In this study, we found that 9 out of 10 women enrolled into the PMTCT Programme were initiated on ART/pARV with the rate of 54 per 100 person-months of follow-up. More than 70% were initiated on ART/pARV within 2 weeks of enrolment with 39% initiated on the date of enrollment to PMTCT programme. The proportion of HIV-positive women initiated on ART/pARV reported in our study was higher than global data on pregnant women living with HIV receiving medicines to prevent MTCT of HIV in 2016 (76%), in China (71%), in Cape town (46%), in Malawi where 63% in ART integrated model (HIV testing, ART provision integrated to antenatal care) and 51% in non-ART integrated model (only HIV testing integrated to antenatal care) [17,18,19,20].
We also found that women with anemia, women whose spouses had their HIV status ascertained and women who were enrolled into to PMTCT program before delivery were more likely to be initiated on ART/pARV. Anemia in HIV-positive pregnancy was usually associated with advanced HIV stage which might have led the clinician to initiate ART early for those with low hemoglobin levels [21]. Women whose spouses knew their HIV status might indicate better disclosure between the partners and better spouse support, which may be a facilitator for uptake of ART/pARV and longer duration of ART. This is similar to findings in other studies that show that involvement of spouse in care and disclosure of HIV status to partners enable initiation of ART, adherence to ART, and for minimizing fear, stigma and discrimination [22]. Our finding on lower rate of ART/pARV initiation among intrapartum/ post-partum women at enrolment may be due to the fact that clinician might give priority to pregnant women compared to those who have already delivered.
The major reason of non-ART/pARV was lost to follow-up and most of these happened within four weeks from enrolled date. This might be related to deficiencies in counselling on the importance of regular follow-up to clinic and importance of ART. In our setting, the counselling is being done predominantly to the pregnant women and this could be insufficient to bring them back to our clinic regularly as they may be dependent on other family members to come to the PMTCT clinic. In addition, there could be several other reasons for not initiating ART/pARV (as shown in other studies) such as patient’s refusal to get on to ART due to stigma, costs involved in accessing ART clinics (e.g., transportation cost), treatment seeking decision being made by husband, unwillingness to disclose HIV serostatus, long waiting time at the clinic and patient-unfriendly health care worker attitudes [22,23,24]. We did not explore these reasons in our study and therefore this is a potential area for further research.
Among HIV-positive mothers who delivered the babies and initiated on ART/pARV, 10% were initiated on ART after delivery and this proportion was relatively lower than a study conducted in Cape Town [2]. The delay in initiating ART was higher among HIV-positive women who lived outside Mandalay in our study. Patients living outside Mandalay might face several challenges in reaching our hospital such as financial constraints, inadequate transportation facilities, transportation cost, fear of stigma or discrimination and inadequate family support, similar to the reasons reported in other studies [22, 24, 25].
WHO recommends early ART in HIV-positive women (as soon as possible) well before delivery to be more effective in reducing mother to child transmission of HIV and studies show that at least 4–13 weeks of ART is required to achieve viral suppression at the time of delivery [26, 27]. About 40% of the women, who were initiated on ART, in our study were on ART for less than 8 weeks prior to delivery. We did not measure viral loads at the time of delivery and therefore what proportion of women in our study had low/suppressed viral loads at the time of delivery is unknown.
Strengths
This is the first study conducted in Myanmar on the ART/pARV initiation and the delays involved in HIV-positive women enrolled under PMTCT programme. We used data that is collected by this programme under routine conditions and therefore this is likely to reflect ground realities. The findings of the study therefore have direct relevance to the hospital based PMTCT care setting. In addition, there is a system of routine data quality assurance in our programme and the data quality is regularly checked and corrected. Therefore, data errors, if any are likely to be minimal.
Limitations
First, The PMTCT programme does not collect data on variables such as socio-economic status, last menstrual period or gestational week at enrolment and other factors shown to be associated in other studies [2, 22, 26]. Therefore, we were unable to study the association between these factors and ART initiation. Second, there was some missing data and we have tried to address this issue by creating a category for missing values and by not excluding such cases. We are not sure how this has affected the estimates used to study the associations in our study.
Recommendations for strengthening the PMTCT programme and future research
First, an assessment should be conducted to know what proportion of eligible pregnant women are enrolled into PMTCT programme, the timing of their first antenatal care visit and time taken to enroll HIV-positive pregnant women into the PMTCT programme from the date of this first antenatal care visit. Second, qualitative studies to assess health seeking behavior among pregnant women, the reasons of late antenatal care presentation, delays in enrolment to PMTCT programme and barriers in ART initiation are required.
Third, recording and reporting of programme data should be strengthened and integrated with the hospital data to get full information on some important variables such as gestational week at HIV diagnosis and at enrolment to PMTCT programme, presence or absence of co-morbidities such as TB. Fourth, mechanisms to expand PMTCT care services to the decentralized ART centers should be strengthened so that the services are more accessible to all HIV-positive women (living outside Mandalay) and can result in earlier initiation of ART.
Fifth, lost to follow-up tracing should be strengthened and reasons for lost to follow-up must be periodically assessed and addressed. Lastly, effort must be made to increase spouse HIV testing and family support to HIV-positive pregnant women by raising awareness about it during antenatal care, PMTCT clinic and in community.