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PMTCT) Programs in Tanzania and Uganda Heiko Karcher1, Andrea Kunz1, Gabriele Poggensee3, Paulina Mbezi4, Kizito Mugenyi5 and Gundel Harms*6

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PMTCT) Programs in Tanzania and Uganda Heiko Karcher1, Andrea Kunz1, Gabriele Poggensee3, Paulina Mbezi4, Kizito Mugenyi5 and Gundel Harms*6 Journal of the International AIDS Society BioMed Central Research article Open Access Outcome of Different Nevirapine Administration Strategies in Preventin g Mother-to-Child Transmission (PMTCT) Programs in Tanzania and Uganda Heiko Karcher1, Andrea Kunz1, Gabriele Poggensee3, Paulina Mbezi4, Kizito Mugenyi5 and Gundel Harms*6 Address: 1research associate, GTZ PMTCT Project, Institute of Tropical Medicine and International Health, Charité-University Medicine, Berlin, Germany, 3Associate Professor of Epidemiology, Department of Infectious Disease Epidemiology, Robert Koch-Institute, Berlin, Germany, 4project coordinator, MoH/GTZ PMTCT Programme, Mbeya Region, Mbeya, Tanzania, 5project coordinator, MoH/GTZ PMTCT Programme, Western Uganda, Fort Portal, Uganda and 6Professor of Tropical Medicine; international coordinator, GTZ PMTCT Project, Institute of Tropical Medicine and International Health, Charité-University Medicine, Berlin, Germany Email: Gundel Harms* - [email protected] * Corresponding author Published: 12 April 2006 Journal of the International AIDS Society 2006, 8:12 This article is available from: http://www.jiasociety.org/content/8/2/12 Abstract Objective: Prevention-of-mother-to-child transmission (PMTCT) interventions based on single- dose nevirapine (NVP) are widely implemented in Africa, but strategies differ regarding how and when to administer the drug to women and infants. The aim of this study was to analyze the outcome of different strategies with regard to NVP intake in pregnant women and their infants in Tanzania and Uganda. Methods: In an observational study carried out between March 2002 and December 2004, we compared a directly observed NVP administration strategy in Tanzania (supervised NVP intake for women and infants at a health unit) and a semi-observed administration strategy (self-administered NVP for women at home and supervised intake for infants at a health unit) in Uganda. Results: The proportions of HIV-positive women accepting receipt of NVP from the health units were similar in the 2 countries (42.4% in Tanzania vs 45.6% in Uganda; P = .06). NVP intake in infants was significantly higher in Tanzania than in Uganda (43.7% vs 24.1%; P < .001). In a multivariate analysis, maternal age above 25 years, secondary education, Catholic faith, and having undergone PMTCT counseling at a hospital were independently associated with infant NVP intake. Conclusion: In our settings, the directly observed administration strategy resulted in a higher NVP intake in infants. The semi-observed strategy, which implies that, after home delivery, the infant has to be presented to a health unit for NVP administration, was less successful. Introduction irapine (NVP) to the mother and her infant at delivery Vertical transmission is one of the most important routes have been adopted by many African countries as part of of HIV-1 transmission in sub-Saharan Africa. Prevention- their national PMTCT policies and guidelines.[1,2] Due to of-mother-to-child transmission of HIV (PMTCT) pro- the simplicity of NVP administration and low drug costs, grams based on the administration of a single dose of nev- this strategy is considered to be exceptionally appropriate Page 1 of 8 (page number not for citation purposes) Journal of the International AIDS Society 2006, 8:12 http://www.jiasociety.org/content/8/2/12 for resource-poor settings. Despite growing skepticism and support to the HIV-affected family. Pregnant women towards NVP because of the development of resistance in are supposed to ingest a single tablet of 200 mg NVP at the the mother and increasing use of combination antiretro- onset of labor, and the newborn should receive 2 mg/kg viral therapy in PMTCT prophylaxis, the NVP-based inter- of NVP syrup within 72 hours after birth. vention will remain the approach of choice in many resource-limited settings for some time because a feasible The communities are continuously sensitized towards and affordable alternative is currently lacking.[3-8] PMTCT measures in workshops, seminars, by brochures, leaflets, drama and theatre performances, and through Most national PMTCT guidelines recommend the NVP- radio spots in local languages. Integration of the PMTCT based single-dose drug regimen for PMTCT intervention, services into the existing health facilities demanded mod- but national strategies of administering the drugs to the ification of space and reconstructions. Health personnel pregnant women and their infants differ. Although of underwent comprehensive PMTCT and counseling train- high public health importance, the question of whether ing, including HIV rapid testing and training in antiretro- and in which way different drug administration strategies viral treatment. influence NVP intake has not yet been addressed. National NVP Administration Strategies Since 2001 the German Agency for Technical Co-opera- In Tanzania, women have to give birth at the intervention tion and Development (GTZ) had supported NVP-based health units in order to receive the NVP tablet and syrup PMTCT programs in rural areas of Tanzania and Uganda. for the child. NVP is not handed out to the pregnant GTZ works in close cooperation with the Ministries of women in advance. The drugs are ingested under supervi- Health of the partner countries, and the programs are inte- sion of the health personnel (directly observed strategy) grated into the existing governmental health facilities. and the mother and her infant are not discharged before Additionally, long-term antiretroviral treatment for the the drug is taken. In Uganda, the NVP tablet is handed to program participants and their families (PMTCT Plus the pregnant woman at the antenatal care (ANC) clinic at approach) was started in 2003 in the Tanzanian and week 28 of pregnancy. If she cannot deliver at an institu- Ugandan sites. tion, she should take the NVP tablet at home. She is advised to present herself at the health facility with the The national PMTCT guidelines of the 2 countries recom- newborn within 72 hours after birth in order to have the mend different NVP administration strategies. In this NVP syrup administered to her infant by health personnel study we analyze the outcome of these different strategies (semi-observed strategy). In both countries NVP is admin- with regard to NVP intake in pregnant women and their istered to the infant within 72 hours after birth. In cases in infants and factors possibly influencing the drug intake. which the mother did not take the NVP tablet within the recommended time frame (48 to 2 hours before delivery), Methods the infant dose is given directly after birth. Study Population and Study Sites An observational study design was used to compare NVP Data Collection intake of PMTCT program participants in Tanzania and Specific program indicators (such as the number of initial Uganda. ANC visits, the number of ANC clients counseled for HIV/ PMTCT, the number of ANC clients tested for HIV infec- In Tanzania, the PMTCT intervention sites are in Mbeya tion, the number of ANC clients testing positive, the Region (Mbeya Referral Hospital, Vwawa Hospital, number of ANC clients receiving NVP, and the number of Ruanda Health Centre, Igawilo Health Centre); in clients and infants who ingested NVP under supervision Uganda, in Kabarole, Kyenjojo, and Kamwenge Districts of the health personnel or at home) were documented on (Fort Portal Hospital, Virika Hospital, Kyenjojo Health a monthly basis and collected between March 2002 and Centre, Rukunyu Health Centre, Kibiito Health Centre). December 2004 (observation period). For a subset of HIV- positive women, sociodemographic data such as age, edu- Program Setting cational level, occupation, marital status, religion, The PMTCT programs comprise voluntary HIV counseling number of deliveries, and site of having undergone and testing for pregnant women and their husbands/part- PMTCT counseling were collected on standardized docu- ners, administration of NVP to the women and their mentation forms at the ANC visit of the women, at deliv- infants, regular follow-up to counsel on infant feeding ery, and at each follow-up visit. Due to logistic options, cotrimoxazole prophylaxis for children of HIV- constraints, these data could only be collected from July to positive mothers, management of infections and illnesses, December 2003. During this period, the data were consist- Page 2 of 8 (page number not for citation purposes) Journal of the International AIDS Society 2006, 8:12 http://www.jiasociety.org/content/8/2/12 ently collected from all women of the observational Uganda. Written informed consent for participation in the cohort presenting at the health units without further selec- program and its evaluation was obtained from all partici- tion. pating pregnant women. NVP Intake and Acceptance of NVP Intervention Results NVP intake was defined as the proportion of women or PMTCT Program Uptake infants who ingested the NVP tablet or syrup, respectively, The total number of ANC attendees in each country, the after they had received it from the health personnel. number of ANC attendees counseled and tested, and the number of ANC attendees who tested HIV positive are Because NVP administration to women and infants in indicated in Figure 1. Tanzania and to infants in Uganda was supervised, exact figures on NVP intake were available and defined as true True, Maximum, and Minimum NVP Intake NVP intake. For women in Uganda, exact figures on NVP In Tanzania, 625 women and 645 infants of a total of intake were not available because clients were allowed to 1475 HIV-positive women ingested NVP under supervi- self-administer NVP at home. For these clients, maximum sion of the health personnel. The true NVP intake was NVP intake was defined as the proportion of all women to therefore 42.4% for women and 43.7% for infants (Figure whom NVP was dispensed at the clinic at the ANC clinic 2). over all women who tested HIV-positive; minimum NVP intake was defined as the proportion of women or infants In Uganda, 979 of 2148 HIV-positive women received the for whom data on NVP intake was available over all NVP tablet at week 28 of pregnancy from the health per- women who tested HIV-positive.
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