Frieda Behets

Objective HIV-exposed uninfected infants are almost twice as likely to die compared to infants born to HIV-uninfected women. HIV-exposed uninfected children whose mothers are on ART and who are breastfed have the lowest risk of dying by 24 months of age. Interventions to improve breastfeeding among HIV-infected mothers are needed. We aimed to assess the association between support/counseling provided by healthcare workers following delivery and the rate of exclusive breastfeeding (EBF) at 6-week postpartum. Methods This is a secondary analysis of data collected as part of a trial to evaluate the effect of conditional cash transfers on retention in and uptake of PMTCT services. Between April 2013 and August 2014, newly diagnosed HIV-infected women, ≤ 32 weeks pregnant, registering for antenatal care (ANC), in 89 clinics in Kinshasa, Democratic Republic of Congo, were recruited and followed through 6 weeks postpartum. At 6-week, participants were asked if they had given anything other than breastmilk to their infant in the 24 h preceding the interview (No = EBF) and whether a nurse or a doctor talked to them about breastfeeding after they gave birth (YES = received breastfeeding support/counseling). Logistic regression was used to estimate the odds ratios (OR) and 95% confidence intervals (CI) measuring the strength of the association between EBF and receiving breastfeeding support/counseling by a healthcare provider following delivery. Results Of 433 women enrolled, 328 attended a 6-week postpartum visit including 320 (97%) with complete information on EBF. Of those 320, 202 (63%) reported giving nothing other than breastmilk to their infant in the previous 24 h; 252 (79%) reported that a healthcare provider came to talk to them about breastfeeding following delivery. Mothers who reported receiveing breastfeeding support/counseling from a healthcare provider were more likely to exclusively breastfeed compared to those who did not (69% vs. 38%, OR 3.74; 95% CI 2.14–6.54). Adjustment for baseline sociodemographic characteristics did not change the association substantially, (adjusted OR 3.72; 95% CI 2.06–6.71). Conclusion for Practice Receipt of breastfeeding support/counseling from a healthcare provider after delivery among HIV-infected mothers in care at 6-weeks postpartum in Kinshasa almost quadrupled the odds of EBF.

Depuis plusieurs années, la République Démocratique du Congo est le théâtre de grèves menées par les médecins du pays. Les revendications des grévistes en question sont essentiellement financières et statutaires, et visent à faire pression sur le gouvernement. Dans ce pays, comme c’est le cas presque partout dans le monde, les grèves médicales sont autorisées. Tout travailleur a le droit de dénoncer par la grève des conditions de travail jugées inacceptables. Mais les médecins sont-ils des travailleurs comme les autres? N’ont-ils pas des obligations morales particulières liées aux spécificités de leur profession? Pour éclairer ces questions, les auteurs de cet article proposent trois repères moraux essentiels généralisables à des situations de grèves médicales ailleurs dans le monde. Le premier porte sur la reconnaissance du droit de grève pour les médecins, y compris pour des motifs strictement financiers. On ne peut demander à des professionnels de santé d’exercer leur métier dans des conditions de travail inhumaines ou sans un salaire permettant de faire vivre leur famille. Le deuxième repère estime que l’on ne peut pas accepter que ce droit de grève s’exerce en sacrifiant les patients les plus fragiles et en niant ainsi l’essence même de la profession médicale. Un troisième repère vient complexifier la réflexion en rappelant que l’extrême délabrement du système de santé congolais rend impossible l’organisation d’un service minimum de qualité en cas de grève. Pour sortir de ces difficultés, nous proposons une alliance thérapeutique nationale entre les médecins et les citoyens pour replacer les patients au centre des préoccupations du système de santé.

Introduction Global initiatives to improve breastfeeding practices have focused on the Ten Steps to Successful Breastfeeding. The aim of this study was to assess the effect of implementing Baby-Friendly Hospital Initiative (BFHI) steps 1–9 and BFHI steps 1–10 on incidence of diarrhea and respiratory illnesses in the first 6 months of life. Methods We reanalyzed a cluster randomized trial in which health-care clinics in Kinshasa, Democratic Republic of Congo, were randomly assigned to standard care (control group), BFHI steps 1–9, or BFHI steps 1–10. Outcomes included episodes of diarrhea and respiratory illness. Piecewise Poisson regression with generalized estimation equations to account for clustering by clinic was used to estimate incidence rate ratios (IRR) and 95% confidence intervals (CI). Results Steps 1–9 was associated with a decreased incidence of reported diarrhea (IRR 0.72, 95% CI 0.53, 0.99) and respiratory illness (IRR 0.48, 95% CI 0.37, 0.63), health facility visits due to diarrhea (IRR 0.60, 95% CI 0.42, 0.85) and respiratory illness (IRR 0.47, 95% CI 0.36, 0.63), and hospitalizations due to diarrhea (IRR 0.42, 95% CI 0.17, 1.06) and respiratory illness (IRR 0.33, 95% CI 0.11, 0.98). Addition of Step 10 attenuated this effect: episodes of reported diarrhea (IRR 1.24, 95% CI 0.93, 1.68) and respiratory illness (IRR 0.77, 95% CI 0.60, 0.99), health facility visits due to diarrhea (IRR 0.76, 95% CI 0.54, 1.08) and respiratory illness (IRR 0.75 95% CI 0.57, 0.97), and hospitalizations due to respiratory illness (IRR 0.48 95% CI 0.16, 1.40); but strengthened the effect against hospitalizations due to diarrhea (IRR 0.14, 95% CI 0.03, 0.60). Conclusions Implementation of steps 1–9 significantly reduced incidence of mild and severe episodes of diarrhea and respiratory infection in the first 6 months of life, addition of step 10 appeared to lessen this effect. Trial Registration NCT01428232.

Despite the rapid adoption of the World Health Organization’s 2013 guidelines, children continue to be infected with HIV perinatally because of sub-optimal adherence to the continuum of HIV care in maternal and child health (MCH) clinics. To achieve the UNAIDS goal of eliminating mother-to-child HIV transmission, multiple, adaptive interventions need to be implemented to improve adherence to the HIV continuum. The aim of this open label, parallel, group randomized trial is to evaluate the effectiveness of Continuous Quality Improvement (CQI) interventions implemented at facility and health district levels to improve retention in care and virological suppression through 24 months postpartum among pregnant and breastfeeding women receiving ART in MCH clinics in Kinshasa, Democratic Republic of Congo. Prior to randomization, the current monitoring and evaluation system will be strengthened to enable collection of high quality individual patient-level data necessary for timely indicators production and program outcomes monitoring to inform CQI interventions. Following randomization, in health districts randomized to CQI, quality improvement (QI) teams will be established at the district level and at MCH clinics level. For 18 months, QI teams will be brought together quarterly to identify key bottlenecks in the care delivery system using data from the monitoring system, develop an action plan to address those bottlenecks, and implement the action plan at the level of their district or clinics. If proven to be effective, CQI as designed here, could be scaled up rapidly in resource-scarce settings to accelerate progress towards the goal of an AIDS free generation. The protocol was retrospectively registered on February 7, 2017. ClinicalTrials.gov Identifier: NCT03048669 .

Although breastfeeding is almost universally accepted in the Democratic Republic (DR) of Congo, by the age of 2 to 3 months 65% of children are receiving something other than human milk. We sought to describe the infant feeding practices and determinants of suboptimal breastfeeding behaviors in DR Congo.

Background We examined HIV prevalence trends over 4.5 years among women receiving antenatal care in Kinshasa, Democratic Republic of Congo, by geographic location, clinic management and urbanicity. Methods Quarterly proportions and 95% confidence intervals (CIs) of pregnant women with HIV positive results were determined using aggregate service provision and uptake data from 22 maternity units that provided vertical HIV prevention services from October 2004 to March 2009. Assuming linearity, proportions were assessed for trend via the Cochran–Armitage test. Multivariable binomial regression was used to describe detailed prevalence trends. Results HIV testing was offered to 220 006 pregnant women; 210 348 (95.6%) agreed to be tested and 191 216 (90.9%) received their results. A total of 3999 women were found to be HIV positive, a prevalence of 1.90% (95% CI: 1.84–1.96%). The median quarterly proportion of women testing positive for HIV was 1.94% (range: 1.44–2.44%). Prevalence was heterogeneous in terms of maternity management, urbanicity and geographic location. Modeling suggested that the overall prevalence dropped from 2.04% (95% CI: 1.92–2.16%) to 1.77% (95% CI: 1.66–1.88%) over 4.5 years, a relative decrease of 13.2% (95% CI: 3.53–22.9%). Trend testing corroborated this decline (P < 0.01). Conclusions The decreasing HIV prevalence among Kinshasa antenatal care seekers is robust and encouraging. The relatively low prevalence and the weak existing healthcare system require prevention of mother-to-child transmission interventions that strengthen maternal and child healthcare service delivery. Complacency would be unwarranted: assuming a uniform national crude birth rate of 50/1000 and 1.8% antenatal HIV prevalence, approximately 7000 pregnant HIV infected women in Kinshasa, and 60 000 nationwide, are in need of care and prevention services yearly.

Women's perceived control over condom use has been found to be an important determinant of actual condom use in some studies. However, many existing analyses used cross-sectional data and little quantitative information exists to characterize the relationships between perceived control and actual condom use among sex worker populations.

Treponema pallidum resistance to azithromycin has been documented in the US, Canada, and Ireland. We found no evidence of resistance to azithromycin in specimens from 141 patients with syphilitic lesions in Madagascar suggesting resistance is geographically isolated and supporting use of azithromycin as alternative treatment for early syphilis in Madagascar.

Scale-up of vertical HIV transmission prevention has been too slow in sub-Saharan Africa. We describe approaches, challenges, and results obtained in Kinshasa. Staff members of 21 clinics managed by public servants or non-governmental organizations were trained in improved basic antenatal care (ANC) including nevirapine (NVP)-based HIV transmission prevention. Program initiation was supported on-site logistically and technically. Aggregate implementation data were collected and used for program monitoring. Contextual information was obtained through a survey. Among 45,262 women seeking ANC from June 2003 through July 2005, 90% accepted testing; 792 (1.9%) had HIV of whom 599 (76%) returned for their result. Among 414 HIV+ women who delivered in participating maternities, NVP coverage was 79%; 92% of newborns received NVP. Differences were noted by clinic management in program implementation and HIV prevalence (1.2 to 3.0%). Initiating vertical HIV transmission prevention embedded in improved antenatal services in a fragile, fragmented, severely resource-deprived health care system was possible and improved over time. Scope and quality of service coverage should further increase; strategies to decrease loss to follow-up of HIV+ women should be identified to improve program effectiveness. The observed differences in HIV prevalence highlight the importance of selecting representative sentinel surveillance centers.

Background: The objective of this study was to develop a culturally appropriate approach for obtaining assent from children aged eight to 17 years to participate in paediatric HIV‐related operational research in Kinshasa, Democratic Republic of Congo (DRC). Included within this objective was to determine whether or not HIV disclosure should be included as part of the assent process prior to research participation, a component of research participation, or not incorporated in any aspect of the child's involvement in the research. Factors that influence parents' and caregivers' decisions to disclose HIV status to children in non‐research contexts were also explored.Methods: A qualitative formative study was conducted. Semi‐structured interviews were conducted with 19 youth living with HIV, 36 parents and caregivers of youth living with HIV, and 17 health professionals who provide care and support to youth living with HIV and their families. Participants were purposefully selected from three HIV care, treatment and/or psychosocial support programmes in Kinshasa, DRC.Results: Most youth interviewed believed minors participating in HIV‐related research should be informed of their HIV‐positive status. Parents and caregivers and health professionals had varied perspectives on if and when HIV status should be disclosed to minors during research participation. The age of the youth influenced parents and caregivers' responses, and disclosure to adolescents was more frequently supported than disclosure to children.Several parents and caregivers, as well as some health professionals, suggested that minors should never be told their HIV‐positive status when participating in HIV‐related research, regardless of their age. Within the context of treatment programmes, disclosure of HIV status to minors was supported by youth, parents and caregivers, and health professionals as a means to improve adherence to medication.Conclusion: In settings where most minors are unaware of their HIV infection, researchers should consider excluding the term, “HIV”, when explaining HIV‐related research to minors, and omitting it from assent forms or informational sheets related to research participation. However, an individualized disclosure plan should be initiated with parents and caregivers at the time of enrolment in HIV‐related research, particularly in research that involves treatment.