Date Published: July 12, 2017
Publisher: Public Library of Science
Author(s): Anna Gamell, Lameck Bonaventure Luwanda, Aneth Vedastus Kalinjuma, Leila Samson, Alex John Ntamatungiro, Maja Weisser, Winfrid Gingo, Marcel Tanner, Christoph Hatz, Emilio Letang, Manuel Battegay, Charlotte Charpentier.
Strategies to improve the uptake of Prevention of Mother-To-Child Transmission of HIV (PMTCT) are needed. We integrated HIV and maternal, newborn and child health services in a One Stop Clinic to improve the PMTCT cascade in a rural Tanzanian setting.
The One Stop Clinic of Ifakara offers integral care to HIV-infected pregnant women and their families at one single place and time. All pregnant women and HIV-exposed infants attended during the first year of Option B+ implementation (04/2014-03/2015) were included. PMTCT was assessed at the antenatal clinic (ANC), HIV care and labour ward, and compared with the pre-B+ period. We also characterised HIV-infected pregnant women and evaluated the MTCT rate.
1,579 women attended the ANC. Seven (0.4%) were known to be HIV-infected. Of the remainder, 98.5% (1,548/1,572) were offered an HIV test, 94% (1,456/1,548) accepted and 38 (2.6%) tested HIV-positive. 51 were re-screened for HIV during late pregnancy and one had seroconverted. The HIV prevalence at the ANC was 3.1% (46/1,463). Of the 39 newly diagnosed women, 35 (90%) were linked to care. HIV test was offered to >98% of ANC clients during both the pre- and post-B+ periods. During the post-B+ period, test acceptance (94% versus 90.5%, p<0.0001) and linkage to care (90% versus 26%, p<0.0001) increased. Ten additional women diagnosed outside the ANC were linked to care. 82% (37/45) of these newly-enrolled women started antiretroviral treatment (ART). After a median time of 17 months, 27% (12/45) were lost to follow-up. 79 women under HIV care became pregnant and all received ART. After a median follow-up time of 19 months, 6% (5/79) had been lost. 5,727 women delivered at the hospital, 20% (1,155/5,727) had unknown HIV serostatus. Of these, 30% (345/1,155) were tested for HIV, and 18/345 (5.2%) were HIV-positive. Compared to the pre-B+ period more women were tested during labour (30% versus 2.4%, p<0.0001). During the study, the MTCT rate was 2.2%. The implementation of Option B+ through an integrated service delivery model resulted in universal HIV testing in the ANC, high rates of linkage to care, and MTCT below the elimination threshold. However, HIV testing in late pregnancy and labour, and retention during early ART need to be improved.
Mother-To-Child Transmission (MTCT) accounts for over 90% of new paediatric HIV infections . The World Health Organization (WHO) has issued several prevention of MTCT (PMTCT) recommendations for low and middle-income countries since 2001 [2,3]. As a result of the scale-up of PMTCT interventions, there has been a 70% decline of new HIV infections among children between 2000 and 2015 . However, in 2015, 23% of HIV-infected pregnant women did not receive effective antiretroviral regimens for PMTCT and 150,000 children acquired HIV .
This is a prospective cohort study describing the PMTCT cascade and uptake of Option B+ guidelines in the SFRH. The uptake of PMTCT recommendations was compared with the one previously described in 2012 . We also assessed the MTCT rate, characterised HIV-infected mothers and analyzed the differences between newly diagnosed pregnant women and women who became pregnant while being under HIV care.
This is the first study to evaluate the Option B+ cascade in Tanzania. Option B+ delivered through the One Stop Clinic model dramatically improved linkage to HIV care after diagnosis in the ANC and resulted in over 90% of enrolled women receiving ART. Retention throughout the PMTCT pathway was challenging for newly diagnosed HIV-infected pregnant women. The observed MTCT rate (2.2%) was below the national average (9%) and the threshold established for elimination of MTCT of HIV in breastfeeding populations (5%) . Nevertheless, gaps such as the poor uptake of HIV testing in the labour ward and an almost inexistent HIV re-screening during late pregnancy remained and need to be urgently addressed.
In summary, Option B+ was successfully implemented in this rural African setting through an integrated service delivery model. Most diagnosed women were linked into HIV care, received appropriate ART and the MTCT rate was below 5%. However, important testing gaps that may have left women undiagnosed were observed. The One Stop Clinic is a feasible, inexpensive and scalable Option B+ delivery model that could be extrapolated to similar rural settings. Despite the success, caution is warranted and additional strategies to ensure universal HIV testing for pregnant and delivering women and to improve early ART retention of newly diagnosed women are crucially needed.