Elimination of mother-to-child HIV transmission: still a pipe dream?

HIV testing among pregnant women who attend antenatal care in Malawi.

Tenthani L, Haas AD, Egger M, van Oosterhout JJ, Jahn A, Chimbwandira F, Tal K, Myer L, Estill J, Keiser O. J Acquir Immune Defic Syndr. 2015 May 6. [Epub ahead of print] 

Malawi adopted the Option B+ strategy in 2011. Its success in reducing MTCT depends on coverage and timing of HIV testing. We assessed HIV status ascertainment and its predictors during pregnancy. HIV status ascertainment was 82.3% (95%-CI 80.2-85.9) in the pre-Option B+ period and 85.7% (95%-CI 83.4-88.0) in the Option B+ period. Higher HIV ascertainment was independently associated with higher age, attending ANC more than once, and registration in 2010. The observed high variability of HIV ascertainment between sites (50.6%-97.7%) and over time suggests that HIV test kits shortages and insufficient numbers of staff posed major barriers to reducing MTCT.

Abstract access  [1]

Editor’s notes: UNAIDS has called for an end to mother-to-child HIV transmission through the Global Plan towards the elimination of new infections among children and keeping their mothers alive. WHO guidelines on the use of antiretroviral medicines for treating and preventing HIV infection in 2013 recommends two options for pregnant and breastfeeding women. One of which is lifelong antiretroviral therapy (ART) for all pregnant women living with HIV regardless of CD4 count or disease stage, commonly referred to as Option B+. The Global Plan requires that 90% of all women living with HIV have access to ART. The success of the Global Plan will depend on sufficient numbers of women being tested for HIV.

This study includes data from 19 secondary and primary health facilities offering antenatal care in Malawi, the first country to introduce the Option B+ strategy in 2011. Introduction of the Option B+ strategy did not result in a significant change in the proportion of women who underwent HIV testing.  HIV ascertainment varied widely across facilities from 50% to 98%, and fluctuated greatly within sites over short time periods. The observed sudden decreases in numbers of women who received an HIV test suggest that important barriers to HIV testing exist at facility level. Previous studies have illustrated that temporary shortages of HIV testing kits and staff interrupt regular antenatal (ANC) HIV testing in health facilities. Women who had had multiple ANC visits were more likely to have had their HIV status ascertained, likely because multiple visits increased their chance to attend when staff and kits were available. Unfortunately, this study was unable to determine individual-level factors associated with HIV testing not having occurred.

We now have highly effective programmes that can virtually eliminate new HIV infections  among children globally. To attain this goal, urgent attention must be paid to strengthening health systems. Elimination of new infections among children will require attention to the whole cascade of care from diagnosis of HIV, through to provision of results and treatment and supporting women to take ART consistently.   

Africa [8]
Malawi [9]
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