CarePack^® for HIV Programmes

In many parts of the world access to care and treatment is limited. There, interventions to prevent opportunistic infections can have a great impact.

The World Health Organization and the Centers For Disease Control recommend that people with HIV in resource-limited settings have access to essential interventions to prevent illness and HIV transmission.

Vestergaard has developed a CarePack® preventive care package, which is comprised of evidence-based interventions designed to improve the health of HIV positive individuals and their families. These interventions targeting infectious diseases are user-friendly and self-managed, which empowers HIV positive individuals to protect themselves.

A standard CarePack® for an HIV programme includes:

• A PermaNet^® long-lasting insecticidal net that can prevent malaria and other vector-borne diseases
• A LifeStraw^® Family household water purifier that can prevent diarrhea and other waterborne diseases
• Printed health education material providing tips on prevention of malaria, diarrhea, and sexually-transmitted diseases
• Condoms, broad-spectrum antibiotics and other items may also be added to the CarePack® depending on country requirements.

Supply chain interventions that require monthly provision create complex supply chains. This is an impediment to the rapid scale up and success of a public health programme. Therefore, the standard components of CarePack® have been designed to be long-lasting and last for a minimum of three years.

Health Impact

Delaying HIV Disease Progression with CarePack^®

HIV positive individuals are often infected for many years before the virus eventually weakens their immune system to a point where they start becoming sick and require drugs to treat the HIV infection (ART). During this time, recurrent infections with malaria and diarrheal diseases may accelerate the progression of the HIV disease. In addition, these infections may lead to an increased amount of the HIV virus in their blood, leading to possible increases in the risk of HIV transmission to their partners.

Providing effective interventions to prevent malaria and diarrheal disease may represent a practical and relatively inexpensive strategy to delay the progression of HIV and, possibly, to reduce HIV transmission.

A 2-year study in Kenya¹ measured the impact of PermaNet® long-lasting insecticidal net (LLIN) and LifeStraw® Family water purifier on HIV disease progression by monitoring CD4 counts. The primary measure of efficacy was time to reach a CD4 count of 350 cells or below which was the retro viral therapy.

The results were as follows:

• Individuals receiving the LLIN and water purifier were 27 percent less likely to reach the endpoint of CD4 count.
• CD4 decline was also significantly less in the group receiving the LLIN and water purifiers than in the control group ( 54 vs. -71 cells/mm /year, p=0.03).

Cost-Effectiveness of Delaying HIV Disease Progression with CarePack^®

Delaying the time to start treatment has obvious economic benefits for programmes due to the reduction in ART and healthcare costs.

A cost and cost effectiveness study² of the Kenya multisite study gave the following results:

• Net cost savings of about USD26,000 for the intervention, over 1.7 years for healthcare providers due to reduced ART use and malaria and diarrhea cases.
• The intervention was found to be very cost-effective at a cost of US$ 3100 per death averted or US$ 99 per disability-adjusted life year (DALY) averted.
• The provision of LLINs and water filters to ART-naive HIV-infected adults in the Kenyan study resulted in substantial net cost savings, due to the delay in the initiation of ART. The addition of an LLIN and a point-of-use water filter to the existing package of care provided to ART-naıve HIV-infected adults could bring substantial cost savings to resource-constrained health systems in low- and middle-income countries.

Reduction of Diarrheal Diseases with LifeStraw^® Family

Unsafe drinking water presents a particular threat to people living with HIV/AIDS (PLHIV) due to the increased risk of opportunistic infections, diarrhea-associated mal absorption of essential nutrients, and increased exposure to untreated water for children of HIV-positive mothers who use replacement feeding to reduce the risk of HIV transmission. This population may particularly benefit from an intervention to improve water quality in the home.

A 12-month randomized, controlled field trial was conducted in Zambia among 120 households with children.³

Findings from the study:

• Filter use was high, with 96% (596/620) of household visits meeting the criteria for users.
• The quality of water stored in intervention households was significantly better than in control households (3 vs. 181 TTC/100 mL, respectively, p<0.001).
• The intervention was associated with reductions in the longitudinal prevalence of reported diarrhea of 53% among children.

Conclusion:

In this population living with HIV/AIDS, a water filter combined with safe storage was used correctly and consistently, was highly effective in improving drinking water quality, and was protective against diarrhea.

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References

¹Walson J. (2013). Evaluation of impact of long-lasting insecticide-terated bed nets and point-of-use water filters on HIV-1 disease progression in Kenya. AIDS. 2013 Jun 1;27(9):1493-501.

²Kern E. (2013). Provision of bednets and water ilters to delay HIV1 progrssion: cost-effectiveness analysis of a Kenyan multisite study. Trop Med Int Health. 2013 Aug 18(8):916-24.

³Peletz R (2012). Assessing water filtration and safe storage in households with young children of HIV-positive mothers: a randomized, controlled trial in Zambia. PLoS One. 2012;7(10):e46548.

CarePack^® for Maternal and Infant Health

Every day, approximately 800 women die from causes related to pregnancy and childbirth¹. The majority of deaths can be prevented through interventions available now that focus on the linkages between care of mothers, newborns, and infants². Clean water can serve as a vital tool towards protecting maternal newborn and child health (MNCH).

The distribution of a CarePack® containing a LifeStraw® Family filter and a PermaNet® through maternal health clinics could not only help in the prevention of malaria and water borne diseases but also serve as an incentive for mothers to attend ante natal care and deliver in health facilities.

Importance of Clean Water to Maternal Health

The world has met the Millennium Development Goal (MDG) drinking water target, which calls for halving the proportion of the population without sustainable access to safe drinking water between 1990 and 2010³. However, 783 million people still have no ready access to safe water. Water sources that have been qualified as “improved” may not truly be safe because of challenges associated in measuring microbiological water quality, risk of contamination at the point of supply, and perhaps most importantly, risk of recontamination at the point of use due to unsafe collection, transportation, and storage. The Millennium Development Goals cannot be viewed in isolation from one another, as the success of each objective both depends on and influences the other. Progress towards improving water, sanitation, and hygiene impacts progress towards reducing maternal and child mortality⁴.

Lack of access to safe drinking water contributes to the staggering burden of diarrheal diseases worldwide, particularly among young children. Over 1 in 10 deaths among children under five – around 1 million deaths every year – is due to diarrhoea⁵. Diarrhoea claims more lives than AIDS, malaria, and measles combined⁶. Access to clean water can contribute to the prevention of child deaths by reducing susceptibility to diarrhea and other water-related diseases. Mothers and children are at high risk particularly in the first days after giving birth. Among children, deaths within the crucial first month of life account for 40% of all under-five deaths⁵. Premature birth complications and complications during and immediately after labor are responsible for over half of these neonatal deaths⁵. Tools to promote safe water and storage are critical to achieving the MDG of reducing under-five mortality by two-thirds and maternal mortality by three-quarters.

In addition, clean water is vital to protecting maternal newborn and child health for the following reasons:

• During pregnancy and childbirth, women are especially vulnerable to diseases such as anaemia. While anaemia is usually associated with nutritional deficiencies, infections such as intestinal worms or malaria, which are related to poor access to safe and reliable water, can also cause the condition^7,8. Anaemia results in weakness and fatigue, can affect development of the fetus, and contributes to up to 20 per cent of maternal deaths ⁹.
• Lack of access to skilled care means that many women in developing countries give birth at home, where they may be more at risk of exposure to unsafe water and as a result, infections.
• Even in cases where mothers see a trained health worker, effective interventions are often unavailable or not implemented, leading to a high risk of death from pregnancy and childbirth¹⁰.
• Only about 60% of women in developing countries have access to skilled care while giving birth, and only about 40% in South Asia and sub-Saharan Africa can access a skilled health provider¹¹. Barriers that stand in the way of women accessing care include trained health worker shortages, insufficient or distant health centres, lack of transportation fees or inability to travel, and lack of education and awareness among women with regards to the need for skilled care¹².
• Giving birth at home can be risky for mother and child due to poor infection control⁴.

Women who give birth in health centers are also often exposed to unsafe water and sanitation and poor management of medical waste⁴. Infections in the first six weeks after childbirth lead to 15% of all maternal deaths, primarily because of poor hygiene practices and poor infection control. Half of all infection-related deaths could be averted if skilled birth attendants adopted hygienic childbirth techniques⁴.

Incentivizing Uptake of Antenatal Care and Prevention of Mother-to-Child Transmission

Providing water treatment, safe storage and soap for hand-washing products in antenatal care (ANC) programs, has shown to dramatically increase regular clinic visits, allowing for pregnant women and partner testing for HIV and early initiation of antiretroviral therapy for infected mothers. (Xue, 2010) An added benefit of ANC clinic attendance is an increase in water treatment behavior and demonstration of proper hand-washing technique. These all result in improved health outcomes for both mother and child, and a greater likelihood of preventing HIV transmission.

Sustaining Healthy Practices during Postnatal Care

Postnatal care (PNC) is also an important period during which regular clinic visits and vaccinations allow for improved health outcomes. Similar to ANC, inclusion of water treatment products and hygiene behaviour support within PNC has shown to increase attendance at PNC. In addition, it provides an opportunity to sustain water treatment practices, even several years after implementation. Such a long-term improvement has not been documented in a stand-alone water treatment effort.

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References

¹World Health Organization (2012). Maternal mortality. Fact sheet N°348.
²Countdown to 2015 (n.d.). Countdown and the Continuum of Care.
³UNICEF/WHO (20120). Joint news release: Millennium Development Goal drinking water target met. Geneva/New York.
⁴Yardley, S. (2010). Joining the Dots: Why better water, sanitation and hygiene are necessary for progress on maternal, newborn and child health. Tearfund.
⁵Liu L, Johnson HL, Cousens S, Perin J, Scott S, Lawn JE, Rudan I, Campbell H, Cibulskis R, Li M, Mathers C, Black RE;
Child Health Epidemiology Reference Group of WHO and UNICEF (2012). Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000. Lancet 9,379(9832), 2151-61.
⁶United Nations Children’s Fund (UNICEF) (2009). Diarrhea: why children are still dying and what can be done. UNICEF/WHO. New York: United Nations Children’s Fund.
 ⁷UNDP (2006) Human development report 2006, p45. UNDP, New York 
⁸WHO/UNICEF (2005). Joint Monitoring Programme for Water Supply and Sanitation (2005). Water for life: making it happen. UNICEF, New York, and WHO, Geneva 
⁹World Health Organization (2001). Water-related diseases fact sheet.
¹⁰The Bill & Melinda Gates Foundation (2012). Maternal, Newborn, & Child Health Overview.
¹¹UNICEF (2007) Progress for children: a world fit for children. Statistical review. 
¹²Goodburn E, Campbell O (2001). Reducing maternal mortality in the developing world: sector-wide approaches may be the key. BMJ, 322, 917-920, quoted in WSSCC (2006). For her, it’s the big issue: putting women at the centre of water supply, sanitation and hygiene. Evidence report. WSSCC, Geneva.
¹³WSSCC (2006). For her, it’s the big issue: putting women at the centre of water supply, sanitation and hygiene. Evidence report. WSSCC, Geneva

Learn about Vestergaard's CarePack® Integrated Prevention Campaign