Date Published: March 13, 2019
Publisher: Public Library of Science
Author(s): Brian Komtenza, Srinath Satyanarayana, Kudakwashe C. Takarinda, Solomon H. Mukungunugwa, Owen Mugurungi, Prosper Chonzi, Ngwarai Sithole, Talent Bvochora, Angela Mushavi, Julie AE Nelson.
Despite high antiretroviral (ARV) treatment coverage among pregnant women for prevention of mother-to-child transmission (PMTCT) of Human Immunodeficiency Virus (HIV) in Zimbabwe, the MTCT rate is still high. Therefore in 2016, the country adopted World Health Organization recommendations of stratifying pregnant women into “High” or”Low” MTCT risk for subsequent provision of HIV exposed infant (HEI) with appropriate follow-up care according to risk status.
The study sought to ascertain, among pregnant women who delivered in clinics of Harare in August 2017: the extent to which high risk MTCT pregnancies were identified at time of delivery; and whether their newborns were initiated on appropriate ARV prophylaxis, cotrimoxazole prophylaxis, subjected to early HIV diagnostic testing and initiated on ARV treatment.
Cross-sectional study using review of records of routinely collected program data.
Of the 1,786 pregnant women who delivered in the selected clinics, HIV status at the time of delivery was known for 1,756 (98%) of whom 197 (11%) were HIV seropositive. Only 19 (10%) could be classified as “high risk” for MTCT and the remaining 90% lacked adequate information to classify them into high or low risk for MTCT due to missing data. Of the 197 live births, only two (1%) infants had a nucleic-acid test (NAT) at birth and 32 (16%) infants had NAT at 6 weeks. Of all 197 infants, 183 (93%) were initiated on single ARV prophylaxis (Nevirapine), 15 (7%) infants’ ARV prophylaxis status was not documented and one infant got dual ARV prophylaxis (Nevirapine+Zidovudine).
There was paucity of data requisite for MTCT risk stratification due to poor recording of data; “high risk” women were missed in the few circumstances where sufficient data were available. Thus “high risk” HEI are deprived of dual ARV prophylaxis and priority HIV NAT at birth and onwards which they require for PMTCT. Health workers need urgent training, mentorship and supportive supervision to master data management and perform MTCT risk stratification satisfactorily.
Most of the 1.8 million human immunodeficiency virus (HIV) infected children are in sub-Saharan Africa , where the majority (~90%) acquired infection through mother-to-child transmission (MTCT) either during pregnancy, at the time of delivery or during breastfeeding. As one of the strategies to end the global AIDS epidemic by 2030, it is necessary to eliminate new HIV infections in children.
Of the1786 pregnant women who delivered in 12 delivery clinics of Harare city in August 2017, HIV status at the time of delivery was known for 1756 (98%) of whom 197 (11%) were HIV seropositive see Fig 1. The characteristics of these women are described in Table 1.
This is one of the first studies reporting the status of implementing the latest national guidelines on high-risk assessment for PMTCT of HIV infection at the time of delivery and follow-up infant management during the post partum period. The HIV testing levels are high (as per the national guidelines) with 98% of the pregnant women’s HIV serostatus known at the time of delivery. Nearly all HIV seropositive pregnant women were on ART at the time of delivery. More than 90% of the HIV exposed infants were initiated on ARV prophylaxis, with almost all initiated on 6 weeks of nevirapine. However, none of the women were classified into high risk or low risk in all clinics. Due to insufficient information recorded, it was not possible for us to classify all pregnancies into high risk or low risk and assess whether the infants received correct ARV prophylaxis or not. The few high risk HEI (that we identified) did not receive 12 weeks of AZT+NVP (as per the guidelines) while one infant in the unclassified risk group got 12 weeks of AZT+NVP. The few “high risk” mothers identified by the study were missed by the clinics despite availability of adequate data (ART naïve status at delivery) at the clinics which more likely indicates poor implementation of the new 2016 PMTCT guidelines. In addition, the proportion of infants tested with NAT at birth and at 6 weeks and the proportion that were initiated on cotrimoxazole prophylaxis at 6 weeks, were negligible. This indicating serious gaps in providing appropriate clinical care, tracking, monitoring and evaluation.
Data management was poor, in particular incomplete recording of program registers and absence of clear mother-baby pair tracking and tracing mechanisms across different health delivery facilities. There were no records for viral load, sero-conversion and 90% of study participants lacked adequate information to classify them as either “high” or “low” risk MTCT. There are several gaps in implementing the PMTCT services as per the 2016 national PMTCT guidelines at the 12 delivery clinics in Harare city. In particular, there is a huge gap in identifying high risk pregnant women thus their babies are denied high risk reduction interventions like twelve weeks of dual ARV prophylaxis and priority access to HIV NAT at birth. The gaps in data management and PMTCT service provision can be addressed by urgent provision of on-going health worker training, mentorship and supportive supervision on data management and PMTCT service delivery like MTCT risk stratification, EID, infant ARV prophylaxis respectively. In the long term, introduction of an electronic health information management system which can link and share health information between facilities, laboratories, pharmacy and the Ministry of health will improve data management.