Long road to successful PMTCT

More and more HIV-positive pregnant women are testing for the virus and seeking out prevention of mother-to-child transmission (PMTCT) services in Sofala Province, in central Mozambique, but local health officials say much work remains to be done.

During the first three months of 2008, HIV tests were offered to 34,200 women during pre-natal checkups; of the 31,303 who agreed to be tested, 16 percent were HIV-positive, and 70 percent of these women were given nevirapine to prevent the virus being passed to their babies.

During the same period in 2007, HIV tests were only offered to 60 percent of the women attending pre-natal clinics, and only 19 percent of them accepted.

The increase in uptake of PMTCT is particularly significant in Sofala, which has one of the highest HIV infection rates in the country - 25 percent compared to the national average of 16 percent.

Despite these encouraging figures, Juvenaldo Amos, of the provincial health department in Sofala, noted that women who could benefit from PMTCT were lost at every stage of the process: at pre-natal check-ups, during counselling and in the maternity ward.

"The stigma and discrimination regarding people who live with the virus is the biggest obstacle causing expecting mothers to drop out of the programme," he told IRIN/PlusNews.

Going for pre-natal checkups is a challenge in itself for women living in rural areas. A Health Ministry report on maternal deaths during the first three months of 2008 in Sofala Province, in the central coastal province of Zambézia, and the capital, Maputo, found that only 52 percent of childbirths were assisted by health professionals.

"Pregnant women take the test, the result comes back positive, they go to their appointments and then they never come back," Amos said.

Pregnant women take the test, the result comes back positive...and then they never come back

The problem is that many women give birth at home, making it extremely difficult to administer nevirapine: 34 percent of the pregnant women diagnosed with HIV in Sofala delivered at home.

According to UNAIDS, some 30,000 HIV-positive babies are born every year in Mozambique, but more than half die before their first birthday.

Juggling the truth

The risk of an HIV-positive pregnant woman transmitting the virus to her baby can be cut in half with nevirapine, but lack of family support can complicate taking the drug. Many mothers do not reveal their HIV status to husbands and relatives because they fear being abandoned.

Domestic worker Teresa Xavier discovered she was HIV-positive during her sixth pregnancy. "I was scared to tell my husband because I thought about the consequences for our five other children," said Xavier, who is now eight months pregnant.

She changed her mind when her youngest child also tested positive for HIV just before his second birthday. She encouraged her husband to test and when his result came back positive, she revealed that she too was living with the virus.

"I went through some difficult moments, to the point where he would separate cooking utensils and prohibit me from cooking for the children, but now the atmosphere is back to normal," she said.

This time Xavier will take nevirapine when she gives birth. In the meantime, she is getting help from the Group of HIV-Positive Mothers, a support and information-sharing group attached to the PMTCT programme.

Not all such situations end well. Josina Celso, 27, did not dare tell her husband when she tested HIV-positive during her pregnancy, but her relatives found the dose of nevirapine she had been given at the clinic.

The young woman was accused of cheating on her husband and bringing the disease into their home. "We had a fight, and neither my relatives, my husband's relatives nor my godparents managed to reconcile us," she said.

The arguments continued after the birth of their daughter and Celso's marriage did not survive her decision to follow the doctor's advice and formula feed her baby to avoid any risk of infection.

"[My husband's family] told me I was violating a fundamental principle that would give him the right to divorce me. My only choice was to leave home," she said.

Education and expansion

"PMTCT isn't just giving a spoonful of nevirapine to the mother during childbirth and to the baby before it's 72 hours old," Amos pointed out, but there is a lack of follow-up to ensure that HIV-positive mothers bring their babies for check-ups and HIV testing for at least 18 months after birth.

According to Amos, only 611 of the 3,655 children of HIV-positive mothers in Sofala Province who were supposed to have returned for testing this year, did so. Of those, 146 were found to be HIV-positive and are now on antiretroviral treatment.

Awareness-raising is being carried out by activists and specially trained traditional midwives, with the goal of improving the rate of follow-up testing in communities.

Sofala's health department also plans to expand its PMTCT programme to 76 health facilities, besides the 26 already offering it, but a lack of health workers and resources presents major barriers to meeting the government's target of offering PMTCT to eight out of every 10 pregnant women by 2010.

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