Suchergebnisse

Positive results from clinical trials of the anti-retroviral medications zidovudine and nevirapine created the possibility of offering an affordable and feasible intervention worldwide to reduce HIV transmission from an infected pregnant woman to her infant. Governmental and nongovernmental health services in many highly affected areas of Africa, Asia, Latin America, and Eastern Europe have responded by piloting and rapidly expanding programs for the prevention of mother-to-child HIV transmission (PMTCT). Since their inception in 1999, programs have offered voluntary HIV counseling and testing (VCT) to more than 800,000 pregnant women around the world. An important objective of VCT is to identify which pregnant women are HIV-positive so they can receive antiretroviral drugs to prevent transmitting HIV to their infants. HIV counseling and testing also offer an opportunity to promote HIV prevention, encourage serostatus disclosure, and foster couple communication on HIV and PMTCT. This brief focuses on VCT in the antenatal care setting, examining service utilization by pregnant women, their perceptions of services, client outcomes as a result of undergoing HIV counseling and testing, and strategies for improving quality and coverage of VCT as a key component of PMTCT programs.

AbstractIntroductionFindings from biomedical, behavioural and implementation studies provide a rich foundation to guide programmatic efforts for the prevention of mother‐to‐child HIV transmission (PMTCT).MethodsWe summarized the current evidence base to support policy makers, programme managers, funding agencies and other stakeholders in designing and optimizing PMTCT programmes. We searched the scientific literature for PMTCT interventions in the era of universal antiretroviral therapy for pregnant and breastfeeding women (i.e. 2013 onward). Where evidence was sparse, relevant studies from the general HIV treatment literature or from prior eras of PMTCT programme implementation were also considered. Studies were organized into six categories: HIV prevention services for women, timely access to HIV testing, timely access to ART, programme retention and adherence support, timely engagement in antenatal care and services for infants at highest risk of HIV acquisition. These were mapped to specific missed opportunities identified by the UNAIDS Spectrum model and embedded in UNICEF operational guidance to optimize PMTCT services.Results and discussionFrom May to November 2019, we identified numerous promising, evidence‐based strategies that, properly tailored and adopted, could contribute to population reductions in vertical HIV transmission. These spanned the HIV and maternal and child health literature, emphasizing the importance of continued alignment and integration of services. We observed overlap between several intervention domains, suggesting potential for synergies and increased downstream impact. Common themes included integration of facility‐based healthcare; decentralization of health services from facilities to communities; and engagement of partners, peers and lay workers for social support. Approaches to ensure early HIV diagnosis and treatment prior to pregnancy would strengthen care across the maternal lifespan and should be promoted in the context of PMTCT.ConclusionsA wide range of effective strategies exist to improve PMTCT access, uptake and retention. Programmes should carefully consider, prioritize and plan those that are most appropriate for the local setting and best address existing gaps in PMTCT health services.

BackgroundWe set out to determine the relative roles of stigma versus health systems in non‐uptake of prevention of mother to child transmission (PMTCT) of HIV‐1 interventions: we conducted cross‐sectional assessment of all consenting mothers accompanying infants for six‐week immunizations.MethodsBetween September 2008 and March 2009, mothers at six maternal and child health clinics in Kenya's Nairobi and Nyanza provinces were interviewed regarding PMTCT intervention uptake during recent pregnancy. Stigma was ascertained using a previously published standardized questionnaire and infant HIV‐1 status determined by HIV‐1 polymerase chain reaction.ResultsAmong 2663 mothers, 2453 (92.1%) reported antenatal HIV‐1 testing. Untested mothers were more likely to have less than secondary education (85.2% vs. 74.9%, p = 0.001), be from Nyanza (47.1% vs. 32.2%, p < 0.001) and have lower socio‐economic status. Among 318 HIV‐1‐infected mothers, 90% reported use of maternal or infant antiretrovirals. Facility delivery was less common among HIV‐1‐infected mothers (69% vs. 76%, p = 0.009) and was associated with antiretroviral use (p < 0.001). Although internal or external stigma indicators were reported by between 12% and 59% of women, stigma was not associated with lower HIV‐1 testing or infant HIV‐1 infection rates; internal stigma was associated with modestly decreased antiretroviral uptake. Health system factors contributed to about 60% of non‐testing among mothers who attended antenatal clinics and to missed opportunities in offering antiretrovirals and utilization of facility delivery. Eight percent of six‐week‐old HIV‐1‐exposed infants were HIV‐1 infected.ConclusionsAntenatal HIV‐1 testing and antiretroviral uptake was high (both more than 90%) and infant HIV‐1 infection risk was low, reflecting high PMTCT coverage. Investment in health systems to deliver HIV‐1 testing and antiretrovirals can effectively prevent infant HIV‐1 infection despite substantial HIV‐1 stigma.

BackgroundAs highly active antiretroviral therapy (HAART) becomes increasingly available to African children, it is important to evaluate simple and feasible methods of improving adherence in order to maximize benefits of therapy.MethodsHIV‐1‐infected children initiating World Health Organization non‐nucleoside reverse transcriptase‐inhibitor‐containing first‐line HAART regimens were randomized to use medication diaries plus counselling, or counselling only (the control arm of the study). The diaries were completed daily by caregivers of children randomized to the diary and counselling arm for nine months. HIV‐1 RNA, CD4+ T cell count, and z‐scores for weight‐for‐age, height‐for‐age and weight‐for‐height were measured at a baseline and every three to six months. Self‐reported adherence was assessed by questionnaires for nine months.ResultsNinety HIV‐1‐infected children initiated HAART, and were followed for a median of 15 months (interquartile range: 2–21). Mean CD4 percentage was 17.2% in the diary arm versus 16.3% in the control arm at six months (p = 0.92), and 17.6% versus 18.9% at 15 months (p = 0.36). Virologic response with HIV‐1 RNA of <100 copies/ml at nine months was similar between the two arms (50% for the diary arm and 36% for the control, p = 0.83). The weight‐for‐age, height‐for‐age and weight‐for‐height at three, nine and 15 months after HAART initiation were similar between arms. A trend towards lower self‐reported adherence was observed in the diary versus the control arm (85% versus 92%, p = 0.08).ConclusionMedication diaries did not improve clinical and virologic response to HAART over a 15‐month period. Children had good adherence and clinical response without additional interventions. This suggests that paediatric HAART with conventional counselling can be a successful approach. Further studies on targeted approaches for non‐adherent children will be important.

The acceleration of prevention of mother-to-child transmission (PMTCT) activities, coupled with the rollout of 2010 World Health Organization (WHO) guidelines, led to important discussions and innovations at global and country levels. One paradigm-shifting innovation was Option B+ in Malawi. It was later included in WHO guidelines and eventually adopted by all 22 Global Plan priority countries. This article presents Malawi's experience with designing and implementing Option B+ and provides complementary narratives from Cameroon and Tanzania. Malawi's HIV program started in 2002, but by 2009, the PMTCT program was lagging far behind the antiretroviral therapy (ART) program because of numerous health system challenges. When WHO recommended Option A and Option B for PMTCT in 2010, it was clear that Malawi's HIV program would not be able to successfully implement either option without increasing existing barriers to PMTCT services and potentially decreasing women's access to care. Subsequent stake-holder discussions led to the development of Option B+. Operationalizing Option B+ required several critical considerations, including the complete integration of ART and PMTCT programs, systematic reduction of barriers to facilitate doubling the number of ART sites in less than a year, building consensus with stakeholders, and securing additional resources for the new program. During the planning and implementation process, several lessons were learned which are considerations for countries transitioning to "treat-all": Comprehensive change requires effective government leadership and coordination; national clinical guidelines must accommodate health system limitations; ART services and commodities should be decentralized within facilities; the general public should be well informed about major changes in the national HIV program; and patients should be educated on clinic processes to improve program monitoring.

Background: Despite strong evidence for the effectiveness of anti-retroviral therapy for improving the health of women living with HIV and for the prevention of mother-to-child transmission (PMTCT), HIV persists as a major maternal and child health problem in sub-Saharan Africa. In most settings antenatal care (ANC) services and HIV treatment services are offered in separate clinics. Integrating these services may result in better uptake of services, reduction of the time to treatment initiation, better adherence, and reduction of stigma. Methodology/Principal Findings: A prospective cluster randomized controlled trial design was used to evaluate the effects of integrating HIV treatment into ANC clinics at government health facilities in rural Kenya. Twelve facilities were randomized to provide either fully integrated services (ANC, PMTCT, and HIV treatment services all delivered in the ANC clinic) or non-integrated services (ANC clinics provided ANC and basic PMTCT services and referred clients to a separate HIV clinic for HIV treatment). During June 2009– March 2011, 1,172 HIV-positive pregnant women were enrolled in the study. The main study outcomes are rates of maternal enrollment in HIV care and treatment, infant HIV testing uptake, and HIVfree infant survival. Baseline results revealed that the intervention and control cohorts were similar with respect to sociodemographics, male partner HIV testing, sero-discordance of the couple, obstetric history, baseline CD4 count, and WHO Stage. Challenges faced while conducting this trial at low-resource rural health facilities included frequent staff turnover, stock-outs of essential supplies, transportation challenges, and changes in national guidelines. Conclusions/Significance: This is the first randomized trial of ANC and HIV service integration to be conducted in rural Africa. It is expected that the study will provide critical evidence regarding the implementation and effectiveness of this service delivery strategy, with important implications for programs striving to eliminate vertical transmission of HIV and improve maternal health.