Effect of having an antiretroviral therapy adherence monitor on CD4 cell count among pregnant women living with HIV in Ghana

Authors: Jennifer R. McCullough [1], Arfah Anjum [1], Vanessa R. Salmo [1], Prince O. Gyebi [2], Kwame S. Sakyi [1,2]

  • Oakland University, School of Health Sciences, Department of Public and Environmental Wellness, 3101 Human Health Building, 433 Meadow Brook Rd, Rochester, MI 48309-4452; 


  • Center for Learning and Childhood Development-Ghana, AF 3190, Adenta Flats, Accra, Ghana

Michigan Academy 2018 Conference; March 2018. 


Background: A key part of HIV care in Ghana is for newly diagnosed patients to attend at least two antiretroviral therapy (ART) adherence counseling sessions with an ART adherence monitor. Research is yet to evaluate the choice of a monitor  and the number of counseling sessions attended with a monitor on CD4 cell count. 

Methods: A retrospective cohort study of 135 pregnant women diagnosed with HIV in 2011-2013 was conducted using data from patients' medical records at Korle Bu Teaching Hospital, Ghana. The outcome was participants’ first post baseline CD4 cell count, categorized as high (≥ 350 cells/mm3 ) vs. low (<350 cells/mm3). 62% attended ≥ 2 counseling sessions with a monitor. 

Results: In a multivariate logistic model, the odds of having a high CD4 cell count was over three times higher among those who attended ≥ 2 counseling sessions with a monitor [Adjusted OR= 3.44; 95% CI: 1.10, 10.70; p-value = 0.03] compared to those who did not. The choice of an adherence monitor (partner vs. non-partner) was not associated with high CD4 cell count. 

Conclusion: Given the benefits of having an ART adherence monitor, efforts should focus on in increase the proportion of women attending ≥ 2 counseling sessions with a monitor.

Stigma experienced by mothers living with HIV with low birth weight babies 

Authors: Kwame S. Sakyi [1,3], Margaret Y. Lartey[2] ,  Prince O. Gyebi [3], Pamela J. Surkan [4]

  • Assistant Professor, Oakland University, School of Health Sciences, Department of Public and Environmental Wellness, 3101 Human Health Building, 433 Meadow Brook Rd, Rochester, MI 48309-4452. 


  • Professor, Department of Medicine & Therapeutics, University of Ghana School of Medicine & Dentistry, CHS, P.O. Box GP 4236, Accra, Ghana. 


  • Co-Director, Center for Learning and Childhood Development Ghana, AF 3190, Adenta Flats, Accra, Ghana. 


  • Associate Professor, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA. 


8th International Conference on Stigma, Howard University, Maryland, USA; Nov, 2017


Background: Low birthweight (LBW) infants are subject to both medical and social vulnerability, including stigma, as are people living with HIV. The impact of dual stigma (being HIV positive and having a small baby) has not been studied, especially in sub-Saharan Africa, where the burden of these conditions is highest.
Methods: We explored stigma related to baby’s size among 30 postpartum women living with HIV (15 with LBW (<2.5g) infants and 15 with normal birth weight infants) in Ghana. In semi-structured interviews, we asked mothers about their perceptions of LBW babies and social experiences living with HIV and caring for LBW infants. Data analysis was informed by interpretive phenomenology.
Results: Mothers’ narratives indicate that having a small baby was a source of stigma because of the newborns “undesirable” physical features and people’s unfamiliarity with their size. Many of the mother’s stories show that they and others characterized small babies as being abnormal or looking “animal-like.” This devalued identity, mothers reported, was the basis for several negative stigmatizing behaviors from society toward the mother-baby dyad, and also from the mother toward the infant. Key facets of the stigma participants report included initial maternal detachment, reluctance to show the baby to others, experiences of gossip and stares from others, and maternal self-blame. Participants described ways in which mental distress from HIV diagnosis contributed to having a small baby and how having a small baby was a reason for not disclosing HIV to partners or relatives.  
Conclusion: In Ghana, having a LBW baby is an attribute that invites stigma toward the mother-child dyad. Living with HIV compounds mental distress associated with having a LBW baby. HIV-infected mothers with very LBW infants may need additional support in disclosing their HIV status to their partners and relatives.

Current needs related to pediatric HIV in Ghana: Early identification, improved communication with parents and children are key to improving HIV care for children in Ghana

Author: Sarah Dalglish, PhD


According to UN statistics, in Ghana there are at nearly 20,000 children aged 0 to 14 living with HIV as of 2015, with an additional 2,400 new paediatric infections each year. Recent studies suggest the most important steps for improving pediatric HIV care in Ghana are 1) promoting early identification of infection and early initiation of treatment and 2) better-quality counselling and communication with both parents and children.

First, only 11% of HIV-positive children in Ghana are currently receiving treatment despite the proven benefits of early initiation of anti-retroviral therapy (ART). A study of 90 HIV-infected children (age 0 to 13 years) starting ART at the paediatric HIV/AIDS care program in Accra, Ghana from 2009 to 2012 found the only significant predictor of treatment failure (as measured by reduced CD4 count) was older age at the start of ART, though effectiveness of first-line treatment was still found to be 83.3% (Barry et al. 2013).

A separate study using the IeDea paediatric West African Database included 3,014 HIV-infected children under age 17 and found that early initiation of ART (before 2 years and before any immunodeficiency) was necessary for the recovery of normal CD4+ cell counts, sustainable beyond 12 months of ART. Initiation of ART in children older than 5 years did not allow for reaching immune recovery (Desmonde et al. 2014). Similarly, late initiation of ART (after 5 years of age) was significantly associated with slower growth improvement (measured by height, weight and body mass index) in a study of HIV-positive children under 10 years from several West African countries including Ghana (Jesson, Leroy 2014). Thus, it is critical for Ghanaian practitioners and policy-makers to focus on identifying HIV in pregnant mothers (only 62% of HIV-positive pregnant women in Ghana receive the most effective ARVs for PMTCT), and in young children (ideally before their 2nd birthday), with immediate initiation of ART.

A number of case-finding strategies have been proposed for early infant identification, including provider-initiated testing, integrated management of childhood illness screening, and screening at immunization clinics, some of which may be more appropriate for relatively low-prevalence settings such as Ghana.

Equally important to early initiation of ART is sustained follow-up of HIV-positive children, with improved communication on proper care targeting both parents and HIV-infected children. Inadequate communication with care-takers about children’s health is a common problem in Ghana: in a study of 153 mothers of infants hospitalized at the Komfo Anokye Teaching Hospital Mother Baby Unit, less than one-third of mothers had a full understanding of the reasons for their baby’s hospitalization (Gold et al. 2013).

Furthermore, babies born to HIV-positive mothers may have special needs, as they are more likely to be born premature and with low-birthweight (Laar et al. 2010). Indeed a study observing HIV-infected children in five tertiary hospitals in West Africa (Ouagadougou, Accra, Cotonou, Dakar, and Bamako) over six months in 2010 found high rates of hospitalization; over half of these hospitalizations were due to infections caused by improper treatment (Dicko et al. 2014). The study’s authors recommend cotrimoxazole prophylaxis for all HIV-infected children; however improved counselling and support for adherence could also help. This is especially important given that early initiation of ART can lead to earlier cumulative toxicity, treatment failure or drug resistance if adherence is poor.

Even at early ages, children can become involved in caring for themselves and adhering to treatment – however a study of 71 parent-and-child pairs at the Pediatric HIV/AIDS Care Programme at the Korle Bu Teaching Hospital in Accra found out that only 1 out 5 parents had told their child s/he was HIV-positive, even though children who know their status are less likely to get sick than those who do not (Kallem et al. 2011). Practitioners in Ghana should take care to communicate the importance of proper adherence and the value of informing children of their HIV-positive status, whereas policymakers should consider how to best support these efforts, for example by providing counselling cards and similar tools.


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