The significant increase in
access to antiretroviral therapy for all pregnant women living with HIV in
Malawi after implementation of Option B+ contrasts with low coverage of early
infant diagnosis (EID) and uptake of cotrimoxazole prophylaxis in HIV-exposed
infants, Priscilla Idele of UNICEF told delegates on Wednesday at the 20th
International AIDS Conference (AIDS 2014) in Melbourne.
She was presenting results of
a four-country assessment of health system performance following the
implementation of the World Health Organization’s 2010 guidelines for the
prevention of mother-to-child HIV transmission.
The study found substantial
variations in performance between countries, and gaps between performance in
testing and provision of antiretrovirals to mothers, and testing of HIV-exposed
In 2010, the World Health Organization (WHO) recommended that
countries should move to providing one of two antiretroviral options for
prevention of mother-to-child transmission (PMTCT) for mothers not eligible for
antiretroviral therapy for their own health:
A: zidovudine from week 14 of pregnancy, single-dose nevirapine for mother and
infant at the time of delivery and zidovudine with lamivudine during
delivery and for one week after delivery.
- Option B:
a triple-drug regimen until one week after breastfeeding has ended; all infants
regardless of feeding mode nevirapine or zidovudine for four to six weeks.
In Malawi, public health
officials decided to adopt Option B+ – a simplified public health approach to
prevent vertical HIV transmission while protecting the health of women, by
providing antiretroviral therapy (ART) for life for all HIV-positive pregnant or breastfeeding women,
regardless of CD4 cell count or disease stage.
In its 2013 consolidated treatment
guidelines, WHO recommended that all countries should
move towards Option B and, where resources allow, to Option B+. However, the
majority of countries are still in the process of reviewing national
Adoption of WHO
recommendations into national guidelines can be a protracted process, requiring
national consultation, economic analysis, staff training and development of new
processes for supply chain management, laboratory testing and data management.
UNICEF and the Global Fund to
Fight AIDS, Tuberculosis and Malaria undertook a four-country survey in 2011
and 2012 to review operational feasibility of the guidance and performance in
implementing its recommendations.
The assessment comprised review
of key policies and reports, key informant interviews and analysis of data from
registers and clinical records at ten health facilities purposively selected in
each country with the Ministry of Health.
It assessed the performance of
six PMTCT interventions in Malawi, Lesotho, Tanzania and Zambia between
November 2011 and February 2012.
Malawi was the only country
of the four implementing Option B+. Lesotho, Tanzania and Zambia chose Option A.
Provision of ART to pregnant women
Testing of HIV-exposed infants by week 8
Cotrimoxazole prophylaxis provided to HIV-exposed
infants by week 8
Uptake of services is
dependent upon the capacity to offer timely diagnostic tests, Priscilla Idele
told delegates. While maternal HIV testing was generally available in all ten
of the selected health facilities in each country, maternal CD4 testing was not,
and on-site early infant diagnosis was only available in two sites in both
Malawi and Tanzania.
Moreover, the majority of
early infant diagnostic tests involved sample transportation to central
laboratories resulting in a long turnaround time. Furthermore, incomplete
record-keeping led to a delay in the initiation of HIV treatment and loss to
follow-up among HIV-exposed and HIV-positive children.
Lesotho had a testing rate at
the first antenatal care visit of 99%, while Malawi, Tanzania and Zambia had
rates of 79%, 62% and 87%, respectively.
HIV testing rates in labour and
delivery were considerably lower in Malawi and Lesotho and highest in Tanzania
and Zambia, 16%, 52%, 91% and 100%, respectively.
In all four countries, the
numbers of antenatal care staff trained in PMTCT was considerably higher than
those trained in early infant diagnosis and paediatric care.
Staff trained in PMTCT was
46%, 60%, 81% and 95% in Malawi, Lesotho, Tanzania and Zambia respectively
compared to 31%, 35%, 6% and 24%, respectively trained in early infant diagnosis and paediatric
She concluded that redressing
the balance between maternal and paediatric HIV services requires:
- A family-centred
approach so mothers and infants get services from the same place
of paediatric HIV care into routine maternal and child health services
longitudinal care of mother-infant pairs until confirmed HIV diagnosis at 18
- Point-of-care diagnostics to minimise loss to follow-up, long turnaround time and late
initiation of care and treatment.
Limitations included: the rapid
assessment did not cover all areas of importance; incomplete national roll-outs;
incomplete and/or lack of data; and while indicative of coverage, data from
only ten facilities in each country were neither comprehensive nor
representative of the national status.