The human immunodeficiency virus (HIV) remains a leading cause of maternal morbidity and mortality in Sub-Saharan Africa. Prevention of mother-to-child transmission (PMTCT) has proven an effective strategy to end paediatric infections and ensure HIV-infected mothers access treatment. Based on cross-sectional data collected from June 2008 to May 2013, we assessed changes in HIV prevalence, risk factors for HIV, provision of PMTCT antiretroviral treatment (ART), and the association between HIV infection, birth outcomes and maternal characteristics at the Simão Mendes National Hospital, Guinea-Bissau’s largest maternity ward. Among 24,107 women, the HIV prevalence was 3.3% for HIV-1, 0.8% for HIV-2 and 0.9% for HIV-1/2. A significant decline in HIV-1, HIV-2, and HIV-1/2 prevalence was observed over time. HIV infection was associated with age and ethnicity. A total of 85% of HIV-infected women received ART as part of PMTCT, yet overall treatment coverage during labour and delivery declined significantly for both mothers and infants. Twenty-two percent of infants did not receive treatment, and 67% of HIV-2-infected mothers and 77% of their infants received ineffective non-nucleoside reverse transcriptase inhibitors for PMTCT. Maternal HIV was associated with low birth weight but not stillbirth. Inadequate continuity of care and ART coverage present challenges to optimal PMTCT in Guinea-Bissau.
The study was conducted by the Bandim Health Project (BHP) (https://www.bandim.org) at the Simão Mendes National Hospital (HNSM) maternity ward located in Bissau. The BHP, a health and demographic surveillance site present in Guinea-Bissau for 4 decades, routinely collects demographic and clinical data on all deliveries at HSNM. This public facility is the principal provider of comprehensive obstetric care in Guinea-Bissau, and approximately 90% of women who deliver at the facility are residents of the country’s capital, Bissau. From June 2008 onwards, opt-out HIV counselling and testing has been offered to women admitted to the maternity ward for the management of labour- and delivery- and/or pregnancy-related complications when HIV tests were available. HIV testing and ART were free of charge and provided by the Guinean Ministry of Health, but all women paid a flat fee of 2000 XOF (3–4 USD) to give birth at HNSM14. All newly diagnosed women and their infants were referred to the Italian-Guinean NGO-clinic, Ceu e Terras, or to other local HIV centres for follow-up, counselling, and further PMTCT ART13. Data registration of testing for HIV at delivery ceased in May 2013 due to funding constraints. While HIV testing at labour and delivery was national policy at the time of the study, not all women were tested. We have previously described the characteristics of women tested compared with those not tested 14. We conducted a retrospective cross-sectional survey exploring HIV prevalence, risk factors for HIV, treatment provision, and birth outcomes (low birth weight, LBW, and stillbirth), drawing on data routinely collected through the BHP surveillance system at HNSM from June 2008 until May 2013. All women presenting to HNSM for delivery or immediate postpartum care who had been tested for HIV were included in this study. Data were recorded in the HNSM maternity ward registration system and included basic socio-demographic and clinical data. Data cleaning was performed daily (including weekends) by trained research assistants from BHP who also collected supplementary demographic and clinical information using separate case report forms (CRFs). We have previously described the data collected in detail14,16. During the study period, it was national policy that hospital midwives offer immediate HIV counselling and testing to all women presenting to the maternity for delivery or, as many women had not attended ANC or did not receive PMTCT testing or counselling during pregnancy. Midwives had been trained to complete a short CRF as part of the counselling and testing routine to collect data on previous HIV testing, known sero-status, and ART use14. HIV screening was performed using the Determine® HIV-1/2 rapid test (Abbot Diagnostics, Maidenhead, United Kingdom). To confirm infection and to discriminate between HIV types, women with positive and inconclusive screening results were subsequently tested with another rapid test, SD Bioline HIV-1/2 3.0 (Standard Diagnostics, Kyonggi-do, South Korea). Provision of PMTCT at the initiation of this survey was guided by the 2006 World Health Organization (WHO) recommendations, i.e., ART prophylaxis in the third trimester (28 weeks) of pregnancy consisting of a regimen of twice daily Zidovudine (AZT), single-dose nevirapine (sd NVP) at onset of labour and Zidovudine plus Lamivudine (AZT + 3TC) for 1 week from birth. Women diagnosed in labour were given a single-dose nevirapine followed by AZT + 3TC for 1 week starting in labour. For women who needed treatment for their own health, triple ART (cART) was initiated as soon as possible. For HIV-2 and HIV-1/2 dually infected mothers, a combination of (AZT + 3TC) + Lopinavir/Ritonavir was recommended. For infants, guidelines recommended sd NVP plus AZT twice a day for either 4 weeks if the mother had received less than 4 weeks AZT prophylaxis prior to labour or for 1 week if the mother had received at least 4 weeks AZT prophylaxis. Infants of mothers receiving cART were recommended AZT twice daily17. After 2010, in line with the revised WHO recommendations, all pregnant women with CD4 count levels < 350 cells/mm3, irrespective of clinical stage, and women with a WHO clinical stage 3 or 4 infection, were started on triple ART. In addition, women not receiving ART for their own health, received (Option A) prophylaxis with AZT as monotherapy from as early as 14 weeks of pregnancy plus a single dose NVP + AZT + 3TC during labour and delivery followed by AZT + 3TC for 7 days after delivery, or triple ART prophylaxis (Option B) from as early as 14 weeks of pregnancy. The infant regime consisted of daily NVP from birth for a minimum of 4–6 weeks, and until 1 week after all exposure to breastmilk had ended. For infants receiving replacement feeding only daily NVP or sd NVP + daily AZT from birth and until 4–6 weeks of age was recommended18. Due to logistical issues, treatment was often started without CD4 cell count measurements based on clinical assessment. Throughout the study period, repeated stock outages and lack of ART at times forced clinicians to switch treatment and often to provide more simple regimes than recommended9, 19. In 2015, Guinea-Bissau began implementing option B+, i.e., lifelong ART from diagnosis20,21. Maternity and HIV testing data were entered in password-secured databases (dBase 5.0, dataBased Inc, Vestal, NY, USA; Microsoft Access 2007, Microsoft, Redmond, WA, USA), and datasets were merged using unique birth numbers. The data were analysed using Stata 14.0 (Stata Corporation, College Station, TX, USA). Outcome variables such as LBW and stillbirths were dichotomized (0 = absent, 1 = present). Continuous explanatory variables were grouped categorically. Factors associated with HIV serostatus and birth outcomes were determined using univariate and multivariate logistical regression models. The multivariate analysis was fitted with statistically significant covariates (as determined by Wald’s test). Birth outcomes i.e., stillbirths and low birthweight (LBW) were examined according to HIV status and adjusted for significant covariates. In accordance with the WHO criteria, stillbirth was defined as a newborn at or above 1,000 g showing no vital signs immediately after birth (Apgar score = 0)22. Low birth weight was defined as birth weight of < 2,500 g23. Miscarriages (birth weight < 1,000 g) were excluded. In the birth outcome analysis, “births” pertain to the number of fetuses at risk. Therefore, the number of total births is higher than the number of pregnant women due to multiple pregnancies. In the logistic regression models, adjustment for birth outcomes was made for clustering of twins using a specific pair number. Inconclusive test results were categorized as HIV-negative. Missing values were included in the logistic regression models. Trends over time (calendar year) for HIV prevalence and treatment were determined using Pearson’s χ2 test. Due to a lack of data to confirm self-reported antenatal treatment regimens and reasons for selecting a given treatment at labour, we opted to assess antenatal and treatment at labour separately. A p value of < 0.05 was considered significant. All patient data were fully anonymised before being accessed. The use of government surveillance maternity data was approved by the National Ethical Committee in Guinea-Bissau (CNES-2010-018). A separate ethical approval was obtained for the analysis of HIV data and linkage of delivery and HIV databases (CNES-2011-030). The study was carried out in accordance with Guinea-Bissau Medical Research Ethics Committee requirements and the Helsinki declaration. All participants were counselled and asked for verbal informed consent before data collection and HIV testing. Newly diagnosed women were offered ART at labour and subsequently referred for follow-up. The manuscript was prepared in accordance with the STROBE guidelines (Supplemental Checklist 1).