Provision of care following prevention of mother-to-child HIV transmission services in resource-limited settings

Elizabeth Glaser Pediatric AIDS Foundation, Santa Monica, CA, USA.
AIDS (London, England) (Impact Factor: 6.56). 12/2007; 21(18):2529-32. DOI: 10.1097/QAD.0b013e3282f155f4
Source: PubMed

ABSTRACT To evaluate the provision of care for mother and child after institution of prevention of mother-to-child transmission (PMTCT) of HIV services.
As part of an effort to improve services, we undertook a review of our multicountry PMTCT program.
Review of key indicators from our PMTCT database and reporting practices from January 2005 to June 2006 throughout 18 resource-limited countries.
1 066 606 pregnant women were counseled and tested, and 102 336 tested HIV-positive. Antiretroviral prophylaxis was dispensed to 81 384 mothers and 52 342 HIV-exposed infants. From available reporting, 1388 pregnant women were dispensed antiretroviral drugs for treatment and 9060 children received cotrimoxazole prophylaxis at 6 weeks.
PMTCT services are integrated into maternal-child health services but adult and pediatric care and treatment programs often function independently, without coordination or linkages. Integrating care into maternal-child health services and linking mother's HIV status to child are necessary for HIV-infected mothers and HIV-exposed children to receive appropriate follow-up and treatment.

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    • "Attention to continuity of care is especially needed, given the rapid pace of urbanisation, increasing internal mobility, especially by young people, and the interdependence of pre-pregnancy, maternal, child and long-term health. A study of prevention of mother-to-child transmission of HIV (PMTCT) programmes in 18 countries found that only 9% of infants born to HIV-positive mothers could be identified at their first immunisation visit (Ginsburg et al., 2007), highlighting the absence of medical records systems that could be linked between health facilities (Forster et al., 2008). "
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    ABSTRACT: We examine progress towards the 1994 International Conference on Population and Development (ICPD) commitment to provide universal access to sexual and reproductive health (SRH) services by 2014, with an emphasis on changes for those living in poor and emerging economies. Accomplishments include a 45% decline in the maternal mortality ratio (MMR) between 1990 and 2013; 11.5% decline in global unmet need for modern contraception; ~21% increase in skilled birth attendance; and declines in both the case fatality rate and rate of abortion. Yet aggregate gains mask stark inequalities, with low coverage of services for the poorest women. Demographic and Health Surveys and Multiple Indicator Cluster Surveys from 80 developing countries highlight persistent disparities in skilled birth attendance by household wealth: in 70 of 80 countries (88%), ≥80% of women in the highest quintile were attended by a skilled provider at last birth; in only 23 of the same countries (29%) was this the case for women in the lowest wealth quintile. While there have been notable declines in HIV incidence and prevalence, women affected by HIV are too often bereft of other SRH services, including family planning. Achieving universal access to SRH will require substantially greater investment in comprehensive and integrated services that reach the poor.
    Global Public Health 01/2015; 10(2):1-25. DOI:10.1080/17441692.2014.986178 · 0.92 Impact Factor
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    • "The World Health Organization recommends triple antiretroviral (ARV) prophylaxis or antiretroviral treatment (ART) for HIV-infected pregnant women to prevent mother-to-child transmission (PMTCT) of HIV during pregnancy, delivery and breastfeeding (WHO 2010a), working towards the elimination of paediatric HIV infection (WHO 2010b). However, effective identification, referral and ART initiation of eligible HIV-infected pregnant women are difficult (Ginsburg et al. 2007). The first crucial step is offering provider-initiated HIV testing and counselling (WHO 2007). "
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    ABSTRACT: HIV-infected women identified through antenatal care (ANC) often fail to access antiretroviral treatment (ART), leaving them and their infants at risk for declining health or HIV transmission. We describe results of measures to improve uptake of ART among eligible pregnant women. Between October 2006 and December 2009, interventions implemented at ANC and ART facilities in urban Lilongwe aimed to better link services for women with CD4 counts <250/μl. A monitoring system followed women referred for ART to examine trends and improve practices in referral completion, on-time ART initiation and ART retention. Six hundred and twelve women were ART eligible: 604 (99%) received their CD4 result, 344 (56%) reached the clinic, 286 (47%) started ART while pregnant and 261 (43%) were either alive on ART or transferred out after 6 months. Between 2006 and 2009, the median (IQR) time between CD4 blood draw and ART initiation fell from 41 days (17, 349) to 15 days (7,42) (P = 0.183); the proportion of eligible individuals starting ART while pregnant and retained for 6 months improved from 17% to 65% (P < 0.001). Delays generally shortened within the continuum of care from 2006 to 2009; however, time from CD4 blood draw to ART referral increased from 7 to 14 days. Referrals between facilities and delays through CD4 count measurements create bottlenecks in patient care. Retention improved over time, but delays within the linkage process remained. ART initiation at ANC plus use of point-of-care CD4 tests may further enhance ART uptake.
    Tropical Medicine & International Health 04/2012; 17(6):751-9. DOI:10.1111/j.1365-3156.2012.02980.x · 2.30 Impact Factor
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    • "Eighty-five per cent of women underwent initial evaluation for HAART eligibility in both study arms, but the proportion of eligible women who initiated HAART was low in both arms at 14% and 33% in control and intervention arms, respectively (Killam et al. 2010). Data from sites in 14 countries showed that only 1.4% of HIV-positive pregnant women had received HAART; the proportion of HAARTeligible women was not reported (Ginsburg et al. 2007). In contrast, the study in Ivory Coast showed exceptionally high uptake of CD4 count testing (100%) and HAART (95%) (Tonwe-Gold et al. 2009). "
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    ABSTRACT: Objectives  To quantify attrition between women testing HIV-positive in pregnancy-related services and accessing long-term HIV care and treatment services in low- or middle-income countries and to explore the reasons underlying client drop-out by synthesising current literature on this topic. Methods  A systematic search in Medline, EMBASE, Global Health and the International Bibliography of the Social Sciences of literature published 2000-2010. Only studies meeting pre-defined quality criteria were included. Results  Of 2543 articles retrieved, 20 met the inclusion criteria. Sixteen (80%) drew on data from sub-Saharan Africa. The pathway between testing HIV-positive in pregnancy-related services and accessing long-term HIV-related services is complex, and attrition was usually high. There was a failure to initiate highly active antiretroviral therapy (HAART) among 38-88% of known-eligible women. Providing 'family-focused care', and integrating CD4 testing and HAART provision into prevention of mother-to-child HIV transmission services appear promising for increasing women's uptake of HIV-related services. Individual-level factors that need to be addressed include financial constraints and fear of stigma. Conclusions  Too few women negotiate the many steps between testing HIV-positive in pregnancy-related services and accessing HIV-related services for themselves. Recent efforts to stem patient drop-out, such as the MTCT-Plus Initiative, hold promise. Addressing barriers and enabling factors both within health facilities and at the levels of the individual woman, her family and society will be essential to improve the uptake of services.
    Tropical Medicine & International Health 03/2012; 17(5):564-580. DOI:10.1111/j.1365-3156.2012.02958.x · 2.30 Impact Factor
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