Pregnant women can be tested for HIV and administered antiretroviral therapy if found to be HIV-positive, to effectively prevent mother-to-child transmission of the disease, says a new international study conducted in India

Pregnant women can be rapidly tested for HIV and counselled even at resource-poor antenatal clinics, with effective results, says a recent study published in PLoS Medicine.

A review of round-the-clock implementation of a testing programme in a busy rural antenatal clinic in Maharashtra, India, has shown that such programmes can be feasibly implemented and result in high levels of HIV identification and prevention of mother-to-child transmission (PMTCT) in settings where many HIV-positive women may go undiagnosed throughout their pregnancy.

For this study, a team of Canadian, Indian and US researchers evaluated the 24-hour rapid HIV testing programme being conduced in an antenatal clinic in a village in Maharashtra . The objectives were to determine if such testing was feasible in the clinic setting, would lead to increased uptake, and would identify women in labour who could be offered prevention of mother-to-child transmission treatment.

In 2007, about 2.1 million children were infected with HIV, 85-90% of whom contracted the infection from their mother. The rapid tests helped doctors quickly decide on whether to start antiretroviral therapy (ART) as a precautionary measure before the test results came in, usually one to three days after delivery.

“These findings are relevant to PMTCT (prevention of mother-to-child transmission) programmes in developing countries. Controlling HIV infection in women and children is crucial for changing the trajectory of the global HIV epidemic,” the researchers write.

During January and September 2006, 1,252 women between 18 and 45 years of age were asked for their consent when they visited the labour and delivery centre at the Mahatma Gandhi Institute of Medical Sciences in Sevagram, Maharashtra . All women admitted to the labour ward during this period were approached by the obstetrician in charge or by attendants, round-the-clock, on a daily basis. No eligible cases were missed, except exclusions due to obstetric emergencies and women with mental health problems.

Acceptance was almost universal: 1,222 (98%) of the women accepted the offer of voluntary counselling and testing (VCT). The 30 (2%) who refused either knew the results of a prior test, or did not perceive themselves to be at any risk.

The average age of the 1,222 women tested was 24 years, nearly all (99%) were married and monogamous, and 84% had no symptoms of a sexually-transmitted disease. Nearly 80% had at least a high school education, but most were poor -- nearly 90% had total monthly household incomes below Rs 5,000.

The HIV testing algorithm itself was as follows: two rapid OraQuick tests, one on saliva and one on fingerstick blood. Rapid OraQuick results were available and presumptively acted upon within 20 minutes; results were confirmed by follow-up with standard reference tests on blood plasma (ELISA for negative rapid-test results; ELISA plus Western blot for rapid-test positives).

Of the 1,222 women tested, 563 (46%) had some history of HIV testing during pregnancy, but most (58%) of these were unaware of the results and a great many (219 of the 563) had such poorly documented results (often provided by unlicensed personnel at private clinics) that the results were suspect. The remaining 659 (54%) had never been tested.

A total of 15 women in the study were identified as HIV-positive. This gave a prevalence rate of 1.23% (95% confidence interval [CI], 0.61-1.8%) -- in accordance with the 1% anticipated from recent antenatal sentinel surveillance. Of these 15, four had presented a previously reported HIV status and 11 were newly detected cases.

All but one of the 15 HIV-positive women received PMTCT interventions. Two of the 15 babies (both of whom were HIV DNA-positive by PCR) born to these women died within a month; the remaining 13 were repeatedly HIV DNA-negative up to four months after birth.

The investigators conclude that they “demonstrated the feasibility and impact of… round-the-clock rapid HIV testing and two-stage counselling,” resulting in “successful documentation of HIV sero status in a large proportion of women who were unaware of their HIV status when admitted” as well as providing nearly universal PMTCT interventions to the HIV-positive women.

Only 9% of pregnant women in India currently receive ART, says Nitika Pai, a postdoctoral fellow at the division of infectious diseases at Canada 's McGill University , and one of the study's authors.

In many rural areas, women fear HIV testing due to social ostracism. In addition, many women cannot access or afford antenatal care to receive preventative therapy. “The labour and delivery period is the last window of opportunity to prevent HIV transmission,” says Pai. “Without ART, the probability of transmission is 30-35%; with ART it is reduced to 10-15%,” she says.

As PLoS editor David Celentano points out in the editorial accompanying the article, that was published this May, the process by which this intervention was carried out was as important as the findings themselves.

The timeframes of the study activities were very short: five to 10 minutes between determination of study eligibility and consent, 15 minutes for pre-test counselling (with a second, more extended session provided postpartum), 20 minutes for the rapid testing algorithm (run concurrently with other study activities), and 10-15 minutes between HIV diagnosis and provision of PMTCT treatment.

Women constitute an estimated 38% of India's HIV cases, and some 60% of people living with HIV/AIDS (PLWHA) are from rural areas. A huge number of pregnant rural women (possibly half, going by anecdotal reports) receive no antenatal care at all before the actual delivery of their child.

Furthermore, despite efforts by India's National AIDS Control Organisation (NACO) to expand voluntary counselling and testing (VCT) services, very few women receive VCT during pregnancy.

A 2008 study found that only 3.3% of a sample of recently pregnant women in rural Maharashtra received VCT. Of these, the vast majority received it through the private sector rather than the official NACO programme.

The rapid tests are awaiting approval in India. Pai told the media that it should be possible to train counsellors to run the tests and provide round-the-clock counselling at primary healthcare centres -- often the first or only point of healthcare for pregnant women.

Source: www.aidsmap.com, May 28, 2008
            www.medicine.plosjournals.org , May 2008
            www.scidev.net, May 19, 2008