Allde, N

Beltman, JJ

Buhendwa, L

Fitzgerald, M

Kazima, J

Moens, M

Zachariah, R

English

MSF Field Research

Accelerated HIV testing for PMTCT in maternity and labour wards is vital 
to capture mothers at a critical point in the programme at district level
in Malawi.
T U P E 0 3 6 8
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JJ Beltman (1),  M Fitzgerald (2), L Buhendwa (2), M Moens (2), R Zachariah (3), J Kazima (2), N Alide (1)
(1) Thyolo District Health Services, Ministry of Health and Population, Thyolo Malawi
(2) Médicins sans Frontières- Belgium, Thyolo District
(3) Médicins sans Frontières- Belgium, Medical Department, Brussels
• Mainly rural population: >570.000
• Prevalence HIV at ANC: approx. 22% 
• No. living with HIV/AIDS: 50.000+ 
• No. with advanced HIV/AIDS: 8-11.000
• No. of estimated deliveries per year: 20-25.000
• No. Orphans – 40.000
Thyolo District
Introduction
Mother to Child transmission (MCT) accounts for almost 1 million newly 
infected children in Sub Saharan Africa annually.
Missed opportunities for HIV testing in the prenatal maternity and labour 
wards were previously documented at 63% in our hospital in 2002-3 (1).   
(March 2002 - September 2003 September 2003 September )
Many HIV+ mothers give birth in health facilities without having had
a previous HIV test, thereby missing an opportunity for prevention of 
transmission of infection to her infant and also care for her own health.
In 2005 an audit of maternal deaths in Thyolo also found that infection 
related deaths accounted for 59% of all maternal mortality 2005.
While only a small number of mothers who died were tested, HIV was 
positive in all those who were tested.
The objective of our study was to examine the impact of accelerated HIV
testing in the maternity and delivery wards in Thyolo District Hospital. 
A prevention of mother to child transmission programme (PMTCT) had 
been implemented since beginning of 2002. Previously most of the 
testing was done at the antenatal clinic (ANC).  (prevalence of 20%)
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Thyolo District Hospital
 Thyolo, Malawi
A programme revision was conducted in 2005. Following this a number 
of changes were made.
From June 2005 – January 2006 the PMTCT programme targeted women
who attended for any inpatient care, including high-risk pregnancies, 
malaria, early labour or pregnancies for caesarean section.
All admissions were offered Opt-out testing and counselling.
Women who tested HIV positive were offered nevirapine (NVP)
prophylaxis intrapartum. Their babies received a single dose of NVP 
within 72 hours after delivery (2 mg/kg).
We adopted a One Stop Approach to our antenatal and maternity services
(this meant that all prevention and care services were integrated in 
the same clinic).  CD4 test and clinical staging were also introduced in 
August 2005.
The One Stop Approach was further accelerated in January 2006.
A retrospective review of birth registers from June 2005 until January 
2006 was done.
Methods
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•
•
•
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•
Months
Number 
tested
Months
Number 
tested
Counselling and testing
120
100
  80
  60
  40
  20
    0
June Aug Oct Dec Feb April Sept June Dec March
Tested Hiv+ of total tested in 
maternity / labour ward
Trend of PMTCT deliveries after starting
accelerated HIV testing in different wards
Tested HIV+ in maternity and labour ward Total number counselled and tested
Total tested in maternity and labour ward
140
120
100
  80
  60
  40
  20
    0
Missed opportunities for HIV testing in hospital
70%
60%
50%
40%
30%
20%
10%
  0%
March (2002)
 - Sept (2003)
June (2005) 
 - Jan (2006)
  Feb (2006)
- May (2006)
Percentage missed opportunities Total inknown Tested in labour ward Tested in maternity ward Tested in ANC Hospital deliveries PMTCT deliveries
350
300
250
200
150
100
  50
    0
60
50
40
 30
  20
 10
   0
Months
Sites of CT of all Hospital deliveries (June 2005 - May 2006)
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June Aug Oct Dec Feb April
Relative contribution 
of HIV testing at 
different sites of 
total hospital deliveries
June Aug Oct Dec Feb April
Months
Number 
tested
Months
Number 
tested
Counselling and testing
120
100
  80
  60
  40
  20
    0
June Aug Oct Dec Feb April Sept June Dec March
Tested Hiv+ of total tested in 
maternity / labour ward
Trend of PMTCT deliveries after starting
accelerated HIV testing in different wards
Tested HIV+ in maternity and labour ward Total number counselled and tested
Total tested in maternity and labour ward
140
120
100
  80
  60
  40
  20
    0
Missed opportunities for HIV testing in hospital
70%
60%
50%
40%
30%
20%
10%
  0%
March (2002)
 - Sept (2003)
June (2005) 
 - Jan (2006)
  Feb (2006)
- May (2006)
Percentage missed opportunities Total inknown Tested in labour ward Tested in maternity ward Tested in ANC Hospital deliveries PMTCT deliveries
350
300
250
200
150
100
  50
    0
60
50
40
 30
  20
 10
   0
Months
Sites of CT of all Hospital deliveries (June 2005 - May 2006)
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June Aug Oct Dec Feb April
Relative contribution 
of HIV testing at 
different sites of 
total hospital deliveries
June Aug Oct Dec Feb April
During the study period 1941 women delivered of whom 212 were 
previously identiﬁ  ed as HIV positive (prevalence of 11%). (Fig. 1, 2)
An additional 30 (12.4%) tested HIV positive in the maternity / labour ward.
With an overall annual hospital based HIV prevalence of 20% a total of 388 
HIV deliveries were expected and 146 (37%) were missed compared with 
63% in 2003. In the ﬁ  nal month of study a 24 hour testing service was 
implemented which resulted in an additional 73 women tested of whom 
17 (24%) were HIV positive.
From February till May 2006, 918 hospital deliveries were reported. 
With an overall prevalence rate of 22% (revised since Jan 2006) a total of 
202 HIV + deliveries were expected. A reported 163 (81%) HIV deliveries 
took place in the hospital. Reduction from 63% to 19% missed opportunities
for HIV testing. (Fig. 3, 4, 5)
This additional PMTCT testing was well accepted by both staﬀ   and patients
in the hospital. Round the clock, 24 x 7 days HIV testing is vital to maintain a 
high PMTCT coverage for women delivering in district health facilities.
Acceleration in HIV testing in maternity and labour ward 24 x 7, could 
beneﬁ  t patients by knowing the HIV status in advance and will make early 
intervention possible, with hopefully a reduction of maternal deaths. 
This needs further research.
Results
•
•
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•
Months
Number 
tested
Months
Number 
tested
Counselling and testing
120
100
  80
  60
  40
  20
    0
June Aug Oct Dec Feb April Sept June Dec March
Tested Hiv+ of total tested in 
maternity / labour ward
Trend of PMTCT deliveries after starting
accelerated HIV testing in different wards
Tested HIV+ in maternity and labour ward Total number counselled and tested
Total tested in maternity and labour ward
140
120
100
  80
  60
  40
  20
    0
Missed opportunities for HIV testing in hospital
70%
60%
50%
40%
30%
20%
10%
  0%
March (2002)
 - Sept (2003)
June (2005) 
 - Jan (2006)
  Feb (2006)
- May (2006)
Percentage missed opportunities Total inknown Tested in labour ward Tested in maternity ward Tested in ANC Hospital deliveries PMTCT deliveries
350
300
250
200
150
100
  50
    0
60
50
40
 30
  20
 10
   0
Months
Sites of CT of all Hospital deliveries (June 2005 - May 2006)
����
���
���
���
���
����
June Aug Oct Dec Feb April
Relative contribution 
of HIV testing at 
different sites of 
total hospital deliveries
June Aug Oct Dec Feb April
Months
Number 
tested
Months
Number 
tested
Counselling and testing
120
100
  80
  60
  40
  20
    0
June Aug Oct Dec Feb April Sept June Dec March
Tested Hiv+ of total tested in 
maternity / labour ward
Trend of PMTCT deliveries after starting
accelerated HIV testing in different wards
Tested HIV+ in maternity and labour ward Total number counselled and tested
Total tested in maternity and labour ward
140
120
100
  80
  60
  40
  20
    0
Missed opportunities for HIV testing in hospital
70%
60%
50%
40%
30%
20%
10%
  0%
March (2002)
 - Sept (2003)
June (2005) 
 - Jan (2006)
  Feb (2006)
- May (2006)
Percentage missed opportunities Total inknown Tested in labour ward Tested in maternity ward Tested in ANC Hospital deliveries PMTCT deliveries
350
300
250
200
150
100
  50
    0
60
50
40
 30
  20
 10
   0
Months
Sites of CT of all Hospital deliveries (June 2005 - May 2006)
����
���
���
���
���
����
June Aug Oct Dec Feb April
Relative contribution 
of HIV testing at 
different sites of 
total hospital deliveries
June Aug Oct Dec Feb April
Months
Number 
tested
Months
Number 
tested
Counselling and testing
120
100
  80
  60
  40
  20
    0
June Aug Oct Dec Feb April Sept June Dec March
Tested Hiv+ of total tested in 
maternity / labour ward
Trend of PMTCT deliveries after starting
accelerated HIV testing in different wards
Tested HIV+ in maternity and labour ward Total number counselled and tested
Total tested in maternity and labour ward
140
120
100
  80
  60
  40
  20
    0
Missed opportunities for HIV testing in hospital
70%
60%
50%
40%
30%
20%
10%
  0%
March (2002)
 - Sept (2003)
June (2005) 
 - Jan (2006)
  Feb (2006)
- May (2006)
Percentage missed opportunities Total inknown Tested in labour ward Tested in maternity ward Tested in ANC Hospital deliveries PMTCT deliveries
350
300
250
200
150
100
  50
    0
60
50
40
 30
  20
 10
   0
Months
Sites of CT of all Hospital deliveries (June 2005 - May 2006)
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����
June Aug Oct Dec Feb April
Relative contribution 
of HIV testing at 
different sites of 
total hospital deliveries
June Aug Oct Dec Feb April
Conclusions
Acknowledgements
We are greatful to the Thyolo District Hospital management, MCH coordinator (MSF and MoH ) 
for their collaboration and encouragement in trying to implement new PMTCT strategies in the 
hospital and district.
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Literature
1 High acceptability of voluntary counselling and HIV-testing but unacceptable loss to follow up in 
a prevention of mother-child HIV transmission programme in rural Malawi: scaling- up requires a 
diﬀ  erent way of acting. M Manzi, R Zachariah, et al. In: Tropical Medicine and International Health
2005. 10, no 12, 1242-1250 
Figure1 Figure2
Figure3 Figure4
Figure5
PosterCanada.2.ndd   1 24-07-2006   13:36:31

Accelerated HIV testing for PMTCT in maternity and labour wards is vital to capture mothers at a critical point in the programme at district level

Accelerated HIV testing for PMTCT in maternity and labour wards is vital to capture mothers at a critical point in the programme at district level

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