January 27, 2004
The current study documents the first-year results of the Dominican Republic's program to prevent mother-to-child transmission (PMTCT) of HIV. Outside sub-Saharan Africa, the Caribbean is the hardest-hit region for HIV/AIDS. Nine of the 12 countries with the highest HIV prevalence in the Americas are in the Caribbean basin. In the Dominican Republic, one adult in 40 has HIV. Data from sentinel site testing of pregnant women, in place since 1991, suggest that the prevalence of HIV among pregnant women ranges from <2 percent to >5 percent and that the epidemic is growing among women of reproductive age.
HIV transmission in the Dominican Republic is primarily heterosexual. Since the first pediatric AIDS case was reported in 1985, the number of infected children has risen sharply. In 2001, almost 500 cumulative HIV/AIDS pediatric cases were documented, the study stated.
On May 15, 2000, the Dominican Republic's Ministry of Health (MOH) initiated an integrated package of interventions to reduce MTCT. The program was to be implemented in 3 phases, the first phase including four mother and child hospitals, the second phase including 8 mother and child health institutions in Santo Domingo, and the third including all remaining (12) mother and child health care institutions in the country.
During the first year, 42,666 women attended prenatal care. Of those, 6,528 (28 percent) went to pretest-counseling sessions, and 3,467 (15 percent) attended posttest-counseling sessions. Fifty-four percent (23,067) of the women took an HIV test; of those, 581 (2.5 percent) had HIV.
PMTCT offered HIV-positive mothers a 200mg nevirapine tablet during labor or 8 hours before elective caesarian section. In the first year, 185 of the mothers delivered. Sixty-seven percent received caesarian sections (124 of 185); the remaining 33 percent were admitted for delivery from the emergency room. Infants born to HIV-positive mothers were given 0.6mL of nevirapine. The program recommended formula feeding rather than breast-feeding and offered formula-feeding counseling and infant formula, which PMTCT dispensed to 47 percent of the mothers.
PTMCT offered testing at age 6 weeks for the first 45 infants only "due to the limited polymerase chain reaction testing by the National AIDS Program for the MTCT program," the study said. Seventy-eight percent of those 45 children had undetectable HIV-1 RNA viral loads.
"This report demonstrates the feasibility of implementing a large-scale program to prevent mother-infant HIV transmission in a developing country," the authors noted. "Based on this 1-year project evaluation, we estimate that implementation of the PMTCT program in the Dominican Republic, using the nevirapine regimen, could reduce the average risk for MTCT by 50 percent, preventing approximately 1,000 infant HIV infections each year."
"Prenatal counseling and testing must be simplified as much as possible and offered routinely while remaining voluntary, confidential, and supportive of HIV and AIDS prevention in women and their partners," the investigators concluded. "These efforts are essential to maintain and further decrease the reduction in HIV vertical transmission observed during the 1st year of this program."
Journal of Acquired Immune Deficiency Syndromes
12.15.03; Vol. 34; No. 5: P.506-511; Eddy Perez-Then, M.D., M.P.H.; Ricarda Peña, R.N.; Maria Tavarez-Rojas, M.D.; Cleotilde Peña, M.Sc.; Salvador Quiñonez, M.D.; Marta Buttler, M.D.; Arthur Ammann, M.D.; William Hernández, M.D.; Miguel Goyanes; Maria Jose Miguez, M.D., Ph.D.; Gail Shor-Posner, Ph.D.; the PMTCT Group