Integrating prevention of mother-to-child HIV transmission (PMTCT) programmes with other health services for preventing HIV infection and improving HIV outcomes in developing countries

Prevention of mother-to-child transmission of hepatitis B virus in antenatal care and maternity services, Mozambique

Objective

To pilot an intervention on the prevention of mother-to-child transmission (PMTCT) of hepatitis B virus (HBV) in an antenatal care and maternity unit in Maputo, Mozambique, during 2017–2019.

Methods

We included HBV in the existing screening programme (for human immunodeficiency virus (HIV) and syphilis) for pregnant women at their first consultation, and followed mother–child dyads until 9 months after delivery. We referred women who tested positive for hepatitis B surface antigen (HBsAg) for further tests, including hepatitis B e antigen (HBeAg) and HBV viral load. According to the results, we proposed tenofovir for their own health or for PMTCT. We administered birth-dose HBV vaccine and assessed infant HBV status at 9 months.

Findings

Of 6775 screened women, 270 (4.0%) were HBsAg positive; in those for whom data were available, 24/265 (9.1%) were HBeAg positive and 14/267 (5.2%) had a viral load of > 200 000 IU/mL. Ninety-eight (36.3%) HBsAg-positive women were HIV coinfected, 97 of whom were receiving antiretroviral treatment with tenofovir. Among HIV-negative women, four had an indication for tenofovir treatment and four for tenofovir PMTCT. Of 217 exposed liveborn babies, 181 (83.4%) received birth-dose HBV vaccine, 160 (88.4%) of these < 24 hours after birth. At the 9-month follow-up, only one out of the 134 tested infants was HBV positive.

Conclusion

Our nurse-led intervention highlights the feasibility of integrating PMTCT of HBV into existing antenatal care departments, essential for the implementation of the triple elimination initiative. Universal birth-dose vaccination is key to achieving HBV elimination.

Motherhood and decision-making among women living with HIV in developed countries: a systematic review with qualitative research synthesis

BACKGROUND

Women living with HIV (WLH) lack evidence-based information about reproductive options while managing pressures from family, clinicians, and communities to give up the idea of having children. As the reproduction intentions of WLH are not well understood, stigmatizing behaviors force them to hide their disease to avoid rejection by their family, partner, and social networks. Compliance with social norms, fear of stigma, and discrimination influence their experience. Current research is individual qualitative studies lacking the synthesis perspective necessary to guide intervention development. The purpose of this study was to synthesize the evidence to explain the reproductive decision-making process for WLH in developed countries.

METHODS

A systematic review with qualitative research synthesis was conducted through searches in 10 electronic databases (CINAHL, EMBASE, MEDLINE, Scopus, Social Science Citation Index, Web of Science, Google Scholar, Cuidatge, Cuiden Enfispo, and SciELO). Studies published in journals from 1995 to 2019 with qualitative data about reproductive decision-making among WLH in developed countries were eligible for inclusion. Developed country was operationalized by membership in the OECD for comparative conditions of social wellbeing and economic stability. The CASP and JBI checklists for qualitative research were used to assess study quality and methodological integrity. Thematic analysis and qualitative meta-summary techniques were used for the synthesis.

RESULTS

Twenty studies from 12 developed countries were included in the synthesis. Findings were organized into 3 meta-themes from 15 themes and 45 subthemes, including: (1) Shattered identity, (2) Barriers, inequities, and misinformation, (3) Coping, resiliency, and support. Reproductive decision-making was perceived as a complex process influenced by facilitators and barriers. The facilitators helped WLH cope with their new situation to become more resilient, while the barriers made their situation more difficult to manage.

CONCLUSION

WLH encounter reproductive decision-making with knowledge deficits and limited social support. An integrated approach to holistic care with comprehensive multidisciplinary counseling is needed to support WLH. Clinicians could benefit from professional development to learn how to be authentically present for WLH, including engaging in conversations, demonstrating compassion, and understanding situations. Evidence-based clinical practice guidelines need to be tailored for the family planning and sexual health needs of WLH.

Brazilian Protocol for Sexually Transmitted Infections, 2020: HIV infection in adolescents and adults

HIV infection is presented in the chapters of the Clinical Protocol and Therapeutic Guidelines for Comprehensive Care for People with Sexually Transmitted Infections, published by the Brazilian Ministry of Health in 2020. Health professionals and managers must learn the signs and symptoms of HIV infection and know how to diagnose it to provide appropriate treatment and reduce complications. HIV infection has become a chronic disease. Its treatment includes addressing common comorbidities such as arterial hypertension, diabetes, and dyslipidemia, in addition to cardiac risk assessment, cancer prevention, and guidance on immunization. Initiation of treatment for HIV patients is recommended regardless of clinical or immunological criteria as adopted by the Ministry of Health since 2013. Lately, it has been simplified with more tolerable first-line medications and fewer drug interactions, making its management easy to implement, including by primary health care.

HIV cases are concentrated in specific population groups, such as sex workers, men who have sex with men, transexuals, people who use alcohol or other drugs, and vulnerable people, such as black, incarcerated, or people living on the streets.

Health Insurance Status of Pregnant Women and the Likelihood of Receipt of Antenatal Screening for HIV in Sub-Saharan Africa

BACKGROUND

We investigated if initiating preventive care against HIV vertical transmission by antenatal HIV screening is independent of the patients' source of financial reimbursement for the care received in sub-Saharan Africa (SSA).

METHODS

Using information from the WHO's Global Health Expenditure Database and the Demographic Health Surveys Database for 27 sub-Saharan countries, we used Spearman's correlation and adjusted survey logistic regression to determine the potential relationship between enrollment in health insurance and the likelihood that expectant mothers would be offered antenatal HIV screening.

RESULTS

We found that expectant mothers covered by health insurance were more than twice as likely to be offered antenatal screening for HIV compared to the uninsured. The likelihood differed by the type of insurance plan the expectant mother carried.

DISCUSSION

Health insurance is more of a financial tool that this study finds to be necessary to boost the uptake of preventive and therapeutic HIV care in SSA.

CONCLUSION

The ensuing disparity in receiving proper care could hinder the goals of 90-90-90 and the forthcoming 95-95-95 plan in SSA.

The impacts of collaboration between local health care and non-health care organizations and factors shaping how they work: a systematic review of reviews

BACKGROUND

Policymakers in many countries promote collaboration between health care organizations and other sectors as a route to improving population health. Local collaborations have been developed for decades. Yet little is known about the impact of cross-sector collaboration on health and health equity.

METHODS

We carried out a systematic review of reviews to synthesize evidence on the health impacts of collaboration between local health care and non-health care organizations, and to understand the factors affecting how these partnerships functioned. We searched four databases and included 36 studies (reviews) in our review. We extracted data from these studies and used Nvivo 12 to help categorize the data. We assessed risk of bias in the studies using standardized tools. We used a narrative approach to synthesizing and reporting the data.

RESULTS

The 36 studies we reviewed included evidence on varying forms of collaboration in diverse contexts. Some studies included data on collaborations with broad population health goals, such as preventing disease and reducing health inequalities. Others focused on collaborations with a narrower focus, such as better integration between health care and social services. Overall, there is little convincing evidence to suggest that collaboration between local health care and non-health care organizations improves health outcomes. Evidence of impact on health services is mixed. And evidence of impact on resource use and spending are limited and mixed. Despite this, many studies report on factors associated with better or worse collaboration. We grouped these into five domains: motivation and purpose, relationships and cultures, resources and capabilities, governance and leadership, and external factors. But data linking factors in these domains to collaboration outcomes is sparse.

CONCLUSIONS

In theory, collaboration between local health care and non-health care organizations might contribute to better population health. But we know little about which kinds of collaborations work, for whom, and in what contexts. The benefits of collaboration may be hard to deliver, hard to measure, and overestimated by policymakers. Ultimately, local collaborations should be understood within their macro-level political and economic context, and as one component within a wider system of factors and interventions interacting to shape population health.

Integrating Prevention of Mother-to-Child Transmission of HIV Care into General Maternal Child Health Care in Western Kenya

BACKGROUND

Health systems integration is becoming increasingly important as the global health community transitions from acute, disease-specific health programming to models of care built for chronic diseases, primarily designed to strengthen public-sector health systems. In many countries across sub-Saharan Africa, including Kenya, prevention of mother-to-child transmission of HIV (pMTCT) services are being integrated into the general maternal child health (MCH) clinics. The objective of this study was to evaluate the benefits and challenges for integration of care within a developing health system, through the lens of an evaluative framework.

METHODS

A framework adapted from the World Health Organization's six critical health systems functions was used to evaluate the integration of pMTCT services with general MCH clinics in western Kenya. Perspectives were collected from key stakeholders, including pMTCT and MCH program leadership and local health providers. The benefits and challenges of integration across each of the health system functions were evaluated to better understand this approach.

RESULTS

Key informants in leadership positions and MCH staff shared similar perspectives regarding benefits and challenges of integration. Benefits of integration included convenience for families through streamlining of services and reduced HIV stigma. Concerns and challenges included confidentiality issues related to HIV status, particularly in the context of high-volume, crowded clinical spaces.

CONCLUSION AND GLOBAL HEALTH IMPLICATIONS

The results from this study highlight areas that need to be addressed to maximize the effectiveness and clinical flow of the pMTCT-MCH integration model. The lessons learned from this integration may be applied to other settings in sub-Saharan Africa attempting to integrate HIV care into the broader public-sector health system.

Perceptions of and barriers to HIV testing of women in Indonesia

Indonesia’s 2014 health reforms advocated for universal health coverage for all Indonesians. The reforms made provision for integrated human immunodeficiency virus (HIV) programmes, with testing available at community health centres and hospitals for pregnant women and women of childbearing age. The question remains, though, as to whether testing has been effective. This article focuses on barriers women face accessing HIV testing and presents findings from the experiences of 18 HIV-positive women. To triangulate findings, interviews were conducted with 26 health workers, 9 non-governmental organisation workers and 12 HIV stakeholders. The article examines barriers to pregnant women’s access to HIV tests, showing that barriers relate to women not having reproductive health rights. It highlights reproductive rights noted in the Respectful Maternity Care Charter, and violations to them relevant to HIV testing in pregnancy. Five reported rights violations include: women being unable to access information; being unable to make informed decisions; having no right to confidentiality and privacy; experiencing ongoing discrimination; and having no right to timely HIV testing. The failure of Indonesia to protect these rights contributes to women being denied HIV testing. Findings show the need for increased HIV testing services for pregnant women and assert that health personnel and programme policy-makers need to be held accountable for the protection and fulfilment of women’s rights in respect of HIV testing. The findings show that policy makers must make changes to ensure health services improve, health professionals must be better trained, and women’s socio-cultural and political contexts must be considered.

Epidemiological and time series analysis on the incidence and death of AIDS and HIV in China

Background

To investigate the regional and age-specific distribution of AIDS/HIV in China from 2004 to 2017 and to conduct time series analysis of the epidemiological trends.

Method

Using official surveillance data from publicly accessible database of the national infectious disease reporting system, we described long-term patterns of incidence and death in AIDS/HIV, analyzed age group and regional epidemic characteristics, and established Autoregressive Integrated Moving Average (ARIMA) models for time series analysis.

Result

The incidence and death of AIDS/HIV have increased rapidly from 2004 to 2017, with significant difference regarding age groups and provincial regions (a few provinces appear as hot spots). With goodness-of-fit criteria and using data from 2004 to 2015, ARIMA (0,1,3) × (2,0,0), ARIMA (3,1,0) × (1,0,1), and ARIMA (0,1,2) × (2,0,0) were chosen as the optimal model for the incidence of AIDS, HIV, and combined; ARIMA (0,1,3) × (1,0,0) was chosen as the optimal model for the death of AIDS, HIV, and combined. ARIMA models robustly predicted the incidence and death of AIDS/HIV in 2016 and 2017.

Conclusion

A focused intervention strategy targeting specific regions and age groups is essential for the prevention and control of AIDS/HIV. ARIMA models function as data-driven and evidence-based methods to forecast the trends of infectious diseases and formulate public health policies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-09977-8.

Mega-map of systematic reviews and evidence and gap maps on the interventions to improve child well-being in low- and middle-income countries

BACKGROUND

Despite a considerable reduction in child mortality, nearly six million children under the age of five die each year. Millions more are poorly nourished and in many parts of the world, the quality of education remains poor. Children are at risk from multiple violations of their rights, including child labour, early marriage, and sexual exploitation. Research plays a crucial role in helping to close the remaining gaps in child well-being, yet the global evidence base for interventions to meet these challenges is mostly weak, scattered and often unusable by policymakers and practitioners. This mega-map encourages the generation and use of rigorous evidence on effective ways to improve child well-being for policy and programming.

OBJECTIVES

The aim of this mega-map is to identify, map and provide an overview of the existing evidence synthesis on the interventions aimed at improving child well-being in low- and middle-income countries (LMICs).

METHODS

Campbell evidence and gap maps (EGMs) are based on a review of existing mapping standards (Saran & White, 2018) which drew in particular of the approach developed by 3ie (Snilstveit, Vojtkova, Bhavsar, & Gaarder, 2013). As defined in the Campbell EGM guidance paper; "Mega-map is a map of evidence synthesis, that is, systematic reviews, and does not include primary studies" (Campbell Collaboration, 2020). The mega-map on child well-being includes studies with participants aged 0-18 years, conducted in LMICs, and published from year 2000 onwards. The search followed strict inclusion criteria for interventions and outcomes in the domains of health, education, social work and welfare, social protection, environmental health, water supply and sanitation (WASH) and governance. Critical appraisal of included systematic reviews was conducted using "A Measurement Tool to Assess Systematic Reviews"-AMSTAR-2 rating scale (Shea, et al., 2017).

RESULTS

We identified 333 systematic reviews and 23 EGMs. The number of studies being published has increased year-on-year since 2000. However, the distribution of studies across World Bank regions, intervention and outcome categories are uneven. Most systematic reviews examine interventions pertaining to traditional areas of health and education. Systematic reviews in these traditional areas are also the most funded. There is limited evidence in social work and social protection. About 69% (231) of the reviews are assessed to be of low and medium quality. There are evidence gaps with respect to key vulnerable populations, including children with disabilities and those who belong to minority groups.

CONCLUSION

Although an increasing number of systematic reviews addressing child well-being topics are being published, some clear gaps in the evidence remain in terms of quality of reviews and some interventions and outcome areas. The clear gap is the small number of reviews focusing explicitly on either equity or programmes for disadvantaged groups and those who are discriminated against.

Socioeconomic Inequalities in the HIV Testing during Antenatal Care in Vietnamese Women

Although HIV (human immunodeficiency virus) testing for all women has been promoted by Vietnam's Ministry of Health since 2000, test acceptance rates in this country were reported to be less than 30% in the community. This country has been facing the barriers to approach the national services towards transmission prevention from mother to child including HIV testing during antenatal care (ANC) towards mothers. Here, we aim to assess the socioeconomic inequalities in HIV testing during ANC among Vietnamese women. This study used available data from the Vietnam Multiple Indicator Cluster Survey 2014. Overall, the prevalence of HIV testing during antenatal care was 30% and the concentrate index (CCI) was 0.1926. There was significant inequality between women classified as poor and rich, and when stratified by social characteristics, inequality was found in women aged 15-49 years (CCI: 0.4), living in rural areas (CCI: 0.3), belonging to ethnic minorities (CCI: 0.5) and having primary or less education (CCI: 0.4). In the multivariate logistic regression analysis, ethnicity and socioeconomic status were significant factors associated with HIV testing during ANC. We found the prevalence of HIV testing during ANC was low, and its inequalities were associated with age, living area, ethnicity, education, and economic status.

A Systematic Review and Meta-analysis of Antiretroviral Therapy (ART) Adherence Interventions for Women Living with HIV

A systematic review and meta-analysis was conducted to determine the efficacy of women-focused ART adherence interventions. Included studies (a) reported on a behavioral ART adherence intervention for cis-women living with HIV, (b) measured ART adherence as an outcome, and (c) employed a randomized controlled trial design. Thirteen studies were included in the meta-analysis. Overall, interventions significantly improved ART adherence compared to control conditions (random-effects d = 0.82, 95% CI [0.18, 1.45], p = 0.01), however, this was largely driven by two studies that had effect sizes greater than 3 standard errors above the mean effect size. Key moderators were location, recruitment method, group-based intervention, and alteration of the healthcare system. Innovative behavioral interventions that focus on young women and adolescents, target the critical periods of pregnancy and postpartum and test the integration of multiple levels of intervention to create lasting effects on ART adherence are needed.

What interventions are effective in improving uptake and retention of HIV-positive pregnant and breastfeeding women and their infants in prevention of mother to child transmission care programmes in low-income and middle-income countries? A systematic review and meta-analysis

OBJECTIVE

This review was conducted to identify interventions effective in improving uptake and retention of HIV-positive mothers and their infants in prevention of mother to child transmission (PMTCT) services in low-income and middle-income countries (LMICs) in order to inform programme planning.

METHODS

We conducted a systematic review of studies comparing usual care with any intervention to improve uptake and retention of HIV-positive pregnant or breastfeeding women and their children from birth to 2 years of age in PMTCT services in LMICs. Twenty-two electronic databases were searched from inception to 15 January 2018, for randomised, quasi-randomised and non-randomised controlled trials, and interrupted time series studies; reference lists of included articles were searched for relevant articles. Risk of bias was assessed using the Cochrane Effective Practice and Organisation of Care group criteria. Random-effects meta-analysis was conducted for studies reporting similar interventions and outcomes.

RESULTS

We identified 29 837 articles, of which 18 studies were included in our review. Because of heterogeneity in interventions and outcome measures, only one meta-analysis of two studies and one outcome was conducted; we found a statistically significant increase in antiretroviral therapy (ART) use during pregnancy for integration of HIV and antenatal care relative to standard non-integrated care (pooled AOR=2.69; 95% CI 1.25 to 5.78, p=0.0113). The remaining studies assessing other patient, provider or health system interventions were synthesised narratively, with small effects seen across intervention categories for both maternal and infant PMTCT outcomes based predominately on evidence with moderate to high risk of bias.

CONCLUSIONS

Evidence on the effectiveness of interventions to improve uptake and retention of mothers and infants in PMTCT care is lacking. Our findings suggest that integration of HIV and antenatal care may improve ART use during pregnancy. Future studies to replicate promising approaches are needed. Improved reporting of key methodological criteria will facilitate interpretation of findings and improve the utility of evidence to PMTCT programme planners.

PROSPERO REGISTRATION NUMBER

CRD42015020829.

Integrated management of type 2 diabetes and gestational diabetes within multi-morbidity conditions in Africa: a systematic review protocol

INTRODUCTION

Multi-morbidity, defined as the co-existence of more than one chronic condition in one person, has been increasing due to comorbid non-communicable and infectious chronic diseases (CNCICDs). Type 2 diabetes (T2D) and gestational diabetes mellitus (GDM) incidences within the CNCICDs conditions are increasing and overwhelming already weak and under-resourced healthcare systems in Africa. There is then an urgent need for the integrated management of CNCICDs. We aim to review the integrated management of T2D and GDM within multi-morbidity conditions in Africa.

METHODS

Studies that have assessed the integrated management of T2D and GDM within multi-morbidity conditions in Africa will be considered based on the Population, Intervention, Comparator and Outcome method: population (adult diagnosed with T2D and GDM, who also have other diseases, non-communicable diseases (NCDs) and infectious, in public primary and secondary healthcare facilities in Africa); Intervention (integrated management of T2D and GDM, also suffering from other diseases in Africa), Comparator (Unintegrated management of T2D and GDM in Africa) and Outcomes (integrated management of T2D and GDM in Africa). The following databases Cochrane Library, MEDLINE, PubMed and SCOPUS, the WHO International Clinical Trials Registry Platform, among others will be searched. Two reviewers (JCM and MW) will independently screen, select eligible studies and extract data. Discrepancies will be resolved by consensus or by a discussion with the third author (AR). Quality of included studies will be assessed using both the newly developed tool, 'the Cochrane Collaboration Risk of Bias Tool' and 'Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I)". A narrative synthesis of extracted data and meta-analysis, if necessary will be conducted and then reported according to the preferred reporting items for systematic review and meta-analysis.

ETHICS CONSIDERATION AND DISSEMINATION

By only using the published data, there is no ethics approval required for this study. This systematic review will be included in JCM's PhD thesis and its findings will also be disseminated through peer-reviewed publication and conference presentation.

PROSPERO REGISTRATION NUMBER

CRD42016046630.

The role of service readiness and health care facility factors in attrition from Option B+ in Haiti: a joint examination of electronic medical records and service provision assessment survey data

Background

Option B+ is a strategy wherein pregnant or breastfeeding women with HIV are enrolled in lifelong antiretroviral therapy (ART) for prevention of mother-to-child transmission (PMTCT) of HIV. In Haiti, attrition from Option B+ is problematic and variable across health care facilities. This study explores service readiness and other facility factors as predictors of Option B+ attrition in Haiti.

Methods

This analysis used longitudinal data from 2012 to 2014 from the iSanté electronic medical record system and cross-sectional data from Haiti's 2013 Service Provision Assessment. Predictors included Service Availability and Readiness Assessment (SARA) measures for antenatal care (ANC), PMTCT, HIV care services and ART services; general facility characteristics and patient-level factors. Multivariable Cox proportional hazards models modelled the time to first attrition.

Results

Analysis of data from 3147 women at 63 health care facilities showed no significant relationships between SARA measures and attrition. Having integrated ANC/PMTCT care and HIV-related training were significant protective factors. Being a public-sector facility, having a greater number of quality improvement activities and training in ANC were significant risk factors.

Conclusion

Several facility-level factors were associated with Option B+ attrition. Future research is needed to explore unmeasured facility factors, clarify causal relationships, and incorporate community-level factors into the analysis of Option B+ attrition.

Knowledge, attitudes and practices of health personnel of maternities in the prevention of mother-to-child transmission of HIV in a sub-Saharan African region with high transmission rate: some solutions proposed

Background

High mother-to-child (MTC) transmission rate of HIV might contribute to the increased pandemic rate. The aim of this study was to identify the knowledge, attitude and practices of health personnel working in maternities in the prevention of MTC transmission of HIV.

Methods

This cross-sectional descriptive study was carried out from 20th February to 30th April, 2017. All health personnel working in the maternity wards were included in this study. The variables recorded included their age, grade, experience (number of year of practice), gender, educational level, health structure and the training in prevention of MTC transmission of HIV. Analyses were done using SPSS 21.0. The Pearson Chi-square test or Fisher’s exact test and logistic regression were used for comparison. The level of significance was P < 0.05.

Results

A total of 140 health personnel were recruited. Knowledge was insufficient amongst 73 of them (52.1%). The factors significantly associated with sufficient knowledge were midwifery qualification (aOR 9.01, 95% CI 1.82–48.60) and training in prevention of MTC transmission of HIV (aOR 2.23, 95% CI 1.02–4.81). Regarding attitudes, it was negative in 85 practitioners (60.7%). Only those aged ≥33 years were significantly associated with a positive attitude (aOR 2.34, 95% CI 1.14–4.23). As concerns practices, only 32 practitioners (22.9%) had good practices. Only midwives were associated with good practices (aOR 3.23, 95% CI 1.21–9.95).

Conclusion

Insufficient knowledge, attitude and practices in the prevention of MTC transmission of HIV were observed among the majority of health personnel in the region. This lack of knowledge in prevention can therefore contribute to the rise of the mother-to-child transmission rate of HIV. To reduce this rate, more health personnel should be trained, especially midwives, in the prevention of MTC transmission of HIV. Moreover, deliveries of all women living with HIV should be conducted or at least supervised by trained midwives, especially those of at least 33 years of age.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-1876-0) contains supplementary material, which is available to authorized users.

Integration of antenatal care services with health programmes in low- and middle-income countries: systematic review

Background

Antenatal care (ANC) presents a potentially valuable platform for integrated delivery of additional health services for pregnant women–services that are vital to reduce the persistently high rates of maternal and neonatal mortality in low– and middle–income countries (LMICs). However, there is limited evidence on the impact of integrating health services with ANC to guide policy. This review assesses the impact of integration of postnatal and other health services with ANC on health services uptake and utilisation, health outcomes and user experience of care in LMICs.

Methods

Cochrane Library, MEDLINE, Embase, CINAHL Plus, POPLINE and Global Health were searched for studies that compared integrated models for delivery of postnatal and other health services with ANC to non–integrated models. Risk of bias of included studies was assessed using the Cochrane Effective Practice and Organisation of Care (EPOC) criteria and the Newcastle–Ottawa Scale, depending on the study design. Due to high heterogeneity no meta–analysis could be conducted. Results are presented narratively.

Findings

12 studies were included in the review. Limited evidence, with moderate– to high–risk of bias, suggests that integrated service delivery results in improved uptake of essential health services for women, earlier initiation of treatment, and better health outcomes. Women also reported improved satisfaction with integrated services.

Conclusions

The reported evidence is largely based on non–randomised studies with poor generalizability, and therefore offers very limited policy guidance. More rigorously conducted and geographically diverse studies are needed to better ascertain and quantify the health and economic benefits of integrating health services with ANC.

The impact of programs for prevention of mother-to-child transmission of HIV on health care services and systems in sub-Saharan Africa - A review

BACKGROUND

The global scale-up of Prevention of mother-to-child transmission (PMTCT) services is credited for a 52% worldwide decline in new HIV infections among children between 2001 and 2012. However, the epidemic continues to challenge maternal and paediatric HIV control efforts in Sub Saharan Africa (SSA), with repercussions on other health services beyond those directly addressing HIV and AIDS. This systematised narrative review describes the effects of PMTCT programs on other health care services and the implications for improving health systems in SSA as reported in the existing articles and scientific literature. The following objectives framed our review:To describe the effects of PMTCT on health care services and systems in SSA and assess whether the PMTCT has strengthened or weakened health systems in SSATo describe the integration of PMTCT and its extent within broader programs and health systems.

METHODS

Articles published in English and French over the period 1st January 2007 (the year of publication of WHO/UNICEF guidelines on global scale-up of the PMTCT) to 31 November 2016 on PMTCT programs in SSA were sought through searches of electronic databases (Medline and Google Scholar). Articles describing the impact (positive and negative effects) of PMTCT on other health care services and those describing its integration in health systems in SSA were eligible for inclusion. We assessed 6223 potential papers, reviewed 225, and included 57.

RESULTS

The majority of selected articles offered arguments for increased health services utilisation, notably of ante-natal care, and some evidence of beneficial synergies between PMTCT programs and other health services especially maternal health care, STI prevention and early childhood immunisation. Positive and negative impact of PMTCT on other health care services and health systems are suggested in thirty-two studies while twenty-five papers recommend more integration and synergies. However, the empirical evidence of impact of PMTCT integration on broader health systems is scarce. Underlying health system challenges such as weak physical and human resource infrastructure and poor working conditions, as well as social and economic barriers to accessing health services, affect both PMTCT and the health services with which PMTCT interacts.

CONCLUSIONS

PMTCT services increase to some extent the availability, accessibility and utilisation of antenatal care and services beyond HIV care. Vertical PMTCT programs work, when well-funded and well-managed, despite poorly functioning health systems. The beneficial synergies between PMTCT and other services are widely suggested, but there is a lack of large-scale evidence of this.

Non-disclosure to male partners and incomplete PMTCT regimens associated with higher risk of mother-to-child HIV transmission: a national survey in Kenya

Health worker experience and community support may be higher in high HIV prevalence regions than low prevalence regions, leading to improved prevention of mother-to-child HIV transmission (PMTCT) programs. We evaluated 6-week and 9-month infant HIV transmission risk (TR) in a high prevalence region and nationally. Population-proportionate-to-size sampling was used to select 141 clinics in Kenya, and mobile teams surveyed mother-infant pairs attending 6-week and 9-month immunizations. HIV DNA testing was performed on HIV-exposed infants. Among 2521 mother-infant pairs surveyed nationally, 2423 (94.7%) reported HIV testing in pregnancy or prior diagnosis, of whom 200 (7.4%) were HIV-infected and 188 infants underwent HIV testing. TR was 8.8% (4.0%-18.3%) in 6-week and 8.9% (3.2%-22.2%) in 9-month cohorts including mothers with HIV diagnosed postpartum, of which 53% of infant infections were due to previously undiagnosed mothers. Of 276 HIV-exposed infants in the Nyanza survey, TR was 1.4% (0.4%-5.3%) at 6-week and 5.1% (2.5%-9.9%) at 9-months. Overall TR was lower in Nyanza, high HIV region, than nationally (3.3% vs. 7.2%, P = 0.02). HIV non-disclosure to male partners and incomplete ARVs were associated with TR in both surveys [aOR = 12.8 (3.0-54.3); aOR = 5.6 (1.2-27.4); aOR = 4.5 (1.0-20.0), aOR = 2.5, (0.8-8.4), respectively]. TR was lower in a high HIV prevalence region which had better ARV completion and partner HIV disclosure, possibly due to programmatic efficiencies or community/peer/partner support. Most 9-month infections were among infants of mothers without prior HIV diagnosis. Strategies to detect incident or undiagnosed maternal infections will be important to achieve PMTCT.

Delivery arrangements for health systems in low-income countries: an overview of systematic reviews

BACKGROUND

Delivery arrangements include changes in who receives care and when, who provides care, the working conditions of those who provide care, coordination of care amongst different providers, where care is provided, the use of information and communication technology to deliver care, and quality and safety systems. How services are delivered can have impacts on the effectiveness, efficiency and equity of health systems. This broad overview of the findings of systematic reviews can help policymakers and other stakeholders identify strategies for addressing problems and improve the delivery of services.

OBJECTIVES

To provide an overview of the available evidence from up-to-date systematic reviews about the effects of delivery arrangements for health systems in low-income countries. Secondary objectives include identifying needs and priorities for future evaluations and systematic reviews on delivery arrangements and informing refinements of the framework for delivery arrangements outlined in the review.

METHODS

We searched Health Systems Evidence in November 2010 and PDQ-Evidence up to 17 December 2016 for systematic reviews. We did not apply any date, language or publication status limitations in the searches. We included well-conducted systematic reviews of studies that assessed the effects of delivery arrangements on patient outcomes (health and health behaviours), the quality or utilisation of healthcare services, resource use, healthcare provider outcomes (such as sick leave), or social outcomes (such as poverty or employment) and that were published after April 2005. We excluded reviews with limitations important enough to compromise the reliability of the findings. Two overview authors independently screened reviews, extracted data, and assessed the certainty of evidence using GRADE. We prepared SUPPORT Summaries for eligible reviews, including key messages, 'Summary of findings' tables (using GRADE to assess the certainty of the evidence), and assessments of the relevance of findings to low-income countries.

MAIN RESULTS

We identified 7272 systematic reviews and included 51 of them in this overview. We judged 6 of the 51 reviews to have important methodological limitations and the other 45 to have only minor limitations. We grouped delivery arrangements into eight categories. Some reviews provided more than one comparison and were in more than one category. Across these categories, the following intervention were effective; that is, they have desirable effects on at least one outcome with moderate- or high-certainty evidence and no moderate- or high-certainty evidence of undesirable effects. Who receives care and when: queuing strategies and antenatal care to groups of mothers. Who provides care: lay health workers for caring for people with hypertension, lay health workers to deliver care for mothers and children or infectious diseases, lay health workers to deliver community-based neonatal care packages, midlevel health professionals for abortion care, social support to pregnant women at risk, midwife-led care for childbearing women, non-specialist providers in mental health and neurology, and physician-nurse substitution. Coordination of care: hospital clinical pathways, case management for people living with HIV and AIDS, interactive communication between primary care doctors and specialists, hospital discharge planning, adding a service to an existing service and integrating delivery models, referral from primary to secondary care, physician-led versus nurse-led triage in emergency departments, and team midwifery. Where care is provided: high-volume institutions, home-based care (with or without multidisciplinary team) for people living with HIV and AIDS, home-based management of malaria, home care for children with acute physical conditions, community-based interventions for childhood diarrhoea and pneumonia, out-of-facility HIV and reproductive health services for youth, and decentralised HIV care. Information and communication technology: mobile phone messaging for patients with long-term illnesses, mobile phone messaging reminders for attendance at healthcare appointments, mobile phone messaging to promote adherence to antiretroviral therapy, women carrying their own case notes in pregnancy, interventions to improve childhood vaccination. Quality and safety systems: decision support with clinical information systems for people living with HIV/AIDS. Complex interventions (cutting across delivery categories and other health system arrangements): emergency obstetric referral interventions.

AUTHORS' CONCLUSIONS

A wide range of strategies have been evaluated for improving delivery arrangements in low-income countries, using sound systematic review methods in both Cochrane and non-Cochrane reviews. These reviews have assessed a range of outcomes. Most of the available evidence focuses on who provides care, where care is provided and coordination of care. For all the main categories of delivery arrangements, we identified gaps in primary research related to uncertainty about the applicability of the evidence to low-income countries, low- or very low-certainty evidence or a lack of studies.

Prevalence, trend and risk factors for antiretroviral therapy discontinuation among HIV-infected adults in Ethiopia in 2003-2015

BACKGROUND

It is well acknowledged that antiretroviral therapy (ART) discontinuation hampers the progress towards achieving the UNAIDS treatment targets that aim to treat 90% of HIV diagnosed patients and achieve viral suppression for 90% of those on treatment. Nevertheless, the magnitude, trend and risk factors for ART discontinuation have not been explored extensively. We carried out a retrospective data analysis to assess prevalence, trend and risk factors for ART discontinuation among adults in Southwest Ethiopia.

METHODS

12 years retrospective cohort analysis was performed with 4900 HIV-infected adult patients between 21 June 2003 and 15 March 2015 registered at the ART clinic at Jimma University Teaching Hospital. ART discontinuation could be loss to follow-up, defaulting and/or stopping medication while remaining in care. Because data for 2003 and 2015 were incomplete, the 10 years data were used to describe trends for ART discontinuation using a line graph. We used binary logistic regression to identify factors that were correlated with ART discontinuation. To handle missing data, we applied multiple imputations assuming missing at random pattern.

RESULTS

In total, 4900 adult patients enrolled on ART, of whom 1090 (22.3%) had discontinued, 954 (19.5%) had transferred out, 300 (6.1%) had died, 2517 (51.4%) were alive and on ART, and the remaining 39 (0.8%) had unknown outcome status. The trend of ART discontinuation showed an upward direction in the recent times and reached a peak, accounting for a magnitude of 10%, in 2004 and 2005. Being a female (AOR = 2.1, 95%CI: 1.7-2.8), having an immunological failure (AOR = 2.3, 1.9-8.2), having tuberculosis/HIV co-infection (AOR = 1.5, 1.1-2.1) and no previous history of HIV testing (AOR = 1.8, 1.4-2.9) were the risk factors for ART discontinuation.

CONCLUSIONS

One out of five adults had discontinued from ART, and the trend of ART discontinuation increased recently. Discontinued adults were more likely to be females, tuberculosis/HIV co-infected, with immunological failure and no history of HIV testing. Therefore, it is vital to implement effective programs such as community ART distribution and linkage-case-management to enhance ART linkage and retention.

Implementation of co-trimoxazole preventive therapy policy for malaria in HIV-infected pregnant women in the public health facilities in Tanzania

Background

In 2011, Tanzania adopted a policy for provision of daily co-trimoxazole prophylaxis to HIV-infected pregnant women for prevention of malaria and other opportunistic infections. As per the policy, HIV-infected pregnant women should not be given sulfadoxine-pyrimethamine (SP) for intermittent preventive therapy. The challenges associated with this policy change and the extent to which the new policy for prevention of malaria in pregnant women coinfected with HIV was implemented need to be assessed.

Aim

To assess the implementation of malaria-preventive therapy policy among HIV-infected pregnant women in the public health facilities in Dar es Salaam, Tanzania.

Methodology

The study was conducted in Kinondoni Municipality, Dar es Salaam, Tanzania, from January 2015 to July 2015. Three hundred and fifty-three HIV-infected pregnant women who were attending antenatal clinics (ANCs) and using co-trimoxazole for prevention of malaria were interviewed. Twenty-six health care workers working at the ANCs were also interviewed regarding provision of co-trimoxazole prophylaxis to pregnant women. A knowledge scale was used to grade the level of knowledge of health care providers. Focus group discussions were also conducted with 18 health care workers to assess the level of implementation of the policy and the challenges encountered.

Results

Twenty-three (6.5%) pregnant women with known HIV serostatus were using co-trimoxazole for prevention of opportunistic infections even before they became pregnant. Out of the 353 HIV-infected pregnant women, eight (2.5%) were coadministered with both SP and co-trimoxazole. Sixty (16.7%) pregnant women had poor adherence to co-trimoxazole prophylaxis. Out of the 26 interviewed health care providers, 20 had high level of knowledge regarding malaria-preventive therapy in HIV-infected pregnant women. Lack of adequate supply of co-trimoxazole in health facilities and inadequate training of health care providers were among the factors causing poor implementation of co-trimoxazole prophylaxis for prevention of malaria in HIV-infected pregnant women.

Conclusion

There is a need to continue sensitization of pregnant women and communities about the importance of early attendance to the ANCs for testing of HIV and provision of co-trimoxazole prophylaxis. Availability of co-trimoxazole in the health facilities, regular training, and sensitization of health care providers are necessary for effective implementation of this policy.

The Complexity of Health Service Integration: A Review of Reviews

BACKGROUND

The aim of health service integration is to provide a sustainable and integrated health system that better meets the needs of the end user. Yet, definitions of health service integration, methods for integrating health services, and expected outcomes are varied. This review was commissioned by Queensland Health, the government department responsible for health service delivery in Queensland, Australia, to inform efforts to integrate their mental health services. This review reports on the characteristics, reported outcomes, and design quality of studies included in systematic reviews of health service integration research.

METHOD

The review was developed by systematically searching nine electronic databases to find peer-reviewed Australian and international systematic reviews with a focus on health service integration. Reviews were included if they were in the English language and published between 2000 and 2015. A standardized assessment tool was used to analyze the study design quality of included reviews. Data relating to the integration types, methods, and reported outcomes of integration were synthesized.

RESULTS

Seventeen publications met the inclusion criteria. Eleven (65%) reviews were published during the past 5 years, which may indicate a trend for increased awareness of the need for service integration. The majority of reviews were published by researchers in the UK (8/47%), USA (3/18%), and Australia (3/18%). Included reviews focused on a variety of integration types, including integrated care pathways, governance models, integration of interventions, collaborative/integrated care models, and integration of different types of health care. Most (53%) of the reviews reported on the cost-effectiveness of service integration, e.g., positive results, no effect, or inconclusive. Only one of the reviews reported on the importance of consumer involvement. The overall design of 70% of the reviews was high, 18% medium, and 12% low.

CONCLUSION

There is no "one size fits all" approach to health service integration. Instead, this literature review highlighted the complexity of service integration, which in most primary studies involved a range of strategies. Rigorous assessments of cost-effectiveness and reporting on consumer involvement are required in future research.

Implementation and Operational Research: Integration of PMTCT and Antenatal Services Improves Combination Antiretroviral Therapy Uptake for HIV-Positive Pregnant Women in Southern Zambia: A Prototype for Option B+?

BACKGROUND

Early initiation of combination antiretroviral therapy (cART) for HIV-positive pregnant women can decrease vertical transmission to less than 5%. Programmatic barriers to early cART include decentralized care, disease-stage assessment delays, and loss to follow-up.

INTERVENTION

Our intervention had 3 components: integrated HIV and antenatal services in 1 location with 1 provider, laboratory courier to expedite CD4 counts, and community-based follow-up of women-infant pairs to improve prevention of mother-to-child transmission attendance. Preintervention HIV-positive pregnant women were referred to HIV clinics for disease-stage assessment and cART initiation for advanced disease (CD4 count <350 cells/μL or WHO stage >2).

METHODS

We used a quasi-experimental design with preintervention/postintervention evaluations at 6 government antenatal clinics (ANCs) in Southern Province, Zambia. Retrospective clinical data were collected from clinic registers during a 7-month baseline period. Postintervention data were collected from all antiretroviral therapy-naive, HIV-positive pregnant women and their infants presenting to ANC from December 2011 to June 2013.

RESULTS

Data from 510 baseline women-infant pairs were analyzed and 624 pregnant women were enrolled during the intervention period. The proportion of HIV-positive pregnant women receiving CD4 counts increased from 50.6% to 77.2% [relative risk (RR) = 1.81; 95% confidence interval (CI): 1.57 to 2.08; P < 0.01]. The proportion of cART-eligible pregnant women initiated on cART increased from 27.5% to 71.5% (RR = 2.25; 95% CI: 1.78 to 2.83; P < 0.01). The proportion of eligible HIV-exposed infants with documented 6-week HIV PCR test increased from 41.9% to 55.8% (RR = 1.33; 95% CI: 1.18 to 1.51; P < 0.01).

CONCLUSIONS

Integration of HIV care into ANC and community-based support improved uptake of CD4 counts, proportion of cART-eligible women initiated on cART, and infants tested.

Loss to Follow-Up within the Prevention of Mother-to-Child Transmission Care Cascade in a Large ART Program in Nigeria

BACKGROUND

The 2013 WHO guidelines incorporated simplified and more effective antiretroviral regimens for the purposes of preventing mother-to-child transmission of HIV. With ideal implementation of these recommendations, perinatal HIV transmission could be reduced to less than 2%. However, loss to follow-up (LTFU) has the potential to erode the success of programs and a number of studies report high rates of LTFU within the prevention of mother-to-child transmission (PMTCT) care cascade. We evaluated the timing and magnitude of LTFU in a large programmatic PMTCT cohort in Nigeria in order to focus future efforts to reduce loss in this high burden setting.

METHODS

From 2004-2014, the APIN/Harvard PEPFAR program supported antenatal HIV screening for nearly one million pregnant women and provided PMTCT care to over 30,000 women. The care cascade for women enrolling in the PMTCT program includes antenatal, delivery, and infant follow-up services through 12-18 months of life. In this retrospective cohort analysis, we examined data collected between 2004-2014 from 31 clinical sites in Nigeria and assessed the numbers of mothers and infants enrolled and LTFU at various points along the care cascade.

RESULTS

Among 31,504 women (median age 30, IQR: 27-34) entering PMTCT care during the antenatal period, 20,679 (66%) completed the entire cascade of services including antenatal, delivery, and at least one infant follow-up visit. The median gestational age at presentation for antenatal care services was 23 weeks (IQR: 17-29). The median infant age at last follow-up visit was 12 months (IQR: 5-18). The greatest loss in the PMTCT care cascade occurred prior to delivery care (21%), with a further 16% lost prior to first infant visit. Of the 38,223 women who entered at any point along the PMTCT cascade, an HIV DNA PCR was available for 20,202 (53%) of their infants. Among infants for whom DNA PCR results were available, the rate of HIV transmission for infants whose mothers received any antenatal and/or delivery care was 2.8% versus 20.0% if their mother received none.

CONCLUSION

In this large cohort analysis, the proportion of women LTFU in the PMTCT care cascade was lower than that reported in previous cohort analyses. Nevertheless, this proportion remains unacceptably high and inhibits the program from maximally achieving the goals of PMTCT care. We also provide the largest analysis to date on rates of perinatal HIV transmission, with low rates among women receiving NNRTI- or PI-based regimens, approaching that reported in clinical trials. However, among mothers who received any antenatal care, infant outcomes were unknown for 48%, and women presented later in pregnancy than that recommended by current guidelines. Implementation research to evaluate ways to improve integration of services, particularly transitions from antenatal to delivery and pediatric care, are critically needed to reduce LTFU within PMTCT programs and achieve the ultimate goal of eliminating pediatric HIV infection.

The effectiveness of interventions to improve uptake and retention of HIV-infected pregnant and breastfeeding women and their infants in prevention of mother-to-child transmission care programs in low- and middle-income countries: protocol for a systematic review and meta-analysis

BACKGROUND

Despite recent improvements, uptake and retention of mothers and infants in prevention of mother-to-child transmission (PMTCT) services remain well below target levels in many low- and middle-income countries (LMICs). Identification of effective interventions to support uptake and retention is the first step towards improvement. We aim to complete a systematic review and meta-analysis to evaluate the effectiveness of interventions at the patient, provider or health system level in improving uptake and retention of HIV-infected mothers and their infants in PMTCT services in LMICs.

METHODS/DESIGN

We will include studies comparing usual care or no intervention to any type of intervention to improve uptake and retention of HIV-infected pregnant or breastfeeding women and their children from birth to 2 years of age attending PMTCT services in LMICs. We will include randomized controlled trials (RCTs), cluster RCTs, non-randomized controlled trials, and interrupted time series. The primary outcomes of interest are percentage of HIV-infected women receiving/initiated on anti-retroviral prophylaxis or treatment, percentage of infants receiving/initiated on anti-retroviral prophylaxis, and percentage of women and infants completing the anti-retroviral regimen/retained in PMTCT care. The following databases will be searched from inception: Ovid MEDLINE and EMBASE, The WHO Global Health Library, CAB abstracts, EBM Reviews, CINAHL, HealthSTAR and Web of Science databases, Scopus, PsychINFO, POPLINE, Sociological Abstracts, ERIC, AIDS Education Global Information System, NLM Gateway, LILACS, Google Scholar, British Library Catalogue, DARE, ProQuest Dissertation & Theses, the New York Academy of Grey Literature, Open Grey, The Cochrane Library, WHO International Clinical Trials Registry, Controlled Clinical Trials, and clinicaltrials.gov. Reference lists of included articles will be hand searched and study authors and content experts contacted to inquire about eligible unpublished or in progress studies. Screening, data abstraction, and risk of bias appraisal using the Cochrane Effective Practice and Organization of Care criteria will be conducted independently by two team members. Results will be synthesized narratively and a meta-analysis conducted using the DerSimonian Laird random effects method if appropriate based on assessment of clinical and statistical heterogeneity.

DISCUSSION

Our findings will be useful to PMTCT implementers, policy makers, and implementation researchers working in LMICs.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015020829.

Supply-side dimensions and dynamics of integrating HIV testing and counselling into routine antenatal care: a facility assessment from Morogoro Region, Tanzania

Background

Integration of HIV into RMNCH (reproductive, maternal, newborn and child health) services is an important process addressing the disproportionate burden of HIV among mothers and children in sub-Saharan Africa. We assess the structural inputs and processes of care that support HIV testing and counselling in routine antenatal care to understand supply-side dynamics critical to scaling up further integration of HIV into RMNCH services prior to recent changes in HIV policy in Tanzania.

Methods

This study, as a part of a maternal and newborn health program evaluation in Morogoro Region, Tanzania, drew from an assessment of health centers with 18 facility checklists, 65 quantitative and 57 qualitative provider interviews, and 203 antenatal care observations. Descriptive analyses were performed with quantitative data using Stata 12.0, and qualitative data were analyzed thematically with data managed by Atlas.ti.

Results

Limitations in structural inputs, such as infrastructure, supplies, and staffing, constrain the potential for integration of HIV testing and counselling into routine antenatal care services. While assessment of infrastructure, including waiting areas, appeared adequate, long queues and small rooms made private and confidential HIV testing and counselling difficult for individual women. Unreliable stocks of HIV test kits, essential medicines, and infection prevention equipment also had implications for provider-patient relationships, with reported decreases in women’s care seeking at health centers. In addition, low staffing levels were reported to increase workloads and lower motivation for health workers. Despite adequate knowledge of counselling messages, antenatal counselling sessions were brief with incomplete messages conveyed to pregnant women. In addition, coping mechanisms, such as scheduling of clinical activities on different days, limited service availability.

Conclusion

Antenatal care is a strategic entry point for the delivery of critical tests and counselling messages and the framing of patient-provider relations, which together underpin care seeking for the remaining continuum of care. Supply-side deficiencies in structural inputs and processes of delivering HIV testing and counselling during antenatal care indicate critical shortcomings in the quality of care provided. These must be addressed if integrating HIV testing and counselling into antenatal care is to result in improved maternal and newborn health outcomes.

Implementation and Operational Research: Effect of Integration of HIV Care and Treatment Into Antenatal Care Clinics on Mother-to-Child HIV Transmission and Maternal Outcomes in Nyanza, Kenya: Results From the SHAIP Cluster Randomized Controlled Trial

BACKGROUND

Many HIV-infected pregnant women identified during antenatal care (ANC) do not enroll in long-term HIV care, resulting in deterioration of maternal health and continued risk of HIV transmission to infants.

METHODS

We performed a cluster randomized trial to evaluate the effect of integrating HIV care into ANC clinics in rural Kenya. Twelve facilities were randomized to provide either integrated services (ANC, prevention of mother-to-child transmission, and HIV care delivered in the ANC clinic; n = 6 intervention facilities) or standard ANC services (including prevention of mother-to-child transmission and referral to a separate clinic for HIV care; n = 6 control facilities).

RESULTS

There were high patient attrition rates over the course of this study. Among study participants who enrolled in HIV care, there was 12-month follow-up data for 256 of 611 (41.8%) women and postpartum data for only 325 of 1172 (28%) women. By 9 months of age, 382 of 568 (67.3%) infants at intervention sites and 338 of 594 (57.0%) at control sites had tested for HIV [odds ratio (OR) 1.45, 95% confidence interval (CI): 0.71 to 2.82]; 7.3% of infants tested HIV positive at intervention sites compared with 8.0% of infants at control sites (OR 0.89, 95% CI: 0.56 to 1.43). The composite clinical/immunologic progression into AIDS was similar in both arms (4.9% vs. 5.1%, OR 0.83, 95% CI: 0.41 to 1.68).

CONCLUSIONS

Despite the provision of integrated services, patient attrition was substantial in both arms, suggesting barriers beyond lack of service integration. Integration of HIV services into the ANC clinic was not associated with a reduced risk of HIV transmission to infants and did not appear to affect short-term maternal health outcomes.

Performance of HIV Prevention of Mother-To-Child Transmission Programs in Sub-Saharan Africa: Longitudinal Assessment of 64 Nevirapine-Based Programs Implemented in 25 Countries, 2000-2011

Background

To evaluate the performance and to identify predictive factors of performance in prevention of mother-to-child HIV transmission programs (PMTCT) in sub-Saharan African countries.

Methods

From 2000 to 2011, PMTCT programs included in the Viramune Donation Programme (VDP) were prospectively followed. Each institution included in the VDP provided data on program implementation, type of management institution, number of PMTCT sites, key programs outputs (HIV counseling and testing, NVP regimens received by mothers and newborns). Nevirapine Coverage Ratio (NCR), defined as the number of women who should have received nevirapine (observed HIV prevalence x number of women in antenatal care), was used to measure performance. Included programs were followed every six months through progress reports.

Results

A total of 64 programs in 25 sub-Saharan African countries were included. The mean program follow-up was 48.0 months (SD = 24.5); 20,084,490 women attended in antenatal clinics were included. The overall mean NCR was 0.52 (SD = 0.25), with an increase from 0.37 to 0.57 between the first and last progress reports (p<.0001); NCR increased by 3.26% per year-program. Between the first and the last report, the number of women counseled and tested increased from 64.3% to 86.0% (p<.0001), the number of women post-counseled from 87.5% to 91.3% (p = 0.08). After mixed linear regression analysis, type of responsible institution, number of women attended in ANC, and program initiation in 2005-2006 were significant predictive factors associated with the NCR. The effect of the time period increased from earlier to later periods.

Conclusion

A longitudinal assessment of large PMTCT programs shows that scaling-up of programs was increased in sub-Saharan African countries. The PMTCT coverage increased throughout the study period, especially after 2006. Performance may be better for programs with a small or medium number of women attended in ANC. Identification of factors that predict PMTCT program performance may help in the development and expansion of additional large PMTCT services in sub-Saharan Africa.

Factors associated with failure to screen for syphilis during antenatal care in Ghana: a case control study

Background

There is little data regarding the effect of ramping up new screening interventions on their uptake by target populations into routine care services in developing countries. This study aimed to determine patient-level factors associated with failure of pregnant women to get screened for syphilis during antenatal care, in the context of a national rollout of rapid syphilis point of care tests (POCTs) in Ghana.

Methods

An unmatched 1:2 case control study conducted among women admitted for delivery in two district hospitals in the Ashanti Region of Ghana from August to October 2010, 7 to 9 months after the introduction of POCTs in the region. Cases were women who had not been screened for syphilis during antenatal care and controls were women who had been screened. Patient-reported factors for being unscreened were examined using logistic regression to obtain odds ratios (ORs) and 95% confidence intervals (CIs).

Results

160 consecutive unscreened and 327 screened women were recruited. Most women had good knowledge of syphilis (58.7% among unscreened women vs. 64.2% among screened; P = 0.24). Factors associated with failure to get screened were: attending antenatal care in a private health facility (adjusted OR, 11.09; 95% CI 5.48-22.48), previous adverse pregnancy outcome (adjusted OR, 1.98; 95% CI 1.22-3.23) and not being screened for HIV during the current pregnancy (adjusted OR, 2.78; 95% CI 1.50-5.13). The odds of being unscreened also increased with decreasing doses of intermittent preventive treatment for malaria in pregnancy received (P trend < 0.001) and decreasing education level (P trend = 0.02).

Conclusion

Significant risk factors for not being screened, following the national rollout of syphilis POCTs, related to the type of health facility where antenatal care was received and some of the women’s personal characteristics. Targeting of private medical facilities to include syphilis POCTs and support other neglected public health interventions should be a priority.

Essential interventions: implementation strategies and proposed packages of care

In an effort to accelerate progress towards achieving Millennium Development Goal (MDG) 4 and 5, provision of essential reproductive, maternal, newborn and child health (RMNCH) interventions is being considered. Not only should a state-of-the-art approach be taken for services delivered to the mother, neonate and to the child, but services must also be deployed across the household to hospital continuum of care approach and in the form of packages. The paper proposed several packages for improved maternal, newborn and child health that can be delivered across RMNCH continuum of care. These packages include: supportive care package for women to promote awareness related to healthy pre-pregnancy and pregnancy interventions; nutritional support package for mother to improve supplementation of essential nutrients and micronutrients; antenatal care package to detect, treat and manage infectious and noninfectious diseases and promote immunization; high risk care package to manage preeclampsia and eclampsia in pregnancy; childbirth package to promote support during labor and importance of skilled birth attendance during labor; essential newborn care package to support healthy newborn care practices; and child health care package to prevent and manage infections. This paper further discussed the implementation strategies for employing these interventions at scale.

mHealth for HIV Treatment & Prevention: A Systematic Review of the Literature

This systematic review assesses the published literature to describe the landscape of mobile health technology (mHealth) for HIV/AIDS and the evidence supporting the use of these tools to address the HIV prevention, care, and treatment cascade. The speed of innovation, broad range of initiatives and tools, and heterogeneity in reporting have made it difficult to uncover and synthesize knowledge on how mHealth tools might be effective in addressing the HIV pandemic.

To do address this gap, a team of reviewers collected literature on the use of mobile technology for HIV/AIDS among health, engineering, and social science literature databases and analyzed a final set of 62 articles. Articles were systematically coded, assessed for scientific rigor, and sorted for HIV programmatic relevance. The review revealed evidence that mHealth tools support HIV programmatic priorities, including: linkage to care, retention in care, and adherence to antiretroviral treatment. In terms of technical features, mHealth tools facilitate alerts and reminders, data collection, direct voice communication, educational messaging, information on demand, and more. Studies were mostly descriptive with a growing number of quasi-experimental and experimental designs. There was a lack of evidence around the use of mHealth tools to address the needs of key populations, including pregnant mothers, sex workers, users of injection drugs, and men who have sex with men.

The science and practice of mHealth for HIV are evolving rapidly, but still in their early stages. Small-scale efforts, pilot projects, and preliminary descriptive studies are advancing and there is a promising trend toward implementing mHealth innovation that is feasible and acceptable within low-resource settings, positive program outcomes, operational improvements, and rigorous study design

Barriers and facilitating factors to the uptake of antiretroviral drugs for prevention of mother-to-child transmission of HIV in sub-Saharan Africa: a systematic review

Objectives

To investigate and synthesize reasons for low access, initiation and adherence to antiretroviral drugs by mothers and exposed babies for prevention of mother-to-child transmission (PMTCT) of HIV in sub-Saharan Africa.

Methods

A systematic literature review was conducted. Four databases were searched (Medline, Embase, Global Health and Web of Science) for studies conducted in sub-Saharan Africa from January 2000 to September 2012. Quantitative and qualitative studies were included that met pre-defined criteria. Antiretroviral (ARV) prophylaxis (maternal/infant) and combination antiretroviral therapy (ART) usage/registration at HIV care and treatment during pregnancy were included as outcomes.

Results

Of 574 references identified, 40 met the inclusion criteria. Four references were added after searching reference lists of included articles. Twenty studies were quantitative, 16 were qualitative and eight were mixed methods. Forty-one studies were conducted in Southern and East Africa, two in West Africa, none in Central Africa and one was multi-regional. The majority (n=25) were conducted before combination ART for PMTCT was emphasized in 2006. At the individual-level, poor knowledge of HIV/ART/vertical transmission, lower maternal educational level and psychological issues following HIV diagnosis were the key barriers identified. Stigma and fear of status disclosure to partners, family or community members (community-level factors) were the most frequently cited barriers overall and across time. The extent of partner/community support was another major factor impeding or facilitating the uptake of PMTCT ARVs, while cultural traditions including preferences for traditional healers and birth attendants were also common. Key health-systems issues included poor staff-client interactions, staff shortages, service accessibility and non-facility deliveries.

Conclusions

Long-standing health-systems issues (such as staffing and service accessibility) and community-level factors (particularly stigma, fear of disclosure and lack of partner support) have not changed over time and continue to plague PMTCT programmes more than 10 years after their introduction. The potential of PMTCT programmes to virtually eliminate vertical transmission of HIV will remain elusive unless these barriers are tackled. The prominence of community-level factors in this review points to the importance of community-driven approaches to improve uptake of PMTCT interventions, although packages of solutions addressing barriers at different levels will be important.

A comparison between antenatal care quality in public and private sector in rural Hebei, China

Aim

To evaluate the quality of antenatal care (ANC) in Hebei Province and compare it between the public and private sector and within the public sector.

Methods

We conducted a Maternal, Newborn and Child Health Household Survey in 2010 using a two-stage sampling procedure and included 1079 mothers. The quality of ANC was assessed on the basis of the number of ANC visits, the time of the first ANC visit, 16 different ANC procedures, owning a maternal health care booklet, and the type of service provider.

Results

Almost all women (98%) received ANC services at least once, 80% at least four times, and 54% at least five times. About half of the women (46%) visited ANC facility within their first trimester. Neither public nor private sector provided all 16 standardized services, but significantly more women in public sector received ANC procedures. Most women received ANC in county or higher-level hospitals (75%) and very few in township hospitals (8%). Significantly fewer women were weighed and tested for HIV/AIDS in township than in county or higher-level hospitals.

Conclusion

The quality of ANC in Hebei was poorer than required by China’s national and World Health Organization norms. Although the public sector performed better than the private sector, the utilization and quality of care of ANC services in this sector varied and women generally visited county or higher-level health facilities.

Prevention of mother-to-child HIV transmission in resource-limited settings: assessment of 99 Viramune Donation Programmes in 34 countries, 2000-2011

BACKGROUND

Transmission of HIV from mother-to-child during pregnancy, labor, or breastfeeding is the primary cause of pediatric HIV infection in sub-Saharan Africa. A regimen of single-dose nevirapine administered to both HIV-positive pregnant women and their infants has been shown to lower the risk of mother-to-child transmission (MTCT) of HIV. In an effort to facilitate scale-up of PMTCT programs in low-income countries, Boehringer Ingelheim, the manufacturer of Viramune (branded nevirapine), initiated the Viramune Donation Programme (VDP) in 2000. The aim of this study was to evaluate the impact of the VDP on participating institutions.

METHODS

A total of 164 institutions in 60 countries were included in the VDP over its 11-year duration. An online quantitative and qualitative questionnaire was submitted to all program managers. The questionnaire collected data on the impact of the VDP on initiation and scale-up of PMTCT services, operational capacity, national PMTCT policies, access to funding, and national and international partnerships. Participants were asked for their opinion of how VDP was perceived by different stakeholders (medical community, patients, government authorities, communities).

RESULTS

Ninety-nine managers (60.4%) in 34 countries responded to the online questionnaire; 89 of institutions (89.9%) were located in Africa The most positive aspects of the VDP identified were: helped to expand PMTCT services (85.9% of program managers), reduced stigma against HIV-positive pregnant women, increased social support mechanisms (78.8%), fostered partnerships with national and international organizations (69.0%), and encouraged access to donor funding (63.0%). Implementation of the VDP triggered improvements in training hospitals and logistical capacity and was associated with changes in policy strategies at the national level.

CONCLUSION

A drug donation program such as the VDP can act as a catalyst for systemic changes at the institutional and national levels. The VDP provides a model for how private initiatives can have a significant impact on public health issues and foster diverse public-private partnerships among governments, commercial organizations, local institutions, and international NGOs.

Externalities of prevention of mother-to-child transmission programs: a systematic review

There has been considerable debate about the effects of targeted global health assistance in low- and middle-income countries on health systems, specifically HIV/AIDS funding. Recently, a handful of studies have emerged that describe the implementation of PMTCT programs, which have many theoretical links to maternal and child health. Through a systematic review of research published between January 2000 and March 2011, this paper synthesizes evidence evaluating the impact of these programs. We assessed 5,855 papers, reviewed 154, and included 21 articles. They offer evidence of beneficial synergies between PMTCT programs and both STI prevention and early childhood immunization. Other data, including information about antenatal and delivery care, family planning, and nutrition supplementation varied considerably across studies demonstrating both positive and negative effects of PMTCT. More research is needed to allow countries and funders to make informed decisions regarding allocation of limited funds to targeted versus broad categories of health care.

The Linked Response: Lessons Emerging from Integration of HIV and Reproductive Health Services in Cambodia

A qualitative assessment was made of service provider and user perceptions of the quality of integrated reproductive health services established through a pilot intervention in Cambodia. The intervention aimed to promote pregnant women's HIV testing and general utilization of reproductive health facilities as well as improve the follow-up of HIV-positive women and exposed infants through strengthened referral and operational linkages amongst health facilities/services and community-based support interventions for PLHIV. The study was conducted in one operational district where the intervention was piloted and for comparative purposes in a district where integrated services had yet to be implemented. Service providers in the pilot district reported improved collaboration and coordination of services, more effective referral, and the positive impact of improved proximity of HIV testing through integrated local level facilities. Community-based support teams for PLHIV embraced their expanded role, were valued by families receiving their assistance, and were understood to have had an important role in referral, PMTCT follow-up and countering PLHIV stigmatization; findings which underscore the potential role of community support in integrated service provision. Challenges identified included stigmatization of PLHIV by health staff at district hospital level and a lack of confidence amongst non-specialized health staff when managing deliveries by HIV-positive women, partly due to fear of HIV transmission.

Missed opportunities to prevent mother-to-child-transmission: systematic review and meta-analysis

OBJECTIVES

To determine magnitude and reasons of loss to program and poor antiretroviral prophylaxis coverage in prevention of mother-to-child transmission (PMTCT) programs in sub-Saharan Africa.

DESIGN

Systematic review and meta-analysis.

METHODS

We searched PubMed and Embase databases for PMTCT studies in sub-Saharan Africa published between January 2002 and March 2012. Outcomes were the percentage of pregnant women tested for HIV, initiating antiretroviral prophylaxis, having a CD4 cell count measured, and initiating antiretroviral combination therapy (cART) if eligible. In children outcomes were early infant diagnosis for HIV, and cART initiation. We combined data using random-effects meta-analysis and identified predictors of uptake of interventions.

RESULTS

Forty-four studies from 15 countries including 75,172 HIV-infected pregnant women were analyzed. HIV-testing uptake at antenatal care services was 94% [95% confidence intervals (CIs) 92-95%] for opt-out and 58% (95% CI 40-75%) for opt-in testing. Coverage with any antiretroviral prophylaxis was 70% (95% CI 64-76%) and 62% (95% CI 50-73%) of pregnant women eligible for cART received treatment. Sixty-four percent (95% CI 48-81%) of HIV exposed infants had early diagnosis performed and 55% (95% CI 36-74%) were tested between 12 and 18 months. Uptake of PMTCT interventions was improved if cART was provided at the antenatal clinic and if the male partner was involved.

CONCLUSION

In sub-Saharan Africa, uptake of PMTCT interventions and early infant diagnosis is unsatisfactory. An integrated family-centered approach seems to improve retention.

Integrating antiretroviral therapy into antenatal care and maternal and child health settings: a systematic review and meta-analysis

OBJECTIVE

To determine whether integrating antiretroviral therapy (ART) into antenatal care (ANC) and maternal and child health (MCH) clinics could improve programmatic and patient outcomes.

METHODS

The authors systematically searched PubMed, Embase, African Index Medicus and LiLACS for randomized controlled trials, prospective cohort studies, or retrospective cohort studies comparing outcomes in ANC or MCH clinics that had and had not integrated ART. The outcomes of interest were ART coverage, ART enrolment, ART retention, mortality and transmission of human immunodeficiency virus (HIV).

FINDINGS

Four studies met the inclusion criteria. All were conducted in ANC clinics. Increased enrolment of pregnant women in ART was observed in ANC clinics that had integrated ART (relative risk, RR: 2.09; 95% confidence interval, CI; 1.78-2.46; I(2): 15%). Increased ART coverage was also noted in such clinics (RR: 1.37; 95% CI: 1.05-1.79; I(2): 83%). Sensitivity analyses revealed a trend for the national prevalence of HIV infection to explain the heterogeneity in the size of the effect of ART integration on ART coverage (P = 0.13). Retention in ART was similar in ANC clinics with and without ART integration.

CONCLUSION

Although few data were available, ART integration in ANC clinics appears to lead to higher rates of ART enrolment and ART coverage. Rates of retention in ART remain similar to those observed in referral-based models.

Quantifying and addressing losses along the continuum of care for people living with HIV infection in sub-Saharan Africa: a systematic review

Introduction

Recent years have seen an increasing recognition of the need to improve access and retention in care for people living with HIV/AIDS. This review aims to quantify patients along the continuum of care in sub-Saharan Africa and review possible interventions.

Methods

We defined the different steps making up the care pathway and quantified losses at each step between acquisition of HIV infection and retention in care on antiretroviral therapy (ART). We conducted a systematic review of data from studies conducted in sub-Saharan Africa and published between 2000 and June 2011 for four of these steps and performed a meta-analysis when indicated; existing data syntheses were used for the remaining two steps.

Results

The World Health Organization estimates that only 39% of HIV-positive individuals are aware of their status. Among patients who know their HIV-positive status, just 57% (95% CI, 48 to 66%) completed assessment of ART eligibility. Of eight studies using an ART eligibility threshold of≤200 cells/µL, 41% of patients (95% CI, 27% to 55%) were eligible for treatment, while of six studies using an ART eligibility threshold of≤350 cells/µL, 57% of patients (95% CI, 50 to 63%) were eligible. Of those not yet eligible for ART, the median proportion remaining in pre-ART care was 45%. Of eligible individuals, just 66% (95% CI, 58 to 73%) started ART and the proportion remaining on therapy after three years has previously been estimated as 65%. However, recent studies highlight that this is not a simple linear pathway, as patients cycle in and out of care. Published studies of interventions have mainly focused on reducing losses at HIV testing and during ART care, whereas few have addressed linkage and retention during the pre-ART period.

Conclusions

Losses occur throughout the care pathway, especially prior to ART initiation, and for some patients this is a transient event, as they may re-engage in care at a later time. However, data regarding interventions to address this issue are scarce. Research is urgently needed to identify effective solutions so that a far greater proportion of infected individuals can benefit from long-term ART.

The study of HIV and antenatal care integration in pregnancy in Kenya: design, methods, and baseline results of a cluster-randomized controlled trial

Background

Despite strong evidence for the effectiveness of anti-retroviral therapy for improving the health of women living with HIV and for the prevention of mother-to-child transmission (PMTCT), HIV persists as a major maternal and child health problem in sub-Saharan Africa. In most settings antenatal care (ANC) services and HIV treatment services are offered in separate clinics. Integrating these services may result in better uptake of services, reduction of the time to treatment initiation, better adherence, and reduction of stigma.

Methodology/Principal Findings

A prospective cluster randomized controlled trial design was used to evaluate the effects of integrating HIV treatment into ANC clinics at government health facilities in rural Kenya. Twelve facilities were randomized to provide either fully integrated services (ANC, PMTCT, and HIV treatment services all delivered in the ANC clinic) or non-integrated services (ANC clinics provided ANC and basic PMTCT services and referred clients to a separate HIV clinic for HIV treatment). During June 2009– March 2011, 1,172 HIV-positive pregnant women were enrolled in the study. The main study outcomes are rates of maternal enrollment in HIV care and treatment, infant HIV testing uptake, and HIV-free infant survival. Baseline results revealed that the intervention and control cohorts were similar with respect to socio-demographics, male partner HIV testing, sero-discordance of the couple, obstetric history, baseline CD4 count, and WHO Stage. Challenges faced while conducting this trial at low-resource rural health facilities included frequent staff turnover, stock-outs of essential supplies, transportation challenges, and changes in national guidelines.

Conclusions/Significance

This is the first randomized trial of ANC and HIV service integration to be conducted in rural Africa. It is expected that the study will provide critical evidence regarding the implementation and effectiveness of this service delivery strategy, with important implications for programs striving to eliminate vertical transmission of HIV and improve maternal health.

Trial Registration

ClinicalTrials.gov NCT00931216 NCT00931216.

Controlling the HIV/AIDS epidemic: current status and global challenges

This review provides an overview of the current status of the global HIV pandemic and strategies to bring it under control. It updates numerous preventive approaches including behavioral interventions, male circumcision (MC), pre- and post-exposure prophylaxis (PREP and PEP), vaccines, and microbicides. The manuscript summarizes current anti-retroviral treatment options, their impact in the western world, and difficulties faced by emerging and resource-limited nations in providing and maintaining appropriate treatment regimens. Current clinical and pre-clinical approaches toward a cure for HIV are described, including new drug compounds that target viral reservoirs and gene therapy approaches aimed at altering susceptibility to HIV infection. Recent progress in vaccine development is summarized, including novel approaches and new discoveries.

Involving fathers in prevention of mother to child transmission initiatives--what the evidence suggests

Introduction

The current UNAIDS goal towards virtual ending or elimination of infants acquiring HIV by 2015 is perhaps the most achievable goal to date. Yet, models show that delivery of antiretroviral compounds alone will not suffice to achieve this goal, and a broader community-based approach to pregnancy, families and HIV is needed. Such an approach would highlight the important role of men in reproduction. Although early studies have shown it is cost-effective to include males, very few interventions have proceeded to involve men.

Methods

This review utilized systematic review techniques to explore the literature on effective interventions for the inclusion of men in the prevention of HIV to infants. A key word search of literature sources generated 248 studies for hand sorting and interrogation. Of these, 13 were found to contain some information on involvement of males in some form of provision. Data were abstracted from these and form the basis of this review.

Results

Background descriptive studies painted a picture of low male involvement, poor male inclusion and barriers to engagement at all stages. Yet, pregnancy intentions among men affected by HIV are high and the importance of fathers to family functioning – from relationships, through conception, pregnancy and parenting – is well established. Search strategies for interventions for males in HIV and pregnancy were used to generate studies of sufficient quality to inform strategies on the future of male involvement. Of the 317,434 papers on pregnancy and HIV, only 4178 included the term male (paternal or father). When these were restricted to intervention studies, only 248 remained for hand sorting, generating 13 studies of relevance for data extraction. The results show that all these interventions were concentrated around male partner HIV testing. In general, male partner testing was low and was amenable to change by offering voluntary counselling and testing (VCT) information, providing couple-based testing facilities and encouraging male attendance. All interventions used indirect approaches to men via their pregnant spouse. Non-health facility (clinic or hospital)-based provision (such as testing facilities in the community in bars and churches) were more effective than healthcare facilities in attracting male participation.

Conclusions

In conclusion, the review showed that approaches to men are limited to HIV testing with little innovative planning and provision for male treatment and care. As such, initiatives run the risk of alienating rather than including males. Direct approaches and the provision of male-specific facilities and benefits should be explored.

Systematic review of public health research on prevention of mother-to-child transmission of HIV in India with focus on provision and utilization of cascade of PMTCT services

Background

In spite of effective strategies to eliminate mother-to-child-transmission of HIV, the implementation of such strategies remains a major challenge in developing countries. In India, programs for the prevention of mother-to-child transmission (PMTCT) have been scaled up widely since 2005. However, these programs reach only a small percentage of pregnant women, and their overall effectiveness is low. Evidence-based program planning and implementation could significantly improve their effectiveness. This study sought to systematically retrieve, thematically categorize and review published research on PMTCT of HIV in India, focusing on research related to the provision and/or utilization of the cascade of services provided in a PMTCT program, in order to direct further research to enhance program implementation and effectiveness.

Methods

A systematic search using MEDLINE, US National Library of Medicine Gateway system (PubMed) and ISI Web of Knowledge resulted in 1,944 abstracts, of which 167 met our inclusion criteria.

Results

A huge share of the empirical literature on PMTCT in India (N = 134) deals with epidemiological studies (N = 60). The 46 papers related to utilization/provision of the cascade of PMTCT services were mostly from the four high HIV prevalence states in southern India and from the public sector. Studies on experiences of implementing a PMTCT program (N = 20) show high rates of drop out of women in the cascade particularly prior to receiving ARV. Studies on individual components of the cascade (N = 26) show that HIV counseling and testing is acceptable and feasible. Literature on other components of the cascade - such as pregnant women’s access to ANC care, HIV infected women’s immunological assessment using CD4 testing, repeat HIV testing among pregnant women, early infant diagnosis and factors related to linking HIV infected women and children to postnatal care – is lacking.

Conclusions

While the scale of the Indian PMTCT program is large, comprehensive understanding of the context-driven factors affecting its efficiency is lacking. Systematic and more focused public health research output is needed on the issues related to reduction of drop outs of women in the cascade, role of PMTCT programs in improving maternal and child health indicators and role of private sector in delivering PMTCT services.

Integrating prevention of mother-to-child HIV transmission programs to improve uptake: a systematic review

Background

We performed a systematic review to assess the effect of integrated perinatal prevention of mother-to-child transmission of HIV interventions compared to non- or partially integrated services on the uptake in low- and middle-income countries.

Methods

We searched for experimental, quasi-experimental and controlled observational studies in any language from 21 databases and grey literature sources.

Results

Out of 28 654 citations retrieved, five studies met our inclusion criteria. A cluster randomized controlled trial reported higher probability of nevirapine uptake at the labor wards implementing HIV testing and structured nevirapine adherence assessment (RRR 1.37, bootstrapped 95% CI, 1.04–1.77). A stepped wedge design study showed marked improvement in antiretroviral therapy (ART) enrolment (44.4% versus 25.3%, p<0.001) and initiation (32.9% versus 14.4%, p<0.001) in integrated care, but the median gestational age of ART initiation (27.1 versus 27.7 weeks, p = 0.4), ART duration (10.8 versus 10.0 weeks, p = 0.3) or 90 days ART retention (87.8% versus 91.3%, p = 0.3) did not differ significantly. A cohort study reported no significant difference either in the ART coverage (55% versus 48% versus 47%, p = 0.29) or eight weeks of ART duration before the delivery (50% versus 42% versus 52%; p = 0.96) between integrated, proximal and distal partially integrated care. Two before and after studies assessed the impact of integration on HIV testing uptake in antenatal care. The first study reported that significantly more women received information on PMTCT (92% versus 77%, p<0.001), were tested (76% versus 62%, p<0.001) and learned their HIV status (66% versus 55%, p<0.001) after integration. The second study also reported significant increase in HIV testing uptake after integration (98.8% versus 52.6%, p<0.001).

Conclusion

Limited, non-generalizable evidence supports the effectiveness of integrated PMTCT programs. More research measuring coverage and other relevant outcomes is urgently needed to inform the design of services delivering PMTCT programs.

Young Women’s Knowledge and Utilization of Prevention of Mother-to-Child Transmission (PMTCT) of HIV Services: Is There Any Relationship?

PURPOSE:To determine knowledge and practices of young women on utilization of prevention of mother-to-child transmission (PMTCT) of HIVservices.

DESIGN:A cross-section descriptive study that used quantitative and qualitative data analysis methodologies.

FINDINGS:Knowledge of PMTCT of HIV among respondents was universal. All respondents (100%,N= 184) stated that utilization of PMTCT services reduces transmission of HIV from mother to child. Respondents knew that HIV transmission can be reduced with exclusive breastfeeding (93%,n= 172), abrupt weaning at 6 months (44%,n= 81), taking single-dose nevirapine (SD-NVP; 43%,n= 79), and giving NVP to the baby (65%,n= 120). Very few respondents (4%,n= 7) stated that avoiding pregnancy is one way of preventing HIV transmission and that a mother who is HIV positive who has received SD-NVP or antiretroviral (ARV) therapy can still deliver a baby who is HIV positive. Actual practice was very low; only 14% breastfed exclusively and only 3% weaned their babies abruptly. Although all the 184 mothers were given NVP to take at onset of labor, very few respondents (22%) took NVP as recommended. Although it was recommended that all babies take NVP at birth and within 72 hr of birth, only 58% of the babies received NVP as recommended and only 3% of the women avoided pregnancy.

CONCLUSION:There was a big discrepancy between knowledge and practice of PMTCT services. Culture was the major barrier because traditionally, babies are expected to be breastfed and supplements are fed to babies, too. Most mothers did not adhere to the taking of NVP at onset of labor. Therefore, there is a need to mobilize communities on PMTCT of HIV. The HIV education programmes should emphasize behavior-change interventions and should focus on both men and women, their partners, and significant others. There is also need to intensify monitoring and evaluation of health workers’ activities to ensure that knowledge is put into practice.

Conceptual framework for behavioral and social science in HIV vaccine clinical research

HIV vaccine clinical research occurs within a context where biomedical science and social issues are interlinked. Previous HIV vaccine research has considered behavioral and social issues, but often treated them as independent of clinical research processes. Systematic attention to the intersection of behavioral and social issues within a defined clinical research framework is needed to address gaps, such as those related to participation in trials, completion of trials, and the overall research experience. Rigorous attention to these issues at project inception can inform trial design and conduct by matching research approaches to the context in which trials are to be conducted. Conducting behavioral and social sciences research concurrent with vaccine clinical research is important because it can help identify potential barriers to trial implementation, as well as ultimate acceptance and dissemination of trial results. We therefore propose a conceptual framework for behavioral and social science in HIV vaccine clinical research and use examples from the behavioral and social science literature to demonstrate how the model can facilitate identification of significant areas meriting additional exploration. Standardized use of the conceptual framework could improve HIV vaccine clinical research efficiency and relevance.

Universal testing and treatment as an HIV prevention strategy: research questions and methods

Achieving high coverage of antiretroviral treatment (ART) in resource-poor settings will become increasingly difficult unless HIV incidence can be reduced substantially. Universal voluntary counselling and testing followed by immediate initiation of ART for all those diagnosed HIV-positive (universal testing and treatment, UTT) has the potential to reduce HIV incidence dramatically but would be very challenging and costly to deliver in the short term. Early modelling work in this field has been criticised for making unduly optimistic assumptions about the uptake and coverage of interventions. In future work, it is important that model parameters are realistic and based where possible on empirical data. Rigorous research evidence is needed before the UTT approach could be considered for wide-scale implementation. This paper reviews the main areas that need to be explored. We consider in turn research questions related to the provision of services for universal testing, services for immediate treatment of HIV-positives and the population-level impact of UTT, and the research methods that could be used to address these questions. Ideally, initial feasibility studies should be carried out to investigate the acceptability, feasibility and uptake of UTT services. If these studies produce promising results, there would be a strong case for a cluster-randomised trial to measure the impact of a UTT intervention on HIV incidence, and we consider the main design features of such a trial.