Reasons for failure of prevention of mother-to-child HIV transmission in a rural South African district hospital.

Clifford Kendall,Kelly Gate,Gloria Mfeka,Lore Claessens,Jienchi Dorward

doi:10.4102/sajhivmed.v16i1.365

Abstract

Further reduction of mother-to-child transmission (MTCT) of HIV requires improved understanding of the reasons for MTCT. We reviewed maternal and infant case notes for HIV-positive infants diagnosed by polymerase chain reaction at Bethesda Hospital. Nineteen cases were analysed. Median gestation at first antenatal consultation (ANC) was 22.5 (interquartile range [IQR] 19.25–24). Eleven (57.9%) mothers were HIV positive at first ANC, whilst eight tested negative and later positive (2 antepartum, 6 postpartum). Median maternal CD4 was 408 cells/μL (IQR 318–531). Six (31.6%) received no antenatal antiretroviral therapy (ART) because they were diagnosed as HIV positive postpartum; 9 (47.3%) received antenatal ART and 3 (15.8%) were never initiated on ART. At 6 weeks postpartum, 5 infants (26.3%) were not on prophylactic nevirapine (NVP) because their mothers had not yet been diagnosed. Maternal seroconversion in pregnancy and breastfeeding, and possibly false-negative HIV tests, were important reasons for prevention of mother-to-child transmission (PMTCT) failure.

Highlights

In 2010, the South African Department of Health (DoH) prevention of mother-to-child transmission (PMTCT) guidelines recommended World Health Organization Option A.[1]
Option B was introduced in April 2013.2 Using these guidelines, mother-to-child transmission (MTCT) in KwaZulu-Natal, South Africa, dropped from 20.8% at 6 weeks postpartum in 2005 to 2.1% in 2011,3,4 with a national target of less than 2% by 2016.5 Further reduction will require a better understanding of the reasons for PMTCT failure in local facilities
Seroconversion in pregnancy or breastfeeding, HIV diagnosis in pregnancy compared with diagnosis prior to conception, and health system-related factors have all been found to play a role in PMTCT failure.[6,7,8]

Summary

Introduction

In 2010, the South African Department of Health (DoH) prevention of mother-to-child transmission (PMTCT) guidelines recommended World Health Organization Option A (prophylactic zidovudine [AZT] for women with a CD4+ count > 350 cells/μL and combination antiretroviral therapy [cART] for all pregnant women with CD4 < 350 cells/μL, with subsequent infant nevirapine [NVP] for a minimum of 6 weeks).[1] Option B (cART for all pregnant and breastfeeding women irrespective of CD4 count and postnatal infant NVP prophylaxis) was introduced in April 2013.2 Using these guidelines, mother-to-child transmission (MTCT) in KwaZulu-Natal, South Africa, dropped from 20.8% at 6 weeks postpartum in 2005 to 2.1% in 2011,3,4 with a national target of less than 2% by 2016.5 Further reduction will require a better understanding of the reasons for PMTCT failure in local facilities. Seroconversion in pregnancy or breastfeeding, HIV diagnosis in pregnancy compared with diagnosis prior to conception, and health system-related factors have all been found to play a role in PMTCT failure.[6,7,8]. Our aim was to identify reasons for these PMTCT failures

Objectives

Results

Discussion

Conclusion