Antiretroviral Treatment Services Research Articles

Effect of provider-initiated testing and counselling and integration of ART services on access to HIV diagnosis and treatment for children in Lilongwe, Malawi: a pre- post comparison

BackgroundThe HIV prevalence in Malawi is 12% and Kamuzu Central Hospital (KCH), in the capital Lilongwe, is the main provider of adult and paediatric HIV services in the central region. The Lighthouse at KCH offers opt-in HIV testing and counselling (HTC) for adults and children. In June 2004, Lighthouse was the first clinic to provide free antiretroviral treatment (ART) in the public sector, but few children accessed the services. In response, provider-initiated HIV testing and counselling (PITC) and an ART clinic were introduced at the paediatric department at KCH in Quarter 4 (Q4) 2004.MethodsWe analysed prospectively collected, aggregated data of quarterly reports from Q1 2003 to Q4 2006 from HTC centre registers, ART registers and clinic registrations at the ART clinics of both Lighthouse and the paediatric department. By comparing data of both facilities before (Q1 2003 to Q3 2004), and after the introduction of the services at the paediatric department (Q4 2004 to Q4 2006), we assessed the effect of this intervention on the uptake of HIV services for children at KCH.ResultsOverall, 3971 children were tested for HIV, 2428 HIV-infected children were registered for care and 1218 started ART. Between the two periods, the median (IQR) number of children being tested, registered and starting ART per quarter rose from 101 (53-109) to 358 (318-440), 56 (50-82) to 226 (192-234) and 18 (8-23) to 139 (115-150), respectively. The median proportion of tested clients per quarter that were children rose from 3.8% (2.7-4.3) to 9.6% (8.8 to 10.0) (p = 0.0009) and the proportion of ART starters that were children rose from 6.9% (4.9-9.3) to 21.1% (19.2-24.2) (p = 0.0036). The proportion of registered children and adults starting ART each quarter increased similarly, from 26% to 53%, and 20% to 52%, respectively.ConclusionsImplementation of PITC and integration of ART services within the paediatric ward are likely to be the main reasons for improved access to HTC and ART for children at KCH, and can be recommended to other hospitals with paediatric inpatients in resource limited settings with high HIV prevalence.

Prevention of mother-to-child transmission of HIV in Zambia: implementing efficacious ARV regimens in primary health centers

BackgroundSafety and effectiveness of efficacious antiretroviral (ARV) regimens beyond single-dose nevirapine (sdNVP) for prevention of mother-to-child transmission (PMTCT) have been demonstrated in well-controlled clinical studies or in secondary- and tertiary-level facilities in developing countries. This paper reports on implementation of and factors associated with efficacious ARV regimens among HIV-positive pregnant women attending antenatal clinics in primary health centers (PHCs) in Zambia.MethodsBlood sample taken for CD4 cell count, availability of CD4 count results, type of ARV prophylaxis for mothers, and additional PMTCT service data were collected for HIV-positive pregnant women and newborns who attended 60 PHCs between April 2007 and March 2008.ResultsOf 14,815 HIV-positive pregnant women registered in the 60 PHCs, 2,528 (17.1%) had their CD4 cells counted; of those, 1,680 (66.5%) had CD4 count results available at PHCs; of those, 796 (47.4%) had CD4 count ≤ 350 cells/mm3 and thus were eligible for combination antiretroviral treatment (cART); and of those, 581 (73.0%) were initiated on cART. The proportion of HIV-positive pregnant women whose blood sample was collected for CD4 cell count was positively associated with (1) blood-draw for CD4 count occurring on the same day as determination of HIV-positive status; (2) CD4 results sent back to the health facilities within seven days; (3) facilities without providers trained to offer ART; and (4) urban location of PHC. Initiation of cART among HIV-positive pregnant women was associated with the PHC's capacity to provide care and antiretroviral treatment services. Overall, of the 14,815 HIV-positive pregnant women registered, 10,015 were initiated on any type of ARV regimen: 581 on cART, 3,041 on short course double ARV regimen, and 6,393 on sdNVP.ConclusionEfficacious ARV regimens beyond sdNVP can be implemented in resource-constrained PHCs. The majority (73.0%) of women identified eligible for ART were initiated on cART; however, a minority (11.3%) of HIV-positive pregnant women were assessed for CD4 count and had their test results available. Factors associated with implementation of more efficacious ARV regimens include timing of blood-draw for CD4 count and capacity to initiate cART onsite where PMTCT services were being offered.

Socio-Demographic Characteristics Of Adults Screened For Hiv/Aids In A Rural Community In Benue State, Nigeria

Background: Benue state has been considered among the ‘hot zones’ for HIV/AIDS in Nigeria with a prevalence rate of 9.3 among adults aged 15 to 45 years. Yet, there is paucity of information on the socio-demographic factors associated with this level of prevalence. We hereby report the prevalence and socio-demographic factors associated with HIV among adults in Abwa-Mbagene, Benue state, Nigeria.Methods: Adults in Abwa-Mbagene community who accepted to participate between 9th and 24th of August 2007 were recruited. After counselling, screening was done using ‘Determine HIV’ kit.Results: 153 subjects (74 males and 79 females) were recruited. Their age ranges from 15 to 60 years (Mean: 26.2years). Fourty-two (27.5%) consisting of 12 (16.2%) males and 30 (38%) females were positive for HIV (male to female ratio, 2:5). The prevalence of HIV was higher among the divorcees (50%); those whose level of education was primary school (41.3%) and below and; farmers (60%). Majority (96%) knows AIDS exists, 85% are informed on mode and prevention of HIV transmission. Cases of AIDS deaths, unprotected casual sex, blood transfusion with unscreened blood and polygamy are common in the community. The single most important cultural factors in HIV transmission identified is indulgence in night parties, which increased the rate of unprotected casual sex.Conclusion: This community represents a high HIV/AIDS prevalence spot in Benue State, Nigeria. There is therefore the need for the establishment of HIV Counselling and Testing (HCT), Prevention of Mother-To-Child Transmission (PMTCT), save blood and antiretroviral treatment services in the community. Vocational centers to engage single women and improve their financial state will boost preventive strategies. Finally, partnership with community leaders towards discouraging night parties will reduce the prevalence of HIV in the community.

Very early mortality in patients starting antiretroviral treatment at primary health centres in rural Malawi

To report on the cumulative proportion of deaths occurring within 3 months of starting antiretroviral treatment (ART) and to identify factors associated with such deaths, among adults at primary health centres in a rural district of Malawi. Retrospective cohort study: from June 2006 to April 2008, deaths occurring over a 3-month period were determined and risk factors examined. A total of 2316 adults (706 men and 1610 women; median age 35 years) were included in the analysis and followed up for a total of 1588 person-years (PY); 277 (12%) people died, of whom 206 (74%) people died within 3 months of initiating ART (cumulative incidence: 13.0; 95% confidence interval: 11.3-14.8 per 100 PY of follow-up). Significant risk factors associated with early deaths included male sex, WHO stage 4 disease, oesophageal or persistent oral candidiasis and unexplained presumed or measured weight loss >10%. One in every 3 patients who either died or was lost to follow up had unexplained weight loss >10%, and survival in this group was significantly different from patients without this condition. Seven in 10 individuals initiating ART at primary health centres die early. Specific groups of patients are at higher risk of such mortality and should receive priority attention, care and support.

Tuberculosis Transmission from Patients with Smear‐Negative Pulmonary Tuberculosis in Sub‐Saharan Africa

SIR-We read with interest the report by Tostmann et al. of a national study of tuberculosis (TB) transmission in The Netherlands between 1996 and 2004 [1]. The relative TB transmission rate among patients with smear-negative, culture-positive pulmonary disease compared with patients with smear-positive disease was found to be 0.24. Overall, 13% of tuberculosis (TB) transmission events were attributable to source patients with sputum smear-negative, culture-positive disease. These important findings are in close agreement with similar studies from San Francisco, USA, and Vancouver, Canada [2,3], collectively showing that at in high-income countries 10–20% of TB transmission a population level is due to source cases with smear-negative pulmonary TB. The authors speculated on the relevance of these data for countries where HIV is endemic and rates of smear-negative disease are high. In sub-Saharan Africa HIV infection has had a devastating impact on TB control [4,5]. In a study community in a township in Cape Town, South Africa, for example, the antenatal HIV seroprevalence rate is approximately 30% and the annual TB notification rate has increased to over 1,500/100,000 [5] – almost 200-fold higher than TB rates in The Netherlands [4]. This has been associated with a major and disproportionate increase in the rate of smear-negative disease among HIV-infected individuals [5]. Moreover, the prevalence of undiagnosed TB (a key determinant of transmission) among HIV-infected patients in this community is very high and disease duration prior to diagnosis is prolonged [6]. In view of these observations, transmission attributable to smear-negative pulmonary TB cases at the community level may be important. Antiretroviral treatment (ART) services continue to expand in sub-Saharan Africa [7]. The high burden of TB in these clinical settings presents a great challenge with regard to morbidity, mortality and TB transmission risk [8,9]. Nosocomial outbreaks of both drug sensitive and drug resistant TB constitute a major threat [10]. In a recent study in an ART service in Gugulethu township, Cape Town, we did routine microbiological screening for TB in all newly referred ART-naive patients who did not already have a diagnosis of TB. Using automated MGIT 960 liquid culture (Becton Dickinson, Sparks, MD) of sputum, we found that over one quarter of patients had culture-confirmed pulmonary TB [11]. In this highly immunocompromised patient group, however, more than 80% of this disease was sputum smear-negative despite use of fluorescence microscopy; culture-based diagnosis took over 3 weeks on average. Recurrent attendance of patients at these overcrowded facilities over a period of several weeks while their TB remains undiagnosed represents an unacceptable hazard. These data have important implications for screening for TB among patients entering HIV care and treatment services in Africa. Rapid and appropriate diagnostic tests that are able to detect smear-negative pulmonary TB are urgently needed to reduce risks of transmission in these clinical environments. In summary, we suspect that TB transmission associated with smear-negative culture-positive TB in communities in Africa with high HIV prevalence may important and especially in the context of ART services where this is the preponderant form of TB.

Reconsidering the impact of conflict on HIV infection among women in the era of antiretroviral treatment scale-up in sub-Saharan Africa: a gender lens

As increasing international and local efforts focus on scaling up access to antiretroviral treatment (ART) in sub-Saharan Africa the United Nations High Commissioner for Refugees (UNHCR) Medecins Sans Frontieres and the Joint United Nations Program on HIV/AIDS have increasingly advocated that the lack of essential medicines in conflict settings including ART is a violation of human rights. HIV infection and armed conflict are disproportionately represented in sub-Saharan Africa with women and children experiencing the largest burden of harms and adverse health outcomes due to both HIV infection risk and impact of conflict. Given emerging disparities in access to ART among HIV-positive women in conflict zones there is an urgent need to reconsider the impact of conflict on HIV infection. Importantly recent evidence suggests that there may be a protective effect of armed conflict on HIV prevalence as a result of reduced mobility and urbanization disruption of sexual networks and decreased casual consensual sex. At the same time substantial evidence suggests an increased vulnerability to HIV in conflict settings among women and children due to widespread human rights violations rape as a weapon of war forced occupational exposure the need for women to turn to sex work to support themselves and their families (i.e. survival sex) and reduced access to HIV prevention and reproductive health services. Regardless inequitable access to ART scale up in conflict zones suggests a need to re-examine the complex relationship between conflict and HIV infection. (excerpt)

A STUDY OF PREDICTORS AND LEVELS OF BURNOUT: THE CASE OF PROFESSIONAL NURSES IN PRIMARY HEALTH CARE FACILITIES IN THE FREE STATE1

AbstractIn South Africa, nurses form the backbone of the primary health care (PHC) system. Their well‐being is, therefore, of paramount importance in the effective provisioning of health services. This paper explores predictors and levels of burnout experienced by professional nurses working in PHC facilities in the Free State. The sample comprised 182 nurses working in facilities rendering antiretroviral treatment (ART) services and 361 nurses working in facilities not rendering ART. Respondents completed a series of standardised instruments. Descriptive statistics were calculated and stepwise regression analysis performed to investigate the relative contribution of various stressors to the variance in burnout. High levels of burnout were identified. Availability of resources, workload and conflict at work explain 21% of the variance in the level of emotional exhaustion reported by the professional nurses. To a large degree, the results indicate that the well‐being of professional nurses is significantly affected by chronic work overload and occupational stress.

Scaling-up antiretroviral treatment in Southern African countries with human resource shortage: How will health systems adapt?

Scaling-up antiretroviral treatment (ART) to socially meaningful levels in low-income countries with a high AIDS burden is constrained by (1) the continuously growing caseload of people to be maintained on long-term ART; (2) evident problems of shortage and skewed distribution in the health workforce; and (3) the heavy workload inherent to presently used ART delivery models. If we want to imagine how health systems can react to such challenges, we need to understand better what needs to be done regarding the different types of functions ART requires, and how these can be distributed through the care supply system, knowing that different functions rely on different rationales (professional, bureaucratic, social) for which the human input need not necessarily be found in formal healthcare supply systems. Given the present realities of an increasingly pluralistic healthcare supply and highly eclectic demand, we advance three main generic requirements for ART interventions to be successful: trustworthiness, affordability and exclusiveness – and their constituting elements. We then apply this analytic model to the baseline situation (no fundamental changes) and different scenarios. In Scenario A there are no fundamental changes, but ART gets priority status and increased resources. In Scenario B the ART scale-up strengthens the overall health system: we detail a B1 technocratic variant scenario, with profoundly re-engineered ART service production, including significant task shifting, away from classical delivery models and aimed at maximum standardisation and control of all operations; while in the B2 community-based variant scenario the typology of ART functions is maximally exploited to distribute the tasks over a human potential pool that is as wide as possible, including patients and possible communities. The latter two scenarios would entail a high degree of de-medicalisation of ART.

Defaulters from antiretroviral treatment in Jimma University Specialized Hospital, Southwest Ethiopia

To determine the prevalence of and factors associated with defaulting from antiretroviral treatment (ART) in Jimma, Ethiopia. Unmatched case control study: cases were individuals who had missed two or more clinical appointments (i.e. had not been seen for the last 2 months) between January 2005 and February 2007; controls were individuals who had been on ART at least for 1 year and were rated as excellent adherers by the providers. Data were collected from patient records, and by telephone call and home visit to identify the reason for defaulting. Of 1270 patients who started ART, 915 (72.0%) were active ART users and 355 (28.0%) had missed two or more clinical appointments. The latter comprised 173 (13.6%) defaulters, 101 (8.0%) who transferred out, 75 (5.9%) who died, and 6 (0.5%) who restarted ART. Reasons for defaulting were unclear in most cases. Reasons given were loss of hope in medication, lack of food, mental illness, holy water, no money for transport, and other illnesses. Tracing was not successful because of incorrect address on the register in 61.6% of the cases. Taking hard drugs (cocaine, cannabis and IV drugs), excessive alcohol consumption, being bedridden, living outside Jimma town and having an HIV negative or unknown HIV status partner were associated with defaulting ART. A significant proportion of patients defaulted from ART treatment. ART clinics should ensure that patients' addresses are correct and complete. Programmatic and counseling efforts to decrease ART defaulting should address illicit drug and excessive alcohol use, decentralise ART services, institute home-based treatment options for seriously ill and bedridden patients, and address patients concerns.

Human Resources for Treating HIV/AIDS: Needs, Capacities, and Gaps

Despite recent international efforts to scale-up antiretroviral treatment (ART), more than 5 million people needing ART in low- and middle-income countries (LMIC) do not receive it. Limited human resources to treat HIV/AIDS (HRHA) are one of the main constraints to achieving universal ART coverage. We model the gap between needed and available HRHA to quantify the challenge of achieving and sustaining universal ART coverage by 2017. We estimate the HRHA gap in LMIC using recently published estimates of ART coverage, HIV incidence, health-worker emigration rates, mortality rates of people needing ART, and numbers of HRHA needed to treat 1000 ART patients (based on review studies, 2006). We project the HRHA gap in 10 years (2017) using a simple discrete-time model with a health worker pool replenished through education and depleted through emigration/death; a population needing ART replenished with a given HIV incidence rate; and higher survival rates for treated populations. We analyze the effects of varying assumptions about HRHA inflows and outflows and the evolution of the HIV pandemic in three different regional base cases (sub-Saharan Africa, non-sub-Saharan African LMIC, and South Africa). Current ART coverage for LMIC is around 28%-32% and, other things equal, will drop to 16%-19% by 2017 with constant current HRHA production rates. A naive model, ignoring the increased survival probability resulting from ART, suggests that approximately the current number of HRHA in ART services needs to be added every year for the next ten years to achieve universal coverage by 2017. In a model accounting for increased survival of treated patients, outcomes vary by region; sub-Saharan Africa requires two times, non-sub-Saharan African LMIC require 1.5 times and South Africa requires more than three times their respective current HRHA population to be added every year for the next 10 years to achieve universal coverage by 2017. Even if achieved by 2017, sustaining universal coverage requires further HRHA increases until the system reaches steady state. ART coverage is sensitive to HRHA inflow and emigration. Our model quantifies the challenge of closing the HRHA gap in LMIC. It shows that strategies to achieve universal ART coverage must account for feedback due to higher survival probabilities of people receiving ART. It suggests that universal ART coverage is unlikely to be achieved and sustained with increased HRHA inflows alone, but will require decreased HRHA outflows, substantially reduced HIV incidence, or changes in the nature or organization of care. Means to decrease HRHA emigration outflows include scholarships for healthcare education that are conditional on the recipient delivering ART in a country with high ART need for a number of years, training health workers who are not internationally mobile, or changing recruitment policies in countries receiving health workers from the developing world. Effective organizational changes include those that reduce the number of HRHA required to treat a fixed number of patients. Given the large number of health workers that even optimistic assumptions suggest will be needed in ART services in the coming decades, policymakers must ensure that the flow of workers into ART programs does not jeopardize the provision of other important health services.

Economic Stress and HIV-Associated Health Care Utilization in a Rural Region of China: A Qualitative Study

China is experiencing an emerging HIV epidemic, primarily affecting the rural poor. For this group, the costs of staying healthy are often beyond their means. A qualitative study was undertaken with 20 HIV-positive people living in a rural area in Anhui, eastern China, 20 of their family members, 20 health care providers, and 20 uninfected villagers. In this area, the majority of HIV-positive people were infected through contaminated commercial plasma/blood donation procedures. In-depth interviews were conducted with participants to identify the barriers and enablers to accessing health care services for HIV. A major concern for affected villagers was the unaffordable costs of health care, which leads them to delay seeking services until symptoms are severe. Use of the health care system was also influenced by the availability of subsidized medications, distance to the health care centre and quality of available services. In contrast, participants were very positive about antiretroviral treatment services, which are now free. In the study area, access to health care is heavily subsidized, yet many still found these services unaffordable. More equitable and affordable services will be needed if China is to control its HIV epidemic.

Promoting Retention in Care: An Effective Model in an Antiretroviral Treatment Service in South Africa

To the Editor—We read with interest the article by Giordano and colleagues [1] regarding the difficulties of retaining HIVinfected patients within care during antiretroviral therapy (ART) in US veterans affairs hospitals and clinics. Despite few financial barriers to treatment, retention in care was poor among a substantial portion of patients, compromising survival probability. The authors highlighted the critical need to develop and implement strategies to improve retention, thereby maximizing the benefits of ART [1]. In the accompanying editorial [2], Cheever described strategies that have been used successfully in other programs in the United States, whereby use of support services resulted in greater engagement of patients in their medical care and enhanced

Tuberculosis-associated immune reconstitution disease: incidence, risk factors and impact in an antiretroviral treatment service in South Africa

To determine the burden and impact of immune reconstitution disease (IRD) associated with tuberculosis (TB) among patients initiating antiretroviral treatment (ART) in sub-Saharan Africa. Retrospective analysis of a study cohort enrolled over 3 years within a community-based ART service in South Africa. Patients receiving treatment for TB at the time ART was initiated (n = 160) were studied. Cases of TB-associated IRD during the first 4 months of ART were ascertained. The median baseline CD4 cell count was 68 cells/microl [interquartile range (IQR), 29-133 cells/microl) and ART was initiated after a median of 105 days (IQR, 61-164 days) from TB diagnosis. Although IRD was diagnosed in just 12% (n = 19) of patients overall, IRD developed in 32% (n = 12) of those who started ART within 2 months of TB diagnosis. Pulmonary involvement was observed in 84% (n = 16) and intra-abdominal manifestations were also common (37%). Overall, 4% (n = 7) of the cohort required secondary level health-care for IRD and two (1%) patients died. In multivariate analysis, risk of IRD was strongly associated with early ART initiation and low baseline CD4 cell count. Of patients with CD4 counts < 50 cells/microl, the proportions who developed IRD following initiation of ART within 0-30, 31-60, 61-90, 91-120 and > 120 days of TB diagnosis were 100%, 33%, 14%, 7% and 0%, respectively. The risk of TB-associated IRD in this setting is very high for those with low baseline CD4 cell counts initiating ART early in the course of antituberculosis treatment. However, most cases were self-limiting; overall secondary health-care utilization and mortality risk from IRD were low.

Utilization of antiretroviral treatment in Ethiopia between February and December 2006: spatial, temporal, and demographic patterns

BackgroundIn 2003, the Ethiopian Ministry of Health (MOH) started to implement a national antiretroviral treatment (ART) program. Using data in the monthly HIV/AIDS Updates issued by the MOH, this paper examines the spatial and temporal distribution of ART on a population basis for Ethiopian towns and administrative zones and regions for the period February to December 2006.ResultsThe 101 public ART hospitals treated 44,446 patients and the 91 ART health centers treated 1,599 patients in December 2006. The number of patients currently receiving ART doubled between February and December 2006 and the number of female patients aged 15 years and older surpassed male patients, apparently due to increased awareness and provision of free ART. Of 58,405 patients who ever started ART in December 2006, 46,045 (78.8%) were adhering to treatment during that month. Population coverage of ART was highest in the three urban administrative regions of Addis Ababa, Harari and Dire Dawa, in regional centers with referral hospitals, and in several small road side towns that had former mission or other NGO-operated hospitals. Hospitals in Addis Ababa had the largest patient loads (on average 850 patients) and those in SNNPR (Southern Nations and Nationalities Peoples Republic) (212 patients) and Somali (130 patients) regions the fewest patients. In bivariate tests, number of patients receiving treatment was significantly correlated with population size of towns, urban population per zone, number of hospitals per zone, and duration of ART services in 2006 (all p < 0.001). The stronger relationship with urban than total zonal populations (p < 0.001 versus p = 0.014) and the positive correlation between distance from 44 health centers to the nearest ART hospital and patients receiving treatment at these health centers may be due to a combination of differential accessibility of ART sites, patient knowledge and health-seeking behavior.ConclusionThe sharp increase in ART uptake in 2006 is largely due to the rapid increase in the provision of free treatment at more sites. The marked variation in ART utilization patterns between urban and rural communities and among zones and regions requires further studies. Recommendations are made for further expansion and sustainability of the ART scale-up.

Conservation of First-Line Antiretroviral Treatment Regimen where Therapeutic Options are Limited

To determine rates and causes of switching from first- to second-line antiretroviral treatment (ART) regimens in a large treatment-naive cohort (a South African community-based ART service) where a targeted adherence intervention was used to manage initial virological breakthrough. ART-naive adults (n=929) commencing first-line non-nucleoside-based ART [according to WHO (2002) guidelines] between September 2002 and August 2005 were studied prospectively. Viral load (VL) and CD4+ T-cell counts were monitored every 4 months. All drug switches were recorded. Counsellor-driven adherence interventions were targeted to patients with a VL > 1000 copies/ml at any visit (virological breakthrough) and the VL measurement was repeated within 8 weeks. Two consecutive VL measurements > 1000 copies/ml was considered virological failure, triggering change to a second-line regimen. During 760 person-years of observation [median (IQR) 189 (85-441) days], 823 (89%) patients were retained on ART, 2% transferred elsewhere, 7% died and 3% were lost to follow-up. A total of 893 (96%) patients remained on first-line therapy and 16 (1.7%) switched to second-line due to hypersensitivity reactions (n=9) or lactic acidosis (n=7). A Kaplan-Meier estimate for switching to second-line due to toxicity was 3.0% at 32 months. Virological breakthrough occurred in 67 (7.2%) patients, but, following use of a targeted adherence intervention, virological failure was confirmed in just 20 (2.2%). Kaplan-Meier estimates at 32 months were 20% for virological breakthrough but only 5.6% for confirmed virological failure. Regimen switches were due to virological failure or toxicity. Although follow-up time was limited, over 95% of individuals remained on first-line ART using a combination of viral monitoring and a targeted adherence intervention.

Integration of Antiretroviral Treatment Within Antenatal Care in Gauteng Province, South Africa

Antenatal clinics are a key entry point into HIV treatment and care, together with interventions to reduce mother-to-child transmission (MTCT). Further evaluation is needed of interventions linking antenatal with antiretroviral (ARV) treatment services and effectiveness of triple-ARV regimens for reducing MTCT in resource-constrained settings. Data were gathered from HIV-infected women attending antenatal care from June 2004 to July 2005 at Coronation Women and Children Hospital, South Africa. After a patient record review, interventions were implemented to strengthen service linkages and integrate ARV treatment within antenatal care. Laboratory investigations were streamlined, including CD4 cell count testing at the first antenatal visit. MTCT risk for women initiating ARV treatment is compared with that of women-infant pairs receiving single-dose nevirapine (sd-NVP). In total, 164 pregnant women initiated ARV treatment and 863 received sd-NVP. After changes to service delivery, time-to-treatment initiation was reduced from a median of 56 days to 37 days (P = 0.041). The risk of MTCT for women receiving ARV treatment (5 [4.3%] of 116 women) was lower than for those given sd-NVP (74 [10.7%] of 692 women; P = 0.032). Strengthening linkages and integrating key components of ARV treatment within antenatal care reduces time-to-treatment initiation. In this setting, among women with a high MTCT risk, triple-ARV regimens are effective in reducing HIV infection in infants.

'We will eat when I get the grant': negotiating AIDS, poverty and antiretroviral treatment in South Africa

The maturing HIV epidemic has led to a decline in the health status of many South Africans. One result is an increasing number of AIDS-affected poor who qualify for a government disability grant. Recent research has drawn attention to the unintended conflict that this may present for poor people who might be faced with choosing between maintaining health through antiretroviral treatment and obtaining money through the state grant. While some evidence suggests that most AIDS-affected people would choose antiretroviral treatment over access to a disability grant, other evidence suggests that some would rather die than lose the grant. This paper is a qualitative exploration of ways that AIDS treatment policies and practices and grants for people disabled by AIDS are currently being negotiated by people caught in the double-bind of managing their own health and income. As South Africa continues to broaden its delivery of antiretroviral treatment and AIDS support services, it is important that planners incorporate an understanding of how an HIV or AIDS diagnosis in the context of entrenched poverty may represent both a threat and a means to financial survival. There is a need to consider the 'disinhibiting' effects on HIV prevention and treatment that may result when AIDS support services are aimed at addressing the needs of individuals as opposed to the needs of highly affected communities.

Determinants of Mortality and Nondeath Losses from an Antiretroviral Treatment Service in South Africa: Implications for Program Evaluation

The scale-up of antiretroviral treatment (ART) services in resource-limited settings requires a programmatic model to deliver care to large numbers of people. Understanding the determinants of key outcome measures--including death and nondeath losses--would assist in program evaluation and development. Between September 2002 and August 2005, all in-program (pretreatment and on-treatment) deaths and nondeath losses were prospectively ascertained among treatment-naive adults (n=1235) who were enrolled in a community-based ART program in South Africa. At study censorship, 927 patients had initiated ART after a median of 34 days after enrollment in the program. One hundred twenty-one (9.8%) patients died. Mortality rates were 33.3 (95% CI, 25.5-43.0), 19.1 (95% CI, 14.4-25.2), and 2.9 (95% CI, 1.8-4.8) deaths/100 person-years in the pretreatment interval, during the first 4 months of ART (early deaths), and after 4 months of ART (late deaths), respectively. Pretreatment and early treatment deaths together accounted for 87% of deaths, and were independently associated with advanced immunodeficiency at enrollment. Late deaths were comparatively few and were only associated with the response to ART at 4 months. Nondeath program losses (loss to follow-up, 2.3%; transfer-out, 1.9%; relocation, 0.7%) were not associated with immune status and were evenly distributed during the study period. Loss to follow-up and late mortality rates were low, reflecting good cohort retention and treatment response. However, the extremely high pretreatment and early mortality rates indicate that patients are enrolling in ART programs with far too advanced immunodeficiency. Causes of late access to the ART program, such as delays in health care access, health system delays, or inappropriate treatment criteria, need to be addressed.

Distribution of primary health care facilities in Mtwara District, Tanzania: availability and accessibility of services

Background: Access to health care services is a significant factor to health seeking practices that contributes to a healthy population. Improving health care accessibility is an important health priority in low-income countries. The objective of this study was to determine distribution of health care facilities and identify the high priority areas, which require more services in Mtwara, southern Tanzania.Methods: This study was carried in Mtwara Rural district of southern Tanzania and involved health care facilities. A hand held global positioning system was used to geo-reference the coordinates of all facilities. A questionnaire with both closed and open-ended questions was used to gather information from patients who attended the respective facilities. Interviews with district health officials and facility in-charges were conducted.Results: There were 38 health in the district. Most of them were located within southern part of the district. The majority of facilities (97%) were government owned. On average each facility was serving 2,400 population. Malaria management, reproductive and child health services, family planning and integrated management of childhood illnesses were offered by all health facilities in the district. Prevention of mother to child transmission of HIV was offered by 34 (89.5%) facilities. Tuberculosis services were offered by only 3 facilities while voluntary counselling and testing of HIV and anti-retroviral treatment services were available in 15 and 10 health facilities, respectively. Only 4 facilities had laboratory and inpatients services. The majority of the staff included Medical Attendants (39%), Nurse Midwives (34%), and Clinical Officers (20%). Assistant Medical Officers and Nursing Officers each accounted for 2% of the total staff. There were no Medical Officers, laboratory technicians or pharmaceutical technicians in the district. A total of 408 health facility clients (≥18yrs) were interviewed. Factors influencing the choice of a health facility were the availability of special services, medicine and qualified human resources.Conclusion: The majority of facilities in Mtwara are government and there is disparity in the distribution of the facilities. Availability of medicines and qualified human resources were the major factors on the preference for accessing health care services.