Implementation of a programme for the prevention of mother-to-child transmission of HIV in a Ugandan hospital over five years: challenges, improvements and lessons learned

Attrition from antiretroviral treatment services among pregnant and non-pregnant patients following adoption of Option B+ in Haiti

BACKGROUND

Access to antiretroviral therapy (ART) has expanded in Haiti because of the adoption of Option B+ and the revision of treatment guidelines. Retention in care and treatment varies greatly and few studies have examined retention rates, particularly among women enrolled in Option B+.

OBJECTIVE

To assess attrition among pregnant and non-pregnant patients initiating ART following adoption of Option B+ in Haiti.

METHODS

Longitudinal data of adult patients initiated on ART from October 2012 through August 2014 at 73 health facilities across Haiti were analyzed using a survival analysis framework to determine levels of attrition. The Kaplan-Meier method and Cox proportional hazards regression were used to examine risk factors associated with attrition.

RESULTS

Among 17,059 patients who initiated ART, 7627 (44.7%) were non-pregnant women, 5899 (34.6%) were men, and 3533 (20.7%) were Option B+ clients. Attrition from the ART program was 36.7% at 12 months (95% CI: 35.9-37.5%). Option B+ patients had the highest level of attrition at 50.4% at 12 months (95% CI: 48.6-52.3%). While early HIV disease stage at ART initiation was protective among non-pregnant women and men, it was a strong risk factor among Option B+ clients. In adjusted analyses, key protective factors were older age (p < 0.0001), living near the health facility (p = 0.04), having another known HIV-positive household member (p < 0.0001), having greater body mass index (BMI) (p < 0.0001), pre-ART counseling (p < 0.0001), and Cotrimoxazole prophylaxis during baseline (p < 0.01). Higher attrition was associated with rapidly starting ART after enrollment (p < 0.0001), anemia (p < 0.0001), and regimen tenofovir+lamivudine+nevirapine (TDF+3TC+NVP) (p < 0.001).

CONCLUSIONS

ART attrition in Haiti is high among adults, especially among Option B+ patients. Identifying newly initiated patients most at risk for attrition and providing appropriate interventions could help reduce ART attrition.

From patient to person: the need for an 'HIV trajectories' perspective in the delivery of prevention of mother-to-child-transmission services

Accelerated efforts to end vertical HIV transmission have resulted in a 52% decrease in new infections among children since 2001. However, current approaches to prevent mother-to-child-transmission (PMTCT) assume a linearity and universality. These insufficiently guide clinicians and programmes toward interventions that comprehensively address the varying and changing needs of clients. This results in high levels of loss-to-follow-up at each step of the PMTCT cascade. Current PMTCT approaches must be adapted to respond to the different and complex realities of women, children and families affected by HIV. Drawing on the concept of an 'HIV trajectories,' we screened peer-reviewed literature for promising PMTCT approaches and selected 13 articles for qualitative review when the described intervention involved more than a biomedical approach to PMTCT and mother-child HIV treatment and care. Our qualitative analysis revealed that interventions which integrated elements of the 'HIV trajectories' perspective and built on people living with HIV support/network, community health worker, primary healthcare and early childhood development platforms were successful because they recognized that HIV is an illness, experienced, moderated and managed by numerous factors beyond biomedical interventions alone.On the basis of this review, we call for the adoption of an 'HIV trajectories' perspective that can help assess the comprehensiveness of care provided to women, children and families affected by HIV and can inform the planning and delivery of HIV and related services so that they more adequately respond to the varying needs of clients on different 'HIV trajectories'.

The uptake of integrated perinatal prevention of mother-to-child HIV transmission programs in low- and middle-income countries: a systematic review

BACKGROUND

The objective of this review was to assess the uptake of WHO recommended integrated perinatal prevention of mother-to-child transmission (PMTCT) of HIV interventions in low- and middle-income countries.

METHODS AND FINDINGS

We searched 21 databases for observational studies presenting uptake of integrated PMTCT programs in low- and middle-income countries. Forty-one studies on programs implemented between 1997 and 2006, met inclusion criteria. The proportion of women attending antenatal care who were counseled and who were tested was high; 96% (range 30-100%) and 81% (range 26-100%), respectively. However, the overall median proportion of HIV positive women provided with antiretroviral prophylaxis in antenatal care and attending labor ward was 55% (range 22-99%) and 60% (range 19-100%), respectively. The proportion of women with unknown HIV status, tested for HIV at labor ward was 70%. Overall, 79% (range 44-100%) of infants were tested for HIV and 11% (range 3-18%) of them were HIV positive. We designed two PMTCT cascades using studies with outcomes for all perinatal PMTCT interventions which showed that an estimated 22% of all HIV positive women attending antenatal care and 11% of all HIV positive women delivering at labor ward were not notified about their HIV status and did not participate in PMTCT program. Only 17% of HIV positive antenatal care attendees and their infants are known to have taken antiretroviral prophylaxis.

CONCLUSION

The existing evidence provides information only about the initial PMTCT programs which were based on the old WHO PMTCT guidelines. The uptake of counseling and HIV testing among pregnant women attending antenatal care was high, but their retention in PMTCT programs was low. The majority of women in the included studies did not receive ARV prophylaxis in antenatal care; nor did they attend labor ward. More studies evaluating the uptake in current PMTCT programs are urgently needed.

Externalities of prevention of mother-to-child transmission programs: a systematic review

There has been considerable debate about the effects of targeted global health assistance in low- and middle-income countries on health systems, specifically HIV/AIDS funding. Recently, a handful of studies have emerged that describe the implementation of PMTCT programs, which have many theoretical links to maternal and child health. Through a systematic review of research published between January 2000 and March 2011, this paper synthesizes evidence evaluating the impact of these programs. We assessed 5,855 papers, reviewed 154, and included 21 articles. They offer evidence of beneficial synergies between PMTCT programs and both STI prevention and early childhood immunization. Other data, including information about antenatal and delivery care, family planning, and nutrition supplementation varied considerably across studies demonstrating both positive and negative effects of PMTCT. More research is needed to allow countries and funders to make informed decisions regarding allocation of limited funds to targeted versus broad categories of health care.

Grounded theory of barriers and facilitators to mandated implementation of mental health care in the primary care setting

Objective. There is limited theory regarding the real-world implementation of mental health care in the primary care setting: a type of organizational coordination intervention. The purpose of this study was to develop a theory to conceptualize the potential causes of barriers and facilitators to how local sites responded to this mandated intervention to achieve coordinated mental health care. Methods. Data from 65 primary care and mental health staff interviews across 16 sites were analyzed to identify how coordination was perceived one year after an organizational mandate to provide integrated mental health care in the primary care setting. Results. Standardized referral procedures and communication practices between primary care and mental health were influenced by the organizational factors of resources, training, and work design, as well as provider-experienced organizational boundaries between primary care and mental health, time pressures, and staff participation. Organizational factors and provider experiences were in turn influenced by leadership. Conclusions. Our emergent theory describes how leadership, organizational factors, and provider experiences affect the implementation of a mandated mental health coordination intervention. This framework provides a nuanced understanding of the potential barriers and facilitators to implementing interventions designed to improve coordination between professional groups.

The impact of Prevention of Mother to Child Transmission (PMTCT) programmes on maternal health care in resource-poor settings: looking beyond the PMTCT programme--a systematic review

BACKGROUND

There is increasing debate about the impact of scaled-up HIV/AIDS programmes on fragile healthcare systems in low-income countries.

OBJECTIVES

To contribute to the understanding of the relation between HIV/AIDS programmes and healthcare systems, this systematic review focuses on the impact of Prevention of Mother to Child Transmission (PMTCT) programmes on maternal health care.

SEARCH STRATEGY

Publications describing the effect of PMTCT programmes on maternal healthcare services were sought through computerised searches in five electronic databases.

SELECTION CRITERIA

Abstracts of publications were evaluated for appropriateness for inclusion based on whether they met the inclusion criteria.

DATA COLLECTION AND ANALYSIS

Copies of all selected publications were obtained. A classification system was developed to group the relevant publications.

MAIN RESULTS

The findings show that empirical evidence of the effect of PMTCT programmes on maternal health care is scarce and further research is badly needed. Twenty-one studies that were included in the systematic review showed that PMTCT programmes are often semi-integrated in maternal health care with positive as well as negative effects on various aspects of maternal health care.

AUTHORS' CONCLUSIONS

It appears that PMTCT programmes miss the opportunity to have an overall positive effect on maternal health care because of their verticality.

Gendered perceptions on infant feeding in Eastern Uganda: continued need for exclusive breastfeeding support

Background

In resource-poor settings, HIV positive mothers are recommended to choose between 'Exclusive breastfeeding' (EBF) or 'Exclusive replacement feeding' (ERF). Acceptability, Feasibility, Affordability, Sustainability and Safety (AFASS) has been the World Health Organization (WHO)'s a priori criteria for ERF the last ten years. 'AFASS' has become a mere acronym among many workers in the field of prevention of mother-to-child transmission of HIV, PMTCT. Thereby, non-breastfeeding has been suggested irrespective of social norms. EBF for the first half of infancy is associated with huge health benefits for children in areas where infant mortality is high. But, even if EBF has been recommended for a decade, few mothers are practicing it. We set out to understand fathers' and mothers' infant feeding perceptions and the degree to which EBF and ERF were 'AFASS.'

Methods

Eight focus groups with 81 informants provided information for inductive content analysis. Four groups were held by men among men and four groups by women among women in Mbale District, Eastern Uganda.

Results

Two study questions emerged: How are the different feeding options understood and accepted? And, what are men's and women's responsibilities related to infant feeding? A mother's commitment to breastfeed and the husband's commitment to provide for the family came out strongly. Not breastfeeding a newborn was seen as dangerous and as unacceptable, except in cases of maternal illness. Men argued that not breastfeeding could entail sanctions by kin or in court. But, in general, both men and women regarded EBF as 'not enough' or even 'harmful.' Among men, not giving supplements to breast milk was associated with poverty and men's failure as providers. Women emphasised lack of time, exhaustion, poverty and hunger as factors for limited breast milk production. Although women had attended antenatal teaching they expressed a need to know more. Most men felt left out from health education.

Conclusion

Breastfeeding was the expected way to feed the baby, but even with existing knowledge among mothers, EBF was generally perceived as impossible. ERF was overall negatively sanctioned. Greater culture-sensitivity in programs promoting safer infant feeding in general and in HIV-contexts in particular is urgently needed, and male involvement is imperative.

Trial Registration

The study was part of formative studies for the ongoing study PROMISE EBF registered at http://clinicaltrials.gov (NCT00397150).

Improving mothers' access to PMTCT programs in West Africa: a public health perspective

Despite technical means and apparent political will, the percentage of pregnant women involved in preventing mother-to-child transmission (PMTCT) interventions is not increasing as fast as public health authorities would expect. This is even more striking when compared to the scaling up of access to antiretroviral treatment. It seems important to analyze the successes and failures of the programs and the "scaling-up" of PMTCT programs. This is a major issue for women at two levels: women are very concerned about the health of their children, and they are the ones who implement prevention in collaboration with health services. A review of achievements and failures described from a public health perspective may lead to greater understanding of the social aspects involved in PMTCT program achievements and failures. This paper is based on the combination of a literature review and empirical evidence collected during 15 years of PMTCT implementation, childcare research and treatment programs in West Africa. The analysis aims to identify the social issues that explain the gap between PMTCT program aims and achievements in order to encourage research in the social sciences regarding relationships between mothers and the care system. We find it is possible to build programs at the national level that have a high degree of acceptance of testing and intervention, with a progressive decline in HIV infection among children. However, many obstacles remain, highlighting the necessity to broaden access to HIV screening, develop mass campaigns on testing for couples and improve HIV care and training for caregivers. Because HIV-infected pregnant women are experiencing great psychological distress, healthcare providers must use an approach that is as friendly as possible.