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Navteq 2013 Vdo Dayton Rapidshare Premium there. Background In spite of effective strategies to eliminate mother-to-child-transmission of HIV, the implementation of such strategies remains a major challenge in developing countries. In India, programs for the prevention of mother-to-child transmission (PMTCT) have been scaled up widely since 2005.
However, these programs reach only a small percentage of pregnant women, and their overall effectiveness is low. Evidence-based program planning and implementation could significantly improve their effectiveness. This study sought to systematically retrieve, thematically categorize and review published research on PMTCT of HIV in India, focusing on research related to the provision and/or utilization of the cascade of services provided in a PMTCT program, in order to direct further research to enhance program implementation and effectiveness.
Results A huge share of the empirical literature on PMTCT in India (N = 134) deals with epidemiological studies (N = 60). The 46 papers related to utilization/provision of the cascade of PMTCT services were mostly from the four high HIV prevalence states in southern India and from the public sector.
Studies on experiences of implementing a PMTCT program (N = 20) show high rates of drop out of women in the cascade particularly prior to receiving ARV. Studies on individual components of the cascade (N = 26) show that HIV counseling and testing is acceptable and feasible. Literature on other components of the cascade - such as pregnant women’s access to ANC care, HIV infected women’s immunological assessment using CD4 testing, repeat HIV testing among pregnant women, early infant diagnosis and factors related to linking HIV infected women and children to postnatal care – is lacking. It has been more than 16 years since a breakthrough clinical trial (ACTG 076) demonstrated that the administration of prophylactic antiretroviral medicine - Zidovudine - to HIV-infected mothers and infants can reduce mother-to-child transmission (MTCT) of HIV by almost 68 percent [ ]. Significant advances have been made since then in developing the science of prevention of mother-to-child transmission of HIV (PMTCT). A number of clinical trials have been conducted to evaluate the effectiveness of different antiretroviral drug regimens in different combinations administered for varied durations.
As a result, MTCT can now be reduced to less than 2 percent from a possible 25–30 percent without any intervention [ ]. With the use of effective antiretroviral treatment (ART) and non-antiretroviral (ARV) strategies, MTCT has been virtually eliminated in developed countries. However, translating the scientific knowledge on an effective ARV regimen and the prevention of transmission through breast milk into field-level action has remained a major challenge for developing countries. Globally, an estimated 3,70,000 children were newly infected with HIV in 2009, and most of them were from developing countries [ ]. Further, in 2009, of the women in low- and middle-income countries eligible to receive antiretroviral medication to prevent the mother-to-child transmission of HIV only on average 53% (40% and 79% respectively) received them [ ]. In June 2011, a new global plan to eliminate HIV infections among children was launched at the UN [ ]. In India, the National AIDS Control Organization (NACO) has adopted the PMTCT program as an important component of its response to the challenge of controlling and reversing the HIV epidemic.
The program which is called the PPTCT program (Prevention of Parent-to-Child Transmission) started in 2002, and has been rapidly scaled up in the country through an increase in HIV counseling and testing facilities for pregnant women. The number of integrated counseling and testing centers rose from 2,815 in 2005–6 to 5,135 in 2009–10 [ ]. Despite this scale-up in the program, only 20% of the annual estimates of pregnant women were counseled and tested for HIV in 2009. Furthermore, only 30 percent of the estimated HIV infected pregnant women were identified and only 60 percent of those identified as HIV-infected received a single dose of Nevirapine for PPTCT, which was the then National protocol [ ].
There are several lacunae in the national PPTCT program. The overall coverage of the cascade of services provided in the program - beginning with counseling and HIV testing for pregnant women followed by immunological assessment of women by CD4 testing, provision of antiretroviral treatment or prophylaxis for the HIV-infected pregnant women, safe obstetric interventions and counseling, support for safer infant feeding options [ ] and linking of HIV infected mother and children to postnatal care - has been quite low [ ]. In spite of the scientific evidence and recommendations on more effective protocols drawn up by WHO in 2006 [ ], and then in 2010 on PMTCT [ ], the acceptance of these protocols in the national program has been slow and delayed. In order to improve the effectiveness of India’s PPTCT program and to meet the goal of achieving the virtual elimination of pediatric HIV in the country, it is important to devise appropriate evidence-based strategies. It is therefore essential to review the existing published literature on the public health aspect of PMTCT in India, in order to facilitate further research and evidence-based planning. In this paper we present the findings of a systematic review of literature on PMTCT of HIV in India. The objectives of this paper are twofold: first, to thematically categorize the existing peer-reviewed literature on PMTCT in India, and second, to describe the findings of public health literature on PMTCT.
For the purpose of this study, public health literature is defined as literature that deals with the provision and/or utilization of the cascade of services provided under a PMTCT project. The findings of this review will help direct future research that can aid program implementation and improve effectiveness of the PMTCT program in India. We retrieved 1,162 abstracts from the first search term and 238 abstracts from the second term in PubMed and MEDLINE and, in addition, respectively 404 and 140 abstracts through ISI Web of Knowledge, totaling 1,944 abstracts. There were 155 papers from PubMed and an additional 12 papers from ISI Web of Knowledge that met the abovementioned criteria for inclusion. These 167 relevant papers were thematically categorized (Figure ), and papers related to the provision and/or utilization of one or more services in the PMTCT cascade were identified for an in-depth review (N = 46). Figure 1 Categorization of published and peer-reviewed literature on PMTCT in India. Thematic categorization of PMTCT literature The categorization of 167 papers meeting the inclusion criteria is shown in Figure.
Of these, 33 summarized the existing known theory of mother-to-child transmission, and the interventions to prevent it (for example [, ]), and this included one book chapter on breast-feeding practices in relation to HIV [ ] and a perspective paper on HIV testing in the labor room [ ]. The remaining 134 papers involved empirical work.
These papers were further classified, based on their primary objective or the main results of the research. A very large proportion of the empirical literature (N = 134) on PMTCT in India deals with epidemiological studies (N = 60) (45%), including studies that reported the estimated HIV prevalence among pregnant women (N = 21), the observed rate of mother-to-child transmission of HIV in children (N = 13), HIV infection in children (N = 20), and drug resistance among women or children (N = 6). The primary objective or the main results of 46 papers (34%) were related to the provision and/or utilization of the cascade of PMTCT services.
In addition, empirical work was done on knowledge about HIV/AIDS among pregnant women (N = 6), fertility desires and perinatal outcomes among HIV-infected women (N = 11), and other subjects (N = 11). Among the 46 studies related to the provision and/or utilization of services, e.g.
The public health literature on PMTCT in India, 20 papers reported on program experiences and were not related to any particular service in the cascade. These papers were categorized as experiences of implementing a PMTCT project, [ – ]. The remaining 26 papers were related to the individual components of the PMTCT cascade. Experiences of implementing a PMTCT program (N = 20) Reference State Facility* Objective Main results Numeric summary of uptake of services (N = 9) Table 2 Barriers to accessing PMTCT services (N = 3) Hancart Petitet et al. (2008) [ ] Tamil Nadu Public To explore sociocultural factors limiting women’s access to PMTCT services.
Lack of caregiver’s access to information, inadequate attention to social and gender issues and lack of decentralization of PMTCT activities affect access to PMTCT. Rahangdale et al. (2010) [ ] Karnataka Public To study the role of stigma on access to PMTCT services. Women who experienced stigma with health care providers, community, & family felt that it was a barrier to access services and disclosure of HIV status to avail PMTCT services was not perceived as an option.
Panditrao et al. (2011) [ ] Maharashtra Private (N = 734&770) To understand the socio-demographic factors associated with loss to follow-up (LTF).
10.9% women were LTF before delivery and 19.6% after delivery. Factors associated with LTF were low education, poor socioeconomic status, late registration in the program and having HIV uninfected partner. Outreach (taking PMTCT services beyond ANC clinics) (N = 1) Madhivanan et al. (2010) [ ] Karnataka - (N = 417) To understand the knowledge and attitudes of traditional birth attendants (TBA) about HIV. Only 12% TBA had heard about AIDS. Among them, knowledge about modes of transmission and PMTCT was low (44%). Cost effectiveness (N = 6) Dandona et al.
(2005) [ ] Andhra Pradesh Public To estimate the total and unit cost of providing voluntary counseling and testing (VCT) services. The cost per client varied 6 fold among VCTCs (range US$ 2.92–17.14). The incremental cost of providing complete VCT services to each HIV-positive and HIV-negative client was US$ 2. Gamestar Black Edition Das Ultimative Kompendium The Elder Scroll here. 54 and US$ 1.22, respectively.
(2006) [ ] - Public To estimate the additional costs of universal HIV screening program for pregnant women. Comparison of universal screening program vs. Program restricted to high prevalence states showed that implementation of program only in high prevalence states would achieve 45% of the target in 20% cost. Dandona et al. (2008a) [ ] Andhra Pradesh Public To assess the cost and efficiency of the PMTCT centers in Andhra Pradesh. The cost per mother-neonate pair who received NVP showed a wide variation, ranging from US$ 98 to US$ 4,047. Cost was inversely related to the scale of the program.
Dandona et al. (2008b) [ ] Andhra Pradesh Public To estimate the changes in the unit cost of VCT and sex-workers program between 2002–2003 and 2005–2006. Over 3 years, the unit cost of VCT dropped by half and it increased 2.4 times for services provided to sex workers due to increases in male condom distribution, staff salaries and training, and treatment for sexually transmitted infections.
Dandona et al. (2009a) [ ] Andhra Pradesh Public To conduct composite economic analysis of HIV prevention interventions to inform efficient utilization of resources. The highest number of HIV infections averted per 1000 persons receiving an intervention was for MSM and women sex worker programs, followed by STI clinics and blood banks, whereas the lowest was for IEC for the general public. Dandona et al.
(2010) [ ] Andhra Pradesh Public To measure cost effectiveness of HIV prevention interventions by estimating disability adjusted life years (DALY) saved. The cost per DALY saved wasUS $100 and up to US $140 for street children, condom promotion, workplace and mass media programs. Integration of family planning (FP)/sexual and reproductive health (SRH) services in PMTCT program (N = 1) Rutenberg et al. (2005) [ ] - - To review field experiences with provision of family planning services within PMTCT. High acceptance of sterilization among women suggests the program’s priority of reducing the number of children born to HIV-infected women rather than ensuring mother’s reproductive health and rights. Studies on individual components of the cascade (N = 26) Counseling and HIV testing (N = 14) Acceptability and utilization of counseling and HIV testing by women (N = 8) Brown et al. (2001) [ ] Tamil Nadu & Karnataka Public (N = 666) To assess attitudes of pregnant women towards prenatal HIV testing and ARV prophylaxis.
86% agreed to undergo prenatal HIV testing, 21% would make this decision independently while 46% said their husband would have to decide. 97% said that they would take ARV if needed. Shankar et al. (2003) [ ] Maharashtra Public (N = 94 in ANC & 50 in DR) To assess acceptability of HIV testing in ANC and delivery room (DR). Acceptance of HIV testing was 83% in ANC clinics and 68% in the DR. Partners demonstrated very strong support for their wives to make such decisions independently. Rogers et al.
(2006) [ ] Karnataka Private (N = 202) To assess knowledge about VCT among pregnant women in rural area. 85% of women were willing to be tested. 94% had heard of HIV/AIDS and 60% had good knowledge about modes of transmission.
However, 48% did not know about PMTCT. Samuel et al. (2007) [ ] Tamil Nadu Public (N = 3722) To assess acceptance of educational session and VCT by pregnant women and to study HIV seroprevalence. 3,691 (99.2%) agreed to participate in the group educational session and 3,715 (99.8%) had VCT. Baseline knowledge regarding HIV was limited and a highly significant improvement was observed ( P.