Ong'ech JO, Hoffman HJ, Kose J, Audo M, Matu L, Savosnick P, Guay L. Provision of services and care for HIV-exposed infants: A comparison of maternal and child health clinic and HIV comprehensive care clinic models. J Acquir Immune Defic Syndr. 2012 Sep 1;61(1):83-9.
To compare the effectiveness of provision of routine services and HIV care to HIV-exposed infants (HEI) in a facility providing an integrated maternal and child health (MCH) model of service delivery with a facility utilizing the HIV comprehensive care clinic (CCC) model.
Two purposively-selected district hospitals in the Western Province of Kenya, with similar characteristics but different models of service delivery. Vihiga District Hospital provided the integrated MCH model of service delivery. Bungoma District Hospital provided the CCC model of service delivery, with a separate MCH clinic.
Prospective observational cohort study.
All HIV-exposed six- to eight-week-old infants and their mothers or caregivers presenting for the 6-week immunization visit to the integrated MCH clinic or the six-week HEI follow-up visit to the CCC at the study facilities.
Attendance at follow-up visits, uptake of HIV testing and uptake of cotrimoxazole (CTX) prophylaxis.
At each site, nurses identified potentially eligible six-to-eight-week-old infants when they presented with their mothers or caregivers and referred them to the study's research clinical officer (RCO). The RCO verified eligibility, obtained consent and enrolled infants daily until the desired sample size was reached.
In the MCH model, infants received HIV testing, CTX prophylaxis, all routine immunizations and growth monitoring in the integrated MCH clinic. In the CCC model, infants received HIV testing and CTX prophylaxis in the CCC but immunizations and growth monitoring in the MCH clinic. In both models, maternal HIV treatment and care were provided in the CCC. Also, in both models, linkages between the MCH clinic and the CCC were facilitated by peer counselors, who provided ongoing support to women and escorted them between the two clinics. These peers were also responsible for escorting HEI who were seen in the MCH clinic to the CCC for HIV services, and vice versa.
Once enrolled, infants were seen by an RCO posted in the respective clinic, who provided routine and study-specific HIV services to participants at all their clinic visits. All enrolled infants seen in the study clinics were given a return date corresponding to the next immunization visit where applicable or the next study scheduled visit. At the time of the study, Kenyan national guidelines for the care of HEI included postnatal visits at one-to-two weeks, six weeks, 10 weeks, 14 weeks, and then monthly until 12 months of age; then every three months until 24 months of age. HEI began CTX prophylaxis and were tested for HIV antigen (early infant diagnosis, EID) at six weeks of age, with follow-up HIV antibody testing at 12 and 18 months of age. Study-specific visits were conducted at the six-to-eight-week enrollment visit and then at the time of the routinely scheduled 14-week, six-month, nine-month and 12-month postnatal visits.
From April 2008 to April 2010, 363 HEI were enrolled in the study and followed up to 12 months of age. In the MCH model, 179 of 183 eligible HEI were enrolled; 184 of 190 eligible HEI were enrolled in the CCC model. By the 14-week immunization visit, the overall attendance rate dropped to 82.6% (88.3% in MCH vs 77.2% in CCC; p=0.005). Attendance declined more rapidly in the CCC model compared with the MCH model, with a slight increase in attendance in the CCC model at the 12-month visit. Overall, the infant attendance rate at the MCH remained significantly higher than that at the CCC model. Estimating from Poisson regression models with robust variance estimation, infants in the integrated MCH clinic were 1.14 times (95% CI 1.04 to 1.26) more likely to attend the 14-week immunization visit, 1.42 times (95% CI 1.23 to 1.65) more likely to attend the 6-month postnatal follow-up visit, 1.95 times (95% CI 1.57 to 2.42) more likely to attend the 9-month postnatal follow-up visit, and 1.29 times (95% CI 1.07 to 1.56) more likely to attend the 12-month postnatal follow-up visit than infants in the CCC.
In the MCH model, 96 infants (53.6%) attended all 4 study follow-up visits, while only 35 infants (19.0%) in the CCC model attended all 4 visits (p<0.0001). Almost all infants received PCR testing (99%) or were initiated on CTX prophylaxis (98%-100%) at enrollment, with no significant differences between MCH and CCC models of service. Overall, infants in the MCH model were significantly more likely to receive oral polio vaccine at 14 weeks, CTX at 6 months, measles vaccine at 9 months, and complete vaccinations and have an HIV antibody test at 12 months, compared with infants in the CCC model. Receipt of diphtheria, tetanus and pertussis (DPT) vaccination was much lower than polio vaccination at 14 weeks in both models due to national vaccine stock outs that occurred during the study period. However, when including only the HEI who attended the specified clinic visit, there were significant differences in the proportion of infants who received the desired service in the integrated MCH clinic compared with the CCC, respectively, for several of the endpoints (see table below).
In an adjusted Poisson regression model, model of service delivery (p<0.0001) and maternal employment status (p=0.006) were the only significant predictors of the average number of visits infants attended. The average number of study follow-up visits for infants in the MCH model was 1.30 times (95% CI 1.16 to 1.46) the number of study follow-up visits for infants in the CCC model after adjusting for employment status. The average number of follow-up visits for infants with unemployed mothers/caregivers was 1.16 times (95% CI 1.04 to 1.30) the number of follow-up visits for infants with employed mothers/caregivers after adjusting for model of service.
Comparison of unadjusted rates of service uptake by infants in the MCH and CCC models of service (from the article).
The study authors conclude that one district hospital with an integrated MCH model of postnatal care for HEI performed significantly better than a similar district hospital that used an HIV CCC model.
The overall risk of bias in the study is low. The study design included a comparison group. The cohorts at baseline were equivalent socio-demographically and on outcome measures. The investigators used statistical analyses to control for potential confounders. Although the loss to follow-up was very high, measuring this loss to follow-up was a primary outcome of the study.
High loss to follow-up is a serious problem in HEI care throughout sub-Saharan Africa,(1, 2, 3) whether it is the result of poor socioeconomic conditions, difficult transport, long distance from the health facility, competing health needs, fear of results, poor record keeping, or unreported deaths.(4, 5,6 ,7) A recent Cochrane review found that integrated MCH and HIV services are feasible to implement and show promise towards improving a variety of health and behavioral outcomes.(8) This study's finding that maternal employment status influences retention is important to investigate further. The World Health Organization (WHO) is expected to release new guidelines on integrated HIV/AIDS service delivery in 2013.
Clinics and hospitals offering MCH and HIV services separately should consider integrating these services. Clinics and hospitals offering only one of these services should consider offering integrated MCH and HIV services, if they have the means to do so.
- Horwood C, Haskins L, Vermaak K, et al. Prevention of mother to child transmission of HIV (PMTCT) programme in KwaZulu-Natal, South Africa: an evaluation of PMTCT implementation and integration into routine maternal, child and women's health services. Trop Med Int Health. 2010;15:992-999.
- Manzi M, Zachariah R, Teck R, et al. High acceptability of voluntary counselling and HIV-testing but unacceptable loss to follow up in a prevention of mother-to-child HIV transmission programme in rural Malawi: scaling-up requires a different way of acting. Trop Med Int Health. 2005;10:1242-1250.
- Ndongwe F, Muigai E, Millicent K. Systems to support retention of HIV exposed infants in care in Central and Eastern Kenya. Paper presented at: Kenya National PMTCT Implementers Meeting; July 18-20, 2011; Nairobi, Kenya.
- Chopra M, Daviaud E, Pattinson R, et al. Saving the lives of South Africa's mothers, babies, and children: can the health system deliver? Lancet. 2009;374:835-846.
- Nyandiko WM, Otieno-Nyunya B, Musick B, et al. Outcomes of HIV-exposed children in western Kenya: efficacy of prevention of mother to child transmission in a resource-constrained setting. J Acquir Immune Defic Syndr. 2010;54:42-50.
- Ioannidis JP, Taha TE, Kumwenda N, et al. Predictors and impact of losses to follow-up in an HIV-1 perinatal transmission cohort in Malawi. Int J Epidemiol. 1999;28:769-775.
- Jones SA, Sherman GG, Varga CA. Exploring socio-economic conditions and poor follow-up rates of HIV-exposed infants in Johannesburg, South Africa. AIDS Care. 2005;17:466-470.
- Lindegren ML, Kennedy CE, Bain-Brickley D, Azman H, Creanga AA, Butler LM, Spaulding AB, Horvath T, Kennedy GE. Integration of HIV/AIDS services with maternal, neonatal and child health, nutrition, and family planning services. Cochrane Database Syst Rev. 2012 Sep 12;9:CD010119.