What will it take for the Global Plan priority countries in Sub-Saharan Africa to eliminate mother-to-child transmission of HIV?

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Study Justification:
– The study aims to understand the factors driving vertical transmission of HIV in Sub-Saharan Africa (SSA) Global Plan priority countries.
– It seeks to compare the characteristics of countries that have achieved elimination of mother-to-child transmission (EMTCT) with those that have not.
– The study uses three theories to analyze and explain the differences between EMTCT-validated and non-validated countries.
– It also examines the associations between infant HIV exposure, access to antiretroviral therapy (ART), and two outcomes: percent MTCT and the number of new pediatric HIV infections.
Study Highlights:
– EMTCT-validated countries have lower HIV prevalence, less breastfeeding, and fewer challenges in leadership, governance, infrastructure, and service delivery compared to Global Plan priority countries.
– Validated countries have implemented contact tracing and integrated maternal and child health services with HIV prevention services.
– Global Plan priority countries have limited data on key sexual and reproductive health indicators and variable coverage of antenatal care, HIV testing, and ART.
– ART access is critical to reducing percent MTCT, while reducing infant HIV exposure is critical to reducing the pediatric HIV case rate.
Study Recommendations:
– Increase efforts to reduce infant HIV exposure through comprehensive prevention strategies.
– Improve access to ART for all HIV-positive pregnant and lactating women.
– Strengthen program monitoring, leadership, and governance in Global Plan priority countries.
– Enhance integration of maternal and child health services with HIV prevention services.
– Collect more data on sexual and reproductive health indicators, antenatal care, HIV testing, and ART coverage in priority countries.
Key Role Players:
– Global health organizations and agencies
– National governments and ministries of health
– HIV/AIDS program managers and coordinators
– Healthcare providers and clinics
– Community health workers and peer educators
– Researchers and scientists
– Civil society organizations and advocacy groups
Cost Items for Planning Recommendations:
– Training and capacity building for healthcare providers and community health workers
– Procurement and distribution of antiretroviral drugs
– Development and implementation of monitoring and evaluation systems
– Integration of maternal and child health services with HIV prevention services
– Data collection and analysis on sexual and reproductive health indicators
– Awareness campaigns and community outreach activities
– Support for leadership and governance strengthening initiatives

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is rated 7 because it provides a comprehensive literature review and applies multiple theories and statistical models to analyze the data. However, it does not mention the specific studies or sources used, which could be improved by providing more transparency and references to the original research.

BACKGROUND: The 2016 ‘Start Free, Stay Free, AIDS Free’ global agenda, builds on the 2011-2015 ‘Global Plan’. It prioritises 22 countries where 90% of the world’s HIV-positive pregnant women live and aims to eliminate vertical  transmission of HIV (EMTCT) and to keep mothers alive. By 2019, no Global Plan priority country had achieved EMTCT; however, 11 non-priority countries had. This paper synthesises the characteristics of the first four countries validated for EMTCT, and of the 21 Global Plan priority countries located in Sub-Saharan Africa (SSA). We consider what drives vertical transmission of HIV (MTCT) in the 21 SSA Global Plan priority countries. METHODS: A literature review, using PubMed, Science direct and the google search engine was conducted to obtain global and national-level information on current HIV-related context and health system characteristics of the first four EMTCT-validated countries and the 21 SSA Global Plan priority countries. Data representing only one clinic, hospital or region were excluded. Additionally, key global experts working on EMTCT were contacted to obtain clarification on published data. We applied three theories (the World Health Organisation’s building blocks to strengthen health systems, van Olmen’s Health System Dynamics framework and Baral’s socio-ecological model for HIV risk) to understand and explain the differences between EMTCT-validated and non-validated countries. Additionally, structural equation modelling (SEM) and linear regression were used to explain associations between infant HIV exposure, access to antiretroviral therapy and two outcomes: (i) percent MTCT and (iii) number of new paediatric HIV infections per 100 000 live births (paediatric HIV case rate). RESULTS: EMTCT-validated countries have lower HIV prevalence, less breastfeeding, fewer challenges around leadership, governance within the health sector or country, infrastructure and service delivery compared with Global Plan priority countries. Although by 2016 EMTCT-validated countries and Global Plan priority countries had adopted a public health approach to HIV prevention, recommending lifelong antiretroviral therapy (ART) for all HIV-positive pregnant and lactating women, EMCT-validated countries had also included contact tracing such as assisted partner notification, and had integrated maternal and child health (MCH) and sexual and reproductive health (SRH) services, with services for HIV infection, sexually transmitted infections, and viral hepatitis. Additionally, Global Plan priority countries have limited data on key SRH indicators such as unmet need for family planning, with variable coverage of antenatal care, HIV testing and triple antiretroviral therapy (ART) and very limited contact tracing. Structural equation modelling (SEM) and linear regression analysis demonstrated that ART access protects against percent MTCT (p<0.001); in simple linear regression it is 53% protective against percent MTCT. In contrast, SEM demonstrated that the case rate was driven by the number of HIV exposed infants (HEI) i.e. maternal HIV prevalence (p<0.001). In linear regression models, ART access alone explains only 17% of the case rate while HEI alone explains 81% of the case rate. In multiple regression, HEI and ART access accounts for 83% of the case rate, with HEI making the most contribution (coef. infant HIV exposure=82.8, 95% CI: 64.6, 101.1, p<0.001 vs coef. ART access=-3.0, 95% CI: -6.2, 0.3, p=0.074). CONCLUSION: Reducing infant HIV exposure, is critical to reducing the paediatric HIV case rate; increasing ART access is critical to reduce percent MTCT. Additionally, our study of four validated countries underscores the importance of contact tracing, strengthening programme monitoring, leadership and governance, as these are potentially-modifiable factors.

Global and national data published in English were sought to synthesise HIV- and PMTCT-related characteristics of EMTCT-validated countries and the 21 SSA Global Plan priority countries. PubMed, Google scholar and Science Direct were used to search for relevant peer- reviewed articles in English, using the terms MTCT, EMTCT and PMTCT effectiveness. As this paper mainly focuses on current status and is not a review of progress over many years, once a document with updated information on a particular indicator or topic was obtained, no additional searches were conducted for prior documents on that indicator. Documents or papers that only focused on a sub-national level such as one clinic, hospital or region were excluded as information from subnational settings were not relevant for this synthesis. Additionally, key individuals participating in global think tanks and expert groups were identified and contacted for relevant global or country-level reports, data, fact sheets and press releases on EMTCT or measuring PMTCT effectiveness. Although the EMTCT criteria specify that all criteria should be met in at least one of the lowest sub-national levels, this synthesis is restricted to national level, given the dearth of reliable data at subnational levels in SSA settings [14, 15]. We applied three theories, the WHO’s six building blocks to strengthen health systems, van Olmen’s Health System Dynamics framework and Baral’s socio-ecological model for HIV risk to understand and explain the differences between EMTCT validated and non-validated countries. The WHO theory states that strengthening six health system building blocks, namely (i) leadership and governance, (ii) health care financing, (iii) the healthcare workforce, (iv) medical products and technologies, (v) information and research and (vi) service delivery improves access, coverage, quality and safety of interventions, resulting in improved outcomes including equity, responsiveness and efficiency [16]. The van Olmen Health Systems Dynamics framework recognizes the existence of an overarching context within which health systems function, as well as the importance of leadership and governance, service delivery, resources (infrastructure, human resources, finances and knowledge and information) and population characteristics on goals and health outcomes [17]. Baral’s social ecological model acknowledges rings of influence on HIV risk, beginning at the individual level, expanding to social and sexual networks, community, public policy and HIV epidemic stage [18]. We considered these three models because they each adopt a different approach, ranging from system-specific [16], system within a context [17] to individual within a system and context [18]. We integrated the information from these theories to compare and understand the EMTCT-validated and SSA Global Plan priority countries, and consider what it will take to achieve EMTCT in the latter. We used both linear regression and Structural Equation modelling (SEM) to estimate the contribution of infant HIV exposure (HEI) and ART access to percent MTCT (%MTCT) and the paediatric case rate (case-rate). The outcome case-rate was defined as the number of new paediatric HIV cases per 100 000 births, and the outcome %MTCT was percentage HIV transmission (numerator: number of new HIV infections amongst infants born to HIV infected mothers; denominator: number of HIV infected mothers), both assessed for 2017. The main exposure for both models was infant HIV exposure (HEI), defined as (number of HIV-positive pregnant women in 2017 *100)/total number of births in 2017. Due to limitations of sample size (number of countries), we reduced the number of variables in the models by creating an “ART-score”. This was defined as: ART-score = total access to treatment = ART access = % of HIV-positive on treatment (general population) + % HIV-suppressed (general population) + % of pregnant women on ART. Prior to deriving the additive score, we checked for internal consistency in the 3 ART-items (Cronbanch’s alpha=0.916) and also performed a confirmatory factor analysis to check how well the three items were loading on a single factor (root mean square error of approximation (RMSEA)0.95, comparative fit index (CFI)>0.95, coefficient of determination (CD)=0.94). We followed published rules of minimum levels of the fit indices, which specify minimum requirement for model acceptance for RMSEA values must be less than 0.06 and for CFIs and TLIs as 0.90 [19]. We also performed confirmatory factor analysis of the overall Structural Equation Model to check how well the model fitted the data (RSMEA0.95, CD=0.88) and used the Sobel test to test for the significance of the mediating factor in both the structural equation model and the linear regression model [20]. For the linear regression model, we used the ‘product of coefficient’ method to test the mediation effects [20].

Based on the information provided, here are some potential innovations that could improve access to maternal health:

1. Integrated Maternal and Child Health (MCH) and Sexual and Reproductive Health (SRH) Services: This innovation involves integrating services for HIV infection, sexually transmitted infections, viral hepatitis, and other reproductive health needs with maternal and child health services. By providing comprehensive care in one location, it can improve access and coordination of care for pregnant women.

2. Assisted Partner Notification: This innovation involves contact tracing and notifying sexual partners of individuals who have tested positive for HIV. By identifying and testing partners, it can help prevent transmission of HIV and improve the health outcomes of both mothers and children.

3. Strengthening Program Monitoring: This innovation involves implementing robust monitoring systems to track the progress of maternal health programs. By collecting and analyzing data on key indicators such as HIV prevalence, ART access, and infant HIV exposure, it can help identify gaps and inform targeted interventions.

4. Leadership and Governance: This innovation focuses on improving leadership and governance within the health sector and country. By strengthening leadership capacity, promoting accountability, and ensuring effective governance structures, it can help drive policy changes and allocate resources to support maternal health initiatives.

5. Health System Strengthening: This innovation involves strengthening the six building blocks of health systems, including leadership and governance, health care financing, the healthcare workforce, medical products and technologies, information and research, and service delivery. By addressing gaps in these areas, it can improve access, coverage, quality, and safety of maternal health interventions.

These innovations, when implemented effectively, have the potential to improve access to maternal health and contribute to the elimination of mother-to-child transmission of HIV.
AI Innovations Description
Based on the provided description, the recommendation to improve access to maternal health and eliminate mother-to-child transmission of HIV in Global Plan priority countries in Sub-Saharan Africa includes the following:

1. Strengthen Health Systems: Focus on strengthening the six building blocks of health systems, namely leadership and governance, health care financing, healthcare workforce, medical products and technologies, information and research, and service delivery. This will improve access, coverage, quality, and safety of interventions, leading to improved outcomes.

2. Integrate Services: Integrate maternal and child health (MCH) and sexual and reproductive health (SRH) services with services for HIV infection, sexually transmitted infections, and viral hepatitis. This integration will ensure comprehensive care for HIV-positive pregnant and lactating women, improving access to necessary interventions.

3. Implement Contact Tracing: Include contact tracing, such as assisted partner notification, to identify individuals who may be at risk of HIV transmission. This will help in early detection, treatment, and prevention of HIV transmission.

4. Improve Program Monitoring: Strengthen program monitoring to track progress and identify areas for improvement. This will ensure that interventions are effectively implemented and outcomes are measured accurately.

5. Enhance Leadership and Governance: Address challenges around leadership and governance within the health sector and country. This includes improving coordination, decision-making, and accountability to ensure effective implementation of interventions.

6. Increase Access to Antiretroviral Therapy (ART): Ensure universal access to lifelong antiretroviral therapy for all HIV-positive pregnant and lactating women. ART access has been shown to protect against mother-to-child transmission of HIV.

7. Reduce Infant HIV Exposure: Implement strategies to reduce infant HIV exposure, such as increasing HIV testing coverage, promoting safe infant feeding practices, and providing support for HIV-positive mothers.

8. Improve Data Collection: Enhance data collection on key sexual and reproductive health indicators, such as unmet need for family planning, antenatal care coverage, HIV testing coverage, and access to triple antiretroviral therapy. This will provide accurate information for monitoring progress and making informed decisions.

By implementing these recommendations, it is possible to improve access to maternal health and work towards eliminating mother-to-child transmission of HIV in Global Plan priority countries in Sub-Saharan Africa.
AI Innovations Methodology
To improve access to maternal health in the context of eliminating mother-to-child transmission of HIV, here are some potential recommendations:

1. Strengthening Health Systems: Focus on improving leadership and governance, healthcare financing, healthcare workforce, medical products and technologies, information and research, and service delivery. This can be achieved through policy reforms, capacity building, and investment in infrastructure and resources.

2. Integration of Services: Integrate maternal and child health (MCH) and sexual and reproductive health (SRH) services with HIV prevention and treatment services. This can improve access to comprehensive care for HIV-positive pregnant women, including antiretroviral therapy (ART), prevention of mother-to-child transmission (PMTCT) interventions, and other essential health services.

3. Contact Tracing: Implement contact tracing strategies, such as assisted partner notification, to identify and reach out to partners of HIV-positive pregnant women. This can help ensure that partners receive appropriate testing, counseling, and treatment, reducing the risk of transmission within the couple.

4. Strengthening Program Monitoring: Enhance monitoring and evaluation systems to track progress, identify gaps, and inform decision-making. This includes collecting and analyzing data on key indicators related to maternal health, HIV prevention, and PMTCT effectiveness.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define the Outcome Measures: Identify specific outcome measures that reflect improved access to maternal health, such as increased coverage of antenatal care, HIV testing, ART access, and reduced mother-to-child transmission rates.

2. Collect Baseline Data: Gather data on the current status of the selected outcome measures in the target population or countries. This can be done through surveys, health facility records, and existing databases.

3. Develop a Simulation Model: Create a mathematical or statistical model that incorporates the potential impact of the recommended interventions on the outcome measures. This model should consider factors such as population size, HIV prevalence, healthcare infrastructure, and resource availability.

4. Input Intervention Scenarios: Define different scenarios that represent the implementation of the recommended interventions. This could include variations in the scale, coverage, and timing of the interventions.

5. Run Simulations: Use the simulation model to estimate the impact of each intervention scenario on the outcome measures. This can be done by adjusting the relevant parameters in the model and running multiple iterations to account for uncertainty.

6. Analyze Results: Analyze the simulation results to assess the potential impact of the interventions on improving access to maternal health. Compare the outcomes across different scenarios to identify the most effective strategies.

7. Validate and Refine the Model: Validate the simulation model by comparing the predicted outcomes with real-world data, if available. Refine the model based on feedback from experts and stakeholders, and incorporate additional factors or interventions as needed.

8. Communicate Findings: Present the findings of the simulation study in a clear and concise manner, highlighting the potential benefits of the recommended interventions for improving access to maternal health. This can inform policy decisions, resource allocation, and program planning.

It is important to note that the methodology described above is a general framework and may need to be adapted based on the specific context and data availability. Collaboration with experts and stakeholders in the field of maternal health and HIV prevention is crucial for developing an accurate and reliable simulation model.

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