Benefits to women and newborns by integrating HIV and ANC services

Integration of PMTCT and antenatal services improves combination antiretroviral therapy (cART) uptake for HIV-positive pregnant women in Southern Zambia - a prototype for option B+?

Herlihy JM, Hamomba L, Bonawitz R, Goggin CE, Sambambi K, Mwale J, Musonda V, Musokatwane K, Hopkins KL, Semrau K, Hammond EE, Duncan J, Knapp AB, Thea DM. J Acquir Immune Defic Syndr. 2015 Jul 15. [Epub ahead of print]

Background: Early initiation of combination anti-retroviral therapy (cART) for HIV-positive pregnant women can decrease vertical transmission to less than 5%. Programmatic barriers to early cART include decentralized care, disease stage assessment delays, and loss-to-follow-up.

Intervention: Our intervention had 3 components: integrated HIV and antenatal services in one location with one provider; lab courier to expedite CD4 counts; and community-based follow-up of women-infant pairs to improve PMTCT attendance. Pre-intervention HIV-positive pregnant women were referred to HIV clinics for disease stage assessment and cART initiation for advanced disease CD4< 350 or WHO stage >2.

Methods: We employed a quasi-experimental design with pre/post-intervention evaluations at 6 government antenatal clinics (ANC) in Southern Province, Zambia. Retrospective clinical data were collected from clinic registers during a 7-month baseline period. Post-intervention data were collected from all ART-naive, HIV-positive pregnant women and their infants presenting to ANC from December 2011-June 2013.

Results: Data from 510 baseline women-infant pairs were analyzed and 624 pregnant women were enrolled during the intervention period. Proportion of HIV-positive pregnant women receiving CD4 counts increased from 50.6% to 77.2%, RR=1.81 95% CI: 1.57-2.08; p<0.01. Proportion of cART-eligible pregnant women initiated on cART increased from 27.5% to 71.5% RR=2.25, 95% CI: 1.78-2.83; p<0.01. Proportion of eligible HIV-exposed infants with documented 6-week HIV PCR test increased from 41.9% to 55.8%, RR=1.33, 95% CI: 1.18-1.51; p<0.01.

Conclusion: Integration of HIV care into ANC and community-based support improved uptake of CD4 counts, proportion of cART-eligible women initiated on cART and infants tested.

Abstract access [1] 

Editor’s notes: Integrating HIV services into other elements of health care, such as family planning or maternal health services, can increase uptake of HIV testing and antiretroviral therapy (ART) initiation. For pregnant women, timely HIV diagnosis and treatment can greatly reduce the probability of mother-to-child transmission. Integrating HIV services into maternal antenatal clinic (ANC) services therefore has potential to bring benefit to women living with HIV and their newborns. This paper describes an experimental study in which six ANC clinics in Zambia – all with high attendance and in provinces with high HIV prevalence – integrated HIV testing and treatment into their routine ANC services. This integration took the form of training existing ANC providers in HIV diagnosis and management; providing a rapid CD4 measurement service; and training volunteer lay counsellors to maintain regular contact with mothers living with HIV to improve ART initiation and adherence. The programme was associated with dramatic increases in ART initiation, early testing of infants and early ART initiation. The integrated approach used here has potential to improve prevention of mother-to-child transmission services. This is done through streamlined combination antiretroviral therapy (cART) initiation and decreasing time gaps in referral models. The approach assists in reducing HIV associated stigma and fear as the clinics offer maternal/child health services as well as HIV care. The clinics offer continuity through a community lay counsellor who follows the mother infant pair through pregnancy, delivery and breastfeeding. Further work is necessary to evaluate strategies for HIV care retention through similar models using community health workers and family-centric HIV care.

Africa [7]
Zambia [8]
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