Brief Report: HIV Testing Among Pregnant Women Who Attend Antenatal Care in Malawi

Spatial patterns and associated factors of HIV testing and counselling (HTC) as a component of antenatal care services in Ethiopia

BACKGROUND

While HIV testing and counselling play a crucial role in preventing mother-to-child transmission, numerous pregnant women did not receive these services. Understanding the spatial variation of HIV testing and counselling and its associated factors during antenatal care in Ethiopia remains limited. Thus, this study was aimed at assessing the spatial patterns and factors associated with HIV testing and counselling during antenatal care visits in Ethiopia.

METHODS

A cross-sectional study design was employed with a two-stage stratified cluster sampling technique. A total of 2,789 women who gave birth in the two years prior to the survey and had at least one antenatal care visit were included in the study. Stata version 16 and ArcGIS version 10.8 software were used for analysis. A multilevel robust Poisson regression model was fitted to identify significantly associated factors since the prevalence of HIV testing and counselling was higher than 10%. A statistically significant association was declared based on multivariable multilevel robust Poisson regression analysis using an adjusted prevalence ratio with its 95% confidence interval at a p-value < 0.05. Spatial regression analysis was conducted, and the local coefficients of statistically significant spatial covariates were visualised.

RESULTS

In Ethiopia, the overall prevalence of HIV testing and counselling during antenatal care visits was 29.5% (95% CI: 27.8%, 31.2%). Significant spatial clustering was observed (Global Moran's I = 0.138, p-value <0.001). In the spatial regression analysis, high and comprehensive knowledge related to HIV, and comprehensive knowledge on the prevention of mother-to-child transmission were significant explanatory variables for the spatial variation of HIV testing and counselling. In the multivariable multilevel robust Poisson regression analysis, education, household wealth, media exposure, number of antenatal care visits, comprehensive knowledge on mother-to-child transmission, comprehensive knowledge on prevention of mother-to-child transmission, and region were significantly associated factors.

CONCLUSION

The prevalence of HIV testing and counselling during antenatal care visits was low. Empowering women through education, promoting mass media exposure, increasing numbers of antenatal care visits, and enhancing women's knowledge related to HIV and mother-to-child transmission by targeting cold spot areas could improve HIV testing and counselling service uptake among pregnant women in Ethiopia.

Measuring Socioeconomic Inequalities in HIV Testing During Antenatal Care: A Peruvian National Survey

Although several Latin American countries have 70% antenatal care coverage, the proportion of human immunodeficiency virus (HIV) testing of Peruvian pregnant women and the socioeconomic inequalities of this preventive measure are unknown. This study aimed to determine socioeconomic inequalities and quantify the contribution of contextual and compositional factors on HIV testing during prenatal care in Peru. A cross-sectional study of the 2021 Demographic and Family Health Survey data was conducted. The outcome variable was HIV testing of pregnant women during prenatal care. An analysis of inequalities was performed including the determination of concentration curves and a decomposition analysis of concentration indices. Of a total of 17521 women aged 15 to 49 years, 91.4% had been tested for HIV during prenatal care. The concentration curves showed that prenatal HIV testing was concentrated among richer women, while the decomposition analysis determined that the main contributors to inequality were having a higher education, residing in an urban area, and in the highlands, belonging to the wealthy quintile, and being exposed to television and newspapers. Strategies focused on improving access, promotion and restructuring of prevention of mother-to-child transmission measures should be prioritized.

Factors affecting antenatal screening for HIV in Nepal: results from Nepal Demographic and Health Surveys 2016 and 2022

OBJECTIVES

Antenatal screening for HIV remains low in Nepal. Identifying factors associated with the uptake of antenatal screening is essential to increase uptake and prevent mother-to-child transmission (MTCT). This study investigated the effects of individual-level and district-level characteristics on the utilisation of antenatal screening for HIV in Nepal and how these effects changed between 2016 and 2022.

DESIGN

We used publicly available cross-sectional data from 2016 to 2022 Nepal Demographic and Health Surveys.

SETTING

Stratified, multistage, random sampling was used to collect nationally representative data.

PARTICIPANTS

1978 and 2007 women aged 15-49 years who gave birth in the 2 years preceding the surveys.

PRIMARY AND SECONDARY OUTCOME MEASURES

We used multilevel models to estimate associations between antenatal screening and potential factors influencing it in 2016 and 2022. We used districts as a random effect and looked at the intraclass correlation coefficients to disentangle the geographical effects. To distinguish barriers to HIV screening from barriers to accessing antenatal care (ANC) services, we performed similar analyses with whether the woman attended at least one ANC visit as the dependent variable.

RESULTS

Factors associated with antenatal screening have not changed significantly between 2016 and 2022. Higher uptake of HIV screening was found among women with higher education, the pregnancy being desired later and women who had four or more ANC visits. Being from a poorer family and having low knowledge of MTCT and the medicines to prevent transmission were associated with lower uptake. From the supply side, no factors had a significant effect on antenatal screening. Factors associated with antenatal screening and those associated with any ANC were different. Our results also showed a partial importance of geographical factors on screening uptake.

CONCLUSIONS

Our results supported that antenatal screening could be improved by enhancing access to information and improving the availability of free screening.

Systematic review and meta-analysis of seroprevalence of human immunodeficiency virus serological markers among pregnant women in Africa, 1984-2020

BACKGROUND

Human immunodeficiency virus (HIV) is a major public health concern, particularly in Africa where HIV rates remain substantial. Pregnant women are at an increased risk of acquiring HIV, which has a significant impact on both maternal and child health.

AIM

To review summarizes HIV seroprevalence among pregnant women in Africa. It also identifies regional and clinical characteristics that contribute to study-specific estimates variation.

METHODS

The study included pregnant women from any African country or region, irrespective of their symptoms, and any study design conducted in any setting. Using electronic literature searches, articles published until February 2023 were reviewed. The quality of the included studies was evaluated. The DerSimonian and Laird random-effects model was applied to determine HIV pooled seroprevalence among pregnant women in Africa. Subgroup and sensitivity analyses were conducted to identify potential sources of heterogeneity. Heterogeneity was assessed with Cochran's Q test and I2 statistics, and publication bias was assessed with Egger's test.

RESULTS

A total of 248 studies conducted between 1984 and 2020 were included in the quantitative synthesis (meta-analysis). Out of the total studies, 146 (58.9%) had a low risk of bias and 102 (41.1%) had a moderate risk of bias. No HIV-positive pregnant women died in the included studies. The overall HIV seroprevalence in pregnant women was estimated to be 9.3% [95% confidence interval (CI): 8.3-10.3]. The subgroup analysis showed statistically significant heterogeneity across subgroups (P < 0.001), with the highest seroprevalence observed in Southern Africa (29.4%, 95%CI: 26.5-32.4) and the lowest seroprevalence observed in Northern Africa (0.7%, 95%CI: 0.3-1.3).

CONCLUSION

The review found that HIV seroprevalence among pregnant women in African countries remains significant, particularly in Southern African countries. This review can inform the development of targeted public health interventions to address high HIV seroprevalence in pregnant women in African countries.

Sub optimal HIV status ascertainment at antenatal clinics and the impact on HIV prevalence estimates: A cross sectional study

BACKGROUND

While many countries including Kenya transitioned from sentinel surveillance to the use of routine antenatal care (ANC) data to estimate the burden of HIV, countries in Sub Saharan Africa reported several challenges of this transition, including low uptake of HIV testing and sub national / site-level differences in HIV prevalence estimates. In Kenya voluntary HIV testing is offered to all 1st ANC clients. However, some women may decline testing. We aim to predict the HIV positivity (as a proxy of prevalence) at ANC assuming 100% uptake of HIV testing and compare this to the observed positivity.

METHODS

Using a cross sectional study design, we examine routine data on HIV testing among all women attending ANC in Kwale County, Kenya, for the period January 2015 to December 2019.We used a generalized estimating equation with binomial distribution to model the observed HIV prevalence as explained by HIV status ascertainment. We then used marginal standardization to predict the HIV prevalence at 100% HIV status ascertainment and make recommendations to improve the utility of ANC routine data for HIV surveillance.

RESULTS

HIV testing at ANC was at 91.3%, slightly above the global target of 90%. If there was 100% HIV status ascertainment at ANC, the HIV prevalence would be 2.7% (95% CI 2.3-3.2). This was 0.3% lower than the observed prevalence. Across the yearly predictions, there was no difference between the observed and predicted values except for 2018 where the HIV prevalence was underestimated with an absolute bias of -0.2 percent. This implies missed opportunities for identifying new HIV infections in the year 2018.

CONCLUSIONS

Imperfect HIV status ascertainment at ANC overestimates HIV prevalence among women attending ANC in Kwale County. However, the use of ANC routine data may underestimate the true population prevalence. There is need to address both community level and health facility level barriers to the uptake of ANC services.

HIV Testing among sexually active Ghanaians: an examination of the rural-urban correlates

HIV testing is critical in reducing the risk of HIV transmission. We investigated the rural-urban correlates of HIV testing amongst sexually active Ghanaians using data from the 2017/2018 Ghana Multiple Indicator Cluster Survey Six (GMICS 6). Robust Poisson models (reporting Adjusted Prevalence Ratios (APR) and 95% Confidence Intervals (CIs)) were used to achieve this aim. About 46% of the participants had ever tested for HIV. According to the results, approximately 52% and 39% of urban and rural dwellers, respectively, have undergone HIV testing. HIV knowledge, HIV stigma, gender, age, education, marital status, childbirth history, sexual history, health insurance coverage, media exposure, household wealth, and region of residence were significantly related to HIV testing with observed variations across rural-urban areas. The findings call for the expansion of advocacy efforts towards encouraging HIV testing, targeting sexually active Ghanaians particularly in rural areas.

Socioeconomic Inequalities and HIV Testing During Antenatal Care in High- Medium- and Low-Conflict Intensity Countries in Sub-Saharan Africa

Understanding HIV testing determinants in different settings is vital to reducing new infections. This study assessed HIV testing rates during antenatal care (ANC) in seven sub-Saharan African countries designated as high, medium, low or no conflict intensity settings. We ranked and plotted concentration curves for HIV testing by socioeconomic inequality and determined their concentration indices (CCI). Testing for HIV during ANC was highest in Zimbabwe (95.7%) and lowest in Sudan (3.6%). Countries with medium and high conflict intensity experienced higher HIV testing inequality (CCI = 0.38) than countries with low or no conflict (CCI = 0.15). Low HIV testing rates were associated with no education, rural areas, poorest wealth index quintiles and home birth, which demonstrate that determinants of HIV testing during ANC in conflict-affected areas are complex and context-based. Programme implementation and policymakers must acknowledge these complexities and local contexts in their program designs and planning.

Prevalence and Associated Factors of HIV Testing Among Pregnant Women: A Multilevel Analysis Using the Recent Demographic and Health Survey Data from 11 East African Countries

Aim

In developing countries, particularly in sub-Saharan Africa, the burden of mother to child transmission (MTCT) of HIV is higher. Although the Joint United Nations Programme on HIV/AIDS (UNAIDS) and other organizations are working to eliminate MTCT, a large number of pregnant women are not screened for HIV in most African countries.

Methods

The demographic health survey (DHS) used two-stage stratified sampling technique to select the study participants and we appended the most recent DHS done in the 11 East African countries. A weighted sample of 53, 420 women were included. A multilevel logistic regression analysis was used due to the hierarchical structure of the DHS data. To determine whether or not there was a clustering, the Interclass Correlation Coefficient (ICC) and Median Odds Ratio (MOR) were determined. Model comparison was conducted using deviance (−2LL).

Results

The prevalence of HIV testing among pregnant women was 77.56% [95% CI= 77.20%, 77.91%]. In the Multivariable multi-level analysis, variables such as respondent age, wealth index, marital status, educational level, HIV knowledge, HIV stigma indicator, risky sexual activity, women visiting health care facilities, multiple sexual partnership, early sexual initiation, and awareness about MTCT were the individual-level factors that were associated with HIV testing among pregnant women. While residence and community-level education were the community-level factors that were significantly associated with HIV testing.

Conclusion

The prevalence of HIV testing and counseling among pregnant women was higher compared to the previous report. Respondent age, wealth index, marital status, educational level, HIV knowledge, HIV stigma indicator, risky sexual activity, women visiting health care facilities, multiple sexual partnership, early sexual initiation, residence, community-level education and awareness about MTCT were the significant determinant of HIV testing.

Socio-cultural and economic barriers, and facilitators influencing men's involvement in antenatal care including HIV testing: a qualitative study from urban Blantyre, Malawi

Background

Male partner involvement in antenatal care (ANC) is associated with positive maternal and neonatal outcomes. However, only a handful of men attend ANC with their partners. This study aimed to understand the underlying barriers and facilitators influencing men’s ANC attendance including HIV testing in Blantyre, Malawi.

Methods

Data were collected during a formative qualitative study of a cluster-randomised trial. Six focus group discussions (FGDs) with 42 men and women and 20 in-depth interviews (IDIs) were conducted at three primary health centres in urban Blantyre, Malawi. FGD participants were purposively sampled with IDI participants subsequently sampled after FGD participation. Thematic analysis was used to analyse the data.

Results

The economic requirement to provide for their families exerted pressure on men and often negatively affected their decision to attend ANC together with their pregnant partners despite obvious benefits. Peer pressure and the fear to be seen by peers queueing for services at ANC, an environment traditionally viewed as a space for women and children made men feel treated as trespassers and with some level of hostility rendering them feeling emasculated when they attend ANC. Health system problems associated with overall organization of the ANC services, which favours women created resistance among men to be involved. An association between ANC and HIV testing services discouraged men from attending ANC because of their fear of testing HIV-positive in the presence of their partners. The availability of a male friendly clinic offering a private, quick, supportive/sensitive and flexible service was considered to be an important incentive that would facilitate men’s ANC attendance. Men described compensation to cover transport and opportunity cost for attending the clinic as a motivator to attending ANC services and accepting an HIV test.

Conclusion

Peer and economic influences were the most influential barriers of men attending ANC and testing for HIV with their pregnant partners. Addressing these socio-economic barriers and having a male friendly clinic are promising interventions to promote male ANC attendance in this setting.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-10112-w.

HIV surveillance based on routine testing data from antenatal clinics in Malawi (2011-2018): measuring and adjusting for bias from imperfect testing coverage

Supplemental Digital Content is available in the text

Objective:

The use of routinely collected data from prevention of mother-to-child transmission programs (ANC-RT) has been proposed to monitor HIV epidemic trends. This poses several challenges for surveillance, one of them being that women may opt-out of testing and/or test stock-outs may result in inconsistent service availability. In this study, we sought to empirically quantify the relationship between imperfect HIV testing coverage and HIV prevalence among pregnant women from ANC-RT data.

Design:

We used reports from the ANC Register of all antenatal care (ANC) sites in Malawi (2011–2018), including 49 244 monthly observations, from 764 facilities, totaling 4 375 777 women.

Methods:

Binomial logistic regression models with facility-level fixed effects and marginal standardization were used to assess the effect of testing coverage on HIV prevalence.

Results:

Testing coverage increased from 78 to 98% over 2011–2018. We estimated that, had testing coverage been perfect, prevalence would have been 0.4% point lower (95% CI 0.3–0.5%) than the 7.9% observed prevalence, a relative overestimation of 6%. Bias in HIV prevalence was the highest in 2012, when testing coverage was lowest (72%), resulting in a relative overestimation of HIV prevalence of 15% (95% CI 12–17%). Overall, adjustments for imperfect testing coverage led to a subtler decline in HIV prevalence over 2011--2018.

Conclusion:

Malawi achieved high coverage of routine HIV testing in recent years. Nevertheless, imperfect testing coverage can lead to overestimation of HIV prevalence among pregnant women when coverage is suboptimal. ANC-RT data should be carefully evaluated for changes in testing coverage and completeness when used to monitor epidemic trends.

Implementing prevention policies for mother-to-child transmission of HIV in rural Malawi, South Africa and United Republic of Tanzania, 2013-2016

OBJECTIVE

To assess adoption of World Health Organization (WHO) guidance into national policies for prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV) and to monitor implementation of guidelines at facility level in rural Malawi, South Africa and the United Republic of Tanzania.

METHODS

We summarized national PMTCT policies and WHO guidance for 15 indicators across the cascades of maternal and infant care over 2013-2016. Two survey rounds were conducted (2013-2015 and 2015-2016) in 46 health facilities serving five health and demographic surveillance system populations. We administered structured questionnaires to facility managers to describe service delivery. We report the proportions of facilities implementing each indicator and the frequency and durations of stock-outs of supplies, by site and survey round.

FINDINGS

In all countries, national policies influencing the maternal and infant PMTCT cascade of care aligned with WHO guidelines by 2016; most inter-country policy variations concerned linkage to routine HIV care. The proportion of facilities delivering post-test counselling, same-day antiretroviral therapy (ART) initiation, antenatal care and ART provision in the same building, and Option B+ increased or remained at 100% in all sites. Progress in implementing policies on infant diagnosis and treatment varied across sites. Stock-outs of HIV test kits or antiretroviral drugs in the past year declined overall, but were reported by at least one facility per site in both rounds.

CONCLUSION

Progress has been made in implementing PMTCT policy in these settings. However, persistent gaps across the infant cascade of care and supply-chain challenges, risk undermining infant HIV elimination goals.

National estimates and risk factors associated with early mother-to-child transmission of HIV after implementation of option B+: a cross-sectional analysis

BACKGROUND

Routine data from Malawi's prevention of mother-to-child transmission (MTCT) option B+ programme suggest high uptake of antiretroviral therapy (ART) among pregnant women. Malawi's Ministry of Health led the National Evaluation of Malawi's PMTCT Program to obtain nationally representative data on maternal ART coverage and prevention of MTCT effectiveness. Here, we present the early transmission data for infants aged 4-12 weeks.

METHODS

We used a multistage cluster design to recruit a nationally representative sample of HIV-exposed infants and their mothers in Malawi. Between October 16, 2014, and May 17, 2016, we screened for HIV in all mothers attending an under-5 vaccination or outpatient sick-child clinic with infants aged 4-26 weeks at 54 health facilities selected across ten districts and four regional sampling zones. Infants with mothers identified as HIV-infected were enrolled in the cohort. We calculated weighted MTCT rates for only the subset of infants aged 4-12 weeks at screening, thereby capturing MTCT from early pregnancy, to delivery, and early breastfeeding. We collected data on maternal and infant demographics and self-reported use of HIV services, ART, and antenatal clinics. We tested HIV-exposed infants for the virus and assessed associations of certain variables with infant HIV status.

FINDINGS

We confirmed HIV exposure in 3542 (10·4%) of 33 980 mother (guardian)-infant pairs with infants aged 4-26 weeks. Of those, 2530 (2514 mothers and 16 guardians) had infants aged 4-12 weeks at the time of screening (2498 singlets and 32 twins). We excluded 25 infants from the analysis because no information was available about their HIV status. 91·3% (95% CI 85·6-96·9) of mothers were on ART during pregnancy. The MTCT rate was 3·7% (2·3-6·0) overall and ranged from 1·4% (0·4-4·4) in women who initiated ART before pregnancy to 19·9% (13·4-28·6) in women not on ART. In multivariable logistic regression analysis, the odds of early MTCT were higher in mothers starting ART post partum (adjusted odds ratio 16·7, 95% CI 1·6-171·5; p=0·022) and in those not on ART with an unknown HIV status during pregnancy (19·1, 8·5-43·0; p<0·0001) than in mothers on ART before pregnancy. Among HIV-exposed infants, 98·0% (95% CI 96·9-99·1) were reported by the mother to have received infant nevirapine prophylaxis, and only 45·6% (34·8-56·4) were already enrolled in an exposed infant HIV care clinic at the time of study screening.

INTERPRETATION

These data suggest that Malawi's decentralisation of ART services has resulted in higher ART coverage and lower early MTCT. However, the uptake of services for HIV-exposed infants remains suboptimal.

FUNDING

President's Emergency Plan for AIDS Relief.

Patterns of caesarean section in HIV infected and non-infected women in Malawi: is caesarean section used for PMTCT?

Background

Caesarean section (CS) is not recommended for PMTCT in Malawi HIV Guidelines, contrary to most high-income countries where CS is indicated if viral suppression is sub-optimal pre-delivery. We describe patterns of CS in HIV-infected and uninfected women in Malawi and explored if insight into the use of Elective CS (ECS) for PMTCT could be obtained.

Methods

We used routinely collected data from individual medical records from 17 large health facilities in the central and southern regions of Malawi, from January 2010 to December 2013. We included data from maternity registers from all HIV-positive women, and randomly selected around every fourth woman with negative or unknown HIV status. We used multivariable logistic regressions and cluster-based robust standard errors to examine independent associations of patient- and facility characteristics with CS and ECS.

Results

We included 62,033 women in the analysis. The weighted percentage of women who had a spontaneous vaginal delivery was 80.0% (CI 95% 79.5–80.4%); 2.4% (95% CI 2.3–2.6%) had a vacuum extraction; 2.3% (95% CI 2.2–2.5%) had a vaginal breech delivery; 14.0% (95% CI 13.6–14.4%) had a CS while for 1.3% (95% CI 1.2–1.4%) the mode of delivery was not recorded. Prevalence of CS without recorded medical or obstetric indication (ECS) was 5.1%, (n = 3152). Presence of maternal and infant complications and older age were independently associated with CS delivery. HIV-positive women were less likely to have ECS than HIV negative women (aOR 0.65; 95%-CI 0.57–0.74). Among HIV-positive women, those on antiretrovirals (ARV’s) for ≥4 weeks prior to delivery were less likely to have ECS than HIV-positive women who had not received ARVs during pregnancy (aOR 0.81; 95% CI 0.68–0.96).

Conclusions

The pattern of CS’s in Malawi is largely determined by maternal and infant complications. Positive HIV status was negatively associated with CS delivery, possibly because health care workers were concerned about the risk of occupational HIV transmission and the known increased risk of post-operative complications. Our results leave open the possibility that CS is practiced to prevent MTCT given that ECS was more common among women at high risk of MTCT due to no or short exposure to ARV’s.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-1722-4) contains supplementary material, which is available to authorized users.

"We have heard it together": a qualitative analysis of couple HIV testing and counselling recruitment in Malawi's Option B+ programme

Encouraging HIV-infected pregnant women to recruit male partners for couple HIV testing and counselling (CHTC) is promoted by the World Health Organization, but remains challenging. Formal strategies for recruiting the male partners of pregnant women have not been explored within an Option B+ programme. Our objective was to learn about experiences surrounding CHTC recruitment within a formal CHTC recruitment study. A randomised controlled trial comparing two CHTC recruitment strategies was conducted among HIV-infected pregnant women presenting to Bwaila Antenatal Unit in 2014. Women were randomised to receive an invitation to attend the clinic as a couple or this invitation plus clinic-led phone and community tracing. A qualitative study was conducted with a subset of participants to learn about recruitment. This paper describes experiences of a subset of HIV-infected pregnant women (N = 20) and male partners (N = 17). One on one in-depth interviews were audio-recorded, transcribed, translated, and coded using content analysis. Nearly all women presented the invitation and disclosed their HIV-positive status to their partners on the day of HIV diagnosis, often to facilitate pill-taking. Men and women in both arms perceived the messages to be more compelling since they came from the clinic, rather than the woman herself. Couples who attended CHTC displayed greater care for one another and mutual support for HIV-related behaviours. Facilitating CHTC with invitations and tracing can support CHTC uptake and support for HIV-affected couples. In an Option B+ context, inviting partners for CHTC can facilitate male involvement and have important benefits for families.

INDIVIDUAL- AND COMMUNITY-LEVEL DETERMINANTS OF ANTENATAL HIV TESTING IN ZIMBABWE

This study contributes to the dialogue on the prevention of mother-to-child HIV transmission (PMTCT) through the use of HIV and antenatal care (ANC) integrated services. The determinants of antenatal HIV testing in Zimbabwe were explored. Multilevel logistic regression models were applied to data for 8471 women from 406 clusters who gave birth in the 5 years preceding Zimbabwe Demographic and Health Surveys conducted in 2005/6 and 2010/11. The uptake of antenatal HIV testing was found to be determined by a wide range of individual-level factors relating to women's economic and demographic status, as well as HIV-related factors, including HIV awareness and stigma within the community. Important individual-level enabling and perceived need factors included high socioeconomic status, not having observed HIV-related stigma and knowledge of HIV status (based on a previous HIV test), such that these groups of individuals had a significantly higher likelihood of being tested for HIV during pregnancy than their counterparts of lower socioeconomic status, and who had observed HIV-related stigma or did not know their HIV status. The results further revealed that community HIV awareness is important for improving antenatal HIV testing, while stigma is associated with reduced testing uptake. Most contextual community-level factors were not found to have much effect on the uptake of antenatal HIV testing. Therefore, policies should focus on individual-level predisposing and enabling factors to improve the uptake of antenatal HIV testing in Zimbabwe.

HIV transmission and retention in care among HIV-exposed children enrolled in Malawi's prevention of mother-to-child transmission programme

Introduction: In Malawi, HIV-infected pregnant and breastfeeding women are offered lifelong antiretroviral therapy (ART) regardless of CD4 count or clinical stage (Option B+). Their HIV-exposed children are enrolled in the national prevention of mother-to-child transmission (PMTCT) programme, but many are lost to follow-up. We estimated the cumulative incidence of vertical HIV transmission, taking loss to follow-up into account.

Methods: We abstracted data from HIV-exposed children enrolled into care between September 2011 and June 2014 from patient records at 21 health facilities in central and southern Malawi. We used competing risk models to estimate the probability of loss to follow-up, death, ART initiation and discharge, and used pooled logistic regression and inverse probability of censoring weighting to estimate the vertical HIV transmission risk.

Results: A total of 11,285 children were included; 9285 (82%) were born to women who initiated ART during pregnancy. At age 30 months, an estimated 57.9% (95% CI 56.6–59.2) of children were lost to follow-up, 0.8% (0.6–1.0) had died, 2.6% (2.3–3.0) initiated ART, 36.5% (35.2–37.9) were discharged HIV-negative and 2.2% (1.5–2.8) continued follow-up. We estimated that 5.3% (95% CI 4.7–5.9) of the children who enrolled were HIV-infected by the age of 30 months, but only about half of these children (2.6%; 95% CI 2.3–2.9) were diagnosed.

Conclusions: Confirmed mother-to-child transmission rates were low, but due to poor retention only about half of HIV-infected children were diagnosed. Tracing of children lost to follow-up and HIV testing in outpatient clinics should be scaled up to ensure that all HIV-positive children have access to early ART.

The Impact of Couple HIV Testing and Counseling on Consistent Condom Use Among Pregnant Women and Their Male Partners: An Observational Study

BACKGROUND

In sub-Saharan Africa couple HIV testing and counseling (CHTC) has been associated with substantial increases in safe sex, especially when at least one partner is HIV infected. However, this relationship has not been characterized in an Option B+ context.

SETTING

The study was conducted at the antenatal clinic at Bwaila District Hospital in Lilongwe, Malawi in 2016 under an Option B+ program.

METHODS

Ninety heterosexual couples with an HIV-infected pregnant woman (female-positive couples) and 47 couples with an HIV-uninfected pregnant woman (female-negative couples) were enrolled in an observational study. Each couple member was assessed immediately before and 1 month after CHTC for safe sex (abstinence or consistent condom use in the last month). Generalized estimating equations were used to model change in safe sex before and after CHTC and to compare safe sex between female-positive and female-negative couples.

RESULTS

Mean age was 26 years among women and 32 years among men. Before CHTC, safe sex was comparable among female-positive couples (8%) and female-negative couples (2%) [risk ratio (RR): 3.7, 95% confidence interval (CI): 0.5 to 29.8]. One month after CHTC, safe sex was higher among female-positive couples (75%) than among female-negative couples (3%) (RR: 30.0, 95% CI: 4.3 to 207.7). Safe sex increased substantially after CTHC for female-positive couples (RR 9.6, 95% CI: 4.6 to 20.0), but not for female-negative couples (RR: 1.2, 95% CI: 0.1 to 18.7).

CONCLUSIONS

Engaging pregnant couples in CHTC can have prevention benefits for couples with an HIV-infected pregnant woman, but additional prevention approaches may be needed for couples with an HIV-uninfected pregnant woman.

HPV prevalence in women attending cervical screening in rural Malawi using the cartridge-based Xpert® HPV assay

BACKGROUND AND OBJECTIVES

Early experience with Cepheid Xpert^® HPV assay (Xpert^® HPV) suggests that its quick turnaround time and ease of application might make it a relevant contender for routine use in low and middle income countries (LMICs). In the context of a cervical screening service in rural Malawi, we aimed to assess practicalities of local laboratory testing with Xpert^® HPV and provide preliminary high-risk HPV (HR-HPV) prevalence data.

STUDY DESIGN

Liquid-based cytology (LBC) specimens were collected from women attending cervical screening clinics in Nkhoma, Malawi. Xpert^® HPV testing was carried out according to manufacturer's instructions. Partial genotyping results were obtained immediately (HPV 16, 18/45 and HR-HPV 'other'). Review of individual channel data provided further breakdown of other HR-HPV types into HPV 31 and related; HPV 51/59 and HPV 39 and related.

RESULTS

Valid HR-HPV results were obtained from 750/763 samples. Most samples were from previously unscreened women, with 92.3% aged between 20 and 60 years. Overall HR-HPV positivity was 19.9%, with HR-HPV 'other' being more than twice as frequent as HPV 16 or HPV 18/45 and HPV 31-related (HPV 31, 33, 35, 52 or 58) most prevalent. Known HIV status was low (7.3%), but HR-HPV positivity in this group was much higher (43.4%).

CONCLUSIONS

HR-HPV testing using Xpert^® HPV was practical in a small rural laboratory. The rapid turnaround (within 2h) could facilitate a 'see and treat' programme. Partial genotyping allows assessment of risk beyond HPV 16/18. The high prevalence of HPV 31 and related types warrants further investigation.

Validation of a screening tool to identify older children living with HIV in primary care facilities in high HIV prevalence settings

Objective:

We previously proposed a simple tool consisting of five items to screen for risk of HIV infection in adolescents (10–19 years) in Zimbabwe. The objective of this study is to validate the performance of this screening tool in children aged 6–15 years attending primary healthcare facilities in Zimbabwe.

Methods:

Children who had not been previously tested for HIV underwent testing with caregiver consent. The screening tool was modified to include four of the original five items to be appropriate for the younger age range, and was administered. A receiver operator characteristic analysis was conducted to determine a suitable cut-off score. The sensitivity, specificity and predictive value of the modified tool were assessed against the HIV test result.

Results:

A total of 9568 children, median age 9 (interquartile, IQR: 7–11) years and 4971 (52%) men, underwent HIV testing. HIV prevalence was 4.7% (95% confidence interval, CI:4.2–5.1%) and increased from 1.4% among those scoring zero on the tool to 63.6% among those scoring four (P < 0.001). Using a score of not less than one as the cut-off for HIV testing, the tool had a sensitivity of 80.4% (95% CI:76.5–84.0%), specificity of 66.3% (95% CI:65.3–67.2%), positive predictive value of 10.4% and a negative predictive value of 98.6%. The number needed to screen to identify one child living with HIV would drop from 22 to 10 if this screening tool was used.

Conclusion:

The screening tool is a simple and sensitive method to identify children living with HIV in this setting. It can be used by lay healthcare workers and help prioritize limited resources.

Retention in care during the first 3 years of antiretroviral therapy for women in Malawi's option B+ programme: an observational cohort study

BACKGROUND

Studies of Malawi's option B+ programme for HIV-positive pregnant and breastfeeding women have reported high loss to follow-up during pregnancy and at the start of antiretroviral therapy (ART), but few data exist about retention during breastfeeding and after weaning. We examined loss to follow-up and retention in care in patients in the option B+ programme during their first 3 years on ART.

METHODS

We analysed two data sources: aggregated facility-level data about patients in option B+ who started ART between Oct 1, 2011, and June 30, 2012, at 546 health facilities; and patient-level data from 20 large facilities with electronic medical record system for HIV-positive women who started ART between Sept 1, 2011, and Dec 31, 2013, under option B+ or because they had WHO clinical stages 3 or 4 disease or had CD4 counts of less than 350 cells per μL. We used facility-level data to calculate representative estimates of retention and loss to follow-up. We used patient-level data to study temporal trends in retention, timing of loss to follow-up, and predictors of no follow-up and loss to follow-up. We defined patients who were more than 60 days late for their first follow-up visit as having no follow-up and patients who were more than 60 days late for a subsequent visit as being lost to follow-up. We calculated proportions and cumulative probabilities of patients who had died, stopped ART, had no follow-up, were lost to follow-up, or were retained alive on ART for 36 months. We calculated odds ratios and hazard ratios to examine predictors of no follow-up and loss to follow-up.

FINDINGS

Analysis of facility-level data about patients in option B+ who had not transferred to a different facility showed retention in care to be 76·8% (20 475 of 26,658 patients) after 12 months, 70·8% (18,306 of 25,849 patients) after 24 months, and 69·7% (17,787 of 25,535 patients) after 36 months. Patient-level data included 29,145 patients. 14,630 (50·2%) began treatment under option B+. Patients in option B+ had a higher risk of having no follow-up and, for the first 2 years of ART, higher risk of loss to follow-up than did patients who started ART because they had CD4 counts less than 350 cells per μL or WHO clinical stage 3 or 4 disease. Risk of loss to follow-up during the third year was low and similar for patients retained for 2 years. Retention rates did not change as the option B+ programme matured.

INTERPRETATION

Our data suggest that pregnant and breastfeeding women who start ART immediately after they are diagnosed with HIV can be retained on ART through the option B+ programme, even after many have stopped breastfeeding. Interventions might be needed to improve retention in the first year on ART in option B+.

FUNDING

Bill & Melinda Gates Foundation, Partnerships for Enhanced Engagement in Research Health, and National Institute of Allergy and Infectious Diseases.