Towards elimination of mother-to-child transmission of HIV: The impact of a rapid results initiative in nyanza province, Kenya

  • AIDS Research and Treatment, Volume 2012, Year 2012

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Study Justification:
The study aimed to address the challenges in delivering prevention of mother-to-child transmission (PMTCT) services, specifically focusing on the uptake of highly active antiretroviral therapy (HAART) for HIV-positive pregnant women and infants. The goal was to eliminate mother-to-child transmission of HIV and improve maternal and child health in Nyanza Province, Kenya.
Highlights:
– The Rapid Results Initiative (RRI) approach was utilized to implement and monitor the interventions.
– The RRI was conducted between April and June 2011 at 119 health facilities in five districts in Nyanza Province, Kenya.
– HAART uptake among HIV-positive pregnant women increased by 40% during the RRI and continued to improve post-RRI.
– HAART uptake in HIV-positive infants remained stable during the RRI and improved by 30% post-RRI.
– The study demonstrated that significant improvements in PMTCT services can be achieved through the introduction of an RRI, leading to sustained benefits for pregnant HIV-infected women and their infants.
Recommendations:
– Implement the RRI approach in other regions to improve PMTCT services and reduce mother-to-child transmission of HIV.
– Strengthen the laboratory network for CD4 sample and result transport to ensure timely assessment of HAART eligibility.
– Increase access to cell stabilizer tubes for daily blood drawing at peripheral sites.
– Improve identification of HIV-exposed infants and prioritize testing through same-day dried blood spot sampling for PCR testing.
– Reduce turnaround time for PCR results and enhance communication of positive results to facilitate prompt intervention.
– Train and empower healthcare staff to rapidly initiate HAART for HIV-infected infants.
– Integrate ART into ANC/MCH clinics or facilitate referrals to HAART sites where it is not available.
Key Role Players:
– FACES (Family AIDS Care and Education Services): Collaborative organization between the University of California San Francisco (UCSF), the Kenya Medical Research Institute (KEMRI), and the Kenyan Ministry of Health (MOH).
– Kenyan MOH: Provides leadership, joint planning, implementation, and support supervision.
– Laboratory staff: Involved in harmonizing CD4 sample and result transport, increasing sample transport frequency, and prioritizing CD4 samples from ANC.
– Health care providers: Notified of eligible CD4 counts, integrated ART into ANC clinics, and used cell phones to contact eligible women.
– Community health workers: Engaged in focused community mobilization and assisted in notifying parents of HIV-positive results and ensuring their return to the facility.
– Local opinion leaders and mass media: Involved in community mobilization efforts.
Cost Items for Planning Recommendations:
– Laboratory network strengthening: Budget for harmonizing CD4 sample and result transport, increasing sample transport frequency, and providing cell stabilizer tubes.
– Training and mentorship: Allocate funds for staff training and mentorship programs.
– Communication tools: Budget for cell phones and other communication devices to facilitate contact with eligible women and parents of HIV-positive infants.
– Integration of ART: Plan for the integration of ART into ANC/MCH clinics, including any necessary infrastructure and equipment.
– Referral facilitation: Allocate funds for facilitating referrals to HAART sites where ART is not available.
– Continuous quality improvement exercises: Budget for regular support supervision and monitoring of PMTCT activities.
Please note that the provided information is based on the description provided and may not include all details from the original study.

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Many HIV-positive pregnant women and infants are still not receiving optimal services, preventing the goal of eliminating mother-to-child transmission (MTCT) and improving maternal child health overall. A Rapid Results Initiative (RRI) approach was utilized to address key challenges in delivery of prevention of MTCT (PMTCT) services including highly active antiretroviral therapy (HAART) uptake for women and infants. The RRI was conducted between April and June 2011 at 119 health facilities in five districts in Nyanza Province, Kenya. Aggregated site-level data were compared at baseline before the RRI (Oct 2010-Jan 2011), during the RRI, and post-RRI (Jul-Sep 2011) using pre-post cohort analysis. HAART uptake amongst all HIV-positive pregnant women increased by 40% (RR 1.4, 95% CI 1.2-1.7) and continued to improve post-RRI (RR 1.6, 95% CI 1.4-1.8). HAART uptake in HIV-positive infants remained stable (RR 1.1, 95% CI 0.9-1.4) during the RRI and improved by 30% (RR 1.3, 95% CI 1.0-1.6) post-RRI. Significant improvement in PMTCT services can be achieved through introduction of an RRI, which appears to lead to sustained benefits for pregnant HIV-infected women and their infants. © 2012 Lisa L. Dillabaugh et al.

The RRI was structured in 3 stages: (1) needs assessment, (2) implementation and monitoring, and (3) followup for sustainability (Figure 1). First, a joint-needs assessment at a provincial level using a Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis was conducted by FACES and the Kenyan MOH in January 2011. Specific objectives were agreed on and targets set for each measurable outcome over a 60-day implementation timeframe scheduled to begin in April 2011. Specific objectives included (1) increase assessment of HAART eligibility and uptake amongst HIV-positive pregnant women, (2) improve uptake of testing for HIV-exposed infants, and (3) increase HAART uptake amongst HIV-positive infants. Rapid Results Initiative Approach. The implementation phase was organized by provincial and district-level multidisciplinary taskforces including laboratory, monitoring and evaluation, community liaison and clinical staff. Strategies for achieving targets were formulated at both provincial and district levels and are described below. Followup and sustainability efforts are ongoing and include routine support supervision and monitoring of PMTCT activities conducted jointly by FACES and the MOH as well as continuous quality improvement exercises conducted quarterly. In addition to strategic approaches for each objective, three overarching strategies were identified as cross-cutting to accomplish all three objectives: (1) MOH leadership and involvement through joint planning, implementation, and support supervision, (2) increased male partner involvement through invitational letters requesting male partners to accompany their pregnant partner to the clinic for HIV couples counseling and testing, and (3) focused community mobilization which involved engaging local opinion leaders, community health workers, and mass media on high impact days such as market days. To increase HAART eligibility assessment among HIV-positive pregnant women, laboratory network for CD4 sample and result transport was harmonized between facilities and hubs; sample transport was increased to daily or twice weekly; access to cell stabilizer tubes was increased to allow for daily blood drawing at peripheral sites; and CD4 samples from ANC were flagged at the lab for prioritization. To increase HAART uptake for eligible women, health care providers were notified of eligible CD4 counts; ART was integrated into ANC clinics to increase access at some sites previously without ART; and cell phones were used to contact eligible women. To improve exposed infant testing uptake, the focus was on (1) improved identification of HIV-exposed infants by prioritizing infant exposure status assessment in the mother’s ANC record (national mother-child booklet), offering to test women of unknown HIV status, and conducting same-day dried blood spot sampling for PCR testing for exposed infants, (2) decreased turnaround time for PCR results through laboratory strengthening mentioned above, facility-level problem-solving to reduce delays, and use of mobile phones to rapidly communicate positive results, and (3) staff training and mentorship was conducted. To increase HAART uptake amongst HIV-positive infants. HIV-positive PCR results were flagged at district hospital labs and immediately communicated by phone to facilities. Facility staff then contacted parents by phone or sent a community health worker to notify parents of the HIV-positive results and ensure return to the facility. Staff were trained and empowered to rapidly initiate HAART on HIV-infected infants. In facilities where HAART was not available, ART was integrated into ANC/MCH clinics, or referrals to HAART sites were facilitated. FACES delivers a comprehensive HIV prevention, care and treatment program in Nyanza Province, where HIV prevalence and infant mortality are highest in the country at 14.9% and 95 per 1000, respectively [21, 22]. FACES, a collaboration between the University of California San Francisco (UCSF), the Kenya Medical Research Institute (KEMRI), and the Kenyan MOH, works to build the capacity of the Kenyan government to implement quality HIV services through targeted technical support, training, and health care workforce support. This intervention was implemented within 119 clinics in 5 districts in Nyanza Province. Clinics were included if they were supported by FACES and currently implementing PMTCT services. Eighty-two (69%) of the 119 clinics were also providing HAART at the time of RRI implementation. All levels of facilities were included including 6 district hospitals, 5 subdistrict hospitals, 26 health centers, and 82 dispensaries. Site-level data were captured at baseline, covering 12 weeks (October 2010–January 2011) and compared to the RRI 12-week period (April 2011–June 2011), and to a 12-week post-RRI period (July 2011–September 2011) to examine changes in testing and uptake of services across the sites. December 2010 data were omitted from baseline due to the shortened work month. Data were collected using routine program PMTCT monthly data collection tools. As part of standard care, maternal-child health (MCH) staff documented daily patient care in ANC, maternal (MAT), postnatal (POST), and HIV-exposed infant (HEI) MOH registers. PMTCT variables were extracted from the registers and entered in aggregated form into PMTCT monthly data collection tools. Key outcomes were assessed at baseline and were compared to RRI and post-RRI periods including (1) number of pregnant women counseled and HIV tested in ANC, (2) proportion of women tested for HIV in ANC who had a male partner HIV tested in ANC, (3) proportion of women tested in ANC with confirmed HIV-positive results, (4) proportion of HIV-positive women in ANC who had blood taken for CD4 testing in ANC, (5) proportion of HIV-positive women who initiated on HAART in ANC, (6) the number of exposed infants that had a HIV PCR test as a proportion of the number of HIV-positive women in ANC, (7) proportion of exposed infants that were HIV-positive, and (8) proportion of HIV-positive infants initiated on HAART. Data obtained during the baseline, RRI and post-RRI periods were compared to assess whether there were significant changes during the three periods using pre-post cohort analysis using Stata 10 (StataCorp, College Station, TX, USA). Temporal changes in indicators were considered significant at a P value of <0.05. The risks, risk difference, and risk ratios (95% confidence Intervals) were reported for each indicator with the RRI baseline period as the reference point. The FACES' program evaluation protocol was reviewed and approved by the KEMRI Ethical Review Committee, UCSF Committee on Human Research, and Centers for Disease Control and Prevention NCHHSTP ADS/ADLS Review Committee.

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The Rapid Results Initiative (RRI) approach was utilized to improve access to maternal health services and prevent mother-to-child transmission of HIV in Nyanza Province, Kenya. The RRI consisted of three stages: needs assessment, implementation and monitoring, and follow-up for sustainability. Several strategies were implemented to achieve the objectives, including:

1. Increasing assessment of highly active antiretroviral therapy (HAART) eligibility and uptake among HIV-positive pregnant women:
– Harmonizing the laboratory network for CD4 sample and result transport between facilities and hubs
– Increasing sample transport frequency and access to cell stabilizer tubes
– Prioritizing CD4 samples from antenatal care (ANC) for faster processing
– Notifying healthcare providers of eligible CD4 counts
– Integrating ART into ANC clinics to increase access

2. Improving uptake of testing for HIV-exposed infants:
– Prioritizing infant exposure status assessment in the mother’s ANC record
– Offering testing to women of unknown HIV status
– Conducting same-day dried blood spot sampling for PCR testing
– Reducing turnaround time for PCR results through laboratory strengthening
– Training and mentorship for staff

3. Increasing HAART uptake among HIV-positive infants:
– Flagging HIV-positive PCR results at district hospital labs and immediately communicating them to facilities
– Contacting parents by phone or sending community health workers to notify them of positive results and ensure return to the facility
– Empowering staff to rapidly initiate HAART on HIV-infected infants
– Integrating ART into ANC/MCH clinics or facilitating referrals to HAART sites

In addition to these strategies, three overarching approaches were identified as cross-cutting:
1. MOH leadership and involvement through joint planning, implementation, and support supervision
2. Increased male partner involvement through invitational letters requesting their presence during HIV couples counseling and testing
3. Focused community mobilization, including engagement of local opinion leaders, community health workers, and mass media on high impact days

The RRI resulted in significant improvements in HAART uptake among HIV-positive pregnant women and infants. The approach continues to be supported through routine support supervision, monitoring, and continuous quality improvement exercises.

Please note that this information is based on the provided description and may not encompass all innovations or recommendations for improving access to maternal health.
AI Innovations Description
The recommendation to improve access to maternal health based on the study is to implement a Rapid Results Initiative (RRI) approach. The RRI approach involves three stages: needs assessment, implementation and monitoring, and follow-up for sustainability.

During the needs assessment stage, a joint-needs assessment at a provincial level was conducted to identify key challenges in the delivery of prevention of mother-to-child transmission (PMTCT) services. Specific objectives were agreed upon, and targets were set for each measurable outcome.

In the implementation and monitoring stage, multidisciplinary taskforces at the provincial and district levels were formed to organize and implement strategies to achieve the targets. Strategies included increasing access to highly active antiretroviral therapy (HAART) for HIV-positive pregnant women and infants, improving testing for HIV-exposed infants, and increasing HAART uptake among HIV-positive infants. Cross-cutting strategies included involving the Ministry of Health (MOH) in planning and implementation, increasing male partner involvement, and community mobilization.

The follow-up for sustainability stage involves routine support supervision and monitoring of PMTCT activities, as well as continuous quality improvement exercises. This ensures that the improvements achieved through the RRI approach are sustained over time.

The study found that the RRI approach led to significant improvements in PMTCT services. HAART uptake among HIV-positive pregnant women increased by 40% during the RRI period and continued to improve post-RRI. HAART uptake among HIV-positive infants remained stable during the RRI period and improved by 30% post-RRI.

Overall, the recommendation is to implement the RRI approach, which involves conducting a needs assessment, implementing targeted strategies, and ensuring follow-up for sustainability. This approach has shown to be effective in improving access to maternal health services, specifically in the context of preventing mother-to-child transmission of HIV.
AI Innovations Methodology
Based on the information provided, here are some potential recommendations for improving access to maternal health:

1. Strengthening laboratory networks: Harmonize CD4 sample and result transport between facilities and hubs, increase sample transport frequency, and ensure access to cell stabilizer tubes for daily blood drawing at peripheral sites.

2. Integration of antiretroviral therapy (ART) into ANC clinics: Increase access to ART by integrating it into ANC clinics at sites previously without ART.

3. Improved identification of HIV-exposed infants: Prioritize infant exposure status assessment in the mother’s ANC record, offer testing to women with unknown HIV status, and conduct same-day dried blood spot sampling for PCR testing.

4. Decreased turnaround time for PCR results: Strengthen laboratory capacity to reduce delays in PCR result communication, use mobile phones to rapidly communicate positive results, and conduct facility-level problem-solving to address delays.

5. Increased male partner involvement: Send invitational letters to male partners requesting their presence during HIV couples counseling and testing at the clinic.

6. Focused community mobilization: Engage local opinion leaders, community health workers, and mass media on high impact days to raise awareness and promote maternal health services.

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

1. Define measurable outcomes: Identify specific indicators that can be used to measure the impact of the recommendations, such as the number of pregnant women counseled and tested for HIV, the proportion of women initiating HAART, and the proportion of exposed infants tested for HIV.

2. Collect baseline data: Gather data on the selected indicators before implementing the recommendations. This can be done by reviewing existing records and conducting surveys or interviews with healthcare providers and patients.

3. Implement the recommendations: Put the recommendations into practice, ensuring that all relevant stakeholders are involved and necessary resources are allocated.

4. Monitor and evaluate: Continuously monitor the implementation of the recommendations and collect data on the selected indicators during and after the implementation period. This can be done through routine data collection, surveys, or interviews.

5. Analyze the data: Use statistical analysis software, such as Stata, to compare the baseline data with the data collected during and after the implementation period. Calculate risks, risk differences, and risk ratios to assess the impact of the recommendations on the selected indicators.

6. Interpret the results: Analyze the findings to determine the effectiveness of the recommendations in improving access to maternal health. Identify any significant changes in the selected indicators and assess the overall impact of the recommendations.

7. Make recommendations for further improvement: Based on the results, identify areas that require further attention and develop additional recommendations or interventions to address any remaining gaps or challenges.

8. Ensure sustainability: Develop strategies to ensure the sustainability of the implemented recommendations, such as continuous quality improvement exercises, routine support supervision, and ongoing monitoring of maternal health activities.

By following this methodology, it is possible to simulate the impact of the recommendations on improving access to maternal health and make evidence-based decisions for further improvement.


Statistics:
Citations: 16
Identifiers:
DOI: 10.1155/2012/602120
ISSN: 20901240
Research Areas:
Community Interventions, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Workforce
Study Countries:
Kenya
Study Design:
Cohort Study, Cross Sectional Study, Grounded Theory, randomised-control-trial
Study Approach:
Quantitative
Participants Gender:
Male & Female
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