HIV Prevention Knowledge Base
Biomedical Interventions: Prevention of Mother-to-Child Transmission of HIV (PMTCT)
Antiretroviral Therapy in Antenatal Care to Increase Treatment Initiation in HIV-Infected Pregnant Women: A Stepped-wedge Evaluation
Few women in low- and middle-income countries have been able to access antiretroviral therapy (ART) early in pregnancy. This study evaluated whether integrating ART provision into antenatal care (ANC) clinics in Lusaka, Zambia, would improve the proportion of treatment-eligible women initiating ART during pregnancy. The researchers compared a large control cohort of pregnant women with an intervention cohort of over 17,000 women who received care at an integrated ANC-ART center. Of the 1,566 treatment-eligible women, a larger proportion of those attending an integrated care center (33 percent) received ART during pregnancy compared to the control arm (14 percent).
Safety and Efficacy of Initiating Highly Active Antiretroviral Therapy in an Integrated Antenatal and HIV Clinic in Johannesburg, South Africa
This study evaluated the safety and efficacy of highly active antiretroviral therapy (HAART) given to 689 pregnant women treated in an integrated antenatal clinic of Johannesburg Hospital, South Africa. Only 302 mother-infant pairs completed follow-up, and of those, the transmission rate was 5 percent. Clinically significant adverse reactions to HAART included life-threatening skin reactions (Stevens-Johnson syndrome), non-fatal hepatitis, and mitochondrial toxicity. The authors caution that the retrospective, observational nature of this study, and the failure of many women to follow-up, is “likely to bias the data” as women who followed up could represent a distinctly different socioeconomic group. Nonetheless, the researchers concluded that initiating pregnant women on HAART was feasible, safe, and effective.
High HIV Incidence During Pregnancy: Compelling Reason for Repeat HIV Testing
The researchers sought to determine the percentage of women who develop HIV during pregnancy (women who test HIV-negative in early pregnancy and test HIV-positive later in pregnancy). Of 5,233 pregnant women registered for antenatal care in the Eastern Cape and Free State of South Africa, 79 percent agreed to an HIV test. Of the 2,377 women who initially tested negative, only 1,278 accepted a repeat HIV test between 36–40 weeks of pregnancy; of those, 72 (3 percent) tested positive. This number represents an incidence rate of HIV of 10.7/100 pregnant-woman-years. The authors conclude that HIV retesting should be offered in pregnancy in order to promote PMTCT and to identify women living with HIV whose antibody levels were low at first testing.
Preventing Mother-to-Child Transmission of HIV in Resource-limited Settings: The Elizabeth Glaser Pediatric AIDS Foundation Experience
The Elizabeth Glaser Pediatric AIDS Foundation has one of the world’s largest PMTCT program datasets. The authors reviewed more than six years of program data from several countries, covering 2.6 million pregnant women through June 2006. They review the number of women who received counseling and testing services, and the number of women and infants receiving antiretroviral prophylaxis. The authors describe a dramatic increase in HIV testing after a policy change from “opt-in” testing to “opt-out” testing, in which the test is presented as a routine part of pregnancy testing that women can decline if they desire. They discuss their wide promotion of single-dose nevirapine for prophylaxis and some of the controversy surrounding this approach.
Approaches for Scaling-up Human Immunodeficiency Virus Testing and Counseling in Prevention of Mother-to-Child Human Immunodeficiency Virus Transmission Settings in Resource-Limited Countries
This article focuses on the weaknesses of the counseling and testing components of PMTCT. The authors state that overall global PMTCT coverage is just 8 percent. Because testing and counseling serves as an entry point for multiple downstream services, such as comprehensive family-centered HIV care, as well as for PMTCT, the authors suggest that improvements in this aspect of HIV prevention and treatment could lead to multiple benefits. The authors make 10 key recommendations, including provider-initiated testing and counseling; group pre-test counseling; use of rapid HIV tests; and the use of auxiliary health care workers. Each of the 10 recommendations is discussed in detail. Data from four African and two United Kingdom studies are presented and illustrate improved uptake of testing and counseling after the introduction of provider-initiated testing, which uses an opt-out technique for testing.
Reducing the Risk of Mother-to-Child Human Immunodeficiency Virus Transmission: Past Successes, Current Progress and Challenges, and Future Directions
The authors review historical events and key research issues relevant to PMTCT. They describe interventions that have succeeded in the United States and Europe and how they have lagged in developing countries. The authors discuss program gaps or challenges to PMTCT in the United States, such as the practice of providers offering testing only to pregnant women felt to be at high-risk, rather than offering it to all pregnant women. Another pitfall is the failure to retest pregnant women who initially test HIV-negative. International gaps and challenges include limited ability to provide PMTCT services at the time of birth and shortly after because many women in resource-limited areas deliver at home. Some successful approaches to these problems are described.
The Role of HIV-Related Stigma in Utilization of Skilled Childbirth Services in Rural Kenya: A Prospective Mixed-Methods Study
The authors report on the results of the Maternity in Migori and AIDS Stigma Study (MAMAS), a prospective, mixed-methods study of how pregnant women’s perceptions of HIV-related stigma affect their use of maternity services. In 2007, MAMAS surveyed 1,777 pregnant women of unknown HIV status at their first antenatal care visit in a high-prevalence region of rural Kenya. These baseline data revealed that more than two-thirds of the respondents anticipated experiencing stigma if they were to test HIV positive. Follow-up interviews were conducted postpartum with a subsample of 411 women—HIV positive, HIV negative, and untested—as were interviews with 48 community health workers, childbearing women, and family members. Qualitative data from the interviews showed that most women in the study believe that delivering in a health facility is preferable for pregnant women with HIV or other health complications. Quantitative data revealed that women with stronger negative attitudes about persons living with HIV are less likely to deliver in a health facility. The authors postulate that women who deliver at a health facility are more likely to be labeled as HIV positive by their communities. Because health outcomes are far better for clinic-based deliveries, the authors recommend community-based interventions to counter HIV-related stigma in order to reduce women’s concerns about using health facilities for childbirth.
Progress, Challenges, and New Opportunities for the Prevention of Mother-to-Child Transmission of HIV under the US President's Emergency Plan for AIDS Relief
This article outlines five priorities for the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), as well as other donors, in programming for prevention of mother-to-child transmission (PMTCT). PEPFAR's comprehensive PMTCT strategy is based on its Global Plan Toward Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive, co-published with the Joint United Nations Programme for HIV/AIDS (UNAIDS). The PMTCT strategy seeks to reduce new pediatric infections by 90 percent and to halve HIV-related maternal mortality by 2015. The authors endorse rapid implementation of the World Health Organization's PMTCT guidelines and of innovative approaches to retain women in care and to help them adhere to prophylaxis and lifelong treatment. According to the authors, in 51 studies of HIV-infected pregnant and postpartum women, adequate adherence (defined as greater than 80 percent) was significantly higher in the antepartum period than postpartum (70 percent versus 52 percent). The authors recommend partner-based support and community-based distribution of medications to increase adherence. They support partner-based HIV testing to more effectively include partners in PMTCT and to integrate HIV care and family planning efforts. Finally, the authors advise measurement of infant HIV prevalence and HIV-free survival at the population level, via household surveys or evaluations within infant immunization clinics, with long-term infant follow-up. At the International AIDS Conference in 2012, dozens of presentations discussed ongoing research and innovation in PMTCT programming, including Option B+, which provides lifelong triple antiretroviral therapy to all pregnant women regardless of their CD4 count.
Community Voices: Barriers and Opportunities for Programmes to Successfully Prevent Vertical Transmission of HIV Identified Through Consultations Among People Living with HIV.
Following an online and in-person consultation with more than 650 people living with HIV (PLHIV) in approximately 60 countries, the Global Network of People Living with HIV and the International Community of Women Living with HIV outlined challenges and potential areas for success within the Draft Strategic Framework (2010-1015) for Primary Prevention of HIV and the Prevention of Unintended Pregnancies in Women Living with HIV in the Context of PMTCT. According to the authors, health care workers’ attitudes about PLHIV were identified as the single most important barrier to service access, with two-thirds of e-survey respondents reporting that they have experienced stigma in health care settings. More than half the respondents said that health care workers’ negative attitudes threatened their ability to access safe contraception. One-fifth of e-survey participants reported that they had been pressured to make sexual and reproductive health decisions, decisions involving sexual abstinence, tubal ligation or hysterectomy, abortion, and/or condom use, without access to any other family planning option. Lack of confidentiality was also cited as a major issue, with more than 50 percent of e-survey respondents reporting that their right to have their health information kept confidential had been violated at least once. Potential solutions to such challenges include: capacity building and training; prevention of gender-based violence; use of peer counselors and support groups; sexual and reproductive health services designed for women and girls; counseling on family planning and safe conception, particularly for PLHIV; decentralization of services; male involvement; and support for disclosure in HIV-discordant relationships.
Three Postpartum Antiretroviral Regimens to Prevent Intrapartum HIV Infection
According to this research study, rapid initiation of antiretroviral therapy (ART) in infants is feasible, acceptable, and effective. The authors evaluated the safety and efficacy of three ART different regimens in infants born to late-presenting HIV-positive mothers who did not receive ART during pregnancy. Within 48 hours of birth, 1,684 formula-fed infants born to HIV-positive mothers were given one of three regimens: zidovudine for six weeks (the “zidovudine-alone group”); zidovudine for six weeks, plus three doses of nevirapine during the first eight days of life (the “two-drug group”); or zidovudine for six weeks along with nelfinavir and lamivudine for two weeks (the “three-drug group”). According to the authors, the overall transmission rate averaged 8.5 percent in all three groups, with a rate of 11 percent in the zidovudine-alone group. The two- and three-drug groups had similar rates and fared better than the zidovudine-alone group. Based on these results, the authors conclude that prophylaxis with a two- or three-drug ART regimen is more effective than zidovudine alone. They also found that the two-drug regimen, which uses liquid nevirapine, is easier to administer than the three-drug regimen, which requires reconstitution of nelfinavir powder before each dose is ingested.
Towards Elimination of Mother-to-Child Transmission of HIV: The Impact of a Rapid Results Initiative in Nyanza Province, Kenya
This article reports on a study that examined the use of a Rapid Results Initiative (RRI)—which is designed to effect organizational change and improve performance in a limited period—to address challenges in delivery of services for prevention of mother-to-child transmission of HIV (PMTCT) implemented between April and June 2011 at 119 Kenyan health facilities. RRI includes two distinct phases: first, needs assessment; then, implementation and monitoring. According to the authors, this RRI was developed to increase service provision and uptake of antiretroviral therapy (ART) for HIV-positive mothers and infants. The authors found that following RRI initiation, ART uptake increased by more than 40 percent among all HIV-positive pregnant women, a rate that continued to improve post-RRI. The authors believe this increase will bring health facilities closer to the goal of providing ART to 30 percent of all eligible HIV-positive women. They also found a 13 percent increase in assessment for HAART eligibility as a result of improved CD4 testing as well as a 30 percent increase in polymerase chain reaction (PCR) testing leading to improved early infant diagnosis and increased male involvement. Attributing part of this success to community mobilization as well as to Ministry of Health leadership and involvement, the authors encourage further research to determine the RRI’s longer-term impact on improving high-quality, cost-effective PMTCT services.
Elimination of Paediatric HIV in KwaZulu-Natal, South Africa: Large-Scale Assessment of Interventions for the Prevention of Mother-to-Child Transmission
Large-scale elimination of pediatric HIV appears feasible in KwaZulu-Natal, South Africa, whose HIV prevalence is among the world’s highest. This study was designed to determine the rates of mother-to-child transmission (MTCT) in KwaZulu-Natal, using all infants receiving their first immunizations as a population proxy. According to the authors, a major decrease in MTCT (66 percent) was achieved within a short period as a result of better programming for prevention of mother-to-child transmission; 90 percent of mothers reported that they had been tested for HIV during their most recent pregnancy, and 9 percent knew they were infected before their most recent pregnancy. The authors also cite the rapid transition of the province’s health facilities to providing dual antiretroviral prophylaxis, which offers more protection than nevirapine alone, and to providing HIV-positive mothers with lifelong antiretroviral therapy. According to the authors, lifelong treatment will contribute significantly to reducing HIV infections in children as well as to lowering mortality in mothers and infants (currently, 14 percent of HIV-positive mothers in KwaZulu-Natal are enrolled in a lifelong treatment program). The authors detected challenges in the current MTCT programming, including ongoing high rates of maternal HIV prevalence and HIV diagnosis late in pregnancy. According to the authors, early HIV testing and ART regimens through the period of breastfeeding for at least 90 percent of HIV-positive women will be essential to reach the overall target of 5 percent or less for prevention of mother-to-child transmission by 2015.
Rapid Advice: Use of Antiretroviral Drugs for Treating Pregnant Women and Preventing HIV Infection in Infants.
These recently-updated, evidence-based recommendations on PMTCT serve as a reference for countries to adopt and adapt according to conditions found at the national level (resource availability and limitations, etc.). They are intended to simplify and standardize previous recommendations by making guidelines for initiating antiretroviral therapy (ART) for pregnant women the same as for nonpregnant women and by taking into account programmatic considerations that affect implementation. They provide guidance for policymakers and program managers responsible for PMTCT programs and serve as a resource for health workers involved in prevention, care, and treatment of pregnant women and their infants.
The recommendations focus on two key areas: treatment and prophylaxis. The authors review drugs of choice for treatment-eligible women and when to start the drugs, and they discuss drugs of choice for prophylaxis in women who do not need ART for their own health and when to start those drugs for the mother and/or the child. Recommendations are given for both breastfeeding and non-breastfeeding infants.
New recommendations include: 1) earlier use of ART for a larger proportion of pregnant women living with HIV; 2) longer provision of antiretroviral (ARV) prophylaxis for pregnant women who do not need ART for their own health; and c) provision of ARVs. These recommendations form part of a larger guideline which is expected to be published and disseminated in 2010.
2010 World Health Organization Guidelines on HIV and Infant Feeding
These World Health Organization guidelines were updated in 2010 in response to significant new programmatic experience and evidence regarding HIV and infant feeding. The 2010 recommendations recognize the important impact of ARVs during the breastfeeding period, and recommend that national authorities in each country decide which infant feeding practice, i.e. breastfeeding with an ARV intervention to reduce transmission or avoidance of all breastfeeding, should be promoted and supported by their Maternal and Child Health services. The document includes the principles, recommendations, and summary of the evidence. Nine key principles focus on overall HIV-free survival; integrated versus vertical infant feeding interventions; setting national strategies for infant feeding; information and counseling for mothers; and promoting breastfeeding among the general population. Seven recommendations are provided on breastfeeding and young child feeding practices.