Implementation and outcomes of guideline revisions for the prevention of mother-to-child HIV transmission in Mother Support Programme, Addis Ababa, Ethiopia
June
Implementation and outcomes of guideline revisions for the prevention of mother-to- child HIV transmission in Mother Support Programme, Addis Ababa, Ethiopia
Alemnesh H. Mirkuzie 0 1
0 Ethiopian Public Health Institute, National Data Management Center , Addis Ababa , Ethiopia
1 Editor: Wenhui Hu, Lewis Katz School of Medicine at Temple University , UNITED STATES
-
Data Availability Statement: All relevant data are
within the paper and its Supporting Information
files.
Funding: The university of Bergen in Norway has
funded the project.
Competing interests: The author has declared that
no competing interests exist.
About 40% of the new HIV infections in Ethiopia are among children < 15 years of age. The
great majority of these infections occur through Mother-to-child HIV transmission (MTCT).
For prevention of MTCT, the national guidelines has been revised to incorporate scientific
advances in HIV prevention, treatment and care. Since 2005, the country has been
implementing a peer mentor programme called Mother Support Group (MSG), which provides
psychosocial and adherence support for HIV positive mothers. This study examined
implementation of PMTCT guidelines revisions and outcomes of HIV exposed babies in the MSG
in Addis Ababa. Retrospective routine data were collected between 2005 and August 2013
from seven randomly selected primary health facilities. Odds ratios and 95% confidence
intervals were calculated using logistic regression models. Several guidelines revisions
were made between 2001 and 2013 in HIV testing approaches, prophylactic antiretroviral
options, infant feeding recommendations and infant HIV testing algorithms. Revisions on
the CD4 thresholds were associated with a significant increase in the proportion of women
initiating antiretroviral treatment from 0 in 2005 to 62% in 2013. Revisions in infant feeding
recommendations led to a 92.3% reported practice of exclusive breastfeeding in 2013
compared to 60.9% in 2005. Two and four percent of the HIV exposed babies were HIV positive
by six and 18 months respectively. Not receiving prophylactic ART and receiving mixed
feeding were independent predictors for babies having an HIV positive antibody test at 18
months. The rate of HIV status disclosure increased significantly year by year. Over the
years, the PMTCT recommendations have moved from having a solo focus on PMTCT to
holistic and inclusive approaches emphasizing survival beyond HIV prevention. The data
reflect favourable outcomes of HIV exposed babies in terms of averted MTCT though
serious gaps in data quality remain. For successful implementation of Option-B plus, the
identified gaps in the MSG need to be addressed.
Introduction
Ethiopia has reported a steady decline in HIV incidence and AIDS related mortality since
2005. The country has also achieved the first target of the Millennium development goal 6,
which is halting and reversing the spread of HIV/AIDS [
1, 2
]. Concerted efforts by the
government, local and international partners including local communities has contributed to this
progress. Despite the overall significant decline in the HIV incidence, the MTCT remains a
significant challenge in controlling the epidemic. Of the 21,000 estimated new HIV infections
which occurred in 2013, 40% were among children <15 years old [2].
In 2009, the UNAIDS set a Global plan for the elimination of new HIV infections among
children and keeping their mothers alive. The plan prioritized 22 high HIV burden low
resource countries in Africa and Ethiopia is one of them [
3
]. In line with this initiative, at the
national level Ethiopia has renewed its commitment and galvanized efforts to eliminate new
HIV infections among children by 2015 and to keep HIV positive mothers alive. For this the
2011 revised national PMTCT guidelines introduced a more efficacious ART prophylactic
option also called Option A. In option A, HIV positive women having CD4 cell count 350
cells/mm3 are eligible for lifelong ART for PMTCT and for their own health, while triple
prophylaxis is prescribed for those who are not eligible for ART [
3
]. Following its implementation,
the country recorded commendable progress. In the 2014 UNAIDS report, the proportion of
women accessing prophylaxis antiretroviral therapy (ART) during pregnancy and
breastfeeding increased from 9% in 2005 to 55% in 2013 [2]. However, this improvement far from
achieving the 90% planned reduction in new HIV infection among children. Later, in 2013
Ethiopia launched Option-B plus to further accelerate progress in PMTCT as well as to
improve access to ART for all HIV positive pregnant women for their own health. In Option-B
plus, all HIV positive pregnant women receive lifelong ART [
3
].
Since the introduction of the first national PMTCT guidelines in 2001, Ethiopia has made
series of guidelines revisions in 2007, 2011 and 2013 to incorporate new knowledge, global
recommendations and scientific advances [4±6]. To facilitate impleme (...truncated)