Child HIV Research Articles

The effects of maternal and child HIV infection on health equity in Tigray Region, Ethiopia, and the implications for the health system: a case–control study

ABSTRACTServices that aim to prevent mother-to-child HIV transmission (PMTCT) can simultaneously reduce the overall impact of HIV infection in a population while also improving maternal and child health outcomes. By taking a health equity perspective, this retrospective case control study aimed to compare the health status of under-5 children born to HIV-positive and HIV-negative mothers in Tigray Region, Ethiopia. Two hundred and thirteen HIV-positive women (cases), and 214 HIV-negative women (controls) participated through interviews regarding their oldest children. Of the children born to HIV-positive mothers, 24% had not been tested, and 17% of those who had been tested were HIV-positive themselves. Only 29% of the HIV-positive children were linked to an ART programme. Unexpectedly, exposed HIV-negative children had fewer reports of perceived poor health as compared to unexposed children. Over 90% of all the children, regardless of maternal HIV status, were breastfed and up-to-date with the recommended immunizations. The high rate of HIV infection among the babies of HIV-positive women along with their low rates of antiretroviral treatment raises serious concerns about the quality of outreach to pregnant women in Tigray Region, and of the follow-up for children who have been exposed to HIV via their mothers.

The rate of mother-to-child transmission of antiretroviral drug-resistant HIV strains is low in the Swiss Mother and Child HIV Cohort Study.

Combination antiretroviral therapy (cART) has reduced mother-to-child transmissions (MTCT) and improved the prognosis of HIV-infected newborns. However, drug resistance mutations (DRM) in HIV-infected children, either transmitted by MTCT (HIV-tDRM) or selected by suboptimal adherence and drug levels (HIV-sDRM), remain a concern. We sought to determine the rate of HIV-tDRM and HIV-sDRM in MTCT pairs in Switzerland. We performed a retrospective analysis of prospectively collected clinical data and available stored samples from MTCT pairs participating in the Swiss Mother-Child HIV (MoCHIV) cohort. We identified 22 HIV-infected mother-child pairs with delivery between 1989 and 2009 who had 15 years of follow-up (33% white ethnicity). Twenty-one women (96%) were treatment-naïve before pregnancy, 8 (36%) had an unknown HIV status and delivered vaginally, 2 were diagnosed but not treated, and 11 (50%) received antiretrovirals during pregnancy or at delivery, of whom only 6 cases (27%) had cART. HIV subtypes were concordant in all mother-child pairs (subtype B 13/22 [59%]). Using stored plasma (n = 66) and mononuclear cell (n = 43) samples from the children, HIV-tDRM (M184V) was identified in 1 of 22 (4.5%) mothers (1/11 treated, 9%) and was followed by HIV-sDRM at 10 months of age. HIV-sDRM (M184V 23%; K103N 4.5%; D67N 13.6%) occurred in 16/22 (73%) after 4 years, half of whom were treatment naïve. HIV-sDRM were associated with a lower CD4 T-cell nadir (p <0.05) and tended to have higher viral loads and more frequent cART changes. HIV-tDRM were low in this Swiss MoCHIV cohort, making them a minor yet preventable complication of prenatal HIV care, whereas HIV-sDRM are a significant challenge in paediatric HIV care.

PG-9 Predictors of final HIV status outcome for HIV-exposed infants at 18 months of age in 10 Nigerian states

Introduction: There were an estimated 37,000 new child HIV infections in Nigeria in 2016, the highest globally. For Nigeria, 6 week and final mother-to-child transmission of HIV (MTCT) rates are estimated at 13.1% and 23.0%, respectively. The UNAIDS has targeted final MTCT rates of <2% and <5% among non-breastfeeding and breastfeeding infants, respectively. Data on 18-month final outcomes among HIV-Exposed Infants (HEI) in Nigeria is scarce. We evaluated for predictors of HIV status among HEI at 18 months of life in 10 Nigerian states. Methods: This retrospective, cross-sectional study collected data from 96 PEPFAR-supported health facilities supported by the Institute of Human Virology Nigeria in 10 Nigerian states between October 2014 and September 2015. Only HEI with a first DNA PCR result at ≥4–6 weeks, and a rapid HIV antibody test result at ≥18 months of age were included. Data including residence, birth weight, breastfeeding status, and maternal ART access were collected for analysis. Multivariate logistic regression (adjusted odds ratios [aORs] evaluated for predictors of HIV test positivity at 18 months. Results: A total of 2405 HEI from the 96 facilities were included in the study. Median birthweight was 3 kg (IQR 1.2–6.1), and at final testing was 10 kg (IQR 5.5–15). Of the 2405 HEI negative at first DNA PCR test and tested at ≥18 months, 68 (2.8%) were positive. After a minimum of 18 months of age, 51 (75%) of the 68 HIV-positive infants were alive on ART; 7 (10%) had died, 4 (6%) were lost to follow-up and 6 (9%) had transferred out to other facilities for care. Infant birth weight of ≥2.5 kg (AOR 0.40, P = 0.009), urban residence (OR 0.45, P = 0.008) and exclusive breastfeeding (OR 0.04, P < 0.001) protected against MTCT; maternal non-initiation/utilization of antenatal/in-labor ART (OR 9.59, P < 0.001) correlated with MTCT. Conclusions: The final HIV positivity rate of 2.8% in our cohort is lower than the national estimates, which is encouraging. However, this should be interpreted with caution: the HIV status of HEI seen at the study facilities who did not present for early and/or final testing was not available and thus not evaluated. Nevertheless, supported by our findings, we recommend strengthening universal maternal access to ART, ideally in the pre-conception and prenatal stages. This should be prioritized especially for rural women living with HIV. Furthermore, our findings correlate with the nationally-recommended 6-months of exclusive infant breastfeeding. We acknowledge that data from non-presenting HEI are also needed to devise interventions for universal uptake of early and final HIV testing. We expect that as Option B plus is scaled up in Nigeria, more women would access and be maintained on ART through their first and subsequent pregnancies, thereby reducing the gaps in maternal-infant HIV service uptake.

I-106 Early treatment initiation in children with vertical HIV infection influences HIV specific immune responses

Background: Despite successes in prevention of mother to child HIV transmission (MTCT), issues related to early diagnosis, ART initiation and adherence play a role in the disease course of HIV infected children. Early ART initiation in HIV infected infants leads to reduced size of HIV reservoirs and curtails clinical progression but role of the immune system in this process is not well understood. With early initiation of ART, HIV infected infants preserve their CD4+ T cells and in some instances remain seronegative for HIV due to limited exposure of B cells to HIV antigen. We are performing immunologic assessments in the HIV Exposed Pediatric Patients (HEPP) Project and discuss a group of children from Rome, Italy. The goal of the present study is to evaluate HIV-specific immunity of vertically HIV infected children in relation to timing of ART initiation. Methods: The study group consists of older vertically infected HIV+ children and adolescents who initiated ART at different ages after birth and have maintained durable viral control (plasma HIV-RNA <50 cp/mL). Immunologic studies were performed in 27 children (at ages 2.1–15.7 yrs) of whom 22 had started ART early, at age <6 mo [early treated (ET)] and 5 who started ART later, at age >2 yrs [late treated (LT)] with ET experiencing longer duration of ART (P < 0.05) at the time of study. ET children were also evaluated by HIV serology (Abbott Architect HIV Ag/Ab Combo Assay) to establish if they were seropositive (SP) or seronegative (SN) to HIV. Flow cytometry was performed using BD LSRFortessa for T cells and BD FACS Aria II for B cells. HIV-gag specific CD4+ and CD8+ T cells were investigated by flow cytometry in cryopreserved PBMC for the induction of intracellular cytokines (IL-2, IFN-g, TNF, IL-21) in CD40L+ CD4+ T cells and intracellular cytokines (IL-2, IFN-g, TNF) as well as Perforin, Granzyme B and CD107a in CD69+ CD8+ T cells following 12 hours stimulation with HIV gag PTE peptides. In addition, Env-specific CD4+ T cells were evaluated following 12 hours stimulation of PBMC with Env peptides. IgD+ and IgM+ B cell subsets were determined in gp140+ B cells. Moreover, env-specific and non-specific B cells were sorted to perform transcriptomic analysis with Fluidigm (Biomark). Differences between groups were determined by unpaired or Mann-Whitney t tests if the data were normally distributed or not, respectively. Results: In this group of HIV+ children, frequencies of HIV gag-specific CD4+ T cells and CD8+ T cells were similar between ET and LT but differed qualitatively. Gag stimulated CD4+ T cells of ET exhibited higher proportions of IL-21 and IFNg with enrichment of polyfunctional T cells defined by the simultaneous presence of 3 or more cytokines. Gag stimulated CD8+ T cells of ET exhibited higher frequencies of cytotoxic cells (CD107a+Perf+GrzB+). In ET, serologic evaluation of HIV Ab revealed 6/22 (27.3%) to be SN. The gp140-specific CD4+ T cell frequencies were similar in SN and SP but intracellular IL-21 expression was higher in SP. Frequencies of gp140+ CD19+ B cells were similar between SN and SP, but HIV-specific CD27+ memory B cells were predominantly IgM+ in SN while in SP, the gp140+CD27+ memory B cells were enriched in IgD-cells. Gene expression signatures in gp140+IgM+ cells revealed upregulation of genes involved in both plasma cell differentiation (PRDM1) and GC reaction (BCL6) only in SP after in-vitro stimulation. Conclusions: Time of ART initiation after birth has a long-term impact on the quality of the host HIV-specific immune responses in vertically infected HIV+ children with durable virus suppression. Earlier ART initiation is associated with preserved HIV gag-specific CD4+ and CD8+ T cells. Moreover, even in those who become seronegative for HIV, the HIV Env-specific CD4+ T cells and B cells persist, the latter demonstrating a blunted differentiation with enrichment of IgM+ B cells. ET children with consistent viral control are prime candidates for therapeutic approaches aimed at permanent remission of HIV. These studies are supported by ViiV Health Care grant to EPIICAL and NIH grant AI127347 to SP.

A review of family planning policies and services in WHO Eastern Mediterranean Region Member States.

Family planning (FP) is a cost-effective public health and development intervention. Eastern Mediterranean Region (EMR), has one of the lowest contraceptive prevalence rate (CPR) and high unmet need for family planning. The aim of this review is to assist Member States in highlighting those areas that need strengthening to improve quality of FP services in information and commodity supplies. A structured questionnaire focusing on FP services was sent to 22 Member States of the WHO Eastern Mediterranean Region between August and December, 2015. Sixteen (73%) countries responded. Family planning services are part of the basic health benefits package and are delivered at hospitals, primary healthcare centres and outreach clinics to all women regardless of their ability to pay in the majority of Member States. In 16 Member States the family planning/birth spacing (FP/BS) counselling and FP methods are provided by general practitioner/ family doctor, nurses and midwives. In many Member States the services are integrated with child health, STI and HIV services. In 16 Member States FP/BS is part of the pre- and in-service training programmes for all cadres of healthcare providers. FP/BS is actively promoted through effective social marketing of FP/BS methods in two thirds of Member States. The findings of the survey indicate that national policies and programmes endorse FP to achieve national targets. Despite progress in many areas in FP services, many countries still struggle with weak implementation of FP programmes. There are also policy gaps for key vulnerable groups including the poor, the disabled and adolescents. This review highlighted policy and programmatic gaps required to strengthen those FP services that can help improve maternal and infant health outcomes. Special programmes for adolescents, refugees and persons with disabilities need to be streamlined and strengthened.

Long-term survival outcomes of HIV infected children receiving antiretroviral therapy: an observational study from Zambia (2003\u20132015)

BackgroundIn 2017, 64% of children living with HIV in Zambia accessed Antiretroviral Therapy (ART). Despite expanded ART coverage, there is paucity of information on effectiveness of pediatric ART in reducing mortality. The aim of this research is to describe treatment outcomes, measure mortality rates and assess predictors of mortality among children receiving ART.MethodsUsing a retrospective cohort study design, we abstracted routinely collected clinical data from medical records of children from birth to 15 years old, who had received ART for at least 6 months at Livingstone Central Hospital in Southern Province Zambia, between January 2003 and June 2015. The primary outcome was death. Cause of death was ascertained from medical records and death certificates. Distribution of survival times according to baseline covariates were estimated using Kaplan Meier and Cox Proportional Hazards methods.ResultsOverall, 1039 children were commenced on ART during the study period. The median age at treatment initiation was 3.6 years (IQR: 1.3–8.6) and 520 (50%) children were female. Of these, 71 (7%) died, 164 (16%) were lost to follow-up, 210 (20%) transferred and 594 (56%) were actively on treatment. After 4450 person years, mortality rate was 1.6/100 (95% CI: 1.4–1.8). Mortality was highest during the first 3 months of treatment (11.7/100 (95% CI: 7.6–16.3). In multivariable proportional hazards regression, the adjusted hazards of death were highest among children aged < 1 year (aHR = 3.1 (95% CI: 1.3–6.4), compared to those aged 6–15 years, WHO stage 4 (aHR =4.8 (95% CI: 2.3–10), compared to WHO stage 1 and 2. In the sensitivity analysis to address bias due to loss to follow-up, mortality increased 5 times when we assumed that all the children who were lost to follow up died within 90 days of their last visit.ConclusionWe observed low attrition due to mortality among children on ART. Loss to follow-up was high (16%). Mortality was highest during the first 3 months of treatment. Children aged less than one year and those with advanced WHO disease stage had higher mortality. We recommend effective interventions to improve retention in care and early diagnosis of HIV in children.

Economic sanctions and child HIV.

Approximately 1.8 million children under age 15 were living with HIV. This study is the first to empirically examine the impact of sanctions on children's new HIV infection and AIDS-related death rates. Using sanction and HIV/AIDS data that are available for 71 developing countries from 1990 to 2012, this study reveals that sanctions increase children's new HIV infection and their AIDS-related death rates. This study increases understanding about the consequences of sanctions, especially their effect on a marginalized population and is in line with previous literature. The significant impacts of sanctions on children's HIV/AIDS suggest that the leader in a country targeted by sanctions needs to consider extending programs to respond to children's HIV/AIDS both during sanctioning and after it is lifted.

Seroprevalence of Hepatitis B, Hepatitis C, and HIV in children with cancer at diagnosis and following therapy in Turkey: progress within the last 25 years.

Aim:Children with cancer receiving intensive chemotherapy require multiple transfusions and are at increased risk for blood transmittable diseases such as hepatitis B virus (HBV), hepatitis C virus (HBC), and HIV infections. The aim of this study was to investigate the seroprevalence of HBV, HCV, and HIV in children with cancer and to compare the results with findings in our previous cancer studies conducted before the national free HBV vaccination and the HCV screening program in blood banks were established.Material and Methods:Sera from 100 children (51 females, 49 males) with cancer treated between January 2010 and January 2012 who received multiple transfusions were investigated for hepatitis B surface antigen (HBsAg), anti-HBs, anti-HCV, anti-HIV at diagnosis and at the end of treatment. Patients were born after 1998 when the national free hepatitis B vaccination program began.Results:HBsAg, anti-HCV, and anti-HIV seropositivities were 0% at diagnosis and at the end of treatment. Anti-HBs seropositivity was 58% at diagnosis and 42% at the end of treatment. HBsAg seropositivity, which was 0% at the end of treatment, was lower than 10% during 1994–95, and 40% from 1986 to 1989. Anti-HCV was 0% in contrast to 14% between 1994 and 1995. Seventeen patients with anti-HBs seropositivity at diagnosis were found to be seronegative after intensive chemotherapy.Conclusion:The nil seroprevalence of anti-HBsAg, anti-HCV, and anti-HIV in this cohort of children with cancer is encouraging. This progress is due to advances in donor screening techniques in blood banks, good hygenic practices, and the national free hepatitis B vaccination program in Turkey.

Predictors of loss to follow-up among children attending HIV clinic in a hospital in rural Kenya.

IntroductionAfrican studies have reported high rates of loss to follow up (LTFU) among children in HIV care and treatment centres. Factors associated with LTFU may vary across populations. Few studies have been conducted among HIV infected children in care in rural areas of Kenya.Methodsthis involved children aged less than 15 years on follow up at Kangundo Level 4 Hospital HIV clinic from January 2010 to December 2015. We obtained sociodemographic and clinical information from patient files and electronic databases. Univariate and multivariate regression analyses were conducted to identify factors predictive of LTFU.Resultsa total of 261 HIV-infected children were followed up. The mean age was 10.0 years (IQR, 7-13) and median CD4 count of 582cells/ul (IQR 314-984). By December 2015, 171 children (65.5%) remained in active care, 32 (12.3%) transferred out, 13 (5%) died, while 45 (17.2%) were classified as LTFU. Out of the 45 children presumed as LTFU, we traced 44 out of the 45 children (98%) and found that their actual current status was as follows: 33 of the 44 children (75.0%) had dropped out of care (true LTFU). Factors strongly predictive of LTFU included low caregiver level of education (HR 2.3, 1.9-3.9, P = 0.001), WHO stage I and II at enrolment (HR 1.6, 1.4-2.1, P = 0.05).ConclusionLTFU of HIV infected children was common with an incidence of 32.9 per 1000 child years and occurred early in treatment and risk factors included poverty, low caregiver education, male child and early HIV disease stage.

The Effect of Human Immunodeficiency Virus-1 Infection on Low Birth Weight, Mother to Child HIV Transmission and Infants’ Death in African Area

Background: It is yet a controversy subject whether low birth weight and infant death are associated to human immunodeficiency virus-1 infection. Objective: To appreciate association between low birth weights, mother to child HIV transmission and infant mortality in HIV-1 infected pregnant women delivering between 2011 and 2016. Materials: We conducted 6 years cohort study in urban Mali. Outcome included preterm delivery, small for gestational age, infant survival status and HIV transmission. Comparison concerned women clinical WHO stage, mother viro-immunological status, and newborn anthropometric parameters. Results: HIV-1 infected women who delivered low birth weight newborn were 20.9% (111/531) versus 16.5% (1910/11.546) in HIV negative patients (p = 0.016). CD4 T cell counts low than 350 T cells count were strongly associated to LBW (p = 0.000; RR = 3.03; 95% CI [1.89 - 3.16]). There is no significant association between ART that was initiated during pregnancy (p = 0.061, RR = 0.02; CI 95% (1.02 - 1.99)) or during delivery (p = 0.571; RR = 1.01; CI 95% (0.10 - 3.02)) and LBW delivery. In multivariate analysis ART regimens containing protease inhibitor (PI) were lone regimens associated with LBW ((p = 0.030; RR = 1.001; 95% confidence interval [1.28 - 3.80]). Very low birth weight was statistically associated to women HIV infection (adjusted relative risk, 2.02; p = 0.000; 95% confidence interval (2.17 - 4.10)). There is no significant difference between mother to child HIV transmission rate in the two HIV-infected pregnant women (10 infected children in group 2: MTCT rate 4.5%) and 3 infected children in group 1 (MTCT rate: 2.7%) (p = 0.56; RR, 0.59; CI 95% (0.18 - 4.39)). In multivariate analysis, LBW was associated with infant death (p = 0.001; RR = 2.04; CI 95% [1.04 - 5.05]). The median weight of infant at the moment of death in group 1 was 851 g (IQR: 520 - 1833 g). Significant relationship was found between infant death among LBW newborn with mother WHO stage 2 (p = 0.004; adjusted RR = 3.22; CI 95% [2.25 - 6.00]), CD4 T cells count < 350 cells/mm3 (p = 0.005; RR = 2.81; CI 95% [1.20 - 4.11]), PI regimens (p = 0.030; RR = 1.00; CI 95% [1.28 - 3.80]). Conclusion: We confirm increased risk of low birth weight and mother HIV-1 infection and we identified strongest association between mortality in infant born to HIV-1 infected mother and LBW.

An evaluation of elvitegravir plus cobicistat plus tenofovir alafenamide plus emtricitabine as a single-tablet regimen for the treatment of HIV in children and adolescents

ABSTRACTIntroduction: Approximately 2.1 million of the estimated 36 million infected with HIV are children or adolescents. International guidelines for HIV-1 Infection suggest starting antiretrovirals (ARV) at the moment of diagnosis. Many factors limit the optimization of antiretroviral therapy in children and adolescents: lack of pediatric formulations, poor adherence, metabolic and pharmacokinetic changes associated withnormal child development and puberty.Areas covered: Three integrase inhibitors are approved by the US Food and Drug Administration and by European Medical Agency for children and adolescents with HIV-1 infection. Raltegravir is approved for children aged 4 weeks to 18 years, while dolutegravir and elvitegravir co-formulated with cobicistat, emtricitabine, and tenofovir alafenamide (E/C/FTC/TAF) are approved for children from 6 years of age. This article evaluates E/C/FTC/TAF as a treatment option.Expert opinion: E/C/FTC/TAF was well tolerated, and the antiretroviral activity and tolerability data of this combination support the use in children and adolescents. However, the studies regarding E/C/FTC/TAF in children and adolescents are scant. Consequently, additional studies investigating its safety and efficacy in children are paramount.

Investigation of prevention of mother to child HIV transmission program from 2011 to 2017 in Suzhou, China

The vertical transmission of HIV, from mother to child remains one of the biggest challenges all over the world. This study evaluated the implementation and effectiveness of the prevention of mother to child HIV transmission (PMTCT) program from 2011 to 2017 in Suzhou. A total of 107 HIV positive women were enrolled in the program, of which 11 were diagnosed through premarital examination, and 96 women were diagnosed through prenatal examination. Among the 96 pregnant women, 67 gave birth to 68 live neonates. Only one infant was diagnosed HIV infected because the HIV positive mother did not enter the PMTCT program until delivery. The HIV prevalence in Suzhou city showed a low-level tendency. To increase the prenatal health utility and antiretroviral medication compliance of the migrant population in Suzhou, there are improvements to make in order to achieve the 90-90-90 targets.

Anorectal malformations and the impact of HIV on surgical outcome.

Anorectal malformations (ARMs) represent a significant surgical load in South African (SA) paediatric surgical centres. Surgical treatment of ARMs may be associated with postoperative complications owing to the nature of surgical procedures necessary in the neonatal and infant period. HIV and its effect on the immune response compound postoperative surgical complications. The impact of HIV exposure and its effect on the child's immune status, independent of the child's HIV status, has yet to be studied in the surgical population. To assess the incidence of complications in our population of ARM patients and to explore whether these were increased in HIV-exposed but serologically negative children compared with HIV-unexposed children. This was a prospective study of all patients presenting with ARMs to the paediatric surgery units attached to the University of the Witwatersrand, Johannesburg, SA. Specifically, exposure to an HIV-positive mother, patient HIV status and presence of surgical complications were documented. Data were analysed for the period August 2016 - September 2017. A total of 50 children were included (none were excluded); 19 (38%) were HIV-exposed but none were HIV-positive, and 28 (56%) were male and 22 (44%) female. Seventy-six operative procedures were performed, with 27 operative complications. In the HIV-exposed group, 68% of patients experienced operative complications, compared with 45% in the unexposed group (p=0.1); 50% of the HIV-exposed patients who had stoma formation experienced complications, compared with 20% in the unexposed group (p=0.08). The incidence of postoperative infectious complications in HIV-exposed patients was higher than in HIV-unexposed patients. The incidence of postoperative complications in HIV-unexposed patients parallels that in the international literature, except in the posterior sagittal anorectoplasty groups. It remains critically important to follow stringent perioperative protocols for infection prevention and aggressively treat any infection that arises, particularly in patients born to HIV-positive mothers, regardless of the patient's HIV status.

Uptake of Prevention of Mother to Child HIV Transmission (PMTCT) Option B+ ART Program among Pregnant and Lactating Mothers Attending Ante Natal Care (ANC) Clinic at Jimma University Specialized Hospital, Southwest Ethiopia

Uptake of Prevention of Mother to Child HIV Transmission (PMTCT) Option B+ ART Program among Pregnant and Lactating Mothers Attending Ante Natal Care (ANC) Clinic at Jimma University Specialized Hospital, Southwest Ethiopia

Acceptability of children's testing for HIV infection during routine care activities in the Pediatrics Department of Sourô Sanou Teaching Hospital in Bobo-Dioulasso (Burkina Faso).

In order to contribute to the fight against the pediatric HIV infection, we have assessed, through a study in which we have systematically proposed to carry out children's testing, the rate of acceptability and the feasibility of children's HIV testing during the routine activities of the department. We have also analyzed the reasons for the acceptability or the refusal of the child's HIV testing by the accompanying person. The study took place from May to September 2015 including all the parents/legal guardians of any child aged 0 to 14 years coming for a consultation or who was hospitalized in the Pediatric Department of Souro Sanou Teaching Hospital. Counseling sessions conducted by community health workers focused on informing and proposing the principle of child testing. After obtaining the verbal and informed consent of the accompanying person, the first test was performed with Determine® by a hospital health worker. A second SD Bioline®/ImmunoCombII® test was performed if the first test was positive. With children aged less than 18 months, after a positive antibody test, we resorted to PCR for confirmation. A total of 848 accompanying persons, 568 of whom were female, underwent a pre-test interview during which the HIV test was offered to them. The mean age of accompanying persons was 30 (25.5 to 38) years; 747 accompanying persons (88.1%) accepted the testing of their child. We have found an influence of the accompanying person's religion (P=0.02) and the type of accompanying person on the acceptability of children's testing. Mothers were more willing to accept the test compared to other accompanying persons (P=0.002). The main reason for refusing the child's testing was the absence of one of the child's parents, mainly the father whose opinion was needed. The test was positive for HIV1 in 10 children. In health centers, getting the informed consent from parents to test their children is a big challenge. However, our study shows that this is possible, through the high rate of acceptability obtained.

Financial Incentives to Increase Uptake of Pediatric HIV Testing (FIT): study protocol for a randomised controlled trial in Kenya

IntroductionIndex case testing (ICT) to identify HIV-infected children is efficient but has suboptimal uptake. Financial incentives (FI) have overcome financial barriers in other populations by offsetting direct and indirect costs....

Tablet-based disclosure counselling for HIV-infected children, adolescents, and their caregivers: a pilot study

Background: Overwhelmed, under-trained medical staff working in resource-limited settings need efficient resources for HIV disclosure counselling. The objective of this study was to describe providers’ experiences using tablet computers for disclosure-related counselling with HIV-infected children and their caregivers in western Kenya, with additional perspectives from adolescents.Methods: A qualitative study design was implemented at three HIV clinics in western Kenya (Bumala, Busia and Port Victoria) within the Academic Model Providing Access to Healthcare (AMPATH) partnership. Twenty-one healthcare providers involved with paediatric disclosure were recruited and enrolled in the study. Initial interviews focused on understanding current disclosure practices and barriers. Tablets containing disclosure-related resources were distributed. Resources included short narrative videos created in this context to highlight issues relevant to child HIV disclosure.Results: Providers reported tablets improved disclosure, child participation, and medication adherence. All reported that reviewing materials increased their knowledge and comfort with disclosure. The most frequently used materials were the narrative videos and an animated video explaining the importance of medication adherence. Time was a major barrier for using the tablet. Clinician self-education persisted at one-year follow-up. Adolescents expressed enjoyment from viewing the tablet resources and had a better understanding of the importance of medication adherence.Conclusions: Tablet computers containing resources for disclosure are an acceptable and potentially effective resource to help providers support families with disclosure. Further work is needed to train the clinical providers in using the resources in a developmentally appropriate manner, and to develop new resources on adolescent-specific and HIV-related topics.

\u201cI will not stop visiting!\u201d a qualitative study of community health workers\u2019 reluctance to withdraw household support following the end of a community-based intervention in Zimbabwe

BackgroundCommunity Health Worker (CHW) programmes are increasingly important in HIV service delivery. CHWs’ familiarity with the local context can improve intervention acceptability and sustainability but concerns have been raised about potential exploitation and “burnout” of CHWs as they become emotionally involved in clients’ lives. Little attention has been paid to what happens at the end of time-limited CHW interventions. This study aimed to examine the experience of CHWs’ withdrawal from clients and their families.MethodsWe conducted a qualitative study of CHWs’ experiences of “exiting” from households during the ZENITH (Zimbabwe Study for Enhancing Testing and Improving Treatment of HIV in Children) intervention, which provided 12 structured home visits over 72 weeks to families with children recently diagnosed with HIV. We conducted semi-structured interviews at 12 and 18 months with all 19 CHWs delivering the intervention and 36 purposively selected caregivers who received home visits. Analysis focused on perceptions of the end of the trial, when CHWs completed the scheduled home-based visits and there was no guarantee of programme continuation beyond the study.ResultsTermination of scheduled home visits caused significant distress to both CHWs and the households they visited. We identify 3 thematic “lessons learned” for CHW programmes. First, CHWs derived pride and self-worth from emotional labour as they became integral to families’ improved ability to cope, motivating them to go beyond formal job requirements. Second, clients’ growing dependence on CHWs led to “exit” being interpreted as abandonment by both CHWs and households, causing distress on both sides. Finally, in response to anxiety about “abandoning” families, CHWs maintained contact with families long after scheduled withdrawal of services.ConclusionsCHWs can forge genuine bonds with households, creating expectations of long-term engagement. On the positive side, CHW derive pride from their work, attach social responsibility to their roles, and feel personal fulfilment in supporting families. If CHWs do not disengage from interventions as planned, or become demoralised by “exits”, interventions will prove less sustainable. CHWs are often lauded for their ability to develop trust with peers, yet this willingness and ability to create enduring emotional bonds could threaten programme delivery.

Maternal peripartum urinary pyrethroid metabolites are associated with thinner children at 3.5 years in the VHEMBE birth cohort (Limpopo, South Africa)

Pyrethroids are the most widely used insecticides globally for domestic, agricultural, and malaria vector control. In 10 countries, dichlorodiphenyl trichloroethane (DDT) is also used for the latter. Thus, high exposure to pyrethroids and DDT have been reported among women and children from rural and/or malaria-endemic areas. Experimental studies suggest that fetal exposure to pyrethroids, particularly cypermethrin, and DDT may have sex-specific growth effects. However, epidemiologic investigations are scarce and inconsistent and have not considered postnatal environment or susceptibility factors. In 665 mother-child dyads participating in the Venda Health Examination of Mothers, Babies, and their Environment (VHEMBE), a rural South African birth cohort with high insecticide exposure, we examined associations of maternal peripartum uri-nary pyrethroid metabolites and serum DDT concentrations with child anthropometrics at 3.5 years using multivariable linear regression. We investigated effect modification by child sex, maternal nutrition and HIV status, and household poverty. Pyrethroid metabolites cis-3-(2,2-dibromovinyl)-2,2-dimethyl-cyclopropane carboxylic acid (cis-DBCA), cis-3-(2,2,-dicholorvinyl)-2,2-dimethyl-cyclopropane carboxylic acid (cis-DCCA), trans-DCCA, and 3-phenoxybenzoic acid (3-PBA) were quantified in nearly all mothers. A 10-fold increase in cis-DCCA concentration was associated with 0.21 kg/m2 lower body mass index (95% confidence interval = -0.41, -0.01), with similar estimates for other cypermethrin or permethrin metabolites (trans-DCCA and 3-phenoxybenzoic acid). In stratified analyses, stronger associations were observed with lower weight, body mass index, arm circumference, and weight-for-height among boys relative to girls. Associations with cis-3-(2,2-dibromovinyl)-2,2-dimethyl-cyclopropane carboxylic acid, a metabolite specific to deltamethrin, were weaker or absent. No substantial associations were observed with DDT. In a population with ubiquitous pyrethroid exposure, maternal concentrations of metabolites of cypermethrin and permethrin were associated with thinness at 3.5 years.

Children's HIV Status and the Acceptance Stage of Grief amongst HIV-Positive Women

Background: Women living with HIV (WLWH) commonly grieve but may pass through the grieving process until reaching the acceptance stage. We try to identify the relationship between children's HIV status and the acceptance stage of grief amongst WLWH. Method: This cross-sectional study utilised consecutive sampling of 235 HIV-positive women in Jakarta, Indonesia. The women were assessed with the Acceptance of Disease and Impairments Questionnaire (ADIQ). Results: Most of the respondents were housewives (65.5%), had been diagnosed over one year previously (74.5%), had an HIV-positive spouse (60.4%), had more than one child (51.5%) but none who were infected (73.6%) and assumed that their HIV status was caused by their spouse (50.2%). The respondents' median score of acceptance of their HIV status was relatively high (3 on a 1-4 scale). This showed a significant negative correlation between children's HIV status and the acceptance stage amongst HIV-positive women ( p = 0.01). Conclusion: Mother-to-child HIV transmission may disrupt the mother's acceptance stage because of feelings of guilt and difficulty disclosing their status. Because the children's HIV status was correlated with the mother's acceptance stage, WLWH must comply with the Preventing Mother-to-Child Transmission of HIV (PMTCT) program during the perinatal period.