Timing of Maternal HIV Testing and Uptake of Prevention of Mother-to-Child Transmission Interventions Among Women and Their Infected Infants in Johannesburg, South Africa

Abstract

Background By 2011, South African prevention of mother-to-child transmission of HIV (PMTCT) programmes had reduced perinatal HIV transmission at 6-weeks of age to 2.7%. We investigated the profile of newly-diagnosed vertically-infected children and their mothers to identify short-falls in the PMTCT programme. Methods In this operational follow-up study, fieldworkers enrolled mothers of newly-diagnosed HIV-infected children up to 2 years of age at 5 major healthcare facilities in Johannesburg. Structured questionnaires and clinical record reviews were conducted and analysed to describe the population and assess factors associated with PMTCT uptake. Results 289 mother-child pairs were enrolled. Timing of maternal HIV diagnosis influenced PMTCT access and feeding choices, and was associated with infants’ age at HIV diagnosis (7 weeks vs. 11 weeks vs. 31 weeks where mothers tested before, during or after the pregnancy respectively; p <0.0001). Women diagnosed before pregnancy (12%) were older (median 31 years) than those diagnosed during the index pregnancy (53% - median 27 years). Women diagnosed after delivery (35%) were younger (median 25 years, p<0.0001), of lower parity, and less likely to be South African citizens. In 81 cases (29%) late maternal diagnosis precluded any PMTCT access. Where women were diagnosed during or before pregnancy, the recommended PMTCT guidelines for mother and infant were followed in 86 (61%) pairs. Conclusion Failure to diagnose maternal HIV infection before delivery was the main reason for missing PMTCT prophylaxis and early infant testing. Timely maternal diagnosis enables PMTCT uptake, but implementation and follow-up gaps require attention to improve infant outcomes.

Despite Access to Antiretrovirals for Prevention and Treatment, High Rates of Mortality Persist Among HIV-infected Infants and Young Children

“…These women were eligible for ART but either did not engage in care or were not initiated on ART. In an analysis of PMTCT uptake among mothers in this cohort, we found that among women enrolled in PMTCT care only one in three meeting eligibility criteria were prescribed ART 34 . Barriers to ART initiation under Option A, the PMTCT approach at the time of this study, have been well described 35,36, 37 .…”

“…The majority of children in our study were identified outside of PMTCT programs. We have previously shown that failure to diagnose HIV infection during pregnancy was a primary reason for missing both PMTCT and EID 34 . Furthermore, MTCT among women who acquire HIV during pregnancy also contributes disproportionately to new pediatric infections 18 .…”

Adherence to HIV Care After Pregnancy Among Women in Sub-Saharan Africa: Falling Off the Cliff of the Treatment Cascade

“…Rates of new infections are consistently higher in women (particularly those of reproductive age) than in men [2–4]. As a result of routine screening protocols, pregnancy is often the point at which an HIV diagnosis is made [5–7]. With intervention (preventing mother to child transmission, or PMTCT), the rate of vertical transmission of HIV is estimated at 1.4-5.9%, with an average of 3.5% [8].…”

Near-real-time tracking of gaps in prevention of mother-to-child transmission of HIV in three districts of KwaZulu-Natal Province, South Africa

“…Gaps identified in the PMTCT cascade that facilitate MTCT include late HIV diagnosis in pregnant women and subsequent lack of or delay in ART initiation during pregnancy. [13,19,20] These factors preclude the sufficient time on ART required to suppress maternal viraemia to levels protective against MTCT risk during pregnancy, at delivery, and during the postpartum period while breastfeeding. Additional potential PMTCT gaps include lack of virological suppression among women already on ART, inadequate prophylaxis for exposed infants, and discontinuation of care by mother-infant pairs (MIPs) postpartum.…”