Publications

OBJECTIVE

To determine whether integrating family planning services into HIV care is associated with increased use of more effective contraceptive methods (sterilization, intrauterine device, implant, injectable or oral contraceptives).

DESIGN

Cluster-randomized trial.

SETTING

Eighteen public HIV clinics in Nyanza Province, Kenya.

PARTICIPANTS

Women aged 18-45 years receiving care at participating HIV clinics; 5682 clinical encounters from baseline period (December 2009-February 2010) and 12,531 encounters from end-line period (July 2011-September 2011, 1 year after site training).

INTERVENTION

Twelve sites were randomized to integrate family planning services into the HIV clinic, whereas six clinics were controls where clients desiring contraception were referred to family planning clinics at the same facility.

MAIN OUTCOME MEASURES

Increase in use of more effective contraceptive methods between baseline and end-line periods. Pregnancy rates during the follow-up year (October 2010-September 2011) were also compared.

RESULTS

Women seen at integrated sites were significantly more likely to use more effective contraceptive methods at the end of the study [increased from 16.7 to 36.6% at integrated sites, compared to increase from 21.1 to 29.8% at controls; odds ratio (OR) 1.81, 95% confidence interval (CI) 1.24-2.63]. Condom use decreased non-significantly at intervention sites compared to controls (OR 0.64, 95% CI 0.35-1.19). No difference was observed in incident pregnancy in the first year after integration comparing intervention to control sites (incidence rate ratio 0.90; 95% CI 0.68-1.20).

CONCLUSIONS

Integration of family planning services into HIV care clinics increased use of more effective contraceptive methods with a non-significant reduction in condom use. Although no significant reduction in pregnancy incidence was observed during the study, 1 year may be too short a period of observation for this outcome.

SETTING

Antiretroviral therapy (ART) reduces pulmonary tuberculosis (PTB) in human immunodeficiency virus (HIV) infected children. Recent ART recommendations have increased the number of children on ART.

OBJECTIVE

To determine the prevalence and incidence of TB in HIV-infected children after the implementation of expanded ART guidelines.

DESIGN

A prospective cohort study including HIV-infected children aged 6 weeks to 14 years was conducted in Kenya. The primary outcome measure was clinically diagnosed TB. Study participants were screened for prevalent TB at enrollment using Kenya's national guidelines and followed at monthly intervals to detect incident TB. Predictors of TB were assessed using logistic regression and Cox proportional hazards regression.

RESULTS

Of 689 participants (median age 6.4 years), 509 (73.9%) were on ART at baseline. There were 51 cases of prevalent TB (7.4%) and 10 incident cases, with over 720.3 child-years of observation (incidence 1.4 per 100 child-years). Months on ART (adjusted hazard ratio [aHR] 0.91, P = 0.003; aOR 0.91, P< 0.001) and months in care before ART (aHR 0.87, P= 0.001; aOR 0.92, P < 0.001) were protective against incident and prevalent TB.

CONCLUSIONS

ART was protective against TB in this cohort of HIV-infected children with high levels of ART use. Optimal TB prevention strategies should emphasize early ART in children.

OBJECTIVE

To evaluate costs, cost-efficiency and cost-effectiveness of integration of family planning into HIV services.

INTERVENTION

Integration of family planning services into HIV care and treatment clinics.

DESIGN

A cluster-randomized trial.

SETTING

Twelve health facilities in Nyanza, Kenya were randomized to integrate family planning into HIV care and treatment; six health facilities were randomized to (nonintegrated) standard-of-care with separately delivered family planning and HIV services.

MAIN OUTCOME MEASURES

We assessed costs, cost-efficiency (cost per additional use of more effective family planning), and cost-effectiveness (cost per pregnancy averted) associated with the first year of integration of family planning into HIV care. More effective family planning methods included oral and injectable contraceptives, subdermal implants, intrauterine device, and female and male sterilization.

PATIENTS AND PARTICIPANTS

We collected cost data through interviews with study staff and review of financial records to determine costs of service integration.

RESULTS

Integration of services was associated with an average marginal cost of $841 per site and $48 per female patient. Average overall and marginal costs of integration were associated with personnel costs [initial ($1003 vs. $872) and refresher ($498 vs. $330) training, mentoring ($1175 vs. $902) and supervision ($1694 vs. $1636)], with fewer resources required for other fixed ($18 vs. $0) and recurring expenses ($471 vs. $287). Integration was associated with a marginal cost of $65 for each additional use of more effective family planning and $1368 for each pregnancy averted.

CONCLUSION

Integration of family planning and HIV services is feasible, inexpensive to implement, and cost-efficient in the Kenyan setting, and thus supports current Kenyan integration policy.

Program implementers and qualitative researchers have described how increasing availability of HIV antiretroviral therapy (ART) is associated with improvements in psychosocial health and internalized stigma. To determine whether, and through what channels, ART reduces internalized stigma, we analyzed data from 262 HIV-infected, treatment-naïve persons in rural Uganda followed from ART initiation over a median of 3.4 years. We fitted Poisson regression models with cluster-correlated robust estimates of variance, specifying internalized stigma as the dependent variable, adjusting for time on treatment as well as socio-demographic, clinical, and psychosocial variables. Over time on treatment, internalized stigma declined steadily, with the largest decline observed during the first 2 years of treatment. This trend remained statistically significant after multivariable adjustment (χ(2) = 28.3; P = 0.03), and appeared to be driven by ART-induced improvements in HIV symptom burden, physical and psychological wellbeing, and depression symptom severity.

OBJECTIVE

To assess the impact of pregnancy on mortality among HIV-infected Ugandan women initiating ART.

DESIGN

Prospective cohort study.

METHODS

HIV-infected women initiating ART in the Uganda AIDS Rural Treatment Outcomes study were assessed quarterly for self-reported pregnancy. The association between pregnancy and postpartum ('pregnancy-related') follow-up periods and mortality was assessed with Cox proportional hazards models adjusted for age, CD4 cell count, plasma HIV-1 RNA levels, and ART duration.

RESULTS

Three hundred and fifty-four women with median age 33 years (IQR: 27-37) and CD4 142 cells/μl (IQR: 82-213) were followed for a median of 4.0 years (IQR: 2.5-4.8) after ART initiation, with 3 and 7% loss-to-follow-up at years 1 and 5. One hundred and nine women experienced pregnancy. Five deaths occurred during pregnancy-related follow-up and 16 during nonpregnancy-related follow-up, for crude mortality rates during the first year after ART initiation of 12.57/100 PYs and 3.53/100 PYs (rate ratio 3.56, 95% CI: 0.97-11.07). In adjusted models, the impact of pregnancy-related follow-up on mortality was highest at ART initiation (aHR: 21.48, 95% CI: 3.73-123.51), decreasing to 13.44 (95% CI 3.28-55.11) after 4 months, 8.28 (95% CI 2.38-28.88) after 8 months, 5.18 (95% CI: 1.36-19.71) after 1 year, and 1.25 (95% CI: 0.10-15.58) after 2 years on ART. Four of five maternal deaths occurred postpartum.

CONCLUSION

Pregnancy and the postpartum period were associated with increased mortality in HIV-infected women initiating ART, particularly during early ART. Contraception proximate to ART initiation, earlier ART initiation, and careful monitoring during the postpartum period may reduce maternal mortality in this setting.

BACKGROUND

With aging, the probability of experiencing multiple chronic conditions has increased, along with symptoms associated with these conditions. Symptoms form a central component of illness burden, and distress. To date, most symptom measures have focused on a particular disease population.

OBJECTIVE

We aimed to develop and evaluate a simple symptom screen using data obtained from a representative sample of community-dwelling older adults.

METHODS

Psychometric analyses were conducted on 10 self-reported dichotomous symptom indicators collected during in-person interviews from a sample of 1000 community-dwelling older adults. Symptoms included shortness of breath, feeling tired or fatigued, problems with balance or dizziness, perceived weakness in legs, constipation, daily pain, stiffness, poor appetite, anxiety, and anhedonia.

RESULTS

Over one third of the individuals (37.4%) had 5 or more concurrent symptoms. Stiffness and feeling tired were the most common symptoms. Confirmatory factor analyses were performed on the 10 symptoms for single factor and bifactor (physical and affective) models of symptom reporting. Goodness-of-fit indices indicated better fit for the bifactor model (χdf=10=89.6; P<0.001), but the practical significance of the improvement in fit was negligible. Differential item functioning analyses showed some differences of relatively high magnitude in location parameters by race; however, because the differential item functioning was in different directions, the impact on the overall measure was most likely lessened.

CONCLUSIONS

Among community-dwelling older adults, a large proportion experienced multiple co-occurring symptoms. This Brief Symptom Screen can be used to quickly measure the overall symptom load in older adult populations, including those with multiple chronic conditions.