Successes and challenges of the national programme for the prevention of mother-to-child HIV transmission (PMTCT) in Addis Ababa, Ethiopia. Implementation and impact

Abstract

Mother-to-child HIV transmission (MTCT) is the main source of HIV infection among children under the age of 15. The majority of these transmissions occur in utero and during the intra-partum period and are associated with high rate of mortality in the first year of life. Virtual elimination of peri-natal HIV transmission has become the global target following the availability of highly efficacious prophylactic medications. However, persistent programmatic challenges where the epidemic is most severe are threatening the realization of the target. These challenges include unsolved issues related to HIV testing, ensuring access and adherence to prophylaxis medication, access to safe delivery services, access to infant follow up and partner involvement in PMTCT programmes. This thesis aims at addressing these issues and to assess the impact of the national PMTCT programme in Addis Ababa, the capital of Ethiopia. The study uses cross-sectional, mixed methods and prospective cohort designs. Retrospective data were collected in 2009 from the national PMTCT programme in Addis Ababa. In the cross-sectional design, 663,603 pregnant mothers attending a national PMTCT programme across the city over a six years period were studied. Trends in PMTCT service utilization were analysed, and the rate of MTCT was assessed in relation to changes in HIV testing policy and changes in prophylactic medication regimen. In the mixed methods design, focus group discussions were conducted first to inform a Theory of Planned Behaviour (TPB) questionnaire. The TPB was applied to explain intended and actual HIV testing. Three thousand and thirty three first time antenatal attendees completed the baseline TPB interviews and 2,928 completed their follow up. The prospective cohort study enrolled 282 HIV-positive mothers. The study assessed the proportions of mothers and infants who adhered to medication recommendations and exposed infants follow up. In the same cohort, the rate of intra-partum transfers and associated adverse outcomes were assessed among the 228 mothers who reported to have given birth. In the trend analysis a year by year increase in the proportion of mothers receiving HIV counselling and testing was observed between 2004 and 2009. In parallel with the increased number of mothers receiving HIV testing, the HIV prevalence showed a steady decline. Substantial increase in HIV testing occurred following the shift to routine opt-out approach. The data collected using the mixed methods design following the implementation of opt-out testing approach revealed that intention and type of pre-test counselling/information received were independent, significant determinants of HIV testing. Further analysis showed that the majority of mothers who had low intention to test were also tested. Positive attitude towards HIV testing and approval from social network were significant determinants of intended use of HIV testing. In the trend analysis the proportions of mothers and infants receiving medication for prophylaxis did not show progress over the years. One year after the shift to routine opt-out approach, only 53% of the mothers and 47% of the infants had received medication. The cohort data further revealed gaps in initiating medication during pregnancy (82%) and ingestion of the medication at birth by mother-infant pairs (68%). Delivering at a health facility was an independent determinant of mother-infant pairs’ ingestion of medication at birth. Overall, 75% of the mothers in the cohort gave birth at emergency obstetric and neonatal care (EmONC) facilities and 42% of them were transferred between facilities during the intra-partum period. Multiple transfers happened to 36% of the mothers due to practical constraints within the health system. Mothers in their second pregnancy were less likely to be transferred than mothers in their first pregnancy. The rate of stillbirths was high. Transferred mothers were about six times more likely to experience stillbirth than mothers who did not. There was no significant association between stillbirth and syphilis test result, mothers’ CD4 cell count and initiating lifelong ART. Both the trend and the cohort data showed sub-optimal infant follow up services. A small proportion of the exposed infants were HIV tested. The cumulative HIV infections among babies on single dose nevirapine (sdNVP) regimen who were tested at 18 months were 14.9% in 2007. In 2009, among infants on combined ZDV regimen the rates of MTCT were 8.2% and 8.4% at six weeks postpartum in the trend data and in the cohort respectively. The proportion of partners involved in PMTCT programme remained low. In the cohort the majority of the HIV-positive mothers had disclosed their HIV sero-status to their partner and about one-third of the partners who underwent HIV testing were sero-discordant. The PMTCT programme has expanded rapidly and has been accompanied by an increased rate of testing. However, the performance of the health system was inadequate in providing subsequent PMTCT services for HIV-positive mothers. Missed opportunities to prophylactic medication uptake, intra-partum care, infant follow up and partner involvement in the PMTCT programme could undermine the effectiveness of the PMTCT programme and negatively impact the survival of exposed infants. This should be a matter of immediate concern and a topic of further research.