Heterogeneous and decreasing HIV prevalence among women seeking antenatal care in Kinshasa, Democratic Republic of Congo

Socio-Structural Factors Influencing the Prevention of Mother-to-Child Transmission of HIV in the Democratic Republic of the Congo: A Systematic Review

Introduction The Democratic Republic of the Congo (DRC) had the second-highest mother-to-child HIV transmission rate in Sub-Saharan Africa at 29% in 2013, however the uptake of preventive services for mother-to-child transmission of HIV (PMTCT) remains suboptimal. This systematic review explores socio-cultural and structural factors influencing PMTCT service uptake in the DRC. Methods We conducted a search of electronic databases. The PEN-3 model was used as a framework to synthesize factors influencing PMTCT service uptake into perceptions, enablers, and nurturers. Results Sixteen studies, 14 quantitative and two qualitative, were retained. Maternal, socio-economic, structural, and cultural factors were found to influence PMTCT service uptake in the DRC. Cost, accessibility, and quality of PMTCT services were key barriers to service uptake. Integration, male partner involvement, and evolving PMTCT policies improved PMTCT service delivery and uptake. This review also revealed several socio-cultural challenges in involving male partners in PMTCT programs. Discussion Findings highlight the need to address barriers and reinforce enablers of PMTCT uptake. Creating culturally appropriate, male-friendly, and family-oriented PMTCT programs will improve service uptake in the DRC.

Implementation and Operational Research: Decentralization Does Not Assure Optimal Delivery of PMTCT and HIV-Exposed Infant Services in a Low Prevalence Setting

BACKGROUND

The consequences of decentralizing prevention of mother-to-child HIV transmission and HIV-exposed infant services to antenatal care (ANC)/labor and delivery (L&D) sites from dedicated HIV care and treatment (C&T) centers remain unknown, particularly in low prevalence settings.

METHODS

In a cohort of mother-infant pairs, we compared delivery of routine services at ANC/L&D and C&T facilities in Kinshasa, Democratic Republic of Congo from 2010-2013, using methods accounting for competing risks (eg, death). Women could opt to receive interventions at 90 decentralized ANC/L&D sites, or 2 affiliated C&T centers. Additionally, we assessed decentralization's population-level impacts by comparing proportions of women and infants receiving interventions before (2009-2010) and after (2011-2013) decentralization.

RESULTS

Among newly HIV-diagnosed women (N = 1482), the 14-week cumulative incidence of receiving the package of CD4 testing and zidovudine or antiretroviral therapy was less at ANC/L&D [66%; 95% confidence interval (CI): 63% to 69%] than at C&T (88%; 95% CI: 83% to 92%) sites (subdistribution hazard ratio, 0.62; 95% CI: 0.55 to 0.69). Delivery of cotrimoxazole and DNA polymerase chain reaction testing to HIV-exposed infants (N = 1182) was inferior at ANC/L&D sites (subdistribution hazard ratio, 0.84; 95% CI: 0.76 to 0.92); the 10-month cumulative incidence of the package at ANC/L&D sites was 89% (95% CI: 82% to 93%) versus 97% (95% CI: 93% to 99%) at C&T centers. Receipt of the pregnancy (20% of 1518, to 64% of 1405) and infant (16%-31%) packages improved post decentralization.

CONCLUSIONS

Services were delivered less efficiently at ANC/L&D sites than C&T centers. Although access improved with decentralization, its potential cannot be realized without sufficient and sustained support.

Implementation and Operational Research: Maternal Combination Antiretroviral Therapy Is Associated With Improved Retention of HIV-Exposed Infants in Kinshasa, Democratic Republic of Congo

BACKGROUND

Programs to prevent mother-to-child HIV transmission are plagued by loss to follow-up (LTFU) of HIV-exposed infants. We assessed if providing combination antiretroviral therapy (cART) to HIV-infected mothers was associated with reduced LTFU of their HIV-exposed infants in Kinshasa, DR Congo.

METHODS

We constructed a cohort of mother-infant pairs using routinely collected clinical data. Maternal cART eligibility was based on national guidelines in effect at the time. Infants were considered LTFU after 3 failed tracking attempts after a missed visit or if more than 6 months passed since they were last seen in clinic. Statistical methods accounted for competing risks (eg, death).

RESULTS

A total of 1318 infants enrolled at a median age of 2.6 weeks (interquartile range: 2.1-6.9), at which point 24% of mothers were receiving cART. Overall, 5% of infants never returned to care after enrollment and 18% were LTFU by 18 months. The 18-month cumulative incidence of LTFU was 8% among infants whose mothers initiated cART by infant enrollment and 20% among infants whose mothers were not yet on cART. Adjusted for baseline factors, infants whose mothers were not on cART were over twice as likely to be LTFU, with a subdistribution hazard ratio of 2.75 (95% confidence limit: 1.81 to 4.16). The association remained strong regardless of maternal CD4 count at infant enrollment.

CONCLUSIONS

Increasing access to cART for pregnant women could improve retention of HIV-exposed infants, thereby increasing the clinical and population-level impacts of prevention of mother-to-child HIV transmission interventions and access to early cART for HIV-infected infants.

[HIV testing among women in delivery rooms in Lubumbashi, Democratic Republic of the Congo: a catch-up strategy for prevention of mother-to-child transmission]

BACKGROUND

Although HIV testing is offered during antenatal care, the proportion of women giving birth without knowing their HIV status is still important in DR Congo. The objective of this study was to determine the acceptability of rapid HIV testing among parturients in labor room, and to identify factors that are associated with the acceptability of HIV testing.

METHODS

Intervention including rapid HIV testing among pregnant women in labor rooms in Lubumbashi for 5 months, from September 2010 to February 2011. Pregnant women who tested HIV positive were attended by prevention of mother-to-child transmission service. Descriptive statistical analysis and logistic regression were performed.

RESULTS

Among 474 pregnant women who enter the labor room, 433 (91.4%; confidence interval [CI]: 95%: 88.4-93.7%) had voluntary testing for HIV in the labor room after counseling. The acceptance of rapid testing for HIV was significantly higher when the duration of counseling was less or equal to 5 minutes (adjusted Odds ratio [aOR]=5.8; [CI] 95%: 2.6-13); among those who did not report having this screening test during antenatal care (aOR=3.8; [CI] 95%: 2-7.8), among those who were in early labor (aOR=2.3; [CI] 95%: 1.2-4.7) and lower in adolescents than in adults (aOR=0.1; [CI] 95%: 0.0-0.7).

CONCLUSION

Counseling and voluntary HIV testing are accepted in our labor rooms. Consistently offering this service in the labor room could be a catch-up strategy to be combined with antenatal care testing.

Modelling the global competing risks of a potential interaction between injectable hormonal contraception and HIV risk

BACKGROUND

Some, but not all, observational studies have suggested an increase in the risk of HIV acquisition for women using injectable hormonal contraception (IHC).

METHODS

We used country-level data to explore the effects of reducing IHC use on the number of HIV infections, the number of live births and the resulting net consequences on AIDS deaths and maternal mortality for each country.

RESULTS

High IHC use coincides with high HIV incidence primarily in southern and eastern Africa. If IHC increases the risk of HIV acquisition, this could generate 27 000-130 000 infections per year globally, 87-88% of which occur in this region. Reducing IHC use could result in fewer HIV infections but also a substantial increase in live births and maternal mortality in countries with high IHC use, high birth rates and high maternal mortality: mainly southern and eastern Africa, South-East Asia, and Central and South America. For most countries, the net impact of reducing IHC use on maternal and AIDS-related deaths is dependent on the magnitude of the assumed IHC-HIV interaction.

CONCLUSIONS

If IHC use increases HIV acquisition risk, reducing IHC could reduce new HIV infections; however, this must be balanced against other important consequences, including unintended pregnancy, which impacts maternal and infant mortality. Unless the true effect size approaches a relative risk of 2.19, it is unlikely that reductions in IHC could result in public health benefit, with the possible exception of those countries in southern Africa with the largest HIV epidemics.

The infant feeding choices and experiences of women living with HIV in Kinshasa, Democratic Republic of Congo

HIV transmission through breastfeeding is a significant public health challenge. While breastfeeding provides important nutrition, and results in reduced morbidity and mortality, there is a risk of HIV transmission through breastfeeding. International prevention of mother-to-child transmission (PMTCT) guidelines recommend exclusive breastfeeding for six months among HIV-infected women on antiretroviral therapy. Promoting exclusive feeding has proved difficult in settings where mixed feeding is a cultural norm. Understanding the factors that influence HIV infected women's infant feeding choices and practices is critical to promoting adherence to PMTCT guidelines. We conducted in-depth interviews with 40 HIV+ pregnant and post-partum women in Kinshasa, Democratic Republic of Congo to understand their infant feeding experiences. Interviews were conducted in Lingala, and transcribed and translated into French for analysis. Deductive and inductive codes were applied, and matrices were created to facilitate cross-case analysis. Women had limited understanding of the specific mechanisms through which their infant feeding practices influenced HIV transmission risk. Clinical staff was the primary source of women's knowledge of HIV mother-to-child-transmission. Among the 24 post-partum women in the sample, seven women adhered to exclusive breastfeeding and two women to exclusive formula feeding for at least six months. Women's beliefs and awareness about HIV transmission through breastfeeding, as well as the information and support from clinical staff and other members of their support networks positively influenced their exclusive feeding. Common barriers to exclusive feeding included financial constraints, breast health problems, misinformation about HIV transmission, local norms, and prior feeding experiences. Health care workers play a key role in providing correct information on PMTCT and supporting women's infant feeding choices to adhere to guidelines of exclusive infant feeding. Optimizing provider-patient communication and creating a supportive environment surrounding infant feeding is critical.

High HIV type 1 group M pol diversity and low rate of antiretroviral resistance mutations among the uniformed services in Kinshasa, Democratic Republic of the Congo

For the first time the genetic diversity among the uniformed personnel in Kinshasa, the capital city of the Democratic Republic of Congo (DRC), a country that has experienced military conflicts since 1998 and in which the global HIV-1/M pandemic started, has now been documented. A total of 94 HIV-1-positive samples, collected in 2007 in Kinshasa garrison settings from informed consenting volunteers, were genetically characterized in the pol region (protease and RT). An extensive diversity was observed, with 51% of the strains corresponding to six pure subtypes (A 23%, C 13.8%, D, G, H, J, and untypable), 15% corresponding to nine different CRFs (01, 02, 11, 13, 25, 26, 37, 43, and 45), and 34% being unique recombinants with one-third being complex mosaic viruses involving three or more different subtypes/CRFs. Only one strain harbored a single mutation, I54V, associated with drug resistance to protease inhibitors. Due to their high mobility and potential risk behavior, HIV infections in military personnel can lead to an even more complex epidemic in the DRC and to a possible increase of subtype C.