HIV This Week

Varga C, Brookes H. Factors Influencing Teen Mothers’ Enrolment and Participation in Prevention of Mother-to-Child HIV Transmission Services in Limpopo Province, South Africa. Qual Health Res. 2008;18(6):786-802.

In this article, Varga and colleagues examine barriers to HIV testing uptake and participation in prevention of mother-to-child HIV transmission services among adolescent mothers aged 15 to 19 years in rural and urban Limpopo Province, South Africa. The authors used the narrative research method involving key informants constructing typical case studies of adolescent experiences with HIV testing and entry into prevention of mother-to-child HIV transmission. Case studies formed the basis of a community-based questionnaire and focus group discussions with adolescent mothers. Client-counsellor dynamics during pre-test counselling were pivotal in determining uptake and participation, and counsellor profile strongly influenced the nature of the interaction. Other factors found to influence adherence to prevention of mother-to-child HIV transmission recommendations included HIV and early premarital pregnancy stigma, fear of a positive test result, and concerns over confidentiality and poor treatment by health care providers. Adolescents described elaborate strategies to avoid HIV disclosure to labour and delivery staff, despite knowing this would mean no antiretroviral therapy for their newborn infants. Theoretical, methodological, and programmatic implications of study findings are also discussed.

Editors’ note: By age 19, 30% of South African adolescent girls have been pregnant. Surveillance data estimate that more than 15% of pregnant adolescents are HIV-positive. The double stigma of pregnancy and HIV infection along with negative attitudes among health care workers poorly prepared to deal with adolescents underpin poor programme uptake. Sufficient training and adequate time to ensure supportive interactions during the initial pre-test counselling contact is an obvious first step to healthier outcomes for both adolescent mothers and their infants.

In developing countries, mother-to-child transmission of HIV is responsible for 5-10% of all new HIV infections. HIV positive mothers can transmit HIV to their babies during pregnancy, childbirth and breast-feeding. Anti-retroviral drugs are effective in reducing the risk of mother-to-child transmission of HIV. The main focus of this study was to describe mothers’ attitudes towards using services for preventing mother-to-child transmission of HIV. A non-experimental, descriptive design with a survey approach was used. The study was conducted at one hospital in Bulawayo, Zimbabwe that offers both prenatal clinic and maternity, including prevention of mother-to-child transmission, services. Fifty pregnant women, who attended prenatal clinics in Bulawayo and who booked to deliver their babies in the hospital’s maternity section, were interviewed. A structured interview survey was used to collect data. The interviewed women required more knowledge about preventing mother-to-child transmission of HIV. Many pregnant women would not use the services available for the prevention of mother-to-child transmission of HIV, for personal, financial and cultural reasons. However, the most important barriers preventing pregnant women from using free prevention of mother-to-child transmission services were structural ones. Only pregnant women who attended prenatal clinics and delivered their babies in hospital could access these services. Prenatal and delivery services might be beyond the financial reach of many Zimbabwean women, making prevention of mother-to-child transmission services inaccessible to them. Free infant formula could not be accessed at hospitals and clinics because of transport costs.

Editors’ note: This small study in one site highlights practical constraints that must be overcome to achieve universal access to prevention of mother-to-child transmission. Although HIV testing and counselling, antiretroviral prophylaxis, and counselling and support for safe infant feeding were available free of charge, basic pre-natal, delivery, and post-natal services were not. When women cannot access these because of transport or financial constraints, prevention of mother-to-child transmission doesn’t even make it to the table.

Bollen and colleagues aimed to evaluate the association between maternal herpes simplex virus type 2 seropositivity and genital herpes simplex virus type 2 shedding with perinatal HIV transmission. Women who participated in a 1996-1997 perinatal HIV transmission prevention trial in Thailand were evaluated. In this non-breastfeeding population, women were randomized to zidovudine or placebo from 36 weeks gestation through delivery; maternal plasma and cervicovaginal HIV viral load and infant HIV status were determined for the original study. Stored maternal plasma and cervicovaginal samples were tested for herpes simplex virus type 2 antibodies by enzyme-linked immunoassay and for herpes simplex virus type 2 DNA by real-time PCR, respectively. Among 307 HIV-positive women with available samples, 228 (74.3%) were herpes simplex virus type 2 seropositive and 24 (7.8%) were shedding herpes simplex virus type 2. Herpes simplex virus type 2 seropositivity was associated with overall perinatal HIV transmission [adjusted odds ratio, 2.6; 95% confidence interval, 1.0-6.7)], and herpes simplex virus type 2 shedding was associated with intrapartum transmission (adjusted odds ratio, 2.9; 95% confidence interval, 1.0-8.5) independent of plasma and cervicovaginal HIV viral load, and zidovudine treatment. Median plasma HIV viral load was higher among herpes simplex virus type 2 shedders (4.2 vs. 4.1 log(10)copies/ml; P = 0.05), and more shedders had quantifiable levels of HIV in cervicovaginal samples, compared with women not shedding herpes simplex virus type 2 (62.5 vs. 34.3%; P = 0.005). The authors found an increased risk of perinatal HIV transmission among herpes simplex virus type 2 seropositive women and an increased risk of intrapartum HIV transmission among women shedding herpes simplex virus type 2. These novel findings suggest that interventions to control herpes simplex virus type 2 infection could further reduce perinatal HIV transmission.

Editors’ note: Co-infected women had higher HIV plasma viral loads than did women without herpes simplex virus-2 (HSV-2) in this study which may explain why women with HSV-2 were more likely to transmit to their infants. If these findings are replicated among women receiving currently recommended drugs for prophylaxis of mother-to-child transmission, further evaluation is warranted of adding suppressive treatment for HSV-2 to help prevent mother-to-child transmission. Acyclovir, a drug that is well tolerated in pregnancy, is off patent and cheap.