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Death without weeping: the violence of everyday life in Brazil

Introduction:
Although prevention of mother-to-child HIV transmission (PMTCT) programs are widely implemented, many children do not benefit from them because of loss to follow-up (LTFU). We conducted a systematic review to determine the magnitude of infant/baby LTFU along the PMTCT cascade.

Methods:
Eligible publications reported infant LTFU outcomes from standard care PMTCT programs (not intervention studies) at any stage of the cascade. Literature searches were conducted in Medline, Embase, Web of Knowledge, CINAHL Plus, and Maternity and Infant Care. Extracted data included setting, methods of follow-up, PMTCT regimens, and proportion and timing of LTFU. For programs in sub-Saharan Africa, random-effects meta-analysis was done using Stata v10. Because of heterogeneity, predictive intervals (PrIs; approximate 95% confidence intervals of a future study based on extent of observed heterogeneity) were computed.

Results:
A total of 826 papers were identified; 25 publications were eligible. Studies were published from 2001 to 2012 and were mostly from sub-Saharan Africa (three were from India, one from UK and one from Ireland). There was extensive heterogeneity in findings. Eight studies reported on LTFU of pregnant HIV-positive women between antenatal care (ANC) registration and delivery, which ranged from 10.9 to 68.1%, pooled proportion 49.08% [95% confidence interval (CI) 39.6–60.9%], and PrI 22.0–100%. Fourteen studies reported LTFU of infants within 3 months of delivery, range 4.8–75%, pooled proportion 33.9% (27.6–41.5), and PrI 15.4–74.2. Children were also lost after HIV testing; this was reported in five studies, pooled estimate 45.5% (35.9–57.6), PrI 18.7–100%. Programs that actively tracked defaulters had better retention outcomes.

Conclusion:
There is unacceptable infant LTFU from PMTCT programs. Countries should incorporate defaulter-tracking as standard to improve retention.

/pdf/the-magnitude-of-loss-to-follow-up-of-hiv-exposed-infants-470kd1g85e.pdf

The magnitude of loss to follow-up of HIV-exposed infants along the prevention of mother-to-child HIV transmission continuum of care: a systematic review and meta-analysis

paper reviews the legal and policy context of HIV disclosure in sub-Saharan Africa, as well as what is known about rates, consequences and social context of disclosure, with special attention to gender issues and the role of health services. Persistent rates of nondisclosure by those diagnosed with HIV raise difficult ethical, public health and human rights questions about how to protect the medical confidentiality, health and well-being of people living with HIV on the one hand, and how to protect partners and children from HIV transmission on the other. Both globally and within the sub-Saharan African region, a spate of recent laws, policies and programmes have tried to encourage or - in some cases - mandate HIV disclosure. These policies have generated ethical and policy debates. While there is consensus that the criminalization of transmission and nondisclosure undermines rights while serving little public health benefit, there is less clarity about the ethics of third party notification, especially in resource-constrained settings. Despite initiatives to encourage voluntary HIV disclosure and to increase partner testing in sub-Saharan Africa, health workers continue to grapple with difficult challenges in the face of nondisclosure, and often express a need for more guidance and support in this area. A large body of research indicates that gender issues are key to HIV disclosure in the region, and must be considered within policies and programmes. Taken as a whole, this evidence suggests a need for more attention to the challenges and dilemmas faced by both clients and providers in relation to HIV disclosure in this region and for continued efforts to consider the perspectives and rights of all those affected.

/pdf/the-social-and-gender-context-of-hiv-disclosure-in-sub-3htwhcb0n2.pdf

The social and gender context of HIV disclosure in sub-Saharan Africa: A review of policies and practices.

BACKGROUND: Services to diagnose early infant HIV infection should be offered at the 6-week immunization visit. Despite high 6-week immunization attendance the coverage of early infant diagnosis (EID) is low in many sub-Saharan countries. We explored reasons for such missed opportunities at 6-week immunization visits. METHODS: We used data from 2 cross-sectional surveys conducted in 2010 in South Africa. A national assessment was undertaken among randomly selected public facilities (n = 625) to ascertain procedures for EID. A subsample of these facilities (n = 565) was revisited to assess the HIV status of 4- to 8-week-old infants receiving 6-week immunization. We examined potential missed opportunities for EID. We used logistic regression to assess factors influencing maternal intention to report for EID at 6-week immunization visits. RESULTS: EID services were available in >95% of facilities and 72% of immunization service points (ISPs). The majority (68%) of ISPs provide EID for infants with reported or documented (on infants Road-to-Health Chart/booklet-iRtHC) HIV exposure. Only 9% of ISPs offered provider-initiated counseling and testing for infants of undocumented/unknown HIV exposure. Interviews with self-reported HIV-positive mothers at ISPs revealed that only 55% had their HIV status documented on their iRtHC and 35% intended to request EID during 6-week immunization. Maternal nonreporting for EID was associated with fear of discrimination poor adherence to antiretrovirals and inadequate knowledge about mother-to-child HIV transmission. CONCLUSIONS: Missed opportunities for EID were attributed to poor documentation of HIV status on iRtHC inadequate maternal knowledge about mother-to-child HIV transmission fear of discrimination and the lack of provider-initiated counseling and testing service for undocumented unknown or undeclared HIV-exposed infants.

/pdf/missed-opportunities-for-early-infant-hiv-diagnosis-results-4yupch9gad.pdf

Missed opportunities for early infant HIV diagnosis : results of a national study in South Africa

This paper reviews the legal and policy context of HIV disclosure in sub-Saharan Africa, as well as what is known about rates, consequences and social context of disclosure, with special attention to gender issues and the role of health services. Persistent rates of nondisclosure by those diagnosed with HIV raise difficult ethical, public health and human rights questions about how to protect the medical confidentiality, health and well-being of people living with HIV on the one hand, and how to protect partners and children from HIV transmission on the other. Both globally and within the sub-Saharan African region, a spate of recent laws, policies and programmes have tried to encourage or - in some cases - mandate HIV disclosure. These policies have generated ethical and policy debates. While there is consensus that the criminalization of transmission and nondisclosure undermines rights while serving little public health benefit, there is less clarity about the ethics of third party notification, especially in resource-constrained settings. Despite initiatives to encourage voluntary HIV disclosure and to increase partner testing in sub-Saharan Africa, health workers continue to grapple with difficult challenges in the face of nondisclosure, and often express a need for more guidance and support in this area. A large body of research indicates that gender issues are key to HIV disclosure in the region, and must be considered within policies and programmes. Taken as a whole, this evidence suggests a need for more attention to the challenges and dilemmas faced by both clients and providers in relation to HIV disclosure in this region and for continued efforts to consider the perspectives and rights of all those affected.
Cet article fait une revue du contexte legal et politique de la revelation du statut VIH, ainsi que des donnees concernant ses niveaux, ses consequences et son contexte social, avec une attention particuliere aux questions de genre et au role des structures de sante. La persistance de bas niveaux de revelation du statut par ceux qui recoivent un diagnostic positif souleve des questions difficiles dans les domaines de l'ethique, des droits humains et de la sante publique. Ces questions on trait aux moyens, d'une part, de proteger la confidentialite, la sante et le bien-etre des personnes vivant avec le VIH, et d'autre part, d'eviter la transmission du virus a leurs partenaires et leurs enfants. Au niveau global et en Afrique sub-Saharienne, beaucoup de lois, politiques et programmes ont recemment essaye d'encourager - et dans certains cas d'obliger - la revelation du statut VIH, ce qui a donne lieu a des debats d'ethique. Alors qu'il y a un consensus sur le fait que la criminalisation de la transmission et de la non revelation du statut va a l'encontre des droits humains et n'est pas utile du point de vue de la sante publique, la notification des tiers est plus controversee, surtout dans les pays a ressources limitees. Malgre des initiatives visant a encourager la revelation volontaire du statut VIH et l'augmentation du depistage des partenaires en Afrique sub-Saharienne, les professionnels de la sante continuent a rencontrer des difficultes vis-a-vis de la revelation du statut et auraient besoin d'etre mieux guides et soutenus pour faire face a ces difficultes. Les recherches montrent que les questions de genre sont capitales pour la revelation du statut et doivent etre incluses dans les politiques et programmes. En general, les donnees disponibles suggerent qu'il faudrait donner plus d'importance aux defis et dilemmes auxquels font face les clients et le personnel de sante concernant la revelation du statut VIH dans la region et qu'il faudrait continuer a faire des efforts pour considerer les perspectives et les droits des personnes impliquees.

The social and gender context of HIV disclosure in sub-Saharan Africa : a review of policies and practices : original article

HIV-infected infants and young children are at high risk of serious illness and death. Morbidity and mortality can be greatly reduced through early infant diagnosis (EID) of HIV and timely initiation of antiretroviral therapy (ART). Despite global efforts to scale-up of EID and infant ART, uptake of these services in resource poor, high HIV burden countries remain low. We conducted a qualitative study of 59 HIV-infected women to identify and explore barriers women face in accessing HIV testing and care for their infants. To capture different perspectives, we included mothers whose infants were known positive (n=9) or known negative (n=14), mothers of infants with unknown HIV status (n=13), and pregnant HIV-infected women (n=20). Five important themes emerged: lack of knowledge regarding EID and infant ART, the perception of health care workers as authority figures, fear of disclosure of own and/or child's HIV status, lack of psychosocial support, and intent to shorten the life of the child. A com...

“They Have Already Thrown Away Their Chicken”: barriers affecting participation by HIV-infected women in care and treatment programs for their infants in Blantyre, Malawi

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“They Have Already Thrown Away Their Chicken”: barriers affecting participation by HIV-infected women in care and treatment programs for their infants in Blantyre, Malawi