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|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
HIV-infected pregnant women and their HIV-exposed infants; male partners of the women.
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.
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.
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).
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).
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).
The authors found that the RRI intervention was associated with short-term sustained improvement in most indicators.
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.
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.
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.