Barriers and enablers of the prevention of mother-to-child transmission of HIV/AIDS program in China: a systematic review and policy implications

Adverse pregnancy outcomes and associated risk factors among pregnant women with syphilis during 2013-2018 in Hunan, China

Objective

To investigate the adverse pregnancy outcomes and associated risk factors among pregnant women with syphilis.

Design

Pregnant women with syphilis in the registry for the prevention of mother-to-child transmission of AIDS, syphilis and hepatitis B in Hunan Province, China, from January 1, 2013 to December 31, 2018 were included in the study.

Results

Among the 14,219 pregnant women with syphilis, 11,346 had definite pregnancy outcomes and were in singleton pregnancy. The risk factors related to adverse pregnancy outcomes include the age of pregnant women with syphilis <20 years old (aOR = 1.274, 95% CI: 1.088-1.493) or ≥ 35 years old (aOR = 1.402, 95% CI: 1.167-1.686), not married (aOR = 1.855, 95% CI: 1.453-2.367), initial syphilis detection in the late pregnancy (aOR = 1.266, 95% CI: 1.032-1.555), diagnosis of syphilis in the late pregnancy (aOR = 5.806, 95% CI: 1.796-18.770), diagnosis of syphilis during labor (aOR = 4.102, 95% CI: 1.263-13.330), husband/sexual partner infected with syphilis (aOR = 1.222, 95% CI: 1.068-1.398), untreated (aOR = 6.756, 95% CI: 5.586-8.197), and nonstandard medication (aOR = 3.300, 95% CI: 2.841-3.846).

Conclusion

The prevalence of adverse pregnancy outcomes among pregnant women with syphilis in Hunan Province, China from 2013 to 2018 was relatively high. The adverse pregnancy outcomes associated with syphilis could be reduced by early detection and standard treatment of syphilis for pregnant women and their husbands/sexual partners.

A Peer-support Mini-counseling Model to Improve Treatment in HIV-positive Pregnant Women in Kupang City, East Nusa Tenggara, Indonesia

OBJECTIVES

Low adherence to antiretroviral (ARV) therapy in pregnant women with human immunodeficiency virus (HIV) increases the risk of virus transmission from mother to newborn. Increasing mothers' knowledge and motivation to access treatment has been identified as a critical factor in prevention. Therefore, this research aimed to explore barriers and enablers in accessing HIV care and treatment services.

METHODS

This research was the first phase of a mixed-method analysis conducted in Kupang, a remote city in East Nusa Tenggara Province, Indonesia. Samples were taken by purposive sampling of 17 people interviewed, consisting of 6 mothers with HIV, 5 peer facilitators, and 6 health workers. Data were collected through semi-structured interviews, focus group discussions, observations, and document review. Inductive thematic analysis was also performed. The existing data were grouped into several themes, then relationships and linkages were drawn from each group of informants.

RESULTS

Barriers to accessing care and treatment were lack of knowledge about the benefits of ARV; stigma from within and the surrounding environment; difficulty in accessing services due to distance, time, and cost; completeness of administration; drugs' side effects; and the quality of health workers and HIV services.

CONCLUSIONS

There was a need for a structured and integrated model of peer support to improve ARV uptake and treatment in pregnant women with HIV. This research identified needs including mini-counseling sessions designed to address psychosocial barriers as an integrated approach to support antenatal care that can effectively assist HIV-positive pregnant women in improving treatment adherence.

Evaluation of a novel in-house HIV-1 genotype drug resistance assay using clinical samples in China

Background

HIV drug resistance poses a major challenge for anti-retroviral treatment (ART) and the prevention and control of HIV epidemic.

Objective

The study aims to establish a novel in-house assay with high efficiency, named AP in- house method, that would be suitable for HIV-1 drug resistance detection in China.

Methods

An in-house HIV-1 genotyping method was used to sequence the partial pol gene from 60 clinical plasma samples; the results of our test were compared with a commercial ViroSeq HIV-1 genotyping system.

Results

Among sixty samples, 58(96.7%) were successfully amplified by AP in-house method, five of them harbored viral load below 1,000 copies/ml. The genotype distribution was 43.1% CRF07_BC (25/58), 39.7% CRF01_AE (23/58), 6.9% CRF55_01B (4/58), 5.2% subtype B (3/58) and 5.2% CRF08_BC (3/58). Compared with that of the ViroSeq system, the consistent rate of these nucleotides and amino acids obtained by AP in-house method was up to 99.5 ± 0.4% and 99.5 ± 0.4%, respectively. A total of 290 HIV-1 drug resistance mutations were identified by two methods, including 126 nucleoside reverse transcriptase inhibitors (NRTIs), 145 non-nucleoside reverse transcriptase inhibitors (NNRTIs) and 19 protease inhibitors (PIs) resistance mutations. Out of them, 94.1% (273/290) were completely concordant between the AP in-house method and the ViroSeq system.

Conclusion

Overall, the evaluation of AP in-house method provided comparable results to those of the ViroSeq system on diversified HIV-1 subtypes in China.

Costs and Cost Drivers of Providing Option B+ Services to Mother-Baby Pairs for PMTCT of HIV in Health Centre IV Facilities in Jinja District, Uganda

Background

In 2013, the World Health Organization (WHO) revised the 2012 guidelines on use of antiretroviral drugs (ARVs) for the prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV). The new guidelines recommended lifelong antiretroviral therapy (ART) for all HIV-positive pregnant and breastfeeding women irrespective of CD4 count or clinical stage (also referred to as Option B+). Uganda started implementing Option B+ in 2012 basing on the 2012 WHO guidelines. Despite the impressive benefits of the Option B+ strategy, implementation challenges, including cost burden and mother-baby pairs lost to follow-up, threatened its overall effectiveness. The researchers were unable to identify any studies conducted to assess costs and cost drivers associated with provision of Option B+ services to mother-baby pairs in HIV care in Uganda. Therefore, this study determined costs and cost drivers of providing Option B+ services to mother-baby pairs over a two-year period (2014–2015) in selected health facilities in Jinja district, Uganda.

Methods

The estimated costs of providing Option B+ to mother-baby pairs derived from the provider perspective were evaluated at four health centres (HC) in Jinja district. A retrospective, ingredient-based costing approach was used to collect data for 2014 as base year using a standardized cost data capture tool. All costs were valued in United States dollars (USD) using the 2014 midyear exchange rate. Costs incurred in the second year (2015) were obtained by inflating the 2014 costs by the ratio of 2015 and 2014 USA Gross Domestic Product (GDP) implicit price deflator.

Results

The average total cost of Option B+ services per HC was 66,512.7 (range: 32,168.2–102,831.1) USD over the 2-year period. The average unit cost of Option B+ services per mother-baby pair was USD 441.9 (range: 422.5–502.6). ART for mothers was the biggest driver of total mean costs (percent contribution: 62.6%; range: 56.0%–65.5%) followed by facility personnel (percent contribution: 8.2%; range: 7.7%–11.6%), and facility-level monitoring and quality improvement (percent contribution: 6.0%; range: 3.2%–12.3%). Conclusions and Recommendations. ART for mothers was the major cost driver. Efforts to lower the cost of ART for PMTCT would make delivery of Option B+ affordable and sustainable.

Determinants of HIV testing among Filipino women: Results from the 2013 Philippine National Demographic and Health Survey

BACKGROUND

The prevalence of having ever tested for HIV in the Philippines is very low and is far from the 90% target of the Philippine Department of Health (DOH) and UNAIDS, thus the need to identify the factors associated with ever testing for HIV among Filipino women.

METHODS

We analysed the 2013 Philippine National Demographic and Health Survey (NDHS). The NDHS is a nationally representative survey which utilized a two-stage stratified design to sample Filipino women aged 15-49. We considered the following exposures in our study: socio-demographic characteristics of respondent and her partner (i.e., age of respondent, age of partner, wealth index, etc.), sexual practices and contraception (i.e., age at first intercourse, condom use, etc.), media access, tobacco use, HIV knowledge, tolerance to domestic violence, and women's empowerment. The outcome variable is HIV testing. We used logistic regression for survey data to study the said associations.

RESULTS

Out of 16,155 respondents, only 372 (2.4%) have ever tested for HIV. After adjusting for confounders, having tertiary education (adjusted odds ratio (aOR) = 2.15; 95% Confidence Interval (CI): 1.15-4.04), living with partner (aOR = 1.72; 95% CI: 1.19-2.48), tobacco use (aOR = 1.87; 95% CI: 1.13-3.11); belonging to the middle class (aOR = 2.72; 95% CI: 1.30-5.67), richer (aOR = 3.00; 95% CI: 1.37-5.68), and richest (aOR = 4.14; 95% CI: 1.80-5.91) populations, having weekly television access (aOR = 1.75; 95% CI: 1.04-2.94) or internet access (aOR = 2.01; 95% CI: 1.35-3.00), living in a rural area (aOR = 1.87; 95% CI: 1.34-2.61); and being a Muslim (aOR = 2.30; 95% CI: 1.15-4.57) were associated with ever testing for HIV.

CONCLUSIONS

The low percentage of respondents who test for HIV is a call to further strengthen efforts to promote HIV testing among Filipino women. Information on its determinants can be used to guide the crafting and implementation of interventions to promote HIV testing to meet DOH and UNAIDS targets.

Growth of HIV-Exposed Infants in Southwest China: A Comparative Study

Objectives. Prevention of mother-to-child HIV transmission has been globally successful leading to a decline in HIV-infected infants. Thus, the number of HIV-exposed, but uninfected, infants is increasing. As growth is an important indicator of child health, this study aimed to evaluate growth parameters of HIV-exposed Chinese infants. Methods. A prospective study was conducted among HIV-exposed (HIV-infected and uninfected) infants born during 2007 to 2015 in Liuzhou, China. Their weight and length were assessed longitudinally from birth to 18 months of age and compared with HIV-unexposed, uninfected (HUU) infants from the same region. Results. There were 467 HIV-exposed infants. Four percent of infants were HIV-infected. The mean weight-for-age (WAZ) and length-for-age (LAZ) z scores of HIV-infected infants were significantly lower than those of HIV-exposed but uninfected (HEU) infants during 9 to 18 months and 12 to 18 months of age, respectively. Additionally, the mean WAZ and LAZ scores of HIV-infected infants were significantly lower than HUU infants during the first 12 months and 18 months of life, respectively. The mean WAZ and LAZ scores of HEU infants were significantly lower than HUU infants during the first 12 months and 6 months of life, respectively. HEU infants also had a lower mean weight-for-length z score than HUU infants during the first 6 months. Conclusion. We demonstrated poor growth among HIV-exposed Chinese infants, including HIV-uninfected, compared with HUU infants. The results emphasize the need for nutritional monitoring and interventions for HIV-exposed infants regardless of HIV infection status. Research is needed on long-term growth trajectories and factors affecting growth of HIV-exposed infants in China.

Mother-to-child transmission prevention of human immunodeficiency virus, syphilis and hepatitis B virus

BACKGROUND

China is the first country to initiate a nationwide program for prevention of mother-to-child transmission of human immunodeficiency virus, syphilis and hepatitis B virus by an integrated approach. However, the progress of this program remains unreported at national or local level for China. Therefore, we performed a hospital-based longitudinal study to assess the integrated prevention effect in Hunan, South-central China.

METHODS

This study was conducted at 123 counties in Hunan and covered all local hospitals providing midwifery and antenatal care services from 2010 to 2016. We used the Cochran-Armitage test to examine the temporal changes of the indicators related with prevention of mother-to-child transmission. Besides, we used Spearman rank correlation analysis to assess the association between mother-to-child transmission rates and the process indicators related with prevention of mother-to-child transmission.

RESULTS

After implementation of integrated prevention program, the indicators related with prevention of mother-to-child transmission are moving in the right direction. From 2010 to 2016, mother-to-child transmission rates significantly decreased from 19.4% to 9.6% for human immunodeficiency virus, and from 116.3 to 13.6 cases per 100,000 live births for syphilis. The proportion of children receiving hepatitis B immunoglobulin injection within 24h after birth increased from 95.2% to 98.9% among exposed neonates. Mother-to-child transmission rates were negatively associated with the process indicators related with prevention of mother-to-child transmission (all P<0.05).

CONCLUSIONS

Our prevention program of mother-to-child transmission for three diseases by an integrated approach proved to be viable and effective. Our model may be of interest to other countries.

Characterization of a New HIV-1 CRF01_AE/CRF07_BC Recombinant Virus in Tianjin, China

HIV is notorious for its rapid evolution since its transmissions from monkey to human. Currently, HIV contains multiple subtypes, circulating recombinant forms (CRFs) and unique recombinant forms (URFs). Here, from an HIV-positive mother and her child in Tianjin, China, we identified a novel HIV-1 second-generation recombinant virus (TJ20170316 and TJ20170317) between CRF01_AE and CRF07_BC. Near full-length genomes (NFLGs) were obtained from both samples, and they shared very close sequences, except some point mutations. Phylogenetic analyses of the NFLGs showed that they consist of CRF01_AE backbone and part CRF07_BC sequences. Recombinant Identification Program and Simplot software identified four breakpoints in gag, pol, vif, and tat genes in TJ20170316, totally different from other reported CRFs and URFs. The emergence of such URFs in Tianjin, China, highlights the complexity of HIV-1 epidemic and more measures should be taken to prevent HIV transmissions.