Lesotho’s Minimum PMTCT Package: Lessons learned for combating vertical HIV transmission using co-packaged medicines

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Study Justification:
– The study aimed to examine the feasibility, acceptability, and potential negative consequences of Lesotho’s Minimum PMTCT Package, which was launched as an alternative to the existing facility-based approach for reducing vertical HIV transmission.
– The study also aimed to assess the effects of the Minimum PMTCT Package on ANC and facility-based delivery rates.
Study Highlights:
– The Minimum PMTCT Package was found to be feasible and acceptable to providers and clients.
– However, there were issues with test kit and medicine stock-outs, and a significant proportion of women did not receive the Minimum PMTCT Package until their second ANC visit.
– Providing adequate instruction on the use of multiple medications was a challenge.
– The proportion of HIV-positive women delivering in facilities declined after the implementation of the Minimum PMTCT Package, while it increased among HIV-negative women.
– The mean number of ANC visits declined more among HIV-positive women than among HIV-negative women, although the difference was not statistically significant.
– Changes in the percentage of women receiving 4 ANC visits did not differ between the two groups.
Study Recommendations:
– Resolve supply issues and ensure adequate availability of test kits and medicines.
– Improve client education materials on the use of multiple medications.
– Monitor potential changes in ANC visits and facility deliveries.
– Conduct further evaluation of adherence, safety, and effectiveness of the Minimum PMTCT Package.
Key Role Players:
– Ministry of Health and Social Welfare (MOHSW)
– UNICEF
– National pharmacy services
– Key partners involved in the design and implementation of the Minimum PMTCT Package
– Elizabeth Glaser Pediatric AIDS Foundation (EGPAF)
– USAID
– Bureau of Statistics
– Measure DHS
Cost Items for Planning Recommendations:
– Procurement and supply chain management of test kits and medicines
– Development and distribution of improved client education materials
– Monitoring and evaluation activities to track changes in ANC visits and facility deliveries
– Training and capacity building for healthcare providers
– Data collection and analysis for further evaluation of adherence, safety, and effectiveness

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on qualitative and quantitative studies, as well as facility assessments and surveys. The authors provide specific data and findings to support their conclusions. However, the evidence could be strengthened by including more details on the methodology and sample size of the studies, as well as the limitations of the research. Additionally, the authors suggest further evaluation of adherence, safety, and effectiveness, indicating the need for more robust evidence. To improve the evidence, future studies could include larger sample sizes, randomized controlled trials, and long-term follow-up to assess the impact of the Minimum PMTCT Package.

Introduction: Mother-to-child transmission of HIV can be reduced to <5% with appropriate antiretroviral medications. Such reductions depend on multiple health system encounters during antenatal care (ANC), delivery and breastfeeding; in countries with limited access to care, transmission remains high. In Lesotho, where 28% of women attending ANC are HIV positive but where geographic and other factors limit access to ANC and facility deliveries, a Minimum PMTCT Package was launched in 2007 as an alternative to the existing facility-based approach. Distributed at the first ANC visit, it packaged together all necessary pregnancy, delivery and early postnatal antiretroviral medications for mother and infant. Methods: To examine the availability, feasibility, acceptability and possible negative consequences of the Minimum PMTCT Package, data from a 2009 qualitative and quantitative study and a 2010 facility assessment were used. To examine the effects on ANC and facility-based delivery rates, a difference-in-differences analytic approach was applied to 2009 Demographic and Health Survey data for HIV-tested women who gave birth before and after Minimum PMTCT Package implementation. Results: The Minimum PMTCT Package was feasible and acceptable to providers and clients. Problems with test kit and medicine stock-outs occurred, and 46% of women did not receive the Minimum PMTCT Package until at least their second ANC visit. Providing adequate instruction on the use of multiple medications represented a challenge. The proportion of HIV-positive women delivering in facilities declined after Minimum PMTCT Package implementation, although it increased among HIVnegative women (difference-in-differences=14.5%, p=0.05). The mean number of ANC visits declined more among HIVpositive women than among HIV-negative women after implementation, though the difference was not statistically significant (p=0.09). Changes in the percentage of women receiving 4 ANC visits did not differ between the two groups. Conclusions: If supply issues can be resolved and adequate client educational materials provided, take-away co-packages have the potential to increase access to PMTCT commodities in countries where women have limited access to health services. However, efforts must be made to carefully monitor potential changes in ANC visits and facility deliveries, and further evaluation of adherence, safety and effectiveness are needed. © 2012 McDougal L et al; licensee International AIDS Society.

To better understand the rationale of the MPP and the required steps for its success, the authors reviewed international PMTCT recommendations [1,2,22,23] and national PMTCT guidelines for several sub-Saharan countries [19,24–27] and obtained input from staff that had been involved in the design and implementation of the MPP in Lesotho. A conceptual framework was then developed against which feasibility, acceptability, service uptake analyses, and potential detrimental effects could be examined. Based on this framework, a series of eight potential barriers for the successful functioning of the MPP was formulated, along with specific questions and data sources for each (Table 1). Conceptual framework for successful implementation of the Minimum PMTCT Package This MOHSW and UNICEF-commissioned study was designed to investigate the procurement and supply chain management of the MPP, its sociocultural acceptability, and the feasibility of scale-up. Methods are detailed in the study report [20], but briefly, data were collected in November–December 2009 using rapid, mixed-methods techniques that consisted of interviews with key informants from the MOHSW and national pharmacy services as well as other key partners; a facility checklist; interviews of service providers; and exit interviews of ANC, delivery, and postnatal visit patients. In addition, separate focus groups for men and women were conducted at community level to assess normative values regarding PMTCT and the MPP. The facility checklist and the service providers and patient interviews were conducted in 42 facilities: 17 of the 18 hospitals in the country, all five filter clinics (an interim level of service between a health centre and hospital), as well as 20 health centres that had been selected using district-level probability-proportionate-to-size sampling. The facility checklists, focus groups, and patient and staff interviewers were conducted by local teams, each of which included a nurse, and were hired and trained by the consulting firm that conducted the evaluation, with field supervision provided by the Lesotho MOHSW, WHO and the independent consulting firm. Patients were selected for exit interviews using a systematic random sampling frame. Data were available for a total of 150 providers and 214 patients, all of whom provided verbal consent [20]. Ethical approval was obtained from the Research and Ethics Committee of the Lesotho MOHSW. Data from the assessment report was used where feasible. In addition, however, the original facility checklist data was re-analysed to better describe the extent to which facilities, particularly clinics, were adequately equipped to provide services for women who may have lacked access to subsequent ANC visits and facility delivery. Finally, the open-ended answers on the individual health worker and client questionnaires were examined to better understand their knowledge of and attitudes towards the MPP. This comprehensive facility HIV services assessment, which was funded by USAID and conducted by the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF), was designed to evaluate the capacity of each health facility in Lesotho to fully implement comprehensive HIV/AIDS services and programs, including PMTCT. Data were collected in June 2010 using a structured questionnaire and chart data abstraction in each of Lesotho's 252 health facilities, of which 203 sites offered ANC services. In each facility, data were extracted from patient records and cards for the previous 3 months. Data collection was conducted by staff from EGPAF and the MOHSW who attended a one-day training course on correct survey procedures and data instruments use [21]. Ethical approval was obtained from the Research and Ethics Committee of the Lesotho MOHSW. For the purpose of this analysis, findings from the report were examined; EGPAF also provided supplementary analyses of facility-level availability of care, testing capacities and medications. This nationally representative, individual level survey was conducted between October 2009 and January 2010, and was implemented by the MOHSW and Bureau of Statistics, with funding from USAID and technical support from Measure DHS. Two-stage cluster sampling was used to select households, and all women age 15–49 within a selected household were eligible to be interviewed. Interviews and HIV testing were conducted by enumerators who underwent extensive training on the DHS protocols and procedures [18]. A total of 7624 women aged 15–49 were interviewed using structured questionnaires on personal data assistants, with an eligible woman response rate of 98% [18]. HIV testing was conducted in 50% of the households where women were interviewed (n=4016). Testing was anonymous and was performed on dried blood spots collected at the time of the interview. For these analyses, records from the individual questionnaires were linked with the HIV test results for all women who had received a DHS-administered HIV test and had given birth during 2005–2009 (n=1545). For women with more than one birth during this period, only the most recent birth was used. Women who were HIV-tested were not significantly different from untested women in terms of urban/rural residence, marital status, age, education level, literacy, wealth, parity and years of residency (results not shown). The linked DHS data were used to investigate the effect of the MPP implementation on maternal and child health services and service utilization. Specific outcomes examined were≥4 ANC visits, the mean number of ANC visits, the quality of ANC care, facility deliveries, and whether or not the infant was brought into a facility by 3 months of age for DPT1 (a proxy for the recommended 6-week follow-up visit for DNA PCR testing). Women were considered to have received quality care if they reported all of the following during their most recent pregnancy: being informed of signs of pregnancy complications; being weighed; having blood pressure, urine and blood samples taken. A difference-in-differences analytic approach was used to assess the percentage change in each outcome after MPP implementation. Specifically, self-reported service utilization from before and after the MPP rollout was compared between women who should have received the MPP (HIV-positive women) and those that should not have received it (HIV-negative women). The HIV-negative group provided the background trends in ANC and delivery services against which the experience of the HIV-positive women could be compared. Pre-/post-implementation of the MPP was differentially defined by district, as the program was implemented on a rolling basis. For purposes of the analysis, the pre-implementation period was 2005–2006 and post was 2007–2009 for Butha Buthe, Leribe, Berea, Mafeteng, Maseru and Mohale's Hoek. For the remaining districts of Quthing, Quacha's Nek, Mokhotlong and Thaba-Tseka, the corresponding years for analysis were 2005–2007 and 2008–2009. The logit models used for this approach contained demographic covariates independently associated with HIV status as well as the outcome in question (assessed by Rao-Scott F-adjusted Chi-square tests [categorical variables] or t-tests [continuous variables] with a 0.05 significance cut-off) as well as HIV status and a pre-/post-implementation dummy variable which were interacted to create the difference-in-difference estimator. District of residence was also included to adjust for district-specific factors not accounted for in other demographic variables, as well as possible spillover effects. No multi-collinearity between variables in any model was detected using a tolerance level of 0.10. Marginal effects at the mean were then applied to the specified logit models to calculate model adjusted predicted prevalence before and after MPP implementation in HIV-positive and HIV-negative women (HIV positive, pre-implementation [n=149]; HIV positive, post-implementation [n=250]; HIV negative, pre-implementation [n=381]; HIV negative, post-implementation [n=765]). All analyses with DHS data were weighted and adjusted for the complex survey design [28]. Data from the 2010 and 2011 Annual Joint Reports of the MOHSW [13,29] and the 2010 UNGASS Report on the Status of the National Response to the 2001 Declaration of Commitment on HIV and AIDS [30] were examined for further historical background and information on PMTCT trends. All statistical calculations were conducted using SAS v.9.2 and Stata 10.

The Minimum PMTCT (Prevention of Mother-to-Child Transmission) Package is an innovative approach to improve access to maternal health, particularly in countries where women have limited access to health services. This package includes all necessary antiretroviral medications for pregnant women and their infants, which can reduce the transmission of HIV from mother to child to less than 5%. Here are the key steps to develop this recommendation into an innovation:

1. Resolve supply issues: Efforts should be made to ensure an adequate supply of test kits and medicines to prevent stock-outs, which can hinder the implementation of the Minimum PMTCT Package.

2. Provide adequate client education: Instructions on the use of multiple medications should be provided to ensure proper adherence and effectiveness. Educational materials should be developed to guide women in using the medications correctly.

3. Monitor changes in ANC visits and facility deliveries: Careful monitoring should be conducted to assess any potential changes in ANC visits and facility deliveries after the implementation of the Minimum PMTCT Package. This will help identify any unintended consequences and allow for adjustments to be made if necessary.

4. Evaluate adherence, safety, and effectiveness: Further evaluation should be conducted to assess the adherence, safety, and effectiveness of the Minimum PMTCT Package. This will provide valuable insights into the impact of the innovation and help identify areas for improvement.

By implementing these recommendations and continuously evaluating and improving the Minimum PMTCT Package, access to maternal health can be improved, particularly in countries where women have limited access to health services.
AI Innovations Description
The recommendation to improve access to maternal health is the implementation of a Minimum PMTCT (Prevention of Mother-to-Child Transmission) Package. This package includes all necessary antiretroviral medications for pregnant women and their infants, which can reduce the transmission of HIV from mother to child to less than 5%. The package is distributed at the first antenatal care (ANC) visit, providing access to these medications for women who may have limited access to ANC and facility deliveries.

To develop this recommendation into an innovation, several steps can be taken:

1. Resolve supply issues: Efforts should be made to ensure an adequate supply of test kits and medicines to prevent stock-outs, which can hinder the implementation of the Minimum PMTCT Package.

2. Provide adequate client education: Instructions on the use of multiple medications should be provided to ensure proper adherence and effectiveness. Educational materials should be developed to guide women in using the medications correctly.

3. Monitor changes in ANC visits and facility deliveries: Careful monitoring should be conducted to assess any potential changes in ANC visits and facility deliveries after the implementation of the Minimum PMTCT Package. This will help identify any unintended consequences and allow for adjustments to be made if necessary.

4. Evaluate adherence, safety, and effectiveness: Further evaluation should be conducted to assess the adherence, safety, and effectiveness of the Minimum PMTCT Package. This will provide valuable insights into the impact of the innovation and help identify areas for improvement.

By implementing these recommendations and continuously evaluating and improving the Minimum PMTCT Package, access to maternal health can be improved, particularly in countries where women have limited access to health services.
AI Innovations Methodology
The methodology used to simulate the impact of the main recommendations in improving access to maternal health in Lesotho’s Minimum PMTCT Package includes the following steps:

1. Review of international and national PMTCT guidelines: The authors reviewed international PMTCT recommendations and national PMTCT guidelines for several sub-Saharan countries to understand the rationale behind the Minimum PMTCT Package and the required steps for its success.

2. Conceptual framework development: A conceptual framework was developed to examine the feasibility, acceptability, service uptake, and potential detrimental effects of the Minimum PMTCT Package. This framework helped identify potential barriers to successful implementation.

3. Data collection: Data was collected through a qualitative and quantitative study conducted in 2009 and a facility assessment conducted in 2010. The study included interviews with key informants, facility checklists, interviews with service providers, exit interviews with ANC, delivery, and postnatal visit patients, and focus groups with men and women at the community level.

4. Data analysis: The collected data was analyzed to assess the availability, feasibility, acceptability, and potential negative consequences of the Minimum PMTCT Package. The effects on ANC and facility-based delivery rates were analyzed using a difference-in-differences analytic approach applied to 2009 Demographic and Health Survey data.

5. Results: The analysis revealed that the Minimum PMTCT Package was feasible and acceptable to providers and clients. However, there were issues with test kit and medicine stock-outs, and some women did not receive the package until their second ANC visit. Providing adequate instruction on the use of multiple medications was also a challenge. The proportion of HIV-positive women delivering in facilities declined after the implementation of the package, while it increased among HIV-negative women. The mean number of ANC visits declined more among HIV-positive women, although the difference was not statistically significant.

6. Conclusions: The study concluded that if supply issues can be resolved and adequate client educational materials provided, the Minimum PMTCT Package has the potential to increase access to PMTCT commodities in countries with limited access to health services. However, careful monitoring of potential changes in ANC visits and facility deliveries is necessary, and further evaluation of adherence, safety, and effectiveness is needed.

This methodology allowed for a comprehensive assessment of the impact of the main recommendations in improving access to maternal health through the implementation of the Minimum PMTCT Package in Lesotho.

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