Table 9 shows that around 55% of antenatal/postnatal women are referred from within government health facilities to the SA-ICTCs and the remaining 45% are referred from nongovernmental facilities.
Registration at antiretroviral treatment
Out of the total pregnant women detected, 1095 (98%) were registered at ART centre. However, there was a 12-day delay (n = 844) in registering the women at ART after HIV detection. Out of the women registered 644 (61%) women underwent CD4 testing the same day and 712 (70%) of all women on ART were initiated on ART the very next day of registration at the ART centre. A total of 1007 (92%) women were initiated on lifelong ART.
The baseline CD4 count at the time of registration at the ART centre for the current pregnancy was 415 (n = 1019). The median baseline CD4 count was 415. For 214 newly detected antenatal pregnant women who were detected and delivered during this period, ART was given for an average period of 8 weeks during pregnancy.
Outcome of pregnancy
Out of the 1073 recorded outcome events, 47% (500) of the pregnant women had live births, 43% (465) were yet to deliver, 7% had medical termination of pregnancy (MTP) (76), and 2% had still births (23).
Of the 500 live births, 84% (422) were conducted in government health facilities. 84% of the live births were conducted as normal vaginal deliveries. 93% (466) of the babies born were started with either 6 or 12 weeks of syrup NVP.
During this period there were three maternal deaths, in which two pregnant women delivered live births and one stillbirth.
Infant feeding and early diagnosis
Out of 500 live births, 231 (46%) infants were recorded as to have completed 6 weeks of age. Among these 231 infants, 191 infants were given exclusive breastfeeding, 37 were given exclusive replacement feeding, and three were being given mixed feeding.
Only 31 infants were registered at the ICTC centre, out of which 29 infants were tested for HIV.
Total 24 infants were tested using dried blood spot sample and five using whole blood sample for DNA PCR. 16 infants were found nonreactive and six infants were found reactive in the HIV testing; results were awaited for seven infants.
Although it has been recorded that 231 infants had completed 6 weeks of age only 29 were tested for EID. Only one infant had completed 6 months of age and had been subjected to second HIV testing at 6 months for HIV antibody; the result was nonreactive. Three infants reportedly died even before completing 6 weeks of age.
A total of 399 (36%) spouses of the pregnant women were tested and 280 (70%) were found HIV positive and subsequently 257 (92%) were registered at ART centre. In total, 30% spouse discordancy has been noted among those tested.
The information generated from the tool provides valuable insight into the PPTCT program for the reported period. It highlights key programmatic areas of concern and provides sufficient information for action. With respect to tracking and follow-up, the services rendered to the mother and her child has been captured at every stage of the process.
The number of newly detected antenatal cases and known cases can be used for the purpose of trend analysis over a period of time, to check whether newly detected cases are decreasing or increasing year after year. Since 60% of the pregnant women are less than 25 years of age, counselling services have to be strengthened and focused more on lifelong ART, safe sexual practice, and family planning measures (considering that 59% are multigravida).
It is seen that an average of 186 cases are detected every month (range minimum 170–maximum 212) and hence, the ART centres can plan for the drug logistics accordingly and also that the ART centres can expect to register roughly 126 newly detected pregnant women every month, since 68% of all HIV-positive pregnant women are newly detected.
Improving testing coverage among all antenatal women in nine districts namely Thane, Pune, Nagpur, Solapur, Yavatmal, Ahmednagar, Sangli, Nashik, and Satara shall yield higher number of positive pregnant women in quick time, since 57% of positive pregnant women are reported in these nine districts only. Likewise, the registrations for treatment shall also be concentrated in the ART centres in these nine districts.
Total 114 of registered pregnant women have presented directly in labour or during the post natal period in the 6-month period, which highlights that they have been missed HIV detection throughout the pregnancy period. The HIV testing coverage has to be increased so that all pregnant women are screened for HIV in early part of pregnancy. Detecting HIV infection in early part of pregnancy is essential since the pregnant mother and baby shall benefit with the ART (minimum 24 weeks of ART during pregnancy is indicated for decreasing viral load sufficiently).
We observe that 45% of the pregnant women are registered only in the third trimester and that too 40% in this group are of second order pregnancy, out of which 40% are already known positive cases and have already been registered at the ART centres. Even though the pregnant women are registered at the ART centre and receiving ART regularly, they are encouraged to get registered at the ICTC for the current pregnancy. The responsibility of registration, treatment, and follow-up of HIV-infected pregnant women until delivery and EID of the baby is vested with the ICTC counsellor. The ART centres should ensure that women under their care who become pregnant should immediately get registered at an ICTC centre which is convenient for the women to visit.
It is observed that 20% of the registered pregnant women are nonliterate, hence the program should ensure that audio visual messages regarding HIV screening and its benefits apart from routine display charts/posters are repeatedly telecasted at the antenatal clinics and ICTC centres.
It is positive to note that 98% of the pregnant women are registered at the ART centre, however, it is also noted that there is a 12-day delay in reaching the ART centre. As it is beneficial for both the mother and baby that she receives ART of 24 weeks during pregnancy and given that 22% of the pregnant women only are detected in the first trimester, nearly two weeks delay in reaching ART centre will deprive majority of the pregnant women the benefit of early initiation of ART.
Again it is noted that the average period of ART given to the newly detected antenatal women is only 8 weeks. Hence more emphasis has to be given on early detection and early initiation of ART.
Total 9% of the women who had either undergone MTP or had stillbirths it has to be ensured that they still continue on ART. As against 231 infants eligible for dried blood spot testing at 6 weeks only 29 have been tested. The program has sufficient details of the mothers whose babies have not undergone EID testing, that they can track the mother and baby and provide necessary services to them. Regular follow-up of the babies and their HIV status confirmation at 18 months shall provide excellent information and insights into the effects of treatment upon HIV transmission.
Only 399 spouses of the registered pregnant women were tested, which resulted detection of 280 (70%) spouses with HIV infection. Increasing the HIV testing of spouses of all the registered pregnant women shall increase the detection of HIV infection in the general population.
As discussed above, the outputs from the tracking tool provides specific information to the program managers to identify programmatic gaps such as delays in HIV testing, detection and linkage to ART registration, and subsequent initiation of lifelong ART; this information shall enable them to manage the program in a more effective manner.
In this tool, the analysis can also be done for a particular institution or a district or for a specific time period. Timely identification of the gaps and planning necessary interventions can help the program reach its ultimate goal of PPTCT of HIV infection.
The PPTCT tracking tool has demonstrated its utility in terms of providing valuable program information for action and it definitely provides much more information when compared with the aggregated monthly reports.
The current tool has some operational challenges; has to be managed manually, in terms of sharing the file between ICTC and ART for data capture and analysis, which is an effort consuming process. The current tool usage and process is person dependant for the timely update and completeness of the data.
Such tools can be developed and provided as web-based software, so that the data entry, sharing and analysis can be effortless and time saving.
R.S.G., A.H., T.M., K.Y., conceived and designed the individual tracking tool. A.H., T.M. and K.Y. collected and analyzed data. P.K.A.B., T.M., and K.Y. contributed to analysis. P.K.A.B. wrote first draft of the analysis. A.H., T.M., K.Y., N.S., S.B., and D.C.S.R. gave significant intellectual contribution to the article.
We thank all the ICTC, DAPCU, ART, and SACS staff of Maharashtra State AIDS Control Society for their sincerity and hard work in facilitating this study. A special acknowledgement to all the ICTC Counsellors who facilitated this study.
*The authors alone are responsible for the views expressed in this article and they do not necessarily represent the decisions, policy or views of the WHO.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
1. “Technical Report India HIV Estimates-2012,” NACO, 2012.
2. “Annual Report 2013–14 NACO,” Department of AIDS Control, Ministry of Health and Family Welfare, Government of India, New Delhi, 2014.
3. “National Strategic Plan Multi Drug ARV for prevention of parent to child transmission of HIV (PPTCT) under National AIDS control program in India,” Department of AIDS Control, Ministry of Health and Family welfare, Government of India, New Delhi, 2013.
Keywords:Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
prevention of parent-to-child transmission line list; prevention of parent-to-child transmission tool; prevention of parent-to-child transmission tracking