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The Achilles' heel of prevention to mother-to-child transmission of HIV: Protocol implementation, uptake, and sustainability.

ABSTRACT: The Joint United Nations Programme on HIV and AIDS proposed to reduce the vertical transmission of HIV from ?72,200 to ?8300 newly infected children by 2015 in South Africa (SA). However, cultural, infrastructural, and socio-economic barriers hinder the implementation of the prevention of mother-to-child transmission (PMTCT) protocol, and research on potential solutions to address these barriers in rural areas is particularly limited. This study sought to identify challenges and solutions to the implementation, uptake, and sustainability of the PMTCT protocol in rural SA. Forty-eight qualitative interviews, 12 focus groups discussions (n?=?75), and one two-day workshop (n?=?32 participants) were conducted with district directors, clinic leaders, staff, and patients from 12 rural clinics. The delivery and uptake of the PMTCT protocol was evaluated using the Consolidated Framework for Implementation Research (CFIR); 15 themes associated with challenges and solutions emerged. Intervention characteristics themes included PMTCT training and HIV serostatus disclosure. Outer-setting themes included facility space, health record management, and staff shortage; inner-setting themes included supply use and availability, staff-patient relationship, and transportation and scheduling. Themes related to characteristics of individuals included staff relationships, initial antenatal care visit, adherence, and culture and stigma. Implementation process themes included patient education, test results delivery, and male involvement. Significant gaps in care were identified in rural areas. Information obtained from participants using the CFIR framework provided valuable insights into solutions to barriers to PMTCT implementation. Continuously assessing and correcting PMTCT protocol implementation, uptake and sustainability appear merited to maximize HIV prevention.

SUBMITTER: Rodriguez VJ

PROVIDER: S-EPMC5638135 | biostudies-literature | 2017 Dec

REPOSITORIES: biostudies-literature

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The Achilles' heel of prevention to mother-to-child transmission of HIV: Protocol implementation, uptake, and sustainability.

Rodriguez Violeta J VJ LaCabe Richard P RP Privette C Kyle CK Douglass K Marie KM Peltzer Karl K Matseke Gladys G Mathebula Audrey A Ramlagan Shandir S Sifunda Sibusiso S Prado Guillermo Willy GW Horigian Viviana V Weiss Stephen M SM Jones Deborah L DL

SAHARA J : journal of Social Aspects of HIV/AIDS Research Alliance 20171201 1

The Joint United Nations Programme on HIV and AIDS proposed to reduce the vertical transmission of HIV from ∼72,200 to ∼8300 newly infected children by 2015 in South Africa (SA). However, cultural, infrastructural, and socio-economic barriers hinder the implementation of the prevention of mother-to-child transmission (PMTCT) protocol, and research on potential solutions to address these barriers in rural areas is particularly limited. This study sought to identify challenges and solutions to the ...[more]

PMID: 28922974

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Project description:BackgroundWe performed a systematic review to assess the effect of integrated perinatal prevention of mother-to-child transmission of HIV interventions compared to non- or partially integrated services on the uptake in low- and middle-income countries.MethodsWe searched for experimental, quasi-experimental and controlled observational studies in any language from 21 databases and grey literature sources.ResultsOut of 28 654 citations retrieved, five studies met our inclusion criteria. A cluster randomized controlled trial reported higher probability of nevirapine uptake at the labor wards implementing HIV testing and structured nevirapine adherence assessment (RRR 1.37, bootstrapped 95% CI, 1.04-1.77). A stepped wedge design study showed marked improvement in antiretroviral therapy (ART) enrolment (44.4% versus 25.3%, p<0.001) and initiation (32.9% versus 14.4%, p<0.001) in integrated care, but the median gestational age of ART initiation (27.1 versus 27.7 weeks, p = 0.4), ART duration (10.8 versus 10.0 weeks, p = 0.3) or 90 days ART retention (87.8% versus 91.3%, p = 0.3) did not differ significantly. A cohort study reported no significant difference either in the ART coverage (55% versus 48% versus 47%, p = 0.29) or eight weeks of ART duration before the delivery (50% versus 42% versus 52%; p = 0.96) between integrated, proximal and distal partially integrated care. Two before and after studies assessed the impact of integration on HIV testing uptake in antenatal care. The first study reported that significantly more women received information on PMTCT (92% versus 77%, p<0.001), were tested (76% versus 62%, p<0.001) and learned their HIV status (66% versus 55%, p<0.001) after integration. The second study also reported significant increase in HIV testing uptake after integration (98.8% versus 52.6%, p<0.001).ConclusionLimited, non-generalizable evidence supports the effectiveness of integrated PMTCT programs. More research measuring coverage and other relevant outcomes is urgently needed to inform the design of services delivering PMTCT programs.

Project description:About 40% of the new HIV infections in Ethiopia are among children < 15 years of age. The great majority of these infections occur through Mother-to-child HIV transmission (MTCT). For prevention of MTCT, the national guidelines has been revised to incorporate scientific advances in HIV prevention, treatment and care. Since 2005, the country has been implementing a peer mentor programme called Mother Support Group (MSG), which provides psychosocial and adherence support for HIV positive mothers. This study examined implementation of PMTCT guidelines revisions and outcomes of HIV exposed babies in the MSG in Addis Ababa. Retrospective routine data were collected between 2005 and August 2013 from seven randomly selected primary health facilities. Odds ratios and 95% confidence intervals were calculated using logistic regression models. Several guidelines revisions were made between 2001 and 2013 in HIV testing approaches, prophylactic antiretroviral options, infant feeding recommendations and infant HIV testing algorithms. Revisions on the CD4 thresholds were associated with a significant increase in the proportion of women initiating antiretroviral treatment from 0 in 2005 to 62% in 2013. Revisions in infant feeding recommendations led to a 92.3% reported practice of exclusive breastfeeding in 2013 compared to 60.9% in 2005. Two and four percent of the HIV exposed babies were HIV positive by six and 18 months respectively. Not receiving prophylactic ART and receiving mixed feeding were independent predictors for babies having an HIV positive antibody test at 18 months. The rate of HIV status disclosure increased significantly year by year. Over the years, the PMTCT recommendations have moved from having a solo focus on PMTCT to holistic and inclusive approaches emphasizing survival beyond HIV prevention. The data reflect favourable outcomes of HIV exposed babies in terms of averted MTCT though serious gaps in data quality remain. For successful implementation of Option-B plus, the identified gaps in the MSG need to be addressed.

Project description:Identifying the socioeconomic and structural issues that act as enablers and/or barriers to HIV testing services is critical in combatting HIV/AIDS amongst mothers and children in Africa. In this study, we used a weighted sample of 46,645 women aged 15-49 who gave birth in the two years preceding the survey from the recent DHS dataset of ten East African countries. Multivariable logistic regression was used to investigate the factors associated with prenatal HIV test uptake in East Africa. The overall prenatal HIV test uptake for the prevention of mother-to-child transmission (PMTCT) of HIV was 80.8% (95% CI: 74.5-78.9%) in East Africa, with highest in Rwanda (97.9%, 95% CI: 97.2-98.3%) and lowest in Comoros (17.0%, 95% CI: 13.9-20.7%). Common factors associated with prenatal HIV test service uptake were higher maternal education level (AOR = 1.29; 95% CI: 1.10-1.50 for primary education and AOR = 1.96; 95% CI: 1.53-2.51 for secondary or higher education), higher partner education level (AOR = 1.24; 95% CI: 1.06-1.45 for primary education and AOR = 1.56; 95% CI: 1.26-1.94 for secondary or higher school), women from higher household wealth index (AOR = 1.29; 95% CI: 1.11-1.50 for middle wealth index; AOR = 1.57; 95% CL: 1.17-2.11 for rich wealth index), improved maternal exposure to the media, and increased awareness about MTCT of HIV. However, residents living in rural communities (AOR = 0.66; 95% CI: 0.51-0.85) and travelling long distances to the health facility (AOR = 0.8; 95% CI: 0.69-0.91) were associated with non-use of prenatal HIV test service in East African countries. In each East African country, factors associated with prenatal HIV test uptake for PMTCT varied. In conclusion, the pooled prenatal HIV test uptake for PMTCT of HIV was low in East Africa compared to the global target. Scaling up interventions to improve enablers whilst addressing barriers to the use of prenatal HIV test services are essential to end the HIV/AIDS epidemic in East African countries.

Project description:In rural South Africa, only two-thirds of HIV-positive pregnant women seeking antenatal care at community health centers took full advantage of 'prevention of mother-to-child transmission' (PMTCT) services in 2010. Studies generally support male involvement to promote PMTCT, but the nature and impact of that involvement is unclear and untested. Additionally, stigma, disclosure and intimate partner violence pose significant barriers to PMTCT uptake and retention in care, suggesting that male involvement may be 'necessary, but not sufficient' to reduce infant HIV incidence. This study expands on a successful United States President's Emergency Plan for AIDS Relief (PEPFAR)-supported PMTCT couples intervention pilot study conducted in the Mpumalanga province, targeting HIV-positive pregnant women and their partners, the primary objective being to determine whether male partner involvement plus a behavioral intervention will significantly reduce infant HIV incidence.The study follows a cluster randomized controlled design enrolling two cohorts of HIV-positive pregnant women recruited from 12 randomly assigned Community Health Centers (CHC) (six experimental, six control). The two cohorts will consist of women attending without their male partners (n = 720) and women attending with their male partners (n = 720 couples), in order to determine whether the influence of male participation itself, or combined with a behavioral PMTCT intervention, can significantly reduce infant HIV infection ante-, peri- and postnatally.It is our intention to significantly increase PMTCT participation from current levels (69%) in the Mpumalanga province to between 90 and 95% through engaging women and couples in a controlled, six session ante- and postnatal risk-reducing and PMTCT promotion intervention addressing barriers to PMTCT (such as stigma, disclosure, intimate partner violence, communication, infant feeding practices and safer conception) that prevent women and men from utilizing treatment opportunities available to them and their infants. Based upon the encouraging preliminary results from our pilot study, successful CHC adoption of the program could have major public health policy implications for containing the epidemic among the most vulnerable populations in rural South Africa: HIV-positive pregnant women and their infants.ClinicalTrials.gov NCT02085356 (registration date: 10 March 2014).

Project description:Novel strategies are needed to increase retention in and uptake of prevention of mother-to-child HIV transmission (PMTCT) services in sub-Saharan Africa. We aimed to determine whether small, increasing cash payments, which were conditional on attendance at scheduled clinic visits and receipt of proposed services can increase the proportions of HIV-infected pregnant women who accept available PMTCT services and remain in care.In this randomised controlled trial, we recruited newly diagnosed HIV-infected women, who were 32 or less weeks pregnant, from 89 antenatal care clinics in Kinshasa, Democratic Republic of Congo, and randomly assigned (1:1) them to either the intervention group or the control group using computer-based randomisation with varying block sizes of four, six, and eight. The intervention group received compensation on the condition that they attended scheduled clinic visits and accepted offered PMTCT services (US$5, plus US$1 increment at every subsequent visit), whereas the control group received usual care. Outcomes assessed included retention in care at 6 weeks' post partum and uptake of PMTCT services, measured by attendance of all scheduled clinic visits and acceptance of proposed services up to 6 weeks' post partum. Analyses were by intention to treat. This trial is registered with ClinicalTrials.org, number NCT01838005.Between April 18, 2013, and Aug 30, 2014, 612 potential participants were identified, 545 were screened, and 433 were enrolled and randomly assigned; 217 to the control group and 216 to the intervention group. At 6 weeks' post partum, 174 participants in the intervention group (81%) and 157 in the control group (72%) were retained in care (risk ratio [RR] 1·11; 95% CI 1·00-1·24). 146 participants in the intervention group (68%) and 116 in the control group (54%) attended all clinic visits and accepted proposed services (RR 1·26; 95% CI 1·08-1·48). Results were similar after adjustment for marital status, age, and education.Among women with newly diagnosed HIV, small, incremental cash incentives resulted in increased retention along the PMTCT cascade and uptake of available services. The cost-effectiveness of these incentives and their effect on HIV-free survival warrant further investigation.President's Emergency Plan for AIDS Relief and the National Institute of Health and Child Development.

Project description:BackgroundNigeria has low antiretroviral therapy (ART) coverage among HIV-positive pregnant women. In a previous cluster-randomized trial in Nigeria, Baby Shower events resulted in higher HIV testing coverage and linkage of pregnant women to ART; here, we assess outcomes of Baby Shower events in a non-research setting.MethodsBaby Shower events, including a prayer ceremony, group education, music, gifting of a "mama pack" with safe delivery supplies, and HIV testing with ART linkage support for HIV-positive pregnant women, were conducted in eighty sites in Benue State, Nigeria. Client questionnaires (including demographics, ANC attendance, and HIV testing history), HIV test results, and reported linkage to ART were analyzed. Descriptive data on HIV testing and ART linkage data for facility-based care at ANC clinics in Benue State were also analyzed for comparison.ResultsBetween July 2016 and October 2017, 10,056 pregnant women and 6,187 male partners participated in Baby Shower events; 61.5% of women attended with a male partner. Nearly half of female participants (n = 4515, 44.9%) were not enrolled in ANC for the current pregnancy, and 22.3% (n = 2,241) of female and 24.8% (n = 1,532) of male participants reported they had never been tested for HIV. Over 99% (n = 16,240) of participants had their HIV status ascertained, with 7.2% of females (n = 724) and 4.0% of males (n = 249) testing HIV-positive, and 2.9% of females (n = 274) and 2.3% of males (n = 138) receiving new HIV-positive diagnoses. The majority of HIV-positive pregnant women (93.0%, 673/724) were linked to ART. By comparison, at health facilities in Benue State during a similar time period, 99.7% of pregnant women had HIV status ascertained, 8.4% had a HIV-positive status, 2.1% were newly diagnosed HIV-positive, and 100% were linked to ART.ConclusionCommunity-based programs such as the faith-based Baby Shower intervention complement facility-based approaches and can reach individuals who would not otherwise access facility-based care. Future Baby Showers implementation should incorporate enhanced support for ART linkage and retention to maximize the impact of this intervention on vertical HIV transmission.

Dataset Information

The Achilles' heel of prevention to mother-to-child transmission of HIV: Protocol implementation, uptake, and sustainability.

Publications

The Achilles' heel of prevention to mother-to-child transmission of HIV: Protocol implementation, uptake, and sustainability.

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