Participation of traditional birth attendants in prevention of mother-to-child transmission of HIV services in two rural districts in Zimbabwe: a feasibility study

Maternal, Sexual and Reproductive Health in Marginalised Areas: Renewing Community Involvement Strategies beyond the Worst of the COVID-19 Pandemic

The COVID-19 pandemic and resultant lockdowns have brought unprecedented challenges for Maternal, Sexual and Reproductive Health (MSRH) services. Components of MSRH services adversely affected include antenatal, postnatal, and newborn care; provision of family planning and post-abortion care services; sexual and gender-based violence care and prevention; and care and treatment for sexually transmitted infections including HIV. Resuscitating, remodeling or inventing interventions to restore or maintain these essential services at the community level, as a gateway to higher care, is critical to mitigating short and long-term effects of the COVID-19 pandemic on essential MSRH. We propose a possible framework for community involvement and propose integrating key information, education, and communication of MSRH messages within COVID-19 messages.

Gender Equity and Vertically Transmitted Infections: A Country-Level Analysis Across 153 Countries

Purpose: Gender inequality is a barrier to education toward women and accessibility to health facilities, which are important for preventing vertical transmission. This study was conducted to analyze the impact of gender equity on vertically transmitted infections (hepatitis viruses, human immunodeficiency virus [HIV], and syphilis) using country-level indicators.

Methods: The relationship between the Global Gender Gap Index (GGGI), which is indicator of gender equity, and vertical transmission was analyzed. GGGI scores were collected from 153 countries in 2020. Vertical transmission included 10 outcomes for hepatitis viruses, HIV, and syphilis. Generalized linear model (GLM) was used for analyzing the relationship. Other predictors included skilled birth attendant and country income.

Results: The median GGGI score was 0.706 (interquartile range, 0.664–0.736). GLM showed that the GGGI score was significantly associated with the incidence of both chronic hepatitis B and C in under 5 years (both p<0.001). For HIV, GGGI score was significantly associated with the pregnant women with unknown HIV status (p=0.001), no early infant diagnosis (p=0.027), and final transmission rate (p=0.005). There was no significant predictor for pregnant women who have not received antiretroviral therapy for prevention of mother-to-child transmission. All syphilis indicators have improved in high-income countries compared to low-income countries. GGGI score had a significant association only with no syphilis screening (p<0.001).

Conclusions: A lower GGGI score was associated with higher vertical transmission of hepatitis and HIV. The improvement of gender equity might prevent vertical transmission of these viruses. Further intervention studies are warranted to verify the results.

Factors Associated With Success in Reducing HIV Mother-to-child Transmission in Sub-Saharan Africa: Interviews With Key Stakeholders

PURPOSE

A key global health challenge is the persistence of new pediatric HIV infections due to mother-to-child transmission (MCTC), particularly in sub-Saharan Africa. The purpose of this study was to identify the key strategies that some sub-Saharan African countries have used to successfully reduce new pediatric HIV infections.

METHODS

A qualitative study utilizing semistructured interviews with key stakeholders in 6 sub-Saharan African countries (Burundi, Malawi, Mozambique, South Africa, Swaziland, and Uganda) was conducted from September 2017 to September 2018. These stakeholders were situated in the National Department of Health or in international health-funding bodies relating to the provision of the HIV/AIDS implementation program in these countries. The countries were selected based on considerable success achieved with HIV treatment in pregnant women. Audio-recorded interviews were transcribed verbatim and thematic analysis was undertaken.

FINDINGS

In all, 6 interviews were conducted, and the mean time of the interviews was 62 min. There were similar numbers of men and women, and most were in the 35- to 45-year age group. Five in six were either a medical doctor or held a doctorate degree. Four in six had >10 years of experience working in the prevention of HIV (PMTCT). Four key strategies that contributed to significant reductions in pediatric HIV infection in the respective countries were identified: (1) committed political leadership; (2) support structures within the community; (3) innovation in service delivery; and (4) robust monitoring and evaluation systems. Stakeholders spoke about how their governments played a leading role in engagement with communities, and in the dissemination of services. Innovative service delivery comprising task-shifting initiatives and the integration of maternal, newborn, and child health and HIV PMCTC services played an important role in reducing the burdens experienced by women and health care workers, leading to improved health outcomes. Peer support also helped mothers to adhere to their treatment during and after pregnancy. The capacity of national programs to monitor and evaluate the PMTCT services and the importance of regular viral-load monitoring were highlighted by the stakeholders.

IMPLICATIONS

These strategies can be reviewed for possible implementation by other sub-Saharan African countries as possible means of reducing new pediatric HIV infections.

Why is mother to child transmission (MTCT) of HIV a continual threat to new-borns in sub-Saharan Africa (SSA)

Sub-Saharan Africa (SSA) accounts for more than two thirds of the world's HIV infection. Despite scaled-up prevention of mother-to-child transmission of HIV (PMTCT) programmes, mother to child transmission of HIV (MTCT) continues to escalate. We describe the challenges faced by PMTCT in MTCT in SSA. The study reviewed articles and reports published online. The most common barriers and challenges were non-disclosure of HIV status, late initiation of ARVs treatment/adherence, STIs screening, long clinics waiting time, non-involvement of men in ANC/PMTCT, infant feeding methods and sensitization of community members on ANC/PMTCT programmes. The study highlights the need to expand PMTCT coverage and the implementation of the 90-90-90 programme toward MTCT elimination in SSA. That is " ≥90% of pregnant and breast-feeding mothers must know their HIV status; ≥90% of those that are positive are enrolled on ARVs treatment and care; ≥90% of those on ARVs treatment and care are virally suppressed.

Initiation of traditional birth attendants and their traditional and spiritual practices during pregnancy and childbirth in Ghana

Background

Prior to the advent of modern obstetric services, traditional birth attendants (TBAs) have rendered services to pregnant women and women in labour for a long time. Although it is anticipated that women in contemporary societies will give birth in hospitals and clinics, some women still patronize the services of TBAs. The study therefore sought to gain an in-depth understanding of the initiation of TBAs and their traditional and spiritual practices employed during pregnancy and childbirth in Ghana.

Methods

The design was an exploratory qualitative one using in-depth individual interviews. Data saturation was reached with 16 participants who were all of Christian faith. Interviews were conducted with a semi-structured interview guide, audiotaped and transcribed verbatim. Content analysis was employed to generate findings.

Results

The findings showed that TBAs were initiated through apprenticeship from family members who were TBAs and other non-family TBAs as well as through dreams and revelations. They practice using both spiritual and physical methods and their work was founded on spiritual directions, use of spiritual artefacts, herbs and physical examination. TBAs delay cutting of the cord and disposal of the placenta was associated with beliefs which indicated that when not properly disposed, it will have negative consequences on the child during adulthood.

Conclusion

Although, TBAs like maternal health professionals operate to improve maternal health care, some of their spiritual practices and beliefs may pose threats to their clients. Nonetheless, with appropriate initiation and training, they can become useful.

Knowledge, perception, access and utilisation of HIV counselling and testing among pregnant women in rural communities of Osogbo town, Nigeria

OBJECTIVE

To assess knowledge, perception, access and utilisation of HIV counselling and testing among pregnant women from rural communities in Nigeria.

DESIGN

Descriptive cross-sectional survey.

SETTING

Primary health care facilities in rural communities of Osogbo, Osun State, Nigeria.

PARTICIPANTS

Three-hundred pregnant women attending antenatal clinics in primary health care facilities.

MAIN OUTCOME MEASURES

Knowledge of HIV counselling and testing, perception of HIV counselling and testing, utilisation of HIV counselling and testing and barriers associated with HIV counselling and testing utilisation.

RESULTS

Findings showed that 59.0% had good knowledge, while 56.7% had good perception. Majority (88.4%) of the 77.7% of respondents who reported the availability of HIV counselling and testing services said it was free and 61.3% of the respondents had HIV counselling and testing done before. Majority (78.3%) had one-on-one counselling, while a little above half (55.4%) gave consent for testing. However, less than half (36.3%) of the respondents were willing to have HIV counselling and testing done in the present pregnancy. There is significant association between the level of perception and utilisation of HIV counselling and testing. A significant association is also found between knowledge of HIV counselling and testing and utilisation. Key barriers found to be associated with utilisation of HIV counselling and testing include 'fear of how to cope with being positive' and 'absence of HIV counselling and testing centre'.

CONCLUSION

Many women selected from rural communities demonstrated good knowledge and perception of HIV counselling and testing. The majority of them also had access to HIV counselling and testing and used it. However, some still have misconception about mother-to-child transmission of HIV.

The role of Community Mobilization in maternal care provision for women in sub-Saharan Africa- A systematic review of studies using an experimental design

BACKGROUND

While the role of community mobilization in improving maternal health outcomes of HIV positive women in sub-Saharan Africa is continuously emphasized, little is known about how legitimate these claims are. The aim of this study is to systematically review the empirical evidence on this issue.

METHODS

A systematic search was conducted in PuBMed, Scopus, Web of Science, MEDLINE, COCHRANE, Allied Health Literature, and Cumulative Index to Nursing.

RESULTS

Our search identified 14 publications on the role of community mobilization in maternal care provision in sub-Saharan Africa, including both HIV negative women and women with HIV, that have used experimental research designs. Regarding HIV negative women, literature has demonstrated that community mobilization is a useful strategy for promoting both positive maternal process results and maternal health outcomes. Most of the literature on women with HIV has focused only on demonstrating the causal link between community mobilization and process results. There has been very little focus on demonstrating the causal link between community mobilization and maternal outcomes for women living with HIV. Overall, the results show that while there is some empirical evidence on a causal link between community mobilization and maternal health outcomes for HIV negative women, this kind of evidence is still missing for HIV positive women. Moreover, as shown by the studies, community mobilization as a maternal health strategy is still in its infancy.

CONCLUSION

Given the gaps identified in our review, we recommend further research with the aim of providing sound evidence on the role of community mobilization in improving maternal health outcomes of women with HIV in sub-Saharan Africa.

Increasing HIV testing among pregnant women in Nigeria: evaluating the traditional birth attendant and primary health center integration (TAP-In) model

Engaging Traditional Birth Attendants (TBAs) may be critical to preventing mother-to-child transmission of HIV (PMTCT) in Nigeria. We integrated TBAs into Primary Health Centers (PHCs) and provided the TBAs with HIV counseling and testing (HCT) training for PMTCT (TAP-In). The purpose of this study was to evaluate the impact of TAP-In on HCT uptake among pregnant women. A quasi-experimental design was used for this study. Twenty PHCs were assigned to the intervention group that integrated TAP-In and 20 were assigned to the control group. Data were collected six months prior to the initiation of TAP-In and six months post, using antenatal clinic registries. Intervention PHCs more than doubled the number of pregnant women who received HCT in their catchment area post TAP-In while control PHCs had no significant change. After initiating TAP-In, intervention PHCs provided almost three times more HCT than the control PHCs (p < 0.01) with TBA provided over half of the HCT post TAP-In. The TAP-In model was effective for increasing HCT among pregnant women.

Praying until Death: Apostolicism, Delays and Maternal Mortality in Zimbabwe

Religion affects people's daily lives by solving social problems, although it creates others. Female sexual and reproductive health are among the issues most affected by religion. Apostolic sect members in Zimbabwe have been associated with higher maternal mortality. We explored apostolic beliefs and practices on maternal health using 15 key informant interviews in 5 purposively selected districts of Zimbabwe. Results show that apostolicism promotes high fertility, early marriage, non-use of contraceptives and low or non-use of hospital care. It causes delays in recognizing danger signs, deciding to seek care, reaching and receiving appropriate health care. The existence of a customized spiritual maternal health system demonstrates a huge desire for positive maternal health outcomes among apostolics. We conclude that apostolic beliefs and practices exacerbate delays between onset of maternal complications and receiving help, thus increasing maternal risk. We recommend complementary and adaptive approaches that address the maternal health needs of apostolics in a religiously sensitive manner.

A comprehensive review of the barriers and promoters health workers experience in delivering prevention of vertical transmission of HIV services in sub-Saharan Africa

Despite significant biomedical and policy advances, 199,000 infants and young children in sub-Saharan Africa (SSA) became infected with HIV in 2013, indicating challenges to implementation of these advances. To understand the nature of these challenges, we sought to (1) characterize the barriers and facilitators that health workers encountered delivering prevention of vertical transmission of HIV (PVT) services in SSA and (2) evaluate the use of theory to guide PVT service delivery. The PubMed and CINAHL databases were searched using keywords barriers, facilitators, HIV, prevention of vertical transmission of HIV, health workers, and their synonyms to identify relevant studies. Barriers and facilitators were coded at ecological levels according to the Determinants of Performance framework. Factors in this framework were then classified as affecting motivation, opportunity, or ability, per the Motivation-Opportunity-Ability (MOA) framework in order to evaluate domains of health worker performance within each ecological level. We found that the most frequently reported challenges occurred within the health facility level and spanned all three MOA domains. Barriers reported in 30% or more of studies from most proximal to distal included those affecting health worker motivation (stress, burnout, depression), patient opportunity (stigma), work opportunity (poor referral systems), health facility opportunity (overburdened workload, lack of supplies), and health facility ability (inadequate PVT training, inconsistent breastfeeding messages). Facilitators were reported in lower frequencies than barriers and tended to be resolutions to challenges (e.g., quality supervision, consistent supplies) or responses to an intervention (e.g., record systems and infrastructure improvements). The majority of studies did not use theory to guide study design or implementation. Interventions addressing health workers' multiple ecological levels of interactions, particularly the health facility, hold promise for far-reaching impact as distal factors influence more proximal factors. Incorporating theory that considers factors beyond the health worker will strengthen endeavors to mitigate barriers to PVT service delivery.

Facility-based delivery in the context of Zimbabwe's HIV epidemic--missed opportunities for improving engagement with care: a community-based serosurvey

Background

In developing countries, facility-based delivery is recommended for maternal and neonatal health, and for prevention of mother-to-child HIV transmission (PMTCT). However, little is known about whether or not learning one’s HIV status affects one’s decision to deliver in a health facility. We examined this association in Zimbabwe.

Methods

We analyzed data from a 2012 cross-sectional community-based serosurvey conducted to evaluate Zimbabwe’s accelerated national PMTCT program. Eligible women (≥16 years old and mothers of infants born 9–18 months before the survey) were randomly sampled from the catchment areas of 157 health facilities in five of ten provinces. Participants were interviewed about where they delivered and provided blood samples for HIV testing.

Results

Overall 8796 (77 %) mothers reported facility-based delivery; uptake varied by community (30–100 %). The likelihood of facility-based delivery was not associated with maternal HIV status. Women who self-reported being HIV-positive before delivery were as likely to deliver in a health facility as women who were HIV-negative, irrespective of when they learned their status - before (adjusted prevalence ratio (PR_a) = 1.04, 95 % confidence interval (CI) = 1.00–1.09) or during pregnancy (PR_a = 1.05, 95 % CI = 1.01–1.09). Mothers who had not accessed antenatal care or tested for HIV were most likely to deliver outside a health facility (69 %). Overall, however 77 % of home deliveries occurred among women who had accessed antenatal care and were HIV-tested.

Conclusions

Uptake of facility-based delivery was similar among HIV-infected and HIV-uninfected mothers, which was somewhat unexpected given the substantial technical and financial investment aimed at retaining HIV-positive women in care in Zimbabwe.

Outcomes of prevention of mother to child transmission of the human immunodeficiency virus-1 in rural Kenya--a cohort study

BACKGROUND

Success in prevention of mother-to-child transmission (PMTCT) raises the prospect of eliminating pediatric HIV infection. To achieve global elimination, however, strategies are needed to strengthen PMTCT interventions. This study aimed to determine PMTCT outcomes and identify challenges facing its successful implementation in a rural setting in Kenya.

METHODS

A retrospective cohort design was used. Routine demographic and clinical data for infants and mothers enrolling for PMTCT care at a rural hospital in Kenya were analysed. Cox and logistic regression were used to determine factors associated with retention and vertical transmission respectively.

RESULTS

Between 2006 and 2012, 1338 infants were enrolled and followed up for PMTCT care with earlier age of enrollment and improved retention observed over time. Mother to child transmission of HIV declined from 19.4 % in 2006 to 8.9 % in 2012 (non-parametric test for trend p = 0.024). From 2009 to 2012, enrolling for care after 6 months of age, adjusted Odds Ratio [aOR]: 23.3 [95 % confidence interval (CI): 8.3-65.4], presence of malnutrition ([aOR]: 2.3 [95 % CI: 1.1-5.2]) and lack of maternal use of highly active antiretroviral therapy (HAART) (aOR: 6.5 [95 % CI: 1.4-29.4]) was associated with increased risk of HIV infection. Infant's older age at enrollment, malnutrition and maternal HAART status, were also associated with drop out from care. Infants who were not actively followed up were more likely to drop out from care (adjusted Hazard Ratio: 6.6 [95 % CI: 2.9-14.6]).

DISCUSSION

We report a temporal increase in the proportion of infants enrolling for PMTCT care before 3 months of age, improved retention in PMTCT and a significant reduction in the proportion of infants enrolled who became HIV-infected, emphasizing the benefits of PMTCT.

CONCLUSION

A simple set of risk factors at enrollment can identify mother-infant pairs most at risk of infection or drop out for targeted intervention.

Impact of HIV testing and counseling (HTC) knowledge on HIV prevention practices among traditional birth attendants in Nigeria

Nigeria is second in the world for the number of people with HIV and has a high rate of mother-to-child transmission (MTCT). Over 60% of births in Nigeria occur outside of health care facilities, and because of this, Traditional Birth Attendants (TBAs) play a significant role in maternal and child health. It is important that TBAs be knowledgeable about HIV prevention. The purpose of this study was to determine the impact of HIV testing and counseling (HTC) knowledge on the HIV prevention practices among TBAs in Nigeria. Five hundred TBAs were surveyed. Chi-square and logistic regression were used to assess differences in HIV prevention practices between TBAs with and without HTC knowledge. TBAs with HTC knowledge are significantly more likely to engage in HIV prevention practices than TBAs without HTC. Prevention practices included: wearing gloves during delivery (p < 0.01), sterilization of delivery equipment (p < 0.01), participation in blood safety training (p < 0.01), and disposal of sharps (p < 0.01). As long as a high percent of births occur outside health care facilities in Nigeria, there will be a need for TBAs. Providing TBAs with HTC training increases HIV prevention practices and can be a key to improve maternal and child health.

Utilization of PMTCT services and associated factors among pregnant women attending antenatal clinics in Addis Ababa, Ethiopia

BACKGROUND

Mother-to-child transmission (MTCT) of human immunodeficiency virus (HIV) remains the major source of HIV infection in young children. Targeting pregnant women attending antenatal clinics provide a unique opportunity for implementing prevention of mother-to-child transmission (PMTCT) programmes against HIV infection of newborn babies. This study aimed to investigate factors associated with the acceptability and utilization of PMTCT of HIV.

METHODS

An institution based cross-sectional study was conducted in April 2010 using exit interviews with 843 pregnant women attending antenatal care (ANC) clinics of 10 health centers and two hospitals in Addis Ababa, Ethiopia. Trained nurses administered structured questionnaires to collect data on socio-demographic characteristics, knowledge about MTCT, practice of HIV testing and satisfaction with the antenatal care services. Six focus group discussions among pregnant women and 22 in-depth interviews with service providers complemented the quantitative data.

RESULTS

About 94% of the pregnant women visited the health facility for ANC check-up. Only 18% and 9% of respondents attended the facility for HIV counselling and testing (HCT) and receiving antiretroviral prophylaxis, respectively. About 90% knew that a mother with HIV can pass the virus to her child, and MTCT through breast milk was commonly cited by most women (72.4%) than transmission during pregnancy (49.7%) or delivery (49.5%). About 94% of them reported that they were tested for HIV in the current pregnancy and 60% replied that their partners were also tested for HIV. About 80% of the respondents reported adequacy of privacy and confidentiality during counseling (90.8% at hospitals and 78.6% at health centers), but 16% wished to have a different counselor. Absence of counselors, poor counselling, lack of awareness and knowledge about HCT, lack of interest and psychological unpreparedness were the main reasons cited for not undergoing HIV testing during the current pregnancy.

CONCLUSIONS

HIV testing among ANC attendees and knowledge about MTCT of HIV was quite high. Efforts should be made to improve the quality and coverage of HCT services and mitigate the barriers preventing mothers from seeking HIV testing. Further research should be conducted to evaluate the uptake of antiretroviral prophylaxis among HIV-positive pregnant women attending ANC clinics.

Socio-cultural factors influencing the prevention of mother-to-child transmission of HIV in Nigeria: a synthesis of the literature

Background

Currently, Nigeria alone accounts for 30% of the burden of mother-to-child transmission of HIV. This review explores the socio-cultural factors influencing prevention of mother-to-child transmission of HIV (PMTCT) service uptake in Nigeria.

Methods

Using the PEN-3 cultural model as a guide, we searched electronic databases and conducted a synthesis of empirical studies conducted from 2001 to 2013 that reported the perceptions people have towards PMTCT, the enablers/resources that influence PMTCT service uptake, and the role of nurturers/family or community in shaping actions and decisions towards PMTCT service uptake.

Results

A total of 42 articles meeting the search criteria were retained in this review. Thirty-six (36) were quantitative cross-sectional surveys; three were mixed methods, while three were qualitative studies. The findings highlight that there are perceptions, ranging from positive to negative that influence PMTCT service uptake in Nigeria. Furthermore, lack of available, accessible, acceptable, and affordable resources negatively influence decisions and actions towards PMTCT. Finally, family contexts matter with decisions and actions towards PMTCT service uptake in Nigeria particularly with disclosure and non-disclosure of sero-positive status, fertility intentions and infant feeding choices.

Conclusion

As ambitious goals are established and unprecedented resources deployed towards the elimination of mother-to-child transmission of HIV globally by 2015, there is clearly a need to develop effective family-oriented, culture-centered community-based PMTCT programs in Nigeria so as to improve the low uptake of PMTCT services.

In-home HIV testing and nevirapine dosing by traditional birth attendants in rural Zambia: a feasibility study

INTRODUCTION

Access to lifesaving prevention of mother-to-child transmission (PMTCT) services is problematic in rural Zambia. The simplest intervention used in Zambia has been 2-dose nevirapine (NVP) administration in the peripartum period, a regimen of 1 NVP tablet to the mother at the onset of labor and 1 dose in the form of syrup to the newborn within 4 to 72 hours after birth. This 2-dose regimen has been shown to reduce MTCT by nearly 50%. We set out to demonstrate that in-home HIV testing and NVP dosing by traditional birth attendants (TBAs) is feasible and acceptable by women in rural Zambia.

METHODS

This was a pilot program using TBAs to perform rapid saliva-based HIV testing and administer single-dose NVP in tablet form to the mother at the onset of labor and syrup to the infant after birth.

RESULTS

A total of 280 pregnant women were consented and enrolled into the program, of whom 124 (44.3%) gave birth at home with the assistance of a trained TBA. Of those, 16 (12.9%) were known to be HIV positive, and 101 of the remaining 108 (93.5%) accepted a rapid HIV test. All these women tested HIV negative. In the subset of 16 mothers who were HIV positive, 13 (81.3%) took single-dose NVP administered by a TBA between 1 and 24 hours prior to birth and 100% of exposed newborns (16 of 16) received NVP syrup within 72 hours after birth, 80% of whom were dosed in the first 24 hours of life.

DISCUSSION

With the substantial shortage of human resources in public health care throughout sub-Saharan Africa, it is extremely valuable to utilize lay health care workers to help extended services beyond the level of the facility. Given the high uptake of PMTCT services we believe that TBAs with proper training and support can successfully provide country-approved PMTCT.

Translation of biomedical prevention strategies for HIV: prospects and pitfalls

Early achievements in biomedical approaches for HIV prevention included physical barriers (condoms), clean injection equipment (both for medical use and for injection drug users), blood and blood product safety, and prevention of mother-to-child transmission. In recent years, antiretroviral drugs to reduce the risk of transmission (when the infected person takes the medicines; treatment as prevention) or reduce the risk of acquisition (when the seronegative person takes them; preexposure prophylaxis) have proven to be efficacious. Circumcision of men has also been a major tool relevant for higher prevalence regions such as sub-Saharan Africa. Well-established prevention strategies in the control of sexually transmitted diseases and tuberculosis are highly relevant for HIV (ie, screening, linkage to care, early treatment, and contact tracing). Unfortunately, only slow progress is being made in some available HIV-prevention strategies such as family planning for HIV-infected women who do not want more children and prevention of mother-to-child HIV transmission. Current studies seek to integrate strategies into approaches that combine biomedical, behavioral, and structural methods to achieve prevention synergies. This review identifies the major biomedical approaches demonstrated to be efficacious that are now available. We also highlight the need for behavioral risk reduction and adherence as essential components of any biomedical approach.

The uptake of integrated perinatal prevention of mother-to-child HIV transmission programs in low- and middle-income countries: a systematic review

BACKGROUND

The objective of this review was to assess the uptake of WHO recommended integrated perinatal prevention of mother-to-child transmission (PMTCT) of HIV interventions in low- and middle-income countries.

METHODS AND FINDINGS

We searched 21 databases for observational studies presenting uptake of integrated PMTCT programs in low- and middle-income countries. Forty-one studies on programs implemented between 1997 and 2006, met inclusion criteria. The proportion of women attending antenatal care who were counseled and who were tested was high; 96% (range 30-100%) and 81% (range 26-100%), respectively. However, the overall median proportion of HIV positive women provided with antiretroviral prophylaxis in antenatal care and attending labor ward was 55% (range 22-99%) and 60% (range 19-100%), respectively. The proportion of women with unknown HIV status, tested for HIV at labor ward was 70%. Overall, 79% (range 44-100%) of infants were tested for HIV and 11% (range 3-18%) of them were HIV positive. We designed two PMTCT cascades using studies with outcomes for all perinatal PMTCT interventions which showed that an estimated 22% of all HIV positive women attending antenatal care and 11% of all HIV positive women delivering at labor ward were not notified about their HIV status and did not participate in PMTCT program. Only 17% of HIV positive antenatal care attendees and their infants are known to have taken antiretroviral prophylaxis.

CONCLUSION

The existing evidence provides information only about the initial PMTCT programs which were based on the old WHO PMTCT guidelines. The uptake of counseling and HIV testing among pregnant women attending antenatal care was high, but their retention in PMTCT programs was low. The majority of women in the included studies did not receive ARV prophylaxis in antenatal care; nor did they attend labor ward. More studies evaluating the uptake in current PMTCT programs are urgently needed.

Knowledge and perception of Prevention of Mother to Child services amongst pregnant women accessing antenatal clinic in a Primary Health Care centre in Nigeria

Background

Few studies have assessed pregnant women's perceptions regarding prevention of mother to child of HIV and the available services at the primary health care level in Nigeria.

Objective

Assessment of knowledge and perception of antenatal clinic (ANC) attendees regarding Prevention of Mother to Child Transmission (PMTCT) of HIV at primary health care facilities in south-west Nigeria.

Method

A cross-sectional survey was conducted amongst 400 antenatal attendees in a Primary Health Care centre in Ibadan, Nigeria.

Results

Known methods of PMTCT were: use of anti-retroviral treatment (ART) during pregnancy (75.0%), ART at birth (65.8%) and not breastfeeding (61.8%). Previous HIV Counselling and Testing (HCT) was reported by 71%, significantly higher proportions of those who were married, in the third trimester of pregnancy or engaged in professional and/or skilled occupations had been tested. Regarding the HCT services provided, 92.2% understood the HIV-related health education provided, 89.7.2% reported that the timing was appropriate, 92.6% assessed the nurses’ approach as acceptable but 34.0% felt the test was forced upon them. Majority (79.6%) were aware of non-breastfeeding options of infant feeding, but only 3.5% were aware of exclusive breastfeeding for a stipulated period as an infant feeding option. Nevertheless, the majority of the women found the non-breast feeding option culturally unacceptable.

Conclusion

Women in this survey were knowledgeable about the methods of PMTCT, but had negative perceptions regarding certain aspects of the HCT services and the recommended non-breastfeeding infant feeding option. Health workers should provide client friendly services and infant feeding counselling that is based on current WHO recommendations and culturally acceptable.

Community-based approaches for prevention of mother to child transmission in resource-poor settings: a social ecological review

INTRODUCTION

Numerous barriers to optimal uptake of prevention of mother to child transmission (PMTCT) services occur at community level (i.e., outside the healthcare setting). To achieve elimination of paediatric HIV, therefore, interventions must also work within communities to address these barriers and increase service use and need to be informed by evidence. This paper reviews community-based approaches that have been used in resource-limited settings to increase rates of PMTCT enrolment, retention in care and successful treatment outcomes. It aims to identify which interventions work, why they may do so and what knowledge gaps remain.

METHODS

First, we identified barriers to PMTCT that originate outside the health system. These were used to construct a social ecological framework categorizing barriers to PMTCT into the following levels of influence: individual, peer and family, community and sociocultural. We then used this conceptual framework to guide a review of the literature on community-based approaches, defined as interventions delivered outside of formal health settings, with the goal of increasing uptake, retention, adherence and positive psychosocial outcomes in PMTCT programmes in resource-poor countries.

RESULTS

Our review found evidence of effectiveness of strategies targeting individuals and peer/family levels (e.g., providing household HIV testing and training peer counsellors to support exclusive breastfeeding) and at community level (e.g., participatory women's groups and home-based care to support adherence and retention). Evidence is more limited for complex interventions combining multiple strategies across different ecological levels. There is often little information describing implementation; and approaches such as "community mobilization" remain poorly defined.

CONCLUSIONS

Evidence from existing community approaches can be adapted for use in planning PMTCT. However, for successful replication of evidence-based interventions to occur, comprehensive process evaluations are needed to elucidate the pathways through which specific interventions achieve desired PMTCT outcomes. A social ecological framework can help analyze the complex interplay of facilitators and barriers to PMTCT service uptake in each context, thus helping to inform selection of locally relevant community-based interventions.

[Matrones and the reduction of maternal morality, a contribution to the debate]

Résumé

Avec le présupposé que la biomédecine était capable de prévenir la majorité des morts maternelles, l’une des recommandations formulées en 1987 par l’Initiative Maternité Sans Risque était de former des matrones. Ces formations réalisées durant trois décennies sont souvent décrites comme étant un échec. Néanmoins, elles n’ont guère pris en compte l’hétérogénéité des statuts sociaux et pratiques des matrones, ni remis en question certaines méthodes pédagogiques essentiellement didactiques et souvent inappropriées. Ainsi, le débat relatif à la pertinence de ces formations est loin d’être clos. Dans cette perspective, l’ouvrage collectif L’art des matrones revisité. Naissances contemporaines en question dirigé par Pascale Hancart Petitet (2011) rassemble neuf contributions d’auteur(e)s dont l’objectif n’est nullement de remettre en cause les effets bénéfiques de la biomédicalisation de l’accouchement mais de montrer, comment, et pourquoi, se construisent les pratiques des matrones et les discours dont elles sont l’objet actuellement.

What about N? A methodological study of sample-size reporting in focus group studies

BACKGROUND

Focus group studies are increasingly published in health related journals, but we know little about how researchers use this method, particularly how they determine the number of focus groups to conduct. The methodological literature commonly advises researchers to follow principles of data saturation, although practical advise on how to do this is lacking. Our objectives were firstly, to describe the current status of sample size in focus group studies reported in health journals. Secondly, to assess whether and how researchers explain the number of focus groups they carry out.

METHODS

We searched PubMed for studies that had used focus groups and that had been published in open access journals during 2008, and extracted data on the number of focus groups and on any explanation authors gave for this number. We also did a qualitative assessment of the papers with regard to how number of groups was explained and discussed.

RESULTS

We identified 220 papers published in 117 journals. In these papers insufficient reporting of sample sizes was common. The number of focus groups conducted varied greatly (mean 8.4, median 5, range 1 to 96). Thirty seven (17%) studies attempted to explain the number of groups. Six studies referred to rules of thumb in the literature, three stated that they were unable to organize more groups for practical reasons, while 28 studies stated that they had reached a point of saturation. Among those stating that they had reached a point of saturation, several appeared not to have followed principles from grounded theory where data collection and analysis is an iterative process until saturation is reached. Studies with high numbers of focus groups did not offer explanations for number of groups. Too much data as a study weakness was not an issue discussed in any of the reviewed papers.

CONCLUSIONS

Based on these findings we suggest that journals adopt more stringent requirements for focus group method reporting. The often poor and inconsistent reporting seen in these studies may also reflect the lack of clear, evidence-based guidance about deciding on sample size. More empirical research is needed to develop focus group methodology.

Traditional birth attendants lack basic information on HIV and safe delivery practices in rural Mysore, India

BACKGROUND

There is little research on HIV awareness and practices of traditional birth attendants (TBA) in India. This study investigated knowledge and attitudes among rural TBA in Karnataka as part of a project examining how traditional birth attendants could be integrated into prevention-of-mother-to-child transmission of HIV (PMTCT) programs in India.

METHODS

A cross-sectional survey was conducted between March 2008 and January 2009 among TBA in 144 villages in Mysore Taluk, Karnataka. Following informed consent, TBA underwent an interviewer-administered questionnaire in the local language of Kannada on practices and knowledge around birthing and HIV/PMTCT.

RESULTS

Of the 417 TBA surveyed, the median age was 52 years and 96% were Hindus. A majority (324, 77.7%) had no formal schooling, 88 (21.1%) had up to 7 years and 5 (1%) had more than 7 yrs of education. Only 51 of the 417 TBA (12%) reported hearing about HIV/AIDS. Of those who had heard about HIV/AIDS, only 36 (72%) correctly reported that the virus could be spread from mother to child; 37 (74%) identified unprotected sex as a mode of transmission; and 26 (51%) correctly said healthy looking people could spread HIV. Just 22 (44%) knew that infected mothers could lower the risk of transmitting the virus to their infants. An overwhelming majority of TBA (401, 96.2%) did not provide antenatal care to their clients. Over half (254, 61%) said they would refer the woman to a hospital if she bled before delivery, and only 53 (13%) felt referral was necessary if excessive bleeding occurred after birth.

CONCLUSIONS

Traditional birth attendants will continue to play an important role in maternal child health in India for the foreseeable future. This study demonstrates that a majority of TBA lack basic information about HIV/AIDS and safe delivery practices. Given the ongoing shortage of skilled birth attendance in rural areas, more studies are needed to examine whether TBA should be trained and integrated into PMTCT and maternal child health programs in India.

Prevalence and barriers to HIV testing among mothers at a tertiary care hospital in Phnom Penh, Cambodia. Barriers to HIV testing in Phnom Penh, Cambodia

BACKGROUND

One-third of all new HIV infections in Cambodia are estimated to be due to mother-to-child transmission. Although the Ministry of Health adopted a policy of provider-initiated HIV testing and counseling (PITC), nearly a quarter of pregnant mothers were not tested in 2007. Greater acceptance of HIV testing is a challenge despite Cambodia's adoption of the PITC policy.

METHODS

A hospital-based quantitative and cross-sectional survey was conducted to assess the prevalence of and barriers to HIV testing among mothers after delivery at the National Maternal and Child Health Center in Phnom Penh. The Center is one of the largest maternal and child care hospitals in the country to offer PITC services. All 600 eligible mothers who were admitted to the hospital after delivery from October to December 2007 were approached and recruited. Data were collected via a semi-structured questionnaire.

RESULTS

The prevalence of HIV testing among women who delivered at the hospital was 76%. In multivariate logistic regression, factors such as the perceived need to obtain a partner's permission to be tested (OR=0.27, 95% CI=0.14-0.51, p<0.01), the lack of knowledge about HIV prevention and treatment (OR=0.38, CI=0.22-0.66, p<0.01), and the lack of access to ANC services (OR=0.35, 95% CI=0.21-0.58, p<0.01) were found to be the main barriers to HIV testing.

CONCLUSION

To achieve greater acceptance of HIV testing, counseling on HIV prevention and treatment must be provided not only to mothers but also to their partners. In addition, utilization of non-laboratory staff such as midwives to provide HIV testing services in rural health facilities could lead to the greater acceptance of HIV testing.

Prevention of mother-to-child transmission of HIV infection: views and perceptions about swallowing nevirapine in rural Lilongwe, Malawi

BACKGROUND

In 2006 the World Health Organization described the status of prevention of mother to child transmission (PMTCT) service implementation as unacceptable, with an urgent need for a renewed public health approach to improve access. For PMTCT to be effective it needs to be accessible, acceptable and affordable; however research in Africa into accessibility, uptake and acceptability of PMTCT services has been predominately urban based and usually focusing on women who deliver in hospitals. The importance of involving other community members to strengthen both PMTCT uptake and adherence, and to support women emotionally, has been advocated. Urban men's and rural traditional birth attendants' (TBAs) involvement have improved uptake of HIV testing and of nevirapine.

METHODS

A qualitative study was carried out in a rural district of Malawi's central region to explore the views about and perceptions of PMTCT antiretroviral treatment. Semi-structured interviews and focus group discussions were held with antenatal and postnatal women, fathers, grandmothers, TBAs, community leaders and PMTCT health workers.

RESULTS

Two broad themes of findings emerged: those that relate to the hospital PMTCT service, and those that relate to the community. Trust in the hospital was strong, but distance, transport costs and perceived harsh, threatening health worker attitudes were barriers to access. Grandmothers were perceived to have influence on the management of labour, unlike fathers, but both were suggested as key people to ensure that babies are brought to the hospital for nevirapine syrup. TBAs were seen as powerful, local, and important community members, but some as uneducated.

CONCLUSION

PMTCT was seen as a community issue in which more than the mother alone can be involved. To support access to PMTCT, especially for rural women, there is need for further innovation and implementation research on involving TBAs in some aspects of PMTCT services, and in negotiating with women which community members, if any, they would like to support them in ensuring that newborn babies receive nevirapine.