Suchergebnisse

IntroductionHigh retention in care is paramount to reduce vertical human immunodeficiency virus (HIV) infections in prevention of mother‐to‐child transmission (PMTCT) programmes but remains low in many sub‐Saharan African countries. We aimed to assess the effects of community health worker–based defaulter tracing (CHW‐DT) on retention in care and mother‐to‐child HIV transmission, an innovative approach that has not been evaluated to date.MethodsWe analyzed patient records of 1878 HIV‐positive pregnant women and their newborns in a rural PMTCT programme in the Tsholotsho district of Zimbabwe between 2010 and 2013 in a retrospective cohort study. Using binomial regression, we compared vertical HIV transmission rates at six weeks post‐partum, and retention rates during the perinatal PMTCT period (at delivery, nevirapine [NVP] initiation at three days post‐partum, cotrimoxazole (CTX) initiation at six weeks post‐partum, and HIV testing at six weeks post‐partum) before and after the introduction of CHW‐DT in the project.ResultsMedian maternal age was 27 years (inter‐quartile range [IQR] 23 to 32) and median CD4 count was 394 cells/µL3(IQR 257 to 563). The covariate‐adjusted rate ratio (aRR) for perinatal HIV transmission was 0.72 (95% confidence intervals [95% CI] 0.27 to 1.96,p=0.504), comparing patient outcomes after and before the intervention. Among fully retained patients, 11 (1.9%) newborns tested HIV positive. ARRs for retention in care were 1.01 (95% CI 0.96 to 1.06,p=0.730) at delivery; 1.35 (95% CI 1.28 to 1.42,p<0.001) at NVP initiation; 1.78 (95% CI 1.58 to 2.01,p<0.001) at CTX initiation; and 2.54 (95% CI 2.20 to 2.93,p<0.001) at infant HIV testing. Cumulative retention after and before the intervention was 496 (85.7%) and 1083 (87.3%) until delivery; 480 (82.9%) and 1005 (81.0%) until NVP initiation; 303 (52.3%) and 517 (41.7%) until CTX initiation; 272 (47.0%) and 427 (34.4%) until infant HIV testing; and 172 (29.7%) and 405 (32.6%) until HIV test result collection.ConclusionsThe CHW‐DT intervention did not reduce perinatal HIV transmission significantly. Retention improved moderately during the post‐natal period, but cumulative retention decreased rapidly even after the intervention. We showed that transmission in resource‐limited settings can be as low as in resource‐rich countries if patients are fully retained in care. This requires structural changes to the regular PMTCT services, in which community health workers can, at best, play a complementary role.

AbstractIntroductionSexually transmitted infections (STIs) remain prevalent and are increasing in several populations. Appropriate STI diagnosis is crucial to prevent the transmission and sequelae of untreated infection. We reviewed the diagnostic accuracy of syndromic case management and existing point‐of‐care tests (POCTs), including those in the pipeline, to diagnose STIs in resource‐constrained settings.MethodsWe prioritized updating the systematic review and meta‐analysis of the diagnostic accuracy of vaginal discharge from 2001 to 2015 to include studies until 2018. We calculated the absolute effects of different vaginal flowcharts and the diagnostic performance of POCTs on important outcomes. We searched the peer‐reviewed literature for previously conducted systematic reviews and articles from 1990 to 2018 on the diagnostic accuracy of syndromic management of vaginal and urethral discharge, genital ulcer and anorectal infections. We conducted literature reviews from 2000 to 2018 on the existing POCTs and those in the pipeline.Results and discussionsThe diagnostic accuracy of urethral discharge and genital ulcer disease syndromes is relatively adequate. Asymptomatic Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections limit the use of vaginal discharge and anorectal syndromes. The pooled diagnostic accuracy of vaginal syndromic case management for CT/NG is low, resulting in high numbers of overtreatment and missed treatment. The absolute effect of POCTs was reduced overtreatment and missed treatment. Findings of the reviews on syndromic case management underscored the need for low‐cost and accurate POCTs for the identification, first, of CT/NG, and, second, of Mycoplasma genitalium (MG) and Trichomonas vaginalis (TV) and NG and MG resistance/susceptibility testing. Near‐patient POCT molecular assays for CT/NG/TV are commercially available. The prices of these POCTs remain the barrier for uptake in resource‐constrained settings. This is driving the development of lower cost solutions.ConclusionsThe WHO syndromic case management guidelines should be updated to raise the quality of STI management through the integration of laboratory tests. STI screening strategies are needed to address asymptomatic STIs. POCTs that are accurate, rapid, simple and affordable are urgently needed in resource‐constrained settings to support the uptake of aetiological diagnosis and treatment.