High proportion of unknown HIV exposure status among children aged less than 2 years: An analytical study using the 2015 National AIDS Indicator Survey in Mozambique

PLoS ONE, Volume 15, No. 4, Year 2020

Interprétation

Background Determination of the human immunodeficiency virus (HIV) exposure status in infants and young children is required to guarantee timely diagnosis and access to appropriate care. HIV prevalence among Mozambican women aged 15-49 years is 15%, and vertical transmission rate is still high. The study investigated HIV exposure in children aged less than 2 years in Mozambique and the factors associated with unknown HIV exposure and with HIV exposure status in this population. Methods This was a cross-sectional analytical study using data from the 2015 Survey of Indicators on Immunization, Malaria and HIV/AIDS in Mozambique. A total of 2141 mothers (15-49 years) with children aged less than 2 years were interviewed. The dependent variables were “known HIV exposure status in a child” and “HIV-exposed child,” and the explanatory variables were mother’s social, demographic, economic, and reproductive health characteristics. We used binary and logistic regression, adjusted for complex sampling, to determine the association between variables. Results HIV exposure status was unknown in 27% of children (95% CI, 25.1-28.9). Mothers residing in the North (AOR, 4.41; 95% CI, 2.18-8.91), in rural area (AOR, 2.44; 95% CI, 1.33-4.35), with no education (AOR, 2.72; 95% CI, 1.38-5.36), and not having utilized any health services in the last pregnancy (AOR, 1.9; 95% CI, 1.42-2.55) were more likely to have a child with unknown HIV exposure status. Six percent of children were HIV-exposed (95% CI, 5-7). Children were less likely to be HIV-exposed if the head of the household was a male (AOR, 0.26; 95% CI, 0.08-0.86), if the mother was residing in the North (AOR, 0.41; 95% CI, 0.26-0.66) and did not utilize any health services in her last pregnancy (AOR, 0.52; 95% CI, 0.32-0.83). Conclusion The high proportion of children with unknown HIV exposure status and the associated socioeconomic factors suggests that HIV retesting of eligible women throughout breastfeeding should be intensified and identifies the urgent need to reach women without prior access to health care using a multisectoral approach. This was a cross-sectional analytical study that used data collected during the 2015 Survey of Indicators on Immunization, Malaria and HIV/AIDS in Mozambique (IMASIDA) [3]. The primary aim of the survey was to estimate the following: HIV prevalence in the adult population, malaria prevalence, and immunization coverage in children aged less than 5 years in Mozambique. Besides the standard “household questionnaire,” the survey included a “woman and child health questionnaire” for women of childbearing age, focusing on malaria, immunization, maternal and child health, and HIV. The survey used a standardized questionnaire designed by the Demographic and Health Surveys (DHS) program, which is available for free download [13]. The questionnaire captured HIV indicators in women and children, which included HIV testing of women at the ANCs, at delivery, and during the postnatal period, the HIV test result at each of the previous contacts with the health services, and HIV testing offered to the child. Standard questions regarding mother and child health, including utilization of healthcare services, medicines taken, and infant’s feeding and immunization practices, were also asked. The survey was conducted between June 2015 and September 2015 using a systematic, multistage, stratified, and proportionate-to-size sampling [3]. The overall survey was designed to obtain the HIV prevalence estimates with 95% confidence intervals (CIs), an error margin of 5%, and a power of 80% and to ensure the representation of rural and urban areas and provincial levels. In the survey, a total of 8204 women were eligible for the interview, 7749 women consented for the same and 6946 women of childbearing age (15–49 years) were interviewed using the “woman and child health questionnaire” [3]. For the purpose of our analysis, we restricted the database to 2141 women aged between 15–49 years with at least one child aged less than 2 years on the day of the interview. Weights were computed by the DHS program [14] and provided as variable in the accessed database, allowing to adjust our analysis for unequal selection probabilities. The DHS program, funded by the US Agency for International Development (USAID), routinely conducts nationally representative surveys, including AIDS Indicator Survey, worldwide and generally in low- and middle-income countries. An HIV-exposed infant/child is an infant/child born to an HIV-positive mother or an infant who has been breastfed or is currently breastfed by an HIV-positive mother and whose definitive diagnosis has not yet been established up to the day of the interview [15]. The analysis considered the following two dependent variables: (1) “known HIV exposure status in a child,” coded as “1” in cases where the “child is known to have been HIV-exposed” or is “known to not have been HIV-exposed” and “0” if HIV exposure could not be ruled out, in cases of “unknown HIV exposure status in a child” and (2) “HIV-exposed status in a child,” coded as “1” if the child is “exposed to HIV,” coded as “0” if a child is “not exposed to HIV,” and coded as “8” in cases of “unknown HIV exposure status.” The variable “HIV-exposed status in a child” was computed by the DHS program and provided in the accessed database. Studies evaluating the determinants of access to and utilization of HIV prevention and care services constituted the basis for defining the key independent variables [16–20]. Besides the woman’s demographic characteristic, educational attainment, employment, religion, area and region of residence, socioeconomic status, and amenities of the households, the independent variables included the variables of health service utilization. Health service utilization was defined as the “use of antenatal care services, maternity, and postnatal care services.” Wealth index was provided as computed by the DHS program [14], which used a factor analysis for household amenities such as television, radio, refrigerator, bicycle, motorcycle, computer, water supply, sanitation, and cooking fuel [14]. Using transformations, we computed the following nominal independent variables: “media utilization” was defined as owing a television (TV) or a radio and watching TV or listening to the radio at least once a week, “mean of transport” was defined as owing a bicycle, or a motor bike or a car, and “immunization status of the child” according to the age-adjusted up-to-date vaccination for diphtheria-tetanus-pertussis (DPT) and measles. We used DPT1 (DPT dose 1), DPT2 (DPT dose 2), DPT3 (DPT dose 3), and Measles1 as the representative vaccines (“tracers”) considering that the other vaccines (rotavirus, HepB, Hib, polio, pneumococcal conjugate vaccine 10) are simultaneously administered with the tracer vaccines. Immunization was defined as up-to-date if the child had DPT1 by 2 months; DPT1 and DPT2 by 3 months; DPT1, DPT2, and DPT3 by 4 months, and DPT1, DPT2, DPT3, and measles by 24 months. If any of these age-adjusted vaccines were not reported, the immunization status of the child was considered “not up-to-date.” “Mother’s participation in family decisions” was obtained based on the answers to the questions on who decides on (1) household financial management, (2) healthcare utilization, (3) household purchases and expenses, and (4) visits to and from relatives. Participating in the decision-making was coded “1” if the mother decided alone or with other members on all of the described aspects and “0” if she reported no participation in one or more of the described aspects. First, the results of the descriptive analysis were expressed as absolute and relative frequencies with respective 95% CIs. Second, analyses were performed to identify the factors associated with “known HIV exposure status in a child” and “HIV-exposed status in a child” against the explanatory variables by bivariate association assessed by p, odds ratio (OR), and 95% CI. Third, binary logistic regression was used to estimate the adjusted OR (AOR) and 95% CI of being a child with unknown HIV exposure status and of being an HIV-exposed child against the socioeconomic, demographic, and health service utilization covariates. The association analysis was weighted and adjusted for complex sampling using the statistical package International Business Machines Corporation Statistical Package for the Social Sciences Statistics for Windows version 24.0 [21]. The 2015 IMASIDA Survey was approved by the Mozambican National Bioethics Committee (IRB00002657, reference 262/CNBS/2014) and the Ministry of Health. The participation was voluntary through a signed informed consent administered by a trained interviewer. For illiterate participants, the informed consent process was witnessed by a literate person chosen by the participant. For participants aged 15–17 years, signed informed consent was obtained from the legal guardian and assent from the participant. For this secondary data analysis, authorization for the use of database has been granted by the DHS program [22], the database was de-identified, and no informed consent was required from the participants. The database is publicly available through an application process to the DHS program site.

Résumé de l’IA

Study Justification:

– Determining HIV exposure status in infants and young children is crucial for timely diagnosis and access to appropriate care.
– Mozambique has a high HIV prevalence among women aged 15-49 years and a high vertical transmission rate.
– This study aimed to investigate HIV exposure in children under 2 years in Mozambique and identify factors associated with unknown HIV exposure and HIV exposure status in this population.

Study Highlights:

– 27% of children had unknown HIV exposure status.
– Factors associated with unknown HIV exposure status included residing in the North, living in rural areas, having no education, and not utilizing health services during the last pregnancy.
– 6% of children were HIV-exposed.
– Factors associated with lower HIV exposure included having a male head of household, residing in the North, and not utilizing health services during the last pregnancy.

Recommendations for Lay Reader:

– Intensify HIV retesting of eligible women throughout breastfeeding to ensure accurate HIV exposure status.
– Implement a multisectoral approach to reach women without prior access to healthcare.
– Increase education and awareness about HIV transmission and prevention among mothers and communities.

Recommendations for Policy Maker:

– Strengthen healthcare services in rural areas and the North to improve access to HIV testing and care.
– Invest in educational programs to improve literacy rates and knowledge about HIV.
– Allocate resources for HIV retesting and counseling services for eligible women during breastfeeding.

Key Role Players:

– Ministry of Health: Responsible for implementing and coordinating healthcare services.
– Community Health Workers: Provide education, testing, and counseling services at the community level.
– Non-Governmental Organizations: Support healthcare programs and provide resources for HIV prevention and care.
– Local Leaders and Community Organizations: Engage communities and promote awareness and acceptance of HIV testing and care.

Cost Items for Planning Recommendations:

– Training and capacity building for healthcare workers and community health workers.
– HIV testing kits and laboratory supplies.
– Educational materials and campaigns.
– Transportation and logistics for reaching rural areas.
– Monitoring and evaluation of program implementation.
Please note that the cost items provided are examples and not actual costs. The actual budget would depend on the specific context and resources available.

Force de la preuve

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study used data from a cross-sectional analytical study and included a large sample size of 2141 mothers with children aged less than 2 years. The study used binary and logistic regression to determine the association between variables. However, the study did not provide information on the representativeness of the sample or the response rate. To improve the strength of the evidence, future studies could include information on the sampling methodology and response rate, as well as conduct a longitudinal study to establish causality.

Abstrait

This was a cross-sectional analytical study that used data collected during the 2015 Survey of Indicators on Immunization, Malaria and HIV/AIDS in Mozambique (IMASIDA) [3]. The primary aim of the survey was to estimate the following: HIV prevalence in the adult population, malaria prevalence, and immunization coverage in children aged less than 5 years in Mozambique. Besides the standard “household questionnaire,” the survey included a “woman and child health questionnaire” for women of childbearing age, focusing on malaria, immunization, maternal and child health, and HIV. The survey used a standardized questionnaire designed by the Demographic and Health Surveys (DHS) program, which is available for free download [13]. The questionnaire captured HIV indicators in women and children, which included HIV testing of women at the ANCs, at delivery, and during the postnatal period, the HIV test result at each of the previous contacts with the health services, and HIV testing offered to the child. Standard questions regarding mother and child health, including utilization of healthcare services, medicines taken, and infant’s feeding and immunization practices, were also asked. The survey was conducted between June 2015 and September 2015 using a systematic, multistage, stratified, and proportionate-to-size sampling [3]. The overall survey was designed to obtain the HIV prevalence estimates with 95% confidence intervals (CIs), an error margin of 5%, and a power of 80% and to ensure the representation of rural and urban areas and provincial levels. In the survey, a total of 8204 women were eligible for the interview, 7749 women consented for the same and 6946 women of childbearing age (15–49 years) were interviewed using the “woman and child health questionnaire” [3]. For the purpose of our analysis, we restricted the database to 2141 women aged between 15–49 years with at least one child aged less than 2 years on the day of the interview. Weights were computed by the DHS program [14] and provided as variable in the accessed database, allowing to adjust our analysis for unequal selection probabilities. The DHS program, funded by the US Agency for International Development (USAID), routinely conducts nationally representative surveys, including AIDS Indicator Survey, worldwide and generally in low- and middle-income countries. An HIV-exposed infant/child is an infant/child born to an HIV-positive mother or an infant who has been breastfed or is currently breastfed by an HIV-positive mother and whose definitive diagnosis has not yet been established up to the day of the interview [15]. The analysis considered the following two dependent variables: (1) “known HIV exposure status in a child,” coded as “1” in cases where the “child is known to have been HIV-exposed” or is “known to not have been HIV-exposed” and “0” if HIV exposure could not be ruled out, in cases of “unknown HIV exposure status in a child” and (2) “HIV-exposed status in a child,” coded as “1” if the child is “exposed to HIV,” coded as “0” if a child is “not exposed to HIV,” and coded as “8” in cases of “unknown HIV exposure status.” The variable “HIV-exposed status in a child” was computed by the DHS program and provided in the accessed database. Studies evaluating the determinants of access to and utilization of HIV prevention and care services constituted the basis for defining the key independent variables [16–20]. Besides the woman’s demographic characteristic, educational attainment, employment, religion, area and region of residence, socioeconomic status, and amenities of the households, the independent variables included the variables of health service utilization. Health service utilization was defined as the “use of antenatal care services, maternity, and postnatal care services.” Wealth index was provided as computed by the DHS program [14], which used a factor analysis for household amenities such as television, radio, refrigerator, bicycle, motorcycle, computer, water supply, sanitation, and cooking fuel [14]. Using transformations, we computed the following nominal independent variables: “media utilization” was defined as owing a television (TV) or a radio and watching TV or listening to the radio at least once a week, “mean of transport” was defined as owing a bicycle, or a motor bike or a car, and “immunization status of the child” according to the age-adjusted up-to-date vaccination for diphtheria-tetanus-pertussis (DPT) and measles. We used DPT1 (DPT dose 1), DPT2 (DPT dose 2), DPT3 (DPT dose 3), and Measles1 as the representative vaccines (“tracers”) considering that the other vaccines (rotavirus, HepB, Hib, polio, pneumococcal conjugate vaccine 10) are simultaneously administered with the tracer vaccines. Immunization was defined as up-to-date if the child had DPT1 by 2 months; DPT1 and DPT2 by 3 months; DPT1, DPT2, and DPT3 by 4 months, and DPT1, DPT2, DPT3, and measles by 24 months. If any of these age-adjusted vaccines were not reported, the immunization status of the child was considered “not up-to-date.” “Mother’s participation in family decisions” was obtained based on the answers to the questions on who decides on (1) household financial management, (2) healthcare utilization, (3) household purchases and expenses, and (4) visits to and from relatives. Participating in the decision-making was coded “1” if the mother decided alone or with other members on all of the described aspects and “0” if she reported no participation in one or more of the described aspects. First, the results of the descriptive analysis were expressed as absolute and relative frequencies with respective 95% CIs. Second, analyses were performed to identify the factors associated with “known HIV exposure status in a child” and “HIV-exposed status in a child” against the explanatory variables by bivariate association assessed by p, odds ratio (OR), and 95% CI. Third, binary logistic regression was used to estimate the adjusted OR (AOR) and 95% CI of being a child with unknown HIV exposure status and of being an HIV-exposed child against the socioeconomic, demographic, and health service utilization covariates. The association analysis was weighted and adjusted for complex sampling using the statistical package International Business Machines Corporation Statistical Package for the Social Sciences Statistics for Windows version 24.0 [21]. The 2015 IMASIDA Survey was approved by the Mozambican National Bioethics Committee (IRB00002657, reference 262/CNBS/2014) and the Ministry of Health. The participation was voluntary through a signed informed consent administered by a trained interviewer. For illiterate participants, the informed consent process was witnessed by a literate person chosen by the participant. For participants aged 15–17 years, signed informed consent was obtained from the legal guardian and assent from the participant. For this secondary data analysis, authorization for the use of database has been granted by the DHS program [22], the database was de-identified, and no informed consent was required from the participants. The database is publicly available through an application process to the DHS program site.

Matériaux

Innovations

Based on the provided information, here are some potential innovations that could improve access to maternal health in Mozambique:

1. Mobile Health (mHealth) Solutions: Develop mobile applications or SMS-based platforms to provide pregnant women and new mothers with information and reminders about antenatal care visits, HIV testing, and postnatal care. These platforms can also provide educational resources on maternal and child health.

2. Community Health Workers (CHWs): Train and deploy CHWs to remote areas to provide maternal health services, including HIV testing and counseling, antenatal care, and postnatal care. CHWs can also conduct home visits to reach women who may not have access to healthcare facilities.

3. Telemedicine: Establish telemedicine services to connect healthcare providers with pregnant women and new mothers in rural or underserved areas. This would enable remote consultations, diagnosis, and monitoring, reducing the need for women to travel long distances for healthcare.

4. Integrated Service Delivery: Implement integrated service delivery models that combine maternal health services with HIV testing and treatment. This would ensure that women receive comprehensive care and reduce the number of missed opportunities for HIV testing and prevention.

5. Public-Private Partnerships: Foster collaborations between the government, private sector, and non-profit organizations to improve access to maternal health services. This could involve leveraging private sector resources and expertise to expand healthcare infrastructure and service delivery.

6. Health Education and Awareness Campaigns: Conduct targeted health education campaigns to raise awareness about the importance of HIV testing during pregnancy and the availability of maternal health services. These campaigns can be conducted through various channels, including radio, television, community gatherings, and social media.

7. Strengthening Health Systems: Invest in strengthening healthcare infrastructure, including the availability of skilled healthcare providers, essential medicines, and diagnostic tools. This would ensure that women have access to quality maternal health services, including HIV testing and treatment.

It is important to note that these recommendations are based on the provided information and may need to be further tailored and adapted to the specific context and needs of Mozambique.

AI Innovations Description

The study mentioned in the description highlights the high proportion of unknown HIV exposure status among children under 2 years old in Mozambique. This poses a challenge in ensuring timely diagnosis and access to appropriate care for these children. To improve access to maternal health and address this issue, the following recommendations can be considered:

1. Strengthen HIV testing and counseling services: It is crucial to enhance the availability and accessibility of HIV testing and counseling services for pregnant women and mothers. This can be achieved by increasing the number of testing sites, ensuring trained healthcare providers, and promoting community-based testing initiatives.

2. Improve antenatal care coverage: Enhancing antenatal care coverage can help identify HIV-positive pregnant women and provide them with appropriate interventions to prevent mother-to-child transmission of HIV. This can be achieved by promoting early and regular antenatal care visits, providing comprehensive services, and integrating HIV testing and counseling into routine antenatal care.

3. Enhance health education and awareness: Increasing awareness about HIV transmission, prevention, and the importance of HIV testing during pregnancy is crucial. Health education campaigns targeting communities, women, and families can help reduce stigma, increase knowledge, and encourage HIV testing and disclosure.

4. Strengthen healthcare infrastructure and services: Improving the overall healthcare infrastructure and services is essential to ensure access to maternal health. This includes increasing the availability of healthcare facilities, trained healthcare providers, essential medicines, and diagnostic tools for HIV testing.

5. Address socioeconomic barriers: Socioeconomic factors, such as education, residence, and utilization of health services, were found to be associated with unknown HIV exposure status. Addressing these barriers through targeted interventions, such as improving access to education, promoting rural healthcare services, and providing financial support for healthcare utilization, can help improve access to maternal health.

6. Multisectoral collaboration: To effectively address the issue of unknown HIV exposure status, a multisectoral approach involving collaboration between the healthcare sector, education sector, community organizations, and government agencies is crucial. This can help ensure coordinated efforts, resource allocation, and implementation of comprehensive interventions.

By implementing these recommendations, it is possible to improve access to maternal health and reduce the proportion of unknown HIV exposure status among children, ultimately leading to better health outcomes for both mothers and children in Mozambique.

AI Innovations Methodology

Based on the provided information, here are some potential recommendations to improve access to maternal health:

1. Strengthen HIV testing and counseling services: Increase the availability and accessibility of HIV testing and counseling services for pregnant women and mothers of young children. This can be done by expanding the number of healthcare facilities offering these services, ensuring trained healthcare providers are available, and implementing community-based testing programs.

2. Improve education and awareness: Implement comprehensive education and awareness campaigns to increase knowledge about HIV transmission, prevention, and the importance of HIV testing during pregnancy. This can include community outreach programs, media campaigns, and targeted messaging to reach vulnerable populations.

3. Enhance antenatal care services: Strengthen antenatal care services to ensure that all pregnant women have access to regular check-ups, HIV testing, and appropriate counseling. This can involve training healthcare providers, improving infrastructure and equipment in healthcare facilities, and promoting early and regular attendance at antenatal care visits.

4. Address socioeconomic barriers: Address socioeconomic factors that contribute to unknown HIV exposure status and limited access to healthcare services. This can involve initiatives to improve education, reduce poverty, and provide financial support for healthcare expenses.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Data collection: Gather data on the current status of maternal health access, including HIV testing rates, utilization of antenatal care services, and socioeconomic factors. This can be done through surveys, interviews, and analysis of existing data sources.

2. Modeling and simulation: Develop a mathematical model or simulation tool that incorporates the various factors influencing access to maternal health. This model should consider the potential impact of the recommended interventions on key outcomes such as HIV testing rates, knowledge levels, and utilization of healthcare services.

3. Parameter estimation: Estimate the parameters of the model based on available data and expert knowledge. This may involve statistical analysis, literature review, and consultation with relevant stakeholders.

4. Scenario analysis: Use the model to simulate different scenarios by adjusting the parameters to reflect the potential impact of the recommended interventions. This can help identify the most effective strategies and estimate the potential improvements in access to maternal health.

5. Evaluation and validation: Evaluate the results of the simulation against real-world data and validate the model’s accuracy and reliability. This may involve comparing the simulated outcomes with observed outcomes from pilot programs or other interventions.

6. Policy recommendations: Based on the simulation results, provide evidence-based policy recommendations to stakeholders and decision-makers. These recommendations should highlight the potential benefits of implementing the recommended interventions and guide the allocation of resources and implementation strategies.

By following this methodology, policymakers and healthcare providers can gain insights into the potential impact of different interventions and make informed decisions to improve access to maternal health.

Auteur

Dima Health

Statistics:

Citations: 2

Identifiers:

DOI: 10.1371/journal.pone.0231143

Research Areas:

Community Interventions, Environmental, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants

Study Countries:

Mozambique

Study Design:

Case-Control Study, Cross Sectional Study

Study Approach:

Quantitative

Participants Gender:

Male & Female

Partagez ceci :