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

Abstract

BACKGROUND Efficacious interventions to prevent mother-to-child HIV transmission (PMTCT) have not translated well into effective programs. Prior studies of systems engineering applications to PMTCT lacked comparison groups or randomization. METHODS Thirty-six health facilities in Côte d’Ivoire, Kenya, and Mozambique were randomized to usual care or a systems engineering intervention, stratified by country and volume. The intervention guided facility staff to iteratively identify and then rectify barriers to PMTCT implementation. Registry data quantified coverage of HIV testing during first antenatal care visit, antiretrovirals (ARVs) for HIV-positive pregnant women, and screening HIV-exposed infants (HEI) for HIV by 6–8 weeks. We compared the change between baseline (January 2013–January 2014) and post-intervention (January–March 2015) periods using t-tests. All analyses were intent-to-treat. RESULTS ARV coverage increased 3-fold (+13.3 percentage points [95% CI: 0.5, 26.0] in intervention vs. +4.1 [−12.6, 20.7] in control facilities) and HEI screening increased 17-fold (+11.6 [−2.6, 25.7] in intervention vs. +0.7 [−12.9, 14.4] in control facilities). In pre-specified sub-group analyses, ARV coverage increased significantly in Kenya (+20.9 [−3.1, 44.9] in intervention vs. −21.2 [−52.7, 10.4] in controls; p=0.02). HEI screening increased significantly in Mozambique (+23.1 [10.3, 35.8] in intervention vs. +3.7 [−13.1, 20.6] in controls; p=0.04). HIV testing did not differ significantly between arms. CONCLUSIONS In this first randomized trial of systems engineering to improve PMTCT, we saw substantially larger improvements in ARV coverage and HEI screening in intervention facilities compared to controls, which were significant in pre-specified sub-groups. Systems engineering could strengthen PMTCT service delivery and protect infants from HIV.

Performance-Based Financing Empowers Health Workers Delivering Prevention of Vertical Transmission of HIV Services and Decreases Desire to Leave in Mozambique

“… 31 Challenges to implementation of national PVT policies and best practices are numerous at the point of care 32 and are linked with delivery of the specific services critical to PVT. 33 , 34 However, evaluation of the implementation of PBF interventions and the impact of PBF on intermediary constructs in the context of PVT are lacking.…”

Mother-to-child transmission of HIV in Kenya: A cross-sectional analysis of the national database over nine years

“…HIV-infected women who deliver outside of facilities tend to have lower income and be less educated and less likely to be on treatment[ 18 ], meaning that their infants are at especially high risk. Pilot interventions that have been shown to improve PMTCT program coverage, retention, and quality include mHealth tools[ 19 ] such as SMS[ 20 ], rapid results initiatives[ 21 ], systems engineering approaches[ 22 ], and efforts to reduce health provider absenteeism[ 23 ]; these could be considered in areas struggling with program performance. In addition, there likely remain inconsistencies with health provider care among women and infants enrolled in PMTCT programs.…”

Successful Deployment of High Flow Nasal Cannula in a Peruvian Pediatric Intensive Care Unit Using Implementation Science—Lessons Learned

“…Anyone who has attempted to enact change in an organization acknowledges the necessity of identifying local champions to oversee the intervention. Borrowing from the engineering industry, many health care organizations have adopted systems analysis and improvement approaches to improve the quality of health care delivery ( 9 , 17 ). These principles focus on involving frontline health care workers in both identifying problems in the current system as well as suggesting possible solutions to streamline the process.…”

“…Implementation science is a rapidly growing field dedicated to improving quality of health care delivery by incorporating evidence-based practices into routine care. Implementation science principles have guided the scale-up of interventions such as prevention of maternal-to-child transmission of HIV in resource-limited settings and could be applied to respiratory technologies to help ensure their success ( 8 , 9 ).…”