Factors associated with Nevirapine adherence in the prevention of mother-to-child transmission of HIV in the Free State province of South Africa and discrepancies between service records and cord-blood surveillance
Master Thesis
2014
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University of Cape Town
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Abstract
Sub-Saharan Africa holds 90% of the HIV-infected children worldwide and most of them are infected through vertical transmission. The elimination of mother-to-child transmission of HIV in this region can be achieved through complementing prophylaxis regimens with effective service delivery. The latter should involve reaching all those at risk and optimizing adherence through adequate and routine follow-up. A study set out to assess the effectiveness of preventing mother-to-child transmission (PMTCT) programs in four African countries including South Africa using the simple nevirapine-based PMTCT regimen, found that prophylaxis coverage for the PMTCT of HIV was on average poor, at only 50% among HIV-exposed infants during 2007-2008. Incomplete HIV testing in pregnancy accounted for 46% of missed opportunities for PMTCT intervention. In addition, discrepancies were found between data from cord-blood samples, which are the gold standard measure of ingestion of the prophylaxis by mothers and routinely collected data on the provision of prophylaxis at antenatal clinics. Clinic records overestimated adherence to prophylaxis which could mislead decisions about service delivery. Adherence to the simple nevirapine regimen, data and service quality should be investigated in order to identify needs for strengthening the effectiveness of WHO Option B guidelines which are being rolled out in resource-poor settings. This project set out to assess the extent of clinic-level PMTCT prophylaxis coverage in the resource-limited setting of the Free State province. Adherence to treatment as well as accuracy of clinic records so as to inform better service implementation were measured. A total of 1572 mother-infant pairs were included in a cross-sectional survey carried out in rural antenatal and delivery services from two health districts between 2007 and 2008. HIV testing and nevirapine prophylaxis data were collected by nurses and compared to anonymously linked cord-blood tests which confirmed true HIV status and ingestion of nevirapine. Logistic regression was used to assess variables from the clinic surveillance data: age, gravidity, mode of delivery, timing of HIV testing and number of antenatal visits during pregnancy, as potential predictors of adherence to nevirapine. The Kappa statistic revealed a disagreement of 10% in HIV test results and 20% in nevirapine intake between clinic records and cord-blood. The clinic records under-estimated maternal HIV prevalence by 9% (22% records versus 31% cord-blood) in mothers aged between 12 and 43 years. Also, cord-blood surveillance revealed that 19.4% of the HIV positive women recorded to have been offered nevirapine during labor, did not actually ingest it. The more frequently a woman sought antenatal care during pregnancy, the more likely she was to ingest nevirapine. Women who had at least 4 antenatal visits were 4.5 times more likely to adhere than women who attended services only once. Even though this is the simplest regimen for preventing vertical HIV transmission, compliance to the entire antenatal cascade during pregnancy is important in improving adherence to therapy and preventing missed opportunities for intervention. Inaccurate collection of routine clinic data negatively impacts on routinely reported data outcomes. Major improvements need to be undertaken both at the service provider and user levels in order to ensure that the effectiveness of the new Option-B guidelines are optimal in remote settings.
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Ngandu, N. 2014. Factors associated with Nevirapine adherence in the prevention of mother-to-child transmission of HIV in the Free State province of South Africa and discrepancies between service records and cord-blood surveillance. University of Cape Town.