Implementation of prevention of mother-to-child transmission of HIV and maternal syphilis screening and treatment programmes in Mwanza region, Tanzania : uptake and challenges

ABSTRACT Literature and other background information on prevention of mother-to-child transmission of HIV (PMTCT) and maternal syphilis screening programmes in Tanzania reveal that little has been documented on accessibility and utilization of these services. This thesis presents the results from a research conducted in Mwanza city, Tanzania to assess the operational performance of PMTCT and maternal syphilis screening and treatment during pregnancy, at delivery and in the postnatal period. From different sub-studies conducted at the antenatal clinics (ANC) and in the maternity ward for this research, a number of missed implementation opportunities were identified. A review of records found that 24% of pregnant women who delivered in hospital left the maternity ward with unknown HIV status and 50% of HIV-positive women tested at ANC did not receive Antiretroviral therapy (ART) for PMTCT. A cross-sectional study at the maternity ward found that 12% of pregnant women who were not screened for syphilis, 27% of RPR-positive women who were not treated at ANC, and all infants of RPR-positive women did not receive any intervention to prevent congenital syphilis. Forty-one percent of HIV-positive women recruited in the cohort study successfully completed all PMTCT interventions. Only 18% of HIV-positive women identified through PMTCT were successfully referred to, and attended an adult care and treatment clinic (CTC). Of 403 HIV- positive women in the cohort study, 50% did not intend to get pregnant and by four months postpartum, 20% of them reported to have not received any counselling on family planning. HIV-positive women who did not receive counselling on FP use were at a higher risk of not using contraception compared to those who were counselled (adj. OR=6, 95% Cl; 2.8-12.9). About 27% of HIV-positive mothers were not counselled regarding infant feeding and 40.2% of women who were not counselled on infant feeding were undecided on how to feed their infants before they left the hospital compared to only 2.5% of women who were counselled (P<O.OOl) It was found that pregnant women attending ANC for the first time during pregnancy spent between three and 5.5 hours at the clinic, on average, 78% of this time was spent waiting for services. 6 Fewer ANC visits, attending private or rural ANC facilities, failure to attend a CTC prenatally, and lack of knowledge among users and provider of health services were factors found to hamper the performance of the programmes. Integration of these programmes at all levels and training of health workers in basic components of the programmes are fundamental to the successful implementation of the programme

The need for further integration of services to prevent mother-to-child transmission of HIV and syphilis in Mwanza City, Tanzania.

OBJECTIVE: To assess the operational integration of maternal HIV testing and syphilis screening in Mwanza, Tanzania. METHODS: Interviews were conducted with 76 health workers (HW) from three antenatal clinics (ANC) and three maternity wards in 2008-2009 and 1137 consecutive women admitted for delivery. Nine ANC health education sessions and client flow observations were observed. RESULTS: Only 25.0% of HWs reported they had received training in both prevention of mother-to-child transmission (PMTCT) and syphilis screening. HIV and syphilis tests were sometimes performed in different rooms and results recorded in separate registers with different formats and the results were not always given by the same person. At delivery, most women had been tested for both HIV (79.4%) and syphilis (88.1%) during pregnancy. Of those not tested antenatally for each infection, 70.1% were tested for HIV at delivery but none for syphilis. CONCLUSION: Integration of maternal HIV and syphilis screening was limited. Integrated care guidelines and related health worker training should address this gap

Adverse birth outcomes in United Republic of Tanzania--impact and prevention of maternal risk factors.

OBJECTIVE: To determine risk factors for poor birth outcome and their population attributable fractions. METHODS: 1688 women who attended for antenatal care were recruited into a prospective study of the effectiveness of syphilis screening and treatment. All women were screened and treated for syphilis and other reproductive tract infections (RTIs) during pregnancy and followed to delivery to measure the incidence of stillbirth, intrauterine growth retardation (IUGR), low birth weight (LBW) and preterm live birth. FINDINGS: At delivery, 2.7% of 1536 women experienced a stillbirth, 12% of live births were preterm and 8% were LBW. Stillbirth was independently associated with a past history of stillbirth, short maternal stature and anaemia. LBW was associated with short maternal stature, ethnicity, occupation, gravidity and maternal malaria whereas preterm birth was associated with occupation, age of sexual debut, untreated bacterial vaginosis and maternal malaria. IUGR was associated with gravidity, maternal malaria, short stature, and delivering a female infant. In the women who had been screened and treated for syphilis, in between 20 and 34% of women with each outcome was estimated to be attributable to malaria, and 63% of stillbirths were estimated as being attributable to maternal anaemia. Screening and treatment of RTIs was effective and no association was seen between treated RTIs and adverse pregnancy outcomes. CONCLUSION: Maternal malaria and anaemia continue to be significant causes of adverse pregnancy outcome in sub-Saharan Africa. Providing reproductive health services that include treatment of RTIs and prevention of malaria and maternal anaemia to reduce adverse birth outcomes remains a priority

Risk factors influencing HIV infection incidence in a rural African population: a nested case-control study.

BACKGROUND: Risk factors influencing the incidence of human immunodeficiency virus (HIV) infection were investigated in a case-control study nested within a community-randomized trial of treatment of syndromic sexually transmitted infections (STIs) in rural Tanzania. METHODS: Case patients were persons who became HIV positive, and control subjects were randomly selected from among persons who remained HIV negative. For each sex, we obtained adjusted odds ratios (ORs) and population-attributable fractions (PAFs) for biomedical and behavioral factors. RESULTS: We analyzed 92 case patients and 903 control subjects. In both sexes, the incidence of HIV infection was significantly higher in subjects with an HIV-positive spouse than in those with HIV-negative spouse (men: OR, 25.1; women: OR, 34.0). The incidence of HIV infection was significantly higher in those who became positive for herpes simplex virus type 2 (HSV-2) (men: OR, 5.60; women: OR, 4.76) and those who were HSV-2-positive at baseline (men: OR, 3.66; women: OR, 2.88) than in subjects who were HSV-2 negative. In women, living elsewhere (OR, 3.22) and never having given birth (OR, 4.27) were significant risk factors. After adjustment, the incidence of HIV infection was not significantly associated with a history of injections or STIs in either sex. CONCLUSION: HSV-2 infection was the most important risk factor for HIV infection, which highlights the need for HSV-2 interventions in HIV infection control, and there were particularly strong associations with recent HSV-2 seroconversion. The PAF associated with having an HIV-positive spouse was low, but this is likely to increase during the epidemic

Effect of herpes simplex suppression on incidence of HIV among women in Tanzania.

BACKGROUND: Infection with herpes simplex virus type 2 (HSV-2) is associated with an increased risk of acquiring infection with the human immunodeficiency virus (HIV). This study tested the hypothesis that HSV-2 suppressive therapy reduces the risk of HIV acquisition. METHODS: Female workers at recreational facilities in northwestern Tanzania who were 16 to 35 years of age were interviewed and underwent serologic testing for HIV and HSV-2. We enrolled female workers who were HIV-seronegative and HSV-2-seropositive in a randomized, double-blind, placebo-controlled trial of suppressive treatment with acyclovir (400 mg twice daily). Participants attended mobile clinics every 3 months for a follow-up period of 12 to 30 months, depending on enrollment date. The primary outcome was the incidence of infection with HIV. We used a modified intention-to-treat analysis; data for participants who became pregnant were censored. Adherence to treatment was estimated by a tablet count at each visit. RESULTS: A total of 821 participants were randomly assigned to receive acyclovir (400 participants) or placebo (421 participants); 679 (83%) completed follow-up. Mean follow-up for the acyclovir and placebo groups was 1.52 and 1.62 years, respectively. The incidence of HIV infection was 4.27 per 100 person-years (27 participants in the acyclovir group and 28 in the placebo group), and there was no overall effect of acyclovir on the incidence of HIV (rate ratio for the acyclovir group, 1.08; 95% confidence interval, 0.64 to 1.83). The estimated median adherence was 90%. Genital HSV was detected in a similar proportion of participants in the two study groups at 6, 12, and 24 months. No serious adverse events were attributable to treatment with acyclovir. CONCLUSIONS: These data show no evidence that acyclovir (400 mg twice daily) as HSV suppressive therapy decreases the incidence of infection with HIV. (Current Controlled Trials number, ISRCTN35385041 [controlled-trials.com].)

Attrition in the cascade of HIV assessment and treatment steps taken by women identified as HIV positive through PMTCT services.

<p>Attrition in the cascade of HIV assessment and treatment steps taken by women identified as HIV positive through PMTCT services.</p

Cascade of referral and care for HIV-positive pregnant women in Tanzan.

<p>Cascade of referral and care for HIV-positive pregnant women in Tanzan.</p

Risk factors for herpes simplex virus type 2 and HIV among women at high risk in northwestern Tanzania: preparing for an HSV-2 intervention trial.

OBJECTIVES: To determine prevalence of and risk factors for herpes simplex virus type 2 (HSV-2) and HIV among women being screened for a randomized, controlled trial of HSV suppressive therapy in northwestern Tanzania. METHODS: Two thousand seven hundred nineteen female facility workers aged 16 to 35 were interviewed and underwent serological testing for HIV and HSV-2. Factors associated with HSV-2 and HIV in women aged 16 to 24 were examined using logistic regression to estimate odds ratios (OR) and 95% confidence intervals (CI). RESULTS: HSV-2 seroprevalence was 80%, and HIV seroprevalence was 30%. Among women aged 16 to 24, both infections were significantly and independently associated with older age, being a bar worker, working at a truck stop, and having more lifetime sexual partners. HSV-2 infection was also associated with lower socioeconomic status, increased alcohol intake, younger age at first sex, inconsistent condom use, and vaginal douching. There was a strong association between the 2 infections after adjustment for other factors (OR = 4.22, 95% CI: 2.6 to 6.9). CONCLUSIONS: Female facility workers in northwestern Tanzania are vulnerable to HSV-2 and HIV infections. Programs designed to increase safer sexual behavior and reduce alcohol use could be effective in reducing HSV-2 incidence and, in turn, HIV infection. This is a suitable population for an HSV suppressive therapy trial

Proportion of HIV positive pregnant women receiving referral and attending an HIV clinic within 4 months post-partum.

1<p>Comprises 240 women tested at the antenatal clinic and 70 women tested at the maternity ward around delivery. Excludes 93 women who were not diagnosed HIV positive for the first time through PMTCT screening in this pregnancy.</p>2<p>Referral post-delivery but pre-discharge from hospital.</p>3<p>Attended an HIV clinic and was issued with HIV clinic attendance/treatment card.</p