Acceptability and uptake of a package to prevent mother-to-child transmission using rapid HIV testing in Abidjan, Côte d'Ivoire

The participation of HIV-1-infected pregnant women in a programme of prevention of mother-to-child transmission (MTCT) of HIV in Abidjan is described. Prenatal counselling with a rapid HIV test was proposed to 14 067 pregnant women, and acceptance was 89.4%. The return rate for results was 74.2%. The HIV-1 prevalence was 11.1%, and 26.2% of HIV-infected women started the prevention of MTCT programme. To increase the uptake, we recommend community mobilization and the strengthening of male involvement. Every day 1900 children acquire HIV-1 infection from their mother in Africa. Short-course antiretroviral prophylaxis is the best confirmed measure to prevent mother-to-child transmission (MTCT) of HIV in this context. Nevertheless, despite the rapid implementation of pilot public health programmes [1], the uptake of services for the prevention of MTCT remains low in Africa. Approximately 20% of all HIV-infected pregnant women identified through counselling and testing took prevention of MTCT antiretroviral drugs in west Africa [2,3]. The factors influencing participation in prevention of MTCT programmes have not been yet clearly identified. The ANRS 1201/1202 Ditrame Plus therapeutic cohort was launched in May 2000 in Abidjan, Côte d'Ivoire, to assess the effectiveness of a prevention of MTCT package combining a short-course antiretroviral regimen of zidovudine plus nevirapine and postpartum interventions. Here, we describe the frequency of missed opportunities for prevention of MTCT and study the profile of HIV-positive women who did not participate in this programme. The Ditrame Plus project progressively reached six community-based antenatal clinics. All pregnant women (age ≥ 18 years) attending these antenatal clinics were provided pre-test counselling. All women accepting the HIV test signed an informed consent document. Their partners were also offered free HIV testing if they were informed by them. HIV testing was conducted using on-site rapid HIV testing in a serial strategy (Determine and Genie II). Women were considered infected with HIV type 1 (HIV-positive) if both tests were positive. If the results of the two rapid tests were discordant, an enzyme-linked immunosorbent assay test was used. The HIV test result was available within 24 h and was provided by the same counsellor as the pre-test counselling. Informed and consenting HIV-positive pregnant women were offered free of charge the prevention of MTCT package of the Ditrame Plus project: antiretroviral prophylaxis (zidovudine plus nevirapine) from 36 weeks of gestation until delivery, alternatives to predominant breastfeeding (formula feeding at birth or exclusive breastfeeding for 3 months followed by rapid weaning) and mother and child cotrimoxazole prophylaxis. Regression logistic analysis was used to identify the risk factors for HIV+ pregnant women who did not return to receive test result and the characteristics of those who did not initiate the PMTCT package despite being informed of their HIV status. From May 2000 to October 2002, 14 067 pregnant women received pre-test counselling. The acceptability of rapid HIV testing was 89.4%. The prevalence of HIV-1 infection (HIV-1 infection alone and dually reactive HIV-1+2) was 11.1% [95% confidence interval (CI) 10.5–11.6%; n = 1396]. The overall acceptability of HIV testing defined by the acceptance of both pre-test and post-test counselling was 9340/14 067 (66.4%). Of the 1396 HIV-1-infected women, 1023 (73.3%) came back for post-test counselling to receive their result. A similar proportion (74.3%) was observed for uninfected women (P = 0.38). No difference was found in HIV-1 prevalence between those who received their HIV test result and those who did not (10.9 versus 11.5%, P = 0.39). Among the 1023 pregnant women who were informed of their HIV-1-seropositive status, only 366 started the peripartum intervention. There are two possible ways of reporting the uptake of this first component of the prevention of MTCT package: 366/1023 (35.8%) among pregnant women who were informed of their HIV serostatus and 366/1396 (26.2%) when considering as the target all HIV-1-infected pregnant women diagnosed through the antenatal testing process. The socioeconomic features of the 373 women who did not return to get their test result were similar except for the age of those of the 1023 women who received it in univariate analysis (Table 1). Women less than 25 years of age remained 1.3 times more likely than older women to refuse post-test counselling (95% CI 1.0–1.6) in multivariate analysis.Table 1: Profile of HIV-1-infected pregnant women eligible for the prevention of mother-to-child transmission of AIDS programme (N = 1396) according to their acceptance of their HIV test result and of the prevention of mother-to-child transmission package in Abidjan, Côte d'Ivoire (ANRS 1201/1202 Ditrame Plus Project, 2002).Among the 1023 HIV-infected women who knew their HIV status, the uptake of the prevention of MTCT package was significantly lower in univariate (Table 1) than multivariate analysis in illiterate women [odds ratio (OR) 1.6; CI 1.2–2.3] and in women living with a partner (OR 1.5 CI 1.1–2.0). This observational survey conducted within a large-scale programme found that the acceptability of a prevention of MTCT package remains largely insufficient in a context of high HIV prevalence, despite the availability of rapid HIV testing on site and a background of the conduct of prevention of MTCT research with antiretroviral drugs [3,4]. Only one-third of HIV-positive women ended up initiating the proposed prevention of MTCT package. Our results unfortunately remain in accordance with the last published reports, despite the evolving context in favour of the prevention of MTCT [2–4]. In this study, there were several reasons to explain the low uptake of the package, but the refusal to believe the result given by the counsellor and the high risk of social stigmatization are key factors to consider early in the sequence of actions needed. The present study found that a low education level was associated with a poor uptake of the prevention of MTCT package in HIV-infected women who knew their status. Particular attention must be paid to illiterate HIV-positive women during counselling in order to explain as clearly as possible the different options and stress the expected benefit to their children. The women who had been living with their partner accepted the prevention of MTCT package less frequently than those who did not. In Kenya, only a third of HIV-positive women informed their partners of their test results because of stigma, domestic violence and disruption of the relationship. To prevent negative reactions of men, Gaillard et al. [5] recommended couple-counselling and enhanced partner involvement in MTCT prevention programmes. The high frequency of missed opportunities documented in the first 2 years of our programme calls for a plan of community mobilization to reduce stigmatization. In this African urban setting, the involvement of community leaders is important to obtain their cooperation and participation in the design and conduct of such actions and is now being seriously considered. There is no universal solution to the successful implementation of a prevention of MTCT package in poor settings. Parameters to be considered among others in operational research programmes leading to the successful prevention of MTCT include: the background community awareness on the prevention of MTCT, the quality of antenatal and obstetric care, the training of healthcare providers, the strengthening of male involvement, and womens’ empowerment and education. ANRS 1201 Ditrame Plus Study Group Principal investigators: François Dabis, Valériane Leroy, Marguerite Timite-Konan, Christiane Welffens-Ekra. Coordination in Abidjan: Laurence Bequet, Didier Koumavi Ekouévi, Besigin Townowne-Gold, Ida Viho. Clinical team: Clarisse Amani-Bosse, Ignace Ayekoe, Gédéon Bédikou, Nacoumba Coulibaly, Christine Danel, Patricia Fassinou, Appolinaire Horo, Ruffin Likikouet, Hassan Toure. Laboratory team: Dominique Bonard, André Inwoley, Crépin Montcho, François Rouet. Biostatistics and data management: Renaud Becquet, Laurence Dequae-Merchadou, Gérard Allou, Charlotte Sakarovitch, Dominique Touchard. Psycho-social team: Hortense Aka-Dogo, Annabel Desgrées du Loû, Alphonse Sihé, Benjamin Zanou. Scientific committee: Stéphane Blanche, Jean-François Delfraissy, Philippe Lepage, Laurent Mandelbrot, Christine Rouzioux, Roger Salamon. This study was presented in part at the 14th International Conference on AIDS (July 2002, Barcelona, Spain) [Abstract ThPe7778], and the presenting author (Didier Koumavi Ekouévi) received the IAS Young Investigator Award for Track D: Prevention Science.