PMTCT Update: Latest must-read Literature
- The Cost-Effectiveness of Preventing Mother-to-Child Transmission of HIV in Low-and Middle-Income Countries: Systematic Review
Johri, M. and D. Ako-Arrey. 2011. Cost Effectiveness and Resource Allocation 9(3): 2-16.
This systematic review of 19 articles (16 about sub-Saharan Africa) provides data on the cost-effectiveness of interventions to prevent mother-to-child transmission (MTCT) of HIV in low- and middle-income countries (LMICs). Measures of effectiveness were used to examine infant HIV infections averted (most common), benefits of MTCT interventions on horizontal transmission, costs per life year gained, and cost per quality-adjusted life years (QALY) or disability-adjusted life years (DALY). Overall, the authors found that interventions to prevent pediatric infections can be cost-effective in a majority of LMICs. However, MTCT efforts based on universal or targeted testing of pregnant women do not fare as well in concentrated epidemics, where HIV prevalence in the general population is lower. They also may not compare well to competing interventions to improve population health. To realize the full potential of prevention of mother-to-child transmission (PMTCT) programming, the authors advocate for future cost-effectiveness studies and operations research to concentrate on unanswered questions in four areas: the most effective PMTCT strategies in a given local context; strategies to improve coverage and reach of PMTCT programs in LMICs, with a particular focus on underserved populations; evaluation of an increasingly complex set of PMTCT interventions (going beyond perinatal transmission to include primary HIV prevention and reproductive counseling); and strengthening linkages to and integration with maternal, newborn, and child health programs.
- Cost-Effectiveness of New WHO Recommendations for Prevention of Mother-to-Child Transmission of HIV in a Resource-Limited Setting
Shah, M., Johns, B., Abimiku, A., & Walker, D. G. AIDS (2011), Vol. 25 No. 8, pp. 1093–1102.
This study determined the cost-effectiveness of the new World Health Organization (WHO) recommendations for long-course triple antiretroviral therapy (ART) prophylaxis for the mother and infant ART prophylaxis, compared to short-course strategies, for prevention of mother-to-child transmission (PMTCT) in Nigeria. Using a decision-analysis model to calculate cost and effects, the authors provided data for policy decisions on PMTCT regimen selections at different levels of program coverage. The authors found that if PMTCT is scaled up to reach 58 percent of HIV-positive mothers, HIV transmission in Nigeria can be reduced to 12.8 percent with the long-course ART regimen and 16.1 percent with short-course ART regimens/minimal standard of care. If PMTCT services are scaled up to reach all HIV-positive pregnant women, the long-course intervention reduces PMTCT to just 3 percent, compared to 9 percent if women receive the short-course ART regimen. Overall, the long-course ART regimen could avert 7,680 infant HIV cases and 230 to 400 disability-adjusted life years (DALY) among all pregnant Nigerian women who are living with HIV. According to the authors, the WHO-recommended regimen is associated with incremental cost-effectiveness ratios of U.S.$113 per DALY averted and is a highly cost-effective intervention compared to short-course regimens. The authors strongly suggested that the Government of Nigeria consider these cost savings and implement the WHO-recommended long-course regimen in its effort to expand and scale-up its PMTCT program.
- What Will It Take to Achieve Virtual Elimination of Mother-to-Child Transmission of HIV? An Assessment of Current Progress and Future Needs
Mahy, M., J. Stover, K. Kiragu, et al., Sexual Transmission Infection (December 2010), Vol. 86 (suppl.): pp. ii48-ii55.
- Male Antenatal Attendance and HIV Testing Are Associated with Decreased Infant HIV Infection and Increased HIV-Free Survival
Aluisio, A., B. Richardson, R. Bosire, et al., Journal of Acquired Immune Deficiency Syndrome (November 2010), Vol. 56: pp. 76-82.
Including male partners in antenatal prevention of mother-to-child HIV transmission (PMTCT) services with associated HIV testing has a positive health outcome on the infant and may represent an underutilized public health intervention. This study investigated the relationship between male involvement in PMTCT and infant HIV acquisition and mortality among 456 HIV-positive female participants and 140 partners. The researchers found that HIV-uninfected infants of participants with male partner involvement had a 63 percent lower mortality risk than those whose partners did not attend. The study also demonstrated that infants of participants with male partner involvement demonstrated a significantly lower risk of HIV infection and greater HIV-free survival. Participants whose partners had been previously tested for HIV demonstrated better adherence to zidovudine treatment and were significantly more likely to formula feed their infants, thus possibly contributing to lower risk of vertical transmission. The lower risk may also be attributed to increased financial, physical, and/or psychosocial support for the HIV-infected pregnant woman and her infant. The authors also observed a disturbing trend: greater mortality risk among HIV-infected infants born to women with partner attendance. According to the authors, although male involvement has been proven effective in lowering risk of HIV infection, obstacles within health systems still inhibit male participation, and these barriers should be addressed before increasing outreach to male partners.
- Sexual and Reproductive Health Services for People Living with HIV: A Systematic Review
Brickley, D. B., L. Almers, C. Kennedy, et al. 2011 (March). AIDS Care 23(3): 303-314.
Combining sexual and reproductive health (SRH) services with routine HIV clinical visits and creating a strong provider-client rapport will lead to improved SRH services for people living with HIV. This systematic review examines nine studies of current practices and presents evidence of effective programming of sexual and reproductive health (SRH) services targeted to people living with HIV in both resource-limited settings and resource-rich environments. All nine studies examined HIV clinics that added SRH services to meet their clients’ needs, as opposed to reproductive health clinics that added services for people living with HIV. The clinical services included family planning, maternal and child health, and STI prevention and management services. Interventions offering family planning and/or STI services to people living with HIV led to improvements in such behavioral outcomes as increased condom and contraceptive use, as well as lower indices of such health issues as unplanned pregnancies and STIs. The authors found that it is important to combine information on potential side effects of contraception with adequate follow-up, as well as offering alternative methods that require minimal client knowledge for correct use, such as Norplant. Including men in decision-making about safe sex and contraception and in proactive rescheduling of missed clinic visits were also reported as important factors in improving SRH services for people living with HIV.
- Triple-Antiretroviral Prophylaxis to Prevent Mother-to-Child HIV Transmission Through Breastfeeding—The Kisumu Breastfeeding Study, Kenya: A Clinical Trial
Thomas, T. K., Masaba, R., Borkowf, C., et al. PLoS Medicine (2011), Vol. 8 No. 3, e1001015.
The Kisumu Breastfeeding Study, a single-arm, open-label trial conducted between July 2003 and February 2009, examines the safety and effectiveness of providing HIV-positive women with a maternal triple-antiretroviral regimen from late pregnancy through six months. Participants in this study were given zidovudine, lamivudine, and either nevirapine or the protease inhibitor nelfinavir from 34 to 36 weeks of pregnancy to six months postpartum. All of the infants born to HIV-positive participants also received single-dose nevirapine at birth. The women were advised to rapidly wean their children just before six months. Using a Kaplan-Meier statistical method, the researchers found that this trial regimen achieved 6-week and 18-month HIV transmission rates of 4.2 percent and 6.7 percent, respectively. HIV transmission rose from 2.5 percent at birth to 7 percent at 24 months. At 24 months, 3 percent of infants born to HIV-positive women with a low viral load were HIV-positive, compared to 8.7 percent of babies born to mothers with a high viral load. According to the authors, these findings are consistent with other studies and demonstrate that providing women with a triple-antiretroviral regimen from late pregnancy to six months, regardless of their baseline CD4 cell count, is a safe, effective, and feasible way to reduce mother-to-child HIV transmission in resource-limited settings. The findings support recent World Health Organization guidelines that recommend either the mother receive triple antiretroviral therapy or the infant receive antiretroviral prophylaxis.
Related AIDSTAR-One Page: The Risk of HIV Transmission During Breastfeeding----A Table of Research Findings
Related AIDSTAR-One Prevention Knowledge Base Topic: Prevention of Mother-to-Child Transmission of HIV
- HIV-1 Drug Resistance Emergence Among Breastfeeding Infants Born to HIV-Infected Mothers During a Single-Arm Trial of Triple-Antiretroviral Prophylaxis for PMTCT: A Secondary Analysis
Zeh, C., Weidle, P. J., Nafisa, L. et al. PLoS Medicine (2011), Vol. 8 No. 3, e1000430.
- “It’s Her Responsibility”: Partner Involvement in Prevention of Mother-to-Child Transmission of HIV Programmes, Northern Tanzania
Faines, E. F., Moland, K. M., Tylleskar, T., et al. Journal of the International AIDS Society (2011), Vol. 14 No. 1, p. 21.
The authors of this study say that ingrained ideas about gender roles and hierarchy play a major role in inhibiting male involvement in prevention of mother-to-child transmission (PMTCT) programming. Creating male-friendly spaces within PMTCT programming, while continuing to provide empowerment programming for women, must be a priority in creating quality PMTCT programs. These results were based on a mixed-methods study exploring the structural and cultural challenges (e.g., men’s attitudes toward testing procedures, partner disclosure, condom use, and infant feeding recommendations) to male involvement in PMTCT programs in the Kilimanjaro region of Tanzania. Between October 2007 and February 2008, the researchers conducted focus groups, in-depth interviews, and a cross-sectional survey among mothers, fathers, and health care workers in five reproductive and child health clinics. The authors found that participants’ male partners strongly supported women’s participation in the PMTCT programs and routine testing for pregnant women. However, they were much more resistant to certain program components such as partner testing, condom use, and infant feeding recommendations. The main barriers to partner testing were female participants’ reluctance to ask their husbands to be tested and the view among men that antenatal clinic settings are a woman’s domain. The authors indicated that rather than focusing on the attitudes of men, programs should explore such options as setting aside “men-friendly” spaces in PMTCT clinics, providing facilities for men or specifically for pregnant couples, and developing condom use messaging directed towards men.
- Optimal Time on HAART for Prevention of Mother-to-Child Transmission of HIV
Chibwesha, C. J., Giganti, M. J., Putta, N., et al. Journal of Acquired Immune Deficiency Syndromes (October 2011), Vol. 58 No. 2, pp. 224-228.
This retrospective cohort analysis of 1,813 HIV-infected pregnant women in Lusaka, Zambia, found that women who receive highly active antiretroviral therapy (HAART) for at least 13 weeks prior to delivery experience a 5.5-fold decreased risk of transmitting HIV to their infants compared to women on HAART for four or fewer weeks prior to delivery. According to the authors, these results confirm that mother-to-child transmission can be reduced to below 5 percent in African settings with the use of HAART. To achieve this, they encourage that HAART be initiated in eligible pregnant women at least 13 weeks prior to delivery, and in settings where this is not possible, at least four weeks prior to delivery. The study also found that a positive syphilis screen during pregnancy can also lead to increased risk of vertical transmission. The authors stress the importance of encouraging women to seek antenatal care early in pregnancy, and urge medical staff to determine eligibility for HAART and provide linkages to appropriate treatment and care services. The authors also urge an increased focus on improving clinical and laboratory services and the integration of HAART services into antenatal clinic settings. Moreover, they urge antenatal clinics to increase the screening and treatment of syphilis, and to provide credentials for nurses and midwives to prescribe HAART.