Ensuring a public health impact of programs to reduce HIV transmission from mothers to infants: the place of voluntary counseling and testing

HIV sero-status disclosure and associated factors among HIV positive women in East Africa: Systematic review and meta-analysis. Implications for prevention of mother-to-child HIV transmission

Background

Women's HIV-positive disclosure plays a pivotal role to achieve the goal of preventing mother-to-child transmission (PMTCT) among pregnant women in particular. Although several primary studies were conducted in the different countries of East Africa, no study concluded the prevalence of women's HIV status disclosure and associated factors in East Africa. Therefore, the current study aimed to assess the pooled prevalence of disclosure status and associated factors among women in East Africa.

Objectives

To assess the pooled prevalence of HIV sero-status disclosure and associated factors among women in East Africa.

Methods

HINARI, PubMed, and Cochrane Library databases were searched. The data were extracted using a Microsoft Excel spreadsheet and STATA v 14.1 was used for the analysis. The Funnel plots and Egger's statistical test was used to check publication bias. Heterogeneity was assessed by conducting sensitivity and subgroup analyses.

Result

The pooled prevalence of sero-status disclosure among women in East Africa was 73.77% (95%CI 67.76, 79.77). Knowing partner's sero-status (OR = 10.04(95%CI 3.36, 31.84), married (OR = 2.46 (95%CI 1.23, 4.89), smooth relationship (OR = 3.30 (95%CI 1.39, 7.84), and discussion on HIV before the test (OR = 6.96 (95%CI 3.21, 15.05) were identified determinants of HIV sero-status disclosure.

Conclusion

The current systematic and meta-analysis revealed that nearly one-fourth of women had not disclosed HIV sero-status to at least one individual. Knowing the partner's HIV sero-status, being married, having a smooth relationship, and discussing on HIV before the test were determinants of disclosure status. Therefore, disclosure of HIV-positive sero-status among women living with HIV needs to be strengthened.

Disclosure Pattern and Its Determinants among Patients Attending Anti-Retroviral Clinics in a North Central Capital City in Nigeria

Background

It has been observed that contributory factors such as unprotected sexual intercourse and vertical transmission of HIV to the unborn child during childbirth still occur among women living with HIV.HIV status disclosure has also been found to lead to improved access to HIV prevention and treatment programmes.

Methodology

The study was a descriptive cross sectional study using quantitative and qualitative data collection tools. Four hundred patients were recruited for the study and systematic sampling was used to select respondents at each treatment centre. Data was collected using a semi-structured interviewer administered questionnaire and a patient focus group discussion (FGD) guide.

Results

The age of the respondents ranged from 20 to 70 years and 75.5% of the respondents were females. More than three-quarters of respondents (77%) had disclosed their status to their partners. Status disclosure to sexual partners was higher among respondents who were currently living with their partners (87.1%, p=<0.001).

Conclusion

The study recommended that Government, partners and multilateral agencies needs to consider establishing empowerment schemes for women and men living with HIV to enable them live economic viable lives and avoid using economic means as a determinant of status disclosure.

Acceptability of provider-initiated HIV testing as an intervention for prevention of mother to child transmission of HIV and associated factors among pregnant women attending at Public Health Facilities in Assosa town, Northwest Ethiopia

BACKGROUND

Despite more efforts for prevention of mother to child HIV transmission, still there are problems with provider-initiated HIV testing. This study was done to assess the acceptance rate of provider-initiated HIV testing among antenatal care attendants and its associated factors.

METHODS

Institutions based cross sectional study with a sample size of 398 was conducted from February to March 2014 in two health facilities in Assosa town. Proportional allocation of the sample size of health facilities followed by systematic sampling method was done; data were collected using an interviewer administered questionnaire. Bivariate and multivariate regression analysis was employed using SPSS version 20.

RESULTS

A total of 386 pregnant women participated with response rate 97 % and 312 (80.8 %) of them accepted provider-initiated HIV testing. The odds of acceptance of provider-initiated HIV testing was higher among rural residents (AOR 4.04; 95 % CI 1.24-13.11) than urban. It was also higher among students (AOR 6.00; 95 % CI 1.45-24.75), merchants (AOR 4.43; 95 % CI 1.18-16.68) and employed women (AOR 2.15; 95 % CI 1.08-4.30) than housewives. Pregnant women who had no stigmatized attitude towards people living with HIV/AIDS were more likely to accept testing (AOR 3.54; 95 % CI 1.23-10.16) than who had a strong stigmatized attitude. In addition, those who planned to disclose their test results from their husbands were higher odd of acceptance (AOR 14.85; 95 % CI 4.60-47.94) than who secreted.

CONCLUSION

Acceptance of provider-initiated HIV testing among pregnant women attending for antenatal care services was relatively high. Mothers from urban residence, occupational satus being housewives, stigmatization and not having a plan to disclose the status of test results were negatively affect the acceptance of provider-initiated HIV testing. During counselling sessions, antenatal care providers should focus on barriers of provider-initiated HIV testing such as residence, occupational status, stigmatized attitudes and disclosure status of results of HIV tests.

Determinant and outcome of early diagnosis of HIV infection among HIV-exposed infants in southwest Ethiopia

BACKGROUND

Preventing mother-to-child transmission (PMTCT) of human immunodeficiency virus infection (HIV) has been a fundamental advancement in the acquired immunodeficiency syndrome (AIDS) response for the past decade. Several countries have made great strides in the efforts to prevent HIV through mother-to-child transmission. The objective of this study is to assess the determinant and outcome of early diagnosis of HIV infection among HIV-exposed infants in southwest Ethiopia.

METHODS

An institutional based retrospective cohort study was conducted in a hospital. Medical records of HIV-exposed infants and their mothers enrolled into the program were reviewed. Data entry and analysis was carried out using SPSS version 20 for Windows.

RESULTS

A total of 426 HIV exposed infant-mother pairs where both mother and infants received a minimum ARV intervention for PMTCT were included in the study. Two hundred fifty-four (59.6%) of mothers had attended antenatal care (ANC). Of all participants, 234(54.9%) mothers did not receive any PMTCT prophylaxis during ANC, while only 104(24.4) received antiretroviral (ART) as PMTCT prophylaxis and 163(38.3%) claimed that did not observe any infant PMTCT interventions while 135(31.7%) of the infants received single-dose NVP + AZT. About 385(90.4%) infants were not infected at their final infection status. Those mothers who did not attended ANC follow-up, infants on mixed and complementary feeding and infants weaned off and mothers who were in WHO clinical stage III and IV were more likely to have HIV sero positive infant.

CONCLUSION

This study showed that 385(90.4%) of the infants were not infected at their final infection status. Therefore, encouraging pregnant women to visit health facilities during their course of pregnancy, focusing on exclusive breast feeding counseling and promotion, and early initiation of antiretroviral treatment to HIV infected pregnant women are recommend.

Use of rapid HIV antibody testing for controlling the HIV pandemic

The HIV pandemic continues to expand throughout Africa and southern Asia. Despite recent advances in therapy, the primary means of prevention continues to be the identification of infected patients through diagnostic testing, and the provision of counseling services to reduce HIV transmission. In order to facilitate the identification of infected patients, great strides have been made during the past 10 years towards the development of simple, rapid HIV antibody assays that require no specialized equipment, are relatively stable at ambient temperatures and can be easily performed by people who do not have a laboratory background. Evaluations of these assays have shown that when used in multiple assay algorithm strategies, they perform comparably with current laboratory-based methods. Effective global implementation of these tests will require a concerted effort from public and private health agencies, however, expanding the use of these assays can provide a significant opportunity to slow the devastating spread of HIV.

Assessment of utilization of provider-initiated HIV testing and counseling as an intervention for prevention of mother to child transmission of HIV and associated factors among pregnant women in Gondar town, North West Ethiopia

Background

Detection of maternal HIV infection early in pregnancy is critical for prevention of mother to child transmission of HIV/AIDS. Most efforts have focused on VCT as the primary means of encouraging people to become aware of their HIV status. However, its uptake is low in many parts of sub-Saharan Africa including Ethiopia. Provider-initiated HIV testing and counseling provides a critical opportunity to diagnose HIV infection, to begin chronic care, and to prevent mother to child transmission. However, little is known about its acceptance and associated factors among pregnant women in the country and particularly in the present study area.

Methods

Health institution based cross-sectional quantitative study was conducted in Gondar town from July 22-August 18, 2010. A total of 400 pregnant women were involved in the study using stratified sampling technique and multiple logistic regression analysis was employed using SPSS version 16.

Results

A total of 400 pregnant women actively participated in this study and 330 (82.5%) of them accepted provider-initiated HIV testing and counseling to be tested for HIV and 70(17.5%) of them refused. Acceptance of provider-initiated HIV testing and counseling was positively associated with greater number of antenatal care visits [Adj. OR (95%CI)=2.64(1.17, 5.95)], residing in the urban areas[Adj. OR (95%CI)=2.85(1.10, 7.41)], having comprehensive knowledge on HIV [Adj. OR (95%CI)=4.30(1.72, 10.73)], positive partners reaction for HIV positive result [Adj. OR (95%CI)=8.19(3.57, 18.80)] and having knowledge on prevention of mother to child transmission of HIV[Adj. OR (95%CI)=3.27(1.34, 7.94)], but negatively associated with increased maternal age and education level.

Conclusion

Utilization of provider-initiated HIV testing and counseling during antenatal care was relatively high among pregnant women in Gondar town. Couple counseling and HIV testing should be strengthened to promote provider-initiated HIV testing and counseling among male partners and to reduce HIV related violence of women from their partner and access to and consistent use of antenatal care should be improved to increase the uptake of provider-initiated HIV testing and counseling service.

Prophylactic treatment uptake and compliance with recommended follow up among HIV exposed infants: a retrospective study in Addis Ababa, Ethiopia

BACKGROUND

Children are being infected by HIV/AIDS mainly through mother-to-child transmission. In Ethiopia currently more than 135,000 children are living with HIV/AIDS. The aim of this study was to describe the pattern of ARV uptake after birth, co-trimoxazole prophylaxis and follow up compliance, and to examine which factors are associated with the intervention outcome.

METHODS

A retrospective quantitative study design was used for data collection through two hospitals. All infants who were delivered by HIV infected mothers between October 2008 and August 2009 were included and information regarding treatment adherence during their first 6 months of age was collected.

FINDINGS

118 HIV exposed infant-mother pairs were included in the study. 107 (90.7%) infants received ARV prophylaxis at birth. Sixty six (56%) of the infants were found to be adherent to co-trimoxazole prophylactic treatment. The majority (n = 110(93.2%)) of infants were tested HIV negative with DNA/PCR HIV test at the age of sixth weeks. Infants who took ARV prophylaxis at birth were found to be more likely to adhere with co-trimoxazole treatment: [OR = 9.43(95% CI: 1.22, 72.9)]. Similarly, infants whose mothers had been enrolled for HIV/ART care in the same facility [OR = 14(95% CI: 2.6, 75.4)], and children whose fathers were tested and known to be HIV positive [OR = 3.0(95% CI: 1.0, 9.0)] were more likely to adhere than their counterparts. Infants feeding practice was also significantly associated with adherence χ2 -test, p < 0.01.

CONCLUSION

The proportion of ARV uptake at birth among HIV exposed infants were found to be high compared to other similar settings. Mother-infant pair enrolment in the same facility and the infant's father being tested and knew their HIV result were major predictors of infants adhering to treatment and follow up. However, large numbers of infants were lost to follow up.

HIV/AIDS stigma and refusal of HIV testing among pregnant women in rural Kenya: results from the MAMAS Study

HIV/AIDS stigma is a common thread in the narratives of pregnant women affected by HIV/AIDS globally and may be associated with refusal of HIV testing. We conducted a cross-sectional study of women attending antenatal clinics in Kenya (N = 1525). Women completed an interview with measures of HIV/AIDS stigma and subsequently information on their acceptance of HIV testing was obtained from medical records. Associations of stigma measures with HIV testing refusal were examined using multivariate logistic regression. Rates of anticipated HIV/AIDS stigma were high—32% anticipated break-up of their relationship, and 45% anticipated losing their friends. Women who anticipated male partner stigma were more than twice as likely to refuse HIV testing, after adjusting for other individual-level predictors (OR = 2.10, 95% CI: 1.15–3.85). This study demonstrated quantitatively that anticipations of HIV/AIDS stigma can be barriers to acceptance of HIV testing by pregnant women and highlights the need to develop interventions that address pregnant women’s fears of HIV/AIDS stigma and violence from male partners.

Effect of a community popular opinion leader HIV/STI intervention on stigma in urban, coastal Peru

Evaluating interventions that reduce HIV stigma may help to craft effective stigma-reduction programs. This study evaluates the effects of a community popular opinion leader HIV/STI intervention on stigma in urban, coastal Peru. Mixed effects modeling was used to analyze data on 3,049 participants from the Peru site of the NIHM collaborative trial. Analyses looked at differences between the comparison and intervention groups on a stigma index from baseline to 12- and 24-month follow-up. Sub-analyses were conducted on heterosexual-identified men (esquineros), homosexual-identified men (homosexuales), and socially marginalized women (movidas). Compared to participants in the comparison group, intervention participants reported lower levels of stigma at 12- and 24-month follow-up. Similar results were found within esquineros and homosexuales. No significant differences were found within movidas. Findings suggest that interventions designed to normalize HIV prevention behaviors and HIV communication can reduce HIV-related stigma and change community norms.

Utilization of HIV voluntary counseling and testing in Vietnam: an evaluation of 5 years of routine program data for national response

This study evaluated the utilization of HIV voluntary counseling-and-testing (VCT) services targeting high-risk populations in Vietnam in order to inform decisions on program improvement and expansion. A total of 158,888 records collected from 55 VCT sites supported by the U.S. Centers for Disease Control and Prevention's Global AIDS Program in the period of 2002 to 2007 were used to analyze sociodemographic characteristics, risk exposures, seropositivity, test refusal, and failure to return for test results among VCT clients. High-risk exposures, such as injection drug use, commercial sex work, homosexual contacts or heterosexual contacts with high-risk sex partners, were reported in 126,815 (81%) records. Among high-risk clients, any condom use in the past month ranged from 34% to 71%. During the study period, 19% of the VCT encounters resulted in a positive HIV test; of those persons tested, 23% of men and 13% of women were HIV-positive. High HIV positivity rates were associated with injection drug use, being ill/recommended by health care provider, and having an HIV-infected sex partner. Of all records, 6.1% documented refusal of HIV testing. Failure to return for results was reported in 3.5% of records for clients who were tested. Previously testing positive was the strongest predictor of test refusal, and being referred by peer educators was associated with failure to return for results. The VCT program in Vietnam successfully targeted high-risk populations, and clients had high return rates using a standard testing strategy. Interventions to increase consistent condom use and promote access to prevention services among sex partners of high-risk individuals should be implemented and evaluated.

Acceptability and challenges of implementing voluntary counselling and testing (VCT) in rural Zimbabwe: evidence from the Regai Dzive Shiri Project

Voluntary counselling and testing (VCT) is an important component of HIV prevention and care. Little research exists on its acceptability and feasibility in rural settings. This paper examines the acceptability and feasibility of providing VCT using data from two sub-studies: (1) client-initiated VCT provided in rural health centres (RHCs) and (2) researcher-initiated VCT provided in a non-clinic community setting. Nurses provided client-initiated VCT in 39 RHCs in three Zimbabwean provinces (2004-2007). Demographic data and HIV status were collected. Qualitative data were also collected to assess rural communities' impressions of services. In a second study in 2007, VCT was offered to participants in a population-based HIV prevalence survey. Quantitative data from clinic-based VCT show that of 3585 clients aged > or =18, 79.4% (95% CI: 78.0-80.7%) were female; young people (aged 18-24) comprised 21.1%. Overall, 32.9% (95% CI: 31.4-34.5%) tested HIV positive. Young people were less likely to be HIV positive 13.5% (95% CI: 11.1-16.1%) vs. 38.1% (95% CI: 36.3-39.9%). In the second study conducted in a non-clinic setting, 27.0% (n=1368/5052) of participants opted to test. Young people were as likely to test as adults (27.3% vs. 26.9%) and an equal proportion of men and women tested. Overall during the second survey, 18.8% (95% CI: 16.7-21.0%) of participants tested positive (youth = 8.4% (95% CI: 6.4-10.7%); adults = 29.1% (95% CI: 25.7-32.7%)). Qualitative data, unique to clinics only, suggested that adults identify RHCs as acceptable VCT sites, whereas young people expressed reservations around these venues. Males reported considering VCT only after becoming ill. While VCT offered through RHCs is acceptable to women, it seems that men and youth are less comfortable with this venue. When VCT was offered in a non-clinic setting, numbers of men and women testing were similar. These data suggest that it may be possible to improve testing uptake in rural communities using non-clinic settings.

Prevention of mother-to-child transmission of HIV in a refugee camp setting in Tanzania

The objective of this article is to describe the results of a 2-year pilot programme implementing prevention of mother to child HIV transmission (PMTCT) in a refugee camp setting. Interventions used were: community sensitization, trainings of healthcare workers, voluntary counselling and HIV testing (VCT), infant feeding, counselling, and administration of Nevirapine. Main outcome measures include: HIV testing acceptance rates, percentage of women receiving post test counselling, Nevirapine uptake, and HIV prevalence among pregnant women and their infants. Ninety-two percent of women (n=9,346) attending antenatal clinics accepted VCT. All women who were tested for HIV received their results and posttest counselling. The HIV prevalence rate among the population was 3.2%. The overall Nevirapine uptake in the camp was 97%. Over a third of women were repatriated before receiving Nevirapine. Only 14% of male counterparts accepted VCT. Due to repatriation, parent's refusal, and deaths, HIV results were available for only 15% of infants born to HIV-infected mothers. The PMTCT programme was successfully integrated into existing antenatal care services and was acceptable to the majority of pregnant women. The major challenges encountered during the implementation of this programme were repatriation of refugees before administration of Nevirapine, which made it difficult to measure the impact of the PMTCT programme.

Follow-up of HIV-infected women diagnosed by antenatal screening in Barbados from 1996-2004

A follow-up study was undertaken to analyze the impact of the early diagnosis of HIV in women by antenatal voluntary counseling and testing (VCT) by way of making a difference to their health status and the social behavior of these women. This is a descriptive study. The study population included all HIV-infected women in this country who were diagnosed to be HIV infected by way of VCT during 1996-2004. Sixty-one (37.4%) never attended the HIV clinic for their care or treatment. The median delay between the time of diagnosis of HIV infection and the time of their presentation to the follow-up clinic was 36 months. Of the 79 women who reported to have been sexually active only 33 had a steady partner; 54 had had one or more casual sex partners at some point in time since their HIV diagnosis. One third never used condoms with their steady partner and one sixth never used condoms with casual partners. Overall, 89 women had one or more repeated pregnancy, mostly from different partners. In conclusion, many of the women diagnosed from antenatal VCT fail to utilize the available health care facilities and continue to engage in risk-taking behaviors.

The feasibility of preventing mother-to-child transmission of HIV using peer counselors in Zimbabwe

Background

Prevention of mother-to-child transmission of HIV (PMTCT) is a major public health challenge in Zimbabwe.

Methods

Using trained peer counselors, a nevirapine (NVP)-based PMTCT program was implemented as part of routine care in urban antenatal clinics.

Results

Between October 2002 and December 2004, a total of 19,279 women presented for antenatal care. Of these, 18,817 (98%) underwent pre-test counseling; 10,513 (56%) accepted HIV testing, of whom 1986 (19%) were HIV-infected. Overall, 9696 (92%) of women collected results and received individual post-test counseling. Only 288 men opted for HIV testing. Of the 1807 HIV-infected women who received posttest counseling, 1387 (77%) collected NVP tablet and 727 (40%) delivered at the clinics. Of the 1986 HIV-infected women, 691 (35%) received NVPsd at onset of labor, and 615 (31%) infants received NVPsd. Of the 727 HIV-infected women who delivered in the clinics, only 396 women returned to the clinic with their infants for the 6-week follow-up visit; of these mothers, 258 (59%) joined support groups and 234 (53%) opted for contraception. By the end of the study period, 209 (53%) of mother-infant pairs (n = 396) came to the clinic for at least 3 follow-up visits.

Conclusion

Despite considerable challenges and limited resources, it was feasible to implement a PMTCT program using peer counselors in urban clinics in Zimbabwe.

Factors influencing teen mothers' enrollment and participation in prevention of mother-to-child HIV transmission services in Limpopo Province, South Africa

In this article, we examine barriers to HIV testing uptake and participation in prevention of mother-to-child HIV transmission (PMTCT) services among adolescent mothers aged 15 to 19 years in rural and urban Limpopo Province, South Africa. We used the narrative research method involving key informants constructing typical case studies of adolescent experiences with HIV testing and entry into PMTCT. Case studies formed the basis of a community-based questionnaire and focus group discussions with adolescent mothers. Client-counselor dynamics during pretest counseling were pivotal in determining uptake and participation, and counselor profile strongly influenced the nature of the interaction. Other factors found to influence adherence to PMTCT recommendations included HIV and early premarital pregnancy stigma, fear of a positive test result, and concerns over confidentiality and poor treatment by health care providers. Adolescents described elaborate strategies to avoid HIV disclosure to labor and delivery staff, despite knowing this would mean no antiretroviral therapy for their newborn infants. Theoretical, methodological, and programmatic implications of study findings are also discussed.

Adjusting HIV prevalence data from a program for the prevention of mother-to-child transmission for surveillance purposes in Uganda

OBJECTIVES

To evaluate a method for adjusting estimates of HIV prevalence based on data from a program for the prevention of mother-to-child transmission (PMTCT) of HIV infection for the potential bias attributable to refusal of PMTCT-related testing.

METHODS

Age-specific logistic regression models were used to estimate the HIV risk coefficients for 10 predictor variables among women who accepted the PMTCT-related testing (n = 1874) at an antenatal clinic in northern Uganda. These risk coefficients were used to predict the prevalence among women who were not tested (n = 1719) and to adjust the PMTCT-based prevalence for nonparticipation bias. Crude and adjusted PMTCT-based prevalence estimates were compared with the prevalence among women who were anonymously tested as part of routine sentinel surveillance (n = 2225).

RESULTS

The PMTCT-based prevalence represented an underestimate compared with that based on anonymous surveillance in 2004 (9.0% vs. 10.5%); in 2005, it constituted an overestimate (11.8% vs. 10.9%). Adjusting the PMTCT-based prevalence reduced the difference attributable to nonparticipation bias by approximately 70% in both years, so that the adjusted prevalence (10.1% in 2004 and 11.2% in 2005) was similar to the surveillance-based prevalence.

CONCLUSIONS

The adjustment method was effective in reducing the nonparticipation bias. Further studies are needed to assess the utility of PMTCT program data for HIV surveillance.

Determinants of HIV counselling and testing participation in a prevention of mother-to-child transmission programme in rural Burkina Faso

OBJECTIVES

To analyse the factors associated with the uptake of HIV counselling, HIV testing and returning for test results in a rural hospital setting in Nouna, Burkina Faso.

METHODS

Cross sectional survey of 435 pregnant women who visited the district hospital for antenatal care, from July to December 2004. Separate multivariate logistic regression analyses including analysis of reported reasons were performed to identify the factors associated with accepting HIV counselling and testing.

RESULTS

HIV testing participation was related to discussing HIV screening with the partner (OR 8.36), and the number of antenatal care (ANC) visits already accomplished (OR 2.23). The quality of pre-test counselling was very poor as 42% did not understand the process. The absence of doctors and mismanagement of time for post-test counselling were the main reasons why women did not receive test results. Analysis of participants by discussion status, counselling and test participation revealed that fewer women dropped out at every stage who discussed HIV testing with their partner.

CONCLUSION

Communication with the partner plays a vital role in the uptake of HIV testing. Encouraging women to engage in a discussion about testing with their partners may be a viable intervention to improve participation. Quality of service needs to be better.

Routine offer of antenatal HIV testing ("opt-out" approach) to prevent mother-to-child transmission of HIV in urban Zimbabwe

OBJECTIVE

To assess the impact of routine antenatal HIV testing for preventing mother-to-child transmission of HIV (PMTCT) in urban Zimbabwe.

METHODS

Community counsellors were trained in routine HIV testing policy using a specific training module from June 2005 through November 2005. Key outcomes during the first 6 months of routine testing were compared with the prior 6-month "opt-in" period, and clients were interviewed.

FINDINGS

Of the 4551 women presenting for antenatal care during the first 6 months of routine HIV testing, 4547 (99.9%) were tested for HIV compared with 3058 (65%) of 4700 women during the last 6 months of the opt-in testing (P < 0.001), with a corresponding increase in the numbers of HIV-infected women identified antenatally (926 compared with 513, P < 0.001). During routine testing, more HIV-infected women collected results compared to the opt-in testing (908 compared with 487, P < 0.001) resulting in a significant increase in deliveries by HIV-infected women (256 compared with 186, P = 0.001); more mother/infant pairs received antiretroviral prophylaxis (n = 256) compared to the opt-in testing (n = 185); and more mother/infant pairs followed up at clinics (105 compared with 49, P = 0.002). Women were satisfied with counselling services and most (89%) stated that offering routine testing is helpful. HIV-infected women reported low levels of spousal abuse and other adverse social consequences.

CONCLUSION

Routine antenatal HIV testing should be implemented at all sites in Zimbabwe to maximize the public health impact of PMTCT.

Investigating factors associated with uptake of HIV voluntary counselling and testing among pregnant women living in North Uganda

We investigated factors potentially associated with the uptake of HIV voluntary counselling and testing (VCT), which is the first step in acceding to programmes for the prevention of mother-to-child transmission of HIV infection. For the period 2001-2003, we estimated the VCT uptake among the 12,252 first-time attendees of the Antenatal Clinic (ANC) at Lacor Hospital (Gulu District, North Uganda). Associations between VCT uptake and socio-demographic characteristics and reproductive history were evaluated using log binomial regression models. VCT uptake was 55.6% for the overall study period; it increased from 51.0% in 2001 to 58.6% in 2002 and 57.7% in 2003 (P <0.001). Having some education [primary versus none, adjusted prevalence proportion ratio (PPR) =1.05, 95% confidence intervals (CI): 1.00-1.10] and being unmarried (cohabitating, PPR =1.07, 95% CI: 1.03-1.10; single/widowed/divorced, PPR =1.10, 95% CI: 1.03-1.18) were significantly associated with VCT uptake. Associations of borderline significance were found for: recent change of residence, having a partner with a modern occupation, and past use of contraceptives. VCT uptake is still low in this district of North Uganda. Although some socio-demographic factors were found to have been associated with uptake, the associations were weak and not of public-health significance.

Operational effectiveness of single-dose nevirapine in preventing mother-to-child transmission of HIV

OBJECTIVE

To determine the operational effectiveness of the South African programme for preventing mother-to-child transmission (PMTCT) of HIV in reducing rates of early transmission of infection.

METHODS

Participants were mother-infant pairs who participated in the South African PMTCT programme between October 2002 and November 2004. This was a prospective cohort study. Three sites in different provinces were selected to represent differences in socioeconomic status and HIV prevalence. Data on antenatal care and labour ward care were obtained from maternal interviews and from reviews of medical records. A total of 665 mother-infant pairs in which the mother was HIV-positive were recruited and 588 (88.4%) were followed up at 3 or 4 weeks postpartum to determine the HIV status and vital status of the infant.

FINDINGS

Rural participants were significantly poorer and their health care was significantly worse. Women of higher socioeconomic status and those who received better counselling were more likely to be treated with nevirapine. Rates of early HIV transmission ranged from 8.6% to 13.7%. Maternal viral load was the only statistically significant risk factor for transmission. After adjusting for maternal viral load and prevalence of low birth weight, the odds of transmission were 1.8 times higher at the rural site. Controlling for having had > or = 4 antenatal visits and any delivery complication reduced the odds of transmission to 1.5 higher at the rural site.

CONCLUSION

Rates of early transmission of HIV in an operational setting using single-dose nevirapine administered both to mother and child are similar to those obtained in clinical trials. Scaling up access to antiretroviral regimens for women will further reduce transmission to infants.

Approaches for scaling up human immunodeficiency virus testing and counseling in prevention of mother-to-child human immunodeficiency virus transmission settings in resource-limited countries

Prevention of mother-to-child human immunodeficiency virus (HIV) transmission (PMTCT) programs have nearly eliminated mother-to-child transmission of HIV in developed countries, but progress in resource-limited countries has been slow. A key factor limiting the scale-up of PMTCT programs is lack of knowledge of HIV serostatus. Increasing the availability and acceptability of HIV testing and counseling services will encourage more women to learn their status, providing a gateway to PMTCT interventions. Key factors contributing to the scale-up of testing and counseling include a policy of provider-initiated testing and counseling with right to refuse (opt-out); group pretest counseling; rapid HIV testing; innovative staffing strategies; and community and male involvement. Integration of testing and counseling within the community and all maternal and child health settings are critical for scaling-up and for linking women and their families to care and treatment services. This paper will review best practices needed for expansion of testing and counseling in PMTCT settings in resource-limited countries.

Attitudes to voluntary counselling and testing prior to the offer of Nevirapine to prevent vertical transmission of HIV in northern Tanzania

In developed countries much progress has been made in reducing vertical transmission of HIV using antiretroviral therapies. To achieve similar gains in Africa the acceptability of routine HIV testing of pregnant women is becoming increasingly important. Evidence of reluctance of pregnant women to undergo HIV testing has led to suggestions to offer antiretroviral therapy to pregnant women without prior HIV testing. In this study we set out to identify risk factors for preferring to avoid HIV testing among women attending an antenatal clinic in northern Tanzania in the context of a hypothetical offer of Nevirapine and to explore the issues raised in more detail in focus group discussions. Two hundred and fifty women attending an antenatal clinic in late pregnancy were interviewed. Almost half of the women preferred to be offered Nevirapine without HIV testing. In a multiple logistic model having a partner with a history of a sexually transmitted disease (OR 2.72, 95% CI 1.14-6.47, p = 0.02) and having a partner who had another sexual partner in the last year (OR 1.89, 95% CI 1.04-3.45, p = 0.04) were positively associated with a preference to avoid HIV testing; while the presence of a partner living at home or feeling able to ask their partner to go for an HIV test were negatively associated with a preference to avoid HIV testing (OR 0.46, 95% CI 0.24-0.89, p = 0.02 and OR 0.56, 95% CI 0.3-1.05, p = 0.07 respectively). FGDs (focus group discussions) suggested that the major concern of women was for the reaction of their male partners to the possibility of a positive HIV test and low confidence in the confidentiality of HIV testing. This fear may lead to low uptake of antiretroviral programmes and treatment without prior testing should be considered.

Acceptability of routine HIV testing ("opt-out") in antenatal services in two rural districts of Zimbabwe

Low uptake of prevention of mother-to-child transmission of HIV (PMTCT) services in resource-limited settings requires new approaches to prevent missed opportunities. Routine HIV testing ("opt-out" testing) in antenatal care (ANC) should be considered. An exploratory cross-sectional survey was conducted in 6 PMTCT sites in rural Zimbabwe. Women who had attended ANC in health centers where PMTCT was provided were surveyed in postnatal services. Of 520 women sampled, 285 (55%) had been HIV tested during their last pregnancy. Primary education or no education (P = 0.02), reporting receiving neither group education in the ANC clinic (P < 0.001) nor individual pretest counseling (P < 0.001), and having attended <6 ANC visits (P < 0.03) were associated with not having been HIV tested. Among the 235 women not HIV tested in ANC, 79% would accept HIV testing if opt-out testing was introduced. Factors associated with accepting the opt-out approach were being <20 years old (P = 0.005), having secondary education or more (P = 0.03), living with a partner (P = 0.001), and the existence of a PMTCT service where the untested women delivered. Thirty-seven women of 235 (16%) would decline routine HIV testing, mainly because of their fear of knowing their HIV status and the need to have their partner's consent. Among the women already tested in ANC (n = 285), 97% would accept the opt-out approach. In Zimbabwe, where 25% of pregnant women are HIV infected, introducing the opt-out strategy for HIV testing may have a far-reaching public health impact on PMTCT. Issues regarding, stigma, quality of post-testing counseling and staffing must be considered, however.

Antenatal HIV testing in rural eastern Uganda in 2003: incomplete rollout of the prevention of mother-to-child transmission of HIV programme?

Background

Uganda began to implement the prevention of mother-to-child transmission (PMTCT) of HIV programme in 2000, and by the end of 2003 it had expanded to cover 38 of the 56 districts including Mbale District. However, reports from Mbale Hospital showed that less than 10% of pregnant women accepted antenatal HIV testing. We therefore conducted a study to determine the proportion of pregnant women who tested for HIV and the gaps and barriers in PMTCT implementation.

Methods

The study was a cross sectional household survey of women aged 18 years or more, with children aged one year or less, who resided in Mbale Town or in the surrounding Bungokho County. We also conducted in-depth interviews with six health workers in Mbale Hospital.

Results

In 2003, we interviewed 457 women with a median age of 24 years. The prevalence of antenatal HIV testing was 10 percent. The barriers to antenatal HIV testing were unavailability of voluntary counselling and testing services (44%), lack of HIV counselling (42%) and perceived lack of benefits for HIV infected women and their infants. Primipara (OR 2.6, 95% CI 1.2–5.8), urban dwellers (OR 2.7, 95% CI 1.3–5.8), women having been counselled on HIV (OR 6.2, 95% CI 2.9–13.2), and women with husbands being their primary confidant (OR 2.3, 95% CI 1.0–5.5) were independently associated with HIV testing.

Conclusion

The major barriers to PMTCT implementation were unavailability of PMTCT services, particularly in rural clinics, and poor antenatal counselling and HIV testing services. We recommend that the focus of the prevention of mother-to-child transmission of HIV programme should shift to the district and sub-district levels, strengthen community mobilization, improve the quality of antenatal voluntary counselling and HIV testing services, use professional and peer counsellors to augment HIV counselling, and ensure follow-up care and support for HIV positive women and their infants.

Psychosocial consequences of early diagnosis of HIV status in vertically exposed infants in Johannesburg, South Africa

Mother-to-child transmission (MTCT) is the most common source of HIV infection in children. One topic that has received virtually no attention in MTCT-related research and programming is the psychosocial consequences among parents and families of receiving a definitive diagnosis of infant HIV status. This study explored experiences of HIV-infected mothers in Johannesburg, South Africa, regarding infant testing and diagnosis. Data collection entailed a key informant workshop and repeat interviews with a convenience sample of 31 HIV-infected mothers. While early testing was desirable, diagnosis had both beneficial and detrimental psychosocial effects, especially in instances of serodiscordance. Programmatic implications are discussed.

A randomized trial of two postexposure prophylaxis regimens to reduce mother-to-child HIV-1 transmission in infants of untreated mothers

BACKGROUND

Single-dose nevirapine (NVP) prophylaxis to mother and infant is widely used in resource-constrained settings for preventing mother-to-child transmission (MTCT) of HIV-1. Where women do not access antenatal care or HIV testing, postexposure prophylaxis to the infant may be an important preventative strategy.

METHODS

This multicentre, randomized, open-label clinical trial (October 2000 to September 2002) in South Africa compared single-dose NVP with 6 weeks of zidovudine (ZDV), commenced within 24 h of delivery among 1051 infants whose mothers had no prior antiretroviral therapy. HIV-1 infection rates were ascertained at birth, and at 6 and 12 weeks of age. Kaplan-Meier survival methods were used to estimate HIV-1 infection rates in an intention-to-treat analysis.

RESULTS

Overall, 6 week and 12 week MTCT probability was 12.8% [95% confidence interval (CI),10.5-15.0] and 16.3% (95% CI,13.4-19.2), respectively. At 12 weeks, among infants who were not infected at birth, 24 (7.9%) infections occurred in the NVP arm and 41 (13.1%) in the ZDV arm (log rank P = 0.06). Using multivariate analysis, factors associated with infection following birth were ZDV use [odds ratio (OR), 1.8; 95% CI,1.1-3.2; P = 0.032), maternal CD4 cell count < 500 x 10(6) cells/l (OR, 2.5; 95% CI,1.3-5.0; P = 0.007), maternal viral load > 50 000 copies/ml (OR, 3.6; 95% CI,2.0-6.2; P < 0.0001) and breastfeeding (OR, 2.2; 95% CI,1.3-3.8; P = 0.006).

CONCLUSION

A single-dose of NVP given to infants offers protection against HIV-1 infection and should be a strategy used in infants of mothers with untreated HIV infection.

Women in couples antenatal HIV counseling and testing are not more likely to report adverse social events

BACKGROUND

Couple counseling has been promoted as a strategy to improve uptake of interventions to prevent mother-to-child HIV transmission (pMTCT) and to minimize adverse social outcomes associated with disclosure of HIV status.

OBJECTIVES

We tested whether women counseled antenatally as part of a couple were more likely to accept HIV testing and nevirapine in a pMTCT program, and whether they would be less likely to experience later adverse social events than women counseled alone.

METHODS

A pMTCT program that included active community education and outreach to encourage couple counseling and testing was implemented in two antenatal clinics in Lusaka, Zambia. A subset of HIV-positive women was asked to report their experience of adverse social events 6 months after delivery. Couple-counseled women were compared with individual-counseled women stratified by whether or not they had disclosed their HIV status to their partners.

RESULTS

Nine percent (868) of 9409 women counseled antenatally were counseled with their husband. Couple-counseled women were more likely to accept HIV testing (96%) than women counseled alone (79%); however uptake of nevirapine was not improved. Six months after delivery, 28% of 324 HIV-positive women reported at least one adverse social event (including physical violence, verbal abuse, divorce or separation). There were no significant differences in reported adverse social events between couple- and individual-counseled women.

CONCLUSIONS

Couple counseling did not increase the risk of adverse social events associated with HIV disclosure. Support services and interventions to improve social situations for people living with HIV need to be further evaluated.

Factors influencing acceptability of voluntary counselling and HIV-testing among pregnant women in Northern Tanzania

Guided by the conceptual framework of the Health Belief Model, this study aimed to identify factors associated with pregnant women's expressed willingness to accept voluntary counselling and HIV-testing (VCT). A cross-sectional interview survey of 500 pregnant women, complemented by focus group discussions, was conducted in the Kilimanjaro region of Tanzania. Constructs derived from the Health Belief Model explained 41.7% of women's willingness to accept VCT. Perceived high personal susceptibility to HIV/AIDS, barriers related to confidentiality and partner involvement, self-efficacy regarding alternative feeding methods and religion were all shown to be associated with willingness to accept VCT. The women's acceptance of VCT seems to depend upon their perceiving that VCT and alternative feeding strategies provide clear benefits, primarily for the child. Whether a positive attitude to VCT and alternative feeding strategies are transformed into actual behaviour depends on a set of complicated decisions in which several potential psychological consequences are assessed. Sharing the diagnosis with partners may not have the intended effect if there is a lack of sensitivity to the women's fear of blame and rejection. If pregnant women are to fully participate in and benefit from mother-to-child-transmission prevention efforts, their partners must be committed and involved in the process.

Implementing a rural programme of prevention of mother-to-child transmission of HIV in Zimbabwe: first 18 months of experience

OBJECTIVE

To report on activities and lessons learned during the first 18 months of a rural programme of prevention of mother-to-child transmission of HIV (PMTCT) in Zimbabwe.

METHODS

The PMTCT services were introduced in Murambinda Mission Hospital (120 beds), Buhera, in 2001. Programme strategies consisted in recruiting counselling staff, training health professionals, improving mother-child health (MCH) facilities and conducting information, education and communication activities within the community to address HIV/AIDS awareness and stigma. The following components were implemented within MCH services: voluntary counselling and testing of HIV using rapid testing, nevirapine short regimen proposed to all HIV-infected mothers identified and their newborns, support to exclusive breastfeeding for 6- and 18-month mother-child follow-up. Routine monitoring data collected from August 2001 to February 2003 were used to estimate programme uptake.

RESULTS

Of 2471 pregnant women using antenatal services, 2298 were pre-test counselled, the acceptance of HIV testing reached 92.9%. Of the women who decided to take an HIV test, 1588 (74.3%) returned to collect their result. Overall HIV prevalence was 20.4% (n = 437); 326 of the HIV-positive women were counselled and 104 (24%) received complete mother-child antiretroviral prophylaxis.

CONCLUSIONS

Acceptability of HIV testing after counselling has remained above 90% since the onset of the programme. Collection of test results and mother-child follow-up are among the most challenging activities of the programme. A district approach and community participation are critical to develop PMTCT programmes in rural settings, even with reasonably good MCH services.

Preventing mother-to-child HIV transmission in the new millennium: the challenge of breast feeding

Short courses of antiretroviral drugs have greatly enhanced the prospect of reducing mother-to-child HIV transmission. Yet transmission by breast feeding clouds hopes for this seemingly simple intervention. We revisit mathematical models to assess the competing risks associated with feeding by breast vs. formula. These indicate that, in the less developed world where the HIV epidemic predominates, neither option, unmodified, offers a reasonable choice for HIV-positive women. Where infant mortality rates are greater than about 40 per 1000 live births, if formula were made available to HIV-infected women only, the excess number of deaths that would result from formula use would be approximately the same or greater than the number of HIV infections that might be prevented. Only at lower infant mortality rates, less than about 40 per 1000, is the risk greater on the breast. There are thus no good grounds for the total avoidance of breast feeding under all conditions. Research to develop and test safer infant feeding alternatives is an urgent priority. On the one hand, ways to reduce HIV transmission while preserving breast feeding, as exclusive breast feeding could do, need to be fully tested. On the other hand, ways to reduce non-HIV morbidity and mortality associated with formula feeding, as educational or sanitary interventions could do, equally need testing. With either approach, a necessary foundation for implementing all the core components of preventing mother-to-child HIV transmission is competent counselling for mothers. Innovative approaches are needed to mobilise and train effective counsellors among health care workers and, as appropriate, community members.

HIV rapid tests: progress, perspective, and future directions

In November 2002, the U.S. Food and Drug Administration approved the OraQuick Rapid HIV-1 Antibody Test (OraSure Technologies, Inc., Bethlehem, PA), a reliable, rapid test that detects HIV-1 antibodies. In contrast to other HIV-testing techniques, the OraQuick test uses blood obtained by finger stick instead of venipuncture and provides results in 20 minutes. Implications for practice, as well as future applications of this technology, are discussed in this article.

HIV-1/AIDS and maternal and child health in Africa

Every day, 1900 children acquire HIV-1 infection from their mother in Africa. The 25-45% risk of mother-to-child transmission can be reduced in several ways: prevention of sexual transmission for women of child-bearing age, access to HIV-1 testing, reduction of unwanted pregnancies by education of HIV-1-infected women, and antiretroviral-based prevention. All antiretroviral regimens of proven efficacy can be used in a minimum package of care for HIV-1-infected pregnant women. At present, programmes in 13 countries reach less than 3% of HIV-1-infected African women. 35-59% of African children infected with HIV-1 die by their second birthday. Infectious complications are preventable by primary prophylaxis with co-trimoxazole. A rapid scaling-up and comprehensive continuum of care is needed for all members of affected families, including access to antiretroviral treatment and community-based responses to the increasing number of orphans. Prevention of mother-to-child transmission should become a universal standard of care in Africa, and research should continue to reduce the transmission risk to well below 5%.