Integrating services works to curb HIV transmission from mothers to their infants and retain mothers in care, study shows

By Emily Bobrow, PhD. A combination of integrated service delivery approaches for mothers who are HIV-positive has been shown in Uganda to improve retaining mothers in HIV care and increasing exclusive breastfeeding for infants, plus providing an increase in completed HIV test results for babies at 18 months of age.

By Emily Bobrow, PhD, MEASURE Evaluation

A combination of integrated service delivery approaches for mothers who are HIV-positive has been shown in Uganda to improve retaining mothers in HIV care (12 months) and increasing exclusive breastfeeding (EBF) for infants, plus providing an increase in completed HIV test results for babies at 18 months of age. An outcome evaluation in Uganda, published this month in JAIDS, documented these results to have occurred at demonstration health facilities implementing the Partnership for HIV-Free Survival (PHFS) approach from 2013–2016.

The goal of this outcome evaluation—conducted by MEASURE Evaluation, funded by the United States Agency for International Development (USAID) and the United States President’s Emergency Plan for AIDS Relief (PEPFAR)—was to assess whether and to what degree the PHFS implementation approach in Uganda improved prevention of mother-to-child transmission (PMTCT) of HIV, improved data quality, and improved child health outcomes at the patient level. The full PHFS program implementation was carried out in six sub-Saharan countries (Kenya, Lesotho, Mozambique, South Africa, Tanzania, and Uganda).

Findings from the study suggested that the PHFS activities contributed to prevention of HIV transmission and, in turn to epidemic control. The study recommended the program should be sustained and scaled up and ought to be a priority for implementation throughout the region. The study further recommended that the approach should include integrated service delivery; training, coaching and mentoring for quality improvement (QI) methods; and stakeholder engagement.

This evaluation gathered patient-level quantitative data from PHFS demonstration and scale-up health facilities, and from non-PHFS comparison facilities. The evaluation assessed individual outcomes, specifically exclusive breastfeeding (EBF), 12-month retention in care, 18-month mother-to-child HIV transmission, and 18-month HIV test data completeness. The evaluation measured the association of these individual outcomes and the sustainability of PHFS after the program ended. Additionally, the evaluation gathered qualitative data from PHFS health facility staff and QI coaches.

PHFS implementation used a QI approach to achieve its two program goals: (1) increased retention in care of HIV-positive mothers and their HIV-exposed children and (2) optimized ART coverage. PHFS examined whether a combination of QI activities could be introduced, implemented, and embraced by frontline staff to improve service delivery and outcomes. It was funded by PEPFAR through USAID in collaboration with the World Health Organization (WHO), UNICEF, and country health ministries.

Further findings of MEASURE Evaluation’s study were that HIV transmission from mother to child had decreased at 18 months but that the lower rate was no different between demonstration sites and control groups. It found that after the program ended, increases in EBF and retention in care were sustained and data completeness continued to increase at demonstration sites. However, at scale-up facilities, PHFS was associated with an increase in EBF, but showed no difference for retention in care, PMTCT, or data completeness. At scale-up sites after the program, the gains in EBF were lost and retention in care declined.

The PHFS intervention was built on 2010 recommendations from WHO that governments address PMTCT aims by providing antiretroviral therapy (ART) and EBF support to HIV-positive mothers. The combination of ART for the mother and EBF for the infant are known to decrease HIV transmission and to provide better nutrition for the infant and reduce the chance of diarrheal disease as well. The PHFS program was begun because many high-burden countries in sub-Saharan Africa had found it difficult to operationalize these policies, particularly in the postpartum period.

Reprinted with permission from Science Speaks

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