A secondary analysis of retention across the PMTCT cascade in selected countries: Rwanda, Malawi, Kenya, and Swaziland

Abstract

This report was made possible through support provided by the President's Emergency Plan for AIDS Relief and the U.S. Agency for International Development (USAID) via HIVCore, a Task Order funded by USAID under the Project SEARCH indefinite quantity contract (Contract No. AID-OAA-TO-11-00060). HIVCore improves the efficiency, effectiveness, scale, and quality of HIV treatment, care, and support, and prevention of mother-to-child transmission (PMTCT) programs. The Task Order is led by the Population Council in partnership with the Futures Group, the Elizabeth Glaser Pediatric AIDS Foundation, and the University of Washington.

A Novel Combined Mother-Infant Clinic to Optimize Post-Partum Maternal Retention, Service Utilization, and Linkage to Services in HIV Care in Rural Rwanda

“…Retention of infants in this cohort at 15-18 months was considerably higher (93.0%) than for other programs in the region, which have reported retention ranging from 33.0-79.2%,[ 9 , 26 ] including Rwanda (76.0%). [ 21 ] The HIV infection rate among HIV-exposed infants discharged from the Combined Clinic was low (1.1%), and consistent with national reports for MTCT in Rwanda (1.8%);[ 14 ] however, the transmission rate in this cohort may be underestimated due to missing results for 18-month tests and indeterminate results without documented confirmatory testing. Overall, rates of MTCT may be lower in Rwanda than in other SSA countries (8.8%)[ 27 ] due to wide availability of integrated PMTCT services, high uptake of routine PMTCT services (including prophylaxis and HIV testing), and early implementation of lifelong ART for pregnant women with HIV.…”

“…[ 6 , 18 - 20 ] In Rwanda, one recent report estimated a post-partum retention rate of 67% at 11-13 months. [ 21 ] Most PMTCT programs in SSA have separate mother and infant services[ 6 , 19 , 20 ] and attempts for service integration are unstructured and often restricted to prenatal, rather than post-partum care. [ 18 ] The barriers that mothers face in the prenatal period, such as lack of family or community support, stigma, waiting time at hospitals and transport difficulties[ 3 , 6 ] are heightened in the post-partum period, particularly with increased clinic visits when mother and infant services are separate.…”

Engagement in care among women and their infants lost to follow-up under Option B+ in eSwatini

“…[7] Mobility within the context of PMTCT among pregnant and postpartum women has been discussed in previous literature, though the degree to which this factor contributes to LTF among Option B+ populations is not well-established. [18,[30][31][32][33][34] In Eswatiniwhich is known to have a highly mobile population-mobility of patients and limitations to existing data systems present a widespread challenge to understanding true levels of engagement in care, and factors related to risk of disengagement. [31,32] Particularly high mobility during pregnancy and after delivery could also have adversely impacted our ability to ascertain outcomes via tracing, and may in part underlie the similar rates of tracing success in other studies of Option B+ populations, lower in relation to many tracing studies of general ART populations.…”

“…[18,[30][31][32][33][34] In Eswatiniwhich is known to have a highly mobile population-mobility of patients and limitations to existing data systems present a widespread challenge to understanding true levels of engagement in care, and factors related to risk of disengagement. [31,32] Particularly high mobility during pregnancy and after delivery could also have adversely impacted our ability to ascertain outcomes via tracing, and may in part underlie the similar rates of tracing success in other studies of Option B+ populations, lower in relation to many tracing studies of general ART populations. [16,17,35] In addition, findings of our exploratory analyses provide preliminary results for practice and future investigation.…”

“…The critical need to improve systems to allow for tracking of patients across time and service points-for example through implementation of a national unique identifier system-is widely understood, and numerous countries including Eswatini are in the process of implementing such a system. [1,32,36,37] However, there were particular gaps in national tools that resulted in missed opportunities to document outcomes, which could be addressed without need for linked national data incorporating unique identifiers. For example, the absence of structured documentation of pregnancy outcomes for ANC patients resulted in substantial undocumented, unreported pregnancy loss.…”