Initiation of antiretroviral therapy or antiretroviral prophylaxis in pregnant women living with HIV registered in five townships of Mandalay, Myanmar: A cross sectional study

Prevention of mother to child transmission (PMTCT) of Human Immunodeficiency Virus (HIV) services include providing maternal antiretroviral therapy (ART)/ antiretroviral prophylaxis and infant’s antiretroviral prophylaxis. This service can dramatically reduce the transmission of HIV infection to less than 2% in non-breastfed infants and less than 5% in breastfed infants and these levels of reductions are also the targets for elimination of mother to child transmission (eMTCT) [1‐6].

Prevention of HIV transmission from pregnant women living with HIV to their infants requires sequential interventions starting from HIV testing of pregnant women to providing antiretroviral prophylaxis to newborn babies. Gaps in each step of interventions can significantly influence the effectiveness of PMTCT interventions. A study in Kenya showed that only 17 and 35.4% of pregnant women tested HIV-positive referred from each of the two government hospital antenatal care services were enrolled in HIV care within 6 months [7]. World Health Organization (WHO) recommends early ART initiation in HIV-positive women (as soon as possible) as an effective intervention in reducing mother to child transmission of HIV and studies show that at least 4–13 weeks of ART is required to achieve viral suppression at the time of delivery [2, 8]. However, a study conducted in Cape Town between 2003 and 2010 showed that there was a delay in initiation of ART (21 days after HIV diagnosis) among pregnant women attending antenatal care services [9]. WHO published updated guideline in 2016 which recommended provision of lifelong ART to HIV-positive pregnant women regardless of WHO staging and CD4 count which can minimize or remove the delay in initiation of ART without waiting for the CD4 results and deterioration of patients’ clinical condition [10].

In Myanmar, HIV prevalence among adult population aged ≥15 years was estimated at 0.59% in 2015 [11]. Since 2005, antiretroviral drugs for PMTCT were available and provided to pregnant women [11]. At the end of 2015, PMTCT services including HIV counselling and testing and referral or onsite ART was established by National AIDS Programme (NAP) in 304 townships and 38 hospitals in collaboration with Maternal and Reproductive Health Division (MRH) and Child Health Division (CHD) [11].

According to UNAIDS estimates, there were 5100 pregnant women living with HIV in 2015 in Myanmar [12]. About 7% of these pregnant women (~ 370) women lived in Mandalay region [13]. An assessment report in Myanmar mentioned that only 59% of women living with HIV accessed antiretroviral prophylaxis between 2012 and 2014 [13]. Further, the rate of initiation of ART/antiretroviral prophylaxis among women enrolled to facilities providing PMTCT services in township health department (THD) have not yet been documented in this setting. In this study, we aimed to estimate the delay in initiation of ART/antiretroviral prophylaxis and the factors associated with delay among pregnant women living with HIV and enrolled in township health facilities providing PMTCT services.

There were 363 pregnant women living with HIV registered in the study sites, of whom, 303 (84%) women were included in the analysis. Sixty women (16%) were excluded because 37/363 (10%) of them did not have HIV diagnosis date and 23/363 (6%) were diagnosed with HIV during or after delivery. The median (IQR) age was 29 (25–32) years. Of 303 women, 89 (29%) were diagnosed with HIV before current pregnancy and 214 (71%) were diagnosed during pregnancy. Figure 3 shows the cascade of care with losses at each step of PMTCT services. The CD4 count at enrolment to HIV care was available for 296 women and median (IQR) baseline CD4 count was 337 (238–475) cells/mm³.

There are three important findings in this study. First, one fourth of the women were diagnosed with HIV before current pregnancy. Second, the ART uptake was very high. Third, there was a delay in initiation of ART/antiretroviral prophylaxis and the delay was longer in township 4.

One-fourth of the pregnant women were tested HIV positive before their current pregnancy. We do not have information on whether these pregnancies were planned/desired or unintended. If those are unintended pregnancies, the HIV care programme should strengthen the family planning among PLHIV by encouraging the consistent use of appropriate contraceptives as recommended in National guideline [16]. On the other hand, if the pregnancy was intended/planned, there are ways to assist women living with HIV to fulfil their desire of giving birth to a child while minimizing the risk of mother to child transmission (MTCT) [18, 19]. In Africa, 30 to 80% of women living with HIV have expressed their desire to give birth to a child [20‐23]. Hence, it is important to have a standard operational procedure in the HIV clinic for PLHIV planning to have children.

There are various strategies for safe conception such as ART, pre-exposure prophylaxis, timed unprotected intercourse, manual/self-insemination, sperm washing, and voluntary male medical circumcision (VMMC) [18]. In Myanmar, NAP recommends the initiation of ART in all PLHIV regardless of WHO staging and at any CD4 count which can be one of the strategies to reduce MTCT of HIV [14]. All medical doctors should be sensitized to follow this recommendation. PLHIV should also be made aware of this policy so as to increase the demand for services.

The ART uptake among pregnant women was very high in our study. The study in Cape Town shows 55, 38 and 45% of eligible women were initiated on ART at three different sites [24]. There are common barriers to initiate ART reported in previous studies conducted in Tanzania and Kenya such as not understanding the importance of HIV care, being too ill to attend, disclosure related issues, wanting to wait until delivery, long distances to the HIV clinic, stigma, denial, poor health services and lack of money [25, 26]. All the pregnant women in our setting were eligible for initiating either ART or antiretroviral prophylaxis with different eligibility criteria. There was a small proportion of pregnant women who did not start ART/antiretroviral prophylaxis by the end of the study period. Barriers for initiating ART/antiretroviral prophylaxis among them needs further exploration.

A systematic review on the impact of different interventions on enrolment to HIV care reported that integration to ANC services, intensified post-test counselling and home visit by peer supporter led to better linkage to care [27]. In our setting, tracking of women referred to HIV care was done by a medical officer employed by The Union and if the HIV positive women had not yet enrolled to care, the medical officer would inform the township PMTCT focal person to trace the woman via basic health staff and encourage enrolling into care. This system could have played an important role in minimizing dropout.

In this study, women living in township 4 experienced longer delays in initiation of ART/antiretroviral prophylaxis. We will report this finding to the responsible person of that township. Although the barriers to initiate ART early were not explored in this study, some qualitative studies reported that the pregnant women were afraid of ART side effects, did not have opportunities to ask questions about drugs and dosage during counselling, had heard of someone’s negative experience on ART and received poor partner or communities support [28, 29]. In addition, health system-related factors such as poor provider– patients interaction, staff shortages and service accessibility were reported as barriers for early ART initiation in pregnant women in other settings [30]. Studies also reported that desire to have HIV-free baby and getting support from partner and family members were enablers for a mother to initiate ART at the recommended time [28, 30]. Hence, specific barriers in referral and linkage to HIV care for initiation of ART/antiretroviral prophylaxis in the study setting should be explored and addressed accordingly.

We found that one in four women living with HIV knew their HIV status before their current pregnancy. There was high uptake of ART among HIV-positive pregnant women. But, there was delayed initiation of ART/antiretroviral prophylaxis. We recommend that additional variables such as gestational age at first ANC, date of first ANC visit and LMP should be included in the recording system to monitor the PMTCT services more effectively. Early initiation of ART/antiretroviral prophylaxis among pregnant women living with HIV enrolled in township PMTCT care should be strengthened.