Services to prevent the mother-to-child transmission (PMTCT) of HIV are gaining ground in Malawi but the country continues to battle drug shortages and mothers and infants that disappear to follow-up and treatment.
In 2005 only three percent of HIV-positive mothers were using PMTCT services, and mother-to-child transmission of HIV accounted for 30 percent of all new infections nationally.
Today, 45 percent of HIV-positive pregnant women are accessing PMTCT services, and paediatric HIV testing and treatment have improved substantially, putting Malawi on track to meet the Millennium Development Goal of reduced infant mortality by 2015, according to a new report by the International Treatment Preparedness Coalition, a support group for people living with HIV and AIDS.
About a year ago the country changed its PMTCT from single-dose nevirapine to combination therapy, which is more effective and also less likely to lead to drug resistance, and issued treatment guidelines that made all HIV-positive infants eligible for antiretroviral (ARV) treatment.
"PMTCT has improved in the last two to three years, especially with the decentralisation of services and integration within antenatal services," said Marielle Bemelmans, Head of Mission at Médecins Sans Frontières (MSF), the international medical charity, in Thyolo, southern Malawi, an area hit hard by HIV.
She said more than 95 percent of pregnant women were opting to test for HIV, and that there were more sites to cater for those who tested positive. In 2007 just four sites offered PMTCT services in Thyolo; three years later there are 32.
Malawi's national HIV prevalence rate is about 12 percent, but this masks large differences in regional infection levels - Thyolo, for example, has an estimated HIV rate of about 21 percent.
Providing ARVs like nevirapine, as part of PMTCT services can lower her baby's chances of being infected by more than 40 percent, according to UNAIDS.
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Changing regimes, needed drugs
In Malawi the difference between a rural clinic and its urban counterpart can be just a 40-minute drive, but that can make all the difference to drug access. At Natenge, about 60km outside the capital, Lilongwe, Kondwani Tambuli, midwife and nurse, was trained on administering combination therapy almost a month ago but still does not have the drugs he needs to put his training into practice.
The country's report to the 2009/10 UN General Assembly's Special Session on HIV/AIDS (UNGASS) showed that drug stock-outs were a major challenge in scaling up PMTCT services. An assessment of 253 PMTCT sites in October 2009 found almost half had no PMTCT drugs.
As of late March, Tambuli was left with no choice but to continue administering less-effective, single-dose therapy. In a country where many women only access antenatal care once and deliver at home, Tambuli often gives the women he sees a the single dose of nevirapine to take with them, and tells them to take it when labour sets in. Although deliveries at the clinic have increased in the last three years, more than 40 percent of women have their babies at home.
Around 93 percent of pregnant women make the first of what should be at least four visits to an antenatal clinic, but Dr Kondwani Ng'oma, a PMTCT and Paediatric HIV Care Specialist for the UN Children's Fund (UNICEF), estimated that about a third of them never make the second.
"We advise them to deliver in the hospitals but there are still some that say [no] because they live far from the facility," said Tambuli. Parents sometimes pressure women into using traditional birth attendants, but home birth means that some mothers and infants will not get the ARVs they need to complete PMTCT treatment.
Now you see them, now you don't
In Kawale, a high-density neighbourhood in the capital, the local clinic has rolled out combination therapy as well as physical patient tracking, a key factor in cutting the number of patients who simply disappear and are not followed up, said Elson Bowa, Lilongwe district PMTCT coordinator and clinical officer.
Photo: Laura Lopez Gonzalez/IRIN
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The Baylor International Paediatric AIDS Initiative has sponsored outreach workers on bicycles to find the missing patients, and HIV-positive pregnant women and new mothers are followed up to make sure they access PMTCT services and early infant dried blood spot (DBS) testing.
DBS tests for HIV, which are ideal in resource-constrained settings, allow a blood sample to be collected and dried on filter paper, and then transported from the clinic to the health facility – in this case via motorbike – without refrigeration. The health facility must be able to perform the sensitive polymerase chain reaction (PCR) test, which accurately tests HIV-exposed infants for the virus.
The bulk this and other HIV testing in Malawi is carried out by health surveillance assistants (HSAs), or community health workers, which allows Malawi's scarce nurses to perform other duties, including examining patients, post-test counselling and dispensing drugs.
Zephi Kuchona, a community health worker for the Baylor International Paediatric AIDS Initiative, who also does HIV testing, said the combination therapy and measures to track missing moms meant that only about one out of every 50 babies born at the clinic was HIV-positive when DBS tests were conducted at six weeks.
Bicycles and outreach workers for such intensive follow-up were expensive, said HSA Mcdonald Maleta, who worried that Baylor's funding would one day dry up, leaving health workers like him without the means of reaching new moms and their babies with the treatment they need.