Quality issues ruining HIV strategy

Evaluating project to stop mothers from transmitting HIV to their babies

  In September 2012, Uganda launched a new HIV prevention strategy that prevents transmission of the virus from a mother to her child during pregnancy, child birth and thereafter. In its first year, the strategy, known as Option B+, registered a big success in reducing mother-to-child HIV infections.Anne Mugisa looks at the few hitches that may threaten our best ever shot at curbing HIV in this decade.  

The new strategy for prevention of mother-to-child transmission (PMTCT) of HIV has paid off handsomely. According to a recent report by a team of technical staff from the Ministry of Health and non-governmental organisations, Option B+ has reduced HIV infection in babies by 80%.

It was cause for celebration on December 1, last year’s World AIDS Day. What is Option B+? Option B+ is a prevention strategy that aims at elimination of mother-to-child transmission of HIV. It involves putting pregnant HIV-positive women on HIV treatment for life, regardless of their CD4 count. ARVs effectively stop HIV progression in pregnant women, thus eliminating its transmission risk. The move protects babies and HIV-negative husbands from contracting the virus from infected women. According to the Ministry of Health report, only Uganda and Malawi have scaled up Option B+ in the world. So far, the results are mpressive.

Background

PMTCT started in 2000, when a research in Uganda discovered that the drug, Nevirapine, could prevent HIV transmission from pregnant mothers to their children. However, only selected health facilities in the country could offer the services. Even then, only HIV+ pregnant women, whose CD4 count was 350 and below, got the treatment.

Those whose CD4 count was above 350 were also given the treatment, but this was stopped sometime after delivery. Statistics in the Ministry of Health show that as of June 2012, only 68% of pregnant women, who tested positive for HIV, received ARVs to prevent transmission of the virus to their babies and only 38% of their babies received ARV treatment after birth.The 2011 Uganda AIDS Indicator Survey, which put the HIV prevalence in the country at 7.3%, up from 6.4% in 2005, also indicated that prevalence was higher in women at 8.6% than in men at 6.1%.

According to the indicator survey, 356 people in Uganda contracted HIV every day and that annual infections stood at 130,000. Of the 130,000, about 22,000 were babies who got the infection from their mothers. Dr. Patrick Ndase, an expert on HIV, says a pregnant woman can transmit HIV to her child during the nine months of pregnancy, if the virus passes through the inflamed placenta into the foetus.

“The baby can also get the infection from the mother’s fluids during birth or later, through close interaction, breast milk and accidents,” he said. Treatment of the mother with ARVs reduces the risk of all this, Ndase said. In 2012, Option B+ was introduced through funding from the US Presidential Emergency Plan For AIDS Relief (PEPFAR).

HIV treatment of all pregnant mothers was spread to sites formally not providing Antiretroviral Therapy. Pregnant mothers who test HIV + get the essential drugs free as they wait for full accreditation to ARVs from supplying centres. Appraising Option B+ Last year, a team from the Ministry of Health and non-governmental organisations commissioned an evaluation of the Option B+ to find out whether it could be sustained.

The findings were released in September last year. While the findings were impressive and Option B+ was being celebrated as a success, the report raised concerns that could spoil the party. First, the report discovered incidents of avoidable drug stock-outs, where 49% of Option B+ sites reported running out of rapid HIV test kits, while 20% reported stock outs of ARVs. When ARVs run out at health centres and are not replenished immediately, mothers miss doses and face the danger of disease progression, drug resistance and treatment failure.

In other cases, mothers who left the health centre after delivery did not return for their ARVs or report to the nearest treatment centres that they were recommended to. In many areas, the evaluation committee found a lack of adequate community support to mothers on treatment. They discovered stigma, unfriendly treatment services and schedules, poor feeding, lack of family involvement and general motivation.

This affects women’s adherence to ARVs, forcing them to fall off HIV treatment, says the report. “As it is now,” the report states, “more than half of the Option B+ implementers have failed to provide two of the most essential elements, adherence support and programmes to ensure patients are retained in care.” To explain the problem, the report shows that only 47% of Option B+ sites were ensuring that mothers and babies were not lost to follow-up; adherence support for mothers and babies was occurring in only 51% of Option B+ sites; and that only 49% of the community groups, designed to provide psychosocial support to Option B+ patients, were active.

In addition, the report stated, many Option B+ sites were transferring new mothers from ante-natal care clinic sites, where they were initiated on treatment, to Antiretroviral Therapy clinics, like health centre IVs, at only six weeks after delivery. As a result, mothers and babies get lost to follow-up, which increases chances of mother-to-child transmission. The report noted that only 34% of Option B+ sites were routinely reporting data in real time on indicators, such as the number of patientsthrough the inflamed placenta into the foetus. “The baby can also get the infection from the mother’s fluids during birth or later, through close interaction, breast milk and accidents,” he said.

Treatment of the mother with ARVs reduces the risk of all this, Ndase said. In 2012, Option B+ was introduced through funding from the US Presidential Emergency Plan For AIDS Relief (PEPFAR). HIV treatment of all pregnant mothers was spread to sites formally not providing Antiretroviral Therapy. Pregnant mothers who test HIV + get the essential drugs free as they wait for full accreditation to ARVs from supplying centres.

Appraising Option B+ Last year, a team from the Ministry of Health and non-governmental organisations commissioned an evaluation of the Option B+ to find out whether it could be sustained. The findings were released in September last year. While the findings were impressive and Option B+ was being celebrated as a success, the report raised concerns that could spoil the party. First, the report discovered incidents of avoidable drug stock-outs, where 49% of Option B+ sites reported running out of rapid HIV test kits, while 20% reported stock outs of ARVs.

When ARVs run out at health centres and are not replenished immediately, mothers miss doses and face the danger of disease progression, drug resistance and treatment failure. In other cases, mothers who left the health centre after delivery did not return for their ARVs or report to the nearest treatment centres that they were recommended to. In many areas, the evaluation committee found a lack of adequate community support to mothers on treatment.

They discovered stigma, unfriendly treatment services and schedules, poor feeding, lack of family involvement and general motivation. This affects women’s adherence to ARVs, forcing them to fall off HIV treatment, says the report. “As it is now,” the report states, “more than half of the Option B+ implementers have failed to provide two of the most essential elements, adherence support and programmes to ensure patients are retained in care.”

To explain the problem, the report shows that only 47% of Option B+ sites were ensuring that mothers and babies were not lost to follow-up; adherence support for mothers and babies was occurring in only 51% of Option B+ sites; and that only 49% of the community groups, designed to provide psychosocial support to Option B+ patients, were active. In addition, the report stated, many Option B+ sites were transferring new mothers from ante-natal care clinic sites, where they were initiated on treatment, to Antiretroviral Therapy clinics, like health centre IVs, at only six weeks after delivery.

As a result, mothers and babies get lost to follow-up, which increases chances of mother-to-child transmission. The report noted that only 34% of Option B+ sites were routinely reporting data in real time on indicators, such as the number of patients alive on treatment to PEPFAR. Reporting on these indicators is considered ‘mandatory.’ According to the report, what is needed is for Uganda to take corrective measures on implementation of Option B+. Dividends from Option B+ can be realised if all implementing health facilities are mandated to provide pregnant women enrolled on treatment, with the essential components of effective programs. The appraisal called for a uniform model of Option B+ service delivery by all partners.

“Some facilities are relying on village health teams, rather than the recommended HIV-positive mentor mothers, to do patient tracking and follow up,” it states. “Village health teams lack expertise to address complex and critical issues regarding disclosure, stigma and confidentiality. It is imperative that community workers, whom patients can trust as supportive, informed and non-judgmental, are deployed for non-facility-based support.

Otherwise, women will drop out of care, avoidable transmissions, which will lead to disease progression.” Asia Russell, the officer in Health Global Access Project, a health advocates organisation in Uganda, says there are enough funds to build up quality programmes, so the apparent lack of prioritisation of quality issues cannot be excused. “PEPFAR is providing $20m (about sh50b) annually, which should be enough for Option B+,” she says.

“There will be consequences if quality assurance is neglected.” “Option B+ will not deliver the viral suppression pregnant women need for their health and that of that of the baby,” Russell added. She says the Government, PEPFAR and donors need to communicate urgently to all implementers about the programme components Option B+ requires and how the Government will monitor compliance.

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Pregnant mothers are put on Option B+ to prevent infecting the foetus

Recommendations 

1. All facilities should implement mandatory retention and adherence support programmes, including home visits and active referrals by trained, supported and monitored community health workers.

2. All facilities should use HIV-positive mentor mothers, who are trained, supervised and compensated. Village health teams alone are not sufficient at this stage, given the complex disclosure and stigma issues pregnant women experience in their homes, with their husbands or sex partners and in their communities.

3. All implementers should adopt a uniform model of service delivery, which is communicated in a formal circular, based on the core components described above.

4. New mothers should be retained in care at the facility where they were initiated, until 18 months. Referrals at six weeks to Antiretroviral Therapy clinics should be stopped immediately. The head of the Joint Clinical Research Centre, Prof. Peter Mugyenyi, says Option B+ is critical. He urged the Government needs to ensure its success and spread it to communities in hard-to-reach areas.

What to know about HIV and pregnancy

HIV-postive mothers can transmit HIV to their babies. This is called mother-to-child transmission. It can happen during pregnancy, during vaginal childbirth and through breastfeeding. However, with proper treatment on ARVs, the risk can be significantly reduced.

An HIV-positive mother who is not on ARVs, has a 25% chance (1 in 4) of passing the virus to her baby. But if she receives ARVs during pregnancy, labour, and delivery; has her baby by Caesarean section; and avoids breastfeeding, the chance of passing the infection to her baby falls to less than 2% (fewer than 2 in 100). The newborn babies are also given treatment after birth to protect them.

Therefore, the best gift you can give your baby is to get tested during antenatal visits and if you find yourself with the virus, you start ARVs immediately. However, you should also avoid smoking, substance abuse, Vitamin A deficiency, malnutrition, infections such as STDs and high viral load in your blood. If you are HIV-positive, your baby should also be tested for HIV. However, the test used for babies of HIV-positive mothers is a little different from other HIV tests.

Most HIV tests look for antibodies to HIV, not the virus itself. But these tests are not very useful for babies born to HIV-positive mothers. That is because the mother’s HIV antibodies get into the baby’s blood during pregnancy. If the mother is HIV-positive, the regular HIV test will show that the baby is HIV-positive, even when that is not the case. Healthcare providers can use special HIV tests on children who are younger than 18 months.

These tests can detect small quantities of the virus in the children’s blood. At a minimum, babies born to HIV-positive mothers should be tested at three different times: At 14 to 21 days after birth, at one to two months of age and at three to six months of age.

If all three of these tests are negative for HIV, then the baby is most likely free of HIV. But if any of the above tests are positive, then another test is done. If two of the tests are positive, then the baby is infected with HIV. Even if the tests show that your baby does not have HIV, it is still safer for the baby to receive long-term follow-up care by a healthcare provider.