Magister Curationis - MCur / Early infant diagnosis (EID) programmes offer diagnosis of HIV, which facilitates provision of life-saving care to infants infected with HIV. Implementing programmes for EID and treatment has proved challenging in Malawi. Many infants access EID late or not at all. Previous studies have shown that lack of knowledge among health care providers (HCPs) is a challenge to effective EID. Little is known on the knowledge and skills of health care providers in Malawi. Aim: The aim of the study was to investigate the knowledge and skills of HCPs on EID of HIV in Mzuzu, Malawi. Objectives: (i) to examine the knowledge of HCPs on EID of HIV; and (ii) to determine the skills of HCPs on EID of HIV. Methods: A descriptive cross-sectional survey design with a quantitative approach was used. The study was conducted in three hospitals in Mzuzu, Malawi. The population was HCPs (doctors, nurses/midwives, clinical officers and medical assistants) working in maternity, paediatric wards and under-five clinics. A total of 68 HCPs participated in the study. A closed-ended self-administered questionnaire was used to collect data. Data were analysed using the Statistical Package for Social Science version 23. Descriptive statistics were used to present the frequency tables of observations. Ethical approval was sought from the University of the Western Cape Senate Research Committee and Malawi National Health Research Council. Results: The results on the knowledge of HCPs demonstrate that 38% of them had a score of <69% (poor), 25% scored within 70–79% (fair), and 37% scored >80% (good). Results on the skills showed that 69% of the HCPs scored <69% (poor), 15% scored within 70–79% (fair), and 16% scored >80% (good). The results also showed a correlation between the knowledge of HCPs and their level of education achievement (certificate, diploma and degree) as well as the skills of HCPs and their department of work. Conclusion: The study found that more than one-third of the HCPs lacked knowledge and skills on EID of HIV. These findings reflect the need to address the practical challenges of EID service delivery. Recommendations: There is a need to increase the efforts that are being put in place to train HCPs on EID of HIV in order to scale up EID. Training should assess the needs of HCPs regarding the knowledge and skills required in the delivery of EID services.

Magister Artium - MA / Introduction A high burden of Human Immunodeficiency Virus (HIV) constitutes a key global public health concern. In South Africa, it is estimated that 260 000 children aged 0-14 years had HIV infection and only 63% of them were reported to have received HIV treatment in 2018. Without antiretroviral therapy (ART), HIV infection during infancy is associated with rapid disease progression where more than half of all infected children are expected to die before two years of age. Early infant diagnosis (EID) of HIV is therefore essential for accessing timely HIV treatment. However, preanalytical errors within the EID diagnostic cascade prevent optimal access to HIV polymerase chain reaction (PCR) results. The aim of this study was to describe the prevalence and contributing factors of preanalytical errors resulting in missed diagnostic opportunities for HIV among children below 18 months of age in Thabo Mofutsanyana (TM) district. Methodology The study was conducted using a descriptive cross-sectional study design and data was collected in two phases. Phase 1 involved obtaining the routine HIV PCR testing data set from the National Health Laboratory Services (NHLS) for all samples collected at TM public health facilities in 2018 and registered by NHLS. Phase 2 included a facility assessment checklist and semi structured questionnaire administered to 36 health care workers (HCWs) from 10 purposively selected health facilities. Data collected in phase 2 was analyzed to describe health facilities and HCW factors that might be contributing to the HIV PCR preanalytical errors. Results Phase 1. Of the 9318 samples included in the analysis, 49.6% were birth HIV PCRs whilst 42.1% and 8.3% were from 10 weeks and above 12 weeks age categories, respectively. A total of 745 (8%) samples were rejected because of the following preanalytical errors: insufficient specimen (84.3%), unsuitable sample (9.9%) and clerical error (5.8%).By age, the preanalytical errors were: birth (534), 10 weeks (170) and the above 12 weeks age category (41). Hospitals had the highest proportion of total preanalytical errors (58.1%). For PHCs the errors were: insufficient specimen (90%), unsuitable sample (5.5%) and clerical (4.8%).

Ce travail de thèse avait pour objectif d’évaluer l’accessibilité, l’efficacité et les difficultés opérationnelles de la prise en charge antirétrovirale précoce des enfants infectés par le VIH en Afrique de l’Ouest : en Côte d’Ivoire, au Mali et au Burkina Faso. Cette région est particulièrement marquée par un faible accès à la prise en charge des enfants infectés par le VIH. Nos travaux ont montré qu’à coté de l’offre de soins qui est insuffisante dans cette région, le retard aux soins chez ces enfants était particulièrement influencé par la faible acceptabilité parentale du dépistage pédiatrique précoce, avec un rôle clé du père dans la décision de soins de l’enfant. Les enfants débutent le traitement antirétroviral très tardivement, à un stade très avancé de la maladie et sévèrement immunodéprimé. Après douze mois de traitement antirétroviral, on observe un échec clinique ou immunologique au traitement chez plus de la moitié des enfants, en particulier chez ceux qui avaient débuté le traitement antirétroviral avec un mauvais état clinique et immunologique. Après cinq ans de traitement, près de la moitié des enfants présentent un échec virologique. Les interventions de prévention de la transmission mère-enfant ne semblent pas associées à l’échec au traitement des enfants dans cette région. Toutefois, l’observance au traitement antirétroviral chez le jeune enfant est bonne dans cette région. Ces résultats sont en faveur de la nécessité d’une prise en charge précoce des enfants infectés par le VIH, à un stade moins avancé de la maladie. Cela passe nécessairement par l’amélioration du dépistage pédiatrique précoce, à travers l’implication des pères, le renforcement du plateau technique pour le dépistage et le suivi des enfants, et la formation du personnel soignant. Aussi, les études de cohorte sur les facteurs pronostiques de l’échec au traitement dans le contexte opérationnel ouest africain sont nécessaires pour approfondir la question de la réponse au traitement antirétroviral chez ces enfants. / This thesis aimed to assess the accessibility, the efficiency and operational difficulties of treatment and care of HIV infected children in West Africa: Cote d’Ivoire, Mali and Burkina Faso. This region is particularly marked by poor access to care for HIV infected children. Our work has show that besides the insufficient provision of care in this region, the delay to care for these children was particularly influenced by the low acceptability of HIV early infant diagnosis, with a key role of the father in the decision making for the care of the child. Children begin antiretroviral treatment very late, at a very advanced stage of disease and severely immunocompromised. After twelve months of antiretroviral therapy, there was a clinical or immunological treatment failure in more than half of all children, especially among those who had started antiretroviral therapy with poor clinical and immunological status. Interventions to prevent mother to child transmission do not seem related to children treatment failure in this region. However, adherence to antiretroviral therapy in young children is good in this region. These results support the need for early antiretroviral treatment for HIV infected children at an earlier stage of the disease. This necessarily requires improved early infant diagnosis, through the involvement of fathers, the strengthening of the technical platform for screening and monitoring of children, and training of health staff. Also, cohort studies on prognostic factors for treatment failure in West African context are needed to investigate the issue of antiretroviral treatment response in these children.

No description available.

Les recommandations de l’OMS sur la prise en charge des enfants nés de mères infectées par le VIH évoluent en fonction des nouvelles données scientifiques souvent issues d’essais thérapeutiques. Leur application en routine, surtout dans les pays à ressources limitées, devrait prendre en compte les contraintes opérationnelles locales pour guider les pratiques. Ce travail de thèse a été développé dans cette optique, avec pour objectif d’évaluer l’ensemble du processus de prise en charge de ces enfants avant l’âge de sept mois, depuis le dépistage précoce de l’infection VIH jusqu’à la mise en œuvre du traitement antirétroviral (ARV) systématiquement proposé dès le diagnostic de l’infection VIH, et leurs réponses aux vaccins administrés dans le Programme Elargi de Vaccination (PEV). Ce travail est issu de l’analyse des données collectées dans deux enquêtes : la cohorte ANRS-PEDIACAM initiée en 2007 et toujours en cours, menée dans trois hôpitaux urbains du Cameroun, et l’enquête transversale ACIP-EPIPEV, menée de novembre 2004 à Mai 2005 dans cinq hôpitaux du Cameroun et de la République Centrafricaine. Nos résultats ont montré que le diagnostic précoce du VIH et l’initiation des ARV chez les nourrissons étaient faisables et largement acceptés en routine dans les services de pédiatrie urbains. Parmi les nourrissons nés de mères séropositives inclus dans PEDIACAM, 89,7% ont été ramenés pour le test VIH à un âge médian de 1,5 mois (IQ : 1,4-1,6) et 83,9% ont complété le processus de diagnostic en revenant chercher les résultats du test avant l’âge de 7 mois. Les facteurs associés au processus incomplet reflétaient plus la qualité des soins prénataux et l’urgence du contexte obstétrical que les conditions environnementales. Parmi les nourrissons infectés par le VIH, 83,5% ont initié les ARV avant l’âge de 7 mois. Mais le processus d’initiation précoce des ARV a été considéré comme suboptimal chez environ un tiers d’entre eux. Les facteurs associés à ce retard étaient liés au système de soins, à la gestion des prélèvements et des résultats du test VIH. Enfin, dans l’étude EPIPEV, nous avons observé des proportions plus faibles de réponses vaccinales adéquates chez les enfants infectés que non infectés par le VIH, nés de mères séropositives. Cette différence était plus marquée pour le vaccin contre la rougeole (20% vs 60%). Le niveau de réponse observé chez les enfants non infectés nés de mères séropositives était néanmoins faible par rapport à celui attendu chez les enfants en population générale. Ce dernier résultat suggérerait que l’exposition au VIH pendant la grossesse pourrait entrainer un dysfonctionnement immunologique, même en l’absence de transmission du VIH à l’enfant. L’ensemble de ces travaux nous ont permis de cibler certains aspects pour améliorer le processus de prise en charge précoce des nourrissons exposés au VIH, portant sur l’organisation des sites, l’application effective des recommandations établies et la mise en place d’une coordination active. / The world health organization (WHO) recommendation updates regarding care of HIV-infected children reflects new scientific findings in clinical trials. Their implementation in routine practice, especially in resource-limited countries, should consider local operational constraints in order to direct good clinical practice guidelines. We put in place this work in order to evaluate the early care process of HIV-exposed infants aged less than 7 months including: early diagnosis of HIV, initiation of antiretroviral therapy (ART), and immune responses to vaccines administered by the Expanded Program on Immunization (EPI). Our data were collected from two surveys: the current ANRS-PEDIACAM cohort which started in 2007, in three urban hospitals located in Cameroon, and the ACIP-EPIPEV cross sectional study conducted from November 2004 to May 2005, in five urban hospitals based in Cameroon and the Central African Republic. Our results strongly suggested that both early HIV diagnosis and initiation of ART in infants were feasible and well accepted in “real pediatric world urban settings”. Among HIV-exposed infants enrolled in the PEDIACAM study, 89.7% were tested for HIV at a median age of 1.5 months and 83.9% completed the process by returning for the result before 7 months of age. Incomplete process was associated to factors related to the quality of antenatal care and obstetrical emergency than environmental ones. Among HIV-infected infants identified, 83.5% started ART before 7 months of age. However, ART initiation was considered as suboptimal in approximately one third of them. Risk factors associated with this delay were related to the care delivery system, including delays in sample collection and turn around procedures. Finally, the EPIPEV study showed that antibody levels to EPI vaccines in HIV-uninfected children born to HIV-infected mothers were higher compared to levels in HIV-infected children (60% vs 20% concerning measles vaccine), but lower than the levels described for children born to HIV-uninfected mothers. This result suggested an immunological dysfunction of HIV-exposed children which occurred during pregnancy and could affect their survival. Overall, our studies contributed in providing findings that could help in improving early care in HIV-exposed infants. These include the structural and functional organization of health structures, the effective implementation of current recommendations, and of active coordination.