Paediatric and perinatal HIV/AIDS in Jamaica: an international leadership initiative, 2002-2007 / VIH/SIDA pediátrico y perinatal en Jamaica: iniciativa de liderazgo internacional, 2002-2007

BACKGROUND: Paediatric and Perinatal HIV/AIDS remain significant health challenges in the Caribbean where the HIV seroprevalence is second only to Sub-Saharan Africa. METHOD: We describe a collaborative approach to the prevention, treatment and care of HIV in pregnant women, infants and children in Jamaica. A team of academic and government healthcare personnel collaborated to address the paediatric and perinatal HIV epidemic in Greater Kingston as a model for Jamaica (population 2.6 million, HIV seroprevalence 1.5%). A five-point plan was utilized and included leadership and training, preventing mother-to-child transmission (pMTCT), treatment and care of women, infants and children, outcomes-based research and local, regional and international outreach. RESULTS: A core group of paediatric/perinatal HIV professionals were trained, including paediatricians, obstetricians, public health practitioners, nurses, microbiologists, data managers, information technology personnel and students to serve Greater Kingston (birth cohort 20 000). During September 2002 to August 2007, over 69 793 pregnant women presented for antenatal care. During these five years, significant improvements occurred in uptake of voluntary counselling (40% to 91%) and HIV-testing (53% to 102%). Eight hundred and eighty-three women tested HIV-positive with seroprevalence rates of 1-2% each year. The use of modified short course zidovudine or nevirapine in the first three years significantly reduced mother-to-child transmission (MTCT) of HIV from 29% to 6% (RR 0.27; 95% CI - 0.10, 0.68). During 2005 to 2007 using maternal highly active antiretroviral therapy (HAART) with zidovudine and lamivudine with either nevirapine, nelfinavir or lopinavir/ritonavir and infant zidovudine and nevirapine, MTCT was further reduced to an estimated 1.6% in Greater Kingston and 4.75% islandwide. In five years, we evaluated 1570 children in four-weekly paediatric infectious diseases clinics in Kingston, St Andrew and St Catherine and in six rural outreach sites throughout Jamaica; 24% (377) had HIV/AIDS and 76% (1193) were HIV-exposed. Among the infected children, 79% (299 of 377) initiated HAART, resulting in reduced HIV-attributable childhood morbidity and mortality islandwide. An outcomes-based research programme was successfully implemented. CONCLUSION: Working collaboratively, our mission of pMTCT of HIV and improving the quality of life for families living and affected by HIV/AIDS in Jamaica is being achieved.

ANTECEDENTES: El VIH/SIDA pediátrico y el perinatal continúan siendo retos significativos para la salud en el Caribe, donde la seroprevalencia de VIH ocupa el segundo lugar tras el África Subsahariana. MÉTODO: Se describe un enfoque colaborativo para tratamiento, prevención y cuidado de embarazadas, bebés y niños en Jamaica. Un equipo de personal académico y gubernamental vinculados a la salud, colaboraron para abordar la epidemia de VIH pediátrico y perinatal en Greater Kingston, como modelo para Jamaica (población de 2.6 millones, 1.5% seroprevalencia VIH). Se utilizó un plan de cinco puntos que incluyó liderazgo y entrenamiento, prevención de la transmisión madre a hijo (PTMAH), tratamiento y cuidado de mujeres, bebés y niños, investigaciones basadas en resultados, y outreach local, regional e internacional. RESULTADOS: Un grupo básico de profesionales del VIH pediátrico/perinatal, que incluía pediatras, obstetras, trabajadores de la salud, enfermeras, microbiólogos, administradores de datos, así como personal y estudiantes de la tecnología de la información, fue entrenado para servir en Greater Kingston (cohorte de nacimiento 20 000). De septiembre de 2002 hasta Agosto de 2007, más de 69 793 embarazadas se presentaron para recibir atención prenatal. Durante estos cinco años, tuvieron lugar mejoras significativos en cuanto a la recepción de asesoramiento (40% to 91%) y pruebas (53% to 102%) de VIH voluntarios. Ochocientos ochenta y tres mujeres resultaron VIH positivas en las pruebas, con tasas de seroprevalencia de 1-2% cada año. El uso de un ciclo corto modificado de zidovudina o nevirapina en los primeros tres años, redujo la transmisión madre a hijo (TMAH) de VIH significativamente de 29% a 6% (RR 0.27; 95% CI - 0.10, 0.68). Durante el 2005 hasta 2007, usando terapia antiretroviral altamente activa (TARAA) materna, con zidovudina y lamivudina con nevirapina, nelfinavir o lopinavir/ritonavir y nevirapina y zidovudina para niños, la TMAH se redujo a un estimado de 1.6 % en Greater Kingston y a .75% a lo largo de la isla. En cinco años, evaluamos 1570 niños en cuatro clínicas infecciosas pediátricas semanales en Kingston, Saint Andrew y Saint Catherine, así como en seis otros lugares destinados al servicio comunitario (outreach) por toda Jamaica; 24% (377) tenían VIH/SIDA y 76% (1193) estaba expuestos al VIH. Entre los niños infectados, 79% (299 de 377) iniciaron el TARAA, lo que trajo como resultado una reducción de la mortalidad y la morbilidad infantil atribuible al VIH, en todo el país. Se implementó exitosamente un programa de investigación basado en resultados. CONCLUSIÓN: Trabajando en colaboración, estamos logrando nuestra misión de prevenir la TMAH del VIH, y mejorar la calidad de vida de las familias que viven afectadas por el VIH/SIDA en Jamaica.

Evolving care of HIV-infected pregnant women in Jamaica from Nevirapine to HAART / Evolución del cuidado de las mujeres jamaicanas infectadas por el VIH - desde la Nevirapina a la TARAA

BACKGROUND: The Ministry of Health, Jamaica, is scaling-up programmes to improve the health of HIV-positive pregnant women according to the modified WHO recommended preventative mother to child transmission (pMTCT) regimens of therapy based upon the mother's clinical and immunological status. Highly-active antiretroviral drugs (HAART) can result in successful pMTCT to < 1%. We report the clinical and immunological characteristics of HIV/AIDS in an era of evolving treatment and care of HIV-infected pregnant Jamaican women. SUBJECTS AND METHOD: Clinical records were reviewed of patients registered in antenatal clinics in Greater Kingston and St Catherine, Jamaica (annual birth cohort - 20 000) between September 2002 and August 2006. Disease status was determined using the Centers for Disease Control and Prevention (CDC) classification system for adult HIV/AIDS. Demographic, clinical and laboratory data were documented and analyzed. RESULTS: During the four-year period, 571 HIV-infected women were enrolled; 62% from Victoria Jubilee Hospital, 25% from Spanish Town Hospital and 13% from the University Hospital of the West Indies. Mean age was 27-29 (range 15-41) years, median parity was 2 (range 0-9) and 68-70% were unemployed. Ninety-five per cent had live births. CDC categories of illnesses were A - mild disease in 82% (n = 473), B - moderate disease in 4.4% (n = 24) and C - severe disease in 1.4% (n = 8) while 12% (n = 66) had insufficient data. During the first three years, CD4+ cell counts were evaluated in only 2.5% (10 of 406) of patients with median of 344 cells/uL, compared to CD4 evaluation in 50% (83 of 165 women) in the last year with median of 573 cells/uL. Antiretroviral (ARV) medications primarily for pMTCT were given to 89% (n = 506) of women. Of these, uptake of HAART increased during years 1-3 from 2-3% to 62% in year four. Within two years post-partum, 24 women died, 92% (n = 22) from the direct complications of HIV/AIDS. CONCLUSION: A comprehensive system of care of HIV in the peripartum period has been developed in Jamaica. Detailed medical evaluation during pregnancy is performed with modern guidelines and increasing laboratory availability of CD4+ cell counts and viral loads. We believe declining HIV infection rates in Jamaican infants and healthier mothers are a direct consequence of increased testing in pregnancy with early diagnosis and initiation of HAART-based pMTCT regimens in pregnant women.

ANTECEDENTES: En la actualidad el Ministerio de Salud de Jamaica se halla en plena campaña por aumentar los programas de salud para mujeres embarazadas por el VIH positivo, sobre la base de regímenes terapéuticos para prevenir la transmisión de madre a hijo (PTMAH), de acuerdo con recomendaciones modificadas de la OMS, a partir del estatus inmunológico y clínico de la madre. Los medicamentos antiretrovirales altamente activos (TARAA) pueden traer como resultado un exitoso PTMAH a < 1%. Reportamos las características clínicas e inmunológicas del VIH/SIDA en una etapa en la que el tratamiento y cuidado de las mujeres embarazadas infectadas con VIH en Jamaica, se halla en evolución. SUJETOS Y MÉTODOS: Se revisaron las historias clínicas de pacientes registrados en las clínicas prenatales en Greater Kingston y Saint Catherine (cohorte de nacimiento anual - 20 000), entre septiembre de 2002 y agosto de 2006. El estatus de la enfermedad fue determinado usando el sistema de clasificación para el VIH/SIDA en adultos, según los Centros para el Control y Prevención de las Enfermedades (CCPE). Se documentario y analizaron datos demográficos, clínicos y de laboratorio. RESULTADOS: Durante el período de cuatro años, se reclutaron 571 mujeres infectadas con el VIH, 62% del Hospital Victoria Jubilee, 25% del Hospital de Spanish Town, y 13% del Hospital Universitario de West Indies. La edad promedio fue de 27-29 años (rango 15-41), la paridad mediana fue 2 (rango 0-9), y el 68-70% eran desempleadas. El noventa y cinco por ciento tuvo nacimientos vivos. Las categorías de enfermedades de CCPE fueron la enfermedad leve A- en 82% (n = 473), la enfermedad moderada B - en 4.4% (n = 24) y la enfermedad severa C - en 1.4% (n = 8) mientras que para el 12% (n = 66) los datos fueron insuficientes. Durante los primeros tres años, los conteos CD4+ fueron evaluados en sólo 2.5% (10 de 406) de los pacientes con la mediana de 344 células/uL, en comparación con la evaluación CD4 en 50% (83 de 165 mujeres) en el último año con una mediana de 573 células/uL. Los medicamentos antiretrovirales (ARV) fundamentalmente para PTMAH fueron dados al 89% (n = 506) de las mujeres. Entre éstas, el consumo de TARAA aumentó durante los años 1-3 de 2-3% a 62% en el cuarto año. En los dos años posteriores al parto, murieron 24 mujeres, 92% (n = 22) de complicaciones directas del VIH/SIDA, CONCLUSIÓN: Un sistema integral de atención al VIH en el período de periparto ha sido desarrollado en Jamaica. Durante el embarazo, se lleva a cabo una evaluación médica detallada con normas modernas y con aumento de la disponibilidad en los laboratorios del conteo CD4+ y cargas virales. Creemos que la disminución de las tasas de infección por VIH en los infantes jamaicanos y el número de madres más saludables, son consecuencia directa del aumento de las pruebas durante el embarazo con diagnóstico precoz y regímenes de PTMAH basados en TARAA en las mujeres embarazadas.

HIV seroprevalence, uptake of interventions to reduce mother-to-child transmission and birth outcomes in greater Kingston, Jamaica

BACKGROUND: The seroprevalence of HIV among pregnant women in the Caribbean is 2-3 and increasing. The Kingston Paediatric and Perinatal HIV Programme is developing and implementing a unified programme to eliminate mother-to-child transmission (MTCT) of HIV in Kingston, Jamaica. METHODS: Pregnant women presenting to Kingston Metropolitan Antenatal Clinics, Victoria Jubilee Hospital, Spanish Town Hospital and the University Hospital of the West Indies had HIV serology performed by ELISA, or by the new Determine Rapid Test after receiving group counselling. HIV-positive women were referred to High Risk Antenatal Clinics. Antiretroviral prophylaxis with zidovudine (AZT), or nevirapine was given. Care was administered using a standard protocol by a multi-disciplinary team of public and academic healthcare personnel. RESULTS: In year one, 19,414 women delivered Among 14,054 women who started antenatal care for this period, 5,558 (40) received group counselling and 7,383 (53) received HIV-testing. During the fourth quarter of follow-up, these comparative rates were 66 (2049/3 118) and 72 (2260/3118) respectively. HIV seroprevalence overall was 2.1 (152/7 383). One hundred and seven HIV+ women at varying gestational ages were identified in the programme, 72 had so far received AZT and nine nevirapine (76). 0f 84 deliveries, birth outcomes were 75 live births (89), six neonatal deaths and four maternal deaths (all from HIV/AIDS). Major challenges include repeat pregnancies of 36 despite prior knowledge of HIV seropositivity and poor partner notification with only 30 (32) having a HIV-test. Although rates of HIV testing in pregnant women in Greater Kingston are increasing, rates of testing overall remain sub-optimal. On the labour ward, there was sub-optimal identification of the HIV+ pregnant woman and administration of AZT chemoprophylaxis, along with issues of patient confidentiality and stigma. CONCLUSION: This programme needs strengthening in order to reduce maternal-fetal transmission of HIV in Greater Kingston, Jamaica [quot]pMTCT-PLUS, or comprehensive family-centred care, is the next step[quot]

Factors associated with size and proportionality at birth in term Jamaican infants.

The objective of this study was to identify the factors associated with size and proportionality at birth in a cohort of term infants established to investigate their growth and development. One hundred and forty term low-birth-weight (birth-weight < 2,500 g) infants and 94 normal birth-weight infants (2,500- < 4,000 g) were recruited within 48 hours of birth at the main maternity hospital, Kingston, Jamaica. Birth anthropometry and gestational age were measured, and maternal information was obtained by interview and from hospital records. Controlling for gestational age, variables independently associated with birth-weight were rate of weight gain in the second half of pregnancy, maternal height, haemoglobin level < 9.5 microg/dL, time of first attendance in antenatal clinic, birth order, pre-eclampsia, and consumption of alcohol, with 33% of the variance in birth-weight explained. Birth length was associated only with maternal height and age, while measures of proportionality (ponderal index and head/length ratio) were associated with characteristics of the environment in late pregnancy, including rate of weight gain, weight in late pregnancy, and pre-eclampsia. The variation in maternal characteristics associated with size or proportionality at birth may reflect the times during gestation when different aspects of growth are most affected.