Articles tagged as "Eliminate new HIV infections among children"

The scale up of PMTCT in China

An integrated city-driven perinatal HIV prevention program covering 1.8 
million pregnant women in Shenzhen, China, 2000 to 2010.

Song J, Feng T, Bulterys M, Zhang D, Korhonen C, Shi X, Wang X, Cheng J, Chen L, Ma H. Sex Transm Dis. 2013
Apr;40(4):329-34. doi: 10.1097/OLQ.0b013e3182805186.

Background: Despite the scale-up of prevention of mother-to-child transmission (PMTCT) programs worldwide, the translation from research studies into public health policy has been slow. This report details the experiences of a city-driven PMTCT program in China using existing health resources.

Methods: The PMTCT program was devised to hospital based and city-wide. It achieves full use of available resources: the local Centers for Disease Control and Prevention, the Infectious Disease Hospital, Maternal and Child Health Hospitals, and all qualified comprehensive hospitals.

Results: From 2000 to 2010, 1 843 122 pregnant women attended prenatal care or labor and delivery services. Overall, 97.4% received pretest HIV counseling, and 96.2% were tested for HIV. Among the 81.1% (1 495 122) of women who attended prenatal clinics, 97.2% (1 452 753) received pretest counseling and 95.7% (1 430 799) were tested for HIV. Among the 18.9% (348 000) of women with an undocumented HIV status at labor and delivery, 98.6% (343 038) received pretest counseling, and 98.1% (341 371) were tested for HIV. In total, 229 women were determined HIV positive for a prevalence of 1.3 per 10 000 pregnant women. Among the 107 HIV-infected women who carried to delivery, 87.9% received antiretroviral prophylaxis for themselves and their infants. Among the 58 women who were identified HIV positive at labor, 10.3% of mothers and 72.4% of infants received antiretroviral prophylaxis. The estimated mother-to-child transmission rate was 5.3% (95% confidence interval, 2.2%, 10.7%).

Conclusions: With appropriate integration, existing health care resources are adequate for a comprehensive city-driven PMTCT program in an area with a low HIV prevalence.

Abstract access

Editor’s notes: The elimination of new HIV infections among children is an important UNAIDS goal. There is the potential for substantial numbers of vertical infections in countries such as China, that have a relatively low population prevalence of HIV infection, but large numbers of people that could be infected with HIV. This paper describes the findings from 10 years of implementing a city driven, large scale PMTCT programme that tested almost 1.5 million women over 10 years. The HIV infection rate detected was low (1.3/10 000 pregnant women), identifying 229 pregnant women living with HIV. Interestingly, less than a half (109) continued the pregnancy to delivery, with four-fifths of these women receiving ART drugs, resulting in a mother to child HIV transmission rate of 5.3%. This scale of programming and achievements is impressive, and illustrate the potential to deliver PMTCT programmes at scale. Questions remain regarding why so many women did not continue with their pregnancy, and the cost and cost-effectiveness of such a broad approach to PMTCT, compared to the potential use of a more targeted approach to PMTCT delivery.

Asia
China
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Lifelong ART eligibility increases treatment rates for pregnant and breastfeeding women in Malawi

Impact of an innovative approach to prevent mother-to-child transmission of HIV - Malawi, July 2011 - September 2012.

Chimbwandira F, Mhango E, Makombe S, Midiani D, Mwansambo C, Njala J, et al. Centers for Disease Control and Prevention (CDC). MMWR Morb Mortal Wkly Rep. 2013 Mar 1;62(8):148-51.

Antiretroviral medications can reduce rates of mother-to-child transmission of human immunodeficiency virus (HIV) to less than 5%. However, in 2011, only 57% of HIV-infected pregnant women in low- and middle-income countries received a World Health Organization (WHO)-recommended regimen for prevention of mother-to-child transmission (PMTCT), and an estimated 300,000 infants acquired HIV infection from their mothers in sub-Saharan Africa; 15,700 (5.2%) of these infants were born in Malawi. An important barrier to PMTCT in Malawi is the limited laboratory capacity for CD4 cell count, which is recommended by WHO to determine which antiretroviral medications to start. In the third quarter of 2011, the Malawi Ministry of Health (MOH) implemented an innovative approach (called "Option B+"), in which all HIV-infected pregnant and breastfeeding women are eligible for lifelong antiretroviral therapy (ART) regardless of CD4 count. Since that time, several countries (including Rwanda, Uganda, and Haiti) have adopted the Option B+ policy, and WHO was prompted to release a technical update in April 2012 describing the advantages and challenges of this approach as well as the need to evaluate country experiences with Option B+. Using data collected through routine program supervision, this report is the first to summarize Malawi's experience implementing Option B+ under the direction of the MOH and supported by the Office of the Global AIDS Coordinator (OGAC) through the President's Emergency Plan for AIDS Relief (PEPFAR). In Malawi, the number of pregnant and breastfeeding women started on ART per quarter increased by 748%, from 1,257 in the second quarter of 2011 (before Option B+ implementation) to 10,663 in the third quarter of 2012 (1 year after implementation). Of the 2,949 women who started ART under Option B+ in the third quarter of 2011 and did not transfer care, 2,267 (77%) continue to receive ART at 12 months; this retention rate is similar to the rate for all adults in the national program. Option B+ is an important innovation that could accelerate progress in Malawi and other countries toward the goal of eliminating mother-to-child transmission of HIV worldwide.

Abstract access 

Editor’s notes: The efficacy of antiretroviral medications for the elimination of new infections among children is well demonstrated; however barriers including lack of trained personnel, lack of integrated ART and antenatal care services, and poor laboratory capacity mean that almost half of pregnant women living with HIV in low and middle income countries do not receive WHO-recommended regimens. This report from Malawi, where “option B+” was implemented, removing the need for CD4 cell count testing in HIV-infected pregnant and breastfeeding women, coupled with decentralization and integration of ART into antenatal clinics, task shifting policies, and extensive training and supervision, demonstrates that very rapid scale-ups in ART provision for the elimination of new infections among children  are possible in resource-limited settings. Encouragingly, these preliminary data suggest that retention in care at 12 months in women started on ART under “option B+” were comparable to rates in the Malawian adult ART programme (in marked contrast to data reviewed in last month’s issue from South Africa, where only 40% of women who initiated ART during pregnancy were retained in care at 6 months). Whilst longer term adherence and outcome data in the “option B+” cohort are required to ensure that lifelong ART adherence can be maintained, along with evaluation of its effectiveness in reducing vertical HIV transmission at a population level, these results provide important initial evidence for the feasibility of such an approach. Innovations such as this will be critical not just in meeting the goal of reducing new HIV infections in children by 90% by 2015, but also in serving as a model for how ART can be scaled up in other populations to prevent the ongoing high rates of mortality and onward HIV transmission seen in many African countries.

Africa
Malawi
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Community health workers can improve PMTCT and other health outcomes

Outcomes of home visits for pregnant township mothers and their infants in South Africa: a cluster randomised controlled trial.

le Roux IM, Tomlinson M, Harwood JM, O'Connor MJ, Worthman CM, Mbewu N, Stewart J, Hartley M, Swendeman D, Comulada WS, Weiss RE, Rotheram-Borus MJ. AIDS. 2013 Feb 21. [Epub ahead of print]

To evaluate the effect of home visits by Community Health Workers (CHW) on maternal and infant well-being from pregnancy through the first six months of life for women living with HIV (WLH) and all neighbourhood mothers.  In a cluster randomised controlled trial in Cape Town townships, neighbourhoods were randomised within matched pairs to either: 1) Standard Care, comprehensive healthcare at clinics (SC; n = 12 neighbourhoods; n = 169 WLH; n = 594 total mothers), or 2) Philani Intervention Program, home visits by CHW in addition to SC (PIP; n = 12 neighbourhoods; n = 185 WLH; n = 644 total mothers). Participants were assessed during pregnancy (2% refusal) and reassessed at one week (92%) and six months (88%) post-birth. We analysed PIP's effect on 28 measures of maternal and infant well-being among WLH and among all mothers using random effects regression models. For each group, PIP's overall effectiveness was evaluated using a binomial test for correlated outcomes.  Significant overall benefits were found in PIP compared to SC among WLH and among all participants. Secondarily, compared to SC, PIP WLH were more likely to complete tasks to prevent vertical transmission, use one feeding method for 6 months, avoid birth-related medical complications, and have infants with healthy height-for-age measurements. Among all mothers, compared to SC, PIP mothers were more likely to use condoms consistently, breastfeed exclusively for 6 months, and have infants with healthy height-for-age measurements. PIP is a model for countries facing significant reductions in HIV funding whose families face multiple health risks.

Abstract access 

Editor’s notes: This article highlights the additive value of community health workers (CHW) on overall health outcomes. The results are most striking for HIV related measures such as adherence to PMTCT regimens and safe feeding practices to reduce post-natal HIV transmission. There was less impact on some other components of overall family health- further understanding on how  the CHW strategy may be modified to have broader health impacts is important. Despite not all indicators being impacted, this article also highlights that CHW that are not HIV-specific cadres can have beneficial impacts on HIV related measures of improved care. In generalized epidemics with relatively high HIV prevalence, stigma and secrecy may not be quite as burdensome as it has in the past, and offers optimism that HIV care can be successfully integrated into general health services, and that community stigma and secrecy may be diminishing.

Africa
South Africa
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Provision of PMTCT prophylaxis does not necessarily successfully link HIV positive women into long term HIV care

Loss to follow-up before and after delivery among women testing HIV positive during pregnancy in Johannesburg, South Africa.

Clouse K, Pettifor A, Shearer K, Maskew M, Bassett J, Larson B, Van Rie A, Sanne I, Fox MP. Trop Med Int Health. 2013 Feb 3. doi: 10.1111/tmi.12072. [Epub ahead of print]

HIV-positive pregnant women are at heightened risk of becoming lost to follow-up (LTFU) from HIV care.  LTFU was examined before and after delivery among pregnant women newly diagnosed with HIV. This is an observational cohort study of all pregnant women ≥18 years (N = 300) testing HIV positive for the first time at their first ANC visit between January and June 2010, at a primary healthcare clinic in Johannesburg, South Africa. Women (n = 27) whose delivery date could not be determined were excluded. Median (IQR) gestation at HIV testing was 26 weeks (21-30). Ninety-eight per cent received AZT prophylaxis, usually started at the first ANC visit. Of 139 (51.3%) patients who were ART eligible, 66.9% (95% CI 58.8-74.3%) initiated ART prior to delivery; median (IQR) ART duration pre-delivery was 9.5 weeks (5.1-14.2). Among ART-eligible patients, 40.5% (32.3-49.0%) were cumulatively retained through 6 months on ART. Of those ART-ineligible patients at HIV testing, only 22.6% (95% CI 15.9-30.6%) completed CD4 staging and returned for a repeat CD4 test after delivery. LTFU (≥1 month late for last scheduled visit) before delivery was 20.5% (95% CI 16.0-25.6%) and, among those still in care, 47.9% (95% CI 41.2-54.6%) within 6 months after delivery. Overall, 57.5% (95% CI 51.6-63.3%) were lost between HIV testing and 6 months post-delivery. These findings highlight the challenge of continuity of care among HIV-positive pregnant women attending antenatal services, particularly those ineligible for ART.

Abstract access 

Editor’s notes: The reach of HIV testing of pregnant women in antenatal care through PMTCT programming has expanded dramatically. Increasingly PMTCT programmes are able to provide CD4 testing in order to identify those women who are eligible for ART as treatment for their own health, as well as for its impact on preventing HIV transmission.  ART, rather than prophylaxis, is a life-long intervention, and the challenges for maintaining adherence and retention are therefore greater. The results of this study are quite concerning – while HIV testing rates, and CD4 testing of the women who were identified as HIV-positive were quite high, the retention of women placed onto ART was low. The retention in ‘pre-ART’ care was even lower. A deeper understanding of these issues is essential as Option B+ - initiation of ART for all pregnant women living with HIV – increasingly is adopted as standard of care. It is likely that there are programmatic and structural interventions that will increase retention in care, but understanding the attitudes, motivations and interests of the women living with HIV towards treatment will be essential.

Africa
South Africa
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Inclusion of fathers in PMTCT remains a challenge

Barriers to Male-Partner Participation in Programs to Prevent Mother-to-Child HIV Transmission in South Africa.

Koo K, Makin JD, Forsyth BW. AIDS Educ Prev. 2013 Feb;25(1):14-24. doi: 10.1521/aeap.2013.25.1.14.

Efforts to prevent mother-to-child HIV transmission (PMTCT) in sub-Saharan Africa have focused overwhelmingly on women, to the unintended exclusion of their male partners. A cross-sectional study was conducted in Tshwane, South Africa, to determine barriers to male-partner participation during PMTCT. In-depth interviews were conducted with 124 men whose partners had recently been pregnant, and five focus group discussions were held with physicians, nurses, HIV counselors, and community representatives. Qualitative analysis revealed that while most fathers believed that HIV testing is an important part of preparing for fatherhood, there are formidable structural and psychosocial barriers: the perception of clinics as not "male-friendly," a narrow focus on HIV testing instead of general wellness, and a lack of expectations and opportunities for fathers to participate in health care. Coupled with more family-oriented approaches to PMTCT, measurable improvements in the way that male partners are invited to and engaged in HIV prevention during pregnancy can help PMTCT programs to achieve their full potential.

Abstract access 

Editor’s notes: PMTCT programming is located within antenatal care settings in health centers, and PMTCT programmes have struggled to increase HIV testing among men along with their pregnant partners. Pilot programs have implemented innovations to increase male involvement, but the opinions and voices of men have not often been directly solicited to further understand how to overcome what men perceive as barriers to their inclusion. This qualitative study identified among men a relatively high value placed on testing in general, and couples-based testing in particular, and indicates a greater willingness to be engaged during their partner’s ANC services, if care delivery could be modified. A re-orientation of health services towards a ‘wellness’ framework, based upon men’s suggestions, may well be a useful technique to implement and evaluate.

Africa
South Africa
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Adverse events associated with nevirapine use in pregnancy

Adverse events associated with nevirapine use in pregnancy: a systematic review and meta-analysis.

Ford N, Calmy A, Andrieux-Meyer I, Hargreaves S, Mills EJ, Shubber Z. AIDS. 2013 Jan 5. [Epub ahead of print]

The risk of adverse drug events associated with nevirapine is suggested to be greater in pregnant women. The authors conducted a systematic review and meta-analysis of severe adverse events in HIV-positive women who initiated NVP while pregnant. Six databases were searched for studies reporting adverse events among HIV-positive pregnant women who had received nevirapine-based antiretroviral therapy for at least seven days. Data were pooled by the fixed-effects method. Twenty studies (3582 pregnant women) from 14 countries were included in the final review. The pooled proportion of patients experiencing a severe hepatotoxic event was 3.6% (95%CI 2.4-4.8%), severe rash was experienced by 3.3% of patients (95%CI 2.1-4.5%), and 6.2% (95%CI 4.0-8.4%) of patients discontinued nevirapine due to an adverse event. These results were comparable to frequencies observed in the general adult patient population, and to frequencies reported in non-pregnant women within the same cohort. For pregnant women with a CD4 cell count >250 cells/mm there was a non-significant tendency towards an increased likelihood of cutaneous events overall (OR 1.1, 95%CI 0.8-1.6) and severe cutaneous adverse events (OR 1.4, 95%CI 0.8-2.4) and consequently an increased risk of toxicity-driven regimen substitution (OR 1.7, 95%CI 1.1-2.6). These results suggest that the frequency of adverse events associated with nevirapine use in pregnant women, while high, is no higher than reported for nevirapine in the general adult population. Pregnant women with a high CD4 count may be at increased risk of adverse events, but evidence supporting this association is weak.

Abstract access 

Editor’s notes: The selection of antiretroviral drug regimens has been particularly challenging for HIV-positive pregnant women. Adverse events are less frequent for men and women with efavirenz use compared to nevirapine, and increasingly efavirenz is a preferred choice. However, due to concerns about the safety of efavirenz in pregnancy, nevirapine continues to be widely used as a component of antiretroviral treatment for pregnant women. However, there have been suggestions that HIV-positive pregnant women have higher rates of nevirapine-associated adverse events, especially for those women with high CD4, compared to non-pregnant women on nevirapine. This meta-analysis of 20 studies did demonstrate a relatively high frequency of adverse events in women who use nevirapine, but not at rates higher than among non-pregnant women on HIV treatment with nevirapine. The data about efavirenz safety for the fetus is being carefully reviewed to elucidate if widespread use of efavirenz is preferable to nevirapine during pregnancy.

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Increasing HIV testing among male partners in PMTCT settings

Increasing HIV testing among male partners. The Prenahtest ANRS 12127 multi-country randomised trial.

Orne-Gliemann J, Balestre E, Tchendjou P, Miric M, Darak S, Butsashvili M, Perez-Then E, Eboko F, Plazy M, Kulkarni S, Loû AD, Dabis F; for the Prenahtest ANRS 12127 Study Group. AIDS. 2013 Jan 22. [Epub ahead of print]

Couple-oriented post-test HIV counselling (COC) provides pregnant women with tools and strategies to invite her partner to HIV counselling and testing. A randomised trial of the efficacy of COC on partner HIV testing in low/medium HIV prevalence settings (Cameroon, Dominican Republic, Georgia, India) was conducted. Pregnant women were randomised to receive standard post-test HIV counselling (SC) or COC and followed until six months postpartum. Partner HIV testing events were notified by site laboratories, self-reported by women or both combined. Impact of COC on partner HIV testing was measured in intention-to-treat analysis. Socio-behavioural factors associated with partner HIV testing were evaluated using multivariable logistic regression. Among 1943 pregnant women enrolled, partner HIV testing rates (combined indicator) were 24.7% among women from COC group vs 14.3% in SC group in Cameroon (Odds Ratio [OR] = 2.0 95%CI [1.2-3.1]), 23.1% vs 20.3% in Dominican Republic (OR = 1.2 [0.8-1.8]), 26.8% vs 1.2% in Georgia (OR = 29.6 [9.1-95.6]) and 35.4% vs 26.6% in India (OR = 1.5 [1.0-2.2]). Women having received COC did not report more conjugal violence or union break-ups than in the SC group. The main factors associated with partner HIV testing were a history of HIV testing among men in Cameroon, Dominican Republic and Georgia and the existence of couple communication around HIV testing in Georgia and India. A simple prenatal intervention taking into account the couple relationship increases the uptake of HIV testing among men in different socio-cultural settings. COC could contribute to the efforts towards eliminating mother-to-child transmission of HIV.

Abstract access 

Editor’s notes: Programmes geared towards the elimination of new HIV infections in children and keeping their mothers alive worldwide have grappled with the challenge to increase partner testing. Partner HIV discordancy is common, and interventions can be tailored to the couple status categories. Antenatal care settings have not necessarily oriented their programming to be male-friendly. It is notable that generally couples-oriented counseling and testing (COC) did increase uptake of HIV testing by male partners, though there was wide variation between countries. In addition, male testing rates remained relatively low in the intervention couples.   It is clear that additional strategies to augment partner testing will need to be implemented and evaluated. This study did provide some reassuring information that conjugal violence and union break-ups were not more common in the COC group. The study sites were in low and medium HIV prevalence settings and these results need to be compared to similar interventions in high prevalence settings.

Africa, Asia, Latin America
Cameroon, Dominican Republic, Georgia, India
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Getting to zero: from option B to option B+

Cost-effectiveness of World Health Organization 2010 Guidelines for Prevention of Mother-to-Child HIV Transmission in Zimbabwe.

Ciaranello AL, Perez F, Engelsmann B, Walensky RP, Mushavi A, Rusibamayila A, Keatinge J, Park JE, Maruva M, Cerda R, Wood R, Dabis F, Freedberg KA. Clin Infect Dis. 2012 Nov 30. [Epub ahead of print]

Background. In 2010, the World Health Organization (WHO) released revised guidelines for prevention of mother-to-child human immunodeficiency virus (HIV) transmission (PMTCT). We projected clinical impacts, costs, and cost-effectiveness of WHO-recommended PMTCT strategies in Zimbabwe.

Methods. We used Zimbabwean data in a validated computer model to simulate a cohort of pregnant, HIV-infected women (mean age, 24 years; mean CD4 count, 451 cells/µL; subsequent 18 months of breastfeeding). We simulated guideline-concordant care for 4 PMTCT regimens: single-dose nevirapine (sdNVP); WHO-recommended Option A, WHO-recommended Option B, and Option B+ (lifelong maternal 3-drug antiretroviral therapy regardless of CD4).

Outcomes included maternal and infant life expectancy (LE) and lifetime healthcare costs (2008 US dollars [USD]). Incremental cost-effectiveness ratios (ICERs, in USD per year of life saved [YLS]) were calculated from combined (maternal + infant) discounted costs and LE.

Results. Replacing sdNVP with Option A increased combined maternal and infant LE from 36.97 to 37.89 years and would reduce lifetime costs from $5760 to $5710 per mother-infant pair. Compared with Option A, Option B further improved LE (38.32 years), and saved money within 4 years after delivery ($5630 per mother-infant pair). Option B+ (LE, 39.04 years; lifetime cost, $6620 per mother-infant pair) improved maternal and infant health, with an ICER of $1370 per YLS compared with Option B.

Conclusions. Replacing sdNVP with Option A or Option B will improve maternal and infant outcomes and save money; Option B increases health benefits and decreases costs compared with Option A. Option B+ further improves maternal outcomes, with an ICER (compared with Option B) similar to many current HIV-related healthcare interventions.

Abstract access

Editor's notes: This very important paper tackles one of the aspects (the differential cost-effectiveness of different interventions) of the current debate around prevention of mother to child transmission. Particularly for women with CD4 cells higher than 350 (below this level, triple therapy is already the rule) progressively switching from option A (AZT/3TC plus single dose nevirapine) to option B or B+ (starting triple therapy as soon as diagnosed and continue it for life) is considered by many countries the way forward, and may soon be translated in the new WHO guidelines. Advantages of option B+ may include: a) the simplification of regimen and service delivery; b) the harmonization with ART programmes; c) the potential use of once daily, single-pill, fixed dose combinations; and d) the independence from CD4 testing for initial decision. In addition, option B+ can assure protection against MTCT in future pregnancies and may prevent sexual transmission to serodiscordant partners. Finally, it avoids the danger of stopping and starting ARV drugs and there is probably a benefit to the mother's health (because of early ART). When comparing the cost-effectiveness of the different options and looking at them in a clinical perspective, the paper suggests that the health benefit of option B+ clearly outweigh the marginal augmentation of its cost as compared with option B.

Africa
Zimbabwe
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Preventing new paediatric infections

Health facility characteristics and their relationship to coverage of PMTCT of HIV services across four African countries: The PEARL Study

Ekouevi DK, Stringer E, Coetzee D, Tih P, Creek T, Stinson K, Westfall AO, Welty T, Chintu N, Chi BH, Wilfert C, Shaffer N, Stringer J, Dabis F. PLoS One. 2012;7(1):e29823. Epub 2012 Jan 20

Health facility characteristics associated with effective prevention of mother-to-child transmission of HIV (PMTCT) coverage in sub-Saharan are poorly understood. Ekouevi and colleagues conducted surveys in health facilities with active PMTCT services in Cameroon, Cote d'Ivoire, South Africa, and Zambia. Data was compiled via direct observation and exit interviews. The authors constructed composite scores to describe provision of PMTCT services across seven topical areas: antenatal quality, PMTCT quality, supplies available, patient satisfaction, patient understanding of medication, and infrastructure quality. Pearson correlations and Generalized Estimating Equations (GEE) to account for clustering of facilities within countries were used to evaluate the relationship between the composite scores, total time of visit and select individual variables with PMTCT coverage among women delivering. Between July 2008 and May 2009, they collected data from 32 facilities; 78% were managed by the government health system. An opt-out approach for HIV testing was used in 100% of facilities in Zambia, 63% in Cameroon, and none in Côte d'Ivoire or South Africa. Using Pearson correlations, PMTCT coverage (median of 55%, (IQR: 33-68) was correlated with PMTCT quality score (rho = 0.51; p = 0.003); infrastructure quality score (rho = 0.43; p = 0.017); time spent at clinic (rho = 0.47; p = 0.013); patient understanding of medications score (rho = 0.51; p = 0.006); and patient satisfaction quality score (rho = 0.38; p = 0.031). PMTCT coverage was marginally correlated with the antenatal quality score (rho = 0.304; p = 0.091). Using GEE adjustment for clustering, the, antenatal quality score became more strongly associated with PMTCT coverage (p<0.001) and the PMTCT quality score and patient understanding of medications remained marginally significant. The authors observed a positive relationship between an antenatal quality score and PMTCT coverage but did not identify a consistent set of variables that predicted PMTCT coverage.

For abstract access click here. 

Editor’s note: The PEARL Study (PMTCT Effectiveness in Africa: Research and Linkages to Care) was conducted from 2007-2009 in 32 health facilities with PMTCT services in four countries: Cameroon (8), Cote d’Ivoire (9), South Africa (6), and Zambia (9). It found that coverage of single-dose nevirapine of both mother and baby was variable and reached only 55% overall. In this first study to do so systematically, the researchers assessed antenatal clinic and service characteristics to see if they would predict coverage. One factor stood out as distinguishing the worst-performing sites from the others and that was the lack of registers with PMTCT information. Although some other obvious variables were associated with coverage, variables related to general antenatal care were more predictive of PMTCT coverage. This supports the importance of strengthening health care in general in order to improve PMCTC coverage. But it does not in anyway decrease the need for quality assessments and creative improvements in PMTCT programmes themselves.

Africa
Cameroon, Côte d'Ivoire, South Africa, Zambia
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Preventing new paediatric infections

The contribution of maternal HIV seroconversion during late pregnancy and breastfeeding to mother-to-child transmission of HIV

Johnson LF, Stinson K, Newell ML, Bland RM, Moultrie H, Davies MA, Rehle TM, Dorrington RE, Sherman GG. J Acquir Immune Defic Syndr. 2011 Dec 21. [Epub ahead of print]

The prevention of mother-to-child transmission (PMTCT) of HIV has been focused mainly on women who are HIV-positive at their first antenatal visit, but there is uncertainty regarding the contribution to overall transmission from mothers who seroconvert after their first antenatal visit and before weaning. A mathematical model was developed to simulate changes in mother-to-child transmission of HIV over time, in South Africa. The model allows for changes in infant feeding practices as infants age, temporal changes in the provision of antiretroviral prophylaxis and counselling on infant feeding, as well as temporal changes in maternal HIV prevalence and incidence. The proportion of MTCT from mothers who seroconverted after their first antenatal visit was 26% (95% CI: 22-30%) in 2008, or 15 000 out of 57 000 infections. It is estimated that by 2014, total MTCT will reduce to 39 000 per annum, and transmission from mothers seroconverting after their first antenatal visit will reduce to 13 000 per annum, accounting for 34% (95% CI: 29-39%) of MTCT. If maternal HIV incidence during late pregnancy and breastfeeding were reduced by 50% after 2010, and HIV screening were repeated in late pregnancy and at 6-week immunization visits after 2010, the average annual number of MTCT cases over the 2010-15 period would reduce by 28% (95% CI: 25-31%), from 39 000 to 28 000 per annum. Maternal seroconversion during late pregnancy and breastfeeding contributes significantly to the paediatric HIV burden, and needs greater attention in the planning of PMTCT programmes.

For abstract access click here. 

Editor’s note: The Global Plan Towards the Elimination of New HIV Infections Among Children by 2015 and Keeping their Mothers Alive covers all low- and middle-income countries, but focuses on the 22 countries with the highest estimated numbers of pregnant women living with HIV, accounting for nearly 90% of pregnant women living with HIV in need of services, including South Africa. [http://www.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2011/20110609_JC2137_Global-Plan-Elimination-HIV-Children_en.pdf]. The results of this modelling study suggest that mothers who seroconvert in pregnancy or during breastfeeding may contribute substantially to vertical HIV transmission. The model estimates for South Africa that number of infections averted when HIV infection is detected at the first antenatal visit and antiretroviral prophylaxis/treatment is offered is substantially higher (62% reduction) than would be prevented with an additional (or first) HIV test in late pregnancy (11% reduction), an HIV test offered at the 6-week immunization visit (3.5% reduction) or by reducing new infections in pregnant women by 50% (16% reduction). The latter would require intensified condom promotion, partner outreach, and effective topical (microbicides) or oral pre-exposure prophylaxis. However, the proportion of vertical transmission from recently infected mothers is increasing as PMTCT programmes based on a positive first antenatal visit screening visit scale up to full coverage. Attention should turn to keeping pregnant and breastfeeding mothers HIV-free if the Global Plan goals are to be fully reached.

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