Prevention of mother-to-child transmission of HIV programme: low vertical transmission in KwaZulu-Natal, South Africa

OBJECTIVE: To describe the operational effectiveness of the prevention of mother-to-child transmission (PMTCT) of HIV programme at McCord Hospital during the period 1 March 2004 - 31 August 2005. DESIGN: Observational cohort study. SETTING: McCord Hospital, Durban, South Africa. SUBJECTS: Antenatal patients attending the PMTCT clinic. MEASUREMENTS AND RESULTS: During the 18 months all 2 624 women (100%) attending the antenatal clinic received HIV counselling, resulting in 91% (2 388) being tested for HIV. The prevalence of HIV in the total cohort was 13% (95% confidence interval (CI) 11.6 - 14.2). Of the HIV-positive mothers 302 (89%) completed their pregnancy at the hospital, and in this group there were 3 intrauterine deaths, 1 miscarriage, 1 maternal death (with the baby in utero) and 297 live births with 1 early neonatal death. Only 11% (36 out of 338) were lost to follow-up. A quarter (668) of the partners of all women attending the antenatal clinic were tested for HIV. Delivery in 70% (209) of live births was by caesarean section. Nevirapine was administered to 98% (290) of live babies and 75% (224) received zidovudine (AZT) as well. The 6-week polymerase chain reaction (PCR) baby test uptake was 81% (239 out of 296 live babies). Of those tested, 2.9% (95% CI 1.3 - 6.2) tested HIV positive. CONCLUSION: Despite challenges faced by PMTCT providers in a resource-constrained setting, this state-aided hospital provides a comprehensive and integrated service and has achieved outcomes that compare favourably with those in the developed world.     

Effect of a mother-to-child HIV prevention programme on infant feeding and caring practices in South Africa.

OBJECTIVES: To conduct a rapid assessment of the impact of the Khayelitsha Prevention of Mother-to-Child Transmission (MTCT) programme on infant care practices among programme participants and the local population. STUDY DESIGN: Cross-sectional survey and qualitative in-depth interviews. SETTING. Khayelitsha, a large formal and informal settlement of about 300,000 people on the outskirts of Cape Town. At the time of the study the HIV seroprevalence rate among antenatal women was about 15% and the MTCT programme had enrolled nearly 800 infected women. SUBJECTS: Seventy randomly selected caregivers with young children in the survey; in-depth structured interviews with 11 nutrition counsellors and 11 mothers enrolled in the programme. RESULTS: Caregivers have good knowledge of the spread and prevention of HIV. A majority knew that breast-feeding can transmit HIV but 90% stated that this did not affect their feeding decisions. Over 80% had stopped exclusively breast-feeding by the time their infants were 3 months of age. All of the respondents felt that being diagnosed HIV-positive would result in serious social and domestic consequences. None of the health workers could correctly estimate the risk of spreading HIV through breast-feeding and many reported feeling confused about what they should counsel mothers. All the mothers on the programme reported exclusive formula-feeding. Some had serious problems with preparation and feeding of formula milk. Nearly all reported running out of feeds before being able to fetch new supplies. None reported any negative social effects of not breast-feeding. Most of the mothers endorsed the programme and felt that it had given them strength to face up to and plan for the consequences of their diagnosis. CONCLUSION: This rapid appraisal of the infant feeding and care component of the MTCT programme has raised a number of important challenges which health managers and policymakers need to address. Similar assessments in the new pilot sites will be important.     

Public health lessons from a pilot programme to reduce mother-to-child transmission of HIV-1 in Khayelitsha.

OBJECTIVE: Short-course antiretroviral therapy (ART) has been shown to be effective in reducing mother-to-child transmission (MTCT) of HIV-1. This article details the public health lessons learnt from a district-based pilot programme where a short-course zidovudine (ZDV) regimen has been used in a typical South African peri-urban setting. METHODS: The pilot programme was initiated at two midwife obstetric units in January 1999. Lay counsellors conducted pre- and post-test counselling and nurses took blood for HIV enzyme-linked immunosorbent assay (ELISA) testing. Short-course ZDV was administered antenatally (from 36 weeks' gestation) and during labour. Mother-infant pairs were followed up at eight child health clinics where free formula feed was dispensed weekly. Infants received co-trimoxazole prophylaxis and were ELISA tested for HIV at 9 and 18 months. After 17 months protocol changes aimed at eliminating weaknesses included initiation of ZDV at 34 weeks, self-administration of the first dose of ZDV with the onset of labour, and rapid HIV testing for both mothers and infants. RESULTS: Voluntary counselling and testing was shown to be highly acceptable, with individual counselling more effective than group counselling. Based on less than optimal availability of records, ZDV utilisation was encouraging with up to 59% of subjects initiating treatment, 3 weeks' median duration of ZDV use, and up to 88% receiving at least one intrapartum ZDV dose. Self-administration of the intrapartum dose reached 41%. CONCLUSIONS: Short-course antenatal and intrapartum ART to prevent MTCT of HIV1 was shown to be feasible.     

The prevention of mother-to-child HIV transmission programme and infant feeding practices.

Since the first cases of HIV transmission through breast-feeding were documented, a fierce debate has raged on appropriate guidelines for infant feeding in resource-poor settings. A major problem is determining when it is safe and feasible to formula-feed, as breast-milk protects against other diseases. A cross-sectional survey of 113 women attending the programme for the prevention of mother-to-child transmission in Khayelitsha, Cape Town, was conducted. Over 95% of women on the programme formula-fed their infants and did not breast-feed at all. Seventy per cent of women said that their infant had never had diarrhoea, and only 3% of children had had two episodes of diarrhoea. Focus groups identified the main reasons for not breast-feeding given by women to their families and those around them. Formula feeding is safe and feasible in an urban environment where sufficient potable water is available.     

Exploring the costs of a limited public sector antiretroviral treatment programme in South Africa.

BACKGROUND: The role of antiretroviral treatment for adults in the pubic sector in South Africa is debated with little consideration of programme choices that could impact on the cost-effectiveness of the intervention. This study seeks to explore the impact of these programme choices at an individual level, as well as explore the total cost of a rationed national public sector antiretroviral treatment programme. METHODS: Eight scenarios were modelled of limited national treatment programmes over the next 5 years, reflecting different programme design choices. The individual cost-effectiveness of these scenarios were compared. The total costs of the most cost-effective scenario were calculated, and the potential for savings in other areas of health care utilisation was explored. RESULTS: The direct programme costs per life-year saved varied between scenarios from R5,923 to R11,829. All the costs of the most cost-effective scenario could potentially be offset depending on assumptions of health care access and utilisation. The total programme costs for the most cost-effective scenario in 2007 with 107,000 people on treatment are around R409 million. CONCLUSION: Specific policy choices could almost double the number of people who could benefit from an investment in a limited national antiretroviral treatment programme. Such a programme is affordable within current resource constraints. The consideration of antiretroviral treatment calls for a unique public health approach to the rationing of health services in the public sector.     

Acceptability and utilisation of voluntary HIV testing and nevirapine to reduce mother-to-child transmission of HIV-1 integrated into routine clinical care.

OBJECTIVES: Use of nevirapine for prevention of mother-to-child transmission (PMTCT) of HIV-1 has been routine clinical care at Coronation Women and Children's Hospital since April 2000. We assessed the effect of regular audit and targeted interventions on the utilisation of the PMTCT programme. METHODS: Review of antenatal cards and hospital records of women discharged following delivery, in three time periods between October 2000 and February 2002. Following the initial audit an intervention was implemented to eliminate weaknesses in our PMTCT service. Following the second audit the hospital became a pilot site for the Gauteng PMTCT programme. RESULTS: In the initial audit 53.2% of women (159/299) were tested for HIV and received their results, while 56% (14/25) of identified HIV-infected women, and 16% (4/25) of their infants, received nevirapine. By the third audit 74.3% of women (266/358) received their results, and 86% (43/50) of HIV-positive women and 74% (37/50) of newborns were documented to have received nevirapine. In all three audits over 90% of women initiating antenatal care at the hospital were tested for HIV, while women who initiated care at district community clinics were less likely to receive testing. CONCLUSIONS: Ongoing audit has been important for targeting obstacles to detection of HIV-infected women and documented nevirapine uptake by women and infants. Rates of HIV testing and nevirapine use have increased significantly. Voluntary counselling and testing for HIV and use of nevirapine are acceptable to pregnant women in our setting. Roll-out of the pilot programme to district community clinics is essential for further improvement.     

The cost of a rapid-test VCT clinic in South Africa.

CONTEXT: Demand for HIV voluntary counselling and testing (VCT) will increase as HIV prevention and treatment scale up in South Africa. Understanding the cost of delivering VCT will inform funding decisions. OBJECTIVE: To determine the cost per client completing VCT (pretest counselling, testing and post-test counselling) in a non-research- based programme using rapid-test technology. DESIGN: One year of expenditure and output data were collected retrospectively as part of the PANCEA (Prevent AIDS: Network for Cost-Effectiveness Analysis) study. Market prices were determined for donated resources. SETTING: An urban, church-based, non-profit organisation that offers rapid-test VCT services in KwaZulu-Natal, South Africa. RESULTS: Financial expenditure for the 2002/2003 fiscal year was 39,761 dollars (calculated using an average conversion rate for July 2003, which was 0.133). Using market prices for donated resources, the economic cost for the year was estimated at 67,248 dollars. Six hundred and sixty-two clients completed VCT, resulting in financial expenditure of 60.06 dollars per client and an economic cost of 101.58 dollars per client. Financial expenditures and economic costs per client decreased over the year by 66% because expenses remained stable as more clients were served. CONCLUSIONS: The cost of providing VCT services was higher than previously reported, but declined with expanding scale.     

Barriers and facilitating factors to the uptake of antiretroviral drugs for prevention of mother-to-child transmission of HIV in sub-Saharan Africa: a systematic review

Objectives

To investigate and synthesize reasons for low access, initiation and adherence to antiretroviral drugs by mothers and exposed babies for prevention of mother-to-child transmission (PMTCT) of HIV in sub-Saharan Africa.

Methods

A systematic literature review was conducted. Four databases were searched (Medline, Embase, Global Health and Web of Science) for studies conducted in sub-Saharan Africa from January 2000 to September 2012. Quantitative and qualitative studies were included that met pre-defined criteria. Antiretroviral (ARV) prophylaxis (maternal/infant) and combination antiretroviral therapy (ART) usage/registration at HIV care and treatment during pregnancy were included as outcomes.

Results

Of 574 references identified, 40 met the inclusion criteria. Four references were added after searching reference lists of included articles. Twenty studies were quantitative, 16 were qualitative and eight were mixed methods. Forty-one studies were conducted in Southern and East Africa, two in West Africa, none in Central Africa and one was multi-regional. The majority (n=25) were conducted before combination ART for PMTCT was emphasized in 2006. At the individual-level, poor knowledge of HIV/ART/vertical transmission, lower maternal educational level and psychological issues following HIV diagnosis were the key barriers identified. Stigma and fear of status disclosure to partners, family or community members (community-level factors) were the most frequently cited barriers overall and across time. The extent of partner/community support was another major factor impeding or facilitating the uptake of PMTCT ARVs, while cultural traditions including preferences for traditional healers and birth attendants were also common. Key health-systems issues included poor staff-client interactions, staff shortages, service accessibility and non-facility deliveries.

Conclusions

Long-standing health-systems issues (such as staffing and service accessibility) and community-level factors (particularly stigma, fear of disclosure and lack of partner support) have not changed over time and continue to plague PMTCT programmes more than 10 years after their introduction. The potential of PMTCT programmes to virtually eliminate vertical transmission of HIV will remain elusive unless these barriers are tackled. The prominence of community-level factors in this review points to the importance of community-driven approaches to improve uptake of PMTCT interventions, although packages of solutions addressing barriers at different levels will be important.     

Estimating the contribution of key populations towards HIV transmission in South Africa

IntroductionIn generalized epidemic settings, there is insufficient understanding of how the unmet HIV prevention and treatment needs of key populations (KPs), such as female sex workers (FSWs) and men who have sex with men (MSM), contribute to HIV transmission. In such settings, it is typically assumed that HIV transmission is driven by the general population. We estimated the contribution of commercial sex, sex between men, and other heterosexual partnerships to HIV transmission in South Africa (SA).MethodsWe developed the “Key‐Pop Model”; a dynamic transmission model of HIV among FSWs, their clients, MSM, and the broader population in SA. The model was parameterized and calibrated using demographic, behavioural and epidemiological data from national household surveys and KP surveys. We estimated the contribution of commercial sex, sex between men and sex among heterosexual partnerships of different sub‐groups to HIV transmission over 2010 to 2019. We also estimated the efficiency (HIV infections averted per person‐year of intervention) and prevented fraction (% IA) over 10‐years from scaling‐up ART (to 81% coverage) in different sub‐populations from 2020.ResultsSex between FSWs and their paying clients, and between clients with their non‐paying partners contributed 6.9% (95% credibility interval 4.5% to 9.3%) and 41.9% (35.1% to 53.2%) of new HIV infections in SA over 2010 to 2019 respectively. Sex between low‐risk groups contributed 59.7% (47.6% to 68.5%), sex between men contributed 5.3% (2.3% to 14.1%) and sex between MSM and their female partners contributed 3.7% (1.6% to 9.8%). Going forward, the largest population‐level impact on HIV transmission can be achieved from scaling up ART to clients of FSWs (% IA = 18.2% (14.0% to 24.4%) or low‐risk individuals (% IA = 20.6% (14.7 to 27.5) over 2020 to 2030), with ART scale‐up among KPs being most efficient.ConclusionsClients of FSWs play a fundamental role in HIV transmission in SA. Addressing the HIV prevention and treatment needs of KPs in generalized HIV epidemics is central to a comprehensive HIV response.     

Priority interventions to reduce HIV transmission in sex work settings in sub-Saharan Africa and delivery of these services

Introduction

Virtually no African country provides HIV prevention services in sex work settings with an adequate scale and intensity. Uncertainty remains about the optimal set of interventions and mode of delivery.

Methods

We systematically reviewed studies reporting interventions for reducing HIV transmission among female sex workers in sub-Saharan Africa between January 2000 and July 2011. Medline (PubMed) and non-indexed journals were searched for studies with quantitative study outcomes.

Results

We located 26 studies, including seven randomized trials. Evidence supports implementation of the following interventions to reduce unprotected sex among female sex workers: peer-mediated condom promotion, risk-reduction counselling and skills-building for safer sex. One study found that interventions to counter hazardous alcohol-use lowered unprotected sex. Data also show effectiveness of screening for sexually transmitted infections (STIs) and syndromic STI treatment, but experience with periodic presumptive treatment is limited. HIV testing and counselling is essential for facilitating sex workers’ access to care and antiretroviral treatment (ART), but testing models for sex workers and indeed for ART access are little studied, as are structural interventions, which create conditions conducive for risk reduction. With the exception of Senegal, persistent criminalization of sex work across Africa reduces sex workers’ control over working conditions and impedes their access to health services. It also obstructs health-service provision and legal protection.

Conclusions

There is sufficient evidence of effectiveness of targeted interventions with female sex workers in Africa to inform delivery of services for this population. With improved planning and political will, services – including peer interventions, condom promotion and STI screening – would act at multiple levels to reduce HIV exposure and transmission efficiency among sex workers. Initiatives are required to enhance access to HIV testing and ART for sex workers, using current CD4 thresholds, or possibly earlier for prevention. Services implemented at sufficient scale and intensity also serve as a platform for subsequent community mobilization and sex worker empowerment, and alleviate a major source of incident infection sustaining even generalized HIV epidemics. Ultimately, structural and legal changes that align public health and human rights are needed to ensure that sex workers on the continent are adequately protected from HIV.     

Progress of preventing mother-to-child transmission of HIV at primary healthcare facilities and district hospitals in three South African provinces

Improving national prevention of mother-to-child (PMTCT) services in South Africa has been challenging. PMTCT outcomes were analysed at 58 primary and secondary level antenatal facilities across seven high HIV-burden sub-districts in three provinces, over an 18 month period during which new South African PMTCT clinical guidelines were implemented and a nurse quality mentor program was expanded. Early infant HIV DNA polymerase chain reaction test positivity reduced by 75.2% from 9.7% (CI: 8.1%-11.5%) to 2.4% (CI: 1.9%-3.1%); p<0.0005. HIV test positivity at 18 months of age decreased by 64.5% from 10.7% (CI: 7.2-15.1%) to 3.8% (CI: 2.4-5.6%); p<0.0005. PMTCT outcomes have improved substantially at these facilities.     

Rapid scale-up of a community-based HIV treatment service: programme performance over 3 consecutive years in Guguletu, South Africa.

BACKGROUND: Despite rapid expansion of antiretroviral therapy (ART) in sub-Saharan Africa there are few longitudinal data describing programme performance during rapid scale-up. METHODS: We compared mortality, viral suppression and programme retention in 3 consecutive years of a public sector community-based ART clinic in a South African township. Data were collected prospectively from establishment of services in October 2002 to the censoring date in September 2005. Viral load and CD4 counts were monitored at 4-monthly intervals. Community-based counsellors provided adherence and programme support. RESULTS: During the study period 1139 ART-na?ve patients received ART (161, 280 and 698 in the 1st, 2nd and 3rd years respectively). The median CD4 cell counts were 84 cells/microl (interquartile range (IQR) 42-139), 89 cells/microl (IQR 490-149), and 110 cells/microl (IQR 55-172), and the proportions of patients with World Health Organization (WHO) clinical stages 3 and 4 were 90%, 79% and 76% in each sequential year respectively. The number of counsellors increased from 6 to 28 and the median number of clients allocated to each counsellor increased from 13 to 33. The overall loss to follow-up was .9%. At the date of censoring, the Kaplan-Meier estimates of the proportion of patients still on the programme were 82%, 86% and 91%, and the proportion who were virally suppressed (< 400 copies/ml) were 100%, 92% and 98% for the 2002, 2003 and 2004 cohorts respectively. CONCLUSIONS: While further operational research is required into optimal models of care in different populations across sub-Saharan Africa, these results demonstrate that a single community-based public sector ART clinic can extend care to over 1000 patients in an urban setting without compromising programme performance.