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Operational effectiveness and 36 week HIV-free survival in the South African programme to prevent mother-to-child transmission of HIV-1
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
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2007 (English)In: AIDS (London), ISSN 0269-9370, Vol. 21, no 4, 509-516 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: Previous studies on the operational effectiveness of programmes to reduce transmission of HIV from mother-to-child (PMTCT) in Africa have generally been hospital-based pilot studies with short follow-up periods. METHOD: Prospective cohort study to evaluate the routine operational effectiveness of the South African National PMTCT Programme, primarily measured by HIV-free survival at 36 weeks post-delivery. Three of eighteen pilot sites participating in the programme were selected as they reflected differences in circumstances, such as HIV prevalence, socioeconomic status and rural-urban location. A total of 665 HIV-positive mothers and their infants were followed. RESULTS: HIV-free survival at 36 weeks varied significantly across sites with 84% in Paarl, 74% in Umlazi and 65% in Rietvlei (P = 0.0003). Maternal viral load was the single most important factor associated with HIV transmission or death [hazard ratio (HR), 1.54; 95% confidence interval (CI), 1.21-1.95]. Adjusting for health system variables (fewer than four antenatal visits and no antenatal syphilis test) explained the difference between Rietvlei and Paarl (crude HR, 2.27; 95% CI, 1.36-3.77; adjusted HR, 1.81; 95% CI, 0.93-3.50). Exposure to breastmilk feeding explained the difference between Umlazi and Paarl (crude HR, 1.74; 95% CI, 1.06-2.84; adjusted HR, 1.41; 95% CI, 0.81-2.48). CONCLUSION: Ever breastfeeding and underlying inequities in healthcare quality within South Africa are predictors of PMTCT programme performance and will need to be addressed to optimize PMTCT effectiveness.

Place, publisher, year, edition, pages
2007. Vol. 21, no 4, 509-516 p.
National Category
Medical and Health Sciences
URN: urn:nbn:se:uu:diva-97660OAI: oai:DiVA.org:uu-97660DiVA: diva2:172687
Available from: 2008-10-28 Created: 2008-10-28 Last updated: 2010-03-29Bibliographically approved
In thesis
1. Prevention of Mother to Child Transmission of HIV in Africa: Operational Research to Reduce Post-natal Transmission and Infant Mortality
Open this publication in new window or tab >>Prevention of Mother to Child Transmission of HIV in Africa: Operational Research to Reduce Post-natal Transmission and Infant Mortality
2008 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

This thesis assesses the effectiveness of the National Prevention of Mother to Child Transmission of HIV (PMTCT) programme in 3 sites in South Africa, and the quality of infant feeding counselling across four countries, Botswana, Kenya, Malawi and Uganda .

Implementation and outcome of PMTCT services were very different across the 3 sites. The Paarl site is achieving results comparable to clinical trial studies with a HIV-free survival rate of 85% at 36 weeks, while Umlazi is somewhat lower (74%) and Rietvlei, with HIV-free survival of 64%. Maternal viral load, prematurity and site were independent risk factors for infection and/or death. The regression analysis suggests that some of this difference is explained by the differences in quality of health systems across the sites. Traditional risk factors (e.g. viral load, prematurity) do not seem to explain the substantial differences in HIV-free survival between the Paarl and Rietvlei sites.

The overall mortality rate for HIV exposed infants in this cohort was 155 per 1000 live births at 36 weeks, a level higher than most other HIV exposed cohorts. The excess mortality is occurring almost completely amongst HIV infected infants who had a nine fold increased risk of mortality compared with HIV exposed but HIV negative infants. There was no significant difference in 36 week survival rates between those HIV exposed but uninfected infants and those who were not HIV exposed, Hazard ratio 0.7 (95% CI 0.3-1.5).

With respect to HIV and infant feeding most health workers across the four countries (234/334, 70%) were unable to correctly estimate the transmission risks of breastfeeding. Exposure to PMTCT training made little difference to this. Infant feeding options were mentioned in 307 out of 640 (48%) observations of PMTCT counselling session and in only 35 (5.5%) were infant feeding issues discussed in any depth; of these 19 (54.3%) were rated as poor. South Africa was similar with only two out of thirty four HIV positive mothers being asked about essential conditions for safe formula feeding before a decision was made.

This body of work has demonstrated that the gap between efficacy and effectiveness can be significant.

Place, publisher, year, edition, pages
Uppsala: Universitetsbiblioteket, 2008. 47 p.
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 389
HIV/AIDS, Prevention of Mother to Child Transmission of HIV, infant feeding, child health, cohort study, health systems evaluation, effectiveness
urn:nbn:se:uu:diva-9331 (URN)978-91-554-7314-3 (ISBN)
Public defence
2008-11-20, Rosénsalen, Akademiska sjukhuset, Ing. 95/96 nb, Uppsala, 13:15
Available from: 2008-10-28 Created: 2008-10-28Bibliographically approved

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