PMTCT Option Research Articles

Probable perinatal depression and social support among women enrolled in Malawi's Option B+ Program: A longitudinal analysis

BackgroundMalawi's PMTCT Option B+ program has expanded the reach of ART services among pregnant and breastfeeding women, but retention in lifelong HIV care remains challenging. Given that depression can undermine retention, it is important to understand how depression changes over the perinatal period, varies across treatment and retention groups, and could be buffered by social support. MethodsData are from an observational study conducted among women enrolled in Malawi's PMTCT Option B+ program. We used multilevel generalized linear models to estimate the odds of probable depression by time, treatment and retention group, and social support. Probable depression was assessed with the Edinburgh Postnatal Depression Scale and Patient Health Questionnaire-9. ResultsOf 468 women, 15% reported probable depression at antenatal enrollment and prevalence differed across newly diagnosed individuals, second line therapy users, and previous defaulters (18%, 21%, 5%, p = 0.001). Odds of probable perinatal depression decreased over time (OR per month: 0.87, 95% CI: 0.82–0.92) but were higher among those newly diagnosed (OR: 3.25, 95% CI: 1.59–6.65) and on second line therapy (OR: 3.39, 95% CI: 1.44–7.99) as compared to previous defaulters. Odds of probable postpartum depression were lower for participants with high social support (OR: 0.19, 95% CI: 0.09–0.39). LimitationsLack of diagnostic psychiatric evaluation precludes actual diagnosis of depression. ConclusionsProbable depression varied across the perinatal period and across treatment and retention groups. Social support was protective for postpartum depression among all participants. Depression screening and provision of social support should be considered in PMTCT programs.

Perceptions and Experiences of Participating in PMTCT Option B Plus: An Explorative Study on HIV-positive Pregnant Women in Eswatini

Background:Eswatini has adopted the PMTCT Option B+ approach as a strategy for the prevention of mother-to-child transmission of HIV.Objective:This study aimed to explore how pregnant Swazi women perceived and experienced PMTCT Option B+ and examined challenges they faced in disclosing their HIV status to their male partners.Methods:We interviewed 15 HIV-positive pregnant women selected using purposeful sampling from the PMTCT programme in Manzini Region, Eswatini. The data were analysed thematically.Results:The women had to deal with the pregnancy, the HIV-positive test results, the immediacy of the antiretroviral treatment (ART), and disclosure issues, all in one visit. They perceived the mandatory HIV testing and the same-day ART initiation as coercive. Regardless, they perceived PMTCT in a positive manner and as a gateway to early treatment for them. The drive to enroll in and remain in PMTCT was motivated by the belief in the efficacy of ART and the desire to protect their unborn babies from HIV infection. Their anticipation of rejection and violence from their partners led to their delaying disclosure and initiation of ART. Following disclosure, some of them were stigmatised, blamed for the infection, and abandoned by their partners.Conclusion:As Eswatini continues to roll out Option B+, there is a need to consider providing individualised counselling sessions to meet the individual needs of women.

Quality and turnaround times of viral load monitoring under prevention of mother-to-child transmission of HIV Option B+ in six South African districts with a high antenatal HIV burden.

Barriers to monitoring maternal HIV viral load (VL) and achieving 90% viral suppression during pregnancy and breastfeeding still need to be understood in South Africa (SA). To measure quality of VL care and turnaround times (TATs) for returning VL results to women enrolled in the prevention of mother-to-child transmission of HIV (PMTCT) programme in primary healthcare facilities. Data were obtained from a 2018 cross-sectional evaluation of the PMTCT Option B+ programme in six SA districts with high antenatal and infant HIV prevalence. Quality of VL care was measured as the proportion of clients reporting that results were explained to them. TATs for VL results were calculated using dates abstracted from four to five randomly selected facility-based client records to report overall facility 'short TAT' (≥80% of records with TAT ≤7 days). Logistical regression and logit-based risk difference statistics were used. Achieving overall short TAT was uncommon. Only 50% of facilities in one rural district, zero in one urban metro district and 9 - 38% in other districts had short TAT. The significant difference between districts was influenced by the duration of keeping results in facilities after receipt from the laboratory. Expected quality of VL care received ranged between 66% and 85%. Client-related factors significantly associated with low quality of care, observed in two urban districts and one rural district, included lower education, recent initiation of antiretroviral treatment and experiencing barriers to clinic visits. Experiencing clinic visit barriers was also negatively associated with short TATs. We demonstrate above-average quality of care and delayed return of results to PMTCT clients. Context-specific interventions are needed to shorten TATs.

Halting the Scourge of HIV in Nigeria by Adopting World Health Organization Guidelines for Preventing New Infections (Policy Brief Paper)

Nigeria bears 10% of global HIV burden and contributes 32% to global unmet-need for Prevention of Mother to Child transmission of HIV (PMTCT), which together with heterosexual transmission are the epidemic’s key drivers as PMTCT clinics show approximately 45% serodiscordance rates among couples. WHO recommends accelerated Anti-retroviral Therapy initiation for all persons living with HIV (PLHIV) for improved quality-of-life and preventing new vertical and horizontal infections, using same drug – Emtricitabine, Tenofovir and Efaverenz (once daily Atripla). The policy paper seeks to make a case that the National PMTCT task team and the Federal Ministry of health of Nigeria, should make a policy change, and shift from the current Option B PMTCT option. The option provides Antiretroviral drugs (ARVs) to pregnant HIV positive women who do for PMTCT, but discontinue them after cessation of breast-feeding, when the viral load is above 500cells/mm³. It proposes that the country should rather adopt the test and treat all policy for all HIV infected persons. The methodology entails the search and use of literature to demonstrate the multiple advantages of early commencement of treatment for all new of HIV infections, considering this has been shown to reduce morbidity and mortality. The results indicate that test and treat all for life, is now less complex as same drug regimen are used in PMTCT and other non PMTCT adult infections. Studies also show that virologic suppression (undetectable) leads to prevention of new HIV transmission (untransmitable), and this applies to different modes of HIV transmission. The brief concludes by proposing that the Federal Ministry of Health, the National AIDS Control agency, and all actors in Nigeria’s HIV terrains should adopt the WHO test and treat guidelines. This remains a critical step for the elimination of Paediatric HIV infections.

Level of Good Adherence on Option B+ PMTCT and Associated Factors Among HIV Positive Pregnant and Lactating Mothers in Public Health Facilities of Ilu Abba Bor and Buno Bedele Zones, Oromia Regional State, Southwestern Ethiopia, 2018.

BackgroundPMTCT programs help safe delivery practices and recommended infant feeding, as well as providing ART for infants exposed to HIV after birth for prevention and effective treatment. PMTCT service helps to reduce about 1.4 million HIV infections among children between 2010 and 2018. This study aimed to assess the good adherence level and associated factors of option B+ PMTCT among HIV-positive pregnant and lactating women in public health facilities of Ilu Abba Bor and Buno Bedele zones, Oromia regional state, Southwestern Ethiopia 2018.MethodologyInstitutional-based cross-sectional study design was implemented to investigate the level of good adherence to option B+ PMTCT and possible predictors. A simple random sampling technique was used to interview a total of 180 mothers using the interviewer-guided questionnaire for data collection. Data were entered into EpiData version 3.1 and analyzed by SPSS version 23.0 statistical software. Descriptive statistics and logistic regression were computed to identify and see the relative effect of predictors on the outcome variable.ResultsIn this study, 146 (81.1%) of the study participants had good adherence to PMTCT option B+. Women who received social and financial support from friends, family members, and partners had good adherence to PMTCT option B+ than their counterparts. Similarly, women who disclosed their HIV status to others had good adherence than those who did not expose their status to their friends and parents.Conclusion and RecommendationThis study identified the overall level of PMTCT option B+ adherence level in the study area to be good compared to the national and some other findings. Providing support and encouraging a woman for disclosing their HV status for partners and families are very important to increase the adherence level of option B+.

Growth and Neurodevelopment Outcomes in HIV-, Tenofovir-, and Efavirenz-Exposed Breastfed Infants in the PMTCT Option B+ Program in Malawi.

Pregnant and breastfeeding women in Option B+ in Malawi received antiretroviral drugs (ARVs) containing efavirenz (EFV) and tenofovir disoproxil fumarate (TDF). However, effects on growth, renal, bone metabolism, and neurodevelopment of long-term exposure to low doses of these drugs through breast milk in HIV-exposed infants are unclear. Prospective cohorts of TDF-and-EFV-exposed and TDF-and-EFV-unexposed breastfed infants of HIV-infected and HIV-uninfected mothers in Option B+ were recruited in 2:1 ratio, respectively, followed from birth to 18 months. Infants with low birth weight, premature birth, and congenital abnormalities were excluded. Anthropometrics were assessed at birth, 6 weeks, 3, 6, 12, and 18 months. Neurodevelopment assessments used the Bayley Scales of Infant and Toddler Development III from 6 weeks. Creatinine, alkaline phosphatase, and phosphorus were assessed at 3, 6, and 12 months. Of 260 HIV-and-ARV-exposed and 125 HIV-and-ARV-unexposed infants enrolled at birth, 87% and 57%, 78% and 59%, 77% and 54%, 73% and 51%, and 65% and 43% completed 6-weeks, 3, 6, 12, and 18 months visits, respectively. There were no significant differences in the mean Z-scores for length-for-age, weight-for-age, weight-for-length, mid-upper arm circumference-for-age, and head circumference-for-age between groups except at 6-weeks for length-for-age. No bone fractures occurred. Neurodevelopment outcomes were similar between groups. Of creatinine, alkaline phosphatase, and serum phosphate measurements, 1.7%, 2.6%, and 3.3% reached any toxicity levels grades 1-4, respectively, with no differences between groups. Long-term exposure to EFV and TDF through breastfeeding in infants of HIV-infected mothers does not seem to result in significant growth, neurodevelopment, renal, or bone adverse outcomes. Data support safety of breastfeeding through 18 months within the Option B+ program.

PMTCT Option B+ 2012 to 2018 — Taking stock: barriers and strategies to improve adherence to Option B+ in urban and rural Uganda

Since 2012, PMTCT Option B+ has been recommended by the World Health Organization to reduce vertical transmission but numerous adherence challenges remain. We conducted a qualitative study at baseline using six focus group discussions and 14 in-depth interviews to explore knowledge, beliefs, attitudes and challenges towards the Option B+ strategy for PMTCT among HIV-infected pregnant and post-partum women and health workers engaged in Uganda’s national Option B+ PMTCT programme. Data were analysed using a thematic approach to capture latent and manifest content with the social ecological model as a theoretic foundation in order to make contextual sense of key stakeholders’ needs for an effective Option B+ intervention. Overall, among all study participants, we found multi-level barriers to adhering to Option B+ cutting across all levels of the social ecological model. In line with the model, our study revealed barriers at personal, relational, organizational and societal levels. Some personal beliefs such as that the baby’s health is more important that the mother’s, organizational (negative attitudes and behaviour of health workers), structural such as poverty, work conflicts, fear and lack of disclosure related to community stigma were all critical obstacles to women adhering to the Option B+ programme. We found that both health workers and participants in the programme have a relatively clear understanding of the benefits of adhering to their treatment; though a more nuanced understanding and thus emphasis in counselling on side effects, is critical to helping patients adhere.

Factors associated with non-attendance at scheduled infant follow-up visits in an observational cohort of HIV-exposed infants in South Africa, 2012\u20132014

BackgroundSince 2001 the South African guidelines to improve child health and prevent vertical HIV transmission recommended frequent infant follow-up with HIV testing at 18 months postpartum. We sought to understand non-attendance at scheduled follow-up study visits up to 18 months, and for the 18-month infant HIV test amongst a nationally representative sample of HIV exposed uninfected (HEU) infants from a high HIV-prevalence African setting.MethodsSecondary analysis of data drawn from a nationally representative observational cohort study (conducted during October 2012 to September 2014) of HEU infants and their primary caregivers was undertaken. Participants were eligible (N = 2650) if they were 4–8 weeks old and HEU at enrolment. All enrolled infants were followed up every 3 months up to 18 months. Each follow-up visit was scheduled to coincide with each child’s routine health visit, where possible. The denominator at each time point comprised HEU infants who were alive and HIV-free at the previous visit. We assessed baseline maternal and early HIV care characteristics associated with the frequency of ‘Missed visits’ (MV-frequency), using a negative binomial regression model adjusting for the follow-up time in the study, and associated with missed visits at 18 months (18-month MV) using a logistic regression model.ResultsThe proportion of eligible infants with MV was lowest at 3 months (32.7%) and 18 months (31.0%) and highest at 12 months (37.6%). HIV-positive mothers not on triple antiretroviral therapy (ART) by 6-weeks postpartum had a significantly increased occurrence rate of ‘MV-frequency’ (adjusted incidence rate ratio, 1.2 (95% confidence interval (CI), 1.1–1.4), p < 0.0001). Compared to those mothers with ART, these mothers also increased the risk of ‘18-month-MV’ (adjusted odds ratio, 1.3 (CI, 1.1–1.6), p = 0.006). Unknown infant nevirapine-intake status increased the rate of ‘MV-frequency’ (p = 0.02). Mothers > 24 years had a significantly reduced rate of ‘MV-frequency’ (p ≤ 0.01) and risk of ‘18-month-MV’ (p < 0.01) compared to younger women. Shorter travel time to health facility lowered the occurrence of ‘MV-frequency’ (p ≤ 0.004).ConclusionLate initiation of maternal ART and infant prophylaxis under the Option- A policy and extended travel time to clinics (measured at 6 weeks postpartum), contributed to higher postnatal MV rates. Mothers older than 24 years had lower MV rates. Targeted interventions may be needed during the current PMTCT Option B+ (lifelong ART to pregnant and lactating women at HIV diagnosis) to circumvent these risk factors and reduce missed visits during HIV-care.

Prevalence of antiretroviral therapy treatment failure among HIV-infected pregnant women at first antenatal care: PMTCT Option B+ in Malawi.

BackgroundIn Malawi’s PMTCT Option B+ program, HIV-infected pregnant women who are already receiving ART are continued on their current therapy regimen without testing for treatment failure at the first antenatal care (ANC) visit. HIV RNA screening at ANC may identify women with treatment failure and ensure that viral suppression is maintained throughout the pregnancy.MethodsWe conducted a cross-sectional study of HIV-infected pregnant women who had been receiving ART for at least 6 months at the first ANC visit under the PMTCT Option B+ program at Bwaila Hospital in Lilongwe, Malawi from June 2015 to December 2017. Poisson regression models with robust variance were used to investigate the predictors of ART treatment failure defined as viral load ≥1000 copies/ml.ResultsThe median age of 864 women tested for ART failure was 31.1 years (interquartile range: 26.9–34.5). The prevalence of treatment failure was 7.6% (95% confidence interval (CI): 6.0–9.6). CD4 cell count (adjusted prevalence ratio (aPR) = 0.57; 95% CI: 0.50–0.65) was strongly associated with treatment failure.ConclusionThe low prevalence of treatment failure among women presenting for their first ANC in urban Malawi demonstrates success of Option B+ in maintaining viral suppression and suggests progress towards the last 90% of the UNAIDS 90-90-90 targets. Women failing on ART should be identified early for adherence counseling and may require switching to an alternative ART regimen.

Maternal ART Retention and HIV-Exposed Infant Testing Under PMTCT Options B and B Strategies: A Systematic Review and Meta-Analysis

Objective: To estimate maternal ART retention and infant testing coverage in PMTCT programs offering option B or B strategies. Methods: For this systematic review and meta-analysis, we searched electronic databases and the grey literature for studies published from January 2010 to May 2017. Estimates were calculated in the presence and absence of interventions aiming to improve retention or infant testing. Random-effects models were fitted to obtain pooled estimates of outcomes and statistical heterogeneity was addressed with I2 statistics. Results: Thirty-three studies representing 59,178 HIV women and 5,655 HIV-exposed infants were included. The pooled 6-month maternal ART retention was 79% (95% CI:77-81; I2=92% n=51,610 women) in settings without intervention to improve follow-up and 77% (95% CI:74-80; I2=62%; n=2,184) with interventions. Pooled 12-month ART retention was 74% (95% CI:70-77; I2=93%; n=30,506) and 69% (95% CI:64-75; I2=87%; n=2,686) with and without interventions, respectively. The proportion of infants benefiting from rapid HIV testing at 12-18 months was 79% (95% CI:70-86; n=1,080) and 60% (95% CI: 17-96; n=3,104) with and without interventions, respectively. Heterogeneity was extremely high (I2 statistics range 89-100%). Conclusion: Pooled retention estimates were low. Study outcomes did not differ according to the presence or absence of targeted interventions. Heterogeneity was substantial, mainly due to the variety of outcome definitions used across studies. Multipronged actions should be taken to achieve better outcomes, otherwise the implementation of PMTCT option B/B will remain sub-optimal despite its originally deemed effectiveness and pediatric HIV elimination will remain out of reach. Funding Statement: The authors state: There was no funding source for this study. Declaration of Interests: The authors state: We declare no competing interests. Ethics Approval Statement: The systematic review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines.

Roles played by community cadres to support retention in PMTCT Option B+ in four African countries: a qualitative rapid appraisal

ObjectivesTo explore the roles of community cadres in improving access to and retention in care for PMTCT (prevent mother-to-child transmission of HIV) services in the context of PMTCT Option B+...

She knows that she will not come back: tracing patients and new thresholds of collective surveillance in PMTCT Option B+

BackgroundMalawi, Uganda, and Zimbabwe have recently adopted a universal ‘test-and-treat’ approach to the prevention of mother-to-child transmission of HIV (Option B+). Amongst a largely asymptomatic population of women tested for HIV and immediately started on antiretroviral treatment (ART), a relatively high number are not retained in care; they are labelled ‘defaulters’ or ‘lost-to-follow-up’ patients.MethodsWe draw on data collected as part of a study looking at ART decentralization (Lablite) to reflect on the spaces created through the instrumentalization of community health workers (CHWs) for the purpose of bringing women who default from Option B+ back into care. Data were collected through semi-structured interviews with CHWs who are designated to trace Option B+ patients in Uganda, Malawi and Zimbabwe.FindingsLost to follow up women give a range of reasons for not coming back to health facilities and often implicitly choose not to be traced by providing a false address at enrolment. New strategies have sought to utilize CHWs’ liminal positionality - situated between the experience of living with HIV, having established local social ties, and being a caretaker - in order to track ‘defaulters’. CHWs are often deployed without adequate guidance or training to protect confidentiality and respect patients’ choice.ConclusionsCHWs provide essential linkages between health services and patients; they embody the role of ‘extension workers’, a bridge between a novel health policy and ‘non-compliant patients’. Option B+ offers a powerful narrative of the construction of a unilateral ‘moral economy’, which requires the full compliance of patients newly initiated on treatment.

Pmtct Option b+ Efavirenz and Tenofovir Exposure Through Breastfeeding and Bayleys Neurodevelopmental Scores in Malawian Infants

Pmtct Option b+ Efavirenz and Tenofovir Exposure Through Breastfeeding and Bayleys Neurodevelopmental Scores in Malawian Infants

Mother to child transmission of HIV and its option B+ cascade predictors: An ecological study

Context: In 2013, the world Health Organization endorsed Option B plus as a strategy towards elimination of vertical transmission of HIV (human immunodeficiency virus). The purpose of the study was to examine the Option B+ trends and outcome predictors in Zimbabwe. Aims: to examine the PMTCT trends in Mashonaland East Province in Zimbabwe to determine the programmatic correlates of reduced MTCT in the first three years of introduction of PMTCT option B+. Settings and Design: Ecological study in Mashonaland East Province, Zimbabwe. Methods and Materials: The study was based on Option B plus data from the Provincial Health information system. Spatial mapping of MTCT rates was done using ArcMap 10.1. Statistical Analysis Used: Descriptive statistics and multiple linear regression of the correlates of MTCT rates using R software based on step-wise Akaike information criterion. Results: The MTCT rate for Mashonaland East was 5.3% in 2014, 5.2% in 2015 and 4.0% in 2016. The predictors for reduced PMTCT included: booking the pregnancy with a known HIV positive status (β= -0.011, SEB=0.0035), arriving in labour and delivery with unknown HIV status (β= -0.029, SEB=0.0078), testing HIV positive at retesting in labour and delivery (β= - 0.04; SEB=0.03), women with unknown HIV status within 24 months post-delivery (β= - 0.0044; SEB=0.0032) and identification of HIV exposed infants within 72 hours of birth (β= - 0.01; SEB=0.0026). Conclusions: PMTCT Option B+ was associated with a decline in MTCT rate. Intensive psychosocial support of pregnant or nursing women may facilitate reduction of MTCT rates.

Uptake of PMTCT Option B-plusamong HIV-Infected Women Attending Antenatal Clinics and Labor WardsatMulago National Referral Hospital in Kampala, Uganda

Uptake of PMTCT Option B-plusamong HIV-Infected Women Attending Antenatal Clinics and Labor WardsatMulago National Referral Hospital in Kampala, Uganda

PMTCT Option B+ Does Not Increase Preterm Birth Risk and May Prevent Extreme Prematurity: A Retrospective Cohort Study in Malawi.

To estimate preterm birth risk among infants of HIV-infected women in Lilongwe, Malawi, according to maternal antiretroviral therapy (ART) status and initiation time under Option B+. A retrospective cohort study of HIV-infected women delivering at ≥27 weeks of gestation, April 2012 to November 2015. Among women on ART at delivery, we restricted our analysis to those who initiated ART before 27 weeks of gestation. We defined preterm birth as a singleton live birth at ≥27 and <37 weeks of gestation, with births at <32 weeks classified as extremely to very preterm. We used log-binomial models to estimate risk ratios and 95% confidence intervals for the association between ART and preterm birth. Among 3074 women included in our analyses, 731 preterm deliveries were observed (24%). Overall preterm birth risk was similar in women who had initiated ART at any point before 27 weeks and those who never initiated ART (risk ratio = 1.14; 95% confidence interval: 0.84 to 1.55), but risk of extremely to very preterm birth was 2.33 (1.39 to 3.92) times as great in those who never initiated ART compared with those who did at any point before 27 weeks. Among women on ART before delivery, ART initiation before conception was associated with the lowest preterm birth risk. ART during pregnancy was not associated with preterm birth, and it may in fact be protective against severe adverse outcomes accompanying extremely to very preterm birth. As preconception ART initiation appears especially protective, long-term retention on ART should be a priority to minimize preterm birth in subsequent pregnancies.

Male Partner Support and Associated Factor on PMTCT Option B+ among HIV Positive Pregnant and Lactating Mothers in South Wollo Zone, North East Ethiopia

Option B+ is an approach in prevention of mother to child transmission of human immune virus (HIV) which means “test and treat” irrespective of CD4 count or clinical stage. In this approach world health organization recommended male partner involvement is vital for accomplishment of the goal of having HIV free children. Now a days there is no study done on male partner involvement in option B+ Prevention of mother to child transmission of HIV in Ethiopia in general and also in our study area of south wollo zone in particular. Objective: The objective of this study was to assess male partner support and associated factor on option B+ prevention of mother to child transmission of HIV among HIV sero positive pregnant and lactating mothers in south wollo zone, north east Ethiopia, 2016. Method: An institution based cross sectional study design was employed. A total of 172 HIV positive pregnant & lactating mothers were involved in the study. Simple random sampling technique was utilized to recruit the study participants. Data was collected by using interviewer administer standared structured questionare. The data were entered in to EpiData version 3.1 and then exported to statistical package for social science (SPSS) window version 21 for statistical analysis. Entered data were explored for errors & missing values and cleaned before analysis. Bivariate and multivariate logistic regression analyses were employed to identify factors associated with male partner involvement in prevention of mother to child transmission of HIV/AIDS. P-value less than 0.05 with 95% confidence interval were used to declare the association between dependent and independent variables. Result: A total of 172 HIV positive pregnant and breast feeding mothers were involved in this study. One hundred forty six (88%) of mothers report good male partner support while the rest 20 (12%) of mothers didn’t had. Primi gravida (pregnant for the first time) had was statistically significant association with male partner involvement in prevention of mother to child transmission of HIV/AIDS (AOR 0.19, 95% CI (0.04-0.94). Conclusion: Being HIV positive pregnant and breast feeding mothers who were pregnant for the first time (primigavida) had stastically significant association with male partner support in option B+ prevention of mother to child transmission of HIV care. Therefore, focusing on those primigravida mothers is essential to improve the support of male sexual partner on prevention of mother to child transmission of HIV.

PMTCT option b+ does not increase preterm birth risk and may prevent extreme prematurity: A retrospective cohort study in Malawi

PMTCT option b+ does not increase preterm birth risk and may prevent extreme prematurity: A retrospective cohort study in Malawi

Population-level effectiveness of PMTCT Option A on early mother-to-child (MTCT) transmission of HIV in South Africa: implications for eliminating MTCT.

Eliminating mother-to-child transmission of HIV (EMTCT), defined as ≤50 infant HIV infections per 100 000 live births, is a global priority. Since 2011 policies to prevent mother-to-child transmission of HIV (PMTCT) shifted from maternal antiretroviral (ARV) treatment or prophylaxis contingent on CD4 cell count to lifelong maternal ARV treatment (cART). We sought to measure progress with early (4-8 weeks postpartum) MTCT prevention and elimination, 2011-2013, at national and sub-national levels in South Africa, a high antenatal HIV prevalence setting ( ≈ 29%), where early MTCT was 3.5% in 2010. Two surveys were conducted (August 2011-March 2012 and October 2012-May 2013), in 580 health facilities, randomly selected after two-stage probability proportional to size sampling of facilities (the primary sampling unit), to provide valid national and sub-national-(provincial)-level estimates. Data collectors interviewed caregivers of eligible infants, reviewed patient-held charts, and collected infant dried blood spots (iDBS). Confirmed positive HIV enzyme immunoassay (EIA) and positive total HIV nucleic acid polymerase chain reaction (PCR) indicated infant HIV exposure or infection, respectively. Weighted survey analysis was conducted for each survey and for the pooled data. National data from 10 106 and 9120 participants were analyzed (2011-12 and 2012-13 surveys respectively). Infant HIV exposure was 32.2% (95% confidence interval (CI) 30.7-33.6%), in 2011-12 and 33.1% (95% CI 31.8-34.4%), provincial range of 22.1-43.6% in 2012-13. MTCT was 2.7% (95% CI 2.1%-3.2%) in 2011-12 and 2.6% (95% CI 2.0-3.2%), provincial range of 1.9-5.4% in 2012-13. HIV-infected ARV-exposed mothers had significantly lower unadjusted early MTCT (2.0% [2011-12: 1.6-2.5%; 2012-13:1.5-2.6%]) compared to HIV-infected ARV-naive mothers [10.2% in 2011-12 (6.5-13.8%); 9.2% in 2012-13 (5.6-12.7%)]. Pooled analyses demonstrated significantly lower early MTCT among exclusive breastfeeding (EBF) mothers receiving >10 weeks ARV prophylaxis or cART compared with EBF and no ARVs: (2.2% [95% CI 1.25-3.09%] vs 12.2% [95% CI 4.7-19.6%], respectively); among HIV-infected ARV-exposed mothers, 24.9% (95% CI 23.5-26.3%) initiated cART during or before the first trimester, and their early MTCT was 1.2% (95% CI 0.6-1.7%). Extrapolating these data, assuming 32% EIA positivity and 2.6% or 1.2% MTCT, 832 and 384 infants per 100 000 live births were HIV infected, respectively. Although we demonstrate sustained national-level PMTCT impact in a high HIV prevalence setting, results are far-removed from EMTCT targets. Reducing maternal HIV prevalence and treating all maternal HIV infection early are critical for further progress.

Predictors of Patient Dissatisfaction with Services for Prevention of Mother-To-Child Transmission of HIV in Dar es Salaam, Tanzania.

BackgroundMother-to-child transmission (MTCT) of HIV remains a major source of new HIV infections in children. Prevention of mother-to-child transmission of HIV (PMTCT) using lifelong antiretroviral treatment (ART) for all pregnant and breastfeeding women living with HIV (Option B+) is the major strategy for eliminating paediatric HIV. Ensuring that patients are satisfied with PMTCT services is important for optimizing uptake, adherence and retention in treatment.MethodsWe conducted a facility based quantitative cross-sectional survey in Dar-es-Salaam, Tanzania, between March and April 2014, when the country was transitioning to the implementation of PMTCT Option B+. We interviewed 595 pregnant and breastfeeding women living with HIV, who received PMTCT care in 36 public health facilities. Predictors of overall dissatisfaction with PMTCT services were identified using a multiple logistic regression.ResultsOverall 8% of the patients expressed dissatisfaction with PMTCT services. Patients who perceived health care workers (HCW) communication skills as poor, had a 5-fold (OR 4.9, 95% CI 1.8–13.4) increased risk of dissatisfaction and those who perceived HCW capacity to understand client concerns as poor, had a 6-fold (OR 5.7, 95% CI 2.3–14.0) increased risk. Having a total visit time longer than two hours was associated with a 2-fold increased risk of being dissatisfied (OR 2.3, 95% CI 1.1–4.7). Every 30-minute increment in total visit time was associated with a 10% higher (OR 1.1, 95% CI 1.0–1.2) risk of being dissatisfied. The probability of being dissatisfied ranged from 4% (95% CI 2% - 6%) in the presence of patient-perceived good communication, good understanding of patient concerns, and a total visit time below two hours, to 70% (95% CI 47% - 86%) if HCW failed in all of these aspects.ConclusionPatient dissatisfaction with PMTCT services was generally low; reflecting that quality of care was maintained during Tanzania’s transition to Option B+ strategy aiming to increase the number of women initiating life-long ART in PMTCT clinics. Improved HCW communication with clients, their understanding of patient concerns and a reduction of the total visit time would further optimize women’s overall satisfaction with PMTCT services in Tanzania.