What Works for Women and Girls

Promising Strategies:5. Integrating ARV therapy into antenatal care, rather than referring women separately forHIV treatment, may reduce time to treatment initiation for pregnant women living withHIV. [See also Chapter 13. Structuring Health Services to Meet Women’s Needs]An evaluation in Zambia that compared integration of antiretroviral therapy in antenatalcare to referral to ART care found that where antiretroviral therapy was integrated withantenatal care, women were more than twice as likely to be enrolled while pregnant andwithin 60 days of HIV diagnosis and to have initiated ART while pregnant. Between2007 and 2008, 13,917 women started antenatal care more than 60 days before theintervention rollout and constituted the control cohort; 17,619 women started antenatalcare after ART was integrated into ANC and constituted the intervention cohort. Ofthe 1,566 patients found eligible for ART, 376 out of 846 (44.4%) enrolled while pregnantand within 60 days of HIV diagnosis as compared with 181 of 716 (25.3%) whowere referred for ART. 278 out of 846 (32.9%) of women who accessed ART in integratedservices in ANC initiated ART while pregnant compared to 103 of 716 (14.4%) ofthose who were referred for ART. Women found to be HIV-positive through antenataltesting had a specimen routinely sent for a CD4 cell count. Separate ART facilities werelocated on the same premises but physically separate and separately staffed (Killam etal., 2009). (Gray III) (treatment, PMTCT, antenatal care, Zambia)A study of 872 women in Zambia found that HAART was less effective among womenwho had been exposed to single dose nevirapine. HIV-positive women who had receivedsingle dose nevirapine between 2001 and 2005 who could be contacted were evaluatedfor eligibility for HAART if they had CD4 counts under 200 or viral counts under35 and evidence of WHO clinical disease stage 3” (Kuhn et al., 2009b). . Mortality inwomen who met ART eligibility criteria was high with 23.7% mortality by 24 monthsin the era before ART became available. Of 161 single dose nevirapine exposed womenwho were still on HAART after six months, 70.8% achieved a viral load less than 400copies per milliliter and 40.4% achieved a viral load less than 50 copies per milliliter. Ofeight women exposed to single dose nevirapine within six months of starting HAART,only three achieved a viral load of less than 400 copies per milliliter by six monthsafter therapy compared with 59.1% of 22 women who started HAART within six to 12months after single dose nevirapine and, 72.1% of 61 who started HAART within 12 to24 months, and 77.1% of 70 who started more than 24 months after exposure. “WithHIV treatment programs now in place, women should be screened for ART during pregnancy”(Kuhn et al., 2009b: 135). “If ART is available, pregnant women should be prioritizedand started on therapy if eligible as a matter of urgency… These results emphasizethe importance of establishing appropriate referrals and coordination between servicesso that pregnant HIV-infected women can be triaged for ART if appropriate” (Kuhn etal., 2009b: 136). (Gray III) (HAART, PMTCT, Zambia)WHAT WORKS FOR WOMEN AND GIRLS243