<div class="title-block" style="border-bottom-color: #628bb3"><h1><img class="title-image" src="http://www.heart-resources.org/wp-content/themes/heart/images/health.svg">HIV and AIDS</h1><div class="post-type-description"></div></div> – Health and Education Advice and Resource Team http://www.heart-resources.org Providing DFID staff and other development actors with health, education and nutrition knowledge and expertise from around the world Fri, 02 Mar 2018 13:10:49 +0000 en-US hourly 1 https://wordpress.org/?v=4.9.4 Targeted interventions for sex workers to reduce HIV http://www.heart-resources.org/2016/07/targeted-interventions-sex-workers-reduce-hiv/ http://www.heart-resources.org/2016/07/targeted-interventions-sex-workers-reduce-hiv/#respond Sat, 16 Jul 2016 15:04:53 +0000 http://www.heart-resources.org/?p=29189 Read more]]> This review has found a number of peer reviewed studies and grey literature on interventions targeted at sex workers for HIV prevention. Several were systematic reviews, some comprehensive reviews and policy papers. A number of individual studies focused on cost effectiveness are presented.

Two interventions in India are considered particularly effective and scalable interventions. A number of studies on these is presented. Both of these programmes focus on community mobilisation, and involve female sex workers (FSWs), as well as other key groups.

The key messages identified are:

  • The evidence for the cost-effectiveness of FSW interventions is strong, particularly for areas with concentrated HIV epidemics, with an estimated average cost of $102 to $184 per participant. Cost analyses demonstrate the cost-effectiveness of scaling up HIV prevention and treatment among sex workers, particularly in higher prevalence settings where it becomes cost-saving.
  • Evidence indicates that effective HIV prevention packages for sex workers should include combinations of biomedical, behavioural, and structural interventions tailored to local contexts, and be led and implemented by sex worker communities. Additionally, programmes should be holistic and complementary.
  • HIV prevention strategies should target the social determinants of health and inequality. The literature on HIV interventions targeting FSWs underscores the inextricable connections between gender, political-legal, and economic structures on the vulnerability of FSWs and their susceptibility to HIV.
  • Community empowerment is an essential approach, as is community participation and leadership.
  • Ultimately, structural and legal changes that align public health and human rights are needed. In the short term, interventions targeted at sex workers could contribute to reducing HIV risk.
  • Evidence is primarily available for interventions with FSWs.
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Cost-effectiveness of male circumcision in reducing HIV http://www.heart-resources.org/2016/07/cost-effectiveness-male-circumcision-reducing-hiv/ http://www.heart-resources.org/2016/07/cost-effectiveness-male-circumcision-reducing-hiv/#respond Sat, 16 Jul 2016 14:40:09 +0000 http://www.heart-resources.org/?p=29185 Read more]]> Evaluation of the evidence on the effectiveness of male circumcision (MC) suggests that implementation should be accelerated in sub-Saharan Africa. Experts reviewing six simulation models agree that programmes that focus on subpopulations with a high HIV prevalence and incidence would have substantial impact on HIV incidence.

The review of the six simulation models found estimates of costs per HIV infections averted (HIA) between $150 and $900 in high HIV prevalence settings over a 10-year time horizon, and $100 to $400 when including infections averted to 20 year. Cost-effectiveness models from individual studies estimate (download the full report for references):

  • With an HIV prevalence of 8.4%, the cost per HIA is $551 (80% CI $344–$1,071) and net savings are $753,000 (80% CI $0.3 million to $1.2 million) based on data from South Africa.
  • Research using data from Uganda estimated the cost per HIA to be $1,269–3,911.
  • Modelling impact and costs of MC for Eastern and Southern Africa research estimates net savings for Zimbabwe to be US$7,031 for 2011-2025.
  • Costs per HIA based on Rwandan data is US$3,932 for adolescent MC and US$4,949 for adult MC. This study also investigated neonatal MC which is considerably less expensive, US$15 instead of US$59 per procedure, though savings will be realised later in time.
  • Estimates from Tanzanian data suggest costs per HIA to be US$11,300 during 2010–2015 and US$3,200 during 2010–2025.
  • The USAID Health Policy Initiative estimated cost-effectiveness in the settings of Swaziland, Zambia, and Lesotho. Costs per HIA were US$176 in Swaziland, US$313 in Zambia, and US$292 in Lesotho.

Value-added from male circumcision comes from reduction in other sexually transmitted diseases.

Cost-effectiveness estimates identified are promising but vary widely, making it difficult to draw conclusions. Estimates are sensitive to inputs such as costing of the MC and treatment averted, the protective effect, and HIV prevalence. Estimates are also likely to vary over time due to inflation.

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Effective behaviour change interventions http://www.heart-resources.org/2016/04/effective-behaviour-change-interventions/ http://www.heart-resources.org/2016/04/effective-behaviour-change-interventions/#respond Thu, 28 Apr 2016 10:05:38 +0000 http://www.heart-resources.org/?p=28953 Read more]]> This helpdesk provides a rapid analysis on the existing evidence related to effective behaviour change interventions. It has a particular focus on where interventions are related to hygiene and sanitation, nutrition, gender based violence, indoor air pollution, family planning adoption, unsafe sex, motor vehicle driving. The geographic focus is Malawi, but where necessary it draws on evidence from the wider sub-Saharan Africa region and other low income contexts. Where possible it presents information on both the nature of interventions, and evidence based factors that contribute to intervention success/failure.

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HIV pre-exposure prophylaxis (PREP), gender and health systems http://www.heart-resources.org/blog/hiv-pre-exposure-prophylaxis-prep-gender-health-systems/ http://www.heart-resources.org/blog/hiv-pre-exposure-prophylaxis-prep-gender-health-systems/#respond Tue, 22 Mar 2016 09:39:01 +0000 http://www.heart-resources.org/?post_type=blog&p=28792 Read more]]> Everyone who was at the Durban AIDS conference in 2000 remembers the moment we learnt of effective medications for HIV. Some of us were too scared to believe it. But it turned out to be true and what unfolded was relatively straightforward. Life rapidly changed for people with the virus who were able access treatment. Reasons to avoid HIV testing fell away. Ageing with HIV would emerge as a paradoxically welcome addition to the agenda. Advocacy rightly became a mantra of demand for universal access to treatment and care especially in poor countries where the epidemic was causing millions of deaths.

In a way the development of anti-retroviral (ARV) based prevention is a similar moment. We now know that when positive people take treatment it can reduce the amount of HIV in their bodies to non-transmissible levels. Pre-exposure prophylaxis (PrEP) for HIV negative people, unarguably has the potential to stop transmission on a scale that could play a significant role in ending the HIV epidemic.

But in another way it is a quite different moment. Rather than a single, self-evidently justified demand PrEP creates a complicated set of ethical, legal, policy and practical challenges. Many of these relate to gender, equity and rights. In the lead up to International Women’s Day it is worth considering how we might collectively meet these challenges and learn from them in relation to the creation of new health technologies.

For people living with HIV the preventive value of ARV medication is a side effect of lifesaving treatment whereas PrEP is taken by well people. In medical ethics it is accepted that the safety level required of medication for treatment differs from that for prevention. The issue is simple, if a drug that might cause damage in the long term saves the lives of patients it is ethical to approve it as treatment but not ethical to provide it to people who are not ill. Despite many studies that suggest that PrEP will, or will not, have harmful side effects, the fact is we don’t know what might emerge in millions of PrEP users over decades. Medical history is littered with such scenarios. This concern led the trials of PrEP to be closed in Cameroon and Cambodia, when sex workers who were the subject of study realised that if the drug damaged them in years to come they would not be eligible for any kind of support. In response to the complaint in Cambodia researchers offered compensation of $36 per participant, which sex workers unsurprisingly took as a deal breaking insult.

A further ethical complication is that since PrEP is not a contraceptive and does not protect from sexually transmitted infections there is potential forharm to come to users who replace a proven prevention technology, condoms, with PrEP. This generates obligations in respect of the messages and targeting of the medication to women. Most research is focused on men, and the most vocal demand for PrEP to be approved and subsidised comes from men. The product developed for ‘high risk’ women whose adherence to daily pills is likely to be poor is a microbicide ring which can be inserted into the vagina for a month at a time. Enthusiasm for the ring has come primarily from public health agencies rather than potential consumers who are keen to lower their HIV risk. Notably the efficacy of the vaginal ring appears to be far lower than for oral PrEP.

Useful, independent research and rich discussions about PrEP and women in various settings do not seem to be occurring. If insightful guidelines about who should, and should not, be prescribed PrEP are being developed this is not an open process. Nor are plans for the anti-discrimination measures or public health messages that will be needed if PrEP is to fulfil its potential. So far we are only seeing grand claims about ‘saving millions of lives’ of people classified as being at risk. These are based on epidemiology’s crude mega-populations – sex workers, men who have sex with men, sero-discordant couples and transwomen.

It is certainly true that many of those most in need of access to PrEP live precarious lives but that precarity is driven by discrimination, violence and laws against drugs, sex work, and homosexuality that form a powerful barrier to any form of health care or preventative measure. The tension between public health and human rights on one hand, and punitive legal environments on the other, has been well documented in relation to HIV. But in many countries law has not kept up with developments in HIV so that the work of public health authorities and services to ‘key populations’ continues to be impeded by policy that reflects irrational fear and stigma. Criminalisation of HIV, sex work, adultery, abortion and the potential for civil legal actions remain a reasonable fear that drives barrier to the regular testing that must accompany PrEP.

One of WHO’s building blocks of the health system is ‘medical products and technologies’. Yet the example of PrEP demonstrates that the existence of an efficacious medication is only the starting point for the complex array of ethical and practical decisions that need to be made to improve health outcomes. And these decisions are molded by, and imbued with, questions of power, gender, and marginality. In the case of HIV sexuality, legal status, and poverty are particularly profound intersecting issues.

All too often we are lacking vital social science research that demonstrates – not that particular medication works – but the situations under which the introduction of a new technology can bring positive benefits, the unanticipated consequences of change, the beliefs and the preferences of particular ‘beneficiaries’ of interventions, and the motivation of those who seek to intervene.

Recent discussions about universal health coverage and its relation to human rights have highlighted that health policy change is not purely a technical, quick fix, driven by costing data alone. Rather there are political questions at play which are profoundly influenced by national and international law and the power and agency of citizens to demand their entitlements.

As discussions about PrEP move forward – and significant progress is being made quite rapidly – there is an urgent need for activists, health systems researchers and public health agencies to use their skills to ensure that due consideration is given to the health and human rights of women. Unless that happens the epidemic ending potential of ARV based HIV prevention will not be realised.

By Cheryl Overs, Research Fellow at the Michael Kirby Centre for Public Health and Human Rights at Monash University in Australia and the Institute of Development Studies in the UK

This blog was originally posted on Health Systems Global on 4 March 2016. Reposted with permission.

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South Africa’s private sector investment in training and its erosion as a result of HIV and AIDS http://www.heart-resources.org/doc_lib/south-africas-private-sector-investment-in-training-and-its-erosion-as-a-result-of-hiv-and-aids/ http://www.heart-resources.org/doc_lib/south-africas-private-sector-investment-in-training-and-its-erosion-as-a-result-of-hiv-and-aids/#respond Mon, 25 Jan 2016 12:30:07 +0000 http://www.heart-resources.org/?post_type=doc_lib&p=28409 Read more]]> The South African economy is dependent on the productivity of its labour. To maximise productivity, the labour force must possess the appropriate skills. The private sector invests more funds than the government on training. However, the HIV and AIDS epidemic is eroding this investment. Based on an estimate of the HIV and AIDS death rate and data on training expenditure by the private sector, this study concludes that the loss for all sectors was estimated at almost R10 million (R9,871,732) during the study year, equating to USD 1,183,661 per annum. This represents on average 0.73 per cent of the investment in training. The real costs of HIV and AIDS on business, which includes absenteeism, declining productivity and other costs are difficult to quantify, but they are likely to significantly exceed this lost training investment as a result of increasing morbidity and mortality rates due to HIV. It is in the private sector’s best interest to ensure that a sound HIV and AIDS policy is in place. Companies must also invest in in effective prevention programmes and provide the appropriate treatment to employees if needed or unavailable through the public health sector.

This document may be accessible through your organisation or institution. If not, you may have to purchase access. Alternatively, the British Library for Development Studies provides a document delivery service.



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Identifying structural barriers to an effective HIV response: using the national composite policy index data to evaluate the human rights, legal and policy environment http://www.heart-resources.org/doc_lib/identifying-stcy-environment/ http://www.heart-resources.org/doc_lib/identifying-stcy-environment/#respond Mon, 07 Dec 2015 10:44:19 +0000 http://www.heart-resources.org/?post_type=doc_lib&p=28178 Read more]]> Attention to the negative effects of structural barriers on HIV efforts is increasing. Reviewing national legal and policy environments with attention to the international human rights commitments of states is a means of assessing and providing focus for addressing these barriers to effective HIV responses. Recognition of the harms inherent in laws that constitute structural barriers to effective HIV responses and the potential positive role that a supportive legal environment can play suggests the need for legal reform to ensure an enabling regulatory framework within which HIV services can be effectively delivered and used by the populations who need them. Moving beyond laws and policies, further efforts are required to determine how to capture information on the range of structural barriers. Teasing apart the impact of different barriers, as well as the structural interventions put in place to address them, remains complicated. Capturing the impact of policy and legal interventions can ultimately support governments and civil society to ensure the human rights of key populations are protected in national HIV responses.


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Funding for HIV and Non-Communicable Diseases: Implications for Priority Setting in the Pacific Region http://www.heart-resources.org/doc_lib/funding-for-hiv-and-non-communicable-diseases-implications-for-priority-setting-in-the-pacific-region/ http://www.heart-resources.org/doc_lib/funding-for-hiv-and-non-communicable-diseases-implications-for-priority-setting-in-the-pacific-region/#respond Tue, 01 Sep 2015 16:48:00 +0000 http://www.heart-resources.org/?post_type=doc_lib&p=27402 Read more]]> There has been increasing global interest in documenting funding flows for health, but none of that work has focused on the Pacific region. This paper outlines external funding for two specific areas of overseas development assistance (ODA) for health in the region—HIV/AIDS and non-communicable diseases (NCDs)— during 2002-09. These are compared to the comparative disease burdens, and some initial thoughts are presented on the dynamics of setting donor health priorities in the Pacific.

Empirical data shows that, despite much higher mortality rates from NCDs, external funding for HIV is higher than for NCDs. From 2002 to 2009, funding totalled US$68,481,730 for HIV and US$32,910,778 for NCDs. External assistance for HIV activities in the Pacific in 2009 was more than US$18 million, while funding for NCDs in the same year was almost US$12 million.

Despite cooperation from many agencies, the funding data were difficult to gather, highlighting the need for greater transparency of funding information and more thorough record keeping. The external funding does not align with the disease and mortality figures, and further interviews suggested that donor funding decisions in the region are driven not by local priorities but by factors including a strong global HIV community, the commitment to the Millennium Development Goals (MDGs) and the lack of coherence in the way NCDs are presented to policy makers.

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Increasing the provision of essential health care services through support of health workers in Sierra Leone http://www.heart-resources.org/assignment/increasing-the-provision-of-essential-health-care-services-through-support-of-health-workers-in-sierra-leone/ http://www.heart-resources.org/assignment/increasing-the-provision-of-essential-health-care-services-through-support-of-health-workers-in-sierra-leone/#respond Thu, 23 Jul 2015 15:23:33 +0000 http://www.heart-resources.org/?post_type=assignment&p=27166 Read more]]> DFID committed 12 million GBP to uplift frontline health workers’ salaries in Sierra Leone from 2010 to 2015 to support the implementation of the Free Healthcare Initiative (FHCI), launched in April 2010, which made health services free for pregnant women, children under five years of age and nursing mothers. Increasing the availability of frontline health workers to deliver services, by uplifting their salaries and introducing a sanction framework was hoped to discourage the application of user fees for services to mothers and children and support the aims of the FHCI. It was estimated that over the implementation period 1.1 million pregnant women and lactating mothers, and 5 million children under the age of five could benefit, with a total of 141,000 lives saved.

DFID funding was allocated as budget support to the Government of Sierra Leone (GoSL), with disbursements released based on progress made against agreed milestones that were monitored by a joint donor Government Payroll Steering Committee (PSC). Over the lifetime of the project underperformance against some of the milestones led to 600,000 GBP of the funding not being disbursed.

The project was delivered through three outputs, aimed at increasing the uptake of health care by the most vulnerable. These included: (1) the efficient management of the payroll, (2) enhanced capacity of the Ministry of Health & Sanitation (MoHS) to manage the attendance and deployment of human resources for health (HRH), and (3) effective community oversight of the FHCI.

Overall, the project has scored an A as it has met expectations. The salary uplift has helped to attract, retain, and motivate health workers in the public health sector and to reduce absenteeism and moonlighting, despite increasingly heavy workloads as a result of the removal of user fees. The salary uplift has also attracted health workers back from the private sector.

The holding of PSC committee meetings and the frequency of monitoring visits to the districts decreased in the last year due to travel restrictions that were put in place because of the Ebola outbreak. This has meant that there is limited data to judge performance against the 2015 milestones. However key informants have reported that the support provided to salaries through this project, and the availability of motivated frontline workers contributed to the resilience of the health workforce during the Ebola outbreak and enhanced the GoSL’s response to it.

This project completion report provides details of programme performance, output scoring, and value for money and financial performance. It also provides a set of recommendations for the GoSL (particularly the MoSH) and DFID and other development partners.

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Gender Equity Analysis: A necessary prerequisite for addressing gender-related outcomes http://www.heart-resources.org/blog/gender-equity-analysis-a-necessary-prerequisite-for-addressing-gender-related-outcomes/ http://www.heart-resources.org/blog/gender-equity-analysis-a-necessary-prerequisite-for-addressing-gender-related-outcomes/#respond Thu, 23 Jul 2015 14:25:51 +0000 http://www.heart-resources.org/?post_type=blog&p=27164 Read more]]> In this blog post Ireen Namakhoma discusses the importance of gender equity analysis within health research.

In March 2015, the Global Health Action produced a special issue on Gender and Health. One of the articles which I co-authored together with colleagues from Liverpool School of Tropical Medicine, Eleanor MacPherson, Sally Theobald and Esther Richards, highlights critical issues regarding sexual and reproductive health (SRH) in East and Southern Africa. We conducted a literature review on gender and health with the aim of identifying important issues for action.

The review found gender inequalities to be common across a range of health issues relating to SRH with women being particularly disadvantaged. Gender inequality is a critical structural constraint to development and improved health outcomes. Gendered social norms undermine women’s position in society leaving women with limited access to social and economic resources and impacting negatively on women and girls’ health and well-being. The ability of women to realise their sexual and reproductive rights is vital to achieving gender equity in health as well as the empowerment of women. SRH relates to the health and well-being of people in matters related to sexual relations, pregnancy, and birth. The ability of women to realize their sexual and reproductive rights is vital to achieving gender equity in health as well as the empowerment of women.

Eastern and Southern Africa have the highest burden of infectious diseases including HIV and AIDS. The high HIV prevalence could be a significant contributor to high mortality rates within this region. This region also has high maternal mortality rates. Comparison of data from the 16 ESA region between 1980 and 2008, actually showed worsening maternal mortality rates in Bostwana, DRC, Lesotho, Mozambique, Namibia, South Africa, Swaziland, Zambia and Zimbabwe. Almost half of all maternal deaths occur during labour, delivery, or the immediate postpartum period. There is also a high unmet need of contraceptives which can lead to higher likelihood of unsafe abortions. Gender based violence is common and takes multiple forms – physical, sexual, psychological and economic. The data on gender based violence is shocking, for example in a study in South Africa, 27.6% of the men interviewed admitted to raping a woman; while estimates by the United Nation’s Children Fund reveal that 13-49% of women having been physically assorted by an intimate male partner.

Gender equity analysis is important

On Sunday March 8, we commemorated the Women’s International Day, which reinforced for me the importance of gender equity analysis. It is critical that the focus on gender analysis is not lost in health research in order to have better understanding of how gender impacts on health inequities and related health outcomes. The Research for Equity and Community Health Trust has been central to debates and research that is close to policy to put forward gender and equity perspectives. Studies have shown gender to be an important determinant in access to health services. Analysis of pathways to care seeking in Malawi shows that women take longer to report to health facilities than men. The delay period amongst TB patients showed that women took longer to be diagnosed with TB than men and had more repeated visits. An exploration of desire to give birth among people living with HIV showed that women often against their wishes, were under pressure from their partners and spouses to fulfill community expectations in having children. Access to family planning was hindered as some men perceived that the use of modern contraceptives negatively affected marital sexual relations. Gender also has impact on men living with HIV as often perceptions of masculinity affect access and retention to HIV services resulting in poor treatment outcomes.

Opportunities for advancing gender equity in health

Many researchers, like the ones in RinGs, are exploring ways to make health systems more gender-responsive and more gender-equitable. An issue that is important to me is the role of close-to-community providers, as I am the principle investigator for the REACHOUT consortium in Malawi. Effective community health worker (CHW) programmes have shown to have potential to better meet the needs of women, tend to be easily accessible, and minimize costs of care seeking. A study which investigated the impact of using CHWs to promote early diagnosis and referral for HIV, showed a 37% increase in new patients initiating antiretroviral therapy and 61% increase in uptake of HIV testing within a 12 month period. CHWs are strategically placed to understand the challenges women face in accessing care and how this relates to broader societal and infrastructural challenges including gender norms. However for CHWs to be effective, there is need for mechanisms that sufficiently support and motivate them such as a responsive referral systems, adequate training, supportive supervision, community engagement and good coordination among the different stakeholders working at community level. We hope to learn more about this as our REACHOUT work progresses.

By Ireen NamakhomaIreen Namakhoma is the Director of the Research for Equity and Community Health (REACH) Trust, Malawi.

Originally posted on RESYST on 30 March 2015.

RinGs (Research in Gender and Ethics: Building stronger health systems) is funded by DFID and brings together three health systems focused Research Programme Consortia (RPC): Future Health Systems, ReBUILD, and RESYST in a partnership to galvanise gender and ethics analysis in health systems.

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Neurodevelopmental trajectory of HIV-infected children accessing care in Kinshasa, Democratic Republic of Congo http://www.heart-resources.org/doc_lib/neurodevelopmental-trajectory-of-hiv-infected-children-accessing-care-in-kinshasa-democratic-republic-of-congo/ http://www.heart-resources.org/doc_lib/neurodevelopmental-trajectory-of-hiv-infected-children-accessing-care-in-kinshasa-democratic-republic-of-congo/#respond Wed, 03 Jun 2015 14:59:38 +0000 http://www.heart-resources.org/?post_type=doc_lib&p=26956 Read more]]>

Objective—To assess the effect of HIV care (including HAART if eligible) on neurodevelopment. Design—Prospective cohort study

Methods—Motor and mental development of 35 HIV-infected children (age 18-71 months) was assessed at entry into care, and after 6 and 12 months using age-appropriate tools. Developmental trajectory was compared to 35 HIV-uninfected, affected and 90 control children using linear mixed effects models. Effects of age (≤ or >29 months) and timing of entry into care (before or after HAART eligibility) were explored in secondary analyses.

Results—At baseline, HIV-infected children had the lowest, control children the highest, and HIV- uninfected affected children intermediate mean developmental scores. After one year of care, HIV- infected children achieved mean motor and cognitive scores that were similar to HIV uninfected, affected children although lower compared to control children. Overall, HIV-infected children experienced accelerated motor development but similar gains in cognitive development compared to control children. Exploratory analyses suggest that younger children and those presenting early may experience accelerated greater gains in development.

Conclusions—HIV-infected children accessing care experience improved motor development, and may, if care is initiated at a young age or an early stage of the disease, also experience gains in cognitive development.

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