Research: Rwanda Study Validates Key Strategy for Reducing Child HIV

The past decade has seen a global watershed for the prevention of mother-to-child transmission of HIV. New international guidelines, stronger treatment regimens for pregnant women with HIV, and increasing adoption of lifelong HIV treatment for mothers all have combined to significantly lower HIV-related risks for women and children.

A study that Partners In Health supported in Rwanda has played a role in that global effort, providing strong data for use by countries around the world and continuing to have lifesaving impacts today.

The improvements in treatment and outcomes have been dramatic.

UNAIDS estimates, for example, that programs known as prevention of mother-to-child transmission, or PMTCT, prevented about 1.4 million potential HIV infections in children between 2010-18. Additionally, 80 percent of pregnant women with HIV worldwide were receiving antiretroviral therapy by 2017, up from about 50 percent in 2010.

But while clinicians and policymakers long have been guided by principles that increasing HIV treatment for pregnant women would reduce HIV transmission to their children, there was little hard data to support those principles, aside from controlled experiments.

That lack of implementation data created barriers for governments and organizations seeking to implement stronger policies and create large-scale improvements for the treatment of pregnant women with HIV.

PIH, known in Rwanda as Inshuti Mu Buzima, helped set the stage for those improvements with a study that examined the effectiveness of improved HIV treatment regimens for pregnant women. The study used routinely reported data from health facilities across the country, during a period from 2009-12.

Results were clear: The adoption of increased treatment “contributed to an immediate decrease in the rate of HIV transmission from mother to child,” and suggested “other countries may benefit from adopting” new guidelines, the study states.

In 2018, the PLOS ONE research journal published the study, titled: “The impact of ‘Option B’ on HIV transmission from mother to child in Rwanda: An interrupted time series analysis.” The study’s authors included Monique Abimpaye, formerly in the HIV division for the Rwanda Biomedical Center, and Catherine Kirk, director of maternal and child health for PIH in Rwanda.

Understanding the study’s impacts requires a quick look back at 2010, when Rwanda’s government implemented a WHO policy known as Option B. The policy essentially dictates pregnant women with HIV be given treatment known as “triple therapy,” which combines HIV drugs to boost effectiveness.

Prior to that implementation, many pregnant women in Rwanda and elsewhere were treated with a single-therapy regimen. Reasons included concerns about the availability and affordability of HIV medicines; thresholds of illness that women had to meet in order to access those medicines; and other factors. 

Those practices changed when Rwanda became one of the first countries in sub-Saharan Africa to implement Option B broadly at its health facilities.

“This was a big shift, to say that we have to prioritize the best available option,” Kirk said. “And clinical trials backed that up.”

The study also assessed Option B+, an additional WHO measure that stipulates women continue triple therapy for life, not just the period surrounding pregnancy and breastfeeding.

“We were curious about whether this triple therapy would reduce HIV transmission from mother to child,” Kirk said. “There had been clinical trials, but in real-world implementation, would we see that same impact?”

The answer was a strong affirmative. Across the country, Kirk said, Option B saw a high impact in reducing HIV transmission from mother to child.

The study also opened new doors for data collection and analysis in Rwanda. Abimpaye, in her role with the Rwanda Biomedical Center, knew that examining the impacts of Option B could enable the center to use data from Rwanda’s own health facilities, rather than data from outside the country.

“Part of the whole goal was to strengthen the HIV/AIDS Division (at the Biomedical Center) and the ability to use their own data for their own learning,” Kirk said.

The study’s impacts spread beyond Rwanda, as well, by adding to a growing body of clinical trials that have influenced international guidelines for treating pregnant women with HIV.

 From 2013 to 2015, WHO guidelines increasingly affirmed the importance of immediate and lifelong antiretroviral therapy for pregnant women with HIV, citing clinical trials in its recommendations. 

By 2017, when authors of the Rwanda study submitted their work to PLOS ONE, many of the 23 countries that UNAIDS had deemed a priority for preventing mother-to-child transmission of HIV were moving to implement WHO guidelines—and now had more concrete data to support those efforts. 

“These results suggest that the adoption of Option B/B+ contributed to a national decline in HIV transmission to children at six weeks following birth in Rwanda,” the study states. “These findings provide population-level evidence that support WHO recommendations for wide-scale adoption and implementation of Option B+ in sub-Saharan Africa.”