Implementation and Operational Research

Abstract

Objective In 2011, Malawi implemented Option B+ (B+), lifelong antiretroviral therapy (ART) for pregnant and breast-feeding women. We aimed to describe changes in service uptake and outcomes along the antenatal PMTCT cascade post B+ implementation. Design Pre/post study using routinely collected program data from two large Lilongwe-based health centers. Methods We compared testing of HIV-infected pregnant women at antenatal care, enrollment into PMTCT services, receipt of ART and six-month ART outcomes pre- (Oct 2009–Mar 2011) and post- (Oct 2011–Mar 2013) B+. Results A total of 13,926 (pre) and 14,532 (post) women presented to antenatal care. Post-B+ a smaller proportion were HIV tested (99.3% vs. 87.7% post-; p<0.0001). There were 1654 (pre) and 1535 (post) HIV-infected women identified, with a larger proportion already known to be HIV-infected (18.1% vs. 41.2% post-; p<0.001) and on ART post-B+ (18.7% vs. 30.2% post-; p<0.001). A significantly greater proportion enrolled into the PMTCT program (68.3% vs. 92.6% post-; p<0.001) and was retained through delivery post-B+ (51.1% vs. 65% post-; p<0.0001). Amongst those not on ART at enrollment there was no change in the proportion newly initiating ART/ARVs (79% vs. 81.9% post-; p=0.11); although median days to initiation of ART decreased (48d [19,130] vs. 0d [0,15.5] post-; p<0.001). Amongst those newly initiating ART, a smaller proportion was alive on ART six-months post-initiation (89.3% vs. 78.8% post-; p=0.0004). Conclusion While several improvements in PMTCT program performance were noted with implementation of B+, challenges remain at several critical steps along the cascade requiring innovative solutions to ensure an AIDS-free generation.

Maximizing adherence and retention for women living with HIV and their infants in Kenya (MOTIVATE! study): study protocol for a randomized controlled trial

“…In this program, pregnant women who initiated ART for PMTCT had a fivefold higher risk of failure to return to clinic compared to those who started ART for their own health [3]. Retention in PMTCT in this program has varied between 65 and 87% [3–6]. A similar picture of imperfect engagement in care is observed across other sub-Saharan African Option B+ programs: 88% retained at 6 months in Ethiopia [7], 83% retained at 6 months in Zimbabwe [8], 66% retained at 1 year in Ghana [9], and 66% completing postnatal follow-up in Nigeria [10].…”

A systematic review of interventions to improve prevention of mother‐to‐child HIV transmission service delivery and promote retention

“…These steps, also referred to us the PMTCT cascade, include maternal HIV testing; and for HIV-positive mothers, assessment of treatment eligibility, initiation of maternal antiretroviral (ARV) drugs or antiretroviral therapy (ART), initiation of infant ARV, infant HIV testing and ART initiation for HIV-infected infants [1]. Approximately 90% retention is required at each step to effectively reduce mother-to-child transmission of HIV (MTCT) [2].…”

“…Approximately 90% retention is required at each step to effectively reduce mother-to-child transmission of HIV (MTCT) [2]. However, loss to follow-up occurs at all stages of the PMTCT cascade [1]. A systematic review of 44 studies in sub-Saharan Africa showed that 94% of pregnant women were tested for HIV, 70% of those who were HIV-positive initiated ARV/ART, 64% of the HIV-exposed infants (HEIs) were tested for HIV at six weeks and 55% of these infants received their final diagnosis at 18 months [3].…”

Implementation and Operational Research: Impact of a Systems Engineering Intervention on PMTCT Service Delivery in Côte d'Ivoire, Kenya, Mozambique: A Cluster Randomized Trial

“…15 A sizable proportion of women – who may feel healthy – refuse or default from cART 4,16,17 or receive no ARVs at all, 18 putting them at risk of increased MTCT. Data on long-term retention and adherence are as yet lacking.…”