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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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