Early infant diagnosis of HIV infection at the John F. Kennedy Medical Center, Monrovia, Liberia.

Background: Vertical transmission accounts for majority of new HIV infections among children worldwide. Ninety percent of HIV-positive children reside in Sub- Saharan Africa with their infection predominantly acquired via vertical transmission. In 2004, the vertical transmission rate of HIV in Africa was estimated at 25 - 40% but, remarkably, the rate has significantly decreased to less than 5% in most African countries following implementation and expansion of prevention of MTCT (PMTCT) programs.Objective: To determine the rate of and factors associated with vertical transmission of HIV among attendees of early infant diagnosis (EID) program of an academic and community-based tertiary facility in Liberia.Design: A retrospective cross-sectional analysis.Methods: A retrospective review of medical records of babies seen at Pediatric Unit of Infectious Disease Clinic of John F Kennedy Medical Center (JFKMC) in Monrovia, Liberia between January 1, 2016 and December 31, 2020. All subjects were children born to HIV-positive mothers and who had HIV DNA PCR testing performed between the ages of 6 weeks and 6 months. Children who suffered early neonatal death and those who did not undergo PCR testing were excluded. Demographics of mother to child pairs as well as factors known to influence vertical transmission of HIV such as partial (15.8%) or full (84.2%) participation in prevention of MTCT (PMTCT) programs, mode of delivery, breastfeeding and utilization of post-exposure prophylaxis were collected and assessed. Binomial logistic regression analyses were used to assess factors associated with vertical transmission.Results: During the study timeframe, 284 children had a HIV DNA PCR test with a male:female ratio - 1.3:1. Sixteen tested positive (conducted at a mean of 155 days post birth) giving a vertical transmission rate of 5.6%. For 239 mothers (84.2%) who had full PMTCT, 1.3% of their children tested positive, while for 45 mothers (15.8%) who had partial PMTCT, 28.8% of their children being positive. Two hundred and seventy six children (97%) had exclusive breastfeeding, 13 of whom tested positive while 2 children who were mixed fed tested positive. Children who had Nevirapine vs no prophylaxis (OR = 1.89[95% CI 1.16 - 2.96]), were delivered via caesarian section vs vaginal delivery (OR= 2.26[95% CI 1.92 - 4.12].) and full versus partial participation in PMTCT programs (OR = 4.02[95% CI 2.06 - 4.13] were more likely to have negative HIV test.Conclusion: Vertical transmission rate was found to be high in Liberia and may be driven by suboptimal PMTCT program participation including post-exposure prophylaxis for infants. Therefore, strategies to scale up and improve uptake of PMTCT services are needed to mitigate the burden of HIV among children.

Contemporary HCV pangenotypic DAA treatment protocols are exclusionary to real world HIV-HCV co-infected patients.

BACKGROUND: Treatments for Hepatitis C virus (HCV) infection have vastly improved over the past few decades with current regimens now offering pangenotypic activity with excellent cure rates reported in clinical trials, including in the HIV-HCV coinfected population. However, there is some concern that stringent inclusion and exclusion criteria in the trials may lead to results that are not achievable in real-world populations. METHODS: Our study evaluated a real-world HIV-HCV coinfected population and compared them to the eligibility criteria for trials of two of the most recent approved HCV agents; sofosbuvir/velpatasvir and glecaprevir/pibrentasvir. RESULTS: Our study included 219 HIV-HCV coinfected patients and found that 89% met exclusion criteria for the sofosbuvir/velpatasvir trial and 90% met exclusion criteria for the glecaprevir/pibrentasvir trial. The majority of patients met more than one exclusion criteria with the most frequent criteria for exclusion being a non-approved ART regimen (58 and 47% respectively), having a psychiatric disorder (52%), active alcohol or injection drug use (27%), having an HIV viral load > 50 copies/ml (15%), a CrCl < 60 ml/min (13%) and a history of decompensated cirrhosis (13%). CONCLUSION: Although the newer Hepatitis C treatments are very effective, the real world HIV-HCV coinfected population often have comorbidities and other characteristics that make them ineligible for clinical trials, such that they are barriers to treatment. These barriers need to be recognized and addressed in order to optimize treatment outcomes in the HIV patient population.

Failure mode and effects analysis of the universal anaesthesia machine in two tertiary care hospitals in Sierra Leone.

BACKGROUND: Anaesthesia care in developed countries involves sophisticated technology and experienced providers. However, advanced machines may be inoperable or fail frequently when placed into the austere medical environment of a developing country. Failure mode and effects analysis (FMEA) is a method for engaging local staff in identifying real or potential breakdowns in processes or work systems and to develop strategies to mitigate risks. METHODS: Nurse anaesthetists from the two tertiary care hospitals in Freetown, Sierra Leone, participated in three sessions moderated by a human factors specialist and an anaesthesiologist. Sessions were audio recorded, and group discussion graphically mapped by the session facilitator for analysis and commentary. These sessions sought to identify potential barriers to implementing an anaesthesia machine designed for austere medical environments-the universal anaesthesia machine (UAM)--and also engaging local nurse anaesthetists in identifying potential solutions to these barriers. RESULTS: Participating Sierra Leonean clinicians identified five main categories of failure modes (resource availability, environmental issues, staff knowledge and attitudes, and workload and staffing issues) and four categories of mitigation strategies (resource management plans, engaging and educating stakeholders, peer support for new machine use, and collectively advocating for needed resources). CONCLUSIONS: We identified factors that may limit the impact of a UAM and devised likely effective strategies for mitigating those risks.

SEQUENTIAL LOW COST INTERVENTIONS DOUBLE HAND HYGIENE RATES AMONG MEDICAL TEAMS IN A RESOURCE LIMITED SETTING. RESULTS OF A HAND HYGIENE QUALITY IMPROVEMENT PROJECT CONDUCTED AT UNIVERSITY TEACHING HOSPITAL OF KIGALI (CHUK), KIGALI, RWANDA.

OBJECTIVE: To assess the impact of multimodal low-cost interventions on hand hygiene practices among medical teams. DESIGN: A four week prospective observational study. SETTING: Medical wards of the University Teaching Hospital of Kigali (CHUK), Kigali, Rwanda. SUBJECTS: Medical teams comprising students, residents and consultant physicians. INTERVENTIONS: During week one, baseline hand sanitising rate (HSR)--the percentage of hand hygiene opportunities during which hands were sanitised- was recorded. On week two, alcohol based handrubs (ABHRs) were provided and placed strategically on every ward. For week three and four respectively, hand hygiene posters (HHPs) were placed at entry sites of each ward at eye level and subsequently at the head of each patient's bed. MAIN OUTCOME MEASURES: Post-intervention HSR was recorded weekly during morning ward rounds. The differences between pre-intervention and post-intervention HSRs as well as end-of-study pre- and post-contact HSR were assessed for significance using Pearson chi square test. RESULT: A total of 780 HHOs were covertly observed throughout the study. Baseline HSR was 24.8%. During week 2, there was a non-significant increase in HSR (26.6% vs. 24.8%, p = 0.66). Overall, hand sanitising rates doubled from 24.8% to 50.6% following all study interventions (p < 0.001). There was a significant increase in post-patient contact and pre-patient contact HSRs with rates improving from 25.2% to 58% and 24.5% to 43% respectively (P < 0.01). CONCLUSION: Our study showed that low-cost interventions involving ensuring availability of ABHRs and posting HHPs significantly increased HSRs among medical teams but post-intervention rates were suboptimal.