Protection of Mother To Child Transmission of HIV

TABLE OF CONTENTS

Abstract

LIST OF TABLES

LIST OF FIGURES

LIST OF APPENDICES

LIST OF ABBREVIATIONS

CHAPTER 1: PROBLEM STATEMENT
1.1. Introduction
1.2 Study questions
1.3. Brief Discussion
1.4. Goals
1.4.1. General goals
1.4.2. Specific goals

CHAPTER 2: BACKGROUND INFORMATIONS
2.1. Introduction
2.2. PMTCT: general overview
2.2.1. Risk factors for MTCT
2.2.2. Strategies to reduce MTCT
2.2.3. PMTCT program in Sichili
2.2.4. PMTCT global initiative: Virtual elimination of vertical transmission

CHAPTER 3: THESIS STATEMENT
3.1. Introduction
3.2. Hypothesis
3.2.1. Socio-demographic hypothesis
3.2.2. Clinical hypothesis
3.2.3. Infant hypothesis
3.2.4. Overall Null hypothesis:

CHAPTER 4: MATERIALS AND METHODOLOGY
4.1. Materials and study design
4.2. Sample size and population
4.3. Data collection process
4.4. Data analysis
4.5. Ethic considerations

CHAPTER 5: RESULTS PRESENTATION
5.1. Introduction
5.2. Socio-demographic factors and PMTCT coverage (Paper1)
5.2.1. Age of respondents (n=80)
5.2.2 Education level of respondents (n=80)
5.2.3. Marital status of respondents (n=80)
5.2.4. Average Monthly income of respondents (n=80)
5.2.5. Religion affiliation of respondents (n=80)
5.2.6. Influence of socio-demographic factors on infant’s outcomes at 2 years
5.3. Specific mothers PMTCT clinical indicators (Paper2)
5.3.1. Place of Delivery (n=80)
5.3.2. Gestational age at delivery (n=80)
5.3.3. Mode of delivery (n=80)
5.3.4. PMTCT Prophylaxis before labour (n=80)
5.3.5. PMTCT Prophylaxis during labour and delivery (n=80)
5.3.7. Influence of Clinical PMTCT indicators on infant outcome at 2 years follow up
5.4. Infant outcomes and Virtual elimination of vertical transmission Indicators (Paper 3)
5.4.1 Infant status (n=80)
5.4.2. Infant sex (n= 80)
5.4.3. Birth weight (n=68)
5.4.4. Breastfeeding history (n=80)
5.4.5. DNA PCR results at 6 weeks (n=80)
5.4.6. Infant ART prophylaxis (n=80)
5.4.7. Infant’s outcomes at 2 years follow-up (n=70)
5.4.8. Influence of Infant clinical indicators on the outcome at 2 years

CHAPTER 6: DISCUSSION
6.1. Socio-demographic factors as key indicators to the 2015 global AIDS Initiative
6.2. Mothers access and adherence to PMTCT protocol: prediction of Infants’ outcomes
6.3. Role of Infants factors
6.4. Virtual elimination of Paediatric HIV: reality or myth?
6.5 Study Limitations

CHAPTER 7: CONCLUSION AND RECOMMENDATIONS

BIBLIOGRAPHY

APPENDICES
APPENDIX 1: AFASS Criteria and assessment table
APPENDIX 2:INTERVIEW QUESTIONNAIRES AND CONSENT FORM QUESTIONNAIRE (INTERVIEW PROTOCOL)
APPENDIX 3: AIU Research Clearance letter
APPENDIX 4: WHO 2010 PMTCT guidelines

LIST OF TABLES

Table 1: Participants level of Education (n=80)

Table 2: Average monthly income (n=80)

Table 3: Descriptive statistics for Socio-demographic factors

Table 4: Correlations for Socio-demographic variables and infant outcome at 2 years

Table 5: place of delivery (n=80)

Table 6: Gestational age at delivery (n=80)

Table 7: Mode of Delivery (n=80)

Table 8: PMTCT prophylaxis before labour (n=80)

Table 9: PMTCT prophylaxis during labour and delivery (n=80)

Table 10: PMTCT prophylaxis after delivery (n=80)

Table 11: Descriptive statistics for Mother’s PMTCT variables

Table 12: Pearson correlation coefficient and significance level for Mothers’ PMTCT clinical indicators and infant outcome at 2 years.

Table 13: Infant ART prophylaxis (n=80)

Table 14: Infant outcome at 2 years (n=70)

Table 15: Descriptive statistics for infant variables

Table 16: Pearson correlation coefficient and significance level for the infant clinical indicators and outcome at 2 years follow-up.

LIST OF FIGURES

Figure 1: Algorithm for care of HIV positive pregnant woman.

Figure 2: Location of Sichili Mission Hospital

Figure 3: Age of respondents

Figure 4: Marital status of respondents

Figure 5: Religion affiliation of respondents

Figure 6: Regression standardized residual for socio-demographic variables and infant outcome at 2 years.

Figure 7: Regression standardized residual for frequency distribution between the mother’s PMTCT indicators and infant outcome at 2 years follow-up

Figure 8: Infant status

Figure 9: Infant sex

Figure 10: Infant weight

Figure 11: Breastfeeding history

Figure 12: DNA PCR at 6 weeks

Figure 13: Infant outcome at 2 years

Figure 14: Regression standardized residual for infant clinical variables and outcome at 2 years.

Figure 15: Infant outcome at 2 years and Virtual elimination of paediatric HIV

LIST OF APPENDICES

Appendix 1: AFASS criteria and Assessment Table

Appendix 2: Interview questionnaires and consent Form

Appendix 3: AIU research clearance letter

Appendix 4: WHO 2010 PMTCT Guidelines

LIST OF ABBREVIATIONS

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Abstract

Limited information exists currently on factors associated with ‘’virtual elimination of paediatric HIV’’ in resource constrained settings since the publication of new PMTCT guidelines by the WHO in 2010.

In this study, we aimed to assess predictors of unfavourable infant clinical outcomes (Mortality and HIV infection) at 2 years follow-up in PMTCT program.

Using data collected from registers (PMTCT and ANC) at Sichili Mission Hospital, 151 women were enrolled in the program from 2008 to 2010 and 80 of them fulfilled the inclusion criteria. An in-depth interview with HIV positive women was conducted using structured questionnaires. Factors associated with ‘’virtual elimination of paediatric HIV’’ were determined by multivariable regression analysis models.

At 2 years follow-up, 8 (10%) children died 47(87%) were HIV negative and 7(13%) were HIV positive on HAART. Socio-demographic factors age and education level were correlated with poor infant outcomes in PMTCT program (Pearson coefficient correlation<0).Home delivery and unskilled conducted deliveries were significantly associated with unfavourable infant clinical outcomes (p<0.0001).

Only 28(35%) pregnant women had received Sd NVP and this was weakly correlated with high HIV transmission rate (Pearson=0.076).The majority of respondents (96%) had exclusively breastfed up to 6 months and this variable was associated with low early mortality and high survival rate (Pearson>1).

Socio-demographic factors, PMTCT specific indicators and infant’s variables are potential determinants to successful attainment of ‘’Virtual elimination of paediatric HIV by 2015’’.

KEY WORDS:

PMTCT, Virtual Elimination of Paediatric HIV, Sichili Mission Hospital, Socio-demographic variables, infant outcomes, Zambia.

CHAPTER 1: PROBLEM STATEMENT

1.1. Introduction

Mother to Child Transmission (MTCT) of HIV is the main way of vertical transmission from an HIV positive mother to her infant.

According to the UNAIDS/WHO AIDS Epidemic Update 2009, an estimate of 430,000 children were newly infected with the VIH virus in 2008 in the world, more than 90% of them trough vertical transmission from their mothers34. (UNAIDS/WHO AIDS Epidemic Update, 2009).Without treatment, more than 50% of these children will die before their second birthdayand Paediatric HIV infection results in approximately 4 folds increase of Mortality by age 2 compare to HIV negative children19(Little K; et all, 2007).The risk of MTCT is 15 to 35% with no intervention and can be as higher as 45% according to the duration of breastfeeding33(UNAIDS, 2010).

Protection of Mother to Child transmission (PMTCT) of HIV is a key to the reduction of Mortality and morbidity due to HIV in children. In developed countries, a 1-2 % transmission rate from mothers to their infant has been achieved through early access to HIV treatment by pregnant women, an elective caesarian section and infant formula feeding 28(Shakira M Cassim,2010).According to WHO,With specific interventions in non-breastfeeding populations, the risk of MTCT can be reduced to less than 2%, and to 5% or less in breastfeeding populations38(WHO ,2010).

In Zambia, roughly 80,000 infants are born annually from HIV infected mothers and are at risk of contracting the disease. An average of 20,000 are born with HIV each year (40%).The rate of vertical transmission varies from 15-25% in non-breastfeeding infants and double in breastfeeding ones 22(Ministry of Health, National Protocol Guidelines, 2010).ForPreventing Vertical transmission of HIV to reach the UNGASS and Millennium Development goals, progress have been made in affected countries but a lot still to be done. Even in the more successful PMTCT programs, there is no room for contentment. Meaning, in resource constrained setting, virtual elimination of paediatric transmission of HIV is still possible and should be seen as an achievable paradigm. From previous experience to actual progress reports, still questions have arisen on specific indicators and constraints to achieve the desired global vision:’’ Virtual elimination of Paediatric HIV’’. There is need for fast track interventions as we are approaching the year 2015.Hence the following study questions.

1.2 Study questions

In this study, the following questions are addressed:

-What are the major socio-demographic indictors contributing to the low coverage of PMTCT services in remote resource settings?
-Do specific Mother clinical indicators play a role in the PMTCT program outcomes?
-What are the infant outcomes after all?
-Is the Virtual elimination of Paediatric HIV a reality or myth?

1.3. Brief Discussion

Mother to Child transmission of HIV happens during pregnancy (10-15%), during labour and delivery (25%) and during breastfeeding (5-10%).The overall transmission rate is 40% in absence of intervention22(Ministry of Health, National Protocol Guidelines, 2010). With minimal intervention during pregnancy (ART prophylaxis), during labour and delivery and during breastfeeding (dual treatment mother and baby) up to 2 years, combine with recommended breastfeeding practices, the ‘’virtual elimination’’ is possible. In most African countries the maximum coverage of these interventions is a myth, still. The transmission rate from a positive mother to her new born baby is high despite effective programs. For instance the sdNVP (single dose Nevirapine) was only received by 49 % of HIV positive pregnant women in 2009.33(2010 International AIDS conference).

Strategies and programs implementations have shown the need to integrate a full PMTCT package in the routine ante-natal care in a comprehensive approach. This has been achieved in places with high index of institutional delivery conducted by a trained skilled worker. In a remote places with high population density, scattered with high index of home delivery, the bottlenecks to attain the desired performance, meaning the ‘’virtual elimination of HIV’’ in children, are to be addressed and measured. The following goals are set to respond to this need.

1.4. Goals

1.4.1. General goals

The general objective of this study is in line with the WHO 2015 PMTCT strategic vision: To analyse PMTCT program coverage from 2008 to 2010 in Sichili, a rural resource constrained area in western Zambia and anticipate the realization of the prediction of ‘’paediatric HIV virtual elimination’’ by 2015.

1.4.2. Specific goals

The specific objectives are as follows:

-To measure the influence of socio-demographic factors, specific clinical indicators on the infant outcomes in PMTCT services in vision of ‘’virtual elimination of paediatric HIV’’.

-To make recommendations based on research findings on how to achieve the 2015 PMTCT vision.
-To make recommendations on how to improve this study in the future.

In the next chapter, we highlight background information related to the study subject.

CHAPTER 2: BACKGROUND INFORMATIONS

2.1. Introduction

This section talks briefly about the current knowledge in PMTCT. This literature review is not exhaustive but could be limited assuming that there have been no much publications on systematic review of current PMTCT strategies since the 2010 new guidelines were launched and agreed upon by the WHO and its partners.

2.2. PMTCT: general overview

Mother to child transmission of HIV is the transmission of the HIV virus from the mother to her child (vertical transmission).This mode of transmission accounts for almost 90% of paediatric HIV globally38(WHO, 2010).

Mother to Child Transmission occurs during pregnancy, childbirth and breastfeeding33(UNAIDS, 2010).Its estimated that 10% of transmissions occur in utero, 60% during labour/delivery and 30%during breastfeeding6(Coovadia, 2011). Globally, nearly 1.4 million pregnant women are in need of PMTCT services33(UNAIDS, 2010).

During pregnancy, the virus can cross the placenta barrier and infect the unborn baby. The precise mechanism is not well known but some facts could support the scientific background. For instance, in the last decade, HIV-1 was localised within Syncytiotrophoblasts and Hofbauer cells in placental tissue sections taken from cases of known in utero infection suggesting a possible reservoir for infection29 (Sheikh AU, 2000). Potential route of infection discussed is the midmixture of maternal and foetal blood across the placenta. Women with placentitis or with illicit drug usage (especially vasoactive drugs) during pregnancy are susceptible of transmitting the HIV virus to their babies in utero23(Ndoko JM, 2009).And an infant is considered to have been infected in utero if the HIV genome is detected by Polymerase Chain Reaction (PCR) or if the virus is detected in his blood 48 hours after birth.

During childbirth, the risk of transmission is more significant. In early 2000, Kuhn and colleagues found that prolonged ruptured of membranes is significantly associated with high risk of vertical transmission17(Kuhn et all, 1999). Statement suggesting an increase exposure time of the baby to trauma in the birth canal, vaginal secretions and maternal blood .A possible oral route should not be excluded.An infant would be considered to have late (intrapartum) infection if diagnostic studies (HIV-1 isolation, PCR, or serum p24 antigen assays) were negative in blood samples obtained during the first week of life but became positive during the period from day 7 to day 90, and the infant had not been breast-fed.32(Sykes,2000).

A non-neglected number of HIV-exposed children (one third) are presumed to have been infected during breastfeeding period. Breastfeeding has been a question of controversy especially in low settings where formula feeding is not affordable. Research shows that exclusive breastfeeding up to six months is as likely to lead to HIV-free survival as avoiding breastfeeding36(WHO, 2007) and formula feeding should be offered after an informed consent only when AFASS22(Ministry of Health, National Protocol Guidelines, 2010).See Appendix 1.

A child is considered to have been infected during breastfeeding when the HIV-1 virus is found in the peripheral blood by performing a Dried Blood Spot (DBS) and DNA PCR at 6 months or later if the child has breastfed and was tested HIV negative at 90 days or less.

A decade ago, Studies have shown that without interventions, the risk of postnatal transmission increases with the duration of breastfeeding period 18(Lewis P.et all, 1998). But exclusive breastfeedingi.e. giving only breast milk and no other liquids or solids, except drugs brings down the transmission rate to less than one fourth compared to mixed breastfeeding7,8 (Coovadia et al. 2007&Coutsoudis et all & 1999 & Iliff et al. 2005).

According to WHO, breastfeeding in the first 6 months of life provides 4- to 6-fold protection against infant mortality as opposed to no breastfeeding35 (UNICEF, 2011).Early cessation of breastfeeding in an effort to limit the exposure to HIV-infected breast milk may be associated with increased infant morbidity and mortality.12(Heinig MJ, 1998).

The question of breastfeeding has been controversial considering that 95% of HIV exposed infant are born in sub-Saharan Africa where AFASS is not available and women associate themselves to the culture of breastfeeding since memorial times.

However, the custom of long breastfeeding period and early introduction of solids food (mixed feeding) has been pointed as a risk factor to vertical transmission of HIV9(De cock et all,2000).This phenomena is associated with other contributing factors detailed in the next paragraphs.

2.2.1. Risk factors for MTCT

Some maternal and foetal factors have been associated with high risk of Mother to Child Transmission of HIV.

Studies have shown that HIV positive pregnant women in advanced state of the disease e.g. WHO stage 3 or 4 are highly prone to transmit the virus to their unborn infants. Advanced HIV is associated with very high viral load or low CD4 cells.

In studies by Dickover and colleagues10, a significantly higher transmission rate was observed for women with HIV-1 RNA levels greater than 50,000 copies per millimetre of plasma (89%) than for women with HIV-1 RNA levels of less than 50,000 per millimetre of plasma (8%).

Other factors include: premature rupture of membranes, vaginal delivery, breast milk, maternal infections (e.g. chorioamnionitis or STIs), first twin born, Drug abuse and low birth weight of the baby.

Premature rupture of membranes would increase the risk of infection to the baby by migrating viruses from vaginal secretions to the amnios especially when this event does not progress into labour immediately or in a short period. It’s known that vaginal delivery expose the baby to trauma and contact with vaginal secretions rich in HIV virus. Transmission via breast milk is not very well understood though some risk factors like breast infections (e.g. mastitis) or baby oral thrush could play an important role. Possible portals of virus entry include M cells in the tonsils or overlying the intestinal lymphoid Peyer’s patches, direct infection of the enterocyte or possibly direct passage through disruptions in mucosa or between immature mucosal junctions. The roles of cell-free and cell associated virus in transmission and the association between virus levels in plasma and in milk havenot been reliably quantified.5(Chopra M, 2008).

Drug abuse especially vasoactive drugs derange the foeto-maternal circulation and exchanges. They may reduce the placenta tissue resistance to harmful microorganisms thus increase the permeability to viruses. Maternal infections could be major contributors due to reduced maternal immunity.

Still more, other mechanisms are not very well understood. Despite the current knowledge on transmission mechanisms, efforts are being implemented on strategies to reduce mother to child transmission.

2.2.2. Strategies to reduce MTCT

Strategies to reduce MTCT include the use of antiretroviral drugs and safe breastfeeding practices. This constitute the all PMTCT ideology .The use of ARV’s during pregnancy, labour/delivery and in post-natal period has shown significant positive results. According to WHO 2008 guidelines37(WHO 2008 HIV update) Zidovudine (AZT) 300mg Bid is given from 28 weeks gestational age or soon after during ante-natal period. Nevirapine Single dose (Sd NVP) 200 mg is given at the onset of labour, followed by AZT/3TC as stat dose then every 12hours until delivery. During post-natal, AZT/3TC Bid is given to the mother for 7 days and Sd NVP 2mg/kg stat is given to the infant. If the mother received ARV’s for less than 4 weeks during ante-natal period, the infant will be given AZT 4mg/kg for 28 days. These recommendations were made regardless of breastfeeding practices.

In 2010, WHO and partners published new PMTCT guidelines22 (Ministry of Health, 2010).All HIV positive pregnant women are given ARV’s short course as early as 14 weeks gestational age and should be initiated on HAART as soonest they are eligible .AZT 300mg twice daily is given as short course antenataly, AZT/3TC/NVP during labour/delivery then AZT/3TC in post-natal for 7 days. Mothers on HAART should continue with their medications.

For all exposed breastfeeding infants, NVP 2mg/kg is given at birth and daily until one week after exposure to breast milk.

For non-breastfeeding infant whose mothers received short course prophylaxis, NVP 2mg/kg is given at birth and for 6 weeks.

For all exposed infants whose mothers are on full HAART, NVP 2mg/kg is given from birth until 6 weeks of age.

All exposed infants should be initiated on co-trimoxazole prophylaxis from 6 weeks of age until a week after all exposure to breast milk has ended and HIV status confirmed negative.

With these new guidelines, MTCT can be reduced as lower as 5%.

The first step is testing. An opt-out HIV testing to all pregnant women at ANC is the key for successful PMTCT services. All these recommendations are summarised in the next algorithm.(Figure 1).

The HIV testing coverage has significantly increased in recent years. According to WHO updates, the number of pregnant women being counselled for HIV has reached almost 3 millions37(WHO, 2008). In most countries in the Sub-Saharan region, markable progress was observed in the coverage of PMTCT. In Zambia, more than 90% of women attending ANC are counselled and tested for HIV22. (Zambian Ministry of Health, 2010).

According to the 2009 report,Towards universal access: scaling up priority HIV/AIDS interventions in the health sector, significantprogress in the area of PMTCT has been made during the pastseveral years.

In 2008, 45% of the estimated HIV-infectedpregnant women in low- and middle-income countries receivedat least some antiretroviral (ARV) drugs to prevent HIVtransmission to their child, up from 35% in 2007 and 10% in2004. In Eastern and Southern African nations, which have the highest rates of infection, coverage with ARVs jumped to58% in 2008 from 46%, in 2007. In fact, severalcountries in sub-Saharan Africa, including Botswana, Namibiaand Swaziland, have now achieved the United Nations GeneralAssembly Special Session (UNGASS) goal of 80% coveragewith significant reductions in new infant infections. Severalother large countries with a high HIV prevalence, includingSouth Africa and Kenya, are accelerating progress towards thisgoal. This demonstrates that with the new guidelines in place, the virtual elimination of paediatric HIV is achievable in most affected countries. And a pooled analysis from 2 cohorts’ studies has shown the effectiveness of PMTCT interventions with a close to 5% postnatal transmission even in population that breastfed up to 18 months.3(Becquet R. et all, 2010).Can the same results be seen in a remote place like Sichili? The following section highlights a brief profile of Sichili Mission Hospital and the PMTCT program.

Figure 1.Algorithm for Care of the HIV positive Pregnant woman based on 2010 WHO Recommendations.

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2.2.3. PMTCT program in Sichili

Sichili mission Hospitalis situated in The Western Province of Zambia, in Sesheke District, approximately 150 km north of Sesheke. The Zone covers Mulobezi constituency and it’s bordered to the North by Kaoma District, the west by Senanga District and the Sesheke zone and in the East by Kazungula District. Sichili is situated at 287 Km from Livingstone town in the southern Province. This is the main town with banks and shops for Sichili residents. See Figure 2.

Built in 1944 by the Catholic Holy Cross Sisters, Sichili Mission Hospital is the only hospital in an allocated area of 17000 square kilometers, with an estimated population of 36,000 inhabitants (2008). Most people in the area are subsistence farmers, growing maize and to a lesser extend Cassava and groundnuts. The Sichili zone is thinly populated. Beside this, the infrastructure in the region is poor. Most of people are not educated despite a basic school and high school in the zone. There is no industry in the Zone. There is no electricity. The Hospital uses renewable energy system (solar system) to supply power and run equipments for various functional areas. Water is accessible through seasonal streams and boreholes in some highly populated areas.

The Hospital is a first Level with 68 beds capacity in 6 wards. Medical, surgical, pediatrics, gynecological and obstetrical services are provided. Out-Patients departments include ART Clinic, VCT, PMTCT and IPD. Specialized clinics like TB, Physiotherapy, ANC, PNC, are provided as well. Imaging using X-ray and Ultrasound is available as well.

The PMTCT program was present as far as 2000 but only became active in 2005 with the support of PEPFAR program. In 2009 Sichili signed the first agreement for sub-award from the United States Federal Financial Assistance via CRS/AIDS-relief for the integrated Support to AIDS and PMTCT (ISAP).With this support, the scope of work for the PMTCT program expanded from its program management to the patient quality of care. The ISAP project has 2 main objectives:

-Pregnant women access high quality PMTCT services at Sichili Mission Hospital
-And Sichili to use Information communication technology (ICT) to expand human resources and health communication capacities.

Under these objectives, ISAP builds capacity to effectively manage comprehensive PMTCT services and link them to ART services; encourage pregnant women to access PMTCT and receive prophylaxis. These are made possible through community mobilization and sensitization on the importance of PMTCT in remote and hard to reach communities. The project has significantly strengthened the PMTCT program and has considerably benefited to the community. With the building capacity encountered with ISAP project and its commitment, The PMTCT global initiative can be achieved in remote places.

Figure 2.Location of Sichili Mission Hospital on the administrative map of Zambia.(source: www.map).

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Sichili mission hospital (30 km north-west Mulobezi)

2.2.4. PMTCT global initiative: Virtual elimination of vertical transmission

Preventing mother-to- child transmission of HIV (PMTCT) is one of the key pillars in the worldwide response to the AIDS epidemic and one of the priorities of UNAIDS secretariat and its cosponsors.

The World Health Organization (WHO) has recently published a strategic document outlining its commitment to support country-level and global efforts to scale up PMTCT services and to integrate the services into maternal, newborn and child health programmes.

The paper titled:’’ PMTCT Strategic Vision 210-2015.Preventing Mother-To-Child Transmission of HIV to reach the UNGASS and Millennium Development Goals’’ presents ambitious ways and targets to achieve the MTCT at less than 5 % by 2015.This is made possible by a call to joined collaboration with partners, such as Global Fund to fight Malaria, Tuberculosis and AIDS; and the US President’s Emergency Plan for AIDS Relief (PEPFAR).

At the recent International AIDS conference in Vienna, a multi-country African research paper displayed coverage of 45% of HIV pregnant women receiving SdNVP in 2008 to prevent mother to child transmission of HIV compare to only 10% in 200431(Stringer EM et all,2010).Despite this success, PMTCT still presenting major challenges in resource-constrained settings. According to UNAIDS/WHO AIDS epidemic update 2009 an estimated 430,000 children were newly infected with HIV in 2008, more than 90% through vertical transmission from their mothers.

But Mother to Child transmission of HIV is preventable. In western Countries Virtual elimination of HIV has been achieved at as low as 1%.25 (Paintsile &Andiman, 2009). In high burden HIV countries, virtual elimination can be achieved as lower as 5% or less with implementation of the following 4 strategic frameworks or prongs: Primary prevention of HIV infection among women of childbearing age; Prevention of unintended pregnancies among women living with HIV; Preventing transmission from a HIV+ mother to her infant; and Providing appropriate treatment, care and support to mothers living with HIV and their children and families.

The 4 prongs are widely possible through 7 strategic directions defined in the document:

- Direction 1: Commitment-Strengthening commitment and leadership to achieve full coverage of PMTCT services.
- Direction 2: Quality-Improve the quality of HIV prevention, care and treatment services for women and their children.
- Direction 3: Integration-Promote and support integration of HIV interventions within maternal, newborn and child health and reproductive programmes.
- Direction 4: Equitable access-Ensure equitable access for all women, including the most vulnerable.
- Direction 5: Health systems-Support health systems interventions to improve service delivery.
- Direction 6: Measurement-Track programme performance and impact.
- Direction 7: Collaboration-Strengthen global, regional and country partnerships and advocate for increased resources.

With these major prongs and directions for the PMTCT programmes, virtual elimination for paediatric HIV is expected to be achieved by 2015 if most-affected countries which implement the new PMTCT and paediatric guidelines that have originated from the PMTCT strategic Vision 2010-2015.And a less than 5 % transmission can be achieved in breastfeeding population settings.

Thus the following chapter draws attention to the thesis statement and hypotheses in line with the PMTCT strategic vision 2010-2015.

CHAPTER 3: THESIS STATEMENT

3.1. Introduction

The PMTCT strategic vision shows that interventions needed vary on country, regional or local surrounding circumstances. For instance, in Latina America a framework is developed tackling both Syphilis and HIV among pregnant women as a key to successful Virtual elimination. In Eastern Europe emphasis is been put on improving PMTCT services for population at risk like drug users. In Sub-Saharan Africa, where 90% of global Paediatric HIV is found, the reality is much far from the efforts made to date .More effort is needed in all areas of program implementation. No matter the case, the need to eliminate MTCT is a paramount necessity. In this paper two hypothesis will be tested to attempt prediction of ‘’Virtual elimination’’ of paediatric HIV by 2015 in Sichili, a resource-constrained setting in rural western Zambia.

3.2. Hypothesis

Hypothesis generation is the process of developing a list of possible candidates for the ‘’causes’’ of the disease and obtaining initial evidence that supports one or more of these candidates14(James F Jekel; et all, 2007).In epidemiological research, A null hypothesis (H0) is the first to be defined. It’s simply implies that there is no association between the cause(s) and the candidate(s).After performing a test of significance, if the null hypothesis is rejected, then the Alternate Hypothesis (Ha) which is the opposite is accepted. In this study, socio-demographic, clinical factors and some infant factors are assumed to be causes of infant outcomes and may present as main predictors for the PMTCT programs outcomes.

3.2.1. Socio-demographic hypothesis

-Socio-demographicNull Hypothesis: There’s no association between the mother’s socio-demographic factors and the exposed infant outcomes in the context of virtual elimination of paediatric HIV.