• HIV care need not hamper maternity care: a descriptive analysis of integration of services in rural Malawi

      van den Akker, T; Bemelmans, M; Ford, N; Jemu, M; Diggle, E; Scheffer, S; Zulu, I; Akesson, A; Shea, J; Thyolo District Health Office, Ministry of Health, Thyolo, Malawi; Médecins Sans Frontières, Thyolo Project, Thyolo, Malawi; Child Health Unit, University of Cape Town, Cape Town, South Africa; Médecins Sans Frontières Operational Centre Brussels, Brussels, Belgium; Médecins Sans Frontières, Geneva, Switzerland; Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa (Wiley-Blackwell, 2012-01-18)
      Please cite this paper as: van den Akker T, Bemelmans M, Ford N, Jemu M, Diggle E, Scheffer S, Zulu I, Akesson A, Shea J. HIV care need not hamper maternity care: a descriptive analysis of integration of services in rural Malawi. BJOG 2012;119:431-438. Objective  To evaluate the use of reproductive health care and incidence of paediatric HIV infection during the expansion of antiretroviral therapy and services for the prevention of mother-to-child transmission in rural Malawi, and the influence of integration of these HIV-related services into general health services. Design  Descriptive analysis. Setting  Thyolo District, with a population of 600 000, an HIV prevalence of 21% and a total fertility rate of 5.7 in 2004. Population  Women attending reproductive health services care in 2005 and 2010. Methods  Review of facility records and databases for routine monitoring. Main outcome measures  Use of antenatal, intrapartum, postpartum, family planning and sexually transmitted infection services; incidence of HIV infection in infants born to mothers who received prevention of mother-to-child transmission care. Results  There was a marked increase in the uptake of perinatal care: pregnant women in 2010 were 50% more likely to attend at least one antenatal visit (RR 1.50, 95% CI 1.48-1.51); were twice as likely to deliver at a healthcare facility (RR 2.05, 95% CI 2.01-2.08); and were more than four times as likely to present for postpartum care (RR 4.40, 95% CI 4.25-4.55). Family planning consultations increased by 40% and the number of women receiving treatment for sexually transmitted infections doubled. Between 2007 and 2010, the number of HIV-exposed infants who underwent testing for HIV went up from 421 to 1599/year, and the proportion testing positive decreased from 13.3 to 5.0%; infants were 62% less likely to test HIV positive (RR 0.38, 95% CI 0.27-0.52). Conclusions  During the expansion and integration of HIV care, the use of reproductive health services increased and the outcomes of infants born to HIV-infected mothers improved. HIV care may be successfully integrated into broader reproductive health services.
    • Predictive value of C-reactive protein for tuberculosis, bloodstream infection or death among HIV-infected individuals with chronic, non-specific symptoms and negative sputum smear microscopy.

      Bedell, RA; van Lettow, M; Meaney, C; Corbett, EL; Chan, AK; Heyderman, RS; Anderson, ST; Akesson, A; Kumwenda, M; Zachariah, R; Harries, AD; Ramsay, AR (Wiley-Blackwell, 2018-01-01)
      BACKGROUND: C-reactive protein (CRP) is an inflammatory biomarker that may identify patients at risk of infections or death. Mortality among HIV-infected persons commencing antiretroviral therapy (ART) is often attributed to tuberculosis (TB) or bloodstream infections (BSI). METHODS: In two district hospitals in southern Malawi, we recruited HIV-infected adults with one or more unexplained symptoms present for at least one month (weight loss, fever or diarrhoea) and negative expectorated sputum microscopy for TB. CRP determination for 452 of 469 (96%) participants at study enrolment was analysed for associations with TB, BSI or death to 120 days post-enrolment. RESULTS: Baseline CRP was significantly elevated among patients with confirmed or probable TB (52), BSI (50) or death (60) compared to those with no identified infection who survived at least 120 days (269). A CRP value of >10 mg/L was associated with confirmed or probable TB (adjusted odds ratio 5.7; 95% CI 2.6, 14.3; 87% sensitivity) or death by 30 days (adjusted odds ratio 9.2; 95% CI 2.2, 55.1; 88% sensitivity). CRP was independently associated with TB, BSI or death, but the prediction of these endpoints was enhanced by including haemoglobin (all outcomes), CD4 count (BSI, death) and whether ART was started (death) in logistic regression models. CONCLUSION: High CRP at the time of ART initiation is associated with TB, BSI and early mortality and so has potential utility for stratifying patients for intensified clinical and laboratory investigation and follow-up. They may also be considered for empirical treatment of opportunistic infections including TB.