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AIDS 2014: Increased ART for Mothers Does Not Guarantee Optimal Care for Infants

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The significant increase in access to antiretroviral therapy (ART) for all pregnant women living with HIV in Malawi after implementation of Option B+ contrasts with low coverage of early diagnosis and uptake of cotrimoxazole prophylaxis for HIV-exposed infants, Priscilla Idele of UNICEF reported at the 20th International AIDS Conference (AIDS 2014) last month in Melbourne.

[Produced in collaboration with Aidsmap]

Idele presented results of a 4-country assessment of health system performance following the implementation of the World Health Organization (WHO) 2010 guidelines for the prevention of mother-to-child HIV transmission.

The study found substantial variations in performance between countries, as well as gaps between performance in testing and provision of antiretrovirals to mothers, and testing of HIV-exposed infants.

In 2010, WHO recommended that countries should move to providing one of 2 antiretroviral options for prevention of mother-to-child transmission for pregnant women not eligible for antiretroviral therapy for their own health:

  • Option A: zidovudine (AZT, Retrovir) from week 14 of pregnancy, single-dose nevirapine (Viramune) for mother and infant at the time of delivery, and zidovudine plus lamivudine (3TC, Epivir) during delivery and for 1 week after delivery.
  • Option B: a triple-drug regimen until 1 week after breastfeeding has ended; all infants regardless of feeding mode receive nevirapine or zidovudine for 4 to 6 weeks.

In Malawi, public health officials decided to adopt Option B+ -- a simplified public health approach to prevent vertical HIV transmission while protecting the health of women by providing ART for life for all HIV positive pregnant or breastfeeding women, regardless of CD4 cell count or disease stage.

In its 2013 consolidated treatment guidelines, WHO recommended that all countries should move towards Option B and, where resources allow, to Option B+. However, the majority of countries are still in the process of reviewing national guidelines.

Adoption of WHO recommendations into national guidelines can be a protracted process, requiring national consultation, economic analysis, staff training, and development of new processes for supply chain management, laboratory testing, and data management.

UNICEF and the Global Fund to Fight AIDS, Tuberculosis and Malaria undertook a four-country survey in 2011 and 2012 to review operational feasibility of the guidance and performance in implementing its recommendations.

The assessment comprised review of key policies and reports, key informant interviews, and analysis of data from registers and clinical records at 10 health facilities purposively selected in each country with the Ministry of Health.

It assessed the performance of 6 PMTCT interventions in Malawi, Lesotho, Tanzania, and Zambia between November 2011 and February 2012.

Malawi was the only country of the 4 implementing Option B+. Lesotho, Tanzania, and Zambia chose Option A.

 

Provision of ART to pregnant women

Testing of HIV-exposed infants by week 8

Cotrimoxazole prophylaxis provided to HIV-exposed infants by week 8

Malawi

71%

45%

17%

Lesotho

31%

83%

83%

Tanzania

5%

58%

80%

Zambia

20%

49%

57%

Uptake of services is dependent upon the capacity to offer timely diagnostic tests, Idele told delegates. While maternal HIV testing was generally available in all 10 of the selected health facilities in each country, maternal CD4 testing was not, and on-site early infant diagnosis was only available at 2 sites in both Malawi and Tanzania.

Moreover, the majority of early infant diagnostic tests involved sample transportation to central laboratories resulting in a long turnaround time. Furthermore, incomplete record-keeping led to a delay in the initiation of HIV treatment and loss to follow-up among HIV-exposed and HIV positive children.

Lesotho had a testing rate at the first antenatal care visit of 99%, while Malawi, Tanzania, and Zambia had rates of 79%, 62%, and 87%, respectively.

HIV testing rates during labor and delivery were considerably lower in Malawi and Lesotho, and highest in Tanzania and Zambia, 16%, 52%, 91%, and 100%, respectively.

In all 4 countries, the numbers of antenatal care staff trained in prevention of mother-to-child transmission was considerably higher than those trained in early infant diagnosis and pediatric care. Proportions of staff trained in prevention of mother-to-child transmission were 46%, 60%, 81%, and 95% in Malawi, Lesotho, Tanzania, and Zambia, respectively, compared to 31%, 35%, 6%, and 24%, respectively, trained in early infant diagnosis and pediatric care.

Idele concluded that redressing the imbalance between maternal and pediatric HIV services requires:

  • A family-centered approach so mothers and infants get services from the same place
  • Integration of pediatric HIV care into routine maternal and child health services
  • Improved longitudinal care of mother-infant pairs until confirmed HIV diagnosis at 18 months
  • Point-of-care diagnostics to minimize loss to follow-up, long turnaround time, and late initiation of care and treatment.

Limitations of the study included: the rapid assessment did not cover all areas of importance; incomplete national roll-outs; incomplete and/or lack of data; and while indicative of coverage, data from only 10 facilities in each country were neither comprehensive nor representative of the national status.

8/1/14

Reference

PA Idele, J Rodrigues, C Luo, et al. Balancing ART access for pregnant women living with HIV and follow-up care for HIV-exposed infants: a four-country assessment of key PMTCT interventions. 20th International AIDS Conference. Melbourne, Australia, July 20-25, 2014. Abstract WEAD0401.