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Prevention of Mother to Child Transmission of HIV Infection

Prevention of Mother to Child Transmission of HIV Infection

The scourge of HIV/AIDS has, no doubt, continued to ravage virtually all parts of the world. According to statistics, 34 million people are estimated to be living with HIV worldwide; 16.7 million of these are women and 3.4 million are children younger than 15 years of age. In 2011, a total of 2.5 million people were newly infected with HIV globally; an estimation of 330 thousand of these new infections in children under 15 years of age. Also in 2011, the world recorded 1.7 million deaths orchestrated by AIDS of which 230 thousand children under 15 years of age were involved (UNAIDS, 2012).Sub-Saharan Africa has just over 10% of the world’s population, but is home to more than 60% of all people living with HIV (UNAIDS, 2004). Eighty five percent of world’s infected children are in the Sub-Saharan Africa (UNAIDS, 2006). AIDS causes 22.6% of mortality in all African countries, making it the leading cause of death (WHO, 2001). Pregnant women living with HIV infection have increased risk of transmitting HIV to their babies. Vertical transmission remains the main mode of acquisition of HIV infection in children with a total of 700,000 newly infected children in 2003 (WHO, 2004).

The transmission of HIV infection from the mother to the child constitutes a global challenge especially for developing countries. In the absence of any intervention, the risk of infection of HIV-exposed children can be as high as 25% for HIV type 1 and 4% for HIV type 2 (Mandelbrot et al, 2004). The Prevention of Mother-to-child Transmission of HIV (PMTCT) is based on four pillars: Primary prevention of HIV infection among women of reproductive age; prevention of unplanned pregnancies among HIV infected women; prevention of HIV transmission during pregnancy and/or breastfeeding; treatment, care and support of HIV infected women and their families (Ndikom et al., 2007).

Globally, the number of women dying from AIDS related causes during pregnancy or within 42 days after delivery was estimated to be 37 million. Also, among the 21 high priority countries (including Nigeria), 33,000 pregnancy – related deaths among women were recorded (UNAIDS, 2011, 2012). Statistics also indicate that maternal mortality was still very high in Nigeria (630/100,000 live births) (UNAIDS, 2011).From the data presented above, it is very correct to aver that in all the HIV infections and deaths, children have continued to be seriously affected. One avenue that has fundamentally aided the infection of children with this deadly disease (HIV) is Mother-to-Child Transmission (MCT). This has, no doubt, served as a major pathway for the spread of the HIV virus. For instance, in Nigeria alone, UNAIDS reported that an estimated 84, 200 children were newly infected with HIV through mother-to-child transmission in 2009. To this end, the World Health Organization (WHO) in 2010 reported that the prevention of mother-to-child transmission of HIV (PMTCT) has been at the forefront of global HIV prevention activities since 1998.The transmission of HIV from a HIV positive mother to her child during pregnancy, delivery or breastfeeding is called mother-to-child transmission (WHO, 2010). Children are mainly infected with HIV through mother-to-child transmission at the time of pregnancy, labour and delivery or through breastfeeding. This has created enormous social and economic problems. Aside the dominant hetero-sexual transmission of HIV, vertical transmission from mother to child accounts for more than 90% of pediatric AIDS. Particularly in developing countries, mother to child transmission has become a critical child health problem (Goncho, 2009)

The World Health Organization (WHO) has stated that without preventive treatment, up to 40% of children born to HIV positive women will be infected; majority through MTCT (WHO, 2001, De cock et al., 2000).It is believed that two-thirds are infected during and around the time of delivery and one-third are infected through breast-feeding. But this value can be reduced to less than 2% through anti-retroviral prophylaxis given to the mother during pregnancy and labour and to the infant after delivery, obstetric interventions including elective caesarean section and appropriate infant feeding (WHO, 2007, Naver et al., 2006, UNAIDS 2006). This set of interventions is collectively known as Prevention of Mother-to-Child Transmission (MTCT) of HIV (Druce et al., 2007). In most industrialized countries where this is a standard of care, its large scale implementation has virtually eliminated new pediatric HIV infection. Unfortunately in Sub-Saharan Africa, less than 6% of pregnant women living with HIV in 2005 were offered intervention to reduce MTCT (Foster et al., 2007)

Definition:

Mother-To-Child-Transmission (MTCT) is the transmission of HIV virus from an infected woman to her unborn child during pregnancy, delivery and breastfeeding. Vertical transmission of HIV occurs when an infected mother’s blood mixes with that of the baby during vaginal delivery (Kourtis et al., 2006; Adogu et al., 2013). 25-35% of breastfed infants born to infected women will be infected.

Abiodun et al., (2007) reiterated that there are cases of Mother-To-Child–Transmission of HIV/ AIDS despite the effort in implementing PMTCT. Mothers are still lacking knowledge about MTCT especially transmission through breastfeeding. Only 10% of 100 pregnant women had knowledge regarding mother to child transmission of HIV/AIDS, 13% of pregnant women knew that breastfeeding while suffering from HIV/AIDS may put the baby at risk of contracting the virus (Maputle, 2008)

Factors association with risk of MTCT/ Determinants of MTCT :

Dr. Abrams explained, many studies conducted over the past decade have demonstrated that women with advanced HIV disease are at the highest risk of transmitting HIV, both during pregnancy and while breastfeeding. High HIV-RNA levels in blood, low CD4+ cell counts, and an AIDS diagnosis are all markers of MTCT risk. HIV-RNA levels in genital fluids, most notably at the time of labor and delivery, are also associated with an increase in transmission risk. “These are the primary maternal factors associated with an increased risk of transmission,” (Abraham, 2004)

Factors Associated with Increased Risk of MTCT :

The intrapartum risk of MTCT is multi factorial involving viral, maternal, placental and foetal factors as well as the delivery process.

1. Viral factors:

  • Viral load. The higher the viraemia the higher the risk of transmission
  • Presence of resistance to antiretroviral drugs.
  • Transmission rates are higher with HIV 1 than HIV 2 infection.

2. Maternal factors: The following maternal factors positively influence MTCT.

  • Maternal immune deficiency.
  • Symptomatic disease in the mother
  • Poor nutritional status of the mother.
  • Presence of sexually transmitted infections and other genital ulcers during labour.

3. Placental factors: disruption from any cause increases the chance of feto-maternal transfusion thereby increasing the risk of HIV infection.

  • Intra partum Haemorrhage
  • Chorioamnionitis

4. Obstetric factors:

  • Vaginal delivery
  • Invasive obstetric procedures during labour like External Cephalic Version, foetal scalp electrodes and foetal blood sampling.
  • Instrumental deliveries like vacuum extraction or forceps.
  • Prolonged duration of rupture of foetal membranes (4 hours and above).
  • Prolonged labour
  • Episiotomy and lacerations.
  • First born of multiple pregnancies.

5. Foetal factors:

  • Prematurity (Preterm birth)
  • Foetal genetic characteristics
Health Workers
Health Workers

Knowledge Attitudes and Practice of Health Workers:

Internationally, studies evaluating attitudes of health care providers toward HIV/AIDS patients have suggested that current negative attitudes of health care workers toward people with HIV—compounded by fear of infection in the workplace, perceptions of risk, and lack of understanding of HIV—perpetuate the prevalence and manifestation of stigma toward this population (Chen et al., 2004; Juan et al., 2004; Quach et al., 2005; Reis et al., 2005). For example, a study examining discriminatory attitudes and practices by health care workers in Nigeria found that providers inadequately trained in HIV/AIDS care and ethics were more likely to agree that it was acceptable to refuse treatment to infected patients and were more likely to have done so (Reis et al., 2005). In China, knowledge of HIV and negative attitudes among nurses were inversely correlated; 50% of nurses reported anxiety about becoming infected with HIV in the workplace, and 49% said they avoided contact with HIV-positive patient’s altogether (Chen et al., 2004).

HIV/AIDS-related stigma has been recognized as one of the largest challenges to improving HIV/AIDS care around the world. Studies suggest that provider stigma may be affecting the quality of care and patient decisions to seek health care services. (Juan et al., 2004) Studies suggest that multivariate regression models revealed that knowledge of HIV was inversely associated with negative attitudes toward PLWHAs (i.e., stigma), and providers who perceived high risk of HIV infection through casual contact had significantly more negative attitudes. One study shows that discriminatory behavior and stigma toward them do exist and may be attributable to poor HIV/AIDS-related knowledge and high perceived risk of infection (Quach et al., 2005)

Stigma has been defined as “… a real or perceived negative response to a person or persons by individuals, community or society…[that] is characterized by rejection, denial, discrediting, disregarding, underrating and social distance” (Reis et al., 2005)

HIV-related stigma and discrimination defined as: a process of devaluation that significantly discredits an individual either living with or associated with HIV/AIDS (The Joint United Nations Programme on HIV/AIDS, 2011). HIV-infected people are discriminated rather than an infection but their character because the mode of transmission of HIV among high-risk group such as a person who is having multiple sexual partners, homosexual men and injection drug users is highly reached among public (Jeevitha et al., 2013). Delivery for HIV positive women were refused by 62% of the doctors and 80% of the patients were referred to other institutions. People living with HIV were experienced that 88% of the doctors refused to conduct surgery and 85% of doctors were also accepted about rejection of surgery. Only 3% of doctors accepted that they had performed surgeries/Invasive procedure for HIV patients. We recommend that seminars, workshops should be organized on a continuous basis for health care workers on universal precautions, stigma and discrimination reduction. The institution should also make available materials needed to protect workers against the risk of acquiring pathogenic infection in the course of providing health services to their patients. (Jeevitha et al., 2013)

Pregnant Woman
Pregnant Woman

Knowledge and Attitudes of Pregnant women:

Cultural factors associated with HIV/AIDS contribute to limited knowledge about MTCT. Age, educational level and religion were factors associated with attitude towards HIV testing (Maputle 2008).

Hussy (2004) reiterated that mother to child transmission of HIV/AIDS counts nearly 90% of the infections in Nigerian children and level of knowledge regarding the transmission is low. The proportion of HIV infected pregnant women receiving antiretroviral prophylaxis has progressed slowly from 2005 (4.2%) to 2007 (10%). Meanwhile, the National Demographic and Health Survey in 2004 revealed that 98% of women in the general population had heard about HIV (National Institute of Statistics, 2005). Some authors have argued that most of the knowledge is on sexual transmission of HIV while knowledge on specific aspects of PMTCT is sparse among women of reproductive age [(National Institute of Statistics, 2005) and (Neves and Gir, 2006)

The coverage rate of antiretroviral prophylaxis in Local Government Area is low despite the involvement of the state and other development partners. PMTCT coverage is low in Nigeria despite being one of the countries with the highest burdens. Nigeria alone contributes 30% to the PMTCT gap – the difference between estimated number of HIV-positive pregnant women and those reached with antiretroviral prophylaxis for PMTCT (WHO, 2009). The strategies for reducing the risk of transmission include serological anti-HIV screening during prenatal, the use of antiretroviral to reduce maternal viral load during gestation and delivery, elective caesarean section, proscription of breastfeeding, and the use of antiretroviral during the newborns first six weeks of life (Mofenson, 2004).

Mother and Child
Mother and Child

Prevention of Mother-to-child Transmission of HIV (PMTCT):

The Prevention of Mother-to-child Transmission of HIV (PMTCT) is based on four pillars: Primary prevention of HIV infection among women of reproductive age; prevention of unplanned pregnancies among HIV infected women; prevention of HIV transmission during pregnancy and/or breastfeeding; treatment, care and support of HIV infected women and their families (Ndikom and Onibokun, 2007). Ineffective implementation of this holistic approach can have serious implications for the transmission of the HIV to the child.

Management of HIV in Pregnant Women and PMTCT:

Testing and Counselling

HIV testing is the process that determines whether a person is infected with HIV or not. HIV counselling is the confidential dialogue between individuals and their health care providers to help clients examine their risk of acquiring or transmitting HIV infection and to make informed decisions based on information available to them.

  • In all settings, HIV testing and counselling should be offered to all pregnant women seeking these services, and service providers should promote strategies to mobilize women of reproductive age (including pregnant women) to go for testing and counselling wherever these services are accessible (FMOH, 2007)

To reduce maternal transmission, high quality, appropriate information and counselling must be provided to ensure that patients are able to make informed decisions before and after testing. Lack of adequate information, knowledge about HIV testing and counseling increases ignorance and promotes stereotypes about HIV/AIDS. Women who acquire better knowledge on Mother to Child Transmission are more likely to take the test (Ho and Loke, 2003). HIV counselling and testing is pivotal to HIV prevention, care and treatment programmes as knowing one’s HIV status is a precursor to accessing the appropriate care and treatment services. However, data from surveys conducted in 12 high-prevalence countries in sub- Saharan Africa show that only 12% of men and 10% of women know their HIV status (WHO, 2007).

Health Workers and Patient
Health Workers and Patient

Rapid HIV testing and counselling in Labour:

In high income countries of the world, MTCT has been virtually eliminated thanks to effective voluntary testing and counseling, access to antiretroviral therapy, safe delivery practices, and the widespread avail- ability and safe use of breast-milk substitutes. If these interventions were used worldwide, they could save lives of thousands of children each year. Hence, there is an urgent need to combat this menace (UNAIDS/WHO, 2005). HIV testing should be recommended to all women of unknown status in labour. This is because some women might not have registered in the antenatal clinic and are presenting for the first time in labour. Such women should be offered the opt-out approach and given appropriate post test counselling in the post partum period or pre test counselling if she had declined the test. The following should be considered:

i. Determine HIV test history

ii. Discuss the benefits of testing and prophylaxis

iii Explain the testing process

iv. Offer the test

If the above is not feasible at the time the woman presents, the steps should be taken to offer the test as soon as possible after delivery. Women whose initial antenatal testing was negative should be offered repeat testing near term or in labour (FMOH, 2007).

Clinical Investigations in PMTCT :

The goals of investigations in PMTCT setting are to:

  • Accurately detect all HIV positive pregnant women Detect the presence of other diseases whose presence can increase the transmission of HIV, or which are themselves transmittable from the mother to the child, or which can increase morbidity in the mother
  • Determine CD4 counts for prophylactic and therapeutic purposes
  • Detect infection status in exposed infants
  • *For women that will require HAART for treatment of their own disease, organ and system function tests should be carried out prior to and while on therapy (FMOH, 2007)

Antenatal Care for HIV Positive Women:

It is important that health workers in the antenatal clinic are able to identify women who have tested positive, in order to treat them appropriately. This must be done in a way that respects the privacy and rights of the HIV positive woman. As part of the initial counselling, women should be told why it is important that health workers know their HIV status. Each health facility will need to identify a way to make this available in the notes, without making it accessible to the public, visitors or others. When a woman is known to be HIV positive or is diagnosed as HIV positive during pregnancy, her obstetric and medical care will need to be strengthened and modified. Post test counselling for HIV positive pregnant women should include the following:

  • Information on disclosure, partner notification and testing
  • Information on the benefits of PMTCT intervention
  • Information on ARV
  • Information on nutrition
  • Information on delivery
  • Infant feeding
  • The need for follow up and adherence

All HIV positive women should be given optimal health care to ensure their safe delivery. In a situation where the life of the woman is adjudged to be threatened by the continuation of the pregnancy, termination of pregnancy should be in accordance with the provisions of the law. (FMOH, 2007)

The Use of Antiretroviral Drugs in PMTCT of HIV:

Pregnancy in the HIV-seropositive woman is an indication for prophylactic ART irrespective of CD4 count, viral load or clinical stage of the disease. The time of commencement and choice of ART in HIV-seropositive pregnant women depends on the clinical setting. Where possible, ART should be provided in consultation with an experienced physician. One of the greatest breakthroughs in the history of MTCT prevention research were the results of PACTG 076, a randomized, double-blind, placebo-controlled trial evaluating the efficacy and safety of zidovudine in reducing MTCT of HIV (Connor, 1994). HIV-infected pregnant women 14 to 34 weeks’ gestation with CD4+ counts above 200 cells/mm3 who had not received antiretroviral therapy during the current pregnancy were enrolled. The zidovudine regimen included antepartum zidovudine (100 mg orally five times daily), intrapartumzidovudine (2 mg/kg given intravenously over one hour, then 1 mg per kilogram per hour until delivery), and zidovudine for the newborn (2 mg per kilogram orally every six hours for six weeks). Infants with at least one positive HIV culture of peripheral blood mononuclear cells (PBMCs) were classified as HIV-infected.”(Abraham, 2004)

Data are also available regarding the use of combination antiretroviral therapy as a component of MTCT prevention. In an open-label, nonrandomized study of 445 pregnant women with HIV infection in France, lamivudine was added at 32 weeks’ gestation to standard zidovudine prophylaxis (Mandelbrot, 2001). Lamivudine was also given to the infant, in addition to zidovudine. The transmission rate in the zidovudine/lamivudine group was 1.6%. In comparison, the transmission rate in a historical control group of women receiving only zidovudine was 6.8%.(Abraham, 2004)
In a longitudinal epidemiologic study ongoing in the United States since 1990—the Women’s Interagency HIV Study (WIHS)—perinatal HIV transmission was observed in 20% of women with HIV infection who received no antiretroviral treatment during pregnancy, 10.4% who received zidovudine alone, 3.8% who received combination therapy without protease inhibitors, and 1.2% who received combination therapy with protease inhibitors (Abraham, 2004). “Combination antiretroviral therapy is a very important consideration,” Dr. Abrams commented. “More recent guidelines stress the importance of treating the mother to protect her own health, not just the health of her baby. Combination antiretroviral therapy is now the norm and its benefits to both the mother and her child have been documented.” (Abraham, 2004)

Operational definition of terms:

Antenatal: This relates to the medical care given to pregnant women before child birth.

Antenatal talk: This is the lecture given to pregnant women addressing particular issues

or subjects in relation to the safe and healthy delivery and also matters relating to hygiene,

nutrition and proper child care practices.

Antenatal Care: Is the care of the women during pregnancy. (PARK, 2007)

Attitude: The opinion, thinking or feeling of pregnant women and the way they behave

towards the antenatal talk.

Attitude: A feeling or opinion about something or someone, or a way of behaving that is caused by this. (Cambridge University Press, 2005)

Pregnancy: The state of carrying an unborn offspring in the uterus.

Antiretroviral treatment: Treatment with drugs that inhibit the ability of the human immunodeficiency virus (HIV) or other types of retroviruses to multiply in the body. Standard antiretroviral therapy (ART) consists of the combination of at least three antiretroviral (ARV) drugs to maximally suppress the HIV virus and stop the progression of HIV disease. Huge reductions have been seen in rates of death and suffering when use is made of a potent ARV regimen, particularly in early stages of the disease. (WHO, 2013)
HIV/AIDS: Human Immunodeficiency Virus, (i.e. Retrovirus isolated and recognized as the etiologic agent of AIDS); while Acquire Immune Deficiency Syndrome (i.e. Collective diseases occurred as a result of HIV infection) Female represent the fastest-growing segment of the AIDS epidemic. (Brunner and Suddarth, 2008)

Infant mortality: The deaths of infants under one year, it include neonatal and postnatal mortality (Oxford University Press, 2004)

Knowledge: Understanding of or information about a subject which has been obtained by experience or study and which is either in a person’s mind or possessed by people generally. (Cambridge University Press, 2005)

MTCT: HIV infection transmitted from an HIV-infected mother to her child during pregnancy, labour, delivery or breastfeeding is known as mother-to-child transmission (WHO, 2010).

PHC: Primary Health Care is a new approach to health care, which integrates at the community level all the factors required for improving the health status of the population. It is the declaration of Alma-Ata in USSR, 1978. It has been defined as “Essential health care based on practically, scientifically sound and socially acceptable methods and technology, mad universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination.” (PARK, 2007)

PMTCT: The prevention of mother-to-child transmission (PMTCT) is a highly effective intervention and has huge potential to improve both maternal and child health. (WHO, 2010).

Practice: When you do something regularly or repeatedly to improve your skill at doing it. (Cambridge University Press, 2005)

Voluntary Counseling and Testing : for HIV usually involves two counseling sessions: one prior to taking the test known as “pre-test counseling” and one following the HIV test when the results are given, often referred to as “post-test counseling”. Counseling focuses on the infection (HIV), the disease (AIDS), the test, and positive behavior change. VCT has become popular in many parts of Africa as a way for a person to learn their HIV status. VCT centers and counselors often use rapid HIV tests that require a drop of blood or some cells from the inside of one’s cheek; the tests are cheap, require minimal training, and provide accurate results in about 15 minutes.( Fonner, 2012).

Conclusion:

It could be concluded that majority of pregnant women lacked knowledge regarding MTCT and its modes. As revealed by this study, the knowledge level of the pregnant women on the PMTCT programme is low. Majority (69.1%) of pregnant women had poor knowledge of MTCT of HIV infection. The healthcare providers in this study had deficient knowledge and practice of PMTCT and still had gaps in certain areas. Over average of respondents could not correctly answer the four pillars of PMTCT.

The study demonstrates that Healthcare providers are poorly informed on practical issues in the prevention of MTCT of HIV. They are therefore handicapped to play an effective role in this important aspect of prevention of mother to child transmission of HIV. Their attitude was fairly appropriate. They showed a discriminatory attitude towards HIV positive pregnant women. There is need for improved knowledge through structured educational intervention. Resources needed for practice should always be made available and the environment should be much more conducive for practice. Most of these healthcare providers willingness to update their knowledge and improve their knowledge and improve their attitude and practice of PMTCT. This illustrates the need for periodic PMTCT training programs for healthcare providers.

Recommendations:

The outcome of this study should be used to design health talks for pregnant women attending clinics. There is a need to do a qualitative study to find out if the information given during antenatal clinic is enough and useful to pregnant women and to see if more health education/counselling sessions are needed for pregnant women during antenatal visits. All new healthcare providers should undergo PMTCT training and those who are in service should have refresher courses on current guidelines. Men involvement is necessary and they need to be encouraged and sensitized from the communities to accompany their partners to the clinic and attend counseling sessions, this will help equip them both with the necessary information on PMTCT.

Formal health education programmes with regard to MTCT should be provided to enhance knowledge and understanding of the subject to all clients and patients who visit the healthcare facilities, irrespective of gender, so that even male as partners should be able to acquire and act upon the information. Encourage healthcare providers to demonstrate positive attitudes towards the programme users as this will increase the utilization of MTCT services.

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