21 June 2012

Zimbabwe: PMTCT Offers Value for Money


AN HIV test is something that most sexually active people, especially men, are not very keen on voluntarily going for. Depending on their knowledge of the disease and pre-test counselling some men and women shudder while waiting for results as this is always an anxious moment.

The tension and pressure eases as one gets his or her results marking a new chapter in that person's life.

Some change their lifestyles for the better and some become reckless, it just depends with how they take the result.

But just knowing that one is HIV negative brings a lot of joy for many especially pregnant mothers.

One such person is Mary Guyo (26) (not real name) of Mbare, who is a mother of three minor children.

She is customarily married to her husband Tinashe and has just given birth to her fourth child.

During her first prenatal visit to their local clinic at three months, Mary underwent a voluntary HIV test, as per health requirements.

"The nurses told me the importance of knowing my status and that I would be put on the Prevention of Mother to Child Transmission programme if the result turned out positive.

"It was my first time to be tested for HIV and I complied and underwent counselling then the test.

"Despite being counselled, I was scared and my results came back HIV negative.

"I was excited that I was OK and nurses advised me to take two other tests during the entire pregnancy. My husband refused to go for testing saying my result was also his.

"I had a normal delivery and did not go under the PMTCT programme since my results remained negative," she told The Herald last week.

After giving birth, Mary did not bother to go for another HIV test and breastfed her son, Nigel.

She allowed her mother-in-law to feed him, porridge, soup and water.

At six months, Mary noticed that Nigel had developed a rash on his body, ulcers in his mouth and would have diarrhoea regularly.

"The rash would not go away, neither did the diarrhoea. My mother-in-law said inhova (fontanelle) and administered traditional herbs, but my son remained sick.

"I took him to the clinic where nurses recommended that we both go for an HIV test. Both my son and I tested positive and I was devastated.

My heart beat fast and I blamed myself for infecting my child. I had been faithful and tested negative for HIV throughout my pregnancy," added Mary.

She said she discovered that during the last trimester of her pregnancy, her husband slept around with different women.

"I do not know if we were discordant when I tested negative or if he contracted HIV later on," she said.

Up to this day, Mary blames herself for this and says she will not forgive her husband.

Mary is one of the thousands of Zimbabwean women who test HIV negative during antenatal care visits and give birth to negative babies but later on infect their newly born babies through breastfeeding when they get infected after delivery.

According to the Elizabeth Glaser Pediatric Aids Foundation, about 40 percent of paediatric HIV infections are acquired during breastfeeding.

National Prevention of Mother to Child Transmission and Paediatric HIV Care and Treatment Co-ordinator in the Ministry of Health and Child Welfare Dr Angela Mushavi emphasised the need for retesting during pregnancy and breastfeeding period to prevent transmission of the virus from a mother to child.

"People should always remember that a negative status is not permanent and we are encouraging retesting of women during pregnancy and when breastfeeding.

"Their sexual partners should also go for regular testing during this period to prevent transmission," said Dr Mushavi during a capacity building workshop for journalists reporting on paediatric infections organised by the Elizabeth Glaser Paediatric Aids Foundation (Egpaf).

She said even if they test negative during the first test, pregnant women should repeat an HIV test at eight months.

"They should also do the same during the breastfeeding period because maybe they would have contracted HIV after giving birth and unknowingly pass it on to their child," she said.

She pointed out the need for parents to continue testing for HIV during and after pregnancy explaining the three stages in which HIV can be transmitted from mother to child.

The stages are during pregnancy, during delivery and while breastfeeding.

"Without any intervention, chances that a baby born to an HIV positive mother will be infected are between 15 and 30 percent without breastfeeding; and 25 to 45 percent with breastfeeding," she said.

She, however, pointed out that even in the absence of any interventions most infants do not become infected.

"With interventions for PMTCT, this can be reduced to 5 percent in developing countries; and to less than 2 percent in developed countries," she added.

Dr Mushavi spoke of how the PMTCT programme was introduced in the country stating its ups and downs.

She said PMTCT started as a three-site pilot in 1999 with the PMTCT programme rolled out in 2002

"Initially we were using only a single dose of nevirapine for both the HIV infected mothers and their HIV exposed infants.

We transitioned to 2006 WHO guidelines in 2009 and Zimbabwe officially adopted the 2010 WHO guidelines in 2010; and implementation started in 2011 at different time points," she pointed out.

Dr Mushavi revealed that 88 percent of expected HIV positive pregnant women were seen in 2010 (52 percent in 2009, 40 percent in 2008). She added that more women are accepting to test in antenatal clinics (ANC); 96 percent of all ANC visits in 2010, compared to 85 percent in 2009 and 78 percent in 2008.

According to Dr Mushavi, 84 percent of estimated HIV positive pregnant women received ARVs for prophylaxis, 74 percent of children received ARV prophylaxis, 12 percent of HIV infected women accessed WHO/CD4 screening out of all HIV positive mothers in 2009. She added that 53 percent of all estimated HIV-exposed infants received CTX prophylaxis, 34 percent out of all HIV-exposed infants had HIV DNA PCR done.

Dr Mushavi added that worldwide, the most successful intervention in the HIV epidemic is the prevention of mother-to-child transmission (PMTCT).

"PMTCT offers value for money and is cost effective (prevent children from getting infected and save costs in future).

"Indeed it is a social injustice against our children if we do not advocate for PMTCT," she said.

Therefore, she said, it is critical to implement the PMTCT programme in line with the global goal of eliminating new paediatric HIV infections Dr Mushavi revealed that the emphasis now is on the use of more efficacious regimens for PMTCT during pregnancy, delivery and the postnatal period.

She said other interventions for prevention of vertical transmission include safe infant feeding practices, proper positioning and proper attachment of baby to the breast when breastfeeding, managing nipple conditions such as cracked nipples and preventing a new HIV infection during pregnancy and lactation (associated with peak viremia and high risk of transmission).

She also added that there is need for safe obstetric practices. Dr Mushavi said even though the country adopted WHO guidelines in May 2010, there was a lag in implementation to allow for revision of training curriculum and M&E tools; and training of health care workers. ARV prophylaxis for HIV positive pregnant women not yet in need of ART for their own health has been characterised in two groups Option A, which is Maternal Zidovudine (also known as AZT). Option B is the Maternal triple ARV prophylaxis. She said nevirapine (NVP) based regimens are not recommended.

"As at end of 2011, 1 390 (85 percent) of all ANC facilities countrywide were implementing Option A of the WHO 2010 guidelines."

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