Provider-initiated testing and counselling programmes in sub-Saharan Africa: a systematic review of their operational implementation.

OBJECTIVE: The routine offer of an HIV test during patient-provider encounters is gaining momentum within HIV treatment and prevention programmes. This review examined the operational implementation of provider-initiated testing and counselling (PITC) programmes in sub-Saharan Africa. DESIGN AND METHODS: PUBMED, EMBASE, Global Health, COCHRANE Library and JSTOR databases were searched systematically for articles published in English between January 2000 and November 2010. Grey literature was explored through the websites of international and nongovernmental organizations. Eligibility of studies was based on predetermined criteria applied during independent screening by two researchers. RESULTS: We retained 44 studies out of 5088 references screened. PITC polices have been effective at identifying large numbers of previously undiagnosed individuals. However, the translation of policy guidance into practice has had mixed results, and in several studies of routine programmes the proportion of patients offered an HIV test was disappointingly low. There were wide variations in the rates of acceptance of the test and poor linkage of those testing positive to follow-up assessments and antiretroviral treatment. The challenges encountered encompass a range of areas from logistics, to data systems, human resources and management, reflecting some of the weaknesses of health systems in the region. CONCLUSIONS: The widespread adoption of PITC provides an unprecedented opportunity for identifying HIV-positive individuals who are already in contact with health services and should be accompanied by measures aimed at strengthening health systems and fostering the normalization of HIV at community level. The resources and effort needed to do this successfully should not be underestimated

Iterative approach to the Schwinger variational principle for electron-molecule collisions

We present an iterative approach which uses the Schwinger variational principle to solve the Lippmann-Schwinger equation for electron-molecule scattering. This method combines the use of discrete basis functions to describe the effects of the noncentral molecular potential with an iterative procedure which provides systematic convergence of the scattering solutions. Results for electron-H2 scattering in the static-exchange approximation show that the method converges rapidly and gives very accurate results

Pregnancy and contraceptive use among women participating in an HIV prevention trial in Tanzania.

OBJECTIVES: Information on pregnancy rates and factors associated with pregnancy and contraceptive use is important for clinical trials in women in sub-Saharan Africa where withdrawal of investigational products may be required in the event of pregnancy with a consequent effect on sample size and trial power. METHODS: A prospective cohort analysis of pregnancy and contraceptive use was conducted in Tanzanian women enrolled in a randomised placebo-controlled trial of herpes simplex virus-suppressive therapy with acyclovir to measure the effect on HIV incidence in HIV-negative women and on genital and plasma HIV viral load in HIV-positive women. The cohort was followed every 3 months for 12-30 months. Women at each visit were categorised into users or non-users of contraception. Pregnancy rates and factors associated with pregnancy incidence and contraceptive use were measured. RESULTS: Overall 254 of 1305 enrolled women became pregnant at least once during follow-up (pregnancy rate: 12.0/100 person-years). Younger age, being unmarried, higher baseline parity and changes in contraceptive method during follow-up were independently associated with pregnancy. Having paid sex and being HIV positive were associated with lower risk of pregnancy. Uptake of contraception was associated with young age, being unmarried, occupation, parity and the number and type of sexual partners. CONCLUSIONS: Data on use of contraceptive methods and risk factors for pregnancy can help to guide decisions on trial eligibility and the need for additional counselling. Mandatory reliable contraceptive use in study participants may be required to reduce pregnancy rates in studies where pregnancy is contraindicated

Measurement and predictors of adherence in a trial of HSV suppressive therapy in Tanzania.

This study estimates adherence and identifies predictors of good adherence among 1305 Tanzanian women participating in a randomised, double-blind, placebo-controlled trial of HSV suppressive therapy to reduce HIV incidence or genital HIV shedding. Women were randomised to acyclovir 400mg BD or placebo and followed every three months for 12-30 months. Adherence was assessed by tablet counts. Random urine samples, collected between 6 and 24 months, were tested for acyclovir. At 12, 24 and 30 month visits, 56%, 52% and 54% of women on treatment had adherence >or=90%, respectively. Factors independently associated with good adherence (taking >or=90% of tablets in the preceding 3-months) included older age, understanding trial concepts at enrolment, living >2 years in the screening site, receiving an unannounced tablet check visit, using oral contraception at screening, living in the same site and house as the previous visit, accessing VCT during the trial, recent malaria and not having a positive pregnancy test. Overall, 55% of urine samples from women randomised to acyclovir had detectable acyclovir. Additional, tailored adherence strategies may be needed for younger, more mobile women and those who have not used oral contraception, which may sensitise them to daily tablet-taking. Use of biomarkers may alert investigators to adherence problems

HIV Infection among Young People in Northwest Tanzania: The Role of Biological, Behavioural and Socio-Demographic Risk Factors.

BACKGROUND: Young people are at high risk of HIV and developing appropriate prevention programmes requires an understanding of the risk factors for HIV in this age group. We investigated factors associated with HIV among participants aged 15-30 years in a 2007-8 cross-sectional survey nested within a community-randomised trial of the MEMA kwa Vijana intervention in 20 rural communities in northwest Tanzania. METHODS: We analysed data for 7259(53%) males and 6476(47%) females. Using a proximate-determinant conceptual framework and conditional logistic regression, we obtained sex-specific Odds Ratios (ORs) for the association of HIV infection with socio-demographic, knowledge, behavioural and biological factors. RESULTS: HSV-2 infection was strongly associated with HIV infection (females: adjOR 4.4, 95%CI 3.2-6.1; males: adjOR 4.2, 95%CI 2.8-6.2). Several socio-demographic factors (such as age, marital status and mobility), behavioural factors (condom use, number and type of sexual partnerships) and biological factors (blood transfusion, lifetime pregnancies, genital ulcers, Neisseria gonorrhoeae) were also associated with HIV infection. Among females, lifetime sexual partners (linear trend, p<0.001), ≥2 partners in the past year (adjOR 2.0, 95%CI 1.4-2.8), ≥2 new partners in the past year (adjOR 1.9 95%CI 1.2, 3.3) and concurrent partners in the past year (adjOR 1.6 95%CI 1.1, 2.4) were all associated with HIV infection. CONCLUSIONS: Efforts must be intensified to find effective interventions to reduce HSV-2. Effective behavioural interventions focusing on reducing the number of sexual partnerships and risk behaviour within partnerships are also needed. An increase in risky sexual behaviour may occur following marriage dissolution or when a young woman travels outside of her community and interventions addressing the needs of these subgroups of vulnerable women may be important. TRIAL REGISTRATION: ClinicalTrial.gov NCT00248469

A systematic review of ethnic minority women’s experiences of perinatal mental health conditions and services in Europe

Background Women from ethnic minority groups are at greater risk of developing mental health problems. Poor perinatal mental health impacts on maternal morbidity and mortality and can have a devastating impact on child and family wellbeing. It is important to ensure that services are designed to meet the unique needs of women from diverse backgrounds. Aim The aim of the review was to explore ethnic minority women's experiences of perinatal mental ill health, help-seeking and perinatal mental health services in Europe. Data sources Searches included CINAHL, Maternity and Infant Care, MEDLINE and PsycINFO with no language or date restrictions. Additional literature was identified by searching reference lists of relevant studies. Design This was a mixed method systematic review. Study selection, appraisal and data extraction were conducted by two researchers independently. A convergent approach was adopted for the analysis and the data were synthesised thematically. Results The 15 eligible studies included women from a range of minority ethnic backgrounds and were all undertaken in the United Kingdom (UK). Seven overarching themes were identified; awareness and beliefs about mental health, isolation and seeking support, influence of culture, symptoms and coping strategies, accessing mental health services, experiences of mental health services and what women want. Conclusion Lack of awareness about mental ill health, cultural expectations, ongoing stigma, culturally insensitive and fragmented health services and interactions with culturally incompetent and dismissive health providers all impact on ethnic minority women's ability to receive adequate perinatal mental health support in the UK. Future research should focus on in-depth exploration of the experiences of these women across multiple European settings and interventions to reduce health inequalities among vulnerable mothers and families affected by perinatal mental ill health

The impact of a human papillomavirus (HPV) vaccination campaign on routine primary health service provision and health workers in Tanzania: a controlled before and after study.

BACKGROUND: The burden of cervical cancer and shortage of screening services in Tanzania confers an urgent need for human papillomavirus (HPV) vaccination. However, the sustainability and impact of another new vaccine campaign in an under-resourced health system requires consideration. We aimed to determine the impact of the government's school-based HPV vaccine campaign in Kilimanjaro region on the provision of routine primary health services and staff workload. METHODS: Data on daily numbers of consultations were collected from health facility register books in 63 dispensaries and health centres in North-West Tanzania for 20 weeks in 2014. Changes in outpatient, antenatal care (ANC), family planning (FP) and immunisation service activity levels before, during and after the two HPV vaccination campaigns in 2014 in 30 facilities within Kilimanjaro region ('intervention facilities') were compared with changes in activity levels in 33 facilities in Arusha region ('controls'). Qualitative interviews were conducted with health workers in Kilimanjaro region who delivered HPV vaccination and those who remained at the facility during in-school HPV vaccine delivery to explore perceptions of workload and capacity. RESULTS: Health facility activity levels were low and very variable in both regions. Controlling for district, facility type, catchment population, clinical staff per 1000 catchment population and the timing of other campaigns, no evidence of a decrease in consultations at the health facility during HPV vaccination week was found across outpatient, ANC, routine immunisation and FP services. However, compared to the average week before and after the campaign, health workers reported longer working hours and patient waiting times, feeling over-stretched and performing duties outside their normal roles whilst colleagues were absent from the facility conducting the HPV vaccine campaign. CONCLUSION: Qualitative interviews with health workers revealed that staff absence from the health facility is common for a number of reasons, including vaccination campaigns. Health workers perceived that the absence of their colleagues increased the workload at the health facility. The numbers of consultations for each service on 'normal days' were low and highly variable and there was no clear detrimental effect of the HPV vaccination campaign on routine health service activity

Costs of delivering human papillomavirus vaccination to schoolgirls in Mwanza Region, Tanzania.

BACKGROUND: Cervical cancer is the leading cause of female cancer-related deaths in Tanzania. Vaccination against human papillomavirus (HPV) offers a new opportunity to control this disease. This study aimed to estimate the costs of a school-based HPV vaccination project in three districts in Mwanza Region (NCT ID: NCT01173900), Tanzania and to model incremental scaled-up costs of a regional vaccination program. METHODS: We first conducted a top-down cost analysis of the vaccination project, comparing observed costs of age-based (girls born in 1998) and class-based (class 6) vaccine delivery in a total of 134 primary schools. Based on the observed project costs, we then modeled incremental costs of a scaled-up vaccination program for Mwanza Region from the perspective of the Tanzanian government, assuming that HPV vaccines would be delivered through the Expanded Programme on Immunization (EPI). RESULTS: Total economic project costs for delivering 3 doses of HPV vaccine to 4,211 girls were estimated at about US$349,400 (including a vaccine price of US$5 per dose). Costs per fully-immunized girl were lower for class-based delivery than for age-based delivery. Incremental economic scaled-up costs for class-based vaccination of 50,290 girls in Mwanza Region were estimated at US$1.3 million. Economic scaled-up costs per fully-immunized girl were US$26.41, including HPV vaccine at US$5 per dose. Excluding vaccine costs, vaccine could be delivered at an incremental economic cost of US$3.09 per dose and US$9.76 per fully-immunized girl. Financial scaled-up costs, excluding costs of the vaccine and salaries of existing staff were estimated at US$1.73 per dose. CONCLUSIONS: Project costs of class-based vaccination were found to be below those of age-based vaccination because of more eligible girls being identified and higher vaccine uptake. We estimate that vaccine can be delivered at costs that would make HPV vaccination a very cost-effective intervention. Potentially, integrating HPV vaccine delivery with cost-effective school-based health interventions and a reduction of vaccine price below US$5 per dose would further reduce the costs per fully HPV-immunized girl

Access and Attitudes to HPV Vaccination amongst Hard-To-Reach Populations in Kenya.

BACKGROUND: Sub-Saharan Africa bears the greatest burden of cervical cancer. Human papillomavirus (HPV) vaccination programmes to prevent the disease will need to reach vulnerable girls who may not be able access health and screening services in the future. We conducted formative research on facilitators and barriers to HPV vaccination and potential acceptability of a future HPV vaccination programme amongst girls living in hard-to-reach populations in Kenya. METHODS: Stakeholder interviews with Ministry of Health staff explored barriers to and support for the uptake of HPV vaccination. A situation assessment was conducted to assess community services in Maasai nomadic pastoralist communities in Kajiado County and in Korogocho informal settlement in Nairobi city, followed by focus group discussions (n=14) and semi-structured interviews (n=28) with health workers, parents, youth, and community and religious leaders. These covered marriage, knowledge of cervical cancer and HPV, factors that might inhibit or support HPV vaccine uptake and intention to accept HPV vaccine if a programme was in place. RESULTS: Reported challenges to an HPV vaccination programme included school absenteeism and drop-out, early age of sex and marriage, lack of parental support, population mobility and distance from services. Despite little prior knowledge of cervical cancer and HPV, communities were interested in receiving HPV vaccination. Adequate social mobilisation and school-based vaccination, supplemented by out-reach activities, were considered important facilitating factors to achieve high coverage. There was some support for a campaign approach to vaccine delivery. CONCLUSIONS: Given the high level of support for a vaccine against cervical cancer and the experience of reaching pastoralist and slum-dwellers for other immunizations, implementing an HPV vaccine programme should be feasible in such hard-to-reach communities. This may require additional delivery strategies in addition to the standard school-based delivery, with vaccine offered at multiple venues, potentially through a campaign approach