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Home > Topics > Perinatal Interventions > Article
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Maternal self-medication and provision of nevirapine to newborns by women in Rakai, Uganda

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Abstract

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To assess the effectiveness of maternal self-administration of nevirapine for prevention of mother-to-child transmission (MTCT) of HIV, we conducted a program to provide maternal and newborn doses of nevirapine to pregnant women in rural Uganda. Women provided blood for HIV testing and were offered voluntary counseling and testing (VCT) during annual community HIV surveys. HIV-positive women who accepted VCT were offered nevirapine tablets and syrup. Blood samples were collected postpartum from women and their babies. Infants were tested for HIV by polymerase chain reaction (PCR), and a subsample of maternal and infant blood was assayed for nevirapine. Among the 981 women tested for HIV, 900 (91.7%) accepted VCT, of whom 105 (11.7%) were HIV-positive. Ninety-three women accepted nevirapine, of whom 81 (87.1%) were followed postpartum; 75 (92.6%) reported receipt of the drug, and 69 reported taking the tablets (85.2%). There were 81 liveborn babies (3 sets of twins), and 67 (84.8%) received the syrup. In a subsample of 25 mothers reporting receipt of the drug, nevirapine was detected in 22 (88.0%) and 24 (96.0%) babies tested. PCR of 67 infant blood samples identified 5 HIV-positive (MTCT rate = 7.5%, 95% confidence interval [CI]: 0.3%-16.6%). Mothers can administer nevirapine to themselves and their newborns and can achieve low rates of perinatal HIV infection.

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Commentary by Arthur Ammann, MD

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Six years have passed since the report of the HIVNET 012 clinical study demonstrating that single-dose nevirapine given to the mother during labor and delivery and to the infant within 72 hours of birth reduces HIV transmission by 50%.(1) Several additional studies have confirmed this result and have indicated that the reduction in perinatal HIV transmission is sustained even in the context of continued breast-feeding.(2,3) Given the low cost (<US$1) and simplicity of the intervention (single dose of the drug), which requires only minimal health care infrastructure, it is both surprising and disappointing that <5% of the estimated 2 million HIV-infected pregnant women who need antiretroviral prophylaxis for the prevention of mother-to-child transmission (PMTCT) of HIV each year are receiving it.(4)

What accounts for this low rate of implementation? Uganda, the country in which the HIVNET 012 clinical trial was performed, is faced with many of the obstacles limiting the uptake of PMTCT services that are present in most resource-poor countries. As stated in the article by Kagaayi et al, 85% of Uganda's population resides in rural areas where health care is scarce. Even when women receive prenatal care, most deliver their babies at home, usually with assistance from a local birth attendant. Other obstacles to PMTCT implementation include the poor availability of rapid HIV testing with same-day results and the lack of skilled counseling staff. Although much has been written about the challenges in getting pregnant women to agree to be tested for HIV, it must be noted that, even when women are tested and receive their results, they often do not receive antiretroviral prophylaxis.

The article by Kagaayi et al evaluated the effectiveness of maternal self-administration of single-dose nevirapine during labor as well as maternal administration of single-dose nevirapine to infants as a means of increasing the uptake of PMTCT services. In the study, women giving birth at home were provided with nevirapine to take themselves and give to their babies. Eighty-five percent of the women took their nevirapine dose and 84% provided their baby with the drug. The HIV transmission rate in the study was 7.5%, which is similar to rates recorded in established hospital settings. The authors conclude that maternal administration of single-dose nevirapine is an effective means of reducing perinatal HIV transmission.

These results are not surprising. For decades, the practice of pediatrics has relied on mothers to administer treatment to themselves and to their infants, for example providing daily treatment with antibiotics for otitis media or medicine for malaria treatment. Certainly, women who are capable of administering these complex regimens also should be capable of taking and administering single-dose nevirapine. What is surprising is that, given the severity of the epidemic and the acknowledged lack of health care infrastructure, solutions such as self-administration of medication have not been aggressively pursued previously.

What went wrong with expansion of PMTCT activities? The unacceptably slow implementation of PMTCT interventions, which has resulted in the loss of tens of thousands of infant lives to HIV infection, may be the result not only of a lack of health care infrastructure and personnel but also of a failure to incorporate traditional caregivers into HIV prevention and treatment. Professional health care workers and public health program directors are too often unwilling to relinquish control of HIV activities to individuals they perceive as being "less qualified." If indeed HIV is a public health emergency, greater effort should be made to incorporate not only mothers but also community workers and birth attendants as qualified allies in filling the infrastructure void while the health care system is being strengthened by national and international programs. The article by Kagaayi et al provides data to support expansion of PMTCT activities by employing a resource that is currently underutilized: mothers. Other recent articles have suggested training the vast numbers of local birth attendants and incorporating them into PMTCT programs, as these women currently deliver the majority of infants in resource-poor settings and will continue to do so for the foreseeable future.(5,6)

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References

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  1. Guay LA, Musoke P, Fleming T, Bagenda D, Allen M, Nakabiito C, Sherman J, Bakaki P, Ducar C, Deseyve M, Emel L, Mirochnick M, Fowler MG, Mofenson L, Miotti P, Dransfield K, Bray D, Mmiro F, Jackson JB. Intrapartum and neonatal single-dose nevirapine compared with zidovudine for prevention of mother-to-child transmission of HIV-1 in Kampala, Uganda: HIVNET 012 randomised trial. Lancet. 1999 Sep 4;354(9181):795-802.
  2. Taha TE, Kumwenda NI, Hoover DR, Fiscus SA, Kafulafula G, Nkhoma C, Nour S, Chen S, Liomba G, Miotti PG, Broadhead RL. Nevirapine and zidovudine at birth to reduce perinatal transmission of HIV in an African setting: a randomized controlled trial. JAMA. 2004 Jul 14;292(2):202-9.
  3. Jackson JB, Musoke P, Fleming T, Guay LA, Bagenda D, Allen M, Nakabiito C, Sherman J, Bakaki P, Owor M, Ducar C, Deseyve M, Mwatha A, Emel L, Duefield C, Mirochnick M, Fowler MG, Mofenson L, Miotti P, Gigliotti M, Bray D, Mmiro F. Intrapartum and neonatal single-dose nevirapine compared with zidovudine for prevention of mother-to-child transmission of HIV-1 in Kampala, Uganda: 18-month follow-up of the HIVNET 012 randomised trial.. Lancet. 2003 Sep 13;362(9387):859-68.
  4. Global HIV Prevention Working Group. HIV Prevention in the Era of Expanded Treatment Access. June 2004. Available at: http://www.gatesfoundation.org/nr/downloads/globalhealth/aids/PWG2004Report.pdf . Accessed June 20, 2005.
  5. De Cock KM, Mbori-Ngacha D, Marum E. Shadow on the continent: public health and HIV/AIDS in Africa in the 21st century . Lancet. 2002, 360:67-72.
  6. Ammann AJ. Preventing HIV . BMJ. 2003 Jun 21;326(7403):1342-3.
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