Prevention of mother-to-child HIV transmission cascade in China: a systematic review and meta-analysis.
ABSTRACT: INTRODUCTION:The Chinese government has invested US$140 million annually on prevention of mother-to-child transmission (PMTCT) of HIV. This study evaluates the programme by examining the improvements in programme coverage HIV testing and provision of antiviral drugs along the PMTCT cascade. METHODS:Data for PMTCT cascade indicators were collected through a comprehensive systematic review of published peer-reviewed English and Chinese literature during 2003-2011. Meta-analysis was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS:This study included 113 publications. HIV prevalence among pregnant women in China who accessed antenatal care (ANC) remained below 0.1% during the past decade. HIV testing coverage in pregnant women attending ANC and in HIV-exposed infants at 18?months significantly increased from 62.4% (95% CI 4.7% to 98.2%) and 22.1% (16.3% to 32.3%) in 2003 to 90.3% (88.4% to 91.8%) and 82.8% (66.9% to 99.5%) in 2011 respectively, whereas antiretroviral (ARV) prophylaxis uptake increased from 35.2% (12.2% to 47.3%) and 26.9% (24.3% to 28.9%) to 86.2% (53.2% to 97.2%) and 90.3% (85.5% to 93.7%). HIV vertical transmission rate substantially decreased from 31.8% (25.7% to 38.6%) prior to the programme to 2.3% (1.4% to 3.8%) in 2011. During 2003-2011, among 25,312 (23,995-26,644) infants born to HIV-positive mothers who received ARV prophylaxis, 975 (564-1395) were diagnosed with HIV, corresponding to an average transmission rate of 3.9% (3.2% to 4.6%). However, while including transmissions among HIV-positive pregnant women who were lost along the cascade, the average transmission rate during 2003-2011 was 17.4% (15.8% to 19.0%). CONCLUSIONS:PMTCT programmes have reduced HIV mother-to-child transmission in China. Further improvements in the continuum of care remain essential in realising the full potential of the programme.
Project description:INTRODUCTION:Following the introduction of option B+ in 2013, and with the perspective of eliminating mother-to-child transmission of HIV by 2025, Cambodia has implemented an integrated active case management (IACM) approach since 2014 to improve the notification and follow-up of all HIV-infected cases including pregnant women, and to ensure access to and use of the full prevention of mother-to-child transmission (PMTCT) service package by HIV-infected pregnant women and their HIV-exposed infants. This study aimed to analyse PMTCT cascade data in 15 operational districts (ODs) implementing the IACM approach in Cambodia. METHODS:We analysed PMTCT cohort data from 15 ODs implementing IACM approach between 1 January 2014 and 31 December 2016. We measured key indicators along the PMTCT cascade and compared them to available (cross-sectional) PMTCT indicators during the 2011 to 2013 period. RESULTS:During the period 2014 to 2016, among 938 identified HIV-infected pregnant women, 308 (32.8%) were tested HIV positive during their pregnancy, 9 (1.0%) during labour, while the remaining 621 (66.2%) were women on antiretroviral therapy (ART) who became pregnant. During the study period, 867 (92.4%) of the 938 women received ART during pregnancy and labour. Subsequently, 456 (85.6%) of the 533 HEI born and alive during the study period received 6-week antiretroviral (ARV) prophylaxis, 390 (76.6%) and 396 (77.8%) of the 509 infants aged six weeks or older received cotrimoxazole prophylaxis and HIV-DNA PCR test respectively. Among the 396 HEI who received HIV-DNA PCR test, 7 (1.8%) were found HIV positive. The comparison with cross-sectional PMTCT indicator obtained during the previous 2011 to 2013 period in the same 15 ODs, showed a significant increase in ARV uptake among HIV-infected pregnant women (from 72.3% to 92.4%), in cotrimoxazole uptake (from 41.6% to 73.2%), and in HIV-DNA PCR testing coverage among HEI (from 41.2% to 74.3%). CONCLUSIONS:The implementation of option B+ and IACM may have contributed to the improvement of the PMTCT cascade in Cambodia. However, some gaps in accessing PMTCT services along the HIV cascade persist and need to be addressed.
Project description:Intimate partner violence (IPV) is a risk factor for non-adherence to HIV treatment for women, however the evidence on the impact of IPV on uptake of the prevention of mother to child transmission of HIV (PMTCT) cascade is inconclusive. We examined data from 433 HIV positive pregnant women in Kinshasa, Democratic Republic of Congo, enrolled between April 2013 and August 2014 and followed-up through 6 weeks postpartum. Participants were asked about their IPV experiences in a face-to-face interview at enrollment. Measures of PMTCT cascade included: uptake of clinical appointments and services, viral suppression, and adherence to antiretrovirals (ARV). Approximately half of the sample (51%) had experienced some form of IPV; 35% had experienced emotional abuse, 29% physical abuse, and 19% sexual abuse. There were no statistically significant associations between experiencing any form of IPV and uptake of clinical appointments and services (Adjusted Prevalence Ratio [aPR] = 1.02; 95% [CI]: 0.89-1.17), viral load suppression (aPR = 1.07, 95% CI:0.96-1.19) and ARV adherence (aPR = 1.01, 95% CI: 0.87-1.18). Findings from this study indicate that, among HIV-infected pregnant women enrolled in PMTCT care, experiencing IPV does not reduce adherence to clinic visits and services, adherence to ARV. The high prevalence of IPV in this population suggests that IPV screening and intervention should be included as part of standard care for PMTCT.
Project description:OBJECTIVE: The World Health Organization (WHO) has recommended a universal antiretroviral therapy (ART) for all HIV-infected children before the age of two since 2010, but this implies an early identification of these infants. We described the Prevention of Mother-to-Child HIV Transmission (PMTCT) cascade, the staffing and the quality of infrastructures in pediatric HIV care facilities, in Ouagadougou, Burkina Faso. METHODS: We conducted a cross-sectional survey in 2011 in all health care facilities involved in PMTCT and pediatric HIV care in Ouagadougou. We assessed them according to their coverage in pediatric HIV care and WHO standards, through a desk review of medical registers and a semi-structured questionnaire administered to health-care workers (HCW). RESULTS: In 2011, there was no offer of care in primary health care facilities for HIV-infected children in Ouagadougou. Six district hospitals and two university hospitals provided pediatric HIV care. Among the 67 592 pregnant women attending antenatal clinics in 2011, 85.9% were tested for HIV. The prevalence of HIV was 1.8% (95% Confidence Interval: 1.7%-1.9%). Among the 1 064 HIV-infected pregnant women attending antenatal clinics, 41.4% received a mother-to-child HIV transmission prevention intervention. Among the HIV-exposed infants, 313 (29.4%) had an early infant HIV test, and 306 (97.8%) of these infants tested received their result within a four-month period. Among the 40 children initially tested HIV-infected, 33 (82.5%) were referred to a health care facility, 3 (9.0%) were false positive, and 27 (90.0%) were initiated on ART. Although health care facilities were adequately supplied with HIV drugs, they were hindered by operational challenges such as shortage of infrastructures, laboratory reagents, and trained HCW. CONCLUSIONS: The PMTCT cascade revealed bottle necks in PMTCT intervention and HIV early infant diagnosis. The staffing in HIV care and quality of health care infrastructures were also insufficient in 2011 in Ouagadougou.
Project description:The success of prevention of mother-to-child transmission of HIV (PMTCT) is dependent upon high retention of mother-infant pairs within these programmes. This is a systematic review to evaluate the effectiveness of interventions that aim to improve PMTCT service delivery and promote retention throughout the PMTCT steps.Selected databases were searched for studies published in English (up to September 2015). Outcomes of interest included antiretroviral (ARV) drugs or antiretroviral therapy (ART) initiation among HIV-positive pregnant and/or breastfeeding women and their infants, retention into PMTCT programs, the uptake of early infant diagnosis (EID) of HIV and infant HIV status. Risk ratios and random-effect meta-analysis were used in the analysis.Interventions assessed in the 34 identified studies included male partner involvement in PMTCT, peer mentoring, the use of community health workers (CHWs), mobile phone-based reminders, conditional cash transfer, training of midwives, integration of PMTCT services and enhanced referral. Five studies (two randomized) that evaluated mobile phone-based interventions showed a statistically significant increase (pooled RR 1.18; 95% CI 1.05 to 1.32, I(2)=83%) in uptake of EID of HIV at around six weeks postpartum. Male partner involvement in PMTCT was associated with reductions in infant HIV transmission (pooled RR 0.61; 95% CI 0.39 to 0.94, I(2)=0%) in four studies (one randomized). Four studies (three randomized) that were grounded on psychological interventions reported non-significant results (pooled RR 1.01; 95% CI 0.93 to 1.09, I(2)=69%) in increasing ARV/ART uptake among HIV-positive pregnant and/or breastfeeding women and infant HIV testing (pooled RR 1.00; 95% CI 0.94 to 1.07, I(2)=45%). The effect of the other interventions on the effectiveness of improving PMTCT uptake was unclear. Heterogeneity of interventions limits these findings.Our findings indicate that mobile phone-based reminders may increase the uptake of EID of HIV. Studies on male partner involvement in PMTCT reported reductions in infant HIV transmission. Stronger evidence is needed and future studies should determine the long-term effects of these interventions in improving retention throughout the PMTCT steps.
Project description:Despite the progress in the Prevention of the Mother-to-Child Transmission of HIV (PMTCT), the paediatric HIV epidemic remains worrying in Cameroon. HIV prevalence rate for the population of pregnant women was 7.6% in 2010 in Cameroon. The extent of the paediatric HIV epidemic is needed to inform policymakers. We developed a stochastic simulation model to estimate the number of new paediatric HIV infections through MTCT based on the observed uptake of services during the different steps of the PMTCT cascade in Cameroon in 2011. Different levels of PMTCT uptake was also assessed.A discrete events computer simulation-based approach with stochastic structure was proposed to generate a cohort of pregnant women followed-up until 6 weeks post-partum, and optionally until complete breastfeeding cessation in both prevalent and incident lactating HIV-infected women. The different parameters of the simulation model were fixed using data sources available from the 2011 national registry surveys, and from external cohorts in Cameroon. Different PMTCT coverages were simulated to assess their impact on MTCT. Available data show a low coverage of PMTCT services in Cameroon in 2011.Based on a simulation approach on a population of 995, 533 pregnant women, the overall residual MTCT rate in 2011 was estimated to be 22.1% (95 % CI: 18.6%-25.2%), the 6-week perinatal MTCT rate among prevalent HIV-infected mothers at delivery is estimated at 12.1% (95% CI: 8.1%-15.1%), with an additional postnatal MTCT rate estimated at 13.3% (95% CI: 9.3%-17.8%). The MTCT rate among children whose mothers seroconverted during breastfeeding was estimated at 20.8% (95% CI: 14.1%-26.9%). Overall, we estimated the number of new HIV infections in children in Cameroon to be 10, 403 (95% CI: 9, 054-13, 345) in 2011. When PMTCT uptake have been fixed at 100%, 90% and 80%, global MTCT rate failed to 0.9% (9% CI: 0.5%-1.7%), 2.0% (95% CI: 0.9%-3.2%) and 4.3% (95% CI: 2.4%-6.7%) respectively.This model is helpful to provide MTCT estimates to guide the national HIV policy in Cameroon. Increasing supply and uptake of PMTCT services among prevalent HIV infected pregnant women, as well as HIV-prevention interventions including the offer and acceptance of HIV testing and counselling in lactating women could reduce significantly the residual HIV MTCT in Cameroon. A public health effort should be made to encourage health care workers and pregnant women to use PMTCT services until complete breastfeeding cessation.
Project description:OBJECTIVES:This study aimed to identify factors associated with access to HIV care and antiretroviral (ARV) drugs for prevention of mother-to-child transmission (PMTCT) of HIV among HIV-positive pregnant women in a community cohort in rural Tanzania (Kisesa). METHODS:Kisesa-resident women who tested HIV-positive during HIV serosurveillance and were pregnant (while HIV-positive) between 2005 and 2012 were eligible. Community cohort records were linked to PMTCT and HIV clinic data from four facilities (PMTCT programme implemented in 2009; referrals to city-based hospitals since 2005) to ascertain service use. Factors associated with access to HIV care and ARVs during pregnancy were analysed using logistic regression. RESULTS:Overall, 24% of women accessed HIV care and 12% accessed ARVs during pregnancy (n=756 pregnancies to 420 women); these proportions increased over time. In multivariate analyses for 2005-2012, being married, prior voluntary counselling and testing, increasing age, increasing year of pregnancy and increasing duration of infection were independently associated with access to care and ARVs. Residence in roadside areas was an independent predictor of access to care but not ARVs. There was no evidence of an interaction with time period. CONCLUSIONS:Access to PMTCT services was low in this rural setting but improved markedly over time. There were fairly few sociodemographic differentials although support for young women and those without partners may be needed. Further decentralisation of HIV services to more remote areas, promotion of voluntary counselling and testing and implementation of Option B+ are likely to improve uptake and may bring women into care and treatment sooner after infection.
Project description:BACKGROUND:In 2012, the World Health Organization (WHO) amended their 2010 guidelines for women receiving limited duration, triple-antiretroviral drug regimens during pregnancy and breastfeeding for prevention of mother-to-child transmission of HIV (tARV-PMTCT) (Option B) to include the option to continue lifelong combination antiretroviral therapy (cART) (Option B+). We evaluated clinical and CD4 outcomes in women who had received antiretrovirals for prevention of mother-to-child transmission and then discontinued antiretrovirals 6-months postpartum. METHODS AND FINDINGS:The Kisumu Breastfeeding Study, 2003-2009, was a prospective, non-randomized, open-label clinical trial of tARV-PMTCT in ARV-naïve, Kenyan women. Women received tARV-PMTCT from 34 weeks' gestation until 6-months postpartum when women were instructed to discontinue breastfeeding. Women with CD4 count (CD4) <250cells/mm3 or WHO stage III/IV prior to 6-months postpartum continued cART indefinitely. We estimated the change in CD4 after discontinuing tARV-PMTCT and the adjusted relative risk [aRR] for factors associated with declines in maternal CD4. We compared maternal and infant outcomes following weaning-when tARV-PMTCT discontinued-by maternal ARV status through 24-months postpartum. Compared with women who continued cART, discontinuing antiretrovirals was associated with infant HIV transmission and death (10.1% vs. 2.4%; P?=?0.03). Among women who discontinued antiretrovirals, CD4<500 cells/mm3 at either initiation (21.8% vs. 1.5%; P?=?0.002; aRR: 9.8; 95%-confidence interval [CI]: 2.4-40.6) or discontinuation (36.9% vs. 8.3%; P<0.0001; aRR: 4.4; 95%-CI: 1.9-5.0) were each associated with increased risk of women requiring cART for their own health within 6 months after discontinuing. CONCLUSIONS:Considering the serious health risks to the woman's infant and the brief reprieve from cART gained by stopping, every country should evaluate the need for and feasibility to implement WHO Option B+ for PMTCT. Evaluating CD4 at antiretroviral initiation or 6-months postpartum can identify pregnant women who would most benefit from continuing cART in settings unable to implement WHO Option B+.
Project description:Background:Great strides have been made in decreasing paediatric human immunodeficiency virus (HIV) infections, especially in sub-Saharan Africa. In South Africa, new paediatric HIV infections decreased by 84% between 2009 and 2015. This achievement is a result of a strong political will and the rapid evolution of the country's prevention of mother-to-child transmission (PMTCT) guidelines. Objectives:In this paper we report on the implementation of a large PMTCT programme in Soweto, South Africa. Methods:We reviewed routinely collected PMTCT data from 13 healthcare facilities, for the period 2002-2015. Antiretroviral therapy (ART) coverage among pregnant women living with HIV (PWLHIV) and the mother-to-child transmission (MTCT) rate at early infant diagnosis were evaluated. Results:In total, 360 751 pregnant women attended the facilities during the review period, and the HIV prevalence remained high throughout at around 30%. The proportion of PWLHIV presenting with a known HIV status increased from 14.3% in 2009 when the indicator was first collected to 45% in 2015, p < 0.001. In 2006, less than 10% of the PWLHIV were initiated on ART, increasing to 88% by 2011. The MTCT rate decreased from 6.9% in 2007 to under 1% from 2013 to 2015, p < 0.001. Conclusion:The achievements in decreasing paediatric HIV infections have been hailed as one of the greatest public health achievements of our times. While there are inherent limitations with using routinely collected aggregate data, the Soweto data reflect progress made in the implementation of PMTCT programmes in South Africa. Progress with PMTCT has, however, not been accompanied by a decline in HIV prevalence among pregnant women.
Project description:<h4>Introduction</h4>Loss-to-follow-up (LTFU) throughout the Prevention of Mother-To-Child Transmission (PMTCT) cascade remains one of the major threats to the success of PMTCT programs. In this study, we aimed to determine the mother-to-child transmission rate in a programmatic setting and to determine factors associated with LTFU among enrolled mothers and unfavorable outcomes among HIV-exposed babies which includes being HIV positive, death and LTFU.<h4>Methods</h4>A retrospective cohort study reviewing routinely collected data in an Integrated HIV care program, Mandalay, Myanmar in June 2016.LTFU means mother/infant missing appointed visit for more than three months.<h4>Results</h4>Of 678 pregnant women enrolled in PMTCT program between March 2011 and June 2014, one stillbirth and 607 live births were recorded in this cohort. Of 457 HIV-exposed babies with HIV-test recorded at the end of the intervention, nine (2%) were HIV-positive. Pregnant women's and exposed-babies' LTFU rate was 7 per 1000 person-years, and 10 per 1000 person-years respectively. PMTCT option B protocol was found to be significantly associate with maternal LTFU [adjusted Hazard Ratio (aHR) 95% CI: 3.52 (1.38-8.96)] when compare to mothers receiving option B+/lifelong antiretroviral therapy (ART). Weight <2.5 Kg at enrolment, receiving mixed-feeding, vaginal delivery and option B PMTCT protocol were significantly associated with unfavorable outcomes among exposed babies [aHR(95% CI): 5.40 (1.66-17.53), 5.91(1.68-20.84), 2.27 (1.22-4.22) and 2.33 (1.16-4.69) respectively].<h4>Conclusion</h4>Mother-to-child HIV transmission rate in this public hospital-based program was lower than the 5% national target, which indicates a successful PMTCT intervention. However, a high proportion of HIV-infected mothers and exposed babies LTFU was recorded. Lifelong ART provision to HIV-positive pregnant women was shown to reduce exposed babies' LTFU, death and transmission rate (unfavorable outcomes) in this setting. Lessons learned from this program could be used to inform policy and practice in the country, while the programmatic challenge of LTFU should be urgently addressed.
Project description:<h4>Objectives</h4>To assess knowledge, attitudes and practices regarding infant feeding among HIV-positive pregnant women in Gaborone, Botswana, and factors that influence their infant feeding choices.<h4>Design</h4>A cross-sectional study.<h4>Methods and study setting</h4>A questionnaire survey of 96 HIV-positive pregnant women attending four public infectious disease control clinics in Gaborone, Botswana.<h4>Results</h4>Only about half of the study participants had knowledge about prevention of mother-to-child transmission (PMTCT) services related to breastfeeding, and very few (19.8%) chose to breastfeed their infants exclusively. Results of multiple logistic regression analysis showed that receiving infant feeding counselling as part of the PMTCT programme was significantly associated with a decision to exclusively breastfeed (OR (95% CI) 5.38 (1.83 to 15.81)). Similarly, HIV-positive pregnant women who received breastfeeding counselling through the PMTCT programme had higher knowledge of PMTCT practices related to appropriate infant feeding (OR (95% CI) 5.91 (1.06 to 34.31)). Women who did not express concern about HIV stigma had significantly higher knowledge of PMTCT practices related to infant feeding (OR (95% CI) 5.91 (1.69 to 15.56)). Knowledge of PMTCT practices related to breastfeeding was negatively associated with the belief that breastfeeding could transmit HIV to the baby (OR (95% CI) 9.73 (3.37 to 28.08)).<h4>Conclusions</h4>Knowledge, attitudes and practices related to breastfeeding among HIV-positive pregnant women need further improvement, and the PMTCT programme should strengthen infant feeding counselling services to assist HIV-positive mothers in making informed and appropriate decisions regarding infant feeding.