Holistic evaluations of PMTCT interventions.
PMTCT interventions, postnatal and otherwise, will be better understood and therefore more effective if they are evaluated more holistically, i.e. in terms of their psychosocial and economic consequences as well as their biological ones. Much of the research on postnatal PMTCT to date has focused solely on the biomedical consequences of infant feeding modalities, primarily disease transmission and survival. Yet the spectrum of strategies for reducing MTCT has frequently come with a range of unintended and often unmeasured psychosocial ramifications, from unintended disclosure to physical abuse, rejection by partners, ostracization by families, and abandonment of infants. Thus, we recommend that regular feedback and open-ended evaluation by study or program participants and staff occurs throughout the course of the intervention to gauge psychosocial consequences. Moreover, these studies should also involve individuals who choose not to participate in PMTCT programs.
Similarly, the magnitude and timing of private costs (individual and household-level expenses), public sector costs (those paid for by the national government), and civil society costs (those paid for by international organizations, nongovernmental organizations, local volunteers, etc.) of interventions to HIV-affected persons is another component of PMTCT interventions that has frequently been overlooked. Individual costs include opportunity costs, such as income foregone while traveling far distances to clinics or waiting in long lines for care, as well as expenditures required to adhere to recommendations, e.g. to buy medicines, to pay for transportation to facilities, and to buy replacement milks for infants. The economic consequences of participating in PMTCT programs and adhering to prescribed recommendations have also received little attention. Families may sell assets to pay for care, HIV-positive women may engage in transactional sex to pay for formula for their infants, and governments may reappropriate funds from other programs to fund the purchase of formula and medicine or the training of health care workers. These consequences are not sufficiently documented in most analyses.
These costs will influence not only the willingness and ability of women to participate in PMTCT programs but also the amount of time they spend in programs and the degree to which they adhere to program recommendations. Therefore, we recommend that a household-level focus be adopted for economic analyses, that careful consideration be given to the economic and other risks to women and to their children (HIV-positive and other) of participating in MTCT programs, and that the likely inherent selectivity biases associated with studying only those women who participate in such programs be carefully addressed.
The measurement of programmatic costs (public sector and civil society) should include the cost of the purchase and distribution of medicines and foods and the burden to health care personnel that increased testing and counseling on HIV, optimal infant feeding, and ARV represents. Desmond et al.’s (138
) work on infant feeding counseling in South Africa is exemplary and rare for its cost analyses. With data on these costs in hand, sound costing and cost-effectiveness calculations will be possible.
In addition to evaluating what are sometimes referred to as downstream factors or the outcomes of a program or intervention, i.e. the adoption of as well as adherence to recommended behaviors, PMTCT interventions must also pay attention to the delivery side, i.e. program coverage and the quality and consistency of implementation (139
). It is important to ascertain the extent to which these interventions are delivered as intended, an endeavor that entails paying attention to and measuring factors such as training effectiveness, quality of supervision, motivational characteristics of frontline workers, and quality of contact between health care worker and client.
Finally, as promising interventions are developed, tested, become recommendations, and are rolled out, it is critical to bear in mind that the majority of MTCT occurs in sub-Saharan Africa. Indeed, in 2008, the majority (91%) of new infections among children occurred in sub-Saharan Africa, with the bulk of these occurring in southern and eastern Africa (31
). It is also worth noting that transmission is disproportionately high, given that only 67% of people living with HIV worldwide live in sub-Saharan Africa (31
). The unique agro-ecological and cultural circumstances of sub-Saharan Africa must be borne in mind as interventions are evaluated and as research priorities and public health policies are set. Although the enormous cultural diversity within sub-Saharan Africa must not be overlooked, it is fair to acknowledge the setting is distinct from middle-income countries or even other low-income regions of the world. These circumstances include particular environmental (e.g. poor access to adequate sanitation, limited availability of clean water, reliance on subsistence farming), cultural (e.g. societal expectations to breastfeed, importance of extended family in raising infant), disease (e.g. high prevalence of malaria and intestinal parasites), and economic (e.g. cash-strapped public health programs, high prevalence of food insecurity) considerations, which must be taken into account when viable interventions are considered. Because of cultural and ecological variation, all interventions must include qualitative, formative research prior to implementation, such as that done in the BAN study in Malawi (140
In summary, a holistic, contextualized understanding of the biological, psychosocial, and economic consequences of PMTCT strategies is critical for determining their real-world implementability, effectiveness, and sustainability. Furthermore, these consequences need to be considered not just for the mother or the health care system but in the context of the household and community in which the HIV-exposed infant is raised. For example, are community members supportive of EBF? And if not, why? How can mothers strategically navigate barriers to EBF? Is it culturally acceptable to give newborns nevirapine syrup for a prolonged period of time? Does the mother need to conceal this behavior? Can she enlist family member support, e.g. others reminding her to administer it or acquiring more from the clinic? Tonwe-Gold et al.’s (141
) evaluation of family-focused HIV care in Cote d’Ivoire is exemplary in its consideration of the family as the unit for PMTCT.
Similarly, the presence and welfare of other children in the household must be considered. The literature to date has tended to focus very narrowly on the infant and his or her HIV-affected mother. Although this focus may be appropriate for single-child households, it is probably inappropriate for households with multiple children in which the welfare of siblings must be considered when making decisions about care sought by HIV-positive mothers and the infant feeding practices they adopt.
Given the need for a holistic evaluation, research on the prevention of postnatal HIV transmission is an endeavor that must engage and involve a multitude of international, government, private, programmatic, advocacy, and research groups. Large-scale international initiatives to prevent MTCT include the President’s Emergency Plan for AIDS Relief, the MTCT-Plus Initiative (Columbia University), the Global Fund, the Call to Action project (Elizabeth Glaser Pediatric AIDS Foundation), the UN Interagency Task Team on MTCT, and the USAID flagship project on infant and young child nutrition (previously the LINKAGES project, currently IYCN). Donor support for multi-sectoral interventions, such as those that simultaneously address infant feeding and vertical transmission, could fuel some very effective partnerships. Currently, such alliances are limited in their appeal to funders. However, the Feed the Future and Global Health Initiatives, both of which have recently been launched by the U.S. government and aim to curb malnutrition and improve maternal and child health in a very comprehensive way, suggest that attitudes toward multidisciplinary interventions may be changing.