Increasing Retention in Care of HIV-Positive Women in PMTCT Services Through Continuous Quality Improvement–Breakthrough (CQI-BTS) Series in Primary and Secondary Health Care Facilities in Nigeria

Oyeledun, Bolanle; Oronsaye, Frank; Oyelade, Taiwo A.; Becquet, Renaud; Odoh, Deborah; Anyaike, Chukwuma; Ogirima, Francis; Ameh, Bernice; Ajibola, Abiola; Osibo, Bamidele; Imarhiagbe, Collins; Inedu, Abutu

doi:10.1097/qai.0000000000000320

Cited by 21 publications

(17 citation statements)

References 2 publications

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“…LTFU was defined as having no additional patient records after a particular stage of care. There are no standard definitions for retention-in-care or LTFU within the PMTCT care cascade [29], but increasingly definitions that incorporate adherence to scheduled visits are being used [30]. Although our definition of care compliance does not account for inconsistent attendance or adherence to ARVs, it requires that women access care across several different clinical settings (antenatal clinics, labor and delivery, and infant follow-up clinics).…”

Section: Methodsmentioning

confidence: 99%

Loss to Follow-Up within the Prevention of Mother-to-Child Transmission Care Cascade in a Large ART Program in Nigeria

Rawizza

Chang

Chaplin³

et al. 2015

CHR

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Background The 2013 WHO guidelines incorporated simplified and more effective antiretroviral regimens for the purposes of preventing mother-to-child transmission of HIV. With ideal implementation of these recommendations, perinatal HIV transmission could be reduced to less than 2%. However, loss to follow-up (LTFU) has the potential to erode the success of programs and a number of studies report high rates of LTFU within the prevention of mother-to-child transmission (PMTCT) care cascade. We evaluated the timing and magnitude of LTFU in a large programmatic PMTCT cohort in Nigeria in order to focus future efforts to reduce loss in this high burden setting. Methods From 2004-2014, the APIN/Harvard PEPFAR program supported antenatal HIV screening for nearly one million pregnant women and provided PMTCT care to over 30,000 women. The care cascade for women enrolling in the PMTCT program includes antenatal, delivery, and infant follow-up services through 12-18 months of life. In this retrospective cohort analysis, we examined data collected between 2004-2014 from 31 clinical sites in Nigeria and assessed the numbers of mothers and infants enrolled and LTFU at various points along the care cascade. Results Among 31,504 women (median age 30, IQR: 27-34) entering PMTCT care during the antenatal period, 20,679 (66%) completed the entire cascade of services including antenatal, delivery, and at least one infant follow-up visit. The median gestational age at presentation for antenatal care services was 23 weeks (IQR: 17-29). The median infant age at last follow-up visit was 12 months (IQR: 5-18). The greatest loss in the PMTCT care cascade occurred prior to delivery care (21%), with a further 16% lost prior to first infant visit. Of the 38,223 women who entered at any point along the PMTCT cascade, an HIV DNA PCR was available for 20,202 (53%) of their infants. Among infants for whom DNA PCR results were available, the rate of HIV transmission for infants whose mothers received any antenatal and/or delivery care was 2.8% versus 20.0% if their mother received none. Conclusions In this large cohort analysis, the proportion of women LTFU in the PMTCT care cascade was lower than that reported in previous cohort analyses. Nevertheless, this proportion remains unacceptably high and inhibits the program from maximally achieving the goals of PMTCT care. We also provide the largest analysis to date on rates of perinatal HIV transmission, with low rates among women receiving NNRTI- or PI-based regimens, approaching that reported in clinical trials. However, among mothers who received any antenatal care, infant outcomes were unknown for 48%, and women presented later in pregnancy than that recommended by current guidelines. Implementation research to evaluate ways to improve integration of services, particularly transitions from antenatal to delivery and pediatric care, are critically needed to reduce LTFU within PMTCT programs and achieve the ultimate goal of eliminating pediatric HIV infection.

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Section: Methodsmentioning

confidence: 99%

Loss to Follow-Up within the Prevention of Mother-to-Child Transmission Care Cascade in a Large ART Program in Nigeria

Rawizza

Chang

Chaplin³

et al. 2015

CHR

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“…30 None have evaluated QI to improve PMTCT services in the era of Option B+, though one other randomized QI intervention is ongoing in Nigeria. 31 …”

Section: Introductionmentioning

confidence: 99%

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

Rustagi

Gimbel

Nduati

et al. 2016

JAIDS Journal of Acquired Immune Deficiency Syndromes

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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.

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“…2) The rigorous pragmatic design. Contrary to the only other randomized trial currently evaluating CQI in Nigeria [38], for which clinics were only eligible if they met a minimum set of organizational criteria such as capacity to provide ART until 12–18 months postpartum, provision of postpartum care follow-up for HIV+ women, or availability of, at least, 2 trained community health extension workers to be eligible, the only requirement to be part of this study is to be one of the top three PMTCT providers in the health districts. 3) The Potential for high impact: if the CQI interventions are proven to be effective in improving long-term outcomes of lifelong ART in MCH clinics, it will provide the DRC government and PEPFAR with a scalable strategy to strengthen the quality of HIV continuum of care and help the country and PEPFAR move towards their aspiration of an AIDS-free generation.…”

Section: Discussionmentioning

confidence: 99%

Continuous quality improvement interventions to improve long-term outcomes of antiretroviral therapy in women who initiated therapy during pregnancy or breastfeeding in the Democratic Republic of Congo: design of an open-label, parallel, group randomized trial

Yotebieng

Behets

Kawende

et al. 2017

BMC Health Serv Res

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BackgroundDespite the rapid adoption of the World Health Organization’s 2013 guidelines, children continue to be infected with HIV perinatally because of sub-optimal adherence to the continuum of HIV care in maternal and child health (MCH) clinics. To achieve the UNAIDS goal of eliminating mother-to-child HIV transmission, multiple, adaptive interventions need to be implemented to improve adherence to the HIV continuum.MethodsThe aim of this open label, parallel, group randomized trial is to evaluate the effectiveness of Continuous Quality Improvement (CQI) interventions implemented at facility and health district levels to improve retention in care and virological suppression through 24 months postpartum among pregnant and breastfeeding women receiving ART in MCH clinics in Kinshasa, Democratic Republic of Congo. Prior to randomization, the current monitoring and evaluation system will be strengthened to enable collection of high quality individual patient-level data necessary for timely indicators production and program outcomes monitoring to inform CQI interventions. Following randomization, in health districts randomized to CQI, quality improvement (QI) teams will be established at the district level and at MCH clinics level. For 18 months, QI teams will be brought together quarterly to identify key bottlenecks in the care delivery system using data from the monitoring system, develop an action plan to address those bottlenecks, and implement the action plan at the level of their district or clinics.DiscussionIf proven to be effective, CQI as designed here, could be scaled up rapidly in resource-scarce settings to accelerate progress towards the goal of an AIDS free generation.Trial registrationThe protocol was retrospectively registered on February 7, 2017. ClinicalTrials.gov Identifier: NCT03048669.

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Increasing Retention in Care of HIV-Positive Women in PMTCT Services Through Continuous Quality Improvement–Breakthrough (CQI-BTS) Series in Primary and Secondary Health Care Facilities in Nigeria

Cited by 21 publications

References 2 publications

Loss to Follow-Up within the Prevention of Mother-to-Child Transmission Care Cascade in a Large ART Program in Nigeria

Loss to Follow-Up within the Prevention of Mother-to-Child Transmission Care Cascade in a Large ART Program in Nigeria

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

Continuous quality improvement interventions to improve long-term outcomes of antiretroviral therapy in women who initiated therapy during pregnancy or breastfeeding in the Democratic Republic of Congo: design of an open-label, parallel, group randomized trial

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