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Awareness of mother to child transmission (MTCT) HIV transmission among women attending antenatal clinic.

INTRODUCTION: Acquired Immunodeficiency Syndrome has emerged as a devastatingly fatal disease all over the world. The tremors of HIV were felt initially in the late 1980s. On 5th June 1981 the first official reporting of AIDS epidemic in Los Angeles (United States) was published in the weekly report of morbidity and mortality (MMWR) by Center for Disease Control and Prevention (CDC) (1) where as in India the first known case of HIV was diagnosed by Dr. Suniti Solmon amongst female sex worker in Chennai. (2)

HIV/AIDS sometimes called "slim disease" (3) is a fatal illness caused by a retrovirus known as the human immune-deficiency virus (HIV) which breaks down the body's immune system, leaving the victim vulnerable to a host of life-threatening opportunistic infections, neurological disorders or unusual malignancies. (4) In this disease person will be affected for life time and no cure or remedy/vaccine is available up till date.

HIV is a retrovirus containing reverse transcriptase. This enzyme allows the virus to transcribe its RNA genome into DNA, which then integrates into host cell DNA. The RNA virus exists in two forms: HIV-1 and HIV-2. HIV-1 is more common. HIV preferentially targets lymphocytes expressing CD4 molecules (CD4 lymphocytes), causing progressive immunosuppression. Therefore, the main problem in clinical illness with AIDS is profound immunosuppression, rendering the patient susceptible to opportunistic infections and neoplasia leading to death. The modes of transmission are sexual route (86%), mother to child (3.6%), injecting drugs (2.4%), transfusion of blood and blood products 2% and others 6%. (5)

The diagnosis is done by ELISA screening test of HIV and conformed by Western blot or immunofluorescence assay and PCR detects viral DNA and RNA. CD4 count decline indicated the degree of immunosuppression. Viral load (HIV-RNA) predicts disease progression.

The worst part about HIV is vertical transmission where mother to child transmission of HIV occurs. It varies between 15-20% in non breast feeding women in Europe and between 25-40% in the breastfeeding African populations. In India, the risk of vertical transmission is about 30%. Two thirds of vertical transmission occurs at delivery if breastfeeding is not practiced. Timing of vertical transmission is (a) Antepartum 0-14 weeks 1%, 14-36 weeks 4%, 36 weeks up to labour 12% (b) Intrapartum 8% (c) Postpartum (with breast feeding) established infection 14% & primary infection 29%. The programme for prevention of vertical transmission is called PPTCT or Prevention of Parent to Child transmission and was commenced in the year 2002.

It causes morbidity and mortality of infants and children, pertaining to its mother-to-child transmission (MTCT) risk. MTCT which occur during pregnancy, labour and breastfeeding, is responsible for 90% childhood HIV infection. The main objective of the prevention of mother-to-child transmission (PMTCT) is to reduce the transmission of HIV infection from HIV infected mothers to their off springs. However, it is to be

noted that the most important public health measure against MTCT remains to be the prevention of infection in women of childbearing age and the prevention of unwanted pregnancies through adequate family planning. (6) Prevention of Mother to Child Transmission (PMTCT) is a commonly used term for program and interventions designed to reduce the risk of mother to child transmission (MTCT) of HIV/AIDS. (7)

The PPTCT programme aims to prevent perinatal transmission of HIV from an HIV infected pregnant mother to her newborn baby. The program entails counseling and testing of pregnant women in the Integrated Counseling and Testing Centre (ICTCs). Pregnant women found to be HIV-positive are given a single dose of nevirapine tablet at the time of labor; their newborn babies also get a single dose of nevirapine syrup within 72 hours after birth s to prevent transmission of HIV from mother to child. (8)

According to joint United Nations Programme on HIV/AIDS (UNAIDS) there has been a 19% reduction in the number of HIV-infected people and a 20% reduction in AIDS-related deaths. However the number of women affected has risen to 50% of which 80% are in their reproductive years. Antenatal positivity has been estimated to be more than 1%. Whereas in their 2012 estimate report by UNAIDS has mentioned that no. of people living with HIV in India is 21 lakhs out of which women population is 7.5 lakhs. (9) This shows the magnitude of the obstetric problem. The aim of UNAIDS 2009 is virtual elimination of mother to child transmission by 2015. Millennium development goal 6 aims to decrease new pediatric HIV infections and improve HIV-free child survival. (10) India accounts for about 7% of all HIV/AIDS cases in the world. (11)

In this study we are trying to evaluate the awareness and knowledge of HIV/AIDS focusing more on different aspect of vertical transmission (MTCT). As we know that prevention of an infection is only choice we have got (no remedy/vaccine is available) which in turn depend upon awareness of the different aspects of diseases which deserves the ultimate importance from the strategic point of view.

MATERIAL AND METHODS: The present study was conducted at Private Medical College and Teaching Hospital from March 2011 to September 2011. Antenatal mothers who were coming in ANC OPD were included in this study. The mothers were from all communities and socio-economic strata. We conducted interviews with randomly selected women during their first antenatal visit. The nature of the study was explained to all women and written informed consent was obtained. The interview was conducted before start of routine ANC check up and each mother was interviewed privately and assured on the confidentiality of the interview. The topic covered in these interviews included demographic and clinical characteristics, like age religion, occupation and income access to media related to HIV and general knowledge of HIV with a focus on maternal to infant transmission. To know the socio economical status patients were divided in three groups (1) first group income up to Rs. 50,000 (2) second group income up to Rs. 1 lakh (3) third group income above Rs. 1 lakh.

The knowledge was evaluated about possible routes of transmission, possibility of co-existing with pregnancy and transmission from mother-to-child (MTCT), timing of it and measures to prevent MTCT. The interview was taken by Medical Officers who were trained with proper interview techniques. All of them were aware of the eligibility criteria of respondents and were capable of providing a detailed explanation of each question in local language.

To maintain systemic record special Performa was planned on which all the information obtained by each patient was written in detail. This Performa included several additive scores based on women's corrected responses. While analyzing data we have specially tried to know whether there is any difference in different aspects of awareness between educated and uneducated status of the patients.

All data was analyzed by applying proper statistical test to know statistical significance.

RESULTS: Total number of women enrolled in our study was 630. After giving consent they were interviewed in detail and all the finding noted on the Performa prepared for the study. The age groups were from (1) 18-20yrs (2) 20-25yrs (3) 26yrs & above. More than 50% were in group 2. All were married and 2 were divorced and 1 widow remarried. Maximum patients were Hindu (70%) and 73% were housewives. For income we had done 3 groups (1) Annual income up to Rs. 50,000/(2) Annual income up to Rs. 1,00,000 /- (3) Annual income above 1,00,000/-. Maximum 65% women were in group 2. In education also we had done 2 groups. Group 1 contains illiterate (20.63%) and group 2 was secondary (44.23%) and graduate (9.92%).

Table 2 shows awareness and knowledge of the patients. The main source of information was media like TV (48.97%) and radio (37.95%) followed by public health camp (35.51%), news papers (31.83%), health workers (28.57%), friends and relatives (24.48). All women had knowledge (awareness) about sexual intercourse (100%) as a route of transmission. Sharing of needles and blood transmission was identified as additional group by 18% and 48% respectively. About 62% women were thinking that HIV person cannot look healthy.

Table no. 3 shows that majority of the women were aware that HIV can co-exist with pregnancy however knowledge about mother to child transmission of HIV was quite low (62%). Statistically it is significant (P <0.05).

Trans-placental route as a mode of mother-to-child transmission of HIV was known to 60% patients. However about vaginal delivery and breast feeding knowledge as route of transmission was significantly low (39.73% and 42.98% respectively). Caesarean section was believed route of transmission by 126 (41.72%) women. 64 patients could not identify any route of MTCT.

The use of anti-retroviral drugs in pregnancy and avoidance of breastfeeding were identified as methods of reducing mother to child transmission (MTCT) by 17% and 25% respectively. Delivery by caesarean section was identified by only 18 (5.96%) patients. Significantly higher proportion of respondent 186 (61.58%) did not know of any method of prevention of MTCT which is statistically significant (P <0.05).

Table no. 4 shows knowledge of MTCT among women with group no. 1no education / primary education as compared with group 2 (secondary education and graduate). Awareness of HIV, its coexistence with pregnancy and mother to child transmission was significantly higher in group 2. It's also shows statistically significant (P < 0.05)

DISCUSSION: Our study sample showed age group is similar Bhalge et al (12) whereas religion table figure similar to Dr. Shrotri et al. (13) About income group three group/figure are similar to Bhalge et al (12) except his income criteria is on lower side which might be due to the geographical variation in the places. More than 75% women in our study were aware of HIV and most of them had knowledge of mode of transmission. This might be due to the Government and NGO efforts to change behavior through education, information and communication.

Sexual intercourse was identified as route of transmission of HIV by all women. This is parallel with other studies done by Kunte et al. (14) Blood transmission and common use of syringes and needles identified by 50% and 18% respectively. However it reflects lower level of awareness of HIV transmission by this route. Kunte et al and Rahbar et al. (14, 15)

91.42% women in our series were aware that HIV and pregnancy can co-exist but significantly lower proportions 61.53% were aware of mother to child transmission of HIV. Another interesting finding in our study shows significant difference of awareness about HIV and MTCT according to the education level. Lower is the education less is the knowledge and awareness i.e. it is inversely proportional to the level of education. Similar conclusions are also drawn by Kunte et al & Rahbar et al. (14, 15)

62% women did not know any method of preventing mother-to-child transmission of HIV. Avoiding breastfeeding was identified by 24.5% of the respondents while only 6% mentioned cesarean section as method of preventing MTCT. It is known that breastfeeding contributes 30.40% of vertical transmissions UNAIDS 2010. (16) In countries like India and other developing countries this is rather controversial issue because breast feeding is cultural norm and exclusive breastfeeding is advocated because of high infant mortality and morbidity from diarrheal diseases and malnutrition. Considering all this things WHO and NACO has prepared guidelines on this issue.

All our efforts should be concentrated for the reduction of vertical transmission. NACO has developed programmes for prevention of MTCT which is called PMTCT which includes strategy like regular enrolling of ANC patient for HIV screening and treatment and also care of babies by giving nevirapine. (8)

The aim of UNAIDS 2009 is virtual elimination of mother to child transmission by 2015. Millennium development goal 6 aims to decrease new paediatric HIV infections and improve HIV-free child survival. (10) To achieve this to increase the awareness about PPTCT knowledge is the only choice for us and we should try to give health education to patients regarding same whenever we get chance and we should contribute our share to fulfill a dream of UNAIDS 200916 and achieve the million development goal six aim.

DOI: 10.14260/jemds/2014/3044

REFERENCES:

(1.) Center for Disease Control (CDC) Morbidity Mortality Weekly Report (MMWR) published by Associated Press Los angles Times (USA) on 5th June 1981.

(2.) Steve Sternberg. HIV Scar India, USA Today on 23rd Feb. 2005.

(3.) Park K. Textbook of Preventive and Social Medicine. 21st edi. M/s Banarsidas Bhanot publishers; 2011

(4.) WHO Technical Report Series. United nations world health organization interim commission expert committee on venereal diseases. Br J Vener Dis. Jun 1949; 25(2): 45-55 .

(5.) Shaila Balakrishnan. HIV Infection in Pregnancy. Textbook of Obstetrics, Paras Medical Publication, 2nd ed 2013: 302-303.

(6.) Haddis M, Gerene D. Awareness of antenatal care clients on mother-to-child-transmission (MTCT) of HIV infection and its prevention Arbaminch. Ethiop. J. health dev; 2006:20(1), 55-58.

(7.) Bassey E.A., Abasiubang F, Ekanem U, Abasiatai. Awareness and knowledge of HIV/AIDS at booking among antenatal clinic attendees in UYO, Nigeri IntJ.med.med.sci., 1(8), 2009, 334-338.

(8.) NACO: Revised PPTCT Training Curriculum Trainer Manual (India), New Delhi, India; 2004

(9.) Joint United Nations Programme on HIV/AIDS (UNAIDS) 2010 & 2012 Progress Report on the Global Plan estimate.

(10.) Kishore J.Burden of Disease and National health Programs. National Health Programs of India, Century Publications, 10th Ed 2012:12.

(11.) Joint United Nations Programme on HIV/AIDS (UNAIDS). Report on the global AIDS epidemic 2008. Available from http: www.unaids.org/en/KnowledgeCentre/HIVData/ Global Report/2008/2008_Global_report.asp [accessed on 2010 Mar 16].

(12.) Udaykiran U. Bhalge, Gautam M Khakse, Kishor P Brahmapurkar, Ravindra Thorat, Vaishali K. Awareness Regarding HIV / AIDS in ANC Client in Tribal District Of Central India. IOSR Journal of Dental and Medical Sciences 2012. Volume 2, Issue 4, PP 44-49.

(13.) Shrotri A, Shankar AV, Sutar S, Joshi A, Suryawanshi N, Pisal H et. al. Awareness of HIV/AIDS and household environment of pregnant women in Pune, India International journal of STD and AIDS. 2003, 14: 835-839.

(14.) Kunte A, Misra V, Paranjape R, Mansukhani N, Padbidri V, Gonjari S, et al. HIV sero prevalence & awareness about AIDS among pregnant women in rural areas of Pune district, Maharashtra, India. Indian J Med Res. 1999; 110: 115-22.

(15.) Rahbar T, Garg S, Tripathi R, Gupta VK, Singh MM. Knowledge, attitude, behavior and practice (KABP) regarding HIV/AIDS among pregnant women attending PPTCT programme in New Delhi. J Commun Dis. 2007; 39(3): 179-84.

(16.) Joint United Nations Programme on HIV/AIDS (UNAIDS). Report on the global AIDS epidemic 2008. Available from http: www.unaids.org/en/KnowledgeCentre/HIVData/ GlobalReport/2008/2008_Global_report.asp [accessed on 2010 Mar 16].

Tambe Vikas [1], Madkar Chandrakant [2], Deshpande Hemant [3], Karuna Ratwani [4], Gosavi Kishor [5], Trivedi Yogesh [6]

AUTHORS:

1. Tambe Vikas

2. Madkar Chandrakant

3. Deshpande Hemant

4. Karuna Ratwani

5. Gosavi Kishor

6. Trivedi Yogesh

PARTICULARS OF CONTRIBUTORS:

1. Assistant Professor, Department of Obstetrics and Gynaecology, D. Y. Patil Medical College, Pune.

2. Professor, Department of Obstetrics and Gynaecology, D. Y. Patil Medical College, Pune.

3. Professor and Head, Department of Obstetrics and Gynaecology, D. Y. Patil Medical College, Pune.

4. Assistant Professor, Department of Obstetrics and Gynaecology, D. Y. Patil Medical College, Pune.

5. Assistant Professor, Department of Obstetrics and Gynaecology, D. Y. Patil Medical College, Pune.

6. Resident, Department of Obstetrics and Gynaecology, D. Y. Patil Medical College, Pune.

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Chandrakant S. Madkar, Professor, Department of Obstetrics and Gynaecology, D. Y. Patil Medical College, Pune. Email: csmadkar@gmail.com

Date of Submission: 10/07/2014. Date of Peer Review: 11/07/2014. Date of Acceptance: 16/07/2014. Date of Publishing: 21/07/2014.
TABLE NO. 1: DEMOGRAPHIC AND SOCIO ECONOMICAL CHARACTERISTICS
OF PREGNANT WOMEN ENROLLED IN THE STUDY N = 630

Characteristic            No.   Percentage

(1) Age (years)

  18-20                   160     25.39%
  20-25                   344     54.60%
  26 & above              126     20.01%

(2) Religion

  Hindu                   440     69.84%
  Others                  190     30.16%

(3) Occupation

  Housewives              460     73.01%
  Others                  170     26.99%

(4) Income

  Lower group Gr 1        23      3.65%
  Middle group Gr 2       405     64.28%
  Higher group Gr 3       192     30.47%

(5) Education

  Illiterate Gr. 1        155     24.60%
  Primary Gr. 1           130     20.63%
  Secondary Gr. 2         285     45.23%
  Graduate & above Gr.2   60      9.52%

TABLE NO. 2: HIV/AIDS AWARENESS

(1) Awareness N = 630                      No.   Percentage

  Yes                                      490     77.77%
  No                                       140     22.23%

(2) Information Sources N =490
  Television                               240     48.97%
  Radio                                    186     37.95%
  Health camps & rallies                   174     35.51%
  Health workers                           140     28.57%
  News papers                              156     31.83%
  Friends & Relatives                      120     24.48%

(3) Route of Transmission N =490
  Intercourse (coitus)                     490      100%
  Sharing / reusing needles and syringes   86      17.55%
  Blood transfusion                        240     48.97%

(4) Status of Infected Person N = 490
  Healthy looking                          53      10.81%
  Unhealthy or ill-looking                 304     62.04%
  Do not know                              134     27.34%

Table No. 3: MTCT (Mother to Child Transmission) Awareness
and Knowledge N = 490

Knowledge                       No.   Percentage

(1) Co-existence of pregnancy with HIV

  Yes                           448     91.42%
  No                            28      5.73%
  Do Not Know                   14      2.85%

(2) MTCT

  Yes                           302     61.53%
  No                            78      15.91%
  Do Not Know                   110     22.44%

(3) MTCT Route of Transmission

  Placenta                      180     59.62%
  Vaginal Delivery              120     39.73%
  Caesarean Section             126     41.72%
  Breast Feeding                160     42.98%
  Do Not Know                   64      21.16%

(4) Method of Preventing MTCT

  ART in pregnancy              52      17.21%
  ART during labour             34      11.25%
  Delivery of Caesarean         18      5.96%
  Special Medicine to Newborn   24      7.94%
  No Breast Feeding             74      24.50%
  Do Not Know                   186     61.58%

Table No. 4: Relation of Education Status and Awareness

Knowledge       No or Primary    Secondary Education   P Value
                Education Gr 1      & Above Gr 2

(1) Awareness / Knowledge of HIV N = 630

  Yes            212 (74.38%)       278 (80.57%)        0.005
  No             76 (26.66%)         64 (18.55%)

(2) Co-existence of HIV with pregnancy N = 490

  Yes            164 (88.17%)       284 (93.11%)        0.047
  No               8 (4.30%           20 (6.5%)
  Do Not Know     13 97.5%)           01 (0.32)

(3) Mother to Child to Transmission (N= 490)

  Yes            34 (18.37%)        267 (87.54%)       <0.0001
  No             46 (24.86%)         33 (10.81)
  Do Not Know    105 (56.75%)         05 (1.63%
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Title Annotation:ORIGINAL ARTICLE
Author:Vikas, Tambe; Chandrakant, Madkar; Hemant, Deshpande; Ratwani, Karuna; Kishor, Gosavi; Yogesh, Trive
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Report
Date:Jul 21, 2014
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