Implementing anti-retroviral triple therapy to prevent HIV mother-to-child transmission: a public health approach in resource-limited settings

Abstract

We conducted a retrospective cohort study of HIV-infected pregnant women and their infants enrolled in the DREAM programme for prevention of HIV mother-to-child transmission (MTCT) in Mozambique. All women delivering between May 2002 and December 2005 were offered participation. The programme consisted of the provision of highly active anti-retroviral therapy (HAART) to pregnant women until 6 months postpartum, and formula, clean water, nutritional supplementation, and continuing HAART to mothers if necessary.In Mozambique 1,259 HIV-positive pregnant women were offered participation: 212 (14.4%; CL95% 12.6-16.2) refused, 54 (3.7%; CL95% 2.5-4.9) dropped out during pregnancy, and eight women died. The remaining 985 women participated, giving birth to 958 infants, including 21 sets of twins. An additional 28 babies were stillborn. Spontaneous abortions occurred in 20 cases. Discontinuation of anti-retroviral (ARV) therapy by mothers was 3.7% (54/1,464) before delivery, 1.5% in the first month (23/ 1,464), and 1.5% (22/1,464) between the first and sixth months after delivery. Overall drop-out rates were 5.2% (CL95% 4.6-5.8). Approximately 80% of pregnant women completed the treatment protocol.

Antiretroviral therapy in antenatal care to increase treatment initiation in HIV-infected pregnant women: a stepped-wedge evaluation

“…Toward that end, the focus of this study was to identify strategies to maximize ART provision to eligible pregnant women. Although most women initiating therapy took it at least until their delivery, we did experience losses to follow-up as noted in similar settings [7,17]. It is possible that by encouraging patients who feel well to initiate ART, the long-term retention after delivery was reduced.…”

“…However, other studies have consistently demonstrated that providing ART to pregnant women is safe, well tolerated, and extremely effective in preventing infant HIV infection [3,7,8,16,17]. In fact, the major challenge in PMTCT is not the safety or efficacy of ART, but instead extending coverage to eligible women [4,18].…”

Excessive Early Mortality in the First Year of Treatment in HIV Type 1-Infected Patients Initiating Antiretroviral Therapy in Resource-Limited Settings

“…Although we excluded pregnant women on treatment from this analysis, we have also seen favorable outcomes with reduced mortality (and significant less HIV-1 transmissions to their infants) in pregnant women initiating HAART at higher CD4 cell thresholds. 14,15 The mortality rate during the first stages of HAART administration is definitely higher among patients in resource-limited countries as compared to western countries. These differences cannot be explained by lower adherence to therapy, considering that results in terms of reduction of viral load and increase in CD4 were comparable to those attained in developed countries.…”

Treatment acceleration program and the experience of the DREAM program in prevention of mother-to-child transmission of HIV

“…Despite the proven efficacy of antiretroviral drugs in the interruption of HIV-1 transmission, there remain significant barriers to the implementation of PMTCT [9][10][11], including very limited access to health centers (in Africa, quite frequently, access is less than 50%), high refusal rates for HIV testing, and high rates of drop out from prenatal care. In addition, there remains the problem of development of increased viral resistance mutations with the regimens locally available, particularly with the use of nevirapine-based HAART regimens [12], all of which are a threat to succeeding pregnancies and the prospect of future treatment for mothers and infants [13,14].…”