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Objective To assess adoption of World Health Organization (WHO) guidance into national policies for prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV) and to monitor implementation of guidelines at facility level in rural Malawi, South Africa and the United Republic of Tanzania. Methods We summarized national PMTCT policies and WHO guidance for 15 indicators across the cascades of maternal and infant care over 2013–2016. Two survey rounds were conducted (2013–2015 and 2015–2016) in 46 health facilities serving five health and demographic surveillance system populations. We administered structured questionnaires to facility managers to describe service delivery. We report the proportions of facilities implementing each indicator and the frequency and durations of stock-outs of supplies, by site and survey round. Findings In all countries, national policies influencing the maternal and infant PMTCT cascade of care aligned with WHO guidelines by 2016; most inter-country policy variations concerned linkage to routine HIV care. The proportion of facilities delivering post-test counselling, same-day antiretroviral therapy (ART) initiation, antenatal care and ART provision in the same building, and Option B+ increased or remained at 100% in all sites. Progress in implementing policies on infant diagnosis and treatment varied across sites. Stock-outs of HIV test kits or antiretroviral drugs in the past year declined overall, but were reported by at least one facility per site in both rounds. Conclusion Progress has been made in implementing PMTCT policy in these settings. However, persistent gaps across the infant cascade of care and supply-chain challenges, risk undermining infant HIV elimination goals.
We purposively selected three out of six countries participating in a wider mortality study being conducted in health and demographic surveillance system sites by the network for Analysing Longitudinal Population HIV/AIDS data in Africa.20,21 These countries were chosen to represent a range of adoption dates of Option B+ (Malawi: 2011; South Africa: 2015; United Republic of Tanzania: 2013) and mother-to-child transmission rates (8.9% in Malawi; 5.3% in South Africa; 12.2% in the United Republic of Tanzania).22–24 The five sites are served by 46 health facilities providing HIV services to approximately 400 000 residents21 (Table 1). HIV: human immunodeficiency virus; PMTCT: prevention of mother-to-child transmission. a All estimates are for adults aged 15–45 years old except Kisesa, where estimates are for adults 15–49 years old. b Data from 2007–2012 Karonga; 2010–2011 Agincourt; 2014–2015 Ifakara; 2015 uMkhanyakude; 2016 Kisesa. c Serving the population at each site. d Facilities offering antenatal care and PMTCT services that were surveyed in both rounds 1 and 2. In 2013, we conducted a review of WHO guidance and national HIV policies from 2003 to 2013, covering HIV testing, PMTCT and ART provision.25 In 2016, we updated the review for the period 2013 to 2015. The first phase involved a review of the literature and consultation with 28 HIV researchers and practitioners to define a conceptual framework with five main areas of health-service factors relating to delivery of HIV testing, PMTCT and ART services (service access and coverage; quality of care; coordination of care and patient tracking; support to people living with HIV; and medical management).25 We devised 54 associated policy indicators and included all 15 that pertained to PMTCT in this study. The second phase involved reviewing WHO guidelines and national policy documents. We retrieved these through online searches of websites of health ministries and national HIV organization or through email communications or in-person visits with representatives of organizations. Documents were included if they were nationally relevant; contained programmatic or clinical guidance on PMTCT services; and were published between January 2003 and June 2015. Information from the documents was summarized in an Excel spreadsheet (Microsoft Corp. Redmond, United States of America) that tracked policy content, source, year of adoption and policy changes over time. We conducted surveys of health facilities between August 2013 and January 2015 (round 1), and between May 2015 and June 2016 (round 2; Table 1). The questionnaire was informed by the WHO service availability and readiness assessment tool,26 and covered the delivery of HIV testing, PMTCT and ART services, as described previously.17 We conducted survey questionnaires face-to-face, in English, with the staff in charge at each facility. Interviewers observed the availability of treatment guidelines and consulted pharmacy records for drug stocks and availability of test kits. All health facilities providing HIV services to the health and demographic surveillance system populations were surveyed, except one small private clinic in Karonga, one public facility in Agincourt and facilities serving fewer than 100 patients per month in Ifakara. In uMkhanyakude and Kisesa, we also included facilities outside the site area, but used by health and demographic surveillance system residents.17 For this analysis, we only included facilities that participated in both survey rounds and offered PMTCT services. We conducted all analysis in Stata, version 15 (Stata Corp., College Station, USA). We recoded categorical variables as binary variables to demonstrate the proportion of facilities that were fully compliant with each policy (versus partial or non-compliance). We then used descriptive statistics to show the proportion of facilities implementing each policy, by survey round and site. HIV test kit and drug stock-outs were recorded for the previous year with median durations for the longest stock-out during this period recorded in days. Ethical approval was obtained locally for each site and from the London School of Hygiene and Tropical Medicine (no. 8891–1). Survey participants provided written informed consent.
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