2 A Family-Based Approach to Preventive Care and Antiretroviral Therapy in Africa Jonathan Mermin CDC Uganda, Entebbe

Background:  In the industrialized world, morbidity and mortality related to HIV was first reduced using prophylaxis against opportunistic illness, and then further lowered with antiretroviral therapy (ART).  To optimize care for persons with HIV in Africa a similar two-pronged approach is necessary.  Using a family perspective allows for the integration of HIV prevention and care, improved health of household members, and reduced HIV transmission.

A preventive care package:  Access to curative services is difficult for persons living in many resource-limited settings.  Comprehensive guidelines are needed for prevention of opportunistic infections in Africa, where the range of illnesses differs from industrialized settings. Using a family-based approach in rural Uganda, we have evaluated several interventions that could help form a preventive care package.  Cotrimoxazole prophylaxis taken by persons with HIV was associated with a 46% reduction in mortality, and 30-70% reductions in the incidence of malaria, diarrhea, and hospitalizations.  In addition, there was a 63% reduction in mortality among HIV-negative children <10 years old when their parents with HIV took prophylaxis, probably because having a parent die was associated with a 3-fold increase in mortality among HIV-negative children. A home-based water purification system using a plastic water vessel and a capful of chlorine was associated with a 25% reduction in diarrhea among persons with HIV. Home-based HIV voluntary counseling and testing (VCT) was offered to 6,000 family members of persons with HIV and accepted by >95%; 35% of married HIV-infected people discovered that they were living with an HIV-uninfected spouse, and 10% of children under 5 years old had undiagnosed HIV.  Other interventions, such as insecticide-treated bed nets, isoniazid prophylaxis, and micronutrients could also be included in a preventive package.  Antiretroviral therapy prevents opportunistic illness and mortality. We are supporting the addition of ART to the preventive care package for 4,000 people in Uganda through a home-based delivery and monitoring system using lay providers.  In a trial, we are evaluating whether quarterly CD4 counts and viral loads provide additional benefits to monitoring by lay workers alone.

Conclusion:  Expansion of preventive care could improve health for persons with HIV and their families, help achieve public health equity, and lay a foundation for ART.