Health facility characteristics and their relationship to coverage of PMTCT of HIV services across four African countries: The PEARL study

Background: Health facility characteristics associated with effective prevention of mother-to-child transmission of HIV (PMTCT) coverage in sub-Saharan are poorly understood. Methodology/Principal Findings: We conducted surveys in health facilities with active PMTCT services in Cameroon, Cote d’Ivoire, South Africa, and Zambia. Data was compiled via direct observation and exit interviews. We constructed composite scores to describe provision of PMTCT services across seven topical areas: antenatal quality, PMTCT quality, supplies available, patient satisfaction, patient understanding of medication, and infrastructure quality. Pearson correlations and Generalized Estimating Equations (GEE) to account for clustering of facilities within countries were used to evaluate the relationship between the composite scores, total time of visit and select individual variables with PMTCT coverage among women delivering. Between July 2008 and May 2009, we collected data from 32 facilities; 78% were managed by the government health system. An opt-out approach for HIV testing was used in 100% of facilities in Zambia, 63% in Cameroon, and none in Côte d’Ivoire or South Africa. Using Pearson correlations, PMTCT coverage (median of 55%, (IQR: 33-68) was correlated with PMTCT quality score (rho = 0.51; p = 0.003); infrastructure quality score (rho = 0.43; p = 0.017); time spent at clinic (rho = 0.47; p = 0.013); patient understanding of medications score (rho = 0.51; p = 0.006); and patient satisfaction quality score (rho = 0.38; p = 0.031). PMTCT coverage was marginally correlated with the antenatal quality score (rho = 0.304; p = 0.091). Using GEE adjustment for clustering, the, antenatal quality score became more strongly associated with PMTCT coverage (p<0.001) and the PMTCT quality score and patient understanding of medications remained marginally significant. Conclusions/Results: We observed a positive relationship between an antenatal quality score and PMTCT coverage but did not identify a consistent set of variables that predicted PMTCT coverage. The PEARL study was a multi-country evaluation of PMTCT effectiveness at the patient, facility, and community levels. We previously reported PMTCT coverage in a survey among women delivering in 43 health facilities in Cameroon, Cote d'Ivoire, South Africa, and Zambia between 2007 and 2009 [5]. PMTCT coverage was defined as the proportion of HIV-positive mother-HIV-exposed baby pairs in which both received single-dose NVP. Maternal dosing was confirmed by biochemical measurement in the cord blood and newborn dosing was confirmed by chart review [5]. As part of this study, we completed facility surveys at delivery centers which also provided antenatal care. We used a modified version of “A Rapid Health Facility Assessment Tool: to Enhance Quality and Access at the Primary Health Care Level.” This tool was developed in 2006 by ICF Macro in collaboration with MEASURE Evaluation and a panel of experts from the United States Agency for International Development (USAID) and other cooperating agencies and modified to include detailed PMTCT information in parallel with other antenatal care information. The original tool is available online http://www.mchipngo.net/controllers/link.cfc?method=tools_rhfa. The questionnaire included general questions such as type of facility, estimated size of the catchment area, and location as well as four discrete modules on clinic operations. Each module contained 32–120 questions. Modules included direct observation of clinician patient encounters, exit interviews of patients, and questions of patients and providers. The survey instrument was adapted and translated into French in Côte d'Ivoire and was pretested in the four countries prior to data collection. All questionnaires were entered into a Microsoft Access database and sent to PEARL's central data management and analysis unit. We examined each variable (n = 377) in the questionnaire individually to determine which ones were associated with PMTCT coverage. In addition, we created seven composite scores that summarized features of the clinic in several domains in a systematic manner. These scores were developed a priori by the study co-investigators based on logical groupings of characteristics, and included composite scores for antenatal care, PMTCT, supplies, staffing level, patient satisfaction, general infrastructure, and patient understanding of medications. Scores were adjusted by country to account for different standards of care (e.g. items relating to malaria were not considered for South Africa since South Africa does not include malaria prophylaxis in routine antenatal care). Table S1 summarize the variables used and how the scores were constructed. In addition, time-motion variables were constructed from the average of up to six patient observations at each facility. Time was recorded at a) registration b) start of exam and c) visit finish (including receipt of medication at pharmacy), allowing the calculation for the median total time of the visit as well as the time spent post test counseling. Antenatal and PMTCT domains were assigned a score of (1) if appropriate care or treatment was given; (0.5) if appropriate care or treatment was given but not recorded in the chart; and (0) if appropriate care was not given. This was done because failure to record information, such as an HIV test, CD4 count, or blood pressure reading will lead to failure to act upon this critical information throughout the pregnancy. Infrastructure, supplies, and staff domains were assigned a score of (1) when available and (0) when not available. Scores were totaled for each domain, and divided by the number of items included. Non-applicable information and missing items were not considered in the scoring. Final domain scores were thus a proportion between 0 and 1, with a higher score reflecting more appropriate care. Patient satisfaction was scored on a scale of 1 to 5, with 5 being extremely satisfied and 1 being extremely unsatisfied. For patient comprehension, (1) point was given for each correct response for each criteria (dose, frequency, duration, and purpose), and (0) points were given for incorrect responses. (Table 1 summarizes the construction of health facility quality scores. All PEARL study facilities with cord blood and facility survey data were included. Site characteristics were summarized using descriptive statistics. We computed means and standard deviations or medians and inter-quartile ranges for continuous variables and percentages for categorical variables. Using all facilities from all 4 countries and PMTCT coverage as a continuous outcome measure, separate regression models were fit for health facility characteristics of interest and the quality scores. Generalized estimating equations (GEE) with an exchangeable correlation structure were used to account for country program -related correlation between facilities in the same country. Statistical analyses were performed using SAS® version 9.1.3 (SAS Institute, Cary, NC, USA) and Stata® version 10.0 (StataCorp. 2007. Stata Statistical Software: Release 10. College Station, TX). Approval was provided by institutional or national review boards at the U.S. Centers for Disease Control and Prevention (CDC), the University of Alabama at Birmingham, and each of the participating countries a) Comite d'éthique des sciences et de la vie, Ministère de la Santé, Côte d'Ivoire, b) University of Zambia Research Ethics Committee, Lusaka Zambia, c) Cameroon Baptist Convention Health Board, Bamenda, Northwest Province, Cameroon, d) South African Medical Research Council Ethics Committee, Cape Town, South Africa. Verbal consent was obtained among the health care workers and the selected pregnant women who participated in the direct interview during this survey. The corresponding author had access to all data in the study and final responsibility for the decision to submit this manuscript.