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BackgroundNew WHO guidelines recommend initiation of antiretroviral therapy for HIV-positive adults with CD4 counts of 500 cells per μL or less, a higher threshold than was previously recommended. Country decision makers have to decide whether to further expand eligibility for antiretroviral therapy accordingly. We aimed to assess the potential health benefits, costs, and cost-effectiveness of various eligibility criteria for adult antiretroviral therapy and expanded treatment coverage.MethodsWe used several independent mathematical models in four settings-South Africa (generalised epidemic, moderate antiretroviral therapy coverage), Zambia (generalised epidemic, high antiretroviral therapy coverage), India (concentrated epidemic, moderate antiretroviral therapy coverage), and Vietnam (concentrated epidemic, low antiretroviral therapy coverage)-to assess the potential health benefits, costs, and cost-effectiveness of various eligibility criteria for adult antiretroviral therapy under scenarios of existing and expanded treatment coverage, with results projected over 20 years. Analyses assessed the extension of eligibility to include individuals with CD4 counts of 500 cells per μL or less, or all HIV-positive adults, compared with the previous (2010) recommendation of initiation with CD4 counts of 350 cells per μL or less. We assessed costs from a health-system perspective, and calculated the incremental cost (in US$) per disability-adjusted life-year (DALY) averted to compare competing strategies. Strategies were regarded very cost effective if the cost per DALY averted was less than the country's 2012 per-head gross domestic product (GDP; South Africa: $8040; Zambia: $1425; India: $1489; Vietnam: $1407) and cost effective if the cost per DALY averted was less than three times the per-head GDP.FindingsIn South Africa, the cost per DALY averted of extending eligibility for antiretroviral therapy to adult patients with CD4 counts of 500 cells per μL or less ranged from $237 to $1691 per DALY averted compared with 2010 guidelines. In Zambia, expansion of eligibility to adults with a CD4 count threshold of 500 cells per μL ranged from improving health outcomes while reducing costs (ie, dominating the previous guidelines) to $749 per DALY averted. In both countries results were similar for expansion of eligibility to all HIV-positive adults, and when substantially expanded treatment coverage was assumed. Expansion of treatment coverage in the general population was also cost effective. In India, the cost for extending eligibility to all HIV-positive adults ranged from $131 to $241 per DALY averted, and in Vietnam extending eligibility to patients with CD4 counts of 500 cells per μL or less cost $290 per DALY averted. In concentrated epidemics, expanded access for key populations was also cost effective.InterpretationOur estimates suggest that earlier eligibility for antiretroviral therapy is very cost effective in low-income and middle-income settings, although these estimates should be revisited when more data become available. Scaling up antiretroviral therapy through earlier eligibility and expanded coverage should be considered alongside other high-priority health interventions competing for health budgets.FundingBill & Melinda Gates Foundation, WHO.

Objective To estimate the incremental cost over 5 years of a policy switch from the Option B to the Option B+ protocol for the prevention of mother-to-child transmission (PMTCT) of the human immunodeficiency virus (HIV). Methods Data from cost studies and other published sources were used to determine the cost, per woman and per cohort (1000 breastfeeding and 1000 non-breastfeeding women), of switching from Option B (maternal triple antiretroviral [ARV] regimen during pregnancy and breastfeeding plus daily nevirapine for the infant for 6 weeks) to Option B+ (maternal triple ARV regimen initiated during pregnancy and continued for life). The variables used to model the different scenarios were maternal CD4+ T lymphocyte (CD4+ cell) count (350-500 versus >500 cells/[micro]l), rate of decline in CD4+ cells (average, rapid, slow), breastfeeding status (yes, no) and breastfeeding duration (12, 18 or 24 months). Findings For women with CD4+ cell counts of 350-500 cells/pl, the incremental cost per 1000 women was 157 345 United States dollars (US$) for breastfeeding women and US$ 92 813 for non-breastfeeding women. For women with CD4+ cell counts > 500 cells/pl, the incremental cost per 1000 women ranged from US$ 363 443 to US$ 484591 for breastfeeding women and was US$ 605 739for non- breastfeeding women. Conclusion From a cost perspective, a policy switch from Option B to Option B+ is feasible in PMTCT programme settings where resources are currently being allocated to Option B. Objectif Estimer le surcout sur 5 ans d un changement de politique, avec le passage du protocole de l'Option B a celui de l'Option B+ dans le cadre de la prevention de la transmission de la mere a l'enfant (PTME) du virus de fimimunodefidence humaine (VIH). Methodes Des donnees issues d'etudes de couts et d'autres sources publlees ont ete utilisees pour determiner le cout, par femme et par cohorte (1000 femmes qui allaltent et 1000 femmes qui n'allaitent pas), du passage de l'Option B (traitement par tritherapie antiretrovirale [ARV] de la mere pendant la grossesse et l'allaitement, et administration quotidienne de nevirapine a l'enfant pendant 6 semaines) a l'Option B+ (traitement par tritherapie ARV initie pendant la grossesse et ensuite pris a vie). Les variables utilisees pour modeliser les differents scenarios ont ete la numeration des lymphocytes T CD4+ (cellules CD4+) chez la mere (350-500 contre > 500 cellules/[micro]l), la vitesse de la baisse des cellules CD4+ (moyenne, rapide, lente), la situation au regard de l'allaitement maternel (oui, non) et la duree de l'allaitement (12,18 ou 24 mois). Resultats Pour les femmes presentant une numeration des cellules CD4+ de 350-500 cellules/pl, le surcout pour 1000 femmes etait de 157 345 dollars pour les femmes qui allaitent et de 92 813 dollars pour les femmes qui n'allaitent pas. Pour les femmes presentant une numeration des cellules CD4+ > 500 cellules/[micro]l, le surcout pour 1000 femmes etait compris entre 363 443 dollars et 484 591 dollars pour les femmes qul allaitent et de 605 739 dollars pour les femmes qui n'allaitent pas. Conclusion En termes de couts, un changement de politique de l'Option B a l'Option B+ est possible dans le cadre du programme PTME ou les ressources sont actuellement affectees a l'Option B. Objetivo Estimar el coste adicional en 5 anos de un cambio en la politica del protocolo de la opcion B a la opcion B+ para la prevencion de la transmision de madre a hijo (PTMI) del virus de inmunodeficiencia humana (VIH). Metodos Se emplearon datos de estudios de costes y otras fuentes publicadas para determinar el coste, por mujer y por cohorte (1000 mujeres lactantesy 1000 mujeres no lactantes), al cambiar de la opcion B (regimen antirretroviral triple materno [ARV] durante el embarazo y la lactancia materna junto con nevlraplna diaria para el lactante durante 6 semanas) a la opcion B+ (regimen antirretroviral triple ARV Iniciado durante el embarazo y tomado de por vida). Las variables empleadas para modelar los diversos escenarios fueron el recuento de linfocitos (CD4+ celulas) CD4+ T maternos (350-500 frente a > 500 celulas/pl), la tasa de disminucion de CD4+ celulas (media, rapida, lenta), el estado de lactancia materna (si, no) y la duracion de la lactancia materna (12, 18 o 24 meses). Resultados En las mujeres con un recuento de CD4+ de 350-500 celulas/[micro]l, el coste adicional por 1000 mujeres fue 157 345 dolares de los Estados Unidos (US$) para las mujeres lactantes y US$ 92 813 para las mujeres no lactantes. En las mujeres con un recuento de CD4 + celulas de > 500 celulas/[micro]l, el coste adicional por 1000 mujeres vario de US$ 363 443 a US$ 484 591 en las mujeres lactantes y US$ 605 739 en las mujeres no lactantes. Conclusion Desde el punto de vista de los costes, un cambio en la politica de la B opcion a la opcion B+ es factible en la configuracion del programa de PTMI, en el que en la actualidad los recursos se estan destinando a la opcion B., Introduction In July 2011, a United Nations political declaration called for greater efforts to eliminate human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS). It established commitments and targets, [...]

A study was conducted to evaluate and investigate the coverage of nevirapine-based services to help prevent the spread of mother-to-child HIV transmission in 4 African countries. Results indicated that only 51% of HIV-exposed infants received the required dosage of nevirapine in these countries.

Ambitious goals for paediatric AIDS control have been set by various international bodies, including a 50% reduction in new paediatric infections by 2010. While these goals are clearly appropriate in their scope, the lack of clarity and consensus around how to monitor the effectiveness of programmes to prevent mother-to-child HIV transmission (PMTCT) makes it difficult for policy-makers to mount a coordinated response. In this paper, we develop the case for using population HIV-free child survival as a gold standard metric to measure the effectiveness of PMTCT programmes, and go on to consider multiple study designs anal source populations. Finally, we propose a novel community survey-based approach that could be implemented widely throughout the developing world with minor modifications to ongoing Demographic and Health Surveys. Resume Des objectifs ambitieux en matiere de lutte contre le VIH/sida en milieu pediatrique ont ete fixes par divers organismes internationaux, et notamment la reduction de moitie du nombre de nouveaux cas d'infection pediatrique d'ici 2010. Meme si ces objectifs sont tout a fait pertinents dans leur contexte, le manque de clarte et de consensus quant aux personnes devant surveiller I'efficacite des programmes de prevention de la transmission mere-enfant du VIH (PMTCT) s'oppose a I'obtention d'une reponse coordonnee de la part des decideurs. Cet article presente les arguments en faveur de I'utilisation du taux de survie des enfants sans contamination par le VIH dans la population comme instrument de mesure cle de I'efficacite des programmes de PMTCT et examine divers types d'etude et plusieurs populations sources. II propose en conclusion une approche novatrice, reposant sur des enquetes en communaute, qui pourrait etre mise en oeuvre a grande echelle dans le monde en developpement, moyennant I'apport de modifications mineures aux enquetes demographiques et sanitaires en cours. Resumen Diversos organos internacionales han fijado metas ambiciosas para la lucha contra el SIDA pediatrico, en particular una reduccion del 50% de las nuevas infecciones pediatricas para 2010. Aunque se trata de metas indudablemente acertadas en cuanto a su alcance, la falta de claridad y consenso respecto a la manera de vigilar la eficacia de los programas de prevencion de la transmision del VIH de la madre al nino (PTMN) es un obstaculo para que las instancias normativas articulen una respuesta coordinada. Se aportan aqui argumentos para utilizar la supervivencia infantil sin infeccion por VIH en la poblacion como criterio de referencia para medir la eficacia de los programas de PTMN, y se examinan luego varios disenos de estudio y poblaciones de diverso origen. Por ultimo, proponemos un nuevo enfoque basado en encuestas comunitarias que podria implementarse ampliamente en todo el mundo en desarrollo introduciendo pequenos cambios en las actuales Encuestas de Demografia y Salud. [TEXT NOT REPRODUCIBLE IN ASCII.], Introduction Despite the availability of proven interventions for the prevention of mother-to-child HIV transmission (PMTCT) and substantial donor investments for implementing them in developing countries, paediatric AIDS remains a largely [...]

The impact of the introduction of routine opt-out HIV testing in antenatal care in Botswana is examined. The results have shown that routine HIV testing is more accepted than voluntary testing and it has led to substantial increases in the uptake of testing and prevention of mother-to-child transmission (PMTCT) interventions without adverse consequences.

Introduction: HIV testing is the entry point for the elimination of mother-to-child transmission of HIV. Decreasing external funding for the HIV response in some low- and middle-income countries has triggered the question of whether a focused approach to HIV testing targeting pregnant women in high-burden areas should be considered. This study aimed at determining and comparing the cost-effectiveness of universal and focused HIV testing approaches for pregnant women across high to very low HIV prevalence settings. Methods: We conducted a modelling analysis on health and cost outcomes of HIV testing for pregnant women using four country-based case scenarios (Namibia, Kenya, Haiti and Viet Nam) to illustrate high, intermediate, low and very low HIV prevalence settings. We used subnational prevalence data to divide each country into high-, medium- and low-burden areas, and modelled different antenatal and testing coverage in each. Results: When HIV testing services were only focused in high-burden areas within a country, mother-to-child transmission rates remained high ranging from 18 to 23%, resulting in a 25 to 69% increase in new paediatric HIV infections and increased future treatment costs for children. Universal HIV testing was found to be dominant (i.e. more QALYs gained with less cost) compared to focused approaches in the Namibia, Kenya and Haiti scenarios. The universal approach was also very cost-effective compared to focused approaches, with $ 125 per quality-adjusted life years gained in the Viet Nam-based scenario of very low HIV prevalence. Sensitivity analysis further supported the findings. Conclusions: Universal approach to antenatal HIV testing achieves the best health outcomes and is cost-saving or cost-effective in the long term across the range of HIV prevalence settings. It is further a prerequisite for quality maternal and child healthcare and for the elimination of mother-to-child transmission of HIV. Keywords: HIV; mother-to-child transmission; HIV testing; cost-effectiveness; universal approach; focused approach., Introduction The prevention of mother-to-child transmission (PMTCT) of HIV by providing antiretroviral therapy (ART) to HIV-positive pregnant women is a highly effective intervention to prevent new HIV infections among infants. [...]

At present, HIV testing and counselling during pregnancy represent the key entry point for women to learn their serostatus and for them to access, if they are HIV-positive, specific interventions to reduce mother-to-child transmission (MTCT) of HIV. However, the provision and uptake of testing and counselling services are inadequate, and many pregnant women in countries most affected by the HIV/AIDS epidemic remain unaware of their HIV status. The offer of single-dose nevirapine prophylaxis to women whose HIV status is unknown at the time of delivery has been proposed to circumvent these problems in high-prevalence settings. The potential advantages and disadvantages of three different programme approaches are considered: targeted programmes in which antiretroviral drugs are offered only to women who are known to be HIV-positive; combined programmes in which nevirapine prophylaxis is offered to women whose serostatus remains unknown at the time of delivery despite targeted programme inputs; and universal nevirapine prophylaxis programmes in which HIV testing and counselling are not available and all pregnant women, regardless of their serostatus, are offered nevirapine prophylaxis. Keywords Nevirapine/therapeutic use; HIV infections/prevention and control; Disease transmission, Vertical/prevention and control; Health status; Pregnancy; Risk assessment (source: MESH, NLM). Mots cles Nevirapine/usage therapeutique; Infection a VIH/prevention et controle; Transmission verticale maladie/prevention et controle; Etat sanitaire; Grossesse; Evaluation risque (source : MESH, INSERM). Palabras clave Nevirapina/uso terapeutico; Infecciones por VIH/prevencion y control; Transmision vertical de enfermedad/prevencion y control; Estado de salud; Embarazo; Medicion de riesgo (fuente: DeCS, BIREME). [TEXT NOT REPRODUCIBLE IN ASCII.], Resume Devrait-on faire appel a la nevirapine pour prevenir la transmission mere-enfant du VIH dans le cas des femmes dont le statut serologique est inconnu ? Actuellement, le depistage du [...]

Research on methods for preventing HIV transmission from pregnant women to their babies in developing countries focuses on breastfeeding, the potential toxicity of AIDS drugs to the fetus, and the development of drug resistance on the part of the virus. Between 15% and 40% of pregnant women in eastern and southern Africa are HIV-positive.

Women who first test positive for HIV during their pregnancy are no more likely to transmit the virus to their baby than those who tested positive before their pregnancy. This was the conclusion of a study in Thailand before HIV-infected pregnant women were given AIDS drugs to prevent transmission.

A PCR assay to determine HIV-1 subtype E appears to be effective in detecting the virus in newborn babies of HIV-infected mothers. The test detected half of the babies who were infected at birth, and detected all infected babies at two and six months of age.

Sex appears to be a common risk factor for HIV infection among pregnant women in Thailand. Researchers studied 342 HIV-positive pregnant women and 344 HIV-negative pregnant women at a hospital prenatal clinic. HIV infection was associated with more than one lifetime sexual partner, a history of sexually transmitted disease, and a partner who engages in high-risk behavior. Twenty-six percent of partners of HIV-infected women were also infected. Sex with their current sex partner, generally the husband or live-in partner, was the only risk factor for 52% of HIV-positive women.

Certain factors in infants of HIV-positive mothers appear to associate with increased likelihood of HIV infection and early death. Among 351 infants born to HIV-positive mothers, 24% were eventually found to be infected. Among these, researchers collected data and compared outcomes for 248 uninfected and 84 infected infants. Fifty-eight percent of mothers of infected infants had CD4 counts less than 500 and 21% had AIDS whereas 39% of noninfecting mothers had CD4 counts that low and 11% had AIDS. Three percent of mothers taking zidovudine infected their infants versus 11% of mothers not taking zidovudine. Infected infants were twice as likely to be born before 37 weeks gestation and almost four times as likely to be born before 34 weeks. Infected infants were twice as likely to be low birth weight, low birth weight at full term, or small for gestational age. Ten percent of infected newborns had generalized infections versus 3% of uninfected infants., ABSTRACT. Background and Methods. Differences in newborn outcome measures for human immunodeficiency virus (HIV-1-infected and HIV-1-exposed but uninfected infants have been found in several studies, but not in others. Eighty-four infected and 248 uninfected children born to HIV-1-seropositive mothers followed prospectively in a multicenter, perinatal HIV-1 transmission cohort study were compared for differences in maternal demographics, health status, and newborn outcome measures, including delivery complications, physical examination findings, neonatal complications, and laboratory results. Results. Mothers of HIV-1-infected infants were more likely than those of uninfected infants to have acquired immunodeficiency syndrome (AIDS) diagnosed through 2 weeks postpartum (21% vs 11%, P = .04); the transmission rate for the 38 women with AIDS was 37% compared with 22% for the 245 women without AIDS. Two of 27 (7%) women receiving zidovudine during pregnancy had infected infants compared with 73 (27%) of 275 women who did not receive zidovudine (P = .033). Mean gestational age was significantly lower among HIV-1-infected (37 weeks) than among uninfected infants (38 weeks; P < .001). Infected infants had significantly higher rates of prematurity (gestational age less than 37 weeks) (33% vs 19%, P = .01) and extreme prematurity (gestational age less than 34 weeks) (18% vs 6%, P = .001) than uninfected infants. Infection was associated with lower birth weight (2533 g vs 2862 & P < .001) and smaller head circumference (32.0 cm vs 33.1 cm, P = .001). HIV-1-infected infants were significantly more likely to be small for gestational age (26% vs 16%, P = .04) and low birth weight (less than 2500 g) (45% vs 29%, P = .006) than infants who were uninfected. Twenty-two (26%) HIV-1-infected children died during a median follow-up of 27.6 months (range 1.9 to 98.3 months). Prematurity was predictive of survival: by Kaplan-Meier, an estimated 55% (95% confidence interval, 31% to 72%) of preterm infected children survived to 24 months compared with 84% (95% confidence interval, 70% to 92%) of full-term infected children (P = .005). Conclusion. Infants born to women with AIDS are at higher risk for HIV-1 infection than are infants born to HIV-1-infected women with AIDS not yet diagnosed. Women receiving zidovudine appear less likely to transmit HIV-1 to their infants. Significantly higher rates of prematurity and intrauterine growth retardation were found among HIV-1-infected infants than among those in the uninfected, HIV-1-exposed control group. Prematurity was associated with shortened survival in HIV-1-infected infants. Measures of intrauterine growth and gestation appear to be important predictors of HIV-1 infection status for seropositive infants and of prognosis for the infected infant. Pediatrics 1995;96:451-458; neonatal predictors of HIV-1 infection, pediatric HIV-1, prematurity., ABBREVIATIONS. AIDS, acquired immunodeficiency syndrome; HIV, human immunodeficiency virus; CDC, Centers for Disease Control and Prevention; ZDV, zidovudine; SGA, small for gestational age; LBW, low birth weight; PCP, Pneumocystis carinii; [...]

HIV-positive teenagers and young adults appear significantly more likely to have been sexually abused and to have a higher frequency of problem behaviors than HIV-negative teenagers. A total of 793 teenagers and young adults between 13 and 21 years old were tested for HIV and interviewed about their sexual behavior and background. Seventy-one of the adolescents were HIV positive. Sixty-three percent of the HIV-positive participants were male. Thirty-two percent of the HIV-positive females and 33% of the HIV-positive males had been sexually abused compared with 28% and 9% of the HIV-negative females and males, respectively. Seventy-three percent of the HIV-positive females and 51% of the HIV-positive males had ever had a sexually transmitted disease compared with 38% and 10% of the HIV-negative females and males, respectively. HIV-positive adolescents were also significantly more likely to have sex with casual partners and to have survival sex. There appeared to be no significant differences in self-esteem, emotional distress or HIV-related protective factors between the HIV-negative and HIV-positive participants., According to the World Health Organization, half of the 14 million people with human immunodeficiency virus (HIV) worldwide were infected between the ages of 15 and 24 years. However, details about HIV-positive (HIV+) youths&apos; risk-related behavior and social context have not been previously reported. Objectives. To outline detailed sexual and drug use practices, social and psychological status of HIV+ youth compared with a cohort of HIV-negative (HIV-) youth; and to examine the ability of the health belief and risk-taking models to predict sexual and drug use acts of HIV+ youth. Methods. HIV testing was conducted on and a 207-item structured interview covering HIV risk-related acts, protective factors and background information was administered to 72 HIV+ and 1142 HIV- adolescents aged 13 through 21 years receiving care in an adolescent clinical care unit of a large medical center in New York City. Data were analyzed for adolescents reporting sexual intercourse (71 HIV+ and 722 HIV-) by logistic regression analysis of five domains to identify variables significantly associated with HIV seropositivity. Results. Logistic regressions indicated significant differences in sexual risk acts based on serostatus and gender. Anonymous, blinded seroprevalence testing identified 11% more HIV+ adolescents than would have been identified by current counseling and testing practices. HIV+ adolescents were significantly more likely to be sexually abused (33 vs 21%, P

The incidence of HIV infection may be increasing among adolescents, especially those with a high-risk lifestyle. Specialized programs need to be developed for the treatment and counseling of high-risk and HIV-positive adolescents. Among 93 adolescents seen in a program for high-risk and HIV-positive adolescents in New York City between Mar 1988 and May 1991, 50 (54%) were HIV-positive. Sixty-six percent of the HIV-positive adolescents were male, and 34% were female. Eighty-two percent were African American or Hispanic. HIV-positive boys were more likely to have had anal intercourse or to have been sexually abused than HIV-negative boys. Eighty-two percent of the HIV-positive girls had been infected through heterosexual intercourse. Forty-four percent of the HIV-infected adolescents had used crack cocaine., To address the unique manifestations of human immunodeficiency virus (HIV) among adolescents aged 13 through 21 years, a comprehensive evaluation and treatment program for high-risk and HIV-positive adolescents was developed in New York City in 1987. Among HIV-infected youth, mean age of testing was 18.2 years. One third of the HIV-positive patients were female and four fifths were African-American or Hispanic. No significant differences were found between HIV-positive (n = 50) and HIV-negative (n = 43) patients for age at first intercourse, injecting or other illicit drug use, history of sexually transmitted diseases, or survival sex (exchange of sex for money or drugs). HIV-positive males were more likely than HIV-negative males to have engaged in anal intercourse and to report a history of sexual abuse. Among infected females, 82% acquired HIV through heterosexual intercourse. Almost half (48%) of HIV-positive adolescents had significant immune dysfunction at the time of their initial visit (CD4