Child's HIV Status Research Articles

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.

Piloting very early infant diagnosis of HIV in Lesotho: Acceptability and feasibility among mothers, health workers and laboratory personnel.

IntroductionMortality associated with in-utero HIV infection rises rapidly within weeks after birth. Very early infant diagnosis of HIV (VEID)–testing within 2 weeks of birth–followed by immediate initiation of antiretroviral therapy has potential to avert mortality associated with in-utero transmission. However, our understanding of acceptability and feasibility of VEID is limited.MethodsVEID was piloted in an observational prospective cohort of HIV-positive pregnant women and their infants in 13 Lesotho health facilities. Between March-July 2016, semi-structured interviews were conducted with HIV-positive women attending 6-week or 14-week postnatal visits and health workers (HWs) in 8 study facilities in 3 districts as well as with district and central laboratory staff. Interview themes included acceptability of birth and subsequent HIV testing and early treatment, perceived VEID challenges, and HIV birth testing procedures and how well they were performed.ResultsInterviews were conducted with 20 women, 18 HWs and 9 district/central laboratory staff. Nearly all mothers perceived knowing their child’s HIV status at birth positively. Mothers and HWs did not indicate that birth testing affected subsequent acceptance of infant HIV testing or clinic attendance. HWs and laboratory staff reported weak follow-up systems for mothers with home deliveries, and concern regarding the increased workload associated with additional testing requirements. All groups reported turnaround time delays for EID, and that sometimes results were never received.ConclusionsWomen, HWs, and laboratory staff found VEID acceptable and were supportive of national implementation of birth testing. However, they identified challenges within the EID system that could be exacerbated by adding a test to the diagnostic algorithm, such as delays in receiving test results, suggesting VEID may not be feasible in certain settings. Policymakers will need to consider whether adding birth testing or strengthening the current clinic and laboratory system is the most appropriate course of action.

Resilient Back-Propagation Algorithm in the Prediction of Mother to Child Transmission of HIV

Prediction of a child HIV status poses real challenges in medical research. Even though there are different statistical techniques and machine learning algorithms that have been used to predict models like HIV for the clinical data with binary outcome variables, yet neural network techniques are major participants for prediction purposes. HIV is the primary cause of mortality among women of reproductive age globally and is a key contributor to maternal, infant and child morbidity and mortality. In this paper, resilient back propagation algorithm is used for training the Neural Network and Multilayer Feed forward network to predict the mother to child transmission of HIV status.

Child Growth According to Maternal and Child HIV Status in Zimbabwe.

Background:Growth failure is common among HIV-infected infants, but there are limited data on the effects of HIV exposure or timing of HIV acquisition on growth.Methods:Fourteen thousand one hundred ten infants were enrolled in the Zimbabwe Vitamin A for Mothers and Babies trial in Zimbabwe before the availability of antiretroviral therapy or co-trimoxazole. Anthropometric measurements were taken from birth through 12–24 months of age. Growth outcomes were compared between 5 groups of children: HIV-infected in utero (IU), intrapartum (IP) or postnatally (PN); HIV-exposed uninfected (HEU); and HIV unexposed.Results:Growth failure was common across all groups of children. Compared with HIV-unexposed children, IU-, IP- and PN-infected children had significantly lower length-for-age and weight-for-length Z scores throughout the first 2 years of life. At 12 months, odds ratios for stunting were higher in IU [6.25, 95% confidence interval (CI): 4.20–9.31] and IP infants (4.76, 95% CI: 3.58–6.33) than in PN infants (1.70, 95% CI: 1.16–2.47). Compared with HIV-unexposed infants, HEU infants at 12 months had odds ratios for stunting of 1.23 (95% CI: 1.08–1.39) and wasting of 1.56 (95% CI: 1.22–2.00).Conclusions:HIV-infected infants had very high rates of growth failure during the first 2 years of life, particularly if IU or IP infected, highlighting the importance of early infant diagnosis and antiretroviral therapy. HEU infants had poorer growth than HIV-unexposed infants in the first 12 months of life.

Could cash and good parenting affect child cognitive development? A cross-sectional study in South Africa and Malawi

BackgroundSocial protection interventions, including cash grants and care provision have been shown to effectively reduce some negative impacts of the HIV epidemic on adolescents and families. Less is known about the role of social protection on younger HIV affected populations. This study explored the impact of cash grants on children’s cognitive development. Additionally, we examined whether combined cash and care (operationalised as good parenting) was associated with improved cognitive outcomes.MethodsThe sample included 854 children, aged 5 – 15, participating in community-based organisation (CBO) programmes for children affected by HIV in South Africa and Malawi. Data on child cognitive functioning were gathered by a combination of caregiver report and observer administered tests. Primary caregivers also reported on the economic situation of the family, cash receipt into the home, child and household HIV status. Parenting was measured on a 10 item scale with good parenting defined as a score of 8 or above.ResultsAbout half of families received cash (55%, n = 473), only 6% (n = 51) reported good parenting above the cut-off point but no cash, 18% (n = 151) received combined cash support and reported good parenting, and 21% (n = 179) had neither. Findings show that cash receipt was associated with enhanced child cognitive outcomes in a number of domains including verbal working memory, general cognitive functioning, and learning. Furthermore, cash plus good parenting provided an additive effect. Child HIV status had a moderating effect on the association between cash or/plus good parenting and cognitive outcomes. The association between cash and good parenting and child cognitive outcomes remained significant among both HIV positive and negative children, but overall the HIV negative group benefited more.ConclusionsThis study shows the importance of cash transfers and good parenting on cognitive development of young children living in HIV affected environments. Our data clearly indicate that combined provision (cash plus good parenting) have added value.

Implementation and Operational Research: Active Referral of Children of HIV-Positive Adults Reveals High Prevalence of Undiagnosed HIV.

Few routine systems exist to test older, asymptomatic children for HIV. Testing all children in the population has high uptake but is inefficient, whereas testing only symptomatic children increases efficiency but misses opportunities to optimize outcomes. Testing children of HIV-infected adults in care may efficiently identify previously undiagnosed HIV-infected children before symptomatic disease. HIV-infected parents in HIV care in Nairobi, Kenya were systematically asked about their children's HIV status and testing history. Adults with untested children ≤12 years old were actively referred and offered the choice of pediatric HIV testing at home or clinic. Testing uptake and HIV prevalence were determined, as were bottlenecks in pediatric HIV testing cascade. Of 10,426 HIV-infected adults interviewed, 8,287 reported having children, of whom 3,477 (42%) had children of unknown HIV status, and 611 (7%) had children ≤12 years of unknown HIV status. After implementation of active referral, the rate of pediatric HIV testing increased 3.8-fold from 3.5 to 13.6 children tested per month (Relative risk: 3.8, 95% confidence interval: 2.3 to 6.1). Of 611 eligible adults, 279 (48%) accepted referral and were screened, and 74 (14%) adults completed testing of 1 or more children. HIV prevalence among 108 tested children was 7.4% (95% confidence interval: 3.3 to 14.1%) and median age was 8 years (interquartile range: 2-11); 1 child was symptomatic at testing. Referring HIV-infected parents in care to have their children tested revealed many untested children and significantly increased the rate of pediatric testing; prevalence of HIV was high. However, despite increases in pediatric testing, most adults did not complete testing of their children.

Associations of Memory and Executive Functioning With Academic and Adaptive Functioning Among Youth With Perinatal HIV Exposure and/or Infection.

Perinatally acquired HIV (PHIV) confers risk for neurocognitive impairment, which potentially affects school performance and functional independence of infected children. In this study, we examined the associations of 2 key neurocognitive domains, memory and executive function (EF), with academic and adaptive skills among youth with PHIV and perinatally HIV-exposed but uninfected (PHEU) youth. Participants ages 9 to <19 years enrolled in the Pediatric HIV/AIDS Cohort Study's Memory and Executive Functioning Study completed standardized measures of reading and math. The primary caregivers completed a standardized measure of their child's adaptive behavior. Participants with PHIV, those with (PHIV/C) and without (PHIV/non-C) a Centers for Disease Control and Prevention class C diagnosis, and PHEU participants were compared. Retrospective memory (RM), prospective memory (PM), and EF were evaluated relative to outcomes using general linear regression models adjusted for sociodemographic characteristics. Of the participants (N = 258; mean age, 14.1 years), 46% were male, 75% were black, and 18% were Hispanic. Adjusted mean scores in math and adaptive behavior did not differ among the youth with PHIV/C (n = 45), those with PHIV/non-C (n = 128), and PHEU youth (n = 85). Youth with PHIV/C had lower adjusted mean reading scores than PHIV/non-C and PHEU youth (86.9 vs 93.8 [P = .02] and 93.2 [P = .04], respectively). There were positive associations of RM, PM, EF, and some sociodemographic characteristics with higher reading and math scores. Immediate and delayed verbal memory, delayed visual memory, PM, and some EF measures were positively associated with adaptive behavior. Higher-order cognitive abilities such as memory and EF seem to play a key role in academic and adaptive capacities, regardless of a child's HIV status, and might serve as intervention targets for improving functional outcomes.

The aetiology of diarrhoea, pneumonia and respiratory colonization of HIV-exposed infants randomized to breast- or formula-feeding

Background:Diarrhoea and pneumonia are common causes of childhood death in sub-Saharan Africa but there are few studies describing specific pathogens.Objectives:The study aimed to describe the pathogens associated with diarrhoea, pneumonia and oropharyngeal colonization in children born to HIV-infected women (HIV-exposed infants).Methods:The Mashi Study randomized 1200 HIV-infected women and their infants to breastfeed for 6 months with ZDV prophylaxis or formula-feed with 4 weeks of ZDV. Children were tested for HIV by PCR at 1, 4, 7, 9 and 12 months and by ELISA at 18 months. Pre-defined subsets of children were sampled during episodes of diarrhoea (n = 300) and pneumonia (n = 85). Stool was tested for bacterial pathogens, rotavirus and parasites. Children with pneumonia underwent bacterial blood culture, and testing of nasopharyngeal aspirates for viral pathogens by PCR. Oropharyngeal swabs were collected from a consecutive subset of 561 infants at the routine 3-month visit for bacterial culture.Results:The median age (range) at sampling was 181 days for diarrhoea (0–730) and 140 days for pneumonia (2–551). Pathogens were identified in 55 (18%) children with diarrhoea and 32 (38%) with pneumonia. No differences in pathogens by child HIV status (HIV-infected vs HIV-uninfected) or feeding strategy were identified. Campylobacter was the most common diarrhoeal pathogen (7%). Adenovirus (22%) and other viruses (19%) were the primary pathogens isolated during pneumonias. More formula-fed infants had oropharyngeal colonization by pathogenic Gram-negative bacteria (16.8% vs 6.2%, P = 0.003), which was associated with a non-significant increased risk of pneumonia (OR 2.2, 95% CI 0.8–5.7).Conclusion:A trend toward oropharyngeal bacterial colonization was observed in formula-fed infants. Although viruses were most commonly detected during pneumonia, respiratory colonization by Gram-negative bacteria may have contributed to pneumonia in formula-fed infants.

P142 Challenges and opportunities of a ‘Look Back’ exercise on child testing

Background/introduction The consensus document ‘Don’t forget the children’ 2009 recommends that all HIV units perform a ‘look back’ exercise to establish the HIV status of children whose HIV positive parents attend that service, as a standard of care. Aim(s)/objectives To perform a ‘look back’ to identify children born to HIV positive females in our unit. Determine their HIV testing status and establish a robust pathway for testing and recording outcome. Methods A retrospective notes review of all HIV positive women registered with the Sexual Health Clinic. Results 76 women identified, 66 had 149 children. Ethnicity was predominantly African (38/76). 48/76 women acquired infection abroad. Children at risk of vertical HIV transmission recognised in 53/66 women. Child testing identified and documented in 29/53 women (65 children); 8 were HIV positive. 10/53 had children resident abroad (23 children). Parental discussions on-going in 6/53 women. A further 3/53 women declined testing. In 3/53 records were incomplete and 2/53 testing in progress. Discussion/conclusion Challenges of retrospectively identifying children at risk of undiagnosed HIV highlighted particularly in parents that have not disclosed their status to children. We identified a reliance on verbally reported documentation as evidence of child testing, the challenges of testing older children and the need for robust reporting between paediatric and adult services. Clinicians should continue to ask about children abroad who subsequently join parents in the UK to avoid missed opportunities for testing.

Maternal Antiretroviral Therapy Is Associated with Lower Risk of Diarrhea in Early Childhood

To identify risk factors, including maternal antiretroviral therapy (ART), for diarrhea in Tanzanian children exposed to HIV during the first 2years of life. Using generalized estimating equations, we analyzed data from a cohort of 2387 Tanzanian children exposed to HIV from age 6weeks to 2years, as well as data from their mothers, to determine risk factors for diarrhea in children. Mothers recorded diarrhea in a diary and reported results at visits scheduled every four weeks. Body mass index was ≥18.5 in 95.6% of mothers. World Health Organization HIV stage was 1/2 for 1255 (87.8%) mothers. ART was received by 24.3% of mothers, most initiating ART during pregnancy. At baseline (6weeks of age) 264 (11.3%) children were infected with HIV. In children whose mothers received ART, the relative risk of diarrhea in children was 0.79 (95% CI 0.68-0.92), after we adjusted for multiple factors, including child HIV status and exclusive breastfeeding duration. Exclusive breastfeeding (relative risk 0.67, 95% CI 0.56-0.80) also was protective. Our results provide additional support to increase ART coverage for all pregnant mothers, to control clinical HIV progression, reduce perinatal HIV infection, but also to reduce the risk of a major cause of death and morbidity in young children worldwide. ClinicalTrials.gov: NCT00197730.

Missed opportunities of inclusion in a cohort of HIV-infected children to initiate antiretroviral treatment before the age of two in West Africa, 2011 to 2013.

IntroductionThe World Health Organization (WHO) 2010 guidelines recommended to treat all HIV-infected children less than two years of age. We described the inclusion process and its correlates of HIV-infected children initiated on early antiretroviral therapy (EART) at less than two years of age in Abidjan, Côte d'Ivoire, and Ouagadougou, Burkina Faso.MethodsAll children with HIV-1 infection confirmed with a DNA PCR test of a blood sample, aged less than two years, living at a distance less than two hours from the centres and whose parents (or mother if she was the only legal guardian or the legal caregiver if parents were not alive) agreed to participate in the MONOD ANRS 12206 project were included in a cohort to receive EART based on lopinavir/r. We used logistic regression to identify correlates of inclusion.ResultsAmong the 217 children screened and referred to the MONOD centres, 161 (74%) were included and initiated on EART. The main reasons of non-inclusion were fear of father's refusal (48%), mortality (24%), false-positive HIV infection test (16%) and other ineligibility reasons (12%). Having previously disclosed the child's and mother's HIV status to the father (adjusted odds ratio (aOR): 3.20; 95% confidence interval (95% CI): 1.55 to 6.69) and being older than 12 months (aOR: 2.05; 95% CI: 1.02 to 4.12) were correlates of EART initiation. At EART initiation, the median age was 13.5 months, 70% had reached WHO Stage 3/4 and 57% had a severe immune deficiency.ConclusionsFear of stigmatization by the father and early competing mortality were the major reasons for missed opportunities of EART initiation. There is an urgent need to involve fathers in the care of their HIV-exposed children and to promote early infant diagnosis to improve their future access to EART and survival.

HIV knowledge, stigma, and illness beliefs among pediatric caregivers in Ghana who have not disclosed their child's HIV status

The majority of HIV-infected children in sub-Saharan Africa have not been informed of their HIV status. Caregivers are reluctant to disclose HIV status to their children because of concern about the child’s ability to understand, parental sense of guilt, and fear of social rejection and isolation. We hypothesized that the low prevalence of pediatric HIV disclosure in Ghana is due to lack of accurate HIV information and high HIV stigma among caregivers. This is a preliminary analysis of baseline data of an HIV pediatric disclosure intervention study in Ghana (“Sankofa”). “Sankofa” – is a two-arm randomized controlled clinical trial comparing disclosure intervention plus usual care (intervention arm) vs usual care (control arm) at Korle-Bu Teaching Hospital (KBTH; control arm) and Komfo-Anokye Teaching Hospital (KATH; intervention arm). We enrolled HIV-infected children, ages 7–18 years who do not know their HIV status, and their caregivers. Baseline data of caregivers included demographic characteristics; Brief HIV Knowledge Questionnaire (HIV-KQ-18); Brief Illness Perception Questionnaire; and HIV Stigma Scale. Simple and multivariable linear regression analyses were used to assess the relationship between caregiver characteristics and HIV knowledge, stigma, and illness perception. Two hundred and ninety-eight caregivers were enrolled between January 2013 and July 2014 at the two study sites; KBTH (n = 167) and KATH (n = 131). The median age of caregivers was 41 years; 80.5% of them were female and about 60% of caregivers were HIV-positive. Seventy-eight percent of caregivers were self-employed with low household income. In both unadjusted and adjusted analyses, HIV negative status and lower level of education were associated with poor scores on HIV-KQ. HIV positive status remained significant for higher level of stigma in the adjusted analyses. None of the caregiver’s characteristics predicted caregiver’s illness perception. Intensification of HIV education in schools and targeted community campaigns are needed.

False-negative HIV-1 polymerase chain reaction in a 15-month-old boy with HIV-1 subtype C infection.

Polymerase chain reaction (PCR) testing is the gold standard for determining the HIV status in children <18 months of age. However, when clinical manifestations are not consistent with laboratory results, additional investigation is required. We report a 15-month-old HIV-exposed boy referred to our hospital after he had been admitted several times for infectious diseases. A rapid antibody test on the child was positive, while routine diagnostic HIV PCRs using the Roche COBAS Ampliprep/COBAS TaqMan HIV Qual Test were negative at 6 weeks, 6 months, 7 months and 15 months. In addition, the same PCR test performed on the HIV-infected mother was also negative. Alternative PCR and viral load assays using different primer sets detected HIV RNA or proviral DNA in both child and mother. Gag sequences from the child and his mother classified both infections as HIV-1 subtype C, with very rare mutations that may have resulted in PCR assay primer/probe mismatch. Consequently, the child was commenced on antiretroviral therapy and made a remarkable recovery. These findings indicate that more reliable PCR assays capable of detecting a wide range of HIV subtypes are desirable to circumvent the clinical problems created by false-negative PCR results.

Caregivers' depressive symptoms and parent-report of child executive function among young children in Uganda

Maternal mental health (particularly depression) may influence how child behavior report. Few research has focused on sub-Saharan countries where pediatric HIV concentrates and impacts child neuropsychological development and caregiver mental health. We investigated the associations between caregivers' depressive symptoms and neuropsychological outcomes in HIV-infected (n=118) and HIV-exposed (n=164) Ugandan children aged 2–5years. We compared performance-based tests of development (Mullen Scales of Early Learning, Color Object Association Test), to a caregiver report of executive function (Behavior Rating Inventory of Executive Function, BRIEF). Caregivers were assessed with Hopkins Symptom Checklist-25 depression subscale. The associations between all BRIEF indices and caregiver's depression symptoms were differential according to child's HIV status. Caregivers with greater depressive symptoms reported their HIV-infected children as having more behavioral problems related to executive functioning. The assessment of behavior of HIV-infected children should incorporate a variety of sources of information and screening of caregiver mental health.

Impact of Art Mother and Child on The HIV Status of the Child Born to HIVPositive Mothers in Burkina Faso: Towards the Adoption of an Effective Pmtct Policy

Objective: To evaluate the impact of ART of the mother and the child on the HIV status of children born to HIV positive mothers in compliance with the policy of mother-child transmission (PMTCT) adopted in Burkina Faso. Method: It is a prospective cohort study. 214 HIV-positive mother - infant pairs were involved over a period of 14 months (2011-2013). Early pediatric laboratory biologic diagnosis of HIV infection with children aged from 6 weeks to 18 months was carried out by RNA/PCR of HIV1 (Kit Biocentric®). Children with viral load lower than 300 copies/mL (>2.48 Log) were considered uncontaminated. All the children were clinically and biologically followed up to 18 months, the age at which an immunochromatographic test (Determine®) and an ELISA test (Immunocoomb II BiSpot HIV1 2®) were made to confirm their serological status. We determined the immunological status of positive mothers through a numeration of TCD4 + lymphocytes on a flow cytometer (FacscountV1.5). HIV positive Women were dispatched following treatment systems in accordance with options A and B + (mothers on nevirapine alone, mothers on highly active antiretroviral therapy (HAART)/mothers without HAART). Results: The median age of the children was 6 months (1.5-18 months). The sex ratio was 0.79. The infection rate was 11.2% (24/214). The MTCT was significantly higher among mothers without HAART on Nevirapine only (22/41) than among those on HAART (2/172) p=0.0000 2. The proportion of children infected through breastfeeding whose mothers were not on HAART (23/23) was significantly higher than those whose mothers were on HAART (0/139) p=0.0000 12. Conclusion: According to the guidelines combined on the use of antiretroviral for the treatment and prevention of HIV infection (June 2013), we also recommend for Burkina Faso, the abandonment of Option A and the adoption of option B + with all pregnant women whatever their immune-clinical status.

Whole Blood Omega 3 Fatty Acid Levels of HIV Exposed and HIV Unexposed 7 - 10 Years Old Children from a Low Income Country with High Burden of Under-Nutrition

Long chain polyunsaturated fatty acids are essential macronutrients that have several benefits which have been described for children’s health. Omega 3 LCPUFA metabolism has been reported to be altered in under-nourished and in HIV infected children. Therefore, we describe Eicosapentaenoic acid, Docosapentaenoic acid and Docosahexaenoic acid levels of HIV infected, HIV exposed uninfected and HIV unexposed uninfected school aged children from a low income country with a high burden of HIV infection and under-nutrition. This cross-sectional study recruited children 7 to 10 years old. Capillary blood was collected on filter paper and whole blood fatty acid analysis done using automated gas liquid chromatography. Kruskal Wallis and Median tests were used to compare the distribution and medians of the Omega 3 LCPUFA among the children according to HIV status, gender, age and nutritional status. A total of 318 children were recruited with 21 (7%) being HIV infected and 116 (37%) being HIV exposed uninfected. Chronic malnutrition was present in 12% of the children. The omega 3 fatty acids were expressed as percent weight of total fatty acids. The medians (interquartile range) for EPA, DPA and DHA for all the children were 0.19 (0.09), 0.79 (0.19) and 2.14 (0.54) %wt/wt respectively. EPA, DPA and DHA levels were not associated with the HIV status of the children. EPA levels were much lower in the 7-year-age group compared with the 8 and 9 - 10-year-age groups. Further studies assessing LCPUFA levels that include larger sample size, children from both urban and rural areas are recommended as this may assist in clearly defining the association of LCPUFA with HIV status in children from low income countries with high burden of under-nutrition.

Experiences of Caregivers in Healthcare for and Social Support of HIV Positive Children Attending Schools in Bangkok

summary Purpose: The study was conducted to explore caregivers' experiences and perceptions of barriers to their children receiving appropriate healthcare and support at schools in Thailand. Method: A qualitative narrative study was conducted to achieve the aim stated above. Twenty caregivers of children living with HIV/AIDS attending schools in Bangkok were interviewed in depth. The interviews were audiotaped, transcribed and analyzed using narrative analysis. Results: The analysis indicated that caregivers fear discrimination, suffer from stigma and most do not reveal their child's HIV status to schools. Obstacles to children living with HIV/AIDS getting appropriate care and support in schools are persistent. Caregivers need to collaborate with the public health sector to provide HIV education and support for themselves and for teachers; community nurses would be well placed to provide this. Conclusion: Our findings can inform the design of systems for educational and social support alongside adequate healthcare for children living with HIV/AIDS attending school. The Thai government needs to establish collaboration between the educational and health sectors to reduce the stigma of HIV, promote acceptance and provide support.

Qualitative assessment of the integration of HIV services with infant routine immunization visits in Tanzania.

In 2009, a project was implemented in 8 primary health clinics throughout Tanzania to explore the feasibility of integrating pediatric HIV prevention services with routine infant immunization visits. We conducted interviews with 64 conveniently sampled mothers of infants who had received integrated HIV and immunization services and 16 providers who delivered the integrated services to qualitatively identify benefits and challenges of the intervention midway through project implementation. Mothers' perceived benefits of the integrated services included time savings, opportunity to learn their child's HIV status and receive HIV treatment, if necessary. Providers' perceived benefits included reaching mothers who usually would not come for only HIV testing. Mothers and providers reported similar challenges, including mothers' fear of HIV testing, poor spousal support, perceived mandatory HIV testing, poor patient flow affecting confidentiality of service delivery, heavier provider workloads, and community stigma against HIV-infected persons; the latter a more frequent theme in rural compared with urban locations. Future scale-up should ensure privacy of these integrated services received at clinics and community outreach to address stigma and perceived mandatory testing. Increasing human resources for health to address higher workloads and longer waiting times for proper patient flow is necessary in the long term.

Clinical malaria diagnosis in pregnancy in relation to early perinatal mother‐to‐child transmission of HIV: a prospective cohort study

We prospectively investigated fever symptoms and maternal diagnosis of malaria in pregnancy (MIP) in relation to child HIV infection among 2368 pregnant HIV-positive women and their infants, followed up from pregnancy until 6 weeks post-delivery in Tanzania. Doctors clinically diagnosed and treated MIP and fever symptoms during prenatal health care. Child HIV status was determined via DNA polymerase chain reaction (PCR). Multivariable logistic regression models were used to estimate relative risks (RRs) and 95% confidence intervals (CIs) for HIV mother-to-child transmission (MTCT) by the 6th week of life. Mean gestational age at enrolment was 22.2 weeks. During follow-up, 16.6% of mothers had at least one MIP diagnosis, 15.9% reported fever symptoms and 8.7% had both fever and MIP diagnosis. Eleven per cent of HIV-exposed infants were HIV-positive by 6 weeks. The RR of HIV MTCT was statistically similar for infants whose mothers were ever vs. never clinically diagnosed with MIP (RR 1.24; 95% CI 0.94-1.64), were diagnosed with one vs. no clinical MIP episodes (RR 1.07; 95% CI 0.77-1.48) and had ever vs. never reported fever symptoms (RR 1.04; 95% CI 0.78-1.38) in pregnancy. However, the HIV MTCT risk increased by 29% (95% CI 4-58%) per MIP episode. Infants of women with at least two vs. no MIP diagnoses were 2.1 times more likely to be HIV infected by 6 weeks old (95% CI 1.31-3.45). Clinical MIP diagnosis, but not fevers, in HIV-positive pregnant women was associated with an elevated risk of early HIV MTCT, suggesting that malaria prevention and treatment in pregnant HIV-positive women may enhance the effectiveness of HIV prevention in MTCT programmes in this setting. Future studies using a laboratory-confirmed diagnosis of malaria are needed to confirm this association.

Undervaccination of perinatally HIV-infected and HIV-exposed uninfected children in Latin America and the Caribbean.

Perinatally HIV-infected (PHIV) children may be at risk of undervaccination. Vaccination coverage rates among PHIV and HIV-exposed uninfected (HEU) children in Latin America and the Caribbean were compared. All PHIV and HEU children born from 2002 to 2007 who were enrolled in a multisite observational study conducted in Latin America and the Caribbean were included in this analysis. Children were classified as up to date if they had received the recommended number of doses of each vaccine at the appropriate intervals by 12 and 24 months of age. Fisher's exact test was used to analyze the data. Covariates potentially associated with a child's HIV status were considered in multivariable logistic regression modeling. Of 1156 eligible children, 768 (66.4%) were HEU and 388 (33.6%) were PHIV. HEU children were significantly (P < 0.01) more likely to be up to date by 12 and 24 months of age for all vaccines examined. Statistically significant differences persisted when the analyses were limited to children enrolled before 12 months of age. Controlling for birth weight, sex, primary caregiver education and any use of tobacco, alcohol or illegal drugs during pregnancy did not contribute significantly to the logistic regression models. PHIV children were significantly less likely than HEU children to be up to date for their childhood vaccinations at 12 and 24 months of age, even when limited to children enrolled before 12 months of age. Strategies to increase vaccination rates in PHIV are needed.