Challenging plan to eliminate mother-to-child transmission

A plan to virtually eradicate mother-to-child transmission of HIV in Uganda by 2015 by adopting a more cost-effective treatment regimen, beefing up health infrastructure and increasing women's access to family planning, comes with high expectations and significant challenges.



After heterosexual transmission, vertical transmission is Uganda's second leading cause of new infections – the country registers at least 20,000 new infections through childbirth each year. In the absence of any interventions, transmission rates range from 15 to 45 percent, but with effective PMTCT interventions this can be lowered to below 5 percent.



"We have not made a lot of headway on PMTCT; the interventions we have work [but] we have to make a new commitment," Jane Ruth Aceng, director-general of Uganda's health services, said during a recent meeting to evaluate the elimination plan.



Uganda started offering PMTCT in 2000, with the initial programme calling for a single dose of the antiretroviral (ARV), Nevirapine, during delivery. The programme was revised in 2006 to introduce combination ARV regimens, but the delivery of those drugs has not been consistent, something the new plan aims to change.



According to Godfrey Esiru, the Ministry of Health's national PMTCT coordinator, there are at least 1,590 facilities offering PMTCT. However, success will require more than just a rapid scale-up to virtually eliminate vertical transmission by 2015 - a target in line with global HIV prevention goals; Uganda will need to overcome the structural bottlenecks and communication gaps that have plagued its PMTCT programme.



A struggling programme



Comprehensive PMTCT services - which include counselling and testing, the use of combination ARVs, safe delivery and proper infant feeding practices - are often limited to larger national and regional referral hospitals, but the smaller health centres that are often the closest options for rural women can only offer limited facilities.



And access to the health system does not guarantee access to PMTCT services; although more than 90 percent of women seek antenatal care at least once during their pregnancy, just 42 percent go on to give birth with the assistance of skilled health professionals.



According to Leonard Okello, country director for the International HIV/AIDS Alliance, the country's myriad problems begin with an ongoing shortage of trained health workers and basic equipment in the community health facilities that pregnant women access most frequently.



"When the nurses know [a mother] is HIV-positive and they have only one pair of gloves, even the nurses... would find it difficult to help, because they're not sure they won't get infected themselves," he said.



The government has faced criticism for a perceived lack of political commitment to PMTCT, but with the launch of the new programme, activists are hopeful that the country will now give the intervention due attention.



A cornerstone of the new plan is a shift to the World Health Organization’s latest guidelines on PMTCT. Starting in January 2012, Uganda will begin the shift from its current regimen - which involves single-dose ARVs from 14 weeks, during delivery and for seven days after delivery for women with a CD4 count, a measure of immune strength, of 350 or below - to Option B, which involves putting eligible women on triple-therapy ARVs from the 14th week of pregnancy until one week after breastfeeding has ended, which can be up to one year.


















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Some activists argue, however, that Uganda should join Malawi and leapfrog both choices to Option B-plus, whereby all HIV-positive pregnant women begin combination ARVs, irrespective of their CD4 count.



"We are wasting money in debates, seminars, meetings, conferences on whether we should do it or not," said Okello. "Just do it [Option B-plus]. Let's get moving."



Due to a cash crunch, the shift to Option B has been delayed, and the country opted first to transition all facilities to Option A, for which it had the drugs in stock. Starting with the launch in January, Option B will be rolled out in phases, first to national and regional referral hospitals, and then to health centres throughout the country.



By February 2013, Esiru said the ministry hoped to roll out Option B to all facilities that offer PMTCT. It also hopes to introduce PMTCT into an additional 20 percent of the country's sub-county health centres; just 10 percent offer PMTCT services.



Wider improvements ahead



Under the plan, the ministry's reproductive health division will work to improve the uptake of contraceptives to at least halve the number of unintended pregnancies, especially among HIV-positive women. The unmet need for family planning in Uganda is estimated at 41 percent, and the country's population growth rate of 3.3 percent is one of the world's highest.



Village health teams will also become more aggressive in reaching out to the community with rapid HIV tests, specifically to identify HIV-positive pregnant women who have not yet entered the health system. After birth, women need to remain connected to health services, to family planning specialists and to resources for testing their child's HIV status.



The Ministry of Health is in the process of consolidating all infant HIV testing to one lab in Kampala that has an automated system – which many regional testing locations lack. Through a network of hubs, government drivers gather blood samples from health centres around the country and deliver them to the central Kampala lab within days.



"Something that was two weeks is now something like two days," said Charles Kiyaga, national coordinator for early infant diagnosis, adding that the system made it easier to track down HIV-positive children and get them started on treatment quickly.



Health workers will have to undergo training to make the transition from Option A to Option B, while new health workers will have to be placed in regional facilities and quickly trained. In addition, the supply of drugs and basic supplies will need to be consistent.



The ministry has not yet finalized the cost of the plan, though it is certain to be high. There is money available, though, both from the Ugandan government and donors. Funding from the US President's Emergency Plan for AIDS Relief will almost certainly make up the majority; in 2010 alone, it gave Uganda more than US$14.8 million for PMTCT, according to ministry documents. Officials hope that if the programme shows initial success, more donors will sign on to support it.



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