Pius M. Tih

Coverage of Nevirapine-Based Services to Prevent Mother-to-Child HIV Transmission in 4 African Countries

CONTEXTnFew studies have objectively evaluated the coverage of services to prevent transmission of human immunodeficiency virus (HIV) from mother to child.nnnOBJECTIVEnTo measure the coverage of services to prevent mother-to-child HIV transmission in 4 African countries.nnnDESIGN, SETTING, AND PATIENTSnCross-sectional surveillance study of mother-infant pairs using umbilical cord blood samples collected between June 10, 2007, and October 30, 2008, from 43 randomly selected facilities (grouped as 25 service clusters) providing delivery services in Cameroon, Côte dIvoire, South Africa, and Zambia. All sites used at least single-dose nevirapine to prevent mother-to-child HIV transmission and some sites used additional prophylaxis drugs.nnnMAIN OUTCOME MEASUREnPopulation nevirapine coverage, defined as the proportion of HIV-exposed infants in the sample with both maternal nevirapine ingestion (confirmed by cord blood chromatography) and infant nevirapine ingestion (confirmed by direct observation).nnnRESULTSnA total of 27,893 cord blood specimens were tested, of which 3324 were HIV seropositive (12%). Complete data for cord blood nevirapine results were available on 3196 HIV-seropositive mother-infant pairs. Nevirapine coverage varied significantly by site (range: 0%-82%). Adjusted for country, the overall coverage estimate was 51% (95% confidence interval [CI], 49%-53%). In multivariable analysis, failed coverage of nevirapine-based services was significantly associated with maternal age younger than 20 years (adjusted odds ratio [AOR], 1.44; 95% CI, 1.18-1.76) and maternal age between 20 and 25 years (AOR, 1.28; 95% CI, 1.07-1.54) vs maternal age of older than 30 years; 1 or fewer antenatal care visits (AOR, 2.91; 95% CI, 2.40-3.54), 2 or 3 antenatal care visits (AOR, 1.93; 95% CI, 1.60-2.33), and 4 or 5 antenatal care visits (AOR, 1.56; 95% CI, 1.34-1.80) vs 6 or more antenatal care visits; vaginal delivery (AOR, 1.22; 95% CI, 1.03-1.44) vs cesarean delivery; and infant birth weight of less than 2500 g (AOR, 1.34; 95% CI, 1.11-1.62) vs birth weight of 3500 g or greater.nnnCONCLUSIONnIn this random sampling of sites with services to prevent mother-to-child HIV transmission, only 51% of HIV-exposed infants received the minimal regimen of single-dose nevirapine.

Monitoring effectiveness of programmes to prevent mother-to-child HIV transmission in lower-income countries

Ambitious goals for paediatric AIDS control have been set by various international bodies, including a 50% reduction in new paediatric infections by 2010. While these goals are clearly appropriate in their scope, the lack of clarity and consensus around how to monitor the effectiveness of programmes to prevent mother-to-child HIV transmission (PMTCT) makes it difficult for policy-makers to mount a coordinated response. In this paper, we develop the case for using population HIV-free child survival as a gold standard metric to measure the effectiveness of PMTCT programmes, and go on to consider multiple study designs and source populations. Finally, we propose a novel community survey-based approach that could be implemented widely throughout the developing world with minor modifications to ongoing Demographic and Health Surveys.

Integrating prevention of mother-to-child HIV transmission into routine antenatal care: the key to program expansion in Cameroon.

With funds from Elizabeth Glaser Pediatric AIDS Foundation, the Cameroon Baptist Convention Health Board implemented a program to prevent mother-to-child transmission of HIV-1 (PMTCT) as part of its routine antenatal care, with single-dose maternal and infant peripartum nevirapine (NVP) prophylaxis of HIV-positive mothers and their babies. Nurses, midwives, nurse aides, and trained birth attendants counseled pregnant women, obtained risk factor data, and offered free HIV testing with same-day results. From February 2000 through December 2004, this program rapidly expanded to 115 facilities in 6 of Cameroons 10 provinces, not only to large hospitals but to remote health centers staffed by trained birth attendants. We trained 690 health workers in PMTCT and counseled 68,635 women, 91.9% of whom accepted HIV testing. Of 63,094 women tested, 8.7% were HIV-1-positive. Independent risk factors for HIV-1 infection included young age at first sexual intercourse, multiple sex partners, and positive syphilis serology (P < 0.001 for each). We counseled 98.7% of positive and negative mothers on a posttest basis. Of 5550 HIV-positive mothers, we counseled 5433 (97.9%) on single-dose NVP prophylaxis. Consistent training and programmatic support contributed to rapid upscaling and high uptake and counseling rates.

Barriers to Men's Participation in Antenatal and Prevention of Mother-to-Child HIV Transmission Care in Cameroon, Africa

INTRODUCTIONnMens role in HIV prevention is pivotal to changing the course of the epidemic. When men participate in Prevention of Mother-to-Child Transmission (PMTCT) programs, their knowledge of HIV increases, their behavior becomes supportive, and their receptiveness to HIV testing increases. In Cameroon, Africa, multiple efforts have been implemented that encourage men to follow their wives to obstetric/PMTCT care and to undergo HIV testing. However, only 18% of men have participated in this care.nnnMETHODSnAs a quality improvement initiative, a survey was administered to identify mens knowledge and attitudes regarding antenatal care (ANC), PMTCT, and HIV. The survey consisted of a questionnaire with an emphasis on identifying barriers to mens participation in PMTCT programs and obtaining HIV testing. A convenience sampling method was used, and no participant identifying information was collected.nnnRESULTSnMens participation in ANC/PMTCT is affected by sociocultural barriers centered in tribal beliefs and traditional gender roles. The barriers identified included the belief that pregnancy is a womans affair; the belief that a mans role is primarily to provide financial support for the womans care; the mans perception that he will be viewed as jealous by the community if he comes to clinic with his pregnant wife; and cultural gender-based patterns of communication.nnnDISCUSSIONnMost men consider accompanying their wife to ANC/PMTCT a good practice. Yet fewer men actually do this, because they feel that the provision of finance for ANC registration and delivery fees is their most important role in supporting their wifes pregnancy. Health care workers should encourage individuals and community leaders to build upon the traditional value of financial responsibility, expanding a mans involvement to include supportive social roles in obstetric care, PMTCT, and HIV testing.

Role of traditional birth attendants in preventing perinatal transmission of HIV

# Role of traditional birth attendants in preventing perinatal transmission of HIV {#article-title-2}nnEvery year a million women infected with HIV deliver babies without professional help. Marc Bulterys and colleagues suggest here that traditional birth attendants could be involved in preventing perinatal transmission of HIV by offering services such as HIV testing and counselling and short courses of antiretroviral drugs. A research doctor in the Gambia comments on this suggestionnnIn many poor parts of the world, the HIV and AIDS epidemic has eroded hard won gains in the survival of infants and children.1 In eastern and southern Africa, infant mortality is one third to two thirds higher than it would have been in the absence of HIV and AIDS, and child mortality continues to rise, leading to a dramatic reduction in life expectancy. 1 2nnIn rich nations, rates of perinatal transmission of HIV less than 2% are now reported because of the use of combinations of antiretroviral drugs, elective caesarean section, and avoidance of breastfeeding.3–5 Transmission rates of 5% or lower may be achievable in middle income countries and some urban areas of the developing world with the use of short courses of combinations of antiretroviral drugs, appropriate infant feeding choices, and possibly elective caesarean delivery. 1 6 However, being able to extend the benefits of these recent advances to most women infected with HIV is a tremendous challenge, particularly in rural communities, in which more than two thirds of the population of sub-Saharan Africa lives.nnThe simplicity and low cost of nevirapines single dose regimen 7 8 suggest that this highly efficacious drug might be very useful in rural settings. Obstacles to its use—including weak, underlying healthcare infrastructures9 and low rates of offering and uptake of voluntary counselling and testing—will be magnified in rural areas. 1 10 As global efforts to prevent perinatal transmission of …

Evaluation of Rapid Prenatal Human Immunodeficiency Virus Testing in Rural Cameroon

ABSTRACT Pregnant women (n = 859) in rural Cameroonian prenatal clinics were screened by two rapid human immunodeficiency virus (HIV) antibody tests (rapid tests [RT]) (Determine and Hema-Strip) using either whole blood or plasma. One additional RT (Capillus, HIV-CHEK, or Sero-Card) was used to resolve discordant results. RT results were compared with HIV-1 enzyme immunoassay (EIA) and Western blot (WB) results of matched dried blood spots (DBS) to assess the accuracy of HIV RTs. DBS EIA/WB identified 83 HIV antibody-reactive, 763 HIV antibody-nonreactive, and 13 indeterminate specimens. RT results were evaluated in serial (two consecutive tests) or parallel (two simultaneous tests) testing algorithms. A serial algorithm using Determine and Hema-Strip yielded sensitivity and specificity results of 97.6% and 99.7%, respectively, whereas a parallel RT algorithm using Determine plus a second RT produced a sensitivity and specificity of 100% and 99.7%, respectively. HIV RTs provide excellent alternatives for identifying HIV infection, and their field performance could be monitored using DBS testing strategies.

Health facility characteristics and their relationship to coverage of PMTCT of HIV services across four African countries: the PEARL study.

Background Health facility characteristics associated with effective prevention of mother-to-child transmission of HIV (PMTCT) coverage in sub-Saharan are poorly understood. Methodology/Principal Findings We conducted surveys in health facilities with active PMTCT services in Cameroon, Cote dIvoire, South Africa, and Zambia. Data was compiled via direct observation and exit interviews. We constructed composite scores to describe provision of PMTCT services across seven topical areas: antenatal quality, PMTCT quality, supplies available, patient satisfaction, patient understanding of medication, and infrastructure quality. Pearson correlations and Generalized Estimating Equations (GEE) to account for clustering of facilities within countries were used to evaluate the relationship between the composite scores, total time of visit and select individual variables with PMTCT coverage among women delivering. Between July 2008 and May 2009, we collected data from 32 facilities; 78% were managed by the government health system. An opt-out approach for HIV testing was used in 100% of facilities in Zambia, 63% in Cameroon, and none in Côte dIvoire or South Africa. Using Pearson correlations, PMTCT coverage (median of 55%, (IQR: 33–68) was correlated with PMTCT quality score (rhou200a=u200a0.51; pu200a=u200a0.003); infrastructure quality score (rhou200a=u200a0.43; pu200a=u200a0.017); time spent at clinic (rhou200a=u200a0.47; pu200a=u200a0.013); patient understanding of medications score (rhou200a=u200a0.51; pu200a=u200a0.006); and patient satisfaction quality score (rhou200a=u200a0.38; pu200a=u200a0.031). PMTCT coverage was marginally correlated with the antenatal quality score (rhou200a=u200a0.304; pu200a=u200a0.091). Using GEE adjustment for clustering, the, antenatal quality score became more strongly associated with PMTCT coverage (p<0.001) and the PMTCT quality score and patient understanding of medications remained marginally significant. Conclusions/Results We observed a positive relationship between an antenatal quality score and PMTCT coverage but did not identify a consistent set of variables that predicted PMTCT coverage.

Measuring Coverage in MNCH: Population HIV-Free Survival among Children under Two Years of Age in Four African Countries

Background Population-based evaluations of programs for prevention of mother-to-child HIV transmission (PMTCT) are scarce. We measured PMTCT service coverage, regimen use, and HIV-free survival among children ≤24 mo of age in Cameroon, Côte DIvoire, South Africa, and Zambia. Methods and Findings We randomly sampled households in 26 communities and offered participation if a child had been born to a woman living there during the prior 24 mo. We tested consenting mothers with rapid HIV antibody tests and tested the children of seropositive mothers with HIV DNA PCR or rapid antibody tests. Our primary outcome was 24-mo HIV-free survival, estimated with survival analysis. In an individual-level analysis, we evaluated the effectiveness of various PMTCT regimens. In a community-level analysis, we evaluated the relationship between HIV-free survival and community PMTCT coverage (the proportion of HIV-exposed infants in each community that received any PMTCT intervention during gestation or breastfeeding). We also compared our community coverage results to those of a contemporaneous study conducted in the facilities serving each sampled community. Of 7,985 surveyed children under 2 y of age, 1,014 (12.7%) were HIV-exposed. Of these, 110 (10.9%) were HIV-infected, 851 (83.9%) were HIV-uninfected, and 53 (5.2%) were dead. HIV-free survival at 24 mo of age among all HIV-exposed children was 79.7% (95% CI: 76.4, 82.6) overall, with the following country-level estimates: Cameroon (72.6%; 95% CI: 62.3, 80.5), South Africa (77.7%; 95% CI: 72.5, 82.1), Zambia (83.1%; 95% CI: 78.4, 86.8), and Côte DIvoire (84.4%; 95% CI: 70.0, 92.2). In adjusted analyses, the risk of death or HIV infection was non-significantly lower in children whose mothers received a more complex regimen of either two or three antiretroviral drugs compared to those receiving no prophylaxis (adjusted hazard ratio: 0.60; 95% CI: 0.34, 1.06). Risk of death was not different for children whose mothers received a more complex regimen compared to those given single-dose nevirapine (adjusted hazard ratio: 0.88; 95% CI: 0.45, 1.72). Community PMTCT coverage was highest in Cameroon, where 75 of 114 HIV-exposed infants met criteria for coverage (66%; 95% CI: 56, 74), followed by Zambia (219 of 444, 49%; 95% CI: 45, 54), then South Africa (152 of 365, 42%; 95% CI: 37, 47), and then Côte DIvoire (3 of 53, 5.7%; 95% CI: 1.2, 16). In a cluster-level analysis, community PMTCT coverage was highly correlated with facility PMTCT coverage (Pearsons ru200a=u200a0.85), and moderately correlated with 24-mo HIV-free survival (Pearsons ru200a=u200a0.29). In 14 of 16 instances where both the facility and community samples were large enough for comparison, the facility-based coverage measure exceeded that observed in the community. Conclusions HIV-free survival can be estimated with community surveys and should be incorporated into ongoing country monitoring. Facility-based coverage measures correlate with those derived from community sampling, but may overestimate population coverage. The more complex regimens recommended by the World Health Organization seem to have measurable public health benefit at the population level, but power was limited and additional field validation is needed. Please see later in the article for the Editors Summary

Achieving high uptake of human papillomavirus vaccine in Cameroon: Lessons learned in overcoming challenges

BACKGROUNDnCameroon has the highest age-standardized incidence rate of cervical cancer (30/100,000 women) in Central Africa. In 2010-2011, the Cameroon Baptist Convention Health Services (CBCHS) received donated human papillomavirus (HPV) vaccine, Gardasil, from Merck & Co. Inc. through Axios Healthcare Development to immunize 6400 girls aged 9-13 years. The aim was to inform the Cameroon Ministry of Health (MOH) of the acceptability, feasibility, and optimal delivery strategies for HPV vaccine.nnnMETHODS AND FINDINGSnFollowing approval by the MOH, CBCHS nurses educated girls, parents, and communities about HPV, cervical cancer, and HPV vaccine through multimedia coverage, brochures, posters, and presentations. Because educators were initially reluctant to allow immunization in schools, due to fear of adverse events, the nurses performed 40.7% of vaccinations in the clinics, 34.5% in community venues, and only 24.7% in schools. When no adverse events were reported, more schools and communities permitted HPV vaccine immunization on their premises. To recover administrative costs, CBCHS charged a fee of US

Time trends and regional differences in the prevalence of HIV infection among women attending antenatal clinics in 2 provinces in Cameroon.

8 per 3-dose series only to those who were able to pay. Despite the fee, 84.6% of the 6,851 girls who received the first dose received all three doses.nnnCONCLUSIONS AND LESSONS LEARNEDnWith adequate education of all stakeholders, HPV vaccination is acceptable and feasible in Cameroon. Following this demonstration project, in 2014 the Global Access to Vaccines and Immunization (GAVI) Alliance awarded the Cameroon MOH HPV vaccine at a price of US