Website: PREVENTION OF MOTHER-TO-CHILD TRANSMISSION (PMTCT) OF HIV
PREVENTION
OF MOTHER-TO-CHILD TRANSMISSION (PMTCT) OF HIV
KEY POINTS
- Prevention of
mother-to-child transmission (PMTCT) programmes offer a range of services
for women of reproductive age living with or at risk of HIV to maintain
their health and stop their infants from acquiring HIV.
- PMTCT services should be
offered before conception, and throughout pregnancy, labour and
breastfeeding.
- PMTCT services should
include early infant diagnosis at four to six weeks after birth, testing
at 18 months and/or when breastfeeding ends, and ART initiation as soon as
possible for HIV-exposed infants to prevent HIV acquisition.
- Keeping women and
infants in PMTCT programmes after delivery is challenging. In some
countries more infant infections are now occurring during the postnatal
period due to breastfeeding rather than pregnancy or labour due to the
high rates of women who leave care.
- Around 1.4 million HIV
infections among children were prevented between 2010 and 2018 due to
PMTCT programmes.
Preventing unintended pregnancies among women living with HIV
Family
planning is one of the most important PMTCT measures. When women living with
HIV are supported to plan when they do and do not have children, the number of
children being born with HIV reduces. HIV positive women are also at greater
risk of dying from pregnancy-related complications than women who are not
living with HIV. In 2015, WHO estimated that 4,700 maternal deaths were caused
indirectly by AIDS-related illnesses globally.29
Sub‐Saharan Africa has the
highest HIV prevalence in the world and the highest unmet need for
contraception, with one in five women unable to plan or limit pregnancies.30
Studies
have shown that women living with HIV have higher unmet need for family
planning and reproductive health services than the general population, in part
due to lack of investment in integrated family planning and HIV services. In
2014, a global survey on the sexual and reproductive health and rights (SRHR)
of women living with HIV, the largest to date, led by and conducted among women
living with HIV, found 60% of respondents had at least one unplanned pregnancy
and that less than half had ever obtained family planning services.31
Integrating
family planning services into HIV services has been one approach to making both
more accessible to women and couples living with HIV, and significant progress
has been made in the past decade. In 2017, a systematic review of the evidence
found overall integration of family planning into HIV care and treatment
programmes with modern methods including contraceptive use and knowledge among
women living with HIV. However, it found the difference it made in meeting
unmet need for family planning was more limited, with the level of need
extremely high, even at the integrated sites.32
Preventing HIV transmission from a woman living with HIV to her
infant
Since
2010, 1.4 million infections among children have been averted33 and there
has been a 48% decline in new child infections among the 23 UNAIDS’ priority
countries.34
However,
in 2017, 180,000 children became HIV positive, the vast majority through
vertical transmission.35
In the
same year, 80% of pregnant women living with HIV were receiving ART.36 At least nine of UNAIDS’ 23 priority countries have
reached or nearly reached the target of 95% of pregnant women living with HIV
on lifelong ART, and another six countries appear on track to do so.37
Recent
gains have been particularly impressive in eastern and southern Africa where in
2017 an estimated 93% of women living with HIV had initiated, or were already
on, ART during pregnancy. As a result, the percentage of children in the region
who acquired HIV from their mother declined from around 18% in 2010 to 10% in
2017.38
Knowledge about HIV, MTCT and PMTCT
Knowledge of HIV status
Confusion over exclusive breastfeeding
Stigma in healthcare
settings
Hard to reach populations
Country and clinic resources
Knowledge about HIV, MTCT and PMTCT
A study of more than 10,000 women in Tanzania
found that only 46% of respondents had adequate knowledge on MTCT and PMTCT.
Factors associated with having adequate knowledge were experiencing at least
one pregnancy, higher education levels, higher household wealth, living in an
urban area, being exposed to HIV education, having taken an HIV test or knowing
where to get tested for HIV. Women living with HIV were more likely to have
adequate knowledge of MTCT than women who were HIV negative (56% compared to
46%).66
Haile, ZT. et al (2016) ‘Correlates of women's knowledge of mother-to-child transmission
of HIV and its prevention in Tanzania: a population-based study’ AIDS
Care, Vol 28, Issue 1
Olugbenga-Bello, A. et al (2013) 'Perception
on prevention of mother-to-child-transmission (PMTCT) of HIV among women of
reproductive age group in Osogbo, Southwestern Nigeria' International
Journal of Women's Health 5:399-405
A study of more than 10,000 women in Tanzania
found that only 46% of respondents had adequate knowledge on MTCT and PMTCT.
Factors associated with having adequate knowledge were experiencing at least
one pregnancy, higher education levels, higher household wealth, living in an
urban area, being exposed to HIV education, having taken an HIV test or knowing
where to get tested for HIV. Women living with HIV were more likely to have
adequate knowledge of MTCT than women who were HIV negative (56% compared to
46%).66
Conversely, other studies have associated high
levels of HIV, MTCT and PMTCT knowledge with lower acceptability of PMTCT. One
study from south west Nigeria recorded that, while 99.8% of pregnant women were
aware of HIV and had very high knowledge of MTCT (92%) and PMTCT (91%), 71% had
negative views towards PMTCT. This was due to factors such as stigma and
discrimination.67
The traditional model for HIV testing is
voluntary counselling and testing (VCT) also known as the 'opt in' method, in
which people take the initiative in asking for an HIV test. Whereas,
increasingly, PMTCT services are adopting an 'opt out' strategy, also known as
physician or provider initiated testing and counselling (PITC), which means
that women have to actively opt out or decline an HIV test after being given
information and counselling about it.70
70. Balogun, FM. and Owoaje, ET (2016) ‘Perception about the 'Opt Out Strategy' for HIV testing
and counselling among pregnant women attending antenatal clinic in Ibadan,
Nigeria’ Journal of Community Medicine and Primary
Health Care, Vol 28, No 1
Knowledge of HIV status
Knowledge of HIV status is vital in order for
pregnant to women access the appropriate treatment and care for themselves and
their infants.
The
percentage of pregnant women being tested for HIV varies greatly between
countries, with many of the priority 23 countries now achieving coverage of 70%
and above. However, others have testing rates far behind this. For example, in
the Democratic of Congo 37% of pregnant women received an HIV test in 2017, and
a similar rate was seen in Nigeria at 35%. In Indonesia, less than a third of
pregnant women (28%) received an HIV test.68
Pregnant
adolescent girls and young women are less likely than older pregnant women to
know their HIV status before starting antenatal care.69
The traditional model for HIV testing is
voluntary counselling and testing (VCT) also known as the 'opt in' method, in
which people take the initiative in asking for an HIV test. Whereas,
increasingly, PMTCT services are adopting an 'opt out' strategy, also known as
physician or provider initiated testing and counselling (PITC), which means
that women have to actively opt out or decline an HIV test after being given
information and counselling about it.70
Some women in the study reported testing because
they feared they would be suspected of being HIV positive should they decline.
Others thought they might be denied antenatal care (ANC) if they refused
testing. This brings to question the voluntariness of the 'opt out' strategy as
about a fifth of the study participants felt that they were forced to have an
HIV test.73
Balogun, FM. and Owoaje, ET (2016) ‘Perception about the 'Opt Out
Strategy' for HIV testing and counselling among pregnant women attending
antenatal clinic in Ibadan, Nigeria’ Journal of Community
Medicine and Primary Health Care, Vol 28, No 1
Not knowing one's HIV status acts as a barrier to
PMTCT services. The point at which women are tested for HIV can also impact on
their journey through PMTCT, should they test positive. For example, a study of
pregnant women living with HIV from Cameroon, Cote d’Ivoire, South Africa, and
Zambia found women who were diagnosed with HIV before their pregnancy were more
likely to adhere to PMTCT treatment than women who tested positive during
pregnancy.74
Dionne-Odam, J. et al (2016) ‘Factors
Associated with PMTCT Cascade Completion in Four African Countries’,
AIDS Research and Treatment, Vol 2016 (2016), Article ID 2403936
In addition, data from a number of African
countries suggests women are three times more likely to acquire HIV during
pregnancy and breastfeeding than at other times. Despite this elevated risk,
many women are not being retested for HIV during these times, and they may be
unaware of the need to take additional precautions. This is a major concern in
settings with high HIV prevalence.75
Confusion over exclusive breastfeeding
There is a certain amount of confusion about the
best approach to breastfeeding for women living with HIV. This may stem from
the fact that the recommended feeding approach is dependent on national or
sub-national advice
Research from Tanzania compared two hospitals
that offered different infant feeding options. Hospital A promoted exclusive
breastfeeding as the only infant feeding option, while hospital B followed
Tanzanian PMTCT infant feeding guidelines which promote patient choice. Women
in hospital A trusted the advice given and were confident in their ability to
exclusively breastfeed, whereas women in hospital B expressed confusion and
uncertainty about how best to feed their infants.76
Vaga, B.B. et al (2014) 'Reflections on
informed choice in resource-poor settings: the case of infant feeding
counselling in PMTCT programmes in Tanzania' Social Science &
Medicine 105:22-29
We
were given the drugs to protect the baby from HIV infection but it can also
happen that the baby may have already been born with HIV and then you
breastfeed him. Again if he is not found with HIV, he may have it in future. So
I start to think that I should just stop breastfeeding and start formula
feeding.
Ngoma-Hazemba, A. and Ncama, BP. (2016) ‘Analysis
of experiences with exclusive breastfeeding among HIV-positive mothers in
Lusaka, Zambia’ Global Health Action, Vol 9, Issue 1
Stigma in healthcare
settings
I
know of a woman living with HIV who went to [an] antenatal [clinic and] at the
point of delivery, [the doctor] went through the files and when he saw her file
he said, ‘This one, [I] am not touching her.’ She was on the stretcher already
and [was] in labour. He said, ‘It’s a positive case... I didn’t leave my house
to come and do a positive case today. I am not prepared.’ The woman was left on
the stretcher.
For
women living with HIV, experiences of stigma, discrimination and abuse often
occur when they seek maternal healthcare. This can take many forms including
physical abuse, non-consented clinical care, non-confidential care,
non-dignified care, abandonment or denial of care, and detention in facilities.87
ICW (2015) ‘International Community of Women Living with
HIV Submission to the UN Working Group on the Issue of Discrimination against
Women in Law and in Practice’ [pdf]
The
International Community of Women Living With HIV reports how pregnant women
living with HIV have experienced service providers using extra gloves or bleach
when dealing with them and asking women to not come close to them, touch
things, and cover their mouths while talking. This discrimination and fear
means that many women avoid going to hospitals and accessing PMTCT services.88
Many
healthcare workers don’t have the necessary skills or equipment to confidently
handle delivery for an HIV-positive woman, and given the risk of accidental
exposure, most nurses shy away from dealing with such patients.89
A
report from the Middle East and North Africa region illustrates numerous human
rights violations experienced by women living with HIV as they attempt to
access healthcare, with a number of women reporting being refused treatment due
to their status.
As
soon as I told [the doctor I was HIV positive], she moved away and so did the
entire medical team. Within half an hour, I was moved to another hospital
carrying the papers that proved I was someone living with HIV – and that made
the answer from every hospital ‘no beds available’. I was physically in pain
from fractures in my shoulder and thigh, and psychologically hurt by the
rejection, stigma and discrimination I was facing. I had to lie to the medical
team in order to get the treatment and care I needed.
In various
countries, women living with HIV report being poorly treated by doctors and
nurses and being told they should not have children. Some women report being
sterilised during delivery via caesarean section with healthcare providers
giving PMTCT as the reason. They routinely report being asked to sign papers or
verbally consent to sterilisation while in labour, or healthcare workers
obtaining consent for the procedure from their husbands or fathers at this
stage. Many women report being unaware they have been sterilised until they try
to have another child.91
During
the caesarean and under the effects of the anaesthesia they forced her into
sterilization so that she couldn’t have more children. She didn’t sign a
consent. When she was recovering from the anaesthesia, she saw that her finger
was stained with ink.
Hard to reach populations
Restrictive
policy environments, stigma and discrimination in healthcare settings, gender
inequality and economic marginalisation undermine access to PMTCT services for
women from populations most affected by HIV, such as sex workers and women who
use drugs.
A
study in Ukraine found pregnant women who inject drugs were more likely than
other pregnant women to be diagnosed with HIV during labour and to have more
advanced HIV. They also were less likely to receive ART. As a consequence,
vertical transmission rates in this population were higher than in the general
population.93
Young
women also face major challenges accessing PMTCT services. Healthcare providers
often lack the training and skills to deliver youth-friendly services and do
not fully understand laws around the age of consent. Age-restrictive laws, such
as those that ban contraception under a certain age, also act as barriers to
sexual and reproductive health and rights (SRHR) and HIV services.
A
South African study found adolescent mothers (aged 15–19) had three times lower
prevention of mother-to-child transmission uptake and triple the early
mother-to-child transmission, compared with mothers aged 20 and over.
Adolescents in the study were found to be having more unplanned pregnancies and
were more likely to have their first ANC visit later in pregnancy.94
More
age-disaggregated data on pregnant women living with HIV is needed to better
understand the specific barriers facing young pregnant women.
Country and clinic resources
In
resource-poor settings, shortages of PMTCT staff, interruptions in treatment
and supplies of medical equipment, as well as a shortfall in counselling
services, all act as barriers to PMTCT services.
These
factors often mean long waiting times for post-test counselling and many leave
without getting their HIV test results.95
Poor
monitoring of PMTCT services by healthcare workers also leads to poor retention
in care. Research from Ethiopia reported poor follow-up rates in the PMTCT
programme because healthcare facilities did not have registered information on
HIV-positive mothers.96
A
study on the provision of reproductive health services including PMTCT services
in a primary healthcare setting in Tshwane, South Africa found patient
overcrowding and long waiting times all hampered people’s access to services.
The factors leading to long waiting times were staff shortages and an increase
in clients as people moved to the area.97
The
importance of virological testing, particularly early infant diagnosis, is
hampered by a lack of resources for point-of-care testing alongside a lack of
knowledge among healthcare providers and mothers or caregivers. The fact that
in many places HIV treatment for mothers and babies is followed up separately,
rather than as a pair, presents another barrier to successful early infant
diagnosis.
Comments
Post a Comment