PMTCT Option Research Articles

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

BackgroundEliminating 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.MethodsTwo 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.FindingsNational 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.ConclusionsAlthough 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.

Retention in Care among HIV-Infected Pregnant Women in Haiti with PMTCT Option B.

Background. Preventing mother-to-child transmission of HIV relies on engagement in care during the prenatal, peripartum, and postpartum periods. Under PMTCT Option B, pregnant women with elevated CD4 counts are provided with antiretroviral prophylaxis until cessation of breastfeeding. Methods. Retrospective analysis of retention in care among HIV-infected pregnant women in Haiti was performed. Logistic regression was used to identify risk factors associated with loss to follow-up (LFU) defined as no medical visit for at least 6 months and Kaplan-Meier curves were created to show LFU timing. Results. Women in the cohort had 463 pregnancies between 2009 and 2012 with retention rates of 80% at delivery, 67% at one year, and 59% at 2 years. Among those who were LFU, the highest risk period was during pregnancy (60%) or shortly afterwards (24.4% by 12 months). Never starting on antiretroviral therapy (aRR 2.29, 95% CI 1.4–3.8) was associated with loss to follow-up. Conclusions. Loss to follow-up during and after pregnancy was common in HIV-infected women in Haiti under PMTCT Option B. Since sociodemographic factors and distance from home to facility did not predict LFU, future work should elicit and address barriers to retention at the initial prenatal care visit in all women. Better tracking systems to capture engagement in care in the wider network are needed.

Serodiscordant twins: A case report of vertical HIV transmission during PMTCT option B+ role out

Serodiscordant twins: A case report of vertical HIV transmission during PMTCT option B+ role out

Exploring the barriers and enablers to ART initiation for HIV-positive pregnant women in a PMTCT Option B+ programme in Shiselweni, Swaziland

Exploring the barriers and enablers to ART initiation for HIV-positive pregnant women in a PMTCT Option B+ programme in Shiselweni, Swaziland

Counseling on Infant and Young Child Feeding Practices for HIV‐infected Women in Malawi's Option B+ Prevention of Mother‐to‐Child Transmission Program

The World Health Organization recommends that HIV‐infected women on lifelong antiretrovirals (ARVs) for the prevention of mother‐to‐child transmission (PMTCT Option B+) exclusively breastfeed for 6 months and continue breastfeeding until 12 months. In Malawi, breastfeeding until 24 months is recommended for women on ARVs. Little is known about the extent, timing, content, or uptake of feeding counseling provided to women participating in Malawi's Option B+ program. To fill this gap, we conducted in‐depth interviews on feeding counseling and practices of 32 HIV‐infected women in PMTCT with children < 24 months and performed observations of postnatal PMTCT clinic visits with another 32 women with the same characteristics at 4 clinics in Lilongwe District. In‐depth interviews revealed that women trusted feeding advice from clinic staff compared to other sources. Counseling in clinics usually occurred during the first antenatal visit or at delivery and focused on exclusive breastfeeding for 6 months, which most women reportedly practiced. Postnatal counseling on feeding practices was infrequent. During clinic observations, about 40% of mothers were asked if they were breastfeeding, 12% were advised on feeding problems, <25% of women with children < 6 months were counseled on the introduction of fluids or foods, and <30% of women with children > 6 months were advised on complementary feeding. In conclusion, the low frequency of feeding counseling during postnatal PMTCT visits represents a missed opportunity for health workers to support optimal infant and young child feeding practices of HIV‐infected women. Funding: NIH BIRCWH K12 program, UNC CFAR developmental award

Quality assurance of prevention of mother-to-child transmission of HIV in Botswana

Background: The HIV prevalence rate among pregnant women is 37% in Botswana. According to UNICEF (2011), maternal and under-5 mortality rates in Botswana were 160 per 100000 live births and 26 per 1000 live births, respectively. Therefore, this study sought to identify the effects of ongoing clinic audits of the prevention of mother-to-child transmission of HIV (PMTCT) in Francistown, Botswana for the period 2008–2012. Methods: Existing data for all women attending antenatal and postnatal clinics were collected and collated manually from monthly from clinic PMTCT registers. Results: There were 19 720 new antenatal clinic visits between 2008 and 2012 with an HIV prevalence of 35% among the women. Mother-to-child transmission of HIV decreased from 3% in 2008 to 1% in 2012. The decrease was due, in part, to the introduction of triple antiretroviral prophylaxis/antiretroviral therapy (TAP/ARV) (PMTCT Option B) in 2011. Conclusions: Audit results over a 5-year period showed a steady improvement in the cascade of PMTCT interventions. Clinic audits should be implemented nationally to reduce maternal and under-5 mortality.

PMTCT Option B+: An opportunity for shaping a new service delivery paradigm

PMTCT Option B+: An opportunity for shaping a new service delivery paradigm