Prevention of mother-to-child transmission

Situation analysis

Prevention of mother-to-child transmission (PMTCT) is a crucial entry point for primary prevention, treatment, care and support for mothers, children and families with HIV. Ensuring availability of antiretroviral (ARV) drugs to mothers and their newborns, safe childbirth, infant feeding counseling and continuity of care are the key components of any PMTCT program.

Despite an enormous progress over the last two years in scaling up PMTCT, Mozambique laggs behind in ensuring equitable access to ARV prophylaxis. In 2007, it was estimated that there were 150,995 HIV+ pregnant women in the country, of which, in the absence of interventions, it would result in an estimated 50,000 new pediatric infections. The Ministry of Health initiated PMTCT activities in April 2002. By the end 2002, eight PMTCT sites were established in the cities of Maputo, Beira, and Chimoio. In 2004, PMTCT component was included in the National Strategic Plan on HIV/ AIDS for the Health Sector (PENSAUDE 2004-2008) as well as in the National Strategic Plan on HIV/AIDS (PEN II 2005-2009). At the start up of the PMTCT, rapid testing for HIV and the prophylactic protocol was single dose Nevirapine to be handed out at 36 weeks of pregnancy, and single dose Nevirapine for newborns. PMTCT interventions were provided in the health centres compounds, but in many facilities, some components (like counselling and testing) were provided in separately.

In early 2006, in line with the Ministry of Health policy, PMTCT services became an integral part of routine maternal and child health. By the end 2007, there were 389 sites and ARV prophylaxis coverage of 29.8%. This has been greatly facilitated by the new norms and guidelines such as Provider initiated (opt out) testing in both antenatal care and maternity settings, blood samples for CD4 count are drawn in the antenatal care facility, the introduction of Early Infant Diagnosis for HIV exposed children under 18 months of age.

The use of combination prophylaxis (Single dose NVP during delivery plus AZT from 28 weeks) was also introduced officially and the provision of NVP to pregnant women shifted from 36 to 28 weeks.

Among the obstacles, worthy to mention, are the poor supervision of PMTCT services, the lack of human resources in quantity and quality, a weak health infrastructure, low knowledge of HIV status among pregnant women, and stigma and discrimination.

There are great examples from across the region that have proved that major investments in human resources and the quality of services such as in Western Cape, South Africa have helped to reduce vertical transmission from 30% to 5% in few years. New approaches to Counselling & Testing and strong leadership in Botswana have contributed to reduction of vertical transmission from 35% to less than 4%. Shift from site to district approach with greater district ownership in Tanzania, strengthening community linkages and involvement, for example the involvement of traditional birth attendants in Uganda, the opt-out approach 80% of women in antenatal care settings have agreed to be tested for HIV in Zimbabwe.

WHO has had an important role in supporting the scaling up of the integrated PMTCT in the country; its contribution for the integration and the scaling up has been also significant either individually as a key partner or collectively through the United Nations Development Assistance Framework (UNDAF).

Challenges

Quality of services

• Lack of Human Resources and low level usage of community agents
• Lack of formative supervision
• Lack of capacity to ensure an uninterrupted supply of drugs and supplies
• Lack of adapted infrastructure to ensure privacy and a client-friendly patient flow.

Community involvement

• Lack of male and key family decision-makers involvement in PMTCT
• Lack of emphasis of the role of the community agent as an essential link health facility-community.

Infant/mother follow-up

• Low level of follow-up of PMTCT mothers and exposed children up to 18 months
• Lack of standard community psycho-social support interventions for HIV infected mothers
• Lack of opportunities for universal access interventions for family members.

Achievements

• Integration of PMTCT into the Reproductive Health Program, specifically into maternal and newborn health programs;
• Accelerated scaling up of PMTCT services at national level;
• Development of several policy guidelines which created a significant momentum for the PMTCT and paediatric care expansion and quality improvement;
• Provider initiated ("opt out") testing was recommended in both antenatal care and maternity settings;
• Blood sample collection for CD4 count drawn in the antenatal care facility (and the sample transported to a centre with a CD4 count facilities), avoiding the need for women to visit a different department within the same facility or a different health facility for this purpose;
• DNA PCR testing introduced for HIV exposed children under 18 months of age;
• Development of targets for each province, for the number of women and children receiving PMTCT services (including ART for pregnant women), and for the number of adults and children receiving ART;
• Introduction of the triple drug prophylactic PMTCT regime including a 3TC-AZT combination during delivery in addition to single dose NVP and for 7 days postpartum;
• Maternal and child health nurses and health technicians were authorized to prescribe ART for pregnant women;
• Institutionalization of long term HIV care management in maternal, newborn and child health settings through the establishment of mothers support groups and the link of Home based care in the follow-up of mothers and exposed babies;
• PMTCT, paediatric ART targets included in the PARPA II and progress monitored bi-annually;
• Design of the national PMTCT integrated algorithm;
• Revision, updating/elaboration of monitoring and evaluation tools.

Next steps

• Reduce the loss to follow-up of women
• Increase the number of pregnant women receiving ART for their own health;
• Ensure sufficient qualified human resources;
• Strengthen the coordination between PMTCT and other HIV prevention and treatment components: need for alignment and consistency in protocols and guidelines as well as planning;
• Ensure and strengthen the quality of maternal and child health services in general, which affects quality of PMTCT services ;
• Ensure support from family members, in particular men and mothers-in-law;
• Avoid missed opportunities for PMTCT by ensuring delivery of quality PMTCT services at identified sites;
• Increase institutional deliveries for HIV+ women and ensure post natal prophylaxis for women and newborns in non institutional delivery settings;
• Ensure optimal infant feeding practices for HIV exposed children, both before the age of 6 months and after that;
• Strengthen monitoring and evaluation including the availability of M&E tools that incorporate all aspects of the PMTCT programme and capacity at all levels to use these tools for service delivery improvement.