Effectiveness of a prevention of mother-to-child HIV transmission programme in an urban hospital in Angola

  • PLoS ONE, Volume 7, No. 4, Year 2012

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Study Justification:
The study aimed to evaluate the effectiveness of a prevention of mother-to-child HIV transmission (PMTCT) program in an urban hospital in Angola. This is important because while antiretroviral therapy has been shown to reduce rates of mother-to-child transmission of HIV, there is limited knowledge about the applicability and efficacy of these programs in real-world settings. By analyzing retrospective data from hospital records, the study aimed to provide valuable insights into the outcomes of the PMTCT program and identify areas for improvement.
Highlights:
– The study analyzed data from 104 pregnancies and 107 infants.
– 65.4% of women received combination antiretroviral treatment (ART) during pregnancy, while 34.6% received no ART.
– Women who received ART had lower mortality rates (4.4%) compared to those who did not receive ART (16.7%).
– The estimated rates of HIV transmission or death in infants were significantly lower among those whose mothers received ART during pregnancy (8.5%) compared to those whose mothers did not receive ART (38.9%).
– Adjusted analysis showed that the absence of ART during pregnancy was associated with a 5-fold higher risk of HIV transmission or death in infants.
– The study highlighted the need for targeted interventions to ensure timely access to prevention and care services for HIV.
Recommendations:
– Improve early access to the PMTCT program by implementing strategies to identify and reach pregnant women at risk of HIV infection.
– Strengthen efforts to ensure that all pregnant women receive ART during pregnancy to reduce the risk of HIV transmission to their infants.
– Enhance follow-up and retention of both mothers and infants in the PMTCT program to ensure optimal outcomes.
– Implement interventions to address the barriers that prevent some women from accessing the PMTCT program in a timely manner.
– Continuously monitor and evaluate the PMTCT program to identify areas for improvement and ensure its effectiveness.
Key Role Players:
– Healthcare providers: Doctors, nurses, and other healthcare professionals involved in the PMTCT program.
– Community health workers: Individuals who can help identify and reach pregnant women at risk of HIV infection.
– Policy makers: Government officials and policymakers responsible for implementing and supporting the PMTCT program.
– NGOs and community-based organizations: Organizations that can provide support and resources for the PMTCT program.
– Researchers and evaluators: Experts who can conduct further studies and evaluations to monitor the program’s effectiveness.
Cost Items for Planning Recommendations:
– Training and capacity building for healthcare providers and community health workers.
– Procurement and distribution of antiretroviral drugs for pregnant women.
– Laboratory testing for HIV diagnosis and monitoring.
– Outreach and awareness campaigns to reach pregnant women at risk of HIV infection.
– Follow-up and retention strategies, including transportation and incentives for mothers and infants.
– Monitoring and evaluation activities to assess the program’s impact and identify areas for improvement.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong, but there are some areas for improvement. The study design is a descriptive study based on retrospective data, which may limit the strength of the evidence. Additionally, the sample size is relatively small, with only 104 pregnancies and 107 infants analyzed. To improve the strength of the evidence, future studies could consider a prospective design with a larger sample size. Additionally, the study could include a control group for comparison, such as HIV-infected pregnant women who did not access the PMTCT program. This would allow for a more robust evaluation of the program’s effectiveness. Finally, the study could consider longer follow-up periods to assess the long-term outcomes of the PMTCT program.

Background: Antiretroviral therapy is effective in reducing rates of mother-to child transmission of HIV to low levels in resource-limited contexts but the applicability and efficacy of these programs in the field are scarcely known. In order to explore such issues, we performed a descriptive study on retrospective data from hospital records of HIV-infected pregnant women who accessed in 2007-2010 the Luanda Municipal Hospital service for prevention of mother-to-child transmission (PMTCT). The main outcome measure was infant survival and HIV transmission. Our aim was to evaluate PMTCT programme in a local hospital setting in Africa. Results: Data for 104 pregnancies and 107 infants were analysed. Sixty-eight women (65.4%) had a first visit before or during pregnancy and received combination antiretroviral treatment (ART) in pregnancy. The remaining 36 women (34.6%) presented after delivery and received no ART during pregnancy. Across a median cohort follow-up time of 73 weeks, mortality among women with and without ART in pregnancy was 4.4% and 16.7%, respectively (death hazard ratio: 0.30, 95% CI 0.07-1.20, p = 0.089). The estimated rates of HIV transmission or death in the infants over a median follow up time of 74 weeks were 8.5% with maternal ART during pregnancy and 38.9% without maternal ART during pregnancy. Following adjustment for use of oral zidovudine in the newborn and exposure to maternal milk, no ART in pregnancy remained associated with a 5-fold higher infant risk of HIV transmission or death (adjusted odds ratio: 5.13, 95% CI: 1.31-20.15, p = 0.019). Conclusions: Among the women and infants adhering to the PMTCT programme, HIV transmission and mortality were low. However, many women presented too late for PMTCT, and about 20% of infants did not complete follow up. This suggests the need of targeted interventions that maintain the access of mothers and infants to prevention and care services for HIV. © 2012 Lussiana et al.

The study is a retrospective analysis of mother and infant data from the hospital records of the perinatal and HIV PMTCT service of the Municipal Hospital Divina Providencia, a general population hospital situated in the urban area of Luanda, Angola. Eligible subjects were HIV-infected pregnant women who accessed the service between March 2007 and August 2010 and delivered live newborns. For those women with repeated pregnancies during the study period, only the last occurred was considered. Cut-off date for follow up was June 2011. The Ethic Committee of our institution approved the study design. Written informed consent was obtained from all the participants in this study. Clinical HIV status was defined according to the WHO definition [6], and CD4 cell counts were measured by flow cytometry. Gestational age was determined on the basis of the last menstrual period, ultrasound biometry, or both. Start of treatment in pregnancy was referred to pregnancy week. Preterm delivery was defined as delivery before 37 completed weeks of gestation. Infant feeding was classified as replacement feeding, breastfeeding or mixed. Replacement feeding and breastfeeding were defined by exclusive assumption of either replacement feeding or breast milk, respectively, in the first six months. Mixed replacement/breastfeeding was defined by alternation of replacement feeding and breast milk in the first six months or by substitution of breastfeeding with formula before six completed months of life. In the newborns, diagnosis (positive tests after 18 months of life) or exclusion (negative tests before or after 18 months) of HIV infection required consistent results of two different rapid blood tests (Determine HIV 1/2, Unipath Limited, Inverness Medical, Bedford, UK; Uni-Gold HIV, Trinity Biotech, Bray, County Wicklow, Ireland), in two occasions at least three months apart. HIV testing for both mothers and infants was free of charge. The main outcomes evaluated were infant survival, HIV transmission rate and maternal survival after delivery. The main variables considered as possible determinants of HIV transmission were ART during pregnancy, oral zidovudine in the newborn, and mode of infant feeding. Women accessing the HIV PMTCT and perinatal care service at the Luanda Divina Providencia hospital are managed according to standardized procedures. Women who become pregnant while on treatment usually continue the ongoing regimen, unless the evaluation of treatment suggests a significant risk of toxicity or teratogenicity. In women with no previous antiretroviral treatment, a CD4 cell count is performed, and antiretroviral treatment is started soon if CD4 counts are below 350/mm3 or if the women has WHO clinical HIV stage III or IV. Otherwise, treatment is started at the beginning of third trimester. The standard regimen for pregnant women is zidovudine plus lamivudine plus nevirapine, administered twice a day. All antiretroviral drugs are given free of charge directly to the women in an amount sufficient to cover the interval between subsequent pregnancy visits (usually two weeks). Tolerability of treatment is assessed monitoring (free of charge) haemoglobin (Hb), blood urea nitrogen (BUN), aspartate aminotransferase (AST) and alanine aminotransferase (ALT), usually on a monthly basis. Women in clinical HIV stage II or higher according to the WHO definition also receive cotrimoxazole, and if tuberculosis (TB) treatment is needed, ART is suspended and specific TB treatment is given. At delivery, women receive intravenous zidovudine. If the woman presents before or at delivery, the newborn receives oral zidovudine within 2 hours from delivery, continued for the first four weeks of life. Cotrimoxazole is given to all infants. Replacement feeding is usually recommended as the preferred infant mode of feeding, but feeding options are evaluated on a single case basis, and a 6-month breastfeeding under antiretroviral treatment may be considered if formula feeding is not regarded as adequate according to AFASS criteria (acceptable, feasible, affordable, sustainable and safe). Replacement-feeding mothers receive free of charge 500 g of powder milk at every infant visit. After delivery, a CD4 count is performed in all women in order to evaluate the indication to antiretroviral treatment. Women already on ART with indication to treatment maintain ART, irrespective of mode of feeding. In women already on ART but with no personal indication to treatment, ART is discontinued if exclusive replacement feeding is the option selected, and otherwise continued until the end of breastfeeding (usually six months). In women with no previous ART presenting after delivery, treatment is started if needed, according to the above treatment recommendations criteria. Follow up of women and their infants takes place in the same health facility. HIV testing in the infants is performed at 9, 12 and 18 months, and infants are usually followed at regular intervals until 24 months of age (usually, with monthly visits). Demographic data were summarized with descriptive statistics. Quantitative data were compared by either Student’s t-test or Mann-Whitney U-test, according to the characteristics of data distribution (normal or skewed, respectively). Categorical data were compared using the chi-square test or the Fisher test, as appropriate. Odds ratios (OR) and 95% confidence intervals [CI] in univariate analyses were calculated by Mantel-Haenszel estimates. The variables with a potential association with the main outcome (HIV transmission or death) in univariate analysis (p<0.10) were included in a multivariable logistic regression model which used occurrence of the main outcome as the dependent variable, calculating an adjusted odds ratio [AOR] with 95% CI for HIV transmission or death. Survival analyses were based on Kaplan-Meyer analysis, log-rank test, and Cox regression. Significance levels were set at 0.05. All the analyses were performed using the SPSS software, version 17.0 (SPSS Inc., Chicago, IL, US).

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Based on the information provided, here are some potential innovations that could improve access to maternal health:

1. Mobile Health (mHealth) Solutions: Implementing mobile health technologies, such as text messaging or mobile apps, to provide pregnant women with important information about prenatal care, reminders for appointments, and access to healthcare providers.

2. Telemedicine: Using telecommunication technology to provide remote consultations and monitoring for pregnant women, especially those in rural or underserved areas who may have limited access to healthcare facilities.

3. Community Health Workers: Training and deploying community health workers to provide education, support, and basic healthcare services to pregnant women in their communities, bridging the gap between healthcare facilities and remote areas.

4. Transportation Support: Establishing transportation services or vouchers to help pregnant women overcome barriers to accessing healthcare facilities, particularly in areas with limited public transportation options.

5. Maternal Health Clinics: Setting up dedicated maternal health clinics within existing healthcare facilities to provide comprehensive prenatal care, including antenatal screenings, counseling, and support services.

6. Financial Assistance Programs: Developing programs that provide financial support for pregnant women, such as subsidies for prenatal care visits, medications, and transportation costs, to reduce financial barriers to accessing maternal health services.

7. Health Education Campaigns: Conducting targeted health education campaigns to raise awareness about the importance of prenatal care, HIV testing, and prevention of mother-to-child transmission of HIV, to encourage early and regular engagement with healthcare services.

8. Integration of Services: Integrating maternal health services with other healthcare services, such as HIV testing and treatment, to ensure comprehensive care for pregnant women and reduce the need for multiple visits to different healthcare providers.

9. Quality Improvement Initiatives: Implementing quality improvement initiatives in healthcare facilities to enhance the delivery of maternal health services, including training healthcare providers, improving infrastructure, and ensuring the availability of essential medications and equipment.

10. Data Monitoring and Evaluation: Establishing robust data monitoring and evaluation systems to track maternal health outcomes, identify gaps in service delivery, and inform evidence-based decision-making for continuous improvement of maternal health programs.
AI Innovations Description
The study analyzed data from the hospital records of HIV-infected pregnant women who accessed the Luanda Municipal Hospital service for prevention of mother-to-child transmission (PMTCT) in Angola between 2007 and 2010. The main objective was to evaluate the effectiveness of the PMTCT program in reducing HIV transmission and improving infant and maternal survival.

The study found that among the women who adhered to the PMTCT program and received antiretroviral therapy (ART) during pregnancy, both HIV transmission and mortality rates were low. However, a significant number of women presented too late for PMTCT, and approximately 20% of infants did not complete follow-up. This highlights the need for targeted interventions to ensure access to prevention and care services for HIV for both mothers and infants.

Based on these findings, a recommendation to improve access to maternal health and enhance the effectiveness of PMTCT programs could be to implement strategies that address the barriers to early presentation for PMTCT. This could include community outreach programs to raise awareness about the importance of early antenatal care and PMTCT services, as well as providing transportation and financial support for pregnant women to access these services. Additionally, efforts should be made to improve the continuity of care for both mothers and infants, ensuring that they receive the necessary follow-up and support throughout the PMTCT process.

By implementing these recommendations, it is possible to enhance access to maternal health services, increase the uptake of PMTCT programs, and ultimately reduce the transmission of HIV from mother to child, leading to improved maternal and infant health outcomes.
AI Innovations Methodology
Based on the provided information, here are some potential recommendations to improve access to maternal health:

1. Strengthening Antenatal Care: Implementing comprehensive antenatal care programs that include regular check-ups, HIV testing, and counseling can help identify and manage maternal health issues early on.

2. Improving Availability of Antiretroviral Therapy (ART): Ensuring that ART is readily available and accessible to all HIV-infected pregnant women can significantly reduce the risk of mother-to-child transmission of HIV.

3. Enhancing Health Education and Awareness: Conducting community-based health education programs to raise awareness about the importance of maternal health, HIV prevention, and PMTCT services can encourage more women to seek timely care.

4. Promoting Early Pregnancy Detection: Encouraging women to seek early pregnancy detection and care can facilitate early initiation of PMTCT services and improve health outcomes for both mothers and infants.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could involve the following steps:

1. Data Collection: Gather data on the current state of maternal health access, including the number of women accessing PMTCT services, HIV transmission rates, and maternal and infant mortality rates.

2. Define Variables: Identify key variables that can measure the impact of the recommendations, such as the number of women receiving antenatal care, the availability of ART, the level of health education, and the rate of early pregnancy detection.

3. Establish Baseline: Determine the baseline values for each variable based on the collected data.

4. Introduce Recommendations: Simulate the implementation of the recommendations by adjusting the variables accordingly. For example, increase the number of women receiving antenatal care, improve the availability of ART, enhance health education efforts, and promote early pregnancy detection.

5. Measure Impact: Analyze the simulated data to measure the impact of the recommendations on access to maternal health. This can be done by comparing the outcomes (e.g., HIV transmission rates, maternal and infant mortality rates) before and after the implementation of the recommendations.

6. Evaluate Results: Assess the effectiveness of the recommendations by evaluating the changes in the measured outcomes. This can help determine the extent to which the recommendations have improved access to maternal health.

7. Refine and Iterate: Based on the evaluation results, refine the recommendations and repeat the simulation process to further optimize the impact on improving access to maternal health.

It’s important to note that the methodology described above is a general framework and may need to be adapted based on the specific context and available data.


Statistics:
Citations: 24
Identifiers:
DOI: 10.1371/journal.pone.0036381
Research Areas:
Community Interventions, Environmental, Health System and Policy, Infectious Diseases, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants
Study Countries:
Angola
Study Design:
Case Study, Case-Control Study, Cohort Study, Cross Sectional Study
Study Approach:
Quantitative
Participants Gender:
Female
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