Feasibility of antenatal and late HIV testing in pregnant women in Phnom Penh Cambodia: the PERIKAM/ANRS1205 study.

Abstract

In Cambodia, the prevalence of HIV among pregnant women was 2.6% in 1999 [1]. The PERIKAM/ANRS1205 study was implemented in Calmette Hospital, Phnom Penh, to assess the acceptability of a strategy to prevent mother-to-child transmission of HIV in the Cambodian context, where attendance at antenatal services is low, HIV testing is not systematically proposed, and antiretroviral treatment is not available in the public sector. The strategy combines: counselling and HIV testing for women in the antenatal clinic (started on 1 July 2000); late counselling and HIV testing in the maternity unit (started on 1 September 2000) for women in labour presenting for the first time (early stages of labour or before the onset of labour); a single 200 mg oral dose of nevirapine prophylactic treatment to HIV-infected women during labour and to their newborns (6 mg oral dose) at 72 h [2]; and counselling on infant feeding options. HIV testing was performed with a rapid test (Abbott Determine HIV-1/2; Abbott Laboratories Inc., Vietnam) and all rapid tests (positive and negative) were laboratory confirmed at the Pasteur Institute of Cambodia using an algorithm based on at least two different enzyme-linked immunosorbent assay tests (Genscreen HIV 1–2 version 2, Biorad and Axsym HIV1/2 gO; Abbott). A visit at 3 months is planned to assess the impact of the intervention on the life conditions of the mother, on care received by both the mother and her infant, and on the HIV status of the infant, as determined by a DNA polymerase chain reaction test. Several seminars were held involving the maternity and antenatal clinic staff before and during the study, to identify and discuss issues such as counselling, the delivery of HIV-positive mothers, confidentiality, interaction with family members, and care of HIV-positive individual. Every woman included in the study gave her informed and signed consent. The study protocol was approved by the ANRS, the appropriate Cambodian authorities and by a French ethical review committee. We present the preliminary results at 12 months. Between 1 July 2000 and 30 June 2001, of the 2079 women attending the antenatal clinic, 82% accepted the proposed HIV testing and 86% returned for the test result; 61 women (3.6%) were found to be HIV positive (Fig. 1).Fig. 1.: HIV counselling and testing at Calmette Hospital between 1 July 2000 and 30 June 2001.Late testing was proposed to 878 women presenting for delivery, among 1648 women (53%) not previously tested for HIV (Fig. 1). The main reasons for not proposing a late test to women in the maternity unit were an advanced stage of labour and the lack of availability of the midwife in charge. A total of 84% of women accepted the proposed HIV testing and 20 (2.7%) were found to be HIV positive. In two cases (tested at the antenatal clinic) out of a total of 81 confirmed HIV-positive cases, including 20 tests at the maternity unit, the confirmatory laboratory test was positive although the rapid test was found to be negative (sensitivity 79/81, 97.5%). Between 1 July and 30 June 2001, a total of 61 detected HIV-positive women delivered; 46 women and 55 babies received nevirapine (one twin delivery). The acceptance rate of HIV testing and the proportion of women coming back for their results at the antenatal clinic were higher than initially expected, and are in concordance with preliminary results from a public health programme in Ivory Coast [3], where antenatal testing was proposed to a population with a higher HIV prevalence (13.5%). In that study, the acceptance rate was 70% (77.6% women returned for the result); however, a small proportion of women (22.6%) could benefit from a short course of zidovudine for the prevention of HIV transmission, which takes more time to implement than a nevirapine single dose regimen. Two studies in Brazil [4,5] proposed late HIV testing during labour or shortly after delivery in populations with a comparable HIV prevalence rate (1.6 and 1.7%). The acceptance rate in such studies was high (95 and 97.8%), contrasting with the small proportion of women receiving a prophylactic treatment with zidovudine [4] (25%) as a result of the late knowledge of the HIV test result. Our study shows promising results, with a high proportion of detected HIV-positive women benefitting from prophylactic treatment. The PERIKAM preliminary results seem to indicate that antenatal counselling and testing, late testing with rapid tests in women presenting for the first time in labour, nevirapine single-dose prophylactic treatment in mothers and their newborns seem to be an acceptable strategy to prevent mother-to-child transmission of HIV in Phnom Penh. Manil Samana Leang Sim Kruyb Philippe Glazioua Claire Rekacewiczc Chanthy Lenga Duong Chan Mina Jean-François Delfraissyd