on Prevention of Mother-To-Child Transmission (PMTCT) of HIV

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1 MEDIA BRIEF on Prevention of Mother-To-Child Transmission (PMTCT) of HIV in Swaziland

2 MEDIA BRIEF on Prevention of Mother-To-Child Transmission (PMTCT) of HIV in Swaziland

3 TABLE OF CONTENTS Acronyms Glossary of some key terms Acknowledgement iv v vi INTRODUCTION: Background and rationale for this Media Brief 1 CHAPTER ONE: COUNTRY PROFILE: General Demographics, Politics and Social Climate 2 CHAPTER TWO: Epidemiological situation and spread of HIV and AIDS in Swaziland 4 CHAPTER THREE: Drivers of HIV and AIDS 7 CHAPTER FOUR: HIV Prevention Strategies 10 CHAPTER FIVE: Prevention of Mother t o Child Transmission of HIV (PMTCT) 13 CHAPTER SIX: HIV Testing and Counselling 22 CHAPTER SEVEN: Some challenges in the PMTCT process 28 CHAPTER EIGHT: Conclusion and Recommendations 32 REFERENCES 34 ii

4 TABLE OF FIGURES AND BOXES Figure 1. Map of Swaziland 2 Figure 2. Swaziland population distribution by region 2 Figure 3. HIV prevalence among population aged 2 years and older 4 Figure 4. HIV prevalence among antenatal clients in Swaziland ( ) 4 Figure 5. Number of sites providing PMTCT from Figure 6. PMTCT Regimen change from Figure 7. HIV Testing Algorithm (For rapid testing in adults and children over 18 months) 22 Figure 8. MTCT elimination conceptual framework 29 Table 1. ANC HIV Prevalence by Regional Variation 5 Table 2. Risk Factors of mother to child transmission during pregnancy, labour and delivery and breastfeeding 16 Table 3. Health Facility Coverage of PMTCT by Region 17 Table 4. Periods, timing and estimated rates of transmission 18 Table 5. Eligibility criteria for ART or ARV prophylaxis in HIV-infected pregnant women 21 Table 6. ARV prophylaxis regimen for HIV infected mothers and exposed infants: 26 Box 1 Comprehensive Care for an HIV Exposed infant 15 Box 2 Key Milestones in the PMTCT Program in Swaziland 18 Box 3 Interpretation of HIV test results 23 iii

5 ACRONYMS AIDS Acquired Immunodeficiency Syndrome ANC Antenatal Care ART Antiretroviral therapy ARV Antiretroviral AZT Azidothymidine (Zidovudine) CTX Co-Trimoxazole DBS Dry Blood Spots DNA Deoxyribonucleic acid EID Early Infant Diagnosis ELISA Enzyme-Linked Immuno absorbent Sero Assay FP Family Planning HAART Highly Active Antiretroviral Therapy HIV Human Immunodeficiency Virus IYCF Infant and Young Child Feeding MCP Multiple Concurrent Partnerships MDGs Millennium Development Goals MNCH Maternal, Neonate and Child Health MOH Ministry of Health MOT Modes of Transmission MTCT Mother-to-Child Transmission NSF National Multisectoral Strategic Framework NVP Nevirapine PCR Polymerase Chain Reaction PICT Provider Initiated Counselling and Testing PMTCT Prevention of Mother-to-Child Transmission PNC Post natal Care RTI Reverse Transcriptase Inhibitor SDHS Swaziland Demographic Health Survey SRHU Sexual and Reproductive Health Unit STIs Sexually Transmitted Infections TB Tuberculosis VCT Voluntary Counselling and Testing WHO World Health Organisation iv

6 GLOSSARY OF SOME KEY TERMS Antiretroviral drugs: ARV Prophylaxis: CD4 cell count: Chorioamnionitis: Drivers of the epidemic: These are medicines that are taken to slow down viral replication with the ultimate aim of reducing the amount of virus in the body of someone living with HIV. This is when antiretroviral drugs are taken in order to prevent HIV infection from happening. CD4 cells are white blood cells that are responsible for immunity in the body. A CD4 cell count is a blood test performed to measure the number of CD4 cells as a way to assess the strength of the immune system. Inflammation of the chorion and the amnion, the membranes that surround the foetus. These are certain behaviours and circumstances that may put an individual in greater risk of contracting HIV. Exclusive breast feeding: This is when a baby is only fed on the breast milk without any additional fluids or foods. HIV Incidence rate: HIV Prevalence: HIV Transmission: Immunodeficiency: Regimen: Replacement feeding: The rate of new HIV infections over a period of one year. The overall prevalence of HIV includes the number of diagnosed as well as undiagnosed people infected with HIV in a given population. HIV can be spread through unprotected and close contact with a variety of body fluids of an infected individual. As the HIV destroys and impairs the function of immune cells, infected individuals gradually become increasingly susceptible to a wide range of infections and diseases that people with healthy immune systems can fight off. Is a set of prescribed treatments that may comprise of a number of types of medicines or foods or other activities. This is when some other substance fluid or solid is given to an infant in place of breast milk. Risk factors: Vertical transmission: Viral Load: Weeks of gestation: These are situations that make something most likely to happen i.e. increases the chances of HIV infection. The transmission of HIV from an HIV-positive mother to her child during pregnancy, labour, delivery or breastfeeding. Number of viral copies in the blood. The amount of time or duration of pregnancy. v

7 ACKNOWLEDGEMENTS A number of stakeholders supported the compilation and production of this Media Brief on Prevention of Mother to Child Transmission (PMTCT) in Swaziland. As Panos Institute Southern Africa (PSAf), we are greatly indebted to the Southern Africa Development Community (SADC) HIV and AIDS Fund for supporting Communicating HIV Prevention in Southern Africa Project, under which this Media Brief was published. We would also like to thank the Swaziland National Emergency Response Council on HIV and AIDS (NERCHA) for supporting the research and compilation of this publication. The PSAf PMTCT Media Brief for Swaziland was compiled by Innocent Hadebe of NERCHA Swaziland, edited by Robert Makola, an independent media consultant. The publication was further edited by Vusumuzi Sifile and Mamoletsane Khati of PSAf, and reviewed by Lilian Chigona. For more information and to request for copies, please contact: Panos Institute Southern Africa Plot 9028 Buluwe Road, Woodlands P. O Box 39163, Lusaka, Zambia Tel: Fax: general@panos.org.zm Website: Panos Institute Southern Africa 2012 vi

8 INTRODUCTION BACKGROUND AND RATIONALE FOR THE MEDIA BRIEF During the last 30 years, the HIV/AIDS pandemic has ravaged the world with very serious consequences. In order to reduce the impact of the pandemic on the health and development agenda of the various communities, African countries, including Swaziland, have embarked on various initiatives, approaches and strategies, both locally and as part of global efforts. In Swaziland, a relatively small country with a population of just above one million people, but severely affected by the pandemic, the media has played a critical role in enhancing the understanding of HIV and AIDS through information dissemination on the various aspects of the pandemic. However, local journalists in the country have lacked a platform and readymade resource upon which to draw relevant, accurate and up-to-date information to facilitate their reporting on HIV and AIDS issues, including the critical Mother-to-Child Transmission of HIV (MTCT). This media brief on the Prevention of Mother-to-Child Transmission of HIV (PMTCT), therefore, has been developed to provide journalists with the necessary information on the programme. PMTCT is one of the national priority biomedical strategies for HIV prevention, with a special focus on ensuring that fewer infants are exposed to or infected with HIV from their infected mothers. The brief is aimed at assisting the journalists to be able to report on PMTCT from an informed point of view, thereby empowering the communities, families and especially mothers on the benefits of PMTCT, reduction of HIV infection risks for the HIV negative sexually active population and reduction of HIV incidence among babies born to HIV infected mothers. The realization of the National Multisectoral Strategic Framework impact level results of having fewer infants becoming infected with HIV and fewer pregnant women becoming HIV positive is dependent upon the active participation of all the relevant stakeholders. In order to bring everybody on board, the media has a pivotal role to play in promoting awareness for increased access to PMTCT and other HIV prevention services. Though the country has made significant headway in reaching pregnant women with PMTCT services at antenatal care (ANC) and Maternal, Neonate and Child Health (MNCH) level, communication is still very essential to maintain and sustain the gains that have been achieved over the years. This is vital if the country is to achieve virtual elimination of Mother-to-Child Transmission of HIV. This brief will form part of the information resource base that can be used by a wide spectrum of stakeholders, even beyond the media. The manual can be adapted for use as resource and reference material at media training institutions. The material can be reproduced and distributed for use as hand outs as long as adequate acknowledgement of Panos Institute Southern Africa is given. 1

9 CHAPTER ONE COUNTRY PROFILE: GENERAL DEMOGRAPHICS, POLITICS AND SOCIAL CLIMATE Swaziland is a small landlocked country situated in the southern part of Africa. It has a surface area of 17,364 square kilometres, and is bordered by the Republic of South Africa, almost entirely, and Mozambique to the east. According to the 2007 Population Census, the population of Swaziland is estimated at 1,018,449 people, of which 481,428 are males (47%), and 537,021 females (53%). The population is evenly distributed across the four regions of Hhohho, Lubombo, Manzini and Shiselweni, though the Manzini Region has a higher population compared to the other three regions. (Fig. 1). Figure 1. Map of Swaziland The young people, under the age of 20 years, form 52% of the population and 79% of the population live in the rural areas. The total fertility rate is estimated at an average of 3.8 births in a woman s life. The literacy rate among women of reproductive age is 91%, with 59% having a secondary education or higher. Swaziland is divided into four administrative regions, Hhohho in the north of the country, Lubombo, which forms the eastern part, Manzini in west-central and Shiselweni to the south. The country is further divided into 55 constituencies known as Tinkhundla and 360 chiefdoms and towns. It became an independent kingdom in 1968, with His Majesty the King as the Head of State and the Prime Minister as the Head of Government. Figure 2: Proportion of population distribution by region 2

10 Swaziland is classified as a lower middle income country with per capital income of US$2,580 (2007), and has an economy that is largely agriculture-driven. South Africa accounts for 80% of its imports and 60% of its exports. Swaziland s Economic growth has slowed down in the last twenty years from a gross domestic product growth rate averaging 8.4% during to 2.6% during The economic slowdown has been driven mainly by fluctuations in the performance of the agricultural sector due to climatic conditions and global fluctuations in the price of agricultural products. 3

11 CHAPTER TWO EPIDEMIOLOGICAL SITUATION AND SPREAD OF HIV AND AIDS IN SWAZILAND Swaziland is among the countries severely affected by the HIV and AIDS epidemic. Despite the curbing efforts made in the response, the HIV prevalence rate is still exceptionally high and has reached unprecedented levels. The SDHS 2007 indicated that in the general population aged 2 years and older, HIV prevalence was 19%, and 26% among the sexually active population aged years. It also indicated that females (22%) were more infected than males (15%). SDHS, 2007 It is worth noting that the age groups mostly affected are the reproductive groups aged years for females (49%) and years for males (45%), as reflected in (Figure 3) above. HIV infection is high in females aged years (32.3%) as compared to their male counterparts (14%). This indicates a higher vulnerability of females at an early age as compared to males. HIV / AIDS among pregnant women A trend analysis, using data from the bi-annual HIV Serial Sentinel Surveillance Survey, 2010, indicated that the prevalence among pregnant women is showing some stabilisation after rapidly increasing through the 1990s and slowing down after The stability may be observed between 2006 and 2010 (Figure 4). Figure 3: HIV Prevalence among population aged 2 and older Percentage HIV positive HIV Prevalence Figure 4: HIV prevalence among antenatal clients in Swaziland Source: 12th Sero-Sentinel Surveillance Report,

12 Regional ANC HIV prevalence Regional HIV prevalence has guided the national prevalence curve. Over time, the Manzini region observed high prevalence until 2004, when it peaked to 45.1% and thereafter assumed a downward trend. Currently, Manzini has the lowest prevalence of 39.5%. On the other hand, Hhohho, which had the lowest prevalence of 15.5% in 1994, has seen an upward swing, reaching 41.9%, Lubombo Region reaching 43.3% and Shiselweni region reaching 40.2% in 2010 (Table 1) (Table 1). ANC HIV Prevalence by Regional Variation Region Number Tested Number positive Percentage Positive 95% Confidence Interval Hhohho ; 46.5 Manzini ; 43.9 Shiselweni ; 45.3 Lubombo ; 48.9 National ; th national HIV Sero-Surveillance among women attending antenatal care services in Swaziland As earlier stated, HIV infection is present in a considerable percentage of adults aged 50+ years (14%) and young children aged 5-14 years (3%). This may be attributed, most probably, to the high incidence of sexual abuse. HIV prevalence by sex and age group shows that the female-to-male ratio of infection is dramatically different in age groups, and HIV prevalence rapidly increases in women between the age groups (12% HIV positive), (38% positive) and (49% HIV positive). Some basic statistics about HIV in Swaziland The HIV incidence rate is at 2.9%. HIV Prevalence: population aged 2 years and older at 19% population aged years at 26% pregnant women at 41.1% 94% of new infections occur through heterosexual contact. About 68% of new infections in adults occur in persons above 25 years of age, the majority of whom are married or cohabit with a steady partner. The majority of new infections are in females. The majority of new infections in children, 0-14 years, are due to mother-to-child transmission during pregnancy, childbirth and breastfeeding. MTCT contributes about 11% of the total annual national incidence rate About 47.3% women have been tested for HIV and know their status About 32.2% of men have been tested and know their status HIV counseling during ANC is at 81.5% HIV testing during ANC is at 77.4% About 19.1% men aged years are circumcised Sex before age 15 years is at 3.8% for young women and 2.6% for young men. Age-mixing among sexual partners, 14.1% women and 0.5% men 5

13 Sex with multiple partners, 2.7% women and 15.4% men Condom use during sex with multiple partners is at 73.1% women and 69.2% men Condom use during sex with non-regular partners is at 76% women and 93.1% men Condom use with non-regular partners is at 73.1% women and 90.6% men. The probability of using a condom during higher risk sex increases with educational attainment in men and women, and is higher in younger age groups than older adults. 6

14 CHAPTER THREE DRIVERS OF HIV AND AIDS The main mode of HIV transmission is through heterosexual contact. According to the Swaziland HIV Prevention Response and Modes of Transmission Analysis (MOT) 2009, approximately 94% of new infections in adults arise from heterosexual transmission. Given that this is the main mode of HIV transmission in Swaziland, the following specific sexual behaviours put people at risk of HIV infection and are by no means listed in order of priority. Multiple Concurrent Partners Multiple Concurrent Partners (MCP) can be generally defined as sexual behaviour distinguishable by having two or more sexual partnerships that overlap in time or in the same time period. This type of sexual behavior increases the risk of HIV infection and has been recently identified as the most immediate cause of new HIV infections and significantly correlates with the majority of drivers of the epidemic. MCP is tacitly accepted in the Swazi socio-cultural dynamics and men are more likely to have multiple sexual partners as compared to women. This behaviour has improved over the years. According to the Swaziland Multiple Indicator Cluster Survey (MICS) 2010, 15% of men aged years had sex with more than one partner in the last 12 months, whereas only 3% of women aged years engaged in such an activity in the last 12 months preceding the survey. This is lower when compared to the Swaziland Demographic and Health Survey (SDHS, 2007), which stated that 23% of men and 2% of women, aged years, reported having sex with more than one partner in the 12 months preceding the survey. Early Sexual Debut By the age of 18 years, 48% of women and 34% of men aged years reported having had sexual intercourse and, of these, 7% women and 5% men initiated sexual activity before their 15th birthday (MICS, 2010). The median age of sexual debut in Swaziland is around 17 years and the average age of marriage is 26 years (SDHS, 2007). Premarital sex, and often with more than one partner, is usually practiced within the ten-year period. Young rural females were significantly more likely to have initiated sex before age 15 or age 18 compared to young urban females, and the opposite can be said about the urban men who would start to have sexual intercourse earlier than their rural counterparts. Low and Inconsistent Levels of Condom Use The use of condoms during sex, especially with non-regular partners, is critical for reducing the spread of HIV. The male condom is 98% effective if used correctly and consistently and the female condom 85% (MICS, 2010). The MICS indicated that 67% women and 93% men had sex with a non-marital, non-cohabiting partner in the last 12 months. Of those, 73% women and 91% men reported that a condom was used the last time they had sex with such a partner. This has indicated some improvement in condom usage when compared to the SDHS findings which stated that, 55% women and 68% men 7

15 who had more than one sexual partner in the past 12 months reported having used condoms the last time they had sex. Only 22.4% women currently married or in relationship reported using a condom. Low Levels of Male Circumcision As a traditionally non-circumcising nation, Male Circumcision (MC) in Swaziland has remained very low with only 8% of men being circumcised. With the roll out of the MC for HIV Prevention, there has been some improvement to 23% (MICS, 2010) in 2011, but it is still lower that the NSF target of 30% (NSF, 2009.) The country adopted MC as an HIV Prevention Strategy following approval and recommendation from WHO and UNAIDS, which was informed by three randomized controlled clinical trials which were conducted in South Africa, Kenya and Uganda. These demonstrated the potential to reduction of HIV infection in circumcised men by almost 60%. Inter-Generational Sex According to the SDHS, 7% of young women who had engaged in high risk sex in the last twelve months reported having sex with a man ten or more years older. This is higher among older girls living in rural areas, but decreases with higher levels of education. The 2010 Swaziland MICS shows that for women aged years who are in marriage or in a union, the most frequent spousal age difference is 5 9 years at 39%, followed by 0 4 years at 37%. About 22% of women aged years are married or in union with spouses who are 10 years older or more. Income Inequality (Poverty) Various studies show that it is not necessarily poverty, but income inequality, which is high in Swaziland, that drives the epidemic. Income inequality is associated with more young girls engaging in what has been referred to as transactional sex or sex for favours and in the process taking more risks towards HIV infection. Mobility and Migration Migration and mobility pose an increased risk of HIV, both to the one who is traveling and the one left behind. This is not simply because men return home to infect their rural partners, but also because rural women become infected outside their primary relationships (Lurie et al.) A significant percentage of Swazis are mobile. Oscillatory migration is a significant factor in sexual behaviour and new HIV infections. The SDHS reported that 42% were away from home or at an assigned duty station for more than five days at a time, at least five times in the past 12 months, mostly for workrelated reasons. A large majority are married or in long-term cohabitating relationships, and there is low condom use with non-regular sexual partners. HIV prevalence amongst these short-term mobile people is more than double than in the general population. Patterns of risky sexual behaviour also differ for men and women who are away from each other, and focus on the non-travelling partner is also needed. 8

16 Commercial Sex According to the MARPS Bio-Behavioral Surveillance Survey (BSS) Results: Men Who Have Sex with Men (MSM) and Sex Workers (SW), 2012, the overall HIV prevalence among sex workers is 70.3%, which is almost double that of the general population. The majority of female sex workers are young women between the ages 21 and just above 30 years and 88.8% are single or never married and most of them (53.4%) have achieved some secondary level school education. There are also some male sex workers. The most frequent number of clients that they serve is between 2 4 clients per month at 43.7% followed by 5 10 clients per month at 33.2% and for 66.7% of them, sex work is the only source of income. Reported condom use with new clients in the past month preceding the survey was 74.2%. Worth noting, though, was the frequency of condom break or slippage with any partner in the past month, which was at 55.3%. Gender Inequalities and Sexual Violence Many cultural norms and values shape negative gender relations that help drive the epidemic. In Swaziland, being a patriarchal society, culturally men have a large degree of control over women. The prevailing values and norms uphold men s privileges and tend to constrain women s autonomy. These values and norms are deep-rooted, and gender discriminatory beliefs are held by many men and women, which also facilitates the tacit acceptance of sexual violence. The 2007 National Study on Violence against Children and Young Women in Swaziland found that violence against female children is highly prevalent, with approximately one in four females having experienced physical violence as a child. Among the year old females, nearly two in three had experienced sexual violence. Overall, 48% of females reported that they had experienced some form of sexual violence in their lifetime, and 21% said they had experienced some form of sexual violence in the preceding 12 months. Over half of all incidents of sexual violence were not reported to anyone, and less than one in seven incidents resulted in a female seeking help from available services. Alcohol and Drug Abuse The SDHS noted that engaging in sexual intercourse while under the influence of alcohol can impair judgment, compromise power relations, and increase the possibility of engaging in risky sexual behaviour. The 2007 Alcohol Use and Sexual Risks for HIV/AIDS in Sub-Saharan Africa: Systematic Review of Empirical Findings, showed a consistent association between alcohol and sexual risk taking. Men are more likely to drink and engage in higher risk behaviours, whereas women s risks were often associated with their male partner s drinking. Alcohol and sexual risks are also linked with sexual coercion and poverty. 9

17 CHAPTER FOUR HIV PREVENTION STRATEGIES Preventing new HIV infections in Swaziland is vital in the efforts to reverse the epidemic and achieve the national targets of the response. HIV prevention strategies, therefore, remain critical for the national response to the epidemic while effective prevention of new infections will also have long term collateral benefits for treatment, care and support and impact mitigation. The HIV prevention interventions are designed to reduce exposure to HIV, reduce the probability of transmission when exposed, and influence change in societal norms, values and practices that tend to impact on peoples ability to adopt key prevention behaviour. According to the National Multisectoral Strategic Framework (NMSF) , the strategic direction for HIV prevention is to ensure that interventions reduce the incidence rates to levels at which the epidemic starts declining and, hence, the following are the five thematic impact level results: 1. The rate of HIV incidence per year is reduced from 2.9% in 2008 to below 2.3% by The percentage of HIV infected infants born to HIV positive mothers is reduced from 21.5% in 2008 to 10% in 2011 and 5% in The percentage of young people aged years who are HIV infected is reduced from 10.1% for women in 2007 to 8% in 2014 and from 1.9% in 2007 for men to 1.5% in The percentage of pregnant women aged years who are HIV infected is reduced from 38.1% in 2008 to 37% in 2011 and 35% in The percentage of female sex workers who are HIV positive is reduced from 23% in 2007 to 20% in To achieve these results, the country has HIV Prevention programme strategies which are divided into two categories according to their levels of priority. The following are priority one interventions: 1. Social and behaviour change communication programmes Target population: (a) Youth aged years Indicators: Increased percentage of in-school youth aged between years who have attended life skills education to 60% by 2011 and to 95% in Increased percentage of young people aged who have been reached with social and behaviour change communication programmes from 54% in 2008 to 60% in 2011 and 69% in Increased percentage of primary and secondary schools that provided life-skills education within the last academic year from 44% in 2008 to 90% in 2014 for primary schools and 71% in 2008 to 95% in 2014 for secondary schools. Increased number of trained and active peer educators from 900 in 2008 to 4500 in

18 (b) Adults 25 years and older Indicator: Increased percentage of couples reached with relationship strengthening and social/behavioural change communication programmes to 40% in 2011 and 60% in (c) Mobile and migrant population Indicator: Increased percentage of formally employed workers reached with a minimum package of HIV Prevention programmes in the last 12 months Increased number of large enterprises / companies that have HIV and AIDS workplace policies and programmes from 48% in 2011 to 75% in Increased and comprehensive knowledge of HIV and AIDS Target population: (a) Young people aged years Indicator: Increased percentage of young people aged who cite a member of the family as a source of HIV and AIDS information from 39.2% in 2006 to 60% in (b) Young people aged years Indicator: Increased percentage of young people aged 15 to 24 who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission, from 52% in 2007 to 78% in (c) Most at Risk Populations (MARPS) Indicator: Increased percentage of most-at-risk populations who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission, from 46.2% in 2008 to 70% in Scaling up of Prevention of Mother-to-Child Transmission of HIV Target population: (a) HIV Positive pregnant women, their infants and sexual partners Indicator: Increased percentage of HIV positive pregnant women who received a course of ARV prophylaxis to reduce MTCT from 65% in 2007 to 90% in Increased percentage of pregnant women who were tested and received their results [during pregnancy, labour and delivery, during post-partum period (<72 hours) and those with previously known HIV status] for a new pregnancy, from 67% in 2007 to 75% in 2011 and 90% in (b) Women aged years Indicators: Decreased percentage of women aged 15 to 49 who did not want any more children when they fell pregnant, from 36.9% in 2007 to 20% in Reduced % of HIV positive women aged with unmet need for family planning from 13% in 2007 to 5% in

19 4. Male Circumcision: Target population: HIV negative men aged years and new born children Indicators: Increased number of young men aged years who are circumcised from in 2008 to in 2014 Increased number of newborns who are circumcised within 5 days of birth to in 2011 and to in 2014 The priority two interventions are those which need to continue because of their importance in sustaining the gains that have already been achieved in HIV Prevention or with the general response. These are the following: (a) HIV Testing and Couselling (HTC) Target population: (a) People Living with HIV (PLHIV) Indicator: Increased percentage of people 15 years and older who know their HIV status has increased from an estimated 20% in 2008 to 70%. (b) All persons: Indicator: Increased number of people aged 2 years and older who have tested for HIV in the last 12 months and know their status, from 22% in 2007 to 50% in 2014 for women and 9% in 2007 to 40% in 2014 for men. (b) Post Exposure Prophylaxis and Universal Precautions Target population: All eligible persons Indicator: Increased number of health facilities that provide PEP from 12% in 2008 to 30% (all sites providing ART) by (c) Treatment of Sexually Transmitted Infections (STIs) Target population: All sexually active persons Indicator: Reduced percentage of persons who present with genital ulcers from 20% in 2007 to 15% in

20 CHAPTER FIVE PREVENTION OF MOTHER TO CHILD TRANSMISSION OF HIV (PMTCT) The PMTCT programme in Swaziland was officially launched in 2003 and has since then been implemented as part of the Maternal, Newborn and Child Health (MNCH) programme services. Notable progress has been achieved in the service coverage since the commencement of the programme. At its inception, for example, the programme had only 3 health facilities offering the PMTCT services. These increased substantially to 137 in 2008, and peaked to a total of 150 facilities by (FIGURE 5). What is PMTCT? The transmission of the Human Immunodeficiency Virus (HIV) from an HIV infected mother to her child is called Mother-to-Child Transmission (MTCT). This can occur during pregnancy, labour and delivery and breastfeeding. The PMTCT is a highly effective intervention which ensures that an HIV infected mother does not pass the infection to her child. This can be achieved through giving the HIV infected pregnant women Antiretroviral (ARV) drugs to prevent them from transmitting HIV to their children, both before and after birth. This is a vital part of the programme because it ensures that children in Swaziland are born free of HIV and that they are prevented from acquiring the virus from an early age. The four prongs of PMTCT Before examining in detail how the HIV virus is transmitted from mother to child, it may be necessary to outline the approach that has been laid out to fight infections at that level. Strategically, the PMTCT programme in Swaziland is being implemented through a four-pronged approach as follows: Prong 1: The primary focus of Prong 1 is on keeping HIV-negative pregnant women and partners of pregnant women HIV-negative. This new approach is based on recent research in Swaziland that showed high levels of new HIV infections of about 5% occurring during the last trimester of pregnancy. Programme strategies The strategic focus for Prong 1 is to target women and partners who test negative, with strong emphasis on HIV risk reduction and the practice of safe sex. Consistent and correct condom use is stressed as part of safe sexual behaviour for all pregnant women and their partners. Prong 2: The primary focus of Prong 2 is on the prevention of unwanted pregnancy among the HIV positive women. The emphasis is on ensuring that actions are being taken in health facilities to ensure that staff is trained and ready to provide family planning to eligible women and ensure that these services are widely available and easily accessible. 13

21 Programme strategies The strategic focus of Prong 2 includes counselling and provision of family planning methods. Pregnant women and their partners are encouraged to discuss and plan for their contraceptive needs after delivery. Prong 3: The primary focus of Prong 3 is the reduction of HIV transmission from infected pregnant mothers to their unborn babies during pregnancy, labour and breastfeeding periods. According to the PMTCT guidelines, ARV prophylaxis has to be started at as early as 14 weeks gestation. HIV retesting is scheduled for the pregnant women 8 weeks after their first negative test, during the last trimester and at 6 weeks postpartum in order to identify new HIV infections and provide ARV prophylaxis immediately. Prong 4: Having learned that focusing only on women after they are infected and pregnant will not lead us to a generation free of HIV, Prong 4 provides an opportunity to provide treatment, care and support for the woman, her partner and the family from before conception and continuing into early childhood. Programme strategies Both Prongs 3 and 4 are specific for HIV infected women and their families to ensure that the appropriate interventions to reduce MTCT (ARV prophylaxis, ART, good obstetric practices and monitoring of labour and delivery) and HIV treatment, care and support services are provided for the mother, infant and family, respectively. HOW IS HIV TRANSMITTED FROM MOTHER TO CHILD? The mother-to-child transmission of HIV can occur during different stages in the child s life, i.e. pregnancy, labour and delivery and breastfeeding. For all these stages of transmission, the level of the mother s viral load is the most important. The MTCT of HIV is most likely to occur when there is a high maternal viral load and a low CD4 count. The three modes of transmission are discussed below. In pregnancy (utero transmission) This may happen if the placenta is damaged, which creates a possibility for HIV-infected blood from the mother to transfer into the blood circulation of the foetus. It may also happen during Chorioamnionitis, which is usually caused by a bacterial infection, and this has been associated with damage to the placenta and increased transmission risk of HIV. This is thought to happen either through infected cells traveling across the placenta, or by progressive infection of different layers of the placenta until the virus reaches the foetoplacental circulation. The reason we know that utero transmission happens is that a proportion of HIV positive babies tested when they are a few days old already have detectable virus in their blood. Usually it takes several weeks from the time someone is infected until HIV shows in their blood. The rapid progression of HIV disease in some babies is evidence that it happens. During labour and delivery (intrapartum transmission) 14

22 HIV transmission during labour and delivery is thought to happen when the baby comes into contact with infected blood and genital secretions from the mother as it passes through the birth canal. This could happen through ascending infection from the vagina or cervix to the foetal membranes and amniotic fluid, and through absorption in the digestive tract of the baby. Alternatively, during contractions in labour, maternal-foetal micro-transfusion may occur. Evidence to this is: 50 percent of babies who turn out to be infected test HIV negative in the first few days of life. There is a rapid increase in the rate of detection of HIV in babies during the first week of life. The way that the virus and the immune system behave in some newborn babies is similar to that of adults when they first become infected. It is also shown by the success in preventing it from happening. This includes: Treatments that have reduced transmission risk, even when given only in labour Delivering the baby by Caesarean section before labour starts (where applicable). If it takes a long time to deliver after the membranes have ruptured (waters breaking) or if there is prolonged labour, the risk of transmission in women not receiving ARV treatment or prophylaxis is increased. A premature baby may be at higher risk of HIV transmission than a full term baby. Breastfeeding HIV transmission at this stage is thought to be through breast milk, which gets through the mucosal lining of the gastrointestinal tract of infants. The gastrointestinal tract of a young baby is immature and more easily penetrated than that of adults. It is believed that damage to the intestinal tract of the baby may be caused by the early introduction of other foods, particularly solid foods and thus increase the risk of infection. Under the MTCT process, it is worth noting, that the most important thing is not how it happens, but how we can prevent it from happening. ARVs have demonstrated that this is feasible. MTCT and breastfeeding Exclusive breastfeeding is considered a safe infant feeding practice that can reduce MTCT. National guidelines for PMTCT recommend exclusive breastfeeding for 6 months, coupled with an appropriate prophylaxis regimen for mother and infant. A protocol for comprehensive care of exposed infants incorporates key components of care such as access to PMTCT services; completion of PMTCT regimen, including NVP prophylaxis during breastfeeding when the mother is not on ART; support of infant feeding methods to reduce postnatal transmission; access to co-trimoxazole prophylaxis for infants; monitoring for early childhood development of infants; and completion of infant immunization regimens. Box 1: Comprehensive Care for a HIV exposed infant. 10 key elements of the clinic visit 1. Document PMTCT regimen received by mother and the infant 2. Test for HIV and give results, when indicated 3. Assess growth and development 4. Give immunization 5. Provide prophylaxis (CTX, IPT) 6. Treat infection early 7. Ask about household TB contacts 8. Counsel on infant feeding and nutrition 9. Ensure that the family is receiving HIV care, FP, social support 10. Maintain suspicion of HIV infection 15

23 Breastfeeding recommendations Under 6 months: Exclusive breastfeeding (only medicines can be taken, no water or other foods.) 6-12 months: breastfeeding PLUS complementary feeding At 12 months: Assess nutrition and diet and make recommendations for feeding based on mother and infant HIV status Knowledge about PMTCT in Swaziland The knowledge of MTCT in the population is an important step for women and men to avoid infecting their unborn babies. The overall PMTCT knowledge level among women aged years and men aged years is 95% for women and 94% for men. These are the people who know that HIV can be transmitted from mother to child. Men and women residing in the Manzini region are most likely to know about PMTCT when compared with those in the other regions. About 61% of women and 50% of men know all the three modes of MTCT while 5% of women and 6% of men did not know of any specific way. Approximately 73% of women and 66% of men know that HIV can be transmitted during pregnancy, while 88% women and 83% of men know that HIV can be transmitted during delivery. In addition, 80% percent of women and 76% of men know that HIV can be transmitted by breastfeeding (12th Sero-Sentinel Surveillance, 2010). During the three phases of possible mother to child transmission of HIV, there are risk factors which may increase the risk of infection. Table 4 below articulates the risk factors at these different stages, which are during pregnancy, labour and delivery, and during breastfeeding. (Table 2). Risk Factors of mother to child transmission during pregnancy, labour and delivery and breastfeeding Pregnancy Labour and Delivery Breastfeeding New HIV infections during pregnancy High maternal viral load Low maternal CD4 count Malaria infection Sexually transmitted infections (STIs) Maternal malnutrition Anaemia Chorioamnionitis (from untreated STI or Viral or bacterial infections infections) High maternal viral load Low maternal CD4 count Rupture of membranes more than 4 hours before delivery Invasive delivery procedures (e.g., episiotomy, artificial rupture of membranes, amniocentesis, vacuum or forceps) Chorioamnionitis (from untreated STI, other infection or due to ascending infection following prolonged rupture of membranes) Premature delivery Low birth weight Breaks in skin or mucous membranes of the baby New HIV infections during pregnancy High maternal viral load Low maternal CD4 count Duration of breastfeeding Mixed feeding (e.g., food or fluids in addition to breast milk) Breast abscesses, nipple fissures, mastitis Poor maternal nutritional status Oral disease in the baby (e.g., thrush or sores) 16

24 PMTCT facilities in 2003 PMTCT facilities in 2010 (SAM, 2010) Figure 5: Number of sites providing PMTCT from (Table 3). Health Facility Coverage of PMTCT by Region Region Number of facilities No. and % of Facilities No. and % of Facilities offering ANC services offering PMTCT Service 2008 offering PMTCT Service 2010 Hhohho (83%) 42 (89%) Manzini (75%) 44 (77%) Lubombo (84%) 36 (97%) Shiselweni (80%) 28 (93%) Total (80%) 150 (88%) Source: SAM 2010 The high antenatal care (ANC) attendance in Swaziland of 97% puts the provision of PMTCT services at an advantage. As HIV testing is part of the ANC package, Swaziland has also witnessed a tremendous increase in the proportion of women tested for HIV during pregnancy. By the end of 2010, about 82% of pregnant women were tested for HIV. The HIV prevalence among pregnant women was estimated at 41.1%. Similarly, the country has also applauded itself on the increase in ARV uptake among pregnant women, either for PMTCT or for their own health, from 4% in 2004 to about 85% in

25 4.3.1 Mother to Child HIV Transmission in Swaziland: Approximately 30,000 deliveries are registered in Swaziland every year. With HIV prevalence among pregnant women of 41.1% (12th Sero-Sentinel Surveillance Report, 2010), approximately 13,000 HIV exposed infants are delivered annually. By 2011, 79% of pregnant women were tested for HIV at ANC. Of those who tested positive and were eligible for ART, 91% received a complete course of antiretroviral prophylaxis while 15% of those were already on ART. Box 2: Key Milestones in the PMTCT Program in Swaziland 2002: PMTCT Guidelines 1st Edition 2002: PMTCT Program piloted in 3 facilities 2003: PMTCT Strategic Plan : PMTCT Guidelines 2nd Edition 2007: PMTCT Operational Plan : Early Infant Diagnosis of HIV using DNA PCR fully established in the Country 2010: PMTCT Guidelines 3rd Edition 2011: Elimination Framework and Operational Plan Clinical records show that only 4% of children aged 6-8 weeks born to infected mothers are HIV positive. HIV testing is an entry point to primary prevention of HIV among young women of reproductive age, prevention of HIV from HIV infected mother to the child and ensures access to treatment and care services for HIV infected women, families and children Periods, timing and estimated rates of transmission: Table 2 below shows the periods and rates of transmission and estimated number of infants exposed to HIV annually if PMTCT services are not put in place. With the new guidelines, Swaziland now has the opportunity to prevent more infant HIV infections by providing ARV prophylaxis and treatment from early pregnancy, through-out labour and delivery and through the breastfeeding period. (Table 4): Periods, timing and estimated rates of transmission Period of Transmission Pregnancy Labour and delivery Breastfeeding Overall for 24 months Transmission Rate %* 5-10% 15-20% 10-15% 30-45% Estimated annual number of infected infants (13000 exposed) Adapted from decock et al, JAMA, 2000, 283: Of the approximately 13,000 HIV exposed babies each year in Swaziland, an estimated 5,200 of these, without any interventions, would be HIV-infected. In 2009, an estimated 2,300 infants became infected during pregnancy, delivery and breastfeeding, indicating that PMTCT interventions prevented nearly 56% of HIV infections in infants born to HIV positive mothers. 18

26 TRENDS IN THE SWAZI PMTCT PROGRAMME The increase in the number of health facilities offering PMTCT services resulted in an exponential growth in the use of PMTCT services by The high antenatal care (ANC) attendance of 97% puts the provision of PMTCT services at an advantage. As HIV testing is part of the ANC package, Swaziland has also witnessed a tremendous increase in the proportion of women tested for HIV during pregnancy. By the end of 2010, about 82% of pregnant women were tested for HIV. The HIV prevalence among pregnant women was estimated at around 41.1% 1 Similarly, the country has also exceeded its expectations on the increase in ARV uptake among pregnant women, either for PMTCT or for their own health, from 4% in 2004 to about 85% by end of During the early days of the programme since its launch in 2003, a single dose of Nevirapine (NVP) was administered to the HIV infected women at the onset of labour and NVP syrup to the baby within 72 hours after birth to reduce mother-to-child HIV transmission. In 2007, the country introduced use of more efficacious ARV regimen of AZT from 28 weeks of pregnancy, NVP+3TC+AZT during labor and delivery with the tail (3TC+AZT) for one week, and infants received NVP plus one week of AZT. Since 2007, a dual ARV regimen of AZT and NVP has been used with a 7 day tail of AZT+3TC to minimize NVP resistance. With these new 2010 guidelines, more efficacious ARV regimens are being made available for HIV-infected women and their infants. By the end of 2010, Swaziland had made commendable progress in expanding PMTCT services and in delivering ARVs to HIV infected pregnant women. For the first time, ARV prophylaxis could be given to make breastfeeding safer for HIV infected women. The new guidelines have ensured improved quality of care for both mother and child and include provision of more efficacious ARV regimens to HIV infected women from as early as 14 weeks gestation, and to exposed infants during breastfeeding. About 76% of all HIV infected pregnant women received a full course of PMTCT prophylaxis in 2010 while 73% of pregnant women were assessed for ART eligibility (CD4<350), and 44% of those eligible were initiated. Early infant diagnosis using DNA PCR testing is also recommended for all exposed infants at 6 weeks. This is a new technology used for HIV early detection testing. The test looks for the DNA copy of the HIV virus itself in the blood instead of testing for HIV antibodies. It is extremely accurate, sensitive and the cutting edge of HIV early detection testing. This new technology can detect HIV as early as 28 days of exposure. DNA PCR is a virologic testing method using the Dried Blood Spot (DBS) technique. This test detects viral DNA and can be used to definitively diagnose children less than 18 months of age. This test is >96% sensitive at detecting HIV in infants as early as four weeks after birth. It is these new guidelines that have provided regimens with very high efficacy to reduce mother-to-child transmission below 5%. 1 Swaziland 12 Round HIV sentinel Surveillance Report, Ministry of Health Routine HMIS Database. 19

27 For the first time, these recommendations include use of ARV for HIV-exposed infants who are breastfeeding as a way of making breastfeeding safer for women with HIV and start of ARV prophylaxis as early as from 14 weeks of gestation (Figure 6). (Figure 6). PMTCT regimen change from : Mother: Single does NVP at onset of labour Baby: NVP within 72 hours post delivery 2007: Mother: AZT at 28 weeks gestation. Intrapartum - 3TC + NVP + AZT and a tail of 3TC + AZT for 7 days post delivery Baby: If mother received AZT beyond 4 weeks before delivery - NVP at birth + AZT for 1 week post delivery If mother received AZT for less than e weeks before delivery - NVP at birth + AZT for 4 weeks post delivery 2010: Mother: AZT at 14 weeks gestation unit delivery. Intrapartum - 3TC + NVP + AZT and a Tail of 3TC + AZT (7 days post delivery) Baby: NVP at birth until 1 week after cessation of breastfeeding For mothers already on HAART (Eligibility criterion CD4 350 and below + WHO clinical stage 3&4) AZT + 3TC + NVP Baby NVP at birth + 6 weeks post delivery TREATMENT ELIGIBILITY CRITERIA UNDER PMTCT While prevention measures are critical to the fight against HIV, treatment during the post-infection period is an important strategy. While the treatments available on the market may not completely eliminate the virus, they help to boost the CD4 count in the body of the infected mother, while at the same time lowering the viral load. 20

28 Lower CD4 count and the emergence of HIV-related signs and symptoms is an indication of an advanced HIV disease state during which the majority of vertical transmissions from an HIV infected mother to her unborn baby may occur. It is estimated that initiating treatment at a CD4 threshold of <350 would prevent 80% of maternal deaths and postnatal infant infections. It is for this reason that all HIV positive pregnant women should urgently be assessed for antiretroviral treatment eligibility and treatment should be promptly initiated for those who are eligible. The 2010 guidelines promote starting lifelong ART for all pregnant women with severe or advanced clinical disease (stage 3 or 4), or with a CD4 count at or below 350 cells/mm3, regardless of symptoms. This ART eligibility criterion is the same as those for adults in general, which emphasizes the need for access to CD4 testing. The new PMTCT ARV guidelines recommend that HIV positive pregnant women in need of treatment for their own health should start ART irrespective of gestational age and should continue with it throughout pregnancy, delivery, during breastfeeding and thereafter. The timing of ART initiation for HIV-positive pregnant women is the same as for non-pregnant women, i.e. as soon as the eligibility criteria are met. The new guidelines have improved the quality of care for both mother and child and included provision of more efficacious ARV regimens to HIV infected women from as early as 14 weeks gestation, and to exposed infants during breastfeeding (Table 3). (Table 5). Eligibility criteria for ART or ARV prophylaxis in HIV-infected pregnant women WHO clinical stage Stage 1 Stage 2 Stage 3 Stage 4 CD4 Count not available ARV prophylaxis ARV prophylaxis ART ART CD4 Count available CD4 <=350 cells/mm 3 CD4 >350 cells/mm 3 ART ARV prophylaxis ART ARV prophylaxis ART ART ART ART PMTCT services are provided within the Maternal, Newborn and Child Health (MNCH) services. The PMTCT services begin with the routine offer of HIV testing as an integral part of ANC services. HIV testing became integrated as part of the antenatal care services and may be viewed as the entry point into the PMTCT programme, primary prevention of HIV among young women of reproductive age, prevention of HIV from HIV infected mother to the child and treatment and care services for HIV infected mothers, families and children to access treatment and care services. 21

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