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ORIGINAL ARTICLE
Year : 2016  |  Volume : 37  |  Issue : 1  |  Page : 52-57
 

Performance of the prevention of parent to child transmission program: A decadal trend from rural Maharashtra, India


1 Department of Community Medicine, Krishna Institute of Medical Sciences Karad, Karad, Maharashtra, India
2 Principal, Krishna Institute of Nursing Sciences, Karad, Maharashtra, India

Date of Web Publication14-Apr-2016

Correspondence Address:
R V Mohite
Department of Community Medicine, Krishna Institute of Medical Sciences University, Karad, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0253-7184.176217

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   Abstract 

Background: Human immunodeficiency virus (HIV) infection is widely spread across the state of Maharashtra with high prevalence among antenatal women. Aims: To assess the effectiveness of prevention of parent to child transmission (PPTCT) services in rural Tertiary Health Care Centre of Western Maharashtra, India and to address the weaknesses in functioning of PPTCT services. Materials and Methods: A cross-sectional study was conducted at Integrated Counselling and Testing Centre (ICTC) of a rural tertiary health center located in rural area of Western Maharashtra over a period of 10 years from 2003 to 2012. A total of 32,575 pregnant women were included as study subjects and data were collected as per the indicators of PPTCT by viewing the retrospective PPTCT records. The data were analyzed over the period of 10 years for the outcome of PPTCT services. The trend of PPTCT indicators over a decade were analyzed by using Chi-square test. Results: The seroprevalence of HIV infection among pregnant women was 2% in 2003 which decreased to 0.2% by 2012. The proportions of women counseled and HIV tested were 88.9% and 100%, respectively in 2003 and pretest counseling trend was steadily increased to 100% by 2012; however; HIV testing trend remained 100% throughout 10 years. Posttest counseling trend ranges from 89.6% to 99.9% whereas trend of HIV testing among partners has been fluctuating from 25% to 100%. The proportional trend of HIV-positive mothers delivered in a tertiary care hospital ranges from 60% to 100%. The proportions of pair receiving prophylaxis Nevirapine has been increased from 83.8% to 100% by 2009, but thereafter decreased to 83.3% by 2012. The overall HIV positivity among babies after 18 months of follow-up was 21%. Conclusion: HIV seroprevalence among the pregnant population is steadily declining. More and more women are availing the facilities of ICTC centers. Intensive health education and availability of diagnostic and therapeutic services in rural health center have reduced the burden of HIV/AIDS problem in the rural community.


Keywords: Evaluation, human immunodeficiency virus, prevention of parent to child transmission


How to cite this article:
Mohite R V, Mohite V R. Performance of the prevention of parent to child transmission program: A decadal trend from rural Maharashtra, India. Indian J Sex Transm Dis 2016;37:52-7

How to cite this URL:
Mohite R V, Mohite V R. Performance of the prevention of parent to child transmission program: A decadal trend from rural Maharashtra, India. Indian J Sex Transm Dis [serial online] 2016 [cited 2019 Nov 20];37:52-7. Available from: http://www.ijstd.org/text.asp?2016/37/1/52/176217



   Introduction Top


Human immunodeficiency virus (HIV)/AIDS - a global public health challenge accounted the 6th leading cause of death worldwide in 2012. Global HIV statistics 2013 estimated around 35 million people living with HIV (PLHIV) and around 2.1 million newly infected with HIV and 1.5 million died of AIDS-related illnesses.[1],[2] India carries the huge burden of HIV infection and ranks 3rd in the world in terms of a large number of PLHIV/AIDS.[3] The total number of PLHIV/AIDS in India is estimated to be around 20.9 lakh in 2011 of which 53% HIV infected population is mainly from high HIV prevalence states of the country (Andhra Pradesh, Karnataka, Maharashtra, and Tamil Nadu).[4]

Mother to child transmission of HIV infection via vertical route is also a major issue in India. Various sentinel surveillance surveys in the last 5 years by different state authorities in India have reported HIV prevalence ranging from 0.1% to 1% among antenatal women.[5],[6],[7],[8] Considering the high prevalence of HIV infection among pregnant women with its consequences, National AIDS Control Programme (NACP) Phase III (2007–2012) advocated to stop and reverse the HIV epidemic in India with maximum emphasis on prevention of HIV transmission from mother to child as a topmost priority.[9]

Based on the HIV surveillance data, Maharashtra state has been classified into the category of high HIV prevalence state. Hence, government intensively implemented prevention of parent to child transmission (PPTCT) services which showed the effectiveness of program with a decline in HIV seropositivity among ante-natal cares from 0.50% to 0.42% since 2007–2011. National AIDS Control Organization (NACO)-2011 report mentioned that some of the districts from Western Maharashtra still have high HIV seropositivity among ANC population, i.e., >1%.[10],[11],[12] NACO-2013 report noted overall seropositivity among ANC population at the national level was 0.17% by December 2012 with maximum 833,213 pregnant women tested for HIV from Maharashtra. NACO-2013 report also noted that Nagaland showed the highest seropositivity (0.84%) among pregnant women followed by Mizoram, Manipur, Meghalaya and Maharashtra. However, some states report zero seroprevalence, does not necessarily mean HIV is absent from the area.[13]

In this context, the present study was designed to assess the effectiveness of PPTCT services among antenatal women residing in rural area of Western Maharashtra, to address the weaknesses in existing service delivery of PPTCT and formulate suitable recommendations for better implementation of various programs and activities to reduce the burden of HIV/AIDS for better health of the community.


   Materials and Methods Top


A cross-sectional study was conducted at Integrated Counselling and Testing Centre (ICTC) of Krishna Hospital and Medical Research Centre, a rural tertiary health center located in Satara district of Western Maharashtra, India. The study was conducted in the year 2013 includes retrospective analysis of records over a period of a decade from 2003 to 2012. Since this duration record has been viewed for all new pregnant women attended and registered for ANC and PPTCT program. A sample size includes a total of 32,575 new pregnant women, registered and completed the formalities of PPTCT services. Data were collected by viewing the records of PPTCT center as per the performance indicators of NACO as follows:[14]

Number of newly registered antenatal cases

This includes all new antenatal cases registered for the 1st time at any of the ICTC that provided PPTCT services during any time of the antenatal period.

Number (%) of newly registered antenatal cases provided pretest counseling

This includes newly registered antenatal cases that were provided counseling on HIV testing before conducting the actual HIV testing.

Number (%) of newly registered antenatal cases accepted for human immunodeficiency virus testing

This includes newly registered antenatal cases counseled who accepted to undergo for HIV testing.

Number (%) of newly registered antenatal cases tested for human immunodeficiency virus

This includes newly registered antenatal cases those tested for HIV status.

Number (%) of newly registered antenatal cases provided posttest counseling

This includes newly registered antenatal cases those tested for HIV, were given posttest counseling for HIV.

Number (%) of newly registered antenatal cases who were found human immunodeficiency virus positive

This includes those antenatal cases that were found HIV positive out of those tested for HIV.

Number (%) of partners who were tested for human immunodeficiency virus

This includes newly registered antenatal cases that were found HIV positive; their partners were tested for HIV.

Number of live births to antenatal cases who were found human immunodeficiency virus positive

This includes delivery of live births to HIV-positive pregnant women during the study period.

Number (%) of pairs (mother and baby) provided with prophylactic treatment

This includes HIV-positive mothers, and their babies were provided with a single dose of Nevirapine as prophylaxis.

Human immunodeficiency virus-exposed live birth cohort analysis

This includes the outcome of HIV-positive deliveries. Live birth babies followed up at regular intervals until the age of 18 months of life and those found alive were tested for HIV with rapid test kits available at the ICTCs.

The data were tabulated and analyzed for each service component over a period of 10 years. The trend of PPTCT indicators were analyzed for statistical significance by using Chi-square trend test. The trend was considered statistically significant when P < 0.05 at 95% confidence interval.


   Observations and Results Top


A total of 32,575 new ANCs were attended the PPTCT center over a period of 10 years from the year 2003 to 2012 and of which 31,649 underwent pretest counseling and among them 29,312 showed acceptance for HIV testing with an overall proportion of 97.1% and 92.6%, respectively.

The proportion of pretest counseling among new ANCs was 88.8% in 2003 which increased to 100% by 2012. The proportion of ANCs showed acceptance for HIV testing among pretest counseled was 83% in 2003 which steadily increased to 98.1% by 2012. The decadal trend of ANCs with pretest counseling and acceptance for HIV testing showed statistical significance (P< 0.05) [Table 1].
Table 1: Trend of pretest counseling and acceptance for HIV testing among ANCs

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[Table 2] depicts, since the year 2003–2012, the new ANCs who were accepted HIV testing almost all underwent for HIV status. A total of 29,312 new ANCs were tested for HIV status of which 233 found HIV seropositive with the overall proportion of 0.8%. The proportion of HIV seropositivity among new ANCs was 2% in 2003 which decreased to 0.2% by 2012 and showed a statistically significant proportional trend (P< 0.05).
Table 2: Trend of ANCs with HIV testing and HIV positivity

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Since 2003–2012, a total of 28,065 ANCs had undergone posttest counseling with the overall proportion of 95.7%. The proportion of new ANCs with HIV posttest counseling was 99.8% in 2003 which decreased to 89.5% by 2006 and thereafter increased to 99.5% by 2012 and showed statistically significant proportional trend (P < 0.05). Over a period decade, a total of 233 new ANCs found HIV seropositive whereas a total number of partners tested for HIV positivity were 128, with overall proportion of 54.9%. The proportion of partners tested for HIV was 38.7% in 2003 which decreased to 25% in the next year but thereafter showed fluctuating trend until 2010. Since 2010 onwards, the trend was increased to 100% by 2012 and showed statistically significant difference (P < 0.05) [Figure 1].
Figure 1: Proportional trend of ANCs with posttest counseling and partners human immunodeficiency virus status. @ = Chi-square test for trend = 4.67; P = 0.03*; # = Chi-square test for trend = 4.61; P = 0.03*

Click here to view


From 2003 to 2012, among the total 233 HIV positive mothers, 188 were delivered in a tertiary health center with overall delivery rate of 80.6%. [Figure 2] depicts, the proportion of delivery of HIV-positive mothers was 100% in 2003 which decreased to 60.6% in 2005 but thereafter ranges from 75% to 94.7% with periodic fluctuation. Out of total 188 HIV positive mothers delivered during a period of 10 years, 162 pairs of mother and baby received prophylaxis of Nevirapine with overall proportion of 86.1%. The proportion of mother and baby pair received prophylaxis of Nevirapine was 83.8% in 2003 which increased to 100% in 2009 but thereafter decreased to 83.3% by 2012.
Figure 2: Trend of delivery of human immunodeficiency virus +ve mother and received prophylaxis Nevirapine. @ = Chi-square test for trend = 0.10; P = 0.74; # = Chi-square test for trend = 0.08; P = 0.76

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Over a period of 10 years, a total of 114 babies were tested for HIV positivity after the age of 18 months of the life and of which 24 were found HIV positive with overall proportion of 21%. The proportion of babies with HIV positivity after 18 months of life was 20% in 2003 which increased to 55.5% by 2009 with a periodic apparent difference. In the year 2010, the proportion was zero percent which further increased to 9% by 2012 [Figure 3]. (Birth cohort - all the live birth baby born to HIV positive mother, received Nevirapine in a specified time [year] followed up to the age of 18 months of life and those remained alive undergo HIV testing).
Figure 3: Proportional trend of human immunodeficiency virus-exposed live birth cohort analysis. Chi-square test for trend = 0.36; P = 0.54

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   Discussion Top


The present study has revealed that over a decade of time, a total of 32,575 new pregnant mothers have been registered under PPTCT services of which 97.1% underwent HIV pretest counseling and the rate was 88.8% in 2003 which increased to 100% by 2012 and showed a statistically significant trend (P < 0.05). A similar finding also has been reported by Mandal et al.[15] from a rural area of West Bengal over a study period of 5 years from 2004 to 2008. A study conducted in Gujarat [16] showed 57.5% pretest counseling rate and this difference could be due to the effective implementation of PPTCT services in the study area.

Among total HIV pretest counseled mothers, overall 92.6% have been accepted to undergo HIV testing and trend of acceptance of HIV testing was increased from 83% to 98.1% with periodic apparent fluctuations. Among the HIV testing accepted mothers, almost all have been tested for HIV seropositivity status. A Mandal et al.[15] from rural area of West Bengal has been observed the similar trend of rise in HIV testing rate from 78.5% to 96.2%. Similar findings also have been reported by Kulkarni and Doibale [17] from Nanded, Maharashtra over a period of 5 years from 2007 to 2011. This rise in rate of HIV testing could be due to increased literacy rate, increased awareness of HIV/AIDS in the general population due to effective health education activities by NACO.

The present study revealed that overall HIV seropositivity rate among new ANCs was 0.7%. The HIV seropositivity rate was 2% in 2003 which decreased to 0.1% by 2012. The trend of HIV seropositivity was statistically significant (P < 0.05). Similar declined trend was observed by Kulkarni and Doibale [17] from 1.5% to 0.5% over a period of 5 years. Dash et al.[18] also reported declined trend from 1.5% to 0.6% from 2006 to 2012. Kwatra et al.[19] also reported declined trend of HIV seropositivity from 3.9% to 0.5% over a period of 7 years. However, a rise in trend of HIV seropositivity was reported by Gupta et al.[20] from India and Oladokun et al.[21] from Nigeria. This difference could be due to the positive attitude of health personals towards HIV/AIDS and effective implementation of PPTCT services under NACP in Maharashtra state.

Among the total HIV tested mothers, the rate of posttest counseling was 99.9% in year 2003 which decreased to 89.6% by 2006 but thereafter increased to 99.6% by 2012. The trend of posttest counseling was statistically significant (P < 0.05). The upward trend of posttest counseling was also reported by Kulkarni and Doibale.[17] The overall posttest counseling rate more than 95.2% was reported by Oladokun et al.[21] from Nigeria.

Among the total 233 HIV positive mothers, 54.9% partners have been tested for HIV positivity. The rate of HIV testing among partner was 38.7% in 2003 which decreased to 25% in the next year and thereafter increased to 100% by 2012 with periodic fluctuation. The trend of HIV testing among partners has been found to be statistically significant (P < 0.05).

The overall delivery rate of HIV-positive mother in this study was 80.6%. The delivery rate of HIV positive mother was 100% in 2003 which decreased to 60.6% in 2005 and thereafter increased to 85.7% by 2012 with periodic up - down trend. A similar trend has been reported by Dash et al. from Odisha.[18] However, the delivery rate of the HIV-positive mother in a tertiary care hospital reported by Kwatra et al.[19] was 87.5%.

Out of total 188 HIV positive mothers delivered in tertiary care hospital, 83.8% pairs, i.e., mother and child received Nevirapine as prophylaxis treatment. The rate of use of Niverapine was 83.9% in 2003 which increased to 100% by 2009 but thereafter decreased to 83.3% by 2012. A similar trend has been reported by Mandal et al.[15] from rural area of West Bengal, Kwatra et al.[19] from Ahamadnagar, Maharashtra and Dash et al.[18] from Odisha. A study conducted in rural South India [22] has reported 68% mothers and 75% babies were received Nevirapine as prophylaxis. This difference could be due to a positive attitude and good counseling in study area.

A total of 114 babies have been followed over a period of 18 months for HIV positivity status of which overall 21% were found to be HIV positive. The rate of HIV positivity among babies after 18 months of follow-up was 20% in 2003 which increased to 55.5% by 2009. In 2010, the rate of HIV positivity reduced to zero percent which was followed by rise by 9% in 2012. The overall 15% babies were found HIV positive reported by Kwatra et al.[19] from Maharashtra. Similar findings also have been reported by Dash et al. from Odisha.[18]


   Conclusion Top


The HIV seroprevalence among antenatal women residing in the rural area of Western Maharashtra have shown declined trend. The positive attitude of public health care authorities, NGOs, strong political support and active community involvement served as the key milestones in reducing the burden of HIV in the study area.

Though, the burden of HIV is reduced but the problem could not be ignored and there is a need for further intensive health education activities, availability of modern therapeutic and diagnostic services in close vicinity to the rural community.

Limitations

This study included only one ICTC center and confined specifically to the rural area only.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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