Factors influencing mother-to-child transmission of HIV during pregnancy and breastfeeding in Mozambique

The World Health Organization recommends a comprehensive approach of prevention of mother-to-child transmission of HIV consisting of four prongs: prevention of primary infection among women in reproductive age; prevention of unintended pregnancies among women living with HIV; care and treatment of HIV positive pregnant women; family approach for HIV services. Mozambique, located in sub-Saharan Africa, has a high HIV burden with a national prevalence of 15.8% among pregnant women (2011). When the prevention of mother-to-child transmission (PMTCT) program initiated in 2002, a single dose nevirapine was used as prophylactic antiretroviral drug, while the current recommended regimen consists of lifelong antiretroviral treatment for all HIV positive diagnosed pregnant and breastfeeding women (Option B+). In the thesis, a combination of quantitative and qualitative methodologies were used to evaluate factors influencing processes of Mozambique’s PMTCT program both during the antenatal care period and the postpartum period. We investigated risk factors for HIV acquisition during pregnancy and breastfeeding period, and access to HIV prevention and care for HIV positive women and their HIV-exposed or infected infants. As described in articles 1 and 3 of this dissertation, the incidence of HIV remains high both during pregnancy and the postpartum period (3.2 and 4.3 per 100 women years, respectively), with a high burden on vertical transmission: one of eight infants infected with HIV is due to a postpartum maternal HIV infection. Risk factors for acquiring HIV during the postpartum period are young age, low parity, higher education of woman’s partner and having sex with someone other than one’s partner; during pregnancy, early sexual debut and living in Maputo province were also identified as risk factors. Strategies of primary prevention of HIV during pregnancy and the postpartum period should be tailored for them, with a special attention to young girls and women. A multi-sectoral approach including the Ministries of Health, Education and Youth is crucial, besides working with communities on awareness and education of the population. Access to HIV care for HIV positive pregnant women is influenced by many factors. Having diagnostic tests for CD4+ T-cell count closer to care showed to lead to earlier initiation of treatment of HIV positive eligible pregnant women. This is important as suppression of viral load of HIV among pregnant women as soon as possible after diagnosis is crucial to decrease risk of transmission to the infant. However, having the necessary tests at the clinic does not always result in a higher uptake of ART initiation, indicating that other contextual factors play a role in uptake of treatment. Article 2 showed that having POC testing at the clinic did not increase uptake of testing. However, it decreased time to antiretroviral treatment initiation for HIV positive eligible women. Contextual factors play a role in uptake of testing and treatment, and need to be taken into consideration when plans for roll-out of rapid diagnostics are discussed. Factors influencing retention in postpartum PMTCT services for HIV positive pregnant and postpartum women and their infants were investigated in article 4. Barriers are mainly individual-level barriers where stigma, preference of alternative care (outside the national health care services) and disbelief in the results are still important. What facilitates retention in services is having hope for a future for the child, presence of symptomatic illness and the belief that the health facility is the appropriate place for care. Male involvement in MCH and PMTCT care is important for prevention of infant HIV infection. This involvement starts with couple attendance at the first antenatal care visit and couple HIV testing. However, the study presented in article 1 showed that knowledge of male partner testing is low: 19% of the women reported that their partner had been tested for HIV. Factors hindering the uptake of male HIV testing are fear of stigma and discrimination, but also the preconception of clinics being places for women. Having men attend ANC may not be the best viable strategy and reaching couples outside of the clinic may be necessary. There is a need for stronger linkages with the community, where decision makers are involved in health promotion activities. Continuous education and awareness are necessary. At institutional level, novel technologies embedded in existing services, new or re-organized health care services (such as male friendly health units, or family clinics) and task-shifting need to be tested to increase uptake and retention of MCH/PMTCT services, aiming at a decreased vertical transmission of HIV.