Implementation and Operational Research

Abstract

Background Integrating antenatal care (ANC) and HIV care may improve uptake and retention in services along the prevention of mother-to-child transmission (PMTCT) cascade. The current study aimed to determine if integration of HIV services into ANC settings improves PMTCT service utilization outcomes. Methods ANC clinics in rural Kenya were randomized to integrated (6 clinics, 569 women) or non-integrated (6 clinics, 603 women) services. Intervention clinics provided all HIV services, including highly active antiretroviral therapy (HAART), while control clinics provided PMTCT services but referred women to HIV care clinics within the same facility. PMTCT utilization outcomes among HIV-infected women (maternal HIV care enrollment, HAART initiation, and 3-month infant HIV testing uptake) were compared using generalized estimating equations and Cox regression. Results HIV care enrollment was higher in intervention compared to control clinics (69% versus 36%, Odds Ratio (OR)=3.94, 95% Confidence Interval (CI): 1.14–13.63). Median time to enrollment was significantly shorter among intervention arm women (0 versus 8 days, Hazard Ratio (HR)=2.20, 95% CI: 1.62–3.01). Eligible women in the intervention arm were more likely to initiate HAART (40% versus 17%, OR=3.22, 95% CI: 1.81–5.72). Infant testing was more common in the intervention arm (25% versus 18%), however not statistically different. No significant differences were detected in postnatal service uptake or maternal retention. Conclusions Service integration increased maternal HIV care enrollment and HAART uptake. However, PMTCT utilization outcomes were still suboptimal, and postnatal service utilization remained poor in both study arms. Further improvements in the PMTCT cascade will require additional research and interventions.

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

“…Most studies measured several outcomes on the PMTCT cascade. Most studies were conducted in sub-Saharan Africa: 13 in South Africa [5–17]; eight in Kenya [18–25]; two studies each in Malawi [26,27], Zambia [28,29] and Mozambique [30,31]; and one study each in Democratic Republic of Congo [32], Swaziland [33], Tanzania [34], Rwanda [35] and Ethiopia [36]. Only one study was conducted in United States of America [37].…”

“…Eleven studies evaluated structural interventions [9,10,18,20,24,28–30,33,35,37]. Structural interventions were defined as interventions that aimed to improve PMTCT service delivery by modifying the structural context of a health facility.…”

“…Structural interventions were defined as interventions that aimed to improve PMTCT service delivery by modifying the structural context of a health facility. Eight studies integrated antenatal care (ANC) and HIV treatment services in a single clinic to increase uptake of HIV care and treatment for women and infants [9,10,18,20,24,28,29,35]. One study that integrated HIV and ANC services also trained ANC nurses and midwives, employed lab courier to expedite CD4 count receipt, and conducted home visits and active tracing of mother-infant pairs by lay counsellors [29].…”

“…Five out the six studies [18,20,22,29,36] that evaluated various interventions (peer mentoring, mobile phone texting, integration of ANC and PMTCT services, training of midwives and lab courier services for CD4 count) to improve the uptake of final diagnosis for HEIs, showed statistically significant benefits. The follow-up periods ranged between 9 and 18 months.…”

“…Nevertheless, the studies reviewed and two previous systematic reviews did not find evidence of significant effectiveness on the uptake of PMTCT services [43,44]. Several reasons for the scant evidence of PMTCT service integration on improving service delivery have been identified, including poor infrastructure, shortage of trained health care workers, low rates of client retention, the small number of study sites and poor service data collection [9,10,18,24]. …”