title: High acceptability of voluntary counselling and HIV-testing but unacceptable loss to follow up in a prevention of mother-to-child HIV transmission programme in rural Malawi: scaling-up requires a different way of acting.
abstract: METHODS
  Thyolo District Hospital, rural Malawi.
  
  
  OBJECTIVE
  In a prevention of mother-to-child HIV transmission (PMTCT) programme, to determine: the acceptability of offering 'opt-out' voluntary counselling and HIV-testing (VCT); the progressive loss to follow up of HIV-positive mothers during the antenatal period, at delivery and to the 6-month postnatal visit; and the proportion of missed deliveries in the district.
  
  
  METHODS
  Cohort study.
  
  
  METHODS
  Review of routine antenatal, VCT and PMTCT registers.
  
  
  RESULTS
  Of 3136 new antenatal mothers, 2996 [96%, 95% confidence interval (CI): 95-97] were pre-test counselled, 2965 (95%, CI: 94-96) underwent HIV-testing, all of whom were post-test counselled. Thirty-one (1%) mothers refused HIV-testing. A total of 646 (22%) individuals were HIV-positive, and were included in the PMTCT programme. Two hundred and eighty-eight (45%) mothers and 222 (34%) babies received nevirapine. The cumulative loss to follow up (n=646) was 358 (55%, CI: 51-59) by the 36-week antenatal visit, 440 (68%, CI: 64-71) by delivery, 450 (70%, CI: 66-73) by the first postnatal visit and 524 (81%, CI: 78-84) by the 6-month postnatal visit. This left just 122 (19%, CI: 16-22) of the initial cohort still in the programme. The great majority (87%) of deliveries occurred at peripheral sites where PMTCT was not available.
  
  
  CONCLUSIONS
  In a rural district hospital setting, at least 9 out of every 10 mothers attending antenatal services accepted VCT, of whom approximately one-quarter were HIV-positive and included in the PMTCT programme. The progressive loss to follow up of more than three-quarters of this cohort by the 6-month postnatal visit demands a 'different way of acting' if PMTCT is to be scaled up in our setting.
authors.affiliation: Médecins sans Frontières-Luxembourg, Thyolo district, Luxembourg, Malawi. m.manzi@belgacom.net
authors.forename: M
authors.initials: M
authors.lastname: Manzi
authors.forename: R
authors.initials: R
authors.lastname: Zachariah
authors.forename: R
authors.initials: R
authors.lastname: Teck
authors.forename: L
authors.initials: L
authors.lastname: Buhendwa
authors.forename: J
authors.initials: J
authors.lastname: Kazima
authors.forename: E
authors.initials: E
authors.lastname: Bakali
authors.forename: P
authors.initials: P
authors.lastname: Firmenich
authors.forename: P
authors.initials: P
authors.lastname: Humblet
mesh_terms: D000328:Adult; D015331:Cohort Studies; D003376:Counseling; D036861:Delivery, Obstetric; D005260:Female; D015658:HIV Infections / Q000175:diagnosis / Q000453:epidemiology / Q000635:transmission*; D006679:HIV Seropositivity / Q000175:diagnosis / Q000453:epidemiology / Q000635:transmission; D006801:Humans; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control*; D008295:Malawi / Q000453:epidemiology; D010342:Patient Acceptance of Health Care / Q000523:psychology*; D011181:Postnatal Care / Q000379:methods; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000175:diagnosis / Q000523:psychology; D012423:Rural Health