PMTCT Services – Prevention of mother to child transmission of HIV
This chapter deals with the review of related literature. The review is divided into the following: theoretical, empirical and conceptual review.
Prevention of mother to child transmission of HIV
According to UNAIDS (2012), PMTCT begins with the non-pregnant woman. Preventing mother-to-child transmission is achievable. Between 2009 and 2011, 409,000 new infections were averted among children UNAIDS (2012).
The success of preventing HIV transmission from mothers to their children requires multiple interventions not only during pregnancy, labour and breastfeeding, but among all women and girls. Without adequate comprehensive intervention, about a third of HIV positive women will transmit the virus to their children during pregnancy, labour and delivery and through breastfeeding (WHO 2012). To control vertical transmission various interventions have been developed since the discovery of MTCT. Preventive interventions aimed at reducing MTCT largely focuses on prevention of intra-partum and post-partum transmission of HIV.
Current effective interventions aimed at reducing MTCT includes use of antiretroviral to decrease maternal viral load, elective caesarean section (aimed at reducing exposure to maternal secretions during vaginal delivery) and the avoidance of breastfeeding (de cook, 2004).
Use of anti –retroviral prophylaxis
In developing countries, the use of antiretroviral medications in combination with other medication or alone lowers the risk of MTCT. There was a major breakthrough in prevention of vertical transmission of HIV in 1994 by the Paediatric AIDS clinical Trial Group. The breakthrough demonstrated Zidovudine monotherapy reduces the risk of MTCT in non-breastfeeding population (Connor, 2004). Zidovudine monotherapy is administered in the second and third trimesters of pregnancy and intravenously during delivery while given to infants at 6 weeks after birth. Also, combined therapy with two or more antiretroviral drugs is assumed to be effective in reduction of the risk of perinatal transmission than monotherapy. There is also the use of Highly active anti-retroviral therapy.
Option B+ is the latest treatment option recommended by the WHO or PMTCT (WHO, 2012). Unlike other treatment options, Option B+ recommends that all HIV positive pregnant women are placed onto a triple antiretroviral regimen for PMTCT, irrespective of their CD4 count and continuing for life. Option B+ reduces the risk of MTCT of HIV and all future pregnancies.
Modification of Obstetrical practices
Several obstetrical measures to prevent mother to child transmission should be implemented when possible.
The risk of MTCT of HIV will be increased following increase in maternal-to-foetal vaginal secretion exposure and maternal-to-foetal blood exposure.
Time of rupture of membranes should also be shortened following vaginal delivery;and progress of labour should be measured using the partograph to prevent prolonged labour which increases the risk of MTCT.
- Avoiding instrumentations
Standard operating procedures during vaginal delivery for PMTCT should be adhered to such as avoidance of instrumentation e.g. forceps delivery, vacuum delivery, and episiotomies should be avoided.
- Caesarean delivery
The secretions and fluids excreted in the birth canal during labour are known to infect the foetus as it passes through the birth canal. Delivery by elective caesarean section is efficacious in reducing mother to child transmission of HIV. Gray (2004) asserted that elective caesarean is a cost-effective intervention for the prevention of vertical transmission of HIV when safely available. In a wide range of circumstances even with the risk of 1% in vaginal deliveries, this is achievable with highly active antiretroviral therapy (Mrus 2011). However, incidence rates of postpartum morbidity after caesarean section delivery in women with advanced AIDS are higher than with vaginal delivery. Scheduled caesarean delivery is recommended at 38weeks for women with viral load of more than 1000 copies/mL (receiving ARV or not) and for women with unknown HIV viral load .
- Immediate care of the infant
Immediately after birth, infant should be cleaned of all maternal blood and secretions. The sites for vitamin k and vaccines injections should be properly cleaned to prevent introduction of HIV to the new born iatrogenically. ARV prophylaxis should begin as soon as possible after delivery.
- Infant feeding
Breastfeeding remains an important route of transmission; however, benefits of replacement feeding in Africa are becoming less clear due to competing co-morbidities. PMTCT can be achieved through exclusively breastfeeding (not more than 6months) or exclusive formula feeding and avoidance of mixed feeding. All HIV infected mothers should be encouraged to exclusively breastfeed their babies for the first six months, after which complementary feeds are introduced and breastfeeding continues for up to 12months. Breastfeeding should be accompanied with maternal ART or ARV prophylaxis and/ or infant ARV prophylaxis. If a mother has previously passed through the PMTCT programme, the reason for the change in policy on infant feeding in the context of HIV should be explained in simple term.
2.1.2 Knowledge about prevention of mother to child transmission (PMTCT) among pregnant women
Umeobika, Ezebialu, Ezenyeaku, Ikeako (2013) assessed knowledge and perception of mother to child transmission (MTCT) of HIV among pregnant women receiving antenatal care in a university teaching hospital in South Eastern Nigeria. The cross-sectional survey of 396 antenatal attendees, using a pre-tested, and interviewer administered questionnaires. Data were analysed using the Epi Info statistical software and presented as percentages and tables. The result showed that the level of and knowledge of HIV/AIDS in the study population is high, but the knowledge and perceptions of PMTCT, is comparatively low.
A descriptive cross sectional survey of 420 women of the reproductive age group (15–49 years) was conducted by Olugbenga-Bello, Adebimpe, Osundina and Abdulsalam (2013) to determine their perception on prevention of mother-to-child-transmission (PMTCT) of HIV among women of reproductive age group in Osogbo, South-western Nigeria. Respondents were selected using a multistage sampling technique. Data were obtained using interviewer-administered, pretested, semi structured questionnaires. The data were analyzed using the Statistical Package for Social Sciences (SPSS) software version 15. The results revealed knowledge about MTCT and PMTCT of HIV was high, 92.1% and 91.4%, respectively. Despite the high level of awareness of HIV/AIDS, and good knowledge about MTCT and PMTCT of HIV/AIDS among the respondents, the attitude towards PMTCT is poor.
Maputle and Jali (2008) conducted a study to determine pregnant women’s knowledge about MTCT of HIV/AIDS infection through breastfeeding. The population consisted of 100 pregnant women. Convenience sampling was used to select mothers during antenatal visits at a particular clinic at Polokwane municipality. Self-constructed questionnaires were translated into Northern Sotho and distributed to the women. Data analysis used descriptive statistics. The findings of the study revealed a high level of awareness of HIV and AIDS and a low level of knowledge about MTCT of HIV and AIDS infection through breastfeeding.
A descriptive cross-sectional study Zoung-Kanyi,Yakana, Monebenimp, Chaby (2011) assessed knowledge of pregnant women on HIV transmission and prevention at the Yaoundé Gynaecology-Obstetrics and Pediatric Hospital. All women presenting at the Ante-Natal Care (ANC) Clinic for the first time were included in the study after obtaining a verbal informed consent. The findings of the study revealed that women have some good knowledge on the Prevention of Mother-To-Child Transmission (PMTCT) of HIV. Nevertheless, improving the formal educational level of these women may contribute to a further reduction of HIV transmission.
2.1.3 Factors influencing utilization of PMTCT
Given the availability of various prophylactic antiretroviral drugs, the PMTCT coverage is below the target globally. The 2006 UNAIDS report revealed that actions directed to mitigate MTCT are not satisfactory. Globally less than 10% of the HIV positive women who are in need of prophylactic ARV received the drug, which is far behind the 80%2005 global target. The coverage was even less (6%) in the sub-Saharan region where the majority of HIV positive births occurred (UNAIDS/WHO 2006). Factors that influence utilization of PMTCT services include
– Socio- economic factors
– Cultural/religious factors
- Socio-economic factors
Age of the pregnant women
There are many studies, investigating the relation between the age of the pregnant women and access and utilization of PMTCT services provided in the antenatal clinic settings. several studies have shown that pregnant women aged twenty six years or above are more willing to have HIV counselling and testing than the younger one (Mahmoud, 2007).
Educational level of the pregnant women
The utilization PMTCT services are influenced by educational level of the pregnant women. A study conducted by Wodi (2005), suggested that low literacy of the pregnant women is one of the factors that prevent pregnant women from utilizing PMTCT services in sub-Saharan Countries.
An educated woman is likely to have more access to information about the PMTCT to her and to her infant than uneducated pregnant woman.
Given this, the education level of the pregnant women is a possible factor that increases the access and utilization of the PMTCT services as literacy level among women in UCTH.
Place of residence of the pregnant women
The residence, of the pregnant women has a role to play in utilization of the PMTCT services. Most PMTCT centres are located in the urban area. Distance to health facilities, as well as increase cost of transport, particularly for the rural women. Furthermore, the intention to accept HIV testing is associated with the husband approval (Bajunirwe and Muzoora, 2005). Also, another study from Tanzania revealed that, the residence of the pregnant women either in urban or rural areas could influence access and utilization of PMTCT services (Falnes, 2010). This means, special arrangements are needed to encourage rural pregnant women to utilize the PMTCT services in UCTH.
Gender Inequality and decision making
Gender is about assigning the roles, between women and men according to the community culture and norms, and this can be different between and within the communities. Gender inequality, between men and women can act as a barrier for the women to utilize health services (WHO, 2009). For instance, women have to take care of children and home.
Some pregnant women need to seek permission from her husband before she goes to the health facility as well as she cannot move alone (WHO, 2009).
Again, gender inequalities also affect the disclosure of the HIV test results to the families because, the women fear domestic violence and loss of the available resources. This more likely undermine the PMTCT services access as well as utilization (WHO, 2004; Kadowa and Nuwaha, 2009; Theuring, 2009). Gender inequalities; also affect participation of these pregnant women in groups at higher risk of HIV infection (WHO, 2012).
Pregnant women’s knowledge of PMTCT services
The information the pregnant women receives, about PMTCT services plays an important role in utilization of the PMTCT services. However, married women receive information from various sources like elderly women in the family, peers and care providers.
This article was extracted from a Project Research Work Topic:
“FACTORS INFLUENCING UTILIZATION OF PREVENTION OF MOTHER TO CHILD TRANSMISSION (PMTCT) SERVICES AMONG PREGNANT WOMEN ATTENDING ANTE-NATAL CLINIC IN UNIVERSITY OF CALABAR TEACHING HOSPITAL (UCTH) ”