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.

IntroductionMortality among HIV‐positive adults awaiting antiretroviral therapy (ART) has previously been found to be high. Here, we compare adolescent pre‐ART mortality to that of adults in a public sector HIV care programme in Bulawayo, Zimbabwe.MethodsIn this retrospective cohort study, we compared adolescent pre‐ART outcomes with those of adults enrolled for HIV care in the same clinic. Adolescents were defined as those aged 10–19 at the time of registration. Comparisons of means and proportions were carried out using two‐tailed sample t‐tests and chi‐square tests respectively, for normally distributed data, and the Mann–Whitney U‐tests for non‐normally distributed data. Loss to follow‐up (LTFU) was defined as missing a scheduled appointment by three or more months.ResultsBetween 2004 and 2010, 1382 of 1628 adolescents and 7557 of 11,106 adults who registered for HIV care met the eligibility criteria for ART. Adolescents registered at a more advanced disease stage than did adults (83% vs. 73% WHO stage III/IV, respectively, p<0.001), and the median time to ART initiation was longer for adolescents than for adults [21 (10–55) days vs. 15 (7–42) days, p<0.001]. Among the 138 adolescents and 942 adults who never commenced ART, 39 (28%) of adolescents and 135 (14%) of adults died, the remainder being LTFU. Mortality among treatment‐eligible adolescents awaiting ART was significantly higher than among adults (3% vs. 1.8%, respectively, p=0.004).ConclusionsAdolescents present to ART services at a later clinical stage than adults and are at an increased risk of death prior to commencing ART. Improved and innovative HIV case‐finding approaches and emphasis on prompt ART initiation in adolescents are urgently needed. Following registration, defaulter tracing should be used, whether or not ART has been commenced.