The objective of this study was to establish the reliability of the scored Patient-Generated Subjective Global Assessment (PG-SGA) in determining nutritional status among antiretroviral therapy (ART) naive HIV-infected adults. A descriptive, cross sectional study was conducted among outpatient medical clinics in the AIDS Support Organisation (TASO), Mulago Centre, Kampala, Uganda. The study sample totalled 217 HIV-positive patients, consisting of 60 male and 157 female patients, aged 18-67 years old. Data collection was done from April-May 2008. Results showed that only 12% of the subjects were underweight and over half (58.2%) had normal weight. The PG-SGA had low sensitivity (69.2%) and specificity (57.1%) at categorising the risk for malnutrition indicated by Body Mass Index of less than 18.5. The authors note that there was a high prevalence of malnutrition among the study group, but the PGSGA could not adequately discriminate between underweight and normal patients. The tool was not reliable enough for determining nutritional status in this population.
Equity and HIV/AIDS
The objectives of this study were to compare undernutrition between groups of HIV-positive and HIV-negative children undergoing anti-retroviral therapy (ART) in Dar es Salaam, Tanzania. From September to October 2010, researchers conducted a cross-sectional survey among 213 ART-treated HIV-positive and 202 HIV-negative children in Dar es Salaam, Tanzania. They found that ART-treated HIV-positive children had higher rates of undernutrition than their HIV-negative counterparts. Among the ART-treated HIV-positive children, 78 (36.6%) were stunted, 47 (22.1%) were underweight, and 29 (13.6%) were wasted. Food insecurity was prevalent in over half of ART-treated HIV-positive children's households. Furthermore, ART-treated HIV-positive children were more likely to be orphaned, to be fed less frequently, and to have lower body weight at birth compared to HIV-negative children. The researchers conclude that HIV and AIDS is associated with an increased burden of child underweight status and wasting, even among ART-treated children. In addition to increasing coverage of ART among HIV-positive children, interventions to ameliorate poor nutrition status may be necessary in this and similar settings. Such interventions should aim at promoting adequate feeding patterns, as well as preventing and treating diarrhoea.
Paediatric antiretroviral adherence is difficult to assess, the authors of this paper argue, and subjective measures are affected by reporting bias, which in turn may depend on psychosocial factors such as alcohol use and depression. In this study, they enrolled 56 child caregiver dyads from Cape Town, South Africa, and followed their adherence over one month via various methods. The Alcohol Use Disorder Inventory Tool and Beck Depression Inventory 1 were used to assess participants’ alcohol use and levels of depression and their effect on drug adherence. The median age of the children was four years, and median time on antiretroviral therapy (ART) was 20 months. Increased time on ART was associated with poorer adherence via three-day recall. Alcohol use was inversely associated with adherence. Having a mother as a caregiver and shorter time on highly active antiretroviral therapy (HAART) were significantly associated with better adherence. The authors conclude that paediatric adherence is affected by caregiver alcohol use, but the caregiver’s relationship to the child is most important. This small study suggests that interventions should aim to keep mothers healthy and alive, as well as alcohol-free.
In this study, researchers aimed to assess the prevalence of primary resistance in six African countries after anti-retroviral therapy (ART) roll-out and to determine if wider use of ART in sub-Saharan Africa is associated with rising prevalence of drug resistance. They conducted a cross-sectional study in antiretroviral-naive adults infected with HIV-1 who had not started first-line ART, recruited between 2007 and 2009 from 11 regions in Kenya, Nigeria, South Africa, Uganda, Zambia, and Zimbabwe. Of a total of 2,590 participants, 2,436 (94.1%) had a pretreatment genotypic resistance result. Drug class-specific resistance prevalence was 2.5% for nucleoside reverse-transcriptase inhibitors (NRTIs), 3.3% for non-NRTIs (NNRTIs), 1.3% for protease inhibitors, and 1.2% for dual-class resistance to NRTIs and NNRTIs. The most common drug-resistance mutations were K103N (1.8%), thymidine analogue mutations (1.6%), M184V (1.2%), and Y181C/I (0.7%). The higher prevalence of primary drug resistance in Uganda than in other African countries is probably related to the earlier start of ART roll-out in Uganda, the authors conclude. Resistance surveillance and prevention should be prioritised in settings where ART programmes are scaled up.
HIV-positive children are at high risk of drug resistance, which is of particular concern in settings where antiretroviral options are limited. In this review, the authors explore resistance rates and patterns among children in developing countries in whom antiretroviral treatment has failed. They did a systematic search of online databases and conference abstracts and included studies reporting HIV-1 drug resistance after failure of first-line paediatric regimens in children (<18 years) in resource-poor regions (Latin America, Africa and Asia). They retrieved 1,312 citations, of which 30 studies reporting outcomes in 3,241 children were eligible. Viruses with resistance-associated mutations were isolated from 90% of children. The prevalence of mutations associated with nucleoside reverse transcriptase inhibitors was 80%, with non-nucleoside reverse transcriptase inhibitors was 88%, and with protease inhibitors was 54%. Methods to prevent treatment failure, including adequate paediatric formulations and affordable salvage treatment options are urgently needed, the authors conclude.
There is an urgent need for valid, reliable, and simple-to-use screening tools for HIV-associated dementia (HAD) in South Africa, as little is known about its impact on South Africa's 5.5 million people living with HIV (PLWH). Screening for HAD in South Africa involves several challenges, including a lack of culturally appropriate and validated screening tools and a shortage of trained personnel to conduct screening. This study examined rates of positive HAD screens as determined by the cut-off score on the International HIV Dementia Scale (IHDS) administered by non-specialist community health workers (CHWs) in South Africa and examined associations between positive HAD screens and common risk factors for HAD. Sixty-five HIV-positive individuals on antiretroviral therapy (ART) with low CD4 counts and documented ART adherence problems were administered a battery of demographic, psychiatric and neurocognitive screening measures. Positive HAD screens were present in 80% of the sample. Presence of a current alcohol dependence disorder and CD4 counts of 200 or lower were significantly associated with positive HAD screens. HIV-positive South Africans on ART with low CD4 counts and ART adherence problems may be at a very high risk for HAD, the authors stress, highlighting the need for more routine screening and monitoring of neurocognitive functions among South Africa's millions of PLWH on ART. Future research is needed to validate IHDS performance against a gold standard neurocognitive battery for the detection of HAD and to compare performance of CHWs to expert health care personnel in administering the IHDS.
In recent years, the ways in which HIV and AIDS-focused programmes interact with the delivery of other health services is often discussed, but the evidence as to whether HIV and AIDS programmes strengthen or distort overall health services is limited. The aim of this study was to examine the effect of a PEPFAR-funded HIV and AIDS programme on six government-run general clinics in Kampala, Uganda. Longitudinal information on the delivery of health services was collected at each clinic. Monthly changes in the volume of HIV and non-HIV services were analysed, along with a cross-sectional survey utilising patient exit interviews to compare perceptions of the experiences of patients receiving HIV care and those receiving non-HIV care. All HIV service indicators showed a positive change after the HIV programme began. For non-HIV and AIDS health services, TB lab tests and diagnoses increased significantly, and malaria service indicators also improved. Patients’ overall impressions were positive in both the HIV and non-HIV groups, with more than 90% responding favourably about their experiences. This study shows that when a collaboration is established to strengthen existing health systems, in addition to providing HIV and AIDS services in a setting in which other primary health care is being delivered, there are positive effects not only on HIV and AIDS services, but also on other essential services.
According to Peter Salama, head of the United Nations Children’s Fund (UNICEF) in Zimbabwe, between 6, 000 and 7,000 children die per year in Zimbabwe as a result of HIV and in most cases it is because these children have failed to access paediatric anti-retroviral therapy (ART). The lack of technology meant that many children were not being tested for HIV, Salama said at an AIDS conference in Harare in September 2011. ‘It is important to have an early infant diagnosis as 50% of those children not tested will not be able to reach the age of two,’ he added. About one in seven Zimbabweans is infected with HIV, and about 13% of pregnant women are HIV-positive in Zimbabwe. However, the relatively high costs of medical care and the poor economy means many women give birth at home or never return to hospital for post-natal checkups.
Uganda's longstanding campaigners in its 30-year fight against HIV have expressed discontent with the government's treatment and prevention approaches. Milly Katana, a long-term activist and one of the inaugural board members of the Global Fund to fight HIV, Tuberculosis and Malaria, said that while the injection of millions of dollars had saved lives through treatment, it had also commercialised the industry, leaving it open to abuse by those not truly interested in defeating the epidemic. For Rubaramira Ruranga, executive director of the National Guidance and Empowerment Network of People Living with HIV/AIDS in Uganda, the lack of proper co-ordination at the top of the HIV response has led to disorganisation in the rest of the sector. He noted that Uganda has strong policies to fight HIV, that are not fully implemented. Gideon Byamugisha, founder member of the International Network of Religious Leaders Living with and Personally Affected by HIV/AIDS, argued that the focus on prevention through safe sex has meant that the 21% of new infections that occur through mother-to-child transmission are being overlooked.
Researchers in this study investigated sub-optimal patient adherence to antiretroviral therapy in 18 clinical sites in rural Zambézia Province, Mozambique. They conducted 18 community and clinic focus groups in six rural districts, interviewing 76 women and 88 men, of whom 124 were community participants (CPs) and 40 were health care workers (HCWs) who provide care for those living with HIV. CP focus groups noted a lack of confidentiality and poor treatment by hospital staff, doubt as to the benefits of antiretroviral therapy and sharing medications with family members. Men expressed a greater concern about poor treatment by HCW than women and health care workers blamed patient preference for traditional medicine and the side effects of medication for poor adherence. In conclusion, perspectives of CP and HCW likely reflect differing socio-cultural and educational backgrounds. Health care workers must understand community perspectives on causes of suboptimal adherence as a first step toward effective intervention.