Hiv testing and counselling for women attending child health clinics: An opportunity for entry to prevent mother-to-child transmission and hiv treatment. Author



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Methods:

Qualitative research was undertaken on a short-term nutrition intervention linked to the provision of free antiretroviral treatment for people living with HIV in western Kenya in late 2005 and early 2006.


Results:

Patients enrolled in the food program while on treatment regimens self-reported greater adherence to their medication, fewer side effects, and a greater ability to satisfy increased appetite. Most clients self-reported weight gain, recovery of physical strength, and the resumption of labor activities while enrolled in dual (food supplementation and treatment) programs. Such improvements were seen to catalyze increased support from family and community.


Conclusions:

These findings provide further empirical support to calls for a more holistic and comprehensive response to the coexistence of AIDS epidemics with chronic nutrition insecurity. Future work is needed to clarify ways of bridging the gap between short-term nutritional support to individuals and longer-term livelihood security programming for communities affected by AIDS. Such interdisciplinary research will need to be matched by intersectoral action on the part of the agriculture and health sectors in such environments.



Lessons learned in the conduct, validation, and interpretation of national population based HIV surveys.
Author: Calleja, J. M.; Marum, L. H.; Carcamo, C. P.; Kaetano, L.; Muttunga, J., and Way, A.
Source : AIDS. 2005 May; 19 Suppl 2:S9-S17.
Abstract: In the past few years several countries have conducted national population-based HIV surveys. Survey methods, levels of participation bias from absence or refusal and lessons learned conducting such surveys are compared in four national population surveys: Mali, Kenya, Peru and Zambia. In Mali, Zambia, and Kenya, HIV testing of adult women and men was included in the national-level demographic and health surveys carried out regularly in these countries, whereas in Peru the national HIV survey targeted young people in 24 cities with populations over 50 000.The household response rate was above 90% in all countries, but some individuals were absent for interviews. HIV testing rates were between 70 and 79% of those eligible, with higher test rates for women. Three critical questions in this type of survey need to be answered: who did the surveys miss; how much it matters that they were missed; and what can be done to increase the participation of respondents so the coverage rates are adequate. The level of representativeness of the populations tested was adequate in each survey to provide a reliable national estimate of HIV prevalence that complements other methods of HIV surveillance. Different lessons were learned from each survey.These population-based HIV seroprevalence surveys demonstrate that reliable and useful results can be obtained, although they require careful planning and increased financial and human resource investment to maximize responses at the household and individual level, which are key elements to validate survey results.This review was initiated through an international meeting on 'New strategies for HIV/AIDS Surveillance in Resource-constrained Countries' held in Addis Ababa on 26-30 January 2004 to share and develop recommendations to guide future surveys.

National scale-up of HIV testing and provision of HIV care to tuberculosis patients in Kenya.
Author: Chakaya, J. M.; Mansoer, J. R.; Scano, F.; Wambua, N.; L'Herminez, R.; Odhiambo, J.; Mohamed, I.; Kangangi, J.; Ombeka, V.; Akeche, G.; Adala, S.; Gitau, S.; Maina, J.; Kibias, S.; Langat, B.; Abdille, N.; Wako, I.; Kimuu, P., and Sitienei, J.
Source : Int J Tuberc Lung Dis. 2008 Apr; 12(4):424-9.
Abstract: Setting:

Kenya, one of the 22 tuberculosis (TB) high-burden countries, whose TB burden is fuelled by the human immunodeficiency virus (HIV).


Objective:

To monitor and evaluate the implementation of HIV testing and provision of HIV care to TB patients in Kenya through the establishment of a routine TB-HIV integrated surveillance system.


Design:

A descriptive report of the status of implementation of HIV testing and provision of HIV interventions to TB patients one year after the introduction of the revised TB case recording and reporting system.


Results:

From July 2005 to June 2006, 88% of 112835 TB patients were reported to the National Leprosy and TB Control Programme, 98773 (87.9%) of whom were reported using a revised recording and reporting system that included TB-HIV indicators. HIV testing of TB patients increased from 31.5% at the beginning of this period to 59% at the end. Of the 46428 patients tested for HIV, 25558 (55%) were found to be HIV-positive, 85% of whom were provided with cotrimoxazole preventive treatment and 28% with antiretroviral treatment.


Conclusion:

A country-wide integrated TB-HIV surveillance system in TB patients can be implemented and provides essential data to monitor and evaluate TB-HIV related interventions.



Correlates of delayed disease progression in HIV-1-infected Kenyan children. Correlates of delayed disease progression in HIV-1-infected Kenyan children.
Author: Author: Chakraborty, R.; Morel, A. S.; Sutton, J. K.; Appay, V.; Ripley, R. M.; Dong, T.; Rostron, T.; Ogola, S.; Palakudy, T.; Musoke, R.; D'Agostino, A.; Ritter, M., and Rowland-Jones, S. L.
Source : J Immunol. 2005 Jun 15; 174(12):8191-9.
Abstract: Without treatment most HIV-1-infected children in Africa die before their third birthday (>89%) and long-term nonprogressors are rare. The mechanisms underlying nonprogression in HIV-1-infected children are not well understood. In the present study, we examined potential correlates of delayed HIV disease progression in 51 HIV-1-infected African children. Children were assigned to progression subgroups based on clinical characterization. HIV-1-specific immune responses were studied using a combination of ELISPOT assays, tetramer staining, and FACS analysis to characterize the magnitude, specificity, and functional phenotype of HIV-1-specific CD8(+) and CD4(+) T cells. Host genetic factors were examined by genotyping with sequence-specific primers. HIV-1 nef gene sequences from infecting isolates from the children were examined for potential attenuating deletions. Thymic output was measured by T cell rearrangement excision circle assays. HIV-1-specific CD8(+) T cell responses were detected in all progression groups. The most striking attribute of long-term survivor nonprogressors was the detection of HIV-1-specific CD4(+) Th responses in this group at a magnitude substantially greater than previously observed in adult long-term nonprogressors. Although long-term survivor nonprogressors had a significantly higher percentage of CD45RA(+)CD4(+) T cells, nonprogression was not associated with higher thymic output. No protective genotypes for known coreceptor polymorphisms or large sequence deletions in the nef gene associated with delayed disease progression were identified. In the absence of host genotypes and attenuating mutations in HIV-1 nef, long-term surviving children generated strong CD4(+) T cell responses to HIV-1. As HIV-1-specific helper cells support anti-HIV-1 effector responses in active disease, their presence may be important in delaying disease progression.

nef gene sequence variation among HIV-1-infected African children nef gene sequence variation among HIV-1-infected African children.
Author: Chakraborty, R.; Reinis, M.; Rostron, T.; Philpott, S.; Dong, T.; D'Agostino, A.; Musoke, R.; Silva, E.; Stumpf, M.; Weiser, B.; Burger, H., and Rowland-Jones, S. L. nef gene sequence variation among HIV-1-infected African children.
Source : HIV Med. 2006 Mar; 7(2):75-84.
Abstract: Background:

There are few data on African children infected with nonclade B HIV-1 in endemic settings, which limits generalizations about pathogenesis and progression. Genotypic and phenotypic variations in host immunogenetics and HIV-1 negative factor (nef) accessory protein may influence disease progression and have frequently been characterized in subjects infected with clade B HIV-1.


Methods:

In this descriptive study, we report nef gene sequence variation and host genetic polymorphisms in 32 Kenyan children, including 12 slow progressors.


Results:

Phylogenetic analysis identified HIV-1 clades A, C and D and a recombinant A/D subtype. Grossly defective nef genes or significant changes from relevant clade reference sequences were not identified in children with delayed disease progression.


Conclusions:

nef sequence variations may not be common in perinatally infected African children. Further studies are warranted in HIV-1-infected subjects in settings where infection is endemic.



HIV testing and counselling for women attending child health clinics: an opportunity for entry to prevent mother-to-child transmission and HIV treatment.
Author: Author: Chersich, M. F.; Luchters, S. M.; Othigo, M. J.; Yard, E.; Mandaliya, K., and Temmerman, M.
Source : Int J STD AIDS. 2008 Jan; 19(1):42-6.
Abstract: This study assessed the potential for HIV testing at child health clinics to increase knowledge of HIV status, and entry to infant feeding counselling and HIV treatment. At a provincial hospital in Mombasa, Kenya, HIV testing and counselling were offered to women bringing their child for immunization or acute care services. Most women said HIV testing should be offered in these clinics (472/493, 95.7%), with many citing the benefits of regular testing and entry to prevent mother-to-child transmission. Of 500 women, 416 (83.4%) received test results, 97.6% on the same day. After 50 participants, point-of-care testing replaced laboratory-based rapid testing. Uptake increased 2.6 times with point-of-care testing (95% confidence interval = 1.4-5.1; P = 0.003). Of 124 women who had not accessed HIV testing during pregnancy, 98 tested in the study (79.0%). Measured by uptake and attitudes, HIV testing in child health clinics is acceptable. This could optimize entry into HIV treatment, infant feeding counselling and family planning services.

Optimizing paediatric HIV care in Kenya: challenges in early infant diagnosis. Bull World Health Organ.
Author: Cherutich, P.; Inwani, I.; Nduati, R., and Mbori-Ngacha, D.
Source : Bull World Health Organ. 2008 Feb; 86(2):155-60.
Abstract: Problem:

In 2003, the goal of the Kenyan Ministry of Health was to avail antiretroviral treatment (ART) to 50% of the estimated 250 000 eligible individuals by the end of 2005. By July 2005, 45 000 adults and more than 2000 children were on treatment. A study was conducted to determine the barriers to identification of HIV-infected children.


Approach:

Existing government policies were reviewed and the ART register of the Kenya National AIDS Control Programme was used to identify facilities providing ART. This paper reports the findings around diagnosis and staging of HIV infection in children.


Local setting:

At the time of the study, 58 health facilities were providing ART to children. Only one institution had achieved universal HIV testing in the antenatal clinics. Six facilities systematically followed up HIV-exposed children. HIV antibody testing was not readily available to the children. Although four research centres were capable of carrying out diagnostic HIV polymerase chain reaction (PCR), the services were restricted to research purposes. Other constraints were inadequate physical infrastructure, inadequate systems for quality control in the laboratories and shortage of staff.


Lessons learnt:

The policy framework to support identification of HIV-infected children had been established, albeit with narrow focus on sick children. The assessment identified the weaknesses in the structures for systematic diagnosis of HIV through laboratory or clinical-based algorithms. The researchers concluded that health staff training and implementation of a systematic standard approach to identification of HIV-infected children is urgently required



Selection for human immunodeficiency virus type 1 envelope glycosylation variants with shorter V1-V2 loop sequences occurs during transmission of certain genetic subtypes and may impact viral RNA levelsSelection for human immunodeficiency virus type 1 envelope glycosylation variants with shorter V1-V2 loop sequences occurs during transmission of certain genetic subtypes and may impact viral RNA levels.
Author: Chohan, B.; Lang, D.; Sagar, M.; Korber, B.; Lavreys, L.; Richardson, B., and Overbaugh, J
Source : Virol. 2005 May; 79(10):6528-31.
Abstract: Designing an effective human immunodeficiency virus type 1 (HIV-1) vaccine will rely on understanding which variants, from among the myriad of circulating HIV-1 strains, are most commonly transmitted and determining whether such variants have an Achilles heel. Here we show that heterosexually acquired subtype A HIV-1 envelopes have signature sequences that include shorter V1-V2 loop sequences and fewer predicted N-linked glycosylation sites relative to the overall population of circulating variants. In contrast, recently transmitted subtype B variants did not, and this was true for cases where the major risk factor was homosexual contact, as well as for cases where it was heterosexual contact. This suggests that selection during HIV-1 transmission may vary depending on the infecting subtype. There was evidence from 23 subtype A-infected women for whom there was longitudinal data that those who were infected with viruses with fewer potential N-linked glycosylation sites in V1-V2 had lower viral set point levels. Thus, our study also suggests that the extent of glycosylation in the infecting virus could impact disease progression.

Infant feeding in the time of HIV: rapid assessment of infant feeding policy and programmes in four African countries scaling up prevention of mother to child transmission programmes.
Author: Chopra, M. and Rollins, N.
Source : Arch Dis Child. 2008 Apr; 93(4):288-91.
Abstract: Objective:

To assess the infant feeding components of prevention of mother to child HIV transmission (PMTCT) programmes.


Methods:

Assessments were performed across Botswana, Kenya, Malawi and Uganda. 29 districts offering PMTCT were selected by stratified random sampling with rural and urban strata. All health facilities in the selected PMTCT district were assessed. The facility level manager and the senior nurse in charge of maternal care were interviewed. 334 randomly selected health workers involved in the PMTCT programme completed self-administered questionnaires. 640 PMTCT counselling observations were carried out and 34 focus groups were conducted amongst men and women.


Results:

Most health workers (234/334, 70%) were unable to correctly estimate the transmission risks of breastfeeding irrespective of exposure to PMTCT training. Infant feeding options were mentioned in 307 of 640 (48%) observations of PMTCT counselling sessions, and in only 35 (5.5%) were infant feeding issues discussed in any depth; of these 19 (54.3%) were rated as poor. Several health workers also reported receiving free samples of infant formula in contravention of the International Code on Breastmilk Substitutes. National HIV managers stated they were unsure about infant feeding policy in the context of HIV. Finally, there was an almost universal belief that an HIV positive mother who breastfeeds her child will always infect the child and intentional avoidance of breastfeeding by the mother indicates that she is HIV positive.


Conclusion:

These findings underline the need to implement and support systematic infant feeding policies and programme responses in the context of HIV programmes



Independent effects of nevirapine prophylaxis and HIV-1 RNA suppression in breast milk on early perinatal HIV-1 transmission.
Author: Chung, M. H.; Kiarie, J. N.; Richardson, B. A.; Lehman, D. A.; Overbaugh, J.; Njiri, F., and John-Stewart, G. C.
Source : Defic Syndr. 2007 Dec 1; 46(4):472-8.
Abstract: Background:

The mechanism of action of single-dose nevirapine on reducing mother-to-child transmission of HIV-1 may involve reduction of maternal HIV-1 or prophylaxis of infants.


Methods:

In a study that randomized pregnant mothers to HIVNET 012 nevirapine versus short-course antenatal zidovudine, we compared breast milk HIV-1 RNA viral shedding and administration of single-dose nevirapine between mothers who transmitted HIV-1 to their infants at 6 weeks postpartum and those who did not.


Results:

In multivariate analyses, maximum breast milk HIV-1 RNA levels (hazard ratio [HR] = 2.50, 95% confidence interval [CI]: 1.25 to 4.99; P = 0.01) and nevirapine use (HR = 0.12, 95% CI: 0.02 to 0.97; P = 0.05) were each independently associated with perinatal transmission at 6 weeks postpartum. Mothers who transmitted HIV-1 to their infants had significantly higher HIV-1 RNA levels in their breast milk between the second day and sixth week postpartum. Among mothers with maximum breast milk virus levels less than a median of 3.5 log(10) copies/mL, the administration of nevirapine further decreased HIV-1 transmission risk from 22.2% to 0.0% (P = 0.04).


Conclusions:

Peripartum administration of single-dose nevirapine to mother and infant decreases early perinatal HIV-1 transmission by means of breast milk HIV-1 RNA suppression and, independently, by providing the infant with exposure prophylaxis.



Mandatory neonatal male circumcision in Sub-Saharan Africa: medical and ethical analysis.
Author: Clark, P. A.; Eisenman, J., and Szapor, S.
Source : Med Sci Monit. 2007 Dec; 13(12):RA205-13.
Abstract: The majority of those infected with HIV in sub-Saharan Africa do not have access to antiretroviral therapy, which is known to prolong the lives of HIV-positive persons in industrialized countries. Although the availability of antiretroviral therapy for those infected with HIV has increased worldwide, the infection rate out surpasses those started on such treatment. Without an AIDS vaccine or curative treatment, and given the difficulty in getting persons at risk to adopt healthy sexual behaviors, alternative approaches to decrease the spread of HIV infection are urgently needed. Three recent randomized controlled trials undertaken in Kisumu, Kenya, Raki District, Uganda and Orange Farm, South Africa have confirmed that male circumcision reduces the risk of heterosexually acquired HIV infection in men by approximately 51% to 60%. These three studies provide a solid evidence-base for future health policy. The procedure for adolescents and adults is expensive compared to abstinence, condoms or other methods; and the surgery is not without serious risks if performed by traditional healers using unsterilized blades as often happens in rural Africa. However, neonatally, the procedure is relatively inexpensive and the risks diminish considerably. Mandating neonatal male circumcision is an effective therapy that has minimal risks, is cost efficient and will save human lives. To deny individuals access to this effective therapy is to deny them the dignity and respect all persons deserve. Neonatal male circumcision is medically necessary and ethically imperative.

Immunoepidemiologic profile of Chlamydia trachomatis infection: importance of heat-shock protein 60 and interferon- gamma.
Author: Cohen, C. R.; Koochesfahani, K. M.; Meier, A. S.; Shen, C.; Karunakaran, K.; Ondondo, B.; Kinyari, T.; Mugo, N. R.; Nguti, R., and Brunham, R. C.
Source : J Infect Dis. 2005 Aug 15; 192(4):591-9.
Abstract: Epidemiological, animal, and in vitro investigations suggest that Chlamydia trachomatis infection engenders acquired immunity, the basis for which is incompletely defined, especially in humans. In a prospective cohort study of women at high risk for C. trachomatis infection, we found that, at baseline and after adjustment for age and other potential confounding variables, production of interferon- gamma by peripheral-blood mononuclear cells (PBMCs) stimulated with chlamydia heat-shock protein 60 strongly correlated with protection against incident C. trachomatis infection. This investigation supports a direct role for C. trachomatis-specific immune responses in altering the risk of infection and suggests immune correlates of protection that are potentially useful in vaccine development.

AIDS-affected children face systemic discrimination in accessing education.
Author: Cohen, J. Southern Africa:
Source : HIV AIDS Policy Law Rev. 2005 Dec; 10(3):24-5.
Abstract: In June 2005, Human Rights Watch (HRW) conducted an investigation in Kenya, South Africa and Uganda to document AIDS-affected children's experiences of inequality and neglect in the school system. HRW found, consistent with previous research, that the sickness of one or both parents due to HIV/AIDS led many children withdraw from school to perform household labour or offset lost family income. Parental death often led to abandonment, discrimination within extended and foster families, and emotional trauma that interfered with school performance.

Market incentives, human lives, and AIDS vaccines.
Author: Craddock, S. Market incentives, human lives, and AIDS vaccines.
Source : Soc Sci Med. 2007 Mar; 64(5):1042-56.
Abstract: For many, an AIDS vaccine holds the promise of intervening in a widespread epidemic because it is not predicated on changing economic structures and social contexts underlying vulnerability to HIV for millions of individuals. Yet 20 years into the AIDS epidemic, there is still no vaccine. Based on interviews of AIDS vaccine researchers, watchdog organizations, and ethics groups from the United States, South Africa, and Kenya conducted between August and December of 2003, this paper explores possible answers to the question of why there is no vaccine, looking in particular at contradictions between a biomedical research industry increasingly driven by market incentives and a disease that primarily affects individuals living in low-income countries with little vaccine purchasing power. Producing a vaccine that could be effective in low-income regions requires new kinds of initiatives that can coordinate research nationally and globally, and circumvent current regulatory mechanisms that dictate against the development and dissemination of low-profit medical technologies. Until such initiatives are supported, however, vaccine research will continue at a devastatingly slow pace at the cost of millions of lives annually.

Cost, affordability and cost-effectiveness of strategies to control tuberculosis in countries with high HIV prevalence.
Author: Currie, C. S.; Floyd, K.; Williams, B. G., and Dye, C
Source : BMC Public Health. 2005; 5:130.
Abstract: Background:

The HIV epidemic has caused a dramatic increase in tuberculosis (TB) in East and southern Africa. Several strategies have the potential to reduce the burden of TB in high HIV prevalence settings, and cost and cost-effectiveness analyses can help to prioritize them when budget constraints exist. However, published cost and cost-effectiveness studies are limited.


Methods:

Our objective was to compare the cost, affordability and cost-effectiveness of seven strategies for reducing the burden of TB in countries with high HIV prevalence. A compartmental difference equation model of TB and HIV and recent cost data were used to assess the costs (year 2003 USD prices) and effects (TB cases averted, deaths averted, DALYs gained) of these strategies in Kenya during the period 2004-2023.



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