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RHO archives : Topics : HIV/AIDS
Annotated Bibliography
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Reproductive health programs can help
Askew I, Berer M. The contribution of sexual and
reproductive health services to the fight against HIV/AIDS: a review.
Reproductive Health Matters. 2003;11(22):51–73.
In this article, the authors examine the track record thus far of sexual
and reproductive health programs in responding to the HIV/AIDS crisis. They
review a wide range of components, including the historical organization
of sexual and reproductive health services; the limited expansion of STI
prevention and treatment services since 1990; the strengths and limitations
of the contribution of sexual and reproductive health services to HIV/AIDS
prevention; the contribution of family planning services; the contribution
of maternal/child health services; where STI services should be situated;
expanding coverage; and recommended policies and programs for the future.
They conclude that sexual and reproductive health services have the capacity
to reduce disease (including HIV/AIDS) among a broad population simply by
ameliorating standards of care and service uptake. Strengthening this capacity
will require better infrastructure, equipment, and supplies; improved staff
training and supervision; and a reliable supply of drugs.
Berer M. HIV/AIDS, sexual and reproductive health:
intimately related. Reproductive Health Matters. 2003;11(22):6–11.
The editorial of a special issue of Reproductive Health Matters devoted
to the links between HIV/AIDS and sexual and reproductive health explores
the context in which efforts to integrate the two fields have occurred.
The author asserts that leaders in the two fields have had trouble agreeing
on the way forward, due to different and entrenched agendas. Within national
government frameworks, responsibilities and funding for HIV/AIDS and maternal-child
health/family planning have remained separate. Bilateral and multilateral
donors have not integrated their departments for HIV/AIDS and sexual and
reproductive health. Some of the most widely renowned actors in the HIV/AIDS
field (including UNAIDS, WHO, and the Global Fund to Fight AIDS, Tuberculosis
and Malaria) have not acknowledged the links between HIV/AIDS and sexual
and reproductive health. The author concludes that “integrated approaches
to sexual and reproductive health care, HIV/AIDS prevention, treatment and
care, and sexuality and health education should be further developed.”
Fleischman Foreit, K. et al. When
does it make sense to consider integrating STI and HIV services with family
planning services? International Family Planning Perspectives
28(2):105–107 (June 2002). Available at: www.guttmacher.org/pubs/journals/2810502.html.
The authors of this article argue that not all services should be integrated
in all situations, and that in some cases services should be offered separately.
Family-planning clients are not always at particularly high risk for HIV
and other STIs. Furthermore, some population groups that are at high risk,
such as men and young people, do not necessarily seek services at family-planning
sites. It may be difficult to combine the delivery and management requirements
of family-planning services with those of STI and HIV services. Also, there
is a lack of simple and effective technologies to diagnose and treat women
who are asymptomatic for STIs, or women with vaginal discharge. The authors
conclude that new services should be combined with existing service only
when existing clients have a clear need for the new services, and when delivery
requirements of new services correspond to those of existing services.
Lush, L. Integrating HIV/STI and family planning
services, service integration: an overview of policy developments. International
Family Planning Perspectives 28(2):71–76 (June 2002).
This article examines the policy-related experience of integrating HIV/STI
and family planning services. It distinguishes between functional integration
and administrative integration, and suggests that in areas of high prevalence
of HIV/STIs, mass treatment may be the most cost-effective strategy, while
in low-prevalence settings, it may be more desirable to focus on high-risk
groups. The author affirms that international donors are sometimes responsible
for influencing policy related to integrated services. She notes some progress
in developing national policy on integrated services—for example,
in the cases of Cambodia and Thailand—but maintains that provincial
and district-level plans for integration are lagging. In general, Latin
American countries have achieved greater progress than most sub-Saharan
African and Asian countries. The author also suggests that there is a dearth
of clear technical guidelines for training staff members, and that health
facility problems such as low pay, poor morale, lack of motivation among
providers, and insufficient infrastructure and equipment all impede the
goal of integrated service delivery. Finally, greater coverage could occur
if policy makers and service providers acknowledged that not only married
women but also men and young, single people are in need of both reproductive
health and HIV/STI services.
Richey LA. HIV/AIDS in the shadows of reproductive
health interventions. Reproductive Health Matters. 2003;11(22):30–35.
In this article, the author describes the experience of dealing with HIV/AIDS
and reproductive health in Tanzania. Her research concluded that programs
devoted to HIV/AIDS and maternal-child health/family planning remained vertical
and separate, unable to meet the needs of women in Tanzania. Although “HIV/AIDS
cannot merely be inserted into existing family planning programmes, renamed
reproductive health programmes,” there is a need to re-evaluate traditional
ways of dealing with population issues.
UNFPA. Preventing
HIV Infection, Promoting Reproductive Health. Geneva: UNAIDS
(2002). Available at: www.unfpa.org/aids/docs/aids.pdf.
UNFPAs annual AIDS report discusses the agencys HIV/AIDS-related work
in several regions, including sub-Saharan Africa, Asia and the Pacific,
Central and Eastern Europe and Latin America. UNPFA works in three key areas
to reduce HIV infections as well as other sexually transmitted infections
and unwanted pregnancies: young people, condom programming and pregnant
women. Among UNFPAs comparative advantages in HIV/AIDS prevention are:
experience addressing issues such as gender relations and sexuality; expertise
in negotiating with governments to guarantee access to reproductive health;
a focus on sexual and reproductive health, including STI prevention; experience
in supporting the introduction and implementation of family-life and sexual
health-education programs for adolescents and youth; a strong network of
governmental and non-governmental partners and a strong country-level presence;
and a unique understanding of the multisectoral nature of the HIV/AIDS epidemic
at country, regional and global levels. UNFPA spent about $46 million on
HIV prevention in 2001.
Reducing mother-to-child transmission
Ayouba A et al. Low rate of mother-to-child
transmission of HIV-1 after nevirapine intervention in a pilot public health
program in Yaoundé, Cameroon. Journal of Acquired Immune Deficiency
Syndrome. 2003;34(3)274–280.
This article presents the findings of a pilot program conducted from January
2000 to December 2002 in Yaoundé, Cameroon. Of 7,871 pregnant women
attending the Chantal Biya Foundation antenatal clinic for the first time,
241 women who tested HIV-positive gave birth after taking a single dose
of nevirapine during labor to prevent mother-to-child HIV transmission.
Of 123 infants given 2 mg/kg of nevirapine syrup at 72 hours and assessed
for HIV infection at six to eight weeks of age, 107 (87 percent) had undetectable
levels of virus. The authors conclude that nevirapine is effective for lowering
the risk of mother-to-child transmission of HIV-1 in real-life settings.
Ayouba A et al. Mother-to-child transmission
of human immunodeficiency virus type 1 in relation to the season in Yaoundé,
Cameroon. American Journal of Tropical Medicine and Hygiene.
2003;69(4):447–449.
Within the framework of the pilot program described above and conducted
in Yaoundé, Cameroon, from January 2000 through December 2002, this
article reviews a study carried out on plasma samples from 119 children
born to HIV-1-positive mothers. Thirteen children, or nearly 11 percent
of the sample, tested positive for HIV-1 RNA at six to eight weeks of age.
The authors found that risk factors associated with perinatal HIV infection
included high maternal viral load, low birth weight, and birth during the
second half of the year (July through December). The authors suspect a correlation
between the rainy season, which corresponds to the malaria Plasmodium
life cycle, and a heightened risk of mother-to-child HIV transmission.
Brahmbhatt H. et al. The effects of placental
malaria on mother-to-child HIV transmission in Rakai, Uganda. AIDS.
2003;17(17):2539–2541.
A study carried out in Rakai, Uganda, from 1994 to 1999 tested 668 placentas
of women of known HIV status. “Among HIV-positive mothers, 13.6% (21/155)
had placental malaria, compared with 8.0% (41/510) in HIV-negative mothers
[…] MTCT rates were 40% (6/15) with placental malaria and 15.4% (12/78)
without malaria […] MTCT was significantly associated with maternal
viral load […] and placental malaria infection.” Among children
born to HIV-infected mothers, the average viral load was higher in infants
whose mothers also had malaria than in those whose mothers had only HIV
infection. The inflammation caused by malaria infection may damage the placenta,
augmenting the chances for the exchange of maternal and fetal blood and
enabling in utero HIV transmission. The authors recommend interventions
aimed at preventing malaria during pregnancy as a means of reducing mother-to-child
HIV transmission.
Culnane, M. et al. Lack of long-term effects
of in utero exposure to zidovudine among uninfected children born to HIV-infected
women. Journal of the American Medical Association 281(2):151–157
(January 13, 1999).
The purpose of this study was to evaluate the long-term effects of
in utero exposure to zidovudine versus placebo among a randomized
cohort of uninfected children. The article presents reassuring data regarding
longitudinal follow-up through the preschool years of uninfected children
who were exposed to in utero and neonatal zidovudine for the prevention
of mother-to-child transmission of HIV. Average follow-up reached age 4.2
years with results revealing no adverse outcomes with respect to growth,
cognitive/developmental function, immune function, cancers, or mortality
of uninfected children randomized to zidovudine in utero when compared
with uninfected children randomized to placebo. The randomized design and
substantial follow-up rates added to the critical strength of this study.
Etiebet M-A et al. Integrating prevention of
mother-to-child HIV transmission into antenatal care: learning from the
experiences of women in South Africa. AIDS Care. 2004;16(1):37–46.
This article reports on the findings of a cross-sectional study of knowledge,
attitudes, and practices carried out between June and September 1999 among
women receiving prenatal or postnatal care from two midwife-obstetric unit
clinics in Khayelitsha, in the Western Cape region of South Africa. The
two clinics participated in a mother-to-child HIV prevention pilot program
being implemented by the Western Cape Health Department. Of the 264 women
who participated in the cross-sectional study, 95 percent had been tested
for HIV and 83 percent of those tested had told their partners about the
HIV test. However, only 60 percent of the women who tested positive had
told their partners about their test results, whereas 90 percent of the
HIV-negative women had shared their results. Partner violence toward HIV-positive
women was a significant factor in nondisclosure of test results. In general,
women had a positive view of the opportunity to reduce perinatal HIV transmission.
Fowler, M. and Newell, M. Breast-feeding and
HIV-1 transmission in resource-limited settings. Journal of Acquired
Immune Deficiency Syndromes 30(2):230–239 (June 1, 2002).
This article summarizes current knowledge about infant-health benefits of
breastfeeding in general populations, outlines what is known about breastfeeding
and HIV, and sums up current research strategies to reduce transmission
through breast-milk for women who choose to breastfeed. The authors found
that viral load in breast-milk is an important infection risk for infants,
and that the period of highest risk may be the first months of life. It
is recommended that future research focus on determining whether short-course
antiretrovirals and infant vaccines (when available) could allow for the
benefits of breastfeeding and at the same time substantially reduce the
risk of HIV transmission during the first few months of life. Research should
also address the co-existence of antiretroviral treatment and perinatal
prevention during the breastfeeding period. The authors conclude that mother-to-child
HIV-prevention efforts should include antenatal voluntary counseling and
testing as well as the offer of peripartum antiretrovirals for pregnant
women who are HIV-positive.
Gibb, D.M. and Tess, B.H. Interventions to reduce
mother-to-child transmission of HIV infection: new developments and current
controversies. AIDS 13 (Suppl. A):S93–S102 (1999).
This article reviews the efficacy, appropriateness, acceptance, and cost-effectiveness
of interventions aimed at reducing mother-to-child transmission of HIV.
Rates of transmission vary significantly between countries. Risk factors
strongly associated with HIV transmission rates include maternal health
and immune status, viral load, and exposure of the infant to maternal blood
during delivery and viral genetics. With indirect evidence strongly suggesting
that transmission occurs most frequently (70%–80%) during the peripartum
period, most interventions focus on late-pregnancy or delivery. The authors
first discuss breastfeeding, and note that a meta-analysis of the literature
indicates that the risk of mother-to-child transmission of HIV from breastfeeding
is approximately 14 percent. Establishing national breastfeeding intervention
policies is difficult, however. Factors such as country-specific ability
to enact and sustain the cost of antenatal HIV testing, existing feeding
practices, the cultural and economic factors influencing feeding decisions,
the attributable risk of HIV transmission through breastfeeding, and the
estimated local attributable risk of mortality associated with formula feeding
must be considered to determine appropriate, local breastfeeding intervention
policies. The authors also discuss antiretroviral therapies for developed
countries and resource-poor settings. They discuss issues such as safety,
efficacy, and cost-effectiveness, and ethical issues that should be addressed
when introducing antiretroviral treatment in resource-limited countries.
Guay, L. et al. Intrapartum and neonatal single-dose
nevirapine compared with zidovudine for prevention of mother-to-child transmission
of HIV-1 in Kampala, Uganda: HIVNET 012 randomised trial. Lancet
354:795–802. (September 1999).
In this comparative study in Kampala, Uganda, a single-dose nevirapine regimen
was compared with zidovudine. The zidovudine regimen required that pregnant
women receive 600 mg of zidovudine orally when they went into labor and
300 mg every three hours until delivery; their infants then received 4 mg/kg
orally two times a day for seven days. For the nevirapine regimen, women
were given a single dose of 200 mg orally when they went into labor, and
their infants received a single dose of 2 mg/kg within three days of birth.
Statistically significant differences in rates of HIV infection in infants
of infected mothers taking zidovudine or nevirapine regimens were reported:
21.3 percent and 11.9 percent, respectively, at 6 to 8 weeks of age, and
25.1 percent and 13.1 percent at 14 to 16 weeks. All infants were breastfed
initially and 96 percent were breastfeeding after 14 to 16 weeks. The single-dose
nevirapine regimen is considerably less expensive than the zidovudine regimen,
and is simpler to administer.
Hashimoto, H. et al. Mass treatment with nevirapine
to prevent mother-to-child transmission of HIV/AIDS in sub-Saharan African
countries. Journal of Obstetrics and Gynaecology Research 28(6):313–319
(December 2002).
This article reviews public health strategies to prevent mother-to-child
transmission of HIV in low-resource settings, with the objective of determining
the effectiveness of mass treatment with a single intrapartum and neonatal
dose of nevirapine to prevent HIV transmission from mothers to infants in
sub-Saharan Africa. The authors determined that costs per HIV case averted
suggest that mass treatment with nevirapine would be extremely cost-effective,
particularly in light of recent pharmaceutical company discounts. Mass treatment
would also circumvent the problem of voluntary counseling and testing, which
many women avoid for fear of discrimination, stigmatization, and violence.
Side effects of nevirapine have thus far proven rare and mild. The authors
conclude that sub-Saharan African countries with high HIV prevalence and
limited resources would greatly benefit from mass treatment of pregnant
mothers and infants with nevirapine.
Jamieson D et al. HIV-1 viral load and other
risk factors for mother-to-child transmission of HIV-1 in a breast-feeding
population in Cote d’Ivoire. Journal of Acquired Immune Deficiency
Syndrome. 2003;34(4):430–435.
In Abidjan, Cote d’Ivoire, a study conducted from 1996 to 1998 examined
the risk factors for HIV transmission to infants by one and 24 months among
breast-feeding women. Eligible HIV-positive pregnant women enrolled in the
clinical trial received either oral zidovudine prophylaxis (300 mg twice
a day from 36 weeks of gestation and every three hours intrapartum) or a
placebo. Viral load at enrollment proved to be the strongest predictor of
transmission. In general, the zidovudine regimen did not provide significant
protection against infection at one or 24 months. However, the zidovudine
prophylaxis appeared to have a significant protective effect on women with
a low viral load at enrollment. The authors recommend finding more effective
perinatal HIV prevention regimens to use in settings with limited resources.
Kanshana, S. and Simonds, R. National program
for preventing mother-to-child HIV transmission in Thailand: successful
implementation and lessons learned. AIDS 16:953–959 (2002).
In Thailand, a national program to prevention mother-to-child HIV transmission
began in 2000. Elements of the program included voluntary counseling and
HIV testing of pregnant women, a short course of zidovudine for HIV-infected
women and their infants, and formula feeding for infants. Research, monitoring
and evaluation of pilot projects, training and policy-making provided an
essential foundation for the program. From October 2000 to July 2001, 93
percent of 318,721 women who gave birth were tested for HIV; 69 percent
of 3,958 HIV-infected women giving birth received zidovudine; 86 percent
of the 3,865 children born to HIV-positive mothers received zidovudine;
and 80 percent of the same children received infant formula. The authors
estimate that further implementation of the program could reduce the risk
of mother-to-child HIV transmission from 30 percent to less than 10 percent.
Kiarie, J. et al. Compliance with antiretroviral
regimens to prevent perinatal HIV-1 transmission in Kenya. AIDS
17(1):65–71 (2003).
Researchers leading a randomized clinical trial set out to study compliance
with antiretroviral regimens to prevent mother-to-child transmission of
HIV in Kenya. The participants were 139 women from primary care clinics
referred to a tertiary hospital antenatal clinic in Nairobi. Seventy women
were randomized to the Thai-CDC regimen, consisting of zidovudine taken
twice a day beginning at 36 weeks gestation and every three hours during
labor. Sixty-nine women were randomly assigned to the HIVNET-012 regimen,
consisting of nevirapine given to the mother at the onset of labor and to
the infant within 72 hours of delivery. Of the women undergoing the Thai-CDC
regimen, 41 percent reported taking at least 80 percent of the antepartum
and 80 percent of the intrapartum zidovudine doses. Women who complied with
the Thai-CDC regimen "were more likely to have known at enrolment that
mother-to-child transmission of HIV-1 can be prevented by antiretroviral
agents and to have partners who supported use of antiretroviral drugs."
Delivering in private hospitals was also a factor that corresponded to compliance
with the regimen. Of the women undergoing the HIVNET-012 regimen, 91 percent
reported taking the maternal dose prior to delivery and 97 percent reporting
administering the infant dose. Women who complied with the HIVNET-012 regimen
"were more likely to have informed their partners of their HIV-1 results
and to report that their partners would be willing to have an HIV-1 test."
Overall, 17 of 110 infants tested positive for HIV six weeks after delivery.
The authors found that partner involvement and support, knowledge of the
use of antiretroviral drugs to prevent mother-to-child HIV transmission,
and positive care-provider attitudes were all important factors in determining
compliance with the regimens.
Marseille, E. et al. Cost-effectiveness of
antiviral drug therapy to reduce mother-to-child HIV transmission in sub-Saharan
Africa. AIDS 12(8):939–948 (1998).
Zidovudine (ZDV) antiretroviral therapy has great implications for national
and global strategies to stem mother-to-child transmission of HIV. A cost-effectiveness
analysis was undertaken in sub-Saharan Africa to compare three regimens
of zidovudine and lamivudine. It was determined that antiviral therapy may
be cost-effective compared with other health interventions if HIV prevalence
is high.
Perez-Then E et al. Preventing mother-to-child
HIV transmission in a developing country: the Dominican Republic experience.
Journal of Acquired Immune Deficiency Syndrome. 2003;34(5):506–511.
In 2000, the Ministry of Health of the Dominican Republic initiated a program
to reduce mother-to-child HIV transmission. The program began in four mother-and-child
clinics, expanding to eight additional mother-and-child hospitals, with
plans for implementation in 12 supplementary institutions. An evaluation
of the program’s first year of operation found an inadequate number
of voluntary counseling sessions and HIV rapid tests, but found more positive
results in the successful administration of antiretroviral treatment to
89 percent of HIV-positive mothers and 98 percent of children born to HIV-infected
women. The authors point to the feasibility of implementing a large-scale
program to prevent perinatal HIV transmission in a developing country and
suggest that a nevirapine regimen could reduce the risk of mother-to-child
transmission by 50 percent, thereby preventing an average of 1,000 infant
HIV infections per year.
Petra study team. Efficacy of three short-course
regimens of zidovudine and lamivudine in preventing early and late transmission
of HIV-1 from mother to child in Tanzania, South Africa and Uganda.
Lancet 359(9313):1178–1186 (April 6, 2002).
From June 1996 to January 2000, the Petra study team conducted a randomized,
double-blind, placebo-controlled trial of zidovudine and lamivudine in short-course
regimens with a predominantly breastfeeding population in South Africa,
Tanzania and Uganda. Four regimens were applied to 1,797 HIV-1-infected
mothers: A) zidovudine plus lamivudine beginning at a gestation period of
36 weeks, then oral intrapartum dosing and seven days of postpartum dosing
of both mothers and infants; B) the same as regimen A, but without the postpartum
constituent; C) intrapartum zidovudine and lamivudine alone; or a placebo.
The study team found that six weeks after birth regimens A and B proved
effective in reducing HIV-1 transmission, but there was a measured decrease
in benefits after 18 months of follow-up. To reduce mother-to-child transmission
of HIV, the team recommends programs to minimize the risk of transmission
through breastfeeding in addition to short-course regimens of antiretrovirals.
When available, triple-drug combinations may be even more effective in reducing
transmission.
Siberry G et al. Management of infants born
to HIV-infected mothers. The Hopkins HIV Report. 2003;15(6):7–9.
The authors of this article list factors associated with increased risk
of perinatal HIV transmission as being high maternal viral load; poor adherence
to antiretroviral therapy; seroconversion during pregnancy; vaginal delivery;
and procedures that increase the exposure of infants to maternal blood.
For the management of HIV-exposed infants, they recommend comprehensive
routine well-child care (including psychosocial support); prevention of
HIV transmission (including the avoidance of breast-feeding and a regimen
of zidovudine from birth to six weeks, where possible); PCP prophylaxis
from 4-6 weeks until HIV infection can be reasonably excluded; and evaluation
for HIV infection.
Sullivan J. Prevention of mother-to-child transmission
of HIV—What next? Journal of Acquired Immune Deficiency Syndrome.
2003;34(Suppl. 1)S67–S72.
This article summarizes the problems of mother-to-child HIV transmission
and current approaches to perinatal transmission prevention. Most mother-to-child
HIV transmission (75 percent) takes place during or after delivery. A high
level of maternal viral load during pregnancy increased the chances of perinatal
transmission during pregnancy. Damaged breast tissue also facilitates viral
transmission from mother to child. In Europe and the United States, rates
of perinatal HIV transmission have decreased dramatically to less than ten
percent and less than two percent, respectively, largely due to the use
of zidovudine for transmission prevention and the treatment of HIV-positive
women with highly active antiretroviral therapy. In developing countries,
short courses of nevirapine and longer courses zidovudine administered both
to mothers and infants have proven effective in reducing perinatal HIV transmission.
However, the problem of drug resistance has emerged, particularly in relation
to even a single dose of nevirapine. The author concludes with the recommendation
to administer triple-combination antiretroviral treatment to all HIV-positive
mothers.
Taha T et al. Nevirapine and zidovudine at birth to reduce perinatal
transmission of HIV in an African setting. Journal of the
American Medical Association. 2004;292(2):202–209.
In this article, the authors describe the results of a trial designed to
test prevention of mother-to-child HIV transmission in Blantyre, Malawi.
The trial enrolled 894 HIV-positive pregnant women who received a 200-mg
single oral dose of nevirapine during delivery. Infants received either
a 2-mg oral dose of nevirapine or the same dose plus 4 mg of zidovudine
twice a day for a week. Of infants receiving nevirapine, only 8.1 percent
tested positive for HIV at birth, while 10.1 percent of infants receiving
nevirapine plus zidovudine tested positive for HIV at birth. At six to
eight weeks of age, 6.5 percent of infants who were uninfected at birth
and received nevirapine only tested positive for the virus, compared to
6.9 percent of infants born uninfected and receiving both nevirapine and
zidovudine. The most significant result of the trial was that the addition
of zidovudine did not appreciably reduce the rate of HIV transmission among
infants born to HIV-infected mothers.
UNAIDS. Mother-to-Child
Transmission of HIV. Technical Update (2000). Available at:
www.unaids.org/publications/documents/mtct/MTCT_TU4.doc.
The latest UNAIDS technical update on mother-to-child transmission of HIV
reports that a recent trial held in Thailand demonstrated that a short regimen
of zidovudine given to women during the last weeks of pregnancy halved the
rate HIV transmission during childbirth. The short course cost less than
10 percent of the longer course. The update states the UNAIDS/UNICEF/WHO
recommendation to provide affordable alternatives to breastfeeding for HIV-positive
women while at the same time strengthening efforts to protect, promote and
support breastfeeding by women who are HIV-negative or whose HIV status
is unknown. In addition, the document reports on other measures to take
during pregnancy, labor and delivery; the growing need for voluntary counseling
and testing services; the need to reorganize pre-, peri-, and post-natal
care and family planning; and care for orphans. In the framework of prevention
of mother-to-child transmission of HIV, girls and women need first to be
protected from infection, as well as referrals to family planning programs,
when appropriate. Service delivery should be improved, and access to voluntary
counseling and testing guaranteed. Service providers need to focus on the
health of the mother, not just the child, and measures to prevention HIV
transmission should be made more affordable. The update also includes a
box of guidelines for policy makers.
WHO. Breastfeeding
and Replacement Feeding Practices in the Context of Mother-to-Child Transmission
of HIV: An Assessment Tool for Research. Geneva: WHO (2001).
Available at: www.unaids.org/publications/documents/mtct/MTCT_tool_en.doc.
This World Health Organization document examines the risk factors for mother-to-child
transmission of HIV through breastfeeding, and offers a questionnaire to
assess infant feeding processes and the associated risks. The questionnaire
contains six modules: baseline data, feeding practices, maternal health,
breast health and breastfeeding-related difficulties, infant health, and
cessation of breastfeeding. The rationale for developing the assessment
tool is the need for more information on risk factors for HIV transmission
through breastfeeding and to ensure that research groups employ the same
definitions and terms.
WHO. New
Data on the Prevention of Mother-to-Child Transmission of HIV and Their
Policy Implications: Conclusions and Recommendations. Geneva:
WHO (January 2001). Available at: www.unaids.org/publications/documents/mtct/MTCT_Consultation_Report.doc.
This document resulted from the October 2000 meeting of the U.N. Inter-Agency
Task Team on Mother-to-Child Transmission of HIV. Participants drew up conclusions
and recommendations on both the use of antiretrovirals and infant feeding.
Antiretroviral recommendations cover the short-term and long-term efficacy
of antiretroviral prophylactic regimens; the safety of such regimens; the
selection of resistant viral populations; women who received a sub-optimal
antepartum regimen; scaling up mother-to-child transmission prevention programs;
and choosing an antiretroviral regimen. Infant-feeding recommendations touch
on the risks of breastfeeding and replacement feeding; cessation of breastfeeding;
infant-feeding counseling; breast health; and maternal health. The document
also includes several tables detailing priority research needs. The document
is available in English, French, Russian and Spanish.
Care and support
Hayes, C. et al. Food and water safety for persons
infected with human immunodeficiency virus. Clinical Infectious Diseases
36 (Suppl. 2):S106–S109 (2003).
The authors of this article provide practical information to assist people
living with HIV/AIDS to avoid food- and water-borne illnesses. These illnesses
can cause diarrhea, nausea, vomiting, and weight loss, and may include Cryptosporidium,
Microsporidium, Salmonella, cytomegalovirus, listeriosis,
shigellosis, cholera, and Vibrio vulnificus. Several precautions
can help people living with HIV/AIDS safeguard their health. These include
avoiding raw or undercooked meat, poultry, fish, or shellfish; reheating
sauces, soups, marinades, and gravies to a boil, and leftovers to at least
165°F; avoiding raw or partially cooked eggs; keeping hot foods hot
(140°F or above) and cold foods cold (40°F or below); freezing fresh
meat, poultry, fish, and shellfish that cannot be used in a few days; avoiding
cross-contamination of foods; avoiding water drawn directly from lakes or
rivers; and boiling water for at least one minute.
Horizons Program. Integrating HIV Prevention
and Care into Maternal and Child Health care Settings: Lessons Learned from
Horizons Studies. Washington, DC : Population Council (2002).
Reporting on a consultation held in Kenya in 2001, this document highlights
the Horizons Programs operations research on a broad range of issues related
to HIV/AIDS work, with particular emphasis on care for mothers and children.
One issue the program explored was training and motivation for improving
health-worker performance. Although health-care workers are receiving training,
many still need enhance skills to provide HIV-related care. In terms of
supervising HIV services and the quality assurance of HIV testing, the report
calls for better coordination and the development of standardized supervision
and monitoring tools. Care for mothers should combine antenatal care, follow-up
for women who test positive for HIV, and efforts to help uninfected women
avoid the virus. Voluntary counseling and testing services could benefit
from the expansion of community-based health-education efforts, diversification
of post-test support sources, and continued counseling for mothers. The
success of infant-feeding counseling hinges on giving clearer guidance on
feeding practices, thus reducing confusion for both counselors and clients.
Antiretroviral treatment to prevent mother-to-child HIV transmission could
be more effective if programs were created to help communities see such
treatment as a routine component of antenatal care. Finally, male involvement
could be increased through strategies to engage directly and through general
efforts to alter harmful beliefs and behavior.
Kaleeba, N. et al. Participatory evaluation
of counselling, medical and social services of The AIDS Support Organization
(TASO) in Uganda. AIDS Care 9(1):13–26 (1997).
This paper presents the results of a participatory evaluation of the counseling,
social, and medical services provided by a Ugandan NGO known as TASO (The
AIDS Support Organization). The study used a combination of data-collection
methods including semi-structured interviews, open-ended interviews, focus
group discussions, client checklist, guidelines for observing counseling
sessions, and case studies, to gather information on key indicators. The
results indicated that TASO counseling services helped clients and their
families to cope with HIV/AIDS. Counseling was also seen to encourage clients
to discuss plans for starting income-generating activities, draft wills,
and make future plans. Furthermore, counseling can help families and the
community better accept and care for people with HIV/AIDS. The evaluation
suggested that TASO was able to bring about positive behavior changes, such
as increased HIV/AIDS-related knowledge, engaging in safer sex practices,
and consistent condom use.
Lepage, P. et al. Care of human immonudeficiency
virus-infected children in developing countries. The Pediatric Infectious
Disease Journal 17(7):581–586 (1998).
There is a need to strengthen the area of pediatric HIV/AIDS care in low-resource
settings. A literature review and postal survey were used to obtain information
on mortality, morbidity, and current standards of care. Although rates of
morbidity and mortality varied from one study to another, it was found that
rates were higher in industrialized countries. Clinical research priorities
were identified, including the impact of primary prophylaxis of opportunistic
and bacterial infections, weaning practices and duration of breastfeeding;
and HIV testing of children and families.
Nsutebu, E. et al. Scaling-up HIV/AIDS and TB
home-based care: lessons from Zambia. Health Policy and Planning
16(3):240–247 (2001).
The authors of this article maintain that home-based coverage for HIV/AIDS
and tuberculosis in Africa is currently insufficient and likely to decrease
still further. Case studies of the Lusaka Family Health Trust HBC Project
and the Ndola Catholic Diocese HBC Programme in Zambia suggest that community-care
services can be more effective if they combine HIV/AIDS and tuberculosis
services. Welfare services, such as food, appear to encourage patients to
use community-care services in low-resource areas like Zambia. The danger
of overburdening volunteers and caregivers is predicted if home-based care
programs attempt to scale up their services, and quality may be affected.
Governments need to step in and either provide direct home-based care services
or support other organizations currently offering such services. Innovative
strategies are needed to forge effective partnerships between NGOs, missionary
organizations and government services.
Pratt, R.J. et al. Kaleidoscope: a 5-year action
research project to develop nursing confidence in caring for patients with
HIV disease in west India. International Nursing News 48:164-173
(2001).
The article discusses "Kaleidoscope," an Indo-British action-research
collaboration designed to build clinical confidence and assist in mobilizing
positive changes for nurses involved in the care of patients living with
HIV in western India. The project, carried out between 1995 and 1999, was
conducted in the form of ten-day educational programs for nurses during
which facilitators applied a change intervention leading to the establishment
of action plans in the areas of infection control, health education, mutual
support, community action, pre-qualifying and post-qualifying nursing education,
nursing practice and research, policy development, and counseling support.
Twelve months later, the nurses participated in a follow-up workshop to
review progress made toward achieving their action-plan objectives. "Data
analysis revealed that the change intervention itself, together with multidisciplinary
support from colleagues, the senior status of the participant, and anticipating
and attending the follow-up of workshops, were all positively correlated
with achievement."
Segurado, A. et al. Evaluation of the care
of women living with HIV/AIDS in São Paulo, Brazil. AIDS Patient
Care and STDs 17(2):85–93 (2003).
The authors of this article administered a questionnaire to 1,068 women
in São Paulo, Brazil, from September 1999 to February 2000. The women
were patients from HIV/AIDS referral clinics, and answered questions about
the circumstances of HIV testing, the attitudes of health care personnel
during diagnosis, adherence to follow-up, services provided by care centers
and access to laboratory monitoring. Some of the women reported having experienced
indifference, discrimination, or criticism when diagnosed. Many also said
that they had unmet needs related to psychological support, nutrition, and
oral health. The authors point to the need for better training of professionals
responsible for diagnosis, and the integration of women’s health and
reproductive health programs with AIDS programs.
UNAIDS. Reaching
Out, Scaling Up: Eight Case Studies of Home and Community Care by and for
People With HIV/AIDS. Best Practice Collection (September 2001).
Available at: www.unaids.org/publications/documents/persons/JC608-ReachOut-E.pdf.
This collection of case studies aims to disseminate examples of providing
care to people living with HIV/AIDS, with a focus on projects that have
been able to increase the scale of their service provision and benefits.
The projects are: Cambodias Home Care Program, which provides referrals
to health centers, hospitals and voluntary counseling and testing centers;
the Center for Socio-Medical Assistance in Côte dIvoire, an outpatient
clinic for people living with HIV/AIDS; Ecuadors Program for AIDS Initiatives,
which funds, trains, links and supports community HIV-prevention and care
programs; the Continuum of Care Project, in Manipur State, India, which
has created core groups within hospitals, NGOs and communities to improve
the quality of services for people with HIV/AIDS; the Kariobangi Community-based
Home Care and Home-based AIDS Care Program in Nairobi, Kenya, which focuses
on HIV-positive children and those who will be or have been orphaned by
AIDS; the Bambisanani health program in South Africas Eastern Cape Province,
which provides a coordinated approach to the problems of HIV/AIDS among
migrant workers and their families, tuberculosis and HIV, and children affected
by the epidemic; the Mildmay Centre for Palliative Care in Kampala, Uganda,
which has an extensive training program aimed at improving the palliative-care
skills of the health sector, NGOs and communities; and the Partnership for
Home-based Care in Rural Areas, also in Uganda, which aims to improve home
care for AIDS in rural regions of the country. In addition to presenting
each case study, the document summarizes lessons learned and common strategies
used.
UNAIDS. AIDS
Palliative Care.
UNAIDS Technical Update. Geneva: UNAIDS (October 2000). Available at: www.unaids.org/publications/documents/care/general/JC-PalliCare-TU-E.pdf.
Palliative care is a philosophy of care that, rather than directly treating
HIV/AIDS, seeks to improve patients quality of life by relieving physical,
emotional, and spiritual pain for patients and their care givers. Palliative
care addresses physical discomfort such as pain; diarrhea and constipation;
nausea, vomiting, anorexia, and weight loss; cough and shortness of breath;
malaise, weakness, and fatigue; fever; skin problems; and brain impairment.
Palliative care also includes counseling in the form of voluntary counseling
and testing; spiritual support; and preparation for death. Finally, palliative
care seeks to address the needs of families and caregivers offering information
on topics such as basic nursing, disease transmission, psychological support,
and respite care.
UNAIDS/WHO/Ministry of Foreign Affairs
(France). Improving
Access to Care in Developing Countries: Lessons from Practice, Research,
Resources and Partnerships. Geneva: UNAIDS (2001). Available
at: www.unaids.org/publications/documents/care/acc_access/JC809-Access-to-Care-E.pdf.
Based on a meeting held in France in 2001, this report offers information
on the following issues: getting people into care; linking prevention and
care; preventing and managing opportunistic infections; monitoring HIV infection
and antiretrovirals; and nutrition and complementary therapies. Also outlined
are several research-related topics; human, material and financial resources;
and the roles and responsibilities of various parts in care and support
activities. The developing-country experiences profiled in the report include
the Benin initiative on access to antiretrovirals, lessons learned from
Brazils efforts to provide essential medicines and AIDS care; and the generic
production of HIV/AIDS-related drugs in Thailand. As an appendix, the report
includes the declaration on improving access to HIV/AIDS care in developing
countries, drawn up by the participants in the meeting.
Uys, L. The practice of community caregivers in
a home-based HIV/AIDS project in South Africa. Journal of Clinical
Nursing 11:99–108 (2002).
This article summarizes a study made of community caregivers attached to
a home-based AIDS care project—the South African Hospice Association—operating
at seven sites in South Africa. The project used the Integrated Community-based
Home Care model, which links people living with HIV/AIDS and their families,
community caregivers and hospices, clinics, and hospitals. Caregivers mainly
engaged in providing information and counseling, while also providing physical
care, to a lesser degree. They averaged five visits per month to each client.
Despite the barriers of stigma, secrecy and poverty, in addition to the
complex burden of dealing with acute illness, caregivers proved to be effective
and efficient. The author recommends that the health sector lend greater
support and advocacy to such efforts at home-based care for people living
with HIV/AIDS.
