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      Outcome of Different Nevirapine Administration Strategies in Preventin g Mother-to-Child Transmission (PMTCT) Programs in Tanzania and Uganda

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          Abstract

          Objective

          Prevention-of-mother-to-child transmission (PMTCT) interventions based on single-dose nevirapine (NVP) are widely implemented in Africa, but strategies differ regarding how and when to administer the drug to women and infants. The aim of this study was to analyze the outcome of different strategies with regard to NVP intake in pregnant women and their infants in Tanzania and Uganda.

          Methods

          In an observational study carried out between March 2002 and December 2004, we compared a directly observed NVP administration strategy in Tanzania (supervised NVP intake for women and infants at a health unit) and a semi-observed administration strategy (self-administered NVP for women at home and supervised intake for infants at a health unit) in Uganda.

          Results

          The proportions of HIV-positive women accepting receipt of NVP from the health units were similar in the 2 countries (42.4% in Tanzania vs 45.6% in Uganda; P = .06). NVP intake in infants was significantly higher in Tanzania than in Uganda (43.7% vs 24.1%; P < .001). In a multivariate analysis, maternal age above 25 years, secondary education, Catholic faith, and having undergone PMTCT counseling at a hospital were independently associated with infant NVP intake.

          Conclusion

          In our settings, the directly observed administration strategy resulted in a higher NVP intake in infants. The semi-observed strategy, which implies that, after home delivery, the infant has to be presented to a health unit for NVP administration, was less successful.

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          Intrapartum and neonatal single-dose nevirapine compared with zidovudine for prevention of mother-to-child transmission of HIV-1 in Kampala, Uganda: HIVNET 012 randomised trial.

          Laura Guay, Philippa Musoke, Thomas Fleming … (1999)
          The AIDS Clinical Trials Group protocol 076 zidovudine prophylaxis regimen for HIV-1-infected pregnant women and their babies has been associated with a significant decrease in vertical HIV-1 transmission in non-breastfeeding women in developed countries. We compared the safety and efficacy of short-course nevirapine or zidovudine during labour and the first week of life. From November, 1997, to April, 1999, we enrolled 626 HIV-1-infected pregnant women at Mulago Hospital in Kampala, Uganda. We randomly assigned mothers nevirapine 200 mg orally at onset of labour and 2 mg/kg to babies within 72 h of birth, or zidovudine 600 mg orally to the mother at onset of labour and 300 mg every 3 h until delivery, and 4 mg/kg orally twice daily to babies for 7 days after birth. We tested babies for HIV-1 infection at birth, 6-8 weeks, and 14-16 weeks by HIV-1 RNA PCR. We assessed HIV-1 transmission and HIV-1-free survival with Kaplan-Meier analysis. Nearly all babies (98.8%) were breastfed, and 95.6% were still breastfeeding at age 14-16 weeks. The estimated risks of HIV-1 transmission in the zidovudine and nevirapine groups were: 10.4% and 8.2% at birth (p=0.354); 21.3% and 11.9% by age 6-8 weeks (p=0.0027); and 25.1% and 13.1% by age 14-16 weeks (p=0.0006). The efficacy of nevirapine compared with zidovudine was 47% (95% CI 20-64) up to age 14-16 weeks. The two regimens were well tolerated and adverse events were similar in the two groups. Nevirapine lowered the risk of HIV-1 transmission during the first 14-16 weeks of life by nearly 50% in a breastfeeding population. This simple and inexpensive regimen could decrease mother-to-child HIV-1 transmission in less-developed countries.
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            Antenatal couple counseling increases uptake of interventions to prevent HIV-1 transmission.

            Carey Farquhar, James N. Kiarie, Barbra Richardson … (2004)
            To determine effect of partner involvement and couple counseling on uptake of interventions to prevent HIV-1 transmission, women attending a Nairobi antenatal clinic were encouraged to return with partners for voluntary HIV-1 counseling and testing (VCT) and offered individual or couple posttest counseling. Nevirapine was provided to HIV-1-seropositive women and condoms distributed to all participants. Among 2104 women accepting testing, 308 (15%) had partners participate in VCT, of whom 116 (38%) were couple counseled. Thirty-two (10%) of 314 HIV-1-seropositive women came with partners for VCT; these women were 3-fold more likely to return for nevirapine (P = 0.02) and to report administering nevirapine at delivery (P = 0.009). Nevirapine use was reported by 88% of HIV-infected women who were couple counseled, 67% whose partners came but were not couple counseled, and 45%whose partners did not present for VCT (P for trend = 0.006). HIV-1-seropositive women receiving couple counseling were 5-fold more likely to avoid breast-feeding (P = 0.03) compared with those counseled individually. Partner notification of HIV-1-positive results was reported by 138 women (64%) and was associated with 4-fold greater likelihood of condom use (P = 0.004). Partner participation in VCT and couple counseling increased uptake of nevirapine and formula feeding. Antenatal couple counseling may be a useful strategy to promote HIV-1 prevention interventions.
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              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.

              E Bakali, J Kazima, M. Manzi … (2005)
              Thyolo District Hospital, rural Malawi. In a prevention of mother-to-child HIV transmission (PMTCT) programme, to determine: the acceptability of offering 'opt-out' voluntary counselling and HIV-testing (VCT); the progressive loss to follow up of HIV-positive mothers during the antenatal period, at delivery and to the 6-month postnatal visit; and the proportion of missed deliveries in the district. Cohort study. Review of routine antenatal, VCT and PMTCT registers. Of 3136 new antenatal mothers, 2996 [96%, 95% confidence interval (CI): 95-97] were pre-test counselled, 2965 (95%, CI: 94-96) underwent HIV-testing, all of whom were post-test counselled. Thirty-one (1%) mothers refused HIV-testing. A total of 646 (22%) individuals were HIV-positive, and were included in the PMTCT programme. Two hundred and eighty-eight (45%) mothers and 222 (34%) babies received nevirapine. The cumulative loss to follow up (n=646) was 358 (55%, CI: 51-59) by the 36-week antenatal visit, 440 (68%, CI: 64-71) by delivery, 450 (70%, CI: 66-73) by the first postnatal visit and 524 (81%, CI: 78-84) by the 6-month postnatal visit. This left just 122 (19%, CI: 16-22) of the initial cohort still in the programme. The great majority (87%) of deliveries occurred at peripheral sites where PMTCT was not available. In a rural district hospital setting, at least 9 out of every 10 mothers attending antenatal services accepted VCT, of whom approximately one-quarter were HIV-positive and included in the PMTCT programme. The progressive loss to follow up of more than three-quarters of this cohort by the 6-month postnatal visit demands a 'different way of acting' if PMTCT is to be scaled up in our setting.
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                Author and article information

                Journal
                Journal ID (nlm-ta): J Int AIDS Soc
                Title: Journal of the International AIDS Society
                Publisher: BioMed Central
                ISSN (Electronic): 1758-2652
                Publication date Collection: 2006
                Publication date (Electronic): 12 April 2006
                Volume: 8
                Page: 12
                Affiliations
                [1 ]research associate, GTZ PMTCT Project, Institute of Tropical Medicine and International Health, Charité-University Medicine, Berlin, Germany
                [2 ]Associate Professor of Epidemiology, Department of Infectious Disease Epidemiology, Robert Koch-Institute, Berlin, Germany
                [3 ]project coordinator, MoH/GTZ PMTCT Programme, Mbeya Region, Mbeya, Tanzania
                [4 ]project coordinator, MoH/GTZ PMTCT Programme, Western Uganda, Fort Portal, Uganda
                [5 ]Professor of Tropical Medicine; international coordinator, GTZ PMTCT Project, Institute of Tropical Medicine and International Health, Charité-University Medicine, Berlin, Germany
                Article
                Publisher ID: 1758-2652-8-2-12
                DOI: 10.1186/1758-2652-8-2-12
                PMC ID: 2759601
                PubMed ID: 19825137
                SO-VID: 465a091f-1817-4227-b839-6bc0d4845f8c
                History
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                Subject: Research

                ScienceOpen disciplines: Infectious disease & Microbiology
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                ScienceOpen disciplines: Infectious disease & Microbiology

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