[Show abstract][Hide abstract] ABSTRACT: Background: In developing countries, facility-based delivery is recommended for maternal and neonatal health, and for prevention of mother-to-child HIV transmission (PMTCT). However, little is known about whether or not learning one's HIV status affects one's decision to deliver in a health facility. We examined this association in Zimbabwe. Methods: We analyzed data from a 2012 cross-sectional community-based serosurvey conducted to evaluate Zimbabwe's accelerated national PMTCT program. Eligible women (≥16 years old and mothers of infants born 9-18 months before the survey) were randomly sampled from the catchment areas of 157 health facilities in five of ten provinces. Participants were interviewed about where they delivered and provided blood samples for HIV testing. Results: Overall 8796 (77 %) mothers reported facility-based delivery; uptake varied by community (30-100 %). The likelihood of facility-based delivery was not associated with maternal HIV status. Women who self-reported being HIV-positive before delivery were as likely to deliver in a health facility as women who were HIV-negative, irrespective of when they learned their status - before (adjusted prevalence ratio (PRa) = 1.04, 95 % confidence interval (CI) = 1.00-1.09) or during pregnancy (PRa = 1.05, 95 % CI = 1.01-1.09). Mothers who had not accessed antenatal care or tested for HIV were most likely to deliver outside a health facility (69 %). Overall, however 77 % of home deliveries occurred among women who had accessed antenatal care and were HIV-tested. Conclusions: Uptake of facility-based delivery was similar among HIV-infected and HIV-uninfected mothers, which was somewhat unexpected given the substantial technical and financial investment aimed at retaining HIV-positive women in care in Zimbabwe.
Preview · Article · Dec 2015 · BMC Pregnancy and Childbirth
[Show abstract][Hide abstract] ABSTRACT: Objectives:
Zimbabwe has started to scale up Option B+ for prevention of mother to child transmission of HIV, but there is little published information about uptake or retention in care. This study determined the number and proportion of pregnant and lactating women in rural districts diagnosed with HIV infection and started on Option B + along with six-month antiretroviral treatment (ART) outcomes.
This was a retrospective record review of women presenting to antenatal care or maternal and child health services at 34 health facilities in Chikomba and Gutu rural districts, Zimbabwe, between January and March 2014.
2728 women presented to care of whom 2598 were eligible for HIV testing: 76% presented to antenatal care, 20% during labour and delivery and 4% while breast-feeding. Of 2097 (81%) HIV-tested women, 7% were HIV positive. Lower HIV testing uptake was found with increasing parity, late presentation to antenatal care, health centre attendance and in women tested during labour. 91% of the HIV-positive women were started on Option B+. Six-month ART retention in care, including transfers, was 83%. Loss to follow-up was the main cause of attrition. Increasing age and gravida status ≥2 were associated with higher six-month attrition.
The uptake of HIV testing and Option B+ is high in women attending antenatal and post-natal clinics in rural Zimbabwe suggesting that the strategy is feasible for national scale-up in the country. This article is protected by copyright. All rights reserved.
Full-text · Article · Nov 2015 · Tropical Medicine & International Health
[Show abstract][Hide abstract] ABSTRACT: We estimated HIV-free infant survival and mother-to-child HIV transmission (MTCT) rates in Zimbabwe, some of the first community-based estimates from a UNAIDS priority country.
In 2012 we surveyed mother-infant pairs residing in the catchment areas of 157 health facilities randomly selected from 5 of 10 provinces in Zimbabwe. Enrolled infants were born 9-18 months before the survey. We collected questionnaires, blood samples for HIV testing, and verbal autopsies for deceased mothers/infants. Estimates were assessed among i) all HIV-exposed infants, as part of an impact evaluation of Option A of the 2010 WHO guidelines (rolled out in Zimbabwe in 2011), and ii) the subgroup of infants unexposed to Option A. We compared province-level MTCT rates measured among women in the community with MTCT rates measured using program monitoring data from facilities serving those communities.
Among 8568 women with known HIV serostatus, 1107 (12.9%) were HIV-infected. Among all HIV-exposed infants, HIV-free infant survival was 90.9% (95% confidence interval (CI): 88.7-92.7) and MTCT was 8.8% (95% CI: 6.9-11.1). Sixty-six percent of HIV-exposed infants were still breastfeeding. Among the 762 infants born before Option A was implemented, 90.5% (95% CI: 88.1-92.5) were alive and HIV-uninfected at 9-18 months of age, and 9.1% (95%CI: 7.1-11.7) were HIV-infected. In four provinces, the community-based MTCT rate was higher than the facility-based MTCT rate. In Harare, the community and facility-based rates were 6.0% and 9.1%, respectively.
By 2012 Zimbabwe had made substantial progress towards the elimination of MTCT. Our HIV-free infant survival and MTCT estimates capture HIV transmissions during pregnancy, delivery and breastfeeding regardless of whether or not mothers accessed health services. These estimates also provide a baseline against which to measure the impact of Option A guidelines (and subsequently Option B+).
[Show abstract][Hide abstract] ABSTRACT: To examine the uptake of services and behaviors in the prevention of mother-to-child HIV transmission (PMTCT) cascade in Zimbabwe and to determine factors associated with MTCT and maternal antiretroviral therapy (ART) or antiretroviral (ARV) prophylaxis.
Analysis of cross-sectional data from mother-infant pairs.
We analyzed baseline data collected in 2012 as part of the impact evaluation of Zimbabwe's Accelerated National PMTCT Program. Using multistage cluster sampling, eligible mother-infant pairs were randomly sampled from the catchment areas of 157 facilities in 5 provinces, tested for HIV infection, and interviewed about PMTCT service utilization.
Of 8800 women, 94% attended ≥1 antenatal care visit, 92% knew their HIV serostatus during pregnancy, 77% delivered in a health facility, and 92% attended the 6-8 week postnatal visit. Among 1075 (12%) HIV-infected women, 59% reported ART/ARV prophylaxis and 63% of their HIV-exposed infants received ARV prophylaxis. Among HIV-exposed infants, maternal receipt of ART/ARV prophylaxis was protective against MTCT [adjusted prevalence ratio (PRa): 0.41, 95% confidence interval (CI): 0.23 to 0.74]. Factors associated with receipt of maternal ART/ARV prophylaxis included ≥4 antenatal care visits (PRa: 1.18, 95% CI: 1.01 to 1.38), institutional delivery (PRa: 1.31, 95% CI: 1.13 to 1.52), and disclosure of serostatus (PRa: 1.30, 95% CI: 1.12 to 1.49).
These data from women in the community indicate gaps in the PMTCT cascade before the accelerated program, which may have been missed by examination of health facility data alone. These gaps were especially noteworthy for services targeted specifically to HIV-infected women and their infants, such as maternal and infant ART/ARV prophylaxis.
No preview · Article · Jun 2015 · JAIDS Journal of Acquired Immune Deficiency Syndromes
[Show abstract][Hide abstract] ABSTRACT: Food insecurity (FI) is the lack of physical, social, and economic access to sufficient food for dietary needs and food preferences. We examined the association between FI and women's uptake of services to prevent mother-to-child HIV transmission (MTCT) in Zimbabwe.
We analyzed cross-sectional data collected in 2012 from women living in five of ten provinces. Eligible women were ≥16 years old, biological mothers of infants born 9-18 months before the interview, and were randomly selected using multi-stage cluster sampling. Women and infants were tested for HIV and interviewed about health service utilization during pregnancy, delivery, and post-partum. We assessed FI in the past four weeks using a subset of questions from the Household Food Insecurity Access Scale and classified women as living in food secure, moderately food insecure, or severely food insecure households.
The weighted population included 8,790 women. Completion of all key steps in the PMTCT cascade was reported by 49%, 45%, and 38% of women in food secure, moderately food insecure, and severely food insecure households, respectively (adjusted prevalence ratio (PRa) = 0.95, 95% confidence interval (CI): 0.90, 1.00 (moderate FI vs. food secure), PRa = 0.86, 95% CI: 0.79, 0.94 (severe FI vs. food secure)). Food insecurity was not associated with maternal or infant receipt of ART/ARV prophylaxis. However, in the unadjusted analysis, among HIV-exposed infants, 13.3% of those born to women who reported severe household food insecurity were HIV-infected compared to 8.2% of infants whose mothers reported food secure households (PR = 1.62, 95% CI: 1.04, 2.52). After adjustment for covariates, this association was attenuated (PRa = 1.42, 95% CI: 0.89, 2.26). There was no association between moderate food insecurity and MTCT in unadjusted or adjusted analyses (PRa = 0.68, 95% CI: 0.43, 1.08).
Among women with a recent birth, food insecurity is inversely associated with service utilization in the PMTCT cascade and severe household food insecurity may be positively associated with MTCT. These preliminary findings support the assessment of FI in antenatal care and integrated food and nutrition programs for pregnant women to improve maternal and child health.
[Show abstract][Hide abstract] ABSTRACT: : Prevention of mother-to-child transmission (PMTCT) elimination goals are hampered by low rates of retention and antiretroviral treatment adherence. The Eliminating Pediatric AIDS in Zimbabwe (EPAZ) project is assessing whether mother support groups (MSGs) increase rates of retention-in-care of HIV-positive mothers and their exposed infants, increase male participation, and improve other maternal and infant health outcomes. EPAZ is a cluster randomized study involving 30 rural facilities in 2 health districts in Mutare province in eastern Zimbabwe. Facilities were randomly assigned to either the standard-of-care or intervention arms. We established MSGs for HIV-positive mothers at the 15 health facilities in the intervention arm. MSGs met every 2 weeks and were led by an HIV-positive mother who was appointed as MSG coordinator (MSG-C). MSG-Cs contacted nonattending patient-members of support groups by cell phone. If members still do not attend, MSG-Cs inform a health worker who initiates further outreach actions that are standard within the health system. At least 10 HIV-positive mothers are enrolled per facility. Enrollment started in July 2014. The primary outcome measure is retention-in-care of HIV-exposed infants at 12 months of age. Secondary outcome measures are: retention-in-care of HIV-positive mothers at 12 months postpartum, male participation, and other maternal and child health indicators. The study relies on routine health system data supplemented by additional data using tools created for the study. If shown to improve PMTCT retention outcomes, facility-based MSGs have the potential to be scaled up throughout the Zimbabwe National PMTCT program and could be considered in other country programs.
Full-text · Article · Nov 2014 · JAIDS Journal of Acquired Immune Deficiency Syndromes
[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.
Full-text · Article · Nov 2014 · JAIDS Journal of Acquired Immune Deficiency Syndromes
[Show abstract][Hide abstract] ABSTRACT: : Countries with high HIV prevalence face the challenge of achieving high coverage of antiretroviral drug regimens interventions including for the prevention of mother-to-child transmission of HIV (PMTCT). In 2011, the World Health Organization and the Department of Foreign Affairs, Trade and Development, Canada, launched a joint implementation research (IR) initiative to increase access to effective PMTCT interventions. Here, we describe the process used for prioritizing PMTCT IR questions in Malawi, Nigeria, and Zimbabwe. Policy makers, district health workers, academics, implementing partners, and persons living with HIV were invited to 2-day workshops in each country. Between 42 and 70 representatives attended each workshop. Using the Child Health Nutrition Research Initiative process, stakeholder groups systematically identified programmatic barriers and formulated IR questions that addressed these challenges. IR questions were scored by individual participants according to 6 criteria: (1) answerable by research, (2) likely to reduce pediatric HIV infections, (3) addresses main barriers to scaling-up, (4) innovation and originality, (5) improves equity among underserved populations, and (6) likely value to policy makers. Highest scoring IR questions included health system approaches for integrating and decentralization services, ways of improving retention-in-care, bridging gaps between health facilities and communities, and increasing male partner involvement. The prioritized questions reflect the diversity of health care settings, competing health challenges and local and national context. The differing perspectives of policy makers, researchers, and implementers illustrate the value of inclusive research partnerships. The participatory Child Health Nutrition Research Initiative approach effectively set national PMTCT IR priorities, promoted country ownership, and strategically allocated research resources.
No preview · Article · Nov 2014 · JAIDS Journal of Acquired Immune Deficiency Syndromes
[Show abstract][Hide abstract] ABSTRACT: Background
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.
We analyzed baseline data from the evaluation of Zimbabwe’s Accelerated National PMTCT Program. Eligible women were randomly sampled from the catchment areas of 157 health facilities offering PMTCT services in five provinces. Eligible women were ≥16 years old and mothers of infants (alive or deceased) born 9 to 18 months prior to the interview. Participants were interviewed about their HIV status, intendedness of the birth, and contraceptive use.
Of 8,797 women, the mean age was 26.7 years, 92.8% were married or had a regular sexual partner, and they had an average of 2.7 lifetime births. Overall, 3,090 (35.1%) reported that their births were unintended; of these women, 1,477 (47.8%) and 1,613 (52.2%) were and were not using a contraceptive method prior to learning that they were pregnant, respectively. Twelve percent of women reported that they were HIV-positive at the time of the survey; women who reported that they were HIV-infected were significantly more likely to report that their pregnancy was unintended compared to women who reported that they were HIV-uninfected (44.9% vs. 33.8%, p<0.01). After adjustment for covariates, among women with unintended births, there was no association between self-reported HIV status and lack of contraception use prior to pregnancy.
Unmet need for family planning and contraceptive failure contribute to unintended pregnancies among women in Zimbabwe. Both HIV-infected and HIV-uninfected women reported unintended pregnancies despite intending to avoid or delay pregnancy, highlighting the need for effective contraceptive methods that align with pregnancy intentions.
[Show abstract][Hide abstract] ABSTRACT: Background
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
Methods and Findings
From August to December 2012 we conducted a cross-sectional survey of a nationally representative sample of 151 MCH facilities. A questionnaire was used to survey each site about staff training, dried blood spot sample (DBS) collection, turnaround time (TAT) for test results, PMTCT services, and HIV care and treatment linkages for HIV-infected mothers and children and HIV-exposed infants. Descriptive analyses were used.
Of the facilities surveyed, all facilities were trained on DBS collection and 92% responded. Approximately, 99% of responding facilities reported providing DBS collection and a basic HIV-exposed infant service package including EID, extended nevirapine prophylaxis, and use of cotrimoxazole. DBS collection was integrated with immunisations at 83% of facilities, CD4 testing with point-of-care machines was available at 37% of facilities, and ART for both mothers and children was provided at 27% of facilities. More than 80% of facilities reported that DBS test results take >4 weeks to return; TAT did not have a direct association with any specific type of transport, distance to the lab, or intermediate stops for data to travel.
Zimbabwe has successfully scaled up and integrated the national EID and PMTCT programs into the existing MCH setting. The long TAT of infant DBS test results and the lack of integrated ART programs in the MCH setting could reduce effectiveness of the national PMTCT and ART programs. Addressing these important gaps will support successful implementation of the 2014 Zimbabwe's PMTCT guidelines under which all HIV-infected pregnant and breastfeeding women will be offered life-long ART and decentralized ART care.
[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.
Full-text · Article · Nov 2012 · Clinical Infectious Diseases
[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.
No preview · Article · Aug 2012 · JAIDS Journal of Acquired Immune Deficiency Syndromes
[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.
[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.