Abstract
BackgroundMother-to-child transmission (MTCT) of HIV has been eliminated from the developed world with the introduction of multi-drug antiretroviral (md-ARV) regimens for the prevention of MTCT (PMTCT); but remains the major cause of HIV infection among sub-Saharan African children. This study compares two service delivery models of PMTCT interventions and documents the lessons learned and the challenges encountered during the transition from single-dose nevirapine (sd-nvp) to md-ARV regimens in a resource-limited setting.MethodsProgram data collected from 32 clinical sites was used to describe trends and compare the performance (uptake of HIV testing, CD4 screening and ARV regimens initiated during pregnancy) of sites providing PMTCT as a stand-alone service (stand-alone site) versus sites providing PMTCT as well as antiretroviral therapy (ART) (full package site). CD4 cell count screening, enrolment into ART services and the initiation of md-ARV regimens during pregnancy, including dual (zidovudine [AZT] +sd-nvp) prophylaxis and highly active antiretroviral therapy (HAART) were analysed.ResultsFrom July 2006 to December 2008, 1,622 pregnant women tested HIV positive (HIV+) during antenatal care (ANC). CD4 cell count screening during pregnancy increased from 60% to 70%, and the initiation of md-ARV regimens increased from 35.5% to 97% during this period. In 2008, women attending ANC at full package sites were 30% more likely to undergo CD4 cell count assessment during pregnancy than women attending stand-alone sites (relative risk (RR) = 1.3; 95% confidence interval (CI): 1.1-1.4). Enrolment of HIV+ pregnant women in ART services was almost twice as likely at full package sites than at stand-alone sites (RR = 1.9; 95% CI: 1.5-2.3). However, no significant differences were detected between the two models of care in providing md-ARV (RR = 0.9; 95% CI: 0.9-1.0).ConclusionsAll sites successfully transitioned from sd-nvp to md-ARV regimens for PMTCT. Full package sites offer the most efficient model for providing immunological assessment and enrolment into care and treatment of HIV+ pregnant women. Strengthening the capacity of stand-alone PMTCT sites to achieve the same objectives is paramount.
Highlights
Mother-to-child transmission (MTCT) of HIV has been eliminated from the developed world with the introduction of multi-drug antiretroviral regimens for the prevention of MTCT (PMTCT); but remains the major cause of HIV infection among sub-Saharan African children
At the time of writing this report, the prescription of highly active antiretroviral therapy (HAART) for eligible patients was still limited to trained physicians, mostly working in antiretroviral therapy (ART) clinics at district or referral hospitals, and could not be initiated by nurses working in PMTCT programs, predominantly at the health center (HC) level
Immunologic assessment and enrolment in ART services during pregnancy Overall, 69% of 2,048 HIV+ pregnant women were screened for their CD4 cell count during pregnancy, with the proportion increasing from 60% in 2006 to 70% in 2007 and 2008
Summary
Mother-to-child transmission (MTCT) of HIV has been eliminated from the developed world with the introduction of multi-drug antiretroviral (md-ARV) regimens for the prevention of MTCT (PMTCT); but remains the major cause of HIV infection among sub-Saharan African children. In November 2009, the WHO issued revised guidelines emphasizing the use of md-ARV for PMTCT as well as the critical need for measuring antenatal CD4 cell counts to determine HAART eligibility [6]. The provision of HAART in antenatal care (ANC) is a challenge due to maternal and child health (MCH) staff shortages, the reliance on medical doctors for HAART initiation and the weak linkages between PMTCT and antiretroviral therapy (ART) services, which often preclude women from being fast-tracked into HIV care and treatment programs [8,9,10,11]. Many sub-Saharan African countries have introduced md-ARV for PMTCT, little has been documented about these experiences [10,11,12,13]
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