Objective: To estimate antiretroviral therapy (ART) adherence rates during pregnancy and postpartum in high-income, middle-income, and low-income countries. Design: Systematic review and meta-analysis. Methods: MEDLINE, EMBASE, SCI Web of Science, NLM Gateway, and Google scholar databases were searched. We included all studies reporting adherence rates as a primary or secondary outcome among HIV-infected pregnant women. Two independent reviewers extracted data on adherence and study characteristics. A random-effects model was used to pool adherence rates; sensitivity, heterogeneity, and publication bias were assessed. Results: Of 72 eligible articles, 51 studies involving 20153 HIV-infected pregnant women were included. Most studies were from United States (n ¼14, 27%) followed by Kenya (n ¼6, 12%), South Africa (n ¼5, 10%), and Zambia (n ¼5, 10%). The threshold defining good adherence to ART varied across studies (>80, >90, >95, 100%). A pooled analysis of all studies indicated a pooled estimate of 73.5% [95% confidence interval (CI) 69.3‐77.5%] of pregnant women who had adequate (>80%) ART adherence. The pooled proportion of women with adequate adherence levels was higher during the antepartum (75.7%, 95% CI 71.5‐79.7%) than during postpartum (53.0%, 95% CI 32.8‐72.7%; P ¼0.005). Selected reported barriers for nonadherence included physical, economic and emotional stresses, depression (especially postdelivery), alcohol or drug use, and ART dosing frequency or pill burden. Conclusion: Our findings indicate that only 73.5% of pregnant women achieved optimal ART adherence. Reaching adequate ART adherence levels was a challenge in pregnancy, but especially during the postpartum period. Further research to

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Adherence to antiretroviral therapy during and after pregnancy in low-income, middle-income, and high-income countries: a systematic review and meta-analysis.

Background
Intimate partner violence (IPV) is very high in Africa. However, information obtained from the increasing number of African studies on IPV among pregnant women has not been scientifically analyzed. This paper presents a systematic review summing up the evidence from African studies on IPV prevalence and risk factors among pregnant women.

https://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0017591&type=printable

A Systematic Review of African Studies on Intimate Partner Violence against Pregnant Women: Prevalence and Risk Factors

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(12)61127-1.pdf

Technologies for global health

There is limited evidence that interventions for depression and other common mental disorders (CMD) can be integrated sustainably into primary health care in Africa. We aimed to pilot a low-cost multi-component 'Friendship Bench Intervention' for CMD, locally adapted from problem-solving therapy and delivered by trained and supervised female lay workers to learn if was feasible and possibly effective as well as how best to implement it on a larger scale. We trained lay workers for 8 days in screening and monitoring CMD and in delivering the intervention. Ten lay workers screened consecutive adult attenders who either were referred or self-referred to the Friendship Bench between July and December 2007. Those scoring above the validated cut-point of the Shona Symptom Questionnaire (SSQ) for CMD were potentially eligible. Exclusions were suicide risk or very severe depression. All others were offered 6 sessions of problem-solving therapy (PST) enhanced with a component of activity scheduling. Weekly nurse-led group supervision and monthly supervision from a mental health specialist were provided. Data on SSQ scores at 6 weeks after entering the study were collected by an independent research nurse. Lay workers completed a brief evaluation on their experiences of delivering the intervention. Of 395 potentially eligible, 33 (8%) were excluded due to high risk. Of the 362 left, 2% (7) declined and 10% (35) were lost to follow-up leaving an 88% response rate (n = 320). Over half (n = 166, 52%) had presented with an HIV-related problem. Mean SSQ score fell from 11.3 (sd 1.4) before treatment to 6.5 (sd 2.4) after 3-6 sessions. The drop in SSQ scores was proportional to the number of sessions attended. Nine of the ten lay workers rated themselves as very able to deliver the PST intervention. We have found preliminary evidence of a clinically meaningful improvement in CMD associated with locally adapted problem-solving therapy delivered by lay health workers through routine primary health care in an African setting. There is a need to test the effectiveness of this task-shifting mental health intervention in an appropriately powered randomised controlled trial. ISRCTN: ISRCTN25476759

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Problem-solving therapy for depression and common mental disorders in Zimbabwe: piloting a task-shifting primary mental health care intervention in a population with a high prevalence of people living with HIV

Introduction: Male participation is a crucial component in the optimization of Maternal and Child Health (MCH) services. This is especially so where prevention strategies to decrease Mother-to-Child Transmission (MTCT) of Human Immunodeficiency Virus (HIV) are sought. This study aims to identify determinants of male partners’ involvement in MCH activities, focusing specifically on HIV prevention of maternal to child transmission (PMTCT) in sub-Saharan Africa. Methods: Literature review was conducted using the following data bases: Pubmed/MEDLINE; CINAHL; EMBASE; COCHRANE; Psych INFORMATION and the websites of the International AIDS Society (IAS), the International AIDS Conference and the International Conference on AIDS in Africa (ICASA) 2011. Results: We included 34 studies in this review, which reported on male participation in MCH and PMTCT services. The majority of studies defined male participation as male involvement solely during antenatal HIV testing. Other studies defined male involvement as any male participation in HIV couple counseling. We identified three main determinants for male participation in PMTCT services: 1) Socio-demographic factors such as level of education, income status; 2) health services related factors such as opening hours of services, behavior of health providers and the lack of space to accommodate male partners; and 3) Sociologic factors such as beliefs, attitudes and communication between men and women. Conclusion: There are many challenges to increase male involvement/participation in PMTCT services. So far, few interventions addressing these challenges have been evaluated and reported. It is clear however that improvement of antenatal care services by making them more male friendly, and health education campaigns to change beliefs and attitudes of men are absolutely needed.

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Determinants of male involvement in maternal and child health services in sub-Saharan Africa: a review

OBJECTIVE: To assess the impact of routine antenatal HIV testing for preventing mother-to-child transmission of HIV (PMTCT) in urban Zimbabwe. METHODS: Community counsellors were trained in routine HIV testing policy using a specific training module from June 2005 through November 2005. Key outcomes during the first 6 months of routine testing were compared with the prior 6-month "opt-in" period, and clients were interviewed. FINDINGS: Of the 4551 women presenting for antenatal care during the first 6 months of routine HIV testing, 4547 (99.9%) were tested for HIV compared with 3058 (65%) of 4700 women during the last 6 months of the opt-in testing (P < 0.001), with a corresponding increase in the numbers of HIV-infected women identified antenatally (926 compared with 513, P < 0.001). During routine testing, more HIV-infected women collected results compared to the opt-in testing (908 compared with 487, P < 0.001) resulting in a significant increase in deliveries by HIV-infected women (256 compared with 186, P = 0.001); more mother/infant pairs received antiretroviral prophylaxis (n = 256) compared to the opt-in testing (n = 185); and more mother/infant pairs followed up at clinics (105 compared with 49, P = 0.002). Women were satisfied with counselling services and most (89%) stated that offering routine testing is helpful. HIV-infected women reported low levels of spousal abuse and other adverse social consequences. CONCLUSION: Routine antenatal HIV testing should be implemented at all sites in Zimbabwe to maximize the public health impact of PMTCT.

/pdf/routine-offer-of-antenatal-hiv-testing-opt-out-approach-to-5f2wfcgazc.pdf

Routine offer of antenatal HIV testing ("opt-out" approach) to prevent mother-to-child transmission of HIV in urban Zimbabwe

Prevention of mother-to-child transmission of HIV (PMTCT) is a major public health challenge in Zimbabwe. Using trained peer counselors, a nevirapine (NVP)-based PMTCT program was implemented as part of routine care in urban antenatal clinics. Between October 2002 and December 2004, a total of 19,279 women presented for antenatal care. Of these, 18,817 (98%) underwent pre-test counseling; 10,513 (56%) accepted HIV testing, of whom 1986 (19%) were HIV-infected. Overall, 9696 (92%) of women collected results and received individual post-test counseling. Only 288 men opted for HIV testing. Of the 1807 HIV-infected women who received posttest counseling, 1387 (77%) collected NVP tablet and 727 (40%) delivered at the clinics. Of the 1986 HIV-infected women, 691 (35%) received NVPsd at onset of labor, and 615 (31%) infants received NVPsd. Of the 727 HIV-infected women who delivered in the clinics, only 396 women returned to the clinic with their infants for the 6-week follow-up visit; of these mothers, 258 (59%) joined support groups and 234 (53%) opted for contraception. By the end of the study period, 209 (53%) of mother-infant pairs (n = 396) came to the clinic for at least 3 follow-up visits. Despite considerable challenges and limited resources, it was feasible to implement a PMTCT program using peer counselors in urban clinics in Zimbabwe.

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The feasibility of preventing mother-to-child transmission of HIV using peer counselors in Zimbabwe.

Introduction The perinatal HIV epidemic remains a major public health problem in Zimbabwe (1) Recent estimates indicate that over 20% of women aged 15-49 years presenting for antenatal care (ANC) are HIV-infected (1) Several trials have reported the efficacy of simple, low-cost antiretroviral prophylactic regimens to reduce mother-to-child transmission of HIV in sub-Saharan Africa (2-4) Although prevention of mother-to-child transmission of HIV (PMTCT) interventions using single-dose nevirapine (sdNVP) have been implemented in many urban and rural clinics in Zimbabwe, (5) uptake of these interventions remains low, primarily due to poor antenatal HIV testing rates (6) Detection of maternal infection early in pregnancy through voluntary counselling and HIV testing (VCT) is critical for PMTCT (7) In Zimbabwe, HIV testing is conducted after individual pre-test counselling, with clients actively choosing whether to be tested (ie an "opt-in" approach or client-initiated testing) The acceptance rate of VCT among our ANC clients has been low, ranging from 20% to 63% (6,8) Several reasons may account for poor antenatal VCT uptake among women in sub-Saharan Africa, including absence of prenatal care, fear of stigma and inadequate counselling experiences (9-11) Thus innovative approaches to antenatal HIV testing are urgently required Provider-initiated routine antenatal HIV testing (ie an "opt-out" approach) is the standard of care in the United States of America (USA) and other developed nations (12-16) Routine antenatal HIV testing policy is rare in sub-Saharan Africa (17-18) Recent data from the PMTCT programme in Botswana demonstrated that routine HIV testing led to a significant increase in HIV-test acceptance at ANC clinics, where HIV prevalence has been [greater than or equal to] 40% since 1995 (18) A recent study from rural Zimbabwe found that routine antenatal HIV testing is acceptable to both clients and health-care providers (19) The objective of this pilot study was to evaluate the impact of routine antenatal HIV testing in urban Zimbabwe Methods Zimbabwe is a southern African country of approximately 125 million inhabitants whose capital city, Harare, has a population of 15 million Antenatal HIV seroprevalence in urban clinics has been estimated to be around 213% (20) Our study was conducted at four antenatal clinics in Chitungwiza, a socioeconomically disadvantaged community 25 km south of Harare Provider-initiated routine HIV testing with right of refusal was offered to all new ANC clients between June 2005 and November 2005 Before implementation of the routine HIV testing policy, a VCT site instrument was used to assess the adequacy of staffing levels, adherence to PMTCT protocols, availability of health education materials, availability of test kits and medical consumables, adherence to staff roles and responsibilities, and general aspects of site operations A counsellor reflection form and a VCT client exit survey form were used to guide the implementation of the routine HIV testing policy Community mobilization activities for improving public awareness of the routine HIV testing policy were carried out by community outreach counsellors A drama skit was developed and presented at health worker in-service training workshops and at the community advisory board meetings for critiques and comments before presentation The community counsellors performed the skit on a rotational basis at the four clinics on Tuesday, Wednesday and Thursday mornings for new ANC clients and during the afternoons in the community and at colleges, churches and industrial facilities Before implementation of the routine HIV testing policy, clinic staff members at the four sites attended a two-day training session conducted by the PMTCT programme staff in which the new strategy was discussed in detail, including data collection and interview techniques …

Routine Offer of Antenatal HIV Testing ("Opt-Out" Approach) to Prevent Mother-to-Child Transmission of HIV in Urban Zimbabwe/ Proposition Systematique D'un Test De Depistage Du VIH Antenatal (Avec Possibilite De Refuser) En Vue De Prevenir la Transmission De la Mere a L'enfant De Ce Virus Dans Les Zones Urbaines Du Zimbabwe/ Oferta Sistematica (Con Derecho a Renuncia) De la Prueba Prenatal

Elizabeth Chirapa

Papers

Routine offer of antenatal HIV testing ("opt-out" approach) to prevent mother-to-child transmission of HIV in urban Zimbabwe

The feasibility of preventing mother-to-child transmission of HIV using peer counselors in Zimbabwe.