Adolescents and PMTCT services: where are the gaps?

PMTCT service uptake among adolescents and adult women attending antenatal care in selected health facilities in Zimbabwe.

Musarandega R, Machekano R, Chideme M, Muchuchuti C, Mushavi A, Mahomva A, Guay L. J Acquir Immune Defic Syndr. 2017 Feb 20. doi: 10.1097/QAI.0000000000001327. [Epub ahead of print]

Background: Age-disaggregated analyses of prevention of mother-to-child transmission (PMTCT) program data to assess the uptake of HIV services by pregnant adolescent women are limited but are critical to understanding the unique needs of this vulnerable, high risk population.

Methods: We conducted a retrospective analysis of patient-level PMTCT data collected from 2011 to 2013 in 36 health facilities in 5 districts of Zimbabwe using an electronic database. We compared uptake proportions for PMTCT services between adolescent (< 19 years) and adult (> 19 years) women. Multivariable binomial regression analysis was used to estimate the association of the women's age group with each PMTCT service indicator.

Results: The study analysed data from 22 215 women aged 12 to 50 years (22.5% adolescents). Adolescents were more likely to present to ANC before 14 weeks gestational age compared to older women (adjusted relative risk (aRR)=1.34; 95% confidence interval (CI): 1.22-1.47) with equally low rates of completion of four ANC visits. Adolescents were less likely to present with known HIV status (aRR=0.34; 95% CI: 0.29-0.41) but equally likely to be HIV tested in ANC. HIV prevalence was 5.5% in adolescents versus 20.1% in adults. While > 84% of both HIV-positive groups received ARVs for PMTCT, 44% of eligible adolescents were initiated on ART versus 51.3% of eligible adults, though not statistically significant.

Conclusions: Pregnant adolescents must be a priority for primary HIV prevention services and expanded HIV treatment services among pregnant women to achieve an AIDS-free generation in Zimbabwe and similar high HIV burden countries.

Abstract access   [1]

Editor’s notes: Young women continue to be a key population at risk of acquiring HIV, and contribute approximately one-third of all new infections in sub-Saharan Africa. Young women face multiple legal, economic and social vulnerabilities that place them not only at higher risk of acquiring HIV but may also have an impact on their ability to access antenatal care (ANC) services and programmes to prevent mother-to-child HIV transmission (PMTCT) if they get pregnant. This in turn has implications for the goal of eliminating paediatric HIV infection.

This retrospective study compared the uptake of PMTCT services between adolescents (people aged 19 years and below) and older women accessing ANC in 36 public sector services across Zimbabwe. The study was conducted between 2011 and 2013, when PMTCT guidelines recommended Option A. Option A called for life-long antiretroviral therapy (ART) for women who were ART-eligible based on immunological or clinical criteria; or, for people ineligible, zidovudine monotherapy through pregnancy followed by single dose nevirapine at the onset of labour. It is no longer formally recommended by World Health Organization (WHO), although it is still used in some countries.      

Nearly a quarter of all women were adolescents and over 80% were on their first pregnancy or primigravid. Adolescent women were 34% more likely to attend their first ANC visit by 14 weeks of gestational age compared to adult women. But among both groups, only about 10% attended their first ANC visit in the first trimester and less than 40% attended the four antenatal visits recommended by WHO. Notably, knowledge of HIV status prior to the first ANC attendance was 66% lower in adolescent women, even after adjusting for parity and facility type, with only 3.1% aware of their HIV status. In addition, the proportion of women who were known HIV-positive and taking ART was also lower, although this may be due partly to fewer adolescents being eligible for ART. The uptake of HIV testing (over 95%) and uptake of zidovudine prophylaxis was high among all women. However, there was a suggestion that adolescents were less likely than older women to start ART if they were eligible, although this was not statistically significant. Indeed, several studies in the region have demonstrated lower levels of ART initiation among pregnant adolescents compared to older women.  

Older women would have been more likely to have undergone HIV testing in previous pregnancies. However, even after adjusting for parity, this study demonstrates that adolescents are less likely to have previously accessed HIV testing. Common barriers to testing highlighted by other studies include lack of information, unavailability of HIV testing services, unfriendly HIV testing environments in health facilities and the need for parental consent. Lack of knowledge of HIV status prior to pregnancy is also a missed opportunity for family planning, and initiation of ART prior to pregnancy. The substantial difference in HIV prevalence among adolescents compared to older women highlights the critical need for implementing prevention programmes such as pre-exposure prophylaxis among young women in high HIV prevalence settings. While adolescents are less likely to be tested for HIV in the general population than adults, this study illustrates that when HIV testing is offered in appropriate, supportive environments, uptake is high.

Overall, the uptake of HIV testing and of prophylaxis were high, demonstrating the potential for eliminating infections in children. A major limitation is that this analysis was limited to women who had sought antenatal care. Promoting early ANC attendance is important to allow early ART initiation, to reduce the risk of intrauterine HIV transmission. Following a positive HIV test result, particular attention is necessary to ensure linkage to care and support for sustained adherence to ART.

Africa [7]
Zimbabwe [8]
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