Magister Public Health - MPH / Since the advent of the HIV pandemic, efforts have been made to find and implement interventions to reduce the risk of transmission of the infection in various risk groups. Mother to child transmission is responsible for a great majority of childhood HIV infections. Interventions have been developed which reduce considerably the risk of mother to child transmission to babies born to women who are infected. To be able to access these interventions, pregnant women first have to know their status by being tested at antenatal clinics. Initial testing protocols in most countries were based on the opt-in, client-initiated approach. However, in many countries, this did not result in many women getting tested and being able to access interventions. Accordingly, many countries have now adopted the routine opt-out approach as a way of increasing testing rates among women attending antenatal clinics. Ghana has had a PMTCT programme since 2004 initially based on opt-in testing. In 2007, there was a change in this testing regimen to the opt-out approach. The aim of this study was to assess the quality, acceptability and factors influencing the acceptability of the use of routine verbal opt-out strategy for HIV testing during pregnancy for women attending antenatal clinics in the Kassena-Nankana district of northern Ghana. A cross-sectional analytical study design was used in this study. The study was conducted in the Kassena-Nankana district of northern Ghana using a structured questionnaire in face to face exit interviews with pregnant women after they had completed their first antenatal clinic visit. A total of 251 women aged between 15-49 years were interviewed after informed consent had been obtained from them. Data was captured with Epidata and analysed with EpiInfo. Cross-tabulations and logistic regression analyses were done. Of the 251 respondents who were interviewed in this survey, 85% of them were aware of MTCT, 82% knew at least one PMTCT strategy, 92% felt they had experienced good quality counselling that day at the ANC and 81% thought that the opt-out testing was acceptable. The perception of the women in the study about the quality of counselling they were given, their exposure to radio and their ethnicity were significantly associated with their acceptability of opt-out testing for HIV. While majority of the respondents felt that the quality of the counselling they received was good and a majority also felt that the opt-out strategy was acceptable, there were concerns about the quality of counselling provided. Recommendations include the need to improve counselling practices in the antenatal clinics by providing more structured information to the women. The District Health Management Team also needs to provide more information to people in the communities about PMTCT using radio as a medium.

<p>This thesis assesses the uptake of the national Prevention of Mother to Child Transmission of HIV (PMTCT) programme in South Africa, and the challenges of achieving safe infant feeding practices in the context of HIV. The research studies contained in this thesis utilised a variety of quantitative and qualitative research methods in order to provide a full understanding of the challenges of moving from efficacy to effectiveness in PMTCT programmes. The first paper utilised a cross-sectional approach to a programme evaluation, papers two and three utilised qualitative methodologies, and paper four was based on a longitudinal cohort study design. The findings highlight the low uptake of PMTCT interventions and inappropriate infant feeding choices. The experiences of women with HIV provide an important insight into the difficulties of operationalising the WHO/UNICEF HIV and infant feeding recommendations in real life settings, where rates of HIV disclosure are low and mixed feeding is the norm. Several personal and environmental characteristics were identified that contributed to success in maintaining exclusive infant feeding practices. The research provides some guidance on the definition of appropriateness in infant feeding choices, and highlights the poor outcomes associated with formula feeding under unsafe conditions. Modifying infant feeding practices is essential in order to reduce postnatal HIV transmission and improve child survival. Interventions to improve infant feeding need to include improving the quality of counselling and support provided by health workers, with more structured assessments used to guide infant feeding choices. Efforts are also needed at the community level to increase rates of disclosure and to promote exclusive infant feeding as a norm.</p>

This thesis assesses the uptake of the national Prevention of Mother to Child Transmission of HIV (PMTCT) programme in South Africa, and the challenges of achieving safe infant feeding practices in the context of HIV. The research studies contained in this thesis utilised a variety of quantitative and qualitative research methods in order to provide a full understanding of the challenges of moving from efficacy to effectiveness in PMTCT programmes. The first paper utilised a cross-sectional approach to a programme evaluation, papers two and three utilised qualitative methodologies, and paper four was based on a longitudinal cohort study design. The findings highlight the low uptake of PMTCT interventions and inappropriate infant feeding choices. The experiences of women with HIV provide an important insight into the difficulties of operationalising the WHO/UNICEF HIV and infant feeding recommendations in real life settings, where rates of HIV disclosure are low and mixed feeding is the norm. Several personal and environmental characteristics were identified that contributed to success in maintaining exclusive infant feeding practices. The research provides some guidance on the definition of appropriateness in infant feeding choices, and highlights the poor outcomes associated with formula feeding under unsafe conditions. Modifying infant feeding practices is essential in order to reduce postnatal HIV transmission and improve child survival. Interventions to improve infant feeding need to include improving the quality of counselling and support provided by health workers, with more structured assessments used to guide infant feeding choices. Efforts are also needed at the community level to increase rates of disclosure and to promote exclusive infant feeding as a norm.

<p>Background: Globally, neonatal mortality (i.e. deaths occurring during the first month of life) accounts for 44% of the 11 million infants that die every year (Lawn, Cousens &amp / Zupan, 2005). Early&nbsp / detection of illness and referral of mothers and infants during the peri-natal period to higher levels of care can lead to substantial reductions in maternal and child mortality in developing&nbsp / countries. Establishing effective referral systems from the community to health facilities can be achieved through greater utilization of community health workers and improved health seeking&nbsp / behaviour. Study design: The Good Start Saving Newborn Lives study being conducted in Umlazi, KwaZulu-Natal, is a community randomized trial to assess the effect of an integrated home&nbsp / visit package delivered to mothers during pregnancy and post delivery on uptake of PMTCT interventions and appropriate newborn care practices. The home visit package is delivered by community health workers in fifteen intervention clusters. Control clusters receive routine health facility antenatal and postpartum care. For any identified danger signs during a home visit,&nbsp / community health workers write a referral and if necessary refer infants to a local clinic or hospital. The aim of this study was to assess the effectiveness of this referral system by describing&nbsp / community health worker referral completion rates as well as health-care seeking practices and perceptions of mothers. A cross- sectional survey was undertaken using a structured&nbsp / questionnaire with all mothers who had been referred to a clinic or hospital by a community health worker since the start of the Good Start Saving Newborn Lives Trial. Data collection: Informed consent was obtained from willing participants. Interviews were conducted by a trained research assistant in the mothers&rsquo / home or at the study&nbsp / offices. Road to Health Cards were reviewed to confirm referral completion. Data was collected by means of a cell phone (mobile researcher software) and the database was later transferred to Epi-info and STATA IC 11 for analysis.&nbsp / Descriptive analysis was&nbsp / conducted so as to establish associations between explanatory factors and referral completion and to describe referral processes experienced by caregivers. Significant&nbsp / associations between categorical variables were assessed using chi square tests and continuous variables using analysis of variance. Results: A total of 2423 women were&nbsp / enrolled in the SNL study and 148 had received a referral for a sick infant by a CHW by June 2010. The majority (95%) of infants were referred only once during the time of enrolment, the&nbsp / highest number of which occurred within&nbsp / the first 4 weeks of life (62%) with 22% of these being between birth and 2 weeks of age. Almost all mothers (95%) completed the referral by taking&nbsp / their child to a health facility. Difficulty in breathing and rash accounted for the highest number of referrals (26% and 19% respectively). None of the six mothers who did not complete referral recognised any danger signs in their infants. In only 16% of cases did a health worker give written feedback on the outcome of the referral to the referring CHW.&nbsp / Conclusion: This study found&nbsp / high compliance with referrals for sick infants by community health workers in Umlazi. This supports the current primary health care re-engineering process being undertaken by the South&nbsp / African National Department of Health (SANDOH) which will involve the establishment of family health worker teams&nbsp / including community health workers. A key function of these workers will&nbsp / be to conduct antenatal and postnatal visits to women in their homes and to identify and refer ill children. Failure of mothers to identify danger signs in the infant was associated with&nbsp / non-completion of referral. This highlights the need for thorough counseling of mothers during the antenatal and early postnatal period on neonatal danger signs which can be reinforced by&nbsp / community health workers. Most of the referrals in this study were&nbsp / neonates which strengthens the need for home visit packages delivered by community health workers during the antenatal&nbsp / and post-natal period as currently planned by the South African National Department of Health.Recommendations: This study supports the current plans of the Department of Health for greater involvement of CHWs in Primary Health Care. Attention should be given to improving communication between health facilities and CHWs to ensure continuity of care and greater&nbsp / realization of a team approach to PHC.</p>

<p>Background: Globally, neonatal mortality (i.e. deaths occurring during the first month of life) accounts for 44% of the 11 million infants that die every year (Lawn, Cousens &amp / Zupan, 2005). Early&nbsp / detection of illness and referral of mothers and infants during the peri-natal period to higher levels of care can lead to substantial reductions in maternal and child mortality in developing&nbsp / countries. Establishing effective referral systems from the community to health facilities can be achieved through greater utilization of community health workers and improved health seeking&nbsp / behaviour. Study design: The Good Start Saving Newborn Lives study being conducted in Umlazi, KwaZulu-Natal, is a community randomized trial to assess the effect of an integrated home&nbsp / visit package delivered to mothers during pregnancy and post delivery on uptake of PMTCT interventions and appropriate newborn care practices. The home visit package is delivered by community health workers in fifteen intervention clusters. Control clusters receive routine health facility antenatal and postpartum care. For any identified danger signs during a home visit,&nbsp / community health workers write a referral and if necessary refer infants to a local clinic or hospital. The aim of this study was to assess the effectiveness of this referral system by describing&nbsp / community health worker referral completion rates as well as health-care seeking practices and perceptions of mothers. A cross- sectional survey was undertaken using a structured&nbsp / questionnaire with all mothers who had been referred to a clinic or hospital by a community health worker since the start of the Good Start Saving Newborn Lives Trial. Data collection: Informed consent was obtained from willing participants. Interviews were conducted by a trained research assistant in the mothers&rsquo / home or at the study&nbsp / offices. Road to Health Cards were reviewed to confirm referral completion. Data was collected by means of a cell phone (mobile researcher software) and the database was later transferred to Epi-info and STATA IC 11 for analysis.&nbsp / Descriptive analysis was&nbsp / conducted so as to establish associations between explanatory factors and referral completion and to describe referral processes experienced by caregivers. Significant&nbsp / associations between categorical variables were assessed using chi square tests and continuous variables using analysis of variance. Results: A total of 2423 women were&nbsp / enrolled in the SNL study and 148 had received a referral for a sick infant by a CHW by June 2010. The majority (95%) of infants were referred only once during the time of enrolment, the&nbsp / highest number of which occurred within&nbsp / the first 4 weeks of life (62%) with 22% of these being between birth and 2 weeks of age. Almost all mothers (95%) completed the referral by taking&nbsp / their child to a health facility. Difficulty in breathing and rash accounted for the highest number of referrals (26% and 19% respectively). None of the six mothers who did not complete referral recognised any danger signs in their infants. In only 16% of cases did a health worker give written feedback on the outcome of the referral to the referring CHW.&nbsp / Conclusion: This study found&nbsp / high compliance with referrals for sick infants by community health workers in Umlazi. This supports the current primary health care re-engineering process being undertaken by the South&nbsp / African National Department of Health (SANDOH) which will involve the establishment of family health worker teams&nbsp / including community health workers. A key function of these workers will&nbsp / be to conduct antenatal and postnatal visits to women in their homes and to identify and refer ill children. Failure of mothers to identify danger signs in the infant was associated with&nbsp / non-completion of referral. This highlights the need for thorough counseling of mothers during the antenatal and early postnatal period on neonatal danger signs which can be reinforced by&nbsp / community health workers. Most of the referrals in this study were&nbsp / neonates which strengthens the need for home visit packages delivered by community health workers during the antenatal&nbsp / and post-natal period as currently planned by the South African National Department of Health.Recommendations: This study supports the current plans of the Department of Health for greater involvement of CHWs in Primary Health Care. Attention should be given to improving communication between health facilities and CHWs to ensure continuity of care and greater&nbsp / realization of a team approach to PHC.</p>

Magister Public Health - MPH / Background: Globally, neonatal mortality (i.e. deaths occurring during the first month of life) accounts for 44% of the 11 million infants that die every year (Lawn, Cousens Zupan, 2005). Early detection of illness and referral of mothers and infants during the peri-natal period to higher levels of care can lead to substantial reductions in maternal and child mortality in developing countries. Establishing effective referral systems from the community to health facilities can be achieved through greater utilization of community health workers and improved health seeking behaviour. Study design: The Good Start Saving Newborn Lives study being conducted in Umlazi, KwaZulu-Natal, is a community randomized trial to assess the effect of an integrated home visit package delivered to mothers during pregnancy and post delivery on uptake of PMTCT interventions and appropriate newborn care practices. The home visit package is delivered by community health workers in fifteen intervention clusters. Control clusters receive routine health facility antenatal and postpartum care. For any identified danger signs during a home visit, community health workers write a referral and if necessary refer infants to a local clinic or hospital. The aim of this study was to assess the effectiveness of this referral system by describing community health worker referral completion rates as well as health-care seeking practices and perceptions of mothers. A cross- sectional survey was undertaken using a structured questionnaire with all mothers who had been referred to a clinic or hospital by a community health worker since the start of the Good Start Saving Newborn Lives Trial. Data collection: Informed consent was obtained from willing participants. Interviews were conducted by a trained research assistant in the mothers home or at the study offices. Road to Health Cards were reviewed to confirm referral completion. Data was collected by means of a cell phone (mobile researcher software) and the database was later transferred to Epi-info and STATA IC 11 for analysis. Descriptive analysis was conducted so as to establish associations between explanatory factors and referral completion and to describe referral processes experienced by caregivers. Significant associations between categorical variables were assessed using chi square tests and continuous variables using analysis of variance. Results: A total of 2423 women were enrolled in the SNL study and 148 had received a referral for a sick infant by a CHW by June 2010. The majority (95%) of infants were referred only once during the time of enrolment, the highest number of which occurred within the first 4 weeks of life (62%) with 22% of these being between birth and 2 weeks of age. Almost all mothers (95%) completed the referral by taking their child to a health facility. Difficulty in breathing and rash accounted for the highest number of referrals (26% and 19% respectively). None of the six mothers who did not complete referral recognised any danger signs in their infants. In only 16% of cases did a health worker give written feedback on the outcome of the referral to the referring CHW. Conclusion: This study found high compliance with referrals for sick infants by community health workers in Umlazi. This supports the current primary health care re-engineering process being undertaken by the South African National Department of Health (SANDOH) which will involve the establishment of family health worker teams including community health workers. A key function of these workers will be to conduct antenatal and postnatal visits to women in their homes and to identify and refer ill children. Failure of mothers to identify danger signs in the infant was associated with non-completion of referral. This highlights the need for thorough counseling of mothers during the antenatal and early postnatal period on neonatal danger signs which can be reinforced by community health workers. Most of the referrals in this study were neonates which strengthens the need for home visit packages delivered by community health workers during the antenatal and post-natal period as currently planned by the South African National Department of Health.Recommendations: This study supports the current plans of the Department of Health for greater involvement of CHWs in Primary Health Care. Attention should be given to improving communication between health facilities and CHWs to ensure continuity of care and greater realization of a team approach to PHC. / South Africa

Grâce aux combinaison d’antirétroviraux (ART), le taux de transmission mère-enfant (TME) du Virus de l’Immunodéficience Humaine VIH est maintenant réduit à moins de 1%. Des progrès restent néanmoins à faire, en particuliers chez les femmes débutant tardivement leurs consultations prénatales. Mais l’évaluation de nouvelles stratégies ART pour la prévention de la TME (PTME) devient de plus en plus complexe à cause des exigences statistiques liées au fait que les transmissions sont rares. Dés lors, il devient crucial de modéliser l’efficacité des ART sur la charge virale (CV) et la transmission. Dans cette thèse, nous modélisons les mécanismes et le moment de la TME du VIH en utilisant des modèles mixtes. Les données proviennent de 4 études de prévention périnatales du VIH en Thaïlande (PHPT-1, PHPT-2, PHPT-5 1st phase et PHPT-5 2nd phase), une base de données historiques de qualité, collectées de 1996 à 2015, où différentes prophylaxies ART ont été prescrites à plus de 4000 femmes enceintes pendant des durées variables: Zidovudine (ZDV) seule; ZDV + une dose unique de nevirapine périnatale (sdNVP); ZDV+lopinavir/ritonavir (LPV/r) ou ZDV+LPV/r+lamivudine (3TC). Les modèles développés apportent un éclairage sur les mécanismes et le moment de la PTME ainsi que sur le rôle respectif de différents ART sur la réduction de la CV et sur leur contribution à la prophylaxie pre/post exposition. Partant de ces connaissances, une approche bayésienne est appliquée à une étude de cas (essai de supériorité dans le contexte d’un événement rare comme la TME du VIH) afin d’améliorer la puissance statistique tout en limitant la taille de l’échantillon, et comparée à une approche fréquentiste. / Nowadays, with the use of highly efficacious antiretroviral (ART) combination, the rate of mother-to-child transmission (MTCT) of Human Immunodeficiency Virus (HIV) is reduced to less than 1%. However, there are still some gaps to be filled, especially in women who initiate antenatal prophylaxis late. The evaluation of new ART strategies or drug combinations for the prevention of MTCT (PMTCT) of HIV becomes more difficult in view of the statistical requirements in case of rare outcomes. Therefore modeling the impact of ART on maternal viral load (VL) and transmission rate is increasingly important. In this thesis, the mechanisms and timing of MTCT of HIV were investigated using mixed model approaches. Data were derived from four perinatal HIV prevention studies in Thailand (PHPT-1, PHPT-2, PHPT-5 1st phase and PHPT-5 2nd phase), a unique set of quality historical data, consistently collected from 1996 to 2015, in which different ART prophylaxis regimens were provided to more than 4000 HIV-infected pregnant women for varying durations: Zidovudine (ZDV) alone; ZDV plus perinatal single dose nevirapine; ZDV+lopinavir/ritonavir (LPV/r) or ZDV+LPV/r+lamivudine. The developed models provide insights on the mechanisms and timing of PMTCT as well as on the respective role of different ARTs on the maternal VL reduction and in turn on their contribution to pre/post-exposure prophylaxis in MTCT of HIV. With this prior knowledge, a Bayesian design is applied to a case study, a trial aimed at evaluating treatment superiority in the context of rare outcomes such as MTCT of HIV, to improve the statistical power –while limiting sample size— and compared to a frequentist design.

Mother-to-infant vertical transmission of HIV usually occurs during pregnancy, labor, delivery or breastfeeding. It is the third leading cause of transmission of HIV after sexual intercourse and blood transfusions. In 2008, 12 million women aged 15 years and above were anticipated to be living with HIV in countries within Sub-Saharan Africa. In this study, the association between parental HIV knowledge, attitudes and risk reduction practices, and HIV vertical transmission in Kenya were explored. The health belief model was used to help understand and interpret the findings. For this quantitative study, data were collected via surveys from 212 participants in 3 HIV clinics in Kenya. Data were analyzed using descriptive and inferential statistics. Around 45% of respondents lacked knowledge on key aspects of Prevention of Mother to Child Transmission (PMTCT) of HIV particularly on expressing and heat treating milk from HIV positive mothers to make it safe for their babies. About 65% of Participants had awareness towards Mother to Child Transmission (MTCT) of HIV. Logistic regression showed no association between socioeconomic factors and parental knowledge on MTCT of HIV. Logistic modeling found that there was association between attitude and MTCT, revealing that attitude increased the likelihood to influence MTCT. Being married was associated with reduced risk of MTCT of HIV. The overall results indicated gaps in knowledge and information packaging. The potential positive social change implication of this study is that factors related to HIV vertical transmission identified in this study might be utilized to develop and implement HIV prevention strategies to reduce HIV vertical transmission and decrease associated morbidity and mortality among this vulnerable population.

This study aimed to identify factors affecting women’s utilisation of the prevention of mother-to-child transmission (PMTCT) of HIV, evaluate the quality of PMTCT services, describe health outcomes of mothers and infants and to identify factors that influence mother-to-child transmission (MTCT) of HIV. Structured interviews were conducted with 384 women who had utilised PMTCT services. Information was also obtained from the health records of these women and of their infants. Better educated women, who had male partners and were self-employed were more likely to use PMTCT services. Being unmarried, poor and feeling stigmatised made it difficult for women to use these services. Respondents were satisfied with PMTCT services except that clinics sometimes had no medications. The health care workers followed the Ethiopian guidelines during HIV testing and counseling but not when prescribing treatment. Although the respondents’ CD4 cell counts improved, their clinical conditions did not improve. The MTCT rate was significantly higher if infants did not receive ARVs, had APGAR scores below seven, weighed less than 2.5kg at birth, were born prematurely, and if their mothers had nipple fissures. PMTCT services could be improved if more women used these services, health care workers followed the national guidelines when prescribing ARVs, clinics had adequate supplies of medicines, all infants received ARVs, and mothers’ nipple fissures could be prevented. Antenatal care should help to avoid premature births of infants weighing less than 2.5kg and having APGAR scores below 7. Future research should compare formula feeding versus breastfeeding of infants with HIV-positive mothers / Health Studies / D. Litt. et Phil. (Health Studies)

This study aimed to identify factors affecting women’s utilisation of the prevention of mother-to-child transmission (PMTCT) of HIV, evaluate the quality of PMTCT services, describe health outcomes of mothers and infants and to identify factors that influence mother-to-child transmission (MTCT) of HIV. Structured interviews were conducted with 384 women who had utilised PMTCT services. Information was also obtained from the health records of these women and of their infants. Better educated women, who had male partners and were self-employed were more likely to use PMTCT services. Being unmarried, poor and feeling stigmatised made it difficult for women to use these services. Respondents were satisfied with PMTCT services except that clinics sometimes had no medications. The health care workers followed the Ethiopian guidelines during HIV testing and counseling but not when prescribing treatment. Although the respondents’ CD4 cell counts improved, their clinical conditions did not improve. The MTCT rate was significantly higher if infants did not receive ARVs, had APGAR scores below seven, weighed less than 2.5kg at birth, were born prematurely, and if their mothers had nipple fissures. PMTCT services could be improved if more women used these services, health care workers followed the national guidelines when prescribing ARVs, clinics had adequate supplies of medicines, all infants received ARVs, and mothers’ nipple fissures could be prevented. Antenatal care should help to avoid premature births of infants weighing less than 2.5kg and having APGAR scores below 7. Future research should compare formula feeding versus breastfeeding of infants with HIV-positive mothers / Health Studies / D. Litt. et Phil. (Health Studies)