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RHO archives : Topics : HIV/AIDS

Annotated Bibliography

This is page 2 of the HIV/AIDS Annotated Bibliography. This page contains:

To access more bibliographic entries, visit page 1 or page 3, or return to the complete list of topics covered in the HIV/AIDS Annotated Bibliography. Bibliographic entries related to additional HIV/AIDS-realted issues may be found on the Special Focus pages. Be sure to use the Glossary if you are unfamiliar with any of the terms on this page.

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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.

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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.

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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.

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