Missed Opportunities along the Prevention of Mother-to-Child Transmission Services Cascade in South Africa: Uptake, Determinants, and Attributable Risk (the SAPMTCTE)

Abstract

ObjectivesWe examined uptake of prevention of mother-to-child HIV transmission (PMTCT) services, predictors of missed opportunities, and infant HIV transmission attributable to missed opportunities along the PMTCT cascade across South Africa.MethodsA cross-sectional survey was conducted among 4–8 week old infants receiving first immunisations in 580 nationally representative public health facilities in 2010. This included maternal interviews and testing infants’ dried blood spots for HIV. A weighted analysis was performed to assess uptake of antenatal and perinatal PMTCT services along the PMTCT cascade (namely: maternal HIV testing, CD4 count test/result, and receiving maternal and infant antiretroviral treatment) and predictors of dropout. The population attributable fraction associated with dropouts at each service point are estimated.ResultsOf 9,803 mothers included, 31.7% were HIV-positive as identified by reactive infant antibody tests. Of these 80.4% received some form of maternal and infant antiretroviral treatment. More than a third (34.9%) of mothers dropped out from one or more steps in the PMTCT service cascade. In a multivariable analysis, the following characteristics were associated with increased dropout from the PMTCT cascade: adolescent (<20 years) mothers, low socioeconomic score, low education level, primiparous mothers, delayed first antenatal visit, homebirth, and non-disclosure of HIV status. Adolescent mothers were twice (adjusted odds ratio: 2.2, 95% confidence interval: 1.5–3.3) as likely to be unaware of their HIV-positive status and had a significantly higher rate (85.2%) of unplanned pregnancies compared to adults aged ≥20 years (55.5%, p = 0.0001). A third (33.8%) of infant HIV infections were attributable to dropout in one or more steps in the cascade.ConclusionA third of transmissions attributable to missed opportunities of PMTCT services can be prevented by optimizing the uptake of PMTCT services. Identified risk factors for low PMTCT service uptake should be addressed through health facility and community-level interventions, including raising awareness, promoting women education, adolescent focused interventions, and strengthening linkages/referral-system between communities and health facilities.

Depression, alcohol use, and stigma in younger versus older HIV-infected pregnant women initiating antiretroviral therapy in Cape Town, South Africa

“…We also found moderately high rates of harmful alcohol use during pregnancy, with the youngest women (18–21) reporting the highest rates of risky alcohol use (29%) and alcohol-related harm (37%). Depressive symptoms and risky alcohol use may be contributing to and be consistent with emerging literature regarding poor PMTCT engagement and outcomes among younger HIV-infected pregnant women (Ramraj 2015; Ronen 2015; Woldesenbet et al 2015). …”

“…Young women in South Africa are also at high risk of new HIV acquisition, with the highest lifetime risk occurring before the age of 25 (Kharsany et al 2012; Pettifor et al 2005). Emerging data from Kenya and South Africa demonstrated that being an HIV-infected adolescent mother was associated with decreased engagement in antenatal care, lower uptake of prevention of mother-to-child transmission (PMTCT) services and antiretroviral therapy (ART), increased dropout at all stages of the PMTCT care and treatment cascade, and 2–3 times the odds of mother-to-child HIV transmission when compared to adult women (Fatti et al 2014; Horwood et al 2013; Ramraj 2015; Ronen 2015; Woldesenbet et al 2015). …”

“…Additional data are needed in South Africa evaluating depression and alcohol use and their effects on uptake and maintence of PMTCT and resulting infant outcomes. In addition, 60% of pregnancies in South Africa are unplanned with even higher rates (85%) among younger women (Woldesenbet et al 2015). Most HIV-infected women are diagnosed when they are routinely tested when presenting for antenatal care during pregnancy.…”

Population–level effectiveness of PMTCT Option A on early mother–to–child (MTCT) transmission of HIV in South Africa: implications for eliminating MTCT

“…Despite a reduction in percentage MTCT, the number of infant HIV infections per 100 000 live births at six weeks postpartum, was above the global validation target. Eliminating unidentified maternal HIV infections [23,24], reducing maternal HIV prevalence and improving retention in HIV-related care (early cART initiation and adherence) [25] are critical to closing current gaps.…”

The Achilles’ heel of prevention to mother-to-child transmission of HIV: Protocol implementation, uptake, and sustainability

“…Drop-out from the PMTCT cascade has been associated with lack of on-site HIV testing, delayed HIV testing results, lack of HIV serostatus awareness, nondisclosure to partners and delayed ART initiation (Woldesenbet et al, 2015). These barriers to PMTCT highlight the need to identify challenges and devise solutions to enhance PMTCT protocol implementation in rural South Africa.…”