Hiv testing and counselling for women attending child health clinics: An opportunity for entry to prevent mother-to-child transmission and hiv treatment. Author

18 MCPs, including 14 nurse/midwives, 2 clinical officers, and 2 ob/gyn specialists.

The HIV/AIDS epidemic has had numerous adverse effects, and a few positive effects, on MCPs in this setting. Adverse effects include reductions in the number of health care providers, increased workload, burnout, reduced availability of services in small health facilities when workers are absent due to attending HIV/AIDS training programs, difficulties with confidentiality and unwanted disclosure, and MCPs’ fears of becoming HIV infected and resultant stigma and discrimination. Positive effects include improved infection control procedures on maternity wards and enhanced MCP knowledge and skills.

A multi-faceted package including policy, infrastructure, and training interventions is needed to support MCPs in these settings and ensure that they are able to perform their critical roles in maternal healthcare and prevention of HIV/AIDS transmission.

Although policies and programs exist to promote safe motherhood in sub-Saharan Africa, maternal health has not improved, and may be deteriorating in some countries. Part of the explanation may be the adverse effects of HIV/AIDS on maternity care.

We conducted a study in Kisumu, Kenya to explore how fears related to HIV/AIDS affect women’s uptake and health workers’ provision of labor and delivery services. In-depth qualitative interviews with 17 maternity workers, 14 pregnant or postpartum women, 4 male partners, and 2 traditional birth attendants; as well as structured observations of 22 births; were conducted at four health facilities.

Participants reported that fears of HIV testing; fears of involuntary disclosure of HIV status to others, including spouses; and HIV/AIDS stigma are among the reasons that women avoid delivering in health facilities. Maternity workers now have to take into account the HIV status of the women they serve (as well as their own fears of becoming infected and stigmatized), but do not seem to be adequately prepared to handle issues related to consent, confidentiality, and disclosure. Importantly, it appeared that women of unknown HIV status during labor and delivery were likely to be targets of stigma and discriminatory practices, and that these women were not receiving needed counseling services. The findings suggest that increasing infection control precautions will not be enough to address the challenges faced by maternity care providers in caring for women in high HIV prevalence settings.

Maternity workers need enhanced culturally sensitive training regarding consent, confidentiality, and disclosure. Furthermore, this study points to the necessity of paying more attention to the care of women of unknown HIV serostatus during labor and delivery. Such interventions may improve the quality of maternity care, increase utilization, and contribute to overall improvements in maternal health, while also enhancing PMTCT and HIV care.

The prevalence HIV infection among pregnant women is varied from one region to another. Sexual behavior among HIV positive patients seems not to change especially in the settings of non-disclosure and emergence of antiretroviral therapy. This imparts negatively on PMTCT strategies. Public health strategies have emphasized partner notification and interventions to reduce sexual risk among HIV positive individuals.

The study aimed to compare the sexual practice patterns among HIV positive and HIV negative pregnant women in relation to HIV status disclosure.
Study design:

Prospective cohort study between February 2007 and July 2007. Participants were followed up for four weeks.

This was a cohort study of 110 HIV positive and 110 HIV negative pregnant women followed up in antenatal clinics of Kenyatta National Hospital, a referral and teaching hospital and Pumwani Maternity hospital, the largest single obstetric unit in the country. Their sexual behaviour was stratified by HIV status and HIV status disclosure over the period of follow up.

To compare sexual practices of HIV positive and HIV negative pregnant women attending antenatal clinics at the Kenyatta National Hospital and Pumwani Maternity hospital.

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  To compare sexual frequency and desire of the HIV infected pregnant women against those who are HIV negative.
  
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  To compare the rates of disclosure of HIV serostatus between HIV positive and negative pregnant mothers.
  
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  To determine the effect of HIV status on frequency of condom use.
  

Change in Sexual desire, condom use, disclosure of HIV status to sexual partner, serodiscordance, effect of couple counseling.

A total of 220 pregnant mothers who were enrolled in this study of whom 110 were HIV positive and 110 were HIV negative. Most of the participants (75%) were tested for HIV during the index antenatal clinic. The HIV positive pregnant women had earlier sexual debut compared to their negative counterparts (p=0.002). Disclosure rate among the HIV positive was 84.5% compared to 96.4% among the HIV negative clients (p=0.005). Frequency of sex and change of sexual desire was not affected by the HIV status at baseline (p=0.076) but significantly different in the follow up between the two groups (p=0.000). About 50% of the HIV negative women did not know the HIV status of their spouses. Two-thirds (67%) of the HIV positive women were either not using condoms or doing so inconsistently. Couple counseling improved condom use among HIV positive couple (OR=1.25).

The HIV status and its disclosure determine change of sexual desire. Couple communication (status disclosure) improves condom use and it should be emphasized in PMCT interventions. Motivating messages should be designed to improve safe sexual practice among the HIV positive and negative in order to prevent more new infections.

Although theoretical efficacy of PMTCT interventions has been established in randomized clinical trials it is important to determine actual transmission rates in program settings. In Kenyatta National Hospital we evaluated the uptake of antiretrovirals, elective caesarean section, replacement feeding and contraception for PMTCT. Program effectiveness was determined by DNA PCR testing of infants.

Service delivery data that is reported to National AIDS and STI Control Program (NASCOP) on monthly was summarized. The PCR test results were obtained from program records. Data entry and analysis was done using SPSS version 11.5.

Of 933 HIV positive women 910 (97%) received ARVs for PMTCT, 570 (61%) opted for replacement feeding and 330 (35%) were delivered by elective caesarian section, and 215 (23%) are on family planning methods.

The uptake of PMTCT antiretrovirals and replacement feeding are high while that of caesarean section and contraception are low. HIVNET 012 and infant PEP account for 60% of the antiretroviral interventions due to late presentation of women. The observed transmission rates with antiretrovirals, caesarean section and replacement feeding are higher than would be expected from the theoretical efficacy of these interventions.

It is estimated that 2.2 million people in Kenya have been infected while 1.5 million have already died from HIV/AIDS, leaving behind approximately 140,000 infants and children living with the virus. The President’s Emergency Funds for AIDS Relief (PEPFAR), working with the U.S. Government is committed to working with international, national and local leaders worldwide to promote integrated prevention, treatment, and care programs to combat the disease

Kenya Service Provision Assessment Survey (KSPA) 2004 on HIV/AIDS determined the capacity of the formal health sector in Kenya to provide both basic and advanced level HIV/AIDS services, availability of record keeping systems for monitoring HIV/AIDS care and support as well youth friendly services. These indicators summarize the PEPFAR indicators.

Data were collected from 440 facilities including hospitals, health centers, maternities, clinics, dispensaries and VCT centers. Facilities managed by the government, non-governmental organizations (NGOs), private-for-profit, and faith based organizations (FBOs) were included in the survey.

In order to address these aspects, HIV/AIDS related services that were assessed included counseling and testing (CT), care and support services (CSS), antiretroviral (ARV) therapy (ART), post-exposure prophylaxis (PEP), prevention of mother-to-child transmission (PMTCT), and youth friendly services.

Counseling and testing (CT), care and support services (CSS), antiretroviral (ARV) therapy (ART), post-exposure prophylaxis (PEP), prevention of mother-to-child transmission (PMTCT), and youth friendly services were available in 37, 68, 7, 8, 24, and 5 percent, respectively of all facilities in Kenya. HIV testing services, were more commonly found in Nairobi (77 percent of all facilities) and least in Nyanza and North Eastern provinces (19 and 135 percent respectively. Assessment of record keeping revealed that 77, 96 and 50 percent of all facilities nationally had records of test results and clients receiving results for all eligible service sites and a written informed consent policy in all sites offering voluntary counseling and testing respectively.

Pumwani Maternity Hospital is the largest maternity hospital in the country conducting 24,000 deliveries per year. It is a low cost public hospital with 256 nurses, 6 obstetricians, 2 pediatricians and 18 medical officers.

A survey in 2003 showed that most women presenting in labour did not know their HIV status. PMTCT services offered in PMH include, HIV counseling and testing (ante-natal, intrapartum and postpartum), counseling and support of infant feeding options, post pregnancy care of HIV infected women (providing continuing counseling, medical care and contraception), Training of service providers, program supervision to improve quality of services and renovation of service delivery points.

Service delivery data submitted to NASCOP were analyzed to assess the impact of Intrapartum and Postpartum testing.

Ninety nine percent of women counseled accepted testing, intrapartum and immediate postpartum counseling and testing accounted for 89% of women tested. Prevalence of HIV among tested women reduced from 21% in 2004 to 13% in 2005, while uptake of antiretrovirals among HIV positive women increased from 49% in 2004 to 89% in 2005. About 52% of HIV positive women opted to formula feed and 23% initiated effective contraception during follow-up post pregnancy.

Intrapartum and Postpartum counseling and testing have been introduced successfully in PMH and reach a high number of women and their children. Uptake of intervention is high inspite most mothers being tested intrapartum and postpartum however contraception uptake remains a challenge.

The urgency to achieve universal access to ART is forcing health systems to find innovative ways of integrating HIV care into the existing established service delivery points. On the other hand, reproductive health clinics have suffered serious set backs since the advent of HIV as more attention went to HIV care parallel programming. It is now becoming quite clear that better results could be achieved in both of the two areas through integration of services. It is not however known how prepared SRH clinics are to be able to offer HIV care. The entry points to HIV care presented by SRH clinics also need evaluation to establish the advantages that they present.

To assess site preparedness to initiate, manage and sustain ARV treatment in SRH clinics. To find out the possibility of ART roll out through SRH clinics using SRH services as entry points.

This was a cross sectional study. A modified DELIVER ARV Site Preparedness Assessment Tool was used. It covered the 6 ART Domains of Leadership & Model of Care; Services and Clinical Care; Monitoring & Evaluation; Human Resource Capacity; Laboratory Capacity and Drug Management & Procurement. Key informant and group interviews were conducted with clinic managers, service providers, laboratory staff, PLWAs and staffs from Ministry of Health. ARV policies, plans and reports and research and accreditation tools were reviewed. Observations were done on status of facilities, equipment and supplies level.

The SRH clinics were found to have the leadership, infrastructural and technical capacities for initiation of ART using the national ARV protocols. Established VCT, management of opportunistic infections, MCH and family planning would act as entry points for ART patient recruitment. However, SRH needs of positive community were not adequately addressed. Links with positive community existed in only two clinics, but were not formalized and there was a reported barrier associated with stigma & discrimination. Similarly, strategic partnerships with other service and care providers had not been institutionalized. Data collection tools needed to be updated to include ARV and HIV/AIDS services. Laboratory had enough capacity in terms of personnel and facilities for basic tests in ART programme. However, there was need for pharmaco-vigilance to monitor adverse drug events. The logistics & dispensing systems were adequate in handling antiretroviral drugs.

With minimal improvements, SRH clinics offer a great opportunity for HIV care. The country could gain a major mileage in increasing access to ART by using these clinics.

SRH clinics, both privately owned, NGO owned and government owned should integrate ART treatment into their services. The clinics would need to be assessed for this service and identified gaps sealed. A pharmaco-vigilance programme should be a component of this service.

Antenatal counseling for HIV/AIDS at the PGH, Nakuru was started on 1^st October 2002. This was important because of the role played by vertical transmission in this pandemic. The desire to know the progress and value of this clinic motivated the undertaking of the study.

To assess the degree of seropositivity among mothers attending the antenatal clinic at PGH, Nakuru.

Retrospective study.

All the available data of clients attending the antenatal clinic at the PGH Nakuru between 1^st October 2002 and 31^st December 2004 was analysed for various parameters.

Over the stated period 7829 clients attended the antenatal clinic and were counselled. Out of this member 5933 clients were tested and 523 (8.8%) found to be positive.

The mean age of the mean age of the attendees was 21.8 year and the range 14-57 years. The age group with the highest attendance was 21-25 years. Of the entire positive cases 39.8% belonged to this age group. However, the highest proportionate percentage of positive cases was that above 35years (11.4%).

The mean gestational age at first visit was 31.2 weeks and the range 5 - 40 weeks. The highest attendance was at 28-32 weeks and highest prevalence of seropositivity was at 13-17 weeks.

The majority of the attended were para 1-2. This group also had the highest number of positive cases (239, 45.7%). The highest prevalence was among those with a parity of 3-4 (15.3%).

Although the majority of the mothers were married and also had the highest number of positive cases (486, 92.9%) the positivity rate was higher among the single than the married clients, 10.7% and 8.7% respectively.

A significant number of mothers were infected during pregnancy and therefore had a high chance of giving birth to infected babies.

Since the rate of vertical transmission can be reduced by counseling and testing and also the use of the anti-retroviral therapy, the establishment of facilities for PMTCT countrywide should be given high priority

The primary objective of the AMPATH PMTCT programme is aligned to the global as well as the national objective to prevent HIV transmission of HIV from infected mothers to their infants, with a target of 20% by year end of year 3 and 40% by end of year 5 having been set for the MTRH programme

Description of programme planning, implementation, programme processes including training and management. Counselling and testing uptake, maternal HIV-seroprevalence, proportion of patients with tracer cards filled for location of defaulters, counseling for and type of infant feeding, ARV prophylaxis and treatment. Infant seroprevalence

More than 14,700 pregnant women have been counselled and tested for HIV between March 2002 and December 2005 while 1,131 HIV positive women have been enrolled into the pMTCT programme and into HAART follow-up programme alongside other patients being followed up in the AMPATH HIV treatment programme. Currently there are 20,128 HIV-Positive patients, 13,372 or approximately two-thirds of who are women, are on follow up. Of the total 9,721 patients who are currently receiving ARVs in the AMPATH programme, 8,871 (91.2%) are on HIV treatment including 576 children while 860 (8.8%) of the patients are pregnant women on prophylaxis for total pMTCT. Several trainings were organised to build capacity of health care providers, and to continue supplementary training to replace health workers lost through transfers and internal brain drain. Ongoing training proved invaluable to keep abreast with the rapid changes in the health care system. It was necessary during the course of the four years to make modifications in the structure of the programme including introducing onsite testing and modifying patient flow. It was also necessary to introduce performance improvement initiatives in order to optimise programme uptake.

Many changes in programme structure, policies regarding testing and antiretroviral drug regimes for prophylaxis as well as changes in practices on infant feeding were necessary to accommodate the changing resource environment new evidence and changing international and national as well as local experience and thinking.

It is possible to achieve ‘90%, 90%, 90%’ regarding PMTC counselling; testing and enrolment into HIV care through aggressive opt-out testing, as well as integration of PMTC services to other reproductive health care services. Stigma and silence are still major challenges hindering uptake of essential PMTC interventions. Comprehensive services synergize different components. Replacement infant feeding is difficult but possible to achieve through individual counselling, community counselling, male involvement and subsidized or free formula supplies.