1
|
Thompson P, Mpody C, Sayre W, Rigney C, Tabala M, Ravelomanana NLR, Malongo F, Kawende B, Behets F, Okitolonda E, Yotebieng M. Hepatitis C prevalence and quality of health services among HIV-positive mothers in the Democratic Republic of the Congo. Sci Rep 2022; 12:1384. [PMID: 35082320 PMCID: PMC8791992 DOI: 10.1038/s41598-022-05014-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 01/05/2022] [Indexed: 11/09/2022] Open
Abstract
Hepatitis C virus (HCV) contributes to liver-related morbidity and mortality throughout Africa despite effective antivirals. HCV is endemic in the Democratic Republic of the Congo (DRC) but data on HCV/HIV co-infection in pregnancy is limited. We estimated the prevalence of and risk factors for HCV/HIV co-infection among pregnant women in the Kinshasa province of the DRC. This cross-sectional study was conducted as a sub-study of an ongoing randomized trial to assess continuous quality improvement interventions (CQI) for prevention of mother-to-child transmission (PMTCT) of HIV (CQI-PMTCT study, NCT03048669). HIV-infected women in the CQI-PMTCT cohort were tested for HCV, and risk factors were evaluated using logistic regression. The prevalence of HCV/HIV co-infection among Congolese women was 0.83% (95% CI 0.43-1.23). Women who tested positive for HCV were younger, more likely to live in urban areas, and more likely to test positive during pregnancy versus postpartum. HCV-positive women had significantly higher odds of infection with hepatitis B virus (HBV) (aOR 13.87 [3.29,58.6]). An inverse relationship was noted between HCV infection and the overall capacity of the health facility as measured by the service readiness index (SRI) (aOR:0.92 [0.86,0.98] per unit increase). Women who presented to rural, for-profit and PEPFAR-funded health facilities were more likely to test positive for HCV. In summary, this study identified that the prevalence of HCV/HIV co-infection was < 1% among Congolese women. We also identified HBV infection as a major risk factor for HCV/HIV co-infection. Individuals with triple infection should be linked to care and the facility-related differences in HCV prevalence should be addressed in future studies.
Collapse
Affiliation(s)
- Peyton Thompson
- Division of Infectious Diseases, Department of Pediatrics, University of North Carolina, Chapel Hill, NC, USA.
| | - Christian Mpody
- Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH, USA
| | - Wesley Sayre
- School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Clare Rigney
- College of Health Sciences, Cleveland State University, Cleveland, OH, USA
| | - Martine Tabala
- School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | | | - Fathy Malongo
- School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Bienvenu Kawende
- School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Frieda Behets
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Emile Okitolonda
- School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Marcel Yotebieng
- Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | | |
Collapse
|
2
|
Moodley K, Rennie S, Behets F, Obasa AE, Yemesi R, Ravez L, Kayembe P, Makindu D, Mwinga A, Jaoko W. Allocation of scarce resources in Africa during COVID-19: Utility and justice for the bottom of the pyramid? Dev World Bioeth 2020; 21:36-43. [PMID: 32845575 PMCID: PMC7461286 DOI: 10.1111/dewb.12280] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 06/29/2020] [Accepted: 07/03/2020] [Indexed: 11/28/2022]
Abstract
The COVID‐19 pandemic has raised important universal public health challenges. Conceiving ethical responses to these challenges is a public health imperative but must take context into account. This is particularly important in sub‐Saharan Africa (SSA). In this paper, we examine how some of the ethical recommendations offered so far in high‐income countries might appear from a SSA perspective. We also reflect on some of the key ethical challenges raised by the COVID‐19 pandemic in low‐income countries suffering from chronic shortages in health care resources, and chronic high morbidity and mortality from non‐COVID‐19 causes. A parallel is drawn between the distribution of severity of COVID‐19 disease and the classic “Fortune at the bottom of the pyramid” model that is relevant in SSA. Focusing allocation of resources during COVID‐19 on the ‘thick’ part of the pyramid in Low‐to‐Middle Income Countries (LMICs) could be ethically justified on utilitarian and social justice grounds, since it prioritizes a large number of persons who have been economically and socially marginalized. During the pandemic, importing allocation frameworks focused on the apex of the pyramid from the global north may therefore not always be appropriate. In a post‐COVID‐19 world, we need to think strategically about how health care systems can be financed and structured to ensure broad access to adequate health care for all who need it. The root problems underlying health inequity, exposed by COVID‐19, must be addressed, not just to prepare for the next pandemic, but to care for people in resource poor settings in non‐pandemic times.
Collapse
|
3
|
Moodley K, Ravez L, Obasa AE, Mwinga A, Jaoko W, Makindu D, Behets F, Rennie S. What Could "Fair Allocation" during the Covid-19 Crisis Possibly Mean in Sub-Saharan Africa? Hastings Cent Rep 2020; 50:33-35. [PMID: 32596891 PMCID: PMC7362067 DOI: 10.1002/hast.1129] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The Covid-19 pandemic has sparked rapid and voluminous production of bioethics commentary in popular media and academic publications. Many of the discussions are new twists on an old theme: how to fairly allocate scarce medical resources, such as ventilators and intensive care unit beds. In this essay, we do not add another allocation scheme to the growing pile, partly out of appreciation that such schemes should be products of inclusive and transparent community engagement and partly out of recognition of their limited utility for physicians working in the field. Instead, we make the more modest claim that context matters when making such decisions and, more specifically, that recommendations from high-income countries about fair allocation during Covid-19 should not be cut and pasted into low-income settings. We offer a few examples of why seemingly universal, well-intentioned ethical recommendations could have adverse consequences if unreflectively applied in sub-Saharan Africa.
Collapse
|
4
|
Yotebieng M, Mpody C, Ravelomanana NLR, Tabala M, Malongo F, Kawende B, Ntangu P, Behets F, Okitolonda E. HIV viral suppression among pregnant and breastfeeding women in routine care in the Kinshasa province: a baseline evaluation of participants in CQI-PMTCT study. J Int AIDS Soc 2019; 22:e25376. [PMID: 31496051 PMCID: PMC6732557 DOI: 10.1002/jia2.25376] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 07/21/2019] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Published data on viral suppression among pregnant and breastfeeding women in routine care settings are scarce. Here, we report provincial estimates of undetectable and suppressed viral load among pregnant or breastfeeding women in HIV care in Kinshasa, Democratic Republic of Congo (DRC) and associated risk factors. METHODS This cross-sectional study was conducted as part of a baseline assessment for the CQI-PMTCT study: an ongoing cluster randomized trial to evaluate the effect of continuous quality interventions (CQI) on long-term ART outcomes among pregnant and breastfeeding women (NCT03048669). From November 2016 to June 2018, in each of the 35 Kinshasa provincial health zones (HZ), study teams visited the three busiest maternal and child health clinics, enrolled all HIV-positive pregnant or breastfeeding women (≤1 year post-delivery) receiving ART, and performed viral load testing. Log binomial models with generalized estimating equations to account for clustering at the HZ level, were used to estimate prevalence ratios comparing participants with undetected (<40 copies/mL) or suppressed (<1000 copies/mL) viral load across levels of individual and site characteristics. RESULTS Of the 1752 eligible women, 1623 had viral load results available, including 38% who had been on ART for <6 months and 74% were on tenofovir-lamivudine-efavirenz. Viral load was undetectable in 53% of women and suppressed in 62%. Among women who were on ART for ≥12 months, only 60% and 67% respectively, had undetectable or suppressed viral load. Viral load was undetectable in 53%, 48% and 58% of women testing during pregnancy, at delivery, and in postpartum respectively. In multivariable log binomial models, duration of ART >12 months, older age, being married, disclosure of HIV status, receiving care in an urban health zone or one supported by PEPFAR were all positively associated with viral suppression. CONCLUSIONS The observed high level of detectable viral load suggests that high ART coverage alone without substantial efforts to improve the quality of care for pregnant and breastfeeding women, will not be enough to achieve the goal of virtual elimination of vertical HIV transmission in high-burden and limited resources settings like DRC.
Collapse
Affiliation(s)
- Marcel Yotebieng
- Division of EpidemiologyCollege of Public HealthThe Ohio State UniversityColumbusOHUSA
| | - Christian Mpody
- Division of EpidemiologyCollege of Public HealthThe Ohio State UniversityColumbusOHUSA
| | - Noro LR Ravelomanana
- Division of EpidemiologyCollege of Public HealthThe Ohio State UniversityColumbusOHUSA
| | - Martine Tabala
- School of Public HealthThe University of KinshasaKinshasaDemocratic Republic of Congo
| | - Fathy Malongo
- School of Public HealthThe University of KinshasaKinshasaDemocratic Republic of Congo
| | - Bienvenu Kawende
- School of Public HealthThe University of KinshasaKinshasaDemocratic Republic of Congo
| | - Paul Ntangu
- National AIDS Control Program (PNLS)Provincial CoordinationKinshasaDemocratic Republic of Congo
| | - Frieda Behets
- Department of EpidemiologyGillings School of Global Public HealthThe University of North Carolina at Chapel HillChapel HillNCUSA
- Department of Social MedicineThe University of North Carolina at Chapel HillChapel HillNCUSA
| | - Emile Okitolonda
- School of Public HealthThe University of KinshasaKinshasaDemocratic Republic of Congo
| | | |
Collapse
|
5
|
Zivich PN, Kawende B, Lapika B, Behets F, Yotebieng M. Effect of Family Planning Counseling After Delivery on Contraceptive Use at 24 Weeks Postpartum in Kinshasa, Democratic Republic of Congo. Matern Child Health J 2019; 23:530-537. [PMID: 30565015 DOI: 10.1007/s10995-018-2667-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Introduction Unintended pregnancy during the postpartum period is common. The aim of this study was to describe contraceptive use among postpartum women and assess whether family planning counseling offered by health care providers during well-baby clinic visits increased use of modern contraceptive methods at 6 months following delivery. Methods Data comes from a cohort of women enrolled in a breastfeeding promotion trial in Kinshasa, Democratic Republic of Congo who reported being sexually active at 24-weeks post-partum. Modern contraceptive methods included intrauterine devices, injectables, implants, and contraception pills. Logistic regression models were used to estimate odd ratios (OR) and 95% confidence intervals (CI) for the impact of nurse counseling on use of modern birth control methods. Results Of 522 participants who reported being sexually active, 251 (48.0%) reported doing at least one thing to avoid pregnancy and were included in this analysis. Of these 251, 14.3% were using a modern contraceptive method, despite availability at the clinic. Discussion with a nurse about family planning was associated with increased odds of using modern birth control relative to other methods (OR 4.0, 95% CI 1.9, 8.6). Discussion Discussion of family planning with a nurse increased the odds of using a modern contraceptive among postpartum women. Integration of family planning counseling into postpartum services offers a potential avenue to increase modern contraceptive use among women with access.
Collapse
Affiliation(s)
- Paul N Zivich
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, 135 Dauer Drive, 2101 McGavran-Greenberg, CB #7435, Chapel Hill, NC, 27599, USA.
| | - Bienvenu Kawende
- School of Public Health, The University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Bruno Lapika
- Department of Anthropology, The University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Frieda Behets
- School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Marcel Yotebieng
- Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH, USA
| |
Collapse
|
6
|
Ravez LJC, Rennie S, Yemesi R, Chalachala JL, Makindu D, Behets F, Fox A, Kashamuka M, Kayembé P. Les grèves de médecins en République Démocratique du Congo : quels repères éthiques généralisables? bioethics 2019. [DOI: 10.7202/1062303ar] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Depuis plusieurs années, la République Démocratique du Congo est le théâtre de grèves menées par les médecins du pays. Les revendications des grévistes en question sont essentiellement financières et statutaires, et visent à faire pression sur le gouvernement. Dans ce pays, comme c’est le cas presque partout dans le monde, les grèves médicales sont autorisées. Tout travailleur a le droit de dénoncer par la grève des conditions de travail jugées inacceptables. Mais les médecins sont-ils des travailleurs comme les autres? N’ont-ils pas des obligations morales particulières liées aux spécificités de leur profession? Pour éclairer ces questions, les auteurs de cet article proposent trois repères moraux essentiels généralisables à des situations de grèves médicales ailleurs dans le monde. Le premier porte sur la reconnaissance du droit de grève pour les médecins, y compris pour des motifs strictement financiers. On ne peut demander à des professionnels de santé d’exercer leur métier dans des conditions de travail inhumaines ou sans un salaire permettant de faire vivre leur famille. Le deuxième repère estime que l’on ne peut pas accepter que ce droit de grève s’exerce en sacrifiant les patients les plus fragiles et en niant ainsi l’essence même de la profession médicale. Un troisième repère vient complexifier la réflexion en rappelant que l’extrême délabrement du système de santé congolais rend impossible l’organisation d’un service minimum de qualité en cas de grève. Pour sortir de ces difficultés, nous proposons une alliance thérapeutique nationale entre les médecins et les citoyens pour replacer les patients au centre des préoccupations du système de santé.
Collapse
Affiliation(s)
- Laurent Jean-Claude Ravez
- Centre de Bioéthique, Institut Espace Philosophique de Namur (ESPHIN), Université de Namur, Belgique
| | - Stuart Rennie
- Department of Social Medicine and Center for Bioethics, University of North Carolina at Chapel Hill, USA
| | - Robert Yemesi
- École de Santé Publique, Centre Interdisciplinaire de Bioéthique pour l’Afrique francophone (CIBAF), Université de Kinshasa et Université de Lodja, République Démocratique du Congo
| | - Jean-Lambert Chalachala
- DRC Country Representative, Family Planning Country Action Process Evaluation (FP CAPE)/Carolina Population Center, University of North Carolina at Chapel Hill, USA
| | - Darius Makindu
- École de Santé Publique, Centre Interdisciplinaire de Bioéthique pour l’Afrique francophone (CIBAF), Université de Kinshasa et Université de Lodja, République Démocratique du Congo
| | - Frieda Behets
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, USA
| | - Albert Fox
- Centre de Bioéthique, Institut Espace Philosophique de Namur (ESPHIN), Université de Namur, Belgique
| | - Melchior Kashamuka
- École de Santé Publique, Université de Kinshasa, République Démocratique du Congo
| | - Patrick Kayembé
- École de Santé Publique, Université de Kinshasa, République Démocratique du Congo
| |
Collapse
|
7
|
Rennie S, Ravez L, Makindu D, Fox A, Grauls B, Yemesi R, Kayembé P, Chalachala JL, Kashamuka M, Behets F. Bioethics education in Democratic Republic of Congo: Experiences and challenges. ACTA ACUST UNITED AC 2018; 15:192-200. [PMID: 34135995 DOI: 10.1016/j.etiqe.2018.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
In regions marked by socio-economic turmoil, the task of teaching bioethics to health professionals and researchers can be more challenging than elsewhere. To demonstrate this, in this article we describe some of our teaching experiences in the Democratic Republic of Congo over the past decade. A first difficulty is linguistic. Anglo-Saxon language and culture largely dominates the field of bioethics, complicating teaching and education for those who do not master the language. A second obstacle is conceptual. Bioethics is often misunderstood as reflection on technological developments in medicine, which distorts its objectives and narrows its scope, particularly in resource-constrained settings. A third difficulty is cultural and political. Ethics in this setting is difficult to distinguish from common morality and the work of moralists, who comment on problems in medicine from a religious standpoint. Moreover, when interacting with communities and institutions that are strongly hierarchical, the critical stance of bioethics can give rise to resistance and rejection. These are among the array of difficulties that undoubtedly have given rise to sharp critiques of bioethics training initiatives in developing countries, where the introduction of bioethics has been depicted as a form of Western imperialism. While taking these criticisms seriously, our experiences in the field show how these seemingly insurmountable difficulties can be transformed into (more or less) manageable challenges.
Collapse
Affiliation(s)
- S Rennie
- Department of Social Medicine and Center for Bioethics, University of North Carolina at Chapel Hill, États-Unis
| | - L Ravez
- Département Sciences-Philosophies-Sociétés, Centre de Bioéthique de l'Université de Namur, Institut, Université de Namur, rue de Bruxelles, 61, 5000 Namur, Belgique
| | - D Makindu
- École de Santé Publique, Centre Interdisciplinaire de Bioéthique pour l'Afrique Francophone (CIBAF), Université de Kinshasa, République Démocratique du Congo.,Université Pédagogique Nationale, République Démocratique du Congo
| | - A Fox
- Département Sciences-Philosophies-Sociétés, Centre de Bioéthique de l'Université de Namur, Institut, Université de Namur, rue de Bruxelles, 61, 5000 Namur, Belgique
| | - B Grauls
- Département Sciences-Philosophies-Sociétés, Centre de Bioéthique de l'Université de Namur, Institut, Université de Namur, rue de Bruxelles, 61, 5000 Namur, Belgique
| | - R Yemesi
- Université Pédagogique Nationale, République Démocratique du Congo.,Université de Lodja, République Démocratique du Congo
| | - P Kayembé
- École de Santé Publique, République Démocratique du Congo
| | - J L Chalachala
- University of North Carolina at Chapel Hill, DRC Country Representative, Family Planning Country Action Process Evaluation (FP CAPE)/Carolina Population Center, États-Unis
| | - M Kashamuka
- École de Santé Publique, République Démocratique du Congo
| | - F Behets
- University of North Carolina at Chapel Hill, Department of Epidemiology, Gillings School of Global Public Health, États-Unis
| |
Collapse
|
8
|
Gichane MW, Moracco KE, Thirumurthy H, Okitolonda EW, Behets F, Yotebieng M. Intimate partner violence and prevention of mother to child transmission of HIV: Evidence from Kinshasa, Democratic Republic of Congo. PLoS One 2018; 13:e0203471. [PMID: 30161260 PMCID: PMC6117078 DOI: 10.1371/journal.pone.0203471] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 08/21/2018] [Indexed: 11/19/2022] Open
Abstract
Intimate partner violence (IPV) is a risk factor for non-adherence to HIV treatment for women, however the evidence on the impact of IPV on uptake of the prevention of mother to child transmission of HIV (PMTCT) cascade is inconclusive. We examined data from 433 HIV positive pregnant women in Kinshasa, Democratic Republic of Congo, enrolled between April 2013 and August 2014 and followed-up through 6 weeks postpartum. Participants were asked about their IPV experiences in a face-to-face interview at enrollment. Measures of PMTCT cascade included: uptake of clinical appointments and services, viral suppression, and adherence to antiretrovirals (ARV). Approximately half of the sample (51%) had experienced some form of IPV; 35% had experienced emotional abuse, 29% physical abuse, and 19% sexual abuse. There were no statistically significant associations between experiencing any form of IPV and uptake of clinical appointments and services (Adjusted Prevalence Ratio [aPR] = 1.02; 95% [CI]: 0.89–1.17), viral load suppression (aPR = 1.07, 95% CI:0.96–1.19) and ARV adherence (aPR = 1.01, 95% CI: 0.87–1.18). Findings from this study indicate that, among HIV-infected pregnant women enrolled in PMTCT care, experiencing IPV does not reduce adherence to clinic visits and services, adherence to ARV. The high prevalence of IPV in this population suggests that IPV screening and intervention should be included as part of standard care for PMTCT.
Collapse
Affiliation(s)
- Margaret W. Gichane
- The University of North Carolina at Chapel Hill, Department of Health Behavior, Chapel Hill, NC, United States of America
- * E-mail:
| | - Kathryn E. Moracco
- The University of North Carolina at Chapel Hill, Department of Health Behavior, Chapel Hill, NC, United States of America
| | - Harsha Thirumurthy
- University of Pennsylvania Pearlman School of Medicine, Department of Medical Ethics and Health Policy, Philadelphia, PA, United States of America
| | - Emile W. Okitolonda
- The University of Kinshasa, School of Public Health, Kinshasa, Democratic Republic of Congo
| | - Frieda Behets
- The University of North Carolina at Chapel Hill, Department of Epidemiology, Chapel Hill, NC, United States of America
- The University of North Carolina at Chapel Hill, Department of Social Medicine, Chapel Hill, NC, United States of America
| | - Marcel Yotebieng
- The University of North Carolina at Chapel Hill, Department of Social Medicine, Chapel Hill, NC, United States of America
- The Ohio State University, College of Public Health, Division of Epidemiology, Columbus, OH, United States of America
| |
Collapse
|
9
|
Ross J, Edmonds A, Hoover DR, Shi Q, Anastos K, Lelo P, Behets F, Yotebieng M. Association between pregnancy at enrollment into HIV care and loss to care among women in the Democratic Republic of Congo, 2006-2013. PLoS One 2018; 13:e0195231. [PMID: 29608618 PMCID: PMC5880386 DOI: 10.1371/journal.pone.0195231] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 03/08/2018] [Indexed: 01/08/2023] Open
Abstract
Background Loss to care is high among asymptomatic HIV-infected women initiated on antiretroviral therapy (ART) during pregnancy or in the postpartum period. However, whether pregnancy itself plays a role in the high loss to care rate is uncertain. We compared loss to care over seven years between pregnant and non-pregnant women at enrollment into HIV care in the Democratic Republic of Congo (DRC). Methods We conducted a retrospective analysis of all ART-naive women aged 15–45 initiating HIV care at two large clinics in Kinshasa, DRC, from 2007–2013. Pregnancy status was recorded at care enrollment. Patients were classified as having no follow-up if they did not return to care after the initial enrollment visit. Among those with at least one follow-up visit after enrollment, we classified patients as lost to care if more than 365 days had passed since their last clinic visit. We used logistic regression to model the association between pregnancy status and no follow-up, and Cox proportional hazards regression to model the association between pregnancy status and time to loss to care. Results Of 2175 women included in the analysis, 1497 (68.8%) were pregnant at enrollment. Compared to non-pregnant women, pregnant women were less likely to be over 35 years of age (19.1% vs. 31.9%, p<0.0001) and less likely to be in WHO stage III or IV (9.0% vs. 26.3%, p<0.0001). Among pregnant women, 106 (7.1%) were not seen after enrollment, versus 25 (3.7%) non-pregnant women (adjusted odds ratio 2.01, 95% CI 1.24–3.24). Of the 2,044 women with at least one follow-up visit, 46.5% of pregnant women and 46.7% of non-pregnant women were lost to care by 5 years; hazards of loss to care were similar for pregnant and non-pregnant women (adjusted hazard ratio 1.08, 95% CI 0.93–1.26). Conclusions In this large cohort of HIV-infected women, patients pregnant at care enrollment were more likely to never return for follow-up. Among those who attended at least one follow-up visit, loss to care was not different between pregnant and non-pregnant women, suggesting that pregnancy itself may not be the main driver of the high attrition observed in this cohort.
Collapse
Affiliation(s)
- Jonathan Ross
- Department of Medicine, Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine / Montefiore Medical Center, Bronx, NY, United States of America
- * E-mail:
| | - Andrew Edmonds
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Donald R. Hoover
- Department of Statistics and Biostatistics, Rutgers University, New Brunswick, NJ, United States of America
| | - Qiuhu Shi
- Department of Epidemiology and Community Health, New York Medical College, Valhalla, NY, United States of America
| | - Kathryn Anastos
- Department of Medicine, Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine / Montefiore Medical Center, Bronx, NY, United States of America
| | - Patricia Lelo
- Kalembelembe Pediatric Hospital, Kinshasa, The Democratic Republic of Congo
| | - Frieda Behets
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Marcel Yotebieng
- College of Public Health, Division of Epidemiology, The Ohio State University, Columbus, OH, United States of America
| |
Collapse
|
10
|
Yotebieng M, Behets F, Kawende B, Ravelomanana NLR, Tabala M, Okitolonda EW. Continuous quality improvement interventions to improve long-term outcomes of antiretroviral therapy in women who initiated therapy during pregnancy or breastfeeding in the Democratic Republic of Congo: design of an open-label, parallel, group randomized trial. BMC Health Serv Res 2017; 17:306. [PMID: 28446232 PMCID: PMC5406969 DOI: 10.1186/s12913-017-2253-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 04/20/2017] [Indexed: 11/11/2022] Open
Abstract
Background Despite the rapid adoption of the World Health Organization’s 2013 guidelines, children continue to be infected with HIV perinatally because of sub-optimal adherence to the continuum of HIV care in maternal and child health (MCH) clinics. To achieve the UNAIDS goal of eliminating mother-to-child HIV transmission, multiple, adaptive interventions need to be implemented to improve adherence to the HIV continuum. Methods The aim of this open label, parallel, group randomized trial is to evaluate the effectiveness of Continuous Quality Improvement (CQI) interventions implemented at facility and health district levels to improve retention in care and virological suppression through 24 months postpartum among pregnant and breastfeeding women receiving ART in MCH clinics in Kinshasa, Democratic Republic of Congo. Prior to randomization, the current monitoring and evaluation system will be strengthened to enable collection of high quality individual patient-level data necessary for timely indicators production and program outcomes monitoring to inform CQI interventions. Following randomization, in health districts randomized to CQI, quality improvement (QI) teams will be established at the district level and at MCH clinics level. For 18 months, QI teams will be brought together quarterly to identify key bottlenecks in the care delivery system using data from the monitoring system, develop an action plan to address those bottlenecks, and implement the action plan at the level of their district or clinics. Discussion If proven to be effective, CQI as designed here, could be scaled up rapidly in resource-scarce settings to accelerate progress towards the goal of an AIDS free generation. Trial registration The protocol was retrospectively registered on February 7, 2017. ClinicalTrials.gov Identifier: NCT03048669.
Collapse
Affiliation(s)
- Marcel Yotebieng
- Division of Epidemiology, The Ohio State University, College of Public Health, 304 Cunz Hall, 1841 Neil Avenue, Columbus, OH, 43210, USA.
| | - Frieda Behets
- Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Department of Social Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Bienvenu Kawende
- The University of Kinshasa, School of Public Health, Kinshasa, Democratic Republic of Congo
| | - Noro Lantoniaina Rosa Ravelomanana
- Division of Epidemiology, The Ohio State University, College of Public Health, 304 Cunz Hall, 1841 Neil Avenue, Columbus, OH, 43210, USA.,The University of Kinshasa, School of Public Health, Kinshasa, Democratic Republic of Congo
| | - Martine Tabala
- The University of Kinshasa, School of Public Health, Kinshasa, Democratic Republic of Congo
| | - Emile W Okitolonda
- The University of Kinshasa, School of Public Health, Kinshasa, Democratic Republic of Congo
| |
Collapse
|
11
|
Mbonze NB, Tabala M, Wenzi LK, Bakoko B, Brouwer M, Creswell J, Van Rie A, Behets F, Yotebieng M. Xpert(®) MTB/RIF for smear-negative presumptive TB: impact on case notification in DR Congo. Int J Tuberc Lung Dis 2017; 20:240-6. [PMID: 26792478 DOI: 10.5588/ijtld.15.0177] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING The impact of Xpert(®) MTB/RIF as a follow-on diagnostic test after smear microscopy on tuberculosis (TB) notification has not yet been well defined. DESIGN Quasi-experimental design with 86 evaluation and 49 control clinics in Kinshasa, Democratic Republic of Congo. Smear microscopy was supported at all 135 clinics, Xpert was placed in 15 evaluation clinics and a sputum transport system was implemented for 25 satellite clinics. The number of cases notified before and during the project (July 2012-June 2013) was obtained from the National TB Program. RESULTS Of 27,147 presumptive TB cases presenting in clinics with access to Xpert, 5922 (21.8%) were smear-positive. Of 18,636 individuals with ⩾ 3 negative microscopy results, 6920 (37.1%) underwent Xpert testing, 991 (14.3%) of whom tested positive. The number of bacteriologically positive cases increased equally in evaluation clinics (15.1%, 95%CI -2.3 to 32.6) and control clinics (13.6%, 95%CI 2.6-29.3), for a difference in increase of 1.5% (95%CI -28.8 to 31.8). There was no difference in the change in smear-negative cases (-42.4%, 95%CI -111.5 to 26.6), nor in all types of TB notified (-6.1%, 95%CI -32.5 to 20.4) between the evaluation and control clinics. CONCLUSION In part due to a restrictive algorithm, Xpert as follow-on to smear microscopy did not increase the overall number of TB notifications, nor the number of bacteriologically positive cases.
Collapse
Affiliation(s)
- N B Mbonze
- School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - M Tabala
- School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - L K Wenzi
- School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - B Bakoko
- Provincial Coordination of the National TB Programme, Kinshasa, Democratic Republic of Congo
| | - M Brouwer
- Public Health, TB and HIV Consult, Tilburg, The Netherlands
| | - J Creswell
- Stop TB Partnership, Secretariat, Geneva, Switzerland
| | - A Van Rie
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - F Behets
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - M Yotebieng
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Division of Epidemiology, College of Public Health, Ohio State University, Columbus, Ohio, USA
| |
Collapse
|
12
|
Yotebieng M, Wenzi LK, Basaki E, Batumbula ML, Tabala M, Mungoyo E, Mangala R, Behets F. Provider-Initiated HIV testing and counseling among patients with presumptive tuberculosis in Democratic Republic of Congo. Pan Afr Med J 2016; 25:161. [PMID: 28292123 PMCID: PMC5326046 DOI: 10.11604/pamj.2016.25.161.8125] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 08/06/2016] [Indexed: 11/20/2022] Open
Abstract
Introduction Provider-initiated HIV testing and counseling (PITC) of patients with presumptive tuberculosis (TB) is not widely implemented and the burden of HIV among them is not well characterized. We assessed the uptake of PITC and prevalence of HIV among patients with presumptive TB in primary care settings in the Democratic Republic of Congo. Methods PITC was implemented in primary care TB clinics in Kinshasa and Kisangani, respectively. In each of the clinics, all patients presenting with cough lasting more than two weeks or any other symptom suggestive of TB were offered HIV testing and counseling and those found to be HIV+ were linked to HIV care and treatment. Results Between November 2011 and June 2013, 43,145 patients with presumptive TB were registered in 65 clinics in Kinshasa of whom 84.0% were counseled; 92.4% of those counseled were tested and 4,320 (12.9%) were found to be HIV+. Similarly, in Kisangani, of the 6,687 patients with presumptive TB were registered in 13 clinics, 80.5% were counseled; 99.3% were tested for HIV and 619 (11.6%) were found to be HIV+. Conclusion Implementation of PITC among patients with presumptive TB in primary care clinics was associated with high uptake of HIV testing and identification of high number of HIV+ patients.
Collapse
Affiliation(s)
- Marcel Yotebieng
- The Ohio State University, College of Public Health, Division of Epidemiology, Columbus, OH, USA; The University of North Carolina at Chapel Hill, Department of Epidemiology, Chapel Hill, NC, USA
| | - Landry Kipula Wenzi
- The University of Kinshasa, School of Public Health, Kinshasa, Democratic Republic of Congo
| | - Emmanuel Basaki
- The University of Kinshasa, School of Public Health, Kinshasa, Democratic Republic of Congo
| | - Marie Louise Batumbula
- The University of Kinshasa, School of Public Health, Kinshasa, Democratic Republic of Congo
| | - Martine Tabala
- The University of Kinshasa, School of Public Health, Kinshasa, Democratic Republic of Congo
| | - Eugenie Mungoyo
- The University of Kinshasa, School of Public Health, Kinshasa, Democratic Republic of Congo
| | - Richard Mangala
- The University of Kinshasa, School of Public Health, Kinshasa, Democratic Republic of Congo
| | - Frieda Behets
- The University of North Carolina at Chapel Hill, Department of Epidemiology, Chapel Hill, NC, USA; The University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA
| |
Collapse
|
13
|
Yotebieng M, Thirumurthy H, Moracco KE, Kawende B, Chalachala JL, Wenzi LK, Ravelomanana NLR, Edmonds A, Thompson D, Okitolonda EW, Behets F. Conditional cash transfers and uptake of and retention in prevention of mother-to-child HIV transmission care: a randomised controlled trial. Lancet HIV 2016; 3:e85-93. [PMID: 26847230 DOI: 10.1016/s2352-3018(15)00247-7] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 12/01/2015] [Accepted: 12/04/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND Novel strategies are needed to increase retention in and uptake of prevention of mother-to-child HIV transmission (PMTCT) services in sub-Saharan Africa. We aimed to determine whether small, increasing cash payments, which were conditional on attendance at scheduled clinic visits and receipt of proposed services can increase the proportions of HIV-infected pregnant women who accept available PMTCT services and remain in care. METHODS In this randomised controlled trial, we recruited newly diagnosed HIV-infected women, who were 32 or less weeks pregnant, from 89 antenatal care clinics in Kinshasa, Democratic Republic of Congo, and randomly assigned (1:1) them to either the intervention group or the control group using computer-based randomisation with varying block sizes of four, six, and eight. The intervention group received compensation on the condition that they attended scheduled clinic visits and accepted offered PMTCT services (US$5, plus US$1 increment at every subsequent visit), whereas the control group received usual care. Outcomes assessed included retention in care at 6 weeks' post partum and uptake of PMTCT services, measured by attendance of all scheduled clinic visits and acceptance of proposed services up to 6 weeks' post partum. Analyses were by intention to treat. This trial is registered with ClinicalTrials.org, number NCT01838005. FINDINGS Between April 18, 2013, and Aug 30, 2014, 612 potential participants were identified, 545 were screened, and 433 were enrolled and randomly assigned; 217 to the control group and 216 to the intervention group. At 6 weeks' post partum, 174 participants in the intervention group (81%) and 157 in the control group (72%) were retained in care (risk ratio [RR] 1·11; 95% CI 1·00-1·24). 146 participants in the intervention group (68%) and 116 in the control group (54%) attended all clinic visits and accepted proposed services (RR 1·26; 95% CI 1·08-1·48). Results were similar after adjustment for marital status, age, and education. INTERPRETATION Among women with newly diagnosed HIV, small, incremental cash incentives resulted in increased retention along the PMTCT cascade and uptake of available services. The cost-effectiveness of these incentives and their effect on HIV-free survival warrant further investigation. FUNDING President's Emergency Plan for AIDS Relief and the National Institute of Health and Child Development.
Collapse
Affiliation(s)
- Marcel Yotebieng
- The Ohio State University, College of Public Health, Division of Epidemiology, Columbus, OH, USA; The University of North Carolina at Chapel Hill, Department of Epidemiology, Chapel Hill, NC, USA.
| | - Harsha Thirumurthy
- The University of North Carolina at Chapel Hill, Department of Health Policy and Management, Chapel Hill, NC, USA
| | - Kathryn E Moracco
- The University of North Carolina at Chapel Hill, Department of Health Behavior, Chapel Hill, NC, USA
| | - Bienvenu Kawende
- The University of Kinshasa, School of Public Health, Kinshasa, Democratic Republic of Congo
| | | | - Landry Kipula Wenzi
- The University of Kinshasa, School of Public Health, Kinshasa, Democratic Republic of Congo
| | | | - Andrew Edmonds
- The University of North Carolina at Chapel Hill, Department of Epidemiology, Chapel Hill, NC, USA
| | - Deidre Thompson
- The University of North Carolina at Chapel Hill, Department of Epidemiology, Chapel Hill, NC, USA
| | - Emile W Okitolonda
- The University of Kinshasa, School of Public Health, Kinshasa, Democratic Republic of Congo
| | - Frieda Behets
- The University of North Carolina at Chapel Hill, Department of Epidemiology, Chapel Hill, NC, USA; The University of North Carolina at Chapel Hill, Department of Social Medicine, Chapel Hill, NC, USA
| |
Collapse
|
14
|
Hogan CA, Iles J, Frost EH, Giroux G, Cassar O, Gessain A, Dion MJ, Ilunga V, Rambaut A, Yengo-Ki-Ngimbi AÉ, Behets F, Pybus OG, Pépin J. Epidemic History and Iatrogenic Transmission of Blood-borne Viruses in Mid-20th Century Kinshasa. J Infect Dis 2016; 214:353-60. [PMID: 26768251 DOI: 10.1093/infdis/jiw009] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 11/13/2015] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The human immunodeficiency virus type 1 (HIV-1) pandemic was ignited in Léopoldville (now known as Kinshasa), in the former Belgian Congo. Factors that jump-started its early expansion remain unclear. Nonlethal hepatitis C virus (HCV) and human T-cell lymphotropic virus (HTLV-1) can be used to investigate past iatrogenic transmission. METHODS We undertook a cross-sectional study of elderly inhabitants of Kinshasa, with serological assays, amplification, and sequencing. Risk factors were assessed through logistic regression. Phylogenetic methods reconstructed the genetic history of HCV. RESULTS A total of 217 of 839 participants (25.9%) were HCV seropositive; 26 (3.1%) were HTLV-1-seropositive. Amplification products were obtained from 118 HCV-seropositive participants; subtypes 4k (in 47 participants) and 4r (in 38) were most common. Independent risk factors for HCV subtype 4r seropositivity were intramuscular tuberculosis therapy, intravenous injections at hospital A, intravenous injections before 1960, and injections at a colonial-era venereology clinic. Intravenous injections at hospital B and antimalarials were associated with HCV subtype 4k seropositivity. Risk factors for HTLV-1 seropositivity included intravenous injections at hospitals C or D and transfusions. Evolutionary analysis of viral sequences revealed independent exponential amplification of HCV subtypes 4r and 4k from the 1950s onward. CONCLUSIONS Iatrogenic transmission of HCV and HTLV-1 occurred in mid-20th century Kinshasa, at the same time and place HIV-1 emerged. Iatrogenic routes may have contributed to the early establishment of the pandemic.
Collapse
Affiliation(s)
| | | | | | | | - Olivier Cassar
- Institut Pasteur Centre National de la Recherche Scientifique, UMR 3569, Paris, France
| | - Antoine Gessain
- Institut Pasteur Centre National de la Recherche Scientifique, UMR 3569, Paris, France
| | | | | | | | | | - Frieda Behets
- Programme ESP/UNC-DRC University of North Carolina, Chapel Hill
| | | | | |
Collapse
|
15
|
Yotebieng M, Behets F. Step 10: the breastfeeding support paradox - Authors' reply. Lancet Glob Health 2016; 4:e20. [PMID: 26718801 DOI: 10.1016/s2214-109x(15)00221-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 09/29/2015] [Indexed: 12/01/2022]
Affiliation(s)
| | - Frieda Behets
- Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7240, USA
| |
Collapse
|
16
|
Edmonds A, Feinstein L, Okitolonda V, Thompson D, Kawende B, Behets F. Implementation and Operational Research: Decentralization Does Not Assure Optimal Delivery of PMTCT and HIV-Exposed Infant Services in a Low Prevalence Setting. J Acquir Immune Defic Syndr 2015; 70:e130-9. [PMID: 26262776 PMCID: PMC4856046 DOI: 10.1097/qai.0000000000000781] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND The consequences of decentralizing prevention of mother-to-child HIV transmission and HIV-exposed infant services to antenatal care (ANC)/labor and delivery (L&D) sites from dedicated HIV care and treatment (C&T) centers remain unknown, particularly in low prevalence settings. METHODS In a cohort of mother-infant pairs, we compared delivery of routine services at ANC/L&D and C&T facilities in Kinshasa, Democratic Republic of Congo from 2010-2013, using methods accounting for competing risks (eg, death). Women could opt to receive interventions at 90 decentralized ANC/L&D sites, or 2 affiliated C&T centers. Additionally, we assessed decentralization's population-level impacts by comparing proportions of women and infants receiving interventions before (2009-2010) and after (2011-2013) decentralization. RESULTS Among newly HIV-diagnosed women (N = 1482), the 14-week cumulative incidence of receiving the package of CD4 testing and zidovudine or antiretroviral therapy was less at ANC/L&D [66%; 95% confidence interval (CI): 63% to 69%] than at C&T (88%; 95% CI: 83% to 92%) sites (subdistribution hazard ratio, 0.62; 95% CI: 0.55 to 0.69). Delivery of cotrimoxazole and DNA polymerase chain reaction testing to HIV-exposed infants (N = 1182) was inferior at ANC/L&D sites (subdistribution hazard ratio, 0.84; 95% CI: 0.76 to 0.92); the 10-month cumulative incidence of the package at ANC/L&D sites was 89% (95% CI: 82% to 93%) versus 97% (95% CI: 93% to 99%) at C&T centers. Receipt of the pregnancy (20% of 1518, to 64% of 1405) and infant (16%-31%) packages improved post decentralization. CONCLUSIONS Services were delivered less efficiently at ANC/L&D sites than C&T centers. Although access improved with decentralization, its potential cannot be realized without sufficient and sustained support.
Collapse
Affiliation(s)
- Andrew Edmonds
- Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Lydia Feinstein
- Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Vitus Okitolonda
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Deidre Thompson
- Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Bienvenu Kawende
- Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Frieda Behets
- Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC
- School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| |
Collapse
|
17
|
Gandhi AD, Pettifor A, Barrington C, Marshall SW, Behets F, Guardado ME, Farach N, Ardón E, Paz-Bailey G. Migration, Multiple Sexual Partnerships, and Sexual Concurrency in the Garífuna Population of Honduras. AIDS Behav 2015; 19:1559-70. [PMID: 26242612 PMCID: PMC4714585 DOI: 10.1007/s10461-015-1139-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The Garífuna, an ethnic minority group in Honduras, have been disproportionately affected by HIV. Previous research suggests that migration and high rates of multiple sexual partnerships are major drivers of the epidemic. Using data from a 2012 population-based survey, we assessed whether temporary migration was associated with (1) multiple sexual partnerships and (2) sexual concurrency among Garífuna men and women in Honduras. Among both men and women, temporary migration in the last year was associated with an increased likelihood of multiple sexual partnerships and with concurrency, though only the association between migration and multiple sexual partnerships among men was statistically significant (Adjusted Prevalence Ratio 1.7, 95 % CI 1.2-2.4). Migration may contribute to HIV/STI vulnerability among Garífuna men and women via increases in these sexual risk behaviors. Research conducted among men and women at elevated risk of HIV should continue to incorporate measures of mobility, including history of internal migration.
Collapse
Affiliation(s)
- Anisha D Gandhi
- HIV Center for Clinical and Behavioral Studies, Columbia University and The New York State Psychiatric Institute, 1051 Riverside Drive, Unit 15, 10032, New York, NY, USA,
| | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Patel MR, Westreich D, Yotebieng M, Nana M, Eron JJ, Behets F, Van Rie A. The Impact of Implementation Fidelity on Mortality Under a CD4-Stratified Timing Strategy for Antiretroviral Therapy in Patients With Tuberculosis. Am J Epidemiol 2015; 181:714-22. [PMID: 25787266 DOI: 10.1093/aje/kwu338] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 11/05/2014] [Indexed: 11/14/2022] Open
Abstract
Among patients with tuberculosis and human immunodeficiency virus type 1, CD4-stratified initiation of antiretroviral therapy (ART) is recommended, with earlier ART in those with low CD4 counts. However, the impact of implementation fidelity to this recommendation is unknown. We examined a prospective cohort study of 395 adult patients diagnosed with tuberculosis and human immunodeficiency virus between August 2007 and November 2009 in Kinshasa, Democratic Republic of the Congo. ART was to be initiated after 1 month of tuberculosis treatment at a CD4 count of <100 cells/mm(3) or World Health Organization stage 4 (other than extrapulmonary tuberculosis) and after 2 months of tuberculosis treatment at a CD4 count of 100-350 cells/mm(3). We used the parametric g-formula to estimate the impact of implementation fidelity on 6-month mortality. Observed implementation fidelity was low (46%); 54% of patients either experienced delays in ART initiation or did not initiate ART, which could be avoided under perfect implementation fidelity. The observed mortality risk was 12.0% (95% confidence interval (CI): 8.2, 15.7); under complete (counterfactual) implementation fidelity, the mortality risk was 7.8% (95% CI: 2.4, 12.3), corresponding to a risk reduction of 4.2% (95% CI: 0.3, 8.1) and a preventable fraction of 35.1% (95% CI: 2.9, 67.9). Strategies to achieve high implementation fidelity to CD4-stratified ART timing are needed to maximize survival benefit.
Collapse
|
19
|
Yotebieng M, Norris A, Chalachala JL, Matumona Y, Ramadhani HO, Behets F. Fertility desires, unmet need for family planning, and unwanted pregnancies among HIV-infected women in care in Kinshasa, DR Congo. Pan Afr Med J 2015; 20:235. [PMID: 27386031 PMCID: PMC4919670 DOI: 10.11604/pamj.2015.20.235.5859] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 01/28/2015] [Indexed: 11/24/2022] Open
Abstract
Introduction We assessed the fertility desires, utilization of family planning (FP) methods, and incidence of pregnancies among HIV-infected women receiving care in an HIV clinic with an onsite FP services in Kinshasa, Democratic Republic of Congo. Methods Between November 2011 and May 2012, all HIV-infected women who attended a routine visit at the clinic were interviewed about their fertility desires and utilization of contraceptive methods using a structured questionnaire. Routine follow-up visit data were used to identify pregnancies recorded between the interview and June 2013. Results Overall, of the 699 HIV-infected women interviewed. 249 (35.7%) reported not wanting another child. Of the 499 (72.2%) participants who were sexually active at the time of interview, 177 (35.5%) were using an effective contraceptive method, including 70 (14.0%) women who reported using condoms consistently and 104 (20.8%) who were using injectable contraception. Overall, 88 (17.6%) sexually active participants who did not want another child were not using an effective FP method, and thus are considered to have had unmet need. During the median follow-up time of 22.2 (IQR: 20.2, 23.6) months, among all women interviewed, 96 (14.1%) became newly pregnant [pregnancy rate 9.3 (95%CI: 7.6, 11.4) per 100 women-years] including 21 (8.7%) among women who initially reported not wanting another child [unwanted pregnancy rate 5.8 (95%CI: 3.6, 9.3) per 100 women-years]. Conclusion The persistence of relatively high unmet need among women receiving HIV care in a clinic with onsite FP services suggests the existence of barriers that must be identified and addressed.
Collapse
Affiliation(s)
- Marcel Yotebieng
- Ohio State University, College of Public Health, Division of Epidemiology, Columbus, OH; University of North Carolina at Chapel Hill, Department of Epidemiology, Chapel Hill, NC
| | - Alison Norris
- Ohio State University, College of Public Health, Division of Epidemiology, Columbus, OH
| | | | - Yori Matumona
- University of Kinshasa, School of Public Health, Kinshasa, DR Congo
| | - Habib Omari Ramadhani
- University of North Carolina at Chapel Hill, Department of Epidemiology, Chapel Hill, NC
| | - Frieda Behets
- University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC
| |
Collapse
|
20
|
Patel MR, Nana M, Yotebieng M, Tabala M, Behets F, Van Rie A. Delayed antiretroviral therapy despite integrated treatment for tuberculosis and HIV infection. Int J Tuberc Lung Dis 2015; 18:694-9. [PMID: 24903941 DOI: 10.5588/ijtld.13.0807] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING Five primary health care clinics in Kinshasa, Democratic Republic of Congo. OBJECTIVE To examine timing and predictors of delayed initiation of antiretroviral therapy (ART) during anti-tuberculosis treatment. DESIGN Prospective observational cohort of adult patients receiving integrated treatment for tuberculosis (TB) and human immunodeficiency virus (HIV) who are expected to initiate ART at 1 month if CD4 count is <100 cells/mm(3) or if patient is World Health Organization (WHO) Clinical Stage 4 for reasons other than extra-pulmonary TB, at 2 months if CD4 count is 100-350 cells/mm(3), or at completion of anti-tuberculosis treatment if subsequently CD4 count is ≤ 350 cells/mm(3) or patient has WHO Clinical Stage 4. RESULTS Of 492 patients, 235 (47.8%) experienced delayed initiation of ART: 171 (72.8%) initiated ART late, after a median delay of 12 days (interquartile range [IQR] 4-27) and 64 (27.2%) never initiated ART. Contraindication to any antiretroviral drug (aOR 2.91, 95%CI 1.22-6.95), lower baseline CD4 count (aOR 1.20, 95%CI 1.08-1.33/100 cells/mm(3)), TB drug intolerance (aOR 1.93, 95%CI 1.23-3.02) and non-disclosure of HIV infection (aOR 1.50, 95%CI 1.03-2.18) predicted delayed ART initiation. CONCLUSION Despite fully integrated treatment, half of all patients experienced delayed ART initiation. Pragmatic approaches to ensure timely ART initiation in those at risk of delayed ART initiation are needed.
Collapse
Affiliation(s)
- M R Patel
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - M Nana
- School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - M Yotebieng
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - M Tabala
- School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - F Behets
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - A Van Rie
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| |
Collapse
|
21
|
Yotebieng M, Meyers T, Behets F, Davies MA, Keiser O, Ngonyani KZ, Lyamuya RE, Kariminia A, Hansudewechakul R, Leroy V, Koumakpai S, Newman J, Van Rie A. Age-specific and sex-specific weight gain norms to monitor antiretroviral therapy in children in low-income and middle-income countries. AIDS 2015; 29:101-9. [PMID: 25562494 PMCID: PMC4383257 DOI: 10.1097/qad.0000000000000506] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Viral load and CD4% are often not available in resource-limited settings for monitoring children's responses to antiretroviral therapy (ART). We aimed to construct normative curves for weight gain at 6, 12, 18, and 24 months following initiation of ART in children, and to assess the association between poor weight gain and subsequent responses to ART. DESIGN Analysis of data from HIV-infected children younger than 10 years old from African and Asian clinics participating in the International epidemiologic Databases to Evaluate AIDS. METHODS The generalized additive model for location, scale, and shape was used to construct normative percentile curves for weight gain at 6, 12, 18, and 24 months following ART initiation. Cox proportional models were used to assess the association between lower percentiles (< 50th) of weight gain distribution at the different time points and subsequent death, virological suppression, and virological failure. RESULTS Among 7173 children from five regions of the world, 45% were underweight at baseline. Weight gain below the 50th percentile at 6, 12, 18, and 24 months of ART was associated with increased risk of death, independent of baseline characteristics. Poor weight gain was not associated with increased hazards of virological suppression or virological failure. CONCLUSION Monitoring weight gain on ART using age-specific and sex-specific normative curves specifically developed for HIV-infected children on ART is a simple, rapid, sustainable tool that can aid in the identification of children who are at increased risk of death in the first year of ART.
Collapse
Affiliation(s)
- Marcel Yotebieng
- The Ohio State University, College of Public Health, Division of Epidemiology, Columbus, OH
- The University of North Carolina at Chapel Hill, Department of Epidemiology, Chapel Hill, NC
| | - Tammy Meyers
- Department of Pediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Frieda Behets
- The University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC
| | - Mary-Ann Davies
- University of Cape Town, School of Public Health and Family Medicine, Cape Town, South Africa
| | - Olivia Keiser
- Institute of Social and Preventive Medicine, University of Bern, Switzerland
| | | | | | - Azar Kariminia
- University of New South Wales, The Kirby Institute for infection and immunity in Society, Darlinghurst, NSW, Australia
| | | | - Valeriane Leroy
- Université Bordeaux, Institut de Santé Publique Epidémiologie et Développement, Bordeaux, France
- Inserm, Centre Inserm U897 “Epidémiologie et Biostatistique”, Bordeaux, France
| | | | - Jamie Newman
- RTI International, Biostatistics and Epidemiology, Research Triangle Park, NC
| | - Annelies Van Rie
- The University of North Carolina at Chapel Hill, Department of Epidemiology, Chapel Hill, NC
| |
Collapse
|
22
|
Vanden Driessche K, Patel MR, Mbonze N, Tabala M, Yotebieng M, Behets F, Van Rie A. Effect of smoking history on outcome of patients diagnosed with TB and HIV. Eur Respir J 2014; 45:839-42. [PMID: 25431269 DOI: 10.1183/09031936.00160714] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
| | - Monita R Patel
- Dept of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Nana Mbonze
- School of Public Health, University of Kinshasa, Kinshasa, DR Congo
| | - Martine Tabala
- School of Public Health, University of Kinshasa, Kinshasa, DR Congo
| | - Marcel Yotebieng
- Dept of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA School of Public Health, University of Kinshasa, Kinshasa, DR Congo College of Public Health, Ohio State University, Columbus, OH, USA
| | - Frieda Behets
- Dept of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Annelies Van Rie
- Dept of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| |
Collapse
|
23
|
Feinstein L, Edmonds A, Chalachala JL, Okitolonda V, Lusiama J, Van Rie A, Chi BH, Cole SR, Behets F. Temporal changes in the outcomes of HIV-exposed infants in Kinshasa, Democratic Republic of Congo during a period of rapidly evolving guidelines for care (2007-2013). AIDS 2014; 28 Suppl 3:S301-11. [PMID: 24991903 PMCID: PMC4600322 DOI: 10.1097/qad.0000000000000331] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Guidelines for prevention of mother-to-child transmission of HIV have developed rapidly, yet little is known about how outcomes of HIV-exposed infants have changed over time. We describe HIV-exposed infant outcomes in Kinshasa, Democratic Republic of Congo, between 2007 and 2013. DESIGN Cohort study of mother-infant pairs enrolled in family-centered comprehensive HIV care. METHODS Accounting for competing risks, we estimated the cumulative incidences of early infant diagnosis, HIV transmission, death, loss to follow-up, and combination antiretroviral therapy (cART) initiation for infants enrolled in three periods (2007-2008, 2009-2010, and 2011-2012). RESULTS 1707 HIV-exposed infants enrolled at a median age of 2.6 weeks. Among infants whose mothers had recently enrolled into HIV care (N = 1411), access to EID by age two months increased from 28% (95% confidence limits [CL]: 24,34%) among infants enrolled in 2007-2008 to 63% (95% CL: 59,68%) among infants enrolled in 2011-2012 (Gray's p-value <0.01). The 18-month cumulative incidence of HIV declined from 16% (95% CL: 11,22%) for infants enrolled in 2007-2008 to 11% (95% CL: 8,16%) for infants enrolled in 2011-2012 (Gray's p-value = 0.19). The 18-month cumulative incidence of death also declined, from 8% (95% CL: 5,12%) to 3% (95% CL: 2,5%) (Gray's p-value = 0.02). LTFU did not improve, with 18-month cumulative incidences of 19% (95% CL: 15,23%) for infants enrolled in 2007-2008 and 22% (95% CL: 18,26%) for infants enrolled in 2011-2012 (Gray's p-value = 0.06). Among HIV-infected infants, the 24-month cumulative incidence of cART increased from 61% (95% CL: 43,75%) to 97% (95% CL: 82,100%) (Gray's p-value <0.01); the median age at cART decreased from 17.9 to 9.3 months. Outcomes were better for infants whose mothers enrolled before pregnancy. CONCLUSIONS We observed encouraging improvements, but continued efforts are needed.
Collapse
Affiliation(s)
- Lydia Feinstein
- The University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Epidemiology, Chapel Hill, North Carolina, USA
| | - Andrew Edmonds
- The University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Epidemiology, Chapel Hill, North Carolina, USA
| | | | - Vitus Okitolonda
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo
| | - Jean Lusiama
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo
| | - Annelies Van Rie
- The University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Epidemiology, Chapel Hill, North Carolina, USA
| | - Benjamin H. Chi
- The University of North Carolina at Chapel Hill, School of Medicine, Department of Obstetrics and Gynecology, Chapel Hill, North Carolina, USA
| | - Stephen R. Cole
- The University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Epidemiology, Chapel Hill, North Carolina, USA
| | - Frieda Behets
- The University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Epidemiology, Chapel Hill, North Carolina, USA
| |
Collapse
|
24
|
Mupenda B, Duvall S, Maman S, Pettifor A, Holub C, Taylor E, Rennie S, Kashosi M, Lema M, Behets F. Terms used for people living with HIV in the Democratic Republic of the Congo. Qual Health Res 2014; 24:209-216. [PMID: 24463633 PMCID: PMC4326230 DOI: 10.1177/1049732313519869] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
For this study we conducted in-depth interviews with 29 youth living with HIV (YLWH) and key informant interviews with 8 HIV care/support providers. We describe terms used to portray people living with HIV (PLWH) in Kinshasa, Democratic Republic of the Congo. Labels commonly used, mostly derogatory, described PLWH as walking corpses, dangers to others, or people deserving to die before others get infected. Blame and other accusations were directed at PLWH through anchoring or objectification. Being labeled sometimes made these youth suffer in silence, afraid to disclose their status, or avoid performing actions in public, preferring to let others do them. YLWH need psychosocial support to mitigate the harmful effects of these labels and strengthen their coping skills, whereas community, institutional, and national efforts are needed for stigma reduction.
Collapse
Affiliation(s)
- Bavon Mupenda
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Sandra Duvall
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Suzanne Maman
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Audrey Pettifor
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Eboni Taylor
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Stuart Rennie
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Mujalambo Kashosi
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Mamie Lema
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Frieda Behets
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| |
Collapse
|
25
|
Henegar C, Behets F, Vanden Driessche K, Tabala M, Van Rie A. Impact of HIV on clinical presentation and outcomes of tuberculosis treatment at primary care level [Short communication]. Int J Tuberc Lung Dis 2013; 17:1411-3. [DOI: 10.5588/ijtld.13.0151] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- C. Henegar
- Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - F. Behets
- Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - K. Vanden Driessche
- Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - M. Tabala
- School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - A. Van Rie
- Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| |
Collapse
|
26
|
Tumlinson K, Speizer I, Archer L, Behets F. Simulated clients reveal programmatic factors that may influence contraceptive use in Kisumu, Kenya. Glob Health Sci Pract 2013; 1:407-416. [PMID: 24683525 PMCID: PMC3966625 DOI: 10.9745/ghsp-d-13-00075] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
While the quality of family planning service delivery was often good, clients reported barriers including: excessively long waiting times, provider absences, informal fees, inappropriate pregnancy tests, misinformation, and provider disrespect. Improved monitoring and oversight of facility practices and examination of provider needs and motivations may increase quality of service. A better understanding of the factors influencing use of family planning has the potential to increase contraceptive prevalence and improve the ability of women and their partners to freely choose the number and spacing of their children. Investigations into factors contributing to unmet need frequently rely on data collected using household surveys or interviews with family planning clients and providers. Our research utilizes qualitative information resulting from simulated client visits to investigate programmatic barriers to contraceptive use in a sample of 19 health care facilities in Kisumu East District, a city in western Kenya. Simulated client reports indicate deficiencies in provider competence as well as tenuous relations between providers and clients. In addition, simulated client data reveal occasional absences of providers during normal facility hours of operation and requests of informal fees for services. Trainings that address specific gaps in provider medical knowledge and counseling skills as well as client-provider relations may reduce such programmatic barriers to contraceptive use. In addition, improved supervision and oversight at facilities may increase physical and financial access to services. Future research investigating provider motivations may illuminate root causes of programmatic barriers.
Collapse
Affiliation(s)
- Katherine Tumlinson
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA ; Carolina Population Center at The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ilene Speizer
- Carolina Population Center at The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA ; Department of Maternal & Child Health, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Linda Archer
- Tupange Project, Jhpiego, an affiliate of Johns Hopkins University, Nairobi, Kenya
| | - Frieda Behets
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| |
Collapse
|
27
|
Yotebieng M, Chalachala JL, Labbok M, Behets F. Infant feeding practices and determinants of poor breastfeeding behavior in Kinshasa, Democratic Republic of Congo: a descriptive study. Int Breastfeed J 2013; 8:11. [PMID: 24083882 PMCID: PMC3850507 DOI: 10.1186/1746-4358-8-11] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Accepted: 09/28/2013] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Although breastfeeding is almost universally accepted in the Democratic Republic (DR) of Congo, by the age of 2 to 3 months 65% of children are receiving something other than human milk. We sought to describe the infant feeding practices and determinants of suboptimal breastfeeding behaviors in DR Congo. METHODS Survey questionnaire administered to mothers of infants aged ≤ 6 months and healthcare providers who were recruited consecutively at six selected primary health care facilities in Kinshasa, the capital. RESULTS All 66 mothers interviewed were breastfeeding. Before initiating breastfeeding, 23 gave their infants something other than their milk, including: sugar water (16) or water (2). During the twenty-four hours prior to interview, 26 (39%) infants were exclusively breastfed (EBF), whereas 18 (27%), 12 (18%), and 10 (15%) received water, tea, formula, or porridge, respectively, in addition to human milk. The main reasons for water supplementation included "heat" and cultural beliefs that water is needed for proper digestion of human milk. The main reason for formula supplementation was the impression that the baby was not getting enough milk; and for porridge supplementation, the belief that the child was old enough to start complementary food. Virtually all mothers reported that breastfeeding was discussed during antenatal clinic visit and half reported receiving help regarding breastfeeding from a health provider either after birth or during well-child clinic visit. Despite a median of at least 14 years of experience in these facilities, healthcare workers surveyed had little to no formal training on how to support breastfeeding and inadequate breastfeeding-related knowledge and skills. The facilities lacked any written policy about breastfeeding. CONCLUSION Addressing cultural beliefs, training healthcare providers adequately on breastfeeding support skills, and providing structured breastfeeding support after maternity discharge is needed to promote EBF in the DR Congo.
Collapse
Affiliation(s)
- Marcel Yotebieng
- College of Public Health, Division of Epidemiology, The Ohio State University, Columbus, OH, USA
- Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Miriam Labbok
- Carolina Global Breastfeeding Institute, Department of Maternal and Child Health, The University of North Carolina at Chapel Hill, Chapel Hill NC, USA
| | - Frieda Behets
- College of Public Health, Division of Epidemiology, The Ohio State University, Columbus, OH, USA
- School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| |
Collapse
|
28
|
Feinstein L, Dimomfu BL, Mupenda B, Duvall S, Chalachala JL, Edmonds A, Behets F. Antenatal and delivery services in Kinshasa, Democratic Republic of Congo: care-seeking and experiences reported by women in a household-based survey. Trop Med Int Health 2013; 18:1211-21. [PMID: 23964667 DOI: 10.1111/tmi.12171] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Increasing coverage of quality reproductive health services, including prevention of mother-to-child transmission services, requires understanding where and how these services are provided. To inform scale-up, we conducted a population-based survey in Kinshasa, Democratic Republic of Congo. METHODS Stratified two-stage cluster sampling was used to select women ≥18 years old who had been pregnant within the prior three years. Participants were interviewed about their reproductive healthcare utilization and impressions of services received. RESULTS We interviewed 1221 women, 98% of whom sought antenatal care (ANC). 78% of women began ANC after the first trimester and 22% reported <4 visits. Reasons for choosing an ANC facility included reputation (51%), friendly/accessible staff (39%), availability of comprehensive services (29%), medication access (26%), location (26%), and cost (21%). Most women reported satisfactory treatment by staff, but 47% reported that the ANC provider ignored their complaints, 23% had difficulty understanding responses to their questions, 22% wanted more time with the provider, 21% wanted more privacy, and 12% felt uncomfortable asking questions. Only 56% reported someone talked to them about HIV/AIDS. Strongest predictors of seeking inadequate ANC included low participant and partner education and lack of certain assets. Only 32% of women sought postnatal care. Some results varied by health zone. CONCLUSIONS Scaling-up interventions to improve reproductive health services should include broad-based health systems strengthening and promote equitable access to quality ANC, delivery, and postnatal services. Personal and structural-level barriers to seeking ANC need to be addressed, with consideration given to local contexts.
Collapse
Affiliation(s)
- Lydia Feinstein
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | | | | | | | | | | |
Collapse
|
29
|
Patel MR, Yotebieng M, Behets F, Vanden Driessche K, Nana M, Van Rie A. Outcomes of integrated treatment for tuberculosis and HIV in children at the primary health care level. Int J Tuberc Lung Dis 2013; 17:1206-11. [PMID: 23827656 DOI: 10.5588/ijtld.12.0833] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Little is known about the integration of tuberculosis (TB) and human immunodeficiency virus (HIV) treatment in pediatric populations. METHODS Prospective cohort of 31 HIV-infected children aged 3-18 years initiating anti-tuberculosis treatment at five primary health care (PHC) clinics in Kinshasa, Democratic Republic of Congo, to describe survival, clinical and immunological outcomes of nurse-centered integrated TB-HIV treatment. RESULTS Almost all of the children (87.1%) were diagnosed with HIV during TB diagnosis. Most (87.0%) were successfully treated for TB. Two (6.5%) died during anti-tuberculosis treatment; both presented with low CD4 counts (36 and 59 cells/mm(3) compared to a median of 228 cells/mm(3) in the entire cohort). Most (74.2%) initiated antiretroviral therapy (ART) during anti-tuberculosis treatment. Overall, a median CD4 count increase of 106 cells/mm(3) was observed (P = 0.014), an increase of 113 cells/mm(3) among children on ART and of 71.5 cells/mm(3) in those not on ART (P = 0.78). Median body mass index increase during anti-tuberculosis treatment was 2.1 kg/m(2) overall (P = 0.002), 2.2 kg/m(2) among children on ART and 0.72 kg/m(2) in those not on ART (P = 0.08). CONCLUSION Integrated, nurse-centered, pediatric TB-HIV treatment at the PHC level in highly resource-limited settings is feasible and effective in achieving successful outcomes, including high ART uptake, low mortality, and immunological and clinical improvement.
Collapse
Affiliation(s)
- M R Patel
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, USA.
| | | | | | | | | | | |
Collapse
|
30
|
Parker L, Maman S, Pettifor A, Chalachala JL, Edmonds A, Golin CE, Moracco K, Behets F, Sympa Study Team. Feasibility Analysis of an evidence-based positive prevention intervention for youth living with HIV/AIDS in Kinshasa, Democratic Republic of the Congo. AIDS Educ Prev 2013; 25:135-50. [PMID: 23514081 PMCID: PMC3777231 DOI: 10.1521/aeap.2013.25.2.135] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
We evaluated the feasibility of a Positive Prevention intervention adapted for youth living with HIV/AIDS (YLWH) ages 15-24 in Kinshasa, Democratic Republic of the Congo. We conducted in-depth interviews and focus group discussions with intervention facilitators and YLWH participants on the following four areas of a feasibility framework: acceptability, implementation, adaptation, and limited-efficacy. The adapted intervention was suitable, satisfying, and attractive to program facilitators and participants and able to be implemented effectively. It performed well with a new population and showed preliminary efficacy. However, we identified certain aspects of the intervention that must be addressed prior to wider implementation such as: (1) including more content on navigating marriage while living with HIV and disclosure; (2) adjusting intervention timing and session length; and (3) simplifying the more complicated content. An adapted evidencebased intervention was found to be feasible and lessons learned can be applied to YLWH in other low-resource settings.
Collapse
Affiliation(s)
- L Parker
- Futures Group, Chapel Hill, NC 27516, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
31
|
Clouse K, Pettifor A, Maskew M, Bassett J, Van Rie A, Gay C, Behets F, Sanne I, Fox MP. Initiating antiretroviral therapy when presenting with higher CD4 cell counts results in reduced loss to follow-up in a resource-limited setting. AIDS 2013; 27:645-50. [PMID: 23169326 PMCID: PMC3646627 DOI: 10.1097/qad.0b013e32835c12f9] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE In August 2011, South Africa expanded its adult antiretroviral therapy (ART) guidelines to allow treatment initiation at CD4 cell values 350 cells/μl or less. Mortality and morbidity are known to be reduced when initiating at higher CD4 levels; we explored the impact on patient loss to follow-up. DESIGN An observational cohort study. METHODS We analyzed routine data of 1430 adult patients initiating ART from April to December 2010 from a Johannesburg primary healthcare clinic offering ART initiation at CD4 cell count 350 cells/μl or less since 2010. We compared loss to follow-up (≥3 months late for the last scheduled visit), death, and incident tuberculosis within 1 year of ART initiation for those initiating at CD4 cell values 200 or less versus 201-350 cells/μl. RESULTS : Half (52.0%) of patients presented in the lower CD4 cell group [≤200 cells/μl, median: 105 cells/μl, interquartile range (IQR): 55-154] and initiated ART, and 48.0% in the higher group (CD4 cell count 201-350 cells/μl, median: 268 cells/μl, IQR: 239-307). The proportion of women and pregnant women was greater in the high CD4 cell group; the lower CD4 cell group included more patients with prevalent tuberculosis. Among men and nonpregnant women, initiating at 201-350 cells/μl was associated with 26-42% reduced loss to follow-up compared to those initiating 200 cells/μl or less. We found no CD4 cell effect among pregnant women. Risk of mortality [adjusted hazard ratio (aHR) 0.34, 95% confidence interval (CI) 0.13-0.84] and incident tuberculosis (aHR 0.44, 95% CI 0.23-0.85) was lower among the higher CD4 cell group. CONCLUSION This is one of the first studies from a routine clinical setting to demonstrate South Africa's 2011 expansion of ART treatment guidelines can be enacted without increasing program attrition.
Collapse
Affiliation(s)
- Kate Clouse
- Department of Internal Medicine, University of the Witwatersrand, Johannesburg, South Africa.
| | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Seña AC, Wolff M, Behets F, Van Damme K, Martin DH, Leone P, McNeil L, Hook EW. Response to therapy following retreatment of serofast early syphilis patients with benzathine penicillin. Clin Infect Dis 2013; 56:420-2. [PMID: 23118269 PMCID: PMC3590030 DOI: 10.1093/cid/cis918] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Accepted: 10/15/2012] [Indexed: 11/14/2022] Open
Abstract
Persistent nontreponemal titers after treatment are common among patients with early syphilis. We retreated 82 human immunodeficiency virus-negative early syphilis participants who were serofast at 6 months using benzathine penicillin. Only 27% exhibited serological response after retreatment and after an additional 6 months of follow-up.
Collapse
Affiliation(s)
- Arlene C Seña
- Division of Infectious Diseases, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA.
| | | | | | | | | | | | | | | |
Collapse
|
33
|
Parker L, Maman S, Pettifor A, Chalachala JL, Edmonds A, Golin CE, Moracco K, Behets F. Adaptation of a U.S. evidence-based Positive Prevention intervention for youth living with HIV/AIDS in Kinshasa, Democratic Republic of the Congo. Eval Program Plann 2013; 36:124-35. [PMID: 23063699 PMCID: PMC3572542 DOI: 10.1016/j.evalprogplan.2012.09.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Revised: 07/31/2012] [Accepted: 09/09/2012] [Indexed: 05/24/2023]
Abstract
Effective HIV prevention programs for people living with HIV/AIDS (PLWH) are important to reduce new infections and to ensure PLWH remain healthy. This paper describes the systematic adaptation of a U.S.-developed Evidence Based Intervention (EBI) using the Centers for Disease Control and Prevention (CDC) Map of Adaption Process for use at a Pediatric Hospital in Kinshasa, Democratic Republic of the Congo (DRC). The adapted intervention, Supporting Youth and Motivating Positive Action or SYMPA, a six-session risk reduction intervention targeted for youth living with HIV/AIDS (YLWH) in Kinshasa was adapted from the Healthy Living Project and guided by the Social Action Theory. This paper describes the process of implementing the first four steps of the ADAPT framework (Assess, Select, Prepare, and Pilot). Our study has shown that an EBI developed and implemented in the U.S. can be adapted successfully for a different target population in a low-resource context through an iterative process following the CDC ADAPT framework. This process included reviewing existing literature, adapting and adding components, and focusing on increasing staff capacity. This paper provides a rare, detailed description of the adaptation process and may aid organizations seeking to adapt and implement HIV prevention EBIs in sub-Saharan Africa and beyond.
Collapse
Affiliation(s)
- L Parker
- Futures Group, Chapel Hill, North Carolina, USA.
| | | | | | | | | | | | | | | |
Collapse
|
34
|
Clouse K, Pettifor AE, Maskew M, Bassett J, Van Rie A, Behets F, Gay C, Sanne I, Fox MP. Patient retention from HIV diagnosis through one year on antiretroviral therapy at a primary health care clinic in Johannesburg, South Africa. J Acquir Immune Defic Syndr 2013; 62:e39-46. [PMID: 23011400 PMCID: PMC3548953 DOI: 10.1097/qai.0b013e318273ac48] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare patient retention at 3 stages of pre-antiretroviral (ART) care and 2 stages of post-ART care to identify when greatest attrition occurs. DESIGN An observational cohort study. METHODS We reviewed files of all adult nonpregnant individuals testing HIV-positive January 1-June 30, 2010, at a primary health clinic in Johannesburg, South Africa (N = 842). We classified retention in pre-ART stage 1 (HIV diagnosis to CD4 results notification in ≤3 months), pre-ART stage 2 (initially ineligible for ART with repeat CD4 test ≤1 year of prior CD4), pre-ART stage 3 (initiating ART ≤3 months after first eligible CD4 result), and at 0-6 and 6-12 months post-ART. RESULTS Retention among all patients during pre-ART stage 1 was 69.8% [95% confidence interval (CI): 66.7% to 72.9%]. For patients initially ART ineligible (n = 221), 57.4% (95% CI: 49.5% to 65.0%) returned for a repeat CD4 during pre-ART stage 2. Among those who were ART eligible (n = 589), 73.5% (95% CI: 69.0% to 77.6%) were retained during pre-ART stage 3. Retention increased with time on ART, from 80.2% (95% CI: 75.3% to 84.5%) at 6 months to 95.3% (95% CI: 91.7% to 97.6%) between 6 and 12 months. Cumulative retention from diagnosis to 12 months on ART was 36.9% (95% CI: 33.0% to 41.1%) for those ART eligible and 43.0% (95% CI: 36.4% to 49.8%) from diagnosis to repeat CD4 testing within one year among those ART ineligible. CONCLUSIONS Patient attrition in the first year after HIV diagnosis was greatest before ART initiation: more than 25% at each of 3 pre-ART stages. As countries expand HIV testing and ART programs, success will depend on linkage to care, especially before ART eligibility and initiation.
Collapse
Affiliation(s)
- Kate Clouse
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | | | | | | | | | | | | | | | | |
Collapse
|
35
|
Parker L, Maman S, Pettifor A, Chalachala JL, Edmonds A, Golin CE, Moracco K, Behets F. Barriers to Provider-Delivered Sexual Behavior Counseling for Youth Living with HIV/AIDS in the Democratic Republic of the Congo. J HIV AIDS Soc Serv 2013; 12:10.1080/15381501.2012.748585. [PMID: 24409092 PMCID: PMC3882125 DOI: 10.1080/15381501.2012.748585] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
AIMS The study aimed to understand providers' role in delivering HIV transmission prevention counseling to youth living with HIV (YLWH). METHODS We conducted 14 in-depth interviews with providers in Kinshasa, DRC. RESULTS Providers' lack of knowledge and comfort in talking to youth about sex because of cultural and religious beliefs about sexuality, coupled with confusion about legal issues related to youth and contraception, made it difficult for them to effectively counsel youth. IMPLICATIONS FOR PRACTICE AND POLICY In order for providers to deliver effective prevention counseling to YLWH, clinics should follow adolescent-friendly clinic standards, provide counseling in an adolescent-friendly style, and institute an effective referral system for additional prevention services. CONCLUSION HIV prevention services can be improved through the creation of an adolescent-friendly environment and by providing "values clarification" and skill-based trainings so that providers are able to assess the role of their own beliefs and learn new skills.
Collapse
Affiliation(s)
| | - S Maman
- Department of Health Behavior, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, U.S
| | - A Pettifor
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, U.S
| | - J L Chalachala
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - A Edmonds
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, U.S
| | - C E Golin
- Department of Health Behavior, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, U.S. ; Department of Medicine, University of North Carolina School of Medicine
| | - K Moracco
- Department of Health Behavior, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, U.S
| | - F Behets
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, U.S
| |
Collapse
|
36
|
Henegar C, Behets F, Vanden Driessche K, Tabala M, Bahati E, Bola V, Van Rie A. Mortality among tuberculosis patients in the Democratic Republic of Congo. Int J Tuberc Lung Dis 2012; 16:1199-204. [PMID: 22871326 DOI: 10.5588/ijtld.11.0613] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING Kinshasa, Democratic Republic of Congo. OBJECTIVE To identify programmatic interventions for improved survival in patients receiving treatment for tuberculosis (TB) at primary care clinics. DESIGN Retrospective cohort of adult patients initiating anti-tuberculosis treatment between January 2006 and May 2007. RESULTS Among 5685 patients, 390 deaths occurred during anti-tuberculosis treatment, of which half (52%) did so during the first 2 months. Patients with smear-negative pulmonary TB were at greater risk of death in the first 2 months of treatment (human immunodeficiency virus [HIV] positive HR 1.49, 95%CI 0.89-2.49; HIV-negative HR 1.77 95%CI 1.06-2.95), but not thereafter. Patients with extra-pulmonary TB were at increased risk of death in the first 2 months of anti-tuberculosis treatment if they were non-HIV-infected (HR 2.42, 95%CI 1.52-3.85), and were half as likely to die during the remainder of treatment (HIV-positive HR 0.46, 95%CI 0.22-0.97; HIV-negative HR 0.47, 95%CI 0.23-0.94). Antiretroviral therapy (ART) reduced the risk of death by an estimated 36% (HR 0.64, 95%CI 0.37-1.11). CONCLUSION High mortality in the first months of anti-tuberculosis treatment could be reduced by addressing diagnostic delays, particularly for extra-pulmonary and smear-negative TB cases and, in HIV-infected patients, by initiation of ART soon after starting anti-tuberculosis treatment.
Collapse
Affiliation(s)
- C Henegar
- Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, USA.
| | | | | | | | | | | | | |
Collapse
|
37
|
Seña AC, Wolff M, Martin DH, Behets F, Van Damme K, Leone P, Langley C, McNeil L, Hook EW. Predictors of serological cure and Serofast State after treatment in HIV-negative persons with early syphilis. Clin Infect Dis 2011; 53:1092-9. [PMID: 21998287 DOI: 10.1093/cid/cir671] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Syphilis management requires serological monitoring after therapy. We compared factors associated with serological response after treatment of early (ie, primary, secondary, or early latent) syphilis. METHODS We performed secondary analyses of data from a prospective, randomized syphilis trial conducted in the United States and Madagascar. Human immunodeficiency virus (HIV)-negative participants aged ≥ 18 years with early syphilis were enrolled from 2000-2009. Serological testing was performed at baseline and at 3 and 6 months after treatment. At 6 months, serological cure was defined as a negative rapid plasma reagin (RPR) test or a ≥4-fold decreased titer, and serofast status was defined as a ≤ 2-fold decreased titer or persistent titers that did not meet criteria for treatment failure. RESULTS Data were available from 465 participants, of whom 369 (79%) achieved serological cure and 96 (21%) were serofast. In bivariate analysis, serological cure was associated with younger age, fewer sex partners, higher baseline RPR titers, and earlier syphilis stage (P ≤ .008). There was a less significant association with Jarisch-Herxheimer reaction after treatment (P = .08). Multivariate analysis revealed interactions between log-transformed baseline titer with syphilis stage, in which the likelihood of cure was associated with increased titers among participants with primary syphilis (adjusted odds ratio [AOR] for 1 unit change in log(2) titer, 1.83; 95% confidence interval [CI], 1.25-2.70), secondary syphilis (AOR, 3.15; 95% CI, 2.14-4.65), and early latent syphilis (AOR, 1.86; 95% CI, 1.44-2.40). CONCLUSIONS Serological cure at 6 months after early syphilis treatment is associated with age, number of sex partners, Jarisch-Herxheimer reaction, and an interaction between syphilis stage and baseline RPR titer.
Collapse
Affiliation(s)
- Arlene C Seña
- Division of Infectious Diseases, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
38
|
Fetzer BC, Mupenda B, Lusiama J, Kitetele F, Golin C, Behets F. Barriers to and facilitators of adherence to pediatric antiretroviral therapy in a sub-Saharan setting: insights from a qualitative study. AIDS Patient Care STDS 2011; 25:611-21. [PMID: 21823909 PMCID: PMC4530354 DOI: 10.1089/apc.2011.0083] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Despite the need for HIV-positive children to adhere effectively to antiretroviral treatment (ART), a guiding theory for pediatric ART in resource-limited settings is still missing. Understanding factors that influence pediatric ART adherence is critical to developing adequate strategies. In-depth qualitative interviews were undertaken in Kinshasa, Democratic Republic of the Congo, with 20 sets of HIV disclosed and nondisclosed children along with respective caregivers to better characterize barriers, facilitators, and adherence experiences in children taking ART. Commonly cited barriers included lack of food or nutritional support, lack of assistance or supervision for children, lack of assistance for caregivers, and being unable to remember to take medicines on a consistent basis. Facilitators included having a strong caregiver-child relationship and support system along with strategies for maintaining adherence. Similar themes arose within the child-caregiver sets, but were often characterized differently between the two. Children who were aware of their HIV status displayed fewer instances of frustration and conflict concerning taking medicines and within the child-caregiver relationship. Continued study on pediatric ART adherence should account for differing perspectives of children and caregivers, as well as between status disclosed and nondisclosed children. Areas of future intervention should focus on child-caregiver relationships, disclosure of HIV status, and available nutritional and psychosocial support for children and their caregivers.
Collapse
Affiliation(s)
- Bradley C Fetzer
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA.
| | | | | | | | | | | |
Collapse
|
39
|
Maman S, Cathcart R, Burkhardt G, Omba S, Thompson D, Behets F. The infant feeding choices and experiences of women living with HIV in Kinshasa, Democratic Republic of Congo. AIDS Care 2011; 24:259-65. [PMID: 21780955 DOI: 10.1080/09540121.2011.597708] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
HIV transmission through breastfeeding is a significant public health challenge. While breastfeeding provides important nutrition, and results in reduced morbidity and mortality, there is a risk of HIV transmission through breastfeeding. International prevention of mother-to-child transmission (PMTCT) guidelines recommend exclusive breastfeeding for six months among HIV-infected women on antiretroviral therapy. Promoting exclusive feeding has proved difficult in settings where mixed feeding is a cultural norm. Understanding the factors that influence HIV infected women's infant feeding choices and practices is critical to promoting adherence to PMTCT guidelines. We conducted in-depth interviews with 40 HIV+ pregnant and post-partum women in Kinshasa, Democratic Republic of Congo to understand their infant feeding experiences. Interviews were conducted in Lingala, and transcribed and translated into French for analysis. Deductive and inductive codes were applied, and matrices were created to facilitate cross-case analysis. Women had limited understanding of the specific mechanisms through which their infant feeding practices influenced HIV transmission risk. Clinical staff was the primary source of women's knowledge of HIV mother-to-child-transmission. Among the 24 post-partum women in the sample, seven women adhered to exclusive breastfeeding and two women to exclusive formula feeding for at least six months. Women's beliefs and awareness about HIV transmission through breastfeeding, as well as the information and support from clinical staff and other members of their support networks positively influenced their exclusive feeding. Common barriers to exclusive feeding included financial constraints, breast health problems, misinformation about HIV transmission, local norms, and prior feeding experiences. Health care workers play a key role in providing correct information on PMTCT and supporting women's infant feeding choices to adhere to guidelines of exclusive infant feeding. Optimizing provider-patient communication and creating a supportive environment surrounding infant feeding is critical.
Collapse
Affiliation(s)
- Suzanne Maman
- Department of Health Behavior and Health Education, University of North Carolina, Chapel Hill, NC, USA.
| | | | | | | | | | | |
Collapse
|
40
|
Holman K, Wolff M, Sena A, Martin D, Behets F, Van Damme K, Leone P, McNeil L, Winestone J, Hook E. O3-S5.05 RPR titre variation following early syphilis therapy: a potential confounder of treatment outcome assessment. Br J Vener Dis 2011. [DOI: 10.1136/sextrans-2011-050109.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
41
|
Penman-Aguilar A, Legardy-Williams J, Turner AN, Rabozakandriana TOO, Williams D, Razafindravoavy S, Behets F, Van Damme K, Jamieson DJ. Effect of treatment assignment on intravaginal cleansing in a randomized study of the diaphragm with candidate microbicide. J Womens Health (Larchmt) 2011; 20:187-95. [PMID: 21314445 DOI: 10.1089/jwh.2010.2143] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Intravaginal cleansing may predispose women to adverse health outcomes and may interfere with the effectiveness and safety of female-initiated methods for preventing sexually transmitted infections (STIs). In a 4-week randomized study of 192 Malagasy sex workers, we evaluated associations between self-reported intravaginal cleansing and randomization assignment: diaphragm with viscous candidate microbicide gel (Acidform™, TOPCAD, Chicago, IL, licensed to Instead, Coppell, TX), diaphragm with placebo hydroxyethylcellulose gel (HEC, ReProtect LLC, Baltimore, MD), Acidform alone, or HEC alone. METHODS Women were counseled to avoid intravaginal cleansing and were blinded to gel assignment. We evaluated changes in self-reported intravaginal cleansing across the study and assessed the effects of treatment assignment and covariates on frequent (more than once daily) intravaginal cleansing. Significant predictors in domain-specific models were evaluated in an all-domain multiple regression model. RESULTS The proportion of women reporting intravaginal cleansing decreased from baseline (97%) to week 1 (82%) (p < 0.001). Self-reported frequent intravaginal cleansing decreased from baseline (87% to 56%) during the same time period (p < 0.001). In adjusted analyses, the Acidform-diaphragm group had 60% lower odds of frequent intravaginal cleansing during the study (odds ratio [OR] 0.4, 95% confidence interval [CI] 0.2-0.8) compared to the control group (HEC only). HEC-diaphragm and Acidform only users did not differ from controls. Living on the coast of Madagascar, not cohabiting, frequent intravaginal cleansing at enrollment, and high coital frequency predicted frequent intravaginal cleansing during follow-up. CONCLUSIONS Gel characteristics and the diaphragm's presence likely influenced women's cleansing. Viscous gel delivered by a cervical barrier (such as a diaphragm) may minimize the likelihood of frequent intravaginal cleansing.
Collapse
Affiliation(s)
- Ana Penman-Aguilar
- Women's Health and Fertility Branch, Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia 30341, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
42
|
Edmonds A, Yotebieng M, Lusiama J, Matumona Y, Kitetele F, Napravnik S, Cole SR, Van Rie A, Behets F. The effect of highly active antiretroviral therapy on the survival of HIV-infected children in a resource-deprived setting: a cohort study. PLoS Med 2011; 8:e1001044. [PMID: 21695087 PMCID: PMC3114869 DOI: 10.1371/journal.pmed.1001044] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2010] [Accepted: 04/28/2011] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The effect of highly active antiretroviral therapy (HAART) on the survival of HIV-infected children has not been well quantified. Because most pediatric HIV occurs in low- and middle-income countries, our objective was to provide a first estimate of this effect among children living in a resource-deprived setting. METHODS AND FINDINGS Observational data from HAART-naïve children enrolled into an HIV care and treatment program in Kinshasa, Democratic Republic of the Congo, between December 2004 and May 2010 were analyzed. We used marginal structural models to estimate the effect of HAART on survival while accounting for time-dependent confounders affected by exposure. At the start of follow-up, the median age of the 790 children was 5.9 y, 528 (66.8%) had advanced or severe immunodeficiency, and 405 (51.3%) were in HIV clinical stage 3 or 4. The children were observed for a median of 31.2 mo and contributed a total of 2,089.8 person-years. Eighty children (10.1%) died, 619 (78.4%) initiated HAART, six (0.8%) transferred to a different care provider, and 76 (9.6%) were lost to follow-up. The mortality rate was 3.2 deaths per 100 person-years (95% confidence interval [CI] 2.4-4.2) during receipt of HAART and 6.0 deaths per 100 person-years (95% CI 4.1-8.6) during receipt of primary HIV care only. The mortality hazard ratio comparing HAART with no HAART from a marginal structural model was 0.25 (95% CI 0.06-0.95). CONCLUSIONS HAART reduced the hazard of mortality in HIV-infected children in Kinshasa by 75%, an estimate that is similar in magnitude but with lower precision than the reported effect of HAART on survival among children in the United States. Please see later in the article for the Editors' Summary.
Collapse
Affiliation(s)
- Andrew Edmonds
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America.
| | | | | | | | | | | | | | | | | |
Collapse
|
43
|
Abstract
OBJECTIVE Adult caregivers provide children living with HIV with varying amounts and types of information about their health status that may affect their coping and health care behaviors. We aimed to describe patterns of information sharing with children and thoughts around disclosure among caregivers in the Democratic Republic of the Congo. METHODS A total of 259 primary caregivers of children aged 5 to 17 years in an HIV pediatric care and treatment program were screened; 8 adult caregivers (3%) had informed their child of the child's HIV status. We conducted structured interviews with 201 caregivers whose children had not yet been told their HIV status. RESULTS Nearly 50% of caregivers had provided no information to their child about their health; 15% had given partial information without mentioning HIV, and 33% provided information that deflected attention from HIV, whether deliberately so or otherwise. Almost all caregivers said that the child should be told their status some day, and three-fourths reported having ever thought about what might lead them to tell. However, nearly one-third of caregivers saw no benefits to informing the child of her/his HIV status. A majority of caregivers felt that they themselves were the best to eventually disclose to the child but some wanted support from health care providers. CONCLUSIONS HIV-infected children are given limited information about their health. Health care providers may serve as important sources of support to caregivers as they decide when and how to talk candidly with their children about their health.
Collapse
Affiliation(s)
- Lara M E Vaz
- From the *Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, TN; †Department of Health Behavior and Health Education, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC; ‡Department of Psychology, Tulane University, New Orleans, LA; §School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo; ∥Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | | | | | | | | | | |
Collapse
|
44
|
Pettifor A, Rosenberg N, Behets F. The need to focus on sex workers in generalized HIV epidemic settings. Sex Transm Dis 2011; 38:324-5. [PMID: 23330153 PMCID: PMC4487876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
|
45
|
Smith JS, Van Damme K, Randrianjafisamindrakotroka N, Ting J, Rabozakandraina T, Randrianasolo BS, Raharinivo M, Zanasaotra S, Hobbs M, Rinas A, Cohen M, Gravitt P, Behets F. Human papillomavirus and cervical neoplasia among female sex workers in Madagascar. Int J Gynecol Cancer 2010; 20:1593-1596. [PMID: 21370602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023] Open
Abstract
INTRODUCTION Human papillomavirus (HPV) prevalence and type distribution were estimated among 90 female sex workers (FSWs) aged 18 to 58 years in Antananarivo, Madagascar. METHODS A total of 90 FSWs aged 18 to 58 years in Antananarivo, Madagascar, were included in this study. Information on sexual and behavioral characteristics was obtained via a questionnaire. Exfoliated cervical cell specimens were collected for conventional cytologic examination and HPV DNA testing by polymerase chain reaction. The prevalence rates of HPV DNA and their corresponding 95% confidence intervals were stratified into the following 3 age groups: younger than 25, 25 to 34, and 35 years or older. To assess the association between HPV DNA positivity and sociodemographic and sexual behavioral factors, age-adjusted odds ratios and 95% confidence intervals were calculated using unconditional logistic regression. RESULTS The HPV prevalence in exfoliated cervical cell specimens was 36.7%. The most common HPV types found were HPV-52 (11.1%), HPV-31 and -39 (each at 5.6%), and HPV-16 and -83 (each at 3.3%). The prevalence of low-grade squamous intraepithelial lesions was 3.3%, and that of atypical squamous cells of undetermined significance was 18.9%. No high-grade lesion was found. Although associations were imprecise, the HPV prevalence was higher among women who reported younger age at the first intercourse, contraceptive use, a history of cervical lesions, and no history of condom use. DISCUSSION The prevalence rates of HPV and cervical lesions among FSWs in Madagascar appear higher than among FSW populations from other African countries with a relatively higher population-based prevalence of human immunodeficiency virus infection.
Collapse
Affiliation(s)
- Jennifer S Smith
- Gillings School of Global Public Health, University of Carolina, Chapel Hill, NC, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
46
|
Marra CM, Sahi SK, Tantalo LC, Godornes C, Reid T, Behets F, Rompalo A, Klausner JD, Yin YP, Mulcahy F, Golden MR, Centurion-Lara A, Lukehart SA. Enhanced molecular typing of treponema pallidum: geographical distribution of strain types and association with neurosyphilis. J Infect Dis 2010; 202:1380-8. [PMID: 20868271 PMCID: PMC3114648 DOI: 10.1086/656533] [Citation(s) in RCA: 148] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Strain typing is a tool for determining the diversity and epidemiology of infections. METHODS Treponema pallidum DNA was isolated from 158 patients with syphilis from the United States, China, Ireland, and Madagascar and from 15 T. pallidum isolates. Six typing targets were assessed: (1) the number of 60‐bp repeats in the acidic repeat protein gene, (2) restriction fragment length polymorphism (RFLP) analysis of T. pallidum repeat (tpr) subfamily II genes, (3) RFLP analysis of the tprC gene, (4) determination of tprD allele in the tprD gene locus, (5) the presence of a 51‐bp insertion between tp0126 and tp0127, and (6) sequence analysis of an 84‐bp region of tp0548. The combination of targets 1 and 2 comprises the Centers for Disease Control and Prevention (CDC) T. pallidum subtyping method. RESULTS Adding sequence analysis of tp0548 to the CDC method yielded the most discriminating typing system. Twenty‐five strain types were identified and designated as "CDC subtype/tp0548 sequence type." Type 14d/f was found in samples from 5 of 6 locations. In Seattle, Washington, strain types changed from 1999 through 2008 (P < .001). Twenty‐one (50%) of 42 patients infected with type 14d/f had neurosyphilis compared with 10 (24%) of 41 patients infected with any of the other types combined (P = .02). CONCLUSION We describe an enhanced T. pallidum strain typing system that shows biological and clinical relevance.
Collapse
Affiliation(s)
- Christina M. Marra
- Department of Neurology, University of Washington School of Medicine, Seattle, WA, USA
| | - Sharon K. Sahi
- Department of Neurology, University of Washington School of Medicine, Seattle, WA, USA
| | - Lauren C. Tantalo
- Department of Neurology, University of Washington School of Medicine, Seattle, WA, USA
| | - Charmie Godornes
- Department of Medicine (Infectious Diseases), University of Washington School of Medicine, Seattle, WA, USA
| | - Tara Reid
- Department of Medicine (Infectious Diseases), University of Washington School of Medicine, Seattle, WA, USA
| | - Frieda Behets
- University of North Carolina Chapel Hill, Departments of Epidemiology, Gillings School of Global Public Health and Medicine, Chapel Hill, NC, USA
| | - Anne Rompalo
- Departments of Medicine (Infectious Diseases) and Obstetrics and Gynecology, Johns Hopkins University, Baltimore, MD, USA
| | | | - Yue-Ping Yin
- Department of Reference STD Laboratory, National Center for STD Control, Chinese Academy of Medical Sciences & Peking Union Medical College Institute of Dermatology, Nanjing, China
| | - Fiona Mulcahy
- Department of Genitourinary Medicine and Infectious Diseases, St James Hospital and Trinity College, Dublin, Ireland
| | - Matthew R. Golden
- Department of Medicine (Infectious Diseases), University of Washington School of Medicine, Seattle, WA, USA
- Public Health - Seattle & King County, WA, USA
| | - Arturo Centurion-Lara
- Department of Medicine (Infectious Diseases), University of Washington School of Medicine, Seattle, WA, USA
| | - Sheila A. Lukehart
- Department of Medicine (Infectious Diseases), University of Washington School of Medicine, Seattle, WA, USA
- Department of Global Health, University of Washington School of Medicine, Seattle, WA, USA
| |
Collapse
|
47
|
Khan MR, Ravelomanana N, Van Damme K, Randrianasolo BS, Ramaniraka V, Ranaivo N, Ratsiambakaina D, Cohen M, Behets F. Notifying partners of patients with early syphilis in Madagascar: case-finding effectiveness and public health implications. Trop Med Int Health 2010; 15:1090-8. [PMID: 20636304 PMCID: PMC5824628 DOI: 10.1111/j.1365-3156.2010.02588.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the case-finding effectiveness of a clinic-based partner notification effort for early syphilis in Madagascar. METHODS We asked index cases who had proven early syphilis to identify and provide contact information of recent sex partners (in the past 3, 6, and 12 months for primary, secondary, and early latent syphilis, respectively). Named sex partners were contacted by index cases (patient notification) or, if approved by the index case, clinic staff members (provider notification); notified of their potential exposure to syphilis; and asked to come to the clinic for evaluation. We assessed case-finding effectiveness and calculated the 'brought-to-treatment' index (number of newly-diagnosed syphilis cases per number of index cases interviewed). RESULTS Of 565 index cases, 534 reported recent sex with at least one sex partner. A total of 3167 sex partners were reported, of whom 276 were contactable (9% of 3167). Providers notified 76% and cases notified 24% of these partners. 270 partners were contacted (98% of 276), and of these, 199 presented to the clinic for evaluation (74% of 270). A total of 99 partners tested positive for syphilis and received treatment (50% of 199). The 'brought-to-treatment' index was 0.18 (99 diagnoses per 565 index cases). CONCLUSION Partner notification was possible in this setting, resulting in treatment of syphilis-infected individuals who otherwise would likely have remained untreated. However, given <10% of the partners reported by index cases were contactable; the results highlight the limitations of partner notification and the need for additional sexually transmitted infection control strategies.
Collapse
Affiliation(s)
- Maria R Khan
- Department of Epidemiology and Biostatistics, School of Public Health, University of Maryland, College Park, MD, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
48
|
Hook III E, Behets F, Van Damme K, Ravelomanana N, Leone P, Sena A, Martin D, Langley C, McNeil L, Wolff M. A Phase III Equivalence Trial of Azithromycin versus Benzathine Penicillin for Treatment of Early Syphilis. J Infect Dis 2010; 201:1729-35. [DOI: 10.1086/652239] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
|
49
|
Behets F, Edmonds A, Kitenge F, Crabbé F, Laga M. Heterogeneous and decreasing HIV prevalence among women seeking antenatal care in Kinshasa, Democratic Republic of Congo. Int J Epidemiol 2010; 39:1066-73. [PMID: 20453017 DOI: 10.1093/ije/dyq060] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND We examined HIV prevalence trends over 4.5 years among women receiving antenatal care in Kinshasa, Democratic Republic of Congo, by geographic location, clinic management and urbanicity. METHODS Quarterly proportions and 95% confidence intervals (CIs) of pregnant women with HIV positive results were determined using aggregate service provision and uptake data from 22 maternity units that provided vertical HIV prevention services from October 2004 to March 2009. Assuming linearity, proportions were assessed for trend via the Cochran-Armitage test. Multivariable binomial regression was used to describe detailed prevalence trends. RESULTS HIV testing was offered to 220,006 pregnant women; 210,348 (95.6%) agreed to be tested and 191,216 (90.9%) received their results. A total of 3999 women were found to be HIV positive, a prevalence of 1.90% (95% CI: 1.84-1.96%). The median quarterly proportion of women testing positive for HIV was 1.94% (range: 1.44-2.44%). Prevalence was heterogeneous in terms of maternity management, urbanicity and geographic location. Modeling suggested that the overall prevalence dropped from 2.04% (95% CI: 1.92-2.16%) to 1.77% (95% CI: 1.66-1.88%) over 4.5 years, a relative decrease of 13.2% (95% CI: 3.53-22.9%). Trend testing corroborated this decline (P < 0.01). CONCLUSIONS The decreasing HIV prevalence among Kinshasa antenatal care seekers is robust and encouraging. The relatively low prevalence and the weak existing healthcare system require prevention of mother-to-child transmission interventions that strengthen maternal and child healthcare service delivery. Complacency would be unwarranted: assuming a uniform national crude birth rate of 50/1000 and 1.8% antenatal HIV prevalence, approximately 7000 pregnant HIV infected women in Kinshasa, and 60,000 nationwide, are in need of care and prevention services yearly.
Collapse
Affiliation(s)
- Frieda Behets
- Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7435, USA.
| | | | | | | | | | | |
Collapse
|
50
|
Vaz LM, Eng E, Maman S, Tshikandu T, Behets F. Telling children they have HIV: lessons learned from findings of a qualitative study in sub-Saharan Africa. AIDS Patient Care STDS 2010; 24:247-56. [PMID: 20397899 DOI: 10.1089/apc.2009.0217] [Citation(s) in RCA: 129] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
HIV-infected children in developing countries are living longer lives as they gain access to antiretroviral treatment programs. As they grow older, their parents/guardians are faced with the difficult decision of if, when, and how to inform their child of his/her HIV status. Both negative and positive social, psychological, and behavioral impacts of disclosure to children have been reported, including improved adherence to medication regimens. Understanding the disclosure process from the perspective of HIV positive children, therefore, is critical to developing these interventions. Through children's experiences we can learn about what works well, what needs to be strengthened, and what is missing in current disclosure practices. We conducted in-depth interviews with eight caregiver-child dyads in Kinshasa, Democratic Republic of the Congo. The children were in a comprehensive HIV pediatric care and treatment program and had already been told their HIV diagnosis. For the analysis we placed particular emphasis on children's reports of communication with their caregivers and health care providers about their illness. Patterns emerged of limited communication between children and their caregivers as well as their providers, before, during, and after disclosure. From the perspective of children in this study, disclosure was largely a discrete event rather than a process. Sociocultural contexts surrounding HIV/AIDS, as well as health status, variations in parent-child communication and the relationships between health providers and children under their care, should inform psychosocial interventions delivered alongside treatment programs.
Collapse
Affiliation(s)
| | - Eugenia Eng
- Department of Health Behavior and Health Education, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Suzanne Maman
- Department of Health Behavior and Health Education, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Tomi Tshikandu
- School of Public Health, University of Kinshasa, Kinshasa Democratic Republic of the Congo, Kinshasa, The Democratic Republic of the Congo
| | - Frieda Behets
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| |
Collapse
|