Academic journal article Bulletin of the World Health Organization

Prevention of Mother-to-Child Transmission of HIV: A Cross-Sectional Study in Malawi/Prevention De la Transmission Mere-Enfant Du VIH: Etude Transversale Au Malawi/Prevencion De Transmision del VIH De Madre a Hijo: Un Estudio Transversal En Malawi

Academic journal article Bulletin of the World Health Organization

Prevention of Mother-to-Child Transmission of HIV: A Cross-Sectional Study in Malawi/Prevention De la Transmission Mere-Enfant Du VIH: Etude Transversale Au Malawi/Prevencion De Transmision del VIH De Madre a Hijo: Un Estudio Transversal En Malawi

Article excerpt

Introduction

Recent global efforts in the fight against human immunodeficiency virus (HIV) have been focused on the virtual elimination of paediatric HIV infection (1) and improvements in the so-called cascade of care for the prevention of mother-to-child transmission of HIV (PMTCT). This cascade includes antenatal HIV testing, uptake of maternal antiretroviral therapy (ART), infant antiretroviral prophylaxis and early infant HIV testing. (2)

In 2011, Malawi adapted the relevant World Health Organization (WHO) guidelines to design a national, public-health-oriented strategy for PMTCT. (3,4) In this strategy, called Option B+, all pregnant and breastfeeding women found infected with HIV are offered lifelong ART, regardless of their CD4+ T-lymphocyte counts or WHO clinical stage. The strategy's development was supported by emerging evidence that universal ART provision in resource-constrained settings could markedly reduce HIV transmission. (5,7) The strategy was designed to remove institutional barriers to care, provide maternal health benefits, reduce maternal mortality and increase ART coverage for future pregnancies in high-fertility settings. (4) During the strategy's early implementation, ART initiations among pregnant women increased sixfold and the proportions of women who, having initiated ART while pregnant, were still receiving HIV care 12 and 24 months later were 72% and 68%, respectively. (8,9)

Although a few studies in large Malawian health facilities have indicated that many mother-infant pairs miss one or more of the four main steps in the cascade of care provided, for PMTCT, by the national HIV programme, the results of such studies cannot be considered nationally representative. (10,11) The summary reports produced by Malawi's national HIV programme use data that are aggregated at health-facility level and do not provide insight into individual risk factors associated with the use of the cascade of care for PMTCT. In 2014, the Malawi Ministry of Health began a national evaluation of Malawi's PMTCT programme. Here we present some of the methods, results and conclusions of that evaluation, which aimed to determine the effectiveness of the Option B+ strategy in a nationally-representative sample of mother-infant pairs enrolled at 4-26 weeks postpartum.

Methods

Study setting

Implementation of the Malawi integrated PMTCT/ART guidelines began in July 2011. In theory, this gave all pregnant and breastfeeding women access to HIV testing, HIV counselling and ART. At the time of HIV status ascertainment, each HIV-infected pregnant woman should be given enough nevirapine to provide her baby with six weeks of prophylaxis from birth. She should also be asked to bring her child, for HIV testing, to a clinic for the care of children younger than five years, known as an under-5 clinic in Malawi, as soon as the course of prophylaxis is complete at an age of six weeks. (4)

Study design and sampling

Our aim was to draw a representative sample for national estimates of the ratios of mother-to-child transmission of HIV (MTCT) in Malawi. The sampling frame included all 579 health facilities that provided PMTCT services in Malawi in 2012-2013. We estimated that we would need to enrol at least 3376 HIV-exposed infants to determine the ratio of MTCT at 24 months postpartum reliably. Probability-proportional-to-size selection was used, without replacement, to select the 54 study facilities: 14 rural and nine urban facilities in the North or Central regions and 22 rural and nine urban in the South region. We subjected data obtained at all 54 study facilities to a cross-sectional analysis.

Data collection and laboratory procedures

Between October 2014 and May 2016, women attending under-5 clinics at each of the study facilities were screened for study eligibility. To be enrolled, a woman had to be a mother of or a legal caregiver for an infant aged 4-26 weeks and be willing and able to give informed consent. …

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