Objective

To describe and compare the health status, emotional wellbeing, and functional status of older people in Uganda and South Africa who are HIV infected or affected by HIV in their families.

Methods

Data came from the general population cohort and Entebbe cohort of the Medical Research Council/Uganda Virus Research Institute, and from the Africa Centre Demographic Information System through cross-sectional surveys in 2009/10 using instruments adapted from the World Health Organization (WHO) Study on Global Ageing and adult health (SAGE). Analysis was based on 932 people aged 50 years or older (510 Uganda, 422 South Africa).

Results

Participants in South Africa were slightly younger (median age − 60 years in South Africa, 63 in Uganda), and more were currently married, had no formal education, were not working, and were residing in a rural area. Adjusting for socio-demographic factors, older people in South Africa were significantly less likely to have good functional ability [adjusted odds ratio (aOR) 0.72, 95% CI 0.53–0.98] than those in Uganda, but were more likely to be in good subjective wellbeing (aOR 2.15, 95% CI 1.60–2.90). South Africans were more likely to be obese (aOR 5.26, 95% CI 3.46–8.00) or to be diagnosed with hypertension (aOR 2.77, 95% CI 2.06–3.73).

Discussion and conclusions

While older people’s health problems are similar in the two countries, marked socio-demographic differences influence the extent to which older people are affected by poorer health. It is therefore imperative when designing policies to improve the health and wellbeing of older people in sub-Saharan Africa that the region is not treated as a homogenous entity.

Objectives

To describe predictors of pregnancy and changes in pregnancy incidence among HIV-positive women accessing HIV clinical care.

Methods

Data were obtained through the linkage of two separate studies; the UK Collaborative HIV Cohort study (UK CHIC), a cohort of adults attending 13 large HIV clinics, and the National Study of HIV in Pregnancy and Childhood (NSHPC), a national surveillance study of HIV-positive pregnant women. Pregnancy incidence was measured using the proportion of women in UK CHIC with a pregnancy reported to NSHPC. Generalised estimating equations were used to identify predictors of pregnancy and assess changes in pregnancy incidence in 2000-2009.

Results

The number of women accessing care at UK CHIC sites increased as did the number of pregnancies (from 72 to 230). Older women were less likely to have a pregnancy (adjusted Relative Rate (aRR) 0.44 per 10 year increment in age [95% CI [0.41-0.46], p<0.001) as were women with CD4<200 cells/mm3 compared with CD4 200-350 cells/mm3 (aRR 0.65 [0.55-0.77] p<0.001) and women of white ethnicity compared with women of black-African ethnicity (aRR 0.67 [0.57-0.80], p<0.001). The likelihood that women had a pregnancy increased over the study period (aRR 1.05 [1.03-1.07], p<0.001). The rate of change did not significantly differ according to age group, ART use, CD4 group or ethnicity.

Conclusions

The pregnancy rate among women accessing HIV clinical care increased in 2000-2009. HIV-positive women with, or planning, a pregnancy require a high level of care and this is likely to continue and increase as more women of older age have pregnancies.

In the context of low rates of participation in a prospective, population-based HIV surveillance programme, researchers at a surveillance site in rural KwaZulu-Natal, South Africa, conducted an operational study from January 2009 to February 2010, with the aim of improving participation rates, particularly in the provision of dried blood spots for the surveillance. Findings suggest, firstly, that consent to participation in the HIV surveillance is informed by the dynamics of relationality in the HIV surveillance “consent encounter.”

Secondly, it emerged that both fieldworkers and participants found it difficult to differentiate between HIV surveillance and HIV testing in the surveillance procedure, and tended to understand and explain giving blood under the aegis of the surveillance as an HIV test. The conflation of surveillance and testing, we argue, is not merely a semantic confusion, but reveals an important tension inherent to global health research between individual risks and benefits and collective good, or between private morality and public good. Because of these structural tensions, we suggest, the HIV surveillance consent encounter activates multiple gift economies in the collection of blood samples. Thinking beyond the complex ethical dimensions provoked by new forms of long-term surveillance and health research, we therefore suggest that deepening relations between scientists, fieldworkers, and study participants in locality deserve more careful methodological consideration and descriptive attention.

Highlights

► Consent and refusal to HIV surveillance take place in the context of everyday social relations and local exchange economies. ► Local notions of gift and relatedness and rights and obligations frame exchanges of blood for knowledge in HIV surveillance. ► Participants struggled to differentiate HIV surveillance from testing, thereby blurring concepts of risk and benefit. ► Surveillance programs should engage with local constructions of risk, benefit and relatedness in research design.

Background

Although access to life-saving treatment for patients infected with HIV in South Africa has improved substantially since 2004, treating all eligible patients (universal access) remains elusive. As the prices of antiretroviral drugs have dropped over the past years, availability of human resources may now be the most important barrier to achieving universal access to HIV treatment in Africa. We quantify the number of HIV health workers (HHWs) required to be added to the current HIV workforce to achieve universal access to HIV treatment in South Africa, under different eligibility criteria.

Methods

We performed a time and motion study in three HIV clinics in a rural, primary care-based HIV treatment program in KwaZulu-Natal, South Africa, to estimate the average time per patient visit for doctors, nurses, and counselors. We estimated the additional number of HHWs needed to achieve universal access to HIV treatment within one year.

Results

For universal access to HIV treatment for all patients with a CD4 cell count of ≤350 cells/μl, an additional 2,200 nurses, 3,800 counselors, and 300 doctors would be required, at additional annual salary cost of 929 million South African rand (ZAR), equivalent to US$ 141 million. For universal treatment (‘treatment as prevention’), an additional 6,000 nurses, 11,000 counselors, and 800 doctors would be required, at an additional annual salary cost of ZAR 2.6 billion (US$ 400 million).

Conclusions

Universal access to HIV treatment for patients with a CD4 cell count of ≤350 cells/μl in South Africa may be affordable, but the number of HHWs available for HIV treatment will need to be substantially increased. Treatment as prevention strategies will require considerable additional financial and human resources commitments.

Hypertension and excess body weight are major risk factors of cardiovascular morbidity and mortality in developing countries. In countries with a high HIV prevalence, it is unknown how increased antiretroviral treatment and care (ART) coverage has affected the prevalence of overweight, obesity, and hypertension. We conducted a health survey in 2010 based on the WHO STEPwise approach in 14,198 adult resident participants of a demographic surveillance area in rural South Africa to investigate factors associated with hypertension and excess weight including HIV infection and ART status. Women had a significantly higher median body mass index (BMI) than men (26.4 vs. 21.2 kg/m2, p<0.001). The prevalence of obesity (BMI≥30 kg/m2) in women (31.3%, 95% confidence interval (CI) 30.2–32.4) was 6.5 times higher than in men (4.9%, 95% CI 4.1–5.7), whereas prevalence of hypertension (systolic or diastolic blood pressure≥140 or 90 mm Hg, respectively) was 1.4 times higher in women than in men (28.5% vs 20.8%, p<0.001). In multivariable regression analysis, both hypertension and obesity were significantly associated with sex, age, HIV and ART status. The BMI of women and men on ART was on average 3.8 (95% CI 3.2–3.8) and 1.7 (95% CI 0.9–2.5) kg/m2 lower than of HIV-negative women and men, respectively. The BMI of HIV-infected women and men not on ART was on average 1.2 (95% CI 0.8–1.6) and 0.4 (95% CI -0.1–0.9) kg/m2 lower than of HIV-negative women and men, respectively. Obesity was a bigger risk factor for hypertension in men (adjusted odds ratio (aOR) 2.99, 95% CI 2.00–4.48) than in women (aOR 1.64, 95% CI 1.39–1.92) and overweight (25≤BMI<30) was a significant risk factor for men only (aOR 1.53 95% CI 1.14–2.06). Our study suggests that, cardiovascular risk factors of hypertension and obesity differ substantially between women and men in rural South Africa.

Background

The prevention of mother-to-child transmission (PMTCT) of HIV has been focused mainly on women who are HIV-positive at their first antenatal visit, but there is uncertainty regarding the contribution to overall transmission from mothers who seroconvert after their first antenatal visit and before weaning.

Method

A mathematical model was developed to simulate changes in mother-to-child transmission of HIV over time, in South Africa. The model allows for changes in infant feeding practices as infants age, temporal changes in the provision of antiretroviral prophylaxis and counselling on infant feeding, as well as temporal changes in maternal HIV prevalence and incidence.

Results

The proportion of MTCT from mothers who seroconverted after their first antenatal visit was 26% (95% CI: 22-30%) in 2008, or 15 000 out of 57 000 infections. It is estimated that by 2014, total MTCT will reduce to 39 000 per annum, and transmission from mothers seroconverting after their first antenatal visit will reduce to 13 000 per annum, accounting for 34% (95% CI: 29-39%) of MTCT. If maternal HIV incidence during late pregnancy and breastfeeding were reduced by 50% after 2010, and HIV screening were repeated in late pregnancy and at 6-week immunization visits after 2010, the average annual number of MTCT cases over the 2010-15 period would reduce by 28% (95% CI: 25-31%), from 39 000 to 28 000 per annum.

Conclusion

Maternal seroconversion during late pregnancy and breastfeeding contributes significantly to the paediatric HIV burden, and needs greater attention in the planning of PMTCT programmes.

Background

Despite the introduction of blood donor screening, worldwide, children continue to become infected with HCV via un-sterile medical injections, receipt of unscreened blood and isolated hospital contamination outbreaks. It is plausible that the natural history and disease progression in these children might differ from that of their vertically infected counterparts.

Materials and Methods

Vertically and parenterally HCV infected children were prospectively followed within the European Paediatric HCV Network and the UK National HCV Register respectively. Biological profiles were compared.

Results

Vertically and parenterally HCV infected children differed in terms of some key characteristics including the male:female ratio and the proportion of children receiving therapy. Parenterally infected children were more likely to have at least one hepatomegaly event during follow-up, 20% vs. 10%. Parenteral infection did not significantly affect the odds of being consistently viraemic, AOR 1.14 p=0.703 and there was no significant difference in the odds of having consistently elevated ALT levels and mode of acquisition, AOR 0.83 p=0.748. The proportion of children with 2 or more markers of HCV infection did not differ significantly by mode of acquisition, χ21.13 p=0.288.

Conclusions

This analysis does not support substantial differences between vertically and parenterally infected groups but there are specific mechanisms identified requiring further investigation. Given the continued parenteral infection of children worldwide it is vital that knowledge of disease progression in this group is accurate and that the differences in comparison to vertically infected children are clarified to inform more accurate and individualised clinical management.

This article presents a detailed description of a community mobilization intervention involving women’s groups in Mchinji District, Malawi. The intervention was implemented between 2005 and 2010.

The intervention aims to build the capacities of communities to take control of the mother and child health issues that affect them. To achieve this it comprises trained local female facilitators establishing groups and using a manual, participatory rural appraisal tools and picture cards to guide them through a community action cycle to identify and implement solutions to mother and child health problems. Significant resource inputs include salaries for facilitators and supervisors, and training, equipment and materials to support their work with groups.

It is hypothesized that the groups will catalyse community collective action to address mother and child health issues and improve the health and reduce the mortality of mothers and children. Their impact, implementation and cost-effectiveness have been rigorously evaluated through a randomized controlled trial design. The results of these evaluations will be reported in 2011.

Background

Maternal and child survival are highly correlated, but the contribution of HIV infection on this relationship, and in particular the impact of HIV treatment has not been quantified. We estimate the association between maternal HIV and treatment and under-5 child mortality in a rural population in South Africa.

Methods

All children born between January 2000-January 2007 in the Africa Centre Demographic Surveillance Area were included. Maternal HIV status information was available from HIV surveillance; maternal antiretroviral treatment (ART) from the HIV Treatment Programme database and linked to surveillance data. Mortality rates were computed as deaths per 1000 person-years observed. Time-varying maternal HIV effect (positive, negative, ART) on U5MR was assessed in Cox regression, adjusting for other factors associated with under-5 mortality.

Results

9,068 mothers delivered 12,052 children, of whom 947 (7.9%) died before age 5. Infant mortality rate (IMR) declined by 49% from 69.0 in 2000 to 35.5 in 2006 deaths per 1000 person-years observed; a significantly decline was observed post-ART (2004-2006). The estimated proportion of deaths across all age groups were higher among the children born to the HIV-positive and HIV-not reported status women than among children of HIV-negative women. Multivariably, mortality in children of mothers on ART was not significantly different from children of HIV-negative mothers (aHR 1.29, 0.53-3.17; p=0.572).

Conclusions

These findings highlight the importance of maternal HIV treatment with direct benefits of improved survival among all children under-5. Timely HIV treatment for eligible women is required to benefit both mothers and children.

Objectives

To describe antiretroviral therapy (ART) use and clinical status, at start of and during pregnancy, for HIV-positive women receiving ART at conception, including the proportion conceiving on drugs (efavirenz and didanosine) not recommended for use in early pregnancy.

Methods

Women with a pregnancy resulting in a live birth after 1995 (n=1,537) were identified in an observational cohort of patients receiving HIV care at 12 clinics in the UK by matching records with national pregnancy study data. Treatment and clinical data were analysed for 375 women conceiving on ART, including logistic regression to identify factors associated with changing regimen during pregnancy.

Results

Of the 375 women on ART at conception, 39 (10%) conceived on dual therapy, 306 (82%) on triple therapy and 30 (8%) on >3 drugs. In total, 116 (31%) women conceived on a regimen containing efavirenz or didanosine (69 efavirenz, 54 didanosine, 7 both). Overall, 38% (143) switched regimen during pregnancy, of whom 41% (n=48) had a detectable viral load (≥50 copies/ml) around that time. Detectable viral load was associated with increased risk of regimen change (adjusted odds ratio 2.2, 95% confidence interval [1.3, 3.8]), while women on efavirenz at conception were three times more likely to switch than women on other drugs (3.3, [1.8, 6.0]). Regimen switching was also associated with calendar year at conception (0.9, [0.8-1.0]).

Conclusions

These findings reinforce the need for careful consideration of ART use among women planning or likely to have a pregnancy in order to reduce viral load before pregnancy and avoid drugs not recommended for early antenatal use.

BACKGROUND

The only successful HIV vaccine trial to date is the RV144 trial of the ALVAC/AIDSVAX vaccine in Thailand, which showed an overall incidence reduction of 31%. Most cases were prevented in the first year, suggesting a rapidly waning efficacy. Here, we predict the population level impact and cost-effectiveness of practical implementation of such a vaccine in a setting of a generalised epidemic with high HIV prevalence and incidence.

METHODS

We used STDSIM, an established individual-based microsimulation model, tailored to a rural South African area with a well-functioning HIV treatment and care programme. We estimated the impact of a single round of mass vaccination for everybody aged 15–49, as well as 5-year and 2-year revaccination strategies for young adults (aged 15–29). We calculated proportion of new infections prevented, cost-effectiveness indicators, and budget impact estimates of combined ART and vaccination programmes.

RESULTS

A single round of mass vaccination with a RV144-like vaccine will have a limited impact, preventing only 9% or 5% of new infections after 10 years at 60% and 30% coverage levels, respectively. Revaccination strategies are highly cost-effective if vaccine prices can be kept below 150 US$/vaccine for 2-year revaccination strategies, and below 200 US$/vaccine for 5-year revaccination strategies. Net cost-savings through reduced need for HIV treatment and care occur when vaccine prices are kept below 75 US$/vaccine. These results are sensitive to alternative assumptions on the underlying sexual network, background prevention interventions, and individual’s propensity and consistency to participate in the vaccination campaign.

DISCUSSION

A modestly effective vaccine can be a cost-effective intervention in highly endemic settings. To predict the impact of vaccination strategies in other endemic situations, sufficient knowledge of the underlying sexual network, prevention and treatment interventions, and individual propensity and consistency to participate, is key. These issues are all best addressed in an individual-based microsimulation model.

Background

The UK Collaborative HIV Cohort (UK CHIC) is an observational study that collates data on HIV-positive adults accessing HIV clinical care at (currently) 13 large clinics in the UK but does not collect pregnancy specific data. The National Study of HIV in Pregnancy and Childhood (NSHPC) collates data on HIV-positive women receiving antenatal care from every maternity unit in the UK and Ireland. Both studies collate pseudonymised data and neither dataset contains unique patient identifiers. A methodology was developed to find and match records for women reported to both studies thereby obtaining clinical and treatment data on pregnant HIV-positive women not available from either dataset alone.

Results

Women in UK CHIC receiving HIV-clinical care in 1996–2009, were found in the NSHPC dataset by initially ‘linking’ records with identical date-of-birth, linked records were then accepted as a genuine ‘match’, if they had further matching fields including CD4 test date. In total, 2063 women were found in both datasets, representing 23.1% of HIV-positive women with a pregnancy in the UK (n = 8932). Clinical data was available in UK CHIC following most pregnancies (92.0%, 2471/2685 pregnancies starting before 2009). There was bias towards matching women with repeat pregnancies (35.9% (741/2063) of women found in both datasets had a repeat pregnancy compared to 21.9% (1502/6869) of women in NSHPC only) and matching women HIV diagnosed before their first reported pregnancy (54.8% (1131/2063) compared to 47.7% (3278/6869), respectively).

Conclusions

Through the use of demographic data and clinical dates, records from two independent studies were successfully matched, providing data not available from either study alone.

Breast-feeding substantially increases the risk of HIV-1 transmission from mother to child, and although peripartum antiretroviral therapy prophylaxis significantly decreases the risk of mother-to-child transmission around the time of delivery, this approach does not affect breast-feeding transmission. Increased maternal RNA viral load in plasma and breast milk is strongly associated with increased risk of transmission through breast-feeding, as is breast health, and it has been suggested that exclusive breast-feeding could be associated with lower rates of breast-feeding transmission than mixed feeding of both breast- and other milk or feeds. Transmission through breast-feeding can take place at any point during lactation, and the cumulative probability of acquisition of infection increases with duration of breast-feeding. HIV-1 has been detected in breast milk in cell-free and cellular compartments; infant gut mucosal surfaces are the most likely site at which transmission occurs. Innate and acquired immune factors may act most effectively in combination to prevent primary HIV-1 infection by breast milk.

Abstract

HIV-1 transmitted drug resistance (TDR) could reverse the gains of antiretroviral rollout. To ensure that current first-line therapies remain effective, TDR levels in recently infected treatment-naive patients need to be monitored. A literature review and data mining exercise was carried out to determine the temporal trends in TDR in South Africa. In addition, 72 sequences from seroconvertors identified from Africa Centre's 2010 HIV surveillance round were also examined for TDR. Publicly available data on TDR were retrieved from GenBank, curated in RegaDB, and analyzed using the Calibrated Population Resistance Program. There was no evidence of TDR from the 2010 rural KwaZulu Natal samples. Ten datasets with a total of 1618 sequences collected between 2000 and 2010 were pooled to provide a temporal analysis of TDR. The year with the highest TDR rate was 2002 [6.67%, 95% confidence interval (CI): 3.09–13.79%; n=6/90]. After 2002, TDR levels returned to <5% (WHO low-level threshold) and showed no statistically significant increase in the interval between 2002 and 2010. The most common mutations were associated with NNRTI resistance, K103N, followed by Y181C and Y188C/L. Five sequences had multiple resistance mutations associated with NNRTI resistance. There is no evidence of TDR in rural KwaZulu-Natal. TDR levels in South Africa have remained low following a downward trend since 2003. Continuous vigilance in monitoring of TDR is needed as more patients are initiated and maintained onto antiretroviral therapy.

Background Previously, HIV epidemic models have used a double Weibull curve to represent high initial and late mortality of HIV-infected children, without distinguishing timing of infection (peri- or post-natally). With more data on timing of infection, which may be associated with disease progression, a separate representation of children infected early and late was proposed.

Methods Paediatric survival post-HIV infection without anti-retroviral treatment was calculated using pooled data from 12 studies with known timing of HIV infection. Children were grouped into perinatally or post-natally infected. Net mortality was calculated using cause-deleted life tables to give survival as if HIV was the only competing cause of death. To extend the curve beyond the available data, children surviving beyond 2.5 years post infection were assumed to have the same survival as young adults. Double Weibull curves were fitted to both extended survival curves to represent survival of children infected perinatally or through breastfeeding.

Results Those children infected perinatally had a much higher risk of dying than those infected through breastfeeding, even allowing for background mortality. The final-fitted double Weibull curves gave 75% survival at 5 months after infection for perinatally infected, and 1.1 years for post-natally infected children. An estimated 25% of the early infected children would still be alive at 10.6 years compared with 16.9 years for those infected through breastfeeding.

Conclusions The increase in available data has enabled separation of child mortality patterns by timing of infection allowing improvement and more flexibility in modelling of paediatric HIV infection and survival.

BACKGROUND

 Human immunodeficiency virus (HIV) is prevalent in many countries where small-for-gestational age (SGA) and premature delivery are also common. However, the associations between maternal HIV, preterm delivery and SGA infants remain unclear. We estimate the prevalence of SGA and preterm (<37 weeks) births, their associations with antenatal maternal HIV infection and their contribution to infant mortality, in a high HIV prevalent, rural area in South Africa.

METHODS

Data were collected, in a non-randomized intervention cohort study, on all women attending antenatal clinics (2001–2004), before the availability of antiretroviral treatment. Newborns were weighed and gestational age was determined (based on last menstrual period plus midwife assessment antenatally). Poisson regression with robust variance assessed risk factors for preterm and SGA birth, while Cox regression assessed infant mortality and associated factors.

RESULTS

Of 2368 live born singletons, 16.6% were SGA and 21.4% were preterm. HIV-infected women (n= 1189) more commonly had SGA infants than uninfected women (18.1 versus 15.1%; P = 0.051), but percentages preterm were similar (21.8 versus 20.9%; P = 0.621). After adjustment for water source, delivery place, parity and maternal height, the SGA risk in HIV-infected women was higher [adjusted relative risk (aRR) 1.28, 95% confidence interval (CI): 1.06–1.53], but the association between maternal HIV infection and preterm delivery remained weak and not significant (aRR: 1.07, 95% CI: 0.91–1.26). In multivariable analyses, mortality under 1 year of age was significantly higher in SGA and severely SGA than in appropriate-for-gestational-age infants [adjusted hazard ratio (aHR): 2.12, 95% CI: 1.18–3.81 and 2.77, 95% CI: 1.56–4.91], but no difference in infant mortality was observed between the preterm and term infants (aHR: 1.18 95% CI: 0.79–1.79 for 34–36 weeks and 1.31, 95% CI: 0.58–2.94 for <34 weeks).

CONCLUSIONS

Maternal HIV infection increases the risk of SGA, but not preterm births, in this cohort.

Healthcare and social needs for mature adults aged 50 years or older differ from those of younger adults due to stigma concerning HIV in older people, beliefs that engagement in sexual activity no longer applies, age driven comorbidities and responses to antiretroviral treatment, which complicate HIV diagnosis and management. In the face of a growing HIV epidemic in mature adults, mostly due to infected people aging with HIV, but also due to new infections in this age group, HIV services, which mostly cater for HIV in young adults and children, and HIV education messages and interventions, which mainly target young adults, leave the mature adult exposed and vulnerable to HIV transmission and to a lack of care and treatment thereafter.

Background

Although the prevalence of depression is similar in pregnant, postpartum and non-pregnant women, the onset of new depression is higher during the perinatal period. Women of low-income, and those living in low and middle income countries, are known to be at particularly high risk. Early identification and treatment of antenatal depression may improve pregnancy outcomes and could serve as an early indicator of postnatal depression. Culturally sensitive and accurate diagnostic tools are urgently needed.

Methods

A consecutive series of 109 pregnant women were recruited in the third trimester at a primary health clinic, in a rural part of South Africa, with a high HIV prevalence. A cross sectional assessment of depression was completed using a structured clinical interview method and DSM-IV diagnostic criteria. Qualitative data on women's descriptions of depressive symptoms was also collected. The aim was to examine the prevalence of depression and to better understand the presentation of depressive symptomatology in this population.

Results

Prevalence of depression was high, 51/109 (47%), with over half of the depressed women 34/51(67%) reporting episode duration greater than two months. 8/51 reported a prior history of depression. Women used psychological language to describe symptoms and, as a result, standardised diagnostic tools were culturally sensitive. Somatic pregnancy symptoms were frequently reported, but did not overestimate depression. Both HIV positive (27/51) and HIV negative (24/51) women were at risk of being depressed.

Limitations

The study is limited by the small sample size and possible attrition biases.

Conclusion

Antenatal depression is high and clinical presentation is similar to high income countries. Standardised diagnostic tools are culturally sensitive and adequate for early detection.

The limitations of existing tuberculosis diagnostic tools are significantly hampering tuberculosis control efforts, most noticeably in areas with high prevalence of human immunodeficiency virus (HIV) infection and antituberculosis drug resistance. However, renewed global interest in tuberculosis research has begun to bear fruit, with several new diagnostic technologies progressing through the development pipeline. There are significant challenges in building a sound evidence base to inform public health policies because most diagnostic research focuses on the accuracy of individual tests, with often significant limitations in the design, conduct, and reporting of diagnostic accuracy studies. Diagnostic accuracy studies may not be appropriate to guide public health policies, and clinical trials may increasingly be required to determine the incremental value and cost-effectiveness of new tools. The urgent need for new diagnostics should not distract from pursuing rigorous scientific evaluation focused on public health impact.

This article provides a summary of emerging psychosocial evidence relevant to the success of comprehensive family-centered approaches to HIV prevention, treatment, care and support programs in poorly resourced settings. This report synthesizes current evidence on maternal, paternal and family experiences of HIV prevention, diagnosis, treatment, adherence and disclosure, with special focus on HIV-infected mothers and HIV-exposed children. Taking a developmental approach, we explore the current challenges and opportunities towards a family-centered approach within the continuum of HIV treatment and care, beginning in pregnancy and following the course of childhood. The discussion is limited to early and middle childhood and excludes discussion of special issues emergent in adolescence, which would warrant discussion outside the scope of this article. Attention is drawn to the complexity of problems arising within the family context and the need for improvements in the integration of aspects of treatment, care and support. While this article focuses on examples from sub-Saharan Africa, the lessons learnt and future challenges outlined are applicable to most low- and middle-income countries, and to poorly resourced contexts in higher-income countries.

Objectives

To determine retention in HIV care for individuals not yet eligible for antiretroviral therapy (ART) and to explore factors associated with retention in a rural public health HIV programme.

Methods

HIV-infected adults (≥16 years) not yet eligible for ART, with CD4 cell count >200cells/μl January 2007 - December 2007 were included in the analysis. Retention was defined by repeat CD4 count within 13 months. Factors associated with retention were assessed using logistic regression with clustering at clinic level.

Results

4,223 were included in the analysis (83.9% female). Overall retention was 44.9% with median time to return 201 days (interquartile range [IQR] 127-274). Retention by initial CD4 count 201-350, 351-500, and >500 cells/μl was 51.6% (95% confidence interval [CI] 49.1-54.0), 43.2% (95% CI 40.5-45.9), and 34.9% (95% CI 32.4-37.4) respectively. Compared to CD4 201-350 cells/μl, higher initial CD4 count was significantly associated with lower odds of retention (CD4 351-500 cells/μl adjusted odds ratio [aOR] 0.72, 95% CI 0.62-0.84; CD4 >500 cells/μl aOR 0.51, 95% CI 0.44-0.60). Male sex was independently associated with lower odds (aOR 0.80, 95% CI 0.67-0.96), and older age with higher odds of retention (for each additional year of age aOR 1.03, 95% CI 1.03-1.04).

Conclusions

Retention in HIV care prior to eligibility for ART is poor, particularly for younger individuals and those at an earlier stage of infection. Further work to optimise and evaluate care and monitoring strategies is required to realise the full benefits of the rapid expansion of HIV programmes in sub-Saharan Africa.

Background

The advent of the HIV pandemic and the more recent prevention and therapeutic interventions have resulted in extensive and rapid changes in cause-specific mortality rates in sub-Saharan Africa, and there is demand for timely and accurate cause-specific mortality data to steer public health responses and to evaluate the outcome of interventions. The objective of this study is to describe cause-specific mortality trends based on verbal autopsies conducted on all deaths in a rural population in KwaZulu-Natal, South Africa, over a 10-year period (2000-2009).

Methods

The study used population-based mortality data collected by a demographic surveillance system on all resident and nonresident members of 12,000 households. Cause of death was determined by verbal autopsy based on the standard INDEPTH/WHO verbal autopsy questionnaire. Cause of death was assigned by physician review and the Bayesian-based InterVA program.

Results

There were 11,281 deaths over 784,274 person-years of observation of 125,658 individuals between Jan. 1, 2000 and Dec. 31, 2009. The cause-specific mortality fractions (CSMF) for the population as a whole were: HIV-related (including tuberculosis), 50%; other communicable diseases, 6%; noncommunicable lifestyle-related conditions, 15%; other noncommunicable diseases, 2%; maternal, perinatal, nutritional, and congenital causes, 1%; injury, 8%; indeterminate causes, 18%. Over the course of the 10 years of observation, the CSMF of HIV-related causes declined from a high of 56% in 2002 to a low of 39% in 2009 with the largest decline starting in 2004 following the introduction of an antiretroviral treatment program into the population. The all-cause age-standardized mortality rate (SMR) declined over the same period from a high of 174 (95% confidence interval [CI]: 165, 183) deaths per 10,000 person-years observed (PYO) in 2003 to a low of 116 (95% CI: 109, 123) in 2009. The decline in the SMR is predominantly due to a decline in the HIV-related SMR, which declined in the same period from 96 (95% CI: 89, 102) to 45 (95% CI: 40, 49) deaths per 10,000 PYO.

There was substantial agreement (79% kappa = 0.68 (95% CI: 0.67, 0.69)) between physician coding and InterVA coding at the burden of disease group level.

Conclusions

Verbal autopsy based methods enabled the timely measurement of changing trends in cause-specific mortality to provide policymakers with the much-needed information to allocate resources to appropriate health interventions.

Background

Since November 2009, WHO recommends that adults infected with HIV should initiate antiretroviral therapy (ART) at CD4+ cell counts of ≤350 cells/µl rather than ≤200 cells/µl. South Africa decided to adopt this strategy for pregnant and TB co-infected patients only. We estimated the impact of fully adopting the new WHO guidelines on HIV epidemic dynamics and associated costs.

Methods and Finding

We used an established model of the transmission and control of HIV in specified sexual networks and healthcare settings. We quantified the model to represent Hlabisa subdistrict, KwaZulu-Natal, South Africa. We predicted the HIV epidemic dynamics, number on ART and program costs under the new guidelines relative to treating patients at ≤200 cells/µl for the next 30 years. During the first five years, the new WHO treatment guidelines require about 7% extra annual investments, whereas 28% more patients receive treatment. Furthermore, there will be a more profound impact on HIV incidence, leading to relatively less annual costs after seven years. The resulting cumulative net costs reach a break-even point after on average 16 years.

Conclusions

Our study strengthens the WHO recommendation of starting ART at ≤350 cells/µl for all HIV-infected patients. Apart from the benefits associated with many life-years saved, a modest frontloading appears to lead to net savings within a limited time-horizon. This finding is robust to alternative assumptions and foreseeable changes in ART prices and effectiveness. Therefore, South Africa should aim at rapidly expanding its healthcare infrastructure to fully embrace the new WHO guidelines.

Summary

Background

Concurrent sexual partnerships are widely believed to be one of the main drivers of the HIV epidemic in sub-Saharan Africa. This view is supported by theoretical models predicting that increases in prevalence of concurrent partnerships could substantially increase the rate of spread of the disease. However, the effect of concurrent partnerships on HIV incidence has not been appropriately tested in a sub-Saharan African setting.

Methods

For this population-based cohort study, we used data from the Africa Centre demographic surveillance site in KwaZulu-Natal, South Africa, to try to find support for the concurrency hypothesis. We used a moving-window approach to construct estimates of the geographical variation in reported concurrent and lifetime partners in sexually active men aged 15–55 years (n=2153) across the study area. We then followed up 7284 HIV-negative women (≥15 years of age) in the population and quantified the effect of the sexual behaviour profiles of men in the surrounding local community on a woman's hazard of HIV acquisition.

Findings

During 5 years' follow-up, 693 new female HIV infections occurred (incidence 3·60 cases per 100 person-years). We identified substantial intercommunity heterogeneity in the estimated point-prevalence of partnership concurrency (range 4·0–76·3%; mean 31·5%) and mean number of lifetime sexual partners (3·4–12·9; mean 6·3) in sexually active men in this population. After adjustment for individual-level sexual behaviour and demographic, socioeconomic, and environmental factors associated with HIV acquisition, mean lifetime number of partners of men in the immediate local community was predictive of hazard of HIV acquisition in women (adjusted hazard ratio [HR] 1·08, 95% CI 1·03–1·14, p=0·004), whereas a high prevalence of partnership concurrency in the same local community was not associated with any increase in risk of HIV acquisition (adjusted HR 1·02, 95% CI 0·95–1·09, p=0·556).

Interpretation

We find no evidence to suggest that concurrent partnerships are an important driver of HIV incidence in this typical high-prevalence rural African population. Our findings suggest that in similar hyperendemic sub-Saharan African settings, there is a need for straightforward, unambiguous messages aimed at the reduction of multiple partnerships, irrespective of whether those partnerships overlap in time.

Funding

US National Institute of Child Health and Human Development; Wellcome Trust.