|AVSI with JAIDS, NIH: Research to inform the fight against HIV in Uganda|
AVSI has been actively implementing programs to support Uganda’s Ministry of Health’s prevention of mother-to-child HIV transmission (PMTCT) program since 2002, working with both public and private hospitals and community-based organizations to find the best ways to reach mothers and their infants. Ten years of experience, including both successes and failures, has positioned AVSI and its partner hospitals like St. Joseph’s Kitgum as perfect entry points for research to inform the global body of knowledge in the fight against HIV/AIDS.
This year, an AVSI publication on delivery of a PMTCT package of services in Uganda was featured in the April 2013 Journal of Acquired Immune Deficiency Syndromes (JAIDS), Volume 62, Issue 5. Future publications are expected from an ongoing study in partnership with the U.S. National Institutes of Health (NIH) and other research institutions. Both studies focus on HIV prevention activities in 4 districts of the conflict-ridden Acholi sub-region in Northern Uganda, where AVSI’s intervention has had surprising success involving both women and men in counseling and treatment, despite the challenging context.
Achievements and lessons learned from the 10-year PMTCT program FREE
The paper, published in the April 2013 volume of the journal, was written by F. Bannink-Mbazzi, M. Lowicki-Zucca and S.V. Kabasomi of AVSI Uganda, L. Ojom of St. Joseph’s Hospital, G. Esiru from the Uganda MoH, and J. Homsy of the University of California San Francisco. It presented data from a 10-year PMTCT program and its innovative, comprehensive integration of social and medical care and support. Data was collected from 24 health facilities from January 2002 to December 2011. Trend analyses were carried out using Predictive Analytics SoftWare (PASW) Statistics.
Of the 140,658 women who newly attended antenatal care (ANC) services from 2002 to 2011, 94.4% received HIV testing and counseling (HTC) and 6.2% tested HIV-positive. HTC of male partners of tested pregnant women steadily increased from 5.9% in 2002 to 75.8% in 2011, compared to 15.5% in 2011 nationally. Overall, 79% of HIV-positive women were started on antiretroviral (ARV) prophylaxis (69.4%) or triple antiretroviral therapy (ART) (9.6%), compared to 52% nationally in 2011. The proportion of HIV-positive women who delivered in health facilities significantly increased from 55.8% in 2004 to 81.1% in 2011 (no national data available). HIV prevalence among HIV-exposed infants tested at or below 18 months of age significantly decreased from 10.3% in 2004 to 5.0% in 2011. Results show how a comprehensive PMTCT program emphasizing social and community engagement alongside medical care and support can succeed in a remote setting with multiple challenges.
The PRIMAL study: keeping women HIV-free throughout pregnancy and breastfeeding
The vast majority of the millions of pregnant women who test for HIV every year through PMTCT programs are HIV-uninfected. Keeping these women uninfected throughout pregnancy and breastfeeding is the first pillar of the World Health Organization (WHO) global PMTCT strategy. WHO recommends that pregnant women who test HIV negative at their first antenatal visit retest in the third trimester of their pregnancy, so that in the case of infection they can begin prophylaxis treatments in time to keep make sure their children are born healthy.
Despite these recommendations, many obstacles prevent women from getting retested. In addition, the effectiveness of such repeat HIV testing and enhanced counseling to lower the incidence of HIV infection has not been assessed. Yet another research gap surrounds the risk of infection in mothers who are breastfeeding, a time in which disease is likely to be transmitted to an infant during that period which lasts up to 2 years.
To address these questions, the University of California San Francisco (UCSF) and Makerere University – John Hopkins University (MU-JHU) received funding from the National Institutes of Health (NIH) in the U.S. to start a stratified randomized trial from 2012-2016 in the Mulago (Kampala) and St. Joseph (Kitgum) hospitals to test an intervention that provides HIV-negative pregnant women, 50% individually and 50% with their spouse/partner, with extended, repeat HIV testing and enhanced counseling (ERHTEC) during late pregnancy and at intervals up to 24 months postpartum or 6 weeks after the end of breastfeeding, whichever occurs first. The comparison group will receive repeat standard counseling and testing during late pregnancy and standard counseling during follow-up.
The study will identify 920 HIV-negative women among the clientele of ANC clinics of the two Ugandan hospitals to participate in the study. AVSI has the responsibility of managing the St. Joseph site in Kitgum, with a research team of 6 staff and a co-investigator.
In early 2013, the AVSI team started recruitment of study participants and has begun providing EHRTEC to the first 70 participants. Publication of results is expected in 2016.