Lesotho's minimum PMTCT package: lessons learned for combating vertical HIV transmission using co-packaged medicines

The state of the pediatric HIV epidemic in Lesotho

OBJECTIVE

Lesotho does not have reliable data on HIV prevalence in children, relying on estimates generated from program data. The 2016 Lesotho Population-based HIV Impact Assessment (LePHIA) aimed to determine HIV prevalence among children 0-14 years to assess the effectiveness of the prevention of mother-to-child transmission (PMTCT) program and guide future policy.

METHODS

A nationally representative sample of children under 15 years underwent household-based, two-stage HIV testing from November 2016-May 2017. Children <18 months with a reactive screening test were tested for HIV infection using total nucleic acid (TNA) PCR. Parents (61.1%) or legal guardians (38.9%) provided information on children's clinical history. Children aged 10-14 years also answered a questionnaire on knowledge and behaviors.

RESULTS

HIV prevalence was 2.1% [95% confidence interval (CI): 1.5-2.6]. Prevalence in 10-14 year olds (3.2%; 95% CI: 2.1, 4.2) was significantly greater compared to 0-4 year olds (1.0%; 95% CI: 0.5, 1.6). HIV prevalence in girls and boys was 2.6% (95% CI: 1.8-3.3) and 1.5% (95% CI: 1.0-2.1), respectively. Based on reported status and/or the presence of detectable antiretrovirals, 81.1% (95% CI: 71.7-90.4) of HIV-positive children were aware of their status, 98.2% (95% CI: 90.7-100.0) of those aware were on antiretroviral therapy (ART) and 73.9% (95% CI: 62.1-85.8) of those on ART were virally suppressed.

CONCLUSIONS

Despite the roll-out of Option B+ in Lesotho in 2013, pediatric HIV prevalence remains high. Further research is required to understand the greater prevalence among girls, barriers to PMTCT, and how to better achieve viral suppression in children with HIV.

Programmatic Retention in Prevention of Mother-to-Child Transmission (PMTCT) Programs: Estimated Rates and Cofactors Using Different Nonretention Measures

BACKGROUND

Prevention of mother-to-child transmission programs serve women continuing and initiating antiretroviral therapy (ART) in pregnancy, and follow-up schedules align to delivery rather than ART initiation, making conventional HIV retention measures (assessed from ART initiation) challenging to apply. We evaluated 3 measures of peripartum nonretention in Kenyan women living with HIV from pregnancy to 2 years postpartum.

METHODS

This longitudinal analysis used programmatic data from the Mobile WAChX trial (NCT02400671). Outcomes included loss to follow-up (LTFU) (no visit for ≥6 months), incomplete visit coverage (<80% of 3-month intervals with a visit), and late visits (>2 weeks after scheduled date). Predictors of nonretention were determined using Cox proportional hazards, log-binomial, and generalized estimating equation models.

RESULTS

Among 813 women enrolled at a median of 24 weeks gestation, incidence of LTFU was 13.6/100 person-years; cumulative incidence of LTFU by 6, 12, and 24 months postpartum was 16.7%, 20.9%, and 22.5%, respectively. Overall, 35.5% of women had incomplete visit coverage. Among 794 women with 12,437 scheduled visits, a median of 11.1% of visits per woman were late (interquartile range 4.3%-23.5%). Younger age, unsuppressed viral load, unemployment, ART initiation in pregnancy, and nondisclosure were associated with nonretention by all measures. Partner involvement was associated with better visit coverage and timely attendance. Women who became LTFU had higher frequency of previous late visits (16.7% vs. 7.7%, P < 0.0001).

CONCLUSIONS

Late visit attendance may be a sentinel indicator of LTFU. Identified cofactors of prevention of mother-to-child transmission programmatic retention may differ depending on retention measure assessed, highlighting the need for standardized measures.

Challenges and commonly used countermeasures in the implementation of lifelong antiretroviral therapy for PMTCT in Central Uganda: Health providers' perspective

INTRODUCTION

Uganda has implemented lifelong antiretroviral therapy for the prevention of mother-to-child HIV transmission since September 2012. Implementation of this strategy has been met with health provider and client challenges which have persisted up to date. This study explored providers' perspectives on the challenges and countermeasures of the implementation and scale-up of lifelong ART among pregnant and breastfeeding women.

METHODS

A qualitative descriptive study was conducted whereby 54 purposively selected participants from six facilities in three districts of Central Uganda namely; Masaka, Mityana, and Luwero were recruited. A key informant interview guide was used to collect data from the study participants. The data were thematically analysed using Atlas-ti, Version 7.

RESULTS

Study participants reported challenges under the themes of 1) inadequacy of HIV service delivery (lack of relevant training, health provider shortages, inadequate counselling, stock-outs of essential HIV commodities); 2) Non-utilization of HIV services (Non-disclosure of HIV- positive results, denial of HIV positive results, fear to be followed up, unwillingness to be referred, large catchment area, lack of transport); and 3) Suboptimal treatment adherence (fear of ART side effects, preference for traditional medicines, low male partner involvement in care and treatment). Strategies such as on-job training, mentorship, task shifting, redistribution of HIV commodities across facilities, accompanying of women to mother-baby care points, ongoing counseling of women, peers, and family support groups were commonly used countermeasures.

CONCLUSIONS

This study highlights key challenges that health providers face in implementing lifelong antiretroviral therapy services among pregnant and postpartum women. Context-specific, innovative, and multilevel system interventions are required at national, district, health facility, community and individual levels to scale up and sustain the lifelong antiretroviral therapy strategy among pregnant and breastfeeding women.

How is implementation research applied to advance health in low-income and middle-income countries?

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.

Supply kits for antenatal and childbirth care: a systematic review

INTRODUCTION

It is critical to increase the uptake of interventions proven to be effective to improve maternal and perinatal outcomes. Supply kits have been suggested to be a feasible strategy designed to ensure timely availability and effective follow-up of care.

OBJECTIVE

We conducted a systematic review to summarize the evidence on the uptake, effectiveness and safety of supply kits for maternal care.

SEARCH STRATEGY

MEDLINE, the Cochrane Pregnancy and Childbirth Group's Trials Register, Campbell Collaboration, Lilacs, Embase and unpublished studies were searched.

SELECTION CRITERIA

Studies that reported the efficacy, safety and use of supply kits for maternal healthcare were eligible. Participants were pregnant women or in childbirth. Supply kits were defined as a collection of medicines, supplies or instruments packaged together with the aim of conducting a healthcare task.

DATA COLLECTION AND ANALYSIS

Two reviewers independently performed the screening, data extraction, and methodological and quality assessment.

MAIN RESULTS

24 studies were included: 4 of them were systematic reviews and 20 primary studies. Eighteen studies evaluated a so-called "clean delivery kit". In all but two studies, the kits were used by more than half of the participants. A meta-analysis was deemed inappropriate due to the heterogeneity in study design, in the components of the interventions implemented, in the content of the kits, and in outcomes. Nine studies assessed neonatal outcomes and found statistically significant reductions in cord infection, sepsis and tetanus-related mortality in the intervention group. Three studies showed evidence of reduced neonatal mortality (OR 0.52, 0.60 and 0.71) with statistically significant confidence intervals in all cases. Four studies reported odd ratios for maternal mortality, but only one showed evidence of a statistically significant decrease in this outcome but it was ascribed to hand washing prior to childbirth and not with the use of kits.

CONCLUSION

This review suggests potential benefits in the use of supply kits to improve maternal and neonatal health. However, the observational nature of the studies, the heterogeneity and the use of kits incorporated within complex interventions limit the interpretation of the findings.

Supply kits for antenatal and childbirth care during antenatal care and delivery: a mixed-methods systematic review, the qualitative approach

Antenatal care reduces maternal and perinatal mortality and morbidity through the detection and treatment of some conditions, but its coverage is less than optimal within certain populations. Supply kits for maternal health were designed to overcome barriers present when providing care during pregnancy and childbirth particularly to women from underserved population.

We conducted a mixed-methods systematic review on the use of supply kits. This manuscript presents the findings from qualitative studies that reported barriers, facilitators, and user’s recommendation in the adoption and implementation of any type of kit designed to be used during pregnancy or childbirth.

This review included eight studies, and seven were implemented in developing countries. Most studies assessed the implementation of clean delivery kits to be used during labour and delivery, and contributed to gain insights into factors that may hinder or foster the use of kits.

Clean delivery kits were conceived to cope with barriers related mainly to access. The most important barrier identified were those related to the socio-cultural and the lack of knowledge dimension such as who held the decision-making authority in the household, as well as popular beliefs behind the idea that birth preparation could bring bad luck, may prevent clients from adhering to their use. In addition, financial constraints and limited understanding of the instructions of use were accessibility barriers found. On the other hand, once used, clean delivery kits for maternal health were accepted by women and health workers. Convenience, hygienic components, and avoidance of delays in receiving care were viewed as satisfactory features.

Supply kits are mostly affordable and easily deployable. Increasing awareness among the population about the offered kits and providing information on their benefits emerges as a critical step to foster use in settings where kits are available. Implementation of this strategy requires low complexity resources and could make the use of kits an accepted alternative to increase the use of evidence-based interventions and thus improve quality of care during pregnancy, childbirth and neonatal period mainly at the community level in low income countries and remote areas with low access.

A 30-year bibliometric analysis of research coverage on HIV and AIDS in Lesotho

Background

Given the well documented undesired impacts of HIV/AIDS globally, there is a need to create a statistical inventory of research output on HIV/AIDS. This need is particularly important for a country such as Lesotho, whose HIV/AIDS prevalence is one of the highest globally. Research on HIV/AIDS in sub-Saharan Africa continues to trail behind that of other regions, especially those of the developed countries. Lesotho, a sub-Saharan country, is a developing country with lower research output in this area when longitudinally compared to other countries. This study reviewed the volume and scope of the general research output on HIV/AIDS in Lesotho and assessed the coverage of the national research agenda on HIV/AIDS, making recourse to statistical principles.

Methods

A bibliometric review of studies on HIV/AIDS retrieved from the SCOPUS and PubMed databases, published within the 30-year period between 1985 and 2016, was conducted. The focus of each of the studies was analysed and the studies were cross-matched with the national research agenda in accordance with bibliometric methodologies.

Results

In total, 1280 studies comprising 1181 (92.3%) journal articles, 91 (7.1%) books and 8 (0.6%) conference proceedings were retrieved. By proportion, estimation of burden of infection (40.7%) had the highest research volume, while basic (5.5%) and preventive measures (24.4%) and national planning (29.4%) had the lowest. Out of the total studies retrieved, only 516 (40.3%) matched the national research agenda. Research on maternal and child health quality of care, viral load point-of-care devices, and infant point-of-care diagnosis had hardly any publications in the high priority research category of the agenda.

Conclusion

Notwithstanding a considerable research output on HIV/AIDS for Lesotho, there is insufficient coverage of the national research agenda in this research area. The major research gaps on general research output are in basic and preventive measures as well as national planning. There is also a need to increase targeted funding for HIV/AIDS research to appropriately address the most compelling gaps and national needs.

Pregnant and Postpartum Women's Experiences and Perspectives on the Acceptability and Feasibility of Copackaged Medicine for Antenatal Care and PMTCT in Lesotho

Objective. To improve PMTCT and antenatal care-related service delivery, a pack with centrally prepackaged medicine was rolled out to all pregnant women in Lesotho in 2011. This study assessed acceptability and feasibility of this copackaging mechanism for drug delivery among pregnant and postpartum women. Methods. Acceptability and feasibility were assessed in a mixed method, cross-sectional study through structured interviews (SI) and semistructured interviews (SSI) conducted in 2012 and 2013. Results. 290 HIV-negative women and 437 HIV-positive women (n = 727) participated. Nearly all SI participants found prepackaged medicines acceptable, though modifications such as size reduction of the pack were suggested. Positive experiences included that the pack helped women take pills as instructed and contents promoted healthy pregnancies. Negative experiences included inadvertent pregnancy disclosure and discomfort carrying the pack in communities. Implementation was also feasible; 85.2% of SI participants reported adequate counseling time, though 37.8% felt pack use caused clinic delays. SSI participants reported improvement in service quality following pack introduction, due to more comprehensive counseling. Conclusions. A prepackaged drug delivery mechanism for ANC/PMTCT medicines was acceptable and feasible. Findings support continued use of this approach in Lesotho with improved design modifications to reflect the current PMTCT program of lifelong treatment for all HIV-positive pregnant women.

Preventing tuberculosis among HIV-infected pregnant women in Lesotho: the case for rolling out active case finding and isoniazid preventive therapy

BACKGROUND

The Lesotho Ministry of Health issued guidelines on active case finding (ACF) for tuberculosis (TB) and isoniazid preventive therapy (IPT) in April 2011. ACF has been recommended in maternal and child health (MCH) settings globally, however, the feasibility of implementing IPT within MCH in countries with high concurrent HIV and TB epidemics is unknown.

DESIGN/METHODS

The study evaluated the implementation of ACF and IPT guidelines in MCH settings in 2 health facilities in Lesotho. This descriptive prospective study analyzed data collected during routine services. Categorical data and continuous variables were summarized using descriptive statistics. The χ test or Wilcoxon rank-sum test was used to ascertain significant associations between categorical and continuous variables, respectively.

RESULTS

Data from 160 HIV-positive and 640 HIV-negative women were reviewed. Within this study population, 99.8% of women were screened for TB, and 11.4% HIV-positive women compared with 2.3% HIV-negative women were reported to have symptoms of TB (P < 0.001). IPT was initiated in 124/158 (78.5%) HIV-positive pregnant women, 64.5% women completed a 6-month IPT regimen, 2 (1.6%) died of causes unrelated to IPT/TB, and 31.5% were lost to follow-up. Predictors of IPT initiation among HIV-positive women included gestational age at the first antenatal visit (unadjusted odds ratio, -0.93; 95% confidence interval: -0.88 to 0.98), and receipt of antiretroviral therapy for treatment rather than for prevention of mother-to-child transmission prophylaxis only (odds ratio, 4.59; 95% confidence interval: 1.32 to 15.93).

CONCLUSIONS

Implementation of ACF and IPT is feasible within the MCH setting. Uptake of IPT during pregnancy among HIV-positive women was high, but with a high rate of loss to follow-up.

Stock-outs of essential health products in Mozambique - longitudinal analyses from 2011 to 2013

OBJECTIVES

To assess the relationship between health system factors and facility-level EHP stock-outs in Mozambique.

METHODS

Service provisions were assessed in 26 health facilities and 13 district warehouses in Sofala Province, Mozambique, from July to August in 2011-2013. Generalised estimating equations were used to model factors associated with facility-level availability of essential drugs, supplies and equipment.

RESULTS

Stock-out rates for drugs ranged from 1.3% for oral rehydration solution to 20.5% for Depo-Provera and condoms, with a mean stock-out rate of 9.1%; mean stock-out rates were 15.4% for supplies and 4.1% for equipment. Stock-outs at the district level accounted for 27.1% (29/107) of facility-level drug stock-outs and 44.0% (37/84) of supply stock-outs. Each 10-km increase in the distance from district distribution warehouses was associated with a 31% (CI: 22-42%), 28% (CI: 17-40%) or 27% (CI: 7-50%) increase in rates of drug, supply or equipment stock-outs, respectively. The number of heath facility staff was consistently negatively associated with the occurrence of stock-outs.

CONCLUSIONS

Facility-level stock-outs of EHPs in Mozambique are common and appear to disproportionately affect those living far from district capitals and near facilities with few health staff. The majority of facility-level EHP stock-outs in Mozambique occur when stock exists at the district distribution centre. Innovative methods are urgently needed to improve EHP supply chains, requesting and ordering of drugs, facility and district communication, and forecasting of future EHP needs in Mozambique. Increased investments in public-sector human resources for health could potentially decrease the occurrence of EHP stock-outs.