Moses A, Zimba C, Kamanga E, Nkhoma J, Maida A, Martinson F, et al. Prevention of mother-to-child transmission: program changes and the effect on uptake of the HIVNET 012 regimen in Malawi. AIDS 2008 Jan 2;22(1):83-7.
To evaluate uptake of HIV testing in a program of prevention of mother-to-child transmission (PMTCT) in Lilongwe, Malawi from April 2002 until December 2006.
Retrospective program analysis of monthly reports on patients attending government clinics.
Four antenatal clinics in Lilongwe, Malawi. Malawi is a country of 13 million, in which more than 90,000 (about 7% of total population) children aged 0-14 years were found to be infected with HIV in 2006. Approximately 90% of these children acquired the virus through vertical (mother-to-child) transmission.
All pregnant women who attended the antenatal clinics and who consented to participate in the PMTCT program were included in the evaluation.
All pregnant women were given information and education on prenatal care, nutrition, HIV, sexually transmitted infections, family planning, and PMTCT in the waiting area of the clinic. Detailed information on PMTCT was given in groups of 8 to 12. Pretest counseling, written informed consent for HIV testing, and a physical exam were done privately. Blood was collected for laboratory testing, HIV was assessed by enzyme-linked immunosorbent assay (ELISA), and women returned for the test results and individual post-test counseling 1-2 weeks later. Mothers and infants were given the HIVNET 012 regimen. That is, HIV positive mothers were given a single dose of nevirapine 200 mg at week 32 to be taken at the onset of labor. All women also received antenatal care according to national guidelines. All exposed infants were given nevirapine 2 mg/kg within 72 h of birth. If the mother delivered before receiving nevirapine or before 32 weeks, the infant was given nevirapine immediately after birth and a second dose within 48-72 h. Rapid HIV testing was instituted in July 2003 using two parallel tests that included a tie-breaker if needed. 'Opt-out' testing was instituted in April 2005, in which all women received health education in the waiting area, then moved into smaller groups of 8 for pretest counseling, and then to a private room for routine antenatal care. Post-test counseling for all women was done individually. With this change, women were given nevirapine during the visit. A yellow identification card was given to each woman so that the nurse on duty in the labor ward did not miss the infant. Infants who returned at 6 weeks postpartum were offered an HIV DNA polymerase chain reaction test starting in 2004. An ELISA was done at 18 months. If the infants were found to be HIV positive, a CD4 cell percentage was obtained and they were referred for further medical evaluation and treatment.
The primary outcomes were acceptance of HIV testing among pregnant women, acceptance of nevirapine tablets by infected mothers and syrup by the newborns, the percentage of women delivering in facilities, and the percentage of babies born to HIV-infected mothers who were tested.
As the program was rolled out and education efforts increased, the percentage of women agreeing to HIV testing increased from 45% (second quarter 2003) to 73% (second quarter 2004) (p<0.001). The program reached 20,000 pregnant women in the first 12 months. The women who refused to participate usually cited a need to speak with their husbands before agreeing to a test. When opt-out testing was instituted, 99% of the mothers agreed to be tested. Formative research of clients did not reveal any evidence of coercion with introduction of opt-out, nor has there been a diminution in the number of clients. Moses et al gave no details of the formative research. The percentage of pregnant women delivering in the facilities steadily increased from 23.5% in 2003 to 54.6% in 2006 (p<0.001). However, 45.4% of infants did not receive nevirapine in 2006, as they were delivered at home. From October 2006 to December 2006, three of four maternity wards reported the number of women who had not been through the PMTCT program and were delivering at the health centers. In 54 of 1,286 (4%) deliveries, the woman had unknown HIV status. During the first year of the program, 459 (19.4%) of the infants born to HIV-infected mothers were tested and 26.6% were infected. Testing increased in 2006 to 1,090 (34.5%) infants tested, of which 15.5% were HIV-positive.
The authors concluded that rapid HIV testing using the opt-out method increased acceptance of HIV testing to 99% in women attending the PMTCT program in urban Lilongwe, Malawi.
This paper described a government program and was a program evaluation, not a study. There is, therefore, no formal system of assessing the quality of the evaluation. However, the program had a few limitations. First, since 45% of women did not deliver in the maternity ward, many infants missed their nevirapine dose. In addition, the program did not have a method of measuring the compliance of mothers taking their own nevirapine dose. Therefore, it was difficult to assess whether mothers took their dose and did so at the appropriate time. The data on HIV transmission rate also was biased towards self-reporting, as many mothers did not bring their infants in for HIV testing.
Compared to some studies, the rate of testing in this program was higher and the rate of nevirapine use was similar. In Thyolo, Malawi, uptake of HIV testing was 95%, but only 45% of mothers and 34% of infants received nevirapine.(1) In Mombasa, Kenya, 69.7% of women were tested; 14% were HIV positive and 30.5% women took nevirapine in labor.(2) In Burkina Faso, 18.3% of pregnant women accepted voluntary counseling and testing (VCT), with a seroprevalence of 10.6%.(3) An evaluation of HIV test acceptance at four antenatal clinics in Francistown, Botswana found that testing uptake increased from 75.3% during traditional opt-in methods to 90.5% when opt-out was introduced.(4) The rate of HIV transmission in this study was similar to that in a study from Malawi, Tanzania, and Zambia, in which transmission after single-dose nevirapine was 15.8-16.2% at 6 weeks.(5)
Linking PMTCT with antenatal care can result in improved uptake of VCT and HIV care and treatment, especially when programs use rapid HIV tests and opt-out VCT policies. However, PMTCT programs in developing settings are challenged because many mothers, regardless of HIV status, deliver their babies at home. Maternal and infant use of nevirapine is therefore unknown. This program in Malawi now provides mothers with a syringe containing the infant's nevirapine dose and incorporates traditional birth attendants to facilitate and record administration of the medicine. Outcome data on this approach is needed. Additionally, although this program was able to improve VCT uptake to the point where 99% of all pregnant mothers came into the clinic for a test, only 34.5% of HIV positive mothers returned at 6 weeks after labor for their infants to have HIV testing. Additional efforts are needed to ensure that children born to HIV-positive mothers receive the appropriate care to minimize postnatal transmission of the virus and to identify infections when they do occur. Finally, highly active antiretroviral therapy and other PMTCT regimens are known to be more effective in reducing vertical transmission of HIV. Given the economic and human resource constraints in settings like Malawi, the HIVNET 012 regimen is a reasonable approach and warrants further implementation.
- Manzi, M, Zachariah R, Teck R, Buhendwa L, Kazima J, Bakali E, et al. High acceptability of voluntary counselling and HIV-testing but unacceptable loss to follow up in a prevention of mother-to-child HIV transmission programme in rural Malawi: scaling-up requires a different way of acting. Trop Med Int Health 2005 Dec;10(12):1242-50.
- Temmerman M, Quaghebeur A, Mwanyumba F, Mandaliya K. Mother-to-child HIV transmission in resource poor settings: how to improve coverage? AIDS 2003 May 23;17(8):1239-42.
- Pignatelli S, Simpore J, Pietra V, Ouedraogo L, Conombo G, Saleri N, et al. Factors predicting uptake of voluntary counselling and testing in a real-life setting in a mother-and-child center in Ouagadougou, Burkina Faso. Trop Med Int Health 2006 Mar;11(3):350-7.
- Centers for Disease Control and Prevention (CDC). Introduction of routine HIV testing in prenatal care-Botswana, 2004. MMWR Morb Mortal Wkly Rep 2004 Nov 26;53(46):1083-6.
- Taha TE, Brown ER, Hoffman IF, Fawzi W, Read JS, Sinkala M, et al. A phase III clinical trial of antibiotics to reduce chorioamnionitis-related perinatal HIV-1 transmission. AIDS 2006 Jun 12;20(9):1313-21.