van der Merwe K, Chersich MF, Technau K, Umurungi Y, Conradie F, Coovadia A. Integration of Antiretroviral Treatment within Antenatal Care in Gauteng Province, South Africa. J Acquir Immune Defic Syndr. 2006 Dec 15;43(5):577-81.
The study compares the rate of mother-to-child transmission (MTCT) of HIV among pregnant women initiating ARV treatment to the rate of MTCT among those receiving single dose nevirapine (NVP); the study also evaluates the effect of improving links between antenatal care and ARV services on uptake of ARV and treatment delay.
This study is a program evaluation based on a retrospective chart review of patients over a 12-month period from mid-2004 to mid-2005. Program changes were initiated in January, 2005.
The study took place at the Coronation Women and Children's Hospital located in Gauteng Province, South Africa.
A total of 164 women initiated ARV treatment during pregnancy, and 863 received single-dose nevirapine; 32/164 women received ARV before changes in service delivery, and 132/164 women received ARV after program changes. Women who were eligible for ARV were significantly older than those eligible only for NVP (1.3 years older; 95% CI=0.4-2.1 years, p=0.005).
The hospital provides HIV testing and counseling to all pregnant women during their first antenatal visit. Women with WHO clinical stage 4, or a CD4 cell count ≤250 cells/mm3 were medically eligible for ARV treatment. HIV-infected pregnant women not eligible for ARV received a single dose of NVP. Changes in service delivery were made to strengthen the linkage between antenatal clinics and ARV treatment, including the following: 1) health care workers from the ARV treatment clinic attended a weekly ANC clinic for HIV-infected women; 2) CD4 cell counts were performed at the first, as well as second, antenatal visit; 3) baseline laboratory investigations for ARV treatment were performed at the second antenatal visit.; 4) women qualifying for ARV treatment received adherence counseling and treatment preparation at the second antenatal visit; 5) a monitoring system to assess uptake and time between HIV diagnosis and ARV treatment was established.
The authors compared outcomes for women attending the antenatal clinic over a six-month period before and after changes to service delivery. Outcomes included: 1) risk of MTCT among women on ARV treatment compared with woman-infant pairs receiving single-dose of nevirapine; 2) time-to-treatment initiation (number of days between HIV diagnosis and initiation of ARV treatment); 3) time to receive CD4 cell count results; 4) mean gestational age at ARV treatment initiation; 5) number of weeks on ARV treatment prior to childbirth; and 6) the uptake of ARV treatment (proportion of medically eligible pregnant women who initiated ARV treatment).
Overall, MTCT rates among women receiving ARV were significantly lower than among women receiving NVP (4.3% (5/116) vs 10.7% (74/692) (p=0.03)). Time-to-treatment initiation decreased after program changes, from a median of 56 days to 37 days (p=0.041), as well as median number of days between HIV diagnosis and receipt of CD4 cell counts (50 days vs. 29 days; p=0.047). After program changes, there was no overall increase in ARV uptake, and MTCT rates before and after changes in service delivery were not presented. Overall, 75.4% of eligible women (129 of 171) initiated treatment. Among the 42 women eligible to receive ARV who declined, 23 (55%) attended follow-up visits and received nevirapine; 17% (4/23) of their infants were infected with HIV.
The authors conclude that accelerated initiation of ARV treatment can decrease the rates of mother-to-child transmission of HIV, and that program changes can improve linkages between ANC and ARV service provision.
There are no widely accepted quality-scoring tools for program evaluations. The study and its interpretation were limited by the following: this was a before-and-after comparison, rather than an intervention control design; MTCT rates for women who received ARV more quickly because of program changes were not compared to those who did not--this outcome would have been the primary outcome of interest; there were discrepancies in the paper regarding the number of women described as receiving ARV; the number of newborns who received NVP is not mentioned.
In Context (Reviewer Comment)
Data on the effectiveness of prevention of MTCT services at this hospital and interventions to improve services have previously been published. Findings in this study are consistent with those of other reports that demonstrate that regular audits and monitoring, accompanied by program changes, can substantially improve service delivery.(1,2) MTCT rates described here for HIV-infected women ineligible for ARV but who receive NVP (MTCT rate=10.7%), versus those who are eligible for and receive ARV (MTCT rate=4.3%), versus those who have advanced HIV disease but receive NVP (17%) are consistent with other studies of mother-to-child transmission among African women receiving prophylaxis.(3,4,5)
Although program changes resulted in earlier HIV testing, measurement of CD4 counts, and initiation of ARV, there was no mention in this study as to whether earlier evaluation and treatment resulted in reduced MTCT. This is the significant outcome of interest. This study does highlight, however, that among pregnant women with low CD4 counts or advanced HIV disease, ARV treatment is better than single-dose NVP in reducing HIV transmission to infants; in addition, transmission rates for women with advanced versus less advanced HIV disease are greater. Therefore, rollout programs need to target pregnant women for antiretroviral therapy.
This study also illustrates that it is possible to provide more timely service delivery by integrating ANC and ARV treatment services. Important steps include measuring CD4 cell counts at the first antenatal visit and placing ARV service providers within antenatal clinics to streamline patient transition and ensure consistent messages.
- Sherman GG, Jones SA, Coovadia AH, et al. PMTCT from research to reality--results from a routine service. S Afr Med J. 2004;94:289-292.
- Urban M, Chersich M. Acceptability and utilisation of voluntary HIV testing and nevirapine to reduce mother-to-child transmission of HIV-1integrated into routine clinical care. S Afr Med J 2004;94:362-366.
- Bajunirwe F, Massaquoi I, Asiimwe S, et al. Effectiveness of nevirapine and zidovudine in a pilot program for the prevention of mother-to-child transmission of HIV-1 in Uganda. Afr Health Sci 2004 Dec;4(3):146-54.
- Gray GE, Urban M, Chersich MF, et al. A randomized trial of two postexposure prophylaxis regimens to reduce mother-to-child HIV-1 transmission in infants of untreated mothers. AIDS 2005 Aug 12;19(12):1289-97.
- Moodley D, Moodley J, Coovadia H, et al. A multicenter randomized controlled trial of nevirapine versus a combination of zidovudine and lamivudine to reduce intrapartum and early postpartum mother-to-child transmission of human immunodeficiency virus type 1. J Infect Dis 2003 Mar 1;187(5):725-35.