Effectiveness of lifelong ART for pregnant and lactating mothers on elimination of mother to child transmission of HIV and on maternal and child health outcomes : Uganda 2013-2015
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Effectiveness of lifelong ART for pregnant and lactating mothers on elimination of mother to child transmission of HIV and on maternal and child health outcomes : Uganda 2013-2015

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      Background: In September 2012, Uganda adopted the provision of lifelong combination antiretroviral therapy (ART) for all HIV positive pregnant and lactating mothers (called Option B+) in order to reduce mother to child transmission (MTCT) of HIV to less than 5%. By August 2013, the program had been scaled up in all the 112 districts of the country. Objectives: We performed an evaluation to measure the effectiveness of the Option B+ strategy on elimination of MTCT of HIV and on maternal and infant health outcomes up to 18 months post-ART inititiation. Specifically, the objectives were to determine i) the rate of MTCT of HIV at 6 weeks after birth [1st polymerase chain reaction (PCR) test] and at 18 months postpartum (based on a final rapid HIV antibody test) among infants born to HIV positive mothers on Option B+, ii) retention of mothers in HIV care, iii) the mean change in CD4 cell count among mothers from ART initiation to 18 months post-initiation and iv) the reasons that mothers drop out of the program. Methods: We identified a representative sample of 145 health facilities providing Option B+ in the 24 districts of the central region of Uganda. We abstracted available health facility record data of 2,169 pregnant or lactating mothers and their infants who had been enrolled on Option B+ between January and March 2013. We calculated MTCT rates and retention in care using survival analysis and evaluated factors associated with HIV transmission and with dropping out of care using cox-proportional hazards modeling. To explore reasons why women drop out of care, we performed 29 focus group discussions with peer mothers and village health team members, 27 in-depth interviews with mothers who were retained in care and 21 in-depth interviews with mothers who dropped out. Results: Only 1,240 (57.2%) infants could be identified as having been in care and linked to their mothers. Of these, 1,089 (87.8%) had a 1st PCR test and 50 (4.6%) were identified as HIV positive. The rate of infection per month, based on the 1st PCR test was 3.2/100 person months (95% CI: 2.4-4.3). Only 352 (28.9%) infants had a final HIV antibody test and no new infections were identified. Poor adherence to antiretroviral (ARV) drugs by the mothers [adjusted Hazard Ratio (aHR) 1.89 (95% CI 1.30-2.73) and an infant receiving no ARV drugs (aHR 1.22 (95% CI 1.03-1.45) were associated with increased risk of MTCT of HIV. The proportion of mothers who were retained in care at 18 months post-ART was 62.0%. Only 58.5% of mothers had a baseline CD4 cell count test, and among these women, 69.3% had a repeat test performed. Among those with follow-up CD4 test at 18 months, the mean CD4 cell count increased from 532.6 cells/ μl (S.D 341.1) at baseline to 726.9 cells/ μl (S.D 365.6) (p<0.001) at 18 months post-ART initiation. MTCT, retention and proportion of women with baseline and follow-up CD4 cell count monitoring varied considerably by district as well as by health facility level; lower level facilities had higher HIV infection rates, lower retention of mothers and fewer women being monitored by CD4 tests. Based on the focus group discussions and in-depth interviews, low levels of retention in care were the result of individual, interpersonal, institutional and community factors. The individual and interpersonal factors included fear of ART toxicities, concerns about disclosure and HIV-related stigma, insufficient partner support, domestic violence and belief in divine healing. The institutional and community factors included inadequate mobilization and tracking of mothers by the village health team members and peer mothers, client difficulty with facilitation to facilities, inadequate staffing at health care sites, poor provider attitudes and stock outs of ARV drugs. Conclusion: These findings suggest that the implementation of the Option B+ program can reduce MTCT of HIV to less than 5%. However, HIV transmission during the postpartum period could not be accurately assessed because the majority of infants did not have a final HIV antibody test. High dropout rates, poor record keeping, failure to provide ARV prophylaxis to infants, poor provider attitudes, high levels of stigma and discrimination in the community, lack of partner support and stock-outs of ARV drugs are some of the factors that could undermine the program. Recommendation: Measures to improve retention in care, availability of ARV drugs and adherence to treatment need to be multi-pronged, addressing not only the provider capacity and attitudes, and availability of medication, but also the social and economic realities of the environment in which women live. Dissemination: The data for this evaluation are the property of the Government of Uganda. Results of the evaluation will be shared with key stakeholders including the Uganda Ministry of Health, Uganda AIDS Commission and the scientific community through reports, meetings, conference presentations and peer-reviewed publications. A final dissemination meeting for District Health Officers, district PMTCT focal persons, implementing partners, Development partners and the scientific community will be held in August 2015. Funded by: The U.S. President’s Emergency Plan for AIDS Relief Funding Mechanism: U.S. Centers for Disease Control and Prevention (CDC) Cooperative Agreement No: U2GPS001945 CDC-5_Uganda_Option B+ Outcome Evaluation Report_Final 20-08-2015.pdf
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