A clinician's experience with the President's Emergency Plan for AIDS Relief in Nigeria: a transformative decade of hope

Prior to the start of the President's Emergency Plan for AIDS Relief (PEPFAR), Nigeria struggled to fight HIV/AIDS. PEPFAR changed everything. I witnessed this change firsthand by directing the response to AIDS, first in my hospital in Jos, in central Nigeria, and now as Nigeria's HIV/AIDS coordinator. When the first AIDS case was diagnosed in Nigeria in 1986, my country had one of the world's poorest health systems, and as the pandemic spread, most Nigerians with AIDS died. Eventually, effective new drugs were developed, but they were too costly for all but a few Nigerians. Then there was a miracle: PEPFAR gave us resources, direction, and expertise to treat hundreds of thousands of people around the country. Today, Nigeria is providing treatment to 500,000 people with AIDS, and 80 percent of them receive treatment supported by PEPFAR. The US effort did more than help us treat people with HIV/AIDS; it also enabled Nigeria to strengthen its health system, improve care for pregnant women and infants, increase the provision of vaccinations, build modern laboratories, and train thousands of new health care workers and technicians.

Early uptake of HIV counseling and testing among pregnant women at different levels of health facilities--experiences from a community-based study in Northern Vietnam

BACKGROUND

HIV counselling and testing for pregnant women is a key factor for successful prevention of mother to child transmission of HIV. Women's access to testing can be improved by scaling up the distribution of this service at all levels of health facilities. However, this strategy will only be effective if pregnant women are tested early and provided enough counselling.

OBJECTIVE

To assess early uptake of HIV testing and the provision of HIV counselling among pregnant women who attend antenatal care at primary and higher level health facilities.

METHODS

A community based study was conducted among 1108 nursing mothers. Data was collected during interviews using a structured questionnaire focused on socio-economic background, reproductive history, experience with antenatal HIV counselling and testing as well as types of health facility providing the services.

RESULTS

In all 91.0% of the women interviewed had attended antenatal care and 90.3% had been tested for HIV during their most recent pregnancy. Women who had their first antenatal checkup at primary health facilities were significantly more likely to be tested before 34 weeks of gestation (OR = 43.2, CI: 18.9-98.1). The reported HIV counselling provision was also higher at primary health facilities, where women in comparison with women attending higher level health facilities were nearly three or and four times more likely to receive pre-test (OR = 2.7; CI:2.1-3.5) and post-test counseling (OR = 4.0; CI: 2.3-6.8).

CONCLUSIONS

The results suggest that antenatal HIV counseling and testing can be scaled up to primary heath facilities and that such scaling up may enhance early uptake of testing and provision of counseling.

Predictors of rapid HIV testing acceptance and successful nevirapine administration in Zambian labor wards

BACKGROUND

Provision of HIV testing in labor provides an opportunity to reach susceptible women and infants.

METHODS

As part of a cluster randomized trial of labor ward-based prevention of mother-to-child transmission services in Lusaka, Zambia, we determined predictors of testing acceptance and nevirapine (NVP) administration in labor. HIV counseling and testing were offered to women unaware of their HIV status. NVP was administered to women who tested positive, and an inert (calcium) tablet was provided to women who tested negative, to avoid stigmatization.

RESULTS

Among the 2435 women who presented in labor, 393 (16%) were unaware of their HIV status, of whom 278 (71%) met eligibility criteria. We offered counseling to 217 (78%) of eligible women: 146 (67%) agreed, 82 (56%) of those counseled were tested for HIV, and 23 (28%) were seropositive. Testing rates were higher among primigravida women [adjusted odds ratio (AOR) 1.5; 95% confidence interval (CI): 1.1 to 2.1] and among those not offered HIV testing during their pregnancy (AOR 3.7; 95% CI: 2.8 to 5.1). Cervical dilation 1 hour (AOR 11.5; 95% CI: 4.5 to 29.2) and >2 hours (AOR 11.4; 95% CI: 4.7 to 27.5) before delivery.

CONCLUSION

Labor ward HIV testing is feasible in this resource-limited setting.

Rapid testing at labor and delivery to prevent mother-to-child HIV transmission in developing settings: issues and challenges

Worldwide, approximately 2.5 million children (95% CI: 2.2-2.6) are living with HIV infection. In 2007 alone, approximately 420,000 children (95%CI: 350,000-540,000) were newly infected with HIV - a vast majority of these infections were acquired through maternal-fetal transmission. Many of these infections could have been reduced by timely diagnosis and the delivery of interventions aimed at preventing mother-to-child HIV transmission. This perspective examines the attitudes preventing women from accessing HIV testing early on during pregnancy and the issues and challenges that remain in the institutionalization of interventions to prevent mother-to-child HIV transmission at labor and delivery. Socio-cultural and economic factors prevent women from accessing testing at an opportune time during pregnancy. In addition, a lack of adequate infrastructure often prevents timely delivery of interventions to those who access testing at the last minute (i.e., during labor and delivery). In the wake of a pediatric HIV epidemic and the need for lifelong provision of antiretroviral therapy to infected children, a simple strategy for provision of round-the-clock rapid testing and counseling services in the labor rooms may be cost saving to the healthcare systems worldwide.

Altered cord blood gammadelta T cell repertoire in Nigeria: possible impacts of environmental factors on neonatal immunity

Infectious diseases during pregnancy can impact the development of fetal immunity, leading to reduced neonatal resistance to infection and decreased responses to pediatric vaccines. Plasmodium falciparum causes placental infection in low parity pregnant women and is among the pathogens that affect fetal immunity. Recognizing the relationship between malaria and gammadelta T lymphocytes in adults, we asked whether neonatal gammadelta T cells would be altered in malaria-endemic regions as a marker for changes in fetal immunity. Our initial studies compared cord blood gammadelta T cells from deliveries to HIV- mothers in Jos (Nigeria) where malaria is endemic, or in Rome (Italy). We noted substantial differences in the Vgamma2 repertoire for cord blood collected in Jos or Rome; differences were consistent with a negative selection mechanism operating on the fetal Vgamma2 chain repertoire in neonates from Jos. A specific disruption affected the fraction of gammadelta T cells that we expect will respond to Bacille Calmette-Guerin (BCG). Fetal gammadelta T cell depletion might be a mechanism for impaired neonatal immunity and lowered responses to pediatric vaccines.