Pregnant women's access to PMTCT and ART services in South Africa and implications for universal antiretroviral treatment

A Scoping Review of Preterm Births in Sub-Saharan Africa: Burden, Risk Factors and Outcomes

Preterm births (PTB) are the leading cause of neonatal deaths, the majority of which occur in low- and middle-income countries, particularly those in Sub-Saharan Africa (SSA). Understanding the epidemiology of prematurity is an essential step towards tackling the challenge of PTB in the sub-continent. We performed a scoping review of the burden, predictors and outcomes of PTB in SSA. We searched PubMed, Embase, and three other databases for articles published from the database inception to 10 July 2021. Studies reporting the prevalence of PTB, the associated risk factors, and/or its outcomes were eligible for inclusion in this review. Our literature search identified 4441 publications, but only 181 met the inclusion criteria. Last menstrual period (LMP) was the most commonly used method of estimating gestational age. The prevalence of PTB in SSA ranged from 3.4% to 49.4%. Several risk factors of PTB were identified in this review. The most frequently reported risk factors (i.e., reported in ≥10 studies) were previous history of PTB, underutilization of antenatal care (<4 visits), premature rupture of membrane, maternal age (≤20 or ≥35 years), inter-pregnancy interval, malaria, HIV and hypertension in pregnancy. Premature babies had high rates of hospital admissions, were at risk of poor growth and development, and were also at a high risk of morbidity and mortality. There is a high burden of PTB in SSA. The true burden of PTB is underestimated due to the widespread use of LMP, an unreliable and often inaccurate method for estimating gestational age. The associated risk factors for PTB are mostly modifiable and require an all-inclusive intervention to reduce the burden and improve outcomes in SSA.

Mentor Mothers Zithulele: exploring the role of a peer mentorship programme in rural PMTCT care in Zithulele, Eastern Cape, South Africa

Background: The majority of global HIV infections in children under 10 years of age occur during pregnancy, delivery or breastfeeding, despite improved coverage of 'prevention of mother-to-child transmission' (PMTCT) guidelines to reduce vertical transmission. This article looks closer at one community-based peer mentorship programme [Mentor Mothers Zithulele (MMZ)] in the Eastern Cape, South Africa which aims to supplement the existing heavily burdened antenatal programmes and improve PMTCT care.Methods: Semi-structured interviews were undertaken with HIV-positive women participating in MMZ and women receiving standard PMTCT care without any intervention. A focus group discussion (FGD) was conducted with women working as Mentor mothers (MMs) for MMZ to explore their experience of the impact of peer mentoring on the rural communities they serve.Results: Six main themes were identified in the interviews with antenatal patients: (i) MMs were a key educational resource, (ii) MMs were important in promoting exclusive breastfeeding, (iii) encouraging early HIV testing during pregnancy and (iv) providing psychosocial support to patients in their homes, thereby reducing stigma and sense of alienation. Respondents requested (v) additional focus on HIV education. MMs can (vi) function as a link between patients and health-care providers, improving treatment adherence. During the FGD two themes emerged; MMs fill the gap between patients and health services, and MMZ should focus on HIV awareness and stigma reduction.Conclusion: Peer mentoring programmes can play an important role in reducing vertical HIV transmission in resource-limited, rural settings by providing participants with education, psychosocial support, and a continuum of care.

Risk Factors for Infectious Diseases in Urban Environments of Sub-Saharan Africa: A Systematic Review and Critical Appraisal of Evidence

Our world is rapidly urbanizing. According to the United Nations, between 1990 and 2015, the percent of the world’s population living in urban areas grew from 43% to 54%. Estimates suggest that this trend will continue and that over 68% of the world’s population will call cities home by 2050, with the majority of urbanization occurring in African countries. This urbanization is already having a profound effect on global health and could significantly impact the epidemiology of infectious diseases. A better understanding of infectious disease risk factors specific to urban settings is needed to plan for and mitigate against future urban outbreaks. We conducted a systematic literature review of the Web of Science and PubMed databases to assess the risk factors for infectious diseases in the urban environments of sub-Saharan Africa. A search combining keywords associated with cities, migration, African countries, infectious disease, and risk were used to identify relevant studies. Original research and meta-analyses published between 2004 and 2019 investigating geographical and behavioral risk factors, changing disease distributions, or control programs were included in the study. The search yielded 3610 papers, and 106 met the criteria for inclusion in the analysis. Papers were categorized according to risk factors, geographic area, and study type. The papers covered 31 countries in sub-Saharan Africa with East Africa being the most represented sub-region. Malaria and HIV were the most frequent disease focuses of the studies. The results of this work can inform public health policy as it relates to capacity building and health systems strengthening in rapidly urbanizing areas, as well as highlight knowledge gaps that warrant additional research.

Challenges and successes in the implementation of option B+ to prevent mother-to-child transmission of HIV in southern Swaziland

Background

Universal antiretroviral therapy (ART) for all pregnant/ breastfeeding women living with Human Immunodeficiency Virus (HIV), known as Prevention of mother-to child transmission of HIV (PMTCT) Option B+ (PMTCTB+), is being scaled up in most countries in Sub-Saharan Africa. In the transition to PMTCTB+, many countries face challenges with proper implementation of the HIV care cascade. We aimed to describe the feasibility of a PMTCTB+ approach in the public health sector in Swaziland.

Methods

Lifelong ART was offered to a cohort of HIV+ pregnant women aged ≥16 years at the first antenatal care (ANC1) visit in 9 public sector facilities, between 01/2013 and 06/2014. The study enrolment period was divided into 3 phases (early: 01–06/2013, mid: 07–12/2013 and late: 01–06/2014) to account for temporal trends. Kaplan-Meier estimates and Cox proportional-hazards regression models were applied for ART initiation and attrition analyses.

Results

Of 665 HIV+ pregnant women, 496 (74.6%) initiated ART. ART initiation increased in later study enrolment phases (mid: aHR: 1.41; later: aHR: 2.36), and decreased at CD4 ≥ 500 (aHR: 0.69). 52.9% were retained in care at 24 months. Attrition was associated with ANC1 in the third trimester (aHR: 2.37), attending a secondary care facility (aHR: 1.98) and ART initiation during later enrolment phases (mid aHR: 1.48; late aHR: 1.67). Of 373 women eligible, 67.3% received a first VL. 223/251 (88.8%) were virologically suppressed (< 1000 copies/mL). Of 670 infants, 53.6% received an EID test, 320/359 had a test result recorded and of whom 7 (2.2%) were HIV+.

Conclusions

PMTCTB+ was found to be feasible in this setting, with high rates of maternal viral suppression and low transmission to the infant. High treatment attrition, poor follow-up of mother-baby pairs and under-utilisation of VL and EID testing are important programmatic challenges.

Implementation effectiveness of revised (post-2010) World Health Organization guidelines on prevention of mother-to-child transmission of HIV using routinely collected data in sub-Saharan Africa: A systematic literature review

BACKGROUND

To synthesize and evaluate the impact of implementing post-2010 World Health Organization (WHO) prevention of mother-to-child transmission (PMTCT) guidelines on attainment of PMTCT targets.

METHODS

Retrospective and prospective cohort study designs that utilized routinely collected data with a focus on provision and utilization of the cascade of PMTCT services were included. The outcomes included the proportion of pregnant women who were tested during their antenatal clinic (ANC) visits; mother-to-child transmission (MTCT) rate; adherence; retention rate; and loss to follow-up (LTFU).

RESULTS

Of the 1210 references screened, 45 met the inclusion criteria. The studies originated from 14 countries in sub-Saharan Africa. The highest number of studies originated from Malawi (10) followed by Nigeria and South Africa with 7 studies each. More than half of the studies were on option A while the majority of option B+ studies were conducted in Malawi. These studies indicated a high uptake of human immunodeficiency virus (HIV) testing ranging from 75% in Nigeria to over 96% in Zimbabwe and South Africa. High proportions of CD4 count testing were reported in studies only from South Africa despite that in most of the countries CD4 testing was a prerequisite to access treatment. MTCT rate ranged from 1.1% to 15.1% and it was higher in studies where data were collected in the early days of the WHO 2010 PMTCT guidelines. During the postpartum period, adherence and retention rate decreased, and LTFU increased for both HIV-positive mothers and exposed infants.

CONCLUSION

Irrespective of which option was followed, uptake of antenatal HIV testing was high but there was a large drop off along later points in the PMTCT cascade. More research is needed on how to improve later components of the PMTCT cascade, especially of option B+ which is now the norm throughout sub-Saharan Africa.

The Repeated Administration of Resveratrol Has Measurable Effects on Circulating T-Cell Subsets in Humans

Preclinical studies have shown that resveratrol exerts immunomodulatory effects with potential clinical value in the amelioration of autoimmune disorders and cancer prevention; however, little is known about the in vivo effects of this naturally occurring polyphenol on human immune cells. We assessed the effects of repeated doses of resveratrol (1000 mg/day for 28 days) on circulating immune cells in healthy Japanese individuals. Resveratrol was safe and well tolerated and was associated with significant increases in the numbers of circulating γδ T cells and regulatory T cells and resulted in small, yet significant, decreases in the plasma levels of the proinflammatory cytokines TNF-α and MCP-1 and a significant increase in the plasma antioxidant activity compared with the corresponding antioxidant baseline activity and with that in four control individuals. In in vitro studies, resveratrol significantly improved the growth of γδ T cells and regulatory T cells. These findings demonstrate that resveratrol has some clear biological effects on human circulating immune cells. Further studies are necessary to interpret the long-term immunological changes associated with resveratrol treatment.

Overcoming Health System Challenges for Women and Children Living With HIV Through the Global Plan

To meet the ambitious targets set by the Global Plan Towards the Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive (Global Plan), the initial 22 priority countries quickly developed innovative approaches for overcoming long-standing health systems challenges and providing HIV testing and treatment to pregnant and breastfeeding women and their infants. The Global Plan spurred programs for prevention of mother-to-child HIV transmission to integrate HIV-related care and treatment into broader maternal, newborn, and child health services; expand the effectiveness of the health workforce through task sharing; extend health services into communities; strengthen supply chain and commodity management systems; reduce diagnostic and laboratory hurdles; and strengthen strategic supervision and mentorship. The article reviews the ongoing challenges for prevention of mother-to-child HIV transmission programs as they continue to strive for elimination of vertical transmission of HIV infection in the post-Global Plan era. Although progress has been rapid, health systems still face important challenges, particularly follow-up and diagnosis of HIV-exposed infants, continuity of care, and the promotion of services that are respectful and client centered.

Fundamental concerns of women living with HIV around the implementation of Option B+

Introduction

In 2011, the Global Plan towards the Elimination of New HIV Infections among Children by 2015 and Keeping Their Mothers Alive was launched to scale up efforts to comprehensively end vertical HIV transmission and support mothers living with HIV in remaining healthy. Amidst excitement around using treatment as prevention, Malawi's Ministry of Health conceived Option B+, a strategy used to prevent vertical transmission by initiating all pregnant and breastfeeding women living with HIV on lifelong antiretroviral therapy, irrespective of CD4 count. In 2013, for programmatic and operational reasons, the WHO officially recommended Option B+ to countries with generalized epidemics, limited access to CD4 testing, limited partner testing, long breastfeeding duration or high fertility rates.

Discussion

While acknowledging the opportunity to increase treatment access globally and its potential, this commentary reviews the concerns of women living with HIV about human rights, community-based support and other barriers to service uptake and retention in the Option B+ context. Option B+ intensifies many of the pre-existing challenges of HIV prevention and treatment programmes. As women seek comprehensive services to prevent vertical transmission, they can experience various human rights violations, including lack of informed consent, involuntary or coercive HIV testing, limited treatment options, termination of pregnancy or coerced sterilization and pressure to start treatment. Yet, peer and community support strategies can promote treatment readiness, uptake, adherence and lifelong retention in care; reduce stigma and discrimination; and mitigate potential violence stemming from HIV disclosure. Ensuring available and accessible quality care, offering food support and improving linkages to care could increase service uptake and retention. With the heightened focus on interventions to reach pregnant and breastfeeding women living with HIV, a parallel increase in vigilance to secure their health and rights is critical.

Conclusion

The authors conclude that real progress towards reducing vertical transmission and achieving viral load suppression can only be made by upholding the human rights of women living with HIV, investing in community-based responses, and ensuring universal access to quality healthcare. Only then will the opportunity of accessing lifelong treatment result in improving the health, dignity and lives of women living with HIV, their children and families.

Time to eligibility for antiretroviral therapy in adults with CD4 cell count > 500 cells/μL in rural KwaZulu-Natal, South Africa

OBJECTIVES

Understanding of progression to antiretroviral therapy (ART) eligibility and associated factors remains limited. The objectives of this analysis were to determine the time to ART eligibility and to explore factors associated with disease progression in adults with early HIV infection.

METHODS

HIV-infected adults (≥ 18 years old) with CD4 cell count > 500 cells/μl were enrolled in the study at three primary health care clinics, and a sociodemographic, behavioural and partnership-level questionnaire was administered. Participants were followed 6-monthly and ART eligibility was determined using a CD4 cell count threshold of 350 cells/μl. Kaplan - Meier and Cox proportional hazard regression modelling were used in the analysis.

RESULTS

A total of 206 adults contributed 381 years of follow-up; 79 (38%) reached the ART eligibility threshold. Median time to ART eligibility was shorter for male patients (12.0 months) than for female patients (33.9 months). Male sex [adjusted hazard ratio (aHR) 3.13; 95% confidence interval (CI) 1.82-5.39], residing in a household with food shortage in the previous year (aHR 1.58; 95% CI 0.99-2.54), and taking nutritional supplements in the first 6 months after enrolment (aHR 2.06; 95% CI 1.11-3.83) were associated with shorter time to ART eligibility. Compared with reference CD4 cell count ≤  559 cells/μl, higher CD4 cell count was associated with longer time to ART eligibility [aHR 0.46 (95% CI 0.25-0.83) for CD4 cell count 560-632 cells/μl; aHR 0.30 (95% CI 0.16-0.57) for CD4 cell count 633-768 cells/μl; and aHR 0.17 (95% CI 0.08-0.38) for CD4 cell count > 768 cells/μl].

CONCLUSIONS

Over one in three adults with CD4 cell count > 500 cells/μl became eligible for ART at a CD4 cell count threshold of 350 cells/μl over a median of 2 years. The shorter time to ART eligibility in male patients suggests a possible need for sex-specific pre-ART care and monitoring strategies.

Missed Opportunities along the Prevention of Mother-to-Child Transmission Services Cascade in South Africa: Uptake, Determinants, and Attributable Risk (the SAPMTCTE)

Objectives

We examined uptake of prevention of mother-to-child HIV transmission (PMTCT) services, predictors of missed opportunities, and infant HIV transmission attributable to missed opportunities along the PMTCT cascade across South Africa.

Methods

A cross-sectional survey was conducted among 4–8 week old infants receiving first immunisations in 580 nationally representative public health facilities in 2010. This included maternal interviews and testing infants’ dried blood spots for HIV. A weighted analysis was performed to assess uptake of antenatal and perinatal PMTCT services along the PMTCT cascade (namely: maternal HIV testing, CD4 count test/result, and receiving maternal and infant antiretroviral treatment) and predictors of dropout. The population attributable fraction associated with dropouts at each service point are estimated.

Results

Of 9,803 mothers included, 31.7% were HIV-positive as identified by reactive infant antibody tests. Of these 80.4% received some form of maternal and infant antiretroviral treatment. More than a third (34.9%) of mothers dropped out from one or more steps in the PMTCT service cascade. In a multivariable analysis, the following characteristics were associated with increased dropout from the PMTCT cascade: adolescent (<20 years) mothers, low socioeconomic score, low education level, primiparous mothers, delayed first antenatal visit, homebirth, and non-disclosure of HIV status. Adolescent mothers were twice (adjusted odds ratio: 2.2, 95% confidence interval: 1.5–3.3) as likely to be unaware of their HIV-positive status and had a significantly higher rate (85.2%) of unplanned pregnancies compared to adults aged ≥20 years (55.5%, p = 0.0001). A third (33.8%) of infant HIV infections were attributable to dropout in one or more steps in the cascade.

Conclusion

A third of transmissions attributable to missed opportunities of PMTCT services can be prevented by optimizing the uptake of PMTCT services. Identified risk factors for low PMTCT service uptake should be addressed through health facility and community-level interventions, including raising awareness, promoting women education, adolescent focused interventions, and strengthening linkages/referral-system between communities and health facilities.

Reproductive desires of men and women living with HIV: implications for family planning counselling

The reproductive desires of people living with HIV/AIDS (PLHIV) of low socioeconomic standing attending public health facilities in South Africa were studied. HIV-positive men, pregnant and non-pregnant women were recruited from two clinics at a large public hospital in Tshwane, South Africa. Individual interviews were used to explore the reproductive desires of HIV-positive participants. HIV counsellors' perceptions of their clients' reproductive desires were explored during focus group discussions. Parenthood proved to be an important factor to all participants in continuation of the family and establishing their gender identities, despite the possible risk of HIV transmission and community stigmatization. Different cultural procreation rules for men and women and stigmatizing attitudes towards PLHIV affected their reproductive decision making. Women had the dilemma of choosing which community expectations they wanted to fulfil. Community stigmatization towards PLHIV was visible in the negative attitudes of some HIV counsellors regarding HIV and procreation. Because the reproductive desires of PLHIV are currently not given high priority in HIV prevention and family planning in the public health sector in South Africa, the prevention of HIV transmission may be jeopardized. These results necessitate the integration of HIV and sexual and reproductive health counselling on a primary health care level.

Evolution of antiretroviral therapy services for HIV-infected pregnant women in Cape Town, South Africa

BACKGROUND

Approaches to antiretroviral therapy (ART) in HIV-infected pregnant women have changed considerably in recent years, but there are few comparative data on the implementation of different models of service delivery.

METHODS

Using routine clinic records we examined ART initiation in pregnant women attending a large antenatal care (ANC) facility between January 2010 and December 2013 in Cape Town, South Africa. Over this time six different service delivery models were implemented sequentially to provide ART in pregnancy, including the integration of ART into ANC, use of point-of-care CD4 cell count testing, and universal ART initiation for all HIV-infected pregnant women.

RESULTS

During the study period 19,432 women sought ANC, levels of HIV testing were high (98%) and 30% of pregnant women tested HIV-positive. Integration of ART into ANC was associated with significant increases in the proportion of eligible women initiating treatment before delivery compared to referral to a separate ART clinic (p<0.001). When CD4 cell counts were used to determine ART eligibility, point-of-care testing was associated with decreased delays to ART initiation compared to laboratory-based testing (p<0.001). The strategy of universal ART led to the highest levels of ART initiation (with 92% of women starting before delivery) and the shortest delays, with 82% of women starting ART on the day of the first ANC visit.

CONCLUSION

Developments in service delivery models, most notably service integration and universal ART for pregnant women, have improved antenatal ART initiation dramatically in this setting. Further research is needed into how strategies for antenatal ART initiation impact maternal and child health over the long-term.

Uptake of prevention of mother-to-child-transmission using Option B+ in northern rural Malawi: a retrospective cohort study

To identify points of dropout on the pathway from offering HIV testing to maintenance on antiretroviral therapy (ART), following the introduction of the Option B+ policy for pregnant women in Malawi (lifelong ART for HIV-positive mothers and 6 weeks nevirapine for the infants), a retrospective cohort study within a demographic surveillance system in northern Malawi. Women living in the demographic surveillance system who initiated antenatal care (ANC) between July 2011 (date of policy change) and January 2013, were eligible for inclusion. Women who consented were interviewed at home about their health facility attendance and care since pregnancy, including antenatal clinic (ANC) visits, delivery and postpartum care. Women's reports, patient-held health records and clinic health records were manually linked to ascertain service use. Among 395 women, 86% had tested for HIV before the pregnancy, 90% tested or re-tested at the ANC visit, and <1% had never tested. Among 53 mothers known to be HIV-positive before attending ANC, 15 (28%) were already on ART prior to pregnancy. Ten women tested HIV-positive for the first time during pregnancy. Of the 47 HIV-positive mothers not already on ART, 26/47 (55%) started treatment during pregnancy. All but five women who started ART were still on treatment at the time of study interview. HIV testing was almost universal and most women who initiated ART were retained in care. However, nearly half of eligible pregnant women not on ART at the start of ANC had not taken up the invitation to initiate (lifelong) ART by the time of delivery, leaving their infants potentially HIV-exposed.

Antiretroviral drug regimens to prevent mother-to-child transmission of HIV: a review of scientific, program, and policy advances for sub-Saharan Africa

Considerable advances have been made in the effort to prevent mother-to-child HIV transmission (PMTCT) in sub-Saharan Africa. Clinical trials have demonstrated the efficacy of antiretroviral regimens to interrupt HIV transmission through the antenatal, intrapartum, and postnatal periods. Scientific discoveries have been rapidly translated into health policy, bolstered by substantial investment in health infrastructure capable of delivering increasingly complex services. A new scientific agenda is also emerging, one that is focused on the challenges of effective and sustainable program implementation. Finally, global campaigns to "virtually eliminate" pediatric HIV and dramatically reduce HIV-related maternal mortality have mobilized new resources and renewed political will. Each of these developments marks a major step in regional PMTCT efforts; their convergence signals a time of rapid progress in the field, characterized by an increased interdependency between clinical research, program implementation, and policy. In this review, we take stock of recent advances across each of these areas, highlighting the challenges--and opportunities--of improving health services for HIV-infected mothers and their children across the region.

Collecting maternal health information from HIV-positive pregnant women using mobile phone-assisted face-to-face interviews in Southern Africa

Background

Most of the world’s women living with human immunodeficiency virus (HIV) reside in sub-Saharan Africa. Although efforts to reduce mother-to-child transmission are underway, obtaining complete and accurate data from rural clinical sites to track progress presents a major challenge.

Objective

To describe the acceptability and feasibility of mobile phones as a tool for clinic-based face-to-face data collection with pregnant women living with HIV in South Africa.

Methods

As part of a larger clinic-based trial, 16 interviewers were trained to conduct mobile phone–assisted personal interviews (MPAPI). These interviewers (participant group 1) completed the same short questionnaire based on items from the Technology Acceptance Model at 3 different time points. Questions were asked before training, after training, and 3 months after deployment to clinic facilities. In addition, before the start of the primary intervention trial in which this substudy was undertaken, 12 mothers living with HIV (MLH) took part in a focus group discussion exploring the acceptability of MPAPI (participant group 2). Finally, a sample of MLH (n=512) enrolled in the primary trial were asked to assess their experience of being interviewed by MPAPI (participant group 3).

Results

Acceptability of the method was found to be high among the 16 interviewers in group 1. Perceived usefulness was reported to be slightly higher than perceived ease of use across the 3 time points. After 3 months of field use, interviewer perceptions of both perceived ease of use and perceived usefulness were found to be higher than before training. The feasibility of conducting MPAPI interviews in this setting was found to be high. Network coverage was available in all clinics and hardware, software, cost, and secure transmission to the data center presented no significant challenges over the 21-month period. For the 12 MHL participants in group 2, anxiety about the multimedia capabilities of the phone was evident. Their concern centered on the possibility that their privacy may be invaded by interviewers using the mobile phone camera to photograph them. For participants in group 3, having the interviewer sit beside vs across from the interviewee during the MPAPI interview was received positively by 94.7% of MHL. Privacy (6.3%) and confidentiality (5.3%) concerns were low for group 3 MHL.

Conclusions

Mobile phones were found both to be acceptable and feasible in the collection of maternal and child health data from women living with HIV in South Africa.

Trial Registration

Clinicaltrials.gov NCT00972699; http://clinicaltrials.gov/ct2/show/NCT00972699 (Archived by WebCite at http://clinicaltrials.gov/ct2/show/NCT00972699)

Integration of antiretroviral therapy services into antenatal care increases treatment initiation during pregnancy: a cohort study

OBJECTIVES

Initiation of antiretroviral therapy (ART) during pregnancy is critical to promote maternal health and prevent mother-to-child HIV transmission (PMTCT). The separation of services for antenatal care (ANC) and ART may hinder antenatal ART initiation. We evaluated ART initiation during pregnancy under different service delivery models in Cape Town, South Africa.

METHODS

A retrospective cohort study was conducted using routinely collected clinic data. Three models for ART initiation in pregnancy were evaluated ART 'integrated' into ANC, ART located 'proximal' to ANC, and ART located some distance away from ANC ('distal'). Kaplan-Meier methods and Poisson regression were used to examine the association between service delivery model and antenatal ART initiation.

RESULTS

Among 14 617 women seeking antenatal care in the three services, 30% were HIV-infected and 17% were eligible for ART based on CD4 cell count <200 cells/µL. A higher proportion of women started ART antenatally in the integrated model compared to the proximal or distal models (55% vs 38% vs 45%, respectively, global p = 0.003). After adjusting for age and gestation at first ANC visit, women who at the integrated service were significantly more likely to initiate ART antenatally (rate ratio 1.33; 95% confidence interval: 1.09-1.64) compared to women attending the distal model; there was no difference between the proximal and distal models in antenatal ART initiation however (p = 0.704).

CONCLUSIONS

Integration of ART initiation into ANC is associated with higher levels of ART initiation in pregnancy. This and other forms of service integration may represent a valuable intervention to enhance PMTCT and maternal health.

[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.

Missed opportunities: poor linkage into ongoing care for HIV-positive pregnant women in Mwanza, Tanzania

Background

Global coverage of prevention of mother-to-child (PMTCT) services reached 53% in 2009. However the number of pregnant women who test positive for HIV in antenatal clinics and who link into long-term HIV care is not known in many resource-poor countries. We measured the proportion of HIV-positive pregnant women in Mwanza city, Tanzania, who completed the cascade of care from antenatal HIV diagnosis to assessment and engagement in care in adult HIV clinics.

Methods

Thirty antenatal and maternity ward health workers were interviewed about PMTCT activities. Nine antenatal HIV education sessions were observed. A prospective cohort of 403 HIV-positive women was enrolled by specially-trained clinicians and nurses on admission to delivery and followed for four months post-partum. Information was collected on referral and attendance at adult HIV clinics, eligibility for highly active antiretroviral therapy (HAART) and reasons for lack of attendance.

Results

Overall, 70% of PMTCT health workers referred HIV-positive pregnant women to the HIV clinic for assessment and care. Antenatal HIV education sessions did not cover on-going care for HIV-infected women. Of 310 cohort participants tested in pregnancy, 51% had received an HIV clinic referral pre-delivery. Only 32% of 244 women followed to four months post-partum had attended an HIV clinic and been assessed for HAART eligibility. Non-attendance for HIV care was independently associated with fewer antenatal visits, poor PMTCT prophylaxis compliance, non-disclosure of HIV status, and non-Sukuma ethnicity.

Conclusion

Most women identified as HIV-positive during pregnancy were not assessed for HAART eligibility during pregnancy or in the first four months post-partum. Initiating HAART at the antenatal clinic, improved counselling and linkages to care between PMTCT and adult HIV treatment services and reducing stigma surrounding disclosure of HIV results would benefit on-going care of HIV-positive pregnant women.