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| Prevention of Mother to Child Transmission of HIV - Experiences and Critical Issues: Report of a Workshop by Society of Women Against AIDS (SWAA). |
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| 8th International Conference of the Society of Women Against AIDS in Africa. Children and AIDS: Challenges and Strategies to Cope |
Society of Women Against AIDS in Africa /SWAA
Prevention of HIV Mother to Child Transmission: Report of a SWAA workshop on Experiences and Critical Issues."
Philippa Musoke, MBCHB, FAAP (Paediatrics)
Department of Paediatrics, Makerere University
Kampala, Uganda
And
Stephen N. Kinoti MBCHB, MMED (Paediatrics), MPSID.
AED/SARA Project,
Washington DC.
"This report was prepared and distributed by SWAA with assistance from Support for Analysis and Research in Africa (SARA) Project. SARA is operated by the Academy for Educational Development (AED) with sub-contractors Tulane University, JHPIEGO Corporation, Morehouse School of Medicine, and Population Reference Bureau. SARA is funded by the United States Agency for International Development (USAID) through the Bureau for Africa, Office of Sustainable Development (AFR/SD/HRD), under the Contract AOT-C-00-99-00237-00)
The opinions expressed herein are those of the authors and do not in necessarily reflect the views of AED, USAID, or the persons acknowledged as providing useful comments during the review."Table of Contents
Executive Summary
Section 1.
Background 1.1
Section 2.
Summaries of Plenaries
The role of regional Institutions and Networks in the
prevention of mother to child transmission 2.1
Breastfeeding : Policy and Program Debate 2.2
Women's Perspectives on PMTCT 2.3
Enhancing Community Involvement in PMTCT 2.4
Section 3
Workshops summaries and Recommendations
Promoting Active Participation in PMTCT 3.1
PMTCT: Program and Clinical Issues 3.2
Voluntary Counselling and PMTCT 3.3
The Nevirapine Study in Uganda 3.4
Breastfeeding issues in the PMTCT of HIV in Africa 3.5
Section 4
Recommendations for SWAA
Overall recommendations 4.1
Conclusion statement 4.2
Executive Summary
The 8th Society for Women Against AIDS (SWAA) conference was held in Kampala, Uganda on 2 - 5th April 2001, with the theme "Children and AIDS: Challenges and Strategies to cope". This report summarizes the Mother to Child Transmission (MTCT) conference presentations, deliberations and recommendations on future activities of SWAA in the area on MTCT.
Ninety percent of the 1 million HIV infected children are found in sub-Saharan Africa and mother to child transmission remains the major mode of acquisition of HIV. Therefore MTCT remains a critical area for development and implementation of prevention programs especially in sub- Saharan Africa.
The main factors determining vertical transmission include maternal viral load, obstetric practices, and infant feeding choice. Anti-retroviral regimens using AZT in the third trimester and Nevirapine single dose to mother and infant have been designed for prevention of MTCT in developing countries. Currently there are programs in Africa that are attempting to integrate PMTCT into the antenatal clinics. These have demonstrated the difficulty in implementing new programs in an already over stretched, under staffed and poorly equipped health system. The low acceptance rate found in many of the programs emphasize the indispensability of community mobilization prior to implementation. The role of women and communities in enhancing program involvement must be emphasized. By providing a minimum care package for the HIV infected women and children, follow up rates may be augmented. Breastfeeding still remains a major dilemma in most of sub-Saharan Africa where the majority of the women breastfeed their children and formula feeding may not be a feasible alternative. However it is important for each women to be counseled about infant feeding options and be given the support and opportunity to make an informed choice.
In order for these programs to be successful, women and their partners must be active participants in PMTCT through sensitization and mobilization of the communities. The lack of capacity to implement voluntary counseling and testing was identified as the major bottleneck to scaling up PMTCT in Africa and there was an need to develop consensus on the basic breastfeeding issues. Whereas the data on exclusive breast feeding offered some hope, the increased maternal mortality in the breast feeding mothers as compared to the mothers who formula fed reported in the Nairobi study raised concern. Nevirapine is a simple, cheap and easy to administer regimen for the PMTCT but the lack of adequate infrastructure and medical personnel has made implementation difficult in most countries. It is crucial for regional institutions and networks in Africa to provide avenues for consensus building on issues that are pertinent to MTCT , as well as mobilize resources and national governments to commit themselves to make PMTCT a priority. By so doing they provide a measure to reduce the incidence of Pediatric HIV infection in sub-Saharan Africa, and improve child survival.
Specific follow-up action plans identified were;
SWAA members in each country should be identified and subsequently mobilized to advocate for PMTCT in the region.
SWAA executive should identify a MTCT task force from its members in the region composed of experts in the field.
Information on MTCT needs to be effectively disseminated to the SWAA members and their communities; MTCT issues are to be prioritized and specific action plans developed, implemented and monitored by the national SWAA teams in the region.
SWAA should play a major role in advocacy, resource mobilization and networking for PMTCT in Africa.
1.1 Background
Mother to child transmission remains the major mode of transmission of HIV in children. There are approximately 5 million children below the age of 15 years who have been infected with HIV since the epidemic began and only 1 million are still alive. Ninety percent of these living children and the 600,000 born infected each year are born to HIV infected women in Africa. Despite therapies to treat HIV infection and interventions to prevent mother to child transmission the AIDS pandemic is escalating in Africa and parts of Asia.
Vertical transmission rates from mother to child range from 25 - 40%. Transmission can occur in utero but the majority occurs at the time of labor and delivery (60%). Where mothers breast feed their infants about 20 - 40% of the vertical transmission occurs through breastmilk. In Africa breast feeding has been a strategy to reduce infant mortality and morbidity. The use of formula in these resource poor settings has been associated with increased morbidity and mortality and thus formula feeding may not be a viable alternative for the HIV infected women in many resource poor settings.
However there are reports from a study in Durban that exclusive breastfeeding may provide some protection from HIV transmission through breastmilk.
Strategies to prevent mother to child transmission of HIV include primary prevention of HIV in women of reproductive age, prevention of pregnancy in HIV infected women and use of antiretrovirals during pregnancy to reduce the transmission of HIV from mother to infant.
In developed countries since the results of ACTG 076, using long course AZT during pregnancy, were made available there has been a significant reduction in childhood HIV infection. Further more with the advent of new more effective HIV treatment regimens the health of the mother has significantly improved with reduction in viral loads and a significant and further reduction in mother to Child transmission (< 1%). The developing world has lagged behind because of the cost of these complex regimens and the logistics of delivering them. Now with even cheaper, less complex regimens like short course AZT in the last trimester of pregnancy and single dose NVP at the onset of labor and to the infant developing countires are still struggling to implement these programs.
Many developing countries do not have access to antiretrovirals and most pregnant women may not know their HIV status. Voluntary and Counseling services in antenatal clinics are limited and even when available may not be under utilized because of multiple factors including stigmatization. Communities are not sensitized about the issues related to prevention of mother to child transmission in particular breastfeeding and alternatives to breastfeeding. Where UNAIDS/UNICEF pilot programs have been implemented they have identified significant problems preventing wide scale implementation of PMTCT programs in antenatal clinics. These included inadequate health infrastructure and staff, limited access to voluntary counselling and HIV testing in the antenatal clinics as well as lack of community sensitization and mobilization for PMTCT.
The MTCT program discussed the major issues through plenary papers and workshops. Specific issues were discussed and key areas were highlighted. Each workshop made specific recommendations to SWAA. The following report summarizes the plenaries, highlights the key issues raised during the workshops and the major recommendations made. Finally a general conclusion statement was generated from the whole MTCT program. 2.1 Title: Interventions to reduce Mother to Child transmission: The role of regional Institutions and Networks in the prevention of mother to Child HIV transmission in sub-Saharan Africa.
Presenter: Dr. Stephen Kinoti, SARA project USA
Background
HIV infection has had a significant impact on child survival and development with over 500,000 children dying from HIV in the year 2000. Strategies for Prevention of mother to child transmission (MTCT) include, comprehensive antenatal care and voluntary counselling and testing (VCT), optimal obstetric services with effective anti-retroviral therapies, safe infant feeding, family planning services linked with VCT and community support for MTCT prevention.
In order to provide MTCT for sub-Saharan Africa there is an urgent need to create an enabling environment for prevention of mother to child transmission (PMTCT) including adopting supportive policies to core interventions at national level. There is a need to identify and share best practices, build capacity through training, strengthen health systems, mobilize community support, information sharing and advocacy for MTCT.
Role of Regional Institutions and Networks e.g. Society of Women Against AIDS (SWAA)
Regional Institutes and Networks such as SWAA need to be advocates for appropriate policies and accession to drugs and commodities, mobilization of resources, strengthening African leadership in policy, technical programming and research as well as identifying and disseminating best practices for the region.
Specific activities need to be strengthened by using existing fora for policy and dialogue as well as consensus building on specific issues. Provision of Quality Health Care including laboratory quality assurance is a requirement for improving access to reproductive health services . Training and education of medical and allied professionals in PMTCT and development of practical operational research questions is a priority. Effective interventions to reduce MTCT should be shared within the region by forming regional working groups on PMTCT. Advocacy for resource mobilization from African Intergovernmental institutions e.g. OAU, SADC, EAC, ECA, CRHC is an area that has not been adequately utilized.
Specific issues in MTCT that need to be addressed
Coping with the growing number of orphans and HIV infected children
Promoting access to and use of antiretrovirals including, inter-country bulk purchasing, essential drug protocols, accelerated training of use of antiretrovirals (ARV’s)
Documentation of Better Practice in the region
Challenge for 1st ladies and SWAA to play the role of advocacy for MTCT
2.2 Title: Breast Feeding: Policy and Program Debate
Presenter: Dr. Saul Onyango, MTCT National Coordinator, Ministry of Health Uganda
Breastfeeding has consistently been shown to reduce infant morbidity and mortality in resource poor settings. It is the main source of infant nutrition in sub-Saharan Africa. The HIV infected woman has the potential to infect her baby through breast milk and therefore formula feeding is the recommended infant feeding option. However in resource poor countries this is not a feasible alternative not only because of the stigma associated with not breastfeeding but also the logistics of preparing the infant formula. Exclusive breastfeeding for 3 months has been associated with a lower risk of HIV transmission compared to mixed feeding.
Policies have focused on protection, promotion and support of breastfeeding (IATT 2000) but have also emphasized the need for the HIV infected mother not to breastfeed. Where replacement feeding is an option it was to be acceptable, feasible, affordable, sustainable and safe. There have been 3 scenarios (A, B, C) suggested for decision on infant feeding choices dependant on the availability of safe water supply, infant mortality rate of the region, and stigma associated with not breastfeeding in the community.
Uganda has developed infant feeding guidelines which recommend counselling on infant feeding options to enable the woman to make an informed choice. The three main options in this resource poor country are exclusive breastfeeding for 3 months with rapid weaning and replacement feeding using locally available animal milk, or unmodified animal milk or infant formula starting from birth. There is an emphasis on providing comprehensive care and follow up for both mothers and children. At the policy level there are still research questions to be answered about breastfeeding in the HIV/AIDS era. At the programme level in most resource constrained settings, exclusive breastfeeding will continue to be the feasible alternative, however improving safety is still an issue that needs to be addressed.
2.3 Title: Women's Perspectives on PMTCT
Presenter: Brigitte Syamalevwe SWAA Malawi
The women in the community of this particular research project in Malawi knew about the benefits of breast feeding but needed to be informed about the risks of transmitting HIV and alternative locally available infant feeds. Most women did not exclusively breastfeed and tended to give food supplements including porridge. Traditional birth attendants were more influential than health care workers in these women's lives. Therefore it was important to take these issues into consideration when implementing PMTCT programs. She emphasized the strategic need to strengthen HIV testing in the current health care services.
2.4 Enhancing Community Involvement in PMTCT
Title: Enhancing Community Involvement in PMTCT: study done in Botswana.
Presenter- Koketso Rontana SWAA Botswana
The main issues raised were the lack of knowledge about PMTCT in the communities, stigma and myths associated with HIV and MTCT and the lack of partner involvement. There was a concern that the men knew very little about MTCT and considered it a women's affair but the communities all agreed that it was important to protect the babies from HIV infection. The recommendations generated from the research were that communities need to be sensitized and mobilized on MTCT and PMTCT, couple counselling should be integrated into the Antenatal clinic and program managers need to involve the communities as much as possible and learn from them so as to have successful programs.
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Workshops
3.1 Promoting Active Participation in PMTCT
Chairs: Dr. Saul Onyango MoH Uganda and Connie Osborne UNAIDS
The issues raised in this workshop were the information gaps about MTCT in SWAA members, health care providers, communities, the women attending ANC and their partners. This led to misinformation and myths being propagated in the communities. The main obstacle to HIV testing where it was available was the reluctance of pregnant women to be identified as HIV infected for fear of stigmatization in the community and the fear of their partner's response if their status were known. Without family or community support the identification of HIV infection in pregnant women where no treatment for HIV infection is offered makes it very difficult for women to accept HIV testing even when its made available. There was a concern that the mother is identified and blamed for MTCT and yet it is usually both parents who are involved and both need to take responsibility. The choice of infant feeding is not always accessable because of the stigma associated with not breastfeeding as well as the logistics of preparing formula at all times of the day. This leads women to practice mixed feeding which is more likely to lead to increased transmission. Tanzania, Botswana and Kenya gave their perspectives on SWAA's contribution to PMTCT including education of SWAA members about crucial MTCT issues. Botswana - SWAA had been involved in the PMTCT program by holding workshops for dialogue on MTCT issues and involvement in research projects
Key Issues
Advocacy by national Societies of Women Against Aids at the community, national and regional level, providing an organization to advocate and network for PMTCT including representation on national and regional boards.
The need for capacity building at country level to inform members and the community as well as strategize and plan activities for PMTCT
Involvement of men should be a priority and practical ways to involve male partners in their communities in PMTCT is critical.
Recommendations
Provide an inventory of SWAA members and identify the professionals who will form the resource task force and develop action plans for PMTCT in the region.
Each country should come together as SWAA and make a commitment to MTCT and then work out a specific activity on PMTCT.
SWAA should network to mobilize and sensitize their communities about MTCT and support of the HIV infected mother.
3.2 PMTCT: Program and Clinical Issues
Chairperson: Dr. Nakabiito - Ministry of Health - Obstetrician Mulago
Presenter: Dr. Philippa Musoke - Makerere University - Paediatrician Mulago
MTCT intervention package involves; voluntary counselling and HIV testing in the antenatal clinic (ANC) , antiretrovirals for the prevention of mother to child transmission, counseling on infant feeding options, follow up, monitoring and promotion of community and family support for both mother and child. Uganda currently has 5 pilot sites funded by UNAIDS/UNICEF and plans to extend to 11 new sites this year. The antiretroviral options available are maternal zidovudine (AZT) starting at 36 weeks gestation and 1 week to the infant versus single dose maternal Nevirapine (NVP) at the onset of labor and single dose to the infant. Infant feeding options were discussed in relation to what is feasible and applicable for the individual woman counselled. Currently in the UNAIDS /UNICEF pilot sites formula is provided free of charge. However, in the women of lower socio-economic status less than 30% choose infant formula but in the women of higher socio-economic status 56 % choose infant formula. This indicated that the besides stigma the main reason for not choosing infant formula was the level of income.
The main clinical issues raised were the lack of a minimum package for the mothers attending the ANC, the limited postnatal follow up of mothers and their infants, poor quality assurance in the area of care and support, and the need for effective coordination and networking within the region. There was a need to provide care and treatment for the HIV infe |
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