Uptake, Outcomes, and Costs of Antenatal, Well-Baby, and Prevention of Mother-to-Child Transmission of HIV Services under Routine Care Conditions in Zambia

Abstract

BackgroundZambia adopted Option A for prevention of mother-to-child transmission of HIV (PMTCT) in 2010 and announced a move to Option B+ in 2013. We evaluated the uptake, outcomes, and costs of antenatal, well-baby, and PMTCT services under routine care conditions in Zambia after the adoption of Option A.MethodsWe enrolled 99 HIV-infected/HIV-exposed (index) mother/baby pairs with a first antenatal visit in April-September 2011 at four study sites and 99 HIV-uninfected/HIV-unexposed (comparison) mother/baby pairs matched on site, gestational age, and calendar month at first visit. Data on patient outcomes and resources utilized from the first antenatal visit through six months postpartum were extracted from site registers. Costs in 2011 USD were estimated from the provider’s perspective.ResultsIndex mothers presented for antenatal care at a mean 23.6 weeks gestation; 55% were considered to have initiated triple-drug antiretroviral therapy (ART) based on information recorded in site registers. Six months postpartum, 62% of index and 30% of comparison mother/baby pairs were retained in care; 67% of index babies retained had an unknown HIV status. Comparison and index mother/baby pairs utilized fewer resources than under fully guideline-concordant care; index babies utilized more well-baby resources than comparison babies. The average cost per comparison pair retained in care six months postpartum was $52 for antenatal and well-baby services. The average cost per index pair retained was $88 for antenatal, well-baby, and PMTCT services and increased to $185 when costs of triple-drug ART services were included.ConclusionsHIV-infected mothers present to care late in pregnancy and many are lost to follow up by six months postpartum. HIV-exposed babies are more likely to remain in care and receive non-HIV, well-baby care than HIV-unexposed babies. Improving retention in care, guideline concordance, and moving to Option B+ will result in increased service delivery costs in the short term.

<p>Evaluation of Antiretroviral Therapy Initiated Among Pregnant Women Under Option B+ by Viral Load and CD4 Count Outcomes in Selected Hospitals of West Shewa Zone, Oromia Region, Ethiopia</p>

“…The study consisted of ART naïve pregnant women while the study had both naïve and ART-experienced participants and ARV-naive pregnant women are more likely to achieve viral loads <1000 copies/mL compared to those who are ARV-experienced. 6 The study results also indicated that majority of the women 89.7% (n=286) HIV pregnant women have suppressed with VL <1000 copies/mL compared to 10.3% (n=33) that were not suppressed (VL >1000 copies/mL). The high viral suppression rates were comparable to another study conducted in Uganda with 96% (67/70) pregnant and lactating women on option B+ suppressed at 6 months, 93.1% (174/187) at 12 months and 95.8% (479/500) at 24 months with suppression VL<1000 copies/mL 12 and also report a viral suppression rate (VL<1000 copies/mL) of 90% (n=448) among pregnant and breastfeeding women enrolled on option B+ in 13 large health facilities in Malawi.…”

“…Detectable VL or none suppression is highest among women that enrol on option B+ with ≤ 4 months of ART. 6,7 The results of this study emphasized the need to intensify support for HIV pregnant women on option B+ during the early months of ART initiation. Most of the respondents in the study at the start of ART presented with high CD4 count with a median of 349.68 cells/µL and IQR (1-1012) and less advanced WHO Treatment stage with 96.9% (n=309) staged as WHO stage 1 and 3.1% (n=10) as stage 2, report that 70.5% of breastfeeding and pregnant women on option B+ in Northeast Ethiopia initiate ART with WHO clinical stage 1 and 6.6% with stage 2.…”

“…14 Findings in seven countries in Sub-Saharan Africa and Thailand suggest that lower CD4 cell increase is independently associated with male sex, older age and lower CD4 cell count at ART initiation, age, baseline CD4+ count, initial regimens, changes in regimen and inclusion of a cotrimoxazole prophylaxis are associated with CD4+ T cell count recovery. 4,6 In North-West Ethiopia, higher baseline CD4 count, younger age, working functional status, and time on treatment contribute positively to the increase of the CD4 cell count. 13 In Abidjan, immunological failure is three times higher in patients ≥15 years of age that had a baseline CD4 cell count of ≥200/mm 3 .…”

Finding a Needle in the Haystack: The Costs and Cost-Effectiveness of Syphilis Diagnosis and Treatment during Pregnancy to Prevent Congenital Syphilis in Kalomo District of Zambia

“…We first estimated that the cost of syphilis screening per patient was $3.10 (see Table 1 ), of which $1.53 was for materials (the test kit and other minor supplies), $1.03 was for health worker time ( Table 4 ), and $0.54 was for health worker training ( Table 4 ). For perspective, an HIV test is also completed during the first visit for antenatal care, and the materials for an HIV test costs less than $1 [16] , with a confirmatory test for those testing positive less than $2. A recent study from Southern Province of Zambia reported that the cost of antenatal and postnatal care for mother/baby pairs through six months post-partum was $31 for HIV-negative mothers and $69 for HIV-positive mothers (not including costs of antiretroviral therapy) [16] .…”

Assessment of Antiretroviral therapy Initiation among pregnant Women under Option B+ Approach; Viral Load and CD4 Count Outcomes in selected Hospitals of West Zone Oromia, Ethiopia: Quantitative Prospective Cohort Study Design

“…For example, low uptake of antenatal care (ANC) services, stigma and lack of disclosure negatively impact PMTCT programs (4). In Zambia reports that HIV-infected women attending PMTC programs present to care late in pregnancy and many are lost to follow up by six months postpartum (5). Similarly, a systematic review conducted among 44 studies in Sub-Saharan Africa assessing barriers and facilitating factors of ART in PMTCT reveals that inadequate knowledge on HIV, ART and vertical transmission; lower maternal education level, stigma, poor staffclient interactions, service accessibility, and non-facility deliveries are among the barriers or factors Option B+ includes the period from pregnancy to lactation which therefore targets both pregnant and lactating women.…”