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Elimination of pediatric HIV requires a robust program for the prevention of mother-to-child transmission (PMTCT). The goal of this study was to assess the implementation of these services in Cambodia.
This prospective study was conducted in Bantey Meanchey at 2 sites. Staff reviewed daily clinic and laboratory registration logs to gather data on PMTCT service access among antenatal women.
A total of 12 140 pregnant women received antenatal care. Only 4034 (33.2%) received pre-HIV test counseling. Of which 3407 (84.5%) received an HIV test. Eighteen (94.7%) of 19 women testing HIV-seropositive received triple-combination antiretroviral (ARV) medication. Fifteen HIV-exposed infants were delivered during the study. One infant tested HIV positive and is on ARV medication.
Acceptance for HIV testing was high among women who received pretest counseling. An increase in the number of counselors may improve the rates of HIV testing. Follow-up mechanisms targeting mother–baby pairs should focus on increasing timely service uptake in the public sector.
Historically, Cambodia has had one of the highest prevalence rates of HIV infection and AIDS in Asia.1 The prevalence of HIV/AIDS among those 15 to 49 years decreased from 2% in 1998 to 0.7% in 20122 and reached as low as 0.4% in 20103 but still remains higher than that in most Asian countries.1 Although significant progress has been achieved in the response to the HIV/AIDS epidemic since the late 1990s, the problem remains serious. Married women in stable relationships are exposed to HIV infection from their partners.4 In 2010, data showed that 0.48% of pregnant women attending antenatal care (ANC) clinics were HIV positive.5
Nearly all HIV infections among children have resulted from transmission during pregnancy, labor and delivery, and breast-feeding. To date, there is no national data on HIV-infected children, however, some modeling estimates approximately 6000 children are infected with HIV and 4700 are in need of antiretroviral therapy (ART).5,6
Approximately 50% of HIV-positive individuals in Cambodia are women of reproductive age who may require prevention of mother-to-child transmission (PMTCT) services in addition to opportunistic infection (OI) and ART services. Compared to 2003, the proportion of ANC clinic attendees living with HIV appears to have decreased from 2.2% to 1.1% in 2006.5 With the dramatic decline in ANC prevalence observed over the past 15 years, Cambodia has begun to develop a strategy for elimination of pediatric HIV by 2020, through a program7 called Cambodia 3.0.
There has been a clear shift from the first wave of the HIV epidemic, in which HIV infection was concentrated among commercial sex workers and their clients, to the second wave, in which HIV infection is spreading to wives and then to their children. This shift in the population distribution of the epidemic underlines the importance of having an effective PMTCT program to minimize the number of children newly infected with HIV.8,9
Following the implementation of the National Operational Framework for the implementation of the continuum of care for people living with HIV/AIDS in 2003, Voluntary Confidentially Counseling Testing (VCCT) services were rapidly expanded. By the end of December 2012, there were 61 health facilities that offered ART services in 50 operational districts in 21 provinces and cities.2 Increased availability of these support services has led to an uptake of VCCT services and an increase in patients seeking care.10 This includes an increase in pregnant mothers seeking antenatal services, who volunteer for HIV testing. National data show that of a total of 48 010 attendees at ANC clinics with PMTCT services, 33 251 (69.2%) were tested for HIV.11 Of the first-visit attendees at ANC clinics with PMTCT services, 53.1% were tested for HIV in 2005,12 69.3% were tested in 2006,13 and 76.7% were tested in 2007.14 The coverage of HIV testing among pregnant women increased to 78.1% in 2011.2
In 2013, the total number of PMTCT sites increased to 1072, which includes national hospitals, referral hospitals, and other health centers.2 In some parts of the world, the wide availability of infrastructure and support services for HIV VCCT has led to an increase in the uptake of VCCT services among patients seeking ANC.15,16 However, in Cambodia, HIV counseling and testing is not yet optimal at PMTCT sites, despite national guidelines offering HIV testing and treatment to all pregnant women. Mothers who receive ANC outside Phnom Penh have less chance of undergoing HIV testing than mothers who receive ANC in Phnom Penh.17
Given that the full acceptance of HIV testing and counseling is still a challenge for Cambodia, the purpose of this study was to assess the implementation of PMTCT services at the largest Cambodian PMTCT site located in the Bantey Meanchey Province.
We measured the acceptability of HIV testing and knowledge among pregnant women seeking ANC in Bantey Meanchey by survey questionnaire. The objectives were to measure HIV knowledge/barriers to HIV testing, the rates of HIV counseling, and testing among pregnant women and to determine the proportion of HIV-infected pregnant women who are offered and receive ART for PMTCT. The secondary objectives were to assess the proportion of babies born to HIV-infected mothers who are offered and receive antiretroviral (ARV) prophylaxis and to determine the rates of mother-to-child transmission of HIV.
This prospective study was conducted at a health center and a referral hospital from July 2010 through June 2011 in the Bantey Meanchey Province in Cambodia that borders Thailand in the northwest. It is a key crossing point between the 2 countries, where men often travel to Thailand searching for better income. Bantey Meanchey has 660 605 inhabitants and is divided into 8 districts, 64 communes, and 638 villages. The target population was all pregnant women with unknown HIV status presenting at the 2 sites. We used a mixed-methods approach of quantitative chart review and qualitative interview–based survey questionnaire.
Data from all pregnant women with unknown HIV status who registered for ANC at the 2 selected sites were included. All women seen in the clinic should have attended prenatal class and been offered HIV testing. Staff reviewed daily clinic and laboratory registration logs to gather data on PMTCT service access among pregnant women accessing the ANC clinic. Data were collected from the following sources: registry logbook at ANC/VCCT clinic (women offered testing and counseled), laboratory logbook of women receiving rapid HIV testing, ANC/VCCT logbook of HIV status (HIV-seropositive and HIV-seronegative), OI/ART clinic logbook only for HIV-seropositive women (accepting ART), maternity and pediatric logbooks (babies receiving ART), and pediatric clinic logbook (HIV status of baby after 6 weeks and routine DNA polymerase chain reaction [PCR] testing at 6 weeks by dried blood spot).
Registered pregnant women who were offered pre- and post-counseling and HIV testing on the same day had a paired rapid HIV test method used. The first test was conducted using Alere Determine (Alere, Waltham, Massachusetts, USA), and positive and indeterminate results were confirmed using Uni-Gold Recombigen (Trinity Biotech, Wichlow, Ireland). Counseling was provided by certified HIV counselors and adhered to national guidelines on HIV pre- and posttest counseling. Those who tested seropositive were informed of treatment and care options available in Cambodia and referred to the nearest OI/ART clinic to enroll in comprehensive continuum of care, where CD4 counts could be tested and ART could be initiated or ARV prophylaxis given according to national PMTCT guidelines. Women were encouraged to go to the nearest PMTCT maternity ward for delivery. For HIV-seronegative mothers, posttest counseling, HIV education, reproductive health, and family planning information were provided.
Women with CD4 counts ≤350 cells/mm3 were eligible to initiate and remain on ART indefinitely, especially through the infant feeding period. All HIV-seropositive mothers were enrolled to receive ART at the referral hospital (RH). If an HIV-seropositive mother was not eligible for ART, the PMTCT team at the RH would maintain patient monitoring and initiate anemia testing and zidovudine (ZDV) prophylaxis. Furthermore, support was provided for the HIV-seropositive mother to adhere to an exclusive feeding method.
In cases where women presented at delivery with unknown HIV status, HIV counseling and testing was routinely offered to women who were less than 6 cm dilated. HIV-seropositive women identified through this means received prophylactic ARV treatment and were linked to care for themselves and their infants. The HIV-seropositive mothers received ARV prophylaxis during labor and were discharged with ART. All HIV-seropositive mothers were enrolled at the OI/ART services to receive their care/treatment and follow-up. Home-based care teams strongly encouraged adherence to drug and care regimens of the mothers. They provided the most appropriate infant feeding option for an HIV-infected mother depending on her individual circumstances, including her health status and the local situation. HIV-exposed babies were HIV tested with the Amplicor HIV-1 DNA PCR assay (Roche Diagnostics, Branchburg, New Jersey, USA) using dried blood spots at 6 weeks of age.
The final questionnaire consisted of 42 open-ended question and 1 close-ended question and captured data on sociodemo-graphics, pregnancy, HIV knowledge and disclosure, satisfaction of clinical services, and access to PMTCT services. The questionnaire was pretested and validated in the field to ensure culturally suitable wording and content understandable to participants. Pretesting was conducted on pregnant women and allowed for clarification and refinement of the questionnaire to meet the proper context of this study design. We evaluated the content, format, length, language, and appropriateness of the questions. The questionnaire was translated to the local language of Khmer and back translated to English to compare accuracy.
Daily, the first 4 consecutive pregnant clients registered in the clinic logbook were asked to participate in the interview portion of the study. If a woman refused, the next patient on the list was chosen. Upon informed consent, 520 women were administered the institutional review board–approved face-to-face interview questionnaire by trained research assistants. Patients were compensated US$3 for their time.
Demographic information included age, education, occupation, monthly income, primary mode of transportation, and distance between home and health center. Pregnancy and ANC information included questions about current and previous pregnancies, number of living children, use of contraception, use of ANC, wait time at ANC clinic, and perception of wait time at ANC clinic. The PMTCT information included knowledge of HIV transmission and testing, opinion toward HIV disclosure, attitude toward HIV, and sharing HIV information with a partner. Statistical analysis was performed using SPSS version 17.0 (SPSS Inc, Chicago, Illinois).
Ethical approvals were obtained from Cambodian National Ethics Committee for Health Research and the Lifespan Institutional Review Board. Participation in the study was voluntary, and written informed consent was obtained prior to interviewing.
A total of 12 140 pregnant women attended ANC between the 2 study sites, each site having only 1 PMTCT counselor available to counsel patients in a group setting. Of these women, 4034 (33.2%) received pre-HIV test counseling (Table 1). Of the women who received pretest counseling, 3407 (84.5%) received an HIV test and HIV prevalence was found to be 0.6%, while 627 (16%) declined HIV testing. Nineteen women tested seropositive for HIV, and of these, 18 (94.7%) received triple-combination ART, 12 (66.7%) received ART before 16 weeks of gestation, and 6 (33.3%) received ART after 16 weeks of gestation. Fifteen HIV-exposed infants were delivered during the study, and 11 (73.3%) of which were delivered at the study sites and 4 at private sector facilities. All 11 HIV-exposed infants born at the study sites received daily nevira-pine (NVP) or ZDV prophylaxis, and only 7 (77.8%) of 9 HIV-exposed infants received DNA-PCR testing at 6 weeks. One infant tested HIV-positive and is on ART.
The mean age of pregnant women surveyed was 27 years. Characteristics of the 520 women can be found in Table 2. The average family monthly income was less than US$100 for 75% of the households, and 91% of patients lived less than 5 km from the health center. The wait time for care was less than 30 minutes for 64% of patients, and the quality of services was considered “good” by 67% of pregnant women. The frequencies of women in their first, second, and third trimester of pregnancy were 59%, 24%, and 17%, respectively; 89% were planned pregnancies and 49% had ever used contraception before.
Ninety-three percent of pregnant women had previously heard about HIV counseling and testing (Table 3). Among those who knew about HIV counseling and testing, pregnant women received this information from friends (9%), the media (27%), and health care workers (59%). The following information on the perceived benefits of HIV testing was reported as being learned from the different sources: protecting my baby from getting HIV (71%), getting my own treatment if HIV positive (14%), and protecting others from getting HIV (9%). In all, 94% of all pregnant women thought that having unprotected sex could lead to HIV. However, only 46% knew that HIV could be contracted from a blood transfusion, and only 58% thought that an HIV-positive mother could transmit HIV to her child. The majority of pregnant women said they would share general HIV information with their partners (77%), while 83% said they would invite their partners to HIV counseling; 99% believed that HIV testing should be a part of prenatal care and 98% agreed to HIV testing at the interview session. Of the 509 interviewed women who were tested for HIV, 2 were found to be HIV seropositive, of mean age 27 years, without opportunistic infections, and have a CD4 count of 534 cells/mm3.
The results of this study suggest and support that PMTCT of HIV is achievable when HIV detection occurs and women are given the adequate ART and ANC. However, not enough women were tested for HIV. Of the women who attended ANC, acceptance of HIV testing was found to be high among those receiving pretest counseling, however, the majority of pregnant women were not offered testing. Among women receiving ART, only 67% received treatment on time as per Cambodian national guidelines (16 weeks of gestation) and 22% of HIV-exposed infants did not receive a DNA PCR test at 6 weeks.
Further study is needed to understand why 16% of the 4034 pregnant women pretest counseled declined HIV testing entirely, as this was not surveyed. Previous data show the perceived need to obtain a partner’s permission to be tested as a barrier to testing.17 A previous study in Cambodia investigated the influence of partner participation in informational PMTCT classes on VCCT.18 During the first visit to ANC, all women were invited to a class where information on PMTCT was provided. Following class participation, the acceptance rate of pretest counseling for those who attended the class alone was 18.7%, while that of the attendees with their partners was 85.1%. All of the couples accepted disclosure of their results to their partners. Including partners in the process could be beneficial and should be explored.
Maternal knowledge of HIV is associated with the acceptance of HIV testing.19,20 Although we do not have information on the HIV knowledge of the 16% (627 of 4034) who declined HIV testing, only 2% of the 520 women surveyed declined HIV testing and 94% of the 520 knew that unprotected sex could lead to HIV transmission. In addition to knowledge, selection bias could be a factor affecting the difference in these numbers. Those who agreed to the interview questionnaire could be systematically more inclined to agree to HIV testing than the greater population of pregnant women seeking ANC (16% refused testing).
Most urgent is the need to increase the number of trained personnel available to test pregnant women, as 67% of women were not offered testing at all. Understaffing is likely the main explanation for this shortfall. Keeping the ratio of ANC clients to HIV counselors low will be key to providing services to all women. The use of an opt-out screening approach, meaning that HIV tests are done routinely unless a patient explicitly refuses to take an HIV test, should be considered.
Equally as important in PMTCT is bringing back the newborn infant for the child’s 6-week follow-up HIV testing. Success stories in resource-limited settings are becoming more common, especially in Southern Africa.21 With an accurate diagnosis, infected babies can be identified quickly and adequate ART started.22 Further, the success of PMTCT programs can only be evaluated fully if diagnosis of HIV in infants is assured and routinely provided. More efforts for postpartum follow-up in children are essential.
This study is not without limitations. Importantly, the study population represents women in only 1 province. This may not reflect the country population or all PMTCT clients and for this reason, generalizability to the country may not be possible. Furthermore, generalizability to the whole province may also be limited, as we did not take a probability sample to pick survey respondents. As previously mentioned, selection bias could have occurred. We have no evidence that our questionnaire sample is not representative of the general population.
There is a need to continuously monitor and evaluate how PMTCT sites are implementing national guidelines to reduce MTCT of HIV. These assessments should facilitate improvements in quality and coverage of PMTCT services and effective resource allocation. Optimal strategies are needed for the cost-effective implementation of the current PMTCT program in Cambodia to maintain maximum retention of patients and to reduce MTCT. Availability of HIV counselors and on-site testing seemed to be the most important in achieving high testing rates.
Pregnant women seeking ANC showed a high acceptance rate of HIV testing. Although almost all pregnant women understood that unprotected sex puts people at risk for HIV infection, only 58% knew that a pregnant woman could transmit HIV to her child. The limited number of HIV counselors was a potential barrier to HIV testing. Provision of counseling and on-site testing by increasing trained staff may help augment HIV testing among pregnant women in all areas of Cambodia.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Brown AIDS International Research and Training Program (Fogarty Center) 5D43TW000237 and Lifespan/Tufts/Brown Center for AID Research: P30AI42853.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.