Implementation of Point-of-Care Diagnostics Leads to Variable Uptake of Syphilis, Anemia and CD4+ T-Cell Count Testing in Rural Maternal and Child Health Clinics

Abstract

IntroductionAnemia, syphilis and HIV are high burden diseases among pregnant women in sub-Saharan Africa. A quasi-experimental study was conducted in four health facilities in Southern Mozambique to evaluate the effect of point-of-care technologies for hemoglobin quantification, syphilis testing and CD4+ T-cell enumeration performed within maternal and child health services on testing and treatment coverage, and assessing acceptability by health workers.MethodsDemographic and testing data on women attending first antenatal care services were extracted from existing records, before (2011; n = 865) and after (2012; n = 808) introduction of point-of-care testing. Study outcomes per health facility were compared using z-tests (categorical variables) and Wilcoxon rank-sum test (continuous variables), while inverse variance weights were used to adjust for possible cluster effects in the pooled analysis. A structured acceptability-assessment interview was conducted with health workers before (n = 22) and after (n = 19).ResultsAfter implementation of point-of-care testing, there was no significant change in uptake of overall hemoglobin screening (67.9% to 83.0%; p = 0.229), syphilis screening (80.8% to 87.0%; p = 0.282) and CD4+ T-cell testing (84.9% to 83.5%; p = 0.930). Initiation of antiretroviral therapy for treatment eligible women was similar in the weighted analysis before and after, with variability among the sites. Time from HIV diagnosis to treatment initiation decreased (median of 44 days to 17 days; p<0.0001). A generally good acceptability for point-of-care testing was seen among health workers.ConclusionsPoint-of-care CD4+ T-cell enumeration resulted in a decreased time to initiation of antiretroviral therapy among treatment eligible women, without significant increase in testing coverage. Overall hemoglobin and syphilis screening increased. Despite the perception that point-of-care technologies increase access to health services, the variability in results indicate the potential for detrimental effects in some settings. Local context needs to be considered and services restructured to accommodate innovative technologies in order to improve service delivery to expectant mothers.

A study to better understand under-utilization of laboratory tests for antenatal care in Senegal

“…However, when rapid tests for HIV (free) and/or proteinuria (not free) were conducted at ANC, a subgroup of women had results for these tests only. Similarly, experiences with POCT for syphilis [25] and CD4+ T-cell enumeration [26] showed wide variability in uptake, indicating the potential for detrimental effects in some settings or sub-populations. If importance of a full ANC laboratory tests packages could be promoted through a health systems approach, then goals and funding of vertical programs could be utilized to improve lab test uptake and quality and levels of service delivery.…”

Impact of Implementing Antenatal Syphilis Point-of-Care Testing on Maternal Mortality in KwaZulu-Natal, South Africa: An Interrupted Time Series Analysis

“…As POC tests are being increasingly designed for use in resource-limited settings [37,38], rigorous assessment of the impact of current and future POC tests on key health outcomes is crucial in order to justify scale up or test replacement. This is supported by De Schacht et al studies which recommend the need to identify optimal health delivery strategies to effectively bring the impact of technological advances such as POC testing to patients that are most at need [13]. Due to the recently reported increasing prevalence of HIV among women in KZN [29], detection of treatable infections that are associated with HIV transmission is crucial for the reduction of HIV-related maternal mortality.…”

“…This was implemented to help improve healthcare access and neonatal health outcomes [7][8][9][10][11]. The introduction of syphilis POC testing has been shown to be effective in strengthening health systems by improving access to quality-assured prenatal screening and saving new-born lives in resource-limited settings [12,13]. The results of our survey which was aimed at determining the availability and utility of POC diagnostics in rural KZN has demonstrated that syphilis testing was available and used in all districts, but the level of availability and use varied from clinic to clinic [14].…”

Improving the Accessibility and Efficiency of Point-of-Care Diagnostics Services in Low- and Middle-Income Countries: Lean and Agile Supply Chain Management

“…Access to rapid and simple POC diagnostics services in healthcare facilities that lack or have poor laboratory infrastructure and inadequately skilled healthcare workers can improve health outcomes in those areas. Luppa et al provided an in-depth review of POC testing to address clinically important analytical techniques, organizational concepts, clinical applications, and trends in healthcare [ 8 , 16 ]. However, this review provides an overview of the impact of POC diagnostics on healthcare outcomes and factors that contribute to the accessibility of POC diagnostics in LMICs, such as characteristics of the supply chain management and quality management systems, characteristics of the geographical location, health infrastructure, and an enabling policy framework for POC diagnostics services.…”