Missed Opportunities to Prevent Mother-to-Child-Transmission in sub-Saharan Africa: Systematic Review and Meta-Analysis.

aDivision of International and Environmental Health, Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland bSchool of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa cInfectious Diseases Clinic, Bern University Hospital, Bern, Switzerland. *Equal contribution.
AIDS (London, England) (Impact Factor: 5.55). 08/2012; 26(18). DOI: 10.1097/QAD.0b013e328359ab0c
Source: PubMed

ABSTRACT OBJECTIVES:: To determine magnitude and reasons of loss to programme and poor antiretroviral prophylaxis coverage in prevention of mother-to-child transmission (PMTCT) programmes in sub-Saharan Africa. DESIGN:: Systematic review and meta-analysis. METHODS:: We searched PubMed and Embase databases for PMTCT studies in sub-Saharan Africa published between January 2002 and March 2012. Outcomes were the percentage of pregnant women (i) tested for HIV, (ii) initiating antiretroviral prophylaxis, (iii) having a CD4 cell count measured, and (iv) initiating antiretroviral combination therapy (cART) if eligible. In children outcomes were (v) early infant diagnosis for HIV, and (vi) cART initiation. We combined data using random-effects meta-analysis and identified predictors of uptake of interventions. RESULTS:: Forty-four studies from 15 countries including 75,172 HIV-infected pregnant women were analyzed. HIV-testing uptake at antenatal care services was 94% (95% confidence intervals [CI] 92-95%) for opt-out and 58% (95% CI 40-75%) for opt-in testing. Coverage with any antiretroviral prophylaxis was 70% (95% CI 64-76%) and 62% (95% CI 50-73%) of pregnant women eligible for cART received treatment. Sixty-four percent (95% CI 48-81%) of HIV exposed infants had early diagnosis performed and 55% (95% CI 36-74%) were tested between 12 and 18 months. Uptake of PMTCT interventions was improved if cART was provided at the antenatal clinic and if the male partner was involved. CONCLUSIONS:: In sub-Saharan Africa, uptake of PMTCT interventions and early infant diagnosis is unsatisfactory. An integrated family-centered approach seems to improve retention.

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    • "It is estimated that ART coverage is still only around 50%, while HIV-related mortality remains high, not only because of low-treatment coverage, but also due to poor retention of patients initiated on treatment [1–3]. Prevention of mother-to-child transmission (PMTCT) fares little better in SSA, as the uptake of PMTCT and early infant diagnosis continue to be unsatisfactory [1, 4]. As such, there is an urgent need for innovative strategies to offer ART to more people, including HIV-positive pregnant women, as well as to retain them in care [5]. "
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    ABSTRACT: Mozambique continues to face many challenges in HIV and maternal and child health care (MCH). Community-based antiretroviral treatment groups (CAG) enhance retention to care among members, but whether such benefits extend to their families and to MCH remains unclear. In 2011 we studied utilization of HIV and MCH services among CAG members and their family aggregates in Changara, Mozambique, through a mixed-method assessment. We systematically revised all patient-held health cards from CAG members and their non-CAG family aggregate members and conducted semistructured group discussions on MCH topics. Quantitative data were analysed in EPI-Info. Qualitative data were manually thematically analysed. Information was retrieved from 1,624 persons, of which 420 were CAG members (26%). Good compliance with HIV treatment among CAG members was shared with non-CAG HIV-positive family members on treatment, but many family aggregate members remained without testing, and, when HIV positive, without HIV treatment. No positive effects from the CAG model were found for MCH service utilization. Barriers for utilization mentioned centred on insufficient knowledge, limited community-health facility collaboration, and structural health system limitations. CAG members were open to include MCH in their groups, offering the possibility to extend patient involvement to other health needs. We recommend that lessons learnt from HIV-based activism, patient involvement, and community participation are applied to broader SRH services, including MCH care.
    AIDS research and treatment 07/2013; 2013(4865):937456. DOI:10.1155/2013/937456
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    • "Despite recent rapid advances in the delivery of services for prevention of mother to child transmission of HIV (PMTCT) in many sub-Saharan African countries, the follow-up of HIV-exposed infants until the age of 18 months remains a critical challenge [1]. Adequate follow-up is important to ensure that HIV-exposed infants receive the necessary prophylaxis for PMTCT, are timely tested for possible HIV infection, and, if tested HIV positive, have access to treatment. "
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    ABSTRACT: The follow-up of HIV-exposed infants remains a public health challenge in many Sub-Saharan countries. Just as integrated antenatal and maternity services have contributed to improved care for HIV-positive pregnant women, so too could integrated care for mother and infant after birth improve follow-up of HIV-exposed infants. We present results of a study testing the viability of such integrated care, and its effects on follow-up of HIV-exposed infants, in Tete Province, Mozambique. Between April 2009 and September 2010, we conducted a mixed-method, intervention-control study in six rural public primary healthcare facilities, selected purposively for size and accessibility, with random allocation of three facilities each for intervention and control groups. The intervention consisted of a reorganization of services to provide one-stop, integrated care for mothers and their children under five years of age. We collected monthly routine facility statistics on prevention of mother-to-child HIV transmission (PMTCT), follow-up of HIV-exposed infants, and other mother and child health (MCH) activities for the six months before (January-June 2009) and 13 months after starting the intervention (July 2009-July 2010). Staff were interviewed at the start, after six months, and at the end of the study. Quantitative data were analysed using quasi-Poisson models for significant differences between the periods before and after intervention, between healthcare facilities in intervention and control groups, and for time trends. The coefficients for the effect of the period and the interaction effect of the intervention were calculated with their p-values. Thematic analysis of qualitative data was done manually. One-stop, integrated care for mother and child was feasible in all participating healthcare facilities, and staff evaluated this service organisation positively. We observed in both study groups an improvement in follow-up of HIV-exposed infants (registration, follow-up visits, serological testing), but frequent absenteeism of staff and irregular supply of consumables interfered with healthcare facility performance for both intervention and control groups. Despite improvement in various aspects of the follow-up of HIV-exposed infants, we observed no improvement attributable to one-stop, integrated MCH care. Structural healthcare system limitations, such as staff absences and irregular supply of essential commodities, appear to overshadow its potential effects. Regular technical support and adequate basic working conditions are essential for improved performance in the follow-up of HIV-exposed infants in peripheral public healthcare facilities in Mozambique.
    BMC Health Services Research 06/2013; 13(1):207. DOI:10.1186/1472-6963-13-207 · 1.71 Impact Factor
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    ABSTRACT: In adults it is well documented that there are substantial losses to the programme between HIV testing and start of antiretroviral therapy (ART). The magnitude and reasons for loss to follow-up and death between HIV diagnosis and start of ART in children are not well defined. We searched the PubMed and EMBASE databases for studies on children followed between HIV diagnosis and start of ART in low-income settings. We examined the proportion of children with a CD4 cell count/percentage after after being diagnosed with HIV infection, the number of treatment-eligible children starting ART and predictors of loss to programme. Data were extracted in duplicate. Eight studies from sub-Saharan Africa and two studies from Asia with a total of 10,741 children were included. Median age ranged from 2.2 to 6.5 years. Between 78.0 and 97.0% of HIV-infected children subsequently had a CD4 cell count/percentage measured, 63.2 to 90.7% of children with an eligibility assessment met the eligibility criteria for the particular setting and time and 39.5 to 99.4% of the eligible children started ART. Three studies reported an association between low CD4 count/percentage and ART initiation while no association was reported for gender. Only two studies reported on pre-ART mortality and found rates of 13 and 6 per 100 person-years. Most children who presented for HIV care met eligibility criteria for ART. There is an urgent need for strategies to improve the access to and retention to care of HIV-infected children in resource-limited settings.
    PLoS ONE 02/2013; 8(2):e56446. DOI:10.1371/journal.pone.0056446 · 3.23 Impact Factor
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