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1.  Tuberculosis case finding and isoniazid preventive therapy among people living with HIV at public health facilities of Addis Ababa, Ethiopia: a cross-sectional facility based study 
BMC Public Health  2014;14:52.
Background
Activities to decrease the burden of tuberculosis (TB) among people living with HIV (PLHIV) include intensified TB case-finding (ICF), Isoniaizid (INH) preventive therapy (IPT) and infection control in health-care and congregate settings (IC). Information about the status of collaborative TB/HIV care services which decreases the burden of TB among PLHIV in Ethiopia is limited. The purpose of the study was to assess TB case finding and provision of IPT among PLHIV in Addis Ababa.
Methods
A cross sectional, facility-based survey was conducted between June 2011 and August 2011. Data was collected by interviewing 849 PLHIV from ten health facilities in Addis Ababa. Both descriptive and inferential statistics were used to analyze findings and the results are described in this report.
Results
The proportion of PLHIV who have been screened for TB during any one of their follow-up cares was 92.8%. Eighty eight (10.4%) of the study participants have been diagnosed for TB during their HIV follow-up cares. PLHIV who had never been diagnosed for TB before they knew their positive HIV status were nearly four times more likely to be diagnosed for TB during follow-up cares than those diagnosed before (AOR [95% CI]: 3.78 [1.69-8.43]). Nearly a third (28.7%) of all interviewed PLHIV self reported that they had been treated with IPT.
Conclusions
It can be concluded that ICF for TB and IPT among PLHIV in Addis Ababa need boosting. Hence, it is recommended to put into practice the national and global guidelines to improve ICF and IPT among PLHIV in the city.
doi:10.1186/1471-2458-14-52
PMCID: PMC3913332  PMID: 24438508
HIV; INH preventive therapy; PLHIV; Screening; Tuberculosis
2.  Improving Tuberculosis Screening and Isoniazid Preventative Therapy in an HIV Clinic in Addis Ababa, Ethiopia 
Summary
Setting
An HIV clinic in Addis Ababa, Ethiopia.
Objective
The World Health Organization (WHO) recommends active tuberculosis (TB) case finding among people living with HIV (PLHIV) in resource-limited settings using a symptom-based algorithm and those without active TB disease should be offered isoniazid preventive therapy (IPT). We evaluated rates of adherence to these recommendations and the impact of a quality improvement (QI) intervention.
Design
A prospective study design was utilized to compare TB symptom screening and IPT administration rates before and after a QI intervention consisting of 1) educational sessions, 2) visual reminders and 3) use of a screening checklist.
Results
A total of 751 HIV-infected patient visits were evaluated. The proportion of patients screened for TB symptoms increased from 22% at baseline to 94% following the intervention (P<0.001). Screening rates improved from 51% to 81% (P<0.001) for physicians and from 3% to 100% (P<0.001) for nurses. Of the 281 patients with negative TB symptom screens and eligible for IPT, 4% were prescribed IPT before the intervention compared to 81%(P<0.001) afterward.
Conclusions
We found a QI intervention significantly increased WHO recommended TB screening rates and IPT administration. Utilizing nurses can help increase TB screening and IPT provision in resource-limited settings.
doi:10.5588/ijtld.13.0315
PMCID: PMC3992289  PMID: 24125440
Quality Improvement; Implementation Science; Checklists; Task shifting
3.  Beneficial Effect of Isoniazid Preventive Therapy and Antiretroviral Therapy on the Incidence of Tuberculosis in People Living with HIV in Ethiopia 
PLoS ONE  2014;9(8):e104557.
Background
IPT with or without concomitant administration of ART is a proven intervention to prevent tuberculosis among PLHIV. However, there are few data on the routine implementation of this intervention and its effectiveness in settings with limited resources.
Objectives
To measure the level of uptake and effectiveness of IPT in reducing tuberculosis incidence in a cohort of PLHIV enrolled into HIV care between 2007 and 2010 in five hospitals in southern Ethiopia.
Methods
A retrospective cohort analysis of electronic patient database was done. The independent effects of no intervention, “IPT-only,” “IPT-before-ART,” “IPT-and-ART started simultaneously,” “ART-only,” and “IPT-after-ART” on TB incidence were measured. Cox-proportional hazards regression was used to assess association of treatment categories with TB incidence.
Results
Of 7,097 patients, 867 were excluded because they were transferred-in; a further 823 (12%) were excluded from the study because they were either identified to have TB through screening (292 patients) or were on TB treatment (531). Among the remaining 5,407 patients observed, IPT had been initiated for 39% of eligible patients. Children, male sex, advanced disease, and those in Pre-ART were less likely to be initiated on IPT. The overall TB incidence was 2.6 per 100 person-years. As compared to those with no intervention, use of “IPT-only” (aHR = 0.36, 95% CI = 0.19–0.66) and “ART-only” (aHR = 0.32, 95% CI = 0.24–0.43) were associated with significant reduction in TB incidence rate. Combining ART and IPT had a more profound effect. Starting IPT-before-ART (aHR = 0.18, 95% CI = 0.08–0.42) or simultaneously with ART (aHR = 0.20, 95% CI = 0.10–0.42) provided further reduction of TB at ∼80%.
Conclusions
IPT was found to be effective in reducing TB incidence, independently and with concomitant ART, under programme conditions in resource-limited settings. The level of IPT provision and effectiveness in reducing TB was encouraging in the study setting. Scaling up and strengthening IPT service in addition to ART can have beneficial effect in reducing TB burden among PLHIV in settings with high TB/HIV burden.
doi:10.1371/journal.pone.0104557
PMCID: PMC4126726  PMID: 25105417
4.  Impact of Isoniazid Preventive Therapy for HIV-Infected Adults in Rio de Janeiro, Brazil: An Epidemiological Model 
Background
The potential epidemiological impact of isoniazid preventive therapy (IPT), delivered at levels that could be feasibly scaled up among people living with HIV (PLHIV) in modern, moderate-burden settings, remains uncertain.
Methods
We used routine surveillance and implementation data from a cluster-randomized trial of IPT among HIV-infected clinic patients with good access to antiretroviral therapy in Rio de Janeiro, Brazil, to populate a parsimonious transmission model of TB/HIV. We modeled IPT delivery as a constant process capturing a proportion of the eligible population every year. We projected feasible reductions in tuberculosis (TB) incidence and mortality in the general population and among PLHIV specifically at the end of five years after implementing an IPT program.
Results
Data on time to IPT fit an exponential curve well, suggesting that IPT was delivered at a rate covering 20% (95% confidence interval: 16%, 24%) of the 2,500 eligible individuals each year. By the end of year 5 after modeled program roll-out, IPT had reduced TB incidence by 3.0% (95% uncertainty range, UR: 1.6%, 7.2%) in the general population and by 15.6% (95%UR: 15.5%, 36.5%) among PLHIV. Corresponding reductions in TB mortality were 4.0% (95%UR: 2.2%, 10.3%) and 14.3% (14.6%, 33.7%). Results were robust to wide variations in parameter values on sensitivity analysis.
Conclusions
TB screening and IPT delivery can substantially reduce TB incidence and mortality among PLHIV in urban, moderate-burden settings. In such settings, IPT can be an important component of a multi-faceted strategy to feasibly reduce the burden of TB in PLHIV.
doi:10.1097/QAI.0000000000000219
PMCID: PMC4257469  PMID: 24853308
Tuberculosis; Infectious Disease Transmission; HIV; Theoretical Models; Brazil; Isoniazid
5.  Unprotected sexual practice and associated factors among People Living with HIV at Ante Retroviral Therapy clinics in Debrezeit Town, Ethiopia: a cross sectional study 
Reproductive Health  2014;11:56.
Background
Magnitude of unprotected sexual practice among PLHIV is generally high in African countries including Ethiopia. Understanding the practice in Ethiopia could have public health significance. However little is known about the issue of unprotected sexual practice among PLHIV in Ethiopia. Hence, this study was aimed to assess unprotected sexual practice and associated factors among PLHIV at ART clinics in Debrezeit town.
Method
Institution based cross-sectional study was conducted. A total of 667 PLHIV were included in the study. Systematic random sampling technique was used to select participants. Analyses were done using SPSS for windows version 15. A crude and adjusted odds ratio with 95% confidence interval was used to measure association between different factors and unprotected sex.
Result
The prevalence of unprotected sexual practice among PLHIV was 22.2% [95% CI: (19.0-25.4)]. Factors associated with unprotected sexual practice include: being female (AOR = 2.1, 95% CI (1.1, 3.9)), being divorced/widowed/separated (AOR = 4.9, 95% CI (2.1, 11.6)), length of stay with the current partner for ≥ 49 months (AOR = 3.3, 95% CI (1.9, 5.7)) and not discussing or partly discussing about safe sex and condom use with sexual partner (AOR = 17.1, 95% CI (8.9, 32.8)).
Conclusion
High proportions of PLHIV were found to engage in unprotected sex. Information Education and Communication (IEC) on safe sex for PLHIV should target females, those who stayed longer with their partner and divorced/widowed/separate ones.
doi:10.1186/1742-4755-11-56
PMCID: PMC4112610  PMID: 25048692
Unprotected sex; Factors; People living with HIV/AIDS
6.  Perceived barriers to the implementation of Isoniazid preventive therapy for people living with HIV in resource constrained settings: a qualitative study 
Introduction
Isoniazid preventive therapy (IPT) reduces the risk of active TB. IPT is a key public health intervention for the prevention of TB among people living with HIV and has been recommended as part of a comprehensive HIV and AIDS care strategy. However, its implementation has been very slow and has been impeded by several barriers. Objective: The Objective of the study is to assess the perceived barriers to the implementation of Isoniazid preventive therapy for people living with HIV in resource constrained settings in Addis Ababa, Ethiopia in 2010.
Methods
A qualitative study using a semi-structured interviewed guide was used for the in-depth interview. A total of 12 key informants including ART Nurse, counselors and coordinators found in four hospitals were included in the interview. Each session of the in-depth interview was recorded via audio tape and detailed notes. The interview was transcribed verbatim. The data was analyzed manually.
Results
The findings revealed that poor patient adherence was a major factor; with the following issues cited as the reasons for poor adherence; forgetfulness; lack of understanding of condition and patient non- disclosure of HIV sero-status leading to insubstantial social support; underlying mental health issues resulting in missed or irregular patient appointments; weak patient/healthcare provider relationship due to limited quality interaction; lack of patient information, patient empowerment and proper counseling on IPT; and the deficient reinforcement by health officials and other stakeholders on the significance of IPT medication adherence as a critical for positive health outcomes.
Conclusion
Uptake of the implementation of IPT is facing a challenge in resource limited settings. This recalled provision of training/capacity building and awareness creation mechanism for the health workers, facilitating disclosure and social support for the patients is recommended.
doi:10.11604/pamj.2014.17.26.2641
PMCID: PMC4048699  PMID: 24932337
Isoniazid preventive therapy; People Living with HIV; TB
7.  Predictors of adherence to isoniazid preventive therapy among HIV positive adults in Addis Ababa, Ethiopia 
BMC Public Health  2011;11:916.
Background
Isoniazide preventive therapy (IPT) is given to individuals with latent infection of tuberculosis (TB) to prevent the progression to active disease. One of the primary reasons for failure of IPT is poor adherence.
Methods
A cross sectional study was conducted in four hospitals in Addis Ababa. Data were collected using a pre-tested interviewer-administered structured questionnaire. Bivariate and multivariate analysis was done to identify predictors of IPT.
Results
A total of 319 (97.5%) individual participated in this study. Within seven days recall period, self-reported dose adherence rate was 86.5%. Individual who received explanation about IPT from health care providers (OR = 7.74; 95%CI: 3.144, 19.058); who had good feeling/comfortable to take IPT in front of other people [OR = 5.981, 95%CI (2.308, 15.502)] and who attended clinical appointment regularly (OR = 4.0; 95%CI: 1.062, 15.073) were more likely to adhere to IPT. Participants who developed IPT related adverse effect were 93% less likely to adhere to the prescribed doses (OR = 0.065; 95%CI: 0.024, 0.179).
Conclusion
The prevalence of self reported dose adherence over the past 7 days was higher. Non-adherence was observed among respondent who were not provided with sufficient information about IPT. The health care providers need to strengthen their educational and counseling efforts to convince the patient before putting them on IPT. To enhance adherence, health education efforts should focus on the importance of IPT, the details of the regimen and adverse effects.
doi:10.1186/1471-2458-11-916
PMCID: PMC3270073  PMID: 22151609
Adherence; TB; Isoniazid Preventive Therapy; HIV; Ethiopia
8.  Sexual Behavior among Persons Living with HIV in Uganda: Implications for Policy and Practice 
PLoS ONE  2014;9(1):e85646.
Introduction
HIV epidemics are sustained and propagated by new cases of infection which result from transmission from infected persons to uninfected susceptible individuals. People living with HIV (PLHIV) play a critical role in prevention if they adopt safer sexual behaviors. This study estimated the prevalence of and factors associated with safer sexual behaviors among PLHIV seeking care from civil society organizations (CSOs).
Methods
In a cross sectional study PLHIV were interviewed about their sexual practices, use of alcohol, HIV status of their regular sexual partners, desire for more children and about their socio-demographic characteristics. We calculated the proportion of PLHIV who abstained and consistently used condoms in the previous twelve months. Independent associations between safer sex and other variables were estimated using adjusted prevalence ratios (aPR) and their 95% confidence intervals (CI).
Results
Of the 939 PLHIV, 54% (508) were either abstaining or using condoms consistently and 291 (31%) desired more children. The prevalence of consistent condom use among the sexually active was 41.3% (300/731). Consistent condom use was higher among PLHIV who: didn't use alcohol (aPR 1.30, CI 1.03–1.63); were educated about re-infection with a new strain of HIV (aPR 1.84, CI 1.08–3.12) and had regular sexual partner who was HIV negative (aPR 1.29, CI 1.05–1.57). Prevalence of abstinence was 22.2% (208/939). Abstinence increased with age from 9.4% among PLHIV <25 years to 40.5% among those >50 years. Abstinence was extremely low (2.5%) among PLHIV who were married.
Conclusions
Effective interventions that reduce alcohol consumption among PLHIV are needed to avert HIV transmission, prevent acquisition of new HIV strains and STIs. In addition, strategies are needed to address needs of PLHIV who desire more children.
doi:10.1371/journal.pone.0085646
PMCID: PMC3900429  PMID: 24465631
9.  HIV Screening among TB Patients and Co-Trimoxazole Preventive Therapy for TB/HIV Patients in Addis Ababa: Facility Based Descriptive Study 
PLoS ONE  2014;9(2):e86614.
Background
Collaborative TB/HIV management is essential to ensure that HIV positive TB patients are identified and treated appropriately, and to prevent tuberculosis (TB) in HIV positive patients. The purpose of this study was to assess HIV case finding among TB patients and Co-trimoxazole Preventive Therapy (CPT) for HIV/TB patients in Addis Ababa.
Methods
A descriptive cross-sectional, facility-based survey was conducted between June and July 2011. Data was collected by interviewing 834 TB patients from ten health facilities in Addis Ababa. Both descriptive and inferential statistics were used to summarize and analyze findings.
Results
The proportion of TB patients who (self reported) were offered for HIV test, tested for HIV and tested HIV positive during their anti-TB treatment follow-up were; 87.4%, 69.4% and 20.2%; respectively. Eighty seven HIV positive patients were identified, who knew their status before diagnosed for the current TB disease, bringing the cumulative prevalence of HIV among TB patients to 24.5%. Hence, the proportion of TB patients who knew their HIV status becomes 79.9%. The study revealed that 43.6% of those newly identified HIV positives during anti-TB treatment follow-up were actually treated with CPT. However, the commutative proportion of HIV positive TB patients who were ever treated with CPT was 54.4%; both those treated before the current TB disease and during anti-TB treatment follow-up.
Conclusions
HIV case finding among TB patients and provision of CPT for TB/HIV co-infected patients needs boosting. Hence, routine offering of HIV test and provision of CPT for PLHIV should be strengthened in-line with the national guidelines.
doi:10.1371/journal.pone.0086614
PMCID: PMC3911916  PMID: 24498278
10.  Adherence to Antiretroviral Therapy (ART) among People Living With HIV (PLHIV): a cross-sectional survey to measure in Lao PDR 
BMC Public Health  2013;13:617.
Rationale
Since 2001, antiretroviral therapy (ART) for people living with HIV (PLHIV) has been available in the Lao People’s Democratic Republic (PDR). A key factor in the effectiveness of ART is good adherence to the prescribed regimen for both individual well-being and public health. Poor adherence can contribute to the emergence of drug resistant strains of the virus and transmission during risky behaviors. Increased access to ART in low-income country settings has contributed to an interest in treatment adherence in resource–poor contexts. This study aims to investigate the proportion of adherence to ART and identify possible factors related to non-adherence to ART among people living with HIV (PLHIV) in Lao PDR.
Methods
A cross-sectional study was conducted with adults living with HIV receiving free ART at Setthathirath hospital in the capital Vientiane and Savannakhet provincial hospitals from June to November 2011. Three hundred and forty six PLHIV were interviewed using an anonymous questionnaire. The estimation of the adherence rate was based on the information provided by the PLHIV about the intake of medicine during the previous three days. The statistical software Epidata 3.1 and Stata 10.1 were used for data analysis. Frequencies and distribution of each variable were calculated by conventional statistical methods. The chi square test, Mann–Whitney test and logistic regression were used for bivariate analyses. Multiple logistic regression analysis was conducted to determine the predictors of non-adherence to ART. A p-value < 0.05 was considered to indicate statistical significance.
Results
Of a total of 346 patients, 60% reported more than 95% adherence to ART. Reasons for not taking medicine as required were being busy (97.0%), and being forgetful (62.2%). In the multivariate analysis, educational level at secondary school (OR=3.7, 95% CI:1.3-10.1, p=0.012); illicit drug use (OR=16.1, 95% CI:1.9-128.3, p=0.011); dislike exercise (OR=0.6, 95% CI:0.4-0.9, p=0.028), and forgetting to take ARV medicine during the last month (OR=2.3, 95% CI:1.4-3.7, p=0.001) were independently associated with non-adherence.
Conclusions
Non-adherence to ART was associated with individual factors and exposure to ART. Priority measures to increase adherence to ART should aim to intensify counseling and comprehensive interventions, such as guidance for PLHIV on medication self-management skills, tailoring the regimen to the PLHIV life style, and improving adherence monitoring and health care services.
doi:10.1186/1471-2458-13-617
PMCID: PMC3707741  PMID: 23809431
Antiretroviral therapy; Adherence; PLWHIV; Self-report; Lao PDR
11.  Does an Isoniazid Prophylaxis Register Improve Tuberculosis Contact Management in South African Children? 
PLoS ONE  2013;8(12):e80803.
Setting
We compared the change in child household contact management of pulmonary tuberculosis (TB) cases before and after the implementation of an isoniazid preventive therapy (IPT) register in an urban clinic setting in Cape Town, South Africa.
Objectives
We determined if the presence of an IPT register was associated with an increase in the number of child contacts identified per infectious case and the proportion of identified children who were started on IPT.
Design
We reviewed routine programme data on IPT delivery to children during two time periods (May 2008–October 2008 and May 2011–October 2011), before and after the implementation of an IPT register used by routine clinic personnel.
Results
Adult TB case demographic and clinical characteristics from the two observation periods were similar. During the post-register period, more child contacts per adult case were identified (0.7 (54 children) vs. 0.3 (24 children)), more of the identified children were started on IPT (54 vs. 4) and 37% of those who started, completed six months of treatment compared to the pre-register period where no adherence information was recorded.
Conclusions
After pilot implementation of an IPT register, documented identification of child contacts, IPT initiation and IPT adherence documentation in TB exposed children was improved. Our findings support further exploration of the potential impact of using standardised IPT recording and reporting in routine clinics in high-burden TB settings to improve TB prevention efforts targeted at young children. Future efforts to improve IPT delivery should be systematic and comprehensive in order to support a change in current operational IPT delivery practices in TB programs.
doi:10.1371/journal.pone.0080803
PMCID: PMC3858233  PMID: 24339884
12.  Sexual life and fertility desire in long-term HIV serodiscordant couples in Addis Ababa, Ethiopia: a grounded theory study 
BMC Public Health  2012;12:900.
Background
Even though remarkable progress has been achieved, HIV/AIDS continues to be a major global health priority. HIV discordant relationship is one of the emerging issues in HIV prevention endeavour. In Ethiopia, very little is known about HIV-serodiscordant couples particularly how they manage their sexual relationship and fertility desire. Therefore, we conduct this study with the aim of exploring the experiences of HIV discordant couples about their sexual life, and fertility desire in the context of long-term relationships in Addis Ababa, Ethiopia.
Methods
A grounded theory approach was employed using in-depth interviews among 36 informants in ART/PMTCT centers of three public hospitals, a health center and one PLHIV association in Addis Ababa. Theoretical sampling was used to recruit 28 clients who lived in a discordant relationship and eight health care providers as key informants. Data collection and analysis were undertaken simultaneously using a constant comparison. The analysis was facilitated using OpenCode software.
Results
A grounded theory pertaining to sexual life and desire to have a child among HIV discordant couples emerged as “maintaining the relationship” as a core category. Couples pass through a social process of struggle to maintain their relationship. The causal conditions for couples to enter into the process of struggle to maintain their relationship were collectively categorized as “Entering in-to a transition” (knowing HIV serostatus) and this includes mismatch of desire to have a child, controversy on safe sex versus desire to have a child, and undeniable change in sexual desire and practice through time were the features in entering into-transition. Then after the transition, couples engaged in certain actions/strategies that are categorized as “dealing with discordancy” such as entertaining partner’s interest by scarifying once self interest to maintain their relationship.
Conclusions
HIV discordant couples’ relationship is filled with controversies of maintaining relationship versus fear of getting infected. The findings of this study have suggested the need to view discordant couple’s actions as a process of maintaining their relationship in the context of eminent risks. Further study should be done among HIV discordant couples to assess the fitness of the current model in different setups and population. In addition, a study could begin to test the hypotheses proposed in this study.
doi:10.1186/1471-2458-12-900
PMCID: PMC3497866  PMID: 23092155
13.  Understanding positive prevention practices among people living with HIV in Karnataka, Southern India 
The Australasian Medical Journal  2011;4(4):150-161.
Background
Understanding positive prevention practices among people living with HIV (PLHIV) can provide useful insights to guide our efforts in preventing further HIV transmission, and helps to enable PLHIVs to lead healthy and responsible lives.
Method
A cross-sectional study was conducted in three sites of Karnataka: namely Belgaum (North Karnataka), Bellary (Central Karnataka) and Hassan (South Karnataka) districts. The study period was from March to September 2010. A total of 477 PLHIV were sampled and interviewed with the help of a structured interview schedule. The interviews were conducted by trained PLHIV community interviewers.
Results
Disclosure of status was fairly good among the studied population. The majority of men disclosed their HIV status first with their spouses, whereas women disclosed first with their mothers. Status disclosure was less among urban PLHIV when compared to rural PLHIV. Knowledge about Sexually Transmitted Infections (STIs) among unmarried men and women was low; higher proportions among them were involved in sexual relationships; and they reported no condom use with their regular partners. Condom use with regular partners is found to be more effective when public health messages are given through peers. Status disclosure is having a role in motivating communities for Regular CD4 testing and ART uptake.
Conclusion
Unmarried PLHIV need to be prioritised in our prevention efforts, to enable them to adopt safe sex practices through appropriate peer-mediated strategies. As status disclosure with family members has an important role in adhering to ART, status disclosure with family members needs to be emphasized in our programmes.
doi:10.4066/AMJ.2011.577
PMCID: PMC3562893  PMID: 23393506
ositive preventionP; disclosure; HIV; Karnataka
14.  Research on Implementation of Interventions in Tuberculosis Control in Low- and Middle-Income Countries: A Systematic Review 
PLoS Medicine  2012;9(12):e1001358.
Cobelens and colleagues systematically reviewed research on implementation and cost-effectiveness of the WHO-recommended interventions for tuberculosis.
Background
Several interventions for tuberculosis (TB) control have been recommended by the World Health Organization (WHO) over the past decade. These include isoniazid preventive therapy (IPT) for HIV-infected individuals and household contacts of infectious TB patients, diagnostic algorithms for rule-in or rule-out of smear-negative pulmonary TB, and programmatic treatment for multidrug-resistant TB. There is no systematically collected data on the type of evidence that is publicly available to guide the scale-up of these interventions in low- and middle-income countries. We investigated the availability of published evidence on their effectiveness, delivery, and cost-effectiveness that policy makers need for scaling-up these interventions at country level.
Methods and Findings
PubMed, Web of Science, EMBASE, and several regional databases were searched for studies published from 1 January 1990 through 31 March 2012 that assessed health outcomes, delivery aspects, or cost-effectiveness for any of these interventions in low- or middle-income countries. Selected studies were evaluated for their objective(s), design, geographical and institutional setting, and generalizability. Studies reporting health outcomes were categorized as primarily addressing efficacy or effectiveness of the intervention. These criteria were used to draw landscapes of published research. We identified 59 studies on IPT in HIV infection, 14 on IPT in household contacts, 44 on rule-in diagnosis, 19 on rule-out diagnosis, and 72 on second-line treatment. Comparative effectiveness studies were relatively few (n = 9) and limited to South America and sub-Saharan Africa for IPT in HIV-infection, absent for IPT in household contacts, and rare for second-line treatment (n = 3). Evaluations of diagnostic and screening algorithms were more frequent (n = 19) but geographically clustered and mainly of non-comparative design. Fifty-four studies evaluated ways of delivering these interventions, and nine addressed their cost-effectiveness.
Conclusions
There are substantial gaps in published evidence for scale-up for five WHO-recommended TB interventions settings at country level, which for many countries possibly precludes program-wide implementation of these interventions. There is a strong need for rigorous operational research studies to be carried out in programmatic settings to inform on best use of existing and new interventions in TB control.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Tuberculosis (TB), caused by Mycobacterium tuberculosis, is curable and preventable, but according to the World Health Organization (WHO), in 2011, 8.7 million people had symptoms of TB (usually a productive cough and fever) and 1.4 million people—95% from low- and middle-income countries—died from TB. TB is also the leading cause of death in people with HIV worldwide, and in 2010 about 10 million children were orphaned as a result of their parents dying from TB. To help reduce the considerable global burden of TB, a global initiative called the Stop TB Partnership, led by WHO, has implemented a strategy to reduce deaths from TB by 50% by 2015—even greater than the target of Millennium Development Goal 6 (to reverse the increase in TB incidence by 2015).
Why Was This Study Done?
Over the past few years, WHO has recommended that countries implement several interventions to help control the spread of tuberculosis through measures to improve prevention, diagnosis, and treatment. Five such interventions currently recommended by WHO are: treatment with isoniazid to prevent TB among people who are HIV positive, and also among household contacts of people infected with TB; the use of clinical pathways (algorithms) for diagnosing TB in people accessing health care who have a negative smear test—the most commonly used diagnostic test, which relies on sputum samples—(“rule-in algorithms”); screening algorithms for excluding TB in people who have HIV (“rule-out algorithms”); and finally, provision of second-line treatment for multidrug-resistant tuberculosis (a form of TB that does not respond to the most commonly used drugs) under programmatic conditions. The effectiveness of these interventions, their costs, and the practicalities of implementation are all important information for countries seeking to control TB following the WHO guidelines, but little is known about the availability of this information. Therefore, in this study the researchers systematically reviewed published studies to find evidence of the effectiveness of each of these interventions when implemented in routine practice, and also for additional information on the setting and conditions of implemented interventions, which might be useful to other countries.
What Did the Researchers Do and Find?
Using a specific search strategy, the researchers comprehensively searched through several key databases of publications, including regional databases, to identify 208 (out of 11,489 found initially) suitable research papers published between January 1990 and March 2012. For included studies, the researchers also noted the geographical location and setting and the type and design of study.
Of the 208 included studies, 59 focused on isoniazid prevention therapy in HIV infection, and only 14 on isoniazid prevention therapy for household contacts. There were 44 studies on “rule-in” clinical diagnosis, 19 on “rule-out” clinical diagnosis, and 72 studies on second-line treatment for TB. Studies on each intervention had some weaknesses, and overall, researchers found that there were very few real-world studies reporting on the effectiveness of interventions in program settings (rather than under optimal conditions in research settings). Few studies evaluated the methods used to implement the intervention or addressed delivery and operational issues (such as adherence to treatment), and there were limited economic evaluations of the recommended interventions. Furthermore, the researchers found that in general, the South Asian region was poorly represented.
What Do These Findings Mean?
These findings suggest that there is limited evidence on effectiveness, delivery, and cost-effectiveness to guide the scale-up of five WHO recommended interventions to control tuberculosis in the countries and settings, despite the urgent need for such interventions to be implemented. The poor evidence base identified in this review highlights the tension between the decision to adopt the recommendation and its implementation adapted to local circumstances, and may be an important reason as to why these interventions are not implemented in many countries. This study also suggests creative thinking is necessary to address the gaps between WHO recommendations and global health policy on new interventions and their real-world implementation in country-wide TB control programs. Future research should focus more on operational studies, the results of which should be made publicly available, and researchers, donors, and medical journals could perhaps re-consider their priorities to help bridge the knowledge gap identified in this study.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001358.
WHO has a wide range of information about TB and research on TB, including more about the STOP TB strategy and the STOP TB Partnership
The UN website has more information about MDG 6
The Global Fund to Fight AIDS, Tuberculosis and Malaria has specific information about progress on TB control
doi:10.1371/journal.pmed.1001358
PMCID: PMC3525528  PMID: 23271959
15.  An e-health driven laboratory information system to support HIV treatment in Peru: E-quity for laboratory personnel, health providers and people living with HIV 
Background
Peru has a concentrated HIV epidemic with an estimated 76,000 people living with HIV (PLHIV). Access to highly active antiretroviral therapy (HAART) expanded between 2004-2006 and the Peruvian National Institute of Health was named by the Ministry of Health as the institution responsible for carrying out testing to monitor the effectiveness of HAART. However, a national public health laboratory information system did not exist. We describe the design and implementation of an e-health driven, web-based laboratory information system - NETLAB - to communicate laboratory results for monitoring HAART to laboratory personnel, health providers and PLHIV.
Methods
We carried out a needs assessment of the existing public health laboratory system, which included the generation and subsequent review of flowcharts of laboratory testing processes to generate better, more efficient streamlined processes, improving them and eliminating duplications. Next, we designed NETLAB as a modular system, integrating key security functions. The system was implemented and evaluated.
Results
The three main components of the NETLAB system, registration, reporting and education, began operating in early 2007. The number of PLHIV with recorded CD4 counts and viral loads increased by 1.5 times, to reach 18,907. Publication of test results with NETLAB took an average of 1 day, compared to a pre-NETLAB average of 60 days. NETLAB reached 2,037 users, including 944 PLHIV and 1,093 health providers, during its first year and a half. The percentage of overall PLHIV and health providers who were aware of NETLAB and had a NETLAB password has also increased substantially.
Conclusion
NETLAB is an effective laboratory management tool since it is directly integrated into the national laboratory system and streamlined existing processes at the local, regional and national levels. The system also represents the best possible source of timely laboratory information for health providers and PLHIV, allowing patients to access their own results and other helpful information about their health, extending the scope of HIV treatment beyond the health facility and providing a model for other countries to follow. The NETLAB system now includes 100 diseases of public health importance for which the Peruvian National Institute of Health and the network of public health laboratories provide testing and results.
doi:10.1186/1472-6947-9-50
PMCID: PMC2797768  PMID: 20003281
16.  Isoniazid preventive therapy, HAART and tuberculosis risk in HIV-infected adults in South Africa: a prospective cohort 
AIDS (London, England)  2009;23(5):631-636.
Background
The World Health Organization recommends isoniazid preventive therapy (IPT) for preventing tuberculosis in HIV-infected adults, although few countries have instituted this policy. Both IPT and highly active antiretroviral therapy (HAART) used separately result in reductions in tuberculosis risk. There is less information on the combined effect of IPT and HAART. We assessed the effect of IPT, HAART or both IPT and HAART on tuberculosis incidence in HIV-infected adults in South Africa.
Methods
Two clinical cohorts of HIV-infected patients were studied. Primary exposures were receipt of IPT and/or HAART and the primary outcome was incident tuberculosis. Crude incident rates and incident rate ratios were calculated and Cox proportional hazards models investigated associations with tuberculosis risk.
Results
Among 2778 HIV-infected patients followed for 4287 person-years, 267 incident tuberculosis cases were diagnosed [incidence rate ratio (IRR) = 6.2/100 person-years; 95% CI 5.5–7.0]. For person-time without IPT or HAART, the IRR was 7.1/100 person-years (95% CI 6.2–8.2); for person-time receiving HAART but without IPT, the IRR was 4.6/100 person-years (95% CI 3.4–6.2); for person-time after IPT but prior to HAART, the IRR was 5.2/100 person-years (95% CI 3.4–7.8); during follow-up in patients treated with HAART after receiving IPT the IRR was 1.1/100 person-years (95% CI 0.02–7.6). Compared to treatment-naive patients, HAART-only patients had a 64% decreased hazard for tuberculosis [adjusted hazard ratio (aHR) = 0.36; 95% CI 0.25–0.51], and patients receiving HAART after IPT had a 89% reduced hazard (aHR = 0.11; 95% CI 0.02–0.78).
Conclusion
Tuberculosis risk is significantly reduced by IPT in HAART-treated adults in a high-incidence operational setting in South Africa. IPT is an inexpensive and cost-effective strategy and our data strengthen calls for the implementation of IPT in conjunction with the roll-out of HAART.
doi:10.1097/QAD.0b013e328327964f
PMCID: PMC3063949  PMID: 19525621
HAART; isoniazid; preventive treatment; sub-Saharan Africa; tuberculosis
17.  Experience of stigma and discrimination and the implications for healthcare seeking behavior among people living with HIV/AIDS in resource-limited setting 
Background
Stigma and discrimination can limit access to care and treatment services. Stigma hides HIV from the public, resulting in reduced pressure for behavioral change. For effective behavior change, empirically grounded and theory-based behavioral change approaches are fundamental as a prevention interventions directed on decreasing stigma and discrimination. The objective of the study was to assess the experience of stigma and discrimination on the psychosocial and health care seeking behavior of people living with HIV/AIDS (PLHIV) in Arba Minch, Ethiopia.
Methods
This study uses qualitative methods involving focus-group discussions and in-depth interviews conducted in Arba Minch town and nearby Kebeles. Our sample consisted of PLHIV and other key informants who were purposively selected. Data were analyzed manually using thematic content analysis framework.
Results
It appears that the magnitude of stigma and discrimination in the area has decreased to a considerably lower level, however, the problem’s severity is still being influenced by various factors including: current residence, disclosure status and level of community’s awareness about HIV/AIDS. Care and support services provided to PLHIV were well accepted by the respondents and the majority of them were willing to make use of any service available. Health information messages that have been disseminated to the public through mass media since the start of the epidemic in 1984 and AIDS cases in 1986 have played a significant role regarding the current prevailing problem of stigma and discrimination of PLHIV.
Conclusion
Stigma and discrimination have come to a level that can be tolerated by most PLHIV that live in this region, especially those who have disclosed their HIV status and were living in urban areas. This calls for a strategy that improves the rates of serostatus disclosure after HIV counseling and testing and strengthens and integrates activities in the task of expanding care and support activities.
doi:10.1080/17290376.2013.806645
PMCID: PMC3819651  PMID: 23721543
HIV/AIDS; stigma; discrimination; EPPM; Ethiopia
18.  Experience of stigma and discrimination and the implications for healthcare seeking behavior among people living with HIV/AIDS in resource-limited setting 
Sahara J  2013;10(1):1-7.
Background
Stigma and discrimination can limit access to care and treatment services. Stigma hides HIV from the public, resulting in reduced pressure for behavioral change. For effective behavior change, empirically grounded and theory-based behavioral change approaches are fundamental as a prevention interventions directed on decreasing stigma and discrimination. The objective of the study was to assess the experience of stigma and discrimination on the psychosocial and health care seeking behavior of people living with HIV/AIDS (PLHIV) in Arba Minch, Ethiopia.
Methods
This study uses qualitative methods involving focus-group discussions and in-depth interviews conducted in Arba Minch town and nearby Kebeles. Our sample consisted of PLHIV and other key informants who were purposively selected. Data were analyzed manually using thematic content analysis framework.
Results
It appears that the magnitude of stigma and discrimination in the area has decreased to a considerably lower level, however, the problem's severity is still being influenced by various factors including: current residence, disclosure status and level of community's awareness about HIV/AIDS. Care and support services provided to PLHIV were well accepted by the respondents and the majority of them were willing to make use of any service available. Health information messages that have been disseminated to the public through mass media since the start of the epidemic in 1984 and AIDS cases in 1986 have played a significant role regarding the current prevailing problem of stigma and discrimination of PLHIV.
Conclusion
Stigma and discrimination have come to a level that can be tolerated by most PLHIV that live in this region, especially those who have disclosed their HIV status and were living in urban areas. This calls for a strategy that improves the rates of serostatus disclosure after HIV counseling and testing and strengthens and integrates activities in the task of expanding care and support activities.
doi:10.1080/17290376.2013.806645
PMCID: PMC3819651  PMID: 23721543
HIV/AIDS; stigma; discrimination; EPPM; Ethiopia; VIH/SIDA; la stigmatisation; la discrimination; EPPM; Ethiopie
19.  Awareness of HIV Status, Prevention Knowledge and Condom Use among People Living with HIV in Mozambique 
PLoS ONE  2014;9(9):e106760.
Objective
To determine factors associated with HIV status unawareness and assess HIV prevention knowledge and condom use among people living with HIV/AIDS (PLHIV) in Mozambique.
Design
Cross-sectional household-based nationally representative AIDS Indicator Survey.
Methods
Analyses focused on HIV-infected adults and were weighted for the complex sampling design. We identified PLHIV who had never been tested for HIV or received their test results prior to this survey. Logistic regression was used to assess factors associated with HIV status unawareness.
Results
Of persons with positive HIV test results (N = 1182), 61% (95% confidence interval [CI] 57–65%) were unaware of their serostatus. Men had twice the odds of being unaware of their serostatus compared with women [adjusted odds ratio (aOR) 2.05, CI 1.40–2.98]. PLHIV in the poorest wealth quintile were most likely to be unaware of their serostatus (aOR 3.15, CI 1.09–9.12) compared to those in the middle wealth quintile. Most PLHIV (83%, CI 79–87%) reported not using a condom during their last sexual intercourse, and PLHIV who reported not using a condom during their last sexual intercourse were more likely to be unaware of their serostatus (aOR 2.32, CI 1.57–3.43) than those who used a condom.
Conclusions
Knowledge of HIV-positive status is associated with more frequent condom use in Mozambique. However, most HIV-infected persons are unaware of their serostatus, with men and persons in the poorest wealth quintile being more likely to be unaware. These findings support calls for expanded HIV testing, especially among groups less likely to be aware of their HIV status and key populations at higher risk for infection.
doi:10.1371/journal.pone.0106760
PMCID: PMC4164358  PMID: 25222010
20.  Stigma and discrimination against people living with HIV by healthcare providers, Southwest Ethiopia 
BMC Public Health  2012;12:522.
Background
Stigma and discrimination against people living with human immunodeficiency virus (HIV) are obstacles in the way of effective responses to HIV. Understanding the extent of stigma / discrimination and the underlying causes is necessary for developing strategies to reduce them. This study was conducted to explore stigma and discrimination against PLHIV amongst healthcare providers in Jimma zone, Southwest Ethiopia.
Methods
A cross-sectional study, employing quantitative and qualitative methods, was conducted in 18 healthcare institutions of Jimma zone, during March 14 to April 14, 2011. A total of 255 healthcare providers responded to questionnaires asking about sociodemographic characteristics, HIV knowledge, perceived institutional support and HIV-related stigma and discrimination. Factor analysis was employed to create measurement scales for stigma and factor scores were used in one way analysis of variance (ANOVA), T-tests, Pearson’s correlation and multiple linear regression analyses. Qualitative data collected using key-informant interviews and Focus Group Discussions (FGDs) were employed to triangulate with the findings from the quantitative survey.
Results
Mean stigma scores (as the percentages of maximum scale scores) were: 66.4 for the extra precaution scale, 52.3 for the fear of work-related HIV transmission, 49.4 for the lack of feelings of safety, 39.0 for the value-driven stigma, 37.4 for unethical treatment of PLHIV, 34.4 for discomfort around PLHIV and 31.1 for unofficial disclosure. Testing and disclosing test results without consent, designating HIV clients and unnecessary referral to other healthcare institutions and refusal to treat clients were identified. Having in-depth HIV knowledge, the perception of institutional support, attending training on stigma and discrimination, educational level of degree or higher, high HIV case loads, the presence of ART service in the healthcare facility and claiming to be non-religious were negative predictors of stigma and discrimination as measured by the seven latent factors.
Conclusions
Higher levels of stigma and discrimination against PLHIV were associated with lack of in-depth knowledge on HIV and orientation about policies against stigma and discrimination. Hence, we recommend health managers to ensure institutional support through availing of clear policies and guidelines and the provision of appropriate training on the management of HIV/AIDS.
doi:10.1186/1471-2458-12-522
PMCID: PMC3506482  PMID: 22794201
Stigma and discrimination; Healthcare providers; HIV/AIDS
21.  Community-wide isoniazid preventive therapy drives drug-resistant tuberculosis: a model-based analysis 
Science translational medicine  2013;5(180):180ra49.
Tuberculosis control has proven especially difficult in settings of high HIV prevalence as HIV co-infection erodes host immunity and leads to a high risk of progression to active tuberculosis. Studies have demonstrated that a 6-month (or longer) course of monotherapy with isoniazid (isoniazid preventative therapy (IPT)) can reduce this risk of progression. The World Health Organization endorses the use of IPT for symptom-free individuals with HIV/tuberculosis co-infection and has placed considerable effort in expanding IPT to entire communities (community-wide IPT). Though previous reviews have not found a statistically significant elevated risk of isoniazid-resistant tuberculosis among those previously treated with IPT, community-wide IPT programs may nonetheless generate substantial selective pressure and increase the burden of drug-resistant TB (DRTB). We develop mathematical models to identify the conditions under which community-wide IPT interventions can increase the burden of isoniazid-resistant M. tuberculosis, even when IPT does not select for resistance among those treated with IPT. In any model that explicitly or implicitly includes forms of inter-strain competition (such as partial immunity conferred by a previous M. tuberculosis infection), community-wide IPT interventions confer an indirect benefit to drug-resistant strains through selective suppression of drug-sensitive infections. We demonstrate that aggressive community-wide IPT can have an impressive impact on reductions of drug-sensitive disease, but at the cost of increasing the selective pressure for resistance. Improving the detection and treatment of DRTB can mitigate this risk. The lack of an observed elevation in the risk of DRTB among those receiving IPT in small-scale studies of limited duration does not imply that the selective pressure imposed by community-wide IPT will not be substantial. Community-wide IPT programs will likely play an important role in disease control in high incidence settings and their roll-out should be accompanied by interventions for the detection and treatment of drug-resistant disease.
doi:10.1126/scitranslmed.3005260
PMCID: PMC3714172  PMID: 23576815
22.  Evaluation of collaborative TB/HIV activities in a general hospital in Addis Ababa, Ethiopia 
BMC Research Notes  2012;5:67.
Background
Ethiopia has had mechanisms for TB/HIV collaborative activities since 2002. However, no published account has defined the role of these collaborative efforts in strengthening linkages between HIV and TB management units at the point-of-care level. Our objective was to assess the extent of linkages between the two programs at the patient management level at Zewditu Memorial Hospital in Addis Ababa, Ethiopia. Between January and December 2008, the registers of 241 TB patients were reviewed to determine the HIV testing rate, the treatment charts of 238 randomly selected patients were reviewed for providers' compliance with evaluation criteria, and exit interviews were conducted with 309 TB/HIV co-infected clients to validate providers' compliance.
Results
From register review, it was determined that the HIV testing acceptance rate was 95%, and that 70% of patients received post-test counseling. A review of the patient chart revealed that of 51 patients with a complaint of cough, duration for cough was recorded in 35 (68.6%) cases and cough > 2 weeks was recorded in 25 (49.0%) cases. Seventy two percent (18 of 25) were linked for sputum microscopy. Linkage to cotrimoxazole prophylactic treatment was 81%, but only 47% of eligible patients were linked to isoniazid preventive therapy (IPT). Correct diagnosis was accomplished at a rate of 100% for smear positive pulmonary TB, 23% for smear negative pulmonary TB and 88% for extra pulmonary TB patients. Both chart review and exit interviews indicated that history of TB contact and cough > 2 weeks predicted TB disease.
Conclusion
The rates of HIV testing and linkage to cotrimoxazole prophylactic therapy were high. Improvement is needed in the areas of recording patient information, screening HIV positives for TB, initiation of IPT, referral, linkages, and TB diagnostic capacity.
doi:10.1186/1756-0500-5-67
PMCID: PMC3293037  PMID: 22277087
23.  Family planning among people living with HIV in post-conflict Northern Uganda: A mixed methods study 
Conflict and Health  2011;5:18.
Background
Northern Uganda experienced severe civil conflict for over 20 years and is also a region of high HIV prevalence. This study examined knowledge of, access to, and factors associated with use of family planning services among people living with HIV (PLHIV) in this region.
Methods
Between February and May 2009, a total of 476 HIV clinic attendees from three health facilities in Gulu, Northern Uganda, were interviewed using a structured questionnaire. Semi-structured interviews were conducted with another 26 participants. Factors associated with use of family planning methods were examined using logistic regression methods, while qualitative data was analyzed within a social-ecological framework using thematic analysis.
Results
There was a high level of knowledge about family planning methods among the PLHIV surveyed (96%). However, there were a significantly higher proportion of males (52%) than females (25%) who reported using contraception. Factors significantly associated with the use of contraception were having ever gone to school [adjusted odds ratio (AOR) = 4.32, 95% confidence interval (CI): 1.33-14.07; p = .015], discussion of family planning with a health worker (AOR = 2.08, 95% CI: 1.01-4.27; p = .046), or with one's spouse (AOR = 5.13, 95% CI: 2.35-11.16; p = .000), not attending the Catholic-run clinic (AOR = 3.67, 95% CI: 1.79-7.54; p = .000), and spouses' non-desire for children (AOR = 2.19, 95% CI: 1.10-4.36; p = .025). Qualitative data revealed six major factors influencing contraception use among PLHIV in Gulu including personal and structural barriers to contraceptive use, perceptions of family planning, decision making, covert use of family planning methods and targeting of women for family planning services.
Conclusions
Multilevel, context-specific health interventions including an integration of family planning services into HIV clinics could help overcome some of the individual and structural barriers to accessing family planning services among PLHIV in Gulu. The integration also has the potential to reduce HIV incidence in this post-conflict region.
doi:10.1186/1752-1505-5-18
PMCID: PMC3191370  PMID: 21933403
HIV/AIDS; contraception; mixed methods; Northern Uganda
24.  Fertility desire and associated factors among people living with HIV attending antiretroviral therapy clinic in Ethiopia 
Background
The reproductive decisions made by PLHIV and their partners have a long-term consequences for the survival and wellbeing of their families and a society at large. Evidence relating to fertility and reproductive intentions among PLHIV is rare, despite the fact that more than 80% of PLHIV are of reproductive age. The aim of the study was to determine fertility desire and associated factors among PLHIV attending ART clinic in Fitche Hospital.
Methods
A facility based cross-sectional study design with both quantitative and qualitative data collection methods was employed from February21-April 20th, 2013. The study participants were selected by using simple random sampling technique. A pre- tested structured questionnaire was used to collect data. Both bivariate and multivariate logistic regressions were used to identify associated factors.
Result
The prevalence of fertility desire of PLHIV in Fitche Hospital was 133(39.1%) with 95% CI of (34.3% -44.3%). This study identified that factors found to be associated with fertility desire were: − Age from 18-29y [AOR = 3.95, 95% CI: 1.69 - 9.22) and 30-39y (AOR = 3.91, 95% CI: 1.90 -8.19)], marital length ≤4y [AOR = 5.49, 95% CI: 2.08-14.51), within 5-9y (AOR = 4.80, 95% CI: 2.14-10.78) and 10-14y (AOR = 2.82, 95% CI: 1.19 -6.63], had not biological living children [AOR = 11.42, 95% CI: 3.27-39.90) and had more than one child (AOR = 3.67, 95% CI: 1.27-10.62)], community pressure [AOR = 3.67, 95% CI: 1.54-8.70], partner fertility [AOR = 7.18, 95% CI: 3.39-15.22)], duration HIV diagnosis≤1y[AOR = 4.99, 95% CI: 1.91-13.09], disclosed HIV serostatus [AOR = 3.9, 95% CI: 1.37-11.10] and partner sero-difference [AOR = 2.05, 95% CI: 1.01- 4.15] were some of the factors significantly associated with fertility desire.
Conclusion
The prevalence of fertility desire of PLHIV in the study area was 39.1%. In this study:- age, marital length, biological child, partner, community pressure, duration of HIV-diagnosis, discordant HIV-test and disclosure of HIV-serostatus to partner were demonstrated to have more associations with fertility desire among PLHIV, therefore, these factors should be emphatically considered during PLHIV’s reproductive health program development.
doi:10.1186/s12884-014-0382-2
PMCID: PMC4243275  PMID: 25410125
People living with HIV; Ethiopia; Fertility desires
25.  Knowledge, attitudes and practices of AIDS associated malignancies among people living with HIV in Nigeria 
Introduction
The epidemic of HIV in sub-Saharan Africa varies significantly across countries in the region with high prevalence in Southern Africa and Nigeria. Cancer is increasingly identified as a complication of HIV infection with higher incidence and mortality in this group than in the general population. Without cancer prevention strategies, improved cancer treatment alone would be an insufficient response to this increasing burden among people living with HIV (PLHIV). Although previous studies have noted low levels of awareness of cancers in sub-Saharan Africa none has examined the knowledge and perceptions of cancer among people living with HIV/AIDS.
Methods
Focus group discussions (FGD) and Key Informant Interviews (KII) were carried out in 4 high volume tertiary care institutions that offer HIV care and treatment in Nigeria. FGD and KII assessed participants’ knowledge of cancer, attitudes towards cancer risk and cancer screening practices.
Results
The mean age (SD) of the FGD participants was 38 (2.8) years. Most participants had heard about cancer and considered it a fatal disease but displayed poor knowledge of the causes of cancer in general and of AIDs associated cancers in particular. PLHIV in Nigeria expressed fear, denial and disbelief about their perceived cancer risk. Some of the participants had heard about cancer screening but very few participants had ever been screened.
Conclusion
Our findings of poor knowledge of cancer among PLHIV in Nigeria indicate the need for health care providers and the government to intervene by developing primary cancer prevention strategies for this population.
doi:10.1186/1750-9378-7-28
PMCID: PMC3527187  PMID: 23098099
Knowledge; Attitudes; Practices (KAP); People living with HIV (PLHIV); HIV-associated cancers; Cancer screening

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