Effectiveness of the Regular Implementation of the Mother to Child Transmission Plus (MTCT-Plus) Program in Burkina Faso, West Africa

Fabio Buelli1,2,5, Virginio Pietra2,3, Richard Fabian Schumacher2,4, Jacques Simpore3, Salvatore Pignatelli2,3, Francesco Castelli1,2 and the ESTHER-Brescia Study Group 1Institute for Infectious and Tropical Diseases, University of Brescia, Brescia, 2Medicus Mundi Italy, Brescia, 3St. Camille Medical Center, Ouagadougou, 4University Children’s Hospital, Brescia, 5Ph.D. in Appropriate Methods and Technologies for International Development Co-operation, University of Brescia (A. Archetti Fund), 1,2,4,5Italy 3Burkina Faso


Introduction
Since the 90s, many developing countries have introduced health strategies aimed at reducing Mother-to-Child transmission rate of HIV. These strategies (PMTCT -Prevention of Mother-to-Child Transmission) are based on (i) adequate counselling for HIV voluntary testing during antenatal care visits, (ii) single dose or a short antiretroviral therapy treatment to the mother and the newly-born baby (WHO, 2001;WHO, 2004;WHO, 2006) and (iii) formula feeding or (iv) exclusive breast-feeding with early weaning (WHO, 2003a;WHO, 2006). During the last years, thanks to the increase of the PMTCT program coverage, the aim of the program was enlarged to address the needs of all the family members of the HIV-positive women detected by the program. The World Health Organization (WHO) then introduced the Mother-to-Child Transmission Plus (MTCT-plus) program aimed at promoting health, eventually including the use of Highly Active Antiretroviral Treatment (HAART) for the infected mothers, their children, even those whose father is different from the current partner, and the partners themselves (WHO, 2003b). Aims of the program are, therefore, (i) to reduce HIV vertical transmission rates through specific antiretroviral therapies for the HIV-infected pregnant women, (ii) to involve a larger number of children and partners in the early stage of the disease and (iii) to increase the children survival rates by improving the HIV-positive mothers' life expectancy. (Berer, 1999;Brahmbatt et al, 2006). Psychosocial and nutritional supports and family planning are also integral components of MTCT-plus activities. Programs also focus on health education, including best breastfeeding practices to reduce transmission risk and nutrition.
Another important expectation of the program is to raise awareness and acceptability of HIV testing and early antiretroviral therapy, thus curbing the incidence of overt AIDS. Since 2003, many MTCT-plus programs have been implemented in HIV endemic developing countries, yielding conflicting results in different settings (Tonwe-Gold et al, 2009). In Burkina Faso, where a stable HIV-prevalence of 1.8% is recorded (UNAIDS, 2006), the PMTCT program started in 2002 and the MTCT-plus program was introduced later on thanks to the World Bank (TAP-Treatment Acceleration Program) and the Global Fund funding, which increased the availability of antiretroviral drugs. Aim of our work is to describe the achievements and the constraints faced by the real-life implementation of MTCT-plus program at the St. Camille Medical Center in Ouagadougou, Burkina Faso. midwives. All women are also asked to invite their partners to undergo the test. Moreover, HIV positive women are invited to test all the children had from previous pregnancies. Should the partner test HIV-infected, possible co-wives are also invited by the partner to undergo the test. Screening test: after informed consent, serological screening is immediately performed by two sequential rapid tests (Determine® and Genie-II®) (Koblavi-Dème et al, 2001) to avoid loss to follow-up and assure adequate post-test counselling. In case of conflicting results, an additional ELISA test is also performed. Polymerase Chain Reaction (PCR) test, available at the Center, is used to detect infection in young children under 18 months (Simporé et al, 2006). Patients management and PMTCT protocol: The national guidelines applied by the Center followed the indications provided by WHO during the study period (WHO, 2003c;WHO, 2006) both with regard to PMTCT protocols, and to the indications for therapy and for any immunological assessment. Nevertheless, until 2006, access to treatment has resulted in waiting lists so that even women in need of therapy have made only prophylaxis in pregnancy, starting HAART after delivery. From 2006 onwards, all women in need of therapy started HAART during pregnancy. Prophylaxis, including the breast-milk substitutes, were provided for free, while for HAART a contribution of 3 USD per month was asked (table1).

Discussion
Since the results of the HIVNET-012 (Guay et al, 1999) and other PMTCT clinical trials (Dabis et al., 1999;Shaffer et al., 1999) were made available, the adoption of single-dose NVP at delivery as preventive strategy to reduce mother to child HIV transmission rate has avoided many neonatal infections in Developing Countries, allowing at the same time to detect -and cure -a high number of HIV-infected women. However, the early emergence of HIV nevirapine-resistant strains urged to identify alternative strategies (Johnson et al, 2005).
To face these limits, WHO guidelines for PMTCT were reviewed in order to avoid the risk of viral resistances (WHO, 2006). Moreover, WHO approved MTCT-plus strategy in 2003, suggesting the adoption of a program of comprehensive care for the HIV-positive woman and for all the members of her family. These treatments include health care, social and psychological support, reproductive health and family planning services, education and nutritional support. With this initiative, the international community has recognized the centrality of the family's role and the great contribution that women offer to the fight against AIDS (Rabkin et al., 2003). This decentralized approach is in line with the most recent recommendations for the progressive increase of antiretroviral coverage as close as possible to the patients' households (Ferradini et al., 2006). MTCT-plus program activities are in fact considered as the most important tool to detect HIV-infected people as early as possible.
The effectiveness of MTCT-plus program depends, first of all, on the VCT acceptance rate, the real entry point into the program. Actually, wide variations in the VCT acceptance rate were recorded in different geographic environment especially because of different cultural and organizational factors (Perez et al., 2004;Pignatelli et al., 2006;Tonwe-Gold et al., 2009). The high number of pregnancies (more than 3,000/year) and of the ante-natal visits did not allowed our staff to provide an individual counselling and obliged us to adopt the opt-in strategy. This may explain the low VCT acceptance rate observed in our centre (20.1%) compared to 80% acceptance rate recorded in other centres in Burkina Faso where the optout strategy is adopted (MSFL, 2006).

www.intechopen.com
Nevertheless we did not observe any relevant loss in the follow-up, proving that women that accept opt-in VCT are highly motivated and willing to follow the program. In our experience the availability of antiretroviral drugs is not a relevant determinant for the acceptance of VCT. In fact, we did not observe any increase in the VCT acceptance rate linked to the increasing HAART availability over time. This observation suggests that cultural factors (partner's consensus, stigmatisation, illness perception, level of education) still play a very important role. An indirect confirmation comes from the higher educational level of our sample compared to that of the general female population attending the centre, 71% of which is illiterate (UNDP report 2009). Education is one of the most important factors facilitating VCT acceptance, together with obstetric history Perez et al., 2006). The recorded HIV prevalence rate at St. Camille Medical Center is then significantly higher than in the general population of Ouagadougou (about 4%) and than the national statistics (1.8%): this suggests not only a predisposition of the women in our urban environment to undergo the test, but a further selection of the population for the PMTCT.
In fact, until the end of 2005, the SCMC in Ouagadougou was the only existing centre in Burkina Faso that implemented the MTCT-plus program. Pregnant seropositive women, followed by other centres, were often reported to SCMC just for the PMTCT before returning to their original center for follow-up. The choice to implement the MTCT-plus program at the St Camille Medical Center compared to other centers, is due to the possibility to have access to many services that are not available in other centers, such as free formula milk, free laboratory follow up (test for children) and the possibility to have access to a Paediatrics unit and to the only neonatology unit existing in the Country. These facts also explain why many HIV-infected women (472/826; 57.1% of those women tested HIV-infected in our study) chose to deliver at the SCMC and to return for continuous follow-up at the original living area once the delivery has taken place.
The repeated offer to test the woman's family members in the period before and after childbirth and during the counselling meetings gave good results in our study as already reported. In particular, the involvement of the male partner in the VCT and the couple counselling was a very important element in order to increase the number of people taking part in the preventive programs (Katz et al., 2009). On average, the immune status of the HIV-positive male partners was more compromised than the one of the pregnant females, suggesting the presence of an older infection. This fact, even if not statistically significant, matches with other report in the country (Saleri et al., 2009). The number of HIV-negative male patients is not negligible (67/182, 36.5% of the tested partners). This is in line with data showing that in Burkina Faso about two thirds of HIVinfected couples are sero-discordant (de Walque, 2007). This shows the usefulness of the MTCT-plus protocol as a unique opportunity to promote preventive measure for negative partners.
The average number of living children is low (1.8/woman), especially if compared to the high fertility rate in Burkina Faso (6.2/woman) (CIA, 2009). This is probably due to the high foetal and infant mortality rate in mothers infected at St. Camille Medical Center . In fact as many as 249 previously dead children were reported in our sample (249/896; 27.8%).
The lower fertility rate in HIV+ women, especially in the advanced stages of the illness, could be another possible reason (Le Coeur et al., 2005), and this reinforce the need to link HIV treatment and reproductive health services in the framework of the MTCT-plus initiative.
The screening of the children born from previous pregnancies was probably hampered by the fear of the parents to verify the status of the infection in their children for whom PMTCT protocols was not adopted and by the fear that elder children may reveal the secret in the community.
As expected, HIV infected pregnant women that entered the PMTCT program were almost all asymptomatic. However, CD4+ lymphocyte count is essential in order to identify those HIV-infected women that are eligible for the HAART. The mother to child HIV transmission rate (4.3%) is due to the failure of the nevirapine mono-prophylaxis and to the limited access to the HAART for those who needed it before 2006. The relative older age of the women in our sample compared to the average of the age of the pregnant women at the SCMC is probably due to the fact that the older women are more free to autonomously accept the VCT proposal and can be more worried about the previous and "unexplainable" loss of a child . The decreasing trend recorded in the sero-prevalence rate among the younger pregnant women in Burkina Faso can be due to the campaigns focused on the education to health (UNAIDS/OMS/UNICEF/ UE, 2006). This effort needs to be strengthened at every level. The progressive increase of HAART availability in resource limited Countries underlines the role of MTCT-plus programs as a possible tool capable to identify motivated people in a sufficiently initial stage of the illness in order to benefit from the antiretroviral treatment.
In our study, the following socio-cultural factors have limited the effectiveness of the program: (i) refusal of the male partner to undergo the test (ii) refusal of the parents to test the children from previous pregnancies (iii) refusal of the pregnant woman to inform the partner about her serostatus. These reasons possibly find their explanation in the social stigma that HIV still cause in Western Africa.

Conclusion
The MTCT-plus approach might be an important tool to increase the early detection of HIV infected patients in the household of the infected pregnant women, allowing for beneficial early treatment. Furthermore detection of discordant couples offers possibilities to prevent infection. However, its effectiveness in the real-life condition of Western Africa is hampered by cultural factors that act at different levels (VCT uptake, notification to the partner, testing of previous children) and it requires new and innovative approaches in order to expand the adoption of HIV testing in Developing Countries. The positive impact that HAART has on the lives of those affected may further increase acceptance of VCT and reduce stigma, thus allowing to save ever more people.

Acknowledgement
The project was made possible thanks to the agreement between the Spedali Civili