One in 10 mothers living with HIV are unaware of their status

Missed opportunities along the prevention of mother-to-child transmission services cascade in South Africa: uptake, determinants, and attributable risk (the SAPMTCTE).

Woldesenbet S, Jackson D, Lombard C, Dinh TH, Puren A, Sherman G, Ramokolo V, Doherty T, Mogashoa M, Bhardwaj S, Chopra M, Shaffer N, Pillay Y, Goga A, South African PET. PLoS One. 2015 Jul 6;10(7):e0132425. doi: 10.1371/journal.pone.0132425. eCollection 2015.

Objectives: We examined uptake of prevention of mother-to-child HIV transmission (PMTCT) services, predictors of missed opportunities, and infant HIV transmission attributable to missed opportunities along the PMTCT cascade across South Africa.

Methods: A cross-sectional survey was conducted among 4-8 week old infants receiving first immunisations in 580 nationally representative public health facilities in 2010. This included maternal interviews and testing infants' dried blood spots for HIV. A weighted analysis was performed to assess uptake of antenatal and perinatal PMTCT services along the PMTCT cascade (namely: maternal HIV testing, CD4 count test/result, and receiving maternal and infant antiretroviral treatment) and predictors of dropout. The population attributable fraction associated with dropouts at each service point are estimated.

Results: Of 9803 mothers included, 31.7% were HIV-positive as identified by reactive infant antibody tests. Of these 80.4% received some form of maternal and infant antiretroviral treatment. More than a third (34.9%) of mothers dropped out from one or more steps in the PMTCT service cascade. In a multivariable analysis, the following characteristics were associated with increased dropout from the PMTCT cascade: adolescent (<20 years) mothers, low socioeconomic score, low education level, primiparous mothers, delayed first antenatal visit, homebirth, and non-disclosure of HIV status. Adolescent mothers were twice (adjusted odds ratio: 2.2, 95% confidence interval: 1.5-3.3) as likely to be unaware of their HIV-positive status and had a significantly higher rate (85.2%) of unplanned pregnancies compared to adults aged ≥20 years (55.5%, p = 0.0001). A third (33.8%) of infant HIV infections were attributable to dropout in one or more steps in the cascade.

Conclusion: A third of transmissions attributable to missed opportunities of PMTCT services can be prevented by optimizing the uptake of PMTCT services. Identified risk factors for low PMTCT service uptake should be addressed through health facility and community-level interventions, including raising awareness, promoting women education, adolescent focused interventions, and strengthening linkages/referral-system between communities and health facilities.

Abstract [1]  Full-text [free] access [2]

Editor’s notes: WHO recommends a comprehensive approach to prevention of mother-to-child transmission. This includes primary prevention of HIV among women of childbearing age, prevention of unintended pregnancies among women living with HIV, prevention of HIV transmission from a woman living with HIV to her infant and the provision of appropriate treatment, care and support to mothers living with HIV, their children and families.

This study assessed the uptake of antenatal and perinatal prevention of mother-to-child transmission services at four key stages along the prevention of mother-to-child transmission cascade (maternal HIV testing, CD4 count test/result, receiving maternal antiretroviral treatment and infant antiretroviral treatment).

Of all mothers included in the study, 31.7% were HIV-positive as identified by reactive infant antibody tests. Some 11% of HIV-positive mothers were reportedly unaware of their HIV-positive status. Being an adolescent was the strongest predictor of unawareness of HIV-positive status.

Overall 35% of mothers missed at least one step in the cascade. Dropout from the cascade, for all stages combined, accounted for 33.8% of HIV infections among infants, and maternal HIV status knowledge contributed to nearly half of this total.

The authors suggest that reported unawareness of being HIV-positive could be due to recent maternal infection or seroconversion during pregnancy. They call for improved repeat HIV testing during antenatal care and at delivery to identify new infections, and increased coverage of testing and counselling on safe sex for couples.

Interestingly the authors found that most pregnancies were unplanned (60%), demonstrating an important gap in the WHO prevention of mother-to-child transmission comprehensive strategy. Adolescent mothers (< 20 years) had a significantly higher rate of unplanned pregnancies compared to adult mothers. The authors suggest that programmes are necessary for sexually active adolescent girls to reduce both unplanned pregnancies and the risk of contracting HIV during conception or thereafter. 

Africa [7]
South Africa [8]
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