[Show abstract][Hide abstract] ABSTRACT: : Evidence for Elimination (E4E) is a collaborative project established in 2012 as part of the INSPIRE (INtegrating and Scaling up PMTCT through Implementation REsearch) initiative. E4E is a cluster-randomized trial with 2 arms; Standard of care and "POC Plus" [in which point-of-care (POC) CD4 devices and related counseling support are provided]; aimed at improving retention-in-care of HIV-infected pregnant women and mothers. In November 2013, Zimbabwe adopted Option B+ for HIV-positive pregnant women under which antiretroviral treatment eligibility is no longer based on CD4 count. However, Ministry of Health and Child Care guidelines still require baseline and 6-monthly CD4 testing for treatment monitoring, until viral load testing becomes widely available. Considering the current limited capacity for viral-load testing, the significant investments in CD4 testing already made and the historical reliance on CD4 by health care workers for determining eligibility for antiretroviral treatment, E4E seeks to compare the impact of the provision of POC CD4 technology and early knowledge of CD4 levels on retention-in-care at 12 months, with the current standard of routine, laboratory-based CD4 testing. The study also compares rates of initiation and time-to-initiation between the 2 arms and according to level of maternal CD4 count, the cost of retaining HIV-positive pregnant women in care and the acceptability and feasibility of POC CD4 in the context of Option B+. Outcome measures are derived from routine health systems data. E4E will provide data on POC CD4 testing and retention-in-care associated with Option B+ and serve as an early learning platform to inform implementation of Option B+ in Zimbabwe.
[Show abstract][Hide abstract] ABSTRACT: Prevention of unintended pregnancies among women living with HIV infection is a strategy recommended by the World Health Organization for prevention of mother-to-child transmission of HIV (PMTCT). We assessed pregnancy intentions and contraceptive use among HIV-positive and HIV-negative women with a recent pregnancy in Zimbabwe.
PLoS ONE 01/2014; 9(8):e105320. · 3.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We assessed the integration of PMTCT services during the postpartum period including early infant diagnosis of HIV (EID) and adult and pediatric antiretroviral therapy (ART) in maternal and child health (MCH) facilities in Zimbabwe.
PLoS ONE 01/2014; 9(6):e98236. · 3.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background. In 2010, the World Health Organization (WHO) released revised guidelines for prevention of mother-to-child human immunodeficiency virus (HIV) transmission (PMTCT). We projected clinical impacts, costs, and cost-effectiveness of WHO-recommended PMTCT strategies in Zimbabwe.Methods. We used Zimbabwean data in a validated computer model to simulate a cohort of pregnant, HIV-infected women (mean age, 24 years; mean CD4 count, 451 cells/µL; subsequent 18 months of breastfeeding). We simulated guideline-concordant care for 4 PMTCT regimens: single-dose nevirapine (sdNVP); WHO-recommended Option A, WHO-recommended Option B, and Option B+ (lifelong maternal 3-drug antiretroviral therapy regardless of CD4). Outcomes included maternal and infant life expectancy (LE) and lifetime healthcare costs (2008 US dollars [USD]). Incremental cost-effectiveness ratios (ICERs, in USD per year of life saved [YLS]) were calculated from combined (maternal + infant) discounted costs and LE.Results. Replacing sdNVP with Option A increased combined maternal and infant LE from 36.97 to 37.89 years and would reduce lifetime costs from $5760 to $5710 per mother-infant pair. Compared with Option A, Option B further improved LE (38.32 years), and saved money within 4 years after delivery ($5630 per mother-infant pair). Option B+ (LE, 39.04 years; lifetime cost, $6620 per mother-infant pair) improved maternal and infant health, with an ICER of $1370 per YLS compared with Option B.Conclusions. Replacing sdNVP with Option A or Option B will improve maternal and infant outcomes and save money; Option B increases health benefits and decreases costs compared with Option A. Option B+ further improves maternal outcomes, with an ICER (compared with Option B) similar to many current HIV-related healthcare interventions.
[Show abstract][Hide abstract] ABSTRACT: In the 30 years of the AIDS pandemic, the devastating effects of HIV on infants and young children have often been overlooked and neglected. However, the ability to prevent mother-to-child transmission of HIV (PMTCT), or vertical transmission, has been one of the most significant prevention success stories in the global AIDS response. New HIV infections in children have been virtually eliminated in high-income countries and programmatic efforts have shifted to low-income and middle-income countries, particularly in sub-Saharan Africa, home to the vast majority of pediatric AIDS cases.Over the past decade, the dramatic scale-up of PMTCT programs has saved millions of lives and has provided a foundation for HIV prevention and care and treatment programs that are integrated within maternal and child health services. Although some countries in sub-Saharan Africa are now approaching universal PMTCT coverage, global access to PMTCT for HIV-positive pregnant women remains at nearly 50%. Recently, a new global plan has focused efforts and resources to keep HIV-positive mothers healthy and to virtually eliminate new pediatric infections by 2015.What programmatic and technical innovations will be necessary to overcome current service gaps and implementation barriers? How can countries continue the current momentum with sustainable locally-led programs that address the epidemic in women and children? And how can the vital perspectives of communities and people living with HIV help drive these efforts? Successfully addressing these and other issues will be key to ending HIV infections in children and creating an AIDS-free generation within the next decade.
[Show abstract][Hide abstract] ABSTRACT: Introduction: In Mashonaland East Province, which is home to 186 PMTCT facilities, the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) conducted a situation analysis to assess the quality of PMTCT program implementation in the province.
Methods: A descriptive quantitative cross-sectional survey was conducted in June and July 2011 among nurses working at all 186 health facilities offering PMTCT services in Mashonaland East. District focal persons (DFPs; specialized EGPAF staff that support PMTCT implementation within districts) carried out the survey, which consisted of a questionnaire on provision of HIV testing and counseling, ARV prophylaxis, ART initiation, early infant diagnosis (EID), referral systems, HIV care, and human resources for PMTCT.
Results: Of all facilities surveyed, 179 (96.2%) offered antenatal care (ANC) services. More than 80% offered HIV testing and counseling, and roughly 75% of facilities offered combination maternal and infant ARV prophylaxis (rather than single-dose nevirapine). The province has 14 ART initiation sites and 76 follow-up sites. Availability of on-site ART eligibility assessment (i.e., clinical staging and CD4 testing) was minimal, with most facilities referring women elsewhere (Table 1). EID services were offered at 121 (65%) facilities but transportation of blood samples was a major challenge, with an average turnaround time for dried-blood spot (DBS) samples of 60 days between submission of samples and results returned to the site. Tracking mechanisms for CD4, EID and ART initiation referrals were present in less than 15% of facilities. The proportions of nurses trained in the various PMTCT components were below 40%.
Conclusion: This analysis provided a critical overview of the status of PMTCT program implementation in the province that helped identify key PMTCT program gaps (e.g., limited capacity of staff to provide PMTCT services and initiate women on ART). Further efforts are needed to improve access to combination ARV prophylaxis for adults and infants, as well as on-site CD4 testing and EID services, and to reduce EID result turnaround times. Based on these findings, the province with EGPAF support will work closely with its district teams to improve each of these components in order to achieve elimination of new pediatric HIV infections by 2015.
[Show abstract][Hide abstract] ABSTRACT: Background: Treatment-eligible HIV-positive pregnant women have the highest risk (>75%) of transmitting HIV to their infants, but only a small proportion of women are being initiated on antiretroviral therapy (ART) during pregnancy in Zimbabwe, partially due to limited access to CD4 testing to determine treatment eligibility. We assessed whether introducing point-of-care (POC) CD4 machines at 43 high-volume, Elizabeth Glaser Pediatric AIDS Foundation supported, PMTCT sites in Zimbabwe increased the proportion of HIV-positive pregnant women assessed for ART eligibility and subsequently initiated on ART.
Methods: A quasi-experimental before and after study design was conducted, with 43 high-volume PMTCT sites selected based on number of HIV-positive pregnant women seen. POC CD4 machines were deployed to all 43 sites in June 2011 following health worker trainings on usage of machines and tools (registers, summary sheets). Data were collected before (April-June 2011) and after (July-September 2011) deployment of POC CD4 machines (intervention). Data were analyzed using SPSS v15.0. Differences between proportions were tested using Wilcoxon signed rank test.
Results: Before introduction of the POC machines, 617 (51%) of 1,210 HIV-positive pregnant women received a CD4 test at the 43 sites. After the machines were introduced, 890 (81%) of 1,100 women received a CD4 test. There was a significance difference between the proportion of women tested for CD4 count before and after the intervention (P=0.023) and between the proportion initiated on ART before and after the introduction of the CD4 machines (9%  before versus 25%  after; (P=0.001).
Conclusions: Deployment of POC CD4 machines was associated with increased CD4 testing and ART initiation for HIV-positive pregnant women at the 43 intervention sites. Based on these early results, expansion of POC CD4 machines to all high volume PMTCT sites in Zimbabwe is recommended to increase access to ART eligibility towards elimination of new HIV infections in children by 2015.
[Show abstract][Hide abstract] ABSTRACT: The World Health Organization (WHO) has called for the "virtual elimination" of pediatric HIV: a mother-to-child HIV transmission (MTCT) risk of less than 5%. We investigated uptake of prevention of MTCT (PMTCT) services, infant feeding recommendations, and specific drug regimens necessary to achieve this goal in Zimbabwe.
We used a computer model to simulate a cohort of HIV-infected, pregnant/breastfeeding women (mean age, 24 y; mean CD4, 451/µl; breastfeeding duration, 12 mo). Three PMTCT regimens were evaluated: (1) single-dose nevirapine (sdNVP), (2) WHO 2010 guidelines' "Option A" (zidovudine in pregnancy, infant nevirapine throughout breastfeeding for women without advanced disease, lifelong combination antiretroviral therapy for women with advanced disease), and (3) WHO "Option B" (pregnancy/breastfeeding-limited combination antiretroviral drug regimens without advanced disease; lifelong antiretroviral therapy with advanced disease). We examined four levels of PMTCT uptake (proportion of pregnant women accessing and adhering to PMTCT services): reported rates in 2008 and 2009 (36% and 56%, respectively) and target goals in 2008 and 2009 (80% and 95%, respectively). The primary model outcome was MTCT risk at weaning. The 2008 sdNVP-based National PMTCT Program led to a projected 12-mo MTCT risk of 20.3%. Improved uptake in 2009 reduced projected risk to 18.0%. If sdNVP were replaced by more effective regimens, with 2009 (56%) uptake, estimated MTCT risk would be 14.4% (Option A) or 13.4% (Option B). Even with 95% uptake of Option A or B, projected transmission risks (6.1%-7.7%) would exceed the WHO goal of less than 5%. Only if the lowest published transmission risks were used for each drug regimen, or breastfeeding duration were shortened, would MTCT risks at 95% uptake fall below 5%.
Implementation of the WHO PMTCT guidelines must be accompanied by efforts to improve access to PMTCT services, retain women in care, and support medication adherence throughout pregnancy and breastfeeding, to approach the "virtual elimination" of pediatric HIV in Zimbabwe. Please see later in the article for the Editors' Summary.
PLoS Medicine 01/2012; 9(1):e1001156. · 15.25 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The Zimbabwean national prevention of mother-to-child HIV transmission (PMTCT) program provided primarily single-dose nevirapine (sdNVP) from 2002-2009 and is currently replacing sdNVP with more effective antiretroviral (ARV) regimens.
Published HIV and PMTCT models, with local trial and programmatic data, were used to simulate a cohort of HIV-infected, pregnant/breastfeeding women in Zimbabwe (mean age 24.0 years, mean CD4 451 cells/µL). We compared five PMTCT regimens at a fixed level of PMTCT medication uptake: 1) no antenatal ARVs (comparator); 2) sdNVP; 3) WHO 2010 guidelines using "Option A" (zidovudine during pregnancy/infant NVP during breastfeeding for women without advanced HIV disease; lifelong 3-drug antiretroviral therapy (ART) for women with advanced disease); 4) WHO "Option B" (ART during pregnancy/breastfeeding without advanced disease; lifelong ART with advanced disease); and 5) "Option B+:" lifelong ART for all pregnant/breastfeeding, HIV-infected women. Pediatric (4-6 week and 18-month infection risk, 2-year survival) and maternal (2- and 5-year survival, life expectancy from delivery) outcomes were projected.
Eighteen-month pediatric infection risks ranged from 25.8% (no antenatal ARVs) to 10.9% (Options B/B+). Although maternal short-term outcomes (2- and 5-year survival) varied only slightly by regimen, maternal life expectancy was reduced after receipt of sdNVP (13.8 years) or Option B (13.9 years) compared to no antenatal ARVs (14.0 years), Option A (14.0 years), or Option B+ (14.5 years).
Replacement of sdNVP with currently recommended regimens for PMTCT (WHO Options A, B, or B+) is necessary to reduce infant HIV infection risk in Zimbabwe. The planned transition to Option A may also improve both pediatric and maternal outcomes.
PLoS ONE 01/2011; 6(6):e20224. · 3.53 Impact Factor