University of California, San Francisco Logo

University of California, San Francisco | About UCSF | Search UCSF | UCSF Medical Center

Home > Global Health Literature Digest > Towards Elimination
Towards Elimination of Mother-to-Child Transmission of HIV: The Impact of a Rapid Results Initiative in Nyanza Province, Kenya
Global Health Sciences Literature Digest
Published June 25, 2012
Journal Article

Dillabaugh LL, Lewis Kulzer J, Owuor K, Ndege V, Oyanga A, Ngugi E, Shade SB, Bukusi E, Cohen CR. Towards Elimination of Mother-to-Child Transmission of HIV: The Impact of a Rapid Results Initiative in Nyanza Province, Kenya. AIDS Res Treat. 2012;2012:602120. Epub 2012 Apr 4.

Objective

To increase eligibility assessment for antiretroviral therapy (ART) in pregnant women with HIV infection; to increase ART uptake in eligible women; to improve uptake of testing in perinatally HIV-exposed infants; and to increase ART uptake in HIV-infected infants.

Setting

Family AIDS Care and Education Services (FACES), a comprehensive HIV prevention, care and treatment program in five districts of Nyanza Province, Kenya, comprising 119 health facilities at all levels of service delivery.

Study Design

Cohort study with pre- and post-intervention evaluation.

Intervention

A "Rapid Results Initiative"(RRI) intervention, a rapid, cross-cutting approach to improving health systems by structuring strategic goals into short cycles. After a needs assessment and decision-making about specific objectives, multidisciplinary provincial- and district-level task-forces (laboratory, monitoring and evaluation, community liaison and clinical staff) developed a range of cross-cutting and specific logistical, technical and training strategies to meet each project objective, and implemented these beginning in April 2011.

Schematic of the RRI

Population

HIV-infected pregnant women and their HIV-exposed infants; male partners of the women.

Main Outcome Measures

Number of pregnant women receiving HIV testing and counseling (HTC) in antenatal clinic (ANC); proportion of women tested in ANC whose male partner also tested in ANC; proportion of women tested in ANC confirmed to be HIV-infected; proportion of HIV-infected women who had blood drawn in ANC for CD4 testing; proportion of HIV-infected women initiating ART in ANC; number of HIV-exposed infants having HIV polymerase chain reaction (PCR) test as a proportion of HIV-infected women initiating ART in ANC; proportion of HIV-infected infants initiating ART.

Methods

To assess changes in testing and uptake of services at each site, data were gathered at baseline (October 2010-January 2011); during the 12-week intervention period (April 2011-June 2011); and for 12 weeks after the intervention period (July 2011-September 2011). Data from each period were aggregated and compared.

Results

Maternal outcomes:

The number of women who received HTC increased from 8591 in the baseline period to 9123 during the intervention period and then decreased to 8068 in the post-intervention period.

In the baseline period, 980/1662 (59%) women testing HIV-positive received CD4 test results. This increased to 1258/1890 (66.6%) during the intervention period (risk ratio [RR] 1.1, 95% confidence interval [CI] 1.1 to 1.2) and remained significantly higher than baseline in the post-intervention period, 966/1526 (63.3%) (RR vs. baseline 1.1, 95% CI 1.0 to 1.1).

In the baseline period, 228/1662 (13.7%) women testing HIV-positive initiated ART. This increased to 373/1890 (19.7%) in the intervention period, (RR 1.4, 95% CI 1.2 to 1.7) and further increased to 331/1526 (21.7%) in the post-intervention period (RR vs. baseline 1.58, 95% CI 1.4 to 1.8).

Infant outcomes:

There were significant increases in the proportion of HIV-exposed infants who were tested using PCR from baseline. In the baseline period, 768 (46%) HIV-exposed infants from 1662 HIV-infected mothers received PCR tests. During the intervention period, 1149/1890 (61%) HIV-exposed infants received PCR tests (RR 1.3, 95% CI 1.2 to 1.4), and in the post-intervention period, 1327/1526 (87%) HIV-exposed infants received PCR tests (RR vs. baseline 1.9, 95% CI 1.8 to 2.0).

There were similar increases in the proportion of PCR-positive infants that began ART from baseline. In the baseline period, 51 of 93 (55%) PCR-positive infants (54.8%) initiated ART. This increased to 95/158 (60%) in the intervention period (RR 1.1, 95% CI 0.9 to 1.4) and increased further to 105/152 (69%) in the post-intervention period (RR vs. baseline 1.3, 95% CI 1.0 to 1.6).

Male partner outcomes:

In the baseline period, 660 (7.7%) male partners of 8591 women receiving HTC received HTC with them. During the intervention period, 1496/9123 (16.3%) received HTC with them (RR 2.1, 95% CI 2.0 to 2.3), and in the post-intervention period, 939/8068 (11.6%) received HTC with them (RR 1.5, 95% CI 1.4 to 1.7).

Conclusions

The authors found that the RRI intervention was associated with short-term sustained improvement in most indicators.

Risk of Bias

As a pre-post intervention evaluation, this study has substantial risk of bias. Using a nine-point scale to assess the study rigor, the study received four points. The study included pre/post intervention data; comparator groups were equivalent socio-demographically and at baseline on outcome measures. Reporting of the study was at times contradictory or unclear; e.g., it could not be determined whether the intervention took place over "60 days" or "12 weeks." In addition, the pre-intervention phase took place over 12 weeks, but then (apparently) one-third of baseline data was omitted from analysis.

In Context

Access to comprehensive and integrated HIV services leads to better outcomes for both mothers and infants.(1) Early diagnosis of HIV-infected infants is crucial to saving their lives but requires a great deal of clinical and logistical coordination within local health systems.(2) This study addresses several important issues in preventing HIV transmission and improving uptake of care in patients testing HIV-positive, as well as in overcoming the significant programmatic, operational and clinical challenges to delivering HIV prevention and treatment services that often exist in sub-Saharan Africa. The World Health Organization (WHO)'s 2010 guidelines for preventing mother-to-child HIV transmission call for a CD4-based determination of whether pregnant women testing HIV-positive should receive ART, or be given prophylactic antiretroviral regimens.(3) With the emerging realization(4, 5, 6, 7, 8, 9) that ART can lead to dramatically reduced HIV transmission, international health policy is evolving rapidly. WHO now proposes for consideration the possibility that all pregnant women, regardless of CD4 count, should begin ART immediately and remain on it for life.(10) WHO already advises that HIV-infected sexual partners in sero-discordant couples should start ART on a similar basis.(11) New WHO guidelines on preventing mother-to-child HIV transmission will be released in 2013.

The "Rapid Results" approach has been used by the World Bank and other agencies to effect dramatic organizational change and improve performance, over a short timeframe.(12, 13, 14) It has recently been used in Kenya to scale up rates of voluntary male medical circumcision (VMMC).(15) This is apparently the first peer-reviewed article of an intervention using a Rapid Results approach to improve HIV treatment outcomes. As it has been less than one year since the intervention was completed, it will be interesting to see in follow-up research whether its effect has been sustained.

Programmatic Implications

While it appears promising, additional follow-up data will be needed to understand if a Rapid Results approach will lead to long-term, sustained improvement in HIV prevention and treatment outcomes.

References

  1. WHO. Technical Consultation on the Integration of HIV Interventions into Maternal, Newborn and Child Health Services. [Accessed 18 June 2008]
  2. WHO. Pediatric advocacy toolkit: For improved pediatric HIV diagnosis, care and treatment in high HIV prevalence countries and regions. [Accessed 18 June 2012]
  3. WHO. Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants: Recommendations for a public health approach (2010). [Accessed 18 June 2012]
  4. Abdool Karim SS, Naidoo K, Grobler A, et al. Timing of initiation of antiretroviral drugs during tuberculosis therapy. N Engl J Med. 2010 Feb 25;362(8):697-706.
  5. Grant RM, Lama JR, Anderson PL, et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med. 2010, 363:2587-2599.
  6. Baetan J, Donnell D, Ndase P, and the Partners PrEP Study Team. ARV PrEP for HIV-1 prevention among heterosexual men and women. Nineteenth Conference on Retroviruses and Opportunistic Infections, 5-8 March 2012, Seattle, Washington State, United States [Abstract number 29].
  7. Thigpen M, Kebaabetswe PM, Smith DK, et al. Daily oral antiretroviral use for the prevention of HIV infection in heterosexually active young adults in Botswana: results from the TDF2 study. Sixth IAS Conference on HIV Pathogenesis, Treatment and Prevention. Rome, Italy, 18-20 July 2011 [Abstract number WELBC01]
  8. Cohen MS, Chen YQ, McCauley M, and the HPTN 052 Study Team. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011 Aug 11;365(6):493-505.
  9. Anglemyer A, Rutherford GW, Baggaley RC, Egger M, Siegfried N. Antiretroviral therapy for prevention of HIV transmission in HIV-discordant couples. Cochrane Database Syst Rev 2011, (8):CD009153.
  10. WHO. Use of antiretroviral drugs for treating pregnant women and preventing HIV infection in infants (2012). [Accessed 18 June 2012]
  11. WHO. Guidance on couples HIV testing and counselling, including antiretroviral therapy for treatment and prevention in serodiscordant couples: Recommendations for a public health approach. [Accessed 18 June 2012]
  12. Matta N, Otoo S, Agapitova N. Connecting the dots. Increasing the yield on learning programs for capacity development: rapid results initiatives and the capacity for development results framework. World Bank Institute. [accessed 18 June 2012]
  13. Rapid Results Institute. Magic of Rapid Results. [accessed 18 June 2012]
  14. The World Bank. Eritrea: Rapid Results Initiative (RRI) on HIV/AIDS. [Accessed 20 June 2012]
  15. Government of Kenya, Ministry of Public Health and Sanitation, National AIDS/STI Control Programme. Voluntary Medical Male Circumcision for HIV Prevention in Kenya: Report of the First Rapid Results Initiative, Conducted in November/December 2009 (2011). [Accessed 18 June 2012]