Barriers and facilitators of completing the steps in the PMTCT cascade at Midwife Obstetric Units in Gauteng - Healthcare Provider and Patient's views

Background: The implementation of Prevention of Mother to Child Transmission (PMTCT) programmes at midwifes obstetric units (MOU) involves the confirmation of HIV diagnosis during labour, early infant HIV diagnosis (EID), initiation/continuation of antiretroviral therapy (ART) for mother and baby as appropriate and counselling for postpartum care. Objectives: The aim of this study was to explore the barriers and facilitators to completing the steps in the PMTCT cascade at MOUs as defined by healthcare providers and recently postpartum women. Methods: We conducted 10 in-depth interviews with healthcare providers, and 24 HIV positive and HIV negative women at the four MOUs and Primary Healthcare Centres (PHC’s) in Gauteng South Africa (SA). Results: The implementation of PMTCT at MOU is impeded by maternal denial of HIV status (both new diagnoses and ANC diagnoses). Challenges with acceptance and disclosure of HIV status were thought to compromise patient commitment to EID tests and postpartum adherence to infant ART. Newly diagnosed (during labour) patients have limited time to process new HIV diagnosis and clinics have limited nurse/counsellor capacity for further one on one counselling. Additional challenges include communication challenges with foreign women and turnaround time for birth HIV tests. Results are often not available at postnatal visit and unclear processes for referral to Primary Healthcare Centre (PHC) for postpartum care increase risk of postpartum loss to follow up. Conclusion: We need to strengthen MOU capacity to prepare women for postpartum PMTCT requirements and facilitate access to EID results. Patient referral processes, including communication of infant HIV test results to the referral PHC, needs improvement.

A tool for estimating antiretroviral medication coverage for HIV-infected women during pregnancy (PMTCT-ACT)

Background In the typical prevention of mother to child transmission (PMTCT) of HIV cascade of care discussion or analysis, the period of analysis begins at the first visit for antenatal care (ANC) for that pregnancy. This starting point is problematic for two reasons: (1) a large number of HIV-infected women are already on life-long antiretroviral therapy (ART) when presenting for ANC; and (2) women present to ANC at different gestational ages. The PMTCT ART Coverage Tool (PMTCT-ACT), which estimates the proportion of days covered (PDC) with ART, was developed to address each of these problems. Methods PDC is a preferred method to measure adherence to chronic medications, such as ART. For evaluating the PMTCT cascade of care, as indicated by PDC with ART over various time periods, a “starting point” based on a specific day before delivery must be defined that applies to all women (treatment experienced or naïve at the first ANC visit at any gestational age). Using the example of 168 days prior to delivery (24 weeks), PMTCT-ACT measures PDC with ART during that period. PMTCT-ACT is provided as a STATA do-file. Using an example dataset for two women (ID1 is treatment experienced; ID2 is treatment naïve), the details of each major portion of the tool (Parts 1–5) are presented. PMTCT-ACT along with the intermediate datasets created during the analysis are provided as supplemental files. Conclusions Evaluating the PMTCT cascade of care requires a standard definition of the follow-up period during pregnancy that applies to all HIV-infected pregnant women and a standard measure of adherence. PMTCT-ACT is a new tool that fits this purpose. PMTCT-ACT can also be easily adjusted to evaluate other ante- and post-natal periods (e.g., final 4 weeks, final 8 weeks, complete pregnancy period, initial 24 weeks postpartum, time periods consistent with infant HIV testing guidelines).

At-scale evidence from 26 national household surveys on the prevention of mother-to-child transmission of HIV cascade

Prevention of mother-to-child transmission of HIV (PMTCT) can virtually eliminate vertical HIV transmission, yet more than 160 000 children were newly infected with HIV in 2016. We conducted a pooled analysis of national household surveys from 26 sub-Saharan African countries and calculated PMTCT coverage and access using unconditional and conditional likelihoods. Logistic regression analysis adjusted for country of residence was used to measure the association between socio-demographic factors and PMTCT coverage. The largest loss in the PMTCT cascade access occurred at being offered a HIV test at an antenatal care (ANC) clinic visit, with only 62.6% of women visiting an ANC clinic being offered a HIV test. Logistic regression analysis adjusted for country of residence indicated that completing primary school was associated with a higher likelihood of completing each step in the PMTCT cascade, including being offered a HIV test [odds ratio 2.18 (95% CI: 2.09–2.26)]. Urban residence was associated with a higher likelihood of completing each step in the PMTCT cascade, including being offered a HIV test [odds ratio 2.23 (95% CI: 2.15–2.30)]. To increase progression through the PMTCT cascade, policy-makers should target the likelihood an ANC client is offered a HIV test and the likelihood of facility delivery, steps where access is the lowest. Low educational attainment women and women in rural areas appear to have the lowest coverage in the cascade, suggesting that policy-makers target these individuals.

Increasing Access and Adherence to the PMTCT Cascade: Is There a Role for Economic Strengthening Interventions?

Interventions aimed at prevention of mother-to-child transmission (PMTCT) of HIV are extremely effective but remain underutilized in many countries. Common economic barriers to PMTCT experienced by pregnant women with HIV are well documented. Addressing these economic barriers has a potential to improve PMTCT utilization and further reduce mother-to-child HIV transmission. This review examines the evidence of the effects economic strengthening (ES) interventions have on use of and adherence to PMTCT and other health services relevant to PMTCT cascade. While very few studies on ES interventions were conducted in PMTCT settings, the results of a recent randomised trial demonstrate that conditional cash transfers offered to women in PMTCT programme can significantly improve retention in care and adherence to treatment. This review also considers evidence on ES interventions conducted within other health care settings relevant to PMTCT cascade. While the evidence from other settings is promising, it may not be fully applicable to PMTCT and more quality research on ES interventions among population of pregnant women with HIV is needed. Answering some of the research questions formulated by this review can provide more evidence for programme implementers and guide decisions about how to increase women’s use of and adherence to PMTCT services.

Factors Associated with PMTCT Cascade Completion in Four African Countries

Background. Many countries are working to reduce or eliminate mother-to-child transmission (MTCT) of HIV. Prevention efforts have been conceptualized as steps in a cascade but cascade completion rates during and after pregnancy are low. Methods. A cross-sectional survey was performed across 26 communities in Cameroon, Cote d’Ivoire, South Africa, and Zambia. Women who reported a pregnancy within two years were enrolled. Participant responses were used to construct the PMTCT cascade with all of the following steps required for completion: at least one antenatal visit, HIV testing performed, HIV testing result received, initiation of maternal prophylaxis, and initiation of infant prophylaxis. Factors associated with cascade completion were identified using multivariable logistic regression modeling. Results. Of 976 HIV-infected women, only 355 (36.4%) completed the PMTCT cascade. Although most women (69.2%) did not know their partner’s HIV status; awareness of partner HIV status was associated with cascade completion (aOR 1.4, 95% CI 1.01–2.0). Completion was also associated with receiving an HIV diagnosis prior to pregnancy compared with HIV diagnosis during or after pregnancy (aOR 14.1, 95% CI 5.2–38.6). Conclusions. Pregnant women with HIV infection in Africa who were aware of their partner’s HIV status and who were diagnosed with HIV before pregnancy were more likely to complete the PMTCT cascade.