Prevention of Parent to Child HIV Transmission (PPTCT): The Sub-Saharan Africa Dilemma

The Sub-Saharan Africa Challenge

Many countries are suffering disproportionately from the scourge of HIV/AIDS and require unique interventions to tackle the challenge they face in order to achieve global eradication of HIV/AIDS. Although significant successes have been recorded with application of PMTCT services in Sub-Saharan Africa much more needs to be done. This paper focuses on highlighting challenges posed in a bid to inform innovative approaches for result oriented interventions and better outcomes.

Sub-Saharan Africa is considered home to over 90% of the children in the world with Nigeria currently ranking the highest for rates of vertical transmission worldwide and this has been attributed to poor knowledge amongst health providers on the knowledge of PMTCT interventions resulting in limited coverage [9]. Women have been strongly implicated in the HIV pandemic due to their susceptible biologic nature as well as social and psychological predisposition influenced by economic, social, cultural and legal elements. This has an effect on how patients adhere to ART and PMTCT requirements [10]. In the developed countries, the situation is different with state of the art medical infrastructure, Available and feasible alternatives for childbirth and infant feeding options, and higher coverage of the population in need of these services.

Poor Surveillance

In 2009 it was on record that 11% of HIV positive women in Nigeria had received a form of PMTCT intervention but issues of follow-up became a challenge with identifying infant HIV cases and the proportion of these infants that received intervention of any sort. Limited facilities for early infant diagnosis affects service delivery and subsequent objective outcome evaluation of PMTCT programs [9]. Even when some facilities are able to provide effective care for the purpose of PMTCT, they lack the capacity to monitor progress after birth and so they fail to provide necessary support after birth and advice on feasible infant feeding options [11]. Even program evaluation studies do not provide clear quantitative findings about MCH services attendance, counseling for infant feeding practices and costs as well as stigma issues [12].

There have been recorded cases of multi drug resistance associated with postnatal infant or maternal prophylaxis through breastfeeding. Breastfeeding exposes infants to ARV drugs in varying quantities and as such ARV drug resistance is observed in infants. Women on triple-drug prophylaxis are likely exposing their breastfed infants to suboptimal doses of ARV through breast milk increasing their potential of developing viruses that are drug-resistance [13]. ART services implemented in Sub- Saharan Africa has expanded so much that it is only right it to effectively monitor the progress and impact of these programs in tackling the high HIV-specific mortality, with untreated infection, disease progression or death being the outcome of interest. Losses to follow up (LTFU) have been indicated to impact long-term retention in care and progress monitoring [14].

Socio-Cultural Barriers

In a recent study in Kenya, it appeared that women who received voluntary testing and counseling did not benefit as much from it because of the little support they got with regards to feeding alternatives and substitutes, considering the value their societies place on breastfeeding. Similarly in Uganda giving up breastfeeding was in addition considered as indirectly disclosing their HIV status [11, 13]. For some others HIV is still seen as a spiritual condition and as such spiritual intervention is usually sought [10]. In spite collaborative efforts amongst some religious organizations and many non-governmental organizations (NGO) to promote access to PMTCT programs, some of the religious organizations associate HIV with immorality as such they do not participate in prevention and treatment interventions.

MTCT is affected by gender inequality as it determines how PMTCT services are accessed. It was seen as a barrier to accessing HIV counseling and testing (HCT) services. In Zimbabwe certain organizations were able to achieve improved male participation in PMTCT programs however the success rate is still below the national target of 30% by 2015, with majority of the districts still below the national mark. In such male dominated societies, a woman’s ability to make decisions is influenced by her partner and this well extends into issues about the woman’s health and pregnancy [15]. In Sub- Saharan Africa, community norms and beliefs puts women in a position where they are not permitted to negotiate sex and safe sex practices. In a given committed sexual relationship, if a woman initiates a conversation about condom use, she was associated with infidelity. Women are afraid of their male partner’s reaction if they got tested without his consent and even worse when they have to disclose a positive test result. They would only be willing if they were sure of their partners consent, to avoid domestic violence or withdrawal of support [1, 16]. Another barrier connected to this was the fact that antenatal care (ANC) was seen as a woman’s activity and the health centers did not carry the men along in these activities. Some societies believed that only over protective men and those who lacked self-confidence follow their wives for ANC. Men were less motivated to partake in PPTCT programs and avoided being ridiculed. Some others had self confidence issues and as such prided themselves as being in good health and so they did not see the need to visit a health facility, how much more be involved in PPTCT programs [17].

Economic and Political Barriers

It is no news that these countries in sub-Saharan Africa and other underserved regions have fragile economies. Cost of implementing and accessing counseling and testing services, ARV interventions, alternative feeding options- formula feeding especially, is likely one luxury too difficult to afford. A significant percentage of these populations still live below a dollar a day. These countries are known to invest less than 5% of their GDP on health and see health as hardly a political agenda. Implementing the new PMTCT guidelines across developing and developed regions has faced challenges that makes success rates incomparable. In the developing countries, the process is more complex due to challenges in cost of resources, planning, and human capacity. In African, HIV/AIDS attracts the most political and stakeholder support compared to all other health problems in a bid to eliminate this pandemic [11]. According to Olugbenga-Bello et al despite most PMTCT programs being donor-driven, they are located in urban centers, which remain inaccessible to many invariably making the uptake of services relatively low.

Most of the health centers offering these PMTCT services are situated in locations that are inaccessible to rural women, who may never visit the health center throughout pregnancy. Those who find the means to visit may do so only once throughout pregnancy and if such woman is asymptomatic at the time of her visit, she cannot be identified as HIV positive and so she will miss out on the ARV therapy and she puts her newborn at a high risk of being infected at birth. Traditional birth attendants (TBA) who deliver babies in rural communities lack the knowledge of PMTCT, as most programs miss out on recognizing the need to incorporate them into PMTCT training programs [13].

Eliminating breastfeeding as a way to prevent MTCT, implies preparation of other infant feeding alternatives or Breast milk substitutes (BMS) under stringent hygienic and sanitary conditions, supported by steady supply of safe drinking water. Breastfeeding increases the chance of vertical transmission by 8-25% in developing countries. BMS is considered an option in developing countries only if it meets the criteria of Accessibility, Feasibility, Affordability, Safety and Sustainability (AFASS), in the absence of this breast milk is best [9]. It is no news that these countries are still dealing with diarrhea and other infectious disease due to poor water, sanitation and hygiene (WASH) conditions. Some of these countries have even been excluded from receiving WASH aids because they are perceived as ineffective users of the aid. Many people still live in deplorable conditions and cannot afford to feed themselves not to talk of alternatives for their babies. However in the developed countries replacement feeding options are sustainable due to more favorable conditions. Some health facilities even offer already made infant formulas at no cost on hospital visits to non-HIV patients, then how much more HIV positive patients.

HIV-positive mothers who breastfeed are encouraged to do so for at least 18months in addition to ART provided for the infant and mother, because each does not entirely eliminate risk. Due to family hardship, most women who are lucky to still have jobs or those who do other forms of trade go back to work in order to keep the home running and provide for other kids. This would normally imply early weaning at about 6months of age or less, putting such HIV-exposed infants at increased risk of malnutrition and death related to infectious disease [9].

Successes Recorded and Enabling Factors

In a recent report, South Africa (known to have the highest adult HIV prevalence), recorded fewer pediatric HIV cases compared to its African counterparts that had fewer epidemics prior to the roll out of the Global plan - geared towards 90% reduction of pediatric HIV incidence and 50% reduction of HIV-related maternal and infant mortality rates in a five-year period. The successes have been largely attributed to massive ART access to HIV positive pregnant women, community support and strong political commitment in addition to other factors [9].

In Africa, a United Kingdom based Christian non-profit organization called Tearfund is making strides toward achieving the WHO zero pediatric HIV goals. Through the Tearfund African PPTCT Alliance (TAPA); local churches and faith-based organizations can reach into rural communities that are not targeted by government and other agency programs, to achieve improved male participation and increased access to PPTCT services for young girls, mothers and children. Through a framework called “Guardians of our Children’s Health” (GOOCH), they are empowering men and their partners to help prevent HIV transmission to their children. This has also improved community participation through leaders and spiritual heads to address issues surrounding stigma and discrimination. They have employed the use of focus groups and discussion sessions to bring men together and encourage them through the stories of others and provide referrals. This is currently being implemented across 11 TAPA sites in Africa, with 2 sites in Jos, Nigeria [4]. In recent studies adherence to ART and PMTCT services has been associated with good knowledge of the etiology of the disease, alternative birth and breastfeeding options and effectiveness of care received. These patients are motivated to attend counseling sessions and subsequently adhere to appointment times. This is however contrary to a study in Southwestern Nigeria, where people demonstrated high knowledge but had low acceptance of PMTCT services due to issues of ejection, stigma and discrimination. The Democratic republic of Congo is considered a low prevalence setting and part of their achievements in tackling pediatric HIV levels is through a decentralized delivery approach. This will ensure the gaps that lead to LTFU and low coverage of PMTCT programs is covered, as services are now shifted to primary care centers. A finding similar to this encourages the integration of PMTCT programs into Maternal, newborn and child health programs so that cases previously missed cab be captured and retained during childhood immunization visits [18, 19].