Strengthening PMTCT implementation through systems engineering

Impact of a systems engineering intervention on PMTCT service delivery in Cote d'Ivoire, Kenya, Mozambique: a cluster randomized trial.

Rustagi AS, Gimbel S, Nduati R, Cuembelo MF, Wasserheit JN, Farquhar C, Gloyd S, Sherr K, with input from the SST. J Acquir Immune Defic Syndr. 2016 Apr 14. [Epub ahead of print]

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 Cote 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.

Abstract access [1]

Editor’s notes: Systems engineering is an interdisciplinary approach to optimise complex processes or systems. In this randomised trial of a systems engineering approach to improving prevention  of mother-to-child HIV transmission programmes, the study programme was a five-step, iterative package of systems analysis and quality improvement tools. In lay terms, the systems engineering activity helped facility staff understand implementation barriers to prevention of mother-to-child transmission programme service delivery, identify bottlenecks and patient dropout along the cascade and develop a facility-specific microintervention to address these issues. This was then repeated in a quality improvement iterative cycle with the overall aim to improve the flow of mother-infant pairs through the prevention of mother-to-child HIV transmission cascade. Study findings suggest that a systems engineering approach could markedly increase antiretroviral therapy coverage and HIV-exposed infant screening in prevention of mother-to-child HIV transmission programmes.  Further studies evaluating a systems engineering approach in the context of programmatic HIV care, especially in resource-poor settings, are required.

Africa [7]
Côte d'Ivoire [8], Kenya [9], Mozambique [10]
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