Increasing proportion of HIV-infected pregnant Zambian women attending antenatal care are already on antiretroviral therapy (2010-2015)

  • Frontiers in Public Health, Volume 7, No. JUN, Year 2019

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Study Justification:
– Accurate estimates of coverage of prevention of mother-to-child (PMTCT) services among HIV-infected pregnant women are crucial for monitoring progress towards HIV elimination targets.
– High coverage and uptake of services along the PMTCT cascade are important for national and international mother-to-child transmission (MTCT) elimination goals.
– The study aimed to assess the implementation of World Health Organization (WHO) guidelines for PMTCT services in Zambia between 2010 and 2015.
Highlights:
– The study used routinely collected data from all pregnant women attending antenatal clinics (ANC) in SmartCare health facilities from January 2010 to December 2015.
– Among the pregnant women who attended ANC services, 9% tested HIV-positive during ANC visits, and 43% had missing HIV test result records.
– The proportion of HIV-positive pregnant women already on antiretroviral therapy (ART) at their first ANC visit increased from 9% in 2011 to 74% in 2015.
– There were variations in HIV infection rates, missing data, and time to initiation of ART, suggesting underlying health service or database issues that require attention.
Recommendations:
– Address the underlying health service or database issues to improve HIV testing and data recording during ANC visits.
– Strengthen efforts to ensure timely initiation of ART for HIV-positive pregnant women.
– Improve coverage and uptake of PMTCT services, especially in areas with geographical inequity.
– Enhance coordination and collaboration between different stakeholders involved in PMTCT programs.
Key Role Players:
– Ministry of Health: Responsible for overall coordination and implementation of PMTCT programs.
– Health facility staff: Provide ANC services and ensure proper documentation of HIV testing and ART initiation.
– Community health workers: Play a crucial role in reaching out to pregnant women and promoting PMTCT services.
– Non-governmental organizations (NGOs): Support implementation of PMTCT programs and provide additional resources and services.
– International partners and donors: Provide funding and technical support for PMTCT programs.
Cost Items for Planning Recommendations:
– Training and capacity building for health facility staff on PMTCT guidelines and data recording.
– Procurement and distribution of HIV testing kits and antiretroviral drugs.
– Information and education campaigns to raise awareness about PMTCT services.
– Monitoring and evaluation activities to assess the impact of interventions.
– Support for community health workers and outreach activities.
– Strengthening health information systems and data management infrastructure.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study used routinely collected data from a large number of pregnant women attending antenatal care over a 6-year period. The study population was representative of different provinces in Zambia. However, there are some limitations, such as missing HIV test result records and variations in HIV infection rates and time to initiation of antiretroviral therapy. To improve the evidence, future studies could address these limitations by ensuring complete data collection and investigating the underlying health service or database issues.

Introduction: Accurate estimates of coverage of prevention of mother-to-child (PMTCT) services among HIV-infected pregnant women are vital for monitoring progress toward HIV elimination targets. The achievement of high coverage and uptake of services along the PMTCT cascade is crucial for national and international mother-to child transmission (MTCT) elimination goals. In eastern and southern Africa, MTCT rate fell from 18% of infants born to mothers living with HIV in 2010 to 6% in 2015. This paper describes the degree to which World Health Organization (WHO) guidelines for PMTCT services were implemented in Zambia between 2010 and 2015. Method: The study used routinely collected data from all pregnant women attending antenatal clinics (ANC) in SmartCare health facilities from January 2010 to December 2015. Categorical variables were summarized using proportions while continuous variables were summarized using medians and interquartile ranges. Results: There were 104,155 pregnant women who attended ANC services in SmartCare facilities during the study period. Of these, 9% tested HIV-positive during ANC visits whilst 43% had missing HIV test result records. Almost half (47%) of pregnant women who tested HIV-positive in their ANC visit were recorded in 2010. Among HIV-positive women, there was an increase in those already on ART at first ANC visit from 9% in 2011 to 74% in 2015. The overall mean time lag between starting ANC care and ART initiation was 7 months, over the 6 year period, but there were notable variations between provinces and years. Conclusion: The implementation of the WHO post 2010 PMTCT guidelines has resulted in an increase in the proportion of HIV-infected pregnant women attending ANC who are already on ART. However, the variability in HIV infection rates, missing data, and time to initiation of ART suggests there are some underlying health service or database issues which require attention.

This was a retrospective cohort study using routinely collected data. The study population was all pregnant women attending antenatal care (ANC) from January 2010 to December 2015 in health facilities using the SmartCare database. In Zambia over 90% of pregnant women attend ANC services at least once during their pregnancy, but only 47% deliver at health facilities (10). Thus, it is difficult to ensure that eligible pregnant women receive the complete treatment to prevent transmission of HIV to their babies. Although more than 75% of the ANC facilities currently provide PMTCT services, the majority of these facilities are along the country’s main rail line and in urban centers, resulting in geographical inequity (10). The study retrospectively analyzed the Ministry of Health electronic SmartCare database, using routinely collected data from all pregnant women attending ANC from January 2010 to December 2015. SmartCare is a Zambian Ministry of Health-led project funded from the United States Centre for Disease Control and Prevention (CDC) (11). The SmartCare database was developed to improve continuity of care and provide timely data on maternal and child health, HIV/AIDS, tuberculosis, and malaria interventions for public health purposes. Since 2005, the SmartCare database has been deployed in over 800 health facilities, which represents 40% of all facilities in Zambia, including the biggest and busiest health facilities. These results come from 886 health facilities from all provinces in Zambia. The Southern province had the most number of facilities (254/886) represented in the dataset, followed by the Copperbelt (187/886), and Eastern (166/886) provinces. Muchinga and Northern provinces had the least number of facilities, 10 and 26, in the analyzed dataset. The data was extracted into Excel, without names, but with the unique identity (ID) number, and then transferred to Stata 13 for cleaning and analysis. All women enrolled in a facility using SmartCare have an electronic health record about their ANC visits which includes information collected in each visit. Records are updated at every point of clinical service. SmartCare is organized into comprehensive modules and sub-modules. The information from various modules is linked through the unique ID number. For this study, the ANC data was linked to the HIV Client Summary module and the ARV Eligibility Interaction Module to identify HIV-positive women. Data from the Obstetric History Module was then used to segregate PMTCT clients from general ART clients. The oldest date of HIV testing and ANC visit date were used to determine whether women had known their HIV status before the ANC visit. The final data were stratified by province using the geography file from the Central Statistical Office (CSO) which has a list of all the districts and provinces. The first step in data cleaning was to remove duplicate data for repeat visits in the same pregnancy (based on parity and gravid status). This was done by keeping the first visit date of each pregnancy then populating any empty fields with information captured at later visits in the same pregnancy. Records for all the mothers <15 years and those above 49 years of age were dropped from the sample making our target group to be those between 15 and 49 years (reproductive age group). The data flow chart is illustrated in Figure 1. Age groups were categorized as 15–24, 25–34, and 35–49 years. Marital status was grouped into single, married, divorced, widowed, and missing. The education status groups were no education, primary education, junior secondary, secondary, and tertiary education. The data flow chart represents the flow chart of participants eligible for inclusion in the analysis. The data were used to estimate the proportion of HIV-positive pregnant women attending ANC by province and year. The study population was divided into three strata: pregnant women with a new HIV test result documented in ANC clinic, pregnant women with known status but not on ART, and pregnant women who were already on ART. Among the total number of pregnant women presenting to ANC clinic in each calendar year; the percentages in each group were calculated. The STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) guidelines were used to conduct and report on the findings of this study (12). Ethical approval was granted from Zambia Biomedical Research Ethic Committee (Ref 101-04-16) and the LSHTM Research Ethics Committee (Ref 12086). Permission to use SmartCare data was granted by the Zambia Ministry of Health. The Ethics Committees that approved the study waived the need for written informed consent to be obtained as this was a secondary analysis of previously collected data and the authors had access only to de-identifiable information.

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

1. Mobile Health (mHealth) Solutions: Develop and implement mobile applications or text messaging systems to provide pregnant women with information about antenatal care, HIV testing, and PMTCT services. This could help increase awareness and encourage more women to seek care.

2. Community Health Workers: Train and deploy community health workers to reach remote or underserved areas where access to healthcare facilities is limited. These workers can provide education, counseling, and support to pregnant women, including information about HIV testing and PMTCT services.

3. Telemedicine: Establish telemedicine services to connect pregnant women in remote areas with healthcare providers who can provide antenatal care and HIV testing remotely. This can help overcome geographical barriers and ensure that women receive the necessary care.

4. Integration of Services: Strengthen the integration of HIV testing and PMTCT services within antenatal care clinics. This can help ensure that all pregnant women are tested for HIV and receive appropriate care and treatment if needed.

5. Quality Improvement Initiatives: Implement quality improvement initiatives to address the underlying health service or database issues identified in the study. This could involve improving data collection and management systems, addressing gaps in HIV testing and treatment, and reducing the time lag between starting ANC care and ART initiation.

6. Public-Private Partnerships: Foster partnerships between the government, private sector, and non-profit organizations to improve access to maternal health services. This could involve leveraging private sector resources and expertise to expand service delivery and reach more pregnant women.

7. Health Education Campaigns: Conduct targeted health education campaigns to raise awareness about the importance of antenatal care, HIV testing, and PMTCT services. This can help reduce stigma, increase knowledge, and encourage more women to seek care.

8. Task Shifting: Explore opportunities for task shifting, where certain healthcare tasks are delegated to lower-level healthcare providers or community health workers. This can help alleviate the burden on higher-level healthcare providers and increase access to care in resource-limited settings.

9. Strengthening Referral Systems: Improve referral systems between antenatal care clinics and HIV treatment centers to ensure seamless care for pregnant women who test positive for HIV. This can help ensure that women receive timely and appropriate treatment and support.

10. Continuous Monitoring and Evaluation: Establish a robust monitoring and evaluation system to track progress in improving access to maternal health services. This can help identify gaps, measure the impact of interventions, and inform future decision-making.

It is important to note that the specific context and resources available in Zambia should be taken into consideration when implementing these innovations.
AI Innovations Description
Based on the information provided, the recommendation to improve access to maternal health is to address the underlying health service or database issues that were identified in the study. This can be done through the following steps:

1. Improve data collection and record-keeping: Ensure that accurate and complete data on pregnant women attending antenatal care (ANC) is collected and recorded in the SmartCare database. This includes HIV test results, ART status, and other relevant information.

2. Strengthen health service delivery: Address the variability in HIV infection rates and missing data by improving the quality and consistency of ANC services. This may involve training healthcare providers on the implementation of World Health Organization (WHO) guidelines for PMTCT services and ensuring that all pregnant women receive the necessary treatment and care.

3. Enhance geographical equity: Address the geographical inequity in access to PMTCT services by expanding the availability of these services to areas outside of the main rail line and urban centers. This can be achieved by increasing the number of health facilities that provide PMTCT services in underserved areas.

4. Promote early initiation of antiretroviral therapy (ART): Reduce the mean time lag between starting ANC care and ART initiation by implementing strategies to identify HIV-positive pregnant women early in their pregnancy and ensuring prompt initiation of ART. This may involve strengthening HIV testing and counseling services in ANC clinics and improving coordination between ANC and ART services.

5. Continuously monitor and evaluate progress: Establish a system for ongoing monitoring and evaluation of PMTCT services to track progress and identify areas for improvement. This can help identify any ongoing challenges or barriers to access and inform future interventions.

By implementing these recommendations, it is expected that access to maternal health, particularly for HIV-infected pregnant women, can be improved, leading to better health outcomes for both mothers and their babies.
AI Innovations Methodology
Based on the information provided, here are some potential recommendations for improving access to maternal health:

1. Strengthening ANC services: Focus on improving the quality and availability of antenatal care services, ensuring that pregnant women have access to comprehensive care, including HIV testing and counseling, as well as PMTCT services.

2. Enhancing HIV testing and counseling: Implement strategies to increase the uptake of HIV testing among pregnant women attending ANC, such as routine opt-out testing, community-based testing, and provider-initiated testing and counseling.

3. Improving data collection and management: Address the issue of missing HIV test result records by implementing robust data collection and management systems. This could involve training healthcare providers on accurate and timely data entry, as well as using electronic health records to improve data completeness and accuracy.

4. Reducing time lag between ANC care and ART initiation: Develop strategies to minimize the time it takes for HIV-positive pregnant women to initiate antiretroviral therapy (ART) after their first ANC visit. This could include streamlining referral processes, improving coordination between ANC clinics and ART clinics, and ensuring a reliable supply of ART medications.

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

1. Define the indicators: Identify key indicators that reflect access to maternal health, such as the proportion of pregnant women attending ANC, the proportion of HIV-positive pregnant women receiving ART, and the time lag between ANC care and ART initiation.

2. Collect baseline data: Gather data on the current status of these indicators before implementing any interventions. This could involve analyzing existing data sources, such as the SmartCare database used in the study, or conducting surveys or interviews to collect additional information.

3. Develop a simulation model: Create a mathematical or statistical model that simulates the impact of the recommended interventions on the identified indicators. This model should take into account factors such as population size, geographical distribution, healthcare infrastructure, and the effectiveness of the interventions.

4. Input intervention scenarios: Input different scenarios into the simulation model to assess the potential impact of each recommendation. For example, simulate the effect of increasing the proportion of pregnant women attending ANC, improving HIV testing and counseling rates, or reducing the time lag between ANC care and ART initiation.

5. Analyze results: Analyze the simulation results to determine the potential impact of each intervention scenario on the identified indicators. This could involve comparing the baseline data with the simulated data to quantify the improvements in access to maternal health.

6. Refine and validate the model: Refine the simulation model based on the analysis results and validate it against real-world data. This could involve comparing the simulated results with data from other sources or conducting additional surveys or studies to verify the model’s accuracy.

7. Make recommendations: Based on the simulation results, make recommendations for implementing the most effective interventions to improve access to maternal health. Consider factors such as feasibility, cost-effectiveness, and sustainability when making these recommendations.

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 data availability. Additionally, involving relevant stakeholders, such as healthcare providers, policymakers, and community members, in the simulation process can help ensure that the recommendations are practical and address the needs of the target population.


Statistics:
Citations: 6
Identifiers:
DOI: 10.3389/fpubh.2019.00155
Research Areas:
Community Interventions, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants
Study Countries:
Zambia
Study Design:
Cohort Study, Cross Sectional Study
Study Approach:
Quantitative
Participants Gender:
Female
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