Marcel Yotebieng

The Effect of Highly Active Antiretroviral Therapy on the Survival of HIV-Infected Children in a Resource-Deprived Setting: A Cohort Study

This observational cohort study by Andrew Edmonds and colleagues reports that treatment with highly active antiretroviral therapy (HAART) markedly improves the survival of HIV-infected children in Kinshasa, DRC, a resource-deprived setting.

Antiretroviral Therapy Responses among Children Attending a Large Public Clinic in Soweto, South Africa

Background: Antiretroviral therapy (ART) access with successful outcomes for children is expanding in resource-limited countries. The aim of this study was to determine treatment responses of children in a routine setting where first-line therapy with lopinavir/ritonavir is routinely included for young children. Methods: Outpatient records of children who initiated ART between April 2004 and March 2008 at a government clinic in Soweto were reviewed. Children <3 years initiated ART with lopinavir/ritonavir and those ≥3 years initiated with efavirenz-containing regimens. Results: ART was initiated at a median age of 4.3 years, 28.6% also received tuberculosis treatment. During 3155 child-years of follow-up (median follow-up 17 months), 132 children (6%) died giving a mortality rate of 4.2 (95% confidence interval: 3.5, 5.0) deaths per 100 child-years. By 12 and 24 months, 84% and 96% of children achieved virologic suppression. The proportion of children with viral rebound increased from 5.4% to 16.3% at 24 and 36 months from start of ART. Younger children (receiving lopinavir/ritonavir-based first-line therapy) with higher viral loads suppressed more slowly and were more likely to die. Children who were started on treatment for tuberculosis at the time of viral suppression were more likely to have virologic rebound. Conclusion: Despite good treatment outcomes overall, children with advanced disease at ART initiation had poorer outcomes, particularly those <3 years of age, most of whom were treated with lopinavir/ritonavir-containing therapy. The increasing risk of viral rebound over time for the whole cohort is concerning, given currently limited available treatment options for children.

Effect on mortality and virological response of delaying antiretroviral therapy initiation in children receiving tuberculosis treatment.

Objective:To estimate the effect of delaying antiretroviral treatment (ART) for 15, 30, or 60 days after tuberculosis (TB) treatment initiation on mortality and virological suppression. Design:Cohort of 573 ART-naive HIV-infected children initiated on TB treatment at an outpatient clinic in South Africa between April 2004 and March 2008. Methods:Hazard ratios for mortality and viral suppression were estimated using marginal structural models and multivariate Cox models, respectively. Results:During follow-up (median 9.64 months), 37 HIV-infected children died after a median of 62 days of TB treatment. ART was initiated in 461 children at a median of 17 days after TB treatment initiation, 415 (90%) achieved viral suppression. The hazard ratios of death for initiating ART more than 15, more than 30, or more than 60 days of TB treatment compared with initiating within 15, 30 and 60 days, respectively, were 0.82 (95% CI: 0.48, 1.41), 0.86 (95% CI: 0.46, 1.60), and 1.32 (95% CI: 0.55, 3.16). Hazard ratios for analysis restricted to severely immunosuppressed children were: 0.92 (95% CI: 0.51, 1.63), 1.08 (95% CI: 0.56, 2.08), and 2.23 (95% CI: 0.85, 5.80), respectively. Hazard ratios for viral suppression were 0.98 (95% CI: 0.76, 1.26), 0.95, (95% CI: 0.73, 1.23), 0.84 (95% CI: 0.61, 1.15), respectively and did not change with restriction to children severely immunosuppressed. Conclusion:In this observational study, we found that delaying ART for 2 months or more in children diagnosed with TB may be associated with poorer virological response and increased mortality, particularly in children with severe immunosuppression. These findings should be confirmed in a randomized controlled trial.

Ten Steps to Successful Breastfeeding programme to promote early initiation and exclusive breastfeeding in DR Congo: a cluster-randomised controlled trial

BACKGROUND Optimisation of breastfeeding practices could reduce high mortality rates in children younger than 5 years, but in DR Congo, despite near-universal breastfeeding initiation and nine of ten children still breastfeeding at 1 year of age, exclusivity remains a difficulty. We assessed the effect on breastfeeding outcomes of a short-cut implementation of a programme called the Ten Steps to Successful Breastfeeding, the key component of the Baby-Friendly Hospital Initiative (BFHI). METHODS We did a cluster-randomised controlled trial and randomly assigned health-care clinics in Kinshasa, DR Congo, to standard care (control group), BFHI steps 1-9 (steps 1-9 group), or BFHI steps 1-9 plus additional support during well-child visits (steps 1-10 group) with computer-generated random numbers used to assign matched pairs to study groups. Mothers at these clinics who had given birth to one healthy baby during enrolment, and who expressed their intentions of visiting a well-baby session at the same clinic, were eligible and received the treatment assigned to their clinic. Mother-infant pairs were excluded if the mothers intended to attend well-baby clinic visits at a different health facility, or to travel before the child was aged at least 6 months. Participants and independent interviewers were masked to group assignment (ie, they were recruited after randomisaion and training of the clinic staff and were not informed of the study scheme), but clinical staff were unmasked. BFHI steps 1-9 and 1-10 were given by health-care staff trained with the WHO/UNICEF BFHI course. The primary outcomes were breastfeeding initiation within 1 h of birth and exclusive breastfeeding at age 14 and 24 weeks, assessed at face-to-face interviews in the clinic. Analysis was by intention to treat. Prevalence ratios (PR) were adjusted for cluster effects and baseline characteristics. This trial is registered at ClinicalTrials.gov, number NCT01428232, and is closed to new participants. FINDINGS Between May 24, and Aug 25, 2012, we randomly assigned two eligible clinics to control, two to BFHI steps 1-9, and two to BFHI steps 1-10. We enrolled 975 eligible mother-infant pairs (304 in the control group, 363 in the steps 1-9 group, and 308 in the steps 1-10 group). 230 (76%) of infants in the control group, 263 (72%) in the steps 1-9 group, and 220 (71%) in the steps 1-10 group were breastfed within 1 h of birth; these results did not differ significantly between groups. Prevalence of exclusive breastfeeding at age 14 weeks was 89 (29%) in the control group, 237 (65%) in the steps 1-9 group (adjusted PR 2·20, 95% CI 1·73-2·77), and 129 (42%) in the steps 1-10 group (1·40, 1·13-1·74). At age 24 weeks, the prevalence of exclusive breastfeeding was 36 (12%) in the control group, 131 (36%) in the steps 1-9 group (3·50, 2·76-4·43), and 43 (14%) in the steps 1-10 group (1·31, 0·91-1·89). INTERPRETATION In the setting of health-care clinics in DR Congo with a high proportion of mothers initiating breastfeeding, implementation of basic training in BFHI steps 1-9 had no additional effect on initiation of breastfeeding but significantly increased exclusive breastfeeding at 6 months of age. Additional support based on the same training materials and locally available breastfeeding support materials, offered during well-child visits (ie, step 10) did not enhance this effect, and might have actually lessened it.

Correlates of condom use among sexually experienced secondary school male students in Nairobi, Kenya.

This study aimed to examine perceptual factors associated with condom use, and the relationship between condom use and the timing of sexual debut among male secondary school students in Nairobi, Kenya. Data are from the TeenWeb study, a school-based project that used the World Wide Web to assess the health needs of secondary school students, and tested the webs utility as a teaching and research modality. Analyses are based on 214 sexually experienced males aged 14 – 20 years who completed webbased questionnaires about their sexual attitudes and behaviour. Results indicate that students did not see themselves as susceptible to HIV/AIDS and believed condom effectiveness in preventing HIV to be low. Consequently, only a marginal association was found between agreeing that buying condoms is embarrassing and condom use at first sexual intercourse. However, contrary to expectation, agreeing that condoms often break (almost half of participants) was associated with a higher likelihood of condom use at first sex. Each year of delay in sexual debut increased the likelihood of using a condom at first sex by 1.44 times. In turn, having used a condom at first sex increased the likelihood of using one at the most recent sex by 4.81 times, and elevated general condom use (‘most or all the time’) by 8.76 times. Interventions to increase awareness about the role of condoms in preventing HIV, delay sexual initiation, and teach proper condom use among secondary-school students in Nairobi are needed.

Effect of consistent condom use on 6-month prevalence of bacterial vaginosis varies by baseline BV status.

Objectives  Bacterial vaginosis (BV) is a condition characterized by a disturbed vaginal ecosystem which fluctuates in response to extrinsic and intrinsic factors. BV recurrence is common. To explore whether consistent condom use was associated with BV occurrence or recurrence, we compared the effect of condom use on BV prevalence after 6 months, among women with and without BV at baseline.

Infant feeding practices and determinants of poor breastfeeding behavior in Kinshasa, Democratic Republic of Congo: a descriptive study

BackgroundAlthough breastfeeding is almost universally accepted in the Democratic Republic (DR) of Congo, by the age of 2 to 3 months 65% of children are receiving something other than human milk. We sought to describe the infant feeding practices and determinants of suboptimal breastfeeding behaviors in DR Congo.MethodsSurvey questionnaire administered to mothers of infants aged ≤ 6 months and healthcare providers who were recruited consecutively at six selected primary health care facilities in Kinshasa, the capital.ResultsAll 66 mothers interviewed were breastfeeding. Before initiating breastfeeding, 23 gave their infants something other than their milk, including: sugar water (16) or water (2). During the twenty-four hours prior to interview, 26 (39%) infants were exclusively breastfed (EBF), whereas 18 (27%), 12 (18%), and 10 (15%) received water, tea, formula, or porridge, respectively, in addition to human milk. The main reasons for water supplementation included “heat” and cultural beliefs that water is needed for proper digestion of human milk. The main reason for formula supplementation was the impression that the baby was not getting enough milk; and for porridge supplementation, the belief that the child was old enough to start complementary food. Virtually all mothers reported that breastfeeding was discussed during antenatal clinic visit and half reported receiving help regarding breastfeeding from a health provider either after birth or during well-child clinic visit. Despite a median of at least 14 years of experience in these facilities, healthcare workers surveyed had little to no formal training on how to support breastfeeding and inadequate breastfeeding-related knowledge and skills. The facilities lacked any written policy about breastfeeding.ConclusionAddressing cultural beliefs, training healthcare providers adequately on breastfeeding support skills, and providing structured breastfeeding support after maternity discharge is needed to promote EBF in the DR Congo.

Integration and task shifting for TB/HIV care and treatment in highly resource-scarce settings: one size may not fit all.

Background:A crucial question in managing HIV-infected patients with tuberculosis (TB) concerns when and how to initiate antiretroviral therapy (ART). The effectiveness of CD4-stratified ART initiation in a nurse-centered, integrated TB/HIV program at primary care in Kinshasa, Democratic Republic of Congo, was assessed. Methods:Prospective cohort study was conducted to assess the effect of CD4-stratified ART initiation by primary care nurses (513 TB patients, August 2007 to November 2009). ART was to be initiated at 1 month of TB treatment if CD4 count is <100 cells per cubic millimeter, at 2 months if CD4 count is 100–350 cells per cubic millimeter, and at the end of TB treatment after CD4 count reassessment if CD4 count is >350 cells per cubic millimeter. ART uptake and mortality were compared with a historical prospective cohort of 373 HIV-infected TB patients referred for ART to a centralized facility and 3577 HIV-negative TB patients (January 2006 to May 2007). Results:ART uptake increased (17%–69%, P < 0.0001) and mortality during TB treatment decreased (20.1% vs 9.8%, P < 0.0003) after decentralized, nurse-initiated, CD4-stratified ART. Mortality among TB patients with CD4 count >100 cells per cubic millimeter was similar to that of HIV-negative TB patients (5.6% vs 6.3%, P = 0.65), but mortality among those with CD4 count <100 cells per cubic millimeter remained high (18.8%). Conclusions:Nurse-centered, CD4-stratified ART initiation at primary care level was effective in increasing timely ART uptake and reducing mortality among TB patients but may not be adequate to prevent mortality among those presenting with severe immunosuppression. Further research is needed to determine the optimal management at primary care level of TB patients with CD4 counts <100 cells per cubic millimeter.

Conditional cash transfers to increase retention in PMTCT care antiretroviral adherence and postpartum virological suppression: a randomized controlled trial.

Background:Novel strategies are needed to increase retention in prevention of mother-to-child HIV transmission (PMTCT) services. We have recently shown that small, incremental cash transfers conditional on attending clinic resulted in increased retention along the PMTCT cascade. However, whether women who receive incentives to attend clinic visits are as adherent to antiretrovirals (ARV) as those who do not was unknown. Objective:To determine whether HIV-infected women who received incentives to remain in care were as adherent to antiretroviral treatment and achieved the same level of viral suppression at 6 weeks postpartum as those who did not receive incentives but also remained in care. Methods:Newly diagnosed HIV-infected women at ⩽32 weeks gestational age were recruited at antenatal care clinics in Kinshasa, Democratic Republic of Congo. Women were randomized in a 1:1 ratio to an intervention or control group. The intervention group received compensation (

Outcomes of integrated treatment for tuberculosis and HIV in children at the primary health care level.

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