Preventing mother-to-child HIV transmission: the first year of Thailand's national program

Elimination of Mother-to-Child Transmission of HIV - Thailand

Thailand experienced a generalized human immunodeficiency virus (HIV) epidemic during the 1990s. HIV prevalence among pregnant women was 2.0% and the mother-to-child transmission (MTCT) rate was >20% (1-3). In June 2016, Thailand became the first country in Asia to validate the elimination of MTCT by meeting World Health Organization (WHO) targets. Because Thailand's experience implementing a successful prevention of MTCT program might be instructive for other countries, Thailand's prevention of MTCT interventions, outcomes, factors that contributed to success, and challenges that remain were reviewed. Thailand's national prevention of MTCT program has evolved with prevention science from national implementation of short course zidovudine (AZT) in 2000 to lifelong highly active antiretroviral therapy regardless of CD4 count (WHO option B+) in 2014 (1). By 2015, HIV prevalence among pregnant women had decreased to 0.6% and the MTCT rate to 1.9% (the elimination of MTCT target is <2% for nonbreastfeeding populations) (4). A strong public health infrastructure, committed political leadership, government funding, engagement of multiple partners, and a robust monitoring system allowed Thailand to achieve this important public health milestone.

Barriers and enablers to integrating maternal and child health services to antenatal care in low and middle income countries

Antenatal care (ANC) represents a delivery platform for a broad range of health services; however, these opportunities are insufficiently utilised. This review explores key barriers and enablers for successful integration of health s"ervices with ANC in different contexts. Data from peer‐reviewed and grey literature were organised using the SURE checklist. We identified 46 reports focusing on integration of HIV, tuberculosis, malaria, syphilis or nutrition services with ANC from Asia, Africa and the Pacific. Perspectives of service users and providers, social and political factors, and health system characteristics (such as resource availability and organisational structures) affected ease of integration.

Tweetable abstract

Health system factors, context and stakeholders must be considered for integrated antenatal care services.

Health system factors, context and stakeholders must be considered for integrated antenatal care services.

Assessment of Prevention of Mother-to-Child Transmission HIV Services in the Bantey Meanchey Province in Cambodia

BACKGROUND

Elimination of pediatric HIV requires a robust program for the prevention of mother-to-child transmission (PMTCT). The goal of this study was to assess the implementation of these services in Cambodia.

METHODS

This prospective study was conducted in Bantey Meanchey at 2 sites. Staff reviewed daily clinic and laboratory registration logs to gather data on PMTCT service access among antenatal women.

RESULTS

A total of 12 140 pregnant women received antenatal care. Only 4034 (33.2%) received pre-HIV test counseling. Of which 3407 (84.5%) received an HIV test. Eighteen (94.7%) of 19 women testing HIV-seropositive received triple-combination antiretroviral (ARV) medication. Fifteen HIV-exposed infants were delivered during the study. One infant tested HIV positive and is on ARV medication.

CONCLUSION

Acceptance for HIV testing was high among women who received pretest counseling. An increase in the number of counselors may improve the rates of HIV testing. Follow-up mechanisms targeting mother-baby pairs should focus on increasing timely service uptake in the public sector.

Counselling services in prevention of mother-to-child transmission (PMTCT) in Delhi, India: an assessment through a modified version of UNICEF-PPTCT tool

The study aims to assess the counselling services provided to prevent mother to child transmission of HIV (PMTCT) under the Indian programme of prevention of parent-to-child transmission of HIV (PPTCT). Five hospitals in Delhi providing PMTCT services were randomly selected. A total of 201 post-test counselled women were interviewed using a modified version of the UNICEF-PPTCT evaluation tool. Knowledge about HIV transmission from mother-to-child was low. Post-test counselling mainly helped in increasing the knowledge of HIV transmission; yet 20%–30% of the clients missed this opportunity. Discussion on window period, other sexually transmitted diseases and danger signs of pregnancy were grossly neglected. The PMTCT services during the antenatal period are feasible and agreeable to be provided; however, certain aspects, like lack of privacy, confidentiality of HIV status of the client, counsellor’s ‘hurried’ attitude, communication skills and discriminant behaviour towards HIV-positive clients, and disinterest of clients in the counselling, remain as gaps. These issues may be addressed through refresher training to counsellors with an emphasis on social and behaviour change communication strategies. Addressing attitudinal aspects of the counsellors towards HIV positives is crucial to improve the quality of the services to prevent mother-to-child transmission of HIV.

The uptake of integrated perinatal prevention of mother-to-child HIV transmission programs in low- and middle-income countries: a systematic review

BACKGROUND

The objective of this review was to assess the uptake of WHO recommended integrated perinatal prevention of mother-to-child transmission (PMTCT) of HIV interventions in low- and middle-income countries.

METHODS AND FINDINGS

We searched 21 databases for observational studies presenting uptake of integrated PMTCT programs in low- and middle-income countries. Forty-one studies on programs implemented between 1997 and 2006, met inclusion criteria. The proportion of women attending antenatal care who were counseled and who were tested was high; 96% (range 30-100%) and 81% (range 26-100%), respectively. However, the overall median proportion of HIV positive women provided with antiretroviral prophylaxis in antenatal care and attending labor ward was 55% (range 22-99%) and 60% (range 19-100%), respectively. The proportion of women with unknown HIV status, tested for HIV at labor ward was 70%. Overall, 79% (range 44-100%) of infants were tested for HIV and 11% (range 3-18%) of them were HIV positive. We designed two PMTCT cascades using studies with outcomes for all perinatal PMTCT interventions which showed that an estimated 22% of all HIV positive women attending antenatal care and 11% of all HIV positive women delivering at labor ward were not notified about their HIV status and did not participate in PMTCT program. Only 17% of HIV positive antenatal care attendees and their infants are known to have taken antiretroviral prophylaxis.

CONCLUSION

The existing evidence provides information only about the initial PMTCT programs which were based on the old WHO PMTCT guidelines. The uptake of counseling and HIV testing among pregnant women attending antenatal care was high, but their retention in PMTCT programs was low. The majority of women in the included studies did not receive ARV prophylaxis in antenatal care; nor did they attend labor ward. More studies evaluating the uptake in current PMTCT programs are urgently needed.

Successful clinical outcomes following decentralization of tertiary paediatric HIV care to a community-based paediatric antiretroviral treatment network, Chiangrai, Thailand, 2002 to 2008

INTRODUCTION

Most paediatric antiretroviral treatments (ARTs) in Thailand are limited to tertiary care hospitals. To decentralize paediatric HIV treatment and care, Chiangrai Prachanukroh Hospital (CRH) strengthened a provincial paediatric HIV care network by training community hospital (CH) care teams to receive referrals of children for community follow-up. In this study, we assessed factors associated with death and clinical outcomes of HIV-infected children who received care at CRH and CHs after implementation of a community-based paediatric HIV care network.

METHODS

Clinical records were abstracted for all children who initiated ART at CRH. Paired Wilcoxon signed rank tests were used to assess CD4% and virological change among all children. Cox proportional hazard models were used to assess factors associated with death. Treatment outcomes (CD4%, viral load (VL) and weight-for-age Z-score (WAZ)) were compared between CRH and CH children who met the criteria for analysis.

RESULTS

Between February 2002 and April 2008, 423 HIV-infected children initiated ART and 410 included in the cohort analysis. Median follow-up for the cohort was 28 months (interquartile range (IQR)=12 to 42); 169 (41%) children were referred for follow-up at CH. As of 31 March 2008, 42 (10%) children had died. Baseline WAZ (< -2 (p=0.001)) and baseline CD4% (<5% (p=0.015)) were independently associated with death. At 48 months, 86% of ART-naïve children in follow-up had VL<400 copies/ml. For sub-group analysis, 133 children at CRH and 154 at CHs were included for comparison. Median baseline WAZ was lower in CH children than in CRH children (p=0.001); in both groups, WAZ, CD4% and VL improved after ART with no difference in rate of WAZ and CD4% gain (p=0.421 and 0.207, respectively).

CONCLUSIONS

Children at CHs had more severe immunological suppression and low WAZ at baseline. Community- and tertiary care-based paediatric ART follow-ups result in equally beneficial outcomes with the strengthening of a provincial referral network between tertiary and community care. Nutrition interventions may benefit children in community-based HIV treatment and care.

Universal voluntary HIV testing in antenatal care settings: a review of the contribution of provider-initiated testing & counselling

OBJECTIVE

To assess the contribution of provider-initiated testing and counselling (PITC) to achieving universal testing of pregnant women and, from available data on components of PITC, assess whether PITC adoption adheres to pre-test information, post-test counselling procedures and linkage to treatment.

METHODS

Systematic review of published literature. Findings were collated and data extracted on HIV testing uptake before and after the adoption of a PITC model. Data on pre- and post-test counselling uptake and linkage to anti-retrovirals, where available, were also extracted.

RESULTS

Ten eligible studies were identified. Pre-intervention testing uptake ranged from 5.5% to 78.7%. Following PITC introduction, testing uptake increased by a range of 9.9% to 65.6%, with testing uptake ≥85% in eight studies. Where reported, pre-test information was provided to between 91.5% and 100% and post-test counselling to between 82% and 99.8% of pregnant women. Linkage to ARVs for prevention of mother to child transmission (PMTCT) was reported in five studies and ranged from 53.7% to 77.2%. Where reported, PITC was considered acceptable by ANC attendees.

CONCLUSION

Our review provides evidence that the adoption of PITC within ANC can facilitate progress towards universal voluntary testing of pregnant women. This is necessary to increase the coverage of PMTCT services and facilitate access to treatment and prevention interventions. We found some evidence that PITC adoption does not undermine processes inherent to good conduct of testing, with high levels of pre-test information and post-test counselling, and two studies suggesting that PITC is acceptable to ANC attendees.

Number and timing of antenatal HIV testing: evidence from a community-based study in Northern Vietnam

BACKGROUND

HIV testing for pregnant women is an important component for the success of prevention of mother-to-child transmission of HIV (PMTCT). A lack of antenatal HIV testing results in loss of benefits for HIV-infected mothers and their children. However, the provision of unnecessary repeat tests at a very late stage of pregnancy will reduce the beneficial effects of PMTCT and impose unnecessary costs for the individual woman as well as the health system. This study aims to assess the number and timing of antenatal HIV testing in a low-income setting where PMTCT programmes have been scaled up to reach first level health facilities.

METHODS

A cross-sectional community-based study was conducted among 1108 recently delivered mothers through face-to-face interviews following a structured questionnaire that focused on socio-economic characteristics, experiences of antenatal care and HIV testing.

RESULTS

The prevalence of women who lacked HIV testing among the study group was 10% while more than half of the women tested had had more than two tests during pregnancy. The following factors were associated with the lack of antenatal HIV test: having two children (aOR 2.1, 95% CI 1.3-3.4), living in a remote rural area (aOR 7.8, 95% CI 3.4-17.8), late antenatal care attendance (aOR 3.6, 95% CI 1.3-10.1) and not being informed about PMTCT at their first antenatal care visits (aOR 7.4, 95% CI 2.6-21.1). Among women who had multiple tests, 80% had the second test after 36 weeks of gestation. Women who had first ANC and first HIV testing at health facilities at primary level were more likely to be tested multiple times (OR 2.9 95% CI 1.9-4.3 and OR = 4.7 95% CI 3.5-6.4), respectively.

CONCLUSIONS

Not having an HIV test during pregnancy was associated with poor socio-economic characteristics among the women and with not receiving information about PMTCT at the first ANC visit. Multiple testing during pregnancy prevailed; the second tests were often provided at a late stage of gestation.

Early uptake of HIV counseling and testing among pregnant women at different levels of health facilities--experiences from a community-based study in Northern Vietnam

BACKGROUND

HIV counselling and testing for pregnant women is a key factor for successful prevention of mother to child transmission of HIV. Women's access to testing can be improved by scaling up the distribution of this service at all levels of health facilities. However, this strategy will only be effective if pregnant women are tested early and provided enough counselling.

OBJECTIVE

To assess early uptake of HIV testing and the provision of HIV counselling among pregnant women who attend antenatal care at primary and higher level health facilities.

METHODS

A community based study was conducted among 1108 nursing mothers. Data was collected during interviews using a structured questionnaire focused on socio-economic background, reproductive history, experience with antenatal HIV counselling and testing as well as types of health facility providing the services.

RESULTS

In all 91.0% of the women interviewed had attended antenatal care and 90.3% had been tested for HIV during their most recent pregnancy. Women who had their first antenatal checkup at primary health facilities were significantly more likely to be tested before 34 weeks of gestation (OR = 43.2, CI: 18.9-98.1). The reported HIV counselling provision was also higher at primary health facilities, where women in comparison with women attending higher level health facilities were nearly three or and four times more likely to receive pre-test (OR = 2.7; CI:2.1-3.5) and post-test counseling (OR = 4.0; CI: 2.3-6.8).

CONCLUSIONS

The results suggest that antenatal HIV counseling and testing can be scaled up to primary heath facilities and that such scaling up may enhance early uptake of testing and provision of counseling.

Gender and access to HIV testing and antiretroviral treatments in Thailand: why do women have more and earlier access?

In the recent scale-up of antiretroviral treatment, gender differences in access to treatment have been reported. In Thailand, as the HIV epidemic became more generalised, there has been a shift from men being disproportionately affected to increased vulnerability of women. In 2007, the Living with Antiretrovirals (LIWA-ANRS 12141) study investigated the gender distribution of all adult patients receiving antiretroviral therapy (N=513 patients) in four community hospitals in northern Thailand and factors influencing the disparities observed. From this retrospective life-event history survey, we found that proportionately more women (53%) were receiving antiretroviral therapy than men, an unexpected result for a country with a higher proportion of infections among men. They were more likely to initiate treatment within one year of diagnosis and were at a more advanced stage of the disease compared to women. This gender distribution is partly explained by the evolving dynamics of the HIV epidemic, initial prioritization of mothers for treatment and earlier access to HIV testing for women. These issues are also entangled with gender differences in the reasons and timing to HIV testing at the individual level. This study found that the majority of men underwent HIV testing for health reasons while the majority of women were tested following family events such as a spouse/child death or during pregnancy. Further qualitative research on gender specific barriers to HIV testing and care, such as perceived low risk of infection, poor access to medical care, lack of social support, actual or anticipated HIV/AIDS-related stigma would provide greater insight. In the meantime, urgent efforts are needed to increase access to voluntary counselling and testing inside and outside the family setting with targeted interventions for men.

Mother to child transmission of HIV-1 in a Thai population: role of virus characteristics and maternal humoral immune response

The objective of this study was to investigate factors influencing mother to child transmission of HIV-1 in Thailand, where HIV-1 CRF01_AE, the major subtype in Southeast Asia, predominates. Samples from 84 HIV-1 infected, anti-retroviral treatment-naïve, non-breast feeding mothers, 28 who transmitted HIV-1 to their babies (transmitters) and 56 who did not (non-transmitters), were studied for maternal humoral immune response and virus characteristics. Maternal humoral immune response was measured by lymphocyte phenotyping; neutralizing antibodies to laboratory HIV-1 MN strain and two clinical isolates; peptide binding antibody to gp41 and V3 from strains CRF01_AE, B, and MN; autologous antibodies; and quasispecies diversity. Virus characteristics studied were viral load, co-receptor usage, and viral replication capacity. No significant difference between transmitters and non-transmitters was found for any parameter of maternal humoral immune response. However, viral load and viral replication capacity were significantly higher in transmitters versus non-transmitters and were not correlated with each other. This suggests that viral replication capacity may be a transmission factor independent of viral load, which is already well established as a risk factor for transmission of HIV-1. All except four viral isolates used the CCR5 co-receptor. This is one of few studies of vertical transmission in a population where HIV-1 CRF01_AE predominates. The data suggest that in this population the maternal humoral immune response was not important in preventing transmission at parturition, but that virus characteristics were key factors, and that viral replication capacity may contribute to birth-associated mother to child transmission of HIV-1.

Update on successes and challenges regarding mother-to-child transmission of HIV

PURPOSE OF REVIEW

There is an unprecedented global commitment to reverse the pediatric HIV epidemic by making prevention of mother-to-child transmission (PMTCT) services accessible in all countries. This review outlines the successes made and the challenges that remain.

RECENT FINDINGS

In resource-rich countries, mother-to-child transmission rates of HIV as low as 1% have been achieved. The efficacy of short-course antiretrovirals for PMTCT in Africa is estimated at 50%. Coinfections with herpes simplex virus type 2, other sexually transmitted infections resulting in genital ulcers, and endemic infectious diseases (e.g., malaria) may increase the risk of mother-to-child transmission of HIV. Vertical transmission of drug-resistant viruses has been reported; the prevalence and effect of transmitted resistant virus on treatment outcomes are under investigation. Obstacles facing PMTCT in resource-limited countries include the lack of healthcare infrastructure, limited manpower, and competing public health priorities with the limited healthcare budget.

SUMMARY

Although the birth of an HIV-infected child in a resource-rich country is now a sentinel health event, in most resource-limited countries the birth of an HIV-infected child continues to be the status quo. Comprehensive PMTCT, including antiretroviral treatment for HIV-infected women and children, should be paramount in resource-limited countries.

Late HIV diagnosis and delay in CD4 count measurement among HIV-infected patients in Southern Thailand

The objectives of this study were to evaluate timeliness of HIV testing and of getting CD4 count measured and their associated factors in Southern Thailand. Between July 2004 and February 2005, consenting HIV-positive patients from seven public hospitals in Songkhla province, Southern Thailand were interviewed. Outcomes were late HIV diagnosis (having HIV-related symptoms at the time of first positive test) and the time between HIV diagnosis and first CD4 count being measured. Of 402 study patients, 55% were late HIV-diagnosed. Factors independently associated with late HIV diagnosis were age above 30 years, male and being unemployed with respective odd ratios (95% CI) of 3.10 (1.90-5.07), 7.95 (4.52-13.99), and 2.14 (1.22-3.76). Only 34% and 47% received CD4 assessment within 6 and 12 months of HIV diagnosis, respectively. Median of first-known CD4 count was 73 (IQR 16-169) and 22 (IQR 9-85) cells/microl among asymptomatic and symptomatic HIV-diagnosed patients, respectively. Common predictors for shortened delay of CD4 count measured among symptomatic and asymptomatic HIV-diagnosed patients were: infection through sexual contact (HR=1.61; 95%CI 1.12-2.33) and receiving posttest counseling (HR 1.71; 95%CI 1.15-2.52). Among the asymptomatic, those aged >25-30 years had significantly shortened delay (HR=2.18; 95%CI 1.50-3.18) compared with the younger age group as did those aged >30 years (HR=1.94; 95%CI 1.32-2.85). Such age effect on the delay was absent in the symptomatic group. Attempts to diagnose HIV at an earlier stage and timely CD4 count measured are needed.

Co-infection with human immunodeficiency virus and tuberculosis in Asia

Asia has the highest numbers of tuberculosis cases (60% of the global total) and has experienced a marked rise in HIV seroprevalence (22% of the global total) in key subpopulations of these highly populous nations. Thus, co-infected patients are a challenge for practitioners and public health workers alike. The U.S.-Japan Cooperative Medical Science Program is spearheading interdisciplinary collaborations in Asia to address the many outstanding research priorities for HIV-tuberculosis co-infection. There is an urgency to this agenda for many reasons, including the frequency with which tuberculosis accounts for the death of HIV-infected persons in Asia, and the continued rise of multiple drug-resistant Mycobacterium tuberculosis. We review briefly the public health situation in Asia, highlighting research questions from US-Japan-Asian partner joint meetings, and cite salient studies to indicate trends and challenges.

Reduction in mother-to-child transmission of HIV in Thailand, 2001-2003: Results from population-based surveillance in six provinces

BACKGROUND

In 2000, Thailand implemented a national program to prevent mother-to-child HIV transmission (PMTCT).

OBJECTIVE

To describe the effectiveness of the prevention of mother-to-child HIV transmission program in Thailand.

DESIGN AND METHODS

A register of HIV-exposed children at birth was created with follow-up of infection status. The register included children born to HIV-infected women between 1 January 2001 and 31 December 2003 at 84 public health hospitals in six provinces of Thailand. The main outcome measure was HIV infection in children.

RESULTS

A total of 2200 children born to HIV-infected mothers were registered. Of these mother-infant pairs, 2105 (95.7%) received some antiretroviral prophylaxis, including 1358 (61.7%) who received the complete short-course zidovudine regimen during pregnancy and labor for the mother and after birth for the infant, with or without other antiretrovirals. HIV infection outcome was determined for 1667 (75.8%) children, of whom 158 [9.5%, 95% confidence interval (CI), 8.1-11.0%] were infected. Transmission risk was 6.8% (95% CI 5.2-8.9%) among 761 mother-infant pairs that received the complete zidovudine regimen alone, and 3.9% (95% CI, 2.2-6.6%) among 361 mother-infant pairs that received the complete zidovudine regimen combined with other antiretrovirals, usually nevirapine. The overall transmission risk from this cohort, including all antiretroviral prophylaxis combinations, is estimated to be 10.2%.

CONCLUSIONS

The Thai national PMTCT program is effective in reducing mother-to-child transmission risk from the historical risk of 18.9-24.2%. The addition of nevirapine to short-course zidovudine beginning in 2004 may further improve program effectiveness in Thailand.

Inconsistent condom use with steady and casual partners and associated factors among sexually-active men who have sex with men in Bangkok, Thailand

HIV/STD risk behavior has not been examined in community samples of men who have sex with men (MSM) in Thailand. The sexually-active sample (n=927) was recruited from bars, saunas, and parks; 20% identified as bisexual and 17% tested HIV-positive. Inconsistent (<100%) condom use was reported by 45% of those with steady partners and 21% of those with casual partners in the prior three months. 21% had heard of effective HIV treatments (n=194), among whom 44% believed HIV was less serious and 36% said their risk behavior had increased after hearing about the treatments. In multivariate analysis, HIV-positive status, gay-identification, getting most HIV information from the radio, believing HIV can be transmitted by mosquito bite, and concern about acquiring an STD were associated with inconsistent condom use during anal sex; slightly older age (25-29 vs. 18-24 years) was associated with more consistent condom use. HIV/STD risk-reduction strategies for MSM in Bangkok should clearly state sexual risk to individuals in this population.

Human papillomavirus (HPV) detection among human immunodeficiency virus-infected pregnant Thai women: implications for future HPV immunization

BACKGROUND

Human immunodeficiency virus (HIV)-infected women are at increased risk for developing cervical cancer and for infection with human papillomavirus (HPV). Prophylactic vaccines targeting HPV types 16 and 18 are being evaluated for efficacy among young women.

GOAL

The goal was to assess the prevalence of HPV among HIV-infected pregnant women in Bangkok and to evaluate the need for prophylactic HPV vaccines studies in this population.

STUDY DESIGN

The study population consisted of 256 HIV-infected pregnant women who participated in a mother-to-child HIV transmission trial. Stored cervicovaginal lavage samples were tested for the presence of HPV DNA by polymerase chain reaction with PGMY09/11 primers and reverse line-blot hybridization for determination of anogenital HPV types.

RESULTS

HPV prevalence was 35.5% (91/256); high-risk HPV prevalence was 23.4% (60/256). HPV type 16 or 18 was present in 8.2% (21/256). Almost half of all infections were multiple. Furthermore, overall HPV detection was associated with abnormal cervical cytology (P<0.001) and higher HIV-plasma viral load (P=0.007).

CONCLUSIONS

Only one-quarter of HIV-infected pregnant women in Bangkok had high-risk HPV types; less than 10% had HPV types 16 or 18. As the HPV prevalence is expected to increase during HIV disease, prophylactic vaccines targeting HPV types 16 and 18 should be studied among HIV-infected women not yet infected with these HPV types and not previously exposed.

Barriers for HIV testing during pregnancy in Southern Brazil

OBJECTIVE

To assess HIV testing rate and determine risk factors for not have been tested during pregnancy.

METHODS

A cross-sectional study was carried out in Porto Alegre, Southern Brazil, from December 2000 to February 2001. Socioeconomic, maternal and healthcare variables were obtained by means of a standardized questionnaire. Crude and adjusted odds ratios and their 95% confidence intervals were obtained in logistic regression models.

RESULTS

A total of 1,642 mothers were interviewed. Of them, 94.3% reported being offered HIV testing before or during pregnancy or during labor; 89 mothers (5.4%) were not tested or did not know if they were tested. Attending fewer than six prenatal visits, being single and younger than 18 years old were relevant barriers preventing HIV testing. There was found a relationship between maternal schooling and the category of prenatal care provider. Having low 22.20 (12.43-39.67) or high 3.38 (1.86-7.68). schooling and being cared in the private sector strongly reduced the likelihood of being HIV tested.

CONCLUSIONS

The Brazilian Health Ministry's recommendation for universal counseling and HIV testing has been successfully implemented in the public sector. In order to improve HIV testing coverage, new strategies need to target women cared in the private sector especially those of low schooling.

Integrating Prevention of Mother-to-Child HIV Transmission Into Routine Antenatal Care

With funds from Elizabeth Glaser Pediatric AIDS Foundation, the Cameroon Baptist Convention Health Board implemented a program to prevent mother-to-child transmission of HIV-1 (PMTCT) as part of its routine antenatal care, with single-dose maternal and infant peripartum nevirapine (NVP) prophylaxis of HIV-positive mothers and their babies. Nurses, midwives, nurse aides, and trained birth attendants counseled pregnant women, obtained risk factor data, and offered free HIV testing with same-day results. From February 2000 through December 2004, this program rapidly expanded to 115 facilities in 6 of Cameroon's 10 provinces, not only to large hospitals but to remote health centers staffed by trained birth attendants. We trained 690 health workers in PMTCT and counseled 68,635 women, 91.9% of whom accepted HIV testing. Of 63,094 women tested, 8.7% were HIV-1-positive. Independent risk factors for HIV-1 infection included young age at first sexual intercourse, multiple sex partners, and positive syphilis serology (P < 0.001 for each). We counseled 98.7% of positive and negative mothers on a posttest basis. Of 5550 HIV-positive mothers, we counseled 5433 (97.9%) on single-dose NVP prophylaxis. Consistent training and programmatic support contributed to rapid upscaling and high uptake and counseling rates.

Risk of HIV Transmission Within Marriage in Rural China: Implications for HIV Prevention at the Family Level

BACKGROUND

Little is known about HIV transmission at the family level in China.

GOAL

: We examined the risks for HIV transmission between husbands and wives and from parents to children in a rural area where HIV spread among former commercial blood donors.

STUDY

A cross-sectional study was conducted among 605 (302 couples) marriage license applicants.

RESULTS

More males (64.6%) than females (52.1%) reported having had premarital sex and multiple sex partners (12.6% and 6.9%, respectively). Among those having had multiple sex partners, 8.5% reported often or always using condoms. Only 36.8% of the couples agreed that they would not plan to have a baby after knowing the status of HIV infection. Approximately 43% of the couples agreed that they would use condoms consistently if 1 of them were HIV-positive.

CONCLUSIONS

There is an urgent need for national programs to prevent HIV infection within couples in rural areas.

Evaluating Programs to Prevent Mother-to-Child HIV Transmission in Two Large Bangkok Hospitals, 1999-2001

The 2 largest maternity hospitals in Bangkok implemented comprehensive programs to prevent mother-to-child HIV transmission in 1998. We conducted a cross-sectional survey of post-partum HIV-infected women in 1999 through 2001 to evaluate these programs. Women were given structured interviews at 0 to 3 days, 1 month, and 2 months postpartum. Medical records of women and their newborns were reviewed. Of 488 enrolled women, 443 (91%) had antenatal care: 391 (88%) at study hospitals and 52 (12%) elsewhere. The HIV diagnosis was first known before pregnancy for 61 (13%) women, during pregnancy for 357 (73%) women, during labor for 22 (5%) women, and shortly after delivery for 48 (10%) women. Antenatal zidovudine (ZDV) was used by 347 (71%) women, and intrapartum ZDV was used by 372 (76%) women. Twelve (55%) of the 22 women who first learned of their HIV infection during labor took intrapartum ZDV. All 495 newborn infants started prophylactic ZDV; the first dose was given within 12 hours for 491 (99%) children. Ten (2%) children were breast-fed at least once by their mother, and 10 (2%) were breast-fed at least once by someone else. Although uptake of services was high, inconsistent antenatal care, fear of stigmatization, and difficulty in disclosing HIV status prevented some women from using services.

Single-dose perinatal nevirapine plus standard zidovudine to prevent mother-to-child transmission of HIV-1 in Thailand

BACKGROUND

Although zidovudine prophylaxis decreases the rate of transmission of the human immunodeficiency virus (HIV) type 1 substantially, a large number of infants still become infected. We hypothesized that the administration, in addition to zidovudine, of a single dose of oral nevirapine to mothers during labor and to neonates would further reduce transmission of HIV.

METHODS

We conducted a randomized, double-blind trial of three treatment regimens in Thai women who were receiving zidovudine therapy during the third trimester of pregnancy. In one group, mothers and infants received a single dose of nevirapine (nevirapine-nevirapine regimen); in another, mothers and infants received nevirapine and placebo, respectively (nevirapine-placebo regimen); and in the last, mothers and infants received placebo (placebo-placebo regimen). The infants also received one week of zidovudine therapy and were formula-fed. The end point of the study was infection with HIV in the infants, established by virologic testing.

RESULTS

Between January 15, 2001, and February 28, 2003, a total of 1844 Thai women were enrolled. At the first interim analysis, the independent data monitoring committee stopped enrollment in the placebo-placebo group. Among women who delivered before the interim analysis, the as-randomized Kaplan-Meier estimates of the transmission rates were 1.1 percent (95 percent confidence interval, 0.3 to 2.2) in the nevirapine-nevirapine group and 6.3 percent (95 percent confidence interval, 3.8 to 8.9) in the placebo-placebo group (P<0.001). The final per-protocol transmission rate in the nevirapine-nevirapine group, 1.9 percent (95 percent confidence interval, 0.9 to 3.0), was not significantly inferior to the rate in the nevirapine-placebo group (2.8 percent; 95 percent confidence interval, 1.5 to 4.1). Nevirapine had an effect within subgroups defined by known risk factors such as viral load and CD4 count. No serious adverse effects were associated with nevirapine therapy.

CONCLUSIONS

A single dose of nevirapine to the mother, with or without a dose of nevirapine to the infant, added to oral zidovudine prophylaxis starting at 28 weeks' gestation, is highly effective in reducing mother-to-child transmission of HIV.

HIV/AIDS in Asia

HIV (ie, HIV-1) epidemics in Asia show great diversity, both in severity and timing. But epidemics in Asia are far from over and several countries including China, Indonesia, and Vietnam have growing epidemics. Several factors affect the rate and magnitude of growth of HIV prevalence, but two of the most important are the size of the sex worker population and the frequency with which commercial sex occurs. In view of the present state of knowledge, even countries with low prevalence of infection might still have epidemics affecting a small percentage of the population. Once HIV infection has become established, growing needs for care and treatment are unavoidable and even the so-called prevention-successful countries of Thailand and Cambodia are seeing burgeoning care needs. The manifestations of HIV disease in the region are discussed with the aim of identifying key issues in medical management and care of HIV/AIDS. In particular, issues relevant to developing appropriate highly active antiretroviral treatment programmes in the region are discussed. Although access to antiretroviral therapy is increasing globally, making it work effectively while simultaneously expanding prevention programmes to stem the flow of new infections remains a real challenge in Asia. Genuine political interest and commitment are essential foundations for success, demanding advocacy at all levels to drive policy, mobilise sufficient resources, and take effective action.

Pain: a common symptom in human immunodeficiency virus-infected Thai children

AIM

To determine the prevalence and characteristics of pain in Thai human immunodeficiency virus-infected children.

METHODS

A cross-sectional study was performed at the HIV/AIDS outpatient clinic at the Queen Sirikit National Institute of Child Health, Bangkok, Thailand from November 2002 to January 2003. Sixty-one human immunodeficiency virus-infected patients aged 4 to 15 y, an equal number of age-matched children with no chronic disease and their caregivers participated. We interviewed children and their caregivers using a structured questionnaire on pain. The main outcome measure was the percentage of human immunodeficiency virus-infected children reporting pain.

RESULTS

Forty-four percent of the human immunodeficiency virus-infected children reported pain compared to 13% of the children with no chronic disease (odds ratio, OR = 5.3; 95% CI: 2.0-14.3). Seven percent of the infected children experienced chronic pain. Children in human immunodeficiency virus clinical categories B and C reported more pain than children in categories N and A (OR = 4.0, 95% CI: 1.1-14.7). Pain in infected children tended to occur in the abdomen, lower limbs or head. Only 44 percent of the infected children experiencing pain received analgesic medication.

CONCLUSION

Despite being a common experience, pain is insufficiently taken into account and treated in Thai children with HIV/AIDS. Therefore, adequate pain identification, assessment and management should be systemically considered in their routine care.

Advances in the prevention of vertical transmission of human immunodeficiency virus

The major mode of acquisition of human immunodeficiency virus (HIV) for children is through mother-to-child transmission, which can occur during pregnancy or labor and delivery, or postnatally through breastfeeding. In resource-rich countries, mother-to-child HIV transmission has decreased to less than 2 percent after recommendations for universal prenatal HIV counseling and testing, antiretroviral prophylaxis and elective cesarean delivery, and avoidance of breastfeeding were implemented. In resource-limited settings, effective, shorter, and less expensive antiretroviral prophylaxis interventions also have been identified, but implementation has been slower, and continued transmission through breastfeeding remains a significant problem. This review summarizes recent advances made in prevention of mother-to-child transmission of HIV in the United States and other resource-rich countries, as well as progress in resource-limited countries.

HIV/AIDS and Sexually-transmitted Infections in Thailand: Lessons Learned and Challenges Ahead

Thailand has been able to reduce the potential impact of HIV/AIDS epidemic with concerted and exemplary efforts. The annual number of new HIV infections in the year 2001 was 25,790, compared to 142,819 in 1991. The key factors that contributed to the success of the HIV/ AIDS programmes include effective political and financial commitment at the highest level, multi- sectoral involvement, systemic epidemiological surveillance, social and behavioral research, and the institution of result-oriented interventions.

Despite this progress, the country must continue to improve the prevention efforts to further reduce the incidence and alleviate the impact of the burden of those persons living with HIV/ AIDS. Some challenges are to maintain and strengthen national STD prevention and control programme, to initiate and strengthen effective prevention programme among injecting drug users, to ensure increase theaccess to medical care for HIV/AIDS patients includingAR Vdrugs, and to expand multi-sectoral partnership in the design, implementation and evaluation of HIV/ AIDS-related policies and programmes to promote research.

A survey of sexual risk behavior for HIV infection in Nakhonsawan, Thailand, 2001

OBJECTIVE

To determine the prevalence of sexual risk behaviors for HIV in the general population aged 15-44 years in Nakhonsawan province, Thailand.

DESIGN

Cross-sectional survey.

METHODS

A two-stage cluster sampling technique was used to select 630 participants aged 15-44 years from the general population. Tape-recorders with earphones provided questions to the respondents, who used self-administered answer sheets to record their responses.

RESULTS

Most participants were rural, married and educated at the primary school level. The mean age was 31.5 years. Seventy-eight percent of all participants had ever had sexual intercourse. The prevalence of premarital sex among married participants was 41%. In the previous year, 20% of the participants had had sex with commercial or non-regular partners. Sex with non-regular partners occurred more frequently than sex with commercial partners. Sixty-one percent had used condoms the last time they had sex with a commercial partner and 46% had used condoms the last time they had sex with non-regular partners. Consistent condom use with non-regular partners was lower than with commercial partners. Voluntary HIV testing during the previous year was reported by 24% of the participants who had had sex with commercial or non-regular partners.

CONCLUSIONS

The results suggest that Nakhonsawan needs to strengthen implementation of the 100% condom programme, address condom use with non-commercial partners, promote awareness of personal risk rather than identification of risk groups and increase voluntary HIV testing among people who engage in risky behaviors.

Accomplishments in HIV prevention science: implications for stemming the epidemic

The past two decades have witnessed substantial advances in the science of preventing HIV infection. Although important issues remain and there is a need for continuing research, arguably the biggest challenge in preventing HIV transmission is the full implementation of existing preventive interventions worldwide.

Short-course therapy with zidovudine plus lamivudine for prevention of mother-to-child transmission of human immunodeficiency virus type 1 in Thailand

To evaluate the efficacy and safety of short-course therapy with zidovudine plus lamivudine for reduction of perinatal transmission of human immunodeficiency virus type 1 (HIV-1), a single-arm, open-label, prospective, nonrandomized study was conducted. One hundred six treatment-naive pregnant women received zidovudine (300 mg) plus lamivudine (150 mg) twice daily from week 34 of gestation until the onset of labor. During labor, zidovudine and lamivudine were given every 3 h. Neonates received zidovudine syrup for 4 weeks and were bottle fed. The median maternal virus load and CD4+ cell count at weeks 32-34 of gestation were 4.33 log10 copies/mL and 274 cells/mm3, respectively. At delivery, the mothers' mean decrease in virus load was 1.55 log10 copies/mL and the mean increase in CD4+ cell count was 93 cells/mm3, compared with enrollment levels. Three neonates were HIV-1 infected, for a transmission rate of 2.83% (95% confidence interval, 1%-8%). There were no serious adverse events in the mothers. Adverse events noted in neonates were anemia (in 6 neonates), elevated transaminase levels (in 1), and thrombocytopenia (in 3). Short-course therapy with zidovudine plus lamivudine appeared to be safe and effective for prevention of perinatal transmission of HIV-1.