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Introduction: Loss to follow-up is a major challenge in the prevention of mother to child transmission of HIV (PMTCT) programme in Malawi with reported loss to follow-up of greater than 70%. Tingathe-PMTCT is a pilot intervention that utilizes dedicated community health workers (CHWs) to create a complete continuum of care within the PMTCT cascade, improving service utilization and retention of mothers and infants.We describe the impact of the intervention on longitudinal care starting with diagnosis of the mother at antenatal care (ANC) through final diagnosis of the infant. Methods: PMTCT service utilization, programme retention and outcomes were evaluated for pregnant women living with HIV and their exposed infants enrolled in the Tingathe-PMTCT programme between March 2009 and March 2011. Multivariate logistic regression was done to evaluate maternal factors associated with failure to complete the cascade. Results: Over 24 months, 1688 pregnant women living with HIV were enrolled. Median maternal age was 27 years (IQR, 23.8 to 30.8); 333 (19.7%) were already on ART. Among the remaining women, 1328/1355 (98%) received a CD4 test, with 1243/1328 (93.6%) receiving results. Of the 499 eligible for ART, 363 (72.8%) were successfully initiated. Prior to, delivery there were 93 (5.7%) maternal/foetal deaths, 137 (8.1%) women transferred/moved, 51 (3.0%) were lost and 58 (3.4%) refused ongoing PMTCT services. Of the 1318 live births to date, 1264 (95.9%) of the mothers and 1285 (97.5%) of the infants received ARV prophylaxis; 1064 (80.7%) infants were tested for HIV by PCR and started on cotrimoxazole. Median age at PCR was 1.7 months (IQR, 1.5 to 2.5). Overall transmission at first PCR was 43/1047 (4.1%). Of the 43 infants with positive PCR results, 36 (83.7%) were enrolled in ART clinic and 33 (76.7%) were initiated on ART. Conclusions: Case management and support by dedicated CHWs can create a continuum of longitudinal care in the PMTCT cascade and result in improved outcomes.
The Tingathe-PMTCT pilot programme took place in Area 25 and Kawale, two large peri-urban communities in Lilongwe. The estimated population is 310,000 people, with 15,000 deliveries/year, 2000 HIV-exposed infants delivered/year and 12% adult HIV prevalence [16]. Over 96% of pregnant women attend at least one antenatal visit [17] and 99% of ANC attendees are tested for HIV [18,19]. All PMTCT clinical care was provided in accordance with MOH and WHO guidelines [20,21]. Figure 2a details all components of the PMTCT cascade available at the intervention sites. HIV testing, counselling and consent were conducted via opt-out testing per MOH guidelines. (a) Components of the PMTCT cascade available at programme intervention sites. (b) Curriculum of community health worker training. At the start of our programme, ART eligibility was defined as WHO Stage 3 or 4 or CD4≤250 cells/mm3 [21]. ART eligibility changed in August 2010 to CD4≤350 cells/mm3 for pregnant or lactating women living with HIV. For women who did not qualify for ART, single dose nevirapine for the mother and infant and a bottle of zidovudine (AZT) syrup for the infant was dispensed at the first ANC visit. AZT was dispensed beginning at 28 weeks, and mothers returned for monthly refills. A 1-week supply of AZT/lamivudine (3TC) tail was distributed during labour and delivery [21]. During the intervention period, the national infant feeding guidelines recommended exclusive breastfeeding until 6 months of age followed by gradual weaning [22,23]. Universal ART initiation for HIV-infected infants younger than 1 year of age was the standard of care. We used three sources for preintervention data. The first was a published report of maternal and infant utilization of PMTCT, EID and paediatric HIV services at five sites (including our two intervention sites) within Lilongwe between 2004 and 2008 [19]. This source contained preintervention comparison data for PMTCT prophylaxis, infant PCRs and ART initiation for HIV-infected infants. For information not included in this report, we used the 2004 Malawi Demographic and Health Survey, which provided national statistics for numbers of women accessing ANC, location of delivery and infant feeding choice after birth [17]. Finally, ANC CD4 log records documented CD4 test dates and whether or not results were returned to pregnant women. Consistent records were not kept at A25. At Kawale, records were available from March to October 2008. The main focus of this programme was CHW-based patient case management in both the health facility and community (Figure 1). The intervention began at ANC when pregnant women identified as living with HIV were assigned a dedicated CHW and voluntarily enrolled into the programme. CHWs ensured that mother-infant pairs received all necessary PMTCT services. They followed their clients at their homes and at health centres, from initial diagnosis up until confirmation of definitive HIV-uninfected status after cessation of breastfeeding or successful ART initiation for HIV-infected infants. Receipt of PMTCT was recorded only upon confirmation with the mother after delivery to verify that medication had actually been ingested, not just dispensed [7]. Women living with HIV who were identified at labour and delivery or after the birth of the infant were also followed up and provided services but were not included in this cohort. Criterion for CHW selection included living within the community, completion of primary schooling and ability to read and write in English and Chichewa, ability to ride a bicycle and HIV-infected or affected. Both men and women were recruited. Due to the large volume of applicants, we first conducted group interviews, inviting those who performed well in these for individual interviews. Once selected, CHWs earned a stipend for work-related transportation and food (2.50 USD/day). A specialized 2-week training, followed by a 2-week on-site orientation, was developed (Figure 2b). Trainees were monitored closely by supervisors and were only allowed to conduct unsupervised patient visits after competency had been verified. CHWs also received half-day quarterly refresher trainings by Baylor paediatricians. To help free up clinical staff for essential clinical care, specific tasks were shifted to CHWs, including patient registration, nutritional assessments, infant feeding counselling, pill counting and distribution of nutritional supplements. All CHWs were responsible for both health centre-based tasks (40% time) and community work (60% time). CHWs generally followed up to a maximum of 50 mother-infant pairs at one time. Prior to the programme intervention, consultative meetings were conducted with community leaders. CHWs conducted daily education sessions in the health centres and held ongoing sensitization meetings in the community. The main focus of education was promoting the utilization of PMTCT, EID and paediatric HIV treatment services. An individual patient mastercard was used to facilitate patient case management, and a patient register was used to monitor CHW activities. The mother-infant mastercard was opened on programme entry, updated after every visit and key data entered into registers weekly. Information from registers was entered into a Microsoft Access database bimonthly. CHWs were supervised weekly by site supervisors and monthly by the programme coordinator. Supervisors also conducted unscheduled visits with patients to ensure that they were satisfied with the services being provided. CHWs received bi-annual performance evaluations. Mother-infant pairs exited the programme if they reached one of the following outcomes: (1) maternal death; (2) miscarriage, stillbirth; (3) infant death; (4) transferred/moved outside the catchment area; (5) lost (patient tracing attempted but patient could not be found); (6) despite counselling, patient refused to return for clinical care; (7) infant infected and successfully enrolled into care and started on ART; and (8) infant definitively not infected (weaned and repeat PCR negative). Data from pregnant women and exposed infants enrolled in the Tingathe-PMTCT programme between March 2009 and March 2011 were analysed. The closing date for follow-up was October 31, 2011. Data were de-identified prior to analysis. Aggregate data were reported as mean with standard deviation or median with interquartile range (IQR) based on normality. For the multivariate logistic regression, all outcomes preventing completion of the PMTCT cascade were grouped together including miscarriage/foetal demise, maternal/infant death, transferred/moved, lost and refused ongoing care. To identify factors that predicted non-completion, unadjusted and adjusted odds ratios and 95% confidence intervals were obtained using binary and multivariate logistic regression, respectively. All covariates, irrespective of the significance of the binary model, were entered into the multivariate model by forward stepwise selection, with entry testing based on the significance of the score statistic and removal testing based on the likelihood-ratio statistic with conditional parameter estimates. Only covariates with a significant score statistic (p<0.05) were retained in the final model. Analyses were performed using IBM SPSS Statistics (version 19; SPSS, Inc., Chicago, IL, USA). The Malawi National Health Sciences Research Committee and the Baylor College of Medicine institutional review board granted ethics approval.
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