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Practice Collection
Prevention of Mother-to-Child
Transmission of HIV in Kenya,
Tanzania and Uganda
Strengthening the
German contribution to the
global AIDS response
Acknowledgements
We would like to express our gratitude to all those involved in this project.This includes, in particular, our
partners at the district, regional, provincial and national levels of the health systems in Kenya, Tanzania and Uganda, and our colleagues and the staff of the participating health units in the three countries.Without their unwavering commitment this project would not have been realized.
We would also like to thank the PMTCT experts at WHO, Dr. Tin Tin Sint and Dr. Ehounou Ekpini, and members of the German HIV Peer Review Group who made time to review and comment in detail on various drafts of this document.
(For a list of other partners, please see Other partners section.) The German HIV Practice Collection
The German HIV Practice Collection is edited by the
PRG members believe that collaborative knowledge German HIV Peer Review Group (PRG), an initiative
management means "getting the right people, at
launched in September 2004 by AIDS experts work-
the right moment, to discuss the right thing".
ing in German and international development coope-
Through the peer review, discussion and dissemina- ration. The aim of this group is to collaboratively
tion of innovative approaches, German development manage knowledge about good practice and lessons
cooperation supports essential principles of capacity learnt in German contributions to AIDS responses
in developing countries.
• The process is organised as a transparent and mutual learning experience involving AIDS experts Based on a set of jointly defined criteria for ‘good of German organisations, their partner institutions practice' (see text box), PRG members assess diffe- in developing countries and AIDS experts working rent ways of responding to AIDS that have been for multilateral organisations.
submitted to them for peer review. Approaches that • It provides planners and practitioners with a range meet the majority of the criteria will be documented, of practical, evidence-based programming models.
published and widely disseminated as part of this • It focuses on the results of the reviewed approches, Practice Collection.While some of the documented looking at their achievements, challenges and practices cannot fully meet, as yet, the criteria for lessons learnt.
"good practice" (i.e. several external evaluations and multiple replications in different countries), all of PRG membership is open to AIDS experts and them represent examples of ‘promising practice' that development cooperation planners and practitioners may inform and inspire other actors in the complex with an interest in German contributions to the and dynamic fields of HIV prevention, AIDS treat- AIDS response in developing countries. For more ment, impact mitigation, support and care.
information, contact the Secretary of the Peer Review Group at at [email protected] or go to
Selection Criteria
• Effectiveness • Transferability • Participatory and empowering approach • Gender awareness • Quality of monitoring and evaluation • Comparative cost-effectiveness • Sustainability Executive summary
It is estimated that about 700 000 children under
15 years of age become infected with HIV each year.
The majority of these children acquire the virus as
infants, during or shortly after birth through vertical
transmission or breastfeeding. Fortunately, it has
been shown that the risk for transmission, which
is between 20% and 40% without any intervention,
can be reduced considerably by the administration
of antiretroviral drugs such as nevirapine in com-
bination with safe delivery methods and proper
infant-feeding options.
Waiting area in Ruanda Health Center, Tanzania In 2001, the German government commissioned GTZ The project included efforts to raise public awareness to partner with national ministries of health and local of HIV; training of health workers; and upgrading of health authorities to implement a six-year project on infrastructure, (building space for counselling and prevention of mother-to-child transmission (PMTCT) health education, and for antiretroviral and STD treat- and antiretroviral treatment (ART) of HIV in three ment, equipment for safe delivery and the renovation east African countries heavily burdened with the of maternity wards etc.). It also allowed for monitor- disease: Kenya, the United Republic of Tanzania and ing and evaluation of programme uptake, and exten- Uganda. The project, which ran until the end of 2006, sive research on awareness and knowledge of PMTCT, was the first of its kind in these countries and prior infant-feeding practices, treatment outcomes, cost- to it, PMTCT services were virtually unavailable. It effectiveness of interventions, drug administration aimed to provide a single dose of nevirapine to preg- strategies and factors influencing the effect of nant mothers and another single dose to each new- born child. Implemented in 11 health units in Kenya, 23 health units in Tanzania and ten health units in Overall the PMTCT and PMTCT-Plus programmes Uganda, it was fully integrated into the existing produced promising results. Almost 100 000 women health structures of each country. The PMTCT project attending ANC clinics received HIV counselling, and provided pregnant women seeking antenatal care nearly 70 000 were tested for HIV. Of those who (ANC) at participating health units with pre-HIV-test were tested, more than 10 000 turned out to be HIV- counselling, HIV-testing and post-test counselling.
positive, and gained the chance to improve their Those women with a positive HIV-test result were health and quality of life, as well as the quality of life offered a single dose of nevirapine and ongoing sup- of their children and families. It was found, however, port and counselling regarding general health matters that women tend to drop out at all stages of the as well as post-delivery follow-up. In a second phase, programme, and that effective follow-up mechanisms beginning in 2003-2004, the project expanded with are critical to ensure that health benefits are sustained.
an approach known as PMTCT Plus. This provides Despite this, the project grew swiftly over its lifetime, sustained antiretroviral therapy (ART) to HIV-positive from 13 sites at the outset to 50 health facilities by women, members of their families, and health per- 2006, and evidence suggests that its positive impact sonnel at participating health units, who need this will continue to grow. The nevirapine-based PMTCT intervention in settings with few resources has proven to be feasible and should be incorporated into all existing ANC services. As well, under PMTCT-Plus about 500 individuals received potentially life-saving treatment in the form of ART.
Worldwide, 700 000 children under 15 become
infected with HIV every year and most of them
acquire the virus from their mothers during
pregnancy, at birth or through breastfeeding. In
December 2006, about 2.3 million children world-
wide were living with HIV, most of them in Africa.
As the period from infection to the development
of AIDS and subsequent death is much shorter for
children than adults, 20-25% of infected children
die before the age of 2 and 60-70% die before 5
(UNAIDS, 2004; 2006).
ANC clinic in Kiwanjampaka Health Center, Tanzania Without health interventions, the risk of HIV trans- These interventions, however, do not prevent all mission from an infected mother to her child during new infections; nor do they help those already living pregnancy, birth and breastfeeding is 20-40%, with with HIV. Therefore, sustained antiretroviral treatment the highest risk being at the time of birth. Since programmes are needed at health facilities providing 20-30% of pregnant women in many countries of care and support to HIV-positive pregnant women east and southern Africa are HIV-positive, up to 10% and family members. This need is highlighted in WHO of all infants here are born with HIV or acquire it recommendations (WHO, 2006b) on assessing the from breast milk within the first weeks or months eligibility of all HIV-positive persons, including preg- nant women, for antiretroviral therapy and providing ART. Among HIV-positive people who are eligible Evidence shows that primary prevention of HIV in for ART, sustained treatment also reduces overall mor- young people through education, counselling, treat- bidity and mortality in affected families.
ment of sexually transmitted diseases and the promo- tion of condom use is the most effective way to The above measures are the essence of the WHO and reduce rates of mother-to-child transmission of HIV UN four-pronged strategy for PMTCT (WHO, 2002).
(MTCT). A variety of measures to assist the avoidance of unintended pregnancies in HIV-positive women is • primary prevention of HIV among women of the second most effective manner of reducing MTCT reproductive age; (WHO, 2006a). These services are most often part of • prevention of unintended pregnancies among comprehensive multisectoral HIV-control or repro- women living with HIV; ductive health programmes.
• prevention of mother-to-child transmission during pregnancy, delivery and breastfeeding; and As well, research has shown that prophylaxis with • provision of care, treatment and support to women antiretroviral drugs during or shortly after birth con- living with HIV, their children and families.
siderably reduces the likelihood of HIV-transmission from mother to child. A single dose of nevirapine To succeed, PMTCT programmes need effective taken by the mother during labour and a single dose measures in each of these four areas.
of nevirapine syrup given to the infant within 72 hours of birth reduces the probability of HIV trans- mission from mother to child by about 50% (Guay, Find tool 1 "Guidelines for PMTCT" in the internet
toolbox for this approach at
1999). Safe delivery practices and safer methods of infant-feeding can further reduce the risk of HIV Getting started
The German Ministry for Economic Cooperation and
and local coordinators were also responsible for the Development (BMZ) through the German Agency
exchange of information about the project with the for Development and Technical Cooperation (GTZ)
national and international partners. The PMTCT supported a project for the prevention of mother-to-
Programme served as a pilot project and from the child transmission of HIV and antiretroviral treatment
beginning, it drew on the expertise of, and exchanged in three African countries over a period of six years.
information closely with, the Inter-Agency Task Team (IATT) on PMTCT, lead by UNICEF, UNAIDS and In 2001, this led to the launch of a comprehensive WHO, among others.
nevirapine-based PMTCT Programme, which provi- ded voluntary antenatal HIV-counselling and testing, Local context and project sites
ARV prophylaxis to HIV-positive mothers and their The project was implemented at selected health infants and counselling on safer methods of infant- facilities (project sites) offering ANC services in feeding. Beginning in 2003, the programme expanded Kenya's Nyanza Province, Tanzania's Mbeya Region with an approach known as PMTCT Plus. This pro- and in western Uganda. Fully integrated into existing motes long-term antiretroviral therapy together with national-health-service structures, all project activities care and support for eligible HIV-positive women, were conducted in accordance with the national their children and families.
guidelines. (At the start of the project, Tanzania and Kenya had yet to develop national guidelines so the project contributed to this process).
The project was also highly relevant. UNAIDS estimates that in Kenya in 2005 1.3 million adults (aged 15 to 49) were infected with HIV, a prevalence rate of 6.1% (range 5.2 % - 7.0%). In Tanzania in 2005, an estimated 1.4 million adults (15-49) were HIV-positive, a preva- lence rate of 6.5% (range 5.8% - 7.2%); and in Uganda at this time, an estimated 1.0 million adults (15-49) were HIV-positive, a prevalence rate of 6.7% (range 5.7%– 7.6%) (UNAIDS, 2006). In Kenya and Tanzania, HIV is causing the premature deaths of so many heads of families and parents, and leaving so many children as orphans that it is exerting a serious downward pressure on social and economic develop- ment. In Uganda, where public debate about HIV and Group counselling on PMTCT at Rukunyu Health Center, vigorous national campaigns helped to reduce overall adult prevalence from 13% in the 1990s to about 4% in 2003, HIV still poses a major public health challenge GTZ's Department of Health, Education and Social – as indicated by again rising prevalence rates – and Protection based in Eschborn, Germany, oversaw pregnant women and their infants are particularly the project. Internationally, it was coordinated by the vulnerable. Prior to the start of the GTZ project in Institute of Tropical Medicine, Charité Medical School, 2001, PMTCT services were virtually unavailable in Berlin; nationally, it depended on close partnerships the three countries.
with officials at both the Regional and District levels, who coordinated the programme. The international Uganda
Kabarole, Kamwenge
and Kyenjojo District
Districts in Kenya, Tanzania and Uganda where the PMTCT project was implemented. Data about the populations served by the health faci- In Tanzania, health workers in the PMTCT Programme lities in this project are often scarce, especially when collaborated with counterparts in the GTZ-supported one focuses on pregnant women. It is difficult, there- AIDS-control programme in the Mbeya Region, which fore, to ascertain the actual coverage of the services later became part of the Tanzanian-German Programme offered by the project. Some idea of the coverage to Support Health (TGPSH). An estimated 400 000 may be gained, however, by considering the number women aged 15 to 49 live in the region (UNAIDS, of women of child-bearing age and the number of 2007) and birth statistics indicate that there are pregnancies per year (based on crude birth rates) in about 16 000 pregnancies per year.When the project the regions of each country where this project took started, the initial PMTCT-Programme sites were Mbeya Referral Hospital, Ruanda Health Center, Igawilo Health Center in Mbeya Town and District, In Kenya, the PMTCT Programme was implemented and Vwawa Hospital in Mbozi District. At the outset, in Nyanza Province, where there are an estimated in 2001, about 12 000 pregnant women attended 156 000 women aged 15 to 49 and where about ANC at the project sites each year. HIV prevalence 24 000 women are pregnant each year. Project sites among pregnant women was about 15% when the included Migori District Hospital and St. Joseph's project started. The PMTCT-Plus Programme was Mission Hospital in Migori District, and Kehancha established at district level at Ruanda Health Center, District Hospital and Isebania Health Center in Kuria where ART was offered to participants and families District. At the beginning of the project, in 2001, as well as to staff from all sites. In 2005-2006, PMTCT about 9000 pregnant women attended ANC services services were being offered at 23 sites.
at the four sites per year. The HIV prevalence among pregnant women was about 26% when the project In Uganda, the project was implemented in Kabarole, started. The PMTCT-Plus Programme was implemented Kamwenge and Kyenjojo Districts. In 2001, there at Migori District Hospital and patients and HIV- were an estimated 220 000 women aged 15 to 49, positive health workers needing ART were referred and 53 000 pregnancies per year. The PMTCT to this facility from all PMTCT Programme sites. By Programme worked closely with the GTZ-supported 2006, 11 health units in the two districts were offer- Basic Health Services Project and was implemented ing services for PMTCT.
at two urban sites, (Buhinga Hospital and Virika Mission Hospital in Fort Portal, Kabarole District), and at three rural sites (Health Centers in Kabarole Peer education about HIV in Mbeya, Tanzania District; in Kamwenge District; and in Kyenjojo The overall goal in the second phase (2005 to 2006) District. About 13 000 pregnant women attended of the project was the implementation of nationally ANC clinics per year at the beginning of and internationally recommended measures "for pre- the project. HIV prevalence among pregnant women vention, treatment and care of HIV at local, regional was about 11% at that time. The PMTCT-Plus and central levels by the health systems of the targeted Programme was implemented at Fort Portal Hospital, countries." The indicators of progress towards this where ART was offered to women seeking services goal by 2006 were: for PMTCT, as well as to their families and health-care • Knowledge and experience of implementing staff at the Programme sites. By 2006, PMTCT services PMTCT-Plus Programmes effectively was to be were extended to a further five sites.
developed by project health workers and made available to participating countries, the German Project goals and indicators
BMZ and other agencies and organizations.
In the first phase of the project (2001 to 2004), the • In the three participating countries, networks overall goal was to ensure that "selected health services were to be established for information exchange offer interventions to prevent HIV transmission from regarding PMTCT and ART, and integrated with mother to child in an efficient and cost-effective man- similar regional and international networks.
ner." Indicators of progress towards this goal were: • At least 70% of health workers engaged in the • By December 2002, health personnel engaged in project were to be able to identify correctly the the project were to be trained to provide counsel- advantages and disadvantages of antiretroviral ling, care and treatment of mothers and their new- born children, according to WHO standards.
• At least 50% of health personnel in the PMTCT • By December 2002, data were to be available on Plus sites were to have been trained to care for minimum costs and infrastructural needs to provide and treat people with HIV, according to regional services for PMTCT.
standards of quality health care.
• By December 2003, at least 2000 HIV-positive • At least 70% of those on treatment within the mothers and their children were to be receiving PMTCT-Plus Programme were to have adhered to health care, including nevirapine prophylaxis under antiretroviral therapy appropriately for at least the project.
six months. This treatment group was to include pregnant women, their children and families, as well as health workers within the Programme, who had been identified as HIV-positive and eligible for ART.
Implementation of PMTCT Programme
Health workers and traditional birth attendants (TBAs) were also asked to name measures to reduce Baseline assessments
MTCT.While safe delivery procedures were the most At the outset, the researchers assessed the use, infra- frequently mentioned measure in Uganda (65%), structure and organization of ANC and maternity ser- avoiding breastfeeding was the most frequently vices at health facilities that were to participate in mentioned measure in Tanzania (49%).When directly the project, with a view to preparing an accurate asked whether drugs could help to reduce MTCT, situational analysis. As part of this overall assessment, 72% of health workers and 24% of the TBAs in particular studies were also undertaken: assessments Uganda confirmed that they could. Researchers, of the awareness and knowledge about mother-to- therefore, concluded that the knowledge of health child transmission of HIV and preventive measures; workers in both countries regarding MTCT was and analyses of local-infant feeding patterns in com- acceptable, but that knowledge on this topic among munities burdened with HIV. The findings of these TBAs was extremely poor. Many TBAs, for example, assessments and studies were used to tailor the inter- thought it was safe for HIV-positive mothers to con- ventions used in the PMTCT Programme (Harms et tinue breastfeeding for 12 to 18 months, contradict- al., 2005). (Please note: these baseline assessments ing WHO recommendations.With this in mind, re- were carried out in Tanzania and Uganda only, as searchers concluded that if PMTCT interventions administrative difficulties delayed the start of the were to be accepted by the population and promoted Kenya programme until mid 2002.) by health personnel, thorough orientation and train- ing would be a mandatory precondition (Harms et Assessments of awareness and knowledge about HIV and preventive measures (KAPB studies) were con- ducted in the target and general populations and To assess local infant-feeding patterns, researchers among health workers in the programme in Tanzania interviewed 440 clients and 43 health workers at the and Uganda. In both countries, the results indicated four future PMTCT intervention sites, as well as 239 high levels of willingness to undergo HIV testing villagers and 29 traditional birth attendants in four (79% and 94%, respectively). It should be noted, how- randomly chosen rural villages. The questions focused ever, that just 14% of respondents in Tanzania and on the appropriate duration of breastfeeding, time 10% in Uganda had actually had an HIV test.When of introduction of additional nutrients and types of asked about modes of HIV transmission, less than 5% solid and liquid nutrients. On average,Tanzanian of respondents in both countries mentioned MTCT.
women said that it was appropriate for breastfeeding However, people's passive knowledge was much to continue for 24 months (range 2 - 36 months), higher.When asked whether HIV-transmission is while Ugandan women said 18 months (range 6 - 36 possible during pregnancy or delivery, more than months). In both countries, women said solid 90% of Tanzanian respondents said that it is, and nutrients could be added at month 6 (on average), more than 80% agreed that breastfeeding is a mode but Tanzanian respondents said that liquids, other of transmission. In Uganda, the same direct questions than breast milk, could be given beginning in month drew the correct responses from 67% and about 4 (on average) while Ugandan women said this 55% of respondents, respectively.
should wait until month 5 (on average). Among the respondents, 40 out of 237 (19%) in Tanzania and 204 out of 424 (48%) in Uganda said it was best to breastfeed infants exclusively until at least 4 months.
According to respondents in Tanzania, exclusive breastfeeding for the duration of six months is rarely Training of health personnel
To ensure quality care for HIV-positive patients, pro- gramme staff developed comprehensive training for health workers. This training was given in intensive courses and workshops lasting several days or weeks, according to the level of knowledge/training of the staff, and it was reinforced regularly with refresher courses. As few training materials were available at the beginning, GTZ helped local staff to develop materials. Later, as national materials and guidelines became available, these became the standard.Training modules and workshops focused on these areas: Drama group performance about PMTCT in Mbeya, • Antenatal counselling, including pre-test counsell- ing on general HIV prevention, family planning and These findings underlined the need to promote STDs; specific counselling on PMTCT and infant exclusive breastfeeding for six months, and support feeding; post-test counselling; women who choose this option, if WHO recommen- • Rapid HIV testing; dations are to be honoured in practice (Poggensee • Administration of ARV prophylaxis to mother and et al., 2004).
• Postnatal counselling, touching on infant nutrition and safe infant-feeding options, growth monitoring, Knowledge about modes of HIV transmission and STD management and family planning; awareness of and openness towards preventive • Management of patients on ART; measures are crucial in efforts to promote PMTCT • Diagnosis and treatment of HIV-related infections among pregnant women, and gain the support of among adults and children; health personnel and members of the wider commu- • New techniques for laboratory staff; and nity. To develop this knowledge and awareness, pro- • Monitoring of patients on ART.
ject staff used research data among other materials to prepare and distribute posters and leaflets, broadcast Upgrading infrastructure, procuring supplies
radio spots, mobilize drama and theatre groups, The PMTCT Programme facilitated significant improve- and offer peer education.This work also promoted ments in health-care infrastructure in many ways.
primary prevention of HIV and reproductive choices This included building adequate space for health that limit the risk of HIV infection.
education, counselling, testing, examination and treat- ment and the provision of supplies for safer obstetrical Find tool 2 "IEC Materials" in the internet toolbox for
practices. The programme supported the upgrading this approach at
of laboratories with equipment to allow for better techniques of identifying those in need of HIV antire- troviral treatment and to monitor the safety of treat- ment, and by creating space for cold-storage of blood samples. It also fostered the implementation of quality- control systems for lab work, provided computers and software for programme monitoring and data management, and boosted access to antiretrovirals and other essential medicines recommended by WHO. As well, the programme established a system 28 weeks into their pregnancies. In the second phase for safe storage and dispensing of antiretroviral of the programme, the tablet was given during the and other drugs.
woman's first ANC visit, regardless of her stage of pregnancy. This method was adopted, because most At Migori District Hospital in Kenya, a new maternal women, in particular those who had already given child health (MCH) unit was established with an ANC birth to one or more children, would not be able to registration and waiting area, counselling and exami- reach the health facility in time to receive nevirapine nation rooms, a family-planning unit, STD clinic and at onset of labour. For the child´s dosage, all women PMTCT-coordinator's office. A laboratory was also in the programmes in Tanzania and Uganda were created in the new complex for ANC-related testing required to come to the health unit within 72 hours such as blood films for malaria, urine analysis and for of giving birth so that their newborn infants could be monitoring of ART outcomes.
given a dose of nevirapine syrup. The Kenyan national guideline, by contrast, demanded that the NVP syrup The upgraded labs also allow for complete blood counts and serum analysis to monitor side effects of ART and CD4-cell counts to assess the need for treat- ment and to analyze immunologic responses. As well, reference laboratories now carry out testing of viral load and ART-drug resistance.
HIV counselling, testing and drug administration
Ready access to voluntary HIV-counselling and testing and to counselling on infant-feeding were needed to support the key drug interventions of the programme.The aim was to provide each pregnant woman attending an ANC clinic with counselling and, if desired, testing for HIV. Counselling covered primary HIV-prevention and women's reproductive choices. As the programme unfolded in ANC services, opt-in counselling and testing gave way to the opt-out approach now favoured in many countries.
Nevirapine was the drug of choice for ARV prophylaxis throughout the project, and when the programme Capillus HIV rapid test began in 2001, it was the most innovative tool in the evolving field of PMTCT. New drug developments in ARV prophylaxis for PMTCT will be responded to in the next phase of the programme (see below, Lessons learnt, Promising perspectives).
Under the programme, nevirapine was provided to the HIV-positive pregnant woman once she had been counselled, agreed to HIV-testing and offered to parti- cipate. Initially, at most participating health facilities, the nevirapine tablet was given to women about Positive Capillus HIV rapid test be supplied to the women so that it could be admi- nistered to the infant at home.
As a considerable number of pregnant women came to participating health facilities at time of delivery, and without knowledge of their HIV-serostatus, programme health workers undertook intra- and postpartum testing, as well.This ensured that the maximum number of HIV-positive women and their infants would benefit from ARV prophylaxis.
Health workers also did regular follow-up of mothers and infants to monitor child growth and the overall health of mother and child.
Old and new antenatal clinic, Migori District Hospital, Implementation of PMTCT-Plus Programme
The primary goal of PMTCT is to protect children from HIV infection and premature death. However, In the PMTCT Plus approach, ART was offered to child health cannot be isolated from maternal health, eligible HIV-positive mothers and any eligible HIV- and it is unacceptable to view HIV-positive mothers positive members of their families. Eligibility was simply as potential transmitters (or vectors) of the determined by CD4-cell testing coupled with a positive appraisal of the person's ability to comply with an ART regimen. If a pregnant woman was deemed eligi- ble, treatment was started immediately to provide the maximum benefit for her and the unborn child.
Figure 1: Interaction of PMTCT and ART components
PMTCT Plus Programme Flow
ANC clinic
Rapid HIV testing
Programme enrolment NVP, infant feeding
Monitoring of treatment indication, CD4-cell counts
Safer delivery with single-dose NVP
If indicated, antiretroviral treatment
NVP administration to newborn within 72 h
Follow-up: Counselling, STDs, Family planning,
If newborn on ART, mother, children, partner
infant feeding, PCR-test of infant
Monitoring of ART: mother, children, partner
The new approach was adopted with the introduc- awareness, and deploying PLWH within the project tion of ART at participating health facilities: in to represent peer role models.
Uganda in January 2003, in Tanzania in November 2003 and in Kenya in March 2004. The interaction Monitoring and evaluation
of the PMTCT and ART components is illustrated in Programme staff continually monitored standard forms documenting the results of antenatal care, delivery and follow-up, and antiretroviral treatment.
Health workers in the PMTCT-Plus Programme followed The forms were revised and improved as the pro- international and national guidelines in determining gramme evolved (see toolset 3, below). Monthly whether antiretroviral treatment was indicated and updates were developed on the most important choosing drug regimens for those in need.
programme indicators, helping health workers to make continuous improvements. These data also When a person was enrolled in the PMTCT-Plus helped in programme supervision and provided a Programme, a CD4-cell count was obtained to screen baseline for research.
for treatment indication. CD4-cell counts below 350 cells/µl were rechecked after a short time to confirm their accuracy. If the subsequent CD4-cell count was below 350 cells/µl again, this was defined as indica- ting the need for treatment.When CD4 counts were above 350 cells/µl, screening was repeated every three months. For monitoring and evaluation, in the first phase of the project, PCR (polymerase chain reaction)-testing in the first weeks after birth was used to assess whether infants needed antiretroviral treatment. It was found, however, that the need for special laboratory work and the costs of PCR made this technique unsustainable. In the second phase of the project, therefore, health workers relied on clinical examinations and CD4-cell counts, as recom- New antenatal clinic, Migori District Hospital, Kenya mended by national and WHO guidelines, to diagnose HIV infection and determine whether treatment was As well, a detailed monitoring and evaluation proto- needed in infants of HIV-positive women.
col was integrated into the PMTCT-Plus Programme.
As patients need to understand how their medicines Safe procurement and supply management of antire- work and their side effects to adhere to their regi- trovirals and related essential medicines is critical for mens, they were given counselling before ART and an effective PMTCT-Plus Programme. In Uganda, drug during subsequent visits to health facilities. As well, procurement, storage and provision was organized patients were examined and lab tests done on a in cooperation with a pharmacy run by a church regular basis to measure their responses to treatment and drug adherence and diagnose any side effects or Advocacy and support for HIV-positive individuals was conceded through associations for people living with HIV/AIDS (PLWH). Particularly in Uganda, those Find tool 3 "Monitoring tools" in the internet toolbox
for this approach at
associations were established very successfully, provid- ing self-support among PLWH, mobilizing community Uptake of PMTCT Programme
facilities. It should also be noted that the nevirapine Between March 2002 and December 2006, 131 229 tablets were handed to the pregnant women at diffe- new ANC clients made use of health services at rent points in time and administered according to facilities participating in the programme in Kenya, different country guidelines. In all countries, howe- Tanzania and Uganda.
ver, the women were instructed to take the tablets at onset of labour, in accordance with WHO guidelines.
Of this number, 94 492 women (72%) were coun- In Kenya, for example, women were asked to take the selled on PMTCT and related issues, and 67 542 tablets themselves, often when they were not at the (52%) agreed to be tested. In all, 10 431 of the health facility, whereas elsewhere tablets were taken women who agreed to be tested (15%) were HIV- under the direct supervision of health workers. It positive. A total of 8399 were enrolled in the PMTCT was not always possible, therefore, to document Programme, and as of 2006, 4356 women had taken whether nevirapine was actually ingested. Nevirapine nevirapine and 1847 were being followed by health intake could clearly be documented in 39% of the workers – in general, for 18 months after delivery.
participants who swallowed the drug in the presence Many other women registered in the programme of a health worker. Among women who were breast- were in earlier stages of the pregnancy and had not feeding exclusively, the HIV-transmission rate in children yet delivered or had nevirapine prophylaxis.
at 6 months was about 14%. This is an encouraging outcome when one recalls that without interventions, As women dropped out of the PMTCT Programme at it is usually estimated that 30% of children born to all stages, the number of women participating at each HIV-positive women will be infected, and that single- stage declined progressively – from HIV counselling dose nevirapine reduces this risk by 50% (in other through testing, enrolment and so on. Consequently, words, lowering the rate of MTCT to 15%) (Guay, nevirapine usage was not as high as it could have been, considering the relatively high number of HIV- positive women who sought ANC at participating Figure 2: Breakdown by country of numbers of women at different stages of PMTCT Programme,
March 2002–December 2006.
Enrolled in PMTCT Programme Figure 3, below, shows the total number of ANC clients documented during the period of March 2002 to December 2006 in the different stages of the PMTCT Programmes.
Figure 3: PMTCT Programme indicators, March 2002–December 2006
Figure 4, below, shows the uptake of the PMTCT Pro- received positive test results, been willing to take gramme in Kenya, comparing numbers of participants nevirapine, been given nevirapine and been monitored per year over a four-year period at various stages (only during a period of follow-up. Overall, a steady rise in the first five stages are presented in figure 4): individuals uptake can be observed over the duration of the pro- presenting for the first time at ANC clinics, followed by those who had had HIV-counselling, been tested, Figure 4: Uptake of PMTCT Programme in Kenya, August 2002–July 2006
Kenya MoH/GTZ PMTCT sites
Willing to take NVP Uptake of PMTCT-Plus Programme
lations of second-line drugs were also needed for Owing to the special expertise and infrastructure children. Some 500 individuals in the three countries required to provide antiretroviral therapy, the PMTCT- received ART under the PMTCT-Plus Programme.
Plus Programme was implemented at just three of the participating health facilities: Fort Portal Hospital In Kenya, as of February 2005, 525 women, children in Uganda, Migori District Hospital in Kenya and and men had undergone tests to determine their Ruanda Health Center in Tanzania. Under this expanded CD4-cell counts in the PMTCT Programme (see programme, antiretroviral treatment was offered to below, Figure 5). Some 345 (66%) of these individuals eligible women engaged in the PMTCT interventions, had been found to be needing treatment and 129 family members and health workers at all health faci- (37%) of them had been deemed eligible for ART lities participating in the PMTCT Programme.
and enrolled in the PMTCT-Plus Programme. Of this number, 80% had started treatment.
In keeping with WHO guidelines, a standard regimen was provided: two nucleoside reverse transcriptase In Uganda, as of December 2004, 1729 individuals inhibitors (NRTIs) and one non-nucleoside reverse had undergone tests to determine their CD4-cell transcriptase inhibitor (NNRTI).The specific drugs counts, of whom 708 (41%) had been identified as used in the regimens, however, differed in each country.
needing treatment. Records show that 279 of these In Uganda, zidovudine, lamivudine and efavirenz individuals had been deemed eligible for enrolment were used; in Tanzania, zidovudine, lamivudine and in PMTCT Plus and 193 (69%) had started treatment.
nevirapine were chosen; and in Kenya, stavudine, In Tanzania, by December 2004, 578 people had lamivudine and nevirapine made up the regimen.
undergone tests to determine their CD4-cell counts, Infants received zidovudine, lamivudine and nevirapine while 217 (38%) had been shown to be ready for syrups. More expensive second-line drugs were needed treatment. Of this number, 119 (55%) had been found in about 14% of patients, who experienced contrain- eligible for enrolment in PMTCT Plus, and 80 patients dications, concomitant diseases such as tuberculosis, (67%) had started ART.
side effects or treatment failure. As well, syrup formu- Figure 5: Uptake of PMTCT Plus Programme in Kenya and Uganda
Treatment Monitoring, Kenya Treatment Monitoring, Uganda Treatment Monitoring, Tanzania Feasibility and outcomes of
Recently, when ART became more widely available antiretroviral therapy
in the project countries through Global Fund- and Within a comprehensive monitoring protocol, clinical, PEPFAR-sponsored programmes, among others, the immunological and virological data were collected PMTCT-Plus component was integrated into the to evaluate different approaches for monitoring of national ART programmes.While pregnant women treatment indication and treatment success. Under who need ART may not have the specialized care the Plus Programme, participants' CD4-cell counts now that they received in a PMTCT-Plus Programme, increased, on average, from 170 cells/µl before treat- the integration of the PMTCT-treatment component ment to 335 cells/µl at 24 weeks after starting treat- into national ART programmes is an important step ment and 380 cells/µl at 48 weeks after starting treat- forward and will better ensure the sustainability of ment. The average (mean) viral load before treatment this critical public-health measure.
was 300 633 c/ml, and this decreased to 7388 c/ml at 24 weeks and to 471 c/ml 48 weeks after starting treatment. The body weight of individuals on ART The project had a strong research element, with both increased by an average of 4 kg at 24 weeks after operational and biomedical studies using qualitative start of treatment. After 24 weeks of treatment, viral and quantitative methodologies. As part of a compre- load in 14% of individuals was either not fully sup- hensive approach, studies attempted to analyse the pressed or had bounced back after initial suppres- impact of interventions, influence of different factors sion, indicating virologic treatment failure.These indi- on vertical HIV transmission and the feasibility of and viduals were switched to another drug regimen. As minimum prerequisites for establishing programmes.
shown in Figure 6, 79% of those who began antiretro- Research was done in cooperation with national and viral therapy were still receiving this treatment after international institutions, and all research protocols 6 months, 9% had died and 12% had been lost to were approved by the research and ethical committees follow-up. Overall, therefore, treatment outcomes of the respective countries.
were comparable to international standards.
Figure 6: ART adherence after 6 months in Kenya, Tanzania and Uganda
Find tool 3 "Various publications about research
conducted by the project" in the internet toolbox for
this approach at
http://hiv.prg.googlepages.com/toolboxpmtct
Operational research looked at these areas: • KAPB (knowledge, attitudes, practice and beliefs) studies of MTCT in different populations; • Practice of infant feeding in areas with high HIV • Minimum prerequisites for the implementation of Cyflow®, Partec, for analysis of CD4-cell count,Migori District Hospital, Kenya • Cost analyses; and • Intake of nevirapine under different strategies Examples of research results: cost analyses and
(self-administration, provision in hospital).
PMTCT programme costs are directly linked to pro- A number of biomedical studies followed a mother- gramme uptake, according to a cost- effectiveness and-child cohort.These examined the: analysis of the programme for the time period of • Influence of nevirapine intake on HIV-transmission; 2002–2003. In the study, costs were listed using a • Correlation between viral load and nevirapine con- spreadsheet model, analysed in terms of allocation centrations in different bodily fluids (plasma, breast to different programme stages, and used to estimate milk, vaginal secretion, oropharyngeal secretion) the cost per prevented child infection – the main and their influence on HIV-transmission; and outcome measure. It was found that the cost of esta- • Emergence of resistant virus and its transmission.
blishing infrastructure and starting the programme was significant. In these early stages, local programme Studies of a cohort receiving antiretroviral therapy, costs alone per pregnant woman counselled were explored both biomedical and operational questions.
16 euros (€) in Kenya and Tanzania and € 13 in These focused on: Uganda. For each woman HIV-tested the equivalent • Clinical, immunological and virological treatment cumulative costs were € 23 in Kenya, € 19 in Tanzania and € 22 in Uganda. For each woman dia- • Side effects of treatment; gnosed as HIV-positive, the equivalent figures were € • Adherence to treatment; 120 in Kenya, € 113 in Tanzania and € 128 in • Assessment of baseline resistance and development Uganda; and for each woman enrolled in the PMTCT of resistance during treatment; Programme, the equivalent figures were € 198 in • Assessment of simpler methods for treatment Kenya, € 117 in Tanzania and € 222 in Uganda.
• Loss to follow-up among patients in need of had agreed to receive nevirapine as part of PMTCT (42% in Tanzania and 46% in Uganda). The study found that nevirapine intake in infants was signifi- cantly higher in Tanzania than in Uganda (44% vs.
24%). Maternal age over 25 years, secondary educa- tion, Catholic faith and having undergone PMTCT counselling at a hospital were factors associated with infant nevirapine intake.The Ugandan strategy, under which, after home delivery, the infant has to be brought to a health unit to receive its nevirapine was less successful, mainly because mothers would often not return to the health unit after giving birth A follow-up of infant HIV status was only possible in at home (Karcher et al., 2006).
the case of Uganda. This study concluded that each HIV infection prevented in infants in Uganda cost an Lessons learnt
average of € 1219 (Harms, 2004) (Further research The project produced encouraging results, however, would be useful to provide comparisons with the cost as indicated in the discussion below, it also revealed of caring for an HIV-infected child, and to identify obstacles that need to be overcome for PMTCT to be the socio-economic benefits of healthy children, as more widely accessible.
well as costs in later stages of the programmes with higher coverage.) Drop-out rates are high and need to be addressed
The overall rate of nevirapine coverage is still too Monthly costs of antiretroviral therapy per person, low, as women tend to drop out of the PMTCT as of December 2004, ranged from € 39 in Tanzania, Programmes at all stages. Even though a single dose to € 58 in Kenya and € 78 in Uganda. These differen- of nevirapine for mother and infant is by far the ces were mainly due to the varying costs of impro- simplest medical intervention to reduce vertical ving infrastructure and starting the PMTCT Plus transmission of HIV, many women drop out before they component in each country. In Uganda, for example, and their infants benefit from this. Further research ART was introduced before cheaper generic fixed is, therefore, needed on the factors that prevent combinations of antiretrovirals became available.
women from benefiting from this form of antiretro- viral prophylaxis.While clinical studies have demon- It should be noted, however, that all of the above strated that other perinatal drug regimens reduce the programme costs decreased over time.
transmission risk more effectively than single-dose nevirapine, research has yet to show that women are As well, an observational study, done between March more likely to remain in PMTCT programmes offe- 2002 and December 2004, compared Tanzania's strategy ring these more complicated drug regimens than in of directly observed (or supervised) nevirapine intake simpler nevirapine-based programmes. Evidence sug- among women and infants at a health clinic to Uganda's gests that higher drop-out rates reduce the cost-effec- strategy of self-administered nevirapine for women at tiveness of PMTCT measures, so new strategies are home and supervised intake of nevirapine for infants needed to address this problem. For example, women at a health unit. The two strategies reflected the might remain in PMTCT programmes for longer, and different national guidelines for nevirapine admini- benefit more from them, if their husbands and male stration. The settings were comparable and similar partners were more involved and supportive.
proportions of HIV-positive women in each country When women drop out of PMTCT programmes, staff PMTCT, and PMTCT Plus in particular, demand
are often unable to follow-up on infants born to HIV- significant human resources
positive mothers and, thus, monitor and evaluate the Every pregnant woman counselled, tested or enrolled effectiveness of programmes. Studies are urgently in PMTCT programmes means additional work for needed, therefore, of the preconditions for successful health workers, who are often already overworked.
follow-up of infants born to HIV-positive mothers.
To guarantee the quality of the services, therefore, it is important to provide facilities offering PMTCT- Male involvement strengthens PMTCT
services with enough health workers with the required It is very common for men to contract HIV and pass training. This strengthening of human resources will the virus on to their wives and other female partners.
not only help to sustain existing programmes, it will Thus, male partners cannot be neglected in any HIV be critical to providing the group counselling and strategy and particularly by programmes aimed at routine offer of HIV testing as part of a basic package pregnant women. Not only do many male partners of of services for all pregnant women attending health HIV-positive women need counselling, testing and facilities. The workload of health workers may also treatment, their support is often needed if their wives be lightened by establishing stronger linkages and or female partners are to follow all the steps, and referral systems for patients needing PMTCT inter- comply with, PMTCT-measures and ART.
ventions and ART.
We now know that women who are supported by their partners during PMTCT interventions are much Health workers in resource-limited settings have more likely to accept HIV-testing and antiretroviral yet to find an effective way of preventing postnatal prophylaxis at delivery, and thus have much better transmission of HIV when mothers cannot breastfeed chances of giving birth to and raising healthy infants.
exclusively for six months before early weaning.
However, fear of stigmatization, violence and divorce prevent many women – particularly those in sero- There are still few sufficient or affordable treatment discordant couples – from disclosing their HIV status options for children who cannot take adult formula- to their male partners.When women do not disclose tions of antiretroviral medicines. First-line antiretroviral their status it is much more likely that they will fail regimens are failing in about 14% of ART patients to benefit from PMTCT measures and antiretroviral and the prices of the second-line regimens that these therapy. Kenya,Tanzania and Uganda's PMTCT people need remain unaffordable.
Programmes have yet to develop methods of out- reach to involve more husbands and male partners and this remains a major impediment.
This project has demonstrated that a majority of HIV-positive pregnant women can gain access to PMTCT services when these are fully integrated with established structures for antenatal care. Over the course of the project, the number of pregnant women who came forward to receive HIV-counsell- ing and testing and who went on to accept antiretro- viral prophylaxis increased steadily, proving the feasibility of implementing PMTCT including the use of single-doses of nevirapine for mother and infant in settings with few resources. This approach, together with intrapartum or postpartum counselling and Waiting area, Migori District Hospital, Kenya testing should, therefore, be adopted by ANC clinics fically to proceed (see for example, the Call to Action and health facilities at all levels in settings with few issued by African leaders and international agencies at Abuja in December 2005 (WHO, 2005)).The next phase of this project is informed by this evolving This project has also confirmed once again that ART knowledge and aims to address two widely agreed is also feasible in resource-poor settings and can pro- on priority issues: the adoption of triple-combination duce treatment outcomes comparable to those in ART prophylaxis and new strategies for reaching out industrialized countries. As well, it has shown that to the partners of women needing PMTCT services.
the full integration of PMTCT programmes with national guidelines and structures greatly contributes The 2006 WHO guidelines for ARV prophylaxis in to their sustainability. This is particularly noticeable PMTCT state that single-dose nevirapine is now the where project countries have integrated the PMTCT- minimum standard. The recommended option for Plus component into national ART programmes. In prophylaxis in pregnant women is now the triple Tanzania, beginning in 2007, this component has combination of zidovudine (AZT), nevirapine (NVP) been fully integrated into the Tanzanian-German and lamivudine (3TC), and in the newborn infant, the Programme to Support Health (TGPSH).
dual combination of zidovudine and nevirapine. The risk of transmission and the emergence of resistance Since 2001, much has been learnt about PMTCT, are believed to be lower for this regimen than for through implementation and discussions led by, for single-dose nevirapine. These guidelines are also con- example, the Inter-Agency Task Team on PMTCT and sistent with the most recent national guidelines in Pediatric HIV, which brings together UN and major Tanzania and Kenya, among other countries.
bilateral agencies with leading research bodies and charities working in this area. As well, a strong inter- national consensus has developed about how speci- Nutrition counselling in Fort Portal, Uganda However, these new recommendations have yet to Programme staff will also be examining new strate- be translated widely into practice in these two coun- gies to engage more husbands and male partners of tries, owing in part to major logistic requirements. As pregnant women in measures for PMTCT, given the well, health workers are not convinced that the use need to strengthen this aspect of services. In the past, of these more complex drug regimens will encourage efforts to promote couples-counselling and testing more women to enrol and stay in PMTCT programmes.
within the PMTCT intervention have encouraged In Tanzania, therefore, the shift from single-dose nevi- few men to come forward in support of their female rapine to triple combination therapy, and the effect partners. In Tanzania, for example, the reasons for this has on participation in PMTCT services, will be this failure will be examined in a survey, and plans closely monitored and evaluated. Field-based research will be drawn up to adopt new approaches for will also be needed to assess the impact of the shift making services more welcoming to the partners of to more complex regimens, as few studies have yet to pregnant women.
examine this.
German HIV Peer Review
The German HIV Peer Review Group has set out a number
Participatory approach and empowerment: High drop-
of criteria that must be met to qualify initiatives supported
out rates among pregnant women – though these are by German development cooperation for its HIV Practice
lower than in other projects – and low participation Collection. The PMTCT approach described here qualifies as
by the male partners significantly undermined parti- a "promising practice" to the extent that it demonstrates
cipation in this project. It did, however, empower the following qualities:
pregnant women in three east African countries with potentially life-saving services. These included pre- Effectiveness: In its first two or three years, the
HIV-test counselling, HIV-testing and post-test coun- PMTCT Programme provided significant numbers of selling, and – for those mothers and infants in need pregnant women and their infants with access to, – nevirapine prophylaxis and ongoing support, coun- what were then, state-of-the-art HIV-prevention ser- selling regarding general health matters, and post- vices integrated with ANC in settings where these delivery follow-up. In its second phase, the project services had not previously existed. The PMTCT-Plus further empowered pregnant women and their Programme, introduced in 2003-2004, extended these infants, as well as family members and health wor- services to include ART.Through the project, nearly kers, with life-saving, sustained antiretroviral therapy 100 000 women attending ANC clinics received HIV (ART), as needed. It should also be noted that the counselling, and nearly 70 000 were tested for HIV.
project worked with local staff exclusively and did Despite these real achievements, it is difficult to not employ foreign nationals at project sites.
assess the coverage of these services, and drop-out by women at all stages of the programmes limited Cost-effectiveness: Measuring and understanding
the extent to which women and infants benefited cost-effectiveness of the services for PMTCT and ART from nevirapine prophylaxis and other services.
provided in resource-poor settings by this project requires further research especially with the emer- Transferability: The PMTCT and PMTCT-Plus
gence of new drug recommendations; however, this Programmes adhered to international and national project included significant research on this topic, guidelines and were fully integrated with existing which generated valuable data towards this under- national health structures in three distinct low-in- come countries with heavy burdens of HIV disease: Kenya,Tanzania, and Uganda.
Gender-awareness: In sub-Saharan Africa, young
women are the group most vulnerable to HIV, and this project specifically targeted pregnant women (many of whom are young) in three countries in this region with serious HIV epidemics. Again, the project's high drop-out rates and failure to engage with many of the male partners of pregnant women point to the need for still greater awareness among programme implementers of the impact of gender relations on PMTCT, as well as further research on this complex Monitoring and evaluation: As noted above, this pro-
ject included a strong research element with interna- tional partners contributing to M&E of the program- mes in the three participating east African countries.
In Tanzania and Uganda, detailed baseline assessments were carried out, and, in all three countries, program- me staff continually monitored the results of antena- tal care, delivery and follow-up, and antiretroviral treatment. A monitoring and evaluation protocol was also integrated into the PMTCT-Plus Programme, and studies were done of the cost-effectiveness of inter- ventions and different nevirapine-intake strategies.
PMTCT coordinator of Migori and Kuria Districts, Kenya Innovation: Single-dose nevirapine for HIV prophylaxis
in pregnant mothers at onset of labour is now the minimum international standard in this area; howe- Sustainability: The programmes were fully integrated
ver, when this project began, in 2001, it was among with existing ANC services and national health pro- the first to provide this highly effective medical inter- grammes and consistent with national and international vention on a major scale. In 2003, the project's guidelines. This, together with their positive outcomes, PMTCT-Plus Programme was also among the first in should help to sustain them over the long term. At sub-Saharan Africa to provide HIV antiretroviral therapy time of publication of this document, in the fourth on a large-scale to pregnant women and infants, as quarter of 2007, each of the three countries were well as to their families, and health workers, where continuing to scale up and build on the services for PMTCT provided under this project.
Tools on CD-ROM
The following tools and materials were developed in the
course of this project, or developed in other contexts and
used by this project. They can be downloaded at
• Toolset 1: Guidelines for PMTCT • Toolset 2: IEC materials (information, education and counselling) • Toolset 3: Various monitoring tools • Toolset 4: Various publications about research conducted by the project Project articles and further reading
Karcher H, Moses A,Weide AL, Stelzenmueller J, Mayer The following articles were produced by project staff A, Harms G. Evaluation of antiretroviral treatment in Fort Portal, western Uganda. 15th International AIDS Conference, Bangkok,Thailand, 11-16 July 2004.
Harms, G, Kunz A, Karcher H, Simo S, Kurowski M.
MedGenMed 2004 Jul 11;6(3):B12706.
Nevirapine concentration in cervicovaginal and oro- pharyngeal secretions after single dose administration Karcher H, Mugenyi K, Odera J, Mbezi P, Masanja B, to the mother. Antivir Ther 2005; 10:777.
Kabasonguzi R, Ali M, Simo S, Kunz A, Mayer A, Weidenhammer A, Harms G. 15th International AIDS Harms G, Mayer A, Schulze K, Moneta I, Baryomunsi C, Conference, Bangkok,Thailand, 11-16 July 2004.
Mbezi P, Poggensee G. Mother-to-Child transmission MedGenMed 2004 Jul 11;6(3):WePeE6828.
of HIV and its prevention: awareness and knowledge in Uganda and Tanzania. JSAHA 2005; 2:258-266.
Karcher H, Omondi A, Odera J, Kunz A, Harms G.
(find a copy in toolset 4 in toolbox section) Risk factors for treatment denial and loss to follow up in an antiretroviral treatment cohort in Kenya.
Harms G,Theuring S, Karcher H, Kunz A, Kagwire F, Trop Med Int Health 2007; 12(5):687-94.
Mbezi P, Odera J. Cost evaluation of PMTCT (find a copy in toolset 4 in toolbox section) Programmes. 15th International AIDS Conference, Bangkok,Thailand, 11-16 July 2004. MedGenMed Kunz A, Mugenyi K, Frank M, Kabasinguzi R, 2004 Jul 11;6(3): TuPeC4953.
Weidenhammer A, Karcher H, Kurowski M, Kloft C, Harms G. Persistence of Nevirapine in breast milk Herzmann C, Karcher H. Nevirapine plus zidovudine and plasma of mothers and children after single dose to prevent mother-to-child transmission of HIV.
administration. J Infect Dis, submitted.
N Engl J Med 2004; 351:2013-2015.
Kunz A, Mayer A, Petruschke I, Kabasinguzi R, Mbezi P, Karcher H, Boehning D, Downing R, Mashate S, Harms Odera J,Weidenhammer A, Karcher H, Harms G.
G. Comparison of two alternative methods for CD4+ Nevirapine intake in PMTCT programmes in Kenya, T-cell determination (Coulter manual CD4 count and Tanzania and Uganda. 15th International AIDS CyFlow) against standard dual platform flow cytometry Conference, Bangkok,Thailand, 11-16 July 2004.
in Uganda. Cytometry B Clin Cytom 2006; 70:163-169.
MedGenMed 2004 Jul 11;6(3):ThPeE8032.
(find a copy in toolset 4 in toolbox section) Kunz A, Mugenyi K, Karcher H, Mayer A, Simo S, Ali Karcher H, Kunz A, Mbezi P, Mugenyi K, Odera J, M, Kurowski M, Harms G. Intrapartum transmission Harms G. Prevention of HIV-1 mother to child after mucosal exposure to HIV was not observed transmission (PMTCT) and antiretroviral treatment with single-dose nevirapine for mother and child.
in East Africa. Abstract; Eur J Med Res 2005; J Acquir Immune Defic Syndr 2007; 44(5):562-5.
10(Suppl II):1-125.
(find a copy in toolset 4 in toolbox section) Karcher H, Kunz A, Poggensee G, Mbezi P, Mugenyi K, Poggensee G, Schulze K, Moneta I, Baryomunsi C, Harms G. Outcome of different nevirapine Mbezi P, Harms G. Infant feeding practices in administration strategies in preventing mother-to- western Tanzania and Uganda: implications for infant child transmission (PMTCT) programs in Tanzania feeding recommendations for HIV-infected mothers.
and Uganda. MedGenMed 2006; 8:12; at J Trop Med Int Hlth 2004; 4:1-9.
(find a copy in toolset 4 in toolbox section) Perinatal HIV Guidelines Working Group. Perinatal Health Service Task Force Recommendations for Department of Health and Human Services (DHHS the Use of Antiretroviral Drugs in Pregnant (USA)). DHHS-Guidelines for the Use of Antiretroviral HIV-1-Infected Women to Reduce Perinatal HIV-1 Agents in HIV-Infected Adults and Adolescents. Transmission in the United States. Washington, DC, Bethesda, National Institutes of Health, June 2003.
DHSS, June 2003.
International GTZ PMTCT Coordination Office UNAIDS/WHO. AIDS Epidemic Update 2006. Berlin. Awareness and knowledge of mother to Geneva, UNAIDS, December 2006.
child transmission of HIV and preventive measures in Mbeya Region, Tanzania. Berlin, GTZ, 2003.
WHO. Scaling up antiretroviral therapy in resource limited settings. Treatment guidelines for a public International GTZ PMTCT Coordination Office health approach. Geneva,WHO, 2003.
Berlin. Awareness and knowledge of mother to child transmission of HIV and preventive measures Working Group on Antiretroviral Therapy and in Western Uganda. Berlin, GTZ, 2002.
Medical Management of HIV-Infected Children, National Pediatric and Family HIV Resource Center International GTZ PMTCT Coordination Office Berlin.
(NPHRC),The Health Resources and Services Evaluation of impact of a PMTCT Programme on Administration (HRSA), and The National Institutes child survival and mother-to-child transmission of of Health (NIH). Guidelines for the Use of Anti- HIV – Proposal for accompanying research of a retroviral Agents in Pediatric HIV Infection. PMTCT programme using nevirapine in Uganda. Bethesda, NIH, June 2003.
Berlin, GTZ, 2002.
International GTZ PMTCT Coordination Office Berlin.
Implementation and Monitoring of an Antiretro- viral Treatment Programme following a HIV PMTCT-Programme in Western Uganda. Berlin, GTZ, 2002.
International GTZ PMTCT Coordination Office Berlin.
Use, infrastructure and organisation of ANC and maternity services in four health facilities in Western Uganda. Berlin, GTZ, 2002.
Ministry of Health, Kenya. National Guidelines for the Prevention of Mother-To-Child HIV/AIDS Transmission (PMTCT). Nairobi, MOH, 2002.
Ministry of Health,Tanzania. National Guidelines for Clinical Management of HIV/AIDS. Dar Es Salaam, MOH, April 2002.
Ministry of Health, Uganda. National Antiretroviral Treatment and Care Guidelines for Adults and Children. Kampala, MOH, June 2003.
(Please see Acknowledgements section for
a list of the project's main partners.)
The project staff would like to thank the following institutional partners who contributed greatly to the project, particularly in the areas of programme monitoring and research: University of Nairobi, Department of Paediatrics and Child Health, Nairobi, Kenya; Kenya Medical Research Institute (KEMRI), Department of Virology and Immunology, Nairobi, Kenya; Muhimbili University, Department of Microbiology, Dar es Salaam,Tanzania; Mbeya Medical Research Programme/University of Munich, Mbeya, Tanzania; Henri Jackson Foundation, Fort Dedrick, United States of America (USA); President's Emergency Plan for AIDS Relief (PEPFAR), USA; Makerere University/Mulago Hospital, Department of Obstetrics and Gynaecology and Department of Paediatrics, Kampala, Uganda; Centers for Disease Control and Prevention/Uganda Virus Research Institute, Department of Virology, Entebbe, Uganda; Joint Clinical Research Center (JCRC), Kampala, Uganda; Robert Koch Institute, Department of Virology, Berlin, Germany; Roche Diagnostics, Mannheim, Germany and Randburg, South Africa; and Boehringer Ingelheim, Ingelheim, Germany.
acquired immune deficiency syndrome antiretroviral treatment Centers for Disease Control and Prevention Deutsche Gesellschaft für Technische Zusammenarbeit (German Technical Cooperation) human immunodeficiency virus information, education, communication Ministry of Health mother-to-child transmission of HIV non-nucleoside reverse transcriptase inhibitor nucleoside reverse transcriptase inhibitor prevention of mother-to-child transmission of HIV sexually transmitted disease traditional birth attendants voluntary counselling and testing Guay LA, Musoke P, Fleming T et al. Intrapartum and WHO, 2006a. Glion Consultation on Strengthening neonatal single-dosed nevirapine compared with the Linkages between Reproductive Health and zidovudine for prevention of mother-to-child trans- HIV/AIDS:_Family Planning and HIV/AIDS in mission of HIV-1 in Kampala, Uganda: HIVNET 012 Women and Children, 25 May 2006. randomised trial. Lancet 1999, 354 (9181):795-802.
Geneva,WHO, 2006.
Harms G, Mayer A, Schulze K, Moneta I, Baryomunsi WHO, 2006b. Antiretroviral drugs for treating C, Mbezi P, Poggensee G. Mother-to-child transmission pregnant women and preventing HIV infection in of HIV and its prevention: awareness and knowledge infants: towards universal access: Recommendations in Uganda and Tanzania. JSAHA 2005; 2:258-266.
for a public health approach. Geneva,WHO, 2006.
Harms G,Theuring S, Karcher H, Kunz A, Kagwire F, Mbezi P, Odera J. Cost evaluation of PMTCT WHO. Prevention of HIV in infants and young Programmes. 15th International AIDS Conference, children. Review of evidence and WHO activities. Bangkok,Thailand, 11-16 July 2004. MedGenMed Geneva,WHO, 2002.
2004 Jul 11;6(3):TuPeC4953.
WHO et al. Call to Action: Towards an HIV-free and Karcher H, Kunz A, Poggensee G, Mbezi P, Mugenyi K, AIDS-free generation. Geneva,WHO, 2005.
Harms G. Outcome of different nevirapine administra- tion strategies in preventing mother-to-child trans- mission (PMTCT) programs in Tanzania and Uganda.
MedGenMed 2006; 8:12.
Poggensee G, Schulze K, Moneta I, Baryomunsi C, Mbezi P, Harms G. Infant feeding practices in western Tanzania and Uganda: implications for infant feeding recommendations for HIV-infected mothers.
J Trop Med Int Hlth 2004; 4:1-9.
UNAIDS. Best Practice Collection. Towards universal access to prevention, treatment and care: experien- ces and challenges from the Mbeya region in Tanzania – a case study. Geneva, UNAIDS, 2007.
UNAIDS. 2006 Report on the global AIDS epidemic. Geneva, UNAIDS, 2006.
UNAIDS. 2004 Report on the global AIDS epidemic. Geneva, UNAIDS, 2004.
Contacts and credits
Authors and experts responsible for the approach:
The German HIV Peer Review Group
Project "Strengthening the German
contribution to the global AIDS response" Gundel Harms, Andrea Kunz, Stefanie Theuring Responsible: Dr. Thomas Kirsch-Woik International GTZ PMTCT Coordination Office Berlin Deutsche Gesellschaft für Institute of Tropical Medicine, Charité – Medical Technische Zusammenarbeit (GTZ) GmbH Spandauer Damm 130 65760 Eschborn / Germany 14050 Berlin, Germany E [email protected] Contact Person in the Federal Ministry for
Economic Cooperation and Development (BMZ)
MoH/GTZ PMTCT Project Migori and Kuria Districts Dr. Jochen Böhmer, Section 311 MOH/GTZ PMTCT Project Mbeya Region E [email protected] MOH/GTZ PMTCT Project Western Uganda Geoffrey Kabagambe Rugamba, DDHS Kabarole District Fort Portal, Uganda Photographs
p.1 Heiko Karcher
p.4, 5 Stefanie Theuring p.6 Inga Petruschke p.8, 10 Charles Mleleu p.11, 12, 13, 18, 21, 24 Gundel Harms p.22 Angelika Mayer Eschborn, November 2007

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