Diese et al. Int J Virol AIDS 2016, 3:026 International Journal of Volume 3 | Issue 2 ISSN: 2469-567X Virology and AIDS Review Article: Open Access Elimination of Mother-to-Child Transmission of HIV in Democratic Re- public of Congo: Implementation of “Test &Treat” Approach at Prima- ry Health Centers Mulamba Diese1*, Susie Villeneuve2, Emile Numbi2, Freddy Salumu2, Guy Clarysse2, Hilo Ilunga3, Franck Fwamba3, Theodore Assani3 and Abel Mukengeshayi Ntambue1,4 1Center for Applied Research and Development (CRAD), Kinshasa, Democratic Republic of Congo 2UNICEF Democratic Republic of Congo, Democratic Republic of Congo 3National Program of AIDS and STD Control, Democratic Republic of Congo 4University of Lubumbashi, Democratic Republic of Congo *Corresponding author: Mulamba Diese, Center for Applied Research and Development (CRAD), Kinshasa, Democratic Republic of Congo, E-mail: [email protected] Abstract samples were collected from 373 (65.6%) for kidney and liver function (K&L) tests, and 128 (22.5%) underwent screening for Background: The “Test & Treat’ approach, also called option B+, tuberculosis co-infections. using combination antiretroviral treatment (cART) for prevention of mother-to-child transmission (PMTCT) has been very effective Women in rural areas were twice as likely to receive cART on the in controlled clinical trials in resource-limited settings. We report day of HIV diagnosis compared to those in urban areas (prevalence on our experiences with implementing this approach at primary risk ratio [PRR] = 2.0; 95% CI = 1.7-2.3; p < 0.001); a similar trend healthcare settings in Katanga province, Democratic Republic of was observed for those who were attended by one cART prescriber Congo (DRC). The objective of this study was to evaluate « Test & at antenatal care compared to those attended by many prescribers Treat » approach for PMTCT interventions implemented between (PRR = 0.4; 95% CI = 0.1-0.5; p < 0.001). A longer time gap of K&L September 2013 and June 2015 at local health centers (LHC) in results delayed cART on the day of HIV diagnosis (PRR = 0.3; 95% the DRC, in order to learn on the challenges for its scale up at CI = 0.01-0.5; p < 0.001). At 6 to 10 weeks of age, 3.7% (4/108) national level. infants were HIV positive. At 12 months of age; 7.5% (37/493) infants were HIV positive, with 6.8% (22/322) in urban versus 8.8% Methods: We conducted a cross-sectional study. In September (15/171) in rural areas (p = 0.47). 2015, data related to the coverage of “Test & Treat” approach for PMTCT interventions were collected using two techniques: Conclusions: The “Test & Treat” approach can be well interview and analysis of routinely collected medical data. Interview implemented at LHC in DRC with most pWLHIV being identified and was conducted with PMTCT focal points at selected LHC using a administered cART and CP on the same day; and < 10% instead questionnaire developed and tested on the following: i) administrative of < 5% as targeted by the global plan for the elimination mother to status of health facility, ii) number of cART prescribers, as well child transmission, MTCT rates were likely to be observed by 12 as iii) availability of renal and liver function tests. The analysis of months of age. However, retention in care and infant HIV diagnosis medical records (registers, patient’s medical records) included services are challenging. data of patients recorded between September 2013 and June 2015 according to PMTCT cascades. Data were analyzed using Keywords Statav13.0 (College Station, TX). Logistic regression was used to Combined antiretroviral treatment, Cotrimoxazole prophylaxis, identify factors associated with initiation of cART on the same day Local health center, PMTCT, Retention in care with tests for all variables having p-value less than or equal to 10% in univariable analysis. The adjustment of the model was made by using the Hosmer and Lemeshow test. The odds ratio adjusted and Background confident interval at 5% were calculated. The significance level was 5%. A majority of children acquire Human Immunodeficiency Virus (HIV) infection from mothers during pregnancy, delivery, or Results: Of 19,932 pregnant women who received PMTCT breastfeeding [1]. Worldwide, new infection cases of HIV among services between October 2013 and April 2015 at 85 LHC, 5,381 (27%), 1,2557 (63%), 1,395 (7%), and 598 (3%) consulted during children declined from an estimated 530,000 in 2000 to 260,000 in the first, second, and third trimester of pregnancy and in labor, 2013; overall 35% decline was observed since 2000 (from 58% among respectively. In total, 569 (2.9%) and 19,633 (98.5%) were tested children); acquired immunodeficiency syndrome (AIDS)-related positive and negative for HIV, respectively. All 569 pWLHIV received deaths declined to 42% since the peak value observed in 2004 as a cotrimoxazole prophylaxis (CP); 557 (97.9%) received cART; blood result of national and concerted global efforts and resources invested Citation: Diese M, Villeneuve S, Numbi E, Salumu F, Clarysse G, et al. (2016) Elimination of Mother-to-Child Transmission of HIV in Democratic Republic of Congo: Implementation of “Test &Treat” Approach at Primary Health Centers. Int J Virol AIDS 3:026 ClinMed Received: June 02, 2016: Accepted: July 27, 2016: Published: July 30, 2016 International Library Copyright: © 2016 Diese M, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. in prevention of mother-to-child transmission (PMTCT) programs As many health changes were needed before a nationwide [1]. Despite this progress, many pregnant women living with HIV implementation of this new approach, DRC decided to start with a (pWLHIV) still do not receive antiretroviral therapy and children pilot program that would allow changes to address long-standing continue to be infected and eventually die from AIDS. In 2014 alone, health-systems issues. Thus, “Test & Treat” approach for pWLHIV the number of women requiring PMTCT services remained high at was introduced at LHC with support from the Swedish International 1.3 million, and three out of four children living with HIV were still Development Authority (SIDA) in Katanga province. PMTCT not receiving HIV treatment in 21 priority countries most affected services were introduced at all LHCs to include those that were not by HIV [2]. previously considered for HIV treatment services in six HZ. These efforts have been technically assisted by UNICEF. The Global Plan for elimination of mother-to-child transmission of HIV and keeping mothers alive (eMTCT) and keeping mothers In this study, we used the term “Test & Treat” approach for alive launched by the United Nations General Assembly High-Level PMTCT for option B+ according to the World Health Organization Meeting on AIDS in July 2011 called for the reduction of mother- guidelines of 2012. According to this approach, HIV infected to-child transmission rate below 5% and universal access (100%) to pregnant women will be initiated cART after the HIV diagnosis is pediatric HIV treatment and care by 2015. This plan adopted the made regardless of the level of CD4 counts. Technically, option World Health Organization (WHO) recommendation for lifelong B+ is indeed a ‘test and treat” approach for HIV infected pregnant combined antiretroviral treatment (cART) that must be initiated women. The package of ‘Test & Treat” efforts for PMTCT included as soon as the diagnosis of HIV is made during pregnancy, and the routine HIV testing for pregnant women including their male nevirapine prophylaxis given from birth up to 6 weeks to all HIV- partners, collection of blood samples for renal and liver function tests, exposed infants [3]. initiation of cART irrespective of CD4 levels, infant ART prophylaxis The key factor to success for this virtual eMTCT is the effective from birth up to 6 weeks of age, cotrimoxazole prophylaxis (CP), and provision of cART to mothers during pregnancy and lactation period, virologic tests using polymerase chain reaction (PCR) techniques which is likely to get translated into undetectable plasmatic levels of for infants from 6 weeks of age. The use of simplified ten of ovir- viral load [4]. To achieve this level of viral load detectability during based cART was recommended for pWLHIV and breastfeeding HIV- pregnancy, cART should be provided early during the pregnancy infected mothers, and the same approach for their HIV seropositive [5-10]. In resource-limited settings that house most HIV infection male partners. Mothers are encouraged to exclusively breastfeed cases in the world, pregnant women attend health facilities usually until 6 months. As the country has adopted this approach for its late during pregnancy because of cultural and socio-economic factors national program, eventual challenges to be addressed for its scale [11]. For pregnant women who do not know their HIV status, late up at national level have not yet been documented. Therefore, this attendance to antenatal care (ANC) also means late screening for study aimed to evaluate this « Test & Treat » approach for PMTCT their status [12]. Even if pWLHIV are identified, access to cART is implemented between September 2013 and June 2015 at LHC in still limited as these therapies are provided mainly at hospitals and/ DRC. or international community supported specialized HIV clinics or primary healthcare clinics run by resident or visiting HIV-trained Methods physicians [4]. Settings Local health centers (LHC), where only nurses provide healthcare, are usually not considered for the provision of cART except for HIV This is the review of routinely collected data at 85 LHC among testing and, sometimes, follow-ups of people living with HIV (PLHIV) 128 health facilities of the pilot phase for “Test & Treat” approach whose condition has been stabilized using cART [11].