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Combining drug addiction treatment and perinatal HIV prevention leads to good outcomes in Kenya
Liz Highleyman, 2017-05-18 09:30:00
An integrated programme offering medication-assisted drug addiction
treatment and services aimed at preventing mother-to-child HIV transmission led
to improved outcomes for opioid-dependent HIV-positive mothers and their
babies, according to a presentation at the 25th International Harm Reduction Conference (HR17) this week in Montréal.
assisted treatment (MAT), also know as opioid substitution therapy, is a proven
effective intervention for people dependent on drugs. Efforts to help pregnant
women with HIV access prenatal care and prophylactic antiretroviral therapy
(ART) can bring perinatal HIV transmission rates below 5%. Integrating these services offers
convenience for women and promotes holistic care.
Kirimo presented findings from a study of an integrated MAT and prevention of
mother-to-child transmission (PMTCT) project in Malindi, a town on the Indian
Ocean coast of Kenya with a population of around 54,600.
surrounding Kilifi County has an estimated HIV prevalence of 4.4%; in 2015 around
651 adults and 60 children were newly infected. The county has 107 PMTCT sites
and 1074 women need these services, Kirimo said.
was among the first countries in sub-Saharan Africa to introduce opioid substitution
therapy using methadone. Around 2000 people in Malindi inject drugs, 10% of
whom are women. The overall prevalence of HIV among people who inject drugs in
Kenya is 18% – about three times that of the general population – rising to 45%
among women who inject drugs.
the Kilifi County government and Ministry of Health, in collaboration with
USAID and the United
Nations Office on Drugs and Crime, introduced medically assisted
treatment at a Malindi hospital. Men who inject drugs and all opioid-dependent
women – regardless of method of administration – were eligible.
entering the programme clients were screened for HIV, hepatitis B and C, and
syphilis, and women received pregnancy tests. Those who were not pregnant were
offered family planning counseling, oral contraception and condoms. Pregnant women
were followed at MAT and prenatal care clinics until delivery.
often stop menstruating while using heroin and methadone can sometimes restore
fertility. Though the women were generally aware of this, their use of
contraception was low, Kirimo said.
born to women taking methadone or other opioids may experience withdrawal
symptoms after delivery, known as neonatal abstinence syndrome (NAS). If
severe, this is typically managed with tapering doses of morphine. National
guidelines in Kenya do not address care for infants exposed to both opioids and
analysis included 43 women on medically assisted treatment. The median age was
29 years and they had used drugs for six years on average. Almost all used more
than one drug and 76% reported injecting. Twelve of the women (29%) were
HIV-positive; three-quarters were on ART at baseline. Three women had co-infection with hepatitis B, three with hepatitis C and one has all three
viruses. None had tuberculosis.
the women became pregnant while on medically assisted treatment. More than
three-quarters attended prenatal care visits during every trimester, but 11%
did so only during the third trimester. Methadone doses were adjusted upwards
as pregnancy progressed, then back down again after delivery.
pregnant women started ART if they were not already on it, along with
cotrimoxazole for infection prophylaxis. HIV-exposed infants received
nevirapine and cotrimoxazole. Mothers were encouraged to breastfeed
exclusively, as mixed feeding of breast milk plus formula or food increases the
risk of HIV infection.
gave birth to six live infants, including one by Cesarean section. The infants
were full-term and birth weight and APGAR scores (used to assess an infant's
physical condition) were within normal ranges. More than 80% of the babies were
infants had mild enough withdrawal symptoms to be managed with
non-pharmacological supportive care. One baby with more severe NAS received
morphine and remained hospitalised for seven days.
infant born to an HIV-positive mother had negative HIV PCR tests at six weeks
and again at six months, confirming that transmission did not occur. Exclusive
breastfeeding was stopped at that point.
MAT with PMTCT "significantly improves pregnancy outcomes for HIV-infected
and opioid-dependent mothers," the researchers concluded. "Scale up
of PMTCT and HIV care for females who use drugs is warranted."
resource-limited settings exclusive breastfeeding of HIV- and opioid-exposed
infants with early interventions at birth is the way to go," they added.
noted that it is important to watch infants for withdrawal symptoms again when breastfeeding
is stopped – although only a small amount of methadone is transferred in breast
milk – but in this case the baby had only mild symptoms.