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Transcript of Ferguson Et Al-2012-Tropical Medicine & International Health
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8/16/2019 Ferguson Et Al-2012-Tropical Medicine & International Health
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Linking women who test HIV-positive in pregnancy-related
services to long-term HIV care and treatment services:
a systematic review
Laura Ferguson1,2, Alison D. Grant3, Deborah Watson-Jones3,4, Tanya Kahawita5, John O. Ong’ech2,6,7
and David A. Ross1
1 Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK2 University of Nairobi, Institute of Tropical and Infectious Diseases, Nairobi, Kenya3 Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK4 Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania5 Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK6 Department of Obstetrics and Gynaecology, Kenyatta National Hospital, University of Nairobi, Nairobi, Kenya7 Elizabeth Glaser Pediatric AIDS Foundation, Nairobi, Kenya
Abstract objectives To quantify attrition between women testing HIV-positive in pregnancy-related services
and accessing long-term HIV care and treatment services in low- or middle-income countries and to
explore the reasons underlying client drop-out by synthesising current literature on this topic.
methods A systematic search in Medline, EMBASE, Global Health and the International Bibliography
of the Social Sciences of literature published 2000–2010. Only studies meeting pre-defined quality
criteria were included.
results Of 2543 articles retrieved, 20 met the inclusion criteria. Sixteen (80%) drew on data from sub-
Saharan Africa. The pathway between testing HIV-positive in pregnancy-related services and accessing
long-term HIV-related services is complex, and attrition was usually high. There was a failure to initiate
highly active antiretroviral therapy (HAART) among 38–88% of known-eligible women. Providing
‘family-focused care’, and integrating CD4 testing and HAART provision into prevention of mother-to-
child HIV transmission services appear promising for increasing women’s uptake of HIV-related ser-
vices. Individual-level factors that need to be addressed include financial constraints and fear of stigma.conclusions Too few women negotiate the many steps between testing HIV-positive in pregnancy-
related services and accessing HIV-related services for themselves. Recent efforts to stem patient drop-
out, such as the MTCT-Plus Initiative, hold promise. Addressing barriers and enabling factors both
within health facilities and at the levels of the individual woman, her family and society will be essential
to improve the uptake of services.
keywords antiretroviral therapy, female, patient dropouts, developing countries, HIV infections
Introduction
For more than a decade, effective antiretroviral (ARV)
treatment has been available for the prevention of mother-
to-child transmission of HIV (PMTCT), and highly activeARV therapy (HAART) for lifelong treatment is becoming
increasingly accessible worldwide (UNAIDS 2010). Many
studies have demonstrated the effectiveness of HAART
during pregnancy and breastfeeding to reduce vertical
transmission when compared with no intervention and
with short-course PMTCT regimens (Thomas et al. 2008;
Kilewo et al. 2009; Shapiro et al. 2009; de Vincenzi and
Study Kesho Bora Group 2009; Kouanda et al. 2010, The
Kesho Bora Study Group 2011). Even where it is impos-
sible to initiate HAART during pregnancy, mother-to-child
HIV transmission can be reduced by promoting rapid
uptake of HAART following delivery (Taha et al. 2009).
Improved access to PMTCT services has decreasedvertical HIV transmission, but parallel attention to
women’s access to HIV care and treatment for themselves
has often been lacking. Initiating HAART during preg-
nancy can result in significant health benefits for women
including a stronger immune system, decreased risk of
HIV-related morbidity and reduced maternal mortality
(Rabkin et al. 2004; Black et al. 2009). Survival of HIV-
exposed infants is also higher among those whose mothers
Tropical Medicine and International Health doi:10.1111/j.1365-3156.2012.02958.x
volume 17 no 5 pp 564–580 may 2012
564 ª 2012 Blackwell Publishing Ltd
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are on HAART and ⁄ or co-trimoxazole preventive therapy
(Newell et al. 2004; Mermin et al. 2008).
The PMTCT ‘cascade’ is the sequence of steps required
for delivery of effective PMTCT interventions; it typically
includes: attendance at antenatal care (ANC), HIV coun-selling, HIV testing, the provision of prophylactic ARVs,
safe delivery, safe infant feeding, infant follow-up and HIV
testing, and family planning. Attention to women’s linkage
into long-term HIV care and treatment services, assessment
for eligibility for HAART and initiation of HAART if
required is also essential but more rarely a priority within
such ‘cascades’.
This study aimed to quantify attrition along the pathway
between women testing HIV-positive in pregnancy-related
services and accessing long-term HIV care and treatment
services in low- or middle-income countries1 (LMIC) and
to explore the reasons underlying client drop-out by
synthesising current literature on this topic.
Methodology
We conducted a systematic search of literature published in
English, French, Portuguese or Spanish between 1st Janu-
ary 2000 and 31st December 2010. Medline, EMBASE,
Global Health and the International Bibliography of the
Social Sciences were searched using the strategy outlined in
Box 1. Experts in the field were consulted, and one PhD
thesis was also included.
Articles were included in the review if the studies were
carried out in a LMIC and contained information specific
to access to long-term HIV care and treatment servicesamong women who test HIV-positive in the context of
pregnancy. Studies could be observational or descriptive.
No publications were excluded on the basis of study
design; rather they were assessed for ‘fatal flaws’ as defined
in Appendix 1.
Two researchers (LF, TK) independently assessed a
randomly selected 10% of all abstracts that were retrieved
by the search and a randomly selected 10% of the articles
selected for full-text review to determine the articles for the
inclusion in the final review. There was adequate concor-
dance between those included at each stage; 98% agree-
ment, kappa 0.97 on titles ⁄ abstracts and 90% agreement,
kappa 0.62 on full-text articles. Results were comparedand disagreements resolved by consensus before the eligible
articles were reviewed by a single researcher (LF).
Reference lists for the articles included in the review were
hand-searched for additional relevant publications.
Where sufficient data existed, client attrition along the
pathway between HIV testing in ANC and initiating
HAART if required was quantified, and extrapolations
were made to estimate the overall number of missed
opportunities for starting HAART. Piot-Fransen models
were created for the three studies with the largest samplesizes that included data on the steps needed to access
treatment, the proportion of women who accessed HAART
and the potential effect of fully functional systems of
linkages from HIV testing in pregnancy-related services to
HAART services.
Results
Results of the systematic search
The search yielded 2543 unique articles. All abstracts were
reviewed, and 93 were selected for full-text review, 18 of
which met the inclusion criteria. One was excluded as it
duplicated reporting in another article, (Tonwe-Gold et al.2007) so 17 were retained. Three additional publications
were found from the hand-searches and expert consulta-
tions. Twenty publications were included in the final
review (Figure 1; Tables 1–3).
Of the 20 publications, 12 (60%) presented quantitative
results, while three (15%) presented qualitative findings,
one was a mixed methods study (5%) and four (20%) were
programme reviews or evaluations, policy analyses or
commentaries. Sixteen (80%) of these publications drew
on data from sub-Saharan Africa, including four from
South Africa.
Patient cascades between testing HIV-positive in ANC and
accessing HAART
Thirteen publications showed attrition rates along the
pathway to HAART services among women testing
HIV-positive in pregnancy-related services. The findings
are summarised in Tables 1 and 2 and divided into
observational studies (n = 7), and studies that report data
following some form of intervention (n = 6). The steps
Box 1 Search strategy for the literature search
Search terms
(HIV or AIDS).ti.
(pregnan* or antenatal or ANC or MCH or maternity).mp.[mp=ti, ab, sh, hw, tn, ot, dm, mf, dv, kw, bt, ps, rs, nm, ui]
(diagnos* or test*).mp. [mp=ti, ab, sh, hw, tn, ot, dm, mf, dv,
kw, bt, ps, rs, nm, ui]
1 and 2 and 3
Limit 4 to (English or French or Portuguese or Spanish)
Limit 5 to yr = ‘2000–2010’
1This is based on the World Bank’s list of low- and middle-income
economies.
Tropical Medicine and International Health volume 17 no 5 pp 564–580 may 2012
L. Ferguson et al. Linking HIV-positive pregnant women to treatment services
ª 2012 Blackwell Publishing Ltd 565
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reported along the cascade, PMTCT regimens used and
timeframes varied by study.
Overall attrition
Pooling the data presented in Tables 1 and 2 forstudies with
sufficient data (Chen, Kranzer, Stinson, Balira, Chi, Killam,
Mandala, Muchedzi) revealed many missed opportunities
for initiating HAART. If all 27 001 HIV-positive women in
these studies had been assessed for HAART eligibility and
the same study-specific proportion found to be eligible as
was found among the women who underwent CD4 count
testing, an estimated 7376 women would have been iden-
tified as immediately HAART-eligible. Yet, only 1338
women initiatedHAART, constituting 43%of those known
to be eligible and, based on these extrapolations, only 18%of those who might have required it.
Points of attrition along the cascade
The individual studies document failure to initiate HAART
among 38%–88% of known-eligible women. However, the
points of attrition along the pathway to assessment and
initiation of HAART varied. In the Tanzanian study, 38%
of women failed to register at the HIV clinic after an HIV
diagnosis in ANC (Balira 2010).
Across most studies, at least 70% of women who
registered at the HIV clinic reportedly had blood taken for
a CD4 count; studies in Botswana and Zambia are notableexceptions with CD4 count uptake of 59% and 17%,
respectively (Mandala et al. 2009; Chen et al. 2010).
The studies that documented the proportion of women
returning for their CD4 count results found attrition of
30–33% at this point of the cascade (Chi et al. 2007;
Mandala et al. 2009; Horwood et al. 2010).
In one South African study, the proportion of individuals
who attended a blood-draw for a CD4 count within
6 months of diagnosis was 84.1% for those tested through
STI services, 81.3% for women tested in ANC, 68.9% for
those tested in tuberculosis services and 53.5% for peopletested through voluntary counselling and testing (Kranzer
et al. 2010).
In Zambia, uptake of HIV-related services was com-
pared where women were referred from ANC to a separate
HAART clinic (control arm) with uptake where HAART
was initiated within ANC (intervention arm). Eighty-five
per cent of women underwent initial evaluation for
HAART eligibility in both study arms, but the proportion
of eligible women who initiated HAART was low in both
arms at 14% and 33% in control and intervention arms,
respectively (Killam et al. 2010). Data from sites in 14
countries showed that only 1.4% of HIV-positive pregnant
women had received HAART; the proportion of HAART-eligible women was not reported (Ginsburg et al. 2007). In
contrast, the study in Ivory Coast showed exceptionally
high uptake of CD4 count testing (100%) and HAART
(95%) (Tonwe-Gold et al. 2009).
Figure 2 shows Piot-Fransen models for the three
selected studies: two observational studies in South Africa
and Zambia, and the intervention arm of Killam et al.’s
study in Zambia. These studies all revealed high levels of
patient attrition, including the intervention arm of Killam
et al.’s evaluation (Figure 2c) where specific efforts were
made to promote uptake of HAART following HIV testing
in ANC.
Factors underlying client attrition along the pathway to
HAART
Some articles in this review provided insufficient quanti-
tative data to be included in Tables 1 or 2 but gave useful
insights into factors affecting attrition along the pathway
to HAART. These are outlined in Table 3. Then, factors
underlying client attrition along the pathway that have
2543 unique titles/abstracts
identified via database searches and
assessed for inclusion
93 full-text articles assessed for
inclusion
2460 articles excluded
based on abstract
review
20 full-text articles included in the
systematic review
Three additional articles selected for
inclusion from hand-searching the
references of these articles and
expert advice
76 articles excluded
based on full-text
review
Figure 1 Results of search strategy.
Tropical Medicine and International Health volume 17 no 5 pp 564–580 may 2012
L. Ferguson et al. Linking HIV-positive pregnant women to treatment services
566 ª 2012 Blackwell Publishing Ltd
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T a b l e 1
P a t
i e n t c a s c a d e s
f o r p r e g n a n t w o m e n
f r o m t e s t
i n g
H I V
- p o s i t i v
e t o
i n i t i a t i n g
H A A R T
– O b s e r v a t
i o n a l s t u
d i e s
C o u n t r y ,
a u t h o r ,
y e a r o
f
p u
b l i c a t i o n
S t u
d y
d e s
i g n
C D 4 f o r
H A A R T
e l i g i b i l i t y
H I V
-
p o s i t i v e
R e f e r r e
d t o
H I V c l
i n i c
f o r
H A A R T
a s s e s s m e n t
R e g
i s t e r e d
a t H I V
c l i n i c
I n i t i a l
s c r e e n
i n g
o r
C D 4
t e s t
p e r
f o r m e d
R e t u r n e d
f o r r e s u
l t s
o f C D 4
t e s t
E l i g i
b l e
f o r
H A A R T
S t a r t e
d
H A A R T
S h o u
l d
h a v e
s t a r t e
d
H A A R T
( E s t
i m a t e
) %
o f t h o s e
e s t i m a t e d
H A A R T
-
e l i g i b l e
w h o
s t a r t e
d
H A A R T
C o m
m e n t s
a
b ( %
= b ⁄ a )
c ( % = c
⁄ b )
d ( %
= d ⁄ a )
e ( %
= e ⁄ d )
f ( %
= f ⁄ d )
g ( %
= g ⁄ f ) §
h ( a ·
% f )
i ( g ⁄ h )
K e n y a
( O t i e n o
e t a l . 2 0 1 0 )
C r o s s -
s e c t
i o n a l
s u r v e y
< 3 5 0
1 1 6
1 1 6 ( 1 0 0 % ) 8 6 ( 7 4
% )
3 3
B a s e d o n
s e l f - r e p o r t e d
d a t a
. A l m o s t
h a l f t h e
i n i t i a l s t u
d y
p o p u
l a t i o n
w a
s L T F U
.
S t u
d y
p o p u
l a t i o n
h a d b e e n p a r t
o f
a P M T C T
s t u
d y t h a t
i n c
l u d e d
i n t
e n s i v e a n
d
p r o
l o n g e
d
i n v
o l v e m e n t
w i t h p r o v i
d e r s
S o u t h
A f r i c a
( K r a n z e r
e t a l . 2 0 1 0 )
R e t r o s p e c t i v e
c o h o r t
< 2 0 0
1 5 0
1 2 5 ( 8 3 % )
1 8 ( 1 4 % )
1 3 ( 7 2 % )
2 1
6 2 %
B a s e d o n
r o u t i n e l y
c o l l e c t e
d h e a
l t h
f a c
i l i t y r e c o r d s .
W o u
l d h a v e
m i s s e d w o m e n
w h
o c h o s e t o
a t t
e n d a
d i f
f e r e n t
H I V
c l i n
i c b u t
t h e n e a r e s t
a l t
e r n a t
i v e w a s
1 0
k m a w a y
Tropical Medicine and International Health volume 17 no 5 pp 564–580 may 2012
L. Ferguson et al. Linking HIV-positive pregnant women to treatment services
ª 2012 Blackwell Publishing Ltd 567
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8/16/2019 Ferguson Et Al-2012-Tropical Medicine & International Health
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T a b l e 1
( C o n t i n u e d )
C o u n t r y ,
a u t h o r ,
y e a r o
f
p u
b l i c a t i o n
S t u
d y
d e s
i g n
C D 4 f o r
H A A R T
e l i g i b i l i t y
H I V
-
p o s i t i v e
R e f e r r e
d t o
H I V c l
i n i c
f o r
H A A R T
a s s e s s m e n t
R e g
i s t e r
e d
a t H I V
c l i n i c
I n i t i a l
s c r e e n
i n g
o r
C D 4
t e s t
p e r
f o r m e d
R e t u r n e d
f o r r e s u
l t s
o f C D 4
t e s t
E l i g i
b l e
f o r
H A A R T
S t a r t e
d
H A A R T
S h o u
l d
h a v e
s t a r t e
d
H A A R T
( E s t
i m a t e
) %
o f t h o s e
e s t i m a t e d
H A A R T
-
e l i g i b l e
w h o
s t a r t e
d
H A A R T
C o m
m e n t s
a
b ( %
= b ⁄ a )
c ( %
= c ⁄ b )
d ( %
= d ⁄ a )
e ( %
= e ⁄ d )
f ( %
= f ⁄ d )
g ( %
= g ⁄ f ) §
h ( a ·
% f )
i ( g ⁄ h )
S o u t h
A f r i c a
( S t i n s o n
e t a l . 2 0 1 0 )
R e t r o s p e c t i v e
c o h o r t
< 2 0 0
3 4 9 8
3 4 0 5 ( 9 7 % )
5 1 6 ( 1 5 % ) 2 6 2 –
( 5 1 % ) 5 2 5
5 0 %
A s o
n l y f o u r
s i t e s w e r e u s e
d
t o r e p r e s e n t
t h r e e s e r v
i c e
d e l i v e r y m o
d e l s ,
d i f f
e r e n c e s
b e t w e e n t h e
f a c i l i t i e s r a t h e r
t h a n
b e t w e e n
t h e
m o
d e l s
m i g
h t e x p
l a i n
s o m
e o
f
t h e
fi n
d i n g s
S o u t h
A f r i c a
( G e d
d e s
e t a l .
, 2 0 0 8 )
R e t r o s p e c t i v e
c o h o r t
< 2 0 0
3 3 8
2 6 2 ( 7 8 % )
1 3 0
R e l i e d o n
r o u
t i n e l y
c o l l e c t e d
h e a
l t h
f a c i l i t y
d a t a .
1 1 %
L T F U
S o u t h
A f r i c a
( H o r w o o
d
e t a l . 2 0 1 0 )
C r o s s -
s e c t
i o n a l
s t u
d y
< 2 0 0
3 1 2
2 4 4 ( 7 8 % )
1 7 1 ( 7 0 % )
2 7
B a s e
d o n
s e l f - r
e p o r t
b y w o m e n
T a n z a n
i a
( B a l
i r a
2 0 1 0 )
P r o s p e c t i v e
c o h o r t
< 2 0 0
2 4 4
1 9 9 ( 8 2 % )
1 2 3 ( 6 2 % ) 7 8 ( 6 3 % )
1 8 ( 2 3 % )
1 0 ( 5 6 % )
5 6
1 8 %
B a s e
d o n
s e l f - r
e p o r t e d
d a t a .
2 0 %
L T F U b y
fi n a
l f o l l o w - u
p
Tropical Medicine and International Health volume 17 no 5 pp 564–580 may 2012
L. Ferguson et al. Linking HIV-positive pregnant women to treatment services
568 ª 2012 Blackwell Publishing Ltd
-
8/16/2019 Ferguson Et Al-2012-Tropical Medicine & International Health
6/17
T a b l e 1
( C o n t i n u e d )
C o u n t r y ,
a u t h o r ,
y e a r o
f
p u
b l i c a t i o n
S t u
d y
d e s
i g n
C D 4 f o r
H A A R T
e l i g i b i l i t y
H I V
-
p o s i t i v e
R e f e r r e
d t o
H I V c l
i n i c
f o r
H A A R T
a s s e s s m e n t
R e g
i s t e r e
d
a t H I V
c l i n i c
I n i t i a l
s c r e e n
i n g
o r
C D 4
t e s t
p e r
f o r m e d
R e t u r n e d
f o r r e s u
l t s
o f C D 4
t e s t
E l i g i
b l e
f o r
H A A R T
S t a r t e
d
H A A R T
S h o u
l d
h a v e
s t a r t e
d
H A A R T
( E s t
i m a t e
) %
o f t h o s e
e s t i m a t e d
H A A R T
-
e l i g i b l e
w h o
s t a r t e
d
H A A R T
C o m m e n t s
a
b ( %
= b ⁄ a )
c ( %
= c ⁄ b
) d ( %
= d ⁄ a )
e ( %
= e ⁄ d )
f ( %
= f ⁄ d )
g ( %
= g ⁄ f ) §
h ( a ·
% f )
i ( g ⁄ h )
Z a m
b i a
( M a n
d a l a
e t a l . 2 0 0 9 )
R e t r o s p e c t i v e
c o h o r t
< 3 5 0
1 4 8 1 5
2 5 2 8 ( 1 7 % ) 1 6 8 0 ( 6 7 % ) 7 9 6 ( 3 1 % ) 5 8 1 ( 7 3 % ) 4 5 9 3
1 3 %
B a s e d
o n
r o u t
i n e l y
c o l l e c t e
d h e a
l t h
f a c i l i t y
d a t a .
N o d a t a o n a g e
o r W
H O c l
i n i c a l
s t a g i n g
H A A R T
, H i g h l y a c t i v e a n t i r e t r o v i r a
l t h e r a p y ;
L T F U
, l o s t t o
f o l l o w - u
p ;
P M T C T
, p r e v e n t i o n o
f m o t h e r - t
o - c
h i l d H I V t r a n s m
i s s i o n
.
E s t
i m a t e d n u m
b e r o
f w o m e n w
h o s h o u
l d h a v e s t a r t e
d H A A R T
= % w o m e n e l
i g i b l e f o r
H A A R T a m o n g t h o s e
h a d
a C D 4 r e s u
l t · t o t a
l H I V
- p o s i t i v e w o m e n
i n t h e s t u
d y .
W h e r e c
i s a v a i
l a b l e
, %
= d
⁄ c ( B a l
i r a )
§ W h e r e
f i s u n a v a i
l a b l e
, n o
%
i s g i v e n
( O t i e n o
, G e d
d e s
, H o r w o o
d )
– I n S t i n s o n
’ s s t u
d y , t h e n u m b
e r o
f w o m e n w
h o s t a r t e
d H A A R T r e
f e r s t o t h e w o m e n w
h o s t a r t e
d H A A R T d u r i n g p r e g n a n c y
. A n o t h e r
6 1 s t a r t e
d H A A R T w
i t h i n
2 y e a r s p o s t -
p a r t u m
, h a l
f o
f t h e m w
i t h i n
7 . 5
m o n t h s o
f d e l
i v e r y .
C l i e n t s w e r e a l s o
d e e m e d e l
i g i b l e f o r
H A A R T i f C D 4 <
3 5 0 a n
d W H
O S t a g e
I I I , o r
i f W H O S t a g e
I V i r r e s p e c t i v e o
f C D 4 c o u n t .
Tropical Medicine and International Health volume 17 no 5 pp 564–580 may 2012
L. Ferguson et al. Linking HIV-positive pregnant women to treatment services
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T a b l e 2
P a t
i e n t c a s c a d e s
f o r
p r e g n a n t w o m e n
f r o m t e s t
i n g
H I V
- p o s i t i v
e t o
i n i t i a t i n g
H A A R T
– I n t e r v e n t i o n s t u d
i e s
C o u n t r y ,
F i r s t a u t h o r ,
Y e a r o
f
P u
b l i c a t i o n
S t u
d y
d e s
i g n
I n t e r v e n t i o n
C D 4
f o r
H A A R T
e l i g i b i l i t y
H I V
-
p o s i t i v e
R e f e r r e d
t o H I V
c l i n i c
f o r
H A A R T
a s s e s s m e n t
R e g
i s t e r e
d
a t H I V
c l i n i c
I n i t i a l
s c r e e n
i n g
o r
C D 4
t e s t
d o n e
R e t u r n e d
f o r r e s u
l t s
o f C D 4
t e s t
E l i g i
b l e
f o r H A
A R T
S t a r t e
d
H A A R T
S h o u
l d
h a v e
s t a r t e
d
H A A R T
( E s t
i m a t e )
%
o f
t h o s e
e s t i m a t e d
H A A R T -
e l i g i b l e
w h o
s t a r t e
d
H A A R T
S t u
d y
l i m
i t a t
i o n s
a
b ( %
= b ⁄ a )
c ( %
= c ⁄ b )
d ( %
= d ⁄ a )
e ( %
= e ⁄ d )
f ( %
= f ⁄ d )
g ( %
= g ⁄ f )
h ( a ·
% f )
i ( g ⁄ h )
B o t s w a n a
( C h e n
e t a l .
2 0 1 0 )
O b s e r v a t
i o n a l
r e t r o s p e c t i v e
c o h o r t
C o n c u r r e n t
c l i n i c a l t r
i a l
p r o v i
d i n g
C D 4 t e s t
i n g
a n d r a p
i d
H A A R T
i n i t i a t i o n
f o r
w o m e n w
i t h
a C D 4
h i g h e r t h a n
t h e n a t
i o n a l
e l i g i b i l i t y
t h r e s h o
l d
< 2 0 0
6 8 8
3 9 7 ( 5 9 % )
6 2
( 1 6 % )
2 3 ( 3 7 % ) 1 0 7
2 1 %
B a s e d o n
r o u t i n e
h o s p
i t a l
d a t a .
Z a m
b i a
( K i l l a m
e t a l .
2 0 1 0 )
S t e p p e d -
w e d g e
e v a l u a t
i o n
I n t e g r a t
i o n o
f
H A A R T
i n t o
A N C
s e r v
i c e s
.
C o n t r o
l a r m
s h o w n
i n
t o p r o w ;
i n t e r v e n t i o n
s h o w n
i n
b o t t o m r o w
< 2 5 0
< 2 5 0
3 0 4 6
3 7 5 3
2 5 8 9 ( 8 5 % )
3 1 9 3 ( 8 5 % )
7 1 6
( 2 8 % )
8 4 6
( 2 6 % )
1 0 3 ( 1 4 % )
2 7 8 ( 3 3 % )
8 5 3
9 7 6
1 2 %
2 8 %
C o s t a n
d
h u m a n
r e s o u r c e s
i m p
l i c a t i o n s
o f s u c h
i n t e g r a t
i o n
n o t
r e p o r t e d
Tropical Medicine and International Health volume 17 no 5 pp 564–580 may 2012
L. Ferguson et al. Linking HIV-positive pregnant women to treatment services
570 ª 2012 Blackwell Publishing Ltd
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8/16/2019 Ferguson Et Al-2012-Tropical Medicine & International Health
8/17
T a b l e 2
( C o n t i n u e d )
C o u n t r y ,
F i r s t a u t h o r ,
Y e a r o
f
P u
b l i c a t i o n
S t u
d y
d e s
i g n
I n
t e r v e n t i o n
C D 4
f o r
H A A R T
e l i g i b i l i t y
H I V
-
p o s i t i v e
R e f e r r e d
t o H I V
c l i n i c
f o r
H A A R T
a s s e s s m e
n t
R e g
i s t e r e
d
a t H I V
c l i n i c
I n i t i a l
s c r e e n
i n g
o r
C D 4
t e s t
d o n e
R e t u r n e d
f o r r e s u
l t s
o f C D 4
t e s t
E l i
g i b l e
f o r H A
A R T
S t a r t e
d
H A A R T
S h o u
l d
h a v e
s t a r t e
d
H A A R T
( E s t
i m a t e )
%
o f
t h o s e
e s t i m a t e d
H A A R T -
e l i g i b l e
w h o
s t a r t e
d
H A A R T
S t u
d y
l i m
i t a t
i o n s
a
b ( %
= b ⁄ a )
c ( %
= c ⁄ b )
d ( %
= d ⁄ a )
e ( %
= e ⁄ d )
f ( %
= f ⁄ d )
g ( %
= g ⁄ f )
h ( a ·
% f )
i ( g ⁄ h )
Z a m
b i a
( C h i
e t a l .
2 0 0 7 )
E v a
l u a t
i o n
S c r
i p t e
d t a
l k
o n t h e
b e n e fi t s o
f
C D 4 t e s t
i n g
a n d
l o n g - t e r m
H I V c a r e ;
e n c o u r a g e m e n t
t o e n r o
l i n t o
l o n g - t e r m c a r e
a n d t r e a t m e n t ;
a n d e s c o r t
b y
C H W s t o t h e
o n - s
i t e
H I V
f a c i
l i t y
f o r
i m m e d
i a t e
a t t e n t i o n
< 2 0 0
6 8 0
4 3 3 ( 6 4 % )
3 0 2 ( 7 0 % )
2 0 6 ( 6 8 % ) 7 2 ( 2 4 % )
3 3 ( 4 6 % ) 1 6 3
2 0 %
B a s e d o n
r o u t i n e
c l i n i c d a t a
I v o r y
C o a s t
( T o n w e -
G o
l d
e t a l .
2 0 0 9 )
D e s c r
i p t i o n
o f
p r o g r a m m e
o u t c o m e s
M
T C T +
i n i t i a t i v e :
f a m
i l y -
f o c u s e
d
c a r e a n
d
t r e a t m e n t w
i t h
r e g u
l a r c l
i n i c a l
a n d l a b
a s s e s s m e n t s
< 2 0 0
6 0 5
6 0 5 ( 1 0 0 % )
2 5 9 ( 4 3 % ) 2 4 6 ( 9 5 % )
N o i n
f o r m a t
i o n
o n t h e n o
.
o f w o m e n
w h o
d e c
l i n e d
p r o g r a m m e
e n r o
l m e n t .
Tropical Medicine and International Health volume 17 no 5 pp 564–580 may 2012
L. Ferguson et al. Linking HIV-positive pregnant women to treatment services
ª 2012 Blackwell Publishing Ltd 571
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8/16/2019 Ferguson Et Al-2012-Tropical Medicine & International Health
9/17
T a b l e 2
( C o n t i n u e d )
C o u n t r y ,
F i r s t a u t h o r ,
Y e a r o
f
P u
b l i c a t i o n
S t u
d y
d e s
i g n
I n t e r v e n t i o n
C D 4
f o r
H A A R T
e l i g i b i l i t y
H I V
-
p o s i t i v e
R e f e
r r e d
t o H
I V
c l i n i c
f o r
H A A
R T
a s s e s s m e n t
R e g
i s t e r e
d
a t H I V
c l i n i c
I n i t i a l
s c r e e n
i n g
o r
C D 4
t e s t
d o n e
R e t u r n e d
f o r r e s u
l t s
o f C D 4
t e s t
E
l i g i
b l e
f o r
H
A A R T
S t a r t e
d
H A A R T
S h o u
l d
h a v e
s t a r t e
d
H A A R T
( E s t
i m a t e )
%
o f
t h o s e
e s t i m a t e d
H A A R T -
e l i g i b l e
w h o
s t a r t e
d
H A A R T
S t u
d y
l i m
i t a t
i o n s
a
b ( %
= b ⁄ a )
c ( %
= c ⁄ b )
d ( %
= d ⁄ a )
e ( %
= e ⁄ d ) f ( %
= f ⁄ d )
g ( %
= g ⁄ f )
h ( a ·
% f )
i ( g ⁄ h )
Z i m b a b w e
( M u c h e d z i
e t a l .
2 0 1 0 )
C r o s s -
s e c t
i o n a l
s u r v e y
P e e r c o u n s e
l l o r s
t o p r o v i
d e
a d d i t i o n a l
s u p p o r t
i n c l u
d i n g
h o m e
t r a c
i n g
i n t h e
c a s e o
f m
i s s e
d
a p p o
i n t m e n t s
< 3 5 0
1 4 7 –
9 5 ( 6 5 % ) 7 7 ( 8 1 % )
4
3 ( 5 6 % ) 3 5 ( 8 1 % ) 8 2
4 3 %
B a s e d o n
s e l f
- r e p o r t
.
2 3 %
L T F U
M u
l t i -
c o u n t r y
( G i n s b u r g
e t a l .
2 0 0 7 )
R e v
i e w o
f
p r o g r a m m a t i c
i n d i c a t o r s
N G O
-
s u p p o r t e d
P M T C T
p r o g r a m m e
V a r
i e d
b y
c o u n t r y
9 8 3 0 4
1 3 8 8
B a s e d o n
r o u t i n e
p r o g r a m m e
m o n
i t o r i n g
d a t a ;
i n c o m p
l e t e
r e p o r t
i n g
H A A R T
, H i g h l y a c t i v e a n t i r e t r o v i r a
l t h e r a p y ;
L T F U
, l o s t t o
f o l l o w - u
p ;
A N C
, a n t e n a t a l c a r e ;
C H W s , c o m m u n
i t y h e a
l t h w o r k e r s ;
P M T C T
, p r e v e n t i o n o
f m o
t h e r - t
o - c
h i l d
H I V t r a n s m
i s s i o n
.
C l i e n t s w e r e a l s o
d e e m e d e
l i g i
b l e f o r
H A A R T i f C D 4 <
3 5 0 a n
d W H O
S t a g e
I I I , o r
i f W H O
.
T h e s e
d a t a w e r e c o
l l e c t e
d b e t w e e n
A u g u s t
2 0 0 3 a n
d A u g u s t
2 0 0 5
. U n t i l D e c
2 0 0 4
, t h e c r
i t e r
i a f o r
i n i t i a t i n g
H A A R T w e r e
C D 4 <
3 5 0 ⁄ m m
3
a n d W H O S t a g e
4 ,
3 o r
2 ,
o r
C D 4 <
2 0 0 m m
3 .
F r o m
J a n u
a r y
2 0 0 5 p a t
i e n t s w
i t h S t a g e
2 a n
d C D 4 <
3 5 0 m m
3
w e r e n o t e l
i g i b l e f o r
H A A R T .
§ W h e r e a
i s u n a v a i
l a b l e
, % =
d ⁄ c ( T o n w e -
G o
l d ) .
– 2 0 1 w o m e n w e r e
d i a g n o s e d
w i t h H I V a n
d e l
i g i b l e f o r t h
i s s t u
d y
b u t , b e
f o r e t h e
f o l l o w - u
p t i m e ,
4 6 w e r e
l o s t - t
o - f o l
l o w - u
p ( 4 1 h a d m o v e
d o u t o
f t h e s t u
d y a r e a
a n d fi v e
h a d
r e l o c a t e
d t o o t h e r c o u n t r
i e s )
a n d e i g h t
h a d
d i e d
. O n
l y t h e r e m a i n
i n g 1 4
7 h a v e
b e e n
i n c l u
d e d
h e r e a s t h e s u r v
i v i n g
o t h e r s m a y
h a v e r e g i s t e r e d a t a
d i f f e r e n t H
I V c l
i n i c
.
Tropical Medicine and International Health volume 17 no 5 pp 564–580 may 2012
L. Ferguson et al. Linking HIV-positive pregnant women to treatment services
572 ª 2012 Blackwell Publishing Ltd
-
8/16/2019 Ferguson Et Al-2012-Tropical Medicine & International Health
10/17
T a b l e 3
S t u
d i e s
i n t h e r e v i e w w
i t h i n s u
f fi c i e n t
d a t a
f o r c r e a t i n g a p a t i e
n t c a s c a d e
A u t h o r , y e a r
o f P u
b l i c a t i o n
S t u
d y s e t t
i n g
S t u
d y
d e s
i g n
C o m m e n t s
A b r a m s e t a l . ( 2 0 0 7 )
R e v
i e w u s i n g
d a t a
f r o m
1 3 c o u n t r
i e s
i n s u
b - S
a h a r a n
A f r i c a n a n
d S o u t h e a s t
A s i a
R e v
i e w o
f r a t i o n a l e s
f o r
l i n
k i n g
P M T C T
a n d H I V t r e a t m e n t s e r v
i c e s
, f o c u s i n g o n
P M T C T a s a g a t e w a y t o
f a m
i l y -
b a s e d
H I V c a r e a n
d t r e a t m e n t .
L o o
k e d a t w
h y
i t i s i m p o r t a n t t o
s t r e n g t
h e n
l i n
k s
b e t w e e n
P M T C T a n
d l o n g - t e r m c a r e
a n d t r e a t m e n t
P r o m o t i o n o
f f a m
i l y - c e n t r e d c a r e a s a n
a p p r o a c
h f o r a c
h i e v i n g t h
i s
C h i n k o n
d e e t a l . ( 2 0 0 9 )
2 U N C
- s u p p o r t e d
P M T C T
p r o g r a m m e s
, L i l o n g w e ,
M a l a w
i
Q u a l
i t a t
i v e
i n t e r v
i e w s a n
d f o c u s g r o u p
d i s c u s s
i o n s w
i t h w o m e n w
h o
h a d
a t t e n
d e d t h e
P M T C T p r o g r a m m e
a n d t h e i r
h u s b a n
d s
S o u g h t t o u n
d e r s t a n
d h i g h l e v e l s
o f a t t r
i t i o n
f r o m t h e
P M T C T p r o g r a m m e
M a j o r
b a r r i e r s t o r e t e n t i o n
i n t h e p r o g r a m m e
i n c l u
d e d :
f e a r o
f i n v o
l u n t a r y
H I V d i s c l o s u r e
a n d n e g a t
i v e c o m m u n
i t y r e a c t i o
n s ; u n e q u a l
g e n
d e r r e
l a t i o n s ;
l o n g w a l
k i n g
d i s t a n c e s ;
a n d l a c k o
f s u p p o r t
f r o m
h u s b a
n d s
F a c
i l i t a t o r : s o c i a l s u p p o r t
D u
f f e t a l . ( 2 0 1 0 )
P M T C T + p r o g r a m m e
i n a
r e g i o n a l
h o s p
i t a l
, U g a n
d a
Q u a l
i t a t
i v e
d e s c r
i p t i v e e x p
l o r a t o r y
s t u
d y : q u a l
i t a t
i v e
i n t e r v
i e w s a n
d a
f o c u s
g r o u p
d i s c u s s
i o n w
i t h H I V
- p o s i t i v e
m o t h e r s
G r e a t e s t
b a r r i e r t o a c c e s s
i n g
H A A R T :
e c o n o m
i c c o n c e r n s , e s p e c
i a l l y t r a n s p o r t
c o s t s t o c l
i n i c s
O t h e r
b a r r i e r s : s t
i g m a , n o n - d
i s c l o s u r e t o
s e x u a l p a r t n e r s ,
l o n g w a i t i n g t i m e s a t
c l i n i c s , a n
d s u
b o p t i m a l p r o v i
d e r – p a t
i e n t
i n t e r a c t
i o n s
G r u s k
i n e t a l . ( 2 0 0 8 )
P o
l i c y a n a l y s
i s
A n a l y s
i s o
f t h e
i m p
l i c a t i o n s o
f W
H O ’ s
g u i d a n c e o n p r o v i
d e r - i
n i t i a t e
d H
I V t e s t
i n g
a n d c o u n s e
l l i n g
( P I T C ) f o r t h e
h e a
l t h a n
d
h u m a n r i g h t s o
f p r e g n a n t w o m e n
P o t e n t i a l o
f P I T C a s a g a t e w a y t o
l o n g - t e r m
c a r e a n
d t r e a t m e n t s e r v
i c e s
i s h i g h l i g h t e
d
A t t e n t i o n t o t h e
i m p
l e m e n t a�
