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: 5.55). 12/2007; 21(18):2529-32. DOI: 10.1097/QAD.0b013e3282f155f4
Source: PubMed


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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    • "Test acceptability after pre-test counselling is variable but overall high ranging from 72% to 97%, as indicated in several previous reports [19,25-27]. In regards to NVP provision to HIV positive pregnant women by site, our finding of 70.2% is consistent with other previous reports indicating rates from 56% to 94% [19,21,23,24,26-31]. "
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    ABSTRACT: Background: Uptake of prevention of mother-to-child HIV transmission (PMTCT) programs remains challenging in sub-Saharan Africa because of multiple barriers operating at the individual or health facility levels. Less is known regarding the influence of program-level and contextual determinants. In this study, we explored the multilevel factors associated with coverage in single-dose nevirapine PMTCT programs. Methods: We analyzed aggregate routine data collected within the framework of the Viramune(®) Donation Programme (VDP) from 269 sites in 20 PMTCT programs and 15 sub-Saharan countries from 2002 to 2005. Site performance was measured using a nevirapine coverage ratio (NCR), defined as the reported number of women receiving nevirapine divided by the number of women who should have received nevirapine (observed HIV prevalence x number of women in antenatal care [ANC]). Data on program-level determinants were drawn from the initial application forms, and country-level determinants from the Demographic and Health Surveys (DHS) and the World Bank (World Development Indicators). Multilevel linear mixed models were used to identify independent factors associated with NCR at the site-, program- and country-level. Results: Of 283,410 pregnant women attending ANC in the included sites, 174,312 women (61.5%) underwent HIV testing after receiving pre-test counselling, of whom 26,700 tested HIV positive (15.3%), and 22,591 were dispensed NVP (84.6%). Site performance was highly heterogeneous between and within programs. Mean NCR by site was 43.8% (interquartile range: 19.1-63.9). Multilevel analysis identified higher HIV prevalence (Beta coefficient: 25.1, 95% confidence interval [CI] 18.7 to 31.6), higher proportion of persons with knowledge of PMTCT (8.3; CI 0.5 to 16.0), higher health expenditure as a proportion of Gross Domestic Product (3.9 per %; CI 2.0 to 5.8) and lower percentage of rural population (-0.7 per %; CI -1.0 to -0.5) as significant country-level predictors of higher NCR at the p<0.05 level. A medium ANC monthly activity (30-100/month) was the only site-level predictor found (-7.6; CI -15.1 to -0.1). Conclusions: Heterogeneity of nevirapine coverage between sites and programs was high. Multilevel analysis identified several significant contextual determinants, which may warrant additional research to further define important multi-level and potentially modifiable determinants of performance of PMTCT programs.
    BMC Public Health 04/2013; 13(1):286. DOI:10.1186/1471-2458-13-286 · 2.26 Impact Factor
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    • "Of eight women identified as HIV positive, six receive ARV prophylaxis. Of infants born to these eight HIV positive women identified, only four will receive prophylaxis [15]. In 2009, only an estimated 26% of pregnant women in low- and middle-income countries were tested for HIV and an estimated 53% [40%–79%] of them received antiretroviral medication to prevent the mother-to-child transmission of HIV [12]. "
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    ABSTRACT: We performed a systematic review to assess the effect of integrated perinatal prevention of mother-to-child transmission of HIV interventions compared to non- or partially integrated services on the uptake in low- and middle-income countries. We searched for experimental, quasi-experimental and controlled observational studies in any language from 21 databases and grey literature sources. Out of 28 654 citations retrieved, five studies met our inclusion criteria. A cluster randomized controlled trial reported higher probability of nevirapine uptake at the labor wards implementing HIV testing and structured nevirapine adherence assessment (RRR 1.37, bootstrapped 95% CI, 1.04-1.77). A stepped wedge design study showed marked improvement in antiretroviral therapy (ART) enrolment (44.4% versus 25.3%, p<0.001) and initiation (32.9% versus 14.4%, p<0.001) in integrated care, but the median gestational age of ART initiation (27.1 versus 27.7 weeks, p = 0.4), ART duration (10.8 versus 10.0 weeks, p = 0.3) or 90 days ART retention (87.8% versus 91.3%, p = 0.3) did not differ significantly. A cohort study reported no significant difference either in the ART coverage (55% versus 48% versus 47%, p = 0.29) or eight weeks of ART duration before the delivery (50% versus 42% versus 52%; p = 0.96) between integrated, proximal and distal partially integrated care. Two before and after studies assessed the impact of integration on HIV testing uptake in antenatal care. The first study reported that significantly more women received information on PMTCT (92% versus 77%, p<0.001), were tested (76% versus 62%, p<0.001) and learned their HIV status (66% versus 55%, p<0.001) after integration. The second study also reported significant increase in HIV testing uptake after integration (98.8% versus 52.6%, p<0.001). Limited, non-generalizable evidence supports the effectiveness of integrated PMTCT programs. More research measuring coverage and other relevant outcomes is urgently needed to inform the design of services delivering PMTCT programs.
    PLoS ONE 04/2012; 7(4):e35268. DOI:10.1371/journal.pone.0035268 · 3.23 Impact Factor
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