Lack of HIV RNA test result is a barrier to breastfeeding among women living with HIV in Botswana

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Study Justification:
The study aimed to investigate the impact of the lack of HIV RNA test results on breastfeeding among women living with HIV in Botswana. This is important because Botswana updated its antiretroviral treatment guidelines to support breastfeeding for WLHIV on ART who have documented HIV RNA suppression during pregnancy. However, the study found that the requirement of HIV RNA suppression documentation in the obstetric record is a barrier to breastfeeding.
Highlights:
– The study analyzed data from the Tsepamo Study, which collects information from obstetric records at public maternity wards in Botswana.
– Among the WLHIV included in the study, 39.7% chose to breastfeed and 60.3% chose to formula feed.
– Women who had a documented HIV RNA result in the obstetric record were more likely to breastfeed compared to those without a documented result.
– A substantial proportion of women who did not meet the criteria for breastfeeding still chose to breastfeed.
– The study revealed that some women had an HIV RNA test during pregnancy, even if it was not recorded in the obstetric record.
Recommendations:
– The requirement of HIV RNA suppression documentation in the obstetric record should be reevaluated as it acts as a barrier to breastfeeding.
– Alternative methods should be explored to ensure accurate and accessible HIV RNA test results for healthcare providers.
– Counseling and education programs should be implemented to provide WLHIV with comprehensive information on infant feeding options and the risks of HIV transmission.
Key Role Players:
– Ministry of Health: Responsible for policy development and implementation.
– Healthcare Providers: Involved in counseling and providing information to WLHIV.
– PMTCT Program: Responsible for implementing prevention of mother-to-child transmission of HIV strategies.
– Laboratory Services: Involved in conducting HIV RNA tests and providing accurate results.
Cost Items:
– Training and Education Programs: Budget for developing and implementing counseling and education programs for healthcare providers and WLHIV.
– Laboratory Services: Budget for conducting HIV RNA tests and ensuring accurate and accessible results.
– Data Management: Budget for maintaining electronic databases and systems for recording and verifying HIV RNA test results.
– Monitoring and Evaluation: Budget for monitoring the implementation of recommendations and evaluating their impact on breastfeeding rates among WLHIV.
Please note that the provided cost items are examples and not actual costs. The actual budget items would depend on the specific context and resources available in Botswana.

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 appears to be well-conducted, with data collected from multiple sites and over a significant period of time. The use of logistic regression analysis to identify factors associated with infant feeding choices is appropriate. However, there are a few limitations that could be addressed to strengthen the evidence. First, the abstract does not provide information on the sample size or representativeness of the study population, which could affect the generalizability of the findings. Second, while the study validates the feeding method at discharge, it does not provide information on the long-term outcomes or HIV transmission rates among the infants. Including this information would provide a more comprehensive understanding of the impact of breastfeeding among WLHIV. Finally, the abstract does not discuss potential confounding factors or limitations of the study, which should be addressed to ensure the validity of the findings. To improve the evidence, the authors could consider providing more details on the sample size and representativeness, including long-term outcomes and HIV transmission rates, and discussing potential confounding factors and limitations of the study.

Background: Botswana updated its antiretroviral treatment (ART) guidelines in May 2016 to support breastfeeding for women living with HIV (WLHIV) on ART who have documented HIV RNA suppression during pregnancy. Methods: From September 2016 to March 2019, we evaluated feeding method at discharge among WLHIV at eight government maternity wards in Botswana within the Tsepamo Study. We validated the recorded feeding method on the obstetric record using the prevention of mother-to-child transmission of HIV (PMTCT) counsellor report, infant formula dispensing log or through direct observation. Available HIV RNA results were recorded from the obstetric record, and from outpatient HIV records (starting February 2018). In a subset of participants, we used electronic laboratory records to verify whether an HIV RNA test had occurred. Univariable and multivariable logistic regression analyses were performed to identify factors associated with infant feeding choice. Results: Among 13,354 WLHIV who had a validated feeding method at discharge, 5303 (39.7%) chose to breastfeed and 8051 (60.3%) chose to formula feed. Women who had a documented HIV RNA result in the obstetric record available to healthcare providers at delivery were more likely to breastfeed (50.8%) compared to women who did not have a documented HIV RNA result (35.4%) (aOR 0.59; 95% CI 0.54, 0.65). Among women with documented HIV RNA, 2711 (94.6%) were virally suppressed ( 400 copies/mL, and 134 (27.4%) of 489 women with no reported ART use. A sub-analysis of electronic laboratory records among 150 women without a recorded result on the obstetric record revealed that 93 (62%) women had an HIV RNA test during pregnancy. Conclusions: In a setting of long-standing use of suppressive ART, with majority of WLHIV on ART from the time of conception, requiring documentation of HIV RNA suppression in the obstetric record to inform infant feeding decisions is a barrier to breastfeeding but unlikely to prevent a substantial amount of HIV transmission.

We performed an analysis of infant feeding and HIV RNA data collected in the Tsepamo Study, an ongoing non-interventional birth outcomes surveillance study that collects data from obstetric records at large public maternity wards throughout Botswana [13]. The primary study aims of Tsepamo are to evaluate adverse birth outcomes and congenital abnormalities by HIV status and ART regimen. The study occurs at geographically distributed sites in major population areas of Botswana (Fig. 1), where > 95% of women deliver in a healthcare facility. Although the study expanded from eight to 18 sites in 2018, only data from the original eight sites were included in this analysis; these sites were located in Gaborone and Francistown (tertiary referral centres) and Maun, Serowe, Selebi-Phikwe, Mahalapye, Molepolole and Ghanzi (district and primary-level hospitals). Tsepamo study sites and percentage of WLHIV breastfeeding at discharge at each site Data were abstracted from obstetric record cards into an electronic database by trained research assistants at the time of maternal discharge from the postnatal ward. The obstetric record card is a standardized government booklet to record the entirety of medical care during pregnancy and delivery, that is started at the first antenatal clinic (ANC) visit, and brought by the mother to each subsequent ANC visit and to the delivery site. Information extracted from the obstetric record included maternal demographic characteristics, medical history, medications prescribed at the time of conception and during pregnancy, maternal diagnoses during pregnancy, infant birth record, type of delivery, APGAR scores, gestational age, birthweight, congenital abnormalities, and vital status of the infant(s) at time of discharge. For WLHIV, the date of HIV diagnosis, most recent CD4 cell count, and antiretroviral history (including start date, regimen, and any switch or discontinuation during pregnancy) were also extracted. When available in the obstetric record, HIV RNA results were recorded. Births that occurred before arrival at the hospital and < 24 weeks gestation were excluded. For this analysis, we used data collected between September 2016 and March 2019 and women were included if they were living with HIV, if their baby was alive at the time of discharge, and if they had a validated feeding method recorded at discharge. Validation started in September 2016 and occurred through direct feeding observation or by checking the prevention of mother-to-child transmission of HIV (PMTCT) counsellor report or formula dispensing log. All HIV RNA results documented in the obstetric record were abstracted. We verified a subset of randomly selected records from our sample (150 with and 150 without a documented HIV RNA result in the obstetric record) to determine whether an HIV RNA test had occurred during pregnancy. This verification was performed using the Integrated Patient Management System (IPMS), a nationwide electronic system that includes laboratory records. After February 2018, we also evaluated participants’ Infectious Disease Control Centre (IDCC) cards (the medical record for outpatient HIV care), when available, to further identify HIV RNA results missing from the available obstetric record. However, it should be noted that the obstetric record was the only source of information routinely available through the Botswana PMTCT programme to help midwives in counselling for appropriate feeding recommendations at the time of delivery. While the IPMS captures laboratory records nationwide, not all maternity facilities have access to these electronic laboratory records. Laboratory results of participants are routinely sent non-electronically to antenatal facilities for the nursing staff to transcribe them into participants’ obstetric records. Data were extracted from the electronic database in an excel format and analysed in Stata (Version 16, StataCorp, College Station, Texas). Descriptive statistics were used to describe the infant feeding choices of WLHIV (proportions of women in each feeding group). To identify factors associated with infant feeding choices of WLHIV, we performed univariable and multivariable logistic regression analyses. Infant feeding choice was categorized as breastfeeding versus formula feeding where breastfeeding was used as the reference category in logistic regression models. All independent variables that were significant or nearly significant in univariable analysis (P < 0.1) were included in the multivariable model. Statistical significance was inferred at a P-value of < 0.05. The outcome variable used was feeding choice at discharge. Independent variables of interest included age, marital status, education, occupation, nationality, delivery site, received antenatal care, documented viral load during pregnancy on the obstetric record, ART status during pregnancy, and gravida.

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

1. Electronic Medical Records (EMR): Implementing a comprehensive EMR system that includes obstetric records, laboratory results, and HIV RNA test results can improve the availability and accessibility of important information for healthcare providers. This would allow for easier verification of HIV RNA suppression and facilitate appropriate counseling for breastfeeding recommendations.

2. Mobile Health (mHealth) Solutions: Developing mobile applications or SMS-based platforms that provide reminders and educational resources for pregnant women and healthcare providers can help improve adherence to antiretroviral treatment and promote optimal infant feeding practices.

3. Point-of-Care Testing: Introducing point-of-care HIV RNA testing devices in maternity wards can provide immediate results, enabling healthcare providers to make informed decisions about infant feeding choices at the time of delivery. This would eliminate the need for relying solely on documented HIV RNA results, which may be missing or delayed.

4. Training and Education: Providing comprehensive training and education programs for healthcare providers on the latest guidelines for breastfeeding among women living with HIV can ensure accurate counseling and support for mothers. This would help address any misconceptions or barriers to breastfeeding and promote informed decision-making.

5. Community Engagement: Engaging community leaders, support groups, and peer educators can help raise awareness about the importance of maternal health and breastfeeding among women living with HIV. This can help reduce stigma, provide social support, and encourage positive health-seeking behaviors.

6. Telemedicine and Teleconsultation: Implementing telemedicine services can enable remote consultations between healthcare providers and pregnant women, especially those in remote or underserved areas. This would improve access to specialized care and counseling, including discussions about infant feeding choices.

7. Integration of Services: Integrating maternal health services with existing HIV care and treatment programs can ensure a holistic approach to care. This would facilitate coordination between healthcare providers, streamline processes, and improve continuity of care for women living with HIV.

It’s important to note that these recommendations are based on the specific context of the study in Botswana. The feasibility and effectiveness of these innovations may vary depending on the local healthcare infrastructure, resources, and cultural considerations.
AI Innovations Description
Based on the information provided, here is a recommendation that can be developed into an innovation to improve access to maternal health:

1. Implement a digital health solution for real-time monitoring and reporting of HIV RNA test results: Develop a mobile application or web-based platform that allows healthcare providers to access and record HIV RNA test results in real-time. This digital solution should be integrated with the existing electronic patient management system (IPMS) to ensure accurate and up-to-date information. By providing healthcare providers with immediate access to HIV RNA test results, they can make informed decisions regarding infant feeding choices and provide appropriate counseling to women living with HIV.

Benefits of this innovation:
– Improved access to HIV RNA test results: Healthcare providers can quickly and easily access HIV RNA test results, reducing the barriers to breastfeeding for women living with HIV.
– Timely and accurate counseling: With real-time access to test results, healthcare providers can provide accurate and up-to-date counseling on infant feeding choices based on the woman’s HIV RNA status.
– Enhanced coordination of care: The digital health solution can facilitate communication and coordination between different healthcare providers involved in the care of women living with HIV, ensuring that all relevant information is available to support decision-making.

Implementation considerations:
– User-friendly interface: The digital health solution should be intuitive and easy to use for healthcare providers, ensuring efficient adoption and utilization.
– Data privacy and security: Robust measures should be in place to protect the confidentiality and security of patient data, complying with relevant data protection regulations.
– Training and support: Adequate training and ongoing support should be provided to healthcare providers to ensure they are proficient in using the digital health solution.

By implementing this innovation, healthcare providers in Botswana can have improved access to HIV RNA test results, leading to better counseling and support for women living with HIV in making informed decisions about infant feeding. This can ultimately contribute to improved maternal and child health outcomes in the country.
AI Innovations Methodology
Based on the provided information, here are some potential recommendations to improve access to maternal health:

1. Strengthening HIV RNA testing: Implement measures to ensure that all women living with HIV have access to HIV RNA testing during pregnancy. This can include improving the availability and accessibility of testing facilities, training healthcare providers on the importance of HIV RNA testing, and promoting awareness among pregnant women about the benefits of HIV RNA testing.

2. Enhancing documentation and record-keeping: Develop standardized protocols and systems for accurately documenting and recording HIV RNA test results in obstetric records. This can help healthcare providers make informed decisions regarding infant feeding choices and improve continuity of care.

3. Improving healthcare provider training: Provide comprehensive training to healthcare providers on the latest guidelines and recommendations for infant feeding among women living with HIV. This can include education on the benefits of breastfeeding for both the mother and the baby, as well as strategies for supporting safe breastfeeding practices in the context of HIV.

4. Strengthening counseling services: Enhance counseling services for women living with HIV, ensuring that they receive accurate and up-to-date information about infant feeding options. This can involve training counselors to provide non-judgmental and supportive counseling, addressing any concerns or misconceptions that women may have about breastfeeding while living with HIV.

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

1. Define the target population: Identify the specific population of women living with HIV in Botswana who would benefit from improved access to maternal health services, particularly in relation to infant feeding choices.

2. Collect baseline data: Gather data on the current state of access to maternal health services, including HIV RNA testing rates, documentation of test results, and infant feeding choices among women living with HIV.

3. Develop a simulation model: Create a simulation model that incorporates the various factors influencing access to maternal health, such as availability of testing facilities, healthcare provider training, and counseling services. This model should also consider the potential impact of the recommended interventions on these factors.

4. Input data and parameters: Input the collected baseline data into the simulation model, along with relevant parameters related to the recommended interventions. This can include data on the number of healthcare providers trained, the availability of testing facilities, and the reach of counseling services.

5. Run simulations: Run multiple simulations using the model to assess the potential impact of the recommended interventions on improving access to maternal health. This can involve varying the parameters and inputs to explore different scenarios and outcomes.

6. Analyze results: Analyze the results of the simulations to determine the potential impact of the recommended interventions. This can include assessing changes in HIV RNA testing rates, documentation of test results, and infant feeding choices among women living with HIV.

7. Interpret and communicate findings: Interpret the findings of the simulations and communicate the potential benefits of the recommended interventions in improving access to maternal health. This can involve presenting the results to relevant stakeholders, such as policymakers, healthcare providers, and community organizations, to inform decision-making and implementation strategies.

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 available data in Botswana.

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