emergency Plan for AIDS Relief (PEPFAR), which specifically addresses adolescent girls and young women at highest risk of HIV acquisition, brings new hope for meeting the prevention and care needs of this important and vulnerable population through political commitment, leadership, financial and human resource investments, advocacy efforts, and a focus on the highest priority settings. Importantly, to achieve the goal of keeping mothers alive, we have to place more emphasis on access to sexual and reproductive health services that (1) include HIV prevention and treatment services for adolescent girls and young women; (2) increase male/paternal responsibility in mother and infant health; and (3) ensure a supportive social environment that enables young women to grow up into young adults who are free to graduate from high school and plan their pregnancies, ultimately entering adulthood safe, healthy, and free from HIV.
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Wong M, Myer L, Zerbe A, Phillips T, Petro G, Mellins CA, Remien RH, Shiau S, Brittain K, Abrams EJ. Depression, alcohol use, and stigma in younger versus older HIV-infected pregnant women initiating antiretroviral therapy in Cape Town, South Africa. Arch Womens Ment Health 2017; 20:149-159. [PMID: 27815628 PMCID: PMC5500299 DOI: 10.1007/s00737-016-0688-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 10/14/2016] [Indexed: 10/20/2022]
Abstract
HIV-infected pregnant women in sub-Saharan Africa are at risk for depression and alcohol abuse. Young women may be more vulnerable, but little is known about the psychosocial functioning of this population. We compared younger (18-24 years old) and older (≥25 years old) HIV-infected pregnant women initiating antiretroviral therapy (ART) in Cape Town, South Africa. Women were assessed on a range of psychosocial measures, including the Alcohol Use Disorders Identification Test and the Edinburgh Postnatal Depression Scale (EPDS). Among 625 women initiating ART, 16 % reported risky alcohol use and 21 % alcohol-related harm; these percentages were similar across age groups. When younger women were stratified by age, 37 % of 18-21 years old versus 20 % of 22-24 years old reported alcohol-related harm (p = 0.02). Overall, 11 % of women had EPDS scores suggesting probable depression, and 6 % reported self-harming thoughts. Younger women reported more depressive symptoms. Report of self-harming thoughts was 11 % in younger and 4 % in older women (p = 0.002). In multivariable analysis, age remained significantly associated with depressive symptoms and report of self-harming thoughts. Level of HIV-related stigma and report of intimate partner violence modified the association between age and depressive symptoms. Young HIV-infected pregnant women in South Africa were more likely to report depressive symptoms and self-harming thoughts compared to older women, and the youngest women reported the highest levels of alcohol-related harm. HIV-related stigma and intimate partner violence may be moderating factors. These findings have implications for maternal and infant health, underscoring the urgent need for effective targeted interventions in this vulnerable population.
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Affiliation(s)
- Marcia Wong
- Department of Medicine, Division of Infectious Disease, Columbia University, 622 W 168th Street, PH 8W-876, New York, NY, 10032, USA.
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Level 5 Falmouth Building, Anzio Road Observatory, Cape Town, South Africa
| | - Allison Zerbe
- ICAP, Mailman School of Public Health, Columbia University, 722 W 168th Street, New York, NY, 10032, USA
| | - Tamsin Phillips
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Level 5 Falmouth Building, Anzio Road Observatory, Cape Town, South Africa
| | - Greg Petro
- Department of Obstetrics and Gynaecology, University of Cape Town, Level 5 Falmouth Building, Anzio Road Observatory, Cape Town, South Africa
| | - Claude A Mellins
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, Unit 15, 1051 Riverside Drive, New York, NY, 10032, USA
| | - Robert H Remien
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, Unit 15, 1051 Riverside Drive, New York, NY, 10032, USA
| | - Stephanie Shiau
- Department of Epidemiology, Mailman School of Public Health, Columbia University, 622 W 168th Street, 19th Floor, Room 110, New York, NY, 10032, USA
| | - Kirsty Brittain
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Level 5 Falmouth Building, Anzio Road Observatory, Cape Town, South Africa
| | - Elaine J Abrams
- ICAP, Mailman School of Public Health, Columbia University, 722 W 168th Street, New York, NY, 10032, USA
- College of Physicians and Surgeons, Columbia University, New York, NY, USA
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Crankshaw TL, Smit JA, Beksinska ME. Placing contraception at the centre of the HIV prevention agenda. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2017; 15:157-62. [PMID: 27399045 DOI: 10.2989/16085906.2016.1204330] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Over the past decade, the global response to the HIV epidemic has been unprecedented, and enormous progress has been made. Significant investment in the roll out of antiretroviral treatment (ART) and efforts to increase treatment coverage have greatly reduced the number of AIDS-related deaths worldwide. There are a growing number of promising innovations to expand the HIV prevention mix. However, the reach of these interventions is still very limited in adolescent girls and young women (15-24 years) and the full realisation of the intervention mandates has not yet been achieved. The HIV prevention field has been criticised for the tendency to adopt a narrow focus. The Fast-Track Strategy offers a unique opportunity for the HIV prevention field to broaden its gaze and to begin to identify synergies (and efficiencies) with prevention approaches from other global development priorities, namely sexual and reproductive health and rights (SRHR). This paper applies a SRHR lens to HIV prevention by highlighting the critical relationship between unintended pregnancy and HIV, and seeks to expand on earlier debates that prevention of HIV and prevention of unintended pregnancy are inextricably linked, complementary activities with interrelated and common goals. We call for the prioritisation of prevention of unintended pregnancy amongst two overlapping population groups - girls and young women (15-24 years old) and women living with HIV - as a key tactic to accomplish the Joint United Nations Programme on HIV/AIDS (UNAIDS) Fast-Track Strategy and as a way to fully realise existing HIV prevention efforts. We discuss the intersecting pathways between HIV prevention and unintended pregnancy prevention and build a case for contraception to be placed at the centre of the HIV prevention agenda.
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Affiliation(s)
- Tamaryn L Crankshaw
- a Health Economics and HIV and AIDS Research Division (HEARD) , University of KwaZulu-Natal , Durban , South Africa
| | - Jennifer A Smit
- b MatCH Research (Maternal, Adolescent, & Child Health Research) Unit, Department of Obstetrics and Gynaecology , Faculty of Health Sciences , University of the Witwatersrand , South Africa
| | - Mags E Beksinska
- b MatCH Research (Maternal, Adolescent, & Child Health Research) Unit, Department of Obstetrics and Gynaecology , Faculty of Health Sciences , University of the Witwatersrand , South Africa
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Ronen K, McGrath CJ, Langat AC, Kinuthia J, Omolo D, Singa B, Katana AK, Ng’Ang’A LW, John-Stewart G. Gaps in Adolescent Engagement in Antenatal Care and Prevention of Mother-to-Child HIV Transmission Services in Kenya. J Acquir Immune Defic Syndr 2017; 74:30-37. [PMID: 27599005 PMCID: PMC5895459 DOI: 10.1097/qai.0000000000001176] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Rates of pregnancy and HIV infection are high among adolescents. However, their engagement in prevention of mother-to-child HIV transmission (PMTCT) services is poorly characterized. We compared engagement in the PMTCT cascade between adult and adolescent mothers in Kenya. METHODS We conducted a nationally representative cross-sectional survey of mother-infant pairs attending 120 maternal child health clinics selected by probability proportionate to size sampling, with a secondary survey oversampling HIV-positive mothers in 30 clinics. Antenatal care (ANC) attendance, HIV testing, and antiretroviral (ARV) use were compared between adolescent (age ≤19 years) and adult mothers using χ tests and logistic regression. RESULTS Among 2521 mothers, 278 (12.8%) were adolescents. Adolescents were less likely than adults to be employed (16.5% vs. 37.9%), married (66.1% vs. 88.3%), have intended pregnancy (40.5% vs. 58.6%), or have disclosed their HIV status (77.5% vs. 90.7%) (P < 0.01 for all). Adolescents were less likely than adults to attend ≥4 ANC visits (35.2% vs. 45.6%, P = 0.002). This effect remained significant when adjusting for employment, household crowding, pregnancy intention, gravidity, and HIV status [adjusted odds ratio (95% confidence interval) = 0.54 (0.37 to 0.97), P = 0.001]. Among 2359 women without previous HIV testing, 96.1% received testing during pregnancy; testing levels did not differ between adolescents and adults. Among 288 HIV-positive women not on antiretroviral therapy before pregnancy, adolescents were less likely than adults to be on ARVs (65.0% vs. 85.8%, P = 0.01) or to have infants on ARVs (85.7% vs. 97.7%, P = 0.005). CONCLUSIONS Adolescent mothers had poorer ANC attendance and uptake of ARVs for PMTCT. Targeted interventions are needed to improve retention of this vulnerable population in the PMTCT cascade.
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Affiliation(s)
- Keshet Ronen
- Departments of Global Health and Epidemiology, University of Washington, Seattle, WA
| | - Christine J. McGrath
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX
| | - Agnes C. Langat
- Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
| | - John Kinuthia
- Department of Obstetrics and Gynecology, Kenyatta National Hospital, Nairobi, Kenya
| | - Danvers Omolo
- Center for Microbiology Research and Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Benson Singa
- Center for Microbiology Research and Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Lucy W. Ng’Ang’A
- Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
| | - Grace John-Stewart
- Departments of Global Health, Epidemiology, Medicine and Pediatrics, University of Washington, Seattle, WA
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Dziuban EJ, Rivadeneira ED. Universal Antiretroviral Treatment Eligibility for Children and Adolescents Living With HIV: A New Era. Pediatr Infect Dis J 2016; 35:1225-1228. [PMID: 27294308 PMCID: PMC6403488 DOI: 10.1097/inf.0000000000001276] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Antiretroviral treatment coverage for children living with HIV is low, and new efforts are underway to expand eligibility so that all children and adolescents qualify for the treatment regardless of immune suppression or clinical stage. Although recent trials provide direct evidence of the benefit of this approach in adults, no such studies have been performed in children. This report examines the available body of evidence regarding universal HIV treatment for children and adolescents and assesses the benefits and challenges both at individual patient health, as well as at programmatic level. Universal treatment eligibility for children with HIV has great potential for improved growth and neurodevelopment and fewer morbidities for children, and treatment coverage would be expected to increase through guideline simplification. However, concerns regarding toxicities, drug resistance and costs require careful planning. Successful implementation will depend on effective strategies for case-finding, treatment adherence support and program monitoring that will contribute to the growing evidence base for this pivotal pediatric HIV policy shift.
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Seeking wider access to HIV testing for adolescents in sub-Saharan Africa. Pediatr Res 2016; 79:838-45. [PMID: 26882367 DOI: 10.1038/pr.2016.28] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 12/13/2015] [Indexed: 11/08/2022]
Abstract
More than 80% of the HIV-infected adolescents live in sub-Saharan Africa. Acquired immune deficiency syndrome (AIDS)-related mortality has increased among adolescents 10-19 y old. The impact is highest in sub-Saharan Africa, where >80% of HIV-infected adolescents live. The World Health Organization has cited inadequate access to HIV testing and counseling (HTC) as a contributing factor to AIDS-related adolescent deaths, most of which occur in sub-Saharan Africa. This review focuses on studies conducted in high adolescent HIV-burden countries targeted by the "All In to End Adolescent AIDS" initiative, and describes barriers to adolescent HTC uptake and coverage. Fear of stigma and family reaction, fear of the impact of a positive diagnosis, perceived risk with respect to sexual exposure, poor attitudes of healthcare providers, and parental consent requirements are identified as major impediments. Most-at-risk adolescents for HIV infection and missed opportunities for testing include, those perinatally infected, those with early sexual debut, high mobility and multiple/older partners, and pregnant and nonpregnant females. Regional analyses show relatively low adolescent testing rates and more restrictive consent requirements for HTC in West and Central Africa as compared to East and southern Africa. Actionable recommendations for widening adolescent access to HTC and therefore timely care include minimizing legal consent barriers, healthcare provider training, parental education and involvement, and expanding testing beyond healthcare facilities.
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Narasimhan M, Loutfy M, Khosla R, Bras M. Sexual and reproductive health and human rights of women living with HIV. J Int AIDS Soc 2015; 18:20834. [PMID: 28326129 PMCID: PMC4813610 DOI: 10.7448/ias.18.6.20834] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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Chandra-Mouli V, Armstrong A, Amin A, Ferguson J. A pressing need to respond to the needs and sexual and reproductive health problems of adolescent girls living with HIV in low- and middle-income countries. J Int AIDS Soc 2015; 18:20297. [PMID: 26643463 PMCID: PMC4672396 DOI: 10.7448/ias.18.6.20297] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2015] [Revised: 10/12/2015] [Accepted: 10/16/2015] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION This commentary provides the rationale and makes a call for greater investment and effort to meet the sexual and reproductive health (SRH) problems of adolescent girls living with HIV in low- and middle-income countries (LMIC). DISCUSSION Adolescent girls in LMIC are at a greater risk of acquiring HIV infection than their male peers. They also face a number of other serious SRH problems--early pregnancy, pregnancy- and childbirth-related complications, unsafe abortions, sexual abuse and intimate partner violence and sexually transmitted infections. While many LMIC have made notable progress in preventing HIV in children and adults and in improving the access of these population groups to HIV treatment and care, adolescents in general and adolescent girls in particular have not received the same effort and investment. CONCLUSIONS Much more needs to be done to implement proven approaches to prevent new HIV infections in adolescent girls in LMIC and to meet the needs of those living with HIV.
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Affiliation(s)
| | - Alice Armstrong
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | - Avni Amin
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Jane Ferguson
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
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Woldesenbet S, Jackson D, Lombard C, Dinh TH, Puren A, Sherman G, Ramokolo V, Doherty T, Mogashoa M, Bhardwaj S, Chopra M, Shaffer N, Pillay Y, Goga A. Missed Opportunities along the Prevention of Mother-to-Child Transmission Services Cascade in South Africa: Uptake, Determinants, and Attributable Risk (the SAPMTCTE). PLoS One 2015; 10:e0132425. [PMID: 26147598 PMCID: PMC4492960 DOI: 10.1371/journal.pone.0132425] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 06/12/2015] [Indexed: 11/30/2022] Open
Abstract
Objectives We examined uptake of prevention of mother-to-child HIV transmission (PMTCT) services, predictors of missed opportunities, and infant HIV transmission attributable to missed opportunities along the PMTCT cascade across South Africa. Methods A cross-sectional survey was conducted among 4–8 week old infants receiving first immunisations in 580 nationally representative public health facilities in 2010. This included maternal interviews and testing infants’ dried blood spots for HIV. A weighted analysis was performed to assess uptake of antenatal and perinatal PMTCT services along the PMTCT cascade (namely: maternal HIV testing, CD4 count test/result, and receiving maternal and infant antiretroviral treatment) and predictors of dropout. The population attributable fraction associated with dropouts at each service point are estimated. Results Of 9,803 mothers included, 31.7% were HIV-positive as identified by reactive infant antibody tests. Of these 80.4% received some form of maternal and infant antiretroviral treatment. More than a third (34.9%) of mothers dropped out from one or more steps in the PMTCT service cascade. In a multivariable analysis, the following characteristics were associated with increased dropout from the PMTCT cascade: adolescent (<20 years) mothers, low socioeconomic score, low education level, primiparous mothers, delayed first antenatal visit, homebirth, and non-disclosure of HIV status. Adolescent mothers were twice (adjusted odds ratio: 2.2, 95% confidence interval: 1.5–3.3) as likely to be unaware of their HIV-positive status and had a significantly higher rate (85.2%) of unplanned pregnancies compared to adults aged ≥20 years (55.5%, p = 0.0001). A third (33.8%) of infant HIV infections were attributable to dropout in one or more steps in the cascade. Conclusion A third of transmissions attributable to missed opportunities of PMTCT services can be prevented by optimizing the uptake of PMTCT services. Identified risk factors for low PMTCT service uptake should be addressed through health facility and community-level interventions, including raising awareness, promoting women education, adolescent focused interventions, and strengthening linkages/referral-system between communities and health facilities.
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Affiliation(s)
- Selamawit Woldesenbet
- Health Systems Research Unit, Medical Research Council, Cape Town, South Africa
- * E-mail:
| | - Debra Jackson
- School of Public Health, University of the Western Cape, Cape Town, South Africa
- United Nations Children’s Fund, New York, United States of America
| | - Carl Lombard
- Health Systems Research Unit, Medical Research Council, Cape Town, South Africa
| | - Thu-Ha Dinh
- Centers for Disease Control and Prevention, Center for Global Health, Division of Global HIV/AIDS, Atlanta, Georgia, United States of America
| | - Adrian Puren
- National Institute for Communicable Diseases of the National Health Laboratory Services, Johannesburg, South Africa
- Division of Virology and Communicable Diseases, Faculty of Health Science, University of the Witwatersrand, Johannesburg, South Africa
| | - Gayle Sherman
- National Institute for Communicable Diseases of the National Health Laboratory Services, Johannesburg, South Africa
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Vundli Ramokolo
- Health Systems Research Unit, Medical Research Council, Cape Town, South Africa
| | - Tanya Doherty
- Health Systems Research Unit, Medical Research Council, Cape Town, South Africa
- School of Public Health, University of the Western Cape, Cape Town, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Mary Mogashoa
- Centers for Disease Control and Prevention, Center for Global Health, Division of Global HIV/AIDS, Pretoria, South Africa
| | | | - Mickey Chopra
- School of Public Health, University of the Western Cape, Cape Town, South Africa
- United Nations Children’s Fund, New York, United States of America
| | | | - Yogan Pillay
- National Department of Health, Pretoria, South Africa
| | - Ameena Goga
- Department of Paediatrics and Child Health, University of Pretoria, Pretoria, South Africa
- Health Systems Research Unit, Medical Research Council, Pretoria, South Africa
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