Integrating Antiretroviral Therapy into Antenatal Care and Maternal and Child Health Settings: A Systematic Review and Meta-analysis/Integration De la Therapie Antiretrovirale Dans Les Etablissements De Soins Prenataux et De Sante Maternelle et Infantile: Revue Systematique et Meta-analyse/Integraciin del Tratamiento Antirretroviral En Los Centros De Atenciin Prenatal Y Salud Materno-Infantil: Examen Sistematico Y Metaanalisis

Article excerpt

Introduction

In 2009, 49% of pregnant women in low- and middle-income countries did not attend the minimum number of antenatal care (ANC) visits recommended by the World Health Organization (WHO) to prevent or manage the complications of pregnancy and support safe delivery. (1) In addition, 74% were not tested for HIV and 63% of those who tested positive did not receive at least two antiretrovirals, as recommended by WHO, for the prevention of mother-to-child transmission (PMTCT) of HIV. (2,3) Of the infants born to mothers with HIV infection, 85% did not receive a diagnostic HIV test and 65% of those who were infected with HIV did not receive antiretroviral prophylaxis. (2) These service delivery gaps largely account for the fact that an estimated 330 000 infants were born with HIV infection in 2011. (4) Without antiretroviral therapy (ART), most of these children will die before their second birthday. (5)

All 192 Member States of the United Nations have agreed to pursue the Millennium Development Goals (MDGs), (1) which include specific targets related to HIV infection, maternal health and child health to be achieved by 2015. Expanding access to ART in ANC and maternal and child health (MCH) clinics could help achieve universal access to ART (Target 6B), reduce mortality in children less than 5 years old (Target 4A) and reduce the maternal mortality ratio (Target 5A). It could also help to achieve the target, set by WHO (6) and the Joint United Nations Programme on HIV/AIDS, of eliminating vertical HIV transmission by 2015. (7)

The limitations of current service delivery systems are such that people living with HIV often present at health-care sites with advanced HIV infection, life-threatening opportunistic infections and CD4+ T-lymphocyte counts well below the WHO-recommended eligibility threshold for ART. (8) Delayed diagnosis also keeps people from making important decisions surrounding prevention and care, such as whether to participate in prevention programmes to reduce the risk of HIV transmission, attend family planning services, or start ART, cotrimoxazole prophylaxis or isoniazid preventive therapy. As part of the Treatment 2.0 initiative, WHO is focusing on providing guidance on the integration of HIV service delivery systems with other health-care services, the decentralization of these systems to the community level, and the achievement of earlier diagnosis linked with prevention, care and treatment services. (9)

WHO currently recommends ART for pregnant women with CD4+ lymphocyte counts < 350 cells/[micro]L. (10) For women with CD4+ lymphocyte counts > 350 cells/[micro]L, WHO recommends triple antiretroviral prophylaxis as one of two options, although practice is shifting towards lifelong ART for all HIV-positive pregnant women. The advantages of lifelong ART for all HIV-positive pregnant women are: (i) likely benefits to the women's own health; (ii) prevention of HIV transmission during subsequent pregnancies; (iii) prevention of transmission to HIV-negative partners; (iv) delivery of a consistent message to communities that ART, once started, should be continued for life; and (v) simpler service delivery by eliminating the need for periodic CD4+ T-lymphocyte counts to know when to start, suspend and re-initiate ART (although CD4+ lymphocyte counts or viral load assays are still desirable for determining baseline immunological status and monitoring response to treatment). (11) In the United States and Europe, vertical HIV transmission has been largely eliminated owing to the scale-up of ART and triple antiretroviral prophylaxis. (12,13) Regardless of PMTCT strategy, WHO recommends providing antiretroviral prophylaxis to children exposed to HIV during breastfeeding, and ART to all children less than 2 years of age with confirmed HIV infection. (10)

In countries with generalized HIV epidemics (i.e. with an antenatal HIV prevalence > 1%), WHO recommends provider-initiated testing and counselling in all health facilities. …