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Rapid Responses: Rapid Responses published:
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But Few Cases of HIV Transmission Averted
- James D. Shelton (12 November 2004)
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Experiences of Prevention of Mother-to-Child Transmission of HIV in Rural Tanzania
- Claire M Naftalin, Anna C Kydd and David O'Connor (19 November 2004)
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HIV/AIDS knowledge and PMTCT demand in rural Zimbabwe
- Maria Zolfo, Thérèse Delvaux , Enrica Tamburrini (29 January 2005)
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PMTCT programmes need to be based in functioning antenatal and delivery care services with good counselling
- Marge Berer (31 March 2005)
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James D. Shelton, Senior Medical Scientist Agency for International Development, Washington, DC 20523
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This is clearly a very significant undertaking, beginning with 2298 women counseled (and presumably more approached for counseling.) But with only 104 women receiving nevirapine, assuming an infection rate of about 15%, and that the nevirapine would reduce the infection rate by about 50% - that means only about 8 infections averted. Even this assumes that the drug is actually properly taken. Perhaps I am missing something, and these efforts might lead to something more. But this cannot even make a dent in the projected 60% child mortality from HIV/AIDS in Zimbabwe. Competing interests: None declared |
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Claire M Naftalin, SHO in paediatrics Homerton University Hospital NHS Trust, Homerton Row, London E9 6SR, Anna C Kydd and David O'Connor
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Editor - Although the authors report that only 23.8 % of HIV-positive pregnant women received nevirapine prophylaxis, this indicates significant progress in the prevention of mother to child transmission of HIV.(1) We have evaluated a similar pilot programme implemented in rural Tanzania. The programme involves voluntary counselling, free HIV testing and nevirapine prophylaxis integrated within a basic but comprehensive existing hospital antenatal service, achieving 70% district coverage. One year after the programme began only one mother had received nevirapine and the number of women tested was low. We undertook structured interviews with staff and conducted questionnaires with pregnant women to identify strategies to improve uptake of these services. Our findings revealed that few women were aware of their HIV status. Despite over 90% attending antenatal services, HIV counselling was offered to less than half of the 62 women questioned and only a small number (6.5%) were actually tested. Over 50% were willing to undergo HIV testing if offered. Reasons for refusing included concerns over privacy and confidentiality, stigma attached to the HIV test and “fear” of a positive result. Much emphasis has been placed on the stigma attached to a diagnosis of HIV but often less consideration is given to the role this may play in the attitudes of health care professionals. Most of those that we interviewed were reluctant to discuss the subject of HIV testing with colleagues or patients. We concluded that urgent educational interventions to reduce the unwillingness of staff to approach this subject were vital for the programme's success. The authors have addressed this issue of training of health professionals as a key strategy and results are promising with 93% of counselled women undergoing HIV testing.(1) Implementing similar changes throughout Africa is one of the challenges that must be faced in tackling paediatric HIV infection. Reference: 1. Perez F, Orne-Gliemann J, Mukotekwa T et al. Prevention of mother to child transmission of HIV: evaluation of a pilot programme in a district hospital in rural Zimbabwe.BMJ. 2004 Nov 13;329(7475):1147-50. Competing interests: None declared |
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Maria Zolfo, MD, HIV/AIDS/STD Clinic Institute of Tropical Medicine, Antwerp, Thérèse Delvaux , Enrica Tamburrini
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Dear Sir/Madam, Perez et al.[1] described the implementation of a rural HIV prevention mother-to-child transmission (PMTCT) programme in Zimbabwe, highlighting the good acceptability of HIV testing and the importance of a district approach and community participation. We would like to share our experience from a similar rural setting in Zimbabwe where up to now, after much efforts, no PMTCT intervention has taken place. Gokwe District Hospital, a governmental hospital situated in the Midlands province of Zimbabwe, was choose from Ministry of Health and Child Welfare (MoHCW) as a pilot site to start a PMTCT programme at the end of the year 2001. In August-September 2002 we conducted a short survey to assess the level of HIV/AIDS knowledge of among pregnant women and the acceptability of a PMTCT programme, before to start PMTCT implementation. Two local trained nurses administered a Shona translated standard questionnaire to 110 pregnant women starting their stay at waiting mother shelter in Gokwe, to evaluate their sociodemographics and obstetric history, the knowledge and perception of HIV infection as well as specific queries about vertical HIV transmission and PMTCT programme. The survey showed a good level of HIV/AIDS knowledge between pregnant women and a demand for a comprehensive PMTCT programme. Strengthened family planning was widely wished in case of HIV seropositivity and absence of a vertical preventive programme. After the 1st round of training in the context of the pilot project, the staff workload, in coincidence of the malaria season, delayed the possibility to amplify the training involving other members of staff. Lost the opportunity to be a pilot site, we afterwards resulted one of the 53 district hospitals in the country with access to the national MoHCW PMTCT programme. A second round of training, based on the national PMTCT guidelines, has been rolled out few months later with the involvement of the whole medical and paramedical staff. However despite the efforts made to simplify the process of providing VCT and ARV to eligible women the staff expressed perplexity about the workload needed for the implementation of the programme, postponing its achievement. No extra VCT counsellors could be hired by the national programme. A recent official report on PMTCT in Zimbabwe highlighted the disappointing uptake all over the country: in 2002 only 35 % of the identified mothers come forward for the program; for 2003 the uptake increased to 56 % but the numbers of children who come for follow up was 29 %. This limited response has been explained as fear of discrimination and stigma, lack of staff training, lack of community mobilization and male participation.[2] We have to add that the ongoing economic crisis enables women in the rural areas to attend antenatal clinics and to dispose of the health facilities. The same reason is at base of health professionals’ overseas flow, responsible of a high vacancy rate in the public health services. Our experience in Gokwe district shows that it is not even a question of uptake and performance of the programme but of starting the intervention. Even in presence of a continuous training plan, the availability of a good VCT service, and free antiretroviral drugs the PMTCT intervention has been perceived from our staff as too demanding in view of the increased workload. The lack of human resource in the public sector is a crucial key component of the complex set of interventions for PMTCT. We experienced even fear from the health providers in disclosing HIV positive status to patient because often related by family linkage or acquaintance in a small city such as Gokwe. The provider’s own fear towards the test and the fact that many staff members have not been through voluntary testing and counselling has been mentioned as a potential barrier to address the issue of VCT with the clients and adhere to the programme.[3] The kind of setting, mission hospital versus public hospital and the financial issues such as salaries/ honoraries of the staff may also play a determinant role for implementation of effective PMTCT, as well as close supervision. We share the author’s concern about the need of community involvement beside that there is much still to learn about cultural obstacles to treatment uptake. 1. Perez F, Orne-Gliemann J, Mukotekwa T, Miller A, Glenshaw M, Mahomva A, Dabis F. Prevention of mother to child transmission of HIV: evaluation of a pilot programme in a district hospital in rural Zimbabwe. BMJ 2004;329:1147-50 (13 November) 2. Zimbabwe: Limited response to PMTC programme. IRIN. UN-OCHA Integrated Regional Information Network http://www.irinnews.org/AIDSreport.asp?reportID=3535 (last accessed 28/01/05). 3. Bassett MT. Ensuring a public health impact of programs to reduce HIV transmission from mothers to infants: the place of voluntary counseling and testing. Am J Public Health 2002;92:347-51. Competing interests: None declared |
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Marge Berer, Editor Reproductive Health Matters, London NW5 1TL, UK
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It was good to read of the pilot programme for prevention of mother- to-child transmission (PMTCT) of HIV in rural Zimbabwe, with a view to scaling it up, and that there are plans for eventually providing treatment for HIV-positive pregnant women themselves. [1] I have some concerns about what is missing in the reported intervention, however. The first is the shortage of basic supplies for comprehensive antenatal care, including syphilis screening, iron tablets, folate tablets, multivitamin supplement and syndromic treatment for symptoms of sexually transmitted diseases. The second is the lack of mention of support for skilled attendance at delivery and emergency obstetric care in the district hospital where this pilot took place. The third is the lack of prioritisation of counselling which must accompany HIV testing if it to provide the support women need if they are to be expected to agree to an HIV test in a setting where stigma is such an issue. When PMTCT programmes were first set up, UNAIDS called for the limitations of antenatal and delivery care in resource-poor settings, such as rural Zimbabwe, to be improved for their own sake and in order to support PMTCT interventions. According to this paper, in Zimbabwe this has not been the case. The paper states that the stigma of HIV prevents many women from accessing the programme, but when women perceive sufficient benefit, including antiretrobiral treatment for themselves, they attend in much higher numbers. James McIntyre points out that more than two million HIV-positive women get pregnant each year globally, and that most HIV infections in women are in resource-constrained settings where the risk of maternal morbidity and mortality is also unacceptably high. There is increasing evidence that HIV-related maternal deaths are escalating considerably, and AIDS has overtaken direct obstetric causes as the leading cause of maternal mortality in some areas of high HIV prevalence. [2] In Zimbabwe, for example, pregnancy-related mortality has increased 2.5 times in parallel with the increasing AIDS epidemic. [3] If those responsible for PMTCT programmes do not work with those responsible for maternity care in countries like Zimbabwe, to ensure that antenatal and delivery care are improved for all pregnant women (among whom up to a quarter in Zimbabwe are HIV-positive), and if HIV-related treatment for HIV-positive pregnant women is not provided from the start of such programmes, rather than planned for some uncertain future date, then womenmay well not perceive the benefit. In addition, maternal deaths and morbidity will remain high and women who are HIV-positive will continue to die of AIDS younger than necessary. They will leave behind even more orphans than the millions who already exist, a somewhat higher proportion of whom may be HIV-negative but whose life chances are greatly reduced when their mothers are at an advanced stage of HIV disease or die, especially while they are still babies. [4] The safe motherhood initiative was first launched in 1987, yet many of those responsible for preventing infant deaths and PMTCT still seem not to consider maternity services and emergency obstetric care for women worthy of sufficient resources, skilled care or priority attention. A vertical, infants-first, mothers-later-or-never approach to PMTCT has proven through continuing low uptake and high mortality rates in sub- Saharan Africa not to work well enough. It took almost ten years for the PMTCT-Plus Initiative to get off the ground and start a trend towards providing treatment and care to HIV-positive pregnant women in a dozen sites in Africa. [5] Isn’ it time for all PMTCT programme interventions take these matters on board? Marge Berer Editor, Reproductive Health Matters References 1. Perez F, Orne-Gliemann J, Mukotekwa T, et al. Prevention of mother -to-child transmission of HIV: evaluation of a pilot programme in a district hospital in rural Zimbabwe. BMJ 2004;329:1147–50. 2. McIntyre J. Maternal health and HIV. Reproductive Health Matters 205;13(25). (In press). 3. Bicego G, Boerma JT, Ronsmans C. The effect of AIDS on maternal mortality in Malawi and Zimbabwe. AIDS 2002;16(7):1078–81. 4. Newell M-L, Coovadia H, Cortina-Borja M, et al. Mortality of infected and uninfected infants born to HIV-infected mothers in Africa: a pooled analysis. Lancet 2004;364:1236–43. 5. Myer L, Rabkin M, Abrams EJ, et al. Focus on women: linking HIV care and treatment with reproductive health care in the Columbia University MTCT-Plus Initiative. Reproductive Health Matters 205;13(25). (In press). Competing interests: None declared |
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