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Antiretroviral therapy in antenatal care to increase treatment initiation in HIV-infected pregnant women: a stepped-wedge evaluation
Global Health Sciences Literature Digest
Published June 21, 2010
Journal Article

Killam WP, Tambatamba BC, Chintu N. Antiretroviral therapy in antenatal care to increase treatment initiation in HIV-infected pregnant women: a stepped-wedge evaluation. AIDS. 2009 Oct 3.

In Context

The World Health Organization (WHO) and many countries encourage HIV-infected pregnant women to initiate highly active antiretroviral therapy (HAART) if they are eligible.(1) In some countries, the CD4 cut-off level is higher for treatment initiation in pregnant women than in the general population. Early treatment not only reduces intrapartum and perinatal transmission of HIV, but also decreases morbidity and mortality among the mothers. The proportion of eligible pregnant women initiating ART remains low, however, in part because HAART is provided at separate treatment services.


To determine whether integrating ART services directly into antenatal clinics (ANCs), rather than referring HIV-infected pregnant women to treatment sites, would increase the number of eligible women starting ART during pregnancy


Program evaluation, using a stepped-wedge design


Eight public-sector ANCs in Lusaka, Zambia


All pregnant women attending ANCs and eligible for ART


Integration of ART into ANCs began in 2007 in one clinic at a time. The strategy was to evaluate differences in uptake of ART at each site before and after integration. Pregnant women presenting to ANC clinics undergo opt-out HIV testing, and if they test positive, have a routine CD4 cell count. Prior to integration of ART within ANCs, eligible women were referred to an ART clinic, usually located on the same premises as the ANC, but physically separate and separately staffed. Following service integration, ART was provided for one to two days per week at the ANCs. If a pregnant woman was found to have a CD4 cell count of ≤250 cell/µL, she was initiated on ART and followed until six weeks postpartum, after which she would be referred to the general ART clinic. All clinics began collecting pre-intervention data at the same time, although they started integrating services in a staggered manner known as a stepped-wedge design. The primary outcomes were the proportion of ART-eligible women enrolling and initiating ART before delivery; the average gestational age at ART initiation, and the average number of weeks on ART prior to delivery.


During the study period, 13,917 women were seen in ANCs and were HIV tested prior to service integration (control cohort); 17,619 were seen in ANCs and were HIV tested after services were integrated (intervention cohort). The overall uptake of HIV testing was 98%. Among women tested, 22% were HIV positive, and among those, 85% had CD4 counts taken. Twenty-eight percent of control women and 27% of intervention women were eligible for ART. A significantly greater proportion of women in the intervention compared to the control cohort were enrolled in ART services (44% vs. 25%, odds ratio [OR] 2.1; 95% confidence interval [CI]: 1.3-3.3), and initiated ART (33% vs. 14%, OR 2.0; 95% CI: 1.4-3.0). There was no significant difference between the two groups in gestational age at ART initiation (27.7 vs. 27.1 weeks) or in weeks on ART before delivery (10.0 vs. 10.8 weeks). Retention for 90 days following ART initiation was also similar (88% in the intervention cohort, 91% in the control cohort; P=0.3).


In the public sector in Zambia, providing ART by integrating services directly into an ANC, compared to actively referring women to a separate ART clinic, doubled the proportion of treatment-eligible pregnant women initiating treatment prior to delivery.

Quality Rating

This was a high-quality program evaluation of a large cohort of women attending public clinics. The integrated electronic patient record system in Zambia allowed the capture of data on enrolment, initiation, and follow-up across clinics and services.

Programmatic Implications

This evaluation shows that integrating ART services within busy public ANCs is feasible and can significantly increase the number of pregnant women who begin HAART. In many settings, pregnant women may not be evaluated for ART eligibility or initiate treatment because of the burden of attending busy and overcrowded ART clinics in addition to their ANC visits. The program evaluated here did not get women into treatment earlier, although the average time on treatment prior to delivery was 10 weeks. It has been shown that being on HAART for at least seven weeks prior to delivery is associated with a <1% risk of perinatal transmission.(2) Despite the programs success, 62% of eligible pregnant women still did not start treatment. Determining reasons for this and strategies to improve enrolment further are needed.(3, 4) Because of loss to follow-up postpartum, the public clinics in this study are extending ART care for women for six months after delivery. This study provides further substantiation for the need to develop comprehensive maternal and child services that include PMTCT and ongoing HIV care.


  1. World Health Organization. Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants in resource-limited settings: towards universal access. Geneva: WHO; 2006. Abstract not available.
  2. Black V, Hoffman RM, Sugar CA, et al. Safety and efficacy of initiating highly active antiretroviral therapy in an integrated antenatal and HIV clinic in Johannesburg, South Africa. J Acquir Immune Defic Syndr 2008; 49:276-81.
  3. Painter TM, Diaby KL, Matia DM, et al. Women's reasons for not participating in follow up visits before starting short course antiretroviral prophylaxis for prevention of mother to child transmission of HIV: qualitative interview study. BMJ 2004;329:543.
  4. Chi BH, Chansa K, Gardner MO, et al. Perceptions toward HIV, HIV screening, and the use of antiretroviral medications: a survey of maternity-based healthcare providers in Zambia. Int J STD AIDS 2004; 15:685-90.