Ongoing challenges in providing PMTCT in Kenya and Malawi

Ongoing systemic issues are affecting the implementation of the 2010 World Health Organisation (WHO) guidelines on prevention of mother-to-child transmission (PMTCT) programmes in Kenya, according to a study presented at the 17th International Conference on AIDS and STIs in Africa (ICASA), held in Cape Town, South Africa, from 7 to 11 December 2013.

Kenya adopted WHO guidelines in 2012 that recommend the initiation of antiretroviral therapy during pregnancy and four visits to an antenatal clinic to maximise the support that can be given in order to successfully prevent HIV transmission. Nevertheless, around 40,000 infants are born with HIV each year in Kenya, despite improvements in the availability of antiretroviral therapy and PMTCT services.

A total of 503 pregnant women were recruited from two PMTCT clinics in Nairobi during their first antenatal clinic visit, as part of a randomised control trial which used mobile phone messaging to improve linkage to antenatal care, adherence to PMTCT medication, postnatal follow-up and to strengthen health information systems.

The data presented evaluated the extent to which study participants received care in compliance with national guidelines:

• The proportion of women with HIV who attended four or more antenatal clinic visits.
• The proportion of women not requiring antiretroviral therapy for their own health who initiated AZT by week 20 of pregnancy.
• The proportion of women given single-dose nevirapine tablets at first contact with the PMTCT service.
• The proportion of women counselled regarding HIV results, disclosure and partner testing.
• The proportion of women who received contraception counselling.
• The proportion of women screened for TB and opportunistic infections.

The study found that 443 (88.8%) of the women had less than four antenatal clinic visits, as recommended in the 2010 WHO PMTCT guidelines. It also found that 185 (36.8%) of the women were more than 28 weeks into gestation at their first antenatal clinic visit, compared to 259 (51.5%) at 21-28 weeks gestation and 59 (11.7%) who were at 20 weeks gestation or less. The 2010 WHO PMTCT guidelines recommend that as early as 14 weeks, HIV-positive pregnant women should start taking AZT and be counselled on adherence. Only 19.8% (n = 82) of the women received single-dose nevirapine at their first visit to the clinic to take them home with them, as recommended by the guidelines.

In the study, 60.8% (n = 306) of the women with HIV disclosed their HIV status to their partners immediately; 8.5% (n = 43) disclosed within the first year after diagnosis; and 5.2% (n = 26) disclosed their status more than one year after diagnosis. A quarter of the women (25.5%, n = 128) did not respond to a question about their disclosure to their partner in the survey.

Half of the women (50.1%) said their current pregnancy was planned; 31.3% discussed contraception methods with the healthcare provider; and 34.5% of the women had received contraception information after their previous pregnancy.

Although some aspects of the PMTCT programme are fairly successful, the researchers concluded, serious deficiencies are apparent in other areas. The lack of difference in results between clinical sites suggests that these problems are systemic rather than facility-specific.

Vertical transmission of HIV occurring at small proportion of South African PMTCT sites

In contrast, a South African study of 124 PMTCT facilities attended by 8077 pregnant women with HIV reported that a small number of PMTCT sites were registering disproportionately high rates of vertical HIV transmission (HIV being passed on from mother to baby).

The study compared sites in seven high-prevalence districts in KwaZulu Natal, Eastern Cape and Mpumalanga provinces, and evaluated outcomes of all pregnant women who presented for care between October 2012 and March 2013.

The comparison found low rates of failure to test for HIV antibodies (1.6% of eligible women did not undergo testing) overall, but at 14.5% of sites, over 10% of women had failed to undergo HIV testing within antenatal services.

Less than 2% of infants tested PCR-positive for HIV at six weeks at 73.7% of the sites, whereas 17.2% of the sites had a PCR-positivity of between 2 and 5% and 9% of the sites had a vertical transmission rate of higher than 5%.

Similar results were shown for the HIV-positivity of children at 18 months across the sites: 79.1% of the sites had a vertical transmission rate of less than 2%, 10.4% had a vertical transmission rate of between 2 and 5%, while 10.4% had a vertical transmission rate of more than 5%.

Of the 124 sites included in the study, 3 (2.4%) were hospitals, 88 (71%) were rural sites and 53 (42.7%) were facilities with ‘Quality Nurse Mentor’ support for nurses. Of the 21,475 pregnant women who attend these facilities, 8077 had HIV (37.6%). Of the 6891 infants tested for HIV using PCR at six weeks, 114 (1.7%) were HIV positive. Of the 4166 children tested for HIV at 18 months, 50 (1.2%) were HIV positive.

HIV infection in infants was strongly associated with antenatal care in hospitals rather than primary healthcare facilities (OR 3.6, 95% confidence interval 1.9-7.1, p<0.001). A similar association held true for  failure to test for HIV and failure to carry out CD4 cell testing (OR 7.5 and 5.1 respectively). The risk of HIV transmission was reduced where a facility was supported by a Quality Nurse Mentor (OR 0.62, 95% CI 0.43-0.90, p = 0.011).

“Identifying sites with poorer outcomes, and implementing measures to address barriers to site PMTCT processes are likely to improve overall PMTCT programme performance,” said Dr Geoffrey Fatti, author of the study.

Malawi facing challenges implementing Option B+

Stigma, confidentiality, privacy and the method of initiating antiretroviral therapy (ART) continue to  challenge PMTCT services in Malawi, according to qualitative research exploring patient and healthcare worker perspectives on the roll-out of Option B+ and integrated PMTCT and ART care in Malawi, presented at the conference by Fabian Cataldo and colleagues.

Option B+ refers to the recommendation that all pregnant and breastfeeding women should be offered and provided with lifelong ART, regardless of clinical stage and CD4 count. Malawi was one of the first countries to implement Option B+ in 2010.

This study is a sub-study of the PMTCT Uptake and Retention in Malawi (PURE) trial, a cluster randomised control trial running from 2012 to 2016 which compares facility- and community-based peer support to standard care and introduces mentor and expert patients who have been through the PMTCT programme. The study has six sites in the southeast, central-west and southwest of Malawi, made up of health centres and mission, district and rural hospitals.

The challenges with current PMTCT care highlighted by patient experiences of Option B+ included a lack of confidentiality or privacy within ART services, the distances patients need to travel by foot to ART services and favouritism being shown towards some patients.

The concerns and challenges that form the healthcare workers’ perspective were that patients express difficulties in understanding immediate ART initiation, difficulty in making contact with patients outside of health facilities due to incorrect personal details being provided, lack of privacy and confidentiality for patients, and staff shortages leading to women being asked to return to the health facility the following day.

The healthcare workers also expressed concerns that the practice of testing a woman for HIV and providing ART on the same day is “too fast” and requires the woman to deal with too much information at once, which can lead to suboptimal uptake of ART and PMTCT medicines. “We test her [patient] today and she is found HIV-positive. We immediately initiate her on ART whilst she is still thinking about how she contracted the virus and she has not yet accepted the reality about her sero-status, and we give her the drugs for the unborn child at the same time,” said one healthcare worker in the study.

Few women were in any form of support group and all but one said that it could be a helpful component of care. All the women in the study requested group talks and support groups, with a preference for talking to someone also on ART.

The women stated that health facilities need to have healthcare workers who are more professional and who are concerned about privacy and confidentiality, or ‘expert mothers’ (women who have been through the PMTCT programme themselves and have received additional training) should conduct home visits. These would result in fewer visits to health facilities and involve the family and partner. “I would prefer [receiving care] at home because the woman would be advising me together with my husband,” said one study participant.