Realities and challenges of a five year follow up of mother and child pairs on a PMTCT program in Zimbabwe

Study Justification:
The study aimed to investigate the realities and challenges of a five-year follow-up of mother and child pairs on a Prevention of Mother-to-Child Transmission (PMTCT) program in Zimbabwe. This research was important because complete follow-up is crucial for observational cohorts, regardless of the disease being studied. By examining the follow-up rates, loss to follow-up (LTFU), and mortality rates of HIV-infected and HIV-negative mothers and their children, the study aimed to identify the gaps and issues within the PMTCT program.
Highlights:
– The study enrolled a total of 479 HIV-infected and 571 HIV-negative pregnant women from three peri-urban clinics in Harare, Zimbabwe.
– Follow-up rates were relatively high, with 92.9% of HIV-infected and 86.6% of HIV-negative mothers being followed up.
– Mortality rates were higher among HIV-infected mothers and their children compared to HIV-negative mothers and their children.
– Loss to follow-up rates were also high within the PMTCT program, particularly among HIV-negative mothers and their children.
Recommendations:
– Improve follow-up strategies and interventions to reduce loss to follow-up rates within the PMTCT program.
– Strengthen support systems for HIV-infected mothers and their children to reduce mortality rates.
– Enhance communication and coordination between healthcare providers, counselors, and support groups to ensure better engagement and retention of participants in the program.
– Increase awareness and education about the importance of PMTCT programs and the benefits of regular follow-up for both HIV-infected and HIV-negative mothers and their children.
Key Role Players:
– Healthcare providers: Doctors, nurses, and midwives involved in the PMTCT program.
– Counselors: Trained counselors responsible for follow-up and support of participants.
– Support groups: Facilitators and coordinators of support groups for HIV-infected and HIV-negative mothers.
– Researchers: Individuals conducting the study and analyzing the data.
– Policy makers: Government officials and policymakers responsible for implementing and improving PMTCT programs.
Cost Items for Planning Recommendations:
– Transportation: Budget for reimbursing transport costs for participants to attend follow-up visits.
– Clinical care expenses: Budget for supporting clinical care expenses related to any clinical events.
– Medications: Budget for providing necessary medications, such as antiretroviral therapy and prophylactic cotrimoxazole.
– Training and capacity building: Budget for training healthcare providers, counselors, and support group facilitators.
– Communication and coordination: Budget for improving communication channels and coordination between different stakeholders in the PMTCT program.
– Awareness and education: Budget for conducting awareness campaigns and educational programs to increase knowledge and understanding of PMTCT programs.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong, but there are some areas for improvement. The study design is a cohort study, which is a robust design for observational research. The sample size is adequate, with 479 HIV infected and 571 HIV negative pregnant women enrolled. The follow-up period of five years is also appropriate. However, there are some limitations to consider. The abstract does not provide information on the representativeness of the sample or the generalizability of the findings. Additionally, there is no mention of any statistical analyses conducted to assess the significance of the results. To improve the strength of the evidence, it would be helpful to include information on the sampling method used to recruit the participants and to provide more details on the statistical analyses conducted. Additionally, including information on the limitations of the study would provide a more comprehensive assessment of the evidence.

Background: Complete follow up is an essential component of observational cohorts irrespective of the type of disease. Objectives: To describe five years follow up of mother and child pairs on a PMTCT program, highlighting loss to follow up (LTFU) and mortality (attrition). Study Design: A cohort of pregnant women was enrolled from the national PMTCT program at 36 weeks gestational age attending three peri urban clinics around Harare offering maternal and child health services. Mother-infant pairs were followed up from birth and twice yearly for five years. Results: A total of 479 HIV infected and 571 HIV negative pregnant women were enrolled, 445(92.9%) and 495(86.6%) were followed up whereas 14(3.0%) and 3(0.5%) died in the 1st year respectively; RR (95%CI) 5.3(1.5-18.7). At five years 227(56.7%) HIV infected and 239(41.0%) HIV negative mothers turned up, whereas mortality rates were 34 and 7 per 100 person years respectively. Birth information was recorded for 401(83.7%) HIV exposed and 441(77.2%) unexposed infants, 247(51.6%) and 232(40.6) turned up in the first year whilst mortality was 58(12.9%) and 22(4.4%) respectively, RR (95%CI) 3.2(2.0-5.4). At five years 210(57.5%) HIV exposed and 239(44.3%) unexposed infants were seen, whilst mortality rates were 53 per 1000 and 15 per 1 000 person years respectively. Mortality rate for HIV infected children was 112 compared to 21 per 1 000 person years for the exposed but uninfected. Conclusion: HIV infected mothers and their children succumbed to mortality whereas the HIV negatives were LTFU. Mortality rates and LTFU are high within PMTCT program.© Kurewa et al.

A cohort of mother and child pairs was recruited from the national PMTCT program and followed up for five years. Three peri urban clinics around Harare the capital city of Zimbabwe, namely; Epworth; St Marys and Seke North. These are primary health care settings offering maternal and child health services. Pregnant women booked at the respective Antenatal Clinics (ANC), who have gone through the national PMTCT (VCT) were followed up together with their index children from birth up to 5 years. Pregnant women from 36 weeks of gestation coming through the national PMTCT program. Pregnant women with known complications and who not had to deliver at a primary health care setting were excluded. The intention was to recruit 300 HIV positive and 600 HIV negative pregnant women allowing for 10% LFU. ‘EPISTAT’ program was used to calculate the sample size. A questionnaire sourcing socio demographic, life styles and living conditions, obstetric and reproductive history, contraception and knowledge of STI/HIV signs and symptoms was administered to the women at enrolment. In addition to routine antenatal care women were screened for other sexually transmitted infections and reproductive tract infections (RTI)s. Those found infected were treated and encouraged to inform their sexual partners to come for treatment which was given for free. A locator form was used to document the physical and postal address of the mother or care giver and next of kin details were obtained for those who consented to home visits, where available contact telephone numbers were obtained for follow up purposes. Trained counselors residing in the same community were responsible for the follow up of those participants who missed their scheduled visits. All transport costs were reimbursed, whilst all clinical care expenses related to any clinical event were supported by the project. At birth HIV infected mothers received a single 200-mg Nevirapine dose at the onset of labor, and their infants received a single 1-2 mg Nevirapine dose within 72 hours of delivery (sdNVP). Nevirapine was provided by the government of Zimbabwe under the national PMTCT program. Support groups were introduced during the second year of follow up where women met clinician once every week. At each study clinic women were encouraged to form one group for both HIV infected and negative women. They chose a convenient day where they would meet at a specified time for up to 2 hours and a coordinator amongst themselves to act as a link person between them and the researchers. Health education talks were given to the women interacting with the research nurses, counselors, psychologist and sociologist to respond to their concerns in a participatory manner. Women were also given an opportunity to suggest topics which they felt relevant to their day to day lives. They were encouraged to bring their spouses and significant members like mothers’ in law or any caregiver for the index child where the mother had been lost. Note: Enrolment was done during the time when prolonged ARVs were not readily available in the country except for the sdNVP, whereas CD4 counts were not routinely done at government institutions due to prohibitive costs. However over the follow up period when they became available and affordable the project facilitated referral for the HIV infected and exposed children to access both CD4 counts and ARVs when indicated from the government opportunistic clinics (OI). This was conducted within the same study clinics where maternal and child health services are provided. A separate room was provided for the study procedures throughout the follow up period. Mothers were followed up according to their expected date of term (EDT) to ascertain site and mode of delivery and for the HIV infected to ensure provision of NVP. A birth form was used to document birth information; onset of labour, time of rupture of membranes, duration of labor, collection of venous blood and for the HIV infected women, time of ingesting Nevirapine tablet. All mothers and their infants were followed up for 6 weeks, four and nine months and every six months thereafter for five years. Mother and child health status was assessed and documented in the appropriate form according to the age after birth. Infant feeding practices were assessed and documented at each visit. HIV infected mothers and their exposed infants were given prophylactic cotrimoxazole. For the exposed infants cotrimoxazole would be stopped if they tested negative for HIV. HIV infected mothers had a general physical and gynaecological examination performed together with CD4 counts that were assessed every six months. Those with a low CD4 count (<less than 200 mm/l would be send for a chest x- ray, blood chemistry; liver function tests (LFTs), Urea and electrolytes (U & Es and full blood count (FBC) for easy access and referral to the government opportunistic infection (OI) clinics for ARV therapy. Outcome information was when the study participants were considered to be alive; they turned up for their scheduled visit, they could be contacted over the phone, could be seen at home or if a spouse or close relative, or care giver of the child could confirm that they were alive during the period under observation. They were considered deceased if a spouse, close relative, landlord or neighbor seen at their house or nearby confirmed verbally or medical records that confirmed their death. In the case where the visit was unsuccessful, they were not proven as deceased or alive and follow up visits would have been repeated for unspecified times and all channels of contact exhausted. They would then be considered as LFU. Follow up of the commenced from birth for both HIV exposed and unexposed neonates was carried out. Birth information was recorded in an infant birth form by the midwife regarding status of the neonate at birth; alive or still born, Apgar score, physical examination including anthropometrical measurements and collection of a cord blood sample for the HIV exposed infants. Thereafter venous blood was collected at each follow up visit; 6 weeks, 4 and 9 months for HIV- DNA PCR test using cell pellets by prototype Roche Amplicor version 1.5 qualitative PCR assay (Roche Diagnostic Systems). At six weeks cotrimoxazole suspension was given to all HIV exposed infants until they were screened and found negative. At each visit a health status was documented in the appropriate form according to age at visit after a complete physical examination of the infant together with anthropometric measurements and feeding practices. A Bailey Infant Neurological development test (BINS) was performed from 3 to 24 months. Thereafter the children continued to have a general health status assessment every six months performed by the study paediatrician. HIV exposed infants were screened for HIV one month after cessation of breastfeeding and from 15 months onwards. HIV infected infants had a full blood count test (FBC), blood chemistry tests and CD4 counts every six months. Where the infants indicated were referred to OI clinics to be commenced on ARVs. Infants were classified at birth according to maternal HIV status that was determined at approximately 36 weeks of gestation and this status was maintained for the analysis of this paper. At each scheduled visit information was sourced from the mother or care giver about the health status of the infant. Those who did not turn up for the scheduled visit were followed up to ascertain reason for defaulting. If found they would be rescheduled for the next visit. An infant was considered as LTFU if he was not brought in for the stipulated visit and not declared as deceased by either the parents or caregiver. The infants were considered dead through evidence from verbal autopsy for the baby given by either the mother or care giver or when available clinical records were analyzed to ascertain cause of death. Attrition, (defined as the total sum of those who were LTFU and those that died) was assessed at each scheduled visit over the five years. Both the Medical Research Council of Zimbabwe and the Ethical Review Committee in Norway approved the study. Mothers who agreed to participate gave an informed written consent that covered themselves and their index babies to be followed up from birth. Data were entered and analyzed using SPSS and STATA Version 9 from StataCorp Texas USA. All mothers enrolled in pregnancy were assessed whilst all live born infants were available for analysis. In the case of multiple births only the first born was included to avoid mixing up of the children. Baseline characteristics were compared using Pearson X2 test for categorical variables and independent sample student’s t test for continuous variables. Follow up of mothers and infants reflecting on those seen, LFU and deceased at each scheduled visit from birth to 5 years is demonstrated by a flow diagram (Figs. ​11, ​22). Mothers follow Up over 5 years. Infants follow up over 5 years. Scheduled visits were combined from birth up to one year to summarize those ever seen and those who were LTFU and the ones that died as outcome information. Risk ratios with their 95% CI of dying or being lost to follow up were estimated over the 1st year and at five years using maternal HIV status at enrolment. Follow up time was measured in months from enrolment up to 60 months ending at the earliest month of death and ending at the last follow up visit, date of last contact. The statistical significance threshold was 5%, whilst all reported p values were 2 sided.

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

1. Mobile health (mHealth) applications: Develop mobile apps that provide pregnant women with access to information about prenatal care, nutrition, and HIV prevention. These apps could also send reminders for clinic visits and medication adherence.

2. Telemedicine services: Implement telemedicine services to allow pregnant women in remote areas to consult with healthcare providers and receive prenatal care remotely. This could help overcome geographical barriers and improve access to healthcare.

3. Community health workers: Train and deploy community health workers to provide education, support, and follow-up care to pregnant women in underserved areas. These workers can help bridge the gap between healthcare facilities and the community.

4. Transportation support: Establish transportation support systems to ensure pregnant women can easily access healthcare facilities for prenatal visits, delivery, and postnatal care. This could involve providing transportation vouchers or organizing community-based transportation services.

5. Integration of services: Integrate maternal health services with other existing healthcare programs, such as HIV/AIDS prevention and treatment programs. This would ensure that pregnant women receive comprehensive care and support for both maternal and HIV-related health needs.

6. Health education and awareness campaigns: Conduct targeted health education and awareness campaigns to increase knowledge and understanding of maternal health issues, including the importance of prenatal care, HIV prevention, and the benefits of skilled birth attendance.

7. Strengthening healthcare infrastructure: Invest in improving healthcare infrastructure, including the availability of skilled healthcare providers, well-equipped clinics, and essential medical supplies. This would ensure that pregnant women have access to quality care when they need it.

8. Empowering women: Promote women’s empowerment and involvement in decision-making regarding their own health. This could be done through community-based support groups, women’s health forums, and initiatives that promote women’s rights and agency in healthcare.

These innovations, if implemented effectively, could help improve access to maternal health services and reduce loss to follow-up and mortality rates among pregnant women and their children.
AI Innovations Description
Based on the provided description, the recommendation to improve access to maternal health is to implement a comprehensive follow-up program for mother and child pairs enrolled in the Prevention of Mother-to-Child Transmission (PMTCT) program in Zimbabwe. This program should address the challenges of loss to follow-up (LTFU) and mortality rates observed in the study.

The following steps can be taken to develop this recommendation into an innovation:

1. Strengthening Antenatal Care: Enhance the national PMTCT program by integrating comprehensive antenatal care services. This includes providing regular check-ups, screening for other sexually transmitted infections and reproductive tract infections, and offering treatment and counseling for infected women and their partners.

2. Improving Communication and Support: Establish support groups for HIV-infected and negative women within the PMTCT program. These groups can provide a platform for women to share experiences, receive health education talks, and address their concerns. Encourage the participation of spouses and other caregivers to ensure a holistic approach to maternal and child health.

3. Enhancing Follow-up Mechanisms: Develop a robust follow-up system for mother and child pairs, starting from birth and continuing for five years. This system should include regular scheduled visits, home visits for those who miss appointments, and the use of trained counselors residing in the same community to facilitate follow-up.

4. Providing Financial Support: Reimburse transport costs for mothers and children attending follow-up visits. Additionally, cover all clinical care expenses related to any clinical event to alleviate financial barriers to accessing healthcare.

5. Strengthening Healthcare Infrastructure: Ensure that primary healthcare settings, such as peri-urban clinics, have the necessary resources and capacity to provide maternal and child health services. This includes access to essential medications, diagnostic tests, and trained healthcare professionals.

6. Promoting Early Infant HIV Testing: Implement routine HIV testing for exposed infants at one month after cessation of breastfeeding and from 15 months onwards. This will enable early detection of HIV infection and timely initiation of antiretroviral therapy if needed.

7. Improving Data Collection and Analysis: Establish a standardized data collection system to accurately track the follow-up status of mother and child pairs. Analyze the data regularly to identify trends, challenges, and areas for improvement in the PMTCT program.

By implementing these recommendations, the innovation aims to improve access to maternal health by reducing loss to follow-up and mortality rates among HIV-infected and negative mothers and their children enrolled in the PMTCT program in Zimbabwe.
AI Innovations Methodology
Based on the provided information, here are some potential recommendations to improve access to maternal health:

1. Strengthening Antenatal Care (ANC) Services: Enhance the quality and availability of ANC services by ensuring that pregnant women have access to comprehensive care, including HIV testing, counseling, and treatment, as well as screening for other sexually transmitted infections and reproductive tract infections.

2. Improving Follow-up and Retention: Implement strategies to reduce loss to follow-up (LTFU) and improve retention of mother and child pairs in the PMTCT program. This could involve the use of community-based follow-up programs, trained counselors residing in the same community, and reimbursement of transport costs for participants.

3. Enhancing Support Groups: Establish support groups for HIV-infected and HIV-negative women within the PMTCT program. These support groups can provide a platform for women to share experiences, receive health education, and address concerns related to maternal and child health.

4. Strengthening Health Education: Provide targeted health education talks to women, research nurses, counselors, psychologists, and sociologists to address their specific concerns and improve knowledge about STIs, HIV signs and symptoms, and infant feeding practices.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the indicators: Identify key indicators to measure the impact of the recommendations, such as the percentage of pregnant women receiving comprehensive ANC services, the rate of LTFU, and the retention rate in the PMTCT program.

2. Collect baseline data: Gather data on the current status of access to maternal health services, including the number of pregnant women enrolled in the PMTCT program, the percentage of women completing follow-up visits, and the mortality rates among mothers and infants.

3. Implement the recommendations: Introduce the recommended interventions, such as strengthening ANC services, establishing support groups, and improving follow-up and retention strategies.

4. Monitor and evaluate: Continuously monitor the implementation of the recommendations and collect data on the selected indicators. This can be done through regular data collection from health facilities, follow-up visits, and surveys.

5. Analyze the data: Analyze the collected data to assess the impact of the recommendations on access to maternal health. Compare the baseline data with the post-intervention data to determine any changes in the indicators.

6. Interpret the results: Interpret the findings to understand the effectiveness of the recommendations in improving access to maternal health. Identify any gaps or areas for further improvement.

7. Adjust and refine: Based on the results and analysis, make adjustments and refinements to the recommendations as needed. This could involve scaling up successful interventions, addressing challenges, and adapting strategies to local contexts.

By following this methodology, it will be possible to simulate the impact of the recommendations on improving access to maternal health and make informed decisions for further interventions and improvements.

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