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Kumwenda W, Bengtson AM, Wallie S, Chikaonda T, Matoga M, Bula AK, Villiera JB, Kamanga E, Hosseinipour MC, Mwapasa V. Acceptability and feasibility of using a blended quality improvement strategy among health workers to monitor women engagement in Option B+ program in Lilongwe Malawi. BMC Health Serv Res 2024; 24:842. [PMID: 39061055 PMCID: PMC11282652 DOI: 10.1186/s12913-024-11342-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Accepted: 07/22/2024] [Indexed: 07/28/2024] Open
Abstract
Option B + provides lifelong ART to pregnant and breastfeeding women with HIV to reduce mother-to-child transmission of HIV (eMTCT) and improve maternal health. The effectiveness of Option B + relies on continuous engagement, but suboptimal monitoring of HIV care hinders our measurements of engagement. Process mapping and quality improvement (PROMAQI) is a quality improvement strategy for healthcare workers (HCWs) to optimize complex processes such as monitoring HIV care. We assessed the acceptability and feasibility of the PROMAQI among HCWs and identified barriers and facilitators for PROMAQI implementation. A cross-sectional study using a mixed method approach was conducted from August 2021 to March 2022 across five urban health facilities participating in PROMAQI implementation n the Lilongwe district, Malawi. We assessed PROMAQI acceptability and feasibility at the end of the study. A 5-point Likert (1 = worst to 5 = best) scale tool was administered to 110 HCWs (n = 15-33 per facility) involved in PROMAQI implementationThese data were analysed using descriptive statistics Among the 110 HCWs, twenty-two (QI team (n = 11) and QI implementers (n = 11)) were purposively selected for in-depth interviews. Thematic analysis was conducted using deducted and inductive approaches. The theoretical framework for acceptability (TFA) was used to identify reasons for acceptability. The Consolidated Framework for Implementation Research (CFIR) was used to characterize the barriers and facilitators of PROMAQI implementation. HCWs recruited had a median age of 37 (32-43) years, 82.0% of whom were female. Most (42%) had completed secondary education, and 84% were nurses and community health workers. The median (IQR) acceptability and feasibility scores for the PROMAQI were 5 (IQR 4-5) and 4 (IQR 4-5), respectively. Reasons for high PROMAQI acceptability included addressing a relevant gap and improving performance. Perceived implementation barriers included poor work attitudes, time constraints, resource limitations, knowledge gaps, and workbook difficulties. The facilitators included communication, mentorship, training, and financial incentives. PROMAQI is a highly acceptable and feasible tool for monitoring engagement of women in Option B + . Addressing these barriers may optimize the implementation of PROMAQI. Scaling up PROMAQI may enhance retention in the Option B + program and facilitate eMTCT.
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Affiliation(s)
- Wiza Kumwenda
- UNC Project-Malawi, Tidziwe Center, P/Bag A104, 100 Mzimba Road, Lilongwe, Malawi.
- Department of Community and Environmental Health, Kamuzu University of Health Sciences, Blantyre, Malawi.
| | | | - Shaphil Wallie
- UNC Project-Malawi, Tidziwe Center, P/Bag A104, 100 Mzimba Road, Lilongwe, Malawi
| | - Tarsizious Chikaonda
- UNC Project-Malawi, Tidziwe Center, P/Bag A104, 100 Mzimba Road, Lilongwe, Malawi
| | - Mitch Matoga
- UNC Project-Malawi, Tidziwe Center, P/Bag A104, 100 Mzimba Road, Lilongwe, Malawi
| | - Agatha K Bula
- UNC Project-Malawi, Tidziwe Center, P/Bag A104, 100 Mzimba Road, Lilongwe, Malawi
| | - Jimmy Ba Villiera
- UNC Project-Malawi, Tidziwe Center, P/Bag A104, 100 Mzimba Road, Lilongwe, Malawi
| | - Edith Kamanga
- UNC Project-Malawi, Tidziwe Center, P/Bag A104, 100 Mzimba Road, Lilongwe, Malawi
| | - Mina C Hosseinipour
- UNC Project-Malawi, Tidziwe Center, P/Bag A104, 100 Mzimba Road, Lilongwe, Malawi
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Victor Mwapasa
- Department of Community and Environmental Health, Kamuzu University of Health Sciences, Blantyre, Malawi
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Cox CM, Masiano S, Mazenga A, Stark M, Udedi M, Simon KR, Ahmed S, Nyasulu P, Kim MH. Phone-based psychosocial counseling for people living with HIV: Feasibility, acceptability and impact on uptake of psychosocial counseling services in Malawi. Glob Ment Health (Camb) 2023; 11:e3. [PMID: 38283875 PMCID: PMC10808978 DOI: 10.1017/gmh.2023.84] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 10/19/2023] [Accepted: 11/16/2023] [Indexed: 01/30/2024] Open
Abstract
People living with HIV experience psychosocial needs that often are not addressed. We designed an innovative low-resource model of phone-based psychosocial counseling (P-PSC). We describe cohort characteristics, acceptability, feasibility and utilization of P-PSC at health facilities supported by Baylor Foundation Malawi. Staff were virtually oriented at 120 sites concurrently. From facility-based phones, people with new HIV diagnosis, high viral load, treatment interruption or mental health concerns were referred without identifiable personal information to 13 psychosocial counselors via a WhatsApp group. Routine program data were retrospectively analyzed using univariate approaches and regressions with interrupted time series analyses. Clients utilizing P-PSC were 63% female, 25% youth (10-24 y) and 9% children (<10 y). They were referred from all 120 supported health facilities. Main referral reasons included new HIV diagnosis (32%), ART adherence support (32%) and treatment interruption (21%). Counseling was completed for 99% of referrals. Counseling sessions per month per psychosocial counselor increased from 77 before P-PSC to 216 in month 1 (95% CI = 82, 350, p = 0.003). Total encounters increased significantly to 31,642 in year 1 from ~6,000 during the 12 prior months, an over fivefold increase. P-PSC implementation at 120 remote facilities was acceptable and feasible with immediate, increased utilization despite few psychosocial counselors in Malawi.
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Affiliation(s)
- Carrie M. Cox
- Baylor College of Medicine Children’s Foundation Malawi, Lilongwe, Malawi
- Baylor College of Medicine, Texas Children’s Hospital, Houston, USA
| | - Steven Masiano
- Baylor College of Medicine Children’s Foundation Malawi, Lilongwe, Malawi
| | - Alick Mazenga
- Baylor College of Medicine Children’s Foundation Malawi, Lilongwe, Malawi
| | - Madeline Stark
- Baylor College of Medicine Children’s Foundation Malawi, Lilongwe, Malawi
| | - Michael Udedi
- Curative, Medical and Rehabilitation Services – Mental Health, Malawi Ministry of Health, Lilongwe, Malawi
| | - Katherine R. Simon
- Baylor College of Medicine Children’s Foundation Malawi, Lilongwe, Malawi
- Baylor College of Medicine, Texas Children’s Hospital, Houston, USA
| | - Saeed Ahmed
- Baylor College of Medicine Children’s Foundation Malawi, Lilongwe, Malawi
- Baylor College of Medicine, Texas Children’s Hospital, Houston, USA
| | - Phoebe Nyasulu
- Baylor College of Medicine Children’s Foundation Malawi, Lilongwe, Malawi
| | - Maria H. Kim
- Baylor College of Medicine Children’s Foundation Malawi, Lilongwe, Malawi
- Baylor College of Medicine, Texas Children’s Hospital, Houston, USA
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Azanaw MM, Baraki AG, Yenit MK. Incidence and predictors of loss to follow-up among pregnant and lactating women in the Option B+ PMTCT program in Northwestern Ethiopia: a seven-year retrospective cohort study. Front Glob Womens Health 2023; 4:1128988. [PMID: 37529507 PMCID: PMC10389654 DOI: 10.3389/fgwh.2023.1128988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 06/21/2023] [Indexed: 08/03/2023] Open
Abstract
Introduction Although Ethiopia has implemented the Option B+ program over the past 7 years, loss to follow-up among HIV-positive women remains a major problem for antiretroviral therapy (ART) treatment. This study was conducted to investigate the number of women who dropped out of follow-up after the Option B+ program. Methods A retrospective follow-up study was conducted among 403 pregnant and lactating women between June 2013 and December 2019 at health facilities in Northwest Ethiopia. The Cox proportional hazards regression model was used to identify predictors of loss to follow-up. The results were reported as hazard ratios with 95% confidence intervals (CIs) at a significance level of p = 0.05. Results The overall incidence rate of loss to follow-up was 9.4 per 1,000 person-months of observation (95% CI: 7.40-11.90). According to the multivariable Cox regression, rural residency [adjusted hazard ratio (AHR): 2.30; 95% CI: 1.08-4.88], being a Muslim religion follower (AHR: 2.44; 95% CI: 1.23-4.81), having no baseline viral load measurement (AHR: 4.21; 95% CI: 2.23-7.96), being on ART before enrolment (AHR: 0.30; 95% CI: 0.15-0.62), having drug side effects (AHR:1.82; 95% CI: 1.01-3.33), same-day ART initiation (AHR: 3.23; 95% CI: 1.53-6.84), and having suboptimal adherence level (AHR: 3.96; 95% CI: 2.18-7.19) were significant predictors of loss to follow-up. Conclusion The incidence of loss to follow-up is lower as compared to evidence from most African countries but slightly higher than the WHO target. It is better to strengthen and expand viral load measurements for all women and to pay attention to women residing in rural areas with fair or poor adherence levels.
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Affiliation(s)
- Melkalem Mamuye Azanaw
- Department of Public Health, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Adhanom Gebreegziabher Baraki
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia
| | - Melaku Kindie Yenit
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia
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Nahirney M, Grist J, Namasopo S, Brophy J, Hawkes MT. Evolution of prevention of vertical
HIV
transmission in Uganda: 2008–2017. HIV Med 2022; 24:605-615. [PMID: 36451299 DOI: 10.1111/hiv.13449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 11/14/2022] [Indexed: 12/05/2022]
Abstract
OBJECTIVES Uganda adapted its policy for prevention of vertical transmission (VT) of HIV transmission as the World Health Organization released Options A, B and B+. We assessed trends in diagnostic testing, breastfeeding practices, maternal and infant antiretroviral therapy (ART), mortality, VT and HIV-free survival (HFS) among Ugandan infants born to women living with HIV during this period of successive guideline changes. METHODS This is is a retrospective observational study of infants attending early infant diagnosis clinics at two Ugandan hospitals. RESULTS A total of 1885 infants (48% female) were managed from 2009 to 2017. DNA polymerase chain reaction (PCR) for early infant diagnosis was performed on 1719 infants (92%, one or more PCR tests) and 676 infants (36%, two PCR tests). HIV serology was performed on 90 infants (4.8%). Testing increased over the study period but remained suboptimal, due to high loss to follow-up (LTFU). A total of 93% of infants were breastfed, for a median of 9.5 months. The duration of breast milk exposure increased over the study period, consistent with guidelines that increasingly encouraged breastfeeding. Nine cases (0.48%) of suspected breast milk transmission were observed. The use of ART increased significantly over the study period. Mortality (3.5%, 2.7% and 1.1%; p = 0.0076) and VT (17%, 12% and 7.4%; p < 0.0001) decreased over the study period (2008-2010, 2011-2012 and 2013-2017, respectively). LTFU values were 31%, 49% and 59% at 6, 12 and 18 months of age, respectively, with only modest improvements over time. HFS could only be conclusively documented in 532 infants (28%) because of LTFU. CONCLUSIONS From 2009 to 2017, outcomes improved among HIV-exposed infants in Uganda. LTFU remains a barrier to optimal care.
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Affiliation(s)
- Marissa Nahirney
- Department of Pediatrics University of Alberta Edmonton Alberta Canada
| | - Jesse Grist
- Department of Pediatrics University of Alberta Edmonton Alberta Canada
| | | | - Jason Brophy
- Department of Pediatrics, Children's Hospital of Eastern Ontario University of Ottawa Ottawa Ontario Canada
| | - Michael T. Hawkes
- Department of Pediatrics University of Alberta Edmonton Alberta Canada
- Department of Medical Microbiology and Immunology University of Alberta Edmonton Alberta Canada
- Department of Global Health, School of Public Health University of Alberta Edmonton Alberta Canada
- Distinguished Researcher, Stollery Science Lab University of Alberta Edmonton Alberta Canada
- Member, Women and Children's Health Research Institute University of Alberta Edmonton Alberta Canada
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Astawesegn FH, Conroy E, Mannan H, Stulz V. Measuring socioeconomic inequalities in prenatal HIV test service uptake for prevention of mother to child transmission of HIV in East Africa: A decomposition analysis. PLoS One 2022; 17:e0273475. [PMID: 35998196 PMCID: PMC9398021 DOI: 10.1371/journal.pone.0273475] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 08/09/2022] [Indexed: 11/19/2022] Open
Abstract
Background Despite efforts made towards the elimination of mother-to-child HIV transmission, socioeconomic inequality in prenatal HIV test uptake in East Africa is not well understood. Therefore, this study aimed at measuring socioeconomic inequalities in prenatal HIV test uptake and explaining its main determinants in East Africa Method We analysed a total weighted sample of 45,476 women aged 15–49 years who birthed in the two years preceding the survey. The study used the most recent DHS data from ten East African countries (Burundi, Comoros, Ethiopia, Kenya, Malawi, Mozambique, Rwanda, Uganda, Zambia, and Zimbabwe). The socioeconomic inequality in prenatal HIV test uptake was measured by the concentration index and illustrated by the concentration curve. Then, regression based Erreygers decomposition method was applied to quantify the contribution of socioeconomic factors to inequalities of prenatal HIV test uptake in East Africa. Results The concentration index for prenatal HIV test uptake indicates that utilization of this service was concentrated in higher socio-economic groups with it being 15.94% higher among these groups in entire East Africa (p <0.001), 40.33% higher in Ethiopia (p <0.001) which was the highest and only 1.87% higher in Rwanda (p <0.01) which was the lowest. The decomposition analysis revealed that household wealth index (38.99%) followed by maternal education (13.69%), place of residence (11.78%), partner education (8.24%), watching television (7.32%), listening to the radio (7.11%) and reading newsletters (2.90%) made the largest contribution to socioeconomic inequality in prenatal HIV test in East Africa. Conclusion In this study, pro-rich inequality in the utilization of prenatal HIV tests was evident. The decomposition analysis findings suggest that policymakers should focus on improving household wealth, educational attainment, and awareness of mother-to-child transmission of HIV (MTCT) through various media outlets targeting disadvantaged sub-groups.
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Affiliation(s)
- Feleke Hailemichael Astawesegn
- Translational Health Research Institute (THRI), School of Medicine, Western Sydney University, Penrith, NSW, Australia
- School of Public Health, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
- * E-mail:
| | - Elizabeth Conroy
- Translational Health Research Institute (THRI), School of Medicine, Western Sydney University, Penrith, NSW, Australia
| | - Haider Mannan
- Translational Health Research Institute (THRI), School of Medicine, Western Sydney University, Penrith, NSW, Australia
| | - Virginia Stulz
- School of Nursing and Midwifery Centre for Nursing and Midwifery Research, Western Sydney University, Nepean, Hospital 1 level Court Building, Kingswood, NSW, Australia
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Interventions to improve early retention of patients in antiretroviral therapy programmes in sub-Saharan Africa: A systematic review. PLoS One 2022; 17:e0263663. [PMID: 35139118 PMCID: PMC8827476 DOI: 10.1371/journal.pone.0263663] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 01/24/2022] [Indexed: 11/24/2022] Open
Abstract
Background Several interventions to improve long term retention (12 months and above) on treatment have been rigorously evaluated in Sub-Saharan Africa (SSA). However, research on interventions to improve retention of patients in the early stages of treatment (6 months) during this era of Universal Test and Treat has only recently emerged. The aim of this study is to systematically map evidence of interventions used to improve early retention of patients in antiretroviral therapy (ART) programmes in SSA. Methods We searched PubMed, EMBASE and Cochrane electronic databases to identify studies describing interventions aimed at improving early retention in ART treatment. We applied the methodological frameworks by Arksey and O’Malley (2005) and Levac et al. (2010). We also followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Interventions were categorized according to key broad areas in the existing literature. Results A total of 2,241 articles were identified of which 19 met the inclusion criteria and were eligible for this review, with the majority either being randomized control trials 32% (n = 6) or cohort studies 32% (n = 6). The studies reviewed were conducted in 11 SSA countries. The most common interventions described under key broad areas included: Health system interventions such as Universal Test-and-Treat, integration of ART initiation, HIV Testing and Counselling and Antenatal Care services and reduction of ART drug costs; Patient centered approaches such as fast track ART initiation, Differentiated Drug Delivery models and point of care HIV birth testing; Behavioral interventions and support through lay counselors, mentor mothers, nurse counselors and application of quality improvement interventions and financial incentives. Majority of the studies targeted the HIV positive adults and pregnant women. Conclusion With the introduction of Universal Test-and-Treat and same-day initiation of ART, findings suggest that adoption of policies that expand ART uptake with the goal of reducing HIV transmission at the population level, promoting patient centered approaches such as fast track ART initiation, Differentiated Service Delivery models and providing adequate support through Mentor Mothers, lay and nurse counselors may improve early retention in HIV care in SSA. However, these interventions have only been tested in few countries in the region which points to how hard evidence based HIV programming is. Further research investigating the impact of individual and a combination of interventions to improve early retention in HIV care, including for various groups at high risk of attrition, is warranted across SSA countries to fast track the achievement of 95-95-95 Joint United Nations Programme on HIV/AIDS (UNAIDS) targets by 2030.
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Toska E, Zhou S, Laurenzi CA, Haghighat R, Saal W, Gulaid L, Cluver L. Predictors of secondary HIV transmission risk in a cohort of adolescents living with HIV in South Africa. AIDS 2022; 36:267-276. [PMID: 34342294 PMCID: PMC8702447 DOI: 10.1097/qad.0000000000003044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 06/18/2021] [Accepted: 07/22/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Preventing secondary HIV transmission from adolescents and young people living with HIV (AYPLHIV) to their partners and children is critical to interrupting the HIV infection cycle in sub-Saharan Africa. We investigated predictors of secondary HIV transmission risk (past-year sexual risk combined with past-year viremia) among AYPLHIV in South Africa. DESIGN A prospective cohort of AYLPHIV in South Africa recruited n = 1046 participants in 2014-2015, 93.6% of whom were followed up in 2016-2017 (1.5% mortality). Questionnaires used validated scales where available and biomarkers were extracted from n = 67 health facilities. METHODS Multivariate logistic regressions tested baseline factors associated with secondary HIV transmission risk, controlling for covariates, with marginal effect modelling combinations. RESULTS About 14.2% of AYPLHIV reported high secondary HIV transmission risk. High-risk AYPLHIV were more likely to be sexually infected [adjusted odds ratio (aOR) 2.79, 95% confidence interval (95% CI) 1.66-4.68, P < 0.001], and report hunger (aOR 1.93, 95% CI 1.18-3.14, P = 0.008) and substance use (aOR 2.19, 95% CI 1.19-4.02, P = 0.012). They were more likely to be in power-inequitable relationships (aOR 1.77, 95% CI 1.08-2.92, P = 0.025) and be parents (aOR 4.30, 95% CI 2.16-8.57, P < 0.001). Adolescents reporting none of these factors had a 4% probability of secondary transmission risk, rising to 89% probability with all five identified factors. Older age and early sexual debut were also strongly associated with a higher risk of secondary HIV transmission. CONCLUSION It is essential to identify and support AYPLHIV at a high risk of secondary transmission. Screening for factors such as mode of infection and parenthood during routine healthcare visits could help identify and provide resources to the most at-risk adolescents.
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Affiliation(s)
- Elona Toska
- Centre for Social Science Research
- Department of Sociology, University of Cape Town, Cape Town, South Africa
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK
| | | | - Christina A. Laurenzi
- Institute for Life Course Health Research, Department of Global Health, Stellenbosch University
| | - Roxanna Haghighat
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK
| | | | | | - Lucie Cluver
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
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Herce ME, Chagomerana MB, Zalla LC, Carbone NB, Chi BH, Eliya MT, Phiri S, Topp SM, Kim MH, Wroe EB, Chilangwa C, Chinkonde J, Mofolo IA, Hosseinipour MC, Edwards JK. Community-facility linkage models and maternal and infant health outcomes in Malawi's PMTCT/ART program: A cohort study. PLoS Med 2021; 18:e1003780. [PMID: 34534213 PMCID: PMC8516224 DOI: 10.1371/journal.pmed.1003780] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 10/14/2021] [Accepted: 08/23/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND In sub-Saharan Africa, 3 community-facility linkage (CFL) models-Expert Clients, Community Health Workers (CHWs), and Mentor Mothers-have been widely implemented to support pregnant and breastfeeding women (PBFW) living with HIV and their infants to access and sustain care for prevention of mother-to-child transmission of HIV (PMTCT), yet their comparative impact under real-world conditions is poorly understood. METHODS AND FINDINGS We sought to estimate the effects of CFL models on a primary outcome of maternal loss to follow-up (LTFU), and secondary outcomes of maternal longitudinal viral suppression and infant "poor outcome" (encompassing documented HIV-positive test result, LTFU, or death), in Malawi's PMTCT/ART program. We sampled 30 of 42 high-volume health facilities ("sites") in 5 Malawi districts for study inclusion. At each site, we reviewed medical records for all newly HIV-diagnosed PBFW entering the PMTCT program between July 1, 2016 and June 30, 2017, and, for pregnancies resulting in live births, their HIV-exposed infants, yielding 2,589 potentially eligible mother-infant pairs. Of these, 2,049 (79.1%) had an available HIV treatment record and formed the study cohort. A randomly selected subset of 817 (40.0%) cohort members underwent a field survey, consisting of a questionnaire and HIV biomarker assessment. Survey responses and biomarker results were used to impute CFL model exposure, maternal viral load, and early infant diagnosis (EID) outcomes for those missing these measures to enrich data in the larger cohort. We applied sampling weights in all statistical analyses to account for the differing proportions of facilities sampled by district. Of the 2,049 mother-infant pairs analyzed, 62.2% enrolled in PMTCT at a primary health center, at which time 43.7% of PBFW were ≤24 years old, and 778 (38.0%) received the Expert Client model, 640 (31.2%) the CHW model, 345 (16.8%) the Mentor Mother model, 192 (9.4%) ≥2 models, and 94 (4.6%) no model. Maternal LTFU varied by model, with LTFU being more likely among Mentor Mother model recipients (adjusted hazard ratio [aHR]: 1.45; 95% confidence interval [CI]: 1.14, 1.84; p = 0.003) than Expert Client recipients. Over 2 years from HIV diagnosis, PBFW supported by CHWs spent 14.3% (95% CI: 2.6%, 26.1%; p = 0.02) more days in an optimal state of antiretroviral therapy (ART) retention with viral suppression than women supported by Expert Clients. Infants receiving the Mentor Mother model (aHR: 1.24, 95% CI: 1.01, 1.52; p = 0.04) and ≥2 models (aHR: 1.44, 95% CI: 1.20, 1.74; p < 0.001) were more likely to undergo EID testing by age 6 months than infants supported by Expert Clients. Infants receiving the CHW and Mentor Mother models were 1.15 (95% CI: 0.80, 1.67; p = 0.44) and 0.84 (95% CI: 0.50, 1.42; p = 0.51) times as likely, respectively, to experience a poor outcome by 1 year than those supported by Expert Clients, but not significantly so. Study limitations include possible residual confounding, which may lead to inaccurate conclusions about the impacts of CFL models, uncertain generalizability of findings to other settings, and missing infant medical record data that limited the precision of infant outcome measurement. CONCLUSIONS In this descriptive study, we observed widespread reach of CFL models in Malawi, with favorable maternal outcomes in the CHW model and greater infant EID testing uptake in the Mentor Mother model. Our findings point to important differences in maternal and infant HIV outcomes by CFL model along the PMTCT continuum and suggest future opportunities to identify key features of CFL models driving these outcome differences.
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Affiliation(s)
- Michael E. Herce
- University of North Carolina Project/Malawi, Lilongwe, Malawi
- Institute for Global Health & Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, United States of America
- * E-mail:
| | - Maganizo B. Chagomerana
- University of North Carolina Project/Malawi, Lilongwe, Malawi
- Institute for Global Health & Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, United States of America
| | - Lauren C. Zalla
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | | | - Benjamin H. Chi
- Division of Global Women’s Health, Department of Obstetrics & Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Michael T. Eliya
- Department of HIV and AIDS, Ministry of Health, Government of the Republic of Malawi, Lilongwe, Malawi
| | - Sam Phiri
- Institute for Global Health & Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, United States of America
- Lighthouse Trust, Lilongwe, Malawi
| | - Stephanie M. Topp
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Queensland, Australia
| | - Maria H. Kim
- Baylor International Pediatrics AIDS Initiative, Texas Children’s Hospital, Houston, Texas, United States of America
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, United States of America
| | - Emily B. Wroe
- Division of Global Health Equity, Department of Medicine, Brigham & Women’s Hospital, Boston, Massachusetts, United States of America
- Abwenzi Pa Za Umoyo/Partners In Health—Malawi, Neno, Malawi
| | | | | | | | - Mina C. Hosseinipour
- University of North Carolina Project/Malawi, Lilongwe, Malawi
- Institute for Global Health & Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, United States of America
| | - Jessie K. Edwards
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
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Lorenzetti L, Swann M, Martinez A, O’Regan A, Taylor J, Hoyt A. Using financial diaries to understand the economic lives of HIV-positive pregnant women and new mothers in PMTCT in Zomba, Malawi. PLoS One 2021; 16:e0252083. [PMID: 34329327 PMCID: PMC8323884 DOI: 10.1371/journal.pone.0252083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 04/13/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Economic strengthening (ES) interventions can address economic barriers to retention and adherence (R&A) to antiretroviral therapy in prevention of mother-to-child transmission (PMTCT) services. To inform tailoring of ES activities for PMTCT, we used financial diaries to understand the economic lives of women in PMTCT and examine associations between participants' finances and their R&A. METHODS We collected financial data from a stratified sample (n = 241) of HIV-positive pregnant women and new mothers enrolled in PMTCT from three clinics in Zomba, Malawi. For 30 weeks, participants met with staff to record cash and in-kind inflows and outflows. We used clinical records to calculate a measure of R&A for each participant. We summarized diary data using R and used cox proportional hazard models to examine the relationship between R&A and participant characteristics and behavior. RESULTS There were 68,097 cash transactions over 30 weeks, with 10% characterized as inflows. The median value of cash inflows was US$3.54 compared with US$0.42 for cash outflows. Fewer than 7% of total transactions were considered related to PMTCT, with the majority classified as food or drink. Participants in the rural site had the lowest hazard of non-adherence. Decreased hazard of non-adherence was also linked to having dependents and years on ART. There were significant differences in cash inflows and outflows between those who were always adherent and those who were not. CONCLUSIONS Financial inflows were large and erratic, whereas outflows were small but consistent. PMTCT expenses comprised a small proportion of overall expenses and focused on proper nutrition. The influence of inflows and outflows on adherence was significant but small; however, always adherent participants demonstrated smoother inflows and outflows, indicating an association between greater adherence and economic stability. Participants would benefit from interventions that bolster and stabilize their economic lives, including income generating activities in the agricultural industry and inclusion in village banks.
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Affiliation(s)
- Lara Lorenzetti
- Global Health and Population Research, Durham, North Carolina, United States of America
| | - Mandy Swann
- Global Education, Employment, and Engagement, Washington, District of Columbia, United States of America
| | - Andres Martinez
- Global Health and Population Research, Durham, North Carolina, United States of America
| | - Amy O’Regan
- Global Health and Population Research, Durham, North Carolina, United States of America
| | - Jamilah Taylor
- Global Health and Population Research, Durham, North Carolina, United States of America
| | - Alexis Hoyt
- Global Health and Population Research, Durham, North Carolina, United States of America
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10
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Outcomes of retained and disengaged pregnant women living with HIV in Uganda. PLoS One 2021; 16:e0251413. [PMID: 34019568 PMCID: PMC8139492 DOI: 10.1371/journal.pone.0251413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 04/26/2021] [Indexed: 02/03/2023] Open
Abstract
Introduction Loss-to-follow-up among women living with HIV (WLWHIV) may lead to unfavorable outcomes for both mother and exposed infant. This study traced WLWHIV disengaged from care and their infants and compared their outcomes with those retained in care. Methods The study included WLWHIV who initiated ART during pregnancy at six public clinics in Uganda. A woman was defined as disengaged (DW) if she had not attended her 6-week post-partum visit by 10 weeks after her estimated date of delivery. DW were matched with retained women (RW) by age and duration on ART. Nurse counselors traced all selected DW via telephone and community visits to assess vital status, infant HIV sero-status and maternal HIV viral load through blood draws. Results Between July 2017 and July 2018, 734 women (359 DW and 375 RW) were identified for the study. Tracing was attempted on 349 DW and 160 (44.6%) were successfully located and enrolled in the study. They were matched with 162 RW. Among DW, 52 (32.5%) transferred to another health facility. Very few DW, 39.0% were HIV virally suppressed (<1000 copies/ml) compared to RW 89.5%, P<0.001). Among 138 babies born to DW, 4.3% tested positive for HIV compared to 1.4% among babies born to RW (P = 0.163). Conclusion Pregnant and breastfeeding WLWHIV who disengage from care are difficult to find in urban environments. Many have detectable viral loads, leading to the potential for an increased risk of MTCT. Efforts to reduce disengagement from care are critical for the successful elimination of MTCT in resource-limited settings.
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11
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Williams SM, Renjua J, Moshabela M, Wringe A. Understanding the influence of health systems on women's experiences of Option B+: A meta-ethnography of qualitative research from sub-Saharan Africa. Glob Public Health 2021; 16:167-185. [PMID: 33284727 PMCID: PMC7612946 DOI: 10.1080/17441692.2020.1851385] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 11/05/2020] [Indexed: 11/21/2022]
Abstract
We explored women's experiences of Option B+ in sub-Saharan African health facility settings through a meta-ethnography of 32 qualitative studies published between 2010 and 2019. First and second-order constructs were identified from the data and authors' interpretations respectively. Using a health systems lens, third-order constructs explored how the health systems shaped women's experiences of Option B+ and their subsequent engagement in care. Women's experiences of Option B+ services were influenced by their interactions with health workers, which were often reported to be inadequate and rushed, reflecting insufficient staffing or training to address pregnant women's needs. Women's experiences were also undermined by various manifestations of stigma which persisted in the absence of resources for social or mental health support, and were exacerbated by space constraints in health facilities that infringed on patient confidentiality. Sub-optimal service accessibility, drug stock-outs and inadequate tracing systems also shaped women's experiences of care. Strengthening health systems by improving health worker capacity to provide respectful and high-quality clinical and support services, improving supply chains and improving the privacy of consultation spaces would improve women's experiences of Option B+ services, thereby contributing to improved care retention. These lessons should be considered as universal test and treat programmes expand.
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Affiliation(s)
- Shannon M. Williams
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Jenny Renjua
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
- Department of Epidemiology and Biostatistics, Kilimanjaro Christian Medical College, Moshi, Tanzania
| | - Mosa Moshabela
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- Africa Health Research Institute, Durban, South Africa
| | - Alison Wringe
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
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12
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Oshosen M, Knettel BA, Knippler E, Relf M, Mmbaga BT, Watt MH. "She Just Told Me Not To Cry": A Qualitative Study of Experiences of HIV Testing and Counseling (HTC) Among Pregnant Women Living with HIV in Tanzania. AIDS Behav 2021; 25:104-112. [PMID: 32572712 PMCID: PMC7752832 DOI: 10.1007/s10461-020-02946-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
HIV testing and counseling (HTC) in antenatal care is extremely effective at identifying women living with HIV and linking them to HIV care. However, retention is suboptimal in this population. We completed qualitative interviews with 24 pregnant women living with HIV in Tanzania to explore perceptions of HTC. Participants described intense shock and distress upon testing positive, including concerns about HIV stigma and disclosure; however, these concerns were rarely discussed in HTC. Nurses were generally kind, but relied on educational content and brief reassurances, leaving some participants feeling unsupported and unprepared to start HIV treatment. Several participants described gaps in HIV knowledge, including the purpose of antiretroviral therapy and the importance of medication adherence. Targeted nurse training related to HIV disclosure, stigma, and counseling skills may help nurses to more effectively communicate the importance of care engagement to prevent HIV transmission and support the long-term health of mother and child.
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Affiliation(s)
- Martha Oshosen
- Kilimanjaro Clinical Research Institute, P.O. Box 2236, Moshi, Tanzania
- The University of Cape Town, Rondebosch 7701, Cape Town, South Africa
| | - Brandon A Knettel
- Duke Global Health Institute, Duke University, 310 Trent Drive, Durham, NC, 27710, USA.
- Duke University School of Nursing, 307 Trent Drive, Durham, NC, 27710, USA.
| | - Elizabeth Knippler
- Duke Global Health Institute, Duke University, 310 Trent Drive, Durham, NC, 27710, USA
- The University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, 27599, USA
| | - Michael Relf
- Duke Global Health Institute, Duke University, 310 Trent Drive, Durham, NC, 27710, USA
- Duke University School of Nursing, 307 Trent Drive, Durham, NC, 27710, USA
| | - Blandina T Mmbaga
- Kilimanjaro Clinical Research Institute, P.O. Box 2236, Moshi, Tanzania
- Duke Global Health Institute, Duke University, 310 Trent Drive, Durham, NC, 27710, USA
- Kilimanjaro Christian Medical Centre, P.O. Box 3010, Moshi, Tanzania
| | - Melissa H Watt
- Duke Global Health Institute, Duke University, 310 Trent Drive, Durham, NC, 27710, USA
- Department of Population Health Sciences, The University of Utah School of Medicine, Salt Lake City, USA
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13
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Hassan F, Renju J, Songo J, Chimukuche RS, Kalua T, McLean E, Luwanda L, Geubbels E, Seeley J, Moshabela M, Kajoka D, Wringe A. Implementation and experiences of integrated prevention of mother-to-child transmission services in Tanzania, Malawi and South Africa: A mixed methods study. Glob Public Health 2020; 16:201-215. [PMID: 33119433 PMCID: PMC7612851 DOI: 10.1080/17441692.2020.1839927] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Although integration of HIV and maternal health services is recommended by the World Health Organization, evidence to guide implementation is limited. We describe facility-level implementation of policies for integrating HIV care within maternal health services and explore experiences of service users and providers in rural Tanzania (Ifakara), South Africa (uMkhanyakude) and Malawi (Karonga). Policy in all countries included HIV testing during antenatal care (ANC), same-day antiretroviral therapy (ART) initiation for HIV-positive pregnant women, and postpartum referral to ART clinics, between six weeks (Malawi, South Africa) and two years after delivery (Tanzania). All facilities offered HIV testing within ANC, most commonly during the first visit. Although most women were comfortable with HIV testing, some felt that opting out would lead to sub-standard services. Some facilities conducted group post-test counselling for HIV-negative women, raising concerns of unintended HIV status disclosure. ART initiation was offered on the same day, the same room as an HIV diagnosis in >90% of facilities. Women’s worries around postpartum referral included having unknown providers, insufficient privacy and queues. Adoption and implementation of policies on integrated HIV and maternal health services varied across settings. Patients’ experiences of these policies may influence uptake and retention in care.
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Affiliation(s)
- Farida Hassan
- Health System, Impact Evaluation and Policy, Ifakara Health Institute, United Republic of Tanzania
| | - Jenny Renju
- Department of population studies, London School of Hygiene and Tropical Medicine, London, UK.,Department of Epidemiology and Biostatistics, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - John Songo
- Malawi Epidemiology and Intervention Research Unit, Karonga, Malawi
| | | | | | - Estelle McLean
- Department of population studies, London School of Hygiene and Tropical Medicine, London, UK.,Malawi Epidemiology and Intervention Research Unit, Karonga, Malawi
| | - Lameck Luwanda
- Health System, Impact Evaluation and Policy, Ifakara Health Institute, United Republic of Tanzania
| | - Eveline Geubbels
- Health System, Impact Evaluation and Policy, Ifakara Health Institute, United Republic of Tanzania
| | - Janet Seeley
- Department of population studies, London School of Hygiene and Tropical Medicine, London, UK.,Africa Health Research Institute, Durban, South Africa
| | - Mosa Moshabela
- Malawi Epidemiology and Intervention Research Unit, Karonga, Malawi.,School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Deborah Kajoka
- Ministry of Health, Community Development, Gender, Elderly and Children, Dodoma, Tanzania
| | - Alison Wringe
- Department of population studies, London School of Hygiene and Tropical Medicine, London, UK
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14
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Kiwuwa-Muyingo S, Abongomera G, Mambule I, Senjovu D, Katabira E, Kityo C, Gibb DM, Ford D, Seeley J. Lessons for test and treat in an antiretroviral programme after decentralisation in Uganda: a retrospective analysis of outcomes in public healthcare facilities within the Lablite project. Int Health 2020; 12:429-443. [PMID: 31730168 DOI: 10.1093/inthealth/ihz090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 07/20/2019] [Accepted: 08/27/2019] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND We describe the decentralisation of antiretroviral therapy (ART) alongside Option B+ roll-out in public healthcare facilities in the Lablite project in Uganda. Lessons learned will inform programmes now implementing universal test and treat (UTT). METHODS Routine data were retrospectively extracted from ART registers between October 2012 and March 2015 for all adults and children initiating ART at two primary care facilities (spokes) and their corresponding district hospitals (hubs) in northern and central Uganda. We describe ART initiation over time and retention and use of Cox models to explore risk factors for attrition due to mortality and loss to follow-up. Results from tracing of patients lost to follow-up were used to correct retention estimates. RESULTS Of 2100 ART initiations, 1125 were in the north, including 944 (84%) at the hub and 181 (16%) at the spokes; children comprised 95 (10%) initiations at the hubs and 14 (8%) at the spokes. Corresponding numbers were 642 (66%) at the hub and 333 (34%) at the spokes in the central region (77 [12%] and 22 [7%], respectively, in children). Children <3 y of age comprised the minority of initiations in children at all sites. Twenty-three percent of adult ART initiations at the north hub were Option B+ compared with 45% at the spokes (25% and 65%, respectively, in the central region). Proportions retained in care in the north hub at 6 and 12 mo were 92% (95% CI 90 to 93) and 89% (895% CI 7 to 91), respectively. Corresponding corrected estimates in the north spokes were 87% (95% CI 78 to 93) and 82% (95% CI 72 to 89), respectively. In the central hub, corrected estimates were 84% (95% CI 80 to 87) and 78% (95% CI 74 to 82), and were 89% (95% CI 77.9 to 95.1) and 83% (95% CI 64.1 to 92.9) at the spokes, respectively. Among adults newly initiating ART, being older was independently associated with a lower risk of attrition (adjusted hazard ratio [aHR] 0.93 per 5 y [95% CI 0.88 to 0.97]). Other independent risk factors included initiating with a tenofovir-based regimen vs zidovudine (aHR 0.60 [95% CI 0.46 to 0.77]), year of ART initiation (2013 aHR 1.55 [95% CI 1.21 to 1.97], ≥2014 aHR 1.41 [95% CI 1.06 to 1.87]) vs 2012, hub vs spoke (aHR 0.35 [95% CI 0.29 to 0.43]) and central vs north (aHR 2.28 [95% CI 1.86 to 2.81]). Independently, patient type was associated with retention. CONCLUSIONS After ART decentralisation, people living with human immunodeficiency virus (HIV) were willing to initiate ART in rural primary care facilities. Retention on ART was variable across facilities and attrition was higher among some groups, including younger adults and women initiating ART during pregnancy/breastfeeding. Interventions to support these groups are required to optimise benefits of expanded access to HIV services under UTT.
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Affiliation(s)
- S Kiwuwa-Muyingo
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine, Uganda Research Unit, PO Box 49, Entebbe, Uganda
- African Population and Health Research Center, P.O. Box 10787-00100, Kitisuru, Nairobi, Kenya
| | - G Abongomera
- Joint Clinical Research Centre, PO Box 10005, Kampala, Uganda
- University of Zurich, Epidemiology, Biostatistics and Prevention Institute, CH 8001, Zurich, Switzerland
| | - I Mambule
- Infectious Diseases Institute, Makerere University, PO Box 22418, Kampala, Uganda
| | - D Senjovu
- Infectious Diseases Institute, Makerere University, PO Box 22418, Kampala, Uganda
| | - E Katabira
- Infectious Diseases Institute, Makerere University, PO Box 22418, Kampala, Uganda
| | - C Kityo
- Joint Clinical Research Centre, PO Box 10005, Kampala, Uganda
| | - D M Gibb
- Medical Research Council, Clinical Trials Unit at University College London, London WC1V 6LH, UK
| | - D Ford
- Medical Research Council, Clinical Trials Unit at University College London, London WC1V 6LH, UK
| | - J Seeley
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine, Uganda Research Unit, PO Box 49, Entebbe, Uganda
- Global Health and Development Department, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
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15
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Topp SM, Carbone NB, Tseka J, Kamtsendero L, Banda G, Herce ME. " Most of what they do, we cannot do!" How lay health workers respond to barriers to uptake and retention in HIV care among pregnant and breastfeeding mothers in Malawi. BMJ Glob Health 2020; 5:e002220. [PMID: 32561513 PMCID: PMC7304641 DOI: 10.1136/bmjgh-2019-002220] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 05/06/2020] [Accepted: 05/09/2020] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND In the era of Option B+ and 'treat all' policies for HIV, challenges to retention in care are well documented. In Malawi, several large community-facility linkage (CFL) models have emerged to address these challenges, training lay health workers (LHW) to support the national prevention of mother-to-child transmission (PMTCT) programme. This qualitative study sought to examine how PMTCT LHW deployed by Malawi's three most prevalent CFL models respond to known barriers to access and retention to antiretroviral therapy (ART) and PMTCT. METHODS We conducted a qualitative study, including 43 semi-structured interviews with PMTCT clients; 30 focus group discussions with Ministry of Health (MOH)-employed lay and professional providers and PMTCT LHWs; a facility CFL survey and 2-4 hours of onsite observation at each of 8 sites and in-depth interviews with 13 programme coordinators and MOH officials. Thematic analysis was used, combining inductive and deductive approaches. RESULTS Across all three models, PMTCT LHWs carried out a number of 'targeted' activities that respond directly to a range of known barriers to ART uptake and retention. These include: (i) fulfilling counselling and educational functions that responded to women's fears and uncertainties; (ii) enhancing women's social connectedness and participation in their own care and (iii) strengthening service function by helping clinic-based providers carry out duties more efficiently and effectively. Beyond absorbing workload or improving efficiency, however, PMTCT LHWs supported uptake and retention through foundational but often intangible work to strengthen CFL, including via efforts to strengthen facility-side responsiveness, and build community members' recognition of and trust in services. CONCLUSION PMTCT LHWs in each of the CFL models examined, addressed social, cultural and health system factors influencing client access to, and engagement with, HIV care and treatment. Findings underscore the importance of person-centred design in the 'treat-all' era and the contribution LHWs can make to this, but foreground the challenges of achieving person-centredness in the context of an under-resourced health system. Further work to understand the governance and sustainability of these project-funded CFL models and LHW cadres is now urgently required.
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Affiliation(s)
- Stephanie M Topp
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia
| | | | | | | | - Godfrey Banda
- University of North Carolina Project, Lilongwe, Malawi
| | - Michael E Herce
- Division of Infectious Diseases, University of North Carolina School of Medicine, Chapel HIll, North Carolina, USA
- Implementation Science Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
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16
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Mnyani CN, Tait CL, Peters RPH, Struthers H, Violari A, Gray G, Buchmann EJ, Chersich MF, McIntyre JA. Implementation of a PMTCT programme in a high HIV prevalence setting in Johannesburg, South Africa: 2002-2015. South Afr J HIV Med 2020; 21:1024. [PMID: 32284888 PMCID: PMC7136691 DOI: 10.4102/sajhivmed.v21i1.1024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 10/20/2019] [Indexed: 11/03/2022] Open
Abstract
Background Great strides have been made in decreasing paediatric human immunodeficiency virus (HIV) infections, especially in sub-Saharan Africa. In South Africa, new paediatric HIV infections decreased by 84% between 2009 and 2015. This achievement is a result of a strong political will and the rapid evolution of the country's prevention of mother-to-child transmission (PMTCT) guidelines. Objectives In this paper we report on the implementation of a large PMTCT programme in Soweto, South Africa. Methods We reviewed routinely collected PMTCT data from 13 healthcare facilities, for the period 2002-2015. Antiretroviral therapy (ART) coverage among pregnant women living with HIV (PWLHIV) and the mother-to-child transmission (MTCT) rate at early infant diagnosis were evaluated. Results In total, 360 751 pregnant women attended the facilities during the review period, and the HIV prevalence remained high throughout at around 30%. The proportion of PWLHIV presenting with a known HIV status increased from 14.3% in 2009 when the indicator was first collected to 45% in 2015, p < 0.001. In 2006, less than 10% of the PWLHIV were initiated on ART, increasing to 88% by 2011. The MTCT rate decreased from 6.9% in 2007 to under 1% from 2013 to 2015, p < 0.001. Conclusion The achievements in decreasing paediatric HIV infections have been hailed as one of the greatest public health achievements of our times. While there are inherent limitations with using routinely collected aggregate data, the Soweto data reflect progress made in the implementation of PMTCT programmes in South Africa. Progress with PMTCT has, however, not been accompanied by a decline in HIV prevalence among pregnant women.
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Affiliation(s)
- Coceka N Mnyani
- Department of Obstetrics and Gynaecology, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa.,South African Centre of Epidemiological Modelling and Analysis (SACEMA), DST-NRF Centre for Excellence, Epidemiological Modelling and Analysis, Stellenbosch University, Stellenbosch, South Africa
| | - Carol L Tait
- Anova Health Institute, Johannesburg, South Africa
| | - Remco P H Peters
- Anova Health Institute, Johannesburg, South Africa.,Department of Medical Microbiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Helen Struthers
- Anova Health Institute, Johannesburg, South Africa.,Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Avy Violari
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Glenda Gray
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Eckhart J Buchmann
- Department of Obstetrics and Gynaecology, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Matthew F Chersich
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - James A McIntyre
- Anova Health Institute, Johannesburg, South Africa.,School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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17
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Kim MH, Tembo TA, Mazenga A, Yu X, Myer L, Sabelli R, Flick R, Hartig M, Wetzel E, Simon K, Ahmed S, Nyirenda R, Kazembe PN, Mphande M, Mkandawire A, Chitani MJ, Markham C, Ciaranello A, Abrams EJ. The Video intervention to Inspire Treatment Adherence for Life (VITAL Start): protocol for a multisite randomized controlled trial of a brief video-based intervention to improve antiretroviral adherence and retention among HIV-infected pregnant women in Malawi. Trials 2020; 21:207. [PMID: 32075677 PMCID: PMC7031891 DOI: 10.1186/s13063-020-4131-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 02/01/2020] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Improving maternal antiretroviral therapy (ART) retention and adherence is a critical challenge facing prevention of mother-to-child transmission (PMTCT) of HIV programs. There is an urgent need for evidence-based, cost-effective, and scalable interventions to improve maternal adherence and retention that can be feasibly implemented in overburdened health systems. Brief video-based interventions are a promising but underutilized approach to this crisis. We describe a trial protocol to evaluate the effectiveness and implementation of a standardized educational video-based intervention targeting HIV-infected pregnant women that seeks to optimize their ART retention and adherence by providing a VITAL Start (Video intervention to Inspire Treatment Adherence for Life) before committing to lifelong ART. METHODS This study is a multisite parallel group, randomized controlled trial assessing the effectiveness of a brief facility-based video intervention to optimize retention and adherence to ART among pregnant women living with HIV in Malawi. A total of 892 pregnant women living with HIV and not yet on ART will be randomized to standard-of-care pre-ART counseling or VITAL Start. The primary outcome is a composite of retention and adherence (viral load < 1000 copies/ml) 12 months after starting ART. Secondary outcomes include assessments of behavioral adherence (self-reported adherence, pharmacy refill, and tenofovir diphosphate concentration), psychosocial impact, and resource utilization. We will also examine the implementation of VITAL Start via surveys and qualitative interviews with patients, partners, and health care workers and conduct cost-effectiveness analyses. DISCUSSION This is a robust evaluation of an innovative facility-based video intervention for pregnant women living with HIV, with the potential to improve maternal and infant outcomes. TRIAL REGISTRATION ClinicalTrials.gov, NCT03654898. Registered on 31 August 2018.
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Affiliation(s)
- Maria H Kim
- Baylor College of Medicine International Pediatric AIDS Initiative, Texas Children's Hospital, Houston, TX, USA. .,Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi.
| | - Tapiwa A Tembo
- Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Alick Mazenga
- Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Xiaoying Yu
- University of Texas Medical Branch at Galveston, Galveston, TX, USA
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Rachael Sabelli
- Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Robert Flick
- Baylor College of Medicine International Pediatric AIDS Initiative, Texas Children's Hospital, Houston, TX, USA.,Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Miriam Hartig
- Baylor College of Medicine International Pediatric AIDS Initiative, Texas Children's Hospital, Houston, TX, USA.,Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Elizabeth Wetzel
- Baylor College of Medicine International Pediatric AIDS Initiative, Texas Children's Hospital, Houston, TX, USA.,Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Katie Simon
- Baylor College of Medicine International Pediatric AIDS Initiative, Texas Children's Hospital, Houston, TX, USA.,Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Saeed Ahmed
- Baylor College of Medicine International Pediatric AIDS Initiative, Texas Children's Hospital, Houston, TX, USA.,Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Rose Nyirenda
- HIV Unit, Malawi Ministry of Health, Lilongwe, Malawi
| | - Peter N Kazembe
- Baylor College of Medicine International Pediatric AIDS Initiative, Texas Children's Hospital, Houston, TX, USA.,Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Mtisunge Mphande
- Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Angella Mkandawire
- Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Mike J Chitani
- Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Christine Markham
- Health Promotion & Behavioral Sciences, The University of Texas School of Public Health, Houston, TX, USA
| | - Andrea Ciaranello
- Division of Infectious Diseases, Department of Medicine; Medical Practice Evaluation Center; both at Massachusetts General Hospital, Boston, MA, USA
| | - Elaine J Abrams
- ICAP at Columbia, Mailman School of Public Health and Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
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de Beer S, Kalk E, Kroon M, Boulle A, Osler M, Euvrard J, Timmerman V, Davies M. A longitudinal analysis of the completeness of maternal HIV testing, including repeat testing in Cape Town, South Africa. J Int AIDS Soc 2020; 23:e25441. [PMID: 31997583 PMCID: PMC6989397 DOI: 10.1002/jia2.25441] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 12/04/2019] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION The virtual elimination of mother-to-child transmission of HIV cannot be achieved without complete maternal HIV testing. The World Health Organization recommends that women in high HIV prevalent settings repeat HIV testing in the third trimester, and at delivery or directly thereafter. The Western Cape Province (South Africa) prevention of mother-to-child transmission (PMTCT) guidelines recommend a repeat maternal HIV test between 32 and 34 weeks gestation and at delivery in addition to testing at the first antenatal visit (ideally <20 weeks gestation). There are few published longitudinal studies on the uptake of initial and repeated maternal HIV testing programmes in sub-Saharan Africa. We aimed to investigate the implementation of initial and repeat maternal HIV testing guidelines in Cape Town, South Africa. METHODS Between 2013 and 2016 we established an electronic PMTCT register that consolidated routine data from a primary healthcare facility and its secondary and tertiary referral sites in Cape Town. This provided a longitudinal record for each participant, from first antenatal visit to delivery. Utilizing these data, we conducted a retrospective analysis investigating the completeness of maternal HIV testing according to the PMTCT HIV testing guidelines in Cape Town, and predictors of complete testing, from 2014 to 2016. RESULTS Among 8558 enrolled pregnant women, 7213 (84%) were not known to be HIV positive at their first visit and thus eligible for HIV testing; 91% of them received ≥1 HIV test during pregnancy/delivery. Testing at the first visit was 98% among the 85% of women who attended antenatal care. Among women eligible to receive all three recommended HIV tests, only 11% achieved all three tests. Delivery HIV testing completion among all women without an HIV-positive diagnosis was 23%. HIV prevalence at delivery was 21% and HIV incidence between first visit and delivery in those with ≥2 HIV tests was 0.2%. Women who enrolled after 2014 were more likely to receive the three recommended tests (aOR: 1.41; 95% CI: 1.10 to 1.81) and retest at delivery (aOR: 1.20; 95% CI: 1.05 to 1.39). CONCLUSIONS Implementation of maternal HIV testing in Cape Town improved between 2014 and 2016 but major gaps remain, particularly at delivery.
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Affiliation(s)
- Shani de Beer
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Emma Kalk
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Max Kroon
- Department of PaediatricsMowbray Maternity HospitalUniversity of Cape TownCape TownSouth Africa
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
- Health Impact Assessment Provincial Government of the Western CapeCape TownSouth Africa
| | - Meg Osler
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Jonathan Euvrard
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Venessa Timmerman
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Mary‐Ann Davies
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
- Health Impact Assessment Provincial Government of the Western CapeCape TownSouth Africa
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Theilgaard ZP, Chiduo MG, Flamholc L, Gerstoft J, Bygbjerg IC, Lemnge MM, Katzenstein TL. Retired Nurses Can Improve Retention in Prevention of Mother-to-Child Transmission Programmes. East Afr Health Res J 2019; 3:88-95. [PMID: 34308201 PMCID: PMC8279289 DOI: 10.24248/eahrj-d-19-00011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 09/06/2019] [Indexed: 12/03/2022] Open
Abstract
Background: The success of prevention of mother-to-child transmission (PMTCT) programmes depends on retention of mothers throughout the PMTCT cascade. Methods: In a clinical trial of short-course combination antiretroviral therapy (cART) for PMTCT in Tanzania, senior nurses were employed to reduce the substantial loss-to-follow up (LTFU) rate. Results: Following intervention, the relative risk (RR) of receiving a CD4 count result and antiretroviral therapy was 1.16 (95% confidence interval [CI], 1.05 to 1.27), the RR of delivery at clinic was 2.51 (95% CI, 2.06 to 3.06), the RR for reporting for follow-up at 6 to 8 weeks postpartum was 4.63 (95% CI, 3.41 to 6.27), and the RR for being retained until 9 months postpartum was 28.19 (95% CI, 11.81 to 67.28). No significant impact on transmission was found. Conclusion: Significantly higher retention was found after senior nurses were employed. No impact on transmission was found. Relatively low transmission was found in both study arms.
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Affiliation(s)
- Zahra Persson Theilgaard
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Mercy G Chiduo
- National Institute for Medical Research, Tanga Centre, Tanga, Tanzania
| | - Leo Flamholc
- Department of Infectious Diseases, University Hospital of Malmö, Malmö, Sweden
| | - Jan Gerstoft
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Ib C Bygbjerg
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | | | - Terese L Katzenstein
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Luoga E, Gamell A. Prevention of Mother-to-Child Transmission of HIV – an Update from Rural Africa. PRAXIS 2019; 108:977-981. [PMID: 31771493 DOI: 10.1024/1661-8157/a003335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Sub-Saharan Africa is home of 85 % of pregnant women living with HIV and 90 % of HIV-infected children. WHO issued the first prevention of mother-to-child transmission of HIV (PMTCT) recommendations in 2000. These guidelines have been revised to incorporate new evidence and align with the goal of universal treatment access and zero infections among children. Currently, 82 % of HIV-infected pregnant women receive antiretroviral treatment, and infections among children have halved since 2010. However, in 2018, 160,000 children became infected. Reasons hindering the success of PMTCT are: a) non-universal HIV testing during pregnancy; b) low retention through the PMTCT cascade; and c) missed opportunities to diagnose women who acquire HIV while pregnant or breastfeeding. To address these gaps innovative strategies are needed.
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Affiliation(s)
- Ezekiel Luoga
- Ifakara Health Institute, United Republic of Tanzania
| | - Anna Gamell
- Malalties Infeccioses i Resposta Inflamatòria Sistèmica en Pediatria, Unitat d'Infeccions, Servei de Pediatria, Institut de Recerca Pediàtrica Hospital Sant Joan de Déu, Barcelona, Spain
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Larson BA, Halim N, Tsikhutsu I, Bii M, Coakley P, Rockers PC. A tool for estimating antiretroviral medication coverage for HIV-infected women during pregnancy (PMTCT-ACT). Glob Health Res Policy 2019; 4:29. [PMID: 31637308 PMCID: PMC6794749 DOI: 10.1186/s41256-019-0121-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 09/23/2019] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND In the typical prevention of mother to child transmission (PMTCT) of HIV cascade of care discussion or analysis, the period of analysis begins at the first visit for antenatal care (ANC) for that pregnancy. This starting point is problematic for two reasons: (1) a large number of HIV-infected women are already on life-long antiretroviral therapy (ART) when presenting for ANC; and (2) women present to ANC at different gestational ages. The PMTCT ART Coverage Tool (PMTCT-ACT), which estimates the proportion of days covered (PDC) with ART, was developed to address each of these problems. METHODS PDC is a preferred method to measure adherence to chronic medications, such as ART. For evaluating the PMTCT cascade of care, as indicated by PDC with ART over various time periods, a "starting point" based on a specific day before delivery must be defined that applies to all women (treatment experienced or naïve at the first ANC visit at any gestational age). Using the example of 168 days prior to delivery (24 weeks), PMTCT-ACT measures PDC with ART during that period. PMTCT-ACT is provided as a STATA do-file. Using an example dataset for two women (ID1 is treatment experienced; ID2 is treatment naïve), the details of each major portion of the tool (Parts 1-5) are presented. PMTCT-ACT along with the intermediate datasets created during the analysis are provided as supplemental files. CONCLUSIONS Evaluating the PMTCT cascade of care requires a standard definition of the follow-up period during pregnancy that applies to all HIV-infected pregnant women and a standard measure of adherence. PMTCT-ACT is a new tool that fits this purpose. PMTCT-ACT can also be easily adjusted to evaluate other ante- and post-natal periods (e.g., final 4 weeks, final 8 weeks, complete pregnancy period, initial 24 weeks postpartum, time periods consistent with infant HIV testing guidelines).
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Affiliation(s)
- Bruce A. Larson
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA 02118 USA
| | - Nafisa Halim
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA 02118 USA
| | - Isaac Tsikhutsu
- Kenya Medical Research Institute, U.S. Army Medical Research Directorate, Africa, Kenya
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD USA
- Henry Jackson Foundation MRI, Kericho, Kenya
| | - Margaret Bii
- Kenya Medical Research Institute, U.S. Army Medical Research Directorate, Africa, Kenya
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD USA
- Henry Jackson Foundation MRI, Kericho, Kenya
| | - Peter Coakley
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD USA
| | - Peter C. Rockers
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA 02118 USA
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Samreth S, Keo V, Tep R, Ke A, Ouk V, Ngauv B, Mam S, Ferradini L, Ly PS, Mean CV, Delvaux T. Access to prevention of mother-to-child transmission of HIV along HIV services cascade through integrated active case management in 15 operational districts in Cambodia. J Int AIDS Soc 2019; 22:e25388. [PMID: 31631583 PMCID: PMC6801228 DOI: 10.1002/jia2.25388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 08/06/2019] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Following the introduction of option B+ in 2013, and with the perspective of eliminating mother-to-child transmission of HIV by 2025, Cambodia has implemented an integrated active case management (IACM) approach since 2014 to improve the notification and follow-up of all HIV-infected cases including pregnant women, and to ensure access to and use of the full prevention of mother-to-child transmission (PMTCT) service package by HIV-infected pregnant women and their HIV-exposed infants. This study aimed to analyse PMTCT cascade data in 15 operational districts (ODs) implementing the IACM approach in Cambodia. METHODS We analysed PMTCT cohort data from 15 ODs implementing IACM approach between 1 January 2014 and 31 December 2016. We measured key indicators along the PMTCT cascade and compared them to available (cross-sectional) PMTCT indicators during the 2011 to 2013 period. RESULTS During the period 2014 to 2016, among 938 identified HIV-infected pregnant women, 308 (32.8%) were tested HIV positive during their pregnancy, 9 (1.0%) during labour, while the remaining 621 (66.2%) were women on antiretroviral therapy (ART) who became pregnant. During the study period, 867 (92.4%) of the 938 women received ART during pregnancy and labour. Subsequently, 456 (85.6%) of the 533 HEI born and alive during the study period received 6-week antiretroviral (ARV) prophylaxis, 390 (76.6%) and 396 (77.8%) of the 509 infants aged six weeks or older received cotrimoxazole prophylaxis and HIV-DNA PCR test respectively. Among the 396 HEI who received HIV-DNA PCR test, 7 (1.8%) were found HIV positive. The comparison with cross-sectional PMTCT indicator obtained during the previous 2011 to 2013 period in the same 15 ODs, showed a significant increase in ARV uptake among HIV-infected pregnant women (from 72.3% to 92.4%), in cotrimoxazole uptake (from 41.6% to 73.2%), and in HIV-DNA PCR testing coverage among HEI (from 41.2% to 74.3%). CONCLUSIONS The implementation of option B+ and IACM may have contributed to the improvement of the PMTCT cascade in Cambodia. However, some gaps in accessing PMTCT services along the HIV cascade persist and need to be addressed.
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Affiliation(s)
| | - Vannak Keo
- National Center for HIV/AIDS, Dermatology and STDPhnom PenhCambodia
| | - Romaing Tep
- National Center for HIV/AIDS, Dermatology and STDPhnom PenhCambodia
| | - Angheng Ke
- National Center for HIV/AIDS, Dermatology and STDPhnom PenhCambodia
| | - Vichea Ouk
- National Center for HIV/AIDS, Dermatology and STDPhnom PenhCambodia
| | - Bora Ngauv
- National Center for HIV/AIDS, Dermatology and STDPhnom PenhCambodia
| | - Sovatha Mam
- University of Health SciencePhnom PenhCambodia
| | | | - Penh S Ly
- National Center for HIV/AIDS, Dermatology and STDPhnom PenhCambodia
| | - Chhi V Mean
- University of Health SciencePhnom PenhCambodia
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Why did I stop? And why did I restart? Perspectives of women lost to follow-up in option B+ HIV care in Dar es Salaam, Tanzania. BMC Public Health 2019; 19:1172. [PMID: 31455306 PMCID: PMC6712622 DOI: 10.1186/s12889-019-7518-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 08/19/2019] [Indexed: 11/13/2022] Open
Abstract
Background Despite an increased uptake of option B+ treatment among HIV- positive pregnant and breastfeeding women, retaining these women in care is still a major challenge. Previous studies have identified factors associated with loss to follow-up (LTFU) in HIV care, however, the perspectives from HIV-positive pregnant and breastfeeding women regarding their LTFU in option B+ needs further exploration. We explored reasons for LTFU and motivation to resume treatment among HIV-positive women initiated in option B+ in an Urban setting. Methods A descriptive qualitative study was conducted at three public care and treatment clinics (CTC) (Buguruni health center, Sinza hospital, and Mbagala Rangitatu health center) in Dar es Salaam, Tanzania between February and May 2017. In-depth interviews were conducted with 30 HIV-positive pregnant and breastfeeding women who were lost to follow up in the option B+ regimen. Analysis of data followed content analysis that was performed using NVivo 10 computer-assisted qualitative data analysis software. Results Eleven women were lost to follow-up and did not resume Option B+, while 19 had resumed treatment. The study indicated a struggle with long term disease amongst HIV-positive pregnant and breastfeeding women initiated in option B+ treatment. The reported reasons contributing to LTFU among these women appeared in three categories. The contribution of LTFU in the first category namely health-related factors included medication side effects and lack of disease symptoms. The second category highlighted the contribution of psychological factors such as loss of hope, fear of medication side effects and HIV-related stigma. The third category underscored the influence of socio-economic statuses such as financial constraints, lack of partner support, family conflicts, non-disclosure of HIV-positive status, and religious beliefs. Motivators to resume treatment after LTFU included support from health care providers and family members, a desire to protect the unborn child from HIV-infection and a need to maintain a healthy status. Conclusion The study has highlighted the reasons for LTFU and motivation to resume treatment among women initiated in Option B+. Our results provide further evidence on the need for future interventions to focus on these factors in order to improve retention in life-long treatment.
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Odayar J, Malaba TR, Allerton J, Lesosky M, Myer L. Delivery of antiretroviral therapy to HIV-infected women during the postpartum period: The Postpartum Adherence Clubs for Antiretroviral Therapy (PACART) trial. Contemp Clin Trials Commun 2019; 16:100442. [PMID: 31709309 PMCID: PMC6833910 DOI: 10.1016/j.conctc.2019.100442] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 07/26/2019] [Accepted: 08/21/2019] [Indexed: 11/19/2022] Open
Abstract
Introduction The World Health Organization recommends initiation of lifelong antiretroviral therapy (ART) in all HIV-infected pregnant women ("Option B+"); however, disengagement from care has been documented postnatally and thereafter. The community-based adherence club (AC) system has been widely implemented in Cape Town, South Africa, and provides HIV care to stable adults on ART, but women who initiated ART in antenatal care services are currently referred to local ART clinics postnatally. Methods The Postpartum Adherence Clubs for Antiretroviral Therapy (PACART) study is a pragmatic randomised controlled trial evaluating ACs to deliver long-term HIV care to women who initiated ART antenatally. Consecutive eligible women seeking care postnatally at a large primary health care facility in Cape Town were randomised to either the local ART clinic (standard of care), or the AC service. The primary objective is to compare maternal HIV viral suppression up to 24 months postpartum. Six study visits are scheduled through 24 months; measurements at each visit include phlebotomy for viral load and questionnaires assessing maternal health, infant health, and ART adherence. Qualitative interviews examining issues of ART adherence and retention, and assessments of costs and cost-effectiveness will also be done. Results Enrolment is complete, with 412 women enrolled. Follow-up visits are ongoing. Discussion There is an urgent need to improve ART delivery for maternal and child health. With a pragmatic trial design, we aim to assess use of the community-based AC system to improve maternal engagement in HIV care in the postpartum period and beyond.
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Affiliation(s)
- Jasantha Odayar
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Corresponding author. Division of Epidemiology and Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Level 5 Falmouth Building, Anzio Road, Cape Town, 7925, South Africa.
| | - Thokozile R. Malaba
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Joanna Allerton
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Maia Lesosky
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Landon Myer
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Centre for Infectious Disease Epidemiology and Research, School of Public Health & Family Medicine, University of Cape Town, South Africa
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Impact of program transfer from a non-governmental organization to a district health office: Evaluation of a program integrating water treatment and hygiene kits into reproductive health and HIV services, Machinga District, Malawi, 2010-2012. PLoS One 2019; 14:e0219984. [PMID: 31365562 PMCID: PMC6668799 DOI: 10.1371/journal.pone.0219984] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Accepted: 07/06/2019] [Indexed: 11/19/2022] Open
Abstract
Background In September 2009, the Machinga Integrated Antenatal Water Hygiene Kit Program began addressing problems of unsafe water, high infant mortality, and low antenatal care (ANC) attendance in Machinga District, Malawi. In March 2011, the supporting international non-governmental organization transitioned management of the program to the Machinga District Health Office (DHO). We evaluated maternal and HIV service use before and after program transition to the DHO. Methods We compared pre- and post-transition periods by examining data recorded in ANC and maternal registries in 15 healthcare facilities (HCFs) by proportion z-tests. We classified HCFs by size, using the median monthly patient volumes as the split for large or small facilities. We used logistic regression to evaluate changes in the use of ANC, maternal, and HIV services and their interactions with HCF size. Results The percentage of women attending their first ANC visit during the first trimester was similar in the pre-and post-transition periods (9.3% vs 10.2%). Although the percentage of women with ≥4 ANC visits was similar from pre- to post-transition (26.0% vs 24.8%), the odds increased among women in small facilities (OR: 1.37, 95% CI: 1.24–1.51), and decreased among women in large facilities (OR: 0.80, 95% CI: 0.75–0.85). Although a similar percentages of pregnant women were diagnosed with HIV in all HCFs in the pre- and post-transitions periods (6.4% vs 4.8%), a substantially larger proportion of women were not tested for HIV in large HCFs (OR: 6.34, 95% CI: 5.88–6.84). A larger proportion of women gave birth at both small (OR: 1.30, 95% CI: 1.16–1.45) and large HCFs (OR: 1.55, 95% CI: 1.43–1.67) in the post-transition vs. the pre-transition period. Conclusions The evaluation results suggest that many positive aspects of this donor-supported program continued following transition of program management from a non-governmental organization to a DHO.
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DiCarlo AL, Gachuhi AB, Mthethwa-Hleta S, Shongwe S, Hlophe T, Peters ZJ, Zerbe A, Myer L, Langwenya N, Okello V, Sahabo R, Nuwagaba-Biribonwoha H, Abrams EJ. Healthcare worker experiences with Option B+ for prevention of mother-to-child HIV transmission in eSwatini: findings from a two-year follow-up study. BMC Health Serv Res 2019; 19:210. [PMID: 30940149 PMCID: PMC6444445 DOI: 10.1186/s12913-019-3997-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 03/07/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Prevention of mother-to-child transmission (PMTCT) across sub-Saharan Africa has rapidly shifted towards Option B+, an approach in which all HIV+ pregnant and breastfeeding women initiate lifelong antiretroviral therapy (ART) independent of CD4+ count. Healthcare workers (HCW) are critical to the success of Option B+, yet little is known regarding HCW acceptability of Option B+, particularly over time. METHODS Ten health facilities in the Manzini and Lubombo regions of eSwatini transitioned from Option A to Option B+ between 2013 and 2014 as part of the Safe Generations study examining PMTCT retention. Fifty HCWs (5 per facility) completed questionnaires assessing feasibility and acceptability: (1) prior to transitioning to Option B+, (2) two months post transition, and (3) approximately 2 years post Option B+ transition. This analysis describes HCW perceptions and experiences two years after transitioning to Option B+. RESULTS Two years after transition, 80% of HCWs surveyed reported that Option B+ was easy for HCWs, noting that it was particularly easy to explain and coordinate. Immediate ART initiation also reduced delays by eliminating need for laboratory tests prior to ART initiation. Additionally, HCWs reported ease of patient follow-up (58%), documentation (56%), and counseling (58%) under Option B+. Findings also indicate that a majority of HCWs reported that their workloads increased under Option B+. Sixty-eight percent of HCWs at two years post-transition reported more work under Option B+, specifically noting increased involvement in adherence counseling, prescribing/monitoring medications, and appointment scheduling/tracking. Some HCWs attributed their higher workloads to increased client loads, now that all HIV-positive women were initiated on ART. New barriers to patient uptake, and issues related to retention, adherence, and follow-up were also noted as challenges face by HCW when implementing Option B+. CONCLUSIONS Overall, HCWs found Option B+ to be acceptable and feasible while providing critical insights into the practical issues of universal ART. Further strengthening of the healthcare system may be necessary to alleviate worker burden and to ensure effective monitoring of client retention and adherence. HCW perceptions and experiences with Option B+ should be considered more broadly as countries implement Option B+ and consider universal treatment for all HIV+ individuals. TRIAL REGISTRATION http://clinicaltrials.gov NCT01891799 , registered on July 3, 2013.
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Affiliation(s)
- Abby L. DiCarlo
- ICAP at Columbia University, Mailman School of Public Health, New York, NY USA
| | | | | | - Siphesihle Shongwe
- ICAP at Columbia University, Mailman School of Public Health, New York, NY USA
| | - Thabo Hlophe
- ICAP at Columbia University, Mailman School of Public Health, New York, NY USA
| | - Zachary J. Peters
- ICAP at Columbia University, Mailman School of Public Health, New York, NY USA
| | - Allison Zerbe
- ICAP at Columbia University, Mailman School of Public Health, New York, NY USA
| | - Landon Myer
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Centre for Infectious Diseases Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Nontokozo Langwenya
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Centre for Infectious Diseases Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Ruben Sahabo
- ICAP at Columbia University, Mailman School of Public Health, New York, NY USA
| | | | - Elaine J. Abrams
- ICAP at Columbia University, Mailman School of Public Health, New York, NY USA
- Vagelos College of Physicians & Surgeons, Columbia University, New York, NY USA
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Alonge O, Rodriguez DC, Brandes N, Geng E, Reveiz L, Peters DH. How is implementation research applied to advance health in low-income and middle-income countries? BMJ Glob Health 2019; 4:e001257. [PMID: 30997169 PMCID: PMC6441291 DOI: 10.1136/bmjgh-2018-001257] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 01/14/2019] [Accepted: 01/19/2019] [Indexed: 12/30/2022] Open
Abstract
This paper examines the characteristics of implementation research (IR) efforts in low-income and middle-income countries (LMICs) by describing how key IR principles and concepts have been used in published health research in LMICs between 1998 and 2016, with focus on how to better apply these principles and concepts to support large-scale impact of health interventions in LMICs. There is a stark discrepancy between principles of IR and what has been published. Most IR studies have been conducted under conditions where the researchers have considerable influence over implementation and with extra resources, rather than in ‘real world’ conditions. IR researchers tend to focus on research questions that test a proof of concept, such as whether a new intervention is feasible or can improve implementation. They also tend to use traditional fixed research designs, yet the usual conditions for managing programmes demand continuous learning and change. More IR in LMICs should be conducted under usual management conditions, employ pragmatic research paradigm and address critical implementation issues such as scale-up and sustainability of evidence-informed interventions. This paper describes some positive examples that address these concerns and identifies how better reporting of IR studies in LMICs would include more complete descriptions of strategies, contexts, concepts, methods and outcomes of IR activities. This will help practitioners, policy-makers and other researchers to better learn how to implement large-scale change in their own settings.
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Affiliation(s)
- Olakunle Alonge
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Daniela Cristina Rodriguez
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Neal Brandes
- Office of Maternal and Child Health and Nutrition, Bureau for Global Health, United States Agency for International Development, Washington, District of Columbia, USA
| | - Elvin Geng
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Ludovic Reveiz
- Knowledge Management, Bioethics, and Research Department, Pan American Health Organization, Washington, District of Columbia, USA
| | - David H Peters
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Jones H, Wringe A, Todd J, Songo J, Gómez-Olivé FX, Moshabela M, Geubbels E, Nyamhagatta M, Kalua T, Urassa M, Zaba B, Renju J. Implementing prevention policies for mother-to-child transmission of HIV in rural Malawi, South Africa and United Republic of Tanzania, 2013-2016. Bull World Health Organ 2019; 97:200-212. [PMID: 30992633 PMCID: PMC6453322 DOI: 10.2471/blt.18.217471] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 11/13/2018] [Accepted: 12/28/2018] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE To assess adoption of World Health Organization (WHO) guidance into national policies for prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV) and to monitor implementation of guidelines at facility level in rural Malawi, South Africa and the United Republic of Tanzania. METHODS We summarized national PMTCT policies and WHO guidance for 15 indicators across the cascades of maternal and infant care over 2013-2016. Two survey rounds were conducted (2013-2015 and 2015-2016) in 46 health facilities serving five health and demographic surveillance system populations. We administered structured questionnaires to facility managers to describe service delivery. We report the proportions of facilities implementing each indicator and the frequency and durations of stock-outs of supplies, by site and survey round. FINDINGS In all countries, national policies influencing the maternal and infant PMTCT cascade of care aligned with WHO guidelines by 2016; most inter-country policy variations concerned linkage to routine HIV care. The proportion of facilities delivering post-test counselling, same-day antiretroviral therapy (ART) initiation, antenatal care and ART provision in the same building, and Option B+ increased or remained at 100% in all sites. Progress in implementing policies on infant diagnosis and treatment varied across sites. Stock-outs of HIV test kits or antiretroviral drugs in the past year declined overall, but were reported by at least one facility per site in both rounds. CONCLUSION Progress has been made in implementing PMTCT policy in these settings. However, persistent gaps across the infant cascade of care and supply-chain challenges, risk undermining infant HIV elimination goals.
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Affiliation(s)
- Harriet Jones
- Department of Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, England
| | - Alison Wringe
- Department of Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, England
| | - Jim Todd
- Department of Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, England
| | - John Songo
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
| | - Francesc Xavier Gómez-Olivé
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, South Africa
| | - Mosa Moshabela
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Eveline Geubbels
- Department of Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, England
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, South Africa
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- Ministry of Health, Community Development, Gender, Elderly and Children, Dodoma, United Republic of Tanzania
- Ministry of Health, Lilongwe, Malawi
- National Institute of Medical Research, Mwanza, Tanzania
| | - Mukome Nyamhagatta
- Ministry of Health, Community Development, Gender, Elderly and Children, Dodoma, United Republic of Tanzania
| | | | - Mark Urassa
- National Institute of Medical Research, Mwanza, Tanzania
| | - Basia Zaba
- Department of Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, England
| | - Jenny Renju
- Department of Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, England
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Retention in HIV Care During Pregnancy and the Postpartum Period in the Option B+ Era: Systematic Review and Meta-Analysis of Studies in Africa. J Acquir Immune Defic Syndr 2019; 77:427-438. [PMID: 29287029 DOI: 10.1097/qai.0000000000001616] [Citation(s) in RCA: 156] [Impact Index Per Article: 31.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Under Option B+ guidelines for prevention of mother-to-child transmission of HIV, pregnant and breastfeeding women initiate antiretroviral therapy for lifelong use. The objectives of this study were: (1) to synthesize data on retention in care over time in option B+ programs in Africa, and (2) to identify factors associated with retention in care. METHODS PubMed, EMBASE, and African Index Medicus were systematically searched from January 2012 to June 2017. Pooled estimates of the proportion of women retained were generated and factors associated with retention were analyzed thematically. RESULTS Thirty-five articles were included in the final review; 22 reported retention rates (n = 60,890) and 25 reported factors associated with retention. Pooled estimates of retention were 72.9% (95% confidence interval: 66.4% to 78.9%) at 6 months for studies reporting <12 months of follow-up and 76.4% (95% confidence interval: 69.0% to 83.1%) at 12 months for studies reporting ≥12 months of follow-up. Data on undocumented clinic transfers were largely absent. Risk factors for poor retention included younger age, initiating antiretroviral therapy on the same day as diagnosis, initiating during pregnancy versus breastfeeding, and initiating late in the pregnancy. Retention was compromised by stigma, fear of disclosure, and lack of social support. CONCLUSIONS Retention rates in prevention of mother-to-child transmission under option B+ were below those of the general adult population, necessitating interventions targeting the complex circumstances of women initiating care under option B+. Improved and standardized procedures to track and report retention are needed to accurately represent care engagement and capture undocumented transfers within the health system.
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Voronin Y, Jani I, Graham BS, Cunningham CK, Mofenson LM, Musoke PM, Permar SR, Scarlatti G. Recent progress in immune-based interventions to prevent HIV-1 transmission to children. J Int AIDS Soc 2018; 20. [PMID: 29282882 PMCID: PMC5810316 DOI: 10.1002/jia2.25038] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 12/04/2017] [Indexed: 11/30/2022] Open
Abstract
Globally, 150,000 new paediatric human immunodeficiency virus type 1 (HIV‐1) infections occurred in 2015. There remain complex challenges to the global elimination of paediatric HIV‐1 infection. Thus, for the global community to achieve elimination of new paediatric HIV‐1 infections, innovative approaches need to be explored. Immune‐based approaches to prevention of mother‐to‐child transmission (MTCT) may help fill some of the remaining gaps and provide new opportunities to achieve an AIDS‐free generation. Immune‐based interventions to prevent MTCT of HIV‐1 may include paediatric HIV vaccines and passive immunization approaches. Recent discoveries providing evidence of robust immune responses to HIV in infants open new and exciting prospects for paediatric HIV vaccines. Moreover, successful vaccination of infants has a different set of requirements than vaccination of adults and may be easier to achieve. Proof‐of‐concept has been established over the last two decades that passively administered HIV‐1 Env‐specific monoclonal antibody (mAbs) can prevent chimeric simian human immunodeficiency virus (SHIV) transmission to newborn nonhuman primates. There has been tremendous progress in isolating and characterizing broadly neutralizing antibodies to HIV, and clinical testing of these antibodies for treatment and prevention in both infants and adults is a major effort in the field. Immune‐based interventions need to be actively explored as they can provide critically important tools to address persistent challenges in MTCT prevention. It is a pivotal time for the field with active discussions on the best strategy to further reduce HIV infection of infants and accomplish the World Health Organization Fast‐Track 2030 goals to eliminate new paediatric HIV infections.
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Affiliation(s)
| | - Ilesh Jani
- Instituto Nacional de Saúde, Maputo, Mozambique
| | - Barney S Graham
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | | | | | - Philippa M Musoke
- Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Sallie R Permar
- Department of Pediatrics and Human Vaccine Institute, Duke University Medical Center, Durham, NC, USA
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Ford N, Penazzato M, Vitoria M, Doherty M, Davies MA, Zaniewski E, Tymejczyk O, Egger M, Nash D. The contribution of observational studies in supporting the WHO 'treat all' recommendation for HIV/AIDS. J Virus Erad 2018; 4:5-8. [PMID: 30515308 PMCID: PMC6248853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
In 2015, the World Health Organization (WHO) recommended that all people living with HIV (PLWH) should start antiretroviral therapy (ART) irrespective of clinical or immune status. This recommendation followed almost 20 years of research into the clinical and population-level benefits and risks of starting ART early compared with deferring treatment. This article summarises the ways in which observational data support the work of WHO, including the support provided by the International epidemiology Databases to Evaluate AIDS (IeDEA), taking the example of 'treat all'.
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Affiliation(s)
- Nathan Ford
- Department of HIV and Global Hepatitis Programme, WHO,
Geneva,
Switzerland
| | - Martina Penazzato
- Department of HIV and Global Hepatitis Programme, WHO,
Geneva,
Switzerland
| | - Marco Vitoria
- Department of HIV and Global Hepatitis Programme, WHO,
Geneva,
Switzerland
| | - Meg Doherty
- Department of HIV and Global Hepatitis Programme, WHO,
Geneva,
Switzerland
| | - Mary-Ann Davies
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine,
University of Cape Town,
South Africa
| | - Elizabeth Zaniewski
- Institute of Social and Preventive Medicine,
University of Bern,
Switzerland
| | | | - Matthias Egger
- Institute of Social and Preventive Medicine,
University of Bern,
Switzerland
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The contribution of observational studies in supporting the WHO ‘treat all’ recommendation for HIV/AIDS. J Virus Erad 2018. [DOI: 10.1016/s2055-6640(20)30346-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
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Harrington BJ, Pence BW, John M, Melhado CG, Phulusa J, Mthiko B, Gaynes BN, Maselko J, Miller WC, Hosseinipour MC. Prevalence and factors associated with antenatal depressive symptoms among women enrolled in Option B+ antenatal HIV care in Malawi: a cross-sectional analysis. J Ment Health 2018; 28:198-205. [PMID: 30270683 DOI: 10.1080/09638237.2018.1487542] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Option B+ has increased the number of pregnant women initiating antiretroviral therapy for HIV, yet retention in HIV care is sub-optimal. Retention may be affected by antenatal depression. However, few data exist on antenatal depression in this population. AIM Describe the prevalence and factors associated with antenatal depression among Malawian women enrolled in Option B+. METHOD At their first antenatal visit, women with HIV provided demographic and psychosocial information, including depression as measured with the locally validated Edinburgh Postnatal Depression Scale (EPDS). Prevalence ratios (PR) for factors associated with probable depression (EPDS ≥6) were estimated with log binomial regression. RESULTS 9.5% (95% CI: 7.5-11.9%) of women screened positive for current depression, and 46% self-reported a history of depression or anxiety. Women were more likely to screen positive for current depression if they reported a history of depression (adjusted PR: 2.42; 95% CI: 1.48-3.95) or had ever experienced intimate partner violence (1.77; 1.11-2.81). Having an unintended current pregnancy (1.78; 0.99-3.21), being unmarried (1.66; 0.97-2.84), or employed (1.56; 1.00-2.44) had potential associations with probable depression. CONCLUSIONS Probable antenatal depression affected a notable proportion of women living with HIV, comparable to other global regions. Screening for antenatal depression in HIV care should be considered.
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Affiliation(s)
- Bryna J Harrington
- a Department of Epidemiology , University of North Carolina at Chapel Hill , Chapel Hill , NC , USA
| | - Brian W Pence
- a Department of Epidemiology , University of North Carolina at Chapel Hill , Chapel Hill , NC , USA
| | - Mathias John
- b Project Malawi, University of North Carolina , Lilongwe , Malawi , and
| | - Caroline G Melhado
- b Project Malawi, University of North Carolina , Lilongwe , Malawi , and
| | - Jacob Phulusa
- b Project Malawi, University of North Carolina , Lilongwe , Malawi , and
| | - Bryan Mthiko
- b Project Malawi, University of North Carolina , Lilongwe , Malawi , and
| | - Bradley N Gaynes
- a Department of Epidemiology , University of North Carolina at Chapel Hill , Chapel Hill , NC , USA
| | - Joanna Maselko
- a Department of Epidemiology , University of North Carolina at Chapel Hill , Chapel Hill , NC , USA
| | - William C Miller
- c College of Public Health , The Ohio State University , Columbus , OH , USA
| | - Mina C Hosseinipour
- a Department of Epidemiology , University of North Carolina at Chapel Hill , Chapel Hill , NC , USA.,b Project Malawi, University of North Carolina , Lilongwe , Malawi , and
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Omonaiye O, Nicholson P, Kusljic S, Manias E. A meta-analysis of effectiveness of interventions to improve adherence in pregnant women receiving antiretroviral therapy in sub-Saharan Africa. Int J Infect Dis 2018; 74:71-82. [PMID: 30003952 DOI: 10.1016/j.ijid.2018.07.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 07/03/2018] [Accepted: 07/03/2018] [Indexed: 10/28/2022] Open
Abstract
OBJECTIVE We evaluated the effectiveness of interventions aimed at improving antiretroviral therapy (ART) adherence during pregnancy in sub-Saharan Africa. METHODS For this meta-analysis, the following databases were searched: MEDLINE Complete, Embase, Global Health, CINAHL Complete, and Google Scholar. Randomized and nonrandomized studies were considered for inclusion if they involved an intervention with the intent of improving medication adherence among pregnant women taking ART in sub-Saharan Africa. Databases were searched from inception to the end of August 2017. The primary outcome assessed was adherence to ART, defined as the proportion of women adherent to treatment in the control and intervention groups. Risk ratios and random effect meta-analysis were undertaken, and heterogeneity was examined with the I2 statistic. RESULTS The systematic search of databases yielded a total of 402 articles, of which 19 studies were selected for meta-analysis with a total of 27,974 participants. Nine types of interventions were identified in the 19 studies to improve ART adherence. The test for the subgroup differences showed that there was a statistically significant difference among the 9 subgroups of interventions, χ2 (8)=102.38; p=0.00001. Collectively, in the meta-analysis, the various intervention types made a significant impact on improving medication adherence. The overall effect estimate with 95% CI was as follows: 1.25 (95% CI=1.03, 1.52, p=0.03). The following risk ratio results for meta-analysis were obtained for the three interventions that showed significant impact on adherence; namely social support and structural support, 1.58 (95% CI=1.36, 1.84, p<0.00001); education, social support and structural support=2.60 (95% CI=1.95, 3.45, p<0.00001); and device reminder=1.13 (95% CI=1.05, 1.20, p=0.0004). The proportion of women who were adherent to ART as a result of the interventions was 59.3% compared with 22.5% in the control groups. CONCLUSION The use of device reminder, a combination of social support and structural support, and education, social support and structural support has the potential to improve ART adherence during pregnancy. Good quality prospective observational studies and randomized control trials are needed in sub-Saharan Africa to determine the most effective interventions.
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Affiliation(s)
- Olumuyiwa Omonaiye
- Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, Deakin University, Melbourne Burwood, Victoria, Australia.
| | - Pat Nicholson
- Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, Deakin University, Melbourne Burwood, Victoria, Australia
| | - Snezana Kusljic
- Department of Nursing, The University of Melbourne, Melbourne, Australia
| | - Elizabeth Manias
- Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, Deakin University, Melbourne Burwood, Victoria, Australia
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Deschamps MM, Jannat-Khah D, Rouzier V, Bonhomme J, Pierrot J, Lee MH, Abrams E, Pape J, McNairy ML. Fifteen years of HIV and syphilis outcomes among a prevention of mother-to-child transmission program in Haiti: from monotherapy to Option B. Trop Med Int Health 2018; 23:724-737. [PMID: 29779260 DOI: 10.1111/tmi.13075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
OBJECTIVE To evaluate mother and infant outcomes in the largest prevention of mother-to-child-transmission (PMTCT) programme in Haiti in order to identify gaps towards elimination of HIV and syphilis. METHODS Based on retrospective data from HIV+ pregnant women and their infants enrolled in PMTCT care from 1999 to 2014, we assessed maternal enrolment in PMTCT, receipt of antiretrovirals before delivery, maternal retention through delivery as well as infant enrolment in PMTCT, HIV testing and HIV infection. Four PMTCT programme periods were compared: period 1 (1999-2004, mono ARV), period 2 (2005-2009, dual ARV), period 3 (2010-2012, Option B) and period 4 (Oct 2012-2014, Option B+). Kaplan-Meier methods were used to assess retention in PMTCT care. RESULTS Among 4665 pregnancies, median age was 27 years and median CD4+ was 494 cells/μl (IQR 328-691). A total of 75% of women received antiretrovirals before delivery, and 73% were retained in care through delivery. Twenty-two percent of women were lost before delivery, <1% died and 6% had stillbirths or abortions. Ninety-four percent of infants who were born alive enrolled in PMTCT, of whom 92% had complete HIV testing. One hundred and sixty-one infants were HIV+, giving a 5.4% HIV transmission rate (9.8%, 4.6%, 5.8% and 3.6% in periods 1-4). Retention among women through 12 months after PMTCT enrolment did not significantly differ across periods. However, among women who received antiretrovirals at the time of enrolment, retention 12 months later was lower in the Option B+ period (83%) than in periods 2 and 3 (94% and 93%) (P < 0.001). Syphilis infection among women decreased from 16% in period 1 to 8% in period 4, whereas syphilis testing of infants increased from 17% to 91%. CONCLUSION Despite dramatic reductions in MTCT in Haiti, interventions are needed to improve retention to achieve MTCT elimination of HIV and syphilis.
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Affiliation(s)
- Marie Marcelle Deschamps
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port au Prince, Haiti
| | - Deanna Jannat-Khah
- Division of General Internal Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Vanessa Rouzier
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port au Prince, Haiti
| | - Jerry Bonhomme
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port au Prince, Haiti
| | - Julma Pierrot
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port au Prince, Haiti
| | - Myung Hee Lee
- Center for Global Health, Weill Cornell Medicine, New York, NY, USA
| | - Elaine Abrams
- ICAP and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Jean Pape
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port au Prince, Haiti.,Center for Global Health, Weill Cornell Medicine, New York, NY, USA
| | - Margaret L McNairy
- Division of General Internal Medicine, Weill Cornell Medicine, New York, NY, USA.,Center for Global Health, Weill Cornell Medicine, New York, NY, USA
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Chersich MF, Newbatt E, Ng’oma K, de Zoysa I. UNICEF's contribution to the adoption and implementation of option B+ for preventing mother-to-child transmission of HIV: a policy analysis. Global Health 2018; 14:55. [PMID: 29859098 PMCID: PMC5984744 DOI: 10.1186/s12992-018-0369-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 05/06/2018] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Between 2011 and 2013, global and national guidelines for preventing mother-to-child transmission (PMTCT) of HIV shifted to recommend Option B+, the provision of lifelong antiretroviral treatment for all HIV-infected pregnant women. METHODS We aimed to analyse how Option B+ reached the policy agenda, and unpack the processes, actors and politics that explain its adoption, with a focus on examining UNICEF's contribution to these events. Analysis drew on published articles and other documentation, 30 key informants interviews with staff at UNICEF, partner organisations and government officials, and country case studies. Cameroon, India, South Africa and Zimbabwe were each visited for 5-8 days. Interview transcripts were analysed using Dedoose software, reviewed several times and then coded thematically. RESULTS A national policy initiative in Malawi in 2011, in which the country adopted Option B+, rather than existing WHO recommended regimens, irrevocably placed the policy on the global agenda. UNICEF and other organisations recognised the policy's potential impact and strategically crafted arguments to support it, framing these around operational considerations, cost-effectiveness and values. As 'policy entrepreneurs', these organisations vigorously promoted the policy through a variety of channels and means, overcoming concerted opposition. WHO, on the basis of scanty evidence, released a series of documents towards the policy's endorsement, paving the way for its widespread adoption. National-level policy transformation was rapid and definitive, distinct from previous incremental policy processes. Many organisations, including UNICEF, facilitated these changes in country, acting individually, or in concert. CONCLUSIONS The adoption of the Option B+ policy marked a departure from established processes for PMTCT policy formulation which had been led by WHO with the support of technical experts, and in which recommendations were developed following shifts in evidence. Rather, changes were spurred by a country-level initiative, and a set of strategically framed arguments that resonated with funders and country-level actors. This bottom-up approach, supported by normative agencies, was transformative. For UNICEF, alignment between the organisation's country focus and the policy's underpinning values, enabled it to work with partners and accelerate widespread policy change.
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Affiliation(s)
- M. F. Chersich
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - K. Ng’oma
- United Nations Children’s Fund, Pretoria, South Africa
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Retention in HIV Care During Pregnancy and the Postpartum Period in the Option B+ Era: Systematic Review and Meta-Analysis of Studies in Africa. JOURNAL OF ACQUIRED IMMUNE DEFICIENCY SYNDROMES (1999) 2018. [PMID: 29287029 DOI: 10.1097/qai.000000000001616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Under Option B+ guidelines for prevention of mother-to-child transmission of HIV, pregnant and breastfeeding women initiate antiretroviral therapy for lifelong use. The objectives of this study were: (1) to synthesize data on retention in care over time in option B+ programs in Africa, and (2) to identify factors associated with retention in care. METHODS PubMed, EMBASE, and African Index Medicus were systematically searched from January 2012 to June 2017. Pooled estimates of the proportion of women retained were generated and factors associated with retention were analyzed thematically. RESULTS Thirty-five articles were included in the final review; 22 reported retention rates (n = 60,890) and 25 reported factors associated with retention. Pooled estimates of retention were 72.9% (95% confidence interval: 66.4% to 78.9%) at 6 months for studies reporting <12 months of follow-up and 76.4% (95% confidence interval: 69.0% to 83.1%) at 12 months for studies reporting ≥12 months of follow-up. Data on undocumented clinic transfers were largely absent. Risk factors for poor retention included younger age, initiating antiretroviral therapy on the same day as diagnosis, initiating during pregnancy versus breastfeeding, and initiating late in the pregnancy. Retention was compromised by stigma, fear of disclosure, and lack of social support. CONCLUSIONS Retention rates in prevention of mother-to-child transmission under option B+ were below those of the general adult population, necessitating interventions targeting the complex circumstances of women initiating care under option B+. Improved and standardized procedures to track and report retention are needed to accurately represent care engagement and capture undocumented transfers within the health system.
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Cataldo F, Seeley J, Nkhata MJ, Mupambireyi Z, Tumwesige E, Gibb DM. She knows that she will not come back: tracing patients and new thresholds of collective surveillance in PMTCT Option B. BMC Health Serv Res 2018; 18:76. [PMID: 29391055 PMCID: PMC5796350 DOI: 10.1186/s12913-017-2826-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 12/29/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Malawi, Uganda, and Zimbabwe have recently adopted a universal 'test-and-treat' approach to the prevention of mother-to-child transmission of HIV (Option B+). Amongst a largely asymptomatic population of women tested for HIV and immediately started on antiretroviral treatment (ART), a relatively high number are not retained in care; they are labelled 'defaulters' or 'lost-to-follow-up' patients. METHODS We draw on data collected as part of a study looking at ART decentralization (Lablite) to reflect on the spaces created through the instrumentalization of community health workers (CHWs) for the purpose of bringing women who default from Option B+ back into care. Data were collected through semi-structured interviews with CHWs who are designated to trace Option B+ patients in Uganda, Malawi and Zimbabwe. FINDINGS Lost to follow up women give a range of reasons for not coming back to health facilities and often implicitly choose not to be traced by providing a false address at enrolment. New strategies have sought to utilize CHWs' liminal positionality - situated between the experience of living with HIV, having established local social ties, and being a caretaker - in order to track 'defaulters'. CHWs are often deployed without adequate guidance or training to protect confidentiality and respect patients' choice. CONCLUSIONS CHWs provide essential linkages between health services and patients; they embody the role of 'extension workers', a bridge between a novel health policy and 'non-compliant patients'. Option B+ offers a powerful narrative of the construction of a unilateral 'moral economy', which requires the full compliance of patients newly initiated on treatment.
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Affiliation(s)
- Fabian Cataldo
- Dignitas International, Medical and Research Department, P.O.Box 1071, Zomba, Malawi
| | - Janet Seeley
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H9SH UK
- Medical Research Council /Uganda Virus Research Institute, Research Unit on AIDS, P.O.Box 49, Entebbe, Uganda
| | - Misheck J. Nkhata
- Dignitas International, Medical and Research Department, P.O.Box 1071, Zomba, Malawi
| | - Zivai Mupambireyi
- University of Zimbabwe, P.O.Box MP167, Mount Pleasant, Harare, Zimbabwe
| | - Edward Tumwesige
- Medical Research Council /Uganda Virus Research Institute, Research Unit on AIDS, P.O.Box 49, Entebbe, Uganda
| | - Diana M. Gibb
- Medical Research Council Clinical Trials Unit at University College London, 90 High Holborn WC1V 6LJ, London, UK
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Odeny TA, Onono M, Owuor K, Helova A, Wanga I, Bukusi EA, Turan JM, Abuogi LL. Maximizing adherence and retention for women living with HIV and their infants in Kenya (MOTIVATE! study): study protocol for a randomized controlled trial. Trials 2018; 19:77. [PMID: 29378622 PMCID: PMC5789594 DOI: 10.1186/s13063-018-2464-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 01/03/2018] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Successful completion and retention throughout the multi-step cascade of prevention of mother-to-child HIV transmission (PMTCT) remains difficult to achieve. The Mother and Infant Visit Adherence and Treatment Engagement study aims to evaluate the effect of mobile text messaging, community-based mentor mothers (cMMs), or both on increasing antiretroviral therapy (ART) adherence, retention in HIV care, maternal viral load suppression, and mother-to-child HIV transmission for mother-infant pairs receiving lifelong ART. METHODS/DESIGN This study is a cluster randomized, 2 × 2 factorial, controlled trial. The trial will be undertaken in the western Kenyan counties of Migori, Kisumu, and Homa Bay. Study sites will be randomized into one of four groups: six sites will implement both text messaging and cMM, six sites will implement cMM only, six sites will implement text messaging only, and six sites will implement the existing standard of care. The primary analysis will be based on the intention-to-treat principle and will compare maternal ART adherence and maternal retention in care. DISCUSSION This study will determine the impact of long-term (up to 12 months postpartum) text messaging and cMMs on retention in and adherence to ART among pregnant and breastfeeding women living with HIV in Kenya. It will address key gaps in our understanding of what interventions may successfully promote long-term retention in the PMTCT cascade of care. TRIAL REGISTRATION ClinicalTrials.gov, NCT02491177 . Registered on 11 March 2015.
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Affiliation(s)
- Thomas A. Odeny
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
- Department of Medicine, University of Missouri-Kansas City, Kansas City, Missouri USA
| | - Maricianah Onono
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Kevin Owuor
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Anna Helova
- Department of Health Care Policy and Organization, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama USA
| | - Iris Wanga
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Elizabeth A. Bukusi
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Janet M. Turan
- Department of Health Care Policy and Organization, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama USA
| | - Lisa L. Abuogi
- Department of Pediatrics, University of Colorado, Denver, Colorado USA
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Peltzer K, Weiss SM, Soni M, Lee TK, Rodriguez VJ, Cook R, Alcaide ML, Setswe G, Jones DL. A cluster randomized controlled trial of lay health worker support for prevention of mother to child transmission of HIV (PMTCT) in South Africa. AIDS Res Ther 2017; 14:61. [PMID: 29248014 PMCID: PMC5732507 DOI: 10.1186/s12981-017-0187-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 12/11/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND We evaluate the impact of clinic-based PMTCT community support by trained lay health workers in addition to standard clinical care on PMTCT infant outcomes. METHODS In a cluster randomized controlled trial, twelve community health centers (CHCs) in Mpumalanga Province, South Africa, were randomized to have pregnant women living with HIV receive either: a standard care (SC) condition plus time-equivalent attention-control on disease prevention (SC; 6 CHCs; n = 357), or an enhanced intervention (EI) condition of SC PMTCT plus the "Protect Your Family" intervention (EI; 6 CHCs; n = 342). HIV-infected pregnant women in the SC attended four antenatal and two postnatal video sessions and those in the EI, four antenatal and two postnatal PMTCT plus "Protect Your Family" sessions led by trained lay health workers. Maternal PMTCT and HIV knowledge were assessed. Infant HIV status at 6 weeks postnatal was drawn from clinic PCR records; at 12 months, HIV status was assessed by study administered DNA PCR. Maternal adherence was assessed by dried blood spot at 32 weeks, and infant adherence was assessed by maternal report at 6 weeks. The impact of the EI was ascertained on primary outcomes (infant HIV status at 6 weeks and 12 months and ART adherence for mothers and infants), and secondary outcomes (HIV and PMTCT knowledge and HIV transmission related behaviours). A series of logistic regression and latent growth curve models were developed to test the impact of the intervention on study outcomes. RESULTS In all, 699 women living with HIV were recruited during pregnancy (8-24 weeks), and assessments were completed at baseline, at 32 weeks pregnant (61.7%), and at 6 weeks (47.6%), 6 months (50.6%) and 12 months (59.5%) postnatally. Infants were tested for HIV at 6 weeks and 12 months, 73.5% living infants were tested at 6 weeks and 56.7% at 12 months. There were no significant differences between SC and EI on infant HIV status at 6 weeks and at 12 months, and no differences in maternal adherence at 32 weeks, reported infant adherence at 6 weeks, or PMTCT and HIV knowledge by study condition over time. CONCLUSION The enhanced intervention administered by trained lay health workers did not have any salutary impact on HIV infant status, ART adherence, HIV and PMTCT knowledge. Trial registration clinicaltrials.gov: number NCT02085356.
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Vrazo AC, Firth J, Amzel A, Sedillo R, Ryan J, Phelps BR. Interventions to significantly improve service uptake and retention of HIV-positive pregnant women and HIV-exposed infants along the prevention of mother-to-child transmission continuum of care: systematic review. Trop Med Int Health 2017; 23:136-148. [PMID: 29164754 DOI: 10.1111/tmi.13014] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Despite the success of Prevention of Mother-to-Child Transmission of HIV (PMTCT) programmes, low uptake of services and poor retention pose a formidable challenge to achieving the elimination of vertical HIV transmission in low- and middle-income countries. This systematic review summarises interventions that demonstrate statistically significant improvements in service uptake and retention of HIV-positive pregnant and breastfeeding women and their infants along the PMTCT cascade. METHODS Databases were systematically searched for peer-reviewed studies. Outcomes of interest included uptake of services, such as antiretroviral therapy (ART) such as initiation, early infant diagnostic testing, and retention of HIV-positive pregnant and breastfeeding women and their infants. Interventions that led to statistically significant outcomes were included and mapped to the PMTCT cascade. An eight-item assessment tool assessed study rigour. PROSPERO ID CRD42017063816. RESULTS Of 686 citations reviewed, 11 articles met inclusion criteria. Ten studies detailed maternal outcomes and seven studies detailed infant outcomes in PMTCT programmes. Interventions to increase access to antenatal care (ANC) and ART services (n = 4) and those using lay cadres (n = 3) were most common. Other interventions included quality improvement (n = 2), mHealth (n = 1), and counselling (n = 1). One study described interventions in an Option B+ programme. Limitations included lack of HIV testing and counselling and viral load monitoring outcomes, small sample size, geographical location, and non-randomized assignment and selection of participants. CONCLUSIONS Interventions including ANC/ART integration, family-centred approaches, and the use of lay healthcare providers are demonstrably effective in increasing service uptake and retention of HIV-positive mothers and their infants in PMTCT programmes. Future studies should include control groups and assess whether interventions developed in the context of earlier 'Options' are effective in improving outcomes in Option B+ programmes.
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Affiliation(s)
- Alexandra C Vrazo
- Office of HIV/AIDS, United States Agency for International Development, Washington, DC, USA
| | - Jacqueline Firth
- Office of HIV/AIDS, United States Agency for International Development, Washington, DC, USA
| | - Anouk Amzel
- Office of HIV/AIDS, United States Agency for International Development, Washington, DC, USA
| | - Rebecca Sedillo
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Julia Ryan
- Office of HIV/AIDS, United States Agency for International Development, Washington, DC, USA
| | - B Ryan Phelps
- Office of HIV/AIDS, United States Agency for International Development, Washington, DC, USA
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Katoba J, Hangulu L, Mashamba-Thompson TP. Evidence of accessibility and utility of point-of-care diagnostics as an integral part of prevention of mother-to-child transmission services: systematic scoping review protocol. BMJ Open 2017; 7:e017884. [PMID: 29102993 PMCID: PMC5695340 DOI: 10.1136/bmjopen-2017-017884] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 08/17/2017] [Accepted: 09/08/2017] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Point-of-care (POC) testing has been shown to help improve healthcare access in resource-limited settings. However, there is paucity of evidence on accessibility of POC testing for prevention of mother-to-child transmission (PMTCT) in resource-limited settings. We propose to conduct a systematic scoping review to map the evidence on POC testing services for PMTCT. METHODS AND ANALYSIS A scoping review framework, proposed by Arksey and O'Malley, will guide the study. A comprehensive literature search will be performed in the following electronic databases: PubMed, Science Direct, Cochrane Central, Google Scholar and databases within EBSCOhost (Medline and CINAHL). The primary research articles published in peer-reviewed journals and grey articles addressing our question will be included. One reviewer will conduct title screening and the results will be exported to endnote library. Two independent reviewers will perform abstract, then full article screening in parallel. The same process shall be employed to extract data from eligible studies. Data analysis will involve a narrative summary of included studies and thematic content analysis aided by NVIVO software V.11. The mixed methods assessment tool will be used to assess the quality of studies that will be included. ETHICS AND DISSEMINATION Ethical approval is not applicable to this study. The study findings will be disseminated through publication in a peer-reviewed journal and presentations at conferences related to syphilis, HIV, PMTCT, bacterial infections and POC diagnostics. TRIAL REGISTRATION NUMBER CRD42017056267.
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Affiliation(s)
- Juliet Katoba
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Lydia Hangulu
- Discipline of Psychology, School of Applied Human Sciences, College of Humanities, University of KwaZulu-Natal, Durban, South Africa
| | - Tivani Phosa Mashamba-Thompson
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
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McLean E, Renju J, Wamoyi J, Bukenya D, Ddaaki W, Church K, Zaba B, Wringe A. 'I wanted to safeguard the baby': a qualitative study to understand the experiences of Option B+ for pregnant women and the potential implications for 'test-and-treat' in four sub-Saharan African settings. Sex Transm Infect 2017; 93:sextrans-2016-052972. [PMID: 28736391 PMCID: PMC5739848 DOI: 10.1136/sextrans-2016-052972] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 03/24/2017] [Accepted: 04/03/2017] [Indexed: 11/04/2022] Open
Abstract
Objective To explore what influences on engagement with Option B+ in four sub-Saharan African settings. Methods In-depth interviews were conducted in 2015, with 22 HIV-positive women who had been pregnant since Option B+ was available, and 15 healthcare workers (HCWs) involved in HIV service delivery. Participants were purposely selected from four health and demographic surveillance sites in Malawi, Tanzania and Uganda. A thematic content analysis was conducted to investigate what influenced engagement with Option B+. Results Feeling ‘ready’ was key to pregnant women accepting antiretroviral treatment (ART) on the same day as diagnosis at antenatal clinic; this was influenced by previous knowledge of HIV-positive status, interactions with HCWs and relationship with their partners. The desire to protect their unborn infant was the main issue that motivated women to initiate treatment, temporarily over-riding barriers to starting ART. Many HCWs recognised that pressurising women into starting ART may lead them to stop treatment following delivery. However, their own responsibility to protect the infant sometimes drove HCWs to use strong persuasive techniques to initiate pregnant women onto ART as early as possible, occasionally causing women to disengage. Conclusions Protecting the baby superseded feelings of unpreparedness for lifelong ART and may explain poor retention observed in Option B+ programmes. Women may benefit from more time to accept their status, and counselling on the long-term value of ART beyond the pregnancy and breastfeeding period. Strategies to promote readiness for same-day initiation of lifelong treatment are urgently needed, and may provide important lessons for universal test-and-treat implementation.
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Affiliation(s)
- Estelle McLean
- Malawi Epidemiology and Intervention Research Unit, Karonga, Malawi.,Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Jenny Renju
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Joyce Wamoyi
- National Institute for Medical Research, Mwanza, Tanzania
| | - Dominic Bukenya
- Medical Research Council/Uganda Virus Research Institute Research Unit on AIDS, Entebbe, Uganda
| | | | - Kathryn Church
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Basia Zaba
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Alison Wringe
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
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Gumede-Moyo S, Filteau S, Munthali T, Todd J, Musonda P. Implementation effectiveness of revised (post-2010) World Health Organization guidelines on prevention of mother-to-child transmission of HIV using routinely collected data in sub-Saharan Africa: A systematic literature review. Medicine (Baltimore) 2017; 96:e8055. [PMID: 28984760 PMCID: PMC5737996 DOI: 10.1097/md.0000000000008055] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND To synthesize and evaluate the impact of implementing post-2010 World Health Organization (WHO) prevention of mother-to-child transmission (PMTCT) guidelines on attainment of PMTCT targets. METHODS Retrospective and prospective cohort study designs that utilized routinely collected data with a focus on provision and utilization of the cascade of PMTCT services were included. The outcomes included the proportion of pregnant women who were tested during their antenatal clinic (ANC) visits; mother-to-child transmission (MTCT) rate; adherence; retention rate; and loss to follow-up (LTFU). RESULTS Of the 1210 references screened, 45 met the inclusion criteria. The studies originated from 14 countries in sub-Saharan Africa. The highest number of studies originated from Malawi (10) followed by Nigeria and South Africa with 7 studies each. More than half of the studies were on option A while the majority of option B+ studies were conducted in Malawi. These studies indicated a high uptake of human immunodeficiency virus (HIV) testing ranging from 75% in Nigeria to over 96% in Zimbabwe and South Africa. High proportions of CD4 count testing were reported in studies only from South Africa despite that in most of the countries CD4 testing was a prerequisite to access treatment. MTCT rate ranged from 1.1% to 15.1% and it was higher in studies where data were collected in the early days of the WHO 2010 PMTCT guidelines. During the postpartum period, adherence and retention rate decreased, and LTFU increased for both HIV-positive mothers and exposed infants. CONCLUSION Irrespective of which option was followed, uptake of antenatal HIV testing was high but there was a large drop off along later points in the PMTCT cascade. More research is needed on how to improve later components of the PMTCT cascade, especially of option B+ which is now the norm throughout sub-Saharan Africa.
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Affiliation(s)
- Sehlulekile Gumede-Moyo
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
- School of Public Health, University of Zambia
| | - Suzanne Filteau
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Tendai Munthali
- School of Public Health, University of Zambia
- Ministry of Health, Lusaka, Zambia
| | - Jim Todd
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
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Abstract
Introduction: There are limited data on factors associated with retention in Option B+. We sought to explore the characteristics of women retained in Option B+ in Malawi, with a focus on the role of HIV disclosure, awareness of partner HIV status, and knowledge around the importance of Option B+ for maternal–child health. Methods: We performed a case-control study of HIV-infected women in Malawi initiated on antiretroviral therapy (ART) under Option B+. Cases were enrolled if they met criteria for default from Option B+ (out of ART for >60 days), and controls were enrolled in approximately 3:1 ratio if they were retained in care for at least 12 months. We surveyed socio-demographic characteristics, HIV disclosure and awareness of partner HIV status, self-report about receiving pre-ART education, and knowledge of Option B+. Univariate logistic regression was performed to determine factors associated with retention. Multivariate logistic regression model was used to evaluate the relationship between HIV disclosure, Option B+ knowledge, and retention after adjusting for age, schooling, and travel time to clinic. Results: We enrolled 50 cases and 153 controls. Median age was 30 years (interquartile range (IQR) 25–34), and the majority (82%) initiated ART during pregnancy at a median gestational age of 24 weeks (IQR 16–28). Ninety-one per cent of the cases (39/43) who started ART during pregnancy defaulted by three months postpartum. HIV disclosure to the primary sex partner was more common among women retained in care (100% versus 78%, p < 0.001). Odds of retention were significantly higher among women with: age >25 years (odds ratio (OR) 2.44), completion of primary school (OR 3.06), awareness of partner HIV status (OR 5.20), pre-ART education (OR 6.17), higher number of correct answers to Option B+ knowledge questions (OR 1.82), and support while taking ART (OR 3.65). Pre-ART education and knowledge were significantly correlated (r = 0.43, p < 0.001). In multivariate analysis, awareness of partner HIV status (OR 4.07, 95% confidence interval (CI) 1.51–10.94, p = 0.02) and Option B+ knowledge (OR 1.60, 95% CI 1.15–2.23, p = 0.004) remained associated with retention. Conclusions: Interventions that address partner disclosure and strengthen pre-ART education around the benefits of ART for maternal and child health should be evaluated to improve retention in Malawi’s Option B+ programme.
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Implementation and Operational Research: Impact of a Systems Engineering Intervention on PMTCT Service Delivery in Côte d'Ivoire, Kenya, Mozambique: A Cluster Randomized Trial. J Acquir Immune Defic Syndr 2017; 72:e68-76. [PMID: 27082507 DOI: 10.1097/qai.0000000000001023] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Efficacious interventions to prevent mother-to-child HIV transmission (PMTCT) have not translated well into effective programs. Previous studies of systems engineering applications to PMTCT lacked comparison groups or randomization. METHODS Thirty-six health facilities in Côte d'Ivoire, Kenya, and Mozambique were randomized to usual care or a systems engineering intervention, stratified by country and volume. The intervention guided facility staff to iteratively identify and then rectify barriers to PMTCT implementation. Registry data quantified coverage of HIV testing during first antenatal care visit, antiretrovirals (ARVs) for HIV-positive pregnant women, and screening HIV-exposed infants (HEI) for HIV by 6-8 weeks. We compared the change between baseline (January 2013-January 2014) and postintervention (January 2015-March 2015) periods using t-tests. All analyses were intent-to-treat. RESULTS ARV coverage increased 3-fold [+13.3% points (95% CI: 0.5 to 26.0) in intervention vs. +4.1 (-12.6 to 20.7) in control facilities] and HEI screening increased 17-fold [+11.6 (-2.6 to 25.7) in intervention vs. +0.7 (-12.9 to 14.4) in control facilities]. In prespecified subgroup analyses, ARV coverage increased significantly in Kenya [+20.9 (-3.1 to 44.9) in intervention vs. -21.2 (-52.7 to 10.4) in controls; P = 0.02]. HEI screening increased significantly in Mozambique [+23.1 (10.3 to 35.8) in intervention vs. +3.7 (-13.1 to 20.6) in controls; P = 0.04]. HIV testing did not differ significantly between arms. CONCLUSIONS In this first randomized trial of systems engineering to improve PMTCT, we saw substantially larger improvements in ARV coverage and HEI screening in intervention facilities compared with controls, which were significant in prespecified subgroups. Systems engineering could strengthen PMTCT service delivery and protect infants from HIV.
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Poppe LK, Chunda-Liyoka C, Kwon EH, Gondwe C, West JT, Kankasa C, Ndongmo CB, Wood C. HIV drug resistance in infants increases with changing prevention of mother-to-child transmission regimens. AIDS 2017; 31:1885-1889. [PMID: 28746086 PMCID: PMC5567858 DOI: 10.1097/qad.0000000000001569] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The objectives of this study were to determine HIV drug resistance (HIVDR) prevalence in Zambian infants upon diagnosis, and to determine how changing prevention of mother-to-child transmission (PMTCT) drug regimens affect drug resistance. DESIGN Dried blood spot (DBS) samples from infants in the Lusaka District of Zambia, obtained during routine diagnostic screening, were collected during four different years representing three different PMTCT drug treatment regimens. METHODS DNA extracted from dried blood spot samples was used to sequence a 1493 bp region of the reverse transcriptase gene. Sequences were analyzed via the Stanford HIVDRdatabase (http://hivdb.standford.edu) to screen for resistance mutations. RESULTS HIVDR in infants increased from 21.5 in 2007/2009 to 40.2% in 2014. Nonnucleoside reverse transcriptase inhibitor resistance increased steadily over the sampling period, whereas nucleoside reverse transcriptase inhibitor resistance and dual class resistance both increased more than threefold in 2014. Analysis of drug resistance scores in each group revealed increasing strength of resistance over time. In 2014, children with reported PMTCT exposure, defined as infant prophylaxis and/or maternal treatment, showed a higher prevalence and strength of resistance compared to those with no reported exposure. CONCLUSION HIVDR is on the rise in Zambia and presents a serious problem for the successful lifelong treatment of HIV-infected children. PMTCT affects both the prevalence and strength of resistance and further research is needed to determine how to mitigate its role leading to resistance.
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Affiliation(s)
- Lisa K Poppe
- aNebraska Center for Virology and School of Biological Sciences, University of Nebraska, Lincoln, Nebraska, USA bUniversity Teaching Hospital-Lusaka Children's Hospital cUniversity of Zambia School of Medicine, Lusaka, Zambia
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Miller K, Muyindike W, Matthews LT, Kanyesigye M, Siedner MJ. Program Implementation of Option B+ at a President's Emergency Plan for AIDS Relief-Supported HIV Clinic Improves Clinical Indicators But Not Retention in Care in Mbarara, Uganda. AIDS Patient Care STDS 2017; 31:335-341. [PMID: 28650703 PMCID: PMC5564010 DOI: 10.1089/apc.2017.0034] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
2013 WHO guidelines for prevention of mother to child transmission recommend combination antiretroviral therapy (ART) for all pregnant women, regardless of CD4 count (Option B/B+). We conducted a retrospective analysis of data from a government-operated HIV clinic in Mbarara, Uganda before and after implementation of Option B+ to assess the impact on retention in care. We limited our analysis to women not on ART at the time of their first reported pregnancy with CD4 count >350. We fit regression models to estimate relationships between calendar period (Option A vs. Option B+) and the primary outcome of interest, retention in care. One thousand and sixty-two women were included in the analysis. Women were more likely to start ART within 6 months of pregnancy in the Option B+ period (68% vs. 7%, p < 0.0001) and had significantly greater increases in CD4 count 1 year after pregnancy (+172 vs. -5 cells, p < 0.001). However, there was no difference in the proportion of women retained in care 1 year after pregnancy (73% vs. 70%, p = 0.34). In models adjusted for age, distance to clinic, marital status, and CD4 count, Option B+ was associated with a nonsignificant 30% increased odds of retention in care at 1 year [adjusted odds ratio (AOR) = 1.30, 95% CI 0.98-1.73, p = 0.06]. After transition to an Option B+ program, pregnant women with CD4 count >350 were more likely to initiate combination therapy; however, interventions to mitigate losses from HIV care during pregnancy are needed to improve the health of women, children, and families.
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Affiliation(s)
- Kathleen Miller
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Winnie Muyindike
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Lynn T. Matthews
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Michael Kanyesigye
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Mark J. Siedner
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
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Hauser BM, Miller WC, Tweya H, Speight C, Mtande T, Phiri S, Ball LM, Hosseinipour MC, Hoffman IF, Rosenberg NE. Assessing Option B+ retention and infant follow-up in Lilongwe, Malawi. Int J STD AIDS 2017; 29:185-194. [PMID: 28750577 DOI: 10.1177/0956462417721658] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Malawi launched Option B+, a program for all pregnant or breastfeeding HIV-positive women to begin lifelong combination antiretroviral therapy (cART), in July 2011. This study characterises a portion of the continuum of care within an antenatal setting in Lilongwe. Women testing HIV-positive and having a cART initiation record at Bwaila Antenatal Clinic from July 2013 to January 2014 were included. Using logistic regression models, we analysed relationships between maternal characteristics and return for infant testing. Among 490 HIV-positive women with a cART initiation record, 360 (73%) were retained at three months. Of these, 203 (56%) were adherent. Records of infant testing were located for 204 women (42%). Women who were not retained were less likely to have an early infant diagnosis record (aOR = 0.20; 95% CI: 0.10, 0.41). Among the women retained, there was a non-significant association between maternal adherence and infant testing (OR = 1.35; 95% CI: 0.89, 2.06). Women lost at earlier continuum stages, who are at higher risk for mother-to-child-transmission, were less likely to bring infants for testing. Even with a test-and-treat program, many women did not remain in care or bring their infant for testing. Facilitating strategies to improve these measures remains an important unmet need.
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Affiliation(s)
- Blake M Hauser
- 1 Department of Environmental Sciences and Engineering, 2331 University of North Carolina at Chapel Hill , Chapel Hill, NC, USA
| | - William C Miller
- 2 Department of Medicine, 2331 University of North Carolina at Chapel Hill , Chapel Hill, NC, USA.,3 Department of Epidemiology, 2331 University of North Carolina at Chapel Hill , Chapel Hill, NC, USA
| | - Hannock Tweya
- 4 Lighthouse Trust, Lilongwe, Malawi.,5 The International Union against Tuberculosis and Lung Disease, Paris, France
| | | | - Tiwonge Mtande
- 6 156288 University of North Carolina Project , Lilongwe, Malawi
| | - Sam Phiri
- 2 Department of Medicine, 2331 University of North Carolina at Chapel Hill , Chapel Hill, NC, USA.,4 Lighthouse Trust, Lilongwe, Malawi.,7 Department of Public Health, College of Medicine, School of Public Health and Family Medicine, University of Malawi, Lilongwe, Malawi
| | - L M Ball
- 1 Department of Environmental Sciences and Engineering, 2331 University of North Carolina at Chapel Hill , Chapel Hill, NC, USA
| | - Mina C Hosseinipour
- 2 Department of Medicine, 2331 University of North Carolina at Chapel Hill , Chapel Hill, NC, USA.,6 156288 University of North Carolina Project , Lilongwe, Malawi
| | - Irving F Hoffman
- 2 Department of Medicine, 2331 University of North Carolina at Chapel Hill , Chapel Hill, NC, USA.,6 156288 University of North Carolina Project , Lilongwe, Malawi
| | - Nora E Rosenberg
- 2 Department of Medicine, 2331 University of North Carolina at Chapel Hill , Chapel Hill, NC, USA.,6 156288 University of North Carolina Project , Lilongwe, Malawi
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Prevention of mother-to-child transmission of HIV Option B+ cascade in rural Tanzania: The One Stop Clinic model. PLoS One 2017; 12:e0181096. [PMID: 28704472 PMCID: PMC5507522 DOI: 10.1371/journal.pone.0181096] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 06/26/2017] [Indexed: 12/21/2022] Open
Abstract
Background Strategies to improve the uptake of Prevention of Mother-To-Child Transmission of HIV (PMTCT) are needed. We integrated HIV and maternal, newborn and child health services in a One Stop Clinic to improve the PMTCT cascade in a rural Tanzanian setting. Methods The One Stop Clinic of Ifakara offers integral care to HIV-infected pregnant women and their families at one single place and time. All pregnant women and HIV-exposed infants attended during the first year of Option B+ implementation (04/2014-03/2015) were included. PMTCT was assessed at the antenatal clinic (ANC), HIV care and labour ward, and compared with the pre-B+ period. We also characterised HIV-infected pregnant women and evaluated the MTCT rate. Results 1,579 women attended the ANC. Seven (0.4%) were known to be HIV-infected. Of the remainder, 98.5% (1,548/1,572) were offered an HIV test, 94% (1,456/1,548) accepted and 38 (2.6%) tested HIV-positive. 51 were re-screened for HIV during late pregnancy and one had seroconverted. The HIV prevalence at the ANC was 3.1% (46/1,463). Of the 39 newly diagnosed women, 35 (90%) were linked to care. HIV test was offered to >98% of ANC clients during both the pre- and post-B+ periods. During the post-B+ period, test acceptance (94% versus 90.5%, p<0.0001) and linkage to care (90% versus 26%, p<0.0001) increased. Ten additional women diagnosed outside the ANC were linked to care. 82% (37/45) of these newly-enrolled women started antiretroviral treatment (ART). After a median time of 17 months, 27% (12/45) were lost to follow-up. 79 women under HIV care became pregnant and all received ART. After a median follow-up time of 19 months, 6% (5/79) had been lost. 5,727 women delivered at the hospital, 20% (1,155/5,727) had unknown HIV serostatus. Of these, 30% (345/1,155) were tested for HIV, and 18/345 (5.2%) were HIV-positive. Compared to the pre-B+ period more women were tested during labour (30% versus 2.4%, p<0.0001). During the study, the MTCT rate was 2.2%. Conclusions The implementation of Option B+ through an integrated service delivery model resulted in universal HIV testing in the ANC, high rates of linkage to care, and MTCT below the elimination threshold. However, HIV testing in late pregnancy and labour, and retention during early ART need to be improved.
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