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      The implications of policy changes on the uptake of a PMTCT programme in rural Malawi: first three years of experience

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          Abstract

          Objective

          To study the implications of policy changes on the demand for antenatal care (ANC), HIV testing and hospital delivery among pregnant women in rural Malawi.

          Design

          Retrospective analysis of monthly reports.

          Setting

          Malamulo SDA hospital in Thyolo district, Makwasa, Malawi.

          Methods

          Three hospital-based registers were analysed from 2005 to 2007. These were general ANC, delivery and Prevention of Mother to Child Transmission (PMTCT) registers. Observations were documented regarding the introduction of specific policies and when changes were effected. Descriptive analytical methods were used.

          Results

          The ANC programme reached 4,528 pregnant mothers during the study period. HIV testing among the ANC attendees increased from 52.6 to 98.8% after the introduction of routine (opt-out) HIV testing and 15.6% of them tested positive. After the introduction of free maternity services, ANC attendance increased by 42% and the ratio of hospital deliveries to ANC attendees increased from 0.50:1 to 0.66:1. Of the HIV-tested ANC attendees, 52.6% who tested positive delivered in the hospital and got nevirapine at the time of delivery.

          Conclusions

          Increasing maternity service availability and uptake can increase the coverage of PMTCT programmes. Barriers such as economic constraints that prevent women in poor communities from accessing services can be removed by making maternity services free. However, it is likely, particularly in resource-poor settings, that significant increases in PMTCT coverage among those at risk can only be achieved by substantially increasing uptake of general ANC and delivery services.

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          Most cited references38

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          Prevention of mother-to-child HIV transmission in resource-poor countries: translating research into policy and practice.

          K M De Cock, M Fowler, E Mercier … (2000)
          Each year, an estimated 590,000 infants acquire human immunodeficiency virus type 1 (HIV) infection from their mothers, mostly in developing countries that are unable to implement interventions now standard in the industrialized world. In resource-poor settings, the HIV pandemic has eroded hard-won gains in infant and child survival. Recent clinical trial results from international settings suggest that short-course antiretroviral regimens could significantly reduce perinatal HIV transmission worldwide if research findings could be translated into practice. This article reviews current knowledge of mother-to-child HIV transmission in developing countries, summarizes key findings from the trials, outlines future research requirements, and describes public health challenges of implementing perinatal HIV prevention interventions in resource-poor settings. Public health efforts must also emphasize primary prevention strategies to reduce incident HIV infections among adolescents and women of childbearing age. Successful implementation of available perinatal HIV interventions could substantially improve global child survival.
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            Mother-to-child transmission of HIV-1 infection during exclusive breastfeeding in the first 6 months of life: an intervention cohort study.

            Hoosen Coovadia, Nigel Rollins, Ruth Bland … (2007)
            Exclusive breastfeeding, though better than other forms of infant feeding and associated with improved child survival, is uncommon. We assessed the HIV-1 transmission risks and survival associated with exclusive breastfeeding and other types of infant feeding. 2722 HIV-infected and uninfected pregnant women attending antenatal clinics in KwaZulu Natal, South Africa (seven rural, one semiurban, and one urban), were enrolled into a non-randomised intervention cohort study. Infant feeding data were obtained every week from mothers, and blood samples from infants were taken monthly at clinics to establish HIV infection status. Kaplan-Meier analyses conditional on exclusive breastfeeding were used to estimate transmission risks at 6 weeks and 22 weeks of age, and Cox's proportional hazard was used to quantify associations with maternal and infant factors. 1132 of 1372 (83%) infants born to HIV-infected mothers initiated exclusive breastfeeding from birth. Of 1276 infants with complete feeding data, median duration of cumulative exclusive breastfeeding was 159 days (first quartile [Q1] to third quartile [Q3], 122-174 days). 14.1% (95% CI 12.0-16.4) of exclusively breastfed infants were infected with HIV-1 by age 6 weeks and 19.5% (17.0-22.4) by 6 months; risk was significantly associated with maternal CD4-cell counts below 200 cells per muL (adjusted hazard ratio [HR] 3.79; 2.35-6.12) and birthweight less than 2500 g (1.81, 1.07-3.06). Kaplan-Meier estimated risk of acquisition of infection at 6 months of age was 4.04% (2.29-5.76). Breastfed infants who also received solids were significantly more likely to acquire infection than were exclusively breastfed children (HR 10.87, 1.51-78.00, p=0.018), as were infants who at 12 weeks received both breastmilk and formula milk (1.82, 0.98-3.36, p=0.057). Cumulative 3-month mortality in exclusively breastfed infants was 6.1% (4.74-7.92) versus 15.1% (7.63-28.73) in infants given replacement feeds (HR 2.06, 1.00-4.27, p=0.051). The association between mixed breastfeeding and increased HIV transmission risk, together with evidence that exclusive breastfeeding can be successfully supported in HIV-infected women, warrant revision of the present UNICEF, WHO, and UNAIDS infant feeding guidelines.
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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): Glob Health Action
                Journal ID (publisher-id): GHA
                Title: Global Health Action
                Publisher: CoAction Publishing
                ISSN (Print): 1654-9716
                ISSN (Electronic): 1654-9880
                Publication date (Electronic): 23 January 2009
                Publication date Collection: 2009
                Volume: 2
                Electronic Location Identifier: 10.3402/gha.v2i0.1883
                Affiliations
                [1 ]Malamulo SDA Hospital, Makwasa, Malawi
                [2 ]Department of Public Health and Clinical Medicine, Umeå International School of Public Health, Epidemiology and Public Health Sciences, Umeå University, Sweden
                Author notes
                [* ] Anna-Karin Hurtig, Department of Public Health and Clinical Medicine, Umeå International School of Public Health, Epidemiology and Public Health Sciences, Umeå University, 901 85 Umeå, Sweden. Tel: +46 90 785 11 64, Fax: +46 90 13 89 77, Email: Anna-Karin.Hurtig@ 123456epiph.umu.se
                Article
                Publisher ID: GHA-2-1883
                DOI: 10.3402/gha.v2i0.1883
                PMC ID: 2779935
                PubMed ID: 20027274
                SO-VID: b04ebbd5-feb7-48fc-aed8-3a814d016c5b
                Copyright © © 2009 Fyson Kasenga et al
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution-Noncommercial 3.0 Unported License, permitting all non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 18 September 2008
                Date revision received : 27 November 2008
                Date accepted : 17 December 2008
                Categories
                Subject: Original Article

                ScienceOpen disciplines: Health & Social care
                Keywords: health policy,antenatal care,pmtct,health service demand,malawi
                Data availability:
                ScienceOpen disciplines: Health & Social care
                Keywords: health policy, antenatal care, pmtct, health service demand, malawi

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