Better prevention needed for HIV-exposed babies

About half the babies exposed to HIV may not be getting the antiretroviral (ARV) drugs they need to be born HIV-free and stay that way, say the findings of a four-country study published in the Journal of the American Medical Association (JAMA).

The study, conducted in Cameroon, Cote d'Ivoire, South Africa and Zambia, found that only 51 percent of HIV-exposed infants had received a single dose of nevirapine before and after birth, the basic tool in prevention of mother-to-child HIV transmission (PMTCT).

The major problem was non-adherence among expecting mothers - more than a quarter did not take the nevirapine tablet at the onset of labour, and health workers also sometimes failed to dispense the drug or check that mothers had taken it. According to UNAIDS, using nevirapine as part of PMTCT services can lower a baby's chances of contracting HIV by more than 40 percent.

The study, partly based on data collected from umbilical cord blood samples, also found that many women did not make use of PMTCT services because they or health workers did not know their HIV status – either due to a failure to test or collect the results.

The rocky road to PMTCT access

Dr Elizabeth Stringer of Zambia's Centre for Infectious Disease Research, lead author of the study, said the findings showed that pregnant women and infants missed the opportunity to use PMTCT services at many stages of antenatal care, from a woman's first visit to the clinic to when the baby was born.

"Non-adherence was significant," Stringer told IRIN/PlusNews. "What this study shows is that when these women, who had forgotten to take their nevirapine ... came to the clinic, no one recognised that they had forgotten; no one recognized that they were HIV-positive and needed PMTCT."

Stringer said these women could be missed because data collection was often difficult. In many areas, women carried their health records with them, while clinics often collected data in multiple, paper-based logs. The inefficiencies of such a system made it hard to keep track of any one woman, even during just nine months of pregnancy.

The lack of data also complicated this kind of research, said Stringer. Most studies charted PMTCT coverage by measuring provision of services, for example, by counting the number of HIV tests given, or PMTCT drugs dispensed.

Results from the new study were likely to be more reliable because of the use of umbilical cord blood samples, and directly observed dosing of the infants by clinic staff to determine whether mother and child had received nevirapine.

"One of the unique things about this study is that it shows where the problems are ... and in different countries, these issues were different," said Stringer. "With information like this, we are able to target the problem areas. I think it just shows us that there's no 'one size fits all' solution when it comes to PMTCT."

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The study recommended better and more counselling for younger, HIV-positive pregnant women, who were less likely to access PMTCT, and for clinics to offer couples counselling to combat the fear of stigma, which prevented some HIV-positive pregnant women from using PMTCT services.

The authors also emphasised the need to change how PMTCT programmes are evaluated, arguing that many of the currently used indicators had led not only to incorrect data, but also to a lack of problem solving.

"We do need to shift the paradigm about how we monitor PMTCT," Stringer told IRIN/PlusNews. "I believe it's possible to eradicate peri-natal HIV but [not] until we take it seriously and target each problem."

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