HIV-sensitive social protection: an assessment of east and southern Africa's social protection policies and programmes.

Despite notable political and financial commitment to fight the HIV epidemic, east and southern Africa (ESA) remains the world regions most affected. Given increasing calls for the implementation of HIV-sensitive social protection programmes to address the multiple individual, community and societal factors that heighten the risk of HIV infection, this article explores the extent to which social protection mechanisms in the region are HIV sensitive. The article is based on a two-phase project where the first phase entailed a desktop review of national social protection policies and programmes. In the second phase, multisectoral stakeholder consultations conducted were 15 fast-track countries in the region. The key findings suggest that social protection policies and social assistance programmes in ESA do not specifically target HIV issues or people living with, at risk of, or affected by HIV. Rather, and in line with the countries' constitutional provisions, the programmes tend to be inclusive of the vulnerabilities of various populations including people living with HIV. To this end, the programmes can be seen as generally sufficient to encompass HIV-related issues and the needs of people infected and affected by the epidemic. However, a recurring argument from many stakeholders is that, to the extent that people living with HIV are often reluctant to either disclose their status and/or access social protection services, it is critical for social protection policies and programmes to be explicitly HIV sensitive. The article thus concludes by making recommendations in this regard as well as by making a class for multisectoral partners to work collaboratively to ensure that social protection policies and programmes are transformative.

Assessment of healthcare worker influenza vaccination program in French geriatric wards: a cluster-randomized controlled trial.

BACKGROUND AND AIMS: The French institute for study of geriatric infection risk (ORIG) has run a multiphase multicenter study (VESTA) to develop and implement active programs promoting healthcare worker (HCW) influenza vaccination. The present article reports results after implementation of the first active program. METHOD: A cluster-randomized controlled trial was conducted from December 1 to December 15, 2005, and a total of 43 geriatric wards (3646 HCWs) were randomly assigned to two clusters. The program cluster (24 wards; 1918 HCWs) received the active program whereas no action was taken in the control cluster (19 wards; 1728 HCWs). The program was educational; its objective was to convince HCWs to be vaccinated by giving them topdown scientific information and developing a sense of altruism. Data from 1201 HCWs (63%) from the program cluster and 1144 HCWs (66%) from the control cluster were collected. RESULTS: The program failed to increase the HCW influenza vaccination rate (program: 34%; control: 32%; p>0.05), but won the faithfulness of vaccinated HCWs (5% vs 8% HCWs quitted vaccination; p<0.05). CONCLUSIONS: Resistance to active influenza vaccination programs was found. Future active programs will have to restore a climate of confidence between sources of knowledge and HCWs and promote "self-protection" in contrast with the protection of elderly people.

Impact of HIV infection on severity of imported malaria is restricted to patients with CD4 cell counts < 350 cells/microl.

OBJECTIVES: To study the relative impact of HIV-1 infection and associated immunodepression on the severity of Plasmodium falciparum malaria in adults returning from areas of endemic malaria. METHODS: We conducted a cross-sectional study, based on data from 104 HIV-infected patients from the French Hospital Database on HIV cohort (FHDH-ANRS CO4) and 161 HIV-negative patients from Bichat hospital, with a diagnosis of imported P. falciparum malaria between 2000 and 2003. The severity of falciparum malaria episode was graded with World Health Organization (WHO) criteria 2000 or on 2007 French recommendations. RESULT: Depending on criteria used, 40% (WHO) and 28% (2007 French recommendations) of episodes of imported P. falciparum malaria in HIV-infected patients were classified as severe, compared with 21% (WHO) and 11% (2007 French recommendations) of episodes among HIV-negative patients. Among HIV-infected patients, the episodes were severe in between 22 (CD4 cell counts > or =350/microl) and 51% (CD4 cell counts <350/microl) of cases using WHO criteria, and between 12 (CD4 cell counts > or =350/microl) and 41% (CD4 cell counts <350/microl) of cases using 2007 French recommendations criteria. Relative to HIV-negative patients, after adjusting for confounding factors, HIV-infected patients with severe immunodepression (CD4 cell counts <350/microl) were at a significantly higher risk of severe malaria than HIV-negative patients (odds ratio 3.2-4.7, depending on the criteria) contrary to HIV-infected patients with CD4 cell counts more than 350/microl (odds ratio 0.7-0.9). CONCLUSION: The association between HIV infection and severity of imported P. falciparum malaria is only observed for HIV-infected patients with severe immunodepression (CD4 cell counts <350/microl).

[Essential medicines and access to primary health care in the medical district of Mambéré-Kadéï]. / Médicaments essentiels génériques et accès aux soins de santé primaires aux populations dans la préfecture sanitaire de Mambéré-Kadéï

OBJECTIVE: To assess whether people in Mambéré-Kadéï have access to essential medicines for primary health care. SETTING: The study was conducted in 14 public health care centres of the medical district of Mambéré-Kadéi (Central African Republic). METHOD: This cross-sectional study assessed the drugs prescribed for 40 randomly selected outpatients consulting in each of 14 randomly selected public health centres from June 1, 2000, through March 30, 2001. The methodology used was adapted from the World Health Organization study protocol (WHO indicators) and the International Network for Rational Use of Drugs (INRUD). MAIN OUTCOME MEASURE: Accessibility and affordability of key medicines. RESULTS: Complete data were available for 512 study consultations. A mean of 79.3%( 95% Confidence Interval (CI): 77.5-81.7%) of the 14 essential generic drugs monitored were available in the health centre pharmacies. A median prescription cost 2800 Francs FCA ($4.5), a cost within the ability to pay of 73.2% (CI: 72.8-76.2). CONCLUSION: These results suggest that the population in Mambéré-Kadéï had access to affordable essential medicines. Although availability and accessibility of the generic essential drugs are good in this medical district, the study also showed the need for action to improve access to primary health care for the patients too poor to pay: 26.8% (95% CI: 23.8-28.2).

Imported malaria in HIV-infected patients enrolled in the ANRS CO4 FHDH study.

BACKGROUND: To describe episodes of imported malaria in human immunodeficiency virus type 1-infected patients and to study the risk factors for severe Plasmodium falciparum malaria. METHODS: Patients enrolled in the French Hospital Database on HIV who were diagnosed with a first episode of malaria between 1996 and 2003 were included. The severity of P. falciparum imported malaria was graded with World Health Organization criteria. Geographic areas were classified according to P. falciparum chemoresistance. Risk factors for severe malaria were identified with logistic regression. RESULTS: We studied 190 patients infected by P. falciparum in 178 cases. All but four of the patients were infected in sub-Saharan Africa, and half were returning from a country with a high P. falciparum chloroquine resistance. Their median age was 37.5 years, and 57% came from a country endemic with malaria. The median CD4 cell count was 299/mm, and the median plasma human immunodeficiency virus type 1 RNA load was 4.5 log10 copies/mL. Sixty-five (36.5%) episodes of P. falciparum malaria were severe. Severe imported malaria was associated with CD4 cells/mm <350 (odds ratio = 2.58; 95% confidence interval: 1.19 to 5.57). The risk of severe malaria was lower in patients returning from a country with a high prevalence of chemoresistance (odds ratio = 0.50; 95% confidence interval: 0.25 to 0.99). CONCLUSIONS: Severe imported malaria in human immunodeficiency virus type 1-infected patients is associated with decreased CD4 cell count. The risk seems lower when P. falciparum infection was acquired in areas of high prevalence of chemoresistance.

[Factors associated with adherence to therapy among HIV-infected patients in Bangui]. / Facteurs associés à une bonne observance thérapeutique chez les patients infectés par le VIH à Bangui.

OBJECTIVE: To identify the factors related to good or non-adherence met among patients under highly active antiretroviral therapy (HAART) or cotrimoxazole prophylaxis (CTX) in Bangui. METHOD: A cross-sectional study was conducted on a sample representative of patients with HIV followed up in two health centres in Bangui. Patients had been under treatment for at least 2 months. Information concerning adherence was collected through a questionnaire and by interview of the patients. The questionnaire was designed to measure if patients with HIV were taking less than the total number of antiretroviral or CTX pills prescribed by their physician. Adherence was measured by the patient self-reported question of taking the drugs during the last 4 days and the remaining pill count (RPC). RESULTS: 141 patients with the criteria of inclusion were questioned; among these, 89 patients under antiretroviral treatment (d4T/3TC/NVP) and 52 patients under cotrimoxazole. In the study, adherence varies from 67.3 to 94.3 %. According to the type of treatment, adherence of the patients under CTX is lower (65.4 %) than that of the patients under HAART (77.5 %). Adherence was better for the patients who had a personal project and with a need of information on HIV infection. It is worse for the patients with another affection. CONCLUSION: These results suggest the necessity of assessing and supporting HIV-infected adult's adherence routinely in AIDS care institutions. In addition, the method used to assess adherence must be simple, accessible and low-cost for the countries with limited resources.