Option B+ in Mozambique: Formative Research Findings for the Design of a Facility-Level Clustered Randomized Controlled Trial to Improve ART Retention in Antenatal Care

Abstract

Introduction:With the rollout of “Option B+” in Mozambique in 2013, initial data indicated major challenges to early retention in antiretroviral therapy (ART) among HIV-positive pregnant women. We sought to develop and test a pilot intervention in 6 large public clinics in central Mozambique to improve retention of mothers starting ART in antenatal care. The results from the formative research from this study described here were used to design the intervention.Methods:The research was initiated in early 2013 and completed in early 2014 in each of the 6 study clinics and consisted of (1) patient flow mapping and measurement of retention through collection of health systems data from antenatal care registries, pharmacy registries, ART clinic databases, (2) workforce assessment and measurement of patient waiting times, and (3) patient and worker individual interviews and focus groups.Results:Coverage of HIV testing and ART initiation were over 90% at all sites, but retention at 30-, 60-, and 90-day pharmacy refill visits was very low ranging from only 5% at 1 site to 30% returning at 90 days. These data revealed major systemic bottlenecks that contributed to poor adherence and retention in the first month after ART initiation. Long wait times, short consultations, and poor counseling were identified as barriers.Conclusions:Based on these findings, we designed an intervention with these components: (1) workflow modification to redefine nurse tasks, shift tasks to community health workers, and enhance patient tracking and (2) an adherence and retention package to systematize active patient follow-up, ensure home visits by community health workers, use text messaging, and intensify counseling by health staff. This intervention is currently under evaluation using a stepped wedge design.

Medication adherence in pregnant women with human immunodeficiency virus receiving antiretroviral therapy in sub-Saharan Africa: a systematic review

“…(396) cART (specific ARV drugs combination NR). **** 40 *Napua, et al 2016 [ 40 ] Mozambique: Urban Clustered(facility level) randomised controlled trial HIV + women pregnant registered in 6 high volume HFs providing PMTCT and ART services. (141) cART (specific ARV drugs combination NR).…”

Job satisfaction and turnover intentions among health care staff providing services for prevention of mother-to-child transmission of HIV in Dar es Salaam, Tanzania

“…To effectively implement Option B+, satisfied and motivated providers is key, since they must be highly committed to spend adequate time with the clients to inform them about the PMTCT program and also to provide individual counselling, emphasizing the importance of adherence to medication (for both mothers and their infants) and retention in ART care [ 16 ].…”

“…The gaps in achieving adequate adherence and retention in Option B+ care may be exacerbated by high competing demands on the health care system, coupled with existing staff shortages [ 15 ]. The understaffing leads to long queues and increased staff workload, which makes it difficult to efficiently counsel the patients and track the defaulters [ 16 ]. Higher workload in already overburdened health systems in resource-limited countries have been linked to a negative effect on health care provider job satisfaction [ 17 , 18 ], especially if the resulting additional tasks and responsibilities are not coupled to incentives [ 19 ].…”

Exploring factors associated with ART adherence and retention in care under Option B+ strategy in Malawi: A qualitative study

“…An observational multi-facility cohort study in Malawi had comparable findings of high LTFU (22%) in the first year of implementing Option B+ [5] while a study from one facility in Malawi further clarified that 47% of LTFU women only collected their drugs at the time of initiation but never returned to the same clinic to refill their drugs [6]. Published works from other sub-Saharan African countries also show similar gaps regarding retention in care [7–8]. Some of the factors associated with LTFU under Option B+ included younger age at initiation, [5–6,9] being pregnant (compared to lactating) [6], starting ART on the same day of diagnosis [4,7,9], lack of disclosure [7], missing CD4 cell counts at ART initiation [9], having less than a secondary education [7], and receiving care at high volume facilities [4–5, 9].…”