Prevention of mother to child transmission of HIV: evaluation of a pilot programme in a district hospital in rural Zimbabwe
http://www.100md.com
《英国医生杂志》
1 Institut de Santé Publique, d'Epidémiologie et de Développement (ISPED), Université Victor Segalen Bordeaux 2, 146 rue Léo-Saignat, 33076 Bordeaux, France, 2 ISPED-Zimbabwe Programme, 3 Elizabeth Glaser Paediatric AIDS Foundation, Zimbabwe, 4 Ministry of Health and Child Welfare of Zimbabwe
Correspondence to: F Perez Freddy.Perez@isped.u-bordeaux2.fr
Abstract
In 2003 an estimated five million people worldwide were newly infected with HIV. Approximately 800 000 of these were children; 90% of them were born to HIV infected women and acquired the virus during pregnancy, labour, or delivery or through breast feeding.1 2 Zimbabwe has one of the highest rates of HIV infection in the world, with an average antenatal HIV prevalence of 24.6% (20.9% in urban areas and 28.1% in rural areas) in 2003.3 By 2005, HIV/AIDS is projected to account for 60% of childhood mortality in Zimbabwe.4 The HIV/AIDS burden coexists with an important economic crisis, limiting access to an already deteriorating public health service.
Voluntary counselling and testing for HIV are essential for all support and treatment interventions against HIV and AIDS. Progress has been made in the prevention of mother to child transmission of HIV in resource poor countries, primarily through the development of short, easy to use, and affordable antiretroviral regimens.5-8
Prevention of mother to child transmission of HIV has been an integrated component of the Zimbabwe HIV/AIDS policy since 1999, when urban pilot programmes were initiated.9 To mitigate the paediatric HIV epidemic in Zimbabwe, countrywide implementation of this initiative is urgently needed.
Context
Population based surveys in Manicaland province (1998-2000) report an HIV prevalence of 22.3% for women aged 15 to 29 years.10 At the end of 2001, only 4% of Zimbabweans in need of services for prevention of mother to child transmission of HIV were receiving them.11 Although HIV/AIDS was considered a priority at Murambinda Mission Hospital, it had no HIV/AIDS programme including prevention of mother to child transmission of HIV. Unpublished observational data showed that stigma surrounding HIV/AIDS and HIV testing was high. This paper reports on the process and feasibility of implementing a programme for prevention of mother to child transmission of HIV in this district hospital.
Key measures of improvement
We introduced a coded intervention card documenting progress in mother-child uptake of activities and HIV serostatus in the hospital data collection system. We used pre-existing monitoring tools such as antenatal and delivery registers and defined basic process indicators to monitor the uptake of activities. We entered data on standard forms and managed and analysed them by using Stata 7.0 software.
Strategies for change
Murambinda Mission Hospital was the first site to implement a programme for prevention of mother to child transmission of HIV in a rural setting in Zimbabwe. Integration of voluntary counselling and rapid testing within routine antenatal care required adjustment of the patient flow to allow sufficient time and ensure confidentiality of these new services. Involvement of district health authorities was key for the integration and reorganisation of services in a sustainable manner.
During the first 18 months of the programme, 2298 pregnant women had pretest counselling; the acceptance of HIV testing reached 93.0% (n = 2137) among these women. Of all women who had an HIV test, 1588 (74.3%) returned to collect their result. Overall HIV prevalence was 20.4% (n = 437); 326 (74.6%) of these HIV positive women had post-test counselling, and 104 (23.8%) received complete mother-child prophylaxis with nevirapine. The reasons women gave for refusing testing were mainly related to the need to consult their husband or partner and their wish to think more about being tested.
The rate of return for test results was low. It is, however, consistent with recent findings from other programmes for prevention of mother to child transmission in West Africa and East Africa as well as the Caribbean.12-16
The minimum estimate of the coverage of the programme is 23.8%—that is, 104 women-child pairs receiving nevirapine out of a total of 437 HIV infected pregnant women given a diagnosis. The maximum estimate is 67.5%, considering that 220 women were prescribed nevirapine among 326 HIV positive women who received post-test counselling.
Reduction in stigma has not been formally documented. Nevertheless, participation in the programme and field observations in the community during information, education, and communication sessions indicated that the perceived disincentive for HIV testing, particularly among women, has been decreasing over time.
Follow up of mothers and children during the postnatal period has been one of the most challenging problems owing to centralisation of activities when the programme started and because of poor access to health facilities and limited trained staff. We subsequently considered a plan of action incorporating district satellite health centres in all activities related to prevention of mother to child transmission of HIV and strengthening community outreach programmes. Communication networks among the different levels of the healthcare system were reinforced to ensure appropriate patient flow and referral systems within the district.
Because the programme was planned and developed as a pilot, we used detailed monitoring tools. This enabled collection of quantitative and qualitative data on routine service uptake as well as identification of existing barriers. The information gathered set the basis for defining priorities for operational research, such as assessment of infant feeding options in the context of HIV infection, which is now being done.
On the basis of the lessons from this first pilot rural programme and others, the national AIDS and TB programme of the Zimbabwean Ministry of Health has initiated widespread scaling-up and replication of programmes for prevention of mother to child transmission of HIV to other regions of the country.17
Lessons learnt
Improving the continuum of care after delivery is a priority for prevention of mother to child transmission of HIV. In close collaboration with the national AIDS and TB programme and other partners, district health authorities are defining a follow up package that includes clinical and psychosocial support protocols, training of health professionals, continued decentralisation of services, and improvement of transport possibilities for community based follow up.
More importantly, the coverage of services for prevention for mother to child transmission of HIV at all points of the intervention cascade needs to be improved. Protocol development combining the introduction of opt-out voluntary counselling and testing, voluntary counselling and testing in labour wards, and prescription of nevirapine to women and children of unknown HIV status are now planned or at least being considered, as has recently been advocated.18 19 In addition, an enhanced basic package for prevention of mother to child transmission of HIV through the selection of more effective antiretroviral regimens than nevirapine alone could be considered.20 Access to antiretroviral therapy for HIV infected women and children identified through the programme and for their HIV infected family members is planned in Buhera district on the basis of principles outlined in the "mother-to-child transmission-plus initiative."21
The World Health Organization and UNICEF have developed the "integrated management of sick children" initiative to improve survival in children.22 A comprehensive HIV/AIDS continuum of care, including prevention of mother to child transmission, will need to be incorporated within this powerful public health strategy so as to facilitate sustainability of the management of paediatric HIV infection in communities such as ours.23
We thank the Zimbabwean National AIDS and Tuberculosis Unit of the Ministry of Health and Child Welfare of Zimbabwe (Inam Chitsike in particular) for supporting the project, the project team members for their continuous dedication, all the staff from Murambinda Mission Hospital and Buhera district health centres who participated in the quality improvement process, and Mathilde Touron for data analysis. Special thanks go to all the mothers and children of Buhera district. We particularly appreciate the assistance of Catherine Wilfert, Dirk Buyse, and Chuck Hoblitzelle at EGPAF offices. Nevirapine was provided through a donation from Boehringer Ingelheim.
Contributors: FP designed the project, coordinated programme implementation, and wrote the paper. JO-G and AMiller wrote the project proposal, collaborated in programme implementation, and contributed to writing the manuscript. TM coordinated local project management. MG and AMahomva provided technical input to programme implementation and suggestions for the manuscript. FD participated in the design of the proposal, coordinated programme implementation, and edited the manuscript. FP is the guarantor.
Funding: Elizabeth Glaser Pediatric AIDS Foundation, Call to Action project No CTA#26-01.
Competing interests: None declared.
Ethical approval: The Ministry of Health of Zimbabwe ethics committee approved the study in 2001.
References
United Nations Joint Program on HIV/AIDS (UNAIDS). Report on the global HIV/AIDS epidemic, December 2003. Geneva: UNAIDS, 2003.
Dabis F, Ekpini ER. HIV-1/AIDS and maternal and child health in Africa. Lancet 2002;359: 2097-104.
Ministry of Health and Child Welfare, Zimbabwe. Zimbabwe national HIV and AIDS estimates 2003. Harare: Ministry of Health, 2003.
Ministry of Health and Child Welfare, Zimbabwe. Report of the consultation of provincial medical directorates on initiating and scaling-up prevention of mother-to-child transmission of HIV infection in Zimbabwe—Gweru 15-16 May 2001. Harare: MTCT Unit, AIDS and TB Programme, 2001.
Dabis F, Msellati P, Meda N, Welffens-Ekra C, You B, Manigart O, et al. 6-month efficacy, tolerance, and acceptability of a short regimen of oral zidovudine to reduce vertical transmission of HIV in breastfed children in C?te d'Ivoire and Burkina Faso: a double-blind placebo-controlled multicentre trial. Lancet 1999;353: 786-92.
Jackson JB, Musoke P, Fleming T, Guay LA, Bagenda D, Allen M, et al. Intrapartum and neonatal single-dose nevirapine compared with zidovudine for prevention of mother-to-child transmission of HIV-1 in Kampala, Uganda: 18-month follow-up of the HIVNET 012 randomised trial. Lancet 2003;362: 859-68.
The Petra Study Team. Efficacy of three short-course regimens of zidovudine and lamivudine in preventing early and late transmission of HIV-1 from mother to child in Tanzania, South Africa, and Uganda (Petra study): a randomised, double-blind, placebo-controlled trial. Lancet 2002;359: 1178-86.
Moodley D, Moodley J, Coovadia H, Gray G, McIntyre J, Hofmyer J, et al. A multicenter randomized controlled trial of nevirapine versus a combination of zidovudine and lamivudine to reduce intrapartum and early postpartum mother-to-child transmission of human immunodeficiency virus type 1. J Infect Dis 2003;187: 725-35.
Ministry of Health and Child Welfare, Zimbabwe. National action plan for use of nevirapine to reduce mother-to-child HIV transmission in operational research settings in Zimbabwe. (First draft, May 2001.) Harare: MTCT Unit, AIDS and TB Programme, 2001.
Gregson S, Chandiwana SK. The Manicaland HIV/STD prevention project: studies on HIV transmission, impact and control in rural Zimbabwe. Zimbabwe Science News 2001;35: 27-42
World Health Organization. The health sector response to HIV/AIDS: coverage of selected services in 2001—preliminary assessment, 2002. Geneva: WHO, 2001.
Stringer EM, Sinkala M, Stringer JS, Mzyece E, Makuka I, Goldenberg RL, et al. Prevention of mother-to-child transmission of HIV in Africa: successes and challenges in scaling-up a nevirapine-based program in Lusaka, Zambia. AIDS 2003;17: 1377-82.
Temmerman M, Quaghebeur A, Mwanyumba F, Mandaliya K. Mother-to-child HIV transmission in resource poor settings: how to improve coverage? AIDS 2003;17: 1239-42.
Msellati P, Hingst G, Kaba F, Viho I, Welffens-Ekra C, Dabis F. Operational issues in preventing mother-to-child transmission of HIV-1 in Abidjan, Cote d'Ivoire, 1998-99. Bull World Health Organ 2001;79: 641-7.
Songok E, Fujiyama Y, Tukei P, Vulule J, Kiptoo M, Adungo N, et al. The use of short-course zidovudine to prevent perinatal transmission of human immunodeficiency virus in rural Kenya. Am J Trop Med Hyg 2003;69: 8-13.
Perez-Then E, Pena R, Tavarez-Rojas M, Pena C, Quinonez S, Butler M, et al. Preventing mother-to-child transmission in a developing country: the Dominican Republic experience. J Acquir Immune Defic Syndr 2003;34: 506-11.
Ministry of Health and Child Welfare, Zimbabwe. The prevention of mother to child transmission of HIV programme, 2002 annual report. Harare: National AIDS and Tuberculosis Programme, 2003.
Stringer J, Rouse D, Sinkala M, Marseille E, Vermund S, Stringer E, et al. Nervirapine to prevent mother-to-child transmission of HIV-1 among women of unknown serostatus. Lancet 2003;362: 1850-53.
Saman M, Kruy LS, Glaziou P, Rekacewicz C, Leng C, Min DC, et al. Feasibility of antenatal and late HIV testing in pregnant women in Phnom Penh Cambodia: the PERIKAM/ANRS1205 study. AIDS 2002;16: 950-1.
World Health Organization. Antiretroviral drugs and the prevention of mother-to-child transmission of HIV infection in resource-limited settings. Expert consultation, Geneva, 5-6 February 2004: a summary of main points from the meeting. www.who.int/3by5/arv_pmtct/en (accessed 22 Mar 2004).
Mitka M. MTCT-Plus programme has two goals: end maternal HIV transmission + treat mothers. JAMA 2002;288: 153-4.
World Health Organization, Division of Diarrhoeal and Acute Respiratory Disease Control. Integrated management of the sick child. Bull World Health Organ 1995;73: 735-40.
Horwood C, Liebeschuetz S, Blaauw D, Cassol S, Qazi S. Diagnosis of paediatric HIV infection in a primary health care setting with a clinical algorithm. Bull World Health Organ 2003;81: 858-66.(Freddy Perez, senior publ)
Correspondence to: F Perez Freddy.Perez@isped.u-bordeaux2.fr
Abstract
In 2003 an estimated five million people worldwide were newly infected with HIV. Approximately 800 000 of these were children; 90% of them were born to HIV infected women and acquired the virus during pregnancy, labour, or delivery or through breast feeding.1 2 Zimbabwe has one of the highest rates of HIV infection in the world, with an average antenatal HIV prevalence of 24.6% (20.9% in urban areas and 28.1% in rural areas) in 2003.3 By 2005, HIV/AIDS is projected to account for 60% of childhood mortality in Zimbabwe.4 The HIV/AIDS burden coexists with an important economic crisis, limiting access to an already deteriorating public health service.
Voluntary counselling and testing for HIV are essential for all support and treatment interventions against HIV and AIDS. Progress has been made in the prevention of mother to child transmission of HIV in resource poor countries, primarily through the development of short, easy to use, and affordable antiretroviral regimens.5-8
Prevention of mother to child transmission of HIV has been an integrated component of the Zimbabwe HIV/AIDS policy since 1999, when urban pilot programmes were initiated.9 To mitigate the paediatric HIV epidemic in Zimbabwe, countrywide implementation of this initiative is urgently needed.
Context
Population based surveys in Manicaland province (1998-2000) report an HIV prevalence of 22.3% for women aged 15 to 29 years.10 At the end of 2001, only 4% of Zimbabweans in need of services for prevention of mother to child transmission of HIV were receiving them.11 Although HIV/AIDS was considered a priority at Murambinda Mission Hospital, it had no HIV/AIDS programme including prevention of mother to child transmission of HIV. Unpublished observational data showed that stigma surrounding HIV/AIDS and HIV testing was high. This paper reports on the process and feasibility of implementing a programme for prevention of mother to child transmission of HIV in this district hospital.
Key measures of improvement
We introduced a coded intervention card documenting progress in mother-child uptake of activities and HIV serostatus in the hospital data collection system. We used pre-existing monitoring tools such as antenatal and delivery registers and defined basic process indicators to monitor the uptake of activities. We entered data on standard forms and managed and analysed them by using Stata 7.0 software.
Strategies for change
Murambinda Mission Hospital was the first site to implement a programme for prevention of mother to child transmission of HIV in a rural setting in Zimbabwe. Integration of voluntary counselling and rapid testing within routine antenatal care required adjustment of the patient flow to allow sufficient time and ensure confidentiality of these new services. Involvement of district health authorities was key for the integration and reorganisation of services in a sustainable manner.
During the first 18 months of the programme, 2298 pregnant women had pretest counselling; the acceptance of HIV testing reached 93.0% (n = 2137) among these women. Of all women who had an HIV test, 1588 (74.3%) returned to collect their result. Overall HIV prevalence was 20.4% (n = 437); 326 (74.6%) of these HIV positive women had post-test counselling, and 104 (23.8%) received complete mother-child prophylaxis with nevirapine. The reasons women gave for refusing testing were mainly related to the need to consult their husband or partner and their wish to think more about being tested.
The rate of return for test results was low. It is, however, consistent with recent findings from other programmes for prevention of mother to child transmission in West Africa and East Africa as well as the Caribbean.12-16
The minimum estimate of the coverage of the programme is 23.8%—that is, 104 women-child pairs receiving nevirapine out of a total of 437 HIV infected pregnant women given a diagnosis. The maximum estimate is 67.5%, considering that 220 women were prescribed nevirapine among 326 HIV positive women who received post-test counselling.
Reduction in stigma has not been formally documented. Nevertheless, participation in the programme and field observations in the community during information, education, and communication sessions indicated that the perceived disincentive for HIV testing, particularly among women, has been decreasing over time.
Follow up of mothers and children during the postnatal period has been one of the most challenging problems owing to centralisation of activities when the programme started and because of poor access to health facilities and limited trained staff. We subsequently considered a plan of action incorporating district satellite health centres in all activities related to prevention of mother to child transmission of HIV and strengthening community outreach programmes. Communication networks among the different levels of the healthcare system were reinforced to ensure appropriate patient flow and referral systems within the district.
Because the programme was planned and developed as a pilot, we used detailed monitoring tools. This enabled collection of quantitative and qualitative data on routine service uptake as well as identification of existing barriers. The information gathered set the basis for defining priorities for operational research, such as assessment of infant feeding options in the context of HIV infection, which is now being done.
On the basis of the lessons from this first pilot rural programme and others, the national AIDS and TB programme of the Zimbabwean Ministry of Health has initiated widespread scaling-up and replication of programmes for prevention of mother to child transmission of HIV to other regions of the country.17
Lessons learnt
Improving the continuum of care after delivery is a priority for prevention of mother to child transmission of HIV. In close collaboration with the national AIDS and TB programme and other partners, district health authorities are defining a follow up package that includes clinical and psychosocial support protocols, training of health professionals, continued decentralisation of services, and improvement of transport possibilities for community based follow up.
More importantly, the coverage of services for prevention for mother to child transmission of HIV at all points of the intervention cascade needs to be improved. Protocol development combining the introduction of opt-out voluntary counselling and testing, voluntary counselling and testing in labour wards, and prescription of nevirapine to women and children of unknown HIV status are now planned or at least being considered, as has recently been advocated.18 19 In addition, an enhanced basic package for prevention of mother to child transmission of HIV through the selection of more effective antiretroviral regimens than nevirapine alone could be considered.20 Access to antiretroviral therapy for HIV infected women and children identified through the programme and for their HIV infected family members is planned in Buhera district on the basis of principles outlined in the "mother-to-child transmission-plus initiative."21
The World Health Organization and UNICEF have developed the "integrated management of sick children" initiative to improve survival in children.22 A comprehensive HIV/AIDS continuum of care, including prevention of mother to child transmission, will need to be incorporated within this powerful public health strategy so as to facilitate sustainability of the management of paediatric HIV infection in communities such as ours.23
We thank the Zimbabwean National AIDS and Tuberculosis Unit of the Ministry of Health and Child Welfare of Zimbabwe (Inam Chitsike in particular) for supporting the project, the project team members for their continuous dedication, all the staff from Murambinda Mission Hospital and Buhera district health centres who participated in the quality improvement process, and Mathilde Touron for data analysis. Special thanks go to all the mothers and children of Buhera district. We particularly appreciate the assistance of Catherine Wilfert, Dirk Buyse, and Chuck Hoblitzelle at EGPAF offices. Nevirapine was provided through a donation from Boehringer Ingelheim.
Contributors: FP designed the project, coordinated programme implementation, and wrote the paper. JO-G and AMiller wrote the project proposal, collaborated in programme implementation, and contributed to writing the manuscript. TM coordinated local project management. MG and AMahomva provided technical input to programme implementation and suggestions for the manuscript. FD participated in the design of the proposal, coordinated programme implementation, and edited the manuscript. FP is the guarantor.
Funding: Elizabeth Glaser Pediatric AIDS Foundation, Call to Action project No CTA#26-01.
Competing interests: None declared.
Ethical approval: The Ministry of Health of Zimbabwe ethics committee approved the study in 2001.
References
United Nations Joint Program on HIV/AIDS (UNAIDS). Report on the global HIV/AIDS epidemic, December 2003. Geneva: UNAIDS, 2003.
Dabis F, Ekpini ER. HIV-1/AIDS and maternal and child health in Africa. Lancet 2002;359: 2097-104.
Ministry of Health and Child Welfare, Zimbabwe. Zimbabwe national HIV and AIDS estimates 2003. Harare: Ministry of Health, 2003.
Ministry of Health and Child Welfare, Zimbabwe. Report of the consultation of provincial medical directorates on initiating and scaling-up prevention of mother-to-child transmission of HIV infection in Zimbabwe—Gweru 15-16 May 2001. Harare: MTCT Unit, AIDS and TB Programme, 2001.
Dabis F, Msellati P, Meda N, Welffens-Ekra C, You B, Manigart O, et al. 6-month efficacy, tolerance, and acceptability of a short regimen of oral zidovudine to reduce vertical transmission of HIV in breastfed children in C?te d'Ivoire and Burkina Faso: a double-blind placebo-controlled multicentre trial. Lancet 1999;353: 786-92.
Jackson JB, Musoke P, Fleming T, Guay LA, Bagenda D, Allen M, et al. Intrapartum and neonatal single-dose nevirapine compared with zidovudine for prevention of mother-to-child transmission of HIV-1 in Kampala, Uganda: 18-month follow-up of the HIVNET 012 randomised trial. Lancet 2003;362: 859-68.
The Petra Study Team. Efficacy of three short-course regimens of zidovudine and lamivudine in preventing early and late transmission of HIV-1 from mother to child in Tanzania, South Africa, and Uganda (Petra study): a randomised, double-blind, placebo-controlled trial. Lancet 2002;359: 1178-86.
Moodley D, Moodley J, Coovadia H, Gray G, McIntyre J, Hofmyer J, et al. A multicenter randomized controlled trial of nevirapine versus a combination of zidovudine and lamivudine to reduce intrapartum and early postpartum mother-to-child transmission of human immunodeficiency virus type 1. J Infect Dis 2003;187: 725-35.
Ministry of Health and Child Welfare, Zimbabwe. National action plan for use of nevirapine to reduce mother-to-child HIV transmission in operational research settings in Zimbabwe. (First draft, May 2001.) Harare: MTCT Unit, AIDS and TB Programme, 2001.
Gregson S, Chandiwana SK. The Manicaland HIV/STD prevention project: studies on HIV transmission, impact and control in rural Zimbabwe. Zimbabwe Science News 2001;35: 27-42
World Health Organization. The health sector response to HIV/AIDS: coverage of selected services in 2001—preliminary assessment, 2002. Geneva: WHO, 2001.
Stringer EM, Sinkala M, Stringer JS, Mzyece E, Makuka I, Goldenberg RL, et al. Prevention of mother-to-child transmission of HIV in Africa: successes and challenges in scaling-up a nevirapine-based program in Lusaka, Zambia. AIDS 2003;17: 1377-82.
Temmerman M, Quaghebeur A, Mwanyumba F, Mandaliya K. Mother-to-child HIV transmission in resource poor settings: how to improve coverage? AIDS 2003;17: 1239-42.
Msellati P, Hingst G, Kaba F, Viho I, Welffens-Ekra C, Dabis F. Operational issues in preventing mother-to-child transmission of HIV-1 in Abidjan, Cote d'Ivoire, 1998-99. Bull World Health Organ 2001;79: 641-7.
Songok E, Fujiyama Y, Tukei P, Vulule J, Kiptoo M, Adungo N, et al. The use of short-course zidovudine to prevent perinatal transmission of human immunodeficiency virus in rural Kenya. Am J Trop Med Hyg 2003;69: 8-13.
Perez-Then E, Pena R, Tavarez-Rojas M, Pena C, Quinonez S, Butler M, et al. Preventing mother-to-child transmission in a developing country: the Dominican Republic experience. J Acquir Immune Defic Syndr 2003;34: 506-11.
Ministry of Health and Child Welfare, Zimbabwe. The prevention of mother to child transmission of HIV programme, 2002 annual report. Harare: National AIDS and Tuberculosis Programme, 2003.
Stringer J, Rouse D, Sinkala M, Marseille E, Vermund S, Stringer E, et al. Nervirapine to prevent mother-to-child transmission of HIV-1 among women of unknown serostatus. Lancet 2003;362: 1850-53.
Saman M, Kruy LS, Glaziou P, Rekacewicz C, Leng C, Min DC, et al. Feasibility of antenatal and late HIV testing in pregnant women in Phnom Penh Cambodia: the PERIKAM/ANRS1205 study. AIDS 2002;16: 950-1.
World Health Organization. Antiretroviral drugs and the prevention of mother-to-child transmission of HIV infection in resource-limited settings. Expert consultation, Geneva, 5-6 February 2004: a summary of main points from the meeting. www.who.int/3by5/arv_pmtct/en (accessed 22 Mar 2004).
Mitka M. MTCT-Plus programme has two goals: end maternal HIV transmission + treat mothers. JAMA 2002;288: 153-4.
World Health Organization, Division of Diarrhoeal and Acute Respiratory Disease Control. Integrated management of the sick child. Bull World Health Organ 1995;73: 735-40.
Horwood C, Liebeschuetz S, Blaauw D, Cassol S, Qazi S. Diagnosis of paediatric HIV infection in a primary health care setting with a clinical algorithm. Bull World Health Organ 2003;81: 858-66.(Freddy Perez, senior publ)