Health system constraints to optimal coverage of the prevention of mother-to-child HIV transmission programme in South Africa: lessons from the implementation of the national pilot programme

Factors associated with loss to follow up among HIV-exposed children: a historical cohort study from 2000 to 2017, in Porto Alegre, Brazil

BACKGROUND

There are many inequalities in terms of prevention and treatment for pregnant women with HIV and exposed children in low and middle-income countries. The Brazilian protocol for prenatal care includes rapid diagnostic testing for HIV, compulsory notification, and monitoring by the epidemiological surveillance of children exposed to HIV until 18 months after delivery. The case is closed after HIV serology results are obtained. Lost to follow-up is defined as a child who was not located at the end of the case, and, therefore, did not have a laboratory diagnosis. Lost to follow-up is a current problem and has been documented in other countries. This study analyzed factors associated with loss to follow-up among HIV-exposed children, including sociodemographic, behavioral, and health variables of mothers of children lost to follow-up.

METHODS

This historical cohort study included information on mothers of children exposed to HIV, born in Porto Alegre, from 2000 to 2017. The research outcome was the classification at the end of the child's follow-up (lost to follow-up or not). Factors associated with loss to follow-up were investigated using the Poisson regression model. Relative Risk calculations were performed. The significance level of 5% was adopted for variables in the adjusted model.

RESULTS

Of 6,836 children exposed to HIV, 1,763 (25.8%) were classified as lost to follow-up. The factors associated were: maternal age of up to 22 years (aRR 1.25, 95% CI: 1.09-1.43), the mother's self-declared race/color being black or mixed (aRR 1.13, 95% CI: 1.03-1.25), up to three years of schooling (aRR 1.45, 95% CI: 1.26-1.67), between four and seven years of schooling (aRR 1.14, 95% CI: 1.02-1.28), intravenous drug use (aRR 1.29, 95% CI: 1.12-1.50), and HIV diagnosis during prenatal care or at delivery (aRR 1.37, 95% CI: 1.24-1.52).

CONCLUSION

Variables related to individual vulnerability, such as race, age, schooling, and variables related to social and programmatic vulnerability, remain central to reducing loss to follow-up among HIV-exposed children.

Providers' definitions of quality and barriers to providing quality care: a qualitative study in rural Mpumalanga Province, South Africa

Background:

South Africa requires high-quality primary health care (PHC) to retain patients and optimize outcomes. While prior research has identified implementation challenges within the PHC system, there is less understanding of how providers define quality, their perceptions of barriers to providing quality care, and how they overcome these barriers. This study assesses provider views on quality at primary care clinics in a rural sub-district of Mpumalanga Province.

Methods:

We conducted in-depth interviews with providers in early 2019 on the value of quality metrics for providers and patients, what indicators they would use to assess clinic performance, and barriers and facilitators of delivering care. Interviews were conducted in Shangaan, audio-recorded, and translated into English. A deductive approach was used to develop a provisional coding schema, which was then refined using an inductive approach in response to patterns and themes emerging from the data.

Results:

Twenty-three providers were interviewed (83% female, 65% professional nurses). Providers did not give a single standard definition of quality care. Clinic structure and resources emerged as a key issue, as providers linked deficiencies in infrastructure and support to deficits in care delivery. Providers identified mitigating strategies including informal coordination across clinics to address medication and equipment shortages. Common across the providers’ discussion was poor communication between the district, PHC supervisors, and implementers at the facility level.

Conclusion:

Providers connected deficits in quality of care to inadequate infrastructure and insufficient support from district and provincial authorities; mitigating strategies across clinics could only partially address these deficits. The existence of a national quality measurement program was not broadly reflected in providers’ views on quality care. These findings underscore the need for effective district and national approaches to support individual facilities, accompanied by feedback methods designed with input from frontline service providers.

Effectiveness of Lifelong ART (Option B+) in the Prevention of Mother-to-Child Transmission of HIV Programme in Zambia: Observations Based on Routinely Collected Health Data

Background: Mother to child transmission of HIV (MTCT) is a global challenge affecting many countries especially in sub-Saharan Africa. In 2009 about 370,000 infants were infected with HIV mainly through MTCT and most of them in sub-Saharan Africa. We aimed to determine the effectiveness of Option B+ compared to other options in reducing rates of early MTCT of HIV infections in Zambia.

Methods: This was a retrospective cohort study based on routinely collected data using SmartCare in Zambia. Survival analysis with Cox Proportional Hazard regression was used to determine association between MTCT and regimen type of mothers. Kaplan-Meier (K-M) curves were used to compare MTCT for infants born to mothers option B+ to those on other options, and Wilcoxon (Breslow) test was used to establish statistical significance.

Results: Overall (n = 1,444), mother-baby pairs with complete data were included in the analysis, with the median age of mothers being 33 (28–38) years; and 57% of these women were on Option B+. MTCT rate was estimated at 5% (73/1,444) [P = 0.025]. A Kaplan-Meier estimate showed that HIV Exposed Infants (HEI) of mothers on Option B+ had lower MTCT rate than those who were on other MTCT prevention interventions [Wilcoxon test; chi2 = 4.97; P = 0.025]. Furthermore, The Nelson Aalen cumulative hazard estimates indicated similar evidence of option B+ being more effective than other options with some statistical significance [HR = 0.63, P = 0.068]. HEI of option B+ mothers had 50% reduced risk of having HIV infection compared to option A/B [adjusted HR = 0.4; 95% CI = 0.28–0.84; P = 0.010]. HEI to women who were married had an increased risk 50% of getting infected compared to those not married [adjusted HR = 1.5; 95% CI = 3.43–6.30; P < 0.001]. Exposed infants whose mothers had assisted delivery had 3 times increased risk of getting infected compared to those born through normal vaginal delivery [Adjusted HR = 3.2; 95% CI = 0.98–10.21; P = 0.050].

Conclusions: The use of Option B+ as PMTCT intervention was found to be more effective in reducing MTCT of HIV compared to other options. Scaling up access to life-long ART and improving retention for women on treatment can potentially reduce further vertical transmission.

Estimating levels of HIV testing coverage and use in prevention of mother-to-child transmission among women of reproductive age in Zambia

Background

Mother to child transmission of HIV (MTCT) still remains a challenge affecting many countries. Globally, an estimated 150,000 children were newly infected with HIV in 2015, over 90% of them in Sub-Saharan Africa through MTCT. In Zambia approximately 500,000 babies are born and 40,000 acquire the infection vertically if there is no intervention annually. This study estimated the HIV testing coverage and associated factors among Zambian women of reproductive age 15–49 years.

Methods

A cross-sectional study based on data extracted from the Zambia Demographics and Health Survey [Zambia Demographic and Health Survey. Central Statistical Office (CSO), Ministry of Health (MOH), Tropical Diseases Research Centre (TDRC), University of Zambia, and Macro International Inc. 2009. 2014]. Women aged 15–49 years, 15,388 who reported having ever tested for HIV or not comprised the de facto eligible sample. Extracted data comprised women’s demographic characteristics; their full birth history and records of antenatal care for the most recent birth within a 5 year period preceding the survey. A weighted multiple logistic regression model was done to determine factors associated with the odds of HIV testing coverage among women of reproductive age.

Results

Out of 15,388 women in the study, 12,413 (81%) reported ever tested for HIV. Of the 6461 women who attended antenatal care (ANC) 6139 (95%) reported ever tested for HIV. Additionally, 6139 (95%) out of 6461 of the women were given information on PMTCT during ANC sessions. Testing coverage was higher among women aged 20–24 years compared to women aged 15–19 years [AOR 2.1, 95% CI 1.14–3.84; p = 0.017]. Women with higher socio-economic status had 6.6 times the odds of having ever tested compared to women with lower status [AOR 6.6, 95% CI 3.04–14.14; p < 0.001].

Conclusions

In this study we have demonstrated that HIV testing coverage is higher among women of reproductive age. HIV testing among women attending ANC is also higher. Older women with higher socio-economic status are more likely to take up HIV testing compared to their young counterparts.

Stakeholders' experiences in implementation of rapid changes to the South African prevention of mother-to-child transmission programme

BACKGROUND

 South Africa's prevention of mother-to-child transmission (PMTCT) of the human immunodeficiency virus (HIV) programme has undergone rapid changes in the last two decades. Initially, the provision of single antiretroviral therapy was based on eligibility criteria in the year 2001, which later changed to combination therapy. This was aimed at preventing mother-to-child transmission of HIV. Since 2015, all pregnant women were eligible for antiretroviral treatment regardless of their CD4 count. Although significant strides were made to reduce mother-to-child transmission of HIV, increased efforts are required to meet UNAIDS targets, World Health Organization (WHO) elimination framework goals and sustainable development goals to eliminate new HIV infections in children and ending the HIV epidemic by 2030.

AIM

 The aim of the study was to explore healthcare workers' experiences and patient perceptions of the implementation of rapid changes to the PMTCT programme in four public healthcare facilities.

SETTING

 The study was conducted in the four public healthcare facilities within the two highly HIV-burdened districts of iLembe and eThekwini in KwaZulu-Natal province, South Africa.

METHODS

 This study used a qualitative, exploratory, descriptive study design using interviews and focus group discussions. Participants were selected using purposive sampling. Following verbatim transcription of the data, thematic data analysis was used through data reduction and data display and the emergence of four themes.

RESULTS

 A total of 61 stakeholders were interviewed. Four major themes emerged: (1) impact of poor health system design, (2) impact of poor communication of changes, (3) contextual factors affecting innovation in healthcare and (4) skill deficit in change management and forward planning.

CONCLUSION

 A healthcare system more responsive to the experiences of healthcare workers and pregnant women is required to effectively implement changes in priority programmes.

Educational Attainment as a Predictor of HIV Testing Uptake Among Women of Child-Bearing Age: Analysis of 2014 Demographic and Health Survey in Zambia

Background: Globally, an estimated 150,000 children were newly infected with HIV in 2015, over 90% of them in Sub-Saharan Africa. In Zambia, ~500,000 babies are born to HIV positive mothers every year, and without intervention 40,000 of them would acquire the infection. Studies have shown a strong association between education and HIV prevalence, but in Zambia, this association has not been demonstrated. There is little published information on the association between educational attainment and HIV testing uptake among pregnant women, which is fundamental in understanding the mother to child transmission of HIV. This study investigated whether educational attainment was associated with uptake of HIV testing among women of reproductive age in Zambia.

Methods: Data were taken from Zambia Demographic and Health Survey in 2014 (ZDHS14). The analysis consisted of all women aged 15–49 years, who responded to the question on HIV testing in the ZDHS. Multivariable logistic regression was used to determine whether educational attainment was associated with uptake of HIV testing among women of reproductive age in Zambia.

Results: Educational attainment was strongly associated with HIV testing among 15,388 women of child bearing age [AOR 3.8, 95% CI 1.7–8.2; p = 0.001]. HIV testing differed greatly by socioeconomic social status with an increased uptake among women with higher wealth index [AOR 4.4, 95% CI 1.9–9.9; p = 0.001]. Additionally, HIV testing was observed to be higher among the older women 25–34 years compared to the young women 15–19 years [AOR 2.3, 95% CI 1.3–4.3; p = 0.007].

Conclusions: This study revealed educational attainment to be a strong predictor of HIV testing among women of child bearing age in this population. High HIV testing uptake among educated pregnant women indicated that low-educated women may not fully realize the benefits of testing for HIV. Therefore, strengthening HIV testing in rural health facilities and providing initiatives to overcome barriers to testing among women with no formal education may help reduce vertical transmission of HIV.

Mapping evidence of interventions and strategies to bridge the gap in the implementation of the prevention of mother-to-child transmission of HIV programme policy in sub-Saharan countries: A scoping review

BACKGROUND

Prevention of mother-to-child transmission (PMTCT) of HIV is a life-saving public health intervention. Sub-Saharan African (SSA) countries have made significant progress in the programme, but little is known about the strategies used by them to eliminate mother-to-child transmission of HIV.

AIM

To map evidence of strategies and interventions employed by SSA in bridging the implementation gap in the rapidly changing PMTCT of HIV programme policy.

METHODS

Electronic search of the databases MEDLINE, PubMed and SABINET for articles published in English between 2001 and August 2016. Key words included 'Sub-Saharan African countries', 'implementation strategies', 'interventions to bridge implementation gap', 'prevention of mother-to-child transmission of HIV' and 'closing implementation gap'.

RESULTS

Of a total of 743 articles, 25 articles that met the inclusion criteria were included in the study. Manual content analysis resulted in the identification of three categories of strategies: (1) health system (referral systems, integration of services, supportive leadership, systematic quality-improvement approaches that vigorously monitors programme performance); (2) health service delivery (task shifting, networking, shared platform for learning, local capacity building, supportive supervision); as well as (3) community-level strategies (community health workers, technology use - mHealth, family-centred approaches, male involvement, culturally appropriate interventions).

CONCLUSION

There are strategies that exist in SSA countries. Future research should examine multifaceted scientific models to prioritise the highest impact and be evaluated for effectiveness and efficiency.

Playing the Catch-Up Game: Accelerating the Scale-Up of Prevention of Mother-To-Child Transmission of HIV (PMTCT) Services to Eliminate New Pediatric HIV Infection in Nigeria

Introduction

As the world is making progress towards elimination of mother-to-child transmission of HIV, poor coverage of PMTCT services in Nigeria remains a major challenge. In order to address this, scale-up was planned with activities organized into 3 phases. This paper describes the process undertaken in eight high burden Nigerian states to rapidly close PMTCT coverage gaps at facility and population levels between February 2013 and March 2014.

Methods

Activities were grouped into three phases–pre-assessment phase (engagement of a wide range of stakeholders), assessment (rapid health facility assessment, a cross sectional survey using mixed methods conducted in the various states between Feb and May 2013 and impact modelling), and post-assessment (drawing up costed state operational plans to achieve eMTCT by 2015, data-driven smart scale-up).

Results

Over a period of 10 months starting June 2013, 2044 facilities were supported to begin provision of PMTCT services. This increased facility coverage from 8% to 50%. A 246% increase was also recorded in the number of pregnant women and their families who have access to HIV testing and counselling in the context of PMTCT. Similarly, access to antiretrovirals for PMTCT has witnessed a 152% increase in these eight states between October 2013 and October 2014.

Conclusion

A data-driven and participatory approach can be used to rapidly scale-up PMTCT services at community and facility levels in this region. These results present us with hope for real progress in Nigeria. We are confident that the efforts described here will contribute significantly to eliminating new pediatric HIV infection in Nigeria.

Engagement of Men in Antenatal Care Services: Increased HIV Testing and Treatment Uptake in a Community Participatory Action Program in Mozambique

Uptake of HIV testing and antiretroviral therapy (ART) services during antenatal care (ANC) in rural Mozambique is disappointing. To nurture supportive male engagement in ANC services, we partnered with traditional birth attendants and trained a new type of male-to-male community health agent, "Male Champions", who focused on counseling male partners to create new, male-friendly community norms around engagement in spousal/partner pregnancies. We assessed ANC service uptake using a pre-post intervention design. The intervention was associated with increases in: (1) uptake of provider-initiated counseling and testing among pregnant woman (81 vs. 92 %; p < 0.001); (2) male engagement in ANC (5 vs. 34 %; p < 0.001); and (3) uptake of ART (8 vs. 19 %; p < 0.001). When men accepted HIV testing, rates of testing rose markedly among pregnant women. With the challenges in scale-up of Option B+ in sub-Saharan Africa, similar interventions may increase testing and treatment acceptability during pregnancy.

A comprehensive review of the barriers and promoters health workers experience in delivering prevention of vertical transmission of HIV services in sub-Saharan Africa

Despite significant biomedical and policy advances, 199,000 infants and young children in sub-Saharan Africa (SSA) became infected with HIV in 2013, indicating challenges to implementation of these advances. To understand the nature of these challenges, we sought to (1) characterize the barriers and facilitators that health workers encountered delivering prevention of vertical transmission of HIV (PVT) services in SSA and (2) evaluate the use of theory to guide PVT service delivery. The PubMed and CINAHL databases were searched using keywords barriers, facilitators, HIV, prevention of vertical transmission of HIV, health workers, and their synonyms to identify relevant studies. Barriers and facilitators were coded at ecological levels according to the Determinants of Performance framework. Factors in this framework were then classified as affecting motivation, opportunity, or ability, per the Motivation-Opportunity-Ability (MOA) framework in order to evaluate domains of health worker performance within each ecological level. We found that the most frequently reported challenges occurred within the health facility level and spanned all three MOA domains. Barriers reported in 30% or more of studies from most proximal to distal included those affecting health worker motivation (stress, burnout, depression), patient opportunity (stigma), work opportunity (poor referral systems), health facility opportunity (overburdened workload, lack of supplies), and health facility ability (inadequate PVT training, inconsistent breastfeeding messages). Facilitators were reported in lower frequencies than barriers and tended to be resolutions to challenges (e.g., quality supervision, consistent supplies) or responses to an intervention (e.g., record systems and infrastructure improvements). The majority of studies did not use theory to guide study design or implementation. Interventions addressing health workers' multiple ecological levels of interactions, particularly the health facility, hold promise for far-reaching impact as distal factors influence more proximal factors. Incorporating theory that considers factors beyond the health worker will strengthen endeavors to mitigate barriers to PVT service delivery.

A Successful Failure: Missing the MDG4 Target for Under-Five Mortality in South Africa

Reflecting on under-five mortality, Peter Byass and colleagues consider how some countries may fail to meet millennium development goal targets despite making considerable advances.

"You Know You Are Sick, Why Do You Carry A Pregnancy Again?" Applying the Socio-Ecological Model to Understand Barriers to PMTCT Service Utilization in Western Kenya

OBJECTIVE

Throughout most of sub-Saharan Africa (SSA), prevention of mother-to-child transmission (PMTCT) services are readily available. However, PMTCT programs in SSA have had suboptimal performance compared to other regions of the world. The main objective of this study is to explore the socio-ecological and individual factors influencing the utilization of PMTCT services among HIV-positive pregnant women in western Kenya using a social ecological model as our analytical lens.

METHODS

Data were collected using in-depth interviews with 33 HIV-infected women attending government health facilities in rural western Kenya. Women with HIV-infected infants aged between 6 weeks to 6 months with a definitive diagnosis of HIV in the infant, as well as those with an HIV-negative test result in the infant were interviewed between November 2012 and June 2013. Coding and analysis of the transcripts followed grounded theory tenets. Coding reports were discussed in a series of meetings held among the authors. We then employed constant comparative analysis to discover dominant individual, family, society and structural determinants of PMTCT use.

RESULTS

Barriers to women's utilization of PMTCT services fell within the broad constructs of the socio-ecological model of individual, family, society and structural determinants. Several themes cut across the different steps of PMTCT cascade and relate to different constructs of the socio-ecological model. These themes include: self-motivation, confidence and resilience, family support, absence or reduced stigma, right provider attitude and quality of health services provided. We also found out that these factors ensured enhanced maternal health and HIV negative children.

CONCLUSION

The findings of this study suggest that a woman's social environment is an important determinant of MTCT. PMTCT Interventions must comprehensively address multiple factors across the different ecological levels. More research is however required for the development of multi-component interventions that combine strategies at different ecological levels.

Potential barriers to rapid testing for human immunodeficiency virus among a commuter population in Johannesburg, South Africa

Background

This study aimed to determine barriers to accessing human immunodeficiency virus (HIV) counseling and testing (HCT) services among a commuter population.

Methods

A cross-sectional, venue-based intercept survey was conducted. Participants were recruited during a 2-day community campaign at the Noord Street taxi rank in Johannesburg, South Africa. Data were collected using a self-administered questionnaire loaded onto an electronic data collection system and analyzed using Stata software. Factors contributing to barriers for HCT were modeled using multivariate logistic regression.

Results

A total of 1,146 (567 male and 579 female) individuals were interviewed; of these, 51.4% were females. The majority (59.5%) were aged 25–35 years. Significant factors were age group (15–19 years), marital status (married), educational level (high school), distance to the nearest clinic (>30 km), area of employment/residence (outside inner city), and number of sexual partners (more than one). Participants aged 15–19 years were more likely to report low-risk perception of HIV as a barrier to HCT (odds ratio [OR] 1.62; 95% confidence interval [CI] 1.01–2.59), the married were more likely to report low-risk perception of HIV as a barrier to HCT (OR 1.49; 95% CI 1.13–1.96), and those living outside the inner city were more likely to report lack of partner support as a potential barrier (OR 1.94; 95% CI 1.34–2.80), while those with a high school education were more likely to report poor health worker attitude as a potential barrier to HIV testing (OR 2.17; 95% CI 1.36–3.45).

Conclusion

Age, marital status, occupation, educational level, area of employment and residence, distance to the nearest clinic, and number of sexual partners were factors significantly associated with barriers to HIV testing in the study population. Future HIV intervention targeting this population need to be reinforced in order to enhance HIV testing while taking cognizance of these factors.

The Age Pattern of Increases in Mortality Affected by HIV: Bayesian Fit of the Heligman-Pollard Model to Data from the Agincourt HDSS Field Site in Rural Northeast South Africa

BACKGROUND

We investigate the sex-age-specific changes in the mortality of a prospectively monitored rural population in South Africa. We quantify changes in the age pattern of mortality in a parsimonious way by estimating the eight parameters of the Heligman-Pollard (HP) model of age-specific mortality. In its traditional form this model is difficult to fit and does not account for uncertainty.

OBJECTIVE

1. To quantify changes in the sex-age pattern of mortality experienced by a population with endemic HIV. 2. To develop and demonstrate a robust Bayesian estimation method for the HP model that accounts for uncertainty.

METHODS

Bayesian estimation methods are adapted to work with the HP model. Temporal changes in parameter values are related to changes in HIV prevalence.

RESULTS

Over the period when the HIV epidemic in South Africa was growing, mortality in the population described by our data increased profoundly with losses of life expectancy of ~15 years for both males and females. The temporal changes in the HP parameters reflect in a parsimonious way the changes in the age pattern of mortality. We develop a robust Bayesian method to estimate the eight parameters of the HP model and thoroughly demonstrate it.

CONCLUSIONS

Changes in mortality in South Africa over the past fifteen years have been profound. The HP model can be fit well using Bayesian methods, and the results can be useful in developing a parsimonious description of changes in the age pattern of mortality.

COMMENTS

The motivating aim of this work is to develop new methods that can be useful in applying the HP eight-parameter model of age-specific mortality. We have done this and chosen an interesting application to demonstrate the new methods.

The magnitude of loss to follow-up of HIV-exposed infants along the prevention of mother-to-child HIV transmission continuum of care: a systematic review and meta-analysis

Introduction:

Although prevention of mother-to-child HIV transmission (PMTCT) programs are widely implemented, many children do not benefit from them because of loss to follow-up (LTFU). We conducted a systematic review to determine the magnitude of infant/baby LTFU along the PMTCT cascade.

Methods:

Eligible publications reported infant LTFU outcomes from standard care PMTCT programs (not intervention studies) at any stage of the cascade. Literature searches were conducted in Medline, Embase, Web of Knowledge, CINAHL Plus, and Maternity and Infant Care. Extracted data included setting, methods of follow-up, PMTCT regimens, and proportion and timing of LTFU. For programs in sub-Saharan Africa, random-effects meta-analysis was done using Stata v10. Because of heterogeneity, predictive intervals (PrIs; approximate 95% confidence intervals of a future study based on extent of observed heterogeneity) were computed.

Results:

A total of 826 papers were identified; 25 publications were eligible. Studies were published from 2001 to 2012 and were mostly from sub-Saharan Africa (three were from India, one from UK and one from Ireland). There was extensive heterogeneity in findings. Eight studies reported on LTFU of pregnant HIV-positive women between antenatal care (ANC) registration and delivery, which ranged from 10.9 to 68.1%, pooled proportion 49.08% [95% confidence interval (CI) 39.6–60.9%], and PrI 22.0–100%. Fourteen studies reported LTFU of infants within 3 months of delivery, range 4.8–75%, pooled proportion 33.9% (27.6–41.5), and PrI 15.4–74.2. Children were also lost after HIV testing; this was reported in five studies, pooled estimate 45.5% (35.9–57.6), PrI 18.7–100%. Programs that actively tracked defaulters had better retention outcomes.

Conclusion:

There is unacceptable infant LTFU from PMTCT programs. Countries should incorporate defaulter-tracking as standard to improve retention.

Translation of biomedical prevention strategies for HIV: prospects and pitfalls

Early achievements in biomedical approaches for HIV prevention included physical barriers (condoms), clean injection equipment (both for medical use and for injection drug users), blood and blood product safety, and prevention of mother-to-child transmission. In recent years, antiretroviral drugs to reduce the risk of transmission (when the infected person takes the medicines; treatment as prevention) or reduce the risk of acquisition (when the seronegative person takes them; preexposure prophylaxis) have proven to be efficacious. Circumcision of men has also been a major tool relevant for higher prevalence regions such as sub-Saharan Africa. Well-established prevention strategies in the control of sexually transmitted diseases and tuberculosis are highly relevant for HIV (ie, screening, linkage to care, early treatment, and contact tracing). Unfortunately, only slow progress is being made in some available HIV-prevention strategies such as family planning for HIV-infected women who do not want more children and prevention of mother-to-child HIV transmission. Current studies seek to integrate strategies into approaches that combine biomedical, behavioral, and structural methods to achieve prevention synergies. This review identifies the major biomedical approaches demonstrated to be efficacious that are now available. We also highlight the need for behavioral risk reduction and adherence as essential components of any biomedical approach.

Scaling up prevention of mother-to-child HIV transmission programs in sub-Saharan African countries: a multilevel assessment of site-, program- and country-level determinants of performance

BACKGROUND

Uptake of prevention of mother-to-child HIV transmission (PMTCT) programs remains challenging in sub-Saharan Africa because of multiple barriers operating at the individual or health facility levels. Less is known regarding the influence of program-level and contextual determinants. In this study, we explored the multilevel factors associated with coverage in single-dose nevirapine PMTCT programs.

METHODS

We analyzed aggregate routine data collected within the framework of the Viramune(®) Donation Programme (VDP) from 269 sites in 20 PMTCT programs and 15 sub-Saharan countries from 2002 to 2005. Site performance was measured using a nevirapine coverage ratio (NCR), defined as the reported number of women receiving nevirapine divided by the number of women who should have received nevirapine (observed HIV prevalence x number of women in antenatal care [ANC]). Data on program-level determinants were drawn from the initial application forms, and country-level determinants from the Demographic and Health Surveys (DHS) and the World Bank (World Development Indicators). Multilevel linear mixed models were used to identify independent factors associated with NCR at the site-, program- and country-level.

RESULTS

Of 283,410 pregnant women attending ANC in the included sites, 174,312 women (61.5%) underwent HIV testing after receiving pre-test counselling, of whom 26,700 tested HIV positive (15.3%), and 22,591 were dispensed NVP (84.6%). Site performance was highly heterogeneous between and within programs. Mean NCR by site was 43.8% (interquartile range: 19.1-63.9). Multilevel analysis identified higher HIV prevalence (Beta coefficient: 25.1, 95% confidence interval [CI] 18.7 to 31.6), higher proportion of persons with knowledge of PMTCT (8.3; CI 0.5 to 16.0), higher health expenditure as a proportion of Gross Domestic Product (3.9 per %; CI 2.0 to 5.8) and lower percentage of rural population (-0.7 per %; CI -1.0 to -0.5) as significant country-level predictors of higher NCR at the p<0.05 level. A medium ANC monthly activity (30-100/month) was the only site-level predictor found (-7.6; CI -15.1 to -0.1).

CONCLUSIONS

Heterogeneity of nevirapine coverage between sites and programs was high. Multilevel analysis identified several significant contextual determinants, which may warrant additional research to further define important multi-level and potentially modifiable determinants of performance of PMTCT programs.

The uptake of integrated perinatal prevention of mother-to-child HIV transmission programs in low- and middle-income countries: a systematic review

BACKGROUND

The objective of this review was to assess the uptake of WHO recommended integrated perinatal prevention of mother-to-child transmission (PMTCT) of HIV interventions in low- and middle-income countries.

METHODS AND FINDINGS

We searched 21 databases for observational studies presenting uptake of integrated PMTCT programs in low- and middle-income countries. Forty-one studies on programs implemented between 1997 and 2006, met inclusion criteria. The proportion of women attending antenatal care who were counseled and who were tested was high; 96% (range 30-100%) and 81% (range 26-100%), respectively. However, the overall median proportion of HIV positive women provided with antiretroviral prophylaxis in antenatal care and attending labor ward was 55% (range 22-99%) and 60% (range 19-100%), respectively. The proportion of women with unknown HIV status, tested for HIV at labor ward was 70%. Overall, 79% (range 44-100%) of infants were tested for HIV and 11% (range 3-18%) of them were HIV positive. We designed two PMTCT cascades using studies with outcomes for all perinatal PMTCT interventions which showed that an estimated 22% of all HIV positive women attending antenatal care and 11% of all HIV positive women delivering at labor ward were not notified about their HIV status and did not participate in PMTCT program. Only 17% of HIV positive antenatal care attendees and their infants are known to have taken antiretroviral prophylaxis.

CONCLUSION

The existing evidence provides information only about the initial PMTCT programs which were based on the old WHO PMTCT guidelines. The uptake of counseling and HIV testing among pregnant women attending antenatal care was high, but their retention in PMTCT programs was low. The majority of women in the included studies did not receive ARV prophylaxis in antenatal care; nor did they attend labor ward. More studies evaluating the uptake in current PMTCT programs are urgently needed.

Loss to Followup: A Major Challenge to Successful Implementation of Prevention of Mother-to-Child Transmission of HIV-1 Programs in Sub-Saharan Africa

Purpose. The purpose of this paper was to explore how loss to followup (LFTU) has affected the successful implementation of prevention of mother to child transmission of HIV-1 (PMTCT) programs in sub-Saharan Africa. Methods. We conducted an electronic search from the following databases PubMed, ScienceDirect, Directory of Open Access Journals (DOAJs), and PyscINFO. Additional searches were made in WHO, UNAIDS, UNICEF, Google, and Google scholar websites for (1) peer-reviewed published research, (2) scientific and technical reports, and (3) papers presented on scientific conferences. Results. A total of 678 articles, published from 1990 to 2011, were retrieved. Only 44 articles met our inclusion criteria and were included in the study. The rates of LTFU of mother-child pairs ranged from 19% to 89.4 in the reviewed articles. Health facility factors, fear of HIV-1 test, stigma and discrimination, home deliveries and socioeconomic factors were identified as reasons for LTFU. Conclusion. There is a great loss of mother-child pairs to follow up in PMTCT programs in sub-Saharan Africa. There is need for more research studies to develop public health models of care that can help to improve followup of mother-child pairs in PMTCT programs in Sub-Saharan Africa.

Improving data quality and supervision of antiretroviral therapy sites in Malawi: an application of Lot Quality Assurance Sampling

Background

High quality program data is critical for managing, monitoring, and evaluating national HIV treatment programs. By 2009, the Malawi Ministry of Health had initiated more than 270,000 patients on HIV treatment at 377 sites. Quarterly supervision of these antiretroviral therapy (ART) sites ensures high quality care, but the time currently dedicated to exhaustive record review and data cleaning detracts from other critical components. The exhaustive record review is unlikely to be sustainable long term because of the resources required and increasing number of patients on ART. This study quantifies the current levels of data quality and evaluates Lot Quality Assurance Sampling (LQAS) as a tool to prioritize sites with low data quality, thus lowering costs while maintaining sufficient quality for program monitoring and patient care.

Methods

In January 2010, a study team joined supervision teams at 19 sites purposely selected to reflect the variety of ART sites. During the exhaustive data review, the time allocated to data cleaning and data discrepancies were documented. The team then randomly sampled 76 records from each site, recording secondary outcomes and the time required for sampling.

Results

At the 19 sites, only 1.2% of records had discrepancies in patient outcomes and 0.4% in treatment regimen. However, data cleaning took 28.5 hours in total, suggesting that data cleaning for all 377 ART sites would require over 350 supervision-hours quarterly. The LQAS tool accurately identified the sites with the low data quality, reduced the time for data cleaning by 70%, and allowed for reporting on secondary outcomes.

Conclusions

Most sites maintained high quality records. In spite of this, data cleaning required significant amounts of time with little effect on program estimates of patient outcomes. LQAS conserves resources while maintaining sufficient data quality for program assessment and management to allow for quality patient care.

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

Background

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

Methods

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

Results

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

Conclusion

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

Health facility characteristics and their relationship to coverage of PMTCT of HIV services across four African countries: the PEARL study

BACKGROUND

Health facility characteristics associated with effective prevention of mother-to-child transmission of HIV (PMTCT) coverage in sub-Saharan are poorly understood.

METHODOLOGY/PRINCIPAL FINDINGS

We conducted surveys in health facilities with active PMTCT services in Cameroon, Cote d'Ivoire, South Africa, and Zambia. Data was compiled via direct observation and exit interviews. We constructed composite scores to describe provision of PMTCT services across seven topical areas: antenatal quality, PMTCT quality, supplies available, patient satisfaction, patient understanding of medication, and infrastructure quality. Pearson correlations and Generalized Estimating Equations (GEE) to account for clustering of facilities within countries were used to evaluate the relationship between the composite scores, total time of visit and select individual variables with PMTCT coverage among women delivering. Between July 2008 and May 2009, we collected data from 32 facilities; 78% were managed by the government health system. An opt-out approach for HIV testing was used in 100% of facilities in Zambia, 63% in Cameroon, and none in Côte d'Ivoire or South Africa. Using Pearson correlations, PMTCT coverage (median of 55%, (IQR: 33-68) was correlated with PMTCT quality score (rho = 0.51; p = 0.003); infrastructure quality score (rho = 0.43; p = 0.017); time spent at clinic (rho = 0.47; p = 0.013); patient understanding of medications score (rho = 0.51; p = 0.006); and patient satisfaction quality score (rho = 0.38; p = 0.031). PMTCT coverage was marginally correlated with the antenatal quality score (rho = 0.304; p = 0.091). Using GEE adjustment for clustering, the, antenatal quality score became more strongly associated with PMTCT coverage (p<0.001) and the PMTCT quality score and patient understanding of medications remained marginally significant.

CONCLUSIONS/RESULTS

We observed a positive relationship between an antenatal quality score and PMTCT coverage but did not identify a consistent set of variables that predicted PMTCT coverage.

Mothers' knowledge and utilization of prevention of mother to child transmission services in northern Tanzania

BACKGROUND

More than 90% of children living with HIV have been infected through mother to child transmission. The aims of our present study were to: (1) assess the utilization of the prevention of mother to child transmission (PMTCT) services in five reproductive and child health clinics in Moshi, northern Tanzania, after the implementation of routine counselling and testing; (2) explore the level of knowledge the postnatal mothers had about PMTCT; and (3) assess the quality of the counselling given.

METHODS

This study was conducted in 2007 and 2008 in rural and urban areas of Moshi in the Kilimanjaro region of Tanzania. Mixed methods were used. We interviewed 446 mothers when they brought their four-week-old infants to five reproductive and child health clinics for immunization. On average, the urban clinics included in the study had implemented the programme two years earlier than the rural clinics. We also conducted 13 in-depth interviews with mothers and nurses, four focus group discussions with mothers, and four observations of mothers receiving counselling.

RESULTS

Nearly all mothers (98%) were offered HIV testing, and all who were offered accepted. However, the counselling was hasty with little time for clarifications. Mothers attending urban antenatal clinics tended to be more knowledgeable about PMTCT than the rural attendees. Compared with previous studies in the area, our study found that PMTCT knowledge had increased and the counsellors had greater confidence in their counselling.

CONCLUSIONS

Routine counselling and testing for HIV at the antenatal clinics was greatly accepted and included practically every mother in this time period. However, the counselling was suboptimal due to time and resource constraints. We interpret the higher level of PMTCT knowledge among the urban as opposed to the rural attendees as a result of differences in the start up of the PMTCT programme and, thus, programme maturation. After comparison with earlier studies conducted in this setting, we conclude that when the programme has had time to get established, both its acceptance and the understanding of the topics dealt with during the counselling increases.

Improving the coverage of the PMTCT programme through a participatory quality improvement intervention in South Africa

BACKGROUND

Despite several years of implementation, prevention of mother-to-child transmission (PMTCT) programmes in many resource poor settings are failing to reach the majority of HIV positive women. We report on a data driven participatory quality improvement intervention implemented in a high HIV prevalence district in South Africa.

METHODS

A participatory quality improvement intervention was implemented consisting of an initial assessment undertaken by a team of district supervisors, workshops to assess results, identify weaknesses and set improvement targets and continuous monitoring to support changes.

RESULTS

The assessment highlighted weaknesses in training and supervision. Routine data revealed poor coverage of all programme indicators except HIV testing. Monthly support to all facilities took place including an orientation to the PMTCT protocol, review of local data and identification of bottlenecks to optimal coverage using a continuous quality improvement approach. One year following the intervention large improvements in programme indicators were observed. Coverage of CD4 testing increased from 40 to 97%, uptake of maternal nevirapine from 57 to 96%, uptake of infant nevirapine from 15 to 68% and six week PCR testing from 24 to 68%.

CONCLUSION

It is estimated that these improvements in coverage could avert 580 new infant infections per year in this district. This relatively simple participatory assessment and intervention process has enabled programme managers to use a data driven approach to improve the coverage of this important programme.

Determinants of knowledge of HIV status in South Africa: results from a population-based HIV survey

BACKGROUND

Over 30% of women and men in the South African national HIV household of 2005 indicated that they had previously been tested for HIV (of which 91% were aware of their test results). This paper seeks to describe the associations between socio-demographic, behavioural and social characteristics and knowledge of HIV status among a nationally representative population in South Africa.

METHODS

A multistage probability sample involving 16395 male and female respondents, aged 15 years or older was selected. The sample was representative of the South African population by age, race, province and type of living area, e.g. urban formal, urban informal, etc. Respondents were interviewed on HIV knowledge, perceptions and behaviour and provided blood for research HIV testing. Bivariate and multivariate logistic regression was used to identify socio-demographic, social and behavioural factors associated with knowledge of HIV status.

RESULTS

From the total sample 27.6% ever and 7.8% knew their HIV status in the past 12 months. In multivariate analyses being female, the age group 25 to 34 years old, other than African Black population group (White, Coloured, Asian), higher educational level, being employed, urban residence, awareness of a place nearby where one could be tested for HIV, impact of HIV on the household and having had two of more sexual partners in the past year were associated with knowledge of HIV status. Among HIV positive persons awareness of a place nearby where one could be tested for HIV and impact of HIV on the household were associated knowledge of HIV status, and among HIV negative persons HIV risk behaviour (multiple partners, no condom use), awareness of a place nearby where one could be tested for HIV, higher knowledge score on HIV and knowledge of serodiscordance were associated knowledge of HIV status.

CONCLUSION

Education about HIV/AIDS and access to HIV counselling and testing (HCT) in rural areas, in particular among the Black African population group needs to be improved, in order to enhance the uptake of HIV counselling and testing services, an essential step for the initiation of treatment.

Infant feeding, HIV transmission and mortality at 18 months: the need for appropriate choices by mothers and prioritization within programmes

OBJECTIVES

To determine the late HIV transmission and survival risks associated with early infant feeding practices.

DESIGN

A nonrandomized intervention cohort.

METHODS

HIV-infected pregnant women were supported in their infant feeding choices. Infant feeding data were obtained weekly; blood samples from infants were taken monthly to diagnose HIV infection. Eighteen-month mortality and HIV transmission risk were assessed according to infant feeding practices at 6 months.

RESULTS

One thousand one hundred and ninety-three live-born infants were included. Overall 18-month probabilities of death (95% confidence interval) were 0.04 (0.03-0.06) and 0.53 (0.46-0.60) for HIV-uninfected and HIV-infected children, respectively. The eighteen-month probability of survival was not statistically significantly different for HIV-uninfected infants breastfed or replacement fed from birth. In univariate analysis of infant feeding practices, the probability of HIV-free survival beyond the first 6 months of life in children alive at 6 months was 0.98 (0.89-1.00) amongst infants replacement fed from birth, 0.96 (0.90-0.98; P = 0.25) and 0.91 (0.87-0.94; P = 0.03) in those breastfed for less or more than 6 months, respectively. In multivariable analyses, maternal unemployment and low antenatal CD4 cell count were independently associated with more than three-fold increased risk of infant HIV infection or death.

CONCLUSION

Breastfeeding and replacement feeding of HIV-uninfected infants were associated with similar mortality rates at 18 months. However, these findings were amongst mothers and infants who received excellent support to first make, and then practice, appropriate infant feeding choices. For programmes to achieve similar results, the quality of counselling and identification of mothers with low CD4 cell count need to be the targets of improvement strategies.

Missed opportunities for participation in prevention of mother to child transmission programmes: simplicity of nevirapine does not necessarily lead to optimal uptake, a qualitative study

BACKGROUND

The objective of this study was to examine missed opportunities for participation in a prevention of mother-to-child transmission (PMTCT) programme in three sites in South Africa. A rapid anthropological assessment was used to collect in-depth data from 58 HIV-positive women who were enrolled in a larger cohort study to assess mother-to-child HIV transmission. Semi-structured interviews were conducted with the women in order to gain an understanding of their experiences of antenatal care and to identify missed opportunities for participation in PMTCT.

RESULTS

15 women actually missed their nevirapine not because of stigma and ignorance but because of health systems failures. Six were not tested for HIV during antenatal care. Two were tested but did not receive their results. Seven were tested and received their results, but did not receive nevirapine. Health Systems failure for these programme leakages ranged from non-availability of counselors, supplies such as HIV test kits, consent forms, health staff giving the women incorrect instructions about when to take the tablet and health staff not supplying the women with the tablet to take.

CONCLUSION

HIV testing enables access to PMTCT interventions and should therefore be strengthened. The single dose nevirapine regimen is simple to implement but the all or nothing nature of the regimen may result in many missed opportunities. A short course dual or triple drug regimen could increase the effectiveness of PMTCT programmes.

Monitoring and evaluation of programmes to prevent mother to child transmission of HIV in Africa

Many countries are expanding the coverage of programmes to prevent mother to child transmission of HIV. Although the need is unquestionable, Richard Reithinger and colleagues are concerned that without true measures of effectiveness we may not be making the best use of resources