Freddy Perez

Prevention of mother to child transmission of HIV: evaluation of a pilot programme in a district hospital in rural Zimbabwe

Abstract Problem Zimbabwe has one of the highest rates of HIV seroprevalence in the world. In 2001 only 4% of women and children in need of services for prevention of mother to child transmission of HIV were receiving them. Design Pilot implementation of the first programme for prevention of mother to child transmission of HIV in rural Zimbabwe. Setting 120 bed district hospital in Buhera district (285 000 inhabitants), Manicaland, Zimbabwe. Key measures for improvement Programme uptake indicators monitored for 18 months; impact of policy evaluated by assessing up-scaling of programme. Strategies for change Voluntary counselling and testing services for HIV were provided in the hospital antenatal clinic. Women identified as HIV positive and informed of their serostatus and their newborn were offered a single dose antiretroviral treatment of nevirapine; mother-child pairs were followed up through routine health services. Nursing staff and social workers were trained, and community mobilisation was conducted. Effects of change No services for prevention of mother to child transmission of HIV were available at baseline. Within 18 months, 2298 pregnant women had received pretest counselling, and the acceptance of HIV testing reached 93.0%. Of all 2137 women who had an HIV test, 1588 (74.3%) returned to collect their result; 326 of the 437 HIV positive women diagnosed had post-test counselling, and 104 (24%) mother-child pairs received nevirapine prophylaxis. Lessons learnt Minimum staffing, an enhanced training programme, and involvement of district health authorities are needed for the implementation and successful integration of services for prevention of mother to child transmission of HIV. Voluntary counselling and testing services are important entry points for HIV prevention and care and for referral to community networks and medical HIV care services. A district approach is critical to extend programmes for prevention of mother to child transmission of HIV in rural settings. The lessons learnt from this pilot programme have contributed to the design of the national expansion strategy for prevention of mother to child transmission of HIV in Zimbabwe.

Implementing a rural programme of prevention of mother-to-child transmission of HIV in Zimbabwe: first 18 months of experience.

Objective  To report on activities and lessons learned during the first 18 months of a rural programme of prevention of mother‐to‐child transmission of HIV (PMTCT) in Zimbabwe.

What Will It Take to Eliminate Pediatric HIV? Reaching WHO Target Rates of Mother-to-Child HIV Transmission in Zimbabwe: A Model-Based Analysis

Using a simulation model, Andrea Ciaranello and colleagues find that the latest WHO PMTCT (prevention of mother to child transmission of HIV) guidelines plus better access to PMTCT programs, better retention of women in care, and better adherence to drugs are needed to eliminate pediatric HIV in Zimbabwe.

Cost-effectiveness of World Health Organization 2010 Guidelines for Prevention of Mother-to-Child HIV Transmission in Zimbabwe

We projected outcomes for mothers and infants following World Health Organization–recommended regimens to prevent mother-to-child human immunodeficiency virus (HIV) transmission. Compared with Option A, Option B improves life expectancy and saves money; compared with Option B, lifelong maternal therapy is of comparable value to common HIV-related interventions.

WHO 2010 Guidelines for Prevention of Mother-to-Child HIV Transmission in Zimbabwe: Modeling Clinical Outcomes in Infants and Mothers

Background The Zimbabwean national prevention of mother-to-child HIV transmission (PMTCT) program provided primarily single-dose nevirapine (sdNVP) from 2002–2009 and is currently replacing sdNVP with more effective antiretroviral (ARV) regimens. Methods Published HIV and PMTCT models, with local trial and programmatic data, were used to simulate a cohort of HIV-infected, pregnant/breastfeeding women in Zimbabwe (mean age 24.0 years, mean CD4 451 cells/µL). We compared five PMTCT regimens at a fixed level of PMTCT medication uptake: 1) no antenatal ARVs (comparator); 2) sdNVP; 3) WHO 2010 guidelines using “Option A” (zidovudine during pregnancy/infant NVP during breastfeeding for women without advanced HIV disease; lifelong 3-drug antiretroviral therapy (ART) for women with advanced disease); 4) WHO “Option B” (ART during pregnancy/breastfeeding without advanced disease; lifelong ART with advanced disease); and 5) “Option B+:” lifelong ART for all pregnant/breastfeeding, HIV-infected women. Pediatric (4–6 week and 18-month infection risk, 2-year survival) and maternal (2- and 5-year survival, life expectancy from delivery) outcomes were projected. Results Eighteen-month pediatric infection risks ranged from 25.8% (no antenatal ARVs) to 10.9% (Options B/B+). Although maternal short-term outcomes (2- and 5-year survival) varied only slightly by regimen, maternal life expectancy was reduced after receipt of sdNVP (13.8 years) or Option B (13.9 years) compared to no antenatal ARVs (14.0 years), Option A (14.0 years), or Option B+ (14.5 years). Conclusions Replacement of sdNVP with currently recommended regimens for PMTCT (WHO Options A, B, or B+) is necessary to reduce infant HIV infection risk in Zimbabwe. The planned transition to Option A may also improve both pediatric and maternal outcomes.

Un modelo de prevención primaria de las enfermedades de transmisión sexual y del VIH/sida en adolescentes

OBJECTIVE To develop, apply, and evaluate an educational model for the primary prevention of sexually transmitted diseases (STDs) and acquired immunodeficiency syndrome (AIDS) that was based on the sexual knowledge, attitudes, and practices (KAPs) of adolescents and on their perceptions and behaviors in this area, with the ultimate goal of helping develop educational tools to prevent infection with STDs and the human immunodeficiency virus (HIV). METHODS An STD/HIV/AIDS primary prevention model was applied with adolescent schoolchildren (12 to 15 years old) in the canton of Santo Domingo de los Colorados, Ecuador. Two groups with similar characteristics were formed: the experimental group, with 358 students, and the control group, with 288 students. Schools were selected according to inclusion criteria, and adolescents at each school were chosen at random. A discussion guide was applied with 16 focus groups, and the resulting information was used to prepare a KAP survey. After being validated, the KAP survey was applied to the experimental group and to the control group. A prevention education program geared to students and teachers was implemented with the experimental group. Eight months later a second KAP survey was done with the experimental group and the control group. The differences in KAPs before and after the intervention were evaluated using the chi-square test. RESULTS There were no statistically significant differences between the two groups before the intervention, but afterwards the differences were statistically significant (P = 0.012), with an increase in the knowledge of sexuality and STDs/AIDS in the experimental group, even though the long-term behavior changes have not been evaluated. CONCLUSIONS This study validated a multifactorial STD/AIDS prevention model adapted to the reality of adolescents, and it suggests the possibility of extrapolating this experience more broadly to contexts similar to those of this Ecuador population.

Participation of traditional birth attendants in prevention of mother-to-child transmission of HIV services in two rural districts in Zimbabwe: a feasibility study

BackgroundPrevention of Mother-to-Child Transmission of HIV (PMTCT) is among the key HIV prevention strategies in Zimbabwe. A decrease in use of antenatal care (ANC) services with an increase in home deliveries is affecting the coverage of PMTCT interventions in a context of accelerated economic crisis. The main objective was to evaluate acceptability and feasibility of reinforcing the role of traditional birth attendants (TBAs) in family and child health services through their participation in PMTCT programmes in Zimbabwe.MethodsA community based cross-sectional survey was undertaken using multistage cluster sampling in two rural districts through interviews and focus group discussions among women who delivered at home with a TBA, those who had an institutional delivery and TBAs.Results45% of TBAs interviewed knew the principles of PMTCT and 8% delivered a woman with known HIV-positive status in previous year. Of the complete package of PMTCT services, more than 75% of TBAs agreed to participate in most activities with the exception of performing a blood test (17%), accompanying new-borns to closest health centre to receive medication (15%) and assisting health centres in documentation of the link ANC-PMTCT services (18%). Women who delivered at home were less likely to have received more than one ANC service or have had contact with a health centre compared to women who delivered in a health centre (91.0% vs 72.6%; P < 0.001). Also, 63.6% of the women who delivered in a health centre had the opportunity to choose the place of delivery compared to 39.4% of women who delivered at home (P < 0.001). More than 85% of women agreed that TBAs could participate in all activities related to a PMTCT programme with the exception of performing a blood test for HIV. Concerns were highlighted regarding confidentiality of the HIV-serostatus of women.ConclusionAlthough the long-term goal of ANC service delivery in Zimbabwe remains the provision of skilled delivery attendance, PMTCT programmes will benefit from complementary approaches to prevent missed opportunities. TBAs are willing to expand their scope of work regarding activities related to PMTCT. There is a need to reinforce their knowledge on MTCT prevention measures and better integrate them into the health system.

Improved knowledge and practices among end-users of mother-to-child transmission of HIV prevention services in rural Zimbabwe.

Objective  To evaluate the influence of a prevention of mother‐to‐child transmission of HIV advocacy and mobilization campaign on awareness and knowledge levels within the community.

Improving child health: the role of research

Child health has improved greatly in the past decade, thanks to research that has quantified health problems and identified strategies for improving child health. The Working Group on Women and Child Health reviews the major advances in this field in developing countries since 1990 and argues that research is fundamental to further improvements in child health Child mortality (before age 5 years) has shown a relative decrease of 15% since 1990 but remains above 100 per 1000 live births in more than 40 countries.1 The risk of death can be reduced through evidence based interventions such as immunisation and oral rehydration treatment. Research has helped to quantify child health problems, identified strategies to improve health, and shown the effectiveness of interventions. In preparation for the forthcoming United Nations special session on children, we review the major advances in child health in developing countries since 1990 and illustrate the role of research in this progress. ### Summary points Child health has improved markedly over the past 10 years In many developing countries, mortality among children under 5 remains above 100 deaths per 1000 live births; most of these deaths are preventable Reduction of childhood morbidity and mortality remains a public health priority worldwide Investing in survival of children is an essential element of national development Research is fundamental to further improvements in child health Without continued and increased research investment, further advances to improve the health of the worlds children are put at risk We reviewed the literature published between January 1990 and June 2001 to document progress of and challenges in child health research since the previous UN session for children in 1990. The Medline search strategy was based on the combination (Boolean operator AND) of “child” and “developing countries” and the following keywords: breastfeeding, …

Prenatal Transmission of Syphilis and Human Immunodeficiency Virus in Brazil: Achieving Regional Targets for Elimination

We used a mathematical model to simulate the conditions necessary for the elimination of mother-to-child transmission of HIV and syphilis in Brazil. Improving access to antenatal care significantly reduces transmission for both diseases, although additional interventions are necessary to meet elimination goals.