Implementation of more complex regimens for prevention of mother-to-child transmission of HIV in Rwanda
Polly Clayden, HIV i-Base
In September 2005, the Rwandan national HIV programme introduced ART for women indicated for treatment and a multi drug regimen for women not indicated for treatment for the prevention of mother-to-child-transmission (PMTCT).
Prior to this women received single dose NVP as PMTCT prophylaxis.
In addition, the new guidelines included routine HIV counselling and testing for all pregnant women and CD4 testing for all HIV-positive women.
A poster from Landry Tsague and coworkers described the experience of the International Center for HIV/AIDS Care and Treatment Programs (ICAP) of providing technical and clinical support in delivering more complex ART regimens for PMTCT in 18 health facilities in Rwanda.
In accordance with new national guidelines (2006), ICAP developed strategies to implement more complex regimens including AZT from 28 weeks gestation with single-dose NVP + 7 days AZT + 3TC tail or HAART (AZT + 3TC + NVP) for pregnant women with CD4 <350 cells/mm3.
The investigators described the main barriers to rapid expansion of PMTCT services and implementation of the new guidelines as: limited number of CD4 machines at district level; weak linkages between PMTCT and ART programmes and a limited number of nurses trained on the new PMTCT protocol.
In order to address these barriers, CD4 capacity was decentralised to two districts and a coordinated district CD4 system was introduced to all PMTCT sites with a district laboratory. In order to facilitate same day diagnosis and CD4 testing, first antenatal clinic visits were scheduled to the day of CD4 blood taking at each centre. Nurses or social workers began escorting women to ART services and doctors were sent to PMTCT sites to help strengthen the link between services.
Training on the new PMTCT protocols was introduced for all appropriate staff, ICAP PMTCT field workers gave clinical mentorship to nurses and regular assessments of the quality of care were made.
In this programme AZT was initiated by nurses for women not indicated for treatment and HAART was initiated by a doctor. In ART/PMTCT sites without doctors, district hospital doctors initiated HAART during weekly visits.
The investigators reported, from July 2006 to September 2007 CD4 testing for HIV-positive women increased from 60% (140/234) in the fourth quarter 2006 (Q4-06) to 82% (136/166) in Q3-07 (p<0.0001). Those getting CD4 testing and receiving their results increased from 43% (100/234) in Q4-06 to 82% in Q3-07 (p<0.0001). The percentage of women with CD4 <350 cells/mm3 increased from 11.4% (16/140) in Q4-06 to 20% 928/136) in Q3-07 (p=0.004).
Women receiving single dose NVP only decreased from 48% (34/71) in Q3-06 to 1% (2/175) (p<0.0001). The proportion initiating more complex ARV regimens increased from 52% (37/71) in Q3-06 to 99% (173/175) in Q3-07 (p<0.0001). And since Q-3-06 93% (762/819) of HIV-positive pregnant women received any ARV drug in pregnancy.
ICAP demonstrated within a short period, the feasibility of implementing more complex regimens for PMTCT at multiple sites in a resource-limited setting.
The investigators highlighted the main challenges:
- Reorganising services to ensure same-day HIV and CD4 testing, which required strong collaboration between ART, PMTCT and laboratory staff and took 1-2 months to accomplish at each site.
- Nurses are not yet allowed to initiate HAART in Rwanda.
- Active referral to the nearest ART site from PMTCT sites with no ART services is time consuming for nurses/social workers escorting patients.
- More complex regimens for PMTCT require strong support for HIV-positive women and their families (for example support groups), which is insufficient at most sites.
- The provision of comprehensive HIV/AIDS care for mother/infant pairs post-partum
They wrote: Increasing CD4 count testing capacities at the district level and providing close mentorship to health providers are critical to quickly expand the scope of PMTCT services and facilitate the implementation of potent multidrug regimens for HIV-positive pregnant women.
Tsague L, Tene G, Adje-Toure C et al. Rapid Implementation of More Efficacious ART Regimens for the Prevention of Mother-to-Child Transmission of HIV in Rwanda. 15th CROI. February 2008. Boston, USA. Poster abstract 830.