PMTCT Update: Latest must-read Literature
- The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) Blueprint: Creating an AIDS-free Generation
PEPFAR (November 2012).
An “AIDS-free generation”—a goal that has finally become realizable due to the effectiveness of recent HIV prevention and treatment breakthroughs—has become a rallying cry for the international response to HIV over the past year. This strategy report released by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) describes how the U.S. Government plans to contribute to this objective. The Blueprint is based on five principles: (1) investing in evidence-based approaches to scale up core interventions, (2) working with a broad array of partner countries, donors, civil society, the private sector, and other stakeholders to mobilize and share resources, (3) improving gender equality in HIV services by focusing on women and girls, (4) ending stigma and discrimination against key populations and people living with HIV, and (5) creating benchmarks to determine whether goals are met. Four “road maps” detail the steps to be taken to achieve these goals. The Road Map for Saving Lives calls for scaling up combination HIV prevention and treatment interventions and eliminating new HIV infections among children by 2015. The Road Map for Smart Investments explains how to target funding to interventions that reach populations most at risk. The Road Map for Shared Responsibility outlines how PEPFAR will build partnerships with other countries and build support for civil society, while theRoad Map for Driving Results with Science supports implementation research and other ways to build the evidence base.
- High PMTCT Program Uptake and Coverage of Mothers, Their Partners, and Babies in Northern Uganda: Achievements and Lessons Learned Over 10 Years of Implementation (2002-2011)
Bannink-Mbazzi, F., Lowicki-Zucca, M., Ojom, L., et al. Journal of Acquired Immune Deficiency Syndromes (April 2013), Vol. 62 No. 5, pp. e138-e145.
The authors presented data from prevention of mother-to-child transmission (PMTCT) programs supported through the Association of Volunteers in International Service Foundation and the Ministry of Health in 24 facilities in four rural districts in northern Uganda from 2002 to 2011. Analysis showed that the comprehensive PMTCT program, including community engagement, attained continuous improvements over 10 years. Of the nearly 140,700 women in all attended antenatal care services, 94 percent were tested for HIV, with overall prevalence of 6 percent. Overall, 79 percent of HIV-positive women started antiretroviral therapy or antiretroviral prophylaxis for PMTCT by 2011--above national proportions. Overall, 49 percent (n=68,928) of clients delivered in a health facility; approximately 7 percent were HIV-positive. HIV prevalence among children decreased from 10 percent in 2004 to 5 percent by 2011. Men's uptake of HIV testing considerably increased (from 6 percent in 2002 to 76 percent in 2011). The authors believed that implementation of interventions such as family support groups, couples testing, and male-friendly clinic spaces contributed to men's engagement, and that collaboration with various stakeholders, linkages among services, and training (including on supply chain management) are essential for successful programs. The authors concluded that comprehensive PMTCT is an effective strategy for reducing HIV transmission.
- Towards an AIDS-Free Generation with Option B+: Reconceptualizing and Integrating Prevention of Mother to Child Transmission (PMTCT) with Pediatric Antiretroviral Therapy Initiatives
Thyssen, A., Lange, J.H., Thyssen, E., et al. Journal of Acquired Immune Deficiency Syndromes (February 2013), Vol. 62 No. 2, pp. 127-128.
In this editorial, the authors discuss a study of mortality and loss to follow-up (LTFU) outcomes in HIV-positive children on antiretroviral therapy (ART) in Asia and East, South, and West Africa, and prevention of mother-to-child transmission (PMTCT) strategies. Cumulative mortality was nearly 6 percent, and LTFU was approximately 12 percent (although varying by country). Children younger than 12 months were at higher risk compared to those between the ages of 10 and 15. Further, because the majority of infections are transmitted during labor or breast feeding, strengthening PMTCT is a focus under the United States Government's goal to create an "AIDS-free generation." Improving outcomes among HIV-positive children may entail adopting PMTCT Option B+ (originally introduced in Malawi), which would place all HIV-positive pregnant women on ART for life-varying from the World Health Organization's two current options, which both recommend cessation of treatment either immediately postpartum or once the child has stopped breastfeeding. While further research and economic feasibility studies are necessary, the authors suggest that placing HIV-positive mothers on ART at the same treatment site with Option B+ may provide more treatment support for their children and ultimately result in improved health outcomes, including lower mortality and LTFU rates.
- Field Effectiveness of Combination Antiretroviral Prophylaxis for the Prevention of Mother-to-Child HIV Transmission in Rural Zambia
Gartland, M.G., Chintu, N.T., Li, M.S., et al. AIDS (2013), Vol. 27 No. 8, pp. 1253-1262.
The authors of this study assessed the effectiveness of combination antiretroviral therapy (ART) prophylaxis for prevention of mother-to-child transmission (PMTCT) in public health facilities in Zambia. The intervention group, which received combination ART prophylaxis during pregnancy and breastfeeding, experienced fewer infant HIV infections, compared with control participants, who received short-course antenatal zidovudine and peripartum nevirapine, and with mothers with high CD4 cell counts (above 350/µL). The results support scale up of ART prophylaxis to all women regardless of CD4 cell count. From 2004 to 2011, 143 and 141 HIV-positive women participated in the intervention and control groups, respectively. Baseline CD4 cell count was lower in the intervention group. Adherence data for 103 invention participants revealed that 20, 45, and 35 percent had poor adherence, sub-optimal adherence, and optimal adherence to ART prophylaxis, respectively. After loss to follow-up prior to delivery, the analysis cohort included 129 intervention and 134 control live-born infants. After one year, 15 infants were HIV-positive (only one in the intervention group). Nearly 59 percent of all live-born infants were born to mothers with CD4 cell count above 350 cells/ µL at the time of regimen initiation (38 percent in the intervention; 62 percent in the control). The authors conclude that adherence problems and patient attrition could lessen effectiveness of benefits of ART prophylaxis; therefore, resources to improve access to and retention in care are critical.
- Reducing the Risk of HIV Infection During Pregnancy among South African Women: A Randomized Controlled Trial
Jones, D.L., Peltzer, K., Villar-Loubet, O., et al. AIDS Care (2013), Vol. 25 No. 6, pp. 702-709.
The authors used a group-randomized controlled study in rural South Africa to evaluate a “PartnerPlus” prevention of mother-to-child transmission (PMTCT) intervention. The intervention was conducted with 239 couples at 12 antenatal care (ANC) clinics. Of these couples, 119 were randomly assigned to receive the intervention (increasing male participation during pregnancy, condom use and HIV knowledge, and sexual communication through four weekly sessions on cognitive skills), and 120 couples received standard PMTCT with time-matched health education videos (control). At baseline, 32 percent of women and 16 percent of men were HIV-positive (24 percent of men declined testing); 26 couples were serodiscordant. At follow-up (32 weeks' gestation) unprotected sex had decreased, and no women had seroconverted in the intervention. While baseline HIV knowledge scores were similar, knowledge increased among intervention participants. The intervention group had an estimated 5.1 odds of increased condom use compared with the control. Further, sexual communication/negotiation strategies increased, and intimate partner violence diminished among intervention couples. Findings suggest that interventions targeting men during pregnancy may be more effective than only encouraging ANC attendance. Because neither group attained complete coverage of male HIV testing or mutual disclosure, future research should explore relevant interventions. The authors emphasized the importance of shared engagement between couples to reduce sexual risk behaviors during pregnancy.
- The Impact of Revised PMTCT Guidelines: A View from a Public Sector ARV Clinic in Cape Town, South Africa
Van Schalkwyk, M., Andersson, M.I., Zeier, M.D., et al. Journal of Acquired Immune Deficiency Syndromes (June 2013), Vol. 63 No. 2, pp. 234-238.
The authors conducted a retrospective review of cohorts of pregnant women who initiated highly active antiretroviral therapy (HAART) between January 2008 and December 2010, and presented mother-to-child transmission (MTCT) rates to assess the impact of the 2010 revised Western Cape, South Africa prevention of mother-to-child transmission guidelines. Findings suggest that the new guidelines led to earlier treatment initiation at higher CD4 counts and less MTCT occurred; however, referral for HAART initiation remained a challenge. Among the 250 pregnant women receiving HAART between 2009 and 2010, median gestation at first antenatal care (ANC) visit and HAART initiation decreased from 30 weeks to 23 weeks, and median CD4 count at first ANC visit was higher. More women received HAART for more than eight weeks before delivery (from 48 percent to 74 percent). However, loss-to-follow-up rates were high; nearly 38 percent within one year. Among 256 live births, MTCT rates were 4.7, 7.0, and 0.0 percent in 2008, 2009, and 2010, respectively. Integrating ANC and ART services could streamline therapy initiation and referral. Future studies should assess impact on maternal health of starting HAART at higher CD4 counts and strategies to improve retention. The authors concluded that HIV prevention programs should educate women on the benefits of earlier HAART initiation and retention in care.