Epidemiologic Modeling to Evaluate Prevention of Mother???Infant HIV Transmission in Ontario

Assessment of the decision support needs of women from HIV endemic countries regarding voluntary HIV testing in Canada

OBJECTIVE

To describe the decision support needs of immigrant and refugee women from HIV endemic countries regarding decision-making about voluntary counseling and testing for HIV (VCT) in Canada; and the needs of practitioners who support these women in making this decision, in a culturally appropriate manner.

METHODS

Adapted, semi-structured questionnaires, based on the Ottawa Decision Support Framework (ODSF), were used to interview practitioners and patients. Practitioners from diverse backgrounds were purposefully selected from centers providing VCT in Ottawa. Adult, English-speaking immigrant and refugee women from HIV endemic countries were recruited from a clinic specializing in immigrant health services. Responses were tabulated using descriptive statistics, and emerging themes coded to identify unique factors affecting decision-making.

RESULTS

Analysis revealed differences between practitioner and patient perceptions of the decision-making needs of women from HIV endemic countries regarding VCT. Practitioners identified women's lack of knowledge about HIV transmission and prevention as a primary need, while patients identified inadequate awareness of HIV screening and treatment services, and their benefits and harms. Patients also perceived that women would not be aware of the various VCT options, while few practitioners highlighted this concern. Both groups held similar viewpoints about counseling strategies that could improve decision-making.

CONCLUSION

Women were unaware of the options available to them for VCT. Both practitioners and patients highlighted the issue of stigma and negative outcomes associated with testing that created barriers or contributed to delays in women receiving testing. Women preferred anonymous testing, and recommended that information and decision support regarding HIV testing be provided via non-targeted strategies, and integrated within general health services or public education.

PRACTICE IMPLICATIONS

Decision support in the context of VCT can improve decision quality, empowering patients to make informed decisions based on personal values. Study findings can inform the development of clinical guidelines for the routine offering of VCT.

Prevention of mother-to-child transmission of HIV infection

PURPOSE OF REVIEW

Mother-to-child transmission of HIV infection is the primary cause of paediatric HIV infections worldwide. Although clinical trials show that antiretroviral therapy, elective caesarean section and formula feeding can significantly reduce the peripartum or postpartum risk of transmission, their application on a population basis is challenging. There is a need for alternative, easier and more effective interventions for population-based programmes.

RECENT FINDINGS

This review addresses recent advances in our understanding of mother-to-child transmission risk factors, including maternal viral load (in plasma, genital tract and breast milk) and gender, and determinants and rates of postnatal transmission. New information on prophylactic antiretroviral therapy includes results from randomized trials in Africa and Thailand, in addition to new information on implementation of prevention of mother-to-child transmission programmes in nontrial settings, in both developed and developing countries. Two important issues relating to use of antiretroviral prophylaxis are discussed: safety and toxicity, including new findings on haemopoiesis, prematurity and mitochondrial abnormalities in antiretroviral therapy-exposed infants and children, and resistance. Recent trends and controversies relating to mode of delivery in HIV-infected pregnant women are outlined. Regarding infant feeding, preliminary results on use of mono-antiretroviral therapy to prevent postnatal transmission in breastfeeding HIV-exposed infants are discussed.

SUMMARY

In resource-rich settings, virtual elimination of mother-to-child transmission is theoretically possible. Even in these settings, however, a substantial number of infected women are not being identified early enough for optimum application of prevention of mother-to-child transmission interventions. In developing country settings, focus is being directed towards scaling-up prevention programmes now that trials have established a variety of effective antiretroviral prophylactic approaches.