Implementation Research for the Prevention of Mother-to-Child HIV Transmission in Sub-Saharan Africa: Existing Evidence, Current Gaps, and New Opportunities

Abstract

Tremendous gains have been made in the prevention of mother-to-child HIV transmission (PMTCT) in sub-Saharan Africa. Ambitious goals for the “virtual elimination” of pediatric HIV appear increasingly feasible, driven by new scientific advances, forward-thinking health policy, and substantial donor investment. To fulfill this promise, however, rapid and effective implementation of evidence-based practices must be brought to scale across a diversity of settings. The discipline of implementation research can facilitate this translation from policy into practice; however, to date, its core principles and frameworks have been inconsistently applied in the field. We reviewed the recent developments in implementation research across each of the four “prongs” of a comprehensive PMTCT approach. While significant progress continues to be made, a greater emphasis on context, fidelity, and scalability – in the design and dissemination of study results – would greatly enhance current efforts and provide the necessary foundation for future evidence-based programs.

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

“…In future publications, our group will explore facility-level factors that explain variations in the fidelity of SAIA implementation, such as leadership engagement, using qualitative data from focus group discussions with health facility staff at the study’s conclusion. 44 Our intervention intrinsically incorporates context, a key consideration in implementation science: 15 microinterventions were responsive to facility-specific barriers, as identified by staff themselves. While being inherently context-specific, the intervention is also applicable to diverse settings and healthcare contexts, even those beyond PMTCT.…”

“…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.…”

Linkage to Care, Early Infant Diagnosis, and Perinatal Transmission Among Infants Born to HIV-Infected Nigerian Mothers: Evidence From the Healthy Beginning Initiative

“…40 Few intervention studies have targeted critical steps for PMTCT further down the continuum of care, and IS research is needed to improve EID uptake, ARV prophylaxis for exposed newborns, and linkage to care for HIV-infected infants. 41 …”

Southern Africa: the Highest Priority Region for HIV Prevention and Care Interventions

“…While political and social awareness regarding HIV/AIDS increases, effective and well-sustained implementation remains a looming challenge for both prevention and treatment. Bhardwaj et al, Williams et al, and Shaunabe and Bock all reference implementation challenges, explaining significant roadblocks in the deploy of effective Option B+ programs and early infant diagnosis (EID), patient monitoring and data collection, and implementation of combination prevention strategies, respectively [•2,•6,•25]. Bolton-Moore and Ciaraldi focus their presentation on the challenges and lessons learned from program expansion and scale-up, emphasizing the need for a sustainable chronic disease care management system for HIV [•5].…”

“…Bolton-Moore and Ciaraldi tackle the health systems issues that underscore these health disparities and highlight areas of ongoing need and improvement [•5]. Bhardwaj et al do the same with the focus on issues specifically related to mothers, neonates, and children, an area of considerable progress in South Africa, for example [Figure], but less so in Mozambique [•6,7,8]. …”