High prevalence of unwanted pregnancies and induced abortions among HIV-infected women from Western India:need to emphasize dual method use?

This study examines the prevalence, reasons, and predictors of unwanted pregnancies and induced abortions among ever married HIV-infected women attending a care facility in Maharashtra, Western India, and discusses its programmatic and policy implications. Retrospectively collected data of pregnancies conceived after the diagnosis of HIV were analyzed using descriptive and logistic regression techniques. Among the 622 women interviewed, 113 women had 158 pregnancies with known outcomes after HIV diagnosis. Among these pregnancies, 80 (51%) were unwanted and 79 (50%) were voluntarily terminated. Fear of transmitting HIV to the child was a frequently mentioned reason for an unwanted pregnancy (71.8%) and induced abortion (59.5%). Women from urban areas [OR 2.43 (95% CI 1.23-4.79)] and with two or more live births before HIV diagnosis [OR 3.33 (95% CI 1.36-8.20)] were significantly more likely to report an unwanted pregnancy. Women with two or more live births before HIV diagnosis [OR 3.16 (95% CI 1.20-8.35)], who did not know that HIV transmission to the baby can be prevented [OR 3.29 (95% CI 1.48-7.34)] and with an unwanted pregnancy [OR 4.82 (95% CI 2.33-10.00)], were significantly more likely to terminate the pregnancy. Despite increased coverage of antiretroviral treatment, effective provision of reproductive healthcare services to HIV-infected women remains challenging. A high prevalence of unwanted pregnancies and induced abortions and a low level of knowledge about prevention of mother to child transmission (PMTCT) underscore the need for preconception counseling and provision of comprehensive family planning services to HIV-infected women. Enrolling all HIV-infected pregnant women, irrespective of their decision to continue with their pregnancy, in the PMTCT program and discussing with HIV-infected women and their partners at HIV diagnosis a full array of contraceptive methods and not just consistent use of condoms might be helpful in reducing unwanted pregnancies.</p

Systematic review of public health research on prevention of mother-to-child transmission of HIV in India with focus on provision and utilization of cascade of PMTCT services

BACKGROUND: In spite of effective strategies to eliminate mother-to-child-transmission of HIV, the implementation of such strategies remains a major challenge in developing countries. In India, programs for the prevention of mother-to-child transmission (PMTCT) have been scaled up widely since 2005. However, these programs reach only a small percentage of pregnant women, and their overall effectiveness is low. Evidence-based program planning and implementation could significantly improve their effectiveness. This study sought to systematically retrieve, thematically categorize and review published research on PMTCT of HIV in India, focusing on research related to the provision and/or utilization of the cascade of services provided in a PMTCT program, in order to direct further research to enhance program implementation and effectiveness. METHODS: A systematic search using MEDLINE, US National Library of Medicine Gateway system (PubMed) and ISI Web of Knowledge resulted in 1,944 abstracts, of which 167 met our inclusion criteria. RESULTS: A huge share of the empirical literature on PMTCT in India (N = 134) deals with epidemiological studies (N = 60). The 46 papers related to utilization/provision of the cascade of PMTCT services were mostly from the four high HIV prevalence states in southern India and from the public sector. Studies on experiences of implementing a PMTCT program (N = 20) show high rates of drop out of women in the cascade particularly prior to receiving ARV. Studies on individual components of the cascade (N = 26) show that HIV counseling and testing is acceptable and feasible. Literature on other components of the cascade - such as pregnant women’s access to ANC care, HIV infected women’s immunological assessment using CD4 testing, repeat HIV testing among pregnant women, early infant diagnosis and factors related to linking HIV infected women and children to postnatal care – is lacking. CONCLUSIONS: While the scale of the Indian PMTCT program is large, comprehensive understanding of the context-driven factors affecting its efficiency is lacking. Systematic and more focused public health research output is needed on the issues related to reduction of drop outs of women in the cascade, role of PMTCT programs in improving maternal and child health indicators and role of private sector in delivering PMTCT services

Occurrence of Pregnancies among HIV Infected Indian Women

This is the first study to examine the behavioural effect of HIV on fertility among HIV infected women in India. Retrospective calendar data from ever-married HIV infected women between 15 and 45 years of age, attending a specialized HIV clinic in Pune, Western India (N = 560), were analysed. Directly standardized overall and parity-specific pregnancy rates were compared among HIV infected women before and after coming to know about their HIV status. The age- and parity-standardized pregnancy rates and age-standardized parity-specific pregnancy rates were statistically significantly lower after knowing about HIV status as compared to before the HIV status was known. Analysis of parity-specific rates suggested lower likelihood of HIV infected women to progress to higher parity. The clear behavioural impact of HIV on fertility observed should be taken into account while estimating HIV infected pregnant women in the country. Ensuring access to information and services for PMTCT to HIV infected couples is essential to support informed reproductive decision making among them

HIV testing among pregnant women living with HIV in India: are private healthcare providers routinely violating women’s human rights?

Background In India, approximately 49,000 women living with HIV become pregnant and deliver each year. While the government of India has made progress increasing the availability of prevention of mother-to-child transmission of HIV (PMTCT) services, only about one quarter of pregnant women received an HIV test in 2010, and about one-in-five that were found positive for HIV received interventions to prevent vertical transmission of HIV. Methods Between February 2012 to March 2013, 14 HIV-positive women who had recently delivered a baby were recruited from HIV positive women support groups, Government of India Integrated Counseling and Testing Centers, and nongovernmental organizations in Mysore and Pune, India. In-depth interviews were conducted to examine their general experiences with antenatal healthcare; specific experiences around HIV counseling and testing; and perceptions about their care and follow-up treatment. Data were analyzed thematically using the human rights framework for HIV testing adopted by the United Nations and India’s National AIDS Control Organization. Results While all of the HIV-positive women in the study received HIV and PMTCT services at a government hospital or antiretroviral therapy center, almost all reported attending a private clinic or hospital at some point in their pregnancy. According to the participants, HIV testing often occurred without consent; there was little privacy; breaches of confidentiality were commonplace; and denial of medical treatment occurred routinely. Among women living with HIV in this study, violations of their human rights occurred more commonly in private rather than public healthcare settings. Conclusions There is an urgent need for capacity building among private healthcare providers to improve standards of practice with regard to informed consent process, HIV testing, patient confidentiality, treatment, and referral of pregnant women living with HIV

Couple-oriented prenatal HIV counseling for HIV primary prevention: an acceptability study

<p>Abstract</p> <p>Background</p> <p>A large proportion of the 2.5 million new adult HIV infections that occurred worldwide in 2007 were in stable couples. Feasible and acceptable strategies to improve HIV prevention in a conjugal context are scarce. In the preparatory phase of the ANRS 12127 Prenahtest multi-site HIV prevention trial, we assessed the acceptability of couple-oriented post-test HIV counseling (COC) and men's involvement within prenatal care services, among pregnant women, male partners and health care workers in Cameroon, Dominican Republic, Georgia and India.</p> <p>Methods</p> <p>Quantitative and qualitative research methods were used: direct observations of health services; in-depth interviews with women, men and health care workers; monitoring of the COC intervention and exit interviews with COC participants.</p> <p>Results</p> <p>In-depth interviews conducted with 92 key informants across the four sites indicated that men rarely participated in antenatal care (ANC) services, mainly because these are traditionally and programmatically a woman's domain. However men's involvement was reported to be acceptable and needed in order to improve ANC and HIV prevention services. COC was considered by the respondents to be a feasible and acceptable strategy to actively encourage men to participate in prenatal HIV counseling and testing and overall in reproductive health services.</p> <p>Conclusions</p> <p>One of the keys to men's involvement within prenatal HIV counseling and testing is the better understanding of couple relationships, attitudes and communication patterns between men and women, in terms of HIV and sexual and reproductive health; this conjugal context should be taken into account in the provision of quality prenatal HIV counseling, which aims at integrated PMTCT and primary prevention of HIV.</p

Usefulness of rights based written narratives on sexual and reproductive health among HIV-infected women in Western Maharashtra, India

Narrative communication is emerging as an effective form of health communication in the research being carried out globally. This exploratory study assessed perceived usefulness of a book of seven narratives on different issues related to sexual and reproductive health among HIV-infected couples. Sixteen in-depth interviews and 174 structured interviews were conducted among HIV-infected women to understand the usefulness of such narratives and differences in knowledge and attitude respectively. Thematic analysis and descriptive statistics were used to analyze the data. The written narratives were perceived to be useful by HIV-infected women. They positively affected the self-efficacy beliefs of women, improved acceptance of the partner, helped them cope with the disease and in making more informed decisions as well as contributing to decreased misconceptions. The narratives were simultaneously perceived as “too emotional”, discouraging women to engage with the text. The knowledge and attitude about sexual and reproductive health (SRH) does not seem to be statistically significantly different among women who read the book compared to those who did not read it. In diseases such as HIV, which can lead to biographical disruption, this research shows that there is need for health communication that supports people in accepting and emotionally coping with the disease

Socio-demographic factors associated with loss to follow-up of HIV-infected women attending a private sector PMTCT program in Maharashtra, India

International audienceCurrently 40 percent of HIV infected women enrolled in national PMTCT program in India are lost to follow-up (LTF) before they can receive single dose Nevirapine. To date no study from India has examined the reasons for inadequate utilization of PMTCT services. This study sought to examine the socio-demographic factors associated with LTF of HIV infected women enrolled during 2002 to 2008 in a large-scale private sector PMTCT project in Maharashtra, India. Data on HIV infected women who were enrolled during pregnancy (N= 734) and who reported live birth (N= 770) were used to analyze factors associated with LTF before delivery and after delivery respectively. Univariate and multivariate analyses were conducted to estimate the associations between being LTF and socio-demographic factors using generalized linear models. Eighty (10.9%) women were LTF before delivery and 151 (19.6%) women were LTF after delivery. Women with less than graduate level education (RR= 6.32), from a poor family (RR= 1.61), who were registered after 20 weeks of pregnancy (RR= 2.02) and whose partners were HIV non-infected or with unknown HIV status (RR=2.69) were more likely to be LTF before delivery. Similarly, the significant factors for LTF after delivery were less than graduate level education (RR=1.82), poor family (RR=1.42) and registration after 20 weeks of pregnancy (RR=1.75). This study highlights the need for innovative and effective counseling techniques for less educated women, economic empowerment of women, better strategies to increase up-take of partner's HIV testing and early registration of women in the program for preventing LTF in PMTCT programs. This need for innovative counseling techniques is even greater for PMTCT programs in the public health sector as the women accessing care in the public sector are likely to be less educated and economically more deprived

Advances in the prevention of mother-to-child transmission of HIV and resulting clinical and programmatic implications

Abstract: Following scientific advancements in the prevention of mother-to-child transmission (PMTCT) of HIV, a global plan is being implemented to virtually eliminate new pediatric HIV infections. However, despite revisions to guidelines for providing antiretroviral medications, including the availability of more effective drug regimens over the past decade, and the recent rapid scale-up of PMTCT services, sizeable challenges persist in achieving this goal. This paper provides a summary of recent approaches to the provision of antiretroviral medicines to pregnant women and the resulting implications. Emerging programmatic and service delivery considerations, aiming to increase the effectiveness of PMTCT programs to overcome barriers faced by women in accessing PMTCT services are also discussed. Worldwide elimination of pediatric HIV is now a possibility due to the increasing similarity of PMTCT guidelines in developing countries to those in developed countries. However the resulting practical challenges of implementation will require resources and support at local, national, and international levels. As developing countries strive to adopt and implement more efficacious drug regimens, the effectiveness of PMTCT programs will be determined by coverage of services and the recruitment and retention of pregnant women in the cascade. To expand services and provide an effective, comprehensive approach in under resourced settings, harmonized efforts to address barriers whilst considering contextual factors will be needed